Chapter 27 - Anger, Aggression, and Violence

Which nursing diagnosis is the priority when planning care for a client who displays considerable anger and occasional aggression? A. Social isolation B. Risk for other-directed violence C. Ineffective coping: overwhelmed D. Ineffective coping: maladaptive

B. Risk for other-directed violence Risk for other-directed violence is the priority diagnosis. The nurse then must determine which of two other diagnoses—ineffective coping: overwhelmed or ineffective coping: maladaptive—is appropriate. Social isolation is not an initial concern.REF: 519

Which statementt about violence and nursing is accurate? A. Unless working in psychiatric mental health settings, nurses are unlikely to experience patient violence B. To date, no legislation exists that addresses workplace violence against nurses C. Emergency, psychiatric, and step-down units have the highest rates of violence towards staff D. Violence primarily affects inexperienced or unskilled staff who cannot calm their patients

C

Anger can best be defined as A. an unhealthy way of releasing anxiety. B. doing intentional harm to others. C. an expression of conflict with others. D. a normal response to a perceived threat.

D

A nurse is caring for a client who is screaming at staff members and other clients. Which of the following is a therapeutic response by the nurse to the client/ A. "Stop screaming, and walk with me outside" B. "Why are you so angry and screaming at everyone?" C. "You will not get your way by screaming" D. "What was going through your mind when you started screaming?"

A

Which assessment finding is the best predictor of violence in a newly admitted client? A. A recent assault on a drinking companion B. A family history of bipolar disorder C. The nurse's subjective feeling that the client is uncooperative. D. A childhood history of being bullied at school

A. A recent assault on a drinking companion. The best predictor of violence is past episodes of violent behavior.REF: 517

Andie is a patient anxiously waiting her turn to speak with you. As you are very busy, you ask Andie if she can wait a few minutes so that you can finish your task. Unfortunately the task takes longer than anticipated and you are delayed getting back to Andie. On seeing you approach her, Andie accuses you of lying and refuses to speak with you. Which response is most likely to be therapeutic at this time? A. "you are angry that I didn't speak with you when I promised I would" B. "I'm sorry for being late, but screaming at me is not the best way to handle it." C. "You are too angry to talk right now. I'll come back in 20 minutes and we can try again." D. "Why are you angry? I told you I was busy and would get to you as soon as I could."

A

You are working on an adolescent psychiatric unit. Katy, aged 16 years, has been angry all day because her boyfriend was not allowed to visit last night. Katy is in the hallway and begins yelling, "It's not fair! You all hate me! I hate this place!" She begins pounding her fists on the wall. To deal with the situation and prevent further escalation, your best response would be to say: A. "Katy, I will help you calm down. Do you want to go to your room and talk or go to the quiet room?" B. "Katy, you may yell and bang your fists but you must do it in your own room so you don't upset the other patients." C. "Katy, stop that right now! You will not be allowed to behave like that!" D. "Katy, you will have to go into seclusion and restraints right now." a

A. "Katy, I will help you calm down. Do you want to go to your room and talk or go to the quiet room?" Approaching the patient in a calm manner and giving choices may de-escalate the situation and gives the patient some control. The patient would not be allowed to yell or possibly hurt herself alone in her room. Commands such as "stop that right now!" could further escalate the situation. Seclusion and restraint may be premature because the situation may be able to be resolved using least restrictive means.Cognitive Level: Analyze (Analysis)Nursing Process: ImplementationNCLEX: Safe and Effective Care EnvironmentText page: 520

Which intervention strategy should be avoided by staff working with a client who is shouting and flailing his arms? A. Defusing the situation by laughing or making a joke of the challenge B. Saying "Let's go to your room to talk about this" C. Moving a few staff close together as a group to provide a show of force D. Allowing one staff person to speak to the client while others provide support

A. Defusing the situation by laughing or making a joke of the challenge Ridiculing a client should always be avoided. The other options are constructive approaches to deescalation.REF: Page 520

Which would be the most appropriate response by the nurse to help a client who is demonstrating escalating anger? A. Walk the client to his room and help him practice stress-reduction techniques, such as deep breathing or muscle relaxation B. Suggest that the client spend some time in the gym with a punching bag to relieve his stress C. Suggest that the client spend some time pacing rapidly in the hallway until he feels less stressed D. Sit with the client in the day room so that he can vent his anger and not isolate himself

A. Walk the client to his room and help him practice stress-reduction techniques, such as deep breathing or muscle relaxation In settings in which the staff can reasonably expect episodes of client anger and aggression, regular teaching and practice of verbal and nonverbal interventions are essential. The most appropriate response by the nurse would be to help the client to a quiet environment and teach or coach the client to use positive coping skills.REF: 520

The most restrictive method for dealing with an aggressive client who is out of control is A. seclusion. B. a show of force. C. verbal intervention. D. antipsychotic medication.

A. seclusion Seclusion is the most restrictive method listed, because it curtails the client's freedom of ambulation.REF: 521-522

The more a nurse's intervention is prompted by emotion A. the less likely it is to be therapeutic B. the less likely it is to be aggressive C. the more likely it is to be effective. D. the more likely it is to be empathetic.

A. the less likely it is to be therapeutic. One study reported in the text found that the nurse's response to anger from a client varied according to the interpretation given to the client's anger and to the nurse's self-appraised ability to manage the situation. Only when self-efficacy was perceived as adequate did the nurse move to help the client. When self-efficacy was not seen as adequate, nurses showed a decreased ability to process the client's message and a decreased ability to problem-solve.REF: 518-519

You respond to a loud, angry voice coming from the day room, where you find Alex is pacing and shouting that he isn't "going to take his (expletive) anymore." which of the following responses is likely to be helpful in de-escalating Alex? Select all that apply A. Remain calm, quiet, and in control B. Tell Alex that his actions are unacceptable and that he must go to his room C. Match Alex's volume so that he is able to hear over his own shouting D. Ask Alex if he can tell you what is upsetting him so you may be able to help E. Sand close to Alex so you can intervene physically if needed to protect others F. Tell Alex that he could be placed in seclusion if he cannot control himself so that the patient is aware of the negative consequences

AD

A nurse is caring for a client who is speaking in a loud voice with clenched fists. Which of the following actions should the nurse take? A. Insist that the client stop yelling B. Request that other staff members remain close by C. Move as close to the client as possible D. Walk away from the client

B

Ian makes the following statements to you while admitting him. Which statement indicates and increased likelihood of violent behavior? A. "When I get mad, I want to be left alone" B. "Last time I was in here I ended up in seclusion for punching my roommate C. "My old man was meek and mild, and I've always said I'm not going to be like him" D. "My girlfriend says I yell way too much, and she's threatened to leave me."

B

When you approach Katy, what considerations should you take? A. Stand close to Katy for reassurance and to convey caring. B. Have other staff as backup, and stand far enough away to avoid injury. C. Take Katy to her room so you can speak with her alone. D. Call security and wait until they arrive before approaching Katy.

B. Have other staff as backup, and stand far enough away to avoid injury. Safety considerations for staff include enlisting other staff to be present, keeping a safe distance from the patient, and approaching the patient in a nonthreatening or nonconfrontational manner. The other options do not allow for staff safety; security personnel may escalate the patient's behavior and should be kept in the background until needed to assist. Furthermore, the patient has an immediate need to be assisted by staff if possible without waiting for security.Cognitive Level: Analyze (Analysis)Nursing Process: PlanningNCLEX: Safe and Effective Care EnvironmentText page: 520

Which neurotransmitter imbalance has been shown to be related to impulsive aggression? A. Low levels of ã-aminobutyric acid B. Low levels of serotonin C. High levels of dopamine D. High levels of acetylcholine

B. Low levels of serotonin Low serotonin levels have been implicated in several research studies as being a factor in impulsive aggression.REF: 516

An angry client frequently loses patience with the nurses and shouts at them while they perform a complicated dressing change. Which plan could they create to intervene effectively in this behavior? A. Tell him they will not change his dressing if he is going to abuse them. B. When the client begins to become abusive, leave the room promising to return in 20 minutes when he has regained control. C. Assure him they will complete the dressing change as quickly as possible. D. Explain that they are professionals and unused to being shouted at by people they are trying to help.

B. When the client begins to become abusive, leave the room promising to return in 20 minutes when he has regained control. The nurse is using behavioral techniques to reinforce desirable behavior (spending time with the client when he is calm) and limit reinforcement of undesirable behavior (leaving when he is acting out anger).REF: Page 521, 525

When a client diagnosed with a cognitive deficit experiences a catastrophic reaction, the priority intervention is to A. decrease sensory stimuli. B. smile and call the client by name. C. take the client to the bathroom. D. calmly ask the client what's wrong. b

B. smile and call the client by name. Getting the client's attention by calling his or her name is necessary. Smiling is necessary to convey the lack of a threat.REF: Page 527

One older concept that is being used currently that may help in violence reduction in patients is: A. aired grievances. B. trauma-informed care. C. shared governance. D. learned helplessness.

B. trauma-informed care.' Trauma-informed care is an older concept of providing care that has been reintroduced. It is based on the notion that disruptive patients often have histories that include violence and victimization. These traumatic histories can impede patients' ability to self-soothe, result in negative coping responses, and create a vulnerability to coercive interventions (e.g., restraint) by staff. Trauma-informed care focuses on the patients' past experiences of violence or trauma and the role it currently plays in their lives. The other options do not refer to a care concept that helps reduce violence.Cognitive Level: Understand (Comprehension)Nursing Process: PlanningNCLEX: Psychosocial IntegrityText page: 517

A nurse is assessing a client in an inpatient mental health unit. Which of the following findings should the nurse expect if the client is in the preassaultive stage of violence? (select all that apply) A. Lethargy B. Defensive responses to questions C. Disorientation D. Facial grimacing E. Agitation

BDE

A nurse is caring for a client in an inpatient mental health facility who gets up from a chair and throws it across the day room. Which of the following is the priority nursing action? A. Encourage the client to express her feelings B. Maintain eye contact with the client C. Move the client away from others D. Tell the client that the behavior is not acceptable

C

You are caring for Malcolm, an 83 y/o African American patient with Alzheimer's disease. Malcolm exhibits agitated behavior at times, especially when he feels he is missing work, and he sometimes attempts to leave the unit to " get to the school where I teach. " which of the following interventions is appropriate for de-escalating Malcolm's agitation. A. Medicate Malcolm with PRN medication at regular intervals to prevent agitation B. Repeatedly explain to Malcolm that he is retired and no longer teaches as the repetition will reinforce the patient's orientation C . Use validation therapy and ask Malcolm about the school and his job D. Reduce stimulation In the environment by having Malcolm sit by himself in his room until the agitation passes

C

The factor most likely to contribute to a client's escalating anger is A. watching violence on television. B. another client's depressed mood. C. a staff member telling him that he is inappropriate. D. a staff member asking him to help another client.

C. a staff member telling him that he is inappropriate. Punitive, threatening, accusatory, or challenging statements to the client should be avoided; rather, the nurse should determine what is behind the client's feelings and behaviors.REF: 520

The client at highest risk for violence directed at others is one who A. has a history of recurrent severe depression. B. is in an alcohol rehabilitation program. C. has delusions of persecution. D. who has somatic symptoms for which no organic basis is found.

C. has delusions of persecution. The client who perceives others to be against him may lash out if he feels threatened.REF: Page 518

When working with an angry client, it is best to A. encourage the client to fully explore and express his or her anger. B. help the client deny and repress the feelings of anger C. help the client reframe the anger-producing situation. D. ignore the client's anger and change the subject.

C. help the client reframe the anger-producing situation. De-escalation occurs more quickly with this strategy than when other approaches are used.REF: 518-519

An adolescent male is swearing and shouting at his physician, who refused to give him a pass to leave the unit. This behavior A. is acceptable if directed at staff but not when directed at other clients. B. may reduce tension and prevent the client from physically acting out. C. is a major indicator that the client may become physically aggressive. D. can be attributed to lack of parental controls applied at an early age.

C. is a major indicator that the client may become physically aggressive. Physical aggression is preceded by anger, which may be expressed by swearing and shouting, pacing, and other menacing behaviors.REF: Page 520

A nurse attempts to intervene verbally when an angry client initially threatens to throw a chair but quickly focuses the anger toward the nurse. Several staff members gather behind the nurse, but then the client shouts, "I will calm down when that nurse isn't in my face." The nurse best demonstrates the ability to help the client deescalate by A. continuing to manage the situation personally. B. telling the client, "It isn't safe for me to leave the room." C. moving to the rear of the staff group. D. apologizing for upsetting the client.

C. moving to the rear of the staff group. There is no need for the nurse to stand her ground to save face. The goal is to deescalate the situation. When the client makes a request that can be met without compromising safety, granting the request is acceptable.REF: Page 520-521

Peter, a 21-year-old patient, asks you, "What's wrong with my brain that I have such a problem with aggression?" Your response is based on the knowledge that: A. the prevailing theory is that diminishment of stress hormones causes anger and aggression. B. no abnormalities of the brain have been identified that correlate with anger and aggression. C. the limbic system, the prefrontal cortex, and neurotransmitters have been implicated in playing a part in aggression. D. personality type plays a much greater part in anger and aggression than physical factors.

C. the limbic system, the prefrontal cortex, and neurotransmitters have been implicated in playing a part in aggression. These have all been implicated by research as playing a part in anger and aggression. The other responses are untrue.Cognitive Level: Apply (Application)Nursing Process: ImplementationNCLEX: Psychosocial IntegrityText page: 516

A nurse is conducting group therapy with a group of clients. Which of the following statements made by a client is an example of aggressive communication? A. "I wish you would not make me angry" B. "I feel angry when you leave me." C. "It makes me angry when you interrupt me." D. "You'd better listen to me"

D

You are working in the emergency department. You notice Matt, your patient's husband, pacing in the hallway, muttering to himself, and looking angrily around the emergency department. Which of the following statements to Matt may help prevent escalation and/or violence? A. "You need to stay with your wife. She needs you." B. "Hey, what's up buddy? You look pissed." C."I am calling security to deal with your behavior." D. You appear upset. Can I help you with anything?"

D. "You appear upset. Can I help you with anything?" Approaching a patient or a visitor with a calm, sincere, and caring manner can de-escalate a situation because the person may feel you are interested in helping. The other responses will not prevent escalation and may in fact anger the person further.Cognitive Level: Analyze (Analysis)Nursing Process: ImplementationNCLEX: Safe and Effective Care EnvironmentText page: 520

A client waiting to see the physician is pacing and looking both angry and tense. When it's determined that the client won't be seen for another 30 minutes, the nurse addresses the client's agitation by A. telling the client that pacing will not help the rate at which clients are seen. B. adjusting the appointment schedule to allow the client to be seen next. C. empathizing with the long wait and asking the client if he would mind sitting down until his turn comes. D. explaining to the client what caused the back-up and suggesting that he has time to go to the coffee shop.

D. explaining to the client what caused the back-up and suggesting that he has time to go to the coffee shop. Taking time to explain to clients and offering measures that will provide comfort can be helpful in reducing tension and anger associated with waiting.REF: Page 521

A client experiencing manic hyperactivity stands up, glares challengingly at clients and staff, and shouts, "This food is garbage! I'll fight anyone who says it's not!" The nurse's most relevant assessment is that the client A. is upset with the quality of the food. B. is getting rid of tension in a harmless way. C. is frustrated by limits imposed by hospitalization. D.has a high potential for other-directed violence.

D. has a high potential for other-directed violence. The client's offers to fight are suggestive of a high potential for violence. Clients may have coping skills that are adequate for day-to-day events in their lives but are overwhelmed by the stresses of illness or hospitalization. Other clients may have a pattern of maladaptive coping, which is marginally effective and consists of a set of coping strategies that have been developed to meet unusual or extraordinary situations.REF: Page 516-517

A client has a history of demonstrating aggression physically. An appropriate short-term goal to help the client manage this anger is to A. strike objects rather than people. B. limit aggression to verbal outbursts. C. isolate in lieu of striking people. D. identify situations that precipitate hostility.

D. identify situations that precipitate hostility. The identification of situations that create hostile feelings must occur if the client is to develop new coping strategies.REF: Page 527

A client has been placed in seclusion to control aggressive behavior. Care while the client is secluded should include A. observation every 30 minutes. B. releasing the client every 8 hours. C. releasing the client every 8 hours. D. providing for nutrition and hydration.

D. providing for nutrition and hydration. Clients must be given meals on schedule and frequently offered cold liquids in paper cups (at least every 2 hours; hourly if the client is highly hyperactive).REF: Page 521

Nurses coping with angry clients may find it helpful to remember that anger and aggression begin as feelings of A. isolation. B. confidence. C. competence. D. vulnerability.

D. vulnerability. The progression is vulnerability, perception of event as a threat, arousal, and then uneasiness and anxiety.REF: 526