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 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.
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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