A triage nurse in a community urgent care center is caring for an older adult client who just received a phone call stating that their spouse of 40 years was killed in a motor vehicle collision. The client is pacing the waiting room, breathing rapidly, and repeatedly stating, "I need to go to the grocery store. He will be expecting dinner soon." Which of the following nursing interventions are appropriate at this time? (Select all that apply.)
- Guide the client to a quiet area and remain with them continuously.Answer
- Communicate using brief, simple, and direct statements.Answer
- CConfront the client's denial by gently but firmly reminding them that their spouse has died.
- DDelegate an unlicensed assistive personnel (UAP) to sit with the client while the nurse contacts family members.
- Monitor the client's respiratory status and instruct them to take slow, deep breaths.Answer
Answer
The correct interventions are to guide the client to a quiet area and remain with them, communicate using brief and simple statements, and monitor their respiratory status while encouraging deep breaths.
Appropriate interventions for a client in acute crisis with severe anxiety prioritize immediate physical and psychological safety. Remaining continuously with the client in a quiet area reduces stimulation and ensures safety. Using brief, direct statements accommodates the client's narrowed perceptual field. Monitoring respiratory status and encouraging slow breaths directly addresses the client's physical symptom of rapid breathing, preventing hyperventilation.
Step-by-Step Solution
Key Concept
During the initial phase of an acute situational crisis, nursing priorities focus on client safety, physiological stabilization, reducing environmental stimuli, and using clear, simple communication.