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Difficulty: MediumCrisis Intervention

A college student rushes into the university health clinic, visibly trembling and crying hysterically. The student shouts, "I was just abruptly evicted from my apartment and I have absolutely nowhere to go!" The nurse notes the student is hyperventilating with a respiratory rate of 34 breaths per minute. Which of the following is the priority nursing intervention?

  1. A
    Tell the student, "Try not to worry; the university has emergency housing programs that will definitely find you a place tonight."
  2. B
    Prompt the student to immediately list any family members or friends who could provide temporary lodging.
  3. Move the student to a quiet, private area and provide direct coaching for slow, deep breathing.Answer
  4. D
    Instruct an unlicensed assistive personnel to monitor the student's respiratory status while the nurse calls the campus social worker.

Answer

The nurse should first move the student to a quiet, private area and provide direct coaching for slow, deep breathing to stabilize the acute panic response.
The correct action focuses on immediate physiological and psychological stabilization. According to Maslow's Hierarchy of Needs, the physical symptom of hyperventilation (impaired breathing pattern) is the most urgent priority. Moving the client to a quiet area reduces sensory overload, and coaching their breathing directly treats the acute panic, allowing them to eventually reach a calm state where they can discuss housing solutions.

Step-by-Step Solution

1
Assess the client's immediate physiological and psychological state.
The student is hyperventilating at 34 breaths per minute and experiencing severe acute panic due to a situational crisis.
Identifying life-threatening or severe physiological instability is always the first step in the nursing process.
2
Determine the highest priority intervention using Maslow's Hierarchy of Needs.
Physiological needs (breathing and stabilization of panic) take precedence over safety and security needs (finding housing).
Clients in acute crisis cannot effectively process information or problem-solve until their physiological arousal and panic are reduced.
3
Select the intervention that directly addresses the highest priority.
Coaching the student through slow, deep breathing in a quiet environment de-escalates the acute physical symptoms.
This action stabilizes the client, creating a foundation for subsequent therapeutic communication and problem-solving.

Key Concept

In crisis intervention, the nurse must prioritize physiological stabilization and safety (such as managing hyperventilation) before progressing to problem-solving or assessing long-term coping strategies.
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Topics

Crisis Intervention

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