An employee with a history of hypertension, visits the employee clinic weekly for blood pressure checks. During the assessment the client reports being upset with coworkers and would like to shoot them. Which action should the nurse take first?

Determine if the client has a weapon available for use.

Inform the healthcare provider of the threat to harm coworkers.

Have the employee escorted to a mental health facility.

Notify security of the client's intention to harm coworkers.

Answer and Explanation

The Correct Answer is A

A) Determining if the client has a weapon available for use is the most immediate and critical action. Assessing the availability of a weapon helps the nurse evaluate the level of risk and potential for harm, which is essential for ensuring safety.

B) Informing the healthcare provider of the threat to harm coworkers is important but should follow an immediate assessment of the client's access to weapons. Safety must be prioritized in situations involving threats of violence.

C) Having the employee escorted to a mental health facility may be necessary, but it should be based on the initial assessment of the risk they pose. This action is more appropriate after determining the client's immediate safety level.

D) Notifying security about the client's intention to harm coworkers is also a necessary step; however, it should occur after assessing the situation and determining if there is an imminent threat. The focus should first be on understanding the potential for harm.

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Correct Answer is D

Explanation

A) Regression involves reverting to earlier developmental behaviors in response to stress. While the client’s current behaviors may reflect regression, her inability to remember specific events points more directly to another mechanism.

B) Denial is the refusal to accept reality or facts. The client acknowledges that her mother ran her father off, so she is not completely denying her past; instead, she seems to lack memory about certain aspects, which suggests a different mechanism.

C) Projection involves attributing one’s own unacceptable feelings or thoughts to someone else. The client is not projecting her feelings onto others; she is reflecting on her own experiences, so this is not the most accurate descriptor.

D) Repression is the unconscious blocking of unacceptable thoughts or memories. The client’s statement about not remembering possible abuse suggests that she may have repressed those memories as a way to cope with the emotional pain associated with her past. This aligns well with the client’s history of chronic depression and suicidal behavior.

A. Reason for the suicide attempt. B. The drug that was ingested. C. The time since drug ingestion. D. Past history of depression.

Correct Answer is B

Explanation

A) While understanding the reason for the suicide attempt can provide important context, it is not as critical in the immediate management of a suspected overdose as knowing the specifics of what was ingested.

B) Identifying the drug that was ingested is the most important information for the nurse to obtain. Knowing the specific substance allows for appropriate and timely treatment, including the administration of antidotes if applicable and understanding potential complications.

C) The time since drug ingestion is also relevant, as it can influence treatment decisions and urgency. However, without knowing the specific drug, it may be challenging to determine the best course of action.

D) A past history of depression is important for the overall understanding of the client's mental health, but it does not have immediate implications for managing an overdose. The priority is to address the acute medical situation first.

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An employee with a history of hypertension, visits the employee clinic weekly for blood pressure checks. During the assessment the client reports being upset with coworkers and would like to shoot them. Which action should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

A young adult client is brought to the emergency department with a suspected drug overdose. Which information is most important for the nurse to obtain from the family?

Correct Answer is B

Explanation

Which goal has the highest priority for an adolescent client who is hospitalized for weight loss related to anorexia nervosa?

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