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
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 reason:
Mild pain in the hip region can be caused by various musculoskeletal issues, such as muscle strains, bursitis, or even referred pain from other areas. It is not a characteristic symptom of scoliosis.
Choice B reason
Scoliosis is characterized by an abnormal sideways curvature of the spine, which can cause uneven shoulders and pelvic heights. As the spine curves abnormally, it can lead to asymmetry in the shoulders and hips, which are noticeable during physical examination. This asymmetry is a key clinical sign that suggests the presence of scoliosis.
Choice C reason:
Limited range of motion (ROM) of the hips is more likely related to hip joint issues or musculoskeletal conditions affecting the hips, not specifically scoliosis.
Choice D reason:
Exaggerated curvature of the sacrum may indicate other spinal abnormalities or conditions affecting the lower back, but it is not typically associated with scoliosis, which primarily affects the curvature of the spine higher up in the thoracic or lumbar regions.
Correct Answer is A
Explanation
A. "We can expect the hospice nurse to provide support for us after our mother's death." This statement indicates that the family understands that hospice care includes bereavement services for up to one year after the death of a loved one.
B. "A hospice nurse will come to the house each time our mother needs pain medication." This statement indicates that the family does not understand that hospice care involves teaching them how to administer pain medication and other comfort measures to their mother at home.
C. "Now that my mother is receiving hospice services, we will not be able to get respite care." This statement indicates that the family does not understand that hospice care offers respite care, which allows them to take a break from caregiving for a short period of time.
D. "Hospice care focuses on arranging treatment that will prolong our mother's life." This statement indicates that the family does not understand that hospice care focuses on providing palliative care, which aims to relieve pain and suffering, rather than curative treatment, which aims to extend life.
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