A nurse in the emergency department is caring for a 52-year-old male client experiencing chest pain. Below are the exhibits to guide your answer:
Complete the diagram by dragging from the choices below to specify:
- The condition the client is most likely experiencing.
- Two actions the nurse should take.
- Two parameters the nurse should monitor to assess the client's progress.
The Correct Answer is []
Condition: Myocardial infarction.
2 actions:
Administer oxygen via nasal cannula 2 L/min,
Request a prescription for aspirin 325 mg.
2 parameters:
Vital signs,
Electrocardiogram (ECG) rhythm.
Rationale for correct condition: A myocardial infarction is indicated by the elevated troponin levels and ST elevation on the ECG. The client’s symptoms of chest pain, elevated heart rate, and low oxygen saturation support this diagnosis. Prompt identification and treatment are crucial to minimize heart damage. The medical history of hypertension and coronary artery disease increases the likelihood. Immediate interventions can significantly improve outcomes.
Rationale for actions: Administer oxygen to improve oxygenation and reduce myocardial workload. Requesting aspirin helps prevent further clot formation. Morphine alleviates pain but may obscure symptoms, making it less urgent. Nitroglycerin relieves chest pain by vasodilation but is secondary. Verapamil is less immediate for acute myocardial infarction management. Vital signs reflect hemodynamic status and response to treatment. ECG rhythm detects ongoing ischemia or arrhythmias. Monitoring WBC count is less relevant acutely. Platelet count is stable; not the focus in immediate management.
Rationale for parameters: Vital signs ensure hemodynamic stability and detect hypotension or shock. ECG rhythm monitors arrhythmias and ongoing ischemia, critical in myocardial infarction. WBC count indicates infection or inflammation, less immediate concern. Platelet count is important for bleeding risks but less immediate. Chronic stable angina presents with predictable, non-severe pain. Ischemic stroke symptoms differ; focus on neurological deficits. Cardiogenic shock would present with more severe hypotension and signs of organ failure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Taking nitroglycerin when experiencing chest pain is correct as it helps to relieve the pain by dilating blood vessels and increasing blood flow to the heart.
Choice B rationale
Calling 911 if chest pain does not improve after taking nitroglycerin is correct and necessary to seek immediate medical assistance.
Choice C rationale
Storing nitroglycerin tablets in a dark, cool place is correct to maintain their potency, as light and heat can degrade the medication.
Choice D rationale
Taking up to three doses of nitroglycerin five minutes apart is correct; however, if the pain persists after one dose, the patient should call 911 immediately rather than waiting for all three doses to be taken.
Correct Answer is B
Explanation
Choice B rationale
Radiating pain to the left arm is a classic symptom of a myocardial infarction (MI). This pain occurs due to the heart muscle not receiving enough oxygen, often because of a blockage in one or more coronary arteries. The pain can radiate to the left arm, jaw, neck, or back, and is a key indicator for diagnosing an MI.
Choice A rationale
Nausea and vomiting can occur during an MI but are not the most distinctive symptoms for diagnosis. They can also be associated with other conditions, making them less specific indicators of MI.
Choice C rationale
Shortness of breath is a common symptom during an MI, resulting from reduced oxygen supply to the heart. However, while it is an important clinical manifestation, it can also be associated with other cardiac or respiratory conditions.
Choice D rationale
Headache is not a typical symptom of an MI. It is less commonly associated with heart attacks and can be caused by a wide range of other factors, making it an unreliable symptom for diagnosing MI.
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