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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

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A rationale:

The nurse should use the client's telephone number or another unique identifier, such as a medical record number or a unique identification code, to confirm the client's identity before administering medication. Using a telephone number or a unique identifier ensures accurate identification of the client and helps prevent medication errors.

Choice B rationale:

Place of birth is not a suitable identifier for confirming a client's identity. It does not provide specific and accurate information about the individual and may not be unique to the client.

Choice C rationale:

Driver license number is not a suitable identifier for confirming a client's identity. It may not be readily available in the healthcare setting, and not all clients have a driver's license. Using this identifier could lead to identification errors.

Choice D rationale:

Room number is not a suitable identifier for confirming a client's identity. Room numbers are not unique to individual clients and can change based on hospital assignments. Relying on room numbers can lead to confusion and medication errors.

A. Hyperthyroidism. B. Asthma. C. High blood pressure. D. Active liver disease.

Correct Answer is D

Explanation

Choice A rationale:

Hyperthyroidism is not a contraindication for niacin use. Niacin is used to lower LDL cholesterol levels and has no specific contraindications related to thyroid disorders.

Choice B rationale:

Asthma is not a contraindication for niacin use. Niacin does not interact with asthma medications or worsen asthma symptoms, so it is not contraindicated in individuals with asthma.

Choice C rationale:

High blood pressure is not a contraindication for niacin use. In fact, niacin can help lower blood pressure and improve overall cardiovascular health. It is often prescribed to individuals with high blood pressure and elevated cholesterol levels.

Choice D rationale:

Active liver disease is a contraindication for niacin use. Niacin can cause liver damage, and individuals with active liver disease should avoid niacin therapy to prevent further harm to the liver. Monitoring liver function tests is crucial in patients taking niacin to ensure their liver health.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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