A nurse working in an emergency department is assessing a client who is experiencing chest pain that began 6 hr ago. Which of the following findings indicates that the client is having a myocardial Infarction?
Decreased creatine kinase-MB
Decrease in respiratory rate
ST segment depression
Increased troponin I
The Correct Answer is D
Rationale:
A. Decreased creatine kinase-MB: CK-MB is a cardiac enzyme that rises within 4–6 hours of myocardial infarction and peaks around 24 hours. A decrease in CK-MB would not indicate acute myocardial injury and is not a diagnostic marker in this case.
B. Decrease in respiratory rate: A lower respiratory rate is not a typical or reliable indicator of myocardial infarction. Clients experiencing an MI are more likely to show signs of dyspnea, anxiety, or increased respiratory effort due to pain or decreased oxygenation.
C. ST segment depression: ST segment depression may indicate myocardial ischemia or a non-ST elevation myocardial infarction (NSTEMI), but it is less specific than biomarkers like troponin. It may also appear in other conditions such as angina or electrolyte imbalances.
D. Increased troponin I: Troponin I is a highly specific and sensitive cardiac biomarker that rises within 3–6 hours of myocardial injury. An elevated troponin I level 6 hours after the onset of chest pain strongly supports the diagnosis of myocardial infarction.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. "Maintain the client in a supine position for 24 hours following surgery.": Prolonged supine positioning increases the risk of pulmonary complications such as atelectasis. Early mobilization and elevating the head of the bed help promote lung expansion and reduce postoperative risks.
B. "Expect the client to have a palpable distended bladder following surgery.": A distended bladder is not expected and may indicate urinary retention, a common complication after anesthesia. The nurse should assess and address it promptly, rather than consider it normal.
C. "Report bleeding that saturates the client's dressing.": Active bleeding that saturates a postoperative dressing may indicate hemorrhage and requires immediate intervention. Reporting this finding is critical to prevent further complications like hypovolemia or shock.
D. "Ensure the client's urinary output is no less than 20 mL per hour.": Urine output should be at least 30 mL per hour in adults. A rate below this may indicate hypoperfusion or renal impairment and should prompt further assessment and intervention.
Correct Answer is C
Explanation
Rationale:
A. A small area rug is placed at the front door: Area rugs increase the risk of falls, especially in older adults or clients with mobility issues. Rugs should be removed or secured with non-slip backing to prevent tripping hazards at entrances and high-traffic areas.
B. The water heater is set at 54° C (129.2° F): This temperature is too high and poses a significant risk for burns or scalding. The recommended maximum water heater setting for safety is 49° C (120° F), especially in homes with children or older adults.
C. The batteries in the smoke alarms are changed annually: Changing smoke alarm batteries once a year aligns with fire safety recommendations. Functioning smoke alarms are a critical part of home safety and fire prevention.
D. A single light fixture hangs along the sidewalk to the house: One light may not provide adequate visibility, especially in poor weather or at night. Multiple, evenly spaced light sources are more effective for preventing trips or falls along walkways.
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