A client is experiencing a panic attack. Which action should the nurse take first?

Correct Answer: A

Rationale: During a panic attack, the immediate priority for the nurse is to provide support and reassurance to the client. Remaining with the client helps establish a sense of safety and trust, which can help calm the client during an episode of panic. Administering medication, encouraging physical activity, and deep breathing techniques are beneficial interventions, but offering reassurance and support should be the initial step to address the immediate emotional distress and anxiety experienced by the client.

Correct Answer: C

Rationale: In alcohol withdrawal syndrome, nurses must prioritize symptoms based on the potential for life-threatening complications, following the ABCs (Airway, Breathing, Circulation) framework to address immediate physiological instability. Increased heart rate (tachycardia) is the priority because it reflects severe autonomic hyperactivity, a hallmark of withdrawal that can rapidly escalate to cardiovascular collapse, arrhythmias, hypertension, or even delirium tremens (DTs), which has a high mortality rate if untreated. Step 1: Recognize that alcohol withdrawal disrupts the central nervous system's GABA-glutamate balance, leading to sympathetic overdrive; tachycardia is an early indicator of this, often exceeding 100 beats per minute and signaling the need for urgent intervention like benzodiazepines (e.g., lorazepam or diazepam) to prevent progression to seizures or DTs. Step 2: Assess vital signs holistically—tachycardia may accompany fever, diaphoresis, and agitation, requiring immediate monitoring and possible transfer to a higher care level. Step 3: Evidence from clinical guidelines (e.g., American Society of Addiction Medicine) emphasizes stabilizing circulation first, as untreated tachycardia increases risks of myocardial ischemia or stroke, especially in clients with comorbidities like liver disease from chronic alcohol use. Now, examining the incorrect choices: Insomnia (A) is a common neuropsychiatric symptom in mild to moderate withdrawal, stemming from disrupted sleep architecture due to rebound excitation in the brain. While distressing and contributing to overall discomfort, it does not pose an immediate threat to life or circulation; it can be managed supportively with environmental adjustments, reassurance, or short-term hypnotics after stabilizing more critical symptoms, but addressing it first could delay intervention for potentially fatal issues. Nausea and vomiting (B) arise from gastrointestinal irritation and central emetic center stimulation during withdrawal, leading to dehydration or aspiration risk if severe. However, these are typically managed with antiemetics (e.g., ondansetron) and fluid replacement, and while they warrant attention to prevent electrolyte imbalances, they are not as acutely dangerous as cardiovascular instability. Prioritizing them over tachycardia could overlook the systemic sympathetic surge that drives multi-organ risks. Tremors (D), often fine and generalized, result from cerebellar and peripheral nerve hyperexcitability and are a classic early sign of withdrawal (appearing 6-12 hours after last drink). They are uncomfortable and may impair mobility, increasing fall risk, but they are not immediately life-threatening and often resolve with the same benzodiazepine therapy used for tachycardia. Focusing on tremors first might ignore the broader autonomic crisis, as tremors can persist without rapid decompensation, whereas unchecked tachycardia demands prompt action to avert cardiac events. In summary, prioritizing increased heart rate ensures the nurse addresses the most urgent threat to hemodynamic stability, aligning with triage principles in emergency care for alcohol withdrawal, where timely pharmacologic control can prevent escalation in up to 5-15% of cases that progress to severe forms. This approach not only stabilizes the client but also allows safer management of secondary symptoms like insomnia, nausea, or tremors.

Correct Answer: C

Rationale: When a client with schizophrenia is experiencing auditory hallucinations, providing reality-based feedback is a therapeutic intervention. This helps the client differentiate between what is real and what is not, aiding in reducing the impact of hallucinations. Encouraging the client to discuss the voices may validate the hallucinations, telling the client that the voices are not real dismisses their experience, and distracting the client may not address the underlying issue of the hallucinations.

Correct Answer: A

Rationale: Defense mechanisms are psychological strategies employed unconsciously to protect individuals from anxiety and threats to their psychological or biological integrity. This makes choice A correct because defense mechanisms fundamentally serve to reduce distress and maintain emotional equilibrium when facing internal or external stressors. They operate automatically, often without conscious awareness, to shield the individual from perceived harm or discomfort, whether it stems from emotional conflict, societal pressures, or personal insecurities. Choice B is incorrect because, while defense mechanisms are rooted in psychoanalytic theory, they are not exclusively controlled by the id. Freud’s structural model of the psyche describes the id as the primitive, instinctual part of the mind, but defense mechanisms are mediated by the ego, which balances the demands of the id, superego, and reality. The ego employs these mechanisms to manage conflicts between primal urges (id) and moralistic constraints (superego), ensuring psychological stability. Thus, attributing defense mechanisms solely to the id oversimplifies their role and misrepresents their function within the broader framework of the psyche. Choice C is incorrect because defense mechanisms are specifically aimed at reducing anxiety, not increasing it. These unconscious processes help individuals cope with uncomfortable emotions, thoughts, or situations by distorting, denying, or reframing reality. For example, repression pushes distressing memories out of conscious awareness, while rationalization provides logical but false explanations for unacceptable behaviors—both serving to alleviate emotional distress. If defense mechanisms increased anxiety, they would fail their primary purpose of maintaining psychological homeostasis. Choice D is partially misleading because defense mechanisms are not exclusively "protective devices for the superego." While they can help manage the superego’s moralistic demands (e.g., reducing guilt through projection or sublimation), their scope extends beyond the superego. The ego employs defense mechanisms to reconcile conflicts between the id’s impulses, the superego’s moral standards, and external reality. Therefore, describing them solely as tools for the superego ignores their broader role in managing overall psychological distress and maintaining ego integrity. In summary, defense mechanisms are unconscious strategies used to mitigate anxiety and protect psychological well-being (A), mediated by the ego rather than the id alone (B), and serve to reduce—not increase—emotional distress (C). While they may interact with the superego, they are not limited to protecting it (D), as their function encompasses a wider range of psychological balancing acts. Understanding these distinctions clarifies their role in mental health and behavior.

Correct Answer: C

Rationale: When assessing a client with moderate anxiety, the nurse should anticipate signs such as fidgeting, laughing inappropriately, and nail biting. These behaviors are common manifestations of increased stress levels. Palpitations, on the other hand, are more commonly associated with severe anxiety or panic attacks. Other symptoms of severe anxiety may include restlessness, difficulty concentrating, muscle tension, and sleep disturbances.