Which of the following clinical manifestations would make the nurse suspect the client is experiencing a myocardial infarction (MI)?
A. Nausea and vomiting.
Radiating pain to the left arm.
Shortness of breath.
Headache.
The Correct Answer is B
Choice B rationale
Radiating pain to the left arm is a classic symptom of a myocardial infarction (MI). This pain occurs due to the heart muscle not receiving enough oxygen, often because of a blockage in one or more coronary arteries. The pain can radiate to the left arm, jaw, neck, or back, and is a key indicator for diagnosing an MI.
Choice A rationale
Nausea and vomiting can occur during an MI but are not the most distinctive symptoms for diagnosis. They can also be associated with other conditions, making them less specific indicators of MI.
Choice C rationale
Shortness of breath is a common symptom during an MI, resulting from reduced oxygen supply to the heart. However, while it is an important clinical manifestation, it can also be associated with other cardiac or respiratory conditions.
Choice D rationale
Headache is not a typical symptom of an MI. It is less commonly associated with heart attacks and can be caused by a wide range of other factors, making it an unreliable symptom for diagnosing MI.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Total parenteral nutrition (TPN) provides essential nutrients intravenously, allowing the bowel to rest and heal, which is important in the management of inflammatory bowel disease (IBD).
Choice B rationale
While reducing inflammation and controlling symptoms are important goals in IBD management, TPN is primarily used to provide nutrition and allow the bowel to rest.
Choice C rationale
Stimulating the bowel is not the purpose of TPN. TPN is used to give the digestive tract a break while ensuring the patient receives necessary nutrients.
Choice D rationale
Preventing malnutrition and promoting weight gain are secondary benefits of TPN, but the primary rationale is to provide nutrients while allowing the bowel to rest and heal.
Correct Answer is ["A","B"]
Explanation
Choice A rationale: A blood glucose level of 55 mg/dL is critically low, indicating hypoglycemia. Immediate intervention is required to prevent potential complications such as loss of consciousness, seizures, or even death. Hypoglycemia in individuals with type 1 diabetes can be life-threatening and requires prompt treatment with fast-acting carbohydrates to restore normal blood glucose levels.
Choice B rationale: The client's report of shakiness, hunger, cool skin, and diaphoresis are classic symptoms of hypoglycemia. These symptoms correlate with the dangerously low blood glucose level and indicate an urgent need for intervention. Addressing these symptoms quickly can prevent further deterioration of the client's condition.
Choice C rationale: While the slight increase in temperature to 37.8°C (100°F) is noteworthy, it does not necessitate immediate intervention compared to the hypoglycemic event. Monitoring for any signs of infection or other issues is important, but it is not the highest priority in this scenario.
Choice D rationale: An oxygen saturation of 97% on room air is within normal limits and does not require immediate follow-up. There are no signs of respiratory distress or hypoxia that would necessitate urgent intervention in this case.
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