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Exhibits

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Answer and Explanation

The Correct Answer is []

  • Myocardial infarction (MI) is suggested by chest pain radiating to the left arm, diaphoresis, shortness of breath, and epigastric discomfort. The pain described as "sharp, tight, and like indigestion" aligns with cardiac ischemia.
  • Administering oxygen helps improve myocardial oxygenation, reducing ischemia.
  • Aspirin 325 mg is a standard intervention in suspected MI to prevent further platelet aggregation and reduce the risk of worsening thrombosis in the coronary arteries.
  • Monitoring vital signs is critical to assess for hemodynamic stability and signs of worsening cardiac function (e.g., hypotension, tachycardia).
  • Monitoring ECG rhythm helps detect ST-elevation or other ischemic changes and assess for life-threatening arrhythmias.
  • Morphine may be used for chest pain, but it is now considered secondary to nitroglycerin and beta-blockers.
  • Verapamil is a calcium channel blocker used for rate control in arrhythmias but is not first-line for acute MI.
  • Platelet count and WBC count are not immediately relevant to MI management.
  • Serum glucose levels may be affected by stress but are not a primary concern in acute MI management.


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Related Questions

Correct Answer is ["A","D","E"]

Explanation

A. Increased blood pressure is expected due to excess fluid in the vascular system, which raises blood volume and pressure.
B. Hematocrit is typically decreased in fluid volume overload due to hemodilution rather than increased.
C. Increased temperature is not a common finding in fluid overload, as fever is usually associated with infection rather than volume excess.
D. Increased heart rate (tachycardia) occurs as the heart compensates for excess fluid and decreased cardiac output.
E. Increased respiratory rate is common due to pulmonary congestion and fluid accumulation in the lungs, leading to dyspnea.

Correct Answer is A

Explanation

A. Defibrillation is the priority intervention for pulseless ventricular tachycardia, as it can restore a normal rhythm. It should be performed as soon as possible.
B. Synchronized cardioversion is used for hemodynamically unstable tachyarrhythmias with a pulse, not for pulseless V-Tach.
C. CPR should be initiated if a defibrillator is not immediately available, but defibrillation is the definitive treatment.
D. Repeating an ECG does not address the immediate life-threatening situation.

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