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 sitting with their head in their hands and appears to be crying
The client pacing around the chair in which their partner is sitting
The client is calmly telling their partner that the "staff here is so controlling."
The client is taking numerous, deep breaths
The Correct Answer is B
A. Sitting with their head in their hands and appearing to cry indicates emotional distress rather than aggression or potential violence.
B. Pacing is often a sign of agitation or anxiety and can be indicative of a potential escalation to violence, especially in individuals with a history of aggressive behavior.
C. While expressing discontent with staff may show frustration, it does not directly indicate imminent violence.
D. Taking numerous, deep breaths may suggest the client is attempting to calm themselves and is not a reliable indicator of potential aggression.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Initiating the process to review the medical record is appropriate; clients have the right to access their medical information under HIPAA regulations, and the nurse can assist in starting that process.
B. While there are restricted parts of a medical record, the response lacks a proactive approach to assisting the client in accessing the information they have the right to view.
C. This response is dismissive of the client's request and does not provide an avenue for understanding the medical record better.
D. Although the provider can provide more detailed information about treatment, it does not
Correct Answer is D
Explanation
A. Providing interpretation services over the telephone is not effective for clients with hearing loss who may benefit more from in-person or visual communication.
B. Exaggerated lip movements can be distracting and may not aid understanding; clear and natural speech is more effective.
C. While providing written materials is helpful, ensuring the client can understand the material is key; using an appropriate reading level is essential but secondary to direct communication strategies.
D. Reducing environmental stimuli helps minimize distractions, making it easier for the client to focus on the nurse's speech or lip movements and improving overall communication.
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