Nokea
The nurse has just received a change-of-shift report about the following four patients. Which patient should the nurse assess first?
- A. 38-year-old who has pericarditis and is complaining of sharp, stabbing chest pain
- B. 45-year-old who had a myocardial infarction (MI) 4 days ago and is anxious about the planned discharge
- C. 51-year-old with unstable angina who has just returned to the unit after having a percutaneous coronary intervention (PCI)
- D. 60-year-old with variant angina who is to receive a scheduled dose of nifedipine (Adalat)
Correct Answer: C
Rationale: This patient is at risk for bleeding from the arterial access site for the PCI, so the nurse should assess the patient's blood pressure, pulse, and the access site immediately. The other patients also should be assessed as quickly as possible, but assessment of this patient has the highest priority.
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The nurse is caring for a patient who is 3 days post myocardial infarction and the patient states, 'I just had a little chest pain. As soon as I get out of here, I'm going for my vacation as planned' Which of the following responses should the nurse make?
- A. Where are you planning to go for your vacation?
- B. What do you think caused your chest pain episode?
- C. Sometimes plans need to change after a heart attack.
- D. Recovery from a heart attack takes at least a few weeks.
Correct Answer: B
Rationale: When the patient is experiencing denial, the nurse should assist the patient in testing reality until the patient has progressed beyond this step of the emotional adjustment to MI. Asking the patient about vacation plans reinforces the patient's plan, which is not appropriate in the immediate post-MI period. Reminding the patient in denial about the MI is likely to make the patient angry and lead to distrust of the nursing staff.
The nurse is caring for a patient who has had an acute myocardial infarction and the patient asks the nurse about when sexual intercourse can be resumed. Which of the following responses by the nurse is best?
- A. Most patients are able to enjoy intercourse without any complications.
- B. Sexual activity uses about as much energy as climbing two flights of stairs.
- C. The doctor will discuss sexual intercourse when your heart is strong enough.
- D. Holding and cuddling are good ways to maintain intimacy after a heart attack.
Correct Answer: B
Rationale: Sexual activity places about as much physical stress on the cardiovascular system as climbing two flights of stairs. The other responses do not directly address the patient's question, or may not be accurate for this patient.
Which of the following information about a patient who has been receiving fibrinolytic therapy for an acute myocardial infarction is most important for the nurse to communicate to the health care provider?
- A. No change in the patient's chest pain
- B. A large bruise at the patient's IV insertion site
- C. A decrease in ST segment elevation on the electrocardiogram (ECG)
- D. An increase in cardiac enzyme levels since admission
Correct Answer: A
Rationale: Continued chest pain suggests that the fibrinolytic therapy is not effective and that other interventions such as percutaneous coronary intervention (PCI) may be needed. Bruising is a possible adverse effect of fibrinolytic therapy, but it is not an indication that therapy should be discontinued. The decrease of the ST segment elevation indicates that fibrinolysis is occurring and perfusion is returning to the injured myocardium. An increase in cardiac enzyme levels is expected with reperfusion and is related to the washout of enzymes into the circulation as the blocked vessel is opened.
Which of the following causes is the most common cause for sudden cardiac death?
- A. Ventricular tachycardia
- B. Aortic stenosis
- C. Hypertrophic cardiomyopathy
- D. Angina
Correct Answer: A
Rationale: Acute ventricular dysrhythmias (e.g., ventricular tachycardia, ventricular fibrillation) cause the majority of cases of SCD. Less commonly, SCD occurs because of a primary left ventricular outflow obstruction (e.g., aortic stenosis, hypertrophic cardiomyopathy) or extreme slowing of the heart (bradycardia).
The nurse is caring for a patient with a non-ST-segment-elevation myocardial infarction (NSTEMI) who is receiving heparin. Which of the following information explains the purpose of the heparin?
- A. Platelet aggregation is enhanced by IV heparin infusion.
- B. Heparin will dissolve the clot that is blocking blood flow to the heart.
- C. Coronary artery plaque size and adherence are decreased with heparin.
- D. Heparin will prevent the development of new clots in the coronary arteries.
Correct Answer: D
Rationale: Heparin helps prevent the conversion of fibrinogen to fibrin and decreases coronary artery thrombosis. It does not change coronary artery plaque, dissolve already formed clots, or enhance platelet aggregation.