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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.
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Which of the following statements about the crisis phase of aggression when the client becomes physically aggressive is true?
- A. All staff should act to take charge of the situation.
- B. The client must be restrained or sedated at once.
- C. Staff should avoid communicating with the client.
- D. Four to six trained staff members are needed to restrain.
Correct Answer: D
Rationale: Four to six trained staff are needed for safe restraint, following protocols, unlike automatic sedation or avoiding communication, which are not standard.
Which of the following are important issues for nurses to be aware of when working with angry, hostile, or aggressive clients?
- A. Nurses must be aware of their own feelings about anger and their use of assertive communication and conflict resolution.
- B. Nurses must not allow themselves to become angry, under any circumstances.
- C. Nurses must know that a client's anger or aggressive behavior is preventable by a skilled nurse.
- D. Nurses must discuss situations or the care of potentially aggressive clients with experienced nurses.
- E. Nurses must be calm, nonjudgmental, and nonpunitive when using techniques to control a client's aggressive behavior.
Correct Answer: A,D,E
Rationale: Self-awareness, consultation with experienced nurses, and a calm, nonjudgmental approach are critical for managing aggressive clients effectively, unlike preventing all anger or suppressing personal emotions.
The nurse is interviewing a client with a history of physical aggression. Which of the following should the nurse avoid?
- A. Anticipating that a loss of control is possible and planning accordingly
- B. Explaining the consequences the client will face if control is lost
- C. Interviewing the client with another staff member present
- D. Responding to verbal threats by terminating the interview and obtaining assistance
Correct Answer: B
Rationale: Explaining consequences may provoke hostility, unlike proactive safety measures like anticipating loss of control or having support, which are appropriate.
Which of the following interventions would assist the client with the appropriate expression of anger?
- A. Encourage catharsis
- B. Encourage verbalization
- C. Improve self-esteem
- D. Isolate the client from others
Correct Answer: B
Rationale: Verbalizing anger is a safe, therapeutic way to express emotions, unlike catharsis or isolation, which may escalate hostility; self-esteem is a separate issue.
The nurse observes two clients in the day room arguing. One client runs into the corner and huddles while the other follows and continues with verbal abuse. Which is the best action by the nurse?
- A. Take an authoritative step between the two clients.
- B. Comfort the client huddled in the corner.
- C. Directly address both clients and ask what is going on.
- D. Engage the attention of the client who is still yelling and ask what is happening.
Correct Answer: D
Rationale: Engaging the dominant client de-escalates the situation by redirecting their focus, avoiding physical intervention or ignoring the aggressor's behavior.