Nokea
A client is observed pacing the hall with clenched fists and swearing at others. The nurse intervenes immediately to prevent the client from moving to which phase of the aggression cycle?
- A. Triggering
- B. Escalation
- C. Crisis
- D. Recovery
Correct Answer: B
Rationale: The client's behaviors (pacing, clenched fists, swearing) indicate the escalation phase, and intervention aims to prevent progression to the crisis phase of physical aggression.
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The client with a history of explosive outbursts becomes angry and states, 'I am really getting angry.' The nurse sees this as
- A. Controlling
- B. Manipulation
- C. Progress
- D. Regression
Correct Answer: C
Rationale: Verbalizing anger is progress, indicating self-awareness and control, unlike manipulation or regression, which involve different behavioral patterns.
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.
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.
A client who has been physically aggressive arrives at the emergency room for a psychiatric assessment. Which would be the best approach for the nurse to use?
- A. Have a sense of humor to show a lack of fear.
- B. Provide close contact to increase the client's sense of safety.
- C. Use brief statements and questions to obtain information.
- D. Use open-ended questions, so the client can elaborate.
Correct Answer: C
Rationale: Brief statements and questions facilitate communication with an aggressive client who may struggle to express themselves, unlike humor or open-ended questions, which may escalate tension.
When interacting with a client in the day room, the nurse determines that a violent outburst is imminent. Which of the following should the nurse do first?
- A. Call for assistance.
- B. Give the client choices.
- C. Remove the other clients.
- D. Talk to the client calmly.
Correct Answer: A
Rationale: Calling for assistance prioritizes safety when a violent outburst is imminent, enabling subsequent interventions like removing others or calming the client.