CH. 33 CAD and Acute Coronary Syndrome

In caring for the patient with angina, the patient said, "While I was having a bowel movement, I started having the worst chest pain ever, like before I was admitted. I called for a nurse, then the pain went away." What further assessment data should the nurse obtain from the patient? "What precipitated the pain?" "Has the pain changed this time?" "In what areas did you feel this pain?" "What is your pain level on a 0 to 10 scale?"

"In what areas did you feel this pain?" Rationale: Using PQRST, the assessment data not volunteered by the patient is the radiation of pain, the area the patient felt the pain, and if it radiated. The precipitating event was going to the bathroom and having a bowel movement. The quality of the pain was "like before I was admitted," although a more specific description may be helpful. Severity of the pain was the "worst chest pain ever," although an actual number may be needed. Timing is supplied by the patient describing when the pain occurred and that he had previously had this pain.

Which person would the nurse identify as having the highest risk for coronary artery disease (CAD)? A 60-yr-old man with low homocysteine levels A 45-yr-old man with a high-stress job who is depressed A 54-yr-old woman vegetarian with increased high-density lipoprotein (HDL) levels A 62-yr-old woman who has a sedentary lifestyle and body mass index (BMI) of 23 kg/m2

A 45-yr-old man with a high-stress job who is depressed Rationale: The 45-yr-old depressed man with a high-stress job is at the highest risk for CAD. Depression and stressful states can contribute to the development of CAD. Elevated HDL levels and low homocysteine levels 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.

The patient is being dismissed from the hospital after acute coronary syndrome (ACS) and will be attending rehabilitation. What information would be taught in the early recovery phase of rehabilitation? Therapeutic lifestyle changes should become lifelong habits. Physical activity is always started in the hospital and continued at home. Attention will focus on managing chest pain, anxiety, dysrhythmias, and other complications. Activity level is gradually increased under cardiac rehabilitation team supervision and monitoring.

Activity level is gradually increased under cardiac rehabilitation team supervision and monitoring. Rationale: In the early recovery phase after the patient is dismissed from the hospital, the activity level is gradually increased 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, 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.

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

Ashen skin Diaphoresis Nausea and vomiting S3 or S4 heart sounds Rationale: During the initial phase of an MI, catecholamines are released from the ischemic myocardial cells, causing increased sympathetic nervous system 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) because 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.

Postoperative care of a patient undergoing coronary artery bypass graft (CABG) surgery includes monitoring for which common complication? Dehydration Paralytic ileus Atrial dysrhythmias Acute respiratory distress syndrome

Atrial dysrhythmias Rationale: Postoperative dysrhythmias, specifically atrial dysrhythmias, are common in the first 3 days after CABG surgery. Although the other complications could occur, they are not common complications.

The nurse is teaching a patient recovering from a myocardial infarction. How should resumption of sexual activity be discussed? Delegated to the primary care provider Discussed along with other physical activities Avoided because it is embarrassing to the patient Accomplished by providing the patient with written material

Discussed along with other physical activities Rationale: Although some nurses may not feel comfortable discussing sexual activity with patients, it is a necessary component of patient teaching. It is helpful to consider sex as a physical activity and to discuss or explore feelings in this area when other physical activities are discussed. Although providing the patient with written material is appropriate, it should not replace a verbal dialogue that can address the patient's questions and concerns.

A patient admitted to the emergency department 24 hours ago with reports of chest pain was diagnosed with a ST-segment-elevation myocardial infarction (STEMI). What complication of myocardial infarction should the nurse anticipate? Dysrhythmias Unstable angina Cardiac tamponade Sudden cardiac death

Dysrhythmias Rationale: Dysrhythmias are present in 80% to 90% of patients after myocardial infarction (MI). 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.

The nurse prepares a discharge teaching plan for a patient who has recently been diagnosed with coronary artery disease (CAD). Which priority risk factor should the nurse plan to focus on during the teaching session? Type A personality Elevated serum lipids Family cardiac history High homocysteine levels

Elevated serum lipids Rationale: Dyslipidemia is one of the four major modifiable risk factors for 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 assessment finding should be considered when caring for a woman with suspected coronary artery disease? Fatigue may be the first symptom. Classic signs and symptoms are expected. Increased risk is present before menopause. Women are more likely to develop collateral circulation.

Fatigue may be the first symptom. Rationale: Fatigue, rather than pain or shortness of breath, may be the first symptom of impaired cardiac circulation. Women may not exhibit the classic signs and symptoms of ischemia such as chest pain which radiates down the left arm. Neck, throat, or back pain may be symptoms experienced by women. Risk for coronary artery disease increases four times after menopause. Men are more likely to develop collateral circulation.

A patient experienced sudden cardiac death (SCD) and survived. Which treatment should the nurse expect to be implemented to prevent an SCD recurrence at home? External cardiac pacemaker An electrophysiologic study (EPS) Medications to prevent dysrhythmias Implantable cardioverter-defibrillator (ICD)

Implantable cardioverter-defibrillator (ICD) Rationale: An ICD is the most common approach to preventing recurrence of SCD. An external pacemaker may be used in the hospital but will not be used for the patient living daily life at home. An EPS may be done to determine if a recurrence is likely and determine the most effective medication treatment. Medications to prevent dysrhythmias are used but are not the best prevention of SCD.

The nurse in the recovery room assesses the right femoral artery puncture site after the patient had a stent inserted into a coronary artery. The insertion site is not bleeding or discolored. What should the nurse do next to ensure the femoral artery is intact? Palpate the insertion site for induration. Assess peripheral pulses in the right leg. Inspect the patient's right side and back. Compare the color of the left and right legs.

Inspect the patient's right side and back. Rationale: The best method to determine that the right femoral artery is intact after inspection of the insertion site is to logroll the patient to inspect the right side and back for retroperitoneal bleeding. The artery can be leaking, and blood is drawn into the tissues by gravity. The peripheral pulses, color, and sensation of the right leg will be assessed per agency protocol.

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

Keep Hgb A1C less than 7%. Rationale: If the Hgb A1C is kept below 7%, this means that the patient has had good control of her blood glucose over the past 3 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.

Which antilipemic medications should the nurse question for a patient who has cirrhosis of the liver? (Select all that apply.) Niacin Cholestyramine Ezetimibe (Zetia) Gemfibrozil (Lopid) Atorvastatin (Lipitor)

Niacin Ezetimibe (Zetia) Gemfibrozil (Lopid) Atorvastatin (Lipitor) Rationale: 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.

A 74-yr-old man with a history of prostate cancer and hypertension is admitted to the emergency department with substernal chest pain. Which priority action will the nurse complete before administering sublingual nitroglycerin? Administer morphine sulfate IV. Auscultate heart and lung sounds. Obtain a 12-lead electrocardiogram (ECG). Assess for coronary artery disease risk factors.

Obtain a 12-lead electrocardiogram (ECG). Rationale: If a patient has chest pain, the nurse should institute the following measures: (1) administer supplemental oxygen and position the patient in upright position unless contraindicated, (2) assess vital signs, (3) obtain a 12-lead ECG, (4) provide prompt pain relief first with a nitrate followed by an opioid analgesic if needed, and (5) auscultate heart sounds. Obtaining a 12-lead ECG during chest pain aids in the diagnosis.

When planning emergent care for a patient with a suspected myocardial infarction (MI), what should the nurse anticipate administering? Oxygen, nitroglycerin, aspirin, and morphine Aspirin, nitroprusside, dopamine, and oxygen Oxygen, furosemide (Lasix), nitroglycerin, and meperidine Nitroglycerin, lorazepam (Ativan), oxygen, and warfarin (Coumadin)

Oxygen, nitroglycerin, aspirin, and morphine Rationale: The American Heart Association's guidelines for emergency care of the patient with chest pain include the administration of oxygen, nitroglycerin, aspirin, and morphine. These interventions serve to relieve chest pain, improve oxygenation, decrease myocardial workload, and prevent further platelet aggregation. The other medications may be used later in the patient's treatment.

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

Pathologic Q wave Rationale: The presence of a pathologic Q wave, as often accompanies 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.

A male patient with coronary artery disease (CAD) has a low-density lipoprotein (LDL) cholesterol of 98 mg/dL and high-density lipoprotein (HDL) cholesterol of 47 mg/dL. What information should the nurse include in patient teaching? Consume a diet low in fats. Reduce total caloric intake. Increase intake of olive oil. The lipid levels are normal.

The lipid levels are normal. Rationale: 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.

Which foods would the nurse encourage patients at risk for coronary artery disease (CAD) to include in their diets? (Select all that apply.) Tofu Walnuts Tuna fish Whole milk Orange juice

Tofu Walnuts Tuna fish Rationale: 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.

a pt is admitted to the ICU with diagnosis of NSTEMI. Which drug(s) would the nurse expect the pt to receive? (select all that apply) a. oral statin therapy b. antiplatelet therapy c. thrombolytic therapy d. prophylactic antibiotics e. intravenous nitroglycerin

a, b, e Rationale: When a patient presents with suspected ACS, antiplatelet therapy, IV NTG, and atorvastatin are drug treatments of choice. For patients with UA and NSTEMI, heparin (UH or LMWH) is recommended to prevent microemboli from forming and causing further chest pain. DAPT (e.g., aspirin and clopidogrel or ticagrelor [Brilinta]) also is recommended for NSTEMI patients (with or without a stent). Thrombolytic therapy and antibiotics are not indicated for NSTEMI

After teaching about ways to decrease risk factors for CAD, the nurse reco that further instruction is needed when pt says: a. "I can keep my BP normal with meds" b. "I would like to add weight lifting to my exercise program" c. "I can change my diet to decrease my intake of saturated fats" d. "I will change my lifestyle to reduce activities that increase my stress"

b Rationale: Risk factors for coronary artery disease include high serum levels of lipids, high BP, tobacco use, physical inactivity, obesity, diabetes, metabolic syndrome, certain psychologic states, and high homocysteine levels. Weight lifting is not a cardioprotective exercise. An example of health-promoting regular physical activity is brisk walking (3 to 4 miles/hr) for at least 30 minutes 5 or more times each week.

The nurse is caring for a pt who is 2 days post MI. the patient reports that she is experiencing chest pain when she takes a deep breath. Which action would be a priority? a. notify provider STAT and obtain 12 lead ECG b. obtain vital signs and auscultate for pericardial friction rub c. apply high flow O2 by face mask and auscultate breath sounds d. medicate the patient with as needed analgesic and reevaluate in 30 min

b Rationale: Acute pericarditis is inflammation of the visceral and/or parietal pericardium. It often occurs 2 to 3 days after an acute myocardial infarction. Chest pain may vary from mild to severe. It is worsened by inspiration, coughing, and movement of the upper body. Sitting in a forward position often relieves the pain. The pain is usually different from pain associated with a myocardial infarction. Assessment of the patient with pericarditis may reveal a friction rub over the pericardium.

a hospitalized pt with hist of chronic stable angina tells the nurse that she is having chest pain. the nurse bases his actions on the knowledge that ischemia: a. will always progress to MI b. can be relieved by rest, nitroglycerin, or both c. is often associated with vomiting and extreme fatigue d. indicates that irreversible myocardial damage is occurring

b Rationale: Chronic stable angina is chest pain that occurs intermittently over a long period with the same pattern of onset, duration, and intensity of symptoms. The chest pain is relieved by rest or by rest and medication (e.g., nitroglycerin). The ischemia is transient and does not cause myocardial damage

In teaching a pt about CAD, the nurse explains that the changes that occur in this disorder include (select all that apply): a. diffuse involvement of plaque formation in coronary veins b. abnormal levels of cholesterol, esp LDL c. accumulation of lipid and fibrous tissue within the coronary arteries d. development of angina due to decreased blood supply to heart muscle e. chronic vasoconstriction of coronary arteries leading to permanent vasospasm

b, c, d Rationale: Atherosclerosis is the major cause of coronary artery disease (CAD). It is characterized by a focal deposit of cholesterol and lipids, primarily within the intimal wall of the artery. The endothelial lining of the coronary arteries becomes inflamed from the presence of unstable plaques and the oxidation of low-density lipoprotein (LDL) cholesterol. Fibrous plaque causes progressive changes in the endothelium of the arterial wall. The result is a narrowing of the vessel lumen and a reduction in blood flow to the myocardial tissue

A pt is recovering from an uncomplicated MI. Which rehabilitation guideline is a priority to include in the teaching plan? a. refrain from sexual activity for a min of 3 weeks b. plan a diet program that aims for a 1 to 2 lb weight loss per week c. begin an exercise program that aims for at least 5 30 min sessions per week d. consider the use of erectile agents and prophylactic NTG before engaging in sexual activity

c Rationale: Physical activity should be regular, rhythmic, and repetitive, with the use of large muscles to build up endurance (e.g., walking, cycling, swimming, rowing). Physical activity sessions should be at least 30 minutes long. Teach the patient to begin slowly at personal tolerance (perhaps only 5 to 10 minutes) and build up to 30 minutes

After teaching a patient with chronic stable angina about nitroglycerin, the nurse recognizes the need for further teaching when the patient makes which statement? "I will replace my nitroglycerin supply every 6 months." "I can take up to 5 tablets every 3 minutes for relief of my chest pain." "I will take acetaminophen (Tylenol) to treat the headache caused by nitroglycerin." "I will take the nitroglycerin 10 minutes before planned activity that usually causes chest pain."

"I can take up to 5 tablets every 3 minutes for relief of my chest pain." Rationale: The recommended dose of nitroglycerin is one tablet taken sublingually (SL) or 1 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 3 doses and contact EMS if symptoms have not resolved completely.

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

"I will take garlic instead of my prescription medication to reduce my cholesterol." Rationale: 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.

Which patient is at greatest risk for sudden cardiac death (SCD)? A 52-yr-old black man with left ventricular failure A 62-yr-old obese man with diabetes and high cholesterol A 42-yr-old white woman with hypertension and dyslipidemia A 72-yr-old Native American woman with a family history of heart disease

A 52-yr-old black man with left ventricular failure Rationale: Patients with left ventricular dysfunction (ejection fraction less than 30%) and ventricular dysrhythmias after myocardial infarction are at greatest risk for SCD. Other risk factors for SCD include: (1) male gender (especially blacks), (2) family history of premature atherosclerosis, (3) tobacco use, (4) diabetes, (5) high cholesterol levels, (6) hypertension, and (7) cardiomyopathy.

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

Acute myocardial infarction Rationale: PCI is indicated to restore coronary perfusion in cases of myocardial infarction. Chronic stable angina and coronary artery disease are normally treated with more conservative measures initially. PCI is not relevant to the pathophysiology of heart failure.

The nurse recognizes additional teaching is needed when the patient prescribed a low-sodium, low-fat cardiac diet selects which food? Baked flounder Angel food cake Canned chicken noodle soup Baked potato with margarine

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

A patient has received a bolus dose and an infusion of alteplase (Activase) for an ST-segment elevation myocardial infarction (STEMI). Which patient assessment would determine the effectiveness of the medication? Presence of chest pain Blood in the urine or stool Tachycardia with hypotension Decreased level of consciousness

Presence of chest pain Rationale: Alteplase is a fibrinolytic agent that is administered to patients who have had a STEMI. If the medication is effective, the patient's chest pain will resolve because the medication dissolves the thrombus in the coronary artery and results in reperfusion of the myocardium. Bleeding is a major complication of fibrinolytic therapy. Signs of major bleeding include decreased level of consciousness, blood in the urine or stool, and increased heart rate with decreased blood pressure.

A patient returns to the unit after a cardiac catheterization. Which nursing care would the registered nurse delegate to the unlicensed assistant personnel (UAP)? Take vital signs and report any abnormal values. Check for bleeding at the catheter insertion site. Prepare discharge teaching related to complications. Monitor the electrocardiogram for S-T segment changes.

Take vital signs and report any abnormal values. Rationale: Vital signs should be delegated to the UAP. Assessment of the site, preparation of discharge teaching, and monitoring for S-T elevation would be registered nurse scope of practice.

the most common finding in people at risk for sudden cardiac death is: a. aortic valve disease b. mitral valve disease c. left ventricular dysfunction d. atherosclerotic heart disease

c. Rationale: Left ventricular dysfunction (ejection fraction less than 30%) and ventricular dysrhythmias after myocardial infarction are the strongest predictors of sudden cardiac death (SCD).