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 D

Explanation

A) Telling the client that irrational thinking is a symptom of schizophrenia may come across as dismissive and could further alienate the client. While it's important to acknowledge the symptoms, this approach does not provide a practical solution to the immediate concern of the client refusing to eat.

B) Obtaining an order for tube feeding should be a last resort. While nutritional intake is essential, invasive interventions should only be considered if the client’s refusal to eat poses an immediate health risk and after other less invasive strategies have been attempted.

C) Assuring the client that all food served in the hospital is safe to eat might be well-intentioned, but it is unlikely to alleviate the client's fears. The client is experiencing

delusions, and simply stating that the food is safe may not be convincing.

D) Providing the client with food in unopened containers is the most appropriate intervention. This respects the client's concerns about food safety while offering a solution that allows them to eat without directly confronting their delusions. Unopened containers can provide a sense of security and control for the client, potentially encouraging them to consume food without feeling threatened.

A. Serum creatinine. B. Blood glucose. C. White blood count. D. Alkaline phosphatase.

Correct Answer is A

Explanation

A) Reviewing serum creatinine is the most critical laboratory finding prior to initiating lithium therapy. Lithium is primarily excreted through the kidneys, and any existing renal impairment can increase the risk of lithium toxicity. Ensuring normal kidney function is vital for safe lithium administration and monitoring throughout the treatment.

B) While blood glucose levels can be relevant in the context of overall health and any potential metabolic syndrome concerns, they are not as directly related to lithium therapy as renal function. Blood glucose levels do not significantly impact the safety or effectiveness of lithium.

C) A white blood count (WBC) can be important in assessing for potential infections or hematological disorders, but it is not the primary focus when starting lithium. Lithium does not typically have a direct effect on white blood cell levels, making this finding less critical compared to renal function.

D) Alkaline phosphatase levels are primarily related to liver function and bone health. While monitoring liver function is important in general, it is not as directly pertinent to the initiation of lithium therapy as assessing renal function through serum creatinine levels. Therefore, this laboratory finding is less of a priority in this context.

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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?

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Correct Answer is D

Explanation

The healthcare provider prescribes lithium carbonate for a client diagnosed with bipolar, manic depression. It is most important for the nurse to review which laboratory finding prior to beginning the drug therapy?

Correct Answer is A

Explanation

A client with somatic symptom disorder reports experiencing chest pain to the nurse. Which action should the nurse take?

A client with schizophrenia receives a prescription for fluphenazine. Which instruction is most important for the nurse to include when teaching the client about this drug?

During admission to the psychiatric unit, a female client is extremely anxious and expresses that she is worried about the sun coming up the next day. Which intervention is most important for the nurse to implement during the admission process?

The nurse is preparing a client for discharge who has been taking alprazolam long-term for generalized anxiety disorder (GAD). When evaluating the client's understanding of the discharge teaching, which statement made by the client shows awareness of the most important self-care goal?

A client who refuses antipsychotic medications disrupts group activities, talks with nonsensical words, and wanders into client's rooms. The nurse decides that the client needs constant observation based on which of these assessment findings?

A client is admitted to the psychiatric unit following aspiration of a caustic material related to a suicide attempt. Which nursing problem has the highest priority?

After several days of being despondent and nonverbal, a female client with depression begins to talk and exhibit energy. Which action should the nurse implement?