A nurse is caring for an infant who has coarctation of the aorta.
Which of the following should the nurse identify as an expected finding?

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.

Answer is… Stay with the client for the first 15 min of the transfusion and Document the blood product transfusion in the client’s medical record are indicated nursing actions for the client. Obtain the first unit of packed RBCs from the blood bank is also indicated, but it should be done before starting the transfusion. Titrate the rate of infusion to maintain the client’s blood pressure at least 90/60 mm Hg and Start an IV bolus of lactated Ringer’s solution are not indicated nursing actions for the client.

Explanation:.

• Staying with the client for the first 15 min of the transfusion is indicated because this is when most adverse reactions occur and the nurse should monitor the client’s vital signs and symptoms closely.
• Documenting the blood product transfusion in the client’s medical record is indicated because this is part of the legal and ethical responsibility of the nurse and it provides a record of the type, amount, duration, and outcome of the transfusion.
• Obtaining the first unit of packed RBCs from the blood bank is indicated because this is part of the preparation for the transfusion and it ensures that the blood product is compatible, fresh, and available. However, this should be done before starting the transfusion, not after.
• Titrating the rate of infusion to maintain the client’s blood pressure at least 90/60 mm Hg is not indicated because this may cause fluid overload or hemolysis in the client who already has a low blood pressure and a high heart rate. The rate of infusion should be based on the client’s condition, weight, and response to the transfusion, not on a fixed target.
• Starting an IV bolus of lactated Ringer’s solution is not indicated because this may cause electrolyte imbalance or hemolysis in the client who already has a positive H. pylori test and a history of gastrointestinal bleeding. The only fluid that should be infused with blood products is 0.9% NaCl (normal saline) because it has a similar osmolarity and pH as blood and it prevents clotting or hemolysis.