Psychiatric Nursing Degree Questions
Situation: J., age 57, is taken to the emergency department by two police officers after he tried to cut a supermarket manager with a piece of broken glass. He said he did this because he was just laid off from his job, which he held for 27 years. He also said his wife recently left him after 25 years of marriage because of his alcohol abuse and the physical abuse he inflicted on her when he was drunk. In the emergency department, he becomes verbally abusive to nursing staff members and demands to be released. When asked to be seated so the nurse can take his blood pressure, he throws a chair across the room. Four staff members are needed to control and restrain him.
J. is admitted to the psychiatric unit, placed in seclusion, and given haloperidol (haldol) 5 mg I.M. After 1 1/2 hours, he appears calmer and is released from seclusion. Although still angry, he is able to control himself from becoming physically or verbally abusive. He apologizes for his behavior and says that he hopes he did not hurt anyone.
18. Which responses to J.'s apology is most therapeutic?
a) we are here to help you. We understand that you didn't mean to hurt us
b) let's see how well you can control yourself from now on
c) it's fortunate no one was hurt. It will not be necessary to use restraints as long as you can control your behavior
d) it was frightening and very dangerous. It is unpleasant to have to restrain someone
19. Based on J.'s history, reason for admission, and behavior in the emergency department, the nurse records that the patient has a Potential for Violence directed to others. Which goal is most appropriate for this nursing diagnostic category?
a) the patient will verbalize anger rather than physical strike out
b) the patient will not strike out more than once a day
c) the patient will be placed in seclusion whenever he threatens anyone verbally or physically
d) the patient will not verbalize anger or strike out at anyone
20. J. refuses his 5pm 10mg dose of haloperidol P.O. He states, "I'm in control now. I don't need any drugs." The nurse's responses to J. should be based on the understanding that the patient:
a) has the right to refuse treatment
b) is potentially violent and must be medicated
c) can be given haloperidol intramuscularly instead of orally
d) must receive haloperidol at regular intervals to ensure the drug's effectiveness
21. The nurse's initial priority when dealing with an assaultive or homicidal patient is to:
a) keep the patient away from others and under one-to-one supervision
b) restore the patient's self-control and prevent further loss of control
c) allow the patient to act out his frustrations, then establish a line of communication
d) clear the area of objects that might harm the patient or others
22. One afternoon, the nurse hears J. yelling in the dayroom. He begins pushing chairs into the wall and swings at other patients with a pool cue. The nurse should intervene by:
a) administering a fast-acting sedative, as ordered
b) telling the patient to go to his room
c) restraining the patient, then calling for assistance
d) following the initial steps of the planned team approach
23. J. continues to swing the pool cue wildly. Which approach is safest in this situation?
a) approaching the patients as a team while holding a mattress and gently backing him toward a wall
b) using chairs or other objects as safety barriers while approaching the patient
c) keeping away from the patient until he puts the pool cue down
d) calling hospital security to subdue the patient
24. Which nursing intervention is most important when restraining a violent patient?
a) reviewing hospital policy regarding how long the patient can be restrained
b) preparing a PRN dose of the patient's psychotropic medication
c) checking that the restraints have been applied correctly
d) asking the patient if he needs to use the bathroom or is thirsty
Psychiatric Nursing Degree Questions:
ANSWERS AND RATIONALE
18) C
- the most therapeutic response to J.'s apology should incorporate a realistic statement acknowledging, in a nonpunitive but serious manner, the possible consequences of his violent behavior. The nurse should also set clear limits by describing the expected behavior and the consequences the patient will face if he again loses control. Violent behavior is dangerous to both the patient and others and should not be excused or made light by saying "I know you didn't mean to hurt us..." or "Let's see how well you control yourself from now on." Such statements neither reinforce the risk of violently acting out or nor define limits for future behavior. Restraining a patient is unpleasant for all concerned, but disclosing this information to the patient without addressing the dangerousness of his behavior and reinforcing what is expected of him is insufficient.
19) A
- verbalizing angry feelings instead of physically striking out is an appropriate treatment goal for this patient. J. needs an outlet for his anger, and as long as he does not express threats of violence, verbalizing his angry feelings is an acceptable way to discharge his emotions. Striking out is an unacceptable behavior at any time. Placing the patient in seclusion in response to his threats is a nursing intervention, not a therapeutic goal.
20) A
- when formulating her response, the nurse must recognize that the patient has the right to refuse treatment, including medications. She also should be knowledgeable about state laws and institutional policies regarding this issue. Generally, patients can be treated against their will only in emergencies in which the safety of the patient or others is threatened. A potential for violence is not a sufficient reason to medicate a patient against his will. Even though haloperidol (haldol) can be given intramusclularly instead of orally, the nurse cannot forcibly administer an intramuscular injection to a patient who refuses treatment but poses no immediate physical threat. Although effective blood levels of haloperidol are achieved through regular dosing, this consideration does not override that of the patient's right to refuse treatment.
21) B
- the priority nursing intervention in response to an assaultive or homicidal patient is to maintain safety by restoring the patient's self-control and preventing further loss of control. The nurse must quickly assess the situation, then attempt to restore control through interpersonal interventions, such as using a team approach, removing the patient from the situation, encouraging verbalization, setting limits, and talking the patient down -- speaking in a calm, well-modualated voice and providing verbal support and reaasurance that the patient will not be harmed and will not be permitted to hurt himself or others. If such measures fails to control the patient, other interventions, such as seclusion, medication, or restraint, may be neccessary. Acting out violently is dangerous to the patient and others and must be controlled. Unless the patient is in seclusion, clearing the area of potentially harmful objects is unrealistic because the staff or other patients may need access to those objects. Also, one of the goals of therapy is to help the patient develop self-control and learn to coexist with others.
22) D
- the treatment team should have a plan for dealing with violent or potentially violent patients, which should be taught to all staff members and received periodically. The plan should clearly define the approach and specify roles for each team member. A show of force by all team members is sometimes sufficient to influence the patient to cooperate. The best plan involves a team leader and four or five additional staff members who are each assigned a specific task, such as securing the patient's left leg, right leg, left arm, and right arm. The leader typically serves as the spokesperson for the team.
Approaching the patient to administer medication or telling him to go to his room may be unsafe without the support and backup of other team members. The nurse should never attempt to approach or restrain a violent patient by herself.
23) A
- the patient's behavior is clearly dangerous and must be stopped before someone is injured. an organized plan to ensure the safety of the patient and the staff is essential. While the patient is striking out, staff members, through a team approach, can be protected from injury by using mattress provides padding to protect the patient as he slowly backed toward the wall and restrained. Trained psychiatric staff members, not hospital security, should handle the restraint of a psychiatric patient.
24) C
- the nurse must determine whether the restraints have been applied correctly. This assessment ensures that the patient's circulation and respiration are not restricted and that adequate padding has been used. The nurse should document carefully the patient's response and status after being restrained. All staff members involved in restraining patients should be aware of hospital policy before using restraints. If PRN medication is ordered, it should be given before restraints are in place and with the assistance of other team members. The nurse should attend to the patient's elimination and hydration needs after the patient is properly restrained.
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