NURS 621 MEd Challenger Cardio Exam Questions
VALVULAR HEART DISEASE
1) A 71-year-old woman with chronic aortic regurgitation complains of worsening dyspnea on
exertion, orthopnea, fatigue, and angina. She is anxious because of an unpleasant awareness
of her heartbeat. Her cardiac silhouette is enlarged, with uncoiling and enlargement of the
aortic root seen on chest x-ray. She has a widened pulse pressure, rapidly rising and falling
carotid pulse, spontaneous nail-bed pulsations, and a to-and-from murmur over the femoral
artery. You find that her systolic blood pressure measured over the femoral artery is 45 mm
Hg higher than her systolic blood pressure measured over the ipsilateral brachial artery. She
has normal S1 and S2 followed by a blowing, diastolic murmur best heard along the left
sternal border. Which of the following classical signs of chronic aortic regurgitation is absent
in this patient?
A diastolic murmur over the femoral artery (Duroziez’s sign)
Rhythmic bobbing of the head (De Musset’s sign)
A visible capillary pulse (Quincke’s pulse)
Rapid upstroke and collapse of the carotid pulse (Corrigan’s pulse)
difference of systolic blood pressure of 40 mm Hg or higher at the femoral artery than at the
ipsilateral brachial artery (Hill sign)
2) You are examining a 69-year-old man who is complaining of dyspnea and chest pain. He has
a history of a heart murmur, which has been present for a long time, but no exact data are
available as to its nature in the past. The mid-diastolic rumble that you hear is an Austin-Flint
murmur. What is known about this type of murmur?
It reflects rapid filling of the left ventricle.
It is caused by a high transmitral gradient during diastole.
It is produced when the regurgitant aortic jet impinges on the mitral valve and causes it to
vibrate.
It occurs when the chordae tendineae are stretched out in midsystole by the prolapsing mitral
valve.
It is best heard during diastole at the left sternal border.
3) A 30-year-old man presents with progressive dyspnea on exertion over the last few months.
His medical history is notable for hypertension, for which he takes hydrochlorothiazide 25
mg daily. On examination, he has a 3/6 systolic murmur in the left upper sternal area that
does not radiate to the carotids. The murmur is increased with Valsalva maneuvering and is
decreased with squatting. He has no jugular venous distension or peripheral edema. What is
the likely diagnosis?
Hypertrophic obstructive cardiomyopathy
aortic stenosis
, pulmonic stenosis
aortic regurgitation
mitral valve prolapse
4) A 65-year-old patient who used to travel the world presents to you for evaluation. He has no
active complaints, although a review of systems reveals a gradual increase in shortness of
breath that the patient attributes to the "normal aging process." The patient is proud of the
fact that he has never needed a physician and has lived in good health in many countries. He
also mentions that he had multiple sexual partners "all over the world." On examination, he
has a 3/6 diastolic blowing decrescendo murmur along the right sternal border that is softer
with inspiration and louder with squatting. His extremities show no edema, but a chronic sore
is noted below his right knee. Electrocardiography shows left atrial enlargement.
Echocardiography shows moderate aortic regurgitation with an ejection fraction of 45%.
Which of the following tests is indicated to evaluate his murmur?
adenosine tracer stress testing
rapid plasma reagin
blood cultures
HIV serology
human leukocyte antigen (HLA) typing
5) You are following up with a man aged 65 years after he received treatment for hypertension.
His only complaint is shortness of breath with moderate to heavy exertion, but he tells you
that it does not occur at rest or when he is performing light activity. His medical history is
only notable for hypertension, for which he takes hydrochlorothiazide and metoprolol. He
does not smoke or drink alcohol. On examination, he has a 2/6 systolic murmur at the right
upper sternal border radiating to the carotids. Echocardiography shows mild left ventricular
hypertrophy, an ejection fraction of 55%, and a bicuspid aortic valve with aortic valve area of
0.9 cm2. What is the appropriate management for his valve disease?
treadmill stress testing
digoxin
left heart catheterization with valvuloplasty
aortic valve replacement
beginning enalapril
6) A 35-year-old woman is seen for palpitations that occur a few times per week. She has no
notable medical history, and her only medication is an oral contraceptive. She does not
smoke or drink alcohol. She works as a city garbage collector. Her vital signs are:
temperature 37.2 °C, heart rate 77 beats/minute and regular, blood pressure 115/75 mm Hg,
respiratory rate 18 breaths/minute, and oxygen saturation 99% on room air. On cardiac
examination, her heart rate is regular with a normal S1 and S2, a midsystolic click followed
by a late systolic murmur at the apex. During the straining phase of the Valsalva maneuver,
the click occurs earlier, and the murmur is more intense. Findings on electrocardiography are
normal. Holter monitor shows occasional premature ventricular contractions and premature
atrial contractions only. What is the most appropriate management in this patient's condition?
,nitroglycerin 0.4 mg sublingual as needed
digoxin
echocardiography
aspirin 500 mg per day
reassurance and low-dose metoprolol
7) A 45-year-old woman presents to you at the request of her dentist. The patient has a medical
history of mitral valve prolapse and takes no medications. She has no symptoms other than
tooth pain. She does not smoke or drink alcohol. She works as a city garbage collector. Her
vitals are: temperature 37.0 °C, heart rate 77 beats/minute and regular, blood pressure 115/75
mm Hg, respiratory rate 18 breaths/minute, and oxygen saturation 99% on room air.
Examination of the head, eyes, ear, nose, and throat, as well as lung, abdominal, and
neurologic examinations are normal. On cardiac examination, the rhythm is regular with a
normal S1 and S2, a midsystolic click followed by a late systolic murmur at the apex. With
squatting, the click and murmur occur later. Findings on electrocardiography are normal.
Transthoracic echocardiography shows thickened mitral valve leaflets that prolapse above the
annulus 4 mm during systole. Her dentist would like to extract her second molar. What do
you recommend?
Administer clindamycin 600 mg 1 hour before procedure.
Do not extract the tooth.
Administer amoxicillin 500 mg twice a day for 2 days prior to procedure.
Proceed with tooth extraction.
Administer amoxicillin 2 g 1 hour before the procedure
8) A 35-year-old woman presents to you complaining of worsening dyspnea on A 35-year-old
woman presents to you complaining of worsening dyspnea
exertion, orthopnea, and paroxysmal nocturnal dyspnea. She has recently noticed blood-
tinged sputum. She reports no notable medical history, and her only medication is a
multivitamin. She was born in rural Sudan and immigrated to the United States in her early
20s. Her family history is unknown. Her vital signs are: temperature 98.5 °F, heart rate 95
beats/minute, blood pressure 108/72 mm Hg, respiratory rate 18 breaths/minute, and oxygen
saturation 99% on room air. She has jugular venous distension to the angle of her jaw. She
has a loud S1, and S2 is normally split. She has a quiet apical impulse and a parasternal lift.
Her heart is regular, with a 3/6 low-pitched early diastolic rumble at the apex. Her chest is
clear to auscultation, with isolated crackles at the bases. Her liver is somewhat enlarged. She
has no stigmata of chronic liver disease. She has 2+ bilateral edema in her feet and ankles.
Complete blood count, basic metabolic panel, and thyroid-stimulating hormone are normal.
You obtain radiography of her chest, echocardiography, magnetic resonance imaging, and
esophagography.
, Figure. Reproduced from Flores Umanzor EJ, Mimbrero M, San Antonio R, Caldentey G,
Vannini L. Giant left atrium as a rare cause of dysphagia. Am J Med. 2016;129(12):e335-
e336.
What is the anatomic diagnosis?
tricuspid stenosis and left atrial enlargement
mitral stenosis, left atrial enlargement, and right ventricular hypertrophy
aortic regurgitation, mitral regurgitation, and tricuspid regurgitation
tricuspid regurgitation
pulmonary stenosis and right atrial enlargement
9) A 75-year-old white man presents to you complaining of worsening shortness of breath and
dry, nonproductive cough. He also recently noticed new-onset hoarseness and worsening
dysphagia. His heart rate is irregular; there is a low diastolic rumble heard in the mitral area,
and there are some crackles at lung bases. He has no history of smoking or alcohol abuse. He
is taking metoprolol and lisinopril for hypertension and metformin for type 2 diabetes
mellitus, which was diagnosed 4 years ago. His family history is noncontributory. His vital
signs are: temperature i98.8 °F, heart rate 92 beats/minute, blood pressure 130/70 mm Hg,
, respiratory rate 16 breaths/minute, and oxygen saturation 99% on room air. He is 5’2" tall
and weighs 200 pounds. Findings on electrocardiography (ECG) show atrial fibrillation. On
chest x-ray, his lung fields are clear except for some vascular congestion and trace pleural
effusions bilaterally. What is the most likely cause of his dysphagia and hoarseness?
aortic aneurysm of ascending aorta, leading to mediastinal compression
lung cancer
sarcoidosis
mitral stenosis
10) You auscultate a 65-year-old woman with known mitral stenosis who complains of
worsening dyspnea and hemoptysis. On palpation, there is a parasternal lift and a quiet apical
impulse. You notice a soft S1, normally split S2, no murmur heard in the mitral area, and a
diastolic 2/6 blowing murmur in the pulmonary area. How should you characterize this
murmur?
mid-diastolic rumble of aortic regurgitation (Austin-Flint murmur)
atypical murmur of mitral stenosis
accompanying pulmonary stenosis
soft, diastolic-blowing murmur of pulmonary insufficiency (Graham-Steell murmur)
benign murmur of hyperdynamic blood flow
11) A 65-year-old woman presents to you with known mitral stenosis and the complaint of some
dyspnea with exertion. She is otherwise in good health. On palpation, there is no parasternal
lift and a quiet apical impulse. You notice a loud S1, a normally split S2, and an opening
snap followed by a low-pitched 2/6 diastolic murmur heard in the mitral area. She has trace
pedal edema. Findings on electrocardiography reveal atrial fibrillation, which was also
present on electrocardiography performed 2 years ago. Her vital signs are: blood pressure
130/85 mm Hg, heart rate 107 beats/minute and irregular, respiratory rate 16 breaths/minute,
temperature 96.8 °F, and 98% saturation on room air. Echocardiography performed last
month shows mild mitral stenosis, mild left atrial enlargement, no pulmonary hypertension,
and a preserved ejection fraction of 65%. What is the best management for this patient's
condition?
hydrochlorothiazide, beta blocker, and aspirin
replacement of mitral valves by open-heart surgery
percutaneous balloon valvotomy
hydrochlorothiazide, beta blocker, and warfarin
cardiac catheterization
12) You are seeing a 55-year-old woman for a routine follow-up visit. Her medical history is
significant for hypertension and hyperlipidemia. She takes metoprolol and simvastatin. She
does not smoke or drink alcohol. She works as a cashier at a convenience store. She walks 2
miles to and from work daily. Her blood pressure is 115/70 mm Hg. Her examination is
normal except for her cardiac examination, for which her point of maximal impulse is
displaced 3 cm. She has a 4/6 systolic murmur at the apex radiating to her axilla
, Transthoracic echocardiography shows severe mitral regurgitation with a left ventricle
ejection fraction of 50%. What is the next step in management of this patient?
Indicate the problem to the patient and discuss options for its treatment.
Begin warfarin with a goal international normalized ratio of 2 to 3.
Reassure her and follow up with repeat echocardiography in 6 to 12 months.
Conduct exercise treadmill stress testing.
13) A 35-year-old woman with long-standing systemic lupus erythematosus complains of
increasing dyspnea with exertion over the last 6 months. She does not have orthopnea,
paroxysmal nocturnal dyspnea, or chest pain. Her lupus is otherwise well controlled on
hydroxychloroquine. She does not smoke or drink alcohol. Her vital signs are: temperature
98.4 °F, heart rate 80 beats/minute, blood pressure 115/80 mm Hg, respiratory rate 16
breaths/minute, and oxygen saturation 100% on room air. Her head, eyes, ear, nose, and
throat, as well as lung, abdomen, extremity, and neurologic examinations are normal. On
cardiac examination, she has a grade 4/6 pansystolic murmur at the apex radiating to the
axilla. Her point of maximal impulse is displaced 1 cm laterally. Electrocardiography (ECG)
is obtained and shows a tall P wave in lead II, a deep S wave in V2 measuring 15 mm, and a
tall R wave in V5 measuring 15 mm. What is the etiology of her symptoms?
chronic mitral regurgitation
chronic tricuspid regurgitation
pulmonary hypertension
coronary artery stenosis
chronic aortic stenosis
14) A 45-year-old man presents with dyspnea on minimal exertion and mild hemoptysis. He
sleeps on 3 pillows and sometimes wakes up at night gasping for breath. He also has
occasional heart palpitations. His only notable finding on his medical history is
appendectomy at age 20 years. He takes no medications. He does not smoke or use illicit
drugs, and he drinks 1 glass of wine per night. He was adopted at age 5 years from
Guatemala, so his medical records before that time are unavailable. His vital signs are;
temperature 97.8 °F, heart rate is 88 beats/minute, blood pressure 115/75 mm Hg, respiratory
rate 22 breaths/minute, and oxygen saturation 97% on room air. His cardiac examination
shows a loud S1 and split S2 with loud second component. There is a mid-diastolic rumble at
the apex with a palpable apical thrill. Lung examination shows crackles halfway up. The rest
of his examination findings are normal. Chest x-ray shows bilateral pulmonary edema.
Electrocardiography shows a biphasic P wave in lead V1 with a large and wide terminal
component. What is the underlying cause of his symptoms?
mitral stenosis due to rheumatoid arthritis
mitral stenosis due to rheumatic heart disease
mitral regurgitation due to rheumatic heart disease
aortic stenosis due to bicuspid aortic valve
mitral regurgitation due to ischemia
