A nurse is caring for a client who has angina.
Complete the following sentence by using the lists of options.
The client is at risk for developing
The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}
Rationale for Correct Answers:
- Myocardial infarction: The client's worsening chest pain and increasing troponin levels strongly indicate myocardial injury. Despite initial nitroglycerin, symptoms persisted, and thrombolytic therapy was started, consistent with acute MI management.
- Troponin levels: Troponin T rose from 0.08 to 0.2 ng/mL, and Troponin I from 0.01 to 0.1 ng/mL, exceeding the normal range. These cardiac biomarkers are sensitive indicators of myocardial cell damage, confirming the progression toward infarction.
Rationale for Incorrect Choices:
- Bleeding: Although thrombolytics and aPTT monitoring are related to bleeding risks, there is no current evidence of bleeding (e.g., hematuria, bruising, low platelets, or elevated aPTT). Platelets and aPTT are within normal ranges, so this is not the primary concern at this time.
- Pulmonary embolism: The client is short of breath and diaphoretic, which could be seen in PE, but there is no indication of risk factors like immobility, recent surgery, or DVT symptoms. Elevated troponins and anginal symptoms more clearly support a cardiac rather than embolic cause.
- Shortness of breath: While SOB is a significant clinical symptom, it is nonspecific and could result from anxiety, cardiac ischemia, or pulmonary causes. It does not directly confirm the most urgent diagnosis, which is best supported by objective lab data such as troponins.
- aPTT levels: The aPTT is within the expected therapeutic range and does not indicate a coagulation problem at this time. It is not a primary driver of the client's current risk status, especially in comparison to the elevated cardiac markers.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is []
Explanation
Rationale for Correct Answers:
- Rheumatoid arthritis: The client presents with bilateral joint inflammation, stiffness (especially in the morning), subcutaneous nodules, positive ANA, and elevated inflammatory markers (ESR and CRP). These findings are characteristic of rheumatoid arthritis, an autoimmune inflammatory disorder primarily affecting small joints.
- Assess joints for warmth and redness: Warmth and redness are signs of active inflammation in affected joints, which helps determine disease activity and guides timely intervention to prevent joint damage.
- Assess for paresthesias: Peripheral nerve involvement may occur in rheumatoid arthritis due to inflammation or nerve compression from swollen joints. Assessing for paresthesias helps identify neurological complications early.
- Weight-bearing joints: Monitoring inflammation and function of weight-bearing joints is essential because rheumatoid arthritis often affects mobility and increases fall risk, as seen with the client’s recent fall.
- Decreased immunity: Rheumatoid arthritis and its treatments (e.g., immunosuppressants) can compromise immunity, increasing infection risk. Monitoring immune status helps prevent and detect infections promptly.
Rationale for Incorrect Choices:
- Osteoporosis: Osteoporosis causes bone density loss and fractures but does not explain the joint inflammation, swelling, and systemic symptoms such as fever and elevated inflammatory markers seen here.
- Osteoarthritis: Osteoarthritis generally presents with joint pain and stiffness but usually involves unilateral weight-bearing joints without systemic signs like fever or elevated ESR and CRP. The symmetrical joint involvement and nodules point away from osteoarthritis.
- Gout: Gout typically causes acute inflammation in the big toe and is associated with elevated uric acid levels, which are normal in this client. The symmetrical joint involvement and systemic symptoms are not typical for gout.
- Recommend the client spend at least 5 min outside in the sun daily: While vitamin D supports bone health, this intervention is not a priority here because the client’s vitamin D level is normal and the condition involves autoimmune inflammation rather than a deficiency.
- Collect a 24-hr urine sample: This is not indicated for diagnosing or managing rheumatoid arthritis but may be relevant in other conditions like gout or kidney disease, which are not supported by this clinical picture.
- Assess for crepitus in weight bearing joints: Crepitus is more associated with osteoarthritis due to cartilage wear, not inflammatory arthritis like rheumatoid arthritis.
- Joint inflammation in the big toe: Inflammation in the big toe is more characteristic of gout and less consistent with the client’s symptoms of polyarticular joint involvement.
- Calcium and vitamin D levels: Both levels are within normal limits and not directly related to rheumatoid arthritis activity or monitoring.
- Cervical neck pain: Though cervical involvement can occur in rheumatoid arthritis, it is not a prominent symptom or primary monitoring parameter at this stage in this client’s presentation.
Correct Answer is B
Explanation
A. Mouth sores: While mouth sores (mucositis) are common in chemotherapy, they are not a contraindication for acupuncture. The therapy does not typically involve the oral cavity and may even help reduce discomfort indirectly by promoting general well-being.
B. Lymphedema: Acupuncture is contraindicated in areas affected by lymphedema due to the risk of introducing infection or worsening fluid accumulation. Clients with a history of lymph node removal or compromised lymphatic drainage should avoid needle insertion in those areas.
C. Headaches: Acupuncture is often used as a nonpharmacologic treatment for chronic headaches and migraines. There is no contraindication for its use in clients experiencing headaches, and many find it beneficial.
D. Urticaria: Urticaria (hives) may indicate an allergic reaction but is not a direct contraindication to acupuncture unless it involves skin sensitivity at proposed needle sites. However, each case should be assessed individually.
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