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

Answer and Explanation

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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Correct Answer is B

Explanation

b. Paralytic ileus: Absence of bowel sounds, abdominal distention, and no passage of flatus are characteristic signs of paralytic ileus, which is a temporary impairment of bowel motility following surgery.

c. Health care-associated Clostridium difficile: Clostridium difficile infection is associated with diarrhea, abdominal pain, and fever. The absence of bowel sounds and abdominal distention is not consistent with C. difficile infection.

d. Fecal impaction: Fecal impaction is characterized by a blockage of hardened stool in the

rectum or colon, leading to difficulty passing stool. It may cause abdominal discomfort, but it does not typically present with the absence of bowel sounds and abdominal distention seen in paralytic ileus.

A. Battle's sign B. Nuchal rigidity C. Lethargy D. Polyuria

Correct Answer is C

Explanation

a. Battle's sign: Battle's sign is bruising over the mastoid process and is not a direct manifestation of increased intracranial pressure.

b. Nuchal rigidity: Nuchal rigidity (stiff neck) is associated with irritation of the meninges and is not a specific sign of increased intracranial pressure.

c. Lethargy: Lethargy or altered level of consciousness is a common manifestation of increased intracranial pressure. It can range from mild drowsiness to severe impairment of consciousness.

d. Polyuria: Polyuria is not a typical manifestation of increased intracranial pressure. Increased urine output may be associated with other conditions, such as diabetes or diuretic use.

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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.)

Nursing Test Bank

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