A patient has been admitted to the coronary care unit (CCU) with an ST-segment-elevation myocardial infarction (STEMI). The patient is restless, anxious, has a blood pressure of 86/40 mm Hg, and a heart rate of 132 beats/min.

What is the priority problem for this patient?

Anxiety

Acute pain

Decreased cardiac output

Stress management

Answer and Explanation

The Correct Answer is C

Choice A rationale
Anxiety is a common response to the stress of hospitalization and illness, especially in the context of a serious condition like ST-segment-elevation myocardial infarction (STEMI).
However, while anxiety can exacerbate physical symptoms and should be addressed, it is not the primary problem in this scenario.
Choice B rationale
Acute pain is a common symptom of STEMI, as the heart muscle is deprived of oxygen. However, the patient’s blood pressure and heart rate readings suggest a more immediate concern related to the cardiovascular system.
Choice C rationale
Decreased cardiac output is likely the priority problem for this patient. The patient’s low blood pressure (86/40 mm Hg) and high heart rate (132 beats/min) suggest that the heart is not pumping enough blood to meet the body’s needs, which is a direct consequence of the STEMI1. This can lead to organ failure and other serious complications if not addressed promptly.
Choice D rationale
Stress management is an important aspect of long-term care for patients with heart disease, as chronic stress can contribute to further heart damage. However, in the acute phase of a STEMI, the focus is on stabilizing the patient’s condition and preventing complications.

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Correct Answer is B

Explanation

Choice A rationale
A pleural friction rub, which is a grating sound caused by the inflammation of the pleural surfaces during respiration, is not typically associated with cardiac tamponade. It is more commonly associated with conditions affecting the lungs, such as pneumonia or pleurisy.
Choice B rationale
Distended neck veins are a classic sign of cardiac tamponade. This occurs due to increased pressure in the right atrium as a result of the impaired filling of the ventricles. This is a critical sign that should be reported immediately.
Choice C rationale
Widening pulse pressure (an increase in the difference between systolic and diastolic blood pressure) is not typically associated with cardiac tamponade. In fact, cardiac tamponade more commonly presents with a narrowed pulse pressure.
Choice D rationale
Bradycardia, or a slow heart rate, is not typically a sign of cardiac tamponade. More commonly, tachycardia, or a fast heart rate, is observed in response to decreased cardiac output.

A. Left heart failure. B. Pericarditis. C. Hypertension. D. Acute pneumonia.

Correct Answer is A

Explanation

Choice A rationale
Left heart failure is a common cause of right heart failure. When the left side of the heart is unable to pump blood efficiently, it can cause increased pressure in the lungs, which can then lead to right heart failure.
Choice B rationale
Pericarditis, an inflammation of the sac-like covering around the heart, is not typically a direct cause of right heart failure.
Choice C rationale
While hypertension, or high blood pressure, can contribute to heart failure, it typically affects the left side of the heart more than the right.
Choice D rationale
Acute pneumonia, an infection that inflames the air sacs in one or both lungs, is not typically a direct cause of right heart failure.

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A patient has been admitted to the coronary care unit (CCU) with an ST-segment-elevation myocardial infarction (STEMI). The patient is restless, anxious, has a blood pressure of 86/40 mm Hg, and a heart rate of 132 beats/min. What is the priority problem for this patient?

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Naxlex Comprehensive Predictor Exams

When caring for a client who has developed cardiac tamponade, what assessments should the nurse expect to find?

Correct Answer is B

Explanation

A 73-year-old patient has increased pulmonary pressure resulting in right heart failure. What could be a potential cause for the right heart to fail?

Correct Answer is A

Explanation

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A patient has been admitted to the coronary care unit (CCU) with an ST-segment-elevation myocardial infarction (STEMI). The patient is restless, anxious, has a blood pressure of 86/40 mm Hg, and a heart rate of 132 beats/min.

What is the priority problem for this patient?