NR 571 Complex Diagnosis and Management in Acute Care
Practicum | Chamberlain University NR571 AGACNP Study
Guide & Exam Prep, Advanced Acute Care Clinical Reasoning,
Comprehensive Patient Assessment, Differential Diagnosis,
Diagnostic Evaluation, Disease Management, Case-Based
Practice Questions, Answers & Detailed Rationales
Question 1: A 68-year-old male with a history of hypertension and type 2
diabetes presents with acute-onset severe epigastric pain radiating to the back,
accompanied by nausea and vomiting. His serum amylase is 1,200 U/L and
lipase is 1,500 U/L. CT abdomen reveals pancreatic necrosis involving 30% of
the gland. Which of the following is the most appropriate initial management
strategy for this patient?
A. Immediate surgical debridement of the necrotic tissue
B. Initiation of broad-spectrum intravenous antibiotics and aggressive fluid resuscitation
C. Endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy
D. Administration of intravenous octreotide to reduce pancreatic secretions
CORRECT ANSWER: B. Initiation of broad-spectrum intravenous antibiotics
and aggressive fluid resuscitation
Rationale: This patient presents with acute necrotizing pancreatitis. Initial management
is supportive, focusing on aggressive intravenous fluid resuscitation to maintain
intravascular volume and prevent renal failure, and broad-spectrum antibiotics if
infection is suspected. Surgical debridement is generally delayed until necrotic tissue
becomes walled-off and infected, typically after 4 weeks. ERCP is indicated for acute
cholangitis or persistent biliary obstruction, not for sterile necrosis. Octreotide has not
been shown to improve outcomes in acute pancreatitis.
Question 2: A 72-year-old female with a history of coronary artery disease and
heart failure with reduced ejection fraction (HFrEF) is admitted with
worsening dyspnea and orthopnea. Her medications include lisinopril,
carvedilol, and furosemide. On exam, she has jugular venous distension,
crackles in the lung bases, and 2+ pitting edema in the lower extremities. Her
blood pressure is 98/62 mmHg, heart rate 88 bpm, and oxygen saturation 92%
on room air. Which of the following is the most appropriate next step in her
management?
A. Increase the dose of lisinopril
B. Initiate intravenous dobutamine
C. Administer an intravenous bolus of furosemide
D. Start oral spironolactone
CORRECT ANSWER: C. Administer an intravenous bolus of furosemide
Rationale: This patient has acute decompensated heart failure with volume overload,
as evidenced by elevated JVP, crackles, and edema. Despite being on oral furosemide,
,she remains symptomatic. The most appropriate next step is to administer an
intravenous loop diuretic to achieve rapid and reliable diuresis. Increasing lisinopril may
cause further hypotension. Dobutamine is used for cardiogenic shock or low-output
states, not primarily for volume overload. Spironolactone is a chronic therapy for HFrEF
and not appropriate for acute management.
Question 3: A 55-year-old male with a 30-pack-year smoking history presents
with hemoptysis and weight loss. A chest CT reveals a 3-cm right hilar mass
and mediastinal lymphadenopathy. Bronchoscopy with biopsy confirms small
cell lung cancer (SCLC). Which of the following is the most important
prognostic factor in this patient's disease?
A. The size of the primary tumor
B. The presence of mediastinal lymphadenopathy
C. The stage of the disease at diagnosis (limited vs. extensive)
D. The patient's performance status
CORRECT ANSWER: C. The stage of the disease at diagnosis (limited vs.
extensive)
Rationale: Small cell lung cancer is an aggressive neuroendocrine tumor. The most
important prognostic factor is the stage at diagnosis, classified as limited-stage (confined
to one hemithorax and can be encompassed in a single radiation field) or extensive-
stage (distant metastases). Survival is significantly longer in limited-stage disease. While
tumor size, lymph node involvement, and performance status are relevant, the
distinction between limited and extensive stage is the primary driver of treatment
decisions and prognosis.
Question 4: A 45-year-old female with systemic lupus erythematosus (SLE)
presents with acute-onset confusion, headache, and a generalized tonic-clonic
seizure. Her temperature is 38.5°C. A lumbar puncture reveals elevated
opening pressure, lymphocytic pleocytosis, and elevated protein. Gram stain
and cultures are negative. Which of the following is the most likely diagnosis?
A. Bacterial meningitis
B. Viral encephalitis
C. Neuroleptic malignant syndrome
D. Central nervous system (CNS) lupus
CORRECT ANSWER: D. Central nervous system (CNS) lupus
Rationale: This patient with known SLE presents with acute neurological symptoms,
including seizure and altered mental status, along with fever. The CSF findings of
elevated opening pressure, lymphocytic pleocytosis, and elevated protein with negative
cultures are consistent with aseptic meningitis or cerebritis, which can occur in CNS
,lupus. Neuroleptic malignant syndrome is not applicable as the patient is not on
antipsychotics. CNS lupus is a serious manifestation requiring prompt
immunosuppressive therapy.
Question 5: A 60-year-old male with end-stage renal disease (ESRD) on
hemodialysis is found to have an elevated serum potassium of 6.8 mEq/L on
routine labs. He is asymptomatic and his EKG shows peaked T-waves but no
other abnormalities. Which of the following is the most appropriate initial
intervention?
A. Intravenous calcium gluconate
B. Intravenous insulin and dextrose
C. Oral sodium polystyrene sulfonate (Kayexalate)
D. Emergent hemodialysis
CORRECT ANSWER: B. Intravenous insulin and dextrose
Rationale: Acute hyperkalemia with EKG changes requires immediate treatment to
shift potassium intracellularly. Insulin with dextrose is the fastest and most effective
initial treatment for this purpose. Calcium gluconate is used to stabilize the cardiac
membrane but does not lower potassium and is indicated in the presence of more
severe EKG changes (e.g., widened QRS or sine wave). Sodium polystyrene sulfonate is
a slow-acting agent. Hemodialysis is the definitive treatment but is not the initial
emergent intervention.
Question 6: A 28-year-old male presents with acute-onset shortness of breath,
pleuritic chest pain, and hemoptysis. He recently returned from a long
international flight. His oxygen saturation is 88% on room air. A CT pulmonary
angiogram (CTPA) reveals bilateral pulmonary emboli. His blood pressure is
110/70 mmHg, heart rate 110 bpm, and troponin is elevated. Which of the
following is the most appropriate management?
A. Initiate therapeutic heparin infusion and admit to the floor
B. Administer systemic thrombolytic therapy
C. Start oral rivaroxaban
D. Perform an echocardiogram to assess for right ventricular strain
CORRECT ANSWER: B. Administer systemic thrombolytic therapy
Rationale: This patient has a massive or high-risk pulmonary embolism (PE) based on
the presence of shock (hypotension is relative, but tachycardia, elevated troponin, and
hypoxia indicate high risk). In high-risk PE, systemic thrombolysis is recommended
unless contraindicated, as it can rapidly reduce clot burden and improve hemodynamics.
Admission to the floor with therapeutic heparin is insufficient. Oral rivaroxaban is for
, stable patients. An echocardiogram is important but should not delay life-saving
thrombolysis.
Question 7: A 50-year-old female with a history of breast cancer (ER/PR
positive, HER2 negative) is undergoing chemotherapy with doxorubicin and
cyclophosphamide. She presents with new-onset dyspnea on exertion,
orthopnea, and peripheral edema. An echocardiogram reveals a new decrease
in left ventricular ejection fraction (LVEF) to 40%. Which of the following is the
most likely cause of her symptoms?
A. Doxorubicin-induced cardiomyopathy
B. Cyclophosphamide-induced hemorrhagic cystitis
C. Metastatic breast cancer to the pericardium
D. Pulmonary embolism
CORRECT ANSWER: A. Doxorubicin-induced cardiomyopathy
Rationale: Doxorubicin is an anthracycline chemotherapy agent known for causing
dose-dependent cardiotoxicity, which can present as heart failure with reduced ejection
fraction (HFrEF). The patient’s new-onset dyspnea, edema, and decreased LVEF are
classic findings. Cyclophosphamide causes hemorrhagic cystitis, not cardiomyopathy.
Metastatic disease and PE are possible but less likely given the known risk of
doxorubicin.
Question 8: A 65-year-old male with chronic obstructive pulmonary disease
(COPD) presents with worsening dyspnea and cough with purulent sputum.
On exam, he has decreased breath sounds, wheezing, and jugular venous
distension. Arterial blood gas (ABG) on room air shows: pH 7.28, PaCO2 65
mmHg, PaO2 55 mmHg, HCO3 28 mEq/L. Which of the following is the most
appropriate next step in management?
A. Administer 100% oxygen via non-rebreather mask
B. Initiate non-invasive positive pressure ventilation (NIPPV)
C. Start intravenous corticosteroids
D. Intubate and mechanically ventilate
CORRECT ANSWER: B. Initiate non-invasive positive pressure ventilation
(NIPPV)
Rationale: This patient has an acute exacerbation of COPD with hypercapnic
respiratory failure (pH < 7.30, PaCO2 > 60 mmHg). NIPPV is the first-line treatment for
such patients if they are hemodynamically stable and able to protect their airway, as it
can improve gas exchange and reduce the need for intubation. High-flow oxygen should
be avoided as it can suppress the hypoxic drive. Corticosteroids are indicated but are
not the primary initial intervention for respiratory failure.
Practicum | Chamberlain University NR571 AGACNP Study
Guide & Exam Prep, Advanced Acute Care Clinical Reasoning,
Comprehensive Patient Assessment, Differential Diagnosis,
Diagnostic Evaluation, Disease Management, Case-Based
Practice Questions, Answers & Detailed Rationales
Question 1: A 68-year-old male with a history of hypertension and type 2
diabetes presents with acute-onset severe epigastric pain radiating to the back,
accompanied by nausea and vomiting. His serum amylase is 1,200 U/L and
lipase is 1,500 U/L. CT abdomen reveals pancreatic necrosis involving 30% of
the gland. Which of the following is the most appropriate initial management
strategy for this patient?
A. Immediate surgical debridement of the necrotic tissue
B. Initiation of broad-spectrum intravenous antibiotics and aggressive fluid resuscitation
C. Endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy
D. Administration of intravenous octreotide to reduce pancreatic secretions
CORRECT ANSWER: B. Initiation of broad-spectrum intravenous antibiotics
and aggressive fluid resuscitation
Rationale: This patient presents with acute necrotizing pancreatitis. Initial management
is supportive, focusing on aggressive intravenous fluid resuscitation to maintain
intravascular volume and prevent renal failure, and broad-spectrum antibiotics if
infection is suspected. Surgical debridement is generally delayed until necrotic tissue
becomes walled-off and infected, typically after 4 weeks. ERCP is indicated for acute
cholangitis or persistent biliary obstruction, not for sterile necrosis. Octreotide has not
been shown to improve outcomes in acute pancreatitis.
Question 2: A 72-year-old female with a history of coronary artery disease and
heart failure with reduced ejection fraction (HFrEF) is admitted with
worsening dyspnea and orthopnea. Her medications include lisinopril,
carvedilol, and furosemide. On exam, she has jugular venous distension,
crackles in the lung bases, and 2+ pitting edema in the lower extremities. Her
blood pressure is 98/62 mmHg, heart rate 88 bpm, and oxygen saturation 92%
on room air. Which of the following is the most appropriate next step in her
management?
A. Increase the dose of lisinopril
B. Initiate intravenous dobutamine
C. Administer an intravenous bolus of furosemide
D. Start oral spironolactone
CORRECT ANSWER: C. Administer an intravenous bolus of furosemide
Rationale: This patient has acute decompensated heart failure with volume overload,
as evidenced by elevated JVP, crackles, and edema. Despite being on oral furosemide,
,she remains symptomatic. The most appropriate next step is to administer an
intravenous loop diuretic to achieve rapid and reliable diuresis. Increasing lisinopril may
cause further hypotension. Dobutamine is used for cardiogenic shock or low-output
states, not primarily for volume overload. Spironolactone is a chronic therapy for HFrEF
and not appropriate for acute management.
Question 3: A 55-year-old male with a 30-pack-year smoking history presents
with hemoptysis and weight loss. A chest CT reveals a 3-cm right hilar mass
and mediastinal lymphadenopathy. Bronchoscopy with biopsy confirms small
cell lung cancer (SCLC). Which of the following is the most important
prognostic factor in this patient's disease?
A. The size of the primary tumor
B. The presence of mediastinal lymphadenopathy
C. The stage of the disease at diagnosis (limited vs. extensive)
D. The patient's performance status
CORRECT ANSWER: C. The stage of the disease at diagnosis (limited vs.
extensive)
Rationale: Small cell lung cancer is an aggressive neuroendocrine tumor. The most
important prognostic factor is the stage at diagnosis, classified as limited-stage (confined
to one hemithorax and can be encompassed in a single radiation field) or extensive-
stage (distant metastases). Survival is significantly longer in limited-stage disease. While
tumor size, lymph node involvement, and performance status are relevant, the
distinction between limited and extensive stage is the primary driver of treatment
decisions and prognosis.
Question 4: A 45-year-old female with systemic lupus erythematosus (SLE)
presents with acute-onset confusion, headache, and a generalized tonic-clonic
seizure. Her temperature is 38.5°C. A lumbar puncture reveals elevated
opening pressure, lymphocytic pleocytosis, and elevated protein. Gram stain
and cultures are negative. Which of the following is the most likely diagnosis?
A. Bacterial meningitis
B. Viral encephalitis
C. Neuroleptic malignant syndrome
D. Central nervous system (CNS) lupus
CORRECT ANSWER: D. Central nervous system (CNS) lupus
Rationale: This patient with known SLE presents with acute neurological symptoms,
including seizure and altered mental status, along with fever. The CSF findings of
elevated opening pressure, lymphocytic pleocytosis, and elevated protein with negative
cultures are consistent with aseptic meningitis or cerebritis, which can occur in CNS
,lupus. Neuroleptic malignant syndrome is not applicable as the patient is not on
antipsychotics. CNS lupus is a serious manifestation requiring prompt
immunosuppressive therapy.
Question 5: A 60-year-old male with end-stage renal disease (ESRD) on
hemodialysis is found to have an elevated serum potassium of 6.8 mEq/L on
routine labs. He is asymptomatic and his EKG shows peaked T-waves but no
other abnormalities. Which of the following is the most appropriate initial
intervention?
A. Intravenous calcium gluconate
B. Intravenous insulin and dextrose
C. Oral sodium polystyrene sulfonate (Kayexalate)
D. Emergent hemodialysis
CORRECT ANSWER: B. Intravenous insulin and dextrose
Rationale: Acute hyperkalemia with EKG changes requires immediate treatment to
shift potassium intracellularly. Insulin with dextrose is the fastest and most effective
initial treatment for this purpose. Calcium gluconate is used to stabilize the cardiac
membrane but does not lower potassium and is indicated in the presence of more
severe EKG changes (e.g., widened QRS or sine wave). Sodium polystyrene sulfonate is
a slow-acting agent. Hemodialysis is the definitive treatment but is not the initial
emergent intervention.
Question 6: A 28-year-old male presents with acute-onset shortness of breath,
pleuritic chest pain, and hemoptysis. He recently returned from a long
international flight. His oxygen saturation is 88% on room air. A CT pulmonary
angiogram (CTPA) reveals bilateral pulmonary emboli. His blood pressure is
110/70 mmHg, heart rate 110 bpm, and troponin is elevated. Which of the
following is the most appropriate management?
A. Initiate therapeutic heparin infusion and admit to the floor
B. Administer systemic thrombolytic therapy
C. Start oral rivaroxaban
D. Perform an echocardiogram to assess for right ventricular strain
CORRECT ANSWER: B. Administer systemic thrombolytic therapy
Rationale: This patient has a massive or high-risk pulmonary embolism (PE) based on
the presence of shock (hypotension is relative, but tachycardia, elevated troponin, and
hypoxia indicate high risk). In high-risk PE, systemic thrombolysis is recommended
unless contraindicated, as it can rapidly reduce clot burden and improve hemodynamics.
Admission to the floor with therapeutic heparin is insufficient. Oral rivaroxaban is for
, stable patients. An echocardiogram is important but should not delay life-saving
thrombolysis.
Question 7: A 50-year-old female with a history of breast cancer (ER/PR
positive, HER2 negative) is undergoing chemotherapy with doxorubicin and
cyclophosphamide. She presents with new-onset dyspnea on exertion,
orthopnea, and peripheral edema. An echocardiogram reveals a new decrease
in left ventricular ejection fraction (LVEF) to 40%. Which of the following is the
most likely cause of her symptoms?
A. Doxorubicin-induced cardiomyopathy
B. Cyclophosphamide-induced hemorrhagic cystitis
C. Metastatic breast cancer to the pericardium
D. Pulmonary embolism
CORRECT ANSWER: A. Doxorubicin-induced cardiomyopathy
Rationale: Doxorubicin is an anthracycline chemotherapy agent known for causing
dose-dependent cardiotoxicity, which can present as heart failure with reduced ejection
fraction (HFrEF). The patient’s new-onset dyspnea, edema, and decreased LVEF are
classic findings. Cyclophosphamide causes hemorrhagic cystitis, not cardiomyopathy.
Metastatic disease and PE are possible but less likely given the known risk of
doxorubicin.
Question 8: A 65-year-old male with chronic obstructive pulmonary disease
(COPD) presents with worsening dyspnea and cough with purulent sputum.
On exam, he has decreased breath sounds, wheezing, and jugular venous
distension. Arterial blood gas (ABG) on room air shows: pH 7.28, PaCO2 65
mmHg, PaO2 55 mmHg, HCO3 28 mEq/L. Which of the following is the most
appropriate next step in management?
A. Administer 100% oxygen via non-rebreather mask
B. Initiate non-invasive positive pressure ventilation (NIPPV)
C. Start intravenous corticosteroids
D. Intubate and mechanically ventilate
CORRECT ANSWER: B. Initiate non-invasive positive pressure ventilation
(NIPPV)
Rationale: This patient has an acute exacerbation of COPD with hypercapnic
respiratory failure (pH < 7.30, PaCO2 > 60 mmHg). NIPPV is the first-line treatment for
such patients if they are hemodynamically stable and able to protect their airway, as it
can improve gas exchange and reduce the need for intubation. High-flow oxygen should
be avoided as it can suppress the hypoxic drive. Corticosteroids are indicated but are
not the primary initial intervention for respiratory failure.
