Which patient is most likely to be in the fibrous stage of development of coronary artery disease (CAD)?
a. Age 40, thrombus adhered to the coronary
... [Show More] artery wall
b. Age 50, rapid onset of disease with hypercholesterolemia
c. Age 32, thickened coronary arterial walls with narrowed vessel lumen
d. Age 19, elevated low-density lipoprotein (LDL) cholesterol, lipid-filled smooth muscle cells - correct answer Age 32, thickened coronary arterial walls with narrowed vessel lumen
c. The fibrous plaque stage has progressive changes that can be seen by age 30.
Collagen covers the fatty streak and forms a fibrous plaque in the artery.
Which stage of CAD does the thrombus adheres to the arterial wall? - correct answer The COMPLICATED LESION STAGE
2. What accurately describes the pathophysiology of CAD?
a. Partial or total occlusion of the coronary artery occurs during the stage of raised fibrous plaque.
b. Endothelial alteration may be caused by chemical irritants such as hyperlipidemia or by tobacco use.
c. Collateral circulation in the coronary circulation is more likely to be present in the young patient with CAD.
d. The leading theory of atherogenesis proposes that infection and fatty dietary intake are the basic underlying causes of atherosclerosis. - correct answer Endothelial alteration may be caused by chemical irritants such as hyperlipidemia or by tobacco use.
b. The etiology of CAD includes atherosclerosis as the major cause. The pathophysiology of atherosclerosis development and resulting atheromas is related to endothelial injury and inflammation, which can be the result of
- tobacco use
- hyperlipidemia
- hypertension
- toxins
- diabetes mellitus
- hyperhomocysteinemia
- infection
causing a local inflammatory response in the inner lining of the vessel walls.
Rapid onset of coronary artery disease (CAD) with hypercholesterolemia may be related to - correct answer familial hypercholesterolemia, not a stage of CAD development.
The fatty streak stage is the - correct answer earliest stage of atherosclerosis and can be seen by age 20.
Partial or total occlusion occurs in the ______________stage. - correct answer complicated lesion
Extra collateral circulation occurs in the presence of - correct answer chronic ischemia.
Therefore it is more likely to occur in an older patient.
3. While obtaining patient histories, which patient does the nurse identify as having the highest risk for CAD?
a. A white man, age 54, who is a smoker and has a stressful lifestyle
b. A white woman, age 75, with a BP of 172/100 mm Hg and who is physically inactive
c. An Asian woman, age 45, with a cholesterol level of 240 mg/dL and a BP of 130/74 mm Hg
d. An obese Hispanic man, age 65, with a cholesterol level of 195 mg/dL and a BP of 128/76 mm Hg - correct answer A white woman, age 75, with a BP of 172/100 mm Hg and who is physically inactive
b. This white woman has one unmodifiable risk factor (age) and two major modifiable risk factors (hypertension and physical inactivity). Her gender risk is as high as a man's because she is 75 years of age. The white man has one unmodifiable risk factor (gender), one major modifiable risk factor (smoking), and one minor modifiable risk factor (stressful lifestyle). The Asian woman has only one major modifiable risk factor (hyperlipidemia), and Asians in the United States have fewer myocardial infarctions (MIs) than do whites. The Hispanic man has an unmodifiable risk factor related to age and one major modifiable risk factor (obesity). Hispanics have slightly lower rates of CAD than non- Hispanic whites or African Americans.
4. Priority Decision: While teaching women about the risks and incidence of CAD, what should the nurse emphasize?
a. Smoking is not as significant a risk factor for CAD in women as it is in men.
b. Women seek treatment sooner than men when they have symptoms of CAD.
c. Estrogen replacement therapy in postmenopausal women decreases the risk for CAD.
d. CAD is the leading cause of death in women, with a higher mortality rate after MI than in men. - correct answer CAD is the leading cause of death in women, with a higher mortality rate after MI than in men.
d. CAD is the number-one killer of American women, and women have a much higher mortality rate within 1 year following MI than do men. Smoking carries specific problems for women because smoking has been linked to a decrease in natural estrogen levels and to early menopause, and it has been identified as the most powerful contributor to CAD in women under the age of 50.
Fewer women than men present with classic manifestations, and women delay seeking care longer than men.
Recent research indicates that estrogen replacement does not always reduce the risk for CAD, even though natural estrogen lowers low-density lipoprotein (LDL) and raises high-density lipoprotein (HDL) cholesterol
5. Which characteristics are associated with LDLs (select all that apply)?
a. Increases with exercise
b. Contains the most cholesterol
c. Has an affinity for arterial walls
d. Carries lipids away from arteries to liver
e. High levels correlate most closely with CAD
f. The higher the level, the lower the risk for CAD - correct answer Contains the most cholesterol
Has an affinity for arterial walls
High levels correlate most closely with CAD
b, c, e. LDLs contain more cholesterol than the other lipoproteins, have an attraction for arterial walls, and correlate most closely with increased incidence of atherosclerosis and CAD.
HDLs increase with exercise and carry lipids away from arteries to the liver for metabolism.
A high HDL level is associated with a lower risk of CAD.
6. Which serum lipid elevation, along with elevated LDL, is strongly associated with CAD?
a. Apolipoproteins
b. Fasting triglycerides
c. Total serum cholesterol
d. High-density lipoprotein (HDL) - correct answer Fasting triglycerides
b. Elevated fasting triglyceride levels are associated with cardiovascular disease and diabetes.
Apolipoproteins are found in varying amounts on the HDLs and activate enzyme or receptor sites that promote removal of fat from plasma, which is protective.
The apolipoprotein A and apolipoprotein B ratio must be done to predict CAD.
Elevated total serum cholesterol must be calculated with HDL for a ratio over time to determine an increased risk of CAD.
Elevated HDLs are associated with a lower risk of CAD
7. The laboratory tests for four patients show the following results. Which patient should the nurse teach first about preventing CAD because the patient is at the greatest risk for CAD even without other risk factors?
a. Total cholesterol: 152 mg/dL, triglycerides: 148 mg/dL, LDL: 148 mg/dL, HDL: 52 mg/dL
b. Total cholesterol: 160 mg/dL, triglycerides: 102 mg/dL, LDL: 138 mg/dL, HDL: 56 mg/dL
c. Total cholesterol: 200 mg/dL, triglycerides: 150 mg/dL, LDL: 160 mg/dL, HDL: 48 mg/dL
d. Total cholesterol: 250 mg/dL, triglycerides: 164 mg/dL, LDL: 172 mg/dL, HDL: 32 mg/dL - correct answer Total cholesterol: 250 mg/dL, triglycerides: 164 mg/dL, LDL: 172 mg/dL, HDL: 32 mg/dL
d. All of this patient's results are abnormal. The patient in option "c" is close to being at risk; if this patient is a woman, the HDL is too low and the other results are at or near the cut off for being normal. The other patients' results are at acceptable levels.
The nurse is encouraging a sedentary patient with major risks for CAD to perform physical exercise on a regular basis. In addition to decreasing the risk factor of physical inactivity, the nurse tells the patient that exercise will also directly contribute to reducing which risk factors?
a. Hyperlipidemia and obesity
b. Diabetes mellitus and hypertension
c. Elevated serum lipids and stressful lifestyle
d. Hypertension and elevated serum homocysteine - correct answer Hyperlipidemia and obesity
a. Increased exercise without an increase in caloric intake will result in weight loss, reducing the risk associated with obesity. Exercise increases lipid metabolism and increases HDL, thus reducing CAD risk. Exercise may also indirectly reduce the risk of CAD by controlling hypertension, promoting glucose metabolism in diabetes, and reducing stress. Although research is needed to determine whether a decline in homocysteine can reduce the risk of heart disease, it appears that dietary modifications are indicated for risk reduction.
9. During a routine health examination, a 48-yr-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.
b. Abstain from alcohol use.
c. Reduce red meat in the diet.
d. Eliminate intake of simple sugars.
e. Avoid egg yolks and foods prepared with whole eggs. - correct answer a. use fat free milk
c. Reduce red meat in the diet.
e. Avoid egg yolks and foods prepared with whole eggs.
a, c, e. Therapeutic Lifestyle Changes diet recommendations emphasize reduction in saturated fat and cholesterol intake.
X - Whole milk products
X - red meats
X - eggs
X- butter
X - stick margarine
X - lard
X - solid shortening
should be reduced or eliminated from diets. If triglyceride levels are high,
X - alcohol
X - simple sugars
should be reduced.
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) - correct answer All patients to reduce CAD risk
10. a. The Therapeutic Lifestyle Changes diet includes recommendations for all people, not just those with risk factors, to decrease the risk for CAD.
11. Patient-Centered Care: A 62-yr-old woman has prehypertension (BP 138/88 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
b. Exercise instruction only
c. Diet therapy and smoking cessation
d. Drug therapy and smoking cessation - correct answer Diet therapy and smoking cessation
c. Without the total serum cholesterol and HDL results, diet therapy and smoking cessation are indicated for this patient without CAD who has prehypertension and an LDL level ≥130 mg/dL.
When the patient's LDL level is 75 to 189 mg/dL with a 10-year risk for CVD of 7.5% or above, drug therapy would be added to diet therapy. Because tobacco use is related to increased BP and LDL level, the benefit of smoking cessation is almost immediate. Exercise is indicated to reduce risk factors throughout treatment
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) - correct answer Unstable angina
ST-segment-elevation myocardial infarction (STEMI)
Non-ST-segment-elevation myocardial infarction (NSTEM
c, d, e. Unstable angina, ST-segment-elevation myocardial
infarction (STEMI), and non-ST-segment-elevation myocardial infarction (NSTEMI) are conditions that are manifestations of acute coronary syndrome (ACS). The other options are not manifestations of ACS
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 - correct answer Increased cardiac workload with aortic stenosis
Angina in the patient with atherosclerotic coronary arteries
Left ventricular hypertrophy caused by chronic hypertension
Sympathetic nervous system stimulation by drugs, emotions, or exertion
b, d, e, f. Increased oxygen demand is caused by increasing the workload of the heart, including left ventricular hypertrophy with hypertension, sympathetic nervous stimulation, and anything precipitating angina. Hypovolemia, anemia, and narrowed coronary arteries contribute to decreased oxygen supply.
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 - correct answer Lactic acid accumulation during anaerobic metabolism
c. When the coronary arteries are occluded, contractility ceases after several minutes, depriving the myocardial cells of glucose and oxygen for aerobic metabolism. Anaerobic metabolism begins and lactic acid accumulates, irritating myocardial nerve fibers that then transmit a pain message to the cardiac nerves and upper thoracic posterior roots. The other factors may occur during vessel occlusion but are not the source of pain.
15. What types of angina can occur in the absence of CAD (select all that apply)?
a. Silent ischemia
b. Nocturnal angina
c. Prinzmetal's angina
d. Microvascular angina
e. Chronic stable angina - correct answer Microvascular angina
Prinzmetal's angina
c, d. Prinzmetal's angina and microvascular angina may occur in the absence of CAD but with arterial spasm in Prinzmetal's angina or abnormalities of the coronary microcirculation.
16. Which characteristics describe unstable angina (select all that apply)?
a. Usually precipitated by exertion
b. New-onset angina with minimal exertion
c. Occurs only when the person is recumbent
d. Characterized by increased duration or severity
e. Usually occurs in response to coronary artery spasm - correct answer New-onset angina with minimal exertion
Characterized by increased duration or severity
b, d. Unstable angina is new-onset angina occurring at rest or with minimal exertion and increases in frequency, duration, or severity. Chronic stable angina is usually precipitated by exertion.
Angina decubitus occurs when the person is . - correct answer recumbent
Prinzmetal's angina is frequently caused by a - correct answer coronary artery spasm.
Silent ischemia is prevalent in persons with diabetes mellitus and contributes - correct answer to asymptomatic myocardial ischemia.
Nocturnal angina occurs - correct answer only at night.
Chronic stable angina refers to chest pain that occurs with the same pattern of - correct answer onset
duration
intensity
intermittently over a long period of time.
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.
b. causes reflex hypotension
c. may lead to atrial dysrhythmias.
d. impairs perfusion of the coronary arteries. - correct answer impairs perfusion of the coronary arteries.
d. An increased heart rate (HR) decreases the time the heart spends in diastole, which is the time of greatest coronary blood flow. Unlike other arteries, coronary arteries are perfused when the myocardium relaxes and blood backflows from the aorta into the sinuses of Valsalva, which have openings to the right and left coronary arteries. Thus the heart has a decreased oxygen supply at a time when there is an increased oxygen demand.
Tachycardia may also lead to ventricular dysrhythmia. The other options are incorrect.
18. Which effects contribute to making nitrates the first-line therapy for the treatment of angina (select all that apply)?
a. Decrease preload
b. Decrease afterload
c. Dilate coronary arteries
d. Decrease heart rate (HR)
e. Prevent thrombosis of plaques
f. Decrease myocardial contractility - correct answer Decrease preload
Decrease afterload
Dilate coronary arteries
a, b, c. Nitrates decrease preload and afterload to decrease the coronary workload and dilate coronary arteries to increase coronary blood supply. The other options are not attributed to nitrates.
19. The patient has used sublingual nitroglycerin (NTG) 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. Captopril
b. Clopidogrel (Plavix)
c. Diltiazem (Cardizem)
d. Metoprolol (Lopressor) - correct answer Captopril
a. Captopril would be added. It is an angiotensin- converting enzyme (ACE) inhibitor that vasodilates and decreases endothelial dysfunction and may prevent ventricular remodeling.
20. When instructing the patient with angina about taking sublingual NTG 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 that 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 - correct answer To lie or sit and place one tablet under the tongue when chest pain occurs
a. A common complication of nitrates is dizziness caused
by orthostatic hypotension, so the patient should sit or lie down and place the tablet under the tongue. The tablet should be allowed to dissolve under the tongue. To prevent the tablet from being swallowed, water should not be taken with it.
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 - correct answer To sit for 2 to 5 minutes before standing when getting out of bed
a. Orthostatic hypotension may cause dizziness and falls in older adults taking antianginal agents that decrease preload. Patients should be cautioned to change positions slowly. Daily exercise programs are indicated for older adults and may increase performance, endurance, and ability to tolerate stress. A change in lifestyle behaviors may increase the quality of life and reduce the risks of CAD, even in the older adult. Aspirin is commonly used in these patients and is not contraindicated
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. Rupture of unstable plaque may cause complete thrombosis of the vessel lumen.
d. Spasm of a major coronary artery may cause total occlusion of the vessel with progression to [Show Less]