NCLEX-PN

Category - Psychosocial Integrity

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:
  1. Fist clenching, glaring
  2. Foot tapping, finger snapping
  3. Pacing, shouting
  4. 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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