Aspirin is administered to the client experiencing an MI because of its:
Antipyretic action
Antiplatelet action
Analgesic action
Antithrombotic action
The Correct Answer is B
Choice A rationale:
Antipyretic action refers to the ability to reduce fever. While aspirin does have antipyretic properties, this is not the primary reason it is administered during an MI. Fever is not a characteristic symptom of MI, and reducing fever would not directly address the underlying cause of the MI, which is the formation of a blood clot in a coronary artery.
Choice B rationale:
Antiplatelet action is the ability to prevent platelets from clumping together and forming blood clots. This is the crucial mechanism by which aspirin helps in the setting of an MI.
During an MI, a blood clot forms in a coronary artery, blocking blood flow to the heart muscle. This blockage can cause severe damage to the heart muscle, leading to chest pain, shortness of breath, and potentially life-threatening complications.
Aspirin irreversibly inhibits the enzyme cyclooxygenase (COX), which is essential for platelet aggregation. By blocking COX, aspirin prevents platelets from sticking together and forming new clots. This can help to:
Limit the size of the existing clot in the coronary artery.
Prevent the formation of additional clots that could further block blood flow.
Allow for better blood flow to the heart muscle, reducing damage and improving outcomes.
Choice C rationale:
Analgesic action refers to the ability to relieve pain. While aspirin does have analgesic properties, this is not the primary reason it is administered during an MI. Pain relief is an important aspect of managing MI symptoms, but it does not directly address the underlying cause of the MI, which is the blood clot.
Choice D rationale:
Antithrombotic action is a broader term that encompasses any action that prevents or reduces blood clot formation. Aspirin's antiplatelet action is a specific type of antithrombotic action. However, it's important to note that aspirin does not directly dissolve existing clots; it primarily prevents new clots from forming.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Calling "all clear" once before discharging the defibrillator is crucial for safety, but it's not the primary action that ensures effective defibrillation.
The purpose of calling "all clear" is to alert everyone in the vicinity to stay clear of the patient and avoid accidental shock.
However, even with a clear announcement, it's essential for the nurse to visually confirm that no one is touching the patient or bed before discharging the defibrillator.
Choice B rationale:
Maintaining firm contact between the paddles and the client's skin is essential for delivering the defibrillation shock effectively.
Here's a detailed breakdown of why this contact is so critical:
Maximizes energy transfer: Firm contact minimizes the impedance (resistance) between the paddles and the skin, allowing for the maximum amount of electrical energy to be transferred to the heart.
Reduces arcing: Arcing occurs when electrical energy jumps through the air instead of passing through the intended path (between the paddles and the heart). This can cause skin burns and reduce the effectiveness of the shock. Firm contact helps prevent arcing by ensuring a direct connection.
Ensures consistent current flow: Consistent contact ensures that the electrical current flows evenly across the chest, reaching all areas of the heart muscle. This increases the likelihood of successful defibrillation.
Minimizes energy loss: Any gaps or poor contact between the paddles and skin can lead to energy loss, reducing the shock's strength and effectiveness.
Choice C rationale:
Sync mode (synchronized cardioversion) is used for specific heart rhythm disturbances, such as atrial fibrillation or atrial flutter, where the shock needs to be timed with the QRS complex on the ECG.
Ventricular fibrillation, however, is a chaotic rhythm without distinct QRS complexes, so sync mode is not appropriate.
Using sync mode in ventricular fibrillation could delay the shock and potentially decrease its effectiveness.
Choice D rationale:
Water is not an appropriate conducting agent for defibrillation.
It can actually increase the risk of burns and decrease the effectiveness of the shock.
Approved conducting agents, such as gel pads or paste, should be used to ensure optimal energy transfer and patient safety.
Correct Answer is B
Explanation
correct answer is Choice B.
Choice B rationale:
Orthostatic hypotension is a significant drop in blood pressure that occurs when a person stands up from a lying or sitting position. It's characterized by a decrease in systolic blood pressure of at least 20 mmHg or a decrease in diastolic blood pressure of at least 10 mmHg within 3 minutes of standing.
The client's assessment data clearly demonstrates orthostatic hypotension, with a systolic blood pressure drop of 23 mmHg and a diastolic drop of 13 mmHg upon standing.
Orthostatic hypotension is a major risk factor for falls, especially in older adults. This is because the sudden decrease in blood pressure can lead to lightheadedness, dizziness, blurred vision, weakness, and even fainting.
Falls in older adults can result in serious injuries, such as fractures, head trauma, and even death. Therefore, it's crucial to identify and address orthostatic hypotension to prevent falls and their associated complications.
Rationales for other choices:
Choice A: Ineffective breathing pattern is not directly related to orthostatic hypotension. While hypotension can cause shortness of breath in some cases, it's not the primary concern in this scenario.
Choice C: Ineffective role performance can be a consequence of frequent falls, but it's not the most immediate or pressing nursing diagnosis in this case.
Choice D: Risk for imbalanced fluid balance is a potential concern in some cases of orthostatic hypotension, but it's not the most likely diagnosis based on the client's assessment data.
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