Exhibits
The nurse reviews chart data.
Complete the diagram by dragging from the choices area which potential condition the client is experiencing, two actions to take, and two parameters the nurse would monitor.
The Correct Answer is []
- Myocardial infarction (MI): The client reports chest pain rated 8/10, radiating to the left arm, and has ST segment elevation on ECG. These findings are classic for ST-elevation myocardial infarction (STEMI), requiring immediate intervention.
- Draw laboratory cardiac markers: Troponin and other cardiac enzymes are critical for confirming myocardial injury. They help guide diagnosis, treatment, and monitoring of MI progression or resolution.
- Insert two peripheral IV (PIV) access devices: Dual IV access ensures reliable and rapid administration of emergency medications, fluids, or thrombolytics. This is vital for stabilizing the client during acute cardiac events.
- Pain level: Ongoing pain assessment is essential for monitoring myocardial ischemia, evaluating treatment response, and guiding further interventions to prevent cardiac tissue damage.
- 12-lead electrocardiogram (ECG): Continuous or repeated ECGs help detect changes in ST segments, arrhythmias, or infarct progression. It’s crucial in monitoring the effectiveness of interventions and early detection of complications.
- Reflux: While reflux may cause chest discomfort, it is not associated with ST elevation or arm radiation. These findings are cardiac in nature and point away from gastrointestinal causes.
- Costochondritis: This musculoskeletal condition causes localized chest pain but does not result in ECG changes or radiating pain. It is not supported by the client's data.
- Atrial fibrillation (A-fib): The client has a normal heart rate and regular rhythm. A-fib would show an irregular rhythm on ECG, not ST elevation, and is not the suspected diagnosis here.
- Insert nasogastric tube (NGT) for nutritional intake: An NGT is not a priority for a client with acute chest pain. The focus should be on stabilizing cardiac function rather than nutritional support.
- Consult nutritionist: Nutritional counseling may be relevant later, but it is not an acute intervention during a suspected myocardial infarction.
- Begin strict bedrest: While activity should be limited, “strict bedrest” is not always necessary and may lead to complications like DVT. The client’s mobility orders depend on cardiac stability.
- Intake and output: While important in general care, it is not as immediately critical in early MI management as pain and ECG monitoring.
- Nutritional intake: Nutritional monitoring is not an immediate priority during acute chest pain evaluation and cardiac stabilization.
- Peripheral edema: Edema may indicate chronic heart failure, but it is not a key indicator for acute myocardial infarction or urgent follow-up in this scenario.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Bilateral tinnitus when initially standing up: Tinnitus is not a common or serious adverse effect of nitroglycerin. While it may indicate another underlying issue, such as hypertension or ototoxicity, it is not immediately life-threatening.
B. Dizziness when rising from the bedside: Dizziness can result from the vasodilatory effects of nitroglycerin causing orthostatic hypotension. It is relatively common and usually managed with safety precautions and monitoring rather than immediate reporting.
C. Hypotension with a systolic of 90 mm Hg: A systolic blood pressure of 90 mm Hg is concerning after nitroglycerin administration, as the drug significantly lowers preload and can precipitate hemodynamic instability. This finding requires prompt HCP notification to prevent complications such as syncope or myocardial underperfusion.
D. Onset of headache after administration: Headache is a well-known and expected side effect of nitroglycerin due to cerebral vasodilation. While uncomfortable, it is generally benign and does not warrant immediate reporting unless it becomes severe or unrelenting.
Correct Answer is C
Explanation
A. Troponin and creatine kinase-myocardial band (CK-MB) levels: These cardiac biomarkers are used to assess myocardial injury, such as in acute coronary syndrome. They are not appropriate for evaluating valvular abnormalities like mitral valve prolapse.
B. Computed tomography (CT) scan of the chest: A CT scan of the chest is used to evaluate pulmonary conditions, aortic dissection, or mediastinal structures, but it is not the test of choice for assessing cardiac valve function or structure.
C. 2D-echocardiography: Echocardiography is the primary diagnostic tool for evaluating mitral valve prolapse. It allows real-time visualization of valve structure and function, including leaflet motion and regurgitation severity, making it the most appropriate step after identifying a midsystolic click.
D. 12-lead electrocardiogram (ECG): An ECG can detect rhythm disturbances or signs of chamber enlargement but cannot diagnose structural valve issues. While useful as part of a general cardiac evaluation, it is not specific enough for diagnosing mitral valve prolapse.
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