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 taking numerous deep, measured breaths
The client is calmly telling their partner that "the staff here is so controlling
The client is sitting with their head in their hands and appears to be crying
The client is pacing around the chair in which their partner is sitting
The Correct Answer is D
The client is pacing around the chair in which their partner is sitting.
Rationale:
- A. The client is taking numerous deep, measured breaths. This is not an indication of potential violence, but rather a coping strategy to calm down and regulate emotions.
- B. The client is calmly telling their partner that "the staff here is so controlling." This is not an indication of potential violence, but rather a expression of frustration or dissatisfaction with the treatment setting.
- C. The client is sitting with their head in their hands and appears to be crying. This is not an indication of potential violence, but rather a sign of sadness or distress.
- D. The client is pacing around the chair in which their partner is sitting. This is an indication of potential violence, as it shows restlessness, agitation, and possible intimidation of the partner.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Almonds are not typically associated with latex allergy or cross-sensitivity. Latex cross-reactivity is more commonly seen with certain fruits such as bananas, avocados, kiwis, and chestnuts.
Choice B rationale:
Bananas are known to be cross-reactive with latex allergy. Individuals allergic to latex are more likely to have allergies to certain fruits, including bananas. This cross-sensitivity occurs due to the structural similarity between latex proteins and proteins found in these fruits.
Choice C rationale:
Hazelnuts are not commonly associated with latex cross-reactivity. While some individuals with latex allergy may also be allergic to hazelnuts, it is not a high-risk food in the context of latex cross-sensitivity.
Choice D rationale:
Strawberries are not typically associated with latex allergy or cross-reactivity. Latex cross-reactivity is more commonly seen with fruits like bananas, avocados, kiwis, and chestnuts. Strawberries are not among the high-risk foods for individuals with latex allergy.
Correct Answer is A
Explanation
"I will not allow anyone to smoke near my baby."
- A. Correct. Avoiding exposure to tobacco smoke is one of the measures to prevent SIDS, as it can affect the respiratory function and arousal of the newborn.
- B. Incorrect. Placing bumper pads in the baby's crib is not recommended, as they can pose a suffocation or strangulation hazard for the newborn.
- C. Incorrect. Placing the baby's head on a pillow for sleeping is not advised, as it can increase the risk of suffocation or rebreathing of carbon dioxide for the newborn.
- D. Incorrect. Placing the baby in a side-lying position for sleeping is not suggested, as it can increase the likelihood of rolling over to a prone position, which is associated with a higher incidence of SIDS.
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