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A client is clenching his fists and yelling at another client on the unit. He appears to be close to losing control of his anger. Which of the following actions by the nurse is appropriate at this time?
- A. Clear others out of the immediate area.
- B. Prepare a PRN sedative.
- C. Tell the client to stop and take a time-out.
- D. Alert the security department of an impending aggressive outburst.
Correct Answer: C
Rationale: Directing the client to take a time-out during the escalation phase is a least restrictive intervention to regain control, prioritizing de-escalation over sedatives or security.
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A married man expresses to the nurse that his wife's frequent nagging angers him. The nurse role-plays assertive communication techniques with the husband. Which of the following indicates the husband understands how to use assertive techniques effectively?
- A. I really wish you would stop nagging me
- B. If you are not perfect either
- C. I feel unappreciated when you criticize me
- D. Are you telling me you want me to change?
Correct Answer: C
Rationale: Assertive communication uses 'I' statements to express specific feelings, like feeling unappreciated, fostering productive dialogue, unlike vague wishes or defensive questions.
The nurse decides to place an aggressive and violent client in mechanical restraints. The nurse bases this decision on which of the following?
- A. Client's mood
- B. Client's safety
- C. Court order
- D. Physician's order
Correct Answer: B
Rationale: Restraints are used when the client's safety is at risk and less restrictive measures fail, not based on mood, court, or physician orders alone.
The client's son is yelling and is hitting his hand with a rolled up newspaper. Which stage of aggression does the nurse identify that the client's son is exhibiting?
- A. Triggering
- B. Escalation
- C. Crisis
- D. Recovery
Correct Answer: B
Rationale: Yelling and self-directed aggression (hitting hand) indicate the escalation phase, where behaviors signal a potential loss of control, not yet reaching crisis.
An angry client has just thrown a chair across the room and is racing to pick up another chair to throw. The most appropriate action by the nurse would be which of the following?
- A. Call for an emergency response from trained personnel.
- B. Approach the client and firmly say, 'Stop, put it down'
- C. Calmly call the client by name and encourage verbal expression of anger.
- D. Assist the client to use problem-solving techniques instead of aggression.
Correct Answer: A
Rationale: In the crisis phase, calling for trained personnel ensures safety, as verbal interventions or problem-solving are ineffective when physical aggression has begun.
Anger management is likely to be included in the care of clients with which of the following psychiatric diagnoses?
- A. Alzheimer's dementia
- B. Schizophrenia
- C. Anorexia nervosa
- D. Acute alcohol intoxication
- E. Generalized anxiety disorder
Correct Answer: A,B,D
Rationale: Clients with Alzheimer's dementia, schizophrenia, or acute alcohol intoxication may exhibit aggression due to cognitive impairments or delusions, requiring anger management, unlike anorexia or anxiety.