A nurse is contributing to the plan of care for a client who experiences panic attacks.
Which of the following strategies should be included for implementation during an attack?

Assist the client with evaluating their coping mechanisms.

Explore with the client what precipitates an attack.

Minimize environmental stimuli.

Encourage the client to set goals.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Assisting the client with evaluating their coping mechanisms is a helpful strategy for preventing future panic attacks and managing anxiety in the long term. However, during an acute panic attack, the client's ability to think rationally and evaluate their coping skills is significantly impaired. The immediate focus should be on reducing overwhelming stimuli.

Choice B rationale

Exploring with the client what precipitates an attack is crucial for identifying triggers and developing preventative strategies. However, during an active panic attack, the client is experiencing intense anxiety and may not be able to effectively process or articulate potential triggers. This intervention is more appropriate for periods between attacks.

Choice C rationale

Minimizing environmental stimuli is a key intervention during a panic attack. Panic attacks involve a surge of intense fear and anxiety, often accompanied by sensory overload. Reducing noise, bright lights, and excessive activity in the immediate surroundings can help decrease the client's distress and promote a sense of calm and safety.

Choice D rationale

Encouraging the client to set goals is a therapeutic strategy aimed at promoting a sense of control and accomplishment, which can be beneficial for overall mental health and managing anxiety in the long term. However, during an acute panic attack, the client is likely overwhelmed and unable to focus on goal setting. The immediate priority is to reduce their acute anxiety.

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Correct Answer is ["B","C","E"]

Explanation

Choice A rationale

Maintaining confidentiality is important in the nurse-client relationship; however, the duty to protect a third party from harm overrides confidentiality. When a client expresses intent to harm someone, the nurse has a legal and ethical obligation to take action to prevent that harm.

Choice B rationale

Notifying local law enforcement about the client's threat is a necessary step to ensure the safety of the potential victim. Law enforcement has the authority and resources to intervene and assess the situation, potentially preventing harm. This aligns with the duty to warn.

Choice C rationale

Preventing the client from leaving the facility is crucial to ensure the safety of the intended victim and to further assess the client's mental state. The client's stated intention to harm someone indicates a potential crisis that requires immediate intervention and prevents them from acting on their threat.

Choice D rationale

Asking for the client's consent to notify the friend is not the appropriate immediate action when there is a direct threat of harm. The safety of the potential victim takes precedence over the client's autonomy in this situation. Delaying notification could have serious consequences.

Choice E rationale

Assessing the client's intent and ability to carry out the threat is a critical step in determining the level of risk. This involves asking further questions about the specifics of their plan, their access to means, and their history of violence. This assessment will guide further intervention and safety measures. .

A. Keep the client's room dark at night. B. Limit the client's need to make decisions. C. Discourage visitation from the client's family. D. Provide a consistent daily routine.

Correct Answer is D

Explanation

Choice A rationale

Keeping the client's room dark at night can worsen delirium by reducing environmental cues and potentially increasing disorientation and fear. Clients with delirium benefit from a well-lit environment that helps them maintain a sense of reality and reduces the risk of misinterpreting stimuli.

Choice B rationale

Limiting the client's need to make decisions can decrease their sense of control and autonomy, potentially increasing agitation and frustration associated with delirium. While simplifying choices is helpful, completely eliminating decision-making can be counterproductive to their engagement and orientation.

Choice C rationale

Discouraging visitation from the client's family can increase the client's feelings of isolation and anxiety, which can exacerbate delirium. Familiar faces and voices can provide comfort and reassurance, aiding in orientation and reducing agitation.

Choice D rationale

Providing a consistent daily routine helps to orient the client with acute delirium to time and place, reducing confusion and anxiety. Predictable patterns of activity, such as meals, hygiene, and rest, offer structure and familiarity, which can stabilize cognitive function and promote a sense of security.

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A nurse is contributing to the plan of care for a client who experiences panic attacks.Which of the following strategies should be included for implementation during an attack?

Nursing Test Bank

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Correct Answer is D

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A nurse is contributing to the plan of care for a client who experiences panic attacks.
Which of the following strategies should be included for implementation during an attack?