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.

Rationales for Correct Choices: Client reports tightness in chest that radiates to left arm: Chest pain radiating to the left arm is a classic manifestation of myocardial ischemia or infarction due to reduced coronary blood flow and myocardial oxygen supply. States pain as 7 on a scale of 0 to 10: Severe, persistent chest pain (especially ≥7/10) is concerning for acute myocardial injury rather than benign or musculoskeletal pain. Client is diaphoretic and short of breath: Diaphoresis and dyspnea occur from sympathetic nervous system activation and decreased cardiac output during myocardial ischemia. Heart rate is irregular and tachycardic: Myocardial ischemia can disrupt cardiac electrical conduction, leading to tachyarrhythmias, which increase myocardial oxygen demand and worsen ischemia. +1 pedal pulses: Diminished peripheral pulses suggest decreased cardiac output and impaired peripheral perfusion, which can occur during acute cardiac events. Skin is cool to touch: Cool skin reflects peripheral vasoconstriction caused by reduced cardiac output and sympathetic compensation during acute coronary syndromes. Rationales for Incorrect Choices: Client states, "I had scrambled eggs and bacon like I do every morning." Dietary habits reported at this moment do not indicate an acute physiological problem and do not explain the sudden onset of cardiac symptoms. Alert and oriented to person, place, and time: Normal mental status indicates adequate cerebral perfusion and does not signal acute deterioration or instability. Lungs clear to auscultation in all lobes: Clear lung sounds suggest no pulmonary edema or heart failure at this time, making this a non-problematic finding. Capillary refill less than 2 seconds: Normal capillary refill indicates adequate peripheral perfusion, which does not reflect an immediate concern.