NURS 5463: Exam 4 Questions With Fully Explained
Solutions
A 68-year-old male patient is currently in the telemetry unit and receiving
treatment for acute decompensated heart failure with reduced ejection
fraction. On day two of his admission, you are called to the bedside to evaluate
him for a complaint of chest pain. The patient reports a severe, dull, pressure-
like pain in the center of his chest with associated dyspnea. It is substernal
and radiates to both shoulders. He is diaphoretic and looks as though he does
not feel good. He has a past medical history of diabetes mellitus type 2 and
hypertension. Vitals: 99.1-95-150/100, sat is 98% on RA. He has rales in his
lungs, and his abdominal exam is unremarkable. Which diagnosis is most
important to keep in your differentials?
Pleuritis
Aortic Dissection
Stable Angina
Acute coronary syndrome Right Ans - Acute coronary syndrome
The clinical scenario is most consistent with acute coronary syndrome. The
pain from an aortic dissection feels like a tearing or ripping sensation between
the scapula. Pleuritis causes a sharp pain with inspiration. Stable angina is
characterized by chest pain, brought on by activity and relieved by rest.
A 68-year-old male patient is currently on the telemetry unit and receiving
treatment for acute decompensated heart failure reduced ejection fraction. On
day two of his admission you are called to the bedside to evaluate him for a
complaint of chest pain. The patient reports a severe, dull, pressure like pain
in the center of his chest with associated dyspnea. It is substernal in nature
and radiates to both shoulders. He is diaphoretic and looks as though he does
not feel good. He has a past medical history of diabetes mellitus type 2 and
hypertension. Vitals: 99.1-95-150/100, sat is 98% on RA. He has rales in his
lungs and his abdominal exam is unremarkable. Which diagnostic test will
best help to confirm the diagnosis?
Echocardiogram
Brain Natriuretic Protein
Serial Troponins
CK MB Right Ans - Serial Troponins
,The clinical scenario is most consistent with an acute coronary syndrome. The
best test to make the diagnosis is serial troponins.
Acute Coronary Syndrome may present atypically in which patient?
Those with chronic kidney disease
Eldery
Caucasian Males
African American Males Right Ans - Eldery
ACS may present atypically in the elderly, women, diabetics and sickle cell
patients.
Which patient is most likely to have chronically elevated troponin levels?
A 55-year-old female with a creatinine of 0.9 mg/dL.
A 45-year-old male with an ejection fraction of 35%.
A 70-year-old male with a metabolic acidosis.
A 30-year-old female with mitral valve prolapse. Right Ans - A 45-year-old
male with an ejection fraction of 35%.
Chronically elevated troponins are seen in persons with heart failure and
chronic kidney disease. The 45-year-old male with an ejection fraction of 35%
has systolic heart failure and one would expect to see chronically elevated
troponin levels in this patient.
A patient presents to the ED with a complaint of chest pain. The EKG results
are below. Which action should the AGACNP take first?
Order a troponin level
Call the intensivist
Activate Cardiac Cath Team
Repeat the EK Right Ans - Activate Cardiac Cath Team
This patient is having a STEMI and must go for emergent reperfusion therapy,
which requires the AGACNP to activate the cardiac cath team.
Post percutaneous treatment for a STEMI the patient should be transferred to
which level of care?
Medical bed
Telemetry
,Observation bed
Intensive care Right Ans - Intensive care
A person post PCI for a STEMI should be admitted to the intensive care unit.
An AGACNP is treating a patient with a new onset of NSTEMI and an O2 sat of
94%. Which therapy is most appropriate for the AGACNP to initiate?
Fibrinolytic therapy
ASA and fibrinolytic therapy
Enoxaparin (Lovenox) and ASA
Clopidogrel (Plavix) loading dose and oxygen Right Ans - Enoxaparin
(Lovenox) and ASA
The AGACNP should initiate enoxaparin and ASA. Fibrinolytic therapy is
contraindicated in NSTEMIs because it does not have any effect on mortality
and increases the risk of intracranial hemorrhage. Oxygen is only indicated in
ACS when the O2 sat is < 90%.
A 55-year-old male is evaluated during a routine examination at your
cardiology practice. He has a 2-year history of non-ischemic cardiomyopathy
with an ejection fraction of 35%. He denies any dyspnea and can walk 2 miles
a day without symptoms. Past medical history is significant for hypertension.
His current medications include lisinopril (Zestril) 40mg daily, carvedilol
(Coreg) 25mg BID, and chlorthalidone (Thalitone) 25mg daily. Vitals: 98.6-65-
16-160/90 mmHg. On exam there is no JVD, lungs are clear, and heart rate is
regular without murmur or gallops. No edema is present. How should the
AGACNP modify this patient's treatment plan?
Order an echocardiogram
Add amlodpine (Norvasc)
Increase the dose of chlorthalidone
Add diltiazem (Cardizem) Right Ans - Add amlodpine (Norvasc)
This patient is on a three-drug regimen for heart failure, HTN management,
and is still hypertensive. He is on optimal doses of his current medications
however he still needs to achieve better blood pressure control. The most
appropriate action is to add amlodipine. Use of calcium channel blockers in
systolic heart failure is generally reserved for treatment of conditions such as
hypertension or angina that are not optimally managed with maximal doses
evidenced based medications. Non-dihydropyridine calcium channel blockers,
, such a diltiazem, are contraindicated in systolic heart failure, because they
impair contraction.
An 88-year-old patient is sent to the ED by his nursing home in acute
decompensated heart failure reduced ejection fraction. His dry weight is 71kg
and current weight is 73.5kg. Heart rate is 104, respiratory rate is 30/minute,
BP of 120/60 mmHg, O2 sat 89% on RA. Heart rate is regular, lungs have rales
in the posterior lung fields and he is using accessory muscles. The initial
evaluation of this patient should include which tests?
CBC, EKG, D-dimer
INR, CT of the Head and EKG
BNP, Chest-x-ray, LFTs
EKG, troponins, BMP Right Ans - EKG, troponins, BMP
The initial evaluation of this patient should include an EKG, troponins and
BMP. This is the only option which is completely correct. A BNP, CXR and CBC
should also be completed.
An 88-year-old patient is sent to the ED by his nursing home in acute
decompensated heart failure reduced ejection fraction. His dry weight is 71kg
and current weight is 73.5kg. Heart rate is 104, respiratory rate is 30/minute,
BP of 120/60 mmHg, O2 sat 89% on RA. Heart rate is regular, lungs have rales
in the posterior lung fields and he is using accessory muscles. To which level
of care should this patient be admitted?
Observation
Telemetry
Intensive care
Medical Right Ans - Intensive care
This patient has impending respiratory failure and requires ICU care
An 88-year-old patient is sent to the ED by his nursing home in acute
decompensated heart failure reduced ejection fraction. His dry weight is 71kg
and current weight is 73.5kg. Heart rate is 104, respiratory rate is 30/minute,
BP of 120/60 mmHg, O2 sat 89% on RA. Heart rate is regular, lungs have rales
in the posterior lung fields and he is using accessory muscles. Initial labs come
back and he is noted to have a creatinine of 3.0 mg/dL and a potassium of 4.5
mEq/L. Baseline creatinine is 1.5 mg/dL. Which intervention should the
AGACNP do next?
Solutions
A 68-year-old male patient is currently in the telemetry unit and receiving
treatment for acute decompensated heart failure with reduced ejection
fraction. On day two of his admission, you are called to the bedside to evaluate
him for a complaint of chest pain. The patient reports a severe, dull, pressure-
like pain in the center of his chest with associated dyspnea. It is substernal
and radiates to both shoulders. He is diaphoretic and looks as though he does
not feel good. He has a past medical history of diabetes mellitus type 2 and
hypertension. Vitals: 99.1-95-150/100, sat is 98% on RA. He has rales in his
lungs, and his abdominal exam is unremarkable. Which diagnosis is most
important to keep in your differentials?
Pleuritis
Aortic Dissection
Stable Angina
Acute coronary syndrome Right Ans - Acute coronary syndrome
The clinical scenario is most consistent with acute coronary syndrome. The
pain from an aortic dissection feels like a tearing or ripping sensation between
the scapula. Pleuritis causes a sharp pain with inspiration. Stable angina is
characterized by chest pain, brought on by activity and relieved by rest.
A 68-year-old male patient is currently on the telemetry unit and receiving
treatment for acute decompensated heart failure reduced ejection fraction. On
day two of his admission you are called to the bedside to evaluate him for a
complaint of chest pain. The patient reports a severe, dull, pressure like pain
in the center of his chest with associated dyspnea. It is substernal in nature
and radiates to both shoulders. He is diaphoretic and looks as though he does
not feel good. He has a past medical history of diabetes mellitus type 2 and
hypertension. Vitals: 99.1-95-150/100, sat is 98% on RA. He has rales in his
lungs and his abdominal exam is unremarkable. Which diagnostic test will
best help to confirm the diagnosis?
Echocardiogram
Brain Natriuretic Protein
Serial Troponins
CK MB Right Ans - Serial Troponins
,The clinical scenario is most consistent with an acute coronary syndrome. The
best test to make the diagnosis is serial troponins.
Acute Coronary Syndrome may present atypically in which patient?
Those with chronic kidney disease
Eldery
Caucasian Males
African American Males Right Ans - Eldery
ACS may present atypically in the elderly, women, diabetics and sickle cell
patients.
Which patient is most likely to have chronically elevated troponin levels?
A 55-year-old female with a creatinine of 0.9 mg/dL.
A 45-year-old male with an ejection fraction of 35%.
A 70-year-old male with a metabolic acidosis.
A 30-year-old female with mitral valve prolapse. Right Ans - A 45-year-old
male with an ejection fraction of 35%.
Chronically elevated troponins are seen in persons with heart failure and
chronic kidney disease. The 45-year-old male with an ejection fraction of 35%
has systolic heart failure and one would expect to see chronically elevated
troponin levels in this patient.
A patient presents to the ED with a complaint of chest pain. The EKG results
are below. Which action should the AGACNP take first?
Order a troponin level
Call the intensivist
Activate Cardiac Cath Team
Repeat the EK Right Ans - Activate Cardiac Cath Team
This patient is having a STEMI and must go for emergent reperfusion therapy,
which requires the AGACNP to activate the cardiac cath team.
Post percutaneous treatment for a STEMI the patient should be transferred to
which level of care?
Medical bed
Telemetry
,Observation bed
Intensive care Right Ans - Intensive care
A person post PCI for a STEMI should be admitted to the intensive care unit.
An AGACNP is treating a patient with a new onset of NSTEMI and an O2 sat of
94%. Which therapy is most appropriate for the AGACNP to initiate?
Fibrinolytic therapy
ASA and fibrinolytic therapy
Enoxaparin (Lovenox) and ASA
Clopidogrel (Plavix) loading dose and oxygen Right Ans - Enoxaparin
(Lovenox) and ASA
The AGACNP should initiate enoxaparin and ASA. Fibrinolytic therapy is
contraindicated in NSTEMIs because it does not have any effect on mortality
and increases the risk of intracranial hemorrhage. Oxygen is only indicated in
ACS when the O2 sat is < 90%.
A 55-year-old male is evaluated during a routine examination at your
cardiology practice. He has a 2-year history of non-ischemic cardiomyopathy
with an ejection fraction of 35%. He denies any dyspnea and can walk 2 miles
a day without symptoms. Past medical history is significant for hypertension.
His current medications include lisinopril (Zestril) 40mg daily, carvedilol
(Coreg) 25mg BID, and chlorthalidone (Thalitone) 25mg daily. Vitals: 98.6-65-
16-160/90 mmHg. On exam there is no JVD, lungs are clear, and heart rate is
regular without murmur or gallops. No edema is present. How should the
AGACNP modify this patient's treatment plan?
Order an echocardiogram
Add amlodpine (Norvasc)
Increase the dose of chlorthalidone
Add diltiazem (Cardizem) Right Ans - Add amlodpine (Norvasc)
This patient is on a three-drug regimen for heart failure, HTN management,
and is still hypertensive. He is on optimal doses of his current medications
however he still needs to achieve better blood pressure control. The most
appropriate action is to add amlodipine. Use of calcium channel blockers in
systolic heart failure is generally reserved for treatment of conditions such as
hypertension or angina that are not optimally managed with maximal doses
evidenced based medications. Non-dihydropyridine calcium channel blockers,
, such a diltiazem, are contraindicated in systolic heart failure, because they
impair contraction.
An 88-year-old patient is sent to the ED by his nursing home in acute
decompensated heart failure reduced ejection fraction. His dry weight is 71kg
and current weight is 73.5kg. Heart rate is 104, respiratory rate is 30/minute,
BP of 120/60 mmHg, O2 sat 89% on RA. Heart rate is regular, lungs have rales
in the posterior lung fields and he is using accessory muscles. The initial
evaluation of this patient should include which tests?
CBC, EKG, D-dimer
INR, CT of the Head and EKG
BNP, Chest-x-ray, LFTs
EKG, troponins, BMP Right Ans - EKG, troponins, BMP
The initial evaluation of this patient should include an EKG, troponins and
BMP. This is the only option which is completely correct. A BNP, CXR and CBC
should also be completed.
An 88-year-old patient is sent to the ED by his nursing home in acute
decompensated heart failure reduced ejection fraction. His dry weight is 71kg
and current weight is 73.5kg. Heart rate is 104, respiratory rate is 30/minute,
BP of 120/60 mmHg, O2 sat 89% on RA. Heart rate is regular, lungs have rales
in the posterior lung fields and he is using accessory muscles. To which level
of care should this patient be admitted?
Observation
Telemetry
Intensive care
Medical Right Ans - Intensive care
This patient has impending respiratory failure and requires ICU care
An 88-year-old patient is sent to the ED by his nursing home in acute
decompensated heart failure reduced ejection fraction. His dry weight is 71kg
and current weight is 73.5kg. Heart rate is 104, respiratory rate is 30/minute,
BP of 120/60 mmHg, O2 sat 89% on RA. Heart rate is regular, lungs have rales
in the posterior lung fields and he is using accessory muscles. Initial labs come
back and he is noted to have a creatinine of 3.0 mg/dL and a potassium of 4.5
mEq/L. Baseline creatinine is 1.5 mg/dL. Which intervention should the
AGACNP do next?
