APEA 3P Exam Prep - Cardiovascular: 2024-2025 Version Questions and Answers - Prof. Smith, Exams of Nursing

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APEA 3P Exam Prep- Cardiovascular

2024 - 2025 VERSION QUESTIONS AND

ANSWERS (RATIONALES PROVIDED)

Which patient could be expected to have the highest systolic blood pressure? A 21-year-old male A 50-year-old perimenopausal female A 35-year-old patient with Type 2 diabetes A 75-year-old male - Answer D. Nearly 25% of the US population has hypertension. The greatest incidence is in older adults because of changes in the intima of vessels as aging and calcium deposition occur. Males of any age are more likely to be hypertensive than females of the same age. African American adults have the highest incidence in the general population. Among adolescents, African Americans and Hispanics have the highest rates. Hypertension occurs in 5-10% of pregnancies. Mrs. Brandy is having contrast dye next week for a heart catheterization. What drug does NOT need to be stopped prior to her catheterization? Naproxen Furosemide Metformin Losartan - Answer D. Naproxen and furosemide should be stopped for 24 hours prior to the catheterization. Metformin should be stopped 48 hours prior to the catheterization. Furosemide is stopped because it contributes to volume depletion. NSAIDs like naproxen are withheld because of the impact on renal prostaglandin production. Metformin has been implicated in lactic acidosis when combined with contrast dye in an impaired kidney. In older adults, the three most common ailments are: hearing loss, vision loss, hypertension. hearing loss, hypertension, arthritis. depression, vision loss, hypertension.

arthritis, hearing loss, depression. - Answer B. Hypertension and arthritis are the two most common ailments in older adults. Hearing loss occurs in half to almost 2/3 of older adults. The most common form is known as presbycusis. There is no consensus for the frequency of screening for hearing loss in older patients, but minimally, it should be grossly evaluated at each visit and screened more thoroughly if deficits are observed. Blood pressure should be screened annually, but it is usually screened at each visit. Arthritis is not routinely screened. Mr. Holbrook, a 75-year-old male, is a former smoker with a 30-pack- year history. He has come in today for an annual exam. He walks daily for 25 minutes, has had intentional weight loss, and has a near-normal BMI. On examination, the patient is noted to have an absence of hair growth on his lower legs. Which statement is true regarding this patient? This is a normal consequence of aging. This might indicate disease in the lower extremities. It might be from exercise initiation. This is secondary to long-term smoking. - Answer B. An absence of hair growth likely indicates peripheral artery disease in this patient. It is part of normal changes of aging that hair growth will diminish, but not become absent. His lower extremity pulses should be assessed, his cardiac risk factors should be assessed (he smoked for years), and he should be questioned about leg pain when he walks. An ankle-brachial index could be measured. If < 0.9, further assessment should be done. A normal ankle-brachial index should be greater than 0.9. Less than 0.4 is considered critical. The usual clinical course of mitral valve prolapse: is benign. results in sudden cardiac death. results in chronic heart failure. is associated with multiple episodes of emboli. - Answer A. The usual course of mitral valve prolapse (MVP) is benign, and most patients who have MVP are asymptomatic. A murmur may be present and is best auscultated with the diaphragm of the stethoscope over the cardiac apex. In a minority of patients, symptoms of heart failure or sudden death may occur. When heart failure results, it is usually a result of mitral regurgitation.

Embolization may occur, but, this is not common or usual in the majority of patients. An ACE inhibitor is specifically indicated in patients who have: hypertension, diabetes with proteinuria, and heart failure. diabetes, hypertension, hyperlipidemia. asthma, hypertension, diabetes. renal nephropathy, heart failure, hyperlipidemia. - Answer A. ACE inhibitors have numerous indications. Three are indicated in the first choice. ACE inhibitors are also indicated in patients who have renal insufficiency. However, ACE inhibitors can worsen renal insufficiency, so the patients must be monitored closely with lab tests for BUN, Cr, and potassium. Diabetes without proteinuria is not a specific indication for ACE inhibitors use, though they are used by some healthcare providers in this way. This is an off-label use. An older adult who has hypertension and angina takes multiple medications. Which one of the following decreases the likelihood of his having angina? ACE inhibitor Beta blocker Diuretic Angiotensin receptor blocker - Answer B. The beta blocker slows down heart rate, depresses myocardial contractility, and decreases sympathetic stimulation. These decrease myocardial oxygen demand and improve angina symptoms. It is an excellent drug class to use to prevent symptoms of angina in patients who have underlying coronary artery disease. Calcium channel blockers are another class of medications that could be used to improve symptoms of angina. Orthostatic hypotension can be diagnosed in an older adult if the systolic blood pressure decreases: more than 20 points anytime after rising. more than 20 points within 3 minutes after rising. more than 20 points within 1 minute after rising. any degree drop if the patient becomes weak or dizzy. - Answer B. Orthostatic hypotension, also called postural hypotension, is diagnosed in older adults when the systolic blood pressure drops 20 mm Hg or more within 3 minutes of moving to a more upright

position. Systolic blood pressure can be expected to decrease within one minute of moving to an upright position. Normally, the blood pressure returns to baseline within one minute of a position change and orthostatic hypotension does not occur. It is always abnormal when blood pressure decreases beyond one minute of moving to an upright position. Orthostatic hypotension can then be diagnosed. Moving to an upright position may be 1) lying to sitting or

2. sitting to standing. Additionally, if the systolic blood pressure does not meet these criteria, but the diastolic drops by 10 mm Hg or more with a position change, orthostatic hypotension can be diagnosed. Patients become symptomatic when this occurs and often report lightheadedness, weakness, dizziness, blurred vision, or decreased hearing. Which hypertensive patient is most likely to have adverse blood pressure effects from excessive sodium consumption? 21 - year-old Asian American male 35 - year-old menstruating female 55 - year-old post menopausal female 70 - year-old African American male - Answer D. Two groups of patients typically experience adverse blood pressure effects from consumption of sodium greater than 2,000 mg daily. Those patients considered to be most sodium-sensitive are elderly patients and African American patients. Thus, choice d is the best choice listed. A patient who takes HCTZ 25 mg daily has complaints of muscle cramps. He probably has: hypocalcemia. hypomagnesemia. hypokalemia. hypercalcemia. - Answer C. HCTZ is a thiazide diuretic that is potassium-wasting. Patients can become hypokalemic and experience side effects of this. A common one is muscle cramps. A 25-year-old patient has aortic stenosis (AS). The etiology of his AS is probably: congenital. rheumatic. acquired calcific.

unknown. - Answer A. In someone younger than 65 years, the most likely cause is congenital. The aortic valve usually consists of three cusps, but some people are born with a bicuspid aortic valve. Rheumatic heart disease is the second most common cause of aortic stenosis in this age group, but the incidence has decreased drastically in the last many decades because of the use of antibiotics to treat Streptococcal infections. In more than 90% of patients older than 65 years, acquired calcifications appear on a normal aortic valve and produce aortic stenosis. A 75-year-old patient with longstanding hypertension takes an ACE inhibitor and a thiazide diuretic daily. He has developed dyspnea on exertion and peripheral edema over the past several days. This probably indicates: worsening hypertension. development of heart failure (HF). noncompliance with medication. acute myocardial infarction. - Answer B. The symptoms of dyspnea on exertion and peripheral edema are symptoms of HF. Long standing hypertension is a risk factor for HF. Acute myocardial infarction would result in acute symptoms, not development of symptoms over the past several days. Noncompliance with medication and fluid or sodium excess might result in peripheral edema and development of heart failure. A patient with newly diagnosed heart failure has started fosinopril in the last few days. She has developed a cough. What clinical finding can help distinguish the etiology of the cough as heart failure and not related to fosinopril? It is dry and nonproductive. It is wet and worse with recumbence. It is purulent and tachycardia accompanies it. Shortness of breath always results after coughing. - Answer B. The cough associated with fosinopril, an ACE inhibitor, is a dry, nonproductive cough that may be described as annoying. Its severity does not change with position or time of day. A cough associated with heart failure is wet, worse when lying down, and is usually described by patients as worse at night. Choice c is often associated with fever and probably reflects an infectious process like pneumonia.

Which choice below would be the best choice for an 80-year-old patient whose blood pressure is 172/72 mm Hg? Chlorthalidone Amlodipine Monopril Acebutolol - Answer B. This patient has isolated systolic hypertension. According to many learned authorities, this is best treated with a long-acting calcium channel blocker, particularly the ones that end in "pine." These belong to the class of calcium channel blockers termed dihydropyridines. Thiazide diuretics are not potent enough to decrease this patient's blood pressure into normal range, and its effect is not additive when combined with calcium channel blockers. Which medication could potentially exacerbate heart failure (HF)? Naproxen Furosemide Atorvastatin Aspirin - Answer A. Naproxen is an NSAID. NSAIDs cause sodium retention and thus, water retention. A single dose of naproxen is unlikely to produce HF symptoms, but repeated subsequent doses are very likely to produce water retention sufficient to cause edema and possible shortness of breath in susceptible people. The other medications listed are unlikely to have any direct effect on cardiac output in a patient who has HF. Which patient is most likely to have mitral valve prolapse? An adolescent male with no cardiac history A 25-year-old male with exercise intolerance A 30-year-old female with no cardiac history A 65-year-old male with shortness of breath - Answer C. Mitral valve prolapse (MVP) is most commonly diagnosed in women aged 14-30 years of age. However, it can be found in children (though not usually) or in older adults. The symptoms most commonly associated with MVP are arrhythmias (both atrial and ventricular) and chest pain. However, most patients with MVP are asymptomatic.

You have been asked to evaluate a heart murmur in a pregnant patient. Can a 3D echocardiogram be safely used to evaluate her? Yes, but this will not yield the best information. Yes, this is perfectly safe. No, this will emit radiation and is not safe. Yes, but the mother will be exposed to radiation - Answer B. An echocardiogram is the best test to evaluate a heart murmur whether the patient is pregnant or not. Echocardiography can be used safely in this patient because no radiation is emitted from 3D echo. The most common murmur in pregnant women is a venous hum murmur. It resolves within several weeks after delivery. It is benign. A patient is diagnosed with mild heart failure (HF). What drug listed below would be a good choice for reducing morbidity and mortality long term? Verapamil Digoxin Furosemide Metoprolol - Answer D. Metoprolol is a beta-blocker. Beta-blockers are known to reduce morbidity and mortality associated with HF. Verapamil is a calcium channel blocker. This class of medications is contraindicated because they decrease the contractility of the heart. Furosemide and digoxin will improve symptoms but not long-term outcomes. Their main benefit is in treating symptomatic patients. The lipid particle with the greatest atherogenic effect is: Cholesterol. HDL. LDL. triglycerides. - Answer C. LDL cholesterol promotes atherosclerosis via several different mechanisms. Consequently, LDL cholesterol tends to be the primary target when patients are treated pharmacologically for elevated lipid levels. Low HDL levels and elevated triglyceride levels can accelerate atherogenesis. A 77-year-old patient has had an increase in blood pressure since the last exam. The blood pressure readings are provided. If

medication is to be started on this patient, what would be a good first choice (VS in image)? ACE inhibitor Beta blocker Calcium channel blocker Thiazide diuretic - Answer C. This patient is 77 years old and should have a goal blood pressure of < 150/90 mmHg according to JNC8. A thiazide diuretic is not a good first choice in this patient because it will not be potent enough to decrease blood pressure by about 20 points to get him to his goal. A long-acting calcium channel blocker is appropriate for patients who have isolated systolic hypertension and will be more likely to get this patient to goal pressure than HCTZ. Beta-blockers are no longer recommended first-line for uncomplicated hypertension. ACE inhibitors are very effective in patients who are high renin producers. Older patients tend to produce lower amounts of renin. The nurse practitioner is caring for an independent 74-year-old female who had acute coronary syndrome (ACS) about 6 weeks ago. What medications should be part of her regimen unless there is a contraindication? ASA and beta blocker ACE and beta blocker ACE, ASA, and beta blocker ACE, ASA, beta blocker, and statin - Answer D. After a myocardial event, an aspirin, ACE inhibitor, beta blocker, and statin should be dosed daily. The aspirin will provide anticoagulation; the ACE inhibitor, statin and beta blocker are associated with reduced morbidity and mortality if given soon after ACS. Mr. Smith is a 72-year-old patient who takes warfarin for chronic atrial fibrillation. His INR and CBC results are provided (CBC in the image, INR 4.0). The nurse practitioner should: stop the warfarin for the next 4 days and repeat the INR on day 5. admit to the hospital immediately. administer vitamin K and repeat INR in 2 hours. stop the warfarin today and repeat the INR tomorrow. - Answer D. An INR range of 2.0-3.0 is therapeutic for most people who take warfarin for chronic atrial fibrillation. An INR of 4.0 is elevated, and this patient could suffer a devastating bleed anywhere in the body.

A patient with an INR < 5 without bleeding may have warfarin stopped temporarily. The maintenance dose should be decreased when it is safe to resume warfarin, i.e. when the INR is closer to the patient's therapeutic range. If the patient were at high risk for bleeding, was bleeding, or if the INR was greater than 4.0, vitamin K could be administered. A good history should be completed to find out the reason for the increase in INR. A high-risk client with an elevated INR would be admitted to the hospital and closely monitored, but a client with no comorbidities (no bleeding history or thrombocytopenia) and considered low risk, may be monitored as an outpatient. Five days is too long to stop warfarin without an INR check. A patient with poorly controlled hypertension and history of myocardial infarction 6 years ago presents today with mild shortness of breath. He takes quinapril, ASA, metoprolol, and a statin daily. What symptom is NOT indicative of heart failure? Fatigue Headache Orthopnea Cough - Answer B. Fatigue is a common symptom in cardiac patients, and it can represent a worsening of many cardiac diseases, such as coronary artery disease, heart failure, or valvular dysfunction. Orthopnea and cough, especially nocturnal, are classic symptoms of worsening heart failure. Headache is a nonspecific symptom and is not typical of heart failure. You are managing the warfarin dose for an older adult with a prosthetic heart valve. Which situation listed requires that warfarin be discontinued now? INR of 3, some bleeding INR of 8, no significant bleeding INR of 6, no significant bleeding INR of 2 with minimal bleeding - Answer B. INR is a good measure of the clotting status in an outpatient who takes an oral anticoagulant like warfarin. When warfarin is overdosed and INR climbs, or when warfarin is overdosed because of food or medication that produces deleterious side effects, warfarin doses may be omitted or discontinued until the INR is in a more acceptable range. Generally, one or two doses may be omitted

before rechecking INR and resuming warfarin or decreasing the dose. A medication that may produce exercise intolerance in a patient who has hypertension is: hydrochlorothiazide. amlodipine. metoprolol. fosinopril. - Answer C. Metoprolol is a cardioselective beta blocker. It can produce bradycardia which is responsible for exercise intolerance. As a patient exercises, a concomitant increase in heart rate allows for an increase in cardiac output. If the heart rate is not able to increase because of beta-blocker influence, neither can the cardiac output. The patient will necessarily slow down his physical activity. Choices a and d have no direct effect on heart rate. Amlodipine is a calcium channel blocker that does not decrease heart rate. A 50-year-old patient with hypertension has taken hydrochlorothiazide 25 mg daily for the past 4 weeks. How should the nurse practitioner proceed (VS in image)? Wait 4 weeks before making a dosage change. Increase the hydrochlorothiazide to 50 mg daily. Add a drug from another class to the daily 25 mg hydrochlorothiazide. Correct Stop the hydrochlorothiazide and start a drug from a different class.

• Answer C. The recommended target blood pressure, according to JNC 8, for this 50-year-old patient is < 140/ 90 mmHg. The current plan has not allowed this patient to meet this goal, so it is not acceptable to continue the current dose. Increasing the hydrochlorothiazide to 50 mg daily will not result in a decrease in blood pressure, only an increase in potassium loss. Adding a drug from a different medication class is a good choice because the combined effects of antihypertensive medications nearly always produce a decrease in blood pressure and both drugs can be maintained in low doses to minimize side effects. Which laboratory abnormality may be observed in a patient who takes lisinopril? Decreased INR

Decreased calcium level Increased potassium level Increased ALT/AST - Answer C. Lisinopril is an ACE inhibitor. This medication causes retention of potassium. A potassium level should be measured about 1 month after initiating therapy and after each dose change. The other laboratory values are not specific to changes that can take place when a patient takes an ACE inhibitor. Mrs. Jones is an 85-year-old who has average blood pressures of 170/70 mmHg. Which agent would be a good starting medication to normalize her blood pressure? Fosinopril Losartan Amlodipine Hydrochlorothiazide - Answer C. This patient has isolated systolic hypertension (ISH), common in older adults. Long-acting calcium channel blockers (CCB), specifically those with the suffix "pine," and thiazide diuretics, are recommended for starting treatment in patients with ISH. Amlodipine is probably a better choice in this patient because she needs a substantial decrease in her systolic blood pressure. Thiazide-type diuretics produce an average decrease of 2-8 points in the systolic blood pressure. The CCBs are more potent and a more significant decrease in blood pressure could be expected. A patient who has mitral valve prolapse (MVP) reports chest pain and frequent arrhythmias. In the absence of other underlying cardiac anomalies, the drug of choice to treat her symptoms is: lisinopril. metoprolol. amlodipine. chlorthalidone. - Answer B. Beta blockers like metoprolol are indicated to alleviate atrial or ventricular arrhythmias associated with mitral valve prolapse. However, long-term effectiveness of beta blockers is uncertain. Most patients with MVP who do not have symptoms of arrhythmias or ectopy at rest usually do not require further evaluation. However, they should be monitored at least annually for a change in their condition.

A patient with hypertension has been diagnosed with gout. Which home medication may have contributed to this episode of gout? Lisinopril Amlodipine Furosemide Allopurinol - Answer C. Gout is characterized by hyperuricemia. Uric acid levels are increased when a patient consumes any medication that results in less circulating fluid volume, specifically, any diuretic. Diuretics such as furosemide will produce hyperuricemia and thus increase the risk of gout in susceptible patients. Diuretics should be avoided when possible in patients who have a history of gout. Which class of medication is frequently used to improve long-term outcomes in patients with systolic dysfunction? Loop diuretics Calcium channel blockers ACE inhibitors Thiazide diuretics - Answer C. ACE inhibitors are commonly used in patients with systolic dysfunction because they reduce morbidity and mortality, i.e. these medications alter prognosis. They also improve symptoms of fatigue, shortness of breath, and exercise intolerance. Loop and thiazide diuretics improve symptoms, but do not alter long-term prognosis with heart failure. Beta blockers should be used in conjunction with ACE inhibitors and diuretics, but not as solo agents. Beta blockers can potentially worsen heart failure, so their use in patients with heart failure should be monitored carefully. Despite this fact, beta blockers decrease morbidity and mortality associated with heart failure. A patient will be screened for hyperlipidemia via a serum specimen. He should be told: to fast for 12-14 hours. to fast for 6-8 hours. that black coffee is allowed. a non-fasting state will not affect the results. - Answer A. Serum total and HDL cholesterol can be measured in fasting or non- fasting patients. There are very small and clinically insignificant differences in these values whether fasting or not. The primary effect of eating on a patient's lipid values is elevation of the

triglyceride levels. The maximum elevation of triglyceride levels occurs at 3-4 hours after eating, but there may be several peaks during a 12-hour period. Therefore, the most accurate triglyceride levels will be obtained following a 12-hour fast. Ramipril has been initiated at a low dose in a patient with heart failure. What is most important to monitor in about 1 week? Heart rate Blood pressure EKG Potassium level - Answer D. ACE inhibitors work in the kidney in the renin-angiotensin aldosterone system and can impair renal excretion of potassium in patients who have normal kidney function. In patients who have impaired renal blood flow and/or function, the risk of hyperkalemia is increased. Common practice is to monitor potassium, BUN, and Cr at about 1 week after initiation of an ACE inhibitor and with each increase in dosage in a patient who has heart failure and who receives an ACE inhibitor. A nurse practitioner has not increased the dosage of an antihypertensive medication even though the patient's blood pressure has remained >140/90 mmHg. This might be described as: clinical inertia. malpractice. resistant hypertension. lackadaisical attitude. - Answer A. Clinical inertia is the term used to describe healthcare providers who fail to intensify therapy despite patients not reaching goal. There are many reasons given as to why this takes place, but healthcare providers can modify these behaviors. Warfarin treatment is greatly influenced by a patient's food and medication intake. Which group listed can potentially decrease INR (International Normalized Ratio) in an outpatient who takes warfarin? Alcohol and an aspirin Flu vaccine and ketoprofen Naproxen and celecoxib Sucralfate and cholestyramine - Answer D.

The drugs listed in choice D will decrease international normalized ratio (INR) in patients who take warfarin concurrently. Sucralfate and calcium carbonate decrease absorption of warfarin. The drugs listed in the other choices will increase INR. Major interactions can occur with celecoxib, ketoprofen, and naproxen. These three NSAIDs are commonly taken by older adults, so this should be part of education with a patient who takes warfarin. The diagnosis of mitral valve prolapse can be confirmed by: physical examination. electrocardiography. echocardiography. chest X-ray. - Answer C. The best means to identify mitral valve prolapse (MVP) is with echocardiography. It will identify bulging of either, or both, of the leaflets (anterior or posterior) into the left atrium. Approximately 2% of the US population is identified to have MVP. A chest X-ray will not enable visualization of the mitral leaflets. Electrocardiography identifies the heart's electrical activity. A physical exam may provide great clues to MVP, but in the absence of definitive mid to late systolic clicks, a diagnosis cannot be confirmed. A patient has shortness of breath. If heart failure is the etiology, which test demonstrates the highest sensitivity in diagnosing this? Echocardiogram B type natriuretic peptide (BNP) EKG Chest X-ray - Answer B. BNP is a hormone involved in regulation of blood pressure and fluid volume. When the BNP level is 80 pg/mL or greater, the sensitivity and specificity is 98% and 92%, favoring a diagnosis of heart failure. Alternatively, BNP levels less than 80 pg/mL strongly suggest that heart failure is not present (some US institutions use 100 pg/mL). Other conditions may cause elevated BNP levels: thoracic and abdominal surgery, renal failure, and subarachnoid hemorrhage. Consequently, careful assessment of the patient is prudent. Echocardiograms mechanically evaluate the heart and establish an ejection fraction. If < 35-40%, then HF can usually be diagnosed. Ejection fractions do not always correlate with patient symptoms. EKG evaluates the electrical activity of the heart. Chest X-ray can indicate heart failure, but a BNP is a more sensitive measure.

Which mitral disorder results from redundancy of the mitral valve's leaflets? Acute mitral regurgitation Chronic mitral regurgitation Mitral valve prolapse Mitral stenosis - Answer C. Mitral valve prolapse (MVP) is the most common adult murmur. It is best heard with the diaphragm of the stethoscope over the cardiac apex. It is a result of redundancy of the mitral valve leaflets and subsequent degeneration of the mitral tissue. The posterior leaflet is more commonly affected than the anterior leaflet. The valve's annulus becomes enlarged in conjunction with elongation of the chordae tendineae. An older adult who has hypertension also has osteoporosis. Which antihypertensive agent would have the secondary effect of improving her osteoporosis? A thiazide diuretic A calcium channel blocker An ACE inhibitor A beta blocker - Answer A. Thiazide diuretics have the secondary effect of increasing serum calcium by decreasing fluid. This makes more calcium available for absorption. This would not be used to treat a patient with osteoporosis, but this mechanism of action could be helpful as an adjunct for patients who are receiving other forms of treatment for osteoporosis. The other agents listed would have no effect on osteoporosis. Calcium channel blockers impede movement of calcium into cells. This has no effect on available serum calcium. An independent 82-year-old male patient is very active but retired last year. His total cholesterol and LDLs are moderately elevated. How should the NP approach his lipid elevation? He has reached an age where treatment holds little benefit Treatment is age dependent; he should receive a statin today Treatment is based on expected length of life He should receive a statin today until he is 85 years - Answer C. Older adults have higher rates of coronary events than younger adults. Treatment of elevated lipids in older adults has been shown to decrease overall mortality, decrease major coronary events, and

is associated with relative risk reduction for subsequent coronary events. United States Preventive Services Task Force and American Heart Association recommend lipid-lowering therapy because it clearly benefits older adults. This patient should have a statin started if lifestyle modifications do not allow him to reach goal lipid values. Tables are used for the determination of maximum blood pressure values for adolescents. How are these blood pressure values established for adolescents? Height percentile, body mass index, and gender Gender and age Height percentile, gender, and age Body mass index and gender - Answer C. Body size is an important determinant of blood pressure in adolescents. Blood pressure tables are NOT based on body mass index. The tables include 50th, 90th, 95th, and 99th percentiles based on age (up to 17 years), height, and gender. After age 17 years, all blood pressures are based on adult values. Usually, three separate elevated blood pressure readings are required for diagnosis of hypertension. A 75-year-old has isolated systolic hypertension. She started on amlodipine 4 weeks ago. She states that since then, she has developed urinary incontinence. What is the nurse practitioner's assessment? This is unrelated to her new medication. It is coincidental. She may have underlying urinary tract pathology. It is probably related to amlodipine. - Answer D. Amlodipine is a long-acting calcium channel blocker (CCB). Calcium is responsible for muscle contraction. Sometimes CCBs worsen or produce urinary incontinence by impairing detrusor contraction. A lower dose of calcium channel blocker could be tried, a different class could be tried, or as a last resort, incontinence products could be used. Which study would be most helpful in evaluating the degree of hypertrophy of the atrium or ventricle? Chest X-ray Electrocardiography

Echocardiography Doppler ultrasound - Answer C. Echocardiography is of greatest value when evaluating valves, chamber size, cardiac output, and overall function of the myocardium. It is noninvasive and allows specific measurement of chamber size and thickness of the myocardium. The chest film is important in identification of chamber enlargement, but its primary importance is in assessment of the pulmonary vasculature. Electrocardiography (ECG) provides information about the heart's conduction system and identifies cardiac rhythm, though ventricular enlargement can be identified on ECG. Doppler ultrasound identifies intracardiac flow velocities and can assist in quantifying the severity of regurgitation or stenosis. The most common arrhythmia resulting from valvular heart disease is: atrial fibrillation. paroxysmal supraventricular tachycardia. ventricular fibrillation. heart block. - Answer A. The most common arrhythmia seen in all forms of valvular disease is atrial fibrillation. It is usually seen in patients who have organic heart disease. Paroxysmal supraventricular tachycardia is one of the most common arrhythmias but often occurs in patients with no underlying heart disease. It is usually caused by reentry in the AV node and not by valvular heart disease. Ventricular fibrillation and heart block are more likely to represent disease in the conduction system of the myocardium. A 55-year-old male is obese, does not exercise, and has hyperlipidemia. His average blood pressure is 150/90 mmHg. How should he be managed today? He should be given low-dose thiazide diuretic. An ACE inhibitor is appropriate. Lifestyle modifications are appropriate. He should receive an ACE inhibitor and thiazide diuretic. - Answer C. According to JNC8, a patient who is diagnosed with hypertension should have lifestyle modifications initiated today. He has several modifiable risk factors. Management of these can be expected to decrease blood pressure. If his blood pressure is not within normal range (<140/90 mmHg) after 3 months, it is reasonable to consider a

medication like an ACE, ARB, thiazide diuretic, or calcium channel blocker. The most common indicator of end-organ damage in adolescents with hypertension is: left ventricular hypertrophy. seizure. renal dysfunction. renal artery damage. - Answer A. The most common manifestation of end-organ damage in hypertensive adolescents is left ventricular hypertrophy (LVH). According to the National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents, as many as 41% of children who have hypertension have LVH identifiable on ECG. A patient taking an ACE inhibitor should avoid: strenuous exercise. potassium supplements. protein-rich meals. grapefruit juice. - Answer B. An ACE inhibitor potentially can produce hyperkalemia because its mechanism of action is to spare potassium in the renin-angiotensin aldosterone system. If potassium is taken in the form of potassium supplements, the effect will be additive and the risk of hyperkalemia can be great. Which choice below characterizes a patient who has aortic regurgitation? Long asymptomatic period followed by exercise intolerance, then dyspnea at rest An acute onset of shortness of breath in the fifth or sixth decade Dyspnea on exertion for a long period of time before sudden cardiac death A long asymptomatic period with sudden death usually during exercise - Answer A. The natural course of aortic regurgitation (AR) is that the patient has a long asymptomatic period with slowing of activities but remains essentially asymptomatic. Shortness of breath develops with activity and finally, shortness of breath at rest. The left ventricle eventually fails unless the aortic valve is replaced.

An 80-year-old patient with longstanding hypertension takes Monopril and HCTZ for hypertension. His most recent blood pressures are listed. What should be done about his blood pressure? Add an angiotensin receptor blocker (ARB) Add another diuretic Add a calcium channel blocker Stop the HCTZ and add a beta blocker - Answer C. This patient takes medications from two different classes of anti- hypertensives. If these are at maximum doses, consideration should be given to adding a medication from a different class. Adding an ARB may result in a precipitous decrease in his blood pressure and an increase in potassium levels because he takes an ACE inhibitor, and both of these medications work in the renin-angiotensin- aldosterone system. Adding another diuretic will likely produce hypokalemia with a minimal decrease in blood pressure. The calcium channel blocker is a good choice because it will have a synergistic effect with the ACE inhibitor Monopril (fosinopril). A beta blocker will slow the heart rate, not a desired effect in an older adult unless he has underlying angina or a rapid heart rate. A 43-year-old Hispanic male has an audible diastolic murmur best heard in the mitral listening point. There is no audible click. His status has been monitored for the past 2 years. This murmur is probably: mitral valve prolapse. acute mitral regurgitation. chronic mitral regurgitation. mitral stenosis. - Answer D. Mitral valve prolapse (MVP) is an unlikely etiology since MVP is a systolic murmur. Additionally, the question states there is no audible click, and a mid to late systolic click is characteristic of MVP. Acute mitral regurgitation (MR) usually develops after rupture of the chordae tendineae, ruptured papillary muscle after myocardial infarction, or secondary to bacterial endocarditis. Symptoms of failure appear with abrupt clinical deterioration in the patient. A 2-year course for this patient as described would not be appropriate if this were an acute development. Dilation of the left atrium and ventricle is typical in chronic MR since both chambers are affected from regurgitant blood flow across the diseased valve, but MR is a systolic murmur, not diastolic. This is mitral stenosis

(MS) because MS produces the only diastolic murmur listed in the question. A patient taking candesartan for treatment of hypertension should avoid: strenuous exercise potassium supplements. protein-rich meals. grapefruit juice. - Answer B. An ARB like candesartan potentially can produce hyperkalemia because its mechanism of action is to spare potassium in the renin- angiotensin aldosterone system. If potassium is taken in the form of potassium supplements, the effect will be additive and the risk of hyperkalemia will be great. Older adults have a unique blood pressure pattern. Which blood pressure reading below reflects this pattern? 100/50 mmHg 40/100 mmHg 160/60 mmHg 160/100 mmHg - Answer C. Nearly 2/3 of all older adults who are hypertensive have isolated systolic hypertension, i.e., the systolic blood pressure is elevated, the diastolic is normal. This probably occurs because vessels stiffen as people age and a higher systolic is required to move blood through stiffened vessels. Elevated systolic blood pressure is an important risk factor for cardiovascular disease and stroke in older adults. Which item below represents the best choice of antihypertensive agents for the indicated patient (VS in image)? Beta blocker for a 38-year-old diabetic patient ACE inhibitor for a patient on a K+ sparing diuretic Lisinopril in a 35-year-old Caucasian male Diuretic in a patient with history of gout - Answer C. An ACE inhibitor is a preferred initial medication choice in a nonblack patient according to JNC8. Beta blockers may mask the signs and symptoms of hypoglycemia in patients who have diabetes and so are not preferred. ACE inhibitors decrease potassium loss and so should not be routinely used in patients who are on potassium-sparing diuretics because hyperkalemia may result.

Diuretics can produce hyperuricemic states due to fluid loss. Therefore, they should be avoided in patients with history of gout. A 74-year-old patient has peripheral artery disease (PAD). Which item listed below is an important nonmodifiable risk factor for PAD? Cigarette smoking Hyperlipidemia Diabetes Alcohol consumption - Answer C. Modifiable risk factors for PAD include hyperlipidemia, cigarette smoking, and hypertension. Diabetes is typically a nonmodifiable risk factor. Cigarette smoking is often considered the most important risk factor for PAD. Stopping cigarette smoking reduces the progression of PAD and is associated with lower rates of amputation, and improves rest ischemia and pain in patients who experience this. Alcohol consumption actually reduces the risk of PAD but can increase the risk of many other diseases. A patient who has diabetes presents with pain in his lower legs when he walks and pain resolution with rest. When specifically asked about the pain in his lower leg, he likely will report pain: in and around the ankle joint. in the calf muscle. radiating down his leg from the thigh. pain in his lower leg which waxes and wanes. - Answer B. This patient's symptoms are typical of arteriosclerosis. The term used to describe this patient's symptom is intermittent claudication. When there is compromised arterial blood flow in the lower legs, a common complaint is reproducible pain in a specific group of muscles. The pain occurs because there is an incongruence between blood supply and demand. This produces pain that causes a patient to stop exercising in order to obtain pain relief. The major difference between varicose veins and arteriosclerosis is the: limbs affected. gender affected. vessels affected. degree of pain. - Answer C. Varicose veins and arteriosclerosis are very different disease processes. While differences can be found in the gender affected,

the major difference between the two diseases is the vessel affected. Arteriosclerosis affects the arteries, varicose veins affect the veins. While there is a predilection for the lower extremities in varicose veins, peripheral artery disease (PAD) is most common in the lower extremities too. Varicose veins are especially common in women 2:1; PAD is more common in men 2:1 after age 70 years. Pain is a subjective measure. Classic symptoms of deep vein thrombosis (DVT) include: swelling, pain, redness. calf complaints, pain with walking, history of exercise. swelling, pain, and discoloration in lower extremity. warmth, edema, and relief of pain with walking. - Answer C. Swelling, pain, and discoloration from impaired blood flow are the classic symptoms. Choice A could describe infection, like cellulitis, and is not classic for DVT. Redness is an inconsistent sign of DVT as is a positive Homan's sign. A history of exercise actually decreases the risk of DVT. Pain secondary to DVT is not relieved by walking. The lower extremities are the most likely location of DVT, but symptoms don't always correlate with location of the thrombosis. Patients must be asked about history, family history of DVT, and precipitating conditions. Which test listed below may be used to exclude a secondary cause of hyperlipidemia in a patient who has elevated lipids? CBC TSH Urine culture and sensitivity Sedimentation rate - Answer B. Patients who have dyslipidemia should be screened for diabetes, renal disease, and hypothyroidism. Nephrotic syndrome can produce remarkably elevated cholesterol levels. Therefore, measurements of glucose, creatinine or eGFR, and thyroid-stimulating hormone should be performed when evaluating a patient who presents with dyslipidemia. Sedimentation rate is a measure of nonspecific inflammation and so is not helpful in this situation. Specifically, hypothyroidism can produce marked lipid abnormalities. Besides hypertension, which risk factor most contributes to development of an abdominal aortic aneurysm? Valvular dysfunction

Elevated LDL values Cigarette smoking Alcohol consumption - Answer C. Smoking clearly increases the risk for abdominal aortic aneurysm (AAA). The prevalence in women is far lower than in men, and the benefits associated with screening women for AAA do not justify the costs. However, the United States Preventive Services Task Force and American Heart Association recommend one-time screening for males aged 65 to 75 who have ever smoked. Other learned authorities recommend screening between ages 65 and 75 if they have a first-degree relative who required repair of an AAA. Which of the following medications may have an unfavorable effect on a hypertensive patient's blood pressure? Lovastatin Naproxen Inhaled fluticasone Amoxicillin - Answer B. Naproxen is an NSAID. NSAIDs produce sodium retention and hence, water retention. This produces many systemic effects, such as an increase in blood pressure, lower extremity edema, increased workload on the heart, and inhibition of prostaglandin synthesis. Patients with hypertension and heart failure should use NSAIDs cautiously. Lovastatin, fluticasone, and amoxicillin would not be expected to increase or decrease blood pressure. A characteristic of an ACE inhibitor-induced cough is that it: is mildly productive. is worse at nighttime. usually begins within 2 weeks of starting therapy. is more common in men. - Answer C. The cough associated with the use of an ACE inhibitor is typically dry and nonproductive. It is more common in women than men and is thought to be due to the buildup of bradykinin. Bradykinin is partly degraded by ACE (angiotensin-converting enzyme). Degradation of bradykinin and conversion of angiotensin I to angiotensin II by ACE occurs in the lung. When degradation is impaired, bradykinin can accumulate and cough can ensue.

An 80-year-old female who is otherwise well has the following blood pressure readings (VS in image). How should she be managed pharmacologically? Thiazide diuretic ACE inhibitor Calcium channel blocker Angiotensin receptor blocker - Answer C. This patient has isolated systolic hypertension (ISH). This is common in older adults and is associated with tragic cardiac and cerebrovascular events if not treated. The drug class of choice to treat these patients is a long-acting calcium channel blocker. The class of calcium channel blockers recommended for ISH has the suffix "pine" (amlodipine, felodipine, etc). A 64-year-old male has been your patient for several years. He is a former smoker. He presents to your clinic with complaints of fatigue and "just not feeling well" for the last few days. His exam is normal. His blood pressure is well controlled. His medication list, most recent lipid panel, and today's vital signs are provided. What should be done next? Order a CBC and consider waiting a few days if normal. Inquire about feelings of depression and hopelessness. Order a CBC, metabolic panel, TSH, and urine analysis. Order a B12 level, TSH, CBC, and chest X-ray. - Answer C. Fatigue is a difficult complaint to assess and diagnose. This patient's exam and vital signs are normal. There is no reason to think that he is infected or is bleeding, so a lone CBC offers little diagnostic help. However, adding a metabolic panel, TSH, and urine (to screen for hematuria in this former smoker) to the CBC is a more thorough laboratory assessment of his fatigue. Without complaints of shortness of breath, cough, or fever, there is no indication to order a chest X-ray at this time. A decrease in blood pressure can occur in men who take sildenafil (Viagra) and: ibuprofen. trimethoprim-sulfamethoxazole. levothyroxine. any antihypertensive medication. - Answer D. Any antihypertensive medication could have an additive effect with sildenafil (or another medication in this class). Caution is advised

and sildenafil should only be used if the male has stable blood pressure. A specific drug-drug interaction to be aware of is the one that can occur with sildenafil and alpha blockers like tamsulosin, alfuzosin, prazosin, doxazosin, or terazosin. This combination of medications may increase the risk of symptomatic hypotension because the effect of these two drugs is additive. A common side effect of thiazide diuretics is: prostatitis. Erectile dysfunction. fatigue. hyperkalemia - Answer B. Several studies have demonstrated that erectile dysfunction (ED) is associated with use of thiazide diuretics, specifically chlorthalidone. When ED was evaluated in patients taking chlorthalidone, acebutolol, amlodipine, enalapril, and doxazosin (medications from major antihypertensive drug classes), the thiazide diuretic chlorthalidone had the greatest incidence of ED. The other drugs in the study were no more likely to cause ED than a placebo. However, a common complaint of men on antihypertensive medications is ED. This should always be evaluated as a side effect of antihypertensive treatment. Which antibiotic should be used with caution if an older patient has cardiac conduction issues? Amoxicillin-clavulanate Trimethoprim-sulfamethoxazole Ciprofloxacin Macrodantin - Answer C. Quinolones such as ciprofloxacin and levofloxacin are often used to treat urinary tract infections, especially in older adults. All of the quinolones have been implicated in possible QT interval prolongation. Knowing this should cause prescribers to use care, especially when using these or other quinolones in adults who have underlying conduction defects. This is especially the case if a patient is concurrently taking other drugs that can prolong the QT interval. A 75-year-old patient with longstanding hypertension takes a combination ACE inhibitor/thiazide diuretic and amlodipine daily. Today his diastolic blood pressure and heart rate are elevated. He