Anger, Aggression, and Violence

MULTIPLE CHOICE

1. Which behavior best demonstrates aggression?
a. Stomping away from the nurses’ station, going to another room, and grabbing a snack from another patient.
b. Bursting into tears, leaving the community meeting, and sitting on a bed hugging a pillow and sobbing.
c. Telling the primary nurse, “I felt angry when you said I could not have a second helping at lunch.”
d. Telling the medication nurse, “I am not going to take that or any other medication you try to give me.”
ANS: A
Aggression is harsh physical or verbal action that reflects rage, hostility, and the potential for physical or verbal destructiveness. Aggressive behavior violates the rights of others. The incorrect options do not feature violation of another’s rights.

DIF: Cognitive Level: Comprehension (Understanding) REF: Page: 462
TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

2. Which scenario predicts the highest risk for directing violent behavior toward others?
a. Major depressive disorder with delusions of worthlessness
b. Obsessive-compulsive disorder; performing many rituals
c. Paranoid delusions of being followed by a military attack team
d. Completion of alcohol withdrawal and beginning a rehabilitation program
ANS: C
The correct answer illustrates the greatest disruption of ability to perceive reality accurately. People who feel persecuted may strike out against those believed to be persecutors. The patients identified in the distractors have better reality-testing ability.

DIF: Cognitive Level: Application (Applying) REF: Pages: 465-466
TOP: Nursing Process: Analysis| Nursing Process: Diagnosis
MSC: NCLEX: Safe, Effective Care Environment

3. A patient is hospitalized after an arrest for breaking windows in the home of a former domestic partner. The history reveals childhood abuse by a punitive parent, torturing family pets and an arrest for disorderly conduct. Which nursing diagnosis has priority?
a. Risk for injury
b. Post-trauma response
c. Disturbed thought processes
d. Risk for other-directed violence
ANS: D
The defining characteristics for Risk for other-directed violence include a history of being abused as a child, having committed other violent acts, and demonstrating poor impulse control. The defining characteristics for the other diagnoses are not present in this scenario.

DIF: Cognitive Level: Analysis (Analyzing) REF: Page: 466
TOP: Nursing Process: Analysis| Nursing Process: Diagnosis
MSC: NCLEX: Psychosocial Integrity

4. A confused older adult patient in a skilled care facility is sleeping. The nurse enters the room quietly and touches the bed to see if it is wet. The patient awakens and hits the nurse in the face. Which statement best explains the patient’s action?
a. Older adult patients often demonstrate exaggerations of behaviors used earlier in life.
b. Crowding in skilled care facilities increases individual tendencies toward violence.
c. The patient interpreted the health care worker’s behavior as potentially harmful.
d. This patient learned violent behavior by watching other patients act out.
ANS: C
Confused patients are not always able to evaluate accurately the actions of others. This patient behaved as though provoked by the intrusive actions of the staff member.

DIF: Cognitive Level: Application (Applying)
REF: Pages: 465-466 | Pages: 474-475 TOP: Nursing Process: Assessment
MSC: NCLEX: Safe, Effective Care Environment

5. A patient is pacing the hall near the nurses’ station and swearing loudly. An appropriate initial intervention for the nurse would be to address the patient by name and say:
a. “Hey, what’s going on?”
b. “Please quiet down immediately.”
c. “I’d like to talk with you about how you’re feeling right now.”
d. “You must go to your room and try to get control of yourself.”
ANS: C
Intervention should begin with an analysis of the patient and situation. With this response, the nurse is attempting to hear the patient’s feelings and concerns, which leads to the next step of planning an intervention. The incorrect responses are authoritarian, creating a power struggle between the patient and nurse.

DIF: Cognitive Level: Application (Applying) REF: Pages: 468-471
TOP: Nursing Process: Implementation MSC: NCLEX: Safe, Effective Care Environment

6. A patient was responding to auditory hallucinations earlier in the morning. The patient approaches the nurse, shaking a fist and shouting, “Back off!” and then goes into the day room. As the nurse follows the patient into the day room, the nurse should:
a. make sure adequate physical space exists between the nurse and the patient.
b. move into a position that allows the patient to be close to the door.
c. maintain one arm’s length distance from the patient.
d. sit down in a chair near the patient.
ANS: A
Making sure space is present between the nurse and the patient avoids invading the patient’s personal space. Personal space needs increase when a patient feels anxious and threatened. Allowing the patient to block the nurse’s exit from the room is not wise. Closeness may be threatening to the patient and provoke aggression. Sitting is inadvisable until further assessment suggests the patient’s aggression is abating. One arm’s length is inadequate space.

DIF: Cognitive Level: Application (Applying) REF: Pages: 467-468
TOP: Nursing Process: Implementation MSC: NCLEX: Safe, Effective Care Environment

7. An intramuscular dose of antipsychotic medication needs to be given to a patient who is becoming increasingly more aggressive. The patient is in the day room. The nurse should enter the day room:
a. and say, “Would you like to come to your room and take some medication your doctor prescribed for you?”
b. accompanied by three staff members and say, “Please come to your room so I can give you some medication that will help you feel more comfortable.”
c. and place the patient in a basket-hold and then say, “I am going to take you to your room to give you an injection of medication to calm you.”
d. accompanied by two security guards and tell the patient, “You can come to your room willingly so I can give you this medication, or the aide and I will take you there.”
ANS: B
A patient gains feelings of security if he or she sees that others are present to help with control. The nurse gives a simple direction, honestly states what is going to happen, and reassures the patient that the intervention will be helpful. This positive approach assumes that the patient can act responsibly and will maintain control. Physical control measures should be used only as a last resort. The security guards are likely to intimidate the patient and increase feelings of vulnerability.

DIF: Cognitive Level: Application (Applying) REF: Pages: 465-469
TOP: Nursing Process: Implementation MSC: NCLEX: Safe, Effective Care Environment

8. 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.” Which response would be the most urgent reason for this nurse to seek supervision?
a. Startle reactions
b. Difficulty sleeping
c. A wish for revenge
d. Preoccupation with the incident
ANS: C
The desire for revenge 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.

DIF: Cognitive Level: Analysis (Analyzing) REF: Page: 473
TOP: Nursing Process: Assessment MSC: NCLEX: Safe, Effective Care Environment

9. The staff development coordinator plans to teach use of physical management techniques when patients become assaultive. Which topic should be emphasized?
a. Practice and teamwork
b. Spontaneity and surprise
c. Caution and superior size
d. Diversion and physical outlets
ANS: A
Intervention techniques are learned behaviors that must be practiced to be used in a smooth, organized fashion. Every member of the intervention team should be assigned a specific task to carry out before beginning the intervention. The other options are useless if the staff does not know how to use physical techniques and how to apply them in an organized fashion.

DIF: Cognitive Level: Application (Applying) REF: Pages: 467-469
TOP: Nursing Process: Implementation MSC: NCLEX: Safe, Effective Care Environment

10. An adult patient assaults another patient and is 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.”
ANS: B
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.

DIF: Cognitive Level: Analysis (Analyzing) REF: Pages: 471-473
TOP: Nursing Process: Evaluation MSC: NCLEX: Safe, Effective Care Environment

11. Which is an effective nursing intervention to assist an angry patient to learn to manage anger without violence?
a. Help the patient identify a thought that increases anger, find proof for or against the belief, and substitute reality-based thinking.
b. Provide negative reinforcement such as restraint or seclusion in response to angry outbursts, whether or not violence is present.
c. Use aversive conditioning, such as popping a rubber band on the wrist, to help extinguish angry feelings.
d. Administer an antipsychotic or antianxiety medication when the patient feels angry.
ANS: A
Anger has a strong cognitive component; therefore, using cognition to manage anger is logical. The incorrect options do nothing to help the patient learn anger management.

DIF: Cognitive Level: Application (Applying) REF: Pages: 475-476
TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

12. Which assessment finding presents the greatest risk for violent behavior? A patient who:
a. is severely agoraphobic.
b. has a history of intimate partner violence.
c. demonstrates bizarre somatic delusions.
d. verbalizes hopelessness and powerlessness.
ANS: B
A history of prior aggression or violence is the best predictor of patients who may become violent. Patients diagnosed with anxiety disorders are not particularly prone to violence unless panic occurs. Patients experiencing hopelessness and powerlessness may have co-existing anger, but violence is not often demonstrated. Patients experiencing paranoid delusions are at greater risk for violence than those with bizarre somatic delusions.

DIF: Cognitive Level: Application (Applying) REF: Pages: 465-466
TOP: Nursing Process: Assessment MSC: NCLEX: Safe, Effective Care Environment

13. A patient being admitted suddenly pulls a knife from a coat pocket and threatens, “I will kill anyone who tries to get near me.” An emergency code is called. The patient is safely disarmed and placed in seclusion. Justification for the use of seclusion is that the patient:
a. evidences a thought disorder, rendering rational discussion ineffective.
b. presents a clear and present danger to others.
c. presents a clear escape risk.
d. is psychotic.
ANS: B
The patient’s threat to kill self or others with the knife he possesses constitutes a clear and present danger to self and others. The distractors are not sufficient reasons for seclusion.

DIF: Cognitive Level: Comprehension (Understanding)
REF: Pages: 467-469 | Pages: 471-473 TOP: Nursing Process: Planning
MSC: NCLEX: Safe, Effective Care Environment

14. 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. The patient is:
a. demonstrating withdrawal.
b. working through angry feelings.
c. attempting to use relaxation strategies.
d. exhibiting clues to potential aggression.
ANS: D
The description of the patient’s behavior shows the classic signs of someone whose potential for aggression is increasing.

DIF: Cognitive Level: Comprehension (Understanding) REF: Pages: 465-466
TOP: Nursing Process: Assessment MSC: NCLEX: Safe, Effective Care Environment

15. A cognitively impaired patient has been a widow for 30 years. This patient is frantically trying to leave the unit, saying, “I have to go home to cook dinner before my husband arrives from work.” To intervene with validation therapy, the nurse should first say:
a. “You must come away from the door.”
b. “You have been a widow for many years.”
c. “You want to go home to prepare your husband’s dinner?”
d. “Was your husband angry if you did not have dinner ready on time?”
ANS: C
Validation therapy meets the patient “where she or he is at the moment” and acknowledges the patient’s wishes. Validation does not seek to redirect, reorient, or probe. The incorrect options do not validate the patient’s feelings.

DIF: Cognitive Level: Application (Applying) REF: Pages: 474-475
TOP: Nursing Process: Implementation MSC: NCLEX: Safe, Effective Care Environment

16. A patient with a history of anger and impulsivity is hospitalized after an accident resulting in injuries. When in pain, the patient loudly scolds the nursing staff for “not knowing enough to give me pain medicine when I need it.” Which nursing intervention would best address this problem?
a. Tell the patient to notify nursing staff 30 minutes before the pain returns so the medication can be prepared.
b. Urge the health care provider to change the prescription for pain medication from as needed to a regular schedule.
c. Tell the patient that verbal assaults on nurses will not shorten the wait for pain medication.
d. Have the clinical nurse leader request a psychiatric consultation.
ANS: B
Scheduling the medication at specific intervals will help the patient anticipate when the medication can be given. Receiving the medication promptly on schedule, rather than expecting nurses to anticipate the pain level, should reduce anxiety and anger. The patient cannot predict the onset of pain before it occurs.

DIF: Cognitive Level: Analysis (Analyzing) REF: Pages: 466-469
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

17. A patient has 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 (Ativan) every 4 hours to reduce the patient’s anxiety.
ANS: B
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.

DIF: Cognitive Level: Application (Applying) REF: Pages: 466-468
TOP: Nursing Process: Planning MSC: NCLEX: Safe, Effective Care Environment

18. A patient with severe injuries is irritable, angry, and belittles the nurses. As a nurse changes a dressing, the patient screams, “Don’t touch me! You are so stupid. You will make it worse!” Which intervention uses a cognitive technique to help this patient?
a. Discontinue the dressing change without comments and leave the room.
b. Stop the dressing change, saying, “Perhaps you would like to change your own dressing.”
c. Continue the dressing change, saying, “Do you know this dressing change is needed so your wound will not get infected?”
d. Continue the dressing change, saying, “Unfortunately, you have no choice. Your doctor ordered this dressing change.”
ANS: C
Anger is cognitively driven. The correct answer helps the patient test his cognitions and may help lower his anger. The incorrect options will escalate the patient’s anger by belittling or escalating the patient’s sense of powerlessness.

DIF: Cognitive Level: Application (Applying) REF: Pages: 475-476
TOP: Nursing Process: Implementation MSC: NCLEX: Safe, Effective Care Environment

19. Which medication should a nurse administer to provide immediate intervention for a psychotic patient whose aggressive behavior continues to escalate despite verbal intervention?
a. lithium (Eskalith)
b. trazodone (Desyrel)
c. olanzapine (Zyprexa)
d. valproic acid (Depakene)
ANS: C
Olanzapine is a short-acting antipsychotic drug that is useful in calming angry, aggressive patients regardless of their diagnosis. The other drugs listed require long-term use to reduce anger. Lithium is for patients with bipolar disorder. Trazodone is for patients with depression, insomnia, or chronic pain. Valproic acid is for patients with bipolar disorder or borderline personality disorder.

DIF: Cognitive Level: Application (Applying) REF: Page: 476
TOP: Nursing Process: Implementation MSC: NCLEX: Safe, Effective Care Environment

20. An emergency department nurse realizes that the spouse of a patient is becoming increasingly irritable while waiting. Which intervention should the nurse use to prevent escalation of anger?
a. Explain that the patient’s condition is not life threatening.
b. Periodically provide an update and progress report on the patient.
c. Explain that all patients are treated in order, based on their medical needs.
d. Suggest that the spouse return home until the patient’s treatment is completed.
ANS: B
Periodic updates reduce anxiety and defuse anger. This strategy acknowledges the spouse’s presence and concerns. The incorrect options are likely to increase anger because they imply that the anxiety is inappropriate.

DIF: Cognitive Level: Application (Applying) REF: Pages: 473-474
TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

21. Information from a patient’s record that indicates marginal coping skills and the need for careful assessment of the risk for violence is a history of:
a. childhood trauma.
b. family involvement.
c. academic problems.
d. substance abuse.
ANS: D
The nurse should suspect marginal coping skills in a patient with substance abuse. He or she is often anxious, may be concerned about inadequate pain relief, and may have a personality style that externalizes blame. The incorrect options do not signal as high a degree of risk as chemical dependence.

DIF: Cognitive Level: Comprehension (Understanding) REF: Pages: 465-466
TOP: Nursing Process: Assessment MSC: NCLEX: Safe, Effective Care Environment

22. A patient diagnosed with pneumonia has been hospitalized for 4 days. Family members describe the patient as “a difficult person who finds fault with others.” The patient verbally abuses nurses for providing poor care. The most likely explanation for this behavior lies in:
a. poor childrearing that did not teach respect for others.
b. automatic thinking, leading to cognitive distortion.
c. personality style that externalizes problems.
d. delusions that others wish to deliver harm.
ANS: C
Patients whose personality style causes them to externalize blame see the source of their discomfort and anxiety as being outside themselves. They displace anger and are often unable to soothe themselves. The incorrect options are less likely to have a bearing on this behavior.

DIF: Cognitive Level: Application (Applying) REF: Pages: 465-466
TOP: Nursing Process: Assessment MSC: NCLEX: Safe, Effective Care Environment

23. A patient with burn injuries has had good coping skills for several weeks. Today, a new nurse is poorly organized and does not follow the patient’s usual schedule is. By mid-afternoon, the patient is angry and loudly complains to the nurse manager. Which is the nurse manager’s best response?
a. Explain the reasons for the disorganization, and take over the patient’s care for the rest of the shift.
b. Acknowledge and validate the patient’s distress and ask, “What would you like to have happen?”
c. Apologize and explain that the patient will have to accept the situation for the rest of the shift.
d. Ask the patient to control the anger and explain that allowances must be made for new staff members.
ANS: B
When a patient with good coping skills is angry and overwhelmed, the goal is to reestablish a means of dealing with the situation. The nurse should solve the problem with the patient by acknowledging the patient’s feelings, validating them as understandable, apologizing if necessary, and then seeking an acceptable solution. Often patients can tell the nurse what they would like to have happen as a reasonable first step.

DIF: Cognitive Level: Application (Applying) REF: Pages: 468-469
TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

24. 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.
ANS: D
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 preassaultive phase but is less effective during escalation.

DIF: Cognitive Level: Comprehension (Understanding) REF: Pages: 466-467
TOP: Nursing Process: Planning MSC: NCLEX: Safe, Effective Care Environment

25. A new patient immediately requires seclusion on admission. The assessment is incomplete, and no prescriptions have been written. Immediately after safely secluding the patient, which action has priority?
a. Provide an opportunity for the patient to go to the bathroom.
b. Notify the health care provider and obtain a seclusion order.
c. Notify the hospital risk manager.
d. Debrief the staff.
ANS: B
Emergency seclusion can be effected by a credentialed nurse but must be followed by securing a medical order within the period specified by the state and agency. The incorrect options are not immediately necessary from a legal standpoint.

DIF: Cognitive Level: Application (Applying) REF: Pages: 471-473
TOP: Nursing Process: Implementation MSC: NCLEX: Safe, Effective Care Environment

MULTIPLE RESPONSE

1. A patient with a history of command hallucinations approaches the nurse, yelling obscenities. The patient mumbles and then walks away. The nurse follows. Which nursing actions are most likely to be effective in de-escalating this scenario? Select all that apply.
a. State the expectation that the patient will stay in control.
b. State that the patient cannot be understood when mumbling.
c. Tell the patient, “You are behaving inappropriately.”
d. Offer to provide the patient with medication to help.
e. Speak in a firm but calm voice.
ANS: A, D, E
Stating the expectation that the patient will maintain control of behavior reinforces positive, healthy behavior and avoids challenging the patient. Offering an as-needed medication provides support for the patient trying to maintain control. A firm but calm voice will likely comfort and calm the patient. Belittling remarks may lead to aggression. Criticism will probably prompt the patient to begin shouting.

DIF: Cognitive Level: Analysis (Analyzing) REF: Pages: 468-471
TOP: Nursing Process: Implementation MSC: NCLEX: Safe, Effective Care Environment

2. A nurse directs the intervention team who must take an aggressive patient to seclusion. Other patients were removed from the area. Before approaching the patient, the nurse should ensure that staff take which actions? Select all that apply.
a. Remove jewelry, glasses, and harmful items from the patient and staff members.
b. Appoint a person to clear a path and open, close, or lock doors.
c. Quickly approach the patient, and grab the closest extremity.
d. Select the person who will communicate with the patient.
e. Move behind the patient to use the element of surprise.
ANS: A, B, D
Injury to staff members and to the patient should be prevented. Only one person should explain what will happen and direct the patient; this person might be the nurse or staff member who has a good relationship with the patient. A clear pathway is essential; those restraining a limb cannot use keys, move furniture, or open doors. The nurse is usually responsible for administering the medication once the patient is restrained. Each staff member should have an assigned limb rather than just grabbing the closest limb. This system could leave one or two limbs unrestrained. Approaching in full view of the patient reduces suspicion.

DIF: Cognitive Level: Application (Applying)
REF: Pages: 467-469 | Pages: 471-473 TOP: Nursing Process: Planning
MSC: NCLEX: Safe, Effective Care Environment

3. Which central nervous system structures are most associated with anger and aggression? Select all that apply.
a. Amygdala
b. Cerebellum
c. Basal ganglia
d. Temporal lobe
e. Parietal lobe
ANS: A, D
The amygdala mediates anger experiences and helps a person judge an event as either rewarding or aversive. The temporal lobe, which is part of the limbic system, also plays a role in aggressive behavior. The cerebellum manages equilibrium, muscle tone, and movement. The basal ganglia are involved in movement. The parietal lobe is involved in interpreting sensations.

DIF: Cognitive Level: Comprehension (Understanding) REF: Pages: 463-464
TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

4. Which behaviors are most consistent with the clinical picture of a patient who is becoming increasingly aggressive? Select all that apply.
a. Pacing
b. Crying
c. Withdrawn affect
d. Rigid posture with clenched jaw
e. Staring with narrowed eyes into the eyes of another
ANS: A, D, E
Crying and a withdrawn affect are not cited by experts as behaviors indicating that the individual has a high potential to behave violently. The other behaviors are consistent with the increased risk for other-directed violence.

DIF: Cognitive Level: Application (Applying) REF: Pages: 465-466
TOP: Nursing Process: Assessment MSC: NCLEX: Safe, Effective Care Environment

5. 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
ANS: A, C, D
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.

DIF: Cognitive Level: Analysis (Analyzing) REF: Pages: 472-473
TOP: Nursing Process: Evaluation MSC: NCLEX: Safe, Effective Care Environment