Author Question: A patient who has been seen responding to auditory hallucinations earlier in the morning approaches ... (Read 82 times)

cherise1989 · **on:** Jul 19, 2018

A patient who has been seen responding to auditory hallucinations earlier in the morning approaches the nurse and shakes his fist, saying, Back off, bitch and then goes into the day room. The nurse follows the patient into the day room.

Which intervention would be best at this time? a. Stay between the patient and the door for easy exit.
b. Stand out of range of possible assault by the patient.
c. Position oneself about 28 inches from the patient.
d. Sit down in a chair near the patient to convey interest.

Question 2

A patient with serious mental illness lives alone in a neighborhood. The patient receives monthly depot medication injections but lately has missed regular clinic appointments, saying, My life is so busy I couldn't find time to come in.

To prevent decompensation and hospitalization, the community mental health nurse should arrange for:
a. a psychosocial rehabilitation program.
b. assertive community treatment (ACT).
c. an appointment with a nurse in private practice.
d. insurance authorization to change to daily oral medication.

Jordin Calloway · **Reply #1 on:** Jul 19, 2018

Answer to Question 1

B
When intervening with an agitated or potentially violent person, it is essential to stay far enough away that you are safe from a punch, kick, or other potential assault. Personal space needs increase when a person feels anxious, angry, or threatened. Standing between the patient and the door could be interpreted as confrontational or could cause the patient to feel trapped, increasing his fear and agitation. Standing within 28 inches places one within the patient's personal space and within range of being struck. Sitting would make it difficult to protect oneself from assault and is inadvisable until further assessment suggests the patient's aggression is abating.

Answer to Question 2

B
The assertive community treatment team could bring the patient's medication to her in her neighborhood. Depot medication is a strategy to reduce noncompliance and is often preferable to daily oral medication. The other distracters do not directly relate to the noncompliance problem.