A nurse is admitting a client who reports tightness in their chest that radiates to left arm. Exhibits 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, "I had 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.

Findings that indicate the client has a potential problem: Chest pain radiating to left arm: Chest pain that radiates to the left arm is a classic symptom of a myocardial infarction (MI). The description of pain (tightness) and its radiation to the left arm are a red flag for an acute cardiac event, which requires immediate intervention. Pain level of 7 on a scale of 0 to 10: A pain level of 7 indicates significant discomfort, and when combined with other symptoms like chest tightness and radiation to the left arm, it further supports the possibility of a myocardial infarction. Started to feel nauseous after breakfast: Nausea can be an associated symptom of acute myocardial infarction (MI), especially in women, the elderly, and those with diabetes. Its presence, along with chest pain, is concerning. Diaphoresis: Diaphoresis (excessive sweating) is often associated with myocardial infarction and is a key sign of acute coronary syndrome. This finding, along with chest pain and shortness of breath, suggests an emergent situation. Tachycardia with irregular heart rate: The client’s heart rate is 110/min and irregular, which can be indicative of arrhythmias commonly seen in acute myocardial infarction. The irregular and tachycardic rhythm should be immediately evaluated to prevent further complications. +1 pedal pulses: While present, +1 pedal pulses are diminished. This could indicate compromised peripheral circulation, possibly related to overall cardiovascular compromise or underlying peripheral artery disease, which is often co-morbid with the client's existing conditions (hyperlipidemia, hypertension, diabetes). Skin is cool to touch: Cool skin, especially when accompanied by other signs of poor perfusion like diminished pulses, can indicate reduced peripheral blood flow, which may be a systemic response to decreased cardiac output from a significant cardiac event. Rationale for Incorrect Findings: Lungs clear to auscultation: Clear lung sounds suggest no signs of pulmonary edema or other lung issues at the moment, ruling out respiratory causes of the symptoms. Bowel sounds present in all 4 quadrants: The presence of bowel sounds in all quadrants is normal and suggests that the gastrointestinal system is functioning well. Capillary refill less than 2 seconds is normal and indicate adequate perfusion, this finding on its own does not require follow up.