A nurse responds to an eerie scream coming from a clients room. Upon entering the room the client states, He has a gun, and is pointing to a male visitor. The nurse does not see a gun. Which action by the nurse would be appropriate?
1. the visitor regarding the situation.
2. Contact security immediately.
3. Call for another nurse to assist in confronting the visitor.
4. Call the clients physician.
Question 2An OB nurse is caring for a young client who is in labor. The nurse learns the client is not married and is hesitant to name the father of the fetus. A male visitor has come to visit the client. The nurse questions the visitor and is concerned.
Which of the following behaviors would cause concern? 1. The father is claiming paternity.
2. The client very anxious with the male present.
3. The visitor is very close and in the nurses personal space regarding the status of the client.
4. The visitor is inquiring about a medical-surgical client and is acting in an odd manner.
Question 3A house supervisor is addressing a client in the ER (emergency room) who has been aggressive. Which of the following techniques would be applicable in addressing an aggressive client? Select all that apply.
1. When addressing the client, present powerful body language.
2. Remain calm and speak in a modest tone.
3. Approach the client with an aggressive, Im in charge attitude.
4. Speak in simple terms and allow the client to speak.
5. Use insightful questions when addressing the clients issues.
6. Control the conversation.
Question 4A medical surgical nurse is caring for a client admitted during the night from ER (emergency room) with a diagnosis of alcohol intoxication.
The nurse has just admitted the client to the room and is unable to obtain much history due to the clients lethargic state. Which of the following would be an appropriate action by the nurse? 1. Approach the client with caution when obtaining vital signs and shift assessments.
2. Place the client in a room farthest from the nurses station as not to disturb other clients.
3. Place the client in four-point restraints as a protective measure.
4. Perform neurovascular assessments every 2 hours to determine level of consciousness.
Question 5An ICU nurse has been caring for a difficult client. The nurse determines the client is suicidal and is threatening to leave. The nurse is unsure who to call. The nurse calls the police.
The police come to the hospital and inform the nurse not to call them in the future. What action should this nurse take? 1. Call the police when needed.
2. Discuss this situation with the clients physician.
3. Discuss this with the supervisor and management.
4. Call the clients family and discuss the incident.
Question 6A nurse manager receives a complaint from staff regarding a nurse supervisors actions of ignoring threatening behavior of clients and their families. The manager is reviewing the units policy regarding violent behavior.
Which of the following questions should the manager focus on when reviewing violence prevention policies? 1. Why is this type of behavior occurring in this environment?
2. Why is this staff person reporting this behavior?
3. What issues does this staff person have with other staff?
4. When someone voices a concern to supervisory staff, is action taken to address the problem quickly?
Question 7A CNA (certified nurses aide) has been threatened by a coworker. The CNA has reported this to the manager of the unit, but threatening behavior continues. The CNA asks the manager if the coworker has been reprimanded.
The manager informs the CNA, You know I cant disclose that information. Which action would be the next appropriate step for the CNA? 1. Give notice of resignation.
2. Inform the director of the department.
3. Inform the charge nurse of the incidents.
4. Discuss the matter with the coworker.
Question 8The emergency room experienced a client who exhibited violent behavior when pain medication was denied. Once the situation was resolved, which action by the ER manager would be appropriate after this incident?
1. Arrange an agreement with law enforcement regarding these types of clients.
2. Discuss the situation with law enforcement.
3. Develop a team of staff who would be on call for these types of situations.
4. Organize a training program to educate staff on how to manage these types of situations.
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