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

Alcohol withdrawal syndrome is characterized by autonomic hyperactivity, which can manifest as tachycardia, hypertension, hyperthermia, diaphoresis, tremors, seizures, and delirium tremens. The nurse should monitor the client's vital signs, provide supportive care, and administer medications as prescribed to prevent complications and promote recovery.

A. Maintain the group's focus on identified issues. B. Encourage the use of problem-solving skills. C. Manage conflict within the group. D. Establish a rapport with group members.

Correct Answer is D

Explanation

During the orientation phase, the nurse should establish a rapport with group members, set ground rules, and clarify goals and expectations. The other actions are more appropriate for the working phase of the group.

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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 has alcohol use disorder and is experiencing withdrawal. The nurse should monitor the client for which of the following manifestations?

Correct Answer is B

Explanation

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 developing a behavioral contract with a client who has antisocial personality disorder. Which of the following client goals should the nurse include in the contract?

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?

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?

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?

A nurse is assessing a client who has anorexia nervosa. Which of the following findings should the nurse expect? (Select all that apply.)

A nurse is leading a grief support group for bereaved clients. Which of the following client statements should the nurse report to the provider as an indication of clinical depression?

A nurse in an in-patient facility is caring for a client who has an anxiety disorder. Which of the following actions should the nurse take while the client is experiencing an acute panic attack?