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) Listening to what the client is saying can be important for understanding their perspective, but in this situation, the client's loud and wild behavior may be disruptive or alarming to others. Prioritizing safety is crucial.

B) Sitting in the chair next to the client could help establish rapport, but it does not address the immediate need to manage the disruptive behavior. The nurse must first ensure a safe environment for all clients.

C) Escorting the client to his room is the best initial action. This intervention helps to remove the client from the potentially stimulating environment of the day room, reducing the likelihood of escalation and providing a quieter space where the client can feel more secure and calm. It also minimizes disruption to other clients.

D) Administering a PRN sedative may be necessary if the behavior continues to escalate, but it should not be the first action taken. Non-pharmacological interventions, such as providing a safe space, should be prioritized before considering medication.

A. Clarifying the nurse's role and clients' responsibilities. B. Discussing ways to use new coping skills learned. C. Helping clients identify areas of problem in their lives. D. Establishing a rapport with group members.

Correct Answer is B

Explanation

A) Clarifying the nurse's role and clients' responsibilities is important but is typically more relevant during the initial stages of group development, specifically in the forming phase. By the working phase, roles should already be established.

B) Discussing ways to use new coping skills learned is the most appropriate approach during the working phase of group development. This phase is characterized by active engagement and collaboration among group members as they explore and practice the skills they’ve learned. It encourages growth and fosters a supportive environment for applying new strategies.

C) Helping clients identify areas of problem in their lives is an essential aspect of group therapy but is often emphasized during earlier phases when members are becoming familiar with each other and establishing trust. In the working phase, the focus shifts toward solutions and skill application.

D) Establishing rapport with group members is crucial in the forming phase of group development. By the working phase, rapport should be well established, allowing for deeper discussions and engagement in the therapeutic process. Therefore, focusing on new coping skills is more aligned with the goals of this phase.

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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

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Correct Answer is C

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Correct Answer is B

Explanation

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