Client Need: Safe Effective Care Environment
Client Need Sub: Management of Care
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 23-4: Discuss how to respond to a violent incident.
Question 14
Type: MCSA
The nurse has just been notified that a client is to be admitted from the emergency department (ED) with a
diagnosis of alcohol intoxication. The ED nurse says they have been unable to obtain much history because of the
client’s lethargic state. Which action is an appropriate intervention 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 nurse’s station so as not to disturb other clients.
3. Place the client in four-point restraints as a protective measure.
4. Post an armed security person at the client’s door.
Client Need: Safe Effective Care Environment
Client Need Sub: Management of Care
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 23-2: Identify threats and threatening behaviors.
Question 15
Type: MCMA
The nurse is talking to a client who has a history of aggressive outbursts. What strategies should this nurse use?
Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Sullivan, Effective Leadership and Management, 8/e Test Bank
Standard Text: Select all that apply.
1. When addressing the client, use powerful body language.
2. Remain calm and speak in a moderate tone.
3. Approach the client with an aggressive “I’m in charge” attitude.
4. Speak in simple terms.
5. Allow the client to speak.
Cognitive Level: Applying
Client Need: Safe Effective Care Environment
Client Need Sub: Management of Care
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 23-4: Discuss how to respond to a violent incident.
Question 18
Type: MCSA
A nurse hears screaming from a client’s room. A male visitor leaves the client’s room. Which is the nurse’s
priority action?
1. Call the police.
2. Notify the client’s physician.
3. Follow the visitor.
4. Check on the client.
Client Need: Safe Effective Care Environment
Client Need Sub: Management of Care
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 23-3: Describe how to recognize escalating violence.
Question 19
Type: MCSA
The nurse appears in the nursing station with multiple facial lacerations and says, “A visitor hit me.” What is the
manager’s priority action?
1. Ask the nurse why the visitor became violent.
Sullivan, Effective Leadership and Management, 8/e Test Bank
2. Ask a nurse to accompany the employee to the emergency department.
3. Call security to report the incident.
4. Call administration and inform them of the incident.
Rationale 4: The manager should not contact the worker’s compensation nurse.
Global Rationale:
Cognitive Level: Applying
Client Need: Safe Effective Care Environment
Client Need Sub: Management of Care
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 23-5: Describe how to handle the follow-up to a violent incident.
Question 21
Type: MCMA
During orientation a newly employed nurse asks about the process of reporting such things as bomb threats to the
organization. The person conducting the orientation says, “Well, I guess you should call 911.” What is incorrect
about this statement?
Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.
1. The person who is doing the orientation should be aware of the reporting policy.
2. The nurse should have been told to notify security.
3. The nurse should never call 911 from the hospital.
4. The nurse should have been told to follow the reporting policy.
5. The nurse should have been reported as suspicious for asking the question.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Safe Effective Care Environment
Client Need Sub: Management of Care
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 23-4: Discuss how to respond to a violent incident.
Question 22
Type: MCSA
A night shift supervisor has been called to the emergency department to assist in managing a violent situation with
a visitor. Once the violent person has been contained and security and police have responded, what should be the
supervisor’s next action?
1. Notify staff on other nursing units.
2. Notify the violent person’s physician.
3. Complete an incident report.
4. No action is necessary; the situation has been managed.
Client Need: Safe Effective Care Environment
Client Need Sub: Management of Care
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 23-5: Describe how to handle the follow-up to a violent incident.
Question 23
Type: MCSA
A nurse enters a client’s room and sees a visitor threatening the client. The nurse questions the visitor in a
nonthreatening manner. The visitor begins to threaten the nurse. What should the nurse do in this situation?
Sullivan, Effective Leadership and Management, 8/e Test Bank