ATI LPN
Test Bank for Psychiatric Nursing: Contemporary Practice
Chapter 19 Questions
Question 1 of 5
A patient has been admitted to the detoxification unit after binge drinking. Even though the patient is not currently intoxicated, he is combative and exhibits altered thought processes. Which nursing diagnosis would be the priority?
Correct Answer: C
Rationale: The priority nursing diagnosis is 'Risk for Other-Directed Violence related to alcohol withdrawal,' as the patient?s combative behavior and altered thought processes pose an immediate risk to others. Safety is the primary concern in this scenario, outweighing risks for injury, self-mutilation, or developmental delays.
Question 2 of 5
While interviewing a patient, a nurse asks, What do you do when you get angry? Which patient response would indicate to the nurse that the patient engages in anger suppression?
Correct Answer: B
Rationale: Withdrawing and pouting indicate anger suppression, as the patient avoids expressing anger directly. Flying off the handle suggests explosive anger, while direct discussion or confiding in a friend indicates healthier anger expression.
Question 3 of 5
The nurse is caring for an older adult patient who has no history of violence but is agitated and appears ready to strike out at a staff member. The nurse would assess the patient for which of the following?
Correct Answer: D
Rationale: Sensory losses, such as hearing or vision impairment, are common in older adults and can lead to agitation or perceived aggression due to frustration or miscommunication. Panic disorder, epilepsy, or bipolar disorder are less likely causes without additional symptoms or history.
Question 4 of 5
A nurse is presenting an in-service program about aggression and violence to a group of newly hired nurses who will be working in an inpatient psychiatric facility. When describing characteristics that may predict the risk for violence and aggression in patients, which of the following would the nurse include? Select all that apply.
Correct Answer: A,B,C,D,E
Rationale: Age, impulsivity, substance withdrawal, gender, and suspiciousness are all predictors of violence risk. Younger age, male gender, impulsivity, withdrawal symptoms, and paranoia or suspiciousness increase the likelihood of aggressive behavior in psychiatric settings.
Question 5 of 5
After working with a patient who has a history of violent behavior to identify possible clues that suggest that his behavior is escalating, the nurse and patient develop a plan for prevention. Which strategy would they be least likely to include?
Correct Answer: C
Rationale: Turning up the music loud could overstimulate the patient and escalate agitation, making it an ineffective prevention strategy. Counting to 10, deep breathing, and voluntary time-outs are calming techniques that help de-escalate potential violence.