NURS 6560 MIDTERM EXAM – QUESTION AND ANSWERS

NURS 6560 MIDTERM EXAM – QUESTION AND
ANSWERS
Question 1

S. is a 59-year-old female who has been followed for several years for aortic
regurgitation. Serial echocardiography has demonstrated normal ventricular function,
but the patient was lost to follow-up for the last 16 months and now presents
complaining of activity intolerance and weight gain. Physical examination reveals a
grade IV/VI diastolic aortic murmur and 2+ lower extremity edema to the midcalf. The
AGACNP considers which of the following as the most appropriate management
strategy?

A. Serial echocardiography every 6 months B. Begin a calcium channel antagonist
C. Begin an angiotensin converting enzyme (ACE) inhibitor D. Surgical
consultation and intervention

C. Begin an angiotensin converting enzyme (ACE) inhibitor
The patient is having grade 6 diastolic aortic murmur. The murmur is not accompanied by any
serious complications because there is a 2+ lower extremity edema to the midcalf. Angiotensin
converting enzyme (ACE) inhibitor lowers the blood pressure. High blood pressure often
worsens the underlying conditions that cause heart murmurs. Beginning an angiotensin
converting enzyme (ACE) inhibitor will help in the management of diastolic aortic murmur by
dealing with the conditions that cause heart murmurs. A surgery would be used only when the
valves are damaged or leaky
Reference
https://www.mayoclinic.org/diseases-conditions/heart-murmurs/diagnosis-treatment/drc-
20373175




Question 2

An ascending thoracic aneurysm of > 5.5 cm is universally considered an indication for
surgical repair, given the poor outcomes with sudden rupture. Regardless of the
aneurysm’s size, all of the following are additional indications for immediate operation
except:

A. Comorbid Marfan’s syndrome B. Enlargement of > 1 cm since diagnosis C.
Crushing chest pain D. History of giant cell arteritis

C. crushing chest pain
Prophylactic surgery is recommended when the aorta reaches a diameter of 5.5 cm, when the
patient falls under the Marfan syndrome bicuspid aortic valve category, when the enlargement
is greater than 0.5 cm, and when the patient has a history of fast-growing cell arteritis. Marfan
syndrome is a connective tissue condition that involves the respiratory, skeletal,
cardiovascular and ocular systems. It is one of the most serious complication of aortic valve
regurgitations and needs an immediate surgery. For this reason, a crushing chest pain is the
odd one out
Reference
https://www.sciencedirect.com/science/article/pii/S235290671500010X

,Question 3

Jasmine is a 31-year-old female who presents with neck pain. She has a long history of
injection drug use and admits to injecting opiates into her neck. Physical examination
reveals diffuse tracking and scarring. Today Jasmine has a distinct inability to turn her
neck without pain, throat pain, and a temperature of 102.1°F. She appears ill and has
foul breath. In order to evaluate for a deep neck space infection, the AGACNP orders:

A. Anteroposterior neck radiography B. CT scan of the neck C. White blood cell
(WBC) differential D. Aspiration and culture of fluid

B. CT Scan of the neck
Deep neck space infection may lead to severe and potentially life-threatening complications,
such as airway obstruction, mediastinitis, septic embolization, dural sinus thrombosis, and
intracranial abscess.
In the evaluation of these infections, ultrasonography is the gold standard:
1. to differentiate abscesses from cellulitis
2. for the diagnosis of lymphadenitis
However, field-of-view limitation and poor anatomical information confine the use of
ultrasonography to the evaluation of superficial lesions and to image-guided aspiration or
drainage.
Computed tomography (CT) combines fast image acquisition and precise anatomical
information without field-of-view limitations. For these reasons, it is the most reliable
technique for the evaluation of deep and multi-compartment lesions
REFERENCE
https://www.ncbi.nlm.nih.gov/pubmed/22964409



Question 4

Mr. Draper is a 39-year-old male recovering from an extended abdominal procedure. As
a result of a serious motor vehicle accident, he has had repair of a small bowel
perforation, splenectomy, and repair of a hepatic laceration. He will be on total
parenteral nutrition postoperatively. The AGACNP recognizes that the most common
complications of parenteral nutrition are a consequence of:

A. Poorly calculated solution B. Resultant diarrhea and volume contraction C. The
central venous line used for infusion D. Bowel disuse and hypomotility

C. The central venous line used for infusion
Total parenteral nutrition is the administration of nutritional components via the venous
system rather than the enteral route/gastrointestinal tract. It can be total or partial where just
a selected number of nutrients are given
This type of nutrient administration comes with a myriad of challenges as a result of the many
complications associated with it. Among the complications the most common is infection which
commonly results from the central venous line used. The contamination of the blood stream is
with normal skin flora around the cannulation site, commonly staphylococcus organisms
The other complications include:
1. Dehydration and electrolyte Imbalances due to inadequate intake
2. Venous thrombosis
3. Hyperglycemia (high blood sugars)
4. Hypoglycemia (low blood sugars)
5. Micro-nutrient deficiencies (vitamin and minerals)

,Question 5

Mr. Mettenberger is being discharged following his hospitalization for reexpansion of his
second spontaneous pneumothorax this year. He has stopped smoking and does not
appear to have any overt risk factors. While doing his discharge teaching, the AGACNP
advises Mr. Mettenberger that his current risk for another pneumothorax is:

A. < 10% B. 25-50% C. 50-75% D. > 90

B. 25-50%
Having one pneumothorax increases the chances for a second and third. Mr. Mettenberger has
been discharge but no surgical intervention was employed to reduce the odds for a second. He
was hospitalized for expansion of his second spontaneous pneumothorax. While he has
stopped smoking and does not appear to have any overt risk factors, there is still a 25-50%
likelihood of having a third attack because there is no surgical intervention. His current risk for
another pneumothorax is 25-50%
Reference
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1758641/
https://www.merckmanuals.com/home/lung-and-airway-disorders/pleural-and-mediastinal-
disorders/pneumothorax


Question 6

One of the earliest findings for a patient in hypovolemic shock is:

A. A drop in systolic blood pressure (SBP) < 10 mm Hg for > 1 minute when sitting up
B. A change in mental status C. SaO2 of < 88% D. Hemoglobin and hematocrit
(H&H) < 9 g/dL and 27%

D. Hemoglobin and hematocrit (H & H) <9 g/dL and 27%.
Hypovolemic shock occurs due to excessive blood loss, either through hemorrhage or internal
bleeding. As blood is lost, hemoglobin is also lost, thus the hemoglobin levels will fall. The
normal hemoglobin levels in an adult ranges from 12 - 17.5 g/DL while the normal hematocrit
level ranges from 36% - 54%. In hypovolemic shock, the hemoglobin can fall to <9g/dL and the
hematocrit can fall to 27%. The blood pressure is likely to fall more than 10mmgHg. The little
blood left will be preferably channelled to the brain and the heart thus mental status
will not be affected until much later.



Question 7

Traumatic diaphragmatic hernias present in both acute and chronic forms. Patients with
a more chronic form are most likely to be present with:

A. Respiratory insufficiency B. Sepsis C. Bowel obstruction D. Anemia

B. Sepsis

, Patients with more chronic traumatic diaphragmatic hernias are most likely to present with
sepsis. Chronic traumatic diaphragmatic hernias can cause bloodstream infections.
Additionally, chronic traumatic diaphragmatic can trigger ventilator-associated pneumonia
(VAT). Ventilator-Associated pneumonia can trigger the body to release chemicals into the
bloodstream to fight the infections. As a consequence, the body's response to the bloodstream
infections and ventilator-associated pneumonia can be out of balance. When the body's
response to the chemicals is out of balance, the condition that occurs is sepsis
References
https://www.mayoclinic.org/diseases-conditions/sepsis/symptoms-causes/syc-20351214
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5359267/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3527804/



Question 8

The AGACNP is managing a patient in the ICU who is being treated for a pulmonary
embolus. Initially the patient was stable, awake, alert, and oriented, but during the last
several hours the patient has become increasingly lethargic. At change of shift, the
oncoming staff nurse appreciates a profound change in the patient’s mental status from
the day before. Vital signs and hemodynamic parameters are as follows: BP 88/54 mm
Hg Pulse 110 bpm Respiratory rate 22 breaths per minute SaO2 93% on a 50% mask
Systemic vascular resistance (SVR) 1600 dynes ∙ sec/cm5 Cardiac index 1.3 L/min
Pulmonary capillary wedge pressure (PCWP) 8 mm Hg This clinical picture is most
consistent with which shock state?

A. Hypovolemic B. Cardiogenic C. Distributive D. Obstructive

C. Distributive
This clinical picture is most consistent with distributive shock state. The vital signs and
hemodynamic parameters make distributive shock as the likely shock state. The cardiac
features of distributive shock include; a respiratory rate that is greater than 20 breaths per
minute, increased pulse pressure, heart rate greater than 90 beats per minute, systolic blood
pressure less than 90mmHg , and vascular resistance. The patient has a respiratory rate
of 22 breaths per minute, and BP of 88/54mmHg Pulse. For this reason, this clinical picture is
consistent with distributive shock state
References
https://emedicine.medscape.com/article/168689-clinical#b3
https://www.medscape.com/answers/168402-27289/what-are-the-causes-and-signs-of-
distributive-shock



Question 9

When counseling patients to prevent postoperative pulmonary complications, the
AGACNP knows that with respect to smoking cessation, the American College of
Surgeons and National Surgical Quality Improvement Program guidelines are clear that
patients who stop smoking _____ weeks before surgery have no increased risk of
smoking related pulmonary complications.

A. 2 B. 4 C. 6 D. 8

Question 10