APEA 3P Exam Test Bank - Version 3
Comprehensive Advanced Practice Examination for
Pathophysiology, Pharmacology, and Physical Assessment
QUESTION 1
A 72-year-old male with a 45-pack-year smoking history presents
with a 3-month history of progressive hoarseness, dysphagia, and a
palpable left supraclavicular mass. CT imaging reveals a 4-cm right
upper lobe mass with mediastinal lymphadenopathy. Biopsy of the
supraclavicular node reveals metastatic adenocarcinoma. Which of
the following paraneoplastic syndromes is most specifically
associated with this patient's underlying malignancy?
A. Syndrome of inappropriate antidiuretic hormone secretion
B. Hypertrophic pulmonary osteoarthropathy
C. Lambert-Eaton myasthenic syndrome
D. Trousseau's syndrome
Correct Answer: C
Rationale: Lambert-Eaton myasthenic syndrome (LEMS) is a
paraneoplastic syndrome most commonly associated with small cell
lung cancer, but can also occur with adenocarcinoma. It is caused
by antibodies against presynaptic voltage-gated calcium channels,
leading to reduced acetylcholine release. SIADH and Cushing's
syndrome are more strongly associated with small cell lung cancer.
Hypertrophic pulmonary osteoarthropathy is associated with non-
,small cell lung cancer. Trousseau's syndrome (migratory
thrombophlebitis) is associated with pancreatic and gastric cancers.
QUESTION 2
A 58-year-old female with a history of type 2 diabetes mellitus,
hypertension, and hyperlipidemia presents with a 4-week history of
progressive dyspnea on exertion, orthopnea, and paroxysmal
nocturnal dyspnea. On cardiac auscultation, an S3 gallop is heard at
the apex, and a soft, blowing, holosystolic murmur is audible at the
apex with radiation to the axilla. Transthoracic echocardiogram
reveals a left ventricular ejection fraction of 30% with severe mitral
regurgitation. Which of the following medication combinations
represents the most evidence-based initial pharmacologic regimen
for this patient?
A. Lisinopril, carvedilol, spironolactone, and furosemide
B. Losartan, amlodipine, digoxin, and furosemide
C. Enalapril, metoprolol succinate, hydralazine, and isosorbide
dinitrate
D. Valsartan, sacubitril, bisoprolol, and spironolactone
Correct Answer: D
Rationale: This patient has heart failure with reduced ejection
fraction (HFrEF). The most evidence-based initial regimen includes
an angiotensin receptor-neprilysin inhibitor (ARNI, e.g.,
sacubitril/valsartan), a beta-blocker (bisoprolol, carvedilol, or
metoprolol succinate), and a mineralocorticoid receptor antagonist
(spironolactone). ARNI has been shown to be superior to ACE
,inhibitors in reducing mortality and hospitalizations. While
lisinopril, carvedilol, and spironolactone are appropriate, the ARNI
combination is now preferred first-line. Hydralazine/isosorbide
dinitrate is reserved for African American patients with persistent
symptoms on standard therapy. Amlodipine is not first-line in
HFrEF.
QUESTION 3
A 34-year-old woman who is 28 weeks pregnant presents with
acute onset of severe right upper quadrant pain, nausea, and
vomiting. She reports a 3-day history of headache and visual
disturbances. Blood pressure is 168/102 mmHg, and urine protein
is 4.5 g/24 hours. Laboratory findings reveal elevated AST (145 U/L),
ALT (168 U/L), and platelet count of 78,000/mm³. Which of the
following is the most appropriate immediate management?
A. Administration of labetalol and magnesium sulfate
B. Emergent cesarean delivery
C. Administration of hydralazine and dexamethasone
D. Administration of nifedipine and aspirin
Correct Answer: A
Rationale: This patient has severe preeclampsia with HELLP
syndrome (hemolysis, elevated liver enzymes, low platelets) based
on elevated liver enzymes, thrombocytopenia, and proteinuria.
Immediate management includes blood pressure control (labetalol
or hydralazine) and seizure prophylaxis (magnesium sulfate).
Emergent delivery is indicated but only after stabilization.
, Dexamethasone may be given for fetal lung maturity but is not the
primary immediate intervention. Aspirin is used for preeclampsia
prevention, not acute management.
QUESTION 4
A 67-year-old male with a history of atrial fibrillation on warfarin
therapy presents with a 2-hour history of acute onset of severe,
tearing chest pain radiating to the interscapular region. Blood
pressure is 195/105 mmHg in the right arm and 142/88 mmHg in
the left arm. CT angiography of the chest reveals a type A aortic
dissection extending from the ascending aorta to the aortic arch.
Which of the following is the most appropriate initial
pharmacologic intervention?
A. Intravenous esmolol
B. Intravenous nitroprusside
C. Intravenous labetalol
D. Intravenous diltiazem
Correct Answer: A
Rationale: The initial pharmacologic management of type A aortic
dissection focuses on reducing the force of left ventricular ejection
(dP/dt) and blood pressure. Esmolol, an ultrashort-acting beta-
blocker, is the preferred agent as it rapidly reduces heart rate and
blood pressure, reducing shear stress on the aortic wall.
Nitroprusside may be added but should not be used alone as it can
increase dP/dt. Labetalol is an option but esmolol is preferred due
to its rapid onset and short half-life. Diltiazem is not first-line.
Comprehensive Advanced Practice Examination for
Pathophysiology, Pharmacology, and Physical Assessment
QUESTION 1
A 72-year-old male with a 45-pack-year smoking history presents
with a 3-month history of progressive hoarseness, dysphagia, and a
palpable left supraclavicular mass. CT imaging reveals a 4-cm right
upper lobe mass with mediastinal lymphadenopathy. Biopsy of the
supraclavicular node reveals metastatic adenocarcinoma. Which of
the following paraneoplastic syndromes is most specifically
associated with this patient's underlying malignancy?
A. Syndrome of inappropriate antidiuretic hormone secretion
B. Hypertrophic pulmonary osteoarthropathy
C. Lambert-Eaton myasthenic syndrome
D. Trousseau's syndrome
Correct Answer: C
Rationale: Lambert-Eaton myasthenic syndrome (LEMS) is a
paraneoplastic syndrome most commonly associated with small cell
lung cancer, but can also occur with adenocarcinoma. It is caused
by antibodies against presynaptic voltage-gated calcium channels,
leading to reduced acetylcholine release. SIADH and Cushing's
syndrome are more strongly associated with small cell lung cancer.
Hypertrophic pulmonary osteoarthropathy is associated with non-
,small cell lung cancer. Trousseau's syndrome (migratory
thrombophlebitis) is associated with pancreatic and gastric cancers.
QUESTION 2
A 58-year-old female with a history of type 2 diabetes mellitus,
hypertension, and hyperlipidemia presents with a 4-week history of
progressive dyspnea on exertion, orthopnea, and paroxysmal
nocturnal dyspnea. On cardiac auscultation, an S3 gallop is heard at
the apex, and a soft, blowing, holosystolic murmur is audible at the
apex with radiation to the axilla. Transthoracic echocardiogram
reveals a left ventricular ejection fraction of 30% with severe mitral
regurgitation. Which of the following medication combinations
represents the most evidence-based initial pharmacologic regimen
for this patient?
A. Lisinopril, carvedilol, spironolactone, and furosemide
B. Losartan, amlodipine, digoxin, and furosemide
C. Enalapril, metoprolol succinate, hydralazine, and isosorbide
dinitrate
D. Valsartan, sacubitril, bisoprolol, and spironolactone
Correct Answer: D
Rationale: This patient has heart failure with reduced ejection
fraction (HFrEF). The most evidence-based initial regimen includes
an angiotensin receptor-neprilysin inhibitor (ARNI, e.g.,
sacubitril/valsartan), a beta-blocker (bisoprolol, carvedilol, or
metoprolol succinate), and a mineralocorticoid receptor antagonist
(spironolactone). ARNI has been shown to be superior to ACE
,inhibitors in reducing mortality and hospitalizations. While
lisinopril, carvedilol, and spironolactone are appropriate, the ARNI
combination is now preferred first-line. Hydralazine/isosorbide
dinitrate is reserved for African American patients with persistent
symptoms on standard therapy. Amlodipine is not first-line in
HFrEF.
QUESTION 3
A 34-year-old woman who is 28 weeks pregnant presents with
acute onset of severe right upper quadrant pain, nausea, and
vomiting. She reports a 3-day history of headache and visual
disturbances. Blood pressure is 168/102 mmHg, and urine protein
is 4.5 g/24 hours. Laboratory findings reveal elevated AST (145 U/L),
ALT (168 U/L), and platelet count of 78,000/mm³. Which of the
following is the most appropriate immediate management?
A. Administration of labetalol and magnesium sulfate
B. Emergent cesarean delivery
C. Administration of hydralazine and dexamethasone
D. Administration of nifedipine and aspirin
Correct Answer: A
Rationale: This patient has severe preeclampsia with HELLP
syndrome (hemolysis, elevated liver enzymes, low platelets) based
on elevated liver enzymes, thrombocytopenia, and proteinuria.
Immediate management includes blood pressure control (labetalol
or hydralazine) and seizure prophylaxis (magnesium sulfate).
Emergent delivery is indicated but only after stabilization.
, Dexamethasone may be given for fetal lung maturity but is not the
primary immediate intervention. Aspirin is used for preeclampsia
prevention, not acute management.
QUESTION 4
A 67-year-old male with a history of atrial fibrillation on warfarin
therapy presents with a 2-hour history of acute onset of severe,
tearing chest pain radiating to the interscapular region. Blood
pressure is 195/105 mmHg in the right arm and 142/88 mmHg in
the left arm. CT angiography of the chest reveals a type A aortic
dissection extending from the ascending aorta to the aortic arch.
Which of the following is the most appropriate initial
pharmacologic intervention?
A. Intravenous esmolol
B. Intravenous nitroprusside
C. Intravenous labetalol
D. Intravenous diltiazem
Correct Answer: A
Rationale: The initial pharmacologic management of type A aortic
dissection focuses on reducing the force of left ventricular ejection
(dP/dt) and blood pressure. Esmolol, an ultrashort-acting beta-
blocker, is the preferred agent as it rapidly reduces heart rate and
blood pressure, reducing shear stress on the aortic wall.
Nitroprusside may be added but should not be used alone as it can
increase dP/dt. Labetalol is an option but esmolol is preferred due
to its rapid onset and short half-life. Diltiazem is not first-line.
