A client is admitted to the telemetry unit with an episode of substernal chest pain.
His diagnostic studies reveal an elevated ST segment on the electrocardiogram (ECG) and an elevated cardiac troponin level.
What would be an appropriate initial nursing goal?
Reduce anxiety and relieve pain.
Improve myocardial oxygenation and reduce cardiac workload.
Eliminate family stressors and provide a calm environment.
Start the client on a low-sodium diet and decrease fluid intake.
The Correct Answer is B
Choice A rationale
While reducing anxiety and relieving pain are important aspects of care, they are not the primary goal for a client with an elevated ST segment on the ECG and an elevated cardiac troponin level. These findings indicate myocardial injury, which requires interventions to improve myocardial oxygenation and reduce cardiac workload.
Choice B rationale
The primary goal for a client with an elevated ST segment on the ECG and an elevated cardiac troponin level is to improve myocardial oxygenation and reduce cardiac workload. This can be achieved through medications, oxygen therapy, and bed rest.
Choice C rationale
Eliminating family stressors and providing a calm environment can contribute to reducing anxiety and promoting relaxation, but it is not the primary goal in this situation.
Choice D rationale
Starting the client on a low-sodium diet and decreasing fluid intake are interventions for managing heart failure, not for an acute myocardial injury.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
This sequence is incorrect because it suggests that blood goes from the lungs to the pulmonary artery, which is not accurate. The pulmonary artery carries deoxygenated blood from the heart to the lungs.
Choice B rationale
This sequence is incorrect because it suggests that blood goes from the pulmonary vein to the lungs, which is not accurate. The pulmonary vein carries oxygenated blood from the lungs to the heart.
Choice C rationale
This sequence correctly describes the direction of blood flow through the heart and lungs. Deoxygenated blood enters the right atrium, goes to the right ventricle, then is sent to the lungs via the pulmonary artery. After picking up oxygen in the lungs, the blood returns to the heart via the pulmonary vein, entering the left atrium, then the left ventricle, from where it is pumped out to the rest of the body.
Choice D rationale
This sequence is incorrect because it suggests that blood goes from the pulmonary vein to the pulmonary artery, which is not accurate. The pulmonary vein carries oxygenated blood from the lungs to the heart, and the pulmonary artery carries deoxygenated blood from the heart to the lungs.
Correct Answer is A
Explanation
Choice A rationale
Tetralogy of Fallot is a congenital heart condition that presents with a combination of four defects in the structure of the heart. The most common symptoms in a newborn with this condition include cyanosis (bluish color of the skin due to reduced oxygen in the blood) and hypoxia (low levels of oxygen in the body)34567.
Choice B rationale
While a high-pitched cry can be a sign of distress in a newborn, it is not specifically associated with tetralogy of Fallot. Dyspnea (difficulty breathing) can occur in severe cases, but it is not one of the primary symptoms of this condition.
Choice C rationale
Leg pain and twitching are not typical symptoms of tetralogy of Fallot. These symptoms could be indicative of other conditions, but they are not associated with this specific congenital heart defect.
Choice D rationale
Epistaxis (nosebleeds) and anemia are not typical symptoms of tetralogy of Fallot. While these conditions can occur in children for various reasons, they are not directly related to this specific congenital heart defect.
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