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 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.

A. Ask the charge nurse to obtain informed consent. B. Contact the facility social worker to obtain the consent. C. Explain implied consent to the client's family. D. Request that the client's guardian sign the consent.

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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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 planning to conduct a support group for adolescents who have cancer. Which of the following actions should the nurse include during the orientation phase?

Correct Answer is D

Explanation

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?

Correct Answer is D

Explanation

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

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