Psych Exam 1 - Ch. 27 (Anger, Aggression, & Violence)

The nurse is performing an assessment on a patient engaged in a recent act of violence. Which patient behavior causes the nurse to believe the patient could become violent again?

The patient has a fixed facial expression. Having a fixed facial expression is a sign of increasing anxiety or tension, which can be an indicator of violence in a patient who was recently violent. Speaking slowly, standing close to others, and fumbling words are not signs that typically precede violence. p. 507

An adolescent male is swearing and shouting at his healthcare provider, who refused to give him a pass to leave the unit. Which of the following is true about this behavior?

Is a major indicator that the patient may become physically aggressive Physical aggression is preceded by anger, which may be expressed by swearing and shouting, pacing, and other menacing behaviors. p. 507, Box 27.1

A nurse attempts to intervene verbally when an angry patient initially threatens to throw a chair but quickly focuses the anger toward the nurse. Several staff members gather behind the nurse, but then the patient shouts, "I will calm down when that nurse isn't in my face." The nurse best demonstrates the ability to help the patient de-escalate by doing which of the following?

Moving to the rear of the staff group There is no need for the nurse to stand his or her ground to save face. The goal is to deescalate the situation. When the patient makes a request that can be met without compromising safety, granting the request is acceptable. p. 509, Box 27.2

An elderly patient with Alzheimer disease is wandering in the in-patient units. When the nurse asks the patient about the reason, the patient starts yelling. This patient has a history of violence. What is the best possible response of the nurse?

"Do you want to go to your room or to a quiet room for a while?" It is important for a nurse to know how to communicate effectively with an angry patient. The nurse should try to understand the feelings behind the anger of the patient and give a few options to the patient to relieve the anger. This encourages the patients to take responsibility for the choices they have made. The nurse asking whether the patient wants to go back to the room or to the quiet room for a while reduces the sense of powerlessness in a patient which is often the reason behind aggression. The nurse should not threaten the patient by saying that the nurse would complain to the head nurse about the patient. The patient needs to be comforted, so the nurse should not order the patient to go back to their room. The patient does not need the nurse's permission to walk around in the ward. pp. 508-509

A patient is pacing in the hallway, muttering to him- or herself, and looking angrily around the unit. Which statement made to the patient may help prevent escalation of violence?

"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 one is interested in helping. The responses "You need to stay calm. You don't want trouble," "Hey, what's up buddy? You look angry," and "I am calling security to deal with your behavior" will not prevent escalation and may in fact anger the person further. p. 508

Which medical condition is associated with aggressive behavior? (SATA)

-Alzheimer disease -Traumatic brain injury -Temporal lobe epilepsy -A prefrontal cortex tumor Many neurological conditions are associated with anger and aggression. For example, certain brain tumors, Alzheimer disease, temporal lobe epilepsy, and traumatic injury to certain parts of the brain result in changes to personality that include increased violence. Many patients with brain injury have severe behavior disorders that disrupt their lives, including aggressiveness. The prefrontal cortex also has been identified as playing an important role in aggressive behavior. This was first noted in persons who had lesions or injury that caused aggressive behavior . There is no current research to support a connection between hydrocephalus and aggressive behavior. pp. 505-506

The nurse is caring for a patient who requires the use of mechanical restraints. Which actions does the nurse take to comply with restraint guidelines? (SATA)

-Monitoring the patient's vital signs -Checking the patient's feet for blood flow -Notifying the patient's guardian, health advocate, or relative -Documenting the patient's behavior leading up to the restraint Specific guidelines to follow when restraining a patient include monitoring the patient's vital signs, documenting the patient's behavior leading up to the restraint (to justify the use of the restraints), checking the patient's feet and hands for blood flow (to ensure adequate circulation with the restraints on), and notifying the patient's guardian, advocate, or relative of the need to use the restraints. The nurse records the patient's status in the medical record every 15 minutes, not 10 minutes. The nurse does not feed the patient intravenously while he or she is in restraints unless that was part of the care plan prior to restraint. Test-Taking Tip: Be alert for details about what you are being asked to do. In this Question Type, you are asked to select all options that apply to a given situation or patient. All options likely relate to the situation, but only some of the options may relate directly to the situation. p. 512

Which intervention is appropriate when addressing possible comorbid conditions observed in patients with a history of violent outbursts? (SATA)

-Regular monitoring of blood pressure -Assessment for indications of substance abuse -Providing education regarding signs of an impending stroke -Role-playing scenarios related to healthy expression of anger A great deal of research has been done on aggression and violence in persons with substance use disorders. Anger also coexists with depression, anxiety, psychosis, and personality disorders. Anger and hostility have effects on physical well-being; they are risk factors for hypertension and cardiovascular disease, including ischemic heart disease and cerebral vascular attacks. It is unrealistic to remove all triggers and doing so would not support the learning of anger management skills. p. 505

A nurse teaches de-escalation techniques to the caregiver of a patient with Alzheimer disease who often becomes aggressive. What appropriate actions followed by the patient's family indicate effective teaching? (SATA)

-Spending more time with the patient -Responding immediately to patient needs -Giving options when the patient demands something De-escalation techniques are used to control the aggressive behavior of the patient. The patients should be attended to as soon as possible because a delay makes the patient feel rejected and worsens aggression. Patients must be given several options when they become demanding and if their demands are irrational. This helps the patient to understand the possible options and enhances the patient's ability to make decisions. This also helps to teach responsible behavior to the patient. The caregiver should spend more time with the patient to understand the stressors and their perceptions. Showing sympathy to the patients can further annoy them. Both verbal and nonverbal communication must be used while interacting with the patient to give clear information to the patient. p. 509, Box 27.2

In a workshop, a nurse has taught anger management techniques to inmates at a jail. Which behavior shown by the inmates indicates effective teaching by the nurse? (SATA)

-The inmates prefer to listen to music every day. -The inmates refrain from bullying the group members. -The inmates maintain a diary to write about aggressive episodes. Patients with a history of violence are at risk for other-directed violence. The effective treatment outcome will be that the patient avoids argument with and stops bullying others. The patient developing self-control indicates an effective treatment outcome. The patient following stress management techniques like listening to music also indicates effective treatment outcomes. The patient identifying situations that increase aggression indicates that the treatment is effective. Gathering personal information of other inmates and minimal interaction with other inmates are suggestive of ineffective treatment outcomes. p. 509, Table 27.1

A primary healthcare provider prescribed mechanical restraint of an aggressive patient with epilepsy. What actions should the nurse take while restraining the patient? (SATA)

-The nurse should provide food and fluids to the patient. -The nurse should observe the blood flow in hands and feet. -The nurse should avoid raising the side rails up on all four sides of the bed. While restraining, the nurse should make sure that the restraints do not obstruct blood flow to the patient's hands and feet. Food and fluids should be provided to the patient during restraining. All four side rails must not be kept up with patients with epilepsy and seizures. It can be fatal if the patient gets seizures during restriction. The nurse should chart the patient's vital signs every 15 minutes. The reason for restriction must be explained after the process of restriction, not during the restriction. The patient must be given assurance that he or she will not be restrained if he or she controls his or her behavior. p. 512, Box 27.3

What is the best definition of anger?

A normal response to a perceived threat Anger is one of the primary emotions and is not in itself a disorder. Anger is not defined as an unhealthy way of releasing anxiety, doing intentional harm to others, or an expression of conflict with others. p. 505

Which patient has the highest risk for violence?

A patient with a history of violence A history of violence is the single best predictor of future violence. Most reactions to stimuli come from one's previous experiences. Patients diagnosed with schizophrenia or with poor coping skills may express themselves in many ways, but not necessarily through violence. Patients diagnosed with antisocial personality disorder have a higher risk of violence. p. 508

A patient with diabetic nephropathy requests chocolates and gets aggressive when the nurse denies the request. The patient abuses the staff when the staff refuses to fulfill the demands. What appropriate action should the nurse take for an effective patient-nurse communication?

Acknowledge the patient's demand Acknowledging the demands and needs of the aggressive patient makes the patient feel that the nurse is available to help. The nurse should set the goals and should clearly explain the patient's need to control aggressive behavior and anger. The nurse should make the eye contact at the same level to decrease the sense of intimidation in the patient. The aggressive patient can cause physical harm, so the nurse should maintain a distance of one foot farther than the patient can reach with their arms or legs, and avoid sitting any nearer to the patient. The nurse should not counsel the patient in an isolated room. The nurse should counsel in a room which is visible to the staff. This would be helpful in ensuring the nurse's safety. pp. 508, 513

The nurse is studying about the functions of the different parts of the brain. Which area of the brain is associated with aggression?

Amygdala Different areas in the brain control different functions of the body. The area of the brain which is known to be associated with aggression is the amygdala, which is a part of the limbic system. The limbic system mediates primitive emotions and behaviors which are required for the survival of a person. Cochlea is not a part of the brain. It is the auditory portion of the inner ear. Carotid body refers to the group of receptors present in the bifurcation of the carotid artery. It detects changes in blood pressure. The parotid gland is not a part of the brain, but part of the salivary glands. pp. 505-506

An aggressive elderly patient was prescribed risperidone. Which nursing intervention is useful to prevent the adverse effects of the drug?

Checking the patient's blood pressure regularly Risperidone is a second-generation antipsychotic drug. It can cause hypotension in the patient and increase the risk of stroke in the elderly. Therefore, the nurse should regularly check the patient's blood pressure. Muscle rigidity must be tested when haloperidol is prescribed to the patient, as it causes extrapyramidal side effects like tremors and muscle rigidity. Dehydration is also caused due to haloperidol, so patients must be given excessive fluids to keep hydrated. Liver functioning must be assessed when lorazepam is prescribed to the patient, as it causes hepatic dysfunction. p. 510, Table 27.2

The nurse is encouraged about the patient who has displayed aggressive behavior in the past when the patient is observed doing which of the following?

Going to his or her room when suggested to do so by staff. It is very encouraging that the patient is willing to remove him- or herself with little prompting. This demonstrates the beginning of self-control. Sitting quietly and sharing the newspaper with others show no indication that the patient is feeling aggressive at this point and so there is no indication of self-control. Making the comment to another patient reflects little indication of self-control but rather warning to the other individual. p. 508

A patient experiencing manic hyperactivity stands up, glares challengingly at patients and staff, and shouts, "This food is garbage! I'll fight anyone who says it's not!" What is the nurse's most relevant assessment of the patient?

Has a high potential for other-directed violence. The patient's offers to fight are suggestive of a high potential for violence. Patients 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 patients 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. pp. 509, 515, Table 27.2

The nurse is giving information about drugs used in the long-term management of chronic aggression. Which drug is used for the management of aggression in children with attention deficit/hyperactivity disorder (ADHD)?

Psychostimulants Psychostimulants are the drug of choice in the management of chronic aggression for children with ADHD. Lithium is used for patients with antisocial behavior, mental retardation, or brain injury. Gabapentin and benzodiazepine are used for patients with anxiety disorder or personality disorder. p. 511, Table 27.3

A patient with schizophrenia and history of chronic aggression is treated with propranolol, a beta blocker, for aggressive behavior. The patient has been recently diagnosed with asthma. Which change in the prescription does the nurse expect for the patient?

Replace propranolol with a different drug should not be given to patients with asthma, as it is a beta-blocker and can constrict the airways. Therefore, the patient should be advised to stop propranolol and consult the primary health-care provider for further advice regarding the drug to be used for aggressive behavior. Increasing the dose of a beta-blocker may worsen the patient's asthma symptoms. Decreasing the dose will not be effective in reducing aggression in the patient. Continuing propranolol at the same dose may lead to complications such as airway restriction. p. 511, Table 27.3

The nurse finds that a patient is clenching fists, pacing the rooms, and is hyperactive. The nurse learns that the patient had assaulted a friend a few years ago and had been a victim of domestic violence when young. The patient also has a history of cocaine addiction. What is the most appropriate nursing diagnosis for this patient?

Risk for other-directed violence The body language of the patient and the history indicate that the patient is prone to aggression. The patient may show violence towards others. Therefore, the most appropriate nursing diagnosis would be risk for other-directed violence. The symptoms and signs of stress overload include feelings of anger, tension, and difficulty in functioning due to stress. A patient with a diagnosis of ineffective coping has difficulty with simple tasks, verbalizes inability to cope, and is unable to work at previous levels. Risk for self-directed violence is the diagnosis used when a patient has suicidal ideation or has a history of self-harm. p. 509, Table 27.1

What is the most restrictive method for dealing with an aggressive patient who is out of control?

Seclusion Seclusion is the most restrictive method listed, because it curtails the patient's freedom of ambulation. A show of force, verbal intervention, and antipsychotic medication are not as restricting. pp. 511-512

When a patient diagnosed with a cognitive deficit experiences a catastrophic reaction, which of the following is the priority intervention?

Smile and call the patient by name. Getting the patient's attention by calling his or her name is necessary. Smiling is necessary to convey the lack of a threat. p. 516

Which intervention strategy should be avoided by staff working with a patient who is shouting and flailing his or her arms?

Striving to speak a little louder than the patient It is important to speak to the patient slowly and in short sentences, using a low and calm voice. Never yell but continue to model controlled behavior. Trying to get the patient to go to his or her room, having staff provide a show of force, and allowing one person to speak to the patient are constructive approaches to deescalation. p. 508

A student nurse is told to assist one of the senior staff with a patient having a catastrophic reaction. What should the student nurse understand by the term catastrophic reaction?

The patient is screaming out of overwhelming fear due to impaired cognition. Patients with a cognitive disorder can have episodes of severe agitation or aggression, where they may scream, strike out, or cry because of overwhelming fear. Such reactions are called catastrophic reactions. It does not mean assault, being unable to be calmed, or sudden aggressive behavior. p. 516

A female Korean patient complains of anger, irritability, insomnia, and anorexia. The patient also complains of headaches and palpitations. The nurse observes that the patient frequently sighs during the interview. What is the most appropriate approach toward the management of this patient?

The patient needs stress management education and psychotherapy. The above-mentioned symptoms and signs of the patient indicate that she most likely has a disorder called hwa-byung. This is an anger syndrome commonly seen in Koreans. It is usually observed in middle-aged Korean women. Anger, irritability, anorexia, insomnia, cardiovascular symptoms like palpitations and frequent sighing are some of the symptoms of this syndrome. The best approach for treatment of these patients is stress management education, psychotherapy, psychopharmacology, acupuncture, music, and drama therapy. It is inappropriate to consider hospital admission, ECG, or blood tests for this patient. p. 506

The nurse interacts with a patient waiting to consult a primary healthcare provider. The nurse finds that the patient has aggressive behavior. Which symptoms in the patient would have led the nurse to conclude this?

The patient talks indistinctly and quietly. The nurse can assess violent behavior in the patient by checking the patient's symptoms. The patient may mumble or talk indistinctly and quietly, making it difficult for others to hear. A patient with violent and aggressive behavior does not make vague statements. That is seen in schizophrenic patients. Patients with violent and aggressive behavior are restless and have excessive movement. These patients can make decisions. Decision-making ability is impaired in severe anxiety as decision-making skills get disrupted. p. 507, Box 27.1

Which patient is at the highest risk for violence directed at others?

The patient who has been abusing alcohol all day. The patient who is intoxicated is at an increased risk for violence. p. 507, Box 27.1

What term is used to identify the concept that violence may result from a history of victimization?

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 patient's past experiences of violence or trauma and the role it currently plays in his or her life. Shared governance and learned helplessness do not refer to a care concept that helps reduce violence. p. 507