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?

Rationale:

• Instruct client to avoid foods that have been fermented or aged: This dietary restriction applies to monoamine oxidase inhibitors (MAOIs), not trazodone, which is a serotonin antagonist and reuptake inhibitor (SARI).
• Encourage client to sleep until later in the morning: Oversleeping can disrupt circadian rhythms and worsen fatigue. A consistent, balanced sleep schedule is more therapeutic.
• Advise client to notify provider if pregnant: Trazodone is a category C medication and should only be used in pregnancy if the benefits outweigh the risks. The provider must be informed if the client is or may become pregnant.
• Encourage high-calorie finger foods: The client has experienced weight loss and decreased appetite. Nutrient-dense, easy-to-eat foods can support caloric intake without requiring full meals.
• Advise client to rise slowly from sitting position: Trazodone can cause orthostatic hypotension. Educating the client to change positions slowly helps prevent dizziness and potential falls.
• Encourage naps during the day when client is tired: Daytime napping can interfere with nighttime sleep and may reduce trazodone’s effectiveness in establishing a healthy sleep pattern.
• Encourage a regular sleep-wake schedule: Trazodone is often prescribed for sleep difficulties. A consistent routine supports sleep hygiene and enhances the medication’s effectiveness.

Rationale:

A. Obtain a 12-lead ECG for the client: An ECG is important for diagnosing myocardial ischemia or infarction, but it is not the immediate first step. The priority is to stop activity and reduce myocardial oxygen demand before further diagnostics.

B. Have the client stop walking and sit down: Angina is often triggered by physical exertion. Stopping activity and sitting down reduces oxygen demand on the heart, alleviates symptoms, and prevents further ischemia. This is the most immediate and essential first action.

C. Administer sublingual nitroglycerin to the client: Nitroglycerin helps relieve anginal pain by dilating coronary arteries, but it should be given after the client has stopped activity and rested. Administering it while the client is still active may not be effective or safe.

D. Measure the client's vital signs: While vital signs are important for assessing the client’s current status, the priority is to stop exertion, which is likely contributing to myocardial oxygen imbalance. Assessment follows immediate symptom relief measures.