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 A

Explanation

A) Becoming the faculty sponsor for Students Against Drunk Driving (SADD) is a proactive and constructive behavior that indicates the client is coping well with her anxiety related to the student’s death. This action demonstrates her ability to channel her grief into positive advocacy, suggesting that she is processing her emotions and seeking to create meaningful change, which is a strong indicator of healthy coping.

B) Describing alternatives to becoming depressed over the student’s death is a positive step, as it shows the client is engaging in cognitive strategies to manage her emotions. However, while this indicates some progress, it is less impactful than taking active steps to address the issue, like becoming involved in advocacy or community efforts.

C) Confronting her parents about the hurt she felt as a child of alcoholic parents can be a significant therapeutic step, but it may not directly relate to her current coping with the loss of her student. While this confrontation may contribute to her overall healing, it does not necessarily indicate coping specifically related to the anxiety from the recent event.

D) Signing a safety contract with the nurse indicates that there may still be significant concerns regarding self-harm or emotional distress. While this is an important safety measure, it suggests that the client is not yet fully coping well with her anxiety, as it implies she is still in a vulnerable state rather than demonstrating effective coping mechanisms.

A. Aspirin 81 milligrams PO daily. B. Losartan 50 mg PO daily. C. Phenelzine 60 mg PO daily. D. Hydrochlorothiazide 12.5 mg PO daily.

Correct Answer is C

Explanation

A) Aspirin 81 milligrams PO daily is commonly used as a low-dose antiplatelet medication and is generally not concerning in this context, especially with the symptoms described. It does not have a direct impact on blood pressure or the acute symptoms presented.

B) Losartan 50 mg PO daily is an antihypertensive medication used to manage high blood pressure. While the client’s blood pressure is elevated, this medication is appropriate for managing hypertension, and it does not pose an immediate concern.

C) Phenelzine 60 mg PO daily is of the most concern. It is a monoamine oxidase inhibitor (MAOI), which can have serious interactions with certain foods and medications, potentially leading to hypertensive crises, especially given the client’s high blood pressure of 216/108 mmHg. The client’s headache, nausea, and vomiting, combined with elevated vital signs, could indicate such a crisis, making this medication a significant concern.

D) Hydrochlorothiazide 12.5 mg PO daily is a thiazide diuretic commonly used to treat hypertension. While the client’s blood pressure is high, this medication is typically used to lower blood pressure and does not pose an immediate risk in this situation.

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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

Correct Answer is A

Explanation

Correct Answer is C

Explanation

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