Nokea
Which scenario predicts the highest risk for directing violent behavior toward others?
- A. Major depressive disorder with delusions of worthlessness
- B. Obsessive-compulsive disorder; performing many rituals
- C. Paranoid delusions of being followed by a military attack team
- D. Completion of alcohol withdrawal and beginning a rehabilitation program
Correct Answer: C
Rationale: The correct answer illustrates the greatest disruption of ability to perceive reality accurately. People who feel persecuted may strike out against those believed to be persecutors. The patients identified in the distractors have better reality-testing ability.
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A patient is pacing the hall near the nurses' station and swearing loudly. An appropriate initial intervention for the nurse would be to address the patient by name and say what?
- A. What is going on?'
- B. Quiet down immediately. You are scaring others.'
- C. I'd like to talk with you about how you're feeling right now.'
- D. You must go to your room and try to get control of yourself.'
Correct Answer: C
Rationale: Intervention should begin with an analysis of the patient and situation. With the correct response, the nurse is attempting to hear the patient's feelings and concerns, which leads to the next step of planning an intervention. The incorrect responses are authoritarian, creating a power struggle between the patient and nurse.
A confused older adult patient in a skilled care facility is sleeping. A health care worker enters the room quietly and touches the bed to see if it is wet. The patient awakens and hits the health care worker in the face. Which statement best explains the patient's action?
- A. Older adult patients often demonstrate exaggerations of behaviors used earlier in life.
- B. Crowding in skilled care facilities increases individual tendencies toward violence.
- C. The patient interpreted the health care worker's behavior as potentially harmful.
- D. This patient learned violent behavior by watching other patients act out.
Correct Answer: C
Rationale: Confused patients are not always able to evaluate accurately the actions of others. This patient behaved as though provoked by the intrusive actions of the staff member.
A patient being admitted suddenly pulls a knife from a coat pocket and threatens, 'I will kill anyone who tries to get near me.' An emergency code is called. The patient is safely disarmed and placed in seclusion. What is the justification for the use of seclusion?
- A. Patient demonstrates a thought disorder, rendering rational discussion ineffective.
- B. Patient's actions present a clear and present danger to others.
- C. Patient demonstrates an apparent and plausible escape risk.
- D. Patient's actions display features of psychotic thinking.
Correct Answer: B
Rationale: The patient's threat to kill self or others with the knife he possesses constitutes a clear and present danger to self and others. The distractors are not sufficient reasons for seclusion.
A cognitively impaired patient has been a widow for 30 years. This patient is frantically trying to leave the unit, saying, 'I have to go home to cook dinner before my husband arrives from work.' To intervene with validation therapy, what should the nurse first say?
- A. You must come away from the door.'
- B. You have been a widow for many years.'
- C. You want to go home to prepare your husband's dinner?'
- D. Was your husband angry if you did not have dinner ready on time?'
Correct Answer: C
Rationale: Validation therapy meets the patient 'where she or he is at the moment' and acknowledges the patient's wishes. Validation does not seek to redirect, reorient, or probe. The incorrect options do not validate the patient's feelings.
A patient is hospitalized after an arrest for breaking windows in the home of a former intimate partner. The history reveals childhood abuse by a punitive parent, torturing family pets, and an arrest for disorderly conduct. Which nursing diagnosis has priority?
- A. Risk for injury
- B. Post-trauma response
- C. Disturbed thought processes
- D. Risk for other-directed violence
Correct Answer: D
Rationale: The defining characteristics for risk for other-directed violence include a history of being abused as a child, having committed other violent acts, and demonstrating poor impulse control. The defining characteristics for the other diagnoses are not present in this scenario.