A nurse is assessing a client who has a history of violent behaviors. Which of the following manifestations should the nurse recognize as a risk for violent behaviors?
Silence
Pacing
Lack of eye contact
Lowered tone of voice
The Correct Answer is B
A. Silence: Silence alone is not necessarily indicative of a risk for violent behavior. While it can be a sign of withdrawal or anger, it does not directly suggest imminent violence.
B. Pacing: Pacing is a significant sign of agitation and restlessness, which can indicate an increased risk for violent behavior. When clients are unable to release tension through physical movement or if they are becoming increasingly agitated, pacing is a common manifestation.
C. Lack of eye contact: A lack of eye contact may be related to anxiety, shyness, or cultural factors. While it can indicate avoidance or discomfort, it is not a strong indicator of an impending violent outburst.
D. Lowered tone of voice: A lowered tone of voice often suggests calmness or control and is not typically associated with violent behavior. It is more likely to indicate de-escalation or subdued emotions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Leave resuscitation equipment and supplies at the bedside: This can be distressing for the family. Removing such equipment before the family views the body promotes a more peaceful environment.
B. Hold the client's eyelids closed until they remain shut: This is part of postmortem care to maintain a natural appearance. It shows respect and helps prepare the body before the family views it.
C. Apply identification tags to the client's extremities: While necessary, identification tagging is not a priority before the family views the body. It is typically done before transport to the morgue.
D. Keep the head of the bed flat: Elevating the head of the bed slightly helps prevent discoloration due to blood pooling and gives the body a more natural appearance. Keeping it flat is not ideal.
Correct Answer is A
Explanation
A. Occupational therapist: An occupational therapist specializes in helping clients with activities of daily living (ADLs), such as dressing, grooming, and bathing. An occupational therapist can assist in creating strategies or using adaptive equipment to help the client become more independent with dressing.
B. Respiratory therapist: A respiratory therapist focuses on managing respiratory issues and providing treatments like oxygen therapy or breathing exercises. This is not directly related to assisting with dressing, so they are not the appropriate team member for this issue.
C. Social worker: While a social worker can assist with psychosocial issues and discharge planning, they are not typically involved in helping with daily functional tasks like dressing. They would not be the primary provider for this need.
D. Physical therapist: A physical therapist focuses on improving movement, strength, and mobility, particularly related to walking and physical rehabilitation. While they may assist with mobility following surgery, they are not primarily focused on ADLs like dressing.
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