Schizophrenia Q 23
Which of the following client behaviors documented in Gio’s chart would validate the nursing diagnosis of Risk for other-directed violence?
A. Gio's description of being endowed with superpowers.
B. Frequent angry outburst noted toward peers and staff.
C. Refusal to eat cafeteria food.
D. Refusal to join in group activities.
Correct Answer: B. Frequent angry outburst noted toward peers and staff
Anger is an important factor that indicates the potential for acting out. Because the client is angry with both peers and staff, any acting out would probably be directed toward others. Frequently assess client’s behavior for signs of increased agitation and hyperactivity. Early detection and intervention of escalating mania will prevent the possibility of harm to self or others, and decrease the need for seclusions.
Option A: The client’s description of being endowed with superpowers indicates he is having delusions. Attempt to understand the significance of these beliefs to the client at the time of their presentation. Important clues to underlying fears and issues can be found in the client’s seemingly illogical fantasies. Recognize the client’s delusions as the client’s perception of the environment.
Option C: His refusal to eat cafeteria food indicates that he may have delusional beliefs, but not necessarily a risk for violence. Do not touch the client; use gestures carefully. Suspicious clients might misinterpret touch as either aggressive or sexual in nature and might interpret it as a threatening gesture. People who are psychotic need a lot of personal space.
Option D: Refusal to join in group activities indicates discomfort with a group, however, no threat of violence is apparent. Structure times each day to include planned times for brief interactions and activities with the client on one-on-one basis. Helps the client to develop a sense of safety in a non-threatening environment. Provide opportunities for the client to learn adaptive social skills in a non-threatening environment. Initial social skills training could include basic social behaviors (e.g., appropriate distance, maintain good eye contact, calm manner/behavior, moderate voice tone).