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 B

Explanation

A: Giving the client atropine 30 min before the procedure is a task that requires professional nursing knowledge and skill to assess the medication's necessity and potential effects, thus it cannot be delegated to an assistive personnel.
B: Assisting with ambulation is a task that can be safely delegated to an assistive personnel, as it does not require the professional judgment or skill of a nurse. The assistive personnel can help maintain the client's safety while walking after the procedure.
C: Witnessing a client's signature on the consent for the procedure is a legal responsibility and requires an understanding of the procedure's risks and benefits, which is beyond the scope of assistive personnel's responsibilities.
D: Checking the client's condition after the procedure involves assessment and interpretation of clinical data, which are responsibilities of the nurse and cannot be delegated to an assistive personnel.

A. Justice B. Veracity C. Autonomy D. Beneficence

Correct Answer is C

Explanation

Autonomy is the ethical principle that respects the right of individuals to make their own decisions, even if they are not in their best interest. The nurse displays autonomy when he supports the client's refusal of medications, even though he might disagree with the client's choice.

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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 is undergoing electroconvulsive therapy. Which of the following tasks should the nurse delegate to an assistive personnel?

Correct Answer is B

Explanation

A nurse is caring for a client who has bipolar disorder and is refusing to take prescribed medications. Which of the following ethical principles is the nurse displaying when he supports the client's refusal of medications?

Correct Answer is C

Explanation

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