CEA Week 1 Final Exam
The suggested International Normalized Ratio (INR) range in a patient being treated for atrial
fibrillation is:
1.0-2.0
4.0-5.0
2.0-3.0
3.0-4.0 -2.0-3.0
Rationale
Remember that for international normalized ratio, the patient is their own normalization with an
INR of 1.0 as the standard of untreated blood, so with an INR of 2.0, think of the patient as twice
as thin for their blood as their normal. Protime can also be used to evaluate bleeding time for
warfarin patients, but has in general been replaced many years ago by the INR as the standard
measurement, where PTT (partial thromboplastin time) or Anti-Xa are more useful for evaluating
bleeding times related to Heparin therapy.
Nonpharmacologic therapy for Raynaud's disease include:
Use of hot soaks
Avoidance of cold
Isometric exercise
Ginkgo biloba -Avoidance of cold
Rationale
Raynaud's disease is a peripheral vascular syndrome triggered by cold exposure which causes
the patient to have extremely pale/white vasoconstricted digits followed by a over-dilated
vasoplegic response causing purplish painful revascularization. Avoidance of cold is the most
effective non-pharmacologic way to mitigate this event from occurring. Pharmacologic therapy
would include the use of medications such as calcium channel blockers.
,At a follow up from a hospitalization, an adult patient presents with ankle edema. Which of the
following medications is the most likely cause of the edema?
Metformin
HCTZ
Norvasc
Nebivolol -Norvasc
Rationale
The most common side effects of calcium channel blockers include constipation and lower
extremity edema. The other options do not have any relationship specifically with edema, in fact,
hydrochlorothiazide specifically reduces edema via diuresis.
An adult patient must maintain an International Normalized Ratio (INR) between 2.0 and 3.0.
The patient goes to a clinic for INR determination, and the result is 1.4. Which of the following
would likely decrease the effects of warfarin (Coumadin)?
Red meat
Grapefruit
Red Wine
Broccoli -Broccoli
Rationale
It's important to remember with warfarin (Coumadin) therapy that it is a vitamin K antagonist,
and therefore it can be counteracted by a patient who is eating a dietary intake of vitamin K.
Leafy green vegetables such as broccoli and spinach are notorious for increasing vitamin K
levels, and therefore inhibiting the anticoagulation effect of warfarin. It's also important to
remember that with the direct oral anticoagulants category, vitamin K is not affected, and
therefore no dietary restrictions are required for this class of medications such as apixaban,
rivaroxaban, and edoxaban, which is a distinct benefit over warfarin as noted above. Also, with
warfarin it is important to remember that the effects are based on the free drug, not the protein
bound drug level, so patients who have considerable protein stores will require more warfarin
than those who are emaciated or have low protein levels chronically.
With respect to this particular question, red wine and grapefruit do not have an effect of lowering
the INR, in fact, they will raise it by their unique mechanisms. Grapefruit specifically causes
warfarin levels to rise through the CYP 450 system, and red wine causes the INR to increase by
thinning the blood and and red meat is not likely to have a considerable impact, although it
might have some impact if the protein stores are otherwise low prior to initiating the red meat in
the diet. Broccoli is the only option that has vitamin K and should be an obvious choice for this
question.
A 50-year-old woman with a history of hypertension presents with dyspnea on exertion and
orthopnea. On examination, she has jugular venous distention and bilateral crackles on lung
auscultation. What is the most likely diagnosis?
Congestive heart failure
Pulmonary embolism
Acute myocardial infarction
Chronic obstructive pulmonary disease -Congestive Heart Failure
,Rationale
Of the available options, the most accurate response is congestive heart failure as it is signifying
both a right ventricular back up with jugular venous extension and crackles on lung assault,
which are suggestive of left ventricular back up. it is possible the patient may have an acute
myocardial infarction that precipitated this, however, a patient has not described that, rather is
only describing dyspnea on exertion and orthopnea, which both speak to a state of fluid
overload. The only appropriate response of these available is congestive heart failure.
An older adult female presents for her annual examination. She has been on antihypertensive
medications for over 20 years, with good control. Laboratory values are within normal ranges.
The nurse practitioner is concerned about the patient's cardiac health risks, due her to weight
and her waist circumference. According to the AHA guidelines, which of the following goals is
expected for this patient?
Physical activity for 60 minutes daily, for a minimum of 6 days a week
Physical activity for 30 minutes daily, for a minimum of 5 days a week
Physical activity for 60 minutes daily, 7 days a week
Physical activity for 30 minutes daily, 7 days a week -Physical activity for 30 minutes daily, for a
minimum of 5 days a week
A 75-year-old patient has just been discharged to a nursing facility following hospitalization for
an exacerbation of chronic heart failure. The patient's condition is classified as stage C, which
involves known structural heart disease with previous or present symptoms of failure. If the
patient is adherent to current clinical guidelines, the nurse practitioner who is visiting can expect
treatment to include which of the following medications?
Hydrochlorothiazide (HCTZ), lisinopril (Zestril), amlodipine (Norvasc)
Furosemide (Lasix), lisinopril (Zestril), carvedilol (Coreg)
Furosemide (Lasix), prazosin (Minipress), propranolol (Inderal)
Hydrochlorothiazide (HCTZ), metoprolol (Lopressor), losartan (Cozaar) -Furosemide (Lasix),
lisinopril (Zestril), carvedilol (Coreg)
Rationale
Goal directed therapy for reducing chronic symptoms of heart failure, and hopefully improving
ejection fraction in a patient with heart failure with reduced ejection fraction should include
carvedilol (Coreg) furosemide (Lasix) or another loop diuretic, and an ACE inhibitor/ARB or
ARB/ARNI such as sacubitril/valsartan (Entresto). Calcium channel blockers are contraindicated
and heart failure such as amlodipine (Norvasc).
Your patient presents with bradycardia, severe nausea, and substernal pain. STEMI was
identified on the EKG. Which region of the heart is most likely involved?
Lateral Wall
Anterior Wall
Inferior Wall
Septal Wall -Inferior Wall
Rationale
The inferior wall, fed by the right coronary artery is commonly associated with these symptoms.
Remember right equals rate as it is the blood supply for the SA and AV nodes in most patients.
Dyspepsia is common in RCA territory injury due to vagal stimulation not typical of other areas.
, What is the key long-term benefit of using carvedilol for patients with coronary artery disease
and heart failure with reduced ejection fraction (HFrEF)?
Increase in libido
Reduction in cardiac output
Baseline reduction of blood pressure
Potential increase in ejection fraction -Potential increase in ejection fraction
Rationale
EF increase is a key reason for using carvedilol over metoprolol for patients with low EF states.
Libido unfortunately can be negatively impacted by any beta blocker. Cardiac output should only
improve with long term use, not decrease, and beta blockers may reduce blood pressure
slightly, but that is not their key long-term benefit. In fact, they are not even considered for
routine anti-hypertensive management per JNC-8 guidelines.
Your patient presents with pale, waxy legs, weak peripheral pulses, and states he is having
difficulty walking great distances due to the pain in his calves. The most appropriate non-
invasive test to evaluate his leg vascular flow quality is which of the following exams?
Exercise stress test
Angiogram of the leg with runoff
Ankle Brachial Index (ABI)
Bilateral popliteal blood pressures -Ankle Brachial Index (ABI)
Rationale
ABI is the most effective way to evaluate vascular flow in a non-invasive way, and the
angiogram of the leg with runoff is the best invasive way. Bilateral popliteal blood pressures
would not show discretion between upper and lower body if both equally low, and exercise
stress tests are not used as a diagnostic tool for claudication or PAD.
An adult patient presents with tachycardia and nervousness. The patient is currently taking
levothyroxine (Synthroid), 75 mcg daily. The nurse practitioner orders a thyroid-stimulating
hormone (TSH) and anticipates having to:
lower the dose to 50 mcg daily.
continue the same daily dose.
raise the dose to 100 mcg daily.
add atenolol, 50 mg daily. -lower the dose to 50 mcg daily.
Rationale
The patient is presenting with symptoms of hyperthyroidism, and since they are being
supplemented with levothyroxine for hypothyroidism, it's suggestive that they are overdosing
and their dose should be decreased. The only option that is appropriate is to lower the dose to
50 mcg daily, and although adding a 50 mg daily dose of propranolol may be helpful to manage
symptoms for a hyperthyroid patient, this hyperthyroid presentation is related to overmedication.
To evaluate this more directly, the patient should have a TSH and T3/T4 level drawn and it is
likely we would find the TSH is low, T3 and T4 are elevated.
Pheochromocytoma is best diagnosed by which of the following tests:
The suggested International Normalized Ratio (INR) range in a patient being treated for atrial
fibrillation is:
1.0-2.0
4.0-5.0
2.0-3.0
3.0-4.0 -2.0-3.0
Rationale
Remember that for international normalized ratio, the patient is their own normalization with an
INR of 1.0 as the standard of untreated blood, so with an INR of 2.0, think of the patient as twice
as thin for their blood as their normal. Protime can also be used to evaluate bleeding time for
warfarin patients, but has in general been replaced many years ago by the INR as the standard
measurement, where PTT (partial thromboplastin time) or Anti-Xa are more useful for evaluating
bleeding times related to Heparin therapy.
Nonpharmacologic therapy for Raynaud's disease include:
Use of hot soaks
Avoidance of cold
Isometric exercise
Ginkgo biloba -Avoidance of cold
Rationale
Raynaud's disease is a peripheral vascular syndrome triggered by cold exposure which causes
the patient to have extremely pale/white vasoconstricted digits followed by a over-dilated
vasoplegic response causing purplish painful revascularization. Avoidance of cold is the most
effective non-pharmacologic way to mitigate this event from occurring. Pharmacologic therapy
would include the use of medications such as calcium channel blockers.
,At a follow up from a hospitalization, an adult patient presents with ankle edema. Which of the
following medications is the most likely cause of the edema?
Metformin
HCTZ
Norvasc
Nebivolol -Norvasc
Rationale
The most common side effects of calcium channel blockers include constipation and lower
extremity edema. The other options do not have any relationship specifically with edema, in fact,
hydrochlorothiazide specifically reduces edema via diuresis.
An adult patient must maintain an International Normalized Ratio (INR) between 2.0 and 3.0.
The patient goes to a clinic for INR determination, and the result is 1.4. Which of the following
would likely decrease the effects of warfarin (Coumadin)?
Red meat
Grapefruit
Red Wine
Broccoli -Broccoli
Rationale
It's important to remember with warfarin (Coumadin) therapy that it is a vitamin K antagonist,
and therefore it can be counteracted by a patient who is eating a dietary intake of vitamin K.
Leafy green vegetables such as broccoli and spinach are notorious for increasing vitamin K
levels, and therefore inhibiting the anticoagulation effect of warfarin. It's also important to
remember that with the direct oral anticoagulants category, vitamin K is not affected, and
therefore no dietary restrictions are required for this class of medications such as apixaban,
rivaroxaban, and edoxaban, which is a distinct benefit over warfarin as noted above. Also, with
warfarin it is important to remember that the effects are based on the free drug, not the protein
bound drug level, so patients who have considerable protein stores will require more warfarin
than those who are emaciated or have low protein levels chronically.
With respect to this particular question, red wine and grapefruit do not have an effect of lowering
the INR, in fact, they will raise it by their unique mechanisms. Grapefruit specifically causes
warfarin levels to rise through the CYP 450 system, and red wine causes the INR to increase by
thinning the blood and and red meat is not likely to have a considerable impact, although it
might have some impact if the protein stores are otherwise low prior to initiating the red meat in
the diet. Broccoli is the only option that has vitamin K and should be an obvious choice for this
question.
A 50-year-old woman with a history of hypertension presents with dyspnea on exertion and
orthopnea. On examination, she has jugular venous distention and bilateral crackles on lung
auscultation. What is the most likely diagnosis?
Congestive heart failure
Pulmonary embolism
Acute myocardial infarction
Chronic obstructive pulmonary disease -Congestive Heart Failure
,Rationale
Of the available options, the most accurate response is congestive heart failure as it is signifying
both a right ventricular back up with jugular venous extension and crackles on lung assault,
which are suggestive of left ventricular back up. it is possible the patient may have an acute
myocardial infarction that precipitated this, however, a patient has not described that, rather is
only describing dyspnea on exertion and orthopnea, which both speak to a state of fluid
overload. The only appropriate response of these available is congestive heart failure.
An older adult female presents for her annual examination. She has been on antihypertensive
medications for over 20 years, with good control. Laboratory values are within normal ranges.
The nurse practitioner is concerned about the patient's cardiac health risks, due her to weight
and her waist circumference. According to the AHA guidelines, which of the following goals is
expected for this patient?
Physical activity for 60 minutes daily, for a minimum of 6 days a week
Physical activity for 30 minutes daily, for a minimum of 5 days a week
Physical activity for 60 minutes daily, 7 days a week
Physical activity for 30 minutes daily, 7 days a week -Physical activity for 30 minutes daily, for a
minimum of 5 days a week
A 75-year-old patient has just been discharged to a nursing facility following hospitalization for
an exacerbation of chronic heart failure. The patient's condition is classified as stage C, which
involves known structural heart disease with previous or present symptoms of failure. If the
patient is adherent to current clinical guidelines, the nurse practitioner who is visiting can expect
treatment to include which of the following medications?
Hydrochlorothiazide (HCTZ), lisinopril (Zestril), amlodipine (Norvasc)
Furosemide (Lasix), lisinopril (Zestril), carvedilol (Coreg)
Furosemide (Lasix), prazosin (Minipress), propranolol (Inderal)
Hydrochlorothiazide (HCTZ), metoprolol (Lopressor), losartan (Cozaar) -Furosemide (Lasix),
lisinopril (Zestril), carvedilol (Coreg)
Rationale
Goal directed therapy for reducing chronic symptoms of heart failure, and hopefully improving
ejection fraction in a patient with heart failure with reduced ejection fraction should include
carvedilol (Coreg) furosemide (Lasix) or another loop diuretic, and an ACE inhibitor/ARB or
ARB/ARNI such as sacubitril/valsartan (Entresto). Calcium channel blockers are contraindicated
and heart failure such as amlodipine (Norvasc).
Your patient presents with bradycardia, severe nausea, and substernal pain. STEMI was
identified on the EKG. Which region of the heart is most likely involved?
Lateral Wall
Anterior Wall
Inferior Wall
Septal Wall -Inferior Wall
Rationale
The inferior wall, fed by the right coronary artery is commonly associated with these symptoms.
Remember right equals rate as it is the blood supply for the SA and AV nodes in most patients.
Dyspepsia is common in RCA territory injury due to vagal stimulation not typical of other areas.
, What is the key long-term benefit of using carvedilol for patients with coronary artery disease
and heart failure with reduced ejection fraction (HFrEF)?
Increase in libido
Reduction in cardiac output
Baseline reduction of blood pressure
Potential increase in ejection fraction -Potential increase in ejection fraction
Rationale
EF increase is a key reason for using carvedilol over metoprolol for patients with low EF states.
Libido unfortunately can be negatively impacted by any beta blocker. Cardiac output should only
improve with long term use, not decrease, and beta blockers may reduce blood pressure
slightly, but that is not their key long-term benefit. In fact, they are not even considered for
routine anti-hypertensive management per JNC-8 guidelines.
Your patient presents with pale, waxy legs, weak peripheral pulses, and states he is having
difficulty walking great distances due to the pain in his calves. The most appropriate non-
invasive test to evaluate his leg vascular flow quality is which of the following exams?
Exercise stress test
Angiogram of the leg with runoff
Ankle Brachial Index (ABI)
Bilateral popliteal blood pressures -Ankle Brachial Index (ABI)
Rationale
ABI is the most effective way to evaluate vascular flow in a non-invasive way, and the
angiogram of the leg with runoff is the best invasive way. Bilateral popliteal blood pressures
would not show discretion between upper and lower body if both equally low, and exercise
stress tests are not used as a diagnostic tool for claudication or PAD.
An adult patient presents with tachycardia and nervousness. The patient is currently taking
levothyroxine (Synthroid), 75 mcg daily. The nurse practitioner orders a thyroid-stimulating
hormone (TSH) and anticipates having to:
lower the dose to 50 mcg daily.
continue the same daily dose.
raise the dose to 100 mcg daily.
add atenolol, 50 mg daily. -lower the dose to 50 mcg daily.
Rationale
The patient is presenting with symptoms of hyperthyroidism, and since they are being
supplemented with levothyroxine for hypothyroidism, it's suggestive that they are overdosing
and their dose should be decreased. The only option that is appropriate is to lower the dose to
50 mcg daily, and although adding a 50 mg daily dose of propranolol may be helpful to manage
symptoms for a hyperthyroid patient, this hyperthyroid presentation is related to overmedication.
To evaluate this more directly, the patient should have a TSH and T3/T4 level drawn and it is
likely we would find the TSH is low, T3 and T4 are elevated.
Pheochromocytoma is best diagnosed by which of the following tests:
