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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Nephrotoxicity causes intrinsic renal failure due to direct damage to the renal parenchyma, not pre-renal failure.
Choice B reason: Acute tubular necrosis is a type of intrinsic renal failure resulting from damage to the renal tubules, not pre-renal failure.
Choice C reason: Hypovolemia is a common cause of pre-renal failure due to decreased blood flow to the kidneys, leading to reduced urine output.
Choice D reason: Acute Glomerulonephritis is an intrinsic renal condition that affects the glomeruli, not a pre-renal cause.
Correct Answer is A
Explanation
Choice A reason: Level of consciousness is the most basic and sensitive indicator of altered brain function and is considered the most reliable indicator of neurologic status.
Choice B reason: Temperature is not a direct indicator of neurologic status and does not change as rapidly in response to neurologic events.
Choice C reason: Blood pressure can be affected by neurologic changes, but it is not as sensitive or specific as the level of consciousness.
Choice D reason: Pulse rate is not a direct indicator of neurologic status and can be influenced by a variety of non- neurologic factors.
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