A nurse is assessing a client with generalized anxiety disorder who has been experiencing increased anxiety symptoms. Which assessment finding would be the MOST concerning and require immediate nursing intervention?
1Reports of chest pain, shortness of breath, and feeling like "I'm going to die"✓ 정답
2Restlessness and difficulty concentrating on the nurse's questions
3Trembling hands and sweating palms during the interview
4Expressing worry about multiple life situations and future events
해설
Chest pain, shortness of breath, and feelings of impending doom indicate a panic attack requiring immediate assessment to rule out cardiac causes. Other options represent typical anxiety symptoms manageable with standard interventions.
Core Nursing ExplanationKey Concept Analysis: This question tests the critical nursing skill of differential assessment and prioritization in a psychiatric setting. While all options describe symptoms of anxiety, the nurse must distinguish between typical manifestations of Generalized Anxiety Disorder (GAD) and signs that could indicate a more acute, life-threatening condition like a panic attack or a medical emergency (e.g., myocardial infarction). The core principle is Key Point!Always rule out medical causes for psychiatric symptoms first (the "medical clearance" rule). Symptoms mimicking cardiac or respiratory distress require immediate intervention to ensure patient safety.
Answer Rationale: Option 1 is correct because it describes the classic triad of a panic attack: chest pain, dyspnea (shortness of breath), and a sense of impending doom ("I'm going to die"). These symptoms are severe, acute, and physiologically taxing. They require immediate nursing intervention to: 1) Assess and stabilize the patient's airway, breathing, and circulation (ABCs), 2) Rule out acute cardiac or pulmonary events, and 3) Implement panic-specific interventions (e.g., providing a calm environment, guiding breathing exercises, administering PRN anxiolytic medications as ordered). This finding represents the highest acuity.
Distractor Analysis:
Watch out for confusion! Option 2 (Restlessness and difficulty concentrating) and Option 3 (Trembling and sweating) are hallmark psychomotor and autonomic symptoms of generalized anxiety. They are expected findings in GAD and are managed with therapeutic communication, anxiety-reduction techniques, and scheduled pharmacotherapy—not immediate intervention.
Watch out for confusion! Option 4 (Expressing worry about multiple situations) describes the core cognitive symptom of GAD—excessive, uncontrollable worry. This is the defining characteristic of the disorder and is addressed through long-term psychotherapy and medication management, not immediate crisis intervention.
Related Concepts: This question integrates knowledge of anxiety disorders, crisis intervention, and medical-surgical nursing. It underscores that nurses in all settings must be vigilant for signs of physiological distress that could have an organic cause. The nursing priority is always patient safety, which begins with assessing and supporting vital functions.
Concept Summary
Concept
Description
Nursing Implication
Panic Attack
Sudden episode of intense fear with physical symptoms (chest pain, palpitations, dyspnea, trembling, paresthesias) and cognitive symptoms (fear of dying, losing control).
Immediate intervention: Ensure safety, rule out medical causes, provide calm reassurance, guide slow breathing, administer PRN meds (e.g., benzodiazepines).
Generalized Anxiety Disorder (GAD)
Chronic, excessive worry about various topics, accompanied by restlessness, fatigue, difficulty concentrating, irritability, muscle tension, sleep disturbance.
Airway, Breathing, Circulation. The foundational framework for assessing any patient's immediate needs.
Symptoms affecting breathing (dyspnea) or circulation (chest pain) take precedence over psychological distress.
Side-by-Side Comparison!
Symptom Cluster
Likely Condition
Key Differentiators & Nursing Action
Chest pain, SOB, Impending doom
Panic Attack vs. Myocardial Infarction (MI)
Panic: Pain often sharp/stabbing, location variable, associated with hyperventilation, relief with distraction/breathing. MI: Pain often crushing/pressure, radiates to arm/jaw, associated with diaphoresis, nausea, unrelieved by rest. Action:Always assess vital signs, get an EKG to rule out MI first.
Restlessness, Trembling, Worry
Generalized Anxiety vs. Akathisia (medication side effect)
Anxiety: Subjective feeling of nervousness, internal restlessness. Akathisia: Objective motor restlessness (pacing, inability to sit still), often a side effect of antipsychotics. Action: Assess medication history; akathisia may require dose adjustment or beta-blocker.
Anatomy, Physiology & Pharmacology Points
Pathophysiology: A panic attack involves a sudden, inappropriate activation of the sympathetic nervous system ("fight-or-flight" response), leading to catecholamine (epinephrine/norepinephrine) surge. This causes tachycardia, hypertension, tachypnea, and increased muscle tension.
Pharmacology - First-Line Treatments: For acute panic, short-acting benzodiazepines (e.g., lorazepam, alprazolam) may be used PRN. For long-term prevention of panic and GAD, SSRIs (e.g., sertraline, paroxetine) and SNRIs (e.g., venlafaxine) are first-line.
Rule of Thumb: "Chest pain + 'I'm dying' = Don't assume it's 'just anxiety.'" Always think ABCs and medical rule-out first.
High-Frequency NCLEX Topics
The NCLEX-RN loves testing prioritization and safety. Questions on anxiety disorders often present a list of findings and ask "Which is most concerning?" or "Which requires immediate intervention?" The correct answer will almost always be the one indicating a threat to physiological integrity (e.g., chest pain, difficulty breathing, suicidal ideation) over psychological distress.
Watch Out for Question Variations!
Shift from Symptom to Intervention: "A client having a panic attack reports chest pain and shortness of breath. Which nursing action is the priority?" (Answer: Assess vital signs and oxygen saturation / Obtain an EKG).
Shift to Patient Education: "The nurse is teaching a client with panic disorder about managing an attack. Which statement by the client indicates understanding?" (Correct response would focus on grounding techniques or controlled breathing, e.g., "I will focus on slow, deep breaths.").
Shift to Medication: "A client is brought to the ED with acute panic symptoms. The provider prescribes lorazepam 1 mg IM stat. Which assessment is most important before administration?" (Answer: Assess for allergies and current use of other CNS depressants like alcohol or opioids).
Nursing Clinical Practice GuideClinical Scenario: You are the nurse on a medical-psychiatric unit. Mr. Jones, a 45-year-old with a history of GAD, presses the call light. You find him sitting on the edge of his bed, pale, clutching his chest, breathing rapidly, and saying, "My heart is pounding... I can't breathe... I think I'm having a heart attack!"
Nursing Intervention Strategy:
Immediate Assessment (ABCs):
Airway/Breathing: Listen for clear breath sounds. Assess respiratory rate and pattern. Is he using accessory muscles? Provide oxygen via nasal cannula if ordered and saturations are low (SpO2 < 92%).
Circulation: Check radial pulse (rate, rhythm, strength). Take blood pressure. Key Point! An elevated heart rate (tachycardia) and hypertension are common in panic, but you must rule out cardiac ischemia.
Focused Questions: "Can you point to where the pain is? Does it radiate anywhere? Are you nauseous or sweaty?" Document pain characteristics using PQRST.
Safety & Environment: Stay with the patient. Speak in a calm, firm, reassuring tone. "Mr. Jones, I'm here with you. You're safe. Let's try to slow your breathing down together." Move him to a quiet, low-stimulation area if possible.
Collaborative Care: Based on your assessment:
If cardiac symptoms are prominent or vital signs are unstable, notify the provider immediately and prepare for an EKG and cardiac enzyme labs.
If symptoms are consistent with a panic attack, implement PRN orders (e.g., administer lorazepam as prescribed).
Guide him through controlled breathing: "Breathe in slowly through your nose for 4 counts, hold for 2, breathe out slowly through your mouth for 6 counts."
Post-Crisis: Once the acute episode subsides, engage in therapeutic communication to explore triggers. Document the event thoroughly: onset, duration, symptoms, interventions, and patient response.
Patient Safety and Precautions
Never Dismiss Symptoms: Even with a known anxiety diagnosis, never assume chest pain is "just anxiety." Always perform a thorough physical assessment.
Medication Caution: Benzodiazepines cause sedation, dizziness, and respiratory depression. Assess fall risk. Monitor for paradoxical reactions (increased agitation).
During Hyperventilation: Do NOT have the patient breathe into a paper bag. This is an outdated practice that can be dangerous if hypoxia is present. Use guided, slow breathing instead.
Nursing Procedure & Medication FlowAdministering a PRN Anxiolytic (e.g., Lorazepam) for Panic:
Assessment: Check the order (drug, dose, route, time). Assess the patient's current anxiety level (use a scale if available), vital signs, respiratory status, and level of consciousness.
Check Contraindications: Verify no allergy. Assess for concurrent use of other CNS depressants (opioids, alcohol, other sedatives).
Administration: For IM injection, use the Z-track method in the vastus lateralis or ventrogluteal site. For oral, ensure the patient swallows the medication.
Monitoring: Stay with the patient. Reassess anxiety level, vital signs (especially respirations), and sedation level every 15-30 minutes. Implement fall precautions.
Documentation: Document pre-administration assessment, time given, route, and post-administration response.
A Word from Your Senior Nurse
"Nursing is not just about carrying out physician orders — it's about being the frontline guardian for your patients! In clinical practice, a patient with anxiety who develops chest pain is one of our biggest 'think twice' moments. Your gut might say 'it's a panic attack,' but your training says 'rule out the heart first.' That moment of thorough assessment—listening to lung sounds, getting a good set of vitals, asking the right questions—is what protects your patient. When studying for your boards, don't just memorize lists of symptoms; practice the thought process: 'If I see this, what's the worst possible thing it could be? What do I need to do first to keep the patient safe?' That clinical reasoning is the heart of nursing and the key to acing the NCLEX."
Panic Attack — A discrete period of intense fear or discomfort, accompanied by physical and cognitive symptoms such as palpitations, sweating, trembling, dyspnea, chest pain, and fear of dying or losing control.
Generalized Anxiety Disorder — A psychiatric disorder characterized by excessive, uncontrollable worry about multiple events or activities, occurring more days than not for at least 6 months, accompanied by physical symptoms like restlessness, fatigue, and muscle tension.
Sympathetic Nervous System — The part of the autonomic nervous system responsible for the "fight-or-flight" response. Its activation during a panic attack releases catecholamines, causing tachycardia, hypertension, tachypnea, and increased alertness.
Nursing Prioritization — A fundamental framework for establishing care priorities: Airway, Breathing, Circulation. It guides nurses to address threats to physiological survival before addressing other needs.
Benzodiazepines — A class of psychoactive drugs (e.g., lorazepam, alprazolam) that enhance the effect of the neurotransmitter GABA, producing sedative, anxiolytic, and muscle-relaxant effects. Used for acute anxiety/panic but carry risk of dependence and sedation.