A nurse is assisting with client care on a medical unit when an individual who appears angry and agitated enters the unit and reveals a weapon. Which of the following actions should the nurse take?

Keep doors unlocked

Increase ringer volume on cell phones

Hide out of sight

Approach the armed individual

Answer and Explanation

The Correct Answer is C

Workplace violence and active threat situations require immediate actions focused on personal safety, de-escalation avoidance, and rapid protection from harm. In the presence of an armed, agitated individual, nursing priorities shift from patient care to survival strategies consistent with emergency safety protocols. Standard guidance emphasizes avoiding confrontation, minimizing visibility, and seeking secure shelter until law enforcement intervenes. Understanding appropriate responses reduces risk of injury or fatality in high-risk events.

Rationale:
A. Keeping doors unlocked is unsafe because it increases accessibility to staff and patients, allowing the armed individual to move freely through the unit. In an active threat situation, securing barriers and limiting entry points is essential to reduce exposure. This action would increase risk rather than promote safety.

B. Increasing the ringer volume on cell phones is inappropriate and may increase the likelihood of detection by the aggressor. Noise can draw attention to staff locations, compromising concealment. In emergency safety situations, silence and minimizing stimuli are critical for survival.

C. Hiding out of sight is correct because it aligns with “run, hide, fight” safety principles used in active shooter or armed intruder scenarios. Remaining concealed reduces visibility and lowers the risk of being targeted by the individual. In situations involving immediate threat, prioritizing concealment and silence is essential for protection while awaiting law enforcement response.

D. Approaching the armed individual is extremely dangerous and not appropriate. Engaging or confronting an active threat increases the likelihood of injury or death. Nursing staff should avoid interaction and instead prioritize evacuation or concealment based on environmental safety.

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Free Nursing Study Resources

Correct Answer is ["A","D","E","F"]

Explanation

Preoperative nursing care for a client scheduled for laparoscopic management of a confirmed Ectopic pregnancy focuses on stabilizing the client, ensuring surgical readiness, and preventing perioperative complications such as hemorrhage and aspiration. The client has a tubal pregnancy confirmed by ultrasound with declining β-hCG levels, requiring urgent surgical intervention. Nursing priorities include airway safety, vascular access for rapid fluid or blood administration, verification of informed consent, and baseline laboratory evaluation to guide intraoperative management.

Rationale:

A. Reminding the client to remain NPO is essential to reduce the risk of aspiration during general anesthesia. Laparoscopic surgery requires sedation or general anesthesia, which depresses protective airway reflexes. Ensuring an empty stomach decreases the likelihood of regurgitation and aspiration pneumonia during induction of anesthesia.

B. Administering Rh immune globulin prior to surgery is not appropriate at this time without provider order and timing consideration. Rh immune globulin is typically given after delivery or significant fetal-maternal hemorrhage, not preoperatively. The priority is surgical stabilization rather than prophylactic administration at this stage.

C. Explaining the surgical procedure to the client is not the nurse’s role because informed consent and procedural explanation are the responsibility of the provider. The nurse may reinforce understanding but should not introduce or explain the procedure in detail. This could interfere with the legal consent process

D. Preparing for insertion of an 18-gauge peripheral IV is critical because ectopic pregnancy surgery carries a risk of sudden hemorrhage. A large-bore IV line allows rapid administration of fluids, medications, and blood products if needed. This ensures immediate vascular access for hemodynamic stabilization during surgery.

E. Verifying that the consent form is signed is a key legal and safety requirement before any surgical procedure. The nurse ensures that informed consent has been obtained, properly documented, and matches the planned procedure. This confirms patient understanding and protects autonomy before anesthesia is initiated.

F. Obtaining a complete blood count is necessary to establish baseline hematologic status before surgery. The client already demonstrates mild anemia, which may worsen if intraoperative bleeding occurs. Hemoglobin, hematocrit, and platelet levels guide perioperative planning and readiness for possible transfusion.

G. Administering AB positive blood products is inappropriate due to ABO and Rh incompatibility. The client is B negative, and transfusion with incompatible blood could trigger a severe hemolytic reaction. If transfusion becomes necessary, properly matched B negative or O negative blood must be used instead.

A. "We've seen steady improvement in other clients who are depressed." B. "No one really knows the answer to that question." C. "The important thing is that he gets better, not how long it takes." D. "Tell me what you know about depression."

Correct Answer is D

Explanation

Supporting families of clients newly diagnosed with depression involves therapeutic communication that promotes understanding, reduces anxiety, and assesses knowledge gaps. Depression is a complex mental health condition influenced by biological, psychological, and social factors, and recovery timelines vary widely depending on severity, treatment adherence, and individual response to therapy. Nurses should avoid giving false reassurance or vague predictions and instead engage the family in dialogue that helps tailor education to their needs. Effective communication strengthens coping and improves support for the client.

Rationale:
A. Providing generalized statements about improvement in other clients is non-therapeutic because it may create unrealistic expectations and does not address the partner’s specific concerns. Each client’s response to treatment for Major depressive disorder is individualized, so comparing outcomes can be misleading and unhelpful.

B. Stating that no one knows the answer may be truthful but is abrupt and non-therapeutic. It can increase anxiety and leave the partner without support or direction. Nursing communication should remain supportive while guiding the family toward understanding and coping.

C. Focusing only on the importance of improvement minimizes the partner’s concern about prognosis and does not provide education or emotional support. This type of response may shut down further discussion and fail to address the family’s need for information about recovery expectations.

D. Asking what the partner knows about depression is a therapeutic communication technique that assesses baseline understanding and allows the nurse to provide individualized education. It encourages dialogue, clarifies misconceptions, and supports emotional processing. This approach fosters engagement and helps build a realistic understanding of recovery.

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Body System	Findings
Cardiovascular	S1,S2, no murmur, bradycardia
Respiratory	decreased respiratory effort, equal chest expansion, bilateral crackles
Neurologic	somnolent
Head, Ears, Eyes, Nose, and Throat (HEENT)	oropharynx clear, mucous membranes moist pinpoint pupils
Vital Signs	Temperature 37.4° C (99.4° F) Heart rate 58/min Respiratory rate 10/min Blood pressure 98/58 mm Hg

A nurse is assisting with client care on a medical unit when an individual who appears angry and agitated enters the unit and reveals a weapon. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse has reviewed the Nurses' Notes and Provider Prescriptions at 1100 and Diagnostic Results on Day 3. The nurse is preparing the client for surgery. Which of the following actions should the nurse take? Select all that apply.

Correct Answer is ["A","D","E","F"]

Explanation

A nurse is caring for a client who was recently diagnosed with depression. The client's partner asks when he will get better. Which of the following Is an appropriate response by the nurse?

Correct Answer is D

Explanation

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