The nurse is performing an intake assessment on a client with a new diagnosis of coronary artery disease. What would be the most important determination to make during this intake assessment?

Whether the client and involved family members understand dietary changes and the role of nutrition

Whether the client and involved family members understand the role of genetics in the etiology of the disease

Whether the client and involved family members are able to recognize symptoms of an acute cardiac problem and respond appropriately

Whether the client and involved family members understand the importance of social support and community agencies

Answer and Explanation

The Correct Answer is C

A. Whether the client and involved family members understand dietary changes and the role of nutrition:

This assessment is important as diet plays a crucial role in managing coronary artery disease (CAD) and preventing further complications. Understanding dietary changes, such as reducing saturated fats, sodium intake, and incorporating heart-healthy foods like fruits, vegetables, and whole grains, is essential. Nutrition education can help clients and their families make informed choices that promote heart health and improve overall well-being. However, while understanding dietary changes is significant, it may not be the most critical determination during the initial intake assessment, especially when compared to immediate concerns like recognizing acute cardiac symptoms.

B. Whether the client and involved family members understand the role of genetics in the etiology of the disease:

Understanding the genetic factors contributing to coronary artery disease can provide valuable insights into the client's risk factors and potential hereditary predispositions. This knowledge can help guide screening, prevention, and management strategies tailored to the client's specific genetic profile. While genetic factors are important considerations in CAD, they typically require a more detailed evaluation and may not be the primary focus during the initial intake assessment, especially compared to immediate concerns related to symptom recognition and response.

C. Whether the client and involved family members are able to recognize symptoms of an acute cardiac problem and respond appropriately:

This is a crucial assessment because recognizing symptoms such as chest pain, shortness of breath, nausea, sweating, and arm or jaw pain is essential in identifying a potential heart attack or unstable angina. Knowing when to seek emergency medical assistance and how to respond appropriately can significantly impact outcomes and reduce the risk of complications. Immediate response to acute cardiac symptoms is a critical aspect of CAD management, making it a top priority during the intake assessment.

D. Whether the client and involved family members understand the importance of social support and community agencies:

Social support and community resources play a valuable role in CAD management, providing emotional support, access to education programs, rehabilitation services, and other supportive resources. Understanding the importance of social support and knowing how to access community agencies can enhance the client's overall well-being and facilitate long-term management.

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Correct Answer is D

Explanation

A. Sinus bradycardia: Sinus bradycardia is characterized by a regular rhythm with a heart rate less than 60 beats per minute. In this case, the heart rate is 64 beats per minute, which falls within the normal range, not consistent with sinus bradycardia.

B. Sinus arrhythmia: Sinus arrhythmia typically presents as a variation in the R-R interval with respiration, often seen as an irregularity in the heart rate. The provided characteristics describe a regular rhythm, so sinus arrhythmia is not the correct interpretation.

C. Sinus tachycardia: Sinus tachycardia is characterized by a regular rhythm with a heart rate greater than 100 beats per minute. The heart rate in this case is 64 beats per minute, which is not indicative of sinus tachycardia.

D. Normal sinus rhythm: Normal sinus rhythm refers to a regular rhythm with a heart rate between 60 and 100 beats per minute, P waves preceding each QRS complex, a normal PR interval (0.12 to 0.20 seconds), and normal QRS complex duration (less than 0.12 seconds). The provided characteristics, including regular P waves, regular QRS complexes, a PR interval of 0.16 seconds, and a heart rate of 64 beats per minute, align with a normal sinus rhythm interpretation.

A. Administer aspirin B. 12 Lead Electrocardiography C. Assess vital signs D. Administer morphine

Correct Answer is B

Explanation

A. Administer aspirin:

Aspirin is commonly given to patients suspected of having a heart attack because it helps to inhibit platelet aggregation and reduce the risk of further clot formation. However, the administration of aspirin typically follows the confirmation of a cardiac event through diagnostic tests like the ECG. Aspirin is not the initial priority compared to obtaining diagnostic data.

B. 12 Lead Electrocardiography (ECG):

This is the most critical and time-sensitive action because it helps to quickly assess the patient's cardiac status. A 12 Lead ECG can identify important findings such as ST-segment elevation or depression, which are indicative of acute myocardial infarction (heart attack) or other cardiac abnormalities. Early detection and intervention are crucial in improving outcomes for patients with suspected cardiac events.

C. Assess vital signs:

Vital signs, including blood pressure, heart rate, respiratory rate, and oxygen saturation, provide valuable information about the patient's overall condition and can help determine the severity of the cardiac event. While assessing vital signs is important, performing the ECG takes precedence due to its immediate relevance in diagnosing and managing a potential cardiac emergency.

D. Administer morphine:

Morphine may be indicated for pain relief in patients with acute coronary syndromes. However, its administration should be based on the patient's pain level, hemodynamic stability, and other factors assessed after obtaining the ECG and vital signs. Morphine administration is not the primary action within the first 10 minutes of the patient's arrival; it follows the initial assessment and diagnostic procedures.

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The nurse is performing an intake assessment on a client with a new diagnosis of coronary artery disease. What would be the most important determination to make during this intake assessment?

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Naxlex Comprehensive Predictor Exams

The nurse is reviewing an electrocardiogram rhythm strip. The P waves and QRS complexes are regular. The PR interval is 0.16 seconds, and the QRS complexes measure 0.06 seconds. The overall heart rate is 64 beats/minute. Which would be a correct interpretation based on these characteristics?

Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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