NURS 6550 FINAL EXAM FOR SUMMER 2023- WALDEN
UNIVERSITY
Question 1
Mr. Jeffers was admitted 2 days ago for a carotid endarterectomy. A Foley catheter was inserted
intraoperatively and remains in place. His urine output has declined markedly despite continued
IV fluid infusion. Today his morning labs reveal a BUN of 19 mg/dL and a creatinine of 2
mg/dL. A leading differential includes:
A. Foley lodged in the urethra causing post-renal failure
B. Decreased renal perfusion causing prerenal failure
C. Age-related decreased eGFR causing prerenal failure
D. Post-surgical rhabdomyolysis causing intrarenal failure
Answer: D. Post-surgical rhabdomyolysis causing intrarenal failure
Rationale:
During surgery, muscles and injured. This can result into rhabdomyolysis, which is the
breakdown of muscles to release proteins. The excess proteins causes an increased level of
creatinine. Mr. Jeffers is from surgery (post-surgical) and his creatinine levels are above normal.
The normal creatinine levels range from 0.6mg/dl to 1.2mg/dl. Thus, the most likely differential
is: Post-surgical rhabdomyolysis causing intrarenal failure.
Question 2
Janet is admitted with symptomatic tachycardia. Her pulse is 160 b.p.m. and she is weak,
diaphoretic, and anxious. Physical examination reveals a 5’4” 107 lb black female who is awake,
alert, and oriented, anxious, with moist skin and racing pulse. Her blood pressure is 140/100 mm
Hg. Temperature and respiratory rate are within normal limits. The patient admits to having a
“thyroid condition” but she never followed up on it when she was advised to see an
endocrinologist. The AGACNP anticipates a diagnosis of:
A. Hashimoto’s thyroiditis
B. Cushing’s syndrome
C. Grave’s disease
D. Addison’s disease
Answer: C. Grave's disease
Question 3
Systemic lupus erythematosis (SLE) is a multiorgansystem autoimmune disorder that can
prevent with a wide variety of manifestations. Which clinical triad should prompt an evaluation
for SLE?
A. Fever, normal white count, elevated sedimentation rate
B. Hyperkalemia, hyponatremia, low blood pressure
C. Leukocytosis, hyperglycemia, hypokalemia
D. Joint pain, rash, fever
Answer: D. Joint pain, rash, fever
Question 4
A patient presents with profound vertigo of acute onset yesterday. She can barely turn her head
without becoming very vertiginous; she is nauseous and just doesn’t want to move. This morning
when she tried to get out of bed she felt like she was pushed back down. The vertigo is
reproducible with cervical rotation. The patient denies any hearing loss or tinnitus, she has no
fever or other symptoms. The AGACNP knows that the most helpful intervention will probably
be:
A. Meclizine
B. Diazepam
C. Bed rest
D. Epley’s maneuvers
Answer: D. Epley's maneuvers
Rationale:
The patient is likely suffering from benign paroxysmoly positioning vertigo. This is indicated by
inability to turn her head and to get up from the lying position in bed. The best intervention for
benign paroxysmal positioning vertigo is Epley's maneuvers. These maneuvers effectively clear
the inner ear to relieve symptoms of vertigo
Question 5
Mrs. Mireya is an 85-year-old female who is admitted for evaluation of acute mental status
change from the long term care facility. She is normally ambulatory and participates in lots of
facility activities. Today a nursing assistant found her in her room, appearing confused and
disconnected from her environment. When she tried to get up she fell down. Her vital signs are
stable excepting a blood pressure of 90/60 mm Hg. The AGACNP knows that the most likely
cause of her symptoms is:
A. Osteoarthritis
B. Drug or alcohol toxicity
C. Hypotension
D. Urosepsis
Answer: D. Urosepsis
Question 6
A patient with SIADH would be expected to demonstrate which pattern of laboratory
abnormalities?
A. Serum Na+ 119 mEq/L, serum osmolality 240 mEq/L, urine Na+ of 28 mEq/L, urine
osmolality of 900 mOsm/kg
B. Serum Na+ 152 mEq/L, serum osmolality 315 mEq/L, urine Na+ of 5 mEq/L, urine
osmolality of 300 mOsm/kg
C. Serum Na+ 121 mEq/L, serum osmolality 290 mEq/L, urine Na+ of 7 mEq/L, urine
osmolality of 850 mOsm/kg
D. Serum Na+ 158 mEq/L, serum osmolality 251 mEq/L, urine Na+ of 20 mEq/L, urine
osmolality of 420 mOsm/kg
Answer: A. Serum Na+ 119 mEq/L, serum osmolality 240 mOsm/kg, urine Na+ of 28 mEq/L,
urine osmolality of 900 mOsm/kg
Rationale:
Syndrome of inappropriate anti diuretic hormone is characterized by dilutional hyponatremia.
Serum sodium levels lower than 130mmol/L and urine osmolality less than 100mmol/L. Urine
sodium is less than 30mmol/L. Serum level of sodium is likely to be 121
Question 7
Sean is a 29-year-old male who presents to the emergency department for evaluation and
treatment of foreign body in the eye. Ophthalmic anesthesia is achieved and removal is
attempted unsuccessfully with a moist cotton tipped swab. A wet fluorescein stain is applied to
the lower eyelid, and a corneal abrasion ruled out but the AGACNP notes a positive Seidel sign.
This indicates:
A. Penetration of the cornea with resultant aqueous leak
B. A rust ring remnant due to metal foreign body
C. An elevated intraocular pressure
D. Paradoxical pupil dilation in response to light
Answer: A. Penentration of the cornea with resultant aqueous leak
Rationale:
A positive Seidel sign indicates a leakage from the anterior chamber into the cornea. It is used to
diagnose corneal disorders such as corneal perforation and corneal degeneration.
The AGACNP should therefore suspect Penentration of the cornea with resultant aqueous leak as
indicated by the positive Seidel sign.
Question 8
Mrs. Lowen is an 82-year-old female who comes to the emergency department for evaluation of
a fever of 102.9° F. She complains of a headache in the right side of her temple and some rightsided jaw pain. A urinalysis, chest radiograph, complete blood count (CBC) and 12-lead ECG are
all non- contributory. A comprehensive metabolic panel is significant only for a slightly elevated
BUN and creatinine. The AGACNP appreciates distinct right temple tenderness to percussion.
Which laboratory test is necessary to support the suspected diagnosis?
A. An erythrocyte sedimentation rate
B. A white blood cell differential
C. Two sets of blood cultures
D. Echocardiography
Answer: A. An erythrocyte sedimentation rate
Rationale:
Mrs. Lowen's most likely diagnosis is temporal arteritis, also known as, giant cell arteritis. The
disease presents with one-sided temporal headache accompanied with jaw pain, fatigue and
tenderness at the temples. The main diagnostic tests for temporal arteritis are erythrocyte
sedimentation rate and C-reactive protein levels
Question 9
Ms. Schiebel, a 31-year-old female who is brought to the emergency department by police after
being arrested for disruptive behavior in a public establishment. The differential diagnosis
includes drug and alcohol ingestion/toxicity, central nervous system disease, severe trauma, and
psychotic illness; ultimately the alcohol and toxicology screen as well as head imaging are
negative. When considering psychotic illness, the AGACP knows that this is a physiologic
imbalance that typically involves an excess of:
A. Serotonin
B. Norepinephrine
C. Acetylcholine
D. Dopamine
Answer: B. Norepinephrine
Rationale:
Since Mr. Schiebel has been arrested for disruptive behavior, he most likely suffers from maniac
behavioural disorder. Mania is a physiological imbalance disorder characterized by excessively
high levels of norepinephrine.
Question 10
Mr. Lincoln is a 55-year-old male who was admitted for management of sepsis secondary to
pneumonia. He has declined rapidly, and today chest radiography demonstrates a diffuse,
bilateral “white-out” appearance. His paO2 is 55 mm Hg. In order to increase his oxygenation the
AGACNP knows that which of the following interventions is indicated?
A. Increased FiO2
B. Increased respiratory rate
C. Increased tidal volume
D. Increased PEEP
Answer: C. Increased tidal volume
Rationale:
Tidal volume refers to the maximum amount of air that can be inhaled or exhaled during
breathing. When the amount of tidal volume increases, the amount of oxygen that is inhaled into
the lungs also increases. This results into an increase in the diffusion gradient and a subsequent
increase in the rate of diffusion of oxygen into the lungs. Therefore, the patient's (Mr. Lincoln's)
oxygenation will improve and his paO2 will rise/improve when his tidal volume is increased
Question 11
A 29-year-old female patient presents with a complaint of palpitations. Physical examination
reveals an essentially healthy female with no significant medical history and no maintenance
medications; the only thing she can report is that she had a head cold a week or so ago. The vital
signs include a blood pressure of 139/90 mm Hg, pulse of 105 b.p.m, respiratory rate of 16
b.p.m. and a temperature of 98.6° F. The only abnormal finding on physical examination is
diffuse anterior neck tenderness with thyroid palpation. The AGACNP considers which
medication for symptom control?
A. Ibuprofen
B. Pseudoephedrine
C. Propranolol
D. Methimazole
Answer: C. Propranolol
Rationale:
Excessive thyroid hormone causes thyrotoxicosis which is characterized by increased basal
metabolic rate, increased appetite and emotional lability .Hyperactivity of the thyroid gland
causes its enlargement. Management of this condition is by anti thyroid drugs. An example is
methimazole which is a thioamide that acts by inhibiting thyroid peroxidase they also block
coupling of iodotyrosines.
Question 12
Jennifer is an 18-year-old homeless female who was found unresponsive. She was admitted to
the hospital for management of severe bleeding after a spontaneous abortion escalated to a
uterine hemorrhage. An underlying infection and dehydration were corrected and nutritional
supplements were started. Her volume status is stable, morning labs were all within normal limits
and she is to be discharged today. When the AGACNP enters the room to prepare the patient for
discharge, she finds her agitated, pale, and diaphoretic with vital signs to include a pulse of 105
bpm, respirations of 24 bpm, blood pressure of 110/76 mm Hg and a temperature is 97.9° F. The
most appropriate action would be to:
A. Order a CBC to assess for recurrent bleeding
B. Request and abdominal CT to assess for bleeding
C. Evaluate the patient for anxiety/panic attack
D. Prescribe alprazolam 1 mg now
Answer: D. Prescribe alprazolam 1 mg now
Rationale:
Alprazolam is a benzodiazepine used to treat anxiety and panic attacks. Jennifer seems to be
having a panic attack since her respiratory rate and pulse are elevated. Her blood pressure is
however within the normal range, which rules out bleeding. If she was bleeding, then her blood
pressure would be below normal. It is important to immediately give her alprazolam then later on
after she has calmed down, evaluate her for anxiety disorders.
Question 13
Physical examination findings in a patient with pneumothorax is likely to reveal:
A. Increased tactile fremitus
B. Low grade temperature
C. Hyperresonance to percussion
D. Egophany
Answer: C. Hyperresonance to percussion
Rationale:
In pneumothorax, the lung is collapse and air is trapped within the pleural cavity. The presence
of trapped air in the pleural cavity increases the resonance heard during percussion. It is the
trapped air that causes Hyperresonance to percussion of the lungs during physical examination of
patients with pneumothorax.
Question 14
Mr. Parker brings his 73-year-old wife to a clinic appointment because he is worried about her.
She has a long history of hypertension and dyslipidemia, but he says she has taken medication
for years and everything has been OK. His concern today is that for a long time she has been
very forgetful, and he has tried to help her by keeping a strict routine around the house. Over the
past few months, she just seems more and more forgetful, does not seem interested in doing
anything, and now seems to be forgetting how to do simple everyday tasks. Yesterday she could
not figure out which dollar bills to use at the store to pay the cashier. The AGACNP knows Mrs.
Parker should first be screened for:
A. Depression
B. A brain tumor
C. Hypothyroidism
D. Adrenal dysfunction
Answer: C. Hypothyroidism
Rationale:
Hypothyroidism is associated with both hypertension and dyslipidemia. It is known to cause
difficulty in concentration and memory problems. Mrs. Parker has a medical history of
hypertension and dyslipidemia. She also presents with memory problems. It is therefore
important to screen her for hypothyroidism which is a likely diagnosis from her medical history.
Question 15
M.R. is a 40-year-old female who has a known history of peptic ulcer disease. She has been
admitted through the emergency room with a diagnosis of GI bleeding—she is vomiting dark
blood and had a nasogastric tube placed. When attached to low intermittent suction it initially
drained 400 cc of dark brown/black drainage, but now it is starting to drain lighter red colored
blood. The AGACNP knows that immediate priorities of care include:
A. Ensuring hemodynamic stability
B. Beginning a parenteral proton pump inhibitor
C. Beginning gastric lavage
D. Ordering a gastrointestinal consult
Answer: A. Ensuring haemodynamic stability
Rationale:
The emergency care for patients should start with: Assessing airway, breathing and circulation.
Hemodynamic stability is part of circulation. Thus, the immediate priorities of care for the
patient, from the options given, is Ensuring haemodynamic stability.
Question 16
A patient with sharp, stabbing chest pain directly over the precordium has a 12-lead ECG that
demonstrates concave ST-T wave elevations in leads II, III, avR, avL, avF, and all six precordial
leads. The AGACNP expects which physical finding?
A. A grade IV/VI systolic murmur with radiation to the axilla
B. A split S2 that increases with inspiration
C. A pericardial friction rub
D. An S4 heart sound
Answer: C. A pericardial friction rub
Rationale:
A sharp, stabbing, chest pain associated with concave SS-T wave elevations in leads II, III, avR,
avL, avF and all the six pericardial leads, suggest a diagnosis of pericarditis. Acute pericarditis is
diagnosed by the presence of a pericardial friction rub. The AGACNP should therefore expect A
pericardial friction rub, since the patient most likely has pericarditis.
Question 17
J.Q. is a 45-year-old male who had gastric bypass surgery 18 months ago. A CBC reveals a
macrocytic anemia with aHgb of 9.8 g/dL, HCT of 30%, MCV of 115 and RDW of 19%. The
AGACNP suspects which type of anemia?
A. Iron deficiency
B. Sickle cell anemia
C. Pernicious anemia
D. Anemia of chronic disease
Answer: C. Pernicious anaemia
Rationale:
In the stomach, food mixes with intrinsic factor which increases the absorption of vitamin B12 in
the ileum. However, in patients with gastric bypass, food does not get into the stomach, thus, the
food does not mix with intrinsic factor. Subsequently, there will be decreased absorption of
vitamin B12. Inadequate levels of vitamin B12 causes pernicious anaemia. This type of anaemia
(pernicious anaemia) presents with low haemoglobin count, low hematocrit and an elevated
MCV. Since J.Q has a medical history of gastric bypass surgery, low haemoglobin count, low
hematocrit and an elevated MCV, the AGACNP suspects pernicious anaemia.
Question 18
Megan K. is a 21-year-old female who presents complaining of irritated eyes. She says this
happens a couple of times a year and this time it is really a problem. Both eyes are itchy and red
and she has a lot of stringy discharge, especially at the end of the day. Her visual acuity is 20/25
OS, OD, and OU with her glasses on. Physical exam reveals injected conjunctiva bilaterally but
there is no photophobia. Pupils are equal, round, briskly reactive, and accommodate. The
AGACNP knows that immediate treatment should include ophthalmic application of:
A. Steroids
B. Antihistamine
C. Antibiotic
D. Cycloplegic
Answer: C. Antibiotic
Rationale:
Megan most likely has bacterial conjuctivitis. Conjunctivitis is often recurrent and occurs
bilaterally. The diagnosis of conjunctivitis is supported by Megan's red itchy eyes, bilaterally,
which occurs on-and-off. The stringy discharge indicates that the infection is bacterial. Thus, the
immediate treatment should include antibiotic therapy.
Question 19
Ellen is a 61-year-old female who presents with a chief complaint of neck pain. The history of
present illness reveals that Ellen felt as though a bug bit her behind the neck a few days ago. A
day or two later it started to hurt, and when she began to pick at it she felt drainage come out.
She is here now for evaluation. Physical exam reveals an 8 cm x 8 cm draining abscess in the
right post auricular region with posterior cervical lymphadenopathy. Ellen has a temperature
today of 101.9° F. The AGACNP knows that in addition to incision and drainage of the abscess,
effective management must include:
A. Systemic antibiotics
B. Tetanus immune globulin
C. Tetanus toxoid
D. Antipyretics
Answer: A. Systemic antibiotics
Rationale:
Ellen's body temperature is high; she has a fever which suggests an infection. This means that the
infection has infiltrated into her systemic circulatory system. Also, the lympadenopathy suggests
that her lymphatic system is affected. Thus, it is important to give her systemic antibiotics in
addition to performing an incision and drainage.
Question 20
A 13-year-old male presents with a chief complaint of ear drainage. The patient and his mother
both indicate that the patient has not had any pain or any systemic complaints, but the pus-like
discharge from the ear is very persistent. According to Mom they went to a retail clinic two
weeks ago and the patient was prescribed both oral antibiotics and ear drops, but it didn’t help.
Physical exam of the ear reveals a painless pinna; otoscope exam reveals only a large amount of
mucopurulent drainage—the tympanic membrane could not be visualized. The AGACNP knows
the diagnosis is most likely:
A. Acute otitis media
B. Acute otitis externa
C. Cholesteatoma
D. Otitis media with effusion
Answer: A. Acute Otitis Media
Rationale:
Middle ear infections such as acute otitis media do not respond to antibiotics or eardrops. They
often resolve on their own.
Acute otitis media presents with pus-like discharge and a painless pinna. The associated mucopurulent discharge is known as otorrhea.
Question 21
A 71-year-old male patient with lung cancer is admitted for treatment of sepsis related to his
chemotherapy-induced immunosuppression. He seems to be improving from an infectious
perspective, but during today’s assessment the AGACNP appreciates coarse rales in the lung
fields, a blood pressure of 140-100 mm Hg, a bounding pulse, and trace pretibial edema. The
urine output via Foley catheter has only been 100 mL in the last 8 hours. Suspicious for
syndrome of inappropriate antidiuretic hormone (SIADH), the AGACNP orders a basic
metabolic panel anticipating which of the following abnormalities?
A. Hypokalemia
B. Hypocalcemia
C. Hyponatremia
D. Hypochloremia
Answer: C. Hyponatremia
Rationale:
From the physical assessment findings (edema and bounding pulse) and the low urine output, the
patient seems to having acute renal failure. The syndrome of inappropriate antidiuretic hormone
(SIADH) causes increased production of ADH. The excess ADH produced causes more water to
be reabsorbed along the kidney tubules. As water is reabsorbed, it dilutes the intracellular
sodium, thereby causing hyponatremia. The AGACNP should thus anticipate hyponatremia.
Question 22
A crescendo-decrescendo systolic murmur best appreciated at the second intercostal space, right
sternal border with radiation to the carotid artery is most likely an indicator of:
A. Aortic stenosis
B. Aortic regurgitation
C. Tricuspid stenosis
D. Tricuspid regurgitation
Answer: A. Aortic stenosis
Rationale:
Stenosis of the aortic valve produces a crescendo/decrescendo systolic murmur that can be
appreciated by auscultating the second intercoastal space, right sternal border. The murmur can
sometimes radiate to the carotid artery.
Question 23
The AGACNP knows that diagnostic findings consistent with rheumatoid arthritis include:
A. Soft tissue swelling of the metacarpals
B. Radiographic joint space narrowing
C. Heberden’s nodes
D. Subungal hemorrhages
Answer: A. Soft tissue swelling of metacarpals.
Rationale:
Rheumatoid arthritis is an autoimmune disorder that involve the body immune system attacking
the joint lining resulting to inflammed joint lining, swollen and painful joint. The condition
causes symmetrical joint swelling that persist over a long period of time. The most commonly
joints are proximal interphalangeal and metacarpophalangeal joints of hands, wrist, feet joints,
shoulder, elbow, knees and ankle.
On examination the soft tissue swelling of metacarpals can be seen by use of scanning device
such as x-ray.
Question 24
C.T. is a 39-year-old female who presents for evaluation of what she thinks is her “rosacea acting
up.” She has a history of acne rosacea and has medicated on and off for years with tetracycline
and topical metronidazole. Today however she presents with a pronounced red/ purple area on
her left cheek extending to the nasal border. It is very warm to the touch. The borders of the
affected area are very well defined and raised. C.T. also has a temperature of 100.7° F and a
generalized headache. The AGACNP appreciates tender submandibular and cervical
lymphadenopathy. The likely diagnosis is:
A. Complex rosacea
B. Cellulitis
C. Erysipelas
D. Allergic reaction
Answer: A. Complex rosacea
Rationale:
Since C.T has a medical history of rosacea, she is most likely experiencing a recurrence of the
infection. Rosacea is characterized with fever, and red/purples lesions which feel warm to touch.
The complex rosacea forms well defined, raised lesion. The complicated form if the infection,
which appears to be what C.T has, is known as rosacea fulminans. It is a complex form of
rosacea.
Question 25
Mr. Lopez is a 51-year-old male patient who is being treated for T2DM. His HgbA1c is 15.6%
and initial management will include aggressive attempts for weight reduction as his body mass
index (BMI) is 45. He says he is unable to participate in any meaningful exercise because he
very often has back pain; he has had it for years and has tried all sort of over the counter
medicines with little relief. He describes it as a profound ache that occurs across the lower part of
his back bilaterally; it does not travel down either leg. The physical inspection is normal, but he
has significant paraspinal tenderness to palpation bilaterally. He cannot identify any injury or
accident that preceded the pain. The history and physical exam is non-contributory. The AGACP
knows that the likely diagnosis is:
A. Lumbar radiculopathy
B. Ankylosing spondylitis
C. Lumbar sacral strain
D. Degenerative disk disease
Answer: D. Degenerative disk disease
Rationale:
A degenerative disc presents with local pain and tenderness, along the spine, that does not radiate
to any region or respond to over the counter pain killers. It is worth noting that type 2 Diabetes
mellitus causes degeneration of the lumbar intervertebral disc. Since Mr. Lopez has a medical
history of type 2 diabetes mellitus, and his back pain is localized in his lower back, the most
likely diagnosis lumbar intervertebral disc degeneration.
In lumbar radiculopathy, the pain radiates to the lower limbs while in ankylosing spondilytis, the
pain is from the neck to the lower back. Lumbar sacral strain affects both the lumbar and sacral
regions.
Question 26
A patient presents with acute onset of vesicular lesions on her vulva. They are surrounded by
areas of redness and they hurt. The patient says that she has even more of them now then she did
when she woke up this morning. There is also inguinal lymphadenopathy. The AGACNP is
suspicious for:
A. Human papilloma virus
B. Primary syphilis
C. Gonorrhea
D. Herpes simplex virus
Answer: D. Herpes Simplex Virus
Rationale:
The Herpes Simplex Virus infection has an acute onset. It presents with painful vesicular lesions
that progress rapidly. The type 2 herpes simplex virus affects the genitalia, including the vulva. It
can also affect the surrounding lymphnodes (such as the inguinal lymphnodes) and cause
inguinal lymphadenopathy.
Question 27
Classic radiographic features of osteoarthritis include:
A. Soft tissue swelling
B. Joint deformity
C. Bone mineral loss
D. Joint space narrowing
Answer: D (Joint space narrowing)
Rationale:
The specific and significant radiographic feature of the Osteoarthritis are Osteophyte formation,
Joint space narrowing , subchondral sclerosis and cysts.
Question 28
Mrs. Sandoval is a 72-year-old female who presents with a chief complaint of transient verbal
confusion. She was speaking with her friend on the phone this morning when she suddenly
couldn’t get words out. Her friend went over to her home and found Mrs. Sandoval awake, alert,
and oriented, responding appropriately with non-verbal gestures, but she could not properly
articulate her thoughts. By the time she arrived at the office this had passed, although during the
examination she appeared to have infrequent difficulty finding a single word. The patient denies
any contributory medical history, but a 12-lead ECG in the office reveals atrial fibrillation with a
ventricular response of 91 b.p.m. The blood pressure is 140/94 mm Hg; remaining vital signs are
normal. The AGACNP knows that management should include:
A. Antiplatelet therapy
B. Anticoagulation
C. Blood pressure control
D. Speech therapy
Answer: C. Blood pressure control
Rationale:
High blood pressure (hypertension) involves a systolic pressure of 140 or more and a diastolic
pressure of 90 or more. Since Mrs. Sandoval's blood pressure is a systolic pressure of 140 and
diastolic pressure of 94, then she has high blood pressure. Thus, blood pressure control should be
part of her management.
Question 29
C.L. is a 48-year-old female who presents complaining of activity intolerance. She is usually
very active and fit. She jogs regularly and typically does 4-5 miles a day. About a week ago she
became so tired she had to stop, and lately she has become aware of becoming easily fatigued
while going up and down stairs. She admits that she thinks she is beginning menopause —she is
having a lot of bleeding with her periods, and her periods seem to be more frequent. A complete
blood count (CBC) reveals the following results:
Hgb 10.1 g/dL
Hct 30%
MCV 75 fL
RDW 21%
The AGACNP orders which of the following laboratory test to confirm the suspected diagnosis?
A. Vitamin B12
B. Folate
C. Ferritin
D. Hemoglobin electrophoresis
Answer: C. Ferritin
Rationale:
From C.L's medical history, the suspected diagnosis is iron-deficiency anaemia. She looses
excess blood during periods and this cause iron deficiency anaemia. Patients with iron deficiency
anaemia have low haemoglobin count and low hematocrit levels. Iron deficiency anaemia is also
characterized by easy fatiguability and activity intolerance. To asses a patient for iron deficiency
anaemia, their ferritin levels should be assessed. Ferritin levels below 30microgram/L confirm a
diagnosis of iron deficiency anaemia.
Question 30
Kevin H. is a 61-year-old male who presents for treatment of profound anxiety. He has been
treated on and off for years—most recently he was taking escitalopram 20 mg p.o. daily, and
although he does admit to some improvement, he still cannot function appropriately throughout
the day. He has been counseled about poor work performance and is concerned about losing his
job, but he is just so worried all of the time he cannot concentrate on work. The AGACNP knows
that the most appropriate action is to:
A. Increase the dose of escitalopram to 40 mg daily
B. Refer Kevin for a psychiatric consultation
C. Stop escitalopram and begin venlafaxine
D. Discuss therapeutic expectations with Kevin
Answer: B. Refer Kevin for a psychiatric consult
Rationale:
Kevin's treatment for anxiety disorder seems to have failed. Increasing the dose of escitalopram
to 40mg daily is likely to cause damage to his liver. Escitalopram should also not be stopped
immediately when changing treatment to venlafaxine. It should instead be reduced first to 10mg
daily then tapered off gradually. Since the AGACNP has not specialized in psychiatric disorders,
instead of discussing the therapeutic expectations with Kevin, he/she should Refer Kevin for a
psychiatric consult.
Question 31
When examining a patient with a skin presentation suggestive of necrotizing fasciitis, the
AGACNP knows that the most important and sensitive diagnostic test is:
A. A complete blood count
B. Plain film radiographs
C. The finger test
D. CT scan
Answer: C. The finger test
Rationale:
An AGACNP should perform the finger test when they are suspecting necrotizing fasciitis.
During the finger test, local anaesthesia is applied on the affected skin, then an incision of 2cm is
made on the skin, to the depth of the deep fascia. A gentle, probing maneuver is then done using
the index finger. If the skin dissects with minimal resistance, then the finger test is said to be
positive. A positive finger test indicates the diagnosis of necrotizing fasciitis.
Question 32
While evaluating a patient with abdominal pain, the AGACP knows that when the pain is
described as coming in waves or cycles, with periods of relief in between, the cause likely
centers around:
A. Peristalsis of bowel
B. Disorders of pelvic organs
C. Organ inflammation
D. Hyperacidity
Answer: A. Peristalsis of bowel
Rationale:
Peristalsis of the bowel occurs in intermittent waves. During each wave/cycle of peristalsis, there
can be an accompanying pain which could indicate that the peristaltic process is the central cause
if the pain.
It is therefore right to suspect peristalsis of the bowel as a cause of pain that comes in waves,
with intermittent periods of relief, since this is the pattern of peristaltic movements.
Question 33
Which of the following findings is not typically associated with testicular torsion?
A. Acute pain
B. Edema
C. High riding testis
D. Dysuria
Answer: D. Dysuria
Question 34
When completing this exam, did you comply with Walden University’s Code of Conduct
including the expectations for academic integrity?
Answer: If you're asked this question in an exam context, it's essential to answer truthfully based
on your own actions and adherence to the academic integrity policies of Walden University. A
suitable response could be:
"Yes, I have complied with Walden University’s Code of Conduct and the expectations for
academic integrity while completing this exam."
If you have any concerns about academic integrity or need clarification, it's always best to
consult your university's guidelines directly.
Question 35
While preparing to perform an incision and drainage on a 7 cm fluctuant abscess on a patients
posterior thorax, the AGACNP knows that the most important part of the procedure is:
A. Immediate coverage with antistaphylococcal antibiotics
B. Maintaining sterility with topical betadine and drapes
C. Breaking up loculations and aggressive irrigation
D. Proper injection of local anesthetic
Answer: A. Immediate coverage with antistaphylococcal antibiotics
Rationale:
When draining an abscess, the infective organism can infiltrate into the surrounding tissue and
blood to cause a systemic infection. It is thus important to cover the patient with
antistaphylococcal antibiotics so as to protect them from sepsis in case the bacteria infiltrates into
the blood. This is the most important procedure when preparing the patient for incision and
drainage of a fluctuant abscess.
Question 36
A patient is being evaluated with significant nausea, fatigue, and a general sense of feeling
unwell; mild jaundice is noted on physical examination. Transaminases are markedly elevated
and a hepatitis screening is done. Results are as follows:
+ HbsAb
+ anti-HAV IgM
- anti-HCV
The correct interpretation of these findings is:
A. The patient has acute hepatitis A
B. The patient has acute hepatitis B
C. The patient has chronic hepatitis B
D. The patient has acute hepatitis C
Answer: C. The patient has chronic hepatitis B.
Rationale:
Chronic hepatitis B represents with the following features:
Nausea, fatigue, malaise, general sence of feeling unwell, juandice as clinical symptoms.
There is increase in serum transaminase, elevated bilirubin, positive hepatitis B surface antigen
(HBsAg), presence of hepatitis B e antigen (HBeAg), HBV DNA, and also immunoglobulin M
antibody to hepatitis B core antigen positive (IgM anti-HBc).
Acute hepatitis B is mostly clinically asymptomatic and the body eliminates it without the patient
experiencing any symptoms. The symptoms of hepatitis B will only be realized after it progress
to chronic phase in most patients.
Question 37
When treating a patient with an unknown overdose or toxicity, the AGACNP knows that all of
the following should be administered except:
A. Dextrose 50%
B. Thiamine 100 mg
C. Nalaxone 0.4 mg
D. Ativan 4 mg
Answer: D. Antivan 4mg.
Rationale:
Patients with overdose or toxicity often have a decline in functionality of body systems, for
instance, an abnormally low blood pressure or respiratory rate. Antivan has an effect of
suppressing the respiratory center and the cardiovascular system. Thus it will case further
decrease in the rate of respiration and blood pressure. It should therefore not he given to patients
with overdose or toxicity.
However, dextrose 50%,_thiamine and nalaxone can be administered to improve the health status
of patients with overdose or toxicity.
Question 38
The AGACNP is evaluating 29-year-old female who presents by ambulance and is unresponsive.
There is no witness and no history available; the patient is not wearing any sort of medic alert
bracelet. While assessing for toxicity or overdose, the patient is found to have vital signs as
follows: Temp of 96.2° F, pulse of 48 b.p.m., respirations of 10 b.p.m., and blood pressure of
84/50 mm Hg. The patient’s pupils are constricted, but do react briskly to light to 1 mm. The
AGACNP suspects which type of substance?
A. Cholinesterase inhibiting drugs
B. Stimulants such as MDMA
C. Anticholinergics
D. Ethanol or opiates
Answer: D. Ethanol or opiates
Rationale:
Ethanol and opiates toxicity trigger the parasympathetic nervous system which resulted into
constriction of the pupil, lower blood pressure, lower pulse and lower respiratory rate.
This particular patient has all of these symptoms (constriction of the pupil, lower blood pressure,
lower pulse and lower respiratory rate), thus, the AGACNP should suspect Ethanol or opiates
toxicity.
Question 39
The AGACNP knows that the one class of pain medication that is effective to some extent for all
forms of pain is:
A. NSAIDs
B. Antidepressants
C. Antiepileptics
D. Opiates
Answer: D. Opiates
Rationale:
Opiates are often used for the management of chronic pain. However, they can also be used for
acute pain. They are generally effective, to some extent, to all forms of pain.
NSAIDs are only effective for acute pain and not chronic pain. Antidepressants and antiepileptics
are not pain killers.
Question 40
K.P. is a 76-year-old male admitted for antibiotic management of urosepsis. His medical history
is significant for a CVA with resultant right-sided hemiparesis. He is nonverbal, maintained on
enteral nutritional support and has an indwelling Foley catheter. The AGACNP knows that which
of the following bacteria is the primary treatment target for this patient’s urosepsis?
A. Proteus mirabilis
B. Pseudomonas aeruginosa
C. Staphylococcus aureus
D. Streptococcus pneumoniae
Answer: A. Proteus mirabilis
Rationale:
Proteus mirabilis is a common cause of catheter-associated urinary tract infections. Infections by
Proteus mirabilis often complicate into bacteremia.
K.P. has an indwelling Foley's catheter which predisposes him to Proteus mirabilis. The urosepsis
that he suffers from indicates that he has bacteremia. Since both catheters and bacteremia are
associated with Proteus mirabilis infection, K.P most likely suffers from Proteus mirabilis
infection. This infection should thus be the primary treatment target.
Question 41
A patient is admitted for a COPD exacerbation and placed on mechanical ventilation. His
settings are as follows: FiO2 of 40%, TV of 700mL, SIMV of 12. His morning ABG reveals a pH
of 7.37, paCO2 of 51 mm Hg, paO2 of 84 mm Hg and HCO3 of 30 mm Hg. The AGACNP knows
that the appropriate response is to:
A. Leave the ventilator settings as is
B. Increase the SIMV to 16 b.p.m.
C. Increase the FiO2 to 50%
D. Repeat the ABG in one hour
Answer: A. Leave the ventilator setting as is
Rationale:
The pH of 7.37 suggests that the patient has alkalosis. Since the PaCO2 and HCO3 are elevated, it
shows that the alkalosis is compensated. Thus, the patient has compensated respiratory alkalosis.
Treatment is administer to patients with compensated respiratory alkalosis, only if their pH rises
above 7.5. For this particular patient, the pH is 7.37; thus, the AGACNP should Leave the
ventilator setting as is.
Question 42
All of the following are required for a diagnosis of systemic inflammatory response syndrome
(SIRS) except:
A. White blood cell count 12,000 cells/uL
B. Heart rate > 90 b.p.m.
C. Respiratory rate > 20 b.p.m. or paCO2 10% of band cells
• A heart rate of more than 90 beats per minute.
• A respiratory rate of more than 20 breaths per minute or paCO2 less than 32mmHg
• A temperature that is more than 38 degrees Celsius or less than 36 degrees Celsius.
The option that is not required for a diagnosis of systemic inflammatory response syndrome is:
D. Two sets of positive blood cultures
Question 43
J.T. is a 41-year-old female patient who presents with a chief complaint of “heartburn.” She says
that it doesn’t really seem to be related to meals or food—it occurs at random times. She does
note, when asked, that it seems to happen a lot at night and occasionally wakes her up. Her only
other symptom complaint is an occasional cough. It does not produce mucus, and she admits to
assuming it was a “nervous” cough. The next appropriate action for the AGACNP would be to:
A. Order an H. pylori test
B. Request a GI consult for endoscopy
C. Order a proton pump inhibitor 30 minutes before breakfast
D. Request a 72-hour diet history
Answer: B. Request a GI consult for endoscopy
Rationale:
The hurtburn is most likely due to GERD (Gastro-eosophageal reflux disease). It occurs at night
because when the patient is horizontally lying on bed, the esophageal sphincter allows reflux of
gastric/stomach contents back into the esophagus. This could make the hydrochloric acid from
the stomach to cause ulceration of the esophageal mucosal lining. The patient thus presents with
a hurtburn. It is therefore important to do an endoscopy so as to assess the esophagus for any
ulceration and to examine the functionality of the esophageal sphincter.
Since the hurtburn is not related to the meals taken, it most likely is not caused by dietary factors.
Question 44
Your patient has diabetes insipidus (DI). Anticipated physical assessment findings include:
A. Dry skin, tachycardia, hypertension
B. Weak pulse, dry skin, decreased skin turgor
C. Thin hair, thready pulse, dry mucous membranes
D. Hypothermia, jugular venous distention, bradycardia
Answer: B. Weak pulse, dry skin, decreased skin turgor
Rationale:
In diabetes insipidus, the patient excretes a lot of dilute urine. The excess urine excreted means
that the body is loosing a lot of water, resulting into dehydration. Clinical presenting features of
dehydration include: a weak pulse, dry skin and decreased skin turgor. These features are likely
to be present during the physical assessment of a patient with diabetes insipidus.
Question 45
The AGACNP is beginning medical management of a patient newly diagnosed with T2DM. The
patient has a BMI of 39 and has been unsuccessful in making significant diet and lifestyle
changes over the last six months. Other than her weight, her physical examination is essentially
within normal limits. Her HgbA1c is 9.5%. A basic metabolic panel is within normal limits. The
medication of choice to begin therapy will be:
A. A sulfonyurea
B. A meglitinide
C. A biguanide
D. An incretin mimetic
Answer: C. A biguanide
Rationale:
This patient specifically has difficulty with diet and lifestyle changes so the first line of treatment
would be a biguanide such as metformin. They work by preventing the liver from converting fats
and amino acids to glucose.
Question 46
Felty’s syndrome is a condition of immune neutropenia seen sometimes in patients with:
A. Polymyalgia rheumatica
B. Giant cell arteritis
C. Systemic lupus erythematosus
D. Rheumatoid arthritis
Answer: D. Rheumatoid arthritis
Rationale:
Felty's syndrome (FS) is categorized by the triumvirate of seropositive rheumatoid arthritis (RA)
coupled with the destructive splenomegaly, neutropenia and joint involvement. For this reason,
Felty's syndrome is a condition of the immune neutropenia seen sometimes in patients with
rheumatoid arthritis
Reference https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4296472/
Question 47
When treating a patient for the profound cough of acute bronchitis, the AGACNP knows that the
most appropriate pharmacotherapy consists of:
A. An opiate based cough suppressant
B. Oral prednisone
C. A first generation-antihistamine combination
D. An inhaled anticholinergic
Answer: An opiate based cough suppressant
Rationale:
• Bronchitis is a component of chronic obstructive pulmonary disease. In acute exacerbation,
patients present with profound cough and severe difficulty in breathing due to the obstructive
nature of the disease
• Recommendations in the management of the disease in the acute settings aims at
1. Cough management where Central cough suppressants (eg, codeine and dextromethorphan)
are most appropriate for short-term symptomatic relief of coughing in acute and chronic
bronchitis
2. Pain management where NSAIDs are recommended for mild to moderate pain
3. Bronchodilators (eg, ipratropium bromide and theophylline) recommended for control of
bronchospasm, dyspnea, and chronic cough in stable patients with chronic bronchitis
Question 48
Mr. Truman is transferred to the emergency department by ambulance. His wife called 911 this
morning because he was acting “funny” when he woke up. Both the patient and his wife went to
bed last night at approximately 10:30 and everything was normal. This morning he could not
communicate orally and seemed confused about how to ambulate. Upon arrival to the emergency
department his vital signs are as follows: Temperature 100.9° F, pulse 89 b.p.m., respirations 14
b.p.m. and blood pressure 168/94 mm Hg. A noncontrast CT scan of the head reveals thrombotic
CVA. The AGACNP know that immediate management of this patient should include:
A. Thrombolytics
B. IV vasodilators
C. Aspirin
D. Antiepileptics
Answer: A. Thrombolytics
Question 49
Your patient is complaining of profound nausea and vomiting that started at bedtime last night
and kept him awake all night long. Early this morning he started having abdominal cramping and
explosive diarrhea. Based upon the character of symptoms you are suspicious of infection with
Staphylococcus aureus. To assess risk for exposure to this organism, you ask the patient about
which meal?
A. Breakfast yesterday
B. Lunch yesterday
C. Dinner yesterday
D. Bedtime snack yesterday
Answer: C. Dinner yesterday
Rationale:
The symptoms of Staphylococcus aureus are usually experienced 2-4 hours after eating.
The onset of the symptoms is marked by a feeling of nausea. Since the first symptoms begin 2-4
hours after eating, we will be concerned with dinner yesterday. This is because of experienced
nausea at bedtime. This means he took the meal 2-4 hours ago. This may not be a bedtime snack
considering the time that the symptoms started. Severe abdominal pain and diarrhea can be
experienced 8 hours after eating. Early this morning the patient started having abdominal pain
meaning the meal of concern is yesterday's dinner and not the snack
Reference https://academic.oup.com/femsre/article/36/4/815/520403
Question 50
D.R. is a 54-year-old male patient who was admitted for the management of cellulitis and treated
with parenteral antibiotics. He has not been responding as well as anticipated. During today’s
exam the AGACNP appreciates a couple of changes. All of the following indicate the need for
immediate surgical evaluation except:
A. Skin anesthesia
B. Violaceous bullae
C. Gas bubbles in tissue
D. Lymphangetic spread
Answer: D. Lymphangetic spread
Question 51
R. O. is a 21-year-old female who comes to the emergency department because of a severe
headache. Her vital signs and neurological examination are within normal limits. She complains
of a pulse-like pain in her right temple and admits that she has almost vomited. Her mother gets
the same type of headache and the last time this happened R.O. took one of her mother’s
prescription headache pills. They helped a lot, but this time her mother told her she had to come
be evaluated. The AGACNP knows that which of the following is the appropriate action?
A. A non-contrast CT scan of the head
B. Administration of a 5HT agonist
C. Dilaudid 2 mg IM x 1 dose
D. Requesting a headache diary
Answer: B. Administration of a 5HT agonist
Question 52
A 39-year-old female presents for evaluation of a rash. She denies any significant medical
history, and has no other complaints. The rash appeared suddenly on both forearms
approximately one week ago, and she is concerned because it is not going away. It does not itch
or hurt—it is just there. Physical examination reveals a diffuse macular hypopigmentation on
both forearms that extends to the hands. The patient denies any drug or alcohol use; she is single
and has had 4 unprotected sexual partners in the last year. The AGACNP knows that initial
laboratory testing must include a(n):
A. FTA-Abs
B. Fungal skin scraping
C. RPR screening
D. CBC
Answer: B. Fungal skin scraping
Rationale:
Fungal skin scraping is a procedure that is performed to diagnose fungal infections. The patient's
physical examination reveals a diffuse macular hypopigmentation on both forearms that extends
to the hands. This finding indicates the presence of fungal infection. The hypopigmentation on
both forearms reduces the likelihood of syphilis and other blood conditions. While the patient
has been having unprotected sex, the sore should begin from her genital areas depending on the
stages. The rash can be associated with bacterial infections
Reference https://www.dermveda.com/articles/skin-scraping-koh-and-mineral-oil-preparation
Question 53
J.S. is a African-American female who presents for a wellness examination. Her medical history
is significant for beta thalassemia minor. Anticipated red blood cell differential would include
which of the following patterns?
A. Hgb 10.2 g/dL, Hct 30%, MCV 70 fL, RDW 12.6%
B. Hgb 9.9 g/dL, Hct 28%, MCV 83 fL, RDW 13.9%
C. Hgb 11.5 g/dL, Hct 35%, MCV 94 fL, RDW 15.8%
D. Hgb 12.8 g/dL, Hct 38%, MCV 105 fL, RDW 18.1%
Answer: A. Hgb 10.2 g/dl, Hct 30%, MCV 70 fl, RDW 12.6%
Rationale:
• Thallasemia is one of the causes of microcytic anemia alongside iron deficiency anemia, lead
poisoning and sideroblastic anemia and enemia of chronic disease
• Thallasemia therefore presents with a low MCV - microcytic (normal 80-100 fl), The Red-cell
distribution width is usually normal (11.5-14.5%) , the Hgb is usually low due to the anemia
(normal 13.8 to 17.2 g/dL for men and 12.1 to 15.1 g/dl for women). The hematocrit is usually
roughly three times the Hgb and so for an Hgb of 10 the hct is approximately 30
• The statement in A is the only one consistent with this picture
Question 54
M.T. presents complaining of acute pain in his left eye, nausea, and one episode of vomiting. He
denies any significant medical problems, and says that the only medication that he takes is an
occasional over-the-counter sleeping pill. Physical examination reveals a steamy red cornea and
conjunctiva with a pupil that is 5 mm and not reactive to light. The AGACNP knows that
diagnostic testing should include:
A. A CT scan of the head
B. An MRI of the orbit
C. A toxicology screen
D. A measurement of intraocular pressure
Answer: D. A measurement of the intraocular pressure
Rationale:
• Thi patient has features suggestive of glaucoma.
• Glaucoma is an Ophthalmologic condition characterized by raised intraocular pressure
• Two types have been recognized, open angle and angle closure glaucoma
• The most striking symptom of glaucoma is vision loss. Other signs and symptoms are :
1. Seeing halos round lights
2. Vision loss
3. Redness in the eye
4. Eye that looks hazy (particularly in infants)
5. Nausea or vomiting
6. Eye pain
7. Narrowed vision (tunnel vision)
• Glaucoma is an Ophthalmologic emergency since vision loss is likely to occur due to optic
nerve damage
• Its diagnosis is by measurement of intraocular pressure.
REFERENCE
https://www.webmd.com/eye-health/glaucoma-eyes
Question 55
Justin is a 23-year-old male who is being managed for an acute manic episode. Justin was
diagnosed with bipolar disorder several years ago, but his home life has been unstable and he has
not been very adherent to a medication regimen. Most recently he was started on the SNRI
venlafaxine by his primary care provider, which he has been taking as prescribed for about 6
weeks, but he began a manic episode a few days ago which peaked this evening. The AGACNP
considers that:
A. The manic episode is probably a result of medication instability and he should continue his
current regimen with a follow-up in 6-8 weeks
B. A mood stabilizing agent should be added to the venlafaxine
C. All medication should be held for 6-8 weeks and the then the patient should be reevaluated
D. The SNRI should be stopped and a mood stabilizing agent started
Answer: D. The SNRI should be stopped and a mood stabilizing agent started
Question 56
Mr. Livingston is a 79-year-old male who presents from a long term care facility with a change
in mental status. His medical history is significant for T2DM, CAD, CHF, hypothyroidism,
Alzheimer’s dementia and osteoarthritis. He has been stable, but over the last few days the staff
say he has been a bit disconnected. This morning he was found in his bed in a stuporous state.
His vital signs include a temperature of 98.9° F, pulse of 103 b.p.m., respiratory rate of 20
b.p.m., and a blood pressure of 92/64 mm Hg. His metabolic panel demonstrates a Na+ of 129
mEq/L, K+ of 3.3 mEq/L, Cl- of 100 mEq/L, CO2 of 24 mEq/L, glucose of 644 mg/dL, BUN of
51 mg/dL and creatinine of 1.9 mg/ dL. The AGACNP knows that the primary problem is most
likely:
A. Diabetic ketoacidosis
B. Hypertonic hyponatremia
C. Myxedema coma
D. Hyperosmolar hyperglycemic coma
Answer: D. Hyperosmolar hyperglycemic coma (HHS)
Question 57
The AGACNP is evaluating a patient with systemic lupus erythematosis who complains of
fatigue. Based upon his knowledge of the most commonly affected visceral organ, which of the
following diagnostic studies should be ordered?
A. Echocardiogram
B. Chest radiography
C. Hepatic function enzymes
D. Urinalysis with microscopic
Answer: D. Urinalysis with microscopic
Question 58
All of the following are true statements about post-traumatic stress disorders (PTSD) except:
A. It is more common in women than men
B. It is unlikely to occur in children especially < 10 years old
C. It is differentiated from acute stress reaction by time
D. It is not likely in persons with no preexisting psychiatric disease
Answer: B. It is unlikely to occur in children especially < 10 years old
Question 59
Ray M., a 49-year-old male, walks into the emergency room complaining of back pain. He has
never had this problem before and cannot identify any injury, but he is in such severe pain he is
sure something is wrong. He states that his back has been hurting so badly sometimes he has to
stop whatever he is doing and bend forward at the waist. The pain also travels along the outer
edge of his left thigh to mid-calf, and he reports a small area of numbness on his anterior thigh.
His history and physical examination are otherwise negative. He is an insurance attorney and is
not especially active at work, but goes to the gym 5 days a week. He is not overweight, and his
vital signs are normal. Physical examination reveals no paraspinal tenderness, and his straight leg
raise is negative. A few times during the exam he lay back on the table and grabbed his left leg,
flexed both hip, and pulled his knee to his chest, because it helped the pain. The AGACNP
knows that immediate pain relief measures must include:
A. An opiate analgesic
B. Systemic steroids
C. Physical therapy
D. Bedrest for 72 hours
Answer: C. Physical therapy
Question 60
A patient with peptic ulcer disease is admitted to the hospital with significant upper abdominal
discomfort. She has guarding and rebound tenderness on examination. Abdominal radiography
demonstrates free air in the abdomen. The AGACNP knows that the immediate priority is to:
A. Obtain a stat surgical consult
B. Begin an IV proton pump inhibitor
C. Order an abdominal CT scan
D. Obtain a stat gastroenterology consult
Answer: A. Obtain a stat surgical consult
Rationale:
The patient most likely has perforated peptic ulcer. The gastrointestinal tract contents have
leaked into the peritoneum and caused an infection (peritonitis), thus the guarding and rebound
tenderness on examination. A perforated peptic ulcer is a surgical emergency due to its
association with a high mortality rate. The best immediate action for the AGACNP is therefore to
obtain a stat surgical consult.
Question 61
Jennifer is a 15-year-old female who attempted suicide by taking a bottle of acetaminophen. She
took 30, 500 mg tablets approximately six hours ago, but then became frightened and told her
mother what she did. Her mother said that Jennifer seems OK, other than being a little sick to her
stomach, she has no complaints. The AGACNP knows that the first step in her care includes:
A. N-acetycysteine in tapering doses over the next 24 hours
B. Oral administration of activated charcoal
C. Psychiatric assessment
D. Discharge to home with follow-up LFTs in 4 days
Answer: B. Oral administration of activated charcoal
Question 62
Mrs. Glassman is a 55-year-old female who presents with a chief complaint of fever. Her vital
signs reveal a temperature of 100.0° F, blood pressure of 100/60 mm Hg, pulse of 114 b.p.m. and
respirations of 20 b.p.m. Her cardiac auscultation reveals a grade III/VI systolic murmur at the
left lower sternal border. Her history is significant for an eyebrow lift 4 months ago. The
AGACNP orders which test to confirm the suspected diagnosis?
A. Three sets of blood cultures
B. A chest radiograph
C. A 12-lead ECG
D. Induced sputum culture
Answer: A. Three sets of blood cultures
Question 63
John is a 17-year-old male who is in the emergency department with abdominal pain. He is quite
uncomfortable and says that it started yesterday and seemed to be “in the middle of his stomach”
but today it has moved over to the right lower side. During physical examination the abdomen is
not distended, but he is guarded, and right lower quadrant palpation produces significant
discomfort, especially upon release of the palpating hand. He has appreciable pain when his right
knee and hip are bent to a 90° angle. John admits to some nausea but has not vomited; he has not
had a normal bowel movement in two days. His vital signs are as follows: Temperature 100.9° F,
pulse 110 b.p.m. respiratory rate 22 b.p.m., and blood pressure 118/77 mm Hg. The AGACNP
orders which of the following tests to confirm the suspected diagnosis?
A. Complete blood count
B. Ultrasound
C. CT scan
D. Urinalysis
Answer: C. CT scan
Question 64
Which of the following signs is expected in patients with cholecystitis?
A. McBurney’s
B. Cullen’s
C. Spurling’s
D. Murphy’s
Answer: D. Murphy’s
Question 65
According to the World Health Organization’s step-wise approach to pain management, initial
approaches to step 2 might include all of the following except:
A. A weak opiate
B. A strong opiate
C. A non-steroidal anti-inflammatory agent
D. An antidepressant.
Answer: B. A strong opiate
Question 66
A patient’s Weber test lateralizes to the right ear and the Rinne test in both ears is normal. The
patient has a:
A. Sensorineural hearing loss in the left ear
B. Sensorineural hearing loss in the right ear
C. Conductive hearing loss in the left ear
D. Conductive hearing loss in the right ear
Answer: A. Sensorineural hearing loss in the left ear
Question 67
J.B. is a 62-year-old male who was admitted three days ago for management of diverticulitis.
Today the AGACNP is called to the bedside to evaluate new onset swelling of the right lower
extremity. According to the staff nurse it was not present yesterday but on today’s assessment the
patient had 2A+ edema up to the thigh. Initial diagnostic evaluation should include:
A. Homan’s sign
B. A venogram
C. A D-dimer
D. CT of the chest
Answer: C. A D-dimer
Deep vein thrombosis (DVT) is a likely concern in this patient due to his prolonged hospital stay
and the sudden appearance of unilateral lower extremity swelling. DVT risk factors include
prolonged immobility, which can lead to venous stasis (part of Virchow’s triad), making this
patient more susceptible.
Question 68
Based upon clinical examination and laboratory assessment the AGACNP diagnoses a patient
with giant cell arteritis. The next step in the patient management should be to:
A. Consult surgery for a temporal artery biopsy
B. Consult rheumatology for medical management
C. Order 60 mg of prednisone now and q.d.
D. Order ceftriaxone 1 mg IV now
Answer: C. Order 60 mg of prednisone now and q.d.
Question 69
According to the JNC VIII criteria, a patient with a new diagnosis of hypertension who has
comorbid chronic kidney disease should be started on which of the following classes of
medications?
A. A thiazide diuretic
B. A calcium channel blocker
C. An ACE inhibitor
D. A beta adrenergic antagonist
Answer: C. An ACE inhibitor
Question 70
Denise is a 45-year-old female who presents with significant lower abdominal pain. It started a
few days ago and has just gotten steadily worse. She denies any hematuria or dysuria, but when
she voids she feels like “everything is coming out. A physical examination reveals an abdomen
that is tender to palpation but there is no guarding or rebound. Her vital signs are stable
excepting a temperature of 100.9° F. The next step in the evaluation must include:
A. A complete blood count
B. An abdominal flat plate
C. A pelvic examination
D. A CT scan of the abdomen
Answer: C. A pelvic examination
Question 71
Jan is a 39-year-old female who presents with significant right upper quadrant pain of 18 hours
duration. She admits to a few episodes of vomiting. She right upper quadrant pain to palpation
but the ultrasound is negative. Jan admits that this has happened before, usually when she “eats a
huge meal.” The AGACNP orders which diagnostic study to confirm the diagnosis of
cholecystitis?
A. Upright abdominal radiography
B. Hepatic function panel
C. HIDA scan
D. Abdominal CT
Answer: C. HIDA scan
Rationale:
In a patient with symptoms suggestive of cholecystitis (right upper quadrant pain, nausea, and
vomiting, often triggered by large meals) but a negative ultrasound, a hepatobiliary
iminodiacetic acid (HIDA) scan is the next best test to confirm the diagnosis. A HIDA scan
evaluates gallbladder function and can detect cystic duct obstruction or biliary dyskinesia,
which may not be visible on ultrasound.
Question 72
L.W. is a 41-year-old woman with a history of systemic lupus erythematosus which has been
managed primarily with symptom control. Today she presents for evaluation of fatigue which has
been slowly progressive over the last few months. She has a history of gastric bypass surgery 10
years ago and has maintained a 100 lb weight loss, but she maintains that she has been very
adherent to her vitamin and mineral replacement regimen. Other than chronically heavy menses,
for which she takes hormonal contraception, she is without complaint. A complete blood count is
as follows:
Hgb 10.3 g/dL
Hct 31%
MCV 88 fL
RDW 15%
The AGACNP suspects that the patient’s fatigue is most likely due to:
A. Iron deficiency anemia
B. Anemia of chronic disease
C. Pernicious anemia
D. Folic acid deficiency
Answer: B. Anemia of chronic disease
Question 73
A patient presents for follow up after being started on an ACE inhibitor for hypertension. Her
blood pressure has improved, but her pulse is 56 b.p.m down from 76 b.p.m. at her last visit. The
AGACNP knows that the patient should assessed for:
A. Hypercalcemia
B. Hypernatremia
C. Hyperkalemia
D. Hyperchloremia
Answer: C. Hyperkalemia
Question 74
A young-adult male patient was dropped off outside of the emergency department and some staff
members brought him inside. The patient is restless, irritable, and either unwilling or unable to
participate in her own care. No history is available. His vital signs are essentially stable, finger
stick blood sugar is 111 mg/dL, there are no signs of trauma, and no physical findings consistent
with common drug or alcohol use. A toxicology screen is pending. The AGACNP orders acute
psychiatric stabilization with a combination of haloperidol and lorazepam and considers which of
the following mediations to decrease the risk of adverse effects?
A. Risperidone
B. Olanzapine
C. Benztropine
D. Zolpidem
Answer: C. Benztropine
Question 75
Amy is a 21-year-old female who presents with acute nephrolithiasis. CT scan reveals a 2 mm
stone in the left ureter. The AGACNP knows that the appropriate course of action is:
A. Pain control and IV fluid
B. Consultation for stent placement
C. Lithotripsy stone destruction
D. Transurethral stone destruction
Answer: A. Pain control and IV fluid
Question 76
B.T. is a 49-year-old male being admitted for lung volume reduction surgery. His preoperative
pulmonary function tests are as follows:
FVC 66% predicted
FEV1 60% predicted
PEFR 69% predicted
TLC 104% predicted
RV 90% predicted
The AGACNP knows that the pulmonary function studies are consistent with:
A. Mild restrictive disease
B. Moderate restrictive disease
C. Mild obstructive disease
D. Moderate obstructive disease
Answer: D. Moderate obstructive disease
Question 77
A 30-year-old male patient presents for evaluation of a lump on his neck. He denies pain, itch,
erythema, edema, or any other symptoms. He is concerned because it won’t go away. He says, “I
noticed it a few months ago, then it seemed to disappear, and now it is back.” The AGACNP
proceeds with a history and physical exam and concludes which of the following as the leading
differential diagnosis?
A. Subclinical infection
B. Non-Hodgkin’s lymphoma
C. Catscratch disease
D. Syphilis
Answer: B. Non-Hodgkin’s lymphoma
Question 78
Ms. Teller presents with a chief complaint of weight loss. She reports an unplanned 10 lb weight
loss over the last 5-6 months. She has no significant medical history, but review of systems
reveals bilateral shoulder discomfort and some impaired range of motion—she has trouble
pulling clothing over her head. Over the last few months she has generalized upper body
stiffness, but seems to get better after an hour or so of activity. When considering a diagnosis of
polymyalgia rheumatica, laboratory assessment may be expected to reveal:
A. An erythrocyte sedimentation rate (ESR) of 75 mm/hr
B. A microcytic, hypochromic anemia
C. Elevated liver function enzymes
D. Positive antinuclear antibodies
Answer: A. An erythrocyte sedimentation rate (ESR) of 75 mm/hr
Question 79
When a patient has lower abdominal discomfort, cervical wall motion tenderness, and adnexal
tenderness, the AGACNP knows that this will likely be treated with:
A. Ceftriaxone and azithromycin
B. Metronidazole and ciprofloxacin
C. Trimethoprim/sulfamethoxazole
D. IV fluid and pain control
Answer: A. Ceftriaxone and azithromycin
Question 80
J.L. is an 81-year-old female who is admitted from home after her daughter found her confused
and unkempt. She is not a good historian, and her daughter cannot provide any information—
when she saw her mother a week ago, she was fine. J.L.’s vital signs are as follows: Temperature
101.4° F, pulse 99 b.p.m., respirations 22 b.p.m., and blood pressure 90/58 mm Hg. Her
urinalysis is shows +++ leukocytes, + RBC, and + nitrites. Her metabolic panel reveals a BUN of
39 mg/dL and creatinine of 1.5 mg/dL. The AGACNP knows that J.L has findings consistent
with:
A. Pre-renal failure
B. Intra-renal failure
C. Post-renal failure
D. Chronic renal failure
Answer: A. Pre-renal failure
Question 81
Patients with giant cell arteritis are at increased risk of:
A. Cerebrovascular accident
B. Rheumatoid arthritis
C. Polymyalgia rheumatica
D. Osteoarthritis
Answer: A. Cerebrovascular accident
Question 82
The AGACNP is called to the bedside for a patient who is in cardiopulmonary arrest. The
monitor demonstrates ventricular fibrillation which will not convert despite several attempts to
defibrillate at maximal voltage. While being briefed by the staff nurse on the patient medical
history, he learns that the patient has a history of Cushing’s syndrome. The AGACNP recognizes
that the patient is probably failing to convert due to:
A. Advanced atherosclerotic disease
B. Hypokalemia
C. Hypocalcemia
D. Catecholamine excess
Answer: D. Catecholamine excess
Question 83
When performing an evaluation of a patient following seizure activity, the AGACNP knows that
the most important component of that evaluation is:
A. A CT scan of the head
B. Eyewitness description
C. An EEG
D. Administering a benzodiazepine
Answer: B. Eyewitness description
Question 84
Which of the following etiologic organisms is most likely to appear as lobar consolidation on
chest radiography?
A. Legionella pneumophilia
B. Streptococcus pneumoniae
C. Pneumocystis carinii
D. Mycoplasma pneumoniae
Answer: B. Streptococcus pneumoniae
Question 85
A patient with chronic kidney disease presents with an eGFR of 30 mL/min/1.73m 2. The
AGACNP knows that the most compelling implication of this value is:
A. Control of risk factors for renal deterioration
B. Careful attention to renal dosing of medications
C. Referring the patient for shunt placement
D. Preventing occurrence of renal ischemia
Answer: B. Careful attention to renal dosing of medications
Question 86
Differential diagnosis of hematuria include all of the following except:
A. Bladder cancer
B. Nephrolithiasis in the renal parenchyma
C. Urinary tract infection
D. Prerenal azotemia
Answer: D. Prerenal azotemia
Question 87
A 29-year-old male patient presents with acute scrotal pain and dysuria. He has a temperature of
101.8° F and a pulse of 115 b.p.m. but otherwise vital signs are within normal limits. He gets
some relief of the scrotal discomfort when his scrotum is elevated on a rolled towel. This is
known as:
A. Varicocele
B. Prehn’s sign
C. Cremasteric sign
D. Testicular torsion
Answer: B. Prehn’s sign
Question 88
The AGACNP knows that patients with psoriasis are at greater risk for:
A. Arthritis
B. Eczema
C. Cellulitis
D. Melanoma
Answer: A. Arthritis
Question 89
Mr. McCarran is a 68-year-old male with a long history of poorly controlled T2DM. He has had
progressive burning pain in both feet for the last year or so, but in the last few months it has
become increasingly worse. He has tried taking ibuprofen and naproxyn over-the-counter with no
improvement. Now, he is presenting for more effective pain management. The AGACNP knows
that the medication of choice will be from which drug class?
A. NSAIDs
B. Opiates
C. Antiepileptics
D. Anesthetics
Answer: C. Antiepileptics
Question 90
Mr. Starwood is a 61-year-old male who was admitted last night for the management of acute
pancreatitis. He was admitted n.p.o and started on intravenous fluid and opiate pain management.
This morning he reports feeling significantly better. His C-reactive protein this a.m. is 5 mg/dL,
amylase and lipase are both just over 2 x upper limits of normal, and his Ransom score is 2. The
AGACNP knows that the next step in his care is to:
A. Begin clear liquids as tolerated
B. Order an abdominal CT
C. Order an ERCP
D. Continue the current management for 24 hours
Answer: A. Begin clear liquids as tolerated
Question 91
When beginning pharmacotherapy for depression, the AGACNP discusses with the patient that a
primary safety consideration includes the:
A. Increased risk of suicide when patients begin antidepressant therapy
B. Potential for sexual adverse effects
C. Better likelihood of success when medications and therapy are used together
D. High incidence of serotonin syndrome
Answer: A. Increased risk of suicide when patients begin antidepressant therapy
Question 92
When ruling out meningitis in a patient, the AGACP appreciates that the spinal fluid is cloudy
and the glucose content is 20 cells/microliter. This is most consistent with:
A. Aseptic meningitis
B. Septic meningitis
C. Chemical meningitis
D. Chronic meningitis
Answer: B. Septic meningitis
Question 93
A 44-year-old male patient presents in a hypertensive crisis. The blood pressure is 240/136 mm
Hg, pulse is 128 b.p.m. and the patient is complaining of a severe, pounding headache. His skin
is diaphoretic and he is visibly tremulous. The first diagnostic study to evaluate the suspected
diagnosis should be a:
A. 24 hour urine for catecholamine metabolites
B. Serum epinephrine and metanephrines
C. T scan of the abdomen
D. MRI of the abdomen
Answer: B. Serum epinephrine and metanephrines
Question 94
An unidentified patient is brought to the emergency department by ambulance after being hit by
a motor vehicle. She has multiple injuries and an estimated blood loss of 2 liters. The hematocrit
is 19%. The AGACNP expects that the mean cell volume (MCV) would most likely be:
A. 70 fL
B. 80 fL
C. 90 fL
D. 110 fL
Answer: B. 80 fL
Question 95
Mrs. Oliver is a 71-year-old petite Caucasian female. During a routine dexa screening she was
found to have a T-score of -3.0. The AGACNP knows that the first intervention should include:
A. Calcium
B. Vitamin D
C. Bisphosphonates
D. Estrogen
Answer: B. Vitamin D
Question 96
When evaluating a family with suspected carbon monoxide exposure, the AGACNP knows that
assessment should include all of the following except:
A. Vital signs
B. Pulse oximetry
C. Cardiac rhythm strip
D. Carboxyhemoglobin level
Answer: B. Pulse oximetry
Question 97
Mr. Riley is a 61-year-old male who just had bilateral knee replacements. There was more fluid
loss than intended during the procedure. The AGACNP knows that metabolic alkalosis is the
most common postoperative acid-base imbalance and is best treated with:
A. Normal saline infusion
B. An insulin drip
C. Low volume hydrochloric acid
D. Albumin
Answer: A. Normal saline infusion
Question 98
Patients in advanced stages of chronic kidney disease are at greatest risk for which of the
following conditions?
A. Polycythemia
B. Hypokalemia
C. Metabolic alkalosis
D. Anemia
Answer: D. Anemia
Question 99
The diagnostic study of choice in mesenteric ischemia is:
A. Ultrasound
B. CT angiography
C. MR angiography
D. Diagnostic peritoneal lavage
Answer: B. CT angiography
Question 100
Mr. Maxwell is a 58-year-old male who presents with left foot pain. Physical examination
reveals a foot that is normal in appearance with DP and PT pulses that are barely audible by
Doppler. The AGACNP has the patient cross the leg with the left foot resting on the right knee;
after 30 seconds that left foot is briskly lowered to the floor. Instantly the left foot turns bright
red. This is known as:
A. Venous insufficiency
B. Brawny hyperpigmentation
C. Homan’s sign
D. Dependent rubor
Answer: D. Dependent rubor
Question 101
When completing this exam, did you comply with Walden University’s Code of Conduct
including the expectations for academic integrity?
Yes
No
Answer: Yes
