Chapt. 32: Anger & Aggression
10. The nurse is counseling a client couple who are trying to reconcile and hold their marriage together. During therapy the wife states, "It's so heartless when he spends all his weekend time with his friends instead of his family. He makes me want to hurt him back." Using concepts from assertiveness training and effective communication techniques, the nurse implements which of the following interventions after hearing the wife's remarks? A) Teach the client to make "I" statements. B) Ask the wife to provide details about what she means by "all his time." C) Ask the husband to discuss why he spends so much time with his friends. D) Encourage the wife to express exactly what she wants her husband to do on weekends.
Ans: A Feedback: 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.
12. While working in a psychiatric-mental health facility, you notice a client pacing back and forth and see that he is becoming increasing agitated. Which of the following is one of the five important steps in communicating with clients to prevent the escalation of aggressive behavior? A) Discover the source of the distress. B) Avoid eye contact. C) Isolate the client in a secluded setting. D) Immediately administer medication to prevent further escalation.
Ans: A Feedback: Five important steps in communicating with clients to prevent the escalation of aggressive behavior include (1) making personal contact, (2) discovering the source of distress, (3) relieving the distress, (4) keeping everyone safe, and (5) assisting with alternative behaviors and problem solving.
15. You are working as a nurse at a psychiatric-mental health facility. You find yourself if a situation with a client who is becoming increasing aggressive and has begun punching the wall. Which of the following is a measure you can take for your personal safety? A) Avoid being alone with the client. B) Stand on the client's dominant side. C) Stand with your hands behind your back. D) Avoid standing close to a door.
Ans: A Feedback: If you get into a "situation": take a position just outside the client's personal space (slightly out of arm's reach). if possible, stand on the client's nondominant side (usually the side on which he or she wears a wristwatch). keep an open posture with your hands in sight, keep the client in visual range, make sure the door of a room is readily accessible. Avoid letting the client get between you and the door, be friendly, concerned, and avoid being demanding unless the danger is imminent. If the latter, it is perfectly acceptable to say "Please stop that now" authoritatively, retreat from the situation and summon help if the client's aggression escalates to imminent violence, avoid being alone with an escalating client.
7. Violent television programs and video games expose children to aggressive models. What part, if any, are these forms of entertainment thought to play in the development of aggressive behavior in children? A) They teach that aggressive behavior results in social recognition and defeat of enemies. B) They have no measurable effect on behavior, even if many adults find them unacceptable. C) They negatively affect aggression by showing that violence has no rewards. D) They only affect children who are exposed to violence in the family.
Ans: A Feedback: Some researchers and theorists believe that television, video, and movie violence portrays coercive behavior that results in the attainment of some material reward, social recognition, or successful retaliation against enemies.
9. The nurse on a psychiatric unit is giving an in-service about restraints to a new group of unlicensed assistive personnel. She tells them that the use of restraints has declined in recent years as a consequence of which of the following factors? A) Studies revealing no therapeutic benefit to their use B) Numbers of restraint-associated deaths, mostly in children and adolescents C) Insufficient staffing to monitor clients in restraints D) Federal legislation limiting the use of restraints to men between 18 and 45 years of age
Ans: B Feedback: Asphyxiation, sudden cardiac events, and suffocation frequently have been the outcome for restrained clients. In addition, an alarming number of deaths have been associated with restrain and seclusion—many of them occurring in children and adolescents.
16. A client has been brought to the emergency department (ED) by ambulance after he was reported to have flown into an inexplicable rage in a fast food restaurant. Paramedics state that he has been shouting, screaming, and swearing in the ambulance, and this behavior now continues in the ED. In order to justify the use of restraints, what condition must be met? A) The client's electronic health record must document a DSM-IV-TR psychiatric diagnosis. B) Less restrictive measures must have been implemented and must have proved unsuccessful. C) The client must be known to a member of the care team and have required restraint in the past. D) The care team must attempt to elicit verbal consent from the client for the use of restraints.
Ans: B Feedback: 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. Verbal consent and a known psychiatric diagnosis are not legally or ethically required in situations where no other option for ensuring safety remains.
8. A nurse is conducting anger management classes. A client admits that she is verbally abusive to her teenagers when they defy her. She comments, "That's how I was raised!" Which of the following interventions is best in this situation? A) Suggest the client use positive reinforcement to affect her children's behavior. B) Teach the client to identify and monitor anger cues. C) Explore how social beliefs about parenting techniques have changed. D) Suggest the client and her children begin family therapy.
Ans: B Feedback: Cognition or thoughtful review of situations should dictate behaviors in all circumstances. Clients need to learn how to identify and monitor their own anger cues, behavioral and physiologic signals related to anger arousal, signs of impending loss of control, and how to re-channel aggressive responses early.
11. Gary is a psychiatric-mental health nurse. He wants to decrease frustration and potential anger among clients on the unit where he is working. Which of the following would aid in decreasing frustration and anger? A) Develop rules that prevent clients from opting out of activities. B) Allow appropriate access to phones, televisions, or rooms. C) Ensure clients comply with their medication regimens. D) Isolate clients who appear to be angry.
Ans: B Feedback: Examples of staff behavior that can contribute to frustration and anger in clients include rules that prevent clients from leaving activities, power disputes over medications, blocked access to phones, televisions, or rooms, denial of requests in general, physical restraint, ignoring clients, and ordering clients to do or not to do something. Rules, medication compliance and isolation are not actions that have the direct potential to reduce frustration and anger.
4. In most states, a client who may harm himself or someone else but will adhere to a treatment plan in a less restrictive setting can be obliged to participate in treatment even if he or she does not require hospitalization. This is referred to as which of the following? A) Preventive commitment B) Outpatient commitment C) Conditional commitment D) Preliminary commitment
Ans: B Feedback: In general, involuntary commitment occurs only when a court deems a client diagnosed as mentally ill as imminently dangerous to self or others. Forty-three states are implementing the requirement for the least-restrictive treatment alternative by permitting commitment to outpatient treatment settings rather than to hospitals when possible (NASMPHD, 2006). In general, criteria for involuntary outpatient commitment reflect that clients do not require continuous hospitalization, could be treated more appropriately in an outpatient program (or a combined inpatient and outpatient program), will adhere to a prescribed treatment plan, and are not likely to become dangerous or suffer further deterioration if they follow the prescribed treatment plan.
1. A group of psychiatric-mental health nurse has implemented a protocol that aims to identify hostility-related variables in clients. Which of the following personality traits is associated with aggressive behavior? A) Self-aggrandizement B) Impulsivity C) Pessimism D) Narcissism
Ans: B Feedback: Irritability, resentment, and impulsivity have been linked with conflict, aggression, and the potential for medical conditions such as essential hypertension, cardiovascular disease, and atherosclerotic heart disease
14. Derrick is a psychiatric-mental health nursewho is considering using restraint and seclusion for a client who is acting out. Which of the following is the primary guideline for the use of restraints and seclusion? A) Use should be limited to times when a client has previously demonstrated violence and has inflicted harm to self or others. B) Use should be limited to times when medications have been unsuccessful in deescalating a situation. 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 emergency situations in which the client is demonstrating a potential to be violent.
Ans: C Feedback: 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.
17. A nurse has observed that an inpatient psychiatric-mental health client has begun speaking loudly and gesturing aggressively to another client in the common area of the unit. After making contact with the client, what question by the nurse is most appropriate and therapeutic? A) "Why are you getting agitated right now?" B) "Do you remember what happened the last time you did this?" C) "Are you feeling angry right now?" D) "What's making you so unsettled?"
Ans: C Feedback: To discover the source of distress, the nurse should use open-ended questions, which elicit meaningful descriptions. Yes-or-no questions are useful for specific information, such as "Are you feeling angry?" The nurse should avoid threatening statements or questions and should avoid asking "why" questions.
5. A client reveals in a therapy session that he has thought about killing his neighbor and has crafted a preliminary plan for doing so. What is the therapist's obligation regarding this revelation? A) The therapist must keep the comment confidential, because the disclosure is protected by therapist-client confidentiality. B) The therapist must evaluate the threat and notify authorities if it meets credibility criteria. C) The therapist must meet with an ethics committee to determine the course of action. D) The therapist must notify authorities and the potential victim.
Ans: D Feedback: As a result of the Tarasoff decision, it is mandatory in most (but not all) states to report any clear threats that psychiatric clients make to harm specific people. Psychiatrists, psychotherapists, and other mental health care providers must warn authorities (if specified by law) and potential victims of possible dangerous actions of their clients, even if the clients protest.
2. A comprehensive assessment of a new client reveals the likely presence of several hostility-related variables. The term "hostility-related variables" refers to what? A) Consequences of aggressive and violent behavior B) Situations that cause the violence-prone person to react C) Societal endorsement of violence through entertainment content D) Emotions, attitudes, and behaviors found in aggressive individuals
Ans: D Feedback: Hostility-related variables are regular and predictable emotions, attitudes, and behaviors in humans confronted with frustrating circumstances, unfair application of rules, unjust practices, discrimination, shaming, or humiliation.
3. The parents of a teen with a history of aggressive behavior relate that their son was shy and fearful as a child, adapted very slowly to new situations, and displayed very intense moods. This description is characteristic of which of the following? A) Adjustment disorder B) Conduct disorder C) Insecure temperament D) Negative emotionality
Ans: D Feedback: Negative emotionality is manifested by irregularity in biologic functions, behavioral inhibition, including shyness, fearfulness, and withdrawal from new or novel situations, slow adaptability, and an intense and negative mood
6. A client with a history of angry outbursts that have caused him to have interpersonal and work conflicts has been in counseling for several months. The nurse judges the plan of care to be effective when which of the following outcomes is met? A) The client is able to describe his thinking when he has an outburst. B) The client has increased self-esteem. C) The client reports increased feelings of self-control. D) The client can successfully manage aggressive impulses.
Ans: D Feedback: Overall goals for aggressive or violent clients are for them not to threaten or harm anyone and to gain insight into and skill at managing aggressive impulses. Successful management of high-risk situations is the highest priority goal.
18. At an interdisciplinary care conference, a nurse has made reference to a client's temperament, which is thought to be a relevant factor in his history of aggression. Which of the following statements about temperament is most accurate? A) "Temperament" is a term that is synonymous with "personality." B) Temperament is the variable that is most affected by psychotropic medications. C) Temperament is primarily influenced by cultural and social norms. D) Temperament is thought to remain fairly consistent throughout the lifespan.
Ans: D Feedback: Temperament is the sum total of a person's constitutional or biologic personality dispositions. However, "temperament" and "personality" are not interchangeable terms. Temperament is partly genetic, evident early in life, and somewhat stable across situations and over time. Temperament is thought to remain consistent throughout the lifespan. Temperament is not primarily determined by culture and society. Medications alter behavior more than they affect temperament, which is more deeply rooted.
13. A clinician is working with a client using specific learning experiences to teach clients how to recognize the connection between their thoughts, feelings, and behaviors. What is the name for this type of cognitive behavioral intervention? A) Anger management B) Token economy C) Social learning D) Guided discovery
Ans: D Feedback: The "guided discovery" technique has been successful with clients who have depression or anger-control problems (Rickelman and Houfek, 1995). In this approach, clinicians use specific learning experiences to teach clients how to recognize the connection between their thoughts, feelings, and behaviors, identify and replace automatic negative thinking with positive thinking, and substitute dysfunctional expectations and appraisals with reality-based interpretations.
