The nurse is caring for a client admitted with unstable angina. The laboratory result for the initial troponin I is elevated in this client. The nurse should recognize what implication of this assessment finding?
This result indicates muscle injury but does not specify the source.
Because the client has a history of unstable angina, this is a poor indicator of myocardial injury.
This is only an accurate indicator of myocardial damage when it reaches its peak in 24 hours.
This is an accurate indicator of myocardial injury.
The Correct Answer is D
A. This result indicates muscle injury but does not specify the source.
This statement is partly correct. An elevated troponin I level does indicate muscle injury, specifically damage to the heart muscle. However, troponin I is highly specific to cardiac muscle, so an elevated level would indeed specify the source as cardiac or myocardial injury.
B. Because the client has a history of unstable angina, this is a poor indicator of myocardial injury.
This statement is incorrect. A history of unstable angina does not diminish the significance of an elevated troponin I level. In fact, unstable angina is itself a serious condition that can lead to myocardial injury or heart attack, and an elevated troponin I level in this context indicates ongoing or recent myocardial damage.
C. This is only an accurate indicator of myocardial damage when it reaches its peak in 24 hours.
This statement is not entirely accurate. While it is true that troponin I levels may continue to rise and peak within 12-24 hours after the onset of myocardial injury, an elevated troponin I level at any point is still a significant indicator of myocardial damage. It's essential to recognize elevated troponin I levels promptly to initiate appropriate interventions and monitor the client's cardiac status closely.
D. This is an accurate indicator of myocardial injury.
This statement is correct. An elevated troponin I level is a highly sensitive and specific marker of myocardial injury. It indicates damage to the heart muscle, which can occur due to conditions like unstable angina, heart attack (myocardial infarction), myocarditis, or other cardiac issues. Therefore, recognizing an elevated troponin I level in a client with unstable angina is crucial for proper management and further evaluation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Pleurisy:
Pleurisy is inflammation of the pleura, which is the lining surrounding the lungs. It can cause sharp chest pain that worsens with breathing. While pleurisy can be associated with conditions such as infections, pneumonia, or pulmonary embolism, it is not typically directly diagnosed or investigated using the brain (B-type) natriuretic peptide (BNP) test. The symptoms of pleurisy may include chest pain, especially with deep breathing, coughing, or sneezing.
B. Cardiomyopathy:
Cardiomyopathy refers to diseases of the heart muscle, which can lead to impaired heart function. Cardiomyopathy can cause symptoms such as fatigue, shortness of breath, chest pain, and fluid retention. While elevated BNP levels can be observed in some cases of cardiomyopathy, the BNP test is not specific to cardiomyopathy alone. It is often used to assess and diagnose heart failure, a condition that can result from various cardiac abnormalities, including cardiomyopathy.
C. Valve Dysfunction:
Valve dysfunction refers to abnormalities or malfunctions of the heart valves, such as stenosis (narrowing) or regurgitation (leakage). Valve dysfunction can lead to symptoms such as shortness of breath, chest pain, palpitations, and fatigue. While valve dysfunction can contribute to heart failure by causing pressure and volume overload on the heart chambers, the BNP test is primarily used to assess heart failure itself rather than specifically identifying valve dysfunction.
D. Heart Failure:
Heart failure is a condition in which the heart is unable to pump blood effectively to meet the body's needs. It can cause symptoms such as fatigue, shortness of breath, fluid retention (edema), and exercise intolerance. Elevated BNP levels are commonly observed in patients with heart failure, especially in cases of acute exacerbations or decompensated heart failure. The BNP test is used to assess and diagnose heart failure, as higher BNP levels indicate increased cardiac stress and volume overload.
Correct Answer is D
Explanation
A. Take the iron with dairy products to enhance absorption: This statement is incorrect. Calcium-rich foods, such as dairy products, can inhibit iron absorption. It's recommended to take iron supplements with vitamin C-rich foods or beverages to enhance iron absorption.
B. Limit foods high in fiber due to the risk for diarrhea: While some individuals may experience gastrointestinal side effects such as constipation or diarrhea when taking iron supplements, it is not generally recommended to limit foods high in fiber. Adequate fiber intake is important for overall digestive health.
C. Increase the intake of vitamin E to enhance absorption: Vitamin E does not directly enhance iron absorption. Vitamin C is the nutrient that enhances iron absorption, so increasing intake of vitamin C-rich foods or taking vitamin C supplements along with iron supplements can improve iron absorption.
D. Iron will cause the stools to darken in color: This statement is correct. Iron supplements can cause stools to become dark or even black in color. This is a harmless side effect known as "iron stools" and is caused by the reaction of iron with substances in the digestive tract.
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