Which electrocardiographic (ECG) change by a client with chest pain is most important for the nurse to report rapidly to the health care provider?

First-degree atrioventricular block

Inverted P wave

Sinus Tachycardia

ST-segment elevation

Answer and Explanation

The Correct Answer is D

ST-segment elevation on an electrocardiogram (ECG) is a critical finding and should be reported rapidly to the health care provider. It is a hallmark ECG change seen in myocardial infarction (heart attack). When there is myocardial ischemia or injury (such as in a heart attack), the ST segment

elevates above the baseline in the affected leads of the ECG. This elevation indicates that there is an ongoing loss of oxygen and blood supply to a part of the heart muscle.

ST-segment elevation is a medical emergency because it suggests acute coronary syndrome (ACS), which can rapidly progress to a myocardial infarction if not promptly treated. Immediate intervention is needed to restore blood flow to the affected coronary artery and prevent further damage to the heart muscle.

The other options listed (A) First-degree atrioventricular block, (B) Inverted P wave, and (C) Sinus tachycardia, while significant in some situations, do not have the same urgency as ST-segment elevation in the context of chest pain. They may require medical attention, but they do not typically indicate an acute myocardial infarction or an immediate life-threatening condition. ST-segment elevation is a critical finding that requires rapid intervention to preserve heart muscle function and prevent complications.

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Correct Answer is A

Explanation

A 3 lb weight gain in a short period, especially overnight, is indicative of fluid overload in a client with end-stage kidney disease receiving hemodialysis. Hemodialysis is performed to remove excess fluid and waste products from the body. If the client is experiencing fluid overload, it means that their body is retaining more fluid than it should, and this can lead to complications such as pulmonary edema, heart failure, and other cardiovascular problems. The nurse should identify this finding as an indication of potential fluid overload and report it to the healthcare provider for further evaluation and intervention.

A. Tremors are noted in the fingers when the client extends the arms. B. The client cannot move the left arm and leg when asked to do so. C. Urine output over 8 hours is 250 mL less than the fluid intake. D. The client reports a headache with pain at level 7 of 10 (0 to 10 scale).

Correct Answer is B

Explanation

The most important finding to report to the healthcare provider in a client admitted to the intensive care unit (ICU) with a hypertensive emergency is option B, "The client cannot move the left arm and leg when asked to do so."

Hypertensive emergencies are critical situations where extremely high blood pressure levels can lead to damage or dysfunction in vital organs, such as the brain, heart, kidneys, and eyes. Neurological symptoms are particularly concerning in this context, as they may indicate acute brain injury or stroke resulting from uncontrolled high blood pressure.

Option A, "Tremors are noted in the fingers when the client extends the arms," could be concerning but is not as immediately critical as the neurological deficit described in option B. Tremors can have various causes and may not directly relate to the hypertensive emergency unless other signs or symptoms of neurologic impairment are also present.

Option C, "Urine output over 8 hours is 250 mL less than the fluid intake," is relevant to monitor the client's fluid status and kidney function, but it does not indicate an acute, life-threatening condition that requires immediate attention like the neurological deficit in option B.

Option D, "The client reports a headache with pain at level 7 of 10 (0 to 10 scale)," is concerning and may be a symptom of the hypertensive emergency, but it is not as urgent as the neurological findings. Headache can be a symptom of elevated blood pressure, but it is not sufficient on its own to determine the severity of the hypertensive crisis.

In a hypertensive emergency, the priority is to identify and manage potential complications, such as neurological deficits, acute organ damage, or signs of target organ dysfunction. Prompt reporting of any neurological changes is crucial, as it may prompt immediate interventions to prevent further neurological deterioration. The healthcare provider needs to assess the client's neurological status promptly and determine appropriate management to prevent further complications.

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Which electrocardiographic (ECG) change by a client with chest pain is most important for the nurse to report rapidly to the health care provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has end-stage kidney disease and is receiving hemodialysis. Which of the following findings should the nurse identify as an indication the client is experiencing fluid overload?

Correct Answer is A

Explanation

The nurse is assessing a client who has been admitted to the intensive care unit (ICU) with a hypertensive emergency. Which finding is most important to report to the health care provider?

Correct Answer is B

Explanation

While assessing an older adult client, the nurse notes jugular venous distention (JVD) with the head of the client's bed elevated 45 degrees. What does this finding indicate?

The nurse teaches a student nurse about diagnostic studies used for acute coronary syndrome. Which statement made by the student nurse indicates effective learning?

A patient with dilated cardiomyopathy has new onset atrial fibrillation that has been unresponsive to drug therapy for several days. What topic should the nurse plan to include in patient teaching?

The nurse is reviewing the laboratory test results for a client who has recently been diagnosed with hypertension. Which result is most important to communicate to the health care provider?

Which diagnostic test will be most useful to the nurse in determining whether a client admitted with acute shortness of breath has heart failure?

Which statement by a client with newly diagnosed heart failure indicates to the nurse that teaching was effective?

The assessment findings of a patient with myocardial infarction (MI) include jugular venous distention, weight gain, peripheral edema, and a heart rate of 108/minute. The nurse suspects what complication?