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

Answer and Explanation

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.

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Correct Answer is ["D","E","G"]

Explanation

A. Reposition the client every 3 hr: This is insufficient. The standard of care for a client at risk is repositioning at least every 2 hours while in bed and every 1 hour while sitting in a chair to ensure adequate blood flow to compressed tissues.

B. Place the client on a donut-shaped cushion: A donut-shaped cushion is not recommended for preventing pressure ulcers. It can increase pressure on the tissue, leading to further complications. A more effective intervention is use of pressure-redistribution surfaces.

C. Elevate the head of the bed to 45°: Elevating the head of the bed can increase pressure on the sacral area and can be uncomfortable for clients with mobility and incontinence issues. The head of the bed should be elevated only when necessary for breathing or comfort, not as a routine practice.

D. Request a consult with a registered dietitian: The client has decreased intake and may be at risk for malnutrition or dehydration. A dietitian’s input is essential to assess nutritional needs, especially for a client with diabetes and decreased mobility, to ensure proper healing and management.

E. Provide a support pressure-redistribution surface: A support pressure-redistribution surface is crucial for this client to reduce the risk of pressure ulcers. These surfaces help alleviate pressure on bony prominences and distribute the body weight evenly to prevent tissue damage.

F. Perform a skin risk assessment weekly: Skin risk assessments should be done more frequently than weekly, especially for a client with decreased mobility, incontinence, and diabetes. Daily or at least twice-weekly assessments are needed to monitor for early signs of skin breakdown.

G. Use a moisture barrier ointment after cleaning the client's skin: Using a moisture barrier ointment is essential for protecting the skin, especially since the client has urinary and fecal incontinence. This will help prevent skin irritation and breakdown caused by exposure to moisture.

A. Urine output 25 mL/hr B. Heart rate 68/min C. Hypoactive bowel sounds D. Serosanguineous drainage on surgical dressing

Correct Answer is A

Explanation

A. Urine output 25 mL/hr: Urine output less than 30 mL/hr is considered inadequate, especially after surgery. This could indicate possible renal insufficiency or hypovolemia, requiring immediate attention.

B. Heart rate 68/min: A heart rate of 68/min falls within the normal adult range (60-100 beats per minute). This finding is generally considered stable and does not typically indicate an immediate complication requiring urgent reporting to the provider in a postoperative client.

C. Hypoactive bowel sounds: Hypoactive bowel sounds are common in the immediate postoperative period, especially after abdominal surgery. This occurs due to the effects of anesthesia and bowel manipulation.

D. Serosanguineous drainage on surgical dressing: Serosanguineous drainage is typical in the early postoperative period and usually decreases over time. It’s not abnormal unless the amount increases significantly or the drainage becomes purulent.

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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?

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Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is A

Explanation

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