Initiating therapy with spironolactone for a patient who is also on an ACE inhibitor
NUR6550 Final Exam
1. The Valsalva maneuver and the squat-to-stand maneuver are likely to increase the sound of a cardiac murmur associated with which of these conditions?
2. Which of the following conditions may result in lower extremity edema?
Nephrotic syndrome
Decompensated congestive heart failure
Cirrhosis
Renal failure
Deep venous thrombosis
Late-stage pregnancy
All of the above
3. Art Bakke is a 46-year-old male who is being treated for an acute myocardial infarction. He has now developed significant dyspnea at rest and, per physical exam, has coarse rales involving the lower 2/3 of the lung fields bilaterally. You suspect acute pulmonary edema due to papillary-muscle rupture and acute mitral-valve regurgitation.
Question: Which of the following physical findings would support this diagnostic hypothesis?
A palpable diastolic murmur maximal in the second intercostal space (ICS) at the left sternal border
A harsh, rumbling, diastolic murmur heard maximally in the fourth ICS at the left sternal border
A holosystolic systolic murmur heard maximally in the fifth ICS at the midclavicular line
4. The most common ECG finding in a patient with a cardiomyopathy is an ST-elevation MI.
True
False
5. Nina Martinez is a 70-year-old female who experienced an episode of acute pulmonary edema following an endovascular aneurysm repair. She was discharged on furosemide 60 mg daily and instructed to follow up with cardiology. She is now seen in the office at 2 weeks post discharge. Her metabolic panel includes the following lab values:
· Na 126 mEq/L
· K 4.0 mEq/L
· Cl 93 mEq/L
· CO2 28 mEq/L
· BUN 40 mg/dL
· Cr 1.3 mg/dL
Question: This patient has which of the following abnormalities as a likely consequence of diuretic overuse?
Hyponatremia
Hypokalemia
Metabolic acidosis
6. Which of the following are primary cardiomyopathy categories, as described by the World Health Organization (WHO) in 1995?
Dilated cardiomyopathy
Symbol Hypertrophic cardiomyopathy (HCM)
Symbol Restrictive cardiomyopathy
Symbol Arrhythmogenic right ventricular dysplasia
Symbol Unclassified
All of the above
7. What is the most common cause of sudden cardiac death in young people?
What is the most common cause of sudden cardiac death in young people?
Myocardial infarction
Hypertrophic cardiomyopathy
Supraventricular tachycardia
Arrhythmogenic right ventricular dysplasia; aka arrhythmogenic right ventricular cardiomyopathy (ARVC)
8. Which of the following are treatment options for a patient who presents with peripartum cardiomyopathy while still carrying the fetus? (Select all that apply.)
ACE inhibitors
Induction if stable
Emergent cesarean section if unstable
Digoxin
Nitroglycerin
9. What are the 3 major clinical complications related to cardiomyopathies?
Arrhythmias; including ventricular tachycardia and ventricular fibrillation
Thromboembolic complications; including DVT, PE, and ventricular thrombi
Acute pulmonary edema
10. Some patients with primary cardiomyopathies remain asymptomatic throughout their lifetime.
True
False
11. A 38-year -old woman comes to the emergency department complaining of a rapid heartbeat, tremors, and chest tightness. She reports earlier in the day she was feeling a migraine starting so she took a pill given to her by her friend who also experiences migraines. Her medical history reveals that she is currently taking a monoamine oxidase inhibitor for depression. Which migraine medication did she most likely take?
Acetaminophen and caffeine (Excedrin ® Migraine)
Naproxen sodium (Aleve ® )
Almotriptan (Axert ® )
Butalbital, acetaminophen and caffeine (Fioricet ® )
12. You are seeing a 68-year-old woman for treatment of an uncomplicated urinary tract infection (UTI). She has well-controlled hypertension, type 2 diabetes mellitus, and dyslipidemia and takes an angiotensin-converting enzyme inhibitor (ACEI), statin, biguanide, and low-dose aspirin (ASA). She worked in a dry cleaning facility until approximately 8 years ago. During her evaluation, she mentions that she sometimes has difficulty understanding conversation, especially in noisy environments. This is likely a:
Drug-related reaction.
Consequence of occupational chemical exposure.
Early sign of dementia.
Normal age-related change in hearing
13. While evaluating a 33-year-old female with a 2-day history of dysuria, which of the following findings in urinalysis is most suggestive of urinary tract infection (UTI) caused by a Gram-negative organism?
Nitrites
30 mg/dL protein
Epithelial cells
pH>8
14. All of the following are examples of primary prevention strategies except:
Counseling an elderly patient prior to discharge about fall risk at home and how to prevent falls through adequate illumination.
Performing a hemoglobin A1C for all patients admitted to the hospital.
Conducting a study to identify the leading cause of mortality in teenagers and how to reduce risk.
Immunizing all adults ?60 years with zoster vaccine.
15. A 23-year-old woman is being evaluated for an upper respiratory tract infection. As you prepare for auscultation, the patient states “I have a benign murmur that has been with me my whole life”. Anticipating a physiologic murmur, you would expect which of the following characteristics?
Usually obliterates S2.
Becomes softer when going from a supine to standing position.
Occurs late in systole.
Has localized area of auscultation
16. You see a 73-year-old woman with a 40 pack- year smoking history, chronic obstructive pulmonary disease (COPD) and peripheral arterial disease (PAD) who presents with an ulcer on the sole of her left foot. The ulcer has an irregular edge and pale base and a punched out appearance, with the surrounding skin white and shiny. The patient states that the pain is worse at night in bed and when the legs are elevated. The most likely diagnosis is:
Pressure ulcer
Pyoderma gangrenosum
Venous ulcer
Arterial ulcer
17. You see a 76-year-old woman living at home who is accompanied by her home care provider. She has COPD and type 2 diabetes mellitus. An example of a secondary prevention strategy is:
Administering the seasonal influenza vaccine.
Screening for physical or financial abuse/Checking her blood glucose level.
Checking her blood pressure.
Adjusting her insulin dosing regimen.
18. A 43-year-old woman is being evaluated in the emergency department with a complaint of a severe headache. She describes a unilateral, pulsing headache that was preceded by a gradual onset of paresthesia affecting the ipsilateral face and arm. The patient stated she noticed a “funny smell” prior to the symptoms starting. This description is most typical of:
Migraine with aura.
Cluster headache.
Transient ischemic attack.
Tension-type headache.
19. You see a 54-year-old man living in subsidized housing with a history of hypertension. He states that he stopped taking his blood pressure medication about 4 months ago because of costs. He is concerned because his blood pressure is high whenever he checks it, though he does not report any symptoms. His BP at this visit is 196/104 mm Hg. Upon examination of this patient, you would expect to detect an S 4 sound heard during:
Early systole.
Late systole.
Early diastole.
Late diastole.
20. 32-year-old man requires evaluation for hepatitis infection prior to taking a job as a restaurant cook. He presents with the following laboratory results:
Hepatitis A Panel Hepatitis B Panel Hepatitis C Panel
Anti-HAV Negative HBsAg Negative Anti-HCV Positive
IgM Negative Anti-HBc Negative HCV RNA Negative
IgM NegativeAnti-HBs Positive
You recognize the patient is susceptible to:
Hepatitis A and B
Hepatitis B and C
Hepatitis B only
Hepatitis A only
21. When evaluating illness symptoms in older patients, the disease will often present differently from younger adults due to:
The likelihood of polypharmacy.
Decreased compensatory mechanisms in the elderly.
An increased physiologic response to illness in the elderly.
Presence of comorbid conditions.
22. When prioritizing risk factors for bacterial endocarditis, the nurse practitioner knows who among the following patients has the highest risk.
A 55-year-old man with 3-vessel coronary artery bypass grafts with stents.
A 23-year-old woman with mitral valve prolapse without tissue redundancy.
A 65-year-old man with nonobstructive cardiomyopathy.
A 75-year-old woman with a nonorganic prosthetic aortic valve.
23. The legal authority for NPs to perform healthcare services as defined by state law is called:
Duty of care.
Non-malfeasance.
Autonomy.
Scope of practice.
24. When developing a management plan for patients with genitourinary infections, which of the following would you most likely recommend for follow-up imaging following resolution of their infection?
A 27-year-old nonpregnant woman with acute, uncomplicated urinary tract infection (UTI).
A 38-year-old nonpregnant woman with 2 acute, uncomplicated UTIs in the past 9 months.
A 57-year-old man with acute bacterial prostatitis.
A 43-year-old man with type 2 diabetes mellitus and recurrent pyelonephritis.
25. The NP is called to evaluate Jane, a 43-year- old woman, who presents with a diffuse maculopapular rash that began on the trunk but now covers the entire body, including the palms and soles. The rash is not itchy but wart-like sores are present in the mouth and genital area as well as skin folds. Initial evaluation reveals generalized lymphadenopathy and a low-grade fever, and she complains of lethargy and headache. The patient reports that she had a painless genital ulcer that healed on its own about 3 weeks earlier. Which of the following is the most likely diagnosis?
Primary syphilis.
Secondary syphilis.
Genital herpes.
Gonorrhea.
26. A 27-year-old man presents with a chief concern of an abnormal mass within his left scrotum. He describes it as feeling like a “bag of worms” and is present when he is standing but disappears when he lies down. His past medical history is unremarkable and his BMI is 29 kg/m 2 . He has been in a monogamous relationship for the past 4months. The most likely diagnosis is:
Testicular torsion.
Syphilis.
Varicocele.
Testicular cancer.
27. An 18-year-old man is being evaluated for a severe exacerbation of asthma. He is currently taking an inhaled corticosteroid, a long- acting beta-agonist, and a short-acting beta-agonist on an as needed basis. The most important component of the initial assessment includes a(n):
Continuous pulse oximetry reading
Peak expiratory flow reading
Chest X-ray
Arterial Blood Gas
28. A 67-year-old man is being evaluated for shortness of breath. His medical history reveals that he experienced a myocardial infarction about 2 years ago and a history of hypertension, which is well controlled by diet.. Otherwise, his medical history is unremarkable. Which of the following would you expect to find on electrocardiogram (ECG)?
T wave inversion.
Pathologic Q wave.
ST segment elevation.
Tall R wave.
29. A 74-year-old male with asymptomatic atrial fibrillation underwent electrical cardioversion that successfully restored the heart’s rhythm. Which of the following medications can be considered for the purpose of maintaining the heart’s rhythm?
Sotalol (Betapace ® )
Digoxin (Lanoxin ® )
Dabigatran (Pradaxa ® )
Enalapri
30. A 14-year-old male is brought in for evaluation after he reportedly collapsed during a tennis match, though he quickly regained consciousness. His medical history is otherwise unremarkable. You suspect hypertrophic cardiomyopathy. Which of the following heart murmur characteristics would support the diagnosis?
Occurs late in systole.
Widely split S?.
Becomes louder when going from a supine to standing position.
Murmur follows mid-systolic click.
31. You see a 64-year-old man with an area of erythema concentrated on the left side of his neck with clusters of vesicles forming a line. He reported pain in the area a couple of days before the eruption of the lesions. He states that he recently initiated biologic therapy for rheumatoid arthritis. Which of the following is the most likely diagnosis?
Impetigo.
Herpes zoster.
Drug-related adverse reaction.
Viral exanthem.
32. An NP’s duty of care can be established:
Only in the setting of a healthcare institution (e.g., hospital, clinic, etc.).
When the NP gives professional advice or treatment in any setting.
Only when a fee is charged, either to the patient or third-party payer, for services.
Only when both the NP and patient acknowledge a patient-provider relationship.
33. In managing a 58-year- old woman who is admitted for deep vein thrombosis, caution should be used with which of the following medications due to a risk of drug-induced thrombocytopenia?
Warfarin (Coumadin®)
Clopidogrel (Plavix®)
Dabigatran (Pradaxa®)
Unfractionated heparin
34. An 84-year-old female patient is admitted from a local long-term care facility (illnes). The patient is normally awake, alert, and oriented. She resides in the LTCF because she has not fully recovered from a broken hip resulting from a fall 4 months ago; otherwise she is in relatively good health. She can walk short distances with a walker, though she primarily stays in a wheelchair. Today, however, the nursing staff found her to be acutely confused and unable to ambulate without falling. She was transferred to the emergency department for evaluation. Initial laboratory testing must include:
2 sets of blood cultures.
Serum thyroid stimulating hormone (TSH) level.
Urinalysis.
Lumbar puncture.
35. A 23-year-old college student presents with a 2-day history of severe sore throat and difficulty eating or drinking due to trouble swallowing. A physical examination reveals exudative pharyngitis and minimally tender anterior and posterior cervical lymphadenopathy. The NP suspects infectious mononucleosis and would expect which of the following laboratory findings?
Neutrophilia with reactive forms.
Thrombocytosis.
Lymphocytosis with atypical lymphocytes.
Diminished ALT/AST levels.
36. “Incident-to” services are defined as those which are “an integral, although incidental, part of the physician’s personal professional services in the course of diagnosis or treatment of an injury or illness”. As long as certain criteria are met, “incident to” billing is an option in all of the following settings except:
Office visits.
Hospital.
Nursing home.
Home visits.
37. A 78-year- old male is being treated for a hypoglycemic episode. He has a long history of type 2 diabetes mellitus as well as congestive heart failure and COPD. He is currently taking basal insulin with a sulfonylurea. What is the acceptable A1C goal for this patient?
≤ 6.5%
≤ 7.0%
≤ 8.0%
≤ 9.0%
38. You see a 74- year-old male who is accompanied by his granddaughter who lives with him. He has hypertension, a prior myocardial infarction, long-standing type 2 diabetes, and recently underwent a lower limb amputation secondary to diabetes. He is currently taking an ACE inhibitor, statin, low-dose aspirin, biguanide, and insulin. The granddaughter reports that since the amputation, her grandfather sometimes becomes withdrawn, irritable and moody for no apparent reason, does not want to participate in the typical activities he enjoys, and often does not appear to eat much during the day. She also states that he often complains of being tired but normally wakes up in the early morning hours. The most appropriate action is to evaluate the patient for:
Dementia.
Depression.
Delirium.
Drug interaction.
39. You see a 58-year-old man who complains of a persistent dry, hacking cough. He reports that he recently started taking a medication to treat high blood pressure. He is most likely taking a(n):
Angiotensin-converting enzyme (ACE) inhibitor
Alpha-adrenergic antagonist
Angiotensin receptor blocker
Beta-adrenergic antagonist
40. A 77-year-old woman is accompanied by her husband for evaluation. She is currently being treated with metoprolol (Lopressor ® ) for hypertension and digoxin (Lanoxin ® ) for atrial fibrillation. He reports that his wife is becoming increasingly forgetful over the past year, failing to note important family events such as birthdays, and sometimes becomes confused with driving directions to familiar locations. She has no previous psychiatric history. The most likely diagnosis is:
Parkinson’s disease.
Delirium.
Dementia.
Early stage of congestive heart failure.
41. Mrs. Conner is a 76- year-old woman living in a long-term care facility and has been bedridden with a respiratory infection for the past 4 days. She is brought in for evaluation and you note signs of dehydration as well as a section of epidermal skin loss about 3 cm in diameter on her right hip. The dermal layer appears intact. This would be considered a pressure ulcer of Stage:
1
2
3
4
42. Which of the following represents the highest level of scientific evidence when evaluating clinical research?
A randomized controlled trial.
Systematic review/ Meta-analysis of randomized controlled troals.
Observational study.
Cohort study.
43. A 64-year- old woman with chronic kidney disease presents with a chief complaint of lethargy. His hemogram is as follows:
-Hemoglobin (Hg)=9.9 g/dL (12–14 g/dL
-Hematocrit (Hct)=30% (36%–42%)
-Mean cell volume (MCV)=81 fL (80–96 fL
-Reticulocytes=0.7% (1%–2%)
These findings are most consistent with:
Iron deficiency anemia.
Anemia of chronic disease.
Folate deficiency anemia.
Thalassemia trait.
44. You see a 68-year-old woman who is being treated for moderate depression. She complains that her medication is causing symptoms of dry mouth and constipation. She is most likely taking which of the following medications?
Venlafaxine (Effexor ® )
Citalopram (Celexa ® )
Fluoxetine (Prozac ® )
Nortriptyline (Pamelor ® )
45. All of the following persons are eligible for Medicare services except:
A 74-year-old ex-smoker with COPD and high income from assets.
A 69-year-old undocumented resident in the US with atrial fibrillation.
A 62-year-old with a permanent physical disability due to a motor vehicle accident.
A 72-year-old permanent legal resident (non-US citizen) with type 1 diabetes mellitus.
46. When initiating therapy with spironolactone for a patient who is also on an ACE inhibitor, you advise the patient to return in 5 days to check which of the following laboratory parameters?
Sodium
Calcium
Potassium
Chloride
47. When considering an end-of-life decision for a terminally ill person with Alzheimer-type dementia who can no longer communicate, all of the following can be used as an advanced directive except:
Testimony from a family member or close friend
A living will.
A “do not resuscitate” order.
A durable power of attorney for healthcare.
48. Which of the following types of clinical studies represents the lowest level of evidence used to guide medical decisions?
Clinical experience of renowned expert in field.
Non-randomized controlled study.
Observational study.
Case-control study.
49. Which of the following electrocardiogram (ECG) changes do you expect to find in a person with myocardial ischemia?calcium
Pathologic Q wave
Tall R wave
T wave inversion
ST segment elevation
50. Which of the following statements is false regarding end-of-life decision-making for a patient that is hopelessly and terminally ill?
A durable power of attorney for healthcare can be used to authorize another person to make healthcare decisions.
A videotaped or audiotaped discussion with the patient can include advanced directives.
Advanced directives are legally binding and recognized in all 50 states.
Living wills and do not resuscitate orders are examples of advanced directives.
51. The nurse practitioner is evaluating a 19-year- old male suffering from a severe headache. He has a history of headaches that tend to occur in clusters over a few days. He has unsuccessfully tried several therapeutic modalities. A positive response to which of the following interventions supports the diagnosis of cluster headache?
Oxygen therapy.
Beta-adrenergic blockade.
Tricyclic antidepressant.
Dietary reduction of amines.
52. All of the following are required Medicare terms and conditions for paying NP services except:
The services are within the NP’s scope of practice as defined by state law.
The services performed are those for which a physician would be able to bill Medicare. The services are performed in collaboration with a physician.
Separate charges are billed for NP services and facility charges.
53. A 28- year- old male with asthma presents with a chief complaint that he has to use his rescue inhaler multiple times each day. An evaluation reveals that he has moderate-to-severe asthma and requires Step 4 treatment. An appropriate regimen would include:
Low-dose inhaled corticosteroid (ICS)
Medium-dose ICS
Medium-dose ICS plus a long-acting beta?-agonist (LABA)
High-dose ICS plus LABA plus omalizumab (Xolair ® )
54. A 62-year-old woman presents in the emergency department complaining of severe toe pain that originated overnight. She has a history of renal disease and is currently taking a thiazide diuretic. Her BMI is 37 kg/m 2 . In considering a diagnosis of acute gouty arthritis, the nurse practitioner knows that the best diagnostic indicator is:
Serum uric acid.
Joint X-ray.
Erythrocyte sedimentation rate (ESR).
Analysis of joint aspirate for urate crystals.
55. Which of the following is the most appropriate antibiotic for a 57-year-old man with acute bacterial rhinosinusitis and who has type 2 diabetes mellitus, COPD and a beta-lactam allergy?
Cephalexin (Keflex ® ).
Amoxicillin-clavulanate (Augmentin ® ).
Trimethoprim with or without sulfamethoxazole (Primsol ® , Bactrim ® ).
Levofloxacin (Levaquin ® )
