A nurse is assessing a client who has delirium. Which of the following findings requires immediate intervention by the nurse?
Impaired memory
Inappropriate speech patterns
Command hallucinations
Rapid mood swings
The Correct Answer is C
Command hallucinations are auditory hallucinations that instruct the client to perform an action, such as harming oneself or others. This is a medical emergency that requires immediate intervention by the nurse to ensure safety and prevent harm.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
During the orientation phase, the nurse should introduce herself and the group members, explain the purpose and goals of the group, and create a trusting and respectful atmosphere. Maintaining focus, encouraging problem-solving, and managing conflict are actions that belong to the working phase of group development.
Correct Answer is D
Explanation
The client's guardian is the legal representative who can provide informed consent for the client who is incompetent. The nurse should ensure that the guardian understands the risks, benefits, and alternatives of the proposed treatment or procedure.
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