A client with coronary artery disease complains of chest pain while brushing their teeth in the bathroom. Which action should the nurse implement first?
Perform a 12-lead electrocardiogram and call a rapid response.
Withhold the client's medications until the healthcare provider arrives.
Instruct the client to stop the activity and provide a chair.
Call the healthcare provider immediately about the client's complaint.
The Correct Answer is C
Choice A reason: Performing a 12-lead electrocardiogram and calling a rapid response is not the first action that the nurse should take. A 12-lead electrocardiogram is a test that measures the electrical activity of the heart and can help diagnose a heart attack or other cardiac problems. ¹ A rapid response is a team of healthcare professionals that can provide immediate care to a client who is experiencing a life-threatening emergency. ² However, these actions are not the priority for a client who has chest pain while brushing their teeth. The nurse should first assess the client's condition and provide comfort measures before performing any tests or calling for help.
Choice B reason: Withholding the client's medications until the healthcare provider arrives is not the first action that the nurse should take. The client's medications may include drugs that can relieve chest pain, such as nitroglycerin, aspirin, or beta-blockers. ³ These drugs can help dilate the blood vessels, prevent blood clots, or reduce the workload of the heart. ³ The nurse should not withhold these medications, as they may help the client's condition and prevent further complications. The nurse should check the client's medication orders and administer them as prescribed.
Choice C reason: Instructing the client to stop the activity and provide a chair is the first action that the nurse should take. Chest pain is a common symptom of coronary artery disease, which is a condition where the arteries that supply blood to the heart become narrowed or blocked by plaque. ⁴ Chest pain can be triggered by physical or emotional stress, such as brushing the teeth, which can increase the heart rate and blood pressure. ⁵ The nurse should instruct the client to stop the activity and provide a chair, as this can help reduce the stress on the heart and ease the chest pain. The nurse should also monitor the client's vital signs and oxygen saturation, and provide oxygen if needed.
Choice D reason: Calling the healthcare provider immediately about the client's complaint is not the first action that the nurse should take. The healthcare provider may need to be notified about the client's condition, especially if the chest pain is severe, persistent, or accompanied by other symptoms, such as shortness of breath, nausea, or sweating. ⁵ However, the nurse should first assess the client's condition and provide comfort measures before calling the healthcare provider. The nurse should also be prepared to initiate emergency protocols if the chest pain does not improve or worsens.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This is the correct answer. Tremors and twitching are signs of hypomagnesemia, which is a low level of magnesium in the blood. Magnesium is a mineral that is involved in many enzymatic reactions and neuromuscular functions. A low magnesium level can cause hyperexcitability of the nerves and muscles, leading to involuntary movements and spasms. Alcoholism can cause hypomagnesemia by reducing the absorption and increasing the excretion of magnesium.
Choice B reason: Positive Chvostek's sign is not a sign of hypomagnesemia, but of hypocalcemia, which is a low level of calcium in the blood. Calcium is another mineral that is important for the function of nerves and muscles. A low calcium level can cause tetany, which is a condition of sustained muscle contraction. Chvostek's sign is a test that involves tapping the facial nerve in front of the ear and observing for a twitching of the facial muscles. A positive Chvostek's sign indicates hypocalcemia, not hypomagnesemia.
Choice C reason: Decreased deep tendon reflexes are not a sign of hypomagnesemia, but of hypermagnesemia, which is a high level of magnesium in the blood. A high magnesium level can cause hyporeflexia, which is a reduced or absent response to stimuli. Magnesium has a sedative effect on the nerves and muscles, and can inhibit the transmission of impulses. Hypermagnesemia can be caused by excessive intake or impaired excretion of magnesium.
Choice D reason: Polyuria and flank pain are not signs of hypomagnesemia, but of kidney problems, such as infection, stones, or failure. Polyuria is the production of abnormally large amounts of urine, and flank pain is the pain in the side or back below the ribs. These symptoms can indicate damage or inflammation of the kidneys, which can affect the balance of fluids and electrolytes in the body. Hypomagnesemia does not directly cause polyuria or flank pain, but it can be a result of kidney dysfunction.
Correct Answer is C
Explanation
Choice A reason: The pain you have is because your heart valves are damaged is not the most appropriate response. This statement may apply to a client with valvular heart disease, but not necessarily to a client with coronary artery disease. The nurse should explain that coronary artery disease is a condition that affects the blood vessels that supply the heart, not the heart valves.
Choice B reason: Your heart muscle is weak and is not pumping forcefully is not the most appropriate response. This statement may apply to a client with heart failure, but not necessarily to a client with coronary artery disease. The nurse should explain that coronary artery disease is a condition that reduces the blood flow to the heart, not the heart's contractility.
Choice C reason: The pain is caused by decreased oxygen to the heart muscle is the most appropriate response. This statement accurately describes the cause of angina, which is the chest pain that occurs when the heart does not receive enough oxygen due to narrowed or blocked coronary arteries. The nurse should also inform the client about the factors that can trigger or relieve angina, such as physical exertion, emotional stress, cold weather, or nitroglycerin.
Choice D reason: The layers of your heart are weak and thin is not the most appropriate response. This statement may apply to a client with cardiomyopathy, but not necessarily to a client with coronary artery disease. The nurse should explain that coronary artery disease is a condition that affects the blood vessels that supply the heart, not the heart's structure.
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