- Which behavior best demonstrates aggression?
a.
Stomping away from the nurses’ station, going to the hallway, and grabbing a tray from the meal cart.
b.
Bursting into tears, leaving the community meeting, and sitting on a bed hugging a pillow and sobbing.
c.
Telling the primary nurse, “I felt angry when you said I could not have a second helping at lunch.”
d.
Telling the medication nurse, “I am not going to take that, or any other, medication you try to give me.”
ANS: A
Aggression is harsh physical or verbal action that reflects rage, hostility, and potential for physical or verbal destructiveness. Aggressive behavior violates the rights of others. Refusing medication is a patient’s right and may be appropriate. The other incorrect options do not feature violation of another’s rights.
- Which clinical scenario predicts the highest risk for directing violent behavior toward others?
a.
Major depressive disorder with delusions of worthlessness
b.
Obsessive-compulsive disorder; performs many rituals
c.
Paranoid delusions of being followed by alien monsters
d.
Completed alcohol withdrawal; beginning a rehabilitation program
ANS: C
Patients who are delusional, hyperactive, impulsive, or predisposed to irritability are at higher risk for violence. The patient in the correct response has the greatest disruption of ability to perceive reality accurately. People who feel persecuted may strike out against those believed to be persecutors. The other patients have better reality-testing ability.
3. A patient was arrested for breaking windows in the home of a former domestic partner. The patient’s history also reveals childhood abuse by a punitive parent, torturing family pets, and an arrest for disorderly conduct. Which nursing diagnosis has priority? a. Risk for injury b. Ineffective coping c. Impaired social interaction d. Risk for other-directed violence
ANS: D
Defining characteristics for risk for other-directed violence include a history of being abused as a child, having committed other violent acts, and demonstrating poor impulse control. There is no indicator that the patient will experience injury. Ineffective coping and impaired social interaction have lower priorities.
- A confused older adult patient in a skilled nursing facility was asleep when unlicensed assistive personnel (UAP) entered the room quietly and touched the bed to see if it was wet. The patient awakened and hit the UAP in the face. Which statement best explains the patient’s action?
a.
Older adult patients often demonstrate exaggerations of behaviors used earlier in life.
b.
Crowding in skilled nursing facilities increases an individual’s tendency toward violence.
c.
The patient learned violent behavior by watching other patients act out.
d.
The patient interpreted the UAP’s behavior as potentially harmful.
ANS: D
Confused patients are not always able to evaluate the actions of others accurately. This patient behaved as though provoked by the intrusive actions of the staff.
- A patient is pacing the hall near the nurses’ station, swearing loudly. An appropriate initial intervention for the nurse would be to address the patient by name and say:
a.
“What is going on?”
b.
“Please be quiet and sit down in this chair immediately.”
c.
“I’d like to talk with you about how you’re feeling right now.”
d.
“You must go to your room and try to get control of yourself.”
ANS: C
Intervention should begin with analysis of the patient and the situation. When anger is escalating, a patient’s ability to process decreases. It is important to speak to the patient slowly and in short sentences, using a low and calm voice. Use open-ended statements designed to hear the patient’s feelings and concerns. This leads to the next step of planning an intervention.
- A patient who was responding to auditory hallucinations earlier in the morning now approaches the nurse shaking a fist and shouts, “Back off!” and then goes to the dayroom. While following the patient into the dayroom, the nurse should
a.
make sure there is adequate physical space between the nurse and patient.
b.
move into a position that places the patient close to the door.
c.
maintain one arm’s length distance from the patient.
d.
begin talking to the patient about appropriate behavior.
ANS: A
Making sure space is present between the nurse and the patient avoids invading the patient’s personal space. Personal space needs increase when a patient feels anxious and threatened. Allowing the patient to block the nurse’s exit from the room may result in injury to the nurse. Closeness may be threatening to the patient and provoke aggression. Sitting is inadvisable until further assessment suggests the patient’s aggression is abating. One arm’s length is inadequate space.
- An intramuscular dose of antipsychotic medication needs to be administered to a patient who is becoming increasingly more aggressive and refused to leave the day room. The nurse should enter the day room
a.
and say, “Would you like to come to your room and take some medication your health care provider prescribed for you?”
b.
accompanied by three staff members and say, “Please come to your room so I can give you some medication that will help you regain control.”
c.
and place the patient in a basket-hold and then say, “I am going to take you to your room to give you an injection of medication to calm you.”
d.
accompanied by a male security guard and tell the patient, “Come to your room willingly so I can give you this medication, or the guard and I will take you there.”
ANS: B
A patient gains feelings of security if he or she sees others are present to help with control. The nurse gives a simple direction, honestly states what is going to happen, and reassures the patient that the intervention will be helpful. This positive approach assumes the patient can act responsibly and will maintain control. Physical control measures are used only as a last resort.
8. After an assault by a patient, a nurse has difficulty sleeping, startles easily, and is preoccupied with the incident. The nurse said, “That patient should not be allowed to get away with that behavior.” Which response poses the greatest barrier to the nurse’s ability to provide therapeutic care? a. Startle reactions b. Difficulty sleeping c. A wish for revenge d. Preoccupation with the incident
ANS: C
The desire for revenge signals an urgent need for professional supervision to work through anger and counter the aggressive feelings. Feelings of revenge create a risk for harm to the patient. The distracters are normal in a person who was assaulted. They usually are relieved with crisis intervention, help the individual regain a sense of control, and make sense of the event.
9. The staff development coordinator plans to teach use of physical management techniques for use when patients become assaultive. Which topic should the coordinator emphasize? a. Practice and teamwork b. Spontaneity and surprise c. Caution and superior size d. Diversion and physical outlets
ANS: A
Intervention techniques are learned behaviors and must be practiced to be used in a smooth, organized fashion. Every member of the intervention team should be assigned a specific task to carry out before beginning the intervention. The other options are useless if the staff does not know how to use physical techniques and how to apply them in an organized fashion.
10. An adult patient assaulted another patient and was then restrained. One hour later, which statement by the restrained patient requires the nurse’s immediate attention? a. “I hate all of you!” b. “My fingers are tingly.” c. “You wait until I tell my lawyer.” d. “The other patient started the fight.”
ANS: B
The correct response indicates impaired circulation and necessitates the nurse’s immediate attention. The incorrect responses indicate the patient has continued aggressiveness and agitation.
- Which is an effective nursing intervention to assist an angry patient learn to manage anger without violence?
a.
Help a patient identify a thought that produces anger, evaluate the validity of the belief, and substitute reality-based thinking.
b.
Provide negative reinforcement such as restraint or seclusion in response to angry outbursts, whether or not violence is present.
c.
Use aversive conditioning, such as popping a rubber band on the wrist, to help extinguish angry feelings.
d.
Administer an antipsychotic or antianxiety medication.
ANS: A
Anger has a strong cognitive component, so using cognition techniques to manage anger is logical. The incorrect options do nothing to help the patient learn anger management.
12. Which assessment finding presents the greatest risk for violent behavior directed at others? a. Severe agoraphobia b. History of spousal abuse c. Bizarre somatic delusions d. Verbalized hopelessness and powerlessness
ANS: B
A history of prior aggression or violence is the best predictor of who may become violent. Patients with anxiety disorders are not particularly prone to violence unless panic occurs. Patients experiencing hopelessness and powerlessness may have coexisting anger, but violence is uncommon. Patients with paran
13. An emergency code was called after a patient pulled a knife from a pocket and threatened, “I will kill anyone who tries to get near me.” The patient was safely disarmed and placed in seclusion. Justification for use of seclusion was that the patient a. was threatening to others. b. was experiencing psychosis. c. presented an undeniable escape risk. d. presented a clear and present danger to others.
ANS: D
The patient’s threat to kill self or others with the knife he possessed constituted a clear and present danger to self and others. The distracters are not sufficient reasons for seclusion
14. A patient sat in silence for 20 minutes after a therapy appointment, appearing tense and vigilant. The patient abruptly stood, paced back and forth, clenched and unclenched fists, and then stopped and stared in the face of a staff member. The patient is a. demonstrating withdrawal. b. working though angry feelings. c. attempting to use relaxation strategies. d. exhibiting clues to potential aggression.
ANS: D
The description of the patient’s behavior shows the classic signs of someone whose potential for aggression is increasing.
- A patient with multi-infarct dementia lashes out and kicks at people who walk past in the hall of a skilled nursing facility. Intervention by the nurse should begin by
a.
gently touching the patient’s arm.
b.
asking the patient, “What do you need?”
c.
saying to the patient, “This is a safe place.”
d.
directing the patient to cease the behavior.
ANS: C
Striking out usually signals fear or that the patient perceives the environment to be out of control. Getting the patient’s attention is fundamental to intervention. The nurse should make eye contact and assure the patient of safety. Once the nurse has the patient’s attention, gently touching the patient, asking what he or she needs, or directing the patient to discontinue the behavior may be appropriate.
- A cognitively impaired patient has been a widow for 30 years. This patient frantically tries to leave the facility, saying, “I have to go home to cook dinner before my husband arrives from work.” To intervene with validation therapy, the nurse will say:
a.
“You must come away from the door.”
b.
“You have been a widow for many years.”
c.
“You want to go home to prepare your husband’s dinner?”
d.
“Your husband gets angry if you do not have dinner ready on time?”
ANS: C
Validation therapy meets the patient “where she or he is at the moment” and acknowledges the patient’s wishes. Validation does not seek to redirect, reorient, or probe. The distracters do not validate the patient’s feelings.
- A patient with a history of anger and impulsivity was hospitalized after an accident resulting in multiple injuries. The patient loudly scolds nursing staff, “I’m in pain all the time but you don’t give me medicine until YOU think it’s time.” Which nursing intervention would best address this problem?
a.
Teach the patient to use coping strategies such as deep breathing and progressive relaxation to reduce the pain.
b.
Talk with the health care provider about changing the pain medication from prn to patient-controlled analgesia.
c.
Tell the patient that verbal assaults on nurses will not shorten the wait for analgesic medication.
d.
Talk with the patient about the risks of dependency associated with overuse of analgesic medication.
ANS: B
Use of patient-controlled analgesia will help the patient manage the pain. This intervention will help reduce the patient’s anxiety and anger. Dependency is not an important concern related to acute pain.
- A patient has a history of impulsively acting-out anger by striking others. Select the most appropriate intervention for avoiding similar incidents.
a.
Teach the patient about herbal preparations that reduce anger.
b.
Help the patient identify incidents that trigger impulsive anger.
c.
Explain that restraint and seclusion will be used if violence occurs.
d.
Offer one-on-one supervision to help the patient maintain control.
ANS: B
Identification of trigger incidents allows the patient and nurse to plan interventions to reduce irritation and frustration, which lead to acting-out anger, and eventually to put into practice more adaptive coping strategies.
- A patient with severe burn injuries is irritable, angry, and belittles the nurses. As a nurse changes a dressing, the patient screams, “Don’t touch me! You are so stupid. You will make it worse!” Which action by the nurse will best help to diffuse the patient’s anger?
a.
Stop the dressing change and say, “I will leave the supplies so that you can change your own dressing.”
b.
Continue the dressing change and say, “This dressing change is necessary because you were careless with fire.”
c.
Discontinue the dressing change, tell the patient, “I will return when you gain control of yourself,” and leave the room.
d.
Continue the dressing change and say, “Dressing changes are needed to prevent infection. What are your ideas about how to make it less painful?”
ANS: D
The nurse should not respond personally to the patient’s comments. The correct answer objectively gives the patient information that may lead to lowering his anger and engages the patient in problem solving. The incorrect options will escalate the patient’s anger by belittling or escalating the patient’s sense of powerlessness. Dressing changes are needed for the patient’s physiological integrity; therefore, the nurse should not abandon the responsibility to perform them
20. Which medication from the medication administration record should a nurse administer to provide immediate intervention for a psychotic patient whose aggressive behavior continues to escalate despite verbal intervention? a. Lithium b. Trazodone c. Olanzapine d. Valproic acid
ANS: C
Olanzapine is a short-acting antipsychotic useful in calming angry, aggressive patients regardless of diagnosis. The other drugs listed require long-term use to reduce anger. Lithium is for bipolar patients. Trazodone is commonly prescribed for patients experiencing depression, insomnia, or chronic pain. Valproic acid is for bipolar or borderline patients.
- An emergency department nurse realizes that the spouse of a patient is becoming increasingly irritable while waiting. Which intervention should the nurse use to prevent further escalation of the spouse’s anger?
a.
Offer the waiting spouse a cup of coffee.
b.
Explain that the patient’s condition is not life threatening.
c.
Periodically provide an update and progress report on the patient.
d.
Suggest that the spouse return home until the patient’s treatment is complete.
ANS: C
Periodic updates reduce anxiety and defuse anger. This strategy acknowledges the spouse’s presence and concern. A cup of coffee is a nice gesture, but it does not address the spouse’s feelings. The other incorrect options would be likely to increase anger because they imply that the anxiety is inappropriate.
22. Which information from a patient’s record would indicate marginal coping skills and the need for careful assessment of the risk for violence? A history of a. academic problems. b. family involvement. c. childhood trauma. d. substance abuse.
ANS: D
The nurse should suspect marginal coping skills in a patient with substance abuse. They are often anxious, may be concerned about inadequate pain relief, and may have personality styles that externalize blame. The incorrect options do not signal as high a degree of risk as substance abuse.
- Family members describe the patient as “a difficult person who finds fault with others.” The patient verbally abuses nurses for their poor care. The most likely explanation lies in
a.
poor childrearing that did not teach respect for others.
b.
automatic thinking leading to cognitive distortions.
c.
a personality style that externalizes problems.
d.
delusions that others wish to deliver harm.
ANS: C
Patients whose personality style causes them to externalize blame see the source of their discomfort and anxiety as being outside themselves. They displace anger and are often unable to self-soothe. The incorrect options are less likely to have a bearing on this behavior.
- A new patient acts out so aggressively that seclusion is required before the admission assessment is completed or orders written. Immediately after safely secluding the patient, which action is the nurse’s priority?
a.
Complete the physical assessment.
b.
Notify the health care provider to obtain a seclusion order.
c.
Document the incident objectively in the patient’s medical record.
d.
Explain to the patient that seclusion will be discontinued when self-control is regained.
ANS: B
Emergency seclusion can be effected by a credentialed nurse but must be followed by securing a medical order within a period of time specified by the state and the agency. The incorrect options are not immediately necessary from a legal standpoint. See related audience response question.
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Chapter 115
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Chapter 217
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Chapter 327
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Chapter 428
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Chapter 522
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Chapter 626
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Chapter 728
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Chapter 822
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Chapter 930
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Chapter 101
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Chapter 110
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Ch. 12-V30
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Ch. 1328
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Ch.20-12-T17
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Ch.20-23-T28
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EXAM 263
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Chapter 19- Sleep Wake Disorders25
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Chapter 25- V28
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Ch. 27-V28
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Chapter 2823
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Chapter 29 v24
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Chapter 32- V29
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Chapter 17- T26
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Chapter 24- T30
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Chapter 25- T30
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Chapter 26-T30
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Chapter 28-T17
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Chapter 29-T15
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Chapter 35-T16
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Chapter 1535
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Chapter 2234
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Chapter 2332
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Chapter 3134
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Chapter 1128
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Chapter 2121
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chapter 1829
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source 130
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Source 218
