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 B

Explanation

A. "You should not delegate this task because you have the capability to obtain clients' weights." The ability to perform a task does not mean it cannot be delegated. Delegation helps manage workload effectively as long as the task is appropriate for the role.
B. "You can delegate this task if the AP has been trained to use our scales." Weighing clients is a routine, noninvasive task that can be delegated to assistive personnel, provided they are trained and competent in using the equipment properly.
C. "You can delegate this task to an AP for new clients before performing a nursing assessment." Initial assessments require nursing judgment and should not be delegated. Data collection like weight should occur after the nurse completes the first assessment.
D. "You should not delegate this task because it requires nursing judgment." Weighing a client does not require clinical judgment and is considered appropriate for delegation to trained assistive personnel under supervision.

A. Trim the fat from red meat prior to cooking. B. Provide a diet high in protein and calories. C. Administer pancreatic enzymes 30 min after meals. D. Give the child hot foods to reduce the sense of fullness.

Correct Answer is B

Explanation

A. Trim the fat from red meat prior to cooking. Children with cystic fibrosis often have difficulty absorbing fats due to pancreatic insufficiency, but they actually need higher fat intake to meet their increased energy demands. Trimming fat is not necessary or recommended.
B. Provide a diet high in protein and calories. Children with cystic fibrosis require a high-calorie, high-protein diet to support growth, maintain weight, and compensate for the energy lost due to chronic lung infections and malabsorption.
C. Administer pancreatic enzymes 30 min after meals. Pancreatic enzymes should be given before or with meals and snacks to aid digestion. Giving them 30 minutes after a meal reduces their effectiveness.
D. Give the child hot foods to reduce the sense of fullness. There is no evidence to support using hot foods to manage fullness in cystic fibrosis. Instead, meals should be nutrient-dense and timed to optimize digestion and absorption.

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Nursing Test Bank

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