A nurse is reviewing the medical records of four clients. Which of the following findings should the nurse identify as a risk factor for violent behavior?

Long-term isolation

Dysthymic disorder

Alcohol intoxication

Schizoid personality disorder

Answer and Explanation

The Correct Answer is C

A. Long-term isolation: Long-term isolation, or social isolation, can lead to feelings of loneliness and depression. While prolonged isolation can contribute to mental health issues, it is not a direct risk factor for violent behavior. People who are socially isolated might suffer from emotional distress, but it doesn't necessarily make them violent.

B. Dysthymic disorder: Dysthymic disorder, also known as persistent depressive disorder, is a type of chronic depression. While individuals with dysthymic disorder may experience low moods and a lack of interest in activities, it doesn't inherently make them prone to violence. Depression is more likely to cause self-directed harm (such as self-harm or suicide) rather than violent behavior towards others.

C. Alcohol intoxication: Alcohol is a substance that impairs judgment and reduces inhibitions. When a person is intoxicated, they may act aggressively or violently, even in situations where they wouldn't normally do so. Alcohol intoxication can lead to a loss of control, impaired decision-making, and aggressive behavior, making it a significant risk factor for violent actions.

D. Schizoid personality disorder: Schizoid personality disorder is characterized by a lack of interest in social relationships, emotional coldness, and detachment. While individuals with this disorder may prefer to be alone and avoid social interactions, they are not necessarily prone to violent behavior. Schizoid personality disorder primarily affects social functioning rather than predisposing someone to violence.

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Correct Answer is D

Explanation

A. "Why did you feel like giving away your belongings?"
This response is empathetic and invites the client to explore their feelings and motivations. It shows understanding and can help the nurse comprehend the client's emotional state better.

B. "You should find a support group to attend."
This response suggests a proactive step to seek support, which can be helpful. However, it might be premature in this context as the nurse hasn't fully assessed the client's situation yet. It's important to understand the client's feelings and circumstances before recommending specific interventions.

C. "Everyone feels a little down sometimes."
This response minimizes the client's feelings and can be invalidating. It doesn't acknowledge the seriousness of the client's statement, which might discourage them from opening up further.

D. "Can you tell me how you have been feeling lately?"
As previously explained, this response is empathetic and open-ended, encouraging the client to share their emotions and thoughts. It's a good starting point for a therapeutic conversation, allowing the nurse to assess the client's current mental state.

A. Summarize the objectives the client achieved during the relationship. B. Present issues regarding confidentiality. C. Promote the client's problem-solving skills. D. identify the responsibilities of the client and nurse.

Correct Answer is C

Explanation

A. Summarize the objectives the client achieved during the relationship:
This intervention is more appropriate for the termination phase of the nurse-client relationship. During termination, the nurse summarizes the progress made, goals achieved, and skills learned during the therapeutic relationship. This helps both the nurse and the client reflect on the journey and celebrate accomplishments.

B. Present issues regarding confidentiality:
Discussing confidentiality is crucial and typically occurs in the orientation phase of the nurse-client relationship. Establishing trust and clarifying the boundaries of confidentiality early in the relationship helps the client feel secure and promotes open communication. This choice is relevant during the initial stages of the therapeutic relationship.

C. Promote the client's problem-solving skills:
This is the correct choice for the working phase of the nurse-client relationship. In this phase, the focus is on active problem-solving, exploring feelings and thoughts, and encouraging the client to develop coping strategies. The nurse supports the client in identifying problems, generating solutions, and implementing effective strategies. Promoting the client's problem-solving skills is a central aspect of therapeutic work during this phase.

D. Identify the responsibilities of the client and nurse:
Clarifying the responsibilities of both the client and nurse is essential to establish clear roles and expectations. This usually occurs in the orientation phase. During this phase, the nurse explains the purpose of the therapeutic relationship, the roles of both parties and the boundaries of the nurse-client interaction. Establishing clear responsibilities helps create a foundation for a respectful and effective therapeutic alliance.

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A nurse is reviewing the medical records of four clients. Which of the following findings should the nurse identify as a risk factor for violent behavior?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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