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 A
Explanation
A) Withhold the dose and reassess the blood pressure in 30 minutes: Given that the client's blood pressure is 90/60, which indicates hypotension, withholding the furosemide is the safest initial action. Administering a diuretic in the context of low blood pressure could exacerbate the hypotensive state, potentially leading to further complications. It is prudent to reassess the blood pressure before proceeding with the medication.
B) Administer the medication and notify the healthcare provider of the blood pressure: Administering furosemide despite the hypotensive reading may pose significant risks to the client. While notifying the healthcare provider is important, the immediate priority should be to ensure the client's safety by withholding the medication until the blood pressure can be reassessed.
C) Administer the dose and continue to monitor the vital signs: This approach is not advisable due to the low blood pressure. Administering the medication without addressing the hypotension could lead to a further drop in blood pressure and increase the risk of adverse effects such as dizziness or syncope.
D) Call the healthcare provider to obtain an order for oral furosemide: While oral furosemide may be a reasonable alternative, the priority is to manage the client's current hypotensive state. The immediate action should focus on reassessing the blood pressure and ensuring the client is stable before considering alternative routes of medication administration.
Correct Answer is D
Explanation
A) Baked chicken, baked beans, french fries, and cake: While baked chicken and baked beans may have some nutritional benefits, the inclusion of french fries and cake adds unhealthy fats and sugars, which are not recommended for a client with hypertension. High sodium levels in processed foods can also be problematic.
B) Grilled steak, fresh green beans, mashed potatoes, and ice cream: Grilled steak can be high in saturated fat, and mashed potatoes may be loaded with butter or cream. Ice cream adds excessive sugar and fat, which are not ideal for managing hypertension.
C) Tomato soup, fried flounder, white rice, and an apple: Fried flounder is high in unhealthy fats, and white rice can be high in carbohydrates without the fiber found in whole grains. While the apple is a healthy choice, the overall menu does not support hypertension management effectively.
D) Baked salmon, fresh broccoli, brown rice, and fresh fruit: This option is the most appropriate for a client with hypertension. Baked salmon is rich in omega-3 fatty acids, fresh broccoli provides fiber and vitamins, brown rice offers whole grains, and fresh fruit adds essential nutrients without excessive sugars. This combination supports heart health and helps manage blood pressure effectively.
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