2
Book: Adult-Gerontology Acute Care Nurse Practitioner
|| || || || || ||
Certification Review Cardiology Exam with answers || || || || ||
1. A 45-year-old man presented to the emergency department after he suffered from
|| || || || || || || || || || || || ||
syncope. He has no significant history except for an upper respiratory tract infection 1 week
|| || || || || || || || || || || || || || ||
ago. Physical exam revealed temperature 98.9°F, pulse 90 beats/min, blood pressure 100/60
|| || || || || || || || || || || ||
mmHg, and respiratory rate 13 breaths/min. His neck veins are distended, and his heart
|| || || || || || || || || || || || || ||
sounds are muffled and distant. Auscultation of the lungs reveals bilateral vesicular
|| || || || || || || || || || || ||
breathing with no added sounds and chest x-ray showed small bilateral pleural effusion
|| || || || || || || || || || || || ||
with enlarged cardiac silhouette. Electrocardiography was done and it showed varied QRS
|| || || || || || || || || || || ||
complex from beat to beat. Which of the following complications is obviously developing in
|| || || || || || || || || || || || || ||
this patient?
||
1. Cardiac tamponade.
|| ||
2. Cardiomyopathy.
||
3. Pulmonary embolism.
|| ||
4. Myocardial infarction.
|| ||
1. Cardiac Tamponade
|| ||
Rationale: This patient with a previous history of upper respiratory tract infection probably
|| || || || || || || || || || || || ||
suffered from a developing cardiac tamponade. This resulted in a pericardial effusion that
|| || || || || || || || || || || || ||
formed as a complication of the previous upper respiratory infection. The electrocardiogram
|| || || || || || || || || || ||
findings described the typical electrical alternans that is seen in cardiac tamponade as a
|| || || || || || || || || || || || || || ||
result of the heart swinging back and forth within the increased amount of fluid in the
|| || || || || || || || || || || || || || || ||
pericardial cavity. ||
2. Which of the following are the main components of the Beck triad in cardiac tamponade?
|| || || || || || || || || || || || || || ||
1. Hypotension, electrical alternans, prominent x-descent in neck veins.
|| || || || || || || ||
2. Muffled heart sounds, friction rub, hypotension.
|| || || || || ||
3. Jugular venous distension, Kussmaul sign, electrical alternans.
|| || || || || || ||
4. Hypotension, muffled heart sounds, jugular venous distension.
|| || || || || || ||
4. Hypotension, muffled heart sounds, jugular venous distension.
|| || || || || || ||
Rationale: Beck's triad alerts clinicians that cardiac tamponade is potentially present. The
|| || || || || || || || || || || ||
main components of cardiac tamponade are hypotension, muffled heart sounds, and jugular
|| || || || || || || || || || ||
venous distension. This triad is often associated with prominent x-descent and absent y-
|| || || || || || || || || || || || ||
descent and pulsus paradoxus. These features are caused by failure of ventricular filling and
|| || || || || || || || || || || || ||
,2
limited cardiac output. The Kussmaul sign is seen in restrictive cardiomyopathy and
|| || || || || || || || || || || || ||
constrictive pericarditis. A friction rub can be seen in any condition associated with
|| || || || || || || || || || || || ||
pericardial inflammation. ||
3. A 66-year-old man, known to have melanoma, presents to the emergency department
|| || || || || || || || || || || || ||
with dizziness and shortness of breath for that last 3 days. On exam his blood pressure is
|| || || || || || || || || || || || || || || || ||
80/50 mmHg. He has muffled heart sounds and pedal edema. Chest x-ray revealed an
|| || || || || || || || || || || || || ||
enlarged cardiac silhouette. Which of the following is most likely true of his physical exam?
|| || || || || || || || || || || || || ||
1. Clear lungs with decreased jugular venous pressure (JVP).
|| || || || || || || ||
2. Increased JVP with inspiration.
|| || || ||
3. A greater than 10 mmHg drop in his systolic blood pressure with inspiration.
|| || || || || || || || || || || || ||
4. Pericardial knock.
|| ||
3. A greater than 10 mmHg drop in his systolic blood pressure with inspiration.
|| || || || || || || || || || || || ||
Rationale: This patient most likely has a developing cardiac tamponade from a previously
|| || || || || || || || || || || || ||
formed pericardial effusion. Melanoma is a known tumor to infiltrate the pericardium.
|| || || || || || || || || || || ||
Cardiac tamponade is characterized by increased jugular venous pressure, muffled heart
|| || || || || || || || || || ||
sounds, hypotension, and pulsus paradoxus (greater than 10 mmHg drop in systolic blood
|| || || || || || || || || || || || ||
pressure with inspiration). Answer 1 is not correct because the JVP increases. A pericardial
|| || || || || || || || || || || || || ||
knock is more likely to be noted in constrictive pericarditis.
|| || || || || || || || ||
4. A 70-year-old woman, known to have breast cancer, presents to the emergency
|| || || || || || || || || || || || ||
department with a sudden attack of syncope. On exam she is hypotensive, blood pressure
|| || || || || || || || || || || || || ||
(BP) is 75/50 mmHg, bilateral vesicular breathing with no added sounds are heard on
|| || || || || || || || || || || || || ||
auscultation of the chest, distant heart sounds, and more than 10 mmHg drop of systolic BP
|| || || || || || || || || || || || || || || ||
with inspiration. Which of the following findings is most probably seen on
|| || || || || || || || || || || ||
electrocardiogram when requested? || ||
1. Prolonged PR interval with dropped P-wave.
|| || || || || ||
2. Widespread ST elevation.
|| || ||
3. Varied QRS complex from beat to beat.
|| || || || || || ||
4. Delta wave in almost all leads.
|| || || || || ||
3. Varied QRS complex from beat to beat.
|| || || || || || ||
Rationale: This patient most likely has cardiac tamponade, which is characterized by altered
|| || || || || || || || || || || ||
and varied QRS complexes from beat to beat caused by the heart swinging in the
|| || || || || || || || || || || || || || || ||
accumulating fluid in the pericardial cavity. || || || || ||
5. All of the following physical findings could be found in cardiac tamponade, except:
|| || || || || || || || || || || || ||
1. Sinus bradycardia.
|| ||
,2
2. Sinus tachycardia.
|| ||
3. Increased jugular venous pressure.
|| || || ||
4. None of the above.
|| || || ||
4. None of the above.
|| || || ||
Rationale: Cardiac tamponade is associated with sinus tachycardia in almost all cases, but
|| || || || || || || || || || || || ||
sinus bradycardia could be found in subacute cardiac tamponade associated with
|| || || || || || || || || || ||
hypothyroidism. The Beck triad (hypotension, increased jugular venous pressure, muffled || || || || || || || || || ||
heart sounds), pulsus paradoxus, and peripheral edema also are present in patients with
|| || || || || || || || || || || || ||
cardiac tamponade. ||
6. All of the following sentences are true about cardiac tamponade, except:
|| || || || || || || || || || ||
1. Acute cardiac tamponade occurs within minutes and it can be caused by trauma.
|| || || || || || || || || || || || ||
2. Subacute cardiac tamponade occurs within days to weeks and it can be caused by
|| || || || || || || || || || || || || || ||
neoplasm.
3. Beck triad (hypotension, increased jugular venous pressure, muffled heart sounds) is
|| || || || || || || || || || || ||
present in almost all patients with cardiac tamponade.
|| || || || || || ||
4. Cardiomegaly associated with acute cardiac tamponade is not usually seen on a chest x-
|| || || || || || || || || || || || || ||
ray until 200 mL fluid accumulates in the pericardial sac.
|| || || || || || || || ||
3. Beck triad (hypotension, increased jugular venous pressure, muffled heart sounds) is
|| || || || || || || || || || || ||
present in almost all patients with cardiac tamponade.
|| || || || || || ||
Rationale: All the previous facts are true about cardiac tamponade except that the Beck
|| || || || || || || || || || || || || ||
triad, which consists of hypotension, elevated jugular venous pressure, and muffled heart
|| || || || || || || || || || || ||
sounds, is present in only a minority of patients.
|| || || || || || || ||
7. Which of the following drugs is involved in cardiac tamponade formation?
|| || || || || || || || || || ||
1. Corticosteroids.
||
2. Ranitidine.
||
3. Amiodarone.
||
4. Procainamide.
||
4. Procainamide.
||
Rationale: Drug-induced cardiac tamponade is rare. Procainamide, isoniazid, and
|| || || || || || || || ||
hydralazine (drug-induced lupus) are involved in cardiac tamponade formation. Others
|| || || || || || || || || ||
drugs found in drug-induced cardiac tamponade include dantrolene, anticoagulants,
|| || || || || || || || ||
thrombolytics, phenytoin, penicillin, and doxorubicin. || || || ||
, 2
8. A 69-year-old man presents to the emergency department with a sudden attack of
|| || || || || || || || || || || || || ||
syncope. On exam, his blood pressure is 70/45 mmHg. He has muffled heart sounds, pulsus
|| || || || || || || || || || || || || || ||
paradoxus, and peripheral edema. The chest x-ray reveals an enlarged cardiac silhouette. He
|| || || || || || || || || || || ||
was diagnosed with lung cancer 3 years ago. Which of the following is most correct
|| || || || || || || || || || || || || || || ||
management step for this patient? || || || ||
1. Giving streptokinase immediately.
|| || ||
2. Urgent catheter pericardiocentesis.
|| || ||
3. Percutaneous coronary intervention within minutes.
|| || || || ||
4. Immediate open cardiac surgery.
|| || || ||
2. Urgent catheter pericardiocentesis.
|| || ||
Rationale: This patient with suspected acute cardiac tamponade is hemodynamically
|| || || || || || || || || ||
unstable. Both catheter pericardiocentesis and surgical drainage of a pericardial effusion are
|| || || || || || || || || || ||
highly effective at removal of pericardial fluid. Catheter pericardiocentesis is the treatment
|| || || || || || || || || || || || ||
of choice because it is less invasive, less expensive, and does not need general anesthesia,
|| || || || || || || || || || || || || || ||
which may worsen the hemodynamic compromise if needle drainage is not performed first
|| || || || || || || || || || || || ||
to reduce the severity of the cardiac tamponade.
|| || || || || || ||
9. A 70-year-old man presented to the emergency department with a sudden attack of
|| || || || || || || || || || || || || ||
syncope after experiencing severe chest pain that radiated to his back. He described the pain
|| || || || || || || || || || || || || ||
as like being stabbed with a knife. He is known to have type 2 diabetes and hypertension.
|| || || || || || || || || || || || || || || || || ||
He has been a heavy smoker since he was young. On exam, his blood pressure is 70/40
|| || || || || || || || || || || || || || || || ||
mmHg. He has muffled heart sounds, pulsus paradoxus, and increased jugular venous
|| || || || || || || || || || || ||
pressure. Which of the following is the most correct next step for the management of this
|| || || || || || || || || || || || || || || ||
patient?
1. Giving streptokinase immediately.
|| || ||
2. Urgent catheter pericardiocentesis.
|| || ||
3. Percutaneous coronary intervention within minutes.
|| || || || ||
4. Immediate open cardiac surgery.
|| || || ||
4. Immediate open cardiac surgery.
|| || || ||
Rationale: This patient with a previous history of diabetes mellitus, hypertension, and long
|| || || || || || || || || || || || ||
history of heavy smoking with presentation of sudden stabbing back pain, severe
|| || || || || || || || || || || ||
hypotension, muffled heart sounds, and increased jugular venous pressure is most likely
|| || || || || || || || || || || ||
suffering from aortic dissection complicated by cardiac tamponade. Aortic dissection and
|| || || || || || || || || || ||
myocardial rupture are contraindications for catheter pericardiocentesis because the relief
|| || || || || || || || || ||
of cardiac tamponade may lead to more severe bleeding. Such patients require immediate
|| || || || || || || || || || || || ||
surgical intervention. ||
Book: Adult-Gerontology Acute Care Nurse Practitioner
|| || || || || ||
Certification Review Cardiology Exam with answers || || || || ||
1. A 45-year-old man presented to the emergency department after he suffered from
|| || || || || || || || || || || || ||
syncope. He has no significant history except for an upper respiratory tract infection 1 week
|| || || || || || || || || || || || || || ||
ago. Physical exam revealed temperature 98.9°F, pulse 90 beats/min, blood pressure 100/60
|| || || || || || || || || || || ||
mmHg, and respiratory rate 13 breaths/min. His neck veins are distended, and his heart
|| || || || || || || || || || || || || ||
sounds are muffled and distant. Auscultation of the lungs reveals bilateral vesicular
|| || || || || || || || || || || ||
breathing with no added sounds and chest x-ray showed small bilateral pleural effusion
|| || || || || || || || || || || || ||
with enlarged cardiac silhouette. Electrocardiography was done and it showed varied QRS
|| || || || || || || || || || || ||
complex from beat to beat. Which of the following complications is obviously developing in
|| || || || || || || || || || || || || ||
this patient?
||
1. Cardiac tamponade.
|| ||
2. Cardiomyopathy.
||
3. Pulmonary embolism.
|| ||
4. Myocardial infarction.
|| ||
1. Cardiac Tamponade
|| ||
Rationale: This patient with a previous history of upper respiratory tract infection probably
|| || || || || || || || || || || || ||
suffered from a developing cardiac tamponade. This resulted in a pericardial effusion that
|| || || || || || || || || || || || ||
formed as a complication of the previous upper respiratory infection. The electrocardiogram
|| || || || || || || || || || ||
findings described the typical electrical alternans that is seen in cardiac tamponade as a
|| || || || || || || || || || || || || || ||
result of the heart swinging back and forth within the increased amount of fluid in the
|| || || || || || || || || || || || || || || ||
pericardial cavity. ||
2. Which of the following are the main components of the Beck triad in cardiac tamponade?
|| || || || || || || || || || || || || || ||
1. Hypotension, electrical alternans, prominent x-descent in neck veins.
|| || || || || || || ||
2. Muffled heart sounds, friction rub, hypotension.
|| || || || || ||
3. Jugular venous distension, Kussmaul sign, electrical alternans.
|| || || || || || ||
4. Hypotension, muffled heart sounds, jugular venous distension.
|| || || || || || ||
4. Hypotension, muffled heart sounds, jugular venous distension.
|| || || || || || ||
Rationale: Beck's triad alerts clinicians that cardiac tamponade is potentially present. The
|| || || || || || || || || || || ||
main components of cardiac tamponade are hypotension, muffled heart sounds, and jugular
|| || || || || || || || || || ||
venous distension. This triad is often associated with prominent x-descent and absent y-
|| || || || || || || || || || || || ||
descent and pulsus paradoxus. These features are caused by failure of ventricular filling and
|| || || || || || || || || || || || ||
,2
limited cardiac output. The Kussmaul sign is seen in restrictive cardiomyopathy and
|| || || || || || || || || || || || ||
constrictive pericarditis. A friction rub can be seen in any condition associated with
|| || || || || || || || || || || || ||
pericardial inflammation. ||
3. A 66-year-old man, known to have melanoma, presents to the emergency department
|| || || || || || || || || || || || ||
with dizziness and shortness of breath for that last 3 days. On exam his blood pressure is
|| || || || || || || || || || || || || || || || ||
80/50 mmHg. He has muffled heart sounds and pedal edema. Chest x-ray revealed an
|| || || || || || || || || || || || || ||
enlarged cardiac silhouette. Which of the following is most likely true of his physical exam?
|| || || || || || || || || || || || || ||
1. Clear lungs with decreased jugular venous pressure (JVP).
|| || || || || || || ||
2. Increased JVP with inspiration.
|| || || ||
3. A greater than 10 mmHg drop in his systolic blood pressure with inspiration.
|| || || || || || || || || || || || ||
4. Pericardial knock.
|| ||
3. A greater than 10 mmHg drop in his systolic blood pressure with inspiration.
|| || || || || || || || || || || || ||
Rationale: This patient most likely has a developing cardiac tamponade from a previously
|| || || || || || || || || || || || ||
formed pericardial effusion. Melanoma is a known tumor to infiltrate the pericardium.
|| || || || || || || || || || || ||
Cardiac tamponade is characterized by increased jugular venous pressure, muffled heart
|| || || || || || || || || || ||
sounds, hypotension, and pulsus paradoxus (greater than 10 mmHg drop in systolic blood
|| || || || || || || || || || || || ||
pressure with inspiration). Answer 1 is not correct because the JVP increases. A pericardial
|| || || || || || || || || || || || || ||
knock is more likely to be noted in constrictive pericarditis.
|| || || || || || || || ||
4. A 70-year-old woman, known to have breast cancer, presents to the emergency
|| || || || || || || || || || || || ||
department with a sudden attack of syncope. On exam she is hypotensive, blood pressure
|| || || || || || || || || || || || || ||
(BP) is 75/50 mmHg, bilateral vesicular breathing with no added sounds are heard on
|| || || || || || || || || || || || || ||
auscultation of the chest, distant heart sounds, and more than 10 mmHg drop of systolic BP
|| || || || || || || || || || || || || || || ||
with inspiration. Which of the following findings is most probably seen on
|| || || || || || || || || || || ||
electrocardiogram when requested? || ||
1. Prolonged PR interval with dropped P-wave.
|| || || || || ||
2. Widespread ST elevation.
|| || ||
3. Varied QRS complex from beat to beat.
|| || || || || || ||
4. Delta wave in almost all leads.
|| || || || || ||
3. Varied QRS complex from beat to beat.
|| || || || || || ||
Rationale: This patient most likely has cardiac tamponade, which is characterized by altered
|| || || || || || || || || || || ||
and varied QRS complexes from beat to beat caused by the heart swinging in the
|| || || || || || || || || || || || || || || ||
accumulating fluid in the pericardial cavity. || || || || ||
5. All of the following physical findings could be found in cardiac tamponade, except:
|| || || || || || || || || || || || ||
1. Sinus bradycardia.
|| ||
,2
2. Sinus tachycardia.
|| ||
3. Increased jugular venous pressure.
|| || || ||
4. None of the above.
|| || || ||
4. None of the above.
|| || || ||
Rationale: Cardiac tamponade is associated with sinus tachycardia in almost all cases, but
|| || || || || || || || || || || || ||
sinus bradycardia could be found in subacute cardiac tamponade associated with
|| || || || || || || || || || ||
hypothyroidism. The Beck triad (hypotension, increased jugular venous pressure, muffled || || || || || || || || || ||
heart sounds), pulsus paradoxus, and peripheral edema also are present in patients with
|| || || || || || || || || || || || ||
cardiac tamponade. ||
6. All of the following sentences are true about cardiac tamponade, except:
|| || || || || || || || || || ||
1. Acute cardiac tamponade occurs within minutes and it can be caused by trauma.
|| || || || || || || || || || || || ||
2. Subacute cardiac tamponade occurs within days to weeks and it can be caused by
|| || || || || || || || || || || || || || ||
neoplasm.
3. Beck triad (hypotension, increased jugular venous pressure, muffled heart sounds) is
|| || || || || || || || || || || ||
present in almost all patients with cardiac tamponade.
|| || || || || || ||
4. Cardiomegaly associated with acute cardiac tamponade is not usually seen on a chest x-
|| || || || || || || || || || || || || ||
ray until 200 mL fluid accumulates in the pericardial sac.
|| || || || || || || || ||
3. Beck triad (hypotension, increased jugular venous pressure, muffled heart sounds) is
|| || || || || || || || || || || ||
present in almost all patients with cardiac tamponade.
|| || || || || || ||
Rationale: All the previous facts are true about cardiac tamponade except that the Beck
|| || || || || || || || || || || || || ||
triad, which consists of hypotension, elevated jugular venous pressure, and muffled heart
|| || || || || || || || || || || ||
sounds, is present in only a minority of patients.
|| || || || || || || ||
7. Which of the following drugs is involved in cardiac tamponade formation?
|| || || || || || || || || || ||
1. Corticosteroids.
||
2. Ranitidine.
||
3. Amiodarone.
||
4. Procainamide.
||
4. Procainamide.
||
Rationale: Drug-induced cardiac tamponade is rare. Procainamide, isoniazid, and
|| || || || || || || || ||
hydralazine (drug-induced lupus) are involved in cardiac tamponade formation. Others
|| || || || || || || || || ||
drugs found in drug-induced cardiac tamponade include dantrolene, anticoagulants,
|| || || || || || || || ||
thrombolytics, phenytoin, penicillin, and doxorubicin. || || || ||
, 2
8. A 69-year-old man presents to the emergency department with a sudden attack of
|| || || || || || || || || || || || || ||
syncope. On exam, his blood pressure is 70/45 mmHg. He has muffled heart sounds, pulsus
|| || || || || || || || || || || || || || ||
paradoxus, and peripheral edema. The chest x-ray reveals an enlarged cardiac silhouette. He
|| || || || || || || || || || || ||
was diagnosed with lung cancer 3 years ago. Which of the following is most correct
|| || || || || || || || || || || || || || || ||
management step for this patient? || || || ||
1. Giving streptokinase immediately.
|| || ||
2. Urgent catheter pericardiocentesis.
|| || ||
3. Percutaneous coronary intervention within minutes.
|| || || || ||
4. Immediate open cardiac surgery.
|| || || ||
2. Urgent catheter pericardiocentesis.
|| || ||
Rationale: This patient with suspected acute cardiac tamponade is hemodynamically
|| || || || || || || || || ||
unstable. Both catheter pericardiocentesis and surgical drainage of a pericardial effusion are
|| || || || || || || || || || ||
highly effective at removal of pericardial fluid. Catheter pericardiocentesis is the treatment
|| || || || || || || || || || || || ||
of choice because it is less invasive, less expensive, and does not need general anesthesia,
|| || || || || || || || || || || || || || ||
which may worsen the hemodynamic compromise if needle drainage is not performed first
|| || || || || || || || || || || || ||
to reduce the severity of the cardiac tamponade.
|| || || || || || ||
9. A 70-year-old man presented to the emergency department with a sudden attack of
|| || || || || || || || || || || || || ||
syncope after experiencing severe chest pain that radiated to his back. He described the pain
|| || || || || || || || || || || || || ||
as like being stabbed with a knife. He is known to have type 2 diabetes and hypertension.
|| || || || || || || || || || || || || || || || || ||
He has been a heavy smoker since he was young. On exam, his blood pressure is 70/40
|| || || || || || || || || || || || || || || || ||
mmHg. He has muffled heart sounds, pulsus paradoxus, and increased jugular venous
|| || || || || || || || || || || ||
pressure. Which of the following is the most correct next step for the management of this
|| || || || || || || || || || || || || || || ||
patient?
1. Giving streptokinase immediately.
|| || ||
2. Urgent catheter pericardiocentesis.
|| || ||
3. Percutaneous coronary intervention within minutes.
|| || || || ||
4. Immediate open cardiac surgery.
|| || || ||
4. Immediate open cardiac surgery.
|| || || ||
Rationale: This patient with a previous history of diabetes mellitus, hypertension, and long
|| || || || || || || || || || || || ||
history of heavy smoking with presentation of sudden stabbing back pain, severe
|| || || || || || || || || || || ||
hypotension, muffled heart sounds, and increased jugular venous pressure is most likely
|| || || || || || || || || || || ||
suffering from aortic dissection complicated by cardiac tamponade. Aortic dissection and
|| || || || || || || || || || ||
myocardial rupture are contraindications for catheter pericardiocentesis because the relief
|| || || || || || || || || ||
of cardiac tamponade may lead to more severe bleeding. Such patients require immediate
|| || || || || || || || || || || || ||
surgical intervention. ||
