A nurse is collecting data from a client who has heart failure and takes chlorothiazide sodium. Which of the following findings should the nurse identify as indicating hypokalemia?

A. Headache:

Headache is not typically a clinical manifestation of an acute myocardial infarction. The more common symptoms are related to chest pain, autonomic responses, and cardiovascular changes.

B. Tachycardia:

Tachycardia, or an increased heart rate, is a common symptom during an acute MI. This occurs as the body attempts to compensate for decreased cardiac output and perfusion.

C. Nausea:

Nausea is a frequent symptom associated with an acute MI. It results from the activation of the autonomic nervous system during the heart attack.

D. Diaphoresis:

Diaphoresis, or excessive sweating, is a classic symptom of an acute MI. It occurs due to the sympathetic nervous system's response to pain and stress from the heart attack.

E. Orthopnea:

Orthopnea, or difficulty breathing when lying down, is more commonly associated with congestive heart failure rather than an acute MI. While shortness of breath can occur during an MI, orthopnea is not a primary manifestation.

A. Arrange referral for family therapy to deal with home stressors:

While family therapy may be beneficial in addressing underlying issues, suspected abuse must be reported promptly to protect the client's safety. Referral for family therapy can be considered as part of a comprehensive intervention plan but should not delay reporting of suspected abuse.

B. Follow the agency's guidelines for reporting suspected abuse:

Reporting suspected abuse is the first priority when there are concerns about a client's safety. Following the agency's guidelines ensures that the appropriate authorities are notified and that the client receives the necessary protection and support.

C. Check the bruises at the next visit to the client's home:

Delaying action and waiting until the next visit to check the bruises could put the client at further risk of harm. Suspected abuse requires immediate attention, and the nurse should follow established protocols for reporting and intervening in such situations.

D. Institute more frequent visits to the client's home:

While more frequent visits may allow for closer monitoring of the client's condition, suspected abuse should be addressed immediately through appropriate reporting channels. Increasing visit frequency alone may not adequately address the safety concerns and may delay necessary intervention.