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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

Answer and Explanation

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.

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Correct Answer is B

Explanation

Rationale:

A. Looking for P waves is important for assessing atrial activity, but it does not directly calculate heart rate.

B. Counting how many QRS complexes occur in a 6-second strip and multiplying by 10 is a quick and accurate way to calculate heart rate.

C. Reading the monitor or ECG interpretation provides information about the rhythm and morphology of the heart, but it does not directly calculate heart rate.

D. Measuring T waves is important for assessing cardiac repolarization, but it does not directly calculate heart rate.

A. Reduce Blood pressure until patient is asymptomatic B. Reduce the blood pressure to normal over a period of hours. C. Reduction of blood pressure to normal over a period of days D. Reduction of blood pressure by 50% in the first hour.

Correct Answer is D

Explanation

Rationale:

A. Reducing blood pressure until the patient is asymptomatic is not specific and may not be achievable or safe.

B. Reducing the blood pressure to normal over a period of hours may be too slow for a hypertensive emergency.

C. Reducing blood pressure to normal over a period of days is too slow for a hypertensive emergency.

D. The goal in a hypertensive emergency is to reduce blood pressure by 25% to 30% within the first hour, with the ultimate goal of a reduction of 50% in the first hour.

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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)

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