A nurse is assessing a patient who has a history of atherosclerosis. Which assessment finding suggests myocardial ischemia?

Chest pain that radiates to the jaw

Sudden and severe abdominal pain

Blurred vision

Dry cough

Answer and Explanation

The Correct Answer is A

A. Chest pain that radiates to the jaw:
This finding suggests myocardial ischemia, as chest pain (angina) that radiates to the jaw is a classic symptom of cardiac origin. It is known as referred pain and occurs because the nerves that innervate the heart and jaw have a similar sensory pathway. The pain may be described as pressure, squeezing, or tightness in the chest, and it often spreads to the neck, shoulders, arms, or jaw. This pattern of pain radiation is typical in myocardial ischemia or heart attack due to inadequate blood supply to the heart muscle.

B. Sudden and severe abdominal pain:
While abdominal pain can be associated with various conditions, sudden and severe abdominal pain is not a typical symptom of myocardial ischemia. Instead, it may indicate other abdominal issues such as gastrointestinal problems, pancreatitis, or intra-abdominal vascular events. Myocardial ischemia typically presents with chest pain or discomfort, rather than abdominal pain.

C. Blurred vision:
Blurred vision is not a typical symptom of myocardial ischemia. It may suggest ocular issues such as refractive errors, dry eyes, or conditions affecting the retina or optic nerve. Myocardial ischemia primarily manifests with symptoms related to the heart, such as chest pain, shortness of breath, or other signs of cardiovascular compromise.

D. Dry cough:
A dry cough is not a typical symptom of myocardial ischemia. It may be associated with various respiratory conditions such as allergies, asthma, or respiratory infections. Myocardial ischemia primarily presents with symptoms related to the heart and cardiovascular system, such as chest pain, palpitations, or dyspnea.

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Correct Answer is C

Explanation

A. Monitors the patient's temperature, heart rate, respiratory rate, and blood pressure:
Monitoring vital signs is crucial for assessing the patient's overall condition, including respiratory status. However, while changes in vital signs may indicate respiratory distress, they do not directly address the need to ensure clear breath sounds. This intervention alone does not actively promote airway clearance or improve breath sounds.

B. Educates the patient to avoid handling pet excreta or cleaning litter boxes, birdcages, or aquariums:
This intervention focuses on reducing the risk of exposure to potential pathogens that could worsen the patient's respiratory condition. While important for infection control, it does not directly address the need to ensure clear breath sounds. Environmental precautions, although necessary, do not actively promote airway clearance or improve breath sounds.

C. Encourages the patient to perform cough, deep breathing, and postural drainage every 2 to 4 hours:
This intervention directly targets promoting airway clearance and improving breath sounds in a patient with pneumonia. Coughing helps mobilize secretions, deep breathing promotes lung expansion and ventilation, and postural drainage assists in the drainage of secretions from different lung segments. Regular performance of these interventions prevents secretion accumulation, thereby improving breath sounds and respiratory function.

D. Provides nutritional support if the patient is unable to take sufficient amounts by mouth:
While nutritional support is important for overall patient care, especially during illness or compromised nutritional intake, it does not directly address the need to ensure clear breath sounds in a patient with pneumonia. Although adequate nutrition supports immune function and overall recovery, it does not directly impact respiratory clearance or breath sounds.

A. Avoid alcohol for the first 3 weeks B. Avoid handling patient's leftover foods C. Have family members get an injection of immunoglobin D. Follow a low-protein, low carbohydrate diet

Correct Answer is B

Explanation

A. Avoid alcohol for the first 3 weeks: Avoiding alcohol may be advisable for patients with hepatitis A to prevent additional strain on the liver. However, it is not specifically related to preventing transmission of the infection to others. Therefore, it is not a transmission measure typically included in discharge instructions for the patient's family.

B. Avoid handling patient's leftover foods: Hepatitis A is primarily transmitted through the fecal-oral route, often via contaminated food or water. By avoiding handling the patient's leftover foods, the risk of transmitting the virus to family members through contaminated food is minimized. This measure helps prevent the spread of infection within the household.

C. Have family members get an injection of immunoglobulin: Immunoglobulin may be administered to individuals who have been exposed to hepatitis A to provide passive immunity and reduce the severity of the illness. However, this measure is typically recommended for individuals who have not been previously vaccinated against hepatitis A and have been in close contact with an infected person, rather than as a general preventive measure for all family members.

D. Follow a low-protein, low carbohydrate diet: While maintaining a healthy diet is important for overall health, there is no specific dietary recommendation related to protein or carbohydrate intake for patients with hepatitis A. Therefore, this measure is not directly related to preventing transmission of the infection to others and would not typically be included in discharge instructions for the patient's family.

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