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Which action often triggers an episode of violence or aggression in a patient with a psychiatric diagnosis involving violent behavior?
- A. Obtaining a history
- B. Asking for input into care
- C. Enforcing rules
- D. Taking a walk
Correct Answer: C
Rationale: Enforcing rules is often a trigger for patients with psychiatric diagnoses involving violent behavior. Limit-setting or denying patient demands can be perceived as control and intimidation, leading to aggressive responses. Nursing staff must respond calmly and professionally to prevent escalation. Avoiding such patients or matching their emotions can worsen the situation. Therefore, enforcing rules can provoke violent episodes in these patients.
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Which nursing action promotes psychosocial development for a newborn?
- A. Washing hands before holding the newborn
- B. Measuring the newborn using an approved length board
- C. Weighing the newborn on the same scale during hospitalization
- D. Placing the newborn in the mother's arms during the first hour of life
Correct Answer: D
Rationale: Placing the newborn in the mother's arms during the first hour of life is a crucial nursing action that promotes psychosocial development by fostering bonding between the newborn and the mother. This skin-to-skin contact enhances emotional attachment, facilitates breastfeeding initiation, and provides a sense of security for the newborn. It helps in regulating the newborn's temperature, heart rate, and breathing, promoting overall well-being.
Washing hands before holding the newborn is essential for infection prevention and control to maintain the newborn's health and safety. Measuring the newborn using an approved length board and weighing the newborn on the same scale during hospitalization are assessments aimed at monitoring the newborn's physical growth and development, rather than directly promoting psychosocial well-being.
The nurse notes bruises on the pregnant client's face and abdomen. There are no bruises on her legs and arms. Further assessment is required to confirm which condition?
- A. Domestic abuse
- B. Hydatidiform mole
- C. Excessive exercise
- D. Thrombocytopenic purpura
Correct Answer: A
Rationale: Domestic abuse is a serious concern during pregnancy as it can escalate, and the bruises on the face and abdomen may indicate physical violence towards the pregnant woman. Hydatidiform mole presents with symptoms like an enlarged uterus for gestational age, hypertension, nausea, vomiting, and vaginal bleeding, not bruises. Excessive exercise typically leads to cardiovascular or pulmonary issues, not bruising. Thrombocytopenic purpura and other bleeding disorders usually present with bruises and petechiae on various body surfaces, not just limited to the face and abdomen.
Which nurse statement defines boundaries in the orientation phase of the nurse-client relationship when talking to a depressed client who has just been admitted to the psychiatric unit?
- A. ''Tell me about the relationship that you have with your mother and father.''
- B. ''Hello! I'm Nurse Andrea. I'll introduce you around and help you settle in.''
- C. ''What is the main thing that you would like to work on during therapy?'
- D. ''I understand that you have been depressed. What can you tell me about that?'
Correct Answer: B
Rationale: In the orientation phase of the nurse-client relationship, setting boundaries involves establishing the nurse's role and responsibilities while maintaining a professional distance. Option B demonstrates a clear boundary by introducing the nurse and offering assistance with settling in, which is appropriate for the initial phase of building rapport with the client. Choices A, C, and D delve into personal or therapeutic topics that are more suitable for the working phase of the relationship when the client's goals and problems are being addressed. Asking about the client's family relationships (Choice A), therapy focus (Choice C), or delving into the client's depression (Choice D) would be more relevant in later stages of the therapeutic process, once trust and rapport have been established during the orientation phase.
A terminally ill client repeatedly talks about her son's upcoming wedding and how much she wants to attend. Which stage of the Kübler-Ross theory of death and dying is the client displaying?
- A. Anger
- B. Denial
- C. Bargaining
- D. Acceptance
Correct Answer: C
Rationale: The client is displaying the stage of bargaining in the Kübler-Ross theory of death and dying. During the bargaining stage, individuals attempt to negotiate for more time or a different outcome in the face of impending death. In this scenario, the client expressing a desire to attend her son's wedding and discussing it frequently reflects a form of bargaining for additional time to be present for the event. Anger, on the other hand, involves extreme expressions of emotion ranging from irritation to rage. Denial is characterized by an inability to accept the reality of the situation. Acceptance signifies coming to terms with the circumstances and may lead to decreased interest in people and surroundings.
Which of the following medications would NOT be an appropriate prn medication for use during an episode of aggression or violence for the patient with a psychiatric diagnosis?
- A. Olanzapine
- B. Meperidine
- C. Ziprasidone
- D. Haloperidol
Correct Answer: B
Rationale: Meperidine is an opioid used to treat pain and is not suitable for managing aggressive or violent behavior in patients with psychiatric diagnoses. Olanzapine, ziprasidone, and haloperidol are appropriate choices for managing aggression or violence. Olanzapine and ziprasidone are second-generation antipsychotic medications, while haloperidol is a traditional antipsychotic. These medications have demonstrated effectiveness in managing aggressive behavior, with or without the adjunctive use of a benzodiazepine. Meperidine's primary indication is for pain relief, making it unsuitable for managing psychiatric-related aggression or violence.