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NCLEX-PN

Category - Psychosocial Integrity

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The nurse should initiate measures to protect the client, self, and others in the unit if a client with a history of aggression demonstrates any of the following behaviors except:

Fist clenching, glaring
Foot tapping, finger snapping
Pacing, shouting
Slamming fist into opposing hand

Explanation

Answer: B - A client who is foot tapping and finger snapping demonstrates lesser risk for increased agitation and angry outbursts. Fist clenching, glaring, pacing, shouting and slamming fist into opposing hand are signs of escalating agitation.

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NCLEX-PN

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NCLEX-PN

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