A patient is noted to have a high level of non-goal-directed motor activity, running from chair to chair in the solarium. He is wide eyed and seems terror stricken
He cries, "They're coming! They're coming!" He neither follows staff direction nor responds to verbal efforts to calm him. Which nursing response should be the highest priority? a. Reduce his fearfulness and running
b. Increase environmental stimuli
c. Respect the patient's personal space
d. Encourage clarification of feelings
A
Safety is of highest priority because the patient experiencing panic is at high risk for self-injury related to increased non-goal-directed motor activity, distorted perceptions, and disordered thoughts. Option B: The goal should be to decrease environmental stimuli. Option C is a lower priority than safety. Option D: Clarification of feelings cannot take place until the level of anxiety is lowered.
You might also like to view...
The nurse is administering eyedrops to a client with an infection in the right eye. The drops go in both eyes, and two different bottles are used to administer the drops. The nurse accidentally uses the left eye bottle for the right eye
What action by the nurse is best? a. Inform the provider of the issue. b. Obtain a new bottle of eyedrops. c. Rinse the client's right eye thoroughly. d. Wipe the left eye bottle with alcohol.
The nurse has been invited to present a program at the local parent-teacher association (PTA) meeting on recognizing and preventing illness in children. Which symptoms of urinary tract infections in preschool age children should the nurse include?
Select all that apply. A) Urinary urgency B) Elevated blood pressure C) Dysuria D) Fever E) Headache
A client admitted to a local health care facility is to undergo surgery with spinal anesthesia. Which of the following is the nurse most likely to observe when caring for this client?
A) Moderate muscle relaxation B) Loss of feeling in the lower abdomen C) Hypotension as anesthesia deepens D) Increase in the client's heart rate
Which of the following assessment findings is least helpful in identifying a cause of Ménière's disease?
A) Family history B) Allergic reactions C) Food intolerance D) Head injury