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Exhibits

Review H and P, nurse's notes, flow chart, laboratory results, and prescriptions. Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the PN should take to address that condition, and two parameters the PN should monitor to assess the client's progress.

Answer and Explanation

The Correct Answer is []

The client’s symptoms—severe chest pain, nausea, dizziness, trembling, and diaphoresis—along with elevated troponin levels, are indicative of a myocardial infarction. Troponin is a cardiac biomarker used to diagnose myocardial infarction, and the client’s symptoms are consistent with this condition.

Actions to Take:

  1. Use Therapeutic Communication to Build Rapport
    Effective therapeutic communication helps the client feel supported and may reduce anxiety and fear related to their condition. This approach can provide a calm environment for the client, which is crucial when managing a myocardial infarction.
  2. Teach Coping Skills
    Teaching coping skills can help the client manage anxiety and stress, which are important for recovery from a myocardial infarction. Understanding how to cope with the emotional and psychological aspects of the condition supports overall care and management.

Parameters to Monitor:

  1. Heart Rhythm
    Monitoring heart rhythm is essential to detect any arrhythmias or complications related to myocardial infarction. Changes in heart rhythm can indicate worsening of the condition or response to treatment.
  2. Vital Signs
    Monitoring vital signs, including blood pressure and heart rate, is crucial for assessing the client’s hemodynamic status and the effectiveness of treatment. Abnormalities in vital signs can indicate worsening of the myocardial infarction or side effects of medications


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Related Questions

Correct Answer is B

Explanation

A. Eliminating citrus drinks is not specifically related to preventing dumping syndrome. While citrus drinks might irritate the stomach, the main dietary consideration for dumping syndrome is the timing of fluid intake.
B. Consuming fluids 30 minutes to one hour after meals helps prevent dumping syndrome. Drinking fluids too close to meal times can increase the risk of dumping syndrome by accelerating gastric emptying.
C. Increasing the intake of carbonated fluids after meals is not recommended for preventing dumping syndrome. Carbonated drinks can exacerbate symptoms rather than help prevent them.
D. Avoiding caffeinated beverages can be part of general dietary recommendations, but it is not the primary measure to prevent dumping syndrome. The timing of fluid intake relative to meals is more crucial.

Correct Answer is D

Explanation

A. C-reactive protein level is a general marker for inflammation and can indicate infection, but it does not provide specific information about the wound infection.
B. Serum albumin is important for assessing nutritional status and wound healing potential, but it does not directly address the acute issue of a possible wound infection.
C. Serum blood glucose level is significant, especially in clients with diabetes, as high glucose can impair healing and increase infection risk. However, it does not directly provide information about the infection itself.
D. Culture for sensitive organisms is the most relevant lab value to evaluate before reporting to the healthcare provider. It identifies the specific pathogens causing the infection and guides appropriate antibiotic treatment.

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