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

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A reason: While it is useful to know the patient's current pain management strategies, new onset severe back pain could indicate a serious complication such as a spinal fracture or compression, which requires immediate attention.

Choice B reason: Reassuring the patient is not appropriate without further assessment, as new onset severe pain could signify a serious issue that needs to be addressed.

Choice C reason: Suggesting a back brace may be part of the management plan, but it should not precede notifying the healthcare provider of new severe pain.

Choice D reason: Notifying the healthcare provider is the correct action because new onset severe back pain in a patient with multiple myeloma could indicate a serious condition such as a spinal fracture or compression, which requires prompt evaluation and treatment.

A. "I should avoid the use of tanning booths." B. "I should use sunscreen even on cloudy days." C. "I should check my skin monthly for any changes." D. "Eating a high-fiber diet will reduce my risk for developing skin cancer."

Correct Answer is D

Explanation

Choice A reason: Avoiding tanning booths is correct and does not indicate a need for further teaching.

Choice B reason: Using sunscreen even on cloudy days is correct and does not indicate a need for further teaching.

Choice C reason: Checking the skin monthly for any changes is correct and does not indicate a need for further teaching.

Choice D reason: The statement about eating a high-fiber diet reducing the risk for developing skin cancer indicates a misunderstanding, as there is no direct correlation between a high-fiber diet and the prevention of skin cancer. This indicates a need for further teaching.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient with multiple myeloma calls the home health nurse complaining of severe back pain of new onset. The appropriate response by the nurse is to do which of the following?

Correct Answer is D

Explanation

A nurse is providing teaching to a client about preventing skin cancer. Which of the following client statements indicates a need for further teaching?

Correct Answer is D

Explanation

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