# A nurse is working with a 22-year-old college student experiencing an acute panic attack with hyperventilation and chest pain. Which intervention should the nurse implement first to ensure client safety? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=543436 > language: ko > subject: Mental Health ## 문제 A nurse is working with a 22-year-old college student experiencing an acute panic attack with hyperventilation and chest pain. Which intervention should the nurse implement first to ensure client safety? ## 보기 1. Encourage the client to discuss their feelings about the recent losses 2. Provide information about community support resources 3. Assess the client's risk for self-harm or harm to others **✔ 정답** 4. Help the client develop new coping strategies **정답: 3** ## 해설 Safety assessment for self-harm or harm to others is priority in acute crisis to ensure immediate safety. Other interventions like discussing feelings or providing resources are secondary. ## 심화 해설 Understanding the Priority: Safety in Acute Panic When a client is experiencing an acute panic attack with hyperventilation and chest pain, the nurse's immediate priority is to ensure physical and psychological safety. Panic attacks involve a sudden surge of intense fear or discomfort that peaks within minutes, accompanied by symptoms such as palpitations, chest pain, and a sensation of shortness of breath. These symptoms are driven by a misinterpretation of benign bodily sensations as catastrophic threats, a phenomenon known as anxiety sensitivity [4]. The client may genuinely believe they are having a heart attack or losing control, which activates the sympathetic nervous system and escalates the physiological crisis [4]. The NCLEX-RN framework consistently prioritizes safety and the assessment of risk before implementing therapeutic communication or health teaching. During the acute phase of a panic attack, the client's cognitive function is narrowed, making complex discussions about feelings, coping strategies, or community resources ineffective and potentially overwhelming. The first and most critical step is to assess for immediate danger. Why Risk Assessment is the First Intervention The correct intervention is to assess the client's risk for self-harm or harm to others. This is grounded in the safety principle that takes precedence over all other nursing actions. A panic attack induces a profound sense of impending doom and a fear of losing control [4]. According to the concept of anxiety sensitivity, the cognitive domain includes the fear that "I'm going crazy or will lose control and do something dangerous" [4]. This perceived loss of control can, in rare but critical instances, lead to impulsive, unsafe behaviors. Therefore, the nurse must immediately evaluate whether the client poses a danger to themselves or others before proceeding with less urgent interventions. This assessment directly addresses the most serious potential outcome of the psychological crisis. Analyzing the Incorrect Options The other options, while valuable components of a comprehensive care plan, are not the first priority during the acute phase of a panic attack: - Encouraging the client to discuss their feelings: During a panic attack, the client's ability to process complex emotions and engage in insight-oriented discussion is severely limited. The immediate physiological and psychological arousal must be de-escalated first. This intervention is more appropriate in the post-crisis or recovery phase. - Providing information about community support resources: This is a health teaching and discharge planning intervention. It is contraindicated during an acute crisis when the client cannot concentrate or retain new information. This action is suitable once the client is stable and able to plan for future management. - Helping the client develop new coping strategies: This is a long-term goal. An acute panic attack is not the time to teach a new skill. The nurse should first help the client regain control using simple, directive techniques. For instance, guided breathing practices are an evidence-based tool for reducing anxiety, but their implementation comes after immediate safety is established . The systematic review on breathing practices highlights their role as a voluntary, regulated intervention, which requires a degree of cognitive readiness not present at the peak of a panic attack . By first assessing for the risk of self-harm or harm to others, the nurse fulfills the fundamental duty to protect the client and environment, establishing a safe foundation upon which all other therapeutic interventions can be built.References (research sources) - [4]Understanding and Managing Anxiety Sensitivity During Critical Illness and Long-Term Recovery.Research articleBoehm LM, Bird CM, Warren AM, Danesh V, Hosey MM, McPeake J, Potter KM, Su H, Eaton TL, Powers MB. (2023) · DOI: 10.4037/ajcc2023975 ## 임상 시나리오 Safety First in Acute Panic AttackImmediate Risk Assessment Overrides All Other Interventions During an acute panic attack with hyperventilation and chest pain, the client's cognitive function is narrowed by intense fear of losing control. The nurse's first action must be to assess for self-harm or harm to others to establish immediate physical and psychological safety. Therapeutic communication, such as discussing feelings or teaching coping strategies, is ineffective during the peak of a crisis. The sympathetic nervous system activation mimics a medical emergency, making the client unable to process complex information. Safety assessment is the foundational step before de-escalation. CautionDo not leave the client alone. A panic attack can trigger a profound sense of impending doom and loss of control, which may lead to impulsive behaviors. Stay with the client in a quiet environment and use short, clear directives after confirming no immediate danger exists. ## 핵심 개념 - **Anxiety Sensitivity** — The fear of anxiety-related sensations based on beliefs that they have harmful physical, psychological, or social consequences. - **Sympathetic Nervous System Activation** — The body's 'fight-or-flight' response triggered during panic, causing symptoms like tachycardia, hyperventilation, and chest pain. - **Safety Principle in Nursing** — The prioritization framework where assessing and ensuring the client's physical and psychological safety takes precedence over all other interventions. - **Acute Panic Attack** — A discrete period of intense fear peaking within minutes, characterized by symptoms like palpitations, chest pain, and a feeling of impending doom. - **Cognitive Narrowing** — A state during high anxiety where the client's perceptual field and ability to process complex information are significantly reduced. ## 같은 주제 문제 - [A nurse is conducting an initial assessment of a 28-year-old client who presents to the em…](https://mymerci.kr/pages/nclex_q.php?qn_id=543430) - [A nurse is providing crisis intervention for a client experiencing an acute psychiatric cr…](https://mymerci.kr/pages/nclex_q.php?qn_id=543431) - [A nurse is working with a client experiencing an acute crisis following a recent job loss …](https://mymerci.kr/pages/nclex_q.php?qn_id=543432) - [A nurse is working with a client experiencing an acute psychological crisis after a trauma…](https://mymerci.kr/pages/nclex_q.php?qn_id=543433) - [A nurse is working with an adolescent client experiencing an acute psychological crisis af…](https://mymerci.kr/pages/nclex_q.php?qn_id=543434) - [A nurse is providing crisis intervention for a 35-year-old client experiencing an acute ps…](https://mymerci.kr/pages/nclex_q.php?qn_id=543435) - [A nurse is caring for a 60-year-old client with dementia who is experiencing an acute beha…](https://mymerci.kr/pages/nclex_q.php?qn_id=543437) --- More free questions: [기출문제](https://mymerci.kr/) _학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요._