A client comes to the emergency Department with chest pain and the nurse suspects a myocardial infarction. Which questions) should the nurse ask the client about the pain in the initial assessment? (SELECT ALL THAT APPLY)

"How long have you had the pain?"

"Do you have a history of coronary artery disease?"

"How would you describe your pain?"

"What were you doing when the pain began?"

"Can you rate your pain on a 0-10 scale?"

Answer and Explanation

Correct Answer : A,C,D,E

A. "How long have you had the pain?"
Asking about the duration of the pain is crucial in assessing a myocardial infarction (MI). The length of time the pain has been occurring can help the nurse determine if the pain is acute or has been ongoing. For instance, chest pain lasting more than 20 minutes or worsening in intensity could indicate an MI. Knowing the timing of the pain also helps establish whether it may be related to acute coronary syndrome (ACS), which requires immediate intervention.

B. "Do you have a history of coronary artery disease?"
While it’s important to understand the patient’s medical history, this question is more secondary during the initial assessment of a client with chest pain. This information is valuable for understanding the risk of cardiovascular events, but it is not the immediate focus when assessing the current pain. The nurse should prioritize questions that address the current symptoms and the characteristics of the pain first.

C. "How would you describe your pain?"
This question is essential to help differentiate the chest pain associated with a myocardial infarction from other causes, such as musculoskeletal pain or gastrointestinal issues. MI pain is typically described as a crushing, pressure-like, or squeezing sensation. Identifying the quality of the pain helps establish whether it’s consistent with a cardiac event. Understanding the description of the pain also provides information about the intensity and potential for myocardial damage.

D. "What were you doing when the pain began?"
This is an important question because activity-related chest pain can help determine the potential cause of the pain. Pain associated with physical exertion or emotional stress may point to an MI or angina. On the other hand, pain unrelated to activity might suggest other causes such as gastrointestinal issues or musculoskeletal pain. Inquiring about the onset of the pain can also provide insight into whether it is associated with physical strain or acute coronary syndrome.

E. "Can you rate your pain on a 0-10 scale?"
Pain assessment using a numeric pain scale (0-10) helps the nurse gauge the severity of the pain and track changes over time. It’s important for determining whether the pain is severe enough to be consistent with an acute myocardial infarction or if it might resolve on its own. This information is vital in deciding the urgency of interventions and treatment decisions.

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Correct Answer is B

Explanation

A. Partially compensated metabolic alkalosis:
Metabolic alkalosis is characterized by elevated bicarbonate levels (HCO3), but in this case, the HCO3 is elevated (29 mEq/L), which suggests alkalosis. However, the PaCO2 is elevated at 47 mmHg, which is more consistent with a respiratory problem. A fully or partially compensated metabolic alkalosis would show a normal or low PaCO2 (due to respiratory compensation). Therefore, this option does not fit the ABG results.

B. Partially compensated respiratory acidosis: In this case, the pH is 7.17, which is low and indicates acidosis. The PaCO2 is 47 mmHg, which is elevated (normal range: 35-45 mmHg), indicating that the respiratory system is contributing to the acidosis. The HCO3 is 29 mEq/L, which is elevated (normal range: 22-26 mEq/L), suggesting a compensatory response from the kidneys to retain bicarbonate in an attempt to buffer the acidosis. Since the pH is still below normal and has not yet returned to the normal range (7.35-7.45), this suggests that the compensation is partial and the primary issue is respiratory acidosis.

C. Fully compensated metabolic alkalosis:
This answer is incorrect because metabolic alkalosis is not the primary disturbance here. Also, for a condition to be fully compensated, the pH would need to be within the normal range (7.35-7.45). Since the pH is 7.17, the condition is not fully compensated.

D. Fully compensated respiratory acidosis:
For fully compensated respiratory acidosis, the pH should be within the normal range, as the kidneys would have fully compensated for the elevated PaCO2. Since the pH is 7.17, this is a sign of partial compensation, not full compensation. Therefore, this option is incorrect.

A. Fluid bolus and IV heparin B. A medical prescription for a stat chest x-ray C. Coronary artery bypass (CABG) surgery if there is no improvement in 12 hours D. Repeat PCI with thrombectomy or angioplasty

Correct Answer is D

Explanation

A) Fluid bolus and IV heparin:
A fluid bolus and IV heparin may be used in certain cardiovascular conditions, such as hypotension or in the setting of acute coronary syndrome (ACS) to prevent clot formation. However, in this case, the client is experiencing chest pain with ST segment elevations, a sign of ongoing ischemia, which suggests that the problem may be related to inadequate blood flow to the heart. Fluid boluses could exacerbate the condition if the heart's function is compromised, and IV heparin alone would not address the root cause of the ischemia. Hence, this is not the most appropriate intervention at this time.

B) A medical prescription for a stat chest x-ray:
A chest x-ray would not be immediately indicated in this scenario. The client's symptoms of chest pain, diaphoresis, and ST segment elevations on the ECG are indicative of myocardial ischemia or infarction, not a respiratory or structural lung issue that would be visualized on an x-ray. The priority here is to address the myocardial ischemia, which could be due to a clot or reocclusion in the coronary artery. A stat chest x-ray would not address the underlying cardiac issue, so this is not the best choice.

C) Coronary artery bypass (CABG) surgery if there is no improvement in 12 hours:
While CABG is an option for clients with severe coronary artery disease, it is generally considered when PCI is not successful or when there are multiple blockages that cannot be stented. In this situation, since the client has just undergone PCI and is now experiencing signs of reocclusion (e.g., chest pain, ST segment elevations), a repeat PCI with thrombectomy or angioplasty is more appropriate and urgent. Waiting 12 hours would delay treatment and risk further myocardial damage. CABG would not be the first intervention after a failed PCI within hours of the procedure.

D) Repeat PCI with thrombectomy or angioplasty:
This is the most appropriate intervention. The client's symptoms (chest pain, diaphoresis, and ST segment elevations) are suggestive of reocclusion of the stented artery, a complication that can occur after PCI. Reocclusion can cause further myocardial ischemia and infarction. A repeat PCI with thrombectomy or angioplasty would aim to reopen the blocked artery and restore blood flow to the myocardium, which is the immediate priority in this situation. This intervention can help resolve the ischemia and prevent further damage to the heart muscle.

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A client comes to the emergency Department with chest pain and the nurse suspects a myocardial infarction. Which questions) should the nurse ask the client about the pain in the initial assessment? (SELECT ALL THAT APPLY)

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Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

Correct Answer is D

Explanation

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