A nurse in a mental health facility is caring for a client who reports palpitations and a sense of impending doom. Which of the following actions should the nurse take first?
Explanation & Rationale
A. Explain to the client that anxiety causes physical manifestations: While educating the client about the connection between anxiety and physical symptoms is important, it does not immediately reduce the acute distress the client is experiencing. B. Minimize environmental stimuli in the client's surroundings: Reducing environmental stimuli helps decrease sensory overload and can lower acute anxiety levels. This intervention addresses the client’s immediate physiological and psychological distress, making it the priority action. C. Explore behaviors that have helped to reduce the client's anxiety in the past: Identifying coping strategies is useful for long-term management, but it does not provide immediate relief during an acute episode of anxiety. D. Administer an anti-anxiety medication: Pharmacological intervention may be necessary, but non-pharmacological measures to reduce stimuli should be implemented first to provide rapid relief and create a calm environment before medication administration.