MEDizzy - A nurse is assessing a client diagnosed with an

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Physiological Integrity and Developmental Needs

A nurse is assessing a client diagnosed with an anterior-lateral myocardial infarction (MI). The nurse adds a nursing diagnosis to the client’s plan of care of decreased cardiac output when which finding is noted on assessment?

ExplanationAn anterior-lateral MI can produce left ventricular dysfunction and low cardiac output. With low cardiac output, blood accumulates in the heart and backs up into the pulmonary system. The increased pulmonary pressure causes fluid to move into interstitial spaces and then into the alveoli. One-sided weakness suggests complications of a cerebrovascular accident, which can be caused from a clot or plaque embolus secondary to the MI. An S4 heart sound is produced when blood flows forcefully from the atrium to a resistant ventricle during late ventricular diastole. Vesicular breath sounds are normal over lesser bronchi, bronchioles, and lobes of the lung.