A nurse is caring for a client brought to the emergency room with acute chest pain. The client is being worked up for possible acute myocardial infarction (MI). The client asks why blood is being drawn for cardiac enzymes. What should the nurse explain to the client regarding why the cardiac enzyme troponin is being collected?
"These tests will enable the provider to determine the heart structure and mobility of the heart valves."
"Cardiac enzymes assist in diagnosing the presence of congestive heart failure."
"Cardiac enzymes like troponin shows there has been damage to the heart tissues and muscle."
"Cardiac enzymes will identify the exact location of the MI."
The Correct Answer is C
A) "These tests will enable the provider to determine the heart structure and mobility of the heart valves." This statement is incorrect because cardiac enzyme tests, including troponin levels, do not assess heart structure or valve mobility. Imaging studies like echocardiograms are typically used for evaluating heart structure and function.
B) "Cardiac enzymes assist in diagnosing the presence of congestive heart failure." While cardiac enzymes can provide some information about heart function, they are not specifically used to diagnose congestive heart failure. The primary role of cardiac enzymes, particularly troponin, is in diagnosing myocardial injury, such as an acute myocardial infarction.
C) "Cardiac enzymes like troponin shows there has been damage to the heart tissues and muscle." This statement accurately reflects the purpose of measuring troponin levels. Troponin is a protein released into the bloodstream when heart muscle cells are damaged, making it a crucial biomarker for diagnosing an acute myocardial infarction.
D) "Cardiac enzymes will identify the exact location of the MI." This statement is misleading. While troponin levels can indicate that damage has occurred, they do not provide information about the specific location of the myocardial infarction. Other imaging techniques, such as an angiogram, are needed to determine the exact location of blockages or damage.
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View Related questions
Correct Answer is C
Explanation
A) Apply cold therapy to the affected leg: Cold therapy may be used for certain conditions to reduce swelling and pain, but in the case of suspected deep vein thrombosis (DVT) indicated by redness, warmth, tenderness, and pain in the calf, cold therapy is not appropriate. Instead, the focus should be on confirming the diagnosis before applying any treatment.
B) Monitor Homan's sign: Homan's sign involves dorsiflexion of the foot to assess for pain in the calf, which can suggest DVT. However, it is no longer considered a reliable diagnostic tool. Instead, confirmation through imaging or other diagnostic measures is preferred, so simply monitoring this sign would not be sufficient in this situation.
C) Obtain a venous duplex ultrasound: A venous duplex ultrasound is the gold standard for
diagnosing DVT. Given the client’s symptoms—redness, warmth, tenderness, and pain in the calf—the appropriate order is to obtain this ultrasound to confirm the presence of a thrombus. This imaging study provides critical information for diagnosis and subsequent management.
D) Obtain impedance plethysmography: While impedance plethysmography can assess venous flow and help diagnose DVT, it is less commonly used than venous duplex ultrasound. The more direct and widely accepted method for diagnosing DVT in this scenario is the ultrasound, making this option less suitable as the initial order.
Correct Answer is ["A","B","C","D"]
Explanation
A) "I will apply my compression stockings." Compression stockings are a standard recommendation for clients with peripheral venous disease (PVD). They help improve venous return and reduce symptoms like swelling and discomfort, indicating that the client understands the importance of managing their condition.
B) "I will limit long periods of standing." This statement reflects an understanding of the need to avoid activities that can exacerbate venous stasis and contribute to worsening symptoms in PVD. Limiting long periods of standing helps promote better blood flow and reduces the risk of complications.
C) "I may develop a brownish discoloration to my lower extremities." This statement indicates an awareness of a potential complication of PVD, often caused by venous stasis and pooling of blood. Brownish discoloration, or stasis dermatitis, can occur in the lower extremities, showing the client’s understanding of the condition.
D) "With this problem, I may have lower extremity hair loss." This statement is accurate as well; hair loss on the lower extremities can occur with PVD due to reduced blood flow and oxygen supply to the tissues. This recognition indicates that the client understands the potential effects of their diagnosis.
E) "I will only take my cholesterol lowering medication every other day in the afternoon." This statement reflects a misunderstanding of medication management. Clients with PVD should take prescribed medications as directed to manage their condition effectively, and altering the dosing schedule without consulting a healthcare provider can lead to adverse outcomes.