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A nurse in an emergency department is assessing a client who is having a suspected acute myocardial infarction (MI). Which of the following manifestations should the nurse expect to find for a client experiencing an acute MI? (Select all that apply.)

A.

Orthopnea

B.

Diaphoresis

C.

Nausea

D.

Headache

E.

Tachycardia

Answer and Explanation

Correct Answer : B,C,E

A. Orthopnea is difficulty breathing while lying flat, and it is typically associated with heart failure or pulmonary conditions, not an acute MI.  
B. Diaphoresis (excessive sweating) is a common symptom of an acute MI due to the body's stress response to the myocardial injury.  
C. Nausea can occur during an acute MI, particularly in women, as a result of the stress response or ischemia affecting the gastrointestinal system.  
D. Headache is not a typical symptom of an acute MI. While it can occur due to stress or other factors, it is not a hallmark of myocardial infarction.  
E. Tachycardia (increased heart rate) is a common response to an acute MI as the body attempts to compensate for reduced cardiac output and oxygenation.


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Related Questions

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

Explanation

Improved:

  • Blood Pressure: Improved from 148/88 mmHg to 130/74 mmHg.
  • Jugular Venous Distention: Improved, now absent.
  • Lung sounds: Improved, now clear bilaterally.
  • Serum Potassium: Improved from 5.7 mEq/L to 4.4 mEq/L.
  • Weight: Improved from 102.7 kg (226 lb.) to 100 kg (220 lb.).

No change:

  • Dyspnea: No change, still observed on exertion.
  • Oxygen saturation: No change, remains at 95% on room air.

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

Explanation

  • Request an antiemetic medication: Contraindicated
    • Rationale: Antiemetic medications are not typically required unless the client is experiencing nausea or vomiting, which is not indicated in this scenario.
  • Encourage the client to cough and deep breathe every 2 hr: Indicated
    • Rationale: Encouraging coughing and deep breathing helps prevent respiratory complications such as pneumonia, which is important postoperatively.
  • Ensure an abductor pillow is in place while the client is in bed: Indicated
    • Rationale: An abductor pillow helps maintain proper hip alignment and prevents dislocation of the hip joint after surgery.
  • Anticipate the administration of antibiotics: Indicated
    • Rationale: Administering antibiotics helps prevent infection, which is a common concern after surgical procedures.
  • Obtain a culture of the drainage from the surgical site: Indicated
    • Rationale: Obtaining a culture of the drainage can help identify any potential infections and guide appropriate treatment.

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