MSN 602 UNIT 5: ADVANCED CLINICAL
PATHOPHYSIOLOGY & PRIMARY CARE MANAGEMENT
BOARD REVIEW EXAM
The pa ent is exhibi ng a produc ve cough and a low-grade fever. Chest X-ray on PA view shows
a le lower chest area of consolida on adjacent to the le border of the heart approximately 2
rib spaces above the costophrenic angle. The lateral x-ray view shows this lesion absent of the
window posterior to the cardiac silhoue e. Which is the most likely loca on of this area of focal
consolida on?
*Le upper lobe apex
*Right middle lobe
*Le upper lobe lingula
*Le lower lobe - correct answers Le upper lobe lingula
Ratonale: Lingular consolida on is described in this ques on precisely. If the cardiac
margin/silhoue e is obliterated by the mass, the lesion is either right middle lobe or le upper
lobe lingula.
The inability to fully relax the myocardium during relaxa on is a trademark of which of the
following diagnoses? - correct answers Diastolic dysfunc on
Ra onale: The inability for the heart to relax is a trademark of the diagnosis of diastolic
dysfunc on and is common in pa ents with thickened hypertrophic myocardium.
An otherwise healthy African American adult male has been diagnosed with hypertension. He
has been restric ng his salt intake, ea ng a DASH (Dietary Approaches to Stop Hypertension)
diet, and exercising more, but his blood pressure is s ll elevated. Which is the BEST medica on
to prescribe him? - correct answers Calcium channel blocker
,Ra onale: African American pa ents per JNC8 Hypertension Guidelines should be managed
with a dihydropyridine calcium channel blocker such as amlodipine (Norvasc) as first line
management therapy for hypertension not at goal with DASH and lifestyle modifica ons.
Your pa ent has been diagnosed with a 4.5cm ascending aor c aneurysm. Which medical
imaging is considered standard of care for serial surveillance? - correct answers CT angiography
of the chest
Ra onale: CT angiography is considered the standard of care for measuring vascular luminal
dimensions with contrast. CT PE protocol is not med properly for the aorta (it's med for the
pulmonary artery). Although a plain film is able to catch large aneurysms at mes, they are not
able to provide mul -axis reconstruc on needed to accurately measure the size.
Transesophageal echo is not needed to accurately measure the aorta and requires the pa ent
to undergo seda on which is unnecessary.
Which of the following medica ons does not cause beta 1 s mula on? - correct answers
phenylephrine
Ra onale: Phenylephrine only s mulates alpha 1 receptors. The remaining three all have beta
receptor ac vity.
A 50-year-old woman with a history of hypertension presents with dyspnea on exer on and
orthopnea. On examina on, she has jugular venous disten on and bilateral crackles on lung
ausculta on. What is the most likely diagnosis? - correct answers Conges ve heart failure
Ra onale: Of the available op ons, the most accurate response is conges ve heart failure as it is
signifying both a right ventricular back up with jugular venous extension and crackles on lung
assault, which are sugges ve of le ventricular back up. it is possible the pa ent may have an
acute myocardial infarc on that precipitated this, however, a pa ent has not described that,
rather is only describing dyspnea on exer on and orthopnea, which both speak to a state of
fluid overload. The only appropriate response of these available is conges ve heart failure.
Your pa ent with a history of HFrEF (heart failure with reduced ejec on frac on) with an
ejec on frac on of 40% who is also not on op mal medical therapy has been diagnosed with a
myocardial infarc on this admission and received emergent placement of a drug-elu ng stent
to the le anterior descending artery. As the medical home who will manage this pa ent a er
,discharge, which medica on strategy would you expect to be a priority in the pa ent's care? -
correct answers Ordering a transthoracic echocardiogram and order a Lifevest if EF is less than
35%
Ra onale: The pa ent should have a protec ve mechanism such as an implantable automated
cardioverter defibrillator (AICD) or a Lifevest if the EF is less than 35% due to the increased risk
of sudden cardiac death with low EF states. Since most pa ents are not eligible for 90 days for
an AICD in this state, op mizing their medica on regimen and repea ng an echo in 2-3 months
to re-evaluate for improvement in their EF is required by most insurance companies. A baseline
echo is needed at discharge to provide a baseline for improvement vs their repeat echo in 2-3
months.
Dual an -platelet therapy is required for 12 months minimum post-MI.
A Holter monitor does not provide any conceivable benefit for this pa ent as presented.
Which of the following people groups represent the least risk of cardiac disease? - correct
answers Caucasians
Ra onale: Sta s cally African Americans, Na ve Hawaiians, and American Indians are at at
increased risk of cardiac disease due to higher rates of hypertension, diabetes, and obesity than
Caucasians.
A 65-year-old woman presents for a follow-up examina on. She is a smoker, and her
hypertension is now adequately controlled with medica on. Her mother died at age 40 from a
heart a ack. The fas ng lipid profile shows cholesterol = 240 mg/dL, HDL = 30, and LDL = 200. In
addi on to star ng therapeu c lifestyle changes, the nurse prac oner should start the pa ent
on: - correct answers a sta n drug.
Ra onale: Bile acid sequestrants and cholesterol absorp on inhibitors may be useful in reducing
ASVD risk, but for a pa ent who is an ac ve smoker with premature coronary disease history
(less than age 65 for women), has hypertension and is far from an LDL goal, this pa ent is most
certainly a candidate for sta n therapy, which represents the most aggressive therapy op on of
these four listed.
Which of the following end-organ sequelae is not directly caused by uncontrolled hypertension?
- correct answers Peripheral neuropathy
, Ra oanle: Although pa ents with hypertension frequently have peripheral neuropathy, it is only
directly a ributed to pa ents who are also diabe c and is commonly found in non-hypertensive
diabe c pa ents. Proteinuria, AV nicking, and hemorrhagic stroke are all caused by uncontrolled
hypertension.
Preven ve cardiac care should focus primarily on addressing all the following except? - correct
answers Gene c predisposi on
Ra onale: Smoking cessa on, exercise, and medica on compliance all represent modifiable risk
factors and should be the focus of preven ve care. Non-modifiable risk factors such as age,
gender, gene c/family history should not be the primary focus of preven on.
A 33-year-old woman presents with irregular menstrual cycles, hirsu sm, and obesity.
Laboratory tests reveal elevated serum testosterone and LH ra o > 2:1. What is the most
appropriate ini al treatment? - correct answers Oral contracep ves
Ra onale: These are classic symptoms of polycys c ovarian syndrome and the pa ent should be
treated with oral contracep ves to help stabilize their estrogen and progesterone. Addi onally,
they may be managed on me ormin and/or spironolactone for their PCOS.
Oral contracep ve pills (OCPs) are o en the first pharmacological treatment for polycys c ovary
syndrome (PCOS) because they help manage in several ways:
Menstrual irregulari es: OCPs can help regulate menstrual cycles, making periods lighter and
more regular. This is important because irregular ovula on can lead to endometrial hyperplasia,
which is a buildup of uterine ssue that can increase the risk of uterine cancer.
Androgen excess: OCPs can reduce androgen produc on and increase sex hormone-binding
globulin (SHBG), which binds androgens. This can help reduce symptoms like acne, hirsu sm
(unwanted body and facial hair), and androgenic alopecia (male pa ern baldness).
Endometrium protec on: OCPs can protect the endometrium by ensuring regular ovula on
A 50-year-old woman with hypertension and diabetes comes in for a rou ne check-up. What
screening test should be regularly performed to monitor for early signs of diabe c
nephropathy? - correct answers Urine dips ck for protein
Ra onale: The most sensi ve indicator of diabe c nephropathy would be the evidence of small
proteins in the urine (proteinuria) as found on urinalysis. The other op ons might describe
PATHOPHYSIOLOGY & PRIMARY CARE MANAGEMENT
BOARD REVIEW EXAM
The pa ent is exhibi ng a produc ve cough and a low-grade fever. Chest X-ray on PA view shows
a le lower chest area of consolida on adjacent to the le border of the heart approximately 2
rib spaces above the costophrenic angle. The lateral x-ray view shows this lesion absent of the
window posterior to the cardiac silhoue e. Which is the most likely loca on of this area of focal
consolida on?
*Le upper lobe apex
*Right middle lobe
*Le upper lobe lingula
*Le lower lobe - correct answers Le upper lobe lingula
Ratonale: Lingular consolida on is described in this ques on precisely. If the cardiac
margin/silhoue e is obliterated by the mass, the lesion is either right middle lobe or le upper
lobe lingula.
The inability to fully relax the myocardium during relaxa on is a trademark of which of the
following diagnoses? - correct answers Diastolic dysfunc on
Ra onale: The inability for the heart to relax is a trademark of the diagnosis of diastolic
dysfunc on and is common in pa ents with thickened hypertrophic myocardium.
An otherwise healthy African American adult male has been diagnosed with hypertension. He
has been restric ng his salt intake, ea ng a DASH (Dietary Approaches to Stop Hypertension)
diet, and exercising more, but his blood pressure is s ll elevated. Which is the BEST medica on
to prescribe him? - correct answers Calcium channel blocker
,Ra onale: African American pa ents per JNC8 Hypertension Guidelines should be managed
with a dihydropyridine calcium channel blocker such as amlodipine (Norvasc) as first line
management therapy for hypertension not at goal with DASH and lifestyle modifica ons.
Your pa ent has been diagnosed with a 4.5cm ascending aor c aneurysm. Which medical
imaging is considered standard of care for serial surveillance? - correct answers CT angiography
of the chest
Ra onale: CT angiography is considered the standard of care for measuring vascular luminal
dimensions with contrast. CT PE protocol is not med properly for the aorta (it's med for the
pulmonary artery). Although a plain film is able to catch large aneurysms at mes, they are not
able to provide mul -axis reconstruc on needed to accurately measure the size.
Transesophageal echo is not needed to accurately measure the aorta and requires the pa ent
to undergo seda on which is unnecessary.
Which of the following medica ons does not cause beta 1 s mula on? - correct answers
phenylephrine
Ra onale: Phenylephrine only s mulates alpha 1 receptors. The remaining three all have beta
receptor ac vity.
A 50-year-old woman with a history of hypertension presents with dyspnea on exer on and
orthopnea. On examina on, she has jugular venous disten on and bilateral crackles on lung
ausculta on. What is the most likely diagnosis? - correct answers Conges ve heart failure
Ra onale: Of the available op ons, the most accurate response is conges ve heart failure as it is
signifying both a right ventricular back up with jugular venous extension and crackles on lung
assault, which are sugges ve of le ventricular back up. it is possible the pa ent may have an
acute myocardial infarc on that precipitated this, however, a pa ent has not described that,
rather is only describing dyspnea on exer on and orthopnea, which both speak to a state of
fluid overload. The only appropriate response of these available is conges ve heart failure.
Your pa ent with a history of HFrEF (heart failure with reduced ejec on frac on) with an
ejec on frac on of 40% who is also not on op mal medical therapy has been diagnosed with a
myocardial infarc on this admission and received emergent placement of a drug-elu ng stent
to the le anterior descending artery. As the medical home who will manage this pa ent a er
,discharge, which medica on strategy would you expect to be a priority in the pa ent's care? -
correct answers Ordering a transthoracic echocardiogram and order a Lifevest if EF is less than
35%
Ra onale: The pa ent should have a protec ve mechanism such as an implantable automated
cardioverter defibrillator (AICD) or a Lifevest if the EF is less than 35% due to the increased risk
of sudden cardiac death with low EF states. Since most pa ents are not eligible for 90 days for
an AICD in this state, op mizing their medica on regimen and repea ng an echo in 2-3 months
to re-evaluate for improvement in their EF is required by most insurance companies. A baseline
echo is needed at discharge to provide a baseline for improvement vs their repeat echo in 2-3
months.
Dual an -platelet therapy is required for 12 months minimum post-MI.
A Holter monitor does not provide any conceivable benefit for this pa ent as presented.
Which of the following people groups represent the least risk of cardiac disease? - correct
answers Caucasians
Ra onale: Sta s cally African Americans, Na ve Hawaiians, and American Indians are at at
increased risk of cardiac disease due to higher rates of hypertension, diabetes, and obesity than
Caucasians.
A 65-year-old woman presents for a follow-up examina on. She is a smoker, and her
hypertension is now adequately controlled with medica on. Her mother died at age 40 from a
heart a ack. The fas ng lipid profile shows cholesterol = 240 mg/dL, HDL = 30, and LDL = 200. In
addi on to star ng therapeu c lifestyle changes, the nurse prac oner should start the pa ent
on: - correct answers a sta n drug.
Ra onale: Bile acid sequestrants and cholesterol absorp on inhibitors may be useful in reducing
ASVD risk, but for a pa ent who is an ac ve smoker with premature coronary disease history
(less than age 65 for women), has hypertension and is far from an LDL goal, this pa ent is most
certainly a candidate for sta n therapy, which represents the most aggressive therapy op on of
these four listed.
Which of the following end-organ sequelae is not directly caused by uncontrolled hypertension?
- correct answers Peripheral neuropathy
, Ra oanle: Although pa ents with hypertension frequently have peripheral neuropathy, it is only
directly a ributed to pa ents who are also diabe c and is commonly found in non-hypertensive
diabe c pa ents. Proteinuria, AV nicking, and hemorrhagic stroke are all caused by uncontrolled
hypertension.
Preven ve cardiac care should focus primarily on addressing all the following except? - correct
answers Gene c predisposi on
Ra onale: Smoking cessa on, exercise, and medica on compliance all represent modifiable risk
factors and should be the focus of preven ve care. Non-modifiable risk factors such as age,
gender, gene c/family history should not be the primary focus of preven on.
A 33-year-old woman presents with irregular menstrual cycles, hirsu sm, and obesity.
Laboratory tests reveal elevated serum testosterone and LH ra o > 2:1. What is the most
appropriate ini al treatment? - correct answers Oral contracep ves
Ra onale: These are classic symptoms of polycys c ovarian syndrome and the pa ent should be
treated with oral contracep ves to help stabilize their estrogen and progesterone. Addi onally,
they may be managed on me ormin and/or spironolactone for their PCOS.
Oral contracep ve pills (OCPs) are o en the first pharmacological treatment for polycys c ovary
syndrome (PCOS) because they help manage in several ways:
Menstrual irregulari es: OCPs can help regulate menstrual cycles, making periods lighter and
more regular. This is important because irregular ovula on can lead to endometrial hyperplasia,
which is a buildup of uterine ssue that can increase the risk of uterine cancer.
Androgen excess: OCPs can reduce androgen produc on and increase sex hormone-binding
globulin (SHBG), which binds androgens. This can help reduce symptoms like acne, hirsu sm
(unwanted body and facial hair), and androgenic alopecia (male pa ern baldness).
Endometrium protec on: OCPs can protect the endometrium by ensuring regular ovula on
A 50-year-old woman with hypertension and diabetes comes in for a rou ne check-up. What
screening test should be regularly performed to monitor for early signs of diabe c
nephropathy? - correct answers Urine dips ck for protein
Ra onale: The most sensi ve indicator of diabe c nephropathy would be the evidence of small
proteins in the urine (proteinuria) as found on urinalysis. The other op ons might describe
