C HAPTER 27: A NGER , A GGRESSION , AND
V IOLENCE
Halter: Varcarolis’ Foundations of Psychiatric -Mental Health Nursing: A
Clinical Approach, 9th Edition
MULTIPLE CHOICE
1. An emergency code was called after a client pulled a dinner knife from a
pocket and threatened, “I will kill anyone who tries to get near me.” The
client was safel y disarmed and placed in seclusion. What is the
justification for this use of seclusion?
a. The client was threatening to others.
b. The client was experiencing psychosis.
c. The client presented an undeniable escape risk.
d. The client presented a clear a nd present danger to others.
ANS: D
The client’s threat to kill self or others with the knife he possessed
constituted a clear and present danger to self and others. The
distracters are not sufficient reasons for seclusion.
PTS: 1 DIF: Cognitive Level: Understand (Comprehension)
TOP: Nursing Process: Planning MSC: Client Needs:
Safe, Effective Care Environment
,2. A client sat in silence for 20 minutes after a therapy appointment,
appearing tense and vigilant. The client abruptl y stood, paced back and
forth, clenched and unclenched fists, and then stopped and stared in the
face of a staff member. What is the client likel y doing?
a. demonstrating withdrawal.
b. working though angry feelings.
c. attempting to use relaxation strategies.
d. exhibiting clues to potentia l aggression.
ANS: D
The description of the client’s behavior shows the classic signs of
someone whose potential for aggression is increasing. The scenario
does not support any of the other options.
PTS: 1 DIF: Cognitive Level: Understand (Comprehensio n)
TOP: Nursing Process: Assessment MSC: Client Needs:
Psychosocial Integrity
3. A client with multi -infarct dementia lashes out and kicks at people who
walk past in the hall of a skilled nursing facilit y. Intervention by the nurse
should begin with what in tervention?
a. gentl y touching the client’s arm.
b. asking the client, “What do you need?”
c. saying to the client, “This is a safe place.”
d. directing the client to cease the behavior.
ANS: C
, Striking out usuall y signals fear or that the client perceives the
environment to be out of control. Getting the client’s attention is
fundamental to intervention. The nurse should make eye contact and
assure the client of safet y. Once the nurse has the client’s attention,
gentl y touching the client, asking what he or she nee ds, or directing the
client to discontinue the behavior may be appropriate.
PTS: 1 DIF: Cognitive Level: Anal yze (Anal ysis) TOP:
Nursing Process: Implementation MSC: Client Needs:
Psychosocial Integrity
4. A cognitivel y impaired client has been a widow for 30 years. This client
franticall y tries to leave the facilit y, sayi ng, “I have to go home to cook
dinner before m y husband arrives from work.” To intervene with
validation therapy, what should the nurse 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. “Your husband gets angry if you do not have dinner ready on time?”
ANS: C
Validation therapy meets the client “where she or he is at the moment”
and acknowledges the client’s wishes. Validation does not seek to
redirect, reorient, or probe. The distracters do not validate the client’s
feelings.
PTS: 1 DIF: Cognitive Level: Appl y (Application)
TOP: Nursing Process: Implementation MSC: Client
Needs: Psychosoci al Integrit y
V IOLENCE
Halter: Varcarolis’ Foundations of Psychiatric -Mental Health Nursing: A
Clinical Approach, 9th Edition
MULTIPLE CHOICE
1. An emergency code was called after a client pulled a dinner knife from a
pocket and threatened, “I will kill anyone who tries to get near me.” The
client was safel y disarmed and placed in seclusion. What is the
justification for this use of seclusion?
a. The client was threatening to others.
b. The client was experiencing psychosis.
c. The client presented an undeniable escape risk.
d. The client presented a clear a nd present danger to others.
ANS: D
The client’s threat to kill self or others with the knife he possessed
constituted a clear and present danger to self and others. The
distracters are not sufficient reasons for seclusion.
PTS: 1 DIF: Cognitive Level: Understand (Comprehension)
TOP: Nursing Process: Planning MSC: Client Needs:
Safe, Effective Care Environment
,2. A client sat in silence for 20 minutes after a therapy appointment,
appearing tense and vigilant. The client abruptl y stood, paced back and
forth, clenched and unclenched fists, and then stopped and stared in the
face of a staff member. What is the client likel y doing?
a. demonstrating withdrawal.
b. working though angry feelings.
c. attempting to use relaxation strategies.
d. exhibiting clues to potentia l aggression.
ANS: D
The description of the client’s behavior shows the classic signs of
someone whose potential for aggression is increasing. The scenario
does not support any of the other options.
PTS: 1 DIF: Cognitive Level: Understand (Comprehensio n)
TOP: Nursing Process: Assessment MSC: Client Needs:
Psychosocial Integrity
3. A client with multi -infarct dementia lashes out and kicks at people who
walk past in the hall of a skilled nursing facilit y. Intervention by the nurse
should begin with what in tervention?
a. gentl y touching the client’s arm.
b. asking the client, “What do you need?”
c. saying to the client, “This is a safe place.”
d. directing the client to cease the behavior.
ANS: C
, Striking out usuall y signals fear or that the client perceives the
environment to be out of control. Getting the client’s attention is
fundamental to intervention. The nurse should make eye contact and
assure the client of safet y. Once the nurse has the client’s attention,
gentl y touching the client, asking what he or she nee ds, or directing the
client to discontinue the behavior may be appropriate.
PTS: 1 DIF: Cognitive Level: Anal yze (Anal ysis) TOP:
Nursing Process: Implementation MSC: Client Needs:
Psychosocial Integrity
4. A cognitivel y impaired client has been a widow for 30 years. This client
franticall y tries to leave the facilit y, sayi ng, “I have to go home to cook
dinner before m y husband arrives from work.” To intervene with
validation therapy, what should the nurse 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. “Your husband gets angry if you do not have dinner ready on time?”
ANS: C
Validation therapy meets the client “where she or he is at the moment”
and acknowledges the client’s wishes. Validation does not seek to
redirect, reorient, or probe. The distracters do not validate the client’s
feelings.
PTS: 1 DIF: Cognitive Level: Appl y (Application)
TOP: Nursing Process: Implementation MSC: Client
Needs: Psychosoci al Integrit y
