Nokea
The nurse has just admitted a 66-year-old patient for cardiac surgery. The patient tearfully admits to the nurse that she is afraid of dying while undergoing the surgery. What is the nurses best response?
- A. Explore the factors underlying the patients anxiety
- B. Teach the patient guided imagery techniques
- C. Obtain an order for a PRN benzodiazepine
- D. Describe the procedure in greater detail
Correct Answer: A
Rationale: An assessment of anxiety levels is required in the patient to assist the patient in identifying fears and developing coping mechanisms for those fears. The nurse must further assess and explore the patients anxiety before providing interventions such as education or medications.
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The nurse is caring for a patient who is believed to have just experienced an MI. The nurse notes changes in the ECG of the patient. What change on an ECG most strongly suggests to the nurse that ischemia is occurring?
- A. P wave inversion
- B. T wave inversion
- C. Q wave changes with no change in ST or T wave
- D. P wave enlargement
Correct Answer: B
Rationale: T-wave inversion is an indicator of ischemic damage to myocardium. Typically, few changes to P waves occur during or after an MI, whereas Q-wave changes with no change in the ST or T wave indicate an old MI.
The nurse providing care for a patient post PTCA knows to monitor the patient closely. For what complications should the nurse monitor the patient? Select all that apply.
- A. Abrupt closure of the coronary artery
- B. Venous insufficiency
- C. Bleeding at the insertion site
- D. Retroperitoneal bleeding
- E. Arterial occlusion
Correct Answer: A,C,D,E
Rationale: Complications after the procedure may include abrupt closure of the coronary artery and vascular complications, such as bleeding at the insertion site, retroperitoneal bleeding, hematoma, and arterial occlusion, as well as acute renal failure. Venous insufficiency is not a postprocedure complication of a PTCA.
You are writing a care plan for a patient who has been diagnosed with angina pectoris. The patient describes herself as being distressed and shocked by her new diagnosis. What nursing diagnosis is most clearly suggested by the womans statement?
- A. Spiritual distress related to change in health status
- B. Acute confusion related to prognosis for recovery
- C. Anxiety related to cardiac symptoms
- D. Deficient knowledge related to treatment of angina pectoris
Correct Answer: C
Rationale: Although further assessment is warranted, it is not unlikely that the patient is experiencing anxiety. In patients with CAD, this often relates to the threat of sudden death. There is no evidence of confusion (i.e., delirium or dementia) and there may or may not be a spiritual element to her concerns. Similarly, it is not clear that a lack of knowledge or information is the root of her anxiety.
The nurse is creating a plan of care for a patient with acute coronary syndrome. What nursing action should be included in the patients care plan?
- A. Facilitate daily arterial blood gas (ABG) sampling
- B. Administer supplementary oxygen, as needed
- C. Have patient maintain supine positioning when in bed
- D. Perform chest physiotherapy, as indicated
Correct Answer: B
Rationale: Oxygen should be administered along with medication therapy to assist with symptom relief. Administration of oxygen raises the circulating level of oxygen to reduce pain associated with low levels of myocardial oxygen. Physical rest in bed with the head of the bed elevated or in a supportive chair helps decrease chest discomfort and dyspnea. ABGs are diagnostic, not therapeutic, and they are rarely needed on a daily basis. Chest physiotherapy is not used in the treatment of ACS.
The nurse is caring for an adult patient who had symptoms of unstable angina upon admission to the hospital. What nursing diagnosis underlies the discomfort associated with angina?
- A. Ineffective breathing pattern related to decreased cardiac output
- B. Anxiety related to fear of death
- C. Ineffective cardiopulmonary tissue perfusion related to coronary artery disease (CAD)
- D. Impaired skin integrity related to CAD
Correct Answer: C
Rationale: Ineffective cardiopulmonary tissue perfusion directly results in the symptoms of discomfort associated with angina. Anxiety and ineffective breathing may result from angina chest pain, but they are not the causes. Skin integrity is not impaired by the effects of angina.