A nurse in a mental health facility is caring for a client who is experiencing a panic level of anxiety. Which of the following actions should the nurse take?

Use short sentences when communicating with the client.

Tell the client to sit alone in a private place and reflect on the situation.

Encourage the client to talk about his feelings.

Have the client journal about what is happening to him.

Answer and Explanation

The Correct Answer is A

A. Use short sentences when communicating with the client. In a panic level of anxiety, the client has impaired concentration, perception, and understanding. Using short, simple sentences helps the client process communication more easily and reduces cognitive overload.
B. Tell the client to sit alone in a private place and reflect on the situation. A client in a panic state may feel unsafe or overwhelmed when left alone. Supervision and a calm presence are essential until the anxiety level decreases.
C. Encourage the client to talk about his feelings. Clients in a panic state are often unable to verbalize or reflect on their emotions clearly. Talking about feelings is more appropriate once the anxiety has decreased to a moderate level.
D. Have the client journal about what is happening to him. Journaling requires organized thought and concentration, which is not possible during a panic-level anxiety episode. It may be useful later, during a lower level of anxiety.

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Correct Answer is A

Explanation

A. The stoma appears dark purple in color. This is a priority finding, as it may indicate impaired circulation or necrosis of the stoma tissue. A healthy stoma should appear pink or red and moist. A dark purple or black color requires immediate evaluation.
B. The colostomy has had no output. While it is important to monitor output, it is not unusual for a new colostomy to have minimal or no output in the first 24–48 hours post-op as bowel function returns.
C. The client refuses to look at the colostomy. This is a psychosocial concern and may indicate body image issues or denial, but it is not the most urgent issue in the immediate postoperative period.
D. The client reports a pain level of 6 on a scale from 0 to 10. Pain management is important, but a pain level of 6, while needing intervention, does not take priority over a potential vascular compromise of the stoma.

A. "You should take a dose every night at bedtime." B. “You should take this medication with food." C. "You may repeat a dose after five minutes." D. “You may crush this medication if needed"

Correct Answer is C

Explanation

A. "You should take a dose every night at bedtime." Sublingual nitroglycerin is not taken on a routine schedule like bedtime. It is used as needed at the onset of chest pain or before activities that might trigger angina, not as a preventive nightly dose.
B. “You should take this medication with food." Sublingual nitroglycerin is placed under the tongue and absorbed directly into the bloodstream, bypassing the gastrointestinal system. It does not require administration with food.
C. "You may repeat a dose after five minutes." If chest pain persists after the first dose, the client may take one tablet every 5 minutes, up to a total of three doses within 15 minutes. If the pain continues after the third dose, emergency services should be contacted.
D. “You may crush this medication if needed." Sublingual tablets should never be crushed or swallowed, as this would prevent proper absorption through the oral mucosa and reduce the medication’s effectiveness in relieving acute chest pain.

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A nurse in a mental health facility is caring for a client who is experiencing a panic level of anxiety. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who had a colostomy 24 hrs ago. Which of the following findings is the nurse's priority?

Correct Answer is A

Explanation

A nurse is teaching a client about self-administration of sublingual nitroglycerin. Which of the following statements should the nurse include?

Correct Answer is C

Explanation

A nurse is documenting at a computer when a second nurse asks to use the computer to quickly document data before taking a break. Which of the following actions should the first nurse take?

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