A nurse at a provider's office receives a telephone call from a client who reports nausea and has unrelieved chest pain after taking a nitroglycerin tablet 5 min ago. Which of the following is an appropriate response by the nurse?
Advise the client to come into the office.
Advise the client to take an antacid.
Instruct the client to call 911.
Tell the client to take another nitroglycerin tablet in 15 min.
The Correct Answer is C
A. Advise the client to come into the office. The client needs immediate emergency intervention, not a routine office visit.
B. Advise the client to take an antacid. Chest pain unrelieved by nitroglycerin may indicate myocardial infarction; an antacid would not help.
C. Instruct the client to call 911. Persistent chest pain unrelieved by nitroglycerin warrants emergency attention due to potential heart attack.
D. Tell the client to take another nitroglycerin tablet in 15 min. The protocol allows taking an additional dose in 5 minutes, but emergency services should be called for unrelieved chest pain.
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Correct Answer is A
Explanation
A. To prevent blood clotting: Aspirin is an antiplatelet agent, and it reduces blood clot formation, which helps prevent further cardiac events after an MI.
B. To reduce inflammation: Although aspirin has anti-inflammatory properties, this is not the primary reason for its use in post-MI clients.
C. To prevent fever: Aspirin can reduce fever, but this is not its purpose in MI prevention.
D. To provide analgesia: Aspirin can relieve pain, but in this context, it is used to prevent blood clotting, not as an analgesic.
Correct Answer is A
Explanation
A. Cerebral blood flow. MAP is crucial for maintaining adequate cerebral perfusion pressure, ensuring enough blood flow to the brain.
B. The client's intake and output needs. MAP does not directly influence intake and output needs; it is more directly related to blood flow and tissue perfusion.
C. Regulation of blood pressure. MAP is a measure of average blood pressure but not a regulator of it.
D. Resorption of cerebrospinal fluid. CSF resorption is not directly influenced by MAP; it’s regulated by intracranial pressure and other factors.