An inpatient client with a known history of violence suddenly begins to pace. Which client behavior should alert a nurse to escalating anger and aggression?

Correct Answer: B

Rationale: In this scenario, the client's pacing behavior, along with the tense facial expression and body language, are indicative of escalating anger and aggression. Pacing is often a sign of restlessness and agitation, while tense facial expressions and body language can signal underlying feelings of anger. It is important for the nurse to recognize these nonverbal cues as potential precursors to aggressive behavior in order to intervene effectively and prevent any escalation of violence. The other options do not directly suggest escalating anger and aggression as clearly as the tense facial expression and body language exhibited by the client.

Correct Answer: A

Rationale: The most accurate way for the nurse to document Arthur's symptom is "Patient is expressing an obsession with germs." Obsessions are recurring and persistent thoughts, urges, or images that are intrusive and unwanted, causing marked anxiety or distress. In this case, Arthur cannot stop thinking about potentially life-threatening germs in the environment, which aligns with the definition of an obsession. Compulsions, on the other hand, are repetitive behaviors or mental acts that an individual feels driven to perform in response to an obsession. Delusions involve false beliefs that are firmly maintained despite being contradicted by reality, which does not apply in this scenario. Arachnophobia is an irrational fear of spiders and not relevant to Arthur's concerns about germs.

Correct Answer: C

Rationale: When a client is experiencing a severe panic attack, the most immediate need is to provide support and reassurance. Staying with the client and offering comfort can help reduce feelings of anxiety and provide a sense of safety. This intervention helps establish a therapeutic nurse-client relationship and promotes a sense of security for the client during a vulnerable and distressing time. It is essential for the nurse to remain present, calm, and supportive to help the client manage the panic attack effectively.

Correct Answer: D

Rationale: Intellectualization is a defense mechanism where the individual avoids uncomfortable emotions by focusing on excessive thinking, analyzing, or rationalizing a situation instead of addressing the associated feelings. In this scenario, the client with obsessive-compulsive disorder discussing the rituals in detail but avoiding any feelings that the rituals generate is demonstrating intellectualization. By focusing solely on the details and processes of the rituals, the client is detaching from the emotions that may be driving these behaviors, thereby protecting themselves from confronting and dealing with the underlying emotional distress.

Correct Answer: C

Rationale: Warren's roommate's reluctance to go out with friends and belief that others wouldn't like him suggest social anxiety disorder, also known as social phobia. People with social anxiety disorder have an intense fear of social situations and interactions, often due to feelings of inadequacy, embarrassment, or humiliation. They may avoid social gatherings or endure them with extreme discomfort. The roommate's belief that others wouldn't like him is also a common feature of social anxiety, as individuals with this disorder often have negative self-beliefs and worry excessively about judgment from others. Agoraphobia involves fear of situations or places that may be difficult to escape or get help in, Mysophobia is fear of germs or contamination, and Panic disorder involves recurrent unexpected panic attacks which are not mentioned in the scenario.