CORONARY ARTERY DISEASE

Questions and Answers with Rationale

1. The community health nurse is planning health promotion teaching targeted at preventing
coronary artery disease (CAD). Which ethnic group would the nurse select as the highest priority
for this intervention?

A. White male
B. Hispanic male
C. African American male
D. Native American female

Answer and Rationale:

A. The incidence of CAD and myocardial infarction (MI) is highest among white, middle-aged
men. Hispanic individuals have lower rates of CAD than non-Hispanic whites or African
Americans. African Americans have an earlier age of onset and more severe CAD than whites
and more than twice the mortality rate of whites of the same age. Native Americans have
increased mortality in less than 35-year-olds and have major modifiable risk factors such as
diabetes

2. Which individuals would the nurse identify as having the highest risk for 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 and Rationale:

A. The 45-year-old depressed male with a high-stress job is at the highest risk for CAD. Studies
demonstrate that depression and stressful states can contribute to the development of CAD.
Elevated HDL levels and low homocysteine levels actually help to prevent CAD. Although a
sedentary lifestyle is a risk factor, a BMI of 23 kg/m2 depicts normal weight, and thus the patient
with two risk factors is at greatest risk for developing CAD.

3. When providing nutritional counseling for patients at risk for CAD, which foods would the
nurse encourage patients to include in their diet (select all that apply)?

A. Tofu
B. Walnuts
C. Tuna fish
D. Whole milk
E. Orange juice
Answer and Rationale:

A, B, C: Tuna fish, tofu, and walnuts are all rich in omega-3 fatty acids, which have been shown
to reduce the risks associated with CAD when consumed regularly.

4. Which antilipemic medications should the nurse question for a patient with cirrhosis of the
liver (select all that apply)?

A. Niacin (Nicobid)
B. Ezetimibe (Zetia)
C. Gemfibrozil (Lopid)
D. Atorvastatin (Lipitor)
E. Cholestyramine (Questran)

Answer and Rationale:

B and D: Ezetimibe (Zetia) should not be used by patients with liver impairment. Adverse effects
of atorvastatin (Lipitor), a statin drug, include liver damage and myopathy. Liver enzymes must
be monitored frequently and the medication stopped if these enzymes increase. Niacin's side
effects subside with time, although decreased liver function may occur with high doses.
Cholestyramine is safe for long-term use.

5. After teaching a patient with chronic stable angina about nitroglycerin, the nurse recognizes
the need for further teaching when the patient makes which statement?

A. "I will replace my nitroglycerin supply every 6 months."

B. "I can take up to five tablets every 3 minutes for relief of my chest pain."
C. "I will take acetaminophen (Tylenol) to treat the headache caused by nitroglycerin."
D. "I will take the nitroglycerin 10 minutes before planned activity that usually causes chest
pain."

Answer and Rationale:

B. "I can take up to five tablets every 3 minutes for relief of my chest pain." The recommended
dose of nitroglycerin is one tablet taken sublingually (SL) or one metered spray for symptoms of
angina. If symptoms are unchanged or worse after 5 minutes, the patient should be instructed to
activate the emergency medical services (EMS) system. If symptoms are improved, repeat the
nitroglycerin every 5 minutes for a maximum of three doses and contact EMS if symptoms have
not resolved completely.

6. The nurse would assess a patient with complaints of chest pain for which clinical
manifestations associated with a myocardial infarction (MI) (select all that apply)?
A. Flushing
B. Ashen skin
C. Diaphoresis
D. Nausea and vomiting
E. S3 or S4 heart sounds

Answer and Rationale:

B, C, D, E. During the initial phase of an MI, catecholamines are released from the ischemic
myocardial cells, causing increased sympathetic nervous system (SNS) stimulation. This results
in the release of glycogen, diaphoresis, and vasoconstriction of peripheral blood vessels. The
patient's skin may be ashen, cool, and clammy (not flushed) as a result of this response. Nausea
and vomiting may result from reflex stimulation of the vomiting center by severe pain.
Ventricular dysfunction resulting from the MI may lead to the presence of the abnormal S3 and
S4 heart sounds.

7. When planning emergent care for a patient with a suspected MI, what should the nurse
anticipate administrating?

A. Oxygen, nitroglycerin, aspirin, and morphine

B. Oxygen, furosemide (Lasix), nitroglycerin, and meperidine
C. Aspirin, nitroprusside (Nipride), dopamine (Intropin), and oxygen
D. Nitroglycerin, lorazepam (Ativan), oxygen, and warfarin (Coumadin)

Answer and Rationale:

A. Oxygen, nitroglycerin, aspirin, and morphine. The American Heart Association's guidelines
for emergency care of the patient with chest pain include the administration of oxygen,
nitroglycerin, aspirin, and morphine. These interventions serve to relieve chest pain, improve
oxygenation, decrease myocardial workload, and prevent further platelet aggregation. The other
medications may be used later in the patient's treatment.

8. The nurse is providing teaching to a patient recovering from an MI. How should resumption of
sexual activity be discussed?

A. Delegated to the primary care provider

B. Discussed along with other physical activities
C. Avoided because it is embarrassing to the patient
D. Accomplished by providing the patient with written material

Answer and Rationale:

B. Discussed along with other physical activities. Although some nurses may not feel
comfortable discussing sexual activity with patients, it is a necessary component of patient
teaching. It is helpful to consider sex as a physical activity and to discuss or explore feelings in
this area when other physical activities are discussed. Although providing the patient with
written material is appropriate, it should not replace a verbal dialogue that can address the
individual patient's questions and concerns.

9. Postoperative care of a patient undergoing coronary artery bypass graft (CABG) surgery
includes monitoring for what common complication?

A. Dehydration
B. Paralytic ileus
C. Atrial dysrhythmias
D. Acute respiratory distress syndrome

Answer and Rationale:

C. Atrial dysrhythmias; Postoperative dysrhythmias, specifically atrial dysrhythmias, are

common in the first 3 days following CABG surgery. Although the other complications could
occur, they are not common complications.

10. A patient was admitted to the emergency department (ED) 24 hours earlier with complaints
of chest pain that were subsequently attributed to ST-segment-elevation myocardial infarction
(STEMI). What complication of MI should the nurse anticipate?

A. Unstable angina
B. Cardiac tamponade
C. Sudden cardiac death
D. Cardiac dysrhythmias

Answer and Rationale:

D. Cardiac dysrhythmias; The most common complication after MI is dysrhythmias, which are
present in 80% of patients. Unstable angina is considered a precursor to MI rather than a
complication. Cardiac tamponade is a rare event, and sudden cardiac death is defined as an
unexpected death from cardiac causes. Cardiac dysfunction in the period following an MI would
not be characterized as sudden cardiac death.

11. The client with coronary artery disease asks the nurse, "Why do I get chest pain?" Which
statement would be the most appropriate response by the nurse?

A. "Chest pain is caused by decreased oxygen to the heart muscle."

B. "There is ischemia to the myocardium as a result of hypoxemia."
C. "The heart muscle is unable to pump effectively to perfuse the body."
D. "Chest pain occurs when the lungs cannot adequately oxygenate the blood."

Answer and Rationale:

 A. "Chest pain is caused by decreased oxygen to the heart muscle." This is a correct
statement presented in layman's terms. When the coronary arteries cannot supply
adequate oxygen to the heart muscle, there is chest pain

12.The nurse is discussing angina with a client who is diagnosed with coronary artery disease.
Which action should the client take first when experiencing angina?

A. Put a nitroglycerin tablet under the tongue.

B. Stop the activity immediately and rest.
C. Document when and what activity caused angina.
D. Notify the health-care provider immediately.

Answer and Rationale:

B. Stop the activity immediately and rest. Stopping the activity decreases the heart's need for
oxygen and may help decrease the angina (chest pain).

13. When developing a teaching plan for a 61-year-old man with the following risk factors for
coronary artery disease (CAD), the nurse should focus on the
a. family history of coronary artery disease.
b. increased risk associated with the patient's gender.
c. increased risk of cardiovascular disease as people age.
d. elevation of the patient's low-density lipoprotein (LDL) level.

Answer and Rationale:

d.elevation of the patient's low-density lipoprotein (LDL) level. 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.

14. Which nursing intervention will be most effective when assisting the patient with coronary
artery disease (CAD) to make appropriate dietary changes?
a. Give the patient a list of low-sodium, low-cholesterol foods that should be included in the diet.
b. Emphasize the increased risk for heart problems unless the patient makes the dietary changes.
c. Help the patient modify favorite high-fat recipes by using monosaturated oils when possible.
d. Inform the patient that a diet containing no saturated fat and minimal salt will be necessary.

Answer and Rationale:

C. Help the patient modify favorite high-fat recipes by using monounsaturated oils when
possible. 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 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 (TLC) 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.

15. Which assessment data collected by the nurse who is admitting a patient with chest pain
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.

Answer and Rationale:

B. The pain has lasted longer than 30 minutes. 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.

16. Which information given by a patient admitted with chronic stable angina will help the nurse
confirm this diagnosis?
a. The patient states that the pain "wakes me up at night."
b. The patient rates the pain at a level 3 to 5 (0 to 10 scale).
c. The patient states that the pain has increased in frequency over the last week.
d. The patient states that the pain "goes away" with one sublingual nitroglycerin tablet.

Answer and Rationale:

D. The patient states that the pain "goes away" with one sublingual nitroglycerin tablet. 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.

17. 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 some nausea as a side effect of nitroglycerin."
b. "I should only take the nitroglycerin if I start to have chest pain."
c. "I will call an ambulance if I still have pain after taking 3 nitroglycerin 5 minutes apart."
d. "Nitroglycerin helps prevent a clot from forming and blocking blood flow to my heart."

Answer and Rationale:

C. "I will call an ambulance if I still have pain after taking 3 nitroglycerin 5 minutes apart."
The emergency medical services (EMS) system should be activated when chest pain or other
symptoms are not completely relieved after 3 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.

18.  Which statement made by a patient with coronary artery disease after the nurse has
completed teaching about 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."

Answer and Rationale:

D."I will miss being able to eat peanut butter sandwiches." 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.

19. 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 help
determine whether the patient has had an AMI?
a. Myoglobin
b. Homocysteine
c. C-reactive protein
d. Cardiac-specific troponin

Answer and Rationale:

D. Cardiac-specific troponin, 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 (CAD) but are not
helpful in determining whether an acute MI is in progress.

20. 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. decrease spasm of the coronary arteries.
c. increase the force of the heart contractions.
d. help prevent plaque from forming in the coronary arteries.

Answer and Rationale:

B. decrease spasm of the coronary arteries. 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. Lipid-lowering 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 oxygen demand.