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Difficulty: MediumCrisis Intervention

A school nurse is caring for a high school student who just witnessed a severe physical altercation between peers in the hallway. The student is pacing rapidly around the health office, demonstrating tachypnea, and shouting, "I am not safe anywhere! They are going to come after me next!" Which of the following is the priority nursing intervention?

  1. Remain with the student in a quiet area and provide brief, direct instructions to slow their breathing.Answer
  2. B
    Guarantee the student that the campus is completely secure and no one will harm them.
  3. C
    Encourage the student to verbalize the specific details of the altercation to help process the trauma.
  4. D
    Contact emergency medical services to transport the student for an acute psychiatric evaluation.

Answer

The priority intervention is to remain with the student in a quiet area and provide brief, direct instructions to help them slow their breathing.
During an acute situational crisis resulting in severe anxiety or panic, the client experiences heightened physiological arousal (such as tachypnea and pacing) and a severe inability to focus or process complex information. According to Maslow's hierarchy of needs, the priority is to address immediate physiological and safety needs. Remaining with the client ensures their physical safety and provides a grounding presence. Using brief, direct instructions to guide breathing helps stabilize the client's physiological response without overwhelming their currently impaired cognitive capacity.

Step-by-Step Solution

1
Assess the client's current level of anxiety and identify immediate physiological or safety needs.
The client is exhibiting signs of severe anxiety or panic, including rapid pacing, tachypnea, and catastrophic thinking.
Determining the phase of the crisis dictates the level of intervention required; acute panic necessitates immediate physiological and environmental stabilization.
2
Implement immediate de-escalation and stabilization techniques based on Maslow's hierarchy.
The nurse stays with the client to ensure safety, reduces environmental stimuli, and gives clear, concise directions for deep breathing.
A client in severe panic has a significantly narrowed perceptual field and cannot process complex information. A calm presence and direct guidance address acute physiological symptoms and restore a sense of safety.

Key Concept

Crisis Intervention: Acute Panic Management
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Topics

Crisis Intervention

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