ATI RN
Aggressive Behavior Nursing Diagnosis Questions
Question 1 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 2 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 3 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.
Question 4 of 5
A nurse is assessing a patient diagnosed with bulimia nervosa. The patient states, 'I feel so ashamed after I eat.' What is the priority nursing intervention?
Correct Answer: C
Rationale: In this scenario, the priority nursing intervention is option C: Offer the patient nonjudgmental support and explore feelings of shame about eating. This is the most appropriate response because it acknowledges the patient's emotional distress and opens up a safe space for them to express their feelings. Option A is incorrect because simply providing positive affirmations may not address the underlying issues causing the patient's shame. Option B, encouraging self-care activities, while important, may not directly address the patient's immediate emotional needs. Option D, telling the patient that shame is not helpful and focusing on balanced nutrition, may come across as dismissive of the patient's feelings and could potentially worsen the therapeutic relationship. In an educational context, it's crucial for nursing students to understand the importance of empathy, active listening, and providing nonjudgmental support in addressing psychological issues like shame in patients with eating disorders. By exploring the patient's feelings and offering support, nurses can help foster trust and facilitate meaningful therapeutic interventions to promote the patient's overall well-being.
Question 5 of 5
A nurse is caring for a patient diagnosed with bipolar disorder who is in the manic phase. The patient states, 'I'm going to buy a new car and take a trip to Paris.' Which of the following is the priority nursing intervention?
Correct Answer: B
Rationale: In caring for a patient with bipolar disorder in the manic phase, the priority nursing intervention is to limit the patient's access to money and credit cards (Option B). This is crucial because individuals in a manic episode may engage in impulsive and risky behaviors, such as excessive spending, which can have serious consequences like financial ruin. By limiting access to money and credit cards, the nurse can help prevent the patient from making poor financial decisions that could harm their well-being. Encouraging the patient to think through the consequences of their actions (Option A) may not be effective during a manic episode as reasoning and judgment are often impaired. Providing information about budgeting and planning (Option C) may also not be productive at this time as the patient's primary need is to be kept safe from harm. Encouraging the patient to express their excitement about their plans (Option D) may inadvertently validate and reinforce risky behaviors associated with the manic episode. In an educational context, it is important for nurses to understand the unique challenges presented by individuals experiencing manic episodes and to prioritize interventions that promote their safety and well-being. Limiting access to potential harmful resources is a key strategy in managing impulsive behaviors associated with bipolar disorder.