A geriatric client in a long-term-care facility becomes increasingly confused and verbally aggressive as evening approaches
Which actions would the nurse interpret as potentially signaling a violent episode? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. The client is moving slowly toward the room door.
2. The client is staring blankly at the nurse.
3. The client suddenly becomes alert and oriented.
4. The client raises his fist.
5. The client says, "I know where there is a gun."
1,2,4
Rationale 1: The client may be about to flee the room, or may be blocking the nurse's exit.
Rationale 2: A blank stare could be related to pathology such as dementia or may signal a violent episode.
Rationale 3: Alertness and orientation do not signal impending violence.
Rationale 4: Preparing for battle signals impending violence.
Rationale 5: It is fairly unlikely that a geriatric client in a long-term-care facility has access to a gun. The nurse must be aware of the statement, but should consider the context.
Global Rationale:
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