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Zorluk: KolayBehavioral 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.Cevap
  4. D
    Call for security staff to prepare for the immediate application of physical restraints.

Cevap

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.

Adım Adım Çözüm

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.

Anahtar Kavram

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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Behavioral Interventions

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