A nurse is collecting data from a client who has an acute myocardial infarction (MI). Which of the following clinical manifestations should the nurse expect to find? (Select all that apply.)
Nausea
Orthopnea
Diaphoresis
Headache
Tachycardia
Correct Answer : A,C,E
a. Nausea: Nausea is a common symptom of myocardial infarction and can be associated with autonomic nervous system activation.
b. Orthopnea: Orthopnea, difficulty breathing while lying down, is more commonly associated with heart failure, not necessarily myocardial infarction.
c. Diaphoresis: Profuse sweating or diaphoresis is a common manifestation of myocardial infarction due to sympathetic nervous system activation.
d. Headache: Headache is not a typical symptom of myocardial infarction. However, some individuals may experience atypical symptoms.
e. Tachycardia: Tachycardia (rapid heart rate) is a common response to myocardial infarction and can be associated with sympathetic nervous system stimulation in response to decreased cardiac output.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
a. Neck vein distention: Neck vein distention may indicate fluid overload, but it is not a direct measure of fluid losses.
b. Body weight: Monitoring body weight before and after hemodialysis provides a direct
measure of fluid losses. Hemodialysis removes excess fluid, and changes in body weight reflect fluid balance.
c. Abdominal girth: Abdominal girth may be affected by fluid accumulation but is not a direct measure of fluid losses during hemodialysis.
d. Blood pressure: While blood pressure may be influenced by fluid status, it is not a specific measure of fluid losses during hemodialysis. Body weight is a more direct indicator of fluid removal.
Correct Answer is A
Explanation
a.The statement "I will drink plenty of fluids after the test" indicates the client's understanding that hydration is important after the procedure, which is also a crucial aspect of post-procedure care. This response suggests the client understands the need to stay hydrated after ingesting barium, which helps eliminate the contrast material from the body and prevents constipation.
b. “I will expect my stool to be black after this procedure.”: The statement is related to the potential side effects of barium, but it does not address the pre-test instructions.
c. “I will expect a warm feeling when the dye is injected.”: This statement may relate to the sensation during the test but does not address the pre-test instructions.
d.while fasting may be required before the test, a clear liquid diet is not typically maintained for 24 hours prior to the procedure.
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