A client enters the emergency department. When performing the initial admission assessment, the nurse recognizes which client behavior as an indicator that the client may become violent?
a. Coherent speech
b. Flat affect
c. A relaxed posture
d. Confusion
ANS: D
Confusion, paranoid ideation, disorganization, and organic impairment are all mental status behavioral categories that indicate potential for violence. Rapid and pressured speech, incoherent speech, menacing tones, raised voice, and verbal threats are all speech pattern behavioral categories that indicate potential for violence. A belligerent, labile, or angry affect is an indicator of potential violence. Eyes darting, prolonged (staring) eye contact, spitting, pale or red (flushed) face, and a menacing posture are indicators of potential violence.
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