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A patient sits in silence for 20 minutes after a therapy appointment, appearing tense and vigilant. The patient abruptly stands and paces back and forth, clenching and unclenching fists, and then stops and stares in the face of a staff member. What is the likely conclusion regarding the patient's behavior?
- A. Patient is demonstrating withdrawal behaviors.
- B. Patient is trying to work through angry feelings.
- C. Patient is attempting to use relaxation strategies.
- D. Patient is exhibiting clues to potential aggression.
Correct Answer: D
Rationale: The description of the patient's behavior shows the classic signs of someone whose potential for aggression is increasing. None of the other options are supported by the behavior.
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Because an intervention is required to control a patient's aggressive behavior, a critical incident debriefing takes place. Which topics should be the focus of the discussion? (Select all that apply.)
- A. Patient behavior associated with the incident
- B. Genetic factors associated with aggression
- C. Intervention techniques used by staff
- D. Effect of environmental factors
- E. Review of theories of aggression
Correct Answer: A,C,D
Rationale: 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. Discussing the views about the theoretical origins of aggression is less effective.
After an assault by a patient, a nurse has difficulty sleeping, startles easily, and is preoccupied with the incident. The nurse says, 'I dread facing potentially violent patients. They make me so angry.' Which response would be the most urgent reason for this nurse to seek supervision?
- A. Startle reactions
- B. Difficulty sleeping
- C. Expression of anger
- D. Preoccupation with the incident
Correct Answer: C
Rationale: The expression of patient-focused anger signals an urgent need for professional supervision to work through anger and counter the aggressive feelings. The distractors are normal in a person who has been assaulted. Nurses are usually relieved with crisis intervention and follow-up designed to give support, help the individual regain a sense of control, and make sense of the event.
An adult patient assaulted another patient and was restrained. One hour later, which statement by this restrained patient necessitates 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. It was not my fault. The other patient started it.'
Correct Answer: B
Rationale: The correct response indicates impaired circulation and necessitates the nurse's immediate attention. The incorrect responses indicate that the patient has continued aggressiveness and agitation.
A patient with a history of impulsively acting out anger by striking others. Which would be an appropriate plan for avoiding such incidents?
- A. Explain that restraint and seclusion will be used if violence occurs.
- B. Help the patient identify incidents that trigger impulsive acting out.
- C. Offer one-on-one supervision to help the patient maintain control.
- D. Administer lorazepam every 4 hours to reduce the patient's anxiety.
Correct Answer: B
Rationale: Identifying trigger incidents allows the patient and nurse to plan interventions to reduce irritation and frustration that lead to acting out anger and to put more adaptive coping strategies eventually into practice. None of the other options allow for self-reflection and understanding of the causes of the aggressive behavior.
When a patient's aggression quickly escalates, which principle applies to the selection of nursing interventions?
- A. Staff members should match the patient's affective level and tone of voice.
- B. Ask the patient what intervention would be most helpful.
- C. Immediately use physical containment measures.
- D. Begin with the least restrictive measure possible.
Correct Answer: D
Rationale: Standards of care require that staff members use the least restrictive measure possible. This becomes the guiding principle for intervention. Physical containment is seldom the least restrictive measure. Asking the out-of-control patient what to do is rarely helpful. It may be an effective strategy during the pre-assaultive phase but is less effective during escalation.