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
- A: Incorrect. Decreased blood pressure is not an indication of chlorpromazine effectiveness, but rather a potential adverse effect that should be monitored and reported.
- B: Correct. Decreased hallucinations are an indication of chlorpromazine effectiveness, as this medication is an antipsychotic that blocks dopamine receptors in the brain and reduces psychotic symptoms such as hallucinations, delusions, and paranoia.
- C: Incorrect. Decreased cholesterol is not an indication of chlorpromazine effectiveness, but rather a potential benefit that may occur due to its effect on lipid metabolism.
- D: Incorrect. Decreased esophageal reflux is not an indication of chlorpromazine effectiveness, but rather a potential adverse effect that should be avoided by taking the medication with food or water and avoiding lying down after administration.
Correct Answer is ["A","B","C","D"]
Explanation
- A: Correct. Firmly massaging the uterine fundus helps to contract the uterus and reduce bleeding.
- B: Correct. Providing emotional support helps to calm the client and reduce anxiety, which can worsen bleeding.
- C: Correct. Administering oxygen helps to improve tissue perfusion and oxygenation, which can be compromised by blood loss. Weighing the perineal pads helps to quantify the amount of blood loss and monitor for hemorrhage.
- D: Correct. Inserting an indwelling urinary catheter helps to empty the bladder and allow the uterus to descend and contract more effectively. Administering methylergonovine helps to stimulate uterine contractions and control bleeding.
- E: Incorrect. Administering terbutaline is contraindicated in this situation, as it relaxes the uterine smooth muscle and increases bleeding.
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