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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?
- 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
Correct Answer: A
Rationale: 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 is not wise. 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.
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When a patient's aggression quickly escalates, which principle applies to the selection of nursing interventions?
- A. Staff members should match the patient's affective level and tone of voice.
- B. Ask the patient what intervention would be most helpful.
- C. Immediately use physical containment measures.
- D. Begin with the least restrictive measure possible.
Correct Answer: D
Rationale: Standards of care require that staff members use the least restrictive measure possible. This becomes the guiding principle for intervention. Physical containment is seldom the least restrictive measure. Asking the out-of-control patient what to do is rarely helpful. It may be an effective strategy during the pre-assaultive phase but is less effective during escalation.
Which behaviors are most consistent with the clinical picture of a patient who is becoming increasingly aggressive? (Select all that apply.)
- A. Pacing
- B. Crying
- C. Withdrawn affect
- D. Rigid posture with clenched jaw
- E. Staring with narrowed eyes into the eyes of another
Correct Answer: A,D,E
Rationale: Crying and a withdrawn affect are not cited by experts as behaviors indicating that the individual has a high potential to behave violently. The other behaviors are consistent with the increased risk for other-directed violence.
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 with burn injuries has demonstrated good coping skills for several weeks. Today, a new nurse is poorly organized and does not follow the patient's usual schedule. By mid-afternoon, the patient is angry and loudly complains to the nurse manager. Which is the nurse manager's best response?
- A. Explain the reasons for the disorganization and take over the patient's care for the rest of the shift.
- B. Acknowledge and validate the patient's distress and ask, 'What would you like to have happen?'
- C. Apologize and explain that the patient will have to accept the situation for the rest of the shift.
- D. Ask the patient to control the anger and explain that allowances must be made for new staff members.
Correct Answer: B
Rationale: When a patient with good coping skills is angry and overwhelmed, the goal is to reestablish a means of dealing with the situation. The nurse should solve the problem with the patient's input by acknowledging the patient's feelings, validating them as understandable, apologizing if necessary, and then seeking an acceptable solution. Often patients can tell the nurse what they would like to have happen as a reasonable first step.
A patient with severe physical injuries is irritable, angry, and belittles the nurses. As a nurse changes a dressing, the patient screams, 'Don't touch me! You are so stupid. You will make it worse!' Which intervention uses a cognitive technique to help this patient?
- A. Discontinue the dressing change without comments and leave the room.
- B. Stop the dressing change, saying, 'Perhaps you would like to change your own dressing.'
- C. Continue the dressing change, saying, 'Do you know this dressing change is needed so your wound will not get infected?'
- D. Continue the dressing change, saying, 'Unfortunately, you have no choice. Your doctor ordered this dressing change.'
Correct Answer: C
Rationale: Anger is cognitively driven. The correct answer helps the patient test his cognitions and may help lower his anger. The incorrect options will escalate the patient's anger by belittling or escalating the patient's sense of powerlessness.