A client admitted to the Emergency Department with a suspected STEM. The nurse anticipates that this client will be immediately prepared for the cardiac catheterization laboratory as the goal of treatment is to:

Measure heart chamber pressures to assess for heart failure

Determine cardiac output during the procedure.

Evaluate the extent of the occlusion of the coronary arteries involved

Prevent extensive myocardial damage

Answer and Explanation

The Correct Answer is D

A) Measure heart chamber pressures to assess for heart failure:
Measuring heart chamber pressures is an important diagnostic tool in assessing heart failure, but it is not the primary goal in the case of a STEMI (ST-Elevation Myocardial Infarction). In STEMI, the primary goal is to identify and treat the blockage in the coronary arteries that is causing the heart attack.

B) Determine cardiac output during the procedure:
Cardiac output is a useful measurement for assessing heart function, but it is not the main focus during the treatment of STEMI. While monitoring cardiac output may be part of the overall care, the urgent priority in STEMI management is to restore blood flow to the affected myocardial tissue as quickly as possible to minimize damage, not to measure cardiac output.

C) Evaluate the extent of the occlusion of the coronary arteries involved:
While evaluating the extent of coronary artery occlusion is part of the process during a cardiac catheterization, the immediate priority for a patient with STEMI is to treat the blockage, not just evaluate it. While the angiogram will reveal the blockage, the treatment goal is to restore perfusion to the affected area of the heart through procedures such as balloon angioplasty or stent placement.

D) Prevent extensive myocardial damage:
This is the correct answer. The main goal of treatment for STEMI is to prevent extensive myocardial damage. In a STEMI, the coronary artery is blocked, depriving the heart muscle of oxygen, which can cause significant damage or death of the myocardial tissue. The most effective way to limit the extent of damage is to restore blood flow as quickly as possible, often through emergent procedures like percutaneous coronary intervention (PCI) or fibrinolytic therapy.

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Correct Answer is D

Explanation

A) Chemical burns to the posterior neck, chest, and back:
Chemical burns primarily affect the skin and underlying tissues where the chemicals have come into contact. Although chemical burns can cause significant damage, particularly to the respiratory system if inhaled, chemical burns to the posterior neck, chest, and back would not typically require endotracheal intubation or tracheostomy unless there is evidence of inhalation injury or airway compromise.

B) Radiation burns to shoulder and bridge of nose:
Radiation burns, such as those from sunburn or therapeutic radiation, generally do not cause immediate airway compromise or respiratory distress unless the radiation exposure has affected the lungs or upper respiratory tract.

C) Electrical burns to the hands causing dysrhythmias:
Electrical burns can cause significant tissue damage, especially if there is a deep tissue injury and potential for electrical burns to the internal organs. They can lead to dysrhythmias, but these burns are more related to cardiac complications rather than direct airway injury. Endotracheal intubation may be required if there are signs of airway compromise or respiratory failure, but the primary concern with electrical burns would be cardiac monitoring and fluid resuscitation.

D) Thermal burns to the head, neck, face, and airway:
The upper airway (including the mouth, throat, and vocal cords) is particularly vulnerable to thermal injury from inhaling hot gases, smoke, or steam. This can lead to edema and airway obstruction, which can rapidly progress to respiratory failure. Endotracheal intubation or even a tracheostomy may be required to secure the airway and prevent suffocation. Inhalation injury is a significant concern in thermal burns involving the head, neck, and face.

A. increased cardiac output. B. inadequate tissue perfusion. C. fluid overload or deficit D. vasoconstriction of vasculature.

Correct Answer is B

Explanation

A) Increased cardiac output:
While cardiac output is an important factor in shock management, the primary goal of nursing care is not specifically to increase cardiac output. Shock typically involves inadequate tissue perfusion, which may be caused by a variety of factors including low cardiac output, vasodilation, or fluid imbalance. The focus of nursing care is to restore adequate perfusion to tissues, which may involve improving cardiac output as part of a larger therapeutic strategy.

B) Inadequate tissue perfusion:
The primary goal in the treatment of shock is to restore adequate tissue perfusion, as shock is defined by a failure of the circulatory system to supply sufficient oxygen and nutrients to the body's tissues and organs. Inadequate tissue perfusion can lead to organ dysfunction and, if not addressed, can result in organ failure and death. Nursing interventions are aimed at improving perfusion through fluid resuscitation, vasoactive medications, and other strategies to ensure that oxygen and nutrients are delivered to vital organs.

C) Fluid overload or deficit:
Managing fluid status is crucial in shock, as fluid imbalance (either overload or deficit) can exacerbate the condition. However, fluid overload or deficit is not the primary focus; rather, it is one aspect of managing inadequate tissue perfusion. For example, in hypovolemic shock, the nurse would manage fluid deficit, while in cardiogenic shock, the focus would be on optimizing fluid balance without causing overload.

D) Vasoconstriction of vasculature:
While vasoconstriction can be a compensatory mechanism in certain types of shock (e.g., hypovolemic shock), the primary goal is not to induce vasoconstriction per se. In some cases, vasodilation may occur (as in septic shock), and vasoconstriction could be harmful. The goal is to optimize the vascular tone and perfusion, which may involve vasodilation or vasoconstriction depending on the type of shock.

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A client admitted to the Emergency Department with a suspected STEM. The nurse anticipates that this client will be immediately prepared for the cardiac catheterization laboratory as the goal of treatment is to:

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