Nokea
A patient is hospitalized after an arrest for breaking windows in the home of a former intimate partner. The history reveals childhood abuse by a punitive parent, torturing family pets, and an arrest for disorderly conduct. Which nursing diagnosis has priority?
- A. Risk for injury
- B. Post-trauma response
- C. Disturbed thought processes
- D. Risk for other-directed violence
Correct Answer: D
Rationale: The defining characteristics for risk for other-directed violence include a history of being abused as a child, having committed other violent acts, and demonstrating poor impulse control. The defining characteristics for the other diagnoses are not present in this scenario.
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A patient diagnosed with pneumonia has been hospitalized for 4 days. Family members describe the patient as 'a difficult person who finds fault with everyone.' The patient verbally abuses nurses for providing poor care. What is the most likely explanation for this behavior?
- A. Poor child-rearing that did not teach respect for others.
- B. Automatic thinking, leading to cognitive distortion.
- C. Personality style that externalizes problems.
- D. Delusions that others wish to deliver harm.
Correct Answer: C
Rationale: Patients whose personality style causes them to externalize blame see the source of their discomfort and anxiety as being outside themselves. They displace anger and are often unable to soothe themselves. The incorrect options are less likely to have a bearing on this behavior.
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.
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.
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 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.