A nurse in a provider's office is caring for a client.

Which of the following findings require follow-up? Select all that apply.

• Tightness in chest that radiates to left arm: Classic symptom of acute coronary syndrome (ACS), including myocardial infarction (MI). Cardiac pain is often described as pressure, squeezing, or tightness and may radiate to the left arm, jaw, or back.
• Pain rated 7 on a scale of 0 to 10: Severe pain is a hallmark of an MI and suggests significant myocardial ischemia. Persistent or worsening chest pain should prompt urgent intervention.
• Nausea after breakfast: Nausea and gastrointestinal discomfort can be atypical signs of an MI, particularly in individuals with diabetes. The presence of nausea alongside chest pain raises suspicion for cardiac ischemia.
• Diaphoresis and shortness of breath: Sweating and dyspnea are common autonomic responses to myocardial ischemia. The body reacts to decreased cardiac output by activating the sympathetic nervous system, which results in these symptoms.
• Heart rate irregular and tachycardic: Irregular tachycardia suggests possible arrhythmias, which can be triggered by myocardial ischemia and infarction. Life-threatening dysrhythmias are a significant complication of an MI.
• Skin is cool to touch: Cool skin indicates decreased peripheral perfusion, which may result from reduced cardiac output due to myocardial dysfunction. It is a concerning sign of potential hemodynamic instability.

• Lungs clear to auscultation in all lobes: The absence of crackles or other abnormal lung sounds suggests that pulmonary congestion is not currently present.
• Bowel sounds are present in all 4 quadrants: Normal bowel sounds do not indicate any gastrointestinal pathology.
• +1 pedal pulses: Diminished pulses may suggest peripheral vascular disease but are not directly indicative of an acute cardiac event.
• Capillary refill less than 2 seconds: Normal capillary refill indicates adequate peripheral perfusion and does not suggest an immediate concern.

A. Provide a diet of fresh fruits and vegetables for the client: While a high-protein, high-calorie diet is essential for wound healing in burn patients, fresh fruits and vegetables may not be appropriate if the client is immunocompromised due to the risk of bacterial contamination. Cooked or peeled produce is often recommended.

B. Apply new gloves when alternating between wound care sites: Burn wounds are highly susceptible to infection. Changing gloves between different wound sites prevents cross-contamination and reduces the risk of spreading bacteria, which is critical in preventing wound infections and sepsis.

C. Clean the equipment in the client's room once per week: Equipment in a burn unit should be cleaned and disinfected daily to minimize the risk of infection. Weekly cleaning is insufficient for infection control in an immunocompromised client.

D. Limit visitation time for the client's children to 40 min per day: While infection control is a priority, limiting visitation is not typically necessary unless the visitors are ill. Emotional support from family can aid in psychological recovery, and proper infection control measures can be implemented without strict visitation limits.