20. Which medication from the medication administration record should a nurse administer to
provide immediate intervention for a psychotic patient whose aggressive behavior continues to escalate despite verbal intervention? a. Lithium b. Trazodone c. Olanzapine d. Valproic acid ANS: C
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Olanzapine is a short-acting antipsychotic useful in calming angry, aggressive patients regardless of diagnosis. The other drugs listed require long-term use to reduce anger. Lithium is for bipolar patients. Trazodone is commonly prescribed for patients experiencing depression, insomnia, or chronic pain. Valproic acid is for bipolar or borderline patients.
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PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Pages 27-17, 44 (Table 27- 2) TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
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21. An emergency department nurse realizes that the spouse of a patient is becoming increasingly
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irritable while waiting. Which intervention should the nurse use to prevent further escalation of the spouse’s anger? a. Offer the waiting spouse a cup of coffee. b. Explain that the patient’s condition is not life threatening. c. Periodically provide an update and progress report on the patient. d. Suggest that the spouse return home until the patient’s treatment is complete. ANS: C
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Periodic updates reduce anxiety and defuse anger. This strategy acknowledges the spouse’s presence and concern. A cup of coffee is a nice gesture, but it does not address the spouse’s feelings. The other incorrect options would be likely to increase anger because they imply that the anxiety is inappropriate.
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PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Pages 27-14, 15 TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity 22. Which information from a patient’s record would indicate marginal coping skills and the need
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for careful assessment of the risk for violence? A history of a. academic problems. b. family involvement. c. childhood trauma. d. substance abuse. ANS: D
The nurse should suspect marginal coping skills in a patient with substance abuse. They are often anxious, may be concerned about inadequate pain relief, and may have personality styles that externalize blame. The incorrect options do not signal as high a degree of risk as substance abuse. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Pages 27-3, 4, 6, 8, 50 (Box 27-1) TOP: Nursing Process: Assessment
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