Western Governors University
CCN: NURS 3117
Course Number: D444
Course Title: Adult Health I
Exam: Objective Assessment
Date:2026
Case: Mr. Torres, 58, is admitted with crushing substernal chest pain radiating to his left arm,
diaphoresis, and nausea. His 12-lead ECG shows ST-elevation in leads II, III, and aVF. Troponin I is 2.8
ng/mL (normal <0.04 ng/mL).
Based on the ECG findings, which coronary artery territory is MOST likely involved in this patient's
infarction?
A. Left anterior descending (LAD) artery
B. Right coronary artery (RCA)
C. Left circumflex artery
D. Left main coronary artery
Correct Answer: B
Rationale: Leads II, III, and aVF represent the inferior wall of the left ventricle. The right coronary
artery supplies the inferior wall in approximately 85% of individuals with right-dominant circulation.
ST-elevation in these leads is the hallmark of an inferior STEMI. The LAD supplies the anterior wall
(V1–V4); the circumflex supplies the lateral wall (I, aVL, V5–V6). This distinction is critical for
anticipating specific complications — inferior MI is associated with right ventricular infarction, heart
block, and bradycardia, while anterior MI carries higher risk of cardiogenic shock and ventricular
arrhythmias.
---
Case: Mrs. Nkemdirim, 64, is admitted with acute heart failure exacerbation. She presents with
dyspnoea, orthopnoea, bilateral crackles at lung bases, jugular venous distension, and bilateral pitting
oedema to the knees. Her BNP is 1,450 pg/mL.
Which pathophysiological mechanism MOST directly accounts for her pulmonary crackles and
dyspnoea?
A. Elevated right ventricular end-diastolic pressure causing systemic venous congestion
1
,B. Elevated left ventricular end-diastolic pressure causing pulmonary venous hypertension and fluid
transudation into the alveoli
C. Reduced systemic vascular resistance causing distributive fluid shifts into the lungs
D. Decreased cardiac output triggering compensatory tachycardia and increased respiratory demand
Correct Answer: B
Rationale: In left-sided heart failure, impaired left ventricular contractility causes elevated LVEDP,
which backs up into the pulmonary veins and capillaries. When hydrostatic pressure exceeds plasma
oncotic pressure (the Starling forces), fluid transudates into the pulmonary interstitium and alveoli,
producing pulmonary oedema, bilateral crackles, and dyspnoea. BNP is released in response to
ventricular wall stretch and serves as a biomarker of both heart failure diagnosis and severity. JVD and
peripheral oedema in this case suggest biventricular failure.
---
Case: Mr. Petrov, 52, is brought to the ED with sudden onset severe headache described as the "worst of
his life," nuchal rigidity, photophobia, and a temperature of 39.2°C. His GCS is 13. CT head shows no
haemorrhage. Lumbar puncture reveals cloudy CSF with elevated protein, low glucose, and neutrophilic
pleocytosis.
The nurse should anticipate which PRIORITY intervention once LP results confirm bacterial aetiology?
A. Administer IV dexamethasone followed immediately by IV broad-spectrum antibiotics
B. Perform a repeat CT scan before initiating any pharmacological treatment
C. Administer oral antipyretics and observe neurological status for 24 hours
D. Initiate IV acyclovir as first-line treatment for suspected bacterial meningitis
Correct Answer: A
Rationale: Bacterial meningitis is a neurological emergency. Current evidence supports immediate IV
dexamethasone administration (to reduce inflammation-mediated neurological injury) followed at once
by IV broad-spectrum antibiotics — typically ceftriaxone plus vancomycin to cover Streptococcus
pneumoniae and Neisseria meningitidis. Any delay in antibiotic administration substantially worsens
outcomes and increases mortality. Acyclovir is reserved for viral (herpetic) encephalitis. The LP findings
of neutrophilic pleocytosis, elevated protein, and low glucose are highly characteristic of bacterial rather
than viral meningitis.
---
Case: A 47-year-old woman with hypertension and a 20-pack-year smoking history presents with sudden
right-sided weakness, right facial droop, and expressive aphasia. Symptoms began 90 minutes ago. CT
head excludes haemorrhage. Her BP on arrival is 172/98 mmHg.
According to current stroke management guidelines, the MOST appropriate immediate intervention is:
A. Administer IV labetalol to aggressively lower BP below 140 mmHg before considering any
thrombolytics
B. Administer IV alteplase (tPA) within the therapeutic window since haemorrhage has been excluded
C. Defer treatment and reassess in 3 hours since TIA symptoms may resolve spontaneously
D. Give aspirin 325 mg immediately as first-line reperfusion therapy for acute ischaemic stroke
Correct Answer: B
Rationale: IV alteplase (tPA) is the standard of care for acute ischaemic stroke within the 4.5-hour
2
,window from symptom onset, provided haemorrhage is excluded by CT. This patient presents within 90
minutes, well within the therapeutic window. BP must be below 185/110 mmHg before tPA
administration — it should not be aggressively lowered below this threshold, as higher BP helps perfuse
ischaemic penumbra. Aspirin is not a reperfusion agent; it is used for secondary stroke prevention post-
thrombolysis. The nurse must monitor closely for haemorrhagic transformation following tPA
administration.
---
Case: Mr. Kimura, 61, is admitted with a COPD exacerbation. He is using accessory muscles, has a
prolonged expiratory phase, SpO2 88% on room air, and ABGs reveal pH 7.32, PaCO2 62 mmHg, PaO2
54 mmHg, and HCO3 32 mEq/L.
How should the nurse correctly interpret these ABG results?
A. Respiratory alkalosis with metabolic compensation
B. Metabolic acidosis with respiratory compensation
C. Respiratory acidosis with metabolic compensation, consistent with chronic respiratory failure
D. Mixed metabolic and respiratory alkalosis
Correct Answer: C
Rationale: pH 7.32 is acidotic. Elevated PaCO2 (62 mmHg) identifies the primary problem as respiratory
acidosis. Elevated HCO3 (32 mEq/L) reflects the kidneys' compensatory retention of bicarbonate to
buffer the chronic acidosis, confirming this is chronic rather than acute CO2 retention. This is the classic
ABG pattern in COPD-associated chronic respiratory failure with metabolic compensation. Target SpO2
in COPD is 88–92% to avoid suppressing the hypoxic drive, which — in chronic CO2 retainers — may
be the primary respiratory stimulus.
---
Case: Mrs. Obiang, 55, is post-operative day 2 following an abdominal hysterectomy. She develops
tachycardia (HR 118), hypotension (BP 88/52 mmHg), cool clammy extremities, urine output of 15
mL/hr, and a rising serum lactate of 4.2 mmol/L. Her surgical drain output has been 400 mL in the last 2
hours.
This clinical presentation is MOST consistent with which type of shock?
A. Distributive (septic) shock
B. Cardiogenic shock
C. Hypovolemic shock
D. Obstructive shock
Correct Answer: C
Rationale: The combination of tachycardia, hypotension, cool clammy peripheries, oliguria, elevated
lactate, and significant postoperative fluid and blood loss is the classic presentation of hypovolaemic
(haemorrhagic) shock. Hypoperfusion drives anaerobic metabolism, raising serum lactate. Distributive
shock (sepsis) classically presents with warm, vasodilated extremities in its early hyperdynamic phase.
Cardiogenic shock is associated with pulmonary congestion and elevated filling pressures. Priority
nursing interventions include establishing large-bore IV access, initiating fluid and blood product
resuscitation, and urgent surgical review for possible haemorrhage.
---
3
, Case: A 70-year-old man with type 2 diabetes presents with polyuria, polydipsia, and altered
consciousness. Serum glucose is 32 mmol/L, serum osmolality is 340 mOsm/kg, urine ketones are trace,
and blood pH is 7.38. There are no Kussmaul respirations.
This clinical presentation is MOST consistent with which diabetic emergency?
A. Diabetic ketoacidosis (DKA)
B. Hyperosmolar Hyperglycaemic State (HHS)
C. Lactic acidosis
D. Hypoglycaemia
Correct Answer: B
Rationale: HHS is characterised by severe hyperglycaemia (>33 mmol/L), markedly elevated serum
osmolality (>320 mOsm/kg), minimal or absent ketonaemia, and absence of significant acidosis (pH
>7.30). It occurs predominantly in elderly Type 2 diabetic patients and carries higher mortality than
DKA due to the degree of hyperosmolality and dehydration. The absence of significant ketosis and
acidosis differentiates it from DKA. Management prioritises gradual rehydration with 0.9% NaCl,
correction of hyperglycaemia with insulin, and electrolyte replacement — especially potassium.
---
Case: A 45-year-old woman develops sudden dyspnoea, pleuritic chest pain, and tachycardia (HR 126)
on post-operative day 2 following orthopaedic surgery. SpO2 is 91%, right calf is swollen and tender,
CXR is unremarkable, and D-dimer is markedly elevated.
Which diagnostic study is considered the gold standard for confirming this suspected diagnosis?
A. Ventilation-perfusion (V/Q) scan
B. CT pulmonary angiography (CTPA)
C. Lower limb Doppler ultrasound
D. Transthoracic echocardiography
Correct Answer: B
Rationale: CT pulmonary angiography is the gold standard for diagnosing pulmonary embolism,
providing direct visualisation of the pulmonary vasculature and identifying clots in the main, lobar, and
segmental pulmonary arteries. V/Q scanning is an alternative when CTPA is contraindicated, such as in
renal impairment or contrast allergy. Lower limb Doppler confirms DVT but does not diagnose PE.
Echocardiography may show right heart strain in massive PE but is not itself a diagnostic tool for PE.
Nursing priorities include anticoagulation initiation, continuous SpO2 monitoring, and haemodynamic
assessment.
---
Case: Mrs. Kwame, 58, presents with haematemesis and melena. On examination her BP is 90/60
mmHg, HR 122 bpm, and Hgb is 6.8 g/dL. She takes daily aspirin and ibuprofen for joint pain.
The nurse's PRIORITY nursing intervention is:
A. Insert a nasogastric tube and perform gastric lavage immediately
B. Establish two large-bore IV access lines, initiate fluid resuscitation, and prepare for blood transfusion
C. Administer oral antacids and IV proton pump inhibitor therapy immediately
D. Position the patient supine and administer IV morphine for pain management
4
CCN: NURS 3117
Course Number: D444
Course Title: Adult Health I
Exam: Objective Assessment
Date:2026
Case: Mr. Torres, 58, is admitted with crushing substernal chest pain radiating to his left arm,
diaphoresis, and nausea. His 12-lead ECG shows ST-elevation in leads II, III, and aVF. Troponin I is 2.8
ng/mL (normal <0.04 ng/mL).
Based on the ECG findings, which coronary artery territory is MOST likely involved in this patient's
infarction?
A. Left anterior descending (LAD) artery
B. Right coronary artery (RCA)
C. Left circumflex artery
D. Left main coronary artery
Correct Answer: B
Rationale: Leads II, III, and aVF represent the inferior wall of the left ventricle. The right coronary
artery supplies the inferior wall in approximately 85% of individuals with right-dominant circulation.
ST-elevation in these leads is the hallmark of an inferior STEMI. The LAD supplies the anterior wall
(V1–V4); the circumflex supplies the lateral wall (I, aVL, V5–V6). This distinction is critical for
anticipating specific complications — inferior MI is associated with right ventricular infarction, heart
block, and bradycardia, while anterior MI carries higher risk of cardiogenic shock and ventricular
arrhythmias.
---
Case: Mrs. Nkemdirim, 64, is admitted with acute heart failure exacerbation. She presents with
dyspnoea, orthopnoea, bilateral crackles at lung bases, jugular venous distension, and bilateral pitting
oedema to the knees. Her BNP is 1,450 pg/mL.
Which pathophysiological mechanism MOST directly accounts for her pulmonary crackles and
dyspnoea?
A. Elevated right ventricular end-diastolic pressure causing systemic venous congestion
1
,B. Elevated left ventricular end-diastolic pressure causing pulmonary venous hypertension and fluid
transudation into the alveoli
C. Reduced systemic vascular resistance causing distributive fluid shifts into the lungs
D. Decreased cardiac output triggering compensatory tachycardia and increased respiratory demand
Correct Answer: B
Rationale: In left-sided heart failure, impaired left ventricular contractility causes elevated LVEDP,
which backs up into the pulmonary veins and capillaries. When hydrostatic pressure exceeds plasma
oncotic pressure (the Starling forces), fluid transudates into the pulmonary interstitium and alveoli,
producing pulmonary oedema, bilateral crackles, and dyspnoea. BNP is released in response to
ventricular wall stretch and serves as a biomarker of both heart failure diagnosis and severity. JVD and
peripheral oedema in this case suggest biventricular failure.
---
Case: Mr. Petrov, 52, is brought to the ED with sudden onset severe headache described as the "worst of
his life," nuchal rigidity, photophobia, and a temperature of 39.2°C. His GCS is 13. CT head shows no
haemorrhage. Lumbar puncture reveals cloudy CSF with elevated protein, low glucose, and neutrophilic
pleocytosis.
The nurse should anticipate which PRIORITY intervention once LP results confirm bacterial aetiology?
A. Administer IV dexamethasone followed immediately by IV broad-spectrum antibiotics
B. Perform a repeat CT scan before initiating any pharmacological treatment
C. Administer oral antipyretics and observe neurological status for 24 hours
D. Initiate IV acyclovir as first-line treatment for suspected bacterial meningitis
Correct Answer: A
Rationale: Bacterial meningitis is a neurological emergency. Current evidence supports immediate IV
dexamethasone administration (to reduce inflammation-mediated neurological injury) followed at once
by IV broad-spectrum antibiotics — typically ceftriaxone plus vancomycin to cover Streptococcus
pneumoniae and Neisseria meningitidis. Any delay in antibiotic administration substantially worsens
outcomes and increases mortality. Acyclovir is reserved for viral (herpetic) encephalitis. The LP findings
of neutrophilic pleocytosis, elevated protein, and low glucose are highly characteristic of bacterial rather
than viral meningitis.
---
Case: A 47-year-old woman with hypertension and a 20-pack-year smoking history presents with sudden
right-sided weakness, right facial droop, and expressive aphasia. Symptoms began 90 minutes ago. CT
head excludes haemorrhage. Her BP on arrival is 172/98 mmHg.
According to current stroke management guidelines, the MOST appropriate immediate intervention is:
A. Administer IV labetalol to aggressively lower BP below 140 mmHg before considering any
thrombolytics
B. Administer IV alteplase (tPA) within the therapeutic window since haemorrhage has been excluded
C. Defer treatment and reassess in 3 hours since TIA symptoms may resolve spontaneously
D. Give aspirin 325 mg immediately as first-line reperfusion therapy for acute ischaemic stroke
Correct Answer: B
Rationale: IV alteplase (tPA) is the standard of care for acute ischaemic stroke within the 4.5-hour
2
,window from symptom onset, provided haemorrhage is excluded by CT. This patient presents within 90
minutes, well within the therapeutic window. BP must be below 185/110 mmHg before tPA
administration — it should not be aggressively lowered below this threshold, as higher BP helps perfuse
ischaemic penumbra. Aspirin is not a reperfusion agent; it is used for secondary stroke prevention post-
thrombolysis. The nurse must monitor closely for haemorrhagic transformation following tPA
administration.
---
Case: Mr. Kimura, 61, is admitted with a COPD exacerbation. He is using accessory muscles, has a
prolonged expiratory phase, SpO2 88% on room air, and ABGs reveal pH 7.32, PaCO2 62 mmHg, PaO2
54 mmHg, and HCO3 32 mEq/L.
How should the nurse correctly interpret these ABG results?
A. Respiratory alkalosis with metabolic compensation
B. Metabolic acidosis with respiratory compensation
C. Respiratory acidosis with metabolic compensation, consistent with chronic respiratory failure
D. Mixed metabolic and respiratory alkalosis
Correct Answer: C
Rationale: pH 7.32 is acidotic. Elevated PaCO2 (62 mmHg) identifies the primary problem as respiratory
acidosis. Elevated HCO3 (32 mEq/L) reflects the kidneys' compensatory retention of bicarbonate to
buffer the chronic acidosis, confirming this is chronic rather than acute CO2 retention. This is the classic
ABG pattern in COPD-associated chronic respiratory failure with metabolic compensation. Target SpO2
in COPD is 88–92% to avoid suppressing the hypoxic drive, which — in chronic CO2 retainers — may
be the primary respiratory stimulus.
---
Case: Mrs. Obiang, 55, is post-operative day 2 following an abdominal hysterectomy. She develops
tachycardia (HR 118), hypotension (BP 88/52 mmHg), cool clammy extremities, urine output of 15
mL/hr, and a rising serum lactate of 4.2 mmol/L. Her surgical drain output has been 400 mL in the last 2
hours.
This clinical presentation is MOST consistent with which type of shock?
A. Distributive (septic) shock
B. Cardiogenic shock
C. Hypovolemic shock
D. Obstructive shock
Correct Answer: C
Rationale: The combination of tachycardia, hypotension, cool clammy peripheries, oliguria, elevated
lactate, and significant postoperative fluid and blood loss is the classic presentation of hypovolaemic
(haemorrhagic) shock. Hypoperfusion drives anaerobic metabolism, raising serum lactate. Distributive
shock (sepsis) classically presents with warm, vasodilated extremities in its early hyperdynamic phase.
Cardiogenic shock is associated with pulmonary congestion and elevated filling pressures. Priority
nursing interventions include establishing large-bore IV access, initiating fluid and blood product
resuscitation, and urgent surgical review for possible haemorrhage.
---
3
, Case: A 70-year-old man with type 2 diabetes presents with polyuria, polydipsia, and altered
consciousness. Serum glucose is 32 mmol/L, serum osmolality is 340 mOsm/kg, urine ketones are trace,
and blood pH is 7.38. There are no Kussmaul respirations.
This clinical presentation is MOST consistent with which diabetic emergency?
A. Diabetic ketoacidosis (DKA)
B. Hyperosmolar Hyperglycaemic State (HHS)
C. Lactic acidosis
D. Hypoglycaemia
Correct Answer: B
Rationale: HHS is characterised by severe hyperglycaemia (>33 mmol/L), markedly elevated serum
osmolality (>320 mOsm/kg), minimal or absent ketonaemia, and absence of significant acidosis (pH
>7.30). It occurs predominantly in elderly Type 2 diabetic patients and carries higher mortality than
DKA due to the degree of hyperosmolality and dehydration. The absence of significant ketosis and
acidosis differentiates it from DKA. Management prioritises gradual rehydration with 0.9% NaCl,
correction of hyperglycaemia with insulin, and electrolyte replacement — especially potassium.
---
Case: A 45-year-old woman develops sudden dyspnoea, pleuritic chest pain, and tachycardia (HR 126)
on post-operative day 2 following orthopaedic surgery. SpO2 is 91%, right calf is swollen and tender,
CXR is unremarkable, and D-dimer is markedly elevated.
Which diagnostic study is considered the gold standard for confirming this suspected diagnosis?
A. Ventilation-perfusion (V/Q) scan
B. CT pulmonary angiography (CTPA)
C. Lower limb Doppler ultrasound
D. Transthoracic echocardiography
Correct Answer: B
Rationale: CT pulmonary angiography is the gold standard for diagnosing pulmonary embolism,
providing direct visualisation of the pulmonary vasculature and identifying clots in the main, lobar, and
segmental pulmonary arteries. V/Q scanning is an alternative when CTPA is contraindicated, such as in
renal impairment or contrast allergy. Lower limb Doppler confirms DVT but does not diagnose PE.
Echocardiography may show right heart strain in massive PE but is not itself a diagnostic tool for PE.
Nursing priorities include anticoagulation initiation, continuous SpO2 monitoring, and haemodynamic
assessment.
---
Case: Mrs. Kwame, 58, presents with haematemesis and melena. On examination her BP is 90/60
mmHg, HR 122 bpm, and Hgb is 6.8 g/dL. She takes daily aspirin and ibuprofen for joint pain.
The nurse's PRIORITY nursing intervention is:
A. Insert a nasogastric tube and perform gastric lavage immediately
B. Establish two large-bore IV access lines, initiate fluid resuscitation, and prepare for blood transfusion
C. Administer oral antacids and IV proton pump inhibitor therapy immediately
D. Position the patient supine and administer IV morphine for pain management
4
