Select words from the choices below to fill in each blank in the following sentence.

To further evaluate the client, the nurse anticipates the client will need

____

and

____

.

A) Measure the client’s vital signs: The first priority after a fall is to assess the client's physical condition to determine if any immediate harm or injury has occurred. Taking the vital signs allows the nurse to assess for signs of shock, internal injury, or other complications that could require urgent intervention. This step should be done before notifying the provider or completing paperwork.

B) Notify the client's provider: While notifying the provider is important, it is not the first step. The nurse's priority is to assess the client’s condition and ensure they are stable. Once the client’s condition has been assessed, the provider can be notified if necessary.

C) Complete an incident report: An incident report should be completed after the client’s immediate needs are addressed. While documentation of the fall is important, the priority is the client’s safety and well-being. The nurse should first evaluate and stabilize the client before focusing on administrative tasks like the incident report.

D) Document the fall in the client's medical record: Although documentation is essential, the first priority should always be assessing and stabilizing the client. Once the client’s safety is ensured, then documenting the event and any findings is appropriate.

A) "Individuals who have this disorder have a flat affect.": A flat affect, which refers to a lack of emotional expression, is more characteristic of conditions like depression or schizophrenia rather than delirium. Delirium typically involves fluctuating levels of consciousness, confusion, and altered attention, but a flat affect is not a defining feature.

B) "This disorder is characterized by a sudden onset of mental confusion.": This statement is correct. Delirium is characterized by a rapid onset of symptoms, including confusion, disorientation, and changes in cognition. The acute nature of delirium distinguishes it from other conditions like dementia, which develops gradually over time.

C) "Individuals who have this disorder speak at a slow pace.": While some individuals with delirium may speak slowly due to confusion or disorientation, this is not a defining characteristic of the disorder. Delirium can cause a variety of speech patterns, including rambling, incoherence, or even rapid speech depending on the individual’s cognitive state.

D) "This disorder is not reversible.": This statement is incorrect. Delirium is typically reversible if the underlying cause (such as infection, dehydration, or medication side effects) is identified and treated. Unlike progressive disorders like dementia, delirium can often be resolved with appropriate medical intervention.