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.
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:
- 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. - 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:
- 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. - 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
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Urinary output of 50 mL/hour is within normal limits and does not directly impact morning care instructions.
B. An oxygen saturation measurement of 95 to 96% is generally acceptable and does not necessitate specific morning care instructions.
C. A blood pressure of 144/84 mm Hg is elevated but not critical in the context of morning care instructions for the UAP.
D. Orientation to person only indicates a cognitive impairment that could affect the client’s ability to understand or follow instructions, cooperate during care, and ensure safety during activities like bathing or moving. This is the most critical factor to consider when providing instructions to the UAP.
Correct Answer is A
Explanation
A. Instructing the UAP to lower the bed for safety is the correct action. The bed should be in a low position to prevent falls and ensure safety during client care activities.
B. Determining if the UAP would like assistance is not the most effective immediate action. The priority is to address the safety concern of the bed position rather than offering assistance.
C. Remaining in the room to supervise the UAP is less effective than directly addressing the safety issue. The bed should be in the proper position for safe client care.
D. Assuming care of the client immediately is not necessary unless there are additional concerns about the client's well-being. The primary action should be to correct the unsafe practice of the bed position.
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