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
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.
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