UNIT K

Question 1

A newborn has several congenital anomalies incompatible with living beyond 1 month. The newborn cannot retain formula, and the temperature drops when the newborn is removed from the warmer. Two nurses who alternate caring for the baby argue about whether or not to attempt bottle feedings and whether the newborn should be removed from the warmer to be held. What is the origin of the conflict described?
a.
Ethical values
b.
Nursing role concerns
c.
Personal goals for advancement
d.
Personality differences

Answer 1

ANS: A
This situation depicts personal issues based on two separate sets of ethics or values regarding the newborn’s care. One nurse places value on nutritional needs and the other on the need for bonding. This conflict is not personality driven among the two nurses. The role of the nurse is to care for the newborn. They both want to care for the newborn, so they are meeting their nursing role; however, the conflict is based on an ethical issue about feeding and bonding.

Question 2

Of the following common areas of conflict between nurses and their patients and families, which does the nurse interpret as the most easily resolved?
a.
Issues of concern about quality of care
b.
Issues surrounding treatment decisions
c.
Issues of family involvement
d.
Issues about quality of parental care

Answer 2

ANS: A
Families typically are concerned with how well their loved one is being attended to. Conflict often arises out of concerns related to quality of care. Whereas this is something that the nurse can directly address, issues of treatment decisions, family involvement, and quality of parental care often require more discussion and intervention.

Question 3

What is the best strategy for resolving the conflict in a situation in which two staff nurses request the same vacation weeks?
a.
Accommodation
b.
Collaboration
c.
Competition
d.
Avoidance

Answer 3

ANS: B
Collaboration is the strategy that involves confrontation and problem solving. Needs, feelings, and desires of both parties are considered to create a win–win outcome. Avoidance is a lose–lose strategy for conflict resolution, which is unassertive and uncooperative. Competition is a win–lose situation in which the use of force or the use of power occurs. Accommodation is the lose–win situation in which one person accommodates the other at his or her own expense but often ends up feeling resentful and angry.

Question 4

On the unit in which you work, one nurse’s aide is usually pleasant and helpful; the other is often abrasive and angry. What is the most important basic guideline to be observed by a nurse who must resolve a conflict between the two nurse’s aides?
a.
Deal with issues, not personalities.
b.
Require the aides to reach a compromise.
c.
Weigh the consequences of each possible solution.
d.
Encourage ventilation of anger and use humor to minimize the conflict.

Answer 4

ANS: A
Dealing with the issues and not the personalities is one of seven important key behaviors in managing conflict. Whereas issues tend to be more concrete, personalities involve emotional issues. Although weighing the consequences is one of the seven key behaviors, it does not apply to this situation which involves the behaviors of the nurse’s aides. Asking parties to compromise may not always be the best approach in resolving the conflict. Although encouraging ventilation of anger and using humor are successful approaches, it is important to always deal with the issue at hand and not the personality of the person.

Question 5

One of your peers, a staff nurse, is a “potshot artist.” This nurse often makes you the butt of innuendo or teasing digs. You are fed up and decide to take action the next time it happens. What strategy should be considered as an effective way of dealing with a “sniper”?
a.
Clam up and allow the individual to fully ventilate her concern.
b.
Confront and tell the individual he/she is wrong.
c.
Coldly withdraw from the individual.
d.
Obtain group confirmation or denial of criticism raised by the individual.

Answer 5

ANS: D
When confronting the sniper, it is important to involve the rest of the staff to get a group consensus of denial or confirmation. Remember to always expose the sniper’s attack by saying, “That sounded like a put-down to me.” Clams tend to withdraw from the individual. Confronting the individual and telling him/her he/she is wrong are ways a Sherman tank would approach the situation because he/she has a strong need to be right.

Question 6

A staff nurse who has worked on the unit for 6 months voices the following concerns to another nurse: “The clinical nurse leader of the unit often follows me into the supply room and stands blocking the doorway and chats. The nurse leader makes opportunities to mention my good looks, muscular physique, or strength in the context of daily work, saying things like, ‘You’re so handsome; no wonder your patients like you.’ The nurse leader frequently touches me on the arm, the shoulder, chest, or the hair, and if I’m sitting, touches my leg. Yesterday, the nurse leader patted my arm and said, ‘You know, if we were dating, I might be able to give you lighter assignments.’ I don’t want to date the nurse leader. I just want to be left alone! What should I do?” What is the best reply?
a.
“Don’t be quite so honorable. Go on a date and see if you get better assignments.”
b.
“Confront the nurse leader with a description of the behavior and state that you want the behavior to stop.”
c.
“Go directly to the human relations office at the agency and tell them what you just told me.”
d.
“Contact your lawyer and get advice ASAP in case the nurse leader decides to turn the tables and accuse you of advances.”

Answer 6

ANS: B
There are two ways to deal with sexual harassment in the workplace: informally by confrontation and formally through a grievance procedure, keeping a record of all confrontations and statements in writing. The best first step is to confront the person directly. Then, if there is no stopping of the behavior, go to the human relations office and explain the situation. At this point, there is no need to contact a lawyer because the human relations office can handle the sexual harassment issue.

Question 7

To resolve a scheduling conflict, a nurse manager is using employment seniority. The nurse manager interprets this as
a.
a win–win strategy.
b.
a win–lose strategy.
c.
a lose–lose strategy.
d.
a compromise.

Answer 7

ANS: B
This is an example of a win–lose strategy, which underpins competition as the method of resolving the conflict. The person with the more seniority wins, and the one with the lesser seniority loses the scheduling issue. Compromise or bargaining is a modified win–lose strategy. In this instance, there is no compromise as the nurse manager uses seniority to resolve the conflict. Avoidance is a lose–lose strategy for conflict resolution, which is unassertive and uncooperative. Win–win strategies involve collaboration and problem solving, which lead to cooperation and objectivity.

Question 8

The nurse manager is attempting to resolve an interpersonal conflict between two nurses. Which action below should be done first?
a.
Determine the facts related to the situation.
b.
Schedule a meeting time for resolution.
c.
Have an accurate understanding of the problem or conflict.
d.
Have the determination to resolve the conflict.

Answer 8

ANS: C
The first step is to make sure that the nurse manager has an accurate understanding of the problem or conflict. The quality of the outcome of resolving a problem depends on proper recognition and identification of the problem or issue. This assessment is best addressed by determining the nature of the differences and the reasons for them. After this has been achieved, the next steps would be identifying the conflicting facts and developing ways to implement a plan for resolution.

Question 9

During a staff meeting, an upset nursing assistant tells the group that the other nursing assistants are given easier patient assignments and are always given their choice of days off. What approach by the nurse manager would be effective to resolve this conflict?
a.
Attempt to persuade the upset nursing assistant to calm down.
b.
Tell the group that this type of conversation needs to be handled privately.
c.
Consider transferring the upset nursing assistant to another unit.
d.
Acknowledge the feelings of the upset nursing assistant and make a plan to meet.

Answer 9

ANS: D
Acknowledging the nursing assistant’s feelings is the first step in conflict resolution. This process requires dealing with issues, not personalities, by communicating openly, listening actively to the complaints, sorting out the issues, identifying key themes of the discussion, and weighing the consequences and options to resolve the conflict. Transferring the upset person avoids dealing with the conflict.

Question 10

Consider the following terms used to label different styles of handling anger—the Sherman tank, the sniper, the constant complainer, and the clam. Which of the following comments would you expect a Sherman tank to make?
a.
“That sure sounded like a put-down to me.”
b.
“How dare you accuse me of not putting away the linen!”
c.
“So, you think you know everything, eh?”
d.
“Why do we always have to rotate shifts?”

Answer 10

ANS: B
Sherman tanks attack individuals and have a strong need to prove to themselves and to others that their view of a situation is right. Their comments are abusive and abrupt and can be intimidating. Snipers take “potshots” at others and are not as openly aggressive as Sherman tanks. Constant complainers do just that—they complain but offer no solution. Clams also behave like their name—they clam up and refuse to respond when you need an answer or want to talk.

Question 11

Which action by the nurse has a potential for creating role conflict?
a.
Arguing that the nurse on the next shift is responsible for weighing a patient
b.
Failing to discuss differences with a coworker the nurse is angry with
c.
Placing the nurse’s personal achievement over that of coworkers
d.
Trying to change another nurse’s personality

Answer 11

ANS: A
Arguing with another nurse about whose responsibility it is to weigh a patient is an example of a role conflict. Failing to discuss differences is a communication conflict. Placing personal achievements about those of others is goal conflict. Trying to change another nurse’s personality is personality conflict.

Question 12

Which of the following scenarios shows an ethical conflict?
a.
A nurse who consistently speaks poorly of another nurse for always being “grumpy”
b.
A nurse who has a hard time respecting “no codes” on young patients
c.
A nurse who refuses to run a systems check on the glucometers because “it’s night shift’s duty”
d.
A nurse who forgets to alert family members to a change in visiting hours

Answer 12

ANS: B
A nurse who has a hard time respecting “no codes” on young patients is experiencing an ethical conflict. A nurse who speaks poorly of another nurse has a personality conflict. A nurse who refuses to run controls on a glucometer has a role conflict. A nurse who forgets to alert family members to a change in visiting hours has a communication conflict.

Question 13

A nurse is aware that an area of conflict between nurses and patients’ families is quality of parental care. Which action would not help the nurse reduce conflict?
a.
Become frustrated with the parents for lack of participation in care.
b.
Model positive parenting techniques.
c.
Encourage parents to meet other parents.
d.
Give out information about parenting classes.

Answer 13

ANS: A
To reduce conflict that nurse can model positive parenting techniques, encourage parents to meet other parents and give out information about parenting classes. The nurse should avoid becoming frustrated with parents because this will likely cause conflict.

Question 14

What can staff nurses do to reduce conflict with patients and families?
a.
Allow nurses to enforce what they feel comfortable with.
b.
Keep treatment decisions between the patient and health care team only.
c.
Do not allow family to participate in patient care.
d.
Maintain consistency in enforcing rules and policies

Answer 14

ANS: D
To reduce conflict with patients and families, the nurse can maintain consistency in enforcing rules and policies. Allowing each nurse to enforce rules they are comfortable with, keeping treatment decisions between the patient and the health care team, and not allowing family to participate in care may increase conflict.

Question 15

A nurse is frustrated about being scheduled on a holiday that had been requested off, but a new nurse with less seniority was given the holiday off. Which action by the nurse shows accommodation?
a.
The nurse works out a schedule change with the new nurse.
b.
The nurse doesn’t mention the issue but feels angry and frustrated.
c.
The nurse works the holiday while the new nurse has the day off.
d.
The nurse requests to have the day before the holiday off.

Answer 15

ANS: C
Accommodation occurs when the nurse decides to work the holiday while the new nurse has the holiday off. Collaboration occurs when the nurses work out a schedule change. Avoidance occurs when the nurse doesn’t bring the issue to the attention of the new nurse but feels angry and frustrated. Compromise occurs when the nurse requests to have the day before the holiday off.

Question 16

A nurse feels angry over a patient assignment and feels that assignments always include the “bad ones.” What is the best way to control this anger?
a.
Ignore the negative feelings.
b.
Talk about the charge nurse in order to vent.
c.
Face this anger and determine what is being felt.
d.
Refuse to speak to any coworkers for fear of lashing out.

Answer 16

ANS: C
The nurse should face the anger and determine what is being felt. Ignoring angry feelings, talking about coworkers behind their backs, and ignoring others will not help to resolve the anger.

Question 17

Which statement by the nurse is true regarding sexual harassment?
a.
“Sexual harassment no longer occurs in the workplace.”
b.
“Sexual harassment is only caused by men.”
c.
“The most common sexual harassment complaint is inappropriate remarks and touching.”
d.
“Nothing can be done to prove sexual harassment.”

Answer 17

ANS: C
The most common sexual harassment complaint is inappropriate remarks and touching. The statements that “sexual harassment no longer occurs in the workplace,” “sexual harassment is only caused by men,” and “nothing can be done to prove sexual harassment” are false.

Question 18

A female nurse is experiencing sexual harassment in the workplace by a male nurse. Which action should this nurse take to stop the sexual harassment?
a.
Ignore the comments made by the male nurse.
b.
Laugh about the comments.
c.
Tell the male nurse to stop.
d.
Begin to sexually harass the male nurse.

Answer 18

ANS: C
The nurse should take the most direct route and tell the male nurse to stop. Ignoring the comments, laughing at them, or sexually harassing the male nurse will not stop the harassment.

Question 19

What action(s) by the staff nurse is an effective way to deal with a sexual harassment issue in the workplace? (Select all that apply.)
a.
Tell the person to stop.
b.
Tell your best friend about the incident.
c.
File a formal grievance.
d.
Explain the situation to your spouse.
e.
Play along with the person and document the activities.
f.
Threaten the person with a sexual harassment lawsuit.

Answer 19

ANS: A, B, C, D
There are two ways to deal with sexual harassment workplace conflict, informally and formally through a grievance procedure. Start with the most direct measure. Ask the person to STOP! Tell the harasser in clear terms that the behavior makes you uncomfortable and that you want it to stop immediately. In addition, put your statement in writing to the person, keeping a copy for yourself. It is also important to tell other people (e.g., family members, friends, your personal physician, your minister) that this is happening and how you are dealing with it.

Question 20

Which of the following are common factors of conflict encountered in nursing? (Select all that apply.)
a.
Ambiguous boundaries around work responsibilities
b.
Unclear communication to family members about visiting hours
c.
Nursing assistant placing personal achievement above everything
d.
Chief of medicine demanding that the nurse/patient ratio be increased
e.
Consideration of 26-week termination of pregnancy by a physician because of mother’s health
f.
Vacation schedules posted with new staff members having to work at least one day during all holidays

Answer 20

ANS: A, B, C, D, E, F
All of these areas are potential factors that can precipitate conflict in a nursing situation—roles, communication, goals, personalities, and conflicting ethics and values.

Question 21

What is important for the nurse manager to understand about resolving conflict in the workplace? (Select all that apply.)
a.
Realize that most new graduates use competition as a form of conflict response.
b.
Effective role socialization reduces negative conflict behaviors among nursing staff.
c.
Use of collaboration to solve conflict issues is an important strategy to encourage.
d.
Thinking like a nurse promotes role socialization and reduces conflict.
e.
Nurse managers need to create working environments that facilitate professional practice.
f.
High self-esteem fosters entitlement-type behavior that promotes conflict.

Answer 21

ANS: B, C, D, E
New graduates use compromise and avoidance as primary means of conflict resolution based on current research. High self-esteem is often found in empowering workplace environments where successful positive conflict resolution occurs. Effective role socialization, positive professional practice environments, using collaboration, and thinking like a nurse are noted in effective conflict resolution situations.

Question 22

What are some positive results that can come from conflict? (Select all that apply.)
a.
Disturbing issues are brought out, which may lead to more serious conflict.
b.
Group cohesiveness may increase as individuals resolve issues.
c.
Results of conflict can be constructive.
d.
Groups can learn from each other.
e.
Talking about issues can avert serious conflict.

Answer 22

ANS: B, C, D, E
Positive aspects of conflict include group cohesiveness increasing as individuals resolve issues, results of conflict being constructive, and groups learning from each other and talking about issues can avert serious conflict.

Question 23

A nurse is caring for an older adult patient when conflict regarding treatment arises between the family and the health care provider. What can the nurse do to resolve this conflict? (Select all that apply.)
a.
Defend the health care provider’s treatment, and try to explain it to the family.
b.
Try to convince the family that the health care provider knows what is best for the patient.
c.
Allow the family to participate in the decision-making process for their loved one.
d.
Encourage the family to speak directly to the health care provider regarding treatments.
e.
Clarify the health care provider’s order with the family.

Answer 23

ANS: C, D, E
The nurse should avoid defending the health care provider’s treatment and convincing the family that the health care provider knows what is best. Instead the nurse should allow the family to participate in the decision-making process, encourage the family to speak directly to the health care provider regarding treatments, and clarify orders with the family.

Question 24

Which of the following statements by the nurse about unresolved conflict are true? (Select all that apply.)
a.
“Conflict makes nursing staff more productive.”
b.
“Conflict reduces productivity among staff.”
c.
“Conflict wastes time.”
d.
“Conflict wastes energy.”
e.
“Conflict increases teamwork.”

Answer 24

ANS: B, C, D
Unresolved conflict reduces productivity, decreases teamwork, and wastes time and energy. Nursing staff are not more productive with unresolved conflict, and this type of conflict does not increase teamwork.

Question 25

What actions can a nurse implement into daily practice to reduce conflict? (Select all that apply.)
a.
Deal with issues and not personalities.
b.
Worry about themselves and no one else.
c.
Communicate openly.
d.
Listen actively.
e.
Sort out issues.

Answer 25

ANS: A, C, D, E
To reduce conflict, nurses can implement the following actions into their daily practice: deal with issues and not personalities, communicate openly, listen actively, and sort out issues.

Question 26

An adult outpatient diagnosed with major depressive disorder has a history of several suicide attempts by overdose. Given this patient’s history and diagnosis, which antidepressant medication would the nurse expect to be prescribed?

a. Amitriptyline
b. Fluoxetine
c. Desipramine
d. Tranylcypromine sulfate

Answer 26

ANS: B
Selective serotonin reuptake inhibitor antidepressants are very safe in overdosage situations, which is not true of the other medications listed. Given this patient’s history of overdosing, it is important that the medication be as safe as possible in the event of another overdose of prescribed medication.

Question 27

Four individuals have given information about their suicide plans. Which plan evidences the
highest suicide risk?
a. Turning on the oven and letting gas escape into the apartment during the night
b. Cutting the wrists in the bathroom while the spouse reads in the next room
c. Overdosing on aspirin with codeine while the spouse is out with friends
d. Jumping from a railroad bridge located in a deserted area late at night

Answer 27

ANS: D
This is a highly lethal method with little opportunity for rescue. The other options are lower lethality methods with higher rescue potential. See relationship to audience response question.

Question 28

Which measure would be considered a form of primary prevention for suicide?

a. Psychiatric hospitalization of a suicidal patient
b. Referral of a formerly suicidal patient to a support group
c. Suicide precautions for 24 hours for newly admitted patients
d. Helping school children learn to manage stress and be resilient

Answer 28

ANS: D
This measure promotes effective coping and reduces the likelihood that such children will become suicidal later in life. Admissions and suicide precautions are secondary prevention measures. Support group referral is a tertiary prevention measure.

Question 29

Which change in the brain’s biochemical function is most associated with suicidal behavior?

a. Dopamine excess
b. Serotonin deficiency
c. Acetylcholine excess
d. -aminobutyric acid deficiency

Answer 29

ANS: B
Research suggests that low levels of serotonin may play a role in the decision to commit suicide. The other neurotransmitter alterations have not been implicated in suicidality.

Question 30

A college student who failed two tests cried for hours and then tried to telephone a parent but got no answer. The student then gave several expensive sweaters to a roommate and asked to be left alone for a few hours. Which behavior provides the strongest clue of an impending suicide attempt?

a. Calling parents
b. Excessive crying
c. Giving away sweaters
d. Staying alone in dorm room

Answer 30

ANS: C
Giving away prized possessions may signal that the individual thinks he or she will have no further need for the item, such as when a suicide plan has been formulated. Calling parents, remaining in a dorm, and crying do not provide direct clues to suicide.

Question 31

A nurse uses the SAD PERSONS scale to interview a patient. This tool provides data relevant to

a. current stress level.
b. mood disturbance.
c. suicide potential.
d. level of anxiety.

Answer 31

ANS: C
The SAD PERSONS tool evaluates 10 major risk factors in suicide potential: sex, age, depression, previous attempt, ethanol use, rational thinking loss, social supports lacking, organized plan, no spouse, and sickness. The tool does not have categories to provide information on the other options listed.

Question 32

A person intentionally overdosed on antidepressants. Which nursing diagnosis has the highest priority?

a. Powerlessness
b. Social isolation
c. Risk for suicide
d. Compromised family coping

Answer 32

ANS: C
This diagnosis is the only one with life-or-death ramifications and is therefore of higher priority than the other options.

Question 33

A person who attempted suicide by overdose was treated in the emergency department and then hospitalized. The initial outcome is that the patient will

a. verbalize a will to live by the end of the second hospital day.
b. describe two new coping mechanisms by the end of the third hospital day.
c. accurately delineate personal strengths by the end of first week of hospitalization.
d. exercise suicide self-restraint by refraining from attempts to harm self for 24 hours.

Answer 33

ANS: D
Suicide self-restraint relates most directly to the priority problem of risk for self-directed violence. The other outcomes are related to hope, coping, and self-esteem.

Question 34

A college student who attempted suicide by overdose was hospitalized. When the parents were contacted, they responded, “We should have seen this coming. We did not do enough.” The parents’ reaction reflects

a. guilt.
b. denial.
c. shame.
d. rescue feelings.

Answer 34

ANS: A
The parents’ statements indicate guilt. Guilt is evident from the parents’ self-chastisement. The feelings suggested in the distracters are not clearly described in the scenario.

Question 35

Select the most critical question for the nurse to ask an adolescent who has threatened to take an overdose of pills.

a. “Why do you want to kill yourself?”
b. “Do you have access to medications?”
c. “Have you been taking drugs and alcohol?”
d. “Did something happen with your parents?”

Answer 35

ANS: B
The nurse must assess the patient’s access to means to carry out the plan and, if there is access, alert the parents to remove from the home and take additional actions to assure the patient’s safety. The information in the other questions may be important to ask but are not the most critical.

Question 36

It has been 5 days since a suicidal patient was hospitalized and prescribed an antidepressant medication. The patient is now more talkative and shows increased energy. Select the highest priority nursing intervention.

a. Supervise the patient 24 hours a day.
b. Begin discharge planning for the patient.
c. Refer the patient to art and music therapists.
d. Consider discontinuation of suicide precautions.

Answer 36

ANS: A
The patient now has more energy and may have decided on suicide, especially given the prior
suicide attempt history. The patient must be supervised 24 hours per day. The patient is still a suicide risk.

Question 37

A nurse and patient construct a no-suicide contract. Select the preferable wording.

a. “I will not try to harm myself during the next 24 hours.”
b. “I will not make a suicide attempt while I am hospitalized.”
c. “For the next 24 hours, I will not in any way attempt to harm or kill myself.”
d. “I will not kill myself until I call my primary nurse or a member of the staff.”

Answer 37

ANS: C
The correct answer leaves no loopholes. The wording about not harming oneself and not making an attempt leaves loopholes or can be ignored by the patient who thinks “I am not going to harm myself, I am going to kill myself” or “I am not going to attempt suicide, I am going to commit suicide.” A patient may call a therapist and leave the telephone to carry out the suicidal plan.

Question 38

A tearful, anxious patient at the outpatient clinic reports, “I should be dead.” The initial task of the nurse conducting the assessment interview is to

a. assess lethality of suicide plan.
b. encourage expression of anger.
c. establish trust with the patient.
d. determine risk factors for suicide.

Answer 38

ANS: C
This scenario presents a potential crisis. Establishing trust facilitates a therapeutic alliance that will allow the nurse to obtain relevant assessment data such as the presence of a suicide plan, lethality of plan, and presence of risk factors for suicide.

Question 39

A nurse interacts with an outpatient who has a history of multiple suicide attempts. Select the most helpful response for a nurse to make when the patient states, “I am considering committing suicide.”

a. “I’m glad you shared this. Please do not worry. We will handle it together.”
b. “I think you should admit yourself to the hospital to keep you safe.”
c. “Bringing up these feelings is a very positive action on your part.”
d. “We need to talk about the good things you have to live for.”

Answer 39

ANS: C
The correct response gives the patient reinforcement, recognition, and validation for making a
positive response rather than acting out the suicidal impulse. It gives neither advice nor false
reassurance, and it does not imply stereotypes such as “You have a lot to live for.” It uses the patient’s ambivalence and sets the stage for more realistic problem solving.

Question 40

Which intervention will the nurse recommend for the distressed family and friends of someone who has committed suicide?

a. Participating in reminiscence therapy
b. Psychological postmortem assessment
c. Attending a self-help group for survivors
d. Contracting for at least two sessions of group therapy

Answer 40

ANS: C
Survivors need outlets for their feelings about the loss and the deceased person. Self-help groups provide peer support while survivors work through feelings of loss, anger, and guilt. Psychological postmortem assessment would not provide the support necessary to work through feelings of loss associated with the suicide. Reminiscence therapy is not geared to loss resolution. Contracting for two sessions of group therapy would not provide sufficient time to work through the issues associated with a death by suicide.

Question 41

Which statement provides the best rationale for closely monitoring a severely depressed patient during antidepressant medication therapy?

a. As depression lifts, physical energy becomes available to carry out suicide.
b. Patients who previously had suicidal thoughts need to discuss their feelings.
c. For most patients, antidepressant medication results in increased suicidal thinking.
d. Suicide is an impulsive act. Antidepressant medication does not alter impulsivity.

Answer 41

ANS: A
Antidepressant medication has the objective of relieving depression. Risk for suicide is greater as the depression lifts, primarily because the patient has more physical energy at a time when he or she may still have suicidal ideation. The other options have little to do with nursing interventions relating to antidepressant medication therapy.

Question 42

A nurse assesses a patient who reports a 3-week history of depression and periods of uncontrolled crying. The patient says, “My business is bankrupt, and I was served with divorce papers.” Which subsequent statement by the patient alerts the nurse to a concealed suicidal message?

a. “I wish I were dead.”
b. “Life is not worth living.”
c. “I have a plan that will fix everything.”
d. “My family will be better off without me.”

Answer 42

ANS: C
Verbal clues to suicide may be overt or covert. The incorrect options are overt references to suicide. The correct option is more veiled. It alludes to the patient’s suicide as being a way to “fix everything” but does not say it outright.

Question 43

A depressed patient says, “Nothing matters anymore.” What is the most appropriate response by the nurse?

a. “Are you having thoughts of suicide?”
b. “I am not sure I understand what you are trying to say.”
c. “Try to stay hopeful. Things have a way of working out.”
d. “Tell me more about what interested you before you became depressed.”

Answer 43

ANS: A
The nurse must make overt what is covert; that is, the possibility of suicide must be openly addressed. The patient often feels relieved to be able to talk about suicidal ideation.

Question 44

A nurse counsels a patient with recent suicidal ideation. Which is the nurse’s most therapeutic comment?

a. “Let’s make a list of all your problems and think of solutions for each one.”
b. “I’m happy you’re taking control of your problems and trying to find solutions.”
c. “When you have bad feelings, try to focus on positive experiences from your life.”
d. “Let’s consider which problems are very important and which are less important.”

Answer 44

ANS: D
The nurse helps the patient develop effective coping skills. Assist the patient to reduce the overwhelming effects of problems by prioritizing them. The incorrect options continue to present overwhelming approaches to problem solving.

Question 45

When assessing a patient’s plan for suicide, what aspect has priority?

a. Patient’s financial and educational status
b. Patient’s insight into suicidal motivation
c. Availability of means and lethality of method
d. Quality and availability of patient’s social support

Answer 45

ANS: C
If a person has plans that include choosing a method of suicide readily available and if the
method is one that is lethal (i.e., will cause the person to die with little probability for
intervention), the suicide risk is high. These areas provide a better indication of risk than the
areas mentioned in the other options. See relationship to audience response question.

Question 46

The feeling experienced by a patient that should be assessed by the nurse as most predictive of elevated suicide risk is

a. hopelessness.
b. sadness.
c. elation.
d. anger.

Answer 46

ANS: A
Of the feelings listed, hopelessness is most closely associated with increased suicide risk. Depression, aggression, impulsivity, and shame are other feelings noted as risk factors for suicide.

Question 47

Which statement by a depressed patient will alert the nurse to the patient’s need for immediate, active intervention?

a. “I am mixed up, but I know I need help.”
b. “I have no one to turn to for help or support.”
c. “It is worse when you are a person of color.”
d. “I tried to get attention before I cut myself last time.”

Answer 47

ANS: B
Hopelessness is evident. Lack of social support and social isolation increases the suicide risk. Willingness to seek help lowers risk. Being a person of color does not suggest higher risk because more whites commit suicide than do individuals of other racial groups. Attention seeking is not correlated with higher suicide risk.

Question 48

A patient previously hospitalized for 2 weeks committed suicide the day after discharge. Which initial nursing measure will be most important regarding this event?
a. Request the information technology manager to verify the patient’s medical record
is secure in the hospital information system.
b. Hold a meeting for staff to provide support, express feelings, and identify
overlooked clues or faulty judgments.
c. Consult the hospital’s legal department regarding potential consequences of the
event.
d. Document a report of a sentinel event in the patient’s medical record.

Answer 48

ANS: B
Support and an opportunity for staff to safely express feelings about the event should occur
first. Interventions should help the staff come to terms with the loss and grow because of the
incident. Identifying overlooked clues or faulty judgments will provide the groundwork for
identifying changes needed in policies and procedures for future patients. Consulting the legal department is not an initial measure. A sentinel event report is not part of the medical record and can be prepared later. The other incorrect options will not control information or would result in unsafe care.

Question 49

After one of their identical twin daughters commits suicide, the parents express concern that the other twin may also have suicidal tendencies. Which reply should the nurse provide?

a. “Genetics are associated with suicide risk. Monitoring and support are important.”
b. “Apathy underlies suicide. Instilling motivation is the key to health maintenance.”
c. “Your child is unlikely to act out suicide when identifying with a suicide victim.”
d. “Fraternal twins are at higher risk for suicide than identical twins.

Answer 49

ANS: A
Twin studies suggest the presence of genetic factors in suicide; however, separating genetic predisposition to suicide from predisposition to depression or alcoholism is difficult. Primary interventions can be helpful in promoting and maintaining health and possibly counteracting genetic load. The incorrect options are untrue statements or an oversimplification.

Question 50

Which individual in the emergency department should be considered at highest risk for completing suicide?
a. An adolescent Asian American girl with superior athletic and academic skills who
has asthma
b. A 38-year-old single, African American female church member with fibrocystic
breast disease
c. A 60-year-old married Hispanic man with 12 grandchildren who has type 2
diabetes
d. A 79-year-old single, white male diagnosed recently with terminal cancer of the
prostate

Answer 50

ANS: D
High-risk factors include being an older adult, single, male, and having a co-occurring medical illness. Cancer is one of the somatic conditions associated with increased suicide risk. Protective factors for African American women and Hispanic individuals include strong religious and family ties. Asian Americans have a suicide rate that increases with age.

Question 51

A nurse assesses five newly hospitalized patients. Which patients have the highest suicide risk? (Select all that apply.)

a. 82-year-old white male
b. 17-year-old white female
c. 22-year-old Hispanic male
d. 19-year-old Native American male
e. 39-year-old African American male

Answer 51

ANS: A, B, D
Whites have suicide rates almost twice those of nonwhites, and the rate is particularly high for older adult males, adolescents, and young adults. Other high-risk groups include young African American males, Native American males, and older Asian Americans. Rates are not high for Hispanic males.

Question 52

Which nursing interventions will be implemented for a patient who is actively suicidal? (Select all that apply.)

a. Maintain arm’s length, one-on-one direct observation at all times.
b. Check all items brought by visitors and remove risk items.
c. Use plastic eating utensils; count utensils upon collection.
d. Remove the patient’s eyeglasses to prevent self-injury.
e. Interact with the patient every 15 minutes.

Answer 52

ANS: A, B, C
One-on-one observation is necessary for anyone who has limited or unreliable control over suicidal impulses. Finger foods allow the patient to eat without silverware; “no silver or glassware” orders restrict access to a potential means of self-harm. Every-15-minute checks are inadequate to assure the safety of an actively suicidal person. Placement in a public area is not a substitute for arm’s-length direct observation; some patients will attempt suicide even when others are nearby. Vision impairment requires eyeglasses (or contacts); although they could be used dangerously, watching the patient from arm’s length at all times would allow enough time to interrupt such an attempt and would prevent the disorientation and isolation that uncorrected visual impairment could create.

Question 53

A college student is extremely upset after failing two examinations. The student said, “No one understands how this will hurt my chances of getting into medical school.” The student then suspends access to his social networking website and turns off his cell phone. Which suicide risk factors are evident? (Select all that apply.)

a. Shame
b. Panic attack
c. Humiliation
d. Self-imposed isolation
e. Recent stressful life event

Answer 53

ANS: A, C, D, E
Failing examinations in the academic major constitutes a recent stressful life event. Shame
and humiliation related to the failure can be hypothesized. The statement, “No one can
understand,” can be seen as recent lack of social support. Terminating access to one’s social networking site and turning off the cell phone represents self-imposed isolation. The scenario does not provide evidence of panic attack.

Question 54

A patient comes to the crisis clinic after an unexpected job termination. The patient paces, sobs, cringes when approached, and responds to questions with only shrugs or monosyllables. Choose the nurse’s best initial comment to this patient.
a. “Everything is going to be all right. You are here at the clinic and the staff will
keep you safe.”
b. “I see you are feeling upset. I’m going to stay and talk with you to help you feel
better.”
c. “You need to try to stop crying and pacing so we can talk about your problems.”
d. “Let’s set some guidelines and goals for your visit here.”

Answer 54

ANS: B
A crisis exists for this patient. The two primary thrusts of crisis intervention are to provide for the safety of the individual and use anxiety-reduction techniques to facilitate use of inner resources. The nurse offers therapeutic presence, which provides caring, ongoing observation relative to the patient’s safety, and interpersonal reassurance.

Question 55

A patient is seen in the clinic for superficial cuts on both wrists. Initially the patient paces and sobs but after a few minutes, the patient is calmer. The nurse attempts to determine the patient’s perception of the precipitating event by asking:

a. “Tell me why you were crying.”
b. “How did your wrists get injured?”
c. “How can I help you feel more comfortable?”
d. “What was happening when you started feeling this way?”

Answer 55

ANS: D
A clear definition of the immediate problem provides the best opportunity to find a solution. Asking about recent upsetting events facilitates assessment of the precipitating event. The patient is unlikely to be able to articulate what interventions will increase feelings of comfort. “Why” questions are nontherapeutic.

Question 56

A patient comes to the crisis center saying, “I’m in a terrible situation. I don’t know what to do.” The triage nurse can initially assume that the patient is

a. suicidal.
b. anxious and fearful.
c. misperceiving reality.
d. potentially homicidal.

Answer 56

ANS: B
Individuals in crisis are universally anxious. They are often frightened and may be mildly confused. Perceptions are often narrowed with anxiety.

Question 57

An adolescent comes to the crisis clinic and reports sexual abuse by an uncle. The adolescent told both parents about the uncle’s behavior, but the parents did not believe the adolescent. What type of crisis exists?

a. Maturational
b. Tertiary
c. Situational
d. Organic

Answer 57

ANS: C
A situational crisis arises from events that are extraordinary, external rather than internal, and often unanticipated. Sexual molestation falls within this classification. Maturational crisis occurs as an individual arrives at a new stage of development, when old coping styles may be ineffective. “Organic” and “Tertiary” are not types of crisis.

Question 58

While conducting the initial interview with a patient in crisis, the nurse should

a. speak in short, concise sentences.
b. convey a sense of urgency to the patient.
c. be forthright about time limits of the interview.
d. let the patient know the nurse controls the interview.

Answer 58

ANS: A
Severe anxiety narrows perceptions and concentration. By speaking in short concise sentences, the nurse enables the patient to grasp what is being said. Conveying urgency will increase the patient’s anxiety. Letting the patient know who controls the interview or stating that time is limited is nontherapeutic.

Question 59

An adult seeks counseling after the spouse was murdered. The adult angrily says, “I hate the beast that did this. It has ruined my life. During the trial, I don’t know what I’ll do if the jury doesn’t return a guilty verdict.” What is the nurse’s highest priority response?
a. “Would you like to talk to a psychiatrist about some medication to help you cope
during the trial?”
b. “What resources do you need to help you cope with this situation?”
c. “Do you have enough support from your family and friends?”
d. “Are you having thoughts of hurting yourself or others?”

Answer 59

ANS: D
The highest nursing priority is safety. The nurse should assess suicidal and homicidal potential. The distracters are options, but the highest priority is safety.

Question 60

Six months ago, a woman had a prophylactic double mastectomy because of a family history of breast cancer. One week ago, this woman learned her husband was involved in an extramarital affair. The woman tearfully says to the nurse, “What else can happen?” What type of crisis is this person experiencing?

a. Maturational
b. Mitigation
c. Situational
d. Recurring

Answer 60

ANS: C
Severe physical or mental illness is a potential cause of a situational crisis. The potential loss of a loved one also serves as a potential cause of a situational crisis. Maturational crisis occurs as an individual arrives at a new stage of development, when old coping styles may be ineffective. No classification of recurring crisis exists. Mitigation refers to attempts to limit a disaster’s impact on human health and community function.

Question 61

A woman said, “I can’t take anymore! Last year my husband had an affair and now we don’t communicate. Three months ago, I found a lump in my breast. Yesterday my daughter said she’s quitting college.” What is the nurse’s priority assessment?

a. Identify measures useful to help improve the couple’s communication.
b. The patient’s feelings about the possibility of having a mastectomy
c. Whether the husband is still engaged in an extramarital affair
d. Clarify what the patient means by “I can’t take anymore.”

Answer 61

ANS: D
During crisis intervention, the priority concern is patient safety. This question helps assess personal coping skills. The other options are incorrect because the focus of crisis intervention is on the event that occurred immediately before the patient sought help.

Question 62

Six months ago, a woman had a prophylactic double mastectomy because of a family history of breast cancer. One week ago, this woman learned her husband was involved in an extramarital affair. The woman says tearfully, “What else can happen?” If the woman’s immediate family is unable to provide sufficient support, the nurse should

a. suggest hospitalization for a short period.
b. ask what other relatives or friends are available for support.
c. tell the patient, “You are a strong person. You can get through this crisis.”
d. foster insight by relating the present situation to earlier situations involving loss.

Answer 62

ANS: B
The assessment of situational supports should continue. Even though the patient’s nuclear family may not be supportive, other situational supports may be available. If they are adequate, admission to an inpatient unit will be unnecessary. Psychotherapy is not appropriate for crisis intervention. Advice is usually nontherapeutic.

Question 63

A woman says, “I can’t take anymore. Last year my husband had an affair and now we do not communicate. Three months ago, I found a lump in my breast. Yesterday my daughter said she’s quitting college and moving in with her boyfriend.” Which issue should the nurse focus on during crisis intervention?

a. The possible mastectomy
b. The disordered family communication
c. The effects of the husband’s extramarital affair
d. Coping with the reaction to the daughter’s events

Answer 63

ANS: D
The focus of crisis intervention is on the most recent problem: “the straw that broke the
camel’s back.” The patient had coped with the breast lesion, the husband’s infidelity, and the
disordered communication. Disequilibrium occurred only with the introduction of the
daughter leaving college and moving.

Question 64

A patient who is visiting the crisis clinic for the first time asks, “How long will I be coming here?” The nurse’s reply should consider that the usual duration of crisis intervention is

a. 1 to 2 weeks.
b. 3 to 4 weeks.
c. 4 to 6 weeks.
d. 8 to 12 weeks.

Answer 64

ANS: C
The disorganization associated with crisis is so distressing that it usually cannot be tolerated for more than 4 to 6 weeks. If it is not resolved by that time, the individual usually adopts dysfunctional behaviors that reduce anxiety without solving the problem. Crisis intervention can shorten the duration.

Question 65

A student falsely accused a college professor of sexual intimidation. The professor tells the nurse, “I cannot teach nor do any research. My mind is totally preoccupied with these false accusations.” What is the priority nursing diagnosis?

a. Ineffective denial related to threats to professional identity
b. Deficient knowledge related to sexual harassment protocols
c. Impaired social interaction related to loss of teaching abilities
d. Ineffective coping related to distress from false accusations

Answer 65

ANS: D
Ineffective coping may be evidenced by inability to meet basic needs, inability to meet role expectations. This nursing diagnosis is the priority because it reflects the consequences of the precipitating event associated with the professor’s crisis. There is no evidence of denial. Deficient knowledge may apply, but it is not the priority. Data are not present to diagnose impaired social interaction.

Question 66

Which communication technique will the nurse use more in crisis intervention than traditional counseling?

a. Role modeling
b. Giving direction
c. Information giving
d. Empathic listening

Answer 66

ANS: B
The nurse working in crisis intervention must be creative and flexible in looking at the
patient’s situation and suggesting possible solutions to the patient. Giving direction is part of
the active role a crisis intervention therapist takes. The other options are used equally in crisis
intervention and traditional counseling roles.

Question 67

Which situation demonstrates use of primary intervention related to crisis?

a. Implementation of suicide precautions for a depressed patient
b. Teaching stress-reduction techniques to a first-year college student
c. Assessing coping strategies used by a patient who attempted suicide
d. Referring a patient diagnosed with schizophrenia to a partial hospitalization program

Answer 67

ANS: B
Primary care-related crisis intervention promotes mental health and reduces mental illness. The incorrect options are examples of secondary or tertiary interventions.

Question 68

A victim of intimate partner violence comes to the crisis center seeking help. Crisis intervention strategies the nurse applies will focus on

a. supporting emotional security and reestablishing equilibrium.
b. long-term resolution of issues precipitating the crisis.
c. promoting growth of the individual.
d. providing legal assistance.

Answer 68

ANS: A
Strategies of crisis intervention address the immediate cause of the crisis and restoration of emotional security and equilibrium. The goal is to return the individual to the precrisis level of function. Crisis intervention is, by definition, short term. The correct response is the most global answer. Promoting growth is a focus of long-term therapy. Providing legal assistance might or might not be applicable.

Question 69

After celebrating the fortieth birthday, an individual becomes concerned with the loss of youthful appearance. What type of crisis has occurred?

a. Reactive
b. Situational
c. Maturational
d. Body image

Answer 69

ANS: C
Maturational crises occur when a person arrives at a new stage of development and finds that old coping styles are ineffective but has not yet developed new strategies. Situational crises arise from sources external to the individual. “Reactive” and “body image” are not types of crisis.

Question 70

Which scenario is an example of a situational crisis?

a. The death of a child from sudden infant death syndrome
b. Development of a heroin addiction
c. Retirement of a 55-year-old person
d. A riot at a rock concert

Answer 70

ANS: D
The rock concert riot is unplanned, accidental, violent, and not a part of everyday life. The incorrect options are examples of maturational crises.

Question 71

Which agency provides coordination in the event of a terrorist attack?

a. Food and Drug Administration (FDA)
b. Environmental Protection Agency (EPA)
c. National Incident Management System (NIMS)
d. Federal Emergency Management Agency (FEMA)

Answer 71

ANS: C
The NIMS provides a systematic approach to guide departments and agencies at all levels of government, nongovernmental organizations, and the private sector during disaster situations.

Question 72

During the initial interview at the crisis center, a patient says, “I’ve been served with divorce papers. I’m so upset and anxious that I can’t think clearly.” Which comment should the nurse use to assess personal coping skills?

a. “In the past, how have you handled difficult or stressful situations?”
b. “What would you like us to do to help you feel more relaxed?”
c. “Tell me more about how it feels to be anxious and upset.”
d. “Can you describe your role in the marital relationship?”

Answer 72

ANS: A
The correct answer is the only option that assesses coping skills. The incorrect options are concerned with self-esteem, ask the patient to decide on treatment at a time when he or she “cannot think clearly,” and seek to explore issues tangential to the crisis.

Question 73

An adult has cared for a debilitated parent for 10 years. The health care provider recently
recommended transfer of the parent to a skilled nursing facility. The adult says, “I’ve always
been able to care for my parents. Nursing home placement goes against everything I believe.”
Successful resolution of this adult’s crisis will most closely relate to
a. resolving the feelings associated with the threat to the person’s self-concept.
b. ability of the person to identify situational supports in the community.
c. reliance on assistance from role models within the person’s culture.
d. mobilization of automatic relief behaviors by the person.

Answer 73

ANS: A
The adult’s crisis clearly relates to a loss of (or threatened change in) self-concept. Her capacity to care for her parents, regardless of the parent’s condition, has been challenged. Crisis resolution will involve coming to terms with the feelings associated with this loss. Identifying situational supports is relevant, but less so than coming to terms with the threat to self-concept. Reliance on lessons from role models can be helpful but not the primary factor associated with resolution in this case. Automatic relief behaviors include withdrawal or flight and will not be helpful. Automatic relief behaviors are part of the third phase of crisis.

Question 74

The principle most useful to a nurse planning crisis intervention for any patient is that the patient

a. is experiencing a state of disequilibrium.
b. is experiencing a type of mental illness.
c. poses a threat of violence to others.
d. has high potential for self-injury.

Answer 74

ANS: A
Disequilibrium is the only answer universally true for all patients in crisis. A crisis represents a struggle for equilibrium when problems seem unsolvable. Crisis does not reflect mental illness. Potential for self-violence or other-directed violence may or may not be a factor in crisis.

Question 75

A nurse assesses a patient in crisis. Select the most appropriate question for the nurse to ask to assess this patient’s situational support.

a. “Has anything upsetting occurred in the past few days?”
b. “Who can be helpful to you during this time?”
c. “How does this problem affect your life?”
d. “What led you to seek help at this time?”

Answer 75

ANS: B
Only the answer focuses on situational support. The incorrect options focus on the patient’s perception of the precipitating event.

Question 76

An adult comes to the crisis clinic after termination from a job of 15 years. The patient says, “I don’t know what to do. How can I get another job? Who will pay the bills? How will I feed my family?” Which nursing diagnosis applies?

a. Hopelessness
b. Powerlessness
c. Chronic low self-esteem
d. Interrupted family processes

Answer 76

ANS: B
The patient describes feelings of lack of control over life events. No direct mention is made of hopelessness or chronic low self-esteem. The patient’s family processes are not interrupted at this point.

Question 77

A troubled adolescent pulled out a gun in a school cafeteria, fatally shot three people and injured many others. Hundreds of parents come to the school after hearing news reports. After police arrest the shooter, which action should occur next?
a. Ask police to encircle the school campus with yellow tape to prevent parents from
entering.
b. Announce over the loudspeakers, “The campus is now secure. Please return to
your classrooms.”
c. Require parents to pass through metal detectors and then allow them to look for their children in the school.
d. Designate zones according to the alphabet and direct students to the zones based
on their surnames to facilitate reuniting them with their parents.

Answer 77

ANS: D
Chaos is likely among students and desperate parents. A directive approach is best. Once the scene is secure, creative solutions are needed. Creating zones by letters of the alphabet will assist anxious parents and their children to unite. Preventing parents from uniting with their children will further incite the situation.

Question 78

At the last contracted visit in the crisis intervention clinic, an adult says, “I’ve emerged from this a stronger person. You helped me get my life back in balance.” The nurse responds, “I think we should have two more sessions to explore why your reactions were so intense.” Which analysis applies?

a. The patient is experiencing transference.
b. The patient demonstrates need for continuing support.
c. The nurse is having difficulty terminating the relationship.
d. The nurse is empathizing with the patient’s feelings of dependency.

Answer 78

ANS: C
Termination is indicated; however, the nurse’s remark is clearly an invitation to work on other
problems and prolong contact with the patient. The focus of crisis intervention is the problem
that precipitated the crisis, not other issues. The scenario does not describe transference. The
patient shows no need for continuing support. The scenario does not describe dependency needs.

Question 79

Emergency response workers arrive in a community after a large-scale natural disaster. What is the workers’ first action?

a. Report to the incident command system (ICS) center.
b. Determine whether the community is safe.
c. Establish teams of workers with varied skills.
d. Evaluate actions completed by local law enforcement.

Answer 79

ANS: A
An ICS provides a common organizational structure facilitating an immediate response. It establishes a clear chain of command that supports the coordination of personnel and equipment at an event site. The incorrect responses describe actions that may or may not be taken by the ICS.

Question 80

A nurse driving home after work comes upon a serious automobile accident. The driver gets out of the car with no apparent physical injuries. Which assessment findings would the nurse expect from the driver immediately after this event? (Select all that apply.)

a. Difficulty using a cell phone
b. Long-term memory losses
c. Fecal incontinence
d. Rapid speech
e. Trembling

Answer 80

ANS: A, D, E
Immediate responses to crisis commonly include shock, numbness, denial, confusion, disorganization, difficulty with decision making, and physical symptoms such as nausea, vomiting, tremors, profuse sweating, and dizziness associated with anxiety. Incontinence and long-term memory losses would not be expected.

Question 81

A team of nurses report to the community after a category 5 hurricane devastates many homes and businesses. The nurses provide emergency supplies of insulin to persons with diabetes and help transfer patients in skilled nursing facilities to sites that have electrical power. Which aspects of disaster management have these nurses fulfilled? (Select all that apply.)

a. Preparedness b. Mitigation
c. Response
d. Recovery
e. Evaluation

Answer 81

ANS: B, C
This community has experienced a catastrophic event. There are five phases of the disaster management continuum. The nurses’ activities applied to mitigation (attempts to limit a disaster’s impact on human health and community function) and response (actual implementation of a disaster plan). Preparedness occurs before an event. Recovery actions focus on stabilizing the community and returning it to its previous status. Evaluation of the response efforts apply to the future.

Question 82

Which behavior best demonstrates aggression?
a. Stomping away from the nurses’ station, going to the hallway, and grabbing a tray
from the meal cart.
b. Bursting into tears, leaving the community meeting, and sitting on a bed hugging a
pillow and sobbing.
c. Telling the primary nurse, “I felt angry when you said I could not have a second
helping at lunch.”
d. Telling the medication nurse, “I am not going to take that, or any other, medication
you try to give me.”

Answer 82

ANS: A
Aggression is harsh physical or verbal action that reflects rage, hostility, and potential for physical or verbal destructiveness. Aggressive behavior violates the rights of others. Refusing medication is a patient’s right and may be appropriate. The other incorrect options do not feature violation of another’s rights.

Question 83

Which clinical scenario predicts the highest risk for directing violent behavior toward others?

a. Major depressive disorder with delusions of worthlessness
b. Obsessive-compulsive disorder; performs many rituals
c. Paranoid delusions of being followed by alien monsters
d. Completed alcohol withdrawal; beginning a rehabilitation program

Answer 83

ANS: C
Patients who are delusional, hyperactive, impulsive, or predisposed to irritability are at higher risk for violence. The patient in the correct response has the greatest disruption of ability to perceive reality accurately. People who feel persecuted may strike out against those believed to be persecutors. The other patients have better reality-testing ability.

Question 84

A patient was arrested for breaking windows in the home of a former domestic partner. The patient’s history also reveals childhood abuse by a punitive parent, torturing family pets, and an arrest for disorderly conduct. Which nursing diagnosis has priority?

a. Risk for injury
b. Ineffective coping
c. Impaired social interaction
d. Risk for other-directed violence

Answer 84

ANS: D
Defining characteristics for risk for other-directed violence include a history of being abused as a child, having committed other violent acts, and demonstrating poor impulse control. There is no indicator that the patient will experience injury. Ineffective coping and impaired social interaction have lower priorities.

Question 85

A confused older adult patient in a skilled nursing facility was asleep when unlicensed assistive personnel (UAP) entered the room quietly and touched the bed to see if it was wet. The patient awakened and hit the UAP in the face. Which statement best explains the patient’s action?
a. Older adult patients often demonstrate exaggerations of behaviors used earlier in
life.
b. Crowding in skilled nursing facilities increases an individual’s tendency toward
violence.
c. The patient learned violent behavior by watching other patients act out.
d. The patient interpreted the UAP’s behavior as potentially harmful.

Answer 85

ANS: D
Confused patients are not always able to evaluate the actions of others accurately. This patient behaved as though provoked by the intrusive actions of the staff.

Question 86

A patient is pacing the hall near the nurses’ station, swearing loudly. An appropriate initial intervention for the nurse would be to address the patient by name and say:

a. “What is going on?”
b. “Please be quiet and sit down in this chair immediately.”
c. “I’d like to talk with you about how you’re feeling right now.”
d. “You must go to your room and try to get control of yourself.”

Answer 86

ANS: C
Intervention should begin with analysis of the patient and the situation. When anger is escalating, a patient’s ability to process decreases. It is important to speak to the patient slowly and in short sentences, using a low and calm voice. Use open-ended statements designed to hear the patient’s feelings and concerns. This leads to the next step of planning an intervention.

Question 87

A patient who was responding to auditory hallucinations earlier in the morning now approaches the nurse shaking a fist and shouts, “Back off!” and then goes to the dayroom. While following the patient into the dayroom, the nurse should

a. make sure there is adequate physical space between the nurse and patient.
b. move into a position that places the patient close to the door.
c. maintain one arm’s length distance from the patient.
d. begin talking to the patient about appropriate behavior.

Answer 87

ANS: A
Making sure space is present between the nurse and the patient avoids invading the patient’s personal space. Personal space needs increase when a patient feels anxious and threatened. Allowing the patient to block the nurse’s exit from the room may result in injury to the nurse. Closeness may be threatening to the patient and provoke aggression. Sitting is inadvisable until further assessment suggests the patient’s aggression is abating. One arm’s length is inadequate space.

Question 88

An intramuscular dose of antipsychotic medication needs to be administered to a patient who is becoming increasingly more aggressive and refused to leave the day room. The nurse should enter the day room
a. and say, “Would you like to come to your room and take some medication your
health care provider prescribed for you?”
b. accompanied by three staff members and say, “Please come to your room so I can
give you some medication that will help you regain control.”
c. and place the patient in a basket-hold and then say, “I am going to take you to your
room to give you an injection of medication to calm you.”
d. accompanied by a male security guard and tell the patient, “Come to your room
willingly so I can give you this medication, or the guard and I will take you there.”

Answer 88

ANS: B
A patient gains feelings of security if he or she sees others are present to help with control. The nurse gives a simple direction, honestly states what is going to happen, and reassures the patient that the intervention will be helpful. This positive approach assumes the patient can act responsibly and will maintain control. Physical control measures are used only as a last resort.

Question 89

After an assault by a patient, a nurse has difficulty sleeping, startles easily, and is preoccupied with the incident. The nurse said, “That patient should not be allowed to get away with that behavior.” Which response poses the greatest barrier to the nurse’s ability to provide therapeutic care?

a. Startle reactions
b. Difficulty sleeping
c. A wish for revenge
d. Preoccupation with the incident

Answer 89

ANS: C
The desire for revenge signals an urgent need for professional supervision to work through anger and counter the aggressive feelings. Feelings of revenge create a risk for harm to the patient. The distracters are normal in a person who was assaulted. They usually are relieved with crisis intervention, help the individual regain a sense of control, and make sense of the event.

Question 90

The staff development coordinator plans to teach use of physical management techniques for use when patients become assaultive. Which topic should the coordinator emphasize?

a. Practice and teamwork
b. Spontaneity and surprise
c. Caution and superior size
d. Diversion and physical outlets

Answer 90

ANS: A
Intervention techniques are learned behaviors and must be practiced to be used in a smooth, organized fashion. Every member of the intervention team should be assigned a specific task to carry out before beginning the intervention. The other options are useless if the staff does not know how to use physical techniques and how to apply them in an organized fashion.

Question 91

An adult patient assaulted another patient and was then restrained. One hour later, which statement by the restrained patient requires the nurse’s immediate attention?

a. “I hate all of you!”
b. “My fingers are tingly.”
c. “You wait until I tell my lawyer.”
d. “The other patient started the fight.”

Answer 91

ANS: B
The correct response indicates impaired circulation and necessitates the nurse’s immediate attention. The incorrect responses indicate the patient has continued aggressiveness and agitation.

Question 92

Which is an effective nursing intervention to assist an angry patient learn to manage anger without violence?

a. Help a patient identify a thought that produces anger, evaluate the validity of the belief, and substitute reality-based thinking.
b. Provide negative reinforcement such as restraint or seclusion in response to angry outbursts, whether or not violence is present.
c. Use aversive conditioning, such as popping a rubber band on the wrist, to help extinguish angry feelings.
d. Administer an antipsychotic or antianxiety medication.

Answer 92

ANS: A
Anger has a strong cognitive component, so using cognition techniques to manage anger is logical. The incorrect options do nothing to help the patient learn anger management.

Question 93

Which assessment finding presents the greatest risk for violent behavior directed at others?

a. Severe agoraphobia
b. History of spousal abuse
c. Bizarre somatic delusions
d. Verbalized hopelessness and powerlessness

Answer 93

ANS: B
A history of prior aggression or violence is the best predictor of who may become violent. Patients with anxiety disorders are not particularly prone to violence unless panic occurs. Patients experiencing hopelessness and powerlessness may have coexisting anger, but violence is uncommon. Patients with paranoid delusions are at greater risk for violence than those with bizarre somatic delusions.

Question 94

An emergency code was called after a patient pulled a knife from a pocket and threatened, “I
will kill anyone who tries to get near me.” The patient was safely disarmed and placed in seclusion. Justification for use of seclusion was that the patient
a. was threatening to others.
b. was experiencing psychosis.
c. presented an undeniable escape risk.
d. presented a clear and present danger to others.

Answer 94

ANS: D
The patient’s threat to kill self or others with the knife he possessed constituted a clear and present danger to self and others. The distracters are not sufficient reasons for seclusion.

Question 95

A patient sat in silence for 20 minutes after a therapy appointment, appearing tense and vigilant. The patient abruptly stood, paced back and forth, clenched and unclenched fists, and then stopped and stared in the face of a staff member. The patient is

a. demonstrating withdrawal.
b. working though angry feelings.
c. attempting to use relaxation strategies.
d. exhibiting clues to potential aggression.

Answer 95

ANS: D
The description of the patient’s behavior shows the classic signs of someone whose potential for aggression is increasing.

Question 96

A patient with multi-infarct dementia lashes out and kicks at people who walk past in the hall of a skilled nursing facility. Intervention by the nurse should begin by

a. gently touching the patient’s arm.
b. asking the patient, “What do you need?”
c. saying to the patient, “This is a safe place.”
d. directing the patient to cease the behavior.

Answer 96

ANS: C
Striking out usually signals fear or that the patient perceives the environment to be out of control. Getting the patient’s attention is fundamental to intervention. The nurse should make eye contact and assure the patient of safety. Once the nurse has the patient’s attention, gently touching the patient, asking what he or she needs, or directing the patient to discontinue the behavior may be appropriate.

Question 97

A cognitively impaired patient has been a widow for 30 years. This patient frantically tries to leave the facility, saying, “I have to go home to cook dinner before my husband arrives from

work. ” To intervene with validation therapy, the nurse will say:
a. “You must come away from the door.”
b. “You have been a widow for many years.”
c. “You want to go home to prepare your husband’s dinner?”
d. “Your husband gets angry if you do not have dinner ready on time?”

Answer 97

ANS: C
Validation therapy meets the patient “where she or he is at the moment” and acknowledges the patient’s wishes. Validation does not seek to redirect, reorient, or probe. The distracters do not validate the patient’s feelings.

Question 98

A patient with a history of anger and impulsivity was hospitalized after an accident resulting in multiple injuries. The patient loudly scolds nursing staff, “I’m in pain all the time but you don’t give me medicine until YOU think it’s time.” Which nursing intervention would best address this problem?
a. Teach the patient to use coping strategies such as deep breathing and progressive relaxation to reduce the pain.
b. Talk with the health care provider about changing the pain medication from prn to patient-controlled analgesia.
c. Tell the patient that verbal assaults on nurses will not shorten the wait for analgesic medication.
d. Talk with the patient about the risks of dependency associated with overuse of
analgesic medication.

Answer 98

ANS: B
Use of patient-controlled analgesia will help the patient manage the pain. This intervention will help reduce the patient’s anxiety and anger. Dependency is not an important concern related to acute pain.

Question 99

A patient has a history of impulsively acting-out anger by striking others. Select the most appropriate intervention for avoiding similar incidents.

a. Teach the patient about herbal preparations that reduce anger.
b. Help the patient identify incidents that trigger impulsive anger.
c. Explain that restraint and seclusion will be used if violence occurs.
d. Offer one-on-one supervision to help the patient maintain control.

Answer 99

ANS: B
Identification of trigger incidents allows the patient and nurse to plan interventions to reduce irritation and frustration, which lead to acting-out anger, and eventually to put into practice more adaptive coping strategies.

Question 100

A patient with severe burn injuries is irritable, angry, and belittles the nurses. As a nurse changes a dressing, the patient screams, “Don’t touch me! You are so stupid. You will make it worse!” Which action by the nurse will best help to diffuse the patient’s anger?
a. Stop the dressing change and say, “I will leave the supplies so that you can change
your own dressing.”
b. Continue the dressing change and say, “This dressing change is necessary because
you were careless with fire.”
c. Discontinue the dressing change, tell the patient, “I will return when you gain
control of yourself,” and leave the room.
d. Continue the dressing change and say, “Dressing changes are needed to prevent
infection. What are your ideas about how to make it less painful?”

Answer 100

ANS: D
The nurse should not respond personally to the patient’s comments. The correct answer objectively gives the patient information that may lead to lowering his anger and engages the patient in problem solving. The incorrect options will escalate the patient’s anger by belittling or escalating the patient’s sense of powerlessness. Dressing changes are needed for the patient’s physiological integrity; therefore, the nurse should not abandon the responsibility to perform them.

Question 101

Which medication from the medication administration record should a nurse administer to provide immediate intervention for a psychotic patient whose aggressive behavior continues to escalate despite verbal intervention?

a. Lithium
b. Trazodone
c. Olanzapine
d. Valproic acid

Answer 101

ANS: C
Olanzapine is a short-acting antipsychotic useful in calming angry, aggressive patients regardless of diagnosis. The other drugs listed require long-term use to reduce anger. Lithium is for bipolar patients. Trazodone is commonly prescribed for patients experiencing depression, insomnia, or chronic pain. Valproic acid is for bipolar or borderline patients.

Question 102

An emergency department nurse realizes that the spouse of a patient is becoming increasingly irritable while waiting. Which intervention should the nurse use to prevent further escalation of the spouse’s anger?

a. Offer the waiting spouse a cup of coffee.
b. Explain that the patient’s condition is not life threatening.
c. Periodically provide an update and progress report on the patient.
d. Suggest that the spouse return home until the patient’s treatment is complete.

Answer 102

ANS: C
Periodic updates reduce anxiety and defuse anger. This strategy acknowledges the spouse’s presence and concern. A cup of coffee is a nice gesture, but it does not address the spouse’s feelings. The other incorrect options would be likely to increase anger because they imply that the anxiety is inappropriate.

Question 103

Which information from a patient’s record would indicate marginal coping skills and the need for careful assessment of the risk for violence? A history of

a. academic problems.
b. family involvement.
c. childhood trauma.
d. substance abuse.

Answer 103

ANS: D
The nurse should suspect marginal coping skills in a patient with substance abuse. They are often anxious, may be concerned about inadequate pain relief, and may have personality styles that externalize blame. The incorrect options do not signal as high a degree of risk as substance abuse.

Question 104

Family members describe the patient as “a difficult person who finds fault with others.” The patient verbally abuses nurses for their poor care. The most likely explanation lies in

a. poor childrearing that did not teach respect for others.
b. automatic thinking leading to cognitive distortions.
c. a personality style that externalizes problems.
d. delusions that others wish to deliver harm.

Answer 104

ANS: C
Patients whose personality style causes them to externalize blame see the source of their discomfort and anxiety as being outside themselves. They displace anger and are often unable to self-soothe. The incorrect options are less likely to have a bearing on this behavior.

Question 105

A new patient acts out so aggressively that seclusion is required before the admission assessment is completed or orders written. Immediately after safely secluding the patient, which action is the nurse’s priority?
a. Complete the physical assessment.
b. Notify the health care provider to obtain a seclusion order.
c. Document the incident objectively in the patient’s medical record.
d. Explain to the patient that seclusion will be discontinued when self-control is
regained.

Answer 105

ANS: B
Emergency seclusion can be effected by a credentialed nurse but must be followed by securing a medical order within a period of time specified by the state and the agency. The incorrect options are not immediately necessary from a legal standpoint. See related audience response question.

Question 106

A patient with a history of command hallucinations approaches the nurse yelling obscenities. Which nursing actions are most likely to be effective in deescalation for this scenario? (Select all that apply.)

a. Stating the expectation that the patient will stay in control.
b. Asking the patient, “Do you want to go into seclusion?”
c. Telling the patient, “You are behaving inappropriately.”
d. Offering to provide the patient with medication to help.
e. Speaking in a firm but calm voice.

Answer 106

ANS: A, D, E
Stating the expectation that the patient will maintain control of behavior reinforces positive, healthy behavior and avoids challenging the patient. Offering as-needed medication provides support for the patient trying to maintain control. A firm but calm voice will likely comfort and calm the patient. Belittling remarks may lead to aggression. Criticism will probably prompt the patient to begin shouting.

Question 107

A nurse directs the intervention team who places an aggressive patient in seclusion. Before approaching the patient, which actions will the nurse direct team members to take? (Select all that apply.)

a. Appoint a person to clear a path and open, close, or lock doors.
b. Quickly approach the patient and take the closest extremity.
c. Select the person who will communicate with the patient.
d. Move behind the patient when the patient is not looking.
e. Remove jewelry, glasses, and harmful items.

Answer 107

ANS: A, C, E
Injury to staff and the patient should be prevented. Only one person should explain what will
happen and direct the patient. This may be the nurse or a staff member with a good
relationship with the patient. A clear pathway is essential because those restraining a limb
cannot use keys, move furniture, or open doors. The nurse is usually responsible for
administering medication once the patient is restrained. Each staff member should have an
assigned limb rather than just grabbing the closest. This system could leave one or two limbs
unrestrained. Approaching in full view of the patient reduces suspicion.

Question 108

Which central nervous system structures are most associated with anger and aggression? (Select all that apply.)

a. Amygdala
b. Cerebellum
c. Basal ganglia
d. Temporal lobe
e. Prefrontal cortex

Answer 108

ANS: A, D, E
The amygdala and prefrontal cortex mediate anger experiences and help a person judge an event as either rewarding or aversive. The temporal lobe, which is part of the limbic system, also plays a role in aggressive behavior. The basal ganglia are involved in movement. The cerebellum manages equilibrium, muscle tone, and movement.

Question 109

Because an intervention was required to control a patient’s aggressive behavior, the nurse plans a critical incident debriefing with staff members. Which topics should be the primary focus of this discussion? (Select all that apply.)

a. Patient behaviors associated with the incident
b. Genetic factors associated with aggression
c. Intervention techniques used by the staff
d. Effects of environmental factors
e. Theories of aggression

Answer 109

ANS: A, C, D
The patient’s behavior, the intervention techniques used, and the environment in which the incident occurred are important to establish realistic outcomes and effective nursing interventions. Discussing views about the theoretical origins of aggression would be less effective and relevant.