A charge nurse is teaching new staff members about factors that increase a client’s risk to become violent.
Which of the following risk factors should the nurse include as the best predictor of future violence?
A history of being in prison.
Previous violent behavior.
Experiencing delusions.
Male gender.
The Correct Answer is B
Previous violent behavior. According to the web search results, this is the best predictor of future violence among the given risk factors.
Other risk factors include past history of aggression, poor impulse control, and violence. Comorbidity that leads to acts of violence (psychotic delusions, command hallucinations, violent angry reactions with cognitive disorders).
Choice A is wrong because a history of being in prison is not a direct cause of violence, but rather a possible consequence of it.
Choice C is wrong because male gender is not a sufficient factor to predict violence, as there are many other variables involved.
Choice D is wrong because experiencing delusions is not necessarily associated with violence unless they are of a paranoid or persecutory nature.
Normal ranges for violence risk assessment are not standardized, but some tools that can be used include the Historical Clinical Risk Management-20 (HCR-20), the Violence Risk Appraisal Guide (VRAG), and the Psychopathy Checklist-Revised (PCL-R). These tools use different scales and criteria to evaluate the likelihood of violent behavior in individuals.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
This is because the first priority for the nurse is to assess the cause of the vomiting and ensure that the NG tube is working properly. If the suction device is malfunctioning, it could lead to gastric distension, nausea and vomiting. The nurse should check the suction settings, tubing, canister and connections for any problems.
Choice A is wrong because replacing the NG tube is not the first action to take.
The nurse should first rule out other causes of vomiting before attempting to reinsert the tube, which could be uncomfortable and risky for the client.
Choice B is wrong because providing oral hygiene care is not the most urgent action to take.
While oral hygiene care is important for comfort and infection prevention, it does not address the underlying cause of vomiting or prevent further complications.
Choice C is wrong because administering an antiemetic medication is not the most appropriate action to take.
The nurse should first identify the cause of vomiting and correct it if possible.
Giving an antiemetic medication without resolving the problem could mask symptoms and delay treatment.
Correct Answer is D
Explanation
Hypertonicity is a sign of increased muscle tone and stiffness, which can indicate that the newborn is experiencing withdrawal from methadone exposure in utero. Methadone is an opioid medication that can cross the placenta and cause neonatal abstinence syndrome (NAS) in the newborn.
Choice A is wrong because it is a normal finding in newborns.
Acrocyanosis is a bluish discoloration of the hands and feet due to immature peripheral circulation. It usually resolves within the first 24 to 48 hours of life.
Choice B is wrong because it is not a typical sign of withdrawal.
Bradycardia is a slow heart rate, usually less than 100 beats per minute in newborns. It can be caused by hypoxia, hypothermia, hypoglycemia, or vagal stimulation.
Choice C is wrong because it is a sign of increased intracranial pressure, not withdrawal. Bulging fontanels can be caused by meningitis, hydrocephalus, or hemorrhage.
Normal ranges for newborn vital signs are as follows:
- Heart rate: 120 to 160 beats per minute
- Respiratory rate: 30 to 60 breaths per minute
- Temperature: 36.5 to 37.5°C (97.7 to 99.5°F)
- Blood pressure: 60 to 80 mm Hg systolic and 40 to 50 mm Hg diastolic
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