The nurse is assessing an inpatient client with a known history of violence. The client suddenly displays clenched fists. What additional behavior by the client would suggest that the aggression is escalating? The client:
refuses to eat lunch.
requests prn medications.
is pacing around the milieu.
sits in a group with their peers.
The Correct Answer is C
a. refuses to eat lunch. Refusal to eat lunch might indicate displeasure or upset but does not directly suggest escalating aggression.
b. requests prn medications. Requesting prn (as needed) medications typically indicates the client is aware of their distress and is seeking help, not escalating aggression.
c. is pacing around the milieu. Pacing can be a sign of increasing agitation and is often observed in clients who are escalating towards aggressive behavior. This physical activity can indicate restlessness and an inability to calm down.
d. sits in a group with their peers. Sitting in a group with peers suggests a level of social engagement and does not indicate escalating aggression.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
a. "There is a chemical imbalance of the brain, which leads to altered perceptions." Schizophrenia is a complex mental health disorder with a strong biological component. While the exact cause is unknown, it's believed to involve abnormalities in brain chemistry and neurotransmitters. This is a general explanation that avoids going into too much detail but acknowledges the biological basis of hallucinations.
b. "The hallucinations are caused by medication interactions." Hallucinations are a core symptom of schizophrenia and not necessarily caused by medication interactions.
c. "There is too little serotonin in the brain, causing delusions and hallucinations." While serotonin might be involved in schizophrenia, it's not the only neurotransmitter implicated.
d. Abnormal hormonal changes have precipitated auditory hallucinations." Hormonal changes might influence mood, but they are not the primary cause of auditory hallucinations in schizophrenia.
Correct Answer is A
Explanation
a. "I can see that you are upset. Let's talk about ways to resolve this." This is correct because it validates the client's feelings, encourages problem-solving, and maintains the therapeutic milieu's principles of respect and support.
b. "I'll fix this right away. You need to calm down." This response does not encourage the client’s participation in resolving the issue and does not foster the therapeutic milieu's goal of client empowerment.
c. "Let's find a way to avoid this conflict in the future." While this promotes future problem-solving, it does not address the immediate concern or validate the client's current feelings.
d. "You should bring this up during group therapy later this week." This delays addressing the client's immediate concerns and might make the client feel unheard.
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