The client has been violent toward other clients on a mental health unit, and interventions have failed. During the application of restraints, which action by the team leader will gain the greatest cooperation from the client?

The older, disheveled client is admitted to the ED with hypertension, severe dehydration, and malnourishment. During the admission interview, the daughter notes that she and her husband, who is temporarily out of work, have been living with the client. Which nursing action is most important?

The NA is helping the ED nurse admit a woman who is the victim of spousal abuse and marital rape. The NA asks the nurse what should be done with the woman’s torn and soiled clothing. What is the nurse‘s best response?

The nurse is collecting information from the family in which Munchausen Syndrome by Proxy (MSP) is suspected. Which finding should the nurse expect?

The nurse is caring for an unresponsive toddler in a PICU. The child’s parent was arrested for alleged child abuse but released on bail. The parent is pounding at the door, belligerent, and demanding to visit the child. Which is the most appropriate nursing plan of action?

The nurse in the ED is admitting an agitated young adult who tried to jump from a bridge after taking a hallucinogenic drug at a party. What should be the nurse’s initial action?

The indigent client with both emotional and physical diagnoses has just attended a discharge planning session with the nurse. Which client behavior shows the greatest commitment to the client’s self-management?

When debriefing the unit’s staff after the client’s catastrophic reaction, the nurse stresses the need for the staff to remain calm during the event. Which statement should be the basis for the nurse’s comment?

The nurse is planning care for the client who has a cognitive deficit and a history of violence following head trauma- What is the primary effect of a cognitive deficit that can contribute to the client having a catastrophically violent reaction?

The client is visibly upset, pounding on the desk at the nurses’ station and shouting,” You’re the nurse, so you have to fix this now.” What should be the nurse’s primary rationale for recognizing that the client is a danger to staff and other clients?

The nurse manager, concerned about the potential for staff harm on a behavioral health unit, is assessing the unit’s milieu. 'Which milieu situation should the nurse manager address because it is a predictive factor for violence?

The client who recently emigrated from Iran is on the mental health unit and has been placed in seclusion. The nurse assesses that the client is now calm and ready to be assimilated back into the mental health milieu. Which action by the nurse demonstrates cultural insensitivity?

The client is experiencing withdrawal symptoms leading to sleep deprivation. The nurse should recognize that the client is at greatest risk for violent behavior due to which assessment finding?

The nurse is unavoidably late in changing the dressing on the client’s leg. The client reacts by becoming verbally aggressive and telling the nurse, “None of you can be trusted. You all just make promises you never intend to keep.” Which should be the nurse’s initial action?

The client is admitted to the ED with multiple lacerations and broken bones after being assaulted. The client’s spouse barges into the client’s ED room with a gun and states, “I’m going to kill you and anyone else who gets in my way.” Which action should be taken by the nurse initially?

The client has been placed in restraints for violent behavior. Which statement best indicates the nurse’s understanding of the risk for client injury while being restrained?

The nurse educator is orienting new nursing staff to the behavioral care unit when one nurse asks, “How will I know which clients are potentially violent?” Which response by the nurse educator is best?

The new nurse is working with the cognitively impaired client who has a history of violent behavior. Which statement, made by the new nurse, reflects an immediate need for follow-up by the mentor?

The client with Alzheimer’s disease becomes Increasingly agitated and states, “I must go and clean out the barn!” Which nursing response is most therapeutic?

Staff members have expressed fear of the client who has a history of violent behavior. Which response made by the lead nurse would be most beneficial in addressing the staff’s expressed concerns?

The newly admitted client is expressing anger with increasing intensity. Which therapeutic site should the nurse recommend to the client for gaining control over the increasing anger?

The client with a history of aggressive behavior to ward staff and peers states to the nurse, “Everyone is just so touchy; I don’t see where I’m being too aggressive.” Which nursing action should be included in the therapeutic plan of care to best effect a difference in perceptions?

The client is placed in seclusion for exhibiting violent behavior. Which should be the nurse’s primary goal of this seclusion?

The client is being admitted to the ICU with drug overdose that resulted in extreme hypertension and an unstable cardiac rhythm. The client suddenly becomes physically combative and is kicking, shoving, throwing items in the room, and threatening staff. The charge nurse calls a behavioral situation code, and 4-point restraints are applied by the team. Which intervention is most important for the nurse to implement next?

The nurse is caring for the toddler who has been hospitalized for observation because of apnea spells that have led to cardiac arrest at home three times in the past 6 months. The nurse suspects Munchausen Syndrome by Proxy (MSP) and contacts the “CF, who does not believe that this is a correct assessment of the condition of the child or of the family dynamics. What should the nurse do?

The nurse is developing the plan of care for the client diagnosed with schizophrenia who is having an alcohol-induced crisis. Which specific client outcome best reflects the primary goal of crisis intervention for this client?

The 28-year-old is being seen in the ED with injuries after being assaulted by her live-in boyfriend. The client acknowledges that this is not the first time that she has been assaulted and that she is afraid. Which client action indicates that an out- come for the client has been achieved?

The nurse is reviewing the medical records of children who have been abused. Which main common characteristic of parents who abuse children is the nurse most likely to identify?

The client has been placed in involuntary seclusion. Which assessment observation best indicates to the nurse the client’s readiness to leave involuntary seclusion?