When the nurse diagnoses that a client is experiencing panic-level anxiety, an intervention that
should be immediately implemented is to
a. teach relaxation techniques.
b. administer anxiolytic medication.
c. provide calm, brief, directive communication.
d. gather a show of force in preparation for physical control.
ANS: C
Calm, brief, directive verbal interaction can help the client gain control of overwhelming feelings
and impulses related to anxiety. Option A: Clients experiencing panic-level anxiety are unable to
focus on reality; thus learning is virtually impossible. Option B should be considered if option C is
ineffective. Option D: Although the client is disorganized, violence may not be imminent, ruling out
this option until other less-restrictive measures are proven ineffective.
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A community health nurse is working to empower clients of a vulnerable population. Which of the following client behaviors indicates that the nurse is achieving this goal?
A) Collaborate with their health care providers B) Demonstrate a reactive focus C) Hesitate to use resources D) View situations as non-changeable
You place an external fetal monitor on a woman in labor. Which of the following instructions would be best to give her?
A) Lie supine so the tracing does not show a shadow. B) Avoid flexing her knees so her abdomen is not tense. C) Lie on her side so she is comfortable. D) Avoid using her call bell to reduce interference.
To relieve a leg cramp, what should the client be instructed to perform?
a. Dorsiflex the foot. b. Apply a warm pack. c. Stretch and point the toe. d. Massage the affected muscle.
A home care nurse was caring for an elderly gentleman who lived with his son. The client kept falling asleep. What action is important for the nurse to take?
A. Call the physician and ask for a daytime stimulant. B. Check the medications for consistency between pills and prescribed doses. C. Suggest that the client get a TV to keep himself entertained. D. Suggest that the client sit up or even try to walk and then try to sleep at night.