A nurse is assessing a client with suspected myocardial infarction (MI). Which assessment finding is most indicative of an acute MI?
Sharp, stabbing chest pain.
Chest pain relieved by rest and nitroglycerin.
Sudden, severe chest pain radiating to the back.
Mild, intermittent chest discomfort during activity.
The Correct Answer is C
A) This choice is incorrect because sharp, stabbing chest pain is not the typical presentation of an acute MI. It is more common in conditions like pleuritis or pneumothorax.
B) This choice is incorrect because chest pain relieved by rest and nitroglycerin is more characteristic of stable angina, not an acute MI. Acute MI pain is typically not relieved by these measures.
C) This choice is correct. Sudden, severe chest pain that radiates to the back is a classic presentation of an acute myocardial infarction. The pain is often described as crushing or pressure-like and may be accompanied by other symptoms such as shortness of breath, diaphoresis, and nausea.
D) This choice is incorrect because mild, intermittent chest discomfort during activity is more typical of stable angina, not an acute MI. Acute MI pain is usually more severe, prolonged, and occurs at rest or with minimal exertion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A) This choice is incorrect because heparin does not directly dissolve existing blood clots in coronary arteries. It is used to prevent further clot formation and growth.
B) This choice is incorrect because heparin's primary action is not to relax blood vessels. It is an anticoagulant that inhibits clot formation.
C) This choice is correct. Heparin is an anticoagulant medication used to prevent further clot formation in coronary arteries and reduce the risk of complications in clients with unstable angina.
D) This choice is incorrect because heparin is not a pain reliever. It does not directly address chest discomfort during angina episodes; its role is in preventing and managing thrombosis.
Correct Answer is A
Explanation
A) This choice is correct. Diaphoresis (profuse sweating) is an early sign of myocardial infarction (MI) and is caused by the activation of the sympathetic nervous system in response to the heart muscle's decreased oxygen supply. Diaphoresis is often accompanied by other symptoms such as chest pain, shortness of breath, and nausea.
B) This choice is incorrect because elevated blood pressure can occur during an acute MI, but it is not an early sign of the condition.
C) This choice is incorrect because elevated body temperature is not typically associated with an MI. It may be indicative of an infection or other inflammatory conditions.
D) This choice is incorrect because bradycardia (slow heart rate) is not an early sign of an MI. Tachycardia (rapid heart rate) is more commonly associated with an acute MI as the body attempts to compensate for the decreased cardiac output.
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