The nurse is caring for a client diagnosed with acute coronary syndrome who has just returned to the nursing unit following an intracoronary stent insertion. Which action is the priority at this time?

Monitoring the skin color and turgor

Monitoring the blood pressure every fifteen minutes.

Monitoring the cardiac enzymes every eight hours

Performing neurological checks every fifteen minutes

Answer and Explanation

The Correct Answer is B

A) Monitoring the skin color and turgor:
While monitoring skin color and turgor is important in assessing fluid status and perfusion, it is not the immediate priority following an intracoronary stent insertion. Skin turgor is more useful in assessing dehydration or hypovolemia, but after a stent placement, the priority is to ensure the client is stable hemodynamically and there are no complications such as bleeding or thrombosis at the insertion site.

B) Monitoring the blood pressure every fifteen minutes:
Following an intracoronary stent insertion, it is crucial to monitor the client's blood pressure closely, as this procedure can lead to complications such as bleeding, clot formation, or vessel rupture. Monitoring blood pressure frequently (every 15 minutes initially) helps detect any signs of hypotension or hypertension that may indicate complications like bleeding or a clot.

C) Monitoring the cardiac enzymes every eight hours:
Cardiac enzymes, such as troponin, are typically used to assess myocardial injury and can be elevated in the setting of acute coronary syndrome. However, this is not the immediate priority post-procedure. The primary concern immediately after an intracoronary stent insertion is ensuring hemodynamic stability and preventing complications such as bleeding or thromboembolism, rather than focusing solely on enzyme levels.

D) Performing neurological checks every fifteen minutes:
Neurological checks are important in cases of stroke, neurological compromise, or complications like a clot dislodging. However, in the context of a patient who has just had an intracoronary stent placement, neurological checks are not the immediate priority unless there are signs of neurological symptoms (such as sudden weakness or confusion) that indicate a complication like an embolism or stroke.

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Correct Answer is A

Explanation

A) Prepare for a STAT computed tomography (CT) scan:
A severe headache in a client with a suspected stroke could be indicative of increased intracranial pressure (ICP), a hemorrhagic stroke, or another serious complication like cerebral edema. The priority intervention is to perform a CT scan to determine whether the stroke is ischemic (caused by a blockage) or hemorrhagic (caused by bleeding). This is crucial because the treatment approach for these two types of strokes differs significantly. For example, hemorrhagic strokes require immediate management to control bleeding and reduce ICP, whereas ischemic strokes may be treated with thrombolytics or other interventions. Therefore, preparing for a CT scan is the most urgent action to accurately diagnose the type of stroke and guide treatment decisions.

B) Obtain a 12-lead electrocardiogram (ECG):
While an ECG may be useful in assessing the cardiac rhythm and identifying potential arrhythmias (which can contribute to stroke risk), it is not the priority intervention in a patient with a suspected stroke and severe headache. The primary concern is to identify the type of stroke (ischemic or hemorrhagic), and a CT scan is the most direct way to do this. A 12-lead ECG can be obtained later if cardiac issues are suspected after stroke diagnosis.

C) Start an intravenous infusion of D5W at 100 mL/hr:
Starting an IV infusion of D5W (5% dextrose in water) is not an appropriate priority for a patient with a severe headache and suspected stroke. In fact, administering dextrose solutions may worsen the patient's condition in the case of a hemorrhagic stroke, as it could exacerbate cerebral edema or increase intracranial pressure. Fluid management in stroke patients should be approached cautiously, and IV fluids should be tailored to the patient's specific needs. The focus should be on imaging to determine the type of stroke before initiating interventions like IV fluids.

D) Administer a nonnarcotic analgesic:
While pain relief is important, administering a nonnarcotic analgesic (such as acetaminophen or ibuprofen) is not the priority in this situation. The patient's severe headache could be a sign of a serious complication like increased ICP or hemorrhagic stroke, which requires immediate diagnostic workup, not just pain management. Administering pain medication without understanding the underlying cause of the headache could mask symptoms and delay critical treatment.

A. Equal but sluggishly reactive pupils B. Widening pulse pressure C. Altered level of consciousness D. Tachycardia and hypotension

Correct Answer is C

Explanation

A) Equal but sluggishly reactive pupils:
Pupillary changes, including sluggish or unequal responses, are significant signs of increasing intracranial pressure (ICP) and should be monitored closely. However, altered level of consciousness (LOC) is typically one of the earliest signs of increased ICP. The response of the pupils to light can become abnormal later, once pressure increases within the brain, particularly when brainstem function is impacted.

B) Widening pulse pressure:
A widening pulse pressure is part of Cushing’s triad, which is a late sign of increased ICP. Cushing’s triad consists of hypertension, bradycardia, and irregular respirations (often seen as Cheyne-Stokes). These changes occur in the later stages of elevated ICP as a compensatory mechanism to preserve cerebral perfusion. While this is an important finding, altered LOC would precede the development of Cushing’s triad.

C) Altered level of consciousness:
Altered level of consciousness (LOC) is typically the first and most sensitive indicator of increased ICP. As pressure increases within the skull, it compresses brain tissue and affects the brainstem, which controls basic functions like consciousness. LOC can range from mild confusion and disorientation to full loss of consciousness or coma, depending on the severity of the ICP increase.

D) Tachycardia and hypotension:
Tachycardia and hypotension can be associated with shock or other conditions, but they are not characteristic of early increased ICP. In fact, as ICP rises, the body typically responds with bradycardia (slower heart rate) and hypertension (increased blood pressure), which are part of the compensatory mechanisms.

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The nurse is caring for a client diagnosed with acute coronary syndrome who has just returned to the nursing unit following an intracoronary stent insertion. Which action is the priority at this time?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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