which of the following is an appropriate tension reduction intervention for the patient who may be escalating toward aggressive behavior
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NCLEX-RN

Psychosocial Integrity NCLEX RN Questions

1. Which of the following is an appropriate tension-reduction intervention for a patient who may be escalating toward aggressive behavior?

Correct answer: D

Rationale: All of the above interventions are appropriate tension-reduction techniques for a patient in the ICU. When a patient is escalating toward aggressive behavior, it is crucial to have a range of strategies to help de-escalate the situation. Asking to speak to someone can provide emotional support and an outlet for communication. Asking to be alone can help the patient have space and time to calm down. Listening to music can be soothing and distracting. These interventions, along with additional ones like walking the hallway, watching television, writing in a journal, or requesting a PRN medication, can be helpful. It is essential to involve the patient in developing the care plan to identify triggers and effective tension-reduction techniques. Patients in escalation may not always recognize the need for intervention, so staff must be observant and offer personalized techniques to address the situation effectively.

2. During a clinic visit, the mother of a 7-year-old reports to the nurse that her child is often awake until midnight playing and is then very difficult to awaken in the morning for school. Which assessment data should the nurse obtain in response to the mother's report?

Correct answer: D

Rationale: When a school-age child has difficulty going to sleep and waking up in the morning, it is important to assess the family's home environment. This includes factors such as bedtime rituals, noise levels, lighting, use of electronic devices, and overall sleep hygiene practices. Understanding the home environment can help identify issues that may be contributing to the child's sleep problems and guide the development of a plan to promote better sleep habits. Options A, B, and C are less relevant in this scenario. Sleep apnea typically causes daytime fatigue rather than resistance to bedtime. Assessing vital signs like blood pressure, pulse, and respirations is unlikely to provide insights into the child's sleep patterns. Monitoring REM sleep duration is not practical in a clinical setting and may not directly address the reported sleep issues in this case.

3. A client who is in a late stage of pancreatic cancer intellectually understands the terminal nature of the illness. Which behaviors indicate the client is emotionally accepting the impending death?

Correct answer: A

Rationale: Revising the will and planning a visit to a friend are indicative of emotional acceptance of impending death as they demonstrate realistic, productive, and constructive ways of using the remaining time. Alternating between crying and talking openly about death may suggest depression rather than acceptance. Seeking multiple medical opinions shows disbelief, denial, or desperation rather than acceptance. Refusing treatments and stating they won't help reflects anger and hopelessness, not acceptance.

4. After informing an older client that an IV line needs to be inserted, the client becomes very apprehensive, loudly verbalizing a dislike for all healthcare providers and nurses. How should the nurse respond?

Correct answer: C

Rationale: The nurse should respond with a calm demeanor to help reduce the client's apprehension. By calmly reassuring the client that the discomfort from the procedure will be temporary, the nurse acknowledges the client's feelings and provides comfort. This response shows empathy and understanding, which can help build trust. Asking the client to remain quiet may escalate the situation and not address the client's underlying concerns. Concentrating solely on completing the insertion efficiently may overlook the client's emotional needs and may increase their anxiety. Telling a joke may not be appropriate in this serious situation and could be perceived as insensitive, failing to address the client's emotional distress effectively.

5. Which response would the nurse make when a client moans softly, 'Oh no, I'm next. They couldn't protect him, and they can't protect me,' after learning a recently discharged client committed suicide?

Correct answer: B

Rationale: The nurse would make the statement, 'You seem to be afraid that you'll hurt yourself.' This response acknowledges the client's emotional distress and opens up the opportunity for the client to discuss their feelings, showing empathy and understanding. Choice A, 'The other person was a lot sicker than you are,' dismisses the client's emotions and fails to address the underlying fear of self-harm. Choice C, 'That was different. He was at home, but you're here,' invalidates the client's concerns and does not encourage further discussion. Choice D, 'There's no need to worry. You have a better support system,' offers false reassurance and does not address the client's expressed fear, missing an opportunity for therapeutic communication.

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