# COMPREHENSIVE CLINICAL
REASONING EXAMINATION
## Advanced Primary Care:
Multisystem and Complex
Patient Management
### Question 1
Frances Drake-Chamberlain (Maura Smith), a 68-year-old female, presents with dizziness. She reports
feeling lightheaded when she stands up quickly and when turning her head. Which assessment finding is
most suggestive of benign paroxysmal positional vertigo (BPPV)?
A. Nystagmus with head positioning
,B. Tinnitus and hearing loss
C. Orthostatic hypotension
D. Carotid bruit on auscultation
💫RATIONALE✔️✔️: BPPV is characterized by brief episodes of vertigo triggered by head movement,
accompanied by nystagmus on examination. The Dix-Hallpike test is the diagnostic maneuver of choice.
Tinnitus and hearing loss suggest Meniere's disease, and orthostatic hypotension would be present with
positional changes. Carotid bruits indicate carotid stenosis.
💫ANSWER✔️✔️: A. Nystagmus with head positioning
---
### Question 2
Frances Drake-Chamberlain's Dix-Hallpike test is positive for BPPV. Which treatment is most
appropriate?
A. Meclizine 25 mg orally as needed
B. Epley maneuver (canalith repositioning)
C. Vestibular rehabilitation therapy
D. Betahistine 16 mg three times daily
💫RATIONALE✔️✔️: The Epley maneuver is the treatment of choice for BPPV. It involves a series of
head and body movements designed to reposition the otoconia out of the semicircular canals. Meclizine
and betahistine are for symptom management and vestibular rehabilitation may be used for other
balance disorders.
,💫ANSWER✔️✔️: B. Epley maneuver (canalith repositioning)
---
### Question 3
James Taylor, a 39-year-old male, presents with fatigue and shortness of breath. He reports worsening
symptoms over the past 3 weeks. His history includes asthma and seasonal allergies. Which finding is
most concerning for a severe asthma exacerbation?
A. Respiratory rate of 24 breaths per minute
B. Peak expiratory flow rate of 50% of personal best
C. Heart rate of 102 beats per minute
D. Oxygen saturation of 92% on room air
💫RATIONALE✔️✔️: A peak expiratory flow rate of 50% of personal best indicates a severe asthma
exacerbation. The patient is at risk for respiratory failure and requires immediate bronchodilator
therapy and corticosteroids. Oxygen saturation of 92% is concerning but the PEFR is more specific for
airway obstruction.
💫ANSWER✔️✔️: B. Peak expiratory flow rate of 50% of personal best
---
### Question 4
James Taylor is treated with nebulized albuterol and ipratropium. After treatment, his peak flow
improves to 65% of personal best. Which action should the nurse take next?
, A. Discharge home with oral corticosteroids and a follow-up plan
B. Repeat the nebulizer treatment immediately
C. Admit the patient to the hospital
D. Obtain a chest x-ray
💫RATIONALE✔️✔️: A peak flow of 65% after initial treatment indicates the patient is responding to
therapy and can be managed as an outpatient with oral corticosteroids. If there were no improvement
or worsening, hospitalization would be indicated. Follow-up should be arranged within 24-48 hours.
💫ANSWER✔️✔️: A. Discharge home with oral corticosteroids and a follow-up plan
---
### Question 5
Jamie Feldman, a 67-year-old male, presents with stable angina and shortness of breath. He reports
chest pressure with exertion that resolves with rest. His blood pressure is 148/88 mmHg and heart rate
is 88 beats per minute. Which medication should be initiated for long-term management?
A. Sublingual nitroglycerin
B. Aspirin 81 mg daily
C. Metoprolol succinate 25 mg daily
D. Atorvastatin 40 mg daily
💫RATIONALE✔️✔️: Metoprolol (a beta-blocker) is indicated for long-term management of stable
angina to reduce myocardial oxygen demand and prevent future cardiovascular events. Aspirin and
REASONING EXAMINATION
## Advanced Primary Care:
Multisystem and Complex
Patient Management
### Question 1
Frances Drake-Chamberlain (Maura Smith), a 68-year-old female, presents with dizziness. She reports
feeling lightheaded when she stands up quickly and when turning her head. Which assessment finding is
most suggestive of benign paroxysmal positional vertigo (BPPV)?
A. Nystagmus with head positioning
,B. Tinnitus and hearing loss
C. Orthostatic hypotension
D. Carotid bruit on auscultation
💫RATIONALE✔️✔️: BPPV is characterized by brief episodes of vertigo triggered by head movement,
accompanied by nystagmus on examination. The Dix-Hallpike test is the diagnostic maneuver of choice.
Tinnitus and hearing loss suggest Meniere's disease, and orthostatic hypotension would be present with
positional changes. Carotid bruits indicate carotid stenosis.
💫ANSWER✔️✔️: A. Nystagmus with head positioning
---
### Question 2
Frances Drake-Chamberlain's Dix-Hallpike test is positive for BPPV. Which treatment is most
appropriate?
A. Meclizine 25 mg orally as needed
B. Epley maneuver (canalith repositioning)
C. Vestibular rehabilitation therapy
D. Betahistine 16 mg three times daily
💫RATIONALE✔️✔️: The Epley maneuver is the treatment of choice for BPPV. It involves a series of
head and body movements designed to reposition the otoconia out of the semicircular canals. Meclizine
and betahistine are for symptom management and vestibular rehabilitation may be used for other
balance disorders.
,💫ANSWER✔️✔️: B. Epley maneuver (canalith repositioning)
---
### Question 3
James Taylor, a 39-year-old male, presents with fatigue and shortness of breath. He reports worsening
symptoms over the past 3 weeks. His history includes asthma and seasonal allergies. Which finding is
most concerning for a severe asthma exacerbation?
A. Respiratory rate of 24 breaths per minute
B. Peak expiratory flow rate of 50% of personal best
C. Heart rate of 102 beats per minute
D. Oxygen saturation of 92% on room air
💫RATIONALE✔️✔️: A peak expiratory flow rate of 50% of personal best indicates a severe asthma
exacerbation. The patient is at risk for respiratory failure and requires immediate bronchodilator
therapy and corticosteroids. Oxygen saturation of 92% is concerning but the PEFR is more specific for
airway obstruction.
💫ANSWER✔️✔️: B. Peak expiratory flow rate of 50% of personal best
---
### Question 4
James Taylor is treated with nebulized albuterol and ipratropium. After treatment, his peak flow
improves to 65% of personal best. Which action should the nurse take next?
, A. Discharge home with oral corticosteroids and a follow-up plan
B. Repeat the nebulizer treatment immediately
C. Admit the patient to the hospital
D. Obtain a chest x-ray
💫RATIONALE✔️✔️: A peak flow of 65% after initial treatment indicates the patient is responding to
therapy and can be managed as an outpatient with oral corticosteroids. If there were no improvement
or worsening, hospitalization would be indicated. Follow-up should be arranged within 24-48 hours.
💫ANSWER✔️✔️: A. Discharge home with oral corticosteroids and a follow-up plan
---
### Question 5
Jamie Feldman, a 67-year-old male, presents with stable angina and shortness of breath. He reports
chest pressure with exertion that resolves with rest. His blood pressure is 148/88 mmHg and heart rate
is 88 beats per minute. Which medication should be initiated for long-term management?
A. Sublingual nitroglycerin
B. Aspirin 81 mg daily
C. Metoprolol succinate 25 mg daily
D. Atorvastatin 40 mg daily
💫RATIONALE✔️✔️: Metoprolol (a beta-blocker) is indicated for long-term management of stable
angina to reduce myocardial oxygen demand and prevent future cardiovascular events. Aspirin and
