Ch. 33: Coronary Artery Disease and Acute Coronary Syndrome

Which effects contribute to making nitrates the first-line therapy for the treatment of angina (select all that apply)? a. Decrease preload b. Decrease afterload c. Dilate coronary arteries d. Decrease heart rate (HR) e. Prevent thrombosis of plaques f. Decrease myocardial contractility

a, b, c. Nitrates decrease preload and afterload to decrease the coronary workload and dilate coronary arteries to increase coronary blood supply. The other options are not attributed to nitrates.

During a routine health examination, a 48-yr-old patient is found to have a total cholesterol level of 224 mg/dL (5.8 mmol/L) and an LDL level of 140 mg/dL (3.6 mmol/L). What does the nurse teach the patient based on the Therapeutic Lifestyle Changes diet (select all that apply)? a. Use fat-free milk. b. Abstain from alcohol use. c. Reduce red meat in the diet. d. Eliminate intake of simple sugars. e. Avoid egg yolks and foods prepared with whole eggs.

a, c, e. Therapeutic Lifestyle Changes diet recommendations emphasize reduction in saturated fat and cholesterol intake. Whole milk products, red meats, and eggs as well as butter, stick margarine, lard, and solid shortening should be reduced or eliminated from diets. If triglyceride levels are high, alcohol and simple sugars should be reduced.

When instructing the patient with angina about taking sublingual NTG tablets, what should the nurse teach the patient? a. To lie or sit and place one tablet under the tongue when chest pain occurs. b. To take the tablet with a large amount of water so that it will dissolve right away. c. That if one tablet does not relieve the pain in 15 minutes, the patient should go to the hospital. d. That if the tablet causes dizziness and a headache, stop the medication and call the doctor or go to the hospital

a. A common complication of nitrates is dizziness caused by orthostatic hypotension, so the patient should sit or lie down and place the tablet under the tongue. The tablet should be allowed to dissolve under the tongue. To prevent the tablet from being swallowed, water should not be taken with it. The recommended dose for the patient for whom nitroglycerin (NTG) has been prescribed 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 contact the emergency response system (ERS) before taking additional NTG. If symptoms are significantly improved by one dose of NTG, instruct the patient or caregiver to repeat NTG every 5 minutes for a maximum of three doses and contact ERS if symptoms have not resolved completely. Headache is also a common complication of nitrates but usually resolves with continued use of nitrates and may be controlled with mild analgesics.

A 58-yr-old patient is in a cardiac rehabilitation program. The nurse teaches the patient to stop exercising if what occurs? a. Pain or dyspnea develop. b. The HR exceeds 150 bpm. c. The respiratory rate increases to 30. d. The HR is 30 bpm over the resting HR.

a. Any activity or exercise that causes dyspnea and chest pain should be stopped in the patient with CAD. The training target for a healthy 58-yr-old is 80% of maximum HR, or 130 bpm. HR, rather than respiratory rate, determines the parameters for exercise.

The patient has used sublingual nitroglycerin (NTG) and various long-acting nitrates but now has an ejection fraction of 38% and is considered at a high risk for a cardiac event. Which medication would first be added for vasodilation and to reduce ventricular remodeling? a. Captopril b. Clopidogrel (Plavix) c. Diltiazem (Cardizem) d. Metoprolol (Lopressor)

a. Captopril would be added. It is an angiotensin- converting enzyme (ACE) inhibitor that vasodilates and decreases endothelial dysfunction and may prevent ventricular remodeling. Clopidogrel (Plavix) is an antiplatelet agent used as an alternative for a patient unable to use aspirin. Diltiazem (Cardizem), a calcium channel blocker, may be used to decrease vasospasm but is not known to prevent ventricular remodeling. Metoprolol (Lopressor) is a β-adrenergic blocker that inhibits sympathetic nervous stimulation of the heart.

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 5 mph c. Cycling at 13 mph d. Mowing the lawn by hand

a. Golfing is a moderate-energy activity that expends about 5 metabolic equivalent units (METs) and is within the 3 to 6 METs activity level desired for a patient by the time of discharge from 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.

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-MB levels within 3 hours of therapy c. Develops major gastrointestinal (GI) or genitourinary (GU) bleeding during treatment d. Develops premature ventricular contractions and ventricular tachycardia during treatment.

a. 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-MB within 3 hours of therapy; and the presence of reperfusion dysrhythmias. Bleeding is a complication of thrombolytic therapy but does not indicate lack of success or successful reperfusion.

The nurse is encouraging a sedentary patient 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 hypertension c. Elevated serum lipids and stressful lifestyle d. Hypertension and elevated serum homocysteine

a. 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 hypertension, 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.

Priority Decision: A patient is hospitalized after a successful resuscitation of an episode of sudden cardiac death (SCD). During the care of the patient, what nursing intervention is most important? a. Continuous ECG monitoring. b. Auscultation of the carotid arteries. c. Frequent assessment of heart sounds. d. Monitoring of airway status and respiratory patterns.

a. Many patients who experience a sudden cardiac death (SCD) experience as a result of CAD do not have an acute MI but have dysrhythmias that cause death, probably as a result of electrical instability of the myocardium. To identify and treat those specific dysrhythmias, continuous monitoring is important. The other assessments can be done but are not the most important after an episode of SCD.

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

a. Morphine sulfate decreases anxiety and cardiac workload as a vasodilator and reduces preload and myocardial O2 consumption, which relieves chest pain. Calcium channel blockers, amiodarone, and ACE inhibitors will not relieve chest pain related to an MI.

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. 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 NTG, 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.

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. Orthostatic hypotension may cause dizziness and falls in older adults taking antianginal agents that decrease preload. Patients should be cautioned to change positions 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.

To which patients should the nurse teach the Therapeutic Lifestyle Changes diet to reduce the risk of coronary artery disease (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. The Therapeutic Lifestyle Changes diet includes recommendations for all people, not just those with risk factors, to decrease the risk for CAD.

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. 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 must be made. Nervous questioning about the expected duration and effect of the condition indicates the presence of anxiety, as does the statement regarding the health care provider's role in treatment.

Priority Decision: A patient hospitalized for evaluation of unstable angina experiences severe chest pain and calls the nurse. Prioritize the interventions below from 1 (highest priority) to 6 (lowest priority). The appropriate medical orders and protocols are available to the nurse. _____ a. Notify the physician. _____ b. Obtain a 12-lead ECG. _____ c. Check the patient's vital signs. _____ d. Administer oxygen per nasal cannula. _____ e. Perform a focused assessment of the chest. _____ f. Assess pain (PQRST) and medicate as ordered.

a. 6; b. 4; c. 2; d. 1; e. 5; f. 3. Apatient having chest pain needs to have the pain assessed and relieved as quickly as possible. The administration of oxygen may help to relieve the pain. Following an assessment of the vital signs and pain, medication may be administered. It is important to know if the pain is accompanied by any other manifestations or ECG changes exist before the report is given to the HCP.

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, c, e. 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.

Myocardial ischemia occurs as a result of increased oxygen demand and decreased oxygen supply. What factors and disorders result in increased oxygen demand (select all that apply)? a. Hypovolemia or anemia. b. Increased cardiac workload with aortic stenosis. c. Narrowed coronary arteries from atherosclerosis. d. Angina in the patient with atherosclerotic coronary arteries. e. Left ventricular hypertrophy caused by chronic hypertension. f. Sympathetic nervous system stimulation by drugs, emotions, or exertion.

b, d, e, f. Increased oxygen demand is caused by increasing the workload of the heart, including left ventricular hypertrophy with hypertension, sympathetic nervous stimulation, and anything precipitating angina. Hypovolemia, anemia, and narrowed coronary arteries contribute to decreased oxygen supply.

Which characteristics describe unstable angina (select all that apply)? a. Usually precipitated by exertion. b. New-onset angina with minimal exertion. c. Occurs only when the person is recumbent. d. Characterized by increased duration or severity. e. Usually occurs in response to coronary artery spasm.

b, d. Unstable angina is new-onset angina occurring at rest or with minimal exertion and increases in frequency, duration, or severity. Chronic stable angina is usually precipitated by exertion. Angina decubitus occurs when the person is recumbent. Prinzmetal's angina is frequently caused by a coronary artery spasm.

A patient admitted to the hospital for evaluation of chest pain has no abnormal serum cardiac biomarkers 4 hours after the onset of pain. What noninvasive diagnostic test can be used to differentiate angina from other types of chest pain? a. 12-lead ECG b. Exercise stress test c. Coronary angiogram d. Transesophageal echocardiogram

b. An exercise stress test will reveal ECG changes that indicate impaired coronary circulation when the oxygen demand of the heart is increased. A single ECG is not conclusive for CAD, and negative findings do not rule out CAD. Coronary angiography can detect narrowing of coronary arteries but is an invasive procedure. Echocardiograms of various types may identify abnormalities of myocardial wall motion under stress but are indirect measures of CAD.

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. 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 total serum cholesterol must be calculated with HDL for a ratio over time to determine an increased risk of CAD. Elevated HDLs are associated with a lower risk of CAD.

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. Prophylactic NTG may be used if angina occurs. c. Foreplay may cause too great an increase in heart rate. d. Performance can be enhanced with the use of sildenafil (Viagra).

b. 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 NTG 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.

The patient has hypertension and just experienced an MI. Which type of medication should the nurse expect to be added to decrease the workload on his heart? a. ACE inhibitor b. β-adrenergic blocker c. Calcium channel blocker d. Angiotensin II receptor blocker (ARB)

b. It is recommended that patients with hypertension and after an MI be on β-adrenergic blockers indefinitely to decrease oxygen demand. They inhibit sympathetic nervous stimulation of the heart; reduce heart rate, contractility, and blood pressure; and decrease afterload. Although calcium channel blockers decrease heart rate, contractility, and blood pressure, they are not used unless the patient cannot tolerate β-adrenergic blockers. ACE inhibitors and angiotensin II receptor blockers (ARBs) are used for vasodilation.

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. Left-sided heart failure (HF), which can escalate to cardiogenic shock, initially occurs and manifests as mild dyspnea, restlessness, agitation, pulmonary congestion with crackles, and/or S3 or S4 heart sounds. Right-sided HF includes jugular vein distention, hepatic congestion, or lower extremity edema. 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 HF, dysrhythmias, and angina. Papillary muscle dysfunction is suspected with a new systolic apical murmur.

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 health care provider when sexual activity can be resumed. d. Inform the patient that impotence is a common long-term complication following MI.

b. 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. HCPs may have preferences regarding the timing of resumption of sexual activity, and the nurse should discuss this with the HCP 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 it usually disappears after several attempts.

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. The etiology of CAD includes atherosclerosis as the major cause. The pathophysiology of atherosclerosis development and resulting atheromas is related to endothelial injury and inflammation, which can be the result of tobacco use, hyperlipidemia, hypertension, toxins, diabetes mellitus, 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.

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 75, with a BP of 172/100 mm Hg 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 mm Hg d. An obese Hispanic man, age 65, with a cholesterol level of 195 mg/dL and a BP of 128/76 mm Hg

b. This white woman has one unmodifiable risk factor (age) and two major modifiable risk factors (hypertension and physical inactivity). Her gender risk is as high as a man's because she is 75 years of age. The white man has one unmodifiable risk factor (gender), one major modifiable risk factor (smoking), and one minor modifiable risk factor (stressful lifestyle). The Asian woman has only one major modifiable risk factor (hyperlipidemia), and Asians in the United States have fewer myocardial infarctions (MIs) than do whites. The Hispanic man has an unmodifiable risk factor related to age and one major modifiable risk factor (obesity). Hispanics have slightly lower rates of CAD than non- Hispanic whites or African Americans.

Teamwork and Collaboration: In planning care for a patient who has just returned to the unit following a PCI, the nurse may delegate which activity to unlicensed assistive personnel (UAP)? a. Monitor the IV fluids and measure urine output. b. Check vital signs and report changes in HR, BP, or pulse oximetry. c. Explain to the patient the need for frequent vital signs and pulse checks. d. Assess circulation to the extremity used by checking pulses, skin temperature, and color.

b. Unlicensed assistive personnel (UAP) can check vital signs and report results to the RN. The other actions include assessment, teaching, and monitoring of IV fluids, which are all responsibilities of the RN.

What are manifestations of acute coronary syndrome (ACS) (select all that apply)? a. Dysrhythmia b. Stable angina c. Unstable angina d. ST-segment-elevation myocardial infarction (STEMI) e. Non-ST-segment-elevation myocardial infarction (NSTEMI)

c, d, e. Unstable angina, ST-segment-elevation myocardial infarction (STEMI), and non-ST-segment-elevation myocardial infarction (NSTEMI) are conditions that are manifestations of acute coronary syndrome (ACS). The other options are not manifestations of ACS.

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, d. 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 diabetes mellitus 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.

A second 12-lead ECG performed on a patient 4 hours after the onset of chest pain reveals ST segment elevation. What does the nurse recognize that this finding indicates? a. Transient ischemia typical of unstable angina. b. Lack of permanent damage to myocardial cells. c. MI associated with prolonged and complete coronary thrombosis. d. MI associated with transient or incomplete coronary artery occlusion.

c. A differentiation is made between MIs that have ST-segment elevations on ECG and those that do not because chest pain accompanied by ST-segment elevations is associated with prolonged and complete coronary thrombosis and is treated with reperfusion therapy. The other options are incorrect.

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 4days after MI b. 4 to 10 days after MI c. 10 to 14 days after MI d. 6 weeks after MI

c. At 10 to 14 days after MI, the new scar tissue is weak and is 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 4 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 in 6 weeks.

Interprofessional care of the patient with NSTEMI differs from that of a patient with STEMI in that NSTEMI is more frequently initially treated with what? a. PCI b. CABG c. Acute intensive drug therapy d. Reperfusion therapy with thrombolytics.

c. Because an NSTEMI is an ACS that indicates a transient thrombosis or incomplete coronary artery occlusion, treatment involves intensive drug therapy with antiplatelets, glycoprotein IIb/IIIa inhibitors, antithrombotics, and heparin to prevent clot extension. In addition, IV NTG is used. Reperfusion therapy using thrombolytics, CABG, or PCI is used for treatment of STEMI.

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. Serum troponin levels increased 4 to 6 hours after the onset. d. Creatine kinase MB (CK-MB) elevations that peak 6 hours after the infarct.

c. Cardiac-specific troponin T and troponin I have a greater sensitivity and specificity for myocardial injury than creatine kinase MB (CK-MB), are released 4 to 6 hours after the onset of MI, peak in 10 to 24 hours, and return to baseline over 10 to 14 days. CK-MB levels begin to rise 6 hours after an acute MI, peak in about 18 hours, and return to normal within 24 to 36 hours. ECG changes are often not apparent immediately after infarct and may be normal when the patient seeks medical attention. An enlarged heart, determined by x-ray, indicates cardiac stress but is not diagnostic of acute MI.

During treatment with reteplase (Retavase) for a patient with a STEMI, which finding should most concern the nurse? a. Oozing of blood from the IV site b. BP of 102/60 mmHg with an HR of 78bpm. c. Decrease in the responsiveness of the patient. d. Presence of intermittent accelerated idioventricular dysrhythmias.

c. Decreasing level of consciousness (LOC) may reflect hypoxemia resulting from internal bleeding, which is always a risk with thrombolytic therapy. Oozing of blood is expected, as are reperfusion dysrhythmias. BP is low but not considered abnormal because the pulse is within normal range. Idioventricular dysrhythmias are common with reperfusion.

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 low-density lipoprotein (LDL) cholesterol, lipid-filled smooth muscle cells.

c. 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 coronary artery disease (CAD) with hypercholesterolemia may be related to familial hypercholesterolemia, not a stage of CAD development. The fatty streak stage is the earliest stage of atherosclerosis and can be seen by age 20.

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. 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.

A patient is scheduled to have CABG surgery. What does the nurse explain to him that is involved with the procedure? a. A synthetic graft will be used as a tube for blood flow from the aorta to a coronary artery distal to an obstruction. b. A stenosed coronary artery will be resected, and a synthetic arterial tube graft will be inserted to replace the diseased artery. c. The internal mammary artery will be detached from the chest wall and attached to a coronary artery distal to the stenosis. d. Reversed segments of a saphenous artery from the aorta will be anastomosed to the coronary artery distal to an obstruction.

c. The most common method of coronary artery bypass involves leaving the internal mammary artery attached to its origin from the subclavian artery but dissecting it from the chest wall and anastomosing it distal to an obstruction in a coronary artery. Synthetic grafts are not commonly used as coronary bypass grafts, although research continues to investigate this option. Saphenous veins are used for bypass grafts when additional conduits are needed.

What describes transmyocardial laser revascularization (TMR)? a. Structure applied to hold vessels open. b. Requires anticoagulation following the procedure. c. Laser-created channels in the heart muscle to allow blood flow to ischemic areas. d. Surgical construction of new vessels to carry blood beyond obstructed coronary artery

c. Transmyocardial laser revascularization (TMR) is a treatment used for patients with inoperable CAD. It uses a high-energy laser to create channels in the heart to allow blood to flow to the ischemic area and can be done using a left anterior thoracotomy incision or with coronary artery bypass graft (CABG) surgery. A stent is the structure used to hold vessels open and requires anticoagulation following the procedure. Surgical construction of new vessels is done with CABG surgery.

When a patient reports chest pain, why must unstable angina be identified and rapidly treated? a. The pain may be severe and disabling. b. ECG changes and dysrhythmias may occur during an attack. c. Rupture of unstable plaque may cause complete thrombosis of the vessel lumen. d. Spasm of a major coronary artery may cause total occlusion of the vessel with progression to MI.

c. Unstable angina is associated with the rupture of a once-stable atherosclerotic plaque, exposing the intima to blood and stimulating platelet aggregation and local vasoconstriction with thrombus formation. Patients with unstable angina require immediate hospitalization and monitoring because the lesion is at increased risk of complete thrombosis of the lumen with progression to MI. Any type of angina may be associated with severe pain, ECG changes, and dysrhythmias. Prinzmetal's angina is characterized by coronary artery spasm.

What causes the pain that occurs with myocardial ischemia? a. Death of myocardial tissue b. Dysrhythmias caused by cellular irritability c. Lactic acid accumulation during anaerobic metabolism d. Elevated pressure in the ventricles and pulmonary vessels

c. When the coronary arteries are occluded, contractility ceases after several minutes, depriving the myocardial cells of glucose and oxygen for aerobic metabolism. Anaerobic metabolism begins and lactic acid accumulates, irritating myocardial nerve fibers that then transmit a pain message to the cardiac nerves and upper thoracic posterior roots. The other factors may occur during vessel occlusion but are not the source of pain.

Patient-Centered Care: A 62-yr-old woman has prehypertension (BP 138/88 mm Hg) 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. Without the total serum cholesterol and HDL results, diet therapy and smoking cessation are indicated for this patient without CAD who has prehypertension and an LDL level ≥130 mg/dL. When the patient's LDL level is 75 to 189 mg/dL with a 10-year risk for CVD of 7.5% or above, drug therapy would be added to diet therapy. Because tobacco use is related to increased BP and LDL level, the benefit of smoking cessation is almost immediate. Exercise is indicated to reduce risk factors throughout treatment.

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. All of this patient's results are abnormal. The patient in option "c" is close to being at risk; if this patient is a woman, the HDL is too low and the other results are at or near the cut off for being normal. The other patients' results are at acceptable levels.

Tachycardia that is a response of the sympathetic nervous system to the pain of ischemia is detrimental because it increases oxygen demand and ________ a. increases cardiac output. b. causes reflex hypotension. c. may lead to atrial dysrhythmias. d. impairs perfusion of the coronary arteries.

d. An increased heart rate (HR) decreases the time the heart spends in diastole, which is the time of greatest coronary blood flow. Unlike other arteries, coronary arteries are perfused when the myocardium relaxes and blood backflows from the aorta into the sinuses of Valsalva, which have openings to the right and left coronary arteries. Thus the heart has a decreased oxygen supply at a time when there is an increased oxygen demand. Tachycardia may also lead to ventricular dysrhythmia. The other options are incorrect.

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. 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.

Priority Decision: While teaching women about the risks and incidence of CAD, what should 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 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 natural 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 men. Recent research indicates that estrogen replacement does not always reduce the risk for CAD, even though natural estrogen lowers low-density lipoprotein (LDL) and raises high-density lipoprotein (HDL) cholesterol.

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

d. 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 anxiety and cardiac workload; and glycoprotein IIb/IIIa inhibitors and antiplatelets prevent the binding of fibrinogen to platelets.

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. TMR b. Stent placement c. Coronary artery bypass graft (CABG) d. Percutaneous coronary intervention (PCI)

d. Emergent percutaneous coronary intervention (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. TMR, stent placement, and CABG are usually done to facilitate circulation in non-emergency situations.

A 52-yr-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. The subjective report of the pain from an MI is usually severe. It usually is unrelieved by NTG, rest, or position change and usually lasts more than the 15 or 20 minutes typical of angina pain. All of the other symptoms may occur with angina as well as with an MI.