Which of the following does the nurse recognize as typical signs and symptoms
exhibited by a client experiencing angina? (Select all that apply.) - answer Diaphoresis ,
Shortness of breath , Substernal chest pain
Rationale: Typical signs and symptoms of angina can include substernal chest pain or
heaviness that may radiate, shortness of breath, dusky or pallor skin, diaphoresis,
weakness, nausea and vomiting, and denial by the client. Pain on inspiration and
tenderness over the apical area are symptoms associated with other disease processes
such as pericarditis or pleurisy.
When administering medication to the client with suspected myocardial infarction, the
nurse understands that morphine has which of the following beneficial effects? (Select
all that apply.) - answerDecreases preload , Decreases afterload , Decreases pain ,
Decreases anxiety
Rationale: Morphine is the drug of choice to reduce pain, thereby reducing anxiety. It
also reduces preload and afterload, decreasing the work of the heart. The client must be
monitored closely for the side effects of hypotension and respiratory depression.
Based on the following ECG waveform, the nurse recognizes that the client is
experiencing which dysrhythmia? - answerVentricular fibrillation
Rationale: Ventricular fibrillation is characterized by a ventricular rate greater than 300
bpm, an extremely irregular rhythm without a specific pattern, and irregular, undulating
waves without recognizable QRS complexes.
Which of the following are cardiac markers assessed in the client experiencing angina
to determine potential myocardial injury? (Select all that apply.) - answerTroponin , CK-
MB
Rationale: Cardiac enzymes and biomarkers, which include troponin, creatine kinase
(CK), and myoglobin, are used to diagnose an acute MI. Of the three CK isoenzymes,
CK-myocardial bound (MB) is specific to the heart muscle. CK-MM is specific to skeletal
muscle and is not an indicator of MI. Hemoglobin is used to determine the amount of
oxygen in the blood. Creatinine is elevated in renal failure, not in myocardial injury.
The nurse knows that which factors may increase the client's risk of developing
coronary artery disease? (Select all that apply.) - answerFamily history , Metabolic
syndrome , Cigarette smoking
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