A nurse is caring for a client who reports chest pain. Which of the following laboratory findings indicates myocardial damage?

Troponin 11.8 ng/mL

Erythrocyte sedimentation rate (ESR) 17 mm/hr

Human B-type natriuretic peptide 88 pg/ml.

aPTT 80 seconds

Answer and Explanation

The Correct Answer is A

A. Troponin is a protein released into the bloodstream when there is damage to the heart muscle (myocardium), such as during a heart attack. Elevated troponin levels indicate myocardial injury or damage, making this the correct choice for indicating myocardial damage.

B. Erythrocyte sedimentation rate (ESR) measures the rate at which red blood cells settle in a tube of blood. It is a non-specific marker of inflammation and is not specific to myocardial damage.

C. Human B-type natriuretic peptide (BNP) is released by the heart in response to increased pressure and volume. Elevated levels are indicative of heart failure, not necessarily myocardial damage.

D. Activated partial thromboplastin time (aPTT) measures the time it takes for blood to clot. It is used to monitor the effectiveness of anticoagulant therapy and is not specific to myocardial

damage.

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Correct Answer is D

Explanation

A. Irregular uterine contractions at 38 weeks of gestation may not be a concern unless they become regular and more intense.

B. A client scheduled for a nonstress test (NST) at 39 weeks of gestation can typically wait until after attending to more urgent matters.

C. A client scheduled for an induction of labor at 40 weeks of gestation is not necessarily a priority unless there are urgent concerns.

D. Decreased fetal movement, especially for 2 days at 36 weeks of gestation, requires immediate assessment to ensure fetal well-being.

A. Perform active range-of-motion exercises. B. Maintain the head at a midline position. C. Suction the airway frequently. D. Perform neurological checks every 4 hours.

Correct Answer is B

Explanation

A. Active range-of-motion exercises are not appropriate for a child with increased intracranial pressure and decreased level of consciousness, as they may increase intracranial pressure.

B. Maintaining the head at a midline position helps promote proper cerebral perfusion and reduces the risk of further increases in intracranial pressure.

C. Frequent suctioning of the airway can stimulate the gag reflex and increase intracranial pressure. Suctioning should only be done as needed to maintain a clear airway.

D. Neurological checks should be performed more frequently than every 4 hours in a child with increased intracranial pressure and decreased level of consciousness, ideally at least every hour or as indicated by the child's condition.

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A nurse is caring for a client who reports chest pain. Which of the following laboratory findings indicates myocardial damage?

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