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. Avoidance: Avoidance is a coping mechanism, not a symptom itself.
b. Obsessive-compulsive disorder (OCD): OCD involves intrusive thoughts and repetitive behaviours, not physical symptoms like limb weakness.
c. a conversion disorder: Conversion disorder is a psychological condition where emotional distress manifests as physical symptoms, like limb weakness, with no medical explanation.
d. A fracture: A fracture is a physical injury with a demonstrable cause, unlike the unexplained weakness in conversion disorder.

A. Thorough explanations with details B. Stimulating words and phrases C. Short words and simple sentences D. Pictures or gestures instead of words

Correct Answer is C

Explanation

a. Thorough explanations with details: This approach may overwhelm a client with a cognitive disorder due to complexity and length.
b. Stimulating words and phrases: Stimulating words and phrases can be confusing and may not be understood clearly by a client with cognitive impairment.
c. Short words and simple sentences: This is correct because it ensures clarity and facilitates understanding, which is essential when communicating with someone who has a cognitive disorder.
d. Pictures or gestures instead of words: While visual aids can be helpful, they should complement, not replace, verbal communication unless the client has severe communication difficulties.

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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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