ATI RN
Aggressive Behavior Nursing Diagnosis Questions
Question 1 of 5
A nurse is caring for a patient diagnosed with anorexia nervosa. The patient states, 'I think I'm too fat, even though I've lost 30 pounds.' Which of the following is the most appropriate response by the nurse?
Correct Answer: B
Rationale: The most appropriate response by the nurse in this scenario is option B: "It sounds like you're feeling very concerned about your body image." This response demonstrates empathy and active listening, acknowledging the patient's feelings without judgment. It opens up the opportunity for the patient to express their emotions and concerns further, fostering a therapeutic nurse-patient relationship. Option A is incorrect because it dismisses the patient's feelings and can be perceived as invalidating. It does not address the underlying issue of body image distortion in anorexia nervosa. Option C is inappropriate as it is directive and does not consider the complexity of the patient's psychological condition. Option D is also not the best response as it focuses solely on the physical aspect of weight gain without addressing the patient's emotional distress. In an educational context, it is essential for nurses to develop strong communication skills to effectively support patients with mental health disorders like anorexia nervosa. By responding empathetically and non-judgmentally, nurses can create a safe space for patients to express their thoughts and feelings, which is crucial for building trust and promoting positive health outcomes.
Question 2 of 5
As a nurse escorts a patient being discharged after treatment for major depression, the patient gives the nurse a necklace with a heart pendant and says, 'Thank you for helping mend my broken heart.' Which is the nurse's best response?
Correct Answer: C
Rationale: The best response for the nurse in this scenario is option C: "I'm glad I could help you, but I can't accept the gift. My reward is seeing you with a renewed sense of hope." This response is appropriate because it acknowledges the patient's gratitude while also maintaining professional boundaries. Accepting gifts can create ethical dilemmas, blur boundaries, and potentially influence care decisions. By politely declining the gift and emphasizing the nurse's satisfaction in seeing the patient's progress, it reinforces the therapeutic nurse-patient relationship. Option A is incorrect as it comes off as rigid and dismissive of the patient's gesture, failing to acknowledge the emotional significance of the gift-giving. Option B, though appreciative, doesn't address the issue of accepting gifts in a healthcare setting. Option D, while highlighting the rewarding aspects of nursing, fails to address the potential ethical implications of accepting a gift from a patient. In an educational context, this scenario teaches students the importance of maintaining professional boundaries, ethical considerations in healthcare, and the significance of therapeutic communication in nursing practice. It underscores the need for nurses to navigate situations involving patient gratitude while upholding professional standards.
Question 3 of 5
A nurse is assessing a patient diagnosed with generalized anxiety disorder. The patient states, 'I feel constantly anxious, and I can't calm down.' Which of the following is the most appropriate nursing diagnosis?
Correct Answer: C
Rationale: In this scenario, the most appropriate nursing diagnosis for a patient with generalized anxiety disorder who expresses feeling constantly anxious and unable to calm down is option C) Anxiety. The correct answer, "Anxiety," aligns with the patient's presenting symptoms and the nursing assessment findings. Generalized anxiety disorder is characterized by persistent and excessive worry or anxiety about various aspects of life. The patient's statement directly reflects this symptom, indicating a high level of anxiety. Option A) Risk for suicide is incorrect because the patient did not express any suicidal ideation or intent in the given scenario. This option would be more appropriate if the patient had mentioned thoughts of self-harm. Option B) Ineffective coping is not the best choice as it does not capture the primary issue of anxiety that the patient is experiencing. While anxiety may lead to ineffective coping mechanisms, the primary focus in this case should be on addressing the underlying anxiety. Option D) Disturbed thought processes is also not the most appropriate choice as the patient's statement does not suggest any cognitive deficits or disorganized thinking. This diagnosis is more relevant in cases involving hallucinations, delusions, or severe cognitive impairments. Educationally, understanding the rationale behind selecting the most appropriate nursing diagnosis is crucial for providing effective patient care. By accurately identifying the patient's primary issue of anxiety, nurses can develop targeted interventions to help the patient manage their symptoms and improve their overall well-being. This exercise highlights the importance of clinical reasoning and the significance of selecting the most relevant nursing diagnosis based on the patient's presentation.
Question 4 of 5
Documentation in a patient's chart shows, 'Throughout a 5-minute interaction, patient fidgeted and tapped left foot, periodically covered face with hands, and looked under chair while stating, 'I enjoy spending time with you.' Which analysis is most accurate?
Correct Answer: C
Rationale: When a verbal message is not reinforced with nonverbal behavior, the message is confusing and incongruent. It is inaccurate to say that the patient is giving positive feedback about the nurse's communication techniques. The concept of a cultural filter is not relevant to the situation because a cultural filter determines what we will pay attention to and what we will ignore. Data are insufficient to draw the conclusion that the patient is demonstrating psychotic behaviors.
Question 5 of 5
A school age child tells the school nurse, 'Other kids call me mean names and will not sit with me at lunch. Nobody likes me.' Select the nurse's most therapeutic response.
Correct Answer: D
Rationale: The correct response, "Tell me more about how you feel," is the most therapeutic because it demonstrates active listening and empathy, allowing the child to express their emotions and concerns openly. This response validates the child's feelings, builds trust, and initiates a supportive dialogue to address the underlying issues causing distress. Option A, "Just ignore them and they will leave you alone," is dismissive and may make the child feel unheard or unsupported. It does not address the emotional impact of the situation and can increase feelings of isolation. Option B, "You should make friends with other children," overlooks the child's current feelings of rejection and does not provide immediate comfort or guidance on how to cope with the current situation. Option C, "Call them names if they do that to you," promotes retaliation and escalation of conflict, which is not a healthy or constructive way to handle bullying or aggression. In an educational context, it is crucial for nurses and educators to respond to children experiencing aggressive behavior with compassion and understanding. By encouraging open communication and offering emotional support, they can help children develop coping skills, resilience, and positive social interactions. Active listening and empathy are essential tools in building trust and fostering emotional well-being in school-age children facing social challenges.