A nurse is caring for a client who has angina.
Complete the following sentence by using the lists of options.
The client is at risk for developing
The Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"C"}
- Myocardial infarction: The rising troponin levels (Troponin T increasing from 0.08 ng/mL to 0.2 ng/mL and Troponin I rising from 0.01 ng/mL to 0.1 ng/mL) indicate myocardial injury. Persistent chest tightness, shortness of breath, diaphoresis, and anxiety suggest ongoing ischemia. The lack of complete pain relief after nitroglycerin further supports myocardial infarction rather than stable angina.
- Pulmonary embolism: Shortness of breath is a symptom of pulmonary embolism, but the absence of acute hypoxia, pleuritic chest pain, or significant coagulation abnormalities makes this less likely. The client's symptoms and laboratory findings more strongly support a cardiac etiology.
- Bleeding: While thrombolytic therapy increases bleeding risk, the aPTT (32 seconds) and platelet count (350,000/mm³) are within normal limits. There are no reported signs of active bleeding, such as hypotension, bruising, or hematuria, making this a less relevant immediate concern.
- Shortness of breath: Often present in myocardial infarction due to decreased cardiac output and pulmonary congestion. The combination of chest pain, diaphoresis, and dyspnea suggests worsening ischemia rather than a primary pulmonary process. However, it is a nonspecific symptom that can also indicate pulmonary embolism or respiratory distress.
- aPTT levels: Normal at 32 seconds (reference: 30–40 seconds), which suggests no immediate risk of abnormal clotting or excessive anticoagulation. This finding does not directly indicate myocardial infarction but is important in monitoring bleeding risk with thrombolytic therapy. A significantly elevated aPTT could raise concern for hemorrhagic complications.
- Elevated troponin levels: A highly specific marker for myocardial injury. The rise in Troponin T and Troponin I over time confirms myocardial damage, distinguishing acute coronary syndrome from stable angina. This trend is critical in diagnosing myocardial infarction, as troponin elevation correlates with the extent of cardiac muscle injury.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Assess the client's bilateral hand grasp strength: Slurred speech in a client with sickle cell crisis raises concern for stroke due to vaso-occlusion in cerebral vessels. Assessing hand grasp strength helps evaluate for unilateral weakness, a key indicator of stroke, necessitating immediate intervention.
B. Place a padded tongue blade at the client's bedside: There is no indication the client is experiencing a seizure. Seizure precautions are not a priority unless additional neurological symptoms suggest seizure activity.
C. Check the client's bedside glucose level: Hypoglycemia can cause slurred speech, but in a client with sickle cell disease, stroke is a more likely cause. Assessing neurological function should take precedence over checking glucose unless the client has a history of diabetes or other risk factors.
D. Administer flumazenil IV per facility policy to the client: Flumazenil is used to reverse benzodiazepine overdose. There is no indication that the client has received benzodiazepines or is experiencing medication toxicity.
Correct Answer is ["B","D","E"]
Explanation
- "The iron supplement might cause my stools to be black.": This statement is correct as one of the common side effects of iron supplementation is darkening of the stools. This occurs due to the unabsorbed iron and is generally harmless, but clients should be educated about this to avoid confusion with gastrointestinal bleeding.
- "I should increase green leafy vegetables in my diet.": Green leafy vegetables are excellent sources of iron, particularly non-heme iron, which can help improve the client's iron levels. Encouraging a diet rich in iron-rich foods is essential for effective management of iron deficiency anemia, especially for clients on a vegan diet.
- "I will take my iron supplement 1 hour before a meal.": Taking iron supplements on an empty stomach enhances absorption. Clients should be instructed to take the supplement ideally 1 hour before meals or 2 hours after meals for optimal efficacy, unless gastrointestinal discomfort occurs.
- "I should expect to have swelling in my feet.": This statement is not appropriate. Swelling in the feet may indicate fluid retention or other medical issues that should be reported. It is not a typical or expected side effect of iron supplementation or iron deficiency anemia.
- "The iron supplement might cause ringing in my ears.": Ringing in the ears (tinnitus) is not a common side effect of iron supplements. If a client experiences this symptom, it may be related to other factors or medications and should be investigated further.
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