The nurse receives reports on four clients. Which client should the nurse assess first?

Chest pressure with diaphoresis and nausea suggests possible acute coronary syndrome and requires immediate assessment. Meal assistance, insomnia, and discharge teaching are important but less urgent. Use ABCs, acute change, and potential instability to prioritize.

In-depth explanation

<span class='merci-scenario-label'>Clinical Judgment</span><br>Prioritization favors acute, potentially life-threatening changes over routine needs.<br><br><span class='merci-scenario-label'>Memory Tip</span><br>Chest pressure plus sweating equals assess first.

Clinical scenario

<span class='merci-scenario-label'>Clinical Practice Guide</span><br>Acute coronary symptoms may include chest discomfort, sweating, nausea, shortness of breath, and pain radiating to the arm, jaw, or back.<br><br><span class='merci-scenario-label'>Caution</span><br>Do not wait for classic crushing chest pain before assessing possible cardiac ischemia.

Key concepts

• Triage — Sorting clients by urgency and risk to determine care priority.
• Diaphoresis — Profuse sweating that can occur with pain, shock, or cardiac ischemia.
• Acute Coronary Syndrome — A spectrum of conditions caused by sudden reduced blood flow to the heart.