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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." - ANSWER ✔✔a. Stomping away
from the nurses' station, going to the hallway, and grabbing a tray from
the meal cart.
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 -
ANSWER ✔✔c. Paranoid delusions of being followed by alien
monsters
A client was arrested for breaking windows in the home of a former
domestic partner. The client's history 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 - ANSWER ✔✔d. Risk for other-
directed violence
A confused older adult client 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 client awakened and hit the
UAP in the face. Which statement best explains the client's
action?
a. Older adult clients often demonstrate exaggerations of behaviors used
earlier in life.
b. Crowding in skilled nursing facilities increases an individual's
tendency toward violence.
c. The client learned violent behavior by watching other clients act out.
d. The client interpreted the UAP's behavior as potentially harmful. -
ANSWER ✔✔d. The client interpreted the UAP's behavior as
potentially harmful.
A client is pacing the hall near the nurses' station, swearing loudly. An
appropriate initial intervention for the nurse would be to address the
client by name and to make what statement?
a. "What is going on?"
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, 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." -
ANSWER ✔✔c. "I'd like to talk with you about how you're feeling right
now."
A client 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 client into the dayroom, the
nurse should take what precaution?
a. make sure there is adequate physical space between the nurse and
client.
b. move into a position that places the client close to the door.
c. maintain one arm's length distance from the client.
d. begin talking to the client about appropriate behavior. - ANSWER
✔✔a. make sure there is adequate physical space between the nurse
and client.