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.
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Related Questions
Correct Answer is D
Explanation
a. Emesis of 100 mL: While emesis is a concern, the priority is to address potential complications related to the surgical procedure first.
b. Oral temperature of 37.5" C (99.5° F): This temperature is within a normal range, and it is not an immediate concern.
c. Pain level of 4 on a 0 to 10 rating scale: Pain is important to address, but the priority is to assess for potential complications such as bleeding or infection.
d. Thick, red-colored urine: This finding suggests the possibility of bleeding, which could be a complication of the TURP procedure. It is the priority finding to report to the provider for further evaluation.
Correct Answer is B
Explanation
a. Rest in a supine position: Resting in a supine position may compromise lung expansion, and an upright position is often recommended for clients with emphysema to improve ventilation.
b. Breathe in through her nose and out through pursed lips: This technique helps maintain
positive airway pressure, preventing premature airway collapse, and can improve gas exchange in clients with emphysema.
c. Limit fluid intake throughout the day: Adequate hydration is important for maintaining
respiratory secretions in a liquefied state and is generally encouraged for clients with respiratory conditions.
d. Consume a low-protein diet: A low-protein diet is not specifically indicated for improving gas exchange in clients with emphysema. Nutrition recommendations may focus on a well-balanced diet to support overall health.
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