A patient admitted to the coronary care unit (CCU) with an ...

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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

Question 2

When caring for a patient with acute coronary syndrome who has returned to the coronary care unit after having angioplasty with stent placement, the nurse obtains the following assessment data.
 
  Which data indicate the need for immediate action by the nurse?
  a. Heart rate 102 beats/min
  b. Pedal pulses 1+ bilaterally
  c. Blood pressure 103/54 mm Hg
  d. Chest pain level 7 on a 0 to 10 point scale

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Answer to Question 1

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.

Answer to Question 2

ANS: D
The patient's chest pain indicates that restenosis of the coronary artery may be occurring and requires immediate actions, such as administration of oxygen and nitroglycerin, by the nurse. The other information indicates a need for ongoing assessments by the nurse.