The nurse is caring for a client receiving thrombolytic therapy following an acute myocardial infarction (MI). Which nursing problem should the nurse identify as priority for this client?
Risk for injury related to effects of thrombolysis.
Activity intolerance related to ischemia.
Ineffective breathing pattern related to adverse drug effects.
Deficient knowledge related to a new medication regimen.
The Correct Answer is A
A. Clients receiving thrombolytic therapy are at an increased risk of bleeding, which can manifest as internal bleeding, hemorrhage at vascular access sites, gastrointestinal bleeding, or intracranial bleeding. The nurse's priority is to closely monitor the client for signs and symptoms of bleeding, such as sudden onset or worsening of headache, changes in level of consciousness, hematuria, melena, ecchymosis, or hematoma formation.
B. While activity intolerance is a common nursing diagnosis for clients following an acute myocardial infarction due to myocardial ischemia, it is not the priority in this case where the client is actively receiving thrombolytic therapy.
C. While respiratory complications can occur following thrombolytic therapy, such as pulmonary embolism or bleeding into the lungs, the risk of bleeding complications takes precedence as the priority nursing problem for this client.
D. Education about the new medication regimen is important for client understanding and adherence, but it is not the priority nursing problem in the immediate post-thrombolytic therapy period.
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Related Questions
Correct Answer is D
Explanation
D. Persistent pain following the resolution of herpes zoster, known as postherpetic neuralgia (PHN), is a common complication, especially in older adults. PHN can cause significant discomfort and affect the client's quality of life. Therefore, it is essential for the nurse to conduct a comprehensive assessment of the client's pain to better understand its characteristics, severity, duration, aggravating or alleviating factors, and impact on daily activities.
A. Patient education should follow a complete assessment of the pain to ascertain the diagnosis.
B. Performing a complete mental status exam is not indicated solely based on the client's report of persistent pain from herpes zoster.
C. Determining if the client has had a shingles vaccination is important for preventive healthcare, but it is not the priority action in addressing the client's current pain concern related to PHN. The focus should be on assessing and managing the client's pain to improve their comfort and well-being.
Correct Answer is D
Explanation
D. Frequent mouth care helps maintain oral hygiene, reduces the risk of infection, and provides comfort to the client by removing debris and soothing irritated tissues.
A. Administering a topical analgesic may provide pain relief, but it should be done in accordance with the healthcare facility's protocol and after assessing the client's oral mucosa for any contraindications or precautions.
B. Cleaning the tongue and mouth with swabs can cause further irritation to the already sore oral tissues.
C. Obtaining a soft diet for the client is appropriate for minimizing trauma to the oral mucosa, but it may not address the immediate discomfort experienced by the client.
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