A nurse is collecting data from a client who has an acute myocardial infarction (MI). Which of the following clinical manifestations should the nurse expect to find? (Select all that apply.)
Nausea
Orthopnea
Diaphoresis
Headache
Tachycardia
Correct Answer : A,C,E
a. Nausea: Nausea is a common symptom of myocardial infarction and can be associated with autonomic nervous system activation.
b. Orthopnea: Orthopnea, difficulty breathing while lying down, is more commonly associated with heart failure, not necessarily myocardial infarction.
c. Diaphoresis: Profuse sweating or diaphoresis is a common manifestation of myocardial infarction due to sympathetic nervous system activation.
d. Headache: Headache is not a typical symptom of myocardial infarction. However, some individuals may experience atypical symptoms.
e. Tachycardia: Tachycardia (rapid heart rate) is a common response to myocardial infarction and can be associated with sympathetic nervous system stimulation in response to decreased cardiac output.
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Related Questions
Correct Answer is D
Explanation
a. "The pain radiates down to my lower back." This statement is not typical of peptic ulcer
disease. Radiation of pain to the lower back may suggest other abdominal or musculoskeletal issues.
b. "I feel so much better after eating." Relief of pain after eating is more indicative of gastric ulcer rather than peptic ulcer disease. Peptic ulcers are often associated with pain that worsens after eating.
c. "My pain is relieved by having a bowel movement." Relief of pain with bowel movements is
not a characteristic finding of peptic ulcer disease. This may suggest other gastrointestinal issues.
d. "The pain is worse after I eat a meal high in fat." This statement is consistent with peptic ulcer disease. High-fat meals stimulate gastric acid secretion, potentially exacerbating the pain
associated with peptic ulcers.
Correct Answer is C
Explanation
a. Serum chloride 99 mEq/L: Serum chloride within the reference range is not an adverse effect of spironolactone.
b. Serum calcium 10.5 mg/dL: Serum calcium within the reference range is not an adverse effect of spironolactone.
c. Serum potassium 5.2: Spironolactone is a potassium-sparing diuretic, and an elevated serum potassium level is an adverse effect that requires monitoring. The nurse should assess for
hyperkalemia.
d. Serum sodium 140 mEq/L: Serum sodium within the reference range is not an adverse effect of spironolactone.
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