A nurse manager is providing staff education about working with patients who have a history of anger and aggression.
Which of the following information should the nurse include in the teaching?
Stand directly in front of the patient when talking.
Know the layout of the facility.
Bring security with you for all patient interactions.
Provide immediate verbal feedback for escalating behavior.
Avoid wearing necklaces during patient care.
Correct Answer : B,D,E
Choice A rationale
Standing directly in front of a patient who has a history of anger and aggression can be perceived as threatening and may escalate the situation.
Choice B rationale
Knowing the layout of the facility can help the nurse to plan for safe exits or to put barriers between themselves and the patient if needed.
Choice C rationale
Bringing security for all patient interactions can escalate the situation and should only be done if there is a clear threat to safety.
Choice D rationale
Providing immediate verbal feedback for escalating behavior can help to de-escalate the situation and reassure the patient.
Choice E rationale
Avoiding wearing necklaces during patient care can reduce the risk of injury to the nurse.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Recording that the nurse was unable to take the patient’s temperature would not be the most appropriate action in this situation. The nurse can wait for a certain period of time and then take the patient’s temperature.
Choice B rationale
Continuing to take the oral temperature immediately after the patient has consumed ice chips could result in an inaccurately low temperature reading. The cold from the ice chips can temporarily lower the temperature in the mouth.
Choice C rationale
Waiting for 30 minutes and then returning to take the oral temperature is the most appropriate action. Consuming cold substances can lower the oral temperature temporarily, so it’s recommended to wait 15-30 minutes after the patient has consumed something cold before taking an oral temperature.
Choice D rationale
Giving the patient a sip of warm water, waiting for 5 minutes, and then taking the temperature is not the standard procedure. While it might help to normalize the temperature in the mouth more quickly, it’s generally recommended to wait at least 15-30 minutes after the patient has consumed something cold before taking an oral temperature.
Correct Answer is A
Explanation
Choice A rationale
Frothy sputum is a common finding in patients with left-sided heart failure. This is due to fluid accumulation in the lungs (pulmonary edema), which can cause the sputum to become frothy.
Choice B rationale
Dependent edema is more commonly associated with right-sided heart failure. It occurs due to fluid accumulation in the systemic circulation, leading to swelling in the lower extremities.
Choice C rationale
Nocturnal polyuria can occur in heart failure, but it is not a specific sign of left-sided heart failure.
Choice D rationale
Jugular venous distention is a sign of right-sided heart failure, not left-sided heart failure. It occurs due to increased pressure in the right atrium, leading to visible distention of the jugular veins.
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