A nurse is caring for a client who has angina and reports a feeling of heaviness in the chest while ambulating in the hall. Which of the following actions should the nurse take first?
Obtain a 12-lead ECG for the client.
Administer sublingual nitroglycerin to the client.
Measure the client's vital signs.
Have the client stop walking and sit down.
The Correct Answer is D
Rationale:
A. Obtain a 12-lead ECG for the client: An ECG is important to assess for myocardial ischemia or infarction, but it should be done after immediate measures are taken to reduce myocardial oxygen demand.
B. Administer sublingual nitroglycerin to the client: Nitroglycerin helps relieve chest pain by dilating coronary arteries, but it should be given only after the client is safely seated or resting to prevent hypotension or injury.
C. Measure the client's vital signs: Vital signs provide valuable baseline data, but addressing the client’s immediate safety and reducing cardiac workload takes priority.
D. Have the client stop walking and sit down: Stopping activity decreases oxygen demand on the heart and prevents worsening ischemia or collapse, making it the first and most critical action.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. The client exhibits a flat affect: A flat affect reflects blunted emotional expression and is typically a symptom of depression. Its persistence suggests the condition has not yet improved.
B. The client can express angry feelings: The ability to identify and express emotions, including anger, indicates improved emotional responsiveness and progress in managing depressive symptoms. This reflects increased insight and healthier coping.
C. The client experiences self-doubt when making decisions: Persistent self-doubt is a common feature of depression and suggests that the client still struggles with confidence and decision-making.
D. The client looks down when speaking to others: Avoiding eye contact and looking down are associated with low self-esteem and social withdrawal, which are characteristic of depression and indicate the condition is not yet improving.
Correct Answer is C
Explanation
Rationale:
A. "I realize it can be hard to know what to expect at the moment my partner passes away.": This statement shows acknowledgment of the approaching death and emotional preparedness. It reflects acceptance and anticipatory grieving rather than denial.
B. "I have been taking pictures of others who visit with my partner so I can remember these days.": This indicates emotional awareness and an effort to preserve memories, suggesting the partner is coping and processing the impending loss.
C. "I'm shocked everyone has lost hope that my partner will overcome this illness.": This reflects denial, a common early grief reaction where the person struggles to accept the reality of impending death. The partner’s belief that recovery is still possible, despite the terminal prognosis, indicates difficulty facing the truth of the illness.
D. "I have been making arrangements so I can be at my partner's side when they pass away.": This demonstrates planning and emotional acceptance. The partner is preparingwhich reflects adaptive coping rather than denial.
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