NSG 550 EXAM 3 DIAGNOSTIC REASONING 2026/2027 |
Nurse Practitioner Review Questions & Verified Answers |
100% Correct | System-Based | A+ Graded
SECTION 1: CARDIOVASCULAR DIAGNOSTIC REASONING
Q1: A 58-year-old male presents with substernal chest pressure radiating to the left arm,
onset 45 minutes ago while mowing the lawn. He is diaphoretic with BP 88/52 mmHg,
HR 110 bpm, RR 22. EKG shows ST elevations in V1-V4. Troponin I is pending. Which is
the most immediate diagnostic and therapeutic priority?
A. Obtain CT coronary angiography to define anatomy
B. Administer thrombolytics and await troponin results
C. Activate the cardiac catheterization lab for primary PCI [CORRECT]
D. Perform echocardiography to assess wall motion abnormalities
Correct Answer: C
Rationale: The patient presents with STEMI (anterior wall, V1-V4) and cardiogenic shock
(hypotension, tachycardia). The 2022 ACC/AHA guidelines recommend primary PCI
within 90 minutes of first medical contact as the preferred reperfusion strategy;
thrombolytics are inferior in shock. CT angiography delays definitive therapy, and echo,
while useful, does not replace emergent revascularization.
Q2: A 72-year-old female with hypertension and diabetes reports progressive dyspnea
on exertion, orthopnea, and lower extremity edema. Physical exam reveals an S3 gallop,
JVD at 6 cm H2O, and bilateral pulmonary crackles. BNP is 1,200 pg/mL.
Echocardiography shows an LVEF of 60%. Which diagnosis best fits this presentation?
A. Heart failure with reduced ejection fraction (HFrEF)
B. Heart failure with preserved ejection fraction (HFpEF) [CORRECT]
C. Acute cor pulmonale
D. Mitral regurgitation with normal forward flow
Correct Answer: B
Rationale: HFpEF is diagnosed when symptoms and signs of heart failure occur with
LVEF ≥50%, often in elderly women with hypertension and diabetes. The elevated BNP
,supports hemodynamic congestion, while preserved LVEF rules out HFrEF. Acute cor
pulmonale typically presents with right heart strain and clear lung fields, and isolated
mitral regurgitation does not explain the full congestive picture.
Q3: A 45-year-old male presents with sudden-onset severe chest pain described as
"tearing" radiating to his back. BP is 185/110 mmHg in the right arm and 140/85 mmHg
in the left arm. Chest X-ray shows a widened mediastinum. Which is the diagnostic test
of choice?
A. Transthoracic echocardiography
B. CT angiography of the chest with IV contrast [CORRECT]
C. Cardiac catheterization
D. MRI of the chest without contrast
Correct Answer: B
Rationale: The presentation is classic for thoracic aortic dissection: tearing chest pain,
blood pressure differential, and widened mediastinum. CT angiography is the first-line
imaging modality with high sensitivity and specificity for detecting the intimal flap and
defining Stanford type. TTE has limited aortic visualization, and catheterization risks
extending the dissection.
Q4: A 62-year-old female with atrial fibrillation on warfarin presents with acute-onset
left-sided weakness and aphasia. NIHSS is 14. CT head shows no hemorrhage. INR is
2.8. Last known well was 2 hours ago. Which is the most appropriate next step?
A. Administer IV tPA immediately regardless of INR
B. Withhold tPA and obtain CT angiography for mechanical thrombectomy candidacy
C. Administer IV tPA if INR ≤1.7, otherwise consider mechanical thrombectomy
[CORRECT]
D. Reverse warfarin with PCC and administer tPA in 6 hours
Correct Answer: C
Rationale: Per AHA/ASA 2023 stroke guidelines, IV tPA is contraindicated when INR
>1.7 due to hemorrhagic transformation risk. Mechanical thrombectomy should be
evaluated via vascular imaging (CTA/MRA) for large vessel occlusion, as it is not
contraindicated by anticoagulation status. Immediate tPA would be dangerous with INR
2.8.
,Q5: A 35-year-old female presents with palpitations, heat intolerance, and tremor.
Physical exam shows lid lag, fine tremor, and a resting heart rate of 112 bpm. EKG
reveals sinus tachycardia with frequent premature beats. TSH is 0.01 mIU/L, free T4 is
elevated. Which diagnostic finding distinguishes Graves' disease from toxic
multinodular goiter?
A. Elevated T3 levels
B. Presence of thyroid peroxidase antibodies
C. Diffuse uptake on radioactive iodine uptake scan [CORRECT]
D. Presence of thyroid nodules on ultrasound
Correct Answer: C
Rationale: Graves' disease demonstrates diffuse, homogeneous uptake on RAIU scan
due to TSI stimulation of the entire gland, whereas toxic multinodular goiter shows
patchy or focal uptake in autonomous nodules with suppressed surrounding tissue.
Both conditions cause hyperthyroidism with suppressed TSH, but the pattern of uptake
differentiates them definitively.
Q6: A 68-year-old male with CAD s/p MI 3 years ago presents with stable exertional
chest pain relieved by rest and sublingual nitroglycerin. He can climb two flights of
stairs before symptom onset. Which test is most appropriate for initial evaluation of his
current ischemic burden?
A. Emergent coronary angiography
B. Exercise stress testing with EKG [CORRECT]
C. Immediate CT coronary angiography
D. Dobutamine stress echocardiography
Correct Answer: B
Rationale: This patient has stable angina (Canadian Cardiovascular Society Class II)
without high-risk features. The 2021 AHA/ACC chest pain guideline recommends
exercise stress EKG as the initial noninvasive test for intermediate-risk patients with
stable symptoms who can exercise and have interpretable EKGs. Emergent angiography
is reserved for ACS, and dobutamine echo is preferred for those unable to exercise.
Q7: A 50-year-old male presents with syncope during a morning jog. He has no
prodrome, recovered quickly, and has no prior cardiac history. Family history reveals a
brother who died suddenly at age 45. Physical exam is unremarkable. EKG shows left
, ventricular hypertrophy with deep T-wave inversions in lateral leads. Which is the most
likely underlying diagnosis?
A. Arrhythmogenic right ventricular cardiomyopathy
B. Hypertrophic cardiomyopathy (HCM) [CORRECT]
C. Long QT syndrome
D. Brugada syndrome
Correct Answer: B
Rationale: Exertional syncope in a young patient with family history of sudden cardiac
death and EKG showing LVH with deep T-wave inversions is classic for hypertrophic
cardiomyopathy, the most common cause of sudden cardiac death in young athletes.
ARVC typically shows epsilon waves and T-wave inversions in V1-V3. Brugada shows
coved ST elevation in V1-V3, and long QT is a repolarization abnormality without
hypertrophy.
Q8: A 55-year-old male with type 2 diabetes and hyperlipidemia presents for a routine
visit. His 10-year ASCVD risk is calculated at 18%. LDL is 142 mg/dL, HDL 38 mg/dL,
triglycerides 220 mg/dL. According to 2022 AHA/ACC cholesterol guidelines, what is
the recommended intensity of statin therapy?
A. Low-intensity statin
B. Moderate-intensity statin
C. High-intensity statin [CORRECT]
D. Statin therapy not indicated; initiate ezetimibe
Correct Answer: C
Rationale: The patient has diabetes (age 40-75) and an LDL 70-189 mg/dL with 10-year
ASCVD risk >7.5%, qualifying for high-intensity statin per 2018/2022 ACC/AHA
guidelines. The presence of diabetes alone in this age group with additional risk factors
supports high-intensity therapy to achieve ≥50% LDL reduction. Ezetimibe is adjunctive,
not first-line monotherapy.
Q9: A 40-year-old female presents with episodic severe headaches, palpitations, and
diaphoresis. During an episode, BP is 220/130 mmHg with heart rate 120 bpm. Between
episodes, vital signs normalize. Plasma metanephrines are elevated 3-fold above the
upper limit of normal. Which is the next best diagnostic step?
A. Begin phenoxybenzamine and proceed directly to adrenalectomy
B. CT or MRI of the abdomen/pelvis to localize the tumor [CORRECT]
Nurse Practitioner Review Questions & Verified Answers |
100% Correct | System-Based | A+ Graded
SECTION 1: CARDIOVASCULAR DIAGNOSTIC REASONING
Q1: A 58-year-old male presents with substernal chest pressure radiating to the left arm,
onset 45 minutes ago while mowing the lawn. He is diaphoretic with BP 88/52 mmHg,
HR 110 bpm, RR 22. EKG shows ST elevations in V1-V4. Troponin I is pending. Which is
the most immediate diagnostic and therapeutic priority?
A. Obtain CT coronary angiography to define anatomy
B. Administer thrombolytics and await troponin results
C. Activate the cardiac catheterization lab for primary PCI [CORRECT]
D. Perform echocardiography to assess wall motion abnormalities
Correct Answer: C
Rationale: The patient presents with STEMI (anterior wall, V1-V4) and cardiogenic shock
(hypotension, tachycardia). The 2022 ACC/AHA guidelines recommend primary PCI
within 90 minutes of first medical contact as the preferred reperfusion strategy;
thrombolytics are inferior in shock. CT angiography delays definitive therapy, and echo,
while useful, does not replace emergent revascularization.
Q2: A 72-year-old female with hypertension and diabetes reports progressive dyspnea
on exertion, orthopnea, and lower extremity edema. Physical exam reveals an S3 gallop,
JVD at 6 cm H2O, and bilateral pulmonary crackles. BNP is 1,200 pg/mL.
Echocardiography shows an LVEF of 60%. Which diagnosis best fits this presentation?
A. Heart failure with reduced ejection fraction (HFrEF)
B. Heart failure with preserved ejection fraction (HFpEF) [CORRECT]
C. Acute cor pulmonale
D. Mitral regurgitation with normal forward flow
Correct Answer: B
Rationale: HFpEF is diagnosed when symptoms and signs of heart failure occur with
LVEF ≥50%, often in elderly women with hypertension and diabetes. The elevated BNP
,supports hemodynamic congestion, while preserved LVEF rules out HFrEF. Acute cor
pulmonale typically presents with right heart strain and clear lung fields, and isolated
mitral regurgitation does not explain the full congestive picture.
Q3: A 45-year-old male presents with sudden-onset severe chest pain described as
"tearing" radiating to his back. BP is 185/110 mmHg in the right arm and 140/85 mmHg
in the left arm. Chest X-ray shows a widened mediastinum. Which is the diagnostic test
of choice?
A. Transthoracic echocardiography
B. CT angiography of the chest with IV contrast [CORRECT]
C. Cardiac catheterization
D. MRI of the chest without contrast
Correct Answer: B
Rationale: The presentation is classic for thoracic aortic dissection: tearing chest pain,
blood pressure differential, and widened mediastinum. CT angiography is the first-line
imaging modality with high sensitivity and specificity for detecting the intimal flap and
defining Stanford type. TTE has limited aortic visualization, and catheterization risks
extending the dissection.
Q4: A 62-year-old female with atrial fibrillation on warfarin presents with acute-onset
left-sided weakness and aphasia. NIHSS is 14. CT head shows no hemorrhage. INR is
2.8. Last known well was 2 hours ago. Which is the most appropriate next step?
A. Administer IV tPA immediately regardless of INR
B. Withhold tPA and obtain CT angiography for mechanical thrombectomy candidacy
C. Administer IV tPA if INR ≤1.7, otherwise consider mechanical thrombectomy
[CORRECT]
D. Reverse warfarin with PCC and administer tPA in 6 hours
Correct Answer: C
Rationale: Per AHA/ASA 2023 stroke guidelines, IV tPA is contraindicated when INR
>1.7 due to hemorrhagic transformation risk. Mechanical thrombectomy should be
evaluated via vascular imaging (CTA/MRA) for large vessel occlusion, as it is not
contraindicated by anticoagulation status. Immediate tPA would be dangerous with INR
2.8.
,Q5: A 35-year-old female presents with palpitations, heat intolerance, and tremor.
Physical exam shows lid lag, fine tremor, and a resting heart rate of 112 bpm. EKG
reveals sinus tachycardia with frequent premature beats. TSH is 0.01 mIU/L, free T4 is
elevated. Which diagnostic finding distinguishes Graves' disease from toxic
multinodular goiter?
A. Elevated T3 levels
B. Presence of thyroid peroxidase antibodies
C. Diffuse uptake on radioactive iodine uptake scan [CORRECT]
D. Presence of thyroid nodules on ultrasound
Correct Answer: C
Rationale: Graves' disease demonstrates diffuse, homogeneous uptake on RAIU scan
due to TSI stimulation of the entire gland, whereas toxic multinodular goiter shows
patchy or focal uptake in autonomous nodules with suppressed surrounding tissue.
Both conditions cause hyperthyroidism with suppressed TSH, but the pattern of uptake
differentiates them definitively.
Q6: A 68-year-old male with CAD s/p MI 3 years ago presents with stable exertional
chest pain relieved by rest and sublingual nitroglycerin. He can climb two flights of
stairs before symptom onset. Which test is most appropriate for initial evaluation of his
current ischemic burden?
A. Emergent coronary angiography
B. Exercise stress testing with EKG [CORRECT]
C. Immediate CT coronary angiography
D. Dobutamine stress echocardiography
Correct Answer: B
Rationale: This patient has stable angina (Canadian Cardiovascular Society Class II)
without high-risk features. The 2021 AHA/ACC chest pain guideline recommends
exercise stress EKG as the initial noninvasive test for intermediate-risk patients with
stable symptoms who can exercise and have interpretable EKGs. Emergent angiography
is reserved for ACS, and dobutamine echo is preferred for those unable to exercise.
Q7: A 50-year-old male presents with syncope during a morning jog. He has no
prodrome, recovered quickly, and has no prior cardiac history. Family history reveals a
brother who died suddenly at age 45. Physical exam is unremarkable. EKG shows left
, ventricular hypertrophy with deep T-wave inversions in lateral leads. Which is the most
likely underlying diagnosis?
A. Arrhythmogenic right ventricular cardiomyopathy
B. Hypertrophic cardiomyopathy (HCM) [CORRECT]
C. Long QT syndrome
D. Brugada syndrome
Correct Answer: B
Rationale: Exertional syncope in a young patient with family history of sudden cardiac
death and EKG showing LVH with deep T-wave inversions is classic for hypertrophic
cardiomyopathy, the most common cause of sudden cardiac death in young athletes.
ARVC typically shows epsilon waves and T-wave inversions in V1-V3. Brugada shows
coved ST elevation in V1-V3, and long QT is a repolarization abnormality without
hypertrophy.
Q8: A 55-year-old male with type 2 diabetes and hyperlipidemia presents for a routine
visit. His 10-year ASCVD risk is calculated at 18%. LDL is 142 mg/dL, HDL 38 mg/dL,
triglycerides 220 mg/dL. According to 2022 AHA/ACC cholesterol guidelines, what is
the recommended intensity of statin therapy?
A. Low-intensity statin
B. Moderate-intensity statin
C. High-intensity statin [CORRECT]
D. Statin therapy not indicated; initiate ezetimibe
Correct Answer: C
Rationale: The patient has diabetes (age 40-75) and an LDL 70-189 mg/dL with 10-year
ASCVD risk >7.5%, qualifying for high-intensity statin per 2018/2022 ACC/AHA
guidelines. The presence of diabetes alone in this age group with additional risk factors
supports high-intensity therapy to achieve ≥50% LDL reduction. Ezetimibe is adjunctive,
not first-line monotherapy.
Q9: A 40-year-old female presents with episodic severe headaches, palpitations, and
diaphoresis. During an episode, BP is 220/130 mmHg with heart rate 120 bpm. Between
episodes, vital signs normalize. Plasma metanephrines are elevated 3-fold above the
upper limit of normal. Which is the next best diagnostic step?
A. Begin phenoxybenzamine and proceed directly to adrenalectomy
B. CT or MRI of the abdomen/pelvis to localize the tumor [CORRECT]
