A nurse is admitting a client who reports tightness in their chest that radiates to left arm. Click to highlight the findings below that would indicate that the client has a potential problem. To deselect a finding, click on the finding again Nurses' Notes: 1000: Client reports tightness in chest that radiates to left arm. States pain as 7 on a scale of 0 to 10. Started to feel nauseous after breakfast Client states Thad scrambled eggs and bacon like I do every morning" Client is diaphoretic and short of breath. Heart rate is irregular and tachycardic Alert and oriented to person, place, and time. Lungs clear to auscultation in all lobes. Bowel sounds are present in all 4 quadrants, +1 pedal pulses. Skin is cool to touch. Capillary refill less than 2 seconds.

Rationale for correct findings: • Chest tightness radiating to the left arm: Radiating chest pain is a classic manifestation of myocardial ischemia. Pain extending to the left arm strongly suggests cardiac origin rather than gastrointestinal discomfort. Given the client’s history of hypertension, hyperlipidemia, and diabetes, this symptom is highly concerning for acute coronary syndrome. • Pain rated 7/10: Severe chest pain indicates significant myocardial oxygen imbalance. Persistent pain at this intensity suggests ongoing ischemia or infarction. Immediate evaluation and intervention are required to prevent permanent myocardial damage. • Nausea: Nausea commonly accompanies myocardial infarction due to vagal stimulation and sympathetic activation. It may be mistaken for gastrointestinal discomfort, especially after eating. In the presence of chest pain and risk factors, it strengthens suspicion of cardiac involvement. • Diaphoresis: Excessive sweating reflects sympathetic nervous system activation during acute myocardial ischemia. It often accompanies severe chest pain and hemodynamic stress. Diaphoresis in this context signals a potentially life-threatening cardiac event. • Shortness of breath: Dyspnea may result from decreased cardiac output and impaired oxygen delivery. It suggests the heart is not effectively pumping blood to meet metabolic demands. In acute myocardial infarction, shortness of breath can indicate left ventricular dysfunction. • Irregular and tachycardic heart rate: An irregular tachycardic rhythm increases myocardial oxygen demand and may indicate ischemia-induced dysrhythmias. Cardiac irritability is common during infarction. Dysrhythmias significantly increase the risk of sudden cardiac death. • Skin cool to touch: Cool skin suggests peripheral vasoconstriction, a compensatory mechanism in response to decreased cardiac output. It indicates the body is redirecting blood flow to vital organs. This is consistent with hemodynamic compromise. Rationale for incorrect findings: • Alert and oriented to person, place, and time: The client demonstrates intact cognition, indicating adequate cerebral perfusion at this time. No neurological compromise is evident. • Lungs clear to auscultation: Clear breath sounds suggest no pulmonary congestion or fluid overload currently. Respiratory distress appears cardiac rather than pulmonary in origin.