A nurse in a mental health facility is caring for a client who is experiencing a panic level of anxiety. Which of the following actions should the nurse take?

Tell the client to sit alone in a private place and reflect on the situation.

Use short sentences when communicating with the client

Have the client journal about what is happening to him

Encourage the client to talk about his feelings.

Answer and Explanation

The Correct Answer is B

Rationale:

A. Tell the client to sit alone in a private place and reflect on the situation: Clients in a panic state are overwhelmed, disorganized, and unable to focus. Leaving them alone can increase feelings of isolation and fear, worsening the anxiety.

B. Use short sentences when communicating with the client: During panic-level anxiety, the client's ability to process information is impaired. Clear, concise communication helps reduce confusion and provides a sense of control and safety.

C. Have the client journal about what is happening to him: Journaling requires introspection and cognitive organization, which are not possible when a client is in a panic state. This intervention is more appropriate once anxiety levels have decreased.

D. Encourage the client to talk about his feelings: While verbalizing emotions is therapeutic, a client in panic may not be able to articulate thoughts. The priority is to first reduce the anxiety to a manageable level using calm, simple guidance.

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Correct Answer is C

Explanation

Rationale:

A. Coarse lung sounds: Coarse lung sounds are typically associated with pulmonary issues such as fluid overload or pneumonia. They are not specific to cardiac tamponade and may appear later or not at all in this condition.

B. Widening pulse pressure: Cardiac tamponade causes narrowing of the pulse pressure due to decreased stroke volume, not widening. A narrowing pulse pressure is a more reliable hemodynamic sign of tamponade.

C. Muffled heart sounds: Muffled or distant heart sounds are a classic early sign of cardiac tamponade. They result from fluid accumulation in the pericardial sac, which insulates the heart and dampens the transmission of sound.

D. Decreased jugular vein distention: Cardiac tamponade typically causes increased jugular vein distention due to impaired venous return to the heart. A decrease in JVD would not be expected and may indicate a different process.

A. Remove the thermometer from client's room for use on another client. B. Wash hands with an alcohol-based cleaner. C. Change gloves after contact with infectious material. D. Wear a gown when providing care. E. Wear an N95 respirator when providing care.

Correct Answer is ["C","D"]

Explanation

Rationale:

A. Remove the thermometer from the client’s room for use on another client: Equipment used for clients with C. difficile should be dedicated or properly disinfected before reuse. Removing and using the same thermometer on other clients without disinfection increases the risk of cross-contamination.

B. Wash hands with an alcohol-based cleaner: Alcohol-based hand sanitizers are ineffective against C. difficile spores. Handwashing with soap and water is required to physically remove the spores from the hands.

C. Change gloves after contact with infectious material: Gloves must be changed between tasks and after contact with infectious material to prevent spread. This is standard contact precaution practice for C. difficile infections.

D. Wear a gown when providing care: A gown should be worn during any direct care or activities likely to involve contact with the client or contaminated surfaces, as C. difficile is transmitted via the fecal-oral route and can persist on surfaces.

E. Wear an N95 respirator when providing care: An N95 respirator is not required for C. difficile, which is transmitted through contact, not airborne routes. Standard and contact precautions, not airborne, are appropriate.

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A nurse in a mental health facility is caring for a client who is experiencing a panic level of anxiety. Which of the following actions should the nurse take?

Nursing Test Bank

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