A client with an acute myocardial infarction (MI) is given a thrombolytic medication, aspirin, and IV heparin in the emergency department. Which finding indicates the client is having a satisfactory response?
Activated partial thromboplastin time (aPTT) is 2 times the control value.
S3 heart sounds are present with auscultation.
Cardiac tracing shows 1.2 mm wide Q waves half the height of the complex.
Guaiac test of the stools is positive.
The Correct Answer is A
A. An aPTT that is 2 times the control value indicates that the heparin is effectively anticoagulating the blood, which is a desired outcome in managing MI to prevent clot formation.
B. S3 heart sounds can indicate heart failure and are not a sign of a satisfactory response to MI treatment.
C. Wide Q waves indicate a previous infarction but do not reflect the immediate effectiveness of the treatment.
D. A positive guaiac test indicates gastrointestinal bleeding, which is a potential complication rather than a satisfactory response.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Asking the spouse about the client's depression can provide insights but might not be as effective as directly addressing the client.
B. While privacy is important, the spouse can often provide additional valuable information.
C. Explaining about post-MI depression is informative but does not directly assess the client's current emotional state.
D. Encouraging the client to describe his feelings allows the nurse to perform a thorough assessment of the client’s mental state and identify any signs of depression or anxiety.
Correct Answer is ["A","B","C","D"]
Explanation
A) This is a common symptom as individuals may avoid social interactions and isolate themselves due to ongoing distress.
B) Exaggerated startle response: Individuals may have an increased startle reflex following trauma, which can persist over time.
C) Intrusive thoughts: These are unwanted and distressing thoughts related to the trauma that can continue to affect the individual.
D) Avoidance of places associated with the assault: This behavior is a protective mechanism to prevent re-experiencing the traumatic event.
E) Overeating: Overeating is not a characteristic sequalae of rape trauma.
F) Hallucinations: Hallucinations are not typically associated with long-term symptoms of rape- trauma syndrome. Hallucinations can occur in severe cases, particularly if there are co-occurring mental health disorders such as PTSD.
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