Question 1

A client admitted to the oncology unit has large amounts of cash, several credit cards, and expensive gold jewelry; which action by the nurse is most appropriate?

Accepted Answer

Answer reason: Best practice is to secure patient valuables in a locked area per facility policy to prevent loss or theft; hiding items in the room is unsafe.

Question 2

When interviewing a patient with a history of violent behavior, the nurse should do all of the following except?

Accepted Answer

Answer reason: For a potentially violent patient, maintain safety: keep the door open, sit near an exit, monitor for escalating tension, and notify security. Closing the door limits escape routes and increases risk, so it is the exception.

Question 3

Which of the following is MOST likely to ensure the safety of the nurse while making a home visit?

Accepted Answer

Answer reason: Constant situational awareness and leaving when unsafe cues appear is the most reliable action to ensure personal safety; absence of noted weapons or prior violence does not guarantee safety, and carrying devices helps but does not prevent harm if the situation is unsafe.

Question 4

During a night shift, a nurse notices an unfamiliar individual wandering near the medication room without visible identification. Which action BEST aligns with the facility’s security plan?

Accepted Answer

Answer reason: Security plans emphasize early identification and verification of unauthorized individuals. Calmly verifying credentials and involving security prevents escalation while maintaining safety.

Question 5

A hospital conducts regular security drills for active threat situations. Which outcome BEST indicates that the security plan is effective?

Accepted Answer

Answer reason: Effective security plans ensure staff understand and can perform required actions during emergencies. Knowledge and correct response matter more than timing or staff emotions.

Question 6

A nurse receives a message threatening violence toward the unit later in the day. What should the nurse do FIRST according to security plan principles?

Accepted Answer

Answer reason: All threats must be reported immediately so security and leadership can assess risk and implement protective measures. Delaying or independently investigating increases danger.

Question 7

A nurse notices escalating verbal aggression from a visitor toward staff at the nurses’ station. According to security plan principles, what is the MOST appropriate initial nursing action?

Accepted Answer

Answer reason: Security plans emphasize early de-escalation and prompt notification of security when aggression escalates. Calm communication and maintaining personal safety help prevent progression to violence.

Question 8

During a facility lockdown, which staff action BEST demonstrates adherence to the security plan?

Accepted Answer

Answer reason: Lockdown procedures require controlled access to protect clients and staff from potential threats. Restricting entry and exit is central to maintaining unit safety during a security event.

Question 9

Which staff behavior MOST increases risk for a security breach in a healthcare facility?

Accepted Answer

Answer reason: Allowing unidentified individuals to bypass access controls undermines security measures and increases the risk of theft, violence, or unauthorized access to patient areas.

Question 10

A nurse observes a coworker allowing a visitor to enter a restricted unit without checking identification because the unit is busy. What is the MOST appropriate action according to the security plan?

Accepted Answer

Answer reason: Security plans require consistent enforcement of access controls. Addressing the lapse immediately and following protocol helps prevent unauthorized access and protects clients and staff.

Question 11

Which scenario BEST demonstrates appropriate response to a potential workplace violence warning sign?

Accepted Answer

Answer reason: Repeated threats are a clear warning sign for potential violence and require prompt security involvement. Early recognition allows preventive action before escalation occurs.

Question 12

During orientation, which instruction BEST supports staff compliance with the facility’s security plan?

Accepted Answer

Answer reason: Effective security plans rely on all staff understanding their role in maintaining safety. Security is a shared responsibility, not limited to specific personnel or times.

Question 13

When assigning rooms, a nurse should not place a client who has a diagnosis of sexual sadism with which other client?

Accepted Answer

Answer reason: Sexual sadism involves arousal from inflicting pain or humiliation, while sexual masochism involves arousal from receiving it, creating a higher risk pairing for coercion, exploitation, or physical injury if roomed together. Nursing room assignments should reduce opportunity for victimization and limit triggers for acting out, especially in inpatient psychiatric settings where supervision is intermittent. Voyeurism and exhibitionism involve noncontact behaviors and do not inherently create the same direct dyadic risk for physical harm in a shared room. Homosexuality is not a paraphilic disorder and is not a rationale for special rooming restrictions.

Question 14

Workplace violence is a growing concern for nurses. Major causes of violence in the hospital include?

Accepted Answer

Answer reason: Violence risk in healthcare is strongly linked to escalation from unmet expectations, perceived disrespect, and poor de-escalation—problems that commonly start with ineffective communication. Clear, consistent explanations and limit-setting reduce confusion, frustration, and confrontations with clients and visitors, making communication failures a major and modifiable driver of incidents. In contrast, realistic expectations and improved understanding of the plan of care are protective factors rather than causes. Increasing mental health resources may reduce risk but is not a primary immediate cause of workplace violence within the hospital setting.

Question 15

The nurse is caring for multiple clients with unpredictable and often dangerous behaviors on a mental health unit. Which is the nurse’s best method for managing the safety of multiple clients?

Accepted Answer

Answer reason: Separating clients who are unpredictable or potentially violent decreases stimulation, prevents contagion of agitation, and reduces the chance of client-to-client assaults when one client escalates. The other options can support longer-term stabilization, but they do not immediately and reliably prevent rapid interpersonal violence across multiple clients. When managing a whole unit, environmental control and spacing are the most direct, unit-level intervention to maintain safety.

Question 16

A client is admitted to the psychiatric unit as part of his probation period for exhibitionism and fetishism. The client seems to be adjusting well, but several clients report that their undergarments are missing. Which action would be most appropriate?

Accepted Answer

Answer reason: Maintaining a safe, secure milieu requires addressing suspected contraband/theft promptly to protect other clients and prevent escalation. Reported missing intimate clothing suggests a boundary/safety concern and possible ongoing paraphilic behavior, so an immediate environmental intervention is indicated. A room search (per facility policy, with appropriate authorization/witnessing) is a direct way to locate missing items and reduce risk to others. Notifying the provider is not the first-line safety action, and a community meeting or questioning about sexual activity delays containment and may increase conflict, shame, or victimization.

Question 17

The client is admitted to the ED with multiple lacerations and broken bones after being assaulted. The client’s spouse barges into the client’s ED room with a gun and states, “I’m going to kill you and anyone else who gets in my way.” Which action should be taken by the nurse initially?

Accepted Answer

Answer reason:  In an armed-threat situation, the immediate priority is safety by de-escalating while gaining control of the weapon with calm, simple, direct commands. A nonthreatening posture and controlled tone reduce the risk of provoking impulsive violence and can increase compliance. Distraction by yelling can startle the person and trigger firing, and attempting reflective discussion is not the first priority when a weapon is present and a lethal threat has been voiced. After initial de-escalation and directing the weapon to be put down, the nurse should activate security/emergency response per facility protocol.

Question 18

The nurse is caring for an unresponsive toddler in a PICU. The child’s parent was arrested for alleged child abuse but released on bail. The parent is pounding at the door, belligerent, and demanding to visit the child. Which is the most appropriate nursing plan of action?

Accepted Answer

Answer reason: The priority is immediate safety and security when an individual is escalating and threatening unit order, especially in a PICU with a vulnerable child. Activating the behavioral emergency response brings trained personnel to de-escalate, control access, and protect the patient, staff, and other families before attempting negotiation or visitation decisions. Allowing entry creates a high-risk environment and could compromise the child’s safety and the integrity of care. Deferring to provider discussion or calling social services may be appropriate later, but neither addresses the urgent, potentially violent situation requiring rapid security intervention.

Question 19

The nurse who works in the newborn nursery notices that one of the babies is missing from the bassinet. Which action should the nurse take first?

Accepted Answer

Answer reason: In a suspected infant abduction, the priority is immediate facility-level security response to prevent the infant from leaving the unit and to rapidly initiate the hospital’s missing-infant protocol. Alerting security/management triggers controlled access (locking exits, monitoring stairwells/elevators) and coordinated searching, while a head count verifies whether this is an actual abduction versus a location/ID error. Notifying the mother or family first delays time-critical containment measures and can increase panic and interference with the search. Police involvement may be required, but it is typically activated through the established institutional chain once immediate containment and verification steps are underway.

Question 20

After lunch, the telemetry nurse is conversing with colleagues in the lobby of the hospital. At the same time a Code Pink is heard. What is the most important intervention for the nurse at this time?

Accepted Answer

Answer reason: A Code Pink typically indicates an infant/child abduction, where immediate containment and surveillance of exits is critical to prevent the suspect from leaving the facility. Being in the lobby places the nurse at a high-yield location to observe for suspicious behavior and potential concealment methods and to promptly report sightings. This action supports the facility’s security response by helping maintain a controlled environment until security and the Code Pink team intervene. Calling the unit or returning to the telemetry area may be appropriate later, but they do not address the urgent need to monitor public egress points during an active abduction alert.

Question 21

A client in the emergency room is experiencing acute intoxication. The client has become aggressive to the nurses on site. There are orders for chlordiazepoxide 50mg IM or PO Q6H PRN. What precaution should be taken by the nurse after the administration of this medication?

Accepted Answer

Answer reason: Sedative benzodiazepines can take time to work and may not reliably prevent immediate violent behavior, so active safety measures are required during the high-risk period. Continuous security presence provides rapid response to escalating aggression and protects staff and the patient while the medication onset is pending. Leaving the patient alone is unsafe because the client may continue to be violent, fall, or deteriorate without observation. Physical restraints are a last resort and require strict indication, monitoring, and typically a provider order; they are not the routine “precaution” after giving a PRN sedative. Delegating constant observation to an LPN/LVN does not address the security risk of an actively aggressive, potentially violent patient.

Question 22

A client has pulled out the IV and Foley and has climbed out of bed. When attempting to get the client back into bed, the client begins to shout and tries to punch the nurse. What is the priority nursing action?

Accepted Answer

Answer reason: Immediate safety is the priority when a patient becomes physically aggressive and is attempting to strike staff. Activating security provides rapid assistance to de-escalate and physically manage the situation while minimizing harm to the patient and healthcare team. Verbal limit-setting alone is unlikely to be sufficient in an actively assaultive scenario and can delay getting adequate help. Restraints may be necessary, but they require adequate personnel, an order per policy, and should follow attempts at least-restrictive interventions when feasible; getting help first enables safe implementation if needed.

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