A client comes into the emergency room with complaints of persistent, crushing chest pain. Along with the chief complaint, what other symptoms would make the nurse suspect that the client is experiencing a myocardial infarction (MI)?
Intermittent claudication with pallor
Jugular vein distention and dependent edema
Mid-epigastric pain and heartburn
Diaphoresis and cool clammy skin
The Correct Answer is D
A. Intermittent claudication with pallor is typically associated with peripheral artery disease (PAD) rather than myocardial infarction.
B. Jugular vein distention and dependent edema are signs of right-sided heart failure, which may develop after an MI but are not classic acute MI symptoms.
C. Mid-epigastric pain and heartburn can sometimes be confused with MI symptoms, but heartburn alone is not diagnostic of an MI.
D. Diaphoresis and cool clammy skin are correct. These symptoms occur due to sympathetic nervous system activation in response to cardiac ischemia, leading to vasoconstriction, sweating, and signs of impending shock.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D"]
Explanation
A. Massaging the calves is incorrect. This action can dislodge a deep vein thrombus (DVT), increasing the risk of a pulmonary embolism.
B. Applying elastic compression stockings is correct. These help promote venous return, reducing the risk of blood stasis and clot formation.
C. Performing passive range of motion exercises is correct. These exercises prevent venous stasis, which is a major risk factor for DVT and PE.
D. Assessing legs for redness is correct. Redness, swelling, and warmth can indicate DVT formation, allowing for early intervention before it leads to PE.
E. Placing pillows under the client's knees is incorrect. This can impair circulation and increase the risk of clot formation by promoting venous stasis.
Correct Answer is B
Explanation
A. Providing health recommendations is important, but the immediate concern is addressing the client's fear.
B. Encouraging the client to express emotions allows the nurse to assess and provide appropriate emotional support.
C. Dismissing the client's fears can make them feel unheard and may increase anxiety.
D. Referring the client to the physician too soon may shut down communication and miss an opportunity for emotional support.
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