Case Study (6/6):
Mr. James, a 58-year-old male, is admitted to the emergency department with complaints of severe chest pain that radiates to his left arm and jaw. He is also experiencing shortness of breath, diaphoresis (sweating), and nausea. His past medical history includes hypertension and hyperlipidemia. His ECG shows ST-segment elevation in leads II, III, and aVF. Troponin levels are elevated.
Question 1-6:
Which of the following nursing interventions is the priority for Mr. James?
A. Administer sublingual nitroglycerin and assess for pain relief.
B. Provide Mr. James with morphine for pain relief.
C. Prepare Mr. James for immediate percutaneous coronary intervention (PCI).
D. Administer aspirin and ensure oxygen is given at 2L/min via nasal cannula.
__________________
Question 2-6: Mr. James is given sublingual nitroglycerin to help manage his acute myocardial infarction (MI). What is the primary pharmacologic action of nitroglycerin in treating MI?
A. Nitroglycerin increases myocardial oxygen supply by dilating the coronary arteries.
B. Nitroglycerin decreases heart rate to reduce myocardial oxygen consumption.
C. Nitroglycerin increases blood pressure to improve coronary perfusion.
D. Nitroglycerin causes venous dilation, reducing preload and myocardial oxygen demand.
_______________
Question 3-6:
After administering sublingual nitroglycerin to Mr. James, the nurse needs to assess its effectiveness in treating his myocardial infarction (MI). Which of the following findings would indicate that the nitroglycerin is having the desired therapeutic effect?
A. Blood pressure increases by 20 mmHg, and heart rate decreases.
B. Mr. James reports that his chest pain has decreased, and his blood pressure is stable.
C. Mr. James develops a headache and reports dizziness.
D. Mr. James' respiratory rate increases, and he continues to experience chest pain.
_______________
Question 4-6:
Which statement by Mr. James indicates a need for further teaching about nitroglycerin use for his myocardial infarction?
A. "I will sit down before taking my nitroglycerin to avoid feeling dizzy or lightheaded."
B. "If I still have chest pain after taking one dose of nitroglycerin, I’ll wait 5 minutes and take another dose."
C. "If I have chest pain, I should take nitroglycerin and call 911 if the pain persists after the third dose."
D. "I’ll keep taking nitroglycerin daily to prevent chest pain even when I’m not having symptoms."
____________
Question 5-6:
Which statement by Mr. James demonstrates an understanding of lifestyle changes to prevent future myocardial infarctions (MIs) while using nitroglycerin?
A. "As long as I take nitroglycerin when I have chest pain, I don’t need to worry about changing my diet or exercise routine."
B. "I should stop taking my antihypertensive medication now that I have nitroglycerin to help with chest pain."
C. "I need to quit smoking, manage my blood pressure, and maintain a healthy diet to help prevent another heart attack."
D. "Using nitroglycerin before activities that cause chest pain means I can continue my same habits without worrying about my heart."
Question 6-6:
During the acute management of Mr. James, who is presenting with an acute myocardial infarction (MI), which of the following nursing interventions should be considered least priority in the initial treatment phase?
A. Administer anticoagulants as prescribed to prevent further clot formation.
B. Perform a thorough assessment of Mr. James’ pain level and its characteristics.
C. Initiate continuous cardiac monitoring to detect any arrhythmias or changes in cardiac status.
D. Review and explain the importance of lifestyle modifications for heart health.
____________
Answers:
1:D, 2:D, 3:B, 4:D, 5:C, 6:D
Explanations;
Question 1-6:
Correct Answer: D. Administer aspirin and ensure oxygen is given at 2L/min via nasal cannula.
### Explanation:
When a patient presents with symptoms of an acute myocardial infarction (MI), prompt interventions are crucial to minimize heart muscle damage.
- D. Administer aspirin and ensure oxygen is given at 2L/min via nasal cannula is the priority because aspirin helps reduce platelet aggregation and prevent further clot formation, while oxygen ensures adequate oxygenation to the myocardium, especially in the presence of ischemia. This step is vital in the early management of MI according to standard protocols like MONA (Morphine, Oxygen, Nitroglycerin, Aspirin), where aspirin and oxygen are typically given first.
- A. Administer sublingual nitroglycerin and assess for pain relief is important but not the first step. Nitroglycerin can help reduce the heart's oxygen demand by dilating coronary arteries, but ensuring that aspirin and oxygen are given promptly takes priority.
- B. Provide Mr. James with morphine for pain relief is part of the MI management plan but is not the immediate priority. Pain relief is essential, but it comes after administering aspirin and oxygen.
- C. Prepare Mr. James for immediate percutaneous coronary intervention (PCI) is essential for definitive treatment, especially in cases of ST-elevation myocardial infarction (STEMI), but the initial focus should be on stabilizing the patient with medications like aspirin and oxygen.
____________
Question 2-6:
Correct Answer: D. Nitroglycerin causes venous dilation, reducing preload and myocardial oxygen demand.
### Explanation:
Nitroglycerin works by dilating veins, which decreases the amount of blood returning to the heart (preload). This reduction in preload reduces the heart's workload and oxygen demand, which is essential during a myocardial infarction. Nitroglycerin can also dilate coronary arteries, improving oxygen delivery to the heart, but its primary benefit in MI is reducing the heart's oxygen needs.
- A. While nitroglycerin does increase coronary artery dilation, its primary action in reducing MI symptoms is through venous dilation and reducing oxygen demand.
- B. Nitroglycerin does not directly affect heart rate; beta-blockers are typically used for that purpose.
- C. Nitroglycerin does not increase blood pressure; it actually causes vasodilation, which can lower blood pressure.
___________
Question 3-6: Correct Answer: B. Mr. James reports that his chest pain has decreased, and his blood pressure is stable.
Explanation:
Nitroglycerin's primary goal in treating an acute MI is to reduce chest pain by decreasing myocardial oxygen demand through vasodilation. A reduction in chest pain and stable blood pressure are clear signs that the medication is working as intended.
- A. An increase in blood pressure is not an expected therapeutic effect of nitroglycerin. Nitroglycerin typically lowers blood pressure due to vasodilation.
- C. While headache and dizziness are common side effects of nitroglycerin due to vasodilation, these do not indicate therapeutic effectiveness. The desired outcome is pain relief and stable vital signs.
- D. An increased respiratory rate and ongoing chest pain suggest that the nitroglycerin has not been effective in relieving ischemic symptoms.
___________
Question 4-6: Correct Answer: D. "I’ll keep taking nitroglycerin daily to prevent chest pain even when I’m not having symptoms."
Explanation:
This statement indicates a need for further teaching, as nitroglycerin in this context is used as needed for acute chest pain (angina or MI symptoms). It should not be taken on a regular schedule unless specifically prescribed for chronic angina management. Sublingual nitroglycerin is typically used when symptoms occur or just before activities that may cause chest pain.
- A. Sitting down before taking nitroglycerin is appropriate because it helps prevent dizziness or lightheadedness due to a potential drop in blood pressure.
- B. This statement correctly reflects the proper timing of nitroglycerin dosing. The patient should wait 5 minutes before taking another dose if pain persists.
- C. Calling 911 if chest pain persists after three doses of nitroglycerin is correct, as it may indicate an ongoing myocardial infarction that requires emergency care.
____________
Question 5-6: Correct Answer: C. "I need to quit smoking, manage my blood pressure, and maintain a healthy diet to help prevent another heart attack."
### Explanation:
This statement reflects a correct understanding of the lifestyle changes that are essential for preventing future myocardial infarctions. Quitting smoking, controlling blood pressure, and following a heart-healthy diet are important measures that reduce the risk of further cardiac events. Nitroglycerin is for acute symptom relief but does not prevent heart attacks by itself.
- A. Relying solely on nitroglycerin without addressing lifestyle changes is incorrect. Diet and exercise play a critical role in heart health.
- B. Stopping antihypertensive medication would be harmful, as managing blood pressure is key to preventing future heart attacks.
- D. Nitroglycerin helps with symptoms but does not eliminate the need for lifestyle modifications to improve overall heart health.
_____________
Question 6-6: Correct Answer: D. Review and explain the importance of lifestyle modifications for heart health.
Explanation:
In the acute phase of managing a myocardial infarction, the focus is on immediate and critical interventions to stabilize the patient and address the ongoing cardiac event.
- A. Administer anticoagulants as prescribed to prevent further clot formation is crucial for managing the MI, as anticoagulants help prevent additional clotting and complications.
- B. Perform a thorough assessment of Mr. James’ pain level and its characteristics is essential for evaluating the effectiveness of pain management and determining the severity of the MI.
- C. Initiate continuous cardiac monitoring to detect any arrhythmias or changes in cardiac status is a priority to monitor the patient’s heart rhythm and detect any life-threatening arrhythmias.
- D. Review and explain the importance of lifestyle modifications for heart health is important for long-term prevention and management but is least priority in the initial treatment phase. Immediate interventions to manage the acute MI take precedence over education about lifestyle changes.
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