ADULT-GERONTOLOGY ACUTE CARE NURSE PRACTITIONER
COMPREHENSIVE CERTIFICATION EXAMINATION 200 EXAM
QUESTIONS WITH EVIDENCE-BASED RATIONALES
Question 1
A 68-year-old male with a history of hypertension and type 2 diabetes
presents with sudden onset of severe tearing chest pain radiating to the
back. BP is 180/100 in the right arm and 140/80 in the left arm. Which
diagnostic study is most appropriate initially?
A) CT angiography of the chest
B) Transthoracic echocardiogram
C) Standard chest x-ray
D) Cardiac catheterization
Answer: A) CT angiography of the chest
Rationale: This patient's presentation is classic for acute aortic
dissection. The blood pressure differential between arms and tearing
chest pain radiating to the back are hallmark findings. CT angiography is
the preferred initial diagnostic study due to its high sensitivity and
specificity for aortic dissection, rapid availability, and ability to define
the extent of dissection. While transesophageal echocardiography can
also diagnose dissection, CT angiography is more readily available in
most emergency settings. Chest x-ray may show a widened
mediastinum but is not diagnostic. Cardiac catheterization is not the
,appropriate initial study and could be dangerous in the setting of aortic
dissection.
Question 2
A 72-year-old female with COPD presents with worsening dyspnea and
productive cough. Arterial blood gas shows pH 7.28, PaCO2 68, PaO2
55, HCO3 30. What is the most appropriate initial ventilation strategy?
A) Intubate and initiate assist-control ventilation with tidal volume 8
mL/kg
B) Apply BiPAP with inspiratory pressure 10 cm H2O and expiratory
pressure 5 cm H2O
C) Apply CPAP at 10 cm H2O
D) Administer high-flow nasal cannula at 40 L/min
Answer: B) Apply BiPAP with inspiratory pressure 10 cm H2O and
expiratory pressure 5 cm H2O
Rationale: This patient has acute hypercapnic respiratory failure from
COPD exacerbation. Non-invasive positive pressure ventilation (NIPPV)
with BiPAP is the first-line treatment for acute hypercapnic respiratory
failure in COPD. BiPAP provides inspiratory pressure support to assist
ventilation and expiratory positive airway pressure to maintain airway
patency, reduce work of breathing, and improve gas exchange. It has
been shown to reduce the need for intubation and mortality. Intubation
is reserved for patients who fail NIPPV or have contraindications such as
inability to protect airway. CPAP alone does not provide ventilatory
assistance for hypercapnia. High-flow nasal cannula is better suited for
hypoxemic respiratory failure.
,Question 3
A 65-year-old male with cirrhosis presents with altered mental status,
jaundice, and abdominal distension. Laboratory findings: ammonia 85,
INR 1.8, platelets 45,000, creatinine 2.1. What is the most appropriate
initial treatment for the altered mental status?
A) IV albumin
B) Lactulose
C) IV ceftriaxone
D) Furosemide
Answer: B) Lactulose
Rationale: This patient is presenting with hepatic encephalopathy as
evidenced by altered mental status in the setting of cirrhosis and
elevated ammonia. Lactulose is the first-line treatment for hepatic
encephalopathy. It works by acidifying the colon, converting ammonia
to ammonium, which is less absorbable, and promoting bowel
movements to eliminate ammonia-producing bacteria. IV ceftriaxone
would be appropriate if there were signs of spontaneous bacterial
peritonitis. Albumin may be needed for volume expansion but does not
treat encephalopathy directly. Furosemide may worsen encephalopathy
by causing electrolyte disturbances and hypovolemia.
Question 4
, A 78-year-old female presents with acute onset of severe headache,
nausea, and confusion. CT head shows a subarachnoid hemorrhage.
Which intervention should be prioritized?
A) Nimodipine
B) Surgical clipping
C) Endovascular coiling
D) Antiepileptic medications
Answer: A) Nimodipine
Rationale: In patients with subarachnoid hemorrhage, nimodipine is the
only medication proven to improve outcomes and should be initiated
immediately. It is a calcium channel blocker that reduces the risk of
delayed cerebral ischemia from vasospasm, which is a major
complication of subarachnoid hemorrhage. While surgical clipping and
endovascular coiling are definitive treatments to prevent rebleeding,
nimodipine should be started emergently regardless of the planned
intervention. Antiepileptic medications are controversial and not
universally recommended for prophylaxis except in high-risk patients.
Question 5
A 67-year-old male with end-stage renal disease on hemodialysis
presents with chest pain. ECG shows ST elevation in leads II, III, and aVF.
BP is 85/50. Which medication should be avoided?
A) Aspirin
B) Nitroglycerin
C) Morphine
D) Heparin
COMPREHENSIVE CERTIFICATION EXAMINATION 200 EXAM
QUESTIONS WITH EVIDENCE-BASED RATIONALES
Question 1
A 68-year-old male with a history of hypertension and type 2 diabetes
presents with sudden onset of severe tearing chest pain radiating to the
back. BP is 180/100 in the right arm and 140/80 in the left arm. Which
diagnostic study is most appropriate initially?
A) CT angiography of the chest
B) Transthoracic echocardiogram
C) Standard chest x-ray
D) Cardiac catheterization
Answer: A) CT angiography of the chest
Rationale: This patient's presentation is classic for acute aortic
dissection. The blood pressure differential between arms and tearing
chest pain radiating to the back are hallmark findings. CT angiography is
the preferred initial diagnostic study due to its high sensitivity and
specificity for aortic dissection, rapid availability, and ability to define
the extent of dissection. While transesophageal echocardiography can
also diagnose dissection, CT angiography is more readily available in
most emergency settings. Chest x-ray may show a widened
mediastinum but is not diagnostic. Cardiac catheterization is not the
,appropriate initial study and could be dangerous in the setting of aortic
dissection.
Question 2
A 72-year-old female with COPD presents with worsening dyspnea and
productive cough. Arterial blood gas shows pH 7.28, PaCO2 68, PaO2
55, HCO3 30. What is the most appropriate initial ventilation strategy?
A) Intubate and initiate assist-control ventilation with tidal volume 8
mL/kg
B) Apply BiPAP with inspiratory pressure 10 cm H2O and expiratory
pressure 5 cm H2O
C) Apply CPAP at 10 cm H2O
D) Administer high-flow nasal cannula at 40 L/min
Answer: B) Apply BiPAP with inspiratory pressure 10 cm H2O and
expiratory pressure 5 cm H2O
Rationale: This patient has acute hypercapnic respiratory failure from
COPD exacerbation. Non-invasive positive pressure ventilation (NIPPV)
with BiPAP is the first-line treatment for acute hypercapnic respiratory
failure in COPD. BiPAP provides inspiratory pressure support to assist
ventilation and expiratory positive airway pressure to maintain airway
patency, reduce work of breathing, and improve gas exchange. It has
been shown to reduce the need for intubation and mortality. Intubation
is reserved for patients who fail NIPPV or have contraindications such as
inability to protect airway. CPAP alone does not provide ventilatory
assistance for hypercapnia. High-flow nasal cannula is better suited for
hypoxemic respiratory failure.
,Question 3
A 65-year-old male with cirrhosis presents with altered mental status,
jaundice, and abdominal distension. Laboratory findings: ammonia 85,
INR 1.8, platelets 45,000, creatinine 2.1. What is the most appropriate
initial treatment for the altered mental status?
A) IV albumin
B) Lactulose
C) IV ceftriaxone
D) Furosemide
Answer: B) Lactulose
Rationale: This patient is presenting with hepatic encephalopathy as
evidenced by altered mental status in the setting of cirrhosis and
elevated ammonia. Lactulose is the first-line treatment for hepatic
encephalopathy. It works by acidifying the colon, converting ammonia
to ammonium, which is less absorbable, and promoting bowel
movements to eliminate ammonia-producing bacteria. IV ceftriaxone
would be appropriate if there were signs of spontaneous bacterial
peritonitis. Albumin may be needed for volume expansion but does not
treat encephalopathy directly. Furosemide may worsen encephalopathy
by causing electrolyte disturbances and hypovolemia.
Question 4
, A 78-year-old female presents with acute onset of severe headache,
nausea, and confusion. CT head shows a subarachnoid hemorrhage.
Which intervention should be prioritized?
A) Nimodipine
B) Surgical clipping
C) Endovascular coiling
D) Antiepileptic medications
Answer: A) Nimodipine
Rationale: In patients with subarachnoid hemorrhage, nimodipine is the
only medication proven to improve outcomes and should be initiated
immediately. It is a calcium channel blocker that reduces the risk of
delayed cerebral ischemia from vasospasm, which is a major
complication of subarachnoid hemorrhage. While surgical clipping and
endovascular coiling are definitive treatments to prevent rebleeding,
nimodipine should be started emergently regardless of the planned
intervention. Antiepileptic medications are controversial and not
universally recommended for prophylaxis except in high-risk patients.
Question 5
A 67-year-old male with end-stage renal disease on hemodialysis
presents with chest pain. ECG shows ST elevation in leads II, III, and aVF.
BP is 85/50. Which medication should be avoided?
A) Aspirin
B) Nitroglycerin
C) Morphine
D) Heparin
