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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Free Nursing Study Resources

Correct Answer is ["A","B","E"]

Explanation

Rationale:

A. Maintain the head of the client's bed at a 30° angle or higher: Elevating the head of the bed reduces the risk of aspiration by preventing gastric contents from entering the airway, especially during and after feeding.

B. Check gastric residuals every 4 hr: Regular residual checks help assess gastric emptying and tolerance of enteral feeding. High residuals may indicate delayed gastric motility and require intervention.

C. Check placement of the feeding tube by x-ray once daily: An x-ray is used only once to confirm initial tube placement. Daily x-rays are unnecessary unless dislodgement is suspected; routine placement verification is done via pH testing or aspiration.

D. Ensure the formula is cold before administration: Cold formula can cause cramping or discomfort. It should be at room temperature before administration to promote tolerance and reduce gastrointestinal side effects.

E. Change the feeding container and tubing every 24 hr: Changing feeding equipment every 24 hours prevents microbial contamination, especially with continuous feeding, and is consistent with infection control guidelines.

A. Tinnitus B. Dizziness C. Sore throat D. Diaphoresis

Correct Answer is C

Explanation

Rationale:

A. Tinnitus: Tinnitus is not a known or common adverse effect of clozapine. While it may indicate another condition, it does not require immediate reporting in the context of clozapine therapy.

B. Dizziness: Dizziness can occur due to clozapine’s hypotensive effects, especially when initiating therapy. It is usually self-limiting and managed symptomatically unless it worsens or affects safety.

C. Sore throat: A sore throat can signal the onset of agranulocytosis, a life-threatening side effect of clozapine marked by a dangerously low white blood cell count. It must be reported immediately for prompt blood count evaluation.

D. Diaphoresis: Diaphoresis may occur with many medications and is not specific to clozapine toxicity or serious adverse effects. It typically does not warrant immediate reporting unless severe or part of a broader concerning symptom complex.

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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

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is receiving continuous enteral feedings. Which of the following actions should the nurse take? (Select all that apply.)

Correct Answer is ["A","B","E"]

Explanation

A nurse is caring for a client who is taking clozapine. Which of the following findings should the nurse report to the provider?

Correct Answer is C

Explanation

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