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The nurse is caring for an older patient in a residential care facility. The patient has been extremely irritable the entire day. When modifying the patient?s plan of care, which of the following would be an appropriate snack to offer the patient to decrease the irritability?
- A. Chocolate candy bar
- B. Handful of raisins
- C. Granola bar
- D. Glass of milk
Correct Answer: D
Rationale: A glass of milk is an appropriate snack for an older patient experiencing irritability. Milk contains tryptophan, which can promote calmness by aiding serotonin production. Chocolate candy bars and granola bars may contain high sugar, potentially worsening irritability, while raisins, though healthy, lack the calming nutrients found in milk.
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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 working with a potentially violent patient in a community clinic. Which of the following would the nurse implement to minimize personal risk?
- A. Using protective devices
- B. Staying close to a door
- C. Keeping the door closed to ensure privacy
- D. Wearing inexpensive jewelry to distract the patient
Correct Answer: B
Rationale: Staying close to a door allows the nurse to exit quickly if the situation escalates, minimizing personal risk. Protective devices may not be practical, closing the door reduces escape options, and wearing jewelry could increase risk by attracting attention.
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 nurse is presenting an in-service program about aggression and violence to a group of newly hired nurses who will be working in an inpatient psychiatric facility. When describing characteristics that may predict the risk for violence and aggression in patients, which of the following would the nurse include? Select all that apply.
- A. Age
- B. Impulsivity
- C. Substance withdrawal
- D. Gender
- E. Suspiciousness
Correct Answer: A,B,C,D,E
Rationale: Age, impulsivity, substance withdrawal, gender, and suspiciousness are all predictors of violence risk. Younger age, male gender, impulsivity, withdrawal symptoms, and paranoia or suspiciousness increase the likelihood of aggressive behavior in psychiatric settings.
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.