A client is experiencing a severe panic attack. Which nursing intervention would meet this client's immediate need?
A. Teach deep breathing relaxation exercises
B. Place the client in a Trendelenburg position
C. Stay with the client and offer reassurance of safety
D. Administer the ordered prn buspirone (BuSpar)
C
The nurse can meet this client's immediate need by staying with the client and offering reassurance of safety and security. The client may fear for his or her life, and the presence of a trusted individual provides assurance of personal safety.
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A week after a client experienced a ruptured cerebral aneurysm, he becomes extremely indecisive and has frequent episodes of incontinence. The nurse reports these events as probable
a. vasospasm. b. automatisms. c. focal seizures. d. early-stage dementia.
A 7-year-old with a head injury is hospitalized after losing consciousness from being hit in the head with a bat at baseball practice. The child was not wearing a helmet
The last set of vital signs showed heart rate 48, blood pressure 148/74, and respiratory rate 28 and irregular. The nurse suspects that these vital signs are which of the following? 1. Probably normal for this child 2. A sign of increased intracranial pressure 3. A sign that this child has a spinal cord injury 4. Typical for a sleeping child at this age
The client is restless and looks at the clock frequently during an admission interview with the nurse. Which should the nurse implement in response to the client's behavior?
1. Present the interview in written form 2. Repeat the information at another time 3. Have another person finish the interview 4. Focus on the client's physical complaints
The nurse notes scattered rhonchi when auscultating the patient's chest. How do rhonchi differ from crackles
1) Rhonchi are best heard in the periphery of the lungs. 2) Rhonchi are affected by coughing. 3) Rhonchi occur predominantly on inspiration. 4) Rhonchi have a rattle-like quality.