The nurse is performing an admission assessment of a client complaining of chest pain. Which question(s) should the nurse ask in the assessment regarding the chief complaint? (SELECT ALL THAT APPLY)

"What were you doing when the pain started?"

"How long has the pain lasted?"

"How would you describe the pain?"

"How has the pain affected your relationship with your spouse?"

"Can you rate the pain on a 0-10 scale with 10 being the worst?"

Answer and Explanation

Correct Answer : A,B,C,E

A. "What were you doing when the pain started?" This question helps identify potential triggers or activities that may have precipitated the chest pain, which is crucial for understanding the context of the pain.

B. "How long has the pain lasted?" Knowing the duration of the pain is vital in assessing the urgency of the situation and determining whether it may be related to a serious condition like angina or myocardial infarction.

C. "How would you describe the pain?" This question allows the client to characterize the pain (e.g., sharp, dull, squeezing), which can provide insights into the potential causes and the nature of the chest pain.

D. "How has the pain affected your relationship with your spouse?" While this question might provide some psychosocial context, it is less directly related to the immediate assessment of the chest pain itself and can be considered secondary.

E. "Can you rate the pain on a 0-10 scale with 10 being the worst?" Pain rating is essential in assessing the severity of the pain, which can help guide treatment and interventions.

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Correct Answer is B

Explanation

A. increased fluid in the pericardial sac: While fluid accumulation can affect heart sounds, it typically leads to muffled heart sounds rather than a loud murmur. Increased fluid in the pericardial sac (pericardial effusion) usually does not produce a classic heart murmur.

B. dysfunction of one or more heart valves: This statement is correct. Heart murmurs are often caused by turbulence in blood flow due to the dysfunction of heart valves, such as stenosis (narrowing) or regurgitation (leaking). A loud murmur suggests significant turbulence, which is often indicative of valvular heart disease.

C. an aneurysm of the descending aorta: While an aortic aneurysm can cause other types of heart sounds or signs of cardiovascular compromise, it is not primarily associated with heart murmurs.

D. an occlusion of the right coronary artery: An occlusion may lead to ischemia or myocardial infarction, which can cause changes in heart sounds, but it does not directly cause a heart murmur. Murmurs are more specifically related to blood flow dynamics, particularly involving valves.

A. The layers of your heart are weak and thin. B. The pain you have is because your heart valves are damaged." C. Your heart muscle is weak and is not pumping forcefully." D. The pain is caused by decreased oxygen to the heart muscle."

Correct Answer is D

Explanation

A. The layers of your heart are weak and thin: This statement does not accurately address the underlying cause of chest pain in coronary artery disease. Weakness in heart layers is not a common explanation for angina.
B. The pain you have is because your heart valves are damaged: While valve damage can lead to cardiac symptoms, it is not the primary cause of chest pain associated with coronary artery disease, which is more directly related to blood flow issues.

C. Your heart muscle is weak and is not pumping forcefully: This statement could be true in the context of heart failure but does not specifically explain the chest pain associated with coronary artery disease.

D. The pain is caused by decreased oxygen to the heart muscle: This is the most accurate and appropriate response. Chest pain in coronary artery disease, often referred to as angina, typically occurs due to reduced blood flow and, consequently, oxygen delivery to the heart muscle. This explanation helps the client understand the physiological basis of their symptoms.

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The nurse is performing an admission assessment of a client complaining of chest pain. Which question(s) should the nurse ask in the assessment regarding the chief complaint? (SELECT ALL THAT APPLY)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse auscultates a loud heart murmur while performing a cardiac assessment on a client. The nurse is aware that a heart murmur reflects:

Correct Answer is B

Explanation

The client with coronary artery disease asks the nurse. "Why do I get this chest pain?" Which would be the most appropriate response?

Correct Answer is D

Explanation

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