A nurse is assessing a client in an inpatient mental health unit. Which of the following findings should the nurse expect if the client I in the preassaultive stage of violence? (Select all that apply.)

Defensive responses to questions

Lethargy

Disorientation

Agitation

Facial grimacing

Answer and Explanation

Correct Answer : A,D,E

A) Defensive responses to questions: During the preassaultive stage, a client may become increasingly defensive and may respond aggressively or defensively to questions, indicating rising tension and frustration. These defensive responses can signal the client’s growing agitation, which can escalate if not addressed appropriately.

B) Lethargy: Lethargy is not typical in the preassaultive stage of violence. Instead, clients in this stage are more likely to exhibit signs of agitation and heightened energy, not a decrease in activity or alertness. Lethargy might indicate a different issue, such as depression or sedation from medications.

C) Disorientation: Disorientation is not a hallmark of the preassaultive stage. While a client may experience confusion or irrational thinking during an acute episode of mental illness, disorientation is more commonly associated with conditions like delirium or cognitive disorders, rather than the early signs of violence.

D) Agitation: Agitation is a classic sign of the preassaultive stage. The client may show physical signs of distress, such as fidgeting, pacing, or increased restlessness. Agitation often precedes violent outbursts, and it’s an important sign that the nurse must be vigilant about in order to intervene before the situation escalates.
E) Facial grimacing: Facial grimacing can be a physical manifestation of increasing tension and aggression, indicating discomfort or frustration. This is another sign that the client may be entering the preassaultive stage, where heightened emotional responses are often accompanied by visible, nonverbal cues of agitation.

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Correct Answer is C

Explanation

A) Tardive dyskinesia: Tardive dyskinesia is a late-onset movement disorder that causes repetitive, involuntary movements, such as tongue protrusion or lip smacking. It typically develops after long-term use of antipsychotics like fluphenazine. Since the client reports restlessness shortly after starting the medication, this is unlikely to be tardive dyskinesia, which takes months to years to develop.

B) Pseudoparkinsonism: Pseudoparkinsonism is a side effect of antipsychotics that causes symptoms similar to Parkinson's disease, such as tremors, rigidity, and bradykinesia. While restlessness is not a hallmark symptom of pseudoparkinsonism, it could lead to a lack of coordination or stiffness, but it does not explain the client's feeling of being restless all the time.

C) Akathisia: Akathisia is a common side effect of antipsychotics, including fluphenazine. It is characterized by an intense feeling of restlessness and an inability to sit still, often accompanied by an urge to move. This matches the client's description of being restless and unable to sit still, making akathisia the most likely cause of their symptoms.

D) Acute dystonia: Acute dystonia involves painful, muscle spasms or abnormal postures, such as twisting of the neck or eyes rolling back, which can occur shortly after taking antipsychotics. However, this condition typically causes muscle rigidity or spasms rather than the restlessness that the client describes, making it less likely in this case.

A. Paroxetine hydrochloride B. Haloperidol C. Lithium carbonate D. Propranolol

Correct Answer is B

Explanation

A) Paroxetine hydrochloride: Paroxetine is an antidepressant in the selective serotonin reuptake inhibitor (SSRI) class and is typically used to treat depression, anxiety, and certain other mood disorders. It is not the appropriate medication for managing acute aggression or violence in a client with paranoid schizophrenia, as it doesn't address psychotic symptoms or acute agitation.

B) Haloperidol: Haloperidol is an antipsychotic medication that is often used to manage acute episodes of aggression and psychosis in individuals with schizophrenia. It is especially effective for controlling agitation and violent behavior. As the client has paranoid schizophrenia and is displaying acute violence, haloperidol is the most appropriate medication to address these symptoms.

C) Lithium carbonate: Lithium is primarily used to treat bipolar disorder, specifically for managing mood swings and preventing manic episodes. It is not indicated for managing acute agitation or violent behavior in schizophrenia and would not be the first choice in this scenario.

D) Propranolol: Propranolol is a beta-blocker, typically used to manage hypertension, anxiety, or certain heart conditions. While it can help with anxiety or physical symptoms of agitation (such as tremors), it does not address the underlying psychosis or violent behaviors in a client with paranoid schizophrenia. Therefore, it would not be the most appropriate choice for this acute situation.

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A nurse is assessing a client in an inpatient mental health unit. Which of the following findings should the nurse expect if the client I in the preassaultive stage of violence? (Select all that apply.)

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Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is B

Explanation

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