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 D
Explanation
A.PRN (as needed) restraint prescriptions are not appropriate because restraints should only be used in situations where there is an immediate need for safety and all other methods of de-escalation have failed. Restraint use must be based on a current assessment of the client's behavior, and a specific prescription should be obtained each time restraints are applied.
B.Restraints should be removed every 2 hours to assess the client's skin, circulation, and range of motion, and to provide an opportunity for toileting, hydration, and movement. Prolonged use without breaks increases the risk of complications such as skin breakdown or impaired circulation.
C.Attach the restraint to the bed's side rails. Restraints should not be attached to the bed's side rails because it can lead to serious injuries if the client attempts to climb over the side rails while restrained. Instead, restraints should be attached to specific restraint ties or straps that are part of the bed frame.
D.The client's condition, including circulation, skin integrity, and behavior, should be monitored and documented every 15 minutes while restraints are in use. This frequent assessment helps ensure the client’s safety and comfort, and allows for early identification of potential complications.
Correct Answer is B
Explanation
Choice A reason:
Wrapping the cord with petroleum gauze is not recommended. Handling the cord directly can lead to vasospasm and worsen the situation.Choice B reason:
The Trendelenburg position involves placing the mother with her head lower than her pelvis. This position helps to alleviate pressure on the umbilical cord, reducing the risk of cord compression and compromising blood flow to the baby. Additionally, the nurse should also manually elevate the presenting part of the fetus off the umbilical cord to further relieve pressure. These actions can help mitigate the potential complications associated with umbilical cord prolapse until further medical interventions can be implemented.Choice C reason:
Evaluate uterine tone. While evaluating uterine tone is an important part of the overall assessment during labour, it is not the priority action in the case of umbilical cord prolapse. The immediate concern is to relieve pressure on the cord.
Choice D reason:
Option D: Apply fundal pressure. Fundal pressure should not be applied during umbilical cord prolapse as it may push the baby's presenting part further onto the cord, worsening the situation.
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