A nurse on a step-down unit is admitting a client.
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Nurses' Notes
Day 3, 1350:
Client transferred to step-down unit from ICU for continued care following a myocardial infarction (MI) 2 days ago. Oriented to room. Client reports a productive cough, States they are short of breathand that ambulating to the bathroom has resulted in chest pain. Reports pain as 3 on a scale of 0 to 10. Client appears anxious and reports a fear of dying.
Oriented to room.
Client reports a productive cough
States they are short of breathand that ambulating to the bathroom has resulted in chest pain.
Reports pain as 3 on a scale of 0 to 10.
Client appears anxious and reports a fear of dying.
The Correct Answer is ["B","C","E"]
Rationale for Correct Findings:
- Productive cough: In a client with COPD and recent MI, this may signal infection or fluid overload, especially if paired with fever, dyspnea, and hypoxia. Immediate assessment is needed to rule out pneumonia or heart failure.
- Shortness of breath and chest pain with ambulation: This raises concern for myocardial ischemia, reinfarction, or worsening heart function. Chest pain with minimal exertion post-MI demands prompt evaluation and possible ECG and oxygen therapy.
- Anxiety and fear of dying: Sudden intense fear may indicate worsening hypoxia, cardiac distress, or even be a prodrome to another MI. It should not be dismissed as purely psychological, especially in the context of other concerning symptoms.
Rationale for Incorrect Findings:
- Pain rated 3/10: A mild pain score suggests the discomfort is currently manageable. While chest pain after MI is always important, this level does not in itself indicate an emergency unless it worsens or is unrelieved.
- Oriented to room: Being alert and oriented indicates preserved cognition and neurologic stability. No immediate follow-up is needed based on this observation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. A client who requests assistance to use the bedside commode: This is a routine activity that falls within the scope of practice for assistive personnel. As long as the AP follows standard safety procedures, there is no immediate need to report this to the nurse.
B. A client who requests to sit in the bedside chair while watching TV: Allowing a client to sit up in a chair is within the AP’s role, provided the client is stable and fall precautions are followed. It does not require nurse notification unless there are complications.
C. A client who has a prescription for compression stockings and did not receive them: This indicates a potential lapse in prescribed therapy, which could increase the risk of complications like deep vein thrombosis. The nurse must be informed to evaluate and correct the omission promptly.
D. A client who consumes all the food from their meal tray: Reporting full meal consumption is not necessary unless the client is on a monitored diet or has specific nutritional concerns. In most cases, this is expected and requires only standard documentation.
Correct Answer is D
Explanation
Rationale:
A. "Let's discuss some weight loss strategies that might work for you.": While well-intentioned, this response shifts focus prematurely to problem-solving rather than acknowledging the client's immediate emotional distress. It can come across as dismissive of the client's feelings and reinforce stigma.
B. "Have you always felt uncomfortable being overweight?": This question delves into the client's history without first validating their current emotional state. It may seem intrusive and bypasses the opportunity to provide empathy in the moment.
C. "How long have you struggled with your weight?": This response centers on the weight issue rather than addressing the client’s expressed feelings of being stared at and judged. It risks making the client feel pathologized rather than supported.
D. “It sounds like you're saying that you feel uncomfortable around others.”: This therapeutic response reflects the client's feelings, validates their emotional experience, and encourages further expression. It helps build trust and demonstrates empathy without judgment.
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