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 A
Explanation
Choice A reason:
The statement is correct because chickenpox is highly contagious, and visiting someone with active chickenpox can put the pregnant individual at risk of contracting the infection. The recommendation is to avoid contact with individuals who have chickenpox, especially during pregnancy. The correct approach is to stay away from the infected person until they are no longer contagious (which is usually after all the sores have crusted over and dried up).
Choice B reason:
The statement Is incorrect because taking antibiotics for a viral infection is not appropriate, as antibiotics are only effective against bacterial infections, not viruses. Using antibiotics inappropriately can lead to antibiotic resistance and other potential side effects. Viral infections are generally managed with supportive care.
Choice C reason:
The statement is incorrect because handwashing is an essential infection prevention measure, but washing hands for 10 seconds with hot water may not be sufficient to remove germs effectively. The recommended duration for handwashing is at least 20 seconds with soap and water.
Choice D reason:
The statement is incorrect because cleaning a cat's litter box during pregnancy is not recommended due to the potential risk of exposure to the parasite Toxoplasma gondii, which is found in cat faeces. Toxoplasmosis can cause serious health issues in the developing foetus. It is best for pregnant individuals to avoid cleaning the litter box and have someone else do it or wear gloves and wash hands thoroughly afterward if no one else can do it.
Correct Answer is C
Explanation
A. Incorrect. Evaluating dietary intake requires nursing judgment and knowledge of nutrition and eating disorders. This task should not be delegated to an AP.
B. Incorrect. Measuring vital signs of a postoperative client requires nursing assessment and monitoring for complications. This task should not be delegated to an AP.
C. Correct. Arranging the lunch tray for a client who has a hip fracture is a routine task that does not require nursing skills or judgment. This task can be delegated to an AP.
D. Incorrect. Assessing I&O for a client who is receiving dialysis requires nursing knowledge of fluid and electrolyte balance and renal function. This task should not be delegated to an AP.
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