Information on this page has been adapted from the Guidelines on the management of co-occurring alcohol and other drug and mental health conditions in alcohol and other drug treatment settings (2nd edition). Developers: Marel C, Mills KL, Kingston R, Gournay K, Deady M, Kay-Lambkin F, Baker A, Teesson M. (2016). B6: Aggressive, angry or violent behaviour. In Guidelines on the management of co-occurring alcohol and other drug and mental health conditions in alcohol and other drug treatment settings (2nd edition), pp. 181-182. Sydney, Australia: Centre of Research Excellence in Mental Health and Substance Use, National Drug and Alcohol Research Centre, University of New South Wales. The Guidelines were funded by the Australian Government Department of Health and Aged Care. Further information about managing phases of aggression can be found in the Guidelines. Costs: Free Year: 2016 Evidence base: These guidelines were developed based on comprehensive reviews of the best available evidence at the time of development. View the full list of references. Nursing approach for "Anxious" Nursing uses active listening; allows for ventilation; supportive, informing; addresses immediate concerns and sources of fear, pain and frustration; offers alternatives. Nursing approach for "Calm" Nurse is professional; helpful; available Nursing approach for "Aggression" Nurse is aware of physical distance; escape routes; physical intervention plan Nursing approach for "Tension Reduction" Nurse re-establishes therapeutic rapport; initiates debriefing Nursing approach for "Agitated" Nurse takes a directive stance and provides short concise instructions Cause of Aggression The individual brings to the current situation, factors such as attitudes, beliefs and behavioral tendencies which lead to aggression Irritable The individual is chronically angry at the world. She may be looking for something to set her off. The client may have had boundaries that were violated and is trying to regain her self-worth. Fear Driven The individual attacks others in an effort to avoid getting hurt Instrumental The individual has learned from past experiences that aggression helps him to get what he wants. A nurse is caring for a client in active alcohol withdrawals on a med-surg unit. The client is observed speaking in a loud voice, using profanity with clenched fists. Which of the following actions should the nurse take? a. Insist that the client stop yelling. b. Request that other staff members remain close by. Which statement about aggression would serve as the rational for care planning using behavioral techniques? Aggression... a. is motivated by rewards received for previous aggression. a. is motivated by rewards received for previous aggression. Rationale: Behavioral therapy does not accept aggressive drives as being instinctual or biological. It views aggressive behavior as a learned response that tends to be repeated if reinforced. Which patient behavior is a criterion for mechanical restraint? a. Assaulting a staff person a. Assaulting a staff person. Rationale: Indications for the use of mechanical restraint include protecting the patient form self-harm and preventing the patient from assaulting others. A client is pacing the hall near the nurses' station, swearing loudly. An appropriate initial intervention for the nurse would be to address the client by name and say... a. "Hey, what's up?" c. "You seem upset. Tell me about it." Rationale: Intervention should begin with analysis of the client and the situation. With this response the nurse is attempting to hear the client's feelings and concerns. This leads to the next step of planing an intervention. The child with autism spectrum disorder (ASD) has difficulty with trust. With this in mind, which of the following nursing actions would be most appropriate? a. Encourage the staff to hold the child as often as possible, conveying trust through touch. c. Avoid direct eye contact. Rationale: Direct eye contact this is extremely uncomfortable for the child with autism, and may even discourage trust. A violent patient is restrained. What is the nurse's first priority? a. Ensure the patient's safety. a. Ensure the patient's safety. Rationale: Once in restraints, a patient must be directly observed and formally assessed at frequent, regular intervals for level of awareness, level of activity, safety with the restraints, hydration, toileting needs, nutrition and comfort. A client is admitted for psychiatric observation after being arrested for breaking windows in the home of his former girlfriend, who had refused to see him. His history reveals abuse as a child by a punitive father, torturing family pets, and one arrest for disorderly conduct. The nursing diagnosis that should be considered for development is: a. Risk for injury b. Risk for other-directed violence Rationale: The defining characteristics for risk for violence directed at others include a history of being abused as a child, having committed other violent acts, and demonstrating poor impulse control. An effective nursing intervention for helping angry clients learn to manage anger without violence would be: a. Using cognitive strategies to identify a thought that increases anger, find proof for or against the belief, and substitute reality-based thinking. a. Using cognitive strategies to identify a thought that increases anger, find proof for or against the belief, and substitute reality-based thinking Rationale: Anger has a strong cognitive component, so using cognition to manage anger is logical. A client has, in the past, had a nursing diagnosis of ineffective coping related to impulsively acting out anger as evidenced by striking others. An appropriate plan for forestalling such incidents would be: a. Request that the client receive lorazapam (Ativan) every 4 hours to reduce anxiety. d. Helping a client identify incidents that trigger impulsive acting out. C Rationale: Identification of trigger incidents allows the client and nurse to plan interventions that reduce irritation and frustration, which lead to acting out anger, and eventually to put into practice more adaptive coping strategies. The nurse directs the intervention team who must take an aggressive client to seclusion. Other clients have been removed from the area. Before approaching the client, the nurse should ensure that staff: Choose all that apply a. Remove jewelry, glasses, and harmful items from their persons. A. B. C. The principle on which nursing intervention should be predicated when a client's aggression quickly escalates is: a. Staff should match client's affective level, tone of voice, and so forth. d. Begin with the least restrictive measure possible. Rationale: Legal constraints require that staff use the least restrictive measure possible. This becomes the principle for intervention. Two hours after a client lost control and required restraints and PRN medication, she is out of restraints, calm, and sitting in her room reading. The post-intervention debriefing process is initiated by the nurse and includes: Choose all that apply a. Reestablishing therapeutic communication and rapport with client. A. C. D. The post-intervention debriefing process should be attempted when the client is calm. This processing helps the client and staff understand what happened and how further incidents of violence can be avoided. Identification of the precipitating event is critical. Once this is accomplished, the client and nurse can discuss possible alternative coping strategies and role play those chosen. The medication protocol the nurse should use to provide immediate intervention for an angry psychotic client whose aggressive behavior continues to escalate despite verbal intervention is: Select one: b. Haloperidol Rationale: Haloperidol is a short-acting antipsychotic that is useful in calming angry, aggressive clients regardless of their diagnosis. An aggressive client was placed in four-point restraints and given an intramuscular dose of anxiolytic medication. Systematic assessment to guide interventions during the period of restraint should include: Choose all that apply a. Nutritional needs A. B. C. D. E. All the options should be assessed. Each pertains to biological and safety needs for the client. Nurses must follow hospital protocol for care. Generally, clients should be observed for level of consciousness at 15-minutes intervals, given food at normal meal times or more often if they are hyperactive, given flouids hourly, have vital signs checked at 4 hour intervals or less if medications administration has caused hypotension, taken to the bathroom every 2 hours, and released from restraints and given range of motion every 2 hours. A client who was brought into the emergency room by EMS intoxicated, suddenly removes a knife from his coat pocket and threatens to kill himself or anyone who tries to stop him from leaving the room. A psychiatric emergency code is called and the client is safely disarmed and placed in restraints. the rationale for use of restraints was that the client: a. Presented a clear and present danger to self and others. a. Presented a clear and present danger to self and others. Rationale: The client's threat to kill himself and others with the knife he possessed constituted a clear and present danger to self and others. The client on the mental health unit who should be assessed as being at highest risk for directing violent behavior towards others is... a. The client who has completed alcohol withdrawal and is beginning a rehabilitation program. d. The client who has paranoid delusions that she is being followed by members of the mafia. Rationale: This client has the greatest disruption of ability to perceive reality accurately. People who feel persecuted may strike out against those believed to be persecutors. What is the team intervention techniques used in nonviolent crisis intervention? a. TIP:
Team, Isolate, Plan a. TIP: Team, Isolate, Plan Rationale: The TIP technique focuses on having a team of two to three staff members with one being the team leader who approaches the client and maintains one-to-one communication. Isolation of the individual and situation helps decrease stimuli, provides for a more therapeutic environment and confidentiality, as well as maintaining a safe and therapeutic milieu. . A plan should be reviewed with the team on how best to to balance or offset the person's behavior with therapeutic responses by the staff. Taking physical control of a person when he has lost complete control is the most therapeutic process possible, if the action by staff is carried out in an nonharmful, nonviolent manner. The first task in assessing violent behavior should be a. Ascertaining degree of injuries. d. Determination of the cause. Rationale: Cause directs treatment. |
A nurse is caring for a client who has become aggressive what is the priority action of the nurse
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