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 C

Explanation

A) Offering a referral to pastoral counseling can be helpful, but it may not address the immediate emotional needs of the client who is experiencing extreme sadness and difficulty controlling emotions. This option can be considered later in the therapeutic process.

B) Suggesting the need for a psychiatric consultation might be appropriate, but it could be premature at this point. The focus should first be on understanding the client’s current emotional state and helping them process their grief.

C) Exploring changes in life that have occurred after the loss is the first and most important action. This approach allows the nurse to facilitate the client’s expression of feelings, which is crucial in the grieving process. By discussing the impact of the loss, the nurse can provide emotional support and help the client begin to process their grief.

D) Encouraging attendance at a local support group can be beneficial, but it may not be the most immediate action. The client needs to be heard and understood in their current emotional state before considering additional resources or support systems.

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for client who is experiencing extreme sadness after the passing of a companion of 30 years. The client describes not being able to think of other things and finds it difficult to control emotions. Which action should the nurse take first?

Correct Answer is C

Explanation

Correct Answer is B

Explanation

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