A client is admitted to the telemetry unit due to an episode of substernal chest pain.
Diagnostic tests reveal an elevated ST segment on the electrocardiogram (ECG) and an increased cardiac troponin level.
What would be an appropriate initial nursing intervention?
Reduce anxiety and alleviate pain.
Enhance myocardial oxygenation and decrease cardiac workload.
Remove family stressors and provide a tranquil environment.
Initiate a low-sodium diet and limit fluid intake.
The Correct Answer is B
Choice A rationale
While reducing anxiety and alleviating pain are important, they are not the most appropriate initial nursing intervention for a client with substernal chest pain, elevated ST segment on the ECG, and increased cardiac troponin level.
Choice B rationale
Enhancing myocardial oxygenation and decreasing cardiac workload are crucial initial nursing interventions for a client presenting with these symptoms. These actions can help prevent further damage to the heart muscle.
Choice C rationale
Removing family stressors and providing a tranquil environment, while beneficial, are not the most appropriate initial nursing interventions for a client with these symptoms.
Choice D rationale
Initiating a low-sodium diet and limiting fluid intake are important for managing heart failure, but they are not the most appropriate initial nursing interventions for a client with these symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Sexual activity uses about as much energy as climbing two flights of stairs. This comparison can help patients understand that if they can perform activities of similar exertion without chest pain or undue fatigue, it may be safe to resume sexual activity. However, patients should always consult with their healthcare provider before resuming sexual activity after an acute myocardial infarction (AMI).
Choice B rationale
While holding and cuddling are good ways to maintain intimacy after a heart attack, this does not directly address the patient’s question about safely resuming sexual intercourse.
Choice C rationale
While it is true that the doctor will provide sexual guidelines when the patient’s heart is strong enough, this response does not provide the patient with immediate guidance or reassurance.
Choice D rationale
While most patients are able to enjoy intercourse without any complications, this statement may be too general and does not take into account the individual patient’s health status and recovery progress.
Correct Answer is A
Explanation
Choice A rationale
Keeping hands warm and wearing gloves when handling cold objects is one of the most effective ways to manage Raynaud’s disease. Cold temperatures can trigger Raynaud’s attacks, which can cause the fingers to turn white, then blue, and feel cold and numb.
Choice B rationale
While avoiding standing for prolonged periods can be beneficial for certain conditions, it is not specifically related to managing Raynaud’s disease.
Choice C rationale
Regular exercise can help improve circulation, which can be beneficial for people with Raynaud’s disease. However, it’s not as crucial as keeping the hands warm.
Choice D rationale
Regularly returning to the clinic for blood pressure checks is not specifically related to managing Raynaud’s disease. While it’s important for individuals with certain conditions, such as hypertension, to regularly monitor their blood pressure, it’s not a key aspect of managing Raynaud’s disease.
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