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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 D

Explanation

Have the client wear a surgical mask while being transported outside the room.

A. Initiate contact precautions for the client upon admission. This is incorrect because contact precautions are not sufficient to prevent the spread of TB, which is an airborne disease that can travel through small droplets in the air.
B. Restrict visitors from entering the client's room during hospitalization. This is incorrect because visitors can enter the client's room as long as they wear appropriate personal protective equipment (PPE) such as an N95 respirator, gown, gloves, and eye protection.
C. Wear a surgical mask while providing care for the client. This is incorrect because a surgical mask does not filter out small airborne particles that carry TB bacteria. The nurse should wear an N95 respirator or higher level of respiratory protection when caring for a client who has active TB.
D. Have the client wear a surgical mask while being transported outside the room. This is correct because a surgical mask can reduce the amount of droplets that are expelled by the client when coughing or sneezing, thus minimizing the risk of infecting others in common areas or hallways.

Correct Answer is ["13"]

Explanation

gtt/min = (mL/hr x gtt/mL) / 60

gtt/min = (50 x 15) / 60 gtt/min = 750 / 60 gtt/min = 12.5 Rounding to the nearest whole number, the answer is 13.

Therefore, the nurse should set the manual IV infusion to deliver 13 gtt/min.

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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

A nurse is caring for a client who has active tuberculosis (TB). Which of the following actions should the nurse plan to take to prevent the transmission of the disease?

Correct Answer is D

Explanation

Correct Answer is ["13"]

Explanation

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