A nurse is caring for a client who is having an acute myocardial infarction (MI). The nurse is aware that which of the following are part of the assessment of cardiac pain. (SELECT ALL THAT APPLY)
Distribution
Onset
Intensity
Location
Radiation
Alleviated
Correct Answer : A,B,C,D,E,F
Rationale:
A. Distribution refers to the area of the body where the pain is felt.
B. Onset refers to when the pain started.
C. Intensity refers to the severity of the pain.
D. Location refers to where the pain is felt.
E. Radiation refers to whether the pain spreads to other areas.
F. Alleviated refers to what makes the pain better or worse.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. Tenormin (Atenolol) is a beta-blocker that reduces the heart rate and may affect the results of the stress test. Therefore, it should be held the morning of the test.
B. Heparin is an anticoagulant and is not typically held before a stress test.
C. Keflex (Cephalexin) is an antibiotic and is not typically held before a stress test.
D. Holding all medications is not necessary for a stress test, but specific medications that may interfere with the test, such as beta-blockers, should be held.
Correct Answer is D
Explanation
Rationale:
A. This is not correct since a sinus tachycardia show have a sinus P wave unlike in the strip.
B. This is incorrect since a junctional rhythm should have a regular ventricular rhythm unlike in the above strip which is irregular.
C. A first degree heart block should have a PR interval greater than 0.20 without a disruption in the atrial to ventricular conduction.
D. This is correct since the rhythm is irregular and the P waves are absent.
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