A nurse is assessing a 45-year-old client who was admitted to the emergency department with complaints of chest pain, shortness of breath, and feeling like they are 'going to die.' The client's vital signs are: heart rate 120 bpm, blood pressure 150/90 mmHg, respiratory rate 28/min, and oxygen saturation 98% on room air. Laboratory results including cardiac enzymes and ECG are normal. What is the most important assessment the nurse should perform next?
1Assess for signs of myocardial infarction by obtaining a 12-lead ECG
2Evaluate the client's pain level using a 0-10 numeric pain scale
3Assess the client's anxiety level and explore precipitating factors✓ 정답
4Check for signs of respiratory distress and consider arterial blood gas analysis
해설
The client presents with classic panic attack symptoms (chest pain, dyspnea, tachycardia) and normal cardiac findings. The priority assessment is to evaluate anxiety level and triggers, as other options focus on ruled-out conditions like MI or respiratory distress.
Clinical Judgment
This question tests the Recognize Cues and Analyze Cues stages of the Clinical Judgment Measurement Model (CJMM). The key is to connect normal test results (cardiac enzymes, ECG, SpO2) with typical panic attack symptoms and prioritize a mental health issue over a life-threatening cardiac or respiratory problem. The patient's expression of "feeling like dying," restlessness, trembling, and sweating are strong indicators of anxiety. The most important next assessment is to determine the severity and cause of this anxiety.
Memory Tip
How to distinguish Panic Attack vs. Heart Attack: "For a Panic attack, the tests are Perfect (normal)." If cardiac enzymes, ECG, and oxygen saturation are normal, suspect a panic attack first.
KR vs US
In a Korean emergency room, the focus might be on physical symptoms (chest pain), potentially leading to excessive testing (repeat ECG, CT, etc.). However, the US NCLEX emphasizes performing a non-invasive assessment (anxiety evaluation) first to reduce unnecessary tests and costs, highlighting a patient-centered approach.
Clinical Practice Guide
When caring for a patient with a panic attack: 1) Move them to a safe and quiet space, 2) Guide them to breathe slowly and deeply (to prevent hyperventilation syndrome), 3) Reassure them that the current symptoms are not dangerous and are temporary, 4) Explore triggering factors (stress, caffeine, etc.) together.
Caution
In SATA (Select All That Apply) questions, options that tell a patient with a panic attack to "ignore chest pain" or "go home" are never the correct answer. An attitude of validating and acknowledging the symptoms is important.
Panic Attack (공황발작) — A condition in which sudden, intense fear or discomfort occurs, accompanied by various physical and cognitive symptoms such as palpitations, sweating, trembling, shortness of breath, and fear of death.
Anxiety (불안) — Worry about future threats, tension, and an emotional response accompanied by nervousness. Panic attacks are a symptom of anxiety disorders.
Sympathetic Nervous System Activation (교감신경계 활성화) — As a "fight or flight" response, it causes physical symptoms such as increased heart rate, elevated blood pressure, sweating, and trembling during a panic attack.
Hyperventilation (과호흡) — Rapid and deep breathing lowers the carbon dioxide level in the blood (respiratory alkalosis), which can cause dizziness, tingling, chest pain, and other symptoms.
Precipitating Factors (유발 요인) — Causes that trigger or worsen symptoms (e.g., stress, caffeine, specific situations, substance use). Must be explored during anxiety assessment.