A 29-year-old women presents to the ER with chest pain that started this evening. She has experienced episodes like this before which typically occur in the evening and resolve by the next morning. The client has a medical history of migraines and Raynaud's disease.
Temp: 98 F
BP: 119/72 mm/Hg
HR: 99 bpm
RR: 16 bpm
Sp02: 96% RA
An EKG is completed and indicates no evidence of a myocardial infarction but supports the diagnosis of Prinzmetal Angina. The nurse finds the client crying stating, "I'm so young, how can my heart arteries be clogged? I eat healthy and the doctor said my cholesterol was normal." What is the nurses best response?
"This condition is caused by the coronary arteries spasming, not by cholesterol."
"Just because you're young and eat right doesn't mean you can't have plaque buildup."
"I understand it can be upsetting to have coronary artery disease at your age."
"I am sure everything will be alright."
The Correct Answer is A
A. The best response is to educate the client about the cause of Prinzmetal angina. It occurs due to spasm in the coronary arteries, which is different from the plaque buildup seen in traditional coronary artery disease. This response addresses the client's concern in an accurate and reassuring manner.
B. While healthy eating is important, Prinzmetal angina is not typically caused by cholesterol or plaque buildup. This response could increase the client's anxiety.
C. While acknowledging the client's emotions is important, this response does not address the underlying concern or provide an accurate explanation of Prinzmetal angina.
D. Offering reassurance without providing accurate information about the condition does not help the client understand the cause of their symptoms and could leave them confused or anxious.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Sucking on small quantities of ice chips is not appropriate in this case as it may worsen the airway obstruction or cause further irritation.
B. Applying oxygen and continuously monitoring the client's pulse oximetry will help ensure that the client's oxygen saturation remains adequate and that they do not experience respiratory distress or hypoxemia due to inhalation injury. Early intervention is crucial to prevent worsening of respiratory status.
C. Humidified room air can help in cases of airway irritation, but the priority is to ensure oxygenation and avoid hypoxia.
D. Antitussive medications may be indicated later, but airway management and oxygenation take precedence.
Correct Answer is D
Explanation
A. Appling a paper bag over the client's nose and mouth is used for hyperventilation or respiratory alkalosis, not for respiratory acidosis. In this case, it would worsen the client’s condition by increasing CO2 retention.
B. Administering 50 mL of 20% glucose and 20 units of regular insulin is appropriate for hyperkalemia or diabetic ketoacidosis, not respiratory acidosis following a seizure.
C. Administering 50 mL of sodium bicarbonate intravenously is used for severe metabolic acidosis. This client’s acidosis is primarily respiratory in origin, making this choice inappropriate.
D. Applying oxygen by mask or nasal cannula helps correct the low oxygen levels and supports respiration post-seizure.
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