Chapter 11: Anger, Hostility, and Aggression (Prep U)

The nurse is caring for a client with rheumatoid arthritis. Upon entering the client's room, the nurse finds that the client is very angry and is punching pillows to express the anger. What should be the nurse's response to this behavior? Select the best answer. "Please do not damage the hospital's property." "I am sure your anger would be reduced by punching the pillows." "I am here so we can talk about what is making you angry." "I appreciate that you are expressing anger in an appropriate manner."

"I am here so we can talk about what is making you angry." Expression of anger by engaging in aggressive but safe activities like punching a pillow is referred to as catharsis. It is now known that this behavior increases feelings of anger rather than alleviate them. The nurse knows that encouraging the client to engage in nonaggressive activities, such as speaking with someone, is more likely to reduce the anger. Asking the client to not damage the hospital's property indicates that the nurse is more concerned about property than the client. Telling the client that the anger would be reduced by punching pillows indicates that the nurse is encouraging the client to express anger through catharsis. Expressing appreciation to the client for expressing anger in an appropriate manner encourages expression of anger through catharsis.

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

"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.

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? "I usually approach the person directly to talk about it." "I try to discuss how I'm feeling about it with a close friend." "I've been known to fly off the handle when I'm angry." "People say I withdraw and pout about the problem."

"People say I withdraw and pout about the problem." Anger suppression is characterized by acting as though nothing has happened; withdrawing from people; and sulking, pouting, or ruminating. Unhealthy, outward anger expression is characterized by flying off the handle or expressing anger in an attacking or blaming way, yelling, or using profanity. Approaching a person directly to talk about it, or discussing how the person feels with a close friend, reflects constructive anger discussion.

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 happens when you get angry?" "Do you feel that you can manage your reactions with anger?" "Do you know why you are being admitted?" "What did you learn about anger when growing up?"

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

"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. Administering medications and making sure that others know where the nurse is may be helpful but it depends on the situation. Confronting the client should be avoided.

The nurse is working with a client who yells at the nurse "I am angry about how you keep treating me without respect!" What is the nurse's best response? "Do you need to take your medication to help calm down?" "I am not going to talk to you while you are angry." "If you don't calm down, I will need you to go to your room." "Why do you think I am not being respectful to you?"

"Why do you think I am not being respectful to you?" The nurse needs to be authentic with the client and try to determine what behavior is interpreted as not being respectful. While it is hard not to feel defensive when being targeted in this way, the nurse does not need to threaten the client with medication or send the client to his or her room. The nurse also doesn't need to ignore the client's feeling but instead stay engaged with the client to try to help understand the client's feelings.

Which describes a strong emotional response to a real or perceived provocation? Physical aggression Hostility Anger Catharsis

Anger 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.

Seclusion and restraint are nursing interventions to be used for an individual in which situation? Observed pacing quickly on the unit Refusing to take a PRN medication when offered for agitation As a last resort As an initial consideration to a client with a history of violence who is shouting at a coclient

As a last resort Seclusion and restraint are controversial interventions to be used judiciously and only when other interventions have failed to control the client's behavior.

Which term is used to describe an activity used to release anger? Catharsis Physical aggression Anger Hostility

Catharsis Catharsis includes activities that provide a release of the anger. Hostility is an emotion expressed through verbal abuse, lack of cooperation, violation of rules or norms, or threatening behavior. Anger is a strong, uncomfortable, emotional response to a real or perceived provocation. Physical aggression is behavior in which a person attacks or injures another person or that involves destruction of property.

The nurse is planning the environment for a newly-admitted client with a history of violence toward others. Which modification would the nurse implement? Place the client in a semi-private room with another client. Confirm that the utility and storage rooms are kept locked. Provide the client metal hangers instead of plastic hangers in closet. Ensure the client is at the end of the hall away from the nurse's station.

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.

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 Extreme aggression Abdominal pain Hallucinations Confusion

Confusion Hallucinations Extreme aggression 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 which phase of the aggression cycle can techniques of seclusion or restraint be used to deal with the aggression quickly? Recovery Crisis Triggering Escalation

Crisis 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? Crisis Triggering Recovery Escalation

Crisis The client's signs of shouting, screaming, hitting others, and throwing objects suggest that the client is in crisis phase of the aggression cycle. This phase is characterized by loss of emotional and physical control. In the triggering phase, the client often becomes angry in response to an event or circumstance in the environment. In the escalation phase, the client may move toward a loss of control. In the recovery phase, the client regains the 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? Manic behaviors Panic disorder Meneire's disease Depression

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? Avoidance of stimuli that provoke the anger Client self-monitoring for anger cues Identification of measures to disrupt the anger response Development of a therapeutic relationship

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.

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 Providing the client with a list of possible goals for behavior change Talking excessively with the client in front of other clients Asking personal questions when they are inappropriate

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 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? Ask the client if the client feels triggered by another client in the group Encourage the client to engage in a relaxation exercise prior to joining the group the the rest of the session Ask another client in the group to respond to the client's comment Explore what is underlying the client's physical and emotional state

Explore what is underlying the client's physical and emotional state 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.

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 verbally. Has paranoid delusions. Expresses anger by acting out. Exhibits physical aggression. Feels guilty for inappropriate anger reaction.

Expresses anger verbally. Feels guilty for inappropriate anger reaction. 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. Request the presence of additional staff. Give the client plenty of space. Encourage the client to talk about this situation Restrain the client. Sit in an open area

Give the client plenty of space. Sit in an open area Request the presence of additional staff. 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 term is used to describe an emotion expressed through verbal abuse and violation of rules or norms? Anger Hostility Physical aggression Catharsis

Hostility Hostility is an emotion expressed through verbal abuse, lack of cooperation, violation of rules or norms, or threatening behavior. Anger is a strong, uncomfortable, emotional response to a real or perceived provocation. Catharsis includes activities that provide a release of the anger. Physical aggression is behavior in which a person attacks or injures another person or that involves destruction of property.

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

Immediately approach the client to engage in communication 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.

Which drug has been effective in treating aggressive clients diagnosed with bipolar disorders? Valproic acid Clozapine Carbamazepine Lithium

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? Carbamazepine Haloperidol Lorazepam Valproate

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? Therapeutic relationship Assertive behavior Mindfulness Low self-esteem

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.

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. Restrain the client Inform the client medication is required Ensure availability of assistance Monitor emotional responses Monitor facial expressions

Monitor facial expressions Monitor emotional responses Ensure availability of assistance 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's response to aggressive behavior on the unit is influenced by the which ability of the nurse? Recognition of client acting out Own awareness and reaction to aggression Actions of not responding to the escalating behavior Losing control and acting defensively

Own awareness and reaction to aggression Nurses' beliefs about themselves as individuals and professionals will influence their responses to aggressive behaviors.

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? Orientation Hunger and thirst Mood and affect Perceptions and delusions

Perceptions and delusions 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.

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

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.

During which phase of the aggression cycle does the staff usually have a debriefing session? Postcrisis Triggering Escalation Recovery

Recovery During the recovery phase, the staff has a debriefing session to discuss the aggressive episode.

The nurse is demonstrating de-escalation techniques on an aggressive client in a forensic setting. Which is the best explanation of this technique? Role modeling expected behavior by staff Stopping dangerous behavior by pointing out unacceptable behavior Resolution of anger in nonviolent ways Increasing self-awareness of early signs of aggression

Resolution of anger in nonviolent ways The primary goal of de-escalation is to resolve angry or violent conflicts in nonviolent ways. Stopping dangerous behavior by pointing out unacceptable behavior is behavior correction. Role modeling is one part of behavior correction. Early recognition involves increase client self-awareness of early signs of their aggressive behavior and reinforces self-management skills that decrease the likelihood of using aggression in future situations.

A client has been admitted to the detoxification unit after binge drinking. Even though the client is not currently intoxicated, the client is combative and exhibits altered thought processes. Which nursing diagnosis would be the priority? Risk for self-mutilation related to alcohol withdrawal and altered thought processes Risk for other-directed violence related to alcohol withdrawal Risk for injury related to effects of alcohol abuse Risk for delayed development related to chronic effects of alcohol intoxication

Risk for other-directed violence related to alcohol withdrawal The priority nursing diagnosis is risk for other-directed violence related to alcohol withdrawal. The most common nursing diagnoses for clients experiencing intense anger and aggression are risk for self-directed violence and risk for other-directed violence. Although the other answers are possible nursing diagnoses, there is no evidence to support a risk for injury, self mutilation, or delayed development.

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

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

The nurse is caring for a client hospitalized in an inpatient psychiatric setting for a history of violent behaviors and delusions. The nurse should instruct the client's family that aggression has been linked to low levels of which bodily chemical? Endorphin Estrogen Serotonin Acetylcholine

Serotonin Low levels of serotonin have been linked to aggressive behaviors.

Aggression control can be measured by the nurse's observation of a client's ability to do what? Withhold his or her thoughts and feelings Show an increased tolerance for frustration Use increased doses of medication to reach a desired effect Display increasing motor activity

Show an increased tolerance for frustration 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? Place the client in a separate room. Take the client to the gym for exercise. Inform the client that restraints may be applied. Speak to the client in a firm voice.

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. Restraints are not required unless the client is a potential threat to safety of self and others. Talking to the client in a firm voice may increase the agitation of the client.

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

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.

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 has increased self-esteem. The client reports increased feelings of self-control. 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.

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 demonstrate the ability to exercise internal control over behavior. The client will withhold from harming others or damaging the hospital property. The client will not have auditory hallucinations. The client will demonstrate decreased acting out behavior. The client will not harm the self.

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. 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.

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

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. Furthermore, restraint and seclusion should be applied only when other less restrictive methods to ensure client safety have failed. Nonphysical interventions are the first choice.

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 express sadness instead of anger while facing unjust situations. Women are more aware about the health consequences related to inappropriate anger expression. Women have a greater threshold for controlling anger. Women are expected not to express so-called negative feelings like anger.

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? catharsis of anger constructive anger discussion anger suppression expressive anger

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. With constructive discussion, the client would have been able to talk to the roommate about reasons for yelling at the client. With expressive anger, the client would also be able to talk about the emotion of anger with either the roommate or a trusted source for advice.

The nurse is asking a client who has developed aggressive behavior about medical history. Which risk factors would the nurse want to explore related to aggression? Select all that apply. history of noncompliance with medications history of obsessive-compulsive disorder history of depression history of substance abuse history of schizophrenia

history of schizophrenia history of substance abuse history of noncompliance with medications

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? reduced use of restraints strict hierarchy of authority flexible unit rules scheduled unit activities

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? acceptance reflection confrontation validation

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.