Priority Action
A nurse is caring for a client who is speaking in a loud voice with clenched fists. Which of the following actions should the nurse take?
a. Insist the client stop yelling.
b. Request that other staff members remain close by.
c. Move as close to the client as possible.
d. Walk away from the client.
b. Request that other staff members remain close by to assist if necessary.
A charge nurse is conducting a class on therapeutic communication with a group of newly licensed nurses. Which of the following aspects of communication should the nurse identify as a component of verbal communication?
a. Personal space
b. Posture
c. Eye contact
d. Intonation
d. Identify intonation as a component of verbal communication. Intonation is the tone of one’s voice and can communicate a variety of feelings.
What are examples of types of aggression? Select all that apply.
a. Expressing feelings about one’s disorder in a firm tone
b. Instrumental
c. Fear driven
d. Irritable
b, c, d: Instrumental is aggressive behavior intended to achieve a goal. Fear driven aggressive behavior is often the result of insecurity or anxiety. Irritable aggression is usually an outlet for frustration or anxiety and should be monitored as it can easily escalate.
A client commits an act of violence towards a clinician. What form of aggressive disorder is presented in this situation?
a. Pre-assaultive
b. Assaultive
c. Post assaultive
b. The cause of assaultive behavior is often the result of disease processes and/or behavioral causes. A physical act is considered assault.
A nurse is caring for a client in an inpatient mental health facility who gets up from a chair and throws it across the day room as patients watch. Which of the following is the priority nursing action?
a. Encourage the client to express feelings out loud
b. Maintain eye contact with the client
c. Move the client away from others
d. Tell the client that the behavior is not acceptable
c. The behavior indicates that the client is at greatest risk for harming others. The priority action for the nurse is to move the client away from others.
A nurse is caring for a client who is screaming at staff members and other clients. Which of the following is a therapeutic response by the nurse to the client?
a. “Stop screaming, and walk with me outside.”
b. “Why are you so angry and screaming at everyone?”
c. “You will not get your way by screaming.”
d. “What was going through your mind when you started screaming?”
a. This is an appropriate therapeutic response. Setting limits and the use of physical activity (walking) to deescalate anger is an appropriate intervention.
What are examples of Comorbidities related to aggressive behavior? Select all that apply.
a. Congestive Heart Failure
b. Substance abuse disorders
c. Personality Disorders
d. Chronic Obstructive Pulmonary Disorder
e. Post Traumatic Stress Disorder (PTSD)
b, c, e: All of these disorders can affect rational thinking and can lead to aggressive behavior.
A nurse is caring for a client who has a new diagnosis of colon cancer. Shortly after the client receives the diagnoses the nurse enters the client’s room and the client begins yelling. I have received terrible care here and no one cares about me. The nurse should recognize that the client is demonstrating which of the following defense mechanisms?
a. Denial
b. Displacement
c. Reaction Formation
d. Projection
b. The nurse should identify displacement as the redirection of thoughts, feelings, and impulses from an object that causes anxiety to a safer, more acceptable one. In this scenario, the client is redirecting his anxiety about the diagnosis to the staff that is providing care
A nurse is caring for a child who has conduct disorder and is behaving in a destructive manner, throwing objects and kicking others. Which of the following therapeutic nursing interventions is the priority?
a. Encourage expression of feelings
b. Promote attendance at an assertiveness training group
c. Assist the client to perform relaxation breathing
d. Reduce environmental stimuli
d. The greatest risk to the child and others is harm. Therefore, the nurse's priority intervention is to reduce environmental stimuli in an attempt to de-escalate the behavior and prevent injury
A nurse is talking with the caregiver of a child who has demonstrated recent changes in behavior and mood. When the caregiver of the child asks the nurse for reassurance about their child’s condition, which of the following responses should the nurse make?
a. “I think your child is getting better. What have you noticed?”
b. “I’m sure everything will be okay. It just takes time to heal.”
c. “I’m not sure what’s wrong. Have you asked the doctor about your concerns?”
d. “I understand you’re concerned. Let’s discuss what concerns you specifically.”
d. This therapeutic response reflects upon, and accepts, the caregivers’ feelings, and it allows them to clarify what they are feeling.
A nurse is caring for a client who is in mechanical restraints. Which of the following statements should the nurse include in the documentation? (select all that apply).
a. The client ate most of his breakfast
b. The client was offered 8oz of water every hour
c. The client shouted obscenities at assertive personnel
d. The client received Chlorpromazine 15mg by mouth at 1000
e. The client acted out after lunch
b, c, d: Clear, accurate, and accessible documentation is an essential element of safe, quality, evidence-based nursing practice.
A nurse at an acute mental health facility for a client who has acute mania due to bipolar disorder. At 0300 the client runs to the nurse's station and demands to see the provider immediately. Choose the therapeutic response the nurse should demonstrate.
a. “Your request is unreasonable. We cannot call your provider at 3:00 in the morning.”
b. “If you can calm down for 5 minutes then I will call your provider for you.”
c. “Calm down, go back to your room, and come back in 15 minutes and we’ll talk about how you’re feeling.”
d. “You must be very upset about something to want to see your provider in the middle of the night.”
d. The nurse should respond to the client’s concern with empathy, which shows concern for the client’s feelings and offers an opportunity for the client to clarify the situation.
A nurse is creating a plan of care for an adult client who has been placed in seclusion after threatening to harm others on the unit. Which of the following interventions should the nurse include in the plan?
a. The nurse should document the client's behavior every 15 to 30 min while the client is in seclusion.
b. There is no indication to limit the client's fluid intake.
c. The nurse should assess the client's behavior frequently during seclusion and should renew the prescription for seclusion for an adult client every 4 hr, for a maximum of 24 hr.
d. The nurse should offer toileting to the client every 15 to 30 min.
c. The nurse should assess the client's behavior frequently during seclusion and should renew the prescription for seclusion for an adult client every 4 hr, for a maximum of 24 hr.
According to The joint commission unless state law is more restrictive, orders for the use of restraint or seclusion used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, staff, or others may be renewed within the following limit: 4 hours for adults 18 years of age or older.
A nurse enters a client’s room and observes the client is agitated and pacing rapidly. The client looks at the nurse and says “Back off leave me alone!” Which statement should the nurse respond with?
a. “I demand that you calm down now. Your behavior is unacceptable.”
b. “I will close the door to provide privacy, and you can tell me what is bothering you.”
c. “I will give you space if you calm down. Tell me what is causing you to feel so tense.”
d. “I will leave you alone for a few minutes while you try to control yourself.”
c. The nurse should stay at a safe distance and remain calm while stressing the importance of maintaining control. The nurse should use verbal de-escalation techniques while determining the client’s needs and respecting the client’s personal space.
A nurse is caring for a client who is experiencing moderate anxiety. Which of the following actions should the nurse take when trying to give necessary information to the client? Select all that apply.
a. Reassure the client that everything will be okay.
b. Discuss prior use of coping mechanisms with the client.
c. Ignore the client’s anxiety so that she will not be embarrassed.
d. Demonstrate a calm manner while using simple and clear directions.
e. Gather information from the client using closed-ended questions.
b, d: If there is a proven successful method to mitigate anxiety for the patient, this should be explored again. Maintaining a calm manner, moderating the caliber of your voice, and using simple, clear directions will all help the patient emulate these behaviors and feel more secure.
A nurse in a mental health facility is caring for a client who has schizophrenia. Which of the following places the client at the greatest risk for self-directed injury or injury to others?
a. inability to communicate with others
b. feelings of the absence of self-worth
c. lack of motivation to perform daily tasks
d. command hallucinations
A nurse is administering an oral sedative to a client who is receiving care following an involuntary admission. The client states, "I'm not taking any more medication." Which of the following actions should the nurse take?
a. Administer medication by another route
b. Refer the client's refusal to the facility ethics committee
c. Inform the client that, due to her involuntary admission, she cannot refuse the sedative
d. Document the client's refusal of the medication in the medical record
d. A client has the legal right to refuse medication. The nurse can only educate the patient as fully as possible about the benefits of treatment recommendations and the risks of no treatment.
Even involuntary admission patients have the right to refuse and legally forcing medication on a patient is assault if so long as they are still presumed competent. The issue will not be taken to the ethics committee.
A nurse is counseling a client who seems relaxed initially but then becomes restless and begins wringing his hands. The nurse states that the client seems tense, and the client agrees. Which of the following statements should the nurse make?
a. “Did I say something wrong that made you feel tense?”
b. “Do you often feel tense when you are talking to a health care provider?”
c. “What were we discussing when you began to feel uncomfortable?”
d. “It is okay to feel nervous during our counseling sessions.”
c. The nurse should avoid using closed-ended questions that block client communication. The nurse should use the therapeutic technique of focusing, which promotes discussion about a specific topic. This technique helps identify the cause of the client’s feelings and promotes further communication.
Guidelines to de-escalation/communication:
a. Use short, and clear direct sentences
b. Keep the "stimulation level" as low as possible
c. Use long, involved explanations
d. Maintain personal space
e. Give advice during the crisis
a, b, d: Long, involved explanations can be difficult for people to handle during a crisis. They are likely to tune you out. Keep the content of communication simple, covering only one topic or direction at a time.
High simulation levels are distracting.
Observe the person's reactions to proximity to create a comfortable space for effective communication. Maintain an appropriate distance to ensure individual safety.
It is essential not to judge, give advice, or belittle a person during a crisis.
After fasting from 2200 the previous evening, a client finds out that the blood test has been canceled. The client swears at the nurse and states, “You are incompetent!” Which is the nurse’s best response?
a. “Do you believe that I was the cause of your blood test being canceled?”
b. “I see that you are upset, but I feel uncomfortable when you swear at me.”
c. “Have you ever thought about ways to express anger appropriately?”
d. “I’ll give you some space. Let me know if you need anything.”
b. This is an example of the appropriate use of feedback. Feedback should be directed toward behavior that the client has the capacity to modify.