The nurse assesses a male client who is brought to the emergency department (ED) by his family who believes he is having a heart attack. Which finding is the best indicator that a client is experiencing an acute myocardial infarction (AMI)?

Pain in the neck, jaw, or medial side of the left arm.

Anterior thorax pain that radiates between the scapulae.

Localized sternal border pain intensified by palpation.

Chest pain that intensifies upon chest excursion.

Answer and Explanation

The Correct Answer is A

A.   Pain radiating to the neck, jaw, or medial side of the left arm is a classic symptom of an acute myocardial infarction (AMI). This type of referred pain occurs because the heart's pain signals are often perceived in other areas of the body. This finding is a strong indicator of AMI and is consistent with the typical presentation of myocardial infarction.
B.   Pain in the anterior thorax that radiates between the scapulae can be associated with various conditions, including myocardial infarction, but it is less specific than pain radiating to the neck, jaw, or arm. While this type of pain can occur in AMI, it is not as distinctive as the classic left arm pain and may also be seen in conditions like angina or musculoskeletal issues.
C.   Localized sternal border pain that worsens with palpation is more indicative of a musculoskeletal issue, such as costochondritis, rather than an acute myocardial infarction. AMI typically presents with diffuse chest pain that is not localized or worsened by palpation.
D.   Chest pain that worsens with chest movement, such as deep breathing or coughing, is more characteristic of pleuritic pain or musculoskeletal pain rather than an acute myocardial infarction. In AMI, the pain is generally persistent and not influenced by respiratory movements.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

A. At six weeks post-hysterectomy, a focused assessment that addresses the specific concerns related to the surgery and recovery would be more appropriate. A full physical examination might be too broad for this purpose, although aspects of it might be included if specific issues are identified.
B. A Pap smear is typically not required during a post-surgical follow-up for a hysterectomy unless there is a specific reason to screen for cervical cancer. In many cases, especially if the hysterectomy was for benign reasons and the cervix was removed, Pap smears might not be necessary.
C. This approach is highly relevant for a post-surgical evaluation. Gathering information about the client’s activities since surgery helps assess the recovery process, identify any issues or complications, and provide appropriate advice for ongoing care. Activities might include physical activity levels, adherence to post-surgical instructions, any new symptoms, and overall well-being.
D. A comprehensive review of systems is a thorough approach to identifying any potential issues across various body systems. While this can be useful in some cases, it may be more extensive than necessary for a routine follow-up after a hysterectomy.

A. Absent or sluggish response consistent with a lower motor neuron lesion. B. Flaccid paralysis. C. Hyperactive response consistent with an upper motor neuron disorder. D. A normal reflex

Correct Answer is C

Explanation

A. An absent or sluggish deep tendon reflex typically indicates a lower motor neuron lesion, which affects the peripheral nerves or spinal cord segments involved in reflex arc processing. Lower motor neuron lesions often result in reduced or absent reflexes, not brisk responses.
B. Flaccid paralysis is characterized by a lack of muscle tone and reflexes, which is usually associated with lower motor neuron damage. A brisk 4+ reflex response does not indicate flaccid paralysis but rather heightened reflex activity.
C. A brisk 4+ response indicates hyperactivity of the deep tendon reflexes, which is consistent with an upper motor neuron disorder. Upper motor neuron lesions, such as those resulting from a cerebrovascular accident (CVA), often lead to increased reflex responses due to disruption in the normal inhibitory signals from the brain.
D. A normal reflex response is typically classified as 2+ on a scale of 0 to 4, where 2+ is considered average or expected. A 4+ response indicates hyperactivity, which is not normal but rather indicates increased reflexes, usually associated with upper motor neuron issues.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

The nurse assesses a male client who is brought to the emergency department (ED) by his family who believes he is having a heart attack. Which finding is the best indicator that a client is experiencing an acute myocardial infarction (AMI)?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client reports to the healthcare provider's office for a routine post-surgical evaluation six weeks after a hysterectomy. Which history-taking approach should the nurse use to gather the needed information?

Correct Answer is C

Explanation

A 75-year-old client with a recent history of a cerebrovascular accident (CVA) presents with right hemiparesis. The nurse tests the deep tendon reflexes on the right side and elicits a brisk 4+ response. Which interpretation of this finding is accurate?

Correct Answer is C

Explanation

Which finding should raise the greatest concern for a nurse who is performing an ear nose and throat (ENT) examination?

When assessing a client's lower extremities, which finding requires immediate intervention by the nurse?

When assessing a client's level of consciousness, the nurse determines that the client is alert and ambulatory, but confused. Which follow- up assessment should the nurse complete next?

In assessing a client's nailbeds, the nurse notes that the angle between the nail and the nailbed is 200 degrees. Which action should the nurse take?

In reading a client's record, the nurse notes that the client is experiencing tinnitus. Which assessment provides the nurse with the information needed to evaluate the effects of this condition?

While obtaining a health history, a client tells the nurse that he sometimes experiences shortness of breath. The nurse determines that the client's respirations are regular and deep, and his respiratory rate is 14 breaths/minute. What is the best nursing action?

A client comes to the clinic due to shoulder discomfort and intermittent pain while swimming laps. To identify normal range of motion (ROM) of the client's shoulder, which assessment technique should the nurse ask the client to perform?