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A history is completed by the healthcare provider (HCP) with a rapid assessment, and vital signs completed by the nurse

 Click to highlight the findings that require follow up.

  • Neurological: Alert and oriented person, place, time, and situation. Agitated. Denies headaches.
  • Cardiovascular: Reported chest pain described as pressure and tightness that is unrelieved with rest. Rapid regular rhythm. Normal heart tones. Radial and pedal pulses 2+. Capillary refill 2 seconds.
  • Respiratory: Rapid and shallow breaths. Clear breath sounds throughout bilateral lungs.
  • Gastrointestinal: Within normal limits (WNL).
  • Genitourinary: WNL
  • Musculoskeletal: WNL
  • Pain: Reported 7 on a 0 to 10 scale, tightness and pressure in chest. Started approximately 2 hours ago and got progressively worse, unrelieved by rest.

A.

Alert and oriented person, place, time, and situation

B.

Agitated

C.

Reported chest pain described as pressure and tightness that is unrelieved with rest

D.

Radial and pedal pulses 2+

E.

Rapid and shallow breaths

F.

Clear breath sounds throughout bilateral lungs

G.

Pain: Reported 7 on a 0 to 10 scale, tightness and pressure in chest

Answer and Explanation

The Correct Answer is ["B","C","E","G"]

Rationale for correct answers:

  • Agitated: In the context of chest pain, agitation or a "sense of impending doom" is a clinical indicator of decreased cerebral perfusion or a sympathetic nervous system surge related to a myocardial infarction.
  • Reported chest pain described as pressure and tightness that is unrelieved with rest: Stable angina usually resolves with rest. Pain that is "unrelieved by rest" and has lasted longer than 20 minutes is a classic hallmark of unstable angina or an acute myocardial infarction.
  • Rapid and shallow breaths: A respiratory rate of 21 and a shallow pattern indicate respiratory distress. This may be a compensatory mechanism for low oxygen saturation (92%) or a result of the pain and anxiety associated with a cardiac event.
  • Pain: Reported 7 on a 0 to 10 scale, tightness and pressure in chest: Any chest pain rated as severe (7/10) requires a STAT ECG and cardiac enzyme markers (Troponin) to rule out heart muscle damage.

Rationale of incorrect answers:

  • Alert and oriented person, place, time, and situation: This is a normal finding (A&O x4), showing that the client currently has enough cardiac output to perfuse the brain.
  • Radial and pedal pulses 2+: This is a normal finding, indicating that peripheral circulation is currently adequate and equal in all extremities.
  • Clear breath sounds throughout bilateral lungs: This is a "normal" finding in this context. While it’s good the lungs are clear (suggesting no immediate heart failure/pulmonary edema), it is not an abnormal cue that needs a change in the plan of care.


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Related Questions

Correct Answer is C

Explanation

A. Ulcerative colitis is an inflammatory bowel disease that primarily affects the colon and rectum, causing symptoms such as diarrhea, rectal bleeding, and abdominal pain. While diet can influence symptoms, lactose-containing foods specifically triggering bloating and cramps is not a hallmark feature of ulcerative colitis.

B. Irritable bowel syndrome (IBS) can cause bloating, abdominal pain, and changes in bowel habits. However, IBS symptoms are not consistently triggered by lactose-containing foods; triggers vary widely among individuals. Therefore, while IBS is possible, the specificity of symptoms after dairy intake points elsewhere.

C. Lactose intolerance is the most likely condition. Lactose intolerance occurs when the body lacks sufficient lactase, the enzyme needed to digest lactose in milk and dairy products. Common symptoms include bloating, abdominal cramps, diarrhea, and gas after consuming foods like ice cream and cheese, matching the client’s reported symptoms.

D. Diverticulitis involves inflammation of diverticula in the colon, causing left lower quadrant abdominal pain, fever, and sometimes constipation or diarrhea. Symptoms are not specifically triggered by dairy intake, making this diagnosis less likely in this scenario.

Correct Answer is ["42"]

Explanation

Step 1: Identify the formula
gtt/min = (Total volume × Drop factor) ÷ Time (in minutes)

Step 2: Insert values
Total volume = 1000 mL, Drop factor = 10 gtt/mL, Time = 4 hr × 60 min/hr = 240 min
gtt/min = (1000 × 10) ÷ 240

Step 3: Calculate
= 10,000 ÷ 240
≈ 41.67

Step 4: Round to the nearest whole number
≈ 42 gtt/min

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