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Difficulty: MediumPhysiological Adaptation

During bedside handoff on a progressive care unit, a client who sustained an anterior myocardial infarction the previous day becomes extremely restless. The assessment reveals pale, diaphoretic skin and a weak radial pulse of 118 beats per minute. The current blood pressure measurement is 84/60 mm Hg, and the client's urine output has been 15 mL over the last hour. Which action is the priority for this client?

  1. Activate the rapid response team and anticipate the administration of inotropic medications.Answer
  2. B
    Infuse a 500 mL bolus of 0.9% sodium chloride to rapidly restore intravascular volume.
  3. C
    Place the client in a high-Fowler's position to maximize respiratory excursion.
  4. D
    Perform a complete 12-lead electrocardiogram prior to alerting the healthcare provider.

Answer

The priority action is to activate the rapid response team and anticipate the administration of inotropic medications.
The correct answer addresses a severe, life-threatening complication. The client is exhibiting classic signs of cardiogenic shock (hypotension, tachycardia, oliguria, altered mental status, and poor peripheral perfusion) resulting from significant left ventricular damage post-anterior myocardial infarction. Activating the rapid response team immediately brings critical care resources to the bedside. Furthermore, inotropes are typically required to improve myocardial contractility and restore adequate tissue perfusion.

Step-by-Step Solution

1
Analyze the clinical findings presented in the scenario.
The client has a history of an anterior myocardial infarction and now presents with extreme restlessness, pale/diaphoretic skin, tachycardia (118 bpm), hypotension (84/60 mm Hg), and oliguria (15 mL/hr).
Identifying the cluster of symptoms is required to determine the underlying physiological complication.
2
Synthesize the findings to identify the specific complication.
The symptoms indicate impaired tissue perfusion and pump failure, specifically cardiogenic shock, which is a known complication of anterior myocardial infarctions.
Recognizing the transition from stable to decompensated status directs the urgency of the intervention.
3
Determine the highest priority nursing intervention.
The nurse must immediately activate the rapid response team to bring critical care resources to the bedside and prepare for interventions that support cardiac output, such as inotropes.
In a state of acute circulatory collapse, immediate collaborative resuscitation is prioritized over independent diagnostic data gathering or contraindicated interventions.

Key Concept

Cardiogenic Shock Recognition and Prioritization
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Topics

Physiological Adaptation

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