A nurse is caring for a client.

Exhibits

Select the 4 findings that require immediate follow-up.

A. Depression: Depression typically involves feelings of sadness, despair, and withdrawal. The client's statement about wanting comfort, rather than prolonged sadness, reflects acceptance, not depression.

B. Bargaining: Bargaining is when individuals try to make deals to reverse their situation, often asking for more time. The client’s statement reflects a decision to stop treatment, not bargaining for more time.

C. Denial: Denial involves refusing to acknowledge the reality of the situation. The client’s statement shows recognition of their condition and prioritizing comfort, which shows acceptance rather than denial.

D. Acceptance: In the acceptance stage, individuals come to terms with their diagnosis and focus on achieving peace. The client’s request for comfort care is consistent with acceptance, where they focus on making the most of their time.

A. Silence: Silence alone is not necessarily indicative of a risk for violent behavior. While it can be a sign of withdrawal or anger, it does not directly suggest imminent violence.

B. Pacing: Pacing is a significant sign of agitation and restlessness, which can indicate an increased risk for violent behavior. When clients are unable to release tension through physical movement or if they are becoming increasingly agitated, pacing is a common manifestation.

C. Lack of eye contact: A lack of eye contact may be related to anxiety, shyness, or cultural factors. While it can indicate avoidance or discomfort, it is not a strong indicator of an impending violent outburst.

D. Lowered tone of voice: A lowered tone of voice often suggests calmness or control and is not typically associated with violent behavior. It is more likely to indicate de-escalation or subdued emotions.