A client comes to the emergency Department with chest pain and the nurse suspects a myocardial infarction. Which questions) should the nurse ask the client about the pain in the initial assessment? (SELECT ALL THAT APPLY)

"How long have you had the pain?"

"Do you have a history of coronary artery disease?"

"How would you describe your pain?"

"What were you doing when the pain began?"

"Can you rate your pain on a 0-10 scale?"

Answer and Explanation

Correct Answer : A,C,D,E

A. "How long have you had the pain?"
Asking about the duration of the pain is crucial in assessing a myocardial infarction (MI). The length of time the pain has been occurring can help the nurse determine if the pain is acute or has been ongoing. For instance, chest pain lasting more than 20 minutes or worsening in intensity could indicate an MI. Knowing the timing of the pain also helps establish whether it may be related to acute coronary syndrome (ACS), which requires immediate intervention.

B. "Do you have a history of coronary artery disease?"
While it’s important to understand the patient’s medical history, this question is more secondary during the initial assessment of a client with chest pain. This information is valuable for understanding the risk of cardiovascular events, but it is not the immediate focus when assessing the current pain. The nurse should prioritize questions that address the current symptoms and the characteristics of the pain first.

C. "How would you describe your pain?"
This question is essential to help differentiate the chest pain associated with a myocardial infarction from other causes, such as musculoskeletal pain or gastrointestinal issues. MI pain is typically described as a crushing, pressure-like, or squeezing sensation. Identifying the quality of the pain helps establish whether it’s consistent with a cardiac event. Understanding the description of the pain also provides information about the intensity and potential for myocardial damage.

D. "What were you doing when the pain began?"
This is an important question because activity-related chest pain can help determine the potential cause of the pain. Pain associated with physical exertion or emotional stress may point to an MI or angina. On the other hand, pain unrelated to activity might suggest other causes such as gastrointestinal issues or musculoskeletal pain. Inquiring about the onset of the pain can also provide insight into whether it is associated with physical strain or acute coronary syndrome.

E. "Can you rate your pain on a 0-10 scale?"
Pain assessment using a numeric pain scale (0-10) helps the nurse gauge the severity of the pain and track changes over time. It’s important for determining whether the pain is severe enough to be consistent with an acute myocardial infarction or if it might resolve on its own. This information is vital in deciding the urgency of interventions and treatment decisions.

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Correct Answer is C

Explanation

A) Arrange for social service consult for assistance with medication purchase:
While arranging for social service support can be beneficial in ensuring the client has access to necessary medications, this is not directly related to fall prevention at home. Falls in Parkinson's disease are more closely associated with mobility, balance, and environmental factors, which should be the focus of interventions aimed at reducing fall risk. Medication access is important but secondary to safety measures related to physical environment and mobility.

B) Have the client seen by a nursing assistant 3 times a week for hygiene:
While assistance with hygiene can certainly help support the client’s daily needs, the frequency of visits for hygiene care alone does not specifically address fall prevention. Falls are more directly linked to issues such as impaired balance, freezing episodes, and poor mobility—issues that should be addressed through environmental modifications and specific interventions aimed at improving safety during ambulation and transfers.

C) Ensure adequate lighting in areas where the client will ambulate:
Ensuring adequate lighting in areas where the client will ambulate is a critical intervention for fall prevention in individuals with Parkinson's disease. Parkinson's disease often causes balance and coordination problems, and inadequate lighting can increase the risk of tripping or falling, especially at night or in poorly lit areas. Proper lighting helps the client see obstacles and navigate their environment safely. This intervention directly addresses a key factor in fall risk and is an important part of the plan of care.

D) Refer the client to a nutritionist to address dietary measures:
Referral to a nutritionist can be helpful in managing some aspects of Parkinson's disease, particularly for addressing issues like constipation, weight management, or dysphagia. However, dietary measures do not have a direct impact on fall prevention. Fall prevention should focus more on mobility, strength, environmental safety, and managing the symptoms of Parkinson's disease that affect balance and movement.

A. there is continuous bubbling in the water-seal chamber. B. the water levels in the water-seal chamber and suction chambers are decreased. C. fluid in the water-seal chamber fluctuates with the client's breathing. D. there is constant bubbling in the suction-control chamber.

Correct Answer is A

Explanation

A. There is continuous bubbling in the water-seal chamber: Continuous bubbling in the water-seal chamber suggests a potential air leak in the system, which needs to be investigated. The water-seal chamber is designed to prevent backflow of air into the pleural space, and persistent bubbling typically indicates that air is escaping from the pleural cavity or there is a problem with the tubing or chest tube placement. This is the first sign that the system may not be sealed properly and should be checked for leaks.

B. The water levels in the water-seal chamber and suction chambers are decreased: Decreased water levels in both the water-seal and suction chambers may be indicative of fluid loss or evaporation, but it does not necessarily point to a leak. In the case of a chest tube, water levels may also drop due to suction pressure or gradual evaporation, which would need to be adjusted or monitored. While this should be addressed, it is not an immediate cause for suspicion of an air leak in the system.

C. Fluid in the water-seal chamber fluctuates with the client's breathing: The fluctuation (also known as "tidaling") in the water-seal chamber is a normal finding that occurs when the client breathes in and out. It reflects the pressure changes in the pleural cavity during respiration. The absence of tidaling might indicate that the lung has re-expanded or that there is a blockage in the tubing. While tidaling is a normal occurrence, the absence or abnormality of this fluctuation would require further assessment but not for an air leak.

D. There is constant bubbling in the suction-control chamber: Constant bubbling in the suction-control chamber generally indicates that suction is appropriately applied to the system. However, if there is continuous bubbling in this chamber, it is typically related to the level of suction being applied, not an air leak. This is a normal occurrence and does not require checking for leaks in the system unless suction pressure is too high or low for optimal functioning.

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A client comes to the emergency Department with chest pain and the nurse suspects a myocardial infarction. Which questions) should the nurse ask the client about the pain in the initial assessment? (SELECT ALL THAT APPLY)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

To achieve the outcome of fall prevention at home in the client diagnosed with Parkinson's Disease (PD), which intervention would the nurse include in the plan of care?

Correct Answer is C

Explanation

The nurse would check for leaks in the chest tube and water seal system when:

Correct Answer is A

Explanation

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