Chapter 16

Question 1

A student nurse has just entered a psychiatric rotation. The student asks a nursing instructor, “How will we know if someone may get violent?” Which is the most appropriate reply by the nursing instructor?

Answer 1

B. “Certain behaviors indicate a potential for violence. They are labeled as a ‘prodromal syndrome’ and include rigid posture, clenched fists, and raised voice.”

Question 2

A nursing instructor is teaching about the concept of anger. Which student statement indicates the need for further instruction?

Answer 2

B. “Anger and aggression are essentially the same.”

Question 3

Which client statement demonstrates improvement in anger/aggression management?

Answer 3

A. “I realize I have a problem expressing my anger appropriately.”

Question 4

A client is served divorce papers while on the inpatient psychiatric unit. When a nurse tells the client the unit telephone cannot be used after hours, the client raises his fists, swears, and spits at the nurse. Which negative coping mechanism has the client exhibited?

Answer 4

D. The defense mechanism of displacement

Question 5

A nurse is caring for four clients. Which client should the nurse identify as least prone to developing problems with anger and aggression?

Answer 5

D. An adolescent raised by Scandinavian immigrant parents

Question 6

After less restrictive means have been attempted, an order for client restraints has been obtained for a hostile, aggressive 30- year-old client. If client aggression continues, how long will the nurse expect the client to remain in restraints without a physician order renewal?

Answer 6

D. 4 hours

Question 7

An adult client assaults another client and is placed in restraints. Which statement from the client while in restraints should alert a nurse that further assessment is necessary?

Answer 7

B. “My fingers are tingly.”

Question 8

After restraints are removed from a client, the staff discusses the incident and establishes guidelines for the client’s return to the therapeutic milieu. Which unit procedure is the staff implementing?

Answer 8

D. Debriefing

Question 9

Once the nurse initiates restraint for an out-of-control 45-year-old patient, what must occur within 1 hour, according to JCAHO standards?

Answer 9

B. A physician or other licensed independent practitioner must conduct an in-person evaluation.

Question 10

For select clients, physical restraint is considered to be a beneficial intervention. This is based on which premise?

Answer 10

B. Clients with limited internal control over their behavior need external controls to prevent harm to themselves and others.

Question 11

A client diagnosed with paranoid schizophrenia has a history of aggravated assault. A nurse assigns “Risk for other-directed violence” as the client’s priority nursing diagnosis. Based on this diagnosis, which would be an appropriate, correctly written outcome for this client?

Answer 11

C. The client will not inflict harm on others during this shift.

Question 12

At 3 a.m., when less restrictive methods fail, a physician orders restraints for an angry, aggressive client. To meet Joint Commission standards, at what time and by whom should a nurse expect an in-person client evaluation?

Answer 12

B. No later than 4 a.m., by a physician or a licensed independent practitioner (LIP)

Question 13

Which risk factor should a nurse recognize as the most reliable indicator of potential client violence?

Answer 13

B. History of assaultive behavior

Question 14

A nursing instructor is teaching about violence-intervention protocols. Which student statement would indicate the need for further instruction?

Answer 14

B. “Soothing the client by stroking an arm or shoulder can be a part of violence-intervention protocols.”

Question 15

A client begins to smash furniture, cannot be “talked down,” and refuses medications. Which is the most appropriate nursing intervention?

Answer 15

A. Call a violence code.

Question 16

On an inpatient psychiatric unit, a restrained 16-year-old client continues to verbally lash out and threatens to abuse staff and kill self when released. To meet Joint Commission standards, at what time should a nurse expect the physician to renew the client’s restraint order?

Answer 16

B. Within 2 hours of the original restraint order

Question 17

A client diagnosed with brief psychotic disorder is pacing the milieu and occasionally punches the wall. Which should be the initial nursing action?

Answer 17

D. Ensure adequate physical space between the nurse and the client.

Question 18

The nurse observes a client’s escalating anger. The client begins to pace the hall and shouts, “You all better watch out. I’m going to hurt anyone who gets in my way.” Which should be the priority nursing intervention?

Answer 18

B. Remove other clients from the area and maintain milieu safety.

Question 19

The client states, “I get into trouble because I respond violently without thinking. That usually gets me into a mess.” Which nursing reply would be most therapeutic to address this client’s problem?

Answer 19

C. “Let’s explore methods to help you stop and think before taking action.”

Question 20

Which initial nursing approach makes limit-setting better accepted by clients who are aggressively acting out?

Answer 20

C. Reflecting back to the client empathy about the client’s distress

Question 21

Which nursing approach is likely to be most therapeutic when dealing with a newly admitted, hostile, suspicious client?

Answer 21

B. Slowly and matter-of-factly state, “I am your nurse and I will show you to your room.”

Question 22

A nurse notices a client clenching fists periodically and pacing the hallway. Which of the following nursing interventions would best assist the client at this time? Select all that apply.

A. Acknowledge the client’s behavior.
B. Initiate forced medication protocol.
C. Assist the client to a quiet area.
D. Initiate confinement measures.
E. Speak with a soft and calming voice.

Answer 22

A, C, E