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.
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Correct Answer is D
Explanation
Choice A reason:
The client experiencing withdrawal symptoms should be monitored, as these symptoms can range from mild to severe. Withdrawal symptoms may include fatigue, depression, and anxiety, which are significant but generally not life-threatening. The nurse should provide supportive care and monitor the client's vital signs and emotional state.
Choice B reason:
If the client is experiencing hallucinations, this indicates a more severe level of withdrawal and possibly the presence of a stimulant-induced psychotic disorder. While hallucinations can be distressing and require intervention, they are not the highest priority when compared to the risk of self-harm or harm to others.
Choice C reason:
The risk for traumatic re-experiencing, or flashbacks, is a concern during withdrawal, particularly if the client has a history of trauma. These experiences can be highly distressing and may lead to further psychological distress. However, the immediate physical safety of the client and others takes precedence.
Choice D reason:
The risk of self-harm or harm to others is the most critical safety concern and must be prioritized. Clients withdrawing from stimulants may exhibit increased agitation, aggression, or impulsivity, which can lead to dangerous behaviors. The nurse must take immediate action to ensure a safe environment, which may include close supervision, the use of restraints, or rapid pharmacological intervention.
Correct Answer is A
Explanation
Choice A reason:
Alcohol use disorder (AUD) is associated with various workplace problems. Individuals with AUD may experience a decline in their work performance due to cognitive, emotional, and behavioral impairments caused by alcohol use. This can manifest as frequent tardiness, absenteeism, and a decrease in productivity. Moreover, alcohol use can lead to workplace injuries and conflicts, which further affect an individual's ability to perform their job effectively. Therefore, asking about the impact of alcohol use on work performance can provide insights into the extent of the disorder's effect on the client's psychosocial behaviors.
Choice B reason:
The age at which an individual begins drinking alcohol is a significant factor in the development of AUD. Studies have shown that early onset of drinking increases the risk of developing alcohol dependence later in life. While this information is valuable for understanding the client's history with alcohol, it does not directly address the current impact of alcohol use on their psychosocial behaviors.
Choice C reason:
Previous treatment for substance use disorder can indicate the severity of the client's condition and their history of seeking help. Treatment history can also reveal patterns of relapse or recovery, which are important in the management of AUD. However, this choice does not specifically inquire about the current psychosocial impact of alcohol use.
Choice D reason:
Mental health disorders often co-occur with AUD, and the presence of such disorders can exacerbate the psychosocial impact of alcohol use. While it is crucial to understand the client's overall mental health, this question does not focus on the specific effects of alcohol use on work performance and other psychosocial behaviors.
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