Nokea
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.
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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.'
Correct Answer: C
Rationale: Intervention should begin with an analysis of the patient and situation. With the correct response, the nurse is attempting to hear the patient's feelings and concerns, which leads to the next step of planning an intervention. The incorrect responses are authoritarian, creating a power struggle between the patient and nurse.
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
Correct Answer: A
Rationale: Intervention techniques are learned behaviors that must be practiced to be used in a smooth, organized fashion. Every member of the intervention team should be assigned a specific task to carry out before beginning the intervention. The other options are useless if the staff does not know how to use physical techniques and how to apply them in an organized fashion.
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?
- 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?'
Correct Answer: C
Rationale: Validation therapy meets the patient 'where she or he is at the moment' and acknowledges the patient's wishes. Validation does not seek to redirect, reorient, or probe. The incorrect options do not validate the patient's feelings.
A patient being admitted suddenly pulls a knife from a coat pocket and threatens, 'I will kill anyone who tries to get near me.' An emergency code is called. The patient is safely disarmed and placed in seclusion. What is the justification for the use of seclusion?
- A. Patient demonstrates a thought disorder, rendering rational discussion ineffective.
- B. Patient's actions present a clear and present danger to others.
- C. Patient demonstrates an apparent and plausible escape risk.
- D. Patient's actions display features of psychotic thinking.
Correct Answer: B
Rationale: The patient's threat to kill self or others with the knife he possesses constitutes a clear and present danger to self and others. The distractors are not sufficient reasons for seclusion.
Which behavior best demonstrates aggression?
- A. Stomping away from the nurses' station, darting to another room, and grabbing a snack from 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'
Correct Answer: A
Rationale: Aggression is harsh physical or verbal action that reflects rage, hostility, and the potential for physical or verbal destructiveness. Aggressive behavior violates the rights of others. The incorrect options do not feature violation of another's rights.