Chapter 27 - Violence [EXAM 3]

Question 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

a. Stomping away from the nurses’ station, going to the hallway, and grabbing a tray from the meal cart.

Question 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

c. Paranoid delusions of being followed by alien monsters

Question 3

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

Answer 3

d. Risk for other-directed violence

Question 4

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.

Answer 4

d. The client interpreted the UAP’s behavior as potentially harmful.

Question 5

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.”

Answer 5

c. “I’d like to talk with you about how you’re feeling right now.”

Question 6

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.

Answer 6

a. make sure there is adequate physical space between the nurse and client.

Question 7

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.”

Answer 7

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.”

Question 8

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

Answer 8

c. A wish for revenge

Question 9

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

Answer 9

a. Practice and teamwork

Question 10

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.”

Answer 10

b. “My fingers are tingly.”

Question 11

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.

Answer 11

a. Help a client identify a thought that produces anger, evaluate the validity of the belief, and substitute reality-based thinking.

Question 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

b. History of spousal abuse

Question 13

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.

Answer 13

d. The client presented a clear and present danger to others.

Question 14

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.

Answer 14

d. exhibiting clues to potential aggression.

Question 15

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.

Answer 15

c. saying to the client, “This is a safe place.”

Question 16

A cognitively impaired client has been a widow for 30 years. This client 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, what should the nurse 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

c. “You want to go home to prepare your husband’s dinner?”

Question 17

A client with a history of anger and impulsivity was hospitalized after an accident resulting in multiple injuries. The client 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 client 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 client-controlled analgesia.
c. Tell the client that verbal assaults on nurses will not shorten the wait for analgesic medication.
d. Talk with the client about the risks of dependency associated with overuse of analgesic medication.

Answer 17

b. Talk with the health care provider about changing the pain medication from prn to client-controlled analgesia.

Question 18

A client has a history of impulsively acting-out anger by physically striking others. What is the most appropriate intervention for avoiding similar incidents?

a. Teach the client about herbal preparations that reduce anger.
b. Help the client 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 client maintain control.

Answer 18

b. Help the client identify incidents that trigger impulsive anger.

Question 19

A client with severe burn injuries is irritable, angry, and belittles the nurses. As a nurse changes a dressing, the client 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 client’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 client, “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

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?

Question 20

Which prescribed medication should a nurse administer to provide immediate intervention for a psychotic client whose aggressive behavior continues to escalate despite verbal intervention?

a. Lithium
b. Trazodone
c. Olanzapine
d. Valproic acid

Answer 20

c. Olanzapine

Question 21

An emergency department nurse realizes that the spouse of a client 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 client’s condition is not life threatening.
c. Periodically provide an update and progress report on the client.
d. Suggest that the spouse return home until the client’s treatment is complete.

Answer 21

c. Periodically provide an update and progress report on the client.

Question 22

Which history information from a client’s record would indicate marginal coping skills and the need for careful assessment of the risk for violence?

a. academic problems.
b. family involvement.
c. childhood trauma.
d. substance abuse.

Answer 22

d. substance abuse.

Question 23

Family members describe the client as “a difficult person who finds fault with others.” The client verbally abuses nurses for their poor care. What is the most likely explanation for this behavior?

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

c. a personality style that externalizes problems.

Question 24

A new client acts out so aggressively that seclusion is required before the admission assessment is completed, or orders written. Immediately after safely secluding the client, 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 client’s medical record.
d. Explain to the client that seclusion will be discontinued when self-control is
regained.

Answer 24

b. Notify the health care provider to obtain a seclusion order.

Question 25

A client with a history of command hallucinations approaches the nurse yelling obscenities. Which nursing actions are most likely to be effective in de-escalation for this scenario? (Select all that apply.)

a. Stating the expectation that the client will stay in control.
b. Asking the client, “Do you want to go into seclusion?”
c. Telling the client, “You are behaving inappropriately.”
d. Offering to provide the client with medication to help.
e. Speaking in a firm but calm voice.

Answer 25

a. Stating the expectation that the client will stay in control.
d. Offering to provide the client with medication to help.
e. Speaking in a firm but calm voice.

Question 26

A nurse directs the intervention team who places an aggressive client in seclusion. Before approaching the client, 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 client and take the closest extremity.
c. Select the person who will communicate with the client.
d. Move behind the client when the client is not looking.
e. Remove jewelry, glasses, and harmful items.

Answer 26

a. Appoint a person to clear a path and open, close, or lock doors.
c. Select the person who will communicate with the client.
e. Remove jewelry, glasses, and harmful items.

Question 27

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

a. Amygdala
d. Temporal lobe
e. Prefrontal cortex

Question 28

Because an intervention was required to control a client’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. Client 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

a. Client behaviors associated with the incident
c. Intervention techniques used by the staff
e. Theories of aggression