A nurse is admitting a client who reports chest pain and has been placed on a telemetry monitor. Which of the following should the nurse analyze to determine whether the client is experiencing a myocardial infarction?

Twave

Ssegment

QRS duration

PR interval

Answer and Explanation

The Correct Answer is B

The Ssegment is the portion of an electrocardiogram (ECG) that represents early ventricular repolarization, which occurs after ventricular contraction and before ventricular relaxation. The Ssegment can be elevated or depressed in cases of myocardial infarction (MI), indicating ischemia or injury to the myocardium due to reduced blood flow or oxygen supply.

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Correct Answer is D

Explanation

The nurse should attend to the client who has thrombocytopenia and reports a nosebleed first, as this client has the most urgent problem and is at risk of hemorrhage. Thrombocytopenia is a condition characterized by a low platelet count, which impairs blood clotting and increases bleeding tendencies. The other clients have chronic or stable conditions that require ongoing monitoring and intervention, but are not as urgent as the client with the nosebleed.

A. Pupillary dilation B. Decorticate posturing C. Altered level of consciousness D. Cheyne-Stokes respirations

Correct Answer is C

Explanation

Altered level of consciousness (LOC) is the earliest and most sensitive indicator of increased ICP, which can result from brain injury, tumor, hemorrhage, infection, or edema.

The nurse should monitor the client's LOC using the Glasgow Coma Scale (GCS) and report any changes or deterioration to the provider. Pupillary dilation, decorticate posturing, and Cheyne-Stokes respirations are later signs of increased ICP that indicate brainstem compression and herniation, which are life-threatening emergencies.

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A nurse is admitting a client who reports chest pain and has been placed on a telemetry monitor. Which of the following should the nurse analyze to determine whether the client is experiencing a myocardial infarction?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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