NR 571 Complex Diagnosis & Management in Acute
Care Practicum | NR571 Chamberlain University
AGACNP Study Guide, Final Exam Review,
Advanced Acute Care Diagnosis & Treatment,
Complex Clinical Cases, Differential Diagnosis,
Critical Care Decision-Making, Diagnostic
Interpretation, Disease Management, Practice
Questions, Answers & Detailed Rationales
Question 1: A 68-year-old male with a history of HTN and DM type 2 presents
with sudden onset of severe, tearing chest pain radiating to the back, with a
documented blood pressure difference of 25 mmHg between the right and left
arms. Which of the following is the most appropriate initial imaging modality
to confirm the suspected diagnosis?
A. Computed Tomography Angiography (CTA) of the chest
B. Transesophageal Echocardiography (TEE)
C. Chest X-ray
D. Magnetic Resonance Angiography (MRA) of the chest
CORRECT ANSWER: A. Computed Tomography Angiography (CTA) of the
chest
Rationale: The patient's presentation is classic for an acute aortic dissection. In the
acute setting, CTA of the chest is the gold standard and the most readily available
imaging modality with high sensitivity and specificity for diagnosing aortic dissection.
While TEE is also highly sensitive, it is invasive and operator-dependent. MRA takes too
long. Chest X-ray is non-diagnostic.
Question 2: A 72-year-old female with a history of CHF (EF 25%) is admitted
with acute decompensated heart failure. She is on maximum doses of ACE
inhibitor, beta-blocker, and loop diuretic. She remains oliguric with a rising
creatinine. Which of the following is the most appropriate next step in
managing her congestion?
A. Increase the loop diuretic dose to maximum
B. Initiate continuous veno-venous hemofiltration (CVVH)
C. Add a thiazide diuretic
D. Initiate dobutamine infusion
CORRECT ANSWER: C. Add a thiazide diuretic
Rationale: In a patient with advanced heart failure and diuretic resistance, sequential
nephron blockade is a standard strategy. Adding a thiazide diuretic (like metolazone) to
a loop diuretic blocks sodium reabsorption in the distal convoluted tubule and can
overcome resistance, producing a synergistic diuretic effect. Increasing the loop diuretic
dose may be limited by side effects and ototoxicity. CVVH is reserved for refractory
,cases with severe acidosis or uremia. Dobutamine is an inotrope, not primarily a
diuretic.
Question 3: A 55-year-old male with acute pancreatitis develops respiratory
distress, hypoxemia, and bilateral infiltrates on CXR 48 hours after admission.
His cardiac exam is normal. What is the most likely diagnosis and appropriate
management?
A. Cardiogenic pulmonary edema; administer IV furosemide
B. Acute Respiratory Distress Syndrome (ARDS); initiate lung-protective ventilation
C. Pneumonia; start broad-spectrum antibiotics
D. Pulmonary embolism; start therapeutic heparin
CORRECT ANSWER: B. Acute Respiratory Distress Syndrome (ARDS); initiate
lung-protective ventilation
Rationale: This patient has risk factors (acute pancreatitis) and clinical findings
(respiratory distress, bilateral infiltrates, no evidence of cardiac failure) consistent with
ARDS. The cornerstone of management is lung-protective mechanical ventilation using
low tidal volumes (6 ml/kg of predicted body weight) and plateau pressures < 30 cm
H2O. Furosemide is for cardiogenic edema. Antibiotics are not the primary therapy
without clear infection. Heparin is for PE.
Question 4: A 45-year-old female with a history of asthma presents with acute
shortness of breath. She is afebrile, tachypneic, and has diffuse expiratory
wheezing. Peak expiratory flow is 30% of personal best. She is on maximum
doses of nebulized albuterol and ipratropium. Which of the following is the
most appropriate next step?
A. Initiate continuous albuterol nebulization
B. Administer IV magnesium sulfate
C. Intubate and initiate mechanical ventilation
D. Administer IV methylprednisolone
CORRECT ANSWER: D. Administer IV methylprednisolone
Rationale: In a severe asthma exacerbation, systemic corticosteroids are crucial to
reduce airway inflammation. While magnesium and continuous albuterol are also used
in severe exacerbations, corticosteroids are the standard of care to prevent progression
and should be given early. The patient is not yet at the point of respiratory failure
requiring intubation, which is a last resort.
,Question 5: A 60-year-old male with ESLD is admitted with massive ascites
and SBP. He is started on IV ceftriaxone. On day 2, he becomes confused,
tremulous, and hyperreflexic. What is the most likely diagnosis and treatment?
A. Hepatic encephalopathy; give lactulose
B. Wernicke's encephalopathy; give thiamine
C. Intracranial hemorrhage; give vitamin K
D. Sepsis-associated encephalopathy; change antibiotics
CORRECT ANSWER: A. Hepatic encephalopathy; give lactulose
Rationale: This patient has end-stage liver disease and developed a change in mental
status with asterixis (implied by tremulousness) after a precipitating event (SBP). This is
classic for hepatic encephalopathy. The first-line treatment is lactulose to reduce serum
ammonia. Thiamine is given for Wernicke's (usually with ophthalmoplegia/ataxia). Vit K
is for coagulopathy, not mental status.
Question 6: A 58-year-old male with a history of CAD and HTN is in the ICU
post-STEMI. He is started on aspirin, clopidogrel, and heparin. 6 hours later,
he develops sudden chest pain, hypotension, and JVD. Echocardiogram shows
a large pericardial effusion with right ventricular collapse. What is the most
appropriate immediate intervention?
A. Increase heparin infusion rate
B. Administer IV protamine
C. Perform emergent pericardiocentesis
D. Administer IV thrombolytics
CORRECT ANSWER: C. Perform emergent pericardiocentesis
Rationale: The patient has cardiac tamponade, likely due to hemorrhagic pericardial
effusion from the anticoagulation. The classic signs are hypotension, JVD, and muffled
heart sounds (Beck's triad). The right ventricular diastolic collapse on echo confirms
tamponade, requiring immediate pericardiocentesis. Protamine is a reversal agent for
heparin and should be given, but it doesn't remove the fluid. The immediate life-saving
intervention is drainage.
Question 7: A 65-year-old female post-operative day 2 from a colectomy
becomes acutely confused, tachypneic, and hypoxemic. Her HR is 120, BP
100/60. CXR is clear. What is the most likely diagnosis?
A. Atelectasis
B. Pulmonary embolism
C. Pneumonia
D. Opioid overdose
, CORRECT ANSWER: B. Pulmonary embolism
Rationale: This patient is post-operative and presents with the classic triad of sudden
onset dyspnea, tachycardia, and hypoxia in the absence of other clear findings (clear
CXR). This is highly suspicious for a pulmonary embolism (PE). Atelectasis is common
but usually doesn't cause sudden severe hypoxia with hypotension. Pneumonia would
take longer to develop and show infiltrates. Opioid overdose would cause respiratory
depression and pinpoint pupils, not tachycardia.
Question 8: A 52-year-old male with AKI secondary to prerenal azotemia is
being evaluated. His BUN/Cr ratio is 32:1, urine sodium is 12 mEq/L, and
FENa is 0.8%. Which of the following is the most likely underlying cause?
A. Acute tubular necrosis
B. Urinary tract obstruction
C. Hypovolemia
D. Glomerulonephritis
CORRECT ANSWER: C. Hypovolemia
Rationale: Prerenal azotemia is characterized by a BUN/Cr ratio > 20:1, low urine
sodium (<20 mEq/L), and low FENa (<1%). These findings indicate the kidneys are
attempting to conserve sodium and water in response to decreased renal perfusion,
most commonly from hypovolemia. ATN shows high FENa. Obstruction shows variable
findings. Glomerulonephritis has proteinuria/hematuria.
Question 9: A 48-year-old female with a history of SLE presents with acute
onset of severe headache, visual disturbances, and a generalized tonic-clonic
seizure. Her BP is 190/110 mmHg. Urinalysis shows proteinuria and RBC casts.
What is the most appropriate initial treatment?
A. IV lorazepam for seizure control
B. IV labetalol for BP control
C. IV methylprednisolone for lupus flare
D. IV magnesium for eclampsia prophylaxis
CORRECT ANSWER: B. IV labetalol for BP control
Rationale: This patient has hypertensive emergency with end-organ damage (brain and
kidneys) due to lupus nephritis. The most immediate threat is the malignant
hypertension. While seizure control is important, the blood pressure must be lowered
emergently to prevent further cerebral edema and damage. IV labetalol or nicardipine
are preferred. Corticosteroids will help the underlying lupus but won't acutely control
the BP.
Care Practicum | NR571 Chamberlain University
AGACNP Study Guide, Final Exam Review,
Advanced Acute Care Diagnosis & Treatment,
Complex Clinical Cases, Differential Diagnosis,
Critical Care Decision-Making, Diagnostic
Interpretation, Disease Management, Practice
Questions, Answers & Detailed Rationales
Question 1: A 68-year-old male with a history of HTN and DM type 2 presents
with sudden onset of severe, tearing chest pain radiating to the back, with a
documented blood pressure difference of 25 mmHg between the right and left
arms. Which of the following is the most appropriate initial imaging modality
to confirm the suspected diagnosis?
A. Computed Tomography Angiography (CTA) of the chest
B. Transesophageal Echocardiography (TEE)
C. Chest X-ray
D. Magnetic Resonance Angiography (MRA) of the chest
CORRECT ANSWER: A. Computed Tomography Angiography (CTA) of the
chest
Rationale: The patient's presentation is classic for an acute aortic dissection. In the
acute setting, CTA of the chest is the gold standard and the most readily available
imaging modality with high sensitivity and specificity for diagnosing aortic dissection.
While TEE is also highly sensitive, it is invasive and operator-dependent. MRA takes too
long. Chest X-ray is non-diagnostic.
Question 2: A 72-year-old female with a history of CHF (EF 25%) is admitted
with acute decompensated heart failure. She is on maximum doses of ACE
inhibitor, beta-blocker, and loop diuretic. She remains oliguric with a rising
creatinine. Which of the following is the most appropriate next step in
managing her congestion?
A. Increase the loop diuretic dose to maximum
B. Initiate continuous veno-venous hemofiltration (CVVH)
C. Add a thiazide diuretic
D. Initiate dobutamine infusion
CORRECT ANSWER: C. Add a thiazide diuretic
Rationale: In a patient with advanced heart failure and diuretic resistance, sequential
nephron blockade is a standard strategy. Adding a thiazide diuretic (like metolazone) to
a loop diuretic blocks sodium reabsorption in the distal convoluted tubule and can
overcome resistance, producing a synergistic diuretic effect. Increasing the loop diuretic
dose may be limited by side effects and ototoxicity. CVVH is reserved for refractory
,cases with severe acidosis or uremia. Dobutamine is an inotrope, not primarily a
diuretic.
Question 3: A 55-year-old male with acute pancreatitis develops respiratory
distress, hypoxemia, and bilateral infiltrates on CXR 48 hours after admission.
His cardiac exam is normal. What is the most likely diagnosis and appropriate
management?
A. Cardiogenic pulmonary edema; administer IV furosemide
B. Acute Respiratory Distress Syndrome (ARDS); initiate lung-protective ventilation
C. Pneumonia; start broad-spectrum antibiotics
D. Pulmonary embolism; start therapeutic heparin
CORRECT ANSWER: B. Acute Respiratory Distress Syndrome (ARDS); initiate
lung-protective ventilation
Rationale: This patient has risk factors (acute pancreatitis) and clinical findings
(respiratory distress, bilateral infiltrates, no evidence of cardiac failure) consistent with
ARDS. The cornerstone of management is lung-protective mechanical ventilation using
low tidal volumes (6 ml/kg of predicted body weight) and plateau pressures < 30 cm
H2O. Furosemide is for cardiogenic edema. Antibiotics are not the primary therapy
without clear infection. Heparin is for PE.
Question 4: A 45-year-old female with a history of asthma presents with acute
shortness of breath. She is afebrile, tachypneic, and has diffuse expiratory
wheezing. Peak expiratory flow is 30% of personal best. She is on maximum
doses of nebulized albuterol and ipratropium. Which of the following is the
most appropriate next step?
A. Initiate continuous albuterol nebulization
B. Administer IV magnesium sulfate
C. Intubate and initiate mechanical ventilation
D. Administer IV methylprednisolone
CORRECT ANSWER: D. Administer IV methylprednisolone
Rationale: In a severe asthma exacerbation, systemic corticosteroids are crucial to
reduce airway inflammation. While magnesium and continuous albuterol are also used
in severe exacerbations, corticosteroids are the standard of care to prevent progression
and should be given early. The patient is not yet at the point of respiratory failure
requiring intubation, which is a last resort.
,Question 5: A 60-year-old male with ESLD is admitted with massive ascites
and SBP. He is started on IV ceftriaxone. On day 2, he becomes confused,
tremulous, and hyperreflexic. What is the most likely diagnosis and treatment?
A. Hepatic encephalopathy; give lactulose
B. Wernicke's encephalopathy; give thiamine
C. Intracranial hemorrhage; give vitamin K
D. Sepsis-associated encephalopathy; change antibiotics
CORRECT ANSWER: A. Hepatic encephalopathy; give lactulose
Rationale: This patient has end-stage liver disease and developed a change in mental
status with asterixis (implied by tremulousness) after a precipitating event (SBP). This is
classic for hepatic encephalopathy. The first-line treatment is lactulose to reduce serum
ammonia. Thiamine is given for Wernicke's (usually with ophthalmoplegia/ataxia). Vit K
is for coagulopathy, not mental status.
Question 6: A 58-year-old male with a history of CAD and HTN is in the ICU
post-STEMI. He is started on aspirin, clopidogrel, and heparin. 6 hours later,
he develops sudden chest pain, hypotension, and JVD. Echocardiogram shows
a large pericardial effusion with right ventricular collapse. What is the most
appropriate immediate intervention?
A. Increase heparin infusion rate
B. Administer IV protamine
C. Perform emergent pericardiocentesis
D. Administer IV thrombolytics
CORRECT ANSWER: C. Perform emergent pericardiocentesis
Rationale: The patient has cardiac tamponade, likely due to hemorrhagic pericardial
effusion from the anticoagulation. The classic signs are hypotension, JVD, and muffled
heart sounds (Beck's triad). The right ventricular diastolic collapse on echo confirms
tamponade, requiring immediate pericardiocentesis. Protamine is a reversal agent for
heparin and should be given, but it doesn't remove the fluid. The immediate life-saving
intervention is drainage.
Question 7: A 65-year-old female post-operative day 2 from a colectomy
becomes acutely confused, tachypneic, and hypoxemic. Her HR is 120, BP
100/60. CXR is clear. What is the most likely diagnosis?
A. Atelectasis
B. Pulmonary embolism
C. Pneumonia
D. Opioid overdose
, CORRECT ANSWER: B. Pulmonary embolism
Rationale: This patient is post-operative and presents with the classic triad of sudden
onset dyspnea, tachycardia, and hypoxia in the absence of other clear findings (clear
CXR). This is highly suspicious for a pulmonary embolism (PE). Atelectasis is common
but usually doesn't cause sudden severe hypoxia with hypotension. Pneumonia would
take longer to develop and show infiltrates. Opioid overdose would cause respiratory
depression and pinpoint pupils, not tachycardia.
Question 8: A 52-year-old male with AKI secondary to prerenal azotemia is
being evaluated. His BUN/Cr ratio is 32:1, urine sodium is 12 mEq/L, and
FENa is 0.8%. Which of the following is the most likely underlying cause?
A. Acute tubular necrosis
B. Urinary tract obstruction
C. Hypovolemia
D. Glomerulonephritis
CORRECT ANSWER: C. Hypovolemia
Rationale: Prerenal azotemia is characterized by a BUN/Cr ratio > 20:1, low urine
sodium (<20 mEq/L), and low FENa (<1%). These findings indicate the kidneys are
attempting to conserve sodium and water in response to decreased renal perfusion,
most commonly from hypovolemia. ATN shows high FENa. Obstruction shows variable
findings. Glomerulonephritis has proteinuria/hematuria.
Question 9: A 48-year-old female with a history of SLE presents with acute
onset of severe headache, visual disturbances, and a generalized tonic-clonic
seizure. Her BP is 190/110 mmHg. Urinalysis shows proteinuria and RBC casts.
What is the most appropriate initial treatment?
A. IV lorazepam for seizure control
B. IV labetalol for BP control
C. IV methylprednisolone for lupus flare
D. IV magnesium for eclampsia prophylaxis
CORRECT ANSWER: B. IV labetalol for BP control
Rationale: This patient has hypertensive emergency with end-organ damage (brain and
kidneys) due to lupus nephritis. The most immediate threat is the malignant
hypertension. While seizure control is important, the blood pressure must be lowered
emergently to prevent further cerebral edema and damage. IV labetalol or nicardipine
are preferred. Corticosteroids will help the underlying lupus but won't acutely control
the BP.
