An inpatient client who has a known history of violence suddenly begins to pace. Which additional client behavior should alert the nurse to escalating anger and aggression? The client:

Sits in group with back to peers.

Has a tense facial expression and body language.

Requests PRN medications.

Does not want to eat lunch.

Answer and Explanation

The Correct Answer is B

Choice A Reason: Sits in group with back to peers

Sitting with one’s back to peers can indicate a desire for isolation or a lack of trust, but it is not a definitive sign of escalating anger or aggression. This behavior might be more indicative of withdrawal or discomfort in social settings rather than an immediate precursor to violence.

Choice B Reason: Has a tense facial expression and body language

This is the correct answer. Tense facial expressions and body language are clear indicators of escalating anger and aggression. Signs such as clenched fists, a rigid posture, and a furrowed brow are physical manifestations of internal tension and can precede aggressive outbursts. Recognizing these non-verbal cues is crucial for early intervention and de-escalation.

Choice C Reason: Requests PRN medications

Requesting PRN (as needed) medications can be a sign that the client is experiencing increased anxiety or distress. However, this behavior alone does not necessarily indicate escalating aggression. It may actually be a positive sign that the client is seeking help to manage their symptoms before they escalate.

Choice D Reason: Does not want to eat lunch

A lack of appetite or refusal to eat can be associated with various conditions, including depression, anxiety, or physical illness. While it may indicate that the client is not feeling well, it is not a specific indicator of escalating anger or aggression.

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Correct Answer is B

Explanation

Choice A Reason:

Draws attention and approval from significant others.

This statement is incorrect. Compulsive washing rituals in Obsessive-Compulsive Disorder (OCD) are not typically performed to draw attention or gain approval from others. Instead, these rituals are driven by an internal need to reduce anxiety and distress associated with obsessive thoughts. The primary function of these behaviors is to manage the individual’s own anxiety rather than to seek external validation.

Choice B Reason:

Provides temporary and partial relief from anxiety.

This is the correct response. Compulsive washing rituals in OCD are performed to alleviate the intense anxiety and distress caused by obsessive thoughts. Although the relief is temporary and partial, it reinforces the behavior, creating a cycle where the individual feels compelled to repeat the ritual to manage their anxiety. This temporary relief is a key characteristic of compulsive behaviors in OCD.

Choice C Reason:

Increases the inhibitory powers of their superego.

This statement is incorrect. The concept of the superego is related to Freud’s psychoanalytic theory, where it represents the internalized moral standards and ideals. Compulsive washing rituals in OCD are not performed to increase the inhibitory powers of the superego but rather to reduce anxiety and distress. The rituals are a response to obsessive thoughts rather than a means of enhancing moral inhibition.

Choice D Reason:

Blocks delusions and hallucinations from awareness.

This statement is incorrect. Delusions and hallucinations are more commonly associated with psychotic disorders, such as schizophrenia, rather than OCD. Compulsive washing rituals in OCD are not intended to block delusions or hallucinations but to manage anxiety related to obsessive thoughts. The focus of these rituals is on reducing distress rather than addressing psychotic symptoms.

Correct Answer is ["600"]

Explanation

Step 1: Identify the total volume to be infused.

Total volume = 250 mL

Step 2: Identify the total time for infusion.

Total time = 25 minutes

Step 3: Calculate the rate in mL per minute.

Rate = Total volume ÷ Total time
Rate = 250 mL ÷ 25 minutes
Rate = 10 mL per minute

Step 4: Convert the rate to mL per hour.

Since there are 60 minutes in an hour, multiply the rate by 60.
Rate per hour = 10 mL per minute × 60
Rate per hour = 600 mL per hour

The nurse should program the pump to infuse at a rate of 600 mL per hour.

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An inpatient client who has a known history of violence suddenly begins to pace. Which additional client behavior should alert the nurse to escalating anger and aggression? The client:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client diagnosed with Obsessive-Compulsive Disorder has developed a number of compulsive washing rituals over the years. The nurse recognizes that these behavioral rituals serve which purpose?

Correct Answer is B

Explanation

A patient with fluid volume deficit must receive a 250 mL IV bolus of NS over 25 minutes via a peripherally inserted central line (PICC) on an IV pump. At what rate will the nurse program the pump? Round to the nearest whole number. Do not use trailing zeros.

Correct Answer is ["600"]

Explanation

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