The nurse assesses a male client who is brought to the emergency department (ED) by his family who believes he is having a heart attack. Which finding is the best indicator that a client is experiencing an acute myocardial infarction (AMI)?

Pain in the neck, jaw, or medial side of the left arm.

Anterior thorax pain that radiates between the scapulae.

Localized sternal border pain intensified by palpation.

Chest pain that intensifies upon chest excursion.

Answer and Explanation

The Correct Answer is A

A.   Pain radiating to the neck, jaw, or medial side of the left arm is a classic symptom of an acute myocardial infarction (AMI). This type of referred pain occurs because the heart's pain signals are often perceived in other areas of the body. This finding is a strong indicator of AMI and is consistent with the typical presentation of myocardial infarction.
B.   Pain in the anterior thorax that radiates between the scapulae can be associated with various conditions, including myocardial infarction, but it is less specific than pain radiating to the neck, jaw, or arm. While this type of pain can occur in AMI, it is not as distinctive as the classic left arm pain and may also be seen in conditions like angina or musculoskeletal issues.
C.   Localized sternal border pain that worsens with palpation is more indicative of a musculoskeletal issue, such as costochondritis, rather than an acute myocardial infarction. AMI typically presents with diffuse chest pain that is not localized or worsened by palpation.
D.   Chest pain that worsens with chest movement, such as deep breathing or coughing, is more characteristic of pleuritic pain or musculoskeletal pain rather than an acute myocardial infarction. In AMI, the pain is generally persistent and not influenced by respiratory movements.

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Correct Answer is A

Explanation

A. A limping gait can be a sign of pain or discomfort while walking. By asking about pain while bearing weight, the nurse can get a better understanding of the underlying cause of the limp.
B. A limping gait is not typically associated with changes in level of consciousness. This assessment is not relevant in this situation.

C. While a spinal deformity can cause a limping gait, it is not the most likely cause in this case. The nurse should first assess for pain while bearing weight to get a better understanding of the underlying issue.
D. Orthostatic blood pressure is a measure of blood pressure changes when a person stands up. It is not typically associated with a limping gait and is not relevant in this situation.

A. “Move closer and place a hand on the client's shoulder to demonstrate concern”. B. “Ignore the angry outburst and continue with the history questions”. C. "You sound angry. Would you like to tell me about it?" D. "I am sorry you feel that way. Perhaps you'd like to return when you have more time."

Correct Answer is C

Explanation

A. While physical touch, such as placing a hand on the client’s shoulder, can sometimes be reassuring, it might not always be appropriate or welcomed, especially if the client is already expressing frustration or anger. It’s important to assess the client's comfort with physical contact before proceeding with such gestures.
B. Ignoring the client's angry outburst is not advisable because it fails to acknowledge the client’s feelings and may escalate their frustration. Addressing emotional responses is crucial in maintaining a therapeutic relationship and ensuring that the client feels heard and respected.
C. This response is the best choice because it acknowledges the client’s emotional state and invites them to share their feelings. By addressing the client's anger directly and expressing a willingness to listen, the nurse helps to validate the client’s emotions and opens the door for a more productive dialogue.
D. While this response acknowledges the client's feelings, it might come across as dismissive of their immediate needs and could imply that their concerns are not worth addressing at this time. It also does not actively engage with the client's emotions or attempt to resolve the frustration.

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The nurse assesses a male client who is brought to the emergency department (ED) by his family who believes he is having a heart attack. Which finding is the best indicator that a client is experiencing an acute myocardial infarction (AMI)?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

During the admission assessment, the nurse observes that a client has a limping gait. Which assessment should the nurse complete next?

Correct Answer is A

Explanation

While the nurse is taking a health history, the client announces, "I don't have time for this. This is a waste of time. I need treatment." Which response is best for the nurse to provide?

Correct Answer is C

Explanation

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