The nurse is assessing an inpatient client with a known history of violence. The client suddenly displays clenched fists. What additional behavior by the client would suggest that the aggression is escalating? The client:

refuses to eat lunch.

requests prn medications.

is pacing around the milieu.

sits in a group with their peers.

Answer and Explanation

The Correct Answer is C

a. refuses to eat lunch. Refusal to eat lunch might indicate displeasure or upset but does not directly suggest escalating aggression.
b. requests prn medications. Requesting prn (as needed) medications typically indicates the client is aware of their distress and is seeking help, not escalating aggression.
c. is pacing around the milieu. Pacing can be a sign of increasing agitation and is often observed in clients who are escalating towards aggressive behavior. This physical activity can indicate restlessness and an inability to calm down.
d. sits in a group with their peers. Sitting in a group with peers suggests a level of social engagement and does not indicate escalating aggression.

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Correct Answer is B

Explanation

a. a client communicates significant distress. While significant distress is important to consider, it alone does not necessarily indicate a risk for developing mental illness unless it also impacts daily functioning and coping mechanisms.
b. maladaptive responses to stress are coupled with interference in daily functioning. This choice is correct because it reflects a combination of maladaptive coping (which can exacerbate mental health issues) and interference with daily functioning (a key indicator of mental illness according to DSM-5 criteria).
c. thoughts, feelings, and behaviors are not reflective of the DSM-5 criteria. While alignment with DSM-5 criteria is crucial for diagnosis, this choice alone does not address the risk aspect. The focus should be on behaviors that lead to impairment in daily functioning and coping.
d. a client uses defense mechanisms as ego protection. Using defense mechanisms is a normal part of human behavior and not necessarily indicative of mental illness risk unless these mechanisms are maladaptive and interfere with functioning.

A. Food is rapidly ingested without proper chewing. B. Purging causes the depletion of dietary calcium. C. Poor dental and oral hygiene lead to dental caries. D. Emesis from purging corrodes the tooth enamel.

Correct Answer is D

Explanation

a. Food is rapidly ingested without proper chewing: While this might happen in bulimia nervosa, it does not explain dental erosion.
b. Purging causes the depletion of dietary calcium: Calcium depletion could affect bones and teeth but is not the primary reason for the dental erosion seen in bulimia nervosa.
c. Poor dental and oral hygiene lead to dental caries: While poor hygiene can contribute to dental issues, the primary cause of dental deterioration in bulimia is the acid from vomiting.
d. Emesis from purging corrodes the tooth enamel. Frequent vomiting in bulimia nervosa exposes teeth to stomach acid, which erodes the enamel and leads to dental deterioration.

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The nurse is assessing an inpatient client with a known history of violence. The client suddenly displays clenched fists. What additional behavior by the client would suggest that the aggression is escalating? The client:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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The nurse is assessing an inpatient client with a known history of violence. The client suddenly displays clenched fists. What additional behavior by the client would suggest that the aggression is escalating? The client:

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