A client has, in the past, had a nursing diagnosis of ineffective ...

[NguyenJ]

A client has, in the past, had a nursing diagnosis of ineffective coping related to impulsively acting
  out anger as evidenced by striking others. An appropriate plan for forestalling such incidents would
  be
 
  a. explaining that restraint and seclusion will be used if violence occurs.
  b. helping a client identify incidents that trigger impulsive acting out.
  c. offer one-on-one supervision to help the client maintain control.
  d. request that the client receive lorazepam (Ativan) every 4 hours to reduce anxiety.

Question 2

A client, aged 82 years, has Alzheimer's disease. She lives with her daughter's family and goes to a
  day care facility on weekdays. The nurse at the day care center noticed the client was unkempt and
  had multiple bruises.
 
  When the daughter arrived to pick her up, the nurse discussed her observations.
  The daughter became defensive and said that her mother was very difficult to manage. She stated
  My mother is not my mother anymore. She is confused and she wanders all night. When I have to
  be out in the evening on business, one of my teenagers has to watch her. Then I have to watch her all
  night. Last night I fell asleep and she fell down the stairs. Sometimes I just cannot bear to care for
  her.. The nursing diagnosis that can be established for the client is
  a. risk for injury related to poor judgment associated with cognitive impairment and
  lack of family caregiver supervision.
  b. noncompliance related to confusion and disorientation, as evidenced by lack of
  cooperation.
  c. anxiety related to confused state, as evidenced by the client wandering at night.
  d. impaired verbal communication related to brain impairment, as evidenced by the
  client's confusion.

[Ptupou85]

Answer to Question 1

B
Identification of trigger incidents allows the client and nurse to plan interventions to reduce irritation
and frustration, which lead to acting out anger, and eventually to put into practice more adaptive
coping strategies. Option A suggests restraint and seclusion are punitive interventions. Option C is
too costly. Option D provides chemical restraint without cause.

Answer to Question 2

A
The client is at high risk for injury because of her confusion. The risk increases when caregivers are
unable to give constant supervision. No assessment data support the diagnoses of anxiety, impaired
verbal communication, or noncompliance.