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

A. Impaired memory

B. Inappropriate speech patterns

C. Command hallucinations

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.

D. Rapid mood swings

This question is an excerpt from Nurse Dive's nursing test bank - RN Mental Health 2019 With NGN Proctored Exam. Take the full exam now


Full 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. 


Similar Questions

QUESTION

A nurse is providing counseling for a family that consists of two parents and their two adolescent children. Which of the following family members should the nurse identify as acting in the role of monopolizer?

A. The mother who expresses hostility toward her spouse

B. The father who intervenes whenever the siblings argue

C. The adolescent son who refuses to share personal feelings

D. The adolescent daughter who attempts to dominate the discussion

A monopolizer is a family member who tries to control communication and prevent others from expressing their thoughts or feelings. The adolescent daughter who attempts to dominate the discussion is acting in this role and may hinder effective family counselling.

Full Explanation

A monopolizer is a family member who tries to control communication and prevent others from expressing their thoughts or feelings. The adolescent daughter who attempts to dominate the discussion is acting in this role and may hinder effective family counselling. 

QUESTION

A nurse is obtaining a medical history from a client who is requesting a prescription for bupropion for smoking cessation. Which of the following assessment findings in the client's history should the nurse report to the provider?

A. Hypothyroidism

B. Knee arthroplasty 1 month ago

C. Hepatitis B infection

D. Recent head injury

Bupropion is contraindicated in clients who have a history of seizures or head trauma, as it can lower the seizure threshold and increase the risk of adverse effects.

Full Explanation

Bupropion is contraindicated in clients who have a history of seizures or head trauma, as it can lower the seizure threshold and increase the risk of adverse effects.

QUESTION

A nurse is creating a plan of care for a client who has major depressive disorder. Which of the following interventions should the nurse include in the plan?

A. Keep a bright light on in the client's room at night.

B. Discourage the client from expressing feelings of anger.

C. Encourage physical activity for the client during the day.

Physical activity can help improve mood, energy, sleep, and cognitive function in clients who have major depressive disorder. It can also reduce stress and increase self esteem.

D. Identify and schedule alternative group activities for the client.

Full Explanation

Physical activity can help improve mood, energy, sleep, and cognitive function in  clients who have major depressive disorder. It can also reduce stress and increase self esteem.