Medical Surgical Nursing Chapter 34 Coronary Artery Disease and Acute Coronary Syndrome

2 Risk for CAD increases with obesity, which is defined as a BMI more than 30 kg/m2. Constipation is not a risk factor for CAD. Traveling abroad to underdeveloped countries is a risk factor for infectious disease, but not for CAD. Pneumococcal vaccine protects the elderly patient from pneumonia, but not from CAD. Text Reference - p. 735

A 67-year-old patient has coronary artery disease (CAD). Which question should the nurse ask to assess a need for additional teaching? 1 When did you last have a bowel movement? 2 Did you have any recent weight gain? 3 Did you travel abroad within the last 12 months? 4 Have you had pneumococcal vaccine?

4 If the Hgb A1C is kept below 7 percent, this means that the patient has had good control of her blood glucose over the past three months. The patient indicates that increasing amounts of insulin are being required to control her blood glucose. This patient may not be adhering to the dietary guidelines or therapeutic regimen, so teaching about how to maintain diet, exercise, and medications to maintain stable blood glucose levels will be needed to achieve this goal. STUDY TIP: Try to decrease your workload and maximize your time by handling items only once. Most of us spend a lot of time picking up things we put down rather than putting them away when we have them in hand. Going straight to the closet with your coat when you come in instead of throwing it on a chair saves you the time of hanging it up later. Discarding junk mail immediately and filing the rest of your bills and mail as they come in rather than creating an ever-growing stack saves time when you need to find something quickly. Filing all items requiring further attention in some fashion helps you remember to take care of things on time rather than being so engrossed in your schoolwork that you forget about them. Many nursing students have had their power or telephone service cut off because the bill simply was forgotten or buried in a pile of old mail. Text Reference - p. 735

A female patient who has type 1 diabetes mellitus has chronic stable angina that is controlled with rest. She states that over the past few months she has required increasing amounts of insulin. What goal should the nurse use to plan care that should help prevent cardiovascular disease progression? 1 Exercise almost every day 2 Avoid saturated fat intake 3 Limit calories to daily limit 4 Keep Hgb A1C less than 7%

2, 4, 5 Nicotine present in tobacco smoke stimulates the release of catecholamines. Catecholamines have a stimulatory effect on the sympathetic nervous system that causes an increase in heart rate and blood pressure. Carbon monoxide present in tobacco smoke has a greater affinity to hemoglobin than does oxygen. Therefore carbon monoxide reduces the oxygen-carrying capacity of blood. Tobacco smoke is known to increase the level of low-density lipoproteins and subsequently a decrease in high-density lipoproteins. All of these factors can lead to atherosclerosis. Tobacco smoke is known to decrease estrogen levels in premenopausal women, thereby increasing their susceptibility to get coronary artery disease. Text Reference - p. 734

A nurse is advising a 24-year-old obese female about smoking cessation, because smoking can lead to coronary artery disease. Why does the nurse discourage cigarette smoking? Select all that apply. 1 Tobacco decreases blood pressure. 2 Tobacco causes release of catecholamines. 3 Tobacco increases the estrogen levels in the body. 4 Smoking decreases the oxygen levels in the blood. 5 Tobacco increases the low-density lipoprotein levels.

4 Following menopause, there is a significant increase in the low-density lipoprotein levels and a consequent reduction in the high-density lipoprotein levels. This occurs due to hormonal changes in the body. This makes postmenopausal women more susceptible to developing coronary artery disease. Obese postmenopausal women may have increased levels of both high-density lipoproteins and low-density lipoproteins (HDLs and LDLs). Because the patient is obese, the low-density lipoprotein (LDL) levels would be high and, because she is postmenopausal, there is a marked reduction in high-density lipoprotein levels (HDLs). Before menopause, high estrogen levels cause an increase in high-density lipoproteins and lowering of low-density lipoprotein levels. Text Reference - p. 733

A nurse is assessing a 53-year-old obese female patient who has been postmenopausal for three years. The nurse suspects that the patient may have coronary artery disease and asks the patient to test her lipid profile. What abnormality in the lipid profile would the nurse expect to find? 1 Increased high-density lipoprotein and low-density lipoprotein levels 2 Decreased high-density lipoprotein and low-density lipoprotein levels 3 Decreased low-density lipoprotein and increased high-density lipoprotein levels 4 Decreased high-density lipoproteins and increased low-density lipoprotein levels

3 This patient is an older adult and, therefore, the occlusion may have occurred slowly over a long period of time. Collateral circulation may have developed which provides adequate blood supply to the myocardium, thereby preventing ischemia. Lowering LDL does not prevent coronary ischemia in the patient whose myocardial blood supply is already compromised. The pulmonary artery consists of deoxygenated blood and does not supply blood to the coronary arteries unless there is a congenital anatomic variation. C-reactive proteins are inflammatory markers that are increased in patients with coronary artery disease. These are not associated with reducing coronary ischemia. Text Reference - p. 731

A nurse is assessing an older adult patient who is diagnosed with coronary artery disease. An angiogram reveals that the patient has 80 percent blockage of the left circumflex artery and 70 percent blockage of the right coronary artery. The patient does not show any symptoms of coronary ischemia. What is the most appropriate reason for this finding? 1 Lowering of low-density lipoprotein (LDL) levels in the body 2 Pulmonary artery supplies oxygenated blood to the heart 3 Formation of collaterals in the coronary circulation 4 Increased production of C-reactive proteins in the liver

4 Papillary muscle dysfunction is a complication of a myocardial infarction and is assessed by the auscultation of a new holosystolic murmur at the cardiac apex. Acute pericarditis is a complication of a myocardial infarction characterized by the auscultation of a friction rub at the mid to lower left sternal border. Dressler syndrome is a complication that develops several weeks after the myocardial infarction and a pericardial friction rub is auscultated at the mid to lower left sternal border. Ventricular aneurysm is a complication of a myocardial infarction without the development of a new holosystolic murmur or friction rub. Text Reference - p. 749

A nurse is auscultating heart sounds on a patient with a myocardial infarction (MI). A new holosystolic murmur is heard at the cardiac apex. Which MI complication does the nurse suspect? 1 Acute pericarditis 2 Dressler syndrome 3 Ventricular aneursym 4 Papillary muscle dysfunction

1 Assessment for changes in neurological status is the priority nursing intervention, because this may indicate a cerebral bleed. Gingival or bleeding gums are expected with thrombolytic therapy and are controlled by applying ice packs. Application of a pressure dressing to the IV insertion site is not done until evidence of bleeding is noted. Monitoring blood pressure for orthostatic changes is necessary with the use of short-acting nitrates. Text Reference - p. 751

A nurse is caring for a patient with a myocardial infarction. The health care provider prescribes an intravenous infusion of alteplase. What is the priority nursing intervention during the administration of this medication? 1 Assess neurologic status. 2 Observe for bleeding gums. 3 Apply a pressure dressing to intravenous (IV) insertion site. 4 Monitor blood pressure for orthostatic changes.

2, 4 Obesity is a major risk factor for the development of coronary artery diseases (CAD). Women below the age of 40 are generally premenopausal. The cardioprotective effects of estrogen make premenopausal women less susceptible for developing atherosclerosis, which can lead to CAD. Apple-shaped obesity is the type of obesity in which there is more fat deposition around the abdomen. This condition is a major risk factor for development of coronary artery disease. Obesity in women is defined as having a body mass index of 30 or greater, which is a major risk factor for development of coronary artery disease. Evidence suggests that people having fat deposition around the thigh and hip regions (pear-shaped figure) are less susceptible to develop coronary artery disease than people having fat deposition around the abdomen (apple-shaped obesity). Obesity in women is defined as having a waist circumference more than 35 inches; therefore, the criterion should be "waist circumference greater than 35 inches." Text Reference - p. 732

A nurse is identifying obese women at risk of developing coronary artery disease in a community for health care research. What are the appropriate criteria for the selection of at-risk women? Select all that apply. 1 Age of less than 40 years 2 Apple-shaped obesity 3 Pear-shaped obesity 4 Body mass index greater than 30 kg/m2 5 Waist circumference more than 30 inches

2 A patient with chest pain due to coronary artery spasms that are unresponsive to intravenous heparin administration would receive percutaneous coronary intervention (PCI). PCI can help open the blockage when thrombolytic therapy fails. Antiplatelet and statins therapy improves vein graft patency in a patient who has undergone CABG involving the saphenous vein. Dual antiplatelet therapy and heparin will help a patient with ongoing angina and negative cardiac markers. Transmyocardial laser revascularization is used for a patient with advanced coronary artery disease and persistent angina even after maximum medical therapy. Text Reference - p. 752

A patient with chest pain due to coronary artery spasms does not respond to intravenous heparin administration. The nurse anticipates that the patient will receive a prescription for which treatment? 1 Antiplatelet and statins therapy 2 Percutaneous coronary intervention 3 Dual antiplatelet therapy and heparin 4 Transmyocardial laser revascularization

1, 4 Aspirin is an antiplatelet drug that can be used to prevent the development of coronary artery disease. It prevents the aggregation of platelets, which can prevent plaque from increasing in size. If blood pressure is high, aspirin can cause bleeding. People with a history of gastrointestinal bleeding are more susceptible to bleeding with aspirin administration. Therefore, before prescribing aspirin, the nurse should assess whether the patient is hypertensive and whether the patient has a history of gastrointestinal bleeding. Aspirin is used as a premedication for the prevention of autonomic symptoms like flushing associated with the use of niacin. Aspirin is also used as an analgesic for treating pain. Unlike statin drugs, low-dose aspirin does not alter liver function. Text Reference - p. 740

A nurse is reviewing a drug therapy regimen for a postmenopausal, obese female for prevention of coronary artery disease. The regimen includes low-dose aspirin. Which specific assessments should the nurse perform to ensure that it is safe for the client to take the aspirin? Select all that apply. 1 Check the blood pressure 2 Obtain the history of chest pain 3 Check liver function test reports 4 Obtain the history of gastrointestinal bleeding 5 Check for the presence of autonomic symptoms like flushing

1, 4 Walnuts and margarine are major sources of polyunsaturated dietary fat. Palm oil, egg yolk, and sour cream are major sources of saturated dietary fat. Text Reference - p. 737

A nurse is teaching a patient with coronary artery disease to decrease saturated and increase polyunsaturated dietary fat. Which major sources of polyunsaturated fats should the nurse include? Select all that apply. 1 Walnuts 2 Palm oil 3 Egg yolk 4 Margarine 5 Sour cream

2, 3, 1, 5, 4 Coronary occlusion causes a reduced blood supply to the heart, thereby leading to myocardial ischemia. Because the blood supply is compromised, there is inadequate oxygen delivery to the myocardium for aerobic metabolism to take place. Anaerobic metabolism begins and leads to the accumulation of lactic acid. Lactic acid irritates the myocardial nerve fibers, and pain impulses are transmitted to the cardiac nerves and upper thoracic posterior nerve roots. This causes referred cardiac pain to the shoulder, neck, lower jaw, and arms. Text Reference - p. 740

A nurse is teaching about coronary artery disease to a group of nursing students. To evaluate their understanding, the nurse asks them to explain why pain is referred to the shoulder, neck, and jaw in a case of stable angina. Prioritize the pathophysiologic events causing referred pain in stable angina. 1. Accumulation of lactic acid in the myocardium 2. Reduced blood supply to the myocardium 3. Inadequate aerobic metabolism in the myocardium 4. Transmission of pain impulses in the cardiac and upper thoracic posterior nerves 5. Irritation of nerve fibers of the myocardial tissue

1 Before performing a cardiac catheterization, the nurse should assess the patient for an allergy to contrast medium, which would have an immediate adverse effect on the patient receiving this procedure. Anemia, dysrhythmia, and change in mental status present less immediate complications during a cardiac catheterization procedure. STUDY TIP: Begin studying by setting goals. Make sure they are realistic. A goal of scoring 100% on all exams is not realistic, but scoring an 85% may be a better goal. Text Reference - p. 758

A nurse preparing a patient for cardiac catheterization should perform a baseline assessment of vital signs, pulse oximetry, and heart and lung sounds. What other vital assessment should the nurse include during a cardiac catheterization? 1 Allergies 2 Anemia 3 Dysrhythmia 4 Mental status

3, 4, 5 Drug therapy for myocardial infarction includes intravenous nitroglycerin, dual antiplatelet therapy (e.g., aspirin and clopidogrel), and systemic anticoagulation with either LMWH given subcutaneously or IV UH, which are the initial drug treatments of choice for acute coronary syndrome (ACS). Oral beta-adrenergic blockers are given after day two if there are no contraindications (e.g., heart failure, heart block, hypotension). Diuretics and prophylactic antibiotics are not appropriate at this time. Text Reference - p. 744

A patient is admitted to the intensive care unit with a diagnosis of myocardial infarction. The patient is in stable condition. What are common medications used to treat this condition? Select all that apply. 1 Diuretics 2 Stool softeners 3 Prophylactic antibiotics 4 Dual antiplatelet therapy 5 Intravenous (IV) nitroglycerin 6 Low molecular weight heparin (LMWH)

1, 2, 3, 4 Statin drugs have been found to lower low-density lipoproteins and triglycerides. Common side effects of this class of drugs include rash, myopathy, rhabdomyolysis, and gastrointestinal disturbance, as well as elevated enzyme levels. Flushing and pruritus in the upper torso and face have not been cited as a side effect of statins but may be seen with the use of niacin. Text Reference - p. 739

A patient is prescribed a statin drug to decrease levels of low-density lipoproteins and triglycerides. For which symptoms should the nurse teach the patient to be observant? Select all that apply. 1 Rash 2 Myopathy 3 Rhabdomyolysis 4 Gastrointestinal disturbance 5 Flushing 6 Pruritus

3 Flushing of the face and neck is a common side effect of niacin. Premedicating the patient with aspirin reduces flushing. Aspirin is an analgesic and antiplatelet medication. Platelet aggregation prevents the formation of atherosclerotic plaque. In this case the most likely reason for the nurse to administer this drug is to relieve flushing. Text Reference - p. 739

A patient with hyperlipidemia has been prescribed niacin. The nurse administers aspirin 30 minutes before administering niacin. What is the most likely reason for the nurse to administer aspirin? 1 To relieve pain 2 To prevent clotting of blood 3 To prevent flushing of skin 4 To prevent the formation of atherosclerotic plaque

3 A patient with heaviness and burning sensation in the substernal and retrosternal region may be having a myocardial infarction (MI) and stimulation of the sympathetic nervous system. This condition may trigger the production of catecholamines, which promote glycogen release, diaphoresis, and vasoconstriction of peripheral blood vessels. Because of this, the patient's skin may appear ashen, clammy, and cool to the touch. Jugular vein distention and abnormal S3 and S4 sounds are caused by ventricular dysfunction. Shortness of breath and anxiety may not necessarily be caused by sympathetic nervous system stimulation. Test-Taking Tip: Recollect the manifestations of sympathetic versus parasympathetic responses to be able to differentiate between the two. Text Reference - p. 748

A patient reports heaviness and burning sensation in the substernal and retrosternal region. Assessment findings include a fasting blood glucose of 190 mg/dL and blood pressure of 145/90 mm Hg. The nurse recognizes that which other finding indicates sympathetic nervous system stimulation? 1 Jugular venous distention 2 Abnormal S3 and S4 sounds 3 Ashen, clammy, and cool skin 4 Shortness of breath and anxiety

4 The most common complication after MI is dysrhythmias, which are present in 80 percent of patients. Unstable angina is considered a precursor to MI rather than a complication. Cardiac tamponade is a rare event, and sudden cardiac death is defined as an unexpected death from cardiac causes. Cardiac dysfunction in the period following an MI would not be characterized as sudden cardiac death. Test-Taking Tip: Once you have decided on an answer, look at the stem again. Does your choice answer the question that was asked? If the question stem asks "why," be sure the response you have chosen is a reason. If the question stem is singular, then be sure the option is singular, and the same for plural stems and plural responses. Many times, checking to make sure that the choice makes sense in relation to the stem will reveal the correct answer. Text Reference - p. 748

A patient was admitted to the emergency department (ED) 24 hours earlier with complaints of chest pain that subsequently were attributed to ST segment elevation myocardial infarction (STEMI). What complication of myocardial infarction (MI) should the nurse anticipate? 1 Unstable angina 2 Cardiac tamponade 3 Sudden cardiac death 4 Cardiac dysrhythmias

3 Prinzmetal's angina often occurs at rest, usually in response to spasms of a major coronary artery due to nicotine, which cause the release of catecholamines such as epinephrine and norepinephrine. When the spasms occur, the patient experiences pain and ST segment elevation. Silent ischemia refers to the ischemia that occurs in the absence of any subjective symptoms. Angina decubitus is chest pain that occurs only when the patient is lying down. Chronic stable angina does not occur at rest and is triggered by physical exertion. Test-Taking Tip: Multiple-choice questions can be challenging, because students think that they will recognize the right answer when they see it or that the right answer will somehow stand out from the other choices. This is a dangerous misconception. The more carefully the question is constructed, the more each of the choices will seem like the correct response. Text Reference - p. 742

A patient who uses nonsmoking tobacco complains of chest pain when at rest. His or her electrocardiogram (ECG) shows ST segment elevation. Which condition is the patient experiencing? 1 Silent ischemia 2 Angina decubitus 3 Prinzmetal's angina 4 Chronic stable angina

3 A patient with a history of diabetes who has chronic stable angina has a high risk for a cardiac event. An angiotensin II converting enzyme (ACE) inhibitor such as captopril can be safely used in this patient. Beta blockers such as diltiazem mask the signs of hypoglycemia and are used cautiously in patients with diabetes. Sirolimus is used in drug-eluting stents that prevent the overgrowth of new intima, the primary cause of stent restenosis. Bivalirudin helps prevent the abrupt closure of the stents during percutaneous coronary intervention. Text Reference - p. 745

A patient with a history of diabetes is diagnosed with chronic stable angina. Which drug would be beneficial to this patient? 1 Diltiazem 2 Sirolimus 3 Captopril 4 Bivalirudin

4 CCB directly acts on cardiac and vascular smooth muscles and promotes smooth muscle relaxation and vasodilation of coronary and systemic arteries, thereby increasing the blood flow. The nurse should closely monitor the serum digoxin levels for toxicity because CCB potentiates the action of digoxin by increasing serum digoxin levels. QT wave prolongation should be monitored upon administration of sodium current inhibitors. Weight should be monitored in patients taking beta blockers. Long-acting nitrates such as isosorbide dinitrate and isosorbide mononitrate can cause hypotension, resulting in orthostatic hypotension. Test-Taking Tip: Digoxin is a drug which has narrow therapeutic index. A small increase in the dose may cause toxicity. Text Reference - p. 745

A patient with angina is prescribed a calcium channel blocker (CCB). Upon reviewing the medication history, the nurse finds that the patient is on digoxin. Which intervention by the nurse helps in ensuring safe care? 1 Monitor for QT prolongation 2 Monitor for increase in weight 3 Monitor for decrease in blood pressure 4 Monitor for increase in serum digoxin levels

1 A patient with angina who is on sublingual nitroglycerine and whose condition worsens or does not resolve after administration of the medication should be referred to an emergency medical service (EMS) immediately for help. The drug should be administered to the patient every five minutes for a maximum of three doses. The nurse should take measures to reduce the severity of the condition first and then monitor vital signs. The patient may have difficulty in breathing so the nurse should not ask the patient to breathe rapidly. The nurse should advise the patient to make position changes slowly after taking the drug to prevent orthostatic hypotension. Test-Taking Tip: If the question asks for an immediate action or response, all of the answers may be correct, so base your selection on identified priorities for action. Text Reference - p. 743

A patient with angina on sublingual nitroglycerine is not relieved after five minutes of drug administration. Which intervention by the nurse would be most appropriate in this situation? 1 Contact the emergency medical services (EMS) immediately. 2 Repeat the medication every 30 minutes for a maximum of three doses. 3 Monitor for vital signs immediately and ask the patient to take rapid breaths. 4 Instruct the patient to change positions rapidly after administration of the next dose.

2 The pain of angina pectoris is caused by an inadequate oxygen supply to the myocardium, resulting in ischemia. The other answer options may lead to myocardial ischemia but are secondary causes. Text Reference - p. 741

A patient with angina pectoris asks the nurse about the cause of the pain. The nurse explains that the pain is primarily produced by: 1 Atherosclerosis 2 Myocardial ischemia 3 Movement of a thromboembolus 4 Coronary artery vasoconstriction

3 The patient has symptoms of unstable angina. The patient on short-acting nitrates such as nitroglycerin may experience orthostatic hypotension, so the blood pressure of the patient should be monitored regularly and the patient asked to make slow movements. A patient on fluoxetine must undergo monitoring for QT interval prolongation because this medication prolongs the QT interval. The patient on beta-adrenergic blockers may experience bradycardia and should be monitored for a decrease in the heart rate. The patients with heart failure should be monitored for ejection fraction. Text Reference - p. 743

A patient with sudden stabbing pain in the chest, arms, and shoulders at unusual times of the day and night is on short-acting nitrates. Which intervention helps promote better care management in the patient? 1 Monitor for QT interval prolongation. 2 Monitor for decrease in the heart rate. 3 Monitor for decrease in blood pressure. 4 Monitor for decreased ejection fraction.

2 A nonproductive and persistent cough may occur in 5 percent to 25 percent of individuals. It may take up to two weeks or longer for coughing to subside after the ACE inhibitor is discontinued. If one ACE inhibitor causes coughing, it is likely that the others will also. Other side effects of ACE inhibitors include drowsiness (versus hyperactivity), elevated (versus decreased) blood potassium levels, and diarrhea (versus constipation). Text Reference - p. 753

A patient with ventricular dysfunction receives a prescription for an angiotensin-converting (ACE) inhibitor. The nurse should monitor the patient for what side effect? 1 Hyperactivity 2 Persistent cough 3 Decreased potassium levels 4 Constipation

2 The recommended dose of nitroglycerin is one tablet taken sublingually (SL) or one metered spray for symptoms of angina. If symptoms are unchanged or worse after five minutes, the patient should be instructed to activate the emergency medical services (EMS) system. If symptoms are improved, repeat the nitroglycerin every five minutes for a maximum of three doses and contact EMS if symptoms have not resolved completely. Text Reference - p. 743

After teaching a patient with chronic stable angina about nitroglycerin, the nurse recognizes the need for further teaching when the patient makes which statement? 1 "I will replace my nitroglycerin supply every six months." 2 "I can take up to five tablets every three minutes for relief of my chest pain." 3 "I will take acetaminophen (Tylenol) to treat the headache caused by nitroglycerin." 4 "I will take the nitroglycerin 10 minutes before a planned activity that usually causes chest pain."

4 Patients with LDL cholesterol levels greater than 160 mg/dL are at a risk for acquiring coronary artery disease and would benefit from receiving cholestyramine. Patients with a triglyceride level of 138 mg/dL are not at a risk for coronary heart disease and cholestyramine is not indicated. Patients with total cholesterol levels less than 200 mg/dL do not require drug treatment because they are not at risk of developing coronary heart disease. Patients with HDL less than 40 mg/dL are at a risk of developing coronary heart disease and must be treated with appropriate drugs. Text Reference - p. 739

Based on the lipid profile reports of four patients in a health care setting, which patient should the nurse expect to have a prescription for cholestyramine? 1 Patient with a triglyceride level of 138 mg/dL 2 Patient with a total cholesterol level of 180 mg/dL 3 Patient with high-density lipoprotein (HDL) cholesterol of 60 mg/dL 4 Patient with low-density lipoprotein (LDL) cholesterol of 190 mg/dL

1, 3, 4, 5 Coronary revascularization with CABG is recommended for patients who have diabetes mellitus, have left main coronary artery or three-vessel disease, patients who are not candidates for percutaneous intervention and who have failed percutaneous intervention and continue to have chest pain, and those who are expected to have longer-term benefits with this surgery than with catheterization. Severe aortic stenosis is not an indicator for cardiac revascularization surgery. Text Reference - p. 752

Coronary revascularization with coronary artery bypass graft (CABG) surgery is recommended for which patients? Select all that apply. 1 Patients with diabetes mellitus 2 Patients with severe aortic stenosis 3 Patients with left main coronary artery or three-vessel disease 4 Patients who are not candidates for percutaneous coronary intervention 5 Patients who have failed percutaneous intervention and have recurrent chest pain

1 The nurse must be most alert for dysrhythmias, which may signal another MI or impending complications. The nurse should also be alert for increased anxiety, which may cause pain and lead to a secondary infarction. Anxiety and fear are highly likely but secondary in importance to monitoring the patient for dysrhythmias. Metabolic acidosis and reactions to new medications are not likely but should still be included as part of overall assessment of the patient. Text Reference - p. 748

During the 48 hours after a myocardial infarction, a nurse should assign the highest priority to monitoring the patient for: 1 Dysrhythmias 2 Anxiety and fear 3 Metabolic acidosis 4 Medication side effects

2, 4 Ezetimibe should not be used by patients with liver impairment. Adverse effects of atorvastatin, a statin drug, include liver damage and myopathy. Liver enzymes must be monitored frequently and the medication stopped if these enzymes increase. Niacin's side effects subside with time, although decreased liver function may occur with high doses. Cholestyramine is safe for long-term use. Text Reference - p. 739

For which antilipemic medications should the nurse question a prescription for in a patient with cirrhosis of the liver? Select all that apply. 1 Niacin 2 Ezetimibe 3 Gemfibrozil 4 Atorvastatin 5 Cholestyramine

4 PCI is indicated to restore coronary perfusion in cases of myocardial infarction. Chronic stable angina and CAD normally are treated with more conservative measures initially. PCI is not relevant to the pathophysiology of heart failure, such as left-sided heart failure. STUDY TIP: Laughter is a great stress reliever. Watching a short program that makes you laugh, reading something funny, or sharing humor with friends helps decrease stress. Text Reference - p. 746

For which problem is percutaneous coronary intervention (PCI) most clearly indicated? 1 Chronic stable angina 2 Left-sided heart failure 3 Coronary artery disease (CAD) 4 Acute myocardial infarction

1 The incidence of CAD and myocardial infarction (MI) is highest among white, middle-aged men. Hispanic individuals have lower rates of CAD than non-Hispanic whites or African Americans. African Americans have an earlier age of onset and more severe CAD than whites and more than twice the mortality rate of whites of the same age. Native Americans have increased mortality in 35-year-old and under people, and have major modifiable risk factors, such as diabetes. Text Reference - p. 732

The community health nurse is planning health promotion teaching targeted at preventing coronary artery disease (CAD). Which ethnic groups would the nurse select as the highest priority for this intervention? 1 White male 2 Hispanic male 3 African American male 4 Native American female

2 Ten minutes of a sharp, stabbing pain in the substernal region radiating to the neck and jaw when lifting a heavy box, and a T wave inversion in the ECG indicates that the patient is experiencing an attack of chronic stable angina. The patient should be advised to take nitroglycerin before engaging in activities, because the exertion will provoke angina and the patient may be at a risk. Patients with Prinzmetal's angina may get relief from chest pain by performing moderate exercise. The patient should wait for 30 minutes to one hour after taking the medication before engaging in daily activities. The patient should not take the nitroglycerine 30 minutes after exertion. Test-Taking Tip: Once you have decided on an answer, look at the stem again. Does your choice answer the question that was asked? If the question stem asks "why," be sure the response you have chosen is a reason. If the question stem is singular, then be sure the option is singular, and the same for plural stems and plural responses. Many times, checking to make sure that the choice makes sense in relation to the stem will reveal the correct answer. Text Reference - p. 741

The electrocardiogram (ECG) shows T wave inversion in a patient who comes to the emergency department complaining about a sharp, stabbing pain in the chest that lasted 10 minutes and occurred when lifting a heavy box at home. Which instructions given to the patient will help in managing the symptoms on reoccurrence? 1 You should perform moderate exercise to relieve the pain. 2 Take nitroglycerin before engaging in strenuous activities. 3 You can engage in daily activities after taking the medication. 4 Take nitroglycerin 30 minutes after performing strenuous activities.

1, 3 High-density lipoproteins and low-density lipoproteins are vehicles for mobilization of fats. HDLs contain fewer lipids than proteins and mobilize lipids from the arteries to the liver for metabolism, thereby preventing the deposition of lipids on the vessel wall. LDLs have more lipid content than proteins and tend to deposit lipids in the arterial walls. HDLs prevent the deposition of lipids and do not directly alter the vessel wall or make it noncompliant. HDLs do not interfere with the production or breakdown of LDLs. Text Reference - p. 733

The lipid profile of a patient is indicative of hyperlipidemia. A nurse advises the patient to consume a diet rich in nutrients that would increase high-density lipoprotein levels based on what rationale? Select all that apply. 1 High-density lipoproteins (HDLs) transport lipids to the liver. 2 High-density lipoproteins (HDLs) prevent stiffening of arterial walls. 3 High-density lipoproteins (HDLs) prevent deposition of lipids in the blood vessels. 4 High-density lipoproteins (HDLs) inhibit the production of low-density lipoproteins (LDLs). 5 High-density lipoproteins (HDLs) stimulate the liver to break down more low-density lipoproteins.

2 Alteplase is a proteolytic enzyme that digests threads and other substances in the blood, including clotting factors, thereby causing hypercoagulability of the blood and possibly bleeding, which is evidenced by blood in the urine. Anorexia and increased temperature are not issues directly related to this drug. Alteplase may cause premature ventricular contractions, which should be monitored, but this is usually not a problem because the drug has a short half-life. Text Reference - p. 752

The nurse assesses a patient who has been administered the tissue-type plasminogen activator alteplase for an acute myocardial infarction. Which assessment finding is the highest priority and should be reported to the primary health care provider immediately? 1 Anorexia 2 Hematuria 3 Oral temperature of 100.4° F (38° C) 4 Occasional premature ventricular contractions

3 Papillary muscle dysfunction occurs if the papillary muscles attached to the mitral valves are involved in infarction. A patient may have papillary muscle infraction if a murmur is heard upon auscultation at the cardiac apex. The presence of crackles of breath sounds and S3 and S4 sounds of the heart indicate heart failure. The deep sound heard at the lower left sternal border upon auscultation indicates acute pericarditis. Text Reference - p. 749

The nurse assesses a patient with papillary muscle dysfunction. Which observation supports the patient's diagnosis? 1 S3 or S4 heart sounds 2 Crackles 3 Murmur at the cardiac apex 4 Deep sound noted while auscultating at the lower sternal border

4 The patient may have microvascular angina, which is chest pain that occurs in the absence of significant coronary atherosclerosis or coronary spasm; it is especially common in women. The chest pain is related to myocardial ischemia associated with abnormalities of coronary microcirculation. If the ischemia occurs in the absence of any subjective symptoms, then the condition is silent ischemia. Nocturnal angina occurs only at night. Angina decubitus occurs only when the patient is lying down or is in a recumbent position, and is relieved when the patient is in the sitting or standing position. Test-Taking Tip: Read the question carefully before looking at the answers: (1) Determine what the question is really asking; look for key words; (2) Read each answer thoroughly and see if it completely covers the material asked by the question; (3) Narrow the choices by immediately eliminating answers you know are incorrect. Text Reference - p. 742

The nurse is caring for a female patient whose chest x-ray reveals that there is no significant coronary atherosclerosis but has chest pain while performing daily activities. Which condition is indicated in the patient? 1 Silent ischemia 2 Nocturnal angina 3 Angina decubitus 4 Microvascular angina

2, 5, 1, 3, 4 After blockage is identified, treatment options, including angioplasty with stent placement, are explored. Stents are small, expandable tubes that are inserted during angioplasty into a blocked section of the coronary artery to open the artery and improve blood flow. During angioplasty, the balloon is placed inside the stent and inflated, which opens the stent and pushes it into place against the artery wall to keep the narrowed artery open. Because the stent is like woven mesh, the cells lining the blood vessel grow through and around the stent to help secure it. Drug-eluting stents are coated with drugs that prevent scar tissue from growing into the artery. Drug-eluting stents may lower the chance that the patient will need a second procedure (angioplasty or surgery) to open the artery again. Text Reference - p. 746

The nurse is caring for a patient that is scheduled for an angioplasty with placement of a drug-eluting stent. The nurse recalls that the steps of the stent procedure occur in what order? 1. Balloon is placed inside and inflated. 2. Blockage is identified. 3. Improved blood flow occurs. 4. Cells line the blood vessels to grow through and around the stent, to help secure it. 5. Stent is placed into the coronary artery.

1, 2, 4, 5 Because most SCD patients have lethal ventricular dysrhythmias associated with a high recurrence rate, they are closely monitored to assess when they are most likely to have a recurrence and to determine which drug therapies are most effective for them. This monitoring includes exercise stress testing, 24-hour Holter monitoring, signal-averaged electrocardiogram, and an electrophysiologic study done under fluoroscopy. Magnetic resonance imaging is not used to monitor for lethal dysrhythmias. Text Reference - p. 763

The nurse is caring for a patient who survived sudden cardiac death (SCD) that was brought on by a lethal ventricular dysrhythmia. To reassure the patient, which tests should the nurse explain will be performed to monitor the effectiveness of drug treatment? Select all that apply. 1 Exercise stress testing 2 24-hour Holter monitoring 3 Magnetic resonance imaging 4 Signal-averaged electrocardiogram 5 Electrophysiologic study under fluoroscopy

1 Patients with diabetes have an increased prevalence of silent ischemia, which is characterized by the absence of any subjective symptoms. When the patient is monitored by Holter monitor and the patient has silent ischemia, changes in electrocardiography (ECG) are noted. Angina decubitus is the chest pain that occurs when the patient is lying down and resolves when the patient stands or sits up. Prinzmetal's angina often occurs at rest, usually due to spasm of major coronary artery. Microvascular angina occurs due to abnormalities in the coronary microcirculation. Test-Taking Tip: Be alert for details. Details provided in the stem of the item, such as behavioral changes or clinical changes (or both) within a certain time period, can provide a clue to the most appropriate response or, in some cases, responses. Text Reference - p. 742

The nurse is caring for a patient with diabetes who shows no symptoms of angina but a Holter monitoring reveals changes in electrocardiography (ECG). Which condition may the patient have? 1 Silent ischemia 2 Angina decubitus 3 Prinzmetal's angina 4 Microvascular angina

1 Indigestion, constipation, and bloating are side effects of cholestyramine therapy, which interferes with the absorption of penicillin. Penicillin is contraindicated for the patient with these symptoms. The patient with arthralgia may be on medication with icosapent ethyl, which is an omega-3 fatty acid. The patient with pruritus and hypotension may be on medications with niacin. The patient with rashes and elevated levels of liver enzymes may be on drugs such as fenofibrate or gemfibrozil. Text Reference - p. 739

The nurse is caring for patients on medication to lower lipid levels. For which patient is the use of penicillin contraindicated? 1 Patient with indigestion, constipation, and bloating 2 Patient with pain in the joints without inflammation 3 Patient with itching below the neck and blood pressure of 80/50 mm Hg 4 Patient with rashes and alanine aminotransferase level of 58 units per liter

2 The presence of a pathologic Q wave, which often accompanies ST segment elevation myocardial infarction (STEMI), is indicative of complete coronary occlusion. Sinus tachycardia, fibrillatory P waves (e.g., atrial fibrillation), or a prolonged PR interval (first-degree heart block) are not direct indicators of extensive occlusion. Test-Taking Tip: Be alert for details. Details provided in the stem of the item, such as behavioral changes or clinical changes (or both) within a certain time period, can provide a clue to the most appropriate response or, in some cases, responses. Text Reference - p. 749

The nurse is examining the ECG of a patient who has just been admitted with a suspected myocardial infarction (MI). Which ECG change is most indicative of prolonged or complete coronary occlusion? 1 Sinus tachycardia 2 Pathologic Q wave 3 Fibrillatory P waves 4 Prolonged PR interval

2, 4, 5, 6 Serum cholesterol level greater than 200 mg/dL is a risk factor for CAD. Stress is an additional risk factor for developing CAD. Secondhand smoke increases the risk of CAD. A sedentary job and lack of exercising are risk factors for CAD. Smoking cessation will lead to a reduced mortality rate after a period of 12 months. Fasting triglyceride levels above 150 mg/dL are a risk factor for CAD. Text Reference - p. 732

The nurse is performing an assessment of a patient whose older brother recently had a myocardial infarction (MI). Which assessment data indicates to the nurse that the patient has additional risk factors for coronary artery disease (CAD)? Select all that apply. 1 Smoking cessation three years ago 2 Serum cholesterol level of 260 mg/dL 3 Fasting triglyceride level of 110 mg/dL 4 Multiple family problems over last two years 5 Living together with son who smokes two packs of cigarettes per day 6 Clerk job in an accounting firm and not exercising

1 A patient with chest pain, peripheral edema, blood pressure of 100/60 mm Hg, pulse rate of 68 beats/minute, and dyspnea may have acute coronary syndrome. In order to avoid further complications, the nurse should regularly monitor neurologic, liver, and renal function to evaluate blood perfusion to the vital organs. The nurse should help the patient with anxiety and stress to work on the losses due to chronic illness to prevent sudden depression-related cardiac workload. A patient with chronic stable angina is advised to avoid heavy meals and extreme weather to reduce the probability of symptoms. The nurse should encourage verbalization of feelings, perceptions, and fears that increases workload on heart. Test-Taking Tip: Be alert for details. Details provided in the stem of the item, such as behavioral changes or clinical changes (or both) within a certain time period, can provide a clue to the most appropriate response or, in some cases, responses. Text Reference - p. 755

The nurse is preparing a care plan for a patient with chest pain. The patient's assessment findings include peripheral edema, blood pressure of 100/60 mm of Hg, pulse rate of 68/minute, and dyspnea. What is the priority nursing intervention? 1 Monitoring the patient's neurologic function 2 Discussing the losses associated with chronic illness 3 Advising the patient to avoid heavy meals and extreme weather conditions 4 Encouraging verbalization of feelings, perceptions, and fears

3 Rapid diagnosis and providing treatment to a patient with acute coronary syndrome help preserve cardiac muscle function. The initial treatment is to manage chest pain; therefore, the patient needs to rest and limit activities (including breathing exercises) for 12 to 24 hours. The nurse should make sure that the oxygen saturation stays at an acceptable level by initiating supplemental oxygen. The intravenous route for emergency medication therapy is preferred for patients with chest pain because this route is faster than oral administration. Continuous monitoring of electrocardiogram, vital signs, and pulse oximetry helps to evaluate the effectiveness of the treatments and monitor for complications. Text Reference - p. 750

The nurse is reviewing a plan of care for emergency treatment of a patient with chest pain. The nurse should question which item listed on the plan? 1 Initiate supplemental oxygen. 2 Administer emergency medications intravenously. 3 Instruct the patient to perform breathing exercises immediately. 4 Monitor the blood pressure and for Q and ST wave abnormalities regularly.

4 Nitroglycerine is a first line treatment for patients with chronic stable angina. The patient should take nitroglycerin (NTG) before beginning any strenuous activities in order to prevent an anginal episode. The patient should keep nitroglycerin tablets away from light and heat sources to protect them from degradation. Therefore, the medication should be stored in a shady area. The patient should replace the tablets in the container every six months. Text Reference - p. 743

The nurse is teaching a patient with chronic stable angina on the use of nitroglycerin (NTG). Which statement made by the patient indicates effective learning? 1 "I should dissolve the tablets in a glass of water." 2 "I should store the medications in a light area." 3 "I should replace the tablets in the container every 18 months." 4 "I should take a tablet one half-hour before beginning activities."

1, 2, 4 Dietary modifications should include a decrease in saturated fat and cholesterol, as well as an increase in complex carbohydrates (whole grains, fruits, and vegetables) and fiber. A moderate physical activity program has to include isotonic exercises, such as walking, hiking, or jogging performed for at least 30 minutes on most week days. Consumption of alcohol and simple sugars will lead to an elevated triglyceride level. Isometric exercises, such as weight lifting, are recommended to increase muscle strength on two days per week only. Text Reference - p. 736

The nurse is teaching the family of a patient recently diagnosed with coronary artery disease (CAD). Which information on health promotion would the nurse include? Select all that apply. 1 Consume diet low in fat and cholesterol 2 Increase whole grains and fiber in the diet 3 No need to limit consumption of simple sugars and alcohol 4 Perform walking or biking at least 30 minutes four or more days per week 5 Perform isometric exercises at least 30 minutes at least four days per week

4 Plavix is an antiplatelet medication, used commonly in patients with cardiovascular disease. Plavix is not an opioid analgesic, NSAID, or vitamin K antagonist. Test-Taking Tip: Bring to your test prep a positive attitude about yourself, your nursing knowledge, and your test-taking abilities. A positive attitude is achieved through self-confidence gained by effective study. This means (a) answering questions (assessment), (b) organizing study time (planning), (c) reading and further study (implementation), and (d) answering questions (evaluation).

The nurse notes that the patient was taking clopidogrel at home. The nurse knows that this medication belongs to which drug class? 1 Vitamin K antagonist 2 Nonsteroidal antiinflammatory drug (NSAID) 3 Opioid analgesic 4 Antiplatelet

4 Angiotensin converting enzyme inhibitors improve ejection fraction, prevents ventricular remodeling, and prevents the progression of heart failure in the patient. Lipid lowering agents reduce low density cholesterol and triglyceride levels in the blood. Beta-adrenergic blockers decrease myocardial oxygen demand by reducing heart rate, blood pressure, and contractility. Calcium channel blockers are prescribed to decrease blood pressure in patients with beta blocker intolerance and Prinzmetal's angina. Test-Taking Tip: You have at least a 25 percent chance of selecting the correct response in multiple-choice items. If you are uncertain about a question, eliminate the choices that you believe are wrong and then call on your knowledge, skills, and abilities to choose from the remaining responses. Text Reference - p. 753

The nurse recognizes that which type of medication may be prescribed for a patient with an ejection fraction of 25%? 1 Lipid lowering agent 2 Beta-adrenergic blocker 3 Calcium channel blocker 4 Angiotensin-converting enzyme (ACE) inhibitor

3 Physical activity improves the physiologic functioning and psychologic well-being of a patient with acute coronary syndrome. Therefore, the nurse should encourage the patient to walk at a rate of three to four miles per hour. Painting while seated is a low-energy activity. Carpentry and running at seven miles per hour are high-energy activities for a patient with acute coronary syndrome. Test-Taking Tip: Sometimes the reading of a question in the middle or toward the end of an exam may trigger your mind with the answer or provide an important clue to an earlier question. Text Reference - p. 760

The nurse provides a list of activities that are considered to be moderate energy to a patient with acute coronary syndrome. Which activity is appropriate to be included on the list? 1 Painting while seated 2 Performing carpentry 3 Walking at four miles per hour (mph) 4 Running at seven miles per hour (mph)

3 The nurse is responsible for monitoring changes in neurovascular status or bleeding. All members of the health care team can address measures that will make the patient more comfortable. Unlicensed assistive personnel (UAP) take vital signs and assists with oral hygiene, hydration, meals and toileting. Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a wrong answer. Text Reference - p. 756

The nurse provides a student nurse with information related to management of a patient following cardiac catheterization. Which intervention should the nurse explain is the specific responsibility of the nurse, rather than that of Unlicensed Assistive Personnel (UAP)? 1 Asking the patient about comfort measures 2 Recording vital signs 3 Monitoring neurovascular changes 4 Assisting with oral hygiene, hydration, meals, and toileting

1 Coronary angiography is considered safe for a patient with stable and controlled angina; however, it is not preferred in a patient with unstable angina. The patient can return to work more quickly after an angioplasty because it is an alternative to surgical interventions, such as coronary artery bypass surgery. Angioplasty is a first line treatment to a patient with confirmed myocardial infarction, definitive electrocardiogram changes, and positive cardiac markers. The most serious complication of angioplasty is dissection of the newly dilated coronary artery; this dissection may lead to coronary artery rupture. Text Reference - p. 751

The nurse provides information about angioplasty treatment to a group of student nurses. Which statement made by a student nurse indicates the need for further teaching? 1 "Angioplasty is safe for a patient with unstable angina." 2 "Patients can return to work more quickly after angioplasty than after coronary bypass surgery." 3 "Angioplasty is considered to be a first line treatment for definitive electrocardiogram changes." 4 "The most serious complication of angioplasty is dissection of the newly dilated coronary artery."

4 Bypass graft surgery involves the replacement of blood vessels that transport blood between the aorta and the blocked coronary artery. The internal mammary artery (IMA) is the most common artery used for bypass graft. The long-term patency rate for an IMA graft is greater than 90 percent after 10 years. Procedures involving the radial, gastroepiploic, or inferior epigastric artery have a comparatively short-term patency rate. Text Reference - p. 752

The nurse recalls that which artery is most commonly used for bypass graft? 1 Radial artery 2 Gastroepiploic artery 3 Inferior epigastric artery 4 Internal mammary artery

2 A patient experiencing fatigue, indigestion, and shortness of breath may experiencing an unstable anginal attack. A patient experiencing dyspnea, hyperglycemia and polyuria may have diabetes. A patient with peripheral edema and a decreased urine output may have right ventricular dysfunction or heart failure due to UA or coronary artery disease. Altered mental status (confusion), difficulty in breathing, dizziness, and dysrhythmias are observed in elder patients with UA. Test-Taking Tip: A patient should never neglect any signs of myocardial infarction. Educating the public, especially females, is important, to identify the complications early. Text Reference - p. 747

The nurse recognizes indications of unstable angina if a patient experiences what symptoms? 1 Dyspnea, hyperglycemia, and polyuria 2 Nausea, sweating, and shortness of breath 3 Peripheral edema and decreased urinary output 4 Confusion, dysrhythmias, and difficulty breathing

2 Acute pericarditits is an inflammation of the pericardium that may occur within two to three days of acute myocardial infarction. The patient's chest pain is relieved after sitting in the forward position. The pain may return after a change in position or inspiration. Massaging the chest region may aggravate the symptoms. Intravenous heparin is given to a patient with an unstable thrombus or coronary artery spasm. Papillary muscle dysfunction treatment involves mitral valve repair or replacement. Acute pericarditis treatment involves nonsteroidal antiinflammatory agents, aspirin, and corticosteroids. Text Reference - p. 749

The nurse teaches a student nurse about acute pericarditis. Which statement made by the student nurse indicates effective learning? 1 "I should massage the patient in the chest region to relieve symptoms." 2 "The patient's chest pain can be relieved by sitting in the forward position." 3 "Acute pericarditis should be treated immediately by intravenous heparin." 4 "Treatment of acute pericarditis involves mitral valve repair or replacement."

2, 3, 4, 5 During the initial phase of an MI, catecholamines are released from the ischemic myocardial cells, causing increased sympathetic nervous system (SNS) stimulation. This results in the release of glycogen, diaphoresis, and vasoconstriction of peripheral blood vessels. The patient's skin may be ashen, cool, and clammy (not flushed) as a result of this response. Nausea and vomiting may result from reflex stimulation of the vomiting center by severe pain. Ventricular dysfunction resulting from the MI may lead to the presence of the abnormal S3 and S4 heart sounds. Text Reference - p. 754

The nurse would assess a patient with complaints of chest pain for which clinical manifestations associated with a myocardial infarction (MI)? Select all that apply. 1 Flushing 2 Ashen skin 3 Diaphoresis 4 Nausea and vomiting 5 S3 or S4 heart sounds

3 Biochemical markers such as creatine phosphokinase (CPK), CPK-MB, and troponin are released specifically by myocardial cells when injured and are detectable in the blood. Myoglobin, although one of the first markers to increase after a myocardial infarction (MI), does not have as high of a cardiac specificity as others. C-reactive protein is increased after an MI as a result of the inflammation caused by tissue damage; however it is also not as highly specific to cardiac tissue. An increased white blood cell count may be present after an MI but is due to a generalized inflammatory response. Text Reference - p. 749

The nurse, reviewing a patient's laboratory results, recognizes what result as most indicative of myocardial infarction? 1 Increased myoglobin 2 Decreased C-reactive protein 3 Increased creatine phosphokinase 4 Increased white blood cell count

4, 5 Nuts such as almonds and peanuts have monounsaturated fatty acids that are safe for a patient predisposed to coronary artery disease (CAD). Fish oil contains polyunsaturated fatty acids that are good for health. The nurse should advise the patient not to consume red meat, which contains saturated fatty acids and cholesterol. Tofu is also a healthy diet option because it contains alpha-linolenic acid, which becomes omega-3 fatty acid in the body. The patient should avoid eating milk or eggs, because they also contain saturated fatty acids and cholesterol, and increase the risk for acquiring coronary artery disease (CAD), especially in patients who are predisposed to CAD. Text Reference - p. 737

What instruction should the nurse give to the patient who is predisposed to coronary artery disease (CAD)? Select all that apply. 1 "Consume red meat." 2 "Avoid consuming tofu." 3 "Consume milk and eggs." 4 "Eat peanuts and almonds." 5 "Take a fish oil supplement."

2 The pain with ACS is severe, prolonged, and not easy to relieve. ACS is associated with deterioration of a once stable atherosclerotic plaque that ruptures, exposes the intima to blood, and stimulates platelet aggregation and local vasoconstriction with thrombus formation. The unstable lesion, if partially occlusive, will be manifest as unstable angina or NSTEMI. If there is total occlusion, it is manifest as STEMI. STUDY TIP: A helpful method for decreasing test stress is to practice self-affirmation. After you have adequately studied and really know the material, start looking in the mirror each time you pass one and say to yourself—preferably out loud—"I know this material, and I will do well on the test." After several times of watching and hearing yourself reaffirm your knowledge, you will gain inner confidence and be able to perform much better during the test period. This technique really works for students who are adventurous enough to use it. It may feel silly at first, but if it works, who cares? It will work for performing skills in clinical as well, as long as you have practiced the skill sufficiently. Text Reference - p. 746

The patient comes to the emergency department with severe, prolonged angina that is not immediately reversible. The nurse knows that if the patient once had angina related to a stable atherosclerostic plaque and the plaque ruptures, there may be occlusion of a coronary vessel and this type of pain. How will the nurse document this situation related to pathophysiology, presentation, diagnosis, prognosis, and interventions for this disorder? 1 Unstable angina 2 Acute coronary syndrome (ACS) 3 ST segment elevation myocardial infarction (STEMI) 4 Non-ST segment elevation myocardial infarction (NSTEMI)

4 In the early recovery phase after the patient is dismissed from the hospital, the activity level is increased gradually under supervision and with ECG monitoring. The late recovery phase includes therapeutic lifestyle changes that become lifelong habits. In the first phase of recovery, activity is dependent on the severity of the angina or myocardial infarction (MI), and attention is focused on the management of chest pain, anxiety, dysrhythmias, and other complications. With early recovery phase, the cardiac rehabilitation team may suggest that physical activity be initiated at home, but this is not always done. STUDY TIP: Regular exercise, even if only a 10-minute brisk walk each day, aids in reducing stress. Although you may have been able to enjoy regular sessions at the health club or at an exercise class several times a week, you now may have to cut down on that time without giving up a set schedule for an exercise routine. Using an exercise bicycle that has a book rack on it at home, the YMCA, or a health club can help you accomplish two goals at once. You can exercise while beginning a reading assignment or while studying notes for an exam. Listening to lecture recordings while doing floor exercises is another option. At least a couple of times a week, however, the exercise routine should be done without the mental connection to school; time for the mind to unwind is necessary, too. Text Reference - p. 757

The patient is being dismissed from the hospital after acute coronary syndrome and will be attending rehabilitation. What information does the patient need to be taught about the early recovery phase of rehabilitation? 1 Therapeutic lifestyle changes should become lifelong habits. 2 Physical activity always is started in the hospital and continued at home. 3 Attention will focus on management of chest pain, anxiety, dysrhythmias, and other complications. 4 Activity level is increased gradually under cardiac rehabilitation team supervision and with ECG monitoring.

3, 4 The patient receiving nitrates must be on a nitrate-free period every day usually for eight hours in the night to limit the effect of orthostatic hypotension, which is caused by venous dilation. Patient tolerance to medication-induced vasodilation can be avoided through eight-hour breaks in dosage. Depression may occur due to beta-blockers. Atherosclerosis is the primary reason for myocardial ischemia in the patient with stable and unstable angina. Raynaud's phenomenon can cause Prinzmetal's angina. Text Reference - p. 745

The primary health care provider suggests the patient with stable angina who is receiving treatment avoid isosorbide dinitrate at night unless symptoms occur. The risk of which complication is reduced through this intervention? Select all that apply. 1 Depression 2 Atherosclerosis 3 Medication Tolerance 4 Orthostatic hypotension 5 Raynaud's phenomenon

1 Celecoxib has been linked to increased cardiovascular events and should therefore be avoided. Lisinopril, an antihypertensive, is cardioprotective. Aspirin is recommended for heart health due to its antiplatelet effects. Diazepam does not have an impact on cardiovascular health. Text Reference - p. 775

To decrease the risk of medication-induced cardiovascular events, the nurse should instruct the patient to avoid which medication? 1 Celecoxib, a COX-2 inhibitor 2 Lisinopril, an ACE-inhibitor 3 Aspirin, an antiplatelet drug 4 Diazepam, a benzodiazepine

2 Muscle pain and elevated creatine kinase levels are manifestations of rhabdomyolysis. Elevated liver enzymes and rhabdomyolysis are adverse effects of statin drugs like Simvastatin. Side effects of niacin include pruritus and flushing. High doses of this drug may cause decreased liver function. Gemfibrozil is a fibric acid derivative that can cause rhabdomyolysis when given with a statin drug. Colestipol is a bile-acid sequestrant drug. This drug does not have any major adverse effects except that it lowers the absorption of drugs such as warfarin, digoxin, and thiazide diuretics. Colestipol is not related to rhabdomyolysis. Text Reference - p. 739

Upon taking a lipid-lowering medication for hyperlipidemia, a patient reports muscle pain. The nurse notes the patient has elevated liver enzymes and creatine kinase levels. It is most likely that which lipid-lowering medication was taken by the patient? 1 Niacin 2 Simvastatin 3 Gemfibrozil 4 Colestipol

2, 3 The patient has a body mass index of 30.0 kg/m2, which is above the healthy range of 18.5 to 24.9 kg/m2. The patient can eat soybeans, because they are a lipid-lowering agent. The patient can also eat red yeast rice because there is strong scientific evidence that red yeast rice reduces total cholesterol, low-density lipoproteins, and triglycerides. The patient should not eat bacon, cream cheese, or palm oil, because they contain saturated fatty acids and may further increase obesity. Text Reference - p. 738

What instruction should the nurse give to the patient who has a body mass index of 30.0 kg/m2? Select all that apply. 1 "Eat bacon." 2 "Eat soybeans." 3 "Eat red yeast rice." 4 "Eat cream cheese." 5 "Consume palm oil.

4 The patient should abstain from sexual activity, which increases the cardiac workload and promotes sympathetic stimulation because it may precipitate angina. The patient should not eat a full meal or perform vigorous exercise to avoid increasing the cardiac workload that could precipitate an angina attack. Patients with stable angina should take nitroglycerin tablets before performing strenuous physical activity, rather than after, in order to prevent the occurrence of anginal attack. Test-Taking Tip: Start by reading each of the answer options carefully. Usually at least one of them will be clearly wrong. Eliminate this one from consideration. Now you have reduced the number of response choices by one and improved the odds. Continue to analyze the options. If you can eliminate one more choice in a four-option question, you have reduced the odds to 50/50. While you are eliminating the wrong choices, recall often occurs. One of the options may serve as a trigger that causes you to remember what a few seconds ago had seemed completely forgotten. Text Reference - p. 741

What instruction should the nurse provide a patient who shows an ST segment depression in the electrocardiogram (ECG) to help relieve symptoms of pain between the shoulder blades? 1 Eat a full meal until you are satisfied. 2 Perform vigorous exercise to relieve the pain. 3 Take nitroglycerine immediately after any strenuous activity. 4 Abstain from any kind of sexual activity until it's deemed safe by a cardiologist.

4 The patient must be encouraged to quit smoking. Smoking cessation medications such as bupropion can be used to prevent the withdrawal symptoms of nicotine. Even if the patient is using smokeless tobacco, the risk of developing coronary artery disease is the same. Changing to filtered cigarettes does not affect the risk of developing coronary artery disease. Changing from high-nicotine to low-nicotine cigarettes also does not affect the risk of getting coronary heart disease. Text Reference - p. 734

What is the most appropriate nursing intervention for a patient who smokes cigarettes and is predisposed to developing coronary artery disease? 1 Recommend smokeless tobacco. 2 Encourage the use of filtered cigarettes. 3 Suggest smoking low nicotine cigarettes. 4 Discuss medication to assist with smoking cessation

4 Stent placement is associated with many risks. Stents increase the risk of clotting; therefore, LMWH is prescribed to prevent this risk. LMWH is not an appropriate treatment for stent displacement or anaphylaxis. LMWH does not help healing an injury on the vessel wall. Text Reference - p. 745

What is the reason behind prescribing low-molecular-weight heparin (LMWH) after a stent placement? 1 Because stents can become displaced 2 Because stents can trigger anaphylaxis 3 Because stents can injure the vessel wall 4 Because stents increase the risk of clotting

1, 3, 4 The patient should be advised to take acetaminophen along with isosorbide mononitrate to avoid a headache due to the dilation of cerebral blood vessels. The patient should have blood pressure measured after the initial dose because isosorbide mononitrate causes venous dilation that may lead to a drop in blood pressure. The patient should be advised to avoid taking isosorbide mononitrate for a period of eight hours during the night to provide a nitrate-free period in order to prevent the effect of orthostatic hypotension. The patient should not be advised to discontinue the medication even if headaches persist. Isosorbide mononitrate is a long-acting nitrate used to reduce the incidence of anginal attacks and should be taken regularly, not only when angina symptoms are present. Test-Taking Tip: Read the question carefully before looking at the answers: (1) Determine what the question is really asking; look for key words; (2) Read each answer thoroughly and see if it completely covers the material asked by the question; (3) Narrow the choices by immediately eliminating answers you know are incorrect. Text Reference - p. 743

What should the nurse advise the patient who is on isosorbide mononitrate regarding drug administration? Select all that apply. 1 "Take acetaminophen along with the medication." 2 "Discontinue the medication if headache is persistent." 3 "Avoid taking isosorbide mononitrate for eight hours at night." 4 "Have your blood pressure measured after the initial dose." 5 "Take the medication only when symptoms of angina appear."

3 Prinzmetal's angina occurs at rest due to coronary artery spasm. The patient should not rest in a recumbent position because that triggers the pain. The nurse should teach the patient about the administration of the medications and limiting the activities that precipitate an anginal attack. Printed information from the nurse helps provide clarity to the patient regarding the elements taught by the nurse and also helps in managing the care better. Text Reference - p. 742

Which action by the student nurse indicates a need for correction while counseling a patient with Prinzmetal's angina who is about to be discharged? 1 Providing information regarding the administration of medications 2 Advising the patient to limit the activities that precipitate an attack 3 Advising the patient to take rest in recumbent position during an attack 4 Providing printed information about the care management to the patient

2 Alteplase is a thrombolytic agent that breaks up the fibrin meshwork in clots. Nadolol is a β adrenergic blocker that inhibits sympathetic nervous stimulation of the heart. Valsartan is an angiotensin II receptor blocker, which inhibits the binding of angiotensin II to angiotensin I receptors. Nicardipine is a calcium channel blocker that prevents calcium entry into the vascular smooth muscles and cardiac cells. Test-Taking Tip: If you are unable to answer a multiple-choice question immediately, eliminate the alternatives that you know are incorrect and proceed from that point. The same goes for a multiple-response question that requires you to choose two or more of the given alternatives. If a fill-in-the-blank question poses a problem, read the situation and essential information carefully and then formulate your response. Text Reference - p. 744

Which drug breaks up the fibrin meshwork in clots? 1 Nadolol 2 Alteplase 3 Valsartan 4 Nicardipine

4 Ranolazine is a sodium current inhibitor that further prolongs the QT interval in patients who have QT prolongation. Aspirin and heparin are safe in patients with chronic stable angina and are used to inhibit clot formation in blood vessels. Captopril is an angiotensin II converting inhibitor that reduces the risk of cardiac events by dilating the blood vessels and reducing blood pressure. Test-Taking Tip: Relate the drugs with the action on the patient and derive the correct answer by its action. Text Reference - p. 745

Which drug in the patient medication chart should be excluded in a patient with chronic stable angina who has a prolonged QT interval? 1 Aspirin 2 Heparin 3 Captopril 4 Ranolazine

1 Captopril is an angiotensin-converting enzyme (ACE) inhibitor that may prevent or limit ventricular remodeling. Valsartan is an angiotensin II receptor blocker that is used in patients who are intolerant to angiotensin-converting enzyme (ACE) inhibitor. Metoprolol is a β-adrenergic blocker that reduces heart rate, contractility, and blood pressure. Nitroglycerin is a nitrate that promotes coronary artery vasodilation. Test-Taking Tip: You have at least a 25 percent chance of selecting the correct response in multiple-choice items. If you are uncertain about a question, eliminate the choices that you believe are wrong and then call on your knowledge, skills, and abilities to choose from the remaining responses. Text Reference - p. 744

Which drug may prevent or limit ventricular remodeling? 1 Captopril 2 Valsartan 3 Metoprolol 4 Nitroglycerin

1 Aspirin produces antiplatelet activity by inhibiting cyclooxygenase, which in turn produces thromboxane A2, a potent platelet activator. Heparin prevents the conversion of fibrinogen to fibrin and prothrombin to thrombin. Abciximab prevents binding of fibrinogen to platelets, thereby blocking platelet aggregation. Clopidogrel acts by inhibiting the adenosine diphosphate receptor on the platelet cell membrane. Test-Taking Tip: You have at least a 25 percent chance of selecting the correct response in multiple-choice items. If you are uncertain about a question, eliminate the choices that you believe are wrong and then call on your knowledge, skills, and abilities to choose from the remaining responses. Text Reference - p. 744

Which drug prevents platelet aggregation by inhibiting cyclooxygenase? 1 Aspirin 2 Heparin 3 Abciximab 4 Clopidogrel

2 Tirofiban is a glycoprotein IIb/IIIa inhibitor, which prevents the binding of fibrinogen to platelets, thereby blocking platelet aggregation. Heparin is an anticoagulant, which prevents conversion of fibrinogen to fibrin and prothrombin to thrombin. Ticagrelor is an antiplatelet agent, which inhibits platelet aggregation. Dalteparin is a low-molecular-weight heparin, which binds to antithrombin III, enhancing its effect. Text Reference - p. 744

Which drug prevents the binding of fibrinogen to platelets, thereby preventing platelet aggregation? 1 Heparin 2 Tirofiban 3 Ticagrelor 4 Dalteparin

1 Warfarin interferes with hepatic synthesis of the vitamin K-dependent clotting factors that result in an anticoagulant effect. Prasugrel causes an antiplatelet effect by inhibiting platelet aggregation. Argatroban acts by directly inhibiting the clotting factor thrombin and results in an anticoagulant effect. Eptifibatide prevents the binding of fibrinogen to platelets, thereby blocking platelet aggregation. Text Reference - p. 744

Which drug produces an anticoagulant effect by interfering with hepatic synthesis of vitamin K-dependent clotting factors? 1 Warfarin 2 Prasugrel 3 Argatroban 4 Eptifibatide

3 Gemfibrozil decreases the hepatic synthesis and secretion of VLDLs, which reduces the levels of triglycerides. Niacin inhibits the synthesis of VLDLs and low-density lipoproteins (LDL). Fluvastatin blocks the synthesis of cholesterol and increases the LDL receptors in the liver. Cholestyramine binds with the bile acids in the intestines, forming an insoluble complex. The binding results in the removal of LDL and cholesterol. Text Reference - p. 739

Which drug reduces triglycerides by decreasing the synthesis and secretion of very-low-density lipoproteins (VLDL)? 1 Niacin 2 Fluvastatin 3 Gemfibrozil 4 Cholestyramine

1, 2 Losartan is an angiotensin II receptor blocker that inhibits binding of angiotensin II to angiotensin I receptors, thereby causing vasodilation. Morphine is an opioid analgesic that acts as a vasodilator to reduce preload and myocardial oxygen consumption. Reteplase is a thrombolytic agent that breaks up the fibrin meshwork in clots. Carvedilol is a β-adrenergic that reduces the heart rate, contractility, and blood pressure. Bivalirudin is a direct thrombin inhibitor that directly inhibits the clotting factor thrombin. Text Reference - p. 744

Which drugs act by causing vasodilation either directly or indirectly? Select all that apply. 1 Losartan 2 Morphine 3 Reteplase 4 Carvedilol 5 Bivalirudin

1, 4 Aspirin is an antiplatelet drug that helps prevent thrombosis around the stent. Ticagrelor is also an antiplatelet drug and helps prevent clotting around the stent, thus maintaining its patency. Captopril is an angiotensin-converting enzyme inhibitor used to treat high risk chronic stable angina. Losartan is an angiotensin II receptor blocker used in patients who are intolerant of angiotensin-converting enzyme (ACE) inhibitors. Ranolazine is a sodium current inhibitor, used to treat chronic angina refractory to other medications. Text Reference - p. 744

Which drugs are used in the dual antiplatelet therapy after a stent placement? Select all that apply. 1 Aspirin 2 Losartan 3 Captopril 4 Ticagrelor 5 Ranolazine

1 A thrombus may form and adhere to the wall of the coronary artery, leading to total occlusion. The transport of cholesterol into the arterial intima may lead to the formation of plaques on one portion of the artery, or in a circular fashion involving the entire lumen. Smooth muscle proliferation may lead to the thickening of the arterial wall. The earliest lesions are fatty streaks characterized by lipid-filled smooth muscle cells. STUDY TIP: Develop a realistic plan of study. Do not set rigid, unrealistic goals. Text Reference - p. 731

Which factor leads to total occlusion of the coronary artery? 1 Thrombus formation in the coronary artery 2 Transport of cholesterol into the arterial intima 3 Smooth muscle proliferation of the arterial wall 4 Lipid-filled smooth muscle cells in the coronary artery

1 The 45-year-old depressed male with a high-stress job is at the highest risk for CAD. Studies demonstrate that depression and stressful states can contribute to the development of CAD. Elevated HDL levels and low homocysteine levels actually help to prevent CAD. Although a sedentary lifestyle is a risk factor, a BMI of 23 kg/m2 depicts normal weight. The patient with two risk factors is at greatest risk for developing CAD. Text Reference - p. 732

Which individuals would the nurse identify as having the highest risk for coronary artery disease (CAD)? 1 A 45-year-old depressed male with a high-stress job 2 A 60-year-old male with below normal homocysteine levels 3 A 54-year-old female vegetarian with elevated high-density lipoprotein (HDL) levels 4 A 62-year-old female who has a sedentary lifestyle and body mass index (BMI) of 23 kg/m2

2 The patient with a history of asthma should avoid beta-adrenergic blockers because they can cause bronchoconstriction, resulting in increased breathlessness. Short-acting nitrates are the first line treatment for a patient with angina and can be used safely in asthma patients. Calcium channel blockers are used in patients if β-blockers are contraindicated, poorly tolerated, or do not control anginal symptoms. Angiotensin II receptor blockers can be given to the patient safely, because they have no harmful effects on the respiratory system. Text Reference - p. 745

Which medication is responsible for the condition of a patient prescribed medications to treat stable angina and with a history of asthma who is admitted to the emergency department complaining of severe chest pain and breathlessness? 1 Short acting nitrates 2 Beta adrenergic blocker 3 Calcium channel blocker 4 Angiotensin II receptor blocker

2 To prevent complications such as cardiac rupture and reinfarction, it is important for the patient to cease any unnecessary activity, thereby decreasing cardiac demands. Straining while having a bowel movement on a bedpan causes an unnecessary increase in cardiac workload. Therefore, allowing a patient to assume a normal elimination position on a bedside commode will facilitate an easy bowel movement and conserve energy. Within the first several days after myocardial infarction (MI), patients may usually return to a regular diet with the addition of a stool softener to ease the passage of stool. Breathing exercises are important in preventing pneumonia when activity is diminished; however, these are still not as important as the bedside commode. Activity is minimized for the first several days after an MI; this includes avoiding active range-of-motion exercises. Text Reference - p. 761

Which nursing intervention is most important for a patient during the first several days after a myocardial infarction? 1 Determining the patient's ability to tolerate a regular diet 2 Instructing the patient in how to utilize a bedside commode 3 Assisting the patient in turning, coughing, and deep-breathing 4 Encouraging the patient to perform active range-of-motion exercises

1 A patient with angina should be placed in an upright position and supplied oxygen to provide comfort and to attain an appropriate amount of oxygen in blood unless contraindicated. A recumbent positioning of the patient may precipitate the attack. Isometric exercises are stressful and may exacerbate the symptoms by increasing the cardiac workload. Salt and saturated fat foods are restricted in the patient to prevent further complications. Text Reference - p. 754

Which nursing intervention will be beneficial in patients with angina? 1 Position the patient upright and supply oxygen. 2 Rest the patient in recumbent position during attack. 3 Encourage the patient to perform isometric exercises. 4 Include a salt-rich diet to prevent orthostatic hypotension.

4 The patient with weak muscles (myopathy) and breakdown of skeletal muscles (rhabdomyolysis) is showing the adverse effects of treatment with HMG-CoA reductase inhibitors such as atorvastatin. These drugs increase the LDL receptors in the liver. The patient with pruritus and flushing on the face may be receiving niacin treatment. The patient with pain in the joints, or arthralgia, may be receiving omega-3 fatty acid treatment. The patient with rashes and mild gastrointestinal disturbances may be receiving treatment with fibric acid derivatives such as fenofibrate. Text Reference - p. 739

Which patient is showing signs of increased low-density lipoprotein (LDL) receptors in the liver because of the therapeutic effects of lipid-lowering treatment? 1 A patient with itching and flushing on the face 2 A patient with pain in the joints without inflammation 3 A patient with rashes and mild gastrointestinal disturbance 4 A patient with weak muscles and break-down of skeletal muscles

4, 5 The patient with 20 mg/dL has low levels of high-density lipoproteins (HDL), and would benefit from fenofibrate, which increases the HDL in the body. The patient with low-density lipoprotein (LDL) levels of 180 mg/dL would benefit from taking fenofibrate because it lowers LDL levels in the body. The patient with a waist circumference of 80 cm is not obese and does not need lipid-lowering therapy. The patient with a triglyceride level of 120 mg/dL is not at a risk of coronary artery disease and would not benefit from fenofibrate. The patient with a total cholesterol level of 160 mg/dL is also not at a risk of coronary artery disease and would not benefit from lipid-lowering drug therapy. Test-Taking Tip: Patients who are obese or who are at a risk for developing coronary artery disease would benefit from lipid-lowering medication. Text Reference - p. 739

Which patient would benefit from receiving fenofibrate? Select all that apply. 1 Patient with a waist circumference of 80 cm 2 Patient with a triglyceride level of 120 mg/dL 3 Patient with total cholesterol level of 160 mg/dL 4 Patient with high-density lipoprotein level of 20 mg/dL 5 Patient with a low-density lipoprotein level of 180 mg/dL

4 Multiple risk factors increase the risk of CAD, and this patient has three risk factors: age over 55, African American ethnic background, and cholesterol level greater than 240 mg/dL. The middle-aged nonsmoking AfricanAmerican male has only two risk factors: middle age and male gender: Caucasian middle-age males are more prone to develop CAD. The Hispanic patient has only two risk factors for CAD: male gender and smoking. The middle-aged white male has only two risk factors (age and gender), because systolic blood pressure is less than 160 mm Hg. Text Reference - p. 732

Which patient would the nurse identify being at higher risk for developing coronary artery disease (CAD)? 1 43-year-old nonsmoking African American male 2 26-year-old Hispanic male smoking one pack of cigarettes per day 3 49-year-old Caucasian male with blood pressure 152/92 mm Hg 4 72-year-old African American female with a cholesterol level of 300 mg/dL

1 Older adults have to use longer rest periods between exercise sessions because of decreased endurance and ability to tolerate stress. Older adults have decreased sweating and, therefore, shouldn't exercise in hot temperatures. Older adults have to perform low-level activity exercise for longer periods of time. Elderly adults have to change their lifestyles to accommodate a physical activity program, even though they are more prone to make such changes during hospitalization or when experiencing symptoms of CAD. Text Reference - p. 740

Which statement by an 84-year-old patient with coronary artery disease (CAD) indicates understanding of discharge teaching about physical activity? 1 "I will use longer rest periods between exercise sessions." 2 "I can stop exercising as soon as my cardiac symptoms disappear." 3 "I should exercise outside all the time to achieve better results" 4 "I have to exercise for longer periods of time and more vigorously compared with younger people."

3 Microvascular angina is a common type of angina in women that occurs due to the absence of coronary atherosclerosis or coronary spasm even while performing daily activities. Chronic stable angina is secondary to coronary artery disease and is not specific to tobacco use or sleep time. Chest pain due to chronic stable angina persists for 5 to 15 minutes and is triggered by exertion and relieved upon rest. Silent ischemia is frequent in the patient with diabetic neuropathy, due to damage of the nerves innervating the cardiovascular system. Text Reference - p. 742

Which statement made by the student nurse indicates effective learning about microvascular angina? 1 "It is common in smokers and occurs even during sleep." 2 "It occurs due to exertion for 5 to 15 minutes and is relieved upon rest." 3 "It is more common in women and is triggered even when performing daily activities." 4 "It occurs in the patient with diabetic neuropathy, affecting the cardiovascular system."

3 Short-acting nitrates such as nitroglycerin (NTG) are first-line medications for angina. The nurse has to instruct the patient on NTG to report any changes in the pattern of pain, frequency of attack, or nocturnal angina to the health care provider. The nurse must direct the patient to spray the medication on his or her tongue. The nurse should ask the patient to slowly change positions after NTG use to avoid the effects of orthostatic hypotension. The nurse should ask the patient to take NTG every five minutes for a maximum of three doses if symptoms are not resolved. Text Reference - p. 743

Which statement made by the student nurse indicates effective learning regarding the instructions to be given to a patient who is on nitroglycerin? 1 "I should direct the patient to inhale the spray containing medication." 2 "I should ask the patient to change position rapidly after the medication use." 3 "I should instruct the patient to report changes in the pattern of pain to the health care provider." 4 "I should encourage the patient to administer the medication every 30 minutes sublingually if symptoms persist."