Chapter 28: Preventing and Managing Aggressive Behavior
8. Which medication would a nurse expect to be prescribed to an adolescent patient diagnosed with a conduct disorder who has a history of physically abusing younger siblings? a. Propranolol (Inderal) b. Propranolol (Ritalin) c. Clozapine (Clozaril) d. Phenytoin (Dilantin)
c. Clozapine (Clozaril) ANS: C Atypical antipsychotic agents are more effective than stimulants in treating aggression in children and conduct disorders in adolescents. The remaining options are not known to be effective for this condition.
16. Which rationale for placing a violent patient into seclusion best reflects the philosophy of nursing? a. It restricts patients to a physical space in order to reduce sensory overload. The goal is to minimize the risk of harm to others while preserving the patients personal safety and dignity. b. It offers safety by removing all potentially harmful objects and allows for the testing of the patients interpersonal control by gradually decreasing and/or increasing sensory input. c. It provides for a carefully protected milieu that offers safety, permeability of sensory input, and only incrementally increased interpersonal relationships. d. It prevents patients from harming themselves or others, reduces the need for proprioception, and provides a protective milieu at the risk of sensory deprivation.
a. It restricts patients to a physical space in order to reduce sensory overload. The goal is to minimize the risk of harm to others while preserving the patients personal safety and dignity. ANS: A Seclusion is the use of a fully protective environment with close observation by nursing staff for the purpose of safety or behavior management based on a professional nursing philosophy of concern for human dignity and optimal fulfillment of basic human needs. The scientific rationale for the use of seclusion is based on three principles: containment, isolation, and decrease in sensory input.
22. A newly admitted patient diagnosed with bipolar disorder is speaking loudly and demanding attention. A nurse assures the patient that the staff is always willing to listen and will help in any way possible but that the patient will need to speak more slowly and softly in order to be understood. The nurse is demonstrating an example of: a. necessary aggression with a difficult patient. b. effective, patient-directed therapeutic use of self. c. implementing therapeutic patience when providing patient care. d. patient education regarding effective nurse-patient communication.
b. effective, patient-directed therapeutic use of self. ANS: B The most valuable resource of a nurse is the ability to use ones self to help others. To ensure the most effective use of self, it is important to be aware of personal stress that can interfere with ones ability to communicate therapeutically with patients.
20. Which response best reflects appropriate assertiveness by a nurse when approached by a patient who demands medications immediately? a. I will get your medications as soon as I am finished with what I am doing right now, so please wait for me in your room. b. I will give you your medications as soon as I finish here. Its not appropriate for you to keep asking me for your medications. c. Ill check on your medications as soon as I finish with what I am doing. If it is not quite time for your medications I will bring them to you when it is. d. We need to talk about your impatient behavior before I give you your medications. You must understand that you are not the only patient on the unit.
c. Ill check on your medications as soon as I finish with what I am doing. If it is not quite time for your medications I will bring them to you when it is. ANS: C Assertive behavior conveys a sense of self-assurance but also communicates respect for the other person. Acknowledging the patients concern and explaining that you will meet needs is considerate and respectful. This response also lets the patient know that you are completing a task and will then meet the needs within a reasonable time.
4. One morning, the nurse manager asks a nurse to work overtime for the fourth week in a row, saying I know youve done a lot of overtime, but Im in a bind. Can you help me out? The nurse had planned to attend a childs recital that evening. Which would be the most appropriate assertive response the nurse could give? a. I cannot work tonight. Im sure you will agree Ive worked more than my share of overtime. b. This isnt a good time for me to help you. Its my childs recital and the family has plans. c. Well, my childs recital is tonight. If I work for you this evening youd have to give me three weekends off on this schedule. d. For goodness sake! Am I the only one working for you? Get someone else. You are not going to take advantage of me anymore!
b. This isnt a good time for me to help you. Its my childs recital and the family has plans. ANS: B The most therapeutic communication is the one that communicates clearly what the nurse is able to do or, in this case, not to do. Assertive people are not afraid to ask for what they want or need.
21. Which statement by a nurse new to the unit best reflects an understanding that staff attitudes and actions have a powerful effect on both patient behavior and milieu management? a. I understand that there are going to be days where the unit will be short-staffed or really busy. As new members of the team, how can we contribute to keeping the stress level on the unit from escalating? b. What are the administrations expectations of us as new employees related to the management of the milieu in general and of individual patient behavior? c. Im new, so I will learn best by observing while one of the more experienced staff members manages control over the patients. d. How do I best involve the health care providers in the management of the milieu when a patient begins to escalate?
a. I understand that there are going to be days where the unit will be short-staffed or really busy. As new members of the team, how can we contribute to keeping the stress level on the unit from escalating? ANS: A Clinicians may intentionally or inadvertently precipitate an outbreak of violence because staff attitudes and actions have a powerful effect on patient behavior. Inexperienced staff members, provocation by staff, poor milieu management, understaffing, close physical encounters, inconsistent limit setting, and a norm of violence all may negatively affect the inpatient environment.
14. A patient attending an aggression management group therapy session disrupts the meeting repeatedly by interrupting the discussion. An appropriate response from the nurse would be: a. It sounds as if your thoughts are troubling you. This may not be a good time for you to be meeting with us. I suggest you take a brief time-out. b. Whats happening with you right now? How can you control the effect this may have on your ability to stay calm and focused on our group goals? c. Can you remember what we talked about in the assertiveness training group yesterday? What do you need to do to regain control of your behavior? d. Do any of you want to share your feelings about what is happening? If not, Ill assume no one is particularly distressed by the disruptive behavior.
a. It sounds as if your thoughts are troubling you. This may not be a good time for you to be meeting with us. I suggest you take a brief time-out. ANS: A The most therapeutic nursing intervention is the one that excuses the patient from the group to protect the patient from being embarrassed once control is regained. In addition, the time-out may provide a reduction in milieu stimulation and provide needed structure and control. In assessing the potential for violent behavior, the nurse measures the patients mental status as well as is possible. A patient who is unable to control talking out loud is not a good participant in a group meeting, whether the behavior is one of manipulation or a sign of potential aggression and disintegration.
11. A crisis team is working to admit a violent patient who has been both medicated and physically restrained. Which statement made to the patient is the best example of team function? a. The team leader tells the patient I believe youre feeling very frightened right now. We can allow you to walk to the unit if you are willing to cooperate. b. A team member tells the patient, Because you have been so violent we had to restrain you. The team leader adds, Try to cooperate with us. We really dont want to hurt you. c. A crisis team member says, I know that youre feeling very frightened, but well help you feel calmer. The admitting nurse says, Do you feel you can do this without being agitated and physically violent? d. The admitting nurse states, You were restrained because you are behaving very violently. The crisis team leader adds, Do you want to be carried into the unit, or will you go quietly?
a. The team leader tells the patient I believe youre feeling very frightened right now. We can allow you to walk to the unit if you are willing to cooperate. ANS: A When working in a crisis team, there is one leader who does all the talking. Having several members of the crisis team talk is confusing to the patient.
7. A patient who is displaying manic behavior enters the units dayroom and declares in a loud, threatening voice, I have friends, and if you dont show me proper respect, youll be sorry! The nurses initial response should be to approach the patient, address him formally, and say in a: a. soft voice, You will always have proper respect here. Lets sit over here and talk. b. soft voice, You are really frightening the other patients. Please go to your room. c. firm voice, You are out of control. I expect you to go to your room immediately. d. firm voice, You seem to be escalating again. Ive brought an injection that will calm you and slow your thinking.
a. soft voice, You will always have proper respect here. Lets sit over here and talk. ANS: A When dealing with a patient who is escalating, the nurse initially assesses the patients ability to use self-control and to respond to verbal cues. Speaking in a calm, soft voice and calling the patient by his or her formal title (unless the patient has insisted on being called by a first name), the nurse attempts to deescalate the patient by engaging him or her in a conversation that allows the expression of concerns. The remaining options either appear to threaten the client or have the nurse determine the topic of the conversation rather than focusing on the clients concerns.
23. A nurse is caring for a patient who has come into the clinic insisting on seeing a psychiatric nurse practitioner immediately because the patient is in crisis. In order to prevent a possible catastrophic reaction, the nurse will: a. take the patient to an exam room immediately and begin to assess the situation and needs. b. ask the patient to please take a seat in the waiting room until the nurse practitioner can be called. c. ask the patient what psychiatric medications have been prescribed and when the patient last self-administered the drugs. d. call the clinic manager to assume responsibility for the patients care so that the other patients can be attended to effectively.
a. take the patient to an exam room immediately and begin to assess the situation and needs. ANS: A Because it is much less dangerous to prevent a crisis than to respond to one, every effort should be made to carefully monitor patients who are at risk for violent behavior and intervene at the first possible sign of increasing agitation.
5. A nurse facilitating a social skills group recognizes that one patient monopolizes the group. After the session the psychologist asks the nurse, Why did you let that patient monopolize the group? A response from the nurse using appropriate assertiveness would be: a. I didnt know what I was supposed to do. You could see how much the patient needed to control the meeting. So you dont think it was appropriate to let it be for today? b. I didnt let the patient monopolize the group. I wasnt sure if I ought to stop the behavior or let the patient talk. What could I have said to end the patients monopolizing of the group? c. Honestly, I never feel you are satisfied with my work. Why dont you lead the group next time? That will give me an opportunity to observe you appropriately managing the patients need to monopolize the group. d. I felt that the patient needed to express feelings and that the control was a rather tenuous one that required sensitivity and patience. I believe the other patients felt that, too, which is why they let the patient monopolize the group.
b. I didnt let the patient monopolize the group. I wasnt sure if I ought to stop the behavior or let the patient talk. What could I have said to end the patients monopolizing of the group? ANS: B The most assertive communication is the one that clarifies any misperceptions and seeks assistance in a direct manner. Rationalization is not professional. Patients will take their cue from the facilitator of the group. Becoming angry because the psychologist has constructively criticized the nurses facilitation skills in dynamic supervision is aggressive.
10. An adolescent patient who just completed a time-out for having slapped another patient complains, The other patient started it, but I get punished. Its unfair. An appropriate response from the nurse would be: a. Dont expect me to take your side in this. You received punishment because you were violent. It doesnt matter who started it. On this unit, violent behavior will always be punished. b. Lets talk about that. Do you think you were asked to take a time-out because you started it or because your response was both out of control and violent? c. You make a good point. We need to punish both of you in a similar fashion. Since I believe in fair play, Ill assign the other patient to a time-out as well. d. Sounds to me as if you have really been bullied. I will have to discuss this with the staff. Im pleased that you accepted the time-out like an adult.
b. Lets talk about that. Do you think you were asked to take a time-out because you started it or because your response was both out of control and violent? ANS: B It is important that the patient identify his or her own inappropriate behavior. It is also important that the nurse deliver the time-out as a consequence in a matter-of-fact manner and not as a punishment. Behavior is altered more adaptively if the consequence (e.g., deduction of tokens, time-out to ones room) is delivered as a support to assist the patient to relearn adaptive ways to behave in problematic situations. The remaining options fail to address the issue of personal responsibility for ones own actions.
17. A patient is being restrained after biting himself and members of the nursing staff. An appropriate response from the nurse would be: a. You have been restrained because you are violent and the staff is unable to deal with you. Until you regain control, we will do our best to make you comfortable and keep you safe. b. You are being restrained because you have been biting yourself and others. Let the staff know if the restraints are uncomfortable. You will be released when you are able to again control your behavior. c. Your thinking is making you violently uncontrollable, and in addition youre trying to bite us. We do not like having to restrain you but it is necessary until you are more in control. We hope to release you soon. d. I know this feels terrible to you, but you are so violent that you may hurt yourself, the staff, and other patients. We wont keep you restrained for long, just long enough for you to regain control of your behavior.
b. You are being restrained because you have been biting yourself and others. Let the staff know if the restraints are uncomfortable. You will be released when you are able to again control your behavior. ANS: B There is no easy way to discuss the use of restraints with a patient who is currently violent. It is important to explain in a nonjudgmental way why restraint is being employed and to open up an avenue of communication so staff members can ensure the patients optimal well-being during the period of restraint.
9. A nurse working in a walk-in clinic is approached by a person with a history of violent behavior. The person states, I want to go to the hospital for a rest. You better get me in or Ill do something bad. I can get a gun. An appropriate response from the nurse would be: a. If I get you admitted, will you promise to behave yourself? b. You seem very anxious to be hospitalized. What do you think will happen if you arent hospitalized? c. Do you have a gun? Im not sure I believe you. Are you really threatening to kill yourself or someone else? d. Do you really want to go to the hospital? Would you be satisfied if I were able to find you someplace safe to rest?
b. You seem very anxious to be hospitalized. What do you think will happen if you arent hospitalized? ANS: B The most therapeutic communication is the one in which the nurse assesses the potential for violence by ascertaining the patients plan, means, and commitment. The remaining options fail to do that satisfactorily.
15. A unit has experienced several violent outbursts that have resulted in the forcible restraint of patients. On review, each violent event and all crisis management strategies were appropriately followed. To maximize staff efficiency the nurse manager should: a. determine the institutions policies regarding the management of crisis situations should be reviewed in mandatory staff education sessions. b. schedule staff breaks at intervals that allow staff members to leave the unit and relax while discussing the problems in the current milieu. c. invite a team of experts to evaluate crisis management on the unit for 1 month to determine whether any procedures are being unintentionally omitted. d. schedule a multidisciplinary team education meeting and invite a distinguished expert who can help staff members understand that they managed each crisis appropriately.
b. schedule staff breaks at intervals that allow staff members to leave the unit and relax while discussing the problems in the current milieu. ANS: B Despite the fact that everything that could be done in each violent event was done, the staff members are still experiencing high levels of stress more often. If feasible, the nurse will provide ways to manage the staffs higher level of stress during this time. The only selection that offers an avenue for immediate stress management is scheduling frequent breaks.
18. During staff debriefing after placing a patient with a history of violence into seclusion, a nurse new to the unit says, I think we acted prematurely. We didnt spend enough time trying to deescalate the situation. An appropriate response from the nurse manager would be: a. Youre new here. Trust the staff to make decisions based on experience and sound, evidence-based practice. b. Were a team. We all need to be open to other possibilities, and I expect that we respect each others viewpoints. c. Id like to hear more specifically what you think we could have said or done to talk the patient down and avoid the need for seclusion. d. Professional nurses are familiar with a variety of communication interventions; maybe its time we had an in-service to improve our communication skills.
c. Id like to hear more specifically what you think we could have said or done to talk the patient down and avoid the need for seclusion. ANS: C The most therapeutic nursing communication is the one that addresses the new nurses concerns more specifically. Often new staff members can offer a new perspective on an issue that will enrich unit operations and provide an expanded approach to effective clinical decision making.
13. A nurse has just explained to a newly admitted patient that the token economy system is employed on the unit. The patient announces, I have a PhD, and Ill be damned if I participate in a barter exchange for my human rights. An appropriate response from the nurse would be: a. Well, according to the unit rules you have just lost four tokens for swearing, and you havent even earned any yet. That makes your score a negative four. b. Being a PhD, Im sure you are familiar with being held responsible for your actions. Thats the policy on this unit, and you now have minus four tokens. c. It seems as if youre having difficulty being here. Are you saying that you feel you dont have to abide by the same policies for living on this unit because you are well educated? d. Well-educated individuals usually have no need to swear. You have now lost four tokens. Well talk when you are able to be more polite.
c. It seems as if youre having difficulty being here. Are you saying that you feel you dont have to abide by the same policies for living on this unit because you are well educated? ANS: C The most therapeutic communication is the one in which the nurse expresses empathy for the patient and asks the patient to reflect on his or her thinking. In this way, the nurse seeks to determine whether the patient is able to think critically about his or her situation and response and how it appears to others. This eliminates any countertransference in the nurses behavior. Lecturing the patient will only stimulate more angry behavior. The nurses goal ought to be to facilitate the patients expression of feelings so that the patient can begin to reflect and eventually problem solve effectively.
3. A newly licensed nurse tells a nurse manager, Id like you to stop referring to me as the smart new degree nurse. The nurse manager replies, I was only teasing. You are being overly sensitive. Which statement accurately evaluates the newly licensed nurses comment to the nurse manager? a. The nurse is appropriately assertive, but now the nurse manager will likely belittle the nurse even more. b. The nurse is behaving aggressively because of the newness of being a graduate licensed nurse and owes the nurse manager an apology. c. The nurse is assertive, and responding that the nurse does not regard the nurse managers comments as teasing would be an effective follow-up communication. d. The nurse is overly sensitive and ought to have ignored the nurse managers teasing until it was extinguished. Now the nurse manager will be more sarcastic than ever.
c. The nurse is assertive, and responding that the nurse does not regard the nurse managers comments as teasing would be an effective follow-up communication. ANS: C In the above communication, a request is made that describes what the newly licensed nurse would like the charge nurse to do (i.e., stop calling the nurse the smart new degree nurse). This communication is clear and concise and describes the behavior that the nurse wants to stop. The remaining options fail to demonstrate effective use of appropriate assertiveness.
12. A patients contract to be taken outside for a fresh air break after meals has been unavoidably postponed. The patient says, Ive waited patiently for 2 hours, and now I want to stay outside for an extra 10 minutes! An appropriate response from the nurse would be: a. Im sorry but you will have to wait. You know that as adults we dont always get what we want when we want it. b. Ill arrange to have someone take you after lunch, and you can stay out for as long as you like if youll just wait patiently. c. You are quite right. Thank you for being so patient. Someone will come right now and take you outside for your break. d. Please show a little consideration; weve been very busy handling other patients problems. You would understand if it were you with the problem.
c. You are quite right. Thank you for being so patient. Someone will come right now and take you outside for your break. ANS: C Contracting is a two-way street. According to the situation presented in this question, the nurse already has received time and understanding from the patient. The nurse or another member of the staff needs to stop and provide the patient with the break time that has been contracted. It is not the patients fault if the unit is busy, and the nurse who responds with anger or sarcasm is not being self-aware or mutually respectful of the patient.
24. A nurse observes a patient with a history of aggressive behavior toward others pacing in the dayroom while appearing to talk to himself. The nurse will best intervene with this patient therapeutically by: a. asking him to sit in the dayroom and watch television with the other patients and staff. b. instructing him to go to his room and remain there until he shows that he can be sociable. c. asking him if he would like to walk to his room where he and the nurse can sit together quietly to discuss the cause of his behavior. d. assigning an ancillary staff member the task of walking him around the unit for several minutes and then returning him to his room.
c. asking him if he would like to walk to his room where he and the nurse can sit together quietly to discuss the cause of his behavior. ANS: C Having the patient return to his room to write about his feelings, do deep-breathing or relaxation exercise, or talk about his emotions with a supportive person can help the patient regain control and lower feelings of tension and agitation. The responsibility of patient/milieu management is not one that may be delegated to ancillary staff.
2. A nurse is facilitating a social skills group on the inpatient unit for nursing assistants. Which comment would the nurse identify as assertive? a. I enjoy my work. I do all my own work, and so I seldom have time to help others. I would if I had the time. b. I love my work. I try to help others whenever they ask because on our unit its certainly a team effort. c. I enjoy my work. I always try to be helpful, but I am careful not to help those who arent willing to help others. d. I enjoy my work. I help others after I have spent sufficient time with my patients and feel my assistance is needed.
d. I enjoy my work. I help others after I have spent sufficient time with my patients and feel my assistance is needed. ANS: D Assertive behavior involves communicating clearly and directly with others. If the assertive individual is conveying negative feelings, thoughts, or issues of concern, the positive aspects are noted in balance with the negative information, and the individual takes responsibility to state what he or she would like to have done differently or changed. Assertiveness also involves accepting positive and negative input and is used for the purposes of expressing ones feelings, wishes, or desires, but not necessarily as a means of getting ones way or winning. Nursing staff members who are unable to demonstrate appropriate assertive behavior and communications will be unsuccessful role models for their patients.
1. An adolescent patient says to a nurse, Im so glad youve come in. The nurse manager ordered me to stay in my room until dinner just because I got into another fight! An appropriate response from the nurse would be: a. Youre not going to split me from the nurse manager. Please go back in your room until your time-out is finished. b. Im wondering why youve left your room, then. Please return to your room until your time-out is completed. I will talk with you after that. c. Im sorry to hear that you are being punished. Please return to your room immediately. We can talk about this when your time-out is over. d. It sounds as if you havent had a very good day. Return to your room, and complete your time-out. I will speak with you after dinner.
d. It sounds as if you havent had a very good day. Return to your room, and complete your time-out. I will speak with you after dinner. ANS: D Firm but empathetic limit setting is required in this situation. The patient is splitting, and the nurse needs to set limits and support the consequence that has been administered. By reflecting the patients psychic distress and providing clear instructions about the behavior that is expected (along with a time limit for that behavior), the nurse is assisting the patient in problem solving more adaptively. In addition, the nurse provides a reward or positive regard when offering a specific time to meet with the patient that occurs after the consequence has been accepted. Although the remaining options also provide similar feedback, they do not provide specific times that the patient can concretely conceptualize. Mutuality and respect for all patients are required from the therapeutic professional nurse, especially for those patients with impulse-control problems; they may try to enter into a regressive struggle with the nurse, who is trying to set limits on behavior.
19. At 7 AM, a patient demands in a loud, tremulous voice, Wheres my doctor? The doctor promised to see me first thing in the morning. Call the doctor and say that Im waiting. An appropriate response from the nurse would be: a. Please get ready for breakfast. Its only 7 AM. Your doctor will be in and Ill make sure that youre seen. b. Dont yell at me like that; it isnt polite and certainly isnt necessary. I want to help you, but I will not be verbally abused. c. You seem very angry that your doctor has not come in yet. Your doctor will be in this morning but not until later. The doctor spends time with everyone. d. Your doctor doesnt come to the unit until after breakfast and morning groups are over. Have your breakfast now so youll be ready when your doctor gets here.
d. Your doctor doesnt come to the unit until after breakfast and morning groups are over. Have your breakfast now so youll be ready when your doctor gets here. ANS: D The most therapeutic communication is the one that does the following: addresses the patient by name (this assesses the patients ability to listen and respond to the nurse) and offers information in a matter-of-fact way (this addresses the well part of the patients communication, that is, the part in which the patient asks, When is my doctor coming?). The patients communication is appropriate and needs to be acknowledged in a respectful manner. The best response promotes structure for the patient by offering a plan that suggests a shower (Maslows hierarchy: the patient will feel better physically while waiting for the doctor) and provides breakfast on the unit with the structure of a reduced-stimulus milieu. (The patient may be escalating, so it is better to order a tray on the unit if the patient is usually able to go to breakfast in the cafeteria.)
6. A nurse leader facilitating a group of recovering alcoholics observes patients drinking nonalcoholic look-alike beer and wine coolers they have brought with them instead of the available decaffeinated coffee and soda. An appropriate response from the nurse would be: a. telling the patients that they are behaving inappropriately and instructing them to throw the nonalcoholic beer and wine drinks away. b. stopping the group and asking the patients who are drinking inappropriately to leave and return next week without the nonalcoholic beverages. c. ignoring their behavior but firmly stating If you want me to return next week, all of you will come prepared to appropriately participate in this group. d. stating, I see that some of you are drinking nonalcoholic beverages and wine coolers. What is your understanding of the purpose of this group?
d. stating, I see that some of you are drinking nonalcoholic beverages and wine coolers. What is your understanding of the purpose of this group? ANS: D There are many dynamic reasons that might be postulated about why alcohol-troubled patients would bring pseudo-alcoholic beverages to the group. The facilitator needs to be assertive and bring the behavior out to the group for its members to examine. It is time to review the purpose of the group and then to assist the group in reflecting on their behavior and its meaning for their sobriety. The remaining options do not attempt to determine the reason for the inappropriate behavior.
