A
Aggression is harsh physical or verbal action that reflects rage, hostility, and
potential for physical or verbal destructiveness. Aggressive behaviour violates
the rights of others. Refusing medication is a patient's right and may be
appropriate. The other incorrect options do not feature a violation of another's
rights. - ANSWER Which behavior best demonstrates aggression?
a. stomping away from the nurses' station, going grabbing a tray from the meal
cart
b. bursting into tears, leaving the community meeting, and sitting on a bed
hugging on a bed hugging a pillow
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."
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. - ANSWER Which scenario
predicts the highest risk for directing violent behavior towards others?
a. major depression with delusions of worthlessness
b. obsessive-compulsive disorder; performed many rituals
c. paranoid delusions of being followed by alien monsters
d. completed alcohol withdrawal; beginning a rehabilitation program
,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. - ANSWER A pt was arrested for breaking windows in the
home of former domestic partner. the pt's hx 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
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. - ANSWER A confused older adult patient in a skilled nursing
facility was asleep when unlicensed assistive personal (UAP) entered the room
quietly and touched the bed to see if it was wet. the pt awakened and hit the
UAP in the face. which statement best explains the pt's action?
a. older adult pt's often demonstrate
exaggerations of behaviors used earlier in life
b. crowding in skilled nursing facilities increases an individual's tendency
toward violence
c. the pt learned violent behavior by watching other pt's act out
d. the pt interpreted the UAP's behavior as potentially harmful
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. - ANSWER A
pt is pacing the hall near the nurses' station, swearing loudly. an appropraite
initial intervention for the nurse would be to address the pt by name and say:
a. "what is going on?"
b. "please be quite and sit down in his 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."
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. - ANSWER A pt 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 day room. while following the pt
into the day room, the nurse should:
a. make sure there is adequate physical space between the nurse and pt
b. move into a position that places the pt close to the door
c. maintain one arm's- length distance from the pt
d. begin talking to the pt about appropriate behavior
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. - ANSWER An
intramuscular dose of antipsychotic medication needs to be administered to a
pt who is becoming increasingly more aggressive and refused to leave the
dayroom. the nurse should enter the say 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 3 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 pt patient in a basket-hold and they 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 pt, "come to your room
willingly so i can give you this medication, or the guard and i will take you
there."
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. - ANSWER
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
A
Aggression is harsh physical or verbal action that reflects rage, hostility, and
potential for physical or verbal destructiveness. Aggressive behaviour violates
the rights of others. Refusing medication is a patient's right and may be
appropriate. The other incorrect options do not feature a violation of another's
rights. - ANSWER Which behavior best demonstrates aggression?
a. stomping away from the nurses' station, going grabbing a tray from the meal
cart
b. bursting into tears, leaving the community meeting, and sitting on a bed
hugging on a bed hugging a pillow
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."
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. - ANSWER Which scenario
predicts the highest risk for directing violent behavior towards others?
a. major depression with delusions of worthlessness
b. obsessive-compulsive disorder; performed many rituals
c. paranoid delusions of being followed by alien monsters
d. completed alcohol withdrawal; beginning a rehabilitation program
,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. - ANSWER A pt was arrested for breaking windows in the
home of former domestic partner. the pt's hx 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
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. - ANSWER A confused older adult patient in a skilled nursing
facility was asleep when unlicensed assistive personal (UAP) entered the room
quietly and touched the bed to see if it was wet. the pt awakened and hit the
UAP in the face. which statement best explains the pt's action?
a. older adult pt's often demonstrate
exaggerations of behaviors used earlier in life
b. crowding in skilled nursing facilities increases an individual's tendency
toward violence
c. the pt learned violent behavior by watching other pt's act out
d. the pt interpreted the UAP's behavior as potentially harmful
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. - ANSWER A
pt is pacing the hall near the nurses' station, swearing loudly. an appropraite
initial intervention for the nurse would be to address the pt by name and say:
a. "what is going on?"
b. "please be quite and sit down in his 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."
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. - ANSWER A pt 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 day room. while following the pt
into the day room, the nurse should:
a. make sure there is adequate physical space between the nurse and pt
b. move into a position that places the pt close to the door
c. maintain one arm's- length distance from the pt
d. begin talking to the pt about appropriate behavior
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. - ANSWER An
intramuscular dose of antipsychotic medication needs to be administered to a
pt who is becoming increasingly more aggressive and refused to leave the
dayroom. the nurse should enter the say 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 3 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 pt patient in a basket-hold and they 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 pt, "come to your room
willingly so i can give you this medication, or the guard and i will take you
there."
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. - ANSWER
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
A
