FNP PREP Cardiac questions with completed 100% correct answers.

FNP PREP Cardiac questions with completed 100% correct answers.Which characteristic listed below is a CHD risk equivalent; that is, which risk factor places the patient at similar risk for CHD as a history of CHD? A) HTN B) Cigarette Smoking C) Male age 45 D) DM D) diabetes mellitus In determining whether a patient should be treated for hypercholesterolemia, a patient's risk category must be determined. After assessing fasting lipids, CHD equivalents must be identified. These are diabetes, symptomatic CAD, PAD, AAA, and multiple risk factors that confer a 10 yr risk of CHD 20%. A patient wants to be screened for hyperlipidemia via a serum specimen. He should be told: A) to fast for 12-14 hours B) to fast for 6-8 hours C) that black coffee is allowed D) a non-fasting state won't affect the results A) to fast for 12-14 hours 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 and not. The primary effect of eating on lipid values is on the triglyceride value. The maximum effect of eating on triglyceride levels occurs at 3-4 hours, but there may be several peaks during a 12 hour period. Therefore, the most accurate levels will be obtained following a 12 hour fast. 00:34 01:10 What class of medications will normalize lipid elevations and decrease risk of a cardiac event? A) Niacin B) Fibric acids C) Statins D) bile acid sequestrants C) Statins The only medication class that lowers elevated lipid levels and has proven efficacy in lowering risk of cardiac events, even for primary prevention is the statins. Statin therapy has been shown to reduce overall mortality due to cardiovascular deaths. Which test listed below may be used to exclude a secondary cause of hyperlipidemia in a patient with elevated lipids? A) CBC B) Urine culture and sensitivity C) TSH D) Fasting glucose C) TSH Patients who have hypercholesterolemia should be screened for diabetes, renal failure, and hypothyroidism. Nephrotic syndrome can produce remarkably elevated cholesterol levels. Therefore, measurements of glucose, creatinine, and TSH should be performed when evaluating hypercholesterolemia. A single fasting glucose is not used to diagnose diabetes (a confirmatory reading is always needed for diagnosis) and, therefore, could not be used in this example to exclude (or include) a secondary cause of hypercholesterolemia. In order to lower lipid levels, statins are taken: A) twice daily B) always with food C) with an aspirin D) in conjunction with diet and exercise D) in conjunction with diet and exercise Statins are used to lower elevated levels of lipids in conjunction with modifications in diet and exercise. They do not specifically need to be take with or without food or aspirin. Though, most patients who take statins are also candidates for aspirin as primary or secondary prevention. Statis are correctly take once daily. A patient taking lovastatin for hyperlipidemia complains of muscle aches in his thighs and right calf for the past three days that has not improved. He has taken lovastatin for 3 months. What should be done? A) Stop the lovastatin immediately B) Check liver enzymes C) Order a CPK D) Ask about nighttime muscle cramps C) order a CPK 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. If this value is elevated, lovastatin should be stopped immediately. Liver enzymes would not assess for myalgias. 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 Two groups of patients typically experience adverse blood pressure effects from consumption of sodium greater than 2000 mg daily. Those patients considered to be most sodium sensitive are elderly patients and African American patients; thus, choice d is the best choice listed. A patient with hypertension and myocardial infarction 6 years ago presents today with mild shortness of breath. He takes quinapril, ASA, metoprolol, and a statin daily. What symptom is NOT indicative of a CHF exacerbation? A) Fatigue B) Headache C) Orthopnea D) Cough B) Headache Fatigue is a common symptom in cardiac patients that can represent a worsening of many cardiac diseases such as coronary artery disease, CHF, valvular dysfunction. Orthopnea and cough, especially nocturnal, are classic symptoms of worsening CHF. A patient with chronic heart failure is on an angiotensin converting enzyme inhibitor. She has developed a cough. What clinical finding can help distinguish the etiology of the cough as chronic 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 The cough associated with an ACE inhibitor is dry, non-productive and is described as annoying. Its severity does not change with position or time of day. A cough associated with CHF is wet, worse when lying down, and is usually described by patients as "worse at night". Choice C is often associated with fever and thus, probably reflects an infectious process. A patient with SOB has suspected CHF. What test would best help determine this? A) Echocardiogram B) BNP C) EKG D) BUN/Cr B) BNP BNP stands for B type naturetic peptide. It 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 CHF. Alternatively, BNP levels less than 80 pg/mL strongly suggest that CHF is not present (some US 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. The most common class of medications used to treat a patient with systolic dysfunction post-myocardial infarction is: A) loop diuretics B) beta blockers C) ACE inhibitors D) thiazide diuretics C) ACE inhibitors 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, SOB, and exercise intolerance. Loop and thiazide diuretics improve symptoms, but do not alter long-term prognosis with CHF. Beta blockers should be used in conjunction with ACE inhibitors and diuretics, but, not as solo agents. Beta blockers can potentially worsen CHF, so their use in patients with CHF should be monitored carefully. Ramipril has been initiated at a low dose in a patient with CHF. What is most important to monitor in about one week? A) Heart rate B) blood pressure C) EKG D) Potassium level D) Potassium level ACE inhibitors work in the kidney 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 CHF in a susceptible individual? A) Metoprolol B) Furosemide C) Metformin D) Acetaminophen A) Metoprolol metoprolol is a cardioselective beta blocker which will slow heart rate and thus, inhibit the ability of a patient with CHF to have an increase in heart rate to compensate for a decreased cardiac output. The use of beta blockers in patients with CHF should be monitored carefully. Furosemide may actually improve SOB in a patient with CHF. Metformin and acetaminophen should have no direct effect on cardiac output in a patient with CHF. A 75 year old patient with longstanding hypertension takes an ACE inhibitor and a thiazide diuretic daily. Today his blood pressure is 128/88; pulse 98. He has developed dyspnea on exertion and peripheral edema over the past several days. These symptoms demonstrate: A) the need for better blood pressure management B) development of CHF C) noncompliance with medication D) fluid or sodium excess B) development of CHF The symptoms of dyspnea on exertion and peripheral edema are symptoms of mild CHF. Longstanding HTN is a major risk factor for development of CHF. Noncompliance with medications or sodium/fluid excess may produce peripheral edema, but it is unlikely that a 75 year old with a history of HTN would have dyspnea and peripheral edema in the absence of CHF. A medication which may produce exercise intolerance in a patient with HTN is: A) hydrochlorothiazide B) amlodipine C) metoprolol D) fosinopril C) Metoprolol Metoprolol is a cardioselective beta blocker. It will produce bradycardia that is responsible for exercise intolerance. As a patient exercises, a concomitant increase in heart rate allows for an increase in cardiac output. If the heart is not able to increase because of beta blocker influence, neither can the cardiac output. The patient will necessarily slow down his physical activity. Choice a and b 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 blood pressure readings of 175/100 and 170/102. What is a reasonable plan of care for this patient? A) Start HCTZ at 25mg daily B) Start the patient on an ACE inhibitor C) Initiate HCTZ and candesartan D) initiate amlodipine C) initiate HCTZ and candesartan This patient has Stage 2 HTN based on JNC VII's classification of HTN. Stage 2 HTN should be treated initially with 2 medications and life style modifications. Based on this, choice c is the best response. A single medication is unlikely to decrease his BP to a normal range. A patient with hypertension has an allergy to sulfa. Which medication is contraindicated in this patient? A) Ramipril B) Metoprolol C) Hydrochlorothiazide D) Verapamil C) Hydrochlorothiazide HCTZ 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. The other medications can be used without concern in the presence of a patient with a sulfa allergy because there is no sulfonamide component. Other medications to be avoided in patients with sulfa allergy are the loop diuretics, but furosemide may be used with caution. Which item below represents the best choice of anti-hypertensive agents? A) Beta blocker for a 38 year old diabetic patient B) ACE inhibitor for a patient on a K+ sparing diuretic C) Beta blocker in a 46 year old patient with migraines D) Diuretic in a patient with a history of gout C) Beta blocker in a 46 year old patient with migraines Beta blockers may be used as prophylactic agents in patients with migraine headaches, thus, serving to treat HTN and as prophylaxis for migraine headaches in this patient. Beta blockers may also mask the signs and symptoms of hypoglycemia in patients with diabetes. The should be used with caution. ACE inhibitors diminish potassium loss and so should not be routinely used in patients who are on potassium sparing diuretics because hyperkalemia may result. Diuretics can produce hyperuricemic states due to fluid loss. Therefore, they should be avoided in patients with gout. A patient has had poorly controlled HTN 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) 3rd ICS MCL C) 5th ICS, left of MCL D) 6th ICS, right of MCL C) 5ht ICS, left of MCL 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 ICS MCL. Certain conditions and diseases like CHF, cardiomyopathy may account for this; or , left ventricular hypertrophy from prolonged HTN can displace the apical impulse. The displacement usually occurs left and laterally from its usual location. Thus 5th ICS, left of MCL. Condition like pregnancy may displace the apical impulse upward and to the left. A patient has newly diagnosed HTN and has received a prescription for Ramipril. He takes no other medications and is otherwise healthy. Which laboratory test would be important to monitor in him? A) INR B) Calcium level C) Potassium level D) ALT/AST C) Potassium level Ramipril 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 HTN has taken 25 mg HCTZ daily for the past 4 weeks. His BP has decreased from 155/95 to 145/90. How should the NP proceed? A) Continue the HCTZ at 25mg daily B) Increase the HCYZ to 50mg daily C) Add a drug from another class to the daily 25mg HCTZ D) Stop the HCTZ and start a drug from a different class C) add a drug from another class to the daily 25mg HCTZ Although we don't know this patient's age, race, or target BP, it still exceeds the minimum threshold of 140/90 mm Hg. It is not acceptable to continue the current dose. Increasing the HCTZ to 50mg daily will not result in a decrease in BP, 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 BP. The valve most commonly involved in chronic rheumatic heart disease is the : A) aortic B) mitral C) pulmonic D) tricuspid B) mitral The mitral valve has a propensity for disorders secondary to rheumatic heart disease. Rarely, is the pulmonic valve involved, but, the aortic and tricuspid valves follow in descending order of involvement. Following an episode of rheumatic fever, which occurs infrequently in the US today but is common in developing countries, the valves can become stenotic or regurgitant. This is a major cause of valvular disease in the US seen primarily in immigrants. A patient has an audible diastolic murmur best heard in the mitral listening point. There is no audible click. His status have been monitored for the past 2 years. This murmur is probably: A) mitral valve prolapse B) acute mitral regurgitation C) chronic mitral regurgitation D) mitral stenosis D) mitral stenosis Mitral valve prolapse (MVP) is an unlikely etiology since MVP is a systolic murmur. Additionally, the question states there is no audible click, and a mid to late systolic click is characteristic of MVP. Acute mitral regurgitation (MR) develops usually after rupture of the chordae tendineae, ruptured papillary muscle after MI, or secondary to bacterial endocarditis. Symptoms of failure appear with abrupt clinical deterioration in the patient. There would not be a 2 year course for this patient. Dilation of the left atrium and ventricle is typical in chronic MR since both chambers are affected from regurgitant blood flow across the diseased valve, but, MR is a systolic murmur, not diastolic. This is mitral stenosis (MS) because MS produces the only diastolic murmur listed in the question. Enlargement of the atrium or ventricle is important in assessing a patient with an audible murmur. Which study below would be most helpful in evaluating the degree of hypertrophy of the atrium or ventricle? A) Chest x-ray B) electrocardiography C) Echocardiography D) Doppler ultrasound C) echocardiography Echocardiography is of greatest value when evaluation valves, 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 heart's 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. A 28 year old has a Grade 3 murmur. Which characteristic indicates a need for referral? A) a fixed spilt B) an increase in splitting with inspiration C) a split S2 with inspiration D) changes in intensity with position change A) a fixed split A split is created because of closure of valves. For example, an S2 is created by closure of the aortic and pulmonic valves. Normally these split with inspiration and almost never with expiration. Splits should never be fixed. This indicates some pathology like an atrial septal defect, pulmonic stenosis, or possibly mitral regurgitation. In any event, this patient needs evaluation because fixed splits are always considered abnormal. A 25 year old patient has aortic stenosis (AS). The etiology of his AS is probably: A) congenital B) rheumatic C) acquired calcific D) unknown A) congenital In someone younger than 65 years of age, the most likely cause is congenital. The aortic valve usually consists of three cusps, but some people are born with a bicuspid aortic valve. Rheumatic heart disease is the second most common cause of aortic stenosis in this age group, but, the incidence has decreased drastically in the last many decades because of the use of antibiotics to treat Streptococcal infections. In more than 90% of patients older than 65 years, acquired calcifications appear on a normal tricuspid valve and produce aortic stenosis. The most common arrhythmia resulting from valvular heart disease is : A) atrial fibrillation B) paroxysmal supraventricular tachycardia C) Ventricular fibrillation D) heart block A) atrial fibrillation The most common arrhythmia seen in all forms of valvular disease is atrial fibrillation. It is usually seen in patients with organic heart disease. Paroxysmal supraventricular tachycardia is one of the most common arrhythmias but often occurs in patients with no valvular heart disease. Ventricular fibrillation and heart block are more likely to represent disease in the conduction system of the myocardium.