The nurse is conducting a physical assessment on a client with infective endocarditis (IE). The nurse observes flat, reddened, non-tender maculae on the hands and feet.

What does the nurse understand these to be?

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.

Choice A rationale
Encouraging exercise to increase heart rate in a patient with myocardial ischemia could potentially worsen the condition. Exercise increases the demand for oxygen in the heart, which may not be met due to the reduced blood flow in ischemia, potentially leading to further damage.
Choice B rationale
Administering a diuretic to decrease volume is not the most beneficial intervention for a patient with myocardial ischemia. While diuretics can reduce the workload of the heart by decreasing blood volume, they do not directly address the issue of reduced blood flow to the heart muscle that characterizes ischemia.
Choice C rationale
Giving an antibiotic to decrease infection is not relevant in this context. Myocardial ischemia is not caused by an infection, but by a reduction in blood flow to the heart muscle, often due to a blockage in one or more of the coronary arteries.
Choice D rationale
Applying oxygen to increase myocardial oxygen supply is the most beneficial intervention for a patient with myocardial ischemia. Oxygen therapy can help to meet the oxygen demand of the heart muscle when blood flow is reduced, alleviating symptoms and preventing further damage.