Ch 20: Management of Anger, Aggression, and Violence

b) Encourage verbalization Pg. 298 Verbally expressing angry feelings is a safe and appropriate way to deal with anger. Isolation and catharsis can increase angry and hostile feelings so they are of no benefit to the client. An increase in self-esteem is not necessarily linked to improvements in the appropriate expression of anger. Verbalization, however, is known to help clients express anger appropriately.

32. Which intervention would assist the client with the appropriate expression of anger? a) Isolate the client from others b) Encourage verbalization c) Improve self-esteem d) Encourage catharsis

a) Low self-esteem Pg. 301 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.

34. A nurse must assess for characteristics that are predictive of violent behavior. Research suggests violent behavior is influenced by possession of which attribute? a) Low self-esteem b) Assertive behavior c) Therapeutic relationship d) Mindfulness

d) Rigid unit rules Pg. 304 Characteristics include rigid unit rules, lack of client autonomy (locked doors, restraints), lack of client's control over the treatment plan, and failure of the staff to listen and convey empathy.

40. What is a characteristic of unit culture that predicts client violence? a) Conveyance of empathy b) Client's control of the treatment plan c) Client autonomy d) Rigid unit rules

d) Escalation Pg. 306 During the escalation phase of aggression, a person may yell and threaten, clench fists, and have other 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.

42. As the nurse is performing an assessment on the client, the client is yelling and is hitting the hand with a rolled up newspaper. Which stage of aggression does the nurse identify that the client is exhibiting? a) Crisis b) Triggering c) Recovery d) Escalation

c) Depression Pg. 297 Maladaptive anger (excessive outwardly directed anger or suppressed anger) is linked to psychiatric conditions, such as depression, as well as a plethora of medical conditions.

44. A nurse is preparing a presentation for a group of staff nurses on anger. When describing maladaptive anger, which psychiatric condition would the nurse identify as being linked to this anger? a) Obsessive-compulsive disorder b) Anxiety disorder c) Depression d) Schizophrenia

b) Teach the client to make "I" statements Pg. 297 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.

45. 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? a) Ask the husband to discuss why he spends so much time with his friends b) Teach the client to make "I" statements c) Ask the wife to provide details about what she means by "all his time" d) Encourage the wife to express exactly what she wants her husband to do on weekends

d) Depression Pg. 297 Some clients with depression have anger attacks that are sudden intense spells of anger, which typically occur in situations 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.

48. The client is being assessed for anger attacks. Which psychiatric disorder makes a person most susceptible to anger attacks that do not result in physical aggression? a) Delusions b) Dementia c) Delirium d) Depression

d) Anger Pg. 297 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. 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.

37. Which describes a strong emotional response to a real or perceived provocation? a) Catharsis b) Hostility c) Physical aggression d) Anger

d) "What have I done or said that is disrespectful?" Pg. 307 The nurse needs to be authentic with the client and try to determine what behavior is interpreted as not being respectful. While it is hard not to feel defensive when being targeted in this way, the nurse does not need to threaten the client with medication or send the client to his or her room. The nurse also doesn't need to ignore the client's feeling but instead stay engaged with the client to try to help understand the client's feelings.

1. The nurse is working with a client who yells at the nurse, "I am angry about how you keep treating me without respect!" What is the nurse's best response? a) "If you don't calm down, I will need you to go to your room" b) "I am not going to talk to you while you are angry" c) "Do you need to take your medication to help calm down?" d) "What have I done or said that is disrespectful?"

c) Anger suppression Pg. 298 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.

10. 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? a) Expressive anger b) Catharsis of anger c) Anger suppression d) Constructive anger discussion

b) The client is sitting in the dayroom reading a book Pg. 306 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.

11. 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? a) The client is having an argument with a roommate b) The client is sitting in the dayroom reading a book c) The client is threatening to hit another client d) The client is having lunch with family members

a) Ensure immediate access to an exit in case leaving is necessary c) Ensure that team members know where the nurse is d) Respect the client's personal space and boundaries Pg. 307 The following approaches are important in caring for clients who are aggressive or violent: use nonthreatening body language; respect the client's personal space and boundaries; have immediate access to a door in case you need to leave the room; leave open the door to an office while talking to a client; know where colleagues are and make sure those colleagues know where you are; and remove or do not wear clothing or accessories that could be used to harm you, such as scarves, necklaces, or dangling earrings. Approaching a client with arms crossed is threatening.

12. A nurse is caring for client who has been aggressive and violent in the past. What would be appropriate for the nurse to do? Select all that apply. a) Ensure immediate access to an exit in case leaving is necessary b) Approach the client with arms crossed and eyes focused on the client c) Ensure that team members know where the nurse is d) Respect the client's personal space and boundaries e) Wear a scarf to cover up any clothing that could be used to injure

c) "You look like you are upset and I want to understand why" Pg. 307 The nurse is helping to deescalate a client's anger with trying to clarify what has upset the client. While the client may not be able to express this, the statement demonstrates caring and concern and can help defuse a angry and potentially violent client. Using language that isn't respectful or is threatening, such as telling the client to calm down or revoking privileges does not help de-escalate anger. Agreeing with the client but offering no solution is also not helpful in de-escalation.

13. A client is becoming increasingly angry while talking with the nurse. Which statement reflects the nurses's appropriate use of de-escalation with the client? a) "I would be upset too but we cannot make any change" b) "I know you are angry but you must calm down" c) "You look like you are upset and I want to understand why" d) "If you can't calm down, you won't be able to watch television"

c) Sobbing inconsolably Pg. Crying is not cited by experts as a behavior indicating that the individual has a high potential to behave violently. The other behaviors are consistent with increased risk for other-directed violence.

14. Which behavior is considered inconsistent with the clinical picture of a client who is becoming increasingly aggressive? a) Staring with narrowed eyes into the eyes of another b) Rigid posture with a clenched jaw c) Sobbing inconsolably d) Pacing

d) A client who stomps away from the nurses' station, goes into the day room, and grabs a pool cue from another client standing at the pool table Pg. 301 Aggression is harsh physical or verbal action that reflects rage, hostility, and potential for physical or verbal destructiveness. Aggressive behavior violates the rights of others; thus this client would be assessed as displaying aggression. The other options do not feature violation of another's rights.

15. Which client should be assessed as demonstrating aggression? a) A client who tells the medication nurse, "I am not going to take that, or any other, medication" b) A client who bursts into tears, leaves the community meeting, and sits on the bed hugging a pillow and sobbing c) A client who tells the primary nurse "When you told me that I could not have a pass, I felt angry" d) A client who stomps away from the nurses' station, goes into the day room, and grabs a pool cue from another client standing at the pool table

d) Validation Pg. 305 Validation involves a clarification of the client's feelings and when a client is angry, many times it can be due to feeling isolated and anxious. Reflection is redirection of an idea back to the client for classification of emotional overtones. Confrontation involves presenting the client with a different reality of the situation. Acceptance would involve encouraging information in a nonjudgmental and interested manner.

16. The nurse states "I know this must be frightening for you" to a client who is angry and has a potential for violence. Which communication technique is the nurse utilizing with this statement? a) Reflection b) Confrontation c) Acceptance d) Validation

d) "We have the most up-to-date information on the best ways to handle this problem" Pg. 309 Clinically, nurses must be provided with training programs in the prevention and management of aggressive behavior. The courses need to be made available to nurses and students regularly so that they have opportunities to reinforce and update what they have learned. Although nurses can use skills and knowledge to prevent violent situations on the unit, they cannot always be avoided and nurses must be prepared to manage escalated anger and crisis. Research shows that nurses who have participated in preventive training programs as students or as professionals become more confident in coping with patient aggression Training programs are not aimed solely at allowing nurses to be aware of current incidences reported in other hospitals.

17. A group of psychiatric nurses working in a community mental health center are participating in a training program for preventing and managing aggressive behavior offered regularly by the center. Which statement by the nurses indicates that the program was successful in achieving its outcome? a) "We still have little confidence in how to cope with aggression" b) "It is important to be aware of current incidences reported in other hospitals" c) "There's very little we can do to minimize the effect of aggression on ourselves" d) "We have the most up-to-date information on the best ways to handle this problem"

b) He or she must be monitored continually Pg. 308 A physician or LIP conducts a face-to-face evaluation of initiation of R/S. Qualified staff assesses the client initially and every 15 minutes thereafter, focusing on signs of injury associated with the application of R/S, nutrition and hydration, circulation and range of motion in the extremities, vital signs, hygiene and elimination needs, physical and psychological status and comfort, and readiness for discontinuation of R/S.

18. When the client is in restraints or seclusion, which of the following must occur? a) He or she must be fed at least every 2 hours b) He or she must be monitored continually c) He or she must be given water at least every 2 hours d) He or she must be seen by a physician or licensed independent practitioner within the first 3 hours of initiation of seclusion or restraint

a) Practice and teamwork Pg. 299 Intervention techniques are learned behaviors and must be practiced to be used in a smooth, organized fashion. Every member of the intervention team should be assigned a specific task to carry out before beginning the intervention. The other options are useless if the staff does not know how to use physical techniques and how to apply them in an organized fashion.

47. A staff development coordinator is planning to teach the use of physical management techniques when clients become physically aggressive. The coordinator should stress the importance of which technique? a) Practice and teamwork b) Spontaneity and surprise c) Caution and superior size d) Diversion and physical outlets

b) Humans can choose to slow their reactions and to think and behave differently in response to various events Pg. 297 A true statement regarding anger is that humans can choose to slow their reactions, and to think and behave differently in response to an event. Common myths include that men are angrier than women, that people have to behave aggressively to get what they want, and that anger behavior in adulthood is determined by temperament and childhood experiences.

19. Which is a true statement regarding anger? a) People have to behave aggressively to get what they want b) Humans can choose to slow their reactions and to think and behave differently in response to various events c) Anger behavior in adulthood is determined by temperament and childhood experiences d) Men are angrier than women

a) Progress Pg. 300 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.

2. The client with a history of explosive outbursts becomes angry and states, "I am really getting angry." The nurse sees this as what? a) Progress b) Manipulation c) Regression d) Controlling

b) Catharsis Pg. 298 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.

20. Which term is used to describe an activity used to release anger? a) Physical aggression b) Catharsis c) Anger d) Hostility

c) The client uses adaptive coping to manage anger impulses Pg. 299 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.

21. 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? a) The client has increased self-esteem b) The client reports increased feelings of self-control c) The client uses adaptive coping to manage anger impulses d) The client has gained insight into situations that trigger anger

a) "It will help you to learn how to control the arousal of anger" Pg. 300 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.

22. A client is attending anger management class and wants to know how the class will help. What is the nurse's best response? a) "It will help you to learn how to control the arousal of anger" b) "You will be able to stop feeling angry when incidents happen out of your control" c) "You will learn how to control your violent behavior" d) "We need to explore what makes you want to hit people when you are angry"

c) "What did you learn about anger when growing up?" Pg. 300 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.

23. 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? a) "What happens when you get angry?" b) "Do you know why you are being admitted?" c) "What did you learn about anger when growing up?" d) "Do you feel that you can manage your reactions with anger?"

d) 1 hour Pg. 308 American institutions that receive Medicare or Medicaid reimbursement must adhere to guidelines issued by the Center for Medicare and Medicaid Services. These guidelines specify that a registered nurse must verify the need for restraint or seclusion, and then contact the physician or other licensed practitioner. Within one hour, that practitioner must examine the client.

24. A nurse has determined that a client requires restraint. Based on guidelines, the nurse contacts the physician who must examine the client within which time frame? a) 3 hours b) 2 hours c) 4 hours d) 1 hour

b) An improvement in mood d) Improved blood pressure control e) Improved overall health Pg. 300 Research shows that anger discussed with other people in a constructive way has a beneficial effect on blood pressure as well as statistically significant associations with better general health, a higher sense of self-efficacy, less depression, and a lower likelihood of obesity.

25. A nurse is conducting a class for a local community group about how to deal with anger in constructive ways. When discussing the benefits of managing anger constructively, which of the following points should the nurse include? Select all that apply. a) Increased likelihood for weight gain b) An improvement in mood c) Reduced self-efficacy d) Improved blood pressure control e) Improved overall health

a) Scheduling one-to-one interactions with the client c) Providing opportunities for clients to resolve conflicts d) Planning group activities such as playing games Pg. 307 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.

26. Which interventions are effective in managing the environment to reduce or eliminate aggressive behavior? Select all that apply. a) Scheduling one-to-one interactions with the client b) Avoiding discussions among clients on the unit c) Providing opportunities for clients to resolve conflicts d) Planning group activities such as playing games e) Discouraging clients from expressing angry feelings

b) Client's safety Pg. 308 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.

27. The nurse decides to place an aggressive and violent client in mechanical restraints. The nurse bases this decision on which of the following? a) Court order b) Client's safety c) Client's mood d) Physician's order

d) Engaging in disputes over medication, supplies, or rules on the unit Pg. 304 Nurses who show respect and empathy are more likely to defuse a client's anger than are nurses who are authoritarian. Examples of authoritarian behavior include preventing clients from leaving the ward, engaging in disputes with them over medication, generally enforcing rules or denying requests, physically restraining clients, taking something from them, ignoring them, or requesting clients to do or not to do something.

28. Which staff behaviors are most likely to trigger clients who are predisposed to aggressive or violent behavior? a) Asking personal questions when they are inappropriate b) Talking excessively with the client in front of other clients c) Providing the client with a list of possible goals for behavior change d) Engaging in disputes over medication, supplies, or rules on the unit

d) Engage the attention of the client who is still yelling and ask what is happening Pg. Engaging the attention of the dominant person will defuse the situation and stop the argument from continuing. Answers A, B, and C would not be appropriate actions in this situation. The nurse placing herself in between two arguing clients is a safety concern.

29. 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. The nurse's most appropriate action would be to... a) Take an authoritative step between the two clients b) Comfort the client huddled in the corner c) Directly address both clients and ask what's going on d) Engage the attention of the client who is still yelling and ask what is happening

c) Cerebral cortex Pg. 301 The brain structures most frequently associated with aggressive behavior are the limbic system and the cerebral cortex, particularly the frontal and temporal lobes.

3. A psychiatric-mental health nurse is reviewing information about biologic theories associated with aggression. The nurse identifies which structure as being primarily involved? a) Medulla b) Sagittal sutures c) Cerebral cortex d) Cerebellum

c) "Anger is a normal feeling, and you can use it to solve problems" Pg. 298-299 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.

30. A nurse is working with a client who has frequent angry outbursts. Which statement is most helpful when working with this client? a) "You can reduce your anger by hitting a punching bag" b) "You need to learn to suppress your angry feelings" c) "Anger is a normal feeling, and you can use it to solve problems" d) "You need to learn how to be less assertive in your communications"

a) Patronizing staff behavior c) Lack of client privacy e) Strict authority hierarchy Pg. 304 Characteristics of the unit and staff that predict violence include rigid unit rules, lack of client privacy, strict hierarchy of authority, patronizing behavior of staff, and failure of the staff to convey empathy.

31. A psychiatric-mental health nurse is working as a part of group to improve the unit culture to reduce the risk of violence. Which factor would the nurse identify as contributing to violence? Select all that apply. a) Patronizing staff behavior b) Empathetic staff c) Lack of client privacy d) Flexible unit rules e) Strict authority hierarchy

d) Serotonin Pg. 299 Low levels of serotonin may lead to aggressive behavior.

33. Low levels of which neurotransmitter may lead to aggressive behavior? a) Dopamine b) Norepinephrine c) Acetylcholine d) Serotonin

a) "What happened that got you so upset?" Pg. 297 As the client regains control, 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 post-crisis to discuss behavior change for the future as the client needs to recover from intense emotions first.

35. After an angry outburst, a client quickly appears more calm and rational. The nurse approaches the client. Which is the most helpful response to the client at this time? a) "What happened that got you so upset?" b) "What can you do differently next time you get angry?" c) "We will have to talk about this later" d) "You really scared me. I'm glad you are okay"

b) All violence is aggressive Pg. 301 Violence is extreme aggression and involves the use of strong force or weapons to inflict bodily harm to another person and in some cases to kill. Violence connotes greater intensity and destruction than aggression. All violence is aggressive, but not all aggression is violent. Aggression involves overt behavior intended to hurt, belittle, take revenge, or achieve domination and control. Aggression can be verbal (sarcasm, insults, threats) or physical (property damage, slapping, hitting).

36. After teaching a class about aggression and violence, the instructor determines that the education was successful when the class states which of the following? a) Aggression is primarily physical b) All violence is aggressive c) Violence involves less forceful than aggression d) Aggression involves behavior directed inwardly

a) Obtain assistance from other staff members Pg. 306 Although is it important to work with clients to find solutions, to approach them calmly, and to empathize and avoid power struggles, safety is the priority because the outburst is imminent. The nurse needs to enlist the aid of a colleagues for protection and assistance. The nurse should use nonthreatening body language and not confront the client, which could exacerbate the client's current state. Telling the client to calm down would be inappropriate and, like confrontation, exacerbate the situation.

38. When interacting with a client in the day room, the nurse determines that a violent outburst is imminent. Which would be most important for the nurse to do? a) Obtain assistance from other staff members b) Confront the client c) Offer the client choices d) Tell the client to calm down

a) "I can see you are angry. Tell me what's going on" Pg. 304 In the triggering phase, the nurse should approach the client in a nonthreatening, calm manner in order to de-escalate the client's emotion and behavior. Conveying empathy for the client's anger or frustration is important. Acknowledging the client's anger and giving the client permission to explain is an appropriate response because it can deescalate the situation. Referring to rules ("You are not allowed ...") may make the situation worse. Stating that the client can leave is not therapeutic and will likely perceived as an ultimatum. It is appropriate to ask, "Why do you say that?" but this should be preceded by an acknowledgment of the client's feelings.

39. 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 what? a) "I can see you are angry. Tell me what's going on" b) "Why do you say that?" c) "You are not allowed to make threats. Please keep your voice down" d) "You are here voluntarily. You can leave if you want"

a) Self-awareness of reactions to aggression by others Pg. 298-299 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.

4. A nurse's response to aggressive behavior on the unit is influenced by which characteristic of the nurse? a) Self-awareness of reactions to aggression by others b) Appreciation of the value of matching anger with anger c) Understanding the importance of non-response to escalating behavior d) Recognition of the reasons for the client's behavior

c) Anger awareness and expression are necessary for women's growth and development Pg. 297 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.

41. The client is sharing some of her experiences with the nurse. Which statement 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) Anger awareness and expression are necessary for women's growth and development d) Most men are socialized to suppress anger

b) Do not personalize a client's anger Pg. Do not take the client's anger or aggressive behavior personally or as a measure of your effectiveness as a nurse. If a nurse takes a client's behavior personally, there is a risk of violating professional boundaries. Clients should not dictate nurses' behaviors and asking how the nurse should change his or her behavior is normally violation of boundaries. Discussing challenges with a supervisor can be emotionally beneficial but does not necessarily affect the nurse's boundary-setting. Similarly, self-reflection is important for nurses but does not necessarily affect professional boundaries.

43. Which 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) Do not personalize a client's anger c) Reflect on actions that may have instigated the client's anger d) Discuss difficult client care situations with a supervisor

a) Reflect on abilities to handle own feelings of anger Pg. 308 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 the nurse handles 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 skills in dealing with angry feelings will help the nurse to work more effectively with clients. Activating a crisis response is a late option in dealing with anger.

46. One of the first steps that a nurse should take to deal effectively with aggressive clients is what? a) Reflect on abilities to handle own feelings of anger b) Understand how to activate crisis response teams c) Become proficient using reflective communication techniques d) Learn professional skills of anger management

b) Rigid unit rules Pg. 304 Characteristics that can increase the risk of violence on a mental health unit include rigid unit rules, lack of meaningful and predictable unit activities, inadequate staffing, and lack of client involvement in the treatment plan.

5. A nurse is part of a team developing strategies to help reduce the risk of violence on the mental health unit. Which of the following would the team identify as contributing to the risk for violence? a) Adequate client-to-staff ratios b) Rigid unit rules c) Client involvement in treatment plan d) Predictable unit activities

c) Use should be limited to emergencies in which the risk of a client physically harming self, staff, or others is imminent Pg. 308 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.

6. 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? a) Use should be limited to times when a client has demonstrated violence and has inflicted harm to self or others b) Use should be limited to emergency situations in which the client is demonstrating a potential to be violent c) Use should be limited to emergencies in which the risk of a client physically harming self, staff, or others is imminent d) Use should be limited to times when medications have been unsuccessful in de-escalating a situation

a) "I feel unappreciated when you criticize me" Pg. 297 Assertive communication uses "I" statements that express feelings and are specific to the situation; for example, "I feel angry when you interrupt me," "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. Accusatory language ("...stop nagging me.") is likely to exacerbate a conflict and is inflammatory, not assertive. Similarly, stating that the other person is "not perfect either" does not focus on the husband's feelings and is likely to worsen conflict. Questioning the other person may provide useful information but does not express the husband's feelings assertively.

7. A married client expresses to the nurse that the client's spouse's frequent nagging angers the client. The nurse role plays assertive communication techniques with the client. Which indicates that the client understands how to use assertive techniques effectively? a) "I feel unappreciated when you criticize me" b) "I really wish you would stop nagging me" c) "Are you telling me you want me to change?" d) "You are not perfect either"

c) "What works best is what fits the client and the situation" Pg. 307 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.

8. 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? a) "Make sure that another colleague knows where you are at all times" b) "I've always had good results with medications" c) "What works best is what fits the client and the situation" d) "You need to confront the client to show you are in charge"

a) Monitoring one's self for cues related to anger arousal b) Engaging in relaxation training d) Identifying ways to disrupt the anger response e) Avoiding stimuli identified to provoke the anger Pg. 301 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. Relaxation training is often introduced early in the treatment because it strengthens the therapeutic alliance and convinces clients that they can indeed learn to calm themselves when angry. Practicing new behaviors as part of a group is used in anger management.

9. A client is receiving cognitive-behavioral therapy as part of the treatment plan for anger. Which of the following would most likely be included? Select all that apply. a) Monitoring one's self for cues related to anger arousal b) Engaging in relaxation training c) Practicing new behaviors as part of a group d) Identifying ways to disrupt the anger response e) Avoiding stimuli identified to provoke the anger