Chapter 37: Coronary Artery Disease and Acute Coronary Syndrome

A patient hospitalized for evaluation of unstable angina reports severe chest pain. Prioritize the following interventions from 1 (highest priority) to 6 (lowest priority). All interventions are available to the nurse. a. Notify the provider. b. Obtain a 12-lead ECG. c. Check the patient's vital signs. d. Apply oxygen per nasal cannula. e. Perform a focused assessment of the chest. f. Assess pain (PQRST) and medicate as ordered.

1. d; 2. c; 3. b; 4. f; 5. e; 6. a 4. A patient having chest pain needs to have the pain assessed and relieved as quickly as possible. Applying oxygen may help relieve the pain. Following an assessment of the vital signs, it is important to know if the pain is accompanied by ECG changes. Then perform a detailed assessment of the pain using PQRST and medicate as ordered. Perform a focused assessment of the heart and lungs before reporting the findings to the provider.

Tachycardia that is a response of the sympathetic nervous system to the pain of ischemia is detrimental because it increases oxygen demand and a. increases cardiac output. b. causes reflex hypotension. c. may lead to atrial dysrhythmias. d. impairs perfusion of the coronary arteries.

d. An increased heart rate (HR) decreases the time the heart spends in diastole, which is the time of greatest coronary blood flow. Unlike other arteries, coronary arteries are perfused when the myocardium relaxes and blood backflows from the aorta into the sinuses of Valsalva, which have openings to the right and left coronary arteries. Thus the heart has a decreased oxygen supply at a time when there is an increased oxygen demand. Tachycardia may also lead to ventricular dysrhythmia. The other options are incorrect.

While assessing the patient who had an MI, the nurse auscultates crackles in the lungs and an S3 heart sound. Which complication would the nurse suspect? a. Pericarditis b. Heart failure c. Ventricular aneurysm d. Papillary muscle dysfunction

. b. Left-sided HF, which can escalate to cardiogenic shock, initially occurs and manifests as mild dyspnea, restlessness, agitation, pulmonary congestion with crackles, and/or S3 or S4 heart sounds. Right-sided HF includes jugular vein distention, hepatic congestion, or lower extremity edema. Pericarditis is a common complication identified with chest pain that is aggravated by inspiration, coughing, and moving the upper body. Ventricular aneurysm is manifested with HF, dysrhythmias, and angina. Papillary muscle dysfunction is suspected with a new systolic apical murmur.

The nurse is encouraging a sedentary patient, with major risks for CAD, to perform physical exercise on a regular basis. In addition to decreasing the risk factor of physical inactivity, the nurse tells the patient that exercise will directly contribute to reducing which risk factors? a. Diabetes and hypertension b. Hyperlipidemia and obesity c. Increased serum lipids and stressful lifestyle d. Hypertension and increased serum homocysteine

Increased exercise without an increase in caloric intake will result in weight loss, reducing the risk associated with obesity. Exercise increases lipid metabolism and increases HDL, thus reducing CAD risk. Exercise may indirectly reduce the risk of CAD by controlling hypertension, promoting glucose metabolism in diabetes, and reducing stress. While high blood levels of homocysteine are linked to an increased risk for CAD, reducing homocysteine levels has not been shown to reduce the risk of heart disease.

Which effects contribute to making nitrates the first-line therapy for the treatment of angina? Select all that apply. a. Decrease preload b. Decrease afterload c. Dilate coronary arteries d. Decrease heart rate (HR) e. Prevent thrombosis of plaques f. Decrease myocardial contractility

a, b, c. Nitrates decrease preload and afterload to decrease the coronary workload and dilate coronary arteries to increase coronary blood supply. The other options are not attributed to nitrates.

During a routine health examination, a 48-year-old patient is found to have a total cholesterol level of 224 mg/dL (5.8 mmol/L) and an LDL level of 140 mg/dL (3.6 mmol/L). What diet changes would the nurse teach the patient to make? Select all that apply. a. Use fat-free milk b. Abstain from alcohol use c. Reduce red meat in the diet d. Eliminate intake of simple sugars e. Avoid foods prepared with egg yolks

a, c, e. Therapeutic Lifestyle Changes diet recommendations emphasize reduction in saturated fat and cholesterol intake. Whole milk products, red meats, and eggs as well as butter, stick margarine, lard, and solid shortening should be reduced or eliminated from diets. If triglyceride levels are high, alcohol and simple sugars should be reduced.

When teaching a patient with angina about taking sublingual NTG tablets, what would the nurse include? a. Lie or sit and place 1 tablet under the tongue when chest pain occurs. b. Take the tablet with a large amount of water so it will dissolve right away. c. If 1 tablet does not relieve the pain in 15 minutes, go to the hospital. d. If the tablet causes dizziness and a headache, stop the medication and call the doctor or go to the hospital.

a. A common complication of nitrates is dizziness caused by orthostatic hypotension, so the patient should sit or lie down and place the tablet under the tongue. The tablet should be allowed to dissolve under the tongue. To prevent the tablet from being swallowed, water should not be taken with it. The recommended dose for the patient for whom nitroglycerin (NTG) has been prescribed is 1 tablet taken sublingually (SL) or 1 metered spray for symptoms of angina. If symptoms are unchanged or worse after 5 minutes, the patient should contact the emergency medical system (EMS) before taking more NTG. If symptoms are significantly improved by 1 dose of NTG, teach the patient or caregiver to repeat NTG every 5 minutes for a maximum of 3 doses and contact EMS if symptoms have not resolved completely. Headache is a common complication of nitrates but usually resolves with continued use of nitrates. It may be controlled with mild analgesics.

A 58-year-old patient is in a cardiac rehabilitation program. Which sign or symptom would the nurse teach the patient is a reason to stop exercising? a. Pain or dyspnea develop b. The HR exceeds 150 bpm c. The respiratory rate increases to 30 d. The HR is 30 bpm over the resting HR

a. Any activity or exercise that causes dyspnea and chest pain should be stopped in the patient with CAD. The training target for a healthy 58-year-old is 80% of maximum HR, or 130 bpm. HR, rather than respiratory rate, determines the parameters for exercise.

Which activity would the nurse and patient identify as a moderate-energy activity during rehabilitation after an MI? a. Golfing b. Walking at 5 mph c. Cycling at 13 mph d. Mowing the lawn using a push lawnmower

a. Golfing is a moderate-energy activity that expends about 5 metabolic equivalent units (METs). It is within the 3 to 6 METs activity level desired for a patient by the time of discharge from the hospital following an MI. Walking at 5 mph and mowing the lawn using a push mower are high-energy activities. Cycling at 13 mph is an extremely high-energy activity.

The nurse evaluates that thrombolytic therapy for the treatment of an MI has not been successful based on which manifestation? a. Continues to have chest pain b. Develops gastrointestinal (GI) bleeding c. Has a marked increase in CK-MB levels within 3 hours of therapy d. Develops premature ventricular contractions and ventricular tachycardia during treatment

a. If chest pain is unchanged, it is a sign that reperfusion was not successful. Indications that the occluded coronary artery is patent and blood flow to the myocardium is reestablished following thrombolytic therapy include return of ST-segment to baseline on the ECG; relief of chest pain; marked, rapid rise of the CK-MB within 3 hours of therapy; and the presence of reperfusion dysrhythmias. Bleeding is a complication of thrombolytic therapy but does not indicate lack of success or successful reperfusion.

A patient is hospitalized after a successful resuscitation of an episode of sudden cardiac death (SCD). During the care of the patient, what nursing intervention is most important? a. Continuous ECG monitoring b. Auscultation of the carotid arteries c. Frequent assessment of heart sounds d. Monitoring airway status and respirations

a. Many patients who have a sudden cardiac death (SCD) experience because of CAD do not have an acute MI but have dysrhythmias that cause death. This is probably because of electrical instability of the myocardium. To identify and treat those specific dysrhythmias, continuous monitoring is important. The other assessments can be done but are not the most important after an episode of SCD.

A patient is reporting chest pain. What would cause the nurse to suspect the patient is experiencing stable angina rather than a myocardial infarction? a. The pain is relieved by NTG. b. The pain is described as a sensation of tightness or squeezing. c. The pain does not radiate to the neck, back, or arms. d. The pain is precipitated by physical or emotional exertion.

a. One of the primary differences between the pain of angina and the pain of an MI is that angina pain is usually relieved by rest or NTG, which reduces the oxygen demand of the heart, while MI pain is not. Both angina and MI pain can cause a pressure or squeezing sensation; may or may not radiate to the neck, back, arms, fingers, and jaw; and may be precipitated by exertion.

A patient is in the ICU with a diagnosis of NSTEMI. Which drugs would the nurse expect the patient to receive? (select all that apply) a. Oral statin therapy b. Antiplatelet therapy c. Thrombolytic therapy d. Prophylactic antibiotics e. Intravenous nitroglycerin

a. Oral statin therapy b. Antiplatelet therapy e. Intravenous nitroglycerin

The nurse is teaching an older adult with CAD about the treatment for angina. What instructions would the nurse include? a. Sit for 2 to 5 minutes before standing when getting out of bed b. Exercise only twice a week to avoid unnecessary strain on the heart c. Lifestyle changes are not as necessary as they would be in a younger person d. Aspirin therapy is contraindicated in older adults because of the risk for bleeding

a. Orthostatic hypotension may cause dizziness and falls in older adults taking antianginal agents that decrease preload. Patients should be cautioned to change positions slowly. Daily exercise programs are indicated for older adults and may increase performance, endurance, and ability to tolerate stress. A change in lifestyle behaviors may increase the quality of life and reduce the risks of CAD, even in the older adult. Aspirin is often used in these patients and is not contraindicated.

A patient with an MI is exhibiting anxiety while being taught about possible lifestyle changes. Which patient statement indicates to the nurse that the anxiety is relieved? a. "I'm going to take this recovery one step at a time." b. "I feel much better and am ready to get on with my life." c. "How soon do you think I will be able to go back to work?" d. "I know you are doing everything possible to save my life."

a. This patient is indicating positive coping with a realization that recovery takes time and that lifestyle changes can be made as needed. The patient who is "just going to get on with life" is likely in denial about the seriousness of the condition and the changes that must be made. Nervous questioning about the expected duration and effect of the condition indicates the presence of anxiety, as does the statement about the HCP's role in treatment.

Which characteristics are associated with LDLs? Select all that apply. a. Increases with exercise b. Contains the most cholesterol c. Has an affinity for arterial walls d. Carries lipids away from arteries to liver e. High levels correlate most closely with CAD f. The higher the level, the lower the risk for CAD

b, c, e. LDLs contain more cholesterol than the other lipoproteins, have an attraction for arterial walls, and correlate most closely with increased incidence of atherosclerosis and CAD. HDLs increase with exercise and carry lipids away from arteries to the liver for metabolism. A high HDL level is associated with a lower risk of CAD.

What are manifestations of acute coronary syndrome (ACS)? Select all that apply. a. Dysrhythmia b. Stable angina c. Unstable angina d. ST-segment-elevation myocardial infarction (STEMI) e. Non-ST-segment-elevation myocardial infarction (NSTEMI)

b, d, e, f. Increased oxygen demand is caused by increasing the workload of the heart, including left ventricular hypertrophy with hypertension, sympathetic nervous stimulation, and anything precipitating angina. Hypovolemia, anemia, and narrowed coronary arteries contribute to decreased oxygen supply.

Which characteristics describe unstable angina? Select all that apply. a. Usually precipitated by exertion b. New-onset angina with minimal exertion c. Occurs only when the person is recumbent d. Characterized by increased duration or severity e. Usually occurs in response to coronary artery spasm

b, d. Unstable angina is new-onset angina occurring at rest or with minimal exertion and increases in frequency, duration, or severity. Chronic stable angina is usually precipitated by exertion. Angina decubitus occurs when the person is recumbent. Prinzmetal's angina is often caused by a coronary artery spasm.

The nurse would teach which patients to make diet changes to reduce the risk of CAD? a. Patients who have had an MI b. All patients to reduce CAD risk c. Those with 2 or more risk factors for CAD d. Those with a cholesterol level > 200 mg/dL (5.2 mmol/L)

b. The Therapeutic Lifestyle Changes diet includes recommendations for all people, not just those with risk factors, to decrease the risk for CAD

What statement accurately describes the pathophysiology of CAD? a. Partial or total occlusion of the coronary artery occurs during the stage of raised fibrous plaque. b. Endothelial changes are caused by chemical irritants, such as hyperlipidemia or tobacco use. c. Collateral circulation in the coronary circulation is more likely to be present in the young patient with CAD. d. The leading theory of atherogenesis proposes that infection and fatty dietary intake are the basic underlying causes of atherosclerosis.

b. The etiology of CAD includes atherosclerosis as the major cause. The pathophysiology of atherosclerosis development and resulting atheromas is related to endothelial injury and inflammation, which can be the result of tobacco use, hyperlipidemia, hypertension, toxins, diabetes, high homocysteine levels, and infection causing a local inflammatory response in the inner lining of the vessel walls. Partial or total occlusion occurs in the complicated lesion stage. Extra collateral circulation occurs in the presence of chronic ischemia. Therefore it is more likely to occur in an older patie

Which patient does the nurse identify as having the greatest risk for CAD? a. A white man, age 54 years, who is a smoker and has a stressful lifestyle b. A white woman, age 75 years, with a BP of 172/100 mm Hg and who is physically inactive c. An Asian woman, age 45 years, with a cholesterol level of 240 mg/dL and a BP of 130/74 mm Hg d. An obese Hispanic man, age 65 years, with a cholesterol level of 195 mg/dL and a BP of 128/76 mm H

b. This white woman has 1 unmodifiable risk factor (age) and 2 major modifiable risk factors (hypertension and physical inactivity). Her gender risk is as high as a man's because she is 75 years of age. The white man has 1 unmodifiable risk factor (gender), 1 major modifiable risk factor (smoking), and 1 contributing modifiable risk factor (stressful lifestyle). The Asian woman has only 1 major modifiable risk factor (hyperlipidemia), and Asian persons in the United States have fewer myocardial infarctions (MIs) than do White persons. The Hispanic man has an unmodifiable risk factor related to age and 1 major modifiable risk factor (obesity). Hispanic persons have slightly lower rates of CAD than non-Hispanic White persons or Black persons.

After teaching a patient about ways to decrease risk factors for CAD, which patient statement indicates to the nurse that further instruction is needed? a. "I can keep my blood pressure normal with medication." b. "I would like to add weightlifting to my exercise program." c. "I can change my diet to decrease my intake of saturated fats." d. "I will change my lifestyle to reduce activities that increase my stress."

b. "I would like to add weightlifting to my exercise program."

Which information would the nurse include in teaching a patient about CAD? (select all that apply) a. Diffuse involvement of plaque formation in coronary veins b. Abnormal levels of cholesterol, especially low-density lipoproteins c. Accumulation of lipid and fibrous tissue within the coronary arteries d. Development of angina due to a decreased blood supply to the heart muscle e. Chronic vasoconstriction of coronary arteries leading to permanent vasospasm

b. Abnormal levels of cholesterol, especially low-density lipoproteins c. Accumulation of lipid and fibrous tissue within the coronary arteries

A patient admitted to the hospital for evaluation of chest pain has normal serum cardiac biomarkers 4 hours after the onset of pain. What noninvasive diagnostic test can be used to differentiate angina from other types of chest pain? a. 12-lead ECG b. Exercise stress test c. Coronary angiogram d. Transesophageal echocardiogram

b. An exercise stress test will reveal ECG changes that indicate impaired coronary circulation when the oxygen demand of the heart is increased. A single ECG is not conclusive for CAD, and negative findings do not rule out CAD. Coronary angiography can detect narrowing of coronary arteries but is an invasive procedure. Echocardiograms of various types may identify abnormalities of myocardial wall motion under stress but are indirect measures of CAD.

What is the rationale for giving docusate sodium (Colace) to a patient after an MI? a. Relieves cardiac workload b. Minimizes vagal stimulation c. Controls ventricular dysrhythmias d. Prevents the binding of fibrinogen to platelets

b. Docusate sodium (Colace) is a stool softener, which prevents straining and provoking dysrhythmias. It does not do any of the other options. Antidysrhythmics are used to control ventricular dysrhythmias; morphine sulfate is used to decrease anxiety and cardiac workload; and glycoprotein IIb/IIIa inhibitors and antiplatelets prevent the binding of fibrinogen to platelets.

Which serum lipid elevation, along with high LDL, is strongly associated with CAD? a. Apolipoproteins b. Fasting triglycerides c. Total serum cholesterol d. High-density lipoprotein (HDL)

b. High fasting triglyceride levels are associated with cardiovascular disease and diabetes. Apolipoproteins are found in varying amounts on the HDLs and activate enzyme or receptor sites that promote removal of fat from plasma, which is protective. The apolipoprotein A and apolipoprotein B ratio must be done to predict CAD. High total serum cholesterol must be calculated with HDL for a ratio over time to determine an increased risk of CAD.

A hospitalized patient with a history of chronic stable angina tells the nurse they are having chest pain. Which information about ischemia would the nurse use as a basis for planning care? a. It will always progress to myocardial infarction. b. It can be relieved by rest, nitroglycerin, or both. c. It is often associated with vomiting and extreme fatigue. d. It indicates that irreversible myocardial damage is occurring.

b. It can be relieved by rest, nitroglycerin, or both.

What advice about sexual activity would the nurse give to a male patient who had an MI? a. The patient should use the superior position. b. Prophylactic NTG may be used if angina occurs. c. Foreplay may cause too great an increase in HR. d. Performance can be enhanced with the use of sildenafil (Viagra).

b. It is common for a patient who has chest pain on exertion to have some angina during sexual stimulation or intercourse. Teach the patient to use NTG prophylactically. Positions during intercourse are a matter of individual choice, and foreplay is desirable because it allows a gradual increase in HR. Sildenafil (Viagra) should be used cautiously in men with CAD and should not be used with nitrates.

A patient who has hypertension just had an MI. Which type of medication would the nurse expect to administer with the goal of decreasing cardiac workload? a. ACE inhibitor b. β-adrenergic blocker c. Calcium channel blocker d. Angiotensin II receptor blocker (ARB)

b. It is recommended that patients with hypertension and after an MI be on β-adrenergic blockers indefinitely to decrease oxygen demand. They inhibit sympathetic nervous stimulation of the heart; reduce heart rate, contractility, and BP; and decrease afterload. Although calcium channel blockers decrease heart rate, contractility, and BP, they are not used unless the patient cannot tolerate β-adrenergic blockers. ACE inhibitors and angiotensin II receptor blockers (ARBs) are used for vasodilation.

The nurse is caring for a patient who is 2 days post MI. The patient reports that chest pain when taking a deep breath. Which action would be a priority? a. Notify the provider STAT and obtain a 12-lead ECG. b. Obtain vital signs and auscultate for a pericardial friction rub. c. Apply high-flow O2 by face mask and auscultate breath sounds. d. Medicate the patient with an opiate analgesic and reevaluate in 30 minutes.

b. Obtain vital signs and auscultate for a pericardial friction rub.

What is the nurse's best approach when counseling the patient about sexual activity following an MI? a. Wait for the patient to ask about resuming sexual activity. b. Discuss sexual activity while teaching about other physical activity. c. Have the patient ask the health care provider when sexual activity can be resumed. d. Inform the patient that impotence is a common long-term complication following an MI.

b. Resumption of sexual activity is often difficult for patients to approach. It is reported that most cardiac patients do not resume sexual activity after MI. The nurse can give the patient permission to discuss concerns about sexual activity by introducing it as a physical activity when other physical activities are discussed. HCPs may have preferences about the timing of resumption of sexual activity. The nurse should discuss this with the HCP and the patient but addressing the patient's concerns is a nursing responsibility. Patients should be taught that impotence after MI is common but that it usually disappears after several attempts

In planning care for a patient who has just returned to the unit following a PCI, which activity can the nurse delegate to assistive personnel (AP)? a. Monitor the IV fluids and measure urine output. b. Check vital signs and report changes in HR, BP, or pulse oximetry. c. Explain to the patient the need for frequent vital signs and pulse checks. d. Assess circulation to the extremity used by checking pulses, skin temperature, and color.

b. The AP can check vital signs and report results to the RN. The other actions include assessment, teaching, and monitoring of IV fluids, which are all responsibilities of the RN.

Myocardial ischemia occurs because of increased oxygen demand and decreased oxygen supply. What factors and disorders result in increased oxygen demand? Select all that apply. a. Hypovolemia or anemia b. Increased cardiac workload with aortic stenosis c. Narrowed coronary arteries from atherosclerosis d. Angina in the patient with atherosclerotic coronary arteries e. Left ventricular hypertrophy caused by chronic hypertension f. Sympathetic nervous system stimulation by drugs, emotions, or exertion

c, d, e. Unstable angina, ST-segment-elevation myocardial infarction (STEMI), and non-ST-segment-elevation myocardial infarction (NSTEMI) are conditions that are manifestations of acute coronary syndrome (ACS). The other options are not manifestations of ACS.

What types of angina can occur in the patient who does not have CAD? Select all that apply. a. Silent ischemia b. Nocturnal angina c. Prinzmetal's angina d. Microvascular angina e. Chronic stable angina

c, d. Prinzmetal angina and microvascular angina may occur in the absence of CAD but with arterial spasm in Prinzmetal angina or abnormalities of the coronary microcirculation. Silent ischemia is prevalent in persons with diabetes and contributes to asymptomatic myocardial ischemia. Nocturnal angina occurs only at night. Chronic stable angina refers to chest pain that occurs with the same pattern of onset, duration, and intensity intermittently over a long period of time.

Which patient is most likely to be in the fibrous stage of development of coronary artery disease (CAD)? a. Age 40 years, thrombus adhered to the coronary artery wall b. Age 50 years, rapid onset of disease with hypercholesterolemia c. Age 32 years, thickened coronary arterial walls with narrowed vessel lumen d. Age 19 years, high low-density lipoprotein (LDL) cholesterol, lipid-filled smooth muscle cells

c. The fibrous plaque stage has progressive changes that can be seen by age 30 years. Collagen covers the fatty streak and forms a fibrous plaque in the artery. The thrombus adheres to the arterial wall in the complicated lesion stage. Rapid onset of coronary artery disease (CAD) with hypercholesterolemia may be related to familial hypercholesterolemia, not a stage of CAD development. The fatty streak stage is the earliest stage of atherosclerosis and can be seen by age 20 years.

A second 12-lead ECG performed on a patient 4 hours after the onset of chest pain reveals ST segment elevation. What does this finding indicate? a. Transient ischemia typical of unstable angina b. Lack of permanent damage to myocardial cells c. MI associated with prolonged and complete coronary thrombosis d. MI associated with transient or incomplete coronary artery occlusion

c. A differentiation is made between MIs that have ST-segment elevations on ECG and those that do not because chest pain accompanied by ST-segment elevations is associated with prolonged and complete coronary thrombosis and is treated with reperfusion therapy. The other options are incorrect.

What initial treatment would the nurse expect when caring for a patient with a NSTEMI? a. PCI b. CABG c. Acute intensive drug therapy d. Reperfusion therapy with thrombolytics

c. An NSTEMI is an ACS that indicates a transient thrombosis or incomplete coronary artery occlusion. Treatment involves intensive drug therapy with antiplatelets, glycoprotein IIb/IIIa inhibitors, antithrombotics, and heparin to prevent clot extension. In addition, IV NTG is used. Reperfusion therapy using thrombolytics, CABG, or PCI is used for treatment of STEMI.

At what point in the healing process of the myocardium following an infarct does early scar tissue result in an unstable heart wall? a. 2 to 4 days after MI b. 4 to 10 days after MI c. 10 to 14 days after MI d. 6 weeks after MI

c. At 10 to 14 days after MI, the new scar tissue is weak and is vulnerable to increased stress because of the unstable state of healing at this point, as well as the increasing physical activity of the patient. At 2 to 4 days, removal of necrotic tissue is taking place by phagocytic cells. By 4 to 10 days, the necrotic tissue has been cleared and a collagen matrix for scar tissue has been deposited. Healing with scar-tissue replacement of the necrotic area is usually complete in 6 weeks.

A patient is recovering from an uncomplicated MI. Which rehabilitation guideline is a priority to include in the teaching plan? a. Refrain from sexual activity for a minimum of 3 weeks. b. Plan a diet program that aims for a 1- to 2-lb. weight loss per week. c. Begin an exercise program that aims for at least 5 30-minute sessions per week. d. Consider the use of erectile agents and prophylactic NTG before sexual activity.

c. Begin an exercise program that aims for at least 5 30-minute sessions per week.

In the patient who reports chest pain, which results can distinguish unstable angina from an MI? a. ECG changes present at the onset of the pain b. A chest x-ray showing left ventricular hypertrophy c. Serum troponin levels increased 4 to 6 hours after the onset d. Creatine kinase MB (CK-MB) elevations that peak 6 hours after the infarct

c. Cardiac-specific troponin T and troponin I have a greater sensitivity and specificity for myocardial injury than creatine kinase MB (CK-MB), are released 4 to 6 hours after the onset of MI, peak in 10 to 24 hours, and return to baseline over 10 to 14 days. CK-MB levels begin to rise 6 hours after an acute MI, peak in about 18 hours, and return to normal within 24 to 36 hours. ECG changes are often not apparent immediately after infarct and may be normal when the patient seeks medical attention. An enlarged heart, determined by x-ray, indicates cardiac stress but is not diagnostic of acute MI.

During treatment with reteplase (Retavase) for a patient with a STEMI, which finding would most concern the nurse? a. Oozing of blood from the IV site b. BP of 102/60 mm Hg with an HR of 78 bpm c. Decrease in the responsiveness of the patient d. Intermittent accelerated idioventricular rhythms

c. Decreasing level of consciousness (LOC) may reflect hypoxemia resulting from internal bleeding, which is always a risk with thrombolytic therapy. Oozing of blood is expected, as are reperfusion dysrhythmias. BP is low but not considered abnormal because the pulse is within normal range. Idioventricular dysrhythmias are common with reperfusion.

Which finding is the strongest predictor of risk for sudden cardiac death? a. Aortic valve disease b. Mitral valve disease c. Left ventricular dysfunction d. Atherosclerotic heart disease

c. Left ventricular dysfunction

What would the nurse do to detect and treat the most common complication of MI? a. Measure hourly urine output. b. Auscultate the lungs for crackles. c. Use continuous cardiac monitoring. d. Take vital signs every 2 hours for the first 8 hours.

c. The most common complication of MI is dysrhythmias. Continuous cardiac monitoring allows identification and treatment of dysrhythmias that may cause further deterioration of the cardiovascular status or death. Measurement of hourly urine output and vital signs is indicated to detect symptoms of the complication of cardiogenic shock. Crackles, dyspnea, and tachycardia may indicate the onset of heart failure (HF).

A patient is scheduled to have CABG surgery. How would the nurse explain the procedure? a. A synthetic graft will be used as a tube for blood flow from the aorta to a coronary artery distal to an obstruction. b. A stenosed coronary artery will be resected, and a synthetic arterial tube graft will be inserted to replace the diseased artery. c. The internal mammary artery will be detached from the chest wall and attached to a coronary artery distal to the stenosis. d. Reversed segments of a saphenous artery from the aorta will be anastomosed to the coronary artery distal to an obstruction.

c. The most common method of coronary artery bypass involves leaving the internal mammary artery attached to its origin from the subclavian artery but dissecting it from the chest wall and anastomosing it distal to an obstruction in a coronary artery. Other grafts options include using the saphenous vein, and/or radial artery.

What phrase describes transmyocardial laser revascularization (TMR)? a. Structure applied to hold vessels open b. Requires anticoagulation following the procedure c. Laser-created channels in the heart muscle to allow blood flow to ischemic areas d. Surgical construction of new vessels to carry blood beyond obstructed coronary artery

c. Transmyocardial laser revascularization (TMR) is a treatment used for patients with inoperable CAD. It uses a high-energy laser to create channels in the heart to allow blood to flow to the ischemic area and can be done using a left anterior thoracotomy incision or with coronary artery bypass graft (CABG) surgery. A stent is the structure used to hold vessels open and requires anticoagulation following the procedure. Surgical construction of new vessels is done with CABG surgery.

Why must unstable angina be identified and rapidly treated? a. The pain may be severe and disabling. b. Electrocardiogram (ECG) changes and dysrhythmias may occur during an attack. c. Rupture of unstable plaque may cause complete thrombosis of the vessel lumen. d. Spasm of a major coronary artery may cause total occlusion of the vessel with progression to MI.

c. Unstable angina is associated with the rupture of a once-stable atherosclerotic plaque, exposing the intima to blood and stimulating platelet aggregation and local vasoconstriction with thrombus formation. Patients with unstable angina need immediate hospitalization and monitoring because the lesion is at increased risk of complete thrombosis of the lumen with progression to MI. Any type of angina may be associated with severe pain, electrocardiogram (ECG) changes, and dysrhythmias. Prinzmetal's angina is characterized by coronary artery spasm.

What causes the pain that occurs with myocardial ischemia? a. Death of myocardial tissue b. Dysrhythmias caused by cellular irritability c. Lactic acid accumulation during anaerobic metabolism d. Increased pressure in the ventricles and pulmonary vessels

c. When the coronary arteries are occluded, contractility ceases after several minutes, depriving the myocardial cells of glucose and oxygen for aerobic metabolism. Anaerobic metabolism begins, and lactic acid accumulates, irritating myocardial nerve fibers that then transmit a pain message to the cardiac nerves and upper thoracic posterior roots. The other factors may occur during vessel occlusion but are not the source of pain

A 62-year-old woman smokes a pack of cigarettes per day and has a BP 138/88 mm Hg. She has no symptoms of CAD, but a recent LDL level was 154 mg/dL (3.98 mmol/L). Based on these findings, which treatment plan would the nurse expect would be used first? a. Diet and drug therapy b. Exercise instruction only c. Diet therapy and smoking cessation d. Drug therapy and smoking cessation

c. Without the total serum cholesterol and HDL results, diet therapy and smoking cessation are indicated for this patient without CAD who has prehypertension and an LDL level ≥ 130 mg/dL. When the patient's LDL level is 75 to 189 mg/dL with a 10-year risk for cardiovascular disease (CVD) of 7.5% or above, drug therapy would be added to diet therapy. Because tobacco use is related to increased BP and LDL level, the benefit of smoking cessation is almost immediate. Exercise is indicated to reduce risk factors throughout treatment.

The nurse reviews the following laboratory results for 4 patients. Which patient would the nurse identify as having the greatest risk for CAD and teach first about prevention? a. Total cholesterol: 152 mg/dL, triglycerides: 148 mg/dL, LDL: 148 mg/dL, HDL: 52 mg/dL b. Total cholesterol: 160 mg/dL, triglycerides: 102 mg/dL, LDL: 138 mg/dL, HDL: 56 mg/dL c. Total cholesterol: 200 mg/dL, triglycerides: 150 mg/dL, LDL: 160 mg/dL, HDL: 48 mg/dL d. Total cholesterol: 250 mg/dL, triglycerides: 164 mg/dL, LDL: 172 mg/dL, HDL: 32 mg/dL

d. All the results are abnormal. The patient in option "c" is close to being at risk; if this patient is a woman, the HDL is too low and the other results are at or near the cut off for being normal. The other patients' results are at acceptable levels.

What would the nurse emphasize when teaching women about the risks and incidence of CAD? a. Smoking is not as significant a risk factor for CAD in women as it is in men. b. Women seek treatment sooner than do men when they have symptoms of CAD. c. Estrogen replacement therapy in postmenopausal women decreases the risk of CAD. CAD is the leading cause of death in women, with a higher mortality rate after myocardial infarction (MI).

d. CAD is the number-one killer of American women, and women have a much higher mortality rate within 1 year following MI than do men. Smoking carries specific problems for women because smoking has been linked to a decrease in natural estrogen levels and to early menopause, and it has been identified as the most powerful contributor to CAD in women under the age of 50 years. Fewer women than men present with classic manifestations, and women delay seeking care longer than men. Estrogen replacement does not always reduce the risk for CAD, even though natural estrogen lowers low-density lipoprotein (LDL) and raises high-density lipoprotein (HDL) cholesterol.

Which statement indicates the patient is experiencing anger as the psychologic response to an acute MI? a. "Yes, I'm having a little chest pain. It's no big deal." b. "I don't think I can take care of myself at home yet." c. "What's going to happen if I have another heart attack?" d. "I hope my wife is happy after harping about my eating habits."

d. Anger about the MI may be directed at family, staff, or the medical regimen. Stating that the chest pain is no big deal is denial. Relaying an inability to care for self relates to dependency. Questioning what will happen if there is another attack is expressing anxiety and fear. Depression may be expressed related to changes in lifestyle. Realistic acceptance is seen with actively engaging in changing modifiable risk factors.

Which treatment is used first for the patient with a confirmed MI to open the blocked artery within 90 minutes of arrival to a health care facility? a. TMR b. Stent placement b. Stent placement c. Coronary artery bypass graft (CABG) d. Percutaneous coronary intervention (PCI)

d. Emergent percutaneous coronary intervention (PCI) is the first treatment for patients with a confirmed MI within 90 minutes of arriving at the facility with an interventional cardiac catheterization laboratory. TMR, stent placement, and CABG are usually done to facilitate circulation in nonemergency situations.

A 52-year-old man is in the emergency department reporting severe chest pain. What assessment finding leads the nurse to believe the patient is experiencing a myocardial infarction? a. He has pale, cool, clammy skin. b. He reports nausea and vomited once at home. c. He says he is anxious and has a feeling of impending doom. d. He reports he has had no relief of the pain with rest or position change.

d. The subjective report of the pain from an MI is usually severe. It usually is unrelieved by NTG, rest, or position change and usually lasts more than the 15 or 20 minutes typical of angina pain. All the other symptoms may occur with angina as well as with an MI.