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 C
Explanation
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.
Correct Answer is D
Explanation
A maladaptive grief response is one that interferes with normal functioning or causes significant distress for the bereaved person. The client who is unable to perform basic hygiene tasks is showing signs of depression and impaired self-care, which indicate a maladaptive grief response. The other behaviors are not necessarily maladaptive, but may reflect normal coping strategies or adjustments after losing a partner.
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