The Emergency Department nurse determines that the client may be having a myocardial infarction
Which of the following pieces of information indicate that the client is experiencing an acute cardiovascular problem? Standard Text: Select all that apply. 1. Blood pressure has dropped from normal and is 90/52.
2. Apical heart rate is 114 beats per minute.
3. Skin is flushed and warm.
4. Respiratory rate is 28 per minute.
5. The client is complaining of a headache.
1,2,4
Rationale 1: Blood pressure has dropped from normal is 90/52. This client is hypotensive and this suggests that an acute cardiovascular problem may be occurring.
Rationale 2: Apical heart rate is 114 beats per minute. The client is tachycardic and this is indicative of an acute cardiovascular problem.
Rationale 3: Skin is flushed and warm. Warm, flushed skin is not necessarily associated with an acute cardiovascular problem. Cyanosis, blue or gray-tinged skin, and pallor are associated with an acute cardiovascular problem.
Rationale 4: Respiratory rate is 28 per minute. This client is tachypneic and this is associated with an acute cardiovascular problem.
Rationale 5: The client is complaining of a headache. A headache is not necessarily a symptom of an acute cardiovascular problem.
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