A patient is admitted to the floor with a diagnosis of chest pain. Which of the following would be a priority for the assessment?
Palpation of the patient’s joints.
Inspection of the patient’s eyes.
Auscultation of the patient’s heart.
Percussion of the patient’s abdomen.
The Correct Answer is C
When a patient is admitted with a complaint of chest pain, the priority assessment would be to determine whether the patient is experiencing an acute cardiac event, such as a heart attack. This would involve a comprehensive assessment that includes obtaining the patient's medical history, vital signs (blood pressure, heart rate, respiratory rate, oxygen saturation), performing a physical exam, and obtaining an electrocardiogram (ECG).
Other important factors to assess include the location and nature of the pain, any associated symptoms (such as shortness of breath or diaphoresis), the patient's current medications and medical history (including any history of heart disease or risk factors), and any recent procedures or interventions that may have led to the current presentation.
Prompt assessment and intervention are crucial in managing a patient with chest pain, as timely treatment can help to minimize damage to the heart muscle and prevent further complications. Therefore, any signs of an acute cardiac event should be immediately reported to the healthcare provider in charge, and appropriate interventions should be initiated promptly.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
When assessing the heart, the nurse will inspect and palpate the precordium, which is the area of the chest overlying the heart, and the PMI (point of maximal impulse), which is the point on the chest where the heartbeat is the strongest. These assessments allow the nurse to gather information about the size, shape, and location of the heart and to detect any abnormalities in the heartbeat or rhythm. The peritoneum is a membrane lining the abdominal cavity and has no relevance in the assessment of the heart. The tricuspid area and left sternal border are areas of the chest that may be auscultated to assess heart sounds but are not palpated during a heart assessment.
Correct Answer is B
Explanation
The SBAR (Situation, Background, Assessment, Recommendation) system is a standardized way of communicating critical information between healthcare professionals, particularly during patient handoffs or when escalating a concern.
The recommendation component is where the healthcare professional providing the report suggests a course of action or plan for the patient based on the situation, background, and assessment. For example, a recommendation might be, "I recommend increasing Mr. Smith's pain medication to manage his discomfort," or "I recommend a consult with the nutritionist to address Mrs. Brown's malnutrition."
Of the options provided, (a) provides the situation, (c) provides the assessment, and (d) provides a specific finding from the assessment. Option (b) is a specific recommendation or plan.
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