A client admitted to the coronary care unit with an inferior wall myocardial infarction is anxious, sweating, tachypneic, and reports midsternal chest discomfort and nausea.
Which nursing diagnosis is the priority?

Anxiety.

Acute pain.

Knowledge deficit.

Nausea and vomiting.

Answer and Explanation

The Correct Answer is B

This is because acute pain is the most urgent and life-threatening problem for a client with myocardial infarction.

Acute pain indicates ongoing ischemia and tissue damage, which can lead to complications such as heart failure, arrhythmias, or cardiogenic shock. Therefore, relieving pain is the priority nursing diagnosis.

Choice A. Anxiety is wrong because anxiety is not a specific symptom of myocardial infarction and anxiety is due to the discomfort that happens due to activation of the sympathetic pathway which is good for survival.

Choice C. Knowledge deficit is wrong because knowledge deficit is not an immediate problem for a client with myocardial infarction.

Knowledge deficit can be addressed after the acute phase of the condition is over and the client is stable.

Choice D. Nausea and vomiting are wrong because nausea and vomiting are common symptoms of myocardial infarction, but they are not as urgent and life-threatening as acute pain.

Nausea and vomiting can be treated with antiemetics and fluids, but they do not affect the outcome of the condition as much as pain does.

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Correct Answer is D

Explanation

Use a fresh washcloth when cleaning each eye. This is because using the same washcloth for both eyes can transfer microorganisms from one eye to the other and cause cross-infection.

The other choices are wrong because:

Choice A is wrong because wiping from the outer part of the eye toward the inner portion can introduce microorganisms into the tear ducts and cause infection.

Choice B is wrong because rinsing the washcloth before washing the second eye does not eliminate all the microorganisms that might be on the cloth.

Choice C is wrong because asking the client to roll the eyes upward does not prevent spreading organisms from one eye to the other when bathing a client.

Normal ranges for eye hygiene are to use a clean washcloth or cotton ball for each eye, wipe from the inner to the outer canthus, and use warm water or saline solution.

A. Chicken, carrots, and fresh grapefruit salad. B. Salmon, turnip greens, brown rice, and an orange. C. Green salad, ground beef patty, corn, and applesauce. D. Plain omelet, bacon, toast with butter, and strawberries.

Correct Answer is B

Explanation

This meal selection best demonstrates a client with osteoporosis understands dietary recommendations because it provides adequate amounts of calcium, vitamin D, and protein, which are essential nutrients for bone health.

Choice A is wrong because chicken, carrots, and fresh grapefruit salad do not provide enough calcium or vitamin D for a person with osteoporosis.

Calcium is mainly found in dairy products, leafy green vegetables, and fish with bones. Vitamin D is mainly found in fatty fish, egg yolks, and fortified foods.

Choice C is wrong because green salad, ground beef patty, corn, and applesauce do not provide enough calcium or vitamin D for a person with osteoporosis.

Green salad may contain some calcium depending on the type of greens, but it is not a rich source.

Ground beef patty and corn are low in calcium and vitamin

D. Applesauce does not contain any calcium or vitamin

D. Choice D is wrong because plain omelet, bacon, toast with butter, and strawberries do not provide enough calcium or vitamin D for a person with osteoporosis.

Plain omelet and bacon are high in protein but low in calcium and vitamin

Toast with butter may contain some vitamin D if the bread or butter are fortified, but it is not a rich source.

Strawberries do not contain any calcium or vitamin

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A client admitted to the coronary care unit with an inferior wall myocardial infarction is anxious, sweating, tachypneic, and reports midsternal chest discomfort and nausea. Which nursing diagnosis is the priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which action will prevent spreading organisms from one eye to the other when bathing a client?

Correct Answer is D

Explanation

Which meal selection best demonstrates a client with osteoporosis understands dietary recommendations?

Correct Answer is B

Explanation

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A client admitted to the coronary care unit with an inferior wall myocardial infarction is anxious, sweating, tachypneic, and reports midsternal chest discomfort and nausea.
Which nursing diagnosis is the priority?