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Question

Difficulty: EasyBehavioral Interventions

A client on the inpatient psychiatric unit is experiencing severe anxiety. They are pacing rapidly, hyperventilating, and frantically stating, "I feel like I am going to die!" Which of the following is the priority nursing action?

  1. A
    Ask the client to explain exactly why they feel like they are going to die.
  2. B
    Instruct an unlicensed assistive personnel (UAP) to evaluate the client's respiratory rate.
  3. Remain with the client and speak using a calm, reassuring voice.Answer
  4. D
    Call for security staff to prepare for the immediate application of physical restraints.

Answer

Remain with the client and speak using a calm, reassuring voice.
The correct action provides immediate support and safety. A client with severe anxiety may feel out of control and extremely fearful. The physical presence of a nurse who remains calm helps to ground the client, reduce isolation, and prevent further escalation of panic. This represents the least restrictive and most therapeutic initial behavioral intervention.

Step-by-Step Solution

1
Assess the client's current behavioral and emotional state.
The client is experiencing severe panic-level anxiety, demonstrated by rapid pacing, hyperventilation, and feelings of impending doom.
Understanding the severity of the anxiety dictates the most appropriate and immediate intervention.
2
Determine the least restrictive, most therapeutic initial intervention to ensure safety.
Providing a physical presence and maintaining a calm demeanor are selected as the first-line strategies.
A client in severe panic cannot process complex information or answer probing questions; a calm, grounding presence is the priority.

Key Concept

During severe panic or anxiety, the nurse's primary behavioral intervention is to provide a safe environment by remaining with the client and using a calm, directive approach.
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Topics

Behavioral Interventions

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