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

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 B

Explanation

A. Weight loss is not a common or serious adverse effect of valproic acid. Valproic acid can cause weight gain, not weight loss.

B. Jaundice is a sign of liver damage, which is a serious and potentially fatal adverse effect of valproic acid. Valproic acid can impair fatty acid metabolism and mitochondrial function, leading to hepatotoxicity and steatosis. The nurse should monitor the client's liver function tests and report any signs of jaundice, such as yellowing of the skin or eyes, dark urine, or clay-colored stools .

C. Bradycardia is not a common or serious adverse effect of valproic acid. Valproic acid can cause cardiac arrhythmias, but they are usually tachycardic, not bradycardic.

D. Polyuria is not a common or serious adverse effect of valproic acid. Valproic acid can cause hypernatremia and hypocalcemia, which can affect urine output, but polyuria is not a specific symptom of these electrolyte imbalances.

A. Arch B. Drooling C. Fever D. Steatorrhea

Correct Answer is C

Explanation

Choice A reason:

Arching should not be expected. Arching of the body is not a typical manifestation of bacterial pneumonia. It may be seen in infants with certain conditions such as abdominal pain or neurologic issues, but it is not specific to pneumonia.

Choice B reason:

Drooling should not be expected. Drooling is not a common manifestation of bacterial pneumonia. It may be seen in certain conditions affecting the throat or mouth, but it is not directly related to pneumonia.

Choice C reason:

Fever is the correct answer. Bacterial pneumonia is an infection in the lungs caused by bacteria. When a child has bacterial pneumonia, their body's immune system responds to the infection, leading to inflammation and fever.

Choice D reason:

Steatorrhea should not be expected. Steatorrhea refers to fatty, bulky, and foul-smelling stools and is not associated with bacterial pneumonia. Steatorrhea may be seen in conditions affecting the gastrointestinal system and fat absorption.

Choice E reason:

Tinnitus should not be expected. Tinnitus is the perception of noise or ringing in the ears and is not a typical manifestation of bacterial pneumonia. Tinnitus can be associated with various ear-related conditions or medication side effects, but it is not directly related to pneumonia.

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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

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Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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