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

The nurse should provide a trained advocate to stay with the client, as this can help reduce the psychological trauma and provide emotional support and information to the client. The other options are also important, but they can be done later or after obtaining the client's consent.

A. Acetaminophen B. Warfarin C. Fluoxetine D. Calcium carbonate

Correct Answer is C

Explanation

Selegiline is a monoamine oxidase inhibitor (MAOI), which can cause a hypertensive crisis if taken with selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine.

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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 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?

Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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

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