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NURS 6550 Midterm Exam Questions
and Answers (Graded A+)
Question 1 1 out of 1 points The AGACNP is caring for a patient who is quite ill and has developed, among other things, a large right sided pleural effusion. Thoracentesis is sent for pleural fluid analysis. While evaluating the fluid analysis, the AGACNP knows that a fluid identified as a(n) is the least worrisome type. Response Feedback: “A” is the correct answer. A transudate is essentially just water and can occur as a consequence of increased hydrostatic pressure in the pulmonary vessels. It typically implies that the some condition has produced an imbalance in colloid-hydrostatic pressures, such as CHF or hypoalbuminemia. While it can represent a serious problem, it may also represent a transient imbalance. Conversely, “B” is not correct as an exudate has more protein in it and implies a condition characterized by protein leaking from vessels, such as a malignancy or some serious systemic stressor. “C” is not correct—a chyliform effusion is characterized by fat and indicates a pathology causing massive triglyceride degradation. “D” is not correct as a hemorrhagic effusion is blood and typically means traumatic injury. Question 2 1 out of 1 points Differentiating vertigo from near-syncope and ataxia is one of the goals of history- taking when a patient presents as “dizzy.” The AGACP knows that vertigo is the problem when the patient reports the primary symptom as: Response Feedback: “A” is the correct answer. Dizzy is a layperson’s term and can mean many different things to patients and health care providers. When the patient identifies the primary symptom as a sense of spinning this supports vertigo, which is usually an inner ear problem. This versus ataxia which is neurologic or near-syncope which may be cardiac, neurological, or neurocardiogenic. “B” is not correct—this may occur with vertigo, but when it is the primary symptom it is most likely ataxia and neurological causes should be considered. “C” is not correct as coincident nausea is not specific and can occur with any of these complaints. “D” is not correct as it is also not specific; while ataxia cannot occur when supine near-syncope can.
Question 3 1 out of 1 points Mr. Banks has been admitted for surgical resection of a metastatic tumor, during surgery it is discovered that he has widespread, diffuse metastasis throughout the abdomen. Surgery is no longer an option, and his oncologist says that chemotherapy is unlikely to produce any meaningful benefit. Mr. Banks is concerned that his sons will not support a transfer to comfort care. The AGACNP advises that he: Response Feedback: “B” is the correct answer. If there is any concern about disagreement among family members, or any concern at all that a patient’s wishes will not be carried out, the best action is to ensure that there is a clearly defined legally executed document. “A” is not correct. Living wills are not legally enforceable documents and when dissention arises among family members they may not be carried out. “C” is not correct - while the patient should arrange for his care as long as he is capable of doing so, if questions arise at such a time that he is not capable of answering his next of kin will need to do so. “D” is not correct -- identifying the proxy is not enough without assigning legal rights and responsibilities. While “A,” “C,” and “D” should all be done and will support his care, the only way to ensure that one’s wishes are carried out is to ensure that a legally enforceable direction is in place. Question 4 Mr. Wilkerson is a 77-year-old male who is being evaluated and treated for his cardiogenic pain. His vital signs are as follows: Temperature of 99.1° F, pulse of 100 bpm, respirations of 22 bpm, and blood pressure of 168/100 mm Hg. A 12-lead ECG 1 out of 1 points reveals deep ST segment depression in leads V 3 -V 6. The AGACNP recognizes which of the following as a contraindication to rTPA therapy? Response Feedback: “D” is the correct answer. rTPA is not indicated in patients with ST segment depression; this is not a ST elevation MI. “A” is not correct as age > 80 is a relative contraindication. “B” is not correct as a temperature of 99.1° F is an expected response to myocardial necrosis, and “C” is not correct—the blood pressure is not prohibitive until > 180/110 mm hg. Question 5 A 71-year-old patient is recovering from a particularly severe exacerbation of chronic obstructive pulmonary disease. He has been in the hospital for almost two weeks and was on mechanical ventilation for 7 days. While discussing his discharge plan he tells 1 out of 1 points
Feedback: population where the most common cause of pneumonia is Streptococcus pneumoniae , and is the primary treatment target for any patient being treated empirically. “A” is not correct—while the patient’s sexual orientation is offered in the provided history, there is no indication that he has HIV/AIDS or any other condition characterized by immunosuppression that would increase his risk for this organism. “B” is not correct, as this organism is not typically seen in the outpatient population without specific risk, e.g. immunosuppression or chronic ventilator therapy. “C” is not the correct answer as this organism is not likely absent specific risk such as instrumentation or known colonization. Question 8 Which of the following is the greatest risk factor for vascular dementia? 0 out of 1 points Response Feedback: “B” is the correct answer. Vascular dementia is a consequence of vascular disease, and is more likely to occur in patients with risk factors for target organ damage, such as hypertension, dyslipidemia, and diabetes. “A” is not a distinct risk factor for vascular dementia; it is a risk for Alzheimer’s dementia. “C” likewise increases risk for Parkinson’s dementia, but does not present a risk for vascular dementia. “D” is not a risk factor for vascular dementia. Although there may be some familial risk for certain vascular diseases that may lead to vascular dementia, there is no clear familial tendency for this type of dementia. Question 9 J.R. is a 55-year-old male who presents for a commercial driver’s license physical 1 out of 1 points examination with a blood pressure of 170/102 mm Hg. He has no medical history and is without complaint. Which of the following findings constitutes hypertensive urgency? Response Feedback: “A” is the correct answer. According to the Joint National Committee (JNC) report, hypertensive urgency is described as hypertension in the setting of progressive target organ damage, such as renal involvement with protein leaking, left ventricular hypertrophy, or retinal changes. “A” is not correct—the headache may or may not be relevant, but because there are many non- hypertension causes, a headache alone does not constitute target organ damage. “C” is not correct—it may indicate carotid plaque, but this is not a consequence of hypertension. “D” is not correct as a 1+ palpable pulse may be a normal finding--it must be taken in the
context of the rest of the examination. Question 10 0 out of 1 points Because of the commonly recognized adverse effects of atypical antipsychotics, annual laboratory assessment for patients taking these medications should include a: Response Feedback: “C” is the correct answer. The atypical antipsychotics such as olanzapine (Zyprexa), clozapine (Clozaril), and quetiapine (Seroquel) are classically associated with dyslipidemia and annual lipid panels should be performed in patients of all ages who take these medications. “A” is incorrect—this is the appropriate annual screening tool for patients on lithium due to lithium-related iodine suppression of the thyroid gland. There are no specific indications for “B” and “D” unique to patients taking atypical antipsychotics. Those laboratory assessments should only be ordered as indicated by any other significant patient history. Question 11 1 out of 1 points K.R. presents for an evaluation of eye discomfort. He works in a fabricating shop for a custom automobile restoration company and while working he felt like something flew into his eye. He was wearing eye protection at the time but still has the sensation that something is there. Physical examination is significant for some tearing and he reports a persistent sense of something in his eye. Which of the following is not indicated in the diagnostic evaluation? Response Feedback: “B” is the correct answer. The patient’s history is consistent with a metal injury and so an MRI should be avoided. “A” may or not be indicated as the history progresses, but there is no contraindication to it should the examiner determine the need to rule out an abrasion. “C” and “D” are both mechanisms to visualize behind the cornea which may be necessary if a penetration injury (which may occur with a high-velocity injury) is suspected. Question 12 0 out of 1 points D.E. is a 41-year-old female who had lumbar surgery two days ago to repair a ruptured nucleus pulposus. She has been doing well postoperatively but today is complaining of resting fatigue and some shortness of breath at rest. In ruling out a pulmonary embolus the AGACNP first orders a:
depressed patient, or even murder or torture committed by an antisocial personality. While dangerous, none of those disorders include a dis-connect from reality as part of the presentation. “C” is incorrect as antipsychotic medications are used to manage a variety of neurotic disorders such as depression or oppositional defiant disorder. “D” is incorrect as lack of conscience and remorse is typical of antisocial personalities. Question 15 0 out of 1 points L.T. is an 85-year-old male who is admitted for evaluation of profound diarrhea that has produced significant dehydration. He also complains of being very tired lately, and feeling like he is going to vomit all of the time. His vital signs are significant for a pulse of 41 b.p.m. and a blood pressure of 90/60 mm Hg. A gastrointestinal evaluation including stool for blood, white blood cells, and ova and parasites is negative. He insists that he has not started any new medications or made any diet changes; the only thing new is that he got new eye drops for his glaucoma. The AGACNP correctly assumes that his new eye drops are: Response Feedback: “B” is the correct answer. The accelerated GI motility and bradycardia are cholinergic adverse effects. Ophthalmic medications are readily absorbed into systemic circulation. All of these medications are used to treat glaucoma and may cause class-related adverse effects, but cholinergic drops are the only ones shown that will slow heart rate and accelerate GI motility. Question 16 1 out of 1 points Janice is a 19-year-old female who presents to the emergency department via ambulance. She is pale, diaphoretic, agitated, and convinced she is having a stroke. Her vital signs include a temperature of 98.9° F, pulse of 114 beats per minute, respirations of 32 breaths per minute, and a blood pressure of 110/74 mm Hg. Diagnostic evaluation is negative and Janice is diagnosed with an acute panic attack. The initial treatment of choice is: Response Feedback: “A” is the correct answer. A panic anxiety attack requires immediate intervention with a short acting benzodiazepine for immediate symptom control. A calm environment would be helpful, but is not adequate alone to manage acute episodes characterized by physical symptoms. Oxygen is not indicated in the absence of organic
Question 17 problems. The numb hands and feet, known as “stocking-glove paresthesia,” are characteristic of respiratory alkalosis consistent with tachypnea and will resolve once the patient slows her breathing and retains CO 2. While cognitive behavioral therapy is an important part of chronic anxiety management, is has no role in acute management of acute panic attack. Lorraine is a 41-year-old female who presents for an asthma follow-up visit. She says she feels very well, has almost no daytime symptoms, and is using her inhaled corticosteroid medication daily as prescribed. Her PEFR is 85% of her personal best. The best approach to this patient is to: 0 out of 1 points Response Feedback: Question 18 “C” is the correct answer. In accordance with EPR-3 guidelines, assessment of asthma follow-up must include a validated asthma questionnaire, such as the ACT. The information gathered so far is encouraging but incomplete and any decision about her care should be made based on a complete assessment. “A” and “B” are not correct as these are treatments that cannot be determined until her assessment is complete. “D” is incorrect because it is not required; at follow-up, objective airflow assessment may be completed with either PEFR or FEV 1. Mrs. Miller is transported to the emergency department by paramedics. She is having profound, unremitting chest pain, is diaphoretic and pale. She has jugular venous distention and a widened pulse pressure. Suspecting ascending aortic aneurysm, the AGACNP order which test to confirm the diagnosis? 0 out of 1 points Response Feedback: “D” is the correct answer. It is the most widely used diagnostic tool as it rapidly and precisely can outline the thoracic and abdominal aorta. “A” is not the correct answer—there are radiographic findings that suggest thoracic aneurysm, but they need confirmation by CT. “B” is not the correct answer as ultrasound is not nearly as precise as a CT scan. “C” is not correct—MRI is only indicated when the patient cannot have a contrast CT. Question 19 Mr. Owen is a 37-year-old patient who has been admitted for surgical resection of a 1 out of 1 points malignant tumor in his lung. His physical recovery has been uneventful and he is being prepared for discharge. While discussing his ongoing cancer therapy with Mr. Owen, the
Response Feedback: “A” is the correct answer. While SSRIs, beta adrenergic antagonists, and even centrally acting antiadrenergic agonists (clonidine) are all used as first line agents depending upon symptom presentation, patients who have more severe symptoms and do not respond to initial treatments often require management with atypical antipsychotics. This patient has been treated with an SSRI, reports no improvement, and has been arrested for his behavior; these circumstances are a clear indication for escalation to the nest level of therapy. Question 22 1 out of 1 points Mrs. Salter is an 81-year-old lady who presents for evaluation of near-syncopal episodes. Her 12-lead ECG, complete blood count, and comprehensive metabolic panel are all essentially normal. A urinalysis shows some trace protein but is otherwise normal. A 24- hour rhythm monitor demonstrates rare premature ventricular contractions. Mrs. Salter has been in good health and had her first episode at her aerobics class. She only gets lightheaded when she exerts herself. Her heart auscultates for a grade III/VI systolic crescendo-decrescendo murmur at the second intercostal space, right sternal border. The AGACP considers that the likely cause of the syncope is: Response Feedback: “C” is the correct answer. This is the classic murmur of aortic stenosis, which impedes cardiac output and as it progresses will produce a symptomatic decrease in carotid perfusion. “A” is not correct as there is no sign or symptom of seizure activity. “B” is not correct—the rare PVC is not likely to cause syncope. “D” is not correct—a blood pressure is not given and the proteinuria could come from any variety of causes. 0 out of 1 points A patient with anterior epistaxis has been treated with 20 minutes of direct pressure to the cartilaginous portion of the nose. Following pressure the patient is instructed to gently blow the nose. Expected findings in the patient who has been successfully treated include all of the following except a: Response Feedback: “C” is the correct answer. If bleeding is successfully stopped with 20 minutes of directed pressure, there will be residual blood and clot formation. This is evacuated either by gentle suction or having the patient gently blow. Residual blood and formed clot may present as a sudden gush of dark blood or discharge with or without a clot— these are all typical expected findings. However, if bleeding is not stopped, it will continue as a bright red steady trickle. When this
occurs, more invasive measures are indicated. Question 23 Kevin is a 14-year-old male who presents for evaluation of a fever of 102.5° F and significant right ear pain. He appears quite ill and says he feels nauseous. Otoscopic evaluation reveals pain to palpation, a very erythematous and bulging tympanic 0 out of 1 points membrane with bullous myringitis. The AGACNP knows that antibiotic therapy must be selected to cover: Response Feedback: “D” is the correct answer. Streptococcus pneumoniae is the most common bacteria that infects the head and neck in immunocompetent persons, and is the primary treatment target when treating otitis media, bacterial sinusitis, and bacterial pharyngitis. “A” is not correct—while likely on broken skin and soft tissue, it is not common in the ear, nose, or throat unless specific risk factors exist. “B” is not correct—this is much more likely in an immunocompromised patient or a patient on mechanical ventilation. “C” is not correct—it is the second most common organism, but strep is the primary treatment target. Question 25 Who among the following patients is at greatest risk for a pulmonary embolus? 1 out of 1 points Response Feedback: “C” is the correct answer. The primary risk factor for pulmonary embolus is deep vein thrombosis, for which primary risks are polycythemia and stasis. “A” is not correct—the concentration of estrogen in most hormonal contraception is so low that it barely increases risk above that of the general circulation. Of the millions of women on hormonal contraception, only a handful develop DVT/PE. “B” is not correct—this patient is likely to have problems bleeding rather than clotting. “D” is not correct—while smoking is a risk factor for many things DVT is not among them. Question 26 1 out of 1 points Mrs. Birdsong is an 85-year-old female who has been admitted for surgical repair of a hip fracture. She is in remarkably good spirits and is quite talkative. She readily answers all of the questions on her intake assessment, and readily acknowledges information provided during her room orientation. Later while talking with the patient's son the AGACNP learns that the patient has had significant cognitive impairment for a few years. She has virtually no short term memory, but compensates by confabulating. Her
Feedback: palsy, and rapid administration of corticosteroids can decrease the intensity and duration of symptoms, as well as reduce the likelihood of residual pain. “B” is not indicated; it does not contribute to the diagnosis. “C” may be used as there is a theory that herpes virus causes Bell’s palsy, but this is equivocal and not uniformly practiced. “D” may become necessary at some point to prevent corneal abrasion but the immediate approach should be corticosteroids. Question 29 A 78-year-old male present for a physical examination. He has no discomfort or 1 out of 1 points complaints other than a general decrease in vision, but it helps when he puts things under a bright light to read. He admits that while driving at night the streetlights appear to be a bit distorted and his night vision is pretty poor. Given the likely diagnosis, the AGACNP expects which of the following physical findings? Response Feedback: “C” is the correct answer. This scenario is consistent with cataracts, a common abnormality seen in older adults. The presence of the cataract diminishes the red reflex and ultimately will obliterate it. “A” is not correct, injected conjunctiva are more consistent with inflammation. “B” is not correct—a sluggish pupil response may occur in response to a variety of conditions, including drug toxicities and poisonings, neurological, or ocular disease, but not with cataracts. “D” is not correct; white spots in the macula is most often suggestive of macular degeneration. Question 30 0 out of 1 points Jason is a 46-year-old male who is being managed for sepsis. He has HIV/AIDS and has had a prolonged hospitalization characterized by a variety of complications. He was extubated 3 days ago but continues gastric decompression with a nasogastric tube(NGT), total parenteral nutrition and antibiotic therapy via a central venous catheter, and urinary drainage via a Foley catheter. He continues to demonstrate consistent low grade fevers but all points of insertion of his tubes are normal to inspection, a chest radiograph demonstrates improvement of his pneumonia, and his urinalysis shows no bacteria, leukocytes, or nitrites. The AGACNP should next order: Response Feedback: “C” is the correct answer. The incidence of bacterial sinusitis is significantly higher in patients with AIDS as compared to the general population and the long term NGT is a risk factor for sinus infection. A maxillofacial CT scan should be considered in any patient with AIDS to rule it out in the setting of persistent fever,
especially when risk factors exist. “A” is not correct—gastric drainage can be expected to grow bacteria and will not contribute to the diagnosis. “B” is not correct; urine that has no bacteria or leukocytes is unlikely to be infected. “D” is not the correct answer— while it may be indicated further along in the diagnostic pathway, sinusitis is more likely and “C” should be ordered first. Question 31 0 out of 1 points The interpretation of a chest radiography should follow a systematic approach to ensure that all vital structures are evaluated and important clinical findings are not missed. The last thing to be assessed when looking at chest radiography should be the : Response Feedback: “A” is the correct answer. The lungs are the last thing to be examined; when not properly taught, new may clinicians go right to the heart and lungs and may miss important information. Like the nursing process (assess, diagnose, plan, intervene, evaluate) and the system for ECG interpretation (rate, rhythm, intervals, axis, morphology) the system for interpretation of the chest radiograph should proceed from assessing patient identification, patient rotation, level of inspiration, film exposure to an assessment of the film proceeding in this order: Mediastinum and hila, thoracic cage, extrathoracic bones and soft tissues, and finally lungs. Using a systematic approach helps eliminate the risk of missing vital findings. Question 32 1 out of 1 points The Short Confusion Assessment Method (Short-CAM) is a widely used four item tool that assesses delirium in the hospitalized patient. It includes observation of all of the following except: Response Feedback: “D” is the correct answer. The tool was developed to improve identification and recognition of delirium, not to diagnose causation. The four items observed with the Short-CAM method are (1) acuity of onset, (2) inattention, (3) disorganized thinking, and (4) level of consciousness. Once delirium is recognized, then clinical diagnosis of underlying cause is indicated. Question 33 Ms. Yang has been hospitalized for 5 days for the management of a gastrointestinal 1 out of 1 points
pathologic clotting. Factor V is a clotting factor that is inhibited by the activated protein C and protein S complex. “B” is not correct— when patients have a mutation of factor V, it is insensitive to the inhibiting properties of protein C and S and clotting cannot be stopped appropriately—resulting in increased risk of clotting. Question 36 1 out of 1 points A patient is diagnosed with acute descending aortic aneurysm and hypertension should be immediately started on which medication pending surgical evaluation? Response Feedback: “A” is the correct answer. Beta adrenergic antagonists decrease the force of contraction therefore decreasing shear force exerted on the dissection. “B” is not correct, intravenous vasodilators are not used initially although are a second option to reduce systolic blood pressure but. “C” and “D” are not correct as other medical management strategies have not demonstrated improved outcomes. Ultimately these patients will require surgical intervention. Question 37 Jason is a 27-year-old with a long history of intermittently controlled asthma. He is currently prescribed Advair daily with albuterol as needed for symptoms. Today he 0 out of 1 points presents to the emergency department with cough and wheezing and difficulty catching his breath. His FEV 1 is 51% at the time of presentation. He is given alternating albuterol and ipratropium nebulizer treatments along with oral prednisone. After one hour his FEV 1 has increased 65%. The appropriate disposition for Jason at this point is: Response Feedback: Question 38 “B” is the correct answer. The EPR-3 guidelines for management of asthma in the urgent and emergency care setting indicate that if the FEV 1 remains below 70% after one hour of emergency care that the patient should be admitted. “A” is not correct—he does not have an indication for intubation as his FEV 1 is improving and is not approaching the 40% that would indicate intubation. “C” is not correct—he has already been assessed and treated for one hour and at this point admission is indicated. “D” is not correct—he cannot be discharged to home unless his FEV 1 is > 70% A patient in the intensive care unit suddenly becomes tachypneic and dyspneic. The physical examination reveals pale, cool, clammy skin and an arterial blood gas demonstrates hypocapnea and hypoxia. Pulmonary artery pressure demonstrates a pattern consistent with obstructive shock. The AGACNP knows that which of the 1 out of 1 points
following causes of this presentation is most likely? Response Feedback: “D” is the correct answer. Pulmonary embolus, cardiac tamponade, and pneumothorax are the most common causes of obstructive shock. The obstructive shock, along with the remaining classic symptom presentation, makes pulmonary embolus very likely. “A” is not correct—the septic patient would demonstrate pulmonary artery pressures consistent with distributive shock. “B” is not correct —the patient with congestive heart failure would demonstrate vascular congestion and cardiogenic shock. “C” is not correct—this patient would demonstrate intravascular hypovolemic shock. Question 39 0 out of 1 points Mr. Bowers is an 81-year-old male who is being terminally extubated at the request of his family due to the presence of a large subdural hematoma with a shift; the patient is not initiating respirations on his own and the prognosis is very poor. After he is extubated he begins to initiate his own respirations and 24 hours later has not expired yet. The decision is made to leave him in the hospital on a general medical floor rather than transfer to another facility for hospice. Which of the following is the best indicator that the patient’s death is imminent? Response Feedback: “A” is the correct answer. Patient may survive in hospice care for days or even weeks after all support, including food and fluids, are withdrawn. “B,” “C,” and “D” can occur for weeks in patients who manage to sustain cardiopulmonary function. However, when there is no urine being produced, the combination of volume contraction and electrolyte and metabolic imbalance will cause death very quickly. The cessation of urine output is the strongest marker of the answer choices provided to predict imminent cardiac arrest. Question 40 A patient is newly admitted to your service for open reduction and internal fixation of 0 out of 1 points the left hip. She seems very down, and as you talk with her you realize that her mood is not just related to her hip fracture. Which of the following symptoms would not be consistent with major depressive disorder? Response Feedback: “D” is the correct answer. Major depressive disorder is not diagnosed when the symptoms may be attributed to bereavement over a loss of < 2 months duration. Conversely, “A,” “B,” and “C” are all consistent with a diagnosis of major depressive disorder.
Feedback: from which to view the amplitude and direction of electrical activity as it moves through the heart in terms of length, width, and depth; the inferior, lateral, and anterior walls respectively. “A” is not correct because QRS axis is determined from the inferior and lateral leads only. “B” is not correct, both atrial and ventricular abnormalities can be determined from a lesser number of select leads. Similarly “D” is not correct as it does not take 12 leads to assess contraction and relaxation. Question 44 A 49-year-old male presents for evaluation of chest tightness. It has happened before, but he just ignored it and it went away. Today he just could not ignore it anymore. He 0 out of 1 points has always enjoyed good health and says he has never been told that he has any chronic medical conditions like high blood pressure or diabetes. A 12-lead ECG demonstrates changes consistent with inferior wall ischemia. Both his symptoms and inferior wall changes improve with the administration of sublingual nitroglycerin. Consistent with ACS protocol, this patient’s assessment is consistent with: Response Feedback: “A” is the correct answer. ACS protocol categorizes acute myocardial pain as either unstable angina/non-ST elevation MI (low or high risk), and ST elevation MI. A non-ST elevation (subendocardial) MI is treated in the same manner as unstable angina and the only question is whether the patient is at high risk or low risk —this is determined by an objective assessment including tools like TIMI and GRACE scores. An ST elevation MI is an infarct that spans the entire thickness of the myocardium and warrants fibrinolytics if the patient is a candidate. This patient presents with inferior wall ischemia which is unstable angina. Therefore the only question is whether he is high or low risk. His absence of medical history, dysrhythmia, instability or any other abnormalities implies low risk. He will be treated conservatively and referred for outpatient long term management of coronary artery disease. Question 45 Mr. Rosen is a 49-year-old male who is being managed for an acute myocardial infarction. He develops significant shortness of breath at rest and coarse rales 2/ up bilaterally. The AGACNP suspects acute pulmonary edema due to papillary muscle 0 out of 1 points rupture and acute mitral valve regurgitation. Which physical finding would support this finding? Response “B” is the correct answer. Murmur assessment requires identification
Feedback: of location (aortic, pulmonic, tricuspid, and mitral valves) and timing (systolic or diastolic). The murmur of mitral regurgitation occurs when the mitral valve is closed, which is a systolic event— therefore “C” and “D” are not correct. The mitral valve is best auscultated at the fifth intercostal space, midclavicular line, which makes “A” incorrect. “B” is the only answer choice that represents the mitral valve location during systole. Question 46 A patient with minor head trauma presents for evaluation. Which of the following findings should be followed up with a CT scan to rule out orbital fracture? 1 out of 1 points Response Feedback: “C” is the correct answer. Even with minor head trauma, > one half of all patients with a black eye will have orbital fracture; the presence of periorbital ecchymosis is an indication to CT scan the orbit. “A” is not correct—a positive Romberg test is more consistent with cerebellar dysfunction. “B” is not correct—it may be related to any number of etiologies or no identifiable ones, but there is no specific link to orbital fracture. “D” is not correct—in the setting of head injury bleeding from the ear’s is more consistent with increased intracranial pressure. Question 47 0 out of 1 points Mrs. Forbes is a 69-year-old lady being discharged from the hospital after complications following a cosmetic surgical procedure. She is basically in good health. She has a history of hypothyroidism for which she takes levothyroxine daily, and mild osteoarthritis which is controlled with only prn nonsteroidal use. Her blood pressure is 148/90 mm Hg. The AGACNP knows that in accordance with the most current guidelines published in JNC 8 the appropriate action is to: Response Feedback: “C” is the correct answer. Absent chronic kidney disease or diabetes, any adult > 60 years old has goal blood pressure of 150/90 mm Hg. This patient is at goal and should just proceed with normal health promotion. “A” is not correct—there is no indication for drug therapy. “B” is not correct—we are not given the patient’s weight, and given her age lack of comorbid kidney disease or diabetes, weight reduction is not indicated in response to her blood pressure. “D” is no correct—while these are the three first line drugs for hypertension and would be indicated if drug therapy were needed, this patient does not require any medication at this time
