Exam #2-ACS/MI
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.
Ans: A Feedback: 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 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
Ans: A, B, D Feedback: 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.
An adult patient is admitted to the ED with chest pain. The patient states that he had developed unrelieved chest pain that was present for approximately 20 minutes before coming to the hospital. To minimize cardiac damage, the nurse should expect to administer which of the following interventions? A) Thrombolytics, oxygen administration, and nonsteroidal anti-inflammatories B) Morphine sulphate, oxygen, and bed rest C) Oxygen and beta-adrenergic blockers D) Bed rest, albuterol nebulizer treatments, and oxygen
Ans: B Feedback: The patient with suspected MI should immediately receive supplemental oxygen, aspirin, nitroglycerin, and morphine. Morphine sulphate reduces preload and decreases workload of the heart, along with increased oxygen from oxygen therapy and bed rest. With decreased cardiac demand, this provides the best chance of decreasing cardiac damage. NSAIDs and beta-blockers are not normally indicated. Albuterol, which is a medication used to manage asthma and respiratory conditions, will increase the heart rate.
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.
Ans: B Feedback: 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 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
Ans: B Feedback: 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.
Family members bring a patient to the ED with pale cool skin, sudden midsternal chest pain unrelieved with rest, and a history of CAD. How should the nurse best interpret these initial data? A) The symptoms indicate angina and should be treated as such. B) The symptoms indicate a pulmonary etiology rather than a cardiac etiology. C) The symptoms indicate an acute coronary episode and should be treated as such. D) Treatment should be determined pending the results of an exercise stress test.
Ans: C Feedback: Angina and MI have similar symptoms and are considered the same process, but are on different points along a continuum. That the patients symptoms are unrelieved by rest suggests an acute coronary episode rather than angina. Pale cool skin and sudden onset are inconsistent with a pulmonary etiology. Treatment should be initiated immediately regardless of diagnosis.
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
Ans: C Feedback: 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.
The nurse is participating in the care conference for a patient with ACS. What goal should guide the care teams selection of assessments, interventions, and treatments? A) Maximizing cardiac output while minimizing heart rate B) Decreasing energy expenditure of the myocardium C) Balancing myocardial oxygen supply with demand D) Increasing the size of the myocardial muscle
Ans: C Feedback: Balancing myocardial oxygen supply with demand (e.g., as evidenced by the relief of chest pain) is the top priority in the care of the patient with ACS. Treatment is not aimed directly at minimizing heart rate because some patients experience bradycardia. Increasing the size of the myocardium is never a goal. Reducing the myocardiums energy expenditure is often beneficial, but this must be balanced with productivity.
3. The client is complaining of severe chest pain radiating down the left arm and is nauseated and diaphoretic. The HCP suspects the client is having a myocardial infarction (MI) and has ordered morphine sulfate (MS), a narcotic analgesic, for the pain. Which interventions should the nurse implement? Select all that apply. Instruct the client not to get up out of the bed without notifying the nurse. Administer the morphine sulfate (MS) intramuscularly in the ventral gluteal muscle. Dilute the morphine sulfate (MS) to a 10-mL bolus with normal saline. Administer the morphine sulfate (MS) slowly over 5 minutes. Question the order because morphine sulfate (MS) should not be administered to a client with a myocardial infarction (MI).
Instruct the client not to get up out of the bed without notifying the nurse. Dilute the morphine sulfate (MS) to a 10-mL bolus with normal saline. Administer the morphine sulfate (MS) slowly over 5 minutes. The client should not get out of the bed without assistance due to the drowsiness the client will experience after receiving MS. Also, the client is having chest pain and should not get out of the bed without assistance Morphine sulfate is the drug of choice for chest pain, and it is administered intravenously so that it acts as soon as possible, within 10-15 minutes. Intravenous push medications should be diluted to help decrease the pain when it is administered and to prevent irritation to the vein. An intravenous push also allows the nurse to inject the medication more accurately over the 5-minute administration time.
A patient with an MI is exhibiting anxiety while being taught about possible lifestyle changes. The nurse evaluates that the anxiety is relieved when the patient states a. "I'm going to take this recovery one step at a time." b. "I feel much better and am ready to get on with my life." c. "How soon do you think I will be able to go back to work?" d. "I know you are doing everything possible to save my life."
. a. This patient is indicating positive coping with a realization that recovery takes time and that lifestyle changes can be made as needed. The patient who is "just going to get on with life" is probably in denial about the seriousness of the condition and the changes that need to be made. Nervous questioning about the expected duration and effect of the condition indicates the presence of anxiety, as does the statement regarding the health care professional's role in treatment.
Prior to administering tissue plasminogen activator (t-PA), the nurse should assess the client for which of the following contradictions to administering the drug? 1. Age greater than 60 years. 2. History of cerebral hemorrhage. 3. History of heart failure. 4. Cigarette smoking.
2. A history of cerebral hemorrhage is a contraindication to administration of t-PA because the risk of hemorrhage may be further increased. Age greater than 60 years, history of heart failure, and cigarette smoking are not contraindications.
A client has driven himself to the emergency department. He is 50 years old, has a history of hypertension, and informs the nurse that his father died from a heart attack at age 60. The client has indigestion. The nurse connects him to an electrocardiogram monitor and begins administering oxygen at 2 L/min per nasal cannula. The nurse's next action should be to: 1. Call for the physician. 2. Start an IV infusion. 3. Obtain a portable chest radiograph. 4. Draw blood for laboratory studies.
2. Advanced cardiac life support recommends that at least one or two IV lines be inserted in one or both of the antecubital spaces. Calling the physician, obtaining a portable chest radiograph, and drawing blood for the laboratory are important but secondary to starting the IV line.
A client with chest pain is prescribed intravenous nitroglycerin. Which assessment is of greatest concern for the nurse initiating the nitroglycerin drip? 1. Serum potassium is 3.5 mEq/L (3.5 mmol/L). 2. Blood pressure is 88/46. 3. ST elevation is present on the electrocardiogram. 4. Heart rate is 61.
2. Nitroglycerin is a vasodilator that will lower blood pressure. The client is having chest pain and the ST elevation indicates injury to the myocardium, which may benefit from nitroglycerin. The potassium and heart rate are within normal range
When administering a thrombolytic drug to the client who is experiencing a myocardial infarction (MI) and who has premature ventricular contractions, the expected outcome of the drug is to: 1. Promote hydration. 2. Dissolve clots. 3. Prevent kidney failure. 4. Treat dysrhythmias.
2. Thrombolytic drugs are administered within the first 6 hours after onset of an MI to lyse clots and reduce the extent of myocardial damage.
Which of the following is an expected outcome for a client on the second day of hospitalization after a myocardial infarction (MI)? The client: 1. Continues to have severe chest pain. 2. Can identify risk factors for MI. 3. Participates in a cardiac rehabilitation walking program. 4. Can perform personal self-care activities without pain.
4. By day 2 of hospitalization after an MI, clients are expected to be able to perform personal care without chest pain. Severe chest pain should not be present on day 2 after an MI. Day 2 of hospitalization may be too soon for clients to be able to identify risk factors for MI or to begin a walking program; however, the client may be sitting up in a chair as part of the cardiac rehabilitation program
A client has chest pain rated at 8 on a 10-point visual analog scale. The 12-lead electrocardiogram reveals ST elevation in the inferior leads and troponin levels are elevated. What is the highest priority for nursing management of this client at this time? 1. Monitor daily weights and urine output. 2. Permit unrestricted visitation by family and friends. 3. Provide client education on medications and diet. 4. Reduce pain and myocardial oxygen demand.
4. Nursing management for a client with a myocardial infarction should focus on pain management and decreasing myocardial oxygen demand. Fluid status should be closely monitored. Client education should begin once the client is stable and amenable to teaching. Visitation should be based on client comfort and maintaining a calm environment.
Alteplase recombinant, or tissue plasminogen activator (t-PA), a thrombolytic enzyme, is administered during the first 6 hours after onset of myocardial infarction (MI) to: 1. Control chest pain. 2. Reduce coronary artery vasospasm. 3. Control the arrhythmias associated with MI. 4. Revascularize the blocked coronary artery.
4. The thrombolytic agent t-PA, administered intravenously, lyses the clot blocking the coronary artery. The drug is most effective when administered within the first 6 hours after onset of MI. The drug does not reduce coronary artery vasospasm; nitrates are used to promote vasodilation. Arrhythmias are managed by antiarrhythmic drugs. Surgical approaches are used to open the coronary artery and re-establish a blood supply to the area.
The nurse is working with a patient who had an MI and is now active in rehabilitation. The nurse should teach this patient to cease activity if which of the following occurs? A) The patient experiences chest pain, palpitations, or dyspnea. B) The patient experiences a noticeable increase in heart rate during activity. C) The patients oxygen saturation level drops below 96%. D) The patients respiratory rate exceeds 30 breaths/min.
Ans: A Feedback: Any activity or exercise that causes dyspnea and chest pain should be stopped in the patient with CAD. Heart rate must not exceed the target rate, but an increase above resting rate is expected and is therapeutic. In most patients, a respiratory rate that exceeds 30 breaths/min is not problematic. Similarly, oxygen saturation slightly below 96% does not necessitate cessation of activity.
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)
Ans: A Feedback: 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.
6. The client diagnosed with a myocardial infarction is receiving thrombolytic therapy. Which data warrants immediate intervention by the nurse? The client's telemetry has reperfusion dysrhythmias. The client is oozing blood from the intravenous site. The client is alert and oriented to date, time, and place. The client has no signs of infiltration at the insertion site.
Any bleeding from the intravenous site, gums, rectum, or vagina should be reported to the HCP. The HCP may not be able to take intervention to prevent the bleeding during therapy, but it warrants notifying the HCP.
9. The client calls the clinic and says, "I am having chest pain. I think I am having another heart attack." Which intervention should the nurse implement first? Call 911 emergency medical services. Instruct the client to take an aspirin. Determine if the client is at home alone. Ask if the client has any sublingual nitroglycerin.
Because the client has had one myocardial infarction, the client may have sublingual nitroglycerin in a pocket and can take it immediately. If the client does not have any on the body, then the nurse should determine if there is anyone in the home that can help the client.
2. The nurse is preparing to administer nitroglycerin, a coronary vasodilator transdermal patch, to the client diagnosed with a myocardial infarction. Which intervention should the nurse implement? Question applying the patch if the client's BP is less than 110/70. Use nonsterile gloves when applying the transdermal patch. Date and time the transdermal patch prior to applying to client's skin. Place the transdermal patch on the site where the old patch was removed.
Date and time the transdermal patch prior to applying to client's skin. The nurse should remove the old patch, wash the client's skin, note the date and time the new patch is applied, and apply it in a new area that is not hairy.
The nurse is administering 0900 medications to the following clients. Which client should the nurse question administering the medication? The client receiving a calcium channel blocker who drank a glass of grapefruit juice. The client receiving a beta blocker who has an apical pulse of 62 beats per minute. The client receiving a nitroglycerin patch who has a blood pressure of 148/92. The client receiving an antiplatelet medication who has a platelet count of 150,000.
The client receiving a calcium channel blocker (CCB) should avoid grapefruit juice because it can cause the CCB to rise to toxic levels.
8. The client being discharged after sustaining an acute myocardial infarction is prescribed the ACE inhibitor lisinopril (Zestril). Which instruction should the nurse include when teaching about this medication? Instruct the client to monitor the blood pressure weekly. Encourage the client to take medication on an empty stomach. Discuss the need to rise slowly from lying to a standing position. Teach the client to take the medication at night only.
This medication causes orthostatic hypotension, and the client should be instructed to rise slowly from lying to sitting to standing position to prevent falls and injury.
The nurse and patient set a patient outcome that at the time of discharge after an MI the patient will be able to tolerate moderate-energy activities that are similar to which activity? a. Golfing c. Cycling at 13 mph b. Walking at 5 mph d. Mowing the lawn by hand
a. Golfing is a moderate-energy activity that expends about 5 metabolic equivalent units (METs) and is within the 3 to 5 METs activity level desired for a patient by the time of discharge from the hospital following an MI. Walking at 5 mph and mowing the lawn by hand are high-energy activities and cycling at 13 mph is an extremely high-energy activity
The nurse recognizes that thrombolytic therapy for the treatment of an MI has not been successful when the patient displays which manifestation? a. Continues to have chest pain b. Has a marked increase in CK enzyme levels within 3 hours of therapy c. Develops major gastrointestinal (GI) or genitourinary (GU) bleeding during treatment d. Develops premature ventricular contractions and ventricular tachycardia during treatment
a. If chest pain is unchanged, it is an indication that reperfusion was not successful. Indications that the occluded coronary artery is patent and blood flow to the myocardium is reestablished following thrombolytic therapy include return of ST segment to baseline on the ECG; relief of chest pain; marked, rapid rise of the CK enzyme within 3 hours of therapy; and the presence of reperfusion dysrhythmias.
When the patient who is diagnosed with an MI is not relieved of chest pain with IV nitroglycerin, which medication will the nurse expect to be used? a. IV morphine sulfate c. IV amiodarone (Cordarone) b. Calcium channel blockers d. Angiotensin-converting enzyme (ACE) inhibitors
a. Morphine sulfate decreases anxiety and cardiac workload as a vasodilator and reduces preload and myocardial O2 consumption, which relieves chest pain. Calcium channel blockers, amiodarone, and ACE inhibitors will not relieve chest pain related to an MI
Myocardial ischemia occurs as a result of increased oxygen demand and decreased oxygen supply. What factors and disorders result in increased oxygen demand (select all that apply)? a. Hypovolemia or anemia b. Increased cardiac workload with aortic stenosis c. Narrowed coronary arteries from atherosclerosis d. Angina in the patient with atherosclerotic coronary arteries e. Left ventricular hypertrophy caused by chronic hypertension f. Sympathetic nervous system stimulation by drugs, emotions, or exertion
b, d, e, f. Increased oxygen demand is caused by increasing the workload of the heart, including left ventricular hypertrophy with hypertension, sympathetic nervous stimulation, and anything precipitating angina. Hypovolemia, anemia, and narrowed coronary arteries contribute to decreased oxygen supply.
During the assessment, the nurse identifies crackles in the lungs and an S3 heart sound. Which complication of MI should the nurse suspect and further investigate? a. Pericarditis c. Ventricular aneurysm b. Heart failure d. Papillary muscle dysfunction
b. Heart failure, which can escalate to cardiogenic shock, initially occurs with mild dyspnea, restlessness, agitation, pulmonary congestion with crackles, S3 or S4 heart sounds, and jugular vein distention. Pericarditis is a common complication identified with chest pain that is aggravated by inspiration, coughing, and moving the upper body. Ventricular aneurysm is manifested with heart failure, dysrhythmias, and angina. Papillary muscle dysfunction is suspected with a new systolic apical murmur.
The patient has hypertension and just experienced an MI. Which type of medication would be expected to be added to decrease the workload on his heart? a. ACE inhibitor c. Calcium channel blocker b. β-adrenergic blocker d. Angiotensin II receptor blocker (ARB)
b. It is recommended that patients with hypertension and after an MI be on β-adrenergic blockers indefinitely to decrease oxygen demand. They inhibit sympathetic nervous stimulation of the heart; reduce heart rate, contractility, and blood pressure; and decrease afterload. Although calcium channel blockers decrease heart rate, contractility, and blood pressure, they are not used unless the patient cannot tolerate β-adrenergic blockers. ACE inhibitors and angiotensin II receptor blockers (ARBs) are used for vasodilation.
In planning care for a patient who has just returned to the unit following a PCI, the nurse may delegate which activity to unlicensed assistive personnel (UAP)? a. Monitor the IV fluids and measure urine output. b. Check vital signs and report changes in HR, BP, or pulse oximetry. c. Explain to the patient the need for frequent vital signs and pulse checks. d. Assess circulation to the extremity used by checking pulses, skin temperature, and color.
b. Unlicensed assistive personnel (UAP) can check vital signs and report results to the RN. The other actions include assessment, teaching, and monitoring of IV fluids, which are all responsibilities of the RN
What are manifestations of acute coronary syndrome (ACS) (select all that apply)? a. Dysrhythmia b. Stable angina c. Unstable angina d. ST-segment-elevation myocardial infarction (STEMI) e. Non-ST-segment-elevation myocardial infarction (NSTEMI)
c, d, e. Unstable angina, ST-segment-elevation myocardial infarction (STEMI), and non-ST-segment-elevation myocardial infarction (NSTEMI) are conditions that are manifestations of acute coronary syndrome (ACS). The other options are not manifestations of ACS.
A second 12-lead ECG performed on a patient 4 hours after the onset of chest pain reveals ST segment elevation. What does the nurse recognize that this finding indicates? a. Transient ischemia typical of unstable angina b. Lack of permanent damage to myocardial cells c. MI associated with prolonged and complete coronary thrombosis d. MI associated with transient or incomplete coronary artery occlusion
c. A differentiation is made between MIs that have ST segment elevations on ECG and those that do not because chest pain accompanied by ST segment elevations is associated with prolonged and complete coronary thrombosis and is treated with reperfusion therapy. The other options are incorrect
During treatment with reteplase (Retavase) for a patient with a STEMI, which finding should most concern the nurse? a. Oozing of blood from the IV site b. BP of 102/60 mm Hg with an HR of 78 bpm c. Decrease in the responsiveness of the patient d. Presence of intermittent accelerated idioventricular dysrhythmias
c. Decreasing level of consciousness (LOC) may reflect hypoxemia resulting from internal bleeding, which is always a risk with thrombolytic therapy. Oozing of blood is expected, as are reperfusion dysrhythmias. BP is low but not considered abnormal because the pulse is within normal range.
What is the rationale for using docusate sodium (Colace) for a patient after an MI? a. Controls ventricular dysrhythmias c. Minimizes bradycardia from vagal stimulation b. Relieves anxiety and cardiac workload d. Prevents the binding of fibrinogen to platelets
c. Docusate sodium (Colace) is a stool softener, which prevents straining and provoking dysrhythmias. It does not do any of the other options. Antidysrhythmics are used to control ventricular dysrhythmias; morphine sulfate is used to decrease cardiac workload and anxiety; and glycoprotein IIb/IIIa inhibitors and antiplatelets prevent the binding of fibrinogen to platelets.
To detect and treat the most common complication of MI, what should the nurse do? a. Measure hourly urine output. c. Use continuous cardiac monitoring. b. Auscultate the chest for crackles. d. Take vital signs every 2 hours for the first 8 hours.
c. The most common complication of MI is cardiac dysrhythmias. Continuous cardiac monitoring allows identification and treatment of dysrhythmias that may cause further deterioration of the cardiovascular status or death. Measurement of hourly urine output and vital signs is indicated to detect symptoms of the complication of cardiogenic shock. Crackles, dyspnea, and tachycardia may indicate the onset of heart failure.
Which statement indicates the patient is experiencing anger as the psychologic response to his acute MI? a. "Yes, I'm having a little chest pain. It's no big deal." b. "I don't think I can take care of myself at home yet." c. "What's going to happen if I have another heart attack?" d. "I hope my wife is happy now after harping at me about my eating habits all these years."
d. Anger about the MI may be directed at family, staff, or the medical regimen. Stating that the chest pain is no big deal is denial. Relaying an inability to care for self relates to dependency. Questioning what will happen if there is another attack is expressing anxiety and fear. Depression may be expressed related to changes in lifestyle. Realistic acceptance is seen with actively engaging in changing modifiable risk factors.
After the administration of t-PA, the nurse should: 1. Observe the client for chest pain. 2. Monitor for fever. 3. Review the 12-lead electrocardiogram (ECG). 4. Auscultate breath sounds
1. Although monitoring the 12-lead ECG and monitoring breath sounds are important, observing the client for chest pain is the nursing assessment priority because closure of the previously obstructed coronary artery may recur. Clients who receive t-PA frequently receive heparin to prevent closure of the artery after administration of t-PA. Careful assessment for signs of bleeding and monitoring of partial thromboplastin time are essential to detect complications. Administration of t-PA should not cause fever.
A 60-year-old comes into the emergency department with crushing substernal chest pain that radiates to the shoulder and left arm. The admitting diagnosis is acute myocardial infarction (MI). Admission prescriptions include oxygen by nasal cannula at 4 L/min, complete blood count (CBC), a chest radiograph, a 12-lead electrocardiogram (ECG), and 2 mg of morphine sulfate given IV. The nurse should first: 1. Administer the morphine. 2. Obtain a 12-lead ECG. 3. Obtain the blood work. 4. Prescribe the chest radiograph.
1. Although obtaining the ECG, chest radiograph, and blood work are all important, the nurse's priority action should be to relieve the crushing chest pain. Therefore, administering morphine sulfate is the priority action.
The nurse is caring for a client diagnosed with an anterior myocardial infarction 2 days ago. Upon assessment, the nurse identifies a systolic murmur at the apex. The nurse should first: 1. Assess for changes in vital signs. 2. Draw an arterial blood gas. 3. Evaluate heart sounds with the client leaning forward. 4. Obtain a 12-lead electrocardiogram.
1. Infarction of the papillary muscles is a potential complication of an MI causing ineffective closure of the mitral valve during systole. Mitral regurgitation results when the left ventricle contracts and blood flows backward into the left atrium, which is heard at the fifth intercostal space, left midclavicular line. The murmur worsens during expiration and in the supine or left-side position. Vital sign changes will reflect the severity of the sudden drop in cardiac output: decrease in blood pressure, increase in heart rate, and increase in respirations. A 12-lead ECG views the electrical activity of the heart; an echocardiogram views valve function.
Which of the following symptoms should the nurse teach the client with unstable angina to report immediately to the physician? 1. A change in the pattern of the chest pain. 2. Pain during sexual activity. 3. Pain during an argument. 4. Pain during or after a physical activity.
1. The client should report a change in the pattern of chest pain. It may indicate increasing severity of coronary artery disease. Pain occurring during stress or sexual activity would not be unexpected, and the client may be instructed to take nitroglycerin to prevent this pain. Pain during or after an activity such as lawn mowing also would not be unexpected; the client may be instructed to take nitroglycerin to prevent this pain or may be restricted from doing such activities.
The ED nurse is caring for a patient with a suspected MI. What drug should the nurse anticipate administering to this patient? A) Oxycodone B) Warfarin C) Morphine D) Acetaminophen
Ans: C Feedback: The patient with suspected MI is given aspirin, nitroglycerin, morphine, an IV beta- blocker, and other medications, as indicated, while the diagnosis is being confirmed. Tylenol, warfarin, and oxycodone are not typically used.
What advice about sexual activity should the nurse give to a male patient who has had an MI? a. The patient should use the superior position. b. Foreplay may cause too great an increase in heart rate. c. Prophylactic nitroglycerin may be used if angina occurs. d. Performance can be enhanced with the use of sildenafil (Viagra).
c. It is not uncommon for a patient who experiences chest pain on exertion to have some angina during sexual stimulation or intercourse and the patient should be instructed to use nitroglycerin prophylactically. Positions ANSWERS TO WORKSHEETS 379 Copyright © 2014 by Mosby, an imprint of Elsevier Inc. All rights reserved. during intercourse are a matter of individual choice and foreplay is desirable because it allows a gradual increase in HR. Sildenafil (Viagra) should be used cautiously in men with CAD and should not be used with nitrates.
A 52-year-old man is admitted to the emergency department with severe chest pain. On what basis would the nurse suspect an MI? a. He has pale, cool, clammy skin. b. He reports nausea and vomited once at home. c. He says he is anxious and has a feeling of impending doom. d. He reports he has had no relief of the pain with rest or position change.
d. The subjective report of the pain from an MI is usually severe. It usually is unrelieved by nitroglycerin, rest, or position change and usually lasts more than the 15 or 20 minutes typical of angina pain. All of the other symptoms may occur with angina as well as with an MI.
The patient has used sublingual nitroglycerin and various long-acting nitrates but now has an ejection fraction of 38% and is considered at a high risk for a cardiac event. Which medication would first be added for vasodilation and to reduce ventricular remodeling? a. Clopidogrel (Plavix) c. Diltiazem (Cardizem) b. Captopril (Capoten) d. Metoprolol (Lopressor)
. b. Captopril (Capoten) would be added. It is an angiotensinconverting enzyme (ACE) inhibitor that vasodilates and decreases endothelial dysfunction and may prevent ventricular remodeling. Clopidogrel (Plavix) is an antiplatelet agent used as an alternative for a patient unable to use aspirin. Diltiazem (Cardizem), a calcium channel blocker, may be used to decrease vasospasm but is not known to prevent ventricular remodeling. Metoprolol (Lopressor) is a β-adrenergic blocker that inhibits sympathetic nervous stimulation of the heart.
When monitoring a client who is receiving tissue plasminogen activator (t-PA), the nurse should have resuscitation equipment available because reperfusion of the cardiac tissue can result in which of the following? 1. Cardiac arrhythmias. 2. Hypertension. 3. Seizure. 4. Hypothermia
1. Cardiac arrhythmias are commonly observed with administration of t-PA. Cardiac arrhythmias are associated with reperfusion of the cardiac tissue. Hypotension is commonly observed with administration of t-PA. Seizures and hypothermia are not generally associated with reperfusion of the cardiac tissue.
A 68-year-old client on day 2 after hip surgery has no cardiac history but reports having chest heaviness. The first nursing action should be to: 1. Inquire about the onset, duration, severity, and precipitating factors of the heaviness. 2. Administer oxygen via nasal cannula. 3. Offer pain medication for the chest heaviness. 4. Inform the physician of the chest heaviness.
1. Further assessment is needed in this situation. It is premature to initiate other actions until further data have been gathered. Inquiring about the onset, duration, location, severity, and precipitating factors of the chest heaviness will provide pertinent information to convey to the physician.
The physician prescribes continuous IV nitroglycerin infusion for the client with myocardial infarction. The nurse should: 1. Obtain an infusion pump for the medication. 2. Take the blood pressure every 4 hours. 3. Monitor urine output hourly. 4. Obtain serum potassium levels daily.
1. IV nitroglycerin infusion requires an infusion pump for precise control of the medication. Blood pressure monitoring would be done with a continuous system, and more frequently than every 4 hours. Hourly urine outputs are not always required. Obtaining serum potassium levels is not associated with nitroglycerin infusio
A 48-year-old man presents to the ED complaining of severe substernal chest pain radiating down his left arm. He is admitted to the coronary care unit (CCU) with a diagnosis of myocardial infarction (MI). What nursing assessment activity is a priority on admission to the CCU? A) Begin ECG monitoring. B) Obtain information about family history of heart disease. C) Auscultate lung fields. D) Determine if the patient smokes.
Ans: A Feedback: The 12-lead ECG provides information that assists in ruling out or diagnosing an acute MI. It should be obtained within 10 minutes from the time a patient reports pain or arrives in the ED. By monitoring serial ECG changes over time, the location, evolution, and resolution of an MI can be identified and monitored; life-threatening arrhythmias are the leading cause of death in the first hours after an MI. Obtaining information about family history of heart disease and whether the patient smokes are not immediate priorities in the acute phase of MI. Data may be obtained from family members later. Lung fields are auscultated after oxygenation and pain control needs are met.
A patient presents to the ED in distress and complaining of crushing chest pain. What is the nurses priority for assessment? A) Prompt initiation of an ECG B) Auscultation of the patients point of maximal impulse (PMI) Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 538 C) Rapid assessment of the patients peripheral pulses D) Palpation of the patients cardiac apex
Ans: A Feedback: The 12-lead ECG provides information that assists in ruling out or diagnosing an acute MI. It should be obtained within 10 minutes from the time a patient reports pain or arrives in the ED. Each of the other listed assessments is valid, but ECG monitoring is the most time dependent priority.
A client with acute chest pain is receiving IV morphine sulfate. Which of the following results are intended effects of morphine? Select all that apply. 1. Reduces myocardial oxygen consumption. 2. Promotes reduction in respiratory rate. 3. Prevents ventricular remodeling. 4. Reduces blood pressure and heart rate. 5. Reduces anxiety and fear.
1, 4, 5. Morphine sulfate acts as an analgesic and sedative. It also reduces myocardial oxygen consumption, blood pressure, and heart rate. Morphine also reduces anxiety and fear due to its sedative effects and by slowing the heart rate. It can depress respirations; however, such an effect may lead to hypoxia, which should be avoided in the treatment of chest pain. Angiotensin-converting enzyme-inhibitor drugs, not morphine, may help to prevent ventricular remodeling.
The nurse is caring for a client who recently experienced a myocardial infarction and has been started on clopidogrel (Plavix). The nurse should develop a teaching plan that includes which of the following points? Select all that apply. 1. The client should report unexpected bleeding or bleeding that lasts a long time. 2. The client should take Plavix with food. 3. The client may bruise more easily and may experience bleeding gums. 4. Plavix works by preventing platelets from sticking together and forming a clot. 5. The client should drink a glass of water after taking Plavix.
1, 3, 4. Plavix is generally well absorbed and may be taken with or without food; it should be taken at the same time every day and, while food may help prevent potential GI upset, food has no effect on absorption of the drug. Bleeding is the most common adverse effect of Plavix; the client must understand the importance of reporting any unexpected, prolonged, or excessive bleeding including blood in urine or stool. Increased bruising and bleeding gums are possible side effects of Plavix; the client should be aware of this possibility. Plavix is an antiplatelet agent used to prevent clot formation in clients that have experienced or are at risk for myocardial infarction, ischemic stroke, peripheral artery disease, or acute coronary syndrome. It is not necessary to drink a glass of water after taking Plavix.
client is admitted with a myocardial infarction and atrial fibrillation. While auscultating the heart, the nurse notes an irregular heart rate and hears an extra heart sound at the apex after the S2 that remains constant throughout the respiratory cycle. The nurse should document these findings as: 1. Heart rate irregular with S3. 2. Heart rate irregular with S4. 3. Heart rate irregular with aortic regurgitation. 4. Heart rate irregular with mitral stenosis.
1. An S3 heart sound occurs early in diastole as the mitral and tricuspid valves open and blood rushes into the ventricles. To distinguish an S3 from a physiologic S2 split, a split S2 occurs during inspiration and S3 remains constant during the respiratory cycle. Its pitch is softer and best heard with the bell at the apex and it is one of the first clinical findings in left ventricular failure. An S4 is heard in late diastole when atrial contraction pumps volume into a stiff, noncompliant ventricle. An S4 is not heard in a client with atrial fibrillation because there is no atrial contraction. Murmurs are sounds created by turbulent blood flow through an incompetent or stenotic valve.
The nurse working on the coronary care unit is caring for a patient with ACS. How can the nurse best meet the patients psychosocial needs? A) Reinforce the fact that treatment will be successful. B) Facilitate a referral to a chaplain or spiritual leader. C) Increase the patients participation in rehabilitation activities. D) Directly address the patients anxieties and fears.
Ans: D Feedback: Alleviating anxiety and decreasing fear are important nursing functions that reduce the sympathetic stress response. Referrals to spiritual care may or may not be appropriate, and this does not relieve the nurse of responsibility for addressing the patients psychosocial needs. Treatment is not always successful, and false hope should never be fostered. Participation in rehabilitation may alleviate anxiety for some patients, but it may exacerbate it for others.
An ED nurse is assessing an adult woman for a suspected MI. When planning the assessment, the nurse should be cognizant of what signs and symptoms of MI that are particularly common in female patients? Select all that apply. A) Shortness of breath B) Chest pain C) Anxiety D) Numbness E) Weakness
Ans: D, E Feedback: Although these symptoms are not wholly absent in men, many women have been found to have atypical symptoms of MI, including indigestion, nausea, palpitations, and numbness. Shortness of breath, chest pain, and anxiety are common symptoms of MI among patients of all ages and genders.
A patient is hospitalized after a successful resuscitation of an episode of sudden cardiac death (SCD). During the care of the patient, what nursing intervention is most important? a. Continuous ECG monitoring c. Frequent assessment of heart sounds b. Auscultation of the carotid arteries d. Monitoring of airway status and respiratory patterns
a. Most patients who experience sudden cardiac death (SCD) as a result of CAD do not have an acute MI but have dysrhythmias that cause death, probably as a result of electrical instability of the myocardium. To identify and treat those specific dysrhythmias, continuous monitoring is important. The other assessments can be done but are not the most important after an episode of SCD.
In counseling the patient about sexual activity following an MI, what should the nurse do? a. Wait for the patient to ask about resuming sexual activity b. Discuss sexual activity while teaching about other physical activity c. Have the patient ask the health care provider when sexual activity can be resumed d. Inform the patient that impotence is a common long-term complication following MI
b. Resumption of sexual activity is often difficult for patients to approach and it is reported that most cardiac patients do not resume sexual activity after MI. The nurse can give the patient permission to discuss concerns about sexual activity by introducing it as a physical activity when other physical activities are discussed. Health care providers may have preferences regarding the timing of resumption of sexual activity and the nurse should discuss this with the health care provider and the patient but addressing the patient's concerns is a nursing responsibility. Patients should be informed that impotence after MI is common but that it usually disappears after several attempts
At what point in the healing process of the myocardium following an infarct does early scar tissue result in an unstable heart wall? a. 2 to 3 days after MI c. 10 to 14 days after MI b. 4 to 10 days after MI d. 6 weeks after MI
c. At 10 to 14 days after MI, the myocardium is considered especially vulnerable to increased stress because of the unstable state of healing at this point, as well as the increasing physical activity of the patient. At 2 to 3 days, removal of necrotic tissue is taking place by phagocytic cells. By 4 to 10 days, the necrotic tissue has been cleared and a collagen matrix for scar tissue has been deposited. Healing with scar-tissue replacement of the necrotic area is usually complete by 6 weeks.
Collaborative care of the patient with NSTEMI differs from that of a patient with STEMI in that NSTEMI is more frequently initially treated with what? a. PCI c. Acute intensive drug therapy b. CABG d. Reperfusion therapy with thrombolytics
c. Because an NSTEMI is an acute coronary syndrome that indicates a transient thrombosis or incomplete coronary artery occlusion, treatment involves intensive drug therapy with antiplatelets, glycoprotein IIb/IIIa inhibitors, antithrombotics, and heparin to prevent clot extension. In addition, IV nitroglycerin is used. Reperfusion therapy using thrombolytics, CABG, or PCI is used for treatment of STEMI
What causes the pain that occurs with myocardial ischemia? a. Death of myocardial tissue b. Dysrhythmias caused by cellular irritability c. Lactic acid accumulation during anaerobic metabolism d. Elevated pressure in the ventricles and pulmonary vessels
c. When the coronary arteries are occluded, contractility ceases after several minutes, depriving the myocardial cells of glucose and oxygen for aerobic metabolism. Anaerobic metabolism begins and lactic acid accumulates, irritating myocardial nerve fibers that then transmit a pain message to the cardiac nerves and upper thoracic posterior roots. The other factors may occur during vessel occlusion but are not the source of pain.
In the patient with chest pain, which results can differentiate unstable angina from an MI? a. ECG changes present at the onset of the pain b. A chest x-ray indicating left ventricular hypertrophy c. Appearance of troponin in the blood 48 hours after the infarct d. Creatine kinase (CK)-MB enzyme elevations that peak 18 hours after the infarct
d. Creatine kinase-muscle and brain subunits band (CKMB) is a tissue enzyme that is specific to cardiac muscle and is released into the blood when myocardial cells die. CK-MB levels begin to rise about 6 hours after an acute MI, peak in about 18 hours, and return to normal within 24 to 36 hours. This increase can identify the presence of and quantify myocardiac damage. Cardiac troponin T and troponin I are released with myocardial damage, rise as quickly as CK-MB does, and remain elevated for 2 weeks. ECG changes are often not apparent immediately after infarct and may be normal when the patient seeks medical attention. An enlarged heart, determined by x-ray, indicates cardiac stress but is not diagnostic of acute MI.
