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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.
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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 with a history of impulsively acting out anger by striking others. Which would be an appropriate plan for avoiding such incidents?
- A. Explain that restraint and seclusion will be used if violence occurs.
- B. Help the patient identify incidents that trigger impulsive acting out.
- C. Offer one-on-one supervision to help the patient maintain control.
- D. Administer lorazepam every 4 hours to reduce the patient's anxiety.
Correct Answer: B
Rationale: Identifying trigger incidents allows the patient and nurse to plan interventions to reduce irritation and frustration that lead to acting out anger and to put more adaptive coping strategies eventually into practice. None of the other options allow for self-reflection and understanding of the causes of the aggressive behavior.
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 sits in silence for 20 minutes after a therapy appointment, appearing tense and vigilant. The patient abruptly stands and paces back and forth, clenching and unclenching fists, and then stops and stares in the face of a staff member. What is the likely conclusion regarding the patient's behavior?
- A. Patient is demonstrating withdrawal behaviors.
- B. Patient is trying to work through angry feelings.
- C. Patient is attempting to use relaxation strategies.
- D. Patient is exhibiting clues to potential aggression.
Correct Answer: D
Rationale: The description of the patient's behavior shows the classic signs of someone whose potential for aggression is increasing. None of the other options are supported by the behavior.
Which behavior best demonstrates aggression?
- A. Stomping away from the nurses' station, darting to another room, and grabbing a snack from from another patient
- B. Bursting into tears, leaving the community meeting, and sitting on a bed hugging a pillow and sobbing
- C. Telling the primary nurse, 'I felt angry when you said I could not have a second helping at lunch'
- D. Telling the medication nurse, 'I am not going to take that or any other medication you try to give me'
Correct Answer: A
Rationale: Aggression is harsh physical or verbal action that reflects rage, hostility, and the potential for physical or verbal destructiveness. Aggressive behavior violates the rights of others. The incorrect options do not feature violation of another's rights.