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A nurse assesses a client with tachycardia. Which clinical manifestation requires immediate intervention by the nurse?

P wave touching the T wave

Midsternal chest pain

Increased urine output

Mild orthostatic hypotension

Answer and Explanation

The Correct Answer is B

A. P wave touching the T wave can indicate an issue but is less urgent than chest pain.

B. Midsternal chest pain could indicate myocardial ischemia or infarction, requiring immediate intervention.

C. Increased urine output is not an urgent concern in this context.

D. Mild orthostatic hypotension is not as urgent as chest pain.

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Correct Answer is A

Explanation

A. Intermittent claudication is characterized by cramping pain in the legs during physical activity, such as walking, due to insufficient blood flow, typically caused by peripheral arterial disease (PAD). This statement aligns with the symptoms of claudication.

B. Shortness of breath during physical exertion is more indicative of cardiovascular or pulmonary issues, not intermittent claudication.

C. Swelling in the feet from standing for extended periods is more consistent with venous insufficiency rather than intermittent claudication.

D. Pain in the fingers due to cold weather suggests Raynaud’s phenomenon, not intermittent claudication.

A. Client who describes intense squeezing pressure across the chest. B. Client who reports moderate pain that is worse on inspiration. C. Client who reports cramping substernal pain. D. Client who describes pain as a dull ache.

Correct Answer is A

Explanation

A. This description is indicative of possible myocardial infarction (MI), a life-threatening emergency. Immediate evaluation and intervention, such as administering oxygen, obtaining an EKG, and providing pain relief, are crucial to prevent further damage to the heart and reduce mortality.

B. Moderate pain worse on inspiration suggests pleuritic pain, often associated with conditions like pleuritis or pulmonary embolism, which are serious but generally not as immediately life-threatening as an MI.

C. Cramping substernal pain may indicate a gastrointestinal issue, such as gastroesophageal reflux disease (GERD), which is less urgent than a potential MI.

D. A dull ache may be related to musculoskeletal or gastrointestinal issues and does not suggest the immediate need for intervention seen in MI.

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A nurse assesses a client with tachycardia. Which clinical manifestation requires immediate intervention by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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