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. The family will communicate their love and concern to the client. B. The client will eat nutritious meals in the hospital cafeteria. C. The client will verbalize feelings of a positive self-esteem. D. The entire family will attend family therapy sessions regularly.

Correct Answer is B

Explanation

A) While it is important for the family to communicate love and concern, this goal does not directly address the immediate medical needs of the adolescent. Focusing on emotional support is valuable, but it is secondary to the need for nutritional recovery.

B) The goal for the client to eat nutritious meals in the hospital cafeteria has the highest priority. Ensuring adequate nutrition is critical in the treatment of anorexia nervosa, as the client is at risk for severe physical complications due to malnutrition. This goal directly addresses the client’s immediate health needs and forms the foundation for further psychological recovery.

C) Verbalizing feelings of positive self-esteem is an important long-term goal in the treatment of anorexia nervosa; however, it cannot be effectively achieved without first addressing the client’s nutritional and physical health needs. Self-esteem often improves with physical recovery, so it should be a goal to work toward after establishing a solid nutritional foundation.

D) While regular family therapy sessions can be beneficial for the overall treatment plan, this goal does not take precedence over the need for the client to stabilize their physical health. Family involvement is important, but the immediate priority should be on the client's individual recovery and nutritional needs.

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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 D

Explanation

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

Correct Answer is B

Explanation

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