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

Weighing the client at the same time every day

Assuring hourly urine output of at least 25 mL per hour

Maintaining strict bedrest for the first 24 hours

Providing pain control and reducing oxygen demand

Answer and Explanation

The Correct Answer is D

A. Weighing the client at the same time every day:
While daily weights are important for monitoring fluid status (especially in patients at risk for heart failure or fluid retention), it is not the highest priority in the immediate post-MI period. Weighing the client daily can be useful to track fluid accumulation, but addressing the client’s pain management and oxygenation needs takes precedence in the acute phase of an MI.

B. Assuring hourly urine output of at least 25 mL per hour:
Maintaining adequate urine output (typically around 30 mL per hour) is important to assess renal perfusion and fluid balance, especially if the patient is at risk for renal insufficiency or cardiogenic shock. However, this is not the highest priority immediately following an MI. The first priority is managing the oxygen supply to the heart, and addressing pain and reducing myocardial oxygen demand is more crucial in the acute phase to prevent further damage.

C. Maintaining strict bedrest for the first 24 hours:
Strict bedrest may have been a common practice in the past for patients following an MI, but current guidelines emphasize early mobilization and gradual activity as tolerated to prevent complications like deep vein thrombosis (DVT), pulmonary embolism (PE), and muscle deconditioning. While some degree of rest may be necessary immediately after an MI, the priority is to control pain and reduce oxygen demand, not strictly maintain bedrest. Prolonged immobility is not recommended in the modern management of MI unless there are specific contraindications.

D. Providing pain control and reducing oxygen demand is the most critical intervention in the acute phase of an anterior wall MI. Effective pain relief helps to reduce sympathetic stimulation, which decreases heart rate, blood pressure, and myocardial oxygen demand, preventing further myocardial injury and improving outcomes. This is essential for stabilizing the client early in their post-MI course.

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Correct Answer is B

Explanation

A. and record vital signs every 4 hours:
While vital signs are important, monitoring every 4 hours may not be frequent enough in an intensive care setting, especially for a client requiring mechanical ventilation. Vital signs, including blood pressure, heart rate, respiratory rate, and oxygen saturation, should be monitored more frequently (at least every hour) to detect changes in the patient's condition, particularly since positive pressure ventilation can significantly affect circulatory status.

B. Intake and output hourly:
In acute respiratory distress syndrome (ARDS), the client may require mechanical ventilation to support breathing. Positive pressure ventilation, while essential for improving oxygenation, can increase intrathoracic pressure, which may impair venous return to the heart, decreasing cardiac output. As a result, it is critical to monitor the fluid balance closely, as fluid overload can worsen the patient's condition and contribute to pulmonary edema or other complications. Hourly assessment of intake and output (I&O) helps the nurse monitor renal function, fluid status, and cardiac output. Maintaining a proper balance of fluids is crucial in managing ARDS and its associated complications.

C. Heart and lung sounds every shift:
A shift assessment of heart and lung sounds is useful but is not frequent enough to detect early changes in a client with decreased cardiac output or other complications related to mechanical ventilation. More frequent monitoring of lung sounds and heart function may be necessary, particularly in clients at risk of ventilator-associated complications like ventilator-associated pneumonia (VAP), pulmonary edema, or arrhythmias.

D. Level of consciousness every shift:
Monitoring level of consciousness is important, especially in clients with ARDS and mechanical ventilation, as changes in consciousness can indicate worsening hypoxia or hypercapnia. However, this assessment is less directly related to the immediate concern of decreased cardiac output, which can be more effectively managed through continuous monitoring of fluid status and vital signs rather than consciousness alone. Though consciousness should be monitored regularly, I&O hourly would be more crucial in this context for managing cardiac output.

A. a sleep aid and used to promote sleep along with melatonin. B. a muscle relaxant medication used to reduce muscle spasms. C. an antibiotic medication used to treat bacterial infections. D. an opiate and is used to relieve severe pain.

Correct Answer is B

Explanation

A. Tizanidine is a sleep aid and used to promote sleep along with melatonin:

This is incorrect. Tizanidine is not classified as a sleep aid. While muscle relaxants like tizanidine may cause drowsiness as a side effect, its primary purpose is to reduce muscle spasms rather than to promote sleep. Using it in combination with melatonin for sleep would not be appropriate unless specifically prescribed by a healthcare provider.

B. Tizanidine is a muscle relaxant medication used to reduce muscle spasms:

Tizanidine is a centrally acting muscle relaxant that is commonly used to treat muscle spasms and spasticity. In clients with amyotrophic lateral sclerosis (ALS), spasticity can be a significant symptom, leading to muscle stiffness and discomfort. Tizanidine helps by relaxing the muscles and alleviating the muscle tightness associated with ALS. It works by inhibiting nerve impulses that cause muscles to contract, thus reducing spasticity and improving mobility. This medication is not intended for sleep promotion or pain relief directly, but rather to manage muscle spasms.

C. Tizanidine is an antibiotic medication used to treat bacterial infections:

This is incorrect. Tizanidine is not an antibiotic and has no role in treating bacterial infections. It is a muscle relaxant used for managing spasticity, not an antimicrobial drug.

D. Tizanidine is an opiate and is used to relieve severe pain:

This is incorrect. Tizanidine is not an opiate and does not belong to the class of opioids. It does not have the pain-relieving effects of opioid analgesics. While it may provide some relief from muscle discomfort, it is not used to treat severe pain in the way opiates like morphine or oxycodone are. Tizanidine’s primary purpose is to address muscle spasticity, not pain management.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client diagnosed with acute respiratory distress syndrome (ARDS) who requires mechanical ventilation. A client problem of decreased cardiac output from the positive pressure ventilator has been identified. What should the nurse include in the plan of care? Assess:

Correct Answer is B

Explanation

The nurse is caring for a client diagnosed with amyotrophic lateral sclerosis (ALS). The client was given a medical prescription for tizanidine. What information would the nurse provide regarding this medication? Tizanidine is

Correct Answer is B

Explanation

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