1. During a routine physical examination of a 66-year-old woman, her nurse practitioner notes a pulsating abdominal mass and refers the woman for further treatment.

1. During a routine physical examination of a 66-year-old woman, her nurse practitioner notes a pulsating abdominal mass and refers the woman for further treatment. The nurse practitioner is explaining the diagnosis to the patient, who is unfamiliar with aneurysms. Which of the following aspects of the pathophysiology of aneurysms would underlie the explanation the nurse provides? (Points : 0.4)

Aneurysms are commonly a result of poorly controlled diabetes mellitus. Hypertension is a frequent modifiable contributor to aneurysms. Individuals with an aneurysm are normally asymptomatic until the aneurysm ruptures. Aneurysms can normally be resolved with lifestyle and diet modifications.

Question 2. 2. A number of patients have presented to the emergency department in the last 24 hours with complaints that are preliminarily indicative of myocardial infarction. Which of the following patients is least likely to have an ST-segment myocardial infarction (STEMI)? (Points : 0.4)

A 70-year-old woman who is complaining of shortness of breath and vague chest discomfort A 66-year-old man who has presented with fatigue, nausea and vomiting, and cool, moist skin A 43-year-old man who woke up with substernal pain that is radiating to his neck and jaw A 71-year-old man who has moist skin, fever, and chest pain that is excruciating when he moves but relieved when at rest

Question 3. 3. A nurse practitioner is instructing a group of older adults about the risks associated with high cholesterol. Which of the following teaching points should the participants try to integrate into their lifestyle after the teaching session? (Points : 0.4)

“Remember, the ‘H’ in HDL and the ‘L’ in LDL correspond to high danger and low danger to your health.” “Having high cholesterol increases your risk of developing diabetes and irregular heart rate.” “Smoking and being overweight increases your risk of primary hypercholesterolemia.” “Your family history of hypercholesterolemia is important, but there are things you can do to compensate for a high inherited risk.”

Question 4. 4. As part of the diagnostic workup for a male patient with a complex history of cardiovascular disease, the care team has identified the need for a record of the electrical activity of his heart, insight into the metabolism of his myocardium, and physical measurements, and imaging of his heart. Which of the following series of tests is most likely to provide the needed data for his diagnosis and care? (Points : 0.4)

Echocardiogram, PET scan, ECG Ambulatory ECG, cardiac MRI, echocardiogram Serum creatinine levels, chest auscultation, myocardial perfusion scintigraphy Cardiac catheterization, cardiac CT, exercise stress testing

Question 5. 5. A 54-year-old man with a long-standing diagnosis of essential hypertension is meeting with his nurse practitioner. The patient’s nurse practitioner would anticipate that which of the following phenomena is most likely occurring? (Points : 0.4)

The patient’s juxtaglomerular cells are releasing aldosterone as a result of sympathetic stimulation. Epinephrine from his adrenal gland is initiating the renin-angiotensin-aldosterone system. Vasopressin is exerting an effect on his chemoreceptors and baroreceptors, resulting in vasoconstriction. The conversion of angiotensin I to angiotensin II in his lungs causes increases in blood pressure and sodium reabsorption.

Question 6. 6. A 6-year-old boy has been brought to the emergency department by ambulance after his mother discovered that his heart rate was “so fast I couldn’t even count it.” The child was determined to be in atrial flutter and his mother is seeking an explanation from the health care team. Which of the following points should underlie an explanation to the mother? (Points : 0.4)

The child is experiencing a reentry rhythm in his right atrium. The resolution of the problem is dependent on spontaneous recovery and is resistant to pacing interventions. The child is likely to have a normal ECG apart from the rapid heart rate. The boy’s atria are experiencing abnormal sympathetic stimulation.

Question 7. 7. A 66-year-old patient’s echocardiogram reveals a hypertrophied left ventricle, normal chamber volume, and a normal ejection fraction from the heart. What is this patient’s most likely diagnosis? (Points : 0.4)

Mitral valve regurgitation Aortic valve stenosis Mitral valve stenosis Aortic valve regurgitation

Question 8. 8. Which of the following assessment findings in a newly admitted 30-year-old male patient would be most likely to cause his nurse practitioner to suspect polyarteritis nodosa? (Points : 0.4)

The man’s blood work indicates polycythemia (elevated red cells levels) and leukocytosis (elevated white cells). The man’s blood pressure is 178/102 and he has abnormal liver function tests. The man is acutely short of breath and his oxygen saturation is 87%. The man’s temperature is 101.9°F and he is diaphoretic (heavily sweating).

Question 9. 9. A physical assessment of a 28-year-old female patient indicates that her blood pressure in her legs is lower than that in her arms and that her brachial pulse is weaker in her left arm than in her right. In addition, her femoral pulses are weak bilaterally. Which of the following possibilities would her care provider be most likely to suspect? (Points : 0.4)

Pheochromocytoma Essential hypertension Coarctation of the aorta An adrenocortical disorder

Question 10. 10. An 81-year-old male resident of a long-term care facility has a long-standing diagnosis of heart failure. Which of the following short-term and longer-term compensatory mechanisms is least likely to decrease the symptoms of his heart failure? (Points : 0.4)

An increase in preload via the Frank-Starling mechanism Sympathetic stimulation and increased serum levels of epinephrine and norepinephrine Activation of the renin-angiotensin-aldosterone (RAA) system and secretion of brain natriuretic peptide (BNP) AV node pacemaking activity and vagal nerve suppression

Question 11. 11. A 70-year-old male patient presents to the emergency department complaining of pain in his calf that is exacerbated when he walks. His pedal and popliteal pulses are faintly palpable and his leg distal to the pain is noticeably reddened. What would his care provider’s preliminary diagnosis and anticipated treatment most likely be? (Points : 0.4)

Acute arterial occlusion that will be treated with angioplasty Raynaud disease that will require antiplatelet medications Atherosclerotic occlusive disease necessitating thrombolytic therapy Giant cell temporal arteritis that will be treated with corticosteroids

Question 12. 12. A patient has suffered damage to his pericardium following a motor vehicle accident. Which of the following consequences should the nurse practitioner be most likely to rule out? (Points : 0.4)

Impaired physical restraint of the left ventricule Increased friction during the contraction/relaxation cycle Reduced protection from infectious organisms Impaired regulation of myocardial contraction

Question 13. 13. The nurse practitioner for a cardiology practice is responsible for providing presurgical teaching for patients who are about to undergo a coronary artery bypass graft. Which of the following teaching points best conveys an aspect of the human circulatory system? (Points : 0.4)

“Your blood pressure varies widely between arteries and veins, and between pulmonary and systemic circulation.” “Only around one quarter of your blood is in your heart at any given time.” “Blood pressure and blood volume roughly mimic one another at any given location in the circulatory system.” “Left-sided and right-sided pumping action at each beat of the heart must equal each other to ensure adequate blood distribution.”

Question 14. 14. A patient in the intensive care unit has a blood pressure of 87/39 and has warm, flushed skin accompanying his sudden decline in level of consciousness. The patient also has arterial and venous dilation and a decrease in systemic vascular resistance. What is this patient’s most likely diagnosis? (Points : 0.4)

Hypovolemic shock Septic shock Neurogenic shock Obstructive shock

Question 15. 15. A 22-year-old male is experiencing hypovolemic shock following a fight in which his carotid artery was cut with a broken bottle. What immediate treatments are likely to most benefit the man? (Points : 0.4)

Resolution of compensatory pulmonary edema and heart arrhythmias Infusion of vasodilators to foster perfusion and inotropes to improve heart contractility Infusion of normal saline of Ringer lactate to maintain the vascular space Administration of oxygen and epinephrine to promote perfusion

Question 16. 16. A 55-year-old male who is beginning to take a statin drug for his hypercholesterolemia is discussing cholesterol and its role in health and illness with his nurse practitioner. Which of the following aspects of hyperlipidemia would the nurse practitioner most likely take into account when teaching the patient? (Points : 0.4)

Hyperlipidemia is a consequence of diet and lifestyle rather than genetics. HDL cholesterol is often characterized as being beneficial to health. Cholesterol is a metabolic waste product that the liver is responsible for clearing. The goal of medical treatment is to eliminate cholesterol from the vascular system.

Question 17. 17. A patient is experiencing impaired circulation secondary to increased systemic arterial pressure. Which of the following statements is the most relevant phenomenon? (Points : 0.4)

Increased preload due to vascular resistance High afterload because of backpressure against the left ventricle Impaired contractility due to aortic resistance Systolic impairment because of arterial stenosis

Question 18. 18. A 72-year-old woman with a recent onset of syncopal episodes has been referred to a cardiology group by her family physician. As part of the patient’s diagnostic workup, the nurse practitioner conducting the intake assessment has ordered a Holter monitor for 24 hours. Which of the following statements best captures an aspect of Holter monitoring? (Points : 0.4)

A Holter monitor is preferable to standard ECG due to its increased sensitivity to cardiac electrical activity. The primary goal is to allow the cardiologist to accurately diagnose cardiomyopathies. Accurate interpretation of the results requires correlating the findings with the activity that the woman was doing at the time of recording. Holter monitors are normally set to record electrical activity of the heart at least once per hour.

Question 19. 19. Which of the following situations related to the transition from fetal to perinatal circulation would be most likely to necessitate medical intervention? (Points : 0.4)

Pressure in the pulmonary circulation and the right side of the infant’s heart fall markedly. Alveolar oxygen tension increases, causing reversal of pulmonary vasoconstriction of the fetal arteries. Systemic vascular resistance and left ventricular pressure are both increasing. Pulmonary vascular resistance, related to muscle regression in the pulmonary arteries, rises over the course of the infant’s first week.

Question 20. 20. A 31-year-old woman with a congenital heart defect reports episodes of lightheadedness and syncope, with occasional palpitations. A resting electrocardiogram reveals sinus bradycardia and she is suspected of having sick sinus syndrome. Which of the following diagnostic methods is the best choice to investigate the suspicion? (Points : 0.4)

Signal-averaged ECG Exercise stress testing Electrophysiologic study Holter monitoring

Question 21. 21. An 81-year-old female patient of a long-term care facility has a history of congestive heart failure. The nurse practitioner caring for the patient has positioned her sitting up at an angle in bed and is observing her jugular venous distention. Why is jugular venous distention a useful indicator for the assessment of the patient’s condition? (Points : 0.4)

Increased cardiac demand causes engorgement of systemic blood vessels, of which the jugular vein is one of the largest. Blood backs up into the jugular vein because there are no valves at the point of entry into the heart. Peripheral dilation is associated with decreased stroke volume and ejection fraction. Heart valves are not capable of preventing backflow in cases of atrial congestion.

Question 22. 22. A 68-year-old male complains to his nurse practitioner that when he tests his blood pressure using a machine at his pharmacy, his heart rate is nearly always very low. At other times, he feels that his heart is racing, and it also seems to pause at times. The man has also occasionally had lightheadedness and a recent syncopal episode. What is this patient’s most likely diagnosis and the phenomenon underlying it? (Points : 0.4)

Sick sinus syndrome as a result of a disease of his sinus node and atrial or junctional arrhythmias Ventricular arrhythmia as a result of alternating vagal and sympathetic stimulation Torsades de pointes as a result of disease of the bundle of His Premature atrial contractions that vacillate between tachycardic and bradycardic episodes as a consequence of an infectious process

Question 23. 23. A nurse practitioner is providing care for several patients on a medical unit of a hospital. In which of the following patient situations would the nurse practitioner be most likely to rule out hypertension as a contributing factor? (Points : 0.4)

A 61-year-old man who has a heart valve infection and recurrent fever An 81-year-old woman who has had an ischemic stroke and has consequent one-sided weakness A 44-year-old man awaiting a kidney transplant who requires hemodialysis three times per week A 66-year-old woman with poorly controlled angina and consequent limited activity tolerance

Question 24. 24. In which of the following patient situations would a nurse practitioner be most justified in preliminarily ruling out pericarditis as a contributing pathology to the patient’s health problems? (Points : 0.4)

A 61-year-old man whose ECG was characterized by widespread T wave inversions on admission but whose T waves have recently normalized A 77-year-old with diminished S3 and S4 sounds, an irregular heart rate, and a history of atrial fibrillation A 56-year-old obese man who is complaining of chest pain that is exacerbated by deep inspiration and is radiating to his neck and scapular ridge A 60-year-old woman whose admission blood work indicates elevated white cells, erythrocyte sedimentation rate, and C-reactive protein levels

Question 25. 25. A 66-year-old obese man with a diagnosis of ischemic heart disease has been diagnosed with heart failure that his care team has characterized as attributable to systolic dysfunction. Which of the following assessment findings is inconsistent with his diagnosis? (Points : 0.4)

His resting blood pressure is normally in the range of 150/90 and an echocardiogram indicates his ejection fraction is 30%. His end-diastolic volume is higher than normal and his resting heart rate is regular and 82 beats per minute. He is presently volume overloaded following several days of intravenous fluid replacement. Ventricular dilation and wall tension are significantly lower than normal.

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1. During a routine physical examination of a 66-year-old woman, her nurse practitioner notes a pulsating abdominal mass and refers the woman for further treatment.

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