The emergency department (ED) nurse determines that the client may be having a myocardial infarction. Which assessment findings support the nurse's conclusion? 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.
Correct Answer: 1, 2, 4
This client is hypotensive and this suggests that an acute cardiovascular problem may be occurring. The client is tachycardic and this is indicative of an acute cardiovascular problem. This client is tachypneic and this is associated with an acute cardiovascular problem. 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. A headache is not necessarily a symptom of an acute cardiovascular problem.
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