Chapter 33 - Coronary Artery Disease and Acute Coronary Syndrome

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

A A 45-year-old depressed male with a high-stress job 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, and thus the patient with two risk factors is at greatest risk for developing CAD.

When providing nutritional counseling for patients at risk for CAD, which foods would the nurse encourage patients to include in their diet (select all that apply)? A Tofu B Walnuts C Tuna fish D Whole milk E Orange juice

A Tofu B Walnuts C Tuna fish Tuna fish, tofu, and walnuts are all rich in omega-3 fatty acids, which have been shown to reduce the risks associated with CAD when consumed regularly.

In preparation for discharge, the nurse teaches a patient with chronic stable angina how to use the prescribed short-acting and long-acting nitrates. Which patient statement indicates that the teaching has been effective? a. "I will sit down before I put the nitroglycerin under my tongue." b. "I will check my pulse rate before I take any nitroglycerin tablets." c. "I will put the nitroglycerin patch on as soon as I get any chest pain." d. "I will remove the nitroglycerin patch before taking sublingual nitroglycerin."

Answer: a. "I will sit down before I put the nitroglycerin under my tongue." Rationale: The patient should sit down before taking the nitroglycerin to decrease cardiac workload and prevent orthostatic hypotension. Transdermal nitrates are used prophylactically rather than to treat acute pain and can be used concurrently with sublingual nitroglycerin. Although the nurse should check blood pressure before giving nitroglycerin, patients do not need to check the pulse rate before taking nitrates.

A patient who has recently started taking pravastatin (Pravachol) and niacin reports several symptoms to the nurse. Which information is most important to communicate to the health care provider? a. Generalized muscle aches and pains. b. Dizziness with rapid position changes. c. Nausea when taking the drugs before meals. d. Flushing and pruritus after taking the drugs.

Answer: a. Generalized muscle aches and pains. Rationale: Muscle aches and pains may indicate myopathy and rhabdomyolysis, which have caused acute kidney injury and death in some patients who have taken the statin medications. These symptoms indicate that the pravastatin may need to be discontinued. The other symptoms are common side effects when taking niacin, and although the nurse should follow-up with the health care provider, they do not indicate that a change in medication is needed.

A patient who is being admitted to the emergency department with intermittent chest pain gives the following list of daily medications to the nurse. Which medication has the most immediate implications for the patient's care? a. Tadalafil (Cialas) b. Furosemide (Lasix) c. Warfarin (Coumadin) d. Diltiazem (Cardizem

Answer: a. Tadalafil (Cialas) Rationale: The nurse will need to avoid giving nitrates to the patient because nitrate administration is contraindicated in patients who are using tadalafil because of the risk of severe hypotension caused by vasodilation. The other home medications should be documented and reported to the health care provider but do not have as immediate an impact on decisions about the patient's treatment.

Which patient statement indicates that the nurse's teaching about carvedilol (Coreg) for preventing anginal episodes has been effective? a. "Carvedilol will help my heart muscle work harder." b. "It is important not to suddenly stop taking the carvedilol." c. "I can expect to feel short of breath when taking carvedilol." d. "Carvedilol will increase the blood flow to my heart muscle."

Answer: b. "It is important not to suddenly stop taking the carvedilol." Rationale: Patients who have been taking -adrenergic blockers can develop intense and frequent angina if the medication is suddenly discontinued. Carvedilol (Coreg) decreases myocardial contractility. Shortness of breath that occurs when taking -adrenergic blockers for angina may be due to bronchospasm and should be reported to the health care provider. Carvedilol works by decreasing myocardial O2 demand, not by increasing blood flow to the coronary arteries.

Which action will the nurse take to evaluate the effectiveness of IV nitroglycerin for a patient with a myocardial infarction (MI)? a. Monitor heart rate. b. Ask about chest pain. c. Check blood pressure. d. Observe for dysrhythmias.

Answer: b. Ask about chest pain. Rationale: The goal of IV nitroglycerin administration in MI is relief of chest pain by improving the balance between myocardial oxygen supply and demand. The nurse will also monitor heart rate and blood pressure and observe for dysrhythmias, but these parameters will not indicate whether the medication is effective.1

To improve the physical activity level for a mildly obese 68-year-old patient, which action should the nurse plan to take? a. Stress that weight loss is a major benefit of increased exercise. b. Determine what kind of physical activities the patient usually enjoys. c. Tell the patient that older adults should exercise for no more than 20 minutes at a time. d. Teach the patient to include a short warm-up period at the beginning of physical activity.

Answer: b. Determine what kind of physical activities the patient usually enjoys. Rationale: Because patients are more likely to continue physical activities that they already enjoy, the nurse will plan to ask the patient about preferred activities. The goal for older adults is 30 minutes of moderate activity on most days. Older adults should plan for a longer warm-up period. Benefits of exercises, such as improved activity tolerance, should be emphasized rather than aiming for significant weight loss in older mildly obese adults.

A patient who has recently had an acute myocardial infarction (AMI) ambulates in the hospital hallway. Which data would indicate to the nurse that the patient should stop and rest? a. O2 saturation drops from 99% to 95%. b. Heart rate increases from 66 to 98 beats/min. c. Respiratory rate goes from 14 to 20 breaths/min. d. Blood pressure (BP) changes from 118/60 to 126/68 mm Hg.

Answer: b. Heart rate increases from 66 to 98 beats/min. Rationale: A change in heart rate of more than 20 beats over the resting heart rate indicates that the patient should stop and rest. The increases in BP and respiratory rate, and the slight decrease in O2 saturation, are normal responses to exercise.

Which data indicates to the nurse that the patient with stable angina is experiencing a side effect of metoprolol (Lopressor)? a. Patient is restless and agitated. b. Patient reports feeling anxious. c. Blood pressure is 90/54 mm Hg. d. Heart monitor shows normal sinus rhythm.

Answer: c. Blood pressure is 90/54 mm Hg. Rationale: Patients taking Beta-adrenergic blockers should be monitored for hypotension and bradycardia. Because this class of medication inhibits the sympathetic nervous system, restlessness, agitation, hypertension, and anxiety will not be side effects. Normal sinus rhythm is a normal and expected heart rhythm.

The nurse is administering a thrombolytic agent to a patient with an acute myocardial infarction. What patient data indicates that the nurse should stop the drug infusion? a. Bleeding from the gums. b. An increase in blood pressure. c. Decreased level of consciousness. d. A nonsustained episode of ventricular tachycardia.

Answer: c. Decreased level of consciousness. Rationale: The change in level of consciousness indicates that the patient may be experiencing intracranial bleeding, a possible complication of thrombolytic therapy. Some bleeding of the gums is an expected side effect of the therapy but not an indication to stop infusion of the thrombolytic medication. A decrease in blood pressure could indicate internal bleeding. A nonsustained episode of ventricular tachycardia is a common reperfusion dysrhythmia and may indicate that the therapy is effective.

The nurse reviews information shown in the accompanying figure from the medical records of a 43-year-old patient. Which risk factor modification for coronary artery disease should the nurse include in patient teaching? Tab 1 - History: * Father died of MI at age 65 * Quit smoking 2 years ago * Works fulltime outside as a landscaper/gardener Tab 2 - Physical Assessment/Vital Signs: * Waist circumference 34 in (86 cm) * BMI 22.5 kg/m2 * Pulse 78 * Blood pressure 136/80 mm Hg Tab 3 - Diagnostic Testing: * Total cholesterol 190 mg/dL * HDL 135 mg/dL * LDL 165 mg/dL * Triglycerides 142 mg/dL a. Importance of daily physical activity. b. Effect of weight loss on blood pressure. c. Dietary changes to improve lipid levels. d. Cardiac risk associated with previous tobacco use.

Answer: c. Dietary changes to improve lipid levels. Rationale: The patient has an elevated low-density lipoprotein cholesterol and low high-density lipoprotein cholesterol, which will increase the risk of coronary artery disease. The patient's waist circumference and body mass index indicate an appropriate body weight. The risk for coronary artery disease a year after quitting smoking is the same as a nonsmoker. The patient's occupation indicates that daily activity is at the levels suggested by national guidelines.

A patient with hyperlipidemia has a new order for colesevelam (Welchol). Which nursing action is appropriate when scheduling this medication? a. Administer the medication at the patient's usual bedtime. b. Have the patient take the colesevelam 1 hour before breakfast. c. Give the patient's other medications 2 hours after colesevelam. d. Have the patient take the dose at the same time as the prescribed aspirin.

Answer: c. Give the patient's other medications 2 hours after colesevelam. Rationale: The bile acid sequestrants interfere with the absorption of many other drugs and giving other medications at the same time should be avoided. Taking an aspirin concurrently with the colesevelam may increase the incidence of gastrointestinal side effects such as heartburn. For maximum effect, colesevelam should be administered with meals.

A patient with diabetes mellitus and chronic stable angina has a new order for captopril. What should the nurse teach this patient about the primary purpose of captopril? a. Decreases the heart rate. b. Controls blood glucose levels. c. Prevents changes in heart muscle. d. Reduces the frequency of chest pain.

Answer: c. Prevents changes in heart muscle. Rationale: The purpose for angiotensin-converting enzyme (ACE) inhibitors in patients with chronic stable angina who are at high risk for a cardiac event is to decrease ventricular remodeling. ACE inhibitors do not directly impact angina frequency, blood glucose, or heart rate.

Nadolol (Corgard) is prescribed for a patient with chronic stable angina and left ventricular dysfunction. What data would indicate to the nurse that the drug is effective? a. Decreased blood pressure and heart rate. b. Improvement in the strength of the distal pulses. c. Fewer complaints of having cold hands and feet. d. Participation in daily activities without chest pain.

Answer: d. Participation in daily activities without chest pain. Rationale: Because the drug is ordered to improve the patient's angina, effectiveness is indicated if the patient is able to accomplish daily activities without chest pain. Blood pressure and heart rate may decrease, but these data do not indicate that the goal of decreased angina has been met. The noncardioselective Beta-adrenergic blockers can cause peripheral vasoconstriction, so the nurse would not expect an improvement in distal pulse quality or skin temperature.

After teaching a patient with chronic stable angina about nitroglycerin, the nurse recognizes the need for further teaching when the patient makes which statement? A "I will replace my nitroglycerin supply every 6 months." B "I can take up to five tablets every 3 minutes for relief of my chest pain." C "I will take acetaminophen (Tylenol) to treat the headache caused by nitroglycerin." D "I will take the nitroglycerin 10 minutes before planned activity that usually causes chest pain."

B "I can take up to five tablets every 3 minutes for relief of my chest pain." 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 5 minutes, the patient should be instructed to activate the emergency medical services (EMS) system. If symptoms are improved, repeat the nitroglycerin every 5 minutes for a maximum of three doses and contact EMS if symptoms have not resolved completely.

The nurse prepares a discharge teaching plan for a 44-year-old male patient who has recently been diagnosed with coronary artery disease. Which risk factor should the nurse plan to focus on during the teaching session? A Type A personality B Elevated serum lipids C Family cardiac history D Hyperhomocysteinemia

B Elevated serum lipids Dyslipidemia is one of the four major modifiable risk factors for coronary artery disease (CAD). The other major modifiable risk factors are hypertension, tobacco use, and physical inactivity. Research findings related to psychologic states (i.e., type A personality) as a risk factor for coronary artery disease have been inconsistent. Family history is a nonmodifiable risk factor. High homocysteine levels have been linked to an increased risk for CAD.

Which antilipemic medications should the nurse question for a patient with cirrhosis of the liver (select all that apply)? A Niacin (Nicobid) B Ezetimibe (Zetia) C Gemfibrozil (Lopid) D Atorvastatin (Lipitor) E Cholestyramine (Questran)

B Ezetimibe (Zetia) D Atorvastatin (Lipitor) Ezetimibe (Zetia) should not be used by patients with liver impairment. Adverse effects of atorvastatin (Lipitor), 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.

The nurse instructs a 68-year-old woman with hypercholesterolemia about natural lipid-lowering therapies. The nurse determines further teaching is necessary if the patient makes which statement? A "Omega-3 fatty acids are helpful in reducing triglyceride levels." B "I should check with my physician before I start taking any herbal products." C "Herbal products do not go through as extensive testing as prescription drugs do." D "I will take garlic instead of my prescription medication to reduce my cholesterol."

D "I will take garlic instead of my prescription medication to reduce my cholesterol." Current evidence does not support using garlic in the treatment of elevated cholesterol. Strong evidence supports the use of omega-3 fatty acids for reduction of triglyceride levels. Many herbal products are not standardized and effects are not predictable. Patients should consult with their health care provider before starting herbal or natural therapies.

When evaluating a patient's knowledge regarding a low-sodium, low-fat cardiac diet, the nurse recognizes additional teaching is needed when the patient selects which food choice? A Baked flounder B Angel food cake C Baked potato with margarine D Canned chicken noodle soup

D Canned chicken noodle soup Canned soups are very high in sodium content. Patients need to be taught to read food labels for sodium and fat content.

A male patient who has coronary artery disease (CAD) has serum lipid values of LDL cholesterol 98 mg/dL and HDL cholesterol 47 mg/dL. What should the nurse include in the patient teaching? A Consume a diet low in fats. B Reduce total caloric intake. C Increase intake of olive oil. D The lipid levels are normal.

D The lipid levels are normal. For men, the recommended LDL is less than 100 mg/dL, and the recommended level for HDL is greater than 40mg/dL. His normal lipid levels should be included in the patient teaching and encourage him to continue taking care of himself. Assessing his need for teaching related to diet should also be done.