An emergency department nurse triages clients who present with chest discomfort. Which client would the nurse plan to assess first?
Client who describes intense squeezing pressure across the chest.
Client who reports moderate pain that is worse on inspiration.
Client who reports cramping substernal pain.
Client who describes pain as a dull ache.
The Correct Answer is A
A. This description is indicative of possible myocardial infarction (MI), a life-threatening emergency. Immediate evaluation and intervention, such as administering oxygen, obtaining an EKG, and providing pain relief, are crucial to prevent further damage to the heart and reduce mortality.
B. Moderate pain worse on inspiration suggests pleuritic pain, often associated with conditions like pleuritis or pulmonary embolism, which are serious but generally not as immediately life-threatening as an MI.
C. Cramping substernal pain may indicate a gastrointestinal issue, such as gastroesophageal reflux disease (GERD), which is less urgent than a potential MI.
D. A dull ache may be related to musculoskeletal or gastrointestinal issues and does not suggest the immediate need for intervention seen in MI.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. The best response is to educate the client about the cause of Prinzmetal angina. It occurs due to spasm in the coronary arteries, which is different from the plaque buildup seen in traditional coronary artery disease. This response addresses the client's concern in an accurate and reassuring manner.
B. While healthy eating is important, Prinzmetal angina is not typically caused by cholesterol or plaque buildup. This response could increase the client's anxiety.
C. While acknowledging the client's emotions is important, this response does not address the underlying concern or provide an accurate explanation of Prinzmetal angina.
D. Offering reassurance without providing accurate information about the condition does not help the client understand the cause of their symptoms and could leave them confused or anxious.
Correct Answer is D
Explanation
A. A blood pressure of 90/50 mm Hg is concerning, but it is less urgent than severe respiratory depression. The nurse should still assess this client promptly.
B. A temperature of 96° F (35.6° C) is mildly low and should be addressed, but it is not as critical as a severely low respiratory rate.
C. A pulse of 118 beats/min is elevated and may require monitoring, but it does not pose as immediate a threat as respiratory depression.
D. A respiratory rate of 6 breaths/min is critically low, which may indicate respiratory depression, particularly after anesthesia. Immediate assessment and intervention are needed to ensure adequate oxygenation and ventilation.
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