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Difficulty: MediumMental Health Concepts

During a routine assessment on a medical unit, a client with a history of panic disorder suddenly removes their blood pressure cuff, begins hyperventilating, and states, 'I cannot breathe in here, the walls are shrinking!' The client is currently receiving continuous intravenous (IV) fluids for cellulitis. Which action is the priority for the practical nurse (PN) to take?

  1. A
    Reassure the client that they are in a safe environment and nothing terrible will happen.
  2. B
    Apply soft wrist restraints to prevent the client from dislodging the continuous IV line.
  3. C
    Ask the client to explain exactly why they feel like the walls are shrinking.
  4. Remain with the client while using a calm demeanor and short, simple sentences.Answer

Answer

The priority nursing action is to remain with the client while maintaining a calm demeanor and communicating with short, simple sentences.
During panic-level anxiety, the client experiences a severe narrowing of the perceptual field, rendering them unable to process complex information or instructions. Remaining with the client promotes physical and emotional safety. Because cognitive function is temporarily impaired, using a calm demeanor along with short, simple, and direct sentences is the only effective communication strategy.

Step-by-Step Solution

1
Assess the client's current behavioral and psychological state.
The client is experiencing panic-level anxiety, evidenced by hyperventilation, a sense of impending doom, and an inability to perceive the environment accurately.
Recognizing the severe level of anxiety determines the appropriate intervention, as clients in panic cannot process complex information or rational thought.
2
Determine the safest and most therapeutic immediate intervention.
The nurse must provide an immediate sense of security by staying in the room, reducing environmental stimuli, and giving clear, concise directions.
Leaving a panicked client alone increases their terror and risk of injury, while lengthy or logical explanations will not be comprehended.

Key Concept

Nursing Management of Severe Anxiety and Panic
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Mental Health Concepts

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