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 B

Explanation

A) Why do you think you have a hostile work environment?:Asking this question might come across as dismissive or challenging the client’s perception of their experience. It is important to validate the client’s feelings and experiences rather than questioning their interpretation of the situation.

B) How have you responded to those in your work environment about these events?:This response encourages the client to reflect on their actions and coping strategies. It shows empathy and interest in understanding the client’s perspective and experiences, which can help build rapport and provide valuable insights for further discussion and support.

C) Have you considered resigning from your position?:Suggesting resignation might not be appropriate at this stage, as it could increase the client’s stress and anxiety. It is important to explore the client’s feelings and experiences first before discussing potential solutions or changes in their employment situation.

D) Have the feelings associated with these events brought you to the clinic?:While this question acknowledges the client’s feelings, it may not provide an opportunity for the client to elaborate on their experiences and coping strategies. It is important to focus on understanding the client’s actions and responses to the events they described.

A. Haloperidol. B. Lorazepam. C. Diphenyhydramine. D. Thiamine.

Correct Answer is B

Explanation

A) Haloperidol is an antipsychotic that may be used for agitation or hallucinations, but it is not the first-line treatment for alcohol withdrawal symptoms. Administering haloperidol without addressing withdrawal may not be effective and could lead to further complications.

B) Lorazepam is a benzodiazepine and is the preferred medication for managing alcohol withdrawal symptoms, including agitation, anxiety, and hallucinations. It helps reduce the risk of severe withdrawal symptoms and seizures while providing sedative effects. Given the client’s symptoms of feeling bugs crawling on his body, which may indicate tactile hallucinations due to withdrawal, lorazepam would be the most appropriate choice.

C) Diphenhydramine is an antihistamine that can be used for allergic reactions or as a sedative, but it is not effective for managing alcohol withdrawal symptoms.

D) Thiamine is important to prevent Wernicke's encephalopathy in clients with a history of alcohol dependency, especially if there are signs of confusion or neurological deficits. However, it does not address the immediate symptoms of withdrawal the client is experiencing.

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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?

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Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

Correct Answer is B

Explanation

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