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University of Phoenix
NSG/506 Transition to Advanced Practice Nursing
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Date
For NSG 506 Exam 1, students should focus on older adult care, cognitive disorders, polypharmacy, age-friendly nursing, acute coronary syndrome (ACS), heart failure, congenital heart disease, pediatric heart failure, and cardiovascular diagnostic testing. High-yield exam questions often require nurses to distinguish dementia from delirium and depression, recognize medication-related risks, identify signs of heart failure, differentiate STEMI from NSTEMI, and prioritize nursing interventions. Understanding the underlying pathophysiology—not simply memorizing symptoms makes it easier to answer clinical judgment and prioritization questions.
This NSG 506 Exam 1 study guide reviews the major concepts in a practical format to support nursing exam preparation and safe clinical decision-making.
Nursing care for older adults begins with understanding the difference between normal aging and changes that may indicate acute or chronic disease. A patient’s baseline cognitive, functional, and physical status is particularly important because older adults may show subtle or atypical signs of illness.
A sudden change in cognition, behavior, mobility, appetite, or functional ability should not automatically be attributed to aging. Nurses should compare the patient’s current condition with the established baseline and investigate potentially reversible causes.
Important areas of assessment include cognition, medication use, mobility, nutrition, hydration, fall risk, sensory function, functional independence, and the patient’s goals and preferences.
Dementia refers to a chronic decline in cognitive abilities that interferes with daily functioning and independence. In current clinical terminology, many conditions historically grouped under “dementia” are described as major neurocognitive disorders.
Unlike delirium, dementia generally develops gradually and follows a progressive course, although the rate and pattern of decline vary according to the underlying disease.
Common characteristics include:
Gradual onset and progressive cognitive decline
Impaired memory and learning
Problems with language, judgment, reasoning, or executive function
Increasing difficulty performing activities of daily living
Generally stable level of consciousness
Functional decline as the condition progresses
Common causes or types include Alzheimer’s disease, vascular cognitive impairment, Lewy body dementia, Parkinson’s disease dementia, and frontotemporal dementia.
Because dementia develops over time, nurses should establish and document the patient’s usual cognitive and functional status. A new, rapid change from that baseline may indicate delirium superimposed on dementia.
Delirium is an acute disturbance in attention and awareness accompanied by changes in cognition. It usually develops over hours to days and often fluctuates during the day.
The most important exam distinction is that delirium has a sudden onset and impaired attention, whereas dementia usually develops gradually.
Delirium is frequently caused by an underlying medical problem, medication effect, substance withdrawal, or environmental stressor. Prompt identification of the cause is essential because delirium can signal a serious acute illness.
Potential contributors include:
Infection
Dehydration
Hypoxia
Electrolyte abnormalities
Hypoglycemia or hyperglycemia
Medication adverse effects or toxicity
Urinary retention
Constipation or fecal impaction
Pain
Sleep disruption
Acute illness or hospitalization
Hyperactive delirium may cause agitation, restlessness, combativeness, hallucinations, or heightened motor activity.
Hypoactive delirium is easier to miss because the patient may appear lethargic, withdrawn, sleepy, or less responsive than usual.
Mixed delirium includes alternating periods of hyperactive and hypoactive symptoms.
Treatment should focus first on identifying and correcting the underlying cause and using nonpharmacologic measures to promote safety and orientation. Antipsychotic medications such as haloperidol may sometimes be prescribed for severe agitation when the patient poses a safety risk, but they are not routine treatment for delirium and require careful risk-benefit assessment.
Depression is not a normal consequence of aging. Older adults may experience depression because of medical illness, loss, social isolation, functional limitations, or other psychosocial and biological factors.
Depression can sometimes resemble cognitive impairment, creating difficulty distinguishing it from dementia. A comprehensive assessment is therefore important.
Typical depressive symptoms may include persistent sadness or loss of interest, sleep or appetite changes, fatigue, impaired concentration, feelings of worthlessness or guilt, psychomotor changes, and thoughts of death or suicide.
Any indication of suicidal thinking requires immediate assessment and appropriate safety intervention.
Unlike many neurodegenerative dementias, depression is potentially treatable, and cognitive symptoms associated with depression may improve when the underlying depression is treated.
| Feature | Dementia | Delirium | Depression |
|---|---|---|---|
| Typical onset | Gradual | Sudden, often hours to days | Usually develops over weeks or longer |
| Course | Progressive | Fluctuating | Variable |
| Attention | Often preserved early | Markedly impaired | Usually relatively preserved |
| Awareness/consciousness | Usually stable | May fluctuate | Usually clear |
| Primary concern | Cognitive and functional decline | Acute change in attention and awareness | Mood and loss of interest |
| Reversibility | Depends on cause; many neurodegenerative forms are not reversible | Often improves when the cause is treated | Often improves with appropriate treatment |
Exam tip: A hospitalized older adult who suddenly becomes confused, inattentive, or disoriented should be assessed for delirium and an underlying acute cause, rather than simply being labeled as having dementia.
Polypharmacy generally refers to the use of multiple medications, particularly when the medication burden becomes unnecessary, inappropriate, or difficult to manage. The number of medications alone does not necessarily mean that treatment is inappropriate; some older adults appropriately require several medications for multiple chronic conditions.
The nursing priority is to identify medications that are unnecessary, duplicative, interacting, incorrectly dosed, or associated with a high risk of adverse effects.
Older adults may be particularly vulnerable to:
Adverse drug events
Drug-drug interactions
Drug-disease interactions
Falls
Orthostatic hypotension
Confusion or delirium
Medication nonadherence
Hospitalization
Functional decline
Medications that require careful monitoring can include anticoagulants, insulin, digoxin, opioids, sedatives, and other drugs with a narrow therapeutic index or substantial adverse-effect potential.
The American Geriatrics Society Beers Criteria is an important resource for identifying potentially inappropriate medications in many older adults. It should be used alongside clinical judgment rather than as a substitute for individualized medication review.
The 4Ms Framework from the Institute for Healthcare Improvement provides a practical approach to age-friendly care. The four components are What Matters, Medication, Mentation, and Mobility.
“What Matters” means understanding the patient’s individual goals, preferences, values, and priorities. Nursing care should be aligned with what the patient considers most important.
Medication management focuses on ensuring that medications are appropriate, safe, effective, and consistent with the patient’s goals. Nurses should monitor for adverse effects, interactions, unnecessary medications, and medication-related functional problems.
Mentation focuses on preventing and addressing conditions affecting cognition and mood, particularly:
Dementia
Delirium
Depression
A sudden cognitive change should prompt assessment for delirium and potentially reversible causes.
Mobility focuses on maintaining physical function and independence while reducing preventable risks such as falls. Safe mobility, appropriate activity, assistive devices, and medication review can all contribute to fall prevention.
Acute coronary syndrome (ACS) describes a group of conditions caused by acute myocardial ischemia, usually associated with disruption of an atherosclerotic coronary plaque and formation of a thrombus.
ACS includes:
Unstable angina
Non-ST-elevation myocardial infarction (NSTEMI)
ST-elevation myocardial infarction (STEMI)
ACS requires rapid assessment because prolonged myocardial ischemia can result in irreversible myocardial injury.
Patients do not always present with classic crushing chest pain. Older adults, women, and patients with diabetes may have atypical symptoms such as dyspnea, fatigue, nausea, weakness, or epigastric discomfort.
NSTEMI is characterized by myocardial injury with elevated cardiac troponin levels and without persistent ST-segment elevation on the ECG. ECG findings may include ST-segment depression or T-wave inversion, although the ECG can sometimes be nondiagnostic.
NSTEMI requires urgent evaluation and evidence-based management to reduce the risk of further myocardial injury and complications.
STEMI is characterized by clinical evidence of acute myocardial ischemia with ST-segment elevation meeting diagnostic criteria, generally reflecting an acute coronary occlusion or severe reduction in coronary blood flow.
STEMI is a time-sensitive emergency. Rapid reperfusion, typically with percutaneous coronary intervention when available and appropriate, is essential.
Exam priority: New or persistent symptoms suggestive of ACS should be treated as an emergency. Obtain an ECG promptly, assess vital signs and symptoms, and follow the institution’s ACS protocol.
Heart failure occurs when the heart is unable to provide adequate cardiac output to meet the body’s needs or can do so only at elevated filling pressures.
Common causes include coronary artery disease, previous myocardial infarction, chronic hypertension, valvular disease, and cardiomyopathy.
Initially, the body attempts to compensate through sympathetic nervous system activation and stimulation of the renin-angiotensin-aldosterone system (RAAS). These mechanisms may temporarily support blood pressure and perfusion but can contribute over time to vasoconstriction, sodium and water retention, ventricular remodeling, and worsening heart failure.
The side of the heart primarily affected helps explain the clinical manifestations.
Left-sided heart failure commonly produces pulmonary congestion because blood backs up into the pulmonary circulation.
Common findings include:
Dyspnea
Orthopnea
Paroxysmal nocturnal dyspnea
Crackles
Pulmonary edema
Fatigue
Reduced exercise tolerance
Hypoxemia in severe cases
A patient with acute pulmonary edema may develop severe respiratory distress and requires immediate intervention.
Right-sided heart failure commonly produces systemic venous congestion.
Typical findings include:
Peripheral edema
Jugular venous distention
Hepatic congestion or hepatomegaly
Ascites
Weight gain
Dependent edema
Right-sided heart failure frequently develops in association with left-sided heart failure, although pulmonary hypertension and other conditions can also cause right ventricular failure.
Heart failure assessment combines history, physical examination, laboratory testing, imaging, and cardiac function assessment.
Common diagnostic studies include ECG, echocardiography, chest radiography, and natriuretic peptide testing such as BNP or NT-proBNP.
An ECG can help identify:
Cardiac rhythm abnormalities
Ischemia
Previous myocardial infarction
Conduction abnormalities
Echocardiography provides information about:
Ventricular function
Ejection fraction
Chamber size
Valve function
Cardiac structure
It is one of the most important tests for evaluating cardiac structure and function.
Natriuretic peptide levels can support the evaluation of suspected heart failure, particularly when interpreted alongside the patient’s clinical presentation. Levels can be influenced by other conditions, so they should not be interpreted in isolation.
A chest X-ray may demonstrate cardiomegaly, pulmonary vascular congestion, or pulmonary edema and can also help evaluate alternative causes of respiratory symptoms.
Nurses should monitor respiratory status, oxygenation, heart rate and rhythm, blood pressure, lung sounds, edema, activity tolerance, urine output, and weight.
Daily weight is particularly useful for monitoring changes in fluid status. Rapid weight gain can indicate fluid retention and should be evaluated in the context of the patient’s prescribed monitoring plan.
Congenital heart disease (CHD) refers to structural abnormalities of the heart or great vessels that are present at birth. CHD encompasses a wide range of defects, from relatively mild abnormalities to complex conditions requiring surgical or catheter-based intervention.
The causes are often multifactorial and may involve genetic, chromosomal, maternal, environmental, and other factors.
Examples include:
Chromosomal abnormalities such as trisomy 21
Genetic syndromes
Maternal diabetes
Certain maternal infections
Maternal autoimmune disease
Certain medication or environmental exposures
Risk factors do not mean that a congenital heart defect will definitely occur; they indicate an association with increased risk.
In children, heart failure frequently develops because of congenital heart disease, although cardiomyopathy, arrhythmias, myocarditis, and other conditions can also contribute.
Infants may not be able to describe symptoms, so nurses must recognize behavioral, respiratory, nutritional, and growth-related clues.
Important findings include:
Tachycardia
Tachypnea
Respiratory distress
Feeding difficulty
Poor feeding endurance
Excessive sweating during feeding
Poor weight gain
Failure to thrive
Irritability
Hepatomegaly
Frequent respiratory symptoms
Exercise intolerance in older children
Sweating and fatigue during feeding are high-yield pediatric heart failure findings because feeding can place significant metabolic demands on an infant.
Management aims to improve cardiac output, reduce fluid overload, support growth, and decrease the workload placed on the heart.
Depending on the child’s condition and treatment plan, management may include diuretics, selected cardiac medications, nutritional support, oxygen or respiratory support, and treatment of the underlying cardiac defect.
Nursing interventions may include monitoring daily weight, assessing respiratory status, monitoring intake and output, providing appropriate nutritional support, allowing adequate rest, and clustering care to minimize energy expenditure.
For infants who fatigue easily during feeding, shorter and more frequent feeding periods may be used according to the care plan. Appropriate positioning, including head elevation when indicated, can also support breathing and feeding.
Digoxin has a narrow therapeutic index, making careful assessment essential.
Possible manifestations of digoxin toxicity include gastrointestinal symptoms such as nausea and vomiting, changes in appetite, bradycardia, dysrhythmias, and neurologic or visual disturbances.
Vomiting in a child receiving digoxin should not automatically be assumed to be a simple gastrointestinal illness. The nurse should assess the child, review the medication history, check the prescribed parameters and relevant laboratory findings, and notify the appropriate healthcare provider when toxicity is suspected.
Understanding what each cardiovascular diagnostic test evaluates can help with NSG 506 exam questions involving assessment and prioritization.
An ECG records the heart’s electrical activity and helps evaluate rhythm, conduction, ischemic changes, and evidence of myocardial injury.
A chest X-ray can help assess:
Cardiac silhouette and heart size
Pulmonary congestion
Pulmonary edema
Other thoracic abnormalities
An echocardiogram uses ultrasound to evaluate cardiac anatomy and function. It can assess ventricular performance, valves, chambers, blood flow, and structural abnormalities.
Cardiac CT and MRI provide detailed imaging of cardiac structures and can be useful for evaluating anatomy, vessels, tissue characteristics, and complex congenital heart disease. The choice of modality depends on the clinical question and patient-specific factors.
Cardiac catheterization can be used to evaluate coronary arteries, measure intracardiac pressures, assess oxygen saturation, and diagnose or treat certain cardiovascular conditions.
After cardiac catheterization, nurses should closely monitor the access site and distal circulation.
Important assessments include:
Vital signs
Access-site bleeding or hematoma
Distal pulses
Skin color and temperature
Capillary refill
Pain
Neurologic and circulatory status of the affected extremity
If a femoral access site was used, the affected leg may need to remain straight for a specified period according to the procedure and institutional protocol. The nurse should follow the facility’s post-procedure orders because activity restrictions vary according to the access site and closure device.
Cardiopulmonary bypass (CPB) temporarily takes over the functions of the heart and lungs during certain cardiac surgeries. It circulates and oxygenates blood while allowing the surgeon to operate on a relatively bloodless and motionless heart.
Because CPB affects multiple body systems, postoperative monitoring is extensive.
Potential complications include:
Bleeding
Systemic inflammatory response
Fluid and electrolyte disturbances
Atelectasis
Pulmonary complications
Renal dysfunction
Myocardial dysfunction or stunning
Temperature instability
Infection
Neurologic complications
Postoperative nursing priorities include hemodynamic monitoring, respiratory assessment, bleeding surveillance, urine output monitoring, temperature management, laboratory evaluation, and early recognition of complications.
The relationship between pulmonary and systemic blood flow is expressed as Qp:Qs, or pulmonary blood flow to systemic blood flow.
In a simplified normal circulation, Qp:Qs is approximately 1:1.
A left-to-right shunt directs oxygenated blood from the systemic side of the circulation back toward the pulmonary circulation. This increases pulmonary blood flow and generally produces an acyanotic or “pink” presentation when oxygen saturation remains adequate.
Common physiologic effects include:
Increased pulmonary blood flow
Increased pulmonary vascular workload
Potential pulmonary congestion
Increased cardiac workload
Qp:Qs greater than 1
Examples of lesions that can produce left-to-right shunting include atrial septal defect, ventricular septal defect, and patent ductus arteriosus.
Understanding the direction of blood flow is important because shunt physiology explains why certain congenital heart defects cause pulmonary overcirculation and heart failure.
When preparing for the exam, concentrate on clinical distinctions and nursing priorities rather than memorizing isolated facts.
Key concepts include:
Distinguishing dementia, delirium, and depression
Identifying reversible causes of acute confusion
Understanding medication-related risks in older adults
Applying the 4Ms Framework
Recognizing ACS symptoms and priorities
Differentiating NSTEMI and STEMI
Recognizing pulmonary versus systemic congestion in heart failure
Identifying signs of pediatric heart failure
Understanding the purpose of major cardiovascular diagnostic tests
Prioritizing post-cardiac-catheterization assessments
Recognizing potential digoxin toxicity
Understanding left-to-right cardiac shunts and Qp:Qs
Delirium is acute, fluctuating, and characterized by impaired attention and awareness. When an older adult suddenly becomes confused, nurses should search for an underlying cause rather than assuming the change represents dementia.
Dementia generally develops gradually and causes progressive cognitive and functional impairment. The patient’s baseline status is essential for identifying new changes.
Depression is not a normal part of aging. It is potentially treatable and may produce cognitive symptoms that resemble dementia.
Polypharmacy can increase medication-related harm. Medication reconciliation and individualized review are essential for older adults taking multiple medications.
The 4Ms are What Matters, Medication, Mentation, and Mobility. Together, they support person-centered and age-friendly care.
STEMI is a time-sensitive cardiac emergency. Rapid recognition and reperfusion are essential when an acute coronary occlusion is suspected.
Left-sided heart failure primarily causes pulmonary congestion, while right-sided heart failure causes systemic venous congestion.
Daily weight is an important indicator of changing fluid status in patients with heart failure.
Pediatric heart failure may appear as feeding difficulty, sweating during feeds, tachypnea, tachycardia, and poor weight gain rather than the classic adult presentation.
After cardiac catheterization, assess the access site and distal circulation. Bleeding, hematoma, loss of pulses, coolness, pallor, or other changes in perfusion require prompt attention.
Prioritize dementia versus delirium versus depression, polypharmacy and the Beers Criteria, the 4Ms Framework, ACS, STEMI versus NSTEMI, left- versus right-sided heart failure, pediatric heart failure, cardiovascular diagnostic tests, cardiac catheterization care, digoxin safety, and congenital heart shunts.
Look at the onset and attention. Dementia typically develops gradually and progresses over time, while delirium develops rapidly and causes impaired, fluctuating attention and awareness.
A sudden cognitive change may indicate delirium caused by infection, dehydration, hypoxia, medication effects, metabolic abnormalities, urinary retention, constipation, pain, or another acute condition. It should be assessed rather than attributed to normal aging.
The four components are What Matters, Medication, Mentation, and Mobility. The framework helps clinicians provide care that is individualized, medication-safe, cognitively supportive, and focused on maintaining function.
NSTEMI involves myocardial injury with elevated cardiac troponin but without persistent diagnostic ST-segment elevation. STEMI involves acute myocardial ischemia with diagnostic ST-segment elevation and generally requires rapid reperfusion.
Left-sided heart failure commonly causes pulmonary congestion, resulting in dyspnea, orthopnea, crackles, pulmonary edema, fatigue, and reduced exercise tolerance.
Right-sided heart failure commonly causes systemic venous congestion, including peripheral edema, jugular venous distention, hepatomegaly, ascites, and weight gain from fluid retention.
Pediatric heart failure may cause tachycardia, tachypnea, feeding difficulty, sweating during feeds, poor weight gain, respiratory distress, irritability, hepatomegaly, and exercise intolerance in older children.
Feeding requires substantial energy and oxygen. Infants with heart failure may fatigue quickly, become tachypneic or diaphoretic, and consume inadequate calories, which can contribute to poor weight gain and failure to thrive.
The nurse should monitor vital signs, the access site, bleeding or hematoma formation, distal pulses, skin color and temperature, capillary refill, pain, and other signs of impaired circulation. Follow the specific post-procedure orders for positioning and activity.
A Qp:Qs ratio greater than 1 generally indicates that pulmonary blood flow exceeds systemic blood flow. This can occur with a significant left-to-right shunt and may lead to pulmonary overcirculation.
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