A nurse is collecting data from a client who has pneumonia and is experiencing acute respiratory acidosis. Which of the following manifestations should the nurse expect to find?

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) Administer another dose of the beta-blocker as prescribed by the physician: Administering another dose of the beta-blocker may not be the best course of action. If the client is experiencing fatigue and weakness, it could be a sign that the medication’s side effects are causing these symptoms. Administering an additional dose may exacerbate these side effects. Adjusting the medication regimen should be done under the direction of the healthcare provider.

(b) Offer the client a salty snack to improve blood pressure: Offering a salty snack may increase blood pressure, but it does not address the underlying issue of the medication’s side effects. Moreover, a diet high in salt can lead to other health problems, such as heart disease and stroke.

(c) Document the client’s symptoms and notify the healthcare provider: Documenting the client’s symptoms and notifying the healthcare provider is the most appropriate initial nursing action. The healthcare provider needs to be informed so that appropriate changes to the medication regimen can be made.

(d) Encourage the client to participate in physical therapy exercises: While physical therapy exercises can be beneficial for overall health, they do not address the immediate concern of the medication’s side effects. The client’s symptoms are indicative of medication side effects rather than a lack of physical activity. While physical therapy is important, it is not the most immediate priority in addressing the client’s current symptoms.