A nurse on an inpatient mental health unit is monitoring a visit between a client who has a history of aggressive behavior and the client's partner. Which of the following observations should the nurse identify as an indication for potential violence?
The client is sitting with their head in their hands and appears to be crying
The client pacing around the chair in which their partner is sitting
The client is calmly telling their partner that the "staff here is so controlling."
The client is taking numerous, deep breaths
The Correct Answer is B
A. Sitting with their head in their hands and appearing to cry indicates emotional distress rather than aggression or potential violence.
B. Pacing is often a sign of agitation or anxiety and can be indicative of a potential escalation to violence, especially in individuals with a history of aggressive behavior.
C. While expressing discontent with staff may show frustration, it does not directly indicate imminent violence.
D. Taking numerous, deep breaths may suggest the client is attempting to calm themselves and is not a reliable indicator of potential aggression.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Bradycardia is not typically associated with pulmonary edema; instead, tachycardia is more common as the body tries to compensate for decreased oxygenation.
B. Wheezing may occur in certain respiratory conditions but is not a classic finding in pulmonary edema; instead, crackles or rales are more expected due to fluid accumulation.
C. Pale, dry skin is not characteristic of pulmonary edema; the client may present with cyanosis or clammy skin due to hypoxia.
D. Pink, frothy sputum is a classic sign of pulmonary edema, indicating fluid in the alveoli and is often associated with acute heart failure.
Correct Answer is A
Explanation
A. Assisting with deep breathing and coughing is the priority action. This is crucial in preventing respiratory complications, such as atelectasis or pneumonia, especially following abdominal surgery. Deep breathing exercises can help expand the lungs and promote ventilation.
B. Monitoring the incision site for signs of infection is important, but it is not the immediate priority. The client’s respiratory function takes precedence in the early postoperative period.
C. Assessing fluid intake is important for overall recovery, but it is not as critical as ensuring the client can breathe effectively and prevent complications.
D. While ambulation is beneficial for recovery and preventing complications such as deep vein thrombosis, the nurse must first ensure the client can manage their airway and breathing.
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