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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 interviewing a patient, a nurse asks, What do you do when you get angry? Which patient response would indicate to the nurse that the patient engages in anger suppression?
- A. I?ve been known to fly off the handle when I?m angry.
- B. People say I withdraw and pout about the problem.
- C. I usually approach the person directly to talk about it.
- D. I try to discuss how I?m feeling about it with a close friend.
Correct Answer: B
Rationale: Withdrawing and pouting indicate anger suppression, as the patient avoids expressing anger directly. Flying off the handle suggests explosive anger, while direct discussion or confiding in a friend indicates healthier anger expression.
The nurse is caring for an older adult patient who has no history of violence but is agitated and appears ready to strike out at a staff member. The nurse would assess the patient for which of the following?
- A. Panic disorder
- B. Epilepsy
- C. Bipolar disorder
- D. Sensory losses
Correct Answer: D
Rationale: Sensory losses, such as hearing or vision impairment, are common in older adults and can lead to agitation or perceived aggression due to frustration or miscommunication. Panic disorder, epilepsy, or bipolar disorder are less likely causes without additional symptoms or history.
The plan of a care for a patient with anger includes behavioral interventions. Which of the following would the nurse be likely to find?
- A. Self-monitoring of cues
- B. Anger management
- C. Relaxation training
- D. Response disruption
Correct Answer: A
Rationale: Self-monitoring of cues is a common behavioral intervention to help patients recognize triggers and manage anger before it escalates. While anger management and relaxation training are also relevant, self-monitoring is a specific, proactive strategy likely included in the care plan.
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.
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.