10. A nurse is planning care for a client admitted with chest pain after myocardial ischemia. Which outcome should the nurse document for this problem?
10. A nurse is planning care for a client admitted with chest pain after myocardial ischemia. Which outcome should the nurse document for this problem?
. Client states that pain is decreased to a tolerable level.
. Client agrees to rest and take pain medication.
. Client rates pain 0 on scale of 1 (least) to 10 (worst).
. Pain medication is administered within 5 minutes.
Test-Taking Tip
Look for the option that indicates the problem is resolved—no pain.
Content Area: Adult Health, Cardiology; Integrated Process: Nursing Process, Planning; Cognitive Level: Analysis; Client Need/Subneed: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems
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Answer 1 is incorrect because often "tolerable pain" is not a reasonable outcome. This pain is a result of ischemia, so any continued pain may mean ongoing damage to the heart. Answer 2 is incorrect because the expected outcome needs to reflect resolution of the problem. A client could agree to rest and even take pain medicine, yet the ischemia could be ongoing. Answer 3 is correct because continuing chest pain indicates continued ischemia. Treatment should be given until the pain is gone. Answer 4 is incorrect because the expected outcome needs to reflect resolution of the problem, not completion of an intervention. Giving pain medications may not resolve the problem, and additional interventions would be required.