A client is observed pacing the hall with clenched fists and swearing at others. The nurse intervenes immediately in a calm manner to prevent the client from moving to which phase of the aggression cycle?

Recovery

Crisis

Escalation

Triggering

Answer and Explanation

The Correct Answer is C

The client's observed behavior of pacing the hall with clenched fists and swearing at others indicates that they are in the escalation phase of the aggression cycle. During this phase, the individual's anger and agitation increase, and their behavior becomes more intense and aggressive. If not addressed promptly and effectively, the situation can escalate further and potentially lead to a crisis or violent outburst.

By intervening immediately and calmly, the nurse aims to prevent the situation from escalating further and moving into the crisis phase, where the risk of harm to the client and others is highest. Effective de-escalation techniques, such as using a calm and non-threatening demeanor, active listening, and providing clear and respectful communication, can help the client regain control and reduce their agitation.

Option A - Recovery: The recovery phase comes after the aggressive incident, during which the individual may feel remorse or embarrassment about their behavior.

Option B - Crisis: The crisis phase is the point where the individual's anger and agitation reach a peak, and there is a high risk of violence or harmful actions.

Option D - Triggering: The triggering phase is the initial phase of the aggression cycle, where the individual's anger begins to build, and certain triggers may set off their aggressive behavior.

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Correct Answer is A

Explanation

This is the best response because it acknowledges the client’s statement while providing realistic, evidence-based information. According to the National Institute of Mental Health (NIMH) and domestic violence research, the period immediately after leaving an abusive partner is often the most dangerous, as abusers may escalate threats or violence when they feel a loss of control. This response validates the client’s concerns, offers safety awareness, and opens the door for further discussion about creating a safety plan.

option B generalizes that all batterers never change, which may not be true for all situations and individuals.

Option C suggeststhat leaving will make the partner change is inappropriate and unsafe. This could give the client false hope that the abuser’s behavior will improve, when evidence shows that abusive partners rarely change without intensive intervention.

Option D may imply a threat or ultimatum, which is not appropriate and can be disempowering for the client. The most important aspect of supporting someone in an abusive relationship is to provide a non-judgmental, understanding, and empowering environment where they can explore their options and make decisions that are best for their safety and well-being.

A. The nurse informs the client that the behavior will not be tolerated and will be addressed by the psychiatrist. B. The nurse throws the medication in the trash and documents the client refuses the medication. C. The nurse pushes the client, and the client falls to the floor and sustains a nosebleed. D. The nurse goes to the client's room and applies restraints, then forces the medication in the client's mouth.

Correct Answer is D

Explanation

Falsely imprisoning a client involves restricting their freedom and movement against their will without proper legal authority or justification. Option D demonstrates false imprisonment because the nurse applies restraints to restrict the client's movement and then forces the medication into the client's mouth, essentially depriving the client of their right to refuse treatment.

Options A, B, and C are not examples of false imprisonment:

A. The nurse informing the client that the behavior will not be tolerated and will be addressed by the psychiatrist is a response to the client's inappropriate behavior. It does not involve restricting the client's freedom or movement.

B. The nurse throwing the medication in the trash and documenting the client's refusal is an appropriate response to the client's refusal of medication. It respects the client's right to refuse treatment.

C. The nurse pushing the client and causing them to fall to the floor, resulting in a nosebleed, is an example of physical assault and battery, not false imprisonment. It is an inappropriate and harmful action by the nurse.

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A client is observed pacing the hall with clenched fists and swearing at others. The nurse intervenes immediately in a calm manner to prevent the client from moving to which phase of the aggression cycle?

Nursing Test Bank

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