A 46-year-old male client who had a myocardial infarction (MI) 24 hours ago comes to the nurse's station fully dressed and wanting to go home. He tells
the nurse that he is feeling much better at this time. Based on this behavior, which client problem should the nurse include in the plan of care?
Ineffective coping related to denial
Emotional conflict due to stress
Deficient knowledge of MI lifestyle changes
Anxiety related to treatment plan
The Correct Answer is A
Choice A reason: This is the correct answer because ineffective coping related to denial is a likely problem for a client who had an MI 24 hours ago and wants to go home despite his condition. Denial is a defense mechanism that helps people avoid facing unpleasant or threatening realities, such as having a heart attack and needing hospitalization and treatment. The nurse should assess the client's coping skills and provide emotional support and education.
Choice B reason: Emotional conflict due to stress is not a specific problem for a client who had an MI 24 hours ago and wants to go home despite his condition. Emotional conflict is a state of having mixed or contradictory feelings about something or someone, such as family, work, or self. Stress is a response to any physical, psychological, or environmental demand that exceeds one's coping resources. The nurse should assess the client's sources of stress and conflict and help him manage them.
Choice C reason: Deficient knowledge of MI lifestyle changes is not a primary problem for a client who had an MI 24 hours ago and wants to go home despite his condition. Deficient knowledge is a state of lacking information or understanding about something, such as disease process, treatment options, or self-care measures. Lifestyle changes are modifications in one's habits or behaviors that promote health and well-being, such as diet, exercise, smoking cessation, or stress management. The nurse should assess the client's learning needs and readiness and provide appropriate education.
Choice D reason: Anxiety related to treatment plan is not an evident problem for a client who had an MI 24 hours ago and wants to go home despite his condition. Anxiety is a feeling of apprehension, worry, or fear that interferes with one's normal functioning or well-being. Treatment plan is a set of goals, interventions, and outcomes that guide the care of a client with a specific health problem, such as MI. The nurse should assess the client's level of anxiety and provide information and reassurance about his treatment plan.
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Related Questions
Correct Answer is C
Explanation
Choice A reason: Monitoring indwelling urinary catheter and measure strict intake and output is not an action that the nurse should immediately take, as this is not relevant or urgent for a client who may have had a stroke. This is a distractor choice.
Choice B reason: Keeping the bed in the lowest position and initiating seizure and fall precautions is not an action that the nurse should immediately take, as this is a preventive measure that does not address the acute problem of impaired cerebral perfusion. This is another distractor choice.
Choice C reason: Starting two large bore IV catheters and reviewing inclusion criteria for IV fibrinolytic therapy is an action that the nurse should immediately take, as this can prepare the client for potential administration of tissue plasminogen activator (tPA), which can dissolve blood clots and restore blood flow to the brain if given within 4.5 hours of stroke onset. Therefore, this is the correct choice.
Choice D reason: Maintaining elevated positioning of the dependent joints on affected side is not an action that the nurse should immediately take, as this can worsen edema and impair circulation in the affected limbs. The recommended position is to keep them at or below heart level. This is another distractor choice.
Correct Answer is C
Explanation
Choice C reason: serum potassium, calcium, and phosphorus are electrolytes that can be affected by ESRD. ESRD is a condition in which the kidneys lose their ability to filter waste products and excess fluids from the blood. This can cause electrolyte imbalances that can lead to serious complications, such as cardiac arrhythmias, bone disorders, or metabolic acidosis. The nurse should closely monitor these electrolytes and report any abnormal values.
Choice A reason: blood pressure, heart rate, and temperature are vital signs that are not specific to ESRD. Vital signs can be influenced by many factors and may not reflect the severity of kidney damage. The nurse should monitor vital signs regularly, but not as closely as electrolytes.
Choice B reason: leukocytes, neutrophils, and thyroxine are not laboratory results that are directly related to ESRD. Leukocytes and neutrophils are types of white blood cells that are involved in immune response and inflammation. Thyroxine is a hormone that regulates metabolism and growth. These laboratory results may be altered by other conditions or medications, but not by ESRD.
Choice D reason: erythrocytes, hemoglobin, and hematocrit are laboratory results that measure the red blood cell count and oxygen-carrying capacity of the blood. These laboratory results may be decreased in ESRD due to anemia, which is a common complication of chronic kidney disease. However, anemia is not as life-threatening as electrolyte imbalances and can be treated with erythropoietin injections or iron supplements.
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