Correct Answer: D

Rationale:
Choice A is wrong because atomoxetine is not an anti-anxiety medication, but a selective norepinephrine reuptake inhibitor (SNRI) used to treat attention deficit hyperactivity disorder (ADH
D). It has no effect on reducing anxiety and can cause side effects such as insomnia, nausea, and increased blood pressure.
Choice B is wrong because encouraging the client to watch television is not a therapeutic intervention for a panic attack. Watching television can increase the stimuli in the client's environment, which can worsen anxiety. The nurse should maintain an environment with low stimulation for the client experiencing a panic attack. Dim lighting, few people, and minimal distractions can assist the nurse to decrease the client's level of anxiety.
Choice C is wrong because teaching the client how to meditate is not appropriate during a panic attack. Meditation is a relaxation technique that can be helpful for preventing or reducing anxiety, but it requires concentration and focus, which are impaired in a panic attack. The nurse should teach the client how to meditate when the client is calm and receptive, not when the client is in crisis. A client who is experiencing a panic attack has a very high level of anxiety and a diminished ability to focus. The nurse should stay with the client and remain calm and reassuring during the panic attack. This can help the client feel safe and supported, and reduce the intensity of the anxiety.

Correct Answer: A

Rationale: Maintaining the head of the bed at a 30-degree angle promotes venous drainage from the brain, reducing intracranial pressure in clients with traumatic brain injury.
Choice B is incorrect because suctioning the endotracheal tube every 2 hours is not routine; it should be done only as needed to avoid hypoxia and ICP spikes.
Choice C is incorrect because, while mannitol is used to reduce ICP, its administration is a medical order, not a nursing action, and requires monitoring for side effects.
Choice D is incorrect because hyperventilation is no longer recommended, as it can cause cerebral vasoconstriction, reducing blood flow and worsening brain injury.

Correct Answer: B

Rationale: Checking the client's blood glucose level is the first action to take, as shakiness and sweating suggest hypoglycemia (blood glucose typically <70 mg/dL) in a client with type 1 diabetes, and the glucose level will guide treatment (e.g., administering 15 g of fast-acting carbohydrates).
Choice A is wrong because administering insulin would worsen hypoglycemia; insulin is used to lower blood glucose, not treat low levels.
Choice C is wrong because a high-protein snack is not appropriate for treating hypoglycemia; fast-acting carbohydrates (e.g., juice, glucose tabs) are needed first to rapidly raise blood glucose.
Choice D is wrong because encouraging rest does not address the urgent need to correct hypoglycemia, which can progress to confusion, seizures, or unconsciousness if untreated.

Correct Answer: B

Rationale: Nausea is common in migraines, often accompanying headache. Leg pain, chest tightness, or fever are not typical.

Correct Answer: C

Rationale: The nurse should not assume that the client's hallucinations are related to medication noncompliance, as this can be perceived as accusatory and judgmental. The nurse should not focus on the duration of the hallucinations, as this is not the priority at this time. The nurse should ask the client what the voices are telling them, because this can help assess the client's risk for harm to self or others, and also show empathy and respect for the client's experience. The nurse should not invalidate the client's reality by stating that they do not hear anything, as this can cause mistrust and alienation.