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Exhibits

Review H and P, nurse's notes, flow chart, laboratory results, and prescriptions. Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the PN should take to address that condition, and two parameters the PN should monitor to assess the client's progress.

Answer and Explanation

The Correct Answer is []

The client’s symptoms—severe chest pain, nausea, dizziness, trembling, and diaphoresis—along with elevated troponin levels, are indicative of a myocardial infarction. Troponin is a cardiac biomarker used to diagnose myocardial infarction, and the client’s symptoms are consistent with this condition.

Actions to Take:

  1. Use Therapeutic Communication to Build Rapport
    Effective therapeutic communication helps the client feel supported and may reduce anxiety and fear related to their condition. This approach can provide a calm environment for the client, which is crucial when managing a myocardial infarction.
  2. Teach Coping Skills
    Teaching coping skills can help the client manage anxiety and stress, which are important for recovery from a myocardial infarction. Understanding how to cope with the emotional and psychological aspects of the condition supports overall care and management.

Parameters to Monitor:

  1. Heart Rhythm
    Monitoring heart rhythm is essential to detect any arrhythmias or complications related to myocardial infarction. Changes in heart rhythm can indicate worsening of the condition or response to treatment.
  2. Vital Signs
    Monitoring vital signs, including blood pressure and heart rate, is crucial for assessing the client’s hemodynamic status and the effectiveness of treatment. Abnormalities in vital signs can indicate worsening of the myocardial infarction or side effects of medications


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Related Questions

Correct Answer is B

Explanation

A. Wearing gloves during breakfast service is not always required, and the focus should be on ensuring proper hand hygiene rather than glove use.
B. The hand rub should be completed in 20-30 seconds, and the UAP’s 2-minute hand rub is excessive. Proper hand hygiene techniques should be reinforced.
C. The UAP does not need to remain in the client's room during hand hygiene; the primary issue is the duration of the hand rub.
D. Inspecting the hands for cleanliness is not necessary if the hand hygiene practice is incorrect; instead, correcting the technique is more important.

Correct Answer is D

Explanation

A. Measles Mumps Rubella (MMR) vaccine is typically administered at 12-15 months of age, not at 2 months. It is part of the recommended immunization schedule but is not given during the 2-month visit.
B. Varicella vaccine is usually given at 12-15 months of age. It is essential for preventing chickenpox but is not included in the 2-month immunization schedule.
C. Hepatitis A vaccine is recommended starting at 12 months of age. It is not part of the immunizations administered at 2 months.
D. Hepatitis B vaccine is part of the routine immunization schedule for infants and is given at birth, 1-2 months, and 6-18 months. At the 2-month visit, it is appropriate to administer the second dose of the Hepatitis B vaccine if it was not given at 1 month.

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