CH 27- Anger, aggression, violence

Nurses coping with angry clients may find it helpful to remember that anger and aggression begin as feelings of which personal characteristic?

Isolation

Confidence

Hopelessness

Vulnerability

Vulnerability

The progression is vulnerability, perception of event as a threat, arousal, and then uneasiness and anxiety. Anger is not as influenced by any of the other options.

Which event is most likely to contribute to a client's escalating anger?

Watching violence on television

Another client's depressed mood

A staff member challenging them

A staff member asking them to help another client

A staff member challenging them

Punitive, threatening, accusatory, or challenging statements to the client should be avoided since they are likely to escalate the client's anger. None of the other options is as likely to escalate existing angry behavior.

Which nursing diagnosis is the priority when planning care for a client who displays considerable anger and occasional aggression?

Social isolation

Risk for other-directed violence

Ineffective coping: overwhelmed

Ineffective coping: maladaptive

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.

How is anger best defined?

An unhealthy way of releasing anxiety

Doing intentional harm to others

An expression of conflict with others

A normal response to a perceived threat

A normal response to a perceived threat

Anger is an emotional response to frustration of desires, a threat to one's needs (emotional or physical), or a challenge. It is a normal emotion that can even be positive when it is expressed in a healthy way. All the other options describe anger as being abnormal and/or dysfunctional

Which neurotransmitter imbalance has been shown to be related to impulsive aggression?

Low levels of ã-aminobutyric acid

Low levels of serotonin

High levels of norepinephrine

High levels of acetylcholine

Low levels of serotonin

Low serotonin levels have been implicated in several research studies as being a factor in impulsive aggression. Research does not support any of the other options.

Which assessment finding is the best predictor of violence in a newly admitted client?

A recent assault on a drinking companion

A family history of bipolar disorder

The nurse's subjective feeling that the client is uncooperative

A childhood history of being bullied at school

A recent assault on a drinking companion

The best predictor of violence is past episodes of violent behavior. None of the remaining options have the predictability of a previous demonstration of anger.

A client has a history of demonstrating aggression physically. What short-term goal will best help the client manage this anger?

Strike objects rather than people.

Limit aggression to verbal outbursts.

Isolate in lieu of striking people.

Identify situations that precipitate hostility.

Identify situations that precipitate hostility.

The identification of situations that create hostile feelings must occur if the client is to develop new coping strategies. All the remaining options only suggest limiting the anger.

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 that focuses on behavior therapy concepts?

Telling him they will not change his dressing if he is going to abuse them.

When the client begins to become abusive, the nurse suggests returning in 20 minutes when he has regained control.

Assuring him they will complete the dressing change as quickly as possible.

Explaining that they are professionals and unused to being shouted at by people they are trying to help.

When the client begins to become abusive, the nurse suggests returning 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). None of the other options demonstrates behavior therapy

Which characteristic places the client at highest risk for violence directed at others?

Has a history of recurrent severe depression

Is in an alcohol rehabilitation program

Has delusions of persecution

Is experiencing somatic symptoms for which no organic basis is found

Has delusions of persecution

The client who perceives others to be against him/her may lash out if he/she feels threatened. Depression and somatic symptoms are risk factors for self-directed violence.

A client has been placed in seclusion to control aggressive behavior. Nursing care while the client is in mechanical restraints should include which intervention?

Observation every 30 minutes

Releasing the client every 8 hours

Increasing sensory stimulation

Providing regularly scheduled nutrition and hydration

Providing regularly scheduled 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). None of the remaining options present accurate information about the management of a client in mechanical restraints.

An adolescent male is swearing and shouting at his physician who refused to give him a pass to leave the unit. What is the primary importance of this behavior?

It is acceptable if directed at staff but not when directed at other clients.

It may reduce tension and prevent the client from physically acting out.

It is a major indicator that the client may become physically aggressive.

It can be attributed to lack of parental controls applied at an early age.

It 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. It is not acceptable behavior regardless of its focus nor is it generally associated with a lack of parental controls. The release of tension is not the focus of this question

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 implementing which intervention?

Continuing to manage the situation personally.

Telling the client, "It isn't safe for me to leave the room."

Moving outside of the client's personal space.

Apologizing for upsetting the client.

Moving outside of the client's personal space.

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. None of the other options are addressing the client's reasonable request

The nurse in an emergency department notices a patient's husband, pacing in the hallway, muttering to himself, and looking angrily around the emergency department. Which statement should the nurse make to the spouse to help prevent escalation and/or violence?

"You need to stay with your wife. She needs you."

"Hey, what's up? You look out of control."

"I am calling security to deal with your behavior."

"You appear upset. Can I help you with anything?"

"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.

DIF: Cognitive Level: Analyze (Analysis)REF: page 14TOP: Nursing Process: ImplementationMSC: NCLEX: Safe and Effective Care Environment

A 21-year-old client asks the nurse, "What's wrong with my brain causing me to be so angry and aggressive?" The nurse's response should be grounded on what research-supported basis?

The diminishment of stress hormones causes anger and aggression.

No abnormalities of the brain have been identified that correlate with anger and aggression.

The limbic system, the prefrontal cortex, and neurotransmitters have been implicated in playing a part in aggression.

Personality type plays a much greater part in anger and aggression than physical factors.

The limbic system, the prefrontal cortex, and neurotransmitters have been implicated in playing a part in aggression.

Research has supported the theory that the brain's limbic system and prefrontal cortex as well as some neurotransmitters play a part in anger and aggression. None of the other options are supported by current research.

DIF: Cognitive Level: Apply (Application)REF: pages 4, 5TOP: Nursing Process: ImplementationMSC: NCLEX: Psychosocial Integrity

What older concept of care is being used currently to help in violence reduction in disruptive clients?

Aired grievances

Trauma-informed care

Shared governance

Learned helplessness

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. None of the other options refer to a care concept that helps reduce violence.

DIF: Cognitive Level: Understand (Comprehension)REF: page 9TOP: Nursing Process: PlanningMSC: NCLEX: Psychosocial Integrity

You are working on an adolescent psychiatric unit. A 16 year old being treated on an adolescent psychiatric unit has become angry and is in the hallway yelling, "It's not fair! You all hate me! I hate this place!" When the client begins pounding his/her fists on the wall the nurse should attempt to de-escalate the situation by providing which response?

"I will help you calm down. Do you want to go to your room and talk or go to the quiet room?"

"You may yell and bang your fists but you must do it in your own room so you don't upset the other patients."

"Stop that right now! I will not allow you to behave like that!"

"You will have to go into seclusion and restraints right now in order to be safe."

"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 himself/herself if left alone in his/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.

DIF: Cognitive Level: Analyze (Analysis)REF: page 15TOP: Nursing Process: ImplementationMSC: NCLEX: Safe and Effective Care Environment

When approaching a client who is acting out aggressively, what interventions should the nurse implement to assure personal safety?

Stand close to the client for reassurance and to convey caring.

Have other staff as backup, and stay out of the client's personal space.

Take the client to his/her room so that his/her privacy will be protected.

Call security and wait until they arrive before approaching the client.

Have other staff as backup, and stay out of the client's personal space.

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. None of the other options focus appropriately on staff safety; security personnel may escalate the patient's behavior and should be kept in the background until needed to assist. Furthermore, being alone in the client's room is not a safe environment when aggressive behavior is being demonstrated.

DIF: Cognitive Level: Apply (Application)REF: page 15TOP: Nursing Process: PlanningMSC: NCLEX: Safe and Effective Care Environment