# A 65-year-old female patient is admitted to the coronary care unit with an acute ST-elevation myocardial infarction. She underwent successful PCI with stent placement to the left anterior descending artery. Continuous cardiac monitoring shows normal sinus rhythm with occasional premature ventricular contractions. Laboratory results show elevated troponin levels and mild hyponatremia. The patient has a history of hypertension and diabetes mellitus type 2. > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=540263 > language: ko > subject: Adult Health ## 문제 A 65-year-old female patient is admitted to the coronary care unit with an acute ST-elevation myocardial infarction. She underwent successful PCI with stent placement to the left anterior descending artery. Continuous cardiac monitoring shows normal sinus rhythm with occasional premature ventricular contractions. Laboratory results show elevated troponin levels and mild hyponatremia. The patient has a history of hypertension and diabetes mellitus type 2. ## 보기 1. Administer prescribed morphine sulfate for chest pain relief 2. Increase oxygen flow rate to 4L nasal cannula to improve oxygenation 3. Encourage deep breathing exercises to reduce anxiety 4. Assess for signs of cardiogenic shock and notify the physician immediately **✔ 정답** **정답: 4** ## 해설 The patient's acute STEMI status requires vigilant assessment for complications like cardiogenic shock, which is life-threatening and demands immediate intervention. Other options address supportive care but are lower priority in this high-risk scenario. ## 심화 해설 Correct Answer: 4. Assess for signs of cardiogenic shock and notify the physician immediately The immediate priority for this patient is a focused assessment for a life-threatening mechanical complication of myocardial infarction (MI). While the patient has undergone successful percutaneous coronary intervention (PCI), the post-procedural period carries a risk of catastrophic structural complications, most notably papillary muscle rupture (PMR). This is a rare but frequently fatal event that leads to acute, severe mitral regurgitation and rapid hemodynamic collapse. Pathophysiology and Clinical Reasoning The left anterior descending (LAD) artery typically supplies the anterolateral papillary muscle, while the posterior descending artery supplies the posteromedial papillary muscle. A transmural infarction in the LAD territory can cause partial or complete rupture of the papillary muscle, which is structurally vulnerable due to its single blood supply. The provided evidence describes PMR as a "rare and life-threatening complication" that can present with "intractable pulmonary oedema" [1]. This manifests clinically as acute-onset dyspnea, crackles, hypotension, and a new holosystolic murmur, which are hallmark signs of cardiogenic shock. The patient's history of hypertension and diabetes increases her risk for adverse outcomes, and the presence of elevated troponin and hyponatremia indicates significant myocardial stress and neurohormonal activation. A systematic assessment for signs of shock—including altered mentation, oliguria, cool extremities, and worsening hemodynamics—is the critical nursing action to detect this deterioration early. Analysis of Incorrect Options - Option 1: Administering morphine is a standard intervention for ischemic chest pain and anxiety, and it has the beneficial effect of preload reduction. However, the question does not indicate the patient is currently experiencing chest pain. Administering a vasodilator and central nervous system depressant without first confirming hemodynamic stability could mask the early signs of shock or exacerbate hypotension from a new mechanical complication. - Option 2: Increasing oxygen flow to 4L nasal cannula is not a priority without evidence of hypoxia. While pulmonary edema from PMR causes respiratory distress, the immediate nursing action is to recognize the underlying cause—a structural cardiac defect—not simply to apply supportive oxygen. In the case of severe mitral regurgitation, oxygenation will not improve until the hemodynamic derangement is addressed, which often requires mechanical support like an intra-aortic balloon pump (IABP) as mentioned in the case report [1]. - Option 3: Deep breathing exercises are a non-pharmacological intervention for anxiety. In the context of a potential mechanical complication where the patient may be developing fulminant pulmonary edema from acute mitral regurgitation, this intervention is inappropriate and delays life-saving medical and surgical management. NCLEX-RN Priority-Setting Framework This scenario tests the principle of prioritizing assessment over intervention when a patient’s status is unstable or at high risk for a sudden change. Using the nursing process, assessment must precede implementation. The patient has a known risk factor (acute STEMI) for a high-mortality complication (PMR). The nurse’s primary responsibility is to recognize the subtle, early signs of this complication through vigilant assessment. The case report underscores that a definitive diagnosis was made via transthoracic and transoesophageal echo after the patient developed refractory pulmonary edema, highlighting that the nurse's clinical suspicion and assessment data are the triggers for such urgent diagnostic and therapeutic steps [1]. The correct sequence is to first assess for signs of shock, then notify the physician to escalate care, which may include emergent echocardiography and mechanical circulatory support.References (research sources) - [1]Fully percutaneous emergency management of an acute myocardial infarction complicated by papillary muscle rupture treated with percutaneous revascularization and mitral transcatheter edge-to-edge repair: a case report.Case reportPennacchi M, De Felice F, Pergolini A, Pingitore A, Gabrielli D. (2026) · DOI: 10.1093/ehjcr/ytag407 ## 임상 시나리오 Post-PCI Monitoring for Mechanical ComplicationsPrioritizing Assessment for Papillary Muscle Rupture Following PCI for STEMI, the immediate nursing priority is a focused assessment to detect life-threatening mechanical complications, primarily papillary muscle rupture. This can occur 2-7 days post-MI. Key assessment findings for acute mitral regurgitation and cardiogenic shock include a new, loud holosystolic murmur at the apex, acute pulmonary edema (crackles, dyspnea), and hypotension. CautionA new murmur with sudden hemodynamic deterioration is a surgical emergency. Do not delay notification of the physician for symptom management; the patient requires immediate echocardiography and likely surgical repair. ## 핵심 개념 - **Papillary Muscle Rupture** — A rare, life-threatening mechanical complication of MI where a heart muscle supporting the mitral valve tears, causing acute severe mitral regurgitation and cardiogenic shock. - **Cardiogenic Shock** — A state of end-organ hypoperfusion due to cardiac pump failure, often presenting with hypotension, altered mental status, pulmonary edema, and oliguria. - **PCI (Percutaneous Coronary Intervention)** — A non-surgical procedure using a catheter to place a stent to open coronary arteries blocked by atherosclerosis, commonly performed during an acute MI. ## 같은 주제 문제 - [A 45-year-old female with diabetes presents with sudden onset of severe substernal chest p…](https://mymerci.kr/pages/nclex_q.php?qn_id=540260) - [A 65-year-old female patient presents to the emergency department with chest pain that beg…](https://mymerci.kr/pages/nclex_q.php?qn_id=540261) - [A 58-year-old patient is admitted to the coronary care unit with an acute ST-elevation myo…](https://mymerci.kr/pages/nclex_q.php?qn_id=540262) - [A 58-year-old patient is admitted to the coronary care unit with unstable angina and recei…](https://mymerci.kr/pages/nclex_q.php?qn_id=540264) - [A 45-year-old male patient is admitted to the emergency department with chest pain that st…](https://mymerci.kr/pages/nclex_q.php?qn_id=540265) - [A 65-year-old female patient is admitted to the emergency department with acute chest pain…](https://mymerci.kr/pages/nclex_q.php?qn_id=540266) --- More free questions: [기출문제](https://mymerci.kr/) _학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요._