# Situation: A 35-year-old man with schizophrenia is brought to the emergency department by police after a dispute with a neighbor. He is not intoxicated on assessment, and his vital signs are normal. The nurse reviews his history. Which item is the STRONGEST predictor that he may become violent in the future?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=630091  
> language: ko  
> subject: Nursing Practice V — Care of Clients with Maladaptive Patterns of Behavior; Care of Clients with Life-Threatening Conditions, Acute Multi-Organ Problems, High Acuity and Emergency Situations

## 문제

Situation: A 35-year-old man with schizophrenia is brought to the emergency department by police after a dispute with a neighbor. He is not intoxicated on assessment, and his vital signs are normal.

The nurse reviews his history. Which item is the STRONGEST predictor that he may become violent in the future?

## 보기

1. He struck his brother with a chair 2 years ago **✔ 정답**
2. He has had schizophrenia for more than 10 years
3. He stopped taking his medicine 3 weeks ago
4. He was physically abused by his father as a child

**정답: 1**

## 해설

A history of violence is the strongest predictor of future violence. Diagnosis, nonadherence, and childhood abuse add to risk, but none predicts violence as strongly as past violent behavior.

## 심화 해설

Clinical context

A 35-year-old man with schizophrenia is brought to the emergency department by police after a dispute with a neighbor. He is not intoxicated, and vital signs are normal. The nurse reviews his history to estimate future violence risk. The question asks which single item is the strongest predictor of future violence.

Why past violence is the strongest predictor

The most reliable indicator of future violent behavior is a documented history of actual violence. In this case, striking his brother with a chair 2 years ago is a concrete episode of interpersonal aggression, not merely a thought, threat, or risk factor. Longitudinal research in schizophrenia-spectrum disorders consistently identifies prior violence as one of the most robust predictors of subsequent violence [3]. This reflects a behavioral pattern rather than a static demographic or clinical variable.

A previous act of violence demonstrates that the person has already crossed the threshold from impulse to action under real-world conditions. That behavioral history carries more predictive weight than diagnosis duration, medication status, or developmental trauma.

Why the other options are weaker

Schizophrenia duration of more than 10 years describes chronicity but does not by itself indicate aggression. Many individuals with long-standing schizophrenia never become violent. The relationship between schizophrenia and violence is heterogeneous and influenced by multiple interacting factors [4].

Medication nonadherence for 3 weeks is a meaningful clinical concern because it can destabilize symptoms, but nonadherence alone is not a direct behavioral predictor. It increases risk indirectly through symptom exacerbation, substance use, or loss of structure. In comparative analyses, clinical factors such as medication status are less specific than a prior violent act .

Childhood physical abuse is a developmental risk factor that can contribute to later aggression, but it is remote and nonspecific. Many abused children do not become violent adults. It is a background vulnerability, not a direct behavioral marker.

How the risk factors compare

| Risk factor | Type | Predictive strength for future violence | Reason |
| --- | --- | --- | --- |
| Past violent act (struck brother with chair) | Behavioral history | Strongest | Direct evidence of aggression; best single predictor [3] |
| Schizophrenia > 10 years | Illness chronicity | Weak | Duration alone does not indicate violence risk [4] |
| Stopped medicine 3 weeks ago | Treatment adherence | Moderate but indirect | Increases risk through symptom instability, not directly |
| Childhood physical abuse | Developmental trauma | Weak to moderate | Remote background factor; nonspecific |

Clinical application for nursing assessment

When performing a violence risk assessment in the emergency department, the nurse should ask specifically about any prior episodes of aggression, including the target, weapon, severity, and context. A past violent act is the single most actionable piece of information. Risk assessment tools for violence in psychosis consistently weight a history of violence more heavily than diagnosis, medication adherence, or childhood adversity. [3]

Watch out! Medication nonadherence and childhood abuse are important to document, but they do not replace a direct behavioral history. Key point! If a patient has a documented prior violent act, that item alone should raise the nurse’s index of suspicion more than any combination of the other three options.References (research sources)

- [3]Systematic review of risk factors for violence in psychosis: 10-year update.Meta-analysis/systematic reviewLagerberg T, Lambe S, Paulino A, Yu R, Fazel S (2025) · DOI: 10.1192/bjp.2024.120

- [4]Risk factors for violent crime in patients with schizophrenia: a retrospective study.Research articleLin R, Li Q, Liu Z, Zhong S, Huang Y, Cao H (2024) · DOI: 10.7717/peerj.18014

## 임상 시나리오

Violence Risk Assessment in Psychiatric EmergenciesPrior violence is the strongest predictor of future violence
A documented history of actual violence, such as striking a family member with an object, is the strongest single predictor of future violent behavior. This reflects a behavioral pattern that has already crossed from impulse to action.

Other factors including diagnosis duration, medication nonadherence, and childhood trauma add to overall risk but do not independently predict violence as strongly as past violent acts.

CautionDo not assume all patients with schizophrenia are violent. Assess each patient individually, and document any prior aggressive episodes with specific details including target, weapon use, and context.

## 핵심 개념

- **Violence risk assessment** — Systematic evaluation of factors predicting future aggressive behavior; past violence is the strongest single predictor.
- **Behavioral history** — Documented pattern of actual actions, which carries more predictive weight than static or clinical variables.
- **Medication nonadherence** — Failure to take prescribed psychiatric medication, a modifiable risk factor for relapse and aggression.
- **Schizophrenia chronicity** — Duration of illness; not independently predictive of violence despite long-term course.

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