The nurse is caring for an anxious client who has an open pneumothorax and a sucking chest wound. An occlusive dressing has been applied to the site. Which intervention by the nurse would best relieve the client's anxiety?

1. A

   Staying with the client

2. B

   Distracting the client with television

3. C

   Interpreting the arterial blood gas report

4. D

   Encouraging the client to cough and breathe deeply

Appeared in: DHS Staff Nurse - 2018 (Shift-2nd)

Explanation

• In a life-threatening emergency like an open pneumothorax, the client's primary emotional response is intense fear and anxiety, often related to the sensation of not being able to breathe and the fear of dying.
• The physical presence of a nurse provides a powerful, non-verbal message of safety, support, and continuous care, which is the most effective way to reduce acute anxiety.
• Staying with the client also serves a critical safety function, allowing the nurse to immediately detect changes in the client's condition, such as signs of a developing tension pneumothorax (e.g., tracheal deviation, severe respiratory distress, hypotension).
• This intervention addresses the client's position at the base of Maslow's hierarchy of needs—safety and security—which must be met before other interventions can be effective.

Why Other Options Were Wrong

• Option B: Distraction with television is a technique used for mild to moderate anxiety or as a diversion from chronic pain. It is wholly inadequate for the terror associated with an acute life-threatening respiratory emergency.
• Option C: Interpreting an ABG report is a vital assessment task for the nurse and healthcare team to guide medical treatment, but it does not directly comfort the client or alleviate their subjective feelings of fear.
• Option D: While deep breathing is beneficial, encouraging coughing can be harmful as it increases intrathoracic pressure, potentially worsening the pneumothorax or causing pain. This is not the primary intervention for anxiety.

Related Visual

Clinical Relevance

• Nursing practice connection: Use the key finding related to The concept tested is the prioritization of nursing interventions for a client experiencing both a physiological crisis (open pneumothorax) and a psychological crisis (severe anxiety) to guide bedside assessment, documentation, and the next nursing action.
• A core nursing responsibility in any emergency is to manage both the patient's physiological stability and their psychological distress. The two are often interlinked.
• Recognizing that a nurse's presence is a therapeutic intervention is fundamental. It builds trust and provides a critical safety net for unstable patients.
• What if? If the client's anxiety does not decrease after the nurse stays with them and they become increasingly agitated with worsening respiratory distress, the nurse must immediately assess for a tension pneumothorax. The occlusive dressing may have become fully occlusive, trapping air. The immediate action would be to lift one side of the dressing to allow trapped air to escape and notify the rapid response team.

How to Approach the Question

• First, identify the patient's condition and the associated level of acuity. An open pneumothorax is a life-threatening emergency.
• Next, identify the specific goal of the question. The question asks for the 'best' intervention to relieve 'anxiety,' not to treat the pneumothorax itself.
• Evaluate each option based on its ability to address severe anxiety in an emergency context.
• Option A (Staying with the client) is a direct psychosocial support and safety intervention.
• Option B (TV) is a distraction, which is inappropriate for this level of crisis.
• Option C (ABGs) is a diagnostic assessment, not a direct comfort measure for the patient.

Concept Tested & Keywords

• Concept Tested: The concept tested is the prioritization of nursing interventions for a client experiencing both a physiological crisis (open pneumothorax) and a psychological crisis (severe anxiety).
• Stem keywords: anxious client, open pneumothorax, sucking chest wound, occlusive dressing
• Lead-in keywords: best relieve, anxiety
• Clinical cues: The client's diagnosis of an open pneumothorax indicates a life-threatening emergency, which elevates the client's anxiety to a severe or panic level.
• Clinical cues: The question specifically asks for an intervention to relieve anxiety, requiring a psychosocial or supportive response rather than a purely physiological one.

Question ID

QfVG4O2l466FL05xymqvJJ

Copy ID

Reference Book

E6 Nursing Fundamentals Taylor p. 1032-1034

E6 Nursing Fundamentals Potter Perry 12e Part 5 p. 2-4