Chapter 11: Anger, Hostility, and Aggression

Acting out is a defense mechanism in which an individual reflects on the feelings that he or she is experiencing. True False

False

Anger is an abnormal emotion and should not be expressed. True False

False

Most people with mental illness are aggressive. True False

False

A history of victimization increases an individual's likelihood of exhibiting aggressive behavior. True False

True

Catharsis is an emotional release through the engagement in aggressive but safe activities. True False

True

Which phase of the aggression cycle is defined as occurring when an event or circumstance in the environment initiates the client's response? a. Triggering b. Recovery c. Escalation d. Crisis

a. Triggering Rationale: During the triggering phase of the aggression cycle, an event or circumstance in the environment initiates the client's response, which is often anger or hostility. None of the other phases of the cycle are focused on the initiation of the anger.

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

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

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

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

In which phase of the aggression cycle is the client removed from restraint or seclusion as soon as he or she meets the behavioral criteria? a. Postcrisis b. Escalation c. Crisis d. Triggering

a. Postcrisis Rationale: In the postcrisis phase, the client is removed from restraint or seclusion as soon as he or she meets the behavioral criteria. The client would not be able to demonstrate control in any of the other phases.

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

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

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

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

When interviewing a potentially violent or aggressive client, which environmental factor is the most important for the nurse to consider? a. The interview should take place in a calm and quiet area to reduce stimuli. b. Care should be taken that to make sure that other staff do not interrupt. c. Restraint devices should be in full view. d. The client should be told that violent behavior will not be tolerated.

a. The interview should take place in a calm and quiet area to reduce stimuli.

Which statements are examples of unacceptable behaviors under the JCAHO standards for a culture of safety? a. "According to your performance evaluation, you must decrease your absenteeism." b. "Don't page me again, I'm very busy." c. "If you tell my supervisor, you'll never hear the end of it." d. "I don't deserve to be yelled at." e. "I haven't seen such stupid behavior since grade school." f. "I request a different assignment today."

b. "Don't page me again, I'm very busy." c. "If you tell my supervisor, you'll never hear the end of it." d. "I don't deserve to be yelled at."

Which is an example of assertive communication? a. "I wish you would stop making me angry." b. "I feel angry when you walk away when I'm talking." c. "You never listen to me when I'm talking." d. "You make me angry when you interrupt me."

b. "I feel angry when you walk away when I'm talking."

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

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

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

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

The nurse is 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. a. Anger helps in increasing relaxation. b. Anger helps to focus attention. c. Anger helps in resolving conflicts. d. Anger helps in improving emotional stability. e. Anger helps in decision making.

b. Anger helps to focus attention. c. Anger helps in resolving conflicts. e. Anger helps in decision making. Rationale: 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.

Which statement about anger is true? a. Expressing anger openly and directly usually leads to arguments. b. Anger results from being frustrated, hurt, or afraid. c. Suppressing anger is a sign of maturity. d. Angry feelings are a negative response to a situation.

b. Anger results from being frustrated, hurt, or afraid.

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

b. Benzodiazepines

The nurse observes a client muttering to himself and pounding his fist in his other hand while pacing in the hallway. Which principle should guide the nurse's action? a. Only one nurse should approach an upset client to avoid threatening the client. b. Clients who can verbalize angry feelings are less likely to become physically aggressive. c. Talking to a client with delusions is not helpful, because the client has no ability to reason. d. Verbally aggressive clients often calm down on their own if staff members don't bother them.

b. Clients who can verbalize angry feelings are less likely to become physically aggressive.

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

b. Development of a therapeutic relationship Rationale: 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.

After a staff member has been involved in a particularly violent episode with a patient, when should the nurse plan for debriefing to occur? a. After the patient is discharged. b. Immediately following the event to facilitate processing of feelings. c. Not until the staff requests such an intervention. d. After a 3-day time-off period.

b. Immediately following the event to facilitate processing of feelings.

When conducting an assessment of a client admitted to the mental health unit to determine the potential for violent or aggressive behavior, what important communication strategy should the nurse use? a. Reassure the client that everything will be all right, and the staff will make sure nothing happens to him/her. b. Reinforce that the client is responsible for his or her own actions and will experience the consequences of acting out. c. Explain that violence is not acceptable, and the staff will not allow the client to act out. d. Reassure the client that limited acting out will be allowed but only in a controlled setting.

b. Reinforce that the client is responsible for his or her own actions and will experience the consequences of acting out.

The nurse is explaining the importance of expressing anger to a client. What should the nurse mention as the possible physical complications associated with suppressing anger? Select all that apply. a. Depression b. Ulcers c. Coronary artery disease d. Migraine headaches e. Low self-esteem

b. Ulcers c. Coronary artery disease d. Migraine headaches Rationale: Suppressing rage or anger could lead to physical complications such as ulcers, coronary artery disease, and migraine headaches. Depression and low self-esteem are emotional problems associated with suppression of anger.

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

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

Which term is used to describe an activity used to release anger? a. Hostility b. Anger c. Catharsis d. Physical aggression

c. Catharsis Rationale: 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.

Increased activity in which neurotransmitter is implicated in increased impulsivity and violent behavior? a. Epinephrine b. Serotonin c. Dopamine d. Acetylcholine

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

A client is pacing in the hallway with clenched fists and a flushed face. She is yelling and swearing. In which phase of the aggression cycle is she? a. Anger b. Triggering c. Escalation d. Crisis

c. Escalation

Which term is used to describe an emotion expressed through verbal abuse and violation of rules or norms? a. Catharsis b. Physical aggression c. Hostility d. Anger

c. Hostility Rationale: 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.

Which drug has been effective in treating aggressive clients diagnosed with bipolar disorders? a. Clozapine b. Valproic acid c. Lithium d. Carbamazepine

c. Lithium Rationale: Lithium, an antimanic medication, has been effective in treating aggressive clients with bipolar disorder.

During which phase of the aggression cycle does the client regain physical and emotional control? a. Postcrisis b. Escalation c. Recovery d. Triggering

c. Recovery Rationale: 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.

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

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

A person brings a parent to the clinic and tells the nurse that the parent has begun to act strangely in the past few days, with unprovoked outbursts of anger. After the incidents, the parent expresses remorse for the outburst. The person says, "I've never seen my parent act this way." Which question would be most appropriate for the nurse to ask next? a. "Has your parent exhibited previous problems expressing anger appropriately?" b. "Does your parent have a history of an anxiety disorder, such as panic disorder?" c. "Has your parent injured the back of the head or neck in the past week?" d. "Has your parent suffered any traumatic injury to the brain recently?"

d. "Has your parent suffered any traumatic injury to the brain recently?" Rationale: 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 abuse 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.

What is the most important interventions by the nurse when a client does not respond to less restrictive interventions and is rapidly escalating toward physical violence and crisis. a. Cease negotiation b. Bargain with client to determine what can be done to prevent assaultive behavior. c. Offer a PRN medication to reduce anxiety. d. Ask the client to move to a less stimulating, private area and spend some time alone.

d. Ask the client to move to a less stimulating, private area and spend some time alone.

In which phase of the aggression cycle can techniques of seclusion or restraint be used to deal with the aggression quickly? a. Recovery b. Escalation c. Triggering d. Crisis

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

A nurse is preparing a presentation for a group of staff nurses on anger. When describing maladaptive anger, which psychiatric condition would the nurse identify as being linked to this anger? a. Anxiety disorder b. Schizophrenia c. Obsessive-compulsive disorder d. Depression

d. Depression Rationale: Maladaptive anger (excessive outwardly directed anger or suppressed anger) is linked to psychiatric conditions, such as depression, as well as a plethora of medical conditions.

When responding to a patient who displays the potential for violence, the nurse would use which intervention as the most restrictive technique? a. Meeting in a quiet room to reduce stimulation. b. Administering a PRN PO. c. Providing physical interventions, such as two-person escort out of a program area. d. Using restraints, such as a four-point restraint.

d. Using restraints, such as a four-point restraint.

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

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