A client with a history of cardiac issues is admitted to the ...

[jCorn1234]

A client with a history of cardiac issues is admitted to the emergency department with suspected myocardial infarction (MI, or heart attack).
 
  The client's spouse tells the nurse that the client had pain in the jaw area that was not relieved with nitroglycerin. The client's spouse asks the nurse how jaw pain is related to having a heart attack. Which explanation by the nurse is the most appropriate?
  1. The doctors would rather treat you as a cardiac client until they find out why the nitroglycerin did not work.
  2. Sometimes cardiac pain is not just in your chest, but in your jaws, arms or back.
  3. They may have been so stressed that they clenched their jaws and did not realized if they had any chest pain or not.
  4. It may not be related, but cardiac pain is so serious to investigate and treat.

Question 2

The nurse is performing a pain assessment on a client who is unable to communicate verbally. Which vital sign data would indicate that the client is in acute pain? Select all that apply.
 
  1. Temperature of 100.6 degrees.
  2. Pulse rate 94.
  3. Respiratory rate 32.
  4. Blood pressure 158/92 mmHg.
  5. Facial grimacing.

[daiying98]

Answer to Question 1

Correct Answer: 2

Referred pain may result when pain is felt in tissues that are not in close proximity to the primary cause or site of the pain. This may be especially true of cardiac pain. It may be exhibited in the jaw, shoulders, arms, or back. It is inappropriate for the nurse to indicate the healthcare provider is treating the client in a manner without certainty. Clenching teeth would not be linked to chest pain. While cardiac pain is serious, this response does not meet the level of client questioning.

Answer to Question 2

Correct Answer: 2, 3, 4, 5

The client may be diaphoretic with acute pain, but not directly as a result of a low-grade temperature. When in acute pain, a client will typically have sympathetic nervous system responses that are exhibited in an increased pulse, respiratory rate, and blood pressure. Facial grimacing may be noted in the expressions of the client experiencing acute pain.

[jCorn1234]

Thank you

[daiying98]

Happy to help you