Exhibits
Click to highlight the findings that require follow up.
Neurological: Alert and oriented. Agitated. Denies headaches.
Cardiovascular: Reported chest pain described as pressure and tightness that is unrelieved with rest. Rapid regular rhythm. Normal heart tones. Radial and pedal pulses 2+. Capillary refill 2 seconds.
Respiratory: Rapid and shallow breaths. Clear breath sounds throughout bilateral lungs.
Gastrointestinal: Within normal limits (WNL).
Genitourinary: WNL
Musculoskeletal: WNL
Pain: 7 on a 0 to 10 scale, tightness and pressure in chest. Started approximately 2 hours ago and got progressively worse, unrelieved by rest.
Alert and oriented
chest pain described as pressure and tightness that is unrelieved with rest
Radial and pedal pulses 2+
Capillary refill 2 seconds
Rapid and shallow breaths
Clear breath sounds throughout bilateral lungs
7 on a 0 to 10 scale, tightness and pressure in chest
The Correct Answer is ["B","E","G"]
Chest pain described as pressure and tightness that is unrelieved with rest: Chest pain that is described as tightness and pressure, particularly when unrelieved by rest, is a classic presentation of acute coronary syndrome (ACS), which includes conditions such as unstable angina or myocardial infarction (MI). This is a red flag symptom, as it indicates a need for immediate medical attention to rule out life-threatening conditions like MI, which can be fatal without timely intervention.
Rapid shallow breaths: Rapid and shallow breathing can be a response to acute pain, particularly in a situation involving cardiovascular stress. It may be indicative of the body's attempt to compensate for inadequate oxygenation due to cardiac ischemia, hypoxia, or anxiety.
Pain 7/10, tightness and pressure in the chest: A pain rating of 7/10 demands immediate evaluation and management, as it could indicate an evolving cardiovascular event. Moreover, tightness and pressure are specific descriptors of pain seen in ischemic heart disease, where there is reduced blood flow to the heart muscle, leading to discomfort due to oxygen deprivation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A: Assistive feeding devices may help, but they do not directly address the risk of aspiration. Improving swallowing mechanics is more immediately beneficial.
B: The tucked-chin position helps protect the airway by improving swallowing coordination and reducing the risk of aspiration during meals. It is a simple technique that can significantly help clients with swallowing difficulties.
C: Lying down can increase the risk of aspiration by allowing food to enter the airway more easily.
D: Supplemental liquid feedings may be necessary for some ALS patients, but addressing the client’s swallowing technique during meals should take priority to prevent aspiration.
Correct Answer is B
Explanation
A. Drinking large amounts of fluids before bedtime may increase nocturia but does not specifically prevent UTIs.
B. Voiding before and after sexual activity helps flush out bacteria that could enter the urethra.
C. Holding urine is harmful and can increase the risk of bacterial growth.
D. Cleaning in a circular motion is not the correct hygiene technique; wiping front to back is the recommended method.
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