Shortly after being admitted to the coronary care unit with an acute myocardial infarction (MI), a client reports midsternal chest pain radiating down the left arm. The nurse notices that the client is restless and slightly diaphoretic, and measures a temperature of 99. 6°F (37.6℃), a heart rate of 102 beats/minute; regular, slightly labored respirations at 26 breaths/minute; and a blood pressure of 150/90mmHg. Which nursing diagnosis takes highest priority ？（）
A．Risk for imbalanced body temperature.
B．Decreased cardiac output.
C．Anxiety.
D．Acute pain.
参考答案：D
解析：
The nursing diagnosis of Acute pain takes highest priority because pain increases the client’s pulse and blood pressure. During an acute phase of an MI, low-grade fever is an expected result of the body’s response to the myocardial tissue necrosis. This makes Risk for imbalanced body temperature an incorrect answer. The client’s blood pressure and heart rate don’t suggest a nursing diagnosis of Decreased cardiac output. Anxiety could be an appropriate nursing diagnosis but it may be corrected by addressing the priority concern- pain.