A client is admitted to the telemetry unit with an episode of substernal chest pain.
His diagnostic studies reveal an elevated ST segment on the electrocardiogram (ECG) and an elevated cardiac troponin level.
What would be an appropriate initial nursing goal?
Reduce anxiety and relieve pain.
Improve myocardial oxygenation and reduce cardiac workload.
Eliminate family stressors and provide a calm environment.
Start the client on a low-sodium diet and decrease fluid intake.
The Correct Answer is B
Choice A rationale
While reducing anxiety and relieving pain are important aspects of care, they are not the primary goal for a client with an elevated ST segment on the ECG and an elevated cardiac troponin level. These findings indicate myocardial injury, which requires interventions to improve myocardial oxygenation and reduce cardiac workload.
Choice B rationale
The primary goal for a client with an elevated ST segment on the ECG and an elevated cardiac troponin level is to improve myocardial oxygenation and reduce cardiac workload. This can be achieved through medications, oxygen therapy, and bed rest.
Choice C rationale
Eliminating family stressors and providing a calm environment can contribute to reducing anxiety and promoting relaxation, but it is not the primary goal in this situation.
Choice D rationale
Starting the client on a low-sodium diet and decreasing fluid intake are interventions for managing heart failure, not for an acute myocardial injury.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Bradycardia, palpitations, confusion, and truncal rash are not typically associated with septic shock. Septic shock is a severe infection that occurs when bacteria enter the bloodstream. It can cause organs to fail and can lead to death.
Choice B rationale
Severe respiratory distress, jugular venous distention, and chest pain are more commonly associated with conditions like heart failure or pulmonary embolism, not septic shock.
Choice C rationale
Low blood pressure and tachycardia are common symptoms of septic shock. This happens because the body’s response to the infection causes blood vessels to dilate, which can lower blood pressure. The heart rate often increases (tachycardia) in an attempt to maintain blood flow to the organs.
Choice D rationale
Reduced cardiac output, increased systemic vascular resistance, and a moist cough are not typical symptoms of septic shock. These symptoms are more commonly associated with conditions like heart failure.
Correct Answer is D
Explanation
Choice A rationale
Homocysteine is an amino acid that your body uses to make protein and to build and maintain tissue. But too much homocysteine in your blood might increase your risk of heart disease.
However, it is not the most specific marker for AMI.
Choice B rationale
C-reactive protein (CRP) is produced by the liver and its level rises when there is inflammation in your body. While its level can increase in those with a heart attack, it is not the most specific marker for AMI6.
Choice C rationale
Myoglobin is a small protein that stores oxygen. It is measured occasionally. Myoglobin is sometimes measured in addition to troponin to help diagnose a heart attack. However, it is not as specific as cardiac-specific troponin.
Choice D rationale
Cardiac-specific troponin is a cardio-specific, highly sensitive marker for myocardial damage. The absolute cardiospecificity of cTnI allows the diagnosis of myocardial infarction distinct from muscle lesions and non-cardiac surgery.
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