Exhibits
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
The Correct Answer is []
- Myocardial infarction (MI) is suggested by chest pain radiating to the left arm, diaphoresis, shortness of breath, and epigastric discomfort. The pain described as "sharp, tight, and like indigestion" aligns with cardiac ischemia.
- Administering oxygen helps improve myocardial oxygenation, reducing ischemia.
- Aspirin 325 mg is a standard intervention in suspected MI to prevent further platelet aggregation and reduce the risk of worsening thrombosis in the coronary arteries.
- Monitoring vital signs is critical to assess for hemodynamic stability and signs of worsening cardiac function (e.g., hypotension, tachycardia).
- Monitoring ECG rhythm helps detect ST-elevation or other ischemic changes and assess for life-threatening arrhythmias.
- Morphine may be used for chest pain, but it is now considered secondary to nitroglycerin and beta-blockers.
- Verapamil is a calcium channel blocker used for rate control in arrhythmias but is not first-line for acute MI.
- Platelet count and WBC count are not immediately relevant to MI management.
- Serum glucose levels may be affected by stress but are not a primary concern in acute MI management.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D","E"]
Explanation
A. Increased blood pressure is expected due to excess fluid in the vascular system, which raises blood volume and pressure.
B. Hematocrit is typically decreased in fluid volume overload due to hemodilution rather than increased.
C. Increased temperature is not a common finding in fluid overload, as fever is usually associated with infection rather than volume excess.
D. Increased heart rate (tachycardia) occurs as the heart compensates for excess fluid and decreased cardiac output.
E. Increased respiratory rate is common due to pulmonary congestion and fluid accumulation in the lungs, leading to dyspnea.
Correct Answer is A
Explanation
A. A murmur is the expected heart sound in mitral valve regurgitation, caused by the backflow of blood into the left atrium during systole. It is typically a holosystolic murmur heard best at the apex of the heart.
B. S3 and S4 heart sounds may be heard in heart failure but are not specific for mitral regurgitation.
C. A friction rub is associated with pericarditis, not valvular disease.
D. A click is typically heard in mitral valve prolapse, not mitral regurgitation.
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