Two patients in a residential care facility have dementia. One shouts to the other, "Move along, you're blocking the road." The other patient turns, shakes a fist, and shouts, "You're trying to steal my car." What is the nurse's best action?
a. Administer one dose of an antipsychotic medication to both patients.
b. Reinforce reality. Say to the patients, "Walk along in the hall. This is not a traffic intersection."
c. Separate and distract the patients. Take one to the day room and the other to an activities area.
d. Step between the two patients and say, "Please quiet down. We do not allow violence here."
ANS: C
Separating and distracting prevents escalation from verbal to physical acting out. Neither patient loses self-esteem during this intervention. Medication probably is not necessary. Stepping between two angry, threatening patients is an unsafe action, and trying to reinforce reality during an angry outburst will probably not be successful when the patients are cognitively impaired.
You might also like to view...
Which electrolytes are cations?
a. Sodium, potassium, and chloride c. Bicarbonate, chloride, and calcium b. Sodium, chloride, and bicarbonate d. Sodium, potassium, and magnesium
Which are the two basic responses a patient can have to a drug's actions?
a. Half-life b. Desired action c. Side effects d. Bioequivalence e. Onset
A baby born without a urinary bladder has a cutaneous ureterostomy with one stoma and a cutaneous ureterostomy has been surgically created. There is one stoma
Discussion with the child's family regarding care should include which of the following? 1. "This urinary diversion is permanent and urine will drain from it continuously." 2. "In the future, there will be a second surgery to offer an exit for the urine from the other kidney." 3. "This pouch needs to be changed only about once a week." 4. "You should notify the surgeon if the stoma becomes paler in color."
The home health care nurse is preparing a care plan for a client admitted with anemia. The client currently lives alone and states, "I can't even take a shower without getting winded."
Which of the following would be the priority nursing diagnosis for this client? 1. Activity Intolerance 2. Anxiety 3. Hopelessness 4. Altered Nutrition, Less than Body Requirements