A client in the emergency department is agitated and hyperventilating after an assault. What should the nurse's priority action be?

A client in the emergency department is agitated and hyperventilating after an assault. What should the nurse's priority action be?

• A. Begin to teach relaxation techniques
• B. Encourage the client to discuss the assault
• C. Remain with the client until the anxiety decreases
• D. Place the client in a quiet room alone to decrease stimulation

Answer: (C)

In the context of a client who is agitated and hyperventilating after a traumatic event, the priority action for the nurse is to remain with the client until the anxiety decreases. This choice is correct because when a client is experiencing high anxiety levels or panic, having a supportive presence can help them feel more secure and reduce their distress. The nurse provides reassurance, which is crucial in moments of acute anxiety, as it can help stabilize the client’s emotional state and may assist in normalizing their breathing. Remaining with the client also allows for immediate intervention if their condition worsens. It facilitates a safe environment where the nurse can monitor vital signs and any potential physical manifestations of anxiety. This action is foundational to building trust, which is essential in therapeutic relationships, particularly after trauma. While teaching relaxation techniques and encouraging the client to discuss the assault can play a role in subsequent care, these interventions may not be appropriate or effective when the client is in an acute state of agitation. Placing the client in a quiet room alone may reduce stimulation, but it could also heighten feelings of isolation and anxiety, making it less effective in reducing their immediate distress. Thus, the focus should first be on providing support and staying with the client during their critical moment of need

In the context of a client who is agitated and hyperventilating after a traumatic event, the priority action for the nurse is to remain with the client until the anxiety decreases. This choice is correct because when a client is experiencing high anxiety levels or panic, having a supportive presence can help them feel more secure and reduce their distress. The nurse provides reassurance, which is crucial in moments of acute anxiety, as it can help stabilize the client’s emotional state and may assist in normalizing their breathing.

Remaining with the client also allows for immediate intervention if their condition worsens. It facilitates a safe environment where the nurse can monitor vital signs and any potential physical manifestations of anxiety. This action is foundational to building trust, which is essential in therapeutic relationships, particularly after trauma.

While teaching relaxation techniques and encouraging the client to discuss the assault can play a role in subsequent care, these interventions may not be appropriate or effective when the client is in an acute state of agitation. Placing the client in a quiet room alone may reduce stimulation, but it could also heighten feelings of isolation and anxiety, making it less effective in reducing their immediate distress. Thus, the focus should first be on providing support and staying with the client during their critical moment of need