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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D"]
Explanation
Rationale:
A. Sleep pattern: Two days without sleep is a red flag in bipolar disorder and may lead to worsening mania or psychosis. Addressing sleep deprivation is a priority to reduce the risk of exhaustion or psychotic deterioration.
B. Skin turgor: Poor skin turgor suggests dehydration, which may be due to poor fluid intake or prolonged activity. It requires immediate follow-up to prevent complications like electrolyte imbalances or renal injury.
C. Hallucinations: Persistent visual hallucinations may indicate an acute psychotic episode or manic psychosis. These require immediate psychiatric intervention to ensure client safety and stabilization.
D. Heart rate: A heart rate of 120/min indicates tachycardia, possibly related to dehydration, agitation, or underlying mania. It requires prompt evaluation to rule out cardiovascular strain or systemic causes.
E. Hygiene: While poor hygiene is a concern and can indicate mental health deterioration, it is not immediately life-threatening. It can be addressed after acute issues such as dehydration, tachycardia, and psychosis are managed.
Correct Answer is C
Explanation
Rationale:
A. Tomato allergy: A tomato allergy is not relevant to the ingredients used in total parenteral nutrition (TPN) with fat emulsion. Tomatoes are not a component of lipid emulsions, so this does not present a concern in this context.
B. Citrus allergy: Citrus fruits are also not involved in the formulation of fat emulsions or TPN components. Therefore, a citrus allergy would not require special precautions related to the prescribed therapy.
C. Egg allergy: Lipid emulsions used in TPN often contain egg phospholipids as an emulsifying agent. Clients with an egg allergy may experience a hypersensitivity reaction, making this a critical finding that must be reported to the provider immediately.
D. Wheat allergy: Wheat is not a component of standard TPN or fat emulsions. While wheat allergies are significant for dietary intake, they do not pose a known risk with parenteral nutrition administration.
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