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, "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.

Rationale for Correct Choices • Client reports tightness in chest that radiates to left arm: Chest pain radiating to the left arm is a classic symptom of myocardial ischemia or acute coronary syndrome (ACS). This indicates myocardial injury and is an urgent clinical concern. Prompt recognition is necessary to prevent complications such as myocardial infarction. • Pain rated 7 on a scale of 0 to 10: Severe pain reflects significant cardiac stress and correlates with ischemic events. Pain intensity guides urgency of intervention and assessment for ACS. Continuous monitoring and pain management are critical to prevent hemodynamic instability. • Nausea after breakfast: Nausea is a common symptom associated with cardiac ischemia due to autonomic nervous system activation. It may be misattributed to gastrointestinal causes, so including it in risk assessment ensures timely cardiac evaluation. • Diaphoresis: Excessive sweating is a sympathetic response to myocardial ischemia. It indicates the body is under stress and is associated with increased risk of complications such as arrhythmias or hypotension. Monitoring for additional signs of ACS is warranted. • Shortness of breath: Dyspnea reflects reduced cardiac output and potential pulmonary congestion. It may indicate early heart failure or significant ischemia. Immediate assessment helps prevent further deterioration. • Heart rate irregular and tachycardic: Tachycardia and irregular rhythm suggest cardiac stress or arrhythmia secondary to ischemia. These findings increase the risk for hemodynamic instability and require urgent monitoring and intervention. • Skin is cool to touch: Cool, clammy skin indicates peripheral vasoconstriction in response to decreased cardiac output. This is a sign of compromised perfusion and potential shock, highlighting the need for prompt cardiac assessment. Rationale for incorrect findings • Alert and oriented to person, place, and time: Normal mental status indicates adequate cerebral perfusion at this time. • Lungs clear to auscultation in all lobes: Clear lung sounds suggest no pulmonary edema or acute respiratory compromise. Pulmonary assessment is important, but the lack of abnormal findings does not indicate a current problem. • Capillary refill less than 2 seconds: Normal capillary refill suggests adequate peripheral perfusion at this time. It does not indicate immediate cardiac compromise.