Coronary Artery Disease and Acute Coronary Syndrome P2

In developing a teaching plan for the patient with angina, the nurse recognizes that teaching about the first line of drug therapy for angina will include instructions about using which of the following medications? a. One aspirin a day b. Transdermal nitrates c. Lovastatin (Mevacor) d. Metoprolol (Lopressor)

ANS: A Daily aspirin is recommended in the absence of contraindications. REF: page 905

A diagnosis of acute coronary syndrome (ACS) is the admission diagnosis for a patient transferred to the CCU. The nurse knows that this diagnosis indicates that the patient has experienced which of the following? a. Unstable angina (UA) or an MI b. Resuscitation following sudden cardiac death c. Onset of any severe cardiac-related chest pain d. MI accompanied by ST-segment elevation

ANS: A ACS develops and encompasses the spectrum of UA, NSTEMI, and STEMI. REF: page 912

A patient admitted to the critical care unit (CCU) with an MI has a physician's orders for continuous amiodarone (Cordarone) infusion, intravenous (IV) nitroglycerin, and morphine sulphate 2 mg IV every 5 minutes until relief of pain occurs, in addition to the standard CCU protocol. The patient is having frequent, multifocal premature ventricular contractions, and he tells the nurse that the pain is worse than he has ever had and asks if he is going to die. On admission to the CCU, the nurse identifies which of the following nursing diagnoses as a priority? a. Acute pain related to myocardial ischemia b. Anxiety related to perceived threat of death c. Decreased cardiac output related to cardiogenic shock d. Activity intolerance related to decreased cardiac output

ANS: A All the nursing diagnoses may be appropriate for this patient, but the data indicate that the priority diagnosis is pain, a physiological stressor. The patient's anxiety will also be reduced if the pain is resolved. REF: page 918, Nursing Care Plan 36-1

Which of the following is the earliest lesion of atherosclerosis and is characterized by lipid-filled smooth muscle cells? a. Fatty streak b. Fibrous plaque c. C-reactive lesion d. Complication lesion

ANS: A Fatty streaks, the earliest lesions of atherosclerosis, are characterized by lipid-filled smooth muscle cells. REF: page 893

A patient has had an elevated temperature of 38.2°C for 3 days since experiencing an MI. What does the nurse understand that this fever indicates? a. A normal response to the necrotic tissue of infarction b. A need for concern only if a leukocytosis is also present c. Beginning congestive heart failure from increased myocardial oxygen demand d. Developing pericarditis as a complication of myocardial necrosis

ANS: A Fever and elevated white blood cell count are normal occurrences after MI as a result of inflammation that occurs after tissue necrosis. REF: page 910

Which of the following signs would the patient experience when the nurse evaluates that fibrinolytic therapy has not been successful in restoring perfusion to the myocardium? a. Continuing chest pain b. Dyspnea and tachycardia c. A marked, rapid rise in the CK enzyme d. An increase in premature ventricular contractions

ANS: A If the patient's chest pain continues, it is an indication that perfusion has not been restored to the myocardium. REF: page 914

To assist the patient with CAD to make the appropriate dietary changes, which of these nursing interventions will be most effective? a. Help the patient modify favourite high-fat recipes by using monounsaturated oils when possible. b. Provide the patient with a list of low-sodium, low-cholesterol foods that should be included in the diet. c. Instruct the patient that a diet containing no saturated fat and minimal sodium will be necessary. d. Emphasize the increased risk for cardiac problems unless the patient makes the dietary changes.

ANS: A Lifestyle changes are more likely to be successful when consideration is given to patient's preferences. The highest percentage of calories from fat should come from monounsaturated fats. REF: page 900

The nurse administers IV nitroglycerin to a patient with an MI. In evaluating the effect of this intervention, the nurse recognizes that which of the following is an expected outcome of the administration of the medication? a. Relief of pain b. Decreased heart rate c. Increased cardiac output d. Control of cardiac dysrhythmias

ANS: A The goal of IV nitroglycerin administration in AMI is relief of chest pain by improving the balance between myocardial oxygen supply and demand. REF: page 915

The nurse determines that outcomes for teaching regarding precipitating factors of angina have been met when the patient states which of the following? a. "I will stop my sexual activities." b. "I will rest for 1 to 2 hours after a heavy meal." c. "I will take my medication before doing my daily walk." d. "I will limit my coffee intake, but I may substitute regular cola products."

ANS: B Adequate rest should be planned for 1 to 2 hours after eating because blood is shunted to the gastrointestinal tract to aid digestion and absorption. REF: page 917

For a patient who was admitted the previous day to the CCU with an AMI, the nurse will anticipate teaching the patient about which one of the following? a. The pathophysiology of CAD b. When patient cardiac rehabilitation will begin c. Home-discharge drugs such as aspirin and b-blockers d. Typical emotional responses to MI

ANS: B At this time, the patient's anxiety level or denial will prevent good understanding of complex information such as CAD pathophysiology. REF: page 920, Table 36-17

While caring for a patient with an AMI, the nurse monitors the patient closely, knowing that which of the following conditions is the most common complication of MI? a. Pericarditis b. Dysrhythmias c. Cardiogenic shock d. Congestive heart failure

ANS: B Dysrhythmias are the most common complication of MI. REF: page 910

While teaching a patient and his wife about the dietary modifications that should be made to reduce the risk of CAD, what should the nurse explain? a. Margarine can be used in any amount, but butter should be avoided. b. Fish is preferable to red meats as sources of protein. c. All vegetable fats are unsaturated and are preferable to meat and dairy fats. d. Polyunsaturated and monounsaturated fats should be restricted to 50% of the total daily calories.

ANS: B Fish and skinless chicken are preferable as sources of protein, as red meat is high in animal (saturated) fat, and patients are advised to reduce their saturated fat intake. REF: pages 900-901

When caring for a patient who has survived a sudden cardiac death event and has no evidence of an AMI, what will the nurse anticipate teaching the patient? a. That sudden cardiac death events rarely recur b. The purpose of outpatient Holter monitoring c. How to self-administer low-molecular weight heparin d. The need to limit activities after discharge to prevent future events

ANS: B Holter monitoring is used to determine whether the patient is experiencing dysrhythmias such as ventricular tachycardia during normal daily activities. REF: page 924

During assessment of a patient with chest pain, how will the nurse recognize the chest pain associated with stable angina? a. It is severe, persistent, and unrelieved by rest. b. Cold, clammy skin accompanied by a feeling of doom. c. It is aggravated by inspiration, coughing, and movement of the upper body. d. It is accompanied by a residual soreness in the chest, which lasts for several days.

ANS: B Stable angina chest pain is usually abrupt, and the patient has a feeling of impending doom. REF: page 913, Table 36-14

During the initial stages of hospitalization for an MI, the patient has been in denial, stating "I just had a little chest pain." What is the most appropriate intervention for the nurse to plan for the patient at this time? a. Have the patient's family encourage him to talk about his plans for the future. b. Allow the patient to use denial as a coping mechanism until he asks questions about his condition. c. Implement reality orientation by reminding the patient several times a day that he has had major cardiac damage. d. Begin teaching the patient about the anatomy and physiology of the heart so that he can understand what has happened to him.

ANS: B The patient is experiencing progression through the normal stages of loss and grief that often occur after an MI. REF: page 920

The nurse evaluates the outcomes of preoperative teaching with a patient scheduled for a coronary artery bypass graft using the internal mammary artery. Which of the following statements by the patient helps the nurse identify that additional teaching is needed? a. "I will need to take an aspirin a day after the surgery to keep the graft open." b. "I will have incisions in my leg where they removed the vein." c. "They will stop my heart and circulate my blood with a machine during the surgery." d. "They will cut between my ribs and use a scope to attach a different artery to the artery that is blocked in my heart."

ANS: B When the internal mammary artery is used, it will not be necessary to remove a saphenous vein from the leg. REF: page 915

The nurse has just received a change-of-shift report about the following four patients. Which patient should the nurse assess first? a. A 38-year-old patient who has pericarditis and is complaining of sharp, stabbing chest pain b. A 45-year-old patient who had an MI 4 days ago and is anxious about the planned discharge c. A 51-year-old patient who has just returned to the unit after a coronary arteriogram and PCI d. A 60-year-old patient who is due for a scheduled dose of atenolol 25 mg orally

ANS: C After PCI, the patient is at risk for bleeding from the arterial access site for the PCI, so the nurse should assess the patient immediately. The other patients also should be assessed as quickly as possible, but assessment of this patient has the highest priority. REF: page 914

Which of the following is an absolute contraindication for the use of fibrinolytic therapy? a. Diabetes b. Pregnancy c. Intercranial neoplasm d. Laser eye surgery

ANS: C An absolute contraindication for the use of fibrinolytic therapy is intercranial neoplasm. Diabetes is not a contraindication. Pregnancy and laser eye surgery are relative contraindications but not absolute ones. REF: page 914, Table 36-15

In preparing a patient for discharge from the hospital following an MI, which of the following statements by the patient indicates to the nurse that further instruction is needed? a. "Exercise will increase the efficiency of my heart." b. "I can control several risk factors of CAD just by exercising." c. "My heart will be as good as new when I finish a cardiac rehabilitation program." d. "I should do more exercises that move my joints than exercises that require static force."

ANS: C It is important for the patient to understand that CAD is a chronic disease that can be managed but cannot be cured. REF: page 921

Which of the following is a mnemonic to assist the nurse in obtaining thorough information from a patient who has chest pain? a. ABCDEF b. PAIN c. PQRST d. AQSP

ANS: C PQRST can be used as a mnemonic to assist in obtaining information for the patient who has chest pain as follows: P, precipitating events; Q, quality of pain; R, radiation of pain; S, severity of pain; and T, timing. REF: page 904, Table 36-9

While observing the ECG monitor of a patient admitted to the ED with chest pain, the nurse suspects that the patient is having a myocardial infarction (MI) rather than angina on finding which of the following data? a. Sinus tachycardia b. Depressed R wave c. Pathological Q wave d. Occasional premature ventricular contractions

ANS: C Patients with ST-segment-elevation myocardial infarction (STEMI) tend to have a more extensive MI associated with prolonged and complete coronary occlusion and the development of a pathological Q wave on the ECG. Patients with unstable angina or non- ST-segment-elevation myocardial infarction (NSTEMI) usually have transient thrombosis or incomplete coronary occlusion and usually do not develop pathological Q waves. REF: page 912

Fibrinolytic therapy is prescribed for a 64-year-old patient with an STEMI. During the administration of the fibrinolytic agent, the nurse recognizes that the therapy should be stopped when the patient experiences which of the following signs? a. Bleeding from the gums b. Surface bleeding from the IV site c. A sudden decrease in the level of consciousness d. Premature ventricular contractions and ventricular tachycardia

ANS: C The change in the level of consciousness indicates that the patient may be experiencing intracranial bleeding, a possible complication of fibrinolytic therapy. REF: page 914

In developing a teaching plan for a patient who has stable angina and is started on sublingual nitroglycerin, which one of the following would the nurse identify as an expected patient outcome? a. States nitroglycerin is to be taken only if chest pain develops b. Lists the side effects of nitroglycerin as gastric upset and dry mouth c. Identifies the need to seek medical attention if chest pain persists 5 minutes after taking nitroglycerin d. Identifies the need for lifelong use of nitroglycerin to prevent the development of an MI

ANS: C The emergency medical services system should be activated when chest pain or other symptoms are not completely relieved 5 minutes after taking nitroglycerin. REF: page 906

A patient who is being admitted to the ED with severe chest pain gives the nurse the following list of medications taken at home. Which medication has the most immediate implications for the patient's care? a. Captopril (Capoten) b. Furosemide (Lasix) c. Sildenafil (Viagra) d. Diazepam (Valium)

ANS: C The nurse will need to avoid giving nitrates to the patient because nitrate administration is contraindicated in patients who are using sildenafil because of the risk of sudden death caused by vasodilation. REF: page 923, Table 36-21

Three days after an MI, the patient develops chest pain that radiates to the back and left arm and is relieved by sitting in a forward position. On auscultation of the patient's chest, what would the nurse expect to hear? a. Distant heart sounds b. S3 or S4 heart sounds c. A pericardial friction rub d. A loud holosystolic apical murmur

ANS: C The patient's symptoms are consistent with the development of pericarditis, a possible complication of MI. The other assessments listed are not consistent with the description of the patient's symptoms. REF: page 911

Three weeks after his hospitalization for an AMI, a patient returns to the cardiac centre for follow-up. When the nurse asks about his sleep patterns, the patient tells the nurse that he sleeps fine but that his wife moved into the spare bedroom to sleep when he returned home. He states, "I guess we will never have sex again after this." What is the best response to the patient? a. "Sexual intercourse will be too strenuous on your heart, but closeness and intimacy can be maintained with holding and cuddling." b. "You should discuss your questions about your sexual activity with your doctor because the activity it requires is a medical concern." c. "Sexual activity can be resumed whenever you and your wife feel like it. Most sexual response is emotional rather than physical." d. "Sexual activity can be gradually resumed like other forms of activity. A good comparison of energy expenditure is climbing two flights of stairs."

ANS: D All activity has to be gradually resumed. A good guide for patients is to tell them that sexual activity places about as much physical stress on the cardiovascular system as climbing two flights of stairs. REF: page 917

Which of the following is the mechanism of action of aspirin that is commonly prescribed for patients that have had acute coronary syndrome? a. Inhibits platelet aggregation b. Promotes coronary artery vasodilation c. Promotes peripheral vasodilation d. Inhibits cyclooxygenase

ANS: D Aspirin is used as an antiplatelet agent in the treatment of acute coronary syndrome; it inhibits cyclooxygenase which produces thromboxane A2, a potent platelet activator. REF: page 924, Table 36-13

When developing a health teaching plan for a 65-year-old patient with all of these risk factors for coronary artery disease (CAD), which of the following will the nurse focus on? a. A family history of heart disease b. Increased risk associated with the patient's ethnicity c. A high incidence of cardiovascular disease in older people d. A low activity level reported by the patient

ANS: D Because family history, ethnicity, and age are nonmodifiable risk factors, the nurse should focus on the patient's activity level. An increase in activity will help reduce the patient's risk for developing CAD. REF: page 896

The nurse is admitting a patient who is complaining of chest pain to the emergency department (ED). Which information collected by the nurse suggests that the pain is caused by an acute myocardial infarction (AMI)? a. The pain worsens when the patient raises the arms. b. The pain increases with deep breathing. c. The pain is relieved after the patient takes nitroglycerin. d. The pain has persisted longer than 30 minutes.

ANS: D Chest pain that lasts for 20 minutes or more is characteristic of AMI. REF: page 910

A patient who has recently started taking rosuvastatin (Crestor) and niacin (Nicobid) reports all the following symptoms to the nurse. Which one is most important to communicate to the physician? a. Skin flushing after taking the medications b. Dizziness when changing positions quickly c. Nausea when taking the drugs before eating d. Generalized muscle aches and pains

ANS: D 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 rosuvastatin may have to be discontinued. REF: pages 901-902

During early assessment of the patient with an MI, the nurse is aware that which of the following diagnostic tests is the most important to determine the extent and treatment of an MI? a. Serial ECGs b. A chest X-ray c. Treadmill exercising d. Serum cardiac markers

ANS: A When the initial ECG is nondiagnostic, serial ECGs are done every 2 to 4 hours to determine the extent and treatment of an MI. REF: page 911

Nadolol (Corgard) is prescribed for a patient with CAD. In evaluating the effectiveness of the drug, the nurse would monitor for which of the following? a. Improvement in the quality of the peripheral pulses b. Ability to do daily activities without chest discomfort c. Decreased blood pressure and apical pulse rate d. Fewer complaints of having cold hands and feet

ANS: B Because the medication is ordered to improve the patient's angina, effectiveness is indicated if the patient's angina is stable. REF: page 918

For which of the following patient conditions is the use of garlic as a complementary therapy to help lower blood pressure contraindicated? a. Pre-existing hypertension b. Diabetes c. Obesity d. Osteoarthritis

ANS: B Garlic is a relatively safe herb but is contradicted in people with bleeding disorders, GI infections, diabetes, and inflammation. REF: page 902, Complementary and Alternative Therapies box

The MB isoenzyme of creatine kinase (CK-MB) level is markedly elevated in a patient with chest pain 12 hours after admission. Of what would the nurse interpret this finding as being evidence? a. Lactic acidosis b. A need for thrombolytic therapy c. Deterioration of cardiac function d. Cellular necrosis of myocardial tissue

ANS: D The CK-MB levels increase as the necrotic myocardial cells release CK-MB enzymes into the circulation after perfusion has been restored to the area. REF: page 912

Which of the following determinants of health is true in relation to CAD in Canada? a. Native-born Canadians have better cardiovascular health than immigrants to Canada. b. Immigrants from South Asia have a very high risk for cardiovascular disease. c. Asian Indians experience lower rates of cardiovascular disease, regardless of where they live. d. Chinese immigrants have a very low rate of cardiovascular disease.

ANS: D Immigrants from China have a particularly low rate of cardiovascular disease. Immigrants to Canada have better cardiovascular health than do native-born Canadians. Immigrants from South Asia have a particularly high risk for cardiovascular disease. Regardless of where they live, Asian Indians appear to suffer high rates of cardiovascular disease. REF: page 892,

A 45-year-old man is admitted to the ED after developing severe chest pain while raking leaves. On admission, he has midchest dullness and a normal electrocardiogram (ECG). The physician schedules the patient for cardiac catheterization with coronary angiography and possible percutaneous coronary intervention (PCI). The nurse prepares the patient for the procedure by explaining that, in his case, it is used for which of the following purposes? a. To determine whether the walls or chambers of the patient's heart have any structural defects b. To determine whether any obstructions are present in his coronary arteries and to test for an allergy to thrombolytic agents c. To measure the amount of blood being pumped from his heart with each contraction to determine whether the heart is damaged d. To visualize any blockages in the coronary arteries and, if necessary, to dilate an obstructed artery with the use of a small balloon

ANS: D In this case, PCI is used for visualization of the coronary arteries, and possible balloon dilation is scheduled for this patient. REF: page 912

After the nurse teaches the patient about the use of atenolol (Tenormin) in preventing anginal episodes, which statement by the patient indicates that the teaching has been effective? a. "Atenolol will increase the strength of my heart muscle." b. "I can expect to feel short of breath when taking atenolol." c. "Atenolol will improve the blood flow to my coronary arteries." d. "It is important not to suddenly stop taking the atenolol."

ANS: D Patients who have been taking -blockers can develop intense and frequent angina if the medication is suddenly discontinued. REF: page 908

The physician has ordered determination of CK-MB and troponin levels for a patient who has experienced chest pain and aching for the last 4 days. What does the nurse expect on reading this order? a. Myoglobin levels will also have to be determined to confirm myocardial damage. b. CK-MB enzyme levels will be the most reliable indicator of any myocardial necrosis that has occurred. c. Any serum cardiac marker will be inconclusive in determining myocardial injury that is several days old. d. The presence of myocardial damage occurring several days earlier can be validated best by the troponin level determination.

ANS: D The heart has two troponin subtypes: cardiac-specific troponin T (cTnT) and cardiac-specific troponin I (cTnI). These markers are highly specific indicators of MI and have greater sensitivity and specificity for myocardial injury than CK-MB (Pagana & Pagana, 2006). Troponin rises as quickly as CK. It is usually used for diagnostic purposes in conjunction with total CK and the MB fraction. Serum levels of cTnI and cTnT increase 3 to 12 hours after the onset of MI, peak at 24 to 48 hours, and return to baseline over 5 to 14 days. REF: page 912

A patient who has chest pain is admitted to the ED, and the following diagnostic tests are ordered. Which one will the nurse arrange to be completed first? a. Chest X-ray b. Troponin level c. Computed tomography scan d. ECG

ANS: D The priority for the patient is to determine whether an AMI is occurring so that reperfusion therapy can begin as quickly as possible. ECG changes occur very rapidly after coronary artery occlusion. REF: page 908