Question

The nurse is assisting a client to walk in the hall on the third day after a myocardial infarction. Which clinical manifestation indicates to the nurse that the client is not ready to advance to the next level of activity?

a. Facial flushing
b. Onset of chest pain
c. Heart rate increase of 10 beats/min at completion of the activity
d. Systolic blood pressure increase of 10 mm Hg at completion of the activity

Answer 1

The onset of chest pain is a critical sign indicating that a client post-myocardial infarction is not ready to advance to the next level of activity, as it suggests myocardial ischemia, which can lead to further damage to the heart muscle.

Step-by-step explanation:

The clinical manifestation that indicates the nurse that the client is not ready to advance to the next level of activity after a myocardial infarction (MI) would be the onset of chest pain. This is a sign that the patient's heart may not be receiving enough oxygen to meet the increased demand of exercise, potentially leading to further damage. While an increase in heart rate by 10 beats per minute or a systolic blood pressure increase of 10 mm Hg may be expected during physical activity, these are not as significant as the onset of chest pain, which is a direct symptom of myocardial ischemia. Facial flushing alone is not indicative of cardiac distress and therefore is not necessarily a sign to halt progression of activity.