The nurse is performing a focused interview with an adult male ...

[burton19126]

The nurse is performing a focused interview with an adult male client who recently experienced a myocardial infarction. The nurse requests information about how he felt during the time of the myocardial infarction.
 
  Which client statement would be unexpected?
  1. I couldn't catch my breath.
  2. My chest didn't actually ever hurt.
  3. My wife said I looked like someone poured water all over me.
  4. I got so sick to my stomach.

Question 2

The intensive care nurse is performing a cardiac assessment on a newly admitted older adult client and notes the following findings:
 
  peripheral edema, jugular venous distention of 5 cm above the sternal angle when the client is at a 45-degree angle, and an enlarged liver. Based on this data, which diagnosis does the nurse suspect?
  1. Pulmonary edema.
  2. Left-sided heart failure.
  3. Myocardial infarction.
  4. Right-sided heart failure.

[Missbam101]

Answer to Question 1

Correct Answer: 2
Typically, males who are experiencing a myocardial infarction will complain of dyspnea, and chest pain that is prolonged, dull, and radiates to the shoulder or jaw. In males, the pain is often accompanied by diaphoresis and they may complain of nausea. Females are more likely to experience nausea and vomiting, indigestion, shortness of breath, or extreme fatigue, without actual chest pain.

Answer to Question 2

Correct Answer: 4
With right-sided heart failure, the right ventricle is ineffective as a pump, which leads to congestion as blood backs up into the systemic circulation. Right-sided heart failure results in increased jugular vein distention. This is a reflection of the increased pressure in the right atrium. Right-sided heart failure also results in peripheral edema and liver enlargement. Left-sided heart failure results in pulmonary congestion and pulmonary edema as blood backs up into the pulmonary system. Heart failure may be caused by a myocardial infarction. However, the clinical manifestations associated with heart failure are not always the result of a myocardial infarction.