A nurse in an acute mental health facility observes a client having a panic atack. Which of the following interventions should the nurse implement first?

Discuss the client's feelings prior to the panic atack.

Encourage the use of positive self-talk strategies

Instruct the client to use abdominal breathing

Administer an anti-anxiety medication

Answer and Explanation

The Correct Answer is C

c. Instruct the client to use abdominal breathing.

When a client is experiencing a panic atack, the nurse's first priority is to help the client manage their symptoms and provide immediate relief. Instructing the client to use abdominal breathing is the most appropriate initial intervention.

Explanation for the other options:

a. Discuss the client's feelings prior to the panic atack. While discussing the client's feelings can be beneficial in addressing the underlying causes of anxiety, it may not be the most eﬀective immediate intervention during a panic atack. The client's focus during a panic atack is typically on managing the physical symptoms and regaining control.

b. Encourage the use of positive self-talk strategies. Positive self-talk can be helpful in managing anxiety in general, but during a panic atack, the individual may have difficulty engaging in positive self-talk due to the intensity of symptoms. Addressing the immediate physical symptoms is a priority before exploring coping strategies.

d. Administer an anti-anxiety medication. Medication administration may be necessary in some cases, but it is not the first-line intervention for managing a panic atack. Non-pharmacological interventions, such as breathing techniques, should be implemented first. If the panic atack persists or worsens despite these interventions, medication may be considered.

In summary, during a panic atack, the immediate focus should be on helping the client manage their symptoms. Instructing the client to use abdominal breathing can help promote relaxation and reduce the intensity of the panic atack.

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Correct Answer is B

Explanation

The charge nurse should explain to the assistive personnel (AP) that one of the responsibilities of a licensed practical nurse (LPN) is providing direct client care. LPNs work under the supervision of registered nurses (RNs) and are trained to deliver basic nursing care to clients. This includes tasks such as administering medications, monitoring vital signs, dressing wounds, assisting with activities of daily living (ADLs), and reporting any changes in the client's condition to the RN.

The other options are not typically within the scope of practice for an LPN:

a. Coordinating client care: The coordination of client care is primarily the responsibility of the RN. While LPNs may contribute to the coordination of care by providing input and collaborating with the healthcare team, the overall coordination is usually managed by the RN.

c. Assessing a client's health status: Assessing a client's health status is a role primarily performed by RNs. LPNs may gather data and contribute to the assessment process, but the comprehensive assessment and interpretation of data is typically the responsibility of the RN.

d. Identifying specific client health problems: Identifying specific client health problems and formulating nursing diagnoses is part of the RN's role. LPNs may assist in collecting data and providing input, but the identification and formulation of nursing diagnoses are within the scope of practice of the RN.

A. Puncture the heel to a depth of 4 mm to obtain the specimen. B. Withhold feeding prior to collecting the specimen. C. Apply a heat pack 5 to 10 minutes prior to the procedure. D. Elevate the newborn's foot for 15 minutes following the procedure.

Correct Answer is C

Explanation

The nurse should apply a heat pack 5 to 10 minutes prior to the procedure when planning to obtain blood from a newborn via a heel stick. This helps to increase blood ﬂow to the area and makes it easier to obtain the specimen.

a) Puncturing the heel to a depth of 4 mm is too deep and can cause injury to the newborn. The recommended depth for a heel stick is 2.4 mm or less.

b) Withholding feeding prior to collecting the specimen is not necessary.

d) Elevating the newborn's foot for 15 minutes following the procedure is not necessary.

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A nurse in an acute mental health facility observes a client having a panic atack. Which of the following interventions should the nurse implement first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A charge nurse is explaining the role of a licensed practical nurse to an assistive personnel (AP). Which of the following responsibilities should the charge nurse include?

Correct Answer is B

Explanation

A nurse is planning to obtain blood from a newborn via a heel stick. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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