A nurse is caring for a client with generalized anxiety disorder who is experiencing a panic attack. Which of the following is the nurse's priority action for this client?
Escort the client to the common area.
Contact security for possible restraints.
Stay with the client.
Stay away from the client.
The Correct Answer is C
Choice A reason:
Escorting the client to the common area is not the priority action. While being around others can sometimes be comforting, during a panic attack, the client may feel overwhelmed and exposed, which could exacerbate the situation.
Choice B reason:
Contacting security for possible restraints should be a last resort and is not the priority action. Restraints can increase anxiety and fear, potentially escalating the panic attack. The use of restraints is only considered when the client is at risk of harming themselves or others and all other interventions have failed.
Choice C reason:
Staying with the client is the priority action. During a panic attack, the client needs reassurance and a sense of safety. The nurse's presence can provide comfort. The nurse should remain calm, use a quiet voice, and avoid making any sudden movements. Implementing relaxation techniques and promoting a calming environment are also beneficial.
Choice D reason:
Staying away from the client is not the priority action. Leaving the client alone can increase feelings of isolation and fear. The nurse should provide continuous observation and support during the panic attack.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason:
Administering activated charcoal can be a treatment option in some overdose cases, particularly when the substance ingested is known to be adsorbed by charcoal. However, its effectiveness varies depending on the substance and the timing of administration post-ingestion. In the case of a stimulant overdose, activated charcoal is not the first-line treatment, especially when the specific stimulant and time of ingestion are unknown.
Choice B Reason:
Obtaining a urine sample for drug testing is important for confirming the type of stimulant ingested and can guide further treatment. However, this is not the immediate priority in an acute overdose situation where the patient's life may be at risk.
Choice C Reason:
Initiating seizure precautions is important in the management of stimulant overdose due to the risk of seizures¹. However, this is a precautionary measure and not the first action to take. The initial focus should be on assessing and stabilizing the patient's vital functions.
Choice D Reason:
Monitoring vital signs is the most critical initial step in managing a suspected stimulant overdose. Stimulants can cause severe hypertension, tachycardia, hyperthermia, and arrhythmias. Frequent monitoring allows for the early detection of life-threatening conditions and the initiation of appropriate interventions to stabilize the patient's condition.
Correct Answer is D
Explanation
Choice A reason:
Missing a dose of medication that increases serotonin levels does not typically increase the risk of serotonin syndrome. In fact, missing a dose may lead to lower levels of serotonin in the body, which is contrary to the condition of serotonin syndrome that arises from an excess of serotonin.
Choice B reason:
Taking MAOI medication alone does not inherently increase the risk of serotonin syndrome. However, combining MAOIs with other medications that affect serotonin levels can significantly increase the risk. It is crucial to avoid taking MAOIs and other serotonergic drugs concurrently without medical supervision.
Choice C reason:
Taking SNRIs as directed by a healthcare provider generally does not increase the risk of serotonin syndrome. These medications are designed to be taken regularly to manage conditions like anxiety and depression. However, any changes in dosage or frequency should be done under medical guidance to avoid any adverse effects.
Choice D reason:
Combining medications that increase serotonin levels is the primary risk factor for developing serotonin syndrome. This can occur when a patient takes multiple serotonergic drugs, such as combining an SNRI with an SSRI, certain pain medications, or even some over-the-counter drugs and supplements that increase serotonin levels. This combination can lead to an excessive accumulation of serotonin in the body, triggering the symptoms of serotonin syndrome.
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