An inpatient client who has a known history of violence suddenly begins to pace. Which additional client behavior should alert the nurse to escalating anger and aggression? The client:
Sits in group with back to peers.
Has a tense facial expression and body language.
Requests PRN medications.
Does not want to eat lunch.
The Correct Answer is B
Choice A Reason: Sits in group with back to peers
Sitting with one’s back to peers can indicate a desire for isolation or a lack of trust, but it is not a definitive sign of escalating anger or aggression. This behavior might be more indicative of withdrawal or discomfort in social settings rather than an immediate precursor to violence.
Choice B Reason: Has a tense facial expression and body language
This is the correct answer. Tense facial expressions and body language are clear indicators of escalating anger and aggression. Signs such as clenched fists, a rigid posture, and a furrowed brow are physical manifestations of internal tension and can precede aggressive outbursts. Recognizing these non-verbal cues is crucial for early intervention and de-escalation.
Choice C Reason: Requests PRN medications
Requesting PRN (as needed) medications can be a sign that the client is experiencing increased anxiety or distress. However, this behavior alone does not necessarily indicate escalating aggression. It may actually be a positive sign that the client is seeking help to manage their symptoms before they escalate.
Choice D Reason: Does not want to eat lunch
A lack of appetite or refusal to eat can be associated with various conditions, including depression, anxiety, or physical illness. While it may indicate that the client is not feeling well, it is not a specific indicator of escalating anger or aggression.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason:
Manifestation of dyslexia.
Dyslexia is a learning disorder characterized by difficulties with accurate and/or fluent word recognition and by poor spelling and decoding abilities. It is not typically associated with the creation of new words or phrases, which is what the term ‘mazurka’ represents in this context. Therefore, the client’s use of ‘mazurka’ is not a manifestation of dyslexia.
Choice B Reason:
Example of loose associations.
Loose associations refer to a thought disorder where ideas are presented with little or no logical connection between them. While this is a common symptom in schizophrenia, it does not specifically involve the creation of new words. The term ‘mazurka’ in this context does not illustrate a lack of logical connection between ideas but rather the invention of a new term.
Choice C Reason:
Neologism.
Neologism refers to the creation of new words or phrases that are often only understood by the person who created them. This is a common symptom in schizophrenia, where individuals may invent words that have meaning only to them. The client’s use of ‘mazurka’ fits this definition, as it is a newly created word that likely holds specific meaning for the client.
Choice D Reason:
Flight of ideas.
Flight of ideas is a symptom characterized by rapid and continuous speech with abrupt changes from topic to topic, usually based on understandable associations, distracting stimuli, or plays on words. This symptom is more commonly associated with manic episodes rather than schizophrenia. The use of ‘mazurka’ does not indicate rapid topic changes but rather the creation of a new word.
Correct Answer is D
Explanation
Choice A Reason:
Uses relaxation techniques for stress reduction.
Using relaxation techniques for stress reduction is generally considered safe and beneficial. Techniques such as deep breathing, meditation, and progressive muscle relaxation can help reduce stress and anxiety without significant risks. Therefore, this information does not require immediate investigation.
Choice B Reason:
Expresses an interest in yoga to improve flexibility.
Expressing an interest in yoga to improve flexibility is also generally safe and beneficial. Yoga can enhance physical flexibility, strength, and mental well-being. Unless the client has specific health conditions that might be affected by certain yoga poses, this information does not require immediate investigation.
Choice C Reason:
Has tried acupressure for pain relief several years ago.
Trying acupressure for pain relief several years ago is not typically a cause for concern. Acupressure is a non-invasive therapy that can help alleviate pain and promote relaxation. Since it was used in the past and not currently, it does not require immediate investigation.
Choice D Reason:
Has been using herbal supplements without consulting a healthcare provider.
This is the correct response. Using herbal supplements without consulting a healthcare provider can be risky because some supplements can interact with prescribed medications or have side effects. It is crucial for the nurse to investigate this information immediately to ensure the client’s safety and prevent potential adverse effects.
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