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Difficulty: MediumStress Management

A client is admitted to the observation unit with atypical chest pain. Following a negative cardiac workup, the client remains visibly tense, exhibits rapid and shallow breathing, and tells the nurse, "I just cannot catch my breath when I think about all the debt I owe." What is the priority nursing action for this client?

  1. Guide the client through slow, deep-breathing exercises.Answer
  2. B
    Assure the client that because their heart is healthy, they have nothing to worry about.
  3. C
    Ask the client why their financial situation has become so overwhelming.
  4. D
    Provide the client with educational brochures on community financial assistance programs.

Answer

The priority nursing action is to guide the client through slow, deep-breathing exercises.
The client is experiencing an acute physical manifestation of stress and anxiety, indicated by rapid, shallow breathing. According to Maslow's Hierarchy of Needs, physiological needs and immediate physical stabilization take precedence. Guiding the client through deep-breathing exercises directly addresses the physiological symptom, promotes relaxation, and restores a normal respiratory pattern.

Step-by-Step Solution

1
Analyze the client's clinical presentation.
The client has a negative cardiac workup but is exhibiting rapid, shallow breathing and expressing severe psychological distress related to finances.
To identify the immediate clinical problem and rule out physiological cardiac emergencies.
2
Apply Maslow's Hierarchy of Needs to prioritize care.
The immediate physiological symptom (rapid, shallow breathing due to acute anxiety) takes precedence over long-term psychosocial or educational needs.
To determine which nursing intervention must occur first to ensure client stability.
3
Select the intervention that addresses the highest priority need.
Guiding the client through deep-breathing exercises is selected to restore a normal respiratory pattern and reduce sympathetic nervous system arousal.
To stabilize the client's immediate physical condition before addressing the underlying psychosocial stressors.

Key Concept

Prioritization of interventions for acute stress and anxiety
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Topics

Stress Management

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