A 40-year-old client presents after starting a new job. One of the main functions of his role is to present new products to large groups of clients. The client expresses that he feels "terrified" of public speaking and, during his first presentation, had a racing heart and dry mouth. Which medication is a first line, as needed treatment for the client's diagnosis?

Choice A reason: Buspirone is an anxiolytic that requires 2 to 4 weeks of consistent daily dosing to achieve therapeutic effects. It is used for generalized anxiety disorder and is not effective as an "as needed" (PRN) medication for acute performance anxiety or social phobia related to specific events like public speaking. Choice B reason: While benzodiazepines like diazepam can reduce anxiety, they are generally not the first-line choice for performance-only social anxiety. They can cause sedation and cognitive impairment, which could negatively impact the client's ability to give a presentation. There is also a risk of dependency with long-term PRN use. Choice C reason: Paroxetine is a selective serotonin reuptake inhibitor (SSRI) used for the long-term treatment of social anxiety disorder. Like buspirone, it must be taken daily and takes several weeks to work. It does not provide the immediate, situational relief needed for a client who only experiences distress during public speaking. Choice D reason: Propranolol, a beta-blocker, is the first-line treatment for performance-related social anxiety when used on an as-needed basis. It works by blocking the peripheral physiological symptoms of anxiety, such as tachycardia (racing heart), tremors, and sweating. It allows the client to remain cognitively sharp while dampening the distressing physical "fight or flight" response during presentations.