A nurse is caring for a client who has delirium.
Which of the following findings should the nurse expect?

Choice A rationale

While a bruise on the shin could indicate abuse, it could also result from an accidental bump or fall, which are common in older adults due to factors like impaired balance or decreased bone density. A single bruise alone is not definitive evidence of caregiver abuse or neglect and requires further assessment to determine the cause.

Choice B rationale

Being 9 kg (20 lb) over the recommended weight is indicative of potential overeating or a sedentary lifestyle, both of which are health concerns but not direct indicators of caregiver abuse or neglect. Weight management is related to dietary habits and physical activity levels, not necessarily the actions of a caregiver.

Choice C rationale

A caregiver paying a client's bills is not necessarily indicative of abuse or neglect. It could be a sign of assistance and support, especially if the client has difficulty managing their finances. Financial arrangements between a client and caregiver need to be assessed within the context of their relationship and the client's capacity.

Choice D rationale

Wearing soiled clothing suggests a lack of proper hygiene and care, which could be a sign of neglect by the caregiver. Inadequate attention to basic needs like cleanliness can lead to skin breakdown, infections, and a decline in the client's overall health and well-being. This warrants further investigation into the care provided.

Choice A rationale

A client repeatedly requesting anxiety medication should be assessed, but their behavior does not indicate an immediate safety risk to themselves or others. While their anxiety needs attention, other clients may have more urgent needs. The nurse should acknowledge their request and address it in a timely manner, but not necessarily as the absolute first priority.

Choice B rationale

A client yelling obscenities and throwing clothes is exhibiting escalating and potentially aggressive behavior. This situation poses an immediate risk to the client's safety and the safety of others on the unit. The nurse must intervene promptly to de-escalate the situation, ensure the client's well-being, and prevent potential harm to themselves or others. This behavior indicates a loss of control and requires immediate attention.

Choice C rationale

A client with bipolar disorder who is continuously pacing is displaying psychomotor agitation, which is characteristic of a manic episode. While this behavior warrants assessment and intervention, it does not present the same level of immediate risk as the client who is actively yelling and throwing objects. The pacing client should be monitored and offered interventions to help manage their agitation, but they are not the highest priority in this scenario.

Choice D rationale

A client screaming at other clients in the dayroom is exhibiting aggressive verbal behavior that is disruptive and potentially threatening to others. This situation requires the nurse's intervention to de-escalate the situation, ensure the safety and comfort of the other clients, and address the yelling client's behavior. However, the client actively throwing objects in their room poses a more immediate and direct safety risk.