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. Ask staff members to describe their most traumatic memories of the event. B. Reassure staff members that the debriefing is confidential. C. Provide stress-management exercises to the staff members. D. Have staff members discuss their involvement in the event.

Correct Answer is B

Explanation

The rationale is that confidentiality is essential to create a safe and trusting environment for staff members to share their feelings and experiences without fear of judgment or reprisal.

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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

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Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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