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The nurse is assessing a patient with acute coronary syndrome (ACS). The nurse includes a careful history in the assessment, especially with regard to signs and symptoms. What signs and symptoms are suggestive of ACS? Select all that apply.
- A. Dyspnea
- B. Unusual fatigue
- C. Hypotension
- D. Syncope
- E. Peripheral cyanosis
Correct Answer: A,B,D
Rationale: Systematic assessment includes a careful history, particularly as it relates to symptoms: chest pain or discomfort, difficulty breathing (dyspnea), palpitations, unusual fatigue, faintness (syncope), or sweating (diaphoresis). Each symptom must be evaluated with regard to time, duration, and the factors that precipitate the symptom and relieve it, and in comparison with previous symptoms. Hypotension and peripheral cyanosis are not typically associated with ACS.
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A patient presents to the walk-in clinic complaining of intermittent chest pain on exertion, which is eventually attributed to angina. The nurse should inform the patient that angina is most often attributable to what cause?
- A. Decreased cardiac output
- B. Decreased cardiac contractility
- C. Infarction of the myocardium
- D. Coronary arteriosclerosis
Correct Answer: D
Rationale: In most cases, angina pectoris is due to arteriosclerosis. The disease is not a result of impaired cardiac output or contractility. Infarction may result from untreated angina, but it is not a cause of the disease.
The nurse is assessing a patient who was admitted to the critical care unit 3 hours ago following cardiac surgery. The nurses most recent assessment reveals that the patients left pedal pulses are not palpable and that the right pedal pulses are rated at +2. What is the nurses best response?
- A. Document this expected assessment finding during the initial postoperative period
- B. Reposition the patient with his left leg in a dependent position
- C. Inform the patients physician of this assessment finding
- D. Administer an ordered dose of subcutaneous heparin
Correct Answer: C
Rationale: If a pulse is absent in any extremity, the cause may be prior catheterization of that extremity, chronic peripheral vascular disease, or a thromboembolic obstruction. The nurse immediately reports newly identified absence of any pulse.
The nurse is caring for patient who tells the nurse that he has an angina attack beginning. What is the nurses most appropriate initial action?
- A. Have the patient sit down and put his head between his knees
- B. Have the patient perform pursed-lip breathing
- C. Have the patient stand still and bend over at the waist
- D. Place the patient on bed rest in a semi-Fowlers position
Correct Answer: D
Rationale: When a patient experiences angina, the patient is directed to stop all activities and sit or rest in bed in a semi-Fowlers position to reduce the oxygen requirements of the ischemic myocardium. Pursed-lip breathing and standing will not reduce workload to the same extent. No need to have the patient put his head between his legs because cerebral perfusion is not lacking.
The triage nurse in the ED assesses a 66-year-old male patient who presents to the ED with complaints of midsternal chest pain that has lasted for the last 5 hours. If the patients symptoms are due to an MI, what will have happened to the myocardium?
- A. It may have developed an increased area of infarction during the time without treatment
- B. It will probably not have more damage than if he came in immediately
- C. It may be responsive to restoration of the area of dead cells with proper treatment
- D. It has been irreparably damaged, so immediate treatment is no longer necessary
Correct Answer: A
Rationale: When the patient experiences lack of oxygen to myocardium cells during an MI, the sooner treatment is initiated, the more likely the treatment will prevent or minimize myocardial tissue necrosis. Delays in treatment equate with increased myocardial damage. Despite the length of time the symptoms have been present, treatment needs to be initiated immediately to minimize further damage. Dead cells cannot be restored by any means.
The nurse is caring for a patient who has undergone percutaneous transluminal coronary angioplasty (PTCA). What is the major indicator of success for this procedure?
- A. Increase in the size of the arterys lumen
- B. Decrease in arterial blood flow in relation to venous flow
- C. Increase in the patients resting heart rate
- D. Increase in the patients level of consciousness (LOC)
Correct Answer: A
Rationale: PTCA is used to open blocked coronary vessels and resolve ischemia. The procedure may result in beneficial changes to the patients LOC or heart rate, but these are not the overarching goals of PTCA. Increased arterial flow is the focus of the procedures.