TEST BANK For Critical Care Nursing- A Holistic Approach, 12th Edition by Morton Fontaine, Verified Chapters 1 - 56, Complete Newest Version
Which behavior best demonstrates aggression?
a. Stomping away from the nurses' station, darting to another room, and grabbing a snack from another patient
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, darting to another room, and grabbing a snack from another patient
A patient is hospitalized after an arrest for breaking windows in the home of a former intimate partner. The 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. Post-trauma response
c. Disturbed thought processes
d. Risk for other-directed violence - ANSWER d. Risk for other-directed violence
A patient is pacing the hall near the nurses' station and swearing loudly. An appropriate initial intervention for the nurse would be to address the patient by name and say what?
a. "What is going on?"
b. "Quiet down immediately. You are scaring others."
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 patient has been responding to auditory hallucinations throughout the day. The patient approaches the nurse, shaking a fist and shouting, "Back off!" and then goes into the day room. As the nurse follows the patient into the day room, the nurse should take what precaution?
a. Making sure adequate physical space exists between the nurse and the patient
b. Moving into a position that allows the patient to be close to the door
c. Maintaining one arm's length distance from the patient
d. Sitting down in a chair near the patient - ANSWER a. Making sure adequate physical space exists between the nurse and the patient An intramuscular dose of antipsychotic medication needs to be administered to a patient who is becoming increasingly more aggressive. The patient is in the day room where there are other patients. When entering the day room what response should the nurse make?
a. States, "Would you like to come to your room and take some medication your doctor prescribed for you?"
b. Accompanied by three staff members and states, "Please come to your room so I can give you some medication that will help you feel more comfortable."
c. Initiates process to place the patient in a basket-hold and then state, "I am going to take you to your room to give you an injection of medication to calm you."
d. Accompanied by two security guards and tell the patient, "You can come to your room willingly so I can give you this medication or the security guards will take you there." - ANSWER b. Accompanied by three staff members and states, "Please come to your room so I can give you some medication that will help you feel more comfortable."
The staff development coordinator plans to teach use of physical management techniques when patients become assaultive. Which topic should be emphasized?
a. Practice and teamwork
b. Spontaneity and surprise
c. Caution and superior size
d. Diversion and physical outlets - ANSWER a. Practice and teamwork
Which assessment finding presents the greatest risk for violent behavior?
a. Severe agoraphobic
b. A history of intimate partner violence
c. Reports of bizarre somatic delusions
d. Verbalization of hopelessness and powerlessness - ANSWER b. A history of intimate partner violence
A patient with a history of anger and impulsivity is hospitalized after an accident resulting in injuries. When in pain, the patient loudly scolds the nurse for "not knowing enough to give me pain medicine when I need it." Which intervention would best address this problem?
a. Tell the patient to notify the nurse 30 minutes before the pain returns so the
medication can be prepared.
b. Urge the health care provider to change the prescription for pain medication from as needed to a regular schedule.
c. Tell the patient that verbal assaults on nurses will not shorten the wait for pain medication.
d. Have the clinical nurse leader request a psychiatric consultation - ANSWER b. Urge the health care provider to change the prescription for pain medication from as needed to a regular schedule.
A patient has a history of impulsively acting out anger by striking others. Which would be an appropriate plan for avoiding such incidents?
a. Explain that restraint and seclusion will be used if violence occurs.
b. Help the patient identify incidents that trigger impulsive acting out.
c. Offer one-on-one supervision to help the patient maintain control.
Which behavior best demonstrates aggression?
a. Stomping away from the nurses' station, darting to another room, and grabbing a snack from another patient
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, darting to another room, and grabbing a snack from another patient
A patient is hospitalized after an arrest for breaking windows in the home of a former intimate partner. The 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. Post-trauma response
c. Disturbed thought processes
d. Risk for other-directed violence - ANSWER d. Risk for other-directed violence
A patient is pacing the hall near the nurses' station and swearing loudly. An appropriate initial intervention for the nurse would be to address the patient by name and say what?
a. "What is going on?"
b. "Quiet down immediately. You are scaring others."
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 patient has been responding to auditory hallucinations throughout the day. The patient approaches the nurse, shaking a fist and shouting, "Back off!" and then goes into the day room. As the nurse follows the patient into the day room, the nurse should take what precaution?
a. Making sure adequate physical space exists between the nurse and the patient
b. Moving into a position that allows the patient to be close to the door
c. Maintaining one arm's length distance from the patient
d. Sitting down in a chair near the patient - ANSWER a. Making sure adequate physical space exists between the nurse and the patient An intramuscular dose of antipsychotic medication needs to be administered to a patient who is becoming increasingly more aggressive. The patient is in the day room where there are other patients. When entering the day room what response should the nurse make?
a. States, "Would you like to come to your room and take some medication your doctor prescribed for you?"
b. Accompanied by three staff members and states, "Please come to your room so I can give you some medication that will help you feel more comfortable."
c. Initiates process to place the patient in a basket-hold and then state, "I am going to take you to your room to give you an injection of medication to calm you."
d. Accompanied by two security guards and tell the patient, "You can come to your room willingly so I can give you this medication or the security guards will take you there." - ANSWER b. Accompanied by three staff members and states, "Please come to your room so I can give you some medication that will help you feel more comfortable."
The staff development coordinator plans to teach use of physical management techniques when patients become assaultive. Which topic should be emphasized?
a. Practice and teamwork
b. Spontaneity and surprise
c. Caution and superior size
d. Diversion and physical outlets - ANSWER a. Practice and teamwork
Which assessment finding presents the greatest risk for violent behavior?
a. Severe agoraphobic
b. A history of intimate partner violence
c. Reports of bizarre somatic delusions
d. Verbalization of hopelessness and powerlessness - ANSWER b. A history of intimate partner violence
A patient with a history of anger and impulsivity is hospitalized after an accident resulting in injuries. When in pain, the patient loudly scolds the nurse for "not knowing enough to give me pain medicine when I need it." Which intervention would best address this problem?
a. Tell the patient to notify the nurse 30 minutes before the pain returns so the
medication can be prepared.
b. Urge the health care provider to change the prescription for pain medication from as needed to a regular schedule.
c. Tell the patient that verbal assaults on nurses will not shorten the wait for pain medication.
d. Have the clinical nurse leader request a psychiatric consultation - ANSWER b. Urge the health care provider to change the prescription for pain medication from as needed to a regular schedule.
A patient has a history of impulsively acting out anger by striking others. Which would be an appropriate plan for avoiding such incidents?
a. Explain that restraint and seclusion will be used if violence occurs.
b. Help the patient identify incidents that trigger impulsive acting out.
c. Offer one-on-one supervision to help the patient maintain control.
