The nurse is to begin a nitroglycerin infusion for a client diagnosed with an anterior wall myocardial infarction. Which assessment finding should the nurse report to the provider immediately?

Serum potassium of 5.2 mEq/L (normal 3.5 mEq/L-5.3 mEq/L.)

T wave depression on electrocardiogram

Heart rate of 90 beats per minute

Blood pressure of 90/50

Answer and Explanation

The Correct Answer is D

A. Serum potassium of 5.2 mEq/L: A potassium level of 5.2 mEq/L is slightly elevated but is still within a potentially acceptable range (normal is 3.5-5.3 mEq/L). While elevated potassium can be a concern, particularly in the context of an MI or with certain medications (like potassium-sparing diuretics), this level is not critically high. The nurse should monitor the potassium levels, but this is not an urgent finding requiring immediate reporting unless it increases further or is accompanied by significant symptoms (such as arrhythmias).

B. T wave depression on electrocardiogram (ECG): T wave depression can be a sign of ischemia or injury, which is common in the setting of an acute myocardial infarction. However, T wave changes are expected in this context and do not indicate an immediate emergency. The nurse should continue to monitor the ECG for any progression or worsening of ischemic changes but should prioritize concerns such as hypotension or worsening clinical status over this finding.

C. Heart rate of 90 beats per minute: A heart rate of 90 beats per minute is within normal limits (60-100 beats per minute), especially in the early stages of an MI. Nitroglycerin may cause a reflex tachycardia as a compensatory response to the decreased blood pressure, but a heart rate of 90 bpm is not an alarming finding. The nurse should continue to monitor the heart rate, but it is not the most pressing concern compared to hypotension. 4o mini

D. Blood pressure of 90/50: A blood pressure of 90/50 mmHg is significantly low and could indicate that the client is experiencing hypotension, which is a known side effect of nitroglycerin infusion. Nitroglycerin causes vasodilation, which can reduce blood pressure, especially in clients who are already at risk due to an acute myocardial infarction (MI). Low blood pressure can compromise perfusion to vital organs, including the heart, brain, and kidneys, and may lead to shock if not corrected promptly. This finding should be reported immediately to the healthcare provider, as it may require adjustment of the nitroglycerin dosage or discontinuation of the infusion.

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Correct Answer is C

Explanation

A) Arrange for social service consult for assistance with medication purchase:
While arranging for social service support can be beneficial in ensuring the client has access to necessary medications, this is not directly related to fall prevention at home. Falls in Parkinson's disease are more closely associated with mobility, balance, and environmental factors, which should be the focus of interventions aimed at reducing fall risk. Medication access is important but secondary to safety measures related to physical environment and mobility.

B) Have the client seen by a nursing assistant 3 times a week for hygiene:
While assistance with hygiene can certainly help support the client’s daily needs, the frequency of visits for hygiene care alone does not specifically address fall prevention. Falls are more directly linked to issues such as impaired balance, freezing episodes, and poor mobility—issues that should be addressed through environmental modifications and specific interventions aimed at improving safety during ambulation and transfers.

C) Ensure adequate lighting in areas where the client will ambulate:
Ensuring adequate lighting in areas where the client will ambulate is a critical intervention for fall prevention in individuals with Parkinson's disease. Parkinson's disease often causes balance and coordination problems, and inadequate lighting can increase the risk of tripping or falling, especially at night or in poorly lit areas. Proper lighting helps the client see obstacles and navigate their environment safely. This intervention directly addresses a key factor in fall risk and is an important part of the plan of care.

D) Refer the client to a nutritionist to address dietary measures:
Referral to a nutritionist can be helpful in managing some aspects of Parkinson's disease, particularly for addressing issues like constipation, weight management, or dysphagia. However, dietary measures do not have a direct impact on fall prevention. Fall prevention should focus more on mobility, strength, environmental safety, and managing the symptoms of Parkinson's disease that affect balance and movement.

A. similar to the angina attacks you had in the past." B. a condition characterized by coronary arteries vasodilating." C. a term used to describe an irregular heartbeat." D. is a less severe type of heart attack compared to STEMI."

Correct Answer is D

Explanation

A. Similar to the angina attacks you had in the past:
This response is not entirely accurate. Angina refers to chest pain that occurs when the heart's demand for oxygen exceeds its supply, usually due to partial blockage of the coronary arteries. NSTEMI (non-ST elevation myocardial infarction) is different from angina in that it involves actual heart muscle injury or damage due to partial or intermittent blockage of a coronary artery, whereas angina does not cause permanent heart muscle damage. Therefore, describing NSTEMI as similar to past angina attacks would be misleading.

B. A condition characterized by coronary arteries vasodilating:
This is incorrect. NSTEMI occurs due to a partial blockage or narrowing of the coronary arteries, usually caused by a blood clot that forms around a ruptured atherosclerotic plaque. The blockage restricts blood flow to the heart muscle, causing injury or infarction. Vasodilation (the widening of blood vessels) is not a characteristic of NSTEMI; in fact, it is the constriction or blockage of the coronary arteries that leads to this type of heart attack.

C. A term used to describe an irregular heartbeat:
This is incorrect. NSTEMI is not related to an irregular heartbeat or arrhythmia directly. While arrhythmias (irregular heartbeats) can occur as a result of a heart attack, NSTEMI specifically refers to a type of heart attack that is not accompanied by the characteristic ST-segment elevation seen on an electrocardiogram (ECG) in a STEMI (ST-elevation myocardial infarction). It indicates a partial blockage of a coronary artery and is generally less severe than STEMI.

D. Is a less severe type of heart attack compared to STEMI:
This is the most accurate response. NSTEMI is a type of heart attack that is often considered less severe than STEMI, but still involves heart muscle injury. The difference between NSTEMI and STEMI lies in the ECG findings: STEMI involves a full-thickness myocardial infarction with a significant blockage of the artery, as indicated by ST-segment elevation on an ECG. In NSTEMI, there is a partial blockage or temporary decrease in blood flow, and the ST-segment does not elevate on the ECG, but biomarkers (like troponin) are elevated, indicating heart muscle damage. NSTEMI is often less severe in terms of the extent of damage compared to STEMI, but it still requires urgent treatment to prevent further complications.

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The nurse is to begin a nitroglycerin infusion for a client diagnosed with an anterior wall myocardial infarction. Which assessment finding should the nurse report to the provider immediately?

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Naxlex Comprehensive Predictor Exams

To achieve the outcome of fall prevention at home in the client diagnosed with Parkinson's Disease (PD), which intervention would the nurse include in the plan of care?

Correct Answer is C

Explanation

The client tells the nurse, "My physician told me that I had a non-ST elevation myocardial infarction (NSTEMI). " I thought all heart attacks were the same. Can you explain this to me?" The nurse's best response to the client's question would be: "NSTEMI is

Correct Answer is D

Explanation

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