A client has chest pain rated 8/10 as stated by the patient. The 12-lead ECG reveals ST elevation in the inferior leads and the lab results reveal cardiac enzyme levels are elevated. What is the highest priority for nursing management of this client at this time?
Monitor daily weights and urine output.
Administer TPA to prevent further damage as a result of a clot.
Provide client education on medications and diet to prevent recurrence.
Reduce pain and myocardial oxygen demand.
The Correct Answer is D
A. Monitor daily weights and urine output.
Monitoring daily weights and urine output is an important aspect of managing heart failure or other cardiac conditions. However, in the context of a client with chest pain, ST elevation, and elevated cardiac enzymes (indicating a myocardial infarction), the immediate focus is on addressing the acute event and reducing myocardial oxygen demand.
B. Administer TPA to prevent further damage as a result of a clot.
Tissue plasminogen activator (TPA) is a thrombolytic medication that can be administered to dissolve blood clots in the coronary arteries during a myocardial infarction. However, the administration of TPA has a specific timeframe within which it is most effective. It is crucial to know the elapsed time since the onset of symptoms, and there are specific criteria and contraindications for its use.
C. Provide client education on medications and diet to prevent recurrence.
Client education on medications, lifestyle modifications, and dietary changes is an essential component of long-term management for preventing recurrence of cardiovascular events. However, during the acute phase of a myocardial infarction, the immediate priority is to stabilize the client and address the acute event, with education being a secondary consideration.
D. Reduce pain and myocardial oxygen demand.
During the acute phase of a myocardial infarction, reducing pain and myocardial oxygen demand is the highest priority. This is typically achieved through the administration of medications such as nitroglycerin for vasodilation and opioids for pain relief. Other interventions to optimize oxygen supply and demand, such as supplemental oxygen and reperfusion strategies, may also be considered.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. “I will need to stop smoking because the nicotine causes less blood to flow to my hands and feet.”
Explanation: This statement reflects an understanding of the association between smoking and reduced blood flow, particularly due to nicotine's vasoconstrictive effects.
B. “The older I get the higher my risk for peripheral arterial disease gets.”
Explanation: While age is a non-modifiable risk factor for PAD, it is not a statement indicating a change in behavior to address risk factors. It is correct information but doesn't involve a proactive approach to risk reduction.
C. “Since my family is from Italy, I have a higher risk of developing peripheral arterial disease.”
Explanation: Family history is a non-modifiable risk factor, and the statement correctly identifies this risk factor. However, it doesn't address modifiable factors or actions to reduce risk.
D. “I will need to increase the amount of green leafy vegetables I eat to lower my cholesterol levels.”
Explanation: This statement demonstrates an understanding of a dietary modification to lower cholesterol levels, which is a positive step toward reducing a modifiable risk factor for PAD.
Correct Answer is ["A","B","C","D","E"]
Explanation
A. Shortness of breath
Shortness of breath can be a symptom of a myocardial infarction in both men and women.
B. Anxiety
Anxiety can be a symptom in some cases, as individuals may feel a sense of impending doom or anxiety during an MI.
C. Unusual fatigue
Unusual fatigue, especially if it is severe or occurs with exertion, can be a symptom of a myocardial infarction.
D. Back pain
Back pain, particularly between the shoulder blades, can be a symptom of a myocardial infarction in women.
E. Chest pain
Chest pain or discomfort is a classic symptom of a myocardial infarction. While women may experience chest pain, they are also more likely than men to have atypical symptoms.
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