Which of the following patients is most likely to become violent?

The patient who is staring at staff in silence while clenching their fist

The patient who overdosed, is under sedation and unconscious

The patient with antisocial personality disorder who wants to leave AMA (against medical advice)

The patient who is hallucinating and believes God is giving them “clear messages”

Answer and Explanation

The Correct Answer is A

A: The patient who is staring at staff in silence while clenching their fist is exhibiting signs of potential aggression. This behavior indicates a high level of tension and possible imminent violence. The clenched fist is a physical sign of anger or frustration, and the silent staring can be intimidating and threatening to staff. This patient requires immediate attention to de-escalate the situation and prevent any violent outburst.

B: The patient who overdosed and is under sedation and unconscious is not likely to become violent in their current state. Sedation and unconsciousness significantly reduce the risk of aggressive behavior. This patient needs medical monitoring and care for their overdose, but they do not pose an immediate threat of violence.

C: The patient with antisocial personality disorder who wants to leave AMA may exhibit manipulative or non-compliant behavior, but this does not necessarily indicate an immediate risk of violence. While patients with antisocial personality disorder can be challenging to manage, their desire to leave AMA is more about non-compliance than aggression.

D: The patient who is hallucinating and believes God is giving them “clear messages” may be experiencing psychosis, which can sometimes lead to unpredictable behavior. However, hallucinations alone do not directly indicate a likelihood of violence. The content of the hallucinations and the patient’s overall behavior would need to be assessed to determine the risk of violence.

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Correct Answer is A

Explanation

A: Placing the difficulty in understanding on yourself by saying, “I’m having trouble following you,” is a therapeutic communication technique. It helps to reduce the patient’s anxiety and encourages them to clarify their thoughts without feeling judged. This approach fosters a supportive environment and can help the patient organize their thoughts better.

B: Letting the patient think you understand to minimize their anxiety is not an effective strategy. It can lead to further confusion and does not help the patient improve their communication. Honesty and clarity are important in therapeutic interactions.

C: Using reality testing to help the patient clarify their statements can be useful, but it may not be the best initial approach. It requires the patient to have some level of insight and ability to engage in reality testing, which may not be possible in severe cases of associative looseness.

D: Telling the patient they are not making any sense can be perceived as judgmental and may increase the patient’s anxiety and frustration. It is not a supportive or therapeutic approach and can hinder effective communication.

A. Anxiety and agitation B. Disorganized thinking C. Pain with bowel and bladder function D. Disorientation E. Displays overly friendly behaviors

Correct Answer is ["A","B","D"]

Explanation

A: Anxiety and agitation are common symptoms of delirium. Patients may become restless and anxious due to confusion and disorientation.

B: Disorganized thinking is a hallmark of delirium. Patients may have trouble maintaining a coherent line of thought and may exhibit incoherent speech.

C: Pain with bowel and bladder function is not a typical symptom of delirium. While discomfort can exacerbate delirium, it is not a defining characteristic.

D: Disorientation, particularly to time and place, is a key symptom of delirium. Patients often cannot accurately perceive their environment or understand their situation.

E: Overly friendly behaviors are not typically associated with delirium. Delirium usually involves confusion, agitation, and sometimes aggression rather than increased sociability.

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Which of the following patients is most likely to become violent?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a person displaying associative looseness. Which of the following would be the best strategy for the nurse to respond to associative looseness?

Correct Answer is A

Explanation

The nurse is caring for a patient diagnosed with delirium. The nurse would note these symptoms as consistent with delirium: Select all that apply.

Correct Answer is ["A","B","D"]

Explanation

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