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AACN ACNPC-AG study materials
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AACN ACNPC-AG practice questions

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Question 1Clinical Judgment: Assessment, Diagnosis and Clinical Reasoning

An arterial blood gas shows pH 7.28, PaCO2 30 mm Hg, and HCO3 14 mEq/L. Which acid-base disorder is present?

  1. Metabolic alkalosis with respiratory compensation
  2. Respiratory alkalosis with metabolic compensation
  3. Metabolic acidosis with respiratory compensation Correct answer.
  4. Combined metabolic and respiratory acidosis

Explanation

The low pH and low bicarbonate indicate a primary metabolic acidosis. The PaCO2 of 30 mm Hg represents compensatory hyperventilation; Winter's formula predicts 29 ± 2 mm Hg, so compensation is appropriate.

Question 2Clinical Judgment: Assessment, Diagnosis and Clinical Reasoning

A patient with suspected infection has a temperature of 38.6°C, heart rate 112/min, and respiratory rate 24/min. Which additional finding best satisfies Sepsis-3 criteria for organ dysfunction?

  1. Blood pressure of 108/70 mm Hg
  2. Serum lactate concentration of 1.8 mmol/L
  3. A qSOFA score of 2 or more at the bedside
  4. SOFA score increase of 2 or more Correct answer.

Explanation

Sepsis-3 defines organ dysfunction as an acute increase in SOFA score of at least 2 points. qSOFA is a bedside screening tool, and neither a normal lactate nor a single blood pressure value establishes organ dysfunction.

Question 3Clinical Judgment: Assessment, Diagnosis and Clinical Reasoning

A 12-lead ECG shows ST-segment elevation in leads II, III, and aVF. Which myocardial territory is most likely infarcted?

  1. Anterior wall
  2. Inferior wall Correct answer.
  3. Lateral wall
  4. Posterior wall

Explanation

Leads II, III, and aVF view the inferior wall of the left ventricle, usually supplied by the right coronary artery. Anterior infarction appears in V1-V4, lateral in I, aVL, V5-V6, and posterior as reciprocal depression in V1-V3.

Question 4Clinical Judgment: Assessment, Diagnosis and Clinical Reasoning

Which laboratory pattern is most consistent with diabetic ketoacidosis?

  1. Glucose 290 mg/dL, pH 7.50, HCO3 32 mEq/L, positive ketones
  2. Glucose 620 mg/dL, pH 7.40, HCO3 25 mEq/L, negative ketones
  3. Glucose 310 mg/dL, pH 7.20, HCO3 12 mEq/L, positive ketones Correct answer.
  4. Glucose 90 mg/dL, pH 7.30, HCO3 17 mEq/L, negative ketones

Explanation

DKA requires hyperglycemia, an anion-gap metabolic acidosis, and ketonemia. The combination of pH 7.20, bicarbonate 12 mEq/L, and positive ketones fits this triad.

Question 5Clinical Judgment: Assessment, Diagnosis and Clinical Reasoning

A patient with suspected acute ischemic stroke arrives 2 hours after symptom onset. Which imaging study should be obtained first?

  1. MRI of the brain with gadolinium
  2. Noncontrast CT of the head Correct answer.
  3. Lumbar puncture with opening pressure
  4. Carotid duplex ultrasonography

Explanation

Noncontrast head CT is the initial study because it rapidly excludes intracranial hemorrhage before thrombolytic therapy. MRI is more sensitive for early ischemia but is not the first required test in this setting.

Question 6Clinical Judgment: Assessment, Diagnosis and Clinical Reasoning

For a patient with an acute COPD exacerbation and risk of hypercapnia, which oxygen saturation target is recommended?

  1. 88% to 92% Correct answer.
  2. 100%
  3. 94% to 98%
  4. 80% to 85%

Explanation

Guidelines recommend a target oxygen saturation of 88% to 92% in COPD exacerbations with risk of hypercapnia. Higher targets can worsen carbon dioxide retention, while lower targets risk hypoxemia.

Question 7Clinical Judgment: Assessment, Diagnosis and Clinical Reasoning

Which ECG finding is typically the earliest manifestation of hyperkalemia?

  1. Peaked T waves Correct answer.
  2. Widened QRS complexes
  3. Sine-wave pattern
  4. Prominent U waves

Explanation

Peaked T waves are the earliest ECG change in hyperkalemia. QRS widening, sine-wave morphology, and ventricular arrhythmias occur with more severe elevation.

Question 8Clinical Judgment: Assessment, Diagnosis and Clinical Reasoning

Which feature most strongly suggests delirium rather than dementia?

  1. Isolated focal neurologic deficit
  2. Preserved level of consciousness
  3. Acute fluctuating attention Correct answer.
  4. Gradual progression of memory loss

Explanation

Delirium is characterized by acute onset, fluctuating course, and inattention. Dementia typically has an insidious, progressive course with preserved attention until late.

Question 9Clinical Judgment: Assessment, Diagnosis and Clinical Reasoning

A patient with pneumonia has a PaO2/FiO2 ratio of 150 while on PEEP 8 cm H2O, bilateral opacities on chest imaging, and no evidence of cardiogenic pulmonary edema. Which ARDS severity category applies?

  1. Mild ARDS
  2. Moderate ARDS Correct answer.
  3. Severe ARDS
  4. Does not meet ARDS criteria

Explanation

Berlin criteria classify ARDS by PaO2/FiO2 ratio with PEEP of at least 5 cm H2O: mild 200-300, moderate 100-200, severe below 100. A ratio of 150 with bilateral opacities and no cardiogenic cause is moderate ARDS.

Question 10Clinical Judgment: Assessment, Diagnosis and Clinical Reasoning

A hemodynamically stable patient has high pretest probability for pulmonary embolism and no contraindication to contrast. Which diagnostic test is most appropriate?

  1. D-dimer assay
  2. Ventilation-perfusion scan
  3. Empiric anticoagulation without imaging
  4. CT pulmonary angiography Correct answer.

Explanation

CT pulmonary angiography is the preferred test when pretest probability is high and contrast is not contraindicated. D-dimer is used to exclude PE in low-probability patients, and a V/Q scan is reserved for contrast contraindications.

Question 11Clinical Judgment: Assessment, Diagnosis and Clinical Reasoning

A patient with cirrhosis presents with hematemesis and a systolic blood pressure of 94 mm Hg. In addition to resuscitation, which medications should be started before endoscopy?

  1. Nadolol and spironolactone
  2. Octreotide and ceftriaxone Correct answer.
  3. Vitamin K and fresh frozen plasma
  4. Proton pump inhibitor alone

Explanation

Suspected variceal hemorrhage should be treated with a vasoactive agent such as octreotide and prophylactic ceftriaxone before endoscopy. These reduce portal pressure and infection risk, respectively.

Question 12Clinical Judgment: Assessment, Diagnosis and Clinical Reasoning

A patient with oliguric AKI is receiving furosemide. Which measurement best helps distinguish prerenal azotemia from acute tubular necrosis in this setting?

  1. Urine specific gravity
  2. Fractional excretion of urea Correct answer.
  3. Fractional excretion of sodium
  4. Serum BUN-to-creatinine ratio

Explanation

Diuretics invalidate fractional excretion of sodium, so fractional excretion of urea is used; a value below 35% suggests prerenal azotemia. Urine specific gravity and BUN-to-creatinine ratio are less reliable in this setting.

Question 13Clinical Judgment: Assessment, Diagnosis and Clinical Reasoning

In the management of thyroid storm, which medication should be administered only after a thionamide has been given?

  1. Propranolol
  2. Acetaminophen
  3. Iodine solution Correct answer.
  4. Hydrocortisone

Explanation

Iodine acutely blocks thyroid hormone release but can also provide substrate for new hormone synthesis. It is therefore given after a thionamide has blocked synthesis; beta-blockade and glucocorticoids can be started earlier.

Question 14Clinical Judgment: Assessment, Diagnosis and Clinical Reasoning

A patient with suspected adrenal crisis is hypotensive and has a random cortisol drawn. What is the most appropriate immediate next step?

  1. Give fludrocortisone as monotherapy
  2. Restrict fluids and observe
  3. Wait for ACTH stimulation test results
  4. Give dexamethasone immediately Correct answer.

Explanation

In suspected adrenal crisis, draw cortisol and give dexamethasone immediately without waiting for confirmatory tests. Dexamethasone does not interfere with the cortisol assay and provides life-saving glucocorticoid coverage.

Question 15Clinical Judgment: Assessment, Diagnosis and Clinical Reasoning

CSF shows opening pressure 28 cm H2O, WBC 1,800/µL with 85% neutrophils, glucose 25 mg/dL (serum 100 mg/dL), and protein 180 mg/dL. Which diagnosis is most likely?

  1. Fungal meningitis
  2. Subarachnoid hemorrhage
  3. Viral meningitis
  4. Bacterial meningitis Correct answer.

Explanation

Bacterial meningitis produces a neutrophilic pleocytosis, low CSF glucose, high protein, and elevated opening pressure. Viral meningitis usually has lymphocytic pleocytosis and normal glucose.

Question 16Clinical Judgment: Assessment, Diagnosis and Clinical Reasoning

A ventilated patient has a peak airway pressure of 45 cm H2O and a plateau pressure of 20 cm H2O. What is the most likely explanation?

  1. Abdominal compartment syndrome
  2. Pneumothorax
  3. Increased airway resistance Correct answer.
  4. Decreased lung compliance from ARDS

Explanation

A peak-to-plateau pressure gradient greater than 15 cm H2O indicates increased airway resistance, such as bronchospasm, secretions, or tube obstruction. A normal plateau pressure makes parenchymal compliance problems unlikely.

Question 17Clinical Judgment: Assessment, Diagnosis and Clinical Reasoning

A patient in shock has cardiac index 4.5 L/min/m2, systemic vascular resistance 500 dynes·s/cm5, mixed venous oxygen saturation 80%, and lactate 5 mmol/L. Which type of shock is most likely?

  1. Septic shock Correct answer.
  2. Hypovolemic shock
  3. Obstructive shock
  4. Cardiogenic shock

Explanation

Septic shock produces vasodilation with high cardiac output, low systemic vascular resistance, and impaired oxygen extraction, so ScvO2 may be elevated. Cardiogenic and hypovolemic shock typically have low cardiac output.

Question 18Clinical Judgment: Assessment, Diagnosis and Clinical Reasoning

A patient develops fever, flank pain, and dark urine minutes after a blood transfusion begins. What is the most appropriate immediate action?

  1. Give furosemide and continue the transfusion
  2. Obtain a chest radiograph and observe
  3. Slow the transfusion and give acetaminophen
  4. Stop the transfusion and maintain IV access Correct answer.

Explanation

Fever, flank pain, and dark urine suggest an acute hemolytic transfusion reaction. The transfusion must be stopped immediately, IV access maintained with crystalloid, and the blood bank notified.

Question 19Clinical Judgment: Assessment, Diagnosis and Clinical Reasoning

Which combination is sufficient to diagnose acute pancreatitis?

  1. Lipase elevated to 2 times the upper limit of normal only
  2. Typical pain with lipase over 3 times normal Correct answer.
  3. Typical epigastric pain only
  4. Normal lipase plus incidental pancreatic calcification

Explanation

Acute pancreatitis is diagnosed when at least two of three criteria are present: characteristic pain, lipase or amylase greater than three times the upper limit of normal, and imaging findings. Pain alone or a lesser enzyme elevation is insufficient.

Question 20Clinical Judgment: Assessment, Diagnosis and Clinical Reasoning

A patient with chronic hyponatremia has a serum sodium of 108 mEq/L and is seizing. After hypertonic saline is started, what is the maximum recommended increase in serum sodium during the first 24 hours?

  1. No limit if seizures are present
  2. 8 to 10 mEq/L Correct answer.
  3. 12 to 14 mEq/L
  4. 4 to 6 mEq/L

Explanation

Chronic hyponatremia should generally be corrected by no more than 8 to 10 mEq/L in 24 hours to reduce the risk of osmotic demyelination. Severe symptoms may require a small hypertonic saline bolus, but the overall correction limit still applies.

Question 21Clinical Judgment: Assessment, Diagnosis and Clinical Reasoning

A patient with chest pain has ST-segment depression in leads V1 through V3 and tall R waves in V1 and V2. Which next step is most likely to reveal the diagnosis?

  1. Order a D-dimer
  2. Start a beta-blocker and observe
  3. Repeat the standard ECG in 6 hours
  4. Obtain posterior leads V7 to V9 Correct answer.

Explanation

ST depression in V1-V3 with tall R waves suggests posterior myocardial infarction. Posterior leads V7-V9 can confirm ST elevation, and the patient should be managed as having a STEMI.

Question 22Clinical Judgment: Assessment, Diagnosis and Clinical Reasoning

A patient with an aspirin overdose has tinnitus, tachypnea, pH 7.48, PaCO2 24 mm Hg, and bicarbonate 18 mEq/L. Which acid-base disturbance is most likely?

  1. Primary respiratory alkalosis without metabolic compensation
  2. Primary metabolic acidosis alone
  3. Mixed respiratory alkalosis and metabolic acidosis Correct answer.
  4. Mixed respiratory acidosis and metabolic alkalosis

Explanation

Salicylate toxicity causes central respiratory stimulation and uncoupled oxidative phosphorylation. The result is a mixed respiratory alkalosis and metabolic acidosis, often with an elevated anion gap.

Question 23Clinical Judgment: Assessment, Diagnosis and Clinical Reasoning

A patient with a subarachnoid hemorrhage develops hyponatremia, polyuria, and a negative fluid balance. Serum osmolality is 270 mOsm/kg, urine sodium 80 mEq/L, and urine osmolality 600 mOsm/kg. Which condition is most likely?

  1. SIADH
  2. Diabetes insipidus
  3. Cerebral salt wasting Correct answer.
  4. Primary polydipsia

Explanation

Cerebral salt wasting causes hyponatremia with hypovolemia, high urine output, and high urine sodium and osmolality after brain injury. SIADH is euvolemic, and diabetes insipidus causes hypernatremia.

Question 24Clinical Judgment: Assessment, Diagnosis and Clinical Reasoning

A patient with DKA has a serum potassium of 3.0 mEq/L. What is the most appropriate management before starting an insulin infusion?

  1. Restrict potassium until the glucose falls below 250 mg/dL
  2. Hold insulin and give intravenous potassium Correct answer.
  3. Give sodium bicarbonate
  4. Begin insulin immediately and recheck potassium in 4 hours

Explanation

Insulin shifts potassium into cells and can worsen hypokalemia. When serum potassium is below 3.3 mEq/L in DKA, insulin should be held while intravenous potassium is replaced.

Question 25Clinical Judgment: Assessment, Diagnosis and Clinical Reasoning

A patient has severe abdominal pain out of proportion to examination findings, atrial fibrillation, and a lactate of 4 mmol/L. Which diagnostic study is most appropriate?

  1. CT angiography of the abdomen Correct answer.
  2. Bedside abdominal ultrasonography with Doppler
  3. Upper endoscopy
  4. Colonoscopy

Explanation

Pain out of proportion to examination in a patient with atrial fibrillation suggests acute mesenteric ischemia. CT angiography is the preferred diagnostic study and should not be delayed for other tests.

Question 26Clinical Judgment: Assessment, Diagnosis and Clinical Reasoning

An adult patient has arterial blood gas results of pH 7.28, PaCO2 55 mm Hg, and HCO3 24 mEq/L. Which acid-base disorder is present?

  1. Acute respiratory acidosis Correct answer.
  2. Chronic respiratory alkalosis
  3. Metabolic acidosis with respiratory compensation
  4. Metabolic alkalosis with respiratory compensation

Explanation

A pH below 7.35 with an elevated PaCO2 and a normal bicarbonate indicates an acute respiratory acidosis. The bicarbonate has not risen, so renal compensation is not yet present.

Question 27Clinical Judgment: Assessment, Diagnosis and Clinical Reasoning

A patient with dyspnea has a BNP of 900 pg/mL. Which interpretation is most appropriate?

  1. It excludes heart failure as the cause
  2. It strongly supports heart failure as the cause Correct answer.
  3. It is diagnostic of pneumonia
  4. It indicates a pulmonary embolism

Explanation

BNP rises with ventricular wall stretch, and a value well above the heart failure threshold strongly supports decompensated heart failure in a dyspneic patient. BNP is not specific and must be interpreted with the clinical picture, but an elevated value does not exclude heart failure; it supports it.

Question 28Clinical Judgment: Assessment, Diagnosis and Clinical Reasoning

Which set of findings meets the qSOFA criteria for sepsis risk?

  1. Temperature 39°C, heart rate 110 beats/min, WBC 18,000/µL
  2. Respiratory rate 24 breaths/min, altered mentation, systolic BP 92 mm Hg Correct answer.
  3. PaO2/FiO2 ratio 200, platelets 80,000/µL, bilirubin 3 mg/dL
  4. Heart rate 120 beats/min, lactate 4 mmol/L, urine output 0.3 mL/kg/h

Explanation

qSOFA uses three bedside findings: respiratory rate 22 breaths/min or higher, altered mentation, and systolic blood pressure 100 mm Hg or lower. Two or more of these identify patients at increased risk of poor outcomes from infection.

Question 29Clinical Judgment: Assessment, Diagnosis and Clinical Reasoning

A patient with acute right-sided weakness was last known well 2 hours ago. Which factor is most important when deciding about intravenous thrombolysis?

  1. The patient's blood glucose level
  2. The patient's family history of stroke
  3. The exact time last known well Correct answer.
  4. The presence of a headache

Explanation

The eligibility window for intravenous thrombolysis is defined by the time last known well, so establishing that time is the critical first step. Other factors matter for safety but do not replace the time criterion.

Question 30Clinical Judgment: Assessment, Diagnosis and Clinical Reasoning

Which bedside finding is most consistent with hypocalcemia?

  1. Murphy sign
  2. Kernig sign
  3. Babinski sign
  4. Trousseau sign Correct answer.

Explanation

Trousseau sign is carpal spasm produced by inflating a blood pressure cuff above systolic pressure and reflects neuromuscular irritability from hypocalcemia. Chvostek sign is a related facial twitch.

Question 31Clinical Judgment: Assessment, Diagnosis and Clinical Reasoning

A patient with DKA has sodium 135 mEq/L, chloride 100 mEq/L, and bicarbonate 10 mEq/L. What is the anion gap?

  1. 25 mEq/L Correct answer.
  2. 15 mEq/L
  3. 45 mEq/L
  4. 35 mEq/L

Explanation

The anion gap is calculated as sodium minus chloride minus bicarbonate. 135 − 100 − 10 = 25 mEq/L, which is elevated and consistent with ketoacidosis.

Question 32Clinical Judgment: Assessment, Diagnosis and Clinical Reasoning

Which variable is part of the CURB-65 score for pneumonia severity?

  1. Oxygen saturation less than 90%
  2. Blood urea nitrogen greater than 19 mg/dL Correct answer.
  3. Temperature greater than 38°C
  4. Heart rate greater than 100 beats/min

Explanation

CURB-65 stands for confusion, urea greater than 7 mmol/L (about 19 mg/dL), respiratory rate 30/min or higher, blood pressure low (systolic <90 or diastolic ≤60 mm Hg), and age 65 years or older. Heart rate, oxygen saturation, and temperature are not components.

Question 33Clinical Judgment: Assessment, Diagnosis and Clinical Reasoning

Which ECG finding is most typical of acute pericarditis?

  1. Peaked T waves in the precordial leads
  2. Diffuse ST-segment elevation with PR depression Correct answer.
  3. ST-segment elevation in leads II, III, and aVF only
  4. ST-segment depression in leads V1 to V3

Explanation

Acute pericarditis classically produces diffuse concave ST elevation and PR depression across multiple vascular territories. The changes are not limited to a single coronary distribution.

Question 34Clinical Judgment: Assessment, Diagnosis and Clinical Reasoning

A patient has euvolemic hyponatremia. Which laboratory finding best supports SIADH?

  1. Urine sodium of 5 mEq/L
  2. Fractional excretion of sodium of 0.2%
  3. Urine osmolality of 620 mOsm/kg Correct answer.
  4. Serum osmolality of 320 mOsm/kg

Explanation

In SIADH, ADH excess concentrates the urine despite low serum osmolality; a urine osmolality above 100 mOsm/kg is expected. The patient is clinically euvolemic and urine sodium is usually high.

Question 35Clinical Judgment: Assessment, Diagnosis and Clinical Reasoning

A patient who received heparin 6 days ago has a platelet count that fell from 250,000 to 90,000/µL. Which feature most increases the likelihood of heparin-induced thrombocytopenia?

  1. Platelet count below 100,000/µL
  2. A platelet fall that began within 24 hours
  3. A 60% platelet fall with new thrombosis Correct answer.
  4. Presence of petechiae only

Explanation

The 4Ts score weighs thrombocytopenia severity, timing, thrombosis, and other causes. A greater than 50% fall with new thrombosis after 5–10 days of heparin strongly supports HIT.

Question 36Clinical Judgment: Assessment, Diagnosis and Clinical Reasoning

A patient taking an SSRI develops agitation, diaphoresis, tremor, and hyperreflexia after a new medication is added. Which finding most favors serotonin syndrome over neuroleptic malignant syndrome?

  1. Lead-pipe rigidity
  2. Marked bradycardia
  3. A creatine kinase level of 200 U/L
  4. Hyperreflexia and clonus Correct answer.

Explanation

Serotonin syndrome typically causes neuromuscular hyperactivity, including hyperreflexia and clonus, along with autonomic instability. Neuroleptic malignant syndrome more often produces lead-pipe rigidity and marked CK elevation.

Question 37Clinical Judgment: Assessment, Diagnosis and Clinical Reasoning

A patient with sudden tearing chest pain has a blood pressure of 180/100 mm Hg in the right arm and 130/80 mm Hg in the left arm. Which diagnosis is most likely?

  1. Aortic dissection Correct answer.
  2. Acute pericarditis
  3. Unstable angina
  4. Pulmonary embolism

Explanation

A marked interarm blood pressure differential with sudden severe tearing pain suggests aortic dissection involving the aorta or branch vessels. Immediate aortic imaging and blood pressure control are priorities.

Question 38Clinical Judgment: Assessment, Diagnosis and Clinical Reasoning

Which cluster of findings most suggests cardiac tamponade?

  1. Fever, pericardial rub, and diffuse ST elevation
  2. Hypotension, distended neck veins, and muffled heart sounds Correct answer.
  3. Hypertension, clear lungs, and a loud S1
  4. Bradycardia, clear lungs, and a widened pulse pressure

Explanation

Beck triad-hypotension, jugular venous distention, and muffled heart sounds-is classic for cardiac tamponade. Pulsus paradoxus may also be present.

Question 39Clinical Judgment: Assessment, Diagnosis and Clinical Reasoning

A patient has an absolute neutrophil count of 400/µL and a temperature of 38.5°C. What is the most appropriate initial action?

  1. Wait for culture results before giving antibiotics
  2. Start oral fluconazole alone
  3. Obtain blood cultures and start empiric broad-spectrum antibiotics Correct answer.
  4. Give acetaminophen and reassess in 24 hours

Explanation

Febrile neutropenia is an emergency; blood cultures should be drawn promptly and empiric antipseudomonal broad-spectrum antibiotics started immediately. Delay increases the risk of rapid deterioration and death.

Question 40Clinical Judgment: Assessment, Diagnosis and Clinical Reasoning

Which laboratory pattern is most consistent with tumor lysis syndrome?

  1. Hypernatremia, hypochloremia, and metabolic alkalosis
  2. Hypokalemia, hypophosphatemia, hypercalcemia, and hypouricemia
  3. Hypoglycemia, hyperkalemia, and respiratory acidosis
  4. Hyperkalemia, hyperphosphatemia, hypocalcemia, and hyperuricemia Correct answer.

Explanation

Tumor lysis releases intracellular potassium, phosphate, and nucleic acids, producing hyperkalemia, hyperphosphatemia, hyperuricemia, and secondary hypocalcemia. This pattern can cause arrhythmias and acute kidney injury.

Question 41Clinical Judgment: Assessment, Diagnosis and Clinical Reasoning

A patient with crush injury has dark urine, a positive urine dipstick for blood, and no red blood cells on microscopy. Which test best confirms rhabdomyolysis?

  1. Urine culture
  2. Serum bilirubin
  3. Renal ultrasound
  4. Serum creatinine kinase Correct answer.

Explanation

A markedly elevated creatine kinase confirms muscle breakdown; myoglobin causes a positive blood dipstick without red cells. The combination of CK elevation and this urinalysis pattern supports rhabdomyolysis.

Question 42Clinical Judgment: Assessment, Diagnosis and Clinical Reasoning

Which finding is a major Duke criterion for infective endocarditis?

  1. Temperature of 38.2°C
  2. An elevated C-reactive protein
  3. A history of intravenous drug use
  4. Persistently positive blood cultures for a typical organism Correct answer.

Explanation

The Duke criteria include major microbiologic findings, such as persistently positive blood cultures with a typical organism, and major imaging findings of endocarditis. Fever, drug use, and elevated CRP are minor or nonspecific.

Question 43Clinical Judgment: Assessment, Diagnosis and Clinical Reasoning

A patient admitted with alcohol use disorder develops tremor, diaphoresis, and a heart rate of 120 beats/min 12 hours after the last drink. Which tool best guides symptom-triggered treatment?

  1. CURB-65
  2. Wells score
  3. CIWA-Ar Correct answer.
  4. Glasgow Coma Scale

Explanation

The Clinical Institute Withdrawal Assessment for Alcohol, revised (CIWA-Ar), quantifies withdrawal severity and supports symptom-triggered benzodiazepine dosing. This approach reduces total medication compared with fixed dosing.

Question 44Clinical Judgment: Assessment, Diagnosis and Clinical Reasoning

Which electrolyte abnormality most increases the risk of digoxin toxicity?

  1. Hyperchloremia
  2. Hypercalcemia
  3. Hypokalemia Correct answer.
  4. Hypernatremia

Explanation

Hypokalemia enhances digoxin binding at the sodium-potassium ATPase and increases the risk of toxicity, especially arrhythmias. Potassium should be corrected carefully while monitoring for hyperkalemia in severe toxicity.

Question 45Clinical Judgment: Assessment, Diagnosis and Clinical Reasoning

A patient with lung cancer has confusion and a serum calcium of 13.5 mg/dL. Which additional finding best supports hypercalcemia of malignancy?

  1. Low parathyroid hormone Correct answer.
  2. Elevated phosphate
  3. Elevated parathyroid hormone
  4. Low alkaline phosphatase

Explanation

Hypercalcemia of malignancy is usually mediated by PTH-related peptide, which suppresses endogenous parathyroid hormone. A low PTH with high calcium supports this diagnosis.

Question 46Clinical Judgment: Assessment, Diagnosis and Clinical Reasoning

A patient has pH 7.40, PaCO2 22 mm Hg, and HCO3 13 mEq/L. Which interpretation is most accurate?

  1. Metabolic alkalosis with compensation
  2. Mixed metabolic acidosis and respiratory alkalosis Correct answer.
  3. Acute respiratory alkalosis only
  4. Normal blood gas with no disorder

Explanation

The bicarbonate is markedly low, indicating metabolic acidosis, while the PaCO2 is also low. A normal pH with both low bicarbonate and low PaCO2 indicates a mixed disorder rather than simple compensation.

Question 47Clinical Judgment: Assessment, Diagnosis and Clinical Reasoning

A patient presents with altered mental status, visual disturbances, and an elevated osmolal gap. Which ingestion is most likely?

  1. Methanol Correct answer.
  2. Iron
  3. Salicylate
  4. Acetaminophen

Explanation

Methanol and other toxic alcohols produce an osmolal gap and can cause visual symptoms and altered mentation. Early recognition is important because treatment differs from that for other overdoses.

Question 48Clinical Judgment: Assessment, Diagnosis and Clinical Reasoning

A patient has been breathing spontaneously on a T-piece for 30 minutes. Which rapid shallow breathing index value suggests a high likelihood of successful extubation?

  1. 80 breaths/min/L Correct answer.
  2. 120 breaths/min/L
  3. 110 breaths/min/L
  4. 150 breaths/min/L

Explanation

The rapid shallow breathing index is respiratory rate divided by tidal volume in liters; a value below 105 predicts extubation success. Values above 105 suggest a higher risk of failure.

Question 49Clinical Judgment: Assessment, Diagnosis and Clinical Reasoning

Which laboratory pattern is most consistent with primary adrenal insufficiency?

  1. High cortisol, low ACTH, and hypokalemia
  2. Low cortisol, high ACTH, hyponatremia, and hyperkalemia Correct answer.
  3. High cortisol, high ACTH, and hypocalcemia
  4. Low cortisol, low ACTH, and hypernatremia

Explanation

Primary adrenal insufficiency causes cortisol deficiency, loss of aldosterone, and lack of negative feedback, producing high ACTH, hyponatremia, and hyperkalemia. Secondary adrenal insufficiency usually has low or inappropriately normal ACTH and less hyperkalemia.

Question 50Clinical Judgment: Assessment, Diagnosis and Clinical Reasoning

Which ECG pattern most suggests severe left main coronary artery ischemia?

  1. Peaked T waves in V2 and V3
  2. ST elevation in aVR with diffuse ST depression Correct answer.
  3. ST elevation in leads II, III, and aVF
  4. PR prolongation with a narrow QRS

Explanation

ST elevation in lead aVR with widespread ST depression suggests global subendocardial ischemia from left main or severe multivessel disease. This pattern warrants urgent evaluation for revascularization.