A client enters the emergency department. When performing the ...

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A client enters the emergency department. When performing the initial admission assessment, the nurse recognizes which client behavior as an indicator that the client may become violent?
 
  a. Coherent speech
  b. Flat affect
  c. A relaxed posture
  d. Confusion

Question 2

The nurse is performing an initial assessment on a mental health client in the emergency department. The client is uncooperative, and the nurse recognizes the client's behavior is escalating. The most appropriate response by the nurse is to
 
  a. use a vulnerable stance.
  b. maintain constant eye contact.
  c. move quickly with hands hidden behind back.
  d. ignore provocative statements.

[canderson530]

Answer to Question 1

ANS: D
Confusion, paranoid ideation, disorganization, and organic impairment are all mental status behavioral categories that indicate potential for violence. Rapid and pressured speech, incoherent speech, menacing tones, raised voice, and verbal threats are all speech pattern behavioral categories that indicate potential for violence. A belligerent, labile, or angry affect is an indicator of potential violence. Eyes darting, prolonged (staring) eye contact, spitting, pale or red (flushed) face, and a menacing posture are indicators of potential violence.

Answer to Question 2

ANS: D
Deescalation tips for mental health emergencies:
 Use a nonthreatening stanceopen, but not vulnerable. Have them take a seat
 Eye contactnot constant, brief to show concern
 Commandsbrief, slow, with simple vocabulary, only as loud as needed, repeat as needed
 Movementnot sudden, announce actions when possible, keep hands where they can be seen
 Attitudecalm, interested, firm, patient, reassuring, respectful, truthful
 Acknowledge legitimacy of feelings, delusions, hallucinations as being real to the client (I understand you are seeing or feeling this, but I am not)
 Remove distractions, upsetting influences
 Keep the client talking/focused on the here and now
 Ignore, rather than argue with, provocative statements
 Allow verbal venting, within reason
 Be sensitive to personal space/comfort zone
 Remove client to a quiet space; remove others from immediate area (avoid the group spectators)
 Give some choices or options, if possible
 Set limits, if necessary
 Limit interaction to just one professional and let that person do the talking
 Avoid rushingslow things down
 Give yourself an out; don't put the client between yourself and the door

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Correct answers!

[canderson530]

Great! Please up vote