Chapter 34: Coronary Artery Disease and Acute Coronary Syndrome

What is a classic sign of unstable angina and coronary artery disease (CAD) in women? A. Fatigue B. Hypotension C. Atrial fibrillation D. Headache

ANS: A Common symptoms that women experience are fatigue (most prominent symptom), shortness of breath, indigestion, and anxiety. Reference: 778

The community health nurse is planning health promotion teaching targeted at preventing coronary artery disease. Which ethnic group would you select as the highest priority for this intervention? A. White male B. Hispanic male C. African American male D. Native American female

ANS: A The incidence of CAD and myocardial infarction is highest among white, middle-aged men. Reference: 763

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

c) Atrial dysrhythmias Postoperative dysrhythmias, specifically atrial dysrhythmias, are common in the first 3 days following CABG surgery. Although the other complications could occur, they are not common complications.

23. A patient who is recovering from an acute myocardial infarction (AMI) asks the nurse about when sexual intercourse can be resumed. Which response by the nurse is best? a. "Most patients are able to enjoy intercourse without any complications." b. "Sexual activity uses about as much energy as climbing two flights of stairs." c. "The doctor will provide sexual guidelines when your heart is strong enough." d. "Holding and cuddling are good ways to maintain intimacy after a heart attack."

ANS: B Sexual activity places about as much physical stress on the cardiovascular system as most moderate-energy activities such as climbing two flights of stairs. The other responses do not directly address the patient's question or may not be accurate for this patient.

What sign or symptom is the most important for you to teach the patient who is taking gemfibrozil (Lipid) or simvastatin (Zocor)? A. Nightmares B. Severe muscle aching C. Diarrhea D. Thrombocytopenia

ANS: B The risk is rhabdomyolysis. Clinical manifestations of rhabdomyolysis are increased creatinine kinase levels and muscle tenderness. Nightmares are a side effect but not as ominous as rhabdomyolysis. Reference: 770

In teaching a patient about coronary artery disease (CAD), you explain which changes that occur in this disorder (select all that apply)? A. Diffuse involvement of plaque formation in coronary veins B. Abnormal levels of cholesterol, particularly low-density lipoproteins C. Accumulation of lipid and fibrous tissue within the coronary arteries D. Development of angina due to decreased blood supply to the heart muscle E. Chronic vasoconstriction of coronary arteries leading to permanent vasospasm

ANS: B,C,D Atherosclerosis is the major cause of coronary artery disease (CAD) and 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 by 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 narrowed vessel lumen and a reduction in blood flow to the myocardial tissue. Reference: 761

The patient with Prinzmetal's angina is prescribed nitroglycerin tablets. What should you teach the patient about this drug? A. Do not use the tablets if they taste tingling when used. B. Store the medication bottle in the bathroom so it is easily located. C. Do not take any drug for erectile dysfunction, such as Viagra. D. Call 911 if you experience flushing when taking the tablet.

ANS: C Nitroglycerin cannot be combined with erectile dysfunction medications because it potentiates vasodilation. Nitroglycerin tablets should taste tingling if still potent (the drug is easily degraded). The medicine should always be easily accessible, but it is not recommended to store it near light or heat. It can degrade and lose potency, and the patient should purchase a new supply every 6 months. Common side effects include increased heart rate, headache, dizziness, and flushing. Reference: 775

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

ANS: C Postoperative dysrhythmias, specifically atrial dysrhythmias, are common in the first 3 days after CABG surgery. Although the other complications can occur, they are not common. Reference: 789

The patient with acute coronary syndrome (ACS) undergoes coronary revascularization with balloon angioplasty with placement of a drug-eluting stent. The physician prescribes a glycoprotein IIb/IIIa inhibitor tirofiban (Aggrastat). What is the main rationale for administering this drug? A. To promote vasodilation B. To inhibit ST elevation C. To prevent closure of the stent D. To inhibit hemorrhage

ANS: C The IIb/IIIa inhibitor prevents the abrupt closure of the stent and is initiated during the percutaneous coronary intervention and maintained for 12 hours after the procedure. Reference: 777

The patient is prescribed propranolol (Inderal) as part of the management of chronic stable angina. What nursing assessment should be done before the drug's administration? A. Breath sounds B. Incidence of gastric esophageal reflux (GERD) C. Apical heart rate D. Presence of depression

ANS: C The β-adrenergic blockers are preferred drugs for the management of chronic stable angina. They reduce myocardial contractility, heart rate, and blood pressure, all which reduce the myocardial oxygen demand. They decrease morbidity and mortality in patients with coronary artery disease (CAD). Side effects include bradycardia and hypotension, and the patient should be assessed, with the drug withheld, if either value is too low. Reference: 776

17. A patient is recovering from a myocardial infarction (MI) and develops chest pain on day 3 that increases when taking a deep breath and is relieved by leaning forward. Which action should the nurse take next? a. Assess the feet for pedal edema. b. Palpate the radial pulses bilaterally. c. Auscultate for a pericardial friction rub. d. Check the heart monitor for dysrhythmias.

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.

14. A patient with ST-segment elevation in three contiguous electrocardiographic (ECG) leads is admitted to the emergency department (ED) and diagnosed as having an ST-segment-elevation myocardial infarction (STEMI). Which question should the nurse ask to determine whether the patient is a candidate for thrombolytic therapy? a. "Do you have any allergies?" b. "Do you take aspirin on a daily basis?" c. "What time did your chest pain begin?" d. "Can you rate your chest pain using a 0 to 10 scale?"

ANS: C Thrombolytic therapy should be started within 6 hours of the onset of the myocardial infarction (MI), so the time at which the chest pain started is a major determinant of the appropriateness of this treatment. The other information will also be needed, but it will not be a factor in the decision about thrombolytic therapy.

32. A patient admitted to the coronary care unit (CCU) with an ST-segment-elevation myocardial infarction (STEMI) is restless and anxious. The blood pressure is 86/40 and heart rate is 123. Based on this information, which nursing diagnosis is a priority for the patient? a. Acute pain related to myocardial infarction b. Anxiety related to perceived threat of death c. Stress overload related to acute change in health d. Decreased cardiac output related to cardiogenic shock

ANS: D All the nursing diagnoses may be appropriate for this patient, but the hypotension and tachycardia indicate decreased cardiac output and shock from the damaged myocardium. This will result in decreased perfusion to all vital organs (e.g., brain, kidney, heart) and is a priority.

1. When developing a teaching plan for a 61-year-old man with the following risk factors for coronary artery disease (CAD), the nurse should focus on the a. family history of coronary artery disease. b. increased risk associated with the patient's gender. c. increased risk of cardiovascular disease as people age. d. elevation of the patient's low-density lipoprotein (LDL) level.

ANS: D Because family history, gender, and age are nonmodifiable risk factors, the nurse should focus on the patient's LDL level. Decreases in LDL will help reduce the patient's risk for developing CAD.

4. Which information given by a patient admitted with chronic stable angina will help the nurse confirm this diagnosis? a. The patient states that the pain "wakes me up at night." b. The patient rates the pain at a level 3 to 5 (0 to 10 scale). c. The patient states that the pain has increased in frequency over the last week. d. The patient states that the pain "goes away" with one sublingual nitroglycerin tablet.

ANS: D Chronic stable angina is typically relieved by rest or nitroglycerin administration. The level of pain is not a consistent indicator of the type of angina. Pain occurring at rest or with increased frequency is typical of unstable angina.

A patient 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 minimum of 3 weeks b. Plan a diet program that aims for a 1 to 2 pound weight loss per week c. Begin an exercise program that aims for at least five 30-minute sessions per week d. Consider the use of erectile agents and prophylactic NTG before engaging in sexual activity

c. Begin an exercise program that aims for at least five 30-minute sessions per week

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

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

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

ANS: A, B, C 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. Reference: 768

33. When admitting a patient with a non-ST-segment-elevation myocardial infarction (NSTEMI) to the intensive care unit, which action should the nurse perform first? a. Obtain the blood pressure. b. Attach the cardiac monitor. c. Assess the peripheral pulses. d. Auscultate the breath sounds.

ANS: B Because dysrhythmias are the most common complication of myocardial infarction (MI), the first action should be to place the patient on a cardiac monitor. The other actions also are important and should be accomplished as quickly as possible.

For what is percutaneous coronary intervention (PCI) most clearly indicated? A. Chronic stable angina B. Left-sided heart failure C. Coronary artery disease (CAD) D. Acute MI

ANS: D PCI is used to restore coronary perfusion in cases of MI. Chronic stable angina and CAD are normally treated with more conservative measures initially. PCI is not relevant to the pathophysiology of heart failure. Reference: 780-781

24. A patient with hyperlipidemia has a new order for colesevelam (Welchol). Which nursing action is most appropriate when giving the medication? a. Have the patient take this medication with an aspirin. b. Administer the medication at the patient's usual bedtime. c. Have the patient take the colesevelam with a sip of water. d. Give the patient's other medications 2 hours after the colesevelam.

ANS: D The bile acid sequestrants interfere with the absorption of many other drugs, and giving other medications at the same time should be avoided. Taking an aspirin concurrently with the colesevelam may increase the incidence of gastrointestinal side effects such as heartburn. An increased fluid intake is encouraged for patients taking the bile acid sequestrants to reduce the risk for constipation. For maximum effect, colesevelam should be administered with meals.

26. A patient who has recently started taking pravastatin (Pravachol) and niacin (Nicobid) reports the following symptoms to the nurse. Which is most important to communicate to the health care provider? a. Generalized muscle aches and pains b. Dizziness when changing positions quickly c. Nausea when taking the drugs before eating d. Flushing and pruritus after taking the medications

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

What should you teach patients with chronic stable angina? A. Do isometric arm exercises to build endurance. B. Wear a face mask when outdoors in cold weather. C. Drive to an emergency department if there is no relief after three nitroglycerin tablets. D. Notify a physician if you experience headache with nitroglycerin.

ANS: B Blood vessels constrict in response to cold and increase the workload of the heart. Isometric exercises can cause exertional anginal. Activity should focus on cardiac health, such as walking. Emergency medical services (EMS) should be called if there is no relief after three nitroglycerine tablets. Driving can be dangerous if a myocardial infarction occurs. Vasodilation occurs as a side effect of nitroglycerin. Reference: 773

What specific diet changes are encouraged to reduce the risks associated with CAD? A. Reduce complex carbohydrates. B. Consume forms of soybeans. C. Increase intake of organ meats. D. Avoid fatty fish such as salmon.

ANS: B The American Heart Association (AHA) recommends eating tofu, other forms of soybean, canola, walnuts, and flaxseed because these products contain α-linolenic acid, which becomes omega-3 fatty acid in the body. Complex carbohydrates (e.g., whole grains, fruit, vegetables) are recommended. Organ meats are not recommended due to high-fat content. Two servings per week of fatty fish (e.g., salmon, tuna) are recommended because they contain two types of omega-3 fatty acids. Reference: 768

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

ANS: B The recommended dose of nitroglycerin is one tablet taken sublingually (SL) or one metered spray for symptoms of angina. If symptoms are unchanged or worse after 5 minutes, the patient should be instructed to activate the EMS system. Reference: 775

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

ANS: A 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 severe hypotension caused by vasodilation. The other home medications also should be documented and reported to the health care provider but do not have as immediate an impact on decisions about the patient's treatment.

What is the main reason a patient is instructed to take the nitroglycerin patch off for 8 hours every night? A. Hypotension will occur. B. It is not needed because the patient is inactive. C. The interruption prevents tolerance to nitroglycerin. D. It causes nightmares.

ANS: C Unless there is nocturnal angina, an 8-hour nitrate-free period is suggested because tolerance to nitroglycerin-induced vasodilation can develop. Reference: 776

The patient is prescribed niacin to help reduce cholesterol. The patient tells you he does not take the medication regularly because it causes uncomfortable flushing in his face and neck. What should you teach the patient to do? A. Administer the medication with food. B. Take the drug at bedtime with milk. C. Administer the drug in split doses. D. Take ibuprofen 30 minutes before the medication.

ANS: D Premedicating with aspirin or a nonsteroidal antiinflammatory drug (NSAID) 30 minutes before taking niacin can reduce flushing. Taking time-released niacin can also prevent flushing. Reference: 770

A patient was admitted to the emergency department 24 hours earlier with complaints of chest pain that were subsequently attributed to ST-segment-elevation myocardial infarction (STEMI). Which complication of MI should you anticipate? A. Unstable angina B. Cardiac tamponade C. Sudden cardiac death D. Cardiac dysrhythmias

ANS: D The most common complication after an MI is dysrhythmias, which occur in c% of patients. Unstable angina is a 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 after an MI is not characterized as sudden cardiac death. Reference: 779

A fibrinolytic agent is administered in the emergency department to the patient diagnosed with an acute myocardial infarction (MI). Which is the best indicator that the drug has achieved its therapeutic effect? A. Return of ST segment to baseline on the ECG B. Early, rapid decline in the CK-MB enzyme levels C. Increase in the prothrombin time, international normalized ratio, and partial thromboplastin time laboratory values D. Vital signs within normal range

ANS: A Fibrinolytics are given to produce an open artery by lysis of the thrombus in the coronary artery. The most reliable marker that this has occurred is the return of the ST segment to baseline on the ECG. Other markers include a resolution of chest pain and an early, rapid rise of the CK-MB enzyme levels within 3 hours of therapy, because the necrotic myocardial cells release CK-MB enzymes into the circulation after perfusion is restored to the area. Reperfusion dysrhythmias are a less reliable maker. The drug is not given specifically to accomplish prolonged clotting time or to alter vital signs. Reference: 781-782

Which individual would you identify as having the highest risk for CAD? A. A 45-year-old, depressed man with a high-stress job B. A 60-year-old man with low homocysteine levels C. A 54-year-old female vegetarian with elevated high-density lipoprotein (HDL) cholesterol levels D. A 62-year-old woman who has a sedentary lifestyle and BMI of 23 kg/m2

ANS: A Studies demonstrate that depression and stressful states can contribute to the development of CAD. Elevated HDL cholesterol 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 the patient with two risk factors is at greatest risk for developing CAD. Reference: 766

When planning emergent care for a patient with a suspected MI, you anticipate administration of A. oxygen, nitroglycerin, aspirin, and morphine. B. oxygen, furosemide (Lasix), nitroglycerin, and meperidine. C. aspirin, nitroprusside (Nipride), dopamine (Intropin), and oxygen. D. nitroglycerin, lorazepam (Ativan), oxygen, and warfarin (Coumadin).

ANS: A 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 relieve chest pain, improve oxygenation, decrease myocardial workload, and prevent further platelet aggregation. Reference: 781, 782

What can best help to decrease the incidence of sudden cardiac death in the community? A. Availability of automatic external defibrillators B. Courses in cardiopulmonary resuscitation (CPR) techniques for the general public C. Public service announcements about myocardial infarction (MI) symptoms. D. Mandatory CPR certification for all school teachers

ANS: A The most common cause of sudden cardiac death is the lethal dysrhythmia ventricular fibrillation, which usually occurs within the first 4 hours after the onset of pain. This lethal ventricular dysrhythmia must be treated immediately with defibrillation. Most patients with sudden cardiac death have not had an MI and have no cardiac symptoms. Reference: 793

34. Which information about a patient who has been receiving thrombolytic therapy for an acute myocardial infarction (AMI) is most important for the nurse to communicate to the health care provider? a. No change in the patient's chest pain b. An increase in troponin levels from baseline c. A large bruise at the patient's IV insertion site d. A decrease in ST-segment elevation on the electrocardiogram

ANS: A Continued chest pain suggests that the thrombolytic therapy is not effective and that other interventions such as percutaneous coronary intervention (PCI) may be needed. Bruising is a possible side effect of thrombolytic therapy, but it is not an indication that therapy should be discontinued. The decrease of the ST-segment elevation indicates that thrombolysis is occurring and perfusion is returning to the injured myocardium. An increase in troponin levels is expected with reperfusion and is related to the washout of cardiac markers into the circulation as the blocked vessel is opened.

25. The nurse is caring for a patient who was admitted to the coronary care unit following an acute myocardial infarction (AMI) and percutaneous coronary intervention the previous day. Teaching for this patient would include a. when cardiac rehabilitation will begin. b. the typical emotional responses to AMI. c. information regarding discharge medications. d. the pathophysiology of coronary artery disease.

ANS: A Early after an AMI, the patient will want to know when resumption of usual activities can be expected. At this time, the patient's anxiety level or denial will interfere with good understanding of complex information such as the pathophysiology of coronary artery disease (CAD). Teaching about discharge medications should be done closer to discharge. The nurse should support the patient by decreasing anxiety rather than discussing the typical emotional responses to myocardial infarction (MI).

21. A few days after experiencing a myocardial infarction (MI) and successful percutaneous coronary intervention, the patient states, "I just had a little chest pain. As soon as I get out of here, I'm going for my vacation as planned." Which reply would be most appropriate for the nurse to make? a. "What do you think caused your chest pain?" b. "Where are you planning to go for your vacation?" c. "Sometimes plans need to change after a heart attack." d. "Recovery from a heart attack takes at least a few weeks."

ANS: A When the patient is experiencing denial, the nurse should assist the patient in testing reality until the patient has progressed beyond this step of the emotional adjustment to MI. Asking the patient about vacation plans reinforces the patient's plan, which is not appropriate in the immediate post-MI period. Reminding the patient in denial about the MI is likely to make the patient angry and lead to distrust of the nursing staff.

Which are considered risk factors for coronary artery disease (CAD) (select all that apply)? A. Cholesterol level of 240 mg/dL B. Elevated serum level of high-density lipoproteins (HDLs) C. Blood pressure of 150/92 mm Hg D. Smokes 2 packs/day E. Body mass index (BMI) of 25 kg/m2

ANS: A,C,D A cholesterol level higher than 200 mg/dL is one of the four most firmly established risk factors. Hypertension (blood pressure greater than 140/90 mm Hg or greater than 130/80 mm Hg if the patient has diabetes or chronic kidney disease) is another major risk factor. Tobacco use (proportional to the number of cigarettes smoked) is major risk factor. High HDL levels are desirable because they transport lipid that accumulates within the arterial walls. The higher the HDL levels in the blood, the lower the risk of CAD. A BMI greater than 30 kg/m2 is a risk factor. Reference: 761-763

A patient is admitted to the coronary care unit with a diagnosis of unstable angina. Which medications do you expect the patient to receive (select all that apply)? A. Antiplatelet therapy B. Fibrinolytic therapy C. β-Adrenergic blockers D. Prophylactic antibiotics E. Intravenous nitroglycerin

ANS: A,C,E Oxygen, nitroglycerin, aspirin (chewable), and morphine may be used to treat unstable angina. For patients with unstable angina with negative cardiac markers and ongoing angina, a combination of aspirin, heparin, and a glycoprotein IIb/IIIa inhibitor (e.g., eptifibatide [Integrilin]) is recommended. β-Adrenergic blockers decrease myocardial oxygen demand by reducing heart rate, blood pressure, and contractility. Reference: 781

The patient with ACS had balloon angioplasty and a drug-eluding stent placed. What is required nursing care in the first 6 hours after the procedure (select all that apply)? A. Assess the pedal pulse in the affected leg. B. Ambulate the patient to prevent thrombus. C. Provide oxygen by mask. D. Administer a glycoprotein IIb/IIIa inhibitor. E. Regularly obtain vital signs.

ANS: A,D,E Neurovascular assessments are performed in the affected leg, a IIb/IIIa inhibitor is given to prevent abrupt closure of the stented vessel, and regularly obtained vital signs help monitor cardiac function. The patient is kept on bed rest with an extended leg and a pressure dressing on the insertion site. Oxygen, if needed, usually is administered in lower concentrations by nasal cannula. Reference: 777

You are caring for a patient 2 days after an MI. She reports that she is experiencing chest pain. She states, "It hurts when I take a deep breath." Which action is a priority? A. Notify the physician STAT, and obtain a 12-lead ECG. B. Obtain vital signs, and auscultate for a pericardial friction rub. C. Apply high-flow oxygen by face mask, and auscultate breath sounds. D. Medicate the patient with an analgesic as needed, and reevaluate in 30 minutes.

ANS: B Acute pericarditis is an inflammation of the visceral or parietal pericardium; it often occurs 2 to 3 days after an acute MI. Chest pain may vary from mild to severe and is aggravated 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 an MI. Assessment of the patient with pericarditis may reveal a friction rub over the pericardium. Reference: 780

A hospitalized patient with a history of chronic stable angina tells you that she is having chest pain. You base your actions on the knowledge that ischemia A. will always progress to myocardial infarction. B. will be relieved by rest or nitroglycerin, or both. C. indicates that irreversible myocardial damage is occurring. D. is frequently associated with vomiting and extreme fatigue.

ANS: B Chronic stable angina refers to 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). Ischemia does not cause myocardial damage. Reference: 772, 773

The patient asks how Prinzmetal's angina (variant angina) is different from chronic stable angina. What is the best response? A. Stable angina occurs at a higher incidence among people with a history of migraine headaches. B. Prinzmetal's angina is not precipitated by increased activity but is a strong spasm. C. Chronic stable angina has hypertension, and Prinzmetal's angina has hypotension. D. Prinzmetal's angina is not influenced by tobacco use, but chronic stable angina is.

ANS: B Prinzmetal's angina is not usually precipitated by increased physical demand. The strong contraction (spasm) of smooth muscle in the coronary artery results from an increase in intracellular calcium levels. It can occur in the absence of coronary artery disease (CAD). Prinzmetal's angina is more frequently seen in a patient with a history of migraine headaches and Raynaud's phenomenon, but stable angina also can occur in patients with this medical history. Nitrates and calcium channel blockers are used by patients with Prinzmetal's angina. Tobacco smoke increases myocardial oxygen demand and is an influence in both conditions. Reference: 772

39. To improve the physical activity level for a mildly obese 71-year-old patient, which action should the nurse plan to take? a. Stress that weight loss is a major benefit of increased exercise. b. Determine what kind of physical activities the patient usually enjoys. c. Tell the patient that older adults should exercise for no more than 20 minutes at a time. d. Teach the patient to include a short warm-up period at the beginning of physical activity.

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

3. Which assessment data collected by the nurse who is admitting a patient with chest pain suggest that the pain is caused by an acute myocardial infarction (AMI)? a. The pain increases with deep breathing. b. The pain has lasted longer than 30 minutes. c. The pain is relieved after the patient takes nitroglycerin. d. The pain is reproducible when the patient raises the arms.

ANS: B Chest pain that lasts for 20 minutes or more is characteristic of AMI. Changes in pain that occur with raising the arms or with deep breathing are more typical of musculoskeletal pain or pericarditis. Stable angina is usually relieved when the patient takes nitroglycerin.

20. When caring for a patient who is recovering from a sudden cardiac death (SCD) event and has no evidence of an acute myocardial infarction (AMI), the nurse will anticipate teaching the patient that a. sudden cardiac death events rarely reoccur. b. additional diagnostic testing will be required. c. long-term anticoagulation therapy will be needed. d. limited physical activity after discharge will be needed to prevent future events.

ANS: B Diagnostic testing (e.g., stress test, Holter monitor, electrophysiologic studies, cardiac catheterization) is used to determine the possible cause of the SCD and treatment options. SCD is likely to recur. Anticoagulation therapy will not have any effect on the incidence of SCD, and SCD can occur even when the patient is resting.

10. The nurse will suspect that the patient with stable angina is experiencing a side effect of the prescribed metoprolol (Lopressor) if the a. patient is restless and agitated. b. blood pressure is 90/54 mm Hg. c. patient complains about feeling anxious. d. cardiac monitor shows a heart rate of 61 beats/minute.

ANS: B Patients taking β-adrenergic blockers should be monitored for hypotension and bradycardia. Because this class of medication inhibits the sympathetic nervous system, restlessness, agitation, hypertension, and anxiety will not be side effects.

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

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

9. Diltiazem (Cardizem) is ordered for a patient with newly diagnosed Prinzmetal's (variant) angina. When teaching the patient, the nurse will include the information that diltiazem will a. reduce heart palpitations. b. decrease spasm of the coronary arteries. c. increase the force of the heart contractions. d. help prevent plaque from forming in the coronary arteries.

ANS: B Prinzmetal's angina is caused by coronary artery spasm. Calcium channel blockers (e.g., diltiazem, amlodipine [Norvasc]) are a first-line therapy for this type of angina. Lipid-lowering drugs help reduce atherosclerosis (i.e., plaque formation), and β-adrenergic blockers decrease sympathetic stimulation of the heart (i.e., palpitations). Medications or activities that increase myocardial contractility will increase the incidence of angina by increasing oxygen demand.

28. Which assessment finding by the nurse caring for a patient who has had coronary artery bypass grafting using a right radial artery graft is most important to communicate to the health care provider? a. Complaints of incisional chest pain b. Pallor and weakness of the right hand c. Fine crackles heard at both lung bases d. Redness on both sides of the sternal incision

ANS: B The changes in the right hand indicate compromised blood flow, which requires immediate evaluation and actions such as prescribed calcium channel blockers or surgery. The other changes are expected and/or require nursing interventions.

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

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

You assess a patient with complaints of chest pain for which clinical manifestations associated with an MI (select all that apply)? A. Flushing B. Ashen skin C. Diaphoresis D. Nausea and vomiting E. S3 or S4 heart sounds

ANS: B,C,D,E During the initial phase of an MI, catecholamines are released from the ischemic myocardial cells, causing increased sympathetic nervous system (SNS) stimulation. This results in the release of glycogen, diaphoresis, and vasoconstriction of peripheral blood vessels, and the patient's skin may be ashen, cool, and clammy (not flushed). Nausea and vomiting may result from reflex stimulation of the vomiting center by severe pain. Ventricular dysfunction resulting from the MI may produce abnormal S3 and S4 heart sounds. Reference: 779

Your patient is recovering from an uncomplicated MI. Which rehabilitation guideline is a priority to include in your teaching? A. Refrain from sexual activity for a minimum of 3 weeks. B. Plan a diet program that aims for a 1- to 2-pound weight loss per week. C. Begin an exercise program that aims for at least five 30-minute sessions per week. D. Consider the use of erectile agents and prophylactic nitroglycerin before engaging in sexual activity.

ANS: C Physical activity should be regular, rhythmic, and repetitive, using large muscles to build up endurance (e.g., walking, cycling, swimming, rowing). Physical activity sessions should be at least 30 minutes long. Instruct the patient to begin slowly at personal tolerance levels (perhaps only 5 to 10 minutes) and build up to 30 minutes. Reference: 792

15. Following an acute myocardial infarction (AMI), a patient ambulates in the hospital hallway. When the nurse is evaluating the patient's response to the activity, which assessment data would indicate that the exercise level should be decreased? a. Blood pressure (BP) changes from 118/60 to 126/68 mm Hg. b. Oxygen saturation drops from 99% to 95%. c. Heart rate increases from 66 to 92 beats/minute. d. Respiratory rate goes from 14 to 20 breaths/minute.

ANS: C A change in heart rate of more than 20 beats over the resting heart rate indicates that the patient should stop and rest. The increases in BP and respiratory rate, and the slight decrease in oxygen saturation, are normal responses to exercise.

12. Heparin is ordered for a patient with a non-ST-segment-elevation myocardial infarction (NSTEMI). What is the purpose of the heparin? a. Heparin enhances platelet aggregation. b. Heparin decreases coronary artery plaque size. c. Heparin prevents the development of new clots in the coronary arteries. d. Heparin dissolves clots that are blocking blood flow in the coronary arteries.

ANS: C Heparin helps prevent the conversion of fibrinogen to fibrin and decreases coronary artery thrombosis. It does not change coronary artery plaque, dissolve already formed clots, or enhance platelet aggregation.

2. Which nursing intervention will be most effective when assisting the patient with coronary artery disease (CAD) to make appropriate dietary changes? a. Give the patient a list of low-sodium, low-cholesterol foods that should be included in the diet. b. Emphasize the increased risk for heart problems unless the patient makes the dietary changes. c. Help the patient modify favorite high-fat recipes by using monosaturated oils when possible. d. Inform the patient that a diet containing no saturated fat and minimal salt will be necessary.

ANS: C Lifestyle changes are more likely to be successful when consideration is given to the patient's values and preferences. The highest percentage of calories from fat should come from monosaturated fats. Although low-sodium and low-cholesterol foods are appropriate, providing the patient with a list alone is not likely to be successful in making dietary changes. Completely removing saturated fat from the diet is not a realistic expectation. Up to 7% of calories in the therapeutic lifestyle changes (TLC) diet can come from saturated fat. Telling the patient about the increased risk without assisting further with strategies for dietary change is unlikely to be successful.

16. During the administration of the thrombolytic agent to a patient with an acute myocardial infarction (AMI), the nurse should stop the drug infusion if the patient experiences a. bleeding from the gums. b. increase in blood pressure. c. a decrease in level of consciousness. d. a nonsustained episode of ventricular tachycardia.

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

35. The nurse obtains the following data when assessing a patient who experienced an ST-segment-elevation myocardial infarction (STEMI) 2 days previously. Which information is most important to report to the health care provider? a. The troponin level is elevated. b. The patient denies ever having a heart attack. c. Bilateral crackles are auscultated in the mid-lower lobes. d. The patient has occasional premature atrial contractions (PACs).

ANS: C The crackles indicate that the patient may be developing heart failure, a possible complication of myocardial infarction (MI). The health care provider may need to order medications such as diuretics or angiotensin-converting enzyme (ACE) inhibitors for the patient. Elevation in troponin level at this time is expected. PACs are not life-threatening dysrhythmias. Denial is a common response in the immediate period after the MI.

5. After the nurse has finished teaching a patient about the use of sublingual nitroglycerin (Nitrostat), which patient statement indicates that the teaching has been effective? a. "I can expect some nausea as a side effect of nitroglycerin." b. "I should only take the nitroglycerin if I start to have chest pain." c. "I will call an ambulance if I still have pain after taking 3 nitroglycerin 5 minutes apart." d. "Nitroglycerin helps prevent a clot from forming and blocking blood flow to my heart."

ANS: C The emergency medical services (EMS) system should be activated when chest pain or other symptoms are not completely relieved after 3 sublingual nitroglycerin tablets taken 5 minutes apart. Nitroglycerin can be taken to prevent chest pain or other symptoms from developing (e.g., before intercourse). Gastric upset (e.g., nausea) is not an expected side effect of nitroglycerin. Nitroglycerin does not impact the underlying pathophysiology of coronary artery atherosclerosis.

42. After reviewing information shown in the accompanying figure from the medical records of a 43-year-old, which risk factor modification for coronary artery disease should the nurse include in patient teaching? a. Importance of daily physical activity b. Effect of weight loss on blood pressure c. Dietary changes to improve lipid levels d. Ongoing cardiac risk associated with history of tobacco use

ANS: C The patient has an elevated low-density lipoprotein (LDL) cholesterol and low high-density lipoprotein (HDL) cholesterol, which will increase the risk of coronary artery disease. Although the blood pressure is in the prehypertensive range, the patient's waist circumference and body mass index (BMI) indicate an appropriate body weight. The risk for coronary artery disease a year after quitting smoking is the same as a nonsmoker. The patient's occupation indicates that daily activity is at the levels suggested by national guidelines.

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

ANS: C The patient should sit down before taking the nitroglycerin to decrease cardiac workload and prevent orthostatic hypotension. Transdermal nitrates are used prophylactically rather than to treat acute pain and can be used concurrently with sublingual nitroglycerin. Although the nurse should check blood pressure before giving nitroglycerin, patients do not need to check the pulse rate before taking nitrates.

37. A patient who has chest pain is admitted to the emergency department (ED) and all of the following are ordered. Which one should the nurse arrange to be completed first? a. Chest x-ray b. Troponin level c. Electrocardiogram (ECG) d. Insertion of a peripheral IV

ANS: C The priority for the patient is to determine whether an acute myocardial infarction (AMI) is occurring so that reperfusion therapy can begin as quickly as possible. ECG changes occur very rapidly after coronary artery occlusion, and an ECG should be obtained as soon as possible. Troponin levels will increase after about 3 hours. Data from the chest x-ray may impact the patient's care but are not helpful in determining whether the patient is experiencing a myocardial infarction (MI). Peripheral access will be needed but not before the ECG.

41. A patient with diabetes mellitus and chronic stable angina has a new order for captopril (Capoten). The nurse should teach the patient that the primary purpose of captopril is to a. lower heart rate. b. control blood glucose levels. c. prevent changes in heart muscle. d. reduce the frequency of chest pain.

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

What is a classic manifestation of chronic stable angina? A. Pain remains during rest. B. Characteristics vary between episodes. C. Discomfort is described as sharp or stabbing. D. Discomfort often is described as squeezing or choking.

ANS: D Chronic, stable angina is described as pain, pressure, or an ache in the chest. It is an unpleasant feeling, often described as a constrictive, squeezing, heavy, choking, or suffocating sensation. It usually is relieved with rest or when the precipitating factor is removed. The symptoms and triggers tend to remain consistent. Angina is rarely sharp or stabbing and usually does not change with position or breathing.

The patient with chronic stable angina is prescribed propranolol (Inderal). You should question the order when noticing what in the patient's history? A. Taking sildenafil (Viagra) B. Taking an angiotensin-converting enzyme (ACE) inhibitor C. History of myocardial infarction D. Asthma

ANS: D Patients with asthma should avoid β-adrenergic blockers because they can contribute to bronchoconstriction and wheezing. Viagra is avoided in patients taking nitrates. Reference: 776

You are administering the prescribed fibrinolytic agent to a patient diagnosed with an acute MI. You should stop the therapy and notify the physician when observing what patient manifestation? A. Bleeding from the intravenous (IV) line site B. Accelerated idioventricular rhythm C. Elevated ST segment on the ECG D. Sudden change in level of consciousness

ANS: D Signs and symptoms of major bleeding require the therapy to be stopped. A major complication of fibrinolytic therapy is bleeding. Signs and symptoms of major bleeding include a drop in blood pressure, an increase in heart rate, a sudden change in the patient's level of consciousness, or blood in the urine or stool. Minor bleeding can be controlled by applying a pressure dressing or ice pack. Reperfusion dysrhythmias are generally self-limiting and do not require aggressive treatment. Elevated ST segment on the ECG indicates an MI and need for the treatment. Reference: 783

6. Which statement made by a patient with coronary artery disease after the nurse has completed teaching about therapeutic lifestyle changes (TLC) diet indicates that further teaching is needed? a. "I will switch from whole milk to 1% milk." b. "I like salmon and I will plan to eat it more often." c. "I can have a glass of wine with dinner if I want one." d. "I will miss being able to eat peanut butter sandwiches."

ANS: D Although only 30% of the daily calories should come from fats, most of the fat in the TLC diet should come from monosaturated fats such as are found in nuts, olive oil, and canola oil. The patient can include peanut butter sandwiches as part of the TLC diet. The other patient comments indicate a good understanding of the TLC diet.

11. Nadolol (Corgard) is prescribed for a patient with chronic stable angina and left ventricular dysfunction. To determine whether the drug is effective, the nurse will monitor for a. decreased blood pressure and heart rate. b. fewer complaints of having cold hands and feet. c. improvement in the strength of the distal pulses. d. the ability to do daily activities without chest pain.

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

36. A patient had a non-ST-segment-elevation myocardial infarction (NSTEMI) 3 days ago. Which nursing intervention included in the plan of care is most appropriate for the registered nurse (RN) to delegate to an experienced licensed practical/vocational nurse (LPN/LVN)? a. Evaluation of the patient's response to walking in the hallway b. Completion of the referral form for a home health nurse follow-up c. Education of the patient about the pathophysiology of heart disease d. Reinforcement of teaching about the purpose of prescribed medications

ANS: D LPN/LVN education and scope of practice include reinforcing education that has previously been done by the RN. Evaluating the patient response to exercise after a NSTEMI requires more education and should be done by the RN. Teaching and discharge planning/ documentation are higher level skills that require RN education and scope of practice.

43. After reviewing a patient's history, vital signs, physical assessment, and laboratory data, which information shown in the accompanying figure is most important for the nurse to communicate to the health care provider? a. Q waves on ECG b. Elevated troponin levels c. Fever and hyperglycemia d. Tachypnea and crackles in lungs

ANS: D Pulmonary congestion and tachypnea suggest that the patient may be developing heart failure, a complication of myocardial infarction (MI). Mild fever and hyperglycemia are common after MI because of the inflammatory process that occurs with tissue necrosis. Troponin levels will be elevated for several days after MI. Q waves often develop with ST-segment-elevation MI.

31. When caring for a patient with acute coronary syndrome who has returned to the coronary care unit after having angioplasty with stent placement, the nurse obtains the following assessment data. Which data indicate the need for immediate action by the nurse? a. Heart rate 102 beats/min b. Pedal pulses 1+ bilaterally c. Blood pressure 103/54 mm Hg d. Chest pain level 7 on a 0 to 10 point scale

ANS: D The patient's chest pain indicates that restenosis of the coronary artery may be occurring and requires immediate actions, such as administration of oxygen and nitroglycerin, by the nurse. The other information indicates a need for ongoing assessments by the nurse.

38. After receiving change-of-shift report about the following four patients, which patient should the nurse assess first? a. 39-year-old with pericarditis who is complaining of sharp, stabbing chest pain b. 56-year-old with variant angina who is to receive a dose of nifedipine (Procardia) c. 65-year-old who had a myocardial infarction (MI) 4 days ago and is anxious about the planned discharge d. 59-year-old with unstable angina who has just returned to the unit after having a percutaneous coronary intervention (PCI)

ANS: D This patient is at risk for bleeding from the arterial access site for the PCI, so the nurse should assess the patient's blood pressure, pulse, and the access site immediately. The other patients should also be assessed as quickly as possible, but assessment of this patient has the highest priority.

8. A patient who has had chest pain for several hours is admitted with a diagnosis of rule out acute myocardial infarction (AMI). Which laboratory test should the nurse monitor to help determine whether the patient has had an AMI? a. Myoglobin b. Homocysteine c. C-reactive protein d. Cardiac-specific troponin

ANS: D Troponin levels increase about 4 to 6 hours after the onset of myocardial infarction (MI) and are highly specific indicators for MI. Myoglobin is released within 2 hours of MI, but it lacks specificity and its use is limited. The other laboratory data are useful in determining the patient's risk for developing coronary artery disease (CAD) but are not helpful in determining whether an acute MI is in progress.

The telemetry nurse notes eight premature ventricular contractions per minute, often with two occurring together, on the patient's electrocardiograph tracing. Why will lidocaine be administered? A. To limit cardiac tissue remodeling B. To prevent ventricular fibrillation C. To promote cardiac conduction D. To stimulate atrial contractility

ANS:B Premature ventricular contractions may precede ventricular tachycardia and fibrillation. These ventricular dysrhythmias are often lethal and need to be prevented. Ventricular remodeling is normal myocardium compensation after an MI. The normal cardiac tissue hypertrophies and dilates after an MI to compensate for the damaged tissue. Reference: 780

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

a) A 45-year-old depressed male with a high-stress job The 45-year-old depressed male with a high-stress job is at the highest risk for CAD. Studies demonstrate that depression and stressful states can contribute to the development of CAD. Elevated HDL levels and low homocysteine levels actually help to prevent CAD. Although a sedentary lifestyle is a risk factor, a BMI of 23 kg/m2 depicts normal weight, and thus the patient with two risk factors is at greatest risk for developing CAD.

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

a) Oxygen, nitroglycerin, aspirin, and morphine 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 community health nurse is planning health promotion teaching targeted at preventing coronary artery disease (CAD). Which ethnic group would the nurse select as the highest priority for this intervention? a) White male b) Hispanic male c) African American male d) Native American female

a) White male The incidence of CAD and myocardial infarction (MI) is highest among white, middle-aged men. Hispanic individuals have lower rates of CAD than non-Hispanic whites or African Americans. African Americans have an earlier age of onset and more severe CAD than whites and more than twice the mortality rate of whites of the same age. Native Americans have increased mortality in less than 35-year-olds and have major modifiable risk factors such as diabetes.

Which antilipemic medications should the nurse question for a patient with cirrhosis of the liver (select all that apply)? a) Niacin (Nicobid) b) Ezetimibe (Zetia) c) Gemfibrozil (Lopid) d) Atorvastatin (Lipitor) e) Cholestyramine (Questran)

b & d 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.

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

b) "I can take up to five tablets every 3 minutes for relief of my chest pain." The recommended dose of nitroglycerin is one tablet taken sublingually (SL) or one metered spray for symptoms of angina. If symptoms are unchanged or worse after 5 minutes, the patient should be instructed to activate the emergency medical services (EMS) system. If symptoms are improved, repeat the nitroglycerin every 5 minutes for a maximum of three doses and contact EMS if symptoms have not resolved completely.

The patient comes to the ED with severe, prolonged angina that is not immediately reversible. The nurse knows that if the patient once had angina related to a stable atherosclerotic plaque and the plaque ruptures, there may be occlusion of a coronary vessel and this type of pain. How will the nurse document this situation related to pathophysiology, presentation, diagnosis, prognosis, and interventions for this disorder? a) Unstable angina b) Acute coronary syndrome (ACS) c) ST-segment-elevation myocardial infarction (STEMI) d) Non-ST-segment-elevation myocardial infarction (NSTEMI)

b) Acute coronary syndrome (ACS) The pain with ACS is severe, prolonged, and not easy to relieve. ACS is associated with deterioration of a once-stable atherosclerotic plaque that ruptures, exposes the intima to blood, and stimulates platelet aggregation and local vasoconstriction with thrombus formation. The unstable lesion, if partially occlusive, will be manifest as unstable angina or NSTEMI. If there is total occlusion, it is manifest as a STEMI.

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

b) Discussed along with other physical activities 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 individual patient's questions and concerns.

In teaching a patient about coronary artery disease, 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, especially low-density lipoproteins c. accumulation of lipid and fibrous tissue within the coronary arteries d. development of angina due to a decreased blood supply to the heart muscle e. chronic vasoconstriction of coronary arteries leading to permanent vasospasm

b, c, & d

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

b, c, d, & e During the initial phase of an MI, catecholamines are released from the ischemic myocardial cells, causing increased sympathetic nervous system (SNS) 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) as a result 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.

The nurse is caring for a patient who is 2 days post-MI. The patient reports that she is experiencing chest pain. She states, "It hurts when I take a deep breath." Which action would be a priority? a. Notify the physician STAT and obtain a 12-lead ECG. b. Obtain vital signs and auscultate for a pericardial friction rub. c. Apply high-flow oxygen by face mask and auscultate breath sounds. d. Medicate the patient with PRN analgesic and reevaluate in 30 minutes.

b. Obtain vital signs and auscultate for a pericardial friction rub.

In caring for the patient with angina, the patient said, "I walked to the bathroom. 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, but the pain is gone now." What further assessment data should the nurse obtain from the patient? a) "What precipitated the pain?" b) "Has the pain changed this time?" c) "In what areas did you feel this pain?" d) "Rate the pain on a scale from 0 to 10, with 0 being no pain and 10 being the worst pain you can imagine."

c) "In what areas did you feel this pain?" 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.

The nurse assesses the right femoral artery puncture site as soon as the patient arrives after having 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? a) Palpate the insertion site for induration. b) Assess peripheral pulses in the right leg. c) Inspect the patient's right side and back. d) Compare the color of the left and right legs.

c) Inspect the patient's right side and back. 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.

The patient is being dismissed from the hospital after ACS and will be attending rehabilitation. What information does the patient need to be taught about the early recovery phase of rehabilitation? a) Therapeutic lifestyle changes should become lifelong habits. b) Physical activity is always started in the hospital and continued at home. c) Attention will focus on management of chest pain, anxiety, dysrhythmias, and other complications. d) Activity level is gradually increased under cardiac rehabilitation team supervision and with ECG monitoring.

d) Activity level is gradually increased under cardiac rehabilitation team supervision and with ECG monitoring. 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 MI, 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.

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

d) Acute myocardial infarction PCI is indicated to restore coronary perfusion in cases of myocardial infarction. Chronic stable angina and CAD are normally treated with more conservative measures initially. PCI is not relevant to the pathophysiology of heart failure, such as left-sided heart failure.

A patient was admitted to the emergency department (ED) 24 hours earlier with complaints of chest pain that were subsequently attributed to ST-segment-elevation myocardial infarction (STEMI). What complication of MI should the nurse anticipate? a) Unstable angina b) Cardiac tamponade c) Sudden cardiac death d) Cardiac dysrhythmias

d) Cardiac dysrhythmias The most common complication after MI is dysrhythmias, which are present in 80% of patients. 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.

A patient experienced sudden cardiac death (SCD) and survived. What should the nurse expect to be used as preventive treatment for the patient? a) External pacemaker b) An electrophysiologic study (EPS) c) Medications to prevent dysrhythmias d) Implantable cardioverter-defibrillator (ICD)

d) Implantable cardioverter-defibrillator (ICD) 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.

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

d) Keep Hgb A1C less than 7%. 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.

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

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

The patient with Prinzmetal's angina is being managed with a calcium channel blocker. The patient is also on Lanoxin (digoxin). Which statement is most important for you to follow-up? A. "Everything now looks fuzzy to me." B. "I cannot perform like I use to." C. "I gained weight this week." D. "I have no interest in things."

ANS: A Calcium channel blockers potentiate the action of digoxin by increasing serum digoxin levels during the first week of therapy. Halo vision is a sign of digoxin toxicity. The others are side effects of antihypertensives but are not as serious. Reference: 776, 807

After teaching about ways to decrease risk factors for CAD, you recognize that additional instruction is needed when the patient says the following: A. "I would like to add weight lifting to my exercise program." B. "I can keep my blood pressure normal only with medication." 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."

ANS: A Risk factors for CAD include elevated serum lipids, elevated blood pressure, tobacco use, physical inactivity, obesity, diabetes, metabolic syndrome, psychologic states, and elevated homocysteine levels. Weight lifting is not a cardiac-protective exercise. An example of health-promoting regular physical activity is brisk walking (3 to 4 miles/hr) for at least 30 minutes five or more times per week. Reference: 761-763

29. When caring for a patient who has just arrived on the medical-surgical unit after having cardiac catheterization, which nursing intervention should the nurse delegate to a licensed practical/vocational nurse (LPN/LVN)? a. Give the scheduled aspirin and lipid-lowering medication. b. Perform the initial assessment of the catheter insertion site. c. Teach the patient about the usual postprocedure plan of care. d. Titrate the heparin infusion according to the agency protocol.

ANS: A Administration of oral medications is within the scope of practice for LPNs/LVNs. The initial assessment of the patient, patient teaching, and titration of IV anticoagulant medications should be done by the registered nurse (RN).

19. Three days after experiencing a myocardial infarction (MI), a patient who is scheduled for discharge asks for assistance with hygiene activities, saying, "I am too nervous to take care of myself." Based on this information, which nursing diagnosis is appropriate? a. Ineffective coping related to anxiety b. Activity intolerance related to weakness c. Denial related to lack of acceptance of the MI d. Disturbed personal identity related to understanding of illness

ANS: A The patient data indicate that ineffective coping after the MI caused by anxiety about the impact of the MI is a concern. The other nursing diagnoses may be appropriate for some patients after an MI, but the data for this patient do not support denial, activity intolerance, or disturbed personal identity.

You are providing teaching to a patient recovering from an MI. Discussion regarding resumption of sexual activity should be A. delegated to the primary care provider. B. discussed along with other physical activities. C. avoided because it is embarrassing to the patient. D. accomplished by providing the patient with written material.

ANS: B 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 individual patient's questions and concerns. Reference: 792

A patient in the emergency department with chest pain that is unrelieved by nitroglycerin is diagnosed with an acute MI. Why is IV morphine now prescribed? A. To relieve the chest pain B. To decrease cardiac workload C. To depress respirations D. To prevent ventricular remodeling

ANS: B Morphine is given as a vasodilator to decrease the cardiac workload by lowering myocardial oxygen consumption, reducing contractility, and decreasing blood pressure and heart rate. It also helps to reduce anxiety and fear. The pain from an MI is from ischemia, and efforts are directed at improving perfusion and oxygenation of tissue rather than at masking the pain. Respiration depression is a side effect that you monitor for. Oxygenation is of prime importance. Ventricular remodeling is part of the healing process later on and a reason for an angiotensin-converting enzyme (ACE) inhibitor to be prescribed. Reference: 775

You are examining the ECG of a patient who has just been admitted with a suspected MI. Which ECG change is most indicative of prolonged or complete coronary occlusion? A. Sinus tachycardia B. Pathologic Q wave C. Fibrillatory P waves D. Prolonged PR interval

ANS: B The presence of a pathologic Q wave, as often accompanies STEMI, indicates 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. Reference: 780

40. Which patient at the cardiovascular clinic requires the most immediate action by the nurse? a. Patient with type 2 diabetes whose current blood glucose level is 145 mg/dL b. Patient with stable angina whose chest pain has recently increased in frequency c. Patient with familial hypercholesterolemia and a total cholesterol of 465 mg/dL d. Patient with chronic hypertension whose blood pressure today is 172/98 mm Hg

ANS: B The history of more frequent chest pain suggests that the patient may have unstable angina, which is part of the acute coronary syndrome spectrum. This will require rapid implementation of actions such as cardiac catheterization and possible percutaneous coronary intervention. The data about the other patients suggest that their conditions are stable.

22. When evaluating the effectiveness of preoperative teaching with a patient scheduled for coronary artery bypass graft (CABG) surgery using the internal mammary artery, the nurse determines that additional teaching is needed when the patient says which of the following? a. "They will circulate my blood with a machine during the surgery." b. "I will have small incisions in my leg where they will remove the vein." c. "They will use an artery near my heart to go around the area that is blocked." d. "I will need to take an aspirin every day after the surgery to keep the graft open."

ANS: B When the internal mammary artery is used there is no need to have a saphenous vein removed from the leg. The other statements by the patient are accurate and indicate that the teaching has been effective.

The patient hospitalized with unstable angina exhibits signs of anxiety. What should you ask or tell the patient? A.Why are you feeling anxious? B. Modern medicine can help heart conditions so effectively these days. C. Fear of dying is a common concern for patients with your condition. D. What information do you need to know about your disease?

ANS: C All patients with acute coronary syndrome (ACS) have anxiety. Frequently, the patient cannot verbalize the most pervasive concern: "Am I going to die?" It is helpful for you to initiate conversation by remarking that fear of dying is a common concern among most patients who have ACS. Reference: 788

What is considered a risk factor for sudden cardiac death (SCD) without having any manifestations of an acute MI? A. Female gender B. Family history of heart attacks C. Diabetes mellitus D. Asthma

ANS: C It is difficult to predict who is at risk for SCD. However, left ventricular dysfunction (ejection fraction less than 30%) and ventricular dysrhythmias after an MI have been found to be the strongest predictors. Other risk factors for SCD include male gender (especially African American men), family history of premature atherosclerosis, tobacco use, diabetes mellitus, hypercholesterolemia, hypertension, and cardiomyopathy. Reference: 793

The most common finding in individuals at risk for sudden cardiac death is A. aortic valve disease. B. mitral valve disease. C. left ventricular dysfunction. D. atherosclerotic heart disease.

ANS: C Left ventricular dysfunction (ejection fraction <30%) and ventricular dysrhythmias after an MI are the strongest predictors of SCD. Reference: 793

The patient presents to the emergency department with crushing chest pain. The electrocardiogram (ECG) is completed within 5 minutes and is normal. What future action is most important? A. Administer 30 mL of antacid. B. Reassure the patient. C. Repeat the ECG later. D. Obtain blood for a complete blood cell (CBC) count.

ANS: C The normal progression is ischemia, injury, infarction, and resolution of the infarction. Initial ECG results can be negative, but serial ECGs may show the injury and infarction. When an initial 12-lead ECG is nondiagnostic, serial 12-lead ECGs are done every 2 to 4 hours. Reference: 780

30. Which electrocardiographic (ECG) change is most important for the nurse to report to the health care provider when caring for a patient with chest pain? a. Inverted P wave b. Sinus tachycardia c. ST-segment elevation d. First-degree atrioventricular block

ANS: C The patient is likely to be experiencing an ST-segment-elevation myocardial infarction (STEMI). Immediate therapy with percutaneous coronary intervention (PCI) or thrombolytic medication is indicated to minimize myocardial damage. The other ECG changes may also suggest a need for therapy, but not as rapidly.

For which antilipemic medication would you question an order for a patient with cirrhosis of the liver? A. Niacin (Nicobid) B. Ezetimibe (Zetia) C. Gemfibrozil (Lopid) D. Atorvastatin (Lipitor)

ANS: D Adverse effects of atorvastatin, a statin drug, include liver damage and myopathy. Liver enzymes must be monitored frequently, and the medication should be stopped if these enzyme levels increase. Liver disease is a contraindication for using atorvastatin. Reference: 770

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

ANS: D Canned soups contain very high sodium levels. Patients need to be taught to read food labels for sodium and fat content. Reference: 768

The patient had an SCD incident caused by a lethal rhythm and now has an implantable cardioverter-defibrillator (ICD). He arrives in the emergency department today unresponsive and in ventricular fibrillation. What action should you take? A. Administer amiodarone (Cordarone). B. Administer epinephrine. C. Check the ICD's battery. D. Defibrillate.

ANS: D If the patient is in ventricular fibrillation and unresponsive, the ICD is not working. Defibrillation is the only effective means to treat ventricular fibrillation initially, not drugs. Amiodarone is used in treating patients with a history of SCD after the initial episode. Reference: 793-794

A patient is admitted to the ICU with a diagnosis of unstable angina. Which medication(s) would the nurse expect the patient to receive (select all that apply)? a. ACE Inhibitor b. Antiplatelet Therapy c. Thrombolytic therapy d. Prophylactic antibiotics e. Intravenous nitroglycerin

a, b, & e

After teaching about ways to decrease risk factors for CAD, the nurse recognizes that additional instruction is needed when the patient says: a. "I would like to add weight lifting to my exercise program." b. "I can only keep my blood pressure normal with medication." 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."

a. "I would like to add weight lifting to my exercise program."

The nurse is examining the ECG of a patient who has just been admitted with a suspected MI. Which ECG change is most indicative of prolonged or complete coronary occlusion? a) Sinus tachycardia b) Pathologic Q wave c) Fibrillatory P waves d) Prolonged PR interval

b) Pathologic Q wave 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 hospitalized patient with a history 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 myocardial infarction b. will be relieved by rest, nitroglycerin, or both c. indicates that irreversible myocardial damage is occurring d. is frequently associated with vomiting and extreme fatigue

b. will be relieved by rest, nitroglycerin, or both