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ACNP Exam Review: Questions/Answers (Graded A+)
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ACNP Exam Review: Questions/Answers (Graded A+)
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ACNP Exam Review: Questions/Answers (Graded A+)Blood flow through the heart Right Ans - SVC --> Rt atria --> Tricuspid -->
Rt ventricle --> Pulmonic valve --> Lungs --> Lt atria --> Mitral valve --> Lt
ventricle --> aortic valve --> aorta --> Body
S1 Right Ans - the first heart sound, heard when the atrioventricular
(mitral and tricuspid) valves close
S2 Right Ans - aortic and pulmonic (semilunar) valves close,
Mitral/Tricuspid (AV) valves closes
Systole Right Ans - Period between S1 and S2
Diastole Right Ans - Period Between S2 and S1
S3 Heart sound Right Ans - "Ken-Tuck-y", increased fluid states such as
CHF, Pregnancy, etc.
Patient position: Left lateral decubitus position
its best heard at the Apex
S4 heart sound Right Ans - "Ten-ne-ssee", Stiff/hypertrophic ventricle
(aortic stenosis, restrictive cardiomyopathy), examples patients with HTN,
CHF, MI, etc
Mitral sternosis Right Ans - Loud S1 murmur, low pitched, mid-diastolic,
apical "crescendo" rumble.
Caused by Rheumatic heart disease, 20-30 years after exposure.
Symptoms: Dyspnea, orthopnea, PND, hemoptysis, AFib.
Dx: Echocardiogram: large left Atriam, mitral valve high pressure indicating
stenosis.
EKG elevated QRS in V1, V2 and V3, Atrial Fib. Chest xray LA (double density),
or pulmonary edema.
Treatment: Loop diuretics, Afib (anticoagulants, rate control)
Procedures: Balloon Valvuloplasty or Mitral Valve Replacement.
Mitral regurgitation Right Ans - S3 with systolic murmur at 5th ICS MCL
(apex), may radiate to base or left axilla, musical, blowing or high pitched.
,mitral insufficiency; incompetent mitral valve allows regurgitation of blood
back into left atrium during systole
s/s: fatigue, diaphoresis, palpitations, dyspnea, edema.
Causes: Rheumatic fever, Endocarditis, MI Or cardiomyopathies.
Dx: Echocardiogram
Treatment: valve repair or replacement, Valvuloplasty, annuloplasty.
Aortic stenosis Right Ans - Systolic, "blowing" rough harsh murmur at 2nd
right ICS usually radiating to the neck.
Causes: for patient <30 is calcification, between the age of 30-70 is Bicuspid
(the most common cause). older than 70 calcification of normal valve
(tricuspid)
S/S: Angina, syncope, CHF, dyspnea, pulses tardes or parves (pulse slow or
late), Sudden Death.
Physical exam: you might hear S4 if not in afib, valsalva maneuver decreases
murmur.
Dx: Echo shows stiff LV, increase afterload, and narrowing of aortic valve.
EKG: atrial fib, atrial kick
Treatment: Bloons Vasoplasty, best ( bioprosthetic valve, or Mechanical valve)
use anticoagulation for mechanical valve no need for bioprosthetics.
Aortic Regurgitation Right Ans - Diastolic, "blowing" murmur at 2nd left
ICS.
causes: pts <50 due to post inflammatory such as RHD, IE, Syphilis. pts >50
aortic root dilation age related, or Marfan syndrome.
S/S: left ventricular hypertrophy, syncope, angina.
Dx: Echo, cxr, cath
Treatment: loop diuretics, decrease afterload with nitrates, hydralazine.
surgical (when you see LV decompensation).
Hypertension Emergency Right Ans - Severe blood pressure elevation
>220/120 mm HG associated with acute end-organ damage:
End Organ Damage
HTN encephalopathy
Stroke ischemic or hemorrhagic
Acute MI
Heart Failure
Aortic Dissection
Acute Kidney Injury
,Preeclampsia/eclampsia
HPI
CNS: HA severe, dizziness, confusion, lethargy, paresthesias, vision changes,
anxious,
CV: CP, back pain, SOB, LE edema
Renal: decreased urine output, urinary frequency, and urgency, nausea,
malaise, weakness
Physical Exam
May be comatose or lethargic, high BP, anxious, agitated.
Fundoscopic exam: AV nicking, copper wiring- flame-shaped hemorrhages,
papilledema.
Focal neuro deficits could include hemiparesis, hemiplegia, eye deviation,
blindness, aphasia, CN palsies.
Signs of CHF- rales, JVD, gallop, LE edema, displaced PMI
Vascular: abdominal pulsatile mass, unequal pulses
Signs of renal failure: leg or back pain, fatigue, edema
Diagnostic Testing
CBC- rule out infectious processes
EKG
CXR
UA-rule out renal damage
Serum Electrolytes-check for imbalances
BUN/creatinine- rule out renal damage
Cardiac enzymes-rule our MI, heart damage
BNP: check for CHF
CT/MRI head if neuro involvement
CT/MRI/TEE abdomen if aortic dissection suspected
Treatment Considerations
#1 reduce BP by 25% (<2hours)
#2Reduce BP<160/100 in 2-6 hours
Caution: avoid agents that are fast-acting or sublingual (dramatic BP
reduction may not be well tolerated)
Meds: #1 Nicardipine initial 5mg/hr , increase every 5min by 2.5mg/hr (max
15mg/hr)
Don't use with AS
, Sodium nitroprusside - Second drug of choice - Can produce profound
hypotension - Limit 72 hours Other agents - Nitroglycerine IV: consider with
ischemia - Esmolol hydrochloride - Labetalol hydrochloride - Hydralazine -
Fenoldopam
Indication for Arterial Line Right Ans - Indications: the blood pressure
must be monitored closely-such as hypertensive emergency
Contraindications: Overlying skin compromise_ trauma, burns, infection,
severe dermatitis, know or suspected severe arterial disease of aneurysmal,
atherosclerotic, inflammatory or vasospastic nature. Confirmation of Line
Placement- palpate arterial pulse overlying acceptable;e vessel- radial,
femoral, brachial, DP. May use US guidance if difficult to palpate- check for
collateral flow to the hand or foot by PE- by PE, Doppler US, pulse ox- or for
radial artery - do the modified Allen test.
Monitoring site- infection, bleeding, hematoma, bruising, pain, swelling, and
iatrogenic blood loss, vascular complications- such as blood vessel injury, limb
ischemia, thromboembolism, vasospasm, Pseudoaneurysm. Damage to
adjacent structures and AV fistula.
cardiogenic shock Right Ans - Results from
cardiac failure with the resultant
inability of the heart to maintain
adequate tissue perfusion. Shock is
present results from tissue hypoxia
due to decreased cardiac output
(Cardiac index less than 2.2
L/min/m2)
s/s: SOB,
PE: hypotension, tachycardia, tachypnea, respiratory fatigue, JVD, cyanotic.
Diagnosis: Non-myocardial cause: right heart cath, or echo.
MI Cause: diagnostic angiography.
Labs: cardiac biomarkers
Treatment: Emergent Revascularization
The NP is caring for a patient with a systolic heart murmur. Which valve
disorders are associated with systolic murmurs Right Ans - Acronym MR.
ASS
stands for
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