A nurse is reviewing the treatment plan for Mr. Johnson with the healthcare team. Which intervention is MOST critical to address immediately to stabilize his cardiac condition given his current presentation?

B) Start dual antiplatelet therapy with clopidogrel.

A) Initiate a low-sodium diet to manage hypertension.

B) Start dual antiplatelet therapy with clopidogrel.

C) Educate on smoking cessation to reduce cardiovascular risk.

D) Adjust his diabetes management plan to improve blood glucose control.

Mr. Johnson has been diagnosed with a non-ST elevation myocardial infarction (NSTEMI) and has a history of chronic hypertension and diabetes mellitus. Based on this information, which nursing intervention is most critical to address his current condition and prevent further cardiac complications?

C) Monitoring for signs of bleeding after starting dual antiplatelet therapy

A) Administering a statin to lower LDL cholesterol levels

B) Initiating strict glycemic control to maintain blood glucose levels below 150 mg/dL

C) Monitoring for signs of bleeding after starting dual antiplatelet therapy

D) Educating the patient on smoking cessation and its impact on cardiovascular health

Mr. Johnson has been diagnosed with heart failure with reduced ejection fraction (HFrEF) and renal artery stenosis. He is being started on an ACE inhibitor. Which nursing intervention is most important to perform after initiating this medication?

A) Monitor the patient's blood pressure closely.

B) Assess the patient for signs of hyperkalemia.

C) Educate the patient on low-sodium diet.

D) Encourage the patient to increase fluid intake.

Mr. Johnson has been diagnosed with heart failure with reduced ejection fraction (HFrEF) and significant renal artery stenosis. The healthcare team has decided to start him on an angiotensin-converting enzyme (ACE) inhibitor. Which of the following nursing assessments is most critical to monitor after initiating this medication?

B) Assess for signs of angioedema, such as swelling of the lips, face, or throat.

A) Monitor for signs of hypokalemia, such as muscle weakness and cramps.

B) Assess for signs of angioedema, such as swelling of the lips, face, or throat.

C) Evaluate for symptoms of bradycardia, such as dizziness and syncope.

D) Check for signs of hypoglycemia, such as sweating and confusion.

A nurse is reviewing the laboratory results of Mr. Johnson, who is on an ACE inhibitor for hypertension management. His serum creatinine has increased from 1.8 mg/dL to 2.0 mg/dL. What is the most appropriate nursing action in response to this finding?

B) Notify the healthcare provider and continue to monitor renal function.

A) Discontinue the ACE inhibitor immediately.

B) Notify the healthcare provider and continue to monitor renal function.

C) Increase the dose of the ACE inhibitor to enhance blood pressure control.

D) Encourage increased fluid intake to promote renal excretion.

During a follow-up assessment, Mr. Johnson reports persistent fatigue and occasional dizziness after starting an ACE inhibitor. His blood pressure has improved, but his serum creatinine has increased slightly. Which nursing intervention is most appropriate to address these symptoms while considering his current condition?

B) Educate Mr. Johnson on slow position changes to reduce dizziness.

A) Encourage Mr. Johnson to increase his oral fluid intake.

B) Educate Mr. Johnson on slow position changes to reduce dizziness.

C) Recommend Mr. Johnson take his medication with food to prevent side effects.

D) Suggest reducing the ACE inhibitor dose to prevent renal function deterioration.

A nurse is reviewing Mr. Johnson's case and considering the implications of his recent changes in medication. Which nursing intervention is most appropriate to address the risk associated with his current treatment plan?

C) Advise Mr. Johnson to avoid sudden position changes to reduce the risk of orthostatic hypotension.

A) Encourage Mr. Johnson to increase his fluid intake to prevent dehydration.

B) Educate Mr. Johnson on how to monitor for signs of hyperkalemia and when to notify his healthcare provider.

C) Advise Mr. Johnson to avoid sudden position changes to reduce the risk of orthostatic hypotension.

D) Schedule Mr. Johnson for regular blood pressure checks at the clinic to monitor his response to the new diuretic therapy.

A nurse is caring for Mr. Johnson, who has been diagnosed with renal artery stenosis and is experiencing dizziness and mild confusion. His ACE inhibitor has been discontinued, and a thiazide diuretic has been initiated. Which nursing intervention is most appropriate to address Mr. Johnson's dizziness and prevent potential complications associated with his current condition?

B) Instruct Mr. Johnson to change positions slowly from lying to standing to prevent orthostatic hypotension.

A) Encourage Mr. Johnson to increase his fluid intake to prevent dehydration.

B) Instruct Mr. Johnson to change positions slowly from lying to standing to prevent orthostatic hypotension.

C) Administer an additional dose of antihypertensive medication to control blood pressure fluctuations.

D) Advise Mr. Johnson to rest in bed until the dizziness subsides completely.

Mr. Johnson, a patient with a history of atherosclerosis, returns to the clinic reporting intermittent episodes of chest discomfort during physical activity despite recent improvements in dizziness and confusion. Which nursing intervention is most appropriate to address his current symptoms while considering his overall health status?

B) Educate Mr. Johnson on the importance of adhering to his prescribed low-dose beta-blocker daily to manage exercise-induced angina.

A) Encourage Mr. Johnson to take his beta-blocker only when he experiences chest discomfort.

B) Educate Mr. Johnson on the importance of adhering to his prescribed low-dose beta-blocker daily to manage exercise-induced angina.

C) Suggest Mr. Johnson increase his physical activity intensity to improve cardiovascular endurance.

D) Advise Mr. Johnson to avoid all physical activity until his chest discomfort completely resolves.

Mr. Johnson, who has a history of atherosclerosis and recently reported intermittent episodes of chest discomfort during physical activity, started a low-dose beta-blocker. Which nursing intervention is most important to monitor after initiating the beta-blocker therapy?

C) Assess for signs of bradycardia and hypotension regularly.

A) Monitor blood glucose levels closely for hypoglycemia.

B) Teach Mr. Johnson to avoid potassium-rich foods to prevent hyperkalemia.

C) Assess for signs of bradycardia and hypotension regularly.

D) Advise Mr. Johnson to increase fluid intake to prevent dehydration.

atherosclerosis - Nursing Case Study

Pathophysiology

• Primary mechanism: Endothelial injury initiates atherosclerosis by damaging the inner arterial lining, often due to factors like high blood pressure, smoking, or high cholesterol. This injury allows lipoproteins to infiltrate the vessel wall, leading to the formation of fatty streaks.

• Secondary mechanism: Inflammatory response follows endothelial injury, where immune cells such as macrophages engulf lipoproteins, becoming foam cells. This accumulation contributes to plaque formation and growth, narrowing the vessel.

• Key complication: Plaque instability can lead to rupture, triggering thrombus formation. This clot can obstruct blood flow, potentially causing complications like myocardial infarction or stroke due to reduced perfusion to the heart or brain.

Patient Profile

Demographics:

62-year-old male, retired construction worker

History:

• Key past medical history: Hypertension, Type 2 Diabetes, Smoking (30 pack-year history), Hyperlipidemia

• Current medications: Atorvastatin, Metformin, Lisinopril, Aspirin

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Chest pain and shortness of breath

• Key symptoms: Intermittent claudication, fatigue, mild dizziness, occasional heart palpitations

• Vital signs: Blood pressure 155/95 mmHg, heart rate 92 bpm, respiratory rate 20 breaths per minute, temperature 98.6°F, oxygen saturation 94% on room air

Section 1

As the healthcare team conducted an initial assessment, several concerning findings emerged. The patient, Mr. Johnson, exhibited signs of worsening cardiovascular compromise. On auscultation, there was a notable S4 heart sound, indicative of decreased ventricular compliance and potential left ventricular hypertrophy, a common consequence of chronic hypertension and atherosclerosis. His peripheral pulses were weak and thready, and there was mild bilateral lower extremity edema, suggesting possible heart failure. An electrocardiogram (ECG) was performed, revealing ST-segment depression and T-wave inversion in the anterior leads, consistent with myocardial ischemia. These findings were corroborated by elevated troponin levels, pointing to a non-ST elevation myocardial infarction (NSTEMI) as a likely complication.

Simultaneously, a comprehensive metabolic panel showed persistent hyperglycemia with a blood glucose level of 180 mg/dL and an HbA1c of 8.5%, indicating suboptimal diabetes management, which likely exacerbates the atherosclerotic process. Lipid profile results were also concerning, with LDL cholesterol at 130 mg/dL, despite statin therapy, revealing the need for more aggressive lipid management. Additionally, the patient’s renal function was compromised, as evidenced by a serum creatinine of 1.8 mg/dL, suggesting possible diabetic nephropathy or decreased renal perfusion due to atherosclerotic changes in renal arteries.

Given these findings, the primary focus now shifts to stabilizing Mr. Johnson's cardiac status and addressing modifiable risk factors. The healthcare team initiated dual antiplatelet therapy with clopidogrel and adjusted his antihypertensive regimen to better control his blood pressure. Furthermore, a cardiology consult was requested for potential coronary angiography to assess the extent of coronary artery disease and consider revascularization options. The team also emphasized the importance of lifestyle modifications, including smoking cessation and dietary changes, to reduce cardiovascular risk and prevent further complications. These interventions aim to restore myocardial perfusion, manage comorbid conditions, and improve overall patient outcomes.

Section 2

As the healthcare team continued to monitor Mr. Johnson, new diagnostic results provided further insight into his condition. A follow-up echocardiogram revealed significant left ventricular hypertrophy and a reduced ejection fraction of 40%, indicative of systolic dysfunction and confirming the suspicion of heart failure with reduced ejection fraction (HFrEF). This finding correlated well with the clinical signs of edema and the S4 heart sound noted during the initial assessment. Additionally, the echocardiogram showed mild mitral regurgitation, likely secondary to the left ventricular remodeling, contributing to the patient's symptoms of dyspnea and fatigue.

In tandem with the echocardiogram, a renal duplex ultrasound was conducted to evaluate the renal arteries, given the elevated creatinine levels and possible diabetic nephropathy. The ultrasound revealed significant stenosis in the right renal artery, which could be contributing to his hypertension and further impairing renal function. This finding underscored the need for an interdisciplinary approach, involving not only cardiology but also nephrology, to effectively manage Mr. Johnson's complex condition and to mitigate the risk of further renal deterioration.

The healthcare team reviewed these results during their next meeting, considering how they might adjust the management plan. The decision was made to start Mr. Johnson on an angiotensin-converting enzyme (ACE) inhibitor to address both his heart failure and renal concerns, while closely monitoring his renal function. The potential need for percutaneous intervention for renal artery stenosis was also discussed. The team recognized the importance of refining Mr. Johnson's diabetes management, as improved glycemic control could positively impact both his cardiovascular and renal status. As Mr. Johnson's case continued to evolve, the focus remained on a coordinated, multifaceted approach to optimize his care and prevent further complications.

Section 3

As Mr. Johnson's treatment plan commenced, the healthcare team closely monitored his response to the interventions. Within the first week of starting the ACE inhibitor, his blood pressure showed a modest improvement, decreasing to an average of 138/85 mmHg, compared to previous readings consistently above 150/95 mmHg. This reduction was an encouraging sign, suggesting initial responsiveness to the medication. However, his renal function required vigilant observation; his serum creatinine levels showed a slight increase from 1.8 mg/dL to 2.0 mg/dL. Although this change was within an expected range when initiating ACE inhibitor therapy in renal artery stenosis, it necessitated continued monitoring to ensure stability.

Clinically, Mr. Johnson reported a slight reduction in his dyspnea, particularly noted during exertion. However, his fatigue persisted, and he experienced occasional episodes of dizziness, raising concerns about potential orthostatic hypotension or medication side effects. A repeat assessment revealed persistent peripheral edema, though there was no significant change in weight, indicating that fluid balance remained a challenge. The healthcare team considered the addition of a diuretic to help manage fluid overload, but they were cautious due to the potential impact on renal function.

In light of these developments, the team scheduled a follow-up consultation with nephrology to further evaluate the renal artery stenosis and discuss the feasibility of percutaneous intervention. Concomitantly, they emphasized the need to enhance Mr. Johnson's diabetes management, liaising with an endocrinologist to optimize his glycemic control, as his HbA1c levels remained at 8.2%. This collaborative approach aimed to address the multifactorial nature of his condition, while preparing for potential adjustments to his care plan based on his evolving clinical picture.

Section 4

A week later, during a routine follow-up visit, Mr. Johnson presented with new symptoms that prompted further investigation. He reported an increase in his episodes of dizziness, now accompanied by mild confusion, particularly in the mornings. His blood pressure readings at home had occasionally dipped to 110/70 mmHg, suggesting potential overcorrection with the current antihypertensive regimen. In the clinic, his blood pressure was measured at 112/68 mmHg, and his heart rate was 62 beats per minute. These findings raised concerns for possible orthostatic hypotension as a side effect of the ACE inhibitor, warranting a careful reassessment of his medication plan.

Laboratory results revealed a concerning trend: his serum creatinine had risen further to 2.3 mg/dL, suggesting a decline in renal function. Additionally, his potassium level was slightly elevated at 5.3 mEq/L, a potential consequence of the ACE inhibitor therapy. In light of these results, the healthcare team decided to temporarily discontinue the ACE inhibitor and initiated a low-dose thiazide diuretic to better manage Mr. Johnson's fluid status while minimizing the impact on his renal function. This decision aimed to address his persistent peripheral edema while carefully balancing the risks of further renal impairment.

The nephrology consultation confirmed significant renal artery stenosis, and after a thorough discussion, it was agreed that Mr. Johnson would benefit from percutaneous transluminal angioplasty. This intervention was planned to improve renal perfusion and potentially stabilize his renal function. Meanwhile, the endocrinologist adjusted his diabetes regimen, introducing a GLP-1 receptor agonist to better control his glucose levels and support cardiovascular health. This integrated approach aimed to stabilize Mr. Johnson's condition, reduce his cardiovascular risks, and prepare him for the upcoming intervention. The team planned close follow-up to monitor his response to these adjustments and to ensure a seamless transition to the next phase of his care.

Section 5

Two weeks after the intervention, Mr. Johnson returned to the clinic for a follow-up evaluation. Upon initial assessment, he reported a noticeable improvement in his dizziness and confusion, particularly in the mornings. His blood pressure readings at home had stabilized, averaging around 125/78 mmHg, and his heart rate was consistently measured at 68 beats per minute. Despite these improvements, Mr. Johnson mentioned experiencing intermittent episodes of chest discomfort during physical activity, which he described as a mild pressure rather than pain. This new symptom prompted further investigation, given his history of atherosclerosis.

The clinical team ordered an electrocardiogram (ECG) and a stress test to evaluate his cardiac function more thoroughly. The ECG revealed no acute ischemic changes, but the stress test indicated exercise-induced angina, likely due to coronary artery disease. The decision was made to initiate a low-dose beta-blocker to manage these symptoms and reduce the cardiac workload, while carefully monitoring for any adverse effects on his already controlled blood pressure.

Laboratory results showed a modest improvement in Mr. Johnson's renal function, with serum creatinine levels decreasing to 1.9 mg/dL, signaling a positive response to the angioplasty. Potassium levels normalized at 4.8 mEq/L, further supporting the suitability of the current therapeutic adjustments. The healthcare team emphasized the importance of lifestyle modifications, including dietary changes and a graduated exercise program, to enhance cardiovascular health and minimize the risk of future complications. Mr. Johnson was scheduled for regular follow-ups to closely monitor his progress and to adjust his treatment plan as necessary, ensuring a comprehensive approach to managing his cardiovascular and renal health.