NSG 554 Exam 3
Nurse Practitioners in Primary Care I
Questions and Answers with Rationales
,1. A 58-year-old man with a history of hypertension presents for a routine visit. His
BP today is 148/92 mmHg, confirmed on repeat measurement. He has no known
diabetes or CKD. According to current ACC/AHA guidelines, what is the most
appropriate next step?
A. Reassure the patient and recheck BP in one year
B. Initiate lifestyle modification and start antihypertensive pharmacotherapy
C. Order a renal ultrasound to rule out secondary hypertension before treating
D. Start a beta-blocker only, since it is first-line for all patients
Correct Answer: B
Rationale:
A BP of 148/92 mmHg meets criteria for Stage 2 hypertension (140/90 mmHg). Current
guidelines recommend combining lifestyle modification (sodium restriction, weight loss,
exercise, DASH diet) with initiation of antihypertensive medication at this stage, since
lifestyle changes alone are unlikely to achieve goal BP. Secondary causes are considered
when there are red flags (resistant hypertension, sudden onset, young age), not as a
routine first step. Beta-blockers are not first-line for uncomplicated hypertension; thiazide
diuretics, ACE inhibitors/ARBs, and calcium channel blockers are preferred first-line
agents.
2. A 64-year-old woman with type 2 diabetes and hyperlipidemia asks about starting
a statin. Her LDL is 145 mg/dL and her 10-year ASCVD risk score is 12%. Which
statement best guides the NP's recommendation?
A. Statins are only indicated if LDL exceeds 190 mg/dL
B. A moderate-intensity statin is appropriate given her diabetes and elevated ASCVD
risk
C. Statins should be deferred until she has a cardiac event
D. Only fibrates are recommended for patients with diabetes
Correct Answer: B
Rationale:
Diabetic patients aged 40-75 with LDL 70 mg/dL are generally recommended for
moderate-intensity statin therapy regardless of calculated ASCVD score, and her risk
score of 12% (intermediate risk, 7.5%) further supports statin initiation. LDL >190 mg/dL
triggers high-intensity statin use independent of risk scoring, but statins are not withheld
until that threshold. Fibrates are used primarily for severe hypertriglyceridemia, not as
first-line LDL-lowering therapy.
3. A 45-year-old man reports intermittent palpitations. An ECG in the office shows
an irregularly irregular rhythm with no discernible P waves. Which condition does
,this most likely represent, and what is the priority assessment?
A. Ventricular tachycardia; assess for pulselessness
B. Atrial fibrillation; assess stroke risk with CHA2DS2-VASc score
C. First-degree AV block; no further workup needed
D. Sinus arrhythmia; reassure and discharge
Correct Answer: B
Rationale:
An irregularly irregular rhythm without P waves is classic for atrial fibrillation. Once
identified, the priority in primary care is stratifying stroke risk using the CHA2DS2-VASc
score to determine need for anticoagulation, along with rate/rhythm control considerations.
Ventricular tachycardia presents as a regular wide-complex rhythm, not irregularly
irregular. First-degree AV block shows a prolonged PR interval with a regular rhythm, and
sinus arrhythmia is a regular variation with respiration, both inconsistent with this
presentation.
4. A 70-year-old woman with heart failure with reduced ejection fraction (HFrEF, EF
35%) is already on an ACE inhibitor and beta-blocker at target doses. She continues
to have NYHA Class II symptoms. Which medication class should be added next per
guideline-directed medical therapy?
A. Calcium channel blocker (dihydropyridine)
B. Mineralocorticoid receptor antagonist (e.g., spironolactone)
C. NSAID for symptom relief
D. Short-acting nitrate as monotherapy
Correct Answer: B
Rationale:
Guideline-directed medical therapy for HFrEF includes four pillars: ACE
inhibitor/ARB/ARNI, beta-blocker, mineralocorticoid receptor antagonist (MRA), and
SGLT2 inhibitor. If a patient remains symptomatic despite ACE inhibitor and beta-blocker
therapy, adding an MRA such as spironolactone is appropriate and has mortality benefit.
Dihydropyridine calcium channel blockers are not part of standard HFrEF therapy and
may worsen outcomes. NSAIDs are contraindicated in heart failure as they promote
sodium/fluid retention. Nitrates alone do not address the underlying neurohormonal
activation in HFrEF.
5. A 55-year-old man presents with exertional chest pressure that resolves with
rest, lasting about 5 minutes. He denies pain at rest. Which description best
characterizes this presentation, and what is the appropriate initial primary care
action?
A. Unstable angina; call 911 immediately
B. Stable angina; obtain resting ECG and refer for stress testing/cardiology evaluation
, C. Non-cardiac chest pain; reassure and discharge with no workup
D. Pericarditis; start high-dose NSAIDs empirically
Correct Answer: B
Rationale:
Exertional chest pressure that predictably resolves with rest is classic for stable angina.
Initial primary care evaluation includes a resting ECG and referral for further cardiac risk
stratification (stress testing or cardiology referral), along with initiation of antiplatelet and
antianginal therapy as appropriate. Unstable angina involves pain at rest or increasing
frequency/severity, which is not described here. Chest pain in a 55-year-old man with
exertional pattern warrants cardiac workup, not reassurance alone. Pericarditis typically
causes sharp, positional chest pain, not exertional pressure.
6. During a routine physical, an NP auscultates a systolic murmur that is loudest at
the right upper sternal border, radiates to the carotids, and is associated with a soft
S2. The patient reports occasional exertional dyspnea. Which valvular condition is
most consistent with these findings?
A. Mitral regurgitation
B. Aortic stenosis
C. Tricuspid regurgitation
D. Mitral valve prolapse
Correct Answer: B
Rationale:
A systolic murmur loudest at the right upper sternal border with radiation to the carotids
and diminished S2 is characteristic of aortic stenosis, especially in the context of
exertional symptoms. Mitral regurgitation produces a holosystolic murmur best heard at
the apex radiating to the axilla. Tricuspid regurgitation is best heard at the left lower
sternal border and increases with inspiration. Mitral valve prolapse typically presents with
a mid-systolic click, not a harsh crescendo-decrescendo murmur radiating to the carotids.
7. A patient on warfarin for atrial fibrillation presents with an INR of 6.8 but no active
bleeding. What is the most appropriate next step?
A. Continue current warfarin dose and recheck INR in one week
B. Hold warfarin and consider oral vitamin K, with close INR monitoring
C. Administer fresh frozen plasma immediately
D. Increase warfarin dose to reach therapeutic range faster
Correct Answer: B
Rationale:
For an INR significantly above therapeutic range (generally >4.5-5) without active
bleeding, guidelines recommend holding warfarin and considering low-dose oral vitamin
K, with close monitoring of INR until it returns to therapeutic range. Continuing the same
Nurse Practitioners in Primary Care I
Questions and Answers with Rationales
,1. A 58-year-old man with a history of hypertension presents for a routine visit. His
BP today is 148/92 mmHg, confirmed on repeat measurement. He has no known
diabetes or CKD. According to current ACC/AHA guidelines, what is the most
appropriate next step?
A. Reassure the patient and recheck BP in one year
B. Initiate lifestyle modification and start antihypertensive pharmacotherapy
C. Order a renal ultrasound to rule out secondary hypertension before treating
D. Start a beta-blocker only, since it is first-line for all patients
Correct Answer: B
Rationale:
A BP of 148/92 mmHg meets criteria for Stage 2 hypertension (140/90 mmHg). Current
guidelines recommend combining lifestyle modification (sodium restriction, weight loss,
exercise, DASH diet) with initiation of antihypertensive medication at this stage, since
lifestyle changes alone are unlikely to achieve goal BP. Secondary causes are considered
when there are red flags (resistant hypertension, sudden onset, young age), not as a
routine first step. Beta-blockers are not first-line for uncomplicated hypertension; thiazide
diuretics, ACE inhibitors/ARBs, and calcium channel blockers are preferred first-line
agents.
2. A 64-year-old woman with type 2 diabetes and hyperlipidemia asks about starting
a statin. Her LDL is 145 mg/dL and her 10-year ASCVD risk score is 12%. Which
statement best guides the NP's recommendation?
A. Statins are only indicated if LDL exceeds 190 mg/dL
B. A moderate-intensity statin is appropriate given her diabetes and elevated ASCVD
risk
C. Statins should be deferred until she has a cardiac event
D. Only fibrates are recommended for patients with diabetes
Correct Answer: B
Rationale:
Diabetic patients aged 40-75 with LDL 70 mg/dL are generally recommended for
moderate-intensity statin therapy regardless of calculated ASCVD score, and her risk
score of 12% (intermediate risk, 7.5%) further supports statin initiation. LDL >190 mg/dL
triggers high-intensity statin use independent of risk scoring, but statins are not withheld
until that threshold. Fibrates are used primarily for severe hypertriglyceridemia, not as
first-line LDL-lowering therapy.
3. A 45-year-old man reports intermittent palpitations. An ECG in the office shows
an irregularly irregular rhythm with no discernible P waves. Which condition does
,this most likely represent, and what is the priority assessment?
A. Ventricular tachycardia; assess for pulselessness
B. Atrial fibrillation; assess stroke risk with CHA2DS2-VASc score
C. First-degree AV block; no further workup needed
D. Sinus arrhythmia; reassure and discharge
Correct Answer: B
Rationale:
An irregularly irregular rhythm without P waves is classic for atrial fibrillation. Once
identified, the priority in primary care is stratifying stroke risk using the CHA2DS2-VASc
score to determine need for anticoagulation, along with rate/rhythm control considerations.
Ventricular tachycardia presents as a regular wide-complex rhythm, not irregularly
irregular. First-degree AV block shows a prolonged PR interval with a regular rhythm, and
sinus arrhythmia is a regular variation with respiration, both inconsistent with this
presentation.
4. A 70-year-old woman with heart failure with reduced ejection fraction (HFrEF, EF
35%) is already on an ACE inhibitor and beta-blocker at target doses. She continues
to have NYHA Class II symptoms. Which medication class should be added next per
guideline-directed medical therapy?
A. Calcium channel blocker (dihydropyridine)
B. Mineralocorticoid receptor antagonist (e.g., spironolactone)
C. NSAID for symptom relief
D. Short-acting nitrate as monotherapy
Correct Answer: B
Rationale:
Guideline-directed medical therapy for HFrEF includes four pillars: ACE
inhibitor/ARB/ARNI, beta-blocker, mineralocorticoid receptor antagonist (MRA), and
SGLT2 inhibitor. If a patient remains symptomatic despite ACE inhibitor and beta-blocker
therapy, adding an MRA such as spironolactone is appropriate and has mortality benefit.
Dihydropyridine calcium channel blockers are not part of standard HFrEF therapy and
may worsen outcomes. NSAIDs are contraindicated in heart failure as they promote
sodium/fluid retention. Nitrates alone do not address the underlying neurohormonal
activation in HFrEF.
5. A 55-year-old man presents with exertional chest pressure that resolves with
rest, lasting about 5 minutes. He denies pain at rest. Which description best
characterizes this presentation, and what is the appropriate initial primary care
action?
A. Unstable angina; call 911 immediately
B. Stable angina; obtain resting ECG and refer for stress testing/cardiology evaluation
, C. Non-cardiac chest pain; reassure and discharge with no workup
D. Pericarditis; start high-dose NSAIDs empirically
Correct Answer: B
Rationale:
Exertional chest pressure that predictably resolves with rest is classic for stable angina.
Initial primary care evaluation includes a resting ECG and referral for further cardiac risk
stratification (stress testing or cardiology referral), along with initiation of antiplatelet and
antianginal therapy as appropriate. Unstable angina involves pain at rest or increasing
frequency/severity, which is not described here. Chest pain in a 55-year-old man with
exertional pattern warrants cardiac workup, not reassurance alone. Pericarditis typically
causes sharp, positional chest pain, not exertional pressure.
6. During a routine physical, an NP auscultates a systolic murmur that is loudest at
the right upper sternal border, radiates to the carotids, and is associated with a soft
S2. The patient reports occasional exertional dyspnea. Which valvular condition is
most consistent with these findings?
A. Mitral regurgitation
B. Aortic stenosis
C. Tricuspid regurgitation
D. Mitral valve prolapse
Correct Answer: B
Rationale:
A systolic murmur loudest at the right upper sternal border with radiation to the carotids
and diminished S2 is characteristic of aortic stenosis, especially in the context of
exertional symptoms. Mitral regurgitation produces a holosystolic murmur best heard at
the apex radiating to the axilla. Tricuspid regurgitation is best heard at the left lower
sternal border and increases with inspiration. Mitral valve prolapse typically presents with
a mid-systolic click, not a harsh crescendo-decrescendo murmur radiating to the carotids.
7. A patient on warfarin for atrial fibrillation presents with an INR of 6.8 but no active
bleeding. What is the most appropriate next step?
A. Continue current warfarin dose and recheck INR in one week
B. Hold warfarin and consider oral vitamin K, with close INR monitoring
C. Administer fresh frozen plasma immediately
D. Increase warfarin dose to reach therapeutic range faster
Correct Answer: B
Rationale:
For an INR significantly above therapeutic range (generally >4.5-5) without active
bleeding, guidelines recommend holding warfarin and considering low-dose oral vitamin
K, with close monitoring of INR until it returns to therapeutic range. Continuing the same
