3 there is no evidence presented in the ques tion

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 exhibiting
social isolation.
TEST-TAKING HINT:
When developing nursing
diagnoses, it is necessary to formulate the
nursing diagnostic statement correctly and
prioritize based on client needs.
36. “Prodromal syndrome” is a group of symptoms
that a client exhibits before acting out and
becoming aggressive. Some of these symptoms
include, but are not limited to, anxiety, tension,
verbal abuse, profanity, and increased
hyperactivity.
1. Prodromal syndrome is associated with
behaviors that occur before the client
begins acting out aggressively, and these
behaviors need to be addressed immedi-
ately by staff members. Successful man-
agement of aggressive behavior depends
on the ability to predict which clients are
most likely to become violent.
2. Prodromal syndrome occurs before, not after,
acting out behaviors are exhibited.
3. During a prodromal syndrome, staff members
must assist clients to gain control. It is impor-
tant for staff members to assess consistently
for prodromal syndrome to maintain safety.
4. Many behavioral symptoms are associated
with prodromal syndrome. Some of these
include 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, and
slamming.
TEST-TAKING HINT:
To answer this question
correctly, the test taker must understand the
meaning of “prodromal syndrome.”
37. 1. Past history of violence is important to note
and document during a risk assessment, but it
is a behavioral, not cognitive, symptom.
2. Disturbed thought process is a cognitive
symptom that is important to note and
document on a risk assessment.
3. A history of throwing objects on the unit is
important to note and document during a risk
assessment, 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 a
physical, not cognitive, symptom.
TEST-TAKING HINT:
The test taker needs to note
that the keyword in the question is “cognitive
symptom.” All symptoms presented need to be
noted and documented, but only the “disturbed
thought process” is a cognitive symptom.
38. 1. Because safety is always a priority, risk for
injury toward others should be prioritized.
The behaviors presented in the question
indicate that the client may be in a pro-
dromal state of crisis and may present an
immediate threat.
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2. Ineffective coping is an appropriate nursing
diagnosis; however, it is not the priority
diagnosis.
3. Anxiety is an appropriate nursing diagnosis;
however, it is not the priority nursing
diagnosis.