The practical nurse (PN) is caring for a client with coronary artery disease who is admitted with intermittent chest pain. The admission laboratory results indicate elevations in troponin I and creatine phosphokinase myoglobin isoenzyme (CK-MB) levels. What should the PN consider the most significant risk for this client on the second day of admission?
The lab results indicate myocardial damage, and the client is at risk for cardiac dysrhythmias.
The client is at risk for pulmonary embolism, and lifestyle modifications need to be implemented.
The client is at risk for recurrent long-term angina pain and subsequent myocardial infarction (MI).
The lab results indicate risk factors for transient ischemic atack (TIA), and neurological vital signs should be monitored.
The Correct Answer is A
Troponin I and CK-MB are cardiac enzymes that are released into the bloodstream when the heart muscle is injured or necrotic. Elevated levels of these enzymes indicate that the client has suffered a myocardial infarction (MI) or heart attack. The damaged heart tissue can impair the electrical conduction system of the heart and cause abnormal heart rhythms or dysrhythmias, which can be life-threatening. The PN should monitor the client's cardiac status closely and report any changes to the charge nurse.
The other options are not correct because:
B. The client is not at risk for pulmonary embolism, which is a blockage of a pulmonary artery by a blood clot or other material. Pulmonary embolism does not cause elevated cardiac enzymes, but it can cause chest pain, shortness of breath, and hypoxia.
C. The client is not at risk for recurrent long-term angina pain, which is chest pain caused by reduced blood flow to the heart muscle due to narrowed or blocked coronary arteries. Angina pain does not cause elevated cardiac enzymes, but it can be a warning sign of an impending MI.
D. The lab results do not indicate risk factors for transient ischemic attack (TIA), which is a temporary interruption of blood flow to a part of the brain due to a clot or plaque. TIA does not cause elevated cardiac enzymes, but it can cause neurological symptoms such as weakness, numbness, or speech difficulties.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is
Choice D rationale:
The practical nurse (PN) should review the client's risk factors for exercise intolerance that impact his quality of life. By doing so, the PN can assess the client's overall health and identify any potential issues that might contribute to his fatigue. This response shows the PN's concern for the client's well-being and is focused on exploring the root cause of his tiredness.
Choice A rationale:
Determining if the client can move to a residential home without lawn maintenance is not appropriate in response to his complaint about feeling tired. This option does not address the underlying issue and assumes the client is unable to care for his own lawn, which may not be the case.
Choice B rationale:
Recommending that the client retires from doing outdoor chores is also not appropriate. It assumes the client's fatigue is solely due to his age and disregards the possibility of other contributing factors that might be addressed.
Choice C rationale:
Advising the client that fatigue is a common characteristic of aging is not a comprehensive response. While fatigue can be related to aging, it is crucial to explore the specific reasons for the client's tiredness before assuming it is solely age-related.
Correct Answer is B
Explanation
Choice A rationale:
The risk of infection is not the priority nursing problem in this scenario. While the darkened membranes and smoky breath may be indicative of potential infection, addressing ineffective airway clearance is more urgent as it directly impacts the client's breathing and oxygenation.
Choice B rationale:
Ineffective airway clearance should be the priority nursing problem. Darkened membranes of the mouth and smoky breath suggest possible inhalation injury or airway obstruction.
Maintaining a patent airway is crucial for adequate oxygenation and to prevent further complications.
Choice C rationale:
Acute pain is not the priority nursing problem in this case. Although it is essential to address any discomfort the client may be experiencing, it takes a back seat to the more critical issue of ineffective airway clearance.
Choice D rationale:
Disturbed body image is not the priority nursing problem when the client has darkened mouth membranes and smoky breath. While it is important to address body image concerns, the immediate focus should be on managing and improving the client's airway clearance.
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