A nurse is assessing a client who has delirium.
Which of the following findings requires immediate intervention by the nurse?
A.
Command hallucinations.
B.
Impaired memory.
C.
Inappropriate speech patterns.
D.
Rapid mood swings.
The correct answer and Explanation is :
The correct answer is A. Command hallucinations.
Explanation:
Delirium is an acute and often fluctuating change in mental status characterized by confusion, disorientation, and disturbances in attention and cognition. Among the various symptoms associated with delirium, command hallucinations are particularly concerning because they can pose an immediate risk to the patient’s safety.
Command Hallucinations refer to auditory hallucinations where the individual hears voices instructing them to perform certain actions, which could potentially be harmful. For instance, if a patient is instructed to harm themselves or others, this could lead to dangerous situations that require urgent intervention. The presence of command hallucinations indicates that the patient’s mental state is severely altered and poses a direct threat to their safety.
Impaired Memory, Inappropriate Speech Patterns, and Rapid Mood Swings are common findings in delirium but do not necessarily indicate an immediate risk to safety. While these symptoms require attention and management, they do not represent an acute danger as command hallucinations do.
In cases where command hallucinations are present, the nurse must prioritize the patient’s safety. This might involve ensuring a safe environment, assessing the patient’s mental status more thoroughly, and possibly consulting a physician for pharmacological interventions to address the hallucinations. Additionally, the nurse should engage with the patient in a calming manner, redirecting their focus and reducing environmental stimuli that may exacerbate their symptoms.
Overall, immediate intervention for command hallucinations is crucial to prevent harm and to stabilize the patient’s condition, underscoring the importance of recognizing and addressing acute psychiatric symptoms in nursing practice.