Which of the following clinical manifestations would make the nurse suspect the client is experiencing a myocardial infarction (MI)?

Choice A rationale

Radiating pain to the left arm is a classic symptom of a myocardial infarction (MI) due to referred pain from the heart.

Choice B rationale

Shortness of breath can also be associated with MI but is not as specific as radiating pain to the left arm.

Choice C rationale

Headache is not a typical symptom of an MI. It is more commonly associated with other conditions.

Choice D rationale

Nausea and vomiting can occur with an MI but are not as specific as radiating pain to the left arm.

Choice C rationale

Administering another nitroglycerin tablet is appropriate if the client's chest pain has not been fully relieved after the initial dose. Nitroglycerin helps to dilate blood vessels, improving blood flow to the heart and relieving angina. A second dose can be given if the pain persists, following the protocol for managing chest pain.

Choice A rationale

Obtaining an ECG is important for diagnosing and monitoring cardiac conditions; however, in this immediate context, further pain relief takes precedence. After ensuring pain relief, an ECG can be performed to assess the client's cardiac status.

Choice B rationale

Calling the Rapid Response Team is unnecessary if the client’s chest pain severity has already decreased. The priority should be to continue managing the chest pain with additional nitroglycerin if needed and monitoring the client's response.

Choice D rationale

Initiating a peripheral IV might be required for administering medications or fluids, but it is not the immediate action needed in this scenario. The priority is to provide additional pain relief with nitroglycerin.