How it Works
Try Naxlex NCLEX-RN (Free-Trial)

A client is admitted with chest pain and is rubbing the left arm. The nurse initiates oxygen at 4 L/minute, and administers a dose of aspirin PO, nitroglycerin sublingually, and morphine sulfate IV. Which additional assessment should the nurse consider for a myocardial infarction (MI)?

A.

Normal coagulation studies.

B.

ST segment elevation.

C.

Premature ventricular contractions (PVC).

D.

Relief of chest pain.

Answer and Explanation

The Correct Answer is B

A. Normal coagulation studies: While important for evaluating bleeding risk, coagulation values do not confirm or exclude myocardial infarction. They are more relevant when planning invasive procedures or anticoagulation, not in the acute diagnosis of MI.

B. ST segment elevation: ST segment elevation on a 12-lead ECG is a critical diagnostic indicator of an ST-elevation myocardial infarction (STEMI). Recognizing this finding guides urgent reperfusion therapy such as PCI or thrombolytics, making it a key priority assessment.

C. Premature ventricular contractions (PVC): PVCs may occur during or after an MI due to myocardial irritability, but they are not diagnostic. Isolated PVCs do not provide definitive evidence of infarction and may be seen in various other cardiac conditions.

D. Relief of chest pain: Pain relief is an important treatment goal, but it is a response to intervention, not a diagnostic tool. Monitoring pain helps evaluate effectiveness of therapy, but confirming the MI requires objective findings like ECG changes.


Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Free Nursing Study Resources

Related Questions

Correct Answer is A

Explanation

A. Troponin I: Troponin I is a highly specific marker for myocardial injury. Elevated levels suggest acute coronary syndrome or myocardial infarction, which could explain the client’s chest pain, shortness of breath, and syncope. This findings may indicate potential for life-threatening cardiac damage.

B. Blood glucose: Abnormal glucose levels can contribute to long-term cardiovascular risk and may affect recovery, but they are not the priority in the acute setting unless critically low or high. They do not explain the acute onset of chest symptoms and syncope.

C. Oxygen saturation: While oxygen saturation is important, it is typically monitored continuously or via spot checks. Unless critically low, a slight reduction in oxygen saturation would not be as urgent as a positive cardiac biomarker in this clinical context.

D. Hematocrit: A low hematocrit could indicate anemia, which might contribute to fatigue or dyspnea, but it is not as immediately concerning as cardiac ischemia in a client with chest pain and syncope. It is a secondary concern in this case.

Correct Answer is {"A":{"answers":"A,B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A,B"},"E":{"answers":"A,B"},"F":{"answers":"B"}}

Explanation

  • Epigastric distress: Epigastric discomfort can occur in both angina and myocardial infarction due to referred pain or visceral irritation from ischemia. Clients may confuse this with indigestion, particularly in atypical presentations.
  • Occurring without cause: Myocardial infarction pain often occurs suddenly and unpredictably, including during rest or sleep. It is not always precipitated by physical exertion or emotional stress, unlike classic stable angina.
  • Pain only relieved by opioids: Myocardial infarction pain is severe and typically not responsive to nitroglycerin alone. Relief often requires opioid analgesics like morphine, which also help reduce cardiac workload.
  • Feelings of fear: A sense of impending doom or intense anxiety is commonly reported in both angina and myocardial infarction, likely due to sympathetic nervous system activation during cardiac distress.
  • Chest pain radiating down arm: Radiation of pain, especially to the left arm, is classic in both angina and myocardial infarction. It reflects the shared neural pathways between the heart and upper extremity.
  • Pain relieved by nitroglycerin: Angina is typically responsive to rest and nitroglycerin, which dilates coronary arteries and reduces oxygen demand. In contrast, MI pain often persists despite nitroglycerin.

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Register