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A nurse on an inpatient mental health unit is admitting a client who has panic-level anxiety. After showing the client to his room, which of the following nursing actions is most therapeutic at this time?
- A. Suggest that the client rest in bed.
- B. Remain with the client for a while.
- C. Medicate the client with a sedative.
- D. Have the client join a therapy group.
Correct Answer: B
Rationale: The correct answer is B: Remain with the client for a while. This is the most therapeutic action as it provides immediate support and reassurance to the client experiencing panic-level anxiety. Remaining with the client allows the nurse to offer a calming presence, demonstrate empathy, and help the client feel safe and supported. It also helps to establish a therapeutic relationship and can assist in de-escalating the client's anxiety.
A: Suggesting the client rest in bed may not address the client's immediate emotional needs and could be perceived as dismissive.
C: Medicating the client with a sedative should only be done after a thorough assessment by a healthcare provider and is not the initial therapeutic action.
D: Having the client join a therapy group may be overwhelming for someone experiencing panic-level anxiety and may not be the most appropriate intervention at this time.
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A nurse in the emergency department is caring for a client who reports chest pain, headache, and shortness of breath. He continues to state, “I don't know why my wife left me.” The client receives a diagnosis of anxiety. The nurse realizes the client’s findings support which level of anxiety?
- A. Mild
- B. Moderate
- C. Severe
- D. Panic
Correct Answer: D
Rationale: The correct answer is D: Panic. The client is experiencing severe physical symptoms (chest pain, headache, shortness of breath) and is unable to identify the source of his distress, which indicates a high level of anxiety. Panic level is characterized by overwhelming fear and physical symptoms that can mimic a heart attack. Mild anxiety (A) is characterized by minor discomfort, moderate anxiety (B) involves increased heart rate and muscle tension, and severe anxiety (C) includes more pronounced physical symptoms. In this case, the client's presentation aligns most closely with panic level anxiety.
A nurse is caring for a client who is experiencing acute alcohol withdrawal. Which of the following findings should the nurse expect?
- A. Hand tremors
- B. Stuporous level of consciousness
- C. Bradycardia
- D. Hypotension
Correct Answer: A
Rationale: The correct answer is A: Hand tremors. During acute alcohol withdrawal, the central nervous system is hyperexcitable due to the sudden absence of alcohol. This can lead to symptoms such as hand tremors, anxiety, agitation, and even seizures. Stuporous level of consciousness (choice B) is not expected in alcohol withdrawal, as clients typically exhibit hyperactivity. Bradycardia (choice C) and hypotension (choice D) are unlikely findings, as alcohol withdrawal commonly causes increased heart rate and blood pressure due to sympathetic nervous system activation.
Which action is most therapeutic for a client with panic-level anxiety?
- A. Suggest the client rest in bed
- B. Remain with the client
- C. Medicate the client with a sedative
- D. Have the client join a therapy group
Correct Answer: B
Rationale: The correct answer is B: Remain with the client. This is the most therapeutic action because it provides immediate reassurance and support to the client, helping to reduce feelings of isolation and fear during a panic attack. By staying with the client, you can offer comfort and help them feel safe and supported.
Choice A is incorrect as suggesting the client rest in bed may not address their immediate needs during a panic attack. Choice C, medicating the client with a sedative, may provide short-term relief but does not address the underlying causes of the anxiety. Choice D, having the client join a therapy group, is not suitable during a panic attack as the client needs immediate support and intervention.
A nurse is caring for a newly admitted client who has obsessive-compulsive disorder (OCD). Which of the following actions should the nurse take first?
- A. Discuss alternative coping strategies with the client.
- B. Identify precipitating factors for ritualistic behaviors.
- C. Instruct the client on relaxation techniques for use when anxiety increases.
- D. Provide a structured activity schedule for the client.
Correct Answer: B
Rationale: The correct answer is B: Identify precipitating factors for ritualistic behaviors. This is the first action the nurse should take because understanding the triggers for the client's ritualistic behaviors is essential in developing an effective care plan. By identifying these factors, the nurse can work with the client to address them and potentially reduce the frequency or intensity of the OCD symptoms. Discussing coping strategies (choice A), teaching relaxation techniques (choice C), and providing a structured activity schedule (choice D) are important interventions but should come after identifying the triggers to ensure they are tailored to the individual's specific needs.
A nurse observes that a client who has depression is sitting alone in the room crying. As the nurse approaches, the client states, "I'm feeling really down and don't want to talk to anyone right now." Which of the following responses should the nurse make?
- A. "It might help you feel better if you talk about it."
- B. "I'll just sit here with you for a few minutes then."
- C. "I understand. I've felt like that before, too."
- D. "Why are you feeling so down?"
Correct Answer: B
Rationale: The correct answer is B: "I'll just sit here with you for a few minutes then." This response demonstrates empathy and support without imposing solutions or pressuring the client to talk. It acknowledges the client's feelings and offers companionship, which can provide comfort and reassurance. Choice A may pressure the client to talk, which may not be what the client needs at the moment. Choice C shifts the focus to the nurse's own experiences, which may not be helpful for the client. Choice D may come across as confrontational or dismissive of the client's emotions. Therefore, choice B is the most appropriate response in this situation.