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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.
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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.
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.
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.
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.
Which scenario predicts the highest risk for directing violent behavior toward others?
- A. Major depressive disorder with delusions of worthlessness
- B. Obsessive-compulsive disorder; performing many rituals
- C. Paranoid delusions of being followed by a military attack team
- D. Completion of alcohol withdrawal and beginning a rehabilitation program
Correct Answer: C
Rationale: The correct answer illustrates the greatest disruption of ability to perceive reality accurately. People who feel persecuted may strike out against those believed to be persecutors. The patients identified in the distractors have better reality-testing ability.