A nurse in the emergency department is assessing a client who has a history of angina and reports chest pain. Which of the following findings is the priority?

Three doses of nitroglycerin relieve the client's pain.

Pain radiates to the client's left arm.

Pain began in the morning while the client was resting.

Pain is greatest in the client's substernal chest area.

Answer and Explanation

The Correct Answer is C

Rationale:

A. Three doses of nitroglycerin relieve the client's pain: While nitroglycerin can relieve chest pain related to angina, the fact that the pain subsides after three doses may indicate stable angina. However, this does not address the underlying concern if the pain began at rest, which is more concerning.

B. Pain radiates to the client's left arm: Pain radiating to the left arm is a common symptom of angina or myocardial infarction (MI). While this is concerning, it is not the most urgent finding compared to the pain onset, especially when pain occurs at rest.

C. Pain began in the morning while the client was resting: Chest pain occurring at rest, especially in the morning, is the most concerning symptom. This could indicate unstable angina or an impending myocardial infarction (MI). Unstable angina is more dangerous than stable angina and requires immediate intervention.

D. Pain is greatest in the client's substernal chest area: Substernal chest pain is characteristic of angina, but it is not as concerning as the timing of pain onset. Pain at rest, especially in the morning, suggests unstable angina or MI, which is a higher priority.

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Correct Answer is C

Explanation

Rationale:

A. Apply a blood pressure cuff: Applying a blood pressure cuff is not the first priorit. The nurse’s first priority should be assessing the client’s circulation and responsiveness. Blood pressure measurement can be done after confirming the client's pulse and overall condition.

B. Establish an IV access: While establishing an IV access may be necessary for medication administration or fluid resuscitation, the immediate concern is assessing the client’s airway, breathing, and circulation. IV access should be obtained after ensuring that these basic life-sustaining functions are stable.

C. Palpate for the client's carotid pulse: The first step in evaluating an unresponsive client who is breathing is to check for a pulse to assess circulation. The nurse should palpate the carotid pulse to determine whether the client has a pulse and is adequately perfusing.

D. Initiate cardiac monitoring for the client: Cardiac monitoring is important, but it is not the first action to take when a client is unresponsive. The nurse should first assess the client’s pulse and breathing to ensure they are receiving adequate circulation before monitoring.

A. Discontinue opioids before trying nonpharmacological methods of pain relief. B. Distraction changes the client's perception of pain, but it does not affect the cause. C. Use imagery with clients who have difficulty with focus and concentration. D. Pain relief from the use of heat and cold continues for several hours after removal of the stimulus.

Correct Answer is B

Explanation

Rationale:

A. "Discontinue opioids before trying nonpharmacological methods of pain relief."
Nonpharmacological methods should complement, not replace, opioids. It's important to continue prescribed medications and incorporate nonpharmacological techniques to manage chronic pain.

B. "Distraction changes the client's perception of pain, but it does not affect the cause."
Distraction techniques, like listening to music, can alter pain perception by redirecting attention, but they do not address the underlying cause of pain.

C. "Use imagery with clients who have difficulty with focus and concentration." Imagery is a relaxation technique that requires focus. It may not be effective for clients with concentration difficulties, as they may struggle to benefit from this method.

D. "Pain relief from the use of heat and cold continues for several hours after removal of the stimulus." Pain relief from heat and cold is temporary and typically fades once the stimulus is removed. It provides short-term relief and should not be expected to last long after application.

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A nurse in the emergency department is assessing a client who has a history of angina and reports chest pain. Which of the following findings is the priority?

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