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 ["A","C","D"]
Explanation
Choice A Reason:
Use a calm voice.
Using a calm voice is essential in de-escalating an agitated client. A calm and steady tone can help soothe the client and reduce their anxiety. It also demonstrates that the nurse is in control of the situation and is there to help, which can be reassuring for the client.
Choice B Reason:
Speak louder than the client so as to be heard.
Speaking louder than the client is not appropriate as it can escalate the situation further. Raising one’s voice can be perceived as confrontational and may increase the client’s agitation. It is important to maintain a calm and composed demeanor to help de-escalate the situation.
Choice C Reason:
Reduce stimuli for the client.
Reducing stimuli is an effective intervention for an agitated client. Excessive noise, bright lights, and other environmental stimuli can exacerbate agitation. Creating a quieter and more controlled environment can help the client feel more at ease and reduce their agitation.
Choice D Reason:
Attempt to redirect the client.
Attempting to redirect the client can be helpful in de-escalating agitation. Redirecting the client’s attention to a different topic or activity can help distract them from the source of their agitation and provide a sense of control. This technique can be effective in calming the client and preventing further escalation.
Choice E Reason:
Reprimand the client for upsetting everyone.
Reprimanding the client is not an appropriate intervention. It can increase the client’s feelings of frustration and agitation. Instead, the focus should be on understanding the client’s needs and providing support to help them calm down.
Correct Answer is C
Explanation
Choice A Reason:
This response is inappropriate as it blurs the professional boundaries between the nurse and the client. Nurses are expected to maintain a professional relationship with their clients to ensure that care is provided in an ethical and unbiased manner. Suggesting a potential future relationship can lead to misunderstandings and compromise the therapeutic relationship.
Choice B Reason:
While this response correctly states hospital policy, it does not address the underlying issue of maintaining professional boundaries. It is important for the nurse to communicate the need for a professional relationship clearly and directly. Simply citing policy may not fully convey the importance of these boundaries to the client.
Choice C Reason:
This response is the most appropriate because it clearly establishes the professional nature of the nurse-client relationship. It helps the client understand that the nurse’s role is to provide care and support within a professional framework. This clarity is essential for maintaining trust and ensuring that the therapeutic relationship remains effective and ethical.
Choice D Reason:
Although this response sets a personal boundary, it does not address the professional aspect of the nurse-client relationship. The nurse’s marital status is irrelevant to the professional boundaries that need to be maintained. It is more important to emphasize the professional nature of the relationship rather than personal reasons for declining the request.
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