NR 603 Week 4 APEA Predictor Exam
Review Questions and Answers
Question 1
A 54-year-old male presents with acute onset of severe, crushing substernal chest pain radiating
to the left arm and jaw, accompanied by diaphoresis and nausea. ECG reveals ST-elevation in
leads II, III, and aVF. Which coronary artery is most likely occluded?
A. Left anterior descending artery
B. Right coronary artery
C. Left circumflex artery
D. Left main coronary artery
Rationale: ST-elevation in leads II, III, and aVF indicates an inferior wall myocardial
infarction, typically supplied by the right coronary artery (RCA). The left anterior descending
artery supplies the anterior wall (leads V1-V4). The left circumflex supplies the lateral wall (leads
I, aVL, V5-V6). The left main coronary artery occlusion typically results in extensive anterolateral
ischemia and cardiogenic shock rather than isolated inferior changes .
Question 2
A 72-year-old male with a history of hypertension presents with acute onset of tearing chest
pain radiating to the back. His blood pressure is 180/95 mmHg in the right arm and 130/80
mmHg in the left arm. What is the most likely diagnosis?
A. Acute Myocardial Infarction
B. Aortic Dissection
C. Pulmonary Embolism
D. Pericarditis
Rationale: This presentation is classic for aortic dissection. Key features include sudden
onset of severe, tearing chest pain radiating to the back, accompanied by a significant blood
pressure differential between arms (≥20 mmHg difference). This is a hypertensive emergency
requiring immediate CT angiography for diagnosis. MI typically presents with pressure-like chest
pain, not tearing quality. PE often presents with pleuritic chest pain and dyspnea. Pericarditis
pain worsens when lying flat and improves when sitting forward .
Question 3
A 65-year-old male with a 40-pack-year smoking history presents with progressive shortness of
,breath, chronic cough, and peripheral edema. Physical examination reveals jugular venous
distention and hepatomegaly. Which pathophysiological process best explains these findings?
A. Left-sided heart failure with pulmonary congestion
B. Right-sided heart failure with systemic venous congestion
C. Chronic obstructive pulmonary disease (COPD) alone
D. Cor pulmonale with left ventricular failure
Rationale: The patient's presentation (peripheral edema, JVD, hepatomegaly) is classic for
right-sided heart failure, which results in systemic venous congestion. The patient's smoking
history and chronic respiratory symptoms suggest underlying COPD, which can lead to
pulmonary hypertension and subsequently right-sided heart failure (cor pulmonale). Left-sided
heart failure typically presents with pulmonary congestion (dyspnea, crackles) .
Question 4
A 68-year-old female with a history of hypertension and hyperlipidemia presents with
progressive shortness of breath, orthopnea, and paroxysmal nocturnal dyspnea. On exam, she
has jugular venous distension, crackles in the lung bases, and lower extremity edema. What is
the most likely diagnosis?
A. Chronic obstructive pulmonary disease
B. Congestive heart failure
C. Pulmonary embolism
D. Pneumonia
Rationale: The classic triad of dyspnea, orthopnea, and paroxysmal nocturnal dyspnea
(PND), along with signs of fluid overload (JVD, crackles, edema), points to congestive heart
failure. The patient's risk factors (hypertension, hyperlipidemia) support this diagnosis .
Question 5
A patient presents with an S3 gallop on cardiac auscultation. This finding is most commonly
associated with which condition?
A. Aortic stenosis
B. Congestive heart failure
C. Mitral regurgitation
D. Hypertrophic cardiomyopathy
Rationale: An S3 gallop is an early diastolic filling sound often heard in conditions of
increased ventricular filling pressure, most commonly congestive heart failure. It indicates
,decreased ventricular compliance and volume overload. S4 is caused by atrial contraction
against a stiff, noncompliant ventricle (hypertrophy) .
Question 6
A 68-year-old male presents with exertional chest pressure. On cardiac auscultation, a harsh
crescendo-decrescendo systolic murmur is heard at the right upper sternal border that radiates
to the carotid arteries. What is the most likely diagnosis?
A. Mitral regurgitation
B. Aortic stenosis
C. Mitral stenosis
D. Aortic regurgitation
Rationale: A harsh crescendo-decrescendo systolic murmur at the right upper sternal
border radiating to the carotids is classic for aortic stenosis. Mitral regurgitation radiates to the
axilla, mitral stenosis is a diastolic rumble at the apex, and aortic regurgitation is a diastolic
decrescendo murmur at the left upper sternal border .
Question 7
During cardiac examination of a 45-year-old female, a mid-systolic click followed by a late
systolic murmur is heard at the apex. The murmur intensifies with standing and Valsalva. What
is the diagnosis?
A. Aortic stenosis
B. Mitral valve prolapse
C. Tricuspid regurgitation
D. Hypertrophic cardiomyopathy
Rationale: Mid-systolic click with late systolic murmur at the apex is pathognomonic for
mitral valve prolapse. Standing/Valsalva (decreased preload) intensifies the murmur. HCM also
intensifies with standing but produces a harsh systolic murmur without a click .
Question 8
Which of the following is a classic sign of infective endocarditis?
A. Osler's nodes
B. Heberden's nodes
C. Bouchard's nodes
D. Swan neck deformity
Rationale: Osler's nodes are painful, erythematous nodules on the pads of the fingers and
toes, classic signs of infective endocarditis. Other signs include Janeway lesions, splinter
, hemorrhages, and Roth spots. Heberden's and Bouchard's nodes are associated with
osteoarthritis. Swan neck deformity is seen in rheumatoid arthritis .
Question 9
A 60-year-old male with a history of coronary artery disease presents with chest pain that
occurs at rest and is relieved by nitroglycerin. Which of the following is the most appropriate
initial diagnostic test?
A. Chest X-ray
B. Electrocardiogram (ECG)
C. Complete blood count
D. Echocardiogram
Rationale: An electrocardiogram (ECG) is the most appropriate initial diagnostic test for
chest pain in a patient with suspected cardiac ischemia. It can reveal ST-segment changes
indicative of myocardial ischemia or infarction .
Question 10
A 72-year-old with heart failure has a displaced PMI to the left of the midclavicular line at the
6th intercostal space. What does this finding indicate?
A. Left ventricular hypertrophy
B. Right ventricular hypertrophy
C. Left atrial enlargement
D. Pericardial effusion
Rationale: A displaced, sustained PMI laterally and inferiorly indicates left ventricular
enlargement/hypertrophy. RVH causes a heave at the left lower sternal border. Pericardial
effusion causes muffled heart sounds and distant PMI .
Question 11
A patient with acute decompensated heart failure has an S3 gallop. What is the pathophysiology
of this finding?
A. Atrial contraction against a noncompliant ventricle
B. Sudden deceleration of blood filling a volume-overloaded ventricle
C. Pericardial inflammation
D. Papillary muscle dysfunction
Rationale: S3 occurs in early diastole due to abrupt cessation of rapid ventricular filling in a
dilated, volume-overloaded ventricle (heart failure). S4 is caused by atrial contraction against a
stiff, noncompliant ventricle (hypertrophy) .
Review Questions and Answers
Question 1
A 54-year-old male presents with acute onset of severe, crushing substernal chest pain radiating
to the left arm and jaw, accompanied by diaphoresis and nausea. ECG reveals ST-elevation in
leads II, III, and aVF. Which coronary artery is most likely occluded?
A. Left anterior descending artery
B. Right coronary artery
C. Left circumflex artery
D. Left main coronary artery
Rationale: ST-elevation in leads II, III, and aVF indicates an inferior wall myocardial
infarction, typically supplied by the right coronary artery (RCA). The left anterior descending
artery supplies the anterior wall (leads V1-V4). The left circumflex supplies the lateral wall (leads
I, aVL, V5-V6). The left main coronary artery occlusion typically results in extensive anterolateral
ischemia and cardiogenic shock rather than isolated inferior changes .
Question 2
A 72-year-old male with a history of hypertension presents with acute onset of tearing chest
pain radiating to the back. His blood pressure is 180/95 mmHg in the right arm and 130/80
mmHg in the left arm. What is the most likely diagnosis?
A. Acute Myocardial Infarction
B. Aortic Dissection
C. Pulmonary Embolism
D. Pericarditis
Rationale: This presentation is classic for aortic dissection. Key features include sudden
onset of severe, tearing chest pain radiating to the back, accompanied by a significant blood
pressure differential between arms (≥20 mmHg difference). This is a hypertensive emergency
requiring immediate CT angiography for diagnosis. MI typically presents with pressure-like chest
pain, not tearing quality. PE often presents with pleuritic chest pain and dyspnea. Pericarditis
pain worsens when lying flat and improves when sitting forward .
Question 3
A 65-year-old male with a 40-pack-year smoking history presents with progressive shortness of
,breath, chronic cough, and peripheral edema. Physical examination reveals jugular venous
distention and hepatomegaly. Which pathophysiological process best explains these findings?
A. Left-sided heart failure with pulmonary congestion
B. Right-sided heart failure with systemic venous congestion
C. Chronic obstructive pulmonary disease (COPD) alone
D. Cor pulmonale with left ventricular failure
Rationale: The patient's presentation (peripheral edema, JVD, hepatomegaly) is classic for
right-sided heart failure, which results in systemic venous congestion. The patient's smoking
history and chronic respiratory symptoms suggest underlying COPD, which can lead to
pulmonary hypertension and subsequently right-sided heart failure (cor pulmonale). Left-sided
heart failure typically presents with pulmonary congestion (dyspnea, crackles) .
Question 4
A 68-year-old female with a history of hypertension and hyperlipidemia presents with
progressive shortness of breath, orthopnea, and paroxysmal nocturnal dyspnea. On exam, she
has jugular venous distension, crackles in the lung bases, and lower extremity edema. What is
the most likely diagnosis?
A. Chronic obstructive pulmonary disease
B. Congestive heart failure
C. Pulmonary embolism
D. Pneumonia
Rationale: The classic triad of dyspnea, orthopnea, and paroxysmal nocturnal dyspnea
(PND), along with signs of fluid overload (JVD, crackles, edema), points to congestive heart
failure. The patient's risk factors (hypertension, hyperlipidemia) support this diagnosis .
Question 5
A patient presents with an S3 gallop on cardiac auscultation. This finding is most commonly
associated with which condition?
A. Aortic stenosis
B. Congestive heart failure
C. Mitral regurgitation
D. Hypertrophic cardiomyopathy
Rationale: An S3 gallop is an early diastolic filling sound often heard in conditions of
increased ventricular filling pressure, most commonly congestive heart failure. It indicates
,decreased ventricular compliance and volume overload. S4 is caused by atrial contraction
against a stiff, noncompliant ventricle (hypertrophy) .
Question 6
A 68-year-old male presents with exertional chest pressure. On cardiac auscultation, a harsh
crescendo-decrescendo systolic murmur is heard at the right upper sternal border that radiates
to the carotid arteries. What is the most likely diagnosis?
A. Mitral regurgitation
B. Aortic stenosis
C. Mitral stenosis
D. Aortic regurgitation
Rationale: A harsh crescendo-decrescendo systolic murmur at the right upper sternal
border radiating to the carotids is classic for aortic stenosis. Mitral regurgitation radiates to the
axilla, mitral stenosis is a diastolic rumble at the apex, and aortic regurgitation is a diastolic
decrescendo murmur at the left upper sternal border .
Question 7
During cardiac examination of a 45-year-old female, a mid-systolic click followed by a late
systolic murmur is heard at the apex. The murmur intensifies with standing and Valsalva. What
is the diagnosis?
A. Aortic stenosis
B. Mitral valve prolapse
C. Tricuspid regurgitation
D. Hypertrophic cardiomyopathy
Rationale: Mid-systolic click with late systolic murmur at the apex is pathognomonic for
mitral valve prolapse. Standing/Valsalva (decreased preload) intensifies the murmur. HCM also
intensifies with standing but produces a harsh systolic murmur without a click .
Question 8
Which of the following is a classic sign of infective endocarditis?
A. Osler's nodes
B. Heberden's nodes
C. Bouchard's nodes
D. Swan neck deformity
Rationale: Osler's nodes are painful, erythematous nodules on the pads of the fingers and
toes, classic signs of infective endocarditis. Other signs include Janeway lesions, splinter
, hemorrhages, and Roth spots. Heberden's and Bouchard's nodes are associated with
osteoarthritis. Swan neck deformity is seen in rheumatoid arthritis .
Question 9
A 60-year-old male with a history of coronary artery disease presents with chest pain that
occurs at rest and is relieved by nitroglycerin. Which of the following is the most appropriate
initial diagnostic test?
A. Chest X-ray
B. Electrocardiogram (ECG)
C. Complete blood count
D. Echocardiogram
Rationale: An electrocardiogram (ECG) is the most appropriate initial diagnostic test for
chest pain in a patient with suspected cardiac ischemia. It can reveal ST-segment changes
indicative of myocardial ischemia or infarction .
Question 10
A 72-year-old with heart failure has a displaced PMI to the left of the midclavicular line at the
6th intercostal space. What does this finding indicate?
A. Left ventricular hypertrophy
B. Right ventricular hypertrophy
C. Left atrial enlargement
D. Pericardial effusion
Rationale: A displaced, sustained PMI laterally and inferiorly indicates left ventricular
enlargement/hypertrophy. RVH causes a heave at the left lower sternal border. Pericardial
effusion causes muffled heart sounds and distant PMI .
Question 11
A patient with acute decompensated heart failure has an S3 gallop. What is the pathophysiology
of this finding?
A. Atrial contraction against a noncompliant ventricle
B. Sudden deceleration of blood filling a volume-overloaded ventricle
C. Pericardial inflammation
D. Papillary muscle dysfunction
Rationale: S3 occurs in early diastole due to abrupt cessation of rapid ventricular filling in a
dilated, volume-overloaded ventricle (heart failure). S4 is caused by atrial contraction against a
stiff, noncompliant ventricle (hypertrophy) .
