Hesi rn medical surgical(cardiac) ( 58 Questions)
Click to highlight the findings that require follow up.
Neurological: Alert and oriented person, place, time, and situation Agitated. Denies headaches.
Cardiovascular: Reported chest pain described as pressure and tightness that is unrelieved with rest. Rapid regular rhythm. Normal heart tones. Radial and pedal pulses 2+. Capillary refill 2 seconds.
Respiratory: Rapid and shallow breaths. Clear breath sounds throughout bilateral lungs.
Gastrointestinal: Within normal limits (WNL).
Genitourinary: WNL.
Musculoskeletal M/MIL
Pain: Reported 7 on a 0 to 10 scale, tightness and pressure in chest. Started approximately 2 hours ago and got progressively worse, unrelieved by rest.
The Correct Answers:
Correct Answer:
- Agitation: Agitation may indicate hypoxia or reduced cerebral perfusion due to cardiac compromise. In a patient with chest pain and borderline hypoxia, it can be an early warning sign of clinical deterioration that requires follow-up.
- Chest pain described as pressure tightness unrelieved by rest: Unrelieved chest pain lasting longer than 20 minutes is strongly suggestive of myocardial infarction rather than stable angina. Immediate cardiac workup and intervention are needed to prevent myocardial damage.
- Pain rated 7/10: A moderate to severe pain rating in the chest warrants urgent evaluation, especially when consistent with cardiac characteristics like tightness and pressure. High pain intensity is often correlated with worsening ischemia.
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