Author Question: A client with a history of violence is admitted to a psychiatric unit. The nurse observes the client ... (Read 433 times)

crazycityslicker · **on:** Jul 8, 2018

A client with a history of violence is admitted to a psychiatric unit. The nurse observes the client pacing the halls and speaking to other clients in a menacing way.

The nurse is concerned that the client will become physically violent. The nurse should initially

a. encourage the client to stop pacing and sit down.
b. increase environmental stimuli by promoting more sensory input
c. call the client by name using a low, calm tone of voice
d. refrain from medicating the client

Question 2

When collecting assessment data, the nurse recognizes that a client might be more prone to violent behavior when having a history of which of the following? (Select all that apply.)

a. Psychosis
b. Childhood abuse
c. Lack of impulsivity
d. Mental retardation
e. Delirium

djpooyouma · **Reply #1 on:** Jul 8, 2018

Answer to Question 1

ANS: C
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

Answer to Question 2

ANS: A, B, D, E
A history of violence, childhood abuse, substance abuse, mental retardation, problems with impulse control, and psychosis, particularly when accompanied by command hallucinations, are common contributing factors to violent behavior. Problems with impulse control (not lack of impulsivity) is a common contributing factor to violent behavior.