NR 603: Advanced Clinical Diagnosis and
Practice Across the Lifespan
CEA Midterm Examination
Chamberlain University |
125 Questions with Expert Rationales
Instructions
• This examination covers advanced clinical diagnosis and management across the
lifespan, focusing on differential diagnosis, diagnostic reasoning, and evidence-based
treatment.
• Select the single best answer for each question.
• Rationales provide clinical reasoning and evidence-based explanations for each
correct answer.
Section 1: Cardiovascular Disorders (Questions 1-20)
1. A 58-year-old male with a 40-pack-year smoking history presents with
substernal chest pressure that occurs with exertion and resolves with rest. He
reports no symptoms at rest. Which of the following is the most likely
diagnosis?
A. Unstable angina
B. Stable angina
C. Myocardial infarction
D. Pericarditis
Answer: B
Rationale: Stable angina is characterized by reproducible chest discomfort with
,exertion or stress that resolves with rest or nitroglycerin. Unstable angina occurs at
rest or with minimal exertion and is increasing in frequency or severity.
2. A 62-year-old female presents with acute-onset severe, tearing chest pain
radiating to the back. Her blood pressure is 190/100 mmHg. Which of the
following is the most appropriate initial imaging study?
A. Chest X-ray
B. CT angiography of the chest
C. Echocardiogram
D. Electrocardiogram
Answer: B
Rationale: Aortic dissection presents with sudden, severe, tearing chest or back pain.
CT angiography is the imaging modality of choice for rapid diagnosis. ECG and chest
X-ray may be obtained but should not delay definitive imaging.
3. A 55-year-old male with a history of hypertension presents with new-onset
dyspnea on exertion, orthopnea, and bilateral lower extremity edema. Physical
exam reveals an S3 gallop and crackles in the lung bases. Which of the
following is the most appropriate initial diagnostic test?
A. Chest X-ray
B. B-type natriuretic peptide (BNP)
C. Echocardiogram
D. Electrocardiogram
Answer: B
Rationale: BNP is a sensitive marker for heart failure; elevated levels support the
diagnosis. Chest X-ray and echocardiogram are important but BNP is a rapid,
accessible initial test. Echocardiogram confirms ejection fraction and structural
abnormalities.
4. A 70-year-old male with a history of atrial fibrillation presents with sudden-
onset left leg pain, pallor, and pulselessness. Which of the following is the most
likely diagnosis?
A. Deep vein thrombosis
B. Acute arterial occlusion
C. Chronic venous insufficiency
D. Peripheral arterial disease
Answer: B
Rationale: Acute arterial occlusion presents with the six Ps: pain, pallor,
pulselessness, poikilothermia (coldness), paresthesia, and paralysis. Atrial fibrillation
is a risk factor for embolic occlusion. This is a vascular emergency.
,5. A 68-year-old female presents with episodes of palpitations, diaphoresis, and
headache. Her blood pressure is 180/105 mmHg during an episode and 130/80
mmHg between episodes. Which of the following is the most appropriate next
step?
A. 24-hour ambulatory blood pressure monitoring
B. Plasma metanephrines
C. Renal artery ultrasound
D. Thyroid function tests
Answer: B
Rationale: Paroxysmal hypertension with palpitations and diaphoresis is concerning
for pheochromocytoma. Plasma or urinary metanephrines are the initial screening
tests.
6. A 72-year-old male with a history of myocardial infarction presents with
progressive dyspnea and fatigue. Echocardiography reveals a left ventricular
ejection fraction of 30%. Which of the following medications has been shown
to reduce mortality in heart failure with reduced ejection fraction?
A. Digoxin
B. Furosemide
C. Carvedilol
D. Hydralazine
Answer: C
Rationale: Beta-blockers (carvedilol, metoprolol succinate, bisoprolol) reduce
mortality and hospitalizations in HFrEF. Digoxin reduces hospitalizations but not
mortality; furosemide is for symptom management.
7. A 65-year-old male presents with a blood pressure of 168/96 mmHg on three
separate occasions. He has no other comorbidities. According to JNC 8
guidelines, what is the initial treatment recommendation?
A. Lifestyle modification only
B. Start antihypertensive medication
C. Start medication if BP remains elevated after 6 months
D. Refer to cardiology
Answer: B
Rationale: JNC 8 recommends initiating antihypertensive medication for patients
with BP ≥140/90 mmHg (or ≥150/90 for those ≥60 years) regardless of other risk
factors, along with lifestyle modification.
8. A 58-year-old female presents with intermittent claudication in her calves
after walking one block. She has a 30-pack-year smoking history. Which of the
following is the most appropriate initial diagnostic test?
A. Ankle-brachial index (ABI)
, B. Arterial duplex ultrasound
C. CT angiography
D. Magnetic resonance angiography
Answer: A
Rationale: ABI is a simple, non-invasive test that compares ankle and brachial
systolic pressures. An ABI <0.90 is diagnostic for peripheral arterial disease. Further
imaging is reserved for those being considered for revascularization.
9. A 75-year-old male presents with syncope during exertion. On exam, a harsh
systolic ejection murmur is heard at the right upper sternal border radiating to
the carotids. Which of the following is the most likely diagnosis?
A. Aortic stenosis
B. Mitral regurgitation
C. Hypertrophic cardiomyopathy
D. Aortic regurgitation
Answer: A
Rationale: Aortic stenosis is characterized by a harsh, late-peaking systolic ejection
murmur at the right upper sternal border radiating to the carotids. Exertional
syncope occurs when cardiac output cannot meet increased demand.
10. A 62-year-old male with a history of hypertension presents with a blood
pressure of 210/115 mmHg, headache, and altered mental status. Which of the
following is the most appropriate management?
A. Oral clonidine and discharge
B. Intravenous antihypertensive and hospital admission
C. Sublingual nifedipine
D. Observation and recheck in 1 hour
Answer: B
Rationale: Hypertensive emergency is severe hypertension with acute end-organ
damage (altered mental status). This requires hospital admission and intravenous
antihypertensive therapy to achieve controlled reduction in blood pressure.
11. A 55-year-old male presents with chest pain that is worse with deep
inspiration and improves when leaning forward. He has a low-grade fever. ECG
shows diffuse ST-segment elevation. Which of the following is the most likely
diagnosis?
A. Myocardial infarction
B. Pericarditis
C. Pulmonary embolism
D. Aortic dissection
Practice Across the Lifespan
CEA Midterm Examination
Chamberlain University |
125 Questions with Expert Rationales
Instructions
• This examination covers advanced clinical diagnosis and management across the
lifespan, focusing on differential diagnosis, diagnostic reasoning, and evidence-based
treatment.
• Select the single best answer for each question.
• Rationales provide clinical reasoning and evidence-based explanations for each
correct answer.
Section 1: Cardiovascular Disorders (Questions 1-20)
1. A 58-year-old male with a 40-pack-year smoking history presents with
substernal chest pressure that occurs with exertion and resolves with rest. He
reports no symptoms at rest. Which of the following is the most likely
diagnosis?
A. Unstable angina
B. Stable angina
C. Myocardial infarction
D. Pericarditis
Answer: B
Rationale: Stable angina is characterized by reproducible chest discomfort with
,exertion or stress that resolves with rest or nitroglycerin. Unstable angina occurs at
rest or with minimal exertion and is increasing in frequency or severity.
2. A 62-year-old female presents with acute-onset severe, tearing chest pain
radiating to the back. Her blood pressure is 190/100 mmHg. Which of the
following is the most appropriate initial imaging study?
A. Chest X-ray
B. CT angiography of the chest
C. Echocardiogram
D. Electrocardiogram
Answer: B
Rationale: Aortic dissection presents with sudden, severe, tearing chest or back pain.
CT angiography is the imaging modality of choice for rapid diagnosis. ECG and chest
X-ray may be obtained but should not delay definitive imaging.
3. A 55-year-old male with a history of hypertension presents with new-onset
dyspnea on exertion, orthopnea, and bilateral lower extremity edema. Physical
exam reveals an S3 gallop and crackles in the lung bases. Which of the
following is the most appropriate initial diagnostic test?
A. Chest X-ray
B. B-type natriuretic peptide (BNP)
C. Echocardiogram
D. Electrocardiogram
Answer: B
Rationale: BNP is a sensitive marker for heart failure; elevated levels support the
diagnosis. Chest X-ray and echocardiogram are important but BNP is a rapid,
accessible initial test. Echocardiogram confirms ejection fraction and structural
abnormalities.
4. A 70-year-old male with a history of atrial fibrillation presents with sudden-
onset left leg pain, pallor, and pulselessness. Which of the following is the most
likely diagnosis?
A. Deep vein thrombosis
B. Acute arterial occlusion
C. Chronic venous insufficiency
D. Peripheral arterial disease
Answer: B
Rationale: Acute arterial occlusion presents with the six Ps: pain, pallor,
pulselessness, poikilothermia (coldness), paresthesia, and paralysis. Atrial fibrillation
is a risk factor for embolic occlusion. This is a vascular emergency.
,5. A 68-year-old female presents with episodes of palpitations, diaphoresis, and
headache. Her blood pressure is 180/105 mmHg during an episode and 130/80
mmHg between episodes. Which of the following is the most appropriate next
step?
A. 24-hour ambulatory blood pressure monitoring
B. Plasma metanephrines
C. Renal artery ultrasound
D. Thyroid function tests
Answer: B
Rationale: Paroxysmal hypertension with palpitations and diaphoresis is concerning
for pheochromocytoma. Plasma or urinary metanephrines are the initial screening
tests.
6. A 72-year-old male with a history of myocardial infarction presents with
progressive dyspnea and fatigue. Echocardiography reveals a left ventricular
ejection fraction of 30%. Which of the following medications has been shown
to reduce mortality in heart failure with reduced ejection fraction?
A. Digoxin
B. Furosemide
C. Carvedilol
D. Hydralazine
Answer: C
Rationale: Beta-blockers (carvedilol, metoprolol succinate, bisoprolol) reduce
mortality and hospitalizations in HFrEF. Digoxin reduces hospitalizations but not
mortality; furosemide is for symptom management.
7. A 65-year-old male presents with a blood pressure of 168/96 mmHg on three
separate occasions. He has no other comorbidities. According to JNC 8
guidelines, what is the initial treatment recommendation?
A. Lifestyle modification only
B. Start antihypertensive medication
C. Start medication if BP remains elevated after 6 months
D. Refer to cardiology
Answer: B
Rationale: JNC 8 recommends initiating antihypertensive medication for patients
with BP ≥140/90 mmHg (or ≥150/90 for those ≥60 years) regardless of other risk
factors, along with lifestyle modification.
8. A 58-year-old female presents with intermittent claudication in her calves
after walking one block. She has a 30-pack-year smoking history. Which of the
following is the most appropriate initial diagnostic test?
A. Ankle-brachial index (ABI)
, B. Arterial duplex ultrasound
C. CT angiography
D. Magnetic resonance angiography
Answer: A
Rationale: ABI is a simple, non-invasive test that compares ankle and brachial
systolic pressures. An ABI <0.90 is diagnostic for peripheral arterial disease. Further
imaging is reserved for those being considered for revascularization.
9. A 75-year-old male presents with syncope during exertion. On exam, a harsh
systolic ejection murmur is heard at the right upper sternal border radiating to
the carotids. Which of the following is the most likely diagnosis?
A. Aortic stenosis
B. Mitral regurgitation
C. Hypertrophic cardiomyopathy
D. Aortic regurgitation
Answer: A
Rationale: Aortic stenosis is characterized by a harsh, late-peaking systolic ejection
murmur at the right upper sternal border radiating to the carotids. Exertional
syncope occurs when cardiac output cannot meet increased demand.
10. A 62-year-old male with a history of hypertension presents with a blood
pressure of 210/115 mmHg, headache, and altered mental status. Which of the
following is the most appropriate management?
A. Oral clonidine and discharge
B. Intravenous antihypertensive and hospital admission
C. Sublingual nifedipine
D. Observation and recheck in 1 hour
Answer: B
Rationale: Hypertensive emergency is severe hypertension with acute end-organ
damage (altered mental status). This requires hospital admission and intravenous
antihypertensive therapy to achieve controlled reduction in blood pressure.
11. A 55-year-old male presents with chest pain that is worse with deep
inspiration and improves when leaning forward. He has a low-grade fever. ECG
shows diffuse ST-segment elevation. Which of the following is the most likely
diagnosis?
A. Myocardial infarction
B. Pericarditis
C. Pulmonary embolism
D. Aortic dissection
