A nurse is caring for a 45-year-old client with generalized anxiety disorder (GAD) who reports persistent worry about multiple life events and physical symptoms including muscle tension and fatigue. Which nursing intervention should the nurse implement first?
1Encourage the client to avoid situations that trigger anxiety
3Refer the client to a psychiatrist for medication evaluation
4Teach the client deep breathing and progressive muscle relaxation techniques✓ 정답
해설
Teaching relaxation techniques is priority as it provides immediate, non-pharmacological coping skills for anxiety. Other options are less appropriate: avoidance worsens anxiety (choice 1), medication requires assessment (choice 2), and referral is not the first step (choice 3).
Clinical Judgment
This question asks about the priority nursing intervention for anxiety symptoms in a patient with Generalized Anxiety Disorder (GAD). The core issue is that symptoms like "persistent worry" and "muscle tension, fatigue" are currently ongoing, and you need to find a non-pharmacological, self-management intervention that the nurse can implement immediately. Option 4 is the first-line intervention that provides immediate symptom relief and gives the patient a sense of control. Other options may be necessary depending on the situation, but they are not the top priority within the nurse's independent scope of judgment for directly addressing the current symptoms.
Memory Tip:
A helpful mnemonic for remembering the priority is Empower before Escalate. Interventions that Empower the patient (teaching relaxation techniques) are considered before interventions that Escalate the situation (reporting to a physician, administering medication).
KR vs US:
In Korean clinical settings, the focus for anxiety symptoms might be on reporting to a physician and obtaining a medication order. In contrast, in US NCLEX and nursing practice, the scope of independent nursing judgment and intervention is broader, prioritizing non-pharmacological symptom management and patient education. "Teaching" is emphasized as a core nursing role.
임상 시나리오
Clinical Practice Guide
When caring for GAD patients, relaxation technique education should be conducted in a structured manner. First, teach simple Deep Breathing (4-7-8 breathing method: inhale for 4 seconds, hold for 7 seconds, exhale for 8 seconds), then guide them through Progressive Muscle Relaxation (PMR). PMR systematically progresses from toes to head or vice versa, tensing major muscle groups for 5 seconds and then fully relaxing them for 30 seconds.
Caution:
A common trap point in SATA (Select All That Apply) questions is "Encourage the client to avoid situations that trigger anxiety." This reinforces avoidance behavior and can worsen functional impairment, thus contradicting the principles of cognitive behavioral therapy (CBT) for GAD. The correct approach is "teach coping skills to help them face those situations."
핵심 개념
Generalized Anxiety Disorder — Generalized anxiety disorder. An anxiety disorder characterized by excessive and difficult-to-control worry about various everyday life events lasting for at least 6 months, accompanied by physical symptoms (muscle tension, fatigue, restlessness, etc.).
Progressive Muscle Relaxation — Progressive muscle relaxation. A technique that systematically tenses and then relaxes the major muscle groups of the body, used as a non-pharmacological intervention to reduce physical tension and anxiety.
Deep Breathing Exercises — Deep breathing exercise. A technique that activates the parasympathetic nervous system by breathing slowly and deeply, calming the sympathetic nervous system's 'fight-or-flight response' and immediately relieving physical symptoms of anxiety.
Non-pharmacological Intervention — Non-pharmacological intervention. An approach to managing symptoms or improving health conditions without using medication. It includes education, counseling, relaxation techniques, exercise, etc., and can often be implemented within the scope of a nurse's independent judgment.
Self-management — Self-management. The ability and skills for a patient to independently monitor and cope with their own health condition and symptoms. It is one of the important goals of nursing intervention, contributing to the improvement of patient autonomy and quality of life.