The nurse is reviewing the chart of a client with a diagnosis of unstable angina. Which laboratory test(s) result(s) should the nurse recognize as an Indication of heart damage? (SELECT ALL THAT APPLY)
Increased platelet count
Elevated troponins
Decreased homocysteine levels
Elevated CK-MB
Decreased alkaline phosphatase (ALT)
The Correct Answer is B
A. Increased platelet count: While platelet activation can occur in unstable angina, an increased platelet count alone does not indicate heart damage. It is more relevant to thrombotic events than direct myocardial injury.
B. Elevated troponins: Troponin is a protein released when the heart muscle is damaged. Elevated levels are a key indicator of myocardial injury, making this a significant finding in the context of unstable angina.
C. Decreased homocysteine levels: Homocysteine levels are related to cardiovascular risk but are not directly indicative of heart damage. Elevated levels may suggest risk but do not confirm damage.
D. Elevated CK-MB: Creatine kinase-MB is an enzyme found in heart muscle. Elevated levels are indicative of myocardial injury, making this a relevant laboratory test for assessing heart damage in unstable angina.
E. Decreased alkaline phosphatase (ALT): Alkaline phosphatase is primarily related to liver and bone health and does not indicate heart damage. Decreased levels of ALT (alanine aminotransferase) are not relevant to myocardial injury.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Monitor serum sodium levels: While serum sodium levels can provide some information about fluid balance, they are not the most direct indicator of the effectiveness of furosemide
in reducing peripheral edema.
B. Auscultate breath sounds: This is important for monitoring potential fluid overload or pulmonary complications, but it does not directly assess the reduction of peripheral edema, which is the primary concern with furosemide administration.
C. Perform daily weights: This method is the best way to evaluate the client's response to furosemide. Daily weights can provide a clear indication of fluid status and changes in peripheral edema, as a decrease in weight typically reflects effective diuresis.
D. Take the blood pressure: While monitoring blood pressure is important, especially in clients receiving diuretics, it does not specifically measure the effectiveness of the medication in addressing peripheral edema.
Correct Answer is ["C","D","E"]
Explanation
A. Decrease fluid intake of 1000 mL/day to prevent fluid overload: This goal is not appropriate. Clients with sickle cell crisis often require increased fluid intake to prevent dehydration and promote circulation, so limiting fluids is counterproductive.
B. The client verbalizes the procedure for a 24-hour urine collection: While understanding this procedure may be relevant for monitoring kidney function or hydration status, it is not a priority goal directly related to managing sickle cell crisis.
C. Oxygenation and perfusion to meet cellular and metabolic needs: Ensuring adequate oxygenation and perfusion is crucial in managing sickle cell crisis, as compromised blood flow can exacerbate pain and lead to further complications.
D. Complications are prevented or minimized: Preventing complications, such as infections or acute chest syndrome, is a key goal in managing a client with sickle cell disease, making this a critical aspect of discharge planning.
E. Pain is relieved or controlled: Pain management is a primary focus during a sickle cell crisis. Ensuring that pain is effectively managed before discharge is essential for the client's comfort and overall well-being.
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