In planning care for a patient with acute myocardial infarction (AMI), which of the following should the nurse identify as the highest priority goal of care?
Stable ECG rhythm
Ability to verbalize causes and effects of CHD/CAD
Adequate relief of pain
Compliance with prescribed bedrest
The Correct Answer is C
Choice A reason : While maintaining a stable ECG rhythm is important, it is not the highest priority. The primary concern is to address life-threatening complications.
Choice B reason : Educating the patient about the causes and effects of coronary heart disease (CHD) or coronary artery disease (CAD) is important for long-term management but is not the immediate priority during acute care.
Choice C reason : Adequate relief of pain is the highest priority in the care of a patient with AMI. Pain is an indicator of ongoing ischemia and can increase the workload of the heart, thereby worsening the condition.
Choice D reason (AMI): While bedrest is part of the care plan, it is not the highest priority compared to pain relief, which has direct implications on the patient's immediate physiological status.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Stopping seizure medication such as phenytoin without medical advice can lead to life-threatening seizures. It is not recommended to stop after a set period of being seizure-free without consulting a healthcare provider.
Choice B reason: Phenytoin should not be taken only during periods of stress; it is intended to be used consistently to maintain therapeutic levels in the body.
Choice C reason: Phenytoin may need to be continued indefinitely, depending on the individual's condition and the doctor's recommendation. It is often used as a long-term treatment for seizure control.
Choice D reason: This statement is misleading; while phenytoin helps control seizures, it does not cure the underlying condition causing them.
Correct Answer is A
Explanation
The correct answer is Choice A
Choice A rationale: Movement of the trachea toward the unaffected side indicates a possible tension pneumothorax, which is a life-threatening condition. This shift occurs due to the increased pressure on the affected side, pushing the trachea away. Immediate intervention is required.
Choice B rationale: Crepitus, or subcutaneous emphysema, can be a common finding around the chest tube insertion site. It indicates air leakage into the subcutaneous tissue but does not necessarily require immediate notification to the provider unless it is extensive or worsening.
Choice C rationale: Bubbling of the water in the water seal chamber with exhalation is expected and indicates that the chest tube is functioning properly by allowing air to escape from the pleural space. This is a normal finding in pneumothorax management.
Choice D rationale: The visibility of eyelets on the chest tube indicates that the tube is in the correct position within the pleural space. If the eyelets are not visible, it means the tube is not functioning correctly, but this is not as urgent as a tracheal shift.
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