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3 there is no evidence presented in the ques tion

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3.There is no evidence presented in the ques-tion that indicates the client is exhibiting dis-turbed thought process.4.There is no evidence presented in the ques-tion that indicates the client is exhibitingsocial isolation.TEST-TAKING HINT:When developing nursingdiagnoses, it is necessary to formulate thenursing diagnostic statement correctly andprioritize based on client needs.36.“Prodromal syndrome” is a group of symptomsthat a client exhibits before acting out andbecoming aggressive. Some of these symptomsinclude, but are not limited to, anxiety, tension,verbal abuse, profanity, and increasedhyperactivity.1. Prodromal syndrome is associated withbehaviors that occur before the clientbegins acting out aggressively, and thesebehaviors need to be addressed immedi-ately by staff members. Successful man-agement of aggressive behavior dependson the ability to predict which clients aremost likely to become violent.2.Prodromal syndrome occurs before, not after,acting out behaviors are exhibited.3.During a prodromal syndrome, staff membersmust assist clients to gain control. It is impor-tant for staff members to assess consistentlyfor prodromal syndrome to maintain safety.4.Many behavioral symptoms are associatedwith prodromal syndrome. Some of theseinclude anxiety, tension, verbal abuse, profan-ity, increasing hyperactivity, rigid posture,clenched fists and jaws, grim defiant affect,talking in rapid and raised voice, threats,arguing, demanding, pacing, pounding, andslamming.TEST-TAKING HINT:To answer this questioncorrectly, the test taker must understand themeaning of “prodromal syndrome.”37.1.Past history of violence is important to noteand document during a risk assessment, but itis a behavioral, not cognitive, symptom.2. Disturbed thought process is a cognitivesymptom that is important to note anddocument on a risk assessment.3.A history of throwing objects on the unit isimportant to note and document during a riskassessment, but it is a behavioral, not cogni-tive, symptom.4.Flushed face is important to note and docu-ment during a risk assessment, but it is aphysical, not cognitive, symptom.TEST-TAKING HINT:The test taker needs to notethat the keyword in the question is “cognitivesymptom.” All symptoms presented need to benoted and documented, but only the “disturbedthought process” is a cognitive symptom.38.1. Because safety is always a priority, risk forinjury toward others should be prioritized.The behaviors presented in the questionindicate that the client may be in a pro-dromal state of crisis and may present animmediate threat.128PSYCHIATRIC/MENTALHEALTHNURSINGSUCCESS
2.Ineffective coping is an appropriate nursingdiagnosis; however, it is not the prioritydiagnosis.3.Anxiety is an appropriate nursing diagnosis;however, it is not the priority nursingdiagnosis.

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