A nurse is caring for a client in the intensive care unit.

Exhibits

The nurse is reviewing the admission assessment, nurses' notes, vital signs, and laboratory results. Drag words from the choices below to fill in each blank in the following sentence. The nurse identifies that the client's and can indicate the development of delirium.

A. Brushing teeth immediately after eating may exacerbate nausea, especially if the client is experiencing pregnancy-related nausea and vomiting.

B. Laying down for 30 minutes after meals may worsen nausea and reflux symptoms.

C. Drinking 12 oz of water with each meal may contribute to feelings of fullness and exacerbate nausea and vomiting.

D. Eating a dry carbohydrate before getting out of bed, such as crackers or dry toast, can help alleviate nausea and vomiting associated with pregnancy by providing a bland, easily digestible source of energy before the client starts moving in the morning.

A. The examination light of the ophthalmoscope should be directed toward the client's eye, not the client's face.

B. When examining the left eye, the nurse should stand on the right side of the client to facilitate proper alignment of the ophthalmoscope with the client's eye.

C. Dimming the lights in the room may improve visualization of the client's internal eye

structures, but it is not typically necessary for ophthalmoscopic examination and may hinder the nurse's ability to assess the client effectively.

D. Placing the ophthalmoscope directly against the client's forehead would not facilitate proper examination of the internal eye structures and may cause discomfort to the client.