A nurse is assessing a client in an inpatient mental health unit. Which of the following findings should the nurse expect if the client I in the preassaultive stage of violence? (Select all that apply.)

A) Defensive responses to questions: During the preassaultive stage, a client may become increasingly defensive and may respond aggressively or defensively to questions, indicating rising tension and frustration. These defensive responses can signal the client’s growing agitation, which can escalate if not addressed appropriately. B) Lethargy: Lethargy is not typical in the preassaultive stage of violence. Instead, clients in this stage are more likely to exhibit signs of agitation and heightened energy, not a decrease in activity or alertness. Lethargy might indicate a different issue, such as depression or sedation from medications. C) Disorientation: Disorientation is not a hallmark of the preassaultive stage. While a client may experience confusion or irrational thinking during an acute episode of mental illness, disorientation is more commonly associated with conditions like delirium or cognitive disorders, rather than the early signs of violence. D) Agitation: Agitation is a classic sign of the preassaultive stage. The client may show physical signs of distress, such as fidgeting, pacing, or increased restlessness. Agitation often precedes violent outbursts, and it’s an important sign that the nurse must be vigilant about in order to intervene before the situation escalates. E) Facial grimacing: Facial grimacing can be a physical manifestation of increasing tension and aggression, indicating discomfort or frustration. This is another sign that the client may be entering the preassaultive stage, where heightened emotional responses are often accompanied by visible, nonverbal cues of agitation.