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?

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

Use short sentences when communicating with the client

Have the client journal about what is happening to him

Encourage the client to talk about his feelings.

Answer and Explanation

The Correct Answer is B

Rationale:

A. Tell the client to sit alone in a private place and reflect on the situation: Clients in a panic state are overwhelmed, disorganized, and unable to focus. Leaving them alone can increase feelings of isolation and fear, worsening the anxiety.

B. Use short sentences when communicating with the client: During panic-level anxiety, the client's ability to process information is impaired. Clear, concise communication helps reduce confusion and provides a sense of control and safety.

C. Have the client journal about what is happening to him: Journaling requires introspection and cognitive organization, which are not possible when a client is in a panic state. This intervention is more appropriate once anxiety levels have decreased.

D. Encourage the client to talk about his feelings: While verbalizing emotions is therapeutic, a client in panic may not be able to articulate thoughts. The priority is to first reduce the anxiety to a manageable level using calm, simple guidance.

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Correct Answer is C

Explanation

Rationale:

A. Instruct the client to be NPO for six hours prior to the procedure: Amniocentesis is typically done under local anesthesia and does not require sedation or general anesthesia, so there is no need for the client to be NPO beforehand.

B. Instruct the client to maintain a full bladder for the procedure: A full bladder is required during early pregnancy to help lift the uterus for better visualization. However, at 22 weeks gestation, the uterus is already an abdominal organ, and a full bladder is not necessary.

C. Monitor the fetal heart rate prior to the procedure: Monitoring the fetal heart rate before an amniocentesis is essential to establish a baseline and ensure fetal well-being. It also aids in identifying any immediate changes following the procedure.

D. Place the client in Trendelenburg position during the procedure: The Trendelenburg position is not appropriate for amniocentesis. The client is typically placed in a supine or slightly tilted position to allow proper access to the uterus and avoid vena cava compression.

A. Massage the client's legs once every 8 hr while the stockings are in place B. Fold the top of the stocking over neatly C. Determine if the stockings are binding D. Apply the stockings after the client is in a chair.

Correct Answer is C

Explanation

Rationale:

A. Massage the client's legs once every 8 hr while the stockings are in place: Massaging the legs of a client at risk for thromboembolism is discouraged, as it could dislodge a clot and lead to a pulmonary embolism. Mechanical methods like stockings are preferred for promoting circulation.

B. Fold the top of the stocking over neatly: Folding the stockings creates a tourniquet effect, restricting venous return and potentially increasing the risk of venous stasis or skin breakdown. Stockings should remain flat and unfolded.

C. Determine if the stockings are binding: It’s important to assess for tightness, especially at the toes and calves, to ensure proper circulation and prevent pressure injuries. Stockings should fit snugly but not impair blood flow.

D. Apply the stockings after the client is in a chair: Stockings are most effective when applied while the client is in a supine position, before blood pools in the lower extremities. Delayed application reduces their preventive benefit.

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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

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Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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