[Osborn chapter] 40 Learning Outcomes [Number and Title ] Learning Outcome 1 Discuss the epidemiological factors of coronary artery disease (CAD) and define the risk factors. Learning Outcome 2 Define and identify the etiology and pathophysiology of CAD/ischemic heart disease and explain the nursing assessment data and interventions used when evaluating a patient with angina pectoris. Learning Outcome 3 Differentiate the three criteria used to evaluate ischemic heart disease and identify the pathologic significance of each criterion. Learning Outcome 4 Compare and contrast the pathogenesis of unstable angina, a non−Q wave, subendocardial, non–ST segment elevation myocardial infarction (MI), and a Q wave, transmural, ST segment elevation (MI). Learning Outcome 5 Identify the complications of an MI and discuss the variables that affect the prognosis of the patient with an MI. Learning Outcome 6 Identify which clinical manifestations and diagnostic findings can be an indication for coronary artery bypass graft surgery (CABG). Learning Outcome 7 Identify three possible complications of CABG and discuss nursing interventions that potentially reduce the incidence of these complications. Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice Copyright 2010 by Pearson Education, Inc.
Transcript
[Osborn chapter] 40
Learning Outcomes [Number and Title ]Learning Outcome 1 Discuss the epidemiological factors of coronary artery disease
(CAD) and define the risk factors.Learning Outcome 2 Define and identify the etiology and pathophysiology of
CAD/ischemic heart disease and explain the nursing assessment data and interventions used when evaluating a patient with angina pectoris.
Learning Outcome 3 Differentiate the three criteria used to evaluate ischemic heart disease and identify the pathologic significance of each criterion.
Learning Outcome 4 Compare and contrast the pathogenesis of unstable angina, a non−Q wave, subendocardial, non–ST segment elevation myocardial infarction (MI), and a Q wave, transmural, ST segment elevation (MI).
Learning Outcome 5 Identify the complications of an MI and discuss the variables that affect the prognosis of the patient with an MI.
Learning Outcome 6 Identify which clinical manifestations and diagnostic findings can be an indication for coronary artery bypass graft surgery (CABG).
Learning Outcome 7 Identify three possible complications of CABG and discuss nursing interventions that potentially reduce the incidence of these complications.
Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice Copyright 2010 by Pearson Education, Inc.
1. While doing client teaching about cardiac risk factors, the nurse knows that which of following laboratory tests, if abnormal, requires further teaching due to the risk for the development of coronary artery disease?
1. Elevated homocysteine 2. Elevated creatinine3. Elevated high density lipoprotein (HDL)4. Elevated INR
Correct Answer: Elevated homocysteine
Rationale: Elevated levels of homocysteine (Hyc > 15 µmol/L) are associated with an increased risk of CAD. Homocysteine is an amino acid that is a by-product of the enzyme reactions from meat, dairy products, vitamin, and mineral metabolism. Homocysteine causes endothelial ulceration and scarring, and increases procoagulant properties of blood, all leading to an increase in the risk of thrombus formation. Elevated creatinine indicates kidney disease. HDL is the good cholesterol, and when elevated it will decrease the risk for the development of CAD. INR is a laboratory test that measures blood clotting function, not CAD.
Cognitive Level: Evaluation Nursing Process: Implementation Client Need: Health Promotion and Maintenance LO: 1
Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice Copyright 2010 by Pearson Education, Inc.
2. When discussing cardiac risk factors with your client who was just admitted for an evaluation of chest pain, which factor puts this client at the highest risk for heart disease?
1. The client is overweight and carries the weight around the waist.2. The client’s mother died at age 70 of an acute myocardial infarction.3. The client is a single mother of four young children with a low income.4. The client has a desk job and works long hours.
Correct Answer: The client is overweight and carries the weight around the waist.
Rationale: Fat accumulation in the upper body, giving the body an appearance of an “apple,” has been linked to a greater risk of coronary artery disease (CAD) as opposed to a “pear” shape, with body fat accumulation in the gluteofemoral region. Abdominal obesity is associated with elevated levels of cholesterol and greater risk for CAD. If the client’s mother had died before age 55, that would be a risk factor. Being a single mother is not a specific risk factor for the development of CAD. Sedentary lifestyle is a risk factor, but not as significant as fat accumulation in the upper body.
Cognitive Level: EvaluationNursing Process: ImplementationClient Need: Health Promotion and Maintenance LO: 1
Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice Copyright 2010 by Pearson Education, Inc.
3. A 60-year-old male is being admitted to the hospital complaining of chest pain with ST segment depression on his ECG and nausea. His laboratory results are: increased homocysteine, increased c-reactive protein, decreased high-density lipoproteins, decreased hemoglobin, and normal cholesterol. Which of these laboratory results increases the risk of an acute cardiac event?
1. Homocysteine, c-reactive protein, and high-density lipoproteins2. Homocysteine, c-reactive protein, hemoglobin, and cholesterol3. C-reactive protein, hemoglobin, and cholesterol 4. Homocysteine, c-reactive protein, hemoglobin, and high-density
lipoproteins
Correct Answer: Homocysteine, c-reactive protein, and high-density lipoproteins
Rationale: Elevations in homocysteine and c-reactive protein and a decrease in high-density lipoproteins increase the risk for heart disease. Because high-density lipoprotein is the good cholesterol that helps prevent the build-up of plaque in the wall of the arteries, the level should be high. The hemoglobin and cholesterol levels do not place the patient at increased risk.
Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice Copyright 2010 by Pearson Education, Inc.
4. A 48-year-old man is brought to the emergency department complaining of chest pain.The nurse performs an assessment of the client. Which of the following symptoms, if present, would be most characteristic of an acute myocardial infarction?
1. Substernal pressure-type pain, radiating down the left arm2. Coli-like epigastric pain3. Sharp, well-localized unilateral chest and left arm pain4. Sharp, burning chest pain moving from place to place
Correct Answer: Substernal pressure-type pain, radiating down the left arm
Rationale: The clinical manifestations of angina pectoris include a sudden onset of discomfort in the chest, jaw, shoulder, back, or arm, aggravated by exertion or emotional stress. Terms such as burning, crushing, suffocating, and pressure are typical descriptors of chest pain from myocardial ischemia, often with pain radiating to other areas of the upper torso. Cardiac chest pain is not usually described as coli-like, localized to a defined spot such as the epigastric area, or as a sharp pain.
Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice Copyright 2010 by Pearson Education, Inc.
5. Prinzmetal or variant angina is a more serious type of chest pain because:
1. It indicates there is a large area of myocardial ischemia.2. It indicates there is associated renal disease.3. It indicates there is associated pulmonary disease.4. It indicates the presence of a myocardial infarction.
Correct Answer: It indicates there is a large area of myocardial ischemia.
Rationale: Variant, prinzmetal, or vasospastic angina is the most serious type of angina. It occurs when single or multiple sites in major coronary arteries and their large branches have vasospasm, thereby cutting off the blood supply to a large area of the myocardium.Prinzmetal angina does not occur due to renal disorders or pulmonary disorders, and is not specifically diagnostic for a myocardial infarction.
Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice Copyright 2010 by Pearson Education, Inc.
6. A client enters the emergency department complaining of chest pain that is radiating down the left arm. The emergent treatment for this client includes:
Select all that apply.
1. Morphine intravenously and oxygen. 2. Aspirin 325 mg po.3. Open-heart surgery.4. Heparin drip at 100 units per hour.5. Foley catheter insertion.
Rationale: Morphine intravenously and oxygen. The mnemonic MONA, cited in the Advanced Cardiac Life Support (ACLS) guidelines, describes a protocol for treatment of clients with suspected myocardial infarction. The mnemonic stands for morphine, oxygen, nitroglycerin, and aspirin. MONA does not, however, imply a correct sequencing of treatment. Aspirin 325 mg po. The mnemonic MONA stands for morphine, oxygen, nitroglycerin, and aspirin. While the mnemonic does not imply a correct sequencing of treatment, it does describe a protocol for treatment of clients with suspected myocardial infarction. Open-heart surgery. Open heart surgery may be indicated later, but not on admission to the emergency department. Heparin drip at 100 units per hour. Heparin is not part of the admission protocol. Foley catheter insertion. A Foley catheter is not part of the admission protocol.
Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice Copyright 2010 by Pearson Education, Inc.
7. Following a transmural myocardial infarction, which ECG change stays with the client for the rest of his or her life?
1. Q wave deepening2. ST segment elevation3. ST segment depression4. P wave inversion
Correct Answer: Q wave deepening
Rationale: The development of an abnormal Q wave is a definitive diagnostic sign of myocardial necrosis. Since it is indicative of a necrosis, it stays with the client for the rest of his or her life. ST segment elevation represents myocardial ischemia, which is reversible by increasing the blood flow to the heart. ST segment depression occurs when muscle ischemia involves only a portion of the heart wall. P wave inversion represents a junctional pacemaker in the heart and is not related to changes that occur with a myocardial infarction.
Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice Copyright 2010 by Pearson Education, Inc.
8. The nurse is admitting a client who reports he has had chest pain, nausea, and vomiting off and on for the last 4 days. He decided to come to the hospital because he thought he had the flu. Which laboratory tests will provide information about acute cardiac damage for this client?
1. Troponin I and T 2. Red blood cells3. CPK-MB 4. Homocysteine and platelets
Correct Answer: Troponin I and T
Rationale: The levels of Troponin T begin to rise within 3 to 6 hours after myocardial injury and remain elevated for 14 to 21 days. Levels of Troponin I begin to increase in about 3 to 5 hours after myocardial ischemia and peak at 14 to 18 hours and remain elevated for 5 to 7 days. Red blood cells are unaffected by acute cardiac damage. The CK-II MB rises within 3 to 6 hours after the MI, peaks within 12 to 24 hours, and levels return to normal 2 to 3 days following the infarction. This client would most likely have normal valves 4 days out from the onset of symptoms. Homocysteine does not change with acute cardiac damage. Platelets are unaffected by acute cardiac damage.
Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice Copyright 2010 by Pearson Education, Inc.
9. Fifteen hours after admission, your client’s CPK-MB level is markedly increased. Which interpretation of the findings by the nurse would be appropriate?
1. Cellular necrosis of myocardial tissue has occurred.2. Lactic acid is present.3. Thrombolytic therapy is indicated.4. Cardiac function has returned to normal.
Correct Answer: Cellular necrosis of myocardial tissue has occurred.
Rationale: CPK-MB is the intracellular enzyme that is released when cell damage and death occur. The ph is the indicator of lactic acid build-up. Thrombolytic therapy is indicated within the first 12 hours after symptoms develop; thus, it is too late for this intervention. Cardiac function has not returned to normal; CPK-MB becomes elevated when myocardial cell death has occurred.
Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice Copyright 2010 by Pearson Education, Inc.
10. The change on the ECG tracing associated with transmural myocardial damage is:
1. ST segment elevation.2. Loss of P waves.3. Bradycardia.4. Widening of the QRS complex.
Correct Answer: ST segment elevation.
Rationale: Transmural damage is present with ST segment elevation. Loss of P waves occurs with atrial flutter and fibrillation. Bradycardia can be a normal or abnormal rhythm. It is not specifically associated with transmural damage. Widening of the QRS complex occurs with bundle branch block. It is not specifically associated with transmural damage.
Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice Copyright 2010 by Pearson Education, Inc.
11. The final extent of cardiac damage after an acute myocardial infarction (AMI) is dependent upon:
1. Reperfusing the ischemic zone.2. The client's ethnicity.3. The client's gender.4. Development of heart block.
Correct Answer: Reperfusing the ischemic zone.
Rationale: Surrounding the area of infarction is the zone of injury and the zone of ischemia. These zones are made of potentially viable tissues. They can become necrotic and die, or be reperfused and remain functional. The goal of treatment for an AMI is to establish reperfusion as early as possible to prevent necrosis and salvage the myocardium. The client’s ethnicity does not impact the final extent of cardiac damage, nor does the client’s gender. Developing a heart block does not impact cardiac damage.
Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice Copyright 2010 by Pearson Education, Inc.
12. Both STEMI and NSTEMI are classified according to the coronary artery involved. Occlusion of the left anterior descending (LAD) artery is referred to as a/an:
Rationale: The left anterior descending artery is referred to as an anterior wall infarct. The circumflex artery is referred to as a lateral wall infarct. The right coronary artery is referred to as an inferior wall infarct. The posterior descending artery is referred to as a posterior wall infarct.
Rationale: Hemorrhage or bleeding is the most common risk; it can be life-threatening. Recurrent chest pain, lethargy, and heart block are not associated with thrombolytic therapy.
Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice Copyright 2010 by Pearson Education, Inc.
14. The nurse hears a S3 and lung crackles in a 75-year-old client with a recent
myocardial infarction (MI). This indicates:
1. Heart failure. 2. Extension of the MI. 3. Renal failure.4. Liver failure.
Correct Answer: Heart failure.
Rationale: S3 and lung crackles are indications of heart failure. Manifestations of MI
extension include chest pain and a return of positive laboratory finding (CPK-MB and troponin). Renal failure is a late complication of heart failure and is not manifested with an S3 and crackles. Liver failure is not manifested with an S3 and
Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice Copyright 2010 by Pearson Education, Inc.
15. Prevention of cell death, reversing cell injury, limiting infarct size or extension, and preventing myocardial remodeling are all dependent on a number of adaptive responses to acute and chronic ischemia, which include:
Select all that apply. 1. The timing of reperfusion2. The presence of ischemic preconditioning3. The extent of collateral circulation4. The amount of myocardial stunning and hibernation5. The amount of cellular apoptosis
Correct Answer: 1. The timing of reperfusion2. The presence of ischemic preconditioning3. The extent of collateral circulation4. The amount of myocardial stunning and hibernation5. The amount of cellular apoptosis
Rationale: The timing of reperfusion. Reperfusion within 20 minutes will abort cell death. The presence of ischemic preconditioning. Vessels with chronic subacute thrombosis lasting a few minutes precondition the tissue for periods of longer ischemia, protecting it from infarction. The extent of collateral circulation. Chronic, progressive coronary obstruction also stimulates the development of coronary collateral vessels. The amount of myocardial stunning and hibernation. Myocardial tissue stunning and hibernation are conditions of reversible muscle contractile dysfunction thought to be adaptive responses to chronic coronary occlusion. The amount of cellular apoptosis. Apoptosis may contribute to the overall magnitude of ischemic necrosis and myocardial remodeling.
Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice Copyright 2010 by Pearson Education, Inc.
16. When teaching a client about coronary artery bypass surgery, the nurse understands that:
1. The client must still reduce or modify cardiac risk factors.2. The surgery will prolong life by 2 years.3. The surgery may only provide a minimal chance of functional
improvement.4. The client will be cured of atherosclerosis.
Correct Answer: The client must still reduce or modify cardiac risk factors.
Rationale: It is essential that the client understand that the goal of the surgery is to relieve the symptoms and improve the quality of life. The client must still reduce or modify controllable risk factors to retard the underlying process. Research indicates that life expectancy is prolonged by greater than 15 years following CABG. Less than 10% of clients who undergo CABG will need subsequent revascularization within 5 to 7 years. CABG provides more complete revascularization and shows better long-term relief of symptoms than percutaneous coronary interventions. The surgery is not done to cure atherosclerosis.
Cognitive Level: Evaluating Nursing Process: Implementation Client Need: Health Promotion and Maintenance LO: 6
Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice Copyright 2010 by Pearson Education, Inc.
17. Under what circumstances would clients with ST elevation MI require immediate revascularization?
Select all that apply.1. Persistent chest pain 2. Hemodynamic instability 3. Repair of postinfarction ventricular septal rupture or mitral
insufficiency4. Cardiogenic shock in clients less than 75 years old 5. Life-threatening ventricular dysrhythmias and > 50% left main
stenosis and/or triple-vessel disease
Correct Answer: 1. Persistent chest pain 2. Hemodynamic instability 3. Repair of postinfarction ventricular septal rupture or mitral
insufficiency4. Cardiogenic shock in clients less than 75 years old 5. Life-threatening ventricular dysrhythmias and > 50% left main
stenosis and/or triple-vessel disease
Rationale: Persistent chest pain. Performing surgery amid an acute MI greatly increases the risks of perioperative complications. The American Academy of Cardiology includes persistent chest pain in its recommendations for these clients. Hemodynamic instability. Performing surgery amid an acute MI greatly increases the risks of perioperative complications. The American Academy of Cardiology includes hemodynamic instability in its recommendations for these clients. Repair of postinfarction ventricular septal rupture or mitral insufficiency. Performing surgery amid an acute MI greatly increases the risks of perioperative complications. The American Academy of Cardiology includes repair of postinfarction ventricular septal rupture or mitral insufficiency in its recommendations for these clients. Cardiogenic shock in clients less than 75 years old. Performing surgery amid an acute MI greatly increases the risks of perioperative complications. The American Academy of Cardiology includes cardiogenic shock in clients less than 75 years old in its recommendations for these clients. Life-threatening ventricular dysrhythmias and > 50% left main stenosis and/or triple-vessel disease. Performing surgery amid an acute MI greatly increases the risks of perioperative complications. The American Academy of Cardiology includes life-threatening ventricular dysrhythmias and > 50% left main stenosis and/or triple-vessel disease in its recommendations for these clients.
Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice Copyright 2010 by Pearson Education, Inc.
Client Need: Safe, Effective Care EnvironmentLO: 6
Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice Copyright 2010 by Pearson Education, Inc.
18. When the client arrives in the intensive care unit following CABG surgery, the nurse obtains the reports from laboratory work including chemistries, a complete blood count (CBC), arterial blood gases (ABGs), and a chest x-ray; an ECG should be done as soon as possible. The rationale for obtaining this data is:
1. To establish a baseline for future assessments.2. To provide the client’s family with the information.3. To provide fellow nurses with the information. 4. To report to the surgery nurses.
Correct Answer: To establish a baseline for future assessments.
Rationale: It is essential to have this baseline information in order to assess trends and changes in the client’s condition. Providing the client’s family with the information is not the primary reason for obtaining the information. There is no need for fellow nurses to know this information.
Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice Copyright 2010 by Pearson Education, Inc.
19. The nurse is doing the discharge teaching for a client who has undergone coronary artery bypass surgery. The client states that it feels good to be cured of heart disease. Understanding that denial is a common coping mechanism for cardiac clients, which response is the most appropriate?
Select all that apply.1. “The surgery only relieves the symptoms; it does not cure the disease.” 2. “You must continue to modify your cardiac risk factors.”3. “You are correct, your heart is now normal.”4. “You should not ever exercise again.” 5. “There no need to monitor your fat intake any longer.”
Correct Answer: 1. “The surgery only relieves the symptoms; it does not cure the disease.”2. “You must continue to modify your cardiac risk factors.”
Rationale: “The surgery only relieves the symptoms; it does not cure the disease.” Denial is a common coping mechanism with cardiac patients; therefore, it is essential for the nurse to stress that CABG is not a cure for CAD. “You must continue to modify your cardiac risk factors.” Atherosclerosis is a progressive disease; therefore, the client needs to continue to modify risk factors. “You are correct, your heart is now normal.” CABG only relives symptoms, it does not cure the disease. “You should not ever exercise again.” The client should begin a cardiac rehabilitation program with a progressive exercise program. “There no need to monitor your fat intake any longer.” The client must continue to modify risk factors such as fat intake.
Cognitive Level: CreatingNursing Process: Implementation Client Need: Health Promotion and Maintenance LO: 7
Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice Copyright 2010 by Pearson Education, Inc.
20. Depending on the institution and surgeon, a patient will have between two and four chest tubes. The nurse documents chest tube output hourly. What should the nurse do if there is an increase in output of greater than 100 milliliters in 1 hour?
Select all that apply. 1. Report to the surgeon.2. Check the hemoglobin and hematocrit. 3. Administer a blood transfusion.4. Notify the family.5. Nothing, as this is normal.
Correct Answer: 1. Report to the surgeon.2. Check the hemoglobin and hematocrit.
Rationale: Report to the surgeon. It is abnormal to have greater than 100 milliliters of drainage in 1 hour. It may indicate bleeding and needs to be assessed by the surgeon. Check the hemoglobin and hematocrit. It is abnormal to have greater than 100 milliliters of drainage in 1 hour. It may indicate bleeding; therefore, checking the hemoglobin and hematocrit is indicated. Administer a blood transfusion. The patient needs to be assessed along with the laboratory data before it is determined if a blood transfusion is necessary. Notify the family. There is no need to notify family until the patient has been assessed. It may not be of significance. Nothing, as this is normal. It is abnormal to have greater than 100 milliliters of drainage in one hour.
Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice Copyright 2010 by Pearson Education, Inc.
21. You are caring for a client who had a stroke following CABG surgery. The client’s family asks what caused this to happen. You respond:
1. “Stroke is usually caused by a blood clot that breaks loose and travels to the brain.”
2. “Stroke is usually caused by ruptured plaque inside the coronary artery.”
3. “Stroke is caused by heart failure.”4. “No one knows what causes strokes.”
Correct Answer: “Stroke is usually caused by a blood clot that breaks loose and travels to brain.”
Rationale: Stroke is usually caused by an embolus from the ascending aorta or aortic arch, which travels through the heart into the vessels leading to the brain. Plaque inside a coronary artery would travel downstream and lodge in a smaller vessel in the heart. Heart failure does not cause a stroke. Stating that no one knows what causes strokes is not a true statement; blood clots and ruptured vessels cause strokes.
Cognitive Level: ApplicationNursing Process: ImplementationClient Need: Health Promotion and Maintenance LO: 7
Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice Copyright 2010 by Pearson Education, Inc.
