NR601 Week 4 Midterm: Valvular Disorders & Principles of
Primary Care for Older Adults Questions With Answers and
Explanations
Question 1. Which visual change is expected with presbyopia?
A. Progressive field loss from glaucoma by definition
B. Acute painful monocular vision loss
C. Reduced ability to focus on near objects
D. Central scotoma from retinal disease
Correct Answer: C. Reduced ability to focus on near objects
Explanation: Presbyopia results from reduced lens elasticity and accommodative ability with age. Near tasks
become more difficult and reading correction is often needed. Painful or sudden visual symptoms are not normal
aging. Visual complaints should be evaluated for treatable ocular disease when present.
Question 2. Which normal age-related cardiovascular change contributes to orthostatic
symptoms?
A. Complete loss of arterial stiffness
B. Increased baroreflex sensitivity
C. Reduced baroreceptor responsiveness
D. Marked increase in beta-adrenergic responsiveness
Correct Answer: C. Reduced baroreceptor responsiveness
Explanation: Baroreflex responses become less efficient with age. When an older adult stands, heart rate and
vascular tone may not increase rapidly enough to maintain cerebral perfusion. Dehydration and medications can
amplify this vulnerability. Orthostatic blood pressure should be assessed when dizziness, syncope, or falls are
reported.
Question 3. Which medication list is most complete for reconciliation?
A. Prescription drugs, OTC products, vitamins, supplements, and as-needed medications
B. Medications from the primary care clinician only
C. Prescription drugs only
D. Cardiac medications only
Correct Answer: A. Prescription drugs, OTC products, vitamins, supplements, and as-needed
medications
Explanation: Adverse interactions can arise from nonprescription products and supplements as well as
prescribed medications. Patients may use sleep aids, pain medicines, herbal products, or duplicate combination
products without realizing the risk. Medication reconciliation must therefore capture everything taken, including
frequency and actual use. The list should be compared with pharmacy and discharge records when available.
Page 1
,NR601 Week 4 Midterm • Valvular Disorders & Primary Care for Older Adults 600-Question Practice Exam
Question 4. A daughter reports that her 78-year-old father is repeating questions and
missing medication doses. What is the best next step?
A. Dismiss the report because only the patient can identify cognitive decline.
B. Order a sedative before assessing cognition.
C. Perform a focused cognitive and functional assessment rather than relying on the absence of a patient
complaint.
D. Wait until the patient becomes disoriented in the office.
Correct Answer: C. Perform a focused cognitive and functional assessment rather than relying on
the absence of a patient complaint.
Explanation: Collateral history is especially valuable because patients may lack awareness of cognitive decline.
Repetition and medication errors indicate a functional concern that merits assessment. A brief validated tool can
be combined with history, medication review, sensory assessment, and examination. The goal is to define
whether there is cognitive impairment and identify potentially reversible contributors.
Question 5. Which finding favors MVP over aortic stenosis when evaluating a systolic
murmur?
A. Soft A2 with severe calcification
B. Radiation to both carotids with delayed upstroke
C. A midsystolic click whose timing changes with posture
D. Late-peaking ejection murmur at the right upper sternal border
Correct Answer: C. A midsystolic click whose timing changes with posture
Explanation: MVP characteristically produces a midsystolic click and late systolic murmur that shift in timing as
LV volume changes. Aortic stenosis instead produces a systolic ejection murmur at the right upper sternal border
with carotid radiation. Carotid pulse delay also supports aortic stenosis. Dynamic click behavior is therefore a
useful bedside clue.
Question 6. A low-risk patient has isolated severe chronic aortic regurgitation requiring
intervention. Which statement about TAVR is most accurate under the 2020 ACC/AHA
guideline framework?
A. No valve intervention is ever used for AR
B. Balloon valvotomy is the preferred definitive treatment
C. Surgical AVR remains the standard approach; TAVR is not recommended for isolated AR in a low-surgical-risk
patient.
D. TAVR is mandatory for every patient with AR
Correct Answer: C. Surgical AVR remains the standard approach; TAVR is not recommended for
isolated AR in a low-surgical-risk patient.
Explanation: TAVR technology and evidence were developed primarily for calcific aortic stenosis, where a
calcified annulus helps anchor the valve. In isolated native aortic regurgitation without calcific stenosis, anatomy
and evidence differ substantially. The 2020 ACC/AHA guideline does not recommend TAVR for isolated AR in
patients who are suitable for surgery. Device options continue to evolve, so complex cases belong in a valve
center.
Page 2
,NR601 Week 4 Midterm • Valvular Disorders & Primary Care for Older Adults 600-Question Practice Exam
Question 7. Why is orientation alone insufficient to rule out delirium?
A. Delirium affects only long-term memory.
B. A patient may know person, place, and date yet still have impaired attention and a fluctuating acute change.
C. Orientation is unrelated to cognition.
D. All delirious patients are permanently disoriented.
Correct Answer: B. A patient may know person, place, and date yet still have impaired attention
and a fluctuating acute change.
Explanation: Delirium is fundamentally a disorder of attention and awareness with acute fluctuation. Some
patients can answer orientation questions correctly, particularly early or between worse periods. Testing
attention and establishing the time course are therefore essential. A normal orientation screen should not
override a compelling history of acute cognitive change.
Question 8. Why can diuretics improve symptoms in mitral stenosis without correcting the
lesion?
A. They prevent all atrial fibrillation
B. They increase valve area permanently
C. They separate fused mitral commissures
D. They lower intravascular volume and pulmonary venous pressure.
Correct Answer: D. They lower intravascular volume and pulmonary venous pressure.
Explanation: Diuretics reduce venous congestion and pulmonary capillary pressure, which can relieve dyspnea.
They do not enlarge the fixed mitral valve or reverse rheumatic fusion. Rate control can also reduce gradients
when tachycardia is present. Definitive intervention is considered when symptoms and valve severity warrant it.
Question 9. Why can severe tricuspid regurgitation produce renal dysfunction?
A. The tricuspid valve directly blocks both renal arteries
B. TR causes glucose nephropathy
C. TR permanently increases glomerular filtration in all patients
D. High systemic venous pressure can cause renal venous congestion and reduce effective renal perfusion.
Correct Answer: D. High systemic venous pressure can cause renal venous congestion and reduce
effective renal perfusion.
Explanation: Right-sided heart failure raises central and renal venous pressure. Venous congestion can reduce
the transrenal perfusion gradient and contribute to worsening kidney function. Low forward output may
compound the problem. Recognizing congestion is important because diuresis and definitive valve management
can improve cardiorenal physiology in selected patients.
Question 10. Which statement best reflects USPSTF guidance for a 70-year-old woman who
has never smoked and has no family history of abdominal aortic aneurysm?
A. Screen every woman once at age 70.
B. Perform screening only with CT angiography.
C. Do not routinely screen for abdominal aortic aneurysm.
D. Perform annual ultrasound indefinitely.
Correct Answer: C. Do not routinely screen for abdominal aortic aneurysm.
Explanation: The USPSTF recommends against routine AAA screening in women who have never smoked and
have no family history of AAA. In this group, the low prevalence means screening harms can outweigh benefit.
This recommendation applies to asymptomatic screening. Symptoms or a known aneurysm in another context
require diagnostic management.
Page 3
, NR601 Week 4 Midterm • Valvular Disorders & Primary Care for Older Adults 600-Question Practice Exam
Question 11. What is a common cause of late bioprosthetic valve dysfunction?
A. Structural valve degeneration with leaflet calcification or tearing
B. Spontaneous conversion into a mechanical valve
C. Lifelong congenital absence of the prosthesis
D. Routine exercise
Correct Answer: A. Structural valve degeneration with leaflet calcification or tearing
Explanation: Bioprosthetic tissue can progressively calcify, stiffen, or tear over years. This structural valve
degeneration can produce recurrent stenosis, regurgitation, or both. Risk is generally higher over longer
follow-up and in younger patients. Serial echocardiography helps detect degeneration before advanced
symptoms develop.
Question 12. An older adult is found to have a high-pitched early diastolic decrescendo
murmur at the left upper sternal border best heard at the left upper sternal border with
diastolic radiation down the sternal edge. Which valvular disorder is most consistent with
this finding?
A. Pulmonic stenosis
B. Pulmonic regurgitation
C. Aortic regurgitation
D. Mitral valve prolapse
Correct Answer: B. Pulmonic regurgitation
Explanation: Pulmonic regurgitation classically produces a high-pitched early diastolic decrescendo murmur at
the left upper sternal border and is best heard at the left upper sternal border with diastolic radiation down the
sternal edge. The auscultatory pattern reflects right ventricular volume overload from diastolic backflow through
the pulmonic valve. Associated findings may include exertional intolerance or right-sided failure after substantial
right ventricular dilation. Echocardiography is used to confirm the lesion and define its severity.
Question 13. How does acute severe aortic regurgitation differ from chronic severe
regurgitation?
A. Acute disease is usually asymptomatic for years
B. Acute disease may cause pulmonary edema with a relatively nondilated left ventricle.
C. Acute disease always produces marked chronic LV dilation first
D. Chronic disease never alters LV size
Correct Answer: B. Acute disease may cause pulmonary edema with a relatively nondilated left
ventricle.
Explanation: In acute regurgitation, the left ventricle has not had time to dilate and increase compliance. A
sudden large regurgitant volume therefore sharply raises LV diastolic and left atrial pressures, causing
pulmonary edema or shock. Chronic regurgitation allows compensatory dilation and may remain asymptomatic
for a long period. The time course strongly influences physical findings and urgency.
Page 4
Primary Care for Older Adults Questions With Answers and
Explanations
Question 1. Which visual change is expected with presbyopia?
A. Progressive field loss from glaucoma by definition
B. Acute painful monocular vision loss
C. Reduced ability to focus on near objects
D. Central scotoma from retinal disease
Correct Answer: C. Reduced ability to focus on near objects
Explanation: Presbyopia results from reduced lens elasticity and accommodative ability with age. Near tasks
become more difficult and reading correction is often needed. Painful or sudden visual symptoms are not normal
aging. Visual complaints should be evaluated for treatable ocular disease when present.
Question 2. Which normal age-related cardiovascular change contributes to orthostatic
symptoms?
A. Complete loss of arterial stiffness
B. Increased baroreflex sensitivity
C. Reduced baroreceptor responsiveness
D. Marked increase in beta-adrenergic responsiveness
Correct Answer: C. Reduced baroreceptor responsiveness
Explanation: Baroreflex responses become less efficient with age. When an older adult stands, heart rate and
vascular tone may not increase rapidly enough to maintain cerebral perfusion. Dehydration and medications can
amplify this vulnerability. Orthostatic blood pressure should be assessed when dizziness, syncope, or falls are
reported.
Question 3. Which medication list is most complete for reconciliation?
A. Prescription drugs, OTC products, vitamins, supplements, and as-needed medications
B. Medications from the primary care clinician only
C. Prescription drugs only
D. Cardiac medications only
Correct Answer: A. Prescription drugs, OTC products, vitamins, supplements, and as-needed
medications
Explanation: Adverse interactions can arise from nonprescription products and supplements as well as
prescribed medications. Patients may use sleep aids, pain medicines, herbal products, or duplicate combination
products without realizing the risk. Medication reconciliation must therefore capture everything taken, including
frequency and actual use. The list should be compared with pharmacy and discharge records when available.
Page 1
,NR601 Week 4 Midterm • Valvular Disorders & Primary Care for Older Adults 600-Question Practice Exam
Question 4. A daughter reports that her 78-year-old father is repeating questions and
missing medication doses. What is the best next step?
A. Dismiss the report because only the patient can identify cognitive decline.
B. Order a sedative before assessing cognition.
C. Perform a focused cognitive and functional assessment rather than relying on the absence of a patient
complaint.
D. Wait until the patient becomes disoriented in the office.
Correct Answer: C. Perform a focused cognitive and functional assessment rather than relying on
the absence of a patient complaint.
Explanation: Collateral history is especially valuable because patients may lack awareness of cognitive decline.
Repetition and medication errors indicate a functional concern that merits assessment. A brief validated tool can
be combined with history, medication review, sensory assessment, and examination. The goal is to define
whether there is cognitive impairment and identify potentially reversible contributors.
Question 5. Which finding favors MVP over aortic stenosis when evaluating a systolic
murmur?
A. Soft A2 with severe calcification
B. Radiation to both carotids with delayed upstroke
C. A midsystolic click whose timing changes with posture
D. Late-peaking ejection murmur at the right upper sternal border
Correct Answer: C. A midsystolic click whose timing changes with posture
Explanation: MVP characteristically produces a midsystolic click and late systolic murmur that shift in timing as
LV volume changes. Aortic stenosis instead produces a systolic ejection murmur at the right upper sternal border
with carotid radiation. Carotid pulse delay also supports aortic stenosis. Dynamic click behavior is therefore a
useful bedside clue.
Question 6. A low-risk patient has isolated severe chronic aortic regurgitation requiring
intervention. Which statement about TAVR is most accurate under the 2020 ACC/AHA
guideline framework?
A. No valve intervention is ever used for AR
B. Balloon valvotomy is the preferred definitive treatment
C. Surgical AVR remains the standard approach; TAVR is not recommended for isolated AR in a low-surgical-risk
patient.
D. TAVR is mandatory for every patient with AR
Correct Answer: C. Surgical AVR remains the standard approach; TAVR is not recommended for
isolated AR in a low-surgical-risk patient.
Explanation: TAVR technology and evidence were developed primarily for calcific aortic stenosis, where a
calcified annulus helps anchor the valve. In isolated native aortic regurgitation without calcific stenosis, anatomy
and evidence differ substantially. The 2020 ACC/AHA guideline does not recommend TAVR for isolated AR in
patients who are suitable for surgery. Device options continue to evolve, so complex cases belong in a valve
center.
Page 2
,NR601 Week 4 Midterm • Valvular Disorders & Primary Care for Older Adults 600-Question Practice Exam
Question 7. Why is orientation alone insufficient to rule out delirium?
A. Delirium affects only long-term memory.
B. A patient may know person, place, and date yet still have impaired attention and a fluctuating acute change.
C. Orientation is unrelated to cognition.
D. All delirious patients are permanently disoriented.
Correct Answer: B. A patient may know person, place, and date yet still have impaired attention
and a fluctuating acute change.
Explanation: Delirium is fundamentally a disorder of attention and awareness with acute fluctuation. Some
patients can answer orientation questions correctly, particularly early or between worse periods. Testing
attention and establishing the time course are therefore essential. A normal orientation screen should not
override a compelling history of acute cognitive change.
Question 8. Why can diuretics improve symptoms in mitral stenosis without correcting the
lesion?
A. They prevent all atrial fibrillation
B. They increase valve area permanently
C. They separate fused mitral commissures
D. They lower intravascular volume and pulmonary venous pressure.
Correct Answer: D. They lower intravascular volume and pulmonary venous pressure.
Explanation: Diuretics reduce venous congestion and pulmonary capillary pressure, which can relieve dyspnea.
They do not enlarge the fixed mitral valve or reverse rheumatic fusion. Rate control can also reduce gradients
when tachycardia is present. Definitive intervention is considered when symptoms and valve severity warrant it.
Question 9. Why can severe tricuspid regurgitation produce renal dysfunction?
A. The tricuspid valve directly blocks both renal arteries
B. TR causes glucose nephropathy
C. TR permanently increases glomerular filtration in all patients
D. High systemic venous pressure can cause renal venous congestion and reduce effective renal perfusion.
Correct Answer: D. High systemic venous pressure can cause renal venous congestion and reduce
effective renal perfusion.
Explanation: Right-sided heart failure raises central and renal venous pressure. Venous congestion can reduce
the transrenal perfusion gradient and contribute to worsening kidney function. Low forward output may
compound the problem. Recognizing congestion is important because diuresis and definitive valve management
can improve cardiorenal physiology in selected patients.
Question 10. Which statement best reflects USPSTF guidance for a 70-year-old woman who
has never smoked and has no family history of abdominal aortic aneurysm?
A. Screen every woman once at age 70.
B. Perform screening only with CT angiography.
C. Do not routinely screen for abdominal aortic aneurysm.
D. Perform annual ultrasound indefinitely.
Correct Answer: C. Do not routinely screen for abdominal aortic aneurysm.
Explanation: The USPSTF recommends against routine AAA screening in women who have never smoked and
have no family history of AAA. In this group, the low prevalence means screening harms can outweigh benefit.
This recommendation applies to asymptomatic screening. Symptoms or a known aneurysm in another context
require diagnostic management.
Page 3
, NR601 Week 4 Midterm • Valvular Disorders & Primary Care for Older Adults 600-Question Practice Exam
Question 11. What is a common cause of late bioprosthetic valve dysfunction?
A. Structural valve degeneration with leaflet calcification or tearing
B. Spontaneous conversion into a mechanical valve
C. Lifelong congenital absence of the prosthesis
D. Routine exercise
Correct Answer: A. Structural valve degeneration with leaflet calcification or tearing
Explanation: Bioprosthetic tissue can progressively calcify, stiffen, or tear over years. This structural valve
degeneration can produce recurrent stenosis, regurgitation, or both. Risk is generally higher over longer
follow-up and in younger patients. Serial echocardiography helps detect degeneration before advanced
symptoms develop.
Question 12. An older adult is found to have a high-pitched early diastolic decrescendo
murmur at the left upper sternal border best heard at the left upper sternal border with
diastolic radiation down the sternal edge. Which valvular disorder is most consistent with
this finding?
A. Pulmonic stenosis
B. Pulmonic regurgitation
C. Aortic regurgitation
D. Mitral valve prolapse
Correct Answer: B. Pulmonic regurgitation
Explanation: Pulmonic regurgitation classically produces a high-pitched early diastolic decrescendo murmur at
the left upper sternal border and is best heard at the left upper sternal border with diastolic radiation down the
sternal edge. The auscultatory pattern reflects right ventricular volume overload from diastolic backflow through
the pulmonic valve. Associated findings may include exertional intolerance or right-sided failure after substantial
right ventricular dilation. Echocardiography is used to confirm the lesion and define its severity.
Question 13. How does acute severe aortic regurgitation differ from chronic severe
regurgitation?
A. Acute disease is usually asymptomatic for years
B. Acute disease may cause pulmonary edema with a relatively nondilated left ventricle.
C. Acute disease always produces marked chronic LV dilation first
D. Chronic disease never alters LV size
Correct Answer: B. Acute disease may cause pulmonary edema with a relatively nondilated left
ventricle.
Explanation: In acute regurgitation, the left ventricle has not had time to dilate and increase compliance. A
sudden large regurgitant volume therefore sharply raises LV diastolic and left atrial pressures, causing
pulmonary edema or shock. Chronic regurgitation allows compensatory dilation and may remain asymptomatic
for a long period. The time course strongly influences physical findings and urgency.
Page 4
