A nurse is caring for a client.
Complete the following sentence by using the list of options.
After notifying the provider, the nurse should first
The Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"C"}
The nurse should first administer oxygen at 2 L/min via nasal cannula because the client has signs of hypoxemia (low oxygen saturation) and respiratory distress (increased respiratory rate) that may worsen the chest pain and myocardial ischemia. Oxygen therapy can help improve oxygen delivery to the heart muscle and reduce the workload of the heart.
The nurse should then administer sublingual nitroglycerin as prescribed because nitroglycerin is a vasodilator that can help relieve chest pain by dilating the coronary arteries and improving blood flow to the heart. Nitroglycerin can also lower blood pressure and reduce cardiac preload and afterload, which can decrease myocardial oxygen demand.
Other choices:
• Prepare the client for cardiac catheterization: This may be a later intervention if the chest pain persists or if the client has a confirmed myocardial infarction, but it is not the first priority for the nurse. Cardiac catheterization is an invasive procedure that involves inserting a catheter into a large artery and advancing it to the coronary arteries to visualize any blockages or stenosis. The procedure may also involve angioplasty or stent placement to restore blood flow to the affected area.
• Request a prescription for an increase in statin: This may be a long-term intervention to lower the client’s LDL cholesterol and prevent further plaque formation in the coronary arteries, but it is not an immediate intervention for chest pain. Statins are lipid-lowering drugs that can reduce the risk of cardiovascular events in clients with CAD, but they do not have a direct effect on chest pain or myocardial ischemia.
• Check a STAT cardiac troponin: This may be a diagnostic test to confirm or rule out a myocardial infarction, but it is not an intervention for chest pain. Cardiac troponin is a protein that is released into the bloodstream when there is damage to the heart muscle. Elevated levels of cardiac troponin indicate a myocardial infarction or other cardiac injury.
• Request a prescription for a beta-blocker: This may be an adjunctive therapy to reduce chest pain and prevent complications, but it is not the first-line intervention for chest pain. Beta-blockers are drugs that block the effects of adrenaline on the heart and blood vessels, which can lower heart rate, blood pressure, and myocardial oxygen demand. Beta-blockers can also prevent arrhythmias and reduce mortality in clients with CAD.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is choice C: “Do you have thoughts of harming yourself?”.
This is the priority question for the nurse to ask the client because it assesses the client’s risk for suicide, which is a serious and potentially life-threatening complication of conduct disorder. The nurse should use a direct and nonjudgmental approach when asking about suicidal ideation and plan.
Choice A: “How do you get along with your peers at school?” is wrong because it is not the most urgent question to ask the client.
While it is important to assess the client’s social relationships and possible peer rejection, this can be done after addressing the client’s safety and mental status.
Choice B: “Do you have a criminal record?” is wrong because it is not relevant to the client’s current condition and might make the client feel defensive or stigmatized.
The nurse should avoid asking questions that imply blame or judgment and focus on the client’s strengths and coping skills.
Choice D: “How do you manage your behavior?” is wrong because it is not appropriate for the nurse to ask the client in an emergency department setting.
This question might imply that the client is responsible for their conduct disorder, which is a complex and multifactorial mental health condition. The nurse should collaborate with the client and their family to develop a behavior management plan that involves positive reinforcement, limit setting, and consistent consequences.
Normal ranges: According to the DSM-5, conduct disorder is characterized by a persistent pattern of behavior that violates the rights of others or societal norms.
The symptoms of conduct disorder include aggression, deceitfulness, destruction of property, serious rule violations, and lack of remorse.
Conduct disorder can cause significant impairment in social, academic, or occupational functioning. The prevalence of conduct disorder is estimated to be 4% among children and adolescents.
The risk factors for conduct disorder include genetic factors, neurobiological factors, environmental factors, and psychological factors.
Correct Answer is C
Explanation
The correct answer is choice C. The nurse should ask the client what the voices are telling them, because this can help assess the client’s risk for harm to self or others, and also show empathy and respect for the client’s experience.
The nurse should not assume that the client’s hallucinations are related to medication noncompliance, as this can be perceived as accusatory and judgmental (choice A).
The nurse should not focus on the duration of the hallucinations, as this is not the priority at this time (choice B).
The nurse should not invalidate the client’s reality by stating that they do not hear anything, as this can cause mistrust and alienation (choice D).
The nurse should use therapeutic communication techniques to establish rapport and safety with the client who has schizophrenia.
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