Nokea
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.
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Which assessment finding presents the greatest risk for violent behavior?
- A. Severe agoraphobia
- B. A history of intimate partner violence
- C. Reports of bizarre somatic delusions
- D. Verbalization of hopelessness and powerlessness
Correct Answer: B
Rationale: A history of prior aggression or violence is the best predictor of patients who may become violent. Patients diagnosed with anxiety disorders are not particularly prone to violence unless panic occurs. Patients experiencing hopelessness and powerlessness may have coexisting anger, but violence is not often demonstrated. Patients experiencing paranoid delusions are at greater risk for violence than those with bizarre somatic delusions.
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.
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.
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.
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.