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

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. Decreased cholesterol is not a primary effect of chlorpromazine; the medication is primarily used for psychiatric conditions, not lipid management.

B. While chlorpromazine may have sedative effects that could impact blood pressure, decreased blood pressure is not a direct indicator of its effectiveness in treating psychiatric symptoms.

C. Decreased esophageal reflux is not a relevant effect of chlorpromazine, as it is primarily used for managing psychotic symptoms.

D. Decreased hallucinations is a direct indication of the medication's effectiveness in treating conditions such as schizophrenia or other psychotic disorders, as chlorpromazine is an antipsychotic medication.

A. Provide opportunities for the client to choose their own mealtimes. B. Supervise the client during and after eating. C. Give the client a choice of foods and beverages. D. Encourage casual conversation about food during mealtimes.

Correct Answer is B

Explanation

A. While offering choices can promote autonomy, allowing clients to choose their own mealtimes may lead to avoidance of meals and is not a structured approach needed for clients with anorexia nervosa.

B. Supervision during and after eating is critical in managing clients with anorexia nervosa to ensure they consume the necessary nutrients and to monitor for any harmful behaviors, such as purging.

C. Although providing choices can support autonomy, it may not be suitable for clients with anorexia nervosa, as they might choose low-calorie or unhealthy options.

D. Encouraging casual conversation about food can sometimes increase anxiety or lead to fixation on eating behaviors, making it an inappropriate strategy for this population.

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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

A nurse is caring for a client who has a prescription for chlorpromazine. Which of the following findings should the nurse identify as an indication that the medication is effective?

Correct Answer is D

Explanation

A nurse in an acute mental health facility is planning care for a client who has anorexia nervosa. Which of the following interventions should the nurse include in the client's plan of care?

Correct Answer is B

Explanation

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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?