Davis Ch 47: Crisis and Violence

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Multiple clients are being cared for on the behavioral health unit. In which circumstances should the nurse plan the therapeutic use of seclusion and/or restraints? (Select all that apply) 1. The client asks to be placed in seclusion 2. The client expresses the likelihood of self-injury 3. The staff feels the client is likely to harm others 4. The legally detained client is threatening to "escape" 5. The staff identifies seclusion as a consequence of the client's behavior 6. The client's threatening behavior is negatively affecting the therapeutic milieu

1, 2, 3, 4 1. The client asks to be placed in seclusion 2. The client expresses the likelihood of self-injury 3. The staff feels the client is likely to harm others 4. The legally detained client is threatening to "escape"

The client is admitted to an ED with facial bruises, a broken arm, and rib fractures. The client states, "I fell down the stairs." During assessment, the nurse sees bruises and lacerations in various stages of healing. Which questions by the nurse are appropriate? (Select all that apply) 1. "Has anyone hurt you?" 2. "Are you afraid of anyone at home?" 3. "Have you been falling down a lot lately?" 4. "Have you had any fainting spells or times that you have been weak?" 5. "I noticed you have more bruises. Can you tell me how they happened?" 6. "You look abused. Why haven't you reported that you have been abused?"

1, 2, 3, 4, 5 1. "Has anyone hurt you?" 2. "Are you afraid of anyone at home?" 3. "Have you been falling down a lot lately?" 4. "Have you had any fainting spells or times that you have been weak?" 5. "I noticed you have more bruises. Can you tell me how they happened?"

The experienced nurse determines that the new nurses actions are therapeutic when managing the cognitively impaired client whose agitated behavior is escalating. Which nursing action should have occurred? Select all that apply 1. Saying Mr. Smith, will you look at me please? 2. Saying you seem upset. How can I help you? 3. Presenting the client with detailed expectations 4. Turning off the TV in the room to reduce noise 5. Saying getting angry will not help you get what you want 6. speaking loudly to ensure that the client here is what is being said

1, 2, 4 1. Saying Mr. Smith, will you look at me please? 2. Saying you seem upset. How can I help you? 4. Turning off the TV in the room to reduce noise

The nurse is caring for the client who was violently raped three months ago and has a diagnosis of rape trauma syndrome. Which assessment findings associated with rape trauma syndrome, should the nurse anticipate? (Select all that apply) 1. anorexia 2.Nightmares 3. Hypertension 4. Fears and phobias 5. Sexual promiscuity

1, 2, 4 1. anorexia 2.Nightmares 4. Fears and phobias

The client who recently emigrated from another country to the U.S. has been placed in seclusion. The nurse assesses that the client is now calm and ready to be assimilated back into the mental health milieu. Which action by the nurse demonstrates cultural insensitivity? 1. Gives the client a thumbs-up gesture 2. Avoids looking at the clock or a watch 3. Has the NA bring the client a cup of tea 4. Offers to get a book that the client chooses

1. Gives the client a thumbs-up gesture Although a thumbs-up gesture may mean "good job" in the U.S., it is considered an offensive gesture by persons from some other cultures. It is comparable to a raised middle finger in the U.S.

The nurse is preparing to document the client's violent episode. Which statements should be included specifically about the violent episode? Select all that apply 1. Clients wife called during the escalation cycle 2. The client refused to voluntarily enter into seclusion 3. The client stated, all of you are just evil people 4. Attempts to identify the cause of clients agitation failed 5. Five staff members responded to emergency code 6. The client asked to leave the seclusion room after 30 minutes

2, 3, 4, 6 2. The client refused to voluntarily enter into seclusion 3. The client stated, all of you are just evil people 4. Attempts to identify the cause of clients agitation failed 6. The client asked to leave the seclusion room after 30 minutes

The nurse observes that the client diagnosed with intermittent explosive disorder is becoming aggressive and Lorazepam was prescribed. The client is now exhibiting a tense posture, a clenched fist, a defiant effect. Prioritize the nurses actions to deescalate the clients aggression. 1. Call other staff for assistance 2. Attempt to talk client down 3. Apply wrist restraints 4. Offer the client the choice of taking the medication voluntarily 5. Provide an alternate use of physical energy, such as suggesting punching a pillow

2, 5, 4, 1, 3 2. Attempt to talk client down 5. Provide an alternate use of physical energy, such as suggesting punching a pillow 4. Offer the client the choice of taking the medication voluntarily 1. Call other staff for assistance 3. Apply wrist restraints

The 28-year-old is being seen in the ED with injuries after being assaulted by her live-in boyfriend. The client acknowledges that this is not the first time that she has been assaulted and that she is afraid. Which client action indicates that an outcome for the client has been achieved? 1. Elects to return to her boyfriend to make amends 2. Accepts arrangements made with a women's shelter 3. Verbalizes plans for staying at the hospital overnight 4. Asks the nurse to report the assault to Adult Health Protective Services

2. Accepts arrangements made with a women's shelter Accepting an arrangement at a women's shelter is a positive outcome for the client

The older, disheveled client is admitted to the ED with hypertension, severe dehydration, and malnourishment. During the admission interview, the daughter notes that she and her husband, who is temporarily out of work, have been living with the client. Which nursing action is most important? 1. Report the suspected elder abuse to Adult Health Protective Services 2. Ask additional questions of the client in private without the family present 3. Ask the daughter whether her father has been eating and taking his medication 4. Call the resource hotline to ask whether abuse and neglect should be considered

2. Ask additional questions of the client in private without the family present Additional questions should be asked of the client in private to elicit information about abuse, maltreatment, or neglect

The toddler is hospitalized for observation after having apnea spells that led to cardiac arrest at home three times in the past 6 months. The nurse suspects Munchausen Syndrome by Proxy (MSP) and contacts the HCP. The HCP does not believe that this is a correct assessment of the child or of the family dynamics. What should the nurse do? 1. Contact the head of the department of pediatrics to report the incident 2. Consult with the clinical charge nurse as to what action should be taken 3. Call a case conference involving physicians, nurses, and social workers 4. File a variance report indicating the HCP was notified but took no action

2. Consult with the clinical charge nurse as to what action should be taken Nurses are mandated reporters of any suspected child abuse. This form of child abuse is one of the most difficult to confirm, and court-ordered video surveillance may be necessary. Therefore to talk with the charge nurse would be most appropriate. Typically, with MSP, there are covert pieces of evidence that would point to such a diagnosis, but hard evidence is difficult to identify

The client is being admitted to the ICU with drug overdose that results in extreme hypertension and an unstable cardiac rhythm. The client suddenly becomes physically combative and abusive. The nurse calls a behavioral situation code, and four-point restraints are applied by the team. Which most important intervention should be next? 1. Have staff who were harmed completing incident report 2. Contact the HCP to obtain an order for straight and use 3. Document the clients behavior in action taken 4. Check that the wrist restraints are tightly secured to the HOB

2. Contact the HCP to obtain an order for straight and use If physical restraints are initiated, a HCP or license independent practitioner must prescribe the restraints, assess the client, and evaluate the need for restraints within one hour of restraints being placed. The restraints could be placed immediately for the client self-protection and protection of others.

The client has been violent toward other clients on a mental health unit, and interventions have failed. During the application of restraints, which action by the team lender will gain the greatest cooperation from the client? 1. Showing sympathy by apologizing for the need to restrain the client 2. Dispassionately explaining why and how the restraints will be applied 3. Affording the client one last opportunity to avoid restraints by "behaving" 4. Offering to remove the restraints as soon as the client can "control the anger"

2. Dispassionately explaining why and how the restraints will be applied By providing an explanation of what is to happen and why, the client may resist less or, in some instances, decide to alter the behavior, especially once an understanding of the intervention is achieved. A dispassionate explanation avoids the nurse's emotions before misinterpreted by the client

The client is placed in seclusion for exhibiting violent behavior. Which should be the nurses primary goal of the seclusion? 1. Assist the client in regaining self control 2. Ensure the safety of the client and others 3. Regain control of the unit's environment 4. Provide a consequence for the client's behavior

2. Ensure the safety of the client and others The primary goal of seclusion is always safety of the client others by decreasing environmental stimuli

The client with Alzheimer's disease becomes increasingly agitated and states "I must go and clean out the barn!" Which nursing response is most therapeutic? 1. What makes you think that the barn needs to be cleaned? 2. So you've cleaned the barn. Tell me did you live on a farm? 3. It's awfully hot today maybe you should wait until tomorrow 4. There are no barns around here. Would you like something to eat?

2. So you've cleaned the barn. Tell me did you live on a farm? Rather than attempting to re orientate the agitated, cognitively impaired client, asking the client to describe feelings of memories related to the situation may affectively divert the clients attention to a less problematic focus

The nurse is developing the plan of care for the client who has schizophrenia and is having an alcohol induced crisis. Which specific outcome best reflects the primary goal of crisis intervention for this client? 1. Client will be successfully detoxified within 20 days 2. The client will return to his or her a part time job within 20 days 3. The client will state two effective coping mechanisms 4. The client will self administer medications before discharge

2. The client will return to his or her a part time job within 20 days The primary goal of crisis intervention is to return the client to his or her pre-crisis level of functioning. Returning to work is the most appropriate outcome directed toward that goal

The client who is indigent and has emotional and physical diagnoses is attending a discharge planning session with the nurse. Which client behavior shows the greatest commitment to self-management? 1. Correctly stating the medications prescribed and the administration schedule 2. Asking to stay with a relative until an affordable place to live can be found 3. Researching the names of and calling contact people at local support centers 4. Promising the nurse to keep the scheduled follow-up appointments at the clinic

3. Researching the names of and calling contact people at local support centers Telephoning contacts at support services shows both an understanding of and a willingness to utilize the services. Research has shown that beginning client linkage to services prior to discharge has a positive effect on client outcomes

Staff are debriefing following the client's violent episode. What information should be included in the debriefing session? (Select all that apply) 1. clients coping mechanisms post event 2. The client's history of violent behavior 3. Adherence to instructional policies and procedures 4. The staff's feeling regarding the effectiveness of the team 5. The staff's ability to respond to the client therapeutically post event

3, 4, 5 3. the staff debriefing should include whether everyone adhere to the facility policy'sand procedures this will help to identify the need for additional remedial staff training 4. The staff debriefing should include team affectedness this will help identify their readiness to respond and manage the event and the need for additional remedial staff training 5. the staff debriefing should include the staff's ability to respond to the client therapeutically post event. This will help to identify the need for additional remedial staff training

During orientation to the behavioral care unit, the new nurse asks, "How will I know which clients are potentially violent?" Which response by the nurse educator is best? 1. "Just be alert and aware of your client's behavioral clues." 2. "The client prone to violence will usually tell you they are angry about something." 3. "As you plan care, review the client's charts to determine who has a history of violence." 4. "Your orientation will include an in-service on violent clients and how to identify them."

3. "As you plan care, review the client's charts to determine who has a history of violence." The two most significant predictors of violence are a history of violence and impulsivity. Thus reviewing the client's chart for this information is best

The NA is helping the ED nurse admit a woman who is the victim of spousal abuse and marital rape. The NA asks the nurse what should be done with the woman's torn and soiled clothing. What is the nurse's best response? 1. "Place items in a plastic bag and avoid blood and body fluid contact." 2. "Ask the woman what she wants done with her clothing; she may want them discarded." 3. "These may be needed by the police. I will remove them and place each item in separate paper bags." 4. "Fold each article of clothing and leave them with her; she can decide later about disposal."

3. "These may be needed by the police. I will remove them and place each item in separate paper bags." To preserve the evidence, items are placed in separate paper bags, labeled, and released with appropriate documentation to the requesting police officer. The nurse specially trained to deal with possible criminal offenses should handle the clothing

The client has been placed in restraints for violent behavior. Which statement best indicates the nurse is understanding of the risk for client injury while being restrained? 1. Can you arrange to order the clients favorite sandwich for his lunch? 2. I need to make sure the restraints release mechanisms are working properly 3. I need someone to continuously monitor the client and relieve me for a few minutes 4. The clients feet feel little cool, but they have a good pulse. I'll get a pair of socks

3. I need someone to continuously monitor the client and relieve me for a few minutes The client must be constantly monitored when in restraints to assess four and prevent any type of client injury.

Staff members have expressed fear of the client has a history of violent behavior. Which response made by the lead nurse would be most beneficial in addressing the staff's express concerns? 1. Let's not prejudge him. His medication should help him control his behavior 2. I will be very attentive to his behavior, monitoring it for any signs of escalation 3. It may be hard, but we need to appear calm and nonthreatening but alert to his behavior at 4. As staff we are all trained to manage violent clients, and we can handle any crisis behavior

3. It may be hard, but we need to appear calm and nonthreatening but alert to his behavior at When dealing with potentially violent clients, although it may be very difficult, it is imperative to present a column, relaxed, nonthreatening demeanor. This option both addresses the staff concerns an offers direction regarding client management

The client with a history of aggressive behavior toward staff and peer states to the nurse, "everyone is just so touchy; I don't see where I'm being too aggressive." which nursing action should be included in the therapeutic plan of care to best affect a difference in perceptions? 1. Refamiliarize the client with the rules of the unit 2. Introduce non aggressive interpersonal behaviors 3. Promote dialogue between the staff and client to discuss the status perception of aggressive behavior 4. Encourage the staff to show patience because the client may have poor aggression control

3. Promote dialogue between the staff and client to discuss the status perception of aggressive behavior Research has shown that staff and clients often have different perceptions of aggressive behavior and of how to control or reduce aggression. Promoting a dialogue between the client and the staff can clarify the different perceptions.

The client has been placed in involuntary seclusion. Which information best indicates to the nurse that the client is ready to leave involuntary seclusion? 1. The client calmly stating, "I have control over my anger now." 2. BP is 110/64 mm Hg; P is 82 bpm and regular; RR is 16 bpm and regular 3. The client is sitting in the seclusion room doorway asking staff for a drink 4. Medical record states, "Seclusion of 45 minutes resulting in improved control."

3. The client is sitting in the seclusion room doorway asking staff for a drink The client is showing the ability to tolerate the stimulation provided by being in the doorway and still appropriately asking for needs to be met. The reintegration of the client into the milieu should be completed gradually so as to monitor the client's ability to handle increased stimulation

When debriefing the unit's staff after the client's catastrophic reaction, the nurse stresses the need for staff to remain calm during the event. Which statement should be the basis for the nurse's comment? 1. The client's safety is at jeopardy if the staff is feeling threatened 2. An agitated staff will not be able to manage the situation as effectively 3. The client will sense the staff's agitation, and aggressive behavior will escalate 4. An agitated staff response is indicative of a need for additional crisis-control training

3. The client will sense the staff's agitation, and aggressive behavior will escalate The presence of other agitated people leads to increased client agitation

The new nurse is working with the cognitively impaired client who has a history of violent behavior. Which statement, made by the new nurse, reflects an immediate need for follow up by the mentor? 1. My first concern is the safety of all of those on the unit 2. I know to turn off the TV when the client starts pacing 3. When the client got aggressive, I tried talking the client down 4. I'm going to assign the same staff to work with the client each shift

3. When the client got aggressive, I tried talking the client down The mentor should follow up when the new nurse attempts to talk to the agitated client. Until the client regains control, talking will be interrupted as external stimulation. As a client becomes calmer and more secure, attempts can then be made to redirect the client's attention and behavior

The newly admitted client is expressing anger with increasing intensity. Which therapeutic site should the nurse recommend to the client for gaining control over the increasing anger? 1. The clients own private room down the hall 2. The unit's common television dayroom 3. An outdoor sheltered client smoking area 4. And out of the way corner near the nursing station

4. And out of the way corner near the nursing station A quiet location that is visible to the staff is best. A quiet environment is critical for client de-escalation.

The client is experiencing withdrawal symptoms leading to sleep deprivation. The nurse should recognize that the client is at greatest risk for violent behavior due to which assessment finding? 1. Poor coping mechanisms 2. Physical pain from withdrawal 3. A sense of guilt/shame regarding family 4. Anxiety over lack of access to the substance of choice

4. Anxiety over lack of access to the substance of choice The client hospitalized for chemical dependency is at risk for developing violent behavior due to anxiety from the loss of access to the drug of choice

The nurse is delayed in changing the dressing on the client's leg. The client reacts by becoming verbally aggressive and telling the nurse, "none of you can be trusted. You all just make promises you never intend to keep." which should the nurse do now? 1. Alert other staff for the clients apparent escalation 2. Ask why the client is overreacting 3. Leave the room until the client regains control 4. Apologize to the client for being late with the treatment

4. Apologize to the client for being late with the treatment By apologizing for being late with the treatment, the nurses validating the client's distress and acknowledging his or her role in creating the situation

The nurse is caring for the unresponsive toddler in a PICU. The child's parent was arrested for alleged child abuse but released on bail. The parent is pounding at the door, belligerent, and demanding to visit the child. Which plan is most appropriate? 1. Allow the parent to enter the room and see the child 2. Tell the parent that the HCP wants to speak with the parent first 3. Contact Social Services to report the parent's abusive behavior 4. Initiate the emergency response system for behavioral situations

4. Initiate the emergency response system for behavioral situations The nurse's primary responsibility is the safety of the child and others. The nurse would initiate the hospital's emergency response system for behavioral situations to a secure a supervisor, security staff, and others

The client is visibly upset, pounding on the desk at the nurses' station, and shouting, "You're the nurse, so you have to fix this now." What should be the nurse's primary rationale for recognizing that the client is a danger to staff and other clients? 1. The client is verbally threatening the nurse to fix the situation now 2. The client does not acknowledge his or her role in solving problems 3. The client does not recognize that he or she is acting inappropriately 4. The client uses intimidation and anger for meeting personal needs and wants

4. The client uses intimidation and anger for meeting personal needs and wants For some, intimidation and anger are the primary strategies for obtaining needs and goals and for achieving feelings of mastery and control. The nurse should recognize that the client is a danger to staff and others when using intimidation and anger

The nurse manager, concerned about the potential for staff harm on a behavioral health unit, is assessing the unit's milieu. Which milieu situation should the nurse manager address because it is a predictive factor for violence? 1. Two clients have a history of spousal abuse 2. Several clients have lost smoking privileges 3. The unit is at less than full client capacity 4. The nurse from a medical unit is assigned to work on the unit

4. The nurse from a medical unit is assigned to work on the unit Staff inexperience is a significant environmental predictor of violent behavior of clients. The nurse manager should address the situation

The client is admitted to the ED with multiple lacerations and broken bones after being assaulted. The clients spouse barging the clients room with a gun and states "I'm going to kill you and anyone else who gets in my way" which action should be taken by the nurse initially? 1. Yell for help to distract the person's attention away from the client 2. firmly state "you don't want to hurt anyone else. Let's talk about it" 3. use gestures to alert another nurse to clear others who may be nearby 4. Using an aggressive posture and tone to state "put the gun on the floor."

4. Using an aggressive posture and tone to state "put the gun on the floor." The nurse should initially talk to the clients spouse who's holding the gun using a non-aggressive posture and tone of voice to diffuse the situation.