A nurse is caring for a client who is having an acute myocardial infarction (MI). The nurse is aware that which of the following are part of the assessment of cardiac pain. (SELECT ALL THAT APPLY)
Distribution
Onset
Intensity
Location
Radiation
Alleviated
Correct Answer : A,B,C,D,E,F
Rationale:
A. Distribution refers to the area of the body where the pain is felt.
B. Onset refers to when the pain started.
C. Intensity refers to the severity of the pain.
D. Location refers to where the pain is felt.
E. Radiation refers to whether the pain spreads to other areas.
F. Alleviated refers to what makes the pain better or worse.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. Mitral valve regurgitation typically presents with a murmur, which is a characteristic sound associated with the backflow of blood into the left atrium during systole.
B. S3 and S4 are not typical heart sounds and do not relate to mitral valve regurgitation.
C. A click is typically associated with mitral valve prolapse, not mitral valve regurgitation.
D. A friction rub is typically associated with pericarditis, not mitral valve regurgitation.
Correct Answer is ["A","B","D"]
Explanation
Rationale:
A. Fluid overload can lead to increased blood pressure due to the excess fluid circulating in the body.
B. Increased heart rate is a compensatory mechanism in response to fluid volume overload.
C. Increased hematocrit is not typically associated with fluid volume overload.
D. Increased respiratory rate is a compensatory mechanism in response to fluid volume overload.
E. Increased temperature is not typically associated with fluid volume overload.
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