AGACNP Spring 2024 Exam 2
(POCUS) and deep venous thrombosis (DVT) and pulmonary embolism (PE)?
Which of the subsequent is real concerning ICU factor-of-care ultrasound
A. Evaluation for DVT is fine finished with a phased array probe with out compression
B. The aggregate of DVT and findings steady with acute right- sided heart strain has
excessive diagnostic accuracy for PE
C. The decrease extremity source of an embolism in addition to the embolism in the
pulmonary vasculature are normally visualized collectively
D. Ultrasonographic photos of right-sided coronary heart findings definitively diagnosis PE -
ANSThe correct answer is B.
Rationale: The aggregate of a decrease extremity supply of an embolism
(DVT) and findings consistent with acute right-sided heart stress in an at-chance patient has
enough diagnostic accuracy for VTE to justify emergent treatment (desire B is correct). While
decrease extremity supply of an embolism is often imaged, simplest the particularly
uncommon thrombus in transit may be visualized through the coronary heart or inside the
primary pulmonary artery by using POCUS (choice C is incorrect). Acute proper-sided heart
stress is suggestive of pulmonary embolism but through itself have to not be taken as
definitive evidence (preference D is wrong). Compression research for a decrease extremity
source of VTE are great completed with a linear vascular probe (7.Five MHz) used for
vascular get right of entry to research (preference A is inaccurate).
A 19-12 months-vintage lady with records of melancholy is discovered unresponsive at the
floor of her grandparent's bathroom with an empty bottle of capsules. She is
respiratory spontaneously and is transported to the nearest sanatorium. After the affected
person is put on cardiac telemetry she all at once is going into pulseless bidirectional
ventricular tachycardia. Cardiopulmonary resuscitation is initiated. Emergency clinical
employees do now not recognise what the empty tablet bottle contained but you suspect
digoxin. What is the digoxin-specific antibody fragments dose to manage to the affected
person?
A, 1 to two vials
B. 5 to ten vials
C. 20 to 30 vials
D. Calculate once serum digoxin degree is known - ANSThe correct solution is B.
Rationale: The empiric dose of digoxin-specific antibody fragments to
administer to a hemodynamically risky affected person following an acute overdose is 5 to
ten vials (desire B is accurate). This dose ought to receive as a bolus inside the placing of
coming near near or lively cardiac arrest. One or vials may be appropriate in the putting of
persistent digoxin poisoning with out impending cardiac arrest, however now not on this
emergent acute case (desire A is incorrect). Twenty to 30 vials is extra than required as
initial dose for most acute overdoses, though a affected person may additionally emerge as
desiring 20 or more vials all through their hospitalization (desire C is incorrect). During
cardiac arrest or imminent arrest, sufferers need to get hold of empirical treatment.
,Physicians have to now not wait to calculate total body burden of digoxin (choice D is
wrong).
A 2-12 months vintage healthy baby on no medicines provides to Arizona emergency
department. He has been inconsolable, agitated, and hysterical for the closing hour. Initial
essential symptoms are effective for tachycardia and tachypnea, but no fever. Exam
demonstrates clean lungs, everyday eye examination, and all 4 extremities are normal with
out a pores and skin lesions. The faucet check is not possible to conduct due to the kid's
nature. What is the most appropriate next step in management?
A. Benzodiazepine
B. Centruroides immune F(ab')2 antivenom
C. Crotalid Antivenom FabAV—10 vials
D. Cr otalid Antivenom F(ab')2AV—10 vials - ANSThe accurate solution is A.
Rationale: While some of the signs and symptoms this toddler is having are consistent with
Centruroides (bark scorpion) envenomation, with out a increase in secretions and no ocular
findings (no opsoclonus) that analysis have to be wondered. The faucet check or tapping in
the vicinity of a suspected scorpion sting to look if pain receives worse, will be impossible to
behavior with this infant. Initial remedy for a Centruroides sting might be benzodiazepines
(choice A is accurate) with antivenom reserved for systemic signs and symptoms. Acute
amphetamine toxicity can appear comparable and would to start with be treated with
benzodiazepines and potentially antipsychotics depending at the response.
A 2-year-old infant presents to the emergency branch at 6pm after being bitten with the aid
of a copperhead. The chew is to the calf, and there are oozing puncture wounds
approximately 1.Five cm aside with a few mild neighborhood erythema. The calf is tender,
and there's no swelling. Vitals are everyday, and physical examination is in any other case
unremarkable. Over the primary few hours of statement the patient has minimal ache. What
is the most suitable control?
A. Administer IV Crotalid Antivenom
B. Admit for observation overnight
C. Discharge now with follow-up in three days
D. Observe for a total of 6 hours, if no development, then follow up in
3 days - ANSThe accurate answer is B.
Rationale: Lower extremity bites from copperheads especially to ankle or calf
may have good sized put off in development of swelling, so admission is warranted (choice
B is correct). Children may have extra extremity harm from a copperhead chunk relative to
adults as their limbs are smaller and the venom load is larger per unit weight. With a full
eight hours statement this patient may be discharged if he has an first rate support
community, terrible/normal laboratories at 6 hours, and a observe-up eight hours after
discharge (commonly by means of smartphone) but waiting 3 days is just too lengthy
(choices C and D are wrong). For this affected person who has what seems to be a "dry"
chew (a chew without venom administration), antivenom must no longer be used at this point
(choice A is inaccurate).
A 20-12 months-old woman has taken an unknown medicinal drug all through a suicide
attempt. She offers complaining of chest pain with her coronary heart racing and pounding.
Her vital symptoms are blood strain 150/90, coronary heart price a hundred thirty bpm,
,respiratory rate 18 breaths/min, and temperature a hundred.4 °F. Her bodily exam is
wonderful for stressful appearance with tremulousness, however her mental fame is
orientated to individual, area, and time. Her pupils are dilated symmetrically. Mucous
membranes are moist. Cardiac exam is excellent for a fast charge with out murmurs, lungs
are clear, stomach is nondistended with active bowel sounds, and neurological examination
suggests a slight tremor and hyperreflexia however no ankle clonus. Which of the following
medicinal drugs did this affected person maximum in all likelihood overdose?
A. Dextromethorphan
B. Diphenhydramine
C. Donepezil
D. Pseudoephedrine - ANSThe correct solution is D.
Rationale: This presentation is regular with a sympathomimetic toxidrome
(tachycardia, hypertension, anxiety, mydriasis, and tremor), making pseudoephedrine the
right answer (desire D is accurate). Dextromethorphan complements significant serotonergic
tone with the aid of blocking its reuptake as well as increasing its release and is an
N-methyl-D-aspartate receptor antagonist this is associated with postsynaptic five-HT
stimulation. Dextromethorphan administrated at supratherapeutic doses or in combination
with serotonergic dealers ought to result in a serotonin syndrome that still has overlapping
signs and symptoms and symptoms of anticholinergic toxicity along with hypertension,
tachycardia, fever, and agitated delirium. The foremost distinguishing feature is often muscle
rigidity and sustained clonus (desire A is incorrect). Diphenhydramine might produce an
anticholinergic syndrome (desire B is wrong). There are many overlapping capabilities with
the sympathomimetic and anticholinergic syndromes. They both may additionally purpose
tachycardia, high blood pressure, temperature elevation, mydriasis, and seizures and motor
signs and symptoms with tremor commonplace inside the sympathomimetic syndrome and
myoclonus inside the anticholinergic syndrome. The foremost distinguishing capabilities for
anticholinergic toxicity are altered intellectual reputation modifications, which could include
agitated delirium and garbled speech, and dry mucous membranes with dwindled bowel
sounds. Donepezil could produce a cholinergic syndrome with bradycardia and hypotension
(choice C is inaccurate).
A 21-12 months-old guy presents with a prime complaint of a spider bite 1 day ago that he
says become a brown recluse. On examination, there's an erythematous, raised, warm
lesion at the left forearm. His vitals are normal, he has no systemic signs and symptoms, his
urine is faded in colour, and his pain is controlled with minimum analgesia. What is the most
appropriate management?
A. Administer recluse antivenom, half of around the web site, half of intravenously
B. Administer black widow antivenom, 1 vial
C. Check CBC with diff, Type and move, LDH, U/A and admit for
statement
D. Evaluate for methicillin-resistant Staphylococcus aureus (MRSA) - ANSThe accurate
solution is D.
Rationale: While brown recluses can motive necrotic lesions in adults, their
evolution is over several days and often the spider chew is unrecognized. Most regularly with
this preliminary presentation the lesion seems to be a pores and skin MRSA contamination
(preference D is correct). There is no antivenom for brown recluse bites. The laboratories
, cautioned is probably suitable for a kid where the history changed into regarding for a
recluse chunk with systemic outcomes together with fever, weak point, and malaise.
A 21-12 months-old previously healthful man is being admitted with fatigue and abdominal
pain with out diarrhea for the past week. Vital signs and symptoms are normal besides for a
coronary heart price of 102 beats/min. There is not any bleeding, and his mental popularity is
everyday. Laboratory studies are massive for the following:
Leukocyte count number 6600/μL
Hemoglobin 7.9 g/dL
Platelet matter 34,000/μL
Creatinine 6.3 mg/dL
Serum lactate dehydrogenase 1600 U/L
Coagulation studies and fibrinogen Normal
ADAMTS-thirteen 49% activity
The peripheral blood smear shows many schistocytes, reduced platelets, and ordinary white
blood cells with out blast paperwork.What is the maximum appropriate remedy?
A. Cryoprecipitate
B. Eculizumab
C. Platelet transfusion
D. Therapeutic plasma alternate - ANSThe correct answer is B.
Rationale: This patient presents with intense acute renal failure,
thrombocytopenia, and hemolytic anemia. Schistocytes are visible on the peripheral blood
smear regular with a thrombotic microangiopathy. The scientific presentation and laboratory
statistics are steady with abnormal HUS (aHUS) and the terminal supplement inhibitor
eculizumab is the encouraged first-line treatment (desire B is accurate). In thrombotic
thrombocytopenia purpura (TTP), the ADAMTS-13 stage is generally underneath five% to
10% and the diploma of renal dysfunction is slight, accordingly therapeutic plasma trade isn't
indicated (choice D is wrong). Coagulation research and fibrinogen are everyday, so there's
no indication for cryoprecipitate substitute (choice A is incorrect). At the current platelet be
counted and without bleeding, platelet transfusion is likewise not indicated (desire C is
wrong).
A 22-year-vintage female with HIV, tuberculosis, and despair who these days immigrated
from Bangladesh is delivered to the health center in reputation epilepticus. On arrival her
vital signs are coronary heart price a hundred and twenty beats in line with minute, blood
pressure150/90 mmHg, respirations 20 consistent with minute, and temperature 38 °C. Initial
laboratory research with normal values in parentheses are proven:
Serum sodium: 138 mEq/L (136-one hundred forty four mEq/L). Serum potassium: 5.8
mEq/L (three.7-five.2 mEq/L). Serum chloride: ninety nine mEq/L (ninety six-106 mEq/L).
CO2 (carbon dioxide): 13 mEq/L (22-28 mEq/L). BUN: 11 mg/dL (eight-23 mg/L).
Creatinine: 0.Nine mg/dL (zero.3-0.Nine mg/L).Glucose: 220 mg/dL (70-110 mg/dL).Serum
calcium (overall): 9.1 mg/dL (8.2-10.2 mg/dL). Serum AST (SGOT) 60 IU/L (eight-48
IU/L).Serum ALT (SGPT) forty nine IU/L (7-55 IU/L).
Treatment with 4 mg intravenous lorazepam 3 times over 30 minutes is ineffective for
stopping her seizures. An overdose of which of the subsequent affected person's medicati -
ANSThe accurate solution is C.
Rationale: Of the medicine listed, this clinical image of seizures refractory to
(POCUS) and deep venous thrombosis (DVT) and pulmonary embolism (PE)?
Which of the subsequent is real concerning ICU factor-of-care ultrasound
A. Evaluation for DVT is fine finished with a phased array probe with out compression
B. The aggregate of DVT and findings steady with acute right- sided heart strain has
excessive diagnostic accuracy for PE
C. The decrease extremity source of an embolism in addition to the embolism in the
pulmonary vasculature are normally visualized collectively
D. Ultrasonographic photos of right-sided coronary heart findings definitively diagnosis PE -
ANSThe correct answer is B.
Rationale: The aggregate of a decrease extremity supply of an embolism
(DVT) and findings consistent with acute right-sided heart stress in an at-chance patient has
enough diagnostic accuracy for VTE to justify emergent treatment (desire B is correct). While
decrease extremity supply of an embolism is often imaged, simplest the particularly
uncommon thrombus in transit may be visualized through the coronary heart or inside the
primary pulmonary artery by using POCUS (choice C is incorrect). Acute proper-sided heart
stress is suggestive of pulmonary embolism but through itself have to not be taken as
definitive evidence (preference D is wrong). Compression research for a decrease extremity
source of VTE are great completed with a linear vascular probe (7.Five MHz) used for
vascular get right of entry to research (preference A is inaccurate).
A 19-12 months-vintage lady with records of melancholy is discovered unresponsive at the
floor of her grandparent's bathroom with an empty bottle of capsules. She is
respiratory spontaneously and is transported to the nearest sanatorium. After the affected
person is put on cardiac telemetry she all at once is going into pulseless bidirectional
ventricular tachycardia. Cardiopulmonary resuscitation is initiated. Emergency clinical
employees do now not recognise what the empty tablet bottle contained but you suspect
digoxin. What is the digoxin-specific antibody fragments dose to manage to the affected
person?
A, 1 to two vials
B. 5 to ten vials
C. 20 to 30 vials
D. Calculate once serum digoxin degree is known - ANSThe correct solution is B.
Rationale: The empiric dose of digoxin-specific antibody fragments to
administer to a hemodynamically risky affected person following an acute overdose is 5 to
ten vials (desire B is accurate). This dose ought to receive as a bolus inside the placing of
coming near near or lively cardiac arrest. One or vials may be appropriate in the putting of
persistent digoxin poisoning with out impending cardiac arrest, however now not on this
emergent acute case (desire A is incorrect). Twenty to 30 vials is extra than required as
initial dose for most acute overdoses, though a affected person may additionally emerge as
desiring 20 or more vials all through their hospitalization (desire C is incorrect). During
cardiac arrest or imminent arrest, sufferers need to get hold of empirical treatment.
,Physicians have to now not wait to calculate total body burden of digoxin (choice D is
wrong).
A 2-12 months vintage healthy baby on no medicines provides to Arizona emergency
department. He has been inconsolable, agitated, and hysterical for the closing hour. Initial
essential symptoms are effective for tachycardia and tachypnea, but no fever. Exam
demonstrates clean lungs, everyday eye examination, and all 4 extremities are normal with
out a pores and skin lesions. The faucet check is not possible to conduct due to the kid's
nature. What is the most appropriate next step in management?
A. Benzodiazepine
B. Centruroides immune F(ab')2 antivenom
C. Crotalid Antivenom FabAV—10 vials
D. Cr otalid Antivenom F(ab')2AV—10 vials - ANSThe accurate solution is A.
Rationale: While some of the signs and symptoms this toddler is having are consistent with
Centruroides (bark scorpion) envenomation, with out a increase in secretions and no ocular
findings (no opsoclonus) that analysis have to be wondered. The faucet check or tapping in
the vicinity of a suspected scorpion sting to look if pain receives worse, will be impossible to
behavior with this infant. Initial remedy for a Centruroides sting might be benzodiazepines
(choice A is accurate) with antivenom reserved for systemic signs and symptoms. Acute
amphetamine toxicity can appear comparable and would to start with be treated with
benzodiazepines and potentially antipsychotics depending at the response.
A 2-year-old infant presents to the emergency branch at 6pm after being bitten with the aid
of a copperhead. The chew is to the calf, and there are oozing puncture wounds
approximately 1.Five cm aside with a few mild neighborhood erythema. The calf is tender,
and there's no swelling. Vitals are everyday, and physical examination is in any other case
unremarkable. Over the primary few hours of statement the patient has minimal ache. What
is the most suitable control?
A. Administer IV Crotalid Antivenom
B. Admit for observation overnight
C. Discharge now with follow-up in three days
D. Observe for a total of 6 hours, if no development, then follow up in
3 days - ANSThe accurate answer is B.
Rationale: Lower extremity bites from copperheads especially to ankle or calf
may have good sized put off in development of swelling, so admission is warranted (choice
B is correct). Children may have extra extremity harm from a copperhead chunk relative to
adults as their limbs are smaller and the venom load is larger per unit weight. With a full
eight hours statement this patient may be discharged if he has an first rate support
community, terrible/normal laboratories at 6 hours, and a observe-up eight hours after
discharge (commonly by means of smartphone) but waiting 3 days is just too lengthy
(choices C and D are wrong). For this affected person who has what seems to be a "dry"
chew (a chew without venom administration), antivenom must no longer be used at this point
(choice A is inaccurate).
A 20-12 months-old woman has taken an unknown medicinal drug all through a suicide
attempt. She offers complaining of chest pain with her coronary heart racing and pounding.
Her vital symptoms are blood strain 150/90, coronary heart price a hundred thirty bpm,
,respiratory rate 18 breaths/min, and temperature a hundred.4 °F. Her bodily exam is
wonderful for stressful appearance with tremulousness, however her mental fame is
orientated to individual, area, and time. Her pupils are dilated symmetrically. Mucous
membranes are moist. Cardiac exam is excellent for a fast charge with out murmurs, lungs
are clear, stomach is nondistended with active bowel sounds, and neurological examination
suggests a slight tremor and hyperreflexia however no ankle clonus. Which of the following
medicinal drugs did this affected person maximum in all likelihood overdose?
A. Dextromethorphan
B. Diphenhydramine
C. Donepezil
D. Pseudoephedrine - ANSThe correct solution is D.
Rationale: This presentation is regular with a sympathomimetic toxidrome
(tachycardia, hypertension, anxiety, mydriasis, and tremor), making pseudoephedrine the
right answer (desire D is accurate). Dextromethorphan complements significant serotonergic
tone with the aid of blocking its reuptake as well as increasing its release and is an
N-methyl-D-aspartate receptor antagonist this is associated with postsynaptic five-HT
stimulation. Dextromethorphan administrated at supratherapeutic doses or in combination
with serotonergic dealers ought to result in a serotonin syndrome that still has overlapping
signs and symptoms and symptoms of anticholinergic toxicity along with hypertension,
tachycardia, fever, and agitated delirium. The foremost distinguishing feature is often muscle
rigidity and sustained clonus (desire A is incorrect). Diphenhydramine might produce an
anticholinergic syndrome (desire B is wrong). There are many overlapping capabilities with
the sympathomimetic and anticholinergic syndromes. They both may additionally purpose
tachycardia, high blood pressure, temperature elevation, mydriasis, and seizures and motor
signs and symptoms with tremor commonplace inside the sympathomimetic syndrome and
myoclonus inside the anticholinergic syndrome. The foremost distinguishing capabilities for
anticholinergic toxicity are altered intellectual reputation modifications, which could include
agitated delirium and garbled speech, and dry mucous membranes with dwindled bowel
sounds. Donepezil could produce a cholinergic syndrome with bradycardia and hypotension
(choice C is inaccurate).
A 21-12 months-old guy presents with a prime complaint of a spider bite 1 day ago that he
says become a brown recluse. On examination, there's an erythematous, raised, warm
lesion at the left forearm. His vitals are normal, he has no systemic signs and symptoms, his
urine is faded in colour, and his pain is controlled with minimum analgesia. What is the most
appropriate management?
A. Administer recluse antivenom, half of around the web site, half of intravenously
B. Administer black widow antivenom, 1 vial
C. Check CBC with diff, Type and move, LDH, U/A and admit for
statement
D. Evaluate for methicillin-resistant Staphylococcus aureus (MRSA) - ANSThe accurate
solution is D.
Rationale: While brown recluses can motive necrotic lesions in adults, their
evolution is over several days and often the spider chew is unrecognized. Most regularly with
this preliminary presentation the lesion seems to be a pores and skin MRSA contamination
(preference D is correct). There is no antivenom for brown recluse bites. The laboratories
, cautioned is probably suitable for a kid where the history changed into regarding for a
recluse chunk with systemic outcomes together with fever, weak point, and malaise.
A 21-12 months-old previously healthful man is being admitted with fatigue and abdominal
pain with out diarrhea for the past week. Vital signs and symptoms are normal besides for a
coronary heart price of 102 beats/min. There is not any bleeding, and his mental popularity is
everyday. Laboratory studies are massive for the following:
Leukocyte count number 6600/μL
Hemoglobin 7.9 g/dL
Platelet matter 34,000/μL
Creatinine 6.3 mg/dL
Serum lactate dehydrogenase 1600 U/L
Coagulation studies and fibrinogen Normal
ADAMTS-thirteen 49% activity
The peripheral blood smear shows many schistocytes, reduced platelets, and ordinary white
blood cells with out blast paperwork.What is the maximum appropriate remedy?
A. Cryoprecipitate
B. Eculizumab
C. Platelet transfusion
D. Therapeutic plasma alternate - ANSThe correct answer is B.
Rationale: This patient presents with intense acute renal failure,
thrombocytopenia, and hemolytic anemia. Schistocytes are visible on the peripheral blood
smear regular with a thrombotic microangiopathy. The scientific presentation and laboratory
statistics are steady with abnormal HUS (aHUS) and the terminal supplement inhibitor
eculizumab is the encouraged first-line treatment (desire B is accurate). In thrombotic
thrombocytopenia purpura (TTP), the ADAMTS-13 stage is generally underneath five% to
10% and the diploma of renal dysfunction is slight, accordingly therapeutic plasma trade isn't
indicated (choice D is wrong). Coagulation research and fibrinogen are everyday, so there's
no indication for cryoprecipitate substitute (choice A is incorrect). At the current platelet be
counted and without bleeding, platelet transfusion is likewise not indicated (desire C is
wrong).
A 22-year-vintage female with HIV, tuberculosis, and despair who these days immigrated
from Bangladesh is delivered to the health center in reputation epilepticus. On arrival her
vital signs are coronary heart price a hundred and twenty beats in line with minute, blood
pressure150/90 mmHg, respirations 20 consistent with minute, and temperature 38 °C. Initial
laboratory research with normal values in parentheses are proven:
Serum sodium: 138 mEq/L (136-one hundred forty four mEq/L). Serum potassium: 5.8
mEq/L (three.7-five.2 mEq/L). Serum chloride: ninety nine mEq/L (ninety six-106 mEq/L).
CO2 (carbon dioxide): 13 mEq/L (22-28 mEq/L). BUN: 11 mg/dL (eight-23 mg/L).
Creatinine: 0.Nine mg/dL (zero.3-0.Nine mg/L).Glucose: 220 mg/dL (70-110 mg/dL).Serum
calcium (overall): 9.1 mg/dL (8.2-10.2 mg/dL). Serum AST (SGOT) 60 IU/L (eight-48
IU/L).Serum ALT (SGPT) forty nine IU/L (7-55 IU/L).
Treatment with 4 mg intravenous lorazepam 3 times over 30 minutes is ineffective for
stopping her seizures. An overdose of which of the subsequent affected person's medicati -
ANSThe accurate solution is C.
Rationale: Of the medicine listed, this clinical image of seizures refractory to
