(Osborn Chapter) 40: Learning Outcomes (Number and Title)

[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
nonQ wave, subendocardial, nonST 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.
2.
3.
4.
Elevated homocysteine
Elevated creatinine
Elevated high density lipoprotein (HDL)
Elevated INR
Correct Answer: Elevated homocysteine

Rationale: Elevated levels of homocysteine (Hyc > 15 mol/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

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.
2.
3.
4.
The client is overweight and carries the weight around the waist.
The clients mother died at age 70 of an acute myocardial infarction.
The client is a single mother of four young children with a low income.
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
clients 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: Evaluation
LO: 1

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.
2.
3.
4.
Homocysteine, c-reactive protein, and high-density lipoproteins

Homocysteine, c-reactive protein, hemoglobin, and cholesterol
C-reactive protein, hemoglobin, and cholesterol
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 highdensity 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.
Cognitive Level: Application
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 1

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.
2.
3.
4.
Substernal pressure-type pain, radiating down the left arm

Coli-like epigastric pain
Sharp, well-localized unilateral chest and left arm pain
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.
Cognitive Level: Analysis
LO: 2

Inc.
5. Prinzmetal or variant angina is a more serious type of chest pain because:

1.
2.
3.
4.
It indicates there is a large area of myocardial ischemia.

It indicates there is associated renal disease.
It indicates there is associated pulmonary disease.
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.
LO: 2

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.
2.
3.
4.
5.
Morphine intravenously and oxygen.

Aspirin 325 mg po.
Open-heart surgery.
Heparin drip at 100 units per hour.
Foley catheter insertion.
Correct Answer:
1. Morphine intravenously and oxygen.
2. Aspirin 325 mg po.
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.
LO: 2

Inc.
7. Following a transmural myocardial infarction, which ECG change stays with the client
for the rest of his or her life?
1.
2.
3.
4.
Q wave deepening
ST segment elevation
ST segment depression
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.
LO: 3

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.
2.
3.
4.
Troponin I and T
Red blood cells
CPK-MB
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.
LO: 3

Inc.
9. Fifteen hours after admission, your clients CPK-MB level is markedly increased.
Which interpretation of the findings by the nurse would be appropriate?
1.
2.
3.
4.
Cellular necrosis of myocardial tissue has occurred.

Lactic acid is present.
Thrombolytic therapy is indicated.
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.
LO: 3

Inc.
10. The change on the ECG tracing associated with transmural myocardial damage is:
1.
2.
3.
4.
ST segment elevation.
Loss of P waves.
Bradycardia.
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.
Nursing Process: Evaluation
LO: 4

Inc.
11. The final extent of cardiac damage after an acute myocardial infarction (AMI) is
dependent upon:
1.
2.
3.
4.
Reperfusing the ischemic zone.

The client's ethnicity.
The client's gender.
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 clients ethnicity does not impact the final extent of
cardiac damage, nor does the clients gender. Developing a heart block does not
impact cardiac damage.
Nursing Process: Evaluation
LO: 4

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:
1.
2.
3.
4.
Anterior wall infarct.

Lateral wall infarct.
Inferior wall infarct.
Posterior wall infarct.
Correct Answer: Anterior wall infarct.

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.
LO: 4

Inc.
13. Nursing care of the client after thrombolytic therapy centers around the assessment of
the most common complication, which is:
1.
2.
3.
4.
Bleeding.
Reperfusion chest pain.
Lethargy.
Heart block.
Correct Answer: Bleeding.

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.
LO: 5

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.
2.
3.
4.
Heart failure.
Extension of the MI.
Renal failure.
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
crackles.
LO: 5

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:
1. The timing of reperfusion
2. The presence of ischemic preconditioning
3. The extent of collateral circulation
4. The amount of myocardial stunning and hibernation
5. The amount of cellular apoptosis
Correct Answer:
1.
2.
3.
4.
5.
The timing of reperfusion

The presence of ischemic preconditioning
The extent of collateral circulation
The amount of myocardial stunning and hibernation
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.
Cognitive Level: Evaluating
LO: 5

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
LO: 6

Inc.
17. Under what circumstances would clients with ST elevation MI require immediate
revascularization?
1. Persistent chest pain
2. Hemodynamic instability
3. Repair of postinfarction ventricular septal rupture or mitral
insufficiency
4. 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
insufficiency
4. 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.
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.
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.

Inc.
Client Need: Safe, Effective Care Environment

LO: 6

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.
2.
3.
4.
To establish a baseline for future assessments.

To provide the clients family with the information.
To provide fellow nurses with the information.
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 clients condition. Providing the clients family with the
information is not the primary reason for obtaining the information. There is no
need for fellow nurses to know this information.
LO: 6

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?
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: Creating
LO: 7

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?
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.
Client Need: Safe, Effective Care Environment
LO: 7

Inc.
21. You are caring for a client who had a stroke following CABG surgery. The clients
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.
LO: 7

Inc.

(Osborn Chapter) 40: Learning Outcomes (Number and Title)

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(Osborn Chapter) 40: Learning Outcomes (Number and Title)

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[Osborn chapter] 40

Learning Outcomes [Number and Title ]

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Correct Answer: Elevated homocysteine

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Homocysteine, c-reactive protein, and high-density lipoproteins

Correct Answer: Homocysteine, c-reactive protein, and high-density lipoproteins

Osborn, et al., Test Item File for Medical-Surgical Nursing:

4. A 48-year-old man is brought to the emergency department complaining of chest pain.

Substernal pressure-type pain, radiating down the left arm

Osborn, et al., Test Item File for Medical-Surgical Nursing:

5. Prinzmetal or variant angina is a more serious type of chest pain because:

It indicates there is a large area of myocardial ischemia.

Correct Answer: It indicates there is a large area of myocardial ischemia.

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Morphine intravenously and oxygen.

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Correct Answer: Q wave deepening

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Correct Answer: Troponin I and T

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Cellular necrosis of myocardial tissue has occurred.

Correct Answer: Cellular necrosis of myocardial tissue has occurred.

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Correct Answer: ST segment elevation.

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Reperfusing the ischemic zone.

Correct Answer: Reperfusing the ischemic zone.

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Anterior wall infarct.

Correct Answer: Anterior wall infarct.

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Correct Answer: Bleeding.

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Correct Answer: Heart failure.

Osborn, et al., Test Item File for Medical-Surgical Nursing:

The timing of reperfusion

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Client Need: Safe, Effective Care Environment

Osborn, et al., Test Item File for Medical-Surgical Nursing:

To establish a baseline for future assessments.

Correct Answer: To establish a baseline for future assessments.

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Osborn, et al., Test Item File for Medical-Surgical Nursing:

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