A home-health nurse is assessing a client who has obsessive-compulsive disorder (OCD) and finds that the client demonstrates constant repetitive cleaning. The nurse knows that this behavior is an attempt to accomplish which of the following?

A. Generalized anxiety disorder and a nursing diagnosis of fear: Generalized anxiety disorder typically involves chronic, excessive worrying and anxiety that is not limited to specific situations or triggers. The sudden and intense symptoms described in the scenario, such as lightheadedness, tremulousness, diaphoresis, tachycardia, and dyspnea, are more indicative of a panic attack rather than generalized anxiety. The nursing diagnosis of fear may not fully capture the acute and intense nature of panic symptoms.

B. Panic disorder and a nursing diagnosis of panic anxiety: This is the correct answer. Panic disorder is characterized by recurrent, unexpected panic attacks, which align with the sudden onset of symptoms described in the scenario. The nursing diagnosis of panic anxiety is appropriate as it addresses the acute distress associated with panic attacks.

C. Pain disorder and a nursing diagnosis of altered role performance: There is no indication of pain being the primary issue in this scenario. The symptoms are more indicative of a panic attack rather than a pain disorder. Additionally, altered role performance is not a priority nursing diagnosis when addressing the acute symptoms of a panic attack.

D. Altered sensory perception and a nursing diagnosis of panic disorder: Altered sensory perception is not the primary issue in this scenario, and it does not specifically address the sudden and intense symptoms described. The focus should be on the panic symptoms and the associated distress, leading to the nursing diagnosis of panic anxiety.

A. Provide personal space to respect the client's boundaries: This is the correct answer. Personal space is crucial when caring for an agitated client with paranoia. Respecting the client's need for distance helps to reduce anxiety and prevent escalation of agitation.

B. Maintain continual eye contact throughout the interview: Continuous eye contact may be perceived as confrontational and can increase anxiety, especially in individuals with paranoia. It is important to be mindful of non-verbal cues and adapt the approach to the client's comfort level.

C. Provide neon lights and soft music: Introducing external stimuli like neon lights and music may not be appropriate for an agitated client with paranoia. It could potentially exacerbate their distress. The focus should be on creating a calm and non-threatening environment.

D. Use therapeutic touch to increase trust and rapport: While therapeutic touch can be beneficial in certain situations, it may not be suitable for a client experiencing paranoia. Touch can be perceived as intrusive and may escalate agitation in this context.