A nurse is caring for a client who experienced a fall. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to collect data about the client's progress.

Rationale for Correct Answers: Potential Condition: Delirium: The client has sudden onset confusion, disorientation to time, place, person, and situation. Inability to recall home address and inappropriate responses (e.g., asking if the washcloth goes in the dryer). Restlessness at night and urinary incontinence. No prior cognitive decline is reported, suggesting an acute condition. These features are consistent with delirium rather than chronic dementia or normal aging. Actions to Take: Monitor for an underlying infection: Delirium in older adults is often triggered by infections, such as UTI or pneumonia. Use symbols rather than written signs for directions: Simplifying communication and providing visual cues helps reduce confusion. Parameters to Monitor: Ability to complete familiar tasks: Functional assessments show if delirium is improving or worsening. Presence of agnosia: Monitoring recognition deficits helps track cognitive recovery. Rationale for Incorrect Options: Alzheimer’s disease: Typically presents with gradual cognitive decline, memory loss over months to years, and progressive functional deterioration. The sudden onset here makes this less likely. Expected aging process: Normal aging can include minor forgetfulness but does not cause disorientation to time, place, person, or situation. Major depressive disorder: While depression can cause low motivation and confusion, it does not usually cause acute disorientation or inappropriate responses. Anticipate a prescription for duloxetine: Duloxetine is an antidepressant and not first-line for delirium; medication is directed toward underlying cause, not symptomatically prescribing antidepressants. Determine the date of the client’s last eye examination: Visual impairment is not the immediate cause of acute delirium in this case. Anticipate a prescription for donepezil: Donepezil is used for chronic dementia like Alzheimer’s, not acute delirium. Oxygen saturation: The client’s O₂ sat is normal; hypoxia is not indicated here. Night vision: Visual problems are not the cause of the acute confusion. Attendance at group therapy: This is not relevant for monitoring acute delirium; the client may not be ready for participation.