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) Asking the employee what she thinks should happen may put additional pressure on her during an extremely distressing moment. In a crisis, individuals often struggle to think clearly, and this response may not provide the immediate support she needs.

B) Calling for transportation to the hospital is the best response. This action demonstrates immediate support and concern for her well-being and allows her to prioritize reaching her child. It provides practical assistance in a moment of crisis and helps ensure she can get to her child as quickly as possible.

C) Asking how serious the collision was may seem relevant, but it could increase anxiety for the employee. She may not have this information, and discussing the severity of the situation could lead to further distress when she is already overwhelmed.

D) Asking what she thinks she should do could also add pressure to make a decision at a time when she is likely feeling helpless and confused. In a crisis, offering direct support and assistance is typically more effective than seeking input from the individual.

A. Regression. B. Denial. C. Projection. D. Repression.

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.

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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

The occupational health nurse is working with a female employee who was just notified that her child was involved in a motor vehicle collision and taken to the hospital. The employee states, 1 can't believe this. What should I do? Which response is best for the nurse to provide in this crisis?

Correct Answer is B

Explanation

Correct Answer is D

Explanation

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