NR 603 CEA Final Exam (2026) – Advanced Clinical Diagnosis|
Chamberlain| Complete A+ Study Guide with Evidence-Based Rationales
(Cardiovascular, Pulmonary, GI, Neurologic, Renal, Endocrine, Infectious
Disease, Musculoskeletal, Psychiatric, Hematology/Oncology, Dermatology,
Women’s Health, Geriatrics)
Section 1: Cardiovascular System (Questions 1–35)
1. A 58-year-old male presents with substernal chest pressure that started 2 hours
ago while walking. The pain radiates to his left arm and is associated with
diaphoresis and nausea. His blood pressure is 150/90 mmHg, heart rate 102 bpm.
What is the most appropriate initial diagnostic test?
A. Chest X-ray
B. 12-lead ECG
C. Cardiac troponin
D. Stress echocardiogram
Answer: B. 12-lead ECG
Rationale: For any patient presenting with symptoms suggestive of acute
coronary syndrome (ACS), a 12-lead ECG should be obtained within 10 minutes of
arrival. The ECG can identify ST-elevation myocardial infarction (STEMI) requiring
immediate reperfusion therapy. While troponin is important, the ECG provides
immediate actionable information.
2. A 12-lead ECG shows ST-segment elevation in leads II, III, and aVF. Which
coronary artery is most likely occluded?
A. Left anterior descending artery
B. Left circumflex artery
C. Right coronary artery
D. Left main coronary artery
Answer: C. Right coronary artery
Rationale: Inferior wall myocardial infarction (ST elevation in leads II, III, aVF) is
typically caused by occlusion of the right coronary artery (RCA). The RCA supplies
the inferior wall of the left ventricle and the right ventricle.
,3. A 72-year-old female with history of hypertension presents with acute onset of
severe “tearing” chest pain radiating to her back. Blood pressure is 100/60 mmHg
in the right arm and 140/80 mmHg in the left arm. What is the most likely
diagnosis?
A. Acute myocardial infarction
B. Pulmonary embolism
C. Aortic dissection
D. Pericarditis
Answer: C. Aortic dissection
Rationale: The classic presentation of aortic dissection includes sudden, severe
“tearing” chest pain radiating to the back, along with asymmetric blood pressures
between arms. Urgent aortic imaging (CT angiography) is needed.
4. Which murmur is best heard at the left sternal border with radiation to the
carotids and increases with squatting?
A. Mitral stenosis
B. Aortic stenosis
C. Hypertrophic cardiomyopathy
D. Mitral regurgitation
Answer: B. Aortic stenosis
Rationale: Aortic stenosis typically produces a harsh crescendo-decrescendo
murmur at the right second intercostal space or left sternal border, radiating to
the carotids. Squatting increases preload, which can intensify the murmur of
aortic stenosis (though in hypertrophic cardiomyopathy it decreases). However,
classic radiation to carotids points to aortic stenosis.
5. A 45-year-old with no prior cardiac history presents with palpitations. ECG
shows a regular, narrow-complex tachycardia at 180 bpm with no visible P waves.
Which medication is first-line for acute termination in a hemodynamically stable
patient?
A. Amiodarone IV
B. Adenosine IV
C. Lidocaine IV
D. Digoxin orally
,Answer: B. Adenosine IV
Rationale: Adenosine is the drug of choice for terminating stable supraventricular
tachycardia (SVT) due to re-entrant mechanisms (e.g., AV nodal reentry). It slows
AV nodal conduction and can interrupt the reentry circuit.
6. A patient with heart failure with reduced ejection fraction (HFrEF) is on
lisinopril, metoprolol, and furosemide. His ejection fraction is 35%. Which
additional medication has been shown to reduce mortality in this population?
A. Spironolactone
B. Hydralazine
C. Diltiazem
D. Digoxin
Answer: A. Spironolactone
Rationale: Mineralocorticoid receptor antagonists (e.g., spironolactone,
eplerenone) reduce mortality and hospitalizations in patients with HFrEF (NYHA
class II-IV) when added to standard therapy with ACE inhibitors and beta-blockers.
7. A 68-year-old with diabetes and hypertension has a blood pressure of 155/92
mmHg. His LDL is 130 mg/dL. According to the ACC/AHA guidelines, what is his
recommended statin intensity?
A. Low-intensity statin
B. Moderate-intensity statin
C. High-intensity statin
D. No statin needed
Answer: C. High-intensity statin
Rationale: Patients with diabetes and hypertension who have an LDL ≥70 mg/dL
or clinical ASCVD risk factors should be on high-intensity statin therapy
(atorvastatin 40-80 mg or rosuvastatin 20-40 mg) for primary prevention if their
10-year risk is ≥7.5% (this patient likely meets criteria).
8. An ECG shows a prolonged PR interval (>200 ms) with a normal QRS duration.
What is the most likely diagnosis?
A. First-degree AV block
B. Second-degree AV block Mobitz I
C. Second-degree AV block Mobitz II
D. Third-degree AV block
, Answer: A. First-degree AV block
Rationale: First-degree AV block is defined by a PR interval >200 ms (5 small
boxes) with each P wave followed by a QRS. It is usually benign and does not
require treatment unless symptomatic.
9. A 55-year-old presents with chest pain that is positional, worse when lying flat,
and improves when leaning forward. He had a viral illness 2 weeks ago. What
physical exam finding is most specific?
A. S3 gallop
B. Pericardial friction rub
C. Jugular venous distension
D. Crackles in lung bases
Answer: B. Pericardial friction rub
Rationale: Acute pericarditis often presents with pleuritic, positional chest pain
(worse supine, better leaning forward). A pericardial friction rub is a
pathognomonic finding, though it may be transient. The history of recent viral
illness supports this diagnosis.
10. Which ECG finding is most consistent with acute pericarditis?
A. ST-segment depression in V1-V4
B. Diffuse concave (saddle-shaped) ST elevation
C. Q waves in leads II, III, aVF
D. PR segment elevation only
Answer: B. Diffuse concave (saddle-shaped) ST elevation
Rationale: Classic ECG changes in acute pericarditis include diffuse concave
upward ST-segment elevation (saddle-shaped) in multiple leads, often with PR
segment depression. The changes evolve over time.
11. A 70-year-old male with chronic kidney disease (stage 4) presents with
dyspnea and fatigue. His heart rate is 48 bpm, BP 100/70. ECG shows a regular
bradycardia with no P waves and a wide QRS at 42 bpm. What is the rhythm?
A. Atrial fibrillation with slow ventricular response
B. Junctional rhythm
C. Idioventricular rhythm
D. Complete heart block (third-degree AV block) with a wide escape rhythm
Chamberlain| Complete A+ Study Guide with Evidence-Based Rationales
(Cardiovascular, Pulmonary, GI, Neurologic, Renal, Endocrine, Infectious
Disease, Musculoskeletal, Psychiatric, Hematology/Oncology, Dermatology,
Women’s Health, Geriatrics)
Section 1: Cardiovascular System (Questions 1–35)
1. A 58-year-old male presents with substernal chest pressure that started 2 hours
ago while walking. The pain radiates to his left arm and is associated with
diaphoresis and nausea. His blood pressure is 150/90 mmHg, heart rate 102 bpm.
What is the most appropriate initial diagnostic test?
A. Chest X-ray
B. 12-lead ECG
C. Cardiac troponin
D. Stress echocardiogram
Answer: B. 12-lead ECG
Rationale: For any patient presenting with symptoms suggestive of acute
coronary syndrome (ACS), a 12-lead ECG should be obtained within 10 minutes of
arrival. The ECG can identify ST-elevation myocardial infarction (STEMI) requiring
immediate reperfusion therapy. While troponin is important, the ECG provides
immediate actionable information.
2. A 12-lead ECG shows ST-segment elevation in leads II, III, and aVF. Which
coronary artery is most likely occluded?
A. Left anterior descending artery
B. Left circumflex artery
C. Right coronary artery
D. Left main coronary artery
Answer: C. Right coronary artery
Rationale: Inferior wall myocardial infarction (ST elevation in leads II, III, aVF) is
typically caused by occlusion of the right coronary artery (RCA). The RCA supplies
the inferior wall of the left ventricle and the right ventricle.
,3. A 72-year-old female with history of hypertension presents with acute onset of
severe “tearing” chest pain radiating to her back. Blood pressure is 100/60 mmHg
in the right arm and 140/80 mmHg in the left arm. What is the most likely
diagnosis?
A. Acute myocardial infarction
B. Pulmonary embolism
C. Aortic dissection
D. Pericarditis
Answer: C. Aortic dissection
Rationale: The classic presentation of aortic dissection includes sudden, severe
“tearing” chest pain radiating to the back, along with asymmetric blood pressures
between arms. Urgent aortic imaging (CT angiography) is needed.
4. Which murmur is best heard at the left sternal border with radiation to the
carotids and increases with squatting?
A. Mitral stenosis
B. Aortic stenosis
C. Hypertrophic cardiomyopathy
D. Mitral regurgitation
Answer: B. Aortic stenosis
Rationale: Aortic stenosis typically produces a harsh crescendo-decrescendo
murmur at the right second intercostal space or left sternal border, radiating to
the carotids. Squatting increases preload, which can intensify the murmur of
aortic stenosis (though in hypertrophic cardiomyopathy it decreases). However,
classic radiation to carotids points to aortic stenosis.
5. A 45-year-old with no prior cardiac history presents with palpitations. ECG
shows a regular, narrow-complex tachycardia at 180 bpm with no visible P waves.
Which medication is first-line for acute termination in a hemodynamically stable
patient?
A. Amiodarone IV
B. Adenosine IV
C. Lidocaine IV
D. Digoxin orally
,Answer: B. Adenosine IV
Rationale: Adenosine is the drug of choice for terminating stable supraventricular
tachycardia (SVT) due to re-entrant mechanisms (e.g., AV nodal reentry). It slows
AV nodal conduction and can interrupt the reentry circuit.
6. A patient with heart failure with reduced ejection fraction (HFrEF) is on
lisinopril, metoprolol, and furosemide. His ejection fraction is 35%. Which
additional medication has been shown to reduce mortality in this population?
A. Spironolactone
B. Hydralazine
C. Diltiazem
D. Digoxin
Answer: A. Spironolactone
Rationale: Mineralocorticoid receptor antagonists (e.g., spironolactone,
eplerenone) reduce mortality and hospitalizations in patients with HFrEF (NYHA
class II-IV) when added to standard therapy with ACE inhibitors and beta-blockers.
7. A 68-year-old with diabetes and hypertension has a blood pressure of 155/92
mmHg. His LDL is 130 mg/dL. According to the ACC/AHA guidelines, what is his
recommended statin intensity?
A. Low-intensity statin
B. Moderate-intensity statin
C. High-intensity statin
D. No statin needed
Answer: C. High-intensity statin
Rationale: Patients with diabetes and hypertension who have an LDL ≥70 mg/dL
or clinical ASCVD risk factors should be on high-intensity statin therapy
(atorvastatin 40-80 mg or rosuvastatin 20-40 mg) for primary prevention if their
10-year risk is ≥7.5% (this patient likely meets criteria).
8. An ECG shows a prolonged PR interval (>200 ms) with a normal QRS duration.
What is the most likely diagnosis?
A. First-degree AV block
B. Second-degree AV block Mobitz I
C. Second-degree AV block Mobitz II
D. Third-degree AV block
, Answer: A. First-degree AV block
Rationale: First-degree AV block is defined by a PR interval >200 ms (5 small
boxes) with each P wave followed by a QRS. It is usually benign and does not
require treatment unless symptomatic.
9. A 55-year-old presents with chest pain that is positional, worse when lying flat,
and improves when leaning forward. He had a viral illness 2 weeks ago. What
physical exam finding is most specific?
A. S3 gallop
B. Pericardial friction rub
C. Jugular venous distension
D. Crackles in lung bases
Answer: B. Pericardial friction rub
Rationale: Acute pericarditis often presents with pleuritic, positional chest pain
(worse supine, better leaning forward). A pericardial friction rub is a
pathognomonic finding, though it may be transient. The history of recent viral
illness supports this diagnosis.
10. Which ECG finding is most consistent with acute pericarditis?
A. ST-segment depression in V1-V4
B. Diffuse concave (saddle-shaped) ST elevation
C. Q waves in leads II, III, aVF
D. PR segment elevation only
Answer: B. Diffuse concave (saddle-shaped) ST elevation
Rationale: Classic ECG changes in acute pericarditis include diffuse concave
upward ST-segment elevation (saddle-shaped) in multiple leads, often with PR
segment depression. The changes evolve over time.
11. A 70-year-old male with chronic kidney disease (stage 4) presents with
dyspnea and fatigue. His heart rate is 48 bpm, BP 100/70. ECG shows a regular
bradycardia with no P waves and a wide QRS at 42 bpm. What is the rhythm?
A. Atrial fibrillation with slow ventricular response
B. Junctional rhythm
C. Idioventricular rhythm
D. Complete heart block (third-degree AV block) with a wide escape rhythm
