Deck 25: Anger, Aggression, and Violence

Question 1

A patient is admitted for psychiatric observation after being arrested for breaking windows in the home of his former girlfriend,who had refused to see him.His history reveals abuse as a child by a punitive father,torturing family pets,and one arrest for disorderly conduct.The priority nursing diagnosis that should be considered is:

A) Stress overload.
B) Ineffective coping.
C) Risk for self-directed violence.
D) Risk for other-directed violence.

Answer 1

Risk for other-directed violence.

Question 2

A patient who has been seen responding to auditory hallucinations earlier in the morning approaches the nurse and shakes his fist,saying,"Back off,bitch!" and then goes into the day room.Which intervention would be most important to undertake before the nurse follows the patient into the day room?

A) Contact the patient's physician to obtain an order for seclusion.
B) Review the patient's history for clues about his risk of violence.
C) Assure that adequate staff are available and nearby for backup.
D) Check for orders for PRN medication and prepare a sedative.

Answer 2

Assure that adequate staff are available and nearby for backup.

Question 3

Which situation would involve the highest risk for violence?

A) A nurse is about to set limits on a patient.
B) Shift change and report are about to begin.
C) A PRN medication is to be offered.
D) The patient is a young adult male.

Answer 3

A nurse is about to set limits on a patient.

Question 4

A patient on a medical unit has a history of hostile and menacing behavior toward staff and sometimes even strikes them.Which plan would be best for forestalling such incidents?

A) Give the patient lorazepam (Ativan)every 4 hours to reduce anxiety.
B) Explain that the response to any violence will be to use restraints.
C) Arrange for security personnel to stand by during all nursing care.
D) Point out the problem and help the patient identify things that are causing frustration.

Question 5

A patient with severe orthopedic injuries after an automobile accident is irritable,angry,and belittles the nurses who provide his care.While the nurse is changing the dressing over a deep laceration,the patient screams,"Don't touch me! You are so stupid;you're only making it worse!" Which intervention would be most therapeutic?

A) Wordlessly leave the room and ask to switch assignments with another nurse who may be more acceptable to the patient.
B) Apologize,explain that the dressing change is necessary to prevent infection,and jointly explore ways to decrease the discomfort involved.
C) State: "Since you believe we nurses aren't able to change your dressing,perhaps you would like to change it yourself."
D) State: "This is frustrating for both of us,but there is no choice because your doctor has ordered this dressing change."

Question 6

The emergency department nurse realizes that the husband of a patient appears increasingly irritable as he waits alone in the waiting room.Which intervention would best prevent further escalation?

A) Periodically update the husband about his wife and what is being done for her.
B) Explain that waiting is necessary because patients are treated in order of need.
C) Reassure him that everything possible is being done and suggest ways to relax.
D) Suggest that he return home and await an update from the physician in 3 hours.

Question 7

A cognitively impaired patient who has been a widow for 30 years is frantically trying to leave the unit,saying,"I have to go home to start dinner before my husband comes home from work." To intervene with validation therapy,the nurse should say:

A) "Please,you must come away from the door."
B) "Mrs.Smith,you have been a widow for many years."
C) "You want to go home to get your husband's dinner."
D) "I think your husband said he is going to eat out tonight."

Question 8

An intramuscular dose of antipsychotic medication needs to be given to a patient who is becoming increasingly more aggressive.The patient is in the day room.Which intervention would be safest and most appropriate?

A) Enter the day room and say,"Would you like to come to your room and take some medication that your doctor has ordered for you?"
B) Take three staff members as backup and say,"Please come to your room so I can give you some medication that will help you feel more comfortable."
C) Take two male aides with you and tell the patient,"You can come to your room willingly so I can give you this medicine,or we will have to take you there."
D) Four staff should clear the room of patients,restrain the target patient,then administer the PRN medication and continue to hold him until he calms.

Question 9

A patient who is known to be angry and impulsive is hospitalized after an automobile accident in which he sustained severe orthopedic injuries.When in pain,he loudly berates nursing staff,saying,"You jerks don't even know enough to give a patient pain medicine when he needs it." The patient's nursing diagnosis is Ineffective coping.Which nursing intervention would best address this situation?

A) "If you could tell us about wanting the medicine before your pain becomes this bad,it would help."
B) "I can see you are frustrated,but rudeness toward nurses will not help you get your medication any sooner."
C) "I'm concerned that there may be something we overlooked;I'm going to ask a psychiatric specialist to evaluate you."
D) "Pain can make anyone miserable;I will ask your doctor to change the order so you get medicine regularly without having to ask."

Question 10

Which information noted in a patient's history most suggests a need for careful assessment of risk for violence in a newly admitted medical patient?

A) Childhood abuse
B) Family estrangement
C) Academic problems
D) Chemical dependence

Question 11

Which characteristics of the unit milieu are most likely to result in a low incidence of violent behavior?

A) A milieu that emphasizes maintaining control and structure
B) A unit that is adequately staffed and not overcrowded
C) A unit that has a high percentage of newer,fresher staff
D) A milieu that focuses on privileges to reward or punish behavior

Question 12

A patient is pacing the hall near the nurses' station,swearing loudly.An appropriate initial intervention for the nurse would be to address the patient by name and say:

A) "Please quiet down."
B) "Hey,what's up?"
C) "You seem upset.Tell me about it."
D) "You need to go to your room to get control of yourself."

Question 13

An elderly patient with multi-infarct dementia is striking out with her arms and kicking at people who walk past in the hall.The nurse determines that the patient believes she is at home and that the other patients have broken into her home.The clinical nurse specialist suggests that staff use validation.Which of the following responses reflect this intervention?

A) "I'm a nurse who has come to check on you.Tell me about your home."
B) "You are in a nursing home.The others here are patients,just like you are."
C) "I wish you could be home,but you have been sick and are in a nursing home."
D) "You are not at home.This is a nursing home.It is September 10th,2010."

Question 14

The patient on the mental health unit who should be assessed as being at highest risk for directing violent behavior toward others is the patient who has:

A) obsessive-compulsive disorder and performs many rituals.
B) paranoid delusions of being followed by the Mafia.
C) severe depression with feelings of worthlessness and self-loathing.
D) completed alcohol withdrawal and is now in a rehabilitation program.

Question 15

A patient who has been seen responding to auditory hallucinations earlier in the morning approaches the nurse and shakes his fist,saying,"Back off,bitch!" and then goes into the day room.The nurse follows the patient into the day room.Which intervention would be best at this time?

A) Stay between the patient and the door for easy exit.
B) Stand out of range of possible assault by the patient.
C) Position oneself about 28 inches from the patient.
D) Sit down in a chair near the patient to convey interest.

Question 16

An elderly patient with multi-infarct dementia is striking out with her arms and kicking at people who walk past in the hall.Intervention by the nurse should begin by:

A) gently touching the patient's arm.
B) saying the patient's name to gain contact.
C) asking the patient what she needs.
D) approaching from behind to reassure her.

Question 17

A patient who had abdominal surgery has been hospitalized for 4 days.He has no history of psychiatric disorder but is described by his family as having "always been a difficult person who blames others for everything that goes wrong." From the day of admission,he has verbally abused the nurses for their inability to provide care that keeps him pain free and comfortable.Which history most likely explains this style of coping?

A) Child-rearing that did not teach respect for others
B) Exposure to violent role models in the media
C) A personality style that externalizes problems
D) Increased levels of the neurotransmitter serotonin

Question 18

Which statement about aggression would accurately serve as a basis for care planning?

A) Brain injury or disorders are often blamed for,but rarely contribute to,violence.
B) Some people are biologically predisposed to become irritated or angry more easily.
C) Aggression is an innate behavior rather than a learned response to frustration.
D) Mature persons with patterns of effective coping almost never behave violently.

Question 19

A patient has sat in stony silence in the day room for 20 minutes after her appointment with her psychiatrist.She appears tense and vigilant.The nurse sees the patient abruptly stand up and pace back and forth across the day room,clenching and unclenching her fists.She then stops and stares intently into the face of the psychiatric technician seated at a table.The priority assessment that should be made is that the patient is:

A) working off the energy of angry feelings.
B) attempting to use relaxation strategies.
C) exhibiting clues to potential aggression.
D) trying to work through her anger.

Question 20

An elderly patient with multi-infarct dementia is striking out with her arms and kicking at people who walk past in the hall.After making contact with the patient,which intervention would be most appropriate?

A) Administering PRN sedation to calm the patient.
B) State: "You may not hit others;you are safe here."
C) Distract the patient into playing a board game.
D) State: "I notice you are trying to hit people."

Question 21

A newly admitted patient required seclusion immediately on entering the inpatient unit.What criteria would the nurse use to decide when to discontinue the use of seclusion?

A) Seclusion can be discontinued when the patient seems calm.
B) Discontinuation is based on outcomes developed for each patient.
C) Seclusion continues until the patient has been calm for at least 4 hours.
D) Seclusion lasts until the physician orders its discontinuation.

Question 22

A newly admitted patient required seclusion immediately on entering the inpatient unit.His assessment was incomplete,and no medical orders had been written.Immediately after secluding the patient,the priority action of the nurse should be to:

A) provide a chance for the patient to use the bathroom.
B) notify the physician and obtain an order for seclusion.
C) complete necessary forms and notify the unit manager.
D) debrief the staff and any witnesses to the incident.

Question 23

A head nurse is concerned about the frequency of patient violence on her unit.Which of the following actions would be likely to reduce such incidents? Select all that apply.

A) Encourage staff to have numerous,brief,nondirective interactions with all patients starting at admission.
B) Increase the percentage of males working on the unit so that the male presence will inhibit violent behavior.
C) Make sure a thorough assessment of risk for violence is completed on all patients at admission.
D) Train staff to implement seclusion and restraint promptly when a patient shows signs of escalating aggression.
E) In supervision,facilitate self-awareness regarding staff's feelings about violence and any possible nontherapeutic responses that might result from these feelings.

Question 24

A nurse deciding whether or not to place an agitated patient in seclusion or restraints would need to keep in mind that:

A) the goal in using either seclusion or restraint is always to maintain the safety of the patient or others.
B) restraints are designed to discourage inappropriate behavior by serving as negative reinforcements.
C) seclusion and restraint are used in place of de-escalation when staff judge that de-escalation would be ineffective.
D) once implemented,restraints should not be terminated until the patient has remained calm for at least 6 hours.

Question 25

A patient requires as-needed sedation.What would the nurse keep in mind when choosing a PRN sedative for an agitated patient?

A) Intramuscular injection can be traumatic,so oral meds should be used where possible.
B) Benzodiazepines are less sedating but have the advantage of no side effects.
C) Lithium carbonate works well but only for those already taking regular daily dosages.
D) Diazepam (Valium)is the preferred benzodiazepine because it is a short-acting sedative.

Question 26

When a patient's aggression quickly escalates,on which principle should nursing intervention be based?

A) Staff should match their tone of voice and level of intensity to the patient's.
B) When there is no time to de-escalate,immediate use of restraint is necessary.
C) Always ask the patient what will be most helpful to increase his sense of control.
D) Choose the least restrictive measure that will keep the patient and others safe.

Question 27

A patient being treated in the burn injury unit has demonstrated good coping skills for several weeks.Today,a new nurse is assigned to care for him and has proven to be poorly organized.The patient's usual schedule has not been followed,and by midafternoon,he is angry and raises his voice to complain to the nurse clinician.Which course of action for the nurse clinician would be best?

A) Explain the reasons for the problem,and take over his care for the rest of the shift.
B) Validate his distress,review the options,and ask what he would like to happen.
C) Apologize and ask that he be patient with the situation for the rest of the shift.
D) Ask him to control his anger,and ask him if he too wasn't once new at something.

Question 28

A patient is ready to be released from leather four-point restraints (restraints on both wrists and both ankles).Place the following actions involved in releasing a patient from restraints in their correct order.

A) Maintain the patient in seclusion and reassess.
B) Complete the removal of the restraints.
C) Continue to observe the patient closely.
D) Reassess the patient for safety.
E) Release one ankle from restraint.
F) Remove the patient from seclusion.