The nurse admits to the coronary care unit a patient diagnosed with an acute myocardial infarction.The patient's blood pressure reading is 86/38 secondary to an infusing nitroglycerine drip.Pulse rate is 120 beats/min and respirations are 14 breaths/min.The patient is pale and grimacing,and moans occasionally.What nursing diagnoses would the nurse anticipate for this patient? Select all that apply.

Question

Quizplus · Accepted Answer

Because ischemia causes pain,acute pain would be an expected diagnosis; the patient exhibits pain symptoms (i.e.,pallor,grimacing,moaning).There is no indication the patient is experiencing shortness of breath or symptoms of anxiety.With a very low blood pressure,such as 86/38,risk for shock would be an appropriate diagnosis.Myocardial infarction is an indication that there is reduced cardiac perfusion,so this would be an appropriate nursing diagnosis.Although there is risk for decreased cardiac output if significant myocardial tissue is damaged,there is no indication cardiac output is currently decreased.

The Nurse Admits to the Coronary Care Unit a Patient