Stress, Crisis, Anger, & Violence Lippy
35. On an oncology unit, the nurse hears noises coming from a client's room. The client is found throwing objects at the walls and has just picked up the phone. She is screaming, "How can God do this to me? It is the third type of cancer I've had. I've gone through all the treatment for nothing." In what order of priority from first to last should the nurse make the following interventions? 1. "Tell me what you are feeling right now." 2. "Please put the telephone down so we can talk." 3. "I can hear how upset you are about the cancer." 4. "I wonder if you would like to talk to a clergyman."
ANS: 2. "Please put the telephone down so we can talk." 3. "I can hear how upset you are about the cancer." 1. "Tell me what you are feeling right now." 4. "I wonder if you would like to talk to a clergyman." The first priority is a safe environment so the client and nurse are not hurt by the phone. Then, it is important to acknowledge the client's anger to help diffuse it. As the client calms down, the nurse can explore the client's feeling in more depth. Since the client implies anger at God, a clergy consult may be appropriate.
82. A young woman has been stalked and then beaten by an ex-boyfriend. Treatment of her injuries is complete and she is ready for discharge. To ensure the woman's safety and security prior to discharge the nurse should? Select all that apply. 1. Determine the current location of the ex-boyfriend. 2. Ask if she plans to see the ex-boyfriend again. 3. Provide information on resources and a safety plan. 4. Ensure that she has a safe place to stay after discharge. 5. Obtain consent to send her emergency department records to her family physician.
ANS: 1, 2, 3, 4. 1. Determine the current location of the ex-boyfriend. 2. Ask if she plans to see the ex-boyfriend again. 3. Provide information on resources and a safety plan. 4. Ensure that she has a safe place to stay after discharge. The crucial interventions involve safety and support. Asking for consent is a Health Information Portability and Accountability Act issue, not a safety issue, and is not essential to the discharge process.
91. A nurse's ex-boyfriend enters the unit and states, "If I can't have her, then no one will." Hospital security escorts him out of the building and warned him not to return. The unit manager held a staff meeting to confirm that which of the following workplace violence policies and procedures will be implemented? Select all that apply. 1. Give a quick overview of the hospital's workplace violence policies and procedures. 2. Offer counseling for the nurse threatened by her ex-boyfriend. 3. Work with security and the nurse to initiate workplace precautions related to the ex-boyfriend. 4. Ask security to help the nurse understand how to initiate a protective order against her ex-boyfriend. 5. Ask the nurse to take a leave of absence until her ex-boyfriend is notified of the protective order.
ANS: 1, 2, 3, 4. 1. Give a quick overview of the hospital's workplace violence policies and procedures. 2. Offer counseling for the nurse threatened by her ex-boyfriend. 3. Work with security and the nurse to initiate workplace precautions related to the ex-boyfriend. 4. Ask security to help the nurse understand how to initiate a protective order against her ex-boyfriend. National guidelines exist for managing workplace violence. Unit staff, hospital administration, and hospital security personnel develop and enforce the resulting policies. These include training all staff about workplace violence, processes for reporting of such violence, and counseling for the staff victim. Protecting staff and clients may include posting the ex-boyfriend's picture at employee entrances and a protective order initiated by the nurse. With these policies and procedures in place, it is counterproductive to ask the nurse to take a leave of absence.
38. The nurse working at the site of a severe flood sees a woman, standing in knee-deep water, staring at an empty lot. The woman states, "I keep thinking that this is a nightmare and that I'll wake up and see that my house is still there." Which of the following crisis intervention strategies are most needed at this time? Select all that apply. 1. Ask the client about any physical injuries she may have. 2. Determine if any of her family are injured or missing. 3. Allow the client to talk about her fears, anger, and other feelings. 4. Tell her that groups are being formed at the shelter for flood survivors. 5. Refer her to the shelter for dry clothes and food. 6. Assess her for risk of suicide and other signs of decompensation.
ANS: 1, 2, 3, 6. 1. Ask the client about any physical injuries she may have. 2. Determine if any of her family are injured or missing. 3. Allow the client to talk about her fears, anger, and other feelings. 6. Assess her for risk of suicide and other signs of decompensation. The immediate needs for this client are for safety and security, so it is important to assess for injuries, safety of her family, suicide risk, and signs of emotional decompensation. Needs for food, clothing, and support are important later, after safety and security are addressed.
37. A woman is being seen in the rape crisis center a few days after being raped. She is reporting loss of appetite, anxiety, depression, and nightmares. The nurse is to make an assessment to determine if she should be admitted to the hospital. In which order of priority from first to last should the nurse assess the following? 1. The client's reaction to the event, including any suicidal thoughts. 2. The client's perceptions of her current skills for coping with the event. 3. The availability of the client's personal support systems. 4. The effect of the event on other aspects of the client's life.
ANS: 1, 4, 2, 3 1. The client's reaction to the event, including any suicidal thoughts. 4. The effect of the event on other aspects of the client's life. 2. The client's perceptions of her current skills for coping with the event. 3. The availability of the client's personal support systems. The nurse should fi rst determine the client's reactions to the rape, especially if she has been suicidal, and then the nurse can assess the full effect of the rape on the client's functioning and life; these are crucial in determining the need for hospitalization for safety and security. Assessing the client's view of the effectiveness of her coping skills and then the availability of her support systems will assist in planning referrals for counseling and other services.
90. A nurse calls the unit manager to report that her purse has been stolen from the locked break room. The nurse says she thinks she knows which of the staff stole the purse. Which of the following actions by the nurse manager would be appropriate? Select all that apply. 1. Confront the person the nurse suspects stole the purse. 2. Call hospital security to initiate an investigation. 3. Ask the nurse to document all the facts related to the stolen purse. 4. Alert nursing administration that a staff's purse has been stolen. 5. Ask other staff to report any suspicious activity they may have observed.
ANS: 2, 3, 4, 5. 2. Call hospital security to initiate an investigation. 3. Ask the nurse to document all the facts related to the stolen purse. 4. Alert nursing administration that a staff's purse has been stolen. 5. Ask other staff to report any suspicious activity they may have observed. It is appropriate for the nurse manager to initiate a security investigation and ask the nurse to document all the facts about the missing purse. Alerting nursing administration is required. Seeking information from other staff will help with the investigation. It is inappropriate to confront any possible suspects while the investigation is ongoing.
59. A client is being admitted to a psychiatric outpatient program for counseling for his ongoing emotional symptoms. He is asked to rate the severity of his depression, anxiety, and anger. He states, "I don't have any anger any more. I lost my temper once and nearly hurt my wife. I never got angry again." In which order of priority from first to last should the following principles related to anger be shared with this client? 1. "You can learn effective ways to discuss anger with others and still maintain control." 2. "Anger is a natural emotion occurring in all human relationships." 3. "Holding your anger inside contributes to your depression." 4. "Unexpressed anger has a negative effect on the human body and mind."
ANS: 2, 4, 3, 1 2. "Anger is a natural emotion occurring in all human relationships." 4. "Unexpressed anger has a negative effect on the human body and mind." 3. "Holding your anger inside contributes to your depression." 1. "You can learn effective ways to discuss anger with others and still maintain control." The clients need to understand that anger is a normal emotion, but if not expressed can have negative effects on the body and mind. Then, the nurse begins to focus on the client's personal situation and that holding anger in aggravates his depressive symptoms as well. One focus of outpatient counseling will be learning safe, effective ways to express anger.
74. A client was brought to the unit and admitted involuntarily. During visiting the next day, the client's brother demands that the client be released immediately. The brother says he might have to hurt staff if the unit door is not opened. In which order of priority from first to last should the following nursing actions be implemented? 1. Call security officers to the unit for the protection of all on the unit. 2. Calmly restate to the client and his brother that the client cannot be released without a primary health care provider's prescription. 3. Quietly ask the other clients and visitors to move to another area of the unit with a staff member. 4. Ask the client's brother to leave the unit quietly when he repeats his demands.
ANS: 2, 4, 3, 1, 2. Calmly restate to the client and his brother that the client cannot be released without a primary health care provider's prescription. 4. Ask the client's brother to leave the unit quietly when he repeats his demands. 3. Quietly ask the other clients and visitors to move to another area of the unit with a staff member. 1. Call security officers to the unit for the protection of all on the unit. The first step is to calmly present the reality that the client cannot be released at this time. Next, the brother should be asked to leave the unit quietly. When he does not, protecting the other clients and visitors is essential for their safety. (The staff member can help them process what is happening on the unit.) Calling security to the unit is a last resort when less restrictive measures have not worked. Calling them, before setting limits with the brother and giving him a choice of actions, will likely escalate the situation. Security can legally escort the brother off the unit and hospital grounds.
19. A client who has not left the bus station for 3 days is brought to the mental health facility by a police officer because she has been bothering other people. She denies this, holds tightly to her purse, and refuses to talk to anyone except to say, "You have no right to keep me here. I have money, and I can take care of myself." The police officer thinks she needs psychiatric evaluation. Evaluation reveals that the client stopped taking her psychotropic medication, but she agrees to start taking her medication again. The charge nurse informs the other staff members that the physician is discharging the client because involuntary commitment is not indicated. An unlicensed personnel states, "How can her physician be so cruel? She should stay in the hospital instead of being discharged." Which response is best for the nurse to make to the unlicensed personnel? 1. "I agree with you. She does have symptoms of mental illness." 2. "Although she may have a mental illness, she is not gravely disabled or dangerous to herself or others now." 3. "The client wants to leave, so the physician is not going to put her through the commitment process." 4. "The client has a home to go to and family to support her. She doesn't need to be here."
ANS: 2. "Although she may have a mental illness, she is not gravely disabled or dangerous to herself or others now." To be committed involuntarily, a client must not only be suffering from a mental illness but must be gravely disabled (unable to care for self or likely to come to harm if discharged) or dangerous to self or others. Having a mental illness alone is not grounds for commitment. Wanting to leave the hospital is not sufficient cause for discharge if the client is dangerous to self or others or is gravely disabled. The physician would not avoid committing a client who meets the criteria to be committed. Having a supportive family or home but not wanting treatment may still result in involuntary commitment if indicated or necessary to ensure the well-being of the client or another person.
39. The nurse is assessing a client who has just experienced a crisis. The nurse should first assess this client for which of the following behaviors? 1. Effective problem solving. 2. Level of anxiety. 3. Attention span. 4. Help-seeking.
ANS: 2. Level of anxiety. During the first phase of crisis, the client exhibits elevated anxiety. A client who can use problem-solving capabilities is not in crisis. A shortened attention span is characteristic of the fourth phase of crisis. Reaching out to others for help is indicative of the third phase of crisis.
19. An 18-year-old pregnant college student presented at the prenatal clinic for an initial visit at 14 weeks' gestation. The client's history revealed that when she was 12, she and her mother survived a plane crash that killed her father and sister. Since that time, she has taken Prozac (fluoxetine) 20 mg orally daily for posttraumatic stress disorder (PTSD) and depression. Her medication was recently increased to 40 mg daily because of reports of increased stress and suicide ideation. Which of the following side effects of Prozac would the nurse judge to be the greatest risk for the young woman and her developing fetus at this stage in her pregnancy? 1. Insomnia. 2. Nausea/anorexia. 3. Headache. 4. Decreased libido.
ANS: 2. Nausea/anorexia. Growth of the fetus is important, so nausea and anorexia that would interfere with the young woman's nutrition would cause the most harm to the developing fetus. It could also lead to electrolyte imbalance if she did not take in enough fluid. While insomnia could cause problems long-term, this side effect could be mitigated through adjustment of the dosing time (earlier in the day) or decrease of the dosage to her former 20 mg daily or even every other day dosing of 40 mg since Prozac has a long half-life. Headaches are uncomfortable but can be treated with mild analgesics or other treatments such as cold cloths that would not harm the fetus. Decreased libido, while not enjoyable for the client or her sexual partner, does not pose any risks for the fetus.
36. A client who has had AIDS for years is being treated for a serious episode of pneumonia. A psychiatric nurse consult was arranged after the client stated that he was tired of being in and out of the hospital. "I'm not coming in here any more. I have other options." The nurse would evaluate the psychiatric nurse consult as helpful if the client makes which of the following statements? 1. "Nobody wants me to commit suicide." 2. "If I talk about suicide, I'll be transferred to the psychiatric unit." 3. "I realize that I really do have more time to enjoy my family and friends." 4. "I'd probably screw up suicide anyway."
ANS: 3. "I realize that I really do have more time to enjoy my family and friends." Focusing on enjoying time with family and friends conveys a renewal of hope for the future and a decreased risk of suicide. Simply saying that no one wants him to commit suicide does not say he doesn't want to do it. Avoiding a transfer to a psychiatric unit does not mean he is no longer suicidal. Fear of not being successful with suicide usually is not a deterrent.
61. The treatment team recommends that a client take an assertiveness training class offered in the hospital. Which of the following behaviors indicates that the client is becoming more assertive? 1. Begins to arrive late for unit activities. When asked why he's late, he says, "Because I feel like it!" 2. Asks the nurse to call his employer about his insurance. 3. Asks his roommate to put away his dirty clothes after telling the roommate that this bothers him. 4. Follows the nurse's advice of asking his doctor about being passive-aggressive.
ANS: 3. Asks his roommate to put away his dirty clothes after telling the roommate that this bothers him. By requesting that the roommate respect his rights (asking the roommate to put the dirty clothes on the floor away after telling him that this bothers him), the client is asserting himself. Arriving late is commonly passive resistance and thus not an indicator that the client is becoming assertive. Asking the nurse to call is dependent behavior. Although asking the doctor is more assertive, the client is relying on the nurse's direction to do so.
37. The nurse's overall goal in planning to assist the client responding to a loss is to: 1. Make sure the client progresses through all of the stages of the grief process. 2. Encourage the client to work to resolve lingering family conflicts. 3. Assist the client to engage in the work associated with the normal grieving process. 4. Allow the client to express anger.
ANS: 3. Assist the client to engage in the work associated with the normal grieving process. Individuals progress through the stages of loss at their own pace. Not everyone experiences each phase, and no one can be forced to advance to the next stage until ready. The overall goal for helping the client to work through the pain of loss is to assist the client in processing and engaging in the pain of loss. This process may involve working on family conflicts and/or anger issues but is not the primary goal.
29. A client who was transferred to the medical unit from intensive care after suffering a myocardial infarction 3 days ago states, "My secretary should be here by now. I don't have time to lie around here and do nothing. I've never had time to relax, and I don't plan on starting now." Based on this initial information, which of the following nursing diagnoses should the nurse judge to be of least importance? 1. Ineffective coping related to serious illness, as evidenced by the statement about lying around and doing nothing. 2. Deficient knowledge related to cardiac rehabilitation, as evidenced by the client's statement about not planning to relax at present. 3. Hopelessness related to serious illness, as evidenced by the client's turning over her work to her secretary. 4. Anxiety related to delayed arrival of the client's secretary, as evidenced by her statement of expecting that the secretary should already have arrived.
ANS: 3. Hopelessness related to serious illness, as evidenced by the client's turning over her work to her secretary. Hopelessness is the least appropriate nursing diagnosis because the client projects an image of a person who is planning for the future and is usually in charge and productive. Ineffective coping is an appropriate diagnosis because the client is rushing to resume her normal activities. Deficient knowledge is an appropriate diagnosis because the client indicates a lack of awareness about the need for relaxation. Anxiety is an appropriate diagnosis because the client is demonstrating impatience and an inability to relax.
36. A nurse in an Employee Assistance Program (EAP) is seeing a woman who wants to report her boss to the police for sexual harassment. She states he says that she will never get a promotion unless she "works and plays at his house on weekends." After getting more details on the boss' statements and behaviors, the nurse should do which of the following? 1. Encourage the client to fi le a police report as soon as possible. 2. Tell the client to return to EAP if she is denied a promotion. 3. Show the client the company's Workplace Violence Policy and agree to help her follow the process. 4. Go with the client to confront her boss about his behaviors and possible consequences.
ANS: 3. Show the client the company's Workplace Violence Policy and agree to help her follow the process. Employers are required to have a Workplace Violence Policy that outlines procedures related to this issue. Filing a police report may or may not be appropriate after the procedures of the policy are completed. Having the client only come back to EAP if a promotion is denied is an inappropriate suggestion. Confronting the boss with the client is only needed if other steps of the procedure are not effective.
63. The treatment team recommends that a client take an assertiveness training class offered in the hospital. Which of the following behaviors indicates that the client is becoming more assertive? 1. The client begins to arrive late for unit activities. When asked why he's late, he says, "Because I feel like it!" 2. The client asks the nurse to call his employer about his insurance. 3. The client asks his roommate to put away his dirty clothes after telling the roommate that this bothers him. 4. The client follows the nurse's advice of asking his doctor about being passive-aggressive.
ANS: 3. The client asks his roommate to put away his dirty clothes after telling the roommate that this bothers him. By requesting that the roommate respect his rights (asking the roommate to put the dirty clothes on the floor away after telling him that this bothers him), the client is asserting himself. Arriving late is commonly passive resistance and thus not an indicator that the client is becoming assertive. Asking the nurse to call is dependent behavior. Although asking the doctor is more assertive, the client is relying on the nurse's direction to do so.
60. A client is admitted to the hospital because of threatening, aggressive behavior toward his family. In the fi rst group meeting after the client is admitted, another client sits near the nurse and says loudly, "I'm sitting here because I'm afraid of Ted. He's so big, and I heard him talk about hitting people." The nurse should say to the client: 1. "Everyone is here for different problems. You know you don't have to worry." 2. "Ted is new to the group. Let's go around and introduce ourselves to him." 3. "You don't know Ted yet. Once you get to know him, I'm sure you won't be afraid." 4. "It's frightening to have new people on the unit. We're here to talk about things like being afraid."
ANS: 4. "It's frightening to have new people on the unit. We're here to talk about things like being afraid." The nurse needs to acknowledge the client's feelings. In doing so, the nurse helps the group accept a new member. Focusing on "everyone" and telling the client not to worry ignores the client's fears. Having the other group members introduce themselves places the focus on the other clients in the group and does not address the client's fears. Implying that getting to know someone will reduce the fear is false reassurance.
44. Three months after the death of her husband in an automobile accident, a client is admitted to the hospital after attempting to overdose on her antidepressant. She states, "I can't live without him. It's no use. I just want to die." Which of the following nursing diagnoses is the priority in the client's plan of care? 1. Complicated grieving related to husband's death as evidenced by a suicide attempt. 2. Powerlessness related to husband's death as evidenced by statement of "It's no use." 3. Hopelessness related to husband's death as evidenced by the client's statement of inability to live without the husband 4. Risk for self-directed violence related to husband's death as evidenced by the client's wish to die.
ANS: 4. Risk for self-directed violence related to husband's death as evidenced by the client's wish to die. Risk for self-directed violence is the priority nursing diagnosis for a client who has attempted or verbalizes the intent to harm herself. Although the client is depressed, feeling hopeless and powerless, and is grieving, these are not the priority concern at this time.
58. A 35-year-old man was experiencing marital discord with his wife of 4 years. When his wife walked out, he became angry, throwing things and breaking dishes. A friend talked him into seeking help at the local mental health center. Which of these questions should the nurse ask initially to begin to assess this man's immediate problem? 1. "Do you feel in control of yourself at this time?" 2. "What did you do to cause your wife to leave?" 3. "In hindsight, how might you have managed this situation differently?" 4."What led you to come in for help today?"
ANS: 4."What led you to come in for help today?" Beginning with a broad opening statement that brings out the client's view of his situation and reasons for seeking treatment is the most neutral beginning and helps to gain the client's perception of events. Blaming the client for his problems is accusatory and nonproductive. A time for reviewing what could be done differently will come later.
