A nurse is assessing a client who has been admitted with chest pain.
Which of the following findings should the nurse report to the provider immediately?
The client has a history of hypertension and diabetes.
The client rates the pain as 8 on a scale of 0 to 10.
The client has crackles in the lower lobes of both lungs.
The client has an elevated troponin level in the blood.
The Correct Answer is D
D) The client has an elevated troponin level in the blood.
Rationale: An elevated troponin level indicates myocardial damage and is a diagnostic marker for acute coronary syndrome (ACS), which includes unstable angina and myocardial infarction (MI). This is a life-threatening condition that requires immediate intervention.
A) The client has a history of hypertension and diabetes. - This is an important finding, as hypertension and diabetes are risk factors for cardiovascular disease, but it is not an urgent finding that requires immediate reporting.
B) The client rates the pain as 8 on a scale of 0 to 10. - This is a significant finding, as chest pain is a cardinal symptom of ACS, but it is not a definitive finding that confirms the diagnosis.
C) The client has crackles in the lower lobes of both lungs. - This is an abnormal finding, as crackles indicate fluid accumulation in the alveoli, which may be caused by heart failure, pneumonia, or pulmonary edema. However, it is not a specific finding for ACS and may be related to other conditions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The Glasgow Coma Scale (GCS) is a tool that measures the level of consciousness based on three parameters: eye opening, verbal response, and motor response. The GCS score ranges from 3 to 15, with lower scores indicating lower levels of consciousness.
Incorrect options:
B) Mini-Mental State Examination (MMSE) - This is a tool that measures cognitive function, such as orientation, memory, attention, and language. It is not used to assess level of consciousness.
C) Confusion Assessment Method (CAM) - This is a tool that screens for delirium, which is an acute and fluctuating disturbance of cognition and attention. It is not used to assess level of consciousness.
D) Morse Fall Scale (MFS) - This is a tool that assesses the risk of falling in hospitalized clients based on six factors: history of falling, secondary diagnosis, ambulatory aid, intravenous therapy, gait, and mental status. It is not used to assess level of consciousness.
Correct Answer is D
Explanation
The nurse should ask open-ended questions that cover the characteristics, duration, frequency, severity, precipitating and relieving factors, associated symptoms, and impact of the cough on the client's health and quality of life.
Incorrect options:
A) "How long have you had this cough?" - This is a correct question, but it is not the only question that should be asked.
B) "What do you think is causing your cough?" - This is a correct question, but it is not the only question that should be asked.
C) "How does your cough affect your daily activities?" - This is a correct question, but it is not the only question that should be asked.
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