A nurse is caring for a client who reports a new onset of severe chest pain. Which of the following actions should the nurse take to determine if the client is experiencing a myocardial infarction?

Rationale: A. While assessing vital signs is important, blood pressure alone cannot confirm or rule out a myocardial infarction (MI); it only provides information about hemodynamic status. B. Heart sounds may reveal murmurs or extra sounds but cannot definitively diagnose an MI. C. A 12-lead ECG is the primary diagnostic tool for identifying an acute MI, as it can detect ST-segment changes, T-wave inversions, or Q waves indicative of myocardial injury or ischemia. D. Pain radiation is a clinical symptom that supports suspicion of MI, but symptoms alone cannot confirm the diagnosis; objective evidence from ECG and cardiac biomarkers is required.