Lewis Chapter 36: Coronary Artery Disease and Acute Coronary Syndrome

Question 1

A nursing student placed on medicine telemetry asks the preceptor how common is heart disease in Canada. What is the best response?

a. It is more common in people experiencing stress.

b. It claims the life of 50 000 Canadians each year.

c. It is the second major cause of all deaths in Canada.

d. It is not very common at all.

Answer 1

C.

Question 2

A nurse is teaching a client about coronary artery disease. Which changes occur in this disorder? (Select all that apply.)

a. Diffuse involvement of plaque formation in coronary veins

b. Abnormal levels of cholesterol, especially low-density lipoproteins

c. Accumulation of lipid plaques or calcification within the coronary arteries

d. Development of angina due to a decreased blood supply to the heart muscle

e. Chronic vasoconstriction of coronary arteries leading to permanent vasospasm

Answer 2

B, C, D.

Question 3

Which statement indicates that the client requires additional instruction in reducing cardiac risk factors?

a. “I would like to add weightlifting to my exercise program.”

b. “I can’t keep my blood pressure normal without medication.”

c. “I can change my diet to decrease my intake of saturated fats.”

d. “I will change my lifestyle to reduce activities that increase my stress.”

Answer 3

A.

Question 4

A hospitalized client with angina tells the nurse that she is having chest pain. What are the nurse’s priorities?

a. Perform vital signs and obtain an ECG.

b. Administer sublingual nitroglycerin and intravenous morphine.

c. Call the rapid response team and the physician.

d. Inform the cardiac catheterization lab and interventional cardiologist.

Answer 4

A.

Question 5

What does the clinical spectrum of ACS include?

a. Unstable angina and STEMI

b. Unstable angina and NSTEMI

c. Stable angina and sudden cardiac death

d. Unstable angina, STEMI, and NSTEMI

Answer 5

D.

Question 6

In a client recovering from an MI, in which period is the heart most vulnerable to stress?

a. 3 weeks after the infarction

b. 4 to 6 days after the infarction

c. 10 to 14 days after the infarction

d. When healing is complete, at 6 to 8 weeks

Answer 6

C.

Question 7

A client is admitted to the ED with chest pain of 2 hours’ duration, ECG findings consistent with an acute MI, and occasional ventricular dysrhythmias. With what pharmacological therapy would the nurse expect the client to be managed initially?

a. Diuretics

b. Nitroglycerin spray

c. β-Adrenergic blockers

d. Thrombolytic therapy with tissue plasminogen activator

Answer 7

B.

Question 8

Five days after an MI, a client is restless and apprehensive. How can the nurse assist the client?

a. By providing all care and doing everything for the client

b. By structuring the environment and the routine so that the client can rest

c. By allowing the client to participate in planning and carrying out activities

d. By encouraging the family to provide for the client’s physical care and give emotional support

Answer 8

C.

Question 9

What is the most common pathological finding in individuals experiencing SCD?

a. Cardiomyopathies

b. Mitral valve disease

c. Atherosclerotic heart disease

d. Left ventricular hypertrophy

Answer 9

C.

Question 10

Place in sequence the developmental stages of atherosclerotic lesions.

Answer 10

Chronic endothelial injury
Fatty streak
Fibrous plague
Complicated lesion

Question 11

Which terms are considered synonymous with coronary artery disease (CAD)?

Answer 11

Arteriosclerotic heart disease (ASHD)
Cardiovascular heart disease (CVHD)
Ischemic heart disease
Coronary heart disease

Question 12

Which statement about collateral circulation is accurate?

A. New arterial anastomoses form only when necessary to increase blood flow.

B. Rapid-onset heart disease causes immediate formation of collateral circulation providing sufficient blood supply.

C. Genetics play a role in a person’s ability to develop collateral circulation.

D. Collateral circulation develops only when atherosclerotic changes decrease arterial blood flow to the myocardium.

Answer 12

C. Genetics play a role in a person’s ability to develop collateral circulation.

The inherited predisposition to develop new blood vessels (angiogenesis) promotes the presence of collateral circulation.

Question 13

Which factor is a major modifiable risk for coronary artery disease (CAD)?

A. Depression

B. Substance use

C. Diabetes mellitus

D. Tobacco use

Answer 13

D. Tobacco use

Tobacco use is a major modifiable risk factor for CAD. Other major modifiable risk factors include physical inactivity, obesity, hypertension, and hyperlipidemia.

Question 14

Which statement differentiates coronary artery disease (CAD) risk between males and females?

A. Women are at more risk than men until age 65.

B. At-risk waist circumference measurements do not differ for men and women.

C. Reproductive influences affect CAD risk for women.

D. Men have more stressful jobs, therefore are at higher risk.

Answer 14

C. Reproductive influences affect CAD risk for women.

Women experience different risk related to the female reproductive system, including early age of menarche, contraceptive use, pregnancy, and premature menopause.

Question 15

Which substance is derived from triglycerides?

A. Phospholipids

B. Fatty acids

C. Chylomicrons

D. Low density lipoproteins

Answer 15

B. Fatty acids

Fatty acids are derived from triglycerides and become saturated or unsaturated.

Question 16

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

A. A 45-year-old depressed male with a high-stress job

B. A 60-year-old male with below-normal homocysteine levels

C. A 54-year-old female vegetarian with elevated high-density lipoprotein (HDL) levels

D. A 62-year-old female who has a sedentary lifestyle and body mass index (BMI) of 23 kg/m2

Answer 16

A. A 45-year-old depressed male with a high-stress job

Studies demonstrate that depression and stressful states can contribute to the development of CAD. This patient has two risk factors.

Question 17

Which statement about diabetes mellitus does the nurse take into consideration when planning coronary artery disease (CAD) risk reduction education for Indigenous people?

A. Because CAD is not common in the Indigenous population, risk reduction education is not necessary.

B. Indigenous people rarely develop diabetes mellitus due to their low reliance on processed foods.

C. Indigenous people are less likely to develop complications from their diabetes such as CAD.

D. The incidence of diabetes in Indigenous people is very high.

Answer 17

D. The incidence of diabetes in Indigenous people is very high.

Diabetes is considered endemic in the Indigenous population, and they are at very high risk of developing diabetes associated complications; therefore, CAD risk reduction should be emphasized when providing their health care.

Question 18

Which statement describes the relationship between coronary artery disease (CAD) risk and substance use?

A. Patients under the influence of illicit drugs admitted to the emergency department predominately are experiencing a myocardial infarction (MI).

B. The major risk associated with illicit drug use is the increased risk of coronary artery spasm.

C. Indigenous people are at less risk for CAD associated with substance use than non-indigenous people.

D. Cannabis has been legalized in Canada as there are no known CAD risk factors.

Answer 18

B. The major risk associated with illicit drug use is the increased risk of coronary artery spasm.

The use of illicit drugs, such as cocaine and methamphetamine, can produce coronary artery spasm resulting in myocardial ischemia and chest pain.

Question 19

For which antilipidemic medication would the nurse question an order in a patient with cirrhosis of the liver?

A. Niacin

B. Ezetimibe

C. Cholestyramine

D. Colestipol

Answer 19

B. Ezetimibe

Ezetimibe acts in the small intestine to inhibit uptake of cholesterol. Adverse effects are infrequent, but include mild GI disturbance (e.g., diarrhea) fatigue, headache, and cough. Its use would be avoided in patients with moderate to severe liver disease and pregnant or breast-feeding persons.

Question 20

Which behaviour would be consistent with coronary artery disease (CAD) risk reduction?

A. Exercise regularly to meet the recommended target of 250 minutes/week.

B. Limit salt intake to 2 300 mg/day.

C. Modify lifestyle choices to obtain/maintain a BMI between 24.9-38.5.

D. Limit caloric intake to 1 200 calories/day.

Answer 20

B. Limit salt intake to 2 300 mg/day.

Limiting salt intake to 2 300 mg/day is the recommended amount of daily dietary sodium intake to reduce the risk of CAD.

Question 21

Which characteristic is associated with chronic stable angina?

A. Has an unpredictable onset

B. Occurs intermittently over a long period of time

C. Has a variable duration

D. Changes in intensity over time

Answer 21

B. Occurs intermittently over a long period of time

Chronic stable angina does occur intermittently over time; however, it has a stable pattern of onset, duration, and intensity of symptoms.

Question 22

Which factor causes an increased oxygen demand?

A. Hypertension

B. Heart failure

C. Low blood volume

D. Coronary artery spasm

Answer 22

A. Hypertension

Hypertension is a factor that causes an increased oxygen demand or consumption. Other factors that increase oxygen demand include anxiety, the use of some drugs, hyperthermia, and hyperthyroidism.

Question 23

Which factor is assessed by the “S” in the PQRST angina assessment?

A. Symmetry of pain

B. Start time of pain

C. Severity of pain

D. Saturation of oxygen

Answer 23

C. Severity of pain

The severity of the pain is assessed on a 0-10 scale and is represented by the “S” in the PQRST angina assessment.

Question 24

Which patient statements indicates that further teaching is required after participating in patient education on nitroglycerin use?

A. “I will replace my nitroglycerin supply every six months.”

B. “I can take up to five tablets every three minutes for relief of my chest pain.”

C. “I will take acetaminophen to treat the headache caused by nitroglycerin.”

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

Answer 24

B. “I can take up to five tablets every three minutes for relief of my chest pain.”

This is an inaccurate understanding of the dosing information. The correct dosing is one tablet every five minutes three times for a total of 3 tablets.

Question 25

Which goal is the aim of the interprofessional management of chronic stable angina?

A. Increasing oxygen demand

B. Decreasing coronary blood flow

C. Decreasing oxygen supply

D. Decreasing risk factors

Answer 25

D. Decreasing risk factors

Risk reduction remains an important strategy throughout one’s life. Helping patients adopt and maintain healthy lifestyle behaviours is useful in the overall management of chronic stable angina.

Question 26

For which classification of medications should the nurse increase their monitoring for respiratory side effects?

A. Calcium channel blockers

B. Nitrates

C. Low molecular weight heparin

D. Adenosine diphosphate receptor antagonists

Answer 26

A. Calcium channel blockers

Shortness of breath and auscultation of crackles, secondary to heart failure, is common with calcium channel blockers.

Question 27

Which characteristic is associated with unstable angina (UA)?

A. The pain is unpredictable in nature.

B. The pain only occurs with the use of some stimulant medications.

C. The intensity of pain remains constant over time.

D. The pain never occurs while at rest.

Answer 27

A. The pain is unpredictable in nature.

Unlike chronic stable angina, UA follows a very unpredictable pattern, including pain at rest.

Question 28

During which myocardial infarction (MI) recovery period is the patient most vulnerable to increased stress on the myocardium?

A. Three weeks after the infarction.

B. Four to six days after the infarction.

C. 10 to 14 days after the infarction.

D. When healing is complete, at six to eight weeks.

Answer 28

C. 10 to 14 days after the infarction.

The patient’s activity level may be increasing while the scar tissue in the injured myocardium is still weak. The increased cardiac workload in response to increased physical activity puts stress on the still weak scar tissue and increases the risk of rupture.

Question 29

Which non-traditional symptom is most likely to be an indication of a myocardial infarction (MI) in an older adult?

A. Angina

B. New onset of incontinence

C. New onset of confusion

D. Flushing of the skin

Answer 29

C. New onset of confusion

While non-specific to MI, confusion in the elderly is a cause for concern. Decreased blood flow to the brain may account for the new onset of confusion.

Question 30

Which ECG finding is consistent with non–ST-elevation myocardial infarction (NSTEMI)?

A. ST-segment elevation

B. Presence of Q-waves

C. No Q-waves

D. T-wave inversion

Answer 30

C. No Q-waves

Q-waves are not seen in NSTEMI.

Question 31

Which statement about cardiac markers is accurate?

A. Cardiac markers are proteins released by the heart when oxygen levels drop.

B. Serum creatine kinase is preferred to serum troponin to assess myocardial tissue damage.

C. Serum levels of creatine kinase peak within 48 hours.

D. Serum levels of troponin peak within 48 hours.

Answer 31

D. Serum levels of troponin peak within 48 hours.

The serum levels of troponin increase three to 12 hours after the onset of MI and peak at 24 to 48 hours. Serum levels of creatine kinase peak within 24, not 48, hours.

Question 32

Which statement about the interpretation of ECG findings in the assessment of MI is accurate?

A. The ST segment is always involved if there is an MI.

B. When a patient initially presents to the ED with chest pain, the ECG may be normal.

C. Electrical disruption within the heart associated with coronary artery narrowing are always immediately reflected on the ECG.

D. The changes in ECG waveforms do not reflect the degree of myocardial involvement.

Answer 32

B. When a patient initially presents to the ED with chest pain, the ECG may be normal.

The disruption of electrical pathways within the heart are not always immediate upon myocardial cell death. The changes can be immediate or can evolve over time. Serial ECGs are done when there is a normal ECG in the presence of angina or other history/symptoms suggestive of MI.

Question 33

Which cardiac assessment finding would be most indicative of left ventricular dysfunction in the patient experiencing a myocardial infarction (MI)?

A. Systolic murmur

B. Third heart sound (S3)

C. Jugular venous distention

D. Peripheral edema

Answer 33

B. Third heart sound (S3)

During an MI, auscultation may reveal a third heart sound (S3) or fourth heart sound (S4) suggestive of ventricular dysfunction.

Question 34

Which complication should the nurse anticipate when providing care for a patient diagnosed 24 hours earlier with ST-segment elevation myocardial infarction (STEMI)?

A. Unstable angina

B. Cardiac tamponade

C. Sudden cardiac death

D. Cardiac dysrhythmias

Answer 34

D. Cardiac dysrhythmias

The most common complication after MI is dysrhythmias, which are present in 80% of patients.

Question 35

Which ECG change is most indicative of prolonged or complete coronary occlusion in a patient with a newly diagnosed MI?

A. Sinus tachycardia

B. Pathological Q-wave

C. Fibrillatory P-waves

D. Prolonged PR interval

Answer 35

B. Pathological Q-wave

The presence of a pathological Q-wave, as it often accompanies ST-segment elevation myocardial infarction (STEMI), is indicative of complete coronary occlusion.

Question 36

Which diagnostic test would be the most useful in confirming the diagnosis of Prinzmetal’s angina?

A. Coronary angiography

B. Serum CK-MB band levels

C. ECG

D. Serum troponin levels

Answer 36

A. Coronary angiography

Coronary angiography is the only way to confirm the presence of coronary artery spasms and the diagnosis of Prinzmetal’s angina.

Question 37

Which procedure would the nurse expect to prepare for when caring for a post-myocardial infarction (MI) patient who suddenly develops dyspnea, pulmonary edema, and a systolic murmur at the cardiac apex radiating toward the axilla?

A. ECG

B. Coronary angiography

C. Open heart surgery

D. Cardioversion

Answer 37

C. Open heart surgery

These symptoms are indicative of papillary muscle rupture, which is a life-threatening complication of MI. Mitral valve replacement via open heart surgery is the definitive and immediate treatment.

Question 38

Which pattern of pain intensity, duration, or severity is most consistent with chest pain related to myocardial infarction (MI)?

A. Occurs most often in the right side of the chest

B. Not relieved by changes in position

C. Has a short duration

D. Usually the only symptom patients have

Answer 38

B. Not relieved by changes in position

Chest pain associated with an MI is not relieved by changing position. It is also not relieved by rest or with nitrate administration.

Question 39

Which patient would be most likely to have fewer complications from a myocardial infarction (MI)?

A. An older adult with previous coronary artery disease (CAD)

B. A younger adult with no history of coronary artery disease (CAD)

C. A younger adult with no coronary artery disease (CAD), but has a family history of CAD

D. An older adult with no history of coronary artery disease (CAD)

Answer 39

A. An older adult with previous coronary artery disease (CAD)

The degree of pre-established collateral circulation influences the severity of infarction. Over time, and in adults with a history of CAD, collateral circulation may be well established and provide alternative blood supplies to otherwise compromised myocardium. Due to the established alternative blood supply, the severity of the infarction may be less with less complications.

Question 40

Which pharmacological therapy would the ED nurse expect to initially manage a client with chest pain of two hours’ duration, ECG findings consistent with an acute MI, and occasional ventricular dysrhythmias?

A. Diuretics

B. Nitroglycerin spray

C. β-Adrenergic blockers

D. Thrombolytic therapy with tissue plasminogen activator

Answer 40

B. Nitroglycerin spray

Nitroglycerin, sublingual (SL) spray or translingual, is the initial management of chest pain. The ultimate goal is to increase blood flow to the myocardium to preserve heart muscle. The nearly immediate vasodilation caused by nitrates helps to increase coronary artery blood flow. While IV route is also an option, the nurse should not wait to establish an IV, so the SL administration is indicated.

Question 41

For which condition is emergent percutaneous coronary intervention (PCI) indicated?

A. Chronic stable angina

B. Left-sided heart failure

C. Acute myocardial infarction (MI)

D. Coronary artery disease (CAD)

Answer 41

C. Acute myocardial infarction (MI)

Emergent PCI is recommended as the first line of treatment for patients with confirmed MI (i.e., definitive ECG changes, presence of cardiac markers, or both). The goal is to open the affected artery within 90 minutes of the patient’s arrival at the ED.

Question 42

Which cardiac revascularization procedure uses a mesh-like frame to stabilize the coronary artery?

A. Coronary artery bypass graft

B. Percutaneous coronary intervention (PCI)

C. Fibrinolytic therapy

D. Transmyocardial laser revascularization

Answer 42

B. Percutaneous coronary intervention (PCI)

PCI generally includes the placement of one or more stents. Stents, either “bare metal” or “drug-eluting” are expandable mesh-like frames to open the vessel for blood flow.

Question 43

Which activity recommendation would a nurse make for a patient who is in Phase I recovery after acute coronary syndrome (ACS)?

A. Climbing eight to 10 stairs

B. Range-of-motion exercises in bed

C. Brisk walk lasting five minutes

D. Lifting a three-pound weight three times with left arm

Answer 43

B. Range-of-motion exercises in bed

Range-of-motion exercises in bed would be appropriate in the hospital phase (Phase I), especially for patients who experienced extensive myocardium injury. Activity is incrementally increased as tolerated. The goal for this patient would be to provide for some movement to avoid the complications of venous thromboembolism (deep vein thrombosis or pulmonary embolism).

Question 44

Which patient would most likely benefit from aggressive post-operative pain management?

A. Coronary artery bypass graft (CABG)

B. Off-pump coronary artery bypass (OPCAB)

C. Cardiac catheterization

D. Percutaneous coronary intervention (PCI)

Answer 44

B. Off-pump coronary artery bypass (OPCAB)

Because patients with thoracotomy incisions report higher levels of pain than those with sternotomy incisions, patients who undergo OPCAB may experience more postoperative surgical-site pain.

Question 45

Which action should the nurse take when providing patient education of the resumption of sexual activity after a myocardial infarction (MI)?

A. Delegate to primary care provider.

B. Avoid discussing because it is embarrassing to the patient.

C. Accomplish the teaching by providing written material to the patient.

D. Discuss along with other physical activities.

Answer 45

D. Discuss along with other physical activities.

Nurses may feel uncertain about how and when to begin counselling about resumption of sexual activity. It is helpful to consider sex a physical activity and to discuss or explore feelings about it when discussing other physical activities with the patient.

Question 46

Which nursing action takes priority when a hospitalized post-operative patient tells the nurse that she is having chest pain?

A. Perform vital signs and obtain an ECG.

B. Administer sublingual nitroglycerin and intravenous morphine.

C. Call the rapid response team and the provider.

D. Inform the cardiac catheterization lab and interventional cardiologist.

Answer 46

A. Perform vital signs and obtain an ECG.

As this would be new chest pain, the priority would be to assess the patient’s hemodynamic response via vital sign assessment and to attempt to discover if the pain is associated with electrical changes within the heart via the ECG.

Question 47

Which intervention would be indicated for a patient five days after a myocardial infarction (MI) who is restless and apprehensive?

A. Provide all care and do everything for the patient.

B. Structure the environment and the routine so that the patient can rest.

C. Allow the patient to participate in planning and carrying out activities.

D. Encourage the family to provide for the patient’s physical care and give emotional support.

Answer 47

C. Allow the patient to participate in planning and carrying out activities.

It is common for MI patients, as they begin to move beyond the initial shock of their situation, to begin to comprehend the life-changing nature of their condition. Fear and anxiety are common reactions and involving the patient directly in decision making and their care will allow them some control over what is perceived to be an out-of-control situation.

Question 48

Which assessment will provide for the early identification of the most common complication of myocardial infarction (MI)?

A. Urinary output measurement

B. Blood pressure monitoring

C. ECG monitoring

D. Continuous pulse oximetry

Answer 48

C. ECG monitoring

Continuous ECG monitoring will provide for the early identification of dysrhythmias, which are the most common complication following an MI. Ventricular fibrillation is the most common lethal dysrhythmia and is usually preceded by proventricular contractions or ventricular tachycardia.

Question 49

Which patient situation reflects a priority teaching moment for patient recovering from a myocardial infarction (MI)?

A. One day post MI who states that they are cured after receiving IV morphine

B. In phase II recovery who says that they are considering lifestyle changes

C. The spouse of a patient being discharged who indicates that she is afraid to have sexual intercourse with her husband

D. Newly started on propranolol who reports gastrointestinal upset

Answer 49

A. One day post MI who states that they are cured after receiving IV morphine

This patient’s knowledge deficit could be very problematic. The patient is likely in denial of their current condition believing that the absence of pain (which was relieved by the morphine) means that they are no longer is at risk. This patient is likely to not decrease their activity level or engage in other contraindicated behaviors, increasing their risk for further myocardial damage.

Question 50

Which nursing action would limit the risk of sternal incision infection in a post-operative coronary artery bypass grafting (CABG) patient?

A. Ensure that the top sheet is not drawn up above the patient’s waist to avoid contact with the incision.

B. Ensure the sternal wound dressing is not changed in the first 48 hours.

C. Ensure that the incision is covered with an impermeable barrier during endotracheal suctioning.

D. Apply soft restraints to ensure the patient does not touch the incision.

Answer 50

C. Ensure that the incision is covered with an impermeable barrier during endotracheal suctioning.

Pulmonary secretions that make contact with the sternal incision are the predominate source of infection for sternal wounds. Using a barrier during endotracheal suctioning will help to prevent secretions from making contact with the dressing/incision.