MS, Autoimmune Diseases, MI
A triage team is assessing a client to determine if reported chest pain is a manifestation of angina pectoris or an MI. The nurse knows that a primary distinction of angina pain is?
Relieved by rest and nitroglycerin Rationale: One characteristic that can differentiate the pain of angina from a myocardial infarction is pain that is relieved by rest and nitroglycerine. There may be some exceptions (unstable angina), but the distinction is helpful especially when combined with other assessment data.
You are monitoring the results of laboratory tests performed on a client admitted to the cardiac ICU with a diagnosis of myocardial infarction. Which test would you expect to show elevated levels?
enzymes
Ataxia
lack of muscle coordination
Nitroglycerin
nitrate drug used in the treatment of angina
The nurse is caring for an older adult man who walks 2 miles every morning. The nurse notes that during his morning walk, he called his child and stated that he thought that he was having a heart attack. Which symptom, identified by the client, is the most common and consistent with that of a heart attack (myocardial infarction)?
sternal pain
The nurse is teaching a client about rheumatic disease. What statement best helps to explain autoimmunity?
"Your symptoms are a result of your body attacking itself."
An ED nurse is assessing a 71-year-old female client for a suspected MI. When planning the assessment, the nurse should be cognizant of what signs and symptoms of MI that are particularly common in female clients? Select all that apply. Shortness of breath Chest pain Indigestion Anxiety Nausea
-indigestion -nausea
A client presents to the ED reporting severe substernal chest pain radiating down his left arm. He is admitted to the coronary care unit (CCU) with a diagnosis of myocardial infarction (MI). What nursing assessment activity is a priority on admission to the CCU?
Begin ECG monitoring.
A client with MS has developed dysphagia as a result of cranial nerve dysfunction. What nursing action should the nurse consequently perform?
Position the client upright during feeding.
A nurse is assessing a client diagnosed with multiple sclerosis (MS). Which symptom does the nurse expect to find? Absent deep tendon reflexes Vision changes Flaccid muscles Tremors at rest
Vision changes
Myocardial infarction (MI)
heart attack; death of myocardial tissue (infarction) caused by ischemia (loss of blood flow) as a result of an occlusion (plugging) of a coronary artery; usually caused by atherosclerosis; symptoms include pain in the chest or upper body (shoulders, neck, and jaw), shortness of breath, diaphoresis, and nausea
A nurse who works in a busy emergency department provides care for numerous patients who present with complaints of chest pain. Which of the following questions is most likely to help the nurse differentiate between chest pain that is attributable to angina and chest pain due to myocardial infarction (MI)? "Does your chest pain make it difficult to move around like you normally would?" "Does resting and remaining still help your chest pain to decrease?" "Have you ever been diagnosed with high blood pressure or diabetes?" "When was the first time that you recall having chest pain?"
"Does resting and remaining still help your chest pain to decrease?"
Angina pectoris
chest pain that results when the heart does not get enough oxygen
A client is newly diagnosed with relapsing-remitting multiple sclerosis (RRMS). Which instruction should the nurse provide?
"You must avoid stress and extreme fatigue, because these can trigger a relapse." Explanation: Stress, fatigue, and temperature extremes can trigger relapses of MS. The client should be taught to practice a healthy lifestyle, including good nutrition, adequate sleep, and management of stress. Clients taking MS medications should take them on a consistent and strict schedule to produce the desired effect of fewer relapses and to prevent sclerotic plaque from forming on the brain and spinal cord. RRMS is characterized by states of remission and relapses. A steady decline in function is consistent with primary progressive MS. RRMS is the most common type, and many treatments are available.
A client has been hospitalized for diagnostic testing. The client has just been diagnosed with Multiple Sclerosis which the physician explains is an autoimmune disorder. How would the nurse explain an autoimmune disease to the client?
A disorder where killer T cells and autoantibodies attack or destroy natural cells—those cells that are "self"
When providing discharge teaching for a client with multiple sclerosis (MS), the nurse should include which instruction?
Avoid hot baths and showers.
The nurse has been asked to teach a patient how to self-administer nitroglycerin. The nurse should instruct the patient to do which of the following? Select all of the teaching points that apply.
Let the tablet dissolve in the mouth and keep the tongue still. The tablet can be crushed between the teeth but not swallowed. Renew the supply every 6 months. Take the tablet in anticipation of any activity that can produce pain. Call emergency services if, after taking three tablets (one every 5 minutes), pain persists.
