123 Punch Final Exam Answers

[DOWNLOAD] 123 Punch Final Exam Answers

Was that clear enough? Waiting to prove that I am better than you. Come and see me if you dare. It won't work. A child can see that. You need to come to the church. I'll speak slowly enough that even you stand a reasonable chance of following this...

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Solve enough of my carefully constructed conundrums and I'll tell you where the rest of my hostages are. The first is in the courtroom. I suggest you hurry. He may have been sentenced already. All through Arkham City, deep, deep undercover are people working to ensure that I am informed of what the other so-called super criminals are planning.

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Right now, one of them is arranging a little welcoming committee for you outside. I'm an instrument? I've got something to do with the heart? I'm a thing that pumps blood, I'm an instrument that sounds like that thing. Like a door, I have keys. I suppose I should fulfill my side of the agreement. A riddle for a bat. Can you solve it? Was it hard? I hope so, because it is time for a reward, and what's more rewarding than a riddle? Well done. You have completed enough of my challenges so now all you have to do is solve my riddle and save the day. Can you do it?

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If you think you can hear me clapping then you are obviously suffering from some sort of delusion for I am doing no such thing. Solve my riddle and find the hostage. What could I be? Do you know what I am? I suppose it was your first attempt. I shouldn't really be surprised, should I. Continue to prove your own stupidity at your own pace, for now. He passed. And is now solving crimes in Gotham City. What is it? Need some help? This is easy. How are you going to save them if you can't even figure out the most trivial of conundrums? Not so easy now, is it? I think it's time to introduce a little penalty to help you comprehend your ignorance.

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What shall it be? Oh yes. I've frozen you out, Dark Knight. Frustrating, isn't it? Take some time to wrap your feeble mind around where you went wrong and try again. No, really. Give up. You cannot solve this. That is becoming increasingly obvious. I could have answered that one when I was six years old. How many times are you going to try and solve that one. Let me give you some time to think about it. Let's give your brain a rest.

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Endovascular aortic aneurysm repair 1 month ago Answers 1. Patients with a recent MI are at significantly increased cardiac risk during noncardiac surgery, particularly within the first month after MI. Since the proposed operation is elective, options A—D would place the patient under unnecessary risk. Although performing the operation under local anesthesia with sedation B seems appealing, there is still considerable stress and cardiac risk with such an approach. The best recommendation for this patient is to postpone surgery for at least 4 weeks. At that point, consideration should still be given to cardiac stress testing prior to surgery or even further surgical delay, as the cardiac risk persists for at least 6 months after an MI. Answer A Major predictors of adverse postoperative cardiac events must be identified prior to elective noncardiac surgery.

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These include recent within 1 month MI, unstable or severe angina, decompensated CHF, and significant arrhythmias. Such cardiac conditions require postponing surgery and performing further cardiac workup. A systolic, crescendo-decrescendo murmur at the sternal border of the right second intercostal space radiating into the neck is highly suggestive of aortic stenosis and would require an echocardiogram to rule out severe aortic stenosis. Aortic stenosis impairs coronary perfusion, which can become further exacerbated during induction of anesthesia. From all the choices listed, it portends the highest operative risk. Adding a point for each factor and a assigning a score from 0 to 6 are highly effective in stratifying cardiac risk. Interestingly, smoking E has not been shown to be an independent risk factor for adverse perioperative cardiac events in most studies.

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Optimally, an additional antiplatelet agent such as clopidogrel and intravenous heparin are also given, but this depends on how recent the operation was and the potential for postoperative bleeding. Consideration should be given to stress testing at 4—6 weeks after surgery, and depending on the results, PCI is then considered. The patient described has a down trend of troponins and relief of symptoms, further supporting medical management.

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Answer D Acute pericarditis is inflammation in the pericardial sac accompanied by pericardial effusion. Patients present with pleuritic chest pain that lessens when leaning forward, friction rub heard on auscultation, global ST elevation, and PR depression. Patients with myocarditis A usually present with signs and symptoms of acute decompensating heart failure e. Chest pain accompanied with MI C would not be expected to lessen with leaning forward. Furthermore, global ST elevation would not be expected. Cardiac tamponade C can occur once the effusion reaches a critical mass in which cardiac output is compromised. Pulmonary embolism E can present with pleuritic chest pain, but it will not be influenced by positioning and is more likely to have ECG findings suggestive of right heart failure. Answer C It is important to know the timing of causes of death after MI. In the first 48 h after MI, death is likely due to ventricular arrhythmia.

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Coronary angiography D is considered the gold standard in identifying coronary artery disease and can estimate ejection fraction, but is not as accurate. Answer E It is important to rapidly identify Stanford type A dissections, as they require urgent surgical intervention due to the fact that they can lead to cardiac tamponade, acute aortic valve insufficiency, acute MI, and stroke. Thus an aortic dissection involving the innominate artery is a Stanford type A. Stanford type B aortic dissection is more common. A Stanford type B dissection begins in the descending aorta, distal to the takeoff of the left subclavian artery A—D. A type B dissection may involve the mesenteric, renal, or iliac arteries, but not occlude them, as blood may continue to flow normally either though the true or the false lumen. Most can be managed medically with blood pressure control beta-blockers. Surgical intervention is needed if the involvement of these vessels leads to malperfusion such as leg ischemia, bowel ischemia, or renal failure.

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Answer C Based on the description of the site of the dissection, this is a type B aortic dissection. These are usually managed medically A unless the patient has evidence of malperfusion. The goal is to maintain a relatively low blood pressure in order to minimize stress on the aorta. Aggressive IV fluids B will not reduce blood pressure and may actually raise it. Nicardipine E will lower blood pressure, but intravenous beta-blocker is the treatment of choice because it also reduces the rate of pressure increase with each beat of the heart, which lowers the stress on the aortic wall. Endovascular therapy D is not routinely needed for most type B dissections.

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Answer A Patients with a recent history of myocardial infarction are at risk of thrombus formation on the scarred endocardium, which can then embolize to the brain and cause a stroke. Patients with a recent history of MI and evidence of thrombus on echocardiography should be treated with warfarin to maintain an INR of 2—3 and followed up within 3 months. Thromboembolism from the left atrial appendage D is a concern in patients with atrial fibrillation. Paradoxical venous thromboembolism E is a concern in patients with an atrial septal defect or patent foramen ovale, wherein a deep venous thrombus can travel through the defect into the left heart and ultimately to the brain.

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Septic embolism B is a concern in IV drug abusers and can lead to cerebral abscess. Type A dissection C would usually present with severe chest pain radiating to the back. Answer A This patient has a postoperative right-sided MI, resulting in compromised cardiac output secondary to decreased preload. One of the steps in management of right-sided MI is to administer fluids to help increase filling of the heart. Avoid nitrates B, C in these patients as it may further reduce preload. Acutely, patients with MI need oxygen, aspirin, analgesics, and beta-blockers. Dihydropyridine calcium channel blockers, such as nifedipine D , are contraindicated in MI because of the associated peripheral vasodilation that may lead to reactive tachycardia and subsequently result in even more stress on the heart.

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ACE inhibitors E should be considered for long-term treatment after the acute episode has resolved. This is a life-threatening infection of the mediastinum with a very high mortality rate that is most commonly associated with cardiac surgery. The source of infection may be a sternal wound infection, combined with instability of the sternum that permits bacteria to enter the mediastinum. Patients will frequently present with chest pain, increased drainage from sternal wound, fevers, and leukocytosis. A CT scan can also support the diagnosis by demonstrating dehiscence of the sternum and stranding, fluid and air pockets within the anterior mediastinum.

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However, the most significant risk factor for aortic dissection is systemic hypertension. Answer D In cardiac tamponade, fluid blood or effusion in the pericardial space externally compresses the heart, which limits diastolic filling and reduces stroke volume. Since pericardial fluid is free flowing, the pressure is distributed equally along the pericardium. As this continues the rising pressure in the pericardium is transmitted to all four cardiac chambers resulting in equalization of central pressures. Pulsus bisferiens A , also known as a biphasic pulse, refers to two strong systolic pulses with a mid-systolic dip, in other words, two pulses during systole.

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It can be seen in aortic regurgitation with or without aortic stenosis and hypertrophic cardiomyopathy. Peaked T waves C is most often associated with hyperkalemia. It is unlikely to be seen in patients with cardiac tamponade since their ECG findings are characteristically low voltage. Pulsus alternans E is a physical exam finding wherein the amplitude of a peripheral pulse changes from beat to beat associated with changing systolic blood pressure. It is most commonly caused by left ventricular failure.

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Answer B Sudden onset of severe abdominal pain in association with an aortic dissection should always raise suspicion for malperfusion of the bowel which can lead to bowel gangrene and death. This most likely would occur if the dissection extends into, and suddenly occludes, the superior mesenteric artery, which supplies blood to the bowel from the ligament of Treitz to the mid-transverse colon. He has not been on broad-spectrum antibiotics, and has no reason to have C. Pancreatitis C presents with epigastric pain radiating to the back, nausea, vomiting, anorexia, fever, and tachycardia and is most commonly associated with cholelithiasis and alcohol abuse. Aortoenteric fistula D is a possible long-term sequela in patients who have had an intra-aortic synthetic graft placed. Diverticulitis E is a common cause of left lower quadrant abdominal pain in elderly patients, and does not typically cause such sudden severe pain. Answer C Wide mediastinum on chest X-ray is concerning for aortic dissection.

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Patients with type A aortic dissection can present with coronary artery malperfusion and thus have a similar presentation as an acute MI. Suspected aortic dissection is considered an absolute contraindication to thrombolysis in patients with myocardial infarction. The remaining choices A—B, D—E are all relative contraindications for intravenous thrombolytics.

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An analogy would be as if this course were covering how houses are built, in this analogy the example textbook would require you to know building codes for each different city you plan to build in, know the screw and bolt length to hold up a ceiling under X amount of load, and the best types of wood to use for different environments. In reality all this analogous OA would really want you to know is that houses are built via a variety of construction contractors electricians, plumbers, roofers, etc I studied for an average of hours a night for 2 weeks. I mostly went through and got the definitions for each page, understood what they meant, and how to contextualize them in relation to other parts of the process, along with big ideas from each section. The same goes for this playlist regarding chapter 6. After going through everything I reviewed my notes and took the PA.

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For the questions that I missed, I made sure to understand not only the right answer but the wrong answers as well. Chapters 3 and 4 go WAY too in depth, like I said you only need to know the big concepts. I made sure to write down every definition that I could usually highlighted in blue boxes , and also some of the ones that were only in italics. Good luck!

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VLAN hopping E. Man-in-the-middle Choose two. Document the reason for the request B. Create a honeypot to store the file on for the customers to use F. Write the SLA for the sales department authorizing the change A user reports that a laptop cannot connect to the Internet despite the fact the wireless Internet was functioning on it yesterday. Which of the following issues should be reviewed to help the user to connect to the wireless network?

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Wireless switch toggled off B. WAP settings C. Wireless controller misconfiguration A network administrator wants to increase the confidentiality of the system by hardening the authentication process. Currently, the users log in using usernames and passwords to access the system. Which of the following will increase the authentication factor to three? Adding a fingerprint reader to each workstation and providing a RSA authentication token B. Adding a fingerprint reader and retina scanner C. Using a smart card and RSA token D. Enforcing a stronger password policy and using a hand geometry scan A network technician is building a network for a small office.

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Chapter 4 Geometry Test Answers

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