Chapter 35 My Nursing Test Banks


Kneisl, Contemporary Psychiatric-Mental Health Nursing, 3/e Test Bank
Chapter 35

Question 1

Type: MCSA

An 83-year-old male client, who was recently admitted for a dementia workup, has been striking out at nursing staff. His wife, who is terribly upset by his recent behavior, states, I just dont understand what has gotten into him, he used to be so kind and gentle. The nurses best response for explaining the etiology of violent behavior is which of the following?

1. The disease process associated with dementia causes a person to become violent.

2. Scientists have linked violent behavior to the genetic mutation of a specific Y chromosome.

3. The renowned psychoanalyst Freud says that it is instinctive for humans to express depression in aggressive ways.

4. There is no simple explanation for aggressive behavior, but research suggests it is caused by a combination of biologic and psychosocial factors.

Correct Answer: 4

Rationale 1: No single theory adequately explains violent behavior. No single gene or variant thereof has been identified as the causative factor of aggression. Freud said that humans express anger in aggressive ways and anger turned inward is depression. The dementia diagnosis alone does not determine that the client will be violent.

Rationale 2: No single theory adequately explains violent behavior. No single gene or variant thereof has been identified as the causative factor of aggression. Freud said that humans express anger in aggressive ways and anger turned inward is depression. The dementia diagnosis alone does not determine that the client will be violent.

Rationale 3: No single theory adequately explains violent behavior. No single gene or variant thereof has been identified as the causative factor of aggression. Freud said that humans express anger in aggressive ways and anger turned inward is depression. The dementia diagnosis alone does not determine that the client will be violent.

Rationale 4: No single theory adequately explains violent behavior. No single gene or variant thereof has been identified as the causative factor of aggression. Freud said that humans express anger in aggressive ways and anger turned inward is depression. The dementia diagnosis alone does not determine that the client will be violent.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Describe theoretical perspectives that are useful in understanding anger and violent behavior.

Question 2

Type: MCSA

A 13-year-old client was admitted for giving a younger sister a black eye and throwing a cat out the window. Which neurotransmitter imbalance is not likely to be associated with this behavior?

1. Dopamine excess

2. Serotonin deficit

3. Gamma-aminobutyric acid (GABA) deficit

4. Acetylcholine excess

Correct Answer: 4

Rationale 1: Aggressive behavior is associated with deficits of acetylcholine, serotonin, GABA, and an excess of dopamine.

Rationale 2: Aggressive behavior is associated with deficits of acetylcholine, serotonin, GABA, and an excess of dopamine.

Rationale 3: Aggressive behavior is associated with deficits of acetylcholine, serotonin, GABA, and an excess of dopamine.

Rationale 4: Aggressive behavior is associated with deficits of acetylcholine, serotonin, GABA, and an excess of dopamine.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: Describe theoretical perspectives that are useful in understanding anger and violent behavior.

Question 3

Type: MCSA

A client with a history of epilepsy has recently experienced more frequent seizures, often followed immediately by episodes of aggressive behavior. Which biological abnormality is likely to be present in this client?

1. A mutation on the genes that encode components of the serotonin system

2. Serum toxicity resulting from chronic exposure to lead

3. A deficit of gamma-aminobutyric acid

4. A problem with the amygdala/temporal lobe

Correct Answer: 4

Rationale 1: Postictal aggressive behavior is associated with a problem with the amygdala/temporal lobe. A deficit of gamma-aminobutyric acid and a mutation on the genes that encode components of the serotonin system are biological factors associated with etiology of aggression but do not fit with the scenario. Lead toxicity is an environmental factor, not a biological factor.

Rationale 2: Postictal aggressive behavior is associated with a problem with the amygdala/temporal lobe. A deficit of gamma-aminobutyric acid and a mutation on the genes that encode components of the serotonin system are biological factors associated with etiology of aggression but do not fit with the scenario. Lead toxicity is an environmental factor, not a biological factor.

Rationale 3: Postictal aggressive behavior is associated with a problem with the amygdala/temporal lobe. A deficit of gamma-aminobutyric acid and a mutation on the genes that encode components of the serotonin system are biological factors associated with etiology of aggression but do not fit with the scenario. Lead toxicity is an environmental factor, not a biological factor.

Rationale 4: Postictal aggressive behavior is associated with a problem with the amygdala/temporal lobe. A deficit of gamma-aminobutyric acid and a mutation on the genes that encode components of the serotonin system are biological factors associated with etiology of aggression but do not fit with the scenario. Lead toxicity is an environmental factor, not a biological factor.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: Describe theoretical perspectives that are useful in understanding anger and violent behavior.

Question 4

Type: MCSA

An aspiring actor was brought in by police for psychiatric evaluation. After learning that the client did not get a callback for the role the client wanted, the client got drunk and physically attacked the director. The client has no previous history of violent behavior. Which theory best explains this clients behavior?

1. Humanistic

2. Psychoanalytic

3. Social-interpersonal

4. Behavioral

Correct Answer: 1

Rationale 1: The client is feeling undervalued and insignificant, two factors that humanistic theory poses as leading to aggression. Psychoanalytic theory poses that aggression is a human instinctual response to anger. Behavioral theory poses that aggression is a learned behavior that continues if reinforced. Social-interpersonal theory poses that aggressive behavior is precipitated by early childhood trauma or abuse and emotional rejection.

Rationale 2: The client is feeling undervalued and insignificant, two factors that humanistic theory poses as leading to aggression. Psychoanalytic theory poses that aggression is a human instinctual response to anger. Behavioral theory poses that aggression is a learned behavior that continues if reinforced. Social-interpersonal theory poses that aggressive behavior is precipitated by early childhood trauma or abuse and emotional rejection.

Rationale 3: The client is feeling undervalued and insignificant, two factors that humanistic theory poses as leading to aggression. Psychoanalytic theory poses that aggression is a human instinctual response to anger. Behavioral theory poses that aggression is a learned behavior that continues if reinforced. Social-interpersonal theory poses that aggressive behavior is precipitated by early childhood trauma or abuse and emotional rejection.

Rationale 4: The client is feeling undervalued and insignificant, two factors that humanistic theory poses as leading to aggression. Psychoanalytic theory poses that aggression is a human instinctual response to anger. Behavioral theory poses that aggression is a learned behavior that continues if reinforced. Social-interpersonal theory poses that aggressive behavior is precipitated by early childhood trauma or abuse and emotional rejection.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: Describe theoretical perspectives that are useful in understanding anger and violent behavior.

Question 5

Type: MCMA

A 13-year-old client was admitted for giving a younger sister a black eye and throwing the cat out the window. Which areas of the brain could have abnormalities associated with this behavior?

Standard Text: Select all that apply.

1. Amygdala

2. Occipital lobe

3. Frontal lobe

4. Hypothalamus

5. Hippocampus

Correct Answer: 1,3,4,5

Rationale 1: Amygdala. Abnormalities of the amygdala are associated with aggressive behavior.

Rationale 2: Occipital lobe. Dysfunction of the occipital lobe is associated with visual and spatial processing problems.

Rationale 3: Frontal lobe. Abnormalities of the frontal lobe are associated with aggressive behavior.

Rationale 4: Hypothalamus. Abnormalities of the hypothalamus are associated with aggressive behavior.

Rationale 5: Hippocampus. Abnormalities of the hippocampus are associated with aggressive behavior.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: Describe theoretical perspectives that are useful in understanding anger and violent behavior.

Question 6

Type: MCSA

A 22-year-old client with schizophrenia was just admitted to the inpatient unit. While assessing the client, the nurse notes that the client is staring at a staff member intensely with a flat affect. The client is mumbling and the clients limbs are in constant motion (bouncing knee up and down and tapping fingers). Without further data, which observation is most indicative of the clients potential for violence?

1. Intense stare

2. Mumbling

3. Flat affect

4. Constant motion

Correct Answer: 1

Rationale 1: Intense stare is one of the warning signs that a person may escalate to violence. Mumbling is indicative that the client is experiencing hallucinations; however, content of hallucinations must be assessed to determine the persons potential for violence. Constant motion could be akathisia (EPS) and must be further assessed. Flat affect is not an indicator of risk for violence.

Rationale 2: Intense stare is one of the warning signs that a person may escalate to violence. Mumbling is indicative that the client is experiencing hallucinations; however, content of hallucinations must be assessed to determine the persons potential for violence. Constant motion could be akathisia (EPS) and must be further assessed. Flat affect is not an indicator of risk for violence.

Rationale 3: Intense stare is one of the warning signs that a person may escalate to violence. Mumbling is indicative that the client is experiencing hallucinations; however, content of hallucinations must be assessed to determine the persons potential for violence. Constant motion could be akathisia (EPS) and must be further assessed. Flat affect is not an indicator of risk for violence.

Rationale 4: Intense stare is one of the warning signs that a person may escalate to violence. Mumbling is indicative that the client is experiencing hallucinations; however, content of hallucinations must be assessed to determine the persons potential for violence. Constant motion could be akathisia (EPS) and must be further assessed. Flat affect is not an indicator of risk for violence.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Assess for the presence of behavioral and verbal cues that indicate escalation of anger.

Question 7

Type: MCSA

A client was brought in to the hospital by police after verbally threatening the staff at a homeless shelter when they turned the client away. Which would be the most appropriate response by the nurse to the clients statement, You all better let me stay here, or the next time, Ill use a gun.

1. Do you have a gun? Are you threatening to kill someone?

2. Sounds like you are trying to manipulate the system. We only treat people with real problems here.

3. It sounds like you are very concerned about having somewhere to stay. Can you tell me more about what you would do if you couldnt stay here?

4. We cannot let you stay here unless you promise not to hurt anyone.

Correct Answer: 3

Rationale 1: Assessment of violence risk includes identification of plan, means, and intent. The clients threat should not be ignored. Admission is not based on the clients ability to contract for safety as the client is a greater threat if unable to contract for safety. Focusing on the gun ignores the basis for the clients anxiety which needs further exploration to determine whether an alternative to hospitalization is an appropriate solution.

Rationale 2: Assessment of violence risk includes identification of plan, means, and intent. The clients threat should not be ignored. Admission is not based on the clients ability to contract for safety as the client is a greater threat if unable to contract for safety. Focusing on the gun ignores the basis for the clients anxiety which needs further exploration to determine whether an alternative to hospitalization is an appropriate solution.

Rationale 3: Assessment of violence risk includes identification of plan, means, and intent. The clients threat should not be ignored. Admission is not based on the clients ability to contract for safety as the client is a greater threat if unable to contract for safety. Focusing on the gun ignores the basis for the clients anxiety which needs further exploration to determine whether an alternative to hospitalization is an appropriate solution.

Rationale 4: Assessment of violence risk includes identification of plan, means, and intent. The clients threat should not be ignored. Admission is not based on the clients ability to contract for safety as the client is a greater threat if unable to contract for safety. Focusing on the gun ignores the basis for the clients anxiety which needs further exploration to determine whether an alternative to hospitalization is an appropriate solution.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Assess for the presence of behavioral and verbal cues that indicate escalation of anger.

Question 8

Type: MCSA

Which of the following clients should be assessed as demonstrating aggression? The client who:

1. Tells the nurse, I dont need that medication and no one can make me take it.

2. Walks into the group room and says to another client, You stole my seat. That is where I always sit. You had better move!

3. Paces back and forth in the hall singing loudly to the music the client is listening to with headphones.

4. Bursts into tears when the doctor says, I dont think you are ready for discharge today.

Correct Answer: 2

Rationale 1: Aggression is a physical or verbal threat that reflects rage, hostility, and potential for physical or verbal destructiveness. Aggressive behavior violates the rights of others. Pacing and singing are disruptive to others but do not violate anyone elses rights. Refusing to take medication and treatment noncompliance could arise for a multitude of reasons and is not necessarily driven by aggression. Crying does not reflect any threat or violation of others rights.

Rationale 2: Aggression is a physical or verbal threat that reflects rage, hostility, and potential for physical or verbal destructiveness. Aggressive behavior violates the rights of others. Pacing and singing are disruptive to others but do not violate anyone elses rights. Refusing to take medication and treatment noncompliance could arise for a multitude of reasons and is not necessarily driven by aggression. Crying does not reflect any threat or violation of others rights.

Rationale 3: Aggression is a physical or verbal threat that reflects rage, hostility, and potential for physical or verbal destructiveness. Aggressive behavior violates the rights of others. Pacing and singing are disruptive to others but do not violate anyone elses rights. Refusing to take medication and treatment noncompliance could arise for a multitude of reasons and is not necessarily driven by aggression. Crying does not reflect any threat or violation of others rights.

Rationale 4: Aggression is a physical or verbal threat that reflects rage, hostility, and potential for physical or verbal destructiveness. Aggressive behavior violates the rights of others. Pacing and singing are disruptive to others but do not violate anyone elses rights. Refusing to take medication and treatment noncompliance could arise for a multitude of reasons and is not necessarily driven by aggression. Crying does not reflect any threat or violation of others rights.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Assess for the presence of behavioral and verbal cues that indicate escalation of anger.

Question 9

Type: MCSA

The nurse suspects that a male client may become violent. Which verbal cue might have indicated this? The client:

1. Receives news that his wife is filing for divorce and begins sobbing inconsolably.

2. Demands, Give me my medicine now or youll be sorry.

3. Begins pacing the hall exhibiting clenched jaw and fists.

4. States, I dont know why people seem afraid of me.

Correct Answer: 2

Rationale 1: Threats or demands are verbal cues that indicate potential for violence. Crying is not a violence risk factor. Pacing and exhibiting clenched fists and jaws are behavioral, not verbal, cues of risk for violence. Nothing in the clients statement of concern about others fears is indicative of impending violence.

Rationale 2: Threats or demands are verbal cues that indicate potential for violence. Crying is not a violence risk factor. Pacing and exhibiting clenched fists and jaws are behavioral, not verbal, cues of risk for violence. Nothing in the clients statement of concern about others fears is indicative of impending violence.

Rationale 3: Threats or demands are verbal cues that indicate potential for violence. Crying is not a violence risk factor. Pacing and exhibiting clenched fists and jaws are behavioral, not verbal, cues of risk for violence. Nothing in the clients statement of concern about others fears is indicative of impending violence.

Rationale 4: Threats or demands are verbal cues that indicate potential for violence. Crying is not a violence risk factor. Pacing and exhibiting clenched fists and jaws are behavioral, not verbal, cues of risk for violence. Nothing in the clients statement of concern about others fears is indicative of impending violence.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Assess for the presence of behavioral and verbal cues that indicate escalation of anger.

Question 10

Type: MCSA

The client on the inpatient unit who should be assessed as being at highest risk for directing violent behavior toward others is which of the following?

1. A veteran who has a diagnosis of post-traumatic stress disorder who was admitted for severe sleep disturbance secondary to nightmares

2. A middle-aged woman who has completed alcohol withdrawal and is participating in a rehabilitation program

3. An adolescent who was admitted for suicidal ideation and was suspended from school for getting into a fight with a classmate

4. A male client in his twenties who has bipolar disorder with delusions of grandeur

Correct Answer: 3

Rationale 1: The greatest risk factor for aggressive behavior is prior history of aggressive behavior. Although the other options contain risk factors (delusions, disturbing symptoms), there is no indication of a prior history of aggressive behavior. Clients experiencing active symptoms of alcohol withdrawal are high risk due to the potential reality distortion, but this risk decreases once the withdrawal is complete.

Rationale 2: The greatest risk factor for aggressive behavior is prior history of aggressive behavior. Although the other options contain risk factors (delusions, disturbing symptoms), there is no indication of a prior history of aggressive behavior. Clients experiencing active symptoms of alcohol withdrawal are high risk due to the potential reality distortion, but this risk decreases once the withdrawal is complete.

Rationale 3: The greatest risk factor for aggressive behavior is prior history of aggressive behavior. Although the other options contain risk factors (delusions, disturbing symptoms), there is no indication of a prior history of aggressive behavior. Clients experiencing active symptoms of alcohol withdrawal are high risk due to the potential reality distortion, but this risk decreases once the withdrawal is complete.

Rationale 4: The greatest risk factor for aggressive behavior is prior history of aggressive behavior. Although the other options contain risk factors (delusions, disturbing symptoms), there is no indication of a prior history of aggressive behavior. Clients experiencing active symptoms of alcohol withdrawal are high risk due to the potential reality distortion, but this risk decreases once the withdrawal is complete.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Identify risk factors that contribute to violent behavior.

Question 11

Type: MCSA

A client is being admitted to the inpatient unit for stabilization of psychoses. The clients mother found the client trying to drown a cat in the bathtub. The client believed it was possessed by the devil. The mother reports that the father also suffered from a mental illness and was physically abusive. Based on this information the priority nursing diagnosis is:

1. Post-Trauma Syndrome.

2. Disturbed Thought Processes.

3. Risk for Injury.

4. Risk for Violence: Other-Directed.

Correct Answer: 4

Rationale 1: Risk factors for violence directed at others include cognitive impairment or psychoses, history of being abused or witnessing abuse as a child, and cruelty to animals. No information is provided that would confirm the presence of post-trauma or risk for self-injury. Disturbed Thought Processes is an appropriate diagnosis but not the priority.

Rationale 2: Risk factors for violence directed at others include cognitive impairment or psychoses, history of being abused or witnessing abuse as a child, and cruelty to animals. No information is provided that would confirm the presence of post-trauma or risk for self-injury. Disturbed Thought Processes is an appropriate diagnosis but not the priority.

Rationale 3: Risk factors for violence directed at others include cognitive impairment or psychoses, history of being abused or witnessing abuse as a child, and cruelty to animals. No information is provided that would confirm the presence of post-trauma or risk for self-injury. Disturbed Thought Processes is an appropriate diagnosis but not the priority.

Rationale 4: Risk factors for violence directed at others include cognitive impairment or psychoses, history of being abused or witnessing abuse as a child, and cruelty to animals. No information is provided that would confirm the presence of post-trauma or risk for self-injury. Disturbed Thought Processes is an appropriate diagnosis but not the priority.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: Identify risk factors that contribute to violent behavior.

Question 12

Type: MCSA

A psychiatric hospital was recently purchased by a large healthcare system. The new administrations business motto is leaner and meaner, consequently, the staff mix has been adjusted by replacing some of the highly experienced nurses with robust male mental health technicians who cost less and are able to provide physical interventions. The change that is likely to increase the risk for violence in this hospital is the:

1. Change in hospital ownership.

2. Advanced age of nursing staff.

3. Adjustment in staff mix.

4. Motto that implies staff will be mean.

Correct Answer: 3

Rationale 1: One factor that has contributed to increased violence is the substitution of high-skilled staff with paraprofessionals (lower skill level). Ownership change could be positive or negative, thus is not a risk factor. A business motto is not necessarily indicative of the care provided. Younger and less experienced nursing staff are at increased risk for violence.

Rationale 2: One factor that has contributed to increased violence is the substitution of high-skilled staff with paraprofessionals (lower skill level). Ownership change could be positive or negative, thus is not a risk factor. A business motto is not necessarily indicative of the care provided. Younger and less experienced nursing staff are at increased risk for violence.

Rationale 3: One factor that has contributed to increased violence is the substitution of high-skilled staff with paraprofessionals (lower skill level). Ownership change could be positive or negative, thus is not a risk factor. A business motto is not necessarily indicative of the care provided. Younger and less experienced nursing staff are at increased risk for violence.

Rationale 4: One factor that has contributed to increased violence is the substitution of high-skilled staff with paraprofessionals (lower skill level). Ownership change could be positive or negative, thus is not a risk factor. A business motto is not necessarily indicative of the care provided. Younger and less experienced nursing staff are at increased risk for violence.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Identify risk factors that contribute to violent behavior.

Question 13

Type: MCSA

A client who is a construction supervisor has a history of becoming violent when the clients workers do not complete their work within the established deadline. Police have been called to the worksite multiple times for behaviors including loud shouting and destruction of property. The most appropriate expected outcome related to resolving this problem would be for the client to:

1. Identify personal needs.

2. Refrain from impulsive behavior.

3. Refrain from self-injury and from injuring others.

4. Identify alternative methods for expressing anger.

Correct Answer: 4

Rationale 1: The client appears unable to respond to disappointment or anger toward employees in an appropriate manner. The other options are appropriate outcomes for a person with violent behavior but do not directly address the situation.

Rationale 2: The client appears unable to respond to disappointment or anger toward employees in an appropriate manner. The other options are appropriate outcomes for a person with violent behavior but do not directly address the situation.

Rationale 3: The client appears unable to respond to disappointment or anger toward employees in an appropriate manner. The other options are appropriate outcomes for a person with violent behavior but do not directly address the situation.

Rationale 4: The client appears unable to respond to disappointment or anger toward employees in an appropriate manner. The other options are appropriate outcomes for a person with violent behavior but do not directly address the situation.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: Identify risk factors that contribute to violent behavior.

Question 14

Type: MCMA

A client is being admitted to the inpatient psychiatric unit. Which actions would be appropriate for the nurse to assess the clients risk of violence?

Standard Text: Select all that apply.

1. Wait to assess the clients risk of violence once the psychiatric symptoms have stabilized.

2. Assess history of psychotic illness as this is the most important predictor of violence potential.

3. Ask the client, What is the most violent thing you have ever done?

4. Review the clients past records and get information from the clients family.

5. Avoid discussing the clients past history of violence as this could provoke the client.

Correct Answer: 3,4

Rationale 1: Wait to assess the clients risk of violence once the psychiatric symptoms have stabilized. Do not wait to assess the clients risk of violence, this should be done as soon as possible so that a plan can be implemented to reduce the clients risk of violent behavior.

Rationale 2: Assess history of psychotic illness as this is the most important predictor of violence potential. History of previous violent behavior is the most important predictor of violence potential, not history of psychotic illness.

Rationale 3: Ask the client, What is the most violent thing you have ever done? Open direct questioning about history of violence is an appropriate strategy for assessing risk.

Rationale 4: Review the clients past records and get information from the clients family. Do not rely on the client alone, but also explore past records and other sources to assess the clients history of violence.

Rationale 5: Avoid discussing the clients past history of violence as this could provoke the client. Do not avoid discussing the clients past history of violencedirect questioning is appropriate.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Identify risk factors that contribute to violent behavior.

Question 15

Type: MCSA

A manic client is pacing the halls of the inpatient unit and making disruptive comments to the other clients. The nurse overhears the client say, I know people, so you better treat me with respect! Which of the following therapeutic nursing interventions would the nurse implement first?

1. Notify security that this client is escalating out of control and the client needs to be escorted to the clients room.

2. Tell the client that the nurse would like to give a PRN injection because the behavior is disrupting others.

3. Approach the client and say in firm voice, That was inappropriate. Go to your room immediately.

4. Address the client and say in a calm voice, The staff will work hard to make sure you receive proper respect here. Lets go over here and talk.

Correct Answer: 4

Rationale 1: Reassuring the client that the client will be respected validates the clients need for respect and provides an opportunity to further assess the clients ability to establish control and to respond to verbal cues. It is a bit premature to notify security until the nurse has determined that the client is nonresponsive to redirection, and this does not reinforce the element of respect in the nurse-client relationship. Telling the client that the behavior is inappropriate is paternalistic and the command sounds punitive, directly the opposite of what the client is demanding, which could provoke a negative response from the client. When used as a method for de-escalation, medication should first be offered as an option rather than a demand and the rationale should be based on the clients needs, not others.

Rationale 2: Reassuring the client that the client will be respected validates the clients need for respect and provides an opportunity to further assess the clients ability to establish control and to respond to verbal cues. It is a bit premature to notify security until the nurse has determined that the client is nonresponsive to redirection, and this does not reinforce the element of respect in the nurse-client relationship. Telling the client that the behavior is inappropriate is paternalistic and the command sounds punitive, directly the opposite of what the client is demanding, which could provoke a negative response from the client. When used as a method for de-escalation, medication should first be offered as an option rather than a demand and the rationale should be based on the clients needs, not others.

Rationale 3: Reassuring the client that the client will be respected validates the clients need for respect and provides an opportunity to further assess the clients ability to establish control and to respond to verbal cues. It is a bit premature to notify security until the nurse has determined that the client is nonresponsive to redirection, and this does not reinforce the element of respect in the nurse-client relationship. Telling the client that the behavior is inappropriate is paternalistic and the command sounds punitive, directly the opposite of what the client is demanding, which could provoke a negative response from the client. When used as a method for de-escalation, medication should first be offered as an option rather than a demand and the rationale should be based on the clients needs, not others.

Rationale 4: Reassuring the client that the client will be respected validates the clients need for respect and provides an opportunity to further assess the clients ability to establish control and to respond to verbal cues. It is a bit premature to notify security until the nurse has determined that the client is nonresponsive to redirection, and this does not reinforce the element of respect in the nurse-client relationship. Telling the client that the behavior is inappropriate is paternalistic and the command sounds punitive, directly the opposite of what the client is demanding, which could provoke a negative response from the client. When used as a method for de-escalation, medication should first be offered as an option rather than a demand and the rationale should be based on the clients needs, not others.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Incorporate the nursing measures to de-escalate potentially violent behavior within the context of the principle of least restrictiveness.

Question 16

Type: MCSA

A 15-year-old client who has been diagnosed with conduct disorder has been prescribed medication to control aggressive behavior. For which medication is the nurse likely to be providing client education?

1. Methylphenidate (Ritalin)

2. Amitriptyline (Elavil)

3. Lithium carbonate (Lithobid)

4. Buspirone (BuSpar)

Correct Answer: 3

Rationale 1: Aggression in children and adolescents is most effectively treated with mood stabilizers and atypical antipsychotics. Nonbenzodiazepine anxiolytics, psychostimulants, and cyclic antidepressants are not indicated for treatment of aggression in children.

Rationale 2: Aggression in children and adolescents is most effectively treated with mood stabilizers and atypical antipsychotics. Nonbenzodiazepine anxiolytics, psychostimulants, and cyclic antidepressants are not indicated for treatment of aggression in children.

Rationale 3: Aggression in children and adolescents is most effectively treated with mood stabilizers and atypical antipsychotics. Nonbenzodiazepine anxiolytics, psychostimulants, and cyclic antidepressants are not indicated for treatment of aggression in children.

Rationale 4: Aggression in children and adolescents is most effectively treated with mood stabilizers and atypical antipsychotics. Nonbenzodiazepine anxiolytics, psychostimulants, and cyclic antidepressants are not indicated for treatment of aggression in children.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Incorporate the nursing measures to de-escalate potentially violent behavior within the context of the principle of least restrictiveness.

Question 17

Type: MCSA

Staff have made several verbal attempts to de-escalate a client, however, the clients level of agitation continues to increase and it becomes necessary to administer a fast-acting pharmacological intervention. Which medication would the nurse most likely provide?

1. Haloperidol (Haldol)

2. Methylphenidate (Ritalin)

3. Lithium carbonate (Lithobid)

4. Amitriptyline (Elavil)

Correct Answer: 1

Rationale 1: Haloperidol is a high-potency, short-acting antipsychotic that is useful in calming agitation. Lithium is a mood stabilizer and amitriptyline is a tricyclic antidepressant; these drugs would be used for long-term management of mood symptoms. Methylphenidate, a psychostimulant, is relatively fast-acting but would not calm agitated behavior.

Rationale 2: Haloperidol is a high-potency, short-acting antipsychotic that is useful in calming agitation. Lithium is a mood stabilizer and amitriptyline is a tricyclic antidepressant; these drugs would be used for long-term management of mood symptoms. Methylphenidate, a psychostimulant, is relatively fast-acting but would not calm agitated behavior.

Rationale 3: Haloperidol is a high-potency, short-acting antipsychotic that is useful in calming agitation. Lithium is a mood stabilizer and amitriptyline is a tricyclic antidepressant; these drugs would be used for long-term management of mood symptoms. Methylphenidate, a psychostimulant, is relatively fast-acting but would not calm agitated behavior.

Rationale 4: Haloperidol is a high-potency, short-acting antipsychotic that is useful in calming agitation. Lithium is a mood stabilizer and amitriptyline is a tricyclic antidepressant; these drugs would be used for long-term management of mood symptoms. Methylphenidate, a psychostimulant, is relatively fast-acting but would not calm agitated behavior.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: Incorporate the nursing measures to de-escalate potentially violent behavior within the context of the principle of least restrictiveness.

Question 18

Type: MCMA

A client who is being treated for psychosis has begun exhibiting signs of increasing agitation and has started repetitively opening and slamming the door to the clients room. Which of the following nursing interventions address and redirect the clients behavior?

Standard Text: Select all that apply.

1. You need to stop slamming your door and go down the hall to the group meeting.

2. How about taking a walk with me so we can find a place for you to let go of some of your nervous energy.

3. I can see that you have some excess energy that you need to get out, but you cannot continue to slam this door.

4. You seem upset, would you like some medication to help you with your agitation?

5. If you dont stop slamming the door, I will lock it for the rest of the day.

Correct Answer: 2,3,4

Rationale 1: You need to stop slamming your door and go down the hall to the group meeting. Attending group is not a priority for a client who is demonstrating agitated behavior.

Rationale 2: How about taking a walk with me so we can find a place for you to let go of some of your nervous energy. Make note of nervous energy and encourage exercise as a means to reduce agitated behavior.

Rationale 3: I can see that you have some excess energy that you need to get out, but you cannot continue to slam this door. Accept the client while rejecting the inappropriate behavior.

Rationale 4: You seem upset, would you like some medication to help you with your agitation? Observe client behavior and offer medication to help decrease agitation.

Rationale 5: If you dont stop slamming the door, I will lock it the rest of the day. This statement does not address the clients agitation which is causing the disruptive behavior.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Incorporate the nursing measures to de-escalate potentially violent behavior within the context of the principle of least restrictiveness.

Question 19

Type: MCSA

A client was admitted for psychosis and aggressive behavior. The client has been noncompliant with the antipsychotic medication because the client says it makes the clients jaw tight and neck stiff. The client is becoming increasingly agitated and needs a quick-acting medication. Which medication would the nurse expect to give?

1. Benztropine (Cogentin)

2. Fluphenazine (Prolixin)

3. Risperidone (Risperdal)

4. Zolpidem (Ambien)

Correct Answer: 3

Rationale 1: An antipsychotic is the treatment for acute agitation. Zolpidem and benztropine are not antipsychotics. Given the clients prior symptoms of dystonia, it would be appropriate to try an atypical antipsychotic (risperidone) over the conventional (fluphenazine).

Rationale 2: An antipsychotic is the treatment for acute agitation. Zolpidem and benztropine are not antipsychotics. Given the clients prior symptoms of dystonia, it would be appropriate to try an atypical antipsychotic (risperidone) over the conventional (fluphenazine).

Rationale 3: An antipsychotic is the treatment for acute agitation. Zolpidem and benztropine are not antipsychotics. Given the clients prior symptoms of dystonia, it would be appropriate to try an atypical antipsychotic (risperidone) over the conventional (fluphenazine).

Rationale 4: An antipsychotic is the treatment for acute agitation. Zolpidem and benztropine are not antipsychotics. Given the clients prior symptoms of dystonia, it would be appropriate to try an atypical antipsychotic (risperidone) over the conventional (fluphenazine).

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Incorporate the nursing measures to de-escalate potentially violent behavior within the context of the principle of least restrictiveness.

Question 20

Type: MCSA

After a nurse addresses an agitated client by setting limits in a calm, direct manner, the client begins pacing, exhibiting a clenched jaw and fists. The nurse would evaluate the approach as ineffective because:

1. The nurse lacks rapport with the client.

2. The nurse lacks adequate de-escalation and limit setting skills.

3. Some clients have limited control, so verbal interventions may not work, but this is not reflective of the nurses skill.

4. In some cases verbal de-escalation and limit setting will not work and the nurse should start with a more restrictive measure.

Correct Answer: 3

Rationale 1: Not all clients will respond to verbal interventions, but this does not mean the nurse lacks skill. The nurse should always follow the principle of least restrictive measures first, even if it does not appear that it may work. A nurses verbal skills or ability to establish rapport are not necessarily measured by the clients response, as some clients are more out of control than others.

Rationale 2: Not all clients will respond to verbal interventions, but this does not mean the nurse lacks skill. The nurse should always follow the principle of least restrictive measures first, even if it does not appear that it may work. A nurses verbal skills or ability to establish rapport are not necessarily measured by the clients response, as some clients are more out of control than others.

Rationale 3: Not all clients will respond to verbal interventions, but this does not mean the nurse lacks skill. The nurse should always follow the principle of least restrictive measures first, even if it does not appear that it may work. A nurses verbal skills or ability to establish rapport are not necessarily measured by the clients response, as some clients are more out of control than others.

Rationale 4: Not all clients will respond to verbal interventions, but this does not mean the nurse lacks skill. The nurse should always follow the principle of least restrictive measures first, even if it does not appear that it may work. A nurses verbal skills or ability to establish rapport are not necessarily measured by the clients response, as some clients are more out of control than others.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: Incorporate the nursing measures to de-escalate potentially violent behavior within the context of the principle of least restrictiveness.

Question 21

Type: MCSA

During the morning community meeting, a client with psychosis becomes agitated, making loud threats to no one in particular, but the other clients appear increasingly uncomfortable. What action should the nurse facilitator take?

1. Address the client by name and say, It sounds as if you are experiencing something very disturbing. Please go see the nurse who may be able to help you.

2. Direct the client by saying, You need to sit quietly and listen until its your turn to talk.

3. Accompany the client to his or her room so that the client can de-escalate.

4. Say to the group, You all appear frightened by this behavior. What should we do about it?

Correct Answer: 1

Rationale 1: The clients thought process is preventing the client from receiving any benefit from group and could escalate if not properly attended to. In this scenario, it is not appropriate for the client to remain in the group, and the behavior must be addressed prior to asking the group for input. As the group facilitator, it would not be appropriate to leave the group.

Rationale 2: The clients thought process is preventing the client from receiving any benefit from group and could escalate if not properly attended to. In this scenario, it is not appropriate for the client to remain in the group, and the behavior must be addressed prior to asking the group for input. As the group facilitator, it would not be appropriate to leave the group.

Rationale 3: The clients thought process is preventing the client from receiving any benefit from group and could escalate if not properly attended to. In this scenario, it is not appropriate for the client to remain in the group, and the behavior must be addressed prior to asking the group for input. As the group facilitator, it would not be appropriate to leave the group.

Rationale 4: The clients thought process is preventing the client from receiving any benefit from group and could escalate if not properly attended to. In this scenario, it is not appropriate for the client to remain in the group, and the behavior must be addressed prior to asking the group for input. As the group facilitator, it would not be appropriate to leave the group.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Develop nursing care plans that balance the issue of safety maintenance with the need to ensure the individual freedom of the violent client.

Question 22

Type: MCMA

A new nurse is being oriented to work on the psychiatric unit. Which of the following statements reflect general principles for maintaining unit safety?

Standard Text: Select all that apply.

1. Staff should be sensitive to a clients need for privacy and personal space.

2. The staff should schedule their breaks during client mealtimes.

3. The nurse:client ratio should be at least one nurse for every four clients.

4. Staff should lock up clients potentially dangerous items and permit use only under direct staff supervision.

5. Staff should provide frequent, short individualized contacts with clients.

Correct Answer: 1,5

Rationale 1: Staff should be sensitive to a clients need for privacy and personal space. Violation of these needs often leads to aggression.

Rationale 2: The staff should schedule their breaks during client mealtimes. Mealtimes are a peak time for violent incidents.

Rationale 3: The nurse:client ratio should be at least one nurse for every four clients. There is no clear-cut staffing ratio that is appropriate for all units; it depends upon client acuity.

Rationale 4: Staff should lock up clients potentially dangerous items and permit use only under direct staff supervision. The protocol for dangerous items varies from one unit to the next; some items may be appropriate for certain client use with staff supervision, whereas other items may not be appropriate to use on the unit at any time.

Rationale 5: Staff should provide frequent, short individualized contacts with clients. This provides reassurance while allowing for privacy and personal space.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: Develop nursing care plans that balance the issue of safety maintenance with the need to ensure the individual freedom of the violent client.

Question 23

Type: MCMA

The nurse manager of an inpatient psychiatric unit is providing an orientation session for new staff. Which of the following statements reflect strategies used to promote a safe, therapeutic milieu?

Standard Text: Select all that apply.

1. Staff should provide frequent, short, individualized contacts with clients.

2. Management of potentially dangerous items such as belts, shoelaces, and electrical appliances is based on unit policy and clinical judgment.

3. A nurse:client ratio of at least one nurse for every four clients is required at all times.

4. Staff should take their breaks during client mealtimes because there is a lower risk of behavioral problems at this time.

5. When a client is becoming disruptive, staff should intervene by engaging the client in a structured group activity.

Correct Answer: 1,2

Rationale 1: Staff should provide frequent, short, individualized contacts with clients. Frequent brief contacts allow opportunities for identification of client needs and observation of change in clients behavior.

Rationale 2: Management of potentially dangerous items such as belts, shoelaces, and electrical appliances is based on unit policy and clinical judgment. Management of potentially dangerous items depends upon individual client and unit acuity and unit or institutional policy.

Rationale 3: A nurse:client ratio of at least one nurse for every four clients is required at all times. There are no standard staffing ratios for safety; it depends upon a number of factors such as client volume and acuity.

Rationale 4: Staff should take their breaks during client mealtimes because there is a lower risk of behavioral problems at this time. Mealtimes are a time of high risk for client violence therefore staff breaks should not be scheduled during this time.

Rationale 5: When a client is becoming disruptive, staff should intervene by engaging the client in a structured group activity. A client who is escalating should be guided to an area of decreased stimulation and activity.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Develop nursing care plans that balance the issue of safety maintenance with the need to ensure the individual freedom of the violent client.

Question 24

Type: MCSA

A client with paranoid schizophrenia is experiencing visual hallucinations of people jumping out of nowhere. The client keeps striking the wall. Repeated attempts by the nurse to orient the client to reality and reassure the client of safety have failed. What would be the nurses next de-escalation approach?

1. Offer the client a PRN medication

2. Apply soft limb restraints on clients wrists

3. Have several staff demobilize the client so that forcible injection can be administered

4. Call security to assist in placing the client in seclusion

Correct Answer: 1

Rationale 1: Offering the client a PRN medication would be the next step as attempts at verbal de-escalation have failed. Restraints are the most restrictive intervention and not warranted at this point. Seclusion will not prevent the client from self-harm inflicted by beating the walls. Forcing medication is a chemical restraint and not warranted until voluntary medication has been refused.

Rationale 2: Offering the client a PRN medication would be the next step as attempts at verbal de-escalation have failed. Restraints are the most restrictive intervention and not warranted at this point. Seclusion will not prevent the client from self-harm inflicted by beating the walls. Forcing medication is a chemical restraint and not warranted until voluntary medication has been refused.

Rationale 3: Offering the client a PRN medication would be the next step as attempts at verbal de-escalation have failed. Restraints are the most restrictive intervention and not warranted at this point. Seclusion will not prevent the client from self-harm inflicted by beating the walls. Forcing medication is a chemical restraint and not warranted until voluntary medication has been refused.

Rationale 4: Offering the client a PRN medication would be the next step as attempts at verbal de-escalation have failed. Restraints are the most restrictive intervention and not warranted at this point. Seclusion will not prevent the client from self-harm inflicted by beating the walls. Forcing medication is a chemical restraint and not warranted until voluntary medication has been refused.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Develop nursing care plans that balance the issue of safety maintenance with the need to ensure the individual freedom of the violent client.

Question 25

Type: MCSA

A client has been placed in seclusion. Which client behavior would have warranted this intervention?

1. The client is manic, has been flirtatious towards staff and refused morning medication, and has verbalized a plan to leave

2. The client is psychotic, sits in the corner with hands over ears, and displays increased suspiciousness of and agitation towards others despite recently receiving 1mg risperidone (Risperdal) PRN

3. The client is depressed and wants to be left alone to rest

4. The client is suicidal, has been banging head against the table in the day room, and was unresponsive to staffs verbal redirection

Correct Answer: 2

Rationale 1: The scientific rationale for the use of seclusion is based on three principles: containment, isolation, and decrease in sensory input. This client exhibits behavior that suggests increased sensitivity to the environment and risk of harm to others. A less restrictive measure has been tried (medication) without success. Seclusion should not be used as punishment for inappropriate behavior or to prevent client elopement. Seclusion is inappropriate when a client is engaging in self-injurious behavior that could continue in the seclusion environment (head-banging); in such circumstances a 1:1 staffing or restraints may be necessary. If a client seeks isolation voluntarily, seclusion (locking the door) is not warranted.

Rationale 2: The scientific rationale for the use of seclusion is based on three principles: containment, isolation, and decrease in sensory input. This client exhibits behavior that suggests increased sensitivity to the environment and risk of harm to others. A less restrictive measure has been tried (medication) without success. Seclusion should not be used as punishment for inappropriate behavior or to prevent client elopement. Seclusion is inappropriate when a client is engaging in self-injurious behavior that could continue in the seclusion environment (head-banging); in such circumstances a 1:1 staffing or restraints may be necessary. If a client seeks isolation voluntarily, seclusion (locking the door) is not warranted.

Rationale 3: The scientific rationale for the use of seclusion is based on three principles: containment, isolation, and decrease in sensory input. This client exhibits behavior that suggests increased sensitivity to the environment and risk of harm to others. A less restrictive measure has been tried (medication) without success. Seclusion should not be used as punishment for inappropriate behavior or to prevent client elopement. Seclusion is inappropriate when a client is engaging in self-injurious behavior that could continue in the seclusion environment (head-banging); in such circumstances a 1:1 staffing or restraints may be necessary. If a client seeks isolation voluntarily, seclusion (locking the door) is not warranted.

Rationale 4: The scientific rationale for the use of seclusion is based on three principles: containment, isolation, and decrease in sensory input. This client exhibits behavior that suggests increased sensitivity to the environment and risk of harm to others. A less restrictive measure has been tried (medication) without success. Seclusion should not be used as punishment for inappropriate behavior or to prevent client elopement. Seclusion is inappropriate when a client is engaging in self-injurious behavior that could continue in the seclusion environment (head-banging); in such circumstances a 1:1 staffing or restraints may be necessary. If a client seeks isolation voluntarily, seclusion (locking the door) is not warranted.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: Implement a variety of nonpharmacological nursing strategies for intervening with violent clients.

Question 26

Type: MCSA

A client is standing in the hallway on the phone arguing with the caller. As the client becomes increasing loud and argumentative, an appropriate action for the nurse to take would be to:

1. Move the other clients away from the area providing the client privacy to continue the conversation.

2. Stand next to the client and say in a calm, firm voice, If you cannot lower your voice, you will lose your phone privileges indefinitely.

3. Walk up to the client and softly say, This conversation appears to be getting you upset, tell this person that you will talk later and come sit with me to discuss what is bothering you.

4. Do nothing. The client does not pose any danger as the person the client is angry with is not physically present.

Correct Answer: 3

Rationale 1: An underlying goal of initial efforts at de-escalation is to assist the client in getting away from the aversive stimulus and to assess his or her ability to regain control. Encroaching upon the clients physical space and making a demand could escalate the aggression level; moreover, no rights can be restricted indefinitely. Allowing the client to continue to engage in escalating behavior could lead to violence.

Rationale 2: An underlying goal of initial efforts at de-escalation is to assist the client in getting away from the aversive stimulus and to assess his or her ability to regain control. Encroaching upon the clients physical space and making a demand could escalate the aggression level; moreover, no rights can be restricted indefinitely. Allowing the client to continue to engage in escalating behavior could lead to violence.

Rationale 3: An underlying goal of initial efforts at de-escalation is to assist the client in getting away from the aversive stimulus and to assess his or her ability to regain control. Encroaching upon the clients physical space and making a demand could escalate the aggression level; moreover, no rights can be restricted indefinitely. Allowing the client to continue to engage in escalating behavior could lead to violence.

Rationale 4: An underlying goal of initial efforts at de-escalation is to assist the client in getting away from the aversive stimulus and to assess his or her ability to regain control. Encroaching upon the clients physical space and making a demand could escalate the aggression level; moreover, no rights can be restricted indefinitely. Allowing the client to continue to engage in escalating behavior could lead to violence.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Implement a variety of nonpharmacological nursing strategies for intervening with violent clients.

Question 27

Type: MCSA

The mother of an 8-year-old client being treated for conduct disorder says that the child often threatens to kung-fu (kick and strike) the clients sister just like a favorite cartoon character does on TV. Based on behavioral theory, the nurse would suspect that the childs aggressive behavior could best be reduced by:

1. Administering a medication that will increase the neurotransmitter serotonin.

2. Engaging the client and sister in family therapy.

3. Providing positive reinforcement when the child exhibits nonaggressive behavior.

4. Identifying and reframing the negative thoughts that the child has toward the sister.

Correct Answer: 3

Rationale 1: Behavioral theory asserts that aggressive behavior is a learned response that tends to be repeated if reinforced. Watching violent TV programs serves as reinforcement. Lack of reinforcement or reinforcing other more desirable behaviors will help extinguish the aggressive behavior. Administration of medication suggests neurotransmitter abnormality as the origin for aggression supporting a biological, not behavioral, etiology. Thought reframing is a cognitive intervention used when it is believed that aggression stems from an individuals negative or distorted thought process. Interpersonal theorists pose that violence stems from poor family dynamics and recommend family therapy as an intervention.

Rationale 2: Behavioral theory asserts that aggressive behavior is a learned response that tends to be repeated if reinforced. Watching violent TV programs serves as reinforcement. Lack of reinforcement or reinforcing other more desirable behaviors will help extinguish the aggressive behavior. Administration of medication suggests neurotransmitter abnormality as the origin for aggression supporting a biological, not behavioral, etiology. Thought reframing is a cognitive intervention used when it is believed that aggression stems from an individuals negative or distorted thought process. Interpersonal theorists pose that violence stems from poor family dynamics and recommend family therapy as an intervention.

Rationale 3: Behavioral theory asserts that aggressive behavior is a learned response that tends to be repeated if reinforced. Watching violent TV programs serves as reinforcement. Lack of reinforcement or reinforcing other more desirable behaviors will help extinguish the aggressive behavior. Administration of medication suggests neurotransmitter abnormality as the origin for aggression supporting a biological, not behavioral, etiology. Thought reframing is a cognitive intervention used when it is believed that aggression stems from an individuals negative or distorted thought process. Interpersonal theorists pose that violence stems from poor family dynamics and recommend family therapy as an intervention.

Rationale 4: Behavioral theory asserts that aggressive behavior is a learned response that tends to be repeated if reinforced. Watching violent TV programs serves as reinforcement. Lack of reinforcement or reinforcing other more desirable behaviors will help extinguish the aggressive behavior. Administration of medication suggests neurotransmitter abnormality as the origin for aggression supporting a biological, not behavioral, etiology. Thought reframing is a cognitive intervention used when it is believed that aggression stems from an individuals negative or distorted thought process. Interpersonal theorists pose that violence stems from poor family dynamics and recommend family therapy as an intervention.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: Implement a variety of nonpharmacological nursing strategies for intervening with violent clients.

Question 28

Type: MCSA

An inpatient psychiatric unit has been operating at an unusually high acuity level over the past week resulting in numerous incidents of seclusion or restraint. A review of each violent event reveals that appropriate crisis management strategies were implemented and unit policy followed. What action is most appropriate?

1. No action is necessary; the staff is following policy appropriately.

2. Create a rotating schedule to allow staff to leave the unit for frequent brief breaks to alleviate stress.

3. Identify the characteristics of the aggressive clients so that admission criteria can be adjusted to reduce risk of violence.

4. Have an expert speak to staff about seclusion and restraint reduction strategies.

Correct Answer: 2

Rationale 1: It is highly likely that staff members are experiencing an increased amount of stress given the high client acuity, so frequent breaks will enable staff to meet personal needs and continue to perform effectively. Taking no action ignores that staff have been operating under conditions that are more stressful than usual and may need supportive measures to cope with the increased job stress. Correct crisis management strategies were followed suggesting that seclusion and restraint interventions were warranted and could not be reduced or prevented. Having an expert speak about reduction at this time could imply that staff did not perform appropriately, which is not the case. Clients with a high risk for violence need treatment, therefore, admission criteria should not be altered to prevent such clients access to treatment.

Rationale 2: It is highly likely that staff members are experiencing an increased amount of stress given the high client acuity, so frequent breaks will enable staff to meet personal needs and continue to perform effectively. Taking no action ignores that staff have been operating under conditions that are more stressful than usual and may need supportive measures to cope with the increased job stress. Correct crisis management strategies were followed suggesting that seclusion and restraint interventions were warranted and could not be reduced or prevented. Having an expert speak about reduction at this time could imply that staff did not perform appropriately, which is not the case. Clients with a high risk for violence need treatment, therefore, admission criteria should not be altered to prevent such clients access to treatment.

Rationale 3: It is highly likely that staff members are experiencing an increased amount of stress given the high client acuity, so frequent breaks will enable staff to meet personal needs and continue to perform effectively. Taking no action ignores that staff have been operating under conditions that are more stressful than usual and may need supportive measures to cope with the increased job stress. Correct crisis management strategies were followed suggesting that seclusion and restraint interventions were warranted and could not be reduced or prevented. Having an expert speak about reduction at this time could imply that staff did not perform appropriately, which is not the case. Clients with a high risk for violence need treatment, therefore, admission criteria should not be altered to prevent such clients access to treatment.

Rationale 4: It is highly likely that staff members are experiencing an increased amount of stress given the high client acuity, so frequent breaks will enable staff to meet personal needs and continue to perform effectively. Taking no action ignores that staff have been operating under conditions that are more stressful than usual and may need supportive measures to cope with the increased job stress. Correct crisis management strategies were followed suggesting that seclusion and restraint interventions were warranted and could not be reduced or prevented. Having an expert speak about reduction at this time could imply that staff did not perform appropriately, which is not the case. Clients with a high risk for violence need treatment, therefore, admission criteria should not be altered to prevent such clients access to treatment.

Global Rationale:

Cognitive Level: Creating

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: Describe common staff responses to anger and violence.

Question 29

Type: MCSA

Following a particularly violent incident which resulted in a client being placed in four-point restraints, the nurse recognizes feeling fearful of having to work with the client again. How should the nurse handle this emotion?

1. Recognize that feeling fear and getting into physical confrontations is part of the job.

2. Accept the fear, process the event with other staff, and continue working with the client.

3. Ignore feelings of fear as it would impede the nurses ability to manage the client effectively.

4. Engage in debriefing with the client to clear up hard feelings.

Correct Answer: 2

Rationale 1: Experiencing fear is normal; understanding is critical and enhanced by processing the event with others who were involved. Debriefing with the client is not intended to help the nurse feel better; it is for the clients benefit. It is not healthy to assume that violence is part of the job and that fear should be ignored.

Rationale 2: Experiencing fear is normal; understanding is critical and enhanced by processing the event with others who were involved. Debriefing with the client is not intended to help the nurse feel better; it is for the clients benefit. It is not healthy to assume that violence is part of the job and that fear should be ignored.

Rationale 3: Experiencing fear is normal; understanding is critical and enhanced by processing the event with others who were involved. Debriefing with the client is not intended to help the nurse feel better; it is for the clients benefit. It is not healthy to assume that violence is part of the job and that fear should be ignored.

Rationale 4: Experiencing fear is normal; understanding is critical and enhanced by processing the event with others who were involved. Debriefing with the client is not intended to help the nurse feel better; it is for the clients benefit. It is not healthy to assume that violence is part of the job and that fear should be ignored.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: Describe common staff responses to anger and violence.

Question 30

Type: MCSA

On the first day of clinical rotation on an inpatient psychiatric unit, nursing student A complains of nausea, sweaty palms, and stomach butterflies. Nursing student B attempts to console student A by saying, You just cant take anything these clients say personally; dont listen to a word they say. Having observed this exchange, the nursing instructor should be most concerned about:

1. Student Bs lack of appropriate fear towards this potentially dangerous environment.

2. Student Bs perception that listening to the client is unnecessary.

3. Student As fear about the psychiatric setting.

4. Student As symptoms of an impending panic attack.

Correct Answer: 2

Rationale 1: A nurses capacity to listen is critical to preventing client aggression. Feelings of fear manifested as symptoms of anxiety (nausea, sweaty palms, and butterflies) are normal for most (but not all) persons new to this environment.

Rationale 2: A nurses capacity to listen is critical to preventing client aggression. Feelings of fear manifested as symptoms of anxiety (nausea, sweaty palms, and butterflies) are normal for most (but not all) persons new to this environment.

Rationale 3: A nurses capacity to listen is critical to preventing client aggression. Feelings of fear manifested as symptoms of anxiety (nausea, sweaty palms, and butterflies) are normal for most (but not all) persons new to this environment.

Rationale 4: A nurses capacity to listen is critical to preventing client aggression. Feelings of fear manifested as symptoms of anxiety (nausea, sweaty palms, and butterflies) are normal for most (but not all) persons new to this environment.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: Analyze personal feelings and attitudes that may affect professional practice when caring for clients exhibiting anger and/or violent behavior.

Kneisl, Contemporary Psychiatric-Mental Health Nursing, 3/e Test Bank

Copyright 2012 by Pearson Education, Inc.

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