The description of the patient’s behavior shows the classic signs of someone whose potential for aggression is increasing. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Pages 27-3, 4, 8, 50 (Box 27-1) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity 15. A patient with multi-infarct dementia lashes out and kicks at people who walk past in the hall
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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. ANS: C
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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.
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PTS: 1 DIF: Cognitive Level: Analyze (Analysis) REF: Pages 27-30 to 32, 51 (Box 27-2) TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity
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16. A cognitively impaired patient has been a widow for 30 years. This patient frantically tries to
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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?”
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ANS: C
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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.
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PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Pages 27-32, 33 TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity
17. 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
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