Question

A nurse is assessing a client in an inpatient mental health unit. Which of the following findings should the nurse expect if the client is in the preassaultive stage of violence? (Select all that apply)

A. Lethargy
B. Defensive responses to questions
C. Disorientation
D. Rapid breathing
E.Facial grimacing
F Agitation

Answer 1

In the preassaultive stage of violence, a nurse may expect to see defensive responses to questions, rapid breathing, facial grimacing, and agitation in a client, which are signs of physiological arousal and potential for aggression.

Step-by-step explanation:

If a nurse is assessing a client who is in the preassaultive stage of violence, they may observe several indicative signs. Among the symptoms that can suggest an individual is at risk of becoming violent are defensive responses to questions, rapid breathing, facial grimacing, and agitation. These behaviors indicate a growing tension and physiological arousal that may escalate to aggressive behavior. Understanding these signs is crucial in a mental health setting to prevent violence and ensure the safety of both the client and the staff.