Psych Chp 11: Anger, Hostility, and Aggression

The nurse is caring for a client with aggressive behavior. The client tells the nurse, "I am feeling extremely angry. I feel like breaking the windows in here." What would be the most appropriate response of the nurse?

"Let's go to the gym and exercise."

Which describes a strong emotional response to a real or perceived provocation?

Anger Explanation 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.

Which term is used to describe an activity used to release anger?

Catharsis Catharsis includes activities that provide a release of the anger.

The nurse is planning the environment for a newly-admitted client with a history of violence toward others. Which modification would the nurse implement? be in a semi-private room Confirm that the utility and storage rooms are kept locked be kept away from the nurses's station replace plastic hangers with metal hangers

Confirm that the utility and storage rooms are kept locked. As part of keeping the environment safe with clients who are potentially violent, the nurse should keep storage and utility rooms locked to decrease access to items that may be used for self-harm or harm to others. The client should be in a single room, and not a semi-private room with another client. The client should be near the nurse's station, and have plastic, not metal, hangers with the clothes closet due to the risk for injury to self or others.

In which phase of the aggression cycle can techniques of seclusion or restraint be used to deal with the aggression quickly?

Crisis Explanation: In the crisis phase, seclusion or restraint may be used to deal with aggression quickly.

A client has lost emotional and physical control. The client is shouting, screaming, hitting others, and throwing objects. Which phase of the aggression cycle is this client expressing? -escalation -triggering -crisis -recovery -postcrisis

Crisis The client's signs of shouting, screaming, hitting others, and throwing objects suggest that the client is in the crisis phase of the aggression cycle. This phase is characterized by loss of emotional and physical control.

A client visits the clinic and tells the nurse that no matter how difficult the client's child acts, the client simply cannot express any anger. The nurse should plan to assess the client for symptoms of which mental health condition?

Depression Anger turned inward has frequently been associated with mood disorders, particularly depression. It has also been associated with essential hypertension, migraine headaches, psoriasis, rheumatoid arthritis, and Raynaud's disease.

A nurse is beginning the process of providing therapy to a client with anger management problems. When implementing this therapy, which should occur first to promote optimal effectiveness?

Development of a therapeutic relationship With cognitive-behavioral therapy, the recommendation is to first establish the therapeutic alliance because some angry individuals are not in a stage of readiness to change their behavior. When clients are more receptive, cognitive-behavioral therapy involves avoidance of provoking stimuli, self-monitoring regarding cues of anger arousal, stimulus control, response disruption, and guided practice of more effective anger behaviors.

While working in a psychiatric-mental health facility, the nurse notices a client pacing back and forth and becoming increasingly agitated. Which is a critical step in communicating with the client to prevent the escalation of aggressive behavior?

Discover the source of the distress. 5 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.

Which staff behaviors are most likely to trigger clients who are predisposed to aggressive or violent behavior? Engaging in disputes over medication, supplies, or rules on the unit

Engaging in disputes over medication, supplies, or rules on the unit 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.

A client with schizophrenia has been brought to the hospital in an agitated state. In order for the nurse to perform the initial assessment, which approaches should the nurse use to manage the situation? Select all that apply. - Ensure availability of assistance - Monitor facial expressions - Monitor emotional responses - Place the client in restraints - Medicate the client

Explanation: The nurse should monitor the client's facial expressions and emotional responses during the assessment. This may help prevent the client from experiencing feelings of rejection or ridicule during the assessment. Restraint and medication should be used as last resorts for managing clients who have the potential to harm themselves or others.

A nurse is leading an anger management group in the inpatient program. A client says, "I'm feeling really tense, and I'm fidgety today." What is the nurse's most appropriate response to the client's comment?

Explore what is underlying the client's physical and emotional state Explanation: Identifying the feelings reduces the frustration. Attempt to discover the concern and respond with empathy, interest, and willingness to help. Encourage the client to describe and clarify the client's experience using open-ended questions to increase the client's awareness of problematic feelings and what triggers them.

A client is attending anger management class and wants to know how the class will help. What is the nurse's best response?

It will help you to learn how to control the arousal of anger. 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.

Which drug has been effective in treating aggressive clients diagnosed with bipolar disorders? lithium clozapine

Lithium Lithium, an antimanic medication, has been effective in treating aggressive clients with bipolar disorder

A client with aggressive behavior shows NO psychotic symptoms. Which medication should the nurse expect to be ordered for this client? valproate haloperidol lorazepam carbamazepine

Lorazepam Lorazepam is the most effective drug in reducing aggression in a client who does not have any other psychotic symptoms. Valproate, haloperidol, and carbamazepine drugs are useful in reducing aggression in those clients who have coexistent psychotic symptoms.

A nurse must assess for characteristics that are predictive of violent behavior. Research suggests violent behavior is influenced by possession of which attribute?

Low self-esteem 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.

While interviewing a client, a nurse asks, "What do you do when you get angry?" Which client response would indicate to the nurse that the client engages in anger suppression?

People say I withdraw and pout about the problem.

During which phase of the aggression cycle does the client regain physical and emotional control? Postcrisis Recovery

Recovery During the recovery phase of the aggression cycle, the client regains physical and emotional control. The nurse should help the client relax, sleep, and return to a calmer state.

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 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.

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

Serotonin Intermittent explosive disorder involves inadequate production or functioning of serotonin

An aggressive client is holding a weapon and threatening to harm other clients in the unit. How should the nurse handle this situation?

Shield one's self with a pillow

Aggression control can be measured by the nurse's observation of a client's ability to do what?

Show an increased tolerance for frustration Explanation: Aggression control is the term used in the Nursing Outcomes Classification (NOC; Moorhead, Johnson, & Maas, 2003). The nurse may observe that the client shows decreased psychomotor activity (e.g., less pacing), has a more relaxed posture, speaks more directly about feelings of anger and personal needs, requires less sedating medication, shows increased tolerance for frustration and the ability to consider alternatives, and makes effective use of other coping strategies.

A client tells the nurse that the client has strong urges to damage property as a result of feelings of hostility and anger. Which is an appropriate nursing action?

Take the client to the gym for exercise. For a client who expresses hostile and aggressive feelings, the nurse can help the client vent the anger and hostility in a nondestructive way by taking the client to the gym to perform physical exercise. As the client is not severely agitated, the nurse should not put the client in seclusion.

The nurse is counseling a client couple who are trying to reconcile and hold their marriage together. During therapy the wife states, "He makes me so mad when he spends all his weekend time with his friends instead of us. He makes me want to hurt him back." Using concepts from assertiveness training and effective communication techniques, the nurse implements which intervention after hearing the wife's remarks?

Teach the client to make "I" statements. 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.

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 emotionally harm the nurse -To punish the nurse -To intimidate the nurse -To force the nurse into compliance

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.

A client with a history of angry outbursts that have caused interpersonal and work problems has been in counseling for several months. The nurse judges the plan of care to be effective when which outcome is met? -The client has gained insight into situations that trigger anger. -The client uses adaptive coping to manage anger impulses.

The client uses adaptive coping to manage anger impulses. Overall goals for aggressive or violent clients are to refrain from threatening or harming anyone during episodes of anger. Using adaptive coping to manage angry impulses indicates the client has gained insight into and skill at managing aggressive impulses. Although gaining insight into situations that trigger anger, increasing self esteem, and reporting increased feelings of self-control are critical elements in working toward effective management of anger, the goal of treatment is achieved when the client can put what he or she has learned into action.

Five-Phase Aggression Cycle

Triggering An event or circumstances in the environment initiates the client's response, which is often anger or hostility. s/s: Restlessness, anxiety, irritability, pacing, muscle tension, rapid breathing, perspiration, loud voice, anger Escalation The client's responses represent escalating behaviors that indicate movement toward a loss of control. s/s: Pale or flushed face, yelling, swearing, agitation, threatening, demanding, clenched fists, threatening gestures, hostility, loss of ability to solve the problem or think clearly Crisis During an emotional and physical crisis, the client loses control. s/s: Loss of emotional and physical control, throwing objects, kicking, hitting, spitting, biting, scratching, shrieking, screaming, inability to communicate clearly Recovery The client regains physical and emotional control. s/s: Lowering of voice; decreased muscle tension; clearer, more rational communication; physical relaxation Postcrisis The client attempts reconciliation with others and returns to the level of functioning before the aggressive incident and its antecedents. s/s: Remorse; apologies; crying; quiet, withdrawn behavior

A nurse is considering using restraint and seclusion for a client who is acting out. Which is the primary guideline for the use of restraint and seclusion?

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

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?

What did you learn about anger when growing up? While all of these questions are pertinent to assessment of anger reactions in a client, questions related to culture need to center around how clients learned about anger when growing up and how it is displayed. While clients can learn to move past learned behaviors as a child, it is important to understand what these learned behaviors are.

A new nurse asks the nurse manager about the best intervention to use when trying to de-escalate a potentially violent client. Which response would be most appropriate? 1. What works best is what fits the client and the situation. 2 Make sure that another colleague knows where you are at all times. 3. Administering medications 4. Confronting the client

What works best is what fits the client and the situation. 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.

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. -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

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.

The nurse working in a psychology clinic finds that suppression of anger is more common in women than in men. What is the possible explanation for such a finding? Choose the best answer.

Women are expected not to express so-called negative feelings like anger. Many women have been socialized to build and maintain relationships with other people and refrain from expressing so-called negative emotions like anger. Thus, they are more likely to avoid expression of anger. Controlling anger and suppressing anger are not the same. Women have not been shown to have a greater threshold for controlling anger compared with men. As a result of the inability to express anger, females tend to express sadness rather than angry emotions. Suppression of anger is known to cause greater adverse health effects than expression of anger; however, it has not been shown that women are more aware of this fact.

A client's roommate yells at the client and the client acts as if nothing has occurred and ignores the roommate. The nurse identifies that the client may have which style of anger expression related to this incident? expressive anger anger suppression Catharsis

anger suppression The client is not expressing anger based on the incident and therefore has anger suppression which means the client is internalizing this emotion. Catharsis of anger would reflect the client being able to express feelings.

The nurse is performing a physical assessment on a 3-year-old client. During the assessment, the child starts screaming and kicking. The nurse suspects this child: depressed Acting out explosive disorder conduct disorder

is acting out. Acting out is an immature defense mechanism where a person deals with a stressor through actions rather than through reflection or feelings. This is a typical behavior in young clients and does not indicate the child is depressed, suffers from conduct disorder, or has explosive disorder.

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? chronic pain myocardial infarction

myocardial infarction 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.

A client who has a history of hostile behavior appears severely agitated. What interventions should the nurse perform to prevent harm to the client and others? Select all that apply. - Anticipate the use of sedatives. - Use a low calm voice - Engaging the client in group activity -Obtain orders for seclusion if needed. - Make arrangements for possible restraint.

reason: A severely agitated client can turn hostile and harm self and others and cause damage to the facility. The nurse should intervene before the client becomes hostile. The client may need to be secluded, thus the nurse should obtain orders for it. Restraints may need to be used; therefore, appropriate arrangements should be done for placing the restraints. A severely agitated client may need to be sedated; therefore, the nurse should anticipate the use of sedatives. A severely agitated client may not respond to talking but using a low calm voice may help prevent increasing the agitation.

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. Confusion Extreme aggression Hallucinations Insomnia abdominal pain

reason: 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.

A client has recovered from an episode of aggressive and hostile behavior. Which behaviors in the client indicate that the client is in the post-crisis stage of the aggression cycle? Select all that apply. The client apologizes for the hostile behavior. The client cries and is remorseful for the event. The client remains withdrawn from others.

reason: In the post-crisis phase, the client attempts reconciliation with others and returns to a normal level of functioning. The client may realize that the aggressive behavior was wrong and may apologize for it. The client may cry and feel remorse for the aggression episode. Due to the guilt related to the aggression episode, the client remains withdrawn from others

The nurses on a mental health unit are reviewing aspects of the unit environment in a staff meeting. Which factor would be predictive of a client becoming aggressive or violent? flexible unit rules strict hierarchy of authority

strict hierarchy of authority Having a strict hierarchy of authority can be predictive of a client being aggressive or violent; others include having rigid, not flexible, unit rules. The unit having a lack of autonomy for clients which would include use of restraints or locked doors is also predictive of client aggression or violence. Another contributing factor would be having a lack of predictable and meaningful ward activities so if there are scheduled activities this would help reduce this potential for clients

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? reflection redirection validation acceptance confrontation

validation 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.