A patient who has been pacing actively approaches the nurse and blurts out, "You've got to help me! Something terrible is happening. I'm falling apart. I can't think. I can't get my breath; I feel like I'm dying
What's happening to me?!" Which of the following nursing responses would be appropriate? Select all that apply. a. "You are having a panic episode; I will stay with you until it passes.".
b. "It's almost visiting time. I'll help you get your hair combed.".
c. "Watch me; I'll show you how to calm by slowing your breathing.".
d. "Let's explore your anxiety. Tell me, what has been going on today?"
e. "I'll get you some orange juice, and we'll walk together for awhile.".
f. "Sometimes anxiety is due to fear. Do you know what you are afraid of?"
A, C, E
The patient's level of anxiety is at the severe-to-panic level. The focus of nursing care for these levels is on maintaining patient safety and reducing the level of anxiety to a more manageable level. Reassuring the patient that he is safe and staying with the patient increases his sense of security and reduces fearfulness. Showing him how to slow his breathing (as opposed to giving verbal instructions, which would be difficult for a severely anxious person to process) helps reduce his level of anxiety via a simple, concrete activity that does not require high levels of concentration. Offering a high-nutrient drink and walking with the patient addresses safety by providing for adequate nutrition and the release of physical energy. Focusing on the patient's hair ignores the issue that concerns the patient and might cause the patient to lose confidence in the ability of the staff to help him. Exploring possible factors contributing to his anxiety is desirable but likely to exceed the patient's ability to concentrate and process information while at this highest level of anxiety. The patient's anxiety level would need to be reduced before these interventions would be helpful.
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