A patient with chronic stable angina tells you that he is having chest pain.
He describes it as being more intense than his usual chest pain and that it feels like it is lasting longer.
What should you be most concerned about after hearing this?
Your patient needs to be placed on a statin medication.
Your patient is not taking his medications regularly.
That your patient could be developing unstable angina.
Your patient is eating too much salt in his diet.
The Correct Answer is C
Choice A rationale
While statin medications are vital for lipid management and stabilization of atherosclerotic plaques in patients with coronary artery disease, an acute change in angina pattern is a much more immediate and life-threatening concern than the need for a new medication order. Statin use is a long-term strategy, not a priority response to acute symptom change.
Choice B rationale
Medication non-adherence is a common cause of symptom recurrence or worsening, yet the described change—more intense and prolonged pain—is the clinical definition of unstable angina. This acute coronary syndrome requires immediate intervention to prevent myocardial infarction and supersedes assumptions about patient compliance.
Choice C rationale
The change in the patient's chronic stable angina—new onset of more intense, longer-lasting chest pain—is the hallmark presentation of unstable angina. This indicates a critical shift, often due to a non-occlusive thrombus forming on a ruptured atherosclerotic plaque, demanding immediate emergency evaluation and treatment to prevent myocardial infarction.
Choice D rationale
High sodium intake exacerbates hypertension and can worsen heart failure symptoms by causing fluid retention, increasing cardiac workload. While dietary habits are important, an acute change in anginal pain pattern, suggestive of plaque instability and impending ischemia, is a far more immediate and critical concern than dietary salt intake. —.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Decreased cardiac output (CO) post-CABG is often due to hypovolemia resulting from third-spacing, blood loss, or insufficient fluid replacement, especially given the open heart procedure's significant fluid shifts. Administering a rapid IV fluid bolus is the initial priority to promptly increase preload and thus stroke volume and cardiac output, assuming no contraindications like signs of pulmonary edema.
Choice B rationale
Increasing the oxygen flow rate addresses potential hypoxemia, but it does not correct the underlying issue of low cardiac output and impaired systemic perfusion. While oxygenation is vital, fluid resuscitation directly targets the most likely hemodynamic cause of decreased CO post-surgery.
Choice C rationale
Assessing for bleeding (e.g., chest tube output) is a necessary step to identify and correct a source of ongoing hypovolemia. However, administering a fluid challenge is the immediate, life-sustaining intervention to temporize the falling CO while the assessment and notification process proceeds.
Choice D rationale
Notifying the physician is necessary after performing initial life-saving interventions and gathering supporting data. The nurse must first implement the standing protocol intervention for low cardiac output, which is often a fluid bolus, as delaying treatment for low CO can lead to critical organ hypoperfusion. —.
Correct Answer is D
Explanation
Choice A rationale
The patient's medication history is important to review after a shock to determine if any drugs (e.g., antiarrhythmics) need adjustment or if a proarrhythmic drug could have contributed to the episode. However, this is a secondary assessment; the immediate priority is determining if the shock restored stable circulation.
Choice B rationale
The ICD insertion site should be assessed for signs of infection, swelling, or hematoma, especially following a shock which can indicate a device malfunction or lead fracture. While necessary for device integrity and infection control, it is not the immediate priority over assessing the patient's cardiac function and stability.
Choice C rationale
The patient's emotional state, including anxiety or fear following a high-voltage shock, requires therapeutic support and debriefing. While critical for holistic care, addressing the psychosocial impact is not the first step; immediate focus must be placed on the physical stability and circulatory status.
Choice D rationale
The patient's hemodynamic status (e.g., blood pressure, heart rate, rhythm, O_2 saturation, level of consciousness) must be assessed first. A shock indicates a potentially life-threatening arrhythmia; the nurse must immediately confirm if the shock was effective in terminating the arrhythmia and whether the patient is now stable or requires further intervention. —.
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