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":"B","dropdown-group-2":"A"}
Rationale for Correct Answers:
- Myocardial infarction: The client's worsening chest pain and increasing troponin levels strongly indicate myocardial injury. Despite initial nitroglycerin, symptoms persisted, and thrombolytic therapy was started, consistent with acute MI management.
- Troponin levels: Troponin T rose from 0.08 to 0.2 ng/mL, and Troponin I from 0.01 to 0.1 ng/mL, exceeding the normal range. These cardiac biomarkers are sensitive indicators of myocardial cell damage, confirming the progression toward infarction.
Rationale for Incorrect Choices:
- Bleeding: Although thrombolytics and aPTT monitoring are related to bleeding risks, there is no current evidence of bleeding (e.g., hematuria, bruising, low platelets, or elevated aPTT). Platelets and aPTT are within normal ranges, so this is not the primary concern at this time.
- Pulmonary embolism: The client is short of breath and diaphoretic, which could be seen in PE, but there is no indication of risk factors like immobility, recent surgery, or DVT symptoms. Elevated troponins and anginal symptoms more clearly support a cardiac rather than embolic cause.
- Shortness of breath: While SOB is a significant clinical symptom, it is nonspecific and could result from anxiety, cardiac ischemia, or pulmonary causes. It does not directly confirm the most urgent diagnosis, which is best supported by objective lab data such as troponins.
- aPTT levels: The aPTT is within the expected therapeutic range and does not indicate a coagulation problem at this time. It is not a primary driver of the client's current risk status, especially in comparison to the elevated cardiac markers.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Discontinue opioids before trying nonpharmacological methods of pain relief: Abruptly stopping opioids can lead to withdrawal symptoms and uncontrolled pain. Nonpharmacological methods are often used alongside pharmacological treatments, not as replacements.
B. Distraction changes the client's perception of pain, but it does not affect the cause: Distraction techniques help reduce the emotional and cognitive experience of pain by shifting the client’s focus, but they do not alter the underlying physical cause. This makes distraction an effective adjunct in pain management.
C. Use imagery with clients who have difficulty with focus and concentration: Guided imagery requires good cognitive engagement and focus, so it may not be suitable for clients with concentration difficulties. Alternative methods may be more appropriate for such clients.
D. Pain relief from the use of heat and cold continues for several hours after removal of the stimulus: The effects of heat and cold therapy typically last for a short period after application, often less than an hour. Continuous or repeated application is usually necessary to maintain pain relief.
Correct Answer is C
Explanation
A. Gently massage the area around the client's incision: Massaging near a recent surgical site can disrupt healing, increase pain, and risk infection or injury, so this intervention is contraindicated postoperatively.
B. Place pillows under the client's knee: Placing pillows directly under the knee can promote flexion contractures, which impede rehabilitation. Instead, the knee should be kept in a neutral or slightly extended position.
C. Apply an ice pack to the client's knee: Applying ice helps reduce inflammation and pain after surgery by constricting blood vessels and numbing the area, making it an appropriate nonpharmacologic pain management strategy.
D. Perform range-of-motion exercises to the client's knee: While important for recovery, initiating range-of-motion exercises during moderate pain (level 6) may increase discomfort and should be timed appropriately with pain control measures.
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