Nokea
A patient is admitted to your acute coronary care unit with the diagnosis of ACS. The nurse has seen ECG changes that are indicative of an anterior wall infarction and is observing the patient for signs/symptoms of complications. The nurse has noted the following vital sign trends: 1100-HR 92, RR 24, BP 140/88, Cardiac rhythm NSR 1115-HR 96, RR 26, BP 128/82, Cardiac rhythm NSR 1130-HR 104, RR 28, BP 102/68, Cardiac rhythm ST 1145-HR 120, RR 32, BP 80/52, Cardiac rhythm ST with frequent PVC's The nurse should be alert for which of the following complications? Choose all that apply.
Correct Answer: C
Rationale: The correct answer is C - Cardiogenic shock. In this scenario, the vital sign trends indicate a progressive decline in blood pressure (BP) along with an increasing heart rate (HR) and respiratory rate (RR), which are signs of hemodynamic instability. Cardiogenic shock is a serious complication of acute coronary syndrome (ACS) and occurs when the heart is unable to pump enough blood to meet the body's demands. The decreasing BP and increasing HR in this patient suggest a failing cardiac output, leading to inadequate tissue perfusion and subsequent shock. Syncope (choice A) is possible but less likely given the progressive decline in vital signs. Pericarditis (choice B) typically presents with chest pain and ECG changes different from those seen in this case. Cardiac tamponade (choice D) is characterized by Beck's triad (muffled heart sounds, hypotension, and jugular venous distention), which is not evident in the vital sign trends provided.