When working on a psychiatric unit, the nurse recognizes that indicators of potential violence include which of the following? (Select all that apply.)
a. Confusion
b. Orientation
c. Coherent speech
d. Exaggerated gestures
e. Prolonged eye contact
ANS: A, D, E
Indicators of potential violence include confusion, exaggerated gestures, and prolonged eye contact. Confusion (not orientation) is an indicator of potential violence. Incoherent (not coherent) speech is an indicator of potential violence.
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