Exam 17: Angeraggression Management

An adult client assaults another client and is placed in restraints at 1345 hours. While the client is in restraints, which client statement should alert a nurse that further assessment is necessary?

On an inpatient psychiatric unit, a restrained 16-year-old client continues to verbally lash out, and threatens to abuse staff and kill self when released. To meet Joint Commission standards, at what time should a nurse expect the physician to renew the client's restraint order?

Which risk factor should a nurse recognize as the most reliable indicator of potential client violence?

A client is served divorce papers while on the inpatient psychiatric unit. When a nurse tells the client the unit telephone cannot be used after hours, the client raises fists, swears, and spits at the nurse. Which negative coping mechanism has the client exhibited?

A nursing instructor is teaching about violence-intervention protocols. Which student statement would indicate the need for further instruction?

Which client statement demonstrates improvement in terms of anger/aggression management?

A nurse notices a client clenching fists periodically and pacing the hallway. Which of the following nursing interventions would best assist the client at this time? (Select all that apply.)

The nurse observes a client's escalating anger. The client begins to pace the hall and shouts, "You all better watch out. I'm going to hurt anyone who gets in my way." Which should be the priority nursing intervention?

After less restrictive means have been attempted, an order for client restraints has been obtained for a hostile, aggressive 30- year-old client. If client aggression continues, how long will the nurse expect the client to remain in restraints without a physician order renewal?

For select clients, physical restraint is considered to be a beneficial intervention. This is based on which premise?

A client diagnosed with paranoid schizophrenia has a history of aggravated assault. A nurse assigns "Risk for other-directed violence" as the client's priority nursing diagnosis. Based on this diagnosis, which would be an appropriate outcome for this client?

How often should a nurse plan to observe a client who is in restraints?

A nurse is caring for four clients. Which client should the nurse identify as least prone to developing problems with anger and aggression?

Which nursing approach is likely to be most therapeutic when dealing with a newly admitted, hostile, suspicious client?

At 3 a.m., when less restrictive methods fail, a physician orders restraints for an angry, aggressive client. To meet Joint Commission standards, at what time and by whom should a nurse expect an in-person client evaluation?

After restraints are removed from a client, the staff discusses the incident and establishes guidelines for the client's return to the therapeutic milieu. Which unit procedure is the staff implementing?

A client begins to smash furniture, cannot be "talked down," and refuses medications. Which is the most appropriate nursing intervention?

The client states, "I get into trouble because I respond violently without thinking. That usually gets me into a mess." Which nursing reply would be most therapeutic to address this client's problem?

A student nurse has just entered a psychiatric rotation. The student asks a nursing instructor, "How will we know if someone may get violent?" Which is the most appropriate reply by the nursing instructor?

Which initial nursing approach makes limit setting better accepted by clients who are aggressively acting out?