A nurse is caring for a client who reports a new onset of severe chest pain. Which of the following actions should the nurse take to determine if the client is experiencing a myocardial infarction?
Perform a 12-lead ECG
Determine if pain radiates to the left arm
Check the client's blood pressure
Auscultate heart tones
The Correct Answer is A
Choice A reason: A 12-lead ECG can reveal changes in the ST segment, T wave, and QRS complex, which are indicative of myocardial ischemia, injury, or infarction. It is the first line diagnostic test that needs to be recorded within 10 minutes after the first medical contact in cases of suspected acute coronary syndromes.
Choice B reason: While pain radiating to the left arm can be a symptom of MI, it is not a definitive diagnostic action. It is a common symptom but can also be associated with other conditions.
Choice C reason: Checking the client's blood pressure is important in the overall assessment of the client's cardiovascular status but does not specifically diagnose MI. Blood pressure can be normal, elevated, or decreased in the case of MI.
Choice D reason: Auscultating heart tones can provide information about the presence of murmurs, gallops, or rubs, but it is not a specific diagnostic action for MI. Heart sounds may be normal during an MI.
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Related Questions
Correct Answer is C
Explanation
Choice A reason: Nausea and faintness Nausea and faintness can be symptoms of hypovolemic shock. Hypovolemic shock occurs when the body loses a significant amount of blood or fluids, leading to a decrease in blood pressure and inadequate oxygen supply to the organs. This can cause various symptoms, including nausea and faintness, as the body struggles to maintain normal function.
Choice B reason: Neurologic deficits and apprehension Neurologic deficits and apprehension can also be symptoms of hypovolemic shock. Neurologic deficits refer to abnormal neurologic function of a body area due to injury of the brain, spinal cord, muscles, or nerves. Apprehension, or anxiety, can occur as the body responds to the stress of significant blood or fluid loss.
Choice C reason: Hypertension and tachypnea Hypertension, or high blood pressure, is not typically a symptom of hypovolemic shock. In fact, hypovolemic shock is usually characterized by hypotension, or low blood pressure, due to the loss of blood or fluids. Tachypnea, or rapid breathing, can be a symptom of hypovolemic shock, but it would not typically be accompanied by hypertension in this context.
Choice D reason: Diaphoresis and oliguria Diaphoresis (excessive sweating) and oliguria (reduced urine production) can be symptoms of hypovolemic shock. Diaphoresis can occur as the body attempts to cool itself in response to the stress of significant blood or fluid loss. Oliguria can occur as the kidneys receive less blood flow due to the decrease in blood volume, leading to decreased urine production.
Correct Answer is D
Explanation
Choice A reason: Morphine is used to manage pain and anxiety after the initial acute phase of an MI.
Choice B reason: Aspirin is used in the initial treatment of MI to prevent further clot formation but is not primarily for pain and anxiety management.
Choice C reason: Oxygen is administered during the acute phase of an MI if the patient is hypoxic.
Choice D reason: Nitroglycerin is used to manage chest pain in MI but is not the primary medication for general pain and anxiety post-acute phase.
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