MSN 622 FINAL ACTUAL EXAM 100+ QUESTION AND ANSWERS LATEST 2024 A 65-year-old man who is a heavy smoker presents with a complaint of pain in both legs when he walks. He claims he can only walk half a block over the past few years without pain. He has been a smoker for 35 years and also drinks alcohol. He does not have a history of hypertension or heart disease. The ankle-brachial index in both legs is 0.70. What should be done to lower this patient's myocardial infarction risk? - Start patient on aspirin or clopidogrel A 65-year-old woman presents to the clinic for a 1-year follow-up and medication management. Her medical history is significant for congestive heart failure, hypertension, hyperlipidemia, diabetes mellitus type 2, and chronic obstructive pulmonary disease (COPD). She has smoked 2 packs of cigarettes for 45 years. She drinks alcohol socially. Her current medications include lisinopril, hydrochlorothiazide, atorvastatin, metformin, albuterol, and inhaled fluticasone. Per the patient, she feels fine other than "some mild tingling in my feet." She denies chest pain, dyspnea, palpitations, dizziness, and weakness. She has not had laboratory work done in over 1 year. Her vital signs are temperature 37 °C (98.6 °F), heart rate 77 bpm, respiratory rate 16 breaths/min, and blood pressure 155/89 mm Hg. A physical exam is significant for absent bilateral pedal and posterior tibial artery pulses, significant edema, and brownish - The ratio of systolic ankle blood pressure to systolic brachial blood pressure A 65-year-old woman with claudication symptoms for the last six months presents to the clinic for evaluation. The patient has a history of diabetes and hypertension. She denies smoking. Physical exam shows palpable pulses on the bilateral lower extremities. Ankle-brachial index done at bedside shows a 1.1 on the right and 1.0 on the left lower extremity. What is the next best step in the management of this patient? - Repeat ankle-brachial index after exercise A 65-year-old female patient presents with complaints of progressive dyspnea on exertion for the past two weeks. The patient has a past medical history of hypertension. She has a 25-year smoking history but quit smoking 4 years ago. The patient reveals further that she initially had dyspnea only on moderate exertion, but now it occurs with activities like showering. The patient denies chest pain, cough, or wheezing. Her medications include metformin, amlodipine, and simvastatin. The patient appears comfortable at rest. Currently, she is afebrile and hemodynamically stable. Physical examination reveals bibasilar crackles. The patient's troponin-T level is normal. What changes are more likely to be seen on an electrocardiogram (ECG) if this patient is a suspected case of unstable angina? - Deep, symmetric T-wave inversions in V2 and V3 accompanied by flat ST-segment What heart sound would one hear in a patient with systolic congestive heart failure (CHF)? - S3 heart sound A 72-year-old man with a recent history of a large anterior wall myocardial infarction complains of dyspnea on exertion, orthopnea, and increasing pedal edema. There is concern about congestive heart failure. Which of the following would support the diagnosis? - . A S3 gallop Which of the following may be the initial presentation of long-term hypertension? - Cerebrovascular accident A patient presents with shortness of breath. Rales are heard in the lower lung fields. There is an S4. Hepatojugular reflux is present. The chest x-ray shows cardiomegaly and enlargement of the mediastinal veins. Congestive heart failure is suspected. Reduced bloodflow in the ascending aorta would not cause decreased blood flow in which of the following arteries? - . Pulmonary artery A 65-year-old man presents with a 4-hour history of progressively worsening left chest pain that radiates to his left neck. A history of present illness reveals minor episodes of transient chest pain over the last 6 months after climbing 2 flights of stairs or running. His past medical history includes hypertension, type 2 diabetes mellitus, and hyperlipidemia. His vital signs are oxygen saturation 98% on room air, respiratory rate 18 breaths/min, heart rate 91 bpm, blood pressure 131/91 mm Hg, and temperature 98.6 °F (37 °C). A 12-lead electrocardiogram (ECG) demonstrates ST depressions in leads V5, V6, and aVL. The patient is administered oxygen, morphine, nitroglycerin, and aspirin. What is the principle behind giving this patient nitroglycerin? - To dilate the venous system and decrease cardiac preload. A 65-year-old woman presents with intermittent, sudden-onset chest pain and shortness of breath, which radiates to her left jaw and arm. A history of present illness reveals that the pain initially occurred with activity, but now it occurs throughout the day. A review of systems is positive for tiring easily with mild physical activity. Her medical history is significant for hypertension and type 2 diabetes mellitus. An electrocardiogram (ECG) and cardiac enzyme markers are ordered. Which of the following tests will be most helpful in differentiating unstable angina from a non-ST segment elevation myocardial infarction (NSTEMI)? - Troponin I A 55-year-old asymptomatic, female smoker, with an extensive family history of premature coronary artery disease, presents to the office for further cardiovascular risk stratification. Her 10-year ASCVD risk score by the pool cohort equation is 5.3%, and she is concerned about testing for further risk stratification as she is reluctant to take medications. Which of the following is most appropriate to order to assist in treatment decision making? - Coronary artery calcium scoring A 51-year-old female patient presents with a chief complaint to shortness of breath, which is present only on exertion. She is a cashier in a local bank. Her history includes type 1 diabetes mellitus and hypertension. She is an active smoker for fifteen years and smokes one pack per day. Her BMI is 32.2. Her current medications include insulin, empagliflozin, and lisinopril. An EKG is obtained in the office, which shows normal sinus rhythm with heart rate 77/min. Evidence of left ventricular hypertrophy is also present on the EKG. An exercise stress test is scheduled, and the patient gets chest pain on the treadmill soon after it is started. Her echo shows a left ventricular ejection fraction of 30%. Cardiac catheterization is performed, which shows 3-vessel coronary artery disease. Which of the following is the best strategy for this patient's mechanical heart disease? - Coronary artery bypass graft (CABG) A 65-year-old man presents for preoperative evaluation. He plans to undergo bilateral total knee replacement for osteoarthritis, which has markedly limited his mobility. All conservative measures for osteoarthritis treatment have failed. He has medical history significant for hypertension, hyperlipidemia, and smoking. He received one drug-eluting stent to the left anterior descending artery four months ago for stable ischemic heart disease. Which of the following is the best step regarding this patient's clearance for surgery? - Defer surgery for at least 2 months. What is the most appropriate initial intervention for an older male who complains of leg pain with walking and at night who has weak pulses in both lower extremities and a reduced ankle-brachial index? - Lifestyle modification A 74-year-old woman smoker with hypertension was found to have weak right lower extremity pulses with a right ankle-brachial index (ABI) of 0.75. She denies any pain with walking. What is the most appropriate treatment? - Smoking cessation A 70-year-old patient comes to the clinic with complaints of increased blood pressure. He was diagnosed with hypertension 10 years ago. His other problems include osteoporosis and hyperlipidemia. His readings range from systolic 160 mmHg to 170 mmHg while diastolic falling in between 70 mmHg to 90 mmHg. His current blood pressure is 160/80 mmHg. His medications include lisinopril, amlodipine, atorvastatin, calcium and vitamin D supplements, and bisphosphonates. He does not exercise and smokes a pack of cigarettes daily. He drinks two glasses of beer every day. Family history is significant for stroke in father and MI in his sister. Which of the following is the most likely effect of increased blood pressure on his heart? - Left ventricular (concentric) hypertrophy A middle-aged patient with diabetes mellitus is referred to the clinic by his primary care provider to diagnose heart failure. The patient states that he does not have any documentation or labs from his previous medical encounters. Which of the following is the most significant and earliest sign of heart failure? - An S3 gallop A woman presents with chronic fatigue and trouble breathing. Upon inspection, there is peripheral edema and significant jugular venous pressure. She has had longstanding hypertension with exertional fatigue, which has been worsening over the past several years. She has not been adherent to medications. What is the most common cause of her symptoms? - Left-sided heart failure A 60-year-old woman with obesity and congestive heart failure (CHF) presents with a complaint of increased abdominal girth. She has noticed this occur over the last week, making her self-conscious about her appearance. She reports shortness of breath, constipation, and abdominal discomfort but denies nausea and vomiting or any changes in appetite. She also reports a history of cholecystectomy and frequently experiences constipation. Physical examination reveals jugular venous distension, pulmonary crackles, a non-tender distended abdomen, and bulging flanks. The liver is non-palpable. Which of the following is the best assessment of this patient? - There is a pathologic buildup of fluid in her peritoneum due to abnormal changes in her hydrostatic pressure due to a CHF exacerbation. Her serum albumin is 4 g/dL, and ascitic fluid albumin is 2 g/dL. A 65-year-old male patient with a medical history of hypertension, diabetes mellitus, and coronary artery disease is being evaluated for chronic stable anginal symptoms. He was prescribed sublingual nitroglycerin as needed for chest pain. Which of the following medications should be avoided in this patient due to this drug? - Sildenafil A 50-year-old man presents to the clinic for recurrent headaches. His office blood pressure has been consistently found to be elevated. He is not on any hypertensive agent. Home blood pressure diary measurements reveal an average systolic blood pressure (SBP) of 135 mm Hg and diastolic blood pressure (DBP) of 85 mm Hg over 3 weeks. The chemistry panel and electrocardiogram are normal. What is the best initial step in the management of this patient? - Hydrochlorothiazide A 44-year-old man comes to the clinic for a follow-up. The patient was found to have elevated blood pressure on his annual physical exam last week. He was thus asked to keep a blood pressure diary for one week. Today, the diary reveals an average blood pressure of between 125-135/80-85 mmHg over the past week. Which of the following the best advice to this patient by the nurse? - Get about 150 minutes of moderate-intensity exercise per week A 70-year-old man with chronic non-ischemic cardiomyopathy and hypertension presents to the emergency department with shortness of breath that started 2 days ago. His last known ejection fraction is 40%. His vitals are blood pressure 110/60 mmHg, heart rate 125 bpm, respiratory rate 20 breaths/min, and oxygen saturation 94% on ambient air. An ECG rhythm strip is shown below. What is the most appropriate treatment for this patient's arrhythmia at this time? - Diltiazem Which of the following findings indicates critical peripheral arterial disease? - . An ankle-brachial index <0.3 A 2-month-old male is brought to the emergency department in distress. He had a normal birth history. He had a history of viral illness 4 weeks ago, which resolved with time. His vital signs are a heart rate of 180 beats per minute, a blood pressure of 85/52 mmHg, a respiratory rate of 50 breaths per minute, and a temperature of 37 C (98.6 F). Physical examination reveals a pale-looking infant. The heart sounds are distant, and there is a gallop. A chest x-ray shows an enlarged cardiac shadow. The electrocardiogram has low voltage. Which of the following explains his presentation? - Dilated cardiomyopathy secondary to myocarditis Which of the following is the next step in managing a patient with claudication who has failed smoking cessation, cilostazol, and walking-trial therapy? - CT angiography A 78-year-old patient with a history of hypertension, coronary artery disease, New York Heart Association (NYHA) Functional Class 2, diabetes mellitus type 2, and Parkinson disease presents with intermittent claudication of the left leg. The