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Difficulty: MediumMental Health Concepts

While completing evening rounds in a mental health facility, a practical nurse (PN) encounters an individual pacing rapidly near the locked exit doors. The individual is hyperventilating, wringing their hands, and repeatedly stating, "I cannot breathe in here, I have to get out before the walls crush me." Which action should the PN take first?

  1. A
    Explain logically that the building is structurally sound and they are entirely safe.
  2. Remain with the individual while maintaining a nonthreatening physical distance.Answer
  3. C
    Ask the individual to explain why they feel the walls are closing in on them.
  4. D
    Gently take the individual by the arm to guide them back to their assigned room.

Answer

The correct action is to remain with the individual while maintaining a nonthreatening physical distance.
An individual experiencing severe anxiety or a panic attack is unable to process complex information and often feels a profound loss of control. The most effective initial action is to provide a calm, steady presence by remaining with the person to ensure their safety. Maintaining a nonthreatening physical distance is crucial because invading their personal space, touching them, or blocking their exit path can increase their sense of being trapped. This feeling of confinement can quickly escalate their panic or provoke a defensive, aggressive physical response.

Step-by-Step Solution

1
Assess the individual's current behavioral and emotional state.
The individual is exhibiting classic signs of severe anxiety or a panic attack, including hyperventilation, pacing, and catastrophic statements.
Recognizing the severity of the anxiety is essential to determine the safest and most effective nursing intervention.
2
Determine the immediate priority of care for this scenario.
The primary focus must be on maintaining the individual's safety, preventing escalation, and providing a non-threatening environment.
Severe anxiety completely impairs judgment, making the individual vulnerable to impulsive actions and highly reactive to perceived threats.
3
Select the nursing action that aligns with the priority of care.
Staying present offers support and ongoing observation, while keeping a physical distance prevents the individual from feeling trapped.
Providing a calm presence without intruding on personal space or demanding logical responses is the safest initial de-escalation technique.

Key Concept

Nursing Interventions for Severe Anxiety and Panic
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Topics

Mental Health Concepts

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