A patient's inability to deescalate his aggressive behavior has resulted in the response team coming to
the unit. When the patient demands to know, "Why are all these people here?", the nurse responds
most therapeutically when stating: - correct answer ✔✔"We are here to keep you safe and stop you
from hurting anyone else."
A patient with a history of aggressive behavior begins pacing while talking on the telephone. The RN
suspects that the patient is in the triggering phases of the assault cycle and implements which
intervention? - correct answer ✔✔Using a calm voice, asks the patient to end the conversation
immediately
Which nursing intervention is most appropriate for the post-crisis depression phase of the assault cycle?
- correct answer ✔✔Asking "Can we talk about what triggered your angry behavior?"
Meeting the immediate safety needs of an aggressive patient is based on which principle of care? -
correct answer ✔✔The least restrictive option is implemented.
What factors determine when seclusion of an aggressive patient is terminated? - correct answer
✔✔Nursing judgment and facility protocols
Which intervention will not be included in the care plan for a patient who is currently being physically
restrained? - correct answer ✔✔The patient is allowed to listen to his/her personal radio during the
isolation process.
An individual calls the hospital during the night shift in crisis and is considering suicide. The nurse will
begin the interaction by saying: - correct answer ✔✔"Let's see what we can work on together."
, The priority nursing intervention when working with a patient who has entered the escalation phase of
the assault cycle is to: - correct answer ✔✔call the patient by name while letting him/her know that the
staff is there to help.
Which behavior demonstrates the most lethal plan by an individual who has recently expressed suicidal
ideations? - correct answer ✔✔He has been hoarding medications and has a large supply of
barbiturates.
A patient has been expressing beliefs that are not in touch with reality. The nurse's decision not to argue
with the patient concerning these delusions is based on the understanding that to argue would: - correct
answer ✔✔reinforce the delusion.
Later life depression and resulting suicide deaths among the older adult population are believed to be
most related to: - correct answer ✔✔increased exposure to grief-induced losses.
The challenge to the nurse inherent in establishing and maintaining a working relationship with a
severely depressed patient is the patient's: - correct answer ✔✔withdrawal from and disinterest in the
relationship.
Which intervention will best address the low self-esteem issues experienced by a middle-aged adult who
has been unemployed for 2 years? - correct answer ✔✔Assist the patient in identifying personal skills
and achievements.
A depressed patient who originally responded to a failure by stating, "I can't do anything right" is
overheard telling a staff member, "I've learned that everyone makes mistakes." This is an example of: -
correct answer ✔✔negative thought reprogramming.
A 70-year-old man comes to the clinic for his annual physical exam and influenza vaccine. He shares that
his "life has no meaning," he "feels tired all the time," and "has lost all hope for the future." The initial
nursing intervention is to: - correct answer ✔✔further assess his concerns and history of psychiatric
issues.
Growth hormone assessment is a frequently used biologic diagnostic tool to diagnosis depression in
which population? - correct answer ✔✔Children
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