Introduction to Patient Assessment and Documentation
Introduction to Patient Assessment and Documentation ( 6 Questions)
A nurse is assessing a client who has been admitted with chest pain.
Which of the following findings should the nurse report to the provider immediately?
This is an important finding, as hypertension and diabetes are risk factors for cardiovascular disease, but it is not an urgent finding that requires immediate reporting.
This is a significant finding, as chest pain is a cardinal symptom of ACS, but it is not a definitive finding that confirms the diagnosis.
This is an abnormal finding, as crackles indicate fluid accumulation in the alveoli, which may be caused by heart failure, pneumonia, or pulmonary edema. However, it is not a specific finding for ACS and may be related to other conditions.
Rationale: An elevated troponin level indicates myocardial damage and is a diagnostic marker for acute coronary syndrome (ACS), which includes unstable angina and myocardial infarction (MI). This is a life-threatening condition that requires immediate intervention.
D) The client has an elevated troponin level in the blood.
Rationale: An elevated troponin level indicates myocardial damage and is a diagnostic marker for acute coronary syndrome (ACS), which includes unstable angina and myocardial infarction (MI). This is a life-threatening condition that requires immediate intervention.
A) The client has a history of hypertension and diabetes. - This is an important finding, as hypertension and diabetes are risk factors for cardiovascular disease, but it is not an urgent finding that requires immediate reporting.
B) The client rates the pain as 8 on a scale of 0 to 10. - This is a significant finding, as chest pain is a cardinal symptom of ACS, but it is not a definitive finding that confirms the diagnosis.
C) The client has crackles in the lower lobes of both lungs. - This is an abnormal finding, as crackles indicate fluid accumulation in the alveoli, which may be caused by heart failure, pneumonia, or pulmonary edema. However, it is not a specific finding for ACS and may be related to other conditions.