Family members bring a client to the ED with pale cool skin, sudden midsternal chest pain unrelieved with rest, and a history of CAD. How should the nurse best interpret these initial data?

The symptoms indicate an acute coronary episode and should be treated as such.

The symptoms indicate angina and should be treated as such.

Treatment should be determined pending the results of an exercise stress test.

The symptoms indicate a pulmonary etiology rather than a cardiac etiology.

Answer and Explanation

The Correct Answer is A

A. The symptoms indicate an acute coronary episode and should be treated as such:

The client's symptoms, including sudden midsternal chest pain unrelieved with rest and a history of coronary artery disease (CAD), strongly suggest an acute coronary event, such as a myocardial infarction (heart attack). Pale, cool skin can also be indicative of decreased perfusion due to cardiac compromise. Given these critical signs and symptoms, the nurse should interpret this as a potential cardiac emergency and initiate immediate interventions aimed at managing and stabilizing the client's condition.

B. The symptoms indicate angina and should be treated as such:

While angina can present with symptoms such as chest pain, it is typically relieved with rest or nitroglycerin. In contrast, the client in this scenario has midsternal chest pain that is not relieved with rest, which is more indicative of an acute coronary event like a myocardial infarction. Therefore, interpreting the symptoms as angina and treating them as such may not be appropriate given the severity and persistence of the chest pain.

C. Treatment should be determined pending the results of an exercise stress test:

Waiting for the results of an exercise stress test is not appropriate in this scenario, as the client's presentation suggests an acute cardiac event that requires immediate intervention. Exercise stress tests are typically used for diagnostic purposes to assess cardiovascular function under controlled conditions but are not suitable for managing acute coronary episodes or emergencies.

D. The symptoms indicate a pulmonary etiology rather than a cardiac etiology:

While some symptoms, such as shortness of breath or chest pain, can overlap between cardiac and pulmonary conditions, the client's presentation with sudden midsternal chest pain unrelieved with rest, pale cool skin, and a history of CAD strongly suggests a cardiac etiology, specifically an acute coronary event. It is essential to prioritize cardiac assessment and intervention based on the client's symptoms and medical history.

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Correct Answer is A

Explanation

A. "Only take one nitroglycerin tablet for each episode of angina."

This instruction is correct. Sublingual nitroglycerin is typically administered as needed for the relief of angina symptoms, with one tablet being the initial dose. If the chest pain persists after 5 minutes, the client may take a second tablet, and if needed, a third tablet after another 5 minutes. However, if the pain is not relieved after three tablets, they should seek immediate medical attention.

B. "Place the nitroglycerin tablet between cheek and gum."

This instruction is incorrect. Sublingual nitroglycerin tablets should be placed under the tongue, allowing them to dissolve and be absorbed directly into the bloodstream. Placing the tablet between the cheek and gum is not the recommended administration route for sublingual nitroglycerin.

C. "Call 911 if you develop a headache following nitroglycerin use."

This instruction is partially correct. Headache is a common side effect of nitroglycerin due to its vasodilatory effects. Clients should be informed about this potential side effect, but not every headache following nitroglycerin use requires immediate medical attention. However, if the headache is severe, persistent, or accompanied by other concerning symptoms, the client should seek medical evaluation.

D. "See if rest relieves the chest pain before using the nitroglycerin."

This instruction is incorrect. Sublingual nitroglycerin is a rapid-acting medication used to relieve angina symptoms quickly. Clients should not delay taking nitroglycerin and wait for rest to relieve chest pain, as this can lead to worsening symptoms and complications.

A. "If I take my blood pressure and it is normal, I don't have to take my blood pressure pills." B. "When getting up from bed, I will sit for a short period before standing up." C. "I will consult a dietician to help get my weight under control." D. "I think I'm going to sign up for a yoga class twice a week to help reduce my stress."

Correct Answer is A

Explanation

A. "If I take my blood pressure and it is normal, I don't have to take my blood pressure pills": This statement reflects a misunderstanding of hypertension management. Blood pressure medications are typically prescribed to help control blood pressure over the long term, regardless of individual blood pressure readings. Stopping medication without consulting a healthcare provider can be dangerous and is not recommended.

B. "When getting up from bed, I will sit for a short period before standing up": This statement demonstrates an understanding of orthostatic hypotension prevention, which is important for clients with hypertension and can be a side effect of certain medications.

C. "I will consult a dietician to help get my weight under control": This statement indicates the client's awareness of the importance of weight management in hypertension control and is a positive step toward healthy lifestyle changes.

D. "I think I'm going to sign up for a yoga class twice a week to help reduce my stress": This statement shows the client's proactive approach to stress reduction, which is beneficial for hypertension management as stress can contribute to elevated blood pressure.

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Family members bring a client to the ED with pale cool skin, sudden midsternal chest pain unrelieved with rest, and a history of CAD. How should the nurse best interpret these initial data?

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