Ch. 27-V

Question 1

1. 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.”

Answer 1

ANS: A
Aggression is harsh physical or verbal action that reflects rage, hostility, and potential for physical or verbal destructiveness. Aggressive behavior violates the rights of others. Refusing medication is a patient’s right and may be appropriate. The other incorrect options do not feature violation of another’s rights.

Question 2

2. 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

Answer 2

ANS: C
Patients who are delusional, hyperactive, impulsive, or predisposed to irritability are at higher risk for violence. The patient in the correct response has the greatest disruption of ability to perceive reality accurately. People who feel persecuted may strike out against those believed to be persecutors. The other patients have better reality-testing ability.

Question 3

3.	A patient was arrested for breaking windows in the home of a former domestic partner. The patient’s history also 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

Answer 3

ANS: D
Defining characteristics for risk for other-directed violence include a history of being abused as a child, having committed other violent acts, and demonstrating poor impulse control. There is no indicator that the patient will experience injury. Ineffective coping and impaired social interaction have lower priorities.

Question 4

4. A confused older adult patient 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 patient awakened and hit the UAP in the face. Which statement best explains the patient’s action?
   a.
   Older adult patients often demonstrate exaggerations of behaviors used earlier in life.
   b.
   Crowding in skilled nursing facilities increases an individual’s tendency toward violence.
   c.
   The patient learned violent behavior by watching other patients act out.
   d.
   The patient interpreted the UAP’s behavior as potentially harmful.

Answer 4

ANS: D
Confused patients are not always able to evaluate the actions of others accurately. This patient behaved as though provoked by the intrusive actions of the staff.

Question 5

5. 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.
   “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.”

Answer 5

ANS: C
Intervention should begin with analysis of the patient and the situation. When anger is escalating, a patient’s ability to process decreases. It is important to speak to the patient slowly and in short sentences, using a low and calm voice. Use open-ended statements designed to hear the patient’s feelings and concerns. This leads to the next step of planning an intervention.

Question 6

6. A patient 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 patient into the dayroom, the nurse should
   a.
   make sure there is adequate physical space between the nurse and patient.
   b.
   move into a position that places the patient close to the door.
   c.
   maintain one arm’s length distance from the patient.
   d.
   begin talking to the patient about appropriate behavior.

Answer 6

ANS: A
Making sure space is present between the nurse and the patient avoids invading the patient’s personal space. Personal space needs increase when a patient feels anxious and threatened. Allowing the patient to block the nurse’s exit from the room may result in injury to the nurse. Closeness may be threatening to the patient and provoke aggression. Sitting is inadvisable until further assessment suggests the patient’s aggression is abating. One arm’s length is inadequate space.

Question 7

7. An intramuscular dose of antipsychotic medication needs to be administered to a patient who is becoming increasingly more aggressive and refused to leave the day room. The nurse should enter the day room
   a.
   and say, “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.
   and place the patient in a basket-hold and then say, “I am going to take you to your room to give you an injection of medication to calm you.”
   d.
   accompanied by a male security guard and tell the patient, “Come to your room willingly so I can give you this medication, or the guard and I will take you there.”

Answer 7

ANS: B
A patient gains feelings of security if he or she sees others are present to help with control. The nurse gives a simple direction, honestly states what is going to happen, and reassures the patient that the intervention will be helpful. This positive approach assumes the patient can act responsibly and will maintain control. Physical control measures are used only as a last resort.

Question 8

8.	After an assault by a patient, a nurse has difficulty sleeping, startles easily, and is preoccupied with the incident. The nurse said, “That patient 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

Answer 8

ANS: C
The desire for revenge signals an urgent need for professional supervision to work through anger and counter the aggressive feelings. Feelings of revenge create a risk for harm to the patient. The distracters are normal in a person who was assaulted. They usually are relieved with crisis intervention, help the individual regain a sense of control, and make sense of the event.

Question 9

9.	The staff development coordinator plans to teach use of physical management techniques for use when patients 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

Answer 9

ANS: A
Intervention techniques are learned behaviors and must be practiced to be used in a smooth, organized fashion. Every member of the intervention team should be assigned a specific task to carry out before beginning the intervention. The other options are useless if the staff does not know how to use physical techniques and how to apply them in an organized fashion.

Question 10

10.	An adult patient assaulted another patient and was then restrained. One hour later, which statement by the restrained patient 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 patient started the fight.”

Answer 10

ANS: B
The correct response indicates impaired circulation and necessitates the nurse’s immediate attention. The incorrect responses indicate the patient has continued aggressiveness and agitation.

Question 11

11. Which is an effective nursing intervention to assist an angry patient learn to manage anger without violence?
    a.
    Help a patient 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.

Answer 11

ANS: A
Anger has a strong cognitive component, so using cognition techniques to manage anger is logical. The incorrect options do nothing to help the patient learn anger management.

Question 12

12.	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

Answer 12

ANS: B
A history of prior aggression or violence is the best predictor of who may become violent. Patients with anxiety disorders are not particularly prone to violence unless panic occurs. Patients experiencing hopelessness and powerlessness may have coexisting anger, but violence is uncommon. Patients with paran

Question 13

13.	An emergency code was called after a patient pulled a knife from a pocket and threatened, “I will kill anyone who tries to get near me.” The patient was safely disarmed and placed in seclusion. Justification for use of seclusion was that the patient
a.
was threatening to others.
b.
was experiencing psychosis.
c.
presented an undeniable escape risk.
d.
presented a clear and present danger to others.

Answer 13

ANS: D
The patient’s threat to kill self or others with the knife he possessed constituted a clear and present danger to self and others. The distracters are not sufficient reasons for seclusion

Question 14

14.	A patient sat in silence for 20 minutes after a therapy appointment, appearing tense and vigilant. The patient abruptly stood, paced back and forth, clenched and unclenched fists, and then stopped and stared in the face of a staff member. The patient is
a.
demonstrating withdrawal.
b.
working though angry feelings.
c.
attempting to use relaxation strategies.
d.
exhibiting clues to potential aggression.

Answer 14

ANS: D
The description of the patient’s behavior shows the classic signs of someone whose potential for aggression is increasing.

Question 15

15. A patient 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 by
    a.
    gently touching the patient’s arm.
    b.
    asking the patient, “What do you need?”
    c.
    saying to the patient, “This is a safe place.”
    d.
    directing the patient to cease the behavior.

Answer 15

ANS: C
Striking out usually signals fear or that the patient perceives the environment to be out of control. Getting the patient’s attention is fundamental to intervention. The nurse should make eye contact and assure the patient of safety. Once the nurse has the patient’s attention, gently touching the patient, asking what he or she needs, or directing the patient to discontinue the behavior may be appropriate.

Question 16

16. A cognitively impaired patient has been a widow for 30 years. This patient frantically tries to leave the facility, saying, “I have to go home to cook dinner before my husband arrives from work.” To intervene with validation therapy, the nurse will say:
    a.
    “You must come away from the door.”
    b.
    “You have been a widow for many years.”
    c.
    “You want to go home to prepare your husband’s dinner?”
    d.
    “Your husband gets angry if you do not have dinner ready on time?”

Answer 16

ANS: C
Validation therapy meets the patient “where she or he is at the moment” and acknowledges the patient’s wishes. Validation does not seek to redirect, reorient, or probe. The distracters do not validate the patient’s feelings.

Question 17

17. A patient with a history of anger and impulsivity was hospitalized after an accident resulting in multiple injuries. The patient loudly scolds nursing staff, “I’m in pain all the time but you don’t give me medicine until YOU think it’s time.” Which nursing intervention would best address this problem?
    a.
    Teach the patient to use coping strategies such as deep breathing and progressive relaxation to reduce the pain.
    b.
    Talk with the health care provider about changing the pain medication from prn to patient-controlled analgesia.
    c.
    Tell the patient that verbal assaults on nurses will not shorten the wait for analgesic medication.
    d.
    Talk with the patient about the risks of dependency associated with overuse of analgesic medication.

Answer 17

ANS: B
Use of patient-controlled analgesia will help the patient manage the pain. This intervention will help reduce the patient’s anxiety and anger. Dependency is not an important concern related to acute pain.

Question 18

18. A patient has a history of impulsively acting-out anger by striking others. Select the most appropriate intervention for avoiding similar incidents.
    a.
    Teach the patient about herbal preparations that reduce anger.
    b.
    Help the patient identify incidents that trigger impulsive anger.
    c.
    Explain that restraint and seclusion will be used if violence occurs.
    d.
    Offer one-on-one supervision to help the patient maintain control.

Answer 18

ANS: B
Identification of trigger incidents allows the patient and nurse to plan interventions to reduce irritation and frustration, which lead to acting-out anger, and eventually to put into practice more adaptive coping strategies.

Question 19

19. A patient with severe burn injuries is irritable, angry, and belittles the nurses. As a nurse changes a dressing, the patient screams, “Don’t touch me! You are so stupid. You will make it worse!” Which action by the nurse will best help to diffuse the patient’s anger?
    a.
    Stop the dressing change and say, “I will leave the supplies so that you can change your own dressing.”
    b.
    Continue the dressing change and say, “This dressing change is necessary because you were careless with fire.”
    c.
    Discontinue the dressing change, tell the patient, “I will return when you gain control of yourself,” and leave the room.
    d.
    Continue the dressing change and say, “Dressing changes are needed to prevent infection. What are your ideas about how to make it less painful?”

Answer 19

ANS: D
The nurse should not respond personally to the patient’s comments. The correct answer objectively gives the patient information that may lead to lowering his anger and engages the patient in problem solving. The incorrect options will escalate the patient’s anger by belittling or escalating the patient’s sense of powerlessness. Dressing changes are needed for the patient’s physiological integrity; therefore, the nurse should not abandon the responsibility to perform them

Question 20

20.	Which medication from the medication administration record should a nurse administer to provide immediate intervention for a psychotic patient whose aggressive behavior continues to escalate despite verbal intervention?
a.
Lithium
b.
Trazodone
c.
Olanzapine
d.
Valproic acid

Answer 20

ANS: C
Olanzapine is a short-acting antipsychotic useful in calming angry, aggressive patients regardless of diagnosis. The other drugs listed require long-term use to reduce anger. Lithium is for bipolar patients. Trazodone is commonly prescribed for patients experiencing depression, insomnia, or chronic pain. Valproic acid is for bipolar or borderline patients.

Question 21

21. An emergency department nurse realizes that the spouse of a patient is becoming increasingly irritable while waiting. Which intervention should the nurse use to prevent further escalation of the spouse’s anger?
    a.
    Offer the waiting spouse a cup of coffee.
    b.
    Explain that the patient’s condition is not life threatening.
    c.
    Periodically provide an update and progress report on the patient.
    d.
    Suggest that the spouse return home until the patient’s treatment is complete.

Answer 21

ANS: C
Periodic updates reduce anxiety and defuse anger. This strategy acknowledges the spouse’s presence and concern. A cup of coffee is a nice gesture, but it does not address the spouse’s feelings. The other incorrect options would be likely to increase anger because they imply that the anxiety is inappropriate.

Question 22

22.	Which information from a patient’s record would indicate marginal coping skills and the need for careful assessment of the risk for violence? A history of
a.
academic problems.
b.
family involvement.
c.
childhood trauma.
d.
substance abuse.

Answer 22

ANS: D
The nurse should suspect marginal coping skills in a patient with substance abuse. They are often anxious, may be concerned about inadequate pain relief, and may have personality styles that externalize blame. The incorrect options do not signal as high a degree of risk as substance abuse.

Question 23

23. Family members describe the patient as “a difficult person who finds fault with others.” The patient verbally abuses nurses for their poor care. The most likely explanation lies in
    a.
    poor childrearing that did not teach respect for others.
    b.
    automatic thinking leading to cognitive distortions.
    c.
    a personality style that externalizes problems.
    d.
    delusions that others wish to deliver harm.

Answer 23

ANS: C
Patients whose personality style causes them to externalize blame see the source of their discomfort and anxiety as being outside themselves. They displace anger and are often unable to self-soothe. The incorrect options are less likely to have a bearing on this behavior.

Question 24

24. A new patient acts out so aggressively that seclusion is required before the admission assessment is completed or orders written. Immediately after safely secluding the patient, which action is the nurse’s priority?
    a.
    Complete the physical assessment.
    b.
    Notify the health care provider to obtain a seclusion order.
    c.
    Document the incident objectively in the patient’s medical record.
    d.
    Explain to the patient that seclusion will be discontinued when self-control is regained.

Answer 24

ANS: B
Emergency seclusion can be effected by a credentialed nurse but must be followed by securing a medical order within a period of time specified by the state and the agency. The incorrect options are not immediately necessary from a legal standpoint. See related audience response question.

Question 25

1. A patient with a history of command hallucinations approaches the nurse yelling obscenities. Which nursing actions are most likely to be effective in deescalation for this scenario? (Select all that apply.)
   a.
   Stating the expectation that the patient will stay in control.
   b.
   Asking the patient, “Do you want to go into seclusion?”
   c.
   Telling the patient, “You are behaving inappropriately.”
   d.
   Offering to provide the patient with medication to help.
   e.
   Speaking in a firm but calm voice.

Answer 25

ANS: A, D, E
Stating the expectation that the patient will maintain control of behavior reinforces positive, healthy behavior and avoids challenging the patient. Offering as-needed medication provides support for the patient trying to maintain control. A firm but calm voice will likely comfort and calm the patient. Belittling remarks may lead to aggression. Criticism will probably prompt the patient to begin shouting.

Question 26

2. A nurse directs the intervention team who places an aggressive patient in seclusion. Before approaching the patient, which actions will the nurse direct team members to take? (Select all that apply.)
   a.
   Appoint a person to clear a path and open, close, or lock doors.
   b.
   Quickly approach the patient and take the closest extremity.
   c.
   Select the person who will communicate with the patient.
   d.
   Move behind the patient when the patient is not looking.
   e.
   Remove jewelry, glasses, and harmful items.

Answer 26

ANS: A, C, E
Injury to staff and the patient should be prevented. Only one person should explain what will happen and direct the patient. This may be the nurse or a staff member with a good relationship with the patient. A clear pathway is essential because those restraining a limb cannot use keys, move furniture, or open doors. The nurse is usually responsible for administering medication once the patient is restrained. Each staff member should have an assigned limb rather than just grabbing the closest. This system could leave one or two limbs unrestrained. Approaching in full view of the patient reduces suspicion.

Question 27

3.	Which central nervous system structures are most associated with anger and aggression? (Select all that apply.)
a.
Amygdala
b.
Cerebellum
c.
Basal ganglia
d.
Temporal lobe
e.
Prefrontal cortex

Answer 27

ANS: A, D, E
The amygdala and prefrontal cortex mediate anger experiences and help a person judge an event as either rewarding or aversive. The temporal lobe, which is part of the limbic system, also plays a role in aggressive behavior. The basal ganglia are involved in movement. The cerebellum manages equilibrium, muscle tone, and movement.

Question 28

4. Because an intervention was required to control a patient’s aggressive behavior, the nurse plans a critical incident debriefing with staff members. Which topics should be the primary focus of this discussion? (Select all that apply.)
   a.
   Patient behaviors associated with the incident
   b.
   Genetic factors associated with aggression
   c.
   Intervention techniques used by the staff
   d.
   Effects of environmental factors
   e.
   Theories of aggression

Answer 28

ANS: A, C, D
The patient’s behavior, the intervention techniques used, and the environment in which the incident occurred are important to establish realistic outcomes and effective nursing interventions. Discussin