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 C
Explanation
a. Reaction Formation: Reaction formation involves expressing the opposite of what one truly feels. Exploring a career that involves controlled expression of anger (such as professional wrestling) can be seen as a reaction formation against uncontrolled anger.
b. Projection: Projection involves attributing one's own unacceptable feelings or thoughts to others. Exploring a career in professional wrestling does not involve projecting one's own feelings onto others.
c. Sublimation: This is correct because sublimation involves channeling unacceptable impulses into socially acceptable activities. Exploring a career in professional wrestling could be seen as channeling anger into a constructive and socially acceptable outlet.
d. Repression: Repression involves pushing unacceptable thoughts or memories out of consciousness. Exploring a career in professional wrestling does not involve repressing anger but rather finding a way to express it constructively.
Correct Answer is D
Explanation
a. "I'm afraid you would feel very guilty leaving your parents." This response assumes a negative outcome and does not encourage independent decision-making.
b. "Why would you want to leave a secure home?" This response discourages the client from considering independence and reinforces dependent behavior.
c. "It would be best to do that to increase independence." This statement provides advice rather than encouraging the client to explore their own feelings and options.
d. "Let's discuss and explore all of your options." This is correct because it encourages the client to consider various possibilities and promotes independent decision-making, which is essential for someone with dependent behaviors.
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