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After 2-hour onset of acute chest pain, the client is brought to the emergency department for evaluation. Elevation of which diagnostic findings would the nurse identify as suggestive of an acute myocardial infarction at this time?
- A. Troponin I
- B. Myoglobin
- C. WBC (white blood cell) count
- D. C-reactive protein
Correct Answer: B
Rationale: Myoglobin is a biomarker that rises in 2 to 3 hours after heart damage. Troponin is the gold standard for determining heart damage, but troponin I levels do not rise until 4 to 6 hours after MI. WBCs and C-reactive protein levels will rise but not until about day 3.
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The nurse provides care for a client following a percutaneous transluminal coronary angioplasty (PTCA). Which is the priority action by the nurse?
- A. Monitor the gag reflex
- B. Evaluate for signs of infection
- C. Monitor for signs of fluid volume deficit
- D. Palpate distal pulses in bilateral extremities
Correct Answer: D
Rationale: The PTCA is an invasive nonsurgical procedure in which a balloon-tipped catheter is inserted and threaded through a peripheral artery. The nurse monitors the client for bleeding postprocedure in addition to palpating distal, bilateral pulses in the appropriate extremity. Fluid volume deficit is not a primary concern. This procedure does not require general anesthesia; therefore, monitoring for an impaired gag reflex is not a priority nursing action. Signs of infection should be monitored post-PTCA, but this is not an immediate concern.
The nurse is caring for a client who is post-varicose vein surgery. The nurse would include which teaching measure(s)? Select all that apply.
- A. Exercise
- B. Cool compresses
- C. Elastic stockings
- D. Lower the extremities
- E. Stand rather than sit
- F. Take warm showers in the morning
Correct Answer: A,C
Rationale: Movement/exercise and use of elastic stocking aid in venous return. Cool compresses can cause vasoconstriction, which can diminish arterial blood flow. Elevation of legs can be helpful in aiding venous return. Standing or sitting for prolonged periods of time should be avoided. Showers in the morning can dilate blood vessels and contribute to venous congestion and edema.
The nurse is caring for a client with coronary artery disease (CAD). What is an appropriate nursing action when evaluating a client with CAD?
- A. Assess the client's mental and emotional status
- B. Assess the skin of the client
- C. Assess the characteristics of chest pain
- D. Assess for any kind of drug abuse
Correct Answer: C
Rationale: The nurse should assess the characteristics of chest pain for a client with CAD. Assessing the client's mental and emotional status, skin, or for drug abuse will not assist the nurse in evaluating the client for CAD. The assessment should be aimed at evaluating for adequate blood flow to the heart.
The nurse knows that women and older adults are at greater risk for a fatal myocardial event. Which factor is the primary contributor of this cause?
- A. Chest pain is typical
- B. Vague symptoms
- C. Decreased sensation to pain
- D. Gender bias
Correct Answer: B
Rationale: Often, women and older adults do not have the typical chest pain associated with a myocardial infarction. Some report vague symptoms (fatigue, abdominal pain), which can lead to misdiagnosis. Some older adults may experience little or no chest pain. Gender is not a contributing factor for fatal occurrence but rather a result of symptoms association.
The nurse provides care to a menopausal client who states, 'I read a news article that says I am at risk for coronary vascular disease due to inflammation.' Which method should the nurse suggest to the client to aid in the prevention of inflammation that can lead to atherosclerosis?
- A. Addressing obesity
- B. Avoiding the use of caffeine
- C. Taking a daily multivitamin
- D. Drinking at least 2 liters of water a day
Correct Answer: A
Rationale: The 2019 ACC/AHA Guideline on the Primary Prevention of Coronary Vascular Disease (CVD) indicates a relationship between body fat and the production of inflammatory and thrombotic (clot-facilitating) proteins. This information suggests that decreasing obesity and body fat stores via exercise, dietary modification, or developing drugs that target proinflammatory proteins may reduce risk factors for heart disease. The risk for CVD accelerates for clients after menopause due to withdrawal of endogenous estradiol levels, which can worsen many traditional CVD risk factors, including body fat distribution. Avoiding the use of caffeine, using a multivitamin, and drinking at least 2 liters of water a day are not actions that will address the prevention of inflammation that can lead to atherosclerosis.