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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The purpose of asking the client to describe their problems during the assessment is to obtain information about their perception of the problem. By asking the client to describe their problems
in their own words, the nurse gains insight into how the client perceives and understands their current situation. This information helps the nurse to understand the client's subjective experience, their concerns, and their specific needs related to the problem. It allows for a more accurate assessment of the client's situation and helps in developing an individualized plan of care tailored to their unique needs.
● Personal needs: While understanding a client’s personal needs is important in providing care, it is not the primary purpose of this specific question. The nurse may ask other questions to gather information about the client’s personal needs.
● Communication skills: Assessing a client’s communication skills may be important in some cases, but it is not the primary purpose of this specific question. The nurse may use other methods to assess the client’s communication skills.
● Admitting diagnosis: The admitting diagnosis is typically determined by a physician and is based on medical tests and examinations. While the nurse may gather information that can contribute to determining the admitting diagnosis, it is not the primary purpose of this specific question.
Correct Answer is D
Explanation
Assessing the carotid pulse simultaneously on both sides of the neck can potentially lead to excessive pressure on the carotid arteries, which supply blood to the brain. This pressure can compromise blood flow to the brain and result in adverse effects, such as decreased blood supply and oxygenation to the brain tissues.
In clinical practice, it is generally recommended to assess the carotid pulse unilaterally, meaning one side at a time, to ensure adequate blood flow to the brain is maintained during the assessment. This allows for a proper evaluation of the pulse without interfering with the circulatory system.
The other choice are incorrect:
Femoral: Assessing the femoral pulse bilaterally at the same time is generally considered safe. The femoral artery is located in the groin area and provides blood supply to the lower
extremities. Bilateral assessment allows for comparison of pulses and evaluation of circulation in both legs.
Popliteal: The popliteal pulse is located behind the knee. Similar to the femoral pulse, assessing the popliteal pulse bilaterally at the same time is typically safe. It allows for comparison between both legs and evaluation of lower limb circulation.
Brachial: The brachial pulse is located in the upper arm and is commonly used for blood pressure measurement in clinical settings. Assessing the brachial pulse bilaterally at the same time is generally considered safe and is routinely done during blood pressure assessment.
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