In planning care for the patient with acute myocardial infarction (AMI), the nurse identifies the highest priority goal of care as which of the following?
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 a stable ECG rhythm is important, it is not the immediate concern post-AMI.
Choice B reason: The ability to verbalize causes and effects of CHD/CAD is an educational goal, not an immediate care priority.
Choice C reason: Adequate relief of pain is a priority to reduce stress on the heart and improve patient comfort.
Choice D reason: Compliance with prescribed bedrest is important but secondary to pain relief.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Pre-Renal failure is caused by factors external to the kidneys, typically involving reduced blood flow or hydration affecting kidney function. Gentamicin does not typically cause this type of failure.
Choice B reason : 'Super-secret double renal failure' is not a medically recognized type of renal failure.
Choice C reason : Post-Renal failure is due to obstruction of urine flow from the kidneys, which is not typically associated with Gentamicin use.
Choice D reason : Intra-Renal failure, also known as intrinsic renal failure, is caused by direct damage to the kidneys themselves. Gentamicin can cause acute kidney injury due to its nephrotoxic effects, leading to Intra-Renal failure.
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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