Which behaviors should a nurse recognize as signs that a client is at risk for imminent violence?

Clenching and unclenching the jaw is a physical manifestation that can indicate a person’s internal agitation or tension, often associated with heightened emotional states such as anger or frustration. This behavior suggests that the individual may be struggling to manage their impulses, leading to a risk for imminent violence. Muscle tension, particularly in the jaw, is a common precursor to aggressive behavior as it can signal that a person is on edge or preparing to react in a volatile manner. Recognizing these types of physical cues is crucial for nurses and other healthcare professionals, as they can help identify clients who may become violent and allow for timely intervention to ensure safety.

The other behaviors listed, such as calmly discussing feelings, maintaining a neutral expression, or ignoring surroundings, may not indicate imminent risk for violence. In fact, calmly discussing feelings suggests emotional processing and control, while a neutral expression may indicate a stable emotional state. Ignoring surroundings typically reflects withdrawal or disengagement rather than a potentially aggressive stance. Understanding these nuances helps nurses assess client behavior and intervene appropriately when there is a risk of violence.