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 B
Explanation
The nurse should have the provider assess the client within 1 hr after applying restraints to ensure that the restraints are necessary and appropriate, and to monitor the client's physical and mental status.
Correct Answer is B
Explanation
The nurse should respect the client's privacy and confidentiality and obtain their consent before disclosing any information to their employer or anyone else who is not directly involved in their care. Contacting the legal department, the provider, or the client's family may be appropriate in some situations, but they are not necessary or ethical actions without the client's permission.
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