Question 1

A client is served divorce papers while on the inpatient psychiatric unit. When a nurse tells the client the unit telephone cannot be used after hours, the client raises fists, swears, and spits at the nurse. Which negative coping mechanism has the client exhibited?

Accepted Answer

The client has exhibited the negative coping mechanism of displacement by directing their angry and aggressive behavior towards the nurse instead of the actual source of their distress, which is receiving divorce papers. The defense mechanism of projection involves attributing one's own undesirable feelings or qualities onto others. Reaction formation involves expressing the opposite behavior of what one really feels. Sublimation involves channeling negative energy into socially acceptable behaviors. None of these defense mechanisms are present in the scenario.

Question 2

A nursing instructor is teaching about the concept of anger. Which student statement indicates the need for further instruction?

Accepted Answer

Anger and aggression are not the same thing. Anger is an emotion, while aggression is a behavior that may or may not result from anger.

Question 3

A client begins to smash furniture, cannot be "talked down," and refuses medications. Which is the most appropriate nursing intervention?

Accepted Answer

This situation poses an immediate danger to the client and others, and therefore warrants activating a violence code to ensure the safety of everyone involved. The other options (B, C, D) may be necessary interventions in certain situations, but do not address the immediate danger posed by the client's behavior.

Question 4

A nurse is caring for four clients. Which client should the nurse identify as least prone to developing problems with anger and aggression?

Accepted Answer

Scandinavian culture is known for promoting emotional restraint and non-violent conflict resolution, which may decrease the likelihood of developing problems with anger and aggression. Children raised by physically abusive parents (A) may learn violent behavior, adults with epilepsy (B) may experience mood changes or irritability as a side effect of medication or due to seizure activity, and young adults living in inner cities (C) may face stressors such as poverty and violence that increase the risk of anger and aggression.

Question 5

Which risk factor should a nurse recognize as the most reliable indicator of potential client violence?

Accepted Answer

A history of assaultive behavior is the most reliable indicator of potential client violence as past behavior is often the best predictor of future behavior. While other risk factors such as mental illness, family history of violence, and homelessness may also increase the risk of violence, a history of assaultive behavior is the strongest indicator.

Question 6

How often should a nurse plan to observe a client who is in restraints?

Accepted Answer

The answer of How often should a nurse plan to...

Question 7

A student nurse has just entered a psychiatric rotation. The student asks a nursing instructor, "How will we know if someone may get violent?" Which is the most appropriate reply by the nursing instructor?

Accepted Answer

Option B provides specific examples of behaviors that may indicate potential violence. This information can help the student nurse to be aware of warning signs and to take necessary precautions. Option A is not entirely accurate, as there are some indicators of potential violence. Option C is overly broad and may create unnecessary anxiety for the student nurse. Option D is not necessarily accurate, as some individuals may become violent while displaying other emotions or behaviors.

Question 8

The client states, "I get into trouble because I respond violently without thinking. That usually gets me into a mess." Which nursing reply would be most therapeutic to address this client's problem?

Accepted Answer

This response acknowledges the client's self-awareness about their behavior and offers to work together to find solutions. It also encourages the client to actively participate in their own recovery process. The other options either minimize or do not address the client's concern.

Question 9

After restraints are removed from a client, the staff discusses the incident and establishes guidelines for the client's return to the therapeutic milieu. Which unit procedure is the staff implementing?

Accepted Answer

Debriefing is the process where staff discusses an incident after it occurs, such as the use of restraints, to understand what happened, evaluate the response, and plan for future care and integration back into the therapeutic environment.

Question 10

After less restrictive means have been attempted, an order for client restraints has been obtained for a hostile, aggressive 30- year-old client. If client aggression continues, how long will the nurse expect the client to remain in restraints without a physician order renewal?

Accepted Answer

If client restraints are necessary beyond the initial physician-ordered duration (usually 4 hours for adults), a physician order renewal is required for the client to remain in restraints. Therefore, the client can only remain in restraints for a maximum of 4 hours without a physician order renewal.

Question 11

Which client statement demonstrates improvement in terms of anger/aggression management?

Accepted Answer

Option A demonstrates self-awareness and acknowledgement of a problem, indicating that the client is taking responsibility for their behavior and is open to change.

Answer: D
 Option D involves avoiding the problem rather than addressing it, and could potentially escalate the issue in the future.

Question 12

The nurse observes a client's escalating anger. The client begins to pace the hall and shouts, "You all better watch out. I'm going to hurt anyone who gets in my way." Which should be the priority nursing intervention?

Accepted Answer

The priority nursing intervention in this situation is to ensure milieu safety by removing other clients from the area. This can reduce the risk of harm to others and help prevent the escalation of the client's behavior. Calmly redirecting the client or offering medication or seclusion should only be considered if other interventions are unsuccessful and if it is necessary to ensure the safety of the client and others. Contacting security may also be appropriate in some situations, but it is not always necessary or feasible.

Question 13

An adult client assaults another client and is placed in restraints at 1345 hours. While the client is in restraints, which client statement should alert a nurse that further assessment is necessary?

Accepted Answer

The client's complaint of tingling fingers could indicate a potential complication from being in restraints, such as decreased circulation or nerve impingement. This requires further assessment by the nurse. The other statements do not indicate a need for immediate assessment.

Question 14

A client diagnosed with paranoid schizophrenia has a history of aggravated assault. A nurse assigns "Risk for other-directed violence" as the client's priority nursing diagnosis. Based on this diagnosis, which would be an appropriate outcome for this client?

Accepted Answer

The priority nursing diagnosis is "Risk for other-directed violence," meaning the client is at risk of inflicting harm on others. Therefore, the appropriate outcome would be for the client to not actually harm anyone during the shift. Option A and B are not appropriate outcomes as they involve the client still feeling anger, which does not address the risk for violence. Option D is not appropriate as physical restraints should only be used as a last resort for the safety of the client and others.

Question 15

At 3 a.m., when less restrictive methods fail, a physician orders restraints for an angry, aggressive client. To meet Joint Commission standards, at what time and by whom should a nurse expect an in-person client evaluation?

Accepted Answer

According to Joint Commission standards, an in-person evaluation by a physician or a licensed independent practitioner (LIP) should occur as soon as possible after restraints are initiated, but no later than 1 hour after the initiation of restraints. Therefore, option B is the best choice as it specifies the appropriate time for the evaluation by a physician or LIP. Option A (8 a.m.) and option D (6 a.m.) are too late and do not meet the standard. Option C (3:30 a.m.) does not specify an appropriate evaluator according to the standards.

Question 16

Which initial nursing approach makes limit setting better accepted by clients who are aggressively acting out?

Accepted Answer

Reflecting back to the client empathy about the client's distress promotes a trusting relationship and may prevent the client's anxiety from escalating when limits are set.

Question 17

On an inpatient psychiatric unit, a restrained 16-year-old client continues to verbally lash out, and threatens to abuse staff and kill self when released. To meet Joint Commission standards, at what time should a nurse expect the physician to renew the client's restraint order?

Accepted Answer

The Joint Commission (JCAHO)requires that a physician or a licensed independent practitioner reissue a new order for restraints every 4 hours for adults,every 2 hours for adolescents,and every 1 hour for children.

Question 18

A client diagnosed with psychotic disorder NOS is pacing the milieu and occasionally punches the wall. Which should be the initial nursing action?

Accepted Answer

Ensuring adequate physical space between the nurse and the client is the best initial nursing action in this situation. This ensures the safety of both the client and the nurse. The client's behavior may be a symptom of their psychotic disorder, and instructing them to stop or encouraging them to write down their feelings may not be effective in managing the behavior. Initiating seclusion protocol should only be done as a last resort if the client presents a danger to themselves or others and all other interventions have failed.

Question 19

For select clients, physical restraint is considered to be a beneficial intervention. This is based on which premise?

Accepted Answer

The premise that physical restraint is beneficial for select clients is based on the understanding that clients with limited internal control over their behavior need external controls to prevent harm to themselves and others. Restraint can be used as a last resort to prevent clients from harming themselves or others. However, it should only be used when alternative interventions have failed, and it should be utilized in the safest and least restrictive way possible.

Question 20

A nursing instructor is teaching about violence-intervention protocols. Which student statement would indicate the need for further instruction?

Accepted Answer

Stroking an arm or shoulder is not an appropriate intervention for addressing violence. It is important for nursing students to understand that violence-intervention protocols prioritize safety for both patients and caregivers. This includes medications, restraints, and requesting assistance as needed. However, physical contact with the patient should only be used if deemed necessary for safety reasons and always with the patient's consent.

Quiz 17: Angeraggression Management