Chapter 11

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

a. 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.

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? a. Serotonin b. Endorphin c. Acetylcholine d. Estrogen

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

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. a. "Please do not damage the hospital's property." b. "I am here so we can talk about what is making you angry." c. "I am sure your anger would be reduced by punching the pillows." d. "I appreciate that you are expressing anger in an appropriate manner."

b. "I am here so we can talk about what is making you angry." Rationale - 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.

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

b. "People say I withdraw and pout about the problem." Rationale - 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 caring for a client with dementia who has become increasingly agitated. Which is the best action for the nurse to perform? a. Sedate the client with medication. b. Place the client in restraints in a chair by the nurse's station. c. Provide a snack and fluids frequently. d. Place the client in their room with the door closed.

c. Provide a snack and fluids frequently. Rationale - 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.

A nurse must assess for characteristics that are predictive of violent behavior. Research suggests violent behavior is influenced by possession of which attribute? a. Mindfulness b. Assertive behavior c. Therapeutic relationship d. Low self-esteem

d. Low self-esteem Rationale - 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.

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? a. "I need to stop feeling angry or I won't be healthy." b. "Being angry all the time overstimulates my nervous system." c. "If I figure out how to lower my anger, it's healthier for me." d. "Managing my anger might help my depression get better."

a. "I need to stop feeling angry or I won't be healthy." Rationale - 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.

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

a. 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.

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? a. Approach the client to engage in communication while remaining 6 feet or more away b. Ask colleagues to contact hospital security for support c. Offer the client an antianxiolytic medication d. Prepare to seclude the client

a. Approach the client to engage in communication while remaining 6 feet or more away Rationale - 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. The nurse should be close enough to communicate but maintain a safe distance.

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

a. 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.

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

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

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? a. Depression b. Panic disorder c. Manic behaviors d. Meneire's disease

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

a. 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.

The inpatient psychiatric nurse removes the restraints from a client who had an aggressive episode earlier and is currently calm and rational. The client asks if they can attend the group. Which response demonstrates insight into the postcrisis phase of anger and aggression? a. Encourage the client to attend with the expectation that they will remain nonaggressive. b. Recommend the client wait another day before interacting with their peers. c. Tell them they can attend but have a staff member stand next to them. d. Remind the client that if they are aggressive, they will be asked to leave.

a. Encourage the client to attend with the expectation that they will remain nonaggressive. Rationale - In the postcrisis phase, the client is removed from restraint or seclusion as soon as they meet the behavioral criteria. The nurse should not lecture or chastise the client for the aggressive behavior but should discuss the behavior in a calm, rational manner. The client can be given feedback for regaining control with the expectation that they will be able to handle feelings or events in a nonaggressive manner in the future. The client should be reintegrated into the milieu and its activities as soon as they can participate.

A nurse is leading an anger management group in an 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? a. Explore what is underlying the client's physical and emotional state b. Encourage the client to engage in a relaxation exercise prior to joining the group for the rest of the session c. Ask the client if the client feels triggered by another client in the group d. Ask another client in the group to respond to the client's comment

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

A nurse technician reports to the nurse manager that a new nurse refuses to inventory client belongings during admission assessments and makes belittling statements to the clients about the nurse technicians. Which consideration(s) by the nurse reflects an understanding of lateral violence? Select all that apply. a. Failure to address the behavior could affect joint commission accreditation. b. The nurse has not taken lateral violence training so the manager cannot do anything. c. Unless the nurse is verbally or physically aggressive, it is not considered violence. d. The organization should provide a process for managing the behavior. e. The nurse technicians deserve the behavior.

a. Failure to address the behavior could affect joint commission accreditation. d. The organization should provide a process for managing the behavior. Rationale - Workplace hostility include overt actions such as verbal outbursts and physical threats, as well as passive activities such as refusing to perform assigned tasks or an uncooperative attitude. In 2016, The Joint Commission added workplace bullying, also known as lateral or horizontal violence, to their accreditation standards. These standards include mandates that outline that accredited organizations must have a code of conduct that outlines acceptable and inappropriate/unacceptable behavior, a process for managers to handle disruptive or unacceptable behavior, education of all team members on expected professional behavior, and a zero tolerance for unacceptable behaviors, meaning all persons are held accountable. Whether the nurse technicians behaved inappropriately or not, the nurse displaying workplace hostility must be held accountable.

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

a. 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.

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. a. In a calm, firm voice tell the client that aggression is not allowed. b. Ask the client to go to their room or the quiet room to regain control. c. Offer the client as-needed antianxiety medication. d. Signal for additional staff to circle the client. e. Ask for assistance to restrain the client.

a. In a calm, firm voice tell the client that aggression is not allowed. b. Ask the client to go to their room or the quiet room to regain control. c. Offer the client as-needed antianxiety medication. Rationale - 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.

When communicating with a client in the triggering phase of the aggression cycle, which intervention should the nurse include? a. Listen to the client's concerns and convey empathy for the client's frustration or anger. b. Help the client understand the complexity and nuances of the client's condition. c. Encourage social interaction with other clients. d. Help the client express anger verbally and through nonharmful physical actions if necessary.

a. Listen to the client's concerns and convey empathy for the client's frustration or anger. Rationale - In the triggering phase, the client is responding to something in the environment with anger or hostility. The client shows one or more of restlessness, anxiety, irritability, pacing, muscle tension, rapid breathing, perspiration, loud voice, and anger. The nurse should approach the client in a nonthreatening, calm manner in order to deescalate the client's emotion and behavior. The nurse should express empathy and listen to the client's concerns. Using clear, simple, short statements and allowing the client time for self-expression are helpful techniques. This is not a good time for socialization with other clients; the nurse may suggest that the client go to a quiet area or get assistance to move other clients to decrease stimulation. Physical activity, such as walking, may also help the client relax and become calmer, but expression of anger in an angry way (e.g., punching a pillow) tends to escalate the emotion.

A client with aggressive behavior shows no psychotic symptoms. Which medication should the nurse expect to be ordered for this client? a. Lorazepam b. Valproate c. Haloperidol d. Carbamazepine

a. Lorazepam Rationale - 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.

When determining a client's potential for aggression and violence prior to engaging in a detailed psychosocial assessment, which would be most important for the nurse to do? a. Obtain a thorough client history b. Ask the client about the client's living situation c. Observe the client for nonverbal indicators d. Review the client's use of medications

a. Obtain a thorough client history Rationale - Although assessing the client's living situation, observing for nonverbal indicators, and reviewing medications are important, a thorough client history is the most important data for determining potential for aggression and violence. This is because a history of violent or aggressive behavior is one of the best predictors of future aggression. Early life adverse circumstances, such as inadequate maternal nutrition, birth complications, traumatic brain injury, and lead exposure, can contribute to risk for aggressive and criminal behaviors in adulthood. Important markers in the client's history include previous episodes of rage and violent behavior, escalating irritability, intruding angry thoughts, and fear of losing control. If the client is determined to be at risk for becoming violent, then the nurse will take particular care to observe nonverbal indicators that identify the beginning of an aggression cycle.

A nurse's response to aggressive behavior on the unit is influenced by which characteristic of the nurse? a. Self-awareness of reactions to aggression by others b. Understanding the importance of non-response to escalating behavior c. Appreciation of the value of matching anger with anger d. Recognition of the reasons for the client's behavior

a. Self-awareness of reactions to aggression by others Rationale - 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 client is diagnosed with intermittent explosive disorder. The nurse understands that this disorder is associated with which neurotransmitter? a. Serotonin b. Dopamine c. Norepinephrine d. gamma-aminobutyric acid (GABA)

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

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

a. Show an increased tolerance for frustration Rationale - 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.

An aggressive client has obtained a piece of sharp glass and holds it threateningly to prevent anyone from entering the room. What interventions can the nurse reasonably perform to ensure safety of the client, staff, and other clients? Select all that apply. a. Summon help from others. b. Step into the doorway to keep the aggressive client from leaving. c. Shift other clients to a safe place. d. Remove the piece of glass from client. e. Order the client to drop the glass in a firm, loud voice.

a. Summon help from others. c. 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 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, so it should be done only as a last resort and preferably by trained personnel. Advancing into the doorway may cause the armed client to feel threatened and provoke an attack; staff should allow the client as much personal space as possible under the circumstances. The nurse should speak to the client in a calm, low voice to help reduce agitation.

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? a. The client is sitting in the dayroom reading a book. b. The client is having an argument with a roommate. c. The client is threatening to hit another client. d. The client is having lunch with family members.

a. The client is sitting in the dayroom reading a book. Rationale - 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 charge nurse on the inpatient psychiatric unit is considering how best to assign clients with a low potential for aggression to a nurse who is seven months pregnant. What client factor is most significant for the nurse to consider? a. a history of violent or aggressive behavior b. content of visual or auditory hallucinations c. feeling victimized or bullied d. pattern of substance abuse

a. a history of violent or aggressive behavior Rationale - A history of violent or aggressive behavior is the best predictor of future aggression. Other factors that are significant include feeling victimized or bullied or having a history of substance abuse. Clients who believe their hallucinated voices to be all-powerful, malevolent, and irresistible are more likely to be aggressive.

A client asks the nurse for a date with them when they are discharged. The nurse tells the client that it is against policy to date clients. The client yells obscenities at the nurse and hits the counter before stomping away. Which defense mechanism does the nurse document that the client is using? a. acting out b. denial c. repression d. projection

a. acting out Rationale - Acting out is an immature defense mechanism by which the person deals with emotional conflicts or stressors through actions rather than through reflection or feelings. Rejection can lead to anger and aggression when that rejection causes the individual emotional pain or frustration, or is a threat to self-esteem. Denial is when a person refuses to accept facts; this client is experiencing rejection, so there is recognition of the reality of the situation. Repression occurs when unfavorable thoughts are ignored; this client reacts to the feeling of rejection. A client using displacement would direct their anger toward something less threatening than the stimuli. This client yelled directly at the source of their anger.

The psychiatric nurse is working in the triage area and has four clients to assess and transfer to the inpatient area for care. Which client should the nurse assess first? a. client who is pacing the lobby stating "I am afraid of losing it" b. client who is sitting with their head in their hands and crying softly c. client whose caregiver reports "muttering to themselves all day about aliens" d. client who is inebriated and trying to urinate in the artificial plants

a. client who is pacing the lobby stating "I am afraid of losing it" Rationale - The client who is pacing and verbally expressing a fear of losing control should be assessed first. This client is at highest risk for the development of aggressive behaviors that are threatening to the client and others. Use of therapeutic communication, as-needed antianxiety medications, and distraction can reduce feelings of vulnerability and promote feelings of safety and support, reducing the risk of violence. Although psychotic or inebriated clients may become aggressive without warning, the client with symptoms of building tension is the priority to assess.

The nurse performs an admission assessment on a client who has been diagnosed with intermittent explosive disorder. The nurse anticipates which treatment will be part of the client's treatment plan? a. cognitive-behavioral therapy b. exposure therapy c. sensory integration therapy d. cardio-boxing physical therapy

a. cognitive-behavioral therapy Rationale - Cognitive-behavioral therapy techniques, such as distraction, problem solving, and changing one's perspective or reframing can be effective in managing situations or problems that provoke angry feelings. These techniques are considered the most effective treatments for intermittent explosive disorder. Exposure, and sensory integration therapies are recommended for phobias and processing disorders respectively. Cardio-boxing therapy would be used with caution in any client with a history of anger or impulse control issues.

After working with a client who has a history of violent behavior to identify possible clues that suggest the behavior is escalating, a nurse and the client develop a plan for prevention. Which strategies will the nurse be most likely to include? Select all that apply. a. counting to 10 b. taking slow, deep breaths c. playing loud music d. taking a voluntary time out e. watch action movies

a. counting to 10 b. taking slow, deep breaths d. taking a voluntary time out Rationale - Turning up the music loudly would add additional stimulation, which could contribute to increasing the stress and stimulation of the situation. This would also occur with watching action movies. Rather, the suggestion to listen to quiet music or reading or watching nonviolenttelevision or movies would be appropriate. Counting to 10; taking slow, deep breaths; and taking a voluntary time out would be appropriate.

The nurse manager is concerned because staff members are talking about a client assaulting a staff nurse; however, the nurse did not inform the manager about the incident. For which reason(s) would the manager encourage the nurse to report the assault? Select all that apply. a. increase public awareness b. could threaten other clients c. support protective legislation d. prevent litigation against the facility e. could cause harm to other care professionals

a. increase public awareness b. could threaten other clients c. support protective legislation e. could cause harm to other care professionals Rationale - Client aggression directed toward nurses is often downplayed or tolerated as being a "part of the job." Attacks on nurses are seldom reported to the police or prosecution of the attackers; however, the incidents should be reported to supervisors and possibly to legal authorities depending on the circumstances. Client aggression needs to be addressed to increase public awareness of the problem, protect other clients, support legislation that addresses violence in the workplace, and prevent harm to other care professionals. Reporting assaults would not be done to prevent litigation against the facility.

The nurse is performing a physical assessment on a 3-year-old client. During the assessment, the child starts screaming and kicking. The nurse suspects this child: a. is acting out. b. is extremely depressed. c. has conduct disorder. d. has intermittent explosive disorder.

a. is acting out. Rationale - Acting out is an immature defense mechanism where a person deals with a stressor through actions rather than through reflection or feelings. This is a typical behavior in young clients and does not indicate the child is depressed, suffers from conduct disorder, or has explosive disorder.

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. a. pacing b. staring at another client c. making sarcastic comments d. changing the television channel e. sitting in a chair with eyes partially closed

a. pacing b. staring at another client c. making sarcastic comments Rationale - 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 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? a. validation b. acceptance c. reflection d. confrontation

a. validation Rationale - 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.

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

b. "What did you learn about anger when growing up?" Rationale - 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? a. "I've always had good results with medications." b. "What works best is what fits the client and the situation." c. "Make sure that another colleague knows where you are at all times." d. "You need to confront the client to show you are in charge."

b. "What works best is what fits the client and the situation." Rationale - 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 administers an antipsychotic medication to a client experiencing auditory hallucinations. The client begins pacing in circles and motions the nurse away saying, "voices are yelling at me." Which action is most appropriate? a. Ask the client what the voices are yelling. b. Allow the client to move around and relocate the other clients to another area. c. Stand closer to the client between them and other clients. d. Turn on the television to distract the client.

b. Allow the client to move around and relocate the other clients to another area. Rationale - The client is displaying signs of being in the triggering phase of the five-cycle phase of aggression. Allowing the client freedom to move around (within safe limits) and relocating the other clients is an appropriate action. The nurse has just administered an antipsychotic medication and there will need to be time for the medication to have an effect. Asking the client to provide detail on what the voices are saying is not therapeutic until the client has returned to a calmer state. Interfering with the client's mobility by standing closer may increase the client's frustration, fears, or perception of threat. Decrease stimulation by turning the television off or lowering the volume, instead of turning it on as a distraction is more therapeutic for a client with an altered perception of stimuli.

The nurse decides to place an aggressive and violent client in mechanical restraints. The nurse bases this decision on what? a. Client's mood b. Client's safety c. Court order d. Physician's order

b. Client's safety Rationale - The use of restraints is warranted only when the client's safety is in jeopardy and other, less restrictive measures have not been effective. The nurse does not base the decision on the client's mood or court order. Just because there is a physician's order for use of restraints, this does not mean that they are appropriate in every situation; this is based on nursing judgment.

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? a. Orient to the care area. b. Create a therapeutic milieu. c. Review behavior expectations. d. Discuss consequences for aggression.

b. Create a therapeutic milieu. Rationale - 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 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. a. Restrain the client. b. Give the client plenty of space. c. Sit in an open area d. Request the presence of additional staff. e. Encourage the client to talk about this situation

b. Give the client plenty of space. c. Sit in an open area d. Request the presence of additional staff. Rationale - 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 personality trait is associated with aggressive behavior? a. Self-centeredness b. Impulsivity c. Pessimism d. Lying

b. Impulsivity Rationale - Irritability, resentment, and impulsivity have been linked with conflict, aggression, and the potential for medical conditions such as essential hypertension, cardiovascular disease, and atherosclerotic heart disease.

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? a. Place the client in a separate room. b. Take the client to the gym for exercise. c. Inform the client that restraints may be applied. d. Speak to the client in a firm voice.

b. Take the client to the gym for exercise. Rationale - 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 assessing a client who expresses extreme hostility toward the nurse. What may be the client's intentions? Select all that apply. a. To punish the nurse b. To intimidate the nurse c. To force the nurse into compliance d. To resolve conflict with the nurse e. To emotionally harm the nurse

b. To intimidate the nurse e. To emotionally harm the nurse Rationale - 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.

To defuse a critical situation, the nurse can use the therapeutic communication techniques for which reason? a. Shout and let the client know that this behavior is not tolerated b. Try to clarify what has upset the client c. Inform client that the nurse is in charge of situation d. Offer medication as the solution to the outburst

b. Try to clarify what has upset the client Rationale - Trying to clarify what has upset the client is important. The nurse can use therapeutic communication techniques to prevent a crisis or defuse a critical situation.

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

b. Women are expected not to express so-called negative feelings like anger. Rationale - 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.

The plan of care for a client with anger includes behavioral interventions. Which intervention(s) is a nurse likely to recommend? Select all that apply. a. self-monitoring of cues b. anger management c. relaxation training d. response disruption e. stimulus control

b. anger management Rationale - Anger management is a psychoeducational intervention. Behavioral treatment of anger involves avoidance of provoking stimuli, self-monitoring regarding cues of anger arousal, stimulus control, response disruption, and guided practice of more effective anger behaviors. Relaxation training is often introduced early in the treatment because it strengthens the therapeutic alliance and convinces clients that they can indeed learn to calm themselves when they are angry.

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? a. constructive anger discussion b. anger suppression c. catharsis of anger d. expressive anger

b. anger suppression Rationale - 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 assigned to care for a client who assaulted another nurse the previous day. Which behavior indicates that the nurse is having an issue providing care to the client? a. provides care as expected b. limits contact with the client c. gives the client extra attention d. follows safety protocols during care

b. limits contact with the client Rationale - Nurses may withdraw from angry clients and try to hide their own anger because "good nurses" do not get angry at clients. However, distancing from the client is painful and indicates the nurse is having an issue providing care to the client. The nurse should provide care as expected. Giving additional attention to the client might cause the client to act out more frequently. All nurses should follow safety protocols when providing care and this would not indicate an ongoing issue with the client.

The nurse assesses a client following an aggressive episode. The client states "I'm good, stay back, I'm good" while slouching against the wall and speaking in a lowered tone of voice. The nurse documents that the client is in which phase of the five-phase aggression cycle? a. triggering b. recovery c. postcrisis d. escalation

b. recovery Rationale - Signs of a client entering the recovery phase of the five-phase aggression cycle include lowering of voice; decreased muscle tension; clearer, more rational communication; and signs of physical relaxation. Restlessness, anxiety, irritability, pacing, muscle tension, rapid breathing, perspiration, and loud voice represent the triggering phase. Clients in the escalation phase demonstrate pale or flushed face, yelling, swearing, agitation, threatening, demanding, clenched fists, threatening gestures, hostility, and loss of ability to solve the problem or think clearly. Clients in the postcrisis phase appear remorseful, may make apologies, and demonstrate crying, quiet, or withdrawn behavior.

Which behavior is considered inconsistent with the clinical picture of a client who is becoming increasingly aggressive? a. pacing b. sobbing inconsolably c. rigid posture with a clenched jaw d. staring with narrowed eyes into the eyes of another

b. sobbing inconsolably Rationale - Crying is not cited by experts as a behavior indicating that the individual has a high potential to behave violently. The other behaviors are consistent with increased risk for other-directed violence.

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 mostappropriate for the nurse to ask next? a. "Does your parent have a history of an anxiety disorder, such as panic disorder?" b. "Has your parent exhibited previous problems expressing anger appropriately?" c. "Has your parent suffered any traumatic injury to their brain recently?" d. "Has your parent injured the back of the irhead or neck in the past week?"

c. "Has your parent suffered any traumatic injury to their 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 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.

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? a. "I should be isolating my child until they learn better impulse control." b. "I will do everything for my child so they can focus on better behavior." c. "I will encourage my child to be age-appropriate independent." d. "I will punish my child when they behave poorly."

c. "I will encourage my child to be age-appropriate independent." Rationale - 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 client is attending anger management class and wants to know how the class will help. What is the nurse's best response? a. "You will learn how to control your violent behavior." b. "We need to explore what makes you want to hit people when you are angry." c. "It will help you to learn how to control the arousal of anger." d. "You will be able to stop feeling angry when incidents happen out of your control."

c. "It will help you to learn how to control the arousal of anger." Rationale - 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.

A client is becoming increasingly angry while talking with the nurse. Which statement reflects the nurses's appropriate use of de-escalation with the client? a. "I know you are angry but you must calm down." b. "If you can't calm down, you won't be able to watch television." c. "You look like you are upset and I want to understand why." d. "I would be upset too but we cannot make any change."

c. "You look like you are upset and I want to understand why." Rationale - The nurse is helping to deescalate a client's anger with trying to clarify what has upset the client. While the client may not be able to express this, the statement demonstrates caring and concern and can help defuse a angry and potentially violent client. Using language that isn't respectful or is threatening, such as telling the client to calm down or revoking privileges does not help de-escalate anger. Agreeing with the client but offering no solution is also not helpful in de-escalation.

A client throwing chairs at other clients in the recreation room is placed in restraints. Which action would the nurse take to adhere to regulatory requirements? a. Remove the restraints for basic needs, then reapply. b. Keep the restraints in place until the client's agitation resolves. c. Ask the health care provider to examine the client within 1 hour. d. Remove the restraints after providing an as-need (PRN) medication for aggression.

c. Ask the health care provider to examine the client within 1 hour. Rationale - The use of restraints can be a traumatic experience for clients; however, in the case of actual violence toward others, they might be the fastest and safest intervention to use. Organizations that receive Medicare or Medicaid reimbursement must adhere to the guidelines for restraint use. These guidelines include a nurse verifying the need for restraints and then contacting the physician or other licensed practitioner within 1 hour for the practitioner to examine the client. The restraints should be removed as soon as possible and not just removed for basic needs. Other approaches to de-escalate agitation should be used so that restraints are the last resort. There are no guidelines that support providing as-needed (PRN) medication for aggression before removing the restraints.

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? a. Triggering b. Escalation c. Crisis d. Recovery

c. Crisis Rationale - The client's signs of shouting, screaming, hitting others, and throwing objects suggest that the client is in the 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, perhaps yelling, making threatening gestures, and being unable to think clearly about the problem. In the recovery phase, the client regains emotional and physical control.

Which staff behaviors are most likely to trigger clients who are predisposed to aggressive or violent behavior? a. Asking personal questions when they are inappropriate b. Providing the client with a list of possible goals for behavior change c. Engaging in disputes over medication, supplies, or rules on the unit d. Talking excessively with the client in front of other clients

c. Engaging in disputes over medication, supplies, or rules on the unit Rationale - 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.

The nurse is caring for a group of clients on the behavioral health unit. Which client will the nurse prepare to intervene with seclusion and restraint? a. a client observed pacing quickly on the unit b. a client with a history of violence who is shouting at another client c. a client for whom all other measures of safety have failed d. a client refusing to take a PRN medication when offered for agitation

c. a client for whom all other measures of safety have failed Rationale - Seclusion and restraint are controversial interventions to be used judiciously and only when other interventions have failed to control the client's behavior. The other clients have not demonstrated a reason to restrain or seclude. A client has the right to refuse medication. Shouting at another client but not being physically aggressive is not a reason to seclude or restrain. De-escalation techniques will be helpful to diffuse the situation. Pacing on the unit is not a reason to seclude or restrain.

A psychiatric-mental health nurse is assessing a group of clients. Which client would be at the highest risk for violence towards others? a. a client diagnosed with depression experiencing anorexia b. a client with chronic psychosomatic concerns c. a client having paranoid delusions that others are out to get them d. a client diagnosed with schizophrenia who is isolating in their room

c. a client having paranoid delusions that others are out to get them Rationale - Although most clients with psychiatric disorders are not aggressive, clients with a variety of psychiatric diagnoses can exhibit angry, hostile, and aggressive behavior. Clients with paranoid delusions may believe others are out to get them may believe that they are protecting themselves, they retaliate with hostility or aggression. Some clients have auditory hallucinations and may have voices that command them to hurt others. Aggressive behavior is also seen in clients with dementia, delirium, head injuries, intoxication with alcohol or other drugs, and antisocial and borderline personality disorders. Violent clients tend to be more symptomatic, have poorer functioning, and show a marked lack of insight compared with nonviolent clients. The client diagnosed with depression experiencing anorexia, the client with chronic psychosomatic complaints, and the client diagnosed with schizophrenia who is isolating in their room do not pose an imminent danger to others. However, the client having paranoid delusions believing that others are out to get them may become violent; therefore, that client would be at the highest risk for violence toward others.

The nurse is caring for a client with bipolar I disorder that is in the manic phase. Which sign of escalating behavior requires immediate intervention? a. using foul language and arguing with the nurse b. staring intensely for a long time at another client on the unit c. banging their head against the wall d. making sarcastic comments to other clients and staff

c. banging their head against the wall Rationale - Banging one's head against the wall is correct because the client may cause serious self-harm. Lengthy intense staring and using foul language and sarcasm are not immediate threats.

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? a. client with a diagnosis of major depressive disorder (MDD) b. client with visual hallucinations c. client with a history of hostile behavior d. client with a diagnosis of borderline personality disorder (BPD)

c. client with a history of hostile behavior Rationale - 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. Unless the hallucinations are threatening, there is no reason to avoid this activity. There is nothing specific about MDD or BPD that would preclude them from this activity.

During a conversation, a hospitalized client reports having frequent angry outbursts. Which condition(s) would the nurse recall are associated with excessive outward directed anger? Select all that apply. a. hypertension b. breast cancer c. metabolic syndrome d. myocardial infarction e. coronary heart disease

c. metabolic syndrome d. myocardial infarction e. coronary heart disease Rationale - Although anger arousal is normal, anger becomes maladaptive when it is too frequent, too intense, or managed in unhealthy ways to include excessive outward expression. Excessive outwardly directed anger is linked to metabolic syndrome, myocardial infarction, and coronary heart disease. Hypertension and breast cancer are related to suppressed anger.

The client with a history of explosive outbursts becomes angry and states, "I am really getting angry." The nurse sees this as what? a. controlling b. manipulation c. progress d. regression

c. progress Rationale - When the client is able to verbalize angry feelings, this is progress from having an outburst. The client is not trying to control the situation. Manipulation occurs when a person tries to persuade another to act in a desired way. Regression occurs when one retreats to an earlier level of functioning and development.

A client with a recent history of violence is admitted to a mental health facility for treatment. Which client statement indicates to the nurse that the client uses aggressive behavior to achieve a goal? a. "He provoked me to punch him." b. "That man continues to nag me and I can't stand it anymore." c. "She kept saying something that she knows pushes my buttons." d. "Breaking windows is the only way anyone pays any attention to me."

d. "Breaking windows is the only way anyone pays any attention to me." Rationale - Instrumental aggression is a goal-directed aggressive behavior that is premeditated and unrelated to immediate feelings of frustration or threat. It is a means to secure a goal or a reward. The breaking of windows to get someone to pay attention to the client is an example of instrumental aggression. Being provoked, nagged, or aggravated would cause impulsive aggression, which occurs in situations of anger and anxiety. The client just lashes out without a plan or premeditation to act aggressively.

A mental-health nurse is caring for a client who displays aggressive behavior and the client asks about the role of neurobiology in their behavior. Which statement made by the nurse demonstrates understanding of the neurobiology role in aggression? a. "Aggression is the result of poor coping ability and neurobiology is not involved." b. "Low norepinephrine plays a primary role in aggressive behaviors." c. "Low dopamine levels may increase the risk for aggressive behaviors." d. "Low serotonin levels may lead to increased aggressive behaviors."

d. "Low serotonin levels may lead to increased aggressive behaviors." Rationale - Researchers have examined the role of neurotransmitters in aggression in animals and humans but have been unable to identify a single cause. Findings reveal that serotonin plays a major inhibitory role in aggressive behavior. Low serotonin levels may lead to increased aggressive behavior. In addition, increased activity of dopamine and norepinephrine in the brain is associated with increased impulsively violent behavior. Although poor coping ability is involved with violence, neurobiology plays a role in aggression. Therefore, the nurse's statements, "Aggression is the result of poor coping ability and neurobiology is not involved", "Low norepinephrine plays a primary role in aggressive behaviors", and "Low dopamine levels may increase the risk for aggressive behaviors", are not accurate. The nurse's statement, "Low serotonin levels may lead to increased aggressive behaviors", is accurate and demonstrated accurate understanding of the neurobiology role in aggression.

A nurse is presenting to a group of colleagues about the relationships between anger, aggression, and violence. Which statement by the nurse would be most appropriate to include? a. "Anger, aggression, and violence are points along a continuum." b. "The terms used to describe anger are very precise." c. "Anger is a knee-jerk reaction to external events." d. "Women experience anger as frequently as men do."

d. "Women experience anger as frequently as men do." Rationale - Women experience anger as frequently as men do, but societal constraints may inhibit their expression of it. 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.

Neurobiologic factors are increasingly being explored as an explanation for aggressive behavior. Which is true? a. Temperament theory is one of the leading hypotheses for violent behavior. b. There have been no links between neurotransmitters and aggression. c. Aggressive behavior is associated with clients who later contract Parkinson's disease. d. Brain neuroimaging studies show that aggressive behavior is linked to damage of brain structures located in the limbic, frontal, and temporal lobes.

d. Brain neuroimaging studies show that aggressive behavior is linked to damage of brain structures located in the limbic, frontal, and temporal lobes. Rationale - Tumors or trauma in the limbic and hypothalamic areas, as well as the frontal and temporal lobes, can stimulate loss of impulse control, aggression, rage, mania, mood lability, altered sexual behavior, and delusions. Examination of the frontal lobe reveals that damage to the orbitofrontal cortex is associated with impulsive outbursts of rage and violence.

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

d. Confirm that the utility and storage rooms are kept locked. Rationale - 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 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? a. The client has gained insight into situations that trigger anger. b. The client has increased self-esteem. c. The client reports increased feelings of self-control. d. The client uses adaptive coping to manage anger impulses.

d. The client uses adaptive coping to manage anger impulses. Rationale - 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 assessing an adolescent in a psychiatric facility. The parent tells the nurse that the adolescent has intense sporadic anger episodes. The adolescent becomes angry for petty reasons and starts throwing objects at home. The adolescent also feels guilty and repents for the actions. Based on this history, the nurse would expect the client to be diagnosed with: a. dementia. b. depression. c. paranoid delusions. d. intermittent explosive disorder.

d. intermittent explosive disorder. Rationale - Intermittent explosive disorder is a rare disorder characterized by intermittent episodes of aggressive impulses that are disproportionate to the precipitating factors. The individual with intermittent explosive disorder can cause severe destruction of property or assault individuals during an anger episode. Dementia is usually not seen in adolescents. The depressed client does not typically exhibit aggressive behaviors. The client with paranoid delusions would not exhibit episodic aggression.

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? a. flexible unit rules b. reduced use of restraints c. scheduled unit activities d. strict hierarchy of authority

d. strict hierarchy of authority Rationale - 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.