Ch 11 - Anger, Hostility, and Aggression PrepU
An interpersonal offense such as unjust or disrespectful treatment (a spouse lying, a coworker taking advantage) often provokes anger. Within a couple relationship, anger in one partner can lead to an anger display in the other. Slow lines at the grocery store are an inconvenience and are a minor annoyance. Daily traffic jams can cause some to express rage; however, this is not an interpersonal relationship offense.
A client has been angry toward their partner. Which element(s) relate to an interpersonal offense? Select all that apply.
Inform the client that their behavior is out of control, and the staff is taking control to provide safety. When the client becomes physically aggressive (crisis phase), the staff must take charge of the situation for the safety of the client, staff, and other clients. The priority nursing action is to inform the client that their behavior is out of control and that the staff is taking control to provide safety and prevent injury. Once the client is safely restrained, the nurse can contact the health care provider and request an order for restraints and may obtain an order for intramuscular (IM) medication in this type of emergency situation. It would be unsafe to attempt to administer an IM medication to a client who is physically aggressive and not restrained.
A client has shown increasing amounts of frustration throughout the morning and attempts at de-escalation have not been successful. The client is now yelling, physically kicking the nurse's station and throwing items at other clients. What is the priority nursing action?
Intermittent explosive disorder involves inadequate production or functioning of serotonin. Other neurotransmitters such as dopamine, norepinephrine, or GABA are not involved.
A client is diagnosed with intermittent explosive disorder. The nurse understands that this disorder is associated with which neurotransmitter?
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 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?
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.
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 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.
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?
Coronary heart disease Suppressed anger is related to arthritis, breast and colorectal cancer, and hypertension. Excessive, outwardly directed anger is linked to coronary heart disease, reduced left ventricular ejection fraction, and myocardial infarction.
A group of new graduate nurses is reviewing information about maladaptive anger. The nurses demonstrate a need for additional review when they identify which physical condition as being linked to suppressed anger?
Experience of health problems and health professionals What is overlooked is the experience of the health problem or the experience of interactions with professionals. Inviting clients and families to talk about their previous experience with the health care system may highlight both their concerns and resources.
A nurse assesses a newly admitted client on the unit. When assessing the client in detail about his/her past medical history, it is important for the nurse to also explore which information about the client?
What is overlooked is the experience of the health problem or the experience of interactions with professionals. Inviting clients and families to talk about their previous experience with the health care system may highlight both their concerns and resources.
A nurse assesses a newly admitted client on the unit. When assessing the client in detail about his/her past medical history, it is important for the nurse to also explore which information about the client?
"It is okay to feel angry when confronted with an angry client." The nurse must be aware of how they deal with anger before helping clients do so. The nurse who is afraid of angry feelings may avoid a client's anger, which allows the client's behavior to escalate. If the nurse's response is angry, the situation can escalate into a power struggle, and the nurse loses the opportunity to "talk down" the client's anger. It is important to practice and gain experience in using techniques for restraint and seclusion before attempting them with clients in crisis. There is a risk of staff injury whenever a client is aggressive. Ongoing education and the practice of safe techniques are essential to minimize or avoid injury to both staff and clients. The nurse must be calm, nonjudgmental, and nonpunitive when using techniques to control a client's aggressive behavior. Therefore, the nurse's statement, "It is okay to feel angry when confronted with an angry client," would indicate a need for further teaching.
A nurse educator has executed an in-service about preventing workplace violence on a psychiatric mental-health unit. Which statement made by a nurse would indicate the need for further education?
The nurse discusses the difficulty of being able to sleep at night. The nurse who is experiencing a physiological response would potentially have difficulty sleeping; the nurse might also report headaches or stomachaches. The nurse who expresses fear and anxiety is having an affective response to the experience. The nurse seeking another job is having a cognitive response to the violence. The nurse eating alone is demonstrating a feeling of isolation, which is a behavioral response. All of these responses may indicate posttraumatic stress disorder (PTSD).
A nurse has been a victim of assault by a client. Which physiologic response would the nurse exhibit to indicate that there was a more long-term consequence for this event?
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 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.
"Would you rather go to the cafeteria or have dinner in the dayroom?" The nurse should try to provide clients with choices so that the client has some control over his/her situation. The choices should be concrete rather than open-ended; therefore, the client having a choice on where to eat dinner would be considered concrete due to limited choices. Being able to select an outfit or an activity would be more open-ended. While having the client be visited in the room does give a choice between having visitors or not, this would have a negative consequence with not having visitors unless the visitors could come to the room.
A nurse is working with a client who has lost unit privileges due to inappropriate behavior. Which statement by the nurse demonstrates appropriate offering of choices?
Perceptions and delusions
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?
This is an example of destructive anger that alienates other people. Constructive anger can be a powerful force for asserting one's rights and achieving social justice. The client is projecting blame on the other client over the loss of their spouse, this coupled with their own angry feelings are projected verbally which is an ineffective coping mechanism. The client does not need to be placed in isolation for this outburst, but this does have to be addressed as an unacceptable behavior.
A nurse must be sensitive when dealing with clients. The client is angry at another client who is on the inpatient unit, even though there has been no real interaction between them. The client yells across the room, "It's because of you I lost my wife." What element(s) are likely the cause? Select all that apply.
Cognitive interventions are usually those that provide new ideas, opinions, information, or education about a particular problem. The nurse offers a cognitive intervention with the goal of inviting the client to consider other possibilities.
A nurse suggests that the client explores new ideas about a particular problem and considers other possibilities to reflect:
Self-awareness of reactions to aggression by others Nurses' beliefs about themselves as individuals and professionals influence their responses to aggressive behaviors. The nurse's self-awareness of responses to anger, including fear of others' anger and any tendency to become angry, will help the nurse maintain composure and use good judgment. The nurse should not respond to negative emotions with similar emotions; the nurse must be calm, nonjudgmental, and nonpunitive when using techniques to control a client's aggressive behavior. The nurse can become more skilled in these techniques through practice and by observing more experienced staff. The response to aggression does not depend on understanding the client's thought processes.
A nurse's response to aggressive behavior on the unit is influenced by which characteristic of the nurse?
"I will encourage my child to be age-appropriate independent." As a child matures, they are expected to develop impulse control and socially acceptable behavior. Positive relationships with parents, teachers, and peers; success in school; and the ability to be responsible for oneself foster the development of these qualities. Therefore, the parent's statement, "I will encourage my child to be age-appropriate independent," demonstrates effective understanding. The parent statements, "I should be isolating my child until their learn better impulse control," "I will do everything for my child so they can focus on better behavior," and "I will punish my child when they behave poorly," do not support better impulse control or socially acceptable behavior.
A parent of a child with poor impulse control is being counseled in an outpatient setting to adopt socially acceptable behavior. Which statement made by the parent demonstrates effective understanding?
"Has your parent suffered any traumatic injury to their brain recently?" Asking about injury to the brain would be most appropriate because the limbic system and cerebral cortex are the brain structures most frequently associated with aggressive behavior. Clients with a history of damage to the cerebral cortex are more likely to exhibit increased impulsivity, decreased inhibition, and decreased judgment than are those who have not experienced such damage. Schizophrenia and substance use disorders are also associated with violent behavior. Asking about previous problems with anger would be important to know but would not be the priority. Additionally, the person states that the parent has never done this before. Injury to the back of the head or neck is not associated with aggression.
An adult child brings their parent to the clinic and tells the nurse that their parent has begun to act strangely in the past few days, with unprovoked outbursts of anger. After the incidents, the parent expresses remorse for their outburst. The adult child says, "I've never seen my parent act this way." Which question is most appropriate for the nurse to ask next?
escalation There are five phases of the aggression cycle including triggering, escalation, crisis, recovery, and postcrisis. The triggering phase is an event or circumstance in the environment that initiates a client response, which is often anger or irritability. In the escalation phase, the client's response escalates toward a loss of control, which may include swearing, demanding, threatening, and hostile behavior. The crisis phase is during an emotional and physical crisis and the client may be throwing items, kicking, hitting, spitting, or screaming. The recovery phase is when the client regains control and lowers their voice and can communicate logically and rationally. The postcrisis phase is when the client attempts to reconcile with others and returns to their baseline functioning. In the postcrisis phase, the client may be crying, quiet, feeling remorseful, and apologetic. The client in the scenario is currently in the escalation phase.
An adult client in the emergency department (ED) is being treated for acute pancreatitis. Upon assessment, the client is yelling, swearing, and demanding the staff to various tasks. Which phase in the aggression cycle does the nurse identify that the client is in?
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 client regain physical and emotional control?
During the recovery phase, the staff has a debriefing session to discuss the aggressive episode.
During which phase of the aggression cycle does the staff usually have a debriefing session?
In the crisis phase, seclusion or restraint may be used to deal with aggression quickly.
In which phase of the aggression cycle can techniques of seclusion or restraint be used to deal with the aggression quickly?
Increased activity of dopamine is implicated in increased impulsivity and violent behavior as a result of changes in cognition and decreased emotional regulation.
Increased activity in which neurotransmitter is implicated in increased impulsivity and violent behavior?
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. The other options would not be appropriate for this situation.
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?
Create a therapeutic milieu. The goals of care for clients in an inpatient mental health facility include promoting safety and preventing violence. Actions to achieve these goals would be for the nurse to create a therapeutic milieu. Orienting to the care area, reviewing behavior expectations, and discussing consequences for aggression would be specific interventions for the plan of care and would be appropriate after the therapeutic milieu is established.
The nurse in the inpatient mental health facility is caring for a new client with a history of aggressive behavior. Which action would the nurse take to promote safety and prevent violent behavior from this client?
"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.
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?
The likely reasons for a client to expressing hostility toward the nurse are to frighten the nurse (intimidate the nurse) and to harm the nurse emotionally. Hostility or verbal aggression would not be useful for punishing the nurse or forcing the nurse into compliance. Resolving conflicts with the nurse may take place only if the client handles his or her anger toward the nurse appropriately.
The nurse is assessing a client who expresses extreme hostility toward the nurse. What may be the client's intentions? Select all that apply.
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 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.
intermittent explosive disorder Because anger and aggression can be symptomatic of many underlying psychiatric or medical disorders, any underlying disorder must be first identified and treated. Because the client's diagnostic tests were negative, the most appropriate condition that care would be planned is intermittent explosive disorder. This is the only anger-related disorder in the Diagnostic and Statistical Manual of Mental Disorders and is characterized by impulsive anger attacks that are aimed at harming people or destroying property. This disorder usually appears during the teen years and persists over the life course. There is no evidence that the client is experiencing low self-esteem, chronic frustration, or a borderline personality disorder.
The nurse is caring for a 17-year-old male client admitted for diagnosis and control of anger. Based upon the information in the medical record, for which condition would the nurse plan care for this client?
Be aware of potential personal bias about the client. Nurses are challenged to recognize and respond to microaggressions when caring for clients with mental health disorders. Self-awareness is essential to recognizing personal biases and identifying personal use of microaggression. According to the general aggression model, situational factors are cues that trigger memories of aggression; however, there is no evidence that the client is aggressive. Until the client is assessed, interventions to address aggression would not be appropriate. Expecting biochemical imbalances to affect the ability to control aggression demonstrates microaggression and would be an inappropriate action for the nurse to take.
The nurse is caring for a client from a culture that does not speak the dominant language. Which action would the nurse take to prevent microaggression when caring for this client?
Low levels of serotonin have been linked to aggressive behaviors.
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?
frontal lobe head injury 2 years ago There are several theories that can be used to help understand aggression and violence. In the biologic theory, the brain structures most frequently associated with aggressive behavior include the cerebral cortex, particularly the frontal and temporal lobes. The head injury to the frontal lobe would be the condition that possibly contributes to the client's aggression. Appendectomy, fractured arm, and arthroscopic surgery would not contribute to the client's aggressive behavior.
The nurse is caring for a client with a history of violent behavior. Which condition in the client's medical history would the nurse consider as contributing to this client's aggression?
Provide a snack and fluids frequently. The client with impaired verbal communication has trouble expressing basic needs such as hunger, thirst, and need to urinate. Having the urge to void can cause a client with dementia to have increasing agitation. Therefore, providing a snack and fluid can help keep the client from having agitation due to an unrecognized need. The client would not be medicated with an anti-anxiety medication or placed in restraints without first exploring basic physiologic needs. While the client would be safe with a staff member at the bedside, it does not address the physiological needs.
The nurse is caring for a client with dementia who has become increasingly agitated. Which is the best action for the nurse to perform?
"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.
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.
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 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?
Explaining the consequences the client will face if control is lost Giving the client an ultimatum is likely to foster hostile or aggressive behavior; the other measures are all appropriate for a client with a history of aggression.
The nurse is interviewing a client with a history of physical aggression. Which should the nurse avoid?
The age, gender, and race of a client are not considered predictors of potential aggression and violence; however, there is evidence of specific characteristics that may predict violent behavior. These characteristics include pacing, staring in an intimidating manner, and making sarcastic or demeaning comments. Changing the television channel and sitting in a chair with the eyes partially closed are not behaviors that suggest aggression or violence.
The nurse is observing clients in the recreation room in a mental health facility. Which behavior(s) indicate to the nurse that a client is at risk for demonstrating violence? Select all that apply.
The client is sitting in the dayroom reading a book. When the client is reading a book, the client may be amenable to the nurse's opening communication about managing anger. The optimal time to provide education for a client on techniques to manage anger and aggression is not when anger and violence are being exhibited. In those cases, the priority is to deescalate the situation and ensure the safety of everyone involved. Therefore, when the client is having an argument or threatening to hit someone else, that is not the best time to provide teaching. It is possible that the client will be receptive to teaching after an incident has resolved, when they may coached to reflect on the outcomes of their behavior and how things could have gone better. Eating lunch with family members is a social situation, and the client should not be interrupted for education until through socializing.
The nurse is planning education for a client who has exhibited aggression on techniques to manage anger. Which situation would be best for providing this education?
Anger can help a person to solve problems and make decisions, if handled appropriately. Anger also energizes the body physically by activating the fight or flight response, which helps the person focus their attention on the stressor. When handled inappropriately, anger can cause physical and emotional problems and, as such, does not improve emotional stability or help in increasing relaxation.
The nurse is teaching a group of clients in a juvenile detention center about anger management and the positive effects of anger, if handled appropriately. What advantages, as explained by the nurse, may be helpful to the clients? Select all that apply.
The client who is having an escalation of anger that may lead to violence needs to be given personal space. If the nurse wants to discuss the indication of anger that is observed, the nurse should approach the client calmly. Sometimes the best approach would be to ignore the client's behavior. The nurse would not want to prevent the client from leaving the dayroom as this would be a form of restraint. While medication may be necessary at some point, it is best to try other de-escalation techniques before this measure.
The nurse is working with a client who is glaring at the other clients and has begun to pace in the dayroom. In determining an intervention to prevent escalation to violence, which would the nurse choose? Select all that apply.
"I need to stop feeling angry or I won't be healthy." Anger becomes negative when the person denies it, suppresses it, or expresses it inappropriately. Possible consequences are physical problems such as migraine headaches, ulcers, or coronary artery disease, and emotional issues such as depression and low self-esteem. It is unreasonable to expect that one will never get angry; what is important is that the anger is appropriately managed.
The nurse leads an education session regarding the effect of suppressing anger on the body. Which statement by the client indicates a need for further teaching?
Angry or out-of-control behavior is highly influenced by contextual factors. Successful psychiatric stabilization and treatment in a hospital often depend on the nature of the unit itself. Documented times of increased violence include during mealtimes and when providing medications. Morning care, after group therapy, and during recreational activities are not identified as times when the risk for violence is increased.
The nurse manager of a mental health care area changes the process of hand-off report during change of shift to reduce the risk of aggressive episodes. Which additional time(s) would the nurse be concerned that the risk for aggression could occur? Select all that apply.
Escalation of behavior from calmness to violence may follow a pattern. The nurse could instruct the client to disrupt the pattern by counting to 10, doing something different, performing deep breathing, and leaving the situation. Explaining the reason for the anger will not break the pattern and would not be effective to deescalate the situation.
The nurse talks with a client who easily demonstrates aggressive behavior. Which action(s) would the nurse take to help the client maintain control? Select all that apply.
A client who has been yelling and progresses physical aggression is considered to be in the escalation phase of anger. The nurse must take control of the situation by providing directions to the client in a calm, firm voice. The client should be directed to take a time-out for cooling off in a quiet area or their room. The nurse should tell the client that aggressive behavior is not acceptable and that the nurse is there to help the client regain control. The client should be offered medications to help manage their emotions. Only if these interventions are unsuccessful should the nurse advance to obtaining assistance from other staff members. Having staff circle the client or restrain the client is inappropriate at this phase and likely to worsen rather than de-escalate the situation.
The psychiatric inpatient nurse hears yelling in the dayroom. The nurse enters the dayroom to find a client yelling and knocking over chairs. Which response(s) by the nurse would demonstrate an appropriate de-escalation technique? Select all that apply.
client with a history of hostile behavior Some people try to express their angry feelings by engaging in aggressive but safe activities such as hitting a punching bag or yelling. Such activities, called catharsis, are supposed to provide a release for anger. However, catharsis can increase rather than alleviate angry feelings. Therefore, cathartic activities may be contraindicated for clients who are currently or recently angry.
The recreational therapist plans to offer clients a punching bag to release tension in the exercise group. Which client should be counseled to participate in this activity with caution?
Lithium
Which drug has been effective in treating aggressive clients diagnosed with bipolar disorders?
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.
Which staff behaviors are most likely to trigger clients who are predisposed to aggressive or violent behavior?
