Answer Choices:
a. Remove jewelry, glasses, and harmful items from the patient and staff members.
b. Appoint a person to clear a path and open, close, or lock doors.
c. Quickly approach the patient and grab the closest extremity.
d. Select the person who will communicate with the patient.
e. Move behind the patient to use the element of surprise.
Answer:
a. Remove jewelry, glasses, and harmful items from the patient and staff members.
b. Appoint a person to clear a path and open, close, or lock doors.
d. Select the person who will communicate with the patient.
Question: The staff development coordinator plans to teach use of physical management techniques when patients become assaultive. Which topic should be emphasized?
Answer Choices:
a. Practice and teamwork
b. Spontaneity and surprise
c. Caution and superior size
d. Diversion and physical outlets
Answer:
a
Question: Confirmation of a history of what scenario from a patient’s record indicates compromised coping skills and the need for careful assessment of the risk for violence?
Answer Choices:
a. Childhood trauma
b. Family involvement
c. Academic problems
d. Daily substance abuse
Answer:
d. Daily substance abuse
Question: A patient with a history of command hallucinations approaches the nurse, yelling obscenities. The patient mumbles and then walks away. The nurse follows. Which nursing actions are most likely to be effective in de-escalating this scenario? (Select all that apply.)
Answer Choices:
a. State the expectation that the patient will stay in control.
b. State that the patient cannot be understood when mumbling.
c. Tell the patient, “You are behaving inappropriately.”
d. Offer to provide the patient with medication to help.
e. Speak in a firm but calm, caring voice.
Answer:
a. State the expectation that the patient will stay in control.
d. Offer to provide the patient with medication to help.
e. Speak in a firm but calm, caring voice.
Question: A cognitively impaired patient has been a widow for 30 years. This patient is frantically trying to leave the unit, saying, “I have to go home to cook dinner before my husband arrives from work.” To intervene with validation therapy, what should the nurse first say?
Answer Choices:
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. “Was your husband angry if you did not have dinner ready on time?”
Answer:
C
Question: Which behaviors are most consistent with the clinical picture of a patient who is becoming increasingly aggressive? (Select all that apply.)
Answer Choices:
a. Pacing
b. Crying
c. Withdrawn affect
d. Rigid posture with clenched jaw
e. Staring with narrowed eyes into the eyes of another
Answer:
a. Pacing
d. Rigid posture with clenched jaw
e. Staring with narrowed eyes into the eyes of another
Question: 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?
Answer Choices:
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
Question: A confused older adult patient in a skilled care facility is sleeping. A health care worker enters the room quietly and touches the bed to see if it is wet. The patient awakens and hits the health care worker in the face. Which statement best explains the patient’s action?
Answer Choices:
a. Older adult patients often demonstrate exaggerations of behaviors used earlier in life.
b. Crowding in skilled care facilities increases individual tendencies toward violence.
c. The patient interpreted the health care worker’s behavior as potentially harmful.
d. This patient learned violent behavior by watching other patients act out.
Answer:
C
Question: After an assault by a patient, a nurse has difficulty sleeping, startles easily, and is preoccupied with the incident. The nurse says, “I dread facing potentially violent patients. They make me so angry” Which response would be the most urgent reason for this nurse to seek supervision?
Answer Choices:
a. Startle reactions
b. Difficulty sleeping
c. Expression of anger
d. Preoccupation with the incident
Answer:
c
Question: Which medication should a nurse administer to provide immediate intervention for a psychotic patient whose aggressive behavior continues to escalate despite verbal intervention?
Answer Choices:
a. Lithium
b. Trazodone
c. Olanzapine
d. Valproic acid
Answer:
c. Olanzapine
Question: A patient is pacing the hall near the nurses’ station and swearing in a loud voice. Which intervention for the nurse would be to address the patient by name and ask?
Answer Choices:
a. “What is going on?”
b. “Quiet down immediately. You are causing a scene.”
c. “You need to walk with me to a conference room and sit down to talk.”
d. “You must go to your room and try to get control of yourself.”
Answer:
C
Question: Which behavior best demonstrates aggression?
Answer Choices:
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
Question: An adult patient assaulted another patient and was restrained. One hour later, which statement by this restrained patient necessitates the nurse’s immediate attention?
Answer Choices:
a. “I hate all of you!”
b. “My fingers are tingly.”
c. “You wait until I tell my lawyer.”
d. “It was not my fault. The other patient started it.”
Answer:
b