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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
When a patient with dilated cardiomyopathy develops new onset atrial fibrillation (AF) that has been unresponsive to drug therapy, the nurse should prioritize patient education about anticoagulant therapy. Atrial fibrillation increases the risk of blood clots forming in the heart's atria due to the irregular and ineffective pumping of blood. These blood clots can potentially travel to other parts of the body, leading to serious complications such as stroke.
Anticoagulant therapy, also known as blood-thinning medication, is commonly prescribed for patients with atrial fibrillation to prevent the formation of blood clots. The most common anticoagulant prescribed for AF is warfarin or direct oral anticoagulants (DOACs) such as apixaban, rivaroxaban, dabigatran, or edoxaban. The nurse should educate the patient about the importance of taking the anticoagulant as prescribed and the need for regular monitoring of clotting times (INR for warfarin) to ensure the medication is effective and the dose is appropriate.
While other options listed in the choices may be relevant in specific situations, the priority in this case is to address the potential risk of stroke associated with atrial fibrillation and the importance of anticoagulant therapy to manage that risk effectively.
Correct Answer is ["C","E"]
Explanation
Based on the client's condition, the nurse should monitor the following:
C. Electrocardiogram (ECG) Rhythm: The client is experiencing chest pain with ST elevation, which indicates a possible myocardial infarction (MI). Continuous monitoring of the ECG rhythm is essential to identify any changes or dysrhythmias that may occur during the course of the client's care.
E. Vital signs: The client's tachycardia with ST elevation suggests cardiac involvement. Monitoring vital signs, including heart rate, blood pressure, respiratory rate, and oxygen saturation, is crucial to assess the client's hemodynamic status and detect any signs of deterioration or improvement.
The other options (A. WBC Count, B. Platelet Count, and D. Serum glucose level) are not directly related to the client's acute chest pain and the possible MI. While these tests may be ordered for other reasons or as part of the overall assessment, they are not the immediate priorities in this situation. Monitoring the ECG rhythm and vital signs are more relevant to the client's acute cardiac condition.
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