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A nurse manager is providing staff education about working with patients who have a history of anger and aggression. Which of the following information should the nurse include in the teaching? What should the nurse include in aggression training?
- A. Stand directly in front of the patient when talking.
- B. Know the layout of the facility.
- C. Bring security with you for all patient interactions.
- D. Provide immediate verbal feedback for escalating behavior.
- E. Avoid wearing necklaces during patient care.
Correct Answer: B,D,E
Rationale: Correct Answer: B, D, E
Rationale:
B: Knowing the layout of the facility is important for quick escape routes and safety measures during a patient's aggressive outburst.
D: Providing immediate verbal feedback for escalating behavior can help in de-escalating the situation and preventing further aggression.
E: Avoiding wearing necklaces during patient care can prevent them from being used as a weapon or trigger for aggressive behavior.
Summary:
A: Standing directly in front of the patient can be confrontational and escalate the situation.
C: Bringing security for all patient interactions may not be feasible or necessary in every situation.
F, G: No additional options are provided, but they would likely be incorrect as they were not included in the correct answer choices.
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A nurse is admitting a patient exhibiting manic behavior. The patient reports recent personal stressors, including the loss of her mother and a divorce. What should be the nurse's priority action? What is the priority action for a manic patient?
- A. Encourage self-care.
- B. Assist the patient in identifying coping behaviors.
- C. Prevent self-directed violence.
- D. Identify support systems.
Correct Answer: C
Rationale: The correct answer is C: Prevent self-directed violence. When dealing with a manic patient, the priority action should always be to ensure the safety of the patient and others. Manic episodes can lead to impulsive and risky behaviors, including self-harm or suicide attempts. By prioritizing the prevention of self-directed violence, the nurse can address the immediate threat to the patient's well-being. Encouraging self-care (choice A) and identifying coping behaviors (choice B) are important aspects of care but may not be the most urgent in this situation. Identifying support systems (choice D) is also valuable but does not address the immediate safety concerns presented by the manic behavior.
A nurse is caring for a patient who has a new prescription for citalopram. Which of the following instructions should the nurse include? What instructions should the nurse include for citalopram?
- A. Take the medication in the morning.
- B. Report any suicidal thoughts.
- C. Avoid foods high in tyramine.
- D. Take the medication with food.
Correct Answer: B
Rationale: The correct answer is B: Report any suicidal thoughts. This is crucial because citalopram is an antidepressant that can increase the risk of suicidal thoughts, especially in the initial stages of treatment. Monitoring and reporting any such thoughts are essential for the patient's safety.
A: Take the medication in the morning - This is incorrect as citalopram can be taken at any time of the day, depending on individual preference and tolerability.
C: Avoid foods high in tyramine - This is incorrect as tyramine restriction is more relevant for MAOIs, not SSRIs like citalopram.
D: Take the medication with food - This is not a specific requirement for citalopram, as it can be taken with or without food.
A nurse is caring for a patient who is receiving mechanical ventilation. Which of the following actions should the nurse take to prevent ventilator-associated pneumonia? Which action prevents ventilator-associated pneumonia?
- A. Perform oral care every 12 hours.
- B. Keep the head of the bed elevated to 30-45 degrees.
- C. Administer antibiotics prophylactically.
- D. Change the ventilator circuit daily.
Correct Answer: B
Rationale: The correct answer is B: Keep the head of the bed elevated to 30-45 degrees. Elevating the head of the bed helps prevent aspiration, which is a significant risk factor for ventilator-associated pneumonia. This position promotes proper lung expansion and drainage of secretions, reducing the likelihood of bacterial growth in the lungs. Performing oral care every 12 hours (A) is important for oral hygiene but does not directly prevent ventilator-associated pneumonia. Administering antibiotics prophylactically (C) can lead to antibiotic resistance and is not recommended routinely. Changing the ventilator circuit daily (D) is important for infection control but does not directly prevent ventilator-associated pneumonia.
A nurse notices a teenage patient with paraplegia in a wheelchair crying. What should the nurse's response be? What should the nurse respond to a crying teenage patient?
- A. I'll return later, and we can talk.
- B. Everything will be okay.
- C. Do you feel like crying helps?
- D. Would you like to be alone?
Correct Answer: A
Rationale: The correct answer is A: "I'll return later, and we can talk." This response acknowledges the patient's emotions, offers support, and opens the door for communication. It shows empathy and a willingness to engage with the patient. Choice B is dismissive and lacks empathy. Choice C may come across as invalidating the patient's feelings. Choice D may make the patient feel isolated. Overall, choice A is the most appropriate as it shows empathy, support, and a willingness to listen to the patient's concerns.
A nurse is caring for a patient who frequently tries to remove his IV catheter. A family member asks the nurse to apply restraints. What should the nurse's response be? What should the nurse respond to a request for restraints?
- A. I will call the doctor and get a prescription.
- B. I will cover the catheter so he can't see it.
- C. Let's wait until tonight to see if he continues this behavior.
- D. I will apply the restraints immediately.
Correct Answer: B
Rationale: The correct answer is B: "I will cover the catheter so he can't see it." This response addresses the root cause of the patient's behavior by removing the visual stimulus that may be prompting the patient to try to remove the IV catheter. By covering the catheter, the patient may be less likely to attempt to remove it. This approach is non-invasive and respects the patient's autonomy while also ensuring the safety of the IV site.
Choice A is incorrect because applying restraints should not be the first course of action without exploring less restrictive alternatives. Choice C delays addressing the issue and risks harm to the patient. Choice D is incorrect as applying restraints immediately is a more invasive intervention that should only be considered after less restrictive measures have been attempted.