NR 509 APEA 3P EXAM WEEK 4 2025 LATEST
QUESTIONS AND GUARANTEED CORRECT
ANSWERS WITH RATIONALES ALREADY
GRADED A+.
A .73-year-old .retired .salesman .presents .to .the .Emergency .Department .complaining .of
chest .pain .that .started .about .2 .hours .ago. .Electrocardiogram, .cardiac .enzymes, .and
chest .x-ray .are .normal. .The .nurse .notes .that .his .blood .pressures .in .the .right .arm .are
significantly .lower .than .of .blood .pressures .in .his .left .arm. .Based .on .history .and .physical
examination, .which .of .the .following .will .most .likely .explain .his .signs .and .symptoms? . -
ANSWER- .a. .Dissecting .aortic .aneurysm
Rationale: .Patients .with .dissecting .aortic .aneurysms .typically .present .with .chest .pain,
many .times .described .as .a ."tearing" .type .pain. .They .are .usually .elderly, .and, .due .to .the
dissection .of .the .aorta, .asymmetric .pulses .in .blood .pressures .in .the .extremities .may .be
present. .Coarctation .of .the .aorta .can .also .cause .similar .symptoms; .however, .it .would .be
unlikely .due .to .the .patient's .age .as .this .is .a .congenital .defect. .MI, .PE, .and .pericarditis
are .also .common .causes .of .concerning .chest .pain; .however, .neither .typically .will .cause
asymmetric .blood .pressures .or .pulses .in .the .extremities.
A .19-year-old .carwash .attendant .sustained .a .laceration .to .the .ulnar .aspect .of .his .mid-
forearm .while .at .work .last .week. .He .did .not .have .it .evaluated .at .that .time .and .is .now
noticing .purulent .discharge .and .increasing .pain .from .the .wound .along .with .fever .and
chills. .Where .would .the .clinician .expect .to .find .the .first .signs .of .lymphadenopathy? . -
ANSWER- .a. .Epitrochlear .nodes
,Rationale: .The .epitrochlear .nodes .are .the .first .nodes .in .the .drainage .region .from .the
ulnar .surface .of .the .forearm .and .hand, .little .and .ring .fingers, .and .adjacent .surface .of .the
middle .finger. .Axillary .nodes, .infraclavicular .nodes, .and .cervical .chain .nodes .are .all
distal .to .this .area .and .may .show .evidence .of .lymphadenopathy .as .well; .however, .that
would .be .secondary .after .the .epitrochlear .nodes.
When .assessing .for .the .femoral .pulse, .where .should .the .clinician .begin .deeply
palpating? .- .ANSWER- .C. .Below .the .inguinal .ligament, .midway .between .the .anterior
superior .iliac .spine .and .symphysis .pubis
Rationale: .The .clinician .would .begin .deeply .palpating .below .the .inguinal .ligament,
midway .between .the .anterior .superior .iliac .spine .in .the .symphysis .pubis. .The .external
iliac .artery .transitions .into .the .femoral .artery .at .the .level .of .the .inguinal .ligament.
Therefore, .palpating .above .the .inguinal .ligament .would .be .assessing .the .external .iliac
artery. .The .femoral .artery .is .typically .located .midway .between .the .anterior .superior .iliac
spine .in .the .symphysis .pubis .in .most .patients.
The .clinician .is .palpating .pulses .in .the .foot .of .a .diabetic .patient .while .in .the .clinic. .A
strong .pulse .is .felt .located .on .the .dorsum .of .the .foot, .just .lateral .to .the .extensor .tendon
of .the .big .toe. .Which .artery .is .being .assessed? .- .ANSWER- .C. .Dorsalis .pedis
Rationale: .The .dorsalis .pedis .artery .is .usually .palpable .on .the .dorsum .of .the .foot .just
lateral .to .the .extensor .tendon .of .the .big .toe. .The .arterial .arch .of .the .foot .is .more .distal
and .runs .transversely .and .is .not .usually .palpable. .The .posterior .tibial .artery .is .found
,behind .the .medial .malleolus .of .the .ankle. .The .popliteal .and .femoral .pulses .are .found
more .proximally .at .the .knee .and .near .the .groin, .respectively.
A .68-year-old .retired .administrative .assistant .complains .of .a .3-month .history .of
recurring .pain .after .ambulating .that .radiates .from .her .back .in .the .upper .lumbar .region
into .both .buttocks, .bilateral .thighs, .and .mid-calf .regions. .Her .pain .is .typically .improved
by .sitting .or .by .leaning .forward. .The .origin .of .her .pain .is .likely .secondary .to .which .of .the
following? .- .ANSWER- .d. .Neurogenic .claudication
Rationale: .Neurogenic .claudication .can .mimic .PAD .by .causing .pain .related .to .walking;
however, .it .is .typically .relieved .simply .by .sitting .or .by .leaning .forward. .Many .patients
with .spinal .stenosis .of .the .lumbar .spine .have .pain .that .originates .in .the .spinal .region
and .radiates .into .the .areas .noted. .PAD .is .not .typically .relieved .just .by .sitting .alone .and
usually .will .take .some .time. .PAD .also .does .not .typically .improve .with .bending .over.
Acute .arterial .occlusion .does .not .cause .recurring .symptoms .and .is .not .usually .bilateral.
Abdominal .aortic .aneurysms .may .cause .similar .pain .as .well; .however, .they .typically .do
not .have .the .same .palliating .factors.
A .patient .that .has .a .known .history .of .cardiovascular .disease .including .a .myocardial
infarction .and .positive .ankle-brachial .index .indicating .peripheral .arterial .disease .in .his
left .leg .is .now .having .some .issues .with .erectile .dysfunction .(ED). .The .clinician .suspects
it .may .be .due .to .medications .or .further .vascular .disease. .He .does .not .complain .of .any
other .symptoms. .If .his .symptoms .are .related .to .vascular .disease, .where .would .the
lesion .likely .be .located? .- .ANSWER- .b. .Iliac .pudendal
, A .61-year-old .retired .librarian .was .recently .diagnosed .with .ovarian .cancer. .She .was
otherwise .healthy .until .her .recent .cancer .diagnosis. .She .has .not .been .feeling .well .lately
and .has .had .a .cough .and .some .mild .shortness .of .breath .for .the .past .couple .of .days.
She .now .presents .to .the .clinic .complaining .of .pain .and .swelling .in .her .right .groin .and
leg, .which .she .says .is .been .there .for .about .a .week .but .is .worsening. .On .physical
examination, .2+ .edema .of .the .right .leg .up .to .the .thigh; .1+ .femoral, .popliteal, .dorsalis
pedis, .and .posterior .tibial .pulses; .and .no .significant .erythema .are .noted. .What .is .the
chief .concern .with .this .patient? .- .ANSWER- .d. .Pulmonary .embolism .(PE)
Rationale: .Cancer .patients .are .at .high .risk .of .deep .venous .thrombosis .(DVT), .and, .with
the .presenting .symptoms .of .swelling .and .pain .in .her .groin, .along .with .recent .history .of
cough .and .shortness .of .breath, .this .patient's .presentation .is .suspicious .for .PE. .Patients
with .DVT .in .the .proximal .leg .veins .are .at .high .risk .of .thromboembolism. .Acute .arterial
occlusion .should .not .cause .significant .edema, .and .pulses .would .likely .be .absent. .The
constellation .of .symptoms .and .history .in .this .patient .also .does .not .suggest .an .acute
arterial .occlusion. .Superficial .thrombophlebitis .typically .only .causes .mild .local .swelling,
redness, .and .warmth .along .with .a .subcutaneous .cord. .Acute .lymphangitis .typically
presents .with .red .streaks .from .an .infection .passing .through .lymph .channels.
A .32-year-old .cabdriver .complains .of .pain .in .his .left .leg. .He .has .a .history .of .type .2
diabetes, .is .a .smoker, .and .recently .was .diagnosed .with .hypertension. .He .does .not
remember .injuring .his .leg; .however, .he .notes .that .there .is .a .small .wound .on .the .lateral
QUESTIONS AND GUARANTEED CORRECT
ANSWERS WITH RATIONALES ALREADY
GRADED A+.
A .73-year-old .retired .salesman .presents .to .the .Emergency .Department .complaining .of
chest .pain .that .started .about .2 .hours .ago. .Electrocardiogram, .cardiac .enzymes, .and
chest .x-ray .are .normal. .The .nurse .notes .that .his .blood .pressures .in .the .right .arm .are
significantly .lower .than .of .blood .pressures .in .his .left .arm. .Based .on .history .and .physical
examination, .which .of .the .following .will .most .likely .explain .his .signs .and .symptoms? . -
ANSWER- .a. .Dissecting .aortic .aneurysm
Rationale: .Patients .with .dissecting .aortic .aneurysms .typically .present .with .chest .pain,
many .times .described .as .a ."tearing" .type .pain. .They .are .usually .elderly, .and, .due .to .the
dissection .of .the .aorta, .asymmetric .pulses .in .blood .pressures .in .the .extremities .may .be
present. .Coarctation .of .the .aorta .can .also .cause .similar .symptoms; .however, .it .would .be
unlikely .due .to .the .patient's .age .as .this .is .a .congenital .defect. .MI, .PE, .and .pericarditis
are .also .common .causes .of .concerning .chest .pain; .however, .neither .typically .will .cause
asymmetric .blood .pressures .or .pulses .in .the .extremities.
A .19-year-old .carwash .attendant .sustained .a .laceration .to .the .ulnar .aspect .of .his .mid-
forearm .while .at .work .last .week. .He .did .not .have .it .evaluated .at .that .time .and .is .now
noticing .purulent .discharge .and .increasing .pain .from .the .wound .along .with .fever .and
chills. .Where .would .the .clinician .expect .to .find .the .first .signs .of .lymphadenopathy? . -
ANSWER- .a. .Epitrochlear .nodes
,Rationale: .The .epitrochlear .nodes .are .the .first .nodes .in .the .drainage .region .from .the
ulnar .surface .of .the .forearm .and .hand, .little .and .ring .fingers, .and .adjacent .surface .of .the
middle .finger. .Axillary .nodes, .infraclavicular .nodes, .and .cervical .chain .nodes .are .all
distal .to .this .area .and .may .show .evidence .of .lymphadenopathy .as .well; .however, .that
would .be .secondary .after .the .epitrochlear .nodes.
When .assessing .for .the .femoral .pulse, .where .should .the .clinician .begin .deeply
palpating? .- .ANSWER- .C. .Below .the .inguinal .ligament, .midway .between .the .anterior
superior .iliac .spine .and .symphysis .pubis
Rationale: .The .clinician .would .begin .deeply .palpating .below .the .inguinal .ligament,
midway .between .the .anterior .superior .iliac .spine .in .the .symphysis .pubis. .The .external
iliac .artery .transitions .into .the .femoral .artery .at .the .level .of .the .inguinal .ligament.
Therefore, .palpating .above .the .inguinal .ligament .would .be .assessing .the .external .iliac
artery. .The .femoral .artery .is .typically .located .midway .between .the .anterior .superior .iliac
spine .in .the .symphysis .pubis .in .most .patients.
The .clinician .is .palpating .pulses .in .the .foot .of .a .diabetic .patient .while .in .the .clinic. .A
strong .pulse .is .felt .located .on .the .dorsum .of .the .foot, .just .lateral .to .the .extensor .tendon
of .the .big .toe. .Which .artery .is .being .assessed? .- .ANSWER- .C. .Dorsalis .pedis
Rationale: .The .dorsalis .pedis .artery .is .usually .palpable .on .the .dorsum .of .the .foot .just
lateral .to .the .extensor .tendon .of .the .big .toe. .The .arterial .arch .of .the .foot .is .more .distal
and .runs .transversely .and .is .not .usually .palpable. .The .posterior .tibial .artery .is .found
,behind .the .medial .malleolus .of .the .ankle. .The .popliteal .and .femoral .pulses .are .found
more .proximally .at .the .knee .and .near .the .groin, .respectively.
A .68-year-old .retired .administrative .assistant .complains .of .a .3-month .history .of
recurring .pain .after .ambulating .that .radiates .from .her .back .in .the .upper .lumbar .region
into .both .buttocks, .bilateral .thighs, .and .mid-calf .regions. .Her .pain .is .typically .improved
by .sitting .or .by .leaning .forward. .The .origin .of .her .pain .is .likely .secondary .to .which .of .the
following? .- .ANSWER- .d. .Neurogenic .claudication
Rationale: .Neurogenic .claudication .can .mimic .PAD .by .causing .pain .related .to .walking;
however, .it .is .typically .relieved .simply .by .sitting .or .by .leaning .forward. .Many .patients
with .spinal .stenosis .of .the .lumbar .spine .have .pain .that .originates .in .the .spinal .region
and .radiates .into .the .areas .noted. .PAD .is .not .typically .relieved .just .by .sitting .alone .and
usually .will .take .some .time. .PAD .also .does .not .typically .improve .with .bending .over.
Acute .arterial .occlusion .does .not .cause .recurring .symptoms .and .is .not .usually .bilateral.
Abdominal .aortic .aneurysms .may .cause .similar .pain .as .well; .however, .they .typically .do
not .have .the .same .palliating .factors.
A .patient .that .has .a .known .history .of .cardiovascular .disease .including .a .myocardial
infarction .and .positive .ankle-brachial .index .indicating .peripheral .arterial .disease .in .his
left .leg .is .now .having .some .issues .with .erectile .dysfunction .(ED). .The .clinician .suspects
it .may .be .due .to .medications .or .further .vascular .disease. .He .does .not .complain .of .any
other .symptoms. .If .his .symptoms .are .related .to .vascular .disease, .where .would .the
lesion .likely .be .located? .- .ANSWER- .b. .Iliac .pudendal
, A .61-year-old .retired .librarian .was .recently .diagnosed .with .ovarian .cancer. .She .was
otherwise .healthy .until .her .recent .cancer .diagnosis. .She .has .not .been .feeling .well .lately
and .has .had .a .cough .and .some .mild .shortness .of .breath .for .the .past .couple .of .days.
She .now .presents .to .the .clinic .complaining .of .pain .and .swelling .in .her .right .groin .and
leg, .which .she .says .is .been .there .for .about .a .week .but .is .worsening. .On .physical
examination, .2+ .edema .of .the .right .leg .up .to .the .thigh; .1+ .femoral, .popliteal, .dorsalis
pedis, .and .posterior .tibial .pulses; .and .no .significant .erythema .are .noted. .What .is .the
chief .concern .with .this .patient? .- .ANSWER- .d. .Pulmonary .embolism .(PE)
Rationale: .Cancer .patients .are .at .high .risk .of .deep .venous .thrombosis .(DVT), .and, .with
the .presenting .symptoms .of .swelling .and .pain .in .her .groin, .along .with .recent .history .of
cough .and .shortness .of .breath, .this .patient's .presentation .is .suspicious .for .PE. .Patients
with .DVT .in .the .proximal .leg .veins .are .at .high .risk .of .thromboembolism. .Acute .arterial
occlusion .should .not .cause .significant .edema, .and .pulses .would .likely .be .absent. .The
constellation .of .symptoms .and .history .in .this .patient .also .does .not .suggest .an .acute
arterial .occlusion. .Superficial .thrombophlebitis .typically .only .causes .mild .local .swelling,
redness, .and .warmth .along .with .a .subcutaneous .cord. .Acute .lymphangitis .typically
presents .with .red .streaks .from .an .infection .passing .through .lymph .channels.
A .32-year-old .cabdriver .complains .of .pain .in .his .left .leg. .He .has .a .history .of .type .2
diabetes, .is .a .smoker, .and .recently .was .diagnosed .with .hypertension. .He .does .not
remember .injuring .his .leg; .however, .he .notes .that .there .is .a .small .wound .on .the .lateral
