A patient has sat in stony silence in the day room for 20 minutes after her appointment with her psychiatrist. She appears tense and vigilant
The nurse sees the patient abruptly stand up and pace back and forth across the day room, clenching and unclenching her fists. She then stops and stares intently into the face of the psychiatric technician seated at a table. The priority assessment that should be made is that the patient is: a. working off the energy of angry feelings.
b. attempting to use relaxation strategies.
c. exhibiting clues to potential aggression.
d. trying to work through her anger.
C
The description of the patient's behavior shows the classic signs of someone whose potential for aggression is increasing. The patient's pacing may reduce some of the urge to respond physically, but this would be a secondary assessment and not as important to safety as are the signs of impending aggression and violence. The patient's behavior and nonverbal indicators are inconsistent with relaxation. The data are inadequate to determine whether the patient is trying to work through her anger, but this too would be a secondary observation.
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