In planning care for the patient with acute myocardial infarction (AMI), the nurse identifies the highest priority goal of care as which of the following?
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 a stable ECG rhythm is important, it is not the immediate concern post-AMI.
Choice B reason: The ability to verbalize causes and effects of CHD/CAD is an educational goal, not an immediate care priority.
Choice C reason: Adequate relief of pain is a priority to reduce stress on the heart and improve patient comfort.
Choice D reason: Compliance with prescribed bedrest is important but secondary to pain relief.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Avoiding tanning booths is correct and does not indicate a need for further teaching.
Choice B reason: Using sunscreen even on cloudy days is correct and does not indicate a need for further teaching.
Choice C reason: Checking the skin monthly for any changes is correct and does not indicate a need for further teaching.
Choice D reason: The statement about eating a high-fiber diet reducing the risk for developing skin cancer indicates a misunderstanding, as there is no direct correlation between a high-fiber diet and the prevention of skin cancer. This indicates a need for further teaching.
Correct Answer is A
Explanation
Choice A reason: Evaluating the effectiveness of opioid analgesics is crucial as pain management is a primary concern for patients experiencing a sickle cell crisis.
Choice B reason: Limiting the patient's intake of oral and IV fluids is not recommended as hydration is important for patients with sickle cell crisis to reduce blood viscosity and improve circulation.
Choice C reason: Teaching the patient about high-protein, high-calorie foods is beneficial for long-term management but is not the immediate nursing intervention during a crisis.
Choice D reason: Encouraging ambulation may be part of recovery but is not the primary intervention during an acute sickle cell crisis due to the risk of pain exacerbation.
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