Psych Ch 11
A nurse is working with a client who has frequent angry outbursts. Which of the following statements is most helpful when working with this client? A) "Anger is a normal feeling, and you can use it to solve problems." B) "You need to learn to suppress your angry feelings." C) "You can reduce your anger by hitting a punching bag." D) "You need to learn how to be less assertive in your communications."
A Feedback: Anger can be a normal and healthy reaction when situations or circumstances are unfair or unjust, personal rights are not respected, or realistic expectations are not met. If the person can express his or her anger assertively, problem solving or conflict resolution is possible. Anger becomes negative when the person denies it, suppresses it, or expresses it inappropriately. A person may deny or suppress (i.e., hold in) angry feelings if he or she is uncomfortable expressing anger. Catharsis can increase rather than alleviate angry feelings. Effective methods of anger expression, such as using assertive communication, to express anger should replace angry aggressive outbursts.
A client approaches the nurse and loudly states, "I'm not putting up with this anymore!" The most appropriate response by the nurse would be which of the following? A) "I can see you are angry. Tell me what's going on." B) "You are not allowed to make threats. Please keep your voice down." C) "Why do you say that?" D) "You are here voluntarily. You can leave if you want."
A Feedback: In the triggering phase, the nurse should approach the client in a nonthreatening, calm manner in order to deescalate the client's emotion and behavior. Conveying empathy for the client's anger or frustration is important. The nurse can encourage the client to express his or her angry feelings verbally, suggesting that the client is still in control and can maintain that control. Use of clear, simple, short statements is helpful.
When interacting with a client in the day room, the nurse determines that a violent outburst is imminent. Which of the following should the nurse do first? A) Call for assistance. B) Give the client choices. C) Remove the other clients. D) Talk to the client calmly.
A Feedback: Safety is the priority; the nurse needs assistance to remove other clients and to deal with the violent outburst. The other interventions may be implemented after calling for assistance.
One of the first steps that a nurse should take to deal effectively with aggressive clients is which of the following? A) Reflect on abilities to handle own feelings of anger B) Learn professional skills of anger management C) Become proficient using reflective communication techniques D) Understand how to activate crisis response teams
A Feedback: The nurse must be aware of how he or she deals with anger before helping clients do so. The nurse who is afraid of angry feelings may avoid a client's anger, which allows the client's behavior to escalate. If the nurse's response is angry, the situation can escalate into a power struggle, and the nurse loses the opportunity to "talk down" the client's anger. Identifying how you handle angry feelings is an initial task. Once the nurse understands his or her own experiences with anger, the clients can be helped through learning the use of assertive communication and conflict resolution. Increasing your skills in dealing with your angry feelings will help you to work more effectively with clients. Activating a crisis response is a late option in dealing with anger.
An angry client has just thrown a chair across the room and is racing to pick up another chair to throw. The most appropriate action by the nurse would be which of the following? A) Call for an emergency response from trained personnel. B) Approach the client and firmly say, "Stop, put it down." C) Calmly call the client by name and encourage verbal expression of anger. D) Assist the client to use problem-solving techniques instead of aggression.
A Feedback: When the client becomes physically aggressive (crisis phase), the staff must take charge of the situation for the safety of the client, staff, and other clients. Psychiatric facilities offer training and practice in safe techniques for managing behavioral emergencies, and only staff with such training should participate in the restraint of a physically aggressive client. Verbal expression and problem solving are ineffective once a client has reached the crisis phase. The priority is to maintain safety and regain control.
Which of the following interventions are most effective in managing the environment to reduce or eliminate aggressive behavior? Select all that apply. A) Planning group activities such as playing games B) Scheduling one-to-one interactions with the client C) Providing structure and consistency in the unit D) Avoiding discussions among clients on the unit E) Discouraging clients from negotiating solutions
A, B, C Feedback: Group and planned activities such as playing card games, watching and discussing movies, or participating in informal discussions give the clients the opportunity to talk about events or issues when they are calm. Scheduling one-to-one interactions with clients indicates the nurse's genuine interest in the client and a willingness to listen to the client's concerns, thoughts, and feelings. Knowing what to expect enhances the client's feelings of security. Avoiding discussions does not give clients the opportunity to talk about events or issues when they are calm. If clients have a conflict or dispute with one another, the nurse can offer the opportunity for problem solving or conflict resolution. Expressing angry feelings appropriately, using assertive communication statements, and negotiating a solution are important skills clients can practice. These skills will be useful for the client when he or she returns to the community.
Anger management is likely to be included in the care of clients with which of the following psychiatric diagnoses? Select all that apply. A) Alzheimer's dementia B) Schizophrenia C) Anorexia nervosa D) Acute alcohol intoxication E) Generalized anxiety disorder
A, B, D Feedback: Although most clients with psychiatric disorders are not aggressive, clients with a variety of psychiatric diagnoses can exhibit angry, hostile, and aggressive behavior. Clients with paranoid delusions may believe others are out to get them; believing they are protecting themselves, they retaliate with hostility or aggression. Some clients have auditory hallucinations that command them to hurt others. Aggressive behavior also is seen in clients with dementia, delirium, head injuries, intoxication with alcohol or other drugs, and antisocial and borderline personality disorders.
Which of the following statements about anger, hostility and aggression are accurate? Select all that apply. A) Anger is an emotional response to a real or perceived provocation. B) Hostility stimulates the sympathetic nervous system. C) Physical aggression involves harming other persons or property. D) Anger, hostility, and physical aggression are normal human emotions. E) Hostility is also referred to as verbal aggression. F) Physical aggression often progresses to hostility.
A, C, E Feedback: Anger is an emotional response to a real or perceived provocation. Anger energizes the body physically for self-defense, when needed, by activating the "fight-or-flight" response mechanism of the sympathetic nervous system. Hostility is different than anger. Physical aggression is behavior in which a person attacks or injures another person or that involves destruction of property. Hostility is also referred to as verbal aggression. Anger is a normal human emotion. Hostility is an emotion that is expressed through negative behavior. Physical aggression is behavior. Hostility may lead to physical aggression.
Which of the following are important issues for nurses to be aware of when working with angry, hostile, or aggressive clients? Select all that apply. A) Nurses must be aware of their own feelings about anger and their use of assertive communication and conflict resolution. B) Nurses must not allow themselves to become angry under any circumstances. C) Nurses must know that a client's anger or aggressive behavior is preventable by a skilled nurse. D) Nurses must discuss situations or the care of potentially aggressive clients with experienced nurses. E) Nurses must be calm, nonjudgmental, and nonpunitive when using techniques to control a client's aggressive behavior.
A, D, E Feedback: Nurses must identify how they handle angry feelings and assess their use of assertive communication and conflict resolution. Increasing their skills in dealing with their angry feelings will help the nurses to work more effectively with the client. Nurses must not take the client's anger or aggressive behavior personally or as a measure of their effectiveness as a nurse. Nurses must discuss situations or the care of potentially aggressive clients with experienced nurses. Nurses must be calm, nonjudgmental, and nonpunitive when using techniques to control a client's aggressive behavior.
A client is observed pacing the hall with clenched fists and swearing at others. The nurse intervenes immediately to prevent the client from moving to which phase of the aggressing cycle? A) Triggering B) Escalation C) Crisis D) Recovery
B Feedback: During escalation, the client's responses represent escalating behaviors that indicate movement toward a loss of control, including pale or flushed face, yelling, swearing, agitated, threatening, demanding, clenched fists, threatening gestures, hostility, loss of ability to solve the problem or think clearly. This phase is followed by the crisis phase. During a period of emotional and physical crisis, the client loses control. Behaviors may include loss of emotional and physical control, throwing objects, kicking, hitting, spitting, biting, scratching, shrieking, screaming, and inability to communicate clearly.
The client's son is yelling and is hitting his hand with a rolled up newspaper. Which stage of aggression does the nurse identify that the client's son is exhibiting? A) Triggering B) Escalation C) Crisis D) Recovery
B Feedback: During the escalation phase of aggression, a person may exhibit yelling and threatening, clenched fist, threatening gestures. During the triggering phase of aggression, a person may exhibit signs and symptoms and behaviors including restlessness, anxiety, irritability, pacing, muscle tension, rapid breathing, perspiration, loud voice, and anger.
The nurse is teaching a client to recognize early signs of anger and aggression. The nurse explores ways that the client can recognize which of the following? A) Decreased problem-solving ability B) Restlessness and irritability C) Remorse D) Severe muscle tension
B Feedback: Earliest signs of anger include restlessness, anxiety, irritability, pacing, muscle tension, rapid breathing, perspiration, loud voice, and anger. Escalated signs include pale or flushed face, yelling, swearing, agitation, threatening, demanding, increased muscle tension such as clenched fists, threatening gestures, hostility, and loss of ability to solve the problem or think clearly. Remorse is seen after the anger crisis when attempts are made at reconciliation.
The nurse is interviewing a client with a history of physical aggression. Which of the following should the nurse avoid? A) Anticipating that a loss of control is possible and planning accordingly B) Explaining the consequences the client will face if control is lost C) Interviewing the client with another staff member present D) Responding to verbal threats by terminating the interview and obtaining assistance
B Feedback: Giving the client an ultimatum is likely to foster hostile or aggressive behavior; the other measures are all appropriate for a client with a history of aggression.
In the psychiatric setting, what is the most effective intervention in preventing the hostile client's behavior from escalating to physical aggression? A) Getting as far away from him or her as possible B) Engaging the hostile person in dialogue C) Yelling at the client to settle down now D) Ensuring that the client gets his or her way
B Feedback: In a psychiatric setting, engaging the hostile person is most effective to prevent the behavior from escalating to physical aggression. In the psychiatric setting, it is not possible to get as far away from them as possible. Yelling at the client will likely escalate the hostility. Ensuring that the client gets his or her way may eliminate frustration that may lead to acting out, but is unrealistic and not ultimately helpful to the client.
The client identifies anger management as a problem. What is the next step in planning therapeutic interactions? A) Give the client a variety of choices on how to express anger. B) Give the client permission to be angry. C) Point out the senselessness of anger. D) Tell the client not to be angry all the time.
B Feedback: Many people view anger as a negative and abnormal feeling in addition to feeling guilty about being angry; the nurse can help the client see anger as a normal, acceptable emotion. Giving choices on how to express anger would not be the next step in the planning stage. Pointing out the senselessness of anger and telling the client not to be angry all the time are not appropriate responses in this situation
Which psychiatric disorder makes a person most susceptible to anger attacks that do not result in physical aggression? A) Delusions B) Depression C) Dementia D) Delirium
B Feedback: Some clients with depression have anger attacks that are sudden intense spells of anger that typically occur in situation where the depressed person feels emotionally trapped. Anger attacks involve verbal expressions of anger or rage but no physical aggression. Persons with delusions, dementia, and delirium are most likely to become physically aggressive
The nurse decides to place an aggressive and violent client in mechanical restraints. The nurse bases this decision on which of the following? A) Client's mood B) Client's safety C) Court order D) Physician's order
B Feedback: The use of restraints is warranted only when the client's safety is in jeopardy and other, less restrictive measures have not been effective. The nurse does not base her decision on the client's mood or court order. Just because there is a physician's order for use of restraints, this does not mean that they are appropriate in every situation; this is based on nursing judgment.
Which of the following interventions would assist the client with the appropriate expression of anger? A) Encourage catharsis B) Encourage verbalization C) Improve self-esteem D) Isolate the client from others
B Feedback: Verbally expressing angry feelings is a safe and appropriate way to deal with anger. Isolation and catharsis can increase angry and hostile feelings. The other choices are not appropriate responses in this situation.
After an angry outburst, a client quickly appears more calm and rational. The nurse approaches the client. Which of the following is the most helpful response to the client at this time? A) "We will have to talk about this later." B) "You really scared me. I'm glad you are okay." C) "What happened that got you so upset?" D) "What can you do differently next time you get angry?"
C Feedback: As the client regains control (recovery phase), he or she is encouraged to talk about the situation or triggers that led to the aggressive behavior. The nurse should help the client relax, perhaps sleep, and return to a calmer state. Talking about the event at a later time does let the client rest, but it does less to address the client's feelings associated with the angry outburst. It is too early postcrisis to discuss behavior change for the future as the client needs to recover from intense emotions first.
What a culture considers acceptable strongly influences the expression of anger. Which culture-bound syndrome is a dissociative episode characterized by a period of brooding followed by an outburst of violent, aggressive, or homicidal behavior directed at other people and objects? A) Hwa-Byung B) Hwabyeong C) Amok D) Bouffée delirante
C Feedback: Bouffée delirante, a condition observed in West Africa and Haiti, is characterized by a sudden outburst of agitated and aggressive behavior, marked confusion, and psychomotor excitement. Hwa-Byung or hwabyeong is a culture-bound syndrome that literally translates as anger syndrome, or fire illness, attributed to the suppression of anger. Amok is a dissociative episode characterized by a period of brooding followed by an outburst of violent, aggressive, or homicidal behavior directed at other people and objects.
A client who has been physically aggressive arrives at the emergency room for a psychiatric assessment. Which would be the best approach for the nurse to use? A) Have a sense of humor to show a lack of fear. B) Provide close contact to increase the client's sense of safety. C) Use brief statements and questions to obtain information. D) Use open-ended questions, so the client can elaborate.
C Feedback: Following an aggressive episode, clients may have difficulty expressing themselves; short, concise statements and questions will get needed information. Humor or open-ended questions may be frustrating or annoying for the client. It is not safe for the nurse to provide close contact under these circumstances.
A client is clenching his fists and yelling at another client on the unit. He appears to be close to losing control of his anger. Which of the following actions by the nurse is appropriate at this time? A) Clear others out of the immediate area. B) Prepare a PRN sedative. C) Tell the client to stop and take a time-out. D) Alert the security department of an impending aggressive outburst.
C Feedback: If the client progresses to the escalation phase (period when client builds toward loss of control), the nurse must take control of the situation. The nurse should provide directions to the client in a calm, firm voice. The client should be directed to take a time-out for cooling off in a quiet area or his or her room. Clearing others from the area or alerting security does not help the client regain control. Administering a sedative is not the least restrictive intervention at this time.
At which point in the stages of aggressive incidents is intervention least likely to be effective in preventing physically aggressive behavior? A) Triggering B) Escalation C) Crisis D) Postcrisis
C Feedback: Interventions during the triggering and escalation phases are key to prevent physically aggressive behavior. During the crisis phase, behavior escalation may lead to physical aggression. During the postcrisis phase, the physically aggressive behavior has stopped and the client returns to the level of functioning before the aggressive incident.
A married man expresses to the nurse that his wife's frequent nagging angers him. The nurse role-plays assertive communication techniques with the husband. Which of the following indicates the husband understands how to use assertive techniques effectively? A) "I really wish you would stop nagging me." B) "You are not perfect either." C) "I feel unappreciated when you criticize me." D) "Are you telling me you want me to change?"
C Feedback: The nurse can help clients express anger appropriately by serving as a model and by role-playing assertive communication techniques. Assertive communication uses "I" statements that express feelings and are specific to the situation; for example, "I feel angry when you interrupt me," or "I am angry that you changed the work schedule without talking to me." Statements such as these allow appropriate expression of anger and can lead to productive problem-solving discussions and reduced anger.
The client with a history of explosive outbursts becomes angry and states, "I am really getting angry." The nurse sees this as A) controlling. B) manipulation. C) progress. D) regression.
C Feedback: When the client is able to verbalize angry feelings, this is progress from having an outburst. The client is not trying to control the situation. Manipulation occurs when a person tries to persuade another to act in a desired way. Regression occurs when one retreats to an earlier level of functioning and development.
Which of the following is most important to maintain therapeutic boundaries when working with aggressive clients? A) Encourage clients to express how the nurse can avoid causing emotional irritation. B) Discuss difficult patient care situations with a supervisor. C) Reflect on your actions that may have instigated the client's anger, D) Do not personalize a client's anger
D Feedback: Do not take the client's anger or aggressive behavior personally or as a measure of your effectiveness as a nurse. The client's aggressive behavior, however, does not necessarily reflect the nurse's skills and abilities. Clients should not dictate nurses' behaviors. The nurse is not responsible for angering the client. Individuals are responsible for their own emotional control. If the nurse cannot maintain boundaries, assistance should be sought form a supervisor.
The nurse observes two clients in the day room arguing. One client runs into the corner and huddles while the other follows and continues with verbal abuse. Which is the best action by the nurse? A) Take an authoritatively step between the two clients. B) Comfort the client huddled in the corner. C) Directly address both clients and ask what is going on. D) Engage the attention of the client who is still yelling and ask what is happening.
D Feedback: Engaging the attention of the dominant person will diffuse the situation and stop the argument from continuing. The other choices would not be appropriate actions in this situation. The nurse placing herself in between two arguing clients is a safety concern
Which of the following statements about the crisis phase of aggression when the client becomes physically aggressive is true? A) All staff should act to take charge of the situation. B) The client must be restrained or sedated at once. C) Staff should avoid communicating with the client. D) Four to six trained staff members are needed to restrain.
D Feedback: Four to six trained staff members are needed to restrain, with four staff members each handling a limb and one protecting the client's head and one helps control the client's torso, if needed. When a client becomes physically aggressive, the staff must take charge of the situation for the safety of the client, staff, and other clients. Only staff with training in safe techniques for managing behavioral emergencies should participate. All staff may not have had this training, and if the team is not working in a cooperative and coordinated fashion, it is less safe to restrain the client. The nurse should follow the facility's protocols and standards for restraint and seclusion. Staff should inform the client that his or her behavior is out of control and that the staff is taking control to provide safety and prevent injury.
After an angry outburst, the client is tearful and remorseful. Which statement by the nurse would be most supportive? A) "You still need to work on your problem-solving skills." B) "I will not allow you to get that angry again.' C) "You should not have let your anger buildup like you did." D) "What could you have done when you first started to feel angry?"
D Feedback: In the postcrisis phase, the nurse should not lecture or chastise the client for the aggressive behavior but should discuss the behavior in a calm, rational manner. The client can be given feedback for regaining control, with the expectation that he or she will be able to handle feelings or events in a nonaggressive manner in the future.
A client suddenly jumps up from the chair and begins yelling and cursing at the nurse. Which would be the best response by the nurse? A) "I can see that you need attention; you should calmly ask for what you want." B) "I don't want to hear that kind of language; don't ever do that again." C) "I will limit your smoking privileges if you can't control yourself." D) "You seem angry. Tell me more about how you're feeling."
D Feedback: The nurse recognizes and validates the client's feelings and offers to focus on those feelings and what the client needs. In this situation, the client is not at a point where he can be calm. Taking away privileges will not help the current situation. "I don't want to hear that kind of language; don't ever do that again" is demeaning to the client.
A client lost control of his behavior, broke a window, and made verbal threats to staff and other clients. The client was placed in mechanical restraints. Which statement should the nurse make to explain the use of restraints to the client? A) "The length of time you'll be in restraints is undetermined." B) "The staff will monitor your behavior closely." C) "This is what happens when you lose control." D) "This is a means of keeping you and others safe."
D Feedback: Use of restraints is a temporary, short-term way of ensuring the safety of everyone until the client regains behavioral control; it is not a punishment. The other choices are not appropriate explanations of the use of restraints.
Which one of the following statements about anger is most accurate? A) Anger is an abnormal human emotion that is always negative. B) It is best to express anger by whatever means possible to minimize its consequences. C) Most men are socialized to suppress anger. D) Anger awareness and expression are necessary for women's growth and development.
D Feedback: Women must recognize that anger awareness and expression are necessary for their growth and development. Anger is a normal human emotion and is often perceived as a negative feeling. However, anger becomes negative when denied, suppressed, or expressed inappropriately. Anger that is expressed inappropriately can lead to hostility and aggression. Catharsis can increase rather than alleviate angry feelings. Men are often socialized to believe that it is acceptable to express anger, while women are often socialized to maintain and enhance relationships with others and avoid expression of emotions such as anger.
Which is most likely to be the subject of an aggressive attack from a client with mental illness? A) Other people B) The client C) Animals D) Objects
Which is most likely to be the subject of an aggressive attack from a client with mental illness? A) Other people B) The client C) Animals D) Objects
