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 A

Explanation

A. This is correct because discomfort while walking can indicate genital trauma or infection, which are possible signs of sexual abuse.
B. This is incorrect because thin extremities can be caused by many factors, such as malnutrition, genetic disorders, or chronic diseases, that are not necessarily related to sexual abuse.
C. This is incorrect because bruises on the upper back can result from accidental injuries, such as falls or bumps, or from physical abuse, such as hitting or kicking, but not specifically from sexual abuse.
D. This is incorrect because a stained shirt can be due to poor hygiene, food spills, or environmental factors, but not necessarily from sexual abuse.

A. A B. B C. C

Correct Answer is C

Explanation

A. Incorrect. HD does not affect the eyes.

B. Incorrect. HD does not affect the respiratory system or cause chest manifestations.

C. Correct. Hirschsprung disease (HD) is a congenital disorder that affects the nerve cells in the colon, causing a lack of peristalsis and bowel obstruction. Infants with HD may have a distended abdomen due to fecal accumulation and gas.

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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 in the emergency department is assessing a preschooler who has a facial laceration. The nurse should identify which of the following findings as a potential indication of child sexual abuse?

Correct Answer is A

Explanation

A nurse is caring for a 2-month-old infant who has Hirschsprung disease (HD). Which of the following areas should the nurse assess for manifestations of HD? (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)

Correct Answer is C

Explanation

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