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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.
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One of the first steps that a nurse should take to deal effectively with aggressive clients is which of the following?
- A. Reflect on abilities to handle own feelings of anger
- B. Learn professional skills of anger management
- C. Become proficient using reflective communication techniques
- D. Understand how to activate crisis response teams
Correct Answer: A
Rationale: Self-reflection on personal anger management enhances the nurse's ability to handle aggressive clients, preceding skill development or crisis response knowledge.
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.
Which is most likely to be the subject of an aggressive attack from a client with mental illness?
- A. Other people
- B. The client
- C. Animals
- D. Objects
Correct Answer: B
Rationale: Clients with mental illness are more likely to harm themselves than others, animals, or objects due to internal distress or self-directed aggression.
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.
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.