Which response by the nurse would best assist a patient in de-escalating aggressive behavior?

Correct Answer: A

Rationale: The correct answer is A because it demonstrates active listening and shows empathy towards the patient, which can help them feel heard and understood. By inviting the patient to express their feelings and concerns, the nurse can help de-escalate the situation by addressing the underlying issues. Choice B is incorrect because it may come across as confrontational and could further provoke the patient's aggression. Choice C is also incorrect as it threatens the patient with consequences, which can escalate the situation. Choice D is not appropriate as it distracts from addressing the current issue of aggression and may not be well-received by the patient in that moment.

Correct Answer: C

Rationale: The correct answer is C because engaging the patient in activities designed to permit success helps boost self-esteem by providing opportunities for achievement. This intervention focuses on building the patient's confidence and self-worth through positive experiences. Choice A is incorrect as it addresses stress relief rather than self-esteem. Choice B is irrelevant as it pertains to hallucinations, not self-esteem. Choice D is also incorrect because while verbalizing feelings is important, it may not directly target the underlying issue of low self-esteem.

Correct Answer: C

Rationale: The correct answer is C because Lewy body disease can affect a patient's ability to communicate pain, making specialized pain assessment tools crucial. Special scales designed for patients with dementia can help in accurately assessing pain levels. These tools consider non-verbal cues and behavioral changes that may indicate pain. Asking the patient's family (A) may not always provide an accurate assessment of pain perception. Using a visual analog scale (B) may be challenging for a patient with cognitive impairment. Focusing solely on mental status (D) may overlook important indicators of pain in patients with Lewy body disease.

Correct Answer: B

Rationale: The correct answer is B because nurses are expected to encourage patients' involvement in therapies to promote holistic care and enhance patient outcomes. By understanding different types of therapies, nurses can educate and motivate patients to participate actively in their treatment plans. This empowers patients to take control of their health and improve their overall well-being. Choices A, C, and D are incorrect because the primary role of the nurse in this context is to support and advocate for the patients' engagement in therapies, rather than focusing on cost-effectiveness, placement, or support of other team members.

Correct Answer: A

Rationale: The correct answer is A because the teen is expressing a fear of losing control over her emotions if she starts crying. This is evident from her belief that she will never stop crying once she starts. Option B (Losing the support of her friends and family) is incorrect as the statement does not suggest concern about losing support. Option C (Embarrassing herself by crying in public) is incorrect as the fear expressed is more about not being able to stop crying rather than embarrassment. Option D (Appearing emotionally immature) is incorrect as there is no indication that the teen is worried about how others perceive her emotional maturity.

Correct Answer: B

Rationale: The correct answer is B: Medications the patient has recently taken. This is crucial because certain medications can cause delirium in elderly patients. Step 1: Evaluate recent medication history. Step 2: Identify medications known to cause delirium. Step 3: Determine if the patient has taken any of these medications. Other choices are incorrect because: A: Evidence of spasticity or flaccidity is more related to neuromuscular conditions. C: Level of preoccupation with somatic symptoms is not specific to delirium assessment. D: The patient’s level of motor activity is not a key factor in distinguishing delirium from other problems.

Correct Answer: A

Rationale: The correct answer is A because prescribing antianxiety agents may mask the woman's grief instead of allowing her to process and work through it naturally. This could potentially prolong her grief by avoiding the necessary emotional processing. The other choices, B, C, and D, all involve support that can help the woman cope with her loss in a healthy way. B offers emotional support and companionship, C helps with practical tasks, and D provides assistance in managing practical matters, all of which can facilitate the grieving process rather than prolong it.

Correct Answer: C

Rationale: The priority nursing diagnosis for a catatonic patient is Risk for deficient fluid volume (C) because catatonic patients are at risk for dehydration due to decreased fluid intake or inability to meet fluid needs. This diagnosis takes precedence over others as dehydration can lead to serious complications. Ineffective coping (A) may be secondary to the catatonic state but addressing fluid volume is more urgent. Impaired physical mobility (B) and Impaired social interaction (D) are important but not as critical as addressing the risk of dehydration in a catatonic patient.

Correct Answer: A

Rationale: The correct answer is A because it demonstrates active listening and shows empathy towards the patient, which can help them feel heard and understood. By inviting the patient to express their feelings and concerns, the nurse can help de-escalate the situation by addressing the underlying issues. Choice B is incorrect because it may come across as confrontational and could further provoke the patient's aggression. Choice C is also incorrect as it threatens the patient with consequences, which can escalate the situation. Choice D is not appropriate as it distracts from addressing the current issue of aggression and may not be well-received by the patient in that moment.