Substance Abuse, Eating Disorders, Impulse Control Disorders no. 5043

Substance Abuse, Eating Disorders, Impulse Control Disorders no. 5043

QUESTION: A client is admitted to a psychiatric facility by court order for evaluation for antisocial personality disorder. This client has a long history of initiating fights and abusing animals and recently was arrested for setting a neighbor's dog on fire. When evaluating this client for the potential for violence, the nurse should assess for which behavioral clues?

✓O a.) A rigid posture, restlessness, and glaring
✘O b.) Depression and physical withdrawal
✘O c.) Silence and noncompliance
✘O d.) Hypervigilance and talk of past violent acts

RATIONALE

RATIONALE: Behavioral clues that suggest the potential for violence include a rigid posture, restlessness, glaring, a change in usual behavior, clenched hands, overtly aggressive actions, physical withdrawal, noncompliance, overreaction, hostile threats, recent alcohol ingestion or drug use, talk of past violent acts, inability to express feelings, repetitive demands and complaints, argumentativeness, profanity, disorientation, inability to focus attention, hallucinations or delusions, paranoid ideas or suspicions, and somatic complaints. Violent clients rarely exhibit depression, silence, or hypervigilance.
NURSING PROCESS STEP: Assessment
CLIENT NEEDS CATEGORY: Psychosocial integrity
CLIENT NEEDS SUBCATEGORY: None
COGNITIVE LEVEL: Analysis