A patient admitted to the coronary care unit (CCU) with an ST-segment-elevation myocardial infarction (STEMI) is restless and anxious. The blood pressure is 86/40 and heart rate is 123
Based on this information, which nursing diagnosis is a priority for the patient?
a. Acute pain related to myocardial infarction
b. Anxiety related to perceived threat of death
c. Stress overload related to acute change in health
d. Decreased cardiac output related to cardiogenic shock
ANS: C
All the nursing diagnoses may be appropriate for this patient, but the hypotension and tachycardia indicate decreased cardiac output and shock from the damaged myocardium. This will result in decreased perfusion to all vital organs (e.g., brain, kidney, heart) and is a priority.
You might also like to view...
The nurse is caring for a patient who has had a severe stroke and requires assistance to use the toilet. Which goal is the highest priority for this patient?
a. The patient will remain continent with no perineal skin breakdown. b. The patient will state satisfaction with use of gait belt for toilet transfers. c. The patient will regain ability to pull up clothing after using the toilet. d. Privacy will be provided once the patient is properly positioned on the toilet.
A patient is recovering from a mild cerebral vascular accident (stroke)
The home care nurse notes that the patient is talking about updating a will and planning funeral arrangements. Which of the following responses is most appropriate for the nurse to make? a. "You seem to be preoccupied with dying." b. "Is there anything I can do to help you?" c. "Are you worried about dying before you get your affairs in order?" d. "Let's focus on how you are recovering rather than on your dying."
Because of the nursing shortage, not many registered nurses are fired; however, there are some reasons for which nurses are terminated immediately, such as:
a. Tardiness b. Personnel reduction c. Falsification of records d. Withdrawn behavior
Among other variables, upon what does damage from a specific chemical depend?
a. The dose b. The environmental factors c. The toxicology d. The virulence and infectivity