NR 603 Week 4 APEA Predictor Exam
Review Questions
Question 1
A 58-year-old male presents with substernal chest pressure that began 30 minutes ago while
mowing the lawn. The discomfort radiates to the left arm and is associated with diaphoresis and
nausea. Which diagnosis should be considered the priority?
A. Gastroesophageal reflux disease
B. Acute coronary syndrome
C. Costochondritis
D. Panic disorder
Rationale: Substernal pressure precipitated by exertion with radiation to the arm,
diaphoresis, and nausea is highly concerning for myocardial ischemia. Acute coronary syndrome
includes unstable angina and myocardial infarction and requires immediate evaluation.
Gastroesophageal reflux may cause substernal discomfort but is less likely to produce this classic
exertional pattern with autonomic symptoms. Costochondritis usually produces reproducible
chest-wall tenderness. Panic attacks may cause chest discomfort but should not be assumed
when potentially life-threatening cardiac disease is present.
Correct Answer: B. Acute coronary syndrome
Question 2
A 67-year-old patient with hypertension has an office blood pressure of 168/94 mmHg on two
separate visits. Which finding would most strongly support a diagnosis of chronic hypertension?
A. One isolated elevated reading during acute pain
B. Persistently elevated measurements obtained on separate occasions
C. A heart rate greater than 100 beats/minute
D. A single elevated home blood-pressure reading
Rationale: Hypertension is diagnosed from appropriately obtained blood-pressure
measurements that demonstrate persistent elevation rather than from a single abnormal value.
Measurements should be confirmed using appropriate office and/or out-of-office monitoring
,when indicated. Acute pain or anxiety can transiently elevate blood pressure. A tachycardic
heart rate does not establish hypertension.
Correct Answer: B. Persistently elevated measurements obtained on separate occasions
Question 3
A patient with heart failure reports increasing dyspnea, orthopnea, and a 6-pound weight gain
over several days. Which finding most strongly suggests acute volume overload?
A. Dry mucous membranes
B. Bilateral lower-extremity edema
C. Bradycardia
D. Increased appetite
Rationale: Peripheral edema, rapid weight gain, orthopnea, pulmonary congestion, and
worsening dyspnea are characteristic of fluid retention in heart failure. A rapid increase in
weight over several days is particularly useful for recognizing changes in fluid status. Dry
mucous membranes suggest volume depletion rather than overload.
Correct Answer: B. Bilateral lower-extremity edema
Question 4
A 72-year-old patient presents with an irregularly irregular pulse. Which arrhythmia is most
likely?
A. Sinus tachycardia
B. Atrial fibrillation
C. Supraventricular tachycardia
D. Atrial flutter with fixed conduction
Rationale: Atrial fibrillation classically produces an irregularly irregular ventricular rhythm
because atrial electrical activity is chaotic and AV conduction varies. An ECG is required for
confirmation. Atrial flutter often produces a more regular ventricular response, especially with
fixed conduction.
Correct Answer: B. Atrial fibrillation
,Question 5
A 55-year-old male with a history of hypertension presents with exertional chest pain that
radiates to the left arm and is relieved by rest. What is the most likely underlying
pathophysiology?
A. Coronary artery vasospasm
B. Fixed atherosclerotic plaque causing myocardial ischemia
C. Coronary embolism
D. Aortic dissection
Rationale: Stable angina is typically caused by fixed atherosclerotic plaques that limit
coronary blood flow during periods of increased demand (exertion). Symptoms are reproducible
and relieved by rest or nitroglycerin. Vasospasm (Prinzmetal angina) occurs at rest. Coronary
embolism is rare. Aortic dissection presents with tearing pain radiating to the back.
Correct Answer: B. Fixed atherosclerotic plaque causing myocardial ischemia
Question 6
A patient with atrial fibrillation is at increased risk for:
A. Thromboembolic stroke
B. Myocardial infarction
C. Cardiac tamponade
D. Ventricular tachycardia
Rationale: Atrial fibrillation results in ineffective atrial contraction, leading to blood stasis in
the atria, particularly the left atrial appendage. This predisposes to thrombus formation and
embolization, most commonly causing ischemic stroke. Risk stratification using CHA₂DS₂-VASc
score guides anticoagulation therapy.
Correct Answer: A. Thromboembolic stroke
Question 7
A patient with aortic stenosis would most likely present with which triad of symptoms?
A. Angina, syncope, and heart failure
B. Palpitations, dizziness, and headache
, C. Chest pain, fever, and hypotension
D. Dyspnea, cough, and wheezing
Rationale: The classic triad of aortic stenosis is angina (due to increased myocardial oxygen
demand and decreased coronary perfusion), syncope (due to fixed cardiac output and cerebral
hypoperfusion during exertion), and heart failure symptoms (due to pressure overload and
eventual left ventricular dysfunction). This triad indicates severe disease.
Correct Answer: A. Angina, syncope, and heart failure
Question 8
A patient with heart failure has a reduced ejection fraction (HFrEF). Which of the following
compensatory mechanisms initially helps maintain cardiac output but ultimately contributes to
disease progression?
A. Activation of the renin-angiotensin-aldosterone system (RAAS)
B. Decreased sympathetic nervous system activity
C. Increased vagal tone
D. Decreased preload
Rationale: In heart failure, decreased cardiac output triggers RAAS activation, leading to
sodium and water retention, increased preload, and vasoconstriction. While these mechanisms
initially help maintain perfusion, they ultimately contribute to volume overload, increased
afterload, and disease progression.
Correct Answer: A. Activation of the renin-angiotensin-aldosterone system (RAAS)
Question 9
A patient with a suspected myocardial infarction has elevated troponin levels. Troponin is a
biomarker for:
A. Myocardial necrosis
B. Ventricular strain
C. Pericardial inflammation
D. Coronary vasospasm
Review Questions
Question 1
A 58-year-old male presents with substernal chest pressure that began 30 minutes ago while
mowing the lawn. The discomfort radiates to the left arm and is associated with diaphoresis and
nausea. Which diagnosis should be considered the priority?
A. Gastroesophageal reflux disease
B. Acute coronary syndrome
C. Costochondritis
D. Panic disorder
Rationale: Substernal pressure precipitated by exertion with radiation to the arm,
diaphoresis, and nausea is highly concerning for myocardial ischemia. Acute coronary syndrome
includes unstable angina and myocardial infarction and requires immediate evaluation.
Gastroesophageal reflux may cause substernal discomfort but is less likely to produce this classic
exertional pattern with autonomic symptoms. Costochondritis usually produces reproducible
chest-wall tenderness. Panic attacks may cause chest discomfort but should not be assumed
when potentially life-threatening cardiac disease is present.
Correct Answer: B. Acute coronary syndrome
Question 2
A 67-year-old patient with hypertension has an office blood pressure of 168/94 mmHg on two
separate visits. Which finding would most strongly support a diagnosis of chronic hypertension?
A. One isolated elevated reading during acute pain
B. Persistently elevated measurements obtained on separate occasions
C. A heart rate greater than 100 beats/minute
D. A single elevated home blood-pressure reading
Rationale: Hypertension is diagnosed from appropriately obtained blood-pressure
measurements that demonstrate persistent elevation rather than from a single abnormal value.
Measurements should be confirmed using appropriate office and/or out-of-office monitoring
,when indicated. Acute pain or anxiety can transiently elevate blood pressure. A tachycardic
heart rate does not establish hypertension.
Correct Answer: B. Persistently elevated measurements obtained on separate occasions
Question 3
A patient with heart failure reports increasing dyspnea, orthopnea, and a 6-pound weight gain
over several days. Which finding most strongly suggests acute volume overload?
A. Dry mucous membranes
B. Bilateral lower-extremity edema
C. Bradycardia
D. Increased appetite
Rationale: Peripheral edema, rapid weight gain, orthopnea, pulmonary congestion, and
worsening dyspnea are characteristic of fluid retention in heart failure. A rapid increase in
weight over several days is particularly useful for recognizing changes in fluid status. Dry
mucous membranes suggest volume depletion rather than overload.
Correct Answer: B. Bilateral lower-extremity edema
Question 4
A 72-year-old patient presents with an irregularly irregular pulse. Which arrhythmia is most
likely?
A. Sinus tachycardia
B. Atrial fibrillation
C. Supraventricular tachycardia
D. Atrial flutter with fixed conduction
Rationale: Atrial fibrillation classically produces an irregularly irregular ventricular rhythm
because atrial electrical activity is chaotic and AV conduction varies. An ECG is required for
confirmation. Atrial flutter often produces a more regular ventricular response, especially with
fixed conduction.
Correct Answer: B. Atrial fibrillation
,Question 5
A 55-year-old male with a history of hypertension presents with exertional chest pain that
radiates to the left arm and is relieved by rest. What is the most likely underlying
pathophysiology?
A. Coronary artery vasospasm
B. Fixed atherosclerotic plaque causing myocardial ischemia
C. Coronary embolism
D. Aortic dissection
Rationale: Stable angina is typically caused by fixed atherosclerotic plaques that limit
coronary blood flow during periods of increased demand (exertion). Symptoms are reproducible
and relieved by rest or nitroglycerin. Vasospasm (Prinzmetal angina) occurs at rest. Coronary
embolism is rare. Aortic dissection presents with tearing pain radiating to the back.
Correct Answer: B. Fixed atherosclerotic plaque causing myocardial ischemia
Question 6
A patient with atrial fibrillation is at increased risk for:
A. Thromboembolic stroke
B. Myocardial infarction
C. Cardiac tamponade
D. Ventricular tachycardia
Rationale: Atrial fibrillation results in ineffective atrial contraction, leading to blood stasis in
the atria, particularly the left atrial appendage. This predisposes to thrombus formation and
embolization, most commonly causing ischemic stroke. Risk stratification using CHA₂DS₂-VASc
score guides anticoagulation therapy.
Correct Answer: A. Thromboembolic stroke
Question 7
A patient with aortic stenosis would most likely present with which triad of symptoms?
A. Angina, syncope, and heart failure
B. Palpitations, dizziness, and headache
, C. Chest pain, fever, and hypotension
D. Dyspnea, cough, and wheezing
Rationale: The classic triad of aortic stenosis is angina (due to increased myocardial oxygen
demand and decreased coronary perfusion), syncope (due to fixed cardiac output and cerebral
hypoperfusion during exertion), and heart failure symptoms (due to pressure overload and
eventual left ventricular dysfunction). This triad indicates severe disease.
Correct Answer: A. Angina, syncope, and heart failure
Question 8
A patient with heart failure has a reduced ejection fraction (HFrEF). Which of the following
compensatory mechanisms initially helps maintain cardiac output but ultimately contributes to
disease progression?
A. Activation of the renin-angiotensin-aldosterone system (RAAS)
B. Decreased sympathetic nervous system activity
C. Increased vagal tone
D. Decreased preload
Rationale: In heart failure, decreased cardiac output triggers RAAS activation, leading to
sodium and water retention, increased preload, and vasoconstriction. While these mechanisms
initially help maintain perfusion, they ultimately contribute to volume overload, increased
afterload, and disease progression.
Correct Answer: A. Activation of the renin-angiotensin-aldosterone system (RAAS)
Question 9
A patient with a suspected myocardial infarction has elevated troponin levels. Troponin is a
biomarker for:
A. Myocardial necrosis
B. Ventricular strain
C. Pericardial inflammation
D. Coronary vasospasm
