Patient Data
Initial testing is complete, and the nurse is reviewing the results.
Choose the most likely options for the information missing from the statement by selecting from the lists of options provided.
The nurse determines that the client has
The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}
Rationale for correct choices:
• New onset angina: The client presents with chest pain described as pressure and tightness that started during activity (mowing the lawn) and was unrelieved by rest, which is consistent with unstable angina. The ECG shows ST depression, which is indicative of myocardial ischemia rather than infarction. Since troponin levels are normal, myocardial cell death has not occurred, confirming that this is likely new-onset or unstable angina rather than a myocardial infarction.
• Troponin: Troponin T and I are cardiac biomarkers used to detect myocardial injury. In this client, both troponin levels are within normal limits, indicating no myocardial necrosis has occurred, which helps differentiate angina from a myocardial infarction.
Rationale for incorrect choices:
• Myocardial infarction: Myocardial infarction is characterized by prolonged chest pain with ECG changes and elevated troponin levels indicating cardiac muscle damage. This client’s troponin levels are normal, so myocardial infarction is unlikely at this time.
• Aortic aneurysm: Aortic aneurysm typically presents with sudden, severe, and tearing chest or back pain, often radiating to the back, and is not associated with ST depression on ECG. This presentation does not fit that diagnosis.
• International normalized ratio (INR) or prothrombin time (PT): These are measures of blood coagulation and are not relevant for diagnosing myocardial ischemia or angina. Troponin is the specific biomarker needed to assess myocardial injury.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"A"}
Explanation
Rationale for correct choices:
• Dry mouth: Sertraline, a selective serotonin reuptake inhibitor (SSRI), commonly causes mild anticholinergic side effects such as dry mouth. This occurs due to decreased salivary secretion and is a frequent, non-serious adverse effect seen in clients taking antidepressants.
• Sips of water: Taking frequent sips of water is an appropriate and effective way to relieve dry mouth. It helps maintain oral moisture and comfort without causing harm or interfering with medication therapy.
Rationale for incorrect choices:
• Hypernatremia: SSRIs like sertraline are more commonly associated with hyponatremia (low sodium), especially in older adults, not hypernatremia. Therefore, this is incorrect.
• Elevated blood pressure: Sertraline does not typically cause hypertension. Some antidepressants (like SNRIs) may increase blood pressure, but SSRIs generally do not.
• Frequent rest: This intervention is more appropriate for managing fatigue, not dry mouth.
• Elevation of legs: This is used for edema or circulation issues and has no role in managing dry mouth.
Correct Answer is B
Explanation
A. Adult respiratory distress syndrome with an oxygen saturation of 88% on room air is unstable. Hypoxemia at this level requires intensive monitoring and possibly mechanical ventilation or high-flow oxygen, making the client unsafe for transfer to a lower-acuity medical unit.
B. Chronic liver failure with a hemoglobin of 10.1 g/dL (101 g/L) and a slight bilirubin elevation is stable enough for transfer. Although the client has mild anemia and liver enzyme changes, vital signs and overall stability are likely maintained, and this condition can be managed safely on a medical unit with routine monitoring and care.
C. Myocardial infarction with sinus bradycardia and multiple ectopic beats indicates ongoing cardiac instability. This client requires continuous cardiac monitoring, potential interventions for arrhythmias, and close hemodynamic observation, which cannot be safely provided outside the critical care unit.
D. Pulmonary embolus with an IV heparin infusion and new onset hematuria is unstable. The new hematuria suggests a bleeding complication, and the client requires close monitoring and potential adjustment of anticoagulation therapy in the critical care setting.
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