Nokea
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.
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A patient with a history of anger and impulsivity is hospitalized after an accident resulting in injuries. When in pain, the patient loudly scolds the nurse for 'not knowing enough to give me pain medicine when I need it.' Which intervention would best address this problem?
- A. Tell the patient to notify the nurse 30 minutes before the pain returns so the medication can be prepared.
- B. Urge the health care provider to change the prescription for pain medication from as needed to a regular schedule.
- C. Tell the patient that verbal assaults on nurses will not shorten the wait for pain medication.
- D. Have the clinical nurse leader request a psychiatric consultation.
Correct Answer: B
Rationale: Scheduling the medication at specific intervals will help the patient anticipate when the medication can be given. Receiving the medication promptly on schedule, rather than expecting nurses to anticipate the pain level, should reduce anxiety and anger. The patient cannot predict the onset of pain before it occurs.
After an assault by a patient, a nurse has difficulty sleeping, startles easily, and is preoccupied with the incident. The nurse says, 'I dread facing potentially violent patients. They make me so angry.' Which response would be the most urgent reason for this nurse to seek supervision?
- A. Startle reactions
- B. Difficulty sleeping
- C. Expression of anger
- D. Preoccupation with the incident
Correct Answer: C
Rationale: The expression of patient-focused anger signals an urgent need for professional supervision to work through anger and counter the aggressive feelings. The distractors are normal in a person who has been assaulted. Nurses are usually relieved with crisis intervention and follow-up designed to give support, help the individual regain a sense of control, and make sense of the event.
Which medication should a nurse administer to provide immediate intervention for a psychotic patient whose aggressive behavior continues to escalate despite verbal intervention?
- A. Lithium
- B. Trazodone
- C. Olanzapine
- D. Valproic acid
Correct Answer: C
Rationale: Olanzapine is a short-acting antipsychotic drug that is useful in calming angry, aggressive patients regardless of their diagnosis. The other drugs listed require long-term use to reduce anger. Lithium is for patients with bipolar disorder. Trazodone is for patients with depression, insomnia, or chronic pain. Valproic acid is for patients with bipolar disorder or borderline personality disorder.
A patient with a history of command hallucinations approaches the nurse, yelling obscenities. The patient mumbles and then walks away. The nurse follows. Which nursing actions are most likely to be effective in de-escalating this scenario? (Select all that apply.)
- A. State the expectation that the patient will stay in control.
- B. State that the patient cannot be understood when mumbling.
- C. Tell the patient, 'You are behaving inappropriately.'
- D. Offer to provide the patient with medication to help.
- E. Speak in a firm but calm, caring voice.
Correct Answer: A,D,E
Rationale: Stating the expectation that the patient will maintain control of behavior reinforces positive, healthy behavior, and avoids challenging the patient. Offering an as-needed medication provides support for the patient trying to maintain control. A firm but calm voice will likely comfort and calm the patient. Belittling remarks may lead to aggression. Criticism will probably prompt the patient to begin shouting.
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.