Adult-Gerontology Acute Care NP Exam
–Practice Questions with Answers and
Rationales
Question 1: A 68-year-old male with a history of hypertension and type 2
diabetes presents to the emergency department with acute onset of
severe, "tearing" chest pain that radiates to his back. His blood pressure
is 180/100 mmHg in the right arm and 140/90 mmHg in the left arm.
Which of the following is the MOST appropriate immediate diagnostic
study?
A. CT angiography of the chest
B. Transthoracic echocardiogram
C. Cardiac catheterization
D. Chest X-ray
Correct Answer: A
Rationale: This patient's presentation—sudden, severe "tearing" chest pain
radiating to the back with a significant blood pressure differential between
arms—is classic for acute aortic dissection. CT angiography is the diagnostic
study of choice for aortic dissection, offering rapid, high-resolution imaging of
the aorta. Transthoracic echocardiogram may miss thoracic aortic dissection,
chest X-ray is nonspecific, and cardiac catheterization is not the appropriate
initial study. Time is critical, as mortality increases by 1-2% per hour without
intervention.
Question 2: A 72-year-old female with heart failure with reduced
ejection fraction (HFrEF) is admitted with acute decompensated heart
failure. She is on optimal medical therapy including an ACE inhibitor,
beta-blocker, and loop diuretic. Her ejection fraction is 25%, and she is
in NYHA Class III. Which of the following additional medications has
,been shown to REDUCE mortality in this patient population and should
be initiated?
A. Spironolactone
B. Digoxin
C. Ivabradine
D. Hydralazine and isosorbide dinitrate
Correct Answer: A
Rationale: Spironolactone (an aldosterone antagonist) has been shown to
reduce mortality in patients with HFrEF (NYHA Class III-IV, EF ≤35%) who are
already on ACE inhibitors and beta-blockers, based on the RALES trial.
Digoxin reduces hospitalizations but does not reduce mortality. Ivabradine is
indicated for patients with EF ≤35%, sinus rhythm, and heart rate ≥70 bpm on
maximally tolerated beta-blocker. Hydralazine and isosorbide dinitrate are
beneficial specifically in African American patients with HFrEF (A-HeFT trial).
Question 3: A 65-year-old male presents with palpitations,
lightheadedness, and shortness of breath. ECG shows atrial fibrillation
with a ventricular rate of 150 bpm. His blood pressure is 110/70 mmHg,
and he is hemodynamically stable. Which of the following is the MOST
appropriate initial management strategy?
A. Immediate synchronized cardioversion
B. Rate control with IV diltiazem or metoprolol
C. Initiation of amiodarone loading
D. Anticoagulation and discharge home
Correct Answer: B
Rationale: For hemodynamically stable patients with atrial fibrillation and
rapid ventricular response, rate control with AV nodal blocking agents
(diltiazem, metoprolol) is first-line. Synchronized cardioversion is indicated
for unstable patients (hypotension, chest pain, heart failure). Anticoagulation
should be initiated but is not sufficient alone; rate control is the priority.
Amiodarone is used for rhythm control in select patients or for chemical
cardioversion.
,Question 4: A 58-year-old male with a history of coronary artery disease
presents with sudden onset of severe chest pain, diaphoresis, and
nausea. ECG shows 3 mm ST-segment elevation in leads V1-V4. Which of
the following is the MOST appropriate immediate intervention?
A. Administration of sublingual nitroglycerin
B. Emergent percutaneous coronary intervention (PCI) within 90 minutes
C. Administration of tissue plasminogen activator (tPA)
D. Emergent coronary artery bypass grafting (CABG)
Correct Answer: B
Rationale: This patient is experiencing an anterior ST-segment elevation
myocardial infarction (STEMI) , indicated by ST elevation in leads V1-V4
(anteroseptal). Emergent PCI is the treatment of choice if it can be performed
within 90 minutes of first medical contact. If PCI is not available within this
timeframe, fibrinolysis (tPA) should be considered. CABG is not the initial
intervention for acute STEMI. Nitroglycerin may provide symptomatic relief
but does not address the underlying occlusion.
Question 5: A 78-year-old female with a history of hypertension and
chronic kidney disease (stage 3) presents with progressive dyspnea on
exertion and orthopnea. On examination, she has jugular venous
distension, bibasilar crackles, and 2+ pitting edema. Her ejection
fraction is 60%. Which of the following is the MOST appropriate
pharmacologic management?
A. Initiation of an ACE inhibitor and diuretic
B. Initiation of a beta-blocker and digoxin
C. Initiation of a calcium channel blocker
D. Initiation of an angiotensin receptor-neprilysin inhibitor (ARNI)
Correct Answer: A
Rationale: This patient has heart failure with preserved ejection fraction
(HFpEF) , as indicated by symptoms of heart failure with an EF ≥50%.
Management of HFpEF focuses on volume management with diuretics
, and blood pressure control with ACE inhibitors or ARBs. Beta-blockers are
not specifically indicated for HFpEF. ARNI is indicated for HFrEF, not HFpEF.
Calcium channel blockers may be used for blood pressure control but are not
first-line for HFpEF management.
Question 6: A 62-year-old male with a history of paroxysmal atrial
fibrillation is started on warfarin for stroke prophylaxis. His INR is 5.5
(target 2-3). He has no signs of bleeding. According to ACCP guidelines,
which of the following is the MOST appropriate management?
A. Hold warfarin and restart when INR is <5
B. Hold warfarin and administer vitamin K 2-5 mg orally
C. Hold warfarin, administer vitamin K 1-2 mg IV, and restart warfarin at a
lower dose
D. Hold warfarin and administer prothrombin complex concentrate (PCC)
Correct Answer: A
Rationale: For patients with an INR >5 but <9 with no bleeding, the ACCP
guidelines recommend holding warfarin and restarting when INR is <5. No
vitamin K is needed in this scenario. For INR >9 without bleeding, hold
warfarin and consider vitamin K 2.5-5 mg orally. For INR >5 with bleeding or
need for urgent reversal, hold warfarin and give vitamin K 1-2 mg IV plus PCC.
Question 7: A 55-year-old female with acute pericarditis presents with
chest pain that worsens with deep inspiration and improves when
leaning forward. On auscultation, you appreciate a friction rub. Which of
the following ECG findings is MOST consistent with acute pericarditis?
A. Diffuse ST-segment elevation with PR depression
B. ST-segment elevation in contiguous leads with reciprocal changes
C. Deep Q waves in inferior leads
D. Tall peaked T waves
Correct Answer: A
Rationale: Acute pericarditis classically presents with diffuse ST-segment
elevation in most leads (except aVR and V1) with PR depression. Unlike
–Practice Questions with Answers and
Rationales
Question 1: A 68-year-old male with a history of hypertension and type 2
diabetes presents to the emergency department with acute onset of
severe, "tearing" chest pain that radiates to his back. His blood pressure
is 180/100 mmHg in the right arm and 140/90 mmHg in the left arm.
Which of the following is the MOST appropriate immediate diagnostic
study?
A. CT angiography of the chest
B. Transthoracic echocardiogram
C. Cardiac catheterization
D. Chest X-ray
Correct Answer: A
Rationale: This patient's presentation—sudden, severe "tearing" chest pain
radiating to the back with a significant blood pressure differential between
arms—is classic for acute aortic dissection. CT angiography is the diagnostic
study of choice for aortic dissection, offering rapid, high-resolution imaging of
the aorta. Transthoracic echocardiogram may miss thoracic aortic dissection,
chest X-ray is nonspecific, and cardiac catheterization is not the appropriate
initial study. Time is critical, as mortality increases by 1-2% per hour without
intervention.
Question 2: A 72-year-old female with heart failure with reduced
ejection fraction (HFrEF) is admitted with acute decompensated heart
failure. She is on optimal medical therapy including an ACE inhibitor,
beta-blocker, and loop diuretic. Her ejection fraction is 25%, and she is
in NYHA Class III. Which of the following additional medications has
,been shown to REDUCE mortality in this patient population and should
be initiated?
A. Spironolactone
B. Digoxin
C. Ivabradine
D. Hydralazine and isosorbide dinitrate
Correct Answer: A
Rationale: Spironolactone (an aldosterone antagonist) has been shown to
reduce mortality in patients with HFrEF (NYHA Class III-IV, EF ≤35%) who are
already on ACE inhibitors and beta-blockers, based on the RALES trial.
Digoxin reduces hospitalizations but does not reduce mortality. Ivabradine is
indicated for patients with EF ≤35%, sinus rhythm, and heart rate ≥70 bpm on
maximally tolerated beta-blocker. Hydralazine and isosorbide dinitrate are
beneficial specifically in African American patients with HFrEF (A-HeFT trial).
Question 3: A 65-year-old male presents with palpitations,
lightheadedness, and shortness of breath. ECG shows atrial fibrillation
with a ventricular rate of 150 bpm. His blood pressure is 110/70 mmHg,
and he is hemodynamically stable. Which of the following is the MOST
appropriate initial management strategy?
A. Immediate synchronized cardioversion
B. Rate control with IV diltiazem or metoprolol
C. Initiation of amiodarone loading
D. Anticoagulation and discharge home
Correct Answer: B
Rationale: For hemodynamically stable patients with atrial fibrillation and
rapid ventricular response, rate control with AV nodal blocking agents
(diltiazem, metoprolol) is first-line. Synchronized cardioversion is indicated
for unstable patients (hypotension, chest pain, heart failure). Anticoagulation
should be initiated but is not sufficient alone; rate control is the priority.
Amiodarone is used for rhythm control in select patients or for chemical
cardioversion.
,Question 4: A 58-year-old male with a history of coronary artery disease
presents with sudden onset of severe chest pain, diaphoresis, and
nausea. ECG shows 3 mm ST-segment elevation in leads V1-V4. Which of
the following is the MOST appropriate immediate intervention?
A. Administration of sublingual nitroglycerin
B. Emergent percutaneous coronary intervention (PCI) within 90 minutes
C. Administration of tissue plasminogen activator (tPA)
D. Emergent coronary artery bypass grafting (CABG)
Correct Answer: B
Rationale: This patient is experiencing an anterior ST-segment elevation
myocardial infarction (STEMI) , indicated by ST elevation in leads V1-V4
(anteroseptal). Emergent PCI is the treatment of choice if it can be performed
within 90 minutes of first medical contact. If PCI is not available within this
timeframe, fibrinolysis (tPA) should be considered. CABG is not the initial
intervention for acute STEMI. Nitroglycerin may provide symptomatic relief
but does not address the underlying occlusion.
Question 5: A 78-year-old female with a history of hypertension and
chronic kidney disease (stage 3) presents with progressive dyspnea on
exertion and orthopnea. On examination, she has jugular venous
distension, bibasilar crackles, and 2+ pitting edema. Her ejection
fraction is 60%. Which of the following is the MOST appropriate
pharmacologic management?
A. Initiation of an ACE inhibitor and diuretic
B. Initiation of a beta-blocker and digoxin
C. Initiation of a calcium channel blocker
D. Initiation of an angiotensin receptor-neprilysin inhibitor (ARNI)
Correct Answer: A
Rationale: This patient has heart failure with preserved ejection fraction
(HFpEF) , as indicated by symptoms of heart failure with an EF ≥50%.
Management of HFpEF focuses on volume management with diuretics
, and blood pressure control with ACE inhibitors or ARBs. Beta-blockers are
not specifically indicated for HFpEF. ARNI is indicated for HFrEF, not HFpEF.
Calcium channel blockers may be used for blood pressure control but are not
first-line for HFpEF management.
Question 6: A 62-year-old male with a history of paroxysmal atrial
fibrillation is started on warfarin for stroke prophylaxis. His INR is 5.5
(target 2-3). He has no signs of bleeding. According to ACCP guidelines,
which of the following is the MOST appropriate management?
A. Hold warfarin and restart when INR is <5
B. Hold warfarin and administer vitamin K 2-5 mg orally
C. Hold warfarin, administer vitamin K 1-2 mg IV, and restart warfarin at a
lower dose
D. Hold warfarin and administer prothrombin complex concentrate (PCC)
Correct Answer: A
Rationale: For patients with an INR >5 but <9 with no bleeding, the ACCP
guidelines recommend holding warfarin and restarting when INR is <5. No
vitamin K is needed in this scenario. For INR >9 without bleeding, hold
warfarin and consider vitamin K 2.5-5 mg orally. For INR >5 with bleeding or
need for urgent reversal, hold warfarin and give vitamin K 1-2 mg IV plus PCC.
Question 7: A 55-year-old female with acute pericarditis presents with
chest pain that worsens with deep inspiration and improves when
leaning forward. On auscultation, you appreciate a friction rub. Which of
the following ECG findings is MOST consistent with acute pericarditis?
A. Diffuse ST-segment elevation with PR depression
B. ST-segment elevation in contiguous leads with reciprocal changes
C. Deep Q waves in inferior leads
D. Tall peaked T waves
Correct Answer: A
Rationale: Acute pericarditis classically presents with diffuse ST-segment
elevation in most leads (except aVR and V1) with PR depression. Unlike
