CH 27 ANGR, AGGRSSIN, VLNC Flashcards
Which behavior best demonstrates aggression?
a. Stomping away from the nurses’ station, going to the hallway, and grabbing a tray
from the meal cart.
b. Bursting into tears, leaving the community meeting, and sitting on a bed hugging a
pillow and sobbing.
c. Telling the primary nurse, “I felt angry when you said I could not have a second
helping at lunch.”
d. Telling the medication nurse, “I am not going to take that, or any other, medication
you try to give me.”
a. Stomping away from the nurses’ station, going to the hallway, and grabbing a tray
from the meal cart.
Which clinical scenario predicts the highest risk for directing violent behavior toward others?
a. Major depressive disorder with delusions of worthlessness
b. Obsessive-compulsive disorder; performs many rituals
c. Paranoid delusions of being followed by alien monsters
d. Completed alcohol withdrawal; beginning a rehabilitation program
c. Paranoid delusions of being followed by alien monsters
A client was arrested for breaking windows in the home of a former domestic partner. The client’s history reveals childhood abuse by a punitive parent, torturing family pets, and an arrest for disorderly conduct. Which nursing diagnosis has priority?
a. Risk for injury
b. Ineffective coping
c. Impaired social interaction
d. Risk for other-directed violence
d. Risk for other-directed violence
A confused older adult client in a skilled nursing facility was asleep when unlicensed assistive personnel (UAP) entered the room quietly and touched the bed to see if it was wet. The client awakened and hit the UAP in the face. Which statement best explains the client’s action?
a. Older adult clients often demonstrate exaggerations of behaviors used earlier in life.
b. Crowding in skilled nursing facilities increases an individual’s tendency toward violence.
c. The client learned violent behavior by watching other clients act out.
d. The client interpreted the UAP’s behavior as potentially harmful.
d. The client interpreted the UAP’s behavior as potentially harmful.
A client is pacing the hall near the nurses’ station, swearing loudly. An appropriate initial intervention for the nurse would be to address the client by name and to make what statement?
a. “What is going on?”
b. “Please be quiet and sit down in this chair immediately.”
c. “I’d like to talk with you about how you’re feeling right now.”
d. “You must go to your room and try to get control of yourself.”
c. “I’d like to talk with you about how you’re feeling right now.”
A client who was responding to auditory hallucinations earlier in the morning now approaches the nurse shaking a fist and shouts, “Back off!” and then goes to the dayroom. While following the client into the dayroom, the nurse should take what precaution?
a. make sure there is adequate physical space between the nurse and client.
b. move into a position that places the client close to the door.
c. maintain one arm’s length distance from the client.
d. begin talking to the client about appropriate behavior.
a. make sure there is adequate physical space between the nurse and client.
An intramuscular dose of antipsychotic medication needs to be administered to a client who is becoming increasingly more aggressive and refused to leave the day room. In what manner should the nurse enter the day room?
a. Saying, “Would you like to come to your room and take some medication your health care provider prescribed for you?”
b. Accompanied by three staff members and say, “Please come to your room so I can give you some medication that will help you regain control.”
c. Placing the client in a basket-hold and then saying, “I am going to take you to your room to give you an injection of medication to calm you.”
d. Being accompanied by a security guard and telling the client, “Come to your room willingly so I can give you this medication, or the guard and I will take you there.”
b. Accompanied by three staff members and say, “Please come to your room so I can give you some medication that will help you regain control.”
After an assault by a client, a nurse has difficulty sleeping, startles easily, and is preoccupied with the incident. The nurse said, “That client should not be allowed to get away with that behavior.” Which response poses the greatest barrier to the nurse’s ability to provide therapeutic care?
a. Startle reactions
b. Difficulty sleeping
c. A wish for revenge
d. Preoccupation with the incident
c. A wish for revenge
The staff development coordinator plans to teach use of physical management techniques for use when clients become assaultive. Which topic should the coordinator emphasize?
a. Practice and teamwork
b. Spontaneity and surprise
c. Caution and superior size
d. Diversion and physical outlets
a. Practice and teamwork
An adult client assaulted another client and was then restrained. One hour later, which statement by the restrained client requires the nurse’s immediate attention?
a. “I hate all of you!”
b. “My fingers are tingly.”
c. “You wait until I tell my lawyer.”
d. “The other client started the fight.”
b. “My fingers are tingly.”
Which is an effective nursing intervention to assist an angry client learn to manage anger without violence?
a. Help a client identify a thought that produces anger, evaluate the validity of the belief, and substitute reality-based thinking.
b. Provide negative reinforcement such as restraint or seclusion in response to angry outbursts, whether or not violence is present.
c. Use aversive conditioning, such as popping a rubber band on the wrist, to help extinguish angry feelings.
d. Administer an antipsychotic or antianxiety medication.
a. Help a client identify a thought that produces anger, evaluate the validity of the belief, and substitute reality-based thinking.
Which assessment finding presents the greatest risk for violent behavior directed at others?
a. Severe agoraphobia
b. History of spousal abuse
c. Bizarre somatic delusions
d. Verbalized hopelessness and powerlessness
b. History of spousal abuse
An emergency code was called after a client pulled a dinner knife from a pocket and threatened, “I will kill anyone who tries to get near me.” The client was safely disarmed and placed in seclusion. What is the justification for this use of seclusion?
a. The client was threatening to others.
b. The client was experiencing psychosis.
c. The client presented an undeniable escape risk.
d. The client presented a clear and present danger to others.
d. The client presented a clear and present danger to others.
A client sat in silence for 20 minutes after a therapy appointment, appearing tense and vigilant. The client abruptly stood, paced back and forth, clenched and unclenched fists, and then stopped and stared in the face of a staff member. What is the client likely doing?
a. demonstrating withdrawal.
b. working though angry feelings.
c. attempting to use relaxation strategies.
d. exhibiting clues to potential aggression.
d. exhibiting clues to potential aggression.
A client with multi-infarct dementia lashes out and kicks at people who walk past in the hall of a skilled nursing facility. Intervention by the nurse should begin with what intervention?
a. gently touching the client’s arm.
b. asking the client, “What do you need?”
c. saying to the client, “This is a safe place.”
d. directing the client to cease the behavior.
d. directing the client to cease the behavior.
