he nurse observes the client experiencing a panic attack in the day room in the behavioral health unit. Which is the priority action by the nurse?

Educate the client in ways to prevent a future panic attack.

Take the client for a walk around the unit

Stay with the client and maintain a safe environment

Redirect the client to an activity or task

Answer and Explanation

The Correct Answer is C

During a panic attack, the client may experience intense fear and anxiety, accompanied by physical symptoms such as rapid heart rate, shortness of breath, and trembling. The most critical action the nurse should take is to stay with the client and provide support. By remaining present, the nurse can help the client feel safe and reassured, while also monitoring their condition for any signs of worsening distress or the need for further intervention. Maintaining a safe environment is also crucial to prevent any harm to the client or others. Once the immediate crisis is managed and the client starts to calm down, the nurse can then proceed with other interventions, such as education on coping strategies or engaging in activities to redirect their focus. However, in this situation, the priority is to provide immediate support and ensure the client's safety.

The following are incorrect because:

Educate the client in ways to prevent a future panic attack: While education on preventing future panic attacks is important, it is not the priority action during an ongoing panic attack. The client is currently in distress and needs immediate support and assistance in managing the panic attack. Education can be provided at a later time when the client is calmer and more receptive to learning.

Take the client for a walk around the unit: Taking the client for a walk may be a beneficial intervention to help reduce anxiety and promote relaxation in some situations. However, during an active panic attack, the client may be experiencing significant distress and physical symptoms that can make movement difficult or exacerbate their symptoms. It is essential to prioritize the client's immediate needs and provide a supportive environment before considering other activities or interventions.

Redirect the client to an activity or task: Redirecting the client to an activity or task may be helpful in some situations to distract them from their anxiety. However, during a panic attack, the client may find it challenging to engage in activities or focus on tasks due to their heightened state of anxiety. Redirecting their attention without addressing their immediate distress may not be as effective or appropriate as providing support and maintaining a safe environment.

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Correct Answer is ["1"]

Explanation

To calculate the amount of mL the nurse should administer, we can use a proportion based on the available concentration of digoxin (Lanoxin) and the prescribed dose.

The available concentration is 0.5 mg/2 mL, which means there are 0.5 mg of digoxin in 2 mL of solution.

The prescribed dose is 0.25 mg.

Now we can set up the proportion:

0.5 mg / 2 mL = 0.25 mg / x mL

Cross-multiplying, we have:

0.5 mg * x mL = 2 mL * 0.25 mg

0.5x = 0.5

Dividing both sides by 0.5, we get:

x = 0.5 / 0.5

x = 1

Therefore, the nurse should administer 1 mL of digoxin (Lanoxin) to deliver a dose of 0.25 mg.

A. "Set firm limits and boundaries for the client." B. “Tell the client that you are going to report to the director of the unit.” C. "Walk away and have someone else take care of the client." D. "It happens frequently so just ignore it they will stop."

Correct Answer is A

Explanation

When encountering a client who is sexually aggressive, it is important for the nurse to establish firm limits and boundaries to ensure the safety and well-being of both the client and the healthcare team. This response promotes the maintenance of a therapeutic environment and helps prevent potential harm to the client, staff, and other patients.

the other choices are incorrect:

1. "Tell the client that you are going to report to the director of the unit." While it is important to report any concerning behaviors or incidents to the appropriate personnel, simply informing the client about reporting to the director may not be the most effective initial response. Prioritizing immediate actions to ensure safety and setting boundaries is crucial before involving higher-level staff.

2. "Walk away and have someone else take care of the client." Leaving the situation and passing the responsibility to someone else without addressing the issue directly is not an appropriate response. It is the nurse's responsibility to provide care and manage challenging situations within their scope of practice and training. Collaboration and support from the healthcare team may be sought, but abandoning the client is not an acceptable approach.

3. "It happens frequently, so just ignore it; they will stop." Ignoring sexually aggressive behavior is not an appropriate response. Such behavior should be taken seriously and addressed promptly to ensure the safety and well-being of everyone involved. Ignoring the behavior may enable its continuation and potentially lead to further harm or escalation of the situation.

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he nurse observes the client experiencing a panic attack in the day room in the behavioral health unit. Which is the priority action by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Order, digoxin (Lanoxin) 0.25 mg IM daily. Available digoxin (Lanoxin) 0.5 mg/2 mL How many mL will the nurse administer?

Correct Answer is ["1"]

Explanation

A novice nurse is beginning work on a behavioral health unit and states to the preceptor, "What if I encounter a client that is sexually aggressive? Which is the appropriate response by the preceptor?

Correct Answer is A

Explanation

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