A patient comes to the emergency department with an acute myocardial infarction. An electrocardiogram shows a heart rate of 116 beats/minute with frequent premature ventricular contractions
The patient experiences ventricular tachycardia and becomes unresponsive. After resuscitation, the patient moves to the intensive care unit. What is the priority nursing diagnosis for this patient?
A) Impaired physical mobility related to complete bed rest
B) Deficient knowledge related to emergency interventions
C) Social isolation related to restricted family visits
D) Anxiety related to the threat of death
Ans: D
Feedback: Anxiety related to the threat of death is an appropriate nursing diagnosis. Anxiety can adversely affect the patient's heart rate and rhythm by stimulating the autonomic nervous system. The threat of death is an immediate and real concern for the patient. The other options are valid, but their priority is less urgent.
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The nurse recognizes that a severe form of self-starvation that can lead to death is called:
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While inspecting the pressure ulcer of a 90-year-old client, the nurse observes new tissue growth around the area, which is pinkish-red in color. The nurse should document the presence of:
1. epithelialization. 2. slough. 3. granulation. 4. eschar.
A client is upset and complains of dizziness, tingling of fingers and toes, and lightheadedness. The nurse assesses a respiratory rate of 46 breaths per minute. Laboratory results show a pH of 7.50 and a PaCO2 of 28, values consistent with:
1. respiratory acidosis. 2. respiratory alkalosis. 3. metabolic acidosis. 4. metabolic alkalosis.