A nurse is caring for a client who has panic disorder. The client tells the nurse she is suddenly feeling very apprehensive, has a sense that something catastrophic is going to happen, and that she sees bugs flying around her room. Which of the following actions should the nurse take first?
Reinforce reality with the client.
Instruct the client to take deep breaths.
Assist the client to identify the cause of the anxiety.
Administer an antianxiety medication to the client.
The Correct Answer is B
A. Reinforce reality with the client. While reinforcing reality can help in addressing the client's hallucinations (seeing bugs), it may not be the immediate priority when the client is experiencing severe panic.
B. Instruct the client to take deep breaths: Helping the client to take deep breaths can provide immediate relief from acute anxiety by promoting relaxation and helping to reduce the physiological symptoms of panic. Once the client is calmer, other interventions can be considered.
C. Assist the client to identify the cause of the anxiety: Insight into triggers is more appropriate after the acute episode resolves.
D. Administer an antianxiety medication to the client: While this may be necessary, it is not the immediate first action in this scenario.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D"]
Explanation
A. Why don't you leave? This question can come across as judgmental and may make Jane feel defensive or unsupported.
B. Is there a safe place to go if you need to? Asking about a safe place respects her autonomy and helps assess her safety plan.
C. Do you have children, and are they safe? Ensures the welfare of potential dependents who may also be at risk.
D. Are you concerned about your safety? Allows Jane to express concerns about her current situation without feeling pressured.
E. You can get help; we can hide you! Offering to "hide" someone could create unrealistic expectations and might compromise her safety.
F. Who is hurting you? This is enough now! This confrontational approach may escalate Jane’s fear and deter her from sharing information.
G. Please stop the madness. This is dismissive and lacks empathy, making it highly inappropriate in a trauma-informed care approach.
Correct Answer is B
Explanation
A. The client explains they are not planning to leave their home: This indicates denial or hesitation, which does not reflect engagement with the safety plan.
B. The client puts the number of the crisis center into their phone. Storing the crisis center number demonstrates that the client acknowledges its importance and takes a step toward implementing the safety plan.
C. The client thinks their home will be safer now that there is a baby in the house: This reflects false hope and lack of understanding of the risks of intimate partner violence.
D. The client thanks the nurse for the information: While polite, this response does not indicate the client has taken action or internalized the safety plan.
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