Care of Patients with Acute Coronary Syndromes

Question 1

coronary artery disease

Answer 1

single largest killer of American men and women ion all ethnic groups, Broad term that includes chronic stable angina and acute coronary syndromes. Affects the arteries that provide blood, oxygen, and nutrients to the myocardium. Ischemia occurs when insufficient oxygen is supplied to meet the requirements. Infarction occurs when severe ischemia is prolonged and decreased perfusion causes irreversible damage to tissue.

Question 2

angina pectoris

Answer 2

chest pain caused by temporary imbalance between the coronary arteries’ ability to supply oxygen and the cardiac muscle’s demand for oxygen. ischemia that occurs is limited in duration and does not cause permanent damage.
Two types: chronic stable angina and unstable angina

Question 3

chronic stable angina

Answer 3

chest discomfort that occurs with moderate to prolonged exertion in a pattern that is familiar to the patient. Frequency, duration, and intensity of symptoms remain the same over several months. Results in only slight limitation of activity and is usually associated with a fixed atherosclerotic plaque. Usually relieved by nitroglycerin or rest; managed with drug therapy.

Question 4

acute coronary syndrome

Answer 4

term used to describe patients who have either unstable angina or acute myocardial infarction. Atherosclerotic plaque in the coronary artery ruptures, resulting in platelet aggregation (clumping), thrombus (clot) formation and vasoconstriction. ACS classified into one of three categories according to the presence or absence of ST- segment elevation on the ECG and positive serum troponin markers:
- STEMI: ST elevated MI (traditional manifestation)
- NSTEMI: Non ST elevated MI (common in women)
- unstable angina pectoris

Question 5

unstable angina pectoris

Answer 5

chest pain or discomfort that occurs at rest or with exertion and causes severe activity limitation. Pressure may last longer than 15 min. Poorly relieved by rest or nitroglycerin. May present with ST changes but do not have changes in troponin or creatine kinase levels.
New onset angina
variant Prinzmetal’s angina
Pre-infarction angina

Question 6

new onset angina

Answer 6

describes the patient who has his or her first angina symptoms, usually after exertion or other increased demands on the heart.

Question 7

variant Prinzmetal’s angina

Answer 7

chest pain or discomfort resulting form coronary artery spasm and typically occurs after rest.

Question 8

pre-infarction angina

Answer 8

refers to chest pain that occurs in the days or weeks before an MI

Question 9

Myocardial Infarction (MI or AMI)

Answer 9

occurs when myocardial tissue is abruptly and severely deprived of oxygen. When blood flow is quickly reduced by 80% to 90%, ischemia develops. Ischemia can lead to injury and necrosis of myocardial tissue if blood flow is not restored. Evolves over a period of several hours. Extent of infarction depends on collateral circulation, anaerobic metabolism and workload demands. Physical changes do not occur in the heart until 6 hours after the infarction. Once infarction occurs, scare tissue permanently changes the size and shape of the entire left ventricle, called ventricular remodeling.

Question 10

NSTEMI

Answer 10

Non ST segment elevation myocardial infarction. ST and T-wave changes on ECG. Indicates myocardial ischemia. Cardiac enzymes may be initially normal but elevate over the next 3-12 hours.

Question 11

causes of a NSTEMI

Answer 11

coronary vasospasm, spontaneous dissection, sluggish blood flow due to narrowing of the coronary artery.

Question 12

STEMI

Answer 12

ST elevated myocardial infarction. ST elevation in two leads on a ECG. Indicates myocardial infarction/necrosis. Attributable to rupture of the fibrous atherosclerotic plaque leading to platelet aggregation and thrombus formation at the site of rupture. Thrombus causes an abrupt 100% occlusion to the coronary artery.

Question 13

CAD/ ACS Etiology

Answer 13

atherosclerosis is the primary factor in the development of CAD; non-modifiable and modifiable risk factors contribute to atherosclerosis

Question 14

non-modifiable risk factors of atherosclerosis

Answer 14

age, gender, family history, ethnic background

Question 15

modifiable risk factors of atherosclerosis

Answer 15

elevated serum lipid levels, smoking, limited physical activity, HTN, DM, obesity, excessive alcohol, excessive stress/ decrease coping skills.

Question 16

CAD/ACS incidence

Answer 16

average age for first MI, 65.1 years in men, 72 for women, postmenopausal women have lower incidence than men, postmenopausal women in their 70s or older have an equal chance.

Question 17

CAD/ACS health promotion

Answer 17

control or alter modifiable risk factors for CAD

Question 18

CAD Prevention

Answer 18

eliminate smoking and tobacco use, diet, have lipid levels checked regularly, increase physical activity, manage diabetes, manage HTN, manage weight, limit alcohol use, manage stress

Question 19

Physical assessment of ACS

Answer 19

may complain of pain or pressure, assess according to onset, location, radiation, intensity, duration, precipitating factors, relieving factors.
assess for associated symptoms such as NV, diaphoresis, dizziness, weakness, palpitations, SOB
assess BP, HR, Cardiac rhythm, dysrhythmias; sinus tach with PVC frequently occur in the first few hours after an MI
assess distal peripheral pulses and skin temp; poor cardiac output can be manifested by cool, diaphoretic skin and diminished or absent pulses.
auscultate for S3 gallop which often indicates HF (complication of MI)
assess resp rate and breath sounds, crackles and wheezes may indicate LSHF
assess for presence of JVD and peripheral edema.
Assess for fever, patient with MI may experience temperature elevation for several days, in response to myocardial necrosis, indicating the inflammatory response.

Question 20

key features of angina

Answer 20

substernal chest discomfort: radiating to the left arm, precipitated by exertion or stress (or rest in variant angina) relieved by nitroglycerin or rest, lasting less than 15 min.

Question 21

key features of MI

Answer 21

pain or discomfort: substernal chest pain/pressure radiating to the left arm, pain discomfort in jaw, back, shoulder, or abdomen, occurring without cause usually in the morning, relieved by opioids, lasting 30 min or more.

Question 22

frequent associated symptoms of MI

Answer 22

N/V, diaphoresis, dyspnea, feelings of fear and anxiety, dysrhythmias, fatigue, palpitations, epigastric distress, anxiety dizziness, disorientation/ acute confusion, feeling SOB

Question 23

ACS psychosocial assessment

Answer 23

denial is common

Question 24

ACS lab assessment

Answer 24

Troponin’s- T&I criterion stnadard use today; can be elevated within 3-4 hours and may remain elevated for 10-14 days.
CK-MB (creatine kinase MB)

Question 25

ACS imaging assessment

Answer 25

thallium scans, contrast enhanced cardiovascular magnetic resonance, echocardiogram, computed tomography coronary angiography

Question 26

Other tests performed for ACS

Answer 26

12 lead ECG, stress test, cardiac catheterization

Question 27

Interventions for ACS to manage acute pain

Answer 27

supplemental oxygen, drug therapy, semi fowler position, quiet, calm environment

Question 28

Interventions for ACS to improve cardiopulmonary tissue perfusion

Answer 28

restoration of perfusion to injured area limits amount od extension, improves left ventricular function. complete, sustained reperfusion of coronary arteries after an ACS has decreased mortality rates.

Question 29

Interventions for ACS to increase activity intolerance

Answer 29

phase 1: patients progress at their own rate to increase levels of activity phase 2: cardiac rehab (all patients with MI should be referred)

Question 30

Interventions for ACS to promote effective coping

Answer 30

denial, anger, depression

Question 31

other examples of intervention for ACS

Answer 31

identify and manage dysrhythmias monitor for and manage HF monitor for and manage recurrent symptoms and extension of injury

Question 32

Invasive corrections to resolve angina or prevent MI

Answer 32

percutaneous coronary intervention (PCI) coronary artery bypass graft (CABG)

Question 33

The patient states that the chest discomfort occurs with moderate to prolonged exertion. He describes the pain as being “about the same over the past several months and going away with nitroglycerin or rest.” Based on the patient’s description of symptoms, what does the nurse suspect in this patient? A. Chronic stable angina (CSA) B. Unstable angina C. Acute ST elevated MI D. Acute Non ST elevated MI

Answer 33

A

Question 34

The patient is prescribed nitroglycerin tablets. What information does the nurse include when teaching the patient about this drug? (Select all that apply) A. If one tablet does not relieve the angina after 5 minutes, take two pills. B. You can tell the pills are active when your tongue feels a tingling sensation. C. Keep your nitroglycerin with you at all times. D. The prescription should last about 12 months before a refill is necessary. E. If pain doesn’t go away, just wait; the medication will eventually take effect. F. The medication can cause a temporary headache.

Answer 34

BCF

Question 35

A 71-year-old female presents to the ED via EMS with pain in her upper back and shoulders that started 2 hours ago. She has been experiencing nausea, dizziness, shortness of breath, and diaphoresis. She reports that she has had more frequent indigestion over the past week and has been unusually fatigued Which of the following is the most likely diagnosis at this time? a. Acute Myocardial Infarction b. Chronic Stable Angina c. Congestive Heart Failure d. Deep Vein Thrombosis

Answer 35

A

Question 36

Which early reaction is most common in patients with the chest discomfort associated with unstable angina or MI? A. Depression B. Anger C. Fear D. Denial

Answer 36

D

Question 37

The patient is admitted for acute MI, but the nurse notes that the traditional manifestation of ST elevation myocardial infarction (STEMI) is not occurring. What other evidence for acute MI does the nurse expect to find in this patient? (Select all that apply) A. Positive troponin markers B. Chronic stable angina C. Non-ST elevation MI (non-STEMI) on ECG D. Cardiac dysrhythmia E. Pulmonary embolus F. Jugular vein distension (JVD)

Answer 37

AC

Question 38

A thallium scan is scheduled for a client who had a myocardial infarction (MI). What should the nurse explain to the client regarding the reason the scan has been prescribed? A. That it will monitor the mitral and aortic valves B. That it establishes the viability of myocardial muscle C. That it can visualize the ventricular systole and diastole D. That it will determine the adequacy of electrical conductivity

Answer 38

B

Question 39

A 55 male patient comes to the walk in clinic reporting left anterior chest discomfort with mild shortness of breath. The patient is alert, oriented, diaphoretic, and anxious. What is the priority action for the nurse? A. Obtain a complete cardiac history to include a full description of the presenting symptoms B. Place the patient in Semi-Fowler’s or Fowler’s position and start supplemental oxygen C. Instruct the patient to go immediately to the closest full-service hospital D. Immediately alert the physician and establish IV access

Answer 39

B

Question 40

The patient is traveling to the hospital via EMS to be admitted with AMI. He begins c/o extreme fatigue, chest pain, and shortness of breath. BP 84/59, HR 94, RR 28 and shallow, pulse thready, skin pale and diaphoretic. These symptoms are associated with: A. Decreased lung capacity B. Increased cardiac muscle tone C. Decreased cardiac output D. Increased cardiac output

Answer 40

C

Question 41

The patient arrives to the hospital. Which of the following are appropriate interventions for managing an Acute Coronary Syndrome? (Select all that apply) A. Supplemental oxygen B. Nitroglycerin SL C. Morphine IV D. Aspirin PO E. Propranolol PO F. Nifedipine PO

Answer 41

ABCDE

Question 42

Which of the following is considered a treatment for acute myocardial infarction? (Select all that apply) A. Supplemental oxygen B. Morphine IV C. Aspirin PO D. Tissue plasminogen activator IV E. PCI (Percutaneous Coronary Intervention) F. PTCA (Percutaneous transluminal coronary angioplasty) G. CABG (Coronary Artery Bypass Graft)

Answer 42

DEFG

Question 43

The patient received thrombolytic therapy for treatment of acute MI. What are post administration nursing responsibilities for this treatment? (Select all that apply) A. Document the patient’s neurologic status B. Observe all IV sites for bleeding and patency C. Monitor white blood cell (WBC) count and differential D. Monitor clotting studies E. Monitor hemoglobin and hematocrit F. Test stools, urine, and emesis for occult blood G. Observe the sternal wound site

Answer 43

ABDEF

Question 44

Which of the following is an appropriate recommendation for a patient being discharged from the hospital following an ACS episode? (Select all that apply) A. You should utilize resources to help you quit smoking B. You should consume no more than 2 g of sodium in 24 hours C. You can return to your usual activities right away D. You will be checking your labs regularly E. You can stop your hypertension medication F. You should find ways to manage your stress

Answer 44

ABDF

Question 45

What are characteristics of chronic stable angina? (Select all that apply) A. Pain is precipitated by exertion or stress B. Pain occurs without cause, usually in the morning C. Pain is relieved only by opioids D. Pain is relieved by nitroglycerin and rest E. Nausea, diaphoresis, feelings of fear, and dyspnea may occur F. Pain lasts less than 15 minutes

Answer 45

ABDF

Question 46

Which of the following may contribute to a patient’s risk for coronary artery disease (CAD)? (Select all that apply) A. Smokes one pack cigarettes daily B. Exercises rarely C. Drinks a few glasses of wine on the weekends D. Has high cholesterol level E. Father and brother have coronary artery disease

Answer 46

ABDE

Question 47

Within 4 to 6 hours after a client has a myocardial infarction, the nurse expects which blood level to increase? A. Lactate dehydrogenase (LDH-1) B. Creatine kinase-MB band (CK-MB) C. Erythrocyte sedimentation rate (ESR) D. Serum aspartate aminotransferase (AST)

Answer 47

B

Question 48

A patient is admitted with AMI and c/o moderate chest discomfort. The nurse asks about which associated symptoms? (Select all that apply) A. Nausea B. Diarrhea C. Diaphoresis D. Dizziness E. Joint pain F. Shortness of breath

Answer 48

ACDF

Question 49

Which of the following are appropriate interventions for managing stable angina? (Select all that apply) A. Supplemental oxygen B. Nitroglycerin SL C. Morphine IV D. Aspirin PO E. Propranolol PO F. Nifedipine PO

Answer 49

BDEF

Question 50

A client is admitted to the hospital with the diagnosis of myocardial infarction. The nurse should monitor this client for which signs and symptoms associated with heart failure? (Select all that apply) A. Weight loss B. Unusual fatigue C. Dependent edema D. Nocturnal dyspnea E. Increased urinary output

Answer 50

BCD

Question 51

Four patients are admitted with an Acute MI. Which one of them is least likely to be developing a complication? A. Pt c/o of increasing chest pain after receiving Morphine IV B. Pt with c/o increased need for urination C. Pt with multiple multifocal PVCs on EKG D. Pt with decreased level of consciousness and thready pulse

Answer 51

B

Question 52

After receiving change of shift report, which client does the nurse assess first? A. The client with percutaneous coronary angioplasty who has a dose of heparin scheduled B. A client admitted for a NSTEMI myocardial infarction who reports dyspnea after ambulating to the bathroom C. A client on telemetry who has a PR interval of 0.14 and QRS complex of 0.10 and noted PVCs D. A client who has received thrombolytic therapy for a myocardial infarction (STEMI) who has facial drooping

Answer 52

D