what are the signs of an acute myocardial infarction

ATI LPN

ATI PN Comprehensive Predictor 2023 with NGN

1. What are the signs of an acute myocardial infarction?

A. Chest pain radiating to the arm and shortness of breath
B. Nausea, vomiting, and high fever
C. Headache, confusion, and low blood pressure
D. Increased heart rate and bradycardia

Correct answer: A

Rationale: The correct answer is A: Chest pain radiating to the arm and shortness of breath. These are classic signs of an acute myocardial infarction. Choice B is incorrect because nausea, vomiting, and high fever are not typical signs of a heart attack. Choice C is incorrect as headache, confusion, and low blood pressure are not specific to myocardial infarction. Choice D is incorrect because an acute myocardial infarction typically presents with an increased heart rate, not bradycardia.

2. When should a nurse suction a client with a tracheostomy?

A. Every 6 hours, regardless of distress signs
B. When the client's respiratory rate drops below 10
C. When the client shows signs of irritability
D. When the client begins to cough or show signs of airway blockage

Correct answer: C

Rationale: The correct answer is to suction the client when they show signs of irritability. Signs of irritability, such as restlessness or agitation, can indicate the need for suctioning in a client with a tracheostomy. This early indicator suggests that there may be an accumulation of secretions affecting the client's airway. Suctioning should be performed promptly to maintain a clear airway and prevent complications. Choices A, B, and D are incorrect because suctioning should be based on clinical signs and symptoms indicating the need for intervention, rather than a fixed schedule or specific vital sign parameters.

3. A nurse is caring for a client who is constipated. What intervention is most appropriate?

A. Administer a laxative to relieve discomfort
B. Encourage the client to increase dietary fiber intake
C. Encourage the client to rest until symptoms resolve
D. Administer a stool softener as prescribed

Correct answer: B

Rationale: The most appropriate intervention for constipation is to encourage the client to increase dietary fiber intake. Fiber helps promote bowel movements and relieve constipation by adding bulk to the stool. Administering a laxative (Choice A) should not be the first-line intervention as it can lead to dependence. Encouraging rest (Choice C) is not directly helpful in relieving constipation. While administering a stool softener (Choice D) can be beneficial, increasing fiber intake is generally preferred as the initial intervention.

4. A nurse is caring for a client who has dementia and frequently gets out of bed unsupervised. What is the best intervention to prevent falls?

A. Place a bed exit alarm
B. Use restraints to prevent the client from getting out of bed
C. Ask the client's family to stay at the bedside
D. Encourage frequent ambulation with assistance

Correct answer: A

Rationale: The best intervention to prevent falls in a client with dementia who gets out of bed unsupervised is to place a bed exit alarm. This device alerts staff when the client attempts to leave the bed, allowing timely intervention to reduce the risk of falls. Using restraints (choice B) can lead to physical and psychological harm and should be avoided unless absolutely necessary. Asking the client's family to stay at the bedside (choice C) may not be feasible at all times and does not provide a continuous monitoring solution. Encouraging frequent ambulation with assistance (choice D) is beneficial for mobility but may not address the immediate risk of falls associated with unsupervised bed exits.

5. A nurse in a pediatric clinic is collecting data from a school-age child whose injuries are inconsistent with the parent's stated cause. Which of the following actions should the nurse take?

A. Provide teaching to the parents
B. Report suspected abuse to the appropriate agency
C. Document the injuries and monitor the child
D. Counsel the parents privately

Correct answer: B

Rationale: In cases where a child's injuries are inconsistent with the parent's stated cause, it raises concerns about possible abuse. The correct action for the nurse in this situation is to report suspected abuse to the appropriate agency. This is a legal and ethical obligation for healthcare professionals when they suspect child abuse. Providing teaching to the parents (Choice A) may not address the immediate safety concerns of the child. Documenting the injuries and monitoring the child (Choice C) is important but reporting suspected abuse takes precedence to ensure the child's safety. Counseling the parents privately (Choice D) may not be effective if abuse is suspected, as the primary focus should be on protecting the child.