A nurse is assessing a client who has a history of violent behaviors. Which of the following manifestations should the nurse recognize as a risk for violent behaviors?
Silence
Pacing
Lack of eye contact
Lowered tone of voice
The Correct Answer is B
A. Silence: Silence alone is not necessarily indicative of a risk for violent behavior. While it can be a sign of withdrawal or anger, it does not directly suggest imminent violence.
B. Pacing: Pacing is a significant sign of agitation and restlessness, which can indicate an increased risk for violent behavior. When clients are unable to release tension through physical movement or if they are becoming increasingly agitated, pacing is a common manifestation.
C. Lack of eye contact: A lack of eye contact may be related to anxiety, shyness, or cultural factors. While it can indicate avoidance or discomfort, it is not a strong indicator of an impending violent outburst.
D. Lowered tone of voice: A lowered tone of voice often suggests calmness or control and is not typically associated with violent behavior. It is more likely to indicate de-escalation or subdued emotions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Have the client roll onto a transfer board and pull the board onto the stretcher: Rolling the client onto a transfer board can be difficult and potentially dangerous, especially for an immobile client. It is safer to use a slide board with assistance to ensure the transfer.
B. Move the client onto the stretcher using a slide board with the assistance of two health care workers: A slide board, along with the assistance of two health care workers, ensures a safer and more controlled transfer of the immobile client, minimizes the risk of injury to both the client and the healthcare workers.
C. Apply a transfer belt to the client prior to transferring to the stretcher: A transfer belt is used for clients who are able to assist in the transfer, but it is not appropriate for immobile clients. Using a slide board with assistance is safer for transferring a client who is immobile.
D. Move the client's upper body onto the stretcher first: It is important to maintain a proper and safe method by transferring the entire body at once. Moving the upper body first could result in uneven weight distribution and increase the risk of injury during the transfer.
Correct Answer is B
Explanation
A. Advance the needle 6 mm (7 in) below the skin's surface: Intradermal injections should be administered just beneath the skin, not deeply. The needle should be inserted at an angle to form a small bleb just below the epidermis. This depth ensures proper absorption.
B. Point the bevel of the needle upward prior to insertion: The bevel should be facing upward when performing an intradermal injection to ensure the medication is injected just below the skin surface. This positioning helps form a visible wheal or bleb, which is necessary for the tuberculin test.
C. Administer the injection on the dorsal forearm: The recommended site for an intradermal tuberculin test is the inner aspect of the forearm, not the dorsal forearm. The inner forearm provides a flatter surface for easy visualization of the wheal.
D. Insert the needle at a 20° angle to the client's skin: An intradermal injection should be administered at a 5-15° angle to ensure the needle is positioned just beneath the skin’s surface. A 20° angle may result in the injection being too deep.
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