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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

a. Loose associations involve a disorganized and fragmented way of thinking where the person’s thoughts are only loosely connected.
b. Dyslexia is a learning disorder characterized by difficulty reading.
c. A neologism is a newly coined word or expression that is often used by individuals with schizophrenia. It is a made-up word that has meaning only to the person using it.
d. Flight of ideas is a rapid shift from one topic to another, typically seen in manic episodes of bipolar disorder.

A. Aphasia B. Delirium C. Apraxia D. Confabulation

Correct Answer is D

Explanation

a. Aphasia: Aphasia is a language disorder that affects a person's ability to communicate. It does not involve the creation of false memories or stories.
b. Delirium: Delirium is an acute, often sudden change in mental status that can cause confusion and impaired attention, but it is not characterized by the fabrication of detailed stories.
c. Apraxia: Apraxia is a motor disorder where a person has difficulty with the motor planning to perform tasks or movements. It does not involve creating false stories.
d. Confabulation: Confabulation involves the creation of false memories or stories without the intention to deceive. This is common in Alzheimer's disease as the brain attempts to fill gaps in memory.

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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:

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