Nokea
A new patient immediately requires seclusion on admission. The assessment is incomplete, and the health care provider has not examined the patient. Immediately after safely secluding the patient, which action has priority?
- A. Provide an opportunity for the patient to go to the bathroom.
- B. Notify the health care provider and obtain a seclusion order.
- C. Notify the hospital risk manager.
- D. Debrief the staff.
Correct Answer: B
Rationale: Emergency seclusion can be affected by a credentialed nurse but must be followed by securing a medical order within the period specified by the state and agency. The incorrect options are not immediately necessary from a legal standpoint.
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Which is an effective nursing intervention to assist an angry patient to learn to manage anger without violence?
- A. Help the patient identify a thought that increases anger, find proof for or against 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 when the patient feels angry.
Correct Answer: A
Rationale: Anger has a strong cognitive component; therefore, using cognition to manage anger is logical. The incorrect options do nothing to help the patient learn anger management.
Because an intervention is required to control a patient's aggressive behavior, a critical incident debriefing takes place. Which topics should be the focus of the discussion? (Select all that apply.)
- A. Patient behavior associated with the incident
- B. Genetic factors associated with aggression
- C. Intervention techniques used by staff
- D. Effect of environmental factors
- E. Review of theories of aggression
Correct Answer: A,C,D
Rationale: The patient's behavior, the intervention techniques used, and the environment in which the incident occurred are important to establish realistic outcomes and effective nursing interventions. Discussing the views about the theoretical origins of aggression is less effective.
A patient with 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.
- D. Administer lorazepam every 4 hours to reduce the patient's anxiety.
Correct Answer: B
Rationale: Identifying trigger incidents allows the patient and nurse to plan interventions to reduce irritation and frustration that lead to acting out anger and to put more adaptive coping strategies eventually into practice. None of the other options allow for self-reflection and understanding of the causes of the aggressive behavior.
An adult patient assaulted another patient and was restrained. One hour later, which statement by this restrained patient necessitates 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. It was not my fault. The other patient started it.'
Correct Answer: B
Rationale: The correct response indicates impaired circulation and necessitates the nurse's immediate attention. The incorrect responses indicate that the patient has continued aggressiveness and agitation.
A nurse directs the intervention team who must take an aggressive patient to seclusion. Other patients were removed from the area. Before approaching the patient, the nurse should ensure that which actions are taken by staff? (Select all that apply.)
- 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.
Correct Answer: A,B,D
Rationale: Injury to staff members and to the patient should be prevented. Only one person should explain what will happen and direct the patient; this person might be the nurse or staff member who has a good relationship with the patient. A clear pathway is essential; those restraining a limb cannot use keys, move furniture, or open doors. The nurse is usually responsible for administering the medication once the patient is restrained. Each staff member should have an assigned limb rather than just grabbing the closest limb. This system could leave one or two limbs unrestrained. Approaching in full view of the patient reduces suspicion.