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Chapter 33: Coronary Artery Disease and Acute Coronary Syndrome Lewis: Medical-Surgical Nursing, 10th Edition MULTIPLE CHOICE 1. When developing a teaching plan for a 61-yr-old patient with multiple risk factors for

coronary artery disease (CAD), the nurse should focus primarily on the family history of coronary artery disease. elevated low-density lipoprotein (LDL) level. increased risk associated with the patient’s gender. increased risk of cardiovascular disease as people age.

a. b. c. d.

ANS: B

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. DIF: Cognitive Level: Apply (application) REF: 703 TOP: Nursing Process: Planning MSC: NCLEX: Health Promotion and Maintenance 2. Which nursing intervention is likely to be most effective when assisting the patient with

coronary artery disease to make appropriate dietary changes? a. Inform the patient about a diet containing no saturated fat and minimal salt. b. Help the patient modify favorite high-fat recipes by using monounsaturated oils. c. Emphasize the increased risk for heart problems unless the patient makes the

dietary changes. d. Give the patient a list of low-sodium, low-cholesterol foods that should be

included in the diet. ANS: B

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 monounsaturated or polyunsaturated 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 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. DIF: Cognitive Level: Analyze (analysis) REF: 705 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 3. The nurse is admitting a patient who has chest pain. Which assessment data 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. DIF: Cognitive Level: Apply (application) REF: 720 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 4. Which information from a patient helps the nurse confirm the previous diagnosis of chronic

stable angina? “The pain wakes me up at night.” “The pain is level 3 to 5 (0 to 10 scale).” “The pain has gotten worse over the last week.” “The pain goes away after a nitroglycerin tablet.”

a. b. c. d.

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. DIF: Cognitive Level: Understand (comprehension) REF: 712 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 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 nausea as a side effect of nitroglycerin.” b. “I should only take nitroglycerin when I have chest pain.” c. “Nitroglycerin helps prevent a clot from forming and blocking blood flow to my

heart.” d. “I will call an ambulance if I still have pain after taking three nitroglycerin 5

minutes apart.” ANS: D

The emergency response system (ERS) should be activated when chest pain or other symptoms are not completely relieved after three 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. DIF: Cognitive Level: Apply (application) REF: 716 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity 6. Which statement made by a patient with coronary artery disease after the nurse has completed

teaching about the 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 monounsaturated 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. DIF: Cognitive Level: Apply (application) REF: 709 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity 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? “Carvedilol will help my heart muscle work harder.” “It is important not to suddenly stop taking the carvedilol.” “I can expect to feel short of breath when taking carvedilol.” “Carvedilol will increase the blood flow to my heart muscle.”

a. b. c. d.

ANS: B

Patients who have been taking b-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 b-adrenergic blockers for angina may be due to bronchospasm and should be reported to the health care provider. Carvedilol works by decreasing myocardial O2 demand, not by increasing blood flow to the coronary arteries. DIF: Cognitive Level: Apply (application) REF: 715 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity 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 best determine whether the patient has had an AMI? a. Myoglobin c. C-reactive protein b. Homocysteine 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 but are not helpful in determining whether an acute MI is in progress. DIF: Cognitive Level: Understand (comprehension) REF: 722 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 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. prevent coronary artery plaque. c. decrease coronary artery spasms. d. increase contractile force of the heart. ANS: C

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. Lipidlowering drugs help reduce atherosclerosis (i.e., plaque formation), and b-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 O2 demand. DIF: Cognitive Level: Apply (application) REF: 713 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 10. The nurse suspects that the patient with stable angina is experiencing a side effect of the

prescribed drug metoprolol (Lopressor) if the patient is restless and agitated. blood pressure is 90/54 mm Hg. patient complains about feeling anxious. heart monitor shows normal sinus rhythm.

a. b. c. d.

ANS: B

Patients taking b-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. Normal sinus rhythm is a normal and expected heart rhythm. DIF: Cognitive Level: Apply (application) REF: 715 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity 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 decreased blood pressure and heart rate. fewer complaints of having cold hands and feet. improvement in the strength of the distal pulses. participation in daily activities without chest pain.

a. b. c. d.

ANS: D

Because the drug 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 b-adrenergic blockers can cause peripheral vasoconstriction, so the nurse would not expect an improvement in distal pulse quality or skin temperature. DIF: Cognitive Level: Apply (application) REF: 715 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity 12. Heparin is ordered for a patient with a non–ST-segment-elevation myocardial infarction

(NSTEMI). What is the purpose of the heparin? Heparin enhances platelet aggregation at the plaque site. Heparin decreases the size of the coronary artery plaque. Heparin prevents the development of new clots in the coronary arteries. Heparin dissolves clots that are blocking blood flow in the coronary arteries.

a. b. c. d.

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. DIF: Cognitive Level: Understand (comprehension) REF: 722 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 13. When titrating IV nitroglycerin for a patient with a myocardial infarction (MI), which action

will the nurse take to evaluate the effectiveness of the drug? c. Check blood pressure. d. Observe for dysrhythmias.

a. Monitor heart rate. b. Ask about chest pain. 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 will also monitor heart rate and blood pressure and observe for dysrhythmias, but these parameters will not indicate whether the medication is effective. DIF: Cognitive Level: Apply (application) REF: 725 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity 14. A patient with ST-segment elevation in three contiguous electrocardiographic leads is

admitted to the emergency department and diagnosed as having an ST-segment-elevation myocardial infarction. 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, so the time at which the chest pain started is a major determinant of the appropriateness of this treatment. The other information is not a factor in the decision about thrombolytic therapy. DIF: Cognitive Level: Apply (application) REF: 723 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 15. After an acute myocardial infarction (AMI), a patient ambulates in the hospital hallway. When

the nurse evaluates the patient’s response to the activity, which data would indicate that the exercise level should be decreased? a. O2 saturation drops from 99% to 95%. b. Heart rate increases from 66 to 98 beats/min. c. Respiratory rate goes from 14 to 20 breaths/min. d. Blood pressure (BP) changes from 118/60 to 126/68 mm Hg. ANS: B

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 O2 saturation, are normal responses to exercise.

DIF: Cognitive Level: Apply (application) REF: 732 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity 16. During the administration of the thrombolytic agent to a patient with an acute myocardial

infarction, the nurse should stop the drug infusion if the patient experiences bleeding from the gums. increase in blood pressure. a decrease in level of consciousness. a nonsustained episode of ventricular tachycardia.

a. b. c. d.

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. DIF: Cognitive Level: Apply (application) REF: 723 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity 17. A patient recovering from a myocardial infarction (MI) 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 as focused follow-up on this symptom? 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. DIF: Cognitive Level: Apply (application) REF: 721 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 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. DIF: Cognitive Level: Apply (application) REF: 716 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity 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 about my heart to be alone while I get washed up.” Based on this information, which nursing diagnosis is appropriate? a. Activity intolerance related to weakness b. Anxiety related to change in health status c. Denial related to lack of acceptance of the MI d. Altered body image related to cardiac disease ANS: B

The patient data indicate 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 altered body image. DIF: Cognitive Level: Apply (application) REF: 725 TOP: Nursing Process: Diagnosis MSC: NCLEX: Psychosocial Integrity 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. limiting physical activity will prevent future SCD 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. DIF: Cognitive Level: Apply (application) REF: 733 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 21. A few days after experiencing a myocardial infarction (MI) and successful percutaneous

coronary intervention, the patient states, “It was just 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. DIF: Cognitive Level: Apply (application) REF: 727 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 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 surgery.” b. “I will have 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. DIF:...