The nurse is caring for a client receiving thrombolytic therapy following an acute myocardial infarction (MI). Which nursing problem should the nurse identify as priority for this client?
Risk for injury related to effects of thrombolysis.
Activity intolerance related to ischemia.
Ineffective breathing pattern related to adverse drug effects.
Deficient knowledge related to a new medication regimen.
The Correct Answer is A
A. Clients receiving thrombolytic therapy are at an increased risk of bleeding, which can manifest as internal bleeding, hemorrhage at vascular access sites, gastrointestinal bleeding, or intracranial bleeding. The nurse's priority is to closely monitor the client for signs and symptoms of bleeding, such as sudden onset or worsening of headache, changes in level of consciousness, hematuria, melena, ecchymosis, or hematoma formation.
B. While activity intolerance is a common nursing diagnosis for clients following an acute myocardial infarction due to myocardial ischemia, it is not the priority in this case where the client is actively receiving thrombolytic therapy.
C. While respiratory complications can occur following thrombolytic therapy, such as pulmonary embolism or bleeding into the lungs, the risk of bleeding complications takes precedence as the priority nursing problem for this client.
D. Education about the new medication regimen is important for client understanding and adherence, but it is not the priority nursing problem in the immediate post-thrombolytic therapy period.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Physical activity helps maintain overall health, including cardiovascular fitness, weight management, and hormonal balance, which may contribute to reducing the risk of BPH development or progression.
B. There is limited evidence to support their role in preventing or reducing the risk of BPH
C. Dietary factors such as overall calorie intake, fat consumption, and specific food choices may play a role in prostate health, but the relationship between protein intake and BPH risk is not well- established.
D. PSA testing is used for screening and monitoring prostate cancer, not BPH.
Correct Answer is D
Explanation
D. Beef steak is an excellent source of heme iron, which is more readily absorbed by the body compared to non-heme iron found in plant-based foods. Steamed broccoli is also a good source of non-heme iron and vitamin C, which enhances iron absorption. Vitamin C-rich foods, such as orange slices, can help increase the absorption of iron from the meal.
A. White fish, such as cod or haddock, is also a healthy protein choice, but it does not provide the iron content needed to address the client's iron deficiency anemia and chronic fatigue effectively
B. Cheese pasta primarily provides carbohydrates and protein but lacks significant amounts of iron. Lettuce and tomato salad is low in calories and rich in vitamins and minerals, but it does not contribute to increasing dietary iron intake.
C. Seasoned rice and asparagus salad are nutritious choices, but they do not contain substantial amounts of iron.
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