Varcarolis Ch 27 Anger, Aggression, and Violence

9. Twenty-four-hour observation is a good choice for restraint in which of the following patients? a. An inmate with suicidal ideation on hospice care b. A sex offender in the psychiatric intensive care unit c. An aggressive female with antisocial personality disorder d. An inmate diagnosed with paranoid schizophrenia

a. An inmate with suicidal ideation on hospice care

Which intervention strategy should be avoided by staff working with a client who is shouting and flailing his arms? A. Defusing the situation by laughing or making a joke of the challenge B. Saying "Let's go to your room to talk about this" C. Moving a few staff close together as a group to provide a show of force D. Allowing one staff person to speak to the client while others provide support

A. Defusing the situation by laughing or making a joke of the challenge Ridiculing a client should always be avoided. The other options are constructive approaches to deescalation.REF: Page 520

The client at highest risk for violence directed at others is one who A. has a history of recurrent severe depression. B. is in an alcohol rehabilitation program. C. has delusions of persecution. D. who has somatic symptoms for which no organic basis is found.

C. has delusions of persecution. The client who perceives others to be against him may lash out if he feels threatened.REF: Page 518

9. The staff development coordinator plans to teach use of physical management techniques for use when patients become assaultive. Which topic should the coordinator emphasize? a. Practice and teamwork c. Caution and superior size b. Spontaneity and surprise d. Diversion and physical outlets

a. Practice and teamwork 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.

12. Which assessment finding presents the greatest risk for violent behavior directed at others? a. Severe agoraphobia b. History of spousal abuse c. Bizarre somatic delusions d. Verbalized hopelessness and powerlessness

b. History of spousal abuse A history of prior aggression or violence is the best predictor of who may become violent. Patients with anxiety disorders are not particularly prone to violence unless panic occurs. Patients experiencing hopelessness and powerlessness may have coexisting anger, but violence is uncommon. Patients with paranoid delusions are at greater risk for violence than those with bizarre somatic delusions.

A nurse attempts to intervene verbally when an angry client initially threatens to throw a chair but quickly focuses the anger toward the nurse. Several staff members gather behind the nurse, but then the client shouts, "I will calm down when that nurse isn't in my face." The nurse best demonstrates the ability to help the client deescalate by A. continuing to manage the situation personally. B. telling the client, "It isn't safe for me to leave the room." C. moving to the rear of the staff group. D. apologizing for upsetting the client.

C. moving to the rear of the staff group. There is no need for the nurse to stand her ground to save face. The goal is to deescalate the situation. When the client makes a request that can be met without compromising safety, granting the request is acceptable.REF: Page 520-521

Peter, a 21-year-old patient, asks you, "What's wrong with my brain that I have such a problem with aggression?" Your response is based on the knowledge that: A. the prevailing theory is that diminishment of stress hormones causes anger and aggression. B. no abnormalities of the brain have been identified that correlate with anger and aggression. C. the limbic system, the prefrontal cortex, and neurotransmitters have been implicated in playing a part in aggression. D. personality type plays a much greater part in anger and aggression than physical factors.

C. the limbic system, the prefrontal cortex, and neurotransmitters have been implicated in playing a part in aggression. These have all been implicated by research as playing a part in anger and aggression. The other responses are untrue.Cognitive Level: Apply (Application)Nursing Process: ImplementationNCLEX: Psychosocial IntegrityText page: 516

You are working in the emergency department. You notice Matt, your patient's husband, pacing in the hallway, muttering to himself, and looking angrily around the emergency department. Which of the following statements to Matt may help prevent escalation and/or violence? A. "You need to stay with your wife. She needs you." B. "Hey, what's up buddy? You look pissed." C."I am calling security to deal with your behavior." D. You appear upset. Can I help you with anything?"

D. "You appear upset. Can I help you with anything?" Approaching a patient or a visitor with a calm, sincere, and caring manner can de-escalate a situation because the person may feel you are interested in helping. The other responses will not prevent escalation and may in fact anger the person further.Cognitive Level: Analyze (Analysis)Nursing Process: ImplementationNCLEX: Safe and Effective Care EnvironmentText page: 520

A nurse is conducting group therapy with a group of clients. Which of the following statements made by a client is an example of aggressive communication? A. "I wish you would not make me angry" B. "I feel angry when you leave me." C. "It makes me angry when you interrupt me." D. "You'd better listen to me"

D. "You'd better listen to me"

Anger can best be defined as A. an unhealthy way of releasing anxiety. B. doing intentional harm to others. C. an expression of conflict with others. D. a normal response to a perceived threat.

D. a normal response to a perceived threat.

A client waiting to see the physician is pacing and looking both angry and tense. When it's determined that the client won't be seen for another 30 minutes, the nurse addresses the client's agitation by A. telling the client that pacing will not help the rate at which clients are seen. B. adjusting the appointment schedule to allow the client to be seen next. C. empathizing with the long wait and asking the client if he would mind sitting down until his turn comes. D. explaining to the client what caused the back-up and suggesting that he has time to go to the coffee shop.

D. explaining to the client what caused the back-up and suggesting that he has time to go to the coffee shop. Taking time to explain to clients and offering measures that will provide comfort can be helpful in reducing tension and anger associated with waiting.REF: Page 521

A client experiencing manic hyperactivity stands up, glares challengingly at clients and staff, and shouts, "This food is garbage! I'll fight anyone who says it's not!" The nurse's most relevant assessment is that the client A. is upset with the quality of the food. B. is getting rid of tension in a harmless way. C. is frustrated by limits imposed by hospitalization. D.has a high potential for other-directed violence.

D. has a high potential for other-directed violence. The client's offers to fight are suggestive of a high potential for violence. Clients may have coping skills that are adequate for day-to-day events in their lives but are overwhelmed by the stresses of illness or hospitalization. Other clients may have a pattern of maladaptive coping, which is marginally effective and consists of a set of coping strategies that have been developed to meet unusual or extraordinary situations.REF: Page 516-517

A client has a history of demonstrating aggression physically. An appropriate short-term goal to help the client manage this anger is to A. strike objects rather than people. B. limit aggression to verbal outbursts. C. isolate in lieu of striking people. D. identify situations that precipitate hostility.

D. identify situations that precipitate hostility. The identification of situations that create hostile feelings must occur if the client is to develop new coping strategies.REF: Page 527

A client has been placed in seclusion to control aggressive behavior. Care while the client is secluded should include A. observation every 30 minutes. B. releasing the client every 8 hours. C. releasing the client every 8 hours. D. providing for nutrition and hydration.

D. providing for nutrition and hydration. Clients must be given meals on schedule and frequently offered cold liquids in paper cups (at least every 2 hours; hourly if the client is highly hyperactive).REF: Page 521

Nurses coping with angry clients may find it helpful to remember that anger and aggression begin as feelings of A. isolation. B. confidence. C. competence. D. vulnerability.

D. vulnerability. The progression is vulnerability, perception of event as a threat, arousal, and then uneasiness and anxiety.REF: 526

3. Which central nervous system structures are most associated with anger and aggression? Select all that apply. a. Amygdala b. Cerebellum c. Basal ganglia d. Temporal lobe e. Prefrontal cortex

a. Amygdala d. Temporal lobe e. Prefrontal cortex The amygdala and prefrontal cortex mediate anger experiences and help a person judge an event as either rewarding or aversive. The temporal lobe, which is part of the limbic system, also plays a role in aggressive behavior. The basal ganglia are involved in movement. The cerebellum manages equilibrium, muscle tone, and movement.

5. Which comorbid condition would result in cautious use of a selective serotonin reuptake inhibitors for a patient with chronic aggression? a. Asthma b. Anxiety disorder c. Glaucoma d. Bipolar disorder

d. Bipolar disorder

1. Which individuals are most at risk for displaying aggressive behavior? Select all that apply. a. An adolescent embarrassed in front of friends. b. A young male who feels rejected by the social group. c. A young adult depressed after the death of a friend. d. A middle-aged adult who feels that concerns are going unheard. e. A patient who was discovered telling a lie.

a. An adolescent embarrassed in front of friends. b. A young male who feels rejected by the social group. d. A middle-aged adult who feels that concerns are going unheard. e. A patient who was discovered telling a lie.

2. A nurse directs the intervention team who places an aggressive patient in seclusion. Before approaching the patient, which actions will the nurse direct team members to take? Select all that apply. a. Appoint a person to clear a path and open, close, or lock doors. b. Quickly approach the patient and take the closest extremity. c. Select the person who will communicate with the patient. d. Move behind the patient when the patient is not looking. e. Remove jewelry, glasses, and harmful items.

a. Appoint a person to clear a path and open, close, or lock doors. c. Select the person who will communicate with the patient. e. Remove jewelry, glasses, and harmful items. Injury to staff and the patient should be prevented. Only one person should explain what will happen and direct the patient. This may be the nurse or a staff member with a good relationship with the patient. A clear pathway is essential because those restraining a limb cannot use keys, move furniture, or open doors. The nurse is usually responsible for administering medication once the patient is restrained. Each staff member should have an assigned limb rather than just grabbing the closest. This system could leave one or two limbs unrestrained. Approaching in full view of the patient reduces suspicion.

3. Which intervention(s) should the nurse implement when helping a patient expresses anger in an inappropriate manner? Select all that apply. a. Approach the patient in a calm, reassuring manner. b. Provide suggestions regarding acceptable ways of communicating anger. c. Warn the patient that being angry is not a healthy emotional state. d. Set limits on the angry behavior that will be tolerated. e. Allow any expression of anger as long as no one is hurt.

a. Approach the patient in a calm, reassuring manner. b. Provide suggestions regarding acceptable ways of communicating anger. d. Set limits on the angry behavior that will be tolerated.

You are working on an adolescent psychiatric unit. Katy, aged 16 years, has been angry all day because her boyfriend was not allowed to visit last night. Katy is in the hallway and begins yelling, "It's not fair! You all hate me! I hate this place!" She begins pounding her fists on the wall. To deal with the situation and prevent further escalation, your best response would be to say: A. "Katy, I will help you calm down. Do you want to go to your room and talk or go to the quiet room?" B. "Katy, you may yell and bang your fists but you must do it in your own room so you don't upset the other patients." C. "Katy, stop that right now! You will not be allowed to behave like that!" D. "Katy, you will have to go into seclusion and restraints right now." a

A. "Katy, I will help you calm down. Do you want to go to your room and talk or go to the quiet room?" Approaching the patient in a calm manner and giving choices may de-escalate the situation and gives the patient some control. The patient would not be allowed to yell or possibly hurt herself alone in her room. Commands such as "stop that right now!" could further escalate the situation. Seclusion and restraint may be premature because the situation may be able to be resolved using least restrictive means.Cognitive Level: Analyze (Analysis)Nursing Process: ImplementationNCLEX: Safe and Effective Care EnvironmentText page: 520

A nurse is caring for a client who is screaming at staff members and other clients. Which of the following is a therapeutic response by the nurse to the client/ A. "Stop screaming, and walk with me outside" B. "Why are you so angry and screaming at everyone?" C. "You will not get your way by screaming" D. "What was going through your mind when you started screaming?"

A. "Stop screaming, and walk with me outside"

Andie is a patient anxiously waiting her turn to speak with you. As you are very busy, you ask Andie if she can wait a few minutes so that you can finish your task. Unfortunately the task takes longer than anticipated and you are delayed getting back to Andie. On seeing you approach her, Andie accuses you of lying and refuses to speak with you. Which response is most likely to be therapeutic at this time? A. "you are angry that I didn't speak with you when I promised I would" B. "I'm sorry for being late, but screaming at me is not the best way to handle it." C. "You are too angry to talk right now. I'll come back in 20 minutes and we can try again." D. "Why are you angry? I told you I was busy and would get to you as soon as I could."

A. "you are angry that I didn't speak with you when I promised I would"

Which assessment finding is the best predictor of violence in a newly admitted client? A. A recent assault on a drinking companion B. A family history of bipolar disorder C. The nurse's subjective feeling that the client is uncooperative. D. A childhood history of being bullied at school

A. A recent assault on a drinking companion. The best predictor of violence is past episodes of violent behavior.REF: 517

You respond to a loud, angry voice coming from the day room, where you find Alex is pacing and shouting that he isn't "going to take his (expletive) anymore." which of the following responses is likely to be helpful in de-escalating Alex? Select all that apply A. Remain calm, quiet, and in control B. Tell Alex that his actions are unacceptable and that he must go to his room C. Match Alex's volume so that he is able to hear over his own shouting D. Ask Alex if he can tell you what is upsetting him so you may be able to help E. Sand close to Alex so you can intervene physically if needed to protect others F. Tell Alex that he could be placed in seclusion if he cannot control himself so that the patient is aware of the negative consequences

A. Remain calm, quiet, and in control D. Ask Alex if he can tell you what is upsetting him so you may be able to help

Which would be the most appropriate response by the nurse to help a client who is demonstrating escalating anger? A. Walk the client to his room and help him practice stress-reduction techniques, such as deep breathing or muscle relaxation B. Suggest that the client spend some time in the gym with a punching bag to relieve his stress C. Suggest that the client spend some time pacing rapidly in the hallway until he feels less stressed D. Sit with the client in the day room so that he can vent his anger and not isolate himself

A. Walk the client to his room and help him practice stress-reduction techniques, such as deep breathing or muscle relaxation In settings in which the staff can reasonably expect episodes of client anger and aggression, regular teaching and practice of verbal and nonverbal interventions are essential. The most appropriate response by the nurse would be to help the client to a quiet environment and teach or coach the client to use positive coping skills.REF: 520

The most restrictive method for dealing with an aggressive client who is out of control is A. seclusion. B. a show of force. C. verbal intervention. D. antipsychotic medication.

A. seclusion Seclusion is the most restrictive method listed, because it curtails the client's freedom of ambulation.REF: 521-522

The more a nurse's intervention is prompted by emotion A. the less likely it is to be therapeutic B. the less likely it is to be aggressive C. the more likely it is to be effective. D. the more likely it is to be empathetic.

A. the less likely it is to be therapeutic. One study reported in the text found that the nurse's response to anger from a client varied according to the interpretation given to the client's anger and to the nurse's self-appraised ability to manage the situation. Only when self-efficacy was perceived as adequate did the nurse move to help the client. When self-efficacy was not seen as adequate, nurses showed a decreased ability to process the client's message and a decreased ability to problem-solve.REF: 518-519

Ian makes the following statements to you while admitting him. Which statement indicates and increased likelihood of violent behavior? A. "When I get mad, I want to be left alone" B. "Last time I was in here I ended up in seclusion for punching my roommate C. "My old man was meek and mild, and I've always said I'm not going to be like him" D. "My girlfriend says I yell way too much, and she's threatened to leave me."

B. "Last time I was in here I ended up in seclusion for punching my roommate

A nurse is assessing a client in an inpatient mental health unit. Which of the following findings should the nurse expect if the client is in the preassaultive stage of violence? (select all that apply) A. Lethargy B. Defensive responses to questions C. Disorientation D. Facial grimacing E. Agitation

B. Defensive responses to questions D. Facial grimacing E. Agitation

When you approach Katy, what considerations should you take? A. Stand close to Katy for reassurance and to convey caring. B. Have other staff as backup, and stand far enough away to avoid injury. C. Take Katy to her room so you can speak with her alone. D. Call security and wait until they arrive before approaching Katy.

B. Have other staff as backup, and stand far enough away to avoid injury. Safety considerations for staff include enlisting other staff to be present, keeping a safe distance from the patient, and approaching the patient in a nonthreatening or nonconfrontational manner. The other options do not allow for staff safety; security personnel may escalate the patient's behavior and should be kept in the background until needed to assist. Furthermore, the patient has an immediate need to be assisted by staff if possible without waiting for security.Cognitive Level: Analyze (Analysis)Nursing Process: PlanningNCLEX: Safe and Effective Care EnvironmentText page: 520

Which neurotransmitter imbalance has been shown to be related to impulsive aggression? A. Low levels of ã-aminobutyric acid B. Low levels of serotonin C. High levels of dopamine D. High levels of acetylcholine

B. Low levels of serotonin Low serotonin levels have been implicated in several research studies as being a factor in impulsive aggression.REF: 516

A nurse is caring for a client who is speaking in a loud voice with clenched fists. Which of the following actions should the nurse take? A. Insist that the client stop yelling B. Request that other staff members remain close by C. Move as close to the client as possible D. Walk away from the client

B. Request that other staff members remain close by

Which nursing diagnosis is the priority when planning care for a client who displays considerable anger and occasional aggression? A. Social isolation B. Risk for other-directed violence C. Ineffective coping: overwhelmed D. Ineffective coping: maladaptive

B. Risk for other-directed violence Risk for other-directed violence is the priority diagnosis. The nurse then must determine which of two other diagnoses—ineffective coping: overwhelmed or ineffective coping: maladaptive—is appropriate. Social isolation is not an initial concern.REF: 519

An angry client frequently loses patience with the nurses and shouts at them while they perform a complicated dressing change. Which plan could they create to intervene effectively in this behavior? A. Tell him they will not change his dressing if he is going to abuse them. B. When the client begins to become abusive, leave the room promising to return in 20 minutes when he has regained control. C. Assure him they will complete the dressing change as quickly as possible. D. Explain that they are professionals and unused to being shouted at by people they are trying to help.

B. When the client begins to become abusive, leave the room promising to return in 20 minutes when he has regained control. The nurse is using behavioral techniques to reinforce desirable behavior (spending time with the client when he is calm) and limit reinforcement of undesirable behavior (leaving when he is acting out anger).REF: Page 521, 525

When a client diagnosed with a cognitive deficit experiences a catastrophic reaction, the priority intervention is to A. decrease sensory stimuli. B. smile and call the client by name. C. take the client to the bathroom. D. calmly ask the client what's wrong. b

B. smile and call the client by name. Getting the client's attention by calling his or her name is necessary. Smiling is necessary to convey the lack of a threat.REF: Page 527

One older concept that is being used currently that may help in violence reduction in patients is: A. aired grievances. B. trauma-informed care. C. shared governance. D. learned helplessness.

B. trauma-informed care.' Trauma-informed care is an older concept of providing care that has been reintroduced. It is based on the notion that disruptive patients often have histories that include violence and victimization. These traumatic histories can impede patients' ability to self-soothe, result in negative coping responses, and create a vulnerability to coercive interventions (e.g., restraint) by staff. Trauma-informed care focuses on the patients' past experiences of violence or trauma and the role it currently plays in their lives. The other options do not refer to a care concept that helps reduce violence.Cognitive Level: Understand (Comprehension)Nursing Process: PlanningNCLEX: Psychosocial IntegrityText page: 517

You are caring for Malcolm, an 83 y/o African American patient with Alzheimer's disease. Malcolm exhibits agitated behavior at times, especially when he feels he is missing work, and he sometimes attempts to leave the unit to " get to the school where I teach. " which of the following interventions is appropriate for de-escalating Malcolm's agitation. A. Medicate Malcolm with PRN medication at regular intervals to prevent agitation B. Repeatedly explain to Malcolm that he is retired and no longer teaches as the repetition will reinforce the patient's orientation C . Use validation therapy and ask Malcolm about the school and his job D. Reduce stimulation In the environment by having Malcolm sit by himself in his room until the agitation passes

C . Use validation therapy and ask Malcolm about the school and his job

Which statementt about violence and nursing is accurate? A. Unless working in psychiatric mental health settings, nurses are unlikely to experience patient violence B. To date, no legislation exists that addresses workplace violence against nurses C. Emergency, psychiatric, and step-down units have the highest rates of violence towards staff D. Violence primarily affects inexperienced or unskilled staff who cannot calm their patients

C. Emergency, psychiatric, and step-down units have the highest rates of violence towards staff

A nurse is caring for a client in an inpatient mental health facility who gets up from a chair and throws it across the day room. Which of the following is the priority nursing action? A. Encourage the client to express her feelings B. Maintain eye contact with the client C. Move the client away from others D. Tell the client that the behavior is not acceptable

C. Move the client away from others

The factor most likely to contribute to a client's escalating anger is A. watching violence on television. B. another client's depressed mood. C. a staff member telling him that he is inappropriate. D. a staff member asking him to help another client.

C. a staff member telling him that he is inappropriate. Punitive, threatening, accusatory, or challenging statements to the client should be avoided; rather, the nurse should determine what is behind the client's feelings and behaviors.REF: 520

When working with an angry client, it is best to A. encourage the client to fully explore and express his or her anger. B. help the client deny and repress the feelings of anger C. help the client reframe the anger-producing situation. D. ignore the client's anger and change the subject.

C. help the client reframe the anger-producing situation. De-escalation occurs more quickly with this strategy than when other approaches are used.REF: 518-519

An adolescent male is swearing and shouting at his physician, who refused to give him a pass to leave the unit. This behavior A. is acceptable if directed at staff but not when directed at other clients. B. may reduce tension and prevent the client from physically acting out. C. is a major indicator that the client may become physically aggressive. D. can be attributed to lack of parental controls applied at an early age.

C. is a major indicator that the client may become physically aggressive. Physical aggression is preceded by anger, which may be expressed by swearing and shouting, pacing, and other menacing behaviors.REF: Page 520

4. Because an intervention was required to control a patients aggressive behavior, the nurse plans a critical incident debriefing with staff members. Which topics should be the primary focus of this discussion? Select all that apply. a. Patient behaviors associated with the incident b. Genetic factors associated with aggression c. Intervention techniques used by the staff d. Effects of environmental factors e. Theories of aggression

a. Patient behaviors associated with the incident c. Intervention techniques used by the staff d. Effects of environmental factors The patients behavior, the intervention techniques used, and the environment in which the incident occurred are important to establish realistic outcomes and effective nursing interventions. Discussing views about the theoretical origins of aggression would be less effective and relevant.

1. A patient with a history of command hallucinations approaches the nurse yelling obscenities. Which nursing actions are most likely to be effective in de-escalation for this scenario? Select all that apply. a. Stating the expectation that the patient will stay in control b. Asking the patient, Do you want to go into seclusion? c. Telling the patient, You are behaving inappropriately. d. Offering to provide the patient with medication to help e. Speaking in a firm but calm voice

a. Stating the expectation that the patient will stay in control d. Offering to provide the patient with medication to help e. Speaking in a firm but calm voice Stating the expectation that the patient will maintain control of behavior reinforces positive, healthy behavior and avoids challenging the patient. Offering as-needed medication provides support for the patient trying to maintain control. A firm but calm voice will likely comfort and calm the patient. Belittling remarks may lead to aggression. Criticism will probably prompt the patient to begin shouting.

1. Which behavior best demonstrates aggression? a. Stomping away from the nurses station, going to the hallway, and grabbing a tray from the meal cart. b. Bursting into tears, leaving the community meeting, and sitting on a bed hugging a pillow and sobbing. c. Telling the primary nurse, I felt angry when you said I could not have a second helping at lunch. d. Telling the medication nurse, I am not going to take that, or any other, medication you try to give me.

a. Stomping away from the nurses station, going to the hallway, and grabbing a tray from the meal cart. 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. Refusing medication is a patients right and may be appropriate. The other incorrect options do not feature violation of anothers rights.

6. A patient who was responding to auditory hallucinations earlier in the morning now approaches the nurse shaking a fist and shouts, Back off! and then goes to the day room. While following the patient into the day room, the nurse should: a. make sure there is adequate physical space between the nurse and patient. b. move into a position that places the patient close to the door. c. maintain one arms-length distance from the patient. d. begin talking to the patient about appropriate behavior.

a. make sure there is adequate physical space between the nurse and patient. Making sure space is present between the nurse and the patient avoids invading the patients personal space. Personal space needs increase when a patient feels anxious and threatened. Allowing the patient to block the nurses exit from the room may result in injury to the nurse. Closeness may be threatening to the patient and provoke aggression. Sitting is inadvisable until further assessment suggests the patients aggression is abating. One arms length is inadequate space.

7. A nurse named Darryl has been hired to work in a psychiatric intensive care unit. He has undergone training on recognizing escalating anger. Which statement indicates that he understands danger signs in regard to aggression? a. "I need to be aware of patients who are withdrawn and sitting alone." b. "An obvious change in behavior is a risk factor for aggression." c. "Patients who seek constant attention are more likely to be violent." d. "Patients who talk to themselves are the most dangerous."

b. "An obvious change in behavior is a risk factor for aggression."

2. A newly admitted male patient has a long history of aggressive behavior toward staff. Which statement by the nurse demonstrates the need for more information about the use of restraint? a. "If his behavior warrants restraints, someone will stay with him the entire time he's restrained." b. "I'll call the primary provider and get an as needed (prn) seclusion/restraint order." c. "If he is restrained, be sure he is offered food and fluids regularly." d. "Remember that physical restraints are our last resort."

b. "I'll call the primary provider and get an as needed (prn) seclusion/restraint order."

18. A patient has a history of impulsively acting out anger by striking others. Select the most appropriate intervention for avoiding similar incidents. a. Teach the patient about herbal preparations that reduce anger. b. Help the patient identify incidents that trigger impulsive anger. c. Explain that restraint and seclusion will be used if violence occurs. d. Offer one-on-one supervision to help the patient maintain control.

b. Help the patient identify incidents that trigger impulsive anger. Identification of trigger incidents allows the patient and nurse to plan interventions to reduce irritation and frustration, which lead to acting out anger, and eventually to put into practice more adaptive coping strategies.

10. An adult patient assaulted another patient and was then restrained. One hour later, which statement by the restrained patient requires the nurses immediate attention? a. I hate all of you! c. You wait until I tell my lawyer. b. My fingers are tingly. d. The other patient started the fight.

b. My fingers are tingly. The correct response indicates impaired circulation and necessitates the nurses immediate attention. The incorrect responses indicate the patient has continued aggressiveness and agitation.

24. A new patient acts out so aggressively that seclusion is required before the admission assessment is completed or orders written. Immediately after safely secluding the patient, which action is the nurse's priority? a. Complete the physical assessment. b. Notify the health care provider to obtain a seclusion order. c. Document the incident objectively in the patient's medical record. d. Explain to the patient that seclusion will be discontinued when self-control is regained

b. Notify the health care provider to obtain a seclusion order. Emergency seclusion can be affected by a credentialed nurse but must be followed by securing a medical order within a period of time specified by the state and the agency. The incorrect options are not immediately necessary from a legal standpoint. See related audience response question.

17. A patient with a history of anger and impulsivity was hospitalized after an accident resulting in injuries. When in pain, the patient loudly scolded nursing staff for not knowing enough to give me pain medicine when I need it. Which nursing intervention would best address this problem? a. Teach the patient to use coping strategies such as deep breathing and progressive relaxation to reduce the pain. b. Talk with the health care provider about changing the pain medication from PRN to patient-controlled analgesia. c. Tell the patient that verbal assaults on nurses will not shorten the wait for analgesic medication. d. Talk with the patient about the risks of dependency associated with overuse of analgesic medication.

b. Talk with the health care provider about changing the pain medication from PRN to patient-controlled analgesia. Use of patient-controlled analgesia will help the patient manage the pain. This intervention will help reduce the patients anxiety and anger. Dependency is not an important concern related to acute pain.

7. An intramuscular dose of antipsychotic medication needs to be administered to a patient who is becoming increasingly more aggressive and refused to leave the dayroom. The nurse should enter the day room: a. and say, Would you like to come to your room and take some medication your health care provider prescribed for you? b. accompanied by 3 staff members and say, Please come to your room so I can give you some medication that will help you regain control. c. and place the patient in a basket-hold and then say, I am going to take you to your room to give you an injection of medication to calm you. d. accompanied by a male security guard and tell the patient, Come to your room willingly so I can give you this medication, or the guard and I will take you there.

b. accompanied by 3 staff members and say, Please come to your room so I can give you some medication that will help you regain control. A patient gains feelings of security if he or she sees others are present to help with control. The nurse gives a simple direction, honestly states what is going to happen, and reassures the patient that the intervention will be helpful. This positive approach assumes the patient can act responsibly and will maintain control. Physical control measures are used only as a last resort.

8. After an assault by a patient, a nurse has difficulty sleeping, startles easily, and is preoccupied with the incident. The nurse said, That patient should not be allowed to get away with that behavior. Which response poses the greatest barrier to the nurses ability to provide therapeutic care? a. Startle reactions c. A wish for revenge b. Difficulty sleeping d. Preoccupation with the incident

c. A wish for revenge The desire for revenge signals an urgent need for professional supervision to work through anger and counter the aggressive feelings. Feelings of revenge create a risk for harm to the patient. The distracters are normal in a person who was assaulted. They usually are relieved with crisis intervention, help the individual regain a sense of control, and make sense of the event.

8. An effective method of preventing escalation in an environment with violent offenders is to develop a level of trust through: a. A casual authoritative demeanor b. Keeping patients busy c. Brief, frequent, nonthreatening encounters d. Threats of seclusion or punishment

c. Brief, frequent, nonthreatening encounters

19. A patient with severe injuries is irritable, angry, and belittles the nurses. As a nurse changes a dressing, the patient screams, Dont touch me! You are so stupid. You will make it worse! Which intervention uses a cognitive technique to help the patient? a. Wordlessly discontinue the dressing change and then leave the room. b. Stop the dressing change, saying, Perhaps you would like to change your own dressing. c. Continue the dressing change, saying, This dressing change is needed so your wound will not get infected. d. Continue the dressing change, saying, Unfortunately, you have no choice in this because your health care provider ordered this dressing change.

c. Continue the dressing change, saying, This dressing change is needed so your wound will not get infected. Anger is cognitively driven. The answer helps the patient test his cognitions and may lead to lowering his anger. The incorrect options will escalate the patients anger by belittling or escalating the patients sense of powerlessness.

6. John Patrick is a widower with four daughters. He has enjoyed a healthy relationship with all of them until they reached puberty. As each girl began to mature physically, he acted in an aggressive manner, beating her without provocation. John Patrick is most likely acting on: a. Self-protective measures b. Stress of raising four daughters c. Frustration of unhealthy desire d. Motivating his daughters to be chaste

c. Frustration of unhealthy desire

5. A patient is pacing the hall near the nurses station, swearing loudly. An appropriate initial intervention for the nurse would be to address the patient by name and say: a. What is going on? b. Please be quiet and sit down in this chair immediately. c. I'd like to talk with you about how you're feeling right now. d. You must go to your room and try to get control of yourself.

c. I'd like to talk with you about how you're feeling right now. Intervention should begin with analysis of the patient and the situation. When anger is escalating, a patients ability to process decreases. It is important to speak to the patient slowly and in short sentences, using a low and calm voice. Use open-ended statements designed to hear the patients feelings and concerns. This leads to the next step of planning an intervention.

20. Which medication from the medication administration record should a nurse administer to provide immediate intervention for a psychotic patient whose aggressive behavior continues to escalate despite verbal intervention? a. Lithium (Eskalith) c. Olanzapine (Zyprexa) b. Trazodone (Desyrel) d. Valproic acid (Depakene)

c. Olanzapine (Zyprexa)

2. Which scenario predicts the highest risk for directing violent behavior toward others? a. Major depression with delusions of worthlessness b. obsessive-compulsive disorder; performs many rituals c. Paranoid delusions of being followed by alien monsters d. Completed alcohol withdrawal; beginning a rehabilitation program

c. Paranoid delusions of being followed by alien monsters Patients who are delusional, hyperactive, impulsive, or predisposed to irritability are at higher risk for violence. The patient in the correct response has the greatest disruption of ability to perceive reality accurately. People who feel persecuted may strike out against those believed to be persecutors. The other patients have better reality-testing ability.

21. An emergency department nurse realizes that the spouse of a patient is becoming increasingly irritable while waiting. Which intervention should the nurse use to prevent further escalation of the spouses anger? a. Offer the waiting spouse a cup of coffee. b. Explain that the patient's condition is not life threatening. c. Periodically provide an update and progress report on the patient. d. Suggest that the spouse return home until the patients treatment is complete.

c. Periodically provide an update and progress report on the patient. Periodic updates reduce anxiety and defuse anger. This strategy acknowledges the spouses presence and concern. A cup of coffee is a nice gesture, but it does not address the spouses feelings. The other incorrect options would be likely to increase anger because they imply that the anxiety is inappropriate.

16. A cognitively impaired patient has been a widow for 30 years. This patient frantically tries to leave the facility, saying, I have to go home to cook dinner before my husband arrives from work. To intervene with validation therapy, the nurse will say: a. You must come away from the door. b. You have been a widow for many years. c. You want to go home to prepare your husbands dinner? d. Your husband gets angry if you do not have dinner ready on time?

c. You want to go home to prepare your husbands dinner? Validation therapy meets the patient where she or he is at the moment and acknowledges the patients wishes. Validation does not seek to redirect, reorient, or probe. The distracters do not validate the patients feelings.

10. Chronic obstructive pulmonary disease, spinal injury, seizure disorder, and pregnancy are conditions that: a. Frequently result in out of control behavior. b. Respond well to therapeutic holding. c. Necessitate the use of only two-point restraint. d. Contraindicate restraint and seclusion.

d. Contraindicate restraint and seclusion.

3. A patient was arrested for breaking windows in the home of a former domestic partner. The patients history also reveals childhood abuse by a punitive parent, torturing family pets, and an arrest for disorderly conduct. Which nursing diagnosis has priority? a. Risk for injury c. Impaired social interaction b. Ineffective coping d. Risk for other-directed violence

d. Risk for other-directed violence Defining characteristics for risk for other-directed violence include a history of being abused as a child, having committed other violent acts, and demonstrating poor impulse control. There is no indicator that the patient will experience injury. Ineffective coping and impaired social interaction have lower priorities.

4. A confused older adult patient in a skilled nursing facility was asleep when unlicensed assistive personnel (UAP) entered the room quietly and touched the bed to see if it was wet. The patient awakened and hit the UAP in the face. Which statement best explains the patients action? a. Older adult patients often demonstrate exaggerations of behaviors used earlier in life. b. Crowding in skilled nursing facilities increases an individuals tendency toward violence. c. The patient learned violent behavior by watching other patients act out. d. The patient interpreted the UAPs behavior as potentially harmful.

d. The patient interpreted the UAPs behavior as potentially harmful. Confused patients are not always able to evaluate the actions of others accurately. This patient behaved as though provoked by the intrusive actions of the staff.

14. A patient sat in silence for 20 minutes after a therapy appointment, appearing tense and vigilant. The patient abruptly stood, paced back and forth, clenched and unclenched fists, and then stopped and stared in the face of a staff member. The patient is: a. demonstrating withdrawal. b. working though angry feelings. c. attempting to use relaxation strategies. d. exhibiting clues to potential aggression.

d. exhibiting clues to potential aggression. The description of the patients behavior shows the classic signs of someone whose potential for aggression is increasing.

13. An emergency code was called after a patient pulled a knife from a pocket and threatened, I will kill anyone who tries to get near me. The patient was safely disarmed and placed in seclusion. Justification for use of seclusion was that the patient: a. was threatening to others. b. was experiencing psychosis. c. presented an undeniable escape risk. d. presented a clear and present danger to others.

d. presented a clear and present danger to others. The patients threat to kill self or others with the knife he possessed constituted a clear and present danger to self and others. The distracters are not sufficient reasons for seclusion.

22. Which information from a patients record would indicate marginal coping skills and the need for careful assessment of the risk for violence? A history of: a. academic problems. c. childhood trauma. b. family involvement. d. substance abuse.

d. substance abuse. The nurse should suspect marginal coping skills in a patient with substance abuse. They are often anxious, may be concerned about inadequate pain relief, and may have personality styles that externalize blame. The incorrect options do not signal as high a degree of risk as substance abuse.

23. Family members describe the patient as a difficult person who finds fault with others. The patient verbally abuses nurses for their poor care. The most likely explanation lies in: a. poor childrearing that did not teach respect for others. b. automatic thinking leading to cognitive distortions. c. a personality style that externalizes problems. d. delusions that others wish to deliver harm.

c. a personality style that externalizes problems. Patients whose personality style causes them to externalize blame see the source of their discomfort and anxiety as being outside themselves. They displace anger and are often unable to self-soothe. The incorrect options are less likely to have a bearing on this behavior.

11. Which is an effective nursing intervention to assist an angry patient learn to manage anger without violence? a. Help a patient identify a thought that produces anger, evaluate the validity of the belief, and substitute reality-based thinking. b. Provide negative reinforcement such as restraint or seclusion in response to angry outbursts, whether or not violence is present. c. Use aversive conditioning, such as popping a rubber band on the wrist, to help extinguish angry feelings. d. Administer an antipsychotic or anti-anxiety medication.

a. Help a patient identify a thought that produces anger, evaluate the validity of the belief, and substitute reality-based thinking. Anger has a strong cognitive component, so using cognition techniques to manage anger is logical. The incorrect options do nothing to help the patient learn anger management.

4. Which guidelines should direct nursing care when deescalating an angry patient? Select all that apply. a. Intervene as quickly as possible b. Identify the trigger for the anger c. Behave calmly and respectfully d. Recognize the patient's need for increased personal space e. Demands are agreed to as long as they won't result in harm to anyone

a. Intervene as quickly as possible b. Identify the trigger for the anger c. Behave calmly and respectfully d. Recognize the patient's need for increased personal space

15. A patient with multi-infarct dementia lashes out and kicks at people who walk past in the hall of a skilled nursing facility. Intervention by the nurse should begin by: a. gently touching the patients arm. b. asking the patient, What do you need? c. saying to the patient, This is a safe place. d. directing the patient to cease the behavior.

c. saying to the patient, This is a safe place. Striking out usually signals fear or that the patient perceives the environment to be out of control. Getting the patients attention is fundamental to intervention. The nurse should make eye contact and assure the patient of safety. Once the nurse has the patients attention, gently touching the patient, asking what he or she needs, or directing the patient to discontinue the behavior may be appropriate.