A client with a history of angina is being admitted to the emergency department with a suspected myocardial infarction (MI). Which of the following findings will help the nurse distinguish stable angina from an MI?
MI only occurs with exertion.
Stable angina can occur for longer than 30 minutes.
Stable angina can be relieved with rest and nitroglycerin.
The pain of an MI lasts less than 15 minutes.
The Correct Answer is C
Choice A reason: Myocardial infarction (MI) is not limited to occurrences with exertion. While stable angina typically occurs during physical activity or emotional stress, MI can happen at any time, even at rest. The underlying cause of an MI is the complete blockage of blood supply to a part of the heart muscle, usually due to a blood clot in a coronary artery. This blockage can lead to the death of heart muscle tissue, a condition that requires immediate medical attention.
Choice B reason: Stable angina does not typically last for more than 30 minutes. It is characterized by chest pain or discomfort that occurs predictably with exertion or emotional stress and is relieved within minutes by rest or nitroglycerin. In contrast, the pain from an MI is more prolonged and severe, and it is not relieved by rest or nitroglycerin. If chest discomfort lasts longer than 15 minutes and is not alleviated by rest or nitroglycerin, it is a warning sign that the individual may be experiencing an MI.
Choice C reason: This is the distinguishing feature between stable angina and an MI. Stable angina is usually relieved within 3-5 minutes by rest or nitroglycerin, which helps to dilate the coronary arteries and improve blood flow to the heart muscle. Nitroglycerin is ineffective in relieving the symptoms of an MI because the problem is not just reduced blood flow but a complete blockage that nitroglycerin cannot overcome.
Choice D reason: The pain associated with an MI typically lasts for more than 15 minutes and can be quite severe. Unlike stable angina, the pain of an MI is not relieved by rest or nitroglycerin. The duration and severity of the pain, along with other symptoms such as shortness of breath, sweating, nausea, or lightheadedness, help differentiate an MI from stable angina.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","E","F"]
Explanation
Choice A: Hypokalemia, or low potassium levels in the blood, is not typically associated with CKD. In fact, patients with advanced CKD are more likely to experience hyperkalemia, which is an elevated potassium level, due to the kidneys’ decreased ability to excrete potassium. The normal range for serum potassium is 3.5 to 5.0 mmol/L.
Choice B: Anemia is a common finding in CKD and is due to the kidneys’ reduced production of erythropoietin, a hormone that stimulates the bone marrow to produce red blood cells. Symptoms of anemia include fatigue, weakness, and pale skin. The normal range for hemoglobin in adults is 13.8 to 17.2 grams per deciliter for men and 12.1 to 15.1 grams per deciliter for women.
Choice C: Hypertension, or high blood pressure, is both a cause and a complication of CKD. The kidneys play a crucial role in regulating blood pressure, and as their function declines, hypertension becomes more common. The normal range for blood pressure is typically considered to be 120/80 mmHg.
Choice D: Crackles in the lungs Crackles in the lungs are not a direct manifestation of CKD, but they can occur if the condition leads to fluid overload and heart failure, resulting in pulmonary edema. This is a secondary complication rather than a direct symptom of CKD.
Choice E: Lethargy and a general feeling of malaise are common in CKD due to the buildup of toxins and waste products in the blood that the kidneys can no longer effectively filter out. This can also lead to decreased mental sharpness and a reduced quality of life.
Choice F: Proteinuria, or the presence of excess protein in the urine, is a hallmark sign of CKD. It indicates damage to the kidneys’ filtering units, allowing protein that would normally be retained to leak into the urine. Persistent proteinuria is a sign of chronic kidney damage.
Correct Answer is C
Explanation
Choice A: Tachypnea Tachypnea, or rapid breathing, is not typically a direct sign of increased ICP. While it can be associated with various medical conditions, it is not specifically indicative of increased ICP. However, it’s important to note that breathing patterns can change with advanced ICP changes, but these are usually characterized by irregularities rather than just increased rate. Increased intracranial pressure (ICP) is a critical condition that can occur after a traumatic brain injury (TBI). It results from the brain tissue’s response to injury, leading to swelling or bleeding within the skull. The skull is a rigid structure, so any increase in content, such as blood or edema, can lead to an increase in pressure.
Choice B: Hypotension Hypotension, or low blood pressure, is generally not associated with increased ICP. In fact, one of the signs of increased ICP is Cushing’s triad, which includes hypertension (high blood pressure), bradycardia (slow heart rate), and irregular respirations. Therefore, hypotension would not be a typical manifestation of increased ICP.
Choice C: Decreased level of consciousness A decreased level of consciousness is a hallmark sign of increased ICP. As pressure within the skull increases, it can lead to compression of the brain tissue and disruption of cerebral blood flow. This can manifest as changes in alertness, drowsiness, confusion, and in severe cases, loss of consciousness1. when monitoring a client who has sustained a TBI, the nurse should be vigilant for signs of increased ICP, with a decreased level of consciousness being a primary indicator. Other signs may include headache, nausea, vomiting, and changes in pupil size or reactivity. It is crucial to identify and treat increased ICP promptly to prevent further brain injury and potential long-term consequences.
Choice D: Bilateral weakness of extremities While bilateral weakness can be a sign of neurological damage, it is not specific to increased ICP. Increased ICP is more likely to cause global effects on consciousness and brain function rather than isolated weakness in limbs unless there is focal brain injury causing raised ICP.
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