An emergency department nurse triages clients who present with ...

[KWilfred]

An emergency department nurse triages clients who present with chest discomfort. Which client should the nurse plan to assess first?
 
  a. A 42-year-old female who describes her pain as a dull ache with numbness in her fingers
  b. A 49-year-old male who reports moderate pain that is worse on inspiration
  c. A 53-year-old female who reports substernal pain that radiates to her abdomen
  d. A 58-year-old male who describes his pain as intense stabbing that spreads across his chest

Question 2

A nurse cares for a client who is recovering from a myocardial infarction. The client states, I will need to stop eating so much chili to keep that indigestion pain from returning. How should the nurse respond?
 
  a. Chili is high in fat and calories; it would be a good idea to stop eating it.
  b. The provider has prescribed an antacid for you to take every morning.
  c. What do you understand about what happened to you?
  d. When did you start experiencing this indigestion?

[kjohnson]

Answer to Question 1

ANS: D
All clients who have chest pain should be assessed more thoroughly. To determine which client should be seen first, the nurse must understand common differences in pain descriptions. Intense stabbing, vise-like substernal pain that spreads through the client's chest, arms, jaw, back, or neck is indicative of a myocardial infarction. The nurse should plan to see this client first to prevent cardiac cell death. A dull ache with numbness in the fingers is consistent with anxiety. Pain that gets worse with inspiration is usually related to a pleuropulmonary problem. Pain that spreads to the abdomen is often associated with an esophageal-gastric problem, especially when this pain is experienced by a male client. Female clients may experience abdominal discomfort with a myocardial event. Although clients with anxiety, pleuropulmonary, and esophageal-gastric problems should be seen, they are not a higher priority than myocardial infarction.

Answer to Question 2

ANS: C
Clients who experience myocardial infarction often respond with denial, which is a defense mechanism. The nurse should ask the client what he or she thinks happened, or what the illness means to him or her. The other responses do not address the client's misconception about recent pain and the cause of that pain.

[KWilfred]

Gracias!

[CAPTAINAMERICA]

TYSM