Nokea
The nurse is caring for a patient who has had severe chest pain for several hours and a diagnosis of possible acute myocardial infarction. Which of the following prescribed laboratory tests should the nurse monitor to help determine the diagnosis?
- A. Homocysteine
- B. C-reactive protein
- C. Cardiac-specific troponin
- D. High-density lipoprotein (HDL) cholesterol
Correct Answer: C
Rationale: Troponin levels increase about 3-12 hours after the onset of myocardial infarction (MI). The other laboratory data are useful in determining the patient's risk for developing coronary artery disease (CAD) but are not helpful in determining whether an acute MI is in progress.
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Which of the following information collected by the nurse who is admitting a patient with chest pain suggests that the pain is caused by an acute myocardial infarction?
- A. The pain increases with deep breathing.
- B. The pain has persisted longer than 30 minutes.
- C. The pain worsens when the patient raises the arms.
- D. The pain is relieved after the patient takes nitroglycerin.
Correct Answer: B
Rationale: Chest pain that lasts for 20 minutes or more is characteristic of an acute myocardial infarction. Changes in pain that occur with raising the arms or with deep breathing are more typical of pericarditis or musculoskeletal pain. Stable angina is usually relieved when the patient takes nitroglycerin.
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 with acute coronary syndrome who has returned to the coronary care unit after having percutaneous coronary intervention and the nurse obtains these assessment data. Which of the following data indicate the need for immediate intervention by the nurse?
- A. Pedal pulses 1+
- B. Heart rate 100 beats/minute
- C. Blood pressure 104/56 mm Hg
- D. Chest pain level 8 on a 10-point scale
Correct Answer: D
Rationale: The patient's chest pain indicates that restenosis of the coronary artery may be occurring and requires immediate actions, such as administration of oxygen and nitroglycerin, by the nurse. The other information indicates a need for ongoing assessments by the nurse.
To assist the patient with coronary artery disease (CAD) in making appropriate dietary changes, which of the following nursing interventions will be most effective?
- A. Instruct the patient that a diet containing no saturated fat and minimal sodium will be necessary.
- B. Emphasize the increased risk for cardiac problems unless the patient makes the dietary changes.
- C. Assist the patient to modify favourite high-fat recipes by using polyunsaturated oils when possible.
- D. Provide the patient with a list of low-sodium, low-cholesterol foods that should be included in the diet.
Correct Answer: C
Rationale: Lifestyle changes are more likely to be successful when consideration is given to the patient's values and preferences. The highest percentage of calories from fat should come from polyunsaturated fats. Although low-sodium and low-cholesterol foods are appropriate, providing the patient with a list alone is not likely to be successful in making dietary changes. Removing saturated fat from the diet completely is not a realistic expectation. Telling the patient about the increased risk without assisting further with strategies for dietary change is unlikely to be successful.
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.