While evaluating a patient diagnosed with angina, the patient asks, “What causes this pain in my heart?” What is the nurse’s BEST response?
Increased afterload.
Inadequate myocardial oxygenation.
Coronary artery disease.
Increased preload.
The Correct Answer is C
Choice A rationale:
Increased afterload refers to the resistance against which the heart must pump to eject blood into the aorta. While increased afterload can contribute to chest pain in certain conditions like aortic stenosis, it's not the primary cause of angina.
Angina is typically triggered by exertion or emotional stress, which increase myocardial oxygen demand. Increased afterload doesn't directly cause this imbalance in oxygen supply and demand, making it less likely to be the primary driver of angina pain.
Choice B rationale:
Inadequate myocardial oxygenation is a key concept in understanding angina, but it's not the most precise answer to the patient's question about the cause of their pain.
It's important to explain the underlying reason for the inadequate oxygenation, which is coronary artery disease.
Choice C rationale:
Coronary artery disease (CAD) is the most common cause of angina. It's characterized by narrowing or blockage of the coronary arteries, which supply oxygen-rich blood to the heart muscle.
When the heart's demand for oxygen exceeds the supply available through the narrowed arteries, it experiences ischemia (lack of oxygen), leading to the characteristic chest pain of angina.
This explanation directly addresses the patient's question about the cause of their pain, linking the symptom to the underlying disease process. Choice D rationale:
Increased preload refers to the amount of blood filling the ventricles before they contract. While increased preload can contribute to heart failure and pulmonary edema, it's not typically a direct cause of angina.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Gently abrading the skin with dry gauze or cloth is not recommended prior to ECG electrode placement.
Research has shown that this practice can actually increase skin impedance and lead to poor signal quality.
It can also cause discomfort and skin irritation, particularly in patients with sensitive skin.
In some cases, it may even damage the skin, leading to infection.
Therefore, it is best to avoid abrading the skin before ECG electrode placement.
Choice B rationale:
Ensuring that the skin is dry is essential for optimal ECG signal quality.
Moisture on the skin can interfere with the electrical connection between the electrodes and the skin, leading to artifacts in the ECG tracing.
These artifacts can make it difficult to interpret the ECG and may even lead to misdiagnosis.
Therefore, it is important to dry the skin thoroughly before applying the electrodes. This can be done using a soft towel or cloth.
Choice C rationale:
Tincture of benzoin is a sticky substance that is sometimes used to improve the adhesion of electrodes to the skin.
However, it is not necessary for ECG electrode placement and can actually irritate the skin.
It is also important to note that tincture of benzoin is flammable and should not be used near open flames or electrical equipment.
Therefore, it is generally not recommended for use with ECG electrode placement.
Choice D rationale:
Povidone-iodine solution is an antiseptic that is used to cleanse the skin and reduce the risk of infection.
However, it is not necessary for ECG electrode placement and can actually interfere with the electrical connection between the electrodes and the skin.
Therefore, it is generally not recommended for use with ECG electrode placement.
Correct Answer is D
Explanation
Choice A rationale:
Assessing lung sounds is important for evaluating respiratory status, but it is not the priority assessment before administering digoxin. Digoxin does not have a direct effect on the respiratory system, and changes in lung sounds would not necessarily indicate a contraindication to its administration.
However, in patients with heart failure, which is a common indication for digoxin, auscultating lung sounds can provide valuable information about fluid status and the effectiveness of treatment. Therefore, while not the priority assessment, lung auscultation remains a relevant part of the overall assessment of a patient receiving digoxin.
Choice B rationale:
Assessing systolic blood pressure is important for monitoring hemodynamic status, but it is not the most critical assessment before administering digoxin. Digoxin does not directly affect blood pressure, and changes in blood pressure would not necessarily indicate a contraindication to its administration.
However, in patients with hypertension, which can be a factor in heart failure, monitoring blood pressure is essential for managing overall cardiovascular health. Therefore, while not the priority assessment, blood pressure measurement remains an important aspect of care for patients receiving digoxin.
Choice C rationale:
Assessing the brachial pulse for 30 seconds can provide a general assessment of heart rate and rhythm, but it is not as accurate as assessing the apical pulse for a full minute.
The apical pulse is the most reliable way to assess heart rate and rhythm, especially in patients with irregular heartbeats or those taking medications that can affect heart rate, such as digoxin.
Therefore, assessing the apical pulse for a full minute is essential to ensure accurate assessment of the patient's cardiac status before administering digoxin.
Choice D rationale:
Assessing the apical pulse for 60 seconds is the priority assessment before administering digoxin. This is because digoxin is a cardiac glycoside that affects the heart's electrical conduction system and can slow the heart rate. It is essential to assess the patient's heart rate and rhythm before administering digoxin to ensure that it is safe to do so.
A slow heart rate (bradycardia), irregular heart rhythms (such as atrial fibrillation), or certain heart block conditions can be contraindications to digoxin administration or require dosage adjustments.
By accurately assessing the apical pulse for a full minute, the nurse can identify any potential contraindications or concerns and ensure the safe administration of digoxin.
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