The nurse at a primary healthcare provider's (HCPs) office is assessing a middle aged client who describes having symptoms of angina pectoris that occured while doing yard work. Which additional finding should the nurse obtain?
A description of the chest pain when client is at rest.
A demonstration of the activity that precipitates pain.
A complete seven (7) day diet history of client's oral intake.
The client's blood pressures sitting and standing.
The Correct Answer is A
A. A description of the chest pain when client is at rest: Determining whether the pain occurs at rest helps differentiate stable from unstable angina. Stable angina typically resolves with rest and is exertion-related, while pain at rest may suggest unstable angina.
B. A demonstration of the activity that precipitates pain: While understanding what provokes the pain is helpful, a physical demonstration is unnecessary and potentially dangerous, especially if it might trigger another anginal episode.
C. A complete seven (7) day diet history of client's oral intake: Dietary intake is not immediately relevant for evaluating recent angina symptoms. Priority should be placed on identifying acute features that may signal unstable angina or myocardial infarction.
D. The client’s blood pressures sitting and standing: Assessing for orthostatic hypotension is useful in evaluating dizziness or syncope but does not directly address the nature or severity of chest pain. It is not the priority assessment for symptoms of angina pectoris following exertion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Irregular heart rate: An irregular heart rate may indicate an arrhythmia, but without other alarming findings, it is not the most critical. It requires monitoring, but it does not confirm a life-threatening process like myocardial infarction.
B. Reports of radiating jaw pain: Jaw pain, especially in women, may be a sign of myocardial ischemia. While concerning, it is still a subjective symptom and less immediately diagnostic than confirmed ECG findings like ST elevation.
C. ST elevation in three leads: ST elevation in two or more contiguous leads confirms an ST-elevation myocardial infarction (STEMI), which is a medical emergency requiring immediate reperfusion therapy.
D. Bile-colored emesis: Bile-colored vomiting may point toward a gastrointestinal issue such as bile reflux or intestinal obstruction. Though unpleasant and possibly indicative of another condition, it is not as life-threatening as ECG-confirmed STEMI.
Correct Answer is D
Explanation
A. Collect a specimen for an arterial blood gas (ABG): While ABG provide detailed information on oxygenation and acid-base status, the process takes time and does not provide immediate correction for hypoxemia. The priority is to stabilize the client's oxygen saturation first.
B. Report the findings to the healthcare provider: Notifying the provider is important, but immediate nursing interventions to correct the hypoxemia should take precedence. The drop in oxygen saturation needs to be addressed before escalation.
C. Evaluate the client’s white blood cell count (WBC): WBC levels help assess infection severity but do not assist with immediate respiratory distress or oxygenation. This is a secondary concern when managing acute hypoxia.
D. Increase the flow rate of oxygen administration: A pulse oximetry reading of 88% indicates hypoxemia. The most urgent action is to increase the oxygen flow rate to improve oxygenation. This is a rapid, nurse-initiated intervention that addresses the client’s saturation.
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