NCLEX Violence practice questions

The nurse is assigned to care for a chemically dependent client who has the potential for violent episodes. In planning care for the client, which action by the nurse would receive priority?

projects an attitude of calmness

A client comes to the emergency department after an assault and is extremely agitated, trembling, and hyperventilating. What is the priority nursing action for this client?

remain with the client until the anxiety decreases

A battered wife says, "My spouse is a bully and a cheater and certainly doesn't provide for our family, but has never beat me up, so I don't think I can say my spouse abusive." Which response by the nurse is therapeutic?

"Do you believe that there are other forms of abuse besides the physical kind?"

A client with a potential for violence is exhibiting aggressive gestures, making belligerent comments to the other clients, and is continuously pacing in the hallway. Which comment by the nurse would be therapeutic at this time?

"What is causing you to behave so agitated?"

A client admitted to the mental health unit after attacking a parent who disturbed the client while working on the computer interrupts the nurse during morning rounds and says, "I need to get out of here so I can work on my computer project to save the world!" Which nursing response will have the greatest therapeutic impact?

"I will be back to talk with you in 15 minutes after I complete nursing rounds."

During a support group session, a client says, "My partner hit me a lot, but when my partner threatened to start hitting our kids, I stabbed my partner. No jury will believe me because my partner can lie to anyone and be believed." If no one in the group responds, which statement is the therapeutic response by the nurse?

"Abuse is a horribly difficult thing to experience. Can anyone in the group relate to what the client is feeling?"

The nurse is planning care for a client who has a history of violent behavior and is at risk for harming others. Which intervention presents a need for follow-up because it could potentially present a danger to the client, health care providers, and others on the nursing unit?

Assigning the client to a room at the end of the hall

A manic client begins to make sexual advances toward visitors in the dayroom. When the nurse firmly states that this is inappropriate and will not be allowed, the client becomes verbally abusive and threatens physical violence to the nurse. Based on the analysis of this situation, which intervention would the nurse implement?

Escort the client to their room, with the assistance of other staff.

Several nurses are engaged in an assignment report when a client with a history of aggressive behavior approaches the nurses' station. The client becomes very loud and offensive, and demands to be seen by the psychiatrist immediately. Which intervention will address the needs of both the client and the milieu?

Offer to assist the client to an examination room until the psychiatrist is notified.

The nurse observes that a client is pacing, agitated, and presenting aggressive gestures. The client's speech pattern is rapid, and affect is belligerent. Based on these observations, which is the nurse's immediate priority of care?

Provide safety for the client and other clients on the unit.

The nurse is assigned to a client who is pacing, agitated, and using aggressive gestures and rapid speech. The nurse would determine that which action is the priority of care at this time?

Providing a safe place for the client to pace that is away from the other client

The nurse is caring for a client in the emergency department who presents with a complaint of fatigue and shortness of breath. Which physical assessment finding, if noted by the nurse, warrants a need for follow-up?

a reddish-purple mark on the neck

The emergency department nurse is caring for an adult client who is a victim of family violence. Which priority information would be included in the discharge instructions?

information regarding shelters

A nurse attends an educational session on family violence. Which statement by the nurse indicates a need for further teaching concerning family violence?

"Abusers are more often from low-income families.

An 87-year-old person is brought to the emergency department for treatment of a fractured arm. On physical assessment, the nurse notes old and new ecchymotic areas on the client's chest and legs and asks the client how the bruises were sustained. The client, although reluctant, tells the nurse in confidence that her adult child frequently hits the client if supper is not prepared on time when arriving home from work. Which is the most appropriate nursing response?

"As a nurse, I am legally bound to report abuse. I will stay with you while you give the report and help find a safe place for you to stay."

A client was raped a few weeks ago but still feels "as if it just happened to me." Which response would the nurse make to the client?

"Tell me more about what happened and what causes you to feel as if the rape just occurred."

When would the nurse determine that it will be safe to remove the restraints from a client who demonstrated violent behavior?

No aggressive behavior has been observed for 1 hour after the release of two of the extremity restraints.

During a group session, a client threatens to "punch every one of you." Which is the appropriate initial nursing action?

Remind the client that talking about personal anger is appropriate, but acting on it is not.