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

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Infection: Infection typically presents with redness, warmth, and purulent drainage at the IV site, not taut and edematous skin. Infiltration, however, can cause swelling and taut skin as the fluid is infused into the surrounding tissue rather than the vein.

B. Infiltration: Infiltration occurs when the IV fluid or medication leaks into the surrounding tissue. This results in swelling, taut, edematous skin, and sometimes discomfort. It is a common complication when the IV catheter is dislodged or not properly placed.

C. Air embolism: An air embolism is a rare but serious complication where air enters the bloodstream. Symptoms include chest pain, shortness of breath, and hypotension, but it does not cause the taut, edematous skin seen with infiltration.

D. Phlebitis: Phlebitis involves inflammation of the vein and is typically characterized by redness, warmth, pain, and swelling along the vein, not taut skin around the IV site. It can be caused by irritation from the IV catheter or the fluid being infused not a leak into tissues.

A. Advance the needle 6 mm (7 in) below the skin's surface. B. Point the bevel of the needle upward prior to insertion. C. Administer the injection on the dorsal forearm. D. Insert the needle at a 20° angle to the client's skin.

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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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?

Nursing Test Bank

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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?