APEA 3P EXAM QUESTIONS AND ANSWERS WITH RATIONALES 2024/2025, Exams of Nursing

Download APEA 3P EXAM QUESTIONS AND ANSWERS WITH RATIONALES 2024/2025 and more Exams Nursing in PDF only on Docsity! APEA 3P EXAM QUESTIONS AND ANSWERS WITH RATIONALES 2024/2025 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 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 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. 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 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 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. 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 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. hypomagnese mia. hypokalemia. hypercalcemia . 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. 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 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 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: Cholester ol. HDL. LDL. triglycerides. 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 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 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. 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 Headach e Orthopne a Cough 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 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. amlodipi ne. metoprol ol. fosinopril 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 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 . 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 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 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. 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 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. 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 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. 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 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 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 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. 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 Electrocardiograp hy Echocardiography Doppler ultrasound 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. A. The most common arrhythmia seen in all forms of valvular disease is atrial 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 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 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. 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. 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 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 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 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. TSH Urine culture and sensitivity Sedimentation rate 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 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 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. 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 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. Which one does NOT? Fosinopril Candesartan Hydrochlorothiazide Amlodipine D. Amlodipine is a calcium channel blocker and its use does not warrant monitoring potassium levels. Fosinopril is an ACE inhibitor and candesartan is an ARB. Both warrant monitoring potassium levels because both have the potential to produce hyperkalemia, especially in patients who have renal impairment or heart failure. Hydrochlorothiazide has the potential to produce hypokalemia, so, it too warrants monitoring of potassium levels. The carotid arteries are auscultated for bruits because: a bruit is indicative of an impending stroke. a bruit is indicative of carotid stenosis. this is indicative of generalized atherosclerosis. this is reflective of stroke risk C. Asymptomatic bruits in the carotid area are more indicative of atherosclerotic disease than increased stroke risk. A symptomatic bruit requires immediate attention. Patients with carotid artery disease are more likely to die of cardiovascular disease than cerebrovascular disease. The Framingham Heart Study found that patients with an asymptomatic carotid bruit were at increased risk of stroke, but the majority of strokes occurred in an area away from the carotid artery. The overall risk of stroke was insignificant when an asymptomatic carotid bruit was identified. An overweight 76-year-old female with a recent onset of diabetes has longstanding hypertension and hyperlipidemia. She has developed atrial fibrillation. The nurse practitioner knows that this patient is at risk for: an S3 gallop. heart failure (HF). peripheral edema. hypothyroidis m. B. This patient has longstanding hypertension that will increase her risk of HF. Once she develops atrial fibrillation (a-fib), she will lose about 30% of her cardiac output, the amount contributed by her atria when she is not in a-fib. Shortness of breath, peripheral edema or an S3 gallop may develop, but these are consequences of HF or an embolism, for which she is also at risk. Hypothyroidism can increase her risk of HF, but the risk of hypothyroidism does not increase once a-fib develops. The most obvious risk of a-fib is stroke, but this was not a choice. mitral. pulmonic. tricuspid. B. The mitral valve has a propensity for disorders secondary to rheumatic heart disease. Rarely is the pulmonic valve involved, but the aortic and tricuspid valves follow in descending order of involvement. Following an episode of rheumatic fever, which occurs infrequently in the US today but is common in developing countries, the valves can become stenotic or regurgitant. This is a major cause of valvular disease in the US, and it is seen primarily in immigrants. Drugs that target the renin-angiotensin-aldosterone system are particularly beneficial in patients who have: hypertension. chronic heart failure. kidney stones. diabetic nephropathy. D. Examples of drugs that target the renin-angiotensin-aldosterone system are angiotensin converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs). These drugs are particularly beneficial to patients who have diabetic nephropathy because they both prevent and treat diabetic nephropathy. Additionally, these agents also lower blood pressure which has been shown to be renoprotective. Management of glucose levels and hypertension is especially important in preventing diabetic nephropathy, but so is aggressive management of hyperlipidemia. A 28-year-old has a Grade 3 murmur. Which characteristic indicates a need for referral? A fixed split An increase in splitting with inspiration A split S2 with inspiration Changes in intensity with position change A. A split is created because of closure of valves. For example, an S2 is created by closure of the aortic and pulmonic valves. Normally these split with inspiration and almost never with expiration. Splits should never be fixed. This indicates pathology such as an atrial septal defect, pulmonic stenosis, or possibly mitral regurgitation. In any event, this patient needs initial evaluation with an echocardiogram because fixed splits are always considered abnormal. He will almost certainly be referred to cardiology. How often should lipids be screened in patients who are 65 years and older if they have lipid disorders or cardiovascular risk factors? Annually Every other year Every 3 years Every 5 years A. Screening should take place annually for patients who have coronary artery disease and other risk factors like diabetes, peripheral artery disease, or prior stroke. These patients are at very high risk and annual screening is economically justified. In a setting of a low-risk patient who does have any of the above mentioned risk factors, United States Preventive Services Task Force recommends screening every 5 years. A patient with aortic stenosis has been asymptomatic for decades. On routine exam, he states that he has had some dizziness associated with activity but no chest pain or shortness of breath. The best course of action for the nurse practitioner is to: monitor closely for worsening of his status. refer to cardiology. order a CBC, metabolic panel and UA. assess his carotid arteries for bruits. B. In a patient with known aortic stenosis (AS) who has been asymptomatic for decades, one should be alert for symptoms that will precede angina, heart failure, and syncope. Dizziness precedes syncope in these patients and so this is an early indication that the patient is becoming symptomatic from his AS. Once symptoms develop, there is a rapid downhill course. Therefore, dizziness, chest discomfort, or exercise intolerance are important symptoms to assess in previously asymptomatic patients who have AS. This patient should be referred to cardiology. Which group of medications would be detrimental if used to treat a patient who has heart failure (HF)? Ramipril, aspirin, metoprolol Digoxin, furosemide, aspirin Fosinopril, HCTZ, verapamil Furosemide, enalapril, aspirin C. The medications often used in managing patients who have HF include ACE inhibitors, beta blockers, diuretics, aspirin, or digoxin. Verapamil is a calcium channel blocker and is contraindicated in patients who have HF because this class depresses myocardial contractility. A 40-year-old African American patient has blood pressure readings of 175/100 mmHg and 170/102 mmHg. What is a reasonable plan of care for this patient today? Start 12.5 mg hydrochlorothiazide daily (usual dose 12.5- 50 mg daily). Start 10 mg lisinopril daily (usual dose is 10- 40 mg daily). A. The left ventricle enlarges as blood regurgitates from the aorta. Atrial fibrillation is not typical or usual in aortic regurgitation (AR), since neither atrium is affected. Pulmonary congestion is seen later in the pathogenesis of AR. The blood pressure in patients with AR is characterized by an elevated systolic and decreased diastolic pressure. This is termed a wide pulse pressure. A patient with mitral regurgitation (MR) has developed the most common arrhythmia associated with MR. The intervention most likely to prevent complications from this arrhythmia is: immediate referral for a pacemaker. anticoagulation. beta blocker administration. valve replacement. B. The most common arrhythmia associated with mitral regurgitation (MR) is atrial fibrillation. Anticoagulation with warfarin will help prevent arterial embolism that can result in stroke or myocardial infarction. Atrial fibrillation occurs because the fibers in the atrium are stretched as the atrium dilates. The stretch results in conduction defects, notably, atrial fibrillation. A 65-year-old male patient has the following lipid levels. What class of medications is preferred to normalize his lipid levels and reduce his risk of a cardiac event? Niacin Fibric acids HMG CoA reductase inhibitors Bile acid sequestrants C. The only medication class that reduces elevated lipid levels and has proven efficacy in reducing risk of cardiac events, even for primary prevention, are the HMG CoA reductase inhibitors, also known as the statins. Statin therapy has been shown to reduce overall mortality resulting from cardiovascular deaths. The statin should significantly reduce his total cholesterol and LDL values. An older adult has renal insufficiency, hypertension, osteoarthritis, hypothyroidism, and varicose veins. Which medication should be avoided? Acetaminophe n Beta blockers NSAIDs Low dose aspirin C. NSAIDs are contraindicated in patients who have renal insufficiency. They may produce a transient decrease in renal function and likely produce sodium retention and thus, water retention. For the same reason, this may worsen hypertension. Acetaminophen, mild narcotics, and/or topical agents could be used to treat her osteoarthritis. NSAIDs will have no effect on her varicose veins or hypothyroidism. Mr. Daigle is an 80-year-old patient who takes warfarin for chronic atrial fibrillation (CBC in image. INR 6.0) The nurse practitioner should: stop warfarin for the next two days and repeat the INR on day 3. admit to the hospital immediately. administer vitamin K and repeat INR tomorrow. stop warfarin for one week and recheck INR. A. An INR of 6.0 is elevated and this patient could suffer a devastating bleed anywhere in the body. A patient with an INR of 5-9 without bleeding may have warfarin stopped temporarily and decrease the maintenance dose when it is safe to resume warfarin, i.e. when the INR is closer to the patient's therapeutic range. If the patient was at high risk for bleeding, was bleeding, or if the INR was higher, vitamin K could be administered. This is not the case with Mr. Daigle. 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. A patient with hypertension describes a previous allergic reaction to a sulfa antibiotic as "sloughing of skin" and hospitalization. Which medication is contraindicated in this patient? Ramipril Metoprolol Hydrochlorothiazide Verapamil C. This patient's allergy to "sulfa" sounds like Stevens-Johnson Syndrome, a potentially life- threatening allergic reaction. Hydrochlorothiazide has a sulfonamide ring in its chemical structure, generally referred to as "sulfa." This sulfonamide ring can initiate an allergic reaction in patients with sulfa allergy. Since the patient's allergic reaction to sulfa was so serious, other sulfonamide medications should be completely avoided until consultation with an allergist. The Insulin Acetaminophe n A. Metoprolol is a cardioselective beta blocker that decreases heart rate. A patient who has acute heart failure will compensate by increasing heart rate to maintain cardiac output (CO). Metoprolol impairs the patient's ability to increase heart rate when needed to maintain cardiac output (CO=stroke volume x heart rate). Consequently, the use of beta blockers in patients with heart failure should be monitored carefully. Furosemide may actually improve shortness of breath in a patient with heart failure. Insulin and acetaminophen have no direct effect on cardiac output in a patient with heart failure. An 87-year-old has history of symptomatic heart failure. He presents today with lower extremity edema and mild shortness of breath with exertion. In addition to a diuretic for volume overload, what other medication should he receive today? ACE inhibitor Beta blocker Calcium channel blocker Oxygen A. This patient needs to begin a medication that will directly address his heart failure. An ACE inhibitor will do this. Additionally, ACE inhibitors have demonstrated reduced morbidity and mortality when given at target doses to patients who have heart failure. A beta blocker should be added when the patient is no longer symptomatic. A calcium channel blocker will worsen systolic dysfunction because it will decrease the force of contractions. Oxygen would be used if the patient were short of breath or having chest pain. Neither of these findings would be seen in someone who was stable. Oxygen is not needed today. A 42-year-old hypertensive patient was given a thiazide diuretic 4 weeks ago for treatment of primary hypertension. On his return visit today, he reports feeling weak and tired. What should the NP consider to evaluate the weakness and fatigue? Glucose level Potassium level CBC TSH B. This patient has classic symptoms of hypokalemia associated with potassium loss secondary to thiazide diuretic use. A potassium level should be measured and he should be supplemented if it is low. Generally, muscle weakness occurs as potassium levels drop below 2.5 mEq/L. If his potassium is low, strong consideration should be given to a thiazide diuretic in combination with a potassium sparing diuretic. In fact, this should be considered when the thiazide is initially prescribed. The correlation between blood pressure and age greater than 60 years is that as age increases: diastolic blood pressure increases. systolic blood pressure decreases. blood pressure remains about the same. diastolic blood pressure decreases. D. As age increases (> 60 years), systolic blood pressure tends to increase, but diastolic blood pressure tends to decrease. This is evidenced by the observation of isolated systolic hypertension, seen almost exclusively in the older population. This results in a widening pulse pressure, a predictor of cardiovascular events in older adults. The pulse pressure is calculated by subtracting the diastolic blood pressure from the systolic blood pressure. Measurements greater than 60-70 points indicate "stiffening" of the vessels. Stiffening commonly occurs as aging occurs. According to the National Heart, Lung and Blood Institute, which characteristic listed below is a coronary heart disease (CHD) risk equivalent; that is, which risk factor places the patient at a CHD risk similar to a history of CHD? Hypertension Cigarette smoking Male age > 45 years Diabetes mellitus D. In determining whether a patient should be treated for hyperlipidemia, a patient's risk factors must be determined. After assessing fasting lipids, specifically LDLs, CHD equivalents must be identified. These are diabetes, symptomatic carotid artery disease, peripheral artery disease, abdominal aortic aneurysm, and multiple risk factors that confer a 10-year risk of CHD > 20%. Major CHD risk factors are elevated LDL cholesterol, cigarette smoking, hypertension, low HDL cholesterol, family history of premature CHD [in male first-degree relatives (FDR) < 55 years; female FDR, 65 years], and age (men > 45 years, women > 55 years). Patients with 2 or more risk factors should have a 10-year risk assessment performed and be treated accordingly.