C H A P T E R
Nursing Management: Coronary Artery
Chapter 34 Nursing Management: Coronary Artery Disease and Acute Coronary Syndrome 139 9. During a routine health examination, a 48-year-old patient is found to have a total cholesterol level of 224 mg/dL
(5.8 mmol/L) and an LDL level of 140 mg/dL (3.6 mmol/L). What does the nurse teach the patient based on the Therapeutic Lifestyle Changes diet (select all that apply)?
a. Use fat-free milk d. Eliminate intake of simple sugars
b. Abstain from alcohol use e. Avoid egg yolks and foods prepared with whole eggs c. Reduce red meat in the diet
10. To which patients should the nurse teach the Therapeutic Lifestyle Changes diet to reduce the risk of coronary artery disease (CAD)?
a. All patients to reduce CAD risk b. Patients who have experienced an MI
c. Individuals with two or more risk factors for CAD
d. Individuals with a cholesterol level >200 mg/dL (5.2 mmol/L)
11. A 62-year-old woman has prehypertension (BP 142/90 mm Hg) and smokes a pack of cigarettes per day. She has no symptoms of CAD but a recent LDL level was 154 mg/dL (3.98 mmol/L). Based on these findings, the nurse would expect that which treatment plan would be used first for this patient?
a. Diet and drug therapy c. Diet therapy and smoking cessation b. Exercise instruction only d. Drug therapy and smoking cessation 12. What are manifestations of acute coronary syndrome (ACS) (select all that apply)?
a. Dysrhythmia b. Stable angina c. Unstable angina
d. ST-segment-elevation myocardial infarction (STEMI) e. Non–ST-segment-elevation myocardial infarction (NSTEMI)
13. Myocardial ischemia occurs as a result of increased oxygen demand and decreased oxygen supply. What factors and disorders result in increased oxygen demand (select all that apply)?
a. Hypovolemia or anemia
b. Increased cardiac workload with aortic stenosis c. Narrowed coronary arteries from atherosclerosis
d. Angina in the patient with atherosclerotic coronary arteries e. Left ventricular hypertrophy caused by chronic hypertension
f. Sympathetic nervous system stimulation by drugs, emotions, or exertion 14. What causes the pain that occurs with myocardial ischemia?
a. Death of myocardial tissue
b. Dysrhythmias caused by cellular irritability
c. Lactic acid accumulation during anaerobic metabolism d. Elevated pressure in the ventricles and pulmonary vessels
15. What types of angina can occur in the absence of CAD (select all that apply)?
a. Silent ischemia d. Microvascular angina
b. Nocturnal angina e. Chronic stable angina
c. Prinzmetal’s angina
16. Which characteristics describe unstable angina (select all that apply)?
a. Usually precipitated by exertion d. Occurs only when the person is recumbent
b. Unpredictable and unrelieved by rest e. Usually occurs in response to coronary artery spasm c. Characterized by progressive severity
17. Tachycardia that is a response of the sympathetic nervous system to the pain of ischemia is detrimental because it increases oxygen demand and
a. increases cardiac output. c. may lead to atrial dysrhythmias.
b. causes reflex hypotension. d. impairs perfusion of the coronary arteries.
140 Chapter 34 Nursing Management: Coronary Artery Disease and Acute Coronary Syndrome
18. Which effects contribute to making nitrates the first-line therapy for the treatment of angina (select all that apply)?
a. Decrease heart rate (HR) d. Dilate coronary arteries
b. Decrease preload e. Prevent thrombosis of plaques
c. Decrease afterload f. Decrease myocardial contractility
19. The patient has used sublingual nitroglycerin and various long-acting nitrates but now has an ejection fraction of 38% and is considered at a high risk for a cardiac event. Which medication would first be added for vasodilation and to reduce ventricular remodeling?
a. Clopidogrel (Plavix) c. Diltiazem (Cardizem)
b. Captopril (Capoten) d. Metoprolol (Lopressor)
20. When instructing the patient with angina about taking sublingual nitroglycerin tablets, what should the nurse teach the patient?
a. To lie or sit and place one tablet under the tongue when chest pain occurs b. To take the tablet with a large amount of water so it will dissolve right away
c. That if one tablet does not relieve the pain in 15 minutes, the patient should go to the hospital
d. That if the tablet causes dizziness and a headache, stop the medication and call the doctor or go to the hospital 21. When teaching an older adult with CAD how to manage the treatment program for angina, which guidelines does the
nurse use to teach the patient?
a. To sit for 2 to 5 minutes before standing when getting out of bed b. To exercise only twice a week to avoid unnecessary strain on the heart
c. That lifestyle changes are not as necessary as they would be in a younger person d. That aspirin therapy is contraindicated in older adults because of the risk for bleeding 22. When a patient reports chest pain, why must unstable angina be identified and rapidly treated?
a. The pain may be severe and disabling.
b. ECG changes and dysrhythmias may occur during an attack.
c. Atherosclerotic plaque deterioration may cause complete thrombus of the vessel lumen.
d. Spasm of a major coronary artery may cause total occlusion of the vessel with progression to MI.
23. The nurse suspects stable angina rather than MI pain in the patient who reports that his chest pain a. is relieved by nitroglycerin. c. does not radiate to the neck, back, or arms.
b. is a sensation of tightness or squeezing. d. is precipitated by physical or emotional exertion.
24. A patient admitted to the hospital for evaluation of chest pain has no abnormal serum cardiac markers 4 hours after the onset of pain. What noninvasive diagnostic test can be used to differentiate angina from other types of chest pain?
a. 12-lead ECG c. Coronary angiogram
b. Exercise stress test d. Transesophageal echocardiogram
25. A 52-year-old man is admitted to the emergency department with severe chest pain. On what basis would the nurse suspect an MI?
a. He has pale, cool, clammy skin.
b. He reports nausea and vomited once at home.
c. He says he is anxious and has a feeling of impending doom.
d. He reports he has had no relief of the pain with rest or position change.
26. At what point in the healing process of the myocardium following an infarct does early scar tissue result in an unstable heart wall?
a. 2 to 3 days after MI c. 10 to 14 days after MI
b. 4 to 10 days after MI d. 6 weeks after MI
27. To detect and treat the most common complication of MI, what should the nurse do?
a. Measure hourly urine output. c. Use continuous cardiac monitoring.
b. Auscultate the chest for crackles. d. Take vital signs every 2 hours for the first 8 hours.
Chapter 34 Nursing Management: Coronary Artery Disease and Acute Coronary Syndrome 141 28. During the assessment, the nurse identifies crackles in the lungs and an S3 heart sound. Which complication of MI
should the nurse suspect and further investigate?
a. Pericarditis c. Ventricular aneurysm
b. Heart failure d. Papillary muscle dysfunction
29. In the patient with chest pain, which results can differentiate unstable angina from an MI?
a. ECG changes present at the onset of the pain b. A chest x-ray indicating left ventricular hypertrophy
c. Appearance of troponin in the blood 48 hours after the infarct
d. Creatine kinase (CK)-MB enzyme elevations that peak 18 hours after the infarct
30. A second 12-lead ECG performed on a patient 4 hours after the onset of chest pain reveals ST segment elevation.
What does the nurse recognize that this finding indicates?
a. Transient ischemia typical of unstable angina b. Lack of permanent damage to myocardial cells
c. MI associated with prolonged and complete coronary thrombosis d. MI associated with transient or incomplete coronary artery occlusion 31. What describes transmyocardial laser revascularization (TMR)?
a. Structure applied to hold vessels open
b. Requires anticoagulation following the procedure
c. Laser-created channels between left ventricular cavity and coronary circulation d. Surgical construction of new vessels to carry blood beyond obstructed coronary artery
32. Which treatment is used first for the patient with a confirmed MI to open the blocked artery within 90 minutes of arrival to the facility?
a. Stent placement c. Percutaneous coronary intervention (PCI)
b. Coronary artery bypass graft (CABG) d. Transmyocardial laser revascularization (TMR) 33. Delegation Decision: In planning care for a patient who has just returned to the unit following a PCI, the nurse may
delegate which activity to unlicensed assistive personnel (UAP)?
a. Monitor the IV fluids and measure urine output.
b. Check vital signs and report changes in HR, BP, or pulse oximetry.
c. Explain to the patient the need for frequent vital signs and pulse checks.
d. Assess circulation to the extremity used by checking pulses, skin temperature, and color.
34. A patient is scheduled to have CABG surgery. What does the nurse explain to him that is involved with the procedure?
a. A synthetic graft will be used as a tube for blood flow from the aorta to a coronary artery distal to an obstruction.
b. A stenosed coronary artery will be resected and a synthetic arterial tube graft will be inserted to replace the diseased artery.
c. The internal mammary artery will be detached from the chest wall and attached to a coronary artery distal to the stenosis.
d. Reversed segments of a saphenous artery from the aorta will be anastomosed to the coronary artery distal to an obstruction.
35. Collaborative care of the patient with NSTEMI differs from that of a patient with STEMI in that NSTEMI is more frequently initially treated with what?
a. PCI c. Acute intensive drug therapy
b. CABG d. Reperfusion therapy with thrombolytics
36. During treatment with reteplase (Retavase) for a patient with a STEMI, which finding should most concern the nurse?
a. Oozing of blood from the IV site
b. BP of 102/60 mm Hg with an HR of 78 bpm c. Decrease in the responsiveness of the patient
d. Presence of intermittent accelerated idioventricular dysrhythmias
142 Chapter 34 Nursing Management: Coronary Artery Disease and Acute Coronary Syndrome
37. The nurse recognizes that thrombolytic therapy for the treatment of an MI has not been successful when the patient displays which manifestation?
a. Continues to have chest pain
b. Has a marked increase in CK enzyme levels within 3 hours of therapy
c. Develops major gastrointestinal (GI) or genitourinary (GU) bleeding during treatment d. Develops premature ventricular contractions and ventricular tachycardia during treatment
38. When the patient who is diagnosed with an MI is not relieved of chest pain with IV nitroglycerin, which medication will the nurse expect to be used?
a. IV morphine sulfate c. IV amiodarone (Cordarone)
b. Calcium channel blockers d. Angiotensin-converting enzyme (ACE) inhibitors 39. What is the rationale for using docusate sodium (Colace) for a patient after an MI?
a. Controls ventricular dysrhythmias c. Minimizes bradycardia from vagal stimulation b. Relieves anxiety and cardiac workload d. Prevents the binding of fibrinogen to platelets
40. The patient has hypertension and just experienced an MI. Which type of medication would be expected to be added to decrease the workload on his heart?
a. ACE inhibitor c. Calcium channel blocker
b. β-adrenergic blocker d. Angiotensin II receptor blocker (ARB)
41. A patient with an MI is exhibiting anxiety while being taught about possible lifestyle changes. The nurse evaluates that the anxiety is relieved when the patient states
a. “I’m going to take this recovery one step at a time.”
b. “I feel much better and am ready to get on with my life.”
c. “How soon do you think I will be able to go back to work?”
d. “I know you are doing everything possible to save my life.”
42. Priority Decision: A patient hospitalized for evaluation of unstable angina experiences severe chest pain and calls the nurse. Prioritize the interventions below from 1 (highest priority) to 6 (lowest priority). The appropriate medical orders and protocols are available to the nurse.
a. Notify the physician
b. Obtain a 12-lead ECG
c. Check the patient’s vital signs
d. Administer oxygen per nasal cannula
e. Perform a focused assessment of the chest
f. Assess pain (PQRST) and medicate as ordered
43. Which statement indicates the patient is experiencing anger as the psychologic response to his acute MI?
a. “Yes, I’m having a little chest pain. It’s no big deal.”
b. “I don’t think I can take care of myself at home yet.”
c. “What’s going to happen if I have another heart attack?”
d. “I hope my wife is happy now after harping at me about my eating habits all these years.”
44. The nurse and patient set a patient outcome that at the time of discharge after an MI the patient will be able to tolerate moderate-energy activities that are similar to which activity?
a. Golfing c. Cycling at 13 mph
b. Walking at 5 mph d. Mowing the lawn by hand
45. A 58-year-old patient is in a cardiac rehabilitation program. The nurse teaches the patient to stop exercising if what occurs?
a. Pain or dyspnea develop c. The respiratory rate increases to 30 b. The HR exceeds 150 bpm d. The HR is 30 bpm over the resting HR
Chapter 34 Nursing Management: Coronary Artery Disease and Acute Coronary Syndrome 143 46. In counseling the patient about sexual activity following an MI, what should the nurse do?
a. Wait for the patient to ask about resuming sexual activity
b. Discuss sexual activity while teaching about other physical activity
c. Have the patient ask the health care provider when sexual activity can be resumed d. Inform the patient that impotence is a common long-term complication following MI 47. What advice about sexual activity should the nurse give to a male patient who has had an MI?
a. The patient should use the superior position.
b. Foreplay may cause too great an increase in heart rate.
c. Prophylactic nitroglycerin may be used if angina occurs.
d. Performance can be enhanced with the use of sildenafil (Viagra).
48. Priority Decision: A patient is hospitalized after a successful resuscitation of an episode of sudden cardiac death (SCD). During the care of the patient, what nursing intervention is most important?
a. Continuous ECG monitoring c. Frequent assessment of heart sounds
b. Auscultation of the carotid arteries d. Monitoring of airway status and respiratory patterns
CASE STUDY
Coronary Artery Disease Patient Profile
H.C., a 47-year-old Navajo woman, comes to the emergency department with a burning sensation in her epigastric area extending into her sternum.
Subjective Data
• Has had chest pain with activity that is relieved with rest for the past 3 months
• Has had type 2 diabetes mellitus since she was age 35
• Has a smoking history of one pack a day for 27 years
• Is more than 30% over her ideal body weight
• Has no regular exercise program
• Expresses frustration with physical problems
• Is reluctant to get medical therapy because it will interfere with her life
• Has no health insurance Objective Data Physical Examination
• Anxious, clutching fists
• Appears overweight and withdrawn Diagnostic Studies
• 12-lead ECG
• Cholesterol: 248 mg/dL (6.41 mmol/L)
• LDL: 160 mg/dL (4.14 mmol/L)
• Glucose: 210 mg/dL (11.7 mmol/L) Collaborative Care
• Metoprolol (Toprol) XL 100 mg PO daily
• Nifedipine (Procardia) 10 mg tid
• Nitroglycerin 0.4 mg sublingual PRN for chest pain
• Exercise treadmill testing
144 Chapter 34 Nursing Management: Coronary Artery Disease and Acute Coronary Syndrome
Discussion Questions
Using a separate sheet of paper, answer the following questions:
1. What are H.C.’s risk factors for CAD?
2. What symptoms should lead the nurse to suspect the pain may be angina?
3. What nursing actions should be taken for H.C.’s discomfort?
4. What kind of ECG changes would indicate myocardial ischemia?
5. What information should the nurse provide for H.C. before the treadmill testing?
6. Priority Decision: What are the priority nursing measures that should be instituted to help H.C. decrease her risk factors?
7. Should H.C.’s angina become chronic stable angina, explain the treatment that would be used using the mnemonic A, B, C, D, E, and F.
8. Priority Decision: Based on the assessment data presented, what are the priority nursing diagnoses? Are there any collaborative problems?
C H A P T E R
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