2026/2027
NR 603 CEA Midterm Exam Clinical
Diagnosis Preparation Manual
2026/2027 with Exam-Style
Questions, Rationales, and Study
Materials
Question 1
A 52-year-old man presents with a productive cough, low-grade fever, and malaise. A
chest radiograph demonstrates a focal area of consolidation adjacent to the left cardiac
border on the PA view, approximately two rib spaces above the costophrenic angle.
On the lateral view, the lesion obscures the normal lucent area posterior to the cardiac
silhouette. Which pulmonary structure is most likely involved?
A. Left upper lobe apex
B. Right middle lobe
C. Left upper lobe lingula
D. Left lower lobe
Correct Answer: C. Left upper lobe lingula
Rationale: The lingula of the left upper lobe lies adjacent to the left heart border.
When consolidation occurs in the lingula, the cardiac silhouette becomes obscured on
chest radiography, producing the classic silhouette sign. Right middle lobe pathology
can obscure the right heart border, while left lower lobe disease typically affects the
diaphragm rather than the cardiac margin. The left upper lobe apex is located
superiorly and would not create the radiographic findings described.
Question 2
A patient with longstanding hypertension undergoes echocardiography. The study
reveals preserved ejection fraction but impaired ventricular relaxation and elevated
filling pressures. Which diagnosis best explains these findings?
A. Systolic heart failure
B. Restrictive pericarditis
C. Diastolic dysfunction
D. Dilated cardiomyopathy
Correct Answer: C. Diastolic dysfunction
,2026/2027
Rationale: Diastolic dysfunction is characterized by impaired myocardial relaxation
and reduced ventricular compliance, resulting in elevated filling pressures despite
preserved systolic function. It commonly occurs in patients with chronic hypertension
and ventricular hypertrophy. Systolic heart failure involves reduced contractility and
decreased ejection fraction. Restrictive pericarditis and dilated cardiomyopathy can
affect filling but do not specifically describe the inability of the myocardium itself to
relax.
Question 3
A 48-year-old African American man has persistent hypertension despite adherence to
a DASH diet, sodium restriction, weight reduction, and regular exercise. According to
current hypertension treatment guidelines, which medication is most appropriate as
first-line pharmacologic therapy?
A. Lisinopril
B. Hydrochlorothiazide
C. Metoprolol
D. Amlodipine
Correct Answer: D. Amlodipine
Rationale: Current hypertension guidelines recommend a dihydropyridine calcium
channel blocker such as amlodipine as an appropriate first-line treatment option for
many African American patients with uncomplicated hypertension. Calcium channel
blockers have demonstrated strong blood pressure-lowering efficacy in this
population. ACE inhibitors, beta-blockers, and other agents may be useful in specific
circumstances but are generally not preferred as initial monotherapy when no
compelling indications exist.
Question 4
A patient is diagnosed with a 4.5-cm ascending thoracic aortic aneurysm. Which
imaging modality is considered the standard method for serial surveillance and
accurate measurement of aneurysm progression?
A. Chest radiograph
B. Transesophageal echocardiography
C. CT angiography of the chest
D. Pulmonary embolism protocol CT scan
Correct Answer: C. CT angiography of the chest
Rationale: CT angiography (CTA) provides high-resolution images, accurate luminal
measurements, and multiplanar reconstruction capabilities, making it the preferred
method for monitoring thoracic aortic aneurysms. Chest radiographs lack sufficient
detail, while transesophageal echocardiography is more invasive and often
,2026/2027
unnecessary for routine surveillance. Pulmonary embolism CT protocols are timed for
pulmonary arterial visualization and may not optimally assess the aorta.
Question 5
Which of the following medications lacks beta-1 adrenergic receptor stimulation?
A. Dobutamine
B. Epinephrine
C. Norepinephrine
D. Phenylephrine
Correct Answer: D. Phenylephrine
Rationale: Phenylephrine is a selective alpha-1 agonist that produces vasoconstriction
without direct beta-1 receptor stimulation. Dobutamine primarily stimulates beta-1
receptors, increasing cardiac contractility and heart rate. Epinephrine and
norepinephrine both exhibit varying degrees of beta receptor activity. Understanding
receptor selectivity is important when selecting vasoactive medications in critically ill
patients.
Question 6
A 50-year-old woman with hypertension presents with dyspnea on exertion,
orthopnea, jugular venous distention, and bilateral crackles. Which diagnosis best
explains her clinical presentation?
A. Pulmonary embolism
B. Congestive heart failure
C. Asthma exacerbation
D. Community-acquired pneumonia
Correct Answer: B. Congestive heart failure
Rationale: This patient demonstrates evidence of both right-sided and left-sided
volume overload. Jugular venous distention indicates systemic venous congestion,
while bilateral crackles suggest pulmonary congestion from elevated left-sided filling
pressures. Dyspnea on exertion and orthopnea are classic symptoms of heart failure.
Pulmonary embolism, asthma, and pneumonia may cause respiratory symptoms but
do not typically produce the combined findings described.
Question 7
A patient with HFrEF and a recent myocardial infarction undergoes coronary stenting.
The ejection fraction is measured at 30%. Which post-discharge strategy is most
important for reducing sudden cardiac death risk?
, 2026/2027
A. Holter monitoring only
B. Repeat stress testing in 1 month
C. Baseline echocardiography and LifeVest placement
D. Discontinue guideline-directed medical therapy
Correct Answer: C. Baseline echocardiography and LifeVest placement
Rationale: Patients with severely reduced ejection fraction following myocardial
infarction are at increased risk for malignant ventricular arrhythmias and sudden
cardiac death. A wearable cardioverter-defibrillator (LifeVest) provides temporary
protection while guideline-directed medical therapy is optimized and ventricular
function is reassessed. Holter monitoring alone does not prevent fatal arrhythmias.
Therapy optimization and repeat evaluation are critical before considering permanent
ICD placement.
Question 8
Which population group has the lowest overall statistical risk for cardiovascular
disease among the options listed?
A. African Americans
B. Native Hawaiians
C. American Indians
D. Caucasians
Correct Answer: D. Caucasians
Rationale: Epidemiologic studies demonstrate higher rates of hypertension, diabetes,
obesity, and cardiovascular disease among African Americans, Native Hawaiians, and
American Indians compared with Caucasian populations. Although cardiovascular
disease affects all groups, these disparities contribute to increased risk in the other
populations listed.
Question 9
A 65-year-old smoker with hypertension has a lipid profile showing total cholesterol
of 240 mg/dL, HDL of 30 mg/dL, and LDL of 200 mg/dL. Her mother died from
myocardial infarction at age 40. Which intervention is most appropriate?
A. Observation only
B. Cholesterol absorption inhibitor alone
C. Bile acid sequestrant alone
D. Statin therapy
Correct Answer: D. Statin therapy
Rationale: This patient possesses multiple major cardiovascular risk factors, including
smoking, hypertension, markedly elevated LDL cholesterol, and a strong family
NR 603 CEA Midterm Exam Clinical
Diagnosis Preparation Manual
2026/2027 with Exam-Style
Questions, Rationales, and Study
Materials
Question 1
A 52-year-old man presents with a productive cough, low-grade fever, and malaise. A
chest radiograph demonstrates a focal area of consolidation adjacent to the left cardiac
border on the PA view, approximately two rib spaces above the costophrenic angle.
On the lateral view, the lesion obscures the normal lucent area posterior to the cardiac
silhouette. Which pulmonary structure is most likely involved?
A. Left upper lobe apex
B. Right middle lobe
C. Left upper lobe lingula
D. Left lower lobe
Correct Answer: C. Left upper lobe lingula
Rationale: The lingula of the left upper lobe lies adjacent to the left heart border.
When consolidation occurs in the lingula, the cardiac silhouette becomes obscured on
chest radiography, producing the classic silhouette sign. Right middle lobe pathology
can obscure the right heart border, while left lower lobe disease typically affects the
diaphragm rather than the cardiac margin. The left upper lobe apex is located
superiorly and would not create the radiographic findings described.
Question 2
A patient with longstanding hypertension undergoes echocardiography. The study
reveals preserved ejection fraction but impaired ventricular relaxation and elevated
filling pressures. Which diagnosis best explains these findings?
A. Systolic heart failure
B. Restrictive pericarditis
C. Diastolic dysfunction
D. Dilated cardiomyopathy
Correct Answer: C. Diastolic dysfunction
,2026/2027
Rationale: Diastolic dysfunction is characterized by impaired myocardial relaxation
and reduced ventricular compliance, resulting in elevated filling pressures despite
preserved systolic function. It commonly occurs in patients with chronic hypertension
and ventricular hypertrophy. Systolic heart failure involves reduced contractility and
decreased ejection fraction. Restrictive pericarditis and dilated cardiomyopathy can
affect filling but do not specifically describe the inability of the myocardium itself to
relax.
Question 3
A 48-year-old African American man has persistent hypertension despite adherence to
a DASH diet, sodium restriction, weight reduction, and regular exercise. According to
current hypertension treatment guidelines, which medication is most appropriate as
first-line pharmacologic therapy?
A. Lisinopril
B. Hydrochlorothiazide
C. Metoprolol
D. Amlodipine
Correct Answer: D. Amlodipine
Rationale: Current hypertension guidelines recommend a dihydropyridine calcium
channel blocker such as amlodipine as an appropriate first-line treatment option for
many African American patients with uncomplicated hypertension. Calcium channel
blockers have demonstrated strong blood pressure-lowering efficacy in this
population. ACE inhibitors, beta-blockers, and other agents may be useful in specific
circumstances but are generally not preferred as initial monotherapy when no
compelling indications exist.
Question 4
A patient is diagnosed with a 4.5-cm ascending thoracic aortic aneurysm. Which
imaging modality is considered the standard method for serial surveillance and
accurate measurement of aneurysm progression?
A. Chest radiograph
B. Transesophageal echocardiography
C. CT angiography of the chest
D. Pulmonary embolism protocol CT scan
Correct Answer: C. CT angiography of the chest
Rationale: CT angiography (CTA) provides high-resolution images, accurate luminal
measurements, and multiplanar reconstruction capabilities, making it the preferred
method for monitoring thoracic aortic aneurysms. Chest radiographs lack sufficient
detail, while transesophageal echocardiography is more invasive and often
,2026/2027
unnecessary for routine surveillance. Pulmonary embolism CT protocols are timed for
pulmonary arterial visualization and may not optimally assess the aorta.
Question 5
Which of the following medications lacks beta-1 adrenergic receptor stimulation?
A. Dobutamine
B. Epinephrine
C. Norepinephrine
D. Phenylephrine
Correct Answer: D. Phenylephrine
Rationale: Phenylephrine is a selective alpha-1 agonist that produces vasoconstriction
without direct beta-1 receptor stimulation. Dobutamine primarily stimulates beta-1
receptors, increasing cardiac contractility and heart rate. Epinephrine and
norepinephrine both exhibit varying degrees of beta receptor activity. Understanding
receptor selectivity is important when selecting vasoactive medications in critically ill
patients.
Question 6
A 50-year-old woman with hypertension presents with dyspnea on exertion,
orthopnea, jugular venous distention, and bilateral crackles. Which diagnosis best
explains her clinical presentation?
A. Pulmonary embolism
B. Congestive heart failure
C. Asthma exacerbation
D. Community-acquired pneumonia
Correct Answer: B. Congestive heart failure
Rationale: This patient demonstrates evidence of both right-sided and left-sided
volume overload. Jugular venous distention indicates systemic venous congestion,
while bilateral crackles suggest pulmonary congestion from elevated left-sided filling
pressures. Dyspnea on exertion and orthopnea are classic symptoms of heart failure.
Pulmonary embolism, asthma, and pneumonia may cause respiratory symptoms but
do not typically produce the combined findings described.
Question 7
A patient with HFrEF and a recent myocardial infarction undergoes coronary stenting.
The ejection fraction is measured at 30%. Which post-discharge strategy is most
important for reducing sudden cardiac death risk?
, 2026/2027
A. Holter monitoring only
B. Repeat stress testing in 1 month
C. Baseline echocardiography and LifeVest placement
D. Discontinue guideline-directed medical therapy
Correct Answer: C. Baseline echocardiography and LifeVest placement
Rationale: Patients with severely reduced ejection fraction following myocardial
infarction are at increased risk for malignant ventricular arrhythmias and sudden
cardiac death. A wearable cardioverter-defibrillator (LifeVest) provides temporary
protection while guideline-directed medical therapy is optimized and ventricular
function is reassessed. Holter monitoring alone does not prevent fatal arrhythmias.
Therapy optimization and repeat evaluation are critical before considering permanent
ICD placement.
Question 8
Which population group has the lowest overall statistical risk for cardiovascular
disease among the options listed?
A. African Americans
B. Native Hawaiians
C. American Indians
D. Caucasians
Correct Answer: D. Caucasians
Rationale: Epidemiologic studies demonstrate higher rates of hypertension, diabetes,
obesity, and cardiovascular disease among African Americans, Native Hawaiians, and
American Indians compared with Caucasian populations. Although cardiovascular
disease affects all groups, these disparities contribute to increased risk in the other
populations listed.
Question 9
A 65-year-old smoker with hypertension has a lipid profile showing total cholesterol
of 240 mg/dL, HDL of 30 mg/dL, and LDL of 200 mg/dL. Her mother died from
myocardial infarction at age 40. Which intervention is most appropriate?
A. Observation only
B. Cholesterol absorption inhibitor alone
C. Bile acid sequestrant alone
D. Statin therapy
Correct Answer: D. Statin therapy
Rationale: This patient possesses multiple major cardiovascular risk factors, including
smoking, hypertension, markedly elevated LDL cholesterol, and a strong family
