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Question

Difficulty: MediumStress Management

A client presents to the clinic following a sudden, traumatic workplace incident. The client is pacing rapidly, wringing their hands, and states, "I cannot think straight. I am going to lose my mind!" The client's respiratory rate is 32 breaths per minute. Which of the following is the priority nursing intervention?

  1. Escort the client to a quiet, low-stimulus environment and remain with them.Answer
  2. B
    Reassure the client that they are safe and will not lose their mind.
  3. C
    Ask the client to describe the workplace incident in detail.
  4. D
    Teach the client how to perform progressive muscle relaxation.

Answer

The priority intervention is to escort the client to a quiet, low-stimulus environment and remain with them to decrease sensory overload and ensure physical and emotional safety.
When a client is in a state of severe anxiety or an acute stress response, their perceptual field is severely narrowed. They are unable to process complex information, engage in deep conversation, or learn new skills. The immediate priority is to reduce sympathetic nervous system arousal by decreasing environmental stimuli and ensuring safety. Remaining with the client provides a sense of security and demonstrates a calming presence without overwhelming them.

Step-by-Step Solution

1
Assess the client's level of anxiety based on clinical presentation.
The client is exhibiting signs of severe anxiety or panic, including rapid pacing, hand-wringing, tachypnea (32 breaths per minute), and an inability to think clearly.
Identifying the severity of the stress response dictates the appropriate nursing intervention.
2
Determine the client's cognitive capacity at this level of stress.
In severe anxiety, the perceptual field is greatly narrowed, and the ability to problem-solve or learn is significantly impaired.
This rules out interventions that require teaching, complex communication, or insight-oriented exploration of feelings.
3
Select the immediate priority action.
Moving the client to a quiet environment and providing a steady, non-threatening physical presence.
Immediate safety and symptom reduction are the highest priorities; a low-stimulus environment helps de-escalate the sympathetic nervous system response.

Key Concept

Acute Stress Response and Severe Anxiety Interventions
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Topics

Stress Management

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