A confused older adult patient in a skilled care facility is in ...

[cookcarl]

A confused older adult patient in a skilled care facility is in bed sleeping. The nurse enters the room quietly and touches the bed to see if it is wet.
 
  The patient awakens and hits the nurse in the face. Which statement best explains the patient's action?
 
  a. Older adult patients often demonstrate exaggerations of behaviors used earlier in life.
  b. Crowding in skilled care facilities increases individual tendencies toward violence.
  c. The patient interpreted the health care worker's behavior as potentially harmful.
  d. This patient learned violent behavior by watching other patients act out.

Question 2

A patient is hospitalized after an arrest for breaking windows in the home of a former domestic partner. The history reveals childhood abuse by a punitive parent, torturing family pets, and an arrest for disorderly conduct.
 
  Which nursing diagnosis has priority?
 
  a. Risk for injury
  b. Posttrauma response
  c. Disturbed thought processes
  d. Risk for other-directed violence

[tdewitt]

Answer to Question 1

ANS: C
Confused patients are not always able to evaluate accurately the actions of others. This patient behaved as though provoked by the intrusive actions of the staff member.

Answer to Question 2

ANS: D
The defining characteristics for Risk for other-directed violence include a history of being abused as a child, having committed other violent acts, and demonstrating poor impulse control. The defining characteristics for the other diagnoses are not present in this scenario.