A client with a history of unstable angina presents to the emergency department with constant chest pressure that is unrelieved with rest. The client appears anxious, pale, and diaphoretic. After obtaining the client's vital signs, which action should the nurse take next?
Evaluate upper and lower extremities for perfusion, pulse volume, and pitting edema.
Secure client consent for coronary angiography and percutaneous coronary intervention.
Administer four 81 mg aspirin tablets providing instructions to chew before swallowing.
Place an indwelling urinary catheter and institute strict intake and output measurements.
The Correct Answer is C
Given the client's symptoms of constant chest pressure that is unrelieved with rest, along with the client's appearance of anxiety, pallor, and diaphoresis, it indicates a high likelihood of an acute coronary event, such as a myocardial infarction (heart attack). In this situation, the nurse should prioritize immediate actions that address the potential cardiac emergency.
Aspirin is an essential medication in the initial management of acute coronary syndrome, including unstable angina and myocardial infarction. It helps to inhibit platelet aggregation and reduce the risk of clot formation in the coronary arteries. The chewable form of aspirin is recommended because it allows for more rapid absorption.
While evaluating extremities for perfusion, pulse volume, and pitting edema is important in assessing the client's overall cardiovascular status, it is not the immediate next step when faced with a suspected acute coronary event.
Securing client consent for coronary angiography and percutaneous coronary intervention (PCI) is a relevant step in the management of unstable angina and myocardial infarction, but it is not the immediate action to be taken in the emergency department. The client requires stabilization and initial medical interventions before procedural consent can be obtained.
Placing an indwelling urinary catheter and instituting strict intake and output measurements is not a priority action in this situation. The focus should be on addressing the potential acute coronary event and ensuring the client's cardiac stability. Urinary catheterization and monitoring of intake and output can be considered later, if necessary.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","E","F"]
Explanation
Correct- This statement indicates a misunderstanding about the relationship between acute stress disorder (ASD) and post-traumatic stress disorder (PTSD). While both are related to traumatic events, ASD is considered an initial reaction that typically resolves within three days to four weeks, whereas PTSD involves symptoms persisting for more than a month. The nurse should provide education on the different timelines and criteria for these disorders.
Incorrect- This statement reflects a proactive approach to managing symptoms and stress through holistic methods like meditation. There's no need for follow-up teaching here.
Incorrect- This statement shows the client's recognition of the potential benefits of therapy in managing their thoughts and emotions. It indicates their willingness to engage in effective coping strategies.
Incorrect- This statement reflects an understanding that their response to the traumatic event is not uncommon and that others may have similar reactions. It's a valid perspective on shared experiences during challenging times.
Correct- The statement "This diagnosis means that I am crazy" reflects a common misconception about mental health diagnoses. The term "crazy" is stigmatizing and does not accurately represent the nature of mental health conditions. The nurse should offer reassurance that a diagnosis of ASD does not define a person's overall mental state and emphasize the importance of seeking help without judgment.
Correct- The statement "I will probably need to be on medication for the rest of my life" implies a sense of hopelessness or a narrow perspective about treatment options. While medication might be part of the treatment plan for some individuals, it's important to emphasize that treatment is personalized and can include a combination of therapies, coping strategies, and lifestyle adjustments. The nurse should encourage an open discussion about treatment goals and possibilities.
Correct Answer is D
Explanation
A) Incorrect- Reviewing transcutaneous bilirubin levels is unrelated to the presence of an enlarged clitoris. Bilirubin levels are typically assessed to monitor jaundice in newborns.
B) Incorrect- Observing and palpating breast tissue for enlargement is not relevant to the condition of salt-wasting congenital adrenal hyperplasia. Breast tissue enlargement would not be associated with this hormonal disorder.
C) Incorrect- Assessing for signs of fluid retention and bilateral pedal edema is important for monitoring for other conditions, but it is not relevant to the enlarged clitoris seen in this specific scenario.
D) Correct- Salt-wasting congenital adrenal hyperplasia is a genetic disorder that results in a deficiency of certain enzymes required for cortisol and aldosterone production. This deficiency leads to an overproduction of androgens, which can cause virilization of female external genitalia. The enlarged clitoris is a result of increased androgen levels. Explaining this finding to the mother provides her with accurate information about the condition and its effects on the infant's anatomy.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.