Chapter 37: Coronary Artery Disease and Acute Coronary Syndrome

FINAL EXAM

A patient experienced sudden cardiac death (SCD) and survived. Which treatment would the nurse expect to be implemented to prevent an SCD recurrence at home?

External cardiac pacemaker

An electrophysiologic study (EPS)

Medications to prevent dysrhythmias

Implantable cardioverter-defibrillator (ICD)

Implantable cardioverter-defibrillator (ICD)

Rationale:

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

The nurse would assess a patient with reports of chest pain for which manifestations associated with a myocardial infarction (MI)? (Select all that apply.)

Flushing

Ashen skin

Diaphoresis

Nausea and vomiting

S₃ or S₄ heart sounds

Your Answer:

Ashen skin

Diaphoresis

Nausea and vomiting

S3 or S4 heart sounds

Rationale:

During the initial phase of an MI, catecholamines are released from the ischemic myocardial cells, causing increased sympathetic nervous system stimulation. This results in the release of glycogen, diaphoresis, and vasoconstriction of peripheral blood vessels. Because of this response, the patient’s skin may be ashen, cool, and clammy (not flushed). Nausea and vomiting may result from severe pain reflex stimulation of the vomiting center. Ventricular dysfunction resulting from the MI may lead to the presence of abnormal S₃ and S₄ heart sounds.

The patient has been discharged from the hospital after acute coronary syndrome (ACS) and is beginning a cardiac rehabilitation program. Which focus of care would the nurse plan for the early recovery phase of rehabilitation?

Therapeutic lifestyle changes need to become lifelong habits.

Activity level is gradually increased under supervision and monitoring.

Physical activity started in the hospital will be progressed independently at home.

Attention is on managing chest pain, anxiety, dysrhythmias, and other complications.

Activity level is gradually increased under supervision and monitoring.

Rationale:

In the early recovery phase after the patient is dismissed from the hospital, the activity level gradually increases under supervision and with ECG monitoring. The late recovery phase includes therapeutic lifestyle changes that become lifelong habits. In the hospital, activity is dependent on the severity of the angina or myocardial infarction, and attention is focused on the management of chest pain, anxiety, dysrhythmias, and other complications. With early recovery phase, the cardiac rehabilitation team may suggest that some physical activity be initiated at home, but this is not always done.

Which information would the nurse consider when caring for a female patient with suspected coronary artery disease?

Fatigue may be the first symptom.

Classic signs and symptoms are expected.

Increased risk is present before menopause.

Females are more likely to develop collateral circulation.

Fatigue may be the first symptom.

Rationale:

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

The nurse in the recovery room assesses the right femoral artery puncture site after the patient has a stent inserted into a coronary artery. The insertion site is not bleeding or discolored.

Which action would the nurse take next to ensure the femoral artery is intact?

Palpate the insertion site for induration.

Inspect the patient’s right hip and back.

Assess peripheral pulses in the right leg.

Compare the color of the left and right legs.

Inspect the patient’s right hip and back.

Rationale:

The best method to determine that the right femoral artery is intact after inspection of the insertion site is to logroll the patient to inspect the right hip 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 nurse providing postoperative care for a patient after coronary artery bypass graft (CABG) surgery would monitor for which common complication?

Dehydration

Paralytic ileus

Atrial dysrhythmias

Acute respiratory distress syndrome

Atrial dysrhythmias

Rationale:

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

Which prescribed antilipemic medications would the nurse question for a patient who has cirrhosis of the liver? (Select all that apply.)

Niacin

Cholestyramine

Ezetimibe (Zetia)

Gemfibrozil (Lopid)

Atorvastatin (Lipitor)

Niacin

Ezetimibe (Zetia)

Gemfibrozil (Lopid)

Atorvastatin (Lipitor)

Rationale:

Ezetimibe (Zetia) should not be used by patients with liver impairment. Adverse effects of atorvastatin (Lipitor), a statin drug, include liver damage and myopathy. Liver enzymes must be monitored frequently, and the medication stopped if these enzymes increase. Niacin’s side effects subside with time, although decreased liver function may occur with high doses. Cholestyramine is safe for long-term use.

Which foods would the nurse encourage patients at risk for coronary artery disease (CAD) to include in their diets? (Select all that apply.)

Tofu

Walnuts

Tuna fish

Whole milk

Orange juice

Tofu

Walnuts

Tuna fish

Rationale:

Tuna fish, tofu, and walnuts are all rich in omega-3 fatty acids, which have been shown to reduce the risks associated with CAD when consumed regularly.

A female patient with type 1 diabetes has chronic stable angina controlled with rest. She states that over the past few months, she has required increasing amounts of insulin. Which goal would the nurse implement when planning care to prevent cardiovascular disease progression?

Exercise almost every day.

Avoid saturated fat intake.

Limit calories to daily limit.

Keep Hgb A1C less than 7%.

Keep Hgb A1C less than 7%.

Rationale:

If the Hgb A1C is kept below 7%, this means that the patient has had good control of her blood glucose over the past 3 months. The patient indicates that increasing amounts of insulin are being required to control her blood glucose. This patient may not be adhering to the dietary guidelines or therapeutic regimen, so teaching about how to maintain diet, exercise, and medications to maintain stable blood glucose levels will be needed to achieve this goal.

The nurse prepares a discharge teaching plan for a patient who has recently been diagnosed with coronary artery disease (CAD). Which priority risk factor would the nurse plan to focus on during the teaching session?

Type A personality

Elevated serum lipids

Family cardiac history

High homocysteine levels

Elevated serum lipids

Rationale:

Dyslipidemia is one of the four major modifiable risk factors for CAD. The other major modifiable risk factors are hypertension, tobacco use, and physical inactivity. Research findings related to psychologic states (i.e., type A personality) as a risk factor for coronary artery disease have been inconsistent. Family history is a nonmodifiable risk factor. High homocysteine levels have been linked to an increased risk for CAD.

Which person would the nurse identify as having the highest risk for coronary artery disease (CAD)?

A 60-yr-old man with low homocysteine levels

A 45-yr-old man with a high-stress job who is depressed

A 54-yr-old woman vegetarian with increased high-density lipoprotein (HDL) levels

A 62-yr-old woman who has a sedentary lifestyle and body mass index (BMI) of 23 kg/m²

A 45-yr-old man with a high-stress job who is depressed

Rationale:

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

The patient with angina tells the nurse, “While I was having a bowel movement, I started having the worst chest pain ever, like before I was admitted. After I called for a nurse, the pain went away.” Which question would be a priority for the nurse to ask the patient?

“What precipitated the pain?”

“Has the pain changed this time?”

“In what areas did you feel the pain?”

“What is your pain level on a 0 to 10 scale?”

“In what areas did you feel the pain?”

Rational:

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 teaches a patient with high cholesterol about natural lipid-lowering therapies. The nurse determines further teaching is necessary when the patient makes which statement?

“Omega-3 fatty acids are helpful in reducing triglyceride levels.”

“I should check with my physician before I start taking any herbal products.”

“Herbal products do not go through as extensive testing as prescription drugs do.”

“I will take garlic instead of my prescription medication to reduce my cholesterol.”

“I will take garlic instead of my prescription medication to reduce my cholesterol.”

Rationale:

Current evidence does not support using garlic in the treatment of elevated cholesterol. Strong evidence supports the use of omega-3 fatty acids for reduction of triglyceride levels. Many herbal products are not standardized, and effects are not predictable. Patients should consult with their health care provider before starting herbal or natural therapies.

A patient admitted 24 hours ago with chest pain is diagnosed with a ST-segment-elevation myocardial infarction (STEMI). Which complication of myocardial infarction would the nurse anticipate?

Dysrhythmias

Unstable angina

Cardiac tamponade

Sudden cardiac death

Dysrhythmias

Rationale:

Dysrhythmias are present in 80% to 90% of patients after myocardial infarction (MI). Unstable angina is considered a precursor to MI rather than a complication. Cardiac tamponade is a rare event, and sudden cardiac death is defined as an unexpected death from cardiac causes. Cardiac dysfunction in the period following an MI would not be characterized as sudden cardiac death.

A patient returns to the unit after a cardiac catheterization. Which nursing care would the registered nurse delegate to the assistant personnel (AP)?

Take vital signs and report abnormal values.

Check for bleeding at the catheter insertion site.

Prepare discharge teaching related to complications.

Notify the health care provider of S-T segment changes.

Take vital signs and report abnormal values.

Rationale:

Vital signs should be delegated to the AP. Assessment of the site, preparation of discharge teaching, and reporting S-T elevation would be registered nurse scope of practice.

Which items would the nurse anticipate administering during emergent care for a patient with a suspected myocardial infarction (MI)?

Oxygen, nitroglycerin, aspirin, and morphine

Aspirin, nitroprusside, dopamine, and oxygen

Oxygen, furosemide (Lasix), nitroglycerin, and meperidine

Nitroglycerin, lorazepam (Ativan), oxygen, and warfarin (Coumadin)

Oxygen, nitroglycerin, aspirin, and morphine

Rationale:

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

The nurse is teaching a patient recovering from a myocardial infarction. How would the nurse present the topic of resuming sexual activity?

Delegated to the primary care provider

Explained along with other physical activities

Avoided because it is embarrassing to the patient

Accomplished by providing the patient with written material

Explained along with other physical activities

Rationale:

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

An older adult patient with a history of prostate cancer and hypertension is in the emergency department with substernal chest pain. Which priority action will the nurse complete before administering sublingual nitroglycerin?

Administer morphine sulfate IV.

Auscultate heart and lung sounds.

Obtain a 12-lead electrocardiogram (ECG).

Assess for coronary artery disease risk factors.

Obtain a 12-lead electrocardiogram (ECG).

Rationale:

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

The nurse recognizes additional teaching is needed when the patient prescribed a low-sodium, low-fat cardiac diet selects which food?

Baked flounder

Angel food cake

Canned chicken noodle soup

Baked potato with margarine

Canned chicken noodle soup

Rationale:

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

The nurse is examining the electrocardiogram (ECG) of a patient just admitted with a suspected myocardial infarction (MI). Which ECG change is most indicative of prolonged or complete coronary occlusion?

Sinus tachycardia

Pathologic Q wave

Fibrillatory P waves

Prolonged PR interval

Pathologic Q wave

Rationale:

The presence of a pathologic Q wave, as often accompanies STEMI, is indicative of complete coronary occlusion. Sinus tachycardia, fibrillatory P waves (e.g., atrial fibrillation), or a prolonged PR interval (first-degree heart block) are not direct indicators of extensive occlusion.

For which condition would the nurse expect that the patient would undergo percutaneous coronary intervention (PCI)?

Chronic stable angina

Left-sided heart failure

Coronary artery disease

Acute myocardial infarction

Acute myocardial infarction

Rationale:

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

The nurse teaches a patient with chronic stable angina about nitroglycerin. Which patient statement would alert the nurse to a need for further teaching?

“I will replace my nitroglycerin supply every 6 months.”

“I can take up to 5 tablets every 3 minutes for relief of my chest pain.”

“I will take acetaminophen (Tylenol) to treat the headache caused by nitroglycerin.”

“I will take nitroglycerin 10 minutes before an activity that usually causes chest pain.”

I can take up to 5 tablets every 3 minutes for relief of my chest pain.”

Rationale:

The recommended dose of nitroglycerin is one tablet taken sublingually (SL) or 1 metered spray for symptoms of angina. If symptoms are unchanged or worse after 5 minutes, the patient should be instructed to activate the emergency medical services (EMS) system. If symptoms are improved, repeat the nitroglycerin every 5 minutes for a maximum of 3 doses and contact EMS if symptoms have not resolved completely.

A male patient with coronary artery disease (CAD) has a low-density lipoprotein (LDL) cholesterol of 98 mg/dL and high-density lipoprotein (HDL) cholesterol of 47 mg/dL. What information would the nurse include in patient teaching?

Increase intake of olive oil.

Reduce total caloric intake.

Consume a diet lower in fats.

Maintain the normal lipid levels.

Maintain the normal lipid levels.

Rationale:

For men, the recommended LDL is less than 100 mg/dL, and the recommended level for HDL is greater than 40 mg/dL. His normal lipid levels should be included in the patient teaching and reinforced. Assessing his need for teaching related to diet should also be done.

A patient has received a bolus dose and an infusion of alteplase (Activase) for an ST-segment elevation myocardial infarction (STEMI). Which finding would be used to evaluate the effectiveness of the medication?

Presence of chest pain

Blood in the urine or stool

Tachycardia with hypotension

Decreased level of consciousness

Presence of chest pain

Rationale:

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

Which patient is at greatest risk for sudden cardiac death (SCD)?

A 52-yr-old black man with left ventricular failureCorrect Answer

A 62-yr-old obese man with diabetes and high cholesterol

A 42-yr-old white woman with hypertension and dyslipidemia

A 72-yr-old Native American woman with a family history of heart disease

A 52-yr-old black man with left ventricular failure

Rationale:

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