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 B
Explanation
Chronic stable angina, also known as angina pectoris, is a type of chest pain that occurs when the heart muscle doesn’t get enough oxygen. It is often triggered by physical activity or emotional stress and is usually relieved by rest or medication such as nitroglycerin. Therefore, a patient statement that the pain goes away after taking a nitroglycerin tablet would help confirm a previous diagnosis of chronic stable angina.
Correct Answer is D
Explanation
Choice A rationale
Aortic regurgitation is a condition where the aortic valve doesn’t close tightly, causing blood to leak back into the left ventricle. This condition can lead to left heart failure but is not typically associated with right heart failure.
Choice B rationale
Mitral regurgitation is a disorder in which the mitral valve on the left side of the heart does not close properly. This condition can lead to left heart failure but is not typically associated with right heart failure.
Choice C rationale
Aortic stenosis is a narrowing of the aortic valve opening. This condition can lead to left heart failure but is not typically associated with right heart failure.
Choice D rationale
Tricuspid regurgitation is a disorder in which the heart’s tricuspid valve does not close properly, causing blood to flow backward into the right atrium. This condition can lead to right heart failure, especially when associated with pulmonary hypertension.
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