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

Answer and Explanation

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.

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Correct Answer is A

Explanation

This response demonstrates empathy and respect for the client's feelings, and encourages the client to explore and express his or her emotions. It also allows the nurse to assess the client's situation and provide appropriate support and interventions.

A. Inform the client that they have the legal right to refuse treatment at any time. B. Encourage the client to have the procedure. C. Request another nurse to review the procedure with the client. D. Obtain consent from the client's family member.

Correct Answer is A

Explanation

The nurse should respect the client's autonomy and inform them of their right to refuse treatment, even if it is against medical advice. The nurse should also explore the reasons for the refusal and provide information and support as needed. The other options are not appropriate as they do not respect the client's decision or may violate their privacy.

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A nurse is assessing a client who has delirium. Which of the following findings requires immediate intervention by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who states, "I am too embarrassed to tell anyone what I did last night." Which of the following responses should the nurse make?

Correct Answer is A

Explanation

A nurse is caring for a client who has an anxiety disorder and is scheduled for a procedure. The client informs the nurse that they do not want to have the procedure. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A charge nurse is educating a newly licensed nurse about various defense mechanisms. Which of the following examples should the charge nurse provide when discussing rationalization?

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A nurse on a mental health unit placed a client in mechanical restraints after the client assaulted another client. Which of the following actions should the nurse take?

A nurse is caring for a client in the emergency department who states that she was beaten and sexually assaulted by her partner. After a rapid assessment, which of the following actions should the nurse plan to take next?

A nurse is providing behavioral therapy for a client who has obsessive-compulsive disorder. The client repeatedly checks that the doors are locked at night. Which of the following instructions should the nurse give the client when using thought stopping technique?

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A nurse is assisting with obtaining informed consent for a client who has been declared legally incompetent. Which of the following actions should the nurse take?