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.

Answer and Explanation

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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Free Nursing Study Resources

Correct Answer is B

Explanation

B. An increase in pain after cast placement could indicate complications such as compartment syndrome, which is a serious condition that occurs when increased pressure within a confined space (such as the area within the cast) compromises circulation and tissue perfusion. Assessing the radial pulse volume on the affected arm is crucial to evaluate perfusion distal to the fracture site.
A. Distraction technique may help manage the client's pain but does not address the underlying cause of the pain increase, which could be related to compromised circulation.
C. Analgesics relieve pain but do not address the immediate limb threatening issue at hand.
D. Measuring blood pressure is not directly related to assessing circulation distal to the fracture site.

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"B"}

Explanation

Option 1-prediabetes

Option 2- impaired glucose tolerance

Rationale

Prediabetes is a condition characterized by higher than normal blood sugar levels, but not high enough to be classified as type 2 diabetes. It's considered a warning sign that indicates an increased risk of developing type 2 diabetes, heart disease, and stroke if left unmanaged.

Prediabetes is diagnosed if FPG levels are between 100-125 mg/dL, OGTT levels are between 140-199 mg/dL, or HbA1c levels are between 5.7-6.4%.

It occurs due to impaired glucose tolerance in insulin resistance. In individuals with insulin resistance, cells, particularly muscle, liver, and fat cells, become less sensitive to insulin's actions. As a result, glucose uptake by cells is impaired, leading to higher blood sugar levels. Hypoglycemia refers to a condition characterized by abnormally low blood sugar levels, typically below 70 mg/dL (3.9 mmol/L). It occurs when there is an imbalance between the amount of glucose in the bloodstream and the body's requirements for energy.

Gestational diabetes mellitus (GDM) is a type of diabetes that develops during pregnancy. It is characterized by high blood sugar levels that occur for the first time during pregnancy and typically resolves after childbirth.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with a right ulnar fracture and cast placement reports an increase in arm pain. Which action should the nurse take next?

Correct Answer is B

Explanation

Patient Data Exhibits Based on the laboratory data, the client has dropdown related to dropdown

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"B"}

Explanation

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