A nurse is caring for a client who is experiencing panic-level anxiety and is becoming increasingly agitated with the staff. Which of the following interventions should the nurse attempt first?

Administer a sedative medication to the client.

Encourage strenuous physical activity to decrease tension.

Encourage the client to explore feelings that contribute to anxiety.

Speak to the client using short and simple statements in calm voice.

Answer and Explanation

The Correct Answer is D

A) Administer a sedative medication to the client: While sedative medications can help manage acute anxiety, they should not be the first intervention. Medication administration comes after attempting non-pharmacological strategies to de-escalate the situation.

B) Encourage strenuous physical activity to decrease tension: Strenuous physical activity can sometimes exacerbate anxiety rather than alleviate it, particularly during a panic-level episode. It might not be safe or effective for immediate calming.

C) Encourage the client to explore feelings that contribute to anxiety: Exploring feelings is more appropriate once the client has been calmed. During a panic-level anxiety episode, the client may not be able to engage in reflective thinking or communication effectively.

D) Speak to the client using short and simple statements in calm voice: Using short, simple statements in a calm voice helps to provide clear and concise communication, which can be grounding and reassuring for someone experiencing panic-level anxiety. This approach helps to de-escalate the situation by reducing confusion and agitation.

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Correct Answer is B

Explanation

A) Maintain the client on bed rest for 48 hr following surgery: While some bed rest is recommended initially post-surgery, maintaining bed rest for 48 hours is excessive and can increase the risk of complications like deep vein thrombosis. Early mobilization is generally encouraged to enhance recovery.

B) Check the tubing for kinks and blood clots at least every 2 hr: Regularly checking the catheter tubing for kinks and blood clots is essential to ensure the continuous flow of urine and prevent catheter blockage. This can help in reducing the risk of complications such as bladder distension and urinary retention.

C) Irrigate the client's bladder continuously using 5% dextrose in Ringer's lactate: Continuous bladder irrigation is often done post-TURP to prevent clot formation, but 5% dextrose in Ringer's lactate is not the recommended solution. Typically, normal saline is used to minimize the risk of electrolyte imbalance and maintain the correct osmolarity.

D) Remove the catheter if the client reports severe bladder spasms: Severe bladder spasms can occur post-TURP, but removing the catheter is not the immediate solution. The catheter is necessary for drainage and should be managed with antispasmodic medications or adjusting the irrigation flow rather than removal.

A. Tachypnea B. Nausea C. Hypothermia D. Bradycardia E. Flank pain

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

Explanation

A) Tachypnea:
Tachypnea, or rapid breathing, is not a typical symptom of acute pyelonephritis. This condition primarily affects the kidneys and urinary tract, and while it can cause systemic symptoms, tachypnea is more commonly associated with respiratory issues.

B) Nausea:
Nausea is a common symptom of acute pyelonephritis. The infection and inflammation of the kidneys can lead to gastrointestinal symptoms, including nausea and vomiting.

C) Hypothermia:
Hypothermia, or abnormally low body temperature, is not commonly associated with acute pyelonephritis. Patients with this condition are more likely to present with fever rather than hypothermia.

D) Bradycardia:
Bradycardia, or slow heart rate, is not typically seen in acute pyelonephritis. In fact, systemic infections and the associated fever can often lead to an increased heart rate (tachycardia).

E) Flank pain:
Flank pain is a hallmark symptom of acute pyelonephritis. The pain is usually located in the back and sides, near the affected kidney, and can be quite severe. This pain results from the inflammation and infection of the kidney.

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A nurse is caring for a client who is experiencing panic-level anxiety and is becoming increasingly agitated with the staff. Which of the following interventions should the nurse attempt first?

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