Nokea
The nurse decides to place an aggressive and violent client in mechanical restraints. The nurse bases this decision on which of the following?
- A. Client's mood
- B. Client's safety
- C. Court order
- D. Physician's order
Correct Answer: B
Rationale: Restraints are used when the client's safety is at risk and less restrictive measures fail, not based on mood, court, or physician orders alone.
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A client suddenly jumps up from the chair and begins yelling and cursing at the nurse. Which would be the best response by the nurse?
- A. I can see that you need attention, you should calmly ask for what you want
- B. I don't want to hear that kind of language, don't ever do that again.
- C. I will limit your smoking privileges if you can't control yourself
- D. You seem angry. Tell me more about how you're feeling
Correct Answer: D
Rationale: Acknowledging the client's anger and encouraging verbal expression promotes de-escalation, unlike punitive responses or assumptions about needs.
Which is most likely to be the subject of an aggressive attack from a client with mental illness?
- A. Other people
- B. The client
- C. Animals
- D. Objects
Correct Answer: B
Rationale: Clients with mental illness are more likely to harm themselves than others, animals, or objects due to internal distress or self-directed aggression.
The client with a history of explosive outbursts becomes angry and states, 'I am really getting angry.' The nurse sees this as
- A. Controlling
- B. Manipulation
- C. Progress
- D. Regression
Correct Answer: C
Rationale: Verbalizing anger is progress, indicating self-awareness and control, unlike manipulation or regression, which involve different behavioral patterns.
Anger management is likely to be included in the care of clients with which of the following psychiatric diagnoses?
- A. Alzheimer's dementia
- B. Schizophrenia
- C. Anorexia nervosa
- D. Acute alcohol intoxication
- E. Generalized anxiety disorder
Correct Answer: A,B,D
Rationale: Clients with Alzheimer's dementia, schizophrenia, or acute alcohol intoxication may exhibit aggression due to cognitive impairments or delusions, requiring anger management, unlike anorexia or anxiety.
A client approaches the nurse and loudly states, 'I'm not putting up with this anymore!' The most appropriate response by the nurse would be which of the following?
- A. I can see you are angry. Tell me what's going on
- B. You are not allowed to make threats. Please keep your voice down.
- C. Why do you say that?
- D. You are here voluntarily. You can leave if you want
Correct Answer: A
Rationale: Recognizing the client's anger and inviting discussion in a calm, nonthreatening manner helps de-escalate during the triggering phase, unlike dismissing or challenging.