A nurse is admitting a client who reports tightness in their chest that radiates to left arm.
Exhibits
The nurse is reviewing the client’s medical record. Select the four findings that require immediate follow-up.
A.
Blood glucose level
B.
Bowel sounds
C.
Blood pressure
D.
Pain level
E.
Electrocardiogram findings
F.
Lung sounds
G.
Troponin T level
The Correct Answer and Explanation is:
In this scenario, the nurse should prioritize findings that could indicate a serious cardiac event, such as a myocardial infarction (heart attack). The four findings that require immediate follow-up are:
C. Blood pressure
D. Pain level
E. Electrocardiogram findings
G. Troponin T level
Explanation
- Blood Pressure (C): Blood pressure readings are critical in assessing cardiovascular stability. Significant hypotension or hypertension can indicate underlying issues such as cardiac tamponade or severe myocardial ischemia. Monitoring blood pressure allows the nurse to detect any immediate changes that may require urgent intervention.
- Pain Level (D): The nature and severity of the client’s chest pain are essential in determining the urgency of the situation. A high pain level may correlate with significant cardiac distress, warranting immediate intervention. The nurse should assess the pain using a standardized scale to gauge the intensity and potentially guide treatment decisions.
- Electrocardiogram Findings (E): ECG results are crucial for diagnosing acute coronary syndromes. ST-segment elevation or depression can indicate ischemia or infarction. Rapid evaluation of these findings is necessary for timely intervention, such as the administration of antiplatelet therapy or preparing for potential procedures like angioplasty.
- Troponin T Level (G): Troponins are biomarkers for myocardial injury. Elevated levels suggest myocardial damage, often indicating an acute coronary event. Timely testing and interpretation of troponin levels can inform treatment plans and interventions, such as the initiation of coronary care protocols.
The other options, while relevant to overall health assessment, do not indicate immediate cardiac distress. A. Blood glucose level and B. Bowel sounds are less urgent in this context, as they do not directly pertain to the suspected cardiac issue. F. Lung sounds can provide useful information but are secondary to the more pressing concerns outlined above. By focusing on these four critical areas, the nurse can ensure that any potentially life-threatening conditions are promptly addressed.