Chapter 11: Anger, Hostility, and Aggression
An adult child brings their parent to the clinic and tells the nurse that their parent has begun to act strangely in the past few days, with unprovoked outbursts of anger. After the incidents, the parent expresses remorse for their outburst. The adult child says, "I've never seen my parent act this way." Which question is most appropriate for the nurse to ask next? "Has your parent suffered any traumatic injury to their brain recently?" "Has your parent injured the back of the irhead or neck in the past week?" "Does your parent have a history of an anxiety disorder, such as panic disorder?" "Has your parent exhibited previous problems expressing anger appropriately?"
"Has your parent suffered any traumatic injury to their brain recently?" Asking about injury to the brain would be most appropriate because the limbic system and cerebral cortex are the brain structures most frequently associated with aggressive behavior. Clients with a history of damage to the cerebral cortex are more likely to exhibit increased impulsivity, decreased inhibition, and decreased judgment than are those who have not experienced such damage. Schizophrenia and substance use disorders are also associated with violent behavior. Asking about previous problems with anger would be important to know but would not be the priority. Additionally, the person states that the parent has never done this before. Injury to the back of the head or neck is not associated with aggression.
A client is attending anger management class and wants to know how the class will help. What is the nurse's best response? "You will learn how to control your violent behavior." "You will be able to stop feeling angry when incidents happen out of your control." "It will help you to learn how to control the arousal of anger." "We need to explore what makes you want to hit people when you are angry."
"It will help you to learn how to control the arousal of anger." Explanation: It is unrealistic for someone to stop feeling angry altogether; however, the goal of anger management therapy can help a client learn how to control the arousal of anger. Anger management therapy is not utilized for clients who are violent when angry because it has not been found to be effective in modifying violent behavior.
While interviewing a client, a nurse asks, "What do you do when you get angry?" Which client response would indicate to the nurse that the client engages in anger suppression? "I try to discuss how I'm feeling about it with a close friend." "I usually approach the person directly to talk about it." "People say I withdraw and pout about the problem." "I've been known to fly off the handle when I'm angry."
"People say I withdraw and pout about the problem." Anger suppression is characterized by acting as though nothing has happened; withdrawing from people; and sulking, pouting, or ruminating. Unhealthy, outward anger expression is characterized by flying off the handle or expressing anger in an attacking or blaming way, yelling, or using profanity. Approaching a person directly to talk about it, or discussing how the person feels with a close friend, reflects constructive anger discussion.
The nurse is assessing a client of an Eastern culture who is admitted due to the need for anger management. What question should the nurse ask to determine the effect of culture on the client's expression of anger? "Do you know why you are being admitted?" "What happens when you get angry?" "Do you feel that you can manage your reactions with anger?" "What did you learn about anger when growing up?"
"What did you learn about anger when growing up?" Explanation: While all of these questions are pertinent to assessment of anger reactions in a client, questions related to culture need to center around how clients learned about anger when growing up and how it is displayed. While clients can learn to move past learned behaviors as a child, it is important to understand what these learned behaviors are.
A new nurse asks the nurse manager about the best intervention to use when trying to de-escalate a potentially violent client. Which response would be most appropriate? "Make sure that another colleague knows where you are at all times." "What works best is what fits the client and the situation." "I've always had good results with medications." "You need to confront the client to show you are in charge."
"What works best is what fits the client and the situation." Explanation: The nurse who intervenes from within the context of the therapeutic relationship must be cognizant of the fit of a particular intervention. Thus, the best intervention is the one that fits the situation and the client. Administering medications and making sure that others know where the nurse is may be helpful but it depends on the situation. Confronting the client should be avoided.
A nurse is working with a client who has lost unit privileges due to inappropriate behavior. Which statement by the nurse demonstrates appropriate offering of choices? "Which activity would you like to participate in today?" "Would you like to have your family come visit you in your room today?" "Can you select an outfit to wear to group therapy?" "Would you rather go to the cafeteria or have dinner in the dayroom?"
"Would you rather go to the cafeteria or have dinner in the dayroom?" Explanation: The nurse should try to provide clients with choices so that the client has some control over his/her situation. The choices should be concrete rather than open-ended; therefore, the client having a choice on where to eat dinner would be considered concrete due to limited choices. Being able to select an outfit or an activity would be more open-ended. While having the client be visited in the room does give a choice between having visitors or not, this would have a negative consequence with not having visitors unless the visitors could come to the room. A nurse assesses a newly admitted client on the unit. When assessing the client in detail about his/her past medical history, it is important for the nurse to also explore which information about the client?-Experience of health problems and health professionals-Delusional content when hospitalized 10 years ago-Preferences of movies that are provided on Thursday nights-Needs to modify environment to ensure that milieu is achieved Experience of health problems and health professionals. Explanation: Inviting clients and families to talk about their previous experience with the health care system may highlight both their concerns and resources.
The nurse is assessing a school-aged child to determine underlying causes for socially inappropriate behavior. The nurse uses knowledge that which children are likely to have impaired impulse control? Select all that apply. Children who belong to low-income families. Children who are hyperactive. Children who get inconsistent responses for their behavior. Children who belong to dysfunctional families. Children who are involved in watching television excessively.
2)Children who belong to low-income families. 3)Children who belong to dysfunctional families. 4)Children who get inconsistent responses for their behavior. Children who are likely to develop socially inappropriate behavior (lack of impulse control) are those belonging to low-income families or dysfunctional families. These children are deprived of essential physical and emotional support. Children who receive inconsistent parental responses for their behavior tend to be less attached to their caregivers and are at increased risk of developing socially inappropriate behavior. Demonstrating hyperactivity or watching television excessively is not related to development of socially inappropriate behavior in the future.
A nurse suggests that the client explores new ideas about a particular problem and considers other possibilities to reflect: A psychoanalytical approach. A cognitive intervention. An affective intervention. A negative approach intervention.
A cognitive intervention. Cognitive interventions are usually those that provide new ideas, opinions, information, or education about a particular problem. The nurse offers a cognitive intervention with the goal of inviting the client to consider other possibilities.
The nurse finds that a client with a history of aggressive behavior is restless, is pacing up and down in the hallway, and has clenched fists. The client also talks in a loud voice. Which intervention would be most appropriate at this point? Offer the client an antianxiolytic medication Prepare to seclude the client Approach the client to engage in communication while remaining 6 feet or more away Ask colleagues to contact hospital security for support
Approach the client to engage in communication while remaining 6 feet or more away The client's behavior and history of aggression indicates the nurse should explore the underlying cause of the escalating behavior in order to address the client's needs prior to moving into the escalation stage of aggression. The nurse should be close enough to communicate but maintain a safe distance.
Which term is used to describe an activity used to release anger? Catharsis Hostility Anger Physical aggression
Catharsis Catharsis includes activities that provide a release of the anger. Hostility is an emotion expressed through verbal abuse, lack of cooperation, violation of rules or norms, or threatening behavior. Anger is a strong, uncomfortable, emotional response to a real or perceived provocation. Physical aggression is behavior in which a person attacks or injures another person or that involves destruction of property.
In which phase of the aggression cycle can techniques of seclusion or restraint be used to deal with the aggression quickly? Crisis Recovery Triggering Escalation
Crisis Explanation: In the crisis phase, seclusion or restraint may be used to deal with aggression quickly. Reference:
A client visits the clinic and tells the nurse that no matter how difficult the client's child acts, the client simply cannot express any anger. The nurse should plan to assess the client for symptoms of which mental health condition? Meneire's disease Manic behaviors Depression Panic disorder
Depression Anger turned inward has frequently been associated with mood disorders, particularly depression. It has also been associated with essential hypertension, migraine headaches, psoriasis, rheumatoid arthritis, and Raynaud's disease.
A nurse is beginning the process of providing therapy to a client with anger management problems. When implementing this therapy, which should occur first to promote optimal effectiveness? Identification of measures to disrupt the anger response Development of a therapeutic relationship Avoidance of stimuli that provoke the anger Client self-monitoring for anger cues
Development of a therapeutic relationship With cognitive-behavioral therapy, the recommendation is to first establish the therapeutic alliance because some angry individuals are not in a stage of readiness to change their behavior. When clients are more receptive, cognitive-behavioral therapy involves avoidance of provoking stimuli, self-monitoring regarding cues of anger arousal, stimulus control, response disruption, and guided practice of more effective anger behaviors.
A nurse is leading an anger management group in the inpatient program. A client says, "I'm feeling really tense, and I'm fidgety today." What is the nurse's most appropriate response to the client's comment? Ask the client if the client feels triggered by another client in the group Ask another client in the group to respond to the client's comment Encourage the client to engage in a relaxation exercise prior to joining the group the the rest of the session Explore what is underlying the client's physical and emotional state
Explore what is underlying the client's physical and emotional state Identifying the feelings reduces the frustration. Attempt to discover the concern and respond with empathy, interest, and willingness to help. Encourage the client to describe and clarify the client's experience using open-ended questions to increase the client's awareness of problematic feelings and what triggers them.
A nurse is leading an anger management group in an inpatient program. A client says, "I'm feeling really tense, and I'm fidgety today." What is the nurse's most appropriate response to the client's comment? Encourage the client to engage in a relaxation exercise prior to joining the group for the rest of the session Ask the client if the client feels triggered by another client in the group Explore what is underlying the client's physical and emotional state Ask another client in the group to respond to the client's comment
Explore what is underlying the client's physical and emotional state Explanation: Identifying the feelings reduces the frustration. Attempt to discover the concern and respond with empathy, interest, and willingness to help. Encourage the client to describe and clarify the client's experience using open-ended questions to increase the client's awareness of problematic feelings and what triggers them.
The nurse is assessing a client who is aggressive. Which safety measures must the nurse ensure are in place prior to continuing the assessment? Select all that apply. Request the presence of additional staff. Encourage the client to talk about this situation Sit in an open area Give the client plenty of space. Restrain the client.
Give the client plenty of space. Sit in an open area Request the presence of additional staff. While assessing an aggressive client, the nurse should give the client plenty of space, sit in an open area, and request the presence of another staff person. The nurse should not restrain the client by him- or herself, but rather get the client restrained by trained personnel. Encouraging the client to talk about the situation in which he or she has been aggressive should be done in the recovery phase of the anger cycle.
Which term is used to describe an emotion expressed through verbal abuse and violation of rules or norms? Anger Catharsis Physical aggression Hostility
Hostility Hostility is an emotion expressed through verbal abuse, lack of cooperation, violation of rules or norms, or threatening behavior. Anger is a strong, uncomfortable, emotional response to a real or perceived provocation. Catharsis includes activities that provide a release of the anger. Physical aggression is behavior in which a person attacks or injures another person or that involves destruction of property.
When communicating with a client in the triggering phase of the aggression cycle, which intervention should the nurse include? Help the client understand the complexity and nuances of the client's condition. Help the client express anger verbally and through nonharmful physical actions if necessary. Listen to the client's concerns and convey empathy for the client's frustration or anger. Encourage social interaction with other clients.
Listen to the client's concerns and convey empathy for the client's frustration or anger. In the triggering phase, the client is responding to something in the environment with anger or hostility. The client shows one or more of restlessness, anxiety, irritability, pacing, muscle tension, rapid breathing, perspiration, loud voice, and anger. The nurse should approach the client in a nonthreatening, calm manner in order to deescalate the client's emotion and behavior. The nurse should express empathy and listen to the client's concerns. Using clear, simple, short statements and allowing the client time for self-expression are helpful techniques. This is not a good time for socialization with other clients; the nurse may suggest that the client go to a quiet area or get assistance to move other clients to decrease stimulation. Physical activity, such as walking, may also help the client relax and become calmer, but expression of anger in an angry way (e.g., punching a pillow) tends to escalate the emotion.
Which drug has been effective in treating aggressive clients diagnosed with bipolar disorders? Lithium Carbamazepine Valproic acid Clozapine
Lithium Lithium, an antimanic medication, has been effective in treating aggressive clients with bipolar disorder.
A client with aggressive behavior shows no psychotic symptoms. Which medication should the nurse expect to be ordered for this client? Valproate Lorazepam Carbamazepine Haloperidol
Lorazepam Lorazepam is the most effective drug in reducing aggression in a client who does not have any other psychotic symptoms. Valproate, haloperidol, and carbamazepine drugs are useful in reducing aggression in those clients who have coexistent psychotic symptoms.
A nurse must assess for characteristics that are predictive of violent behavior. Research suggests violent behavior is influenced by possession of which attribute? Therapeutic relationship Assertive behavior Low self-esteem Mindfulness
Low self-esteem Explanation: Research suggests that particular characteristics are predictive of violent behaviors. Low self-esteem that may be further eroded during hospitalization or treatment may influence a client to use force to meet his or her needs or to experience some sense of empowerment.
A nurse must assess a client's thought process and content to identify risk for aggression. The assessment of the client's thought process and content would allow the nurse to identify what? Mood and affect Orientation Perceptions and delusions Hunger and thirst
Perceptions and delusions Explanation: The thought processes and content of greatest interest to the nurse in assessing a client's potential for aggression and violence are perception and delusion.
A nurse's response to aggressive behavior on the unit is influenced by which characteristic of the nurse? Self-awareness of reactions to aggression by others Appreciation of the value of matching anger with anger Recognition of the reasons for the client's behavior Understanding the importance of non-response to escalating behavior
Self-awareness of reactions to aggression by others Explanation: Nurses' beliefs about themselves as individuals and professionals influence their responses to aggressive behaviors. The nurse's self-awareness of responses to anger, including fear of others' anger and any tendency to become angry, will help the nurse maintain composure and use good judgment. The nurse should not respond to negative emotions with similar emotions; the nurse must be calm, nonjudgmental, and nonpunitive when using techniques to control a client's aggressive behavior. The nurse can become more skilled in these techniques through practice and by observing more experienced staff. The response to aggression does not depend on understanding the client's thought processes.
The nurse is caring for a client hospitalized in an inpatient psychiatric setting for a history of violent behaviors and delusions. The nurse should instruct the client's family that aggression has been linked to low levels of which bodily chemical? Acetylcholine Endorphin Estrogen Serotonin
Serotonin Explanation: Low levels of serotonin have been linked to aggressive behaviors. Reference:
Aggression control can be measured by the nurse's observation of a client's ability to do what? Use increased doses of medication to reach a desired effect Withhold his or her thoughts and feelings Show an increased tolerance for frustration Display increasing motor activity
Show an increased tolerance for frustration Aggression control is the term used in the Nursing Outcomes Classification (NOC; Moorhead, Johnson, & Maas, 2003). The nurse may observe that the client shows decreased psychomotor activity (e.g., less pacing), has a more relaxed posture, speaks more directly about feelings of anger and personal needs, requires less sedating medication, shows increased tolerance for frustration and the ability to consider alternatives, and makes effective use of other coping strategies.
A client tells the nurse that the client has strong urges to damage property as a result of feelings of hostility and anger. Which is an appropriate nursing action? Place the client in a separate room. Inform the client that restraints may be applied. Take the client to the gym for exercise. Speak to the client in a firm voice.
Take the client to the gym for exercise. For a client who expresses hostile and aggressive feelings, the nurse can help the client vent the anger and hostility in a nondestructive way by taking the client to the gym to perform physical exercise. As the client is not severely agitated, the nurse should not put the client in seclusion. Restraints are not required unless the client is a potential threat to safety of self and others. Talking to the client in a firm voice may increase the agitation of the client.
The nurse is counseling a client couple who are trying to reconcile and hold their marriage together. During therapy the wife states, "He makes me so mad when he spends all his weekend time with his friends instead of us. He makes me want to hurt him back." Using concepts from assertiveness training and effective communication techniques, the nurse implements which intervention after hearing the wife's remarks? Teach the client to make "I" statements. Ask the husband to discuss why he spends so much time with his friends. Ask the wife to provide details about what she means by "all his time." Encourage the wife to express exactly what she wants her husband to do on weekends.
Teach the client to make "I" statements. Explanation: Assertiveness skills are an effective method for controlling aggression by teaching clients appropriate tools for meeting their needs without infringing on the rights of others. The client can be taught about making "I" statements ("I feel hurt by your remarks") instead of "you" statements ("You hurt my feelings") to avoid making judgments by relating feelings rather than opinions and to develop better listening skills.
A client has recovered from an episode of aggressive and hostile behavior. Which behaviors in the client indicate that the client is in the post-crisis stage of the aggression cycle? Select all that apply. The client remains withdrawn from others. The client is irritable and paces restlessly. The client cries and is remorseful for the event. The client talks to others in a loud voice. The client apologizes for the hostile behavior.
The client apologizes for the hostile behavior. The client cries and is remorseful for the event. The client remains withdrawn from others. There are five phases of an aggression cycle. These include triggering, escalation, crisis, recovery, and post-crisis. In the post-crisis phase, the client attempts reconciliation with others and returns to a normal level of functioning. The client may realize that the aggressive behavior was wrong and may apologize for it. The client may cry and feel remorse for the aggression episode. Due to the guilt related to the aggression episode, the client remains withdrawn from others. The client talking in a loud voice, exhibiting irritable behavior, and pacing restlessly indicates that the client is in the triggering phase of the aggression cycle.
The nurse is planning education for a client who has exhibited aggression on techniques to manage anger. Which situation would be best for providing this education? The client is having lunch with family members. The client is threatening to hit another client. The client is having an argument with a roommate. The client is sitting in the dayroom reading a book.
The client is sitting in the dayroom reading a book. Explanation: When the client is reading a book, the client may be amenable to the nurse's opening communication about managing anger. The optimal time to provide education for a client on techniques to manage anger and aggression is not when anger and violence are being exhibited. In those cases, the priority is to deescalate the situation and ensure the safety of everyone involved. Therefore, when the client is having an argument or threatening to hit someone else, that is not the best time to provide teaching. It is possible that the client will be receptive to teaching after an incident has resolved, when they may coached to reflect on the outcomes of their behavior and how things could have gone better. Eating lunch with family members is a social situation, and the client should not be interrupted for education until through socializing.
A client with a history of angry outbursts that have caused interpersonal and work problems has been in counseling for several months. The nurse judges the plan of care to be effective when which outcome is met? The client has increased self-esteem. The client has gained insight into situations that trigger anger. The client reports increased feelings of self-control. The client uses adaptive coping to manage anger impulses.
The client uses adaptive coping to manage anger impulses. Overall goals for aggressive or violent clients are to refrain from threatening or harming anyone during episodes of anger. Using adaptive coping to manage angry impulses indicates the client has gained insight into and skill at managing aggressive impulses. Although gaining insight into situations that trigger anger, increasing self esteem, and reporting increased feelings of self-control are critical elements in working toward effective management of anger, the goal of treatment is achieved when the client can put what he or she has learned into action.
The nurse is explaining the importance of expressing anger to a client. What should the nurse mention as the possible physical complications associated with suppressing anger? Select all that apply. Ulcers Depression Coronary artery disease Migraine headaches Low self-esteem
Ulcers Coronary artery disease Migraine headaches Suppressing rage or anger could lead to physical complications such as ulcers, coronary artery disease, and migraine headaches. Depression and low self-esteem are emotional problems associated with suppression of anger.
The nurse is caring for a client with aggression disorder. The client has an anger episode and is threatening other clients in the emergency room with a knife. What should be the approach of the nurse in this situation? Select all that apply. The nurse should attempt to kick the knife out of the client's hand. The nurse should yell at the client to put the knife down. The nurse should call for outside assistance. The nurse should try to grab the knife out of the client's hand. The nurse should remain close to the client.
The nurse should yell at the client to put the knife down. The nurse should attempt to kick the knife out of the client's hand.
Which phase of the aggression cycle is defined as occurring when an event or circumstance in the environment initiates the client's response? Crisis Escalation Triggering Recovery
Triggering Explanation: During the triggering phase of the aggression cycle, an event or circumstance in the environment initiates the client's response, which is often anger or hostility. None of the other phases of the cycle are focused on the initiation of the anger.
A nurse is considering using restraint and seclusion for a client who is acting out. Which is the primary guideline for the use of restraint and seclusion? Use should be limited to times when medications have been unsuccessful in de-escalating a situation. Use should be limited to emergencies in which the risk of a client physically harming self, staff, or others is imminent. Use should be limited to times when a client has demonstrated violence and has inflicted harm to self or others. Use should be limited to emergency situations in which the client is demonstrating a potential to be violent.
Use should be limited to emergencies in which the risk of a client physically harming self, staff, or others is imminent. Explanation: Because of the risks of restraint and seclusion, a primary guideline is that use should be limited to emergencies in which the risk of a client physically harming self, staff, or others is imminent. Furthermore, restraint and seclusion should be applied only when other less restrictive methods to ensure client safety have failed. Nonphysical interventions are the first choice. Reference:
Under which circumstances can an expression of anger be considered a normal and healthy reaction? Select all that apply. When personal rights are not respected. To relieve anxiety. When realistic expectations are not met. When facing an unjust situation. When discussing differing opinions with a colleague.
When facing an unjust situation. When personal rights are not respected. When realistic expectations are not met Anger is considered a normal and healthy reaction when facing unfair or unjust circumstances, when personal rights are not respected, and when realistic expectations are not met. Anger is not useful when the client expresses it to relieve anxiety. When discussing differing opinions with a colleague, a person should be able to maintain objectivity.
The nurse working in a psychology clinic finds that suppression of anger is more common in women than in men. What is the possible explanation for such a finding? Choose the best answer. Women have a greater threshold for controlling anger. Women are more aware about the health consequences related to inappropriate anger expression. Women are expected not to express so-called negative feelings like anger. Women express sadness instead of anger while facing unjust situations.
Women are expected not to express so-called negative feelings like anger. Explanation: Many women have been socialized to build and maintain relationships with other people and refrain from expressing so-called negative emotions like anger. Thus, they are more likely to avoid expression of anger. Controlling anger and suppressing anger are not the same. Women have not been shown to have a greater threshold for controlling anger compared with men. As a result of the inability to express anger, females tend to express sadness rather than angry emotions. Suppression of anger is known to cause greater adverse health effects than expression of anger; however, it has not been shown that women are more aware of this fact.
A client's roommate yells at the client and the client acts as if nothing has occurred and ignores the roommate. The nurse identifies that the client may have which style of anger expression related to this incident? expressive anger catharsis of anger anger suppression constructive anger discussion
anger suppression The client is not expressing anger based on the incident and therefore has anger suppression which means the client is internalizing this emotion. Catharsis of anger would reflect the client being able to express feelings. With constructive discussion, the client would have been able to talk to the roommate about reasons for yelling at the client. With expressive anger, the client would also be able to talk about the emotion of anger with either the roommate or a trusted source for advice.
The nurse is orienting a new staff member in an inpatient mental health unit when a client begins to act in a violent manner. The nurse should explain to the new staff member that some clients use violence and aggression to ... have their needs met. practice assertiveness skills. be placed in their rooms by themselves. relive their childhood experiences.
have their needs met. The nurse should explain to the new staff member that some clients use violence and aggression to get what they want or to force change or regain control. The client may also be seeking attention.
The nurse is performing a physical assessment on a 3-year-old client. During the assessment, the child starts screaming and kicking. The nurse suspects this child: is extremely depressed. has conduct disorder. has intermittent explosive disorder. is acting out.
is acting out. Acting out is an immature defense mechanism where a person deals with a stressor through actions rather than through reflection or feelings. This is a typical behavior in young clients and does not indicate the child is depressed, suffers from conduct disorder, or has explosive disorder. Reference: Videbeck, S, Psychiatric
The nurses on a mental health unit are reviewing aspects of the unit environment in a staff meeting. Which factor would be predictive of a client becoming aggressive or violent? strict hierarchy of authority flexible unit rules scheduled unit activities reduced use of restraints
strict hierarchy of authority Having a strict hierarchy of authority can be predictive of a client being aggressive or violent; others include having rigid, not flexible, unit rules. The unit having a lack of autonomy for clients which would include use of restraints or locked doors is also predictive of client aggression or violence. Another contributing factor would be having a lack of predictable and meaningful ward activities so if there are scheduled activities this would help reduce this potential for clients.
