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
The correct answer is: D. The client has several siblings.
Choice A reason:
The client being the oldest of their siblings is not directly linked to the development of conduct disorder. Conduct disorder is more influenced by factors such as family conflict, inconsistent discipline, and parental issues rather than birth order.
Choice B reason:
The client's father living in the client's home does not inherently contribute to conduct disorder. The presence of a father figure can be a stabilizing factor unless there are issues such as abuse, neglect, or inconsistent parenting.
Choice C reason:
The client's mother having asthma is unrelated to the development of conduct disorder. Conduct disorder is typically associated with psychological, social, and familial factors rather than the physical health conditions of parents.
Choice D reason:
The client having several siblings can contribute to conduct disorder due to potential for increased familial conflict and competition for parental attention. Larger family sizes can sometimes lead to less individual attention and more sibling rivalry, which can exacerbate behavioral issues.
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