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The nurse is caring for a family whose older father with dementia is living in their home. The nurse has instructed the family about how to decrease the father?s agitation. The nurse determines that the son has understood the nurse?s instructions when he states which of the following?
- A. Restraints can help reduce my father?s agitation.
- B. I should place my father in the bedroom with me so I can watch him more closely.
- C. It?s important that he gets out shopping with me or my wife.
- D. If I simplify our home environment, my father may be less agitated.
Correct Answer: D
Rationale: Simplifying the home environment reduces sensory overload, which can decrease agitation in patients with dementia. Restraints can increase agitation, close monitoring in a bedroom may not address triggers, and shopping outings may overstimulate the patient.
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While talking with a patient who has been experiencing aggression and intense anger, the nurse identifies that the patient feels isolation and anxious. Which statement by the nurse would be most appropriate?
- A. This must be scary for you.
- B. Once you relax, things will improve.
- C. I really understand how you feel.
- D. If you calm down, I can help you.
Correct Answer: A
Rationale: Acknowledging the patient?s fear validates their emotions and builds rapport, which is therapeutic for someone feeling isolated and anxious. The other statements may dismiss the patient?s feelings or imply they must change before receiving help, which could escalate agitation.
The nurse is reviewing the medical record of a patient who is experiencing aggressive and violent behavior for possible risk factors. Which of the following would the nurse identify? Select all that apply.
- A. Damage to the frontal lobe of the brain
- B. Low testosterone levels
- C. Family history of aggression
- D. Gender
- E. High level of competitiveness
Correct Answer: A,C
Rationale: Damage to the frontal lobe can impair impulse control, increasing aggression risk. A family history of aggression suggests genetic or environmental predisposition. Low testosterone is less associated with aggression, gender alone is not a specific risk factor, and competitiveness is not a direct predictor.
A unit in an inpatient psychiatric facility is experiencing an increase in violence episodes by patients. A group of nurses working on this unit is developing a plan to address this issue. When developing this plan which of the following would the nurses most likely address as the problem areas? Select all that apply.
- A. Inconsistent unit activities
- B. Medication power struggles
- C. Empathetic staff response
- D. Clear set boundaries
- E. Little patient participation in treatment plan
Correct Answer: A,B,E
Rationale: Inconsistent unit activities, medication power struggles, and little patient participation in treatment plans can contribute to increased violence by creating uncertainty, conflict, or disengagement. Empathetic staff responses and clear boundaries are protective factors, not problem areas.
A patient has been admitted to the detoxification unit after binge drinking. Even though the patient is not currently intoxicated, he is combative and exhibits altered thought processes. Which nursing diagnosis would be the priority?
- A. Risk for Injury related to effects of alcohol abuse
- B. Risk for Self-Mutilation related to alcohol withdrawal and altered thought processes
- C. Risk for Other-Directed Violence related to alcohol withdrawal
- D. Risk for Delayed Development related to chronic effects of alcohol intoxication
Correct Answer: C
Rationale: The priority nursing diagnosis is 'Risk for Other-Directed Violence related to alcohol withdrawal,' as the patient?s combative behavior and altered thought processes pose an immediate risk to others. Safety is the primary concern in this scenario, outweighing risks for injury, self-mutilation, or developmental delays.
A son brings his father to the clinic and tells the nurse that his father has begun to act strangely in the past few days and has unprovoked outbursts of anger. After the incidents, the father expresses remorse for his outburst. The son says, I?ve never seen him act this way. Which question would be most appropriate for the nurse to ask next?
- A. Does your father have a history of an anxiety disorder such as panic disorder?
- B. Has your father exhibited previous problems expressing anger appropriately?
- C. Has your father suffered any traumatic injury to his brain recently?
- D. Has your father injured the back of his head or neck in the past week?
Correct Answer: C
Rationale: Asking about recent traumatic brain injury is most appropriate, as sudden behavioral changes, such as unprovoked anger outbursts in an older adult with no prior history, may indicate a neurological issue, such as a brain injury. The other options are less likely to explain the sudden onset of symptoms.