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A nurse in an emergency department is caring for a client.

Exhibits

Which of the following information provided by the client indicates improvement? Select all that apply.

“I have gained 1.8 kg (4 lb) recently, and my BMI is 18.9.”

“My adult child prepares two meals per day for me.”

“My clothing is always clean and appropriate for the weather.”

“I receive three baths per week from a home care aide.”

“I frequently have toothaches and haven’t had dental care in a while.”

“I make eye contact and smile while speaking.”

Answer and Explanation

Correct Answer : A,B,E

The correct answer is choice a, b, e.

Choice A rationale: A recent weight gain of 1.8 kg (4 lb) with a BMI of 18.9 may indicate potential nutritional issues or underlying health problems that require further investigation.

Choice B rationale: Having an adult child prepare meals could suggest the client may have difficulties with meal preparation, possibly due to physical or cognitive limitations.

Choice C rationale: Clean and weather-appropriate clothing indicates the client is managing their personal hygiene and dressing appropriately, which does not typically prompt further assessment.

Choice D rationale: Receiving regular baths from a home care aide suggests the client has support for personal hygiene, which is generally a positive indicator and does not necessitate further assessment.

Choice E rationale: Frequent toothaches and lack of dental care can indicate poor oral health, which can have significant implications for overall health and nutrition, warranting a more detailed assessment.

Choice F rationale: Making eye contact and smiling while speaking generally indicates good social interaction skills and mental well-being, which does not typically prompt further assessment.

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Correct Answer is B

Explanation

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.

A. Creatine kinase (CK) test B. Creatine kinase-myocardial band (CK-MB) test C. Brain natriuretic peptide (BNP) test D. Troponin T test

Correct Answer is D

Explanation

Answer:D. Troponin T test

Rationale:

A. Creatine kinase (CK) test: While creatine kinase isoenzymes, including CK-MB, can be elevated following myocardial infarction (MI), they are not specific to cardiac muscle injury. CK is found in various tissues throughout the body, so elevated levels can also indicate damage to skeletal muscle or brain tissue, among other sources.

B. Creatine kinase-myocardial band (CK-MB) test: CK-MB is a cardiac-specific isoform of creatine kinase, and elevated levels can indicate myocardial injury, particularly in the context of an acute MI. However, troponin T is a more sensitive and specific marker for myocardial injury.

C. Brain natriuretic peptide (BNP) test: Brain natriuretic peptide is primarily used in the diagnosis and management of heart failure. While elevated BNP levels can indicate heart muscle strain or stress, they are not specific markers for acute myocardial infarction or early injury to the cardiac muscle.

D. Troponin T test: This is the correct answer. Troponin T is a highly specific marker for cardiac muscle injury. Elevated troponin levels can be detected within hours of myocardial infarction and persist for several days, making it an essential tool in the diagnosis of acute coronary syndromes, including myocardial infarction. Troponin T is considered one of the gold standard biomarkers for detecting early injury to the cardiac muscle.

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A nurse in an emergency department is caring for a client. Exhibits Which of the following information provided by the client indicates improvement? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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A nurse in an emergency department is caring for a client.

Exhibits

Which of the following information provided by the client indicates improvement? Select all that apply.