Evolve Case Study: Medical/Surgical - CAD

Risk Factors 1. Which information in Kyra's history increases her risk for coronary artery disease (CAD)? A) Frequent episodes of hypoglycemia. Feedback: INCORRECT Hypoglycemia does not increase the risk for CAD. A history of diabetes mellitus is a contributing risk factor. B) Positive family history for hyperlipidemia. Feedback: CORRECT Genetic predisposition is a significant factor in the development of CAD.  C) Frequent air travel. Feedback: INCORRECT This is not considered a risk factor for CAD. However, recent studies indicate an increased risk for blood clot formation among people who fly, particularly long distances. D) Participation in a bowling league. Feedback: INCORRECT Physical inactivity is a major modifiable risk factor for CAD, but participation in athletic events is not a risk factor. Other risk factors identified by the nurse include obesity, smoking two packs of cigarettes per day, and reported job stress. Points Earned: 1.0/1.0 Correct Answer(s): B Therapeutic Communication: Noncompliance Since Kyra has numerous risk factors for CAD, she attends the clinic's class on reducing the risk for heart disease. At the conclusion of the class, Kyra tells the nurse, "I don't need any more of these classes, because I know that God is going to take care of my heart." 2. Which nursing diagnosis is most appropriate for Kyra? A) Knowledge deficit related to disease process. Feedback: INCORRECT Although all of these diagnoses could be appropriate, based on the data available to the nurse, there is a more appropriate diagnosis. B) Adjustment impaired related to health condition. Feedback: CORRECT Although all of these diagnoses could be appropriate, based on the data available to the nurse, this is the most appropriate diagnosis. C) Noncompliance with health regimen related to denial of condition. Feedback: INCORRECT Although all of these diagnoses could be appropriate, based on the data available to the nurse, there is a more appropriate diagnosis. D) Personal identity disturbance related to need to change behaviors. Feedback: INCORRECT Although all of these diagnoses could be appropriate, based on the data available to the nurse there is a more appropriate diagnosis. Points Earned: 0.0/1.0 Correct Answer(s): B 3. What is the best response by the nurse to Kyra's statement? A) "I believe that God helps those who help themselves." Feedback: INCORRECT Therapeutic communication should be free of the nurse's personal values. This blocks further communication. B) "You will have a heart attack if you don't change your lifestyle." Feedback: INCORRECT This statement is overly threatening and confrontational, and it does not promote further communication. C) "You feel that you don't need to be involved in your health care?" Feedback: CORRECT Clarification of the client's statement is a useful therapeutic technique that encourages further communication. D) "You must accept that you have a responsibility to care for yourself." Feedback: INCORRECT This statement is confrontational and does not promote further communication. After further discussion, Kyra agrees to go for her scheduled lab appointment, and to consider making some modifications in her lifestyle. Points Earned: 1.0/1.0 Correct Answer(s): C Client Teaching: Hyperlipidemia Kyra's lab results are: Serum cholesterol of 280 mg/dl. Low-density lipoproteins (LDL) of 180 mg/dl. High-density lipoproteins (HDL) of 32 mg/dl.  Kyra asks the nurse if these results are bad. 4. What information should the nurse include in the teaching plan? A) Serum cholesterol under 300 mg/dl is considered a "healthy heart" level. Feedback: INCORRECT Serum cholesterol less than 200 mg/dl is the desired level. B) Serum cholesterol greater than 200 mg/dl requires medical intervention. Feedback: INCORRECT While 200 mg/dl or less is considered desirable, medical intervention is not generally initiated for levels under 240 mg/dl. Clients with cholesterol levels between 200-240 mg/dl should, however, be advised to begin lifestyle modifications. C) As long as LDL is less than 200 mg/dl, it is within an acceptable range. Feedback: INCORRECT This is too high. LDL is the "bad" cholesterol that can accumulate in the arteries, eventually leading to angina, infarction, or CVA. Less than 100 mg/dl is now considered the optimal level, with readings above 190 considered very high. Here's a good memory trick: LDL= low down lousy. D) An HDL of less than 40 mg/dl indicates increased risk. Feedback: CORRECT HDL is considered the "good" cholesterol, which reduces the risk of heart disease. Current guidelines state that an HDL of less than 40 mg/dl is too low to safeguard the arteries. HDL= highly desirable level. Points Earned: 0.0/1.0 Correct Answer(s): D After discussing these test results with the healthcare provider and the nurse, Kyra expresses interest in learning how to lower her cholesterol and lose weight. The healthcare provider prescribes the antihyperlipidemic agent lovastatin (Mevacor) 20 mg PO daily. 5. Which instructions should the nurse include in Kyra's teaching plan related to the use of antihyperlipidemic? A) Take extra fluids during the day. Feedback: INCORRECT Fluid intake is not related to antihyperlipidemic administration. B) Report excessive bruising. Feedback: CORRECT Antihyperlipidemics reduce the absorption of lipid-soluble vitamins, including Vitamin K, and can therefore affect prothrombin time. This increases the client's risk for bleeding, so the client should be instructed to report any signs of bleeding, such as excessive bruising.  C) Avoid dairy products. Feedback: INCORRECT Antihyperlipidemics reduce the absorption of lipid-soluble vitamins, including vitamin D. Milk contains vitamin D, so low-fat or non-fat milk should be encouraged. D) Take one hour before eating. Feedback: INCORRECT Mevacor is better absorbed when taken with food. Other statins, such as Pravachol and Zocor can be taken without regard to food intake. However, all the statin drugs can cause adverse GI effects such as cramps, diarrhea, constipation, flatus and heartburn, and they are generally taken with the evening meal or at bedtime. Points Earned: 0.0/1.0 Correct Answer(s): B 6. Which ongoing lab test should Kyra anticipate during treatment with antihyperlipidemics? A) T3, T4 and TSH. Feedback: INCORRECT Antihyperlipidemics do not affect thyroid function. B) Liver enzymes. Feedback: CORRECT Because antihyperlipidemics can cause increased liver enzymes, they should be monitored periodically during treatment. C) Serum amylase. Feedback: INCORRECT Antihyperlipidemics do not affect pancreatic function. D) Serum electrolytes. Feedback: INCORRECT Electrolytes, such as sodium and potassium, do not need to be monitored as the result of antihyperlipidemic therapy. Points Earned: 0.0/1.0 Correct Answer(s): B In addition to teaching Kyra about her antihyperlipidemic medication, the nurse provides information about a low-fat/low cholesterol diet, an exercise regimen, a smoking cessation plan, and stress management skills. Kyra agrees to attend a series of "Healthy Heart" classes at the clinic. Angina Several months later, Kyra visits the clinic for her routine lab work. After walking into the clinic on a very hot day, she reports to the nurse that she is experiencing chest pain. Following assessment and ECG evaluation, Kyra is diagnosed with stable angina and receives two prescriptions: Nitroglycerin 0.2 mg/hour transdermal patch. Apply q a.m., and remove at bedtime daily. Nitroglycerin 0.3 mg sublingual PRN for chest pain. 7. Which instruction should the nurse include when teaching Kyra about the use of sublingual nitroglycerin? A) Put one tablet under the tongue each morning to help prevent angina attacks. Feedback: INCORRECT Sublingual tablets are used when chest pain occurs, rather than on a daily basis. The transdermal patch is used daily to prevent angina attacks. B) Obtain a fresh supply of tablets if tingling occurs when the tablet is placed under the tongue. Feedback: INCORRECT Nitroglycerin tablets should tingle slightly if they are fresh. Tablets should be replaced six months after the container is opened to ensure potency. C) Place a tablet under the tongue every 5 minutes until the pain is relieved, up to 3 tablets. Feedback: CORRECT Nitroglycerin tablets should be placed under the tongue when chest pain occurs. They may be taken one tablet every 5 minutes for 15 minutes, for a total maximum dose of three tablets. If the pain is not relieved after three doses, the client should be instructed to go to the Emergency Department.   D) Store the container of nitroglycerin tablets in the refrigerator to maintain freshness. Feedback: INCORRECT Nitroglycerin tablets should not be exposed to light or air. Kyra should be instructed to check the expiration date and keep the medication in its original container. Refrigeration of nitroglycerin tablets is not required. Points Earned: 1.0/1.0 Correct Answer(s): C 8. The nurse should prepare Kyra for which adverse effect that can occur when starting a daily dose of transdermal nitroglycerin? A) Green-yellow visual changes. Feedback: INCORRECT This is an adverse effect of digitalis preparations, not nitroglycerin. B) Diarrhea. Feedback: INCORRECT This is not an adverse effect of nitroglycerin, although nausea can occur with overdose. C) Dizziness. Feedback: CORRECT Nitroglycerin is a nitrate, causing systemic vasodilation. This often leads to hypotension, which can cause Kyra to feel dizzy. She should be instructed to change positions slowly and to avoid prolonged standing. In addition, Kyra may experience tachycardia and a headache. D) Tinnitus. Feedback: INCORRECT Ringing in the ears is not an adverse effect of nitroglycerin. Points Earned: 1.0/1.0 Correct Answer(s): C Kyra is scheduled for a stress echocardiogram. 9. Which instructions should the nurse provide Kyra prior to the test? A) The dye that is injected may cause a flushing sensation. Feedback: INCORRECT A contrast medium is used during angiography, but one is not used during a stress echocardiogram. B) A mild sedative will be given during the test. Feedback: INCORRECT The client will be exercising. Sedation is not administered. C) It will be necessary to keep a diary of all activities while wearing the monitor. Feedback: INCORRECT These instructions apply to a client undergoing ambulatory ECG, or Holter monitoring. The client wears a portable ECG monitor continuously while going about normal daily activities to evaluate concurrent cardiac electrical activity. D) It is important to return to the exam table immediately after exercising. Feedback: CORRECT This is important so the echocardiogram can be performed while the heart is still stressed from the exercise on the treadmill.  Points Earned: 0.0/1.0 Correct Answer(s): D Acute Myocardial Infarction (MI) Kyra's angina remains stable, and she undergoes a hysterectomy for dysmenorrhea related to uterine fibroids. The day after being discharged from the hospital, Kyra comes to the emergency department with crushing substernal chest pain radiating down her left arm. She is dyspneic, pale, and diaphoretic. 10. Which nursing intervention should be implemented first? A) Start an IV of 0.9% Normal Saline. Feedback: INCORRECT This intervention, involving circulation, is a third priority for emergency care. B) Administer oxygen. Feedback: CORRECT All of these interventions should be implemented and are often performed simultaneously by several emergency room staff working together. However, to demonstrate critical thinking, you must be able to select interventions based on priorities. Remember the ABCs of emergency care: Airway, Breathing, and Circulation: 1. First, ensure that there is an open airway and that the client is breathing, then provide for adequate oxygenation. 2. Second, ensure circulation, establish IV access, and start IV fluids. 3. Third, obtain more data based on your observations, i. e., take the blood pressure, obtain a specimen for cardiac enzymes, start an ECG, and get a chest x-ray. C) Obtain a 12 lead Electrocardiogram (ECG). Feedback: INCORRECT While this intervention will be useful in establishing the client's baseline rhythm upon arrival in the emergency center, and helpful in locating the area of myocardial infarction, circulation is the third priority for emergency care. D) Assess the client's blood pressure. Feedback: INCORRECT Obtaining the client's baseline vital signs, including blood pressure, heart rate, and temperature, is the third priority for emergency care (Circulation). Points Earned: 1.0/1.0 Correct Answer(s): B ECG findings indicate that Kyra has had a myocardial infarction (MI). 11. Which intervention should the nurse implement first? A) Notify the gynecologist of Kyra's admission. Feedback: INCORRECT This is an appropriate intervention, but it is not the intervention with the highest priority. B) Notify the hospital chaplain or Kyra's spiritual leader. Feedback: INCORRECT This would be an appropriate intervention if requested by the client's family. C) Inform the emergency department physician of Kyra's recent surgery. Feedback: CORRECT Since Kyra has had recent surgery, she may not be a candidate for some past MI treatments, such as tPA. The emergency department physician should be notified immediately, so that further evaluation can be done. tPA is a thrombolytic agent, or coagulation modifier, that breaks down clots in the coronary arteries. If blood flow is established quickly, the heart muscle will not become ischemic or necrotic. To be most effective, tPA should be given within the first 4 hours following an MI. D) Notify Kyra's husband of her condition. Feedback: INCORRECT This is an appropriate intervention, but it is not the intervention with the highest priority. Points Earned: 1.0/1.0 Correct Answer(s): C IV nitroglycerin (Tridil) is prescribed for Kyra. 12. What is a primary goal of this medication? A) Increase the force and velocity of myocardial systolic contraction. Feedback: INCORRECT Increasing the force and velocity of myocardial systolic contraction is the action of digitalis preparations, not nitroglycerin. B) Perfuse cardiac tissue by dilating coronary arteries. Feedback: CORRECT Nitrates cause the coronary blood vessels to dilate, allowing improved oxygen delivery to cardiac muscle. In addition, nitrates cause systemic vasodilation, reducing the workload on the heart, which in turn reduces the myocardium's need for oxygen. C) Provide relaxation to cardiac muscles. Feedback: INCORRECT Nitroglycerin perfuses cardiac muscle, but it does not relax the muscle. D) Dilate cerebral vessels to prevent hypoxia to the brain during myocardial infarction. Feedback: INCORRECT Nitroglycerin dilates cerebral vessels, which is why clients often complain of headache. However, this is an adverse effect, rather than the goal of nitrate therapy. Points Earned: 1.0/1.0 Correct Answer(s): B Diagnostic Tests Kyra's healthcare provider orders serial cardiac enzymes. The diagnosis of myocardial infarction is confirmed by ECG changes and the elevation of cardiac enzymes and isoenzymes. 13. Which ECG change is indicative of myocardial injury? A) ST segment elevation. Feedback: CORRECT ST segment elevation is indicative of myocardial injury. ST segment depression and inverted T waves are indicative of ischemia, and the development of a pathological Q wave is indicative of myocardial necrosis.  B) Peaked P waves. Feedback: INCORRECT The P wave represents depolarization of the atria. Peaked P waves seen in leads II, III and aVF are typically associated with right atrial enlargement, although they may be normal in tall, slender individuals with a more ventrical positioning of the heart. They are not usually indicative of myocardial injury. C) Inverted P wave. Feedback: INCORRECT The P wave represents depolarization of the atria. Inverted P waves are characteristic of dysrhythmias associated with abnormal conduction within the atria or at the atrioventricular junction (AV node). They are indicative of electrical conduction problems within the atria or the AV node (for example, atrial dysrhythmias or junctional rhythms). D) Prolonged PR interval. Feedback: INCORRECT Prolongation of the PR interval is typical of a first-degree AV block, an electrical conduction disturbance within the heart. While development of a conduction block may occur as a result of myocardial injury, the presence of a prolonged PR interval is not itself indicative of myocardial injury. Points Earned: 1.0/1.0 Correct Answer(s): A 14. Which cardiac isoenzyme is the most sensitive indicator for myocardial damage? A) Creatine Kinase - Total (CK). Feedback: INCORRECT Elevation of this enzyme indicates possible myocardial, brain, or skeletal muscle injury. Another isoenzyme is more definitive for myocardial damage. B) Creatine Kinase - MB Fraction (CK-MB). Feedback: CORRECT This is the most sensitive isoenzyme for myocardial damage. Peak elevation occurs within 24 hours. In addition to cardiac isoenzymes, a serum troponin level may be obtained. Troponin is a marker of myocardial injury with a broad diagnostic time frame, especially useful when clients are seen several hours after the suspected infarction has occurred.  C) Lactate Dehydrogenase (LDH). Feedback: INCORRECT LDH, like creatine phosphokinase (CPK), is an enzyme that is nonspecific to cardiac muscle injury. However, LDH1 is a sensitive cardiac isoenzyme, which is often compared with LDH2 as a ratio during the diagnosis of myocardial infarction. D) Low-Density Lipoproteins (LDL). Feedback: INCORRECT Increased serum lipids, such as LDL, indicate a high risk for coronary artery disease, but they are not increased as the result of muscle damage. Points Earned: 1.0/1.0 Correct Answer(s): B Clinical Manifestations The nurse assesses Kyra's symptoms during the myocardial infarction. 15. Which question should the nurse include in the assessment of Kyra's chest pain? A) "Did you follow your diet and exercise plan?" Feedback: INCORRECT During an acute MI is not the appropriate time to discuss long-term management of CAD. B) "Why did the pain start?" Feedback: INCORRECT This is too broad and general a question, and it may be seen as challenging and judgmental by the client. Avoid questions starting with "why." C) "What other symptoms are you experiencing?" Feedback: CORRECT The client should describe the onset, location, duration, and quality of the pain, as well as any pain radiation, such as to the arm, jaw, or back. Additional symptoms, such as dyspnea, palpitations, or diaphoresis should be noted, as well as any actions that were taken in an attempt to relieve the pain.    D) "Did you tell anyone about your pain?" Feedback: INCORRECT This is not critical information at this time. Points Earned: 1.0/1.0 Correct Answer(s): C Nursing Diagnoses & Interventions The nurse also assesses Kyra for changes in vital signs and dysrhythmias. Other assessment findings related to MI include: Dyspnea. Pallor. Diaphoresis. Weakness. Fatigue. Nausea. Vomiting. Fever. Kyra is transferred to the critical care unit for treatment and monitoring. She is still receiving oxygen at 2 L/minute and her IV nitroglycerin infusion. Her vital signs are stable. Her oxygen saturation is 94%, her breath sounds are clear, and she denies any pain at the present time. Kyra's nurse develops a plan of care based on the following nursing diagnoses: Pain related to an imbalance between myocardial oxygen supply and demand. Ineffective tissue perfusion (cardiac) related to blood flow interruption. Activity intolerance related to imbalance between oxygen supply and demand. Anxiety related to pain and fear.   16. Which nursing intervention should be included in the plan of care? A) Encourage Kyra to refrain from discussing fears for the first few days. Feedback: INCORRECT Clients experiencing anxiety may need to discuss their fears to help reduce anxiety, and they should be encouraged to do so. An antianxiety medication, such as alprazolam (Xanax), may be prescribed following MI to reduce the client's anxiety. B) Maintain client in shock position. Feedback: INCORRECT As long as Kyra's vital signs are stable, the nurse should assist her to a position of comfort. Frequently, a semi-Fowler's position is used to relieve the client's dyspnea and promote improved oxygenation. C) Discuss cardiac rehabilitation exercise protocols. Feedback: INCORRECT While cardiac rehabilitation is a vital part of post-MI treatment, it is too early in the course of Kyra's illness to discuss this topic. D) Administer morphine sulfate IV PRN for chest pain. Feedback: CORRECT Following a healthcare provider's prescription or agency protocol, the nurse should ensure that Kyra receives adequate analgesia. Morphine sulfate is frequently prescribed to relieve the pain of myocardial infarction. It should be administered IV to get the fastest relief, and to avoid the muscle damage caused by IM injections. Other important interventions include maintaining oxygen per nasal cannula, ensuring a calm, quiet environment, providing adequate rest with limited stimuli, and then gradually increasing activity.  Points Earned: 0.0/1.0 Correct Answer(s): D A Complication Occurs On her second day post-MI, the nurse notes a change in Kyra's cardiac monitor. Kyra's rhythm strip changed from normal sinus rhythm to sinus rhythm with short runs of ventricular tachycardia. The nurse assesses Kyra, whose blood pressure is now 100/54. She is lethargic, but arousable. 17. Which intervention should the nurse initiate first? A) Place the crash cart in close proximity to the room. Feedback: INCORRECT Since Kyra's condition may be a life-threatening dysrhythmia, this intervention may be required if Kyra's dysrhythmia does not respond to medication. However, this is not the best initial action. B) Administer amiodarone (cordarone) IV push. Feedback: CORRECT The treatment of choice for frequent premature ventricular contractions (PVCs) and ventricular tachycardia is an immediate IV bolus of amiodarone.    C) Hang an IV infusion of dopamine (Intropin). Feedback: INCORRECT Dopamine is a vasopressor and inotropic agent that is used to treat severe hypotension and shock. This intervention may be required if Kyra's dysrhythmia is not controlled and cardiogenic shock develops. However, this is not the best initial action. D) Charge the defibrillator to 200 joules. Feedback: INCORRECT Since Kyra's condition may be a life-threatening dysrthymia, this intervention may be required if Kyra's dysrhythmia does not respond to medication. However, this is not the best initial action. Points Earned: 0.0/1.0 Correct Answer(s): B Percutaneous Transluminal Angioplasty Kyra is started on a continuous IV infusion of lidocaine at 2 mg/minute. The ventricular tachycardia is controlled, and her cardiac monitor strip shows a sinus rhythm with occasional PVCs. The nurse monitors Kyra for adverse effects of the infusion, including hypotension, drowsiness, seizures, bradycardia, and confusion. Kyra is scheduled for Percutaneous Transluminal Coronary Angioplasty (PTCA) via femoral insertion. PTCA involves the insertion of a balloon-tipped catheter into the diseased coronary artery. When the balloon is inflated, it compresses the plaque against the vessel wall, resulting in an increase in the inner diameter of the blood vessel so blood can flow more easily.     18. Which nursing intervention should be implemented when Kyra returns to her room? A) Encourage intake of oral fluids. Feedback: INCORRECT For the first 24 hours following the procedure, intake and output should be monitored, but forcing fluids is not indicated. B) Immobilize the affected leg. Feedback: CORRECT The prevention of catheter dislodgement and of bleeding or oozing at the insertion site are high priorities in the immediate post-procedure period. The site should be immobilized and closely monitored for signs of hematoma formation (bleeding, inflammation, tenderness, or swelling). In addition, distal circulation should be monitored closely by assessment of pedal pulses, color, warmth, and capillary refill. C) Obtain apical pulse every 15 minutes. Feedback: INCORRECT Kyra should be continuously monitored for the onset of any dysrhythmias, but frequent (every 15 minutes) assessment of the apical pulse is not necessary. D) Limit visitors to one per hour. Feedback: INCORRECT Limiting visitors is not routine or necessary, but it should be implemented if Kyra's comfort or safety is jeopardized. Points Earned: 0.0/1.0 Correct Answer(s): B Management Issues: Priorities The next day, Kyra is transferred to the Progressive Cardiac Unit. During report, the nurse is assigned four clients. 19. Which client should the nurse assess first? A) Kyra, post-PTCA, whose pulse distal to the insertion site is +3, with capillary refill of 2 seconds. Feedback: INCORRECT Kyra's condition is stable, and her circulation is strong, so assessment of Kyra is not the highest priority. B) Jack, a client with unstable angina who is complaining of chest discomfort and has been given one nitroglycerin tablet sublingually (SL). Feedback: CORRECT Jack is the least stable of the four clients. The nurse needs to assess the effectiveness of the nitroglycerin and for other symptoms that may indicate the onset of a myocardial infarction. C) Kent, a client 5 days post-MI who is complaining that he is constipated and demands that his healthcare provider be called. Feedback: INCORRECT Although it is important to ensure that clients avoid straining post-MI, another client requires more immediate assessment. D) Carl, a client recently started on propranolol (Inderal) and aspirin for coronary artery disease. Feedback: INCORRECT Carl's condition is stable. Propranolol is a beta-blocker frequently used to reduce myocardial oxygen demand, and aspirin is used to reduce the risk of thrombus formation. Carl's response to the medications should be monitored, but this is not the nurse's most immediate priority. Points Earned: 1.0/1.0 Correct Answer(s): B When determining the highest priority need, the nurse should always intervene first for the client who is the most physiologically unstable, establishing priorities using the ABCs… airway, breathing, and circulation. Ethical-Legal Considerations: Client Rights While the nurse is assessing Kyra, a group of people dressed in street clothes and lab coats enters Kyra's room. They are carrying clipboards and pens, and begin to ask Kyra questions related to her hospitalization. Kyra seems unsure how to respond. 20. The nurse should immediately intervene to prevent violation of which client right? A) The right to be free from assault and battery. Feedback: INCORRECT This client right is not being violated in this situation. B) The right to sufficient information to make an informed decision about treatment. Feedback: INCORRECT This client right is not being violated in this situation. C) The right to have information about the qualifications of caregivers. Feedback: CORRECT The persons in the group should wear name tags that clearly identify their role, introduce themselves, and explain to Kyra why they would like to ask her some questions. Clients have the right to privacy during examination and treatment, as well as the right to refuse observation by those not directly involved in their care. D) The right to health care without discrimination. Feedback: INCORRECT This client right is not being violated in this situation. Points Earned: 1.0/1.0 Correct Answer(s): C Discharge Preparation The nurse asks the group to leave Kyra's room and determines that they are a group of beginning nursing students learning to interview clients. The nurse reviews the importance of promoting client rights and ways to achieve this. Upon learning the students' goal, Kyra is delighted to visit with them, and she talks at length about her impending discharge, the concerns she has, and her plans to engage in a healthier lifestyle. The nurse completes Kyra's discharge teaching and schedules Kyra to begin therapy at the Cardiac Rehabilitation Unit the following week. 21. Which expected outcome indicates that the nurse's discharge teaching was effective? A) Kyra chooses walking as her initial form of exercise. Feedback: CORRECT Walking is the best initial activity/exercise for the post-MI client. Kyra should be instructed to establish a gradually progressive walking schedule and to assess pulse and tolerance when increasing activity. Activities such as heavy lifting that cause straining should be avoided for several weeks.  B) Kyra recognizes the need to avoid all aspirin products. Feedback: INCORRECT This is not an expected outcome, unless the client is taking a prescribed anticoagulant, such as warfarin (Coumadin). Daily low-dose aspirin is frequently prescribed to reduce the risk for thrombosis. C) Kyra talks with her husband about avoiding sexual intercourse for the next 6 months. Feedback: INCORRECT This is not an expected outcome. Sexual activity can be resumed once Kyra's tolerance to activity has been assessed. Generally, once the client can tolerate walking about a block, or climbing two flights of stairs, intercourse can be resumed. The nurse should instruct the client regarding measures such as positioning and wait at least half an hour after eating to avoid undue strain, and the prophylactic use of nitroglycerin prior to intercourse. D) Kyra states she feels confident about driving herself home from the hospital. Feedback: INCORRECT This is not a desired outcome. Clients discharged post-MI can be weak and fatigue easily. Activities that could cause straining or excessive stress should be avoided. Points Earned: 1.0/1.0 Correct Answer(s): A Case Outcome Kyra continues to work closely with the cardiac rehabilitation house nurse and the healthcare provider. Over the next year, she loses 20 pounds by working with a nutritionist and walking for one hour 5 days a week. Kyra also quit smoking. Although her job remains stressful, Kyra practices meditation daily to decrease her stress levels.