A nurse is caring for a client diagnosed with heart failure and atrial fibrillation. The client reports feeling palpitations and shortness of breath. The nurse is aware that clients with atrial fibrillation are at risk for which complication?
Hypertensive crisis
Cardiogenic shock
Embolic cerebral vascular accident
Flash pulmonary edema
The Correct Answer is C
A. Hypertensive crisis is not a direct complication of atrial fibrillation. It is typically caused by uncontrolled hypertension rather than arrhythmias.
B. Cardiogenic shock can occur in severe heart failure but is not a primary complication of atrial fibrillation.
C. Embolic cerebral vascular accident (stroke) is a major risk for clients with atrial fibrillation. The irregular atrial contractions allow blood to pool in the atria, increasing the risk of clot formation. If a clot dislodges, it can travel to the brain and cause a stroke.
D. Flash pulmonary edema is a complication of acute decompensated heart failure but is not directly caused by atrial fibrillation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Holding all medications is not necessary; only certain medications that affect heart rate or blood pressure are held.
B. Keflex (Cephalexin) is an antibiotic and does not affect stress test results, so it should not be held.
C. Tenormin (Atenolol) is a beta-blocker that reduces heart rate and can interfere with the stress test by blunting the expected heart rate response. Beta-blockers are typically held before an exercise stress test.
D. Heparin is an anticoagulant and does not impact the stress test results.
Correct Answer is ["A","B","C","E","F"]
Explanation
A. Location of the pain is an essential component of assessing cardiac pain, as MI-related pain is often described as substernal or radiating.
B. Distribution refers to how the pain spreads, such as from the chest to the jaw, neck, back, or arms, which is common in an MI.
C. Intensity helps determine the severity of pain and is often rated on a scale from 0 to 10.
D. While identifying factors that alleviate pain is important for overall assessment, it is not a core component of the initial pain assessment for MI.
E. Onset refers to when the pain began and whether it occurred suddenly or gradually, which helps in determining the cause.
F. Radiation is a critical aspect of cardiac pain assessment, as MI pain often radiates to the left arm, jaw, or back.
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