A nurse in an acute mental health facility observes a client having a panic atack. Which of the following interventions should the nurse implement first?

Discuss the client's feelings prior to the panic atack.

Encourage the use of positive self-talk strategies

Instruct the client to use abdominal breathing

Administer an anti-anxiety medication

Answer and Explanation

The Correct Answer is C

c. Instruct the client to use abdominal breathing.

When a client is experiencing a panic atack, the nurse's first priority is to help the client manage their symptoms and provide immediate relief. Instructing the client to use abdominal breathing is the most appropriate initial intervention.

Explanation for the other options:

a. Discuss the client's feelings prior to the panic atack. While discussing the client's feelings can be beneficial in addressing the underlying causes of anxiety, it may not be the most eﬀective immediate intervention during a panic atack. The client's focus during a panic atack is typically on managing the physical symptoms and regaining control.

b. Encourage the use of positive self-talk strategies. Positive self-talk can be helpful in managing anxiety in general, but during a panic atack, the individual may have difficulty engaging in positive self-talk due to the intensity of symptoms. Addressing the immediate physical symptoms is a priority before exploring coping strategies.

d. Administer an anti-anxiety medication. Medication administration may be necessary in some cases, but it is not the first-line intervention for managing a panic atack. Non-pharmacological interventions, such as breathing techniques, should be implemented first. If the panic atack persists or worsens despite these interventions, medication may be considered.

In summary, during a panic atack, the immediate focus should be on helping the client manage their symptoms. Instructing the client to use abdominal breathing can help promote relaxation and reduce the intensity of the panic atack.

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Correct Answer is B

Explanation

Explanation:

The nurse should respond by recommending that the parent avoids administering aspirin to the child. The use of aspirin in children, especially those under the age of 18, is associated with the risk of developing Reye's syndrome, a rare but serious condition that aﬀects the liver and brain. It is important to educate parents about the potential risks of using aspirin in children, particularly when they have a fever. Instead, the nurse should advise the parent to use appropriate dosages of acetaminophen or ibuprofen based on the child's weight and follow the label directions for administration.

Option a suggests following the label directions based on the child's weight, which may not specifically address the use of aspirin in children and the risk of Reye's syndrome. Option c, stating that the child will require an antibiotic if she develops a fever, is incorrect because antibiotics are not indicated for all fevers and should only be prescribed if there is an underlying bacterial infection. Option d, suggesting that the child can have two baby aspirins every 4 hours, is incorrect and contradicts the recommendation to avoid administering aspirin to the child.

A. Reassure the client that she will adjust to changes to her body. B. Contact an occupational therapist to talk with the client C. Initiate a client referral to Reach to Recovery D. Explain that surgery can restore the breast to its original appearance

Correct Answer is C

Explanation

c. Initiate a client referral to Reach to Recovery.

Explanation:

When caring for a female client who has a new diagnosis of breast cancer and expresses concerns about potential changes to her body image, the nurse should initiate a client referral to Reach to Recovery. Reach to Recovery is a program provided by the American Cancer Society that connects breast cancer patients with trained volunteers who have gone through a similar experience. These volunteers can provide emotional support, information, and resources to help the client cope with the physical and emotional changes that may occur due to breast cancer and its treatment.

Explanation for the other options:

a .Reassure the client that she will adjust to changes to her body:

While providing reassurance is important, it may not be sufficient to address the client's concerns about potential changes to her body image. Initiating a referral to Reach to Recovery can provide the client with additional support and resources tailored to her specific needs.

b. Contact an occupational therapist to talk with the client:

While an occupational therapist may have valuable input on certain aspects of the client's care, such as functional abilities and adaptations, initiating a referral to Reach to Recovery would be more appropriate for addressing the client's concerns related to body image.

d. Explain that surgery can restore the breast to its original appearance:

While surgery options such as breast reconstruction can restore the breast to a similar appearance, it is not appropriate for the nurse to make guarantees about the outcome or appearance of the breast after surgery. Every individual's situation is unique, and the decision to undergo surgery and the results of such procedures are dependent on various factors. Referring the client to Reach to Recovery would be more beneficial in addressing her concerns holistically.

In summary, when a client with a new diagnosis of breast cancer expresses concerns about potential changes to her body image, the nurse should initiate a client referral to Reach to Recovery. This program can provide the client with the necessary emotional support and resources to navigate the physical and emotional changes associated with breast cancer and its treatment.

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A nurse in an acute mental health facility observes a client having a panic atack. Which of the following interventions should the nurse implement first?

Nursing Test Bank

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