Family members bring a client to the ED with pale cool skin, sudden midsternal chest pain unrelieved with rest, and a history of CAD. How should the nurse best interpret these initial data?

The symptoms indicate an acute coronary episode and should be treated as such.

The symptoms indicate angina and should be treated as such.

Treatment should be determined pending the results of an exercise stress test.

The symptoms indicate a pulmonary etiology rather than a cardiac etiology.

Answer and Explanation

The Correct Answer is A

A. The symptoms indicate an acute coronary episode and should be treated as such:

The client's symptoms, including sudden midsternal chest pain unrelieved with rest and a history of coronary artery disease (CAD), strongly suggest an acute coronary event, such as a myocardial infarction (heart attack). Pale, cool skin can also be indicative of decreased perfusion due to cardiac compromise. Given these critical signs and symptoms, the nurse should interpret this as a potential cardiac emergency and initiate immediate interventions aimed at managing and stabilizing the client's condition.

B. The symptoms indicate angina and should be treated as such:

While angina can present with symptoms such as chest pain, it is typically relieved with rest or nitroglycerin. In contrast, the client in this scenario has midsternal chest pain that is not relieved with rest, which is more indicative of an acute coronary event like a myocardial infarction. Therefore, interpreting the symptoms as angina and treating them as such may not be appropriate given the severity and persistence of the chest pain.

C. Treatment should be determined pending the results of an exercise stress test:

Waiting for the results of an exercise stress test is not appropriate in this scenario, as the client's presentation suggests an acute cardiac event that requires immediate intervention. Exercise stress tests are typically used for diagnostic purposes to assess cardiovascular function under controlled conditions but are not suitable for managing acute coronary episodes or emergencies.

D. The symptoms indicate a pulmonary etiology rather than a cardiac etiology:

While some symptoms, such as shortness of breath or chest pain, can overlap between cardiac and pulmonary conditions, the client's presentation with sudden midsternal chest pain unrelieved with rest, pale cool skin, and a history of CAD strongly suggests a cardiac etiology, specifically an acute coronary event. It is essential to prioritize cardiac assessment and intervention based on the client's symptoms and medical history.

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Correct Answer is ["A","B","C"]

Explanation

A. Relieve client symptoms - Heart failure can cause symptoms like shortness of breath, fatigue, swelling (edema), and difficulty exercising. Relieving these symptoms is an important goal to improve the client's quality of life and overall well-being.

B. Extend survival - Heart failure is a chronic condition that can significantly impact life expectancy. One of the goals of care is to optimize management to extend the client's survival and reduce the risk of complications.

C. Improve functional status - Heart failure can limit a person's ability to perform daily activities and exercise. Improving functional status involves strategies such as medication management, lifestyle modifications, and cardiac rehabilitation to enhance the client's ability to engage in daily activities and maintain independence.

D. Prevent endocarditis - Endocarditis is an infection of the inner lining of the heart chambers and heart valves. While preventing infections is important for overall health, preventing endocarditis may not be directly related to the primary goals of heart failure management. However, maintaining good hygiene and avoiding infections can contribute to the overall well-being of the client.

E. Limit physical activity - This statement is incorrect in the context of heart failure management. Encouraging appropriate levels of physical activity is often part of heart failure care. Physical activity, when tailored to the individual's abilities and guided by healthcare professionals, can improve cardiovascular function, strengthen muscles, and enhance overall health outcomes in clients with heart failure.

A. "Yes. Hypertension is prevalent among men; it is fortunate we caught this during your routine examination." B. "We will need to reevaluate your blood pressure because age places you at high risk for hypertension." C. "A single elevated blood pressure does not confirm hypertension. You will need to have your blood pressure reassessed several times before a diagnosis can be made. D. "You have no need to worry. Your pressure is probably elevated because you are being tested."

Correct Answer is C

Explanation

A. "Yes. Hypertension is prevalent among men; it is fortunate we caught this during your routine examination.": This response is premature as it assumes a diagnosis of hypertension based on a single elevated blood pressure reading without further assessment or confirmation.

B. "We will need to reevaluate your blood pressure because age places you at high risk for hypertension.": While age is a risk factor for hypertension, it is important not to jump to conclusions based on one blood pressure reading. Reevaluation and monitoring are necessary before making any definitive diagnoses or treatment decisions.

C. "A single elevated blood pressure does not confirm hypertension. You will need to have your blood pressure reassessed several times before a diagnosis can be made.": This response is appropriate because it acknowledges the need for further assessment and monitoring before determining if the client has hypertension. It also educates the client about the importance of multiple readings for an accurate diagnosis.

D. "You have no need to worry. Your pressure is probably elevated because you are being tested.": This response dismisses the client's concerns and does not provide accurate information about blood pressure assessment and hypertension diagnosis.

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Family members bring a client to the ED with pale cool skin, sudden midsternal chest pain unrelieved with rest, and a history of CAD. How should the nurse best interpret these initial data?

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Naxlex Comprehensive Predictor Exams

The nurse is planning the care of a client with heart failure. The nurse should identify what overall goals of this client's care? (Select All that Apply.)

Correct Answer is ["A","B","C"]

Explanation

A 56-year-old male client at a screening event has a blood pressure reading of 146/96 mm Hg. Upon hearing the reading, the client states, "My pressure has never been this high. Do you think my doctor will prescribe medication to reduce it?" What is the nurse's best response?

Correct Answer is C

Explanation

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