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. Position the client flat in bed: This position may increase pressure on the abdomen and exacerbate ascites. The head of the bed should be elevated to enhance respiratory function.
b. Weigh the client weekly: Weighing the client daily is more appropriate to monitor fluid retention and assess the effectiveness of interventions.
c. Medicate the client with acetaminophen for discomfort: While acetaminophen can be used for pain relief, its use should be monitored closely due to the potential for liver toxicity in clients with cirrhosis.
d. Measure the client’s abdominal girth every 8 hours: Monitoring abdominal girth is crucial for assessing the degree of ascites and evaluating the effectiveness of interventions.
Correct Answer is B
Explanation
a. "Both illnesses begin in the rectum." This statement is not accurate. Ulcerative colitis typically begins in the rectum and progresses proximally, while Crohn's disease can involve any part of the digestive tract.
b. "Both illnesses are inflammatory in nature." This is the correct statement. Both ulcerative colitis and Crohn's disease are inflammatory bowel diseases characterized by chronic
inflammation of the gastrointestinal tract.
c. "Both illnesses manifest fistula formation." Fistula formation is more commonly associated with Crohn's disease, not ulcerative colitis.
d. "Both illnesses result in malabsorption of nutrients." While malabsorption can occur in both conditions, it is generally more associated with Crohn's disease than ulcerative colitis.
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