FNP Review questions and answers 2021/2022 with complete solutions.

According to the National Heart, Lung and Blood Institute, which characteristic listed below is a coronary heart disease (CHD) risk equivalent; that is, which risk factor places the patient at similar risk for CHD as a history of CHD? a. Hypertension b. Cigarette smoking c. Male age 45 years d. Diabetes mellitus d. Diabetes mellitus Rationale: In determining whether a patient should be treated for hyperlipidemia, a patient's risk factors must be determined. After assessing fasting lipids, specifically LDLs, CHD equivalents must be identified. These are diabetes, symptomatic carotid artery disease, peripheral artery disease, abnormal aortic aneurysm, and multiple risk factors that confer a 10 year risk of CHD 20%. Major CHD risk factors are elevated LDL cholesterol, cigarette smoking, hypertension, low HDL cholesterol, family history of premature CHD [in male first degree relatives (FDR) 55years; female FDR, 65 years] , and age (men ≥ 45 years, women ≥ 55 years). Patients with 2 or more risk factors should have a 10 risk assessment performed and treated accordingly. A patient will be screened for hyperlipidemia via a serum specimen. He should be told: a. to fast for 12 to 14 hours b. to fast for 6 to 8 hours c. that black coffee is allowed d. a non-fasting state will not affect the results a. to fast for 12 to 14 hours Rationale: Serum total and HDL cholesterol can be measured in fasting or non-fasting individuals. There are very small and clinically insignificant differences in these values when fasting or not. The primary effect of eating on a patient's lipid values is on the triglyceride levels. The maximum effect of eating on triglyceride levels occurs at 3 to 4 hours after eating, but there may be several peaks during a 12-hour period. Therefore, the most accurate triglyceride levels will be obtained following a 12-hour fast. A 65-year-old male patient has the following lipid levels: Total cholesterol = 240 mg/dL LDL = 140 mg/dL HDL = 35 mg/dL Triglycerides = 129 mg/dL What class of medications is preferred to normalize his lipid levels and reduce his risk of a cardiac event? a. Niacin b. Fibric acids c. HMG Co-A reductase inhibitors d. Bile acid sequestrants c. HMG Co-A reductase inhibitors Rationale: The only medication class that reduces elevated lipid levels and has proven efficacy in reducing risk of cardiac events, even for primary prevention, is a HMG Co-A reductase inhibitor, a statin. Statin therapy has been shown to reduce overall mortality due to cardiovascular deaths. The statin should significantly reduce his total cholesterol and LDL levels. Which test listed below may be used to exclude a secondary cause of hyperlipidemia in a patient with elevated lipids? a. CBC b. TSH c. Urine culture and sensitivity d. Sedimentation rate b. TSH Rationale: Patients who have dyslipidemia should be screened for diabetes, renal disease, and hypothyroidism. Nephrotic syndrome can produce remarkably elevated cholesterol levels. Therefore, measurements of glucose, creatinine, and thyroid stimulating hormone should be performed when elevating dyslipidemia. Sedimentation rate is a measurement of non-specific inflammation and so it is not helpful in this situation. Specifically, hypothyroidism can produce marked lipid abnormalities. In order to reduce lipid levels, statins are most beneficial when taken: a. once daily in the AM b. always with food c. with an aspirin in the evening d. in conjunction with diet and exercise d. in conjunction with diet and exercise Rationale: Statins are used to reduce elevated level of lipids in conjunction with modifications in diet and exercise. The timing of statin dosing and and indication with food (or not) is different for each statin. Most patients who take statins are also candidates for aspirin therapy as primary or secondary prevention, but aspirin does not improve statin tolerance. Statins are correctly taken once daily. A patient is taking atorvastatin for newly diagnosed dyslipidemia complains of muscle aches in his upper and lower legs for the past 3-weeks. It has not improved with rest. How should this be evaluated? a. Stop the atorvastatin immediately. b. Check liver enzymes first. c. Order a CPK level d. Ask about nighttime muscle cramps. c. Order a CPK level Rationale: This patient has a complaint of myalgias that could be associated with statin use. This patient should be assessed for rhabdomyolysis. This is done by measuring a CPK level. If this level is elevated, atorvastatin should be stopped immediately. Liver enzymes would not assess for the etiology of myalgias. They assess tolerance of statins in the liver. Nighttime muscle cramps are not associated with statin use. Which hypertensive patient is most likely to have adverse blood pressure effects from excessive sodium consumption? a. 21-year-old Asian American male b. 35-year-old menstruating female c. 55-year-old post menopausal female d. 70-year-old African American male d. 70-year-old African American male Rationale: Two groups of patients typically experience adverse blood pressure effects from consumption of sodium greater than 2,000 mg daily. Those patients considered to be most sodium sensitive are elderly patients and African American patients. A patient with poorly controlled hypertension and history of myocardial infarction 6-years-ago presents today with mild shortness of breath. He takes quinapril, ASA, metoprolol, and a statin daily. What symptom in NOT indicative of a heart failure exacerbation? a. fatigue b. headache c. orthopnea d. cough b. headache Rationale: Fatigue is a common symptom in cardiac patients that can represent a worsening of many cardiac diseases such as coronary artery disease, heart failure, and valvular dysfunction. Orthopnea and cough, especially nocturnal, are classic symptoms of heart failure. A patient with newly diagnosed heart failure has started fosinapril in the last few days. She has developed a cough. What clinical finding can help distinguish the etiology of the cough as heart failure? a. It is dry and non-productive. b. It is wet and worse with recumbence. c. It is purulent and tachycardia accompanies it. d. Shortness of breath always results after coughing. b. It is wet and worse with recumbence. Rationale: The cough associated with fosinapril (an ACE inhibitor), is dry, non-productive and may be described as annoying. Its severity does not change with position or time of day. A cough associated with heart failure is wet, worse when lying down, and is usually described by patients as "worse at night". A cough that is purulent and when tachycardia accompanies it is often associated with fever and probably reflects an infectious process like pneumonia. A patient with shortness of breath has suspected heart failure. What diagnostic test would best help determine this? a. Echocardiogram b. B type natriuretic peptide (BNP) c. EKG d. Chest x-ray b. B type natriuretic peptide (BNP) Rationale: BNP is a hormone involved in regulation of blood pressure and fluid volume. When the BNP level is 80 pg/mL or greater, the sensitivity and specificity is 98% and 92%, favoring a diagnosis of heart failure. Alternatively, BNP level less than 80 pg/mL strongly suggest that heart failure is not present (some U.S. institutions use 100 pg/mL). Other conditions may cause elevated BNP levels: thoracic and abdominal surgery, renal failure, and subarachnoid hemorrhage. Consequently, careful assessment of the patient is prudent. Echocardiograms mechanically evaluate the heart and establish an ejection fraction. If 35-40%, then CHF can usually be diagnosed. Ejection fractions do not always correlate with patient symptoms. EKG evaluates the electrical activity of the heart. Chest x-ray can indicate heart failure, but a BNP is a more sensitive measure. Which class of medication id frequently used to improve long-term outcomes in patients with systolic dysfunction? a. Loop diuretics b. Calcium channel blockers c. ACE inhibitors d. Thiazide diuretics c. ACE inhibitors Rationale: ACE inhibitors are commonly used in patients with systolic dysfunction because they reduce morbidity and mortality, i.e. these medications alter prognosis. They also improve symptoms of fatigue, shortness of breath, and exercise intolerance. Loop and thiazide diuretics improve symptoms, but do not alter long-term prognosis with heart failure. Beta blockers should be used in conjunction with ACE inhibitors and diuretics, but not as solo agents. Beta blockers can potentially worsen heart failure, so their use in patients with heart failure should be monitored carefully. Ramipril has been initiated at a low dose in a patient with heart failure. What is most important to monitor in about one week? a. Heart rate b. Blood pressure c. EKG d. Potassium level d. Potassium level Rationale: ACE inhibitors work in the kidney in the renin angiotensin aldosterone system and can impair renal excretion of potassium in patients with normal kidney function. In patients with impaired renal blood flow and/or function, the risk of hyperkalemia is increased. Common practice is to monitor potassium, BUN, and Cr at about one week after initiation of an ACE inhibitor and with each increase in dosage. Which medication listed below could potentially exacerbate heart failure in a susceptible individual? a. Metoprolol b. Furosemide c. Metformin d. Acetaminophen a. Metoprolol Rationale: Metoprolol is a cardioselective beta blocker that decreases heart rate. A patient with heart failure wil compensate for heart failure by increasing heart rate to maintain cardiac output (CO). Metoprolol impairs the patient's ability to increase heart rate when needed to maintain cardiac output (CO=stroke volume x heart rate). Consequently, the use of beta blockers in patients with heart failure should be monitored carefully. Furosemide may actually improve shortness of breath in a patient with heart failure. Metformin and acetaminophen have no direct effect on cardiac output on a patient with heart failure. A 75-year-old patient with longstanding hypertension takes a combination ACE inhibitor/thiazide diuretic and amlodipine daily. Today his diastolic blood pressure and heart rate are elevated. He has developed dyspnea on exertion and peripheral edema over the past several days. These symptoms demonstrate: a. primary renal dysfunction b. development of heart failure c. failure of HCTZ d. dietary indiscretions b. development of heart failure Rationale: The symptoms of increased heart rate in the presence of dyspnea on exertion and peripheral edema are symptoms of heart failure. Longstanding hypertension is a major risk factor for development of heart failure. Dietary indiscretion, like sodium/fluid excess may produce peripheral edema, but should not produce dyspnea and peripheral edema in the absence of heart failure. A medication which may produce exercise intolerance in a patient with hypertension is a. hydrochlorothiazide b. amlodipine c. metoprolol d. fosinopril c. metoprolol Rationale: Metoprolol is a cardioselective beta blocker. It will produce bradycardia that is responsible for exercise intolerance. As a patient exercises, concomitant increase in heart rate allows for an increase in cardiac output. If the heart rate is not able to increase because of beta blocker influence, neither can the cardiac output. The patient will necessarily slow down his physical activity. Choices a and d have no direct effect on heart rate. Amlodipine is a calcium channel blocker that does not decrease heart rate. A 40-year-old African American patient has a B/P readings of 175/100 and 170/102. What is the reasonable plan of care for this patient today? a. Start low dose thiazide diuretic b. Start an ACE inhibitor twice daily c. Initiate low dose HCTZ and candesartan d. Initiate amlodipine, beta blocker, or ACE inhibitor c. Initiate low dose HCTZ and candesartan Rationale: This patient has Stage 2 hypertension based on JNC VII's classification of hypertension. Stage 2 hypertension should be treated initially with two medications and lifestyle modifications. Based on this, choice c is the best response. A single medication is unlikely to decrease his blood pressure to a normal range. A patient with hypertension describes a previous allergy to a sulfa antibiotic as "sloughing of skin" and hospitalization. Which medication is contraindicated in this patient? a. Ramipril b. Metoprolol c. Hydrochlorothiazide d. Verapamil c. Hydrochlorothiazide Rationale: This patient's allergy to "sulfa" sounds like Stevens-Johnson Syndrome, a potentially life-threatening allergic reaction. Hydrochlorothiazide has a sulfonamide ring in its chemical structure, generally referred to as "sulfa". This sulfonamide ring can initiate an allergic reaction in patients with sulfa allergy. Since the patient's allergic reaction to sulfa was so serious, other sulfonamide medications should be completely avoided until consultation with an allergist. The other medications can be used without concern in the presence of a patient with sulfa allergy because there is no sulfonamide component. Which item below represents the best choice of anti-hypertensive agents for the indicated patient? a. Beta blocker for a 38-year-old diabetic patient b. ACE inhibitor for a patient on a K⁺ sparing diuretic c. Beta blocker for a 46-year-old patient with migraines d. Diuretic for a patient with a history of gout c. Beta blocker for a 46-year-old patient with migraines Rationale: Beta blockers may be used is prophylactic agents in patients with migraine headaches, thus, serving to treat hypertension and as prophylaxis for migraine headaches in this patient. Beta blockers may mask the signs and symptoms of hypoglycemia in patients with diabetes. They should be used with caution, but use when indicated. ACE inhibitors decrease potassium loss and should not be routinely used in patients who are on potassium sparing diuretics because hypercalcemia may result. Diuretics can produce hyperuricemic states due to fluid loss. Therefore, they should be avoided in patients with gout. A patient has poorly controlled hypertension for more than 10 years. Indicate the most likely position of his point of maximal impulse (PMI): a. 5th Intercostal space (ICS) mid-clavicular line (MCL) b. 8th ICS MCL c. 5th ICS, left of MCL d. 6th ICS, right of MCL c. 5th ICS, left of MCL Rationale: The PMI or apical impulse is produced when the left ventricle moves anteriorly and touches the chest wall during contraction. This is normally found at the 5th intercostal space, mid-clavicular line. Certain conditions and diseases like heart failure, cardiomyopathy may account for this, or left ventricular hypertrophy from prolonged hypertension can displace the apical impulse. The displacement usually occurs left and laterally from its usual location. Thus, 5th ICS, left of mid-clavicular line. Conditions like pregnancy may displays apical impulse upward and to the left. Which laboratory abnormality may be observed in a patient who takes lisinopril? a. Decreased INR b. Decreased calcium level c. Increased potassium level d. Increased ALT/AST c. Increased potassium level Rationale: Lisinopril is an ACE inhibitor. This medication causes retention of potassium. A potassium level should be measured about one month after initiating therapy and after each dose change. The other laboratory values are not specific to changes that can take place when a patient takes an ACE inhibitor. A patient with hypertension has taken hydrochlorothiazide 25 mg daily for the past 4-weeks. His B/P has decreased from 155/95 to 145/90. How should the nurse practitioner proceed? a. Wait 4-weeks before making a dosage change b. Increase the hydrochlorothiazide to 50 mg daily c. Add a drug from another class to the daily 25 mg of hydrochlorothiazide d. Stop the hydrochlorothiazide and start a drug from a different class c. Add a drug from another class to the daily 25 mg of hydrochlorothiazide Rationale: Although we do not know this patient's age, race, or target blood pressure, it still exceeds the minimum threshold of 140/90 mm Hg. It is not acceptable to continue the current dose. Increasing the hydrochlorothiazide to 50 mg daily will not result in a decrease in blood pressure, only an increase in potassium loss. Adding a drug from a different medication class is a good choice because the combined effects of antihypertensive medications nearly always produce a decrease in blood pressure and both drugs can be maintained in low doses to minimize side effects. Which study would be most helpful in evaluating the degree of hypertrophy of the atrium or ventricle? a. Chest x-ray b. Electrocardiogram c. Echocardiogram d. Doppler ultrasound c. Echocardiogram Rationale: Echocardiography is of greatest value when evaluating values, chamber size, cardiac output, and overall function of The myocardium. It is non-invasive and allow specific measurement of chamber size and thickness of the myocardium. The chest film is important in identification of chamber enlargement, but its primary importance is in assessment of the pulmonary vasculature. Electrocardiography (ECG) provides information about the hearts conduction system and identifies cardiac rhythm, though ventricular enlargement can be identified on ECG. Doppler ultrasound identifies intracardiac flow velocities and can assist in quantifying the severity of regurgitation or stenosis.