The practical nurse (PN) is caring for a client with coronary artery disease who is admitted with intermittent chest pain. The admission laboratory results indicate elevations in troponin I and creatine phosphokinase myoglobin isoenzyme (CK-MB) levels. What should the PN consider the most significant risk for this client on the second day of admission?
The lab results indicate myocardial damage, and the client is at risk for cardiac dysrhythmias.
The client is at risk for pulmonary embolism, and lifestyle modifications need to be implemented.
The client is at risk for recurrent long-term angina pain and subsequent myocardial infarction (MI).
The lab results indicate risk factors for transient ischemic atack (TIA), and neurological vital signs should be monitored.
The Correct Answer is A
Troponin I and CK-MB are cardiac enzymes that are released into the bloodstream when the heart muscle is injured or necrotic. Elevated levels of these enzymes indicate that the client has suffered a myocardial infarction (MI) or heart attack. The damaged heart tissue can impair the electrical conduction system of the heart and cause abnormal heart rhythms or dysrhythmias, which can be life-threatening. The PN should monitor the client's cardiac status closely and report any changes to the charge nurse.
The other options are not correct because:
B. The client is not at risk for pulmonary embolism, which is a blockage of a pulmonary artery by a blood clot or other material. Pulmonary embolism does not cause elevated cardiac enzymes, but it can cause chest pain, shortness of breath, and hypoxia.
C. The client is not at risk for recurrent long-term angina pain, which is chest pain caused by reduced blood flow to the heart muscle due to narrowed or blocked coronary arteries. Angina pain does not cause elevated cardiac enzymes, but it can be a warning sign of an impending MI.
D. The lab results do not indicate risk factors for transient ischemic attack (TIA), which is a temporary interruption of blood flow to a part of the brain due to a clot or plaque. TIA does not cause elevated cardiac enzymes, but it can cause neurological symptoms such as weakness, numbness, or speech difficulties.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is choice B: Thinning of the skin with loss of elasticity.
Choice A rationale:
While a decreased ability to communicate can be a significant challenge in elderly clients, it is not the primary physical characteristic of aging that contributes to the risk of pressure ulcers. Pressure ulcers develop due to prolonged pressure on specific areas of the skin, leading to reduced blood flow and tissue damage.
Choice B rationale:
Thinning of the skin with loss of elasticity is a critical physical characteristic of aging that contributes to the risk of pressure ulcers. As the skin becomes thinner and less elastic with age, it becomes more susceptible to injury from pressure and shear forces, increasing the likelihood of developing pressure ulcers.
Choice C rationale:
A 16 percent increase in overall body fat does not directly contribute to the risk of pressure ulcers. While changes in body composition occur with aging, the primary risk factors for pressure ulcers are related to skin integrity and mobility, not body fat percentage.
Choice D rationale:
Calcium loss in the bones (osteoporosis) is not the main contributing factor to pressure ulcers. Osteoporosis primarily affects bone density and strength but does not directly influence the development of pressure ulcers.
Correct Answer is C
Explanation
Choice A rationale:
Urinary output is not directly related to stomatitis, which is inflammation of the mouth and throat. While monitoring urinary output is important in many situations, it is not relevant in this case.
Choice B rationale:
Blood pressure while standing is not directly related to stomatitis either. This assessment is more relevant for conditions such as orthostatic hypotension, which can cause a drop in blood pressure upon standing.
Choice C rationale:
Ability to swallow is crucial in the context of stomatitis. Stomatitis can cause painful sores in the mouth, making it difficult for the client to eat or drink. Assessing the client's ability to swallow will help determine the impact of stomatitis on their nutritional intake and overall well-being.
Choice D rationale:
Frequency of bowel movements is unrelated to stomatitis. This assessment is more relevant for gastrointestinal issues or constipation, not for a condition affecting the mouth and throat.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today