NR 603 CEA Midterm Exam (2026) - Advanced Clinical
Diagnosis Chamberlain University College of Nursing
Complete A+ Guide with Rationales
Section 1: Cardiovascular System (Questions 1-40)
1. A 62-year-old male presents to the emergency department with substernal
chest pressure that began 90 minutes ago while shoveling snow. The pain
radiates to his left arm and jaw, and he reports diaphoresis and nausea. His
blood pressure is 155/95 mmHg, heart rate 110 bpm. What is the most
appropriate initial diagnostic test?
A. Chest X-ray
B. 12-lead ECG
C. Cardiac troponin
D. Stress echocardiogram
Answer: B. 12-lead ECG
Rationale: For any patient presenting with symptoms suggestive of acute
coronary syndrome (ACS), a 12-lead ECG should be obtained within 10
minutes of arrival. The ECG can identify ST-elevation myocardial infarction
(STEMI) requiring immediate reperfusion therapy. While troponin is
important for diagnosis, the ECG provides immediate actionable information
for time-sensitive interventions .
2. The ECG shows ST-segment elevation in leads V1-V4. Which coronary
artery is most likely occluded?
A. Right coronary artery
B. Left circumflex artery
C. Left anterior descending artery
D. Posterior descending artery
Answer: C. Left anterior descending artery
Rationale: ST-segment elevation in the anterior precordial leads (V1-V4)
indicates an anterior wall myocardial infarction, which is typically caused by
,occlusion of the left anterior descending artery (LAD). The LAD supplies a
large portion of the left ventricular myocardium, and occlusion carries
significant morbidity and mortality .
3. A patient with chest pain has ECG findings consistent with acute STEMI.
Troponin I is elevated at 3.2 ng/mL (normal <0.04 ng/mL). According to
current ACC/AHA guidelines, what is the appropriate next step?
A. Administer aspirin and observe
B. Transfer for percutaneous coronary intervention (PCI)
C. Administer thrombolytics immediately
D. Perform stress testing
Answer: B. Transfer for percutaneous coronary intervention (PCI)
Rationale: For patients with STEMI, the ACC/AHA guidelines recommend
immediate reperfusion with primary PCI within 90 minutes of first medical
contact. If PCI cannot be performed within 120 minutes, fibrinolytic therapy
should be administered. Aspirin should be given immediately, but PCI is the
preferred reperfusion strategy .
4. A patient presents with chest pain that is sharp, positional, and worse
when lying flat. The pain improves when sitting forward. ECG shows diffuse
ST-segment elevation. What is the most likely diagnosis?
A. Acute myocardial infarction
B. Pericarditis
C. Pulmonary embolism
D. Aortic dissection
Answer: B. Pericarditis
Rationale: Acute pericarditis classically presents with sharp, pleuritic chest
pain that is positional—worse when lying flat and improved by sitting
forward. ECG shows diffuse ST-segment elevation (concave upward) and PR-
segment depression. A pericardial friction rub may be auscultated .
5. Which of the following findings is most specific for pericarditis?
A. ST-segment elevation in all leads except aVR and V1
B. Pathologic Q waves
,C. Deep T-wave inversions
D. Prolonged QT interval
Answer: A. ST-segment elevation in all leads except aVR and V1
Rationale: Acute pericarditis typically presents with diffuse ST-segment
elevation (concave upward) in most leads, with reciprocal ST depression in
aVR and V1. PR-segment depression may also be seen. This pattern reflects
subepicardial inflammation .
6. A 70-year-old female presents with dyspnea on exertion, orthopnea, and
peripheral edema. On auscultation, crackles are heard at both lung bases.
What is the most appropriate initial intervention?
A. Metoprolol
B. Furosemide
C. Lisinopril
D. Digoxin
Answer: B. Furosemide
Rationale: The patient is presenting with signs and symptoms of acute
decompensated heart failure, including pulmonary congestion (crackles,
dyspnea) and peripheral edema. Loop diuretics such as furosemide are the
mainstay of initial treatment to reduce volume overload and relieve
symptoms. After stabilization, guideline-directed medical therapy (GDMT)
should be initiated .
7. The New York Heart Association (NYHA) Class II heart failure is
characterized by:
A. No limitation of physical activity
B. Slight limitation; ordinary activity causes symptoms
C. Marked limitation; less than ordinary activity causes symptoms
D. Symptoms at rest
Answer: B. Slight limitation; ordinary activity causes symptoms
Rationale: NYHA Class II indicates slight limitation of physical activity.
Patients are comfortable at rest, but ordinary physical activity (e.g., walking
, one block, climbing one flight of stairs) causes fatigue, palpitation, or
dyspnea. This classification helps guide treatment decisions .
8. A patient with heart failure has an ejection fraction of 30%. Which
medication has demonstrated mortality benefit in heart failure with reduced
ejection fraction (HFrEF)?
A. Metoprolol tartrate
B. Carvedilol
C. Atenolol
D. Propranolol
Answer: B. Carvedilol
Rationale: Carvedilol, along with metoprolol succinate (not tartrate) and
bisoprolol, is FDA-approved for HFrEF and has demonstrated mortality
benefit in clinical trials. Carvedilol has additional alpha-1 blocking properties
that provide vasodilation .
9. A 55-year-old African American male has hypertension. According to
current guidelines, which class of medication is recommended as first-line
therapy for this patient?
A. ACE inhibitor
B. Angiotensin receptor blocker
C. Thiazide diuretic or calcium channel blocker
D. Beta-blocker
Answer: C. Thiazide diuretic or calcium channel blocker
Rationale: In African American patients, thiazide diuretics and calcium
channel blockers are recommended as first-line therapy due to lower renin
levels and better blood pressure response compared to ACE inhibitors or
ARBs. This recommendation is based on clinical trial data showing improved
outcomes with these agents .
10. A 68-year-old male presents with sudden onset of severe, tearing chest
pain that radiates to his back. He has a blood pressure of 160/50 mmHg in
the right arm and 110/70 mmHg in the left arm. What is the most likely
diagnosis?
Diagnosis Chamberlain University College of Nursing
Complete A+ Guide with Rationales
Section 1: Cardiovascular System (Questions 1-40)
1. A 62-year-old male presents to the emergency department with substernal
chest pressure that began 90 minutes ago while shoveling snow. The pain
radiates to his left arm and jaw, and he reports diaphoresis and nausea. His
blood pressure is 155/95 mmHg, heart rate 110 bpm. What is the most
appropriate initial diagnostic test?
A. Chest X-ray
B. 12-lead ECG
C. Cardiac troponin
D. Stress echocardiogram
Answer: B. 12-lead ECG
Rationale: For any patient presenting with symptoms suggestive of acute
coronary syndrome (ACS), a 12-lead ECG should be obtained within 10
minutes of arrival. The ECG can identify ST-elevation myocardial infarction
(STEMI) requiring immediate reperfusion therapy. While troponin is
important for diagnosis, the ECG provides immediate actionable information
for time-sensitive interventions .
2. The ECG shows ST-segment elevation in leads V1-V4. Which coronary
artery is most likely occluded?
A. Right coronary artery
B. Left circumflex artery
C. Left anterior descending artery
D. Posterior descending artery
Answer: C. Left anterior descending artery
Rationale: ST-segment elevation in the anterior precordial leads (V1-V4)
indicates an anterior wall myocardial infarction, which is typically caused by
,occlusion of the left anterior descending artery (LAD). The LAD supplies a
large portion of the left ventricular myocardium, and occlusion carries
significant morbidity and mortality .
3. A patient with chest pain has ECG findings consistent with acute STEMI.
Troponin I is elevated at 3.2 ng/mL (normal <0.04 ng/mL). According to
current ACC/AHA guidelines, what is the appropriate next step?
A. Administer aspirin and observe
B. Transfer for percutaneous coronary intervention (PCI)
C. Administer thrombolytics immediately
D. Perform stress testing
Answer: B. Transfer for percutaneous coronary intervention (PCI)
Rationale: For patients with STEMI, the ACC/AHA guidelines recommend
immediate reperfusion with primary PCI within 90 minutes of first medical
contact. If PCI cannot be performed within 120 minutes, fibrinolytic therapy
should be administered. Aspirin should be given immediately, but PCI is the
preferred reperfusion strategy .
4. A patient presents with chest pain that is sharp, positional, and worse
when lying flat. The pain improves when sitting forward. ECG shows diffuse
ST-segment elevation. What is the most likely diagnosis?
A. Acute myocardial infarction
B. Pericarditis
C. Pulmonary embolism
D. Aortic dissection
Answer: B. Pericarditis
Rationale: Acute pericarditis classically presents with sharp, pleuritic chest
pain that is positional—worse when lying flat and improved by sitting
forward. ECG shows diffuse ST-segment elevation (concave upward) and PR-
segment depression. A pericardial friction rub may be auscultated .
5. Which of the following findings is most specific for pericarditis?
A. ST-segment elevation in all leads except aVR and V1
B. Pathologic Q waves
,C. Deep T-wave inversions
D. Prolonged QT interval
Answer: A. ST-segment elevation in all leads except aVR and V1
Rationale: Acute pericarditis typically presents with diffuse ST-segment
elevation (concave upward) in most leads, with reciprocal ST depression in
aVR and V1. PR-segment depression may also be seen. This pattern reflects
subepicardial inflammation .
6. A 70-year-old female presents with dyspnea on exertion, orthopnea, and
peripheral edema. On auscultation, crackles are heard at both lung bases.
What is the most appropriate initial intervention?
A. Metoprolol
B. Furosemide
C. Lisinopril
D. Digoxin
Answer: B. Furosemide
Rationale: The patient is presenting with signs and symptoms of acute
decompensated heart failure, including pulmonary congestion (crackles,
dyspnea) and peripheral edema. Loop diuretics such as furosemide are the
mainstay of initial treatment to reduce volume overload and relieve
symptoms. After stabilization, guideline-directed medical therapy (GDMT)
should be initiated .
7. The New York Heart Association (NYHA) Class II heart failure is
characterized by:
A. No limitation of physical activity
B. Slight limitation; ordinary activity causes symptoms
C. Marked limitation; less than ordinary activity causes symptoms
D. Symptoms at rest
Answer: B. Slight limitation; ordinary activity causes symptoms
Rationale: NYHA Class II indicates slight limitation of physical activity.
Patients are comfortable at rest, but ordinary physical activity (e.g., walking
, one block, climbing one flight of stairs) causes fatigue, palpitation, or
dyspnea. This classification helps guide treatment decisions .
8. A patient with heart failure has an ejection fraction of 30%. Which
medication has demonstrated mortality benefit in heart failure with reduced
ejection fraction (HFrEF)?
A. Metoprolol tartrate
B. Carvedilol
C. Atenolol
D. Propranolol
Answer: B. Carvedilol
Rationale: Carvedilol, along with metoprolol succinate (not tartrate) and
bisoprolol, is FDA-approved for HFrEF and has demonstrated mortality
benefit in clinical trials. Carvedilol has additional alpha-1 blocking properties
that provide vasodilation .
9. A 55-year-old African American male has hypertension. According to
current guidelines, which class of medication is recommended as first-line
therapy for this patient?
A. ACE inhibitor
B. Angiotensin receptor blocker
C. Thiazide diuretic or calcium channel blocker
D. Beta-blocker
Answer: C. Thiazide diuretic or calcium channel blocker
Rationale: In African American patients, thiazide diuretics and calcium
channel blockers are recommended as first-line therapy due to lower renin
levels and better blood pressure response compared to ACE inhibitors or
ARBs. This recommendation is based on clinical trial data showing improved
outcomes with these agents .
10. A 68-year-old male presents with sudden onset of severe, tearing chest
pain that radiates to his back. He has a blood pressure of 160/50 mmHg in
the right arm and 110/70 mmHg in the left arm. What is the most likely
diagnosis?
