In planning care for a patient with acute myocardial infarction (AMI), which of the following should the nurse identify as the highest priority goal of care?

Stable ECG rhythm

Ability to verbalize causes and eﬀects of CHD/CAD

Adequate relief of pain

Compliance with prescribed bedrest

Answer and Explanation

The Correct Answer is C

Choice A reason : While maintaining a stable ECG rhythm is important, it is not the highest priority. The primary concern is to address life-threatening complications.

Choice B reason : Educating the patient about the causes and eﬀects of coronary heart disease (CHD) or coronary artery disease (CAD) is important for long-term management but is not the immediate priority during acute care.

Choice C reason : Adequate relief of pain is the highest priority in the care of a patient with AMI. Pain is an indicator of ongoing ischemia and can increase the workload of the heart, thereby worsening the condition.

Choice D reason (AMI): While bedrest is part of the care plan, it is not the highest priority compared to pain relief, which has direct implications on the patient's immediate physiological status.

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Correct Answer is C

Explanation

Choice A reason: While disturbed body image is a concern, it is not the highest priority for a patient undergoing a bone marrow transplant.

Choice B reason: Anxiety is important to address but does not take precedence over physical health concerns in the immediate post-transplant period.

Choice C reason: Ineﬀective protection is the highest priority because patients undergoing bone marrow transplants have compromised immune systems and are at high risk for infection.

Choice D reason: Imbalanced nutrition is a concern but is secondary to the risk of infection in the immediate care of a patient post bone marrow transplant.

A. Screening for metastasis will be important. B. Minimizing sun exposure reduces the risk for future BCC. C. The treatment plan includes watchful waiting. D. Low-dose systemic chemotherapy is used to treat BCC.

Correct Answer is B

Explanation

Choice A reason: Screening for metastasis is not typically necessary for BCC because it rarely metastasizes.

Choice B reason: Minimizing sun exposure is crucial in reducing the risk for future BCC, as UV radiation is a significant risk factor.
Choice C reason: Watchful waiting is not a standard treatment plan for BCC; treatment usually involves removal of the lesion.
Choice D reason: Low-dose systemic chemotherapy is generally not used to treat BCC; local treatments such as surgery or topical medications are preferred.

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In planning care for a patient with acute myocardial infarction (AMI), which of the following should the nurse identify as the highest priority goal of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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