Chapter 47: Lipid-Lowering Agents
The nurse conducts a review of research related to Beta-hydroxy-beta-methylglutaryl coenzyme A inhibitors and finds the only one associated with data to show a reduction in coronary artery disease and incidence of myocardial infarction is what drug? A) Pravastatin (Pravachol) B) Lovastatin (Mevacor) C) Atorvastatin (Lipitor) D) Fluvastatin (Lescol)
A Feedback: Pravastatin is the only statin with outcome data to show effectiveness in decreasing coronary artery disease and incidence of myocardial infarction (MI); it prevents a first MI even in patients who do not have a documented elevated cholesterol level. The other medications do not have any evidence of effectiveness for this patient.
The nurse is engaged in patient teaching about a newly prescribed bile acid sequestrant that may be mixed with a carbonated beverage. What bile acid sequestrant is the nurse describing? A) Cholestyramine (Questran) B) Colesevelam (Welchol) C) Colestipol (Colestid) D) Ezetimibe (Zetia)
C Feedback: Colestipol can be mixed with a carbonated beverage. The mixture should be stirred and all of the liquid should be swallowed. Ezetimibe is a cholesterol absorption inhibitor and comes in tablet form. The other two options are bile acid sequestrants, but should not be taken with carbonated beverages. The carbonation interferes with the absorption of the drug.
The nurse teaches the patient at risk for coronary artery disease (CAD) that some risk factors can be controlled or modified. What modifiable factors would the nurse include? A) Gender, obesity, family history, and smoking B) Inactivity, stress, gender, and smoking C) Obesity, inactivity, diet, and smoking D) Stress, family history, and obesity
C Feedback: The risk factors for CAD that can be controlled or modified include obesity, inactivity, diet, stress, and smoking. Gender and family history are risk factors that cannot be controlled.
The nurse is taking a health history on a 38-year-old man who is taking atorvastatin (Lipitor) for high cholesterol. What will the nurse question specifically related to the safe use of this drug? A) Alcohol B) Nicotine C) Caffeine D) Herbal therapy
A Feedback: Beta-hydroxy-beta-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors are contraindicated with active liver disease or a history of alcohol-related liver disease so it is important for the nurse to ask about the patients use of alcohol. Nicotine, caffeine, and herbal therapies are usually not identified as producing any drugdrug interactions with atorvastatin.
The nurse cares for a patient who is in her second trimester of pregnancy with extremely high serum cholesterol levels. What lipid lowering medication would be appropriate for the nurse to administer to this patient? A) Colesevelam (Welchol) B) Pravastatin (Pravachol) C) Simvastatin (Zocor) D) Atorvastatin (Lipitor)
A Feedback: Bile acid sequestrants are the drug of choice for pregnant women if a lipid-lowering agent is needed. Women of child-bearing age should not take beta-hydroxy-beta-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors because they are in Pregnancy Category X. Pravastatin, simvastatin, and atorvastatin are all HMG-CoA reductase inhibitors.
The nurse is caring for an obese patient with hyperlipidemia who has tried to modify his diet to lose weight and control serum lipid levels without success. He is currently taking a combination of medications but his total cholesterol remains above 200. What future therapy might help this patient? A) Endocannabinoid blocker B) Bile acid sequestrant with niacin C) Beta-hydroxy-beta-methylglutaryl coenzyme A (HMG-CoA) reductase and gemfibrozil D) Peroxisome proliferator receptor alpha activator
A Feedback: Blocking the endocannabinoid system results in feelings of satiety and decreased appetite, leading to weight loss; decreased release of growth hormone, increased oxygen and glucose use in the muscle, decreased fat synthesis in the liver, decreased levels of triglycerides and low density lipoproteins, and increased levels of high density lipoproteins, improving the lipid profile; increased sensitivity of insulin receptor sites, leading to decreased blood glucose levels; decreased fat production and storage; increased levels of adiponectin; and decreased activity of tumor necrosis factor, a proinflammatory agent, and decreased activity of C-reactive protein, which is associated with proinflammatory and prothrombotic states. Combining bile acid sequestrant with niacin or HMG-CoA with gemfibrozil is contraindicated. Peroxisome proliferator receptor alpha activators help to control lipid levels but do not contribute to dietary changes and appetite suppression.
A patient is diagnosed as having an elevated cholesterol level. The nurse is aware that plaque on the inner lumen of arteries begins as what? A) Fatty streaks B) White blood cells (WBCs) C) Foam cells D) Platelets and fibrin
A Feedback: Coronary artery disease is characterized by the progressive growth of atheromatous plaques, or atheromas, in the coronary arteries. These plaques, which begin as fatty streaks in the endothelium, eventually injure the endothelial lining of the artery, causing an inflammatory reaction. This inflammatory process triggers the development of characteristic foam cells, containing fats and WBCs that further injure the endothelial lining. Over time, platelets, fibrin, other fats, and remnants collect on the injured vessel lining and cause the atheroma to grow, further narrowing the interior of the blood vessel and limiting blood flow.
A patient tells the nurse he has had an exacerbation of hemorrhoidal irritation. What drug would the nurse suspect is most likely to contribute to this adverse effect? A) Bile acid sequestrants B) Beta-hydroxy-beta-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors C) Cholesterol absorption inhibitor D) Fibrates
A Feedback: Direct gastrointestinal (GI) irritation, including nausea, constipation that may progress to fecal impaction, and aggravation of hemorrhoids, may occur with use of bile acid sequestrants. GI irritation, and specifically irritation of hemorrhoids is not associated with use of HMG-CoA reductase inhibitors, cholesterol absorption inhibitors, or fibrates.
What are the most common adverse effects of lovastatin (Mevacor)? A) Nausea, flatulence, and constipation B) Increased appetite and blood pressure C) Confusion and mental disorientation D) Hiccups, sinus congestion, and dizziness
A Feedback: GI problems such as nausea, vomiting, flatulence, constipation, or diarrhea can occur with lovastatin. Increased appetite is not associated with lovastatin but patients may think that taking this drug means they can now eat anything they want and this would indicate the need for further teaching. Confusion and mental disorientation are not associated with this drug. Hiccups, sinus congestion, and dizziness would require exploration for cause because they are not normally associated with lovastatin therapy.
The nurse explains the action of a beta-hydroxy-beta-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitor as inhibiting what? A) An enzyme that controls the final step in production of cellular cholesterol B) An enzyme used immediately for energy C) An enzyme that combines with proteins to become chylomicrons D) An enzyme used to make bile acids
A Feedback: HMG-CoA reductase is an enzyme that controls the final step in production of cellular cholesterol. Some fats are used immediately for energy. Bile acids act like detergents to break down or metabolize fats into small molecules called micelles, which are absorbed into the intestinal wall and combined with proteins to become chylomicrons, to allow transport throughout the circulatory system. Cholesterol is a fat that is used make bile acids.
The nurse is teaching a 45-year-old patient about ways to lower cholesterol levels and explains that exercise has what effect? A) Increases high density lipoproteins (HDLs) and decreases low density lipoproteins (LDL) B) Increases LDL and decreases triglycerides C) Decreases HDL and increases LDL D) Decreases both HDL and LDL
A Feedback: Moderate exercise increases HDL levels, which assist in lowering LDL levels. Exercise also decreases triglyceride levels.
The nurse is providing medication teaching to a patient who will begin taking niacin with a bile acid sequestrant. How does the nurse instruct the patient to take these two medications? A) "Both medications should be taken 4 to 6 hours apart." B) "Both medications should be taken in the morning." C) "One medication should be taken in the morning but the other is taken at bedtime." D) "Both medications can be taken at once just before going to bed."
A Feedback: When niacin is prescribed with a bile acid sequestrant, the patient should be told to take the two medications 4 to 6 hours apart in the evening, with the niacin normally taken first.
When providing patient teaching to a patient beginning therapy with a beta-hydroxy-beta-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitor, the nurse will explain the need for regular monitoring of what laboratory studies? (Select all that apply.) A) Renal function tests B) Liver function tests C) Lipid panel D) Hemoccult of stool E) Albumin level
A,B,C Feedback: It is important to monitor renal and liver function to identify early signs of toxicity or rhabdomyolysis. Monitoring lipid levels contributes to evaluation of the effectiveness of drug therapy. Hemoccult of stool would be more important with bile acid sequestrants that are associated with GI irritation. Altered albumin levels are not associated with HMG-CoA reductase inhibitors.
The patient receives a prescription for a lipid lowering medication from the health care provider and, before discharge, asks the nurse what else he or she can do to improve his or her lipid levels besides just taking medication. What recommendation will the nurse make? (Select all that apply.) A) Quitting smoking B) Exercising C) Following a low sodium diet D) Reducing stress E) Avoiding alcohol
A,B,D Feedback: Lifestyle changes including low-fat diet, exercise, smoking cessation, and stress reduction should be tried before any antihyperlipidemic drug is used. Avoiding alcohol is not indicated as a means to lower serum lipid levels. Although a low sodium diet is a healthy choice, it is not associated with elevating lipid levels.
The nurse provides patient teaching related to medication and lifestyle changes the patient can make to reduce serum lipid levels. One month later, the nurse evaluates the patient teaching as having been effective based on what data? (Select all that apply.) A) Total cholesterol 184 B) High density lipoprotein (HDL) cholesterol 84 C) Low density lipoprotein (LDL) cholesterol 164 D) Triglycerides 184 E) Weight loss of 8 pounds
A,B,E Feedback: Serum lab levels within the desirable level would indicate the teaching was effective; they include a total cholesterol level of less than 200, an HDL cholesterol level of higher than 40, an LDL cholesterol level of less than 129, and a triglyceride level of less than 50. Weight loss is also a positive outcome.
The nurse is teaching the patient how to reduce risk for coronary artery disease (CAD). What condition does the nurse encourage the patient to control in order to reduce CAD risk? (Select all that apply.) A) Obesity B) Hypertension C) Bradycardia D) Depression E) High stress levels
A,B,E Feedback: Successful treatment in reducing risk for CAD involves reducing risk factors including decreasing dietary fats (decreasing total fat intake and limiting saturated fats seems to have the most impact on serum lipid levels); losing weight, which helps to decrease insulin resistance and the development of type 2 diabetes; eliminating smoking; increasing exercise levels; decreasing stress; and treating hypertension, diabetes, and gout. Depression and bradycardia have not been linked to CAD.
The patient asks the nurse what atorvastatin (Lipitor), newly prescribed, will do. What expected outcome will the nurse describe? A) Decrease in serum cholesterol only B) Decrease in serum cholesterol and low density lipoprotein (LDL) levels C) Decrease in sitosterol and serum cholesterol D) Decrease in campesterol and LDL levels
B Feedback: Atorvastatin is a beta-hydroxy-beta-methylglutaryl coenzyme A reductase inhibitor and should lower serum cholesterol and LDL levels as well as prevention of a first myocardial infarction and slow the progression of coronary artery disease. A decrease in serum cholesterol alone would result from the use of a bile acid sequestrant. A cholesterol absorption inhibitor would also decrease sitosterol and campesterol levels as well as decrease levels of serum cholesterol and LDL.
A patient is being discharged on cholestyramine (Questran). Patient teaching should include what about this medication? A) Should be administered with other medications B) Should be administered 1 hour before or 4 to 6 hours after other medications C) Should be administered 1 hour after other medications D) Should be administered on an empty stomach
B Feedback: Gemfibrozil inhibits peripheral breakdown of lipids, reduces production of triglycerides and LDLs, and increases HDL concentrations. It is associated with gastrointestinal (GI) and muscle discomfort. Fenofibrate, niacin, and atorvastatin do not increase HDL concentrations.
The nurse is preparing a patient for discharge who will receive a prescription for an beta-hydroxy-beta-methylglutaryl coenzyme A (HMG-CoA) inhibitor. What statement by the patient demonstrates that they have a clear understanding of the teaching provided by the nurse? A) "I will not need to follow that low-fat diet anymore because this drug will take care of my lipids." B) "I should plan to take this drug before bedtime, because my body makes lipids mostly at night." C) "After I start taking this drug, I will not have to worry about the exercise routine the doctor prescribed." D) "I should take this drug first thing in the morning and make sure I drink a full glass of water."
B Feedback: HMG-CoA inhibitors should be taken at bedtime because the body produces lipids mostly at night. Diet and exercise are still important when taking these drugs because the drug is most effective in combination with other lipid-lowering actions.
The patient receives a prescription for niacin and the nurse is teaching his or her about the medication. The nurse instructs the patient to call the provider if what common adverse effect of niacin occurs? A) Hypotension B) Abdominal pain C) Vomiting D) Diarrhea
B Feedback: Niacin is associated with intense cutaneous flushing, nausea, and abdominal pain, making its use somewhat limited. It also increases serum levels of uric acid and may predispose patients to the development of gout. Hypotension, vomiting, and diarrhea are not normally associated with the drug.
When planning patient care the nurse recognizes what patient is at greatest risk of developing coronary artery disease? A) A 32-year-old Asian American with total cholesterol of 120 mg/dL B) A 62-year-old white American with total cholesterol of 260 mg/dL C) A 48-year-old African American with total cholesterol of 198 mg/dL D) A 26-year-old Native American with total cholesterol of 150 mg/dL
B Feedback: White Americans have the highest incidence of coronary artery disease (CAD). This patient has total cholesterol of 260 mg/dL, which is considered high according to the Third Report of the National Cholesterol Education Program Expert Panel. The other three patients could be at risk due to cultural risk factors such as hypertension, diabetes, high (HDL) and low density lipoprotein (LDL) levels, and HDL level to cholesterol ratio. However, their total cholesterol levels fall within normal or desirable range.
The nurse cares for a 10-year-old child brought to the clinic for an annual checkup who is diagnosed with hypercholesterolemia. What is the most common cause of hypercholesterolemia in children? A) Gender B) Diet C) Familial connection D) Exercise
C Feedback: Familial hypercholesterolemia may be seen in children. Because of the importance of lipids in the developing nervous system, treatment is usually restricted to tight dietary restrictions to limit fats and calories. Gender, diet, or exercise-resistant hypercholesterolemia is possible in children, but they are not the most common causes.
Which drug is most effective in reducing serum triglyceride levels? A) Beta-hydroxy-beta-methylglutaryl coenzyme A reductase inhibitors B) Bile acid sequestrants C) Fibrates D) Niacin
C Feedback: Fibrates decrease hepatic production of triglycerides. They are the most effective drugs for reducing serum triglycerides. The other options are incorrect.
A patient taking atorvastatin (Lipitor) comes to the clinic with complaints of acute muscle pain not associated with exercise or injury. The nurse will ask questions to determine if this patient has been taking what contraindicated substance? A) Over-the-counter (OTC) medications B) Ginseng C) Grapefruit juice D) Saw palmetto
C Feedback: Grapefruit juice can decrease the breakdown of atorvastatin, leading to increased serum levels and toxic adverse effects, including rhabdomyolysis. Patients on this drug should be cautioned to avoid drinking grapefruit juice. OTC drugs, ginseng, and saw palmetto are not associated with increased toxicity.
A 54-year-old patient has a cholesterol level of 240 mg/dL. How would the nurse categorize this serum concentration of cholesterol? A) Optimal B) Desirable C) High D) Very high
C Feedback: High is rated at or exceeding 240 mg/dL. Levels below 200 mg/dL are considered desirable, although lower levels may be preferred if the patient has a history of coronary artery disease. Low density lipoprotein (LDL) cholesterol below 100 mg/dL is considered optimal, whereas LDL levels above 190 or triglycerides above 500 mg/dL is considered very high.
The nurse is caring for a 35-year-old woman taking a beta-hydroxy-beta-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitor to lower serum lipid levels. When teaching this patient about her medications what priority teaching point will the nurse include in the teaching plan? A) Need for frequent ophthalmic examinations B) Information about a cholesterol-lowering diet C) Use of barrier contraceptives D) Calling her doctor with any respiratory symptoms
C Feedback: It is important to teach a woman of childbearing age taking HMG-CoA reductase inhibitors to use barrier contraceptives because there is a risk of severe fetal abnormalities associated with these drugs if taken during pregnancy. She should have routine ophthalmic examinations but does not need more frequent examinations. Cholesterol lowering diet should have been initiated before beginning medications to lower lipid levels. There are no associated respiratory risks with these medications so she would call the doctor with respiratory symptoms as she normally would.
The nurse is caring for a patient taking ezetimibe (Zetia) and monitors the patient for what common adverse effects? A) Bloating and flank pain B) Neuropathy and flatulence C) Mild abdominal pain and diarrhea D) Constipation and flank pain
C Feedback: The most common adverse effects of ezetimibe are mild abdominal pain and diarrhea. Bloating and flatulence are associated with bile acid sequestrants and the fibrates. Constipation is usually associated with bile acid sequestrants. Neuropathy and flank pain are usually not associated with lipid-lowering agents.
A 9-year-old child has received an order for oral pravastatin (Pravachol) 40 mg/d for genetically linked hyperlipidemia. In preparation for patient teaching concerning this drug, what initial action will the nurse take? A) Ask the parents to be present for the teaching session. B) Determine the appropriate time to discuss the drug with the patient. C) Question the doctor concerning the ordered dosage. D) Review the child's normal daily dietary intake of fatty foods.
C Feedback: The nurse should question the order initially. The dosage is twice the dose for a 9-year-old is expected to receive. The other options are appropriate and would be done. However, out of safety concerns, the nurse would clarify the dosage first.
The nurse is preparing to teach the patient about diet therapy when beginning bile sequestrant medication to lower lipid levels. What important teaching point will the nurse include in the teaching plan? A) Increasing carbohydrate intake B) Reducing protein intake C) Increasing fiber intake D) Reducing fluid intake
C Feedback: The nurse would want to teach this patient to increase fiber intake to avoid constipation that often occurs with this medication. Protein intake does not need to be reduced, but the patient should be taught to avoid fatty protein and instead meet protein needs with vegetable proteins, fish, and lean poultry. Carbohydrate intake should be reduced if weight loss is needed, otherwise no change is needed. Fluid intake should be maintained or increased if there are no diagnoses that would contraindicate fluid intake to help avoid constipation.
The nurse is assessing a patient who reports taking cholestyramine (Questran) mixed with diet cola twice per day. What is an appropriate nursing diagnosis for this patient? A) Acute pain related to central nervous system and GI effects B) Constipation related to GI effects C) Noncompliance related to how the drug is taken D) Deficient knowledge regarding drug therapy
D Feedback: Cholestyramine should be mixed with water or other noncarbonated fluids so the nurse now recognizes the need for medication teaching and chooses the nursing diagnosis related to deficient knowledge. Nothing in this question indicates that the patient is experiencing any adverse effects from the drug so that pain and constipation would not be optimal nursing diagnoses. Until the nurse assesses the patients understanding of how to take the drug, it would be incorrect to assume noncompliance when it may actually be lack of understanding.
The nurse is teaching a patient about a peroxisome proliferator receptor alpha activator named Trilipix (fenofibric acid). The patient asks what this drug does. What is the nurse's best response? A) "Micelles are absorbed into the intestinal wall and combined with proteins to become chylomicrons." B) "The drug makes the liver use cholesterol to produce more bile acids." C) "The drug works in the brush border of the small intestine to prevent the absorption of dietary cholesterol." D) "The drug activates a specific hepatic receptor, resulting in increased breakdown of lipids and reduction in triglyceride levels."
D Feedback: Fenofibric acid is the first drug in this class. It activates a specific hepatic receptor that results in increased breakdown of lipids, elimination of triglyceride-rich particles from the plasma and reduction in the production to an enzyme that naturally inhibits lipid breakdown. The result is seen as a decrease in triglyceride levels, changes in low density lipoprotein production, which makes them more easily broken down in the body, and an increase in high density lipoprotein levels.
The pharmacology instructor asks what drug inhibits peripheral breakdown of lipids, reduces low density lipoproteins (LDLs), and increases high density lipoprotein (HDL) concentrations. What is the correct answer? A) Fenofibrate (Tricor) B) Niacin (Niaspan) C) Atorvastatin (Lipitor) D) Gemfibrozil (Lopid)
D Feedback: Gemfibrozil inhibits peripheral breakdown of lipids, reduces production of triglycerides and LDLs, and increases HDL concentrations. It is associated with gastrointestinal (GI) and muscle discomfort. Fenofibrate, niacin, and atorvastatin do not increase HDL concentrations.
The patient is admitted to the acute care facility with a diagnosis of acute renal failure. While collecting the nursing history the patient reveals he was taking Pravastatin to reduce lipid levels and enjoyed a glass of grapefruit juice every morning. The patient complains of muscle pain. What does the nurse suspect caused this patient's renal failure? A) Gastric ulceration B) Rhabdomyolysis C) Congestive heart failure D) Drug Toxicity
D Feedback: Grapefruit juice increases the risks of toxicity and rhabdomyolysis. However, toxicity would cause liver damage, whereas the breakdown of muscle that occurs with rhabdomyolysis results in kidney damage and acute renal failure. The patient identified no symptoms related to gastric ulceration or congestive heart failure.
The nurse is caring for a patient who takes fluvastatin (Lescol). Which laboratory value should be assessed regularly on this patient? A) Blood urea nitrogen (BUN) B) Complete blood count (CBC) C) Activated partial thromboplastin time D) Liver function studies
D Feedback: Increased concentrations of liver enzymes commonly occur, and acute liver failure has been reported with the use of atorvastatin and fluvastatin. Liver function studies should be monitored at the onset of therapy, at 6 and 12 weeks, and intermittently during course of therapy. The other tests would not be pertinent to this specific drug.
The nurse is caring for a patient with high serum cholesterol and triglyceride levels. In teaching the patient about therapeutic lifestyle changes such as diet and exercise, the nurse explains that the desired goal for cholesterol levels is what? A) High high density lipoprotein (HDL) values and high triglyceride values B) Low soluble fiber C) Elevated blood lipids, fasting glucose less than 100 D) Low low density lipoprotein (LDL) values and high HDL values
D Feedback: The desired goal for cholesterol readings is for a patient to have low LDL and high HDL values. HDL serves as a protective mechanism to reduce cholesterol so higher levels are desirable. High LDL levels increase plaque formation. Fiber does not contribute to risk for coronary artery disease (CAD) although a diet high in fiber is preferable. Elevated blood lipids are never desirable but control of blood sugar levels reduces CAD risk.
