The nurse is caring for a client who reports persistent, crushing chest pain. What additional signs or symptoms would make a nurse suspect that the client is experiencing a myocardial infarction?

Intermittent claudication and pallor

Jugular vein distention and dependent edema

Diaphoresis and cool, clammy skin

Mid-epigastric pain and heartburn

Answer and Explanation

The Correct Answer is C

A. Intermittent claudication and pallor: These symptoms are more indicative of peripheral vascular disease, not a myocardial infarction.

B. Jugular vein distention and dependent edema. These symptoms suggest right-sided heart failure or fluid overload, not myocardial infarction.

C. Diaphoresis and cool, clammy skin. Diaphoresis (sweating) and cool, clammy skin are common signs of myocardial infarction due to the body's response to pain and decreased cardiac output.

D. Mid-epigastric pain and heartburn. While heartburn can mimic some symptoms of a heart attack, mid-epigastric pain and heartburn are more likely to be related to gastrointestinal issues rather than myocardial infarction.

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Correct Answer is B

Explanation

A. Pelvic fracture: Pelvic fractures may cause significant pain and instability but do not typically result in a shortened, adducted, and externally rotated leg.

B. Femoral neck fracture: These findings (shortened, adducted, externally rotated leg) are classic for a femoral neck fracture due to muscle contraction and displacement of the bone.

C. Tibia fracture: Tibia fractures typically present with swelling and deformity, not shortening or rotation of the leg.

D. Fibula fracture: A fibula fracture alone rarely causes leg shortening or rotation as it is a non-weight-bearing bone.

A. ventricular aneurysm B. heart failure C. pulmonary embolism D. dysrhythmia

Correct Answer is D

Explanation

A. Ventricular aneurysm. Ventricular aneurysms are a complication that typically develops weeks or months after an MI.

B. Heart failure. While heart failure is a risk following an MI, it is more of a concern in the longer term after the acute phase.

C. Pulmonary embolism. Pulmonary embolism is not a direct complication of MI and is less common in the immediate post-MI period.

D. Dysrhythmia: Within the first 24 hours following a myocardial infarction, dysrhythmias, particularly ventricular arrhythmias, are common and can be life-threatening. This is the highest risk during the early period after MI.

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The nurse is caring for a client who reports persistent, crushing chest pain. What additional signs or symptoms would make a nurse suspect that the client is experiencing a myocardial infarction?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assessing a client and find their right leg is shortened, adducted and externally rotated. These assessment findings would indicate which type of injury?

Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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