Lewis Ch 34 MI & CAD

10. To which patients should the nurse teach the Therapeutic Lifestyle Changes diet to reduce the risk of CAD? a. All patients to reduce CAD risk b. Patients who have experienced an MI c. Individuals with two or more risk factors for CAD d. Individuals with a cholesterol level >200 mg/dL (5.2 mmol/L)

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

37. The nurse recognizes that thrombolytic therapy for the treatment of an MI has not been successful when the patient displays which manifestation? a. Continues to have chest pain b. Has a marked increase in CK enzyme levels within 3 hours of therapy c. Develops major GI or GU bleeding during treatment d. Develops premature ventricular contractions and ventricular tachycardia during treatment

a. Continues to have chest pain If chest pain is unchanged, it is an indication that reperfusion was not successful. Indications that the occluded coronary artery is patent and blood flow to the myocardium is reestablished following thrombolytic therapy include return of ST segment to baseline on the ECG; relief of chest pain; marked, rapid rise of the CK enzyme within 3 hours of therapy; and the presence of reperfusion dysrhythmias.

44. The nurse and patient set a patient outcome that at the time of discharge after an MI the patient will be able to tolerate moderate-energy activities that are similar to which activity? a. Golfing b. Walking at 5mph c. Cycling at 13 mph d. Mowing the lawn by hand

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

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

a. Hyperlipidemia and obesity Increased exercise without an increase in caloric intake will result in weight loss, reducing the risk associated with obesity. Exercise increases lipid metabolism and increases HDL, thus reducing CAD risk. Exercise may also indirectly reduce the risk of CAD by controlling HTN, promoting glucose metabolism in diabetes, and reducing stress. Although research is needed to determine whether a decline in homocysteine can reduce the risk of heart disease, it appears that dietary modifications are indicated for risk reduction.

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

a. I'm going to take this recovery one step at a time This patient is indicating positive coping with a realization that recovery takes time and that lifestyle changes can be made as needed. The patient who is "just going to get on with life' is probably in denial about the seriousness of the condition and the changes that need to be made. Nervous questioning about the expected duration and effect of the condition indicates the presence of anxiety, as does the statement regarding the healthcare professional's role in treatment.

38. When the patient who is diagnosed with an MI is not relieved of chest pain with IV nitroglycerin, which medication will the nurse expect to be used? a. IV morphine sulfate b. Calcium channel blockers c. IV amiodarone (Cordarone0 d. Angiotensin-converting enzyme (ACE) inhibitors

a. IV morphine sulfate Morphine sulfate decreasees anxiety and cardiac workload as a vasodilator and reduces preload and myocardial oxygen consumption, which relieves chest pain. Calcium channel blockers, amiodarone, and ACE inhibitors will not relieve chest pain related to an MI.

21. When teaching an older adult with CAD how to manage the treatment program for angina, which guidelines does the nurse use to teach the patient? a. To sit for 2 to 5 minutes before standing when getting out of bed b. To exercise only twice a week to avoid unnecessary strain on the heart c. That lifestyle changes are not as necessary as they would be in a younger person d. That aspirin therapy is contraindicated in older adults because of the risk for bleeding

a. To sit for 2 to 5 minutes before standing when getting out of bed Orthostatic hypotension may cause dizziness and falls in older adults taking antiangianl agents that decrease preload. Patients should be cautioned to change position slowly. Daily exercise programs are indicated for older adults and may increase performance, endurance, and ability to tolerate stress. A change in lifestyle behaviors may increase the quality of life and reduce the risks of CAD, even in the older adult. Aspirin is commonly used in these patients and is not contraindicated.

23. The nurse suspects stable angina rather than MI pain in the patient who reports that his chest pain a. is relieved by nitroglycerin b. is a sensation of tightness or squeezing c. does not radiate to the neck, back, or arms d. is precipitated by physical or emotional exertion

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

3. While obtaining patient histories, which patient does the nurse identify as having the highest risk for CAD? a. A white man, age 54, who is a smoker and has a stressful lifestyle b. A white woman, age 68, with a BP of 172/100 mmHg and who is physically inactive c. An Asian woman, age 45, with a cholesterol level of 240 mg/dL and a BP of 130/74 mmHg d. An obese African American man, age 65, with a cholesterol level of 195 mg/dL and a BP of 128/76 mmHg

b. A white woman, age 68, with a BP of 172/100 mmHg and who is physically inactive This white woman has one unmodifiable risk factor (age) and two major modifiable risk factors (HTN and physical inactivity). Her gender risk is as high as a man's because she is over 65 years of age. The white man has one unmodifiable risk factor (gender), one major modifiable risk factor (smoking), and one miinor modifiable risk factor (stressful lifestyle). The Asian woman has only one major modifiable risk factor (hyperlipidemia) and Asians in the US have fewer MIs than do whites. The African American man has an unmodifiable risk factor r/t age and one major modifiable risk factor (obesity).

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

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

46. In counseling the patient about sexual activity following an MI, what should the nurse do? a. Wait for the patient to ask about resuming sexual activity. b. Discuss sexual activity while teaching about other physical activity c. Have the patient ask the HCP when sexual activity can be resumed d. Inform the patient that impotence is a common long-term complication following MI

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

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

b. Endothelial alteration may be caused by chemical irritants such as hyperlipidemia or by tobacco use The etiology of CAD includes atherosclerosis as the major cause. The pathophysiology of atherosclerosis development is r/t endothelial chemical injury and inflammation, which can be the result of tobacco use, hyperlipidemia, HTN, toxins, DM, hyperhomocysteinemia, and infection causing a local inflammatory response in the inner lining of the vessel walls. Partial or total occlusion occurs in the complicated lesion stage. Extra collateral circulation occurs in the presence of chronic ischemia. Therefore it is more likely to occur in an older patient.

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

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

28. During the assessment, the nurse identifies crackles in the lungs and an S3 heart sound. Which complication of MI should the nurse suspect and further investigate? a. Pericarditis b. Heart failure c. Ventricular aneurysm d. Papillary muscle dysfunction

b. Heart failure Heart failure, which can escalate to cardiogenic shock, initially occurs with mild dyspnea, restlessness, agitation, pulmonary congestion with crackles, S3 or S4 heart sounds, and jugular vein distention. Pericarditis is a common complication identified with chest pain that is aggravated by inspiration, coughing, and moving the upper body. Ventricular aneurysm is manifested with heart failure, dysrhythmias, and angina. Papillary muscle dysfunction is suspected with a new systolic apical murmur.

40. The patient has hypertension and just experienced an MI. Which type of medication would be expected to be added to decrease the workload on his heart? a. Controls ventricular dysrhythmias b. Relieves anxiety and cardiac workload c. Minimizes bradycardia from vagal stimulation d. Prevents the binding of fibrinogen to platelets

b. Relieves anxiety and cardiac workload It is recommended that patients with HTN and after an MI be on beta-adrenergic blockers indefinitely to decrease oxygen demand. They inhibit sympathetic nervous stimulation of the heart; reduce heart rate, contractility, and B/P; and decrease afterload. Although calcium channel blockers decrase heart rate, contractility, and blood pressure, they are not used unless the patient cannot tolerate beta-adrenergic blockers. ACE inhibitors and angiotensin 2 receptor blockers are used for vasodilation.

26. At what point in the healing process of the myocardium following an infarct does early scar tissue result in an unstable heart wall? a. 2 to 3 days after MI b. 4 to 10 days after MI c. 10 to 14 days after MI d. 6 weeks after MI

c. 10 to 14 days after MI At 10 to 14 days after MI, the myocardium is considered especially vulnerable to increased stress because of the unstable state of healing at this point, as well as the increasing physical activity of the patient. At 2 to 3 days, removal of necrotic tissue is taking place by phagocytic cells. by 4 to 10 days, the necrotic tissue has been cleared and a collagen matrix for scar tissue has been deposited. Healing with scar-tissue replacement of the necrotic area is usually complete by 6 weeks.

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

c. Age 32, thickened coronary arterial walls with narrowed vessel lumen The fibrous plaque stage has progressive changes that can be seen by age 30. Collagen covers the fatty streak and forms a fibrous plaque in the artery. The thrombus adheres to the arterial wall in the complicated lesion stage. Rapid onset of CAD with hypercholesterolemia may be r/t familial hypercholesterolemia, not a stage of CAD development. The fatty streak stage is the earliest stage of atherosclerosis and can be seen by age 15.

11. A 62-year-old woman has prehypertension (BP 142/90 mmHg) and smokes a pack of cigarettes per day. She has no symptoms of CAD but a recent LDL level was 154 mg/dL (3.98 mmol/L). Based on these findings, the nurse would expect that which treatment plan would be used first for this patient? a. Diet and drug therapy b. Exercise instruction only c. Diet therapy and smoking cessation d. Drug therapy and smoking cessation

c. Diet therapy and smoking cessation Diet therapy and smoking cessation are indicated for a patient without CAD who has prehypertension and LDL level > or = 130 mg/dL. When the patient's LDL level is > or = 160 mg/dL, drug therapy would be added to diet therapy. Because tobacco use is related to increased BP and LDL level, the benfit of smoking cessation is almost immediate. Exercise is indicated to reduce risk factors throughout treatment.

39. What is the rationale for using docusate sodium (Colace) for a patient with an MI? a. Controls ventricular dysrhythmias b. Relieves anxiety and cardiac workload c. Minimizes bradycardia from vagal stimulation d. Prevents the binding of fibrinogen to platelets

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

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

c. Percutaneous coronary intervention (PCI) Emergent PCI is the first treatment for patients with a confirmed MI within 90 minutes of arriving at the facility with an interventional cardiac catheterization lab. Stent placement, CABG, and TMR are usually done to facilitate circulation in non-emergency situations.

15. What types of angina can occur in the absence of CAD? (select all that apply) a. Silent ischemia b. Nocturnal angina c. Prinzmetal's angina d. Microvascular angina e. Chronic stable angina

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

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

c. Prophylactic nitroglycerin may be used if angina occurs. It is not uncommon for a patient who experiences chest pain on exertion to have some angina during sexual stimulation or intercourse and the patient should be instructed to use nitroglycerin prophylactically. Positions during intercourse are a matter of individual choice and foreplay is desirable because it allows a gradual increase in HR. Sildenafil (Viagra) should be used cautiously in men with CAD and should not be used with nitrates.

27. To detect and treat the most common complication of MI, what should the nurse do? a. Measure hourly urine output b. Auscultate the chest for crackles. c. Use continuous cardiac monitoring. d. Take vital signs every 2 hours for the first 8 hours.

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

4. Priority decision: While teaching women about the risks and incidence of CAD, what does the nurse emphasize? a. Smoking is not as significant a risk factor for CAD in women as it is in men. b. Women seek treatment sooner than men when they have symptoms of CAD. c. Estrogen replacement therapy in postmenopausal women decreases the risk for CAD. d. CAD is the leading cause of death in women, with a higher mortality rate after MI than in men.

d. CAD is the leading cause of death in women, with a higher mortality rate after MI than in men. CAD is the number-one killer of American women and women have a much higher mortality rate within 1 year following MI than do men. Smoking carries specific problems for women because smoking has been linked to a decrease in estrogen levels and to early menopause and it has been identified as the most powerful contributor to CAD in women under the age of 50. Fewer women than men present with classic manifestations and women delay seeking care longer than man. Recent research indicates that estrogen replacement does not reduce the risk for CAD, even though estrogen lowers LDL and raises HDL.

29. In the patient with chest pain, which results can differentiate unstable angina from an MI? a. ECG changes present at the onset of the pain b. A chest x-ray indicating left ventricular hypertrophy c. Appearance of troponin in the blood 48 hours after the infarct d. Creatinine kinase (CK)-MB enzyme elevations that peak 18 hours after the infarct

d. Creatinine kinase (CK)-MB enzyme elevations that peak 18 hours after the infarct Creatinine knase-muscle and brain subunits band (CK-MB) is a tissue enzyme that is specific to cardiac muscle and is released into the blood when myocardial cells die. CK-MB levels begin to rise about 6 hours after an acute MI, peak in about 18 hours, and return to normal within 24 to 36 hours. The increase can identify the presence of and quantify myocardiac damage. Cardiac troponin T and troponin I are released with myocardial damage, rise as quickly as CK-MB does, and remain elevateed for 2 weeks. ECG changes are often not apparent immediately after infart and may be normal when the patient seeks medical atention. An enlarged heart, determined by x-ray, indicates cardiac stress but is not diagnostic of acute MI.

25. A 52-year-old man is admitted to the emergency department with severe chest pain. On what basis would the nurse suspect an MI? a. He has pale, cool, clammy skin. b. He reports nausea and vomited once at home. c. He says he is anxious and has a feeling of impending doom. d. He reports he has had no relief of the pain with rest or position change.

d. He reports he has had no relief of the pain with rest or position change. The subjective report of the pain from an MI is usually severe. It usually is unrelieved by nitroglycerin, rest, or position change and usually lasts more than 15 or 20 minutes typical of angina pain. All of the other symptoms may occur with angina as well as with an MI.

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

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

7. The laboratory tests for four patients show the following results. Which patient should the nurse teach first about preventing CAD because the patient is at the greatest risk for CAD even without other risk factors? a. Total cholesterol: 152 mg/dL, triglycerides: 148 mg/dL, LDL: 148 mg/dL, HDL: 52 mg/dL b. Total cholesterol: 160 mg/dL, triglycerides: 102 mg/dL, LDL: 138 mg/dL, HDL: 56 mg/dL c. Total cholesterol: 200 mg/dL, triglycerides: 150 mg/dL, LDL: 160 mg/dL, HDL: 48 mg/dL d. Total cholesterol: 250 mg/dL, triglycerides: 164 mg/dL, LDL: 172 mg/dL, HDL: 32 mg/dL

d. Total cholesterol: 250 mg/dL, triglycerides: 164 mg/dL, LDL: 172 mg/dL, HDL: 32 mg/dL All of this patient's results are abnormal. The patient in option c is close to being at risk, as all of that patient's results are at or near the cutoff for being acceptable. If this patient is a woman, the HDL is too low. The other patients' results are at acceptable levels.