After working with a patient who has a history of violent behavior to identify possible clues that suggest that his behavior is escalating, the nurse and patient develop a plan for prevention. Which strategy would they be least likely to include?

Correct Answer: C

Rationale: The correct answer is C: Turning up the music loud. This strategy would be least likely to be included because it does not directly address the escalation of violent behavior. Counting to 10 and taking slow deep breaths are both commonly used techniques to help manage anger and prevent escalation. Taking a voluntary time out is also effective in creating a safe space to de-escalate. Turning up the music loud may serve as a distraction, but it does not actively address the underlying issues or help the patient stay in control of their emotions.

Correct Answer: C

Rationale: The correct answer is C: To act as a predictor of the client's risk for a suicide attempt. Assessing the client's level of anxiety and reactions to stressful situations is crucial in determining the likelihood of a suicide attempt, as individuals with schizoaffective disorder are at a higher risk for suicide. By understanding the client's anxiety levels and responses to stress, the nurse can intervene early to prevent potential harm. Choice A is incorrect because assessing anxiety levels is more focused on immediate risk factors rather than long-term outcomes. Choice B is incorrect because mental competency is typically assessed through other means. Choice D is incorrect as social skills evaluation is not the primary purpose of assessing anxiety levels in this context.

Correct Answer: C

Rationale: The correct answer is C: Alprazolam. Alprazolam is a benzodiazepine that works quickly to alleviate anxiety symptoms due to its rapid onset of action. It enhances the effects of GABA, a neurotransmitter that reduces brain activity, providing immediate relief. Buspirone (A) may take weeks to reach full effect. Venlafaxine (B) is an SNRI that also takes time to show efficacy. Imipramine (D) is a tricyclic antidepressant with delayed onset of action and is not typically used as a first-line treatment for anxiety.

Correct Answer: B

Rationale: The correct answer is B: "Have you ever felt sorry after acting as you did on the spur of the moment?" This question directly assesses the client's level of impulsivity by probing into their past impulsive actions and their subsequent feelings of regret. Impulsivity is characterized by acting without thinking of the consequences, often leading to regret afterwards. Choices A, C, and D do not directly address impulsivity but instead focus on the client's emotions, views on others, and dissociative experiences respectively, which are not specifically related to impulsivity.

Correct Answer: B

Rationale: The correct answer is B: The client's experience of pain is real. In complex somatic symptom disorder, physical symptoms are real to the client even if there is no clear medical explanation. It is crucial for the nurse to validate the client's experience of pain to establish trust and promote therapeutic alliance. This approach can help address the underlying psychological factors contributing to the pain. Incorrect choices: A: Opioid analgesics are not always the primary mode of therapy for somatic symptom disorder as they may not address the underlying psychological factors contributing to the pain. C: Complementary therapies can be beneficial in managing pain and promoting overall well-being in clients with somatic symptom disorder. D: Outcomes need to consider not only the biologic aspects but also the psychosocial and environmental factors influencing the client's pain experience.