A client with coronary artery disease presents to the emergency department reporting chest pain. What action should the nurse take next?
Ask the client when the pain started and if it radiates.
Ask the client if they have a family history of heart disease.
Assess the client's nutrition and smoking history.
Assess the client's extremities for swelling.
The Correct Answer is A
Choice A reason: When a client with known coronary artery disease presents with acute chest pain, the nurse must immediately perform a focused symptom analysis. Determining the onset, duration, and radiation of the pain helps differentiate between stable angina and a more serious event like an acute myocardial infarction.
Choice B reason: While family history is important for long-term risk stratification, it is not a priority during an acute clinical presentation. The nurse must focus on the current physiological crisis rather than collecting historical data that does not influence the immediate emergency interventions required to stabilize the client's myocardium.
Choice C reason: Assessing nutrition and smoking status are components of chronic disease management and lifestyle education. In the emergency department, these assessments are secondary to the immediate evaluation of ischemia. The nurse's priority is to address the acute pain and potential life-threatening obstruction of coronary blood flow.
Choice D reason: Assessing for peripheral edema is useful for identifying chronic heart failure or venous insufficiency. However, in the context of acute chest pain and CAD, this does not provide information about the immediate ischemic state of the heart. The priority must remain on the characteristics of the chest pain itself.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Crackles, also known as rales, are adventitious lung sounds heard during auscultation with a stethoscope. They are caused by the popping open of small airways and alveoli collapsed by fluid or exudate. While they are "crackling" in nature, they are an internal acoustic finding rather than a tactile sensation felt on the skin.
Choice B reason: Croup is a clinical pediatric syndrome characterized by a "barking" cough, inspiratory stridor, and hoarseness due to upper airway inflammation. It is a diagnostic conclusion based on history and audible symptoms, not a physical sensation palpated under the subcutaneous tissue during a manual skin assessment of the thorax.
Choice C reason: Crepitus, specifically subcutaneous emphysema, is a tactile sensation similar to "Rice Krispies" popping under the skin. It occurs when air escapes from the respiratory tract and becomes trapped in the subcutaneous tissues. This often follows thoracic surgery, chest tube placement, or a traumatic pneumothorax where air leaks into the chest wall.
Choice D reason: Consolidation refers to the replacement of alveolar air with fluid, pus, or blood, commonly seen in lobar pneumonia. While consolidation can be identified through increased tactile fremitus or dullness to percussion, it does not produce a crackling sensation under the skin; it creates a solid mass effect within the lung parenchyma.
Correct Answer is A
Explanation
Choice A reason: Non-modifiable risk factors are those that an individual cannot change, such as age, gender, race, and genetic predisposition. Family history is a primary non-modifiable risk factor; inquiring about it shows the client recognizes that their inherited biological background contributes significantly to their overall cardiovascular risk profile.
Choice B reason: Making an appointment with a dietician is an action aimed at changing modifiable risk factors. Diet, weight, and nutritional intake are behaviors that can be controlled or altered through intervention. While beneficial for heart health, they do not fall under the category of non-modifiable biological traits.
Choice C reason: Limiting alcohol intake is a lifestyle modification. Alcohol consumption is a behavioral choice that can impact blood pressure and lipid levels. Because the client has the power to change this behavior, it is categorized as a modifiable risk factor rather than an inherent, unchangeable biological factor.
Choice D reason: Starting a regular walking schedule addresses physical inactivity, which is a modifiable risk factor. Increasing physical exertion improves cardiovascular health and can be initiated at the client's discretion. This does not reflect an understanding of factors like age or genetics that are beyond personal control
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