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. Weigh yourself once a week. B. Drink 3 liters of fluid per day. C. Engage in exercise daily. D. Restrict dietary potassium.

Correct Answer is C

Explanation

A. Weigh yourself once a week:

This is an important part of heart failure management as weight gain can indicate fluid retention, a common symptom of heart failure. The nurse should instruct the client to weigh themselves at the same time of day, using the same scale, and wearing similar clothing each time. Any sudden weight gain should be reported to the healthcare provider promptly.

B. Drink 3 liters of fluid per day:

This option is not appropriate for most heart failure patients, especially those with fluid retention issues. Fluid intake should be monitored and restricted based on the individual's condition and healthcare provider's recommendations. Consuming too much fluid can exacerbate fluid retention and worsen heart failure symptoms.

C. Engage in exercise daily:

Exercise is generally recommended for heart failure patients, but the type, intensity, and frequency of exercise should be tailored to the individual's condition. The nurse should encourage the client to engage in regular physical activity as tolerated, following a structured exercise plan approved by their healthcare provider. Activities like walking, cycling, or water aerobics can be beneficial for heart health.

D. Restrict dietary potassium:

This option is not typically included in lifestyle modifications for heart failure unless the client has specific potassium-related issues or is taking medications that require potassium restriction. Potassium is an important electrolyte for heart function, and most heart failure patients are advised to consume a balanced diet with moderate potassium intake, unless otherwise directed by their healthcare provider.

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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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Naxlex Comprehensive Predictor Exams

When providing discharge instructions for a client who has been prescribed sublingual nitroglycerin for stable angina, the nurse should plan to include which instructions?

Correct Answer is A

Explanation

The nurse is teaching a client about lifestyle modifications after a heart failure diagnosis. What will be included in the teaching?

Correct Answer is C

Explanation

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