A nurse is caring for a client experiencing panic-level anxiety. The nurse understands which of the following nursing actions should be considered a priority?

Correct Answer: B

Rationale: The correct answer is B because staying with the client and reducing stimuli helps provide a sense of safety and security, essential in managing panic-level anxiety. This action can prevent the situation from escalating. Choice A is incorrect as leaving the client alone can worsen their anxiety. Choice C is incorrect because focusing on the trigger may not be immediately helpful in managing the acute anxiety episode. Choice D is also incorrect as guiding through relaxation techniques may not be effective during a panic attack where the client may not be receptive.

Correct Answer: B

Rationale: The correct answer is B. Ensuring the child does not receive an injury from body movements is the best nursing action because safety is the top priority when dealing with a child exhibiting self-injurious behaviors like headbanging and spinning. By preventing injuries, the child's well-being is prioritized. Choice A is incorrect because instructing the child to follow directions may not be effective if the child is non-responsive due to their autism spectrum disorder. Choice C is incorrect as placing the child in seclusion is not recommended for managing behaviors related to autism spectrum disorder. It does not address the underlying cause and can lead to further distress. Choice D is incorrect as showing the child how to maintain eye contact may not be feasible or effective at that moment, especially if the child is exhibiting self-injurious behaviors.

Correct Answer: C

Rationale: The correct answer is C. Physical neglect is characterized by a lack of adequate care or supervision, resulting in a child's basic needs not being met. The assessment data provided in choice C, such as frequent absences, dirty clothes, withdrawal, and fatigue, are indicators of physical neglect. Absences may be due to lack of attention to the child's well-being, dirty clothes suggest poor hygiene care, and withdrawal and tiredness can stem from emotional neglect and lack of proper nutrition or sleep. Choices A, B, and D are not indicative of physical neglect. Choice A relates to sexual behavior knowledge, choice B to emotional well-being, and choice D to physical abuse.

Correct Answer: C

Rationale: The correct answer is C: Place on one-on-one, constant observation to ensure she does not harm herself. This is the priority nursing intervention because the client is at high risk for self-harm, as evidenced by hearing voices telling her to cut herself and already having marks on her wrists. Since she will not contract for safety, one-on-one observation is necessary to prevent harm. Removing plastic utensils (choice A) may not be sufficient to prevent self-harm. Conducting 15-minute checks (choice B) is not appropriate given the level of risk. Seclusion (choice D) is a restrictive intervention and should only be used as a last resort when less restrictive measures are insufficient. Constant observation ensures immediate intervention if self-harm is attempted, making it the most appropriate intervention in this scenario.

Correct Answer: A

Rationale: The correct answer is A because the client's statement of feeling that his faith has failed him and refusal to attend church indicate anger, which is a stage of grief according to Kubler-Ross. The client is expressing frustration and resentment towards his faith. Choice B reflects acceptance and preparation for death, not anger. Choice C shows a coping mechanism of setting a future goal, which is a form of denial or bargaining, not anger. Choice D reflects bargaining with God, which is another stage of grief, not anger. In summary, the other choices do not specifically demonstrate anger as a grief state according to Kubler-Ross, making choice A the correct answer.