A Geriatric Client in a Long-Term-Care Facility Becomes Increasingly Confused

A geriatric client in a long-term-care facility becomes increasingly confused and verbally aggressive as evening approaches. Which actions would the nurse interpret as potentially signaling a violent episode?

A) The client is moving slowly toward the room door.
B) The client is staring blankly at the nurse.
C) The client suddenly becomes alert and oriented.
D) The client raises his fist.
E) The client says, "I know where there is a gun."