The nurse is caring for a patient who has recently been admitted with a myocardial infarction

Question

Based on clinical manifestations and nursing assessment, the patient has a nursing diagnosis of ineffective cardiac tissue perfusion related to decreased coronary blood flow from coronary thrombus and atherosclerotic plaque. In order to promote adequate tissue perfusion, the nurse is aware that in the initial phase of treatment a nursing intervention that is particularly helpful in reducing myocardial oxygen consumption is:
A) Relieving anxiety
B) Bed or chair rest
C) Frequent assessment of peripheral pulses
D) Scrupulous attention to fluid volume status

Answer 1

Ans: B
Feedback: Limiting the patient to bed or chair rest during the initial phase of treatment after an MI is helpful in reducing myocardial oxygen consumption as well as the administration of oxygen. Relieving anxiety is an important nursing function that reduces sympathetic stress response, which decreases the workload of the heart. Checking skin temperature and peripheral pulses frequently is very important to monitor tissue perfusion, not to reduce oxygen consumption. Scrupulous attention to fluid volume status is also very important to prevent overload of the heart and lungs.