Substance Abuse and Abuse Q 19
A woman comes into the ER in a severe state of anxiety following a car accident. The most appropriate nursing intervention is to:
A. Remain with the client.
B. Put the client in a quiet room.
C. Teach the client deep breathing.
D. Encourage the client to talk about their feelings and concerns.
Correct Answer: A. Remain with the client.
If a client with severe anxiety is left alone; the client may feel abandoned and become overwhelmed. Remain with the client at all times when levels of anxiety are high (severe or panic); reassure the client of his or her safety and security. The client’s safety is an utmost priority. A highly anxious client should not be left alone as his anxiety will escalate.
Option B: Placing the client in a quiet room is also important, but the nurse must stay with the client. Move the client to a quiet area with minimal stimuli such as a small room or seclusion area (dim lighting, few people, and so on.) Anxious behavior escalates by external stimuli. A smaller or secluded area enhances a sense of security as compared to a large area which can make the client feel lost and panicked.
Option C: Teaching the client deep breathing or relaxation is not possible until the anxiety decreases. Encourage the client’s participation in relaxation exercises such as deep breathing, progressive muscle relaxation, guided imagery, meditation and so forth. Relaxation exercises are effective nonchemical ways to reduce anxiety.
Option D: Encouraging the client to discuss concerns and feelings would not take place until the anxiety has decreased. Observe for increasing anxiety. Assume a calm manner, decrease environmental stimulation, and provide temporary isolation as indicated. Early detection and intervention facilitate modifying a client’s behavior by changing the environment and the client’s interaction with it, to minimize the spread of anxiety.