Page 2326 - Saunders Comprehensive Review For NCLEX-RN

D. Assessment
1. History of violence or self-harm
2. Poor impulse control and low tolerance of frustration
3. Defiant and argumentative
4. Raising of voice
5. Making verbal threats
6. Pacing and agitation
7. Muscle rigidity
8. Flushed face
9. Glaring at others
E. Interventions

1. Ensure a safe and low stimuli environment.
2. Use a calm approach and communicate with a calm,
clear tone of voice (be assertive, not aggressive, and
avoid verbal struggles).
3. Maintain a large personal space and use a
nonaggressive posture (e.g., arms and hands at the
side rather than folded across the chest or placed on
the hips).
4. Listen actively and acknowledge the client’s anger.
5. Determine what the client considers to be her or his
need.
6. Provide the client with clear options that deal with the
client’s behavior, set limits on behavior, and make the
client aware of the consequences of anger and
violence.
7. Discuss the use of restraints (security devices) or
seclusion if the client is unable to control angry
behavior that may lead to violence.
8. Assist the client with problem solving and decision
making regarding the options.

F. Restraints (security devices) and seclusion

1. Description
a. Physical restraints: Any physical or
environmental means of controlling an
individual’s behavior or actions that
inhibits free movement
b. Seclusion: A type of restraint in which a
client is confined in a room specially
designed for protection and close
supervision from which they cannot
freely exit.
c. Chemical restraints: Medications given
for a specific purpose of inhibiting a
specific behavior or movement and

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