NR 569 Midterm Exam - Differential Diagnosis in Acute Care - 2026/2027 Chamberlain University - 100% Correct | Grade A
Midterm Exam: NR569 / NR 569
Differential Diagnosis in Acute Care Practicum
Questions with Verified Answers | 100% Correct | Grade A
Latest 2026/2027 Update
Course NR 569 - Differential Diagnosis in Acute Care Practicum
Institution Chamberlain University Graduate Nursing Program
Exam Midterm Exam - Acute Care Differential Diagnosis
Update Latest 2026/2027 Update
Total Questions 150 Multiple Choice (4 options, single best answer)
Cognitive Levels 25% Recall / 55% Application / 20% Analysis
Question Style 85% Scenario-based / 15% Direct recall of diagnostic criteria and guidelines
Format Questions with Verified Answers | 100% Correct | Grade A
Sections 9 sections covering all acute care practicum competencies
Guidelines Surviving Sepsis 2021, AHA/ACC 2023, GOLD 2024, ATLS 2024, NCS, IDSA
Examination Purpose: This 150-question comprehensive midterm exam prepares graduate nursing students for NR 569
Differential Diagnosis in Acute Care Practicum at Chamberlain University. Each question includes verified rationales
reflecting graduate-level acute care clinical reasoning, time-sensitive diagnostic prioritization, urgency assessment, and
2026/2027 evidence-based acute care guidelines (Surviving Sepsis 2021, AHA/ACC 2023, GOLD 2024, ATLS 2024,
Neurocritical Care Society, IDSA). Scenario-based questions reflect real acute care practitioner decision-making, including
rapid assessment, shock state differentiation, lethal dysrhythmia recognition, stroke and time-critical intervention
windows, toxicology emergencies, and interprofessional escalation. Distractors represent common acute care
practitioner pitfalls (delaying time-sensitive intervention, misdiagnosing stroke mimics, failing to recognize early septic
shock, misapplying sepsis bundle timing). Rationales double as study guide content with diagnostic rationale, urgency
thresholds, guideline references, and immediate priority actions.
Examination Sections:
# Section Title Question Range Count
1 Acute Care Clinical Reasoning and Rapid Diagnostic Strategy Q1 - Q16 16
2 Acute Cardiovascular Presentations Q17 - Q36 20
3 Acute Respiratory Presentations Q37 - Q54 18
4 Acute Neurologic Presentations Q55 - Q72 18
Latest 2026/2027 Update - Questions with Verified Answers Page 1
,NR 569 Midterm Exam - Differential Diagnosis in Acute Care - 2026/2027 Chamberlain University - 100% Correct | Grade A
5 Acute Endocrine and Metabolic Emergencies Q73 - Q89 17
6 Acute Gastrointestinal, Hepatic, and Renal Presentations Q90 - Q107 18
7 Sepsis, Shock, and Multisystem Critical Illness Q108 - Q123 16
8 Trauma, Toxicology, and Environmental Emergencies Q124 - Q137 14
9 Practicum Integration, Prioritization, and Escalation Q138 - Q150 13
Section 1: Acute Care Clinical Reasoning and Rapid Diagnostic Strategy
Hypothesis Generation, Differential Prioritization, Time-Sensitive Assessment, & Evidence-Based Practice - Q1-Q16
Q1: An acute care NP is evaluating a 58-year-old with acute onset chest pain. Which characteristic most strongly
suggests acute coronary syndrome (ACS) requiring immediate ECG and troponin?
A. Pleuritic pain that worsens with deep inspiration
B. Substernal pressure radiating to the left arm and jaw, with diaphoresis and dyspnea [CORRECT]
C. Sharp pain lasting 5 seconds, relieved by position change
D. Pain reproduced by palpation of the chest wall
Correct Answer: B
Rationale:
Classic ACS presentation is substernal pressure (often described as 'crushing' or 'squeezing') radiating to the left arm, jaw, or
back, with associated diaphoresis, dyspnea, nausea, or lightheadedness. The 2024 AHA/ACC chest pain guideline ranks these
symptoms as 'most predictive' of ACS. Pleuritic, positional, or reproducible pain is less likely cardiac but does not exclude ACS —
the NP must obtain a 12-lead ECG within 10 minutes and high-sensitivity troponin. Time-sensitive assessment is critical because
reperfusion timing (PCI within 90 minutes, thrombolytics within 30 minutes for STEMI) determines outcomes. The NP should
not anchor on atypical features without objective cardiac testing.
Q2: A 72-year-old presents with dyspnea, bilateral crackles, and an S3 gallop. BNP is 1,200 pg/mL. Which
additional finding most strongly differentiates acute decompensated heart failure (ADHF) from non-cardiogenic
causes of dyspnea?
A. Pulse oximetry 90% on room air
B. Elevated jugular venous pressure (JVP) and an S3 gallop on auscultation [CORRECT]
C. White blood cell count 12,000/mm3
D. Respiratory rate 24
Correct Answer: B
Rationale:
Framingham criteria for heart failure diagnosis require 2 major or 1 major + 2 minor criteria. Major criteria include JVD, S3
gallop, acute pulmonary edema, cardiomegaly, and hepatojugular reflux. The S3 gallop is highly specific for systolic dysfunction
and elevated LV end-diastolic pressure. BNP >500 pg/mL strongly supports HF (BNP <100 excludes HF in most cases). While
hypoxemia and tachypnea occur in both cardiac and non-cardiac dyspnea, JVD and S3 are specific to ADHF. Lung ultrasound
(B-lines) and POCUS showing reduced LV function or E/e' ratio elevation further differentiate. The NP should assess volume
status, identify triggers (ischemia, dysrhythmia, non-adherence), and initiate IV loop diuretic therapy per ADHF guidelines.
Q3: A 60-year-old presents with acute tearing chest pain radiating to the back, BP 180/110 in the right arm and
90/60 in the left arm, and a widened mediastinum on chest X-ray. What is the IMMEDIATE priority action?
Latest 2026/2027 Update - Questions with Verified Answers Page 2
,NR 569 Midterm Exam - Differential Diagnosis in Acute Care - 2026/2027 Chamberlain University - 100% Correct | Grade A
A. Administer aspirin 325 mg and arrange for cardiac catheterization
B. Activate the aortic emergency team, obtain STAT CT angiogram of the chest/abdomen, and initiate IV
beta-blocker to control heart rate and BP [CORRECT]
C. Start a heparin drip for suspected pulmonary embolism
D. Administer nitroglycerin sublingual and repeat BP in 30 minutes
Correct Answer: B
Rationale:
This presentation is classic for acute aortic dissection (tearing pain, BP differential >20 mmHg between arms, widened
mediastinum). The 2022 ACC/AHA thoracic aortic disease guideline mandates immediate CTA for suspected dissection. Initial
management focuses on heart rate control (target HR <60-80) with IV beta-blocker (esmolol, labetalol) BEFORE vasodilator
therapy (nicardipine, nitroprusside), because vasodilation without rate control can worsen the dissection due to reflex
tachycardia. Aspirin, heparin, and nitroglycerin are inappropriate and may worsen outcomes. Time-to-diagnosis and
time-to-surgical consultation for Type A dissection is critical — surgical repair within 24 hours reduces mortality. The NP should
immediately notify cardiothoracic surgery.
Q4: A 68-year-old with septic shock has BP 78/40 after 30 mL/kg crystalloid, lactate 5.2 mmol/L, and mottled
extremities. Per Surviving Sepsis 2021 guidelines, what is the IMMEDIATE priority action?
A. Continue crystalloid at 200 mL/hr and recheck BP in 1 hour
B. Initiate norepinephrine infusion titrated to MAP >=65 mmHg without further delay [CORRECT]
C. Administer hydrocortisone 200 mg IV immediately
D. Place central line and re-assess after 4 hours
Correct Answer: B
Rationale:
Per the 2021 Surviving Sepsis Campaign (SSC) guidelines, adult patients with septic shock (defined as requiring vasopressors to
maintain MAP >=65 AND lactate >2 mmol/L after adequate fluid resuscitation) should receive norepinephrine as the first-line
vasopressor without delay. Norepinephrine is preferred over dopamine (higher arrhythmia risk) and phenylephrine (lacks
inotropy). The guidelines suggest initiating vasopressors EARLY — even during fluid resuscitation — if BP remains critically low,
rather than waiting for completion of fluid bolus. Early vasopressor initiation improves outcomes and prevents prolonged
hypoperfusion. Hydrocortisone 200 mg/day is suggested for shock refractory to fluids and vasopressors (not first-line). The SSC
1-hour bundle includes lactate, blood cultures, antibiotics, 30 mL/kg crystalloid, and vasopressors for hypotension.
Q5: An NP evaluates a 65-year-old with acute substernal chest pain. The 12-lead ECG shows ST elevation in II, III,
and aVF with reciprocal ST depression in I and aVL. What is the anatomic location of the infarction and the
IMMEDIATE priority?
A. Anterior wall; administer aspirin and arrange PCI
B. Inferior wall MI; assess for right ventricular involvement (obtain right-sided ECG V4R), withhold nitrates if RV
infarct suspected, and activate cath lab [CORRECT]
C. Lateral wall MI; administer nitroglycerin and morphine
D. Posterior wall MI; administer beta-blocker and observe
Correct Answer: B
Rationale:
ST elevation in II, III, aVF indicates inferior wall MI (RCA occlusion). Right ventricular infarction complicates 30-50% of inferior
MIs and is identified by ST elevation in V4R. RV infarction is preload-dependent — nitrates can cause profound hypotension due
to venodilation in patients with reduced RV filling. The NP should obtain right-sided ECG, avoid nitrates if RV infarct suspected
(treat hypotension with IV fluids), administer aspirin 325 mg, administer P2Y12 inhibitor, and activate the cath lab for primary
PCI (goal door-to-balloon <90 minutes). Time is muscle — every 30-minute delay in reperfusion increases 1-year mortality by
7.5%. The NP should also assess for bradycardia/AV block (RCA supplies SA and AV nodes).
Latest 2026/2027 Update - Questions with Verified Answers Page 3
, NR 569 Midterm Exam - Differential Diagnosis in Acute Care - 2026/2027 Chamberlain University - 100% Correct | Grade A
Q6: A 55-year-old male presents with crushing chest pain for 1 hour. ECG shows 2 mm ST elevation in V1-V4.
Aspirin 325 mg has been given. The closest PCI center is 90 minutes away by ground. What is the BEST action per
AHA/ACC STEMI guidelines?
A. Administer clopidogrel and transfer for PCI regardless of time
B. Administer fibrinolytic therapy (tenecteplase) within 30 minutes of arrival (door-to-needle time) if no
contraindications, then transfer for PCI [CORRECT]
C. Continue monitoring and arrange elective PCI the next day
D. Administer beta-blocker and nitroglycerin, then discharge home
Correct Answer: B
Rationale:
Per 2022 AHA/ACC STEMI guideline, if first medical contact-to-device time at a PCI center cannot be achieved within 120
minutes, fibrinolytic therapy should be administered within 30 minutes of arrival (door-to-needle). Anterior STEMI, large infarct
size, and short symptom duration (<12 hours) favor fibrinolytic benefit. Tenecteplase is preferred (single bolus, fibrin-specific).
Contraindications: prior hemorrhagic stroke, ischemic stroke within 6 months, intracranial neoplasm, active bleeding,
suspected aortic dissection. After fibrinolytics, transfer for PCI within 3-24 hours (pharmacoinvasive strategy). The NP should
administer dual antiplatelet (aspirin + ticagrelor/clopidogrel), anticoagulant (heparin/enoxaparin), and high-intensity statin. PCI
within 90 minutes (door-to-balloon) is preferred when achievable.
Q7: A 48-year-old female with history of migraine presents with the 'worst headache of her life' that reached
maximum intensity within 1 minute. Exam shows nuchal rigidity. What is the PRIORITY diagnostic study?
A. Outpatient MRI brain in 24 hours
B. Non-contrast head CT immediately (suspected subarachnoid hemorrhage from ruptured aneurysm) [CORRECT]
C. Lumbar puncture without CT
D. Carotid ultrasound
Correct Answer: B
Rationale:
Thunderclap headache (maximum intensity within 1 minute) is classic for subarachnoid hemorrhage (SAH) from ruptured
aneurysm until proven otherwise. Mortality is 30-50%, and rebleeding risk is highest in the first 24 hours. The 2023 AHA SAH
guideline recommends non-contrast head CT immediately, which has >95% sensitivity within 6 hours. If CT is negative but
suspicion remains, lumbar puncture (looking for xanthochromia and RBCs) should be performed. CTA is used to identify the
aneurysm once SAH is confirmed. Outpatient MRI, LP without CT (risk of herniation if increased ICP), and carotid ultrasound are
inappropriate. The NP should also assess for altered mental status, focal deficits, and seizure activity. Time-sensitive diagnosis
enables neurosurgical intervention (clipping or coiling).
Q8: A 70-year-old presents with acute onset right-sided weakness and slurred speech that began 90 minutes ago.
NIHSS is 8. BP is 190/100. What is the IMMEDIATE priority action?
A. Lower BP to 120/80 with IV labetalol
B. Obtain STAT non-contrast head CT to rule out hemorrhage, then determine eligibility for IV thrombolytics (tPA
window 4.5 hours) and mechanical thrombectomy (window up to 24 hours for large vessel occlusion) [CORRECT]
C. Administer aspirin 325 mg immediately
D. Transfer to rehab facility
Correct Answer: B
Rationale:
Acute neurologic deficit = stroke until proven otherwise. The AHA/ASA 2019 acute ischemic stroke guideline mandates
immediate non-contrast head CT to differentiate ischemic from hemorrhagic stroke (CT is highly sensitive for blood). IV
thrombolytics (alteplase or tenecteplase) within 4.5 hours of symptom onset improve outcomes — every minute of delay loses
1.9 million neurons. Mechanical thrombectomy is indicated for large vessel occlusion (LVO) within 6 hours, extended to 24
hours with favorable imaging (DAWN/DEFUSE 3 criteria). BP must be <185/110 before tPA (labetalol or nicardipine). Aspirin is
Latest 2026/2027 Update - Questions with Verified Answers Page 4
Midterm Exam: NR569 / NR 569
Differential Diagnosis in Acute Care Practicum
Questions with Verified Answers | 100% Correct | Grade A
Latest 2026/2027 Update
Course NR 569 - Differential Diagnosis in Acute Care Practicum
Institution Chamberlain University Graduate Nursing Program
Exam Midterm Exam - Acute Care Differential Diagnosis
Update Latest 2026/2027 Update
Total Questions 150 Multiple Choice (4 options, single best answer)
Cognitive Levels 25% Recall / 55% Application / 20% Analysis
Question Style 85% Scenario-based / 15% Direct recall of diagnostic criteria and guidelines
Format Questions with Verified Answers | 100% Correct | Grade A
Sections 9 sections covering all acute care practicum competencies
Guidelines Surviving Sepsis 2021, AHA/ACC 2023, GOLD 2024, ATLS 2024, NCS, IDSA
Examination Purpose: This 150-question comprehensive midterm exam prepares graduate nursing students for NR 569
Differential Diagnosis in Acute Care Practicum at Chamberlain University. Each question includes verified rationales
reflecting graduate-level acute care clinical reasoning, time-sensitive diagnostic prioritization, urgency assessment, and
2026/2027 evidence-based acute care guidelines (Surviving Sepsis 2021, AHA/ACC 2023, GOLD 2024, ATLS 2024,
Neurocritical Care Society, IDSA). Scenario-based questions reflect real acute care practitioner decision-making, including
rapid assessment, shock state differentiation, lethal dysrhythmia recognition, stroke and time-critical intervention
windows, toxicology emergencies, and interprofessional escalation. Distractors represent common acute care
practitioner pitfalls (delaying time-sensitive intervention, misdiagnosing stroke mimics, failing to recognize early septic
shock, misapplying sepsis bundle timing). Rationales double as study guide content with diagnostic rationale, urgency
thresholds, guideline references, and immediate priority actions.
Examination Sections:
# Section Title Question Range Count
1 Acute Care Clinical Reasoning and Rapid Diagnostic Strategy Q1 - Q16 16
2 Acute Cardiovascular Presentations Q17 - Q36 20
3 Acute Respiratory Presentations Q37 - Q54 18
4 Acute Neurologic Presentations Q55 - Q72 18
Latest 2026/2027 Update - Questions with Verified Answers Page 1
,NR 569 Midterm Exam - Differential Diagnosis in Acute Care - 2026/2027 Chamberlain University - 100% Correct | Grade A
5 Acute Endocrine and Metabolic Emergencies Q73 - Q89 17
6 Acute Gastrointestinal, Hepatic, and Renal Presentations Q90 - Q107 18
7 Sepsis, Shock, and Multisystem Critical Illness Q108 - Q123 16
8 Trauma, Toxicology, and Environmental Emergencies Q124 - Q137 14
9 Practicum Integration, Prioritization, and Escalation Q138 - Q150 13
Section 1: Acute Care Clinical Reasoning and Rapid Diagnostic Strategy
Hypothesis Generation, Differential Prioritization, Time-Sensitive Assessment, & Evidence-Based Practice - Q1-Q16
Q1: An acute care NP is evaluating a 58-year-old with acute onset chest pain. Which characteristic most strongly
suggests acute coronary syndrome (ACS) requiring immediate ECG and troponin?
A. Pleuritic pain that worsens with deep inspiration
B. Substernal pressure radiating to the left arm and jaw, with diaphoresis and dyspnea [CORRECT]
C. Sharp pain lasting 5 seconds, relieved by position change
D. Pain reproduced by palpation of the chest wall
Correct Answer: B
Rationale:
Classic ACS presentation is substernal pressure (often described as 'crushing' or 'squeezing') radiating to the left arm, jaw, or
back, with associated diaphoresis, dyspnea, nausea, or lightheadedness. The 2024 AHA/ACC chest pain guideline ranks these
symptoms as 'most predictive' of ACS. Pleuritic, positional, or reproducible pain is less likely cardiac but does not exclude ACS —
the NP must obtain a 12-lead ECG within 10 minutes and high-sensitivity troponin. Time-sensitive assessment is critical because
reperfusion timing (PCI within 90 minutes, thrombolytics within 30 minutes for STEMI) determines outcomes. The NP should
not anchor on atypical features without objective cardiac testing.
Q2: A 72-year-old presents with dyspnea, bilateral crackles, and an S3 gallop. BNP is 1,200 pg/mL. Which
additional finding most strongly differentiates acute decompensated heart failure (ADHF) from non-cardiogenic
causes of dyspnea?
A. Pulse oximetry 90% on room air
B. Elevated jugular venous pressure (JVP) and an S3 gallop on auscultation [CORRECT]
C. White blood cell count 12,000/mm3
D. Respiratory rate 24
Correct Answer: B
Rationale:
Framingham criteria for heart failure diagnosis require 2 major or 1 major + 2 minor criteria. Major criteria include JVD, S3
gallop, acute pulmonary edema, cardiomegaly, and hepatojugular reflux. The S3 gallop is highly specific for systolic dysfunction
and elevated LV end-diastolic pressure. BNP >500 pg/mL strongly supports HF (BNP <100 excludes HF in most cases). While
hypoxemia and tachypnea occur in both cardiac and non-cardiac dyspnea, JVD and S3 are specific to ADHF. Lung ultrasound
(B-lines) and POCUS showing reduced LV function or E/e' ratio elevation further differentiate. The NP should assess volume
status, identify triggers (ischemia, dysrhythmia, non-adherence), and initiate IV loop diuretic therapy per ADHF guidelines.
Q3: A 60-year-old presents with acute tearing chest pain radiating to the back, BP 180/110 in the right arm and
90/60 in the left arm, and a widened mediastinum on chest X-ray. What is the IMMEDIATE priority action?
Latest 2026/2027 Update - Questions with Verified Answers Page 2
,NR 569 Midterm Exam - Differential Diagnosis in Acute Care - 2026/2027 Chamberlain University - 100% Correct | Grade A
A. Administer aspirin 325 mg and arrange for cardiac catheterization
B. Activate the aortic emergency team, obtain STAT CT angiogram of the chest/abdomen, and initiate IV
beta-blocker to control heart rate and BP [CORRECT]
C. Start a heparin drip for suspected pulmonary embolism
D. Administer nitroglycerin sublingual and repeat BP in 30 minutes
Correct Answer: B
Rationale:
This presentation is classic for acute aortic dissection (tearing pain, BP differential >20 mmHg between arms, widened
mediastinum). The 2022 ACC/AHA thoracic aortic disease guideline mandates immediate CTA for suspected dissection. Initial
management focuses on heart rate control (target HR <60-80) with IV beta-blocker (esmolol, labetalol) BEFORE vasodilator
therapy (nicardipine, nitroprusside), because vasodilation without rate control can worsen the dissection due to reflex
tachycardia. Aspirin, heparin, and nitroglycerin are inappropriate and may worsen outcomes. Time-to-diagnosis and
time-to-surgical consultation for Type A dissection is critical — surgical repair within 24 hours reduces mortality. The NP should
immediately notify cardiothoracic surgery.
Q4: A 68-year-old with septic shock has BP 78/40 after 30 mL/kg crystalloid, lactate 5.2 mmol/L, and mottled
extremities. Per Surviving Sepsis 2021 guidelines, what is the IMMEDIATE priority action?
A. Continue crystalloid at 200 mL/hr and recheck BP in 1 hour
B. Initiate norepinephrine infusion titrated to MAP >=65 mmHg without further delay [CORRECT]
C. Administer hydrocortisone 200 mg IV immediately
D. Place central line and re-assess after 4 hours
Correct Answer: B
Rationale:
Per the 2021 Surviving Sepsis Campaign (SSC) guidelines, adult patients with septic shock (defined as requiring vasopressors to
maintain MAP >=65 AND lactate >2 mmol/L after adequate fluid resuscitation) should receive norepinephrine as the first-line
vasopressor without delay. Norepinephrine is preferred over dopamine (higher arrhythmia risk) and phenylephrine (lacks
inotropy). The guidelines suggest initiating vasopressors EARLY — even during fluid resuscitation — if BP remains critically low,
rather than waiting for completion of fluid bolus. Early vasopressor initiation improves outcomes and prevents prolonged
hypoperfusion. Hydrocortisone 200 mg/day is suggested for shock refractory to fluids and vasopressors (not first-line). The SSC
1-hour bundle includes lactate, blood cultures, antibiotics, 30 mL/kg crystalloid, and vasopressors for hypotension.
Q5: An NP evaluates a 65-year-old with acute substernal chest pain. The 12-lead ECG shows ST elevation in II, III,
and aVF with reciprocal ST depression in I and aVL. What is the anatomic location of the infarction and the
IMMEDIATE priority?
A. Anterior wall; administer aspirin and arrange PCI
B. Inferior wall MI; assess for right ventricular involvement (obtain right-sided ECG V4R), withhold nitrates if RV
infarct suspected, and activate cath lab [CORRECT]
C. Lateral wall MI; administer nitroglycerin and morphine
D. Posterior wall MI; administer beta-blocker and observe
Correct Answer: B
Rationale:
ST elevation in II, III, aVF indicates inferior wall MI (RCA occlusion). Right ventricular infarction complicates 30-50% of inferior
MIs and is identified by ST elevation in V4R. RV infarction is preload-dependent — nitrates can cause profound hypotension due
to venodilation in patients with reduced RV filling. The NP should obtain right-sided ECG, avoid nitrates if RV infarct suspected
(treat hypotension with IV fluids), administer aspirin 325 mg, administer P2Y12 inhibitor, and activate the cath lab for primary
PCI (goal door-to-balloon <90 minutes). Time is muscle — every 30-minute delay in reperfusion increases 1-year mortality by
7.5%. The NP should also assess for bradycardia/AV block (RCA supplies SA and AV nodes).
Latest 2026/2027 Update - Questions with Verified Answers Page 3
, NR 569 Midterm Exam - Differential Diagnosis in Acute Care - 2026/2027 Chamberlain University - 100% Correct | Grade A
Q6: A 55-year-old male presents with crushing chest pain for 1 hour. ECG shows 2 mm ST elevation in V1-V4.
Aspirin 325 mg has been given. The closest PCI center is 90 minutes away by ground. What is the BEST action per
AHA/ACC STEMI guidelines?
A. Administer clopidogrel and transfer for PCI regardless of time
B. Administer fibrinolytic therapy (tenecteplase) within 30 minutes of arrival (door-to-needle time) if no
contraindications, then transfer for PCI [CORRECT]
C. Continue monitoring and arrange elective PCI the next day
D. Administer beta-blocker and nitroglycerin, then discharge home
Correct Answer: B
Rationale:
Per 2022 AHA/ACC STEMI guideline, if first medical contact-to-device time at a PCI center cannot be achieved within 120
minutes, fibrinolytic therapy should be administered within 30 minutes of arrival (door-to-needle). Anterior STEMI, large infarct
size, and short symptom duration (<12 hours) favor fibrinolytic benefit. Tenecteplase is preferred (single bolus, fibrin-specific).
Contraindications: prior hemorrhagic stroke, ischemic stroke within 6 months, intracranial neoplasm, active bleeding,
suspected aortic dissection. After fibrinolytics, transfer for PCI within 3-24 hours (pharmacoinvasive strategy). The NP should
administer dual antiplatelet (aspirin + ticagrelor/clopidogrel), anticoagulant (heparin/enoxaparin), and high-intensity statin. PCI
within 90 minutes (door-to-balloon) is preferred when achievable.
Q7: A 48-year-old female with history of migraine presents with the 'worst headache of her life' that reached
maximum intensity within 1 minute. Exam shows nuchal rigidity. What is the PRIORITY diagnostic study?
A. Outpatient MRI brain in 24 hours
B. Non-contrast head CT immediately (suspected subarachnoid hemorrhage from ruptured aneurysm) [CORRECT]
C. Lumbar puncture without CT
D. Carotid ultrasound
Correct Answer: B
Rationale:
Thunderclap headache (maximum intensity within 1 minute) is classic for subarachnoid hemorrhage (SAH) from ruptured
aneurysm until proven otherwise. Mortality is 30-50%, and rebleeding risk is highest in the first 24 hours. The 2023 AHA SAH
guideline recommends non-contrast head CT immediately, which has >95% sensitivity within 6 hours. If CT is negative but
suspicion remains, lumbar puncture (looking for xanthochromia and RBCs) should be performed. CTA is used to identify the
aneurysm once SAH is confirmed. Outpatient MRI, LP without CT (risk of herniation if increased ICP), and carotid ultrasound are
inappropriate. The NP should also assess for altered mental status, focal deficits, and seizure activity. Time-sensitive diagnosis
enables neurosurgical intervention (clipping or coiling).
Q8: A 70-year-old presents with acute onset right-sided weakness and slurred speech that began 90 minutes ago.
NIHSS is 8. BP is 190/100. What is the IMMEDIATE priority action?
A. Lower BP to 120/80 with IV labetalol
B. Obtain STAT non-contrast head CT to rule out hemorrhage, then determine eligibility for IV thrombolytics (tPA
window 4.5 hours) and mechanical thrombectomy (window up to 24 hours for large vessel occlusion) [CORRECT]
C. Administer aspirin 325 mg immediately
D. Transfer to rehab facility
Correct Answer: B
Rationale:
Acute neurologic deficit = stroke until proven otherwise. The AHA/ASA 2019 acute ischemic stroke guideline mandates
immediate non-contrast head CT to differentiate ischemic from hemorrhagic stroke (CT is highly sensitive for blood). IV
thrombolytics (alteplase or tenecteplase) within 4.5 hours of symptom onset improve outcomes — every minute of delay loses
1.9 million neurons. Mechanical thrombectomy is indicated for large vessel occlusion (LVO) within 6 hours, extended to 24
hours with favorable imaging (DAWN/DEFUSE 3 criteria). BP must be <185/110 before tPA (labetalol or nicardipine). Aspirin is
Latest 2026/2027 Update - Questions with Verified Answers Page 4
