A nurse is assessing a client who has a history of violent behaviors. Which of the following manifestations should the nurse recognize as a risk for violent behaviors?
Explanation & Rationale
A. Silence: Silence alone is not necessarily indicative of a risk for violent behavior. While it can be a sign of withdrawal or anger, it does not directly suggest imminent violence. B. Pacing: Pacing is a significant sign of agitation and restlessness, which can indicate an increased risk for violent behavior. When clients are unable to release tension through physical movement or if they are becoming increasingly agitated, pacing is a common manifestation. C. Lack of eye contact: A lack of eye contact may be related to anxiety, shyness, or cultural factors. While it can indicate avoidance or discomfort, it is not a strong indicator of an impending violent outburst. D. Lowered tone of voice: A lowered tone of voice often suggests calmness or control and is not typically associated with violent behavior. It is more likely to indicate de-escalation or subdued emotions.