The emergency department (ED) nurse triages a client experiencing a panic attack. The client reports nausea, chest discomfort, and a feeling of impending doom. The nurse should plan to take which priority action based on the client's symptoms?
The emergency department (ED) nurse triages a client experiencing a panic attack. The client reports nausea, chest discomfort, and a feeling of impending doom. The nurse should plan to take which priority action based on the client's symptoms?
A. Assess the client for suicide
[12%]
B. Obtain a 12-lead electrocardiogram (ECG)
[62%]
C. Develop a therapeutic rapport with the client
[16%]
D. Inquire about the precipitating event
[10%]
Statistics
Subject/Lesson
Subject
Mental Health
Lesson
Mental Health
Client Need
Test Plan
Physiological Adaptation
Related Topic
Illness Management
Item Type
Item Type
Application
Explanation
Choice B is correct. When a client is experiencing a panic attack, somatic symptoms such as hyperventilation, perspiration, chest discomfort, and nausea are likely. However, the nurse should always prioritize physical needs/reports such as chest pain. The nurse should obtain a 12-lead electrocardiogram as this is an effective way to rule out acute coronary syndrome (ACS). ACS may cause similar symptoms, such as a feeling of impending doom, and the nurse should intervene and obtain this necessary test.
Choices A, C, and D are incorrect. These actions are essential. However, they do not prioritize over physical needs. The nurse should assess the client for suicide; however, the time assessing for suicide should be spent determining the physical stability of the client. Developing a therapeutic rapport would be helpful. Inquiring about the precipitating event would be unhelpful during a panic attack because clients cannot solve problems and effectively reflect.
Related Videos
2 Key Topics
ABCs: Airway
15.5 Prioritization Part 1
Additional Info
Maslow's Hierarchy of Needs can be an effective tool in solving this item. You may recognize that physical needs are at the bottom of the framework that is because it would be ineffective to keep a client safe who is physically unstable. Thus, physical reports and needs should always come first.
