Final Test Review: Clinical Case Questions & Solutions for Advanced Practice Nursing, Exams of Nursing

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APRN ACNPC(AG)

Final Test Review

(Questions & Solutions)

1. STEMI + CKD

A 78-year-old man (eGFR 28 mL/min/1.73 m²) presents 90 min after chest-pain onset. ECG shows an anterior STEMI; PCI lab is 40 min away. Which medication sequence is most appropriate before transfer? A. Aspirin 325 mg PO + ticagrelor 180 mg PO + half-dose tenecteplase IV B. Aspirin 325 mg PO + clopidogrel 600 mg PO + full-dose tenecteplase IV C. Aspirin 325 mg PO + prasugrel 60 mg PO + abciximab IV bolus D. Aspirin 325 mg PO only; defer all other antithrombotics to cath lab ANS A Rationale — Guidelines favor fibrinolysis when door-to-balloon will exceed 120 min. CKD heightens bleeding risk, so weight- and renal- adjusted (half-dose) tenecteplase is recommended; ticagrelor’s renal safety profile is superior to prasugrel. Abciximab adds little benefit pre- transfer.

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2. Rapid-AF in Decompensated HFpEF An 82-year-old woman with EF 60 % and pulmonary edema is in AF at 160 bpm. BP 94/56 mmHg; she is mildly confused. Optimal first intervention? A. IV amiodarone 150 mg bolus B. IV metoprolol 5 mg q5 min × C. Synchronized cardioversion 200 J D. IV diltiazem 20 mg bolus ANS C Rationale — Unstable tachyarrhythmia (hypotension, altered mentation) mandates immediate synchronized cardioversion; negative inotropes (β-blocker, calcium-channel blocker) can precipitate shock in acutely decompensated HF.

develops rigid muscles and hyperthermia. Which agent should be infused emergently? A. IV lorazepam B. IV bromocriptine C. IV dantrolene D. IV amantadine ANS B Rationale — Acute withdrawal of dopaminergic therapy provokes parkinsonism-hyperpyrexia syndrome; bromocriptine (dopamine agonist) reverses dopamine deficiency, while dantrolene addresses malignant hyperthermia, not dopaminergic crisis.

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6. Myasthenic vs Cholinergic Crisis A 70-year-old with myasthenia gravis on pyridostigmine develops respiratory distress. Ice-pack test equivocal. Giving 1 mg IV edrophonium improves strength for 3 min. Interpretation? A. Cholinergic crisis; stop anticholinesterase B. Myasthenic crisis; escalate immunotherapy C. Insufficient dose; repeat at 3 mg D. Test invalid in older adults ANS B Rationale — Transient improvement after edrophonium confirms myasthenic crisis (acetylcholine deficit). Cholinergic crisis would worsen.

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7. Intracerebral Hemorrhage Blood-Pressure Target An 84-year-old with lobar ICH (CT volume 35 mL) presents BP 198/ mmHg. According to latest AHA/ASA guidance, target SBP in first hour? A. <140 mmHg B. 140–160 mmHg

C. 160–180 mmHg D. <120 mmHg ANS A Rationale — Rapid SBP reduction to <140 mmHg is safe and limits hematoma expansion; more aggressive targets risk cerebral hypoperfusion.

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8. CO₂ Retention in COPD Exacerbation A 76-year-old with severe COPD on BiPAP shows ABG: pH 7.33, PaCO₂ 72 mmHg, PaO₂ 58 mmHg on FiO₂ 0.28, BiPAP 12/6. Best adjustment? A. Increase FiO₂ to 0. B. Increase EPAP to 8 cmH₂O C. Increase IPAP to 16 cmH₂O D. Decrease rate of bronchodilator nebs ANS C Rationale — Raising IPAP widens pressure support, augments tidal volume, and clears CO₂. Higher FiO₂ risks blunting hypoxic drive; raising EPAP aids oxygenation but not ventilation.

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9. Differentiating ARDS vs Cardiogenic Edema An 80-year-old with bilateral infiltrates has BNP 110 pg/mL, wedge pressure 12 mmHg, PaO₂/FiO₂ 110. This profile supports: A. Cardiogenic pulmonary edema B. Transfusion-related lung injury C. Acute respiratory distress syndrome D. Mixed etiology ANS C Rationale — Low wedge pressure plus severe shunt hypoxemia and

A 74-year-old dialysis patient is K⁺ 6.8 mEq/L, peaked T waves. He dialyzed yesterday. After calcium chloride and insulin-glucose, what next? A. Kayexalate 30 g PO B. Sodium-zirconium cyclosilicate 10 g PO C. Emergency hemodialysis D. IV loop diuretic + bicarb ANS C Rationale — ESRD limits renal or GI K⁺ clearance; definitive removal via emergent dialysis is fastest and safest.

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13. Distinguishing DKA vs HHS A frail 71-year-old with T2DM presents glucose 860 mg/dL, pH 7.36, bicarbonate 22 mEq/L, serum osmolality 345 mOsm/kg, β-OH-butyrate mild. Diagnosis? A. DKA B. HHS C. Mixed acidosis D. Euglycemic DKA ANS B Rationale — Severe hyperglycemia with minimal acidosis/ketosis and high effective osmolality defines hyperosmolar hyperglycemic state.

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14. Thyroid Storm An 80-year-old with AF, fever 39 °C, agitation, free T4 5× ULN. After propranolol, which drug next? A. PTU 600 mg load B. Levothyroxine 100 μg C. Amiodarone IV

D. Recombinant TSH ANS A Rationale — Propylthiouracil blocks organification and peripheral T4→T3 conversion; administer before iodine therapy.

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15. Adrenal Crisis A 69-year-old on chronic prednisone for COPD develops septic shock; Na⁺ 126, K⁺ 5.8, glucose 58 mg/dL. Action? A. Hydrocortisone 100 mg IV + IVF B. Fludrocortisone 0.1 mg PO C. Methylprednisolone 40 mg IV q12 h D. Discontinue steroids pending cosyntropin test ANS A Rationale — Stress-dose hydrocortisone treats adrenal insufficiency and offers mineralocorticoid effect; testing can follow stabilization.

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16. Febrile Neutropenia A 72-year-old with AML (ANC 300) spikes 38.5 °C. BP 100/62, no focus. Which empiric antibiotic regimen? A. Piperacillin-tazobactam B. Vancomycin + cefepime C. Meropenem + linezolid D. Ceftriaxone ANS A Rationale — Antipseudomonal β-lactam monotherapy suffices initially; add gram-positive coverage only for catheter infection, hypotension, or SSTI.

B. Moderate, score 2 C. Severe, score 3 D. Critical, score 5 ANS C Rationale — BISAP points: BUN >25, SIRS, age >60 =3 → high risk severe pancreatitis.

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20. Recurrent C. diff in Frail Elder An 88-year-old after two prior C. diff episodes develops relapse. Recommended therapy? A. Metronidazole 500 mg TID 10 d B. Vancomycin taper-pulse 6 weeks C. Fidaxomicin 200 mg BID 10 d D. Fecal microbiota transplant first-line ANS B Rationale — Second recurrence: vancomycin tapered regimen or fidaxomicin taper; metronidazole obsolete; FMT reserved for ≥ recurrences.

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21. HFpEF Optimization A 80-year-old with persistent exertional dyspnea, EF 55 %, NYHA III. BP 138/78, eGFR 50. Evidence-based medication to add? A. Sacubitril/valsartan B. Spironolactone 25 mg C. Empagliflozin 10 mg D. Verapamil SR 240 mg ANS C Rationale — SGLT2 inhibitors reduce HFpEF hospitalizations regardless

of diabetes; ARNI benefit less robust; spironolactone limited by renal function; verapamil lacks outcome data.

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22. Hypertensive Emergency—ICH In question 7 we lowered BP aggressively; which IV agent is preferred for rapid titration in ICH? A. Nitroprusside B. Nicardipine C. Hydralazine D. Esmolol ANS B Rationale — Nicardipine offers smooth BP reduction without raising ICP or cyanide toxicity of nitroprusside.

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23. Aortic Dissection Imaging Choice A 69-year-old with CKD stage 4, sudden tearing pain, BP 180/90. Which imaging balances speed and nephrotoxicity? A. CTA chest/abdomen with contrast B. Transesophageal echocardiography bedside C. MRA with gadolinium D. Transthoracic echo only ANS B Rationale — TEE provides rapid bedside diagnosis, spares iodinated contrast in renal impairment.

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24. Ruptured AAA Pre-Hospital Orders Paramedics notify ED: 82-year-old, hypotension, pulsatile abdominal

Rationale — STOPP flags TCAs in elders due to strong anticholinergic burden, orthostatic risk, and confusion.

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27. Beers List & NOACs An 86-year-old with CrCl 28 mL/min is on dabigatran 150 mg BID. According to 2023 Beers update, the APRN should: A. Continue regimen B. Reduce to 75 mg BID C. Switch to apixaban 2.5 mg BID D. Stop anticoagulation ANS C Rationale — Beers cautions dabigatran when CrCl <30 due to GI bleed risk; apixaban safest DOAC in severe CKD at reduced dose.

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28. Palliative Sedation Ethics A terminal 79-year-old with refractory dyspnea requests “to sleep.” Which principle distinguishes palliative sedation from euthanasia? A. Doctrine of double effect B. Non-maleficence C. Patient autonomy D. Distributive justice ANS A Rationale — Intent is symptom relief; any life-shortening is a foreseeable but unintended secondary effect.

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29. Sepsis Bundle Adaptation for Elders Early goal-directed therapy in geriatric sepsis should prioritize which

hemodynamic endpoint over CVP? A. Lactate clearance ≥20 % B. ScvO₂ >65 % C. Urine output >0.3 mL/kg/h D. MAP ≥75 mmHg ANS A Rationale — Lactate clearance correlates with microcirculatory recovery and avoids invasive lines; geriatric kidneys may not achieve classic 0.5 mL/kg/h.

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30. Pressure Injury Staging A sacral ulcer shows full-thickness skin loss, exposed bone, slough, undermining. Stage? A. II B. III C. IV D. Unstageable ANS C Rationale — Exposure of bone denotes Stage IV; Stage III lacks bone/tendon.

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31. Malnutrition Diagnosis (GLIM) An 81-year-old lost 8 % weight in 6 months; BMI 20; CRP 18 mg/L; reduced intake 50 % × 2 weeks. According to GLIM, severity? A. Moderate malnutrition B. Severe malnutrition C. No malnutrition D. At risk only

To plan discharge, which instrument evaluates complex IADLs (shopping, finance, meds)? A. Katz Index B. Barthel Index C. Lawton-Brody Scale D. Braden Scale ANS C Rationale — Lawton-Brody assesses eight instrumental ADLs critical for community living.

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35. Capacity vs Competence A 90-year-old refuses surgery. Which statement is accurate? A. Capacity is a legal finding made by courts B. Competence is task-specific and clinical C. Capacity is decision-specific and determined by clinicians D. Competence fluctuates hour to hour ANS C Rationale — Capacity = clinical, decision-specific; competence = global legal judgment.

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36. Elder Abuse Screening Which tool has highest sensitivity in ED for cognitive-intact elders? A. HITS B. CASE C. EASI D. PHQ- 9 ANS C Rationale — Elder Abuse Suspicion Index quickly screens five domains

and one caregiver question.

37. Advance Directive Components POLST differs from living will because it: A. Is legal only when patient lacks capacity B. Requires physician/APRN signature to guide EMS C. Cannot limit intubation D. Expires after 12 months ANS B Rationale — POLST is actionable medical order completed with clinician signature, honored across settings. Which of the following is the most common cause of heart failure in older adults? A) Hypertension B) Coronary artery disease C) Valvular heart disease D) Diabetes mellitus Correct ANS : B) Coronary artery disease Rationale: Coronary artery disease leads to ischemia and myocardial injury, making it the most prevalent cause of heart failure in the geriatric population. In managing chronic pain in older adults, which of the following medications is considered first-line treatment? A) Opioids B) Nonsteroidal anti-inflammatory drugs (NSAIDs) C) Acetaminophen D) Antidepressants Correct ANS : C) Acetaminophen

Which of the following is a common side effect of anticholinergic medications in older adults? A) Bradycardia B) Confusion C) Hypertension D) Hyperglycemia Correct ANS : B) Confusion Rationale: Anticholinergic drugs can cross the blood-brain barrier, leading to cognitive impairment and confusion, particularly in older adults. What is the primary goal of advance care planning in geriatric patients? A) To increase hospital admissions B) To ensure patient autonomy and preferences are respected C) To limit treatment options D) To decrease healthcare costs Correct ANS : B) To ensure patient autonomy and preferences are respected Rationale: Advance care planning facilitates discussions about future medical care, ensuring that patients' wishes are honored in critical situations. Which condition is characterized by the presence of both cognitive impairment and functional disability in older adults? A) Alzheimer’s disease B) Delirium C) Dementia D) Frailty Correct ANS : D) Frailty Rationale: Frailty encompasses a syndrome of decreased reserve and resistance to stressors, resulting in cognitive and functional decline. In assessing an older adult for depression, which symptom is considered a cardinal feature?

A) Fatigue B) Weight gain C) Anhedonia D) Insomnia Correct ANS : C) Anhedonia Rationale: Anhedonia, or loss of interest or pleasure in previously enjoyed activities, is a key indicator of depression in older adults. Which of the following is the most effective intervention for preventing falls in older adults? A) Increasing calcium intake B) Regular vision checks C) Home safety assessments D) Strength and balance training Correct ANS : D) Strength and balance training Rationale: Exercise programs targeting strength and balance have been shown to significantly reduce fall risk among older adults. Which condition is often referred to as the "silent epidemic" in older adults due to its underdiagnosis? A) Osteoporosis B) Hypertension C) Diabetes mellitus D) Heart disease Correct ANS : A) Osteoporosis Rationale: Osteoporosis frequently goes undiagnosed until a fracture occurs, hence its designation as a silent epidemic. What is the primary purpose of the Comprehensive Geriatric Assessment (CGA)? A) To determine life expectancy B) To evaluate physical health only C) To provide a holistic view of an older adult's health D) To focus solely on mental health Correct ANS : C) To provide a holistic view of an older adult's health