I85PREP
⌘ K
BCGP study materials
BCGP study resources

BCGP practice questions

One question at a time. Build your BCGP understanding.

First 50 of 200 questions. Each one lists the choices, the correct answer, and an explanation. The checker at the top of this page saves progress in this browser when it is available.

Continue in the practice tool above to load more questions, 50 at a time.

Question 1General Principles of Geriatric Care and Aging

Which age-related change most directly reduces the reliability of the rectal temperature reading in an older adult?

  1. Slower rectal mucosal blood flow and lower core-to-skin gradient Correct answer.
  2. Reduced subcutaneous fat in the perianal region
  3. Increased density of sweat glands in the anal canal
  4. Heightened shivering threshold in the rectal mucosa

Explanation

Rectal temperature lags behind true core temperature because mucosal blood flow declines and the core-to-periphery gradient widens with age. This delay makes the reading less responsive to rapid changes such as fever onset or cooling during sepsis. Clinicians should therefore interpret rectal readings with caution and correlate them with the clinical picture.

Question 2General Principles of Geriatric Care and Aging

Which statement best describes normal age-related change in glomerular filtration rate?

  1. It falls only when hypertension is present
  2. It rises steadily until age 70 then plateaus
  3. It declines by roughly 8 mL/min per decade after age 40 Correct answer.
  4. It remains unchanged but tubular secretion increases

Explanation

GFR declines progressively with age, averaging about 8 mL/min per 1.73 m² per decade after roughly age 40. This decline occurs even in healthy adults without kidney disease. Because serum creatinine also falls with reduced muscle mass, creatinine alone underestimates the degree of renal impairment.

Question 3General Principles of Geriatric Care and Aging

An 82-year-old with a serum creatinine of 0.9 mg/dL is prescribed a renally cleared drug. Which action best reflects correct interpretation of this value?

  1. Assume normal renal function because creatinine is within range
  2. Estimate creatinine clearance using weight, age, and sex Correct answer.
  3. Order a 24-hour urine only if edema is present
  4. Double the dose because muscle mass is preserved

Explanation

Low muscle mass in frail older adults lowers creatinine production, so a normal serum creatinine can mask substantial renal impairment. An estimated clearance calculation using age, weight, and sex gives a more realistic estimate for dose adjustment. Relying on the creatinine value alone risks drug accumulation and toxicity.

Question 4General Principles of Geriatric Care and Aging

Which pharmacokinetic change of aging most increases the risk of accumulation of water-soluble drugs?

  1. Increased total body water
  2. Decreased lean body mass and total body water Correct answer.
  3. Increased serum albumin
  4. Increased hepatic blood flow

Explanation

Aging reduces lean body mass and total body water, shrinking the volume of distribution for hydrophilic drugs. A smaller volume means a given dose produces higher concentrations and prolongs elimination half-life. This raises the risk of accumulation for agents such as aminoglycosides and lithium.

Question 5General Principles of Geriatric Care and Aging

Which age-related change most raises the risk of bleeding from warfarin in an older adult?

  1. Increased platelet aggregation
  2. Enhanced renal clearance of warfarin
  3. Increased hepatic synthesis of clotting factors
  4. Reduced vitamin K intake and decreased albumin binding Correct answer.

Explanation

Older adults often consume less vitamin K and have lower albumin, increasing the free fraction of warfarin and its anticoagulant effect. Reduced hepatic synthesis of clotting factors further amplifies sensitivity. These factors together narrow the therapeutic window and raise bleeding risk.

Question 6General Principles of Geriatric Care and Aging

Which presentation of acute coronary syndrome is most characteristic in an older adult?

  1. Sharp pleuritic pain relieved by leaning forward
  2. Classic crushing substernal pain radiating to the arm
  3. Sudden dyspnea, confusion, or fatigue without chest pain Correct answer.
  4. Isolated unilateral leg swelling

Explanation

Older adults frequently present with atypical ischemic symptoms such as dyspnea, delirium, syncope, or profound fatigue rather than classic chest pain. Reduced pain perception and comorbid conditions contribute to this presentation. Clinicians must maintain a high index of suspicion to avoid missing myocardial infarction.

Question 7General Principles of Geriatric Care and Aging

Which factor most strongly predicts adverse drug events in an older adult?

  1. Preferred pharmacy chain
  2. Patient's level of education
  3. Number of concurrent medications Correct answer.
  4. Season of the year

Explanation

Polypharmacy is among the strongest predictors of adverse drug events because each additional agent raises the chance of interactions and cumulative toxicity. Risk climbs with the number of prescribers and the use of high-risk drug classes. Regular medication reconciliation is therefore a core geriatric safety practice.

Question 8General Principles of Geriatric Care and Aging

A 78-year-old reports dizziness on standing. Which finding best supports a diagnosis of orthostatic hypotension?

  1. A rise of 15 mm Hg diastolic on standing
  2. A drop of 20 mm Hg systolic within 3 minutes of standing Correct answer.
  3. A stable blood pressure with a heart rate rise of 5 beats per minute
  4. A drop of 10 mm Hg systolic on standing

Explanation

Orthostatic hypotension is defined as a sustained fall of at least 20 mm Hg systolic or 10 mm Hg diastolic within 3 minutes of standing. The delayed timing captures cases missed by immediate measurement. Identifying this condition guides deprescribing and fall prevention.

Question 9General Principles of Geriatric Care and Aging

Which intervention is most appropriate first-line for preventing falls in a community-dwelling older adult with balance impairment?

  1. Routine use of a wheelchair
  2. A structured exercise program targeting strength and balance Correct answer.
  3. Nightly sedative hypnotic to ensure sleep
  4. Bed rest to limit exposure to falls

Explanation

Exercise programs that combine strength, balance, and gait training reduce falls in community-dwelling older adults and are recommended as a core intervention. They address the underlying impairments rather than restricting activity. Sedatives and immobility increase fall risk and should be avoided.

Question 10General Principles of Geriatric Care and Aging

Which feature most reliably distinguishes delirium from dementia at the bedside?

  1. Preserved attention throughout the day
  2. Acute onset with fluctuating attention Correct answer.
  3. Stable course across weeks
  4. Gradual onset over several years

Explanation

Delirium is characterized by acute onset, fluctuating course, and impaired attention, which distinguishes it from the insidious and progressive decline of dementia. Attention testing at the bedside is a key discriminator. Recognizing delirium promptly allows treatment of the underlying cause.

Question 11General Principles of Geriatric Care and Aging

Which medication class is most strongly associated with precipitating delirium in an older adult?

  1. Anticholinergics Correct answer.
  2. Topical emollients
  3. Inhaled corticosteroids
  4. Oral iron supplements

Explanation

Anticholinergic medications impair central cholinergic transmission and are a well-recognized precipitant of delirium. Older adults are especially vulnerable because of reduced cholinergic reserve. Reviewing and stopping such agents is a key step in delirium management.

Question 12General Principles of Geriatric Care and Aging

An older adult with depression reports poor appetite, insomnia, and vague somatic complaints but denies sadness. Which concept best explains this presentation?

  1. Early Parkinson disease
  2. Malingering for secondary gain
  3. Masked depression with prominent somatic features Correct answer.
  4. Normal aging with no psychiatric component

Explanation

Depression in older adults often presents with somatic complaints and vegetative symptoms rather than reported sadness, sometimes called masked depression. Screening tools help uncover the underlying mood disorder. Untreated depression worsens function and mortality.

Question 13General Principles of Geriatric Care and Aging

Which screening instrument is specifically designed to assess cognitive impairment in older adults?

  1. Mini-Cog Correct answer.
  2. CAGE questionnaire
  3. Braden Scale
  4. PHQ-9

Explanation

The Mini-Cog combines a three-item recall with a clock-drawing task and is validated for brief cognitive screening in older adults. It is quick to administer and relatively unaffected by education level. The other instruments assess mood, alcohol use, and pressure ulcer risk, respectively.

Question 14General Principles of Geriatric Care and Aging

Which statement about normal aging and sleep architecture is most accurate?

  1. Slow-wave sleep and total sleep time tend to decrease Correct answer.
  2. REM sleep disappears entirely after age 70
  3. Nighttime awakenings become less frequent
  4. Sleep latency shortens markedly with age

Explanation

Aging is associated with reduced slow-wave sleep, more fragmented sleep, and shorter total sleep time. Sleep latency often lengthens rather than shortens, and nighttime awakenings increase. Recognizing these changes helps avoid inappropriate prescribing of hypnotics.

Question 15General Principles of Geriatric Care and Aging

Which change in body composition contributes most to altered drug distribution for lipophilic agents in older adults?

  1. Increased muscle mass
  2. Increased proportion of adipose tissue Correct answer.
  3. Decreased serum albumin only
  4. Decreased total body fat

Explanation

The proportion of adipose tissue rises with age even when total weight is stable, increasing the volume of distribution for lipophilic drugs. This prolongs their half-life and can delay elimination. Water-soluble drugs behave oppositely because total body water falls.

Question 16General Principles of Geriatric Care and Aging

An 85-year-old is started on a drug with a narrow therapeutic index. Which monitoring approach is most appropriate?

  1. Start low, titrate slowly, and monitor closely early in therapy Correct answer.
  2. Use the highest dose first to reach steady state quickly
  3. Start at a standard adult dose and monitor annually
  4. Withhold all monitoring unless symptoms appear

Explanation

The principle of starting low and going slow reflects reduced clearance, altered distribution, and heightened sensitivity in older adults. Close early monitoring detects toxicity before it becomes severe. Standard adult dosing risks accumulation and adverse events.

Question 17General Principles of Geriatric Care and Aging

Which of the following best illustrates the concept of a prescribing cascade?

  1. Switching to a generic equivalent of the same drug
  2. Reducing a diuretic dose when blood pressure falls
  3. Adding a laxative to manage constipation caused by an opioid Correct answer.
  4. Discontinuing a sedative after a fall

Explanation

A prescribing cascade occurs when a new drug is prescribed to treat an adverse effect of another drug, often without recognizing the causal link. Adding a laxative for opioid-induced constipation is a classic example. Recognizing the cascade allows the original drug to be reconsidered rather than adding more agents.

Question 18General Principles of Geriatric Care and Aging

Which physiologic change best explains increased sensitivity to benzodiazepines in older adults?

  1. Increased sensitivity of central nervous system receptors to drug effect Correct answer.
  2. Increased hepatic first-pass metabolism
  3. Increased GABA receptor density
  4. Reduced blood-brain barrier permeability

Explanation

Older adults show increased central nervous system sensitivity to benzodiazepines, producing greater sedation and cognitive impairment at lower concentrations. This pharmacodynamic change compounds the effect of reduced hepatic metabolism of long-acting agents. The result is a markedly elevated risk of falls and confusion.

Question 19General Principles of Geriatric Care and Aging

An older adult with mild cognitive impairment and preserved decision-making capacity refuses a recommended procedure. Which action is most appropriate?

  1. Obtain consent from a distant relative without legal authority
  2. Delay all discussion until capacity is lost
  3. Proceed because cognitive impairment removes autonomy
  4. Respect the refusal after confirming understanding of risks and alternatives Correct answer.

Explanation

Decision-making capacity is task-specific, and mild cognitive impairment does not automatically eliminate it. When capacity is preserved, the patient's informed refusal should be respected. Clinicians should document the discussion of risks, benefits, and alternatives.

Question 20General Principles of Geriatric Care and Aging

Which concept best describes the compression of morbidity in successful aging?

  1. Extending lifespan while shortening the period of disability near the end of life Correct answer.
  2. Eliminating all chronic disease through screening
  3. Prolonging disability earlier in life to shorten lifespan
  4. Increasing hospital admissions in the final year of life

Explanation

Compression of morbidity proposes that healthy behaviors can postpone the onset of disability so that the disabled period is confined to a shorter interval before death. This contrasts with simply extending lifespan while prolonging disability. It emphasizes healthspan as well as lifespan.

Question 21Pharmacokinetics and Pharmacodynamics in Older Adults

Which age-related change most consistently reduces the renal clearance of renally eliminated drugs in older adults?

  1. A rise in serum albumin concentration
  2. A decline in glomerular filtration rate and renal blood flow Correct answer.
  3. An increase in hepatic cytochrome P450 activity
  4. An increase in total body water

Explanation

Aging typically reduces renal blood flow and glomerular filtration rate, so drugs cleared mainly by the kidney accumulate and require dose adjustment. Serum creatinine may appear normal despite reduced clearance because muscle mass has fallen, so creatinine clearance should be estimated rather than relying on the raw value.

Question 22Pharmacokinetics and Pharmacodynamics in Older Adults

An 82-year-old woman has a serum creatinine of 0.9 mg/dL. Why can this value overestimate her kidney function?

  1. Creatinine is reabsorbed completely in the distal tubule
  2. Creatinine is bound extensively to albumin
  3. Creatinine is actively secreted by the liver
  4. Creatinine production falls with reduced muscle mass Correct answer.

Explanation

Creatinine is a product of muscle metabolism, so sarcopenic older adults generate less of it and may have a deceptively normal serum concentration despite substantially reduced clearance. Estimating creatinine clearance with an equation that accounts for age, sex, and weight gives a better picture of elimination capacity.

Question 23Pharmacokinetics and Pharmacodynamics in Older Adults

Which pharmacokinetic change best explains why older adults often show a prolonged elimination half-life of lipid-soluble benzodiazepines such as diazepam?

  1. Increased gastric pH accelerates absorption
  2. Increased serum albumin binds more free drug
  3. Reduced intestinal motility lowers bioavailability
  4. Increased body fat raises the volume of distribution Correct answer.

Explanation

With aging, adipose tissue increases while lean mass and total body water decline, so highly lipophilic drugs distribute into a larger fat compartment. The expanded volume of distribution prolongs the half-life and can cause accumulation and prolonged sedation even when clearance is unchanged.

Question 24Pharmacokinetics and Pharmacodynamics in Older Adults

Which statement about the first-pass metabolism of orally administered drugs in older adults is most accurate?

  1. Reduced hepatic first-pass extraction can increase oral bioavailability Correct answer.
  2. First-pass metabolism increases, lowering systemic exposure
  3. First-pass metabolism is unaffected by aging
  4. First-pass metabolism occurs primarily in the kidney

Explanation

Hepatic oxidative metabolism and liver blood flow decline with age, so drugs with high first-pass extraction may reach the systemic circulation in higher fractions after oral dosing. This can raise plasma concentrations and adverse-effect risk for agents such as some opioids and calcium channel blockers, sometimes warranting lower starting doses.

Question 25Pharmacokinetics and Pharmacodynamics in Older Adults

A 78-year-old man takes warfarin and is started on a drug that inhibits CYP2C9. What is the most appropriate monitoring plan?

  1. Reassure the patient that enzyme inhibition is clinically insignificant
  2. Stop checking the INR until symptoms of bleeding appear
  3. Double the warfarin dose to overcome the interaction
  4. Check the INR within a few days and adjust the warfarin dose Correct answer.

Explanation

CYP2C9 inhibition reduces warfarin metabolism, raising its anticoagulant effect and bleeding risk. The INR should be checked within several days of starting or stopping the interacting drug, and the warfarin dose adjusted accordingly.

Question 26Pharmacokinetics and Pharmacodynamics in Older Adults

Which principle best describes how aging affects pharmacodynamics of drugs acting on the central nervous system?

  1. The blood-brain barrier becomes more permeable to all drugs
  2. Older adults show greater sensitivity to sedatives at the same plasma concentration Correct answer.
  3. Central receptor density increases with age
  4. Older adults require higher sedative concentrations for the same effect

Explanation

Age-related changes in neurotransmitter systems and receptor density increase brain sensitivity to sedatives, opioids, and anticholinergics, so similar plasma concentrations produce greater effects. This pharmacodynamic change supports starting these drugs at lower doses in older adults.

Question 27Pharmacokinetics and Pharmacodynamics in Older Adults

Which drug class is most likely to cause orthostatic hypotension and falls in an older adult because of age-related baroreceptor changes?

  1. Proton pump inhibitors
  2. Topical emollients
  3. Alpha-1 receptor blockers Correct answer.
  4. Inhaled corticosteroids

Explanation

Alpha-1 blockers lower vascular tone, and blunted baroreceptor reflexes in older adults reduce the ability to compensate for the resulting drop in blood pressure. This combination increases the risk of orthostatic hypotension, dizziness, and falls, so these agents warrant cautious dosing and monitoring.

Question 28Pharmacokinetics and Pharmacodynamics in Older Adults

Which statement about the anticholinergic burden in older adults is correct?

  1. Central muscarinic blockade can cause confusion and urinary retention Correct answer.
  2. Anticholinergic effects are limited to the gastrointestinal tract
  3. Anticholinergic drugs lower the risk of falls
  4. Anticholinergic drugs increase salivary flow

Explanation

Older adults have reduced cholinergic reserve, so muscarinic blockade readily produces confusion, dry mouth, constipation, urinary retention, and blurred vision. Cumulative anticholinergic burden from multiple drugs is associated with cognitive decline and should be minimized.

Question 29Pharmacokinetics and Pharmacodynamics in Older Adults

A 75-year-old woman has a creatinine clearance estimated at 35 mL/min. Which adjustment is most appropriate for a renally eliminated drug with a narrow therapeutic index?

  1. Use the standard adult dose because age does not affect dosing
  2. Increase the dose to saturate renal elimination
  3. Give the drug only with grapefruit juice
  4. Reduce the dose or extend the dosing interval and monitor levels Correct answer.

Explanation

When creatinine clearance is reduced, renally eliminated drugs accumulate, and agents with a narrow therapeutic index require dose reduction or interval extension plus therapeutic drug monitoring. Standard adult doses can produce toxic concentrations in this setting.

Question 30Pharmacokinetics and Pharmacodynamics in Older Adults

Which age-related change in hepatic function most affects the clearance of drugs that undergo extensive hepatic metabolism?

  1. Enhanced phase II conjugation
  2. Increased hepatic enzyme induction
  3. Reduced liver mass and hepatic blood flow Correct answer.
  4. Increased bile acid synthesis

Explanation

Liver mass and hepatic blood flow decline with age, reducing clearance of drugs with high hepatic extraction. Phase I oxidative metabolism is affected more than phase II conjugation, which is relatively preserved, so dosing of hepatically cleared drugs may need reduction.

Question 31Pharmacokinetics and Pharmacodynamics in Older Adults

Which pharmacokinetic parameter is most useful for predicting the loading dose of a drug in an older adult?

  1. Volume of distribution Correct answer.
  2. Renal clearance
  3. Hepatic extraction ratio
  4. Half-life

Explanation

The loading dose depends on the volume of distribution and the target concentration, not on clearance. Because body composition changes with age and alters volume of distribution, loading doses may differ from those in younger adults even when maintenance dosing is unchanged.

Question 32Pharmacokinetics and Pharmacodynamics in Older Adults

A frail 85-year-old man is started on a drug with a long half-life. Why is steady state delayed compared with a younger adult?

  1. Increased clearance shortens the time to reach steady state
  2. Volume of distribution is always smaller in older adults
  3. Reduced clearance lengthens the time to reach steady state Correct answer.
  4. Protein binding is always higher in older adults

Explanation

Time to steady state depends primarily on half-life, and reduced clearance prolongs half-life, so accumulation to steady state takes longer. This means dose changes should not be assessed too early, and adverse effects may emerge gradually during accumulation.

Question 33Pharmacokinetics and Pharmacodynamics in Older Adults

Which pharmacodynamic change explains why older adults may experience more bleeding with the same dose of an anticoagulant?

  1. Increased vascular fragility and reduced hemostatic reserve Correct answer.
  2. Increased platelet aggregation
  3. Increased renal excretion of clotting factors
  4. Enhanced clotting factor synthesis

Explanation

Aging is associated with more fragile vessels and reduced reserve in hemostatic mechanisms, so a given degree of anticoagulation carries a higher bleeding risk. This pharmacodynamic vulnerability supports careful dose selection and monitoring in older patients.

Question 34Pharmacokinetics and Pharmacodynamics in Older Adults

Which statement about serum albumin and drug protein binding in older adults is most accurate?

  1. Only basic drugs bind to albumin
  2. Albumin rises with age and reduces free drug
  3. Protein binding changes always require a loading dose increase
  4. Lower albumin can increase the free fraction of highly bound acidic drugs Correct answer.

Explanation

Albumin often declines modestly with age or with frailty and illness, so highly protein-bound acidic drugs such as phenytoin can have a higher free fraction. Free drug is the pharmacologically active portion, so interpretation of total concentrations and dosing may need adjustment.

Question 35Pharmacokinetics and Pharmacodynamics in Older Adults

Which drug is most likely to cause clinically significant accumulation in an older adult because it is eliminated largely unchanged by the kidney?

  1. Amlodipine
  2. Gentamicin Correct answer.
  3. Warfarin
  4. Atorvastatin

Explanation

Gentamicin is eliminated almost entirely unchanged by glomerular filtration, so reduced renal function in older adults causes accumulation and nephrotoxicity or ototoxicity. Dosing should be guided by renal function and drug levels.

Question 36Pharmacokinetics and Pharmacodynamics in Older Adults

An older adult reports new confusion after starting an over-the-counter sleep aid. Which mechanism best explains this adverse effect?

  1. Reduced central nervous system penetration
  2. Anticholinergic and sedating effects of first-generation antihistamines Correct answer.
  3. Enhanced hepatic glucuronidation
  4. Increased renal clearance of the drug

Explanation

First-generation antihistamines such as diphenhydramine have anticholinergic and sedating properties that readily cause confusion, delirium, and falls in older adults. Because central sensitivity increases with age, these agents should generally be avoided in this population.

Question 37Pharmacokinetics and Pharmacodynamics in Older Adults

Which concept best explains why the same dose of a benzodiazepine produces deeper sedation in an 80-year-old than in a 30-year-old?

  1. Higher hepatic clearance in the older adult
  2. Increased renal excretion of the drug
  3. Altered pharmacodynamics with increased receptor sensitivity Correct answer.
  4. Lower brain penetration in the older adult

Explanation

Age-related changes in GABA receptor function and neuronal reserve increase the pharmacodynamic response to benzodiazepines, producing more sedation and cognitive impairment at equivalent concentrations. Pharmacokinetic accumulation from reduced clearance can further amplify the effect.

Question 38Pharmacokinetics and Pharmacodynamics in Older Adults

Which statement about the Cockcroft-Gault equation is correct when estimating renal function for drug dosing in older adults?

  1. It is independent of body weight
  2. It is valid only in patients over 90 years old
  3. It directly measures glomerular filtration rate with a radiotracer
  4. It estimates creatinine clearance using age, weight, sex, and serum creatinine Correct answer.

Explanation

The Cockcroft-Gault equation estimates creatinine clearance from age, weight, sex, and serum creatinine, and it is commonly used to guide renal dose adjustments. It is an estimate and may be less accurate in extremes of body weight or in patients with rapidly changing renal function.

Question 39Pharmacokinetics and Pharmacodynamics in Older Adults

A 79-year-old woman with heart failure is started on a diuretic and develops rising creatinine and hypotension. Which pharmacokinetic principle best explains the altered drug handling?

  1. Increased plasma volume raises clearance
  2. Increased hepatic blood flow accelerates metabolism
  3. Reduced renal perfusion decreases clearance of renally eliminated drugs Correct answer.
  4. Reduced protein binding eliminates the drug faster

Explanation

Diuretic-induced volume depletion and heart failure reduce renal perfusion, lowering clearance of renally eliminated drugs and raising their concentrations. This can cause accumulation and toxicity, so renal function and hemodynamics should be reassessed when such changes occur.

Question 40Pharmacokinetics and Pharmacodynamics in Older Adults

Which strategy best applies pharmacokinetic and pharmacodynamic principles when initiating a drug with a long half-life in a frail older adult?

  1. Start at the full adult dose and reduce only if toxicity occurs
  2. Give a large loading dose to reach steady state quickly
  3. Start at a low dose and titrate slowly while monitoring for adverse effects Correct answer.
  4. Avoid monitoring because age-related changes are predictable

Explanation

Starting low and titrating slowly accounts for reduced clearance, altered volume of distribution, and increased pharmacodynamic sensitivity in frail older adults. Because steady state may take longer to reach, dose changes should be spaced appropriately and adverse effects monitored.

Question 41Cardiovascular Disorders

Which laboratory parameter is used to monitor the anticoagulant effect of unfractionated heparin when the goal is therapeutic anticoagulation?

  1. Bleeding time
  2. International normalized ratio (INR)
  3. Platelet count
  4. Activated partial thromboplastin time (aPTT) Correct answer.

Explanation

Unfractionated heparin potentiates antithrombin and prolongs the activated partial thromboplastin time, so aPTT or anti-Xa levels are used for monitoring. The INR reflects the extrinsic pathway and is used for warfarin, not heparin.

Question 42Cardiovascular Disorders

A patient with heart failure and reduced ejection fraction is started on sacubitril/valsartan. Which medication must be discontinued before this agent is begun?

  1. Furosemide
  2. Spironolactone
  3. An ACE inhibitor such as lisinopril Correct answer.
  4. Metoprolol succinate

Explanation

Sacubitril/valsartan and ACE inhibitors both increase bradykinin, so concurrent use markedly raises the risk of angioedema. A washout period of at least 36 hours is required when switching from an ACE inhibitor.

Question 43Cardiovascular Disorders

Which finding on a lipid panel is most consistent with the atherogenic dyslipidemia typically seen in metabolic syndrome?

  1. Elevated HDL cholesterol
  2. LDL cholesterol above 190 mg/dL
  3. Elevated triglycerides with low HDL cholesterol Correct answer.
  4. Isolated hypercholesterolemia with normal triglycerides

Explanation

Metabolic syndrome classically produces high triglycerides, low HDL cholesterol, and small dense LDL particles. Isolated severe LDL elevation suggests familial hypercholesterolemia rather than the metabolic pattern.

Question 44Cardiovascular Disorders

Which adverse effect is most characteristic of amiodarone therapy during long-term use?

  1. Hemolytic anemia
  2. Peripheral neuropathy from copper deficiency
  3. Thyroid dysfunction Correct answer.
  4. Renal tubular acidosis

Explanation

Amiodarone is iodine-rich and can cause both hypothyroidism and hyperthyroidism, so thyroid function should be checked periodically. It also causes pulmonary, hepatic, ocular, and neurologic toxicity but not the other listed effects.

Question 45Cardiovascular Disorders

Which class of antihypertensive agents is most likely to cause a persistent dry cough?

  1. Thiazide diuretics
  2. Alpha-1 blockers
  3. Angiotensin-converting enzyme inhibitors Correct answer.
  4. Dihydropyridine calcium channel blockers

Explanation

ACE inhibitors reduce bradykinin breakdown, and accumulated bradykinin in the airways produces a dry cough in a subset of patients. Switching to an angiotensin receptor blocker usually resolves the cough.

Question 46Cardiovascular Disorders

Which agent is the preferred initial anticoagulant for a patient with a mechanical mitral valve?

  1. Warfarin Correct answer.
  2. Dabigatran
  3. Rivaroxaban
  4. Apixaban

Explanation

Direct oral anticoagulants are contraindicated in patients with mechanical heart valves, so warfarin remains the standard of care. Warfarin dosing is guided by INR targets that are typically higher for mitral valve prostheses.

Question 47Cardiovascular Disorders

Which electrocardiographic change is most characteristic of hypokalemia?

  1. Peaked T waves
  2. Delta waves
  3. Prolonged PR interval only
  4. Prominent U waves Correct answer.

Explanation

Hypokalemia delays ventricular repolarization, producing ST depression, flattened T waves, and prominent U waves. Hyperkalemia, by contrast, classically produces tall peaked T waves.

Question 48Cardiovascular Disorders

A patient stabilized after acute decompensated heart failure is being optimized for discharge. Which combination best reflects guideline-directed medical therapy for reduced ejection fraction?

  1. Amlodipine, hydralazine, and clonidine
  2. Sacubitril/valsartan, carvedilol, and spironolactone Correct answer.
  3. Diltiazem, digoxin, and furosemide
  4. Verapamil, ivabradine, and nitroglycerin

Explanation

Guideline-directed therapy for reduced ejection fraction combines a renin-angiotensin system inhibitor or sacubitril/valsartan, an evidence-based beta-blocker, a mineralocorticoid receptor antagonist, and an SGLT2 inhibitor. Carvedilol is one of the beta-blockers with proven mortality benefit.

Question 49Cardiovascular Disorders

A patient on warfarin with a stable INR of 2.5 is prescribed trimethoprim-sulfamethoxazole for a urinary tract infection. What is the most appropriate management?

  1. Continue warfarin at the same dose and recheck INR in one month
  2. Double the warfarin dose to offset antibiotic-induced enzyme induction
  3. Stop warfarin for the duration of the antibiotic course
  4. Choose an alternative antibiotic or reduce the warfarin dose with close INR monitoring Correct answer.

Explanation

Trimethoprim-sulfamethoxazole inhibits CYP2C9 and displaces warfarin from albumin, raising INR and bleeding risk. Selecting a non-interacting antibiotic or intensifying INR monitoring with dose adjustment is appropriate.

Question 50Cardiovascular Disorders

A patient with hypertension and gout requires antihypertensive therapy. Which agent is least appropriate because it raises serum uric acid?

  1. Lisinopril
  2. Amlodipine
  3. Losartan
  4. Hydrochlorothiazide Correct answer.

Explanation

Thiazide diuretics reduce renal uric acid excretion and can precipitate gout flares. Losartan is actually associated with modest uric acid lowering and is a favorable choice in gout.