A client was brought in to the hospital by police after verbally ...

[Melani1276]

A client was brought in to the hospital by police after verbally threatening the staff at a homeless shelter when they turned the client away.
 
  Which would be the most appropriate response by the nurse to the client's statement, You all better let me stay here, or the next time, I'll use a gun. 1. Do you have a gun? Are you threatening to kill someone?
  2. Sounds like you are trying to manipulate the system. We only treat people with real problems here.
  3. It sounds like you are very concerned about having somewhere to stay. Can you tell me more about what you would do if you couldn't stay here?
  4. We cannot let you stay here unless you promise not to hurt anyone.

Question 2

A 22-year-old client with schizophrenia was just admitted to the inpatient unit. While assessing the client, the nurse notes that the client is staring at a staff member intensely with a flat affect.
 
  The client is mumbling and the client's limbs are in constant motion (bouncing knee up and down and tapping fingers). Without further data, which observation is most indicative of the client's potential for violence? 1. Intense stare
  2. Mumbling
  3. Flat affect
  4. Constant motion

[amynguyen1221]

Answer to Question 1

3
Rationale: Assessment of violence risk includes identification of plan, means, and intent. The client's threat should not be ignored. Admission is not based on the client's ability to contract for safety as the client is a greater threat if unable to contract for safety. Focusing on the gun ignores the basis for the client's anxiety which needs further exploration to determine whether an alternative to hospitalization is an appropriate solution.

Answer to Question 2

1
Rationale: Intense stare is one of the warning signs that a person may escalate to violence. Mumbling is indicative that the client is experiencing hallucinations; however, content of hallucinations must be assessed to determine the person's potential for violence. Constant motion could be akathisia (EPS) and must be further assessed. Flat affect is not an indicator of risk for violence.