NCLEX style question....

[Bonny619]

What do you think?

The nurse is caring for a client with a myocardial infarction. Which finding requires the nurse's immediate action?

1. Periorbital edema

2. Dizzy spells

3. Lethargy

4. Shortness of breath

[Eirene, ASN, RN]

i'm going to go with option 4. my rationale is the abc's-- sob.

[Daytonite, BSN, RN]

the nurse is caring for a client with a myocardial infarction. which finding requires the nurse's immediate action?

1. periorbital edema

2. dizzy spells

3. lethargy

4. shortness of breath

while shortness of breath is this obvious answer upon first glance, dizzy spells (#2) might be the correct answer. arrhythmias are a complication of an mi. some arrhythmias lead to poor or no perfusion of blood and oxygen to the brain which are manifested as dizzy spells and syncope. oxygen to the brain trumps oxygen to the lungs. the brain dies minutes faster than heart or lung tissue.

[Bonny619]

Daytonite is right!

I was thrown by this one though.

[Kiringat]

Very sneaky!

[Daytonite, BSN, RN]

Keep in mind that NCLEX questions also test your knowledge of disease and medical treatment. This is a question of one's knowledge of myocardial infarction, it's signs, symptoms, complications and how that affects nursing care and nursing interventions. Add Maslow's hierarchy of needs (#1 - need for oxygen) and which organ of the body has priority for oxygen and the answer was right there. Critical thinking--gotta love it!

[Eirene, ASN, RN]

dang! i learned something today. these posts are so much fun.

dayton-- you've officially took my title as the 'queen of cool'.