A nurse is caring for a client in the emergency department who states that she was beaten and sexually assaulted by her partner.
After a rapid assessment, which of the following actions should the nurse plan to take next?

Choice A rationale:

Command hallucinations require immediate intervention by the nurse. Command hallucinations are auditory hallucinations in which the client hears voices instructing them to perform specific actions, often harmful or dangerous. These hallucinations can lead to the client engaging in harmful behaviors or self-harm. The nurse must address this symptom promptly to ensure the client's safety and well-being.

Choice B rationale:

Impaired memory is a common symptom in clients with delirium, but it does not require immediate intervention. While impaired memory can be distressing for the client, it is not an immediate safety concern. The nurse should address memory deficits as part of the overall care plan but prioritize more urgent issues like command hallucinations.

Choice C rationale:

Inappropriate speech patterns are also common in clients with delirium. While they may be concerning, they do not typically pose an immediate risk to the client's safety. The nurse should assess and address inappropriate speech patterns but prioritize the safety of the client, especially when command hallucinations are present.

Choice D rationale:

Rapid mood swings are a symptom of delirium but, like impaired memory and inappropriate speech patterns, do not require immediate intervention to the same extent as command hallucinations. The nurse should address mood swings as part of the overall care plan and ensure that the client's safety is not compromised due to their condition.

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? The correct answer is choice C. The adolescent daughter who attempts to dominate the discussion.

Choice A rationale:

The father who intervenes whenever the siblings argue does not necessarily fit the role of a monopolizer. While his intervention may affect the dynamics, it may not be an attempt to monopolize the discussion. His actions could be aimed at conflict resolution.

Choice B rationale:

The mother who expresses hostility toward her spouse also does not fit the role of a monopolizer. Expressing hostility is a different issue and does not necessarily mean she's monopolizing the discussion.

Choice C rationale:

The adolescent daughter who attempts to dominate the discussion is likely acting as the monopolizer. In family dynamics, a monopolizer is someone who seeks to control and dominate the conversation, often not allowing others to express their thoughts or opinions. This behavior can disrupt effective communication within the family.

Choice D rationale:

The adolescent son who refuses to share personal feelings is not acting as a monopolizer. While his behavior may affect communication, it is different from actively dominating the discussion.