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 finding could indicate agranulocytosis, a potentially life threatening adverse effect of clozapine that causes a severe decrease in white blood cells and increases the risk of infection. The other findings are also important to monitor, but they are not as critical as sore throat.

A. RBC count 4.9 million/mm3 B. Hemoglobin 16 g/dL C. WBC count 8,000/mm3 D. Platelets 100,000/mm3

Correct Answer is D

Explanation

A low platelet count (thrombocytopenia) can indicate bleeding disorders, infections, or adverse effects of medications. Clonazepam can cause thrombocytopenia as a rare but serious side effect. The nurse should report this finding to the provider as it may indicate a need to discontinue or adjust the medication.

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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

What is the priority finding to report to the provider for a client who has schizophrenia and is taking clozapine?

Correct Answer is A

Explanation

A nurse is reviewing the laboratory report of a client who has a panic disorder and is taking clonazepam. Which of the following laboratory results should the nurse report to the provider?

Correct Answer is D

Explanation

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