Chapter 11: Anger, Hostility, and Aggression
The nurse is working with a client that becomes angry at something that was said and starts throwing things at the nurse and being physically threatening. Which action is appropriate at this time?
A. All staff should act to take charge of the situation.
B. The client must be restrained or sedated at once.
C. Staff should avoid communicating with the client and walk away.
D. Four to six trained staff members are needed to restrain the client.
Answer: D
Rationale: Four to six trained staff members are needed to restrain, with four staff members each handling a limb and one protecting the client's head and one helping control the client's torso, if needed. When a client becomes physically aggressive, the staff must take charge of the situation for the safety of the client, staff, and other clients. Only staff with training in safe techniques for managing behavioral emergencies should participate. All staff may not have had this training, and if the team is not working in a cooperative and coordinated fashion, it is less safe to restrain the client. The nurse should follow the facility's protocols and standards for restraint and seclusion. Staff should inform the client that their behavior is out of control and that the staff is taking control to provide safety and prevent injury.
Due to an increase in reported violence at the college, a nurse at the health services clinic has been asked to meet with a freshman class about warning signs of relationship violence. Which warning sign will the nurse emphasize to the group to be cognizant of?
A. Dislikes the person's friends
B. Acts indifferently to the person's life choices
C. Is excessively jealous
D. Views the person as superior
Answer: C
Rationale: Excessive jealousy is a notable warning sign of possible relationship violence. Abusers often see themselves as superior to the person being abused. An abuser may be excessively involved in the person's life choices and highly opinionated, not indifferent. Controlling the person's choice of friends is a warning sign of abuse, but simple dislike is not necessarily a warning sign.
A nurse is talking to a client, who quietly and with a flat affect tells the nurse about arriving at the scene of an automobile–pedestrian accident 3 days ago. The client performed CPR on a victim, but it was unsuccessful. Which statement by the nurse would be most appropriate?
A. "Tell me what you saw."
B. "That is horrible!"
C. "Why did you perform CPR?"
D. "I know how you feel; the same thing happened to me several years ago and I never recovered."
Answer: A
Rationale: One of the most effective ways of avoiding pathologic responses to trauma is effectively dealing with the trauma soon after it occurs. Describing what the client saw may be very helpful. "That is horrible," is a judgment and is not likely to be helpful. "Why did you perform CPR," might make the colleague feel defensive. "I know how you feel; the same thing happened to me several years ago and I never recovered," is nonsupportive and robs the colleague of any hope that they will recover.
The nurse is teaching a client with an anxiety disorder ways to manage anxiety. Which will the nurse discuss with the client about the appropriate time for practicing relaxation techniques?
A. Reserve for episodes of panic.
B. Use as needed when experiencing severe anxiety.
C. Practice the techniques when calm.
D. Practice when meeting with a therapist.
Answer: C
Rationale: The nurse can teach the client relaxation techniques to use when they are experiencing stress or anxiety, including deep breathing, guided imagery and progressive relaxation, and cognitive restructuring techniques. For any of these techniques, it is important for the client to learn and to practice them when they are relatively calm. These techniques are most effective when implemented before the client's anxiety reaches a severe level or a panic. The client may be taught these techniques by a therapist but does not usually have an opportunity to practice them during a therapy session.
After an angry outburst, a client quickly appears calmer and receptive to input from the nurse. Which is the most helpful response to the client at this time?
A. "We will have to talk about this later."
B. "You really scared me. I'm glad you are okay."
C. "What happened that got you so upset?"
D. "Your behavior is unacceptable and will not be tolerated?"
Answer: C
Rationale: As the client regains control, they are encouraged to talk about the situation or triggers that led to the aggressive behavior. The nurse should help the client relax, perhaps sleep, and return to a calmer state. Talking about the event at a later time does let the client rest, but it does less to address the client's feelings associated with the angry outburst. The client should not be chastised for the behavior since it is nontherapeutic and achieves nothing.
A college student comes to the counseling center and tells the nurse that they fear their partner. The student states, "My partner is so jealous and overprotective. My partner wants to know where I am and who I'm with every minute." Which is the best response by the nurse?
A. “Are you sure you are not overreacting to their feelings for you?”
B. “You will need to obtain a restraining order.”
C. “It sounds like they are simply insecure and need reassurance.”
D. “This is characteristic of the tension-building phase of the violence cycle.”
Answer: D
Rationale: In tension building, the abuser attempts to establish complete control over all the person's actions. It is more appropriate for the nurse to listen to the client, rather than to judge whether the client is overreacting. This may or may not require legal measures such as a restraining order. It would be unsafe and non-therapeutic to presume that the student is overreacting. The boyfriend's actions may be motivated by insecurity, but the student's need for safety and violence prevention is more important than meeting the boyfriend's security needs.
The nurse is creating a plan of care for a client with posttraumatic stress disorder (PTSD), who has frequent flashbacks. Which intervention will the nurse include in this plan?
A. Encourage repression of memories associated with the traumatic event.
B. Explain that physical symptoms are unrelated to the psychological state.
C. Teach grounding techniques to avoid or diminish episodes.
D. Discuss that the event has no basis in reality.
Answer: C
Rationale: The client needs to confront the feared emotions, situations, and thoughts associated with the trauma rather than attempting to avoid them. Various relaxation techniques are employed to help the client tolerate and manage the anxiety response. The event has an intensely real meaning for the client, which can often manifest in physical symptoms related to sympathetic stimulation.
A client asks the nurse, "Why do I have to go to counseling? Why can't I just take medications?" Which is the most appropriate response by the nurse?
A. "Both therapies are effective. You can eventually choose one or the other."
B. "You cannot get the full effect of your medications without cognitive therapy as well."
C. "As soon as your medications reach therapeutic level, you can omit the therapy."
D. "Medications combined with therapy help you change how well you function."
Answer: D
Rationale: Treatment for anxiety disorders usually involves medication and therapy. This combination produces better results than either one alone. These interventions complement one another and are not mutually exclusive. The effectiveness of medications is not wholly dependent on cognitive therapy.
After an angry outburst, the client is tearful and remorseful. Which statement by the nurse would be most supportive?
A. "You still need to work on your problem-solving skills."
B. "I will not allow you to get that angry again."
C. "You should not have let your anger build up like it did."
D. "What could you have done when you first started to feel angry?"
Answer: D
Rationale: In the postcrisis phase, 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 nurse is assessing an older adult in the emergency department. The client has many bruises on the body in varying stages of healing. After documenting the bruising in the assessment, what will the nurse do next?
A. Ask the client when and how the bruises occurred.
B. Call the nursing supervisor immediately.
C. Follow the facility's policy and procedures for reporting abuse.
D. Notify the health care provider that abuse is suspected.
Answer: A
Rationale: The nurse should not assume the bruises were caused by abuse; the client's explanation is an important step in the assessment of potential abuse. A nurse must assess for abuse prior to getting the supervisor and health care provider involved. Reporting abuse would be initiated after a thorough assessment.
A client tells a nurse about recent episodes of strange behavior that the client cannot recall but has discussed with family. The client reports being told of going out late at night dressed, but not in the usual wardrobe but without recall of the event. Which is the best response by the nurse?
A. “You should tell the family members to record this event when it happens.”
B. “Let’s talk with your family to be sure you are kept safe when this occurs.”
C. “You are probably just sleep walking which occurs in a lot of people during stress.”
D. “You may want to watch what you are eating and drinking in the evening.”
Answer: B
Rationale: The priority issue is the client’s safety since when experiencing these episodes, harm could easily come to them from wandering. Recording the episode may be helpful when seeking help from a therapist but is not the priority action. Although the client may be sleep walking, the nurse is not offering any information related to the episodes. The nurse should be specific when informing the client to watch what they are eating and drinking in the evening before going to bed. This would not likely have an effect on the client’s wandering.
A client asks how the client's prescribed alprazolam helps the client's anxiety disorder. The nurse explains while teaching the client about medications that antianxiety medications such as alprazolam affect the function of which neurotransmitter that is believed to be dysfunctional in anxiety disorders?
A. Serotonin
B. Norepinephrine
C. Gamma-aminobutyric acid (GABA)
D. Dopamine
Answer: C
Rationale: GABA is the amino acid neurotransmitter believed to be dysfunctional in anxiety disorders. GABA reduces anxiety, and norepinephrine increases it; researchers believe that a problem with the regulation of these neurotransmitters occurs in anxiety disorders. Serotonin is usually implicated in psychosis and mood disorders. Dopamine is indicated in psychosis.
The nurse will be working in a unit with a client that is known to become aggressive. Which action will the nurse take to deal effectively with this client?
A. Reflect on abilities to handle the nurse’s own feelings of anger.
B. Learn professional skills of anger management.
C. Become proficient using reflective communication techniques.
D. Understand how to activate crisis response teams.
Answer: A
Rationale: The nurse must be aware of how they deal with anger before helping clients do so. The nurse who is afraid of angry feelings may avoid a client's anger, which allows the client's behavior to escalate. If the nurse's response is angry, the situation can escalate into a power struggle, and the nurse loses the opportunity to "talk down" the client's anger. Identifying how the nurse handles angry feelings is an initial task. Once the nurse understands their own experiences with anger, the clients can be helped through learning the use of assertive communication and conflict resolution. Increasing skills in dealing with angry feelings will help the nurse to work more effectively with clients. Activating a crisis response is a late option in dealing with anger.
A nurse is working with a client who has a history of repeated abusive intimate relationships. The nurse has difficulty understanding why a person would repeatedly enter into relationships with abusive partners. When working with this client, the nurse can best maintain a therapeutic relationship through which approach?
A. Keeping focused on the client's feelings about the client's life situation
B. Honestly asking the client why the client repeats the cycles of victimization
C. Convincing the client to develop a self-rescue plan
D. Not prying into the details of the client's private life
Answer: A
Rationale: The nurse must focus on the client's feelings and emotional needs in order to establish and maintain a therapeutic relationship. Asking the client why they do not end the violence is likely to be perceived as judgmental. Pushing the client to create a self-rescue plan may be practically necessary but this action does not necessarily enhance the therapeutic relationship. Empathic engagement with the details of the client's private life is necessary in order for the nurse to generate rapport.
A client is suspected to have dissociative identity disorder. Which characteristic does the nurse identify that the disturbed personal identity is most likely related to?
A. Poor impulse control
B. Chronic low self-esteem
C. High risk for self-directed violence
D. Unresolved childhood abuse issues
Answer: D
Rationale: With dissociative identity disorder (formerly multiple personality disorder), the client displays two or more distinct identities or personality states that recurrently take control of their behavior. Nearly all clients with dissociative identity disorder, resulting in disturbance of personal identity, have a history of having been abused in childhood. Disruptions to impulse control, low self-esteem, and risk for self-harm are effects, not causes, of dissociative identity disorder.
A nurse begins working in an outpatient behavioral health clinic for clients with panic disorders. Which outcome(s) will the nurse evaluate for these clients to determine effectiveness of treatment? Select all that apply.
A. The client will be able to use relaxation techniques when a panic attack begins.
B. The client will use cognitive restructuring techniques to avoid a full panic attack.
C. The client will decrease stressors and avoid anxiety producing activities.
D. The client will take antianxiety medication when they are experiencing a panic attack.
E. The client will self-isolate when they are triggered with a panic attack
Answer: A, B, C
Rationale: The nurse will determine the plan of care and use ongoing assessment to determine if the plan of care is working and evaluate this plan frequently. The client outcomes for panic attacks will be to help educate regarding technique such as cognitive restructuring, relaxation, decreasing stressors, and avoiding anxiety-producing activities. The client should not be isolated or alone when a panic attack occurs to prevent injury or harm. Antianxiety medication may be prescribed to use daily and not only during a panic attack. It may be too late and the onset too long to be effective.
The nurse will be transferred to a behavioral health unit to work. Which issue would be most important for the nurse to be aware of when working with angry, aggressive, or violent clients? Select all that apply.
A. Be aware of their own feelings about anger and use of assertive communication and conflict resolution.
B. The nurse should not allow themselves to become angry under any circumstances.
C. The nurse must be aware that a client's anger or aggressive behavior is completely preventable.
D. Discuss situations or the care of potentially aggressive clients with experienced nurses.
E. Be calm, nonjudgmental, and nonpunitive when using techniques to control aggressive behavior.
Answer: A, D, E
Rationale: Nurses must identify how they handle angry feelings and assess their use of assertive communication and conflict resolution. Increasing their skills in dealing with their angry feelings will help the nurses to work more effectively with the client. Nurses must not take the client's anger or aggressive behavior personally or as a measure of their effectiveness as a nurse. Nurses must discuss situations or the care of potentially aggressive clients with experienced nurses. Nurses must be calm, nonjudgmental, and nonpunitive when using techniques to control a client's aggressive behavior.
The nurse is caring for a client that comes to the clinic after experiencing intimate partner violence and sustaining a fractured arm and jaw. Which statement(s) by the nurse is most therapeutic? Select all that apply.
A. “You both need couples counseling.”
B. “How could anyone do this to another person?”
C. “I am so sorry that you have been hurt.”
D. “You have a right to be safe and respected.”
E. “This abuse is not your fault.”
Answer: C, D, E
Rationale: The most therapeutic comments the nurse can make are nonjudgmental and empathetic statements such as “I am so sorry that you have been hurt.” Letting the client know that they have rights to be safe in their home and in a relationship and that they did nothing to cause someone else to be violent toward them are therapeutic responses. The nurse should never encourage the client to broach the subject of couples counseling but do encourage the client to access community resources for safety. The nurse should not express outrage against the perpetrator of the abuse since it is likely the client will feel as though they are required to defend them.
The nurse is creating a plan of care for a client with a dissociative disorder who is undergoing therapy for treatment. Which treatment outcome(s) will the nurse evaluate for successful therapy? Select all that apply.
A. The client will not have to take any medication for treatment.
B. The client will be free from any symptoms of dissociation.
C. The client will have an improved quality of life .
D. The client will have improved functional abilities.
E. The client will have reduced symptoms and reduced occurrences.
Answer: C, D, E
Rationale: Therapy for clients who dissociate focuses on reassociation, or putting the consciousness back together. This specialized treatment addresses trauma-based dissociative symptoms. The goals of therapy are to improve quality of life, improve functional abilities, and reduce symptoms. Clients with dissociative disorders may be treated symptomatically, that is, with medications for anxiety or depression or both if these symptoms are predominant. It is not realistic to expect the client not to have any signs or symptoms of dissociation.
The nurse is caring for clients who have anxiety disorders. Which cognitive–behavioral therapy technique(s) will the nurse discuss with the client that may be used effectively? Select all that apply.
A. Positive reframing
B. Decatastrophizing
C. Assertiveness training
D. Humor
E. Unlearning
Answer: A, B, C
Rationale: Positive reframing means turning negative messages into positive messages. Decatastrophizing involves the therapist's use of questions to more realistically appraise the situation. Assertiveness training helps the person take more control over life situations. Positive reframing, decatastrophizing, and assertiveness training are cognitive–behavioral therapy techniques. Humor is not a cognitive–behavioral therapy technique. Unlearning is the theory underlying behavioral therapy but it is not a therapy technique in and of itself.