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An intramuscular dose of antipsychotic medication needs to be administered to a patient who is becoming increasingly more aggressive. The patient is in the day room where there are other patients. When entering the day room what response should the nurse make?
- A. States, 'Would you like to come to your room and take some medication your doctor prescribed for you?'
- B. Accompanied by three staff members and states, 'Please come to your room so I can give you some medication that will help you feel more comfortable.'
- C. Initiates process to place the patient in a basket-hold and then state, 'I am going to take you to your room to give you an injection of medication to calm you.'
- D. Accompanied by two security guards and tell the patient, 'You can come to your room willingly so I can give you this medication or the security guards will take you there.'
Correct Answer: B
Rationale: A patient gains feelings of security if he or she sees that others are present to help with control. The nurse gives a simple direction, honestly states what is going to happen, and reassures the patient that the intervention will be helpful. This positive approach assumes that the patient can act responsibly and will maintain control. Physical control measures should be used only as a last resort. The security guards are likely to intimidate the patient and increase feelings of vulnerability.
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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 nurse directs the intervention team who must take an aggressive patient to seclusion. Other patients were removed from the area. Before approaching the patient, the nurse should ensure that which actions are taken by staff? (Select all that apply.)
- A. Remove jewelry, glasses, and harmful items from the patient and staff members.
- B. Appoint a person to clear a path and open, close, or lock doors.
- C. Quickly approach the patient and grab the closest extremity.
- D. Select the person who will communicate with the patient.
- E. Move behind the patient to use the element of surprise.
Correct Answer: A,B,D
Rationale: Injury to staff members and to the patient should be prevented. Only one person should explain what will happen and direct the patient; this person might be the nurse or staff member who has a good relationship with the patient. A clear pathway is essential; those restraining a limb cannot use keys, move furniture, or open doors. The nurse is usually responsible for administering the medication once the patient is restrained. Each staff member should have an assigned limb rather than just grabbing the closest limb. This system could leave one or two limbs unrestrained. Approaching in full view of the patient reduces suspicion.
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.
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.