Question 1
The patient is exhibiting a productive cough and a low-grade fever. Chest X-ray on PA view
shows a left lower chest area of consolidation adjacent to the left 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 silhouette. Which is the most likely
location of this area of focal consolidation?
*Left upper lobe apex
*Right middle lobe
*Left upper lobe lingula
*Left lower lobe
CORRECT ANSWER
Left upper lobe lingula
Ratonale: Lingular consolidation is described in this question precisely. If the cardiac
margin/silhouette is obliterated by the mass, the lesion is either right middle lobe or left
upper lobe lingula.
Question 2
The inability to fully relax the myocardium during relaxation is a trademark of which of the
following diagnoses?
CORRECT ANSWER
Diastolic dysfunction
Rationale: The inability for the heart to relax is a trademark of the diagnosis of diastolic
dysfunction and is common in patients with thickened hypertrophic myocardium.
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,Question 3
An otherwise healthy African American adult male has been diagnosed with hypertension.
He has been restricting his salt intake, eating a DASH (Dietary Approaches to Stop
Hypertension) diet, and exercising more, but his blood pressure is still elevated. Which is
the BEST medication to prescribe him?
CORRECT ANSWER
Calcium channel blocker
Rationale: African American patients 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
modifications.
Question 4
Your patient has been diagnosed with a 4.5cm ascending aortic aneurysm. Which medical
imaging is considered standard of care for serial surveillance?
CORRECT ANSWER
CT angiography of the chest
Rationale: CT angiography is considered the standard of care for measuring vascular
luminal dimensions with contrast. CT PE protocol is not timed properly for the aorta (it's
timed for the pulmonary artery). Although a plain film is able to catch large aneurysms at
times, they are not able to provide multi-axis reconstruction needed to accurately measure
the size. Transesophageal echo is not needed to accurately measure the aorta and requires
the patient to undergo sedation which is unnecessary.
Question 5
Which of the following medications does not cause beta 1 stimulation?
CORRECT ANSWER
phenylephrine
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@THE STUDY VAULT
, Rationale: Phenylephrine only stimulates alpha 1 receptors. The remaining three all have
beta receptor activity.
Question 6
A 50-year-old woman with a history of hypertension presents with dyspnea on exertion
and orthopnea. On examination, she has jugular venous distention and bilateral crackles
on lung auscultation. What is the most likely diagnosis?
CORRECT ANSWER
Congestive heart failure
Rationale: Of the available options, the most accurate response is congestive heart failure
as it is signifying both a right ventricular back up with jugular venous extension and
crackles on lung assault, which are suggestive of left ventricular back up. it is possible the
patient may have an acute myocardial infarction that precipitated this, however, a patient
has not described that, rather is only describing dyspnea on exertion and orthopnea, which
both speak to a state of fluid overload. The only appropriate response of these available is
congestive heart failure.
Question 7
Your patient with a history of HFrEF (heart failure with reduced ejection fraction) with an
ejection fraction of 40% who is also not on optimal medical therapy has been diagnosed
with a myocardial infarction this admission and received emergent placement of a drug-
eluting stent to the left anterior descending artery. As the medical home who will manage
this patient after discharge, which medication strategy would you expect to be a priority in
the patient's care?
CORRECT ANSWER
Ordering a transthoracic echocardiogram and order a Lifevest if EF is less than 35%
Rationale: The patient should have a protective 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 patients are not
eligible for 90 days for an AICD in this state, optimizing their medication regimen and
repeating an echo in 2-3 months to re-evaluate for improvement in their EF is required by
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@THE STUDY VAULT
, 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 anti-platelet therapy is required for 12 months minimum post-MI.
A Holter monitor does not provide any conceivable benefit for this patient as presented.
Question 8
A 65-year-old woman presents for a follow-up examination. She is a smoker, and her
hypertension is now adequately controlled with medication. Her mother died at age 40
from a heart attack. The fasting lipid profile shows cholesterol = 240 mg/dL, HDL = 30, and
LDL = 200. In addition to starting therapeutic lifestyle changes, the nurse practitioner
should start the patient on:
CORRECT ANSWER
a statin drug.
Rationale: Bile acid sequestrants and cholesterol absorption inhibitors may be useful in
reducing ASVD risk, but for a patient who is an active smoker with premature coronary
disease history (less than age 65 for women), has hypertension and is far from an LDL goal,
this patient is most certainly a candidate for statin therapy, which represents the most
aggressive therapy option of these four listed.
Question 9
Which of the following end-organ sequelae is not directly caused by uncontrolled
hypertension?
CORRECT ANSWER
Peripheral neuropathy
Ratioanle: Although patients with hypertension frequently have peripheral neuropathy, it is
only directly attributed to patients who are also diabetic and is commonly found in non-
hypertensive diabetic patients. Proteinuria, AV nicking, and hemorrhagic stroke are all
caused by uncontrolled hypertension.
4
@THE STUDY VAULT
The patient is exhibiting a productive cough and a low-grade fever. Chest X-ray on PA view
shows a left lower chest area of consolidation adjacent to the left 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 silhouette. Which is the most likely
location of this area of focal consolidation?
*Left upper lobe apex
*Right middle lobe
*Left upper lobe lingula
*Left lower lobe
CORRECT ANSWER
Left upper lobe lingula
Ratonale: Lingular consolidation is described in this question precisely. If the cardiac
margin/silhouette is obliterated by the mass, the lesion is either right middle lobe or left
upper lobe lingula.
Question 2
The inability to fully relax the myocardium during relaxation is a trademark of which of the
following diagnoses?
CORRECT ANSWER
Diastolic dysfunction
Rationale: The inability for the heart to relax is a trademark of the diagnosis of diastolic
dysfunction and is common in patients with thickened hypertrophic myocardium.
1
@THE STUDY VAULT
,Question 3
An otherwise healthy African American adult male has been diagnosed with hypertension.
He has been restricting his salt intake, eating a DASH (Dietary Approaches to Stop
Hypertension) diet, and exercising more, but his blood pressure is still elevated. Which is
the BEST medication to prescribe him?
CORRECT ANSWER
Calcium channel blocker
Rationale: African American patients 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
modifications.
Question 4
Your patient has been diagnosed with a 4.5cm ascending aortic aneurysm. Which medical
imaging is considered standard of care for serial surveillance?
CORRECT ANSWER
CT angiography of the chest
Rationale: CT angiography is considered the standard of care for measuring vascular
luminal dimensions with contrast. CT PE protocol is not timed properly for the aorta (it's
timed for the pulmonary artery). Although a plain film is able to catch large aneurysms at
times, they are not able to provide multi-axis reconstruction needed to accurately measure
the size. Transesophageal echo is not needed to accurately measure the aorta and requires
the patient to undergo sedation which is unnecessary.
Question 5
Which of the following medications does not cause beta 1 stimulation?
CORRECT ANSWER
phenylephrine
2
@THE STUDY VAULT
, Rationale: Phenylephrine only stimulates alpha 1 receptors. The remaining three all have
beta receptor activity.
Question 6
A 50-year-old woman with a history of hypertension presents with dyspnea on exertion
and orthopnea. On examination, she has jugular venous distention and bilateral crackles
on lung auscultation. What is the most likely diagnosis?
CORRECT ANSWER
Congestive heart failure
Rationale: Of the available options, the most accurate response is congestive heart failure
as it is signifying both a right ventricular back up with jugular venous extension and
crackles on lung assault, which are suggestive of left ventricular back up. it is possible the
patient may have an acute myocardial infarction that precipitated this, however, a patient
has not described that, rather is only describing dyspnea on exertion and orthopnea, which
both speak to a state of fluid overload. The only appropriate response of these available is
congestive heart failure.
Question 7
Your patient with a history of HFrEF (heart failure with reduced ejection fraction) with an
ejection fraction of 40% who is also not on optimal medical therapy has been diagnosed
with a myocardial infarction this admission and received emergent placement of a drug-
eluting stent to the left anterior descending artery. As the medical home who will manage
this patient after discharge, which medication strategy would you expect to be a priority in
the patient's care?
CORRECT ANSWER
Ordering a transthoracic echocardiogram and order a Lifevest if EF is less than 35%
Rationale: The patient should have a protective 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 patients are not
eligible for 90 days for an AICD in this state, optimizing their medication regimen and
repeating an echo in 2-3 months to re-evaluate for improvement in their EF is required by
3
@THE STUDY VAULT
, 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 anti-platelet therapy is required for 12 months minimum post-MI.
A Holter monitor does not provide any conceivable benefit for this patient as presented.
Question 8
A 65-year-old woman presents for a follow-up examination. She is a smoker, and her
hypertension is now adequately controlled with medication. Her mother died at age 40
from a heart attack. The fasting lipid profile shows cholesterol = 240 mg/dL, HDL = 30, and
LDL = 200. In addition to starting therapeutic lifestyle changes, the nurse practitioner
should start the patient on:
CORRECT ANSWER
a statin drug.
Rationale: Bile acid sequestrants and cholesterol absorption inhibitors may be useful in
reducing ASVD risk, but for a patient who is an active smoker with premature coronary
disease history (less than age 65 for women), has hypertension and is far from an LDL goal,
this patient is most certainly a candidate for statin therapy, which represents the most
aggressive therapy option of these four listed.
Question 9
Which of the following end-organ sequelae is not directly caused by uncontrolled
hypertension?
CORRECT ANSWER
Peripheral neuropathy
Ratioanle: Although patients with hypertension frequently have peripheral neuropathy, it is
only directly attributed to patients who are also diabetic and is commonly found in non-
hypertensive diabetic patients. Proteinuria, AV nicking, and hemorrhagic stroke are all
caused by uncontrolled hypertension.
4
@THE STUDY VAULT
