Which nursing intervention is highest priority for the client who has suffered an acute anterior wall mycordial infarction?

Maintaining strict bedrest for first 24 hours

Measuring urine output hourly and performing daily weighs

Keeping the environment quiet to decrease cardiac workload

Reducing oxygen demand and providing pain control

Answer and Explanation

The Correct Answer is D

A) Maintaining strict bedrest for first 24 hours:
While bedrest is often recommended in the early stages following a myocardial infarction (MI), the priority nursing intervention is to reduce oxygen demand on the heart, which can be achieved through pain management and controlling the workload on the heart, rather than solely relying on bedrest. Bedrest alone may not address the underlying physiological needs of the heart, such as reducing ischemia or controlling pain.

B) Measuring urine output hourly and performing daily weights:
Monitoring urine output and performing daily weights are important in managing fluid balance, especially for those with heart failure or volume overload. However, in the acute phase of an anterior wall myocardial infarction, the priority intervention is addressing the oxygen demand on the heart and providing pain relief, which is more immediate in stabilizing the client and reducing myocardial injury.

C) Keeping the environment quiet to decrease cardiac workload:
While creating a calm and quiet environment helps in reducing stress and decreasing cardiac workload, it is still secondary to actively managing the oxygen demand of the heart. Decreasing the workload of the heart is essential, but this is done more effectively through interventions such as pain management, oxygen therapy, and medications that reduce myocardial oxygen demand (e.g., nitroglycerin, beta-blockers).

D) Reducing oxygen demand and providing pain control:
This is the highest priority intervention for a client who has suffered an acute anterior wall myocardial infarction (MI). Pain from an MI increases the heart's oxygen demand and can exacerbate ischemia. Pain relief, often with morphine, not only reduces pain but also helps in vasodilation, reducing the heart's workload. Additionally, oxygen therapy should be given to ensure adequate oxygenation, and medications like beta-blockers, nitroglycerin, and ACE inhibitors are used to reduce the workload of the heart.

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Correct Answer is A

Explanation

A) Start fluid resuscitation and prepare for transport to a Burn Center:
In this case, the patient has burns that cover 27% of the total body surface area (TBSA), which falls within the moderate to severe range for burn injuries. Fluid resuscitation is critical to prevent hypovolemic shock, a common complication of severe burns due to fluid loss. The "rule of nines" or Lund-Browder chart can be used to calculate the amount of fluids needed. The patient should also be prepared for transport to a specialized burn center, where advanced care can be provided for wound management, infection prevention, and long-term rehabilitation.

B) Apply petroleum-based antibiotic cream to the affected areas:
Although topical antibiotics are an essential part of burn care to prevent infection, petroleum-based ointments are typically not recommended in the emergent phase of burn management. Applying such creams could potentially trap heat and cause further tissue damage, and petroleum-based products can be occlusive, which may interfere with wound healing.
C) Cover the burns with saline-soaked gauze and medicated ointment:
While it is important to keep burns covered to prevent infection, the use of saline-soaked gauze and medicated ointments are more appropriate after initial fluid resuscitation and stabilization of the patient. Immediate burn care focuses on preventing further injury and initiating fluid resuscitation. Saline-soaked gauze is typically used in a controlled setting, like in a burn unit, and the patient's wounds should not be excessively covered with ointment during the emergent phase.

D) Clean the wounds with soap and room temperature water:
In burn management, cleaning the wounds with soap and water can disrupt the skin's protective barrier, particularly in the emergent phase. It is important to gently clean the wounds with sterile saline or an antiseptic solution and avoid harsh cleansers. Soap and water might cause irritation, exacerbate pain, and increase the risk of infection. The focus should be on stabilizing the patient and initiating proper wound management with sterile techniques.

A. CD4 count of less than 200 cells/uL, (ranges 500-1800) and new diagnosis of pneumocystis pneumonia B. CD4 count of 1200 cells/uL (ranges 500-1800) and a new diagnosis hepatitis A C. low grade fever with the diagnosis of influenza A D. New atopic dermatitis and a White Blood count 11 million/mm3

Correct Answer is A

Explanation

A) CD4 count of less than 200 cells/uL, and new diagnosis of pneumocystis pneumonia:
A CD4 count of less than 200 cells/uL and the diagnosis of a severe opportunistic infection, such as pneumocystis pneumonia (PCP), are major criteria for the diagnosis of acquired immunodeficiency syndrome (AIDS). AIDS is the final stage of HIV infection, where the immune system is severely compromised, and the individual is highly susceptible to opportunistic infections like PCP, tuberculosis, and others. The CD4 count, which measures the number of immune system cells (specifically T-helper cells), is used to monitor disease progression, with values below 200 cells/uL indicating a diagnosis of AIDS.

B) CD4 count of 1200 cells/uL and a new diagnosis of hepatitis A:
While hepatitis A is an important condition that should be managed, it is not an opportunistic infection associated with AIDS. A CD4 count of 1200 cells/uL is within the normal range (500-1800 cells/uL), indicating that the immune system is not severely compromised.

C) Low grade fever with the diagnosis of influenza A:
A low-grade fever and a diagnosis of influenza A do not indicate AIDS. Influenza is a viral infection that can affect both individuals with and without HIV. It is common to experience flu-like symptoms in the early stages of HIV infection, but the presence of a fever and influenza does not confirm AIDS. A low-grade fever is also not specific to AIDS or opportunistic infections.

D) New atopic dermatitis and a white blood count of 11 million/mm³:
Atopic dermatitis is a chronic inflammatory skin condition that is not specifically associated with HIV or AIDS. The white blood cell (WBC) count of 11 million/mm³ is elevated, but this alone does not confirm a diagnosis of AIDS. Elevated WBC counts can occur with various conditions, including infections and allergic reactions, but they are not a diagnostic feature of AIDS.

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Which nursing intervention is highest priority for the client who has suffered an acute anterior wall mycordial infarction?

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