A nurse is admitting a client who reports tightness in their chest that radiates to left arm. Complete the following sentence by using the lists of options. The nurse should first address the client's dropdownfollowed by the client'sdropdown
Explanation & Rationale
Rationale for Correct Choices: Pain level: The client reports chest pain 7/10, radiating to the left arm, with associated nausea and diaphoresis. Chest pain in this context indicates acute myocardial ischemia or infarction and is immediately life-threatening. Managing pain also helps reduce sympathetic stimulation and myocardial oxygen demand. ECG results: The ECG shows ST-segment elevation and T-wave changes, which are hallmark signs of ST-elevation myocardial infarction (STEMI). ECG changes confirm the need for emergent cardiac interventions, such as reperfusion therapy. After addressing pain and stabilizing the client, the ECG results guide definitive treatment. Rationale for Incorrect Choices: Creatine kinase level: Elevated CK reflects myocardial injury but is diagnostic, not immediately life-threatening. Action is guided by ECG and clinical status. Cholesterol level: Hyperlipidemia is a long-term cardiovascular risk factor; it does not require immediate intervention during an acute MI. Blood glucose level: Blood glucose is normal (103 mg/dL) and not contributing to the acute event; it does not need urgent intervention.