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

Answer and Explanation

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.

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Correct Answer is A

Explanation

Rationale:

A. “You can obtain a personal response system that will be activated if you fall.": Personal emergency response systems (PERS) allow individuals who live alone to call for help immediately in case of a fall or emergency.

B. “You need to move to a skilled nursing facility where they can prevent falls.": Moving to a skilled nursing facility is a major step and is not necessary solely due to fear of falling. It may also provoke anxiety or feelings of loss of autonomy, especially if less invasive alternatives are available.

C. "You can have an unlicensed assistive personnel (UAP) come to your house daily to stay with you.": Daily UAP support may not be realistic or necessary for someone who is still generally independent. This level of care may be excessive unless the client has significant mobility or cognitive impairments.

D. "You should contact a family member once a week to keep in touch.": While weekly contact with family can offer emotional support, it does not provide real-time assistance in the event of a fall. It’s not a sufficient solution for immediate safety concerns.

A. Use a cane for support while walking. B. Avoid the use of orthotics. C. Implement a rigorous range-of-motion exercise plan. D. Walk with feet close together for stability.

Correct Answer is A

Explanation

Rationale:

A. Use a cane for support while walking: A cane can enhance balance and reduce the risk of falls in clients with multiple sclerosis, who may experience muscle weakness, spasticity, or ataxia. It promotes mobility while maintaining safety in the home environment.

B. Avoid the use of orthotics: Orthotic devices, such as ankle-foot orthoses, can actually be helpful in improving gait and preventing foot drop. Advising against their use may deprive the client of important supportive tools.

C. Implement a rigorous range-of-motion exercise plan: While exercise is important, a rigorous plan may lead to fatigue and overheating, which can worsen MS symptoms. A gentle, balanced routine tailored to the client’s tolerance is safer.

D. Walk with feet close together for stability: Keeping the feet close together narrows the base of support and increases fall risk. A wider stance improves balance and stability, which is safer for ambulating clients with MS.

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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?

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Naxlex Comprehensive Predictor Exams

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