Chapter 11: Anger, Hostility, & Aggression PrepU

A nurse is caring for a family whose older parent with dementia is living in their home. The nurse has instructed the family about how to decrease the parent's agitation. The nurse determines that the child of the parent has understood the instructions when stating: "Restraints can help reduce my parent's agitation." "I should place my parent in the bedroom with me so I can watch my parent more closely." "It's important that my parent gets out shopping with me or my spouse." "If I simplify our home environment, my parent may be less agitated."

"If I simplify our home environment, my parent may be less agitated." Explanation: The nurse determines that the child of the parent has understood the nurse's instructions when saying, "If I simplify our home environment, my parent may be less agitated." The goal is to reduce environmental stimuli and adapt the environment to the client. Restraints are used only as a last resort. Continuous surveillance is unrealistic. Taking the client out shopping would add to the already intense and highly confusing stimulation.

A psychiatric-mental health nurse is teaching a class for a group of colleagues about anger, aggression, and violence. Which statement by the nurse would be most appropriate to include? "Anger, aggression, and violence are points along a continuum." "The terms used to describe anger are very precise." "Anger is a knee-jerk reaction to external events." "Women often supress their feelings of anger."

"Women often supress their feelings of anger." Explanation: Societal constraints often inhibit women's expression of their anger; they have been socialized to maintain and enhance relationships with others and avoid expressing so-called negative or unfeminine emotions such as anger. Anger, aggression, and violence should not be viewed as a continuum because one does not necessarily lead to another. Language related to anger is imprecise and confusing. People can choose to slow down their reactions and to think and behave differently in response to events; therefore, anger is not a knee-jerk reaction to external events.

Which clients in the psychiatric inpatient unit should the nurse watch closely for risk of aggressive behavior? Select all that apply. A client with a history of violence. A client with history of being personally victimized. A client with a history of substance abuse. A client with history of depression. A client with history of obsessive compulsive disorder.

A client with a history of violence. A client with history of being personally victimized. A client with a history of substance abuse. Explanation: Some clients are at increased risk of aggressive and hostile behavior. A client who has a past history of violence tends to repeat the behavior again. A client who has been victimized during an aggressive episode tends to be hostile. A client who had been abusing drugs or other substances tends to be more aggressive and hostile due to lack of self-control. Clients with a history of depression or obsessive compulsion disorder are less likely to have aggressive episodes unless there was a documented history of aggressive behavior.

When communicating with a client in the triggering phase of the aggression cycle, which intervention should the nurse include? Allow the client to take a "time out" in a quiet area Suggest that the client is still in control and can maintain that control Use seclusion or restraint Help the client relax and return a calmer state

Allow the client to take a "time out" in a quiet area Explanation: During the triggering phase, the nurse should approach the client in a nonthreatening, calm manner in order to deescalate the client's emotion and behavior. The nurse can suggest that the client go to a quiet area or may get assistance to move other clients to decrease stimulation.

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 are hyperactive. Children who belong to low-income families. Children who belong to dysfunctional families. Children who get inconsistent responses for their behavior. Children who are involved in watching television excessively.

Children who belong to low-income families. Children who belong to dysfunctional families. Children who get inconsistent responses for their behavior. Explanation: 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 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? Depression Obsessive-compulsive disorder Anxiety disorder Schizophrenia

Depression Explanation: 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.

Increased activity in which neurotransmitter is implicated in increased impulsivity and violent behavior? Dopamine Serotonin Epinephrine Acetylcholine

Dopamine Explanation: Increased activity of dopamine is implicated in increased impulsivity and violent behavior as a result of changes in cognition and decreased emotional regulation.

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: What is overlooked is the experience of the health problem or the experience of interactions with professionals. 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 caring for a client with depression. The client has an anger episode. What are the possible behaviors expected in this client during and immediately following the episode? Select all that apply. Expresses anger by acting out. Expresses anger verbally. Exhibits physical aggression. Has paranoid delusions. Feels guilty for inappropriate anger reaction.

Expresses anger verbally. Feels guilty for inappropriate anger reaction. Explanation: Clients with depression tend to express their anger verbally. After the anger episode, the client feels remorse and guilt for the anger reactions. Clients with depression are unlikely to exhibit physical aggression or to act out. An anger episode in a client with depression does not indicate that the client has paranoid delusions.

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. Restrain the client. Give the client plenty of space. Sit in an open area Request the presence of additional staff. Encourage the client to talk about this situation

Give the client plenty of space. Sit in an open area Request the presence of additional staff. Explanation: 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 drug has been effective in treating aggressive clients diagnosed with bipolar disorders? Lithium Carbamazepine Valproic acid Clozapine

Lithium Explanation: 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? Lorazepam Valproate Haloperidol Carbamazepine

Lorazepam Explanation: 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.

The nurse is caring for a client with dementia who has become increasingly agitated. What is the best action for the nurse to perform? Request a routine anti-anxiety medication for the client. Discuss with the family the need to place the client in restraints. Place the client on a regular toileting schedule. Have a staff member stay with the client.

Place the client on a regular toileting schedule. Explanation: The client with impaired verbal communication has trouble expressing basic needs such as hunger, thirst and need to urinate. Having the urge to void can cause a client with dementia to have increasing agitation. Therefore, placing the client on scheduled toileting can help keep the client from having agitation due to an unrecognized need. The client would not be medicated with an anti-anxiety medication or placed in restraints without first exploring basic physiologic needs. While the client would be safe with having a staff member stay at the bedside, it does not address the physiological needs.

The nurse has been working on anger management with the client. The client yells during dinner, "Give me that salt shaker!" What is the best nursing intervention at this time? Remind the client about communication skills discussed earlier Set limits with the client regarding hostile communication at the dinner table Inform the client that the client is being inappropriate Ask the client what the client believes is wrong with the communication style

Remind the client about communication skills discussed earlier Explanation: Major treatment strategies include verbal interventions, limit setting, and problem solving. Three steps in preventing behavioral escalation involve making contact, discovering the source of distress, and assisting the person with alternative behaviors. Reminding the client about communication skills or strategies discussed earlier emphasizes the use of personal strengths in communication as well as the therapeutic relationship as a means to assist the client in using more adaptive communication. The other options would not be appropriate for this situation.

A client is diagnosed with intermittent explosive disorder. The nurse understands that this disorder is associated with which neurotransmitter? Serotonin Dopamine Norepinephrine gamma-aminobutyric acid (GABA)

Serotonin Explanation: Intermittent explosive disorder involves inadequate production or functioning of serotonin. Other neurotransmitters such as dopamine, norepinephrine, or GABA are not involved.

An aggressive client is holding a weapon and threatening to harm other clients in the unit. How should the nurse handle this situation? Try to subdue the client Reach out for the client's knife Shield oneself with a pillow Instruct the client to put the knife down

Shield oneself with a pillow Explanation: An armed, aggressive client is dangerous and potentially harmful. The nurse should shield oneself form the client's weapon using a pillow, mattress, or folded blanket. It helps to protect against any potential harm. The nurse should never try to subdue an armed client as the client may harm the nurse. Reaching out to the client's weapon may increase harm to the nurse. Instructing the client may not be helpful, as the client may not be able to follow the instructions.

Which situation is likely to have the least influence on the a child's ability to develop socially appropriate behaviors? Spending time in foster care Being part of a dysfunctional family with poor parenting Receiving inconsistent responses to behavior Being from a family of lower socioeconomic status

Spending time in foster care Explanation: In a situation where the child is taken into foster care, the circumstances surrounding the child being removed from the family home is detrimental to the development of socially appropriate behaviors; however, the child in foster care can receive effective parenting from a functional care provider.

A nurse is assessing a Korean client. The caregiver of the client tells the nurse that the client had been diagnosed with Hwa-Byung by their local health care provider. What should the nurse interpret from this? The client had somatization disorder. The client had paranoid delusions and hallucinations. The client had intermittent episodes of anger outbursts. The client had health-related issues due to suppression of anger.

The client had health-related issues due to suppression of anger. Explanation: Hwa-Byung, or fire illness, is a culture-bound syndrome in Korea where a client has symptoms such as abdominal pain and insomnia as a result of suppression of anger. A nurse who is aware of the culture bound syndromes would understand that the client's health-related complaints are due to suppression of anger. Somatization is an incorrect diagnosis for this condition, often given by Western practitioners unaware of Hwa-Byung. Paranoid delusions and hallucinations are not seen in this culture-bound syndrome. This condition is not known to include intermittent episodes of anger outbursts.

The nurse is planning treatment for a client with aggressive and psychotic behavior. What should be the immediate goals of treatment for this client? Select all that apply. The client will not harm the self. The client will not have auditory hallucinations. The client will demonstrate decreased acting out behavior. The client will withhold from harming others or damaging the hospital property. The client will demonstrate the ability to exercise internal control over behavior.

The client will not harm the self. The client will demonstrate decreased acting out behavior. The client will withhold from harming others or damaging the hospital property. Explanation: The immediate goals of therapy for treatment of a client with aggressive and psychotic behavior include that the client should be able to refrain from harming the self. The aggressive client tends to act out. Therefore, with treatment the client should be able to demonstrate decreased acting out behavior. An aggressive client may harm the self or others. The treatment should be aimed help the client refrain from harming others or damaging the hospital property. The client cannot be expected to stop having hallucinations immediately after therapy. The client cannot be expected to demonstrate the ability to exercise internal control over his or her behavior immediately after therapy. These are unrealistic immediate goals.

Which type of drugs requires cautious use with potentially aggressive clients? a. Antipsychotic medications b. Benzodiazepines c. Mood stabilizers d. Lithium

b. Benzodiazepines

A group of nurses is reviewing information about maladaptive anger. The nurses demonstrate a need for additional study when they identify which physical condition as being linked to suppressed anger? coronary heart disease arthritis hypertension breast cancer

coronary heart disease Explanation: Suppressed anger is related to arthritis, breast and colorectal cancer, and hypertension. Excessive, outwardly directed anger is linked to coronary heart disease, reduced left ventricular ejection fraction, and myocardial infarction.

Behaviors observed during the recovery phase of the aggression cycle include: a. angry feelings. b. anxiety. c. apologizing to staff. d. decreased muscle tension. e. lowered voice volume. f. rational communication.

d. decreased muscle tension. e. lowered voice volume. f. rational communication.

The nurse is utilizing the general aggression model to determine what may have contributed to one client's violence toward a roommate. Which would be considered a situational factor? the client being called lazy by the roommate the client's work ethic the client's previous disagreement with the roommate the client feeling depressed about own progress

the client being called lazy by the roommate Explanation: The general aggression model is a framework that accounts for the interaction of cognition, affect, and arousal during an aggressive episode, which in this case is the client's violence toward a roommate. The situational factor is the actual insult- in this scenario, the client being called lazy. Cognition includes hostile thoughts and scripts; with this situation, this involves the client having a previous disagreement with the roommate. The client's affect involves the client feeling depressed; this could have contributed to the roommate thinking the client was lazy. The client's work ethic is a person factor that also could have contributed.

The nurse is planning education for a client on techniques to manage anger and aggression. Which client situation would be bestfor providing this education? the client who is sitting in the dayroom reading a book the client who is having an argument with a roommate the client who is threatening to hit another client the client who is having lunch with family members

the client who is sitting in the dayroom reading a book Explanation: The time to provide education for a client on techniques to manage anger and aggression is not during times when anger and violence are being exhibited. Therefore, the client having an argument with a roommate or threatening to hit another client are both in situations which are provoking anger and aggression. The client who is reading a book is more amenable to teaching techniques for this because they're not involved in a situation that is provoking aggressive or violent behavior. The client who is eating lunch with family members is involved with a social situation and should not be interrupted for education until through eating.

An adult client is pacing and yelling. Which is the best response by the nurse? "Why do you feel angry?" "When did these feelings begin?" "With whom are you angry?" "What are you doing?"

"When did these feelings begin?" Explanation: When a client is angry, use open-ended questions to clarify the client's behavior. Use an empathetic approach to assist the client to discover the source of the anger. Asking a "why" question implies criticism of the feeling. The client may become defensive and angrier. Similarly asking, "What are you doing?" asks the client to explain behavior when the client may not be fully aware of the source. The question also implies criticism rather than offering empathy. Asking, "With whom are you angry," is a closed-ended question that will not open the thinking and dialogue with the client. Further, asking about the object of the anger focuses on an external reason for the anger rather than assisting the client to look within for the source.

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. Explanation: 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 is teaching a group of clients in a juvenile detention center about anger management and the positive effects of anger, if handled appropriately. What advantages, as explained by the nurse, may be helpful to the clients? Select all that apply. Anger helps to focus attention. Anger helps in decision making. Anger helps in resolving conflicts. Anger helps in improving emotional stability. Anger helps in increasing relaxation.

Anger helps to focus attention. Anger helps in decision making. Anger helps in resolving conflicts. Explanation: Anger can help a person to solve problems and make decisions, if handled appropriately. Anger also energizes the body physically by activating the fight or flight response, which helps the person focus their attention on the stressor. When handled inappropriately, anger can cause physical and emotional problems and, as such, does not improve emotional stability or help in increasing relaxation.

A nurse is assessing a Haitian client. The caregiver of the client tells the nurse that the client is having an episode of Bouffée delirante. What symptoms would the nurse expect to find in this client? Select all that apply. Insomnia Confusion Hallucinations Abdominal pain Extreme aggression

Confusion Hallucinations Extreme aggression Explanation: Bouffée delirante is a culture-bound syndrome observed in West Africa and Haiti. This condition is characterized by sudden outbursts of aggression. The client is confused and may have auditory and visual hallucinations. Insomnia and abdominal pain are not associated with Bouffée delirante. These symptoms are associated with Hwa-Byung, which is a culture-bound syndrome in Korea.

In observing a client's pattern of development of aggression, which techniques can a nurse teach a client to help with management of anger? Select all that apply. Count to the number 10. Ignore the increase in anger. Use deep breathing exercises. Take a time-out from the situation. Watch a television show.

Count to the number 10. Use deep breathing exercises. Take a time-out from the situation. Watch a television show. Explanation: Taking a time-out from the situation, or finding an alternative activity, such as watching TV can help defuse anger for a client. The client can also count to 10, or use relaxation techniques such as deep breathing. If the client ignores the increase in anger, it will not help the client recognize the pattern of this. This can lead to increased anger, and potentially aggression and violence.

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? Immediately approach the client to engage in communication Ask colleagues to contact hospital security for support Offer the client an antianxiolytic medication Prepare to seclude the client

Immediately approach the client to engage in communication Explanation: 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.

When determining a client's potential for aggression and violence prior to engaging in a detailed psychosocial assessment, which would be most important for the nurse to do? Obtain a thorough client history Ask the client about the client's living situation Observe the client for nonverbal indicators Review the client's use of medications

Obtain a thorough client history Explanation: Although assessing the client's living situation, observing for nonverbal indicators, and reviewing medications are important, obtaining a thorough client history is the most important predictor for aggression and violence. Early life adverse circumstances, such as inadequate maternal nutrition, birth complications, traumatic brain injury, and lead exposure, can contribute to risk for aggressive and criminal behaviors in adulthood. Important markers in the client's history include previous episodes of rage and violent behavior, escalating irritability, intruding angry thoughts, and fear of losing control.

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 Hunger and thirst Orientation Perceptions and delusions

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.

An aggressive client gets hold of a glass piece and prevents anyone from entering the room. What interventions should the nurse perform to ensure safety of the client, staff, and other clients? Select all that apply. Summon help from others Leave the area immediately Shift other clients to a safe place Remove glass piece from client Try to talk down the client

Summon help from others Leave the area immediately Shift other clients to a safe place Explanation: The aggressive client with a potentially harmful weapon in hand can be dangerous to self, staff, and other clients. The nurse should summon help to help control the client. The nurse should leave the area immediately if unable to calm the client and the situation is an emergent one. The other clients should be shifted to another area to ensure safety. Attempting to remove the weapon from the client may increase the risk of injury to the nurse. The client may not be able to understand the instructions; therefore, taking down the client may not be helpful.

A nurse has been a victim of assault by a client. Which physiologic response would the nurse exhibit to indicate that there was a more long-term consequence for this event? The nurse is seeking a job in another hospital. The nurse expresses that fear and anxiety are daily emotions. The nurse eats lunch alone every day at work. The nurse discusses the difficulty of being able to sleep at night.

The nurse discusses the difficulty of being able to sleep at night. Explanation: The nurse who is experiencing a physiological response would potentially have difficulty sleeping, or report headaches or stomach aches. The client who expresses fear and anxiety is having an affective response to the experience. The nurse seeking another job is having a cognitive response to the violence. The nurse eating alone is demonstrating a feeling of isolation, which is a behavioral response.

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 yell at the client to put the knife down. The nurse should try to grab the knife out of the client's hand. The nurse should attempt to kick the knife out of the client's hand. The nurse should call for outside assistance. The nurse shout remain close to the client.

The nurse should attempt to kick the knife out of the client's hand. The nurse should call for outside assistance. Explanation: When necessary to remove the weapon, the nurse should try to kick the weapon out of the client's hand. The nurse should not reach for a weapon with his or her hand. The nurse should know the hospital's staff assistance plan and summon for outside assistance, especially in the event the client has a gun. The nurse should talk to the client in a low, calm voice; yelling may only exacerbate the situation. The nurse should remain aware of the client's body space or territory and not trap the client.

The nurse is assessing a client who expresses extreme hostility toward the nurse. What may be the client's intentions? Select all that apply. To punish the nurse To intimidate the nurse To force the nurse into compliance To resolve conflict with the nurse To emotionally harm the nurse

To intimidate the nurse To emotionally harm the nurse Explanation: The likely reasons for a client to expressing hostility toward the nurse are to frighten the nurse (intimidate the nurse) and to harm the nurse emotionally. Hostility or verbal aggression would not be useful for punishing the nurse or forcing the nurse into compliance. Resolving conflicts with the nurse may take place only if the client handles his or her anger toward the nurse appropriately.

The nurse is working with a client who is glaring at the other clients and has begun to pace in the dayroom. In determining an intervention to prevent escalation to violence, which would the nurse choose? Select all that apply. giving the client personal space approaching the client calmly overlooking the client's behavior preventing the client from leaving the dayroom explaining to the client medication may be needed

giving the client personal space approaching the client calmly overlooking the client's behavior Explanation: The client who is having an escalation of anger that may lead to violence needs to be given personal space. If the nurse wants to discuss the indication of anger that is observed, the nurse should approach the client calmly. Sometimes the best approach would be to ignore the client's behavior. The nurse would not want to prevent the client from leaving the dayroom as this would be a form of restraint. While medication may be necessary at some point, it is best to try other de-escalation techniques before this measure.

A nurse is reading a journal article about anger and violence. Which would the nurse expect to see as being linked to excessive, outwardly directed anger? myocardial infarction hypertension arthritis chronic pain

myocardial infarction Explanation: 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. For example, excessive, outwardly directed anger is linked to coronary heart disease and myocardial infarction. Suppressed anger is related to arthritis, breast and colorectal cancer, chronic pain, and hypertension. Furthermore, suppressed anger was a predictor of early mortality for both men and women in a large, 17-year study.