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.

Answer and Explanation

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.

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Correct Answer is ["A","B","C","D"]

Explanation

A. Normal sinus rhythm that becomes sinus tachycardia

Sinus tachycardia can be an indication of increased sympathetic activity in response to decreased cardiac output. It may suggest the heart's compensatory response to maintain adequate perfusion.

B. Onset of a cough with pink, frothy sputum

Pink, frothy sputum is a classic sign of pulmonary edema, which can occur in the setting of worsening heart failure. It indicates the presence of blood-tinged fluid in the alveoli.

C. Presence of dyspnea at rest

Dyspnea at rest suggests that the client is experiencing difficulty breathing even without physical exertion. This can be indicative of more severe heart failure.

D. Falls asleep when not disturbed

Falling asleep when not disturbed may indicate fatigue or exhaustion, which is common in individuals with heart failure. However, it is not a direct indicator of worsening heart failure and can be influenced by various factors.

E. Urine drainage is increased in amount

Increased urine output can be a sign of diuretic therapy or an attempt by the body to compensate for fluid overload. However, it is essential to consider other factors such as renal function and medication effects.

A. Shortness of breath B. Anxiety C. Unusual fatigue D. Back pain E. Chest pain

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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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse on a cardiac unit is caring for a client admitted with an acute exacerbation of heart failure. The nurse concludes that the client’s condition is worsening after noting which client data during assessment. (SELECT ALL THAT APPLY)

Correct Answer is ["A","B","C","D"]

Explanation

An emergency department nurse is assessing an adult woman for a suspected myocardial infarction (MI). When planning the assessment, the nurse should be aware that female patients may have which of the following symptoms for an MI? (SELECT ALL THAT APPLY)

Correct Answer is ["A","B","C","D","E"]

Explanation

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