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A nurse is caring for a client who has angina.

Exhibits

Complete the following sentence by using the lists of options.

The client is at risk for developing

due to.
Answer and Explanation

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.


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Related Questions

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"C"},"D":{"answers":"B"},"E":{"answers":"C"},"F":{"answers":"A"}}

Explanation

  • Creatinine 1.8 mg/dL: Increased creatinine reflects declining kidney function, potentially due to poor perfusion or overuse of diuretics. This suggests the heart is not maintaining adequate output, worsening the heart failure status.
  • Weight 113 kg (249 lb): A 2-kg gain over 24 hours strongly suggests fluid retention, which is a hallmark of worsening heart failure due to ineffective diuresis or poor cardiac output.
  • Shortness of breath with exertion: While still present, SOB limited to exertion rather than at rest represents an improvement in pulmonary congestion and oxygenation.
  • Lung sounds clear: The absence of crackles shows resolution of pulmonary edema and a positive response to diuretics or other heart failure treatments.
  • Temperature 38.5° C (101.3° F): A fever may indicate an infection (e.g., UTI), which is not a direct indicator of heart failure status but can indirectly affect the condition if not managed.
  • WBC count 11,800/mm³: A mildly elevated WBC count suggests an infectious process such as a urinary tract infection but is not specific to heart failure progression or improvement.

Correct Answer is A

Explanation

A. Apply new gloves when alternating between wound care sites: Using new gloves between wound sites prevents cross-contamination and reduces the risk of infection, which is critical in clients with full-thickness burns due to loss of skin integrity.
B. Provide a diet of fresh fruits and vegetables for the client: While a nutritious diet is important, fresh produce may harbor bacteria and is often restricted in severely immunocompromised burn clients during the acute phase to prevent infection.
C. Clean the equipment in the client's room once per week: Cleaning should be performed daily or more frequently to reduce microbial load and prevent hospital-acquired infections, especially in burn clients who are at high risk.
D. Limit visitation time for the client's children to 40 min per day: There is no strict standard for limiting visitation to this duration; infection control practices and the client's condition guide safe visitation rather than arbitrary time limits.

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