Difficulty: Medium
Average Score: 65%
Simulated
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.)
Correct answer
A,D,E
Rationale
The correct answers are A, D, and E because they are indicative of the preassaultive stage of violence. Defensive responses (A) suggest the client is becoming defensive and may escalate to violence. Agitation (D) signifies increasing tension and potential aggression. Facial grimacing (E) can be a nonverbal sign of anger or frustration. Lethargy (B) and disorientation (C) are not typically associated with the preassaultive stage, as they indicate a lack of energy or confusion rather than impending violence. Therefore, choices B and C are incorrect in this context.