A nurse in an emergency department is assessing a client who is having a suspected acute myocardial infarction (MI). Which of the following manifestations should the nurse expect to find for a client experiencing an acute MI? (Select all that apply.)

Orthopnea

Diaphoresis

Nausea

Headache

Tachycardia

Answer and Explanation

Correct Answer : B,C,E

A. Orthopnea is difficulty breathing while lying flat, and it is typically associated with heart failure or pulmonary conditions, not an acute MI.
B. Diaphoresis (excessive sweating) is a common symptom of an acute MI due to the body's stress response to the myocardial injury.
C. Nausea can occur during an acute MI, particularly in women, as a result of the stress response or ischemia affecting the gastrointestinal system.
D. Headache is not a typical symptom of an acute MI. While it can occur due to stress or other factors, it is not a hallmark of myocardial infarction.
E. Tachycardia (increased heart rate) is a common response to an acute MI as the body attempts to compensate for reduced cardiac output and oxygenation.

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Correct Answer is A

Explanation

A. An S3 heart sound is known as a ventricular gallop and occurs during the rapid filling phase of the ventricle in early diastole. It is commonly heard in conditions like heart failure, where the ventricles are overfilled, or in younger individuals with healthy hearts.
B. The closure of the pulmonic valve occurs at the end of systole and is associated with the second heart sound (S2), not S3.
C. An atrial gallop is represented by an S4 sound, which occurs just before S1 when the atria contract to fill the ventricles.
D. The closure of the mitral valve occurs during S1, not S3, and marks the beginning of systole.

A. Obtain a blood sample. B. Initiate oxygen therapy. C. Insert the IV catheter. D. Attach the leads for a 12-lead ECG.

Correct Answer is B

Explanation

A. Obtaining a blood sample is important for diagnosing a myocardial infarction, but it is not the immediate priority. The nurse should first focus on stabilizing the patient before performing diagnostic tests.
B. Initiating oxygen therapy is the priority action. Oxygen is critical in improving oxygenation and reducing myocardial stress during a myocardial infarction. It helps prevent further damage to the heart muscle and supports overall cardiac function.
C. Inserting the IV catheter is important for administering medications and fluids, but it is not as urgent as providing oxygen therapy, which directly impacts the client's oxygenation and cardiac function.
D. Attaching the leads for a 12-lead ECG is essential for diagnosing a myocardial infarction, but the priority is to stabilize the patient by administering oxygen before performing diagnostic tests.

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A nurse in an emergency department is assessing a client who is having a suspected acute myocardial infarction (MI). Which of the following manifestations should the nurse expect to find for a client experiencing an acute MI? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is performing a cardiac assessment on a client and auscultates an S3 sound. The nurse should recognize that this sound represents which of the following heart conditions?

Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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