A nurse in the emergency department is caring for a client who is experiencing chest pain. Physical Examination

0900:

Client admitted with a report of chest pain radiating to the left arm, sweating, shortness of breath, and epigastric discomfort

Client awake, alert, and oriented x3.

Lung sounds clear bilaterally, S1S2 heart sounds noted.

All pulses palpable.

Skin cool and diaphoretic to touch.

Rates pain as 6 on a 0 to 10 pain scale.

tachycardia with ST elevation. Provider notified.

Medication Administration Record:

Sildenafil 50 mg PO once daily

Simvastatin 40 mg PO once daily

Metoprolol 100 mg PO once daily

Multivitamin once daily

The nurse is reviewing the client's assessment data to prepare the plan of care. What is the potential condition for this client? Select one (1) answer.

Ischemic Stroke

Chronic Stable Angina

Myocardial Infarction

Cardiogenic Shock

Answer and Explanation

The Correct Answer is C

The client's presentation of chest pain radiating to the left arm, sweating, shortness of breath, epigastric discomfort, cool and diaphoretic skin, tachycardia, and ST elevation on the electrocardiogram (ECG) are indicative of myocardial infarction (heart attack). These symptoms and findings are typical of acute coronary syndrome, specifically an ST-segment elevation myocardial infarction (STEMI).

Option A (Ischemic Stroke) is not the correct answer because the symptoms described in the client's presentation are primarily related to the cardiovascular system and not indicative of an ischemic stroke.

Option B (Chronic Stable Angina) is not the correct answer because chronic stable angina typically presents with chest pain on exertion or stress, and it usually subsides with rest or nitroglycerin. The client's symptoms of chest pain at rest, along with other findings, are more concerning for an acute cardiac event like a myocardial infarction.

Option D (Cardiogenic Shock) is a severe complication that can occur following a myocardial infarction, but the information provided in the scenario does not suggest that the client is in cardiogenic shock at this time. The client's blood pressure is not mentioned in the scenario, which is a crucial parameter to assess for cardiogenic shock.

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Correct Answer is D

Explanation

ST-segment elevation on an electrocardiogram (ECG) is a critical finding and should be reported rapidly to the health care provider. It is a hallmark ECG change seen in myocardial infarction (heart attack). When there is myocardial ischemia or injury (such as in a heart attack), the ST segment

elevates above the baseline in the affected leads of the ECG. This elevation indicates that there is an ongoing loss of oxygen and blood supply to a part of the heart muscle.

ST-segment elevation is a medical emergency because it suggests acute coronary syndrome (ACS), which can rapidly progress to a myocardial infarction if not promptly treated. Immediate intervention is needed to restore blood flow to the affected coronary artery and prevent further damage to the heart muscle.

The other options listed (A) First-degree atrioventricular block, (B) Inverted P wave, and (C) Sinus tachycardia, while significant in some situations, do not have the same urgency as ST-segment elevation in the context of chest pain. They may require medical attention, but they do not typically indicate an acute myocardial infarction or an immediate life-threatening condition. ST-segment elevation is a critical finding that requires rapid intervention to preserve heart muscle function and prevent complications.

A. Delegated to the health care provider B. Discussed along with other physical activities C. Avoided because it is embarrassing to the patient D. Accomplished by providing the patient with written material

Correct Answer is B

Explanation

Resumption of sexual activity after a myocardial infarction (MI) is an important topic to address as part of the overall recovery and rehabilitation process. It should be discussed along with other physical activities during the patient's recovery. The nurse should initiate the discussion in a supportive and non-judgmental manner, addressing the patient's concerns, fears, and questions about sexual activity after an MI.

Sexual activity is a normal part of life, and patients may have concerns about the safety and appropriateness of engaging in sexual activity after a significant cardiac event like an MI. Discussing it along with other physical activities helps normalize the topic and allows the nurse to provide accurate information, address any misconceptions, and offer guidance on when and how to resume sexual activity safely. Patients should be encouraged to have an open dialogue with their healthcare provider about their concerns and any specific questions they may have related to resuming sexual activity.

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Naxlex Comprehensive Predictor Exams

Which electrocardiographic (ECG) change by a client with chest pain is most important for the nurse to report rapidly to the health care provider?

Correct Answer is D

Explanation

The nurse is providing teaching to a patient recovering from a myocardial infarction (MI). How should resumption of sexual activity be discussed?

Correct Answer is B

Explanation

client with acute coronary syndrome has returned to the coronary care unit after having angioplasty with stent placement. Which assessment data indicate the need for immediate action by the nurse?

The nurse on the intermediate care unit received a change-of-shift report on four patients with hypertension. Which patient should the nurse assess first?

Which information is most important for the nurse to include when teaching a client newly diagnosed with hypertension?

The nurse identifies that a patient with chronic kidney disease is at risk for which electrolyte disturbance?

Which action will the nurse include in the plan of care for a patient who was admitted with syncopal episodes of unknown origin?

The nurse is reviewing the laboratory test results for a client who has recently been diagnosed with hypertension. Which result is most important to communicate to the health care provider?

A female client with chronic kidney disease (CKD) is receiving peritoneal dialysis with 2-L inflows. Which information should the nurse report promptly to the health care provider?

While assessing an older adult client, the nurse notes jugular venous distention (JVD) with the head of the client's bed elevated 45 degrees. What does this finding indicate?