The nurse is caring for a client who reports persistent, crushing chest pain. What additional signs or symptoms would make a nurse suspect that the client is experiencing a myocardial infarction?

Intermittent claudication and pallor

Jugular vein distention and dependent edema

Diaphoresis and cool, clammy skin

Mid-epigastric pain and heartburn

Answer and Explanation

The Correct Answer is C

A. Intermittent claudication and pallor: These symptoms are more indicative of peripheral vascular disease, not a myocardial infarction.

B. Jugular vein distention and dependent edema. These symptoms suggest right-sided heart failure or fluid overload, not myocardial infarction.

C. Diaphoresis and cool, clammy skin. Diaphoresis (sweating) and cool, clammy skin are common signs of myocardial infarction due to the body's response to pain and decreased cardiac output.

D. Mid-epigastric pain and heartburn. While heartburn can mimic some symptoms of a heart attack, mid-epigastric pain and heartburn are more likely to be related to gastrointestinal issues rather than myocardial infarction.

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Correct Answer is A

Explanation

A. Compartment syndrome. The client’s unrelieved pain, despite analgesics, and the presence of swelling distal to the cast are warning signs of compartment syndrome. This is a medical emergency that occurs when increased pressure within a closed muscle compartment reduces blood flow, leading to tissue damage and pain.

B. Muscle wasting. Muscle wasting typically occurs over time due to disuse and is not a sudden, acute complication like compartment syndrome.

C. Skin breakdown. Skin breakdown could occur from improper cast fitting or prolonged pressure, but it would not cause unrelieved pain in the same way as compartment syndrome.

D. Joint stiffness. Joint stiffness can occur in casted limbs after removal, but it is not an acute complication like compartment syndrome.

A. “There is some swelling in your right leg that is making you feel this way." B. "Your brain is responding to being inactive from the surgery." C. "Don't worry about your right foot. The pain will go away within a few days." D. "Your brain is still receiving impulses about your right foot."

Correct Answer is D

Explanation

A. “There is some swelling in your right leg that is making you feel this way.” Swelling would typically cause discomfort or pressure, but it would not be responsible for the sensation of pain in the amputated limb.

B. "Your brain is responding to being inactive from the surgery." This answer does not address the real cause of the pain, which is related to the brain's continued perception of the missing limb.

C. "Don't worry about your right foot. The pain will go away within a few days." Phantom limb pain is a common phenomenon after amputation and may persist long-term. Dismissing it is not appropriate.

D. "Your brain is still receiving impulses about your right foot." This is an accurate explanation for phantom limb pain. After amputation, the brain may still interpret sensations from the absent limb, causing pain or discomfort in the "missing" foot.

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The nurse is caring for a client who reports persistent, crushing chest pain. What additional signs or symptoms would make a nurse suspect that the client is experiencing a myocardial infarction?

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Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

The nurse is caring for a client who is postoperative following a right below-the-knee amputation. The client asks the nurse, " I keep having pain in my right foot. Why is that?" Which response would be appropriate for the nurse to make?

Correct Answer is D

Explanation

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