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 A

Explanation

A. Administer a dose of subcutaneous epinephrine.: The swelling of the lips and tongue is indicative of angioedema, a serious adverse reaction to captopril. Epinephrine is the first-line treatment for severe allergic reactions or angioedema to quickly counteract the swelling and prevent airway obstruction.

B. Advise the client not to consume grapefruit products.: Grapefruit can interact with some medications, but it is not related to the management of angioedema. This action would be more relevant for drugs metabolized by CYP3A4, not specifically for angioedema.

C. Place warm compresses on both sides of the client's face.: Warm compresses are not appropriate for angioedema and may not address the underlying issue. This action does not manage the immediate, potentially life-threatening reaction caused by captopril.

D. Swab the client's oral mucosa with nystatin suspension.: Nystatin is used for fungal infections of the oral mucosa, not for angioedema. This action does not address the adverse reaction related to captopril.

A. Multiple clots in the client's urinary bag B. Client reports bladder spasms when repositioning in bed C. Obstruction in client's urinary catheter continues after manual irrigation D. Client reports a pain rating of 3 on a 0 to 10 scale

Correct Answer is C

Explanation

A) Multiple clots in the client's urinary bag:
Multiple clots in the urinary bag can be expected after a transurethral resection of the prostate (TURP) as part of the normal postoperative bleeding. While clots can cause concern if they become excessive or obstructive, they are not as immediately critical as a persistent obstruction.

B) Client reports bladder spasms when repositioning in bed:
Bladder spasms are a common postoperative symptom following TURP and can be managed with antispasmodic medications and proper catheter care. Although uncomfortable, bladder spasms do not pose an immediate threat to the client’s health.

C) Obstruction in client's urinary catheter continues after manual irrigation:
A persistent obstruction in the urinary catheter after manual irrigation is a significant concern. This can indicate a severe blockage that might prevent urine from draining, leading to bladder distention, potential damage to the surgical site, and increased risk of infection. Immediate intervention is required to resolve the obstruction and ensure proper urinary drainage.

D) Client reports a pain rating of 3 on a 0 to 10 scale:
A pain rating of 3 on a 0 to 10 scale indicates mild pain, which is common in the postoperative period and can be managed with analgesics. While pain management is important, this level of pain does not constitute an urgent issue requiring immediate reporting to the provider.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is monitoring a client who is taking captopril and has developed swelling of the lips and tongue. Which of the following actions should the nurse plan to take to manage this adverse medication reaction?

Correct Answer is A

Explanation

A nurse is caring for a client who is 4 hr postoperative following a transurethral resection of the prostate to treat benign prostatic hypertrophy. The client has an indwelling urinary catheter. Which of the following findings should the nurse report to the provider immediately?

Correct Answer is C

Explanation

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