Adult-Gerontology Primary Care Final ACTUAL
EXAM ALL QUESTIONS AND ANSWERS ALREADY
GRADED A+. 100% VERIFIED SOLUTIONS |
UPDATED PER LATEST GUIDELINES | GRADED A+
Section 1: Cardiovascular System (Questions 1-15)
Question 1
A 68-year-old male with a history of hypertension and type 2 diabetes presents with substernal
chest pressure that radiates to his left arm, diaphoresis, and nausea. His ECG shows 2-mm ST-
segment elevations in leads V1-V4. What is the most likely diagnosis and immediate
management?
A) Unstable angina; admit for observation and stress testing
B) ST-elevation myocardial infarction (STEMI); immediate reperfusion therapy
C) Non-ST-elevation myocardial infarction (NSTEMI); start heparin and clopidogrel
D) Aortic dissection; obtain CT angiography
Answer: B) ST-elevation myocardial infarction (STEMI); immediate reperfusion therapy
Rationale: ST-segment elevations in leads V1-V4 indicate an anterior wall STEMI. This is a
medical emergency requiring immediate reperfusion therapy (PCI or fibrinolysis). The classic
presentation of substernal chest pressure radiating to the arm with diaphoresis and nausea
supports the diagnosis. Unstable angina and NSTEMI do not present with ST elevations. Aortic
dissection presents with tearing pain and pulse deficits.
Question 2
A 72-year-old female presents with dyspnea on exertion, orthopnea, and bilateral lower
extremity edema. On exam, she has jugular venous distention, crackles at the lung bases, and
an S3 gallop. An echocardiogram shows an ejection fraction of 25%. Which of the following is
the most appropriate initial pharmacologic management for heart failure with reduced ejection
fraction (HFrEF)?
,A) Furosemide and digoxin
B) ACE inhibitor and beta-blocker
C) Calcium channel blocker and hydralazine
D) Loop diuretic and spironolactone
Answer: B) ACE inhibitor and beta-blocker
Rationale: Guideline-directed medical therapy for HFrEF includes an ACE inhibitor (or ARB/ARNI)
and an evidence-based beta-blocker (carvedilol, metoprolol succinate, or bisoprolol). These
medications reduce mortality and hospitalizations. ACE inhibitors also reduce afterload and
improve survival. Diuretics are used for symptom management but do not reduce mortality.
Calcium channel blockers are not first-line in HFrEF due to negative inotropic effects.
Question 3
A 65-year-old male with hypertension and hyperlipidemia presents with new-onset atrial
fibrillation. His CHA₂DS₂-VASc score is 4. Which of the following is the most appropriate stroke
prevention strategy?
A) Aspirin 81 mg daily
B) Warfarin with target INR 2-3
C) Direct oral anticoagulant (DOAC) such as rivaroxaban or apixaban
D) No anticoagulation due to age
Answer: C) Direct oral anticoagulant (DOAC) such as rivaroxaban or apixaban
Rationale: A CHA₂DS₂-VASc score of 4 indicates high stroke risk. DOACs are preferred over
warfarin for stroke prevention in non-valvular atrial fibrillation due to lower bleeding risk, fewer
drug interactions, and no need for routine INR monitoring. Aspirin is insufficient for stroke
prevention in high-risk patients. Age alone is not a contraindication to anticoagulation.
Question 4
An 80-year-old patient is prescribed warfarin for atrial fibrillation. His INR is 5.0 without any
signs of bleeding. What is the appropriate management?
A) Administer vitamin K 10 mg orally
B) Hold the next dose and resume at a lower dose when INR is therapeutic
C) Administer fresh frozen plasma
D) Increase the warfarin dose
Answer: B) Hold the next dose and resume at a lower dose when INR is therapeutic
,Rationale: For an INR between 5 and 9 without bleeding, the standard recommendation is to
hold warfarin and resume at a lower dose when the INR returns to the therapeutic range (2-3).
Vitamin K is typically reserved for INR >10 or active bleeding. Fresh frozen plasma is for active
bleeding requiring rapid reversal.
Question 5
A 72-year-old male with heart failure with reduced ejection fraction is started on an ACE
inhibitor. Which laboratory value should be monitored closely?
A) Serum sodium
B) Serum potassium and serum creatinine
C) Serum calcium
D) Serum magnesium
Answer: B) Serum potassium and serum creatinine
Rationale: ACE inhibitors can cause hyperkalemia and acute kidney injury, particularly in patients
with renal impairment or those taking potassium-sparing diuretics. Monitoring serum potassium
and creatinine is essential to detect these adverse effects early. This is particularly important in
older adults who may have age-related renal decline.
Question 6
A 55-year-old female presents with sharp, pleuritic chest pain that worsens when lying flat and
improves when leaning forward. On exam, a pericardial friction rub is heard. Which of the
following is the most likely diagnosis?
A) Acute pericarditis
B) Myocardial infarction
C) Pulmonary embolism
D) Pneumothorax
Answer: A) Acute pericarditis
Rationale: Acute pericarditis is characterized by sharp, pleuritic chest pain that worsens with
lying flat and improves with leaning forward. A pericardial friction rub is a hallmark physical
finding. MI pain is typically pressure-like and not positional. PE causes dyspnea and pleuritic
pain. Pneumothorax is associated with sudden dyspnea and absent breath sounds.
, Question 7
A 60-year-old male with a history of smoking presents with pain in his calves when walking that
is relieved by rest. He has diminished pulses in his feet. Which of the following is the most likely
diagnosis?
A) Peripheral artery disease
B) Deep vein thrombosis
C) Venous insufficiency
D) Sciatica
Answer: A) Peripheral artery disease
Rationale: Intermittent claudication—leg pain with walking relieved by rest—is the hallmark of
peripheral artery disease (PAD). Diminished pulses are a key physical finding. DVT causes pain,
swelling, and warmth. Venous insufficiency causes edema, skin changes, and dependent pain.
Sciatica causes radiating pain with neurologic symptoms. The ankle-brachial index (ABI) is the
initial diagnostic test.
Question 8
A 70-year-old male presents with a new onset of a systolic ejection murmur at the right upper
sternal border that radiates to the carotids. He reports syncope and dyspnea on exertion. Which
of the following is the most likely diagnosis?
A) Aortic stenosis
B) Mitral regurgitation
C) Aortic regurgitation
D) Hypertrophic cardiomyopathy
Answer: A) Aortic stenosis
Rationale: Aortic stenosis presents with the classic triad of syncope, angina, and dyspnea on
exertion. The murmur is a systolic ejection murmur heard best at the right upper sternal border
and radiates to the carotids. Mitral regurgitation is a holosystolic murmur at the apex radiating
to the axilla. Aortic regurgitation is a diastolic murmur. Hypertrophic cardiomyopathy presents
with a systolic murmur that increases with Valsalva.
Question 9
A 65-year-old female presents with an irregularly irregular pulse. Her ECG shows no P waves and
an irregular ventricular response. Which of the following is the most likely diagnosis?
EXAM ALL QUESTIONS AND ANSWERS ALREADY
GRADED A+. 100% VERIFIED SOLUTIONS |
UPDATED PER LATEST GUIDELINES | GRADED A+
Section 1: Cardiovascular System (Questions 1-15)
Question 1
A 68-year-old male with a history of hypertension and type 2 diabetes presents with substernal
chest pressure that radiates to his left arm, diaphoresis, and nausea. His ECG shows 2-mm ST-
segment elevations in leads V1-V4. What is the most likely diagnosis and immediate
management?
A) Unstable angina; admit for observation and stress testing
B) ST-elevation myocardial infarction (STEMI); immediate reperfusion therapy
C) Non-ST-elevation myocardial infarction (NSTEMI); start heparin and clopidogrel
D) Aortic dissection; obtain CT angiography
Answer: B) ST-elevation myocardial infarction (STEMI); immediate reperfusion therapy
Rationale: ST-segment elevations in leads V1-V4 indicate an anterior wall STEMI. This is a
medical emergency requiring immediate reperfusion therapy (PCI or fibrinolysis). The classic
presentation of substernal chest pressure radiating to the arm with diaphoresis and nausea
supports the diagnosis. Unstable angina and NSTEMI do not present with ST elevations. Aortic
dissection presents with tearing pain and pulse deficits.
Question 2
A 72-year-old female presents with dyspnea on exertion, orthopnea, and bilateral lower
extremity edema. On exam, she has jugular venous distention, crackles at the lung bases, and
an S3 gallop. An echocardiogram shows an ejection fraction of 25%. Which of the following is
the most appropriate initial pharmacologic management for heart failure with reduced ejection
fraction (HFrEF)?
,A) Furosemide and digoxin
B) ACE inhibitor and beta-blocker
C) Calcium channel blocker and hydralazine
D) Loop diuretic and spironolactone
Answer: B) ACE inhibitor and beta-blocker
Rationale: Guideline-directed medical therapy for HFrEF includes an ACE inhibitor (or ARB/ARNI)
and an evidence-based beta-blocker (carvedilol, metoprolol succinate, or bisoprolol). These
medications reduce mortality and hospitalizations. ACE inhibitors also reduce afterload and
improve survival. Diuretics are used for symptom management but do not reduce mortality.
Calcium channel blockers are not first-line in HFrEF due to negative inotropic effects.
Question 3
A 65-year-old male with hypertension and hyperlipidemia presents with new-onset atrial
fibrillation. His CHA₂DS₂-VASc score is 4. Which of the following is the most appropriate stroke
prevention strategy?
A) Aspirin 81 mg daily
B) Warfarin with target INR 2-3
C) Direct oral anticoagulant (DOAC) such as rivaroxaban or apixaban
D) No anticoagulation due to age
Answer: C) Direct oral anticoagulant (DOAC) such as rivaroxaban or apixaban
Rationale: A CHA₂DS₂-VASc score of 4 indicates high stroke risk. DOACs are preferred over
warfarin for stroke prevention in non-valvular atrial fibrillation due to lower bleeding risk, fewer
drug interactions, and no need for routine INR monitoring. Aspirin is insufficient for stroke
prevention in high-risk patients. Age alone is not a contraindication to anticoagulation.
Question 4
An 80-year-old patient is prescribed warfarin for atrial fibrillation. His INR is 5.0 without any
signs of bleeding. What is the appropriate management?
A) Administer vitamin K 10 mg orally
B) Hold the next dose and resume at a lower dose when INR is therapeutic
C) Administer fresh frozen plasma
D) Increase the warfarin dose
Answer: B) Hold the next dose and resume at a lower dose when INR is therapeutic
,Rationale: For an INR between 5 and 9 without bleeding, the standard recommendation is to
hold warfarin and resume at a lower dose when the INR returns to the therapeutic range (2-3).
Vitamin K is typically reserved for INR >10 or active bleeding. Fresh frozen plasma is for active
bleeding requiring rapid reversal.
Question 5
A 72-year-old male with heart failure with reduced ejection fraction is started on an ACE
inhibitor. Which laboratory value should be monitored closely?
A) Serum sodium
B) Serum potassium and serum creatinine
C) Serum calcium
D) Serum magnesium
Answer: B) Serum potassium and serum creatinine
Rationale: ACE inhibitors can cause hyperkalemia and acute kidney injury, particularly in patients
with renal impairment or those taking potassium-sparing diuretics. Monitoring serum potassium
and creatinine is essential to detect these adverse effects early. This is particularly important in
older adults who may have age-related renal decline.
Question 6
A 55-year-old female presents with sharp, pleuritic chest pain that worsens when lying flat and
improves when leaning forward. On exam, a pericardial friction rub is heard. Which of the
following is the most likely diagnosis?
A) Acute pericarditis
B) Myocardial infarction
C) Pulmonary embolism
D) Pneumothorax
Answer: A) Acute pericarditis
Rationale: Acute pericarditis is characterized by sharp, pleuritic chest pain that worsens with
lying flat and improves with leaning forward. A pericardial friction rub is a hallmark physical
finding. MI pain is typically pressure-like and not positional. PE causes dyspnea and pleuritic
pain. Pneumothorax is associated with sudden dyspnea and absent breath sounds.
, Question 7
A 60-year-old male with a history of smoking presents with pain in his calves when walking that
is relieved by rest. He has diminished pulses in his feet. Which of the following is the most likely
diagnosis?
A) Peripheral artery disease
B) Deep vein thrombosis
C) Venous insufficiency
D) Sciatica
Answer: A) Peripheral artery disease
Rationale: Intermittent claudication—leg pain with walking relieved by rest—is the hallmark of
peripheral artery disease (PAD). Diminished pulses are a key physical finding. DVT causes pain,
swelling, and warmth. Venous insufficiency causes edema, skin changes, and dependent pain.
Sciatica causes radiating pain with neurologic symptoms. The ankle-brachial index (ABI) is the
initial diagnostic test.
Question 8
A 70-year-old male presents with a new onset of a systolic ejection murmur at the right upper
sternal border that radiates to the carotids. He reports syncope and dyspnea on exertion. Which
of the following is the most likely diagnosis?
A) Aortic stenosis
B) Mitral regurgitation
C) Aortic regurgitation
D) Hypertrophic cardiomyopathy
Answer: A) Aortic stenosis
Rationale: Aortic stenosis presents with the classic triad of syncope, angina, and dyspnea on
exertion. The murmur is a systolic ejection murmur heard best at the right upper sternal border
and radiates to the carotids. Mitral regurgitation is a holosystolic murmur at the apex radiating
to the axilla. Aortic regurgitation is a diastolic murmur. Hypertrophic cardiomyopathy presents
with a systolic murmur that increases with Valsalva.
Question 9
A 65-year-old female presents with an irregularly irregular pulse. Her ECG shows no P waves and
an irregular ventricular response. Which of the following is the most likely diagnosis?
