Nokea
A client with a history of myocardial infarction is admitted with chest pain. Which laboratory value should the nurse monitor closely?
- A. White blood cell count
- B. Serum creatinine
- C. Troponin level
- D. Hemoglobin level
Correct Answer: C
Rationale: The correct answer is C: Troponin level. Troponin levels should be closely monitored in a client with chest pain and a history of myocardial infarction to assess for ongoing myocardial injury. Troponin is a specific marker for myocardial damage. Monitoring white blood cell count (choice A) is not directly related to myocardial infarction. Serum creatinine (choice B) is more indicative of renal function rather than cardiac status. Hemoglobin level (choice D) is important but does not directly reflect ongoing myocardial injury.
You may also like to solve these questions
A 46-year-old male client who had a myocardial infarction 24 hours ago comes to the nurse's station fully dressed and wanting to go home. He tells the nurse that he is feeling much better at this time. Based on this behavior, which nursing problem should the nurse formulate?
- A. Ineffective coping related to denial.
- B. Risk for impaired cardiac function.
- C. Noncompliance related to lack of knowledge.
- D. Anxiety related to hospitalization.
Correct Answer: A
Rationale: The correct answer is A: Ineffective coping related to denial. The client's desire to leave the hospital shortly after a myocardial infarction despite the severity of the condition indicates denial and ineffective coping. This behavior could lead to complications as the client may not adequately address his health needs. Choice B, Risk for impaired cardiac function, is not the most appropriate nursing problem in this scenario as the client's behavior is more indicative of psychological coping issues rather than a direct physiological risk at this moment. Choice C, Noncompliance related to lack of knowledge, does not align with the client's behavior of wanting to leave the hospital. Choice D, Anxiety related to hospitalization, may not be the best option as the client's behavior is more suggestive of denial rather than anxiety about being hospitalized.
A woman who takes pyridostigmine for myasthenia gravis (MG) arrives at the emergency department complaining of extreme muscle weakness. Her adult daughter tells the nurse that since yesterday her mother has been unable to smile. Which assessment finding warrants immediate intervention by the nurse?
- A. Uncontrollable drooling.
- B. Inability to raise voice.
- C. Tingling of extremities.
- D. Eyelid drooping.
Correct Answer: A
Rationale: Uncontrollable drooling can be a sign of a myasthenic crisis, which requires immediate medical intervention to prevent respiratory failure. Drooling indicates difficulty in swallowing, which can lead to aspiration and respiratory compromise. Inability to raise voice (choice B) and tingling of extremities (choice C) are not typically associated with myasthenic crisis. Although eyelid drooping (choice D) is a common symptom of myasthenia gravis, it is not as urgent as uncontrollable drooling in indicating a potential crisis.
A 3-year-old boy with a congenital heart defect is brought to the clinic by his mother. During the assessment, the mother asks the nurse why her child is at the 5th percentile for growth. What response is best for the nurse to provide?
- A. Does your child seem mentally slower than his peers also?
- B. His smaller size is probably due to the heart disease
- C. Haven't you been feeding him according to recommended daily allowances for children?
- D. You should not worry about the growth tables. They are only averages for children
Correct Answer: B
Rationale: Heart disease can affect growth, leading to smaller size in children.
A client with a history of heart failure presents to the clinic with nausea, vomiting, yellow vision, and palpitations. Which finding is most important for the nurse to assess for this client?
- A. Assess distal pulses and signs of peripheral edema
- B. Determine the client's level of orientation and cognition
- C. Obtain a list of medications taken for cardiac history
- D. Ask the client about exposure to environmental heat
Correct Answer: C
Rationale: The correct answer is to obtain a list of medications taken for cardiac history. The client's presentation is indicative of digitalis toxicity, commonly associated with medications like digoxin (Lanoxin) used in heart failure treatment. Understanding the client's medication history, particularly the use of digoxin, is crucial in confirming and managing digitalis toxicity. Assessing distal pulses and signs of peripheral edema (Choice A) may be relevant in heart failure but are not the priority in this case. Determining the client's level of orientation and cognition (Choice B) and asking about exposure to environmental heat (Choice D) are not directly related to the client's current symptoms and are less pertinent in this scenario.
A male client with rheumatoid arthritis is scheduled for a procedure in the morning. The procedure cannot be completed because of early morning stiffness. Which intervention should the nurse implement?
- A. Assign a UAP to assist the client with a warm shower early in the morning.
- B. Provide the client with a warm blanket to reduce stiffness.
- C. Delay the procedure until the client is less stiff.
- D. Encourage the client to perform range-of-motion exercises.
Correct Answer: A
Rationale: A warm shower can help reduce morning stiffness, making the procedure more comfortable for the client. This intervention promotes comfort and mobility, addressing the immediate issue of stiffness. Providing a warm blanket (choice B) may offer some comfort but will not address the stiffness as effectively as a warm shower. Delaying the procedure (choice C) may inconvenience the client and not address the underlying stiffness issue. Encouraging range-of-motion exercises (choice D) is important for long-term management but may not provide immediate relief from the stiffness that is hindering the procedure.