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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Hypertensive crisis is not a direct complication of atrial fibrillation. It is typically caused by uncontrolled hypertension rather than arrhythmias.
B. Cardiogenic shock can occur in severe heart failure but is not a primary complication of atrial fibrillation.
C. Embolic cerebral vascular accident (stroke) is a major risk for clients with atrial fibrillation. The irregular atrial contractions allow blood to pool in the atria, increasing the risk of clot formation. If a clot dislodges, it can travel to the brain and cause a stroke.
D. Flash pulmonary edema is a complication of acute decompensated heart failure but is not directly caused by atrial fibrillation.
Correct Answer is ["B","C","D","E","F"]
Explanation
A. Increased appetite is not a symptom of worsening right-sided heart failure; clients may actually experience nausea or anorexia due to fluid congestion in the gastrointestinal system.
B. Distended neck veins (jugular venous distension) indicate increased venous pressure and systemic congestion, which are signs of worsening right-sided heart failure.
C. Worsening lower extremity edema occurs due to fluid retention and poor venous return, which are hallmark signs of right-sided heart failure.
D. Feeling fatigued is common as the heart struggles to pump blood effectively, leading to decreased oxygen delivery to tissues.
E. Unable to lie flat (orthopnea) is typically associated with left-sided heart failure but can also occur in right-sided failure due to fluid overload and pulmonary congestion.
F. Weight gain >2 lb in 24 hours suggests significant fluid retention and worsening heart failure, requiring prompt medical attention.
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