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NR601 Week 4 Midterm Exam

The NP is evaluating a patient with mixed hyperlipidemia, characterized by elevated fasting plasma levels of triglycerides (TGs) and LDL-C, along with reduced HDL-C levels. Which combination of interventions should be PRIORITIZED to reduce the patient’s risk of atherosclerotic cardiovascular disease (ASCVD)?

1. Recommend a high-fat diet to normalize the patient’s lipid profile before prescribing medication
2. Focus solely on weight loss and then have the patient return to the clinic in 6 months to evaluate the lipid profile
3. ✔️ Implement lifestyle changes such as diet and exercise and consider pharmacologic interventions
4. Focus on managing the patient’s lipid profile through diet before addressing factors such as obesity and insulin resistance

A 76-year-old patient presents with dyspnea on exertion, orthopnea, and mild peripheral edema. On physical exam, the NP notes a laterally displaced point of maximal impulse and bibasilar crackles. Which of the following diagnostic findings is MOST consistent with heart failure with reduced ejection fraction (HFrEF)?

1. ✔️ Left ventricular ejection fraction <40%
2. Absence of S3 on cardiac auscultation
3. Elevated BNP with normal chamber size
4. Preserved left ventricular wall thickness on echocardiography

According to the “Rule of Fourths”, which of the following BEST reflects the multifactorial contributors to functional decline in older adults?

1. ✔️ Functional decline is equally influenced by aging, disuse, disease, and iatrogenic factors, each contributing approximately one-quarter
2. The Rule of Fourths is primarily applied in epidemiology to describe disease prevalence, not functional status
3. While aging contributes to functional decline, it is the predominant factor in most older adults, outweighing the effects of disease or disuse
4. Functional loss in older adults is largely irreversible, with limited benefit from interventions targeting disuse or iatrogenic causes

A 67-year-old male patient presents with persistent hypertension despite adherence to lifestyle modifications and compliance with antihypertensive monotherapy. His blood pressure remains above target on follow-up visits. What is the MOST appropriate next step in managing this patient?

1. Increase the dose of the current antihypertensive medication
2. ✔️ Add a second antihypertensive agent from a different class
3. Advise continued lifestyle modification and re-evaluate in 3 months
4. Refer for renal artery imaging to rule out secondary hypertension

The NP is evaluating the management plan of a patient with multiple co-morbidities diagnosed with asthma. The patient continues to present with mild to moderate symptoms of asthma despite treatment. Which of the following comorbidities is MOST likely contributing to the difficulty in controlling asthma?

1. ✔️ Chronic rhinosinusitis
2. Hypertension
3. Hyperlipidemia
4. Diabetes mellitus

The NP is evaluating a patient with advanced heart failure (HF) for symptoms of reduced perfusion. Which combination of symptoms would MOST likely indicate reduced cardiac output (CO) and systemic perfusion?

1. ✔️ Fatigue, weakness of the lower extremities, and mental dullness
2. Elevated blood pressure, increased urine output, and insomnia
3. Increased appetite, weight gain, and hyperactivity
4. Improved exercise tolerance, euphoria, and increased energy levels

A 65-year-old patient with a history of paroxysmal atrial fibrillation (AF) presents for follow-up. The patient reports occasional episodes of palpitations but is currently asymptomatic and in AF on today’s ECG. There is no history of thromboembolic events, valvular heart disease, or structural abnormalities. The patient is not on anticoagulation. What is the MOST appropriate next step in managing this patient?

1. Refer for catheter ablation prior to starting medical therapy
2. Schedule immediate cardioversion regardless of AF duration
3. ✔️ Initiate rate control and assess stroke risk using the CHA₂DS₂-VASc score
4. Reassure the patient that no treatment is needed for asymptomatic AF

During a physical exam, the NP suspects right-sided heart failure in a 78-year-old patient with fatigue and bilateral lower extremity swelling. Which of the following findings MOST strongly supports this suspicion?

1. Basilar crackles with inspiratory wheezing
2. Loud S2 and irregular rhythm
3. ✔️ Elevated jugular venous pressure
4. Displaced apical impulse

The NP is evaluating a 72-year-old man with diabetes and a history of smoking who reports calf pain that occurs while walking and resolves with rest. Which physical exam finding would MOST support a diagnosis of peripheral artery disease (PAD)?

1. Bilateral lower extremity edema
2. Warm feet with intact capillary refill
3. ✔️ Absent dorsalis pedis pulse
4. Bounding pedal pulses

Which of the following statements best reflects the current state of advance care planning among adults in the United States?

1. Younger adults are more likely than older adults to complete advance directives
2. Most adults aged 18 and older have completed written advance directives
3. ✔️ Most adults have discussed end-of-life wishes, but few adults have formalized them in writing
4. The percentage of Americans with written advance directives has significantly increased since 2011

The NP diagnosed a patient with a history of COPD and smoking with community-acquired pneumonia (CAP). Which pathogen is MOST likely responsible for the patient’s CAP based on their history of COPD and smoking?

1. Staphylococcus aureus
2. Mycobacterium tuberculosis
3. Escherichia coli
4. ✔️ Haemophilus influenzae

The NP is managing an 84-year-old patient with multiple chronic conditions. Which approach BEST aligns with person-centered geriatric assessment?

1. Screening based on chronological age alone
2. Avoiding diagnostic testing due to advanced age
3. Following the same screening protocols used in middle-aged adults
4. ✔️ Tailoring care to function, prognosis, and patient goals

In the primary care evaluation of a patient with suspected angina, which of the following historical findings would most warrant expedited cardiology referral and further diagnostic testing?

1. Localized left-sided chest pain that is reproducible with exertion
2. Chest pain consistently relieved by antacids
3. ✔️ Chest pressure that now occurs with less exertion than previously
4. Chest discomfort occurring predictably only after large meals

A 68-year-old woman with a history of hypertension and diabetes presents with fatigue, mild ankle swelling, and exertional dyspnea. Echocardiography shows a preserved ejection fraction. What is the MOST LIKELY underlying pathophysiology of her symptoms?

1. Aortic stenosis with increased afterload
2. Acute mitral regurgitation with volume overload
3. ✔️ Abnormal ventricular relaxation and increased stiffness
4. Reduced preload and impaired systolic contraction

A NP is developing a preventive counseling program based on the U.S. Preventive Services Task Force (USPSTF) recommendations. Which combination of interventions would BEST address the prevention of cardiovascular disease in adults at increased risk?

1. Genetic counseling for BRCA-related cancer and screening for osteoporosis
2. Screening and counseling for anxiety disorders and prescribing low-dose aspirin
3. ✔️ Behavioral counseling for a healthy diet and physical activity, and screening for hypertension
4. Screening for asymptomatic bacteriuria and prescribing risk-reducing medications for breast cancer

The NP is evaluating a patient with mitral regurgitation (MR). Which findings are MOST indicative of chronic severe MR?

1. ✔️ Presence of dyspnea, fatigue, orthopnea, and palpitations
2. Mild left atrial enlargement with no symptoms
3. Normal left ventricular (LV) size and function
4. Occasional irregular heartbeat without significant symptoms

The NP is assessing an older adult for symptoms of aortic stenosis (AS). Which of the following symptoms is MOST likely to be precipitated by sudden changes in heart rate, volume status, or cardiac output (CO)?

1. ✔️ Syncope
2. Palpitations
3. Cough
4. Peripheral edema

The NP is counseling an older adult patient on nutrition to reduce chronic disease risk. Which dietary pattern is MOST aligned with current evidence-based health promotion strategies?

1. Ketogenic diet with intermittent fasting and protein supplementation
2. ✔️ Emphasis on nutrient-dense whole foods with minimal added sugars and sodium
3. Elimination of dairy, gluten, and legumes to reduce inflammation
4. Reliance on fortified snack products to boost calorie intake

A 58-year-old man with exertional chest discomfort undergoes evaluation in your primary care office. His physical exam is normal. Which of the following laboratory findings would provide the most useful information for cardiovascular risk stratification and potentially influence decisions about lipid-lowering therapy?

1. Normal hematocrit of 44%
2. Elevated hemoglobin A1C of 6.2%
3. ✔️ High-sensitivity C-reactive protein (CRP) level of 2.5 mg/L
4. Mildly decreased thyroid-stimulating hormone (TSH)

The NP is counseling a patient with persistent asthma. Which of the following factors is MOST associated with airway hyperresponsiveness in asthma?

1. Surfactant deficiency in alveoli which results in elevated white blood cells
2. ✔️ Subepithelial collagen deposition and airway wall thickening
3. Pulmonary capillary wedge pressure elevation
4. Isolated airway infection with Mycoplasma pneumoniae

The NP is evaluating a patient who reports frequent nocturnal breathing disturbances and daytime sleepiness. What additional information is required for the diagnosis of Obstructive Sleep Apnea (OSA)?

1. ✔️ Five or more episodes of obstructive apnea or hypopnea per hour of sleep
2. Ten or more episodes of obstructive apnea or hypopnea per hour of sleep
3. Fifteen or more episodes of obstructive apnea or hypopnea per hour of sleep
4. Three or more episodes of obstructive apnea or hypopnea per hour of sleep

What is the MINIMUM apnea-hypopnea index (AHI) required to diagnose OSA in the absence of symptoms?

1. AHI ≥ 5 episodes per hour
2. AHI > 10 episodes per hour
3. AHI ≥ 30 episodes per hour
4. ✔️ AHI ≥ 15 episodes per hour

A NP orders a chest x-ray (CXR) for a patient. What are the benefits of using CXR images to diagnose respiratory diseases?

1. They provide a 3-dimensional view of the chest structures
2. It offers detailed views of vascular structures.
3. ✔️ They help examine superimposed structures and monitor disease progression.
4. They are most useful for diagnosing patients while hospitalized.

Which of the following physical examination findings in a patient with suspected stable angina would most suggest the presence of generalized atherosclerotic disease and warrant further cardiovascular risk assessment?

1. Clear lung fields and a regular apical impulse
2. Tenderness over the left costochondral junction on palpation
3. ✔️ Diminished peripheral pulses and carotid bruits
4. A loud S1 and soft S2 on cardiac auscultation

Which class of antihypertensive medication SHOULD NOT be used in patients with bilateral renal artery stenosis?

1. ✔️ ACE inhibitors
2. Thiazide diuretics
3. Beta-blockers
4. Calcium channel blockers

A 68-year-old patient recovering from an acute myocardial infarction is experiencing frequent PVCs and NSVT. Which of the following management strategies is MOST appropriate to reduce the risk of sudden cardiac death?

1. Suppression of PVCs with long-term amiodarone and ACE inhibitors
2. Catheter ablation of the PVCs and treatment of NSVT with digoxin
3. ✔️ Initiation of beta-blocker therapy and correction of electrolyte imbalances
4. Admit to Critical Care and begin immediate administration of IV lidocaine

The NP is managing pain for a terminally ill patient. Which approach should the NP take to EFFECTIVELY manage the patient’s pain?

1. Question the patient’s report of pain and minimize the use of pain medications to prevent potential misuse
2. Use opioids as the primary method of pain management, disregarding other analgesic options
3. Avoid using opioids due to the risk of addiction and focus solely on non-opioid analgesics
4. ✔️ Incorporate opioids as part of a multimodal analgesia approach, tailored to the patient’s needs and reports of pain

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