III first time audible, IV first time thrill
3 months of synthroid, TSH increased, T4 normal, what do you do?
3 ways to assess cognitive function in patient with signs/symptoms of memory loss
4 month old with strabismus, mom is worried……
4 month old wont keep anything down, what is the main thing you look at?
6 month old closed anterior fontanel.
Abnormal cells on PAP, what do you do next?
Cut down
Annoyed by criticism
Guilty about drinking
Eye opener drink
Cranial nerves responsible for extraocular eye movements
Definition of metabolic syndrome
cluster of conditions that increase risk of heart disease, stroke, diabetes.
Elderly presents with atrophic vaginitis, small uterus, palpable 4×5 ovary, what do you do next?
Definitive diagnosis of acute bacterial prostatitis
Grade 3 cells on Pap, treatment?
Fingernail hematoma treatment?
Increased risk of ectopic pregnancy
Salpingitis, or history of abortion, PID,
Measles (rubeola). Grains of salt lesions inside mouth in Measles
Measles (rubeola). Grains of salt lesions inside mouth in Measles
Avascular necrosis of the proximal femoral head
Lipid level of 1500, increased risk for?
Low HGB, Low HCT, High MCV indicates what?
Man with BPH, prostate feels on digital exam?
Man with HTN, CAD, present femoral pulses but absent pedal
McMurray’s Sign
(+) palpable or audible click while extending with varus stress
Newborn with foot turned in, what do you do?
Pt presents with rash on shoulder, erythematous maculopapular rash with center clearing and scaling?
Pt presents with “bag of worms:, indicates?
Pt with atopic dermatitis, look for what other diseases?
Pt with bleeding after menopause
endometrial biopsy, need to screen for cancer
Pt with hx of PID, increased rick for?
Pt with HIV took high potency anti viral treatments and CD4 is >400, what does this indicate?
This is good. Want higher than 350
Pt with hx of htn and stroke, now having memory loss. What does this indicate?
Pregnant teacher with exposure to 5ths disease (SLAP CHEEK), what risk is there to the fetus?
slap cheek, PVB19, rash hands / feet Fetal death and birth defects
Quick assessment of patients fall risk? Timed Get up and Go
Rotator cuff injury presentation
disturbs sleep, arm weakness, dull ache
immediate referral to ophthalmology
Signs and symptoms of Roseola (6ths disease) ?
Viral infection
Can result in a maculopapular rash, but up to 70% of cases proceed without the rash stage
-Usually accompanied by a high fever (41°C or 105°F) that comes on quickly and lasts up to 3 days followed by rash
-Seizures may occur during this period.
-On the fourth day, the fever disappears and the rash appears, first on chest and trunk, then less prominently on the face and limbs.
-High fever, pink flat or raised rash
Treatment for chronic alcoholism:
Make a hole and drain the blood
Without inflammation: Topical retinoid
Moderate inflammation: Topical Retinoid or benzoyl peroxide or Azaleic acic ( very expensive and hard to get covered)
PLUS ADD
Oral antibiotics: doxycycline or tetracycline or minocycline- (tetracyclines has been proven most affective for inflammatory acne)
Minocycline- long term use has been linked with pseudotumor cerebri
Oral contraceptives for hormone related
Spironolactone
heart murmur with holosystolic or pan systolic
Heart mumur with mid systolic
MR – radiate axilla, 5th ICS MCL, apex,
AS – radiate neck, 2ICS right sternal border
MR ASSH
pt. with gradual onset of fever, hemorrhages on nail beds, painful raised red nodules, rash on palms
endocarditis , painful red spots on fingers olser’s nodes, janeway legions rash on palms and soles.
Smoking cessation
Pulmonary rehabilitation
Pharmacologic therapy
Supplemental oxygen
TB… PPD is positive if area of induration is:
AV nicking (Arterioles pressing on vein of the eye)
Fluid pressure inside the eye; measured with tonometry
pain in the RLQ when the LLQ is palpated (indicative of appendicitis)
Pencil-like stools occur in an obstruction of what
Folate shares a close relationship with this other B Vitamin.
be changed to NSAID, SED rate is a sign of inflammation
Which medication causes low sperm count for a patient
Exaggerated belief in or claims about one’s importance or identity.
Bipolor
HPV test if not done. Refer for colposcopy
Doxycycline (+ ceftriaxone for gonorrhea coinfection)
Cryotherapy
OR
Podophyllotoxin cream –
OR
Imiquimod (Aldara cream)
HIV pt. with antiviral and CD4 count still less than 200. What should NP tell the pt.
tell the pt. that he is qualified to be diagnosed with AIDS according to CDC
Most common cause of death in children
a gradual loss of sensorineural hearing that occurs as the body ages
Molluscum contagiosum treatment
non bilious vomiting, olive like firm mass palpated on right upper quadrant
horizontal nystagmus that stops when eye is close to midline in a college student
the involuntary jerking of the eyes as a person gazes to the side
eating, painful lump noted on the jaw that comes and go.
Etopic Pregnancy: Risk Factors
Previous ectopic pregnancy
Prior fallopian tube surgery
Previous pelvic or abdominal surgery
Certain sexually transmitted infections (STIs)
Pelvic inflammatory disease
Endometriosis
cigarette smoking
age older than 35 years
history of infertility
use of assisted reproductive technology, such as in vitro fertilization (IVF)
Which among the list can cause increase in respiration
Options include (low oxygen, high oxygen, hypercapnia, hypocapnia)?
Which among the list can cause increase in respiration
Osteoporosis Risk Factors (ACCESS)
to prevent fracture in a pt. with low vitamin d hydroxyl, high TSH and low Hct
abnormal flow of blood through the carotid artery
abnormal flow of blood through the carotid artery due to atherosclerotic disease
Zeprexa. What lab and intervention to put in place
Assessment on patient with ascites
Assessment on patient with ascites
patient with IOP of 32mmHg, what do you expect during fundoscopic exam
patient with IOP of 32mmHg, what do you expect during fundoscopic exam
increase cup-to-disc ratio
retinal hemorrhage
optic nerve asymmetry and pallor
measured w tonometry
TX anticholinergics/oxybutynin,
impamine/tricyclic antidepressant
seasonal affective disorder (SAD)
a mood disorder caused by the body’s reaction to low levels of sunlight in the winter months
IBS (irritable bowel syndrome)
IBS (irritable bowel syndrome)
TX first line is bisphosphonates alendronate, Fosamax, calcium500 mg, vitamin d thru food and supplementation, testosterone, wt bearing exercise
Osteopenia- increase calcium dark green vegetables, salmon, sardines, soy and OJ
Hormone (estrogen) replacement therapy (HRT) slows bone loss
Natural progesterone cream prompts new bone growth
Statins increase bone mineral density
TX BIOPHOSPHATES alendronate, Fosamax, CALCIUM 500 mg, vitamin D food and supplementation, testosterone, WT BEARING EXERCISE
CAUCASIAN and ASIAN affected most
RISK PPI, STATIN, STEROIDS, THYROID,
Osteopenia- increase calcium dark green vegetables, salmon, sardines, soy and OJ
Hormone (estrogen) replacement therapy (HRT) slows bone loss
Natural progesterone cream prompts new bone growth
BONE DENSITY >2.5
white reflection in child’s pupil
for staph aureus infection (skin) with pus
MRSA- TX Bactrim or tetracyclines?
methimazole, PTU-propylthiouracil (preferred in pregnancy)
Radioactive iodine, Beta blockers
-Age 45 – 54 yearly mammogram
-55 and older every 2 years
Fifth’s Disease (Erythema Infectiosum)
pt has AOM but has hives on Amoxicillin and N/V with erythromycin, what meds to give
optic disc swollen w/ blurred edges due to increased ICP EXAM
COPD- Gold 1-2- SABA or SAMA ON EXAM.BASCIALLY ANTICHOLINERGIC FIRST LINE FOR COPD ON EXAM
Gold 1-2 that are poor controlled- LAMA or LABA. May use SABA for rescue.
Gold 3-4 LAMA first line. If poor use LAMA plus LABA. Alternative is LABA + ICS.
Gold 3-4- refer
SABA- Albuterol, levoalbuterol (terol)
LABA- Formeterol, salmeterol (Terol)
SAMA- Atrovent Ipatropium (tropium)
LAMA- Spiriva Tiotroium (tropium)
COPD long term is OXYGEN
– Shoulder shrug/ ROMBERG test EXAM
Herpes. CORNEAL ABRASION. EXAM
Do not give <12 mo. EXAM QUESTION
is on EXAM in elderly night vision issues. Opaque
– acute high fever, enlarged lymph. BRIGHT RED RASH, conjunctivitis, dry cracked lips, strawberry tongue, Swollen hands, feet, AFTER the fever resides the rash PEELS on hands/feet. Treated with high dose aspirin and gamma globulin. This is TOXIC and VASCULAR, think blood clots, heart problems etc. Treat: high dose aspirin. EXAM
Erythema Migraines- (stage 1 Lyme) Target bulls-eye, usually appears in 7-14 days POST bitten tick. Rash is hot to touch with rough texture, flu like symptoms. DX: B. Burgdorferi via ELISA, confirm with western blot. Increased ESR. TREATMENT: Less than 7 Amoxicillin or cefuroxime axetil. Older than 7 Doxycycline. EXAM
OSTEOPOROSIS = WEIGHT BEARING- walking, lifting weights etc. bones are forced against gravity. EXAM
PTH is responsible for calcium loss or gain from bones, kidneys, and GI tract. EXAM
Primary amenorrhea: NO menarche by 15 y. with or w/o secondary sex characteristics.
Cancer sores. Aphthous stomatitis: painful shallow ulcers heal 7-10 days. Magic mouthwash.
“contagious 48 h. before, until all lesions crusted over” low grade fever, generalized lymphadenopathy, intense itching, erythematous macules, papules develop over macules, then vesicles erupt. “initially on trunk, then scalp and face” TREATMENT supportive, antihistamines, acyclovir 20mg/kg 5xd. If given first 24 hours works best. EXAM
fever chills, n/v, located arms, upper legs, or the trunk. Biten area becomes swollen, red, and tender, and blisters appear within 24-48 hours. Necrotic in center, which kills the tissue. Ice packs to wound and cold inactivates the toxin, tx like cellulitis of the skin, abx ointment at first, watch etc. Exam
Corneal Abrasions- Round/Irregular. Was on EXAM.
acute/severe halos, cupping optic nerve, cloudy cornea, mid-dilated oval pupil. ER STAT. EXAM
Sensorineural: Lateralization to good ear. Rinne- AC > BC.
Ear pressure, popping, muffled hearing, chronic allergic rhinitis, sterile serious fluid is trapped in the middle ear. TM should NOT BED RED. TM may bulge or retract. TREATMENT: Oral decongestants, steroid nasal spray, treat like allergies. Usually Painless. Weber- Lateralization to affected ear. Rhinne- BC > AC. PRECEDES OR USUALLY FOLLOWS AOM. SUPPORTIVE CARE AND WAIT 3 MOS SOMEX. EXAM
TX AMOXICILLIN OR AUGMENTIN ALLERGY MACROLIDE
VERTIGO TINNITUS, HEARING LOSS. nystagmas
test heterophile antibody test. ON EXAM
(Systolic Murmur) Only systolic murmurs will radiate to a location on the exam.
All diastolic murmurs are pathological. Grades Murmurs
I-barely II-audible III- clearly audible. IV- first time thrill V-Steth edge VI-entire steth. EXAM
PAD/ PVD (same)- Nocturnal pain relieved by lowering legs, poor pulses, dependent rubor, intermittent claudication, atrophy, shiny, hairless, cold feet. Initial do a pulse check, ABI 0.9 or less is PAD. Ateriography is the most DEFINITIVE test. Try to develop collateral circulation. Otherwise- Trental, Pletal. EXAM
Acute Bacterial Pneumonia- CXR
does not include Microglossia which is an absent tongue congenital. EXAM
fatigue, fever, cough. Never do fewer than 3-4 drugs initially if positive, then u can narrow it down. Latent TB usually treated with INH. If u suspect ACTIVE TB order, NAAT, C&S, AFB. The AFB is not diagnostic. SPUTUM FOR C & S if gold standard. Deep morning cough collected for three “consecutive days”. TB is usually upper lobes.
TPO- this lab is off MEANING ELEVATED in BOTH hyper/hypo thyroidism. TPO is GOLD stand for diagnosis in Hashimotos. But you always want to order a TSH first, THEN ur thyroid panel do not get ahead of yourself. Check ur TSH lab on both in 6-8 weeks but never sooner than 6 weeks that is how long these meds take to work. TOPIC ON EXAM
checks sugar for past 2-4 weeks.
slow growing blood cancer. blood too thick, clots. bone marrow to many RBC. risk bleed , anemia, CBC
anxiety and insomnia, don’t mix w sedating benzos.
lithium- monitor TSH, toxicity bind to TH cause hypothyroidism.
Depression med
acute Anxiety/ panic med
GAD med
depression SSRI
panic benzo, Xanax, ativan
GAD SSRI
SNRI- Buspar, Effexor, Cymbalta- Taper OFF
Buspar, Effexor, Cymbalta and Benzo Taper OFF
Glyceridemia
Lipidemia
Uricacidemia
Triglyceridemia
HYPO-Kalemia
pregnancy
Renal failure
Renal Stenosis
Triglyceride < 300 what do we do first?
Triglyceride in 300 plus risk for ___ what do we do?
Lifestyle modification
Pancreatitis, Niacin then add, fenofibrates
HF and ARF
increase BP impair renal prostaglandin and sodium retention
misalignment of eyes, abnormal after 6 months
sharply demarcated yellowish deposit of cholesterol underneath the eye
retinoblastoma (leukorrhea) , cataracts, glaucoma.
Will have white reflex
4-6 weeks when spleenolmegaly resolves
Mono spot/ Heterophile
ulcer on cheek
(Aphthous)- viral canker sore
Acute Closed Angle Glaucoma
Vs
Open Angle
Swollen, optic disc, increase cup to disc ratio, HA, ICP, HTN,
Pt on PPI, has osteoporosis has a cough,
blue pale turbinate clear drainage. Tx inhaled corticosteroids
hordeolum Vs
chalazion
blepharitis
painful lump, calculi or salivary stones.
sub mandibular gland whartons; duct.
Roseola infantum- Sixth disease
viral, young children, high Fever 3-4 days followed by maculopapular rash
Cranial nerves responsible for extraoculomotor movements?
Patient with hx of hypertension and stroke, now having memory loss and confusion – indicates what?
a. Alzheimer’s
b. Vascular Dementia?
?
Treatment for chronic alcoholism?
?
Frail elderly mammogram breast tissue?
?
a. Refer to oncologist?
b. Refill prescription?
3 months on Symmetrel, TSH increased, T4 normal, what do you do?
a. Increase medication?
b. Decrease medication?
Lipid level of 1500, increased risk for?
Frail elder, increased creatinine, indication?
?
Fingernail hematoma treatment?
a. drill hole and drain blood?
Abnormal cells on PAP, what do you do next?
a. Pernicious Anemia?
b. Iron Deficiency?
c. Folate Deficiency?
Low Hemoglobin, Low Hematocrit, High MCV – Indicates what?
?
Signs and Symptoms of Roseola?
Pregnant teacher, with exposure to Fifths’ Disease – what risk is there for the fetus?
6 Month Old with Closed Anterior Fontanel?
4 Month Old with Strabismus, mom worried, what do you tell her?
4 Month Old “won’t keep anything down”, what is the main thing you look for?
Man with HTN, CAD, present femoral pulses, but absent pedal pulses?
a. DVT?
b. Venous Insufficiency?
c. Arterial Insufficiency?
Diabetic patient with foot laceration, at risk for what?
a. foot ulcer?
b. acute osteomyelitis
Definition of metabolic syndrome?
a. Rocephin IM and Zithromax po
b. Doxycycline po
Patient with history of PID, increase risk for?
Increased risk for ectopic pregnancy, history of…?
Newborn with foot turned in (“toeing in”), what do you do?
a. Refer immediately to orthopedist?
b. Routine followup?
Osgood Schlatter Disease pain location?
Growth plate fracture (Salter-Harris fx) location and pain?
Rotator Cuff injury presentation?
a. Fever?
b. Anemia?
c. Hypotension?
Definitive diagnosis of acute bacterial proctatitis?
Man with high BPH, perform digital rectal exam – how does prostate feel?
a. Asymmetrical, Nodular, Firm
b. Symmetrical, Boggy
?
Patient present with “bag of worms”, what does this indicate?
Avascular necrosis of the proximal femoral head…
a. anterior septum?
b. middle turbinate?
c. sinus turbinate?
Elderly presents with atrophic vaginitis, small uterus, and palpable 4×5 ovary, what do you do?
Grade 3 cells on Pap, treatment?
?
Patient with bleeding after menopause?
Shingles near eye, patient wants cream and analgesic, what do you do?
a. Order Acyclovir cream and analgesic?
b. Immediate referral to opthamologist?
a. Tinea Pedis?
b. Tinea Corporis?
c. Psoriasis?
Peripheral vision loss = ?
Central vision loss = ?
Patient with Atopic Dermatitis, look for what other diseases?
Quick assessment of patients fall risk?
a. Mini Mental
b. Depression Screen
c.
d.
a. DVT?
b. Venous Insufficiency?
c. Arterial Insufficiency?
Patient with HIV took high-potency anti-viral treatments and CD4 is >400, what does this indicate?
a. Patient has full-blown AIDS as defined by the CDC?
?
how long will a cough last for acute bronchitis?
up to three weeks is completely normal
how do you treat acute bronchitis?
95% cases are viral– tessalon pearls to help with cough. * prednisone is never the answer **
what is the gold standard for diagnosing community acquired pneumonia
chest xray- PA/lateral, repeat post treatment in 6 weeks (repeat not really done anymore)
treatment guidelines for CAP- healthy adult no comorbidities
treatment guidelines for CAP- adult with comorbidities
what are common respiratory fluroquinolones?
Think FLOXACIN– moxifloxacin, gemifloxacin, levofloxacin
what are common macrolides for CAP
think “MYCIN” — azithromycin, clarithromycin
what are common tetracyclines for CAP
what are common beta lactams for CAP
amoxicillin, augmentin (amox with clav), cefpodoxime, cefuroxime
how would you treat a pregnant 29 year old with pneumonia?
how long do you give antibiotics to patient with pneumonia?
When do you get a chest xray for pneumonia?
When do you give pneumococcal vaccine?
adults > 65 years old you give PPSV23 or you can give both PCV 13 and PPSV23 but must be 1 year apart
adults > 65 with immunocompromising condition give both pcv 13 and ppsv23
adults 19-64 at increased risk of pneumococcal disease (asthma, copd, smokers, cv dz) – give PPSV23 only
adults 19-64 with asplenia, cochlear implants, csf leak– give pCV13 NOW then PPSV23 in 8 weeks , then PPSV23 in 5 years.
What is the diagnostic criterion for COPD
What are characteristics of COPD
what are characteristics of asthma
what are characteristics of heart failure (when evaluating diff dx of COPD)
chest xray with dilated heart, pulmonary edema
what are characteristics of tuberculosis when ruling out for COPD patient
onset all ages, chest xray with lung infiltrate, microbiologic confirmation
what are the characteristics of bronchiectasis
LOTS OF PURULENT SPUTUM, chest xray shows bronchial wall thickening and bronchial dilation
What intervention has the greatest influence on slowing progression of a COPD patient?
what are first line smoking cessation drugs? (3)
varenicline (chantix), nicotine patch, buproprion extended release (zyban)
what is second line smoking cessation drug?
what smoking cessation drug would you give to someone with a history of a suicide attempt?
nicotine patch– NOT CHANTIX OR ZYBAN
What are the short acting beta agonists
what are the long acting beta agonists
How do inhaled anticholinergic drugs work?
used in COPD, prevent bronchoconstriction
stimulate beta 1 (tachycardia) and beta 2 (bronchodilation)
what is the suffix for inhaled anti-cholinergic drugs?
“tropium” think ipratropium (atrovent) SHORT ACTING, tiotropium (spiriva) long acting
short acting antimuscarinic (anticholinergic) – Ipratropium
long acting muscarinic antagonist (anticholinergic) Tiotropium (spiriva)
what are the 4 steps of GOLD guidelines
How to manage COPD exacerbation?
right supraventricular nodes signal what malignancies?
left supraventricular nodes signal what malignancies?
abnormal (stomach, GB, liver, pancreas, ovaries, prostate)
how do you diagnose asthma > 5 years of age:
acute bronchitis classic case symptoms
objective findings in acute bronchitis
lungs: clear to severe wheezing, rhonchi
percussion: resonant
CXR: normal
afebrile to low grade fever
complications of acute bronchitis
exacerbation of asthma
pneumonia from secondary bacterial infection
sinusitis, otitis media, pneumonia, fainting, rib fractures from coughing
Assessment of the optic disc is a component of the evaluation of cranial nerve:
I.
II.
III.
.IV
You examine a 62-year-old woman with a 20-year history of hypertension. She reports intermittent use of antihypertensive medications, stating, “I feel better without the medications.” Today she presents for a “check-up.”On physical examination, you note the following: PMI with a downward and lateral shift as well as a Gr II/VI holosystolic murmur with radiation to the axilla.
This patient’s health history is most likely to include a report of:
Syncopal episodes.
Episodes of chest pain at rest.
Dyspnea with exertion.
Vertigo.
Ans: FEV (force expiratory volume)
A 58-year-old woman presents for an initial examination in order to become a patient in your primary care practice. She is a nonsmoker, drinks 1 to 2, 5 oz (0.15 L) glasses of wine per week, and works as an administrative assistant in a law office. She is without complaint and reports that she is generally in good health. Physical exam reveals BMI=34 kg/m2 and BP=144/98 mm Hg bilaterally.
The rest of her examination is unremarkable.
Prescribe a low-dose thiazide diuretic.
Arrange for additional blood pressure measurements within the next four weeks.
Order a serum creatinine, urea nitrogen and urinalysis.
Advise restricting sodium intake and limiting alcohol intake to no more than 1 glass of wine per week.
Ans: Arrange for additional blood pressure measurements within the next four weeks.
The NP demonstrates fulfillment of the advanced practice nursing leadership role by participating in which of the following activities?
Teaching a 56-year-old man with newly-diagnosed type 2 diabetes mellitus about the importance of self-glucose monitoring
Volunteering to teach a class on contraceptive methods to a group of teen mothers
Discussing barriers to achieving blood pressure control with a 65-year-old woman with hypertension who “does not want to take any medicine”
Collaborating with the regional public health department on an initiative to combat obesity through a community-based exercise program
You are asked to speak to a group of healthcare executives on the NP role. Which of the following provides the strongest support for NP practice?
Number of academic credits earned during the NP program
Evidence of NP practice outcomes
The quantity of clinical hours and type of clinical rotations in the NP program
The professional experience of the person prior to entering the NP program
Ans: Evidence of NP practice outcomes
Rank the following from highest (1) to lowest (4) level of research design.
__Case reports
__Meta-analysis
__Randomized controlled trials
__Expert opinion
1-Case reports 2-Meta-analysis 3-Randomized controlled trials 4-Expert opinion
2-Case reports 1-Meta-analysis 3-Randomized controlled trials 4-Expert opinion
3-Case reports 1-Meta-analysis 2-Randomized controlled trials 4-Expert opinion
4-Case reports 3-Meta-analysis 2-Randomized controlled trials 1-Expert opinion
Ans:
3-Case reports 1-Meta-analysis 2-Randomized controlled trials 4-Expert opinion
In a 46-year-old woman with hypertension and dyslipidemia, choose the correct prevention:
Primary prevention
Secondary prevention
Tertiary prevention
Counseling about reducing risk for sexually transmitted infection __
Skin survey for precancerous lesions __
1-Primary prevention 2-Secondary prevention
1-Secondary prevention 2-Primary prevention
1-Primary prevention 2-Tertiary prevention
1-Tertiary prevention 2-Secondary prevention
Ans: 1-Primary prevention 2-Secondary prevention
In a 66-year-old woman with type 2 diabetes mellitus (T2DM), choose the correct prevention:
Primary prevention
Secondary prevention
Tertiary prevention
1. Administering influenza vaccine __
2. Adjusting therapy to enhance glycemic control __
1-Tertiary prevention 2-Primary prevention
1-Secondary prevention 2-Primary prevention
1-Primary prevention 2-Secondary prevention
1-Primary prevention 2-Tertiary prevention
Ans: 1-Primary prevention 2-Tertiary prevention
In a 25-year-old well woman with a strong family history of T2DM, choose the correct prevention:
Primary prevention
Secondary prevention
Tertiary prevention
1. Checking fasting lipid profile __
2. Teaching the benefits of participating in a consistent program of moderate-intensity physical activity __
1-Primary prevention 2-Secondary prevention
1-Tertiary prevention 2-Secondary prevention
1-Secondary prevention 2-Primary prevention
1-Primary prevention 2-Tertiary prevention
Ans: 1-Secondary prevention 2-Primary prevention
In a 76-year-old man with chronic obstructive pulmonary disease (COPD), choose the correct prevention:
Primary prevention
Secondary prevention
Tertiary prevention
1. Ensuring adequate illumination at home __
2. Screening for physical, emotional, or financial abuse __
1-Primary prevention 2-Secondary prevention
1-Primary prevention 2-Tertiary prevention
1-Tertiary prevention 2-Secondary prevention
1-Secondary prevention 2-Tertiary prevention
Ans: 1-Primary prevention 2-Secondary prevention
Joseph is a 28-year-old man who presents to your practice with a 2 h history of a superficial laceration on his forearm that is approximately 5 cm (2″) that happened when he was replacing a windowpane and was cut by the glass. Physical examination is consistent with history.His record notes a Tdap vaccine given approximately 2 years ago and documentation of a primary tetanus series.
When considering his needs for tetanus immunization today, the NP appreciates that today Joseph should receive:
A Td (tetanus, diphtheria) booster.
A Tdap (tetanus, diphtheria, acellular pertussis) booster.
A dose of TIG (tetanus immune globulin).
No tetanus vaccine.
In a community undergoing a disaster, the use of select vaccines will be prioritized. Match the type of disaster with the priority vaccine:
Immunization against tetanus
Immunization against influenza
Immunization against Hepatitis A
1. Uninjured adults and children evacuated to a crowded group setting __
2. Adults with multiple deep lacerations from flying debris __
3. A community exposed to unsafe water supply after a hurricane __
1. Immunization against tetanus 2. Immunization against influenza 3. Immunization against Hepatitis A
1. Immunization against influenza 2. Immunization against tetanus 3. Immunization against Hepatitis A
1. Immunization against tetanus 2. Immunization against Hepatitis A 3. Immunization against influenza
1. Immunization against Hepatitis A 2. Immunization against tetanus 3. Immunization against influenza
True or False?
1. Immune globulin is a concentrated solution of antibodies derived from pooled donated blood. __
2. Tdap (tetanus, diphtheria, acellular pertussis [Adacel®, Boostrix®]) vaccine should replace a single dose of Td (tetanus, diphtheria) vaccine for most adults who have not previously received a dose of Tdap in order to provide additional protection against pertussis. __
3. Previously unvaccinated adults age 19 through 59 years with diabetes mellitus type 1 or type 2 should be vaccinated against hepatitis B as soon as possible after the diabetes diagnosis is made. __
1. True 2. True 3. False
1. True 2. True 3. True
1. False 2. True 3. False
1. True 2. False 3. False
A 67-year-old man with well-controlled hypertension and dyslipidemia who received one dose of PPSV23 (Pneumovax®) 1 year ago asks about a “new pneumonia shot” he heard about in a TV promotion. You advise that:
He is adequately immunized against pneumococcal disease.
That there is another pneumococcal vaccine available but its use is not advised in older adults due to its adverse effect profile.
He is eligible for a dose of PCV13 (Prevnar®) today to be optimally protected against pneumococcal disease.
In 4 more years, he should receive a second dose of PPSV23.
While counseling a 32-year-old man in good health about influenza vaccination, he reports that he occasionally experiences hives when consuming eggs (e.g., scrambled eggs), but has no reaction when consuming foods that contain eggs (e.g., cake). The NP considers the best course of action is to:
Note the allergy in his records so that immunization will not be offered in the future.
Offer vaccination with trivalent recombinant influenza vaccine (RIV3).
Offer vaccination with live attenuated influenza vaccine (LAIV).
Refer him to a specialist for allergy testing prior to immunization with high-dose trivalent inactivated influenza vaccine (IIV3).
Ans: Offer vaccination with trivalent recombinant influenza vaccine (RIV3).
When considering influenza vaccination for an adult who claims to experience a hive-form reaction when exposed to eggs without a history of angioedema or respiratory distress, which of the following is most appropriate?
Administer any vaccine appropriate for his age and health status
Only offer the recombinant influenza vaccine (RIV3)
Referral for vaccination at an allergy practice.
Do not administer vaccine as it is contraindicated for this patient
Ans: Administer any vaccine appropriate for his age and health status
A 19-year-old woman returns to receive her third dose of the HPV vaccine series. Her first two doses were with the quadrivalent vaccine, but the practice currently only stocks the 9-valent HPV vaccine. The NP considers the best course of action is to:
Complete her vaccination series with the 9-valent vaccine.
Defer completing the vaccination series until the quadrivalent vaccine is available in the practice.
Refer her to a practice where the quadrivalent vaccine is currently available.
Restart the series with the 9-valent vaccine and schedule her next two doses within 6 months.
Ans: Complete her vaccination series with the 9-valent vaccine.
A person with a latent tuberculosis infection (True/False):
1. Does not exhibit any signs or symptoms of active infection. __
2. Can spread the disease to others. __
3. Will have a positive tuberculin skin test. __
4. Will have >50% lifetime risk of developing active tuberculosis. __
1-False 2-True 3-False 4-False
1-True 2-True 3-False 4-False
1-True 2-False 3-True 4-False
1-False 2-False 3-False 4-False
Ans: 1-True 2-False 3-True 4-False
Identify which of the following patients should undergo testing for tuberculosis (Yes/No).
1. A 22-year-old male with HIV. __
2. A healthy 18-year-old woman who lives with her father who was recently diagnosed with active tuberculosis infection. __
3. 45-year-old man who was recently released from prison after 2 years of incarceration. __
4. 32-year-old woman who recently emigrated from Southeast Asia. __
1-No 2-Yes 3-Yes 4-Yes
1-Yes 2-Yes 3-Yes 4-Yes
1-Yes 2-No 3-No 4-Yes
1-No 2-No 3-No 4-No
The diameter of induration surrounding the injection site.
In a 51-year-old woman at average risk of breast cancer, choose the prevention:
Primary prevention
Secondary prevention
Tertiary prevention
1. Counseling about the hazard of tobacco use. __
2. Obtaining breast cancer screening via mammography. __
1-Secondary prevention 2-Primary prevention
1-Tertiary prevention 2-Primary prevention
1-Primary prevention 2-Secondary prevention
1-Tertiary prevention 2-Secondary prevention
Ans: In a 51-year-old woman at average risk of breast cancer, choose the prevention:
Match each example with the appropriate communication skill.
Broad opening/open-ended question
Clarification
Active listening
Restating
1. “You said that you got angry when your boyfriend came home late.” __
2. Use of eye contact and non-verbal cues. __
3. “What’s on your mind?” __
4. “I don’t think I see the connection. Can you explain that to me again?” __
1-Broad opening/open-ended question 2-Clarification 3-Active listening 4-Restating
1-Broad opening/open-ended question 2-Restating 3-Active listening 4-Clarification
1-Restating 2-Clarification 3-Active listening 4-Broad opening/open-ended question
1-Restating 2-Active listening 3-Broad opening/open-ended question 4-Clarification
Ans: 1-Restating 2-Active listening 3-Broad opening/open-ended question 4-Clarification
A 51-year-old woman of European ancestry who has had no primary care for more than 10 years presents to your practice. She has a 40 pack-year cigarette smoking history, currently smoking 1 PPD and reports drinking about 3-4, 12 oz (0.35 L) beers per month. Her history is otherwise unremarkable as is her physical examination. You order the following screening test:
Hemoglobin electrophoresis.
Mammography.
Chest x-ray.
Fasting serum triglycerides.
A 65-year-old Native American man presents for a “physical.” He feels well, denies tobacco or alcohol use, and has not seen a healthcare provider in more than 10 years.
The patient states, “I am a really healthy person. I would not come in except my wife and daughter told me I should have a checkup.” As part of today’s visit, he should be screened for:
Pancreatic cancer.
Hemolytic anemia.
Hepatic sclerosis.
Visual defect.
A 30-year-old woman of Asian ancestry presents for a routine health visit. She is in good health and reports she is concerned about her personal breast and ovarian cancer risk and asks about BRCA gene mutation testing. You advise the following:
BRCA gene mutation testing should be offered to all women who request this evaluation.
A standardized screening questionnaire for BRCA gene mutation such as FHS-7 should be administered today to determine if BRCA gene mutation testing is warranted.
She is not a candidate for this test due to her ethnicity.
A referral to genetic counseling for guidance on BRCA gene mutation testing should be ordered.
Suicide: True or False?
1. Males represent nearly 80% of all completed suicides. __
2. When compared with male suicide attempts, female attempts at suicide are approximately 2-3 times more common. __
3. The highest rate of completed suicide is found in teenage males. __
4. Inquiring about suicidal ideation could precipitate the act. __
1-True 2-True 3-False 4-False
1-True 2-Flase3-False 4-True
1-False 2-True 3-False 4-False
1-False 2-False 3-False 4-False
Ms. Kane is a 25-year-old woman who presents with finger-shaped ecchymotic areas on her right shoulder that are an incidental finding during a physical examination. She denies abuse or assault. The NP’s most appropriate response is:
“Your bruises look as if they were caused by someone grabbing you.”
“Was this an accident?”
“I notice the bruises are in the shape of a hand.”
“How did you fall?”
Ans: “I notice the bruises are in the shape of a hand.”
Mr. Jacobs is a 65-year-old man with COPD and a 60 pack-year history who is currently smoking 1.5 packs of cigarettes per day. He is reading a pamphlet in your office about smoking cessation.You ask him if he has any questions and he states, “I don’t plan to quit smoking at my age. I am too old to quit now. Why bother?” The NP’s most appropriate response is:
Since you have COPD, you really should quit smoking.
You know your lungs will get more damaged if you continue to smoke.
Tell me what you mean by, “I am too old to quit.”
I can provide medication that will help you to quit smoking.
Ans: Tell me what you mean by, “I am too old to quit.”
According to current nationally-recognized recommendations, are the following cancer screenings indicated? Yes or No
1. Annual digital rectal exam as colorectal cancer screening in a 63-year-old man __
2. An initial liquid-based Pap test with HPV cotesting in a 19-year-old woman who is one year post-coitarche __
3. Endometrial biopsy in a 52-year-old woman who is two years post-LMP and who denies vaginal bleeding __
4. Annual prostate specific antigen testing in an 81-year-old man who has hypertension and benign prostatic hypertrophy __
5. Lung cancer screening with low-dose CT (LDCT) for a 60-year-old who is generally in good health who has a 35 pack-year cigarette smoking history who quit smoking 5 years ago __
1-Yes 2-Yes 3-No 4-Yes 5-No
1-No 2-No 3-No 4-Yes 5-No
1-No 2-Yes 3-No 4-Yes 5-No
1-No 2-No 3-No 4-No 5-Yes
Ans: 1-No 2-No 3-No 4-No 5-Yes
A person with a latent tuberculosis infection: (True/False)
1. Does not exhibit any signs or symptoms of active infection. __
2. Can spread the disease to others. __
3. Will have a positive tuberculin skin test. __
4. Will have >50% lifetime risk of developing active tuberculosis. __
1-False 2-True 3-True 4-False
1-True 2-True 3-True 4-True
1-False 2-True 3-False 4-False
1-True 2-False 3-True 4-False
Identify which of the following patients should undergo testing for tuberculosis. (Yes/No)
1. A 22-year-old male with HIV __
2. A healthy 18-year-old woman who lives with her father who was recently diagnosed with active tuberculosis infection __
3. A 45-year-old man who was recently released from prison after 2 years of incarceration __
4. A 32-year-old woman who recently immigrated from Southeast Asia __
1-Yes 2-No 3-Yes 4-No
1-Yes 2-No 3-No 4-No
1-No 2-No 3-Yes 4-No
1-Yes 2-Yes 3-Yes 4-Yes
According to current nationally recognized recommendations (True/False):
1. Screening for lung cancer with a low-dose CT scan is indicated for a 62-year-old man in good health who is a current smoker and has a 40 pack-year smoking history. __
2. PSA testing is indicated for a 68-year-old man with end-stage heart failure. __
3. PV test and Pap test are recommended for a 37-year-old woman who had negative cervical cytology results 5 years ago. __
A 24-year-old woman who completed the HPV vaccination regimen 2 years ago is not recommended to undergo cervical cancer screening until she reaches 30 years of age. __
1-True 2-False 3-False 4-True
1-True 2-False 3-True 4-True
1-True 2-False 3-True 4-False
1-False 2-False 3-False 4-True
Match each definition with the appropriate term:
Prevalence
Incidence
False positive
False negative
Specificity
Sensitivity
1. Refers to the ability of a test to correctly identify those with a condition. __
2. Refers to the ability of a test to correctly identify those without a condition. __
3. Proportion or number of individuals with a condition at a given time. __
4. Number of new cases occurring within a period of time. __
1-Prevalence 2-False negative 3-Sensitivity 4-Incidence
1-Sensitivity 2-Specificity 3-Prevalence 4-Incidence
1-False positive 2-False negative 3-Specificity 4-Incidence
Ans: 1-Sensitivity 2-Specificity 3-Prevalence 4-Incidence
A 78-year-old woman presents with fatigue, spoon-shaped nails and the following laboratory results.
-Hb=9 g/dL (90 g/L)
-Hct=28.1% (0.281 proportion)
-RBC=2.4 million/mm3
-MCV=70 fL
-MCHC=24.2 g/dL (242 g/L)
-RDW=19% (0.19 proportion)
A critical causative diagnosis to consider as origin of her anemia is:
Gastrointestinal blood loss.
Micronutrient malabsorption.
Chronic ileitis.
Folic acid deficiency.
Ans: Gastrointestinal blood loss.
Which of the following represents the optimal advice to a patient who is taking oral iron therapy to maximize the medication’s effectiveness?
Take your medication with an antacid.
Take your medication on an empty stomach.
Take your medication after the largest meal of the day.
Take your medication with a large glass of milk.
Ans: Take your medication on an empty stomach.
A 68-year-old woman presents with a 6-month history of increasingly severe peripheral numbness and oral irritation.
Hemogram results are as follows.
-Hb=6.2 g/dL (62 g/L)
-Hct=20% (0.2 proportion)
-RBC=2.1 million/mm3
-MCV=132 fL
-MCHC=32.4 g/dL (324 g/L)
-RDW=19% (0.19 proportion)
Physical exam reveals pale conjunctiva, a grade 2/6 systolic ejection murmur over the precordium without radiation, and a smooth, red tongue.
In the above-mentioned patient has not been present on previous examination. As a result, you consider that this is likely a _________ murmur and will resolve with anemia treatment.
Pathologic
Hemic
Venous hum
The most likely cause of this anemia is:
Based on the below scenario:
A 68-year-old woman presents with a 6-month history of increasingly severe peripheral numbness and oral irritation.
Hemogram results are as follows.
-Hb=6.2 g/dL (62 g/L)
-Hct=20% (0.2 proportion)
-RBC=2.1 million/mm3
-MCV=132 fL
-MCHC=32.4 g/dL (324 g/L)
-RDW=19% (0.19 proportion)
Physical exam reveals pale conjunctiva, a grade 2/6 systolic ejection murmur over the precordium without radiation, and a smooth, red tongue.
Vitamin B12 deficiency.
Iron deficiency.
Hemolysis.
Chronic disease.
A 65-year-old woman with rheumatoid arthritis who is on optimized therapy and continues to have significant symptoms presents with the following hemogram.
-Hb=10.1 g/dL (12-14 g/dL)
101 g/L (120-140 g/L)
-Hct=32% (36-42%)
0.32 proportion (0.36-0.42 proportion)
-RBC=3.2 million/mm3 (4.2-5.4 million/mm3)
– MCV=82 fL (80-96 fL)
-RDW=12.8% (11-15%)
0.128 proportion (0.11-0.15 proportion)
-Reticulocytes=0.7% (1-2%)
0.007 proportion (0.01-0.02 proportion)
These findings are most consistent with:
Iron deficiency anemia.
Folate deficiency anemia.
Anemia of chronic disease.
Alpha thalassemia minor.
Ans: Anemia of chronic disease.
You see Maria, a a 32-year-old well woman of Mediterranean ancestry. Hemogram results are as follows:
-Hb=10.6 g/dL (12-14 g/dL)
106 g/L (120-140 g/L)
-Hct=32% (36-42%)
0.32 proportion (0.36-0.42 proportion)
-RBC=5.2 million/mm3 (3.2-4.3 million/mm3)
-MCV=71 fL (80-96 fL)
-MCHC=25.2 g/dL (31-37 g/dL)
252 g/L [310-370 g/L]
-RDW=12% (<15%)
0.12 proportion (<0.15 proportion)
These findings are most consistent with:
Iron deficiency anemia.
Cooley’s anemia.
Beta thalassemia minor.
Acute blood loss.
The use of all of the following nutritional supplements is potentially associated with increased bleeding risk and should be discontinued at least 7‒10 days prior to elective surgical procedure. (True/False)
1. Ginseng __
2. Gingko __
3. Fish oil __
4. Vitamin D __
1-True 2-False 3-True 4-True
1-True 2-True 3-True 4-False
1-False 2-False 3-True 4-True
1-False 2-False 3-True 4-False
Ans: 1-True 2-True 3-True 4-False
Primary care of Sarah, a 27-year-old woman with beta thalassemia minor, should include:
Prescribing a low-dose iron supplement to counteract microcytosis.
An evaluation of hemoglobin electrophoresis every 5 years.
Advising taking a multivitamin with high-dose folate supplementation daily.
Offering genetic counseling prior to pregnancy.
Ans:
Offering genetic counseling prior to pregnancy.
A 37-year-old woman with ulcerative colitis with poor symptom control without rectal bleeding presents with the following hemogram:
-Hg=9.9 g/dL (12-14 g/dL) (99 g/L [120-140 g/dL])
-MCHC=33 g/dL (31-37 g/dL) (330 g/L [310-370 g/L])
-MCV=86 fL (80-96 fL)
-RDW=12% (11%-15%) (0.12 proportion [0.11-0.15 proportion])
These findings are most consistent with:
Iron deficiency.
Beta thalassemia minor.
Anemia of chronic disease.
Pernicious anemia.
Ans: Anemia of chronic disease.
A 67-year-old man taking NSAIDs daily for back pain and reporting fatigue presents with the following hemogram:
-Hg=8.4 g/dL (12-14 g/dL) (84 g/L [120-140 g/dL])
-MCHC=26 g/dL (31-37 g/dL) (260 g/L [310-370 g/L])
-MCV=69 fL (80-96 fL)
-RDW=19% (11%-15%) (0.19 proportion [0.11-0.15 proportion])
These findings are most consistent with:
Iron deficiency anemia.
Beta thalassemia minor.
Vitamin B12 deficiency.
Drug-induced macrocytosis.
You see a 47-year-old man in urgent care who has hypertension, dyslipidemia, and depression. He states, “I am on a big list of medications but I am not sure of all the names.” He also has a history of penicillin allergy with a hive-form reaction. He has not taken a systemic antimicrobial in more than a year and denies recent hospitalization. When developing a treatment plan for acute bacterial rhinosinusitis, you consider prescribing the following course of an oral antimicrobial
A 5-day course of clarithromycin.
A 7-day course of doxycycline.
A 10-day course of amoxicillin- clavulanate.
A 7-day course of moxifloxacin.
Ans: A 7-day course of doxycycline.
Sandra is a 45-year-old well woman diagnosed with a left-sided unilateral acute otitis media 10 days ago and treated with an antimicrobial.
She is seen today with a report of resolution of ear pain, but with persistent sensation of ear fullness and diminished ability to discriminate speech in the affected ear.
Anticipated findings on today’s physical examination include:
Erythema of the ear canal.
Weber test lateralizing to the affected ear
Discomfort on tragus pull.
Anterior cervical lymphadenopathy on the affected side.
Feedback
Ans: Weber test lateralizing to the affected ear
Sandra’s hearing loss is best described as:
Based on the below scenario:
Sandra is a 45-year-old well woman diagnosed with a left-sided unilateral acute otitis media 10 days ago and treated with an antimicrobial.
She is seen today with a report of resolution of ear pain, but with persistent sensation of ear fullness and diminished ability to discriminate speech in the affected ear.
Sensorineural.
Conductive.
Auditory processing.
Mixed origin.
For Sandra, which of the following represents the best advice for this point?
Based on the below scenario:
Sandra is a 45-year-old well woman diagnosed with a left-sided unilateral acute otitis media 10 days ago and treated with an antimicrobial.
She is seen today with a report of resolution of ear pain, but with persistent sensation of ear fullness and diminished ability to discriminate speech in the affected ear.
She should have a second course of antimicrobial therapy.
A short course of an oral corticosteroid should be prescribed.
The sensation of ear fullness is an anticipated finding.
She should be seen by an otolaryngology specialist.
Ans: The sensation of ear fullness is an anticipated finding.
Hank is a 58-year-old man who presents with a chief complaint of bilateral itchy eyes occurring intermittently throughout the year. Exam reveals 20/30 vision OD (right eye), OS (left eye), OU (both eyes) with corrective lenses bilateral hyperemic bulbar and palpebral conjunctiva, and a small amount of rope-like pale yellow discharge.
These findings are most consistent with:
Bacterial conjunctivitis.
Blepharoconjunctivitis.
Allergic conjunctivitis.
Dry-eye syndrome.
The most appropriate treatment option for Hank is the use of:
Based on the below scenario:
Hank is a 58-year-old man who presents with a chief complaint of bilateral itchy eyes occurring intermittently throughout the year. Exam reveals 20/30 vision OD (right eye), OS (left eye), OU (both eyes) with corrective lenses bilateral hyperemic bulbar and palpebral conjunctiva, and a small amount of rope-like pale yellow discharge.
Ocular antimicrobial.
Lubricating eye solution
Ocular antihistamine.
Systemic decongestant.
Edgar is a 75-year-old man with a 60 pack-year history of cigarette smoking and COPD who presents with a chief complaint of a “sore” on the base of his tongue. This lesion has been present for a number of months, remaining relatively stable in size and is not painful. Physical examination reveals a painless ulcerated lesion with indurated margin and is accompanied by a firm, nontender submandibular node. His current medications include inhaled corticosteroids with a long-acting beta2-agonist.
This clinical scenario is most consistent with:
Syphilitic chancre.
Aphthous stomatitis.
Squamous cell carcinoma.
Oral candidiasis.
Risk factors for Edgar’s condition include:
Based on the below scenario:
Edgar is a 75-year-old man with a 60 pack-year history of cigarette smoking and COPD who presents with a chief complaint of a “sore” on the base of his tongue. This lesion has been present for a number of months, remaining relatively stable in size and is not painful. Physical examination reveals a painless ulcerated lesion with indurated margin and is accompanied by a firm, nontender submandibular node. His current medications include inhaled corticosteroids with a long-acting beta2-agonist.
Recent high-risk sexual contact.
Current use of an inhaled corticosteroid.
Long-term HPV-16 infection.
Chronic irritation from poorly-fitting dentures.
Ans:
Long-term HPV-16 infection.
The next step in Edgar’s care should include:
Based on the below scenario:
Edgar is a 75-year-old man with a 60 pack-year history of cigarette smoking and COPD who presents with a chief complaint of a “sore” on the base of his tongue. This lesion has been present for a number of months, remaining relatively stable in size and is not painful. Physical examination reveals a painless ulcerated lesion with indurated margin and is accompanied by a firm, nontender submandibular node. His current medications include inhaled corticosteroids with a long-acting beta2-agonist.
An oral antifungal.
Referral for lesion biopsy.
Use of topical anesthetic paste.
Serologic testing to confirm the diagnosis.
Ans: Referral for lesion biopsy.
The function of which of the following cranial nerves is being tested with the following patient requests?
A. CN I
B. CN XI
C. CN III
D. CN VII
E. CN XII
1. Puff out your cheeks. __
2. Do you recognize this scent? __
3. Without moving your head, follow my finger with your eyes. __
4. Shrug your shoulders. __
5. Stick out your tongue. __
1-D 2-A 3-C 4-B 5-E
1-B 2-A 3-D 4-C 5-E
1-A 2-E 3-C 4-D 5-B
1-C 2-D 3-B 4-A 5-E
Matthew is a 29-year-old man who presents with a 6-hour history of sudden onset of inability to raise his eyebrow or smile on the right side. He also reports decreased lacrimation in the right eye and difficulty closing the right eyelid. The rest of his health history and physical examination is otherwise unremarkable.
This likely represents paralysis of cranial nerve (CN):
III.
VIII.
IV.
VII.
Which of the following is the most appropriate next step in Matthew’s care?
Based on the below scenario:
Matthew is a 29-year-old man who presents with a 6-hour history of sudden onset of inability to raise his eyebrow or smile on the right side. He also reports decreased lacrimation in the right eye and difficulty closing the right eyelid. The rest of his health history and physical examination is otherwise unremarkable.
Emergent referral for neuroimaging
Initiating a course of oral corticosteroids
Prescribing a short course of high-dose antiviral therapy
Referral to a neurology specialist within the next 24‒48 hours
Feedback
Ans: Initiating a course of oral corticosteroids
You see a 55-year-old woman who presents for a health maintenance visit. She has longstanding myopia and newer-onset presbyopia, both corrected with eyeglasses. She is normotensive and without ocular complaint. You anticipate the following on today’s eye exam:
Retinal arteries wider than veins.
Equal, sluggish pupillary response.
Sharp disc margins.
Lid ectropion.
Ans:
A deeply-cupped optic disc
Match each vision alteration with the most likely etiology.
A. Macular degeneration
B. Untreated open-angle glaucoma
C. Proliferative diabetic retinopathy
1. Peripheral vision loss __
2. Floating spots in visual field Macular degeneration Untreated open-angle glaucoma __
3. Central vision loss __
1-B 2-C 3-A
1-A 2-B 3-C
1-C 2-B 3-A
1-B 2-A 3-C
Match the following select ophthalmologic tests with the appropriate indication.
A. Amsler grid test
B. Snellen chart
C. Slit-lamp examination
D. Tonometry
1. Evaluation of anterior eye structures, including cornea, conjunctiva, sclera, and iris __
2. General visual acuity screen __
3. Early detection of macular degeneration __
4. Measurement of intraocular pressure, glaucoma screening test __
1-B 2-C 3-D 4-A
1-C 2-B 3-A 4-D
1-A 2-C 3-B 4-D
1-D 2-C 3-B 4-A
During a clinical encounter with a 78-year-old man who has presbycusis, the NP considers that communication will be enhanced by all of the following except:
Maintaining eye contact with the patient.
Ensuring the patient can see the NP’s face clearly.
Playing soft music in the background.
Providing adequate illumination in the exam room.
Ans: Playing soft music in the background.
Ans: Amoxicillin-clavulanate (Augmentin®).
Ans: Living in a rural setting.
Macular degeneration would most likely be found in which of the following patients?
A 72-year-old woman who smoked cigarettes up until 10 years ago
A 54-year-old man with a family history of glaucoma
A 64-year-old man with well-controlled hypertension
A 32-year-old woman recently diagnosed with type 2 diabetes mellitus
Ans: A 72-year-old woman who smoked cigarettes up until 10 years ago
Ans: An intranasal corticosteroid.
Identify the following types of skin lesions with its corresponding description:
A. Macule
B. Papule
C. Plaque
D. Cyst
E. Wheal
F. Purpura
1. Single, uniformly brown-colored, slightly raised, irregular-shaped with defined borders, 6 mm in diameter. Patient states “That mole on my shoulder hasn’t changed in years.” __
2. Single, flat, non-palpable area of discoloration, irregularly-shaped, and 0.5 cm at the widest diameter. Patient states “I’ve had that spot on my lower lip for years.” __
3. Single, firm, smooth, raised, dome-shaped, fluid-filled, flesh-colored encapsulated lesion of 1.5 cm in diameter on back of neck. Patient states “A smelly, liquid leaks out of it sometimes.” __
4. Raised, irregular-shaped with defined borders, different color than surrounding skin, patches of >2 cm in diameter, located over the knees. Patient states “These patches have been here for years. When I pick at one, it bleeds just a drop or two.” __
5. Flat, non-blanchable, confluent, purple-colored irregular-shaped lesions on skin ranging 2?20 mm in size. Patient states “These purple splotches appeared on my arms and legs following a round of chemotherapy.” __
6. Clustered, smooth, slightly-raised, circumscribed, pruritic skin-colored lesions of various sizes up to 2 cm, surrounded by area of erythema. Patient states “This itchy rash appeared all over my body a few days after starting my antibiotic.” __
1-C 2-B 3-A 4-E 5-F 6-D
1-B 2-F 3-A 4-D 5-C 6-D
1-B 2-A 3-D 4-C 5-F 6-E
1-A 2-E 3-D 4-B 5-F 6-C
Match each dermatologic term with the description.
A. Annular
B. Scattered
C. Confluent or coalescent
D. Clustered
E. Linear
1. In streaks such as the typical phytodermatitis caused by exposure to plant oil (urushiol) contained in poison ivy, poison oak, poison sumac. __
2. Occurring in a group without pattern, such as the lesions seen in an outbreak of herpes simplex type 1 (HSV-1, “cold sore”). __
3. Generalized over body without a specific pattern or distribution, as seen in a viral exanthem such as rubella or roseola. __
4. Multiple lesions blending together, such as the lesions seen in psoriasis vulgaris. __
5. In a ring, often seen in the characteristic “Bull’s Eye” lesion seen in Lyme disease. __
1-A 2-D 3-E 4-C 5-B
1-B 2-C 3-E 4-D 5-A
1-E 2-D 3-B 4-C 5-A
1-C 2-A 3-B 4-D 5-E
A 60-year-old otherwise well man presents with a dermatologic condition. Which of the following conditions requires biopsy to confirm the diagnosis?
Scaling flesh-colored lesions in a cluster, ranging in size from 3?10 mm on the dorsal aspect of the hand, present for a number of months, without patient complaint
Well-demarcated round-to-oval erythematous coin-shaped plaques approximately 10 mm in diameter on the anterior aspects of the lower legs described as being intermittently itchy that has been present for a number of months.
Painless ulcerated lesion approximately 1.5 cm over the sternum that has been present for a number of weeks.
Oval plaque that is approximately 5 cm in diameter with a central wrinkled salmon-colored area and a dark red peripheral zone on the anterior trunk that has been present for 5 days without patient complaint.
Match each treatment option with the relevant condition.
A. Permethrin lotion
B. Medium-potency topical corticosteroid
C. Imiquimod cream
D. Topical ketoconazole
E. Topical metronidazole
1. Psoriasis Vulgaris __
2. Scabies __
3. Verruca Vulgaris __
4. Tinea Pedis __
5. Rosacea __
1-C 2-B 3-A 4-D 5-E
1-D 2-C 3-A 4-B 5-E
1-A 2-B 3-C 4-D 5-E
1-B 2-A 3-C 4-D 5-E
dentify each condition with the most likely location.
A. Pityriasis rosea
B. Psoriasis vulgaris
C. Actinic keratosis
D. Scabies
E. Eczema
1. Antecubital fossa __
2. Anterior surface of knees __
3. Sun-exposed areas __
4. Over waistband area __
5. Usually preceded by herald patch on the trunk __
1-A 2-B 3-D 4-E 5-C
1-E 2-B 3-C 4-D 5-A
1-C 2-B 3-D 4-E 5-A
1-D 2-A 3-B 4-E 5-C
Ana is a 22-year-old well woman who presents with a four-day history of an intense itch with skin lesions on hands and arms as well as her right cheek. She has used an over-the-counter hydrocortisone cream on the affected area with little effect, and denies any other symptoms or previous history of similar rash. Ana denies recent travel and exposure to new creams, soaps, or medications. She works as a landscaper. When considering a diagnosis of phytodermatitis due to exposure to urushiol (poison ivy, poison oak, poison sumac), you anticipate finding three of the following.
Fever and generalized malaise
Vesicles
Crusts
Fissures
Most of the lesions in a linear pattern
When evaluating Ana, you note that approximately 20% total body surface area is affected. You consider treatment with:
Based on the Evaluation Below:
Ana is a 22-year-old well woman who presents with a four-day history of an intense itch with skin lesions on hands and arms as well as her right cheek. She has used an over-the-counter hydrocortisone cream on the affected area with little effect, and denies any other symptoms or previous history of similar rash. Ana denies recent travel and exposure to new creams, soaps, or medications. She works as a landscaper.
Topical application of a medium-potency corticosteroid cream
An oral antihistamine
A systemic corticosteroid
A topical antihistamine
Ans: A systemic corticosteroid
A 28-year-old woman who works in food service presents with a chief complaint of an on-the-job injury caused when her right forearm was accidentally exposed to steam. Approximately 2% body surface area is involved. You assess the injury as a partial thickness (second degree) burn and describe the skin lesion as appearing:
Reddened easily blanched with gentle pressure
Red, moist with peeling borders and scattered bulla
Thickened, hypopigmented tissue
Vesicular with hyperpigmentation
Ans: Red, moist with peeling borders and scattered bulla
You see a 20-year-old college wrestler with purulent cellulitis. He reports that a couple of his teammates were recently diagnosed with MRSA skin infections. Initial treatment options would include all of the following except:
Trimethoprim-sulfamethoxazole (Bactrim®)
Clindamycin (Cleocin®)
Doxycycline (Doryx®)
Levofloxacin (Levaquin®)
Match each description with the most appropriate diagnosis.
A. Psoriasis
B. Viral exanthem
C. Basal cell carcinoma
1. A 64-year-old ex-truck driver who reports a persistent open sore on his left forearm that repeatedly bleeds and then crusts over. __
2. A 36-year-old man who presents with a raised patch of skin on his right elbow covered with silvery-white scaly skin. He reports the area is “very itchy.” __
A 14-month-old unimmunized girl without recent medication use who presents with a diffuse rash and low-grade fever. __
Match each description with the most appropriate diagnosis.
A. Psoriasis
B. Viral exanthem
C. Basal cell carcinoma
1-C 2-A 3-B
Untreated hyperthyroidism or hypothyroidism or both?
Hypo
Hyper
Hypo/Hyper
1. Dry Skin __
2. Fine tremor __
3. Hypoactive deep tendon reflexes (DTR) __
4. Mood or mentation change __
5. Menorrhagia __
6. Exophath1-
Hyper 3-Hyper 4-Hypo/Hyper 5-Hypo 6-Hypo/Hyperalmos __
1-Hyper 2-Hyper 3-Hyper 4-Hypo/Hyper 5-Hypo 6-Hypo/Hyper
1-Hypo/Hyper 2-Hypo 3-Hyper 4-Hypo/Hyper 5-Hypo 6-Hypo/Hyper
1-Hypo 2-Hyper 3-Hypo 4-Hypo/Hyper 5-Hypo 6-Hyper
1-Hyper 2-Hypo 3-Hypo/Hyper 4-Hypo 5-Hypo 6-Hypo/Hyper
1-Hypo 2-Hyper 3-Hyper 4-Hypo/Hyper 5-Hypo 6-Hypo/Hyper
Ans: 1-Hypo 2-Hyper 3-Hypo 4-Hypo/Hyper 5-Hypo 6-Hyper
You see a 38-year-old woman with hypothyroidism who is currently taking levothyroxine 75 mcg/d with excellent adherence, stating, “I take the medicine every morning on an empty stomach with a big glass of water.” She is feeling well. Results of today’s laboratory testing includes a TSH=4.5 mIU/mL. The next best step in her care is to:
Continue on the same levothyroxine dose and obtain a repeat TSH in 1 year
Decrease the levothyroxine dose by 25 mcg/d and repeat a TSH in 1 month
Increase the levothyroxine dose by 25 mcg/d and repeat a TSH in 2 months
Provide counseling to take the medication with breakfast
Ans: ncrease the levothyroxine dose by 25 mcg/d and repeat a TSH in 2 months
Mrs. Lange is a 79-year-old woman with a >20-year history of well-controlled hypertension and dyslipidemia, currently taking an ACE inhibitor, low-dose thiazide diuretic, and a statin. She presents today with a chief complaint of a 6-month history of progressive symptoms, including fatigue, difficulty initiating and maintaining sleep, increased difficulty with raising her arms above her head, and a sensation of “my heart not beating right, sometimes I feel like it’s going to hop right out of my chest.” She denies shortness of breath, chest pain, cough, or difficulty breathing when supine and admits to “losing weight without even trying.” Cardiac examination reveals an irregularly irregular cardiac rhythm, without S3, S4, or murmur and no neck vein distention.The result of Mrs. Lange’s electrocardiogram is consistent with:
Sinus tachycardia
Multifocal atrial tachycardia
First-degree heart block
Atrial fibrillation
The remainder of her physical examination reveals flat affect, fine tremor, 3-4+ DTR response, mild proximal muscle weakness, symmetric thyroid enlargement without tenderness or mass and a 10-lb (4.5-kg) weight loss since her last visit 8 months ago. The remainder of Mrs. Lange’s examination is at her baseline. Which of the following is the most likely diagnosis?
Based on the Physical Examination Below:
Mrs. Lange is a 79-year-old woman with a >20-year history of well-controlled hypertension and dyslipidemia, currently taking an ACE inhibitor, low-dose thiazide diuretic, and a statin. She presents today with a chief complaint of a 6-month history of progressive symptoms, including fatigue, difficulty initiating and maintaining sleep, increased difficulty with raising her arms above her head, and a sensation of “my heart not beating right, sometimes I feel like it’s going to hop right out of my chest.” She denies shortness of breath, chest pain, cough, or difficulty breathing when supine and admits to “losing weight without even trying.” Cardiac examination reveals an irregularly irregular cardiac rhythm, without S3, S4, or murmur and no neck vein distention.
Thyrotoxicosis
Statin-induced myopathy
Heart failure
Hypothyroidism
Choose the two most important tests to help support Mrs. Lange’s diagnosis.
Based on the Physical Examination Below:
Mrs. Lange is a 79-year-old woman with a >20-year history of well-controlled hypertension and dyslipidemia, currently taking an ACE inhibitor, low-dose thiazide diuretic, and a statin. She presents today with a chief complaint of a 6-month history of progressive symptoms, including fatigue, difficulty initiating and maintaining sleep, increased difficulty with raising her arms above her head, and a sensation of “my heart not beating right, sometimes I feel like it’s going to hop right out of my chest.” She denies shortness of breath, chest pain, cough, or difficulty breathing when supine and admits to “losing weight without even trying.” Cardiac examination reveals an irregularly irregular cardiac rhythm, without S3, S4, or murmur and no neck vein distention.
Serum creatine kinase
Serum electrolytes
Serum thyroid stimulating hormone
B-type natriuretic peptide
Free thyroxine (FT4)
Ans: Serum thyroid stimulating hormone
Free thyroxine (FT4)
Ans: Primary hyperparathyroidism.
Examination of a 56-year-old woman identifies a palpable thyroid mass of relatively fixed position. TSH level is within normal limits. Ultrasound reveals a solid mass of approximately 5 cm in size. Which of the following is the most appropriate next course of action?
Watch and wait with rescan in 6 months
Initiate levothyroxine therapy
Refer for fine-needle aspiration biopsy
Refer for radioiodine ablation
Ans: Refer for fine-needle aspiration biopsy
You see a 46-year-old woman with hypothyroidism who is currently being treated with levothyroxine at 100 mcg/d. She insists that she takes her medicine every morning. A laboratory test reveals that her TSH is 0.3 mIU/L (NL=0.4-4.0 mIU/L). You recommend:
Maintaining the levothyroxine dose and reevaluate in 2 months
Increasing the levothyroxine dose and reevaluate in 2 months
Decreasing the levothyroxine dose and reevaluate in 2 months
Discontinuing levothyroxine therapy and reevaluate in 6 months
ans: Decreasing the levothyroxine dose and reevaluate in 2 months
Katie is a 33-year-old woman who reports a 10-year history of unilateral, pulsing headache that lasts about 6-10 hours, occurring 3-4 times per month. The headache is typically preceded by a gradual onset of paresthesia affecting the ipsilateral face and arm, which lasts about 20 minutes.
She reports severe photophobia and phonophobia as well as left-sided cephalgia during the 6-10 h headache duration. She states the headaches appear randomly. As a result of her headaches, Katie typically needs to either call in sick or leave work early at least once a month due to headache.
Katie has used OTC medications with partial relief of pain but continued photo- and phonophobia. She is currently headache-free and neurological exam is within normal limits. Katie’s presentation is consistent with:
Migraine with aura
Tension-type headache
Cluster headache
Intracranial lesion
Katie asks if she needs “any tests to see what causes my headaches.” You respond that she should:
Based on the Scenario Below:
Katie is a 33-year-old woman who reports a 10-year history of unilateral, pulsing headache that lasts about 6-10 hours, occurring 3?4 times per month. The headache is typically preceded by a gradual onset of paresthesia affecting the ipsilateral face and arm, which lasts about 20 minutes.
She reports severe photophobia and phonophobia as well as left-sided cephalgia during the 6-10 h headache duration. She states the headaches appear randomly. As a result of her headaches, Katie typically needs to either call in sick or leave work early at least once a month due to headache.
Katie has used OTC medications with partial relief of pain but continued photo-and phonophobia. She is currently headache-free and neurological exam is within normal limits.
Have head CT conducted
Keep a headache diary for the next month
Be promptly referred to a neurologist
Have head MRI conducted
Ans: Keep a headache diary for the next month
Given Katie’s clinical presentation, you prescribe which of the following? Choose all that apply.
Based on the Scenario Below:
Katie is a 33-year-old woman who reports a 10-year history of unilateral, pulsing headache that lasts about 6-10 hours, occurring 3?4 times per month. The headache is typically preceded by a gradual onset of paresthesia affecting the ipsilateral face and arm, which lasts about 20 minutes.
She reports severe photophobia and phonophobia as well as left-sided cephalgia during the 6-10 h headache duration. She states the headaches appear randomly. As a result of her headaches, Katie typically needs to either call in sick or leave work early at least once a month due to headache.
Katie has used OTC medications with partial relief of pain but continued photo-and phonophobia. She is currently headache-free and neurological exam is within normal limits.
An oral triptan
Migraine prophylactic therapy
An oral NSAID
A short course of a systemic corticosteroid
Ans: An oral triptan,
Migraine prophylactic therapy
An oral NSAID
Katie requests advice on family planning. She has not been pregnant in the past. Given her history, which of the following is the least desirable contraceptive form for Katie?
Based on the Scenario Below:
Katie is a 33-year-old woman who reports a 10-year history of unilateral, pulsing headache that lasts about 6-10 hours, occurring 3?4 times per month. The headache is typically preceded by a gradual onset of paresthesia affecting the ipsilateral face and arm, which lasts about 20 minutes.
She reports severe photophobia and phonophobia as well as left-sided cephalgia during the 6-10 h headache duration. She states the headaches appear randomly. As a result of her headaches, Katie typically needs to either call in sick or leave work early at least once a month due to headache.
Katie has used OTC medications with partial relief of pain but continued photo-and phonophobia. She is currently headache-free and neurological exam is within normal limits.
Levonorgestrel IUD (Skyla®, Lilleta®, Mirena®)
Copper IUD (ParaGard®).
Combined estrogen-progestin oral contraceptive.
A progestin-only implant (Nexplanon®).
Ans: Combined estrogen-progestin oral contraceptive.
Mrs. Jensen is an 82-year-old woman with generalized osteoarthritis and systolic hypertension who presents with a 3-day history of right-sided headache with accompanying right-sided jaw pain on chewing. OTC analgesics have provided little relief. She states she is eating little due to the pain on chewing but is taking liquids without difficulty. Mrs. Jensen reports “I can hardly wash my hair, my scalp is so sore.” Physical examination reveals: BP=168/88 mm Hg bilateral, P=88 regular, RR=18, alert, appears uncomfortable with poorly-groomed hair on the right only PERLA, cranial nerve function II‒XII intact, remaining neurological exam WNL, carotid upstroke within normal limits without bruit. There is a tender, palpable, pulseless structure in the right temple area. Mrs. Jensen’s clinical presentation is most consistent with:
Postherpetic neuralgia.
Transient ischemic attack.
Giant cell arteritis.
Acute venous occlusion.
Which of the following represents the best choice of initial test to support Mrs. Jensen’s presumptive diagnosis?
Based on the scenario below:
Mrs. Jensen is an 82-year-old woman with generalized osteoarthritis and systolic hypertension who presents with a 3-day history of right-sided headache with accompanying right-sided jaw pain on chewing. OTC analgesics have provided little relief. She states she is eating little due to the pain on chewing but is taking liquids without difficulty. Mrs. Jensen reports “I can hardly wash my hair, my scalp is so sore.” Physical examination reveals: BP=168/88 mm Hg bilateral, P=88 regular, RR=18, alert, appears uncomfortable with poorly-groomed hair on the right only PERLA, cranial nerve function II‒XII intact, remaining neurological exam WNL, carotid upstroke within normal limits without bruit. There is a tender, palpable, pulseless structure in the right temple area.
Erythrocyte sedimentation rate
Enhanced contrast brain MRI
Head CT without contrast
Arterial biopsy
Ans: Erythrocyte sedimentation rate
As you develop a treatment plan for Mrs. Jensen, you consider that likely:
Based on the scenario below:
Mrs. Jensen is an 82-year-old woman with generalized osteoarthritis and systolic hypertension who presents with a 3-day history of right-sided headache with accompanying right-sided jaw pain on chewing. OTC analgesics have provided little relief. She states she is eating little due to the pain on chewing but is taking liquids without difficulty. Mrs. Jensen reports “I can hardly wash my hair, my scalp is so sore.” Physical examination reveals: BP=168/88 mm Hg bilateral, P=88 regular, RR=18, alert, appears uncomfortable with poorly-groomed hair on the right only PERLA, cranial nerve function II‒XII intact, remaining neurological exam WNL, carotid upstroke within normal limits without bruit. There is a tender, palpable, pulseless structure in the right temple area.
NSAIDs will be helpful
Reducing her blood pressure is important
Long-term, high-dose systemic corticosteroid therapy will be needed
Opioid use is contraindicated
Ans: Long-term, high-dose systemic corticosteroid therapy will be needed
Which of the following is a potential serious complication of Mrs. Jensen’s presumptive diagnosis?
Based on the scenario below:
Mrs. Jensen is an 82-year-old woman with generalized osteoarthritis and systolic hypertension who presents with a 3-day history of right-sided headache with accompanying right-sided jaw pain on chewing. OTC analgesics have provided little relief. She states she is eating little due to the pain on chewing but is taking liquids without difficulty. Mrs. Jensen reports “I can hardly wash my hair, my scalp is so sore.” Physical examination reveals: BP=168/88 mm Hg bilateral, P=88 regular, RR=18, alert, appears uncomfortable with poorly-groomed hair on the right only PERLA, cranial nerve function II‒XII intact, remaining neurological exam WNL, carotid upstroke within normal limits without bruit. There is a tender, palpable, pulseless structure in the right temple area.
Hemiparesis
Arthritis
Blindness
Anterior uveitis
When counseling a patient about lifestyle modifications to prevent migraines, the NP recommends:
Using tinted glasses to minimize glare and bright lights
Substituting artificial sweeteners for cane sugar
Avoiding regular exercise for at least one week after each migraine episode
Moving to a high-altitude environment
Ans: Using tinted glasses to minimize glare and bright lights
Ans: Eliminate the incidence of headaches
Anticipated clinical findings in acute appendicitis for Jordan, an otherwise well 24-year-old man with a BMI=32 kg/m2 include all of the following except:
Leukocytosis with neutrophilia and bandemia
Positive obturator and psoas signs
A 2-hour history of sudden onset of vomiting and generalized abdominal pain accompanied by fever
A 12-hour history of epigastric discomfort and anorexia that gradually shifts to nausea and right lower quadrant abdominal pain
Mr. Lam, a 78-year-old man with longstanding GERD, presents with a 1-month history of “feeling like the food gets stuck way down in my throat.” This sensation occurs with meats and other solid food types and less likely with softer or liquid foods. He denies nausea, vomiting, constipation, diarrhea, aspiration, or melena. His physical examination is unremarkable. A hemogram today reveals a microcytic hypochromic anemia with an elevated RDW. The most likely etiology of this anemia is:
Anemia of chronic disease
Vitamin B12 deficiency
Iron deficiency
Acute blood loss
All of the following diagnostic studies are available as part of Mr. Lam’s evaluation. Rank from 1 (most helpful) to 3 (least helpful) as these tests pertain to the evaluation of Mr. Lam’s symptoms.
Based on the scenario below:
Mr. Lam, a 78-year-old man with longstanding GERD, presents with a 1-month history of “feeling like the food gets stuck way down in my throat.” This sensation occurs with meats and other solid food types and less likely with softer or liquid foods. He denies nausea, vomiting, constipation, diarrhea, aspiration, or melena. His physical examination is unremarkable. A hemogram today reveals a microcytic hypochromic anemia with an elevated RDW.
A. Barium swallow __
B. Upper endoscopy __
C. Abdominal ultrasound __
A-2 B-1 C-3
A-1 B-2 C-3
A-3 B-1 C-2
A-2 B-3 C-1
Match each clinical presentation with one of the following conditions.
A. Erosive gastritis
B. Acute pancreatitis
C. Duodenal ulcer
D. Cholecystitis
E. Diverticulitis
1. A 45-year-old man who drinks 8-10 beers/day with a 12-hour history of acute-onset epigastric pain radiating into the back with bloating, nausea, vomiting. Objective: Epigastric tenderness, hypoactive bowel sounds, abdomen distended and hypertympanic. Laboratory evaluation reveals elevated lipase and amylase. __
2. A 64-year-old woman with a 3-day history of intermittent left lower quadrant (LLQ) abdominal pain accompanied by fever, cramping, nausea, and 4-5 loose stools per day. Objective: Abdomen soft, +bowel sounds, tenderness to LLQ abdominal palpation, negative Blumberg’s sign. Laboratory evaluation reveals leukocytosis with neutrophilia. __
3. A 34-year-old man w/3-month history of intermittent upper abdominal pain described as epigastric burning, gnawing pain about 2-3 h PC. Relief with foods, antacids. Awakening at 1-2 AM with symptoms. Objective: Tender at the epigastrium, LUQ, slightly hyperactive bowel sounds. __
4. A 52-year-old woman who was recently laid off from her job, taking 3-4 doses of ibuprofen/day for the past 2-3 months to help with headaches; 1-month history of intermittent nausea, burning, and pain, limited to upper abdomen, often worse with eating. Objective: Tender at the epigastrium, LUQ, slightly hyperactive bowel sounds. __
5. A 54-year-old woman who presents with a 24-h history of significant epigastric and RUQ abdominal pain that is constant with 2‒3-minute periods of increased pain, accompanied by nausea, 2 episodes of vomiting, and intermittent fever. Objective: Tenderness at the epigastrium and abdominal RUQ, positive Murphy’s sign, moderately elevated AST, ALT, and ALP. __
1-B 2-C 3-A 4-E 5-D
1-A 2-D 3-C 4-B 5-E
1-B 2-E 3-C 4-A 5-D
1-C 2-A 3-E 4-B 5-D
Janet, a 47-year-old well woman who is 64″ (163 cm) tall with BMI=25 kg/m2, presents for a periodic health evaluation and to establish care in your practice. She reports drinking approximately 1 to 2 mixed drinks containing 1.5 oz. (44.4 mL) 80-proof liquor per week and takes approximately 1 to 2 doses of acetaminophen per month. Her last visit with a healthcare provider was more than 5 years ago; she was told that her “liver tests were a bit higher than normal.” She felt well and decided not to return for follow-up. She denies history of injection drug use and has no tattoos. Her last vaccines were administered more than 10 years ago. She is without complaint. Abdominal examination is within normal limits. Janet’s laboratory results are as follows.
HBsAg=positive (evidence HBV on board, Ag=Always growing, HBV persists, in acute or chronic hepatitis B) Anti-HAV=positive (immune to HAV, include HAV IgG, G=Gone) Anti-HCV=negative (no evidence of past or present HCV infection) AST=56 unit/L (0-40) (modest elevation, with ALT>AST) ALT=98 unit/L (0-40) (modest elevation, with ALT>AST)
These findings are most consistent with which of the following? Choose two that apply:
Chronic hepatitis B
Evidence of hepatitis B infection immunity
Evidence of hepatitis A immunity
Acute hepatitis B infection
Evidence of hepatitis C infection
Ans: Chronic hepatitis B,
Evidence of hepatitis A immunity
Choosing all that apply, you offer Janet the following immunizations against:
Based on the scenario below:
Janet, a 47-year-old well woman who is 64″ (163 cm) tall with BMI=25 kg/m2, presents for a periodic health evaluation and to establish care in your practice. She reports drinking approximately 1 to 2 mixed drinks containing 1.5 oz. (44.4 mL) 80-proof liquor per week and takes approximately 1 to 2 doses of acetaminophen per month. Her last visit with a healthcare provider was more than 5 years ago; she was told that her “liver tests were a bit higher than normal.” She felt well and decided not to return for follow-up. She denies history of injection drug use and has no tattoos. Her last vaccines were administered more than 10 years ago. She is without complaint. Abdominal examination is within normal limits. Janet’s laboratory results are as follows.
HBsAg=positive (evidence HBV on board, Ag=Always growing, HBV persists, in acute or chronic hepatitis B) Anti-HAV=positive (immune to HAV, include HAV IgG, G=Gone) Anti-HCV=negative (no evidence of past or present HCV infection) AST=56 unit/L (0-40) (modest elevation, with ALT>AST) ALT=98 unit/L (0-40) (modest elevation, with ALT>AST).
Hepatitis B
Hepatitis A
Seasonal influenza
Tetanus, diphtheria, and acellular pertussis
Ans: Seasonal influenza
Tetanus, diphtheria, and acellular pertussis
Thomas is a 45-year-old man who has a past history of injection drug use, currently with 5 years of sobriety. He is unsure about his vaccine history but believes he had “some when I was a child.” Results of recent laboratory tests reveal the following. HCV RNA=positive (evidence of current HCV infection) Anti-HBs/HBSab=positive (evidence of HBV immunity, HBSab= B=”Bye” as HBV no longer on board) Anti-HAV=negative (no evidence of HAV infection or immunity, negative= “Never had HAV”) AST=45 unit/L (0-40) (modest elevation, with ALT>AST)ALT=72 unit/L (0-40) (modest elevation, with ALT>AST)
You offer the following immunization(s) against:
Hepatitis B
Hepatitis A
Hepatitis A and B
Seasonal influenza, tetanus, diphtheria, and acellular pertussis
Ans: WBC 17,500/mm3, Neutrophils 72%, Bands 10%
ndicate whether each characteristic is better associated with irritable bowel syndrome (IBS) or inflammatory bowel disease (IBD).
1. Intestinal ulceration present.
2. Absence of rectal bleeding.
3. CRP and ESR levels are elevated.
4. Surgical intervention often needed.
1-IBD 2-IBS 3-IBS 4-IBD
1-IBS 2-IBS 3-IBS 4-IBD
1-IBD 2-IBS 3-IBD 4-IBD
1-IBS 2-IBD 3-IBS 4-IBD
Ans: Oral levofloxacin (Levaquin®) plus oral metronidazole (Flagyl®)
Ans:
S. pneumoniae and select respiratory viruses
Mr. Spaulding is a 70-year-old man with a 50 pack-year cigarette smoking history, chronic obstructive pulmonary disease, and hypertension, who presents with a 24-hour history of increasing dyspnea and productive cough with white-yellow sputum. He is alert, oriented, and answers questions with ease. Physical examination reveals the following:
Alert, breathing slightly labored at rest, BP=130/78 mm Hg, T=99.8°F (37.7°C), HR=96, RR=22, dullness to percussion over the left base with increased tactile fremitus and tubular breath sounds as well as crackles in the right base. Cardiac examination reveals no S3, no S4, no murmur, with nondistended neck veins.
His physical examination findings are suggestive of:
A left lower lobe consolidation
Diffuse hyperinflation
Heart failure
Compromised pulmonary vascular perfusion
Ans:
A left lower lobe consolidation
Teresa, a 38-year-old woman with no chronic health problems, presents with a chief complaint of “A cold I cannot shake for the past three weeks. She also reports an intermittent frontal headache and has taken acetaminophen with relief, as well as general malaise and a dry cough that is particularly problematic at night. She denies nausea, vomiting, chills, fever, or dyspnea. She has not taken an antimicrobial within the past year, underwent a bilateral tubal ligation approximately 10 years ago, and is allergic to penicillin with a hive-form reaction.
Examination reveals the following: SaO2=97%, BP=114/70 mm Hg, T=98°F (36.7°C), HR=88, RR=20, bilateral coarse late inspiratory crackles without wheeze. She is in no acute distress. Chest x-ray demonstrates bilateral interstitial infiltrates.
Which of the following describes the recommended additional diagnostic testing for Teresa? Choose all that apply.
Blood urea nitrogen (BUN) and creatinine (Cr)
CBC with WBC differential
Blood culture
Sputum culture
Ans: Blood urea nitrogen (BUN) and creatinine (Cr), CBC with WBC differential
The results of her laboratory testing do not show alarm findings. In treating Teresa, you prescribe the following.
Based on the scenario below:
Teresa, a 38-year-old woman with no chronic health problems, presents with a chief complaint of “A cold I cannot shake for the past three weeks. She also reports an intermittent frontal headache and has taken acetaminophen with relief, as well as general malaise and a dry cough that is particularly problematic at night. She denies nausea, vomiting, chills, fever, or dyspnea. She has not taken an antimicrobial within the past year, underwent a bilateral tubal ligation approximately 10 years ago, and is allergic to penicillin with a hive-form reaction.
Examination reveals the following: SaO2=97%, BP=114/70 mm Hg, T=98°F (36.7°C), HR=88, RR=20, bilateral coarse late inspiratory crackles without wheeze. She is in no acute distress. Chest x-ray demonstrates bilateral interstitial infiltrates.
A 7-day course of oral doxycycline
A 10-day course of oral moxifloxacin
A 3-day course of parenteral vancomycin
Timed inhaled short-acting beta2-agonist use
Ans: A 7-day course of oral doxycycline
Teresa’s CURB-65 score __
Based on the scenario below:
Teresa, a 38-year-old woman with no chronic health problems, presents with a chief complaint of “A cold I cannot shake for the past three weeks. She also reports an intermittent frontal headache and has taken acetaminophen with relief, as well as general malaise and a dry cough that is particularly problematic at night. She denies nausea, vomiting, chills, fever, or dyspnea. She has not taken an antimicrobial within the past year, underwent a bilateral tubal ligation approximately 10 years ago, and is allergic to penicillin with a hive-form reaction.
Examination reveals the following: SaO2=97%, BP=114/70 mm Hg, T=98°F (36.7°C), HR=88, RR=20, bilateral coarse late inspiratory crackles without wheeze. She is in no acute distress. Chest x-ray demonstrates bilateral interstitial infiltrates.
0-1
1-2
2-3
3-4
Teresa’s location of treatment should be __
Based on the scenario below:
Teresa, a 38-year-old woman with no chronic health problems, presents with a chief complaint of “A cold I cannot shake for the past three weeks. She also reports an intermittent frontal headache and has taken acetaminophen with relief, as well as general malaise and a dry cough that is particularly problematic at night. She denies nausea, vomiting, chills, fever, or dyspnea. She has not taken an antimicrobial within the past year, underwent a bilateral tubal ligation approximately 10 years ago, and is allergic to penicillin with a hive-form reaction.
Examination reveals the following: SaO2=97%, BP=114/70 mm Hg, T=98°F (36.7°C), HR=88, RR=20, bilateral coarse late inspiratory crackles without wheeze. She is in no acute distress. Chest x-ray demonstrates bilateral interstitial infiltrates.
Inpatient
Outpatient
Mr. Spaulding returns in 2 days. He states that he is feeling somewhat better, with less shortness of breath but with continued fatigue and production of small amounts of white-yellow sputum. He states he has taken his antimicrobial therapy as advised without difficulty. Physical examination reveals the following: Alert, BP=130/78 mm Hg, T=97.8°F (36.6°C), HR=88, RR=18, dullness to percussion over the left base with increased tactile fremitus and tubular breath sounds. Cardiac examination reveals no S3, no S4, no murmur, with nondistended neck veins. At this point, you consider the following two best options:
Based on the scenario below:
Mr. Spaulding is a 70-year-old man with a 50 pack-year cigarette smoking history, chronic obstructive pulmonary disease, and hypertension, who presents with a 24-hour history of increasing dyspnea and productive cough with white-yellow sputum. He is alert, oriented, and answers questions with ease. Physical examination reveals the following:
Alert, breathing slightly labored at rest, BP=130/78 mm Hg, T=99.8°F (37.7°C), HR=96, RR=22, dullness to percussion over the left base with increased tactile fremitus and tubular breath sounds as well as crackles in the right base. Cardiac examination reveals no S3, no S4, no murmur, with nondistended neck veins.
A repeat chest x-ray should be obtained today
His antimicrobial needs to be changed to an agent with wider spectrum of activity
Mr. Spaulding should be advised to complete his current course of therapy
Pneumococcal and seasonal influenza vaccines should be updated today as needed
Which of the numbered areas on the chest x-ray best correlates with Mr. Spaulding’s physical examination findings?
Based on the scenario below:
Mr. Spaulding is a 70-year-old man with a 50 pack-year cigarette smoking history, chronic obstructive pulmonary disease, and hypertension, who presents with a 24-hour history of increasing dyspnea and productive cough with white-yellow sputum. He is alert, oriented, and answers questions with ease. Physical examination reveals the following:
Alert, breathing slightly labored at rest, BP=130/78 mm Hg, T=99.8°F (37.7°C), HR=96, RR=22, dullness to percussion over the left base with increased tactile fremitus and tubular breath sounds as well as crackles in the right base. Cardiac examination reveals no S3, no S4, no murmur, with nondistended neck veins.
Ans: left lower lobe with consolidation (picture in module) look for Xray film images online.
Mr. Spaulding’s current medications include an inhaled corticosteroid, a long-acting beta2-agonist, an ACE inhibitor with a thiazide diuretic, a statin, and low-dose aspirin, as well as a short-acting beta2-agonist as needed. Laboratory testing reveals BUN and hematocrit=WNL.
The preferred choice of antimicrobial therapy for Mr. Spaulding is a:
Based on the scenario below:
Mr. Spaulding is a 70-year-old man with a 50 pack-year cigarette smoking history, chronic obstructive pulmonary disease, and hypertension, who presents with a 24-hour history of increasing dyspnea and productive cough with white-yellow sputum. He is alert, oriented, and answers questions with ease. Physical examination reveals the following:
Alert, breathing slightly labored at rest, BP=130/78 mm Hg, T=99.8°F (37.7°C), HR=96, RR=22, dullness to percussion over the left base with increased tactile fremitus and tubular breath sounds as well as crackles in the right base. Cardiac examination reveals no S3, no S4, no murmur, with nondistended neck veins.
7-day course of oral clarithromycin
5-day course of oral levofloxacin
10-day course of oral amoxicillin-clavulanate
3-day course of injectable ceftriaxone
Ans: 5-day course of oral levofloxacin
Mr. Spaulding’s CURB-65 score. __
Based on the scenario below:
Mr. Spaulding is a 70-year-old man with a 50 pack-year cigarette smoking history, chronic obstructive pulmonary disease, and hypertension, who presents with a 24-hour history of increasing dyspnea and productive cough with white-yellow sputum. He is alert, oriented, and answers questions with ease. Physical examination reveals the following:
Alert, breathing slightly labored at rest, BP=130/78 mm Hg, T=99.8°F (37.7°C), HR=96, RR=22, dullness to percussion over the left base with increased tactile fremitus and tubular breath sounds as well as crackles in the right base. Cardiac examination reveals no S3, no S4, no murmur, with nondistended neck veins.
0
1
2
3
4
Mr. Spaulding’s location of treatment should be __.
Based on the scenario below:
Mr. Spaulding is a 70-year-old man with a 50 pack-year cigarette smoking history, chronic obstructive pulmonary disease, and hypertension, who presents with a 24-hour history of increasing dyspnea and productive cough with white-yellow sputum. He is alert, oriented, and answers questions with ease. Physical examination reveals the following:
Alert, breathing slightly labored at rest, BP=130/78 mm Hg, T=99.8°F (37.7°C), HR=96, RR=22, dullness to percussion over the left base with increased tactile fremitus and tubular breath sounds as well as crackles in the right base. Cardiac examination reveals no S3, no S4, no murmur, with nondistended neck veins.
Inpatient
Outpatient
A 63-year-old man who resides at the homeless shelter is brought to urgent care with a chief complaint of chronic cough and chest pain. His temperature is 102.3°F (39.1°C), respiratory rate of 45 bpm, and blood pressure of 135/85 mm Hg. Which of the following findings would best support a diagnosis of active tuberculosis infection?
Erythematous plaques on the extremities
Hemoptysis
Dry cough with bronchospasm
Unexplained weight gain
Ans: nfiltrate in the right upper lobe ( picture in the module or online)
Ans:
FEV1: FVC ratio <0.70 post-bronchodilator
You see Michelle, a 38-year-old woman with moderate persistent asthma who is using medium-dose inhaled fluticasone daily and albuterol via MDI as needed. In a typical month, she uses albuterol 2 puffs “about 2 times, when I feel my chest getting a little tight, and it works right away.” In an average month, she has no episodes of nocturnal awakening with cough or wheeze, typically has excellent activity tolerance. Which of the following is the most important additional clinical parameter to obtain today in evaluating Michelle’s baseline asthma control?
SaO2
Peak expiratory flow
Auscultation of breath sounds
Resting respiratory rate
Michelle returns for an urgent care visit three weeks later with a 2-day history of URI symptoms. She has a dry cough and reports, “The albuterol is not working as well as usual. I was up all night coughing. When I cough, a little bit of white phlegm sometimes comes up.” She denies fever, nausea, or vomiting. Which of the following is the most important clinical parameter in assessing Michelle’s asthma flare?
Based on the scenario below:
You see Michelle, a 38-year-old woman with moderate persistent asthma who is using medium-dose inhaled fluticasone daily and albuterol via MDI as needed. In a typical month, she uses albuterol 2 puffs “about 2 times, when I feel my chest getting a little tight, and it works right away.” In an average month, she has no episodes of nocturnal awakening with cough or wheeze, typically has excellent activity tolerance.
SaO2=97%.
Peak expiratory flow=55% of personal best
Presence of bilateral expiratory wheezes
Patient report of reduced response to beta2-agonist use
Ans: Peak expiratory flow=55% of personal best
Michelle’s physical examination is consistent with an asthma flare triggered by viral RTI. Her medication regimen should be adjusted to include which of the following? Choose all that apply.
Based on the scenario below:
You see Michelle, a 38-year-old woman with moderate persistent asthma who is using medium-dose inhaled fluticasone daily and albuterol via MDI as needed. In a typical month, she uses albuterol 2 puffs “about 2 times, when I feel my chest getting a little tight, and it works right away.” In an average month, she has no episodes of nocturnal awakening with cough or wheeze, typically has excellent activity tolerance.
An oral systemic bronchodilator titrated to therapeutic level
A short course of oral corticosteroid
An oral macrolide antimicrobial
A single dose of injectable corticosteroid
Ans: A short course of oral corticosteroid
A 76-year-old man with COPD, who uses an inhaled LAMA daily on a set schedule and SABA via MDI as needed for symptom relief, presents with a COPD exacerbation. Which of the following describes the role of imaging in the evaluation of COPD exacerbation?
Chest x-ray is a routine part of the evaluation of a person with COPD exacerbation
In COPD exacerbation, chest x-ray should not be obtained due to radiation risk
A chest x-ray should be ordered in COPD exacerbation in the patient with fever and/or low SaO2 to help rule out concomitant pneumonia
A thoracic CT is the preferred imaging study to order in a COPD exacerbation
Ans: Provide relief of acute bronchospasm
Matthews is a 78-year-old woman with severe COPD, who is currently using tiotropium bromide via inhaler and medium-dose inhaled fluticasone with salmeterol via MDI, and who presents for an acute care visit. Her current medications include enalapril, hydrochlorothiazide, lovastatin, and low-dose aspirin. She reports increasing dyspnea and a productive cough with small amounts of yellow-green sputum for the past 24 hours. She states, “I hardly slept at all last night. I kept waking up coughing.” She denies nausea, vomiting, or fever. Physical examination reveals bilateral expiratory wheezes and rhonchi with hyperresonance to percussion without increased tactile fremitus or dullness to percussion. SaO2=98%, T=97.6°F (36.4°C), BP=136/84 mm Hg, P=92, regular, RR=20.
When considering pharmacologic therapy to treat Ms. Matthews, the NP prescribes:
Oral cefpodoxime and a single dose of an injectable, sustained-release corticosteroid
Oral clarithromycin with an increase of her inhaled corticosteroid/LABA via MDI by 2 puffs per day
IM ceftriaxone and an opioid-containing cough suppressant
Oral doxycycline with a short-course of an oral corticosteroid
Ans: Oral doxycycline with a short-course of an oral corticosteroid
Ans: Long-acting beta2-agonists (LABA)
Ans: Inhaled long-acting muscarinic antagonists (LAMA) (e.g., tiotropium bromide [Spiriva®])
The NP is counseling a 67-year-old patient with severe COPD who is considering the use of long-term oxygen therapy. The patient is currently taking an inhaled corticosteroid (ICS) with a long-acting beta2-agonist (LABA). The NP advises that:
Oxygen therapy can be used in place of the ICS
Effective treatment will require at least 4‒6 hours of therapy per day
Effective treatment will require at least 15 hours of therapy per day
Consistent use of oxygen therapy can improve FEV1 to near normal values
Ans: Effective treatment will require at least 15 hours of therapy per day
Juan is a 30-year-old man with a 10-year history of moderate persistent asthma who presents for a routine visit, requesting refills of his medium-dose budesonide per DPI and albuterol per MDI. He states, “I am doing great, no complaints here.” His blood pressure, heart rate, temperature, and respiratory rate are within normal limits, he is in no distress, and his physical exam reveals no evidence of wheezing or crackles. You consider that:
His current treatment regimen should be continued
Due to patient report and today’s objective findings, his asthma appears to be well-controlled
His asthma therapy should be intensified
More information is needed to determine his level of asthma control
Ans:
More information is needed to determine his level of asthma control
You see Kevin, a 25-year-old man with a BMI=38 kg/m2 and hyperpigmented plaques with a velvet-like appearance at the nape of the neck and axillary region. He states his skin has had this appearance since he was approximately age 13 and it has not changed significantly over time. He denies itch or pain in these areas. This most likely represents:
Acanthosis nigricans.
Lichens planus.
Actinic keratosis.
Erythema migrans.
Ms. Leonardo is a 68-year-old woman of Italian ancestry who presents with a new diagnosis of primary hypertension. Recent lab analysis reveals the
following: A1C=5.3% (0.053 proportion), calculated GFR=98 mL/min/1.73 m2.
Physical examination findings include the following: BMI=26.4 kg/m2, no S3, S4, or murmur, PMI at 5th ICS, MCL. Funduscopic examination is within normal limits. In the past 6 months, she has increased physical activity by walking for at least 40 minutes 5-6 days per week and has cut back on dietary sodium. Which of the following represent(s) the best advice? Choose all that apply.
Advise that beta-blocker therapy should be started
Initiate therapy with a thiazide diuretic
Encourage weight reduction
Advise Ms. Leonardo that drug therapy will be initiated when there is evidence of target organ damage
Ans: Initiate therapy with a thiazide diuretic, Encourage weight reduction
As part of Kevin’s healthcare, consideration should be given for obtaining which of the following laboratory tests?
Based on the below scenario:
You see Kevin, a 25-year-old man with a BMI=38 kg/m2 and hyperpigmented plaques with a velvet-like appearance at the nape of the neck and axillary region. He states his skin has had this appearance since he was approximately age 13 and it has not changed significantly over time. He denies itch or pain in these areas.
Hemoglobin A1C
Serum transaminases
Rapid plasma reagent
Erythrocyte sedimentation rate
Feedback
With Kevin’s skin condition, lesions are most often found in all of the following areas except:
Based on the below scenario:
You see Kevin, a 25-year-old man with a BMI=38 kg/m2 and hyperpigmented plaques with a velvet-like appearance at the nape of the neck and axillary region. He states his skin has had this appearance since he was approximately age 13 and it has not changed significantly over time. He denies itch or pain in these areas.
Groin folds.
Over the knuckles.
Elbows.
Plantar surface of the feet.
Ans: Plantar surface of the feet.
You see an 81-year-old woman with type 2 DM. Today she presents for follow-up care. Results of recent laboratory assessment include the following: GFR=45 mL/min/1.73 m2, A1C=7.2% (0.072 proportion), K+=4.8 mEq/L (4.8 mmol/L). Her current medications include metformin, glyburide, lisinopril, and simvastatin. She is generally feeling well, is self-sufficient in ADL, and states, “I can get around in my home with my cane. I am a little less certain on my feet if I do not use the cane.”
Due to age and impaired renal function, her risk of adverse effects from metformin is increased.
Glipizide is preferred over glyburide as a sulfonylurea in the older adult.
With poor hydration, she is at risk for hyperkalemia.
She should be treated to an A1C goal of <7% (0.07 proportion).
Ans: She should be treated to an A1C goal of <7% (0.07 proportion).
You see a 55-year-old woman with type 2 diabetes mellitus, hypertension, and dyslipidemia. Evaluation today reveals a BMI=36 kg/m2. She states, “I just do not know where to start in trying to lose some weight.” Which of the following is the most appropriate response to this statement?
“How much weight do you want to lose?”
“How do you feel about your weight?”
“What barriers do you see to losing weight?”
“Your blood sugar control will likely improve if you lose some weight.”
Ans: “What barriers do you see to losing weight?”
With an 8:00 AM dose of the following insulins, followed by inadequate dietary intake/excessive energy utilization, at what time would hypoglycemia occur?
Select the time of onset of hypoglycemia Medication:
A. 8:30AM-10:30AM
B. 10:00AM-11:00AM
C. 2:00 PM-10:00 PM
1. Lispro (Humalog®) __
2. Regular insulin (Humulin R®) __
3. NPH (Novolin N®, Humulin N®) __
1-A 2-B 3-C
1-C 2-A 3-B
1-B 2-A 3-C
1-A 2-C 3-B
Mr. Jones, a 52-year-old African-American man, presents for treatment of hypertension. He is currently taking a calcium channel blocker for the past 2 months. He is feeling well with no complaint and physical examination is within normal limits. His blood pressure today is 160/94 mm Hg bilaterally. The next best step is to:
Add an ACEI and have the patient follow-up in 2 weeks
Discontinue the calcium channel blocker and start an aldosterone antagonist
Advise Mr. Jones that his blood pressure is in an acceptable range and he should follow-up in approximately 2 months
Prescribe a thiazide diuretic and advise a 1-month follow-up
Ans: Prescribe a thiazide diuretic and advise a 1-month follow-up
Mr. Kelly is a 66-year-old man with type 2 DM and HTN who presents with the following lipid profile:
HDL=35 mg/dL (0.9 mmol/L)
LDL=150 mg/dL (3.9 mmol/L)
Triglycerides=210 mg/dL (2.4 mmol/L)
Which of the following represents the best choice of dyslipidemia therapy for Mr. Kelly?
Optimized oral selective cholesterol absorption inhibitor therapy
Moderate-intensity oral statin therapy
Injectable PCSK9 therapy
High-intensity oral omega-3 fatty acid therapy
Ans: Moderate-intensity oral statin therapy
A 45-year-old woman with hypertension and dyslipidemia is currently taking moderate-intensity statin therapy and she is at LDL-reduction goal. She is feeling well. As part of her ongoing healthcare, the NP considers that:
A. Serum transaminases should be checked periodically.
Evaluation of serum creatine kinase is needed.
A CBC with WBC and platelet count is advised.
In the absence of symptoms or concerns, no particular laboratory monitoring is recommended
Ans: In the absence of symptoms or concerns, no particular laboratory monitoring is recommended.
When initiating treatment with an antihypertensive medication for a 72-year-old male with mild renal impairment, you consider all of the following except:
Sodium depletion can result with the use of a thiazide diuretic.
An increased risk of hyperkalemia is associated with ARB use.
The risk of hyperkalemia with the use of an aldosterone antagonist is increased when combined with an ACE inhibitor.
Calcium channel blockers are appropriate to use in the presence of heart failure.
Ans: Calcium channel blockers are appropriate to use in the presence of heart failure.
You see a 56-year-old male who is newly diagnosed with dyslipidemia. Prior to initiating statin treatment, his hepatic enzyme levels are measured to establish baseline values. In the absence of symptoms of liver injury, which of the following is the recommended schedule for hepatic enzyme monitoring during statin use?
Every 3 months
Every 6 months
Every 12 months
No additional hepatic enzyme monitoring is needed
Ans: No additional hepatic enzyme monitoring is needed
Match each medication used to manage dyslipidemia with its major anticipated change in the lipid profile. An answer can be used more than once.
A. Decreases triglycerides
B. Decreases triglycerides, increases HDL-C
C. Decreases LDL-C
1. Statins __
2. Niacin __
3. Fibrates __
4. Fish oil __
5. PCSK9 inhibitor __
1-C 2-A 3-B 4-B 5-A
1-C 2-B 3-B 4-A 5-C
1-B 2-C 3-A 4-B 5-A
1-A 2-B 3-C 4-C 5-A
Ans: High-dose ACE inhibitor use.
Ans: 1-A (clue cells with alkaline pH) 2-B (pseudohyphae) 3-C (WBC’s)
Choose from the following (an option can be used more than once):
A. Candida vulvovaginitis
B. Trichomoniasis
C. Bacterial vaginosis
D. Trichomoniasis, Bacterial vaginosis
1. Clotrimazole cream __
2. Oral metronidazole __
3. Metronidazole gel __
4. Clindamycin cream __
1-A 2-D 3-C 4-C
1-B 2-C 3-D 4-A
1-D 2-D 3-C 4-A
1-A 2-D 3-B 4-C
Treatment for which of the following STIs? An option can be used more than once.
A. Ceftriaxone
B. Injectable penicillin
C. Imiquimod
D. Trichloroacetic acid (TCA)
1. External genital warts in a 25-year-old man __
2. Gonococcal urethritis in a 22-year-old man __
3. Syphilis in a 45-year-old man __
4. External genital warts in a 28-year-old pregnant woman __
1-C 2-A 3-B 4-D
1-D 2-A 3-B 4-C
1-A 2-B 3-C 4-D
1-B 2-D 3-A 4-C
considerations in caring for a 68-year-old man with a BMI=38 kg/m2 who is otherwise well and presents with genital candidiasis includes which of two most helpful measures?
Advice on the use of antibacterial soap to the region.
Obtain an in-office blood glucose.
Prescribing topical miconazole.
Order a medium-potency topical corticosteroid to the affected region to help with symptom control.
Ans:
Obtain an in-office blood glucose.
Prescribing topical miconazole.
Ans: Surgical intervention should be offered early in the disease process.
Ans:
Report of recent-onset intermittent acute urinary retention
Ans: Ovary palpable on bimanual examination
Match the following urinary incontinence types:
A. Urge incontinence
B. Stress incontinence
C. Functional incontinence
D. Transient incontinence
1. Associated with lifting __
2. Occurs during an acute illness __
3. Reports of strong sensation of needing to void __
4. Often occurs in presence of mobility problems __
1-D 2-A 3-B 4-C
1-B 2-A 3-D 4-C
1-C 2-D 3-B 4-A
1-B 2-D 3-A 4-C
Which of the following patients should have screening for HPV-associated cancer?
An annual Pap test for cervical cancer screening in a 21-year-old woman
A cervical Pap test every 3 years for a 40-year-old woman who has undergone a total hysterectomy for uterine fibroids
An anal Pap in a 45-year-old man with a history of anal and genital warts
An anal Pap in a 21-year-old woman who has received HPV-9 vaccine
Ans: An anal Pap in a 45-year-old man with a history of anal and genital warts
Samantha, a healthy 32-year-old woman who is taking combined oral contraceptives, is here to review the results of her recent liquid-based Pap screening that revealed atypical squamous cells of unknown significance (ASCUS) and high-risk HPV positive.
She has no history of previous abnormal cervical cytology, with her last screening obtained approximately 2 years ago. After explaining the significance of these findings, the most appropriate next step is to:
Advise that she return in 6-12 months for a repeat Pap with HPV cotesting.
Obtain screening tests for N. gonorrhoeae and C. trachomatis infection.
Referral for colposcopy.
Counsel that the usual cervical cancer screening guidelines should be followed.
Match the following cancer types:
A. Cervical cancer
B. Endometrial cancer
C. Ovarian cancer
D. Cervical cancer, Endometrial cancer
E. Endometrial cancer, Ovarian cancer
F. All
1. Risk factors include obesity and personal history of PCOS __
2. Risk factors include long-term infection with HPV 16 and/or 18 __
3. Risk factors include BRCA1 and BRCA2 gene mutation __
4. Clinical presentation includes unexplained abdominal bloating and constipation __
5. Clinical presentation includes abnormal vaginal bleeding __
6. Often without significant clinical signs and symptoms until later disease __
7. Screening includes Pap test __
8. No specific screening tests available or recommended __
1-D 2-F 3-A 4-C 5-E 6-B 7-A 8-C
1-B 2-A 3-C 4-C 5-D 6-F 7-A 8-E
1-E 2-F 3-A 4-C 5-E 6-B 7-A 8-C
1-A 2-E 3-B 4-D 5-B 6-A 7-F 8-D
Ans: 1-B ( PCOS and obesity increases risks of endometrial cancer )
2-A risks of longterm infection with HPV 16/18 increases risks of cervical cancer
3-C (BRCA1 and BRCA2 gene mutation increase risks of ovarian cancer)
4-C (ovarian cancer has clinical presentation include unexplained abdominal bloating and constipation)
5-D (cervical and endometrial cancers often have abnormal vaginal bleeding)
6-F ( ovarian, endometrial and cervical are often without significant clinical s/s until later disease
7-A Screening for cervical cancer recommends only
8-E (No recommended screening for endometrial and ovarian at present time)
Match the following:
A. Hydrocele
B. Varicocele
C. Testicular torsion
D. Phimosis
E. Paraphimosis
F. Cryptorchidism
1. Retracted foreskin that cannot be brought forward to cover the glans __
2. A palpable “nest of worms” scrotal mass that is only evident in standing position __
3. Collection of serous fluid that causes painless scrotal swelling, easily recognized by transillumination __
4. With this, the foreskin cannot be pulled back to expose the glans __
5. Characterized by scrotal pain and loss of the cremasteric reflex __
6. Testicle located in inguinal canal or abdomen __
1-B 2-C 3-A 4-D 5-E 6-F
1-D 2-A 3-B 4-C 5-F 6-E
1-E 2-B 3-A 4-D 5-C 6-F
1-A 2-F 3-E 4-C 5-D 6-B
Match each type of urinary incontinence with its most appropriate management option [Each condition can have multiple answers].
A. Availability of an assistant to help with toileting activities
B. Identify and treat the underlying condition
C. Antimuscarinic therapy
D. Pelvic floor exercises
E. Antimuscarinic therapy or pelvic floor exercises
1. Urge incontinence __
2. Stress incontinence __
3. Functional incontinence __
4. Transient incontinence __
1-B 2-C 3-D 4-A
1-A 2-D 3-C 4-B
1-E 2-D 3-A 4-B
1-E 2-A 3-C 4-B
ans: Nitrofurantoin (Macrobid)
You see a 28-year-old woman with HIV and being treated with antiretroviral therapy. At this visit, she mentions that she is considering pregnancy. In counseling the patient, you mention that antiretroviral therapy:
Should be discontinued prior to attempting pregnancy
Should be discontinued once pregnancy is confirmed
Will likely continue throughout the pregnancy
Should be discontinued only during the first trimester of pregnancy
ans: Will likely continue throughout the pregnancy
For the patient described above, the most appropriate treatment would be:
Based on the below scenario:
You see a 24-year-old male with small flesh-colored verruca-form lesions on the shaft and tip of the penis. He reports some itching and discomfort in the genital area, but no voiding symptoms.
IM ceftriaxone (Rocephin®)
Topical imiquimod (Aldara®)
Oral doxycycline (Doryx®)
Topical acyclovir (Zovirax®)
In evaluating an 18-year-old man with testicular torsion, the NP considers the most appropriate course of action is:
Watch and wait with re-evaluation in 2 days as it may resolve spontaneously
Attempt manual detorsion
Analgesics plus an anti-inflammatory agent
Prompt referral to an urologist for surgical evaluation
ans: Prompt referral to an urologist for surgical evaluation
Match the following. An item can be used more than once.
A. Paroxetine
B. Fluoxetine
C. Citalopram
D. Escitalopram
1. Most energizing SSRI __
2. Most sedating SSRI __
3. Dose limitation due to potential QT prolongation __
4. Least drug interaction potential __
5. Longest T ½ __
1-B 2-A 3-C 4-D 5-B
1-D 2-B 3-C 4-A 5-B
1-B 2-A 3-D 4-A 5-C
1-A 2-C 3-B 4-D 5-A
Ans: A 2-week supply of nortriptyline
Of the following in need of an antidepressant, who is the best candidate for fluoxetine (Prozac®) therapy?
An 80-year-old woman who is taking multiple medications and who presents with depressed mood and agitation
A 45-year-old man with anorgasmia who is an occasional marijuana user
A 28-year-old woman who occasionally “skips a dose” of her prescribed medication and is using a progestin implant (Nexplanon®) for contraception
A 44-year-old woman with decreased appetite who is on hydrochlorothiazide for the treatment of hypertension
ou see a 45-year-old woman with major depressive disorder (MDD) who started taking standard dose sertraline one week ago. She returns today with a chief complaint of “not really feeling any better.” “In fact, I think I might feel worse. I have this on-and-off headache right over my eyes since I started the medication.” Results of physical examination reveal the following: Well-groomed and appropriately dressed for the occasion, PERLA, fundi WNL, CN 2-12 intact, clear, fluid speech. Today, you provide the following advice, choosing two of the following responses.
The sertraline dose is likely inadequate and needs to be increased.
She should be switched to a SNRI such as venlafaxine.
Due to her headache report, the sertraline should be immediately discontinued.
A lag of a number of weeks in the onset of SSRI therapeutic effect is expected.
Frontal headache is a common short-term problem with early SSRI use.
Ms. Yancy is a 56-year-old woman with a history of depression and has been taking citalopram for about 6 months. Four days ago, she decided to discontinue the citalopram as she states her depressive symptoms have been much improved.
Today, she presents with “not feeling well,” with a 2-day history of persistent frontal headache. When assessing Ms. Yancy for additional findings of antidepressant discontinuation syndrome, the NP anticipates that Ms.Yancy will report all of the following except:
Nausea.
Fever.
Flu-like symptoms.
Anxiety.
Ans: Blood sugar and lipid profile
Which of the following provides the most accurate information on assessing for alcohol abuse in a 55-year-old man who states, “I drink 5‒6 beers every night but I get to work every day.”
Elevated ALT/AST to ≥6 times upper limit of normal
Positive response to two items on the CAGE questionnaire
Modest RBC macrocytosis
Elevated serum triglycerides
Ans: Positive response to two items on the CAGE questionnaire
The use of opioid analgesia is most appropriate in which of the following clinical situations?
A 40-year-old man with acute low back pain × 2 days
A 28-year-old woman with a 24-hour history of migraine headache
A 48-year-old woman who is 1 day postoperative after abdominal hysterectomy
A 54-year-old woman with 5-year history of fibromyalgia
Ans: A 48-year-old woman who is 1 day postoperative after abdominal hysterectomy
Select components of substance-abuse disease include all of the following except:
Craving or a strong desire to use the problematic substance.
Over time, diminished effect with the same amount of the substance.
Set of characteristic withdrawal symptoms.
Social or occupational function remains intact.
Ans: Social or occupational function remains intact.
You see a 26-year-old college student diagnosed with major depressive disorder. He has been treated with a SSRI for the past 6 months with minimal clinical effect. You recommend as the next course of action:
Adding a benzodiazepine.
Adding a second-generation antipsychotic (SGA).
Switching to a SNRI.
Switching to a tricyclic antidepressant (TCA).
A 56-year-old woman who is being treated for COPD, hypertension, and dyslipidemia is recently diagnosed with moderate depression and requires antidepressant therapy. Which of the following agents is the least favorable choice due to concerns about potential drug-drug interactions?
Citalopram (Celexa®)
Escitalopram (Lexapro®)
Bupropion (Wellbutrin®)
Fluoxetine (Prozac®)
Treatment with a second-generation antipsychotic (SGA) is being initiated for a 37-year-old woman with schizophrenia who is otherwise healthy. Following initiation of the SGA, the NP understands that regular monitoring should be performed for which of the following?
AST/ALT
Fasting blood glucose
Hct
TSH
Ans: Fasting blood glucose due to weight gain
According to the recommendations found in the Beers Criteria, the use of certain medications and the other members of its class should be avoided in the older adult. Match the medication with the rationale for avoiding or using with caution in the elder.
A. Zolpidem (Ambien®)
B. Amitriptyline (Elavil®)
C. Naproxen sodium (Aleve®, Anaprox®)
D. Sertraline (Zoloft®)
1. Significant risk of orthostatic hypotension __
2. Increase in fall and fracture risk __
3. Potential to promote fluid retention and minimize effect of many anti-HTN medications __
4. Increased risk for hyponatremia, especially when used with diuretic __
1-C 2-B 3-A 4-D
1-B 2-D 3-C 4-A
1-B 2-A 3-C 4-D
1-D 2-C 3-B 4-A
Ans: 1-B (Amtriptiline) 2-A (Ambien) 3-C (Naproxen sodium) 4-D (Sertraline-Zoloft)
Ans: 1-A (Sycope) 2-B (Dizziness) 3-C (the room is spinning)
Mrs. Little is a 78-year-old woman with recently-diagnosed Alzheimer-type dementia (AD) who is here today for an office visit with her 55-year-old daughter. According to her daughter, Mrs. Little struggles with word-finding and has difficulty following directions. She appears “not to care about what is going on around her,” while other times is engaged in family activities. According to her daughter, Mrs. Little will have an angry verbal outburst that is triggered by a minor problem. Her daughter states, “This is not like my mother. Usually she is very patient.” When evaluating Mrs. Little, the NP considers that irritability in a person with early-stage dementia is often indicative of a:
Mood disorder.
Thought disorder.
Normal pressure hydrocephalus.
Hyperparathyroidism.
Mrs. Little currently resides with her daughter’s family and they voice a desire for this to continue “as long as possible and safe.” When evaluating Mrs. Little’s healthcare needs, choose the two options that do not apply.
Based on the below scenario:
Mrs. Little is a 78-year-old woman with recently-diagnosed Alzheimer-type dementia (AD) who is here today for an office visit with her 55-year-old daughter. According to her daughter, Mrs. Little struggles with word-finding and has difficulty following directions. She appears “not to care about what is going on around her,” while other times is engaged in family activities. According to her daughter, Mrs. Little will have an angry verbal outburst that is triggered by a minor problem. Her daughter states, “This is not like my mother. Usually she is very patient.”
A home safety evaluation should be conducted and appropriate modifications carried out.
If Mrs. Little has a sudden change in mental status, her healthcare provider should be contacted as soon as possible.
Behavioral difficulties often arise in individuals with AD if their usual routine is disrupted.
The use of a cholinesterase inhibitor will likely improve her mental status to a point that is nearly equivalent to her predementia baseline.
The most common adverse effects from cholinesterase inhibitor use include nausea and diarrhea.
A second-generation antipsychotic such as risperidone should be started to help minimize the angry outburst risk.
Ms. Hopkins is a 78-year-old woman with a history of hypertension, dyslipidemia, and stable angina pectoris who presents for follow-up care. She is a former smoker who quit 25 years ago with a 40 pack-year history. She denies chest pain or shortness of breath. Her current medications include a beta-adrenergic antagonist, sustained-release nitrate, angiotensin-converting enzyme inhibitor, statin, low-dose aspirin, and a thiazide diuretic. She complains of feeling a “catch or cramp” in her lower posterior legs bilaterally when she walks for extended periods. This is promptly relieved by rest. Which of the following do you anticipate finding on examination of her lower extremities?
Hyperpigmentation with bilateral ankle edema
Diminished bilateral pedal pulses with thinning of the skin
Extensive dry skin with evidence of lichenification on the plantar aspects of both feet
Diminished sensory perceptions and abnormal monofilament examination
Ans: Diminished bilateral pedal pulses with thinning of the skin
An appropriate diagnostic test to perform next for Ms. Hopkins is:
Based on the below scenario:
Ms. Hopkins is a 78-year-old woman with a history of hypertension, dyslipidemia, and stable angina pectoris who presents for follow-up care. She is a former smoker who quit 25 years ago with a 40 pack-year history. She denies chest pain or shortness of breath. Her current medications include a beta-adrenergic antagonist, sustained-release nitrate, angiotensin-converting enzyme inhibitor, statin, low-dose aspirin, and a thiazide diuretic. She complains of feeling a “catch or cramp” in her lower posterior legs bilaterally when she walks for extended periods. This is promptly relieved by rest.
Venography of lower legs.
Ankle-brachial index (ABI).
ECG.
Serum B-type natriuretic peptide (BNP).
Ans:
Ankle-brachial index (ABI).
Ans: 1-B (Cilostazol) 2-C (compression stockings) 3-A (TCA-Neuropathy)
Indicate whether each event is likely due to normal age-related mental changes (N) or is a possible warning sign of Alzheimer-type dementia (W).
1. Occasionally adding the wrong amount of an ingredient when following a recipe. __
2. Getting lost while driving to usual house of worship. __
3. Placing the house keys in the freezer. __
4. Forgetting a son’s birthday until late in the day. __
5. Incorrectly identifies the current US President. __
6. Cannot immediately remember what they had for dinner the night before but remembers this later. __
1-N 2-N 3-W 4-N 5-W 6-W
1-W 2-W 3-N 4-N 5-W 6-W
1-N 2-W 3-W 4-N 5-W 6-N
1-N 2-W 3-N 4-N 5-W 6-W
Which of the following do you not expect to find in the examination of a full-term healthy newborn?
Holding the baby about 16-20 inches (41-51 cm) away from the caregiver’s face takes advantage of the newborn’s visual range.
Bluish scleral tint is noted regardless of ethnicity or eye color.
The newborn’s eyes are quite light and glare sensitive.
If an object goes towards the newborn’s eye, the baby will likely react with a defensive blink reflex.
Ans: A visual preference for the human face.
Ans: 39 weeks and 40 weeks plus 6 days of gestation.
When counseling the parents of Joshua, a healthy term newborn, about sleeping safety, the NP advises the following:
Position the baby on the side with a positioning wedge or back, as he is most comfortable.
Place the baby in a face-up position for sleep.
Place a soft bumper in the crib to minimize the risk of injury.
Even when a caregiver is in attendance, the tummy-down position is not safe in the first two months of life
Ans:
Chapter 16-A- Review of Questions- Primary Care of the Well and Sick Infant, Child, and Teen
n considering jaundice in the neonate, the NP considers that:
Neonatal jaundice usually starts first in the trunk and extremities and then progresses to the face.
Using visual evaluation of bilirubin levels to estimate the degree of jaundice is an acceptable way to evaluate the newborn.
The onset of physiologic jaundice is usually within the first 12 hours of life.
Encouraging feedings at minimum every 2?3 hours at the breast per day while avoiding dextrose and water feedings will help minimize the newborn’s risk of hyperbilirubinemia.
You are providing counseling for the parents and caregivers of a healthy full-term newborn who is being breastfed. The counseling should include information on all of the following except:
The baby should make at least 6 wet diapers a day.
Newborns often lose up to 10% of birth weight in the first week of life.
A breastfed baby usually has 4 or more bowel movements per day.
The baby should be back up to birth weight by age 3-4 weeks.
Ans: The baby should be back up to birth weight by age 3-4 weeks.
You see Alexandra, born at 40.5 weeks’ gestation, who is now 14 days old. According to her mother, she is a vigorous eater and is both breast- and formula-fed. On examination of the neonate, you note bilateral breast engorgement with physiologic galactorrhea on the left. You appreciate all of the following are correct concerning this condition except:
Its onset is usually at approximately day 3-4 of life.
That maternal hormonal influences are likely the cause.
This breast engorgement will resolve without intervention within the first two months of life.
Further evaluation is required to confirm this assessment.
Further evaluation is required to confirm this assessment.
A 12-day-old infant who is otherwise well presents with a 2-day history of irritation of both eyes. He was born at a local birth center and received standard newborn care including ocular chemoprophylaxis. Examination reveals bilateral lid swelling, chemosis, and mucoid eye discharge. The most likely cause of this condition is:
Chemical irritation from neonatal ocular chemoprophylaxis.
Chlamydial (inclusion) conjunctivitis.
Gonococcal conjunctivitis.
Neonatal adenovirus infection.
Ans: Chlamydial (inclusion) conjunctivitis.
You are rounding in the nursery and see the neonate of a mother who is HBsAg-positive. Your most appropriate action is to:
Check the baby for HBsAb.
Inform the mother that she should not breastfeed.
Administer hepatitis B immunization to mother and infant.
Give hepatitis B immunization and hepatitis B immune globulin to the newborn.
Ans: Give hepatitis B immunization and hepatitis B immune globulin to the newborn.
Indicate the appropriate neonatal/-infant reflex for each description.
A. Moro reflex
B. Palmar grasp
C. Babinski reflex
D. Stepping reflex
E. Rooting reflex
1. Walking motion made with legs and feet when held upright and feet touching the ground. Appears for first 3-4 months, then reappears at 12-24 months. __
2. Turning of head and sucking when cheek is stroked. No longer seen by 6-12 months. __
3. Throwing out arms and legs followed by pulling them back to the body following a sudden movement or loud noise. No longer seen by 16 weeks. __
4. Stroking the sole of the foot elicits fanning of the toes. No longer seen by 6 months. __
1-D 2-E 3-A 4-C
1-A 2-B 3-D 4-E
1-D 2-E 3-B 4-A
1-C 2-D 3-B 4-A
Ans: 1-D (stepping reflex) 2-E (rooting reflex) 3-A (moro reflex) 4-C (babinski reflex)
Ans: in the first days of life
Ans: 1 minute for each year of life
Ans: With eruption of the first tooth.
Which of the following is most consistent with a normal developmental exam for a thriving 6-month-old infant born at 32 weeks’ gestation?
Responds to own name and sits without support
Reaches for toy with one hand and recognizes familiar people and objects at a distance
Babbles mamama, bababa and transfers objects hand-to-hand without difficulty
Vocalizes “ah” and “oh” sounds, and is able to lift head briefly when positioned on the tummy and turn it from side-to-side
Ans: Reaches for toy with one hand and recognizes familiar people and objects at a distance
You examine a healthy 2-month-old boy and note that his foreskin cannot be retracted. You consider that:
The foreskin should be forcibly retracted to facilitate cleaning.
In most instances, the foreskin is not easily retractable until the child is about 3 years old.
The risk for hypospadias or epispadias is increased in the presence of this finding.
Persistent maternal hormonal influences contribute to this problem.
Ans: n most instances, the foreskin is not easily retractable until the child is about 3 years old.
You examine a thriving 4-week-old boy who was born at 39 weeks’ gestation and note a painless, tense, non-reducible, relatively symmetric scrotal enlargement that brightly and evenly transilluminates. The parents report that the scrotum “always looks like this,” without change in size during the course of the day. Bilateral testes, approximately 1 cm in length, are palpable and held within the scrotum. The penis is approximately 4 cm in length. You consider these findings are most consistent with:
A normal examination.
Bilateral inguinal hernias.
Micropenis.
Noncommunicating hydrocele.
Ans: Noncommunicating hydrocele.
Which of the following is most consistent with pyloric stenosis (upper GI obstruction [PS]) or intussusception (lower GI obstruction [I]) or both?
A. Pyloric stenosis
B. Intussusception
C. Both
1. Significantly more common in males. __
2. Sudden onset, colicky, severe, and intermittent abdominal pain, often with knees drawn to chest during most intense discomfort. __
3. Accompanied by loose stools that are often described as currant jelly appearance (mixture of blood and sloughed mucous). __
4. Most common time for symptom onset is= Approximately age 3 weeks. __
5. Post-fed projectile vomiting is present, with the baby eager to eat again immediately post emesis. __
6. Accompanied by a sausage-shaped abdominal mass. __
7. Olive-shaped RUQ abdominal mass occasionally noted. __
8. Usually occurs between ages 6-12 months. __
9. Ultrasonography is usually first-line diagnostic study. __
1-A 2-B 3-A 4-A 5-B 6-C 7-C 8-B 9-A
1-C 2-B 3-B 4-A 5-A 6-B 7-A 8-B 9-C
1-C 2-A 3-B 4-A 5-B 6-B 7-A 8-B 9-A
1-B 2-B 3-C 4-C 5-C 6-A 7-B 8-A 9-B
Pediatric immunizations: True or false?
1. MMR should not be given to a 12-month-old whose mother is pregnant. __
2. A 6-month-old who is taking amoxicillin for acute otitis media (AOM) should have immunizations delayed until the antimicrobial course is completed. __
3. Preterm infants are usually immunized at the schedule that corresponds with their birth or extrauterine age. __
4. One of the best ways to protect infants younger than 6 months of age from influenza is to make sure members of their household and their caregivers are vaccinated against the disease. __
5. Pregnant women should receive inactivated influenza vaccine to protect both mother and unborn child. __
6. The risk of autism can be reduced through the use of an early childhood vaccination schedule that minimizes the number of immunizations given at a single visit. __
7. In order to avoid post-vaccine discomfort, younger children should be given a weight- and age-appropriate dose of an antipyretic, such as acetaminophen or ibuprofen, prior to receiving immunizations. __
8. Children 6-11 months of age who are traveling outside the United States should receive 1 dose of MMR. __
1-True 2-True 3-False 4-True 5-False 6-True 7-False 8-False
1-False 2-True 3-True 4-True 5-False 6-True 7-False 8-True
1-False 2-False 3-True 4-True 5-True 6-False 7-False 8-True
1-False 2-True 3-False 4-True 5-False 6-True 7-False 8-True
Ans: 1-False 2-False 3-True 4-True 5-True 6-False 7-False 8-True
Of the following, who should receive Tdap (tetanus, diphtheria, acellular pertussis) vaccine? (Yes or no)
1. A 28-year-old woman who is 29-weeks pregnant and received Tdap approximately 3 years ago __
2. The spouse of a woman in the 2nd trimester of pregnancy who provides documentation of receiving Tdap 2 years ago __
3. A 70-year-old man who received a Td about 8 years ago, slated to be one of his son’s newborn’s caregivers __
1-Yes 2-No 3-Yes
1-Yes 2-Yes 3-Yes
1-No 2-No 3-Yes
1-No 2-Yes 3-Yes
A 2½-year-old boy is brought by his mother who reports that, approximately 10 minutes ago, the child was injured when he pulled a pot of boiling water off the stove. The child is alert and crying, and age-appropriately resists the examination. Skin survey reveals approximately 18% body surface area of moist, red skin with peeling borders, largely involving the posterior thighs, buttocks, and scrotum. No other injury is noted. Identify the two most important considerations in his care.
The injury should be débrided as soon as possible.
The affected area should be promptly washed with an antiseptic solution.
Specialty burn care should be promptly sought.
Child protective services should be immediately notified.
A course of oral antibiotics should be initiated.
You see Sharon for a well-child visit. She is a 12-year-old who is at Tanner stage 2-3 and states unhappily, “I am the shortest girl in my class.”When reviewing her growth chart, you notice she has been consistently between the 10th and 15th percentile for height and weight during her childhood. The rest of her examination is within normal limits. You advise that:
She should have an evaluation by a pediatric endocrinology specialist.
Her growth spurt will start soon.
Due to her age, she is likely near her adult height.
X-ray determination of bone age should be obtained.
Ans: Her growth spurt will start soon.
Ans: A 14-year-old male who is at Tanner stage 3
Ans: Hip and breast enlargement.
Fragile X-syndrome: In males, large forehead, ears, prominent jaw, tendency to avoid eye contacts, large testicles (macrochidism), noted after beginning after puberty, large body habitus, behavioral and learning differences common.
In females, less prominent findings, occurs in all racial ethnic groups, common cause for autism in both genders.
Klinefelter syndrome (XXY) only in males, with specific physical habitus, low testicular volume, hip and breast enlargement, infertility most commonly is language development
Turner syndrome: (XO) : usually is short stature <5ft, evident by age 5, wide webbed neck broad shield shaped-chest absent menses, infertility, most noted often at birth with high-arched palate, low-set ears, edema of hands and feet,
A 12-year-old boy presents with his mother for a well-child visit. What is the most helpful approach to this visit?
Interview and examine the child in the absence of the mother.
Interview the child with the mother, asking her to leave for the examination.
Ask the child if he wishes his mother to be there for the interview and examination.
Ask the mother if she wishes to be included in the interview and examination
Ans: Ask the child if he wishes his mother to be there for the interview and examination.
Match the following.
A. Benzoyl peroxide
B. Isotretinoin (Accutane®)
C. Tretinoin (Retin-A®)
D. Combined oral contraceptive
1. Indicated for treatment of cystic acne __
2. Most cost-effective topical antibacterial in mild acne __
3. Used as a keratolytic in acne treatment __
4. Use results in reduction of androgen levels __
1-A 2-B 3-C 4-D
1-B 2-A 3-C 4-D
1-C 2-A 3-D 4-B
1-B 2-C 3-A 4-D
Ans: 1-B (Accutane) 2-A (Benzoyl peroxide) 3-C (Tretinoin Retin-A) 4-D(Combined oral contraceptives)
Adolescent issues: True or false?
1. Although adolescents tend to drink alcohol less frequently than adults, they drink considerably more alcohol per occasion of drinking. __
2. USPSTF recommends depression screening using a validated questionnaire in adolescents (ages 12-18 years). __
3. The majority of states require either parental consent or notification for teenagers younger than 18 to have a pregnancy termination. __
1-True 2-True 3-True
1-False 2-True 3-True
1-False 2-True 3-False
1-True 2-False 3-False
James is a 15-year-old who arrives for a well-teen visit with his mother.Prior to the beginning of the visit, his mother pulls you aside and states, “I want him checked for all drugs, but he said he is not using anything and does not want to be tested.” Which of the following is your most appropriate response?
“What drugs do you think James is taking?”
“I cannot force James to take a drug test.”
“Let’s discuss your concerns with James.”
“Since you are concerned, I can order the test without James’ consent.”
Ans:
“Let’s discuss your concerns with James.”
In which of the following scenarios is parental consent for care required?
An 18-year-old female who is seeking a pregnancy termination
A 16-year-old female requesting a prescription for oral contraceptives
A 15-year-old male requesting testing for sexually transmitted infection
A 17-year-old male who requests treatment for contact dermatitis
Ans:
A 17-year-old male who requests treatment for contact dermatitis
True or false? When approaching the provision of primary care for LGBT youth, the NP considers that:
1. The healthcare provider should ask the adolescent how he/she self-identifies. __
2. Therapy which attempts to change one’s sexual orientation or gender identity is inconsistent with current standards of medical care. __
3. Because victimized LGBT youth are at increased risk of depression and suicidality, providers should screen for these mental health issues and intervene as appropriate. __
4. In adolescents, sexual orientation and gender identity are relatively fixed constructs. __
1-True 2-True 3-True 4-True
1-False 2-True 3-True 4-True
1-True 2-True 3-True 4-False
1-True 2-False 3-True 4-False
Ans: 1-True 2-True 3-True 4-False
Ans: Family history of type 1 diabetes mellitus.
Tina is an otherwise well 15-year-old who presents with her mother. They report that Tina has had a one-day history of “sore throat and swollen glands” as well as a low-grade fever and rash. Examination reveals a diffuse maculopapular rash, mildly tender posterior cervical and postauricular lymphadenopathy, and pharyngeal erythema without exudate. The remainder of her history and review of systems is unremarkable. Per her mother’s report, Tina has not received any immunizations since age 6 months.
The most likely diagnosis is:
Scarlet fever.
Roseola.
Rubella.
Rubeola.
Jannetta is a 16-year-old who presents with a 3-day history of pharyngitis and fatigue. Findings include exudative pharyngitis, minimally tender anterior and posterior cervical lymphadenopathy, and right and left upper quadrant abdominal tenderness. Per Jannetta’s record, she is up-to-date with all recommended vaccinations.
This is most consistent with:
S. pyogenes pharyngitis.
Infectious mononucleosis.
Hodgkin disease.
Gonococcal pharyngitis.
Ans: Infectious mononucleosis.
Jared is a 17-year-old with no known medication allergy who has suspected infectious mononucleosis. He is febrile and complains of acute otalgia on the left for the past three days. Physical examination reveals a left tympanic membrane that is red and bulging. When considering therapy for Jared, which of the following should not be prescribed?
Acetaminophen
Ibuprofen
Amoxicillin
Azithromycin
Ans: Amoxicillin (secondary reaction due to Mononucleosis infection)
Timmy is a 4-year-old boy who presents with his Mom today for a sick visit. For the past 8 days, he has had intermittent fever as high as 104.5ºF (40.3ºC) and has complained of a sore throat and increased throat pain with swallowing, but without difficulty taking fluids. He has little appetite, but his mother denies nausea, vomiting, diarrhea, or constipation. On examination, you note he is alert, appears ill without acute distress, and has extensive cervical lymphadenopathy, injected conjunctivaoral erythema, and a peeling rash on his hands. You consider a diagnosis of:
Infectious mononucleosis.
Fifth’s disease.
Hand, foot, and mouth disease.
Kawasaki disease.
Identify the two children that are at greatest risk for iron deficiency anemia.
3-month-old who takes about 24 oz (0.71 L) of iron-fortified formula per day
11-month-old, breastfed about 7 times a day, taking iron-fortified cereal, fruit, and vegetables three times per day
16-month-old who drinks about 1 qt (0.95 L) whole milk per day and a few solids
4-year-old who eats small amounts of meat, fruit, and cheese
6-month-old who was born at 30 weeks’ gestation and is exclusively breastfed without additional supplements
Jackson is a 13-month-old who is in for a well-child visit. Height and weight are at approximately 40th percentile and he is on target developmentally. His diet consists of approximately 18 oz (0.53 L) of whole cow’s milk per day and a variety of vegetables, fruits, lean meats, and grains. You advise that Jackson:
Is eating a well-balanced diet and no nutritional supplements are needed.
Should receive iron supplement equivalent to 1 mg/kg/d.
Receive vitamin D 400 IU as a daily oral supplement.
Should be taking in more calcium via increased cow’s milk intake to ≥28 fl oz (0.83 L) per day.
Ans: Receive vitamin D 400 IU as a daily oral supplement.
You are seeing an 8-year-old healthy boy who is brought in by his mother who states, “He is in trouble in school and failing two classes. His teacher thinks he is too hyper and will not sit still and wants him to be evaluated. I do not understand this. He is fine at home.”
When considering the diagnosis of attention deficit/hyperactivity disorder in this child, you understand that:
In the majority of children diagnosed with ADHD, the symptoms and behaviors will resolve by early adulthood.
Psychostimulant use in the child with ADHD can lead to substance abuse disorders in adolescence.
To confirm the diagnosis of ADHD, assessment of the child’s behavior at home and school should be conducted using standardized scales.
When psychostimulants are prescribed with the diagnosis of ADHD, concomitant behavioral therapy is usually not needed.
Adam, a 7-year-old boy with a prior diagnosis of moderate persistent asthma, presents with his parents for a well-child visit. He is new to your practice and has not had a healthcare visit in the past year. Adam’s mom mentions that he took a “pill to control his breathing, but we ran out.” “Right now, he uses the albuterol pump once or twice a day. This keeps his cough under pretty good control. The inhaler works quickly most of the time.” You advise the following:
Add a twice-a-day long-acting beta2-agonist as needed to ensure Adam has better cough control.
An inhaled corticosteroid should be added to Adam’s treatment regimen.
A leukotriene modifier is an acceptable first-line controller medication for Adam.
No additional medication is needed as Adam has adequate symptom control with the current albuterol dose and frequency.
Ans: An inhaled corticosteroid should be added to Adam’s treatment regimen.
dentify the following children with AOM as a candidate for initial antimicrobial therapy or watchful waiting therapy.
A. Antimicrobial therapy
B. Watchful waiting therapy
1. A 5-month-old with unilateral AOM, T=101.2°F (38.4°C),. and 48 -h history of crankiness __
2. A 3-year-old with bilateral AOM and, T=102.4°F (39.1°C), and a 8- h history of otalgia complaint __
3. A 4-year-old with unilateral AOM, T= 100.6°F (38.1°C), and a 12 -h history of mild ear discomfort __
4. A 2 ½-year-old with bilateral AOM, T=101.2°F (38.4°C), and a 3-day history of otalgia complaint __
1-A 2-B 3-A 4-B
1-B 2-A 3-B 4-B
1-A 2-A 3-B 4-A
1-B 2-A 3-A 4-A
Taylor is a 2½-year-old otherwise well child who presents today for a sick visit. According to his father, Taylor has vomited approximately 10 times in the past 18 hours, with the last episode about 4 hours ago. He has retained sips of water during the last hour. He also developed watery stools approximately 8 hours ago with 4 episodes in total. The last stooling episode was about 1 hour ago. Fever is reported to be elevated to 38.4ºC (101.2ºF) on a number of occasions during the past day. On assessment, he is lying in his father’s arms, is alert and nods his head when asked if he is thirsty. His lips are dry and slightly cracked and there is a small amount of saliva in the oral cavity. His heart rate is 110 BPM and capillary refill is <2 seconds. Dad tells you Taylor’s diaper was dry when he awoke 4 hours ago but due to watery stools, he is unsure if Taylor has voided this morning. Currently, Taylor is wearing a diaper that is slightly wet in the front. Based on these findings, you consider that Taylor appears to be:
Mildly dehydrated.
Moderately dehydrated.
Severely dehydrated.
Adequately hydrated.
You provide the following information to Taylor’s father.
Based on the below scenario:
Taylor is a 2½-year-old otherwise well child who presents today for a sick visit. According to his father, Taylor has vomited approximately 10 times in the past 18 hours, with the last episode about 4 hours ago. He has retained sips of water during the last hour. He also developed watery stools approximately 8 hours ago with 4 episodes in total. The last stooling episode was about 1 hour ago. Fever is reported to be elevated to 38.4ºC (101.2ºF) on a number of occasions during the past day. On assessment, he is lying in his father’s arms, is alert and nods his head when asked if he is thirsty. His lips are dry and slightly cracked and there is a small amount of saliva in the oral cavity. His heart rate is 110 BPM and capillary refill is <2 seconds. Dad tells you Taylor’s diaper was dry when he awoke 4 hours ago but due to watery stools, he is unsure if Taylor has voided this morning. Currently, Taylor is wearing a diaper that is slightly wet in the front.
Taylor can go home now on rehydration therapy with an appropriate oral rehydration solution and clear liquids.
Taylor should be started on rehydration therapy with an appropriate oral rehydration solution in the office now with a goal of demonstrating ability to tolerate oral fluids.
Given Taylor’s hydration status, he should be hospitalized for parenteral fluid replacement.
Taylor is able to go home on a diet of dry toast, mashed bananas, applesauce and white rice along with sips of clear liquids.
A father presents his 2-year-old daughter with suspected gastroenteritis. She has had two episodes of vomiting and several episodes of diarrhea beginning 24 hours ago. Her last diarrheal episode was 2 hours ago and her diaper is wet. She has been able to consume small amounts of fluid but shows signs of mild dehydration. An appropriate treatment option to prevent further dehydration is a single oral dose of:
An antidiarrheal agent (e.g., bismuth salicylate [Pepto Bismol®]).
An antimotility agent (e.g., loperamide [Imodium®]).
A 5-HT3 antagonist (e.g., ondansetron [Zofran®]).
Antiparasitic antimicrobial (e.g. metronidazole [Flagyl®]).
Ans: A 5-HT3 antagonist (e.g., ondansetron [Zofran®]).
True or False?
1. In a febrile child, the degree of temperature reduction in response to antipyretic therapy is not predictive of presence or absence of bacteremia. __
2. Response to antipyretic medication does not change the likelihood of a febrile child having a serious bacterial infection and should not be used for clinical decision-making. __
3. The absence of tachypnea is the most useful clinical finding for ruling out pneumonia in children. __
1-True 2-True 3-False
1-False 2-True 3-False
1-True 2-True 3-True
1-False 2-False 3-False
You are seeing Benjamin, an 18-month-old, who presents with his mother for a sick visit. His last well-child visit was at age 5 months, when he was up-to-date for recommended immunizations. Mom states that Benjamin has not been seen by another healthcare provider nor received vaccines since his last visit at your practice.
He now presents with a 2-day history of crankiness and fever. Benjamin has had a poor appetite for the past 2 days but has not vomited and has been taking small amount of fluids. His last wet diaper was approximately 2 hours ago. Exam reveals T=39.6ºC (103.4ºF), P=150 BPM, RR=45/min. Additional findings include slightly dry mucous membranes, capillary refill of <2 seconds, oropharyngeal redness, bilateral, red, immobile TMs, and a clear chest. The child has a high-pitched cry, is difficult to console, and does not regard his mother’s face. Your next best action is to:
Start the child on high-dose PO amoxicillin and oral analgesia with ibuprofen.
Give Benjamin an age- and weight-appropriate dose of an oral antipyretic with plans to reassess after 1 hour.
Initiate an evaluation for sepsis and consider for inpatient admission.
Administer a single dose of IM ceftriaxone and arrange for revisit tomorrow.
Ans: Initiate an evaluation for sepsis and consider for inpatient admission.
A mother presents her 5-year-old son who has a 3-day history of a reticular-form pink-red rash originating on his face that is spreading to his trunk and extremities. The mother reports that he had a mild fever and headache as well but is without GI symptoms other than slightly reduced appetite. A number of other children in his preschool have similar signs and symptoms. The most likely diagnosis for this patient is:
Croup.
Measles.
Roseola.
Fifth’s disease.
dentify at which age each of the following characteristics would indicate a potential problem with a child’s development.
A. By 9 months
B. By 12 months
C. By 16 months
1. Fails to return a smile or other facial expression. __
2. Lack of any spoken words. __
3. Shows no response to his/her name”. __
1-A 2-C 3-B
1-B 2-A 3-C
1-A 2-B 3-C
1-C 2-A 3-B
A 6-year-old boy returns to the clinic with his mother 2 months following an episode of acute otitis media that was treated with a regimen of amoxicillin (Amoxil®). Examination reveals persistent effusion and mild bulging of the tympanic membrane, but there is no observed redness. The patient reports little-to-no pain in the affected ear and he is without fever. The most appropriate management option for this patient is:
Watchful waiting.
A course of an oral decongestant.
1 week therapy with amoxicillin-clavulanate (Augmentin®).
Cefpodoxime (Vantin®) at a therapeutic dose for 5 days.
A 14-month-old girl is brought in for evaluation by her mother. She reports that her daughter has been fussy for the past 3 days and tugging at her left ear. Evaluation reveals moderate bulging of the tympanic membrane and her temperature is 102.6ºF (39.2ºC). The child has no reported medication allergies and has not received any antimicrobials in the past 3 months. You recommend:
Watchful waiting and follow-up in 3 days.
Amoxicillin (Amoxil®).
Clarithromycin (Biaxin®).
Levofloxacin (Levaquin®).
A woman brings in her 23 month-old grandson who has been fussy for the past two days with frequent holding of both ears and crying for the past 2 days. Evaluation reveals bulging and erythema of both tympanic membranes and a temperature of 100.4ºF (38.0ºC). The boy has no reported allergy to penicillin and is otherwise healthy. The most appropriate course of action is:
Analgesics and watchful waiting.
Amoxicillin.
Cefpodoxime.
Azithromycin.
A father brings in his 7-year-old daughter for evaluation. She has experienced moderate pain in both ears for the past 2 days and has a fever (103.1ºF [39.5ºC]). Examination reveals bilateral moderate bulging tympanic membranes. She has a history of penicillin allergy. You prescribe therapy with:
Analgesics only and follow-up in 2 days.
Amoxicillin-clavulanate (Augmentin®).
Cefuroxime axetil (Ceftin®).
Ciprofloxacin (Cipro®).
Ans: Cefuroxime axetil (Ceftin®).
While counseling the mother of a healthy full-term newborn who is being formula-fed, she asks how much and how often will the baby eat. The most appropriate response is:
1.5 to 3 ounces (45-90 mL) every 2-3 hours.
4 to 5 ounces (120-150 mL) every 2-3 hours.
About 6 ounces (180 mL) every 3 hours.
About 2 ounces (60 mL) every 6-8 hours.
Ans:
1.5 to 3 ounces (45-90 mL) every 2-3 hours.
Which of the following is not a component of the CRAFFT questionnaire when evaluating an adolescent for substance abuse?”
Do you ever have trouble sleeping because you crave alcohol or drugs?
Have you ever gotten in trouble while you were using alcohol or drugs?
Do you ever use alcohol or drugs when you are alone?
Do you ever feel the need to use alcohol or drugs to relax or feel better about yourself?
ans: Do you ever have trouble sleeping because you crave alcohol or drugs?
breastfeeding mother brings in her 5-month-old son experiencing an episode of gastroenteritis. She reports that he has had 3 loose stools in the past 24 hours and vomited twice. Evaluation reveals that blood pressure, pulse, and skin turgor are all within normal limits. The NP recommends:”
Temporarily switching to soy-based formula.
Initiating therapy with oral rehydration solution.
Supplementing with 50% diluted fruit drink or sports drink.
Continuing breastfeeding.
Which of the following patients with acne is the best candidate for oral isotretinoin (Accutane®)?
A 15-year-old with 10-15 comedones and has not responded adequately to benzoyl peroxide.
A 17-year-old with type 1 diabetes and a total lesion count of 80-100 and has a sulfa allergy
An 18-year-old with 5-10 nodules and ~60 inflammatory lesions who has not responded to multiple prior therapies
A 19-year-old woman with severe acne (>125 total lesions) who does not wish to initiate contraceptive therapy
Ans: Azithromycin (Zithromax®).
Ans: Down syndrome (Trisomy 21).
Adolescent issues: By high school senior year (Match the following).
20%
40%
50%
70%
A. Tried alcohol. __
B. Used an illegal/restricted drug including marijuana. __
C. Smoked a cigarette. __
D. Used a prescription drug for a nonmedical purpose. __
A-50% B-70% C-40% D-20%
A-70% B-40% C-50% D-20%
A-40% B-50% C-20% D-70%
A-70% B-50% C-40% D-20%
Match the correct car safety device for each of the following children. An answer may be used more than once.
A. Rear-facing car seat
B. Forward-facing seat with harness
C. Belt-positioning booster seat
D. Seat belt
1. An 18-month-old born at 38-weeks’ gestation. __
2. A 9-year-old who is 4 feet 10 inches tall. __
3. A 1-year-old who is at 50th percentile in height and weight. __
4. A 7-year-old who is at 75th percentile in height and weight. __
1-C 2-B 3-D 4-A
1-A 2-D 3-A 4-C
1-B 2-B 3-A 4-D
1-A 2-C 3-C 4-B
As part of a well-child visit, you advise the parents of a well 6-month-old that a mild fever of 1-2 days in duration is most likely to occur after the baby receives:
Inactivated polio virus (IPV) vaccine.
Haemophilus influenzae type B (Hib) vaccine.
Pneumococcal conjugate 13-valent vaccine (PCV13).
Injectable influenza vaccine.
Ans: Haemophilus influenzae type B (Hib)
A 78 Year-old woman with a 30-year history of hypertension and dyslipidemia and a 10-year history of type 2 diabetes presents with suspected acute coronary syndrome. She is most likely to report a recent onset of:
Retrosternal chest pain with radiation to the left arm.
Syncope.
Unusual fatigue.
Nausea and vomiting.
Jack is a 16 year-old varsity basketball player who presents for a sports clearance physical examination. His health history is unremarkable and reports excellent activity tolerance. Which of the following would be a finding on Jack’s cardiac examination that would warrant immediate evaluation?
A split second heart sound that increases on inspiration and closes on expiration accompanied by a point of maximum impulse (PMI) at the 5th intercostal space (ICS) midclavicular line (MCL)
A grade 2/6 midsystolic murmur that increases in intensity with position change from supine to standing accompanied by a loud S4
PMI with palpable single impulse at the 5th intercostal space accompanied by S1 louder than S2 at the apex
A grade 2/6 systolic murmur noted over the precordium without radiation that disappears with position change from supine to standing accompanied by S2 louder than S1 at the base
Jane is a 27 year-old woman who presents for a “pap test.” She is new to your practice, has not significant health history and reports excellent exercise tolerance, running up to 5 miles 5-7 days a week and recently was first place in her age division in a 6K road race. Jane reports taking a low-dose combined oral contraceptive and a daily multivitamin. Physical examination reveals a BMI=22.1 kg/m2, mild pectus excavatum, PMI WNL with both heart sounds intact. There is a midsystolic click with late systolic murmur and the murmur moves forward with position change from supine to stand. The rest of her physical examination is unremarkable. The next most appropriate step in her care is to:
Prescribe an antibiotic that she should take prior to dental work.
Inform her that she should curtail her running program.
Advise Jane that she should discontinue the use of a combined oral contraceptive immediately.
Inform Jane that obtaining an echocardiogram is a prudent next step.
Ans: Inform Jane that obtaining an echocardiogram is a prudent next step.
Mrs. Rivera is an 82 year-old woman with infrequent contact with her HCP. She presents for sick visit with the following chief complaint, “I get really dizzy when I walk up a flight of stairs.” She denies chest pain, agrees that she feels “a bit winded” when physically active; this symptom resolves quickly with cessation of trigger activity. Physical examination reveals the following: BP=110/90, gr 2/6 harsh systolic murmur with radiation to the neck, loudest along USB, softer towards axilla, both heart sounds preserved, no S3 or S4, no neck vein distention, no carotid bruit, delayed carotid upstroke. Her clinical presentation is most consistent with the presence of:
Mitral stenosis.
Carotid artery dissection.
Systolic heart disease.
Calcific aortic stenosis.
Raymond is an 18 year-old high school basketball player. He is in for a sports clearance physical examination and denies activity intolerance, chest pain, and syncope. Today’s Assessment Reveals the Following: 74″ (188 cm), 220 lb (99.8 kg), Tanner Stage 5. Both heart sounds intact, a grade 2/6 harsh systolic murmur with radiation to the neck, loudest along USB, softer towards axilla, somewhat softer with position change from supine to standing, no delay in carotid upstroke, other pulses intact. Raymond’s findings are most likely the result of:
Aortic stenosis.
Aortic regurgitation.
Mitral valve prolapse.
Physiologic murmur.
Richard is a 62 year-old man w/ HTN heart disease and HF. He presents today for follow up and is without new symptoms. Physical examination reveals the following: PMI @ 5th ICS AAL with a sustained impulse, Gr 3/6 blowing holosystolic murmur with radiation to axilla. The murmur accentuated by rolling patient onto left side, softens when going from supine to standing position, louder with hand grip, 2d heart sound not preserved, and full carotid upstroke bilaterally is noted. These findings are most consistent with:
Mitral valve prolapse.
Aortic stenosis.
Pulmonic stenosis.
Mitral regurgitation.
Joe is a 54-year-old man with COPD who presents with an 18-hour history of sudden-onset monoarticular pain consistent with acute gouty arthritis. He denies trauma to the area and has taken acetaminophen 1 g × 2 doses with little effect. The most likely presentation of this condition is:
Swelling at the third distal interphalangeal joint.
Redness at the first metatarsophalangeal.
Firm, white 4 mm nodular auricular lesion.
Effusion in the right knee.
Ans:
Redness at the first metatarsophalangeal.
Which of the following medications would be ineffective in treating Joe’s episode of acute gouty arthritis?
Based on the below scenario:
Joe is a 54-year-old man with COPD who presents with an 18-hour history of sudden-onset monoarticular pain consistent with acute gouty arthritis. He denies trauma to the area and has taken acetaminophen 1 g × 2 doses with little effect.
Intraarticular corticosteroid injection
Naproxen sodium (Aleve®, Anaprox®)
Febuxostat (Uloric®)
Colchicine (Colcrys®)
ans: Report of recently increased intake of acidic foods
Match each test or sign with the relevant condition below:
A. Drop arm test
B. Finkelstein test
C. McMurray test
D. Lachman test
E. Spurling test
F. Straight-leg raising test
G. Talar tilt
H. Tinel’s Sign
Conditions:
1. Meniscal tear __
2. Ankle instability __
3. Carpal tunnel syndrome __
4. Anterior cruciate ligament tear __
5. Lumbar nerve root compression __
6. Cervical nerve root compression __
7. Rotator cuff evaluation __
8. De Quervain’s tenosynovitis __
Ans: 1-C (McMurray Test- Meniscal tear of the knee)
2-G (Talar Tilt test for ankle instability)
3-H (Tinel’s sign for Carpal tunnel syndrome – two hand place against with hyperflexion of the wrists, if numbness or tingling sensation is elicited test is +)
4-D (Lachman Test for ACL injury of the knee where tendon is twisted causing injury; patient cannot squat, very painful)
5-F (straigth leg raising test_ leg is raised 45 degrees, ask pt to hyperextend against the examiner’s hand if pt is experienced pain, test is +)
6-E (Spruling test – test for range of motion (flexion.. of neck)
7-A (Drop-arm test for rotator cuff evaluation)
8-B (Finkelstein test)
Ms. Hannigan is a 70-year-old woman with well-controlled hypertension, dyslipidemia, and hypothyroidism. Her current medications include a statin, ACE inhibitor, a thiazide diuretic, and levothyroxine replacement. She presents today with a chief complaint of a 2-month history of fatigue and aching sensation accompanied by morning stiffness in her hips and shoulders. During this time, she has lost 8 lb (3.6 kg) “without even trying” and reports struggling to get dressed, especially when putting on a shirt or pants. Physical exam reveals full limb strength, decreased active range of motion in the hips and shoulders, cool, smooth joints, and no excessive muscle tenderness. Laboratory test results include:
Hb=10.8 g/dL (108 g/L)
Hct=32% (0.32 proportion)
MCV=86 fL
RDW=12.2% (0.122 proportion)
ESR=112 mm/h (ULN=20 mm/h)
The result of her hemogram reveals:
Iron deficiency anemia.
Pernicious anemia.
Anemia of chronic disease.
Age-relative normative findings.
Ans: Anemia of chronic disease.
Ms. Hannigan’s clinical presentation is most consistent with:
Based on the below scenario:
Ms. Hannigan is a 70-year-old woman with well-controlled hypertension, dyslipidemia, and hypothyroidism. Her current medications include a statin, ACE inhibitor, a thiazide diuretic, and levothyroxine replacement. She presents today with a chief complaint of a 2-month history of fatigue and aching sensation accompanied by morning stiffness in her hips and shoulders. During this time, she has lost 8 lb (3.6 kg) “without even trying” and reports struggling to get dressed, especially when putting on a shirt or pants. Physical exam reveals full limb strength, decreased active range of motion in the hips and shoulders, cool, smooth joints, and no excessive muscle tenderness. Laboratory test results include:
Hb=10.8 g/dL (108 g/L)
Hct=32% (0.32 proportion)
MCV=86 fL
RDW=12.2% (0.122 proportion)
ESR=112 mm/h (ULN=20 mm/h)
Rheumatoid arthritis.
Fibromyalgia.
Osteoarthritis.
Polymyalgia rheumatica.
The most appropriate next step in Ms. Hannigan’s plan of care is:
Based on the below scenario:
Ms. Hannigan is a 70-year-old woman with well-controlled hypertension, dyslipidemia, and hypothyroidism. Her current medications include a statin, ACE inhibitor, a thiazide diuretic, and levothyroxine replacement. She presents today with a chief complaint of a 2-month history of fatigue and aching sensation accompanied by morning stiffness in her hips and shoulders. During this time, she has lost 8 lb (3.6 kg) “without even trying” and reports struggling to get dressed, especially when putting on a shirt or pants. Physical exam reveals full limb strength, decreased active range of motion in the hips and shoulders, cool, smooth joints, and no excessive muscle tenderness. Laboratory test results include:
Hb=10.8 g/dL (108 g/L)
Hct=32% (0.32 proportion)
MCV=86 fL
RDW=12.2% (0.122 proportion)
ESR=112 mm/h (ULN=20 mm/h)
Referral to physical therapy.
Rest and ice to the affected areas.
Initiating a course of systemic corticosteroids.
Prescribing oral low-dose bisphosphonate therapy.
Ans: Initiating a course of systemic corticosteroids
Richard is a 28-year-old man who presents with a chief complaint of left knee pain and swelling for the past month, as well as redness and tearing in the left eye for the past week. He also has had intermittent dysuria and 2-3 loose stools per day for the past 2 weeks. He denies weight loss, skin rash, or fever. Physical exam reveals a smooth, swollen, red, warm left knee with decreased range of motion, pupils equal and reactive to light with marked unilateral conjunctival redness. The urinary meatus is reddened. Richard’s clinical presentation is most consistent with:
Systemic lupus erythematosus.
Polymyalgia rheumatica.
Reactive arthritis (Reiter’s syndrome).
Psoriatic arthritis.
ans: Reactive arthritis (Reiter’s syndrome).
n evaluating Richard, the next most appropriate test to obtain is:
Based on the below scenario:
Richard is a 28-year-old man who presents with a chief complaint of left knee pain and swelling for the past month, as well as redness and tearing in the left eye for the past week. He also has had intermittent dysuria and 2-3 loose stools per day for the past 2 weeks. He denies weight loss, skin rash, or fever. Physical exam reveals a smooth, swollen, red, warm left knee with decreased range of motion, pupils equal and reactive to light with marked unilateral conjunctival redness. The urinary meatus is reddened.
Serum antinuclear antibodies.
Serum rheumatoid factor.
Urinary PCR testing for N. gonorrhoeae and C. trachomatis.
Stool for ova and parasites.
ans: Urinary PCR testing for N. gonorrhoeae and C. trachomatis.
Josh is a 14-year-old basketball player who presents with anterior knee pain that has occurred intermittently over the past 3 months. The pain worsens with squatting and walking up or down stairs, and is better with rest. He denies fever, weight loss, joint redness, or skin rash. Physical examination reveals a Tanner 3 male in no acute distress with a tender, swollen tibial tuberosity in the affected knee. Pain can be reproduced with resisted active extension and passive hyperflexion of the knee. No effusion is present. Josh’s presentation is most consistent with:
Osgood-Schlatter disease.
Prepatellar bursitis.
Meniscal tear.
Reactive arthritis.
Ans: Osgood-Schlatter disease.
Intervention for Josh should include information about:
Based on the below scenario:
Josh is a 14-year-old basketball player who presents with anterior knee pain that has occurred intermittently over the past 3 months. The pain worsens with squatting and walking up or down stairs, and is better with rest. He denies fever, weight loss, joint redness, or skin rash. Physical examination reveals a Tanner 3 male in no acute distress with a tender, swollen tibial tuberosity in the affected knee. Pain can be reproduced with resisted active extension and passive hyperflexion of the knee. No effusion is present.
Curtailing his participation in sporting activities.
Avoiding sports that involve heavy quadriceps loading or deep knee bending.
The benefit of intraarticular corticosteroid injection for the control of discomfort.
The likely need for surgical correction of the defect.
Ans: Avoiding sports that involve heavy quadriceps loading or deep knee bending.
You are evaluating Karen, a 48-year-old African American woman who is a nonsmoker and drinks 2 glasses of wine per week. She has a longstanding intermittent lumbosacral strain that she attributes in part to her work, which requires her to be physically active. Today she presents with a 2-week history of shooting pain down the right leg and occasional “dragging” of the right foot with walking. Karen denies any recent trauma or precipitating event. Examination reveals abnormal straight-leg raising, diminished right patellar reflex, and difficulty performing heel walking. She relates, “I am really uncomfortable. This is different than my usual back pain.” Her presentation is most consistent with:
Lumbar radiculopathy.
Exacerbation of chronic lumbar-sacral strain.
Vertebral compression fracture.
Spondyloarthropathy.
Which of the following represents the most appropriate next step in Karen’s plan of care?
Based on the below scenario:
You are evaluating Karen, a 48-year-old African American woman who is a nonsmoker and drinks 2 glasses of wine per week. She has a longstanding intermittent lumbosacral strain that she attributes in part to her work, which requires her to be physically active. Today she presents with a 2-week history of shooting pain down the right leg and occasional “dragging” of the right foot with walking. Karen denies any recent trauma or precipitating event. Examination reveals abnormal straight-leg raising, diminished right patellar reflex, and difficulty performing heel walking. She relates, “I am really uncomfortable. This is different than my usual back pain.”
Advise a 3-day course of bedrest
Refer to physical therapy
Order a lumbosacral MRI
Obtain a standing lumbosacral x-ray
Ans: Refer to physical therapy
Match each of the following findings with the associated disease state. An item can be used more than once.
A. Rheumatoid arthritis
B. Systemic lupus erythematosus
C. Osteoarthritis
1. Anemia of chronic disease
2. Elevated C-reactive protein
3. Joint-space narrowing on x-ray
4. Positive antinuclear antibody titer
1-A & B 2-A & B 3-C 4-A & B
1-A 2-C 3-B & A 4- A & B
1-A & B 2-A 3-A 4-A & C
1-C 2-A 3-C 4-A & B
Mrs. Garcia is a 78-year-old woman who presents with a chief complaint of progressively increasing aches, limited to her hands and fingers, particularly after doing yard work. Otherwise, she denies musculoskeletal problems. Physical examination reveals bilateral Heberden’s and Bouchard’s nodes.
1. Identify the location of the Heberden’s nodes. _____
2. Identify the location of the Bouchard’s nodes. _____
1-A 2-B
Jane is a 56-year-old woman who undergoes DXA testing of the spine and reveals a T-score of ‒2.9. Based on recommendations by the American College of Physicians, the NP suggests:
No treatment needed at this time.
Initiating treatment with risedronate.
Initiating treatment with estrogen therapy.
Initiating treatment with raloxifene.
Ans: Initiating treatment with risedronate.
Ans: At the completion of therapy
Ans: Erythema surrounding the joint.
Ans: use of hyaluronic acid injection
A 20-year-old woman requests information about emergency contraception using high-dose progestin after having unprotected sexual intercourse approximately 18 hours ago. Today is day 12 of her normally 27-29 day menstrual cycle. You respond that:
The use of this type of emergency contraception reduces the risk of pregnancy by approximately 33% if taken at this point.
All forms of emergency contraception must be used within 18 hours of unprotected intercourse to be effective.
The likelihood of pregnancy is minimal and emergency contraception is not indicated.
Progestin-based emergency contraceptive is likely helpful in reducing pregnancy risk when used as long as 120 hours post intercourse.
According to the US medical eligibility criteria for contraceptive use which of the following clinical scenarios describes a Category 3 (exercise caution) situation for the use of a combined oral contraceptive?
Presence of factor V Leiden mutation
Report of ectopic pregnancy 2 years ago
Treatment 3 years ago for high grade squamous intraepithelial neoplasia (HGSIL) with loop electrical excision procedure (LEEP)
History of gastric bypass surgery
A 23-year-old- woman is breastfeeding her healthy newborn. She wishes to use hormonal contraception. Which of the following represents an unacceptable choice?
Combined oral contraception initiated at 2 weeks
Progestin-only oral contraception initiated at 3 weeks
Medroxyprogesterone acetate (Depo-Provera®) given day 1 postpartum
CU-containing IUD (ParaGard®)
Ans: Combined oral contraceptives initiated at 2 weeks.
Who is a combined oral contraceptive (estrogen/progestin) candidate?
A. Category 1
B. Category 2
C. Category 3
D. Category 4
E. Category 1 for Initiation & Category 2 for continuation
F. Category 3 for Initiation & Category 4 for continuation
1. 22-year-old who smokes 1 PPD__
2. 29-year-old with pelvic inflammatory disease __
3. 45-year-old with recurrent tension-type headache: Non-migrainous headache __
4. Age ›40 years __
5. 36-year-old woman with well controlled primary hypertension who is taking ARB and HCTZ: HTN with adequate control __
6. HTN with poor control __
1-A 2-B 3-E 4-C 5-C 6-D
1-B 2-A 3-E 4-B 5-C 6-D
1-C 2-A 3-D 4-F 5-B 6-A
1-F 2-D 3-A 4-A 5-A 6-C
Ans: Increase in serum albumin
PPIs such as lansoprazole, omeprazole and esomeprazole are all inhibitors of CYP450:
3A4
2C19
1A2
2D6
Ans: ARBs orACIs due to increase risks of hypotension and cardiac events
For an 87-year-old man with a history of cardiovascular disease and requires an LDL-C reduction of approximately 33%, the NP recommends:
Initiating atorvastatin 20 mg daily
Initiating rosuvastatin 20 mg daily
Initiating simvastatin 10 mg daily
No statin therapy as there is likely no significant benefit at his age
Once I have achieved national certification, I can practice as a nurse practitioner.
True
False
The charge of the State Board of Nursing is to ensure public safety.
True
False
State level authorization dictates the ability of the NP to obtain a Federal DEA number.
True
False
Which of the following describes the ethical principle of beneficence?
The right of the competent person to choose a personal plan of life and action.
The obligation of the healthcare provider to help people in need.
The duty of healthcare provider to do no harm.
The responsibility of the healthcare provider to treat all in the same fair manner.
Ans: The obligation of the healthcare provider to help people in need.
The majority of NPs are eligible to obtain a Federal DEA number.
True
False
Which of the following describes the ethical principle of utilitarianism?
Healthcare resources are allocated so that the best is done for the greatest number of people.
The healthcare provider must be truthful and avoid deception.
The healthcare provider has an obligation to be faithful to commitments made to self and others.
The responsibility of the healthcare provider is to treat all people in the same fair manner.
Ans: Healthcare resources are allocated so that the best is done for the greatest number of people.
Which of the following describes the ethical principle of veracity?
Healthcare resources are allocated so that the best is done for the greatest number of people.
The healthcare provider must be truthful and avoid deception.
The healthcare provider has an obligation to be faithful to commitments made to self and others.
The responsibility of the healthcare provider is to treat all people in the same fair manner.
Ans: The healthcare provider must be truthful and avoid deception.
A mother presents her 3-year-old son with a 2-day history of cough and runny nose without fever. The NP explains that this is likely a viral infection and treatment should focus on symptom management. However, the mother is insistent on getting a prescription for antibiotics despite the NP’s explanation that antibiotics will have limited effectiveness and may cause adverse effects. In this scenario, which of the following best demonstrates the ethical principle of nonmaleficence?
Providing a prescription for an antibiotic regimen.
Providing a 2-day sample of antibiotics with follow-up at 3 days to determine if additional antibiotics are needed.
Denying a prescription for antibiotics.
Getting approval from a physician prior to giving the antibiotic prescription
Ans: Denying a prescription for antibiotics.
Which of the following best demonstrates the intent of informed consent?
Discussing the risks of surgery with the parent of a 20-year-old
Advising a 48-year-old woman about the likely course of illness if no treatment is rendered
Conferring with the husband of a 30-year-old woman who has pneumonia about the benefits of antimicrobial therapy
Recommending a course of treatment to a 70-year-old man with prostate cancer
Ans: Advising a 48-year-old woman about the likely course of illness if no treatment is rendered
A patient who underwent CABG following a MI develops a surgical site infection. Upon reviewing the patient’s records, the NP notices that standard antimicrobial prophylaxis was not provided prior to surgery. The ethical principle of ________ requires the NP to report this finding.
Nonmaleficence
Justice
Veracity
Utilitarianism
A mentally competent patient with advanced cancer is explained 2 treatment options. He decides to take the less invasive technique, despite counseling him that his choice has a lower chance for success. Respecting the patient’s choice demonstrates the ethical principle of:
Justice
Veracity
Paternalism
Autonomy
A 90-year-old woman with moderate dementia, heart failure, and chronic renal insufficiency presents with a new onset of weakness. Further evaluation reveals marked hyperkalemia with a eGFR=22 mL/min/1.73 m2. Nephrology recommends hemodialysis. When discussing this option with the patient, she declines this treatment. She also inaccurately reports the current year, location, and name of the USA president. When asked why she does not want dialysis, she states, “I do not want to be on a machine. I am quite old and my health is not good.” When asked what she believes will happen if she does not have dialysis, she states, “I guess I will die. That is OK.” In reflecting on this patient, the NP appreciates that:
She demonstrates competency in this situation and her wishes can be followed.
Due to her inability to report accurate date, location, or current president, she is not competent to make healthcare decisions.
A patient with a documented diagnosis of dementia is considered incompetent to make all healthcare decisions.
Court-appointed guardianship should be sought.
Ans:
She demonstrates competency in this situation and her wishes can be followed.
Mr. Nelson is a 75-year-old man in need of surgery. Mr. Nelson has been treated unsuccessfully with conservative therapy for a bowel obstruction. Documented on his record is his consent to surgery that was obtained by the chief surgical resident. During your preoperative visit with Mr. Nelson, he is alert and relatively comfortable. His wife mentions that her husband had a dose of promethazine (Phenergan®) to manage his nausea around the time the surgical consent was obtained. Mrs. Nelson asks, “Is the consent OK since my husband clearly does not feel well?” You respond:
Since the chief surgical resident obtained the surgical consent, this should be considered valid.
Legal counsel should be obtained prior to proceeding.
That surgical consent should be obtained from Mrs. Nelson as she is Mr. Nelson’s de facto healthcare proxy.
You will call the chief surgical resident to clarify the issue of consent.
Ans: You will call the chief surgical resident to clarify the issue of consent.
For an individual to demonstrate the capability to make an informed healthcare decision, all of the following must be present except:
The patient has the ability to understand the nature of the clinical condition.
The patient can interpret the information presented.
The patient is able give a reason for the choice if asked.
The patient does not need to be able to communicate what the care preference is.
Ans: The patient does not need to be able to communicate what the care preference is.
The adult daughter of an 88-year-old man telephones the nurse practitioner to inquire about her father’s medications. The daughter reports that “my father relies upon me to explain everything to him.” The nurse practitioner’s initial response is to:
Ask the daughter to provide a copy of the patient’s advance directive document.
Assure the daughter that the NP can share the requested information.
Inform the daughter that she must come to the clinic to discuss her father’s care.
Tell the daughter that the NP can discuss the information only with the patient.
Ans: Tell the daughter that the NP can discuss the information only with the patient.
A 50-year-old man of Croatian ancestry has a follow-up appointment after cardiac bypass surgery. The patient brings his father with him into the examination room. They are both fluent English speakers. The NP provides culturally sensitive care by the following action.
Ask the patient’s father if he has any questions regarding his son’s care.
Request the patient’s father to leave the room due to confidentiality issues.
Acknowledge the father’s presence and complete the visit while reporting all findings to the patient.
Perform the clinical evaluation, then report to the patient’s father the examination findings.
Ans: Ask the patient’s father if he has any questions regarding his son’s care.
You see a 62-year-old man, Mr. Tran, who is from Southeast Asia. He is accompanied in the exam room by his 39-year-old son. Both are fluent English speakers. Mr. Tran is seen in follow-up on type 2 diabetes and hypertension. As you speak with Mr. Tran, he smiles, nods his head in response to your questions. He frequently looks down at the floor. You consider that:
Mr. Tran is conveying that he understands your questions.
His downcast gaze should trigger an assessment for depression or other mood disorder.
Directing your questions to Mr. Tran’s son is likely a more appropriate approach to the visit.
Mr. Tran is showing respect for the healthcare provider’s authority.
Ans:
Mr. Tran is showing respect for the healthcare provider’s authority.
Mr. Miller is a 60-year-old man with hypertension. On today’s office visit, his blood pressure is noted to be 122/78. The rest of his history and physical examination are unremarkable. He mentions that, in addition to his antihypertensive medication you have prescribed, he uses a teaspoon of hot pepper sauce in a glass of warm water daily to help “clean my blood and lower the pressure. I feel much better when I take it.” Your most appropriate response is to:
Advise Mr. Miller to stop using the hot pepper sauce.
Explore what Mr. Miller means by “clean my blood.”
Inform Mr. Miller that this practice can result in serious gastrointestinal complications.
Ask Mr. Miller to stop the hot pepper sauce use until you can examine the contents of the product he uses.
Ans: Explore what Mr. Miller means by “clean my blood.”
Mr. Santorini is a 71-year-old man with a 10-year history of hypertension. He is currently taking a fixed-dose lisinopril/hydrochlorothiazide tablet daily and reports excellent adherence. On today’s visit, he is without complaint and physical examination is within normal limits, with BP=138/84. He mentions that, for the past three months, he has been sprinkling a “pinch” of cumin and coriander mixture on his food once a day to “help control my blood pressure” and reports “feeling like I have more energy” since starting this. You consider that:
This mixture will likely interact with his antihypertensive medications.
Using cumin or coriander could raise his blood pressure.
Additional medications can be prescribed if his blood pressure control worsens.
He is advocating for his health and the practice should be supported.
Ans:
He is advocating for his health and the practice should be supported.
Medicaid is the largest payer for nursing facility care.
True
False
Impoverishment is the primary requirement for Medicaid eligibility.
True
False
A 52-year-old woman who is Muslim arrives for an office visit. Her last primary healthcare visit was more than 10 years ago. She mentions that she does not want to disrobe or remove her head cover for a physical exam. You consider that:
Her healthcare visit cannot proceed until the patient is able to disrobe for the physical exam.
A mammogram should be ordered without prior breast examination.
The option of having a modified physical examination with minimal disrobing should be discussed with the patient.
The health history can be completed today and the physical examination deferred until a future office visit.
You see a 54-year-old woman, Senora Sanchez, who is not fluent in speaking English, who comes into the emergency department of a 300-bed hospital with a chief complaint of abdominal pain and is accompanied by Tomas, her 10-year-old nephew. Tomas states, “I am here to help my aunt since she does not speak English.” Which of the following is the most appropriate way in conducting this clinical encounter?
Direct questions to Tomas, asking him to translate the information to his aunt.
Direct questions to Senora Sanchez, asking Tomas to translate.
Advise that Senora Sanchez return with an adult interpreter.
Call the hospital’s interpreter services department for assistance.
Ans: Call the hospital’s interpreter services department for assistance.
You see a 24-year-old mother who presents with her healthy 18-month-old son. He is being seen for a well child visit. An interactive child who is quite playful, his examination is within normal limits. When you ask if the mom has any concerns, she states, “I do not like it when people stare at my baby. He is going to get sick.” You respond:
“What type of illness do you think your son will get when people look at him?”
“You are concerned he will get sick if people look at him?”
“Please make sure you come back for a sick visit with your baby whenever you have concerns about your son.”
“Your baby is just delightful. I can imagine that people often look at him.”
Ans:
“You are concerned he will get sick if people look at him?”
The APRN writes a prescription for trimethoprim-sulfamethoxazole for a patient who has a skin and soft tissue infection and known sulfa allergy. The patient takes two doses of the medication, has no reaction, then realizes this might be one of the problematic antibiotics. The patient notifies the practice and the APRN changes the medication. He makes a full recovery.
Yes or No
1. Is there negligence? __
2. Is there damage? __
1-Yes 2-Yes
1-No 2-Yes
1-Yes 2-No
1-No 2-No
Billing and coding are basically the same thing.
True
False
True/False In keeping with HIPAA’s requirements:
1. You cannot announce a patient’s name in a waiting room.__
2. If interrupted during a patient visit, prior to leaving the exam room, the healthcare provider should lock or otherwise disable the electronic health record (EHR) to minimize the risk of unauthorized access to information.__
3. A healthcare provider can leave a patient a message on his or her answering machine unless specifically asked not to do so but the amount of information disclosed should be limited.__
4. Unless asked not to do so by the patient, a healthcare provider is allowed to leave a message with a family member or other person who answers the phone when the patient is not home.__
5. If interrupted during a patient visit, prior to leaving the exam room, the healthcare provider should take the paper healthcare record with him/her, in order to minimize the risk of unauthorized access to information.__
6. Unless under the control of the healthcare provider or staff, paper records should be kept in a secure location, such as a locked desk, locked filing cabinet or office with appropriate staff.__
7. An employee of a healthcare facility is only able to access patient records for legitimate, job-related purposes.__
8. If a patient requests a paper copy of his/ her record, the healthcare facility can charge a reasonable fee for this service.__
1-False 2-True 3-True 4-True 5-True 6-True 7-True 8-True
1-False 2-False 3-True 4-False 5-True 6-True 7-True 8-True
1-True 2-True 3-True 4-False 5-False 6-True 7-True 8-False
Ans: 1-False 2-True 3-True 4-True 5-True 6-True 7-True 8-True
Ans: Current procedural terminology
Which information concerning the use of email messages is included in the Health Insurance Portability and Accountability Act?
Email messages are not an acceptable form of communication under any circumstances.
Email messages are suitable only if this communication contains medical record numbers, instead of patient names.
Email messages are acceptable between healthcare providers, but not between healthcare providers and patients.
Email messages containing private patient information are acceptable if the information is encrypted.
Which of the following represents a valid ICD 10 code?
370.21
99202
K25.1
AZ5.32
diagnostic test that is used to identify patients with colon cancer is determined to have a high sensitivity. Which of the following statements about the test is most accurate?
A negative test result is not a reliable indicator for the absence of colon cancer.
The test reliably provides a negative result for those without colon cancer.
A positive test result reliably identifies someone with colon cancer.
A positive test result is not a reliable indicator for the presence of colon cancer.
Ans: A positive test result reliably identifies someone with colon cancer.
The NP is counseling a 51-year-old male patient who is considering undergoing a PSA test to check for prostate cancer. In explaining the possibility of a false negative result of the test, the NP explains that this can occur when:
A patient without cancer gets a negative test result.
A patient without cancer gets a positive test result.
A patient with cancer gets a negative test result.
A patient with cancer gets a positive result.
Ans: A patient with cancer gets a negative test result.
Ans: RRR is the relative risk (10/40) x 100 = 25%; 100-25% = 75%
Of 40% who received placebo, only 10% received the vaccine which is proportionally equated to 0.25% who have prevented from diseases; remaining 75% who do not receive the vaccine can be infected with diseases.
When RRR is > 1, risk of good or bad outcome of the intervention or treatment is increased. When RRR< 1 the risk of good or bad outcome of the intervention is decreased; when RRR = 1 no change.
Ans: Certain target organs in a predictable manner.
Ans: Alcohol-based lotion to prevent infection.
A new family nurse practitioner is beginning a practice in weight management. While reviewing the literature on techniques to promote weight loss, he finds a research report of 30 adult women who recorded their daily caloric intake on a new iPhone® application while on a weight loss plan. The women lost an average of 10% starting weight during the study. In the discussion section of the paper, the author suggested that based on these data, adult women who used this iPhone® application while on a weight loss plan would lose 10% of starting weight. The new FNP questions whether or not the iPhone® application is the cause of the weight loss.
This suggests questionable:
Reliability.
Power.
Confidence level.
External validity.
Ans:
External validity.
In this situation, 30 adult women used Iphone appl. to log in their daily caloric intake has helped these women to lose 10% starting weight. The Iphone appl. is considered an external inference which can be generalised to other situations or outside of the studied population. FNP questions if ” the Iphone appl. is the cause of the weight loss for other people as well?”
For the newborn described above, you advise:
A referral to a dermatologist who specializes in pulse dye laser therapy.
These lesions will likely lighten over time and disappear during childhood.
Evaluation at 6-month intervals due to increased malignancy potential.
Initiating a course of corticosteroid cream for the affected area.
Ans: These lesions will likely lighten over time and disappear during childhood.
ans: 1%
10,000/1,000,000= 0.001 x 100% = 1%
A 21 year old woman with normal BMI prior to pregnancy is now 38-weeks pregnant. Her weight gain up to 28 weeks was 12 lbs (5.45 kg) and she has gained 2 lbs (0.9 kg) from 29 weeks to 38 weeks. Her weight gain pattern is most likely to affect her baby’s:
Birth weight.
Head circumference.
Birth length.
Apgar scores.
A 2-week-old boy is presented by his mother for evaluation. The boy was born at 39 weeks’ gestation and appears healthy. The mother expresses concern about an area of abnormal growth under his left ear. She states that he was born with a pinkish “blotch” in the area but has noticed a significant change over the past few days. Upon examination, you note a red slightly-protruding spongy mass approximately 0.5 cm in diameter.
For the infant described above, an appropriate initial treatment option would be:
Corticosteroid injection.
Oral propranolol.
Mohs surgery.
Laser therapy.
Parents of Asian ancestry brings in her healthy 1-month-old daughter born at 40-weeks’ gestation for a well child evaluation. Upon examination, you notice multiple non-tender blue-black macular lesions on the lower back and buttocks.
The most likely diagnosis is:
Port wine lesion.
Milia.
Keratosis pilaris.
Mongolian spot.
When counseling a patient with hypertension and/or dyslipidemia on recommended physical activity, all of the following are appropriate goals to strive for except:
Aerobic physical activity (e.g., brisk walking) of at least 40 minutes at a time.
Exercise of at least 3‒4 times per week.
Achieving a peak heart rate of 150 BPM or greater.
No more than 48 hours without exercise.
Ans: Achieving a peak heart rate of 150 BPM or greater.
A 32-year-old landscaper with a history of seasonal allergic rhinitis presents with a variety of symptoms. Match each symptom with the appropriate medication.
A. Oral antihistamine
B. Decongestant nasal spray
C. Corticosteroid nasal spray
1. Acute relief of nasal congestion __
2. Relieve pharyngeal itch __
3. Prevent allergy symptoms __
1-A 2-B 3-C
1-C 2-B 3-A
1-B 2-A 3-C
1-A 2-C 3-B
Ans: 1-B (decongestant nasal spray) 2-A (oral histamine) 3-C ( prevent allergy symptoms)
Match each of the following patients with the most appropriate diagnosis.
A. Increased intracranial pressure
B. Migraine with aura
C. Tension-type headache
D. Cluster headache
1. A 33-year-old man who reports a 3-week history of recurrent headaches that awaken him during the night. Pain lasts up to 2 hours and is focused primarily behind the right eye. __
2. A 29-year-old woman with a 2-year history of recurrent, unilateral, pulsating headaches that are often accompanied by nausea/vomiting and photophobia. She reports seeing “squiggles before my eyes” about 10 minutes before a headache occurs. __
3. A 54-year-old man reporting occasional bilateral, pressing, nonpulsatile headaches of moderate intensity without nausea, photophobia, or phonophobia. __
4. A 45-year-old man who reports a pressing, nonpulsatile headache that is greatest in severity upon awakening each morning and lessens as the day progresses. __
1-A 2-C 3-B 4-D
1-D 2-B 3-C 4-A
1-B 2-A 3-D 4-C
Ans: 1-cluster head ( 4. A 45-year-old man who reports a pressing, nonpulsatile headache that is greatest in severity upon awakening each morning and lessens as the day progresses)
2- Migraine w aura (A 29-year-old woman with a year history of recurrent, unilateral, pulsating headaches that are often accompanied by nausea/vomiting and photophobia. She reports seeing “squiggles before my eyes” about 10 minutes before a headache occurs.
3-tension-type h/a (A 33-year-old man who reports a 3-week history of recurrent headaches that awaken him during the night. Pain lasts up to 2 hours and is focused primarily behind the right eye)
4- Increased intracranial pressure ( A 45-year-old man who reports a pressing, nonpulsatile headache that is greatest in severity upon awakening each morning and lessens as the day progresses).
Ans: A disorder of insulin resistance with eventual insulin deficiency.
ans:
Atrophy in intertriginous areas
Ans: Well-demarcated plaques and coalescing papules on the knees.
When initiating pharmacologic therapy for the patient with first diagnosis of major depression disorder, the nurse practitioner advises the patient that treatment should:
Generally be given for about 4-6 months before improvement is noted.
Continue for at least 6 months after remission is achieved.
Be continued indefinitely after therapeutic goals are met.
Be started at a higher dose then titrated to a lower dose once symptom relief is achieved.
Ans: Continue for at least 6 months after remission is achieved.
our neighbor asks you to refill her high blood pressure medicine as she could not make her last office visit to her provider due to a family emergency. You are aware that she is going through a difficult time personally and agree to call in the prescription. As a result:
A healthcare provider-patient relationship has been formed.
The Good Samaritan Act will protect you from liability since you volunteered to help her out.
You should charge your neighbor for a standard office visit in order to keep your relationship with her on a professional level.
You realize this action is acceptable as her antihypertensive medication is not a controlled substance.
Ans: A healthcare provider-patient relationship has been formed.
Gary is a 26-year-old graduate student who is diagnosed with major depressive disorder (MDD) without psychotic features. His medical history is unremarkable and he states that he does not wish to undergo psychotherapy. An appropriate first-line medication is:
Sertraline (Zoloft®).
Bupropion (Wellbutrin®).
Amitriptyline (Elavil®).
Trazodone (Oleptro®).
Ans:
Reproduction of symptoms with forced flexion of the wrists
Ans: III, IV, VI.
I – oldfactory nerve -smell – SENSORY
II – optic (vision) -MOTOR- test for accommodation, visual field, pupillary reaction
III- oculomotor nerve – eye move up or down; outward or inward; drooping lid-reflag. MOTOR
IV- trochlear nerve- eye movement down and inward – MOTOR
V- trigeminal nerve – corneal blink reflex, sensation (wisp of cotton, light vs. dull touch) BOTH
VI- Aducens nerve- eye movements (ability to move eyes bilaterally) MOTOR
VII- Facial nerve – facial expression, clench teeth, puff cheeks out, production of saliva and tears, raise eyebrown, close eyes against resistance- MOTOR
Usually V and VII are tested together.
VIII- Acoustic nerve- hearing -Wiber test (lateralization) Rinne test (air vs bone conduction) SENSORY
IX- glossaphareangeal – test gag reflex (say Ahh)- BOTH
X- Vagus nerve- swallowing or gag reflex, voice – BOTH
XI- Spinal accessory – test shoulder movements like shrugging, push up against resistance – MOTOR
XII- Hypoglossal – tongue movements (sticks tongue out, move tongue side-to-side) MOTOR
Ans: White blood cell (WBC) casts.
Mr. Woods is a 63-year-old man who presents for initial evaluation at your practice. He has a 45 pack-year smoking history and COPD that is currently being treated with daily oral theophylline and albuterol via MDI prn. He complains of shortness of breath and chronic cough with sputum production. He states, “I can barely walk to my car without getting out of breath.” Spirometric assessment reveals an FEV1 of 45% predicted and a FEV1:FVC of 62%. His health history reveals 3 exacerbations in the past year. The best course of action for Mr. Woods to minimize COPD exacerbation risk is to:
Continue on theophylline therapy.
Advise using albuterol on a set schedule rather than prn.
Switch to a long-acting beta2-agonist as needed for shortness of breath.
Add therapy with a long-acting muscarinic antagonist uses on a set schedule.
Ans: Add therapy with a long-acting muscarinic antagonist uses on a set schedule.
A 20-year-old male complains of being fatigued for the past week. The physical examination is significant for anterior and posterior cervical lymphadenopathy and right and left upper quadrant abdominal tenderness. A white blood cell differential is significant for lymphocytosis with reactive forms. Which of the following additional findings does the nurse practitioner anticipate?
Pharyngitis with exudate
Supraclavicular lymphadenopathy
Diffuse maculopapular rash
Marked sinus tenderness
A 33-year-old woman comes to your office and reports that she is “having a stroke.” She has no medical history and no significant risk factors for cerebrovascular disease, but today she has sudden onset of inability to tightly close her eyelid and to frown or smile on the right side of her face. Her physical examination is otherwise unremarkable. The nurse practitioner recognizes that this likely represents paralysis of cranial nerve (CN):
IV.
V.
VI.
VII.
Ans: TPO antibodies. (thyroid protease antibodies)
Ans: Assessment of visual acuity.
One of the preferred pharmacologic options of persistent cough in an otherwise well 25-year-old woman with acute uncomplicated bronchitis would most likely include:
Antibiotic therapy to cover atypical pathogens.
An inhaled short-acting muscarinic antagonist.
An inhaled corticosteroid.
A dextromethorphan-based cough suppressant.
Ans: An inhaled short-acting muscarinic antagonist.
The Federal Drug Enforcement Administration (DEA) provides registration numbers for prescription of controlled substances to which of the following groups?
NPs with federal prescription authority
Physicians, veterinarians, dentists, and NPs who practice in oncology or palliative care
NPs with state-determined controlled substance prescriptive authority
Nationally-certified APRNs with state licensure
Ans:
NPs with state-determined controlled substance prescriptive authority
In initial prescription of thyroxine therapy, which of the following statements is true?
TSH should be checked about 2 days after dose adjustment.
The anticipated thyroxine dose is usually calculated using an age- and weight-based formula.
TSH should be suppressed to undetectable measures when seeking therapeutic effect.
The therapeutic dose of thyroxine needed by the elderly is approximately the same as that needed by the younger adult and child.
Ans: The anticipated thyroxine dose is usually calculated using an age- and weight-based formula.
A 38-year-old woman presents complaining of weight loss, agitation, and new-onset tremor. The nurse practitioner suspects hyperthyroidism. Laboratory assessment will most likely include:
TSH=8.9 mIU/L (0.4-4.0 mIU/L), free T4 =15 pmol/L (10-27 pmol/L).
TSH<0.15 mIU/L (0.4-4.0 mIU/L), free T4 =79 pmol/L (10-27 pmol/L).
TSH=24 mIU/L (0.4-4.0 mIU/L), free T4 =3 pmol/L (10-27 pmol/L).
TSH=1.9 mIU/L (0.4-4.0 mIU/L), free T4 =22 pmol/L (10-27 pmol/L).
Ans: TSH<0.15 mIU/L (0.4-4.0 mIU/L), free T4 =79 pmol/L (10-27 pmol/L).
Clinical evaluation of a 43-year-old man with a BMI=42 kg/m2 who presents with recurrent genital Candida albicans infection should include all of the following except:
Treatment with oral or topical antifungals.
Offering testing for HIV antibodies.
Avoidance of soap on the genitals.
Checking A1C.
Ans: Avoidance of soap on the genitals.
Ans:
Offering genetic counseling prior to pregnancy.
Which of the following are potential candidates to receive the PCV13 pneumococcal vaccine? (YES or NO)
1. A 67-year-old man who received the PPSV23 vaccine 1 year ago __
2. A healthy 58-year-old woman who is receiving the seasonal influenza vaccine today __
3. A 48-year-old man who uses smokeless tobacco __
4. A 36-year-old woman with HIV infection who received the PPSV23 vaccine 3 years ago __
1-Yes 2-No 3-Yes 4-No
1-No 2-No 3-Yes 4-No
1-Yes 2-No 3-No 4-No
1-Yes 2-No 3-No 4-Yes
Ans: Radioactive ablation of overactive thyroid tissue.
A 54-year-old man with COPD is experiencing an exacerbation characterized by increased cough and shortness of breath for the past 48 hours, as well as mild sore throat, clear nasal discharge and body aches. He is currently being managed with a long-acting beta2-agonist and long-acting muscarinic antagonist . An appropriate treatment for this patient would include:
Oral amoxicillin/clavulanate.
Oral levofloxacin.
Oral corticosteroid.
Theophylline.
ans: Trimethoprim-sulfamethoxazole
Ans: Enhanced insulin release.
Metformin – Biguanide – 1st line therapy- insulin sensitizer; neutral weight loss. Complication: can cause GI symptoms (diarrhea) or renal acidosis; monitor renal function.
Glipizide, glipizide..- Sulfonuleas class- constant insulin release- causes weight gain, high risk of hypoglycemia, monitor in adult patients.
Sitagliptin- DDP-4 (-gliptins) – insulin release post glucose rise in the body- neutral weight control- rare side effects
Pioglitazones (TZDs)- insulin sensitizers- modest gain weight, avoid use in CHF causing edema, increase risk of fractures.
Exenatide (SQ Injection)- insulin release post glucose rise- GI symptoms
Canagliflozin – SGLT2- glucose excretion (through urine) post glucose rise- modest weight loss, increase chance of urethral/vaginal yeast infection, dehydration or fractures, monitor renal function.
Ans: An 85-year-old male who lives alone
Ans :
Consistent early morning wakening
A 52-year-old woman presents to your office as a new patient. She reports a long history of high blood pressure, and admits she does not regularly take her medication. Which of the following is an anticipated funduscopic finding?
Narrowing of arterioles
An increased cup:disk ratio
Macular degeneration
Cotton-wool spots
Performing Weber and Rinne tests is part of the evaluation of cranial nerve (CN):
V.
VI.
VII.
VIII.
ans: Keeping bedroom windows open in the early morning.
A 22-year-old man presents for hepatitis screening. He is without symptoms but needs the testing for a job in the food service industry.
Laboratory results are as follows:
-Anti-HCV with HCV RNA present
-HBsAg=positive
-Anti-HAV=negative
You advise the patient that he:
Has chronic hepatitis A, B, and C.
Is immune to hepatitis A and B but has hepatitis C.
Has chronic hepatitis B and C and needs immunization against hepatitis A.
Had hepatitis A in the past, is immune to hepatitis B, and has chronic hepatitis C.
Ans: Has chronic hepatitis B and C and needs immunization against hepatitis A.
A 41-year-old woman was recently diagnosed with systemic lupus erythematous. She complains of feeling generally fatigued and sometimes palpitations.
Her hemogram results are as follows:
-Hb=9.5 g/dL (95 g/L)
-Hct=28% (.28 proportion)
-MCV=86 fL
-RDW= 12.5%
-Reticulocytes=0.9% (.09 proportion)
These findings are most consistent with:
Iron deficiency anemia.
Anemia of chronic disease.
Pernicious anemia.
Alpha thalassemia minor.
Ans: Anemia of chronic disease.
Ans:
Perineal pain with defecation is a common complaint.
Ans: TSH=7.7 mIU/L (0.4-4.0 mIU/L); free T4=22 pmol/L (10-27 pmol/L).
A 45-year-old man complains of bilateral, intermittent itchy eyes, often accompanied by rope-like discharge and without vision change or eye pain. The nurse practitioner expects that the history will include a patient report of:
Trauma to the eye.
Sexually transmitted infection.
Seasonal allergies
Decreased visual acuity.
ans: A 1-2-day prodrome of pain prior to lesions erupting
One week into sertraline (Zoloft®) therapy, a 34-year-old woman complains of a recurrent dull frontal headache that is relieved with acetaminophen. You advise her that:
This is a common, transient adverse effect of SSRI therapy.
Bupropion (Wellbutrin®) should be substituted.
Desipramine (Norpramin®) should be added.
She should discontinue the medication.
Ans: This is a common, transient adverse effect of SSRI therapy.
When prescribing an SSRI, the nurse practitioner considers that:
There will be full therapeutic effect within 2-3 days of the first dose.
These drugs are potentially photosensitizing.
These medications cannot be used in patients with cardiovascular disease.
Mild GI upset is often reported in first weeks of use.
Ans: Mild GI upset is often reported in first weeks of use.
A 52-year-old man presents for evaluation of fatigue. His physical examination is significant only for intention tremor and asymptomatic pharyngeal redness. He reports a history of recurrent gastritis.
Laboratory examination results are as follows:
-Hb=14.3 g/dL (143 g/L)
-Hct=48% (.48 proportion)
-MCV=109 fL
-HDL-C=58 mg/dL (1.5 mmol/L)
-LDL-C=118 mg/dL (3.06 mmol/L)
-Triglycerides=318 mg/dL (3.59 mmol/L)
These findings are most consistent with:
Pernicious anemia.
Iron deficiency anemia.
Alcohol abuse.
Normal findings.
Ans: Unexplained vaginal bleeding
A 27-year-old woman presents for care. She reports a 3-day history of intense vaginal itch, burning with urination, and white, clumping discharge. She denies a foul odor but says her genitals “smell a little musty.” Which of the following history findings supports your diagnosis?
New sexual partner
Swimming in a local lake
Recent antibiotic use
Recent insertion of levonorgestrel-releasing IUD
ans: Trichomoniasis (pics on the desk top)
flagella tail bacteria
A 36-year-old man presents with a 12-h history of anorexia, nausea, and right lower quadrant abdominal pain.
A white blood cell count with differential demonstrates:
-TWBC=16,500 cells/mm3
-Neutrophils=66%
-Bands=8%
-Lymphocytes=22%
Expected physical examination findings include:
Murphy’s sign.
A palpable left lower quadrant mass.
Periumbilical ecchymosis.
A positive obturator sign.
Ans:
A positive obturator sign (appendicitis)
Ans: Using single-use injection drug paraphernalia.
36-year-old man with asthma has been treating his asthma with albuterol once or twice a week for the last few years. He reports that for the last month or so he has had to use it much more often—”not every day, but almost.” The nurse practitioner should consider all of the following except:
Administering the Asthma Control Test questionnaire.
Spirometric assessment.
A complete symptom assessment.
Adding an inhaled long-acting beta2-agonist.
Ans: Adding an inhaled long-acting beta2-agonist.
A 40-year-old man complains of a recurrent dry cough. He is not a smoker, has no airway disease, and his history is significant only for recently diagnosed hypertension. He admits having just started taking medication for his high blood pressure, but doesn’t know what it is called. The nurse practitioner suspects that he is most likely taking a(n):
Angiotensin-converting enzyme (ACE) inhibitor.
Calcium channel antagonist.
Angiotensin receptor blocker.
Beta-adrenergic antagonist.
Ans: Angiotensin-converting enzyme (ACE) inhibitor.
Ans: Right upper quadrant abdominal ultrasound.
Ans: Slightly rough, pink or flesh-colored lesions on the face.
A 52-year-old female of European ancestry with a BMI=24 kg/m2 is diagnosed with new-onset hypertension. She has no significant medical history, no concomitant health problems, and takes no medications. Along with therapeutic lifestyle changes, therapy should begin with which of the following classes of drug?
Aldosterone antagonist
Beta-adrenergic antagonist
Centrally-acting agent
Thiazide diuretic
A 53-year-old woman complains of vaginal dryness and discomfort during sexual activity . She feels like she might have a urinary tract infection, but the urinalysis is negative. Pelvic examination reveals a lack of vaginal rugae. The nurse practitioner considers prescribing:
Antimicrobial therapy.
Oral metronidazole.
Vaginal antifungal.
Topical estrogen.
A 54-year-old woman presents for evaluation of a “cold sore” on her tongue. She has never had one in the past. She denies any pain, drainage, foul taste, or any other symptoms—just has an ulcer that has been there “for a while.” The history is significant for a 62 pack-year smoking history. Physical examination reveals an ulcerated lesion with firm, palpable, indurated margins. The most likely diagnosis is:
Aphthous stomatitis.
Foreign body.
Herpangina.
Squamous cell carcinoma.
A new 27-year-old female patient presents for a health maintenance examination as required by her employer. She tells you that she has had a heart murmur “all of her life” and has been told that it is an “innocent” murmur. Anticipated findings include:
A harsh late systolic snap.
A soft systolic murmur that disappears when in a standing position.
A diastolic murmur best heard at the base of the heart.
A high-pitched murmur that is synchronous with the carotid pulse.
A soft systolic murmur that disappears when in a standing position.
Ans: Upper respiratory tract infection symptoms persisting for ≥10 days
Ans: TSH=0.04 mIU/L (NL=0.15-4.0 mIU/L)
Ans: Frequent application of lubricants.
A patient with newly-diagnosed type 2 diabetes mellitus who has an A1C=8.2% will most likely begin therapy with a medication from which of the following drug classes?
GLP-1 agonist such as exenatide
DPP-4 inhibitor such as saxagliptin
Thiazolidinedione such as pioglitazone
Biguanide such as metformin
Ans: Biguanide such as metformin
You are examining a 21-year-old man who is seeking a sports clearance physical examination. He is generally healthy with an unremarkable medical history. During cardiovascular examination, you identify a physiologic split S2 and realize that this:
Is usually first noticed in early adulthood.
Can progress to a pathologic condition during adulthood.
Will be more pronounced with inspiration.
Is associated with S4 heart sound.
Ans: Will be more pronounced with inspiration.
Ans: A hard, immobile induration.
Ans: Loss of the cremasteric reflex
The nurse practitioner is beginning pharmacologic management of dyslipidemia in a 47-year-old male patient whose lipid panel is as follows:
-Total cholesterol=249 mg/dL (6.45 mmol/L)
-HDL-C=39 mg/dL (1.01 mmol/L)
-TG=279 mg/dL (3.15 mmol/L)
-LDL-C=191 mg/dL (4.94 mmol/L)
The appropriate class of agent is a(n):
Omega-3 fatty acid such as fish oil.
Fibric acid derivative such as fenofibrate.
Cholesterol absorption inhibitor such as ezetimibe.
HMG-CoA reductase inhibitor such as simvastatin.
Ans: HMG-CoA reductase inhibitor such as simvastatin.
In keeping with HIPPA’s requirements, all of the following are true except:
The healthcare provider or designate cannot announce a patient’s name in a waiting room.
If interrupted during a patient visit, prior to leaving the examination room, the healthcare provider should lock or otherwise disable the electronic health record (EHR) to minimize the risk of unauthorized access to information.
An employee of a healthcare facility is only able to access patient records for legitimate, job-related purposes.
If a patient requests a paper copy of his/her record, the healthcare facility can charge a reasonable fee for this service.
ans: The healthcare provider or designate cannot announce a patient’s name in a waiting room.
Managed care is best defined as a:
Collaborative approach to provide coordination of the healthcare services to a defined population.
System for determining what healthcare services are reimbursable.
Process of reviewing the appropriateness of select healthcare interventions.
Method of review to ensure adherence to evidence-based practice.
Meeting the eligibility requirements for national NP certification signifies that the nurse practitioner:
Attained the required academic and clinical skills for specialty practice.
Graduated from an accredited nurse practitioner educational program.
Has achieved select prerequisites determined by a nongovernmental professional organization.
Has permission to practice as a nurse practitioner.
Ans: Has achieved select prerequisites determined by a nongovernmental professional organization.
Ans: Reduction in frequency and severity of vasomotor symptoms.
A 38-year-old woman reports having 3-5 migraine episodes each month that can last 1-3 days. Her medical history is otherwise unremarkable other than bilateral tubal ligation (BTL) 6 years ago. She asks if there is any medication that can help to prevent these migraines. An appropriate prophylactic treatment options to offer this patient is:
Ergotamine (Ergomar®).
Sumatriptan (Imitrex®).
Topiramate (Topamax®).
Verapamil (Verelan).
Ans: Joint space narrowing on X-ray.
Ans: Personal history of polycystic ovary syndrome.
The difference between a macule and a patch is:
Location.
Disease state.
Size.
Configuration.
Ans: Increase in insulin release in response to rising glucose.
Ans: Systolic with radiation to the axillae.
Ans:
A 1-hour post-prandial glucose of 98 mg/dL (5.44 mmol/L)
A 64-year-old man presents complaining of difficulty initiating urination, a weak urine stream, and inability to completely empty the bladder. Suspecting benign prostatic hyperplasia, you prescribe tamulosin and advise the patient that this will:
Decrease the size of the prostate.
Relax the bladder neck muscles to ease urination.
Eradicate bacteria that cause inflammation of the prostate.
Reverse hormonal changes that cause prostate enlargement.
Ans: Relax the bladder neck muscles to ease urination.
A 68-year-old woman presents for evaluation. She reports a recent history of fatigue and says she can barely go up the steps without becoming short of breath.
Hemogram results are as follows:
-Hb=8.7 g/dL (87 g/L)
-Hct=27% (.27 proportion)
-MCV=70 fL
-RDW=18% (.18 proportion)
A critical diagnosis to consider is:
Vitamin B12 deficiency.
Folic acid deficiency.
Renal insufficiency.
Gastrointestinal blood loss.
Ans: Gastrointestinal blood loss.
The nurse practitioner is counseling a patient who is new to insulin therapy. The patient is advised that when injecting a short-acting, rapid-onset formulation such as insulin aspart, the greatest risk time for hypoglycemia is:
15-60 minutes after injection.
1-3 hours after injection.
3-4 hours after injection.
4-5 hours after injection.
Ans: 1-3 hours after injection.
Insulin Analog — Aspart and Lispro (short-acting)-onset 15mins, peak 1hr, duration 3-4hrs
Humilin R and Novolin R (regular)- 30mins, peak 2-3hrs, duration 3-6 hrs
NPH (intermediate), Humilin N and Novolin N- 1-2 hrs, peak 6-14hrs, duration 16-24hrs
Long-acting Lantus or Detemir- 1-2 hrs, peak and duration – none
A 66-year-old man presents for a “check-up.” He has no complaints and admits he’s been smoking 2 packs a day for 40 years. Which additional finding would be consistent with a diagnosis of chronic obstructive pulmonary disease?
Markedly increased chest AP diameter
Pleuritic chest pain
FEV1:FVC ratio <0.70 post SABA use
FEV1 improving by 50% with use of SAMA
Ans:
FEV1:FVC ratio <0.70 post SABA use
A 63-year-old patient presents for evaluation of fever. She reports that 3 days ago she went to the urgent care and was diagnosed with acute bacterial rhinosinusitis (ABRS). She was given a prescription for antibiotics which she is taking as ordered, but is concerned because she has a fever today. Which of the following findings suggests a serious complication of ABRS?
Tender preauricular lymph nodes
Foul-tasting post nasal drip
Facial tenderness
Eyelid erythema and edema
Ans: Eyelid erythema and edema
A 61-year-old retired schoolteacher presents with moderate persistent allergic rhinitis that is impacting his ability to sleep most nights. He has a history of hypertension and suffered an NSTEMI 3 years ago. Which of the following should be avoided for this patient?
Antihistamine nasal spray
Leukotriene modifier
Oral decongestant
Intranasal corticosteroid
Upon examining a 67-year-old woman, the NP detects a palpable thyroid nodule that is 1.5 cm in diameter. The most appropriate next step for this patient is:
Schedule follow-up in 3 months to determine if the size changes.
Obtain TSH measurement and thyroid ultrasound.
Schedule MRI imaging of the head and neck.
Referral to an oncologist.
Ans: Obtain TSH measurement and thyroid ultrasound.
When communicating healthcare decisions through a healthcare proxy, the NP recognizes:
The proxy has the same rights to request or refuse treatment that the patient would have if he or she were capable of making and communicating decisions.
Only management decisions that are considered life-saving are required to be communicated to the healthcare proxy.
The proxy has the right to refuse treatment except in situations when treatment is necessary to preserve life.
The closest relative to the patient is assumed to take the proxy responsibilities.
A 61-year-old woman sees you in follow-up after being discharged from the hospital. She recently had an inferior wall myocardial infarction and is asking about supervised cardiac rehabilitation. She is shocked that she had a heart attack, and says she never even knew that her cholesterol was so high. She hasn’t seen a healthcare provider since having her last child 27 years ago. Tertiary prevention strategy for this patient will include:
Referral for mammography.
Lipid-lowering therapy with an HMG-CoA reductase inhibitor (statin).
Influenza and pneumococcal vaccination.
Screening for diabetes.
Ans: Lipid-lowering therapy with an HMG-CoA reductase inhibitor (statin).
Ans:
C. trachomatis cervicitis.
All of the following are appropriate candidates for tuberculosis (TB) testing except:
A 28-year-old with HIV infection.
A 55-year-old man who recently emigrated from a country where TB is endemic.
A 33-year-old woman who works at a child care center.
A 56-year-old man who was recently released from prison.
Ans: A 33-year-old woman who works at a child care center.
Indicate whether each of the suggested long-acting reversible contraceptives (LARCs) for the following patients is (yes) or is not (no) appropriate.
1. A 19-year-old woman to receive the levonorgestrel-releasing IUS (Mirena®) __
2. A 30-year-old woman who smokes 1 PPD to receive the etonogestrel implant (Nexplanon®) __
3. A 38-year-old woman with a history of large uterine fibroids and heavy menses to receive the copper-containing IUD (ParaGard®) __
4. A 28-year-old woman who is currently taking antiepileptic medications to receive the etonogestrel implant (Nexplanon®) __
1-No 2-Yes 3-No 4-Yes
1-No 2-No 3-No 4-Yes
1-Yes 2-Yes 3-No 4-Yes
1-Yes 2-No 3-No 4-Yes
Match each of the following signs and symptoms with the appropriate dehydration status for a younger child.
A. Mild dehydration
B. Moderate dehydration
C. Severe dehydration
1. Reduced blood pressure, Fontanels depressed, lethargic __
2. Normal blood pressure, capillary refill of <1.5 seconds, slightly dry lips and thick saliva __
3. Slightly sunken eyes, normal blood pressure, capillary refill of ~2 seconds __
1-B 2-A 3-C
1-A 2-B 3-C
1-C 2-B 3-A
1-C 2-A 3-B
The most appropriate next diagnostic step for Caleb is:
Based on the below scenario:
Caleb, a 9-month-old boy, is presented for evaluation after sudden onset of intermittent severe abdominal pain. He often draws his knees to his abdomen when he appears to be in greatest pain. The mother reports that he has had episodes of diarrhea that contain a mixture of blood and mucous. He has not vomited during this time, but also has a lack of appetite.
Ultrasound of the abdomen
Flat plate of the abdomen
Stool culture with susceptibility testing
Stool sample to check for ova and parasites
Ans: Ultrasound of the abdomen
The most appropriate treatment option for Jackson is:
Based on the below scenario:
A mother brings in Jackson, her 4-year-old son, for evaluation after
reporting that she stayed up all night with him because he was
experiencing somewhat labored breathing and had a loud “barking-like”
cough. The child has a hoarse voice, is without acute respiratory
distress, and a temperature of 101.6ᵒF (38.7ᵒC).
Short-term systemic corticosteroid
Nebulized beta2-agonist
Inhaled corticosteroid
Guaifenesin
Ans:
Short-term systemic corticosteroid
Ans: Benzoyl peroxide lotion with salicylic acid facial wash.
A 19-year-old female comes to your office to discuss birth control. She has just become sexually active and wants to be responsible. She has heard a lot from her friends about “the pill” (combined oral contraception {COC}) and is asking you for advice. You tell her that:
Premenstrual syndrome symptoms are often improved with COC use.
Long-term use is discouraged as the body needs a COC “rest” from time to time.
The menstrual flow volume is typically increased with COC use.
There is an increase in the rate of uterine cancer after protracted COC use.
Ans: Premenstrual syndrome symptoms are often improved with COC use.
In advising a woman with menstruation-related migraine without aura and combined oral contraceptive use, the nurse practitioner considers that:
A high-dose estrogen pill should be prescribed.
Uninterrupted use can help minimize headache frequency and severity.
Headache severity is likely to increase.
Cardiovascular risk is markedly increased.
Ans:
Uninterrupted use can help minimize headache frequency and severity.
According to the World Health Organization Medical Eligibility for Contraceptive Use, which of the following is a Category 4 (use represents unacceptable health risk) for the use of a combined oral contraceptive?
Controlled hypertension
Migraine with focal neurologic symptoms
Age >35 years and smoking <10 cigarettes per day.
BMI ≥30 kg/m2
Ans: Migraine with focal neurologic symptoms
Ans:
Bone mineral density loss.
A father presents his 3-year-old with viral gastroenteritis. He reports that she has been experiencing multiple episodes of diarrhea for the past 24 hours, with the most recent episode about 1 hour ago. Evaluation of the child suggests moderate dehydration. The NP recommends:
Initiating oral rehydration therapy with oral rehydration solution.
Referral for parenteral IV fluid.
Offering child ginger ale in small sips.
Offering child sports drink (e.g., Gatorade) diluted 1:1 with water in small sips.
Ans:
Initiating oral rehydration therapy with oral rehydration solution.
A 16-year-old young woman presents to you the day after a “condom break.” She is concerned that she might become pregnant and is asking about emergency contraception. Appropriate counseling about the use of hormonal emergency contraception (EC) includes all of the following except:
An established pregnancy will not be interrupted.
There is about a 50% reduction in pregnancy risk with properly-timed use.
There is no increased risk of birth defect if pregnancy occurs.
Ulipristal (ella®) is more effective than levonorgestrel in days 3-5 following unprotected intercourse.
Ans: There is about a 50% reduction in pregnancy risk with properly-timed use.
A mother brings in her 4-year-old son for a well child visit. The mother explains that he is recovering from a cold, but he is in generally good health with no complaints. Upon examination, the NP notices a reddened tympanic membrane but an absence of any bulge. The NP explains:
A follow-up visit is needed in 2 days to determine if the infection clears.
Antimicrobial therapy with amoxicillin should be initiated.
Antimicrobial therapy with azithromycin should be initiated.
The benefits of antimicrobial therapy do not outweigh potential risks of adverse effects and resistance development.
Ans: Have 6-8 wet diapers per day.
Major indications that a child could have attention-deficit/hyperactivity disorder (ADHD) include all of the following except:
Does not readily respond to his/her name on a regular basis.
Symptoms are present before the age of 7 years.
Exhibits problematic behavior in 2 different settings.
Struggling in school academically.
Ans:
Does not readily respond to his/her name on a regular basis.
Ans: Prior to the time when the child can roll from tummy-to-back and back-to-tummy.
Ans: Absence of signs for start of puberty.
The mother of a 12-month-old son is expected to bring him to clinic for vaccinations later that day. She asks if she can give him some ibuprofen prior to the visit to minimize pain and fever from the vaccinations. The NP responds:
Acetaminophen is preferred over ibuprofen.
Ibuprofen should be administered about 1 hour prior to the visit.
Half a dose can be given before the visit and half immediately following the visit.
Antipyretic use is not recommended prior to vaccinations.
Ans: Antipyretic use is not recommended prior to vaccinations.
Ans: Can roll from tummy-to-back and back-to-tummy with ease.
A 3-year-old girl presents with gastroenteritis and who has vomited 4 times in the past 12 hours. The child has signs of mild-to-moderate dehydration. The most appropriate treatment for this child is:
Parenteral dexamethasone (Decadron®).
Oral metoclopramide (Reglan®).
Oral disintegrating tablets of ondansetron (Zofran®).
Rectally-administered trimethobenzamide (Tigan®).
Ans:
Oral disintegrating tablets of ondansetron (Zofran®).
Caleb, a 9-month-old boy, is presented for evaluation after sudden onset of intermittent severe abdominal pain. He often draws his knees to his abdomen when he appears to be in greatest pain. The mother reports that he has had episodes of diarrhea that contain a mixture of blood and mucous. He has not vomited during this time, but also has a lack of appetite.
The most likely diagnosis for this child is:
Pyloric stenosis.
Small bowel obstruction.
Giardiasis.
Intussusception.
A mother brings in Jackson, her 4-year-old son, for evaluation after reporting that she stayed up all night with him because he was experiencing somewhat labored breathing and had a loud “barking-like” cough. The child has a hoarse voice, is without acute respiratory distress, and a temperature of 101.6ᵒF (38.7ᵒC).
The most likely diagnosis is:
Upper airway foreign body.
Croup.
Asthma.
Bronchiolitis.
A mother who is breastfeeding her 2-day-old daughter expresses concern because the child makes a “clicking sound” when nursing. On physical examination of the baby, the NP notices that she is able to thrust her tongue beyond the lip margins with ease. The NP explains that the noise is most likely due to:
An incomplete latch.
Immature motor control.
Ankyloglossia.
An occult cleft palate.
During a well child visit of a 14-year-old boy, the mother expresses concern that he is the shortest boy on the soccer team. Physical examination reveals a small amount of coarse, pigmented hair at the base of the penis and the scrotal sac is slightly reddened and rugated. You advise:
Testing for serum human growth hormone level.
That he is likely near his adult height.
That his growth spurt will start soon.
Performing a genetic test to detect a chromosomal abnormality.
Ans: That his growth spurt will start soon.
A 15-week-old infant presents with a fever of 100.5ᵒF (38.1ᵒC) and bilateral erythematous tympanic membranes. The infant is alert with excellent skin turgor, no evidence of difficulty breathing, acknowledges her mother’s face, and is wearing a wet diaper. Her parents report that she is vigorously nursing every 3 hours without vomiting or excessive stooling. The appropriate management would be to:
Counsel the mother to observe for 72 hours and return to clinic if there is no improvement.
Start topical therapy with otic antibiotic drops.
Initiate a sepsis workup.
Begin a systemic antibiotic regimen.
Ans: Begin a systemic antibiotic regimen.
A 17-year-old woman presents complaining of left lower abdominal and groin pain. She admits that she has had a “light period everyday” for nearly 3 weeks. The presumptive diagnosis of ectopic pregnancy is supported by which of the following?
Positive urine hCG
Negative pelvic ultrasound
Abdominal rebound tenderness
Breast pain
A first-time father brings in his 1-month-old infant for evaluation. He is concerned that she “throws up all of the time.” The child has an appropriate weight gain since the last office visit at age 1 week and appears well today. The nurse practitioner knows that the most common cause of frequent spitting and vomiting in a young infant is:
GI tract immaturity allowing reflux.
Overfeeding.
Pyloric stenosis.
Allergy or intolerance to a component of infant formula.
ANs: GI tract immaturity allowing reflux.
During a 12-month well-child checkup, the nurse practitioner notices that the child is able to pull to stand, haltingly cruises, but is not walking independently. The mother is very concerned and insists that her other three children were all walking by the age of 1 year. The most appropriate action would be to:
Tell the mother that while on average children are walking by 1 year, many children do so later; schedule a follow-up in 1-2 months to assess progress.
Reassure the mother that children with older siblings often do not start walking until later; schedule the next routine well-child checkup in 3 months.
Counsel the mother that while there is no need to panic, this does represent a developmental delay and the child should see a pediatric orthopedic specialist.
Request a radiographic assessment of the spinal cord, pelvis, and femurs to rule out structural bony anomalies that frequently delay walking.
Mrs. Jansen is a 34-year-old healthy female patient who is nursing her first child. She has just been diagnosed with mastitis and wants to know what to do about breastfeeding. The nurse practitioner advises her to:
Continue to nurse only on the unaffected side.
Pump the breasts and discard the milk.
Continue to nurse the baby as the mother tolerates.
Discontinue breastfeeding.
Ans:
Continue to nurse the baby as the mother tolerates.
Mrs. Perry presents her 19-month-old for evaluation of a 2-day history of crankiness and fever. Physical examination is significant for a sustained fever (up to 103.4ᵒF or 39.7ᵒC). The tympanic membranes are erythematous around the edges but otherwise normal. The chest is clear to auscultation and her respiratory rate is within normal limits. The child is alert and age-appropriately resists examination. The remainder of the physical examination is normal. Initial assessment should include:
A chest radiograph.
A lumbar puncture.
A sterile urine specimen for culture and sensitivity.
Stool for ova, parasites, and culture.
Ans: A sterile urine specimen for culture and sensitivity.
A father brings in his 20-month-old daughter who presents with a diffuse rosy-pink macular rash and fever of 102.3ᵒF (39.1ᵒC). He reports that he first noticed the rash this morning but that she has had a fever for the past 3-4 days. Today, the child is without fever. . The most likely diagnosis is:
Roseola
Rubeola.
Scarlet fever.
Rubella.
Ans:
Roseola – study childhood rash and fevers condition.
Scarlet fever: sand-paper like rash with exudative pharyngitis fever, headache, tender localized anterior cervical lymphadenopathy. Rash usually erupts on day 2 of pharyngitis, and often peels a few days later.
Treatment: caused by Strep, oral Amoxicillin as 1st line, Penicillin Po or IM, oral Macrolide (Azithromycin, Clarithromycin, Erythromycin) only if pts has PCN allergy.
Roseola (Agent Herpes virus) HHV 6: dicrete pink-rose macular rash or maculopapillar rash lasting hours to 3-7 days often with high fevers. 90% cases found in children < 2 yrs. Treatment: supportive therapy
Rubella (virus): mild symptoms sore throat, malaise, nasal discharge, diffuse maculopapillar rash lasting about 3 days; posterior cervical and postauricular lymphadenopathy begining 5-10 days. Prior to rash eruption, 10% most common in women c/o myalgia.
Incubation period: 10-14 days, most infectious 1 -2 wk prior to onset of rash rash, generally self-limiting, greatest risks to unborn child especially during 1st trimester (infant can expose to congenital rubella syndrome). It is a reportable disease to HHS department, laboratory confirmation by presence of serum Rubella IgM.
MMR virus- usually acute on presentation with fever, nasal discharge, cough, generalized lymphadenopathy, conjuctivitis (copius clear discharge), Koplik spots appears 2 days prior with blue rings held within red spots on oral mucosa, pharyngitis w/o exudative, maculopapular rash onset 3-4 days after onset of symptoms, may coalesce to generalized erythema. Complications: CNS and respiratory tract are common, permanent neurological impairment or death possible, is a reportable disease to HHS department, Vaccine-preventable disease, laboratory confirmatory by presence of serum rubeola IgM.
Infectious Mononucleosis: caused by Epstein-Barr virus- Maculopapular rash or petechiae rare, fever, purple white pharyngeal exudate, malaise, marked diffuse lymphadenopathy, hepatic and splenic tenderness, splenic enlargement.
Dx: Mono spot, lymphocytosis, atypical lymphocytes presence.
Incubation period: 20-50 days.
>90% will develop rash if given Amoxicillin or Ampixicillin during the illness. Potential for resp. distress due to enlarged tonsils and lymphoid tissues impinged on the airway, corticosteroids maybe helpful, splenomegaly often noted between day 6-21 after onset of illness. Avoid contact sports > 1 mo due to risk of splenic rupture.
Ans: Uterus fundus palpable directly above symphysis pubis
While reviewing the records of a 3-year-old patient who is new to your practice, you learn that she has a Still’s murmur. As a result, you anticipate which of the following physical findings?
An audible systolic murmur with a buzzing quality
Height and weight in the bottom 25% of the growth chart
A hyperdynamic point of maximal impulse
Joint laxity and hyperextension
ans: An audible systolic murmur with a buzzing quality
Maria is a G1P0AB0 woman with is 28-weeks pregnant. Her pregnancy to date has been uneventful and she has no chronic health problems. Maria has not received any immunizations in the past year.
1. What should she receive today? Choose all that apply.
A. A Tdap
B. Injected influenza immunization
C. Live attenuated influenza vaccine (LAIV)
D.Pneumococcal vaccine.
Ans:
A. A Tdap
B. Injected influenza immunization
Which of the following vaccines should be offered to him today? Choose all that apply.
Based on the below scenario:
Maria is a G1P0AB0 woman with is 28-weeks pregnant. Her pregnancy to date has been uneventful and she has no chronic health problems. Maria has not received any immunizations in the past year.
Maria’s 28-year-old spouse, who is generally in good health, also presents today.
A. Tdap
B. Injectable influenza vaccine
C. Pneumococcal conjugate vaccine
D. Zoster vaccine
Ans: A. Tdap
B. Injectable influenza vaccine
ADA screening for DM in Children
-symptomatic children (polyuria, polydipsia, polyphagia, blurred vision) regardless of risk factors
-asymptomatic children after puberty or 10 years of age or older if overweight or obese (>85th percentile). Plus 1 of the following:
*T2DM in 1st or 2nd degree relative
*high risk racial/ethnic group
*signs of insulin resistance (HTN, dyslipidemia, acanthosis nigricans, PCOS, SGA)
*maternal hx of DM or GDM during the child’s gestation
– leading causes of death: Heart disease, cancer, lung disease
– leading cause of cancer death: lung
– leading cause of death in adolescents: accidents
– most common cancer: skin.
– in males: prostate. in females: breast
suicide: males more successful, women more attempts. highest rate is older white males.
If patient has right sided weakness, etc. the CVA occurred where
initial evaluation of symptoms of acute prostatitis
A 65-year-old woman presents for a follow-up examination after a new patient visit. She has not seen a healthcare provider for several years. She is a smoker and her hypertension is now adequately controlled with medication. Her mother died at age 40 from a heart attack. The fasting lipid profile shows cholesterol = 240 mg/dL, HDL = 30, and LDL = 200. In addition to starting Therapeutic Lifestyle Changes, the nurse practitioner should start the patient on:
1. bile acid sequestrant.
2. a statin drug.
3. a cholesterol absorption inhibitor.
4. low-dose aspirin.
Erythrocyte sedimentation rate (ESR)
What are narrow therapeutic index drugs?
Fluoroquinolone & Polymyxin B cortisporin drops
sedimentation rate (expect to be very elevated)
Normal, healthy woman of reproductive age
Multiple infections from bacteria and fungus?
erythromycin for chlamydia eye infection in infants
…
to assess pts ability to think abstractly a nurse pract could ask the patient
the meaning of a common proverb
etiology: candida albican (80-90%)
white, curdy, “cottage-cheese” like, sometimes increased, itching/burning discharge, pH <4.5, odor is usually absent, microscopic shows mycelia, budding yeast, pseudohyphae w/KOH prep. Treatment: oral diflucan or vaginal miconazole or terconazole
PSEUDOHYPHAE, CLOTRIMAZOLE CREAM
Eye drops or ointment: Polytrim, trimethoprim, polymyxin, macrolide
-Shift to the left
-Serious bacterial infection
A patient with macular degeneration has deficit vision in?
A1C: 5.7% to 6.4%
Fasting: 100-125
2 hour GTT: 140-199
– individual actions: eating nutritious diet, exercise, seatbelts, gun safety. IMMUNIZATIONS
squamous epithelial cells with stippling appearance, no lactobacilli and many WBCs is
trigeminal neuralgia manifests
To assess a patient’s ability to think abstractly, a nurse practitioner could ask the patient:
the meaning of a common proverb.
droplets of blood when scales removed = psoriasis
etiology: unclear, likely polymicrobial, associated with G. vaginalis, M. hominid, others.
thin, homogeneous, white, gray, adherent, often increased, discharge is foul odor(fishy), itching is occasionally present, pH 5-7(alkaline- no active bacilli in vagina), “fishy” smell, microscopic > 20 clue cells/HPF, few or no WBCs. Treatment: metronidazole topical, oral Flagyl, clindamycin vaginal cream, oral tinidazole (Tindamax)
CLUE CELLS, METRONIDAZOLE GEL OR ORAL, CLINDAMYCIN CREAM
Antihistamine, decongestant drops (Trigluridine in herpes conjunctivitis)
What is the common presentation of a navicular fracture?
A1C: >6.5%
Fasting: >126
2 hour GTT: >200
Random: >200
the headache of an intracranial tumor
focal neurological signs and pain worse in supine position
not important during employment physical with 21 yo with bruising on breasts
The nurse practitioner prescribes amitriptyline (Elavil) for a patient with neuropathic pain secondary to diabetes mellitus. On follow-up, the patient complains of urine retention and dry mouth. The practitioner would:
1.
discontinue amitriptyline and begin ibuprofen (Motrin).
2.
refer to physical therapy.
3.
start methocarbamol (Robaxin).
4.
discontinue amitriptyline and begin gabapentin (Neurontin).
discontinue amitriptyline and begin gabapentin (neurontin)
To assess spinal function at the S1 level, which deep tendon reflex should be tested?
– screening tests (pap, mammogram, CBC).
PCN, amoxicillin, macrolide, cephalosporin
Vitamin K Agonist Warfarin (Coumadin)
Atrophic vaginitis (genitourinary syndrome of menopause GSM)
Diverticulitis: Treatment s/s:
Antibiotics and clear liquids and increased fiber (some say no nuts or seeds). (7 to 10 days ABT)
Ciprofloxacin (500 mg PO twice daily) plus metronidazole (500 mg PO three times daily). Amoxicillin-clavulanate (875/125 mg twice daily) is an acceptable alternative.
The criteria for patients with acute uncomplicated diverticulitis to be treated in the outpatient setting include:
●Reliability to return for medical reevaluation if condition worsens
●Compliance with outpatient treatment plan
●Abdominal pain is not severe
●No higher than a low-grade fever
●Can tolerate oral intake
●No or minimal comorbid illnesses
●Available support system
Approximately six weeks following the resolution of symptoms of acute diverticulitis, patients who have not had a recent colonoscopy should undergo one to exclude other possible diagnoses (such as colonic neoplasia) and to evaluate the extent of the diverticulosis.
Recomendations for surgery: Patients in whom elective surgery has been recommended following a single attack of diverticulitis include younger patients (variously defined in the literature as less than 40 or 50 years of age) and those who are immunosuppressed.
in order to improve longevity of patient with COPD, tx of choice is
current social relationships,
history of present or past traumas
mental health status
all important on the pe of 21 yo, for employment with bruising on breasts
A 17-year-old male with rheumatoid arthritis is being treated with an NSAID and omeprazole (Prilosec). The patient complains of headache, abdominal pain, and gas. These symptoms are most likely:
1.
associated with the omeprazole.
2.
related to the underlying condition.
3.
the result of the NSAID.
4.
caused by viral gastroenteritis.
associated with the omeprazole
white with red ring inside cheek from rubeola or mumps
– AA, support groups, education for those with the disease, rehab, exercise programs for obese
Pain worse in supine position; focal neurological signs
Wait 10 days then Amoxicillin or Augmentin (If allergy, use fluouroquinolones/tetracyclines)
Impairment in social communication and social interaction. Restricted, repetitive patterns of behavior, interests and activities.
Red flags: delayed language/communication milestones, regression in social and language skills, sibling with autism
screen at 9, 18, 24 and 30 months or when concerns are raised by parents
causative organism: human herpes virus 2
clinical findings: painful, ulcerated lesions, marked lymphadenopathy with initial lesions. Women=thin vaginal discharge if lesion at vagina or intoitus
with recurrence symptoms vary- asymptomatic transmission common
treatment: oral acyclovir (Zovirax), famciclovir (Famvir), valacyclovir(Valtrex), dose and length of treatment depends on the medication choice and the clinical presentation.
Diverticulosis: Treatment s/s:
leukocoria: Hallmark sign white spots in eye. Cancer. Red light reflex negative
What are first and second line antibiotics for acute otitis media?
1. Amoxicillin
2. Amoxicillin-Clavulanate (Augmentin)
– Breast Cancer: 50yrs q2years until 75yo. (40-49 is individualized)
– Cervical Cancer: 21yrs q3yrs until 65y. no screening after hysterectomy
– Colorectal Cancer: 50yrs until 75. FOBT x3 yearly. Flex sig q5yrs OR colonoscopy q 10yrs
– Lipids: men >35y and women >45y. unless increased risk for heart disease
– Prostate: don’t screen
– Skin Cancer counseling: 10-24yo with fair skin
which of the following criteria differentiates a TIA from a CVA
most widely accepted indicators of HIV infection
slapped cheek and lacy exanthem
Erythema Infectiosum or Fifths disease
Atypical antipsychotics:
Risperidone (Risperdal)
Olanzapine (Zyprexa)
Quetiapine (Seroquel)
Dry skin. Use petroleum based product.
Nongonococcal urethritis and cervicitis
causative organism: chlamydia trachoma’s, ureaplasma urealyticum, mycoplasma genitalium (obligate intracellular pathogen)
clinical findings: Friable cervix=bleeds easily, may have no symptoms, irritative voiding symptoms, occasional mucopurulent discharge, microscopic shows large number of WBCs. Treatment: azithromycin 1 g PO 1 time dose
ABUNDANT WBCs
Bacterial vaginosis: s/s and treatment
Clue cells such as: stipling of squamous epithelial cells with indistinct borders, no lactobacillus rods, many white blood cells
Nonpregnant women
Drugs — Metronidazole or clindamycin administered either orally or intravaginally results in a high rate of clinical cure (70 to 80 percent at four weeks of follow-up) (table 4) [88-91]. Oral medication is more convenient, but associated with a higher rate of systemic side effects than vaginal administration.
Side effects of metronidazole (oral or vaginal) include a metallic taste, nausea (in 10 percent of patients), transient neutropenia (7.5 percent), a disulfiram-like effect with alcohol, prolongation of International Normalized Ratio in patients taking vitamin K antagonists (eg, warfarin), and peripheral neuropathy.
Most common bacterial pathogen causing pneumonia
strep pneumoniae, but most pathogens 6 months to 5 years are viral
Biphosphonates:
Alendronate (Fosamax)
Risedronate (Actonel)
management of polymalgia rheumatica
A 12-year-old with sickle cell anemia has recently experienced a sickle cell crisis and presents for a follow-up examination after a recent hospitalization. It is most important to continue monitoring growth, development, and:
1.
white blood cell levels.
2.
fecal occult blood test.
3.
hemoglobin levels.
4.
urine dipsticks.
– 55-74yo with >30y pack smoking history and who quit <15y ago. LDCT annually
med of choice for polymyalgia rheumatica
Gonococcal urethritis and vaginitis
1 million cases daily WW- abx resistance prevalent
causative organism: neisseria gonorrhoeae (gram – bacteria)
clinical findings: irritative voiding symptoms, occasional purulent discharge, often w/o symptoms in either gender
Microscopic exam: large number of WBCs
STI most likely to give penile DC also called the “drip”
Treatment: ceftriaxone 250 mg IM as a one time dose plus azithromycin 1 g PO x 1 dose
If you find Gonorrhea ALWAYS tx for chlamydia
CEFTRIAXONE
most sensitive sign of pneumonia in children
increased respirations. fever is inconsistent.
1. Albuterol inhaler (Ventolin)
2. OR a combination inhaler
Statins
Atrovastatin (Lipitor)
Lovastatin (Mevacor)
Rosuvastatin (Crestor)
Simvastain (Zocor)
A 90-year-old female is brought to the clinic by her neighbor. She states that everything is fine, but the nurse practitioner notes that she has poor hygiene and bruises on her trunk. The neighbor is concerned that the patient often has no money to buy food, despite income from social security and a coal miner’s pension. The nurse practitioner suspects abuse. Which of the following is the nurse practitioner obligated to do next?
1.
Report the case to the proper authorities.
2.
Tell the neighbor to check on the woman daily and report back.
3.
Document the data and report the information to risk management.
4.
Call the patient’s family and inquire about the concerns.
report the case to proper authorities
Which of the following best describes psoriatic lesions in an elderly patient?
Red, sharply defined plaques with silvery scales
– via immunization or a person who was exposed to agent
helical CT pulmonary angiography
Topical 5 fluoracil 5-FU cryotherapy
What is the classic triad of symptoms for mononucleosis?
1. sore throat
2. prolonged fatigue
3. enlarged cervical nodes
(usually a teen)
causative organism: trichomonas vaginalis (protozoan pathogen)
clinical findings: dysuria, itching, vulvovaginal irritation, yellow-green vaginal discharge, occasionally frothy (30%), cervical petechial hemorrhages (“strawberry spots”) in about 30%, often w/o symptoms in either gender, microscopic exam: motile organisms and large number of WBCs, pH is alkaline
Treatment: metronidazole 2 g (No alcohol) PO or tinidazole 2 g PO as a 1 time dose (parasitic infection) no etoh -GI upset
ORAL METRONIDAZOLE
treatment of bacterial pneumonia in children:
electric shock unilateral facial pain
distinguish iron deficiency anemia from other anemias
A 25-year-old presents with the chief complaint of decreased mobility and pain of the right shoulder exacerbated by movement. The patient reports that he participated in extensive house painting 24 hours prior to the onset of pain. He denies any trauma. Passive ROM is intact. No redness or ecchymosis is present. What is the next step that should be taken in order to make a diagnosis?
Palpate structures around the shoulder.
Galeazzi’s Sign (aka Allis sign)
uneven knee heights – Developmental Displasia of the Hip
– immunoglobulin or through breast feeding/from mother
Lincosamides
Clindamycin (cleocin)
Higher risk of CDAD
Metronidazole (flagyl) PO TID x 10-14 days
Probiotics daily-BID x few weeks
Alpha thalassemia is more common with what ethnicity?
causative agent: treponema pallidum (spirochete bacterium)
clinical findings:
Primary stage: chancre, firm, round, painless genital and/or anal ulcers with clean bas and indurated margins, localized lymphadenopathy, aprox 3 weeks duration, resolves w/o treatment. Secondary stage: nonpruritic skin rash, *palms and soles, as well as mucous membrane lesions, fever, lymphadenopathy, sore throat, patchy hair loss, headaches, weight loss, muscle aches, and fatigue. Resolution w/o treatment is possible.
Latent stage: presentation variable w/ decrease in cognitive function, occurs when primary and secondary symptoms have resolved
Treatment: antimicrobial therapy, with dosage and length of therapy usually dictated by disease stage. Options include injectable PCN or PO doxycycline
IM Bi-cillin- used as well
INJECTABLE PENICILLIN OR IF SEVERE PENICILLIN THEN GIVE DOXYCYCLINE
Other Childlike rashes: Key characteristics:
sudden vision loss in which person feels like a curtain came down over his eye
tx with clear liquids and oral antibiotics
osioniazid (nydrazid) for 9 months
Tx: doxycycline/fluoroquinolones
Genital warts (Condyloma acuminata)
Causative organisms: HPV (commonly HPV-6 & 11)
Clinical findings: verruca-form lesions can be subclinical or unrecognized
Treatment: prevent w/immunization, topical podofilox, liquid nitrogen, cryoprobe, trichloroacetic acid, bichloracetic acid, surgical removal, or topical imiquimod (only indicated for external warts treatment).
trichloroacetic acid use acceptable in pregnancy
DO NOT USE IF PREGNANT: podofilox, podophyllin, sinecatechins and imiquimod
IMIQUIMOD
AT 16 WEEKS TEST FOR AFP
Low- Downs
High-Neural tube deficits
Beta thalassemia is more common with what ethnicity?
decreased gastric production with aging
…
tests for polycystic ovarian syndrome
A 29-year-old male with noncomplicated Chlamydia infection may exhibit:
no remarkable clinical symptoms.
What do pica and spoon shaped nails indicate?
Which HPV viruses most likely to cause malignancies
16, 18, 31, 33, 45, 52,& 58. Gardasil effective against all of these plus 6 & 11
*Sx: fatigue. stomach ache, irritability.
*IDA
*Cognitive and behavioral changes cannot be reversed
primary amennorhea presentation
17 yo Tanner Stage III- never had menses, normal weight and height
A young child with asthma presents for follow-up evaluation. After numerous changes in medications and doses, the parents report that the child continues to have difficulty with coughing, especially during the night. Which of the following conditions would be the most likely cause of the continued asthma symptoms?
1.
Vocal cord dysfunction
2.
Cystic fibrosis
3.
Gastroesophageal reflux
4.
Allergic rhinitis
Forward bend test for scoliosis
*Most common in children ALL
*Pancytopenia
*Long bone pain
*Hepatosplenomegaly
*Lymphoblasts
What is a common presentation for systemic lupus erythematosus (SLE)?
malar rash (butterfly rash) and should minimize sunlight exposure
Impedance of arterial blood flow in lower extremity ankle brachial index <0.9, plaque develops in vessel d/t atherosclerosis, pain with exercise, relief w rest, lack of hair growth on LE, gangrene toes Tx: check pedal pulses, ABI test, exercise by walking, lifestyle Modifications – smoking cessation, antiplatelet
Pelvic inflammatory disease (PID)
causative organisms: N. gonorrhoeae C. trachomatis, bactericides, enterobacteriaceae, streptococci, gram – anarobes
clinical findings: irritative voiding symptoms, fever, abdominal pain, cervical motion tenderness, vaginal discharge. *Increased risk of ectopic pregnancy and/or infertility with each outbreak.
treatment– Ceftriaxone 250mg IM as a single dose plus doxy 100mg po bid x14days with or without metronidazole 500mg PO BID 14days
SSRIs can cause delayed ejaculation
…
A pregnant woman with known HIV infection can reduce the risk of perinatal transmission through zidovudine (Retrovir) therapy. Based on current research, optimal therapy is to start daily dosing:
1.
post amniocentesis.
2.
after 14 weeks of gestation.
3.
if premature rupture of membranes occurs.
4.
if maternal viral loads are greater than 10,000.
A patient with macular degeneration has difficulty seeing objects:
in the center of the visual field.
Flex hips 90 degrees pain with extension of leg = meningitis or subarachnoid hemorrhage
*awakens child
*thunderclap
*neuro findings – n/v, AMS
*<3 years old
*absent family hx of migraines
What is the presentation of polymyalgia rheumatica (PMR) and first-line treatment?
Vulvovaginitis or STI?
1. Clue cells with alkaline pH
2. Pseudohyphae
3. Abundant WBCs
Fever, loss of appetite, and a sore throat, followed by painful, blisterlike sores in the mouth. Rash on the palms of the hands, the soles of the feet, and sometimes the buttocks. The rash starts as small flat red dots that may turn into bumps or blisters. Most common in preschoolers but can occur at any age.
best laboratory test to distinguish IDA anemia from other anemias is
whether the pt has reversible airway obstruction
office spirometry using an albuterol nebulizer can confirm asthma, because it can indicate
Which of the following is the leading cause of cancer-related deaths in the majority of women?
Involuntary flexion of legs when neck is passively flexed = meningitis
What is the gold standard exam for temporal arteritis?
1. biopsy of the temporal artery
2. Refer to ophthalmology
Fever, chills, anorexia, weight loss. malaise, headache, myalgia, arthralgia, night sweats, abdominal pain, dyspnea, cough, pleuritic pain. Symptoms janeway lesions, red spots on the soles of the feet or palms. Osler’s nodes red, tender spots under the skin, whites of your eyes, or inside your mouth.
Splinter hemorrhages on nails, Janeway lesion (red macules palms/soles not painful), Osler’s nodes (painful violaceous nodes found mostly on pads of the fingers and toes).
Small red bumps that may be itchy. Often develops around the nose and mouth but can easily spread to other parts of the body. Bumps become pus-filled blisters that may burst and develop a soft yellowish-brown crust. Child may have a fever and swollen lymph glands in the neck. Most common in children between 2 and 6 years old.
*c/o abdominal pain, n/v
*auras common
bump on testicle can indicate cancer of testicle
…
CBC and hemoglobin electrophoresis
12 yo, family hx of thalassemia and anemia, with Tanner Stage II, HCT 35 should order this
The 16-year-old mother of a 2-month-old presents the infant, reporting that the child is very irritable and does not feed well. During physical examination, the child’s head drops back and the child exhibits sudden flexing of the extremities. As the flexing stops, the child cries uncontrollably. Funduscopic examination reveals retinal hemorrhages. Which of the following diagnostic tests should be ordered?
1.
Skull X-rays
2.
MRI
3.
CT scan
4.
Pet scan
neurofibromatosis (tumors and seizures)
– LIVE
– 2 doses one month apart.
– give if no history of chicken pox
What does a positive Finkelstein test indicate?
Starts with fever; a runny nose; red, watery eyes; and a cough. Red bumps with tiny white dots appear a few days later on the inside of the cheeks. Next, a rash appears on the face and progresses down the back and trunk to the arms and hands and finally to the legs and feet. The rash starts as flat, red patches but eventually develops bumps and may be itchy. It lasts about five days, then fades to a brownish color, leaving skin dry and flaky. Rare due to vaccinations; most likely to occur in unvaccinated children.
– 60yo
– regardless of history of shingles
for diabetic patients taking beta blockers, best indication of hypoglycemic episode will be
sweating (WILL NOT SEE TACHY AND PALPITATIONS DUE TO BETA BLOCKER USE)
differentiates TIA from stroke
Which of the following gastrointestinal changes is associated with normal aging?
Decreased production of gastric acid
Howell-Jolly Bodies and target cells
What does a positive Anterior drawer or Lachman maneuver indicate?
Positive indicated anterior cruciate ligament (ACL) is damaged
An induration of 10 or more millimeters
-Recent immigrants (< 5 years) from high-prevalence countries
-Injection drug users
-Residents and employees of high-risk congregate settings
-Mycobacteriology laboratory personnel
-Persons with clinical conditions that place them at high risk
-Children < 4 years of age
– Infants, children, and adolescents exposed to adults in high-risk categories
Genital Candida albicans infection in men typically presents
1-2 doses: 11-12yo and booster at 16yo
leading cause of cancer deaths in men and women.
Which of the following is NOT an indication of preeclampsia?
Thin, blue-black discoloration of gingival border = lead poisoning
S1 spinal function is assessed with what DTR
Petroleum based product (not lotions)
Consideration in caring for a 68 yo m w/a BMI of 38, otherwise healthy, who is now presenting with genital candidiasis includes which of the two most helpful measures?
A. Order a medium potency topical steroid to the affected region to help with symptom control
B. prescribe topical miconazole
C. obtain an in office blood glucose
D. advice on the use of antimicrobial soap to the region
B. prescribe topical miconazole
C. obtain an in office blood glucose
Postmenopausal bleeding f/u testing
*Frequent regurgitation
*GERD = pathology
*Immature LES until 9-12 months old
*Red Flags: choking with eating, coughing with eating, forceful vomiting, bilious vomit, blood in stool, poor weight gain, refusal to eat, constipation or diarrhea, abdominal tenderness, fever.
*Avoid smoke, small frequent feedings (thickened), trial of PPI.
What can a positive McMurray’s sign indicate?
A patient on warfarin (Coumadin) therapy for recurrent deep vein thrombosis (DVT) is about to have lumbar spinal fusion surgery. The patient’s warfarin is put on hold starting 5 days prior to the surgery and subcutaneous Lovenox has been ordered for DVT prophylaxis until the resumption of the warfarin. The nurse practitioner knows that the patient’s postoperative warfarin dose should be restarted based on the:
1.
value of her morning Prothrombin time.
2.
loading dose of 10 mg, plus the previous warfarin dose.
3.
baseline PT and INR values.
4.
target INR of 2.
Assessment findings that would support a diagnosis of mitral regurgitation include:
loud, high-pitched pansystolic murmur.
Softening of the cervix (pregnancy indication)
children over 8 years old can use doxy
…
Acute, uncomplicated UTI in non pregnant women
Usually starts with a sudden relatively high fever, often over 103 degrees Fahrenheit, that typically lasts three to five days. A pink rash on torso and neck follows and may spread to the arms, legs, and face. Child may be irritable and may have diarrhea or vomiting. Most common in children between 6 months and 3 years old.
Atrophic vaginitis cause and tx
lack a estrogen, apply topical estrogens
On eye exam, what does neovascularization, cotton wool spots, and micro-aneurysms indicate?
– children receive
– give first
– only ever need 1 dose
in doing initial eval of patient with suspected acute prostatitis, what test to do
Type 1 diabetes with increased early am levels with correct insulin dose
On eye exam, what can atrioventricular nicking, silver and/or copper wire arterioles indicate?
Croup (laryngotracheobronchitis) Parainfluenza (*)
D. surgical intervention should be offered early in the disease process
WET PREP for which gu infections
Softening of the cervicouterine junction
A 3-year-old presents with a 2-day history of acute diarrhea with a total of 8 watery stools without blood or mucus, and 2 episodes of vomiting in the past 48 hours. Assessment reveals no current antibiotic therapy, dehydration <5%, soft abdomen with hyperactive bowel sounds, no masses or organomegaly; other physical findings are normal. Which of the following is the most appropriate management plan?
1.
Stool culture; Immodium AD liquid.
2.
No laboratory workup; instruct parents on signs and symptoms of dehydration; diet of clear liquids, advancing to bananas, rice cereal, Jell-O, and soup.
3.
Start diet of clear liquids, advancing to bananas, rice cereal, Jell-O, and soup over next 72 hours; Imodium AD liquid, 1 mg/sml
4.
Stool for ova and parasites; advise parents of likely sources of Giardia; prescribe furazolidone (Furoxone)
Atb on wound, cold packs, NSAIDS
The achilles reflex may be absent or hypoactive (0-1+)
Epididymoorchitis (upper reproductive e tract infection with inflammation of epididymis/testis)
Age ⬇️35
Causative organisms: N. gonorrhoeae, C. trachomatis
Presentation: irritative voiding symptoms, fever, painful swelling of epididymis and scrotum. Infertility is possible post infection due to scarring of the vas deferins
Treatment: Ceftriaxone 250 mg IM x 1 dose plus doxycycline 100 mg po BID x 10 day.
Scrotal elevation to help with symptom relief. (Prehn’s sign=relief of discomfort with scrotal elevation)
Analgesics: Tylenol, nsaids, Demerol
ATB: Augmentin/doxycycline/Bactrim,
smoker with acute bronchitis with cough with thick, yellow-green foul smelling sputum
A mother presents her 12-month-old child with concern because the child does not yet say “mama” or “dada.” The mother reports that in the first months of life, the child loved listening to music and being talked to. The past medical history is negative for ear infections. The nurse practitioner should:
1.
evaluate for hearing loss.
2.
refer to speech therapy.
3.
re-evaluate in 3 months.
4.
check for cerumen impaction.
pernicious anemia is B12 deficiency
…
True or false, a benign S4 heart sound may be auscultated in some elderly patients
Epididymoorchitis usually e-coli
Severely itchy rash of scattered red bumps, usually between the fingers, around the wrists, in the armpits and diaper area, and around the elbows. May also show up on the kneecaps, palms, soles, scalp, or face. May leave curvy white or thin red lines or little blisters on nearby skin. Itching is most intense after a hot bath or at night and may keep the child awake. May occur at any age.
most appropriate dx tests for PCOS are
testosterone, LH, prolactin, TSH
Which of the following findings is typically a sign of acute appendicitis?
Rebound tenderness at McBurney’s point
Dix-Hallpike or Nylen-Barany maneuver
What is a rare but life threatening reaction to ace-inhibitors? What is a common side effect?
Doxycycline, amoxicillin, or azithromycin
Age ⬇️ 35
Causative organisms: N. gonorrhoeae, C. trachomatis
“it hurts when my bottom hits the chair.”
Presentation: irritative voiding symptoms, suprapubic, perineal pain, fever, a tender, boggy prostate, leukocytosis increased white count
Treatment: ceftriaxone 250 mg IM as 1 x dose w/doxycycline 100 mg PO BID x 10 days
The rash begins as a mass of tiny red bumps in the armpits, neck, chest, and groin and rapidly spreads over the entire body. The bumps feel like fine sandpaper and may itch. Child may have a fever and a red sore throat. Early in the infection, the tongue may have a white or yellowish coating that later turns red. The bumps on the tongue may appear larger than normal, a condition called strawberry tongue. Tonsils may be swollen and red. As the rash fades, the skin may peel, especially on the hands and feet and in the groin. Uncommon before age 2.
BV : s/s, microscopy, test, tx,
*Causes: Bowel and bladder dysfunction (withholding, incontinence, constipation), anatomic abnormalities, vesicoureteral reflux.
*Treatment: 2nd or 3rd generation cephalosporin (cefixime, cefdinir, ceftibuten) for 3-5 days if afebrile, 10 days if febrile.
*Renal and bladder US for all infants 2 to 24 months with 1st febrile UTI.
*Voiding cystourethrogram for vesicoureteral reflux.
*Get US in any child with recurrent febrile UTIs and UTI with family hx of renal or urologic disease, poor growth or HTN
weight loss, shoulder and pelvic pain, pain with ROM, no weakness, elevated ESR
The best laboratory test to distinguish iron deficiency anemia from other anemias is:
Acute bacterial prostatitis (uncomplicated disease in men with low risk for STI)
What class of drug is Ipratropium (Atrovent)
A small grainy bump or cluster of bumps, usually on a hand but can occur anywhere on the body. Warts are usually skin-toned but may be lighter or darker in color and can contain black dots. Flat warts, which are smaller and smoother, can also appear anywhere on the body, but in children they most often show up on the face. Plantar warts show up on the soles of the feet. Most warts disappear on their own in a few months to a few years. Uncommon before age 2.
LSIL in 21-24 y/o. 25-29 year old. >30 year old
Doxycycline/Fluoroquinolones (Cipro)
During a well-child examination of an 18-month-old, premature tooth decay and inflamed gums, particularly of the maxillary incisors, are noted. The approach to this problem includes:
1.
referring the child to a dentist, assessing for bottle feeding and fluoride in local water.
2.
teaching the mother to brush the child’s teeth, encouraging vitamin supplements.
3.
recommending fluoride mouthwash and toothpaste, suggesting celery sticks for snacks.
4.
providing fluoride treatment, teaching dental hygiene, and eating foods high in calcium.
referring the child to a dentist, assessing for bottle feeding and fluoride in local water
A patient is referred with a diagnosis of diabetes mellitus, hypertension, and coronary artery disease. The patient is on both insulin and a beta blocker. Assuming that the patient will continue the beta blocker, it will be important to educate the patient on the recognition of hypoglycemia. Which symptom would be most indicative of hypoglycemia in this patient?
What drug class are erythomycin, azithromycin (Z-pack), clarithromycin (Biaxin)?
firm, smooth, nontender
*about as firm as pressing in on the tip of your nose*
What antibiotic is used for corneal abrasion:
Gentimicin ophthalmic solution
Young woman with breast mass. Preferred imaging
Folstein Mini-Mental State Examination
name first generation cephalosporins
Contraindication for beta blockers?
tender, boggy, indurated
*about as firm as pressing in over your puffed out cheek*
Risk factors/findings for ovarian ca
Chronic Venous Insufficiency tx
Light exercise, stockings, Wt loss, elevate legs
migraines and menstrual cramps
decreased reabsorption of sodium-glucose transporters
Which of the following wet-mount results confirms a preliminary diagnosis of bacterial vaginosis?
nodular, firm, nontender
*usually malignant lesions not palpable until disease is advanced*
Name second and third generation cephalosporins
Second- Cefaclor, Ceftin, Cefzil
Third- Rocephin, Suprax, Omnicef
3 years old – age, gender and height
Adverse effects of beta blockers
Bronchospasm, bradycardia, depression, fatigue, ED, HF, hypoglycemia
most common 2 pathogens for older adults residing in community
In pulmonary function testing, forced vital capacity represents the:
1.
maximum volume of air that can be forcefully exhaled after maximum inspiration.
2.
total volume of air that is exhaled after normal inspiration.
3.
total volume of air that the lungs can hold, minus the expiratory reserve volume.
4.
volume of air that can be forcefully exhaled in 1 second.
maximum volume of air that can be forcefully exhaled after maximum inspiration
whether a patient has reversible airway obstruction.
lie supine, leg elevated off table produces radiating or sciatic pain – herniated disc
D. report of recent-onset intermittent acute urinary retention
Absent cremaster reflex, testicular pain, difficulty walking, nausea, MORE?
Ectopic pregnancy s/s, physical exam findings, increased risk for
what age should dyslipidemia risk assessment begin?
2 years old. 2, 4, 6, 8, 10 then annually
ACEs – With stenosed renal arteries, afferent flow cannot be increased, angiotensin II can actually become the only mechanism by which the kidney can increase filtration, and with severe stenosis, efferent arteriole constriction is crucial for maintaining some degree of filtration. ACE inhibitors would prevent conversion of Ang. I (which is inactive) to Ang. II, and therefore make everything worse by removing the kidney’s only remaining regulatory mechanism as well as cutting the perfusion pressure and eliminating what little renal function remains. With tubular cells that are already less effective due to damage from chronic ischemia, the resulting decrease in GFR would effectively accelerate kidney failure .
An adult male presents as first patient of the day after awaking about 5:00 AM with indigestion and chest pressure. On checking his pulse, he found no change from previous measurements. He states that, while waiting for the nurse practitioner to arrive, he began to feel a little clammy. A 12-lead EKG records the following patterns. On the basis of these EKG readings, the diagnosis is:
1.
anterior-septal acute myocardial infarction.
2.
lateral acute myocardial infarction.
3.
inferior acute myocardial infarction.
4.
anterior acute myocardial infarction.
inferior acute myocardial infarction
CHD is the most common what in newborns?
Name a quinolone with Gram + coverage
Levaquin, moxifloxacin, gatifloxacin
C. ovary palpable on bimanual exam
Alternate ABT for erythromycin for mycoplasma pneumonia?
macrolide such as azithromycin.
BPH physical findings, tx, when to take meds, evaluating PSA post tx,
HCTZ should not be taken with digoxin
may increase risk of digoxin toxicity
During the past 24 hours, a 62-year-old has experienced abdominal pain that radiates to the back. The patient also reports several episodes of nausea and vomiting, a low-grade temperature, and a history of excessive drinking. Physical examination reveals a distended abdomen. Laboratory serum values indicate elevated alkaline phosphatase, amylase, and serum lipase. The most likely diagnosis is:
1.
alcoholic liver disease.
2.
acute mesenteric ischemia.
3.
viral hepatitis.
4.
acute pancreatitis.
gastritis and peptic ulcer disease.
lifting the scrotum relieves pain of epididymitis
Cholesterol <200
HDL >40
LDL <100
Triglycerides <150
Lifestyle modification first line
Niacin, fenofibrate
1. Trimethoprim-sulfamethoxazole (Bactrim, Septra)
2. Nitrofurantoin (macrobid)
better with standing and worse with sitting
Acute bacterial prostatitis: S/s, physical exam findings, labs, tx based on age
reports of strong sensation of needing to void that cannot be supressed, often has involuntary loss of urine
most common in older adults
Treatment: behavioral therapy, pharmacotherapy (antimuscarinics such as: Detrol,Ditropan, VESIcare, Enablex, Toviaz. Adverse effects = dry mouth, sedation, mental status change, particularly in higher doses.
a milder form of Stevens-Johnson syndrome that produces pink-to-red targetlike lesions, wheals, and blisters, with no mucosal involvement. The clinician should look for a history of antibiotic and other drug treatment such as sulfa drugs, penicillins, and other drugs. Hypersensitivity reaction from meds, allergy, or infection.
An otherwise healthy adult female presents complaining of vaginal burning and itching during urination. She has a social history of two sexual partners. She denies fever or vaginal discharge, but has noted a lesion on one labium. The nurse practitioner should order all of the following EXCEPT:
1.
wet mount and potassium hydroxide.
2.
dark-field microscopy of fluid from the lesion.
3.
nucleic acid amplification testing for gonorrhea.
4.
serology for Haemophilus ducreyi.
dark-field microscopy of fluid from lesion
A 2-month-old infant is presented for examination and immunizations. History includes an uncomplicated full-term delivery and hepatitis B virus immunization shortly after birth. Examination is unremarkable except for a diffusely erythematous (non-beet-red) macular rash in the diaper area, sparing the inguinal folds. No satellite lesions are noted. The infant’s diaper rash is most likely caused by:
1. doxycycline
2. minocycline (Minocin)
is aggravated by long periods of standing and walking, relieved by sitting and rest.
associated with lifting, coughing, sneezing, exercise, anything that causes intraabdominal pressure
more common in F, rare in M
Treatment: vaginal tampon, urethral stents, periurethral bulking agent injections, pessary use. Kegel exercise in younger, premenopausal patients. Pelvic floor rehab w/biofeedback, electrical stimulation and bladder training.
Side effects and uses of ortho-novum and other antibiotics:
INSERT HERE: spotting? amenorrhea etc
SSRI, SNRI, Wellbutrin. May do benzo for short time (for acute anxiety attack)
Meclizine (Antivert), diuretics, diazepam
A 3-year-old female has been diagnosed with bacterial meningitis. She attends preschool daily at a local church day care program. The day before her diagnosis, she ate lunch with her mother at a local restaurant. For which contact(s) would chemoprophylaxis with rifampin be recommended?
1.
Preschool contacts in the past 7 days
2.
A friend of the patient’s sister who visited after school yesterday
3.
The checkout employee at the grocery store yesterday
4.
Diners at the restaurant during lunch the day the patient ate there
preschool contacts in past 7 days
Helical CT pulmonary angiography
Tests cerebellar function – patient alternately points from their nose to examiner’s finger
– To detect hip dislocation in newborn
What category of drugs are allowed for pregnant or lactating women? (A, B, C, D)
sentinel nodes (virchow’s nodes)
often occurs I presence of mobility problems, associated w/the inability to get to the toilet or the lack of knowing that there is a need to void.
Usually found in those with limited mobility or altered cognition. Worsens when there is limited availability of an assistant for toileting.
Treatment: Ameliorated by having an assistant who is aware of voiding cue available to help with toileting activities.
Orthonovum (estrogen based contraception) causes spotting? T/F
PTSD, major and minor depression, first choice meds?
diabetes can contribute to pregnancy induced HTN
…
more commonly affects both hips
A 65-year-old male presents to a clinic complaining of increasing fatigue, dyspnea on exertion, and ankle edema during the day. He has a history of mild hypertension, for which he saw his physician years ago. The physician advised the patient to decrease his salt intake. On physical examination, the patient is tachycardic, positive for jugular venous distention, and positive for S3, with a systolic murmur. Chest X-ray reveals cardiomegaly with vascular redistribution. The nurse practitioner’s diagnosis should be:
Tests cerebellar function – runs heel of one foot along the shin of the opposite leg fairly quickly
ACE inhibitors. How to monitor? Test renal function.
What is the preferred treatment for cutaneous anthrax and how do you get it?
Where should the examiners 2nd-5th fingers be placed to perform Ortolani’s
Acute serotonin syndrome, s/s , causes
Blood glucose. Checking the blood glucose is indicated for patients with syncopal and near-syncopal episodes. The nurse practitioner should also perform a thorough history of the incident. Possible causes of syncope are cardiac arrhythmia, vasovagal, hypoglycemia, orthostatic hypotension, seizure, accidental fall, and others.
Trigeminal neuralgia manifests itself primarily with:
electric-shock-like unilateral facial pain.
hold assistive device (like cane) on opposite side
…
Treatable causes of urinary incontinence
Acute bacterial sinusitis is treated with?
Aggravated by long periods of standing and walking. Relieved by forward flexion, sitting and rest.
sickle cell, thalassemia and leukemia can all cause
hepatosplenomegaly – but IDA wil not
The clinical presentation of placenta previa that develops during the third trimester includes:
1.
intermittent dark-red spotting.
2.
occult bleeding with abdominal or back pain.
3.
sudden onset of painless and profuse bleeding.
4.
painless occult bleeding that becomes visible upon onset of labor.
sudden onset of painless and profuse bleeding
Which of the following criteria differentiates a TIA from a stroke?
Idiopathic Thrombocytopenia purpura tx
Initial: Glucocorticosteroids (prednisone)
Overactive bladder medication with highest anticholinergic effect and lowest
S/s of acute bacterial sinusitis versus viral?
Insert here. How long before treat? Alternative to amox allergy?
“c” shaped foot or “kidney bean shaped” foot without ankle deviation. in-toeing
Myerson’s Sign / Glabellar tap sign
cyanosis and poor feeding – murmur is heard in tricuspid area
A 27-year-old male patient, who works as a janitor, presents with a 6-month history of an intermittent rash on his hands. History reveals itching and occasional burning. Examination reveals irregularly-distributed scaly maculopapular erythematous patches extending from the dorsum of the hand several inches up the forearms, and dry palms with no nail involvement. The most likely diagnosis is:
1.
contact dermatitis.
2.
scabies infestation.
3.
psoriasis.
4.
eczema.
A chart used to test for color blindness. (7 yr old)
Contraindications for Metformin
Healthy 32 yo F who is taking combined oral contraceptives, is here to review the results of her recent liquid-based Pap screening that revealed atypical squamous cells of unknown significance(ASCUS) and high risk HPV +. No h/o previous abnormal cervial cytology, with her last screening aprox 2 yr ago. After discussing the significance of these findings, the most appropriate next step is to:
A. Advise that she return in 6-12 months for a repeat Pap w/HPV cotesting
B. obtain screening tests for N. gonorrhoeae and C. trachomatis infection.
C. referral for colposcopy
D. counsel that the usual cervical cancer screening guidelines should be followed
Delayed ejaculation is caused by a common medication:
Treatment to prevent fracture in patient with low vitamin D high TSH low HCT
– VITAMIN D 600-800, CALCIUM 1000-1200.
Annular ligament displacement over the radial head
Macrocytic Folate Deficiency tx
Folate, leafy green veggies, beans, liver, pasta, cereals
A 65-year-old female presents with shoulder and pelvic girdle pain for the past 6 months. She reports recent unintentional weight loss. On physical examination, there is pain on ROM, with no weakness noted. Laboratory studies show a low hemoglobin and an elevated sedimentation rate. Which of the following is the most likely diagnosis?
Deep pain on inspiration while fingers are placed under right rib cage = cholecystitis
Down’s syndrome patients can have
congenital heart defects, seizures, eye issues, hearing loss, obesity – NOT failure to thrive
Uncomplicated chlymydia: may present with?
No clinical s/s:
Difference between complicated and uncomplicated chlamydia?
>10 degree curve. Use Adam’s forward bend test
hyperinflation of lungs can be seen on chest X-ray in patients with asthma
…
one femur appears shorter when infant is supine
INSERT HERE: azithromycin. Alternative tx?
Tibial overuse stress syndrome
What is Acute Dacryostenosis? How to dx?
A patient reports to your office, having been struck on the right cheek with a baseball bat. On examination, you notice tenderness and swelling over the cheek. The patient is unable to gaze laterally with his left eye, and he complains of double vision when he attempts to do so. This is most likely associated with:
1.
retinal hemorrhage.
2.
orbital rim fracture.
3.
subarachnoid hemorrhage.
4.
periorbital cellulitis.
A 70-year-old male presents with paresthesia of the lower extremities. On examination, the patient appears pale and shows a decreased vibratory sense. Laboratory tests reveal elevated indirect bilirubin; Hct = 30%; mean corpuscular volume (MCV) = 120 µm3 [normal = 87-103 µm3]. The most likely diagnosis is:
RLQ pain with internal rotation of flexed right thigh = appendicitis
Kerley’s B lines on X-ray indicate
Don’t get pregnant within the next 4 weeks
COPD patients may prolong their life by the use of?
Legg-Calve-Perthes disease, SCFE, irritable hip
Diffuse edema of scalp due to intrauterine pressure (Cone head)
A 7-year-old child presents with group A streptococcal infection confirmed by throat culture. Past history includes treatment for positive streptococcal infection with erythromycin (EryPed oral suspension) 3 weeks ago. What is the most appropriate next intervention?
1.
Treat with amoxicillin for 10 days.
2.
Obtain culture for all household members.
3.
Treat with azithromycin (Zithromax) for 10 days.
4.
Intramuscular Penicillin.
treat with amoxicillin for 10 days
RLQ pain when pressure is applied to the LLQ = appendicitis
menstrual irregularities and amenorrhea
A palpable “nest of worms” scrotal mass that is only evident in a standing position.
COPD- other points of interest?
: NSAIDS, steroids, DMARDS, TNF.
when rx hormones, consider fam hx of what cancers
A 16-year-old female adolescent is brought to the nurse practitioner’s office by her mother, who is concerned about her daughter’s recent weight loss. History reveals that the daughter was consistently in the 50th percentile for weight, but is now in the 10th percentile. The mother states that she is concerned that her daughter is purging herself after meals since she often goes to the restroom after eating and remains there for a long period of time. The daughter denies any self-induced vomiting, starvation or excessive activity. She does state that she jogs five miles a day and is in good condition. In addition to a complete blood count with differential, which of the following laboratory tests will be most helpful for further assessment?
1.
Electrolytes, fasting blood sugar
2.
Creatine phosphokinase, follicle-stimulating hormone (FSH)
3.
Electrolytes, blood urea nitrogen (BUN)/creatinine, urinalysis
4.
Electrolytes, FSH, stool for occult blood
electrolytes, blood urea nitrogen (BUN)/creatinine, urinalysis
A 72-year-old female presents with a medical history unremarkable except for the occasional headache. She enjoyed emotional health throughout marriage and childrearing, although her family history is significant for strokes and nervous breakdowns. Since her husband died a year ago, however, she has been waking every morning at 3:00 A.M., is reluctant to go out although she has family members living nearby, and feels a continual urge to sleep. She cannot discuss her late husband without crying. Differential diagnoses would include:
depression, unresolved grief, and hypothyroidism.
Horizontal lines on CXR = heart failure
*hip/knee pain
*limp
*common in teens
*Trendelenburg test
Clenched fist over chest sign = ischemic chest pain
nuva ring does not affect menstrual cycle
…
Osteopenia is defined as T-score
The foreskin cannot be pulled back to expose the glans. head of penis
Potential urologic emergency.
Swelling to PIP, in RA there will be Bouchard’s nodes (and not Heberden’s nodes)
Transient Synovitis of the Hip
…
A 2-year-old male presents for reevaluation. Two days ago, he had four episodes of vomiting and six diarrheal stools. On physical examination today, his vital signs reveal P = 120 and capillary refill of 3 seconds. The patient’s eyes are sunken and his extremities are mottled and cool to the touch. The treatment plan would include:
1.
start oral electrolyte mixture every hour.
2.
hospitalization for IV fluid replacement.
3.
giving the child loperamide for each diarrheal stool.
4.
catheterizing the child to obtain accurate urine output.
hospitalization for IV fluid replacement
palm of the hand to the chest = ischemic chest pain
Osteoporosis is defined as T-score
involuntary repetitive muscle movements muscle spasms
Retracted foreskin that cannot be brought forward to cover the glans.
Potential urologic emergency.
Feels like curtian coming over vision, flashes of light OTHERS? TX?
Osteoarthritis s/s, first line tx
…
A nurse practitioner places a 76-year-old patient on nifedipine (Procardia) 10 mg t.i.d. for angina. The patient is unable to remember to take the medication at the scheduled times. The practitioner should:
1.
discontinue the issue with the patient’s daughter.
2.
change the dose to extended release 30 mg daily.
3.
reinforce the importance of taking the medication.
4.
increase the dosage to 20 mg b.i.d.
change the dose to extended release 30mg daily
touching the left arm with right arm = ischemic chest pain
Used to diagnose gonorrheal pharyngitis or proctitis
abnormal involuntary muscle rigidity
Testicle located in inguinal canal or abdomen. Undescended testicle.
Osteoarthritis recommended exercise
Parvovirus B19. “Slapped cheek” rash. Lacy. Macular rash.
A pediatric male is present with his mother, who states that he is extremely restless at night and constantly scratches his anal area. Which diagnostic procedure would confirm a diagnosis of pinworm infestation?
1.
The patch test
2.
Examination of bed linens
3.
Examination of transparent tape sample from perianal skin
4.
Blood tests for anemia and eosinophilia
examination of transparent tape sample from perianal skin
A 38-year-old male experiences a sudden onset of acute abdominal pain radiating to his groin. He is having difficulty walking and is nauseated. He denies any trauma or previous groin injuries. Examination reveals diffuse swelling of the left testicle and negative cremasteric reflex. The most likely diagnosis is:
pointing to chest with 1 finger = non-ischemic chest pain
Positive strep allergic to PCN
clarithromycin (biaxin) 250 mg bid x 10 days
Symptoms of initial hearing loss in adults
Loss of high frequency tones & harder to hear consonants than vowel sounds
Current guidelines recommend initiating antiretroviral therapy (ART) when?
Lachman’s: how to do, what does it test for
…
Which of the following microorganisms are most frequently associated with acute bacterial rhino-sinusitis?
1.
Staphylococcus aureus and Mycoplasma pneumonia
2.
Staphylococcus aureus and Methicillin Resistant Staph aureus
3.
Streptococcus pneumoniae and Haemophilus influenzae
4.
Streptococcus pneumoniae and Pseudomonas aeruginosa
strep pneumo and haemophilus influenzae
intense need to move, restlessness
What is the goal of antiretroviral therapy (ART)?
bruising around the mastoid process (behind ears) = serious head / brain injury
slight increase in growth velocity
flex knee 90 degrees. sits on toes of the tested extremity to help stabilize it. The examiner grasps the proximal lower leg, approximately at the tibial plateau or joint line, and attempts to translate the lower leg posteriorly. The test is considered positive if there is a lack of end feel or excessive posterior translation
Herpes virus. Vesicular lesions on erythematous base appearing in crops
additional testing= for STI risk reduction
GC/Chlamydia
HIV
syphilis
HAV
HBV
HCV
HSV-2
inability to recognize familiar people or objects
A geriatric female presents for her annual examination. She has been on antihypertensive medications for over 20 years, with good control. Laboratory values are within normal ranges. The nurse practitioner is concerned about the patient’s cardiac health risks, due her to weight and her waist circumference. According to the AHA guidelines, which of the following goals is expected for this patient?
1.
Physical activity for 60 minutes daily, for a minimum of 6 days a week
2.
Physical activity for 30 minutes daily, 7 days a week
3.
Physical activity for 30 minutes daily, for a minimum of 5 days a week
4.
Physical activity for 60 minutes daily, 7 days a week
physical activity for 30 minutes daily, for a minimum of 5 days a week
tender nodule with blue discoloration on the upper pole of the testicle = testicular torsion
defined by the nurse practice act in the state where you practice.
McMurray’s test – how to do, what does it test for
McMurrays test- “CLICK” medial meniscus (valgus) EXAM. LateRal meniscus (vaRus).
With the patient supine the examiner holds the knee and palpates the joint line with one hand, thumb on one side and fingers on the other, whilst the other hand holds the sole of the foot and acts to support the limb and provide the required movement through range. The examiner then applies a valgus stress to the knee whilst the other hand rotates the leg externally and extends the knee. Pain and/or an audible click while performing this maneuver can indicate a torn medial meniscus. To examine the lateral meniscus the examiner repeats this process from full flexion but applies a varus stress to the knee and medial rotation to the tibia prior to extending the knee once again.
inability recognize object placed in palm
Amoxicillin-Clavulanate (Augmentin)
Pt with pulmonary embolus suspected. After x ray what is next test?
helical CT pulmonary angiogram
exotoxin rash secondary to group A strep. Sandpaper like rash that ultimately desquamates
bicep tendon rupture, normally with the elbow in flexion and arm supinated, you can hook your finger under the biceps tendon at the level of the AC and it will meet with resistance as you pull your finger against the tendon. A distal bicep tendon tear means that your finger will not feel resistance or be able to hook under the tendon in a hook test. (positive).
Symogi effect v dawn phenomenon:
difficulty cording voluntary movement
A 40-year-old male presents with a 2-week history of rectal pain and itching. He reports a past history of constipation and finding spots of bright red blood on toilet paper several times a week. Rectal examination reveals a tender, swollen, bluish, ovoid mass. The stool guaiac test is negative. Which of the following actions should the nurse practitioner take?
Prescribe bulk-forming agents and hydrocortisone suppositories.
difficulty to remember learned motor skill
A 50-year-old male presents with bruises and abrasions on the left leg and forearm, claiming to have had a number of minor accidents at home and at work. The patient reports general feelings of depression, forgetfulness, and, despite the fact that he is regularly employed, a mounting collection of unpaid and overdue bills. In taking the patient’s history, a significant pattern of parental alcohol abuse, stroke, TIA, and MI emerges. During questioning to elicit a more thorough diagnosis, the patient becomes hostile and leaves the clinic without further treatment. The most likely explanation for this behavior is:
1.
Alzheimer’s disease.
2.
chronic alcoholism.
3.
cancer.
4.
carotid artery stenosis.
Knee joint laxity. Suggestive of ACL damage of the knee.
How to test s1 nerve function?
bicep tendon rupture – looks like
bicep is curled up into a giant ball
painful vesicles on the soft palate and mouth
hand foot and mouth resolves when
How to test s2 function? S3, s4? etc?
?
Cancers of the Female Reproductive Tract
– cervical cancer caused by HPV types=abnormal vag bleeding, vag discomfort during intercourse, malodorous dc and dysuria- symptomatic w 1st abnormal pap
pap test followed by colposcopy and biopsy
pelvic ct/MRI or PET
Tx based on disease progression surgery radiation chemo
– uterine or endometrial cancer- older age , estrogen tx, nulliparity, obesity, tamoxoifin use, DM family hx-abnormal vag bleeding, Diagnostics – transvag ultrasonography hydroutrsonography endometrial biopsy and D&C
– ovarian cancer- post menopausal nuliparity 1st preg after 35 fertitlity drugs Braca + has shared etiology with breast ca
minimal non specific symptoms bloating bladder pressure constipation vag bleeding indigestion, SOB, lethargy weight loss
Diagnostics- CT w/ contrast of abdomen,
MRI,US tumor markers 125
surgery followed by chemo
form of aphasia, unable to recall names of everyday objects
cyclic fever = rarely seen in Hodgkin’s lymphoma
A 28-year-old patient presents with profuse yellow vaginal discharge, odor, and local irritation. She reports completing a 7-day course of oral metronidazole (Flagyl), 500 mg b.i.d. 4 weeks ago. She has had multiple recurrences over the last 18 months. Microscopic examination reveals presence of clue cells. What is the most appropriate treatment intervention?
1.
Oral metronidazole (Flagyl), 500 mg b.i.d., plus metronidazole vaginal gel (MetroGel), for 5 days
2.
Treat both patient and partner(s) with oral metronidazole (Flagyl), 500 mg b.i.d., for 7 days
3.
Metronidazole vaginal gel (MetroGel) twice weekly for 4 to 6 months
4.
Treat patient with metronidazole vaginal gel (MetroGel) b.i.d. and partner(s) with tetracycline, 250 mg q.i.d., for 7 days
Treat both patient and partner(s) with oral metronidazole (Flagyl), 500 mg b.i.d., for 7 days
An adult female who recently returned from a business trip to Japan presents for a recheck appointment. The only remarkable laboratory result is for thyroid-stimulating hormone (TSH), at 0.3 microunits/mL (normal = 0.4-6 microunits/mL). The patient reports that her neck hurts; examination reveals thyroid tenderness. Which of the following laboratory tests should the nurse practitioner order now?
1.
Triiodothyronine (T3) and free thyroxine (FT4)
2.
Triiodothyronine (T3) only
3.
Triiodothyronine (T3) resin uptake assay
4.
Triiodothyronine (T3) and free triiodothyronine (FT3)
Triiodothyronine (T3) and free thyroxine (FT4)
vaccination for sickle cell pts
all vax given Preventive strategies that decrease the risk of infection are the routine use of daily antibiotics until five years of age, immunization of children with the 7-valent pneumococcal conjugate vaccine in addition to the 23-valent polysaccharide pneumococcal vaccine, annual influenza vaccination after six months of age, and meningococcal vaccination after two years of age
Lidocaine and epinephrine can be used on fingers, earlobes, nose?
False- may lack blood supply due to epinephrine.
match the following cancer types
1-cervical cancer
2-endometrial cancer
3-ovarian cancer
A-Risk factors include obesity and personal history of PCOs (do not shed lining of uterus obesity increases estrogen
B-Long term infection with HPV19 and or-18
C-BRACA1 and BRACA2 gene mutation
D-presentation includes unexplained abdominal bloating and constipation
E-Presentation includes abnormal vaginal bleeding
F-Often without significant clinical signs and symptoms until later disease
G-Screening include PAP
No specific screening tests available or recommended
Risk factors include obesity and personal history of PCOs (do not shed lining of uterus obesity increases estrogen= Endometrial Ca
Long term infection with HPV19 and or-18+Cervical Ca
BRACA1 and BRACA2 gene mutation= Ovarian Ca
presentation includes unexplained abdominal bloating and constipation=Ovarian
Presentation includes abnormal vaginal bleeding= Cervical and Endometrial Ca
Often without significant clinical signs and symptoms until later disease=Cervical, ovarian and endometrial
Screening include PAP=Cervical
No specific screening tests available or recommended =Endo and ovarian ca
loss of muscle mass related to aging
scarlet fever: s/s and treatment and alternative ABT for those who cannot accept 1st line ABT.
???
lead poisoning anemia type, s/s
* <6 months: ABX
* 6 months to 2 years – ABX ASAP if bilateral or severe illness. Otherwise observe if unilateral or mild
* >2 years – ABX if severe, observe if not severe or uncertain of diagnosis
* Amoxicillin.
* Recent ABX – Augmentin
* Mild PCN reaction – cefdinir, ceftriaxone, cefuroxime, cefpodoxime
* Severe PCN allergy – Zpack or clindamycin
Prostatitis- first test to dx?
LCL ligament stability — test should be done at both 0 and 30 degrees.
1) Examiner places fingers of one hand over the lateral joint line assessing for increase in joint line opening while applying a varus stress to the other.
2) Must be done bilaterally for comparison in order to asses laxity/disruption of ligament.
Positive test is that one joint line is opening is larger than the other side. Indicates possible LCL ligament laxity on the side of the larger joint line opening.
underlying illness involving marked weight loss and muscle loss
A common rule to follow when prescribing many medications for the elderly is to:
start at a lower dose than what is commonly prescribed for adults, and increase the dose slowly.
3-oz (85 g) weight gain over the past 2 weeks
thalassemia alpha – which population
leg, buttock or back pain precipitated by walking
thalassemia beta – which population
African, Mediterranean, Middle Eastern
???
– Genetic d/o that bone marrow produces abnormal hemoglobin
– microcytic, hypochromic, ferritin/iron normal or high, high RDW
– Gold standard: Hgb electrophoresis: abnormal in beta
– Blood smear: microcytosis, anisocytosis, poikilocytosis
– Ferritin and iron normal
– Provide genetic counseling
– Minor trait does not require treatment
Acute Bronchitis with purulent discharge with fever tx? (NOT PCN!)
Primary Options:
azithromycin : 500 mg orally as a single dose on day one, followed by 250 mg once daily for 4 days, or 500 mg once daily for 3 days
Secondary Options
erythromycin base : 250-500 mg orally every 6 hours for 7-14 days
clarithromycin : 250 mg orally every 12 hours for 7-14 days
doxycycline : 100 mg orally every 12 hours on day one, followed by 100 mg once daily for 7-14 days
trimethoprim/sulfamethoxazole : 160/800 mg orally every 12 hours for 7-14 days
cephalexin : 250-500 mg orally every 6 hours for 7-14 days
clear liquids and oral antibiotics.
A 70-year-old patient presents to the clinic complaining of dyspnea, palpitations, and fatigue. The patient reports a 2-week history of blackened stools, which the patient attributes to drinking berry juice. Assessment reveals vital signs of BP = 110/60, P = 100, R = 24; Hgb = 4.5 g/dL; Hct = 16%. What is the most appropriate immediate intervention?
1.
Order serum iron, total iron-binding capacity (TIBC), and ferritin.
2.
Refer to a gastroenterologist.
3.
Send to the emergency room.
4.
Order a complete blood count (CBC) with differential.
6 months hx of 39 year old pt who has daily swelling of wrists?
treatment of iron deficiency anemia
– 325 mg ferrous sulfate daily treat 3-6 months, take w Vit C for better absorption
– Increase fiber and fluid to prevent constipation. May notice black-colored stools.
– Red meat, beans, green leafy vegetables
– Do not take w antacids, dairy, FQ, tetracyclines
– recheck reticulocytes/CBC after 2 weeks after tx started to make sure the problem isn’t in the bone marrow (the reticulocytes should be higher).
The symptoms of benign prostatic hypertrophy are often overlooked because the older male:
1.
understands that surgery is the only cure for this condition.
2.
considers urinary problems to be a normal part of aging.
3.
is fearful of the side effects of additional medication.
4.
is concerned that he will no longer be able to obtain an erection.
considers urinary problems to be normal part of aging
The most common bacteria responsible for pneumonia in older adults residing in the community is:
Dx: AST ALT bilirubin lipase amylase
Refer to GI surgeon for Whipple procedure
how to differential b/t B12 and folate deficiency – both are macrocytic
Multiple myeloma- cancer of the bone marrow, bone pain, weakness… how to dx & tx?
Dx: CBC, FOBT,
Refer to hematologist affects African race
Angiotensin-converting enzyme (ACE) inhibitors
reevaluate the patient in 10 days.
-Preadolescent, no pubic hair, other than fine hair similar to abdomen
-No breast dev.
Polymyalgia Rheumatica dx & tx?
DX elevated sed rate, Creactive protein, (Low hemoglobin)
line TX oral prednisone
The management of choice for polymyalgia rheumatica includes:
A 26-year-old female presents with abdominal distention, bloating, and intermittent crampy abdominal pain relieved by defecation. She has four to six loose stools a day when stressed. Between bouts of diarrhea, she often has constipation. Physical examination results are normal. The CBC was normal. The most likely diagnosis is:
1.
diverticulitis.
2.
viral gastroenteritis.
3.
inflammatory bowel disease.
4.
irritable bowel syndrome
how does fever affect seizure threshold
fever lowers seizure threshold
A mother has just noticed that her 15-month-old, 15-kg child has recently ingested an unknown quantity of iron tablets. The mother has ipecac syrup and activated charcoal on hand. The mother should be advised to:
1.
take the child to the primary care provider.
2.
give ipecac per recommendation on the bottle label.
3.
take the child to the emergency room.
4.
give the child 30 g of activated charcoal diluted with water
Gentamicin ophthalmic (Genoptic)
gets worse when lying down and neurological focal deficits
A 13-year-old is concerned because she has not yet begun to menstruate. Physical examination indicates that the patient is at Tanner stage IV and is of average height and weight. Which of the following would be the most appropriate response to this patient?
1.
“We’ll need to refer you to an endocrinologist for a complete workup.”
2.
“We’ll need to do some tests to find out why you are not having periods.”
3.
“I’ll give you some pills that will make your periods start.”
4.
“Your development is exactly as expected for your age; you’ll probably begin to have periods within a year.”
ABSENCE SEIZURE other name, define
PETIT MAL SEIZURE: SUDDEN BRIEF LAPSES OF IN ATTENTION. SEEN ON
Migraine s/s? Tx? differ from tension, cluster, stroke?
?
Bouchards nodes can be found in?
A patient with type 1 diabetes mellitus who is on NPH and regular insulin split-dosing presents with complaints of early morning rise in fingerstick blood glucose. A review of an at-home glucose test reveals increased morning levels. After an increase in the evening insulin dose, the problem worsens. This is most likely an example of:
mini mental status exam MMSE – what is the cut off for dementia
MMSE- <24 dementia. The lower your score the worse off you are
Most common cause of death cancer Women? Men?
Heberden’s nodes can be found in?
skateboarding concussion. Diagnosed with CT.
skin: melatonin cancer most deadly?
Basal cell cancer: most incidence?
testes enlarge/few straight fine hairs
small round projection on bone or surface
follow-up evaluation of the ears in 2 months.
A 46-year-old female found a lump in her breast this morning. History includes: no prior breast disease; G2P2 (first birth, age 22); maternal aunt diagnosed with breast cancer at age 72; last menstrual period was 2.5 weeks ago. On examination, a nurse practitioner palpates a 2-cm round, soft, mobile, tender lesion in the upper outer quadrant of the right breast. Mammogram is negative. Which of the following actions is most appropriate?
1.
Reassure the patient that no further action is necessary.
2.
Repeat unilateral right mammogram in 3 months.
3.
Schedule a right-breast ultrasound.
4.
Refer for genetic testing if the lump increases in size.
schedule a right breast ultrasound
11/18 points. Widespread pain for at least three months
Penis lengthens, darker coarse hair starts to curl
fracture of distal radius of the forearm, DINNER FORK fracture, most common type wrist fracture
A 50-year-old male presents with a chief complaint of malaise. Further questioning reveals that his primary concern is delayed ejaculation. He is currently taking the following medications: atenolol (Tenormin), 50 mg daily; paroxetine (Paxil), 20 mg daily; loratadine (Claritin-D), 1 tablet daily; and hydrochlorothiazide (HCTZ), 25 mg daily. The most likely cause of the patient’s concern would be:
multiple sexual partners and years of sexual activity
A 68-year-old female presents with a new onset of left-sided throbbing headache. She has noticed some spots in her visual fields that come and go. She is being treated with an NSAID for arthritis. Sedimentation rate is elevated, but all other laboratory values are within normal limits. The headache is most likely due to:
penis widens, thicker, darker, coarse, curly hair
Ovaries in women
What about men? Prostate?
cluster headaches: tx, abortive and prophylaxis
tx High dose O2 via Mask 12L 100%, imitrex (abort) and a CCB for prophylaxis. VERAPAMIL
midepigastric pain radiates to midback
Which of the following is the most serious outcome of Barrett’s esophagus?
A 65-year-old patient being treated with digoxin (Lanoxin) for chronic heart failure (HF) presents with complaints of palpitations. Three days ago, the patient was placed on clarithromycin (Biaxin) by another provider for community-acquired pneumonia. The appropriate course of action at this point would be to:
1.
increase the digoxin dosage by 25%.
2.
obtain a digoxin level and change the antibiotic to azithromycin (Zithromax).
3.
obtain a chest X-ray.
4.
obtain a serum potassium level and perform a 12-lead EKG.
obtain a digoxin level and change the antibiotic to azithromycin (zithromax)
A 39-year-old patient was diagnosed with acute bronchitis in the emergency department and treated with acetaminophen, dextromethorphan, and metaproterenol (Alupent). The patient’s history reveals a smoking habit of 1 pack per day. The patient now presents to a nurse practitioner’s office with a fever of 101.2°F (39.4°C) and a cough productive of thick, yellow-green, foul-smelling sputum. The nurse practitioner should encourage smoking cessation and prescribe:
A 54-year-old male who is 30 pounds overweight states that he awakens at night with heartburn and the taste of hot acid in his mouth. Stress makes his condition worse, yet baking soda seems to provide some relief. Findings on examination are normal and the stool for occult blood is negative. The preliminary diagnosis(es) should be:
1.
esophagitis.
2.
esophageal spasm.
3.
helicobacter pylori.
4.
gastroesophageal reflux disease.
migraine tx: abortive and prophylaxis
whitish patches on genitals, lesions chronic affect vulva/anal in elderly patients, risk for cancer
test used to monitor kidney function and evaluate chronic kidney disease
Other anemia: s/s, tx, differentiation
yellow-greenish discharge with dyspareunia, pelvic exam reveals strawberry patches on cervix
A 15-year-old patient returns for contraceptive services 2 weeks after a diagnosis of trichomonas vaginitis and treatment with 2 g of metronidazole (Flagyl). She reports that discharge and itching are gone, but she is urinating frequently, accompanied with a lot of burning. The patient has not resumed sexual activity and has menstruated since her last visit. Examination reveals mild suprapubic tenderness, no leukorrhea, and a normal wet mount. Gonococcal culture and chlamydia tests are negative. Which diagnostic test should be performed immediately?
Microscopic examination of urine
A late adolescent patient presents with complaints of acute-onset unilateral right eye pain, visual changes, seeing halos around lights, abdominal pain, and intermittent nausea. Physical findings include an erythematous right eye without discharge, a cloudy cornea, and a moderately dilated right pupil that is nonreactive to light. The nurse practitioner should immediately:
1.
apply steroid drops to the right eye.
2.
apply mydriatic drops to the eye.
3.
refer to the emergency department.
4.
make an appointment for him to see an ophthalmologist.
dx is wet mount/prep, flagella, partner needs treated too TX flagyl PO for 7 days
EOM- CN III, IV, VI. (LR6SO4) 3-pupil/accommodation `
A 4-year-old girl with a history of recurrent urinary tract infections returns for follow-up after diagnosis of the most recent infection. During the physical examination, the 4-year-old tells the nurse practitioner that her brother (age 9) lies on top of her and rubs his penis near her pubic area. After completing the physical examination, the nurse practitioner must:
report suspicions to the appropriate child protective services agency.
An 86-year-old patient is experiencing radiculopathy-associated lower back pain that has not improved over the past 4 weeks. The medical history includes a lumbar discectomy. The best type of imaging study for evaluating this patient would be a/an:
1.
MRI.
2.
spinal X-ray.
3.
myelography.
4.
nuclear bone scan.
DX NAAT TX ceftriaxone, doxy, flagyl
UTI urine culture positive when….
3+ protein in urine, how do you follow up ?
do 24 hour urine for protein and creat clear
the child quickly begins to use the affected arm.
A 30-month-old with a history of frequent ear infections was seen in September after a symptom-free summer. Examination revealed bilateral bulging eardrums. After two separate courses of antibiotics, fluid is noted in both ears. The parent reports speech difficulties. The most likely diagnosis is:
1.
otitis media with effusion.
2.
myringitis.
3.
recurrent acute otitis.
4.
Esutachian tube dysfunction.
uterine fundus first rises above the symphysis pubis.
Any baby 2-24 months with UTI and fever. how do you follow up?
– do renal and bladder ultrasound for first febrile UTI
difficulty with comprehension but none with speech
A 67-year-old patient with type 2 diabetes mellitus, congestive heart failure (CHF), and mild coronary artery disease is currently taking digoxin, 0.25 mg daily; hydrochlorothiazide, 25 mg daily; metformin, 500 mg daily; glipizide, 10 mg daily; and atorvastatin (Lipitor), 20 mg h.s. Which of the following is an accurate statement regarding this regimen?
The hydrochlorothiazide will predispose the patient to digoxin toxicity.
UF is between symphysis pubis and the umbilicus
RBC casts in urine, what is possible diagosis
comprehends speech but unable to verbalize speech
A frail elderly widow presents to the senior clinic with a 3- to 4-day history of confusion that became worse the evening before but currently seems a little better, although her speech is rambling and difficult to follow. During the examination, the patient is anxious and agitated. She is on cardiac medications, an antidepressant, and insulin. The most likely diagnosis is:
1.
mild stroke.
2.
polypharmacy.
3.
electrolyte imbalance.
4.
agitated depression.
s: h2 first bedtime, may combine them with PPI. Do 6-8 weeks. PUNT after.
Smaller, more frequent feedings while holding infant
patient current HAS HbSAg (the test has the word “HAS” in it)
When is it increased?
10. Fremitus is enhanced by consolidation.
11. Fremitus is decreased by pleural fluid.
12. Fremitus is decreased by pneumothorax.
10. TRUE. Fremitus is enhanced by consolidation.
11. TRUE. Fremitus is markedly decreased by pleural fluid.
12. TRUE. Fremitus is decreased by pneumothorax.
The cause of the blood vessel inflammation is unknown. In some cases, the swelling affects just part of an artery with sections of normal vessel in between. Symptoms include acute onset of headaches located on one temple, skin over artery is indurated, jaw pain, vision loss, fever, and weight loss, anorexia, fatigue.
immunity either from previous disease or vaccine
tumors causes stomach to produce too much acid resulting in PUD
Increases risk of cancer of esophagus
too much insulin in the blood at night causes a rebound increasing blood sugar in the AM
Sedimentation rate is elevated and patient has visual spots and left sided-headache:
Anti-HCV positive. What is next step?
order HCV RNA. Biopsy of liver to check stage.
Psoriasis diagnosis s/s and tx:
sharply defined plaques with silvery scales: use auspitz sign when scales are pealed away and capillary bleeding. Sun helps pt. OTHER INFO?
Chronic inflammatory skin disease characterized by extensive erythematous, circumscribed scaly papules, and plaques.
Runs a variable course and seldom completely subsides. Severity is aggravated by genetic, infectious, emotional, and environmental factors.
Lesions are red, inflamed, silvery-white scaly, and circumscribed papules and plaques on elbows, knees, extensor limbs, and scalp. Psoriatic nails have a pitted surface and/or hypertrophic (subungual) changes.
Diagnosis is usually clinical.
Mild or limited psoriasis is treated with topical corticosteroids and/or vitamin D analogs.
Moderate to severe and/or extensive psoriasis may require phototherapy, oral retinoids, methotrexate, biological agents, or cyclosporine.
vaginal bleeding with pain and cervical dilation and/or effacement.
early morning increase in blood sugar between 2-8am
vaginal bleeding without dilation of the cervix or passage of tissue. minimal pain
headache, visual disturbances, edema.
Tests:
Treatments: metoprolol
S/s Intussusception and age it ususally occurs
moderate to diffuse bleeding with the passage of tissue and painful uterine cramping
Contraindications for Thiazides
How to palpate for rotator cuff injury:
??
How to assess for knee injury:
Lachman
Drawer test:
Miniscus versus cruciable ligament tear
Presumptive signs of pregnancy
signs felt by women, amenorrhea, nausea, breast tenderness, N/V, urinary frequency,
Don’t use this DM med with insulin
medications that can increase GERD
BB, CCB, HTN meds increase GERD.
what time of day should H2 blockers be taken
Primary amenorrhea: lack of menses by age 15 years in a patient with appropriate development of secondary sexual characteristics, or absent menses by age 13 years and no other pubertal maturation.
Secondary amenorrhea: lack of menses in a non-pregnant female for at least 3 cycles of her previous interval, or lack of menses for 6 months in a patient who was previously menstruating.
6.5 or greater and confirmed on a different day
Initial evaulation check the ankle and brachial blood pressure before and after exercise.
caused by fall onto wrist: x rays may show positive flat pad sign also known as sail sign.
epigastric pain that radiates to the back
Random glucose that confirms DM
different between amylase and lipase
contraindicated drugs are erythromycin, phenytoin and cimetidine.
after reduction the child quickly resumes activity
treatment for high triglycerides.
used to test for both conductive and neural hearing loss.
Which medications increase the risk of developing Type 2 DM?
Glucocorticosteroids
HCTZ
Atypical antipsychotics
HMG Co-A reductase inhibitors
spoon shaped nails associated with IDA.
checks sugar for past 2-4 weeks, high results = high blood sugar
hyperparathyroidism – labs and causes
Bulk forming agents with hydrocortisone tx
opening snap, CHF, normal variant in healthy young adults and athelets
Type of ulcer where symptoms occur 2-5 hours after eating. (Symptoms can be relieved by antacids).
herbal remedies commonly used:
Fever few: migraines, migraines during menstration.
Type of ulcer where symptoms occur within minutes after eating (less relief from antacids)
treatment for hyperparathyroidism
Addison’s :electrolytes, symptoms, treatment
The onset of menses occurs between Tanner stages III and IV.
A common early finding in pt with chronic aortic regurgitation.
Tests that can be used to dx shingles
decreases the threshold of seizures.
progestin-only method and provides three yrs of pregnancy protection.
parathyroid gland and PTH – role in the body
– PTH is responsible for calcium loss or gain from bones, kidneys, and GI tract.
Neutral Protamine Hagedorn (NPH)
The Most common pathogen with Pyleonephritis
HIV monitor progress of disease?
A patient with a primary case of scabies was probably infected how long ago?
Referral for aggressive treatment if they are 7 yrs of age
best test to differentiate iron deficiency from other anemias?
Hypothyroidism- lab findings, diseases associated with, tx
A pt taking HCTZ and complaining of muscle cramps probably has?
-no menarche by age 16
-usually due to anatomic or genetic causes
Facial pain syndrome in the distribution of ≥1 divisions of the trigeminal nerve.
Diagnosis is clinical, with a history of paroxysms of sharp, stabbing, intense pain lasting up to 2 minutes.
First-line therapy is medical, to which the majority of patients are partially responsive.
Primary Options
carbamazepine : 200 mg/day orally initially given in 1-2 divided doses, usual maintenance dose is 400-1200 mg/day given in 2 divided doses
oxcarbazepine : 300 mg/day orally initially, usual maintenance dose is 600-1200 mg/day, maximum 1200 mg/day given in 2 divided doses
Which tx for hyperthyroidism is preferred in pregnancy
AV Nicking is seen in what disease?
tests the elasticity of cartilage in the ears only.
Acute bacterial conjunctivitis in infants:
chorionic villus sampling (CVS)
CVS 10- 12 weeks
Amniocentesis 15-18 weeks
Complications of Cellulitis with a diabetic patient
Medications used for migraine prophylaxis
Hashimotos, TSH and Free T3/t4 , plus test to connfirm
most common pathogens for community acquired pneumonia in older adults:
H.Influenza and S. Pneumoniae
Pneumocystis jiroveci can cause pneumonia in people whose immune system is not working well.
Streptococcus pneumoniae, or Pneumococcus, continues to be responsible for 20 to 50 percent of CAP, and is the single most common pathogen causing CAP.
Mycoplasma, Chlamydophila, and Legionella, collectively known as the “atypical” CAP pathogens, cause 20 – 30% of CAP. Legionella is commonly implicated in severe CAP, while Mycoplasma and Chlamydophila more often result in mild clinical disease.
Influenza is the most common respiratory virus resulting in CAP. Influenza infection also predisposes to subsequent development of bacterial CAP, referred to as “post-influenza pneumonia”.
Hemophilus and Moraxella are common pathogens, particularly in patients with COPD or intrinsic lung disease.
A skin lesion fluoresces under a Wood’s lamp. What microscopic finding is consistent with this?
Latent TB usually treated with INH
Most common cause of acute bacterial sinusitis:
Neg PPD, a second test PPD should be performed in 1 week.
A supplement known to cause constipation?
Key historic findings
female of reproductive age
irregular menstruation
infertility
hirsutism
Other Factors
scalp hair loss
oily skin or excessive sweating
acne
overweight or obesity
hypertension
acanthosis nigricans
1st Tests To Order
serum total and free testosterone
serum dehydroepiandrosterone sulfate (DHEAS)
serum 17-hydroxyprogesterone
serum prolactin
serum TSH
oral glucose tolerance test
fasting lipid panel
Other Tests to Consider
serum androstenedione
pelvic ultrasound
basal body temperature monitoring
luteal phase progesterone measurement
serum LH and FSH
Tx:
Acute
with infertility and desiring fertility
weight loss
metformin
clomiphene
metformin
dexamethasone
gonadotropins
metformin
in vitro fertilization
metformin
laparoscopic ovarian drilling
Ongoing
not desiring current fertility
with hyperandrogenic features alone
oral contraceptive pill
metformin
mechanical hair removal or topical therapy
antiandrogen
antiandrogen plus oral contraceptive pill
long-acting GnRH analog plus oral contraceptive pill
with oligoamenorrhea alone
weight loss
oral contraceptive pill
metformin
cyclic progestin
with hyperandrogenic features plus oligoamenorrhea
weight loss
oral contraceptive pill
metformin
mechanical hair removal or topical therapy
antiandrogen plus oral contraceptive pill
long-acting GnRH analog plus oral contraceptive pill
Diagnosing TB, which is gold standard for dx of TB
ACTIVE TB order, NAAT, C&S, AFB. The AFB is not diagnostic. SPUTUM FOR C & S is gold standard.
An elderly patient will take Saw Palmetto because he thinks it will help with what?
management of COPD for the elderly
CDC recommends Zoster vaccine in what age of immunocompetent pt?
Mantoux test results, what size induration is considered positive.
28 week old pregnant patient has single episode of vaginal bleeding without other s/s: What to do?
Tia has absence of residual s/s.
If a pt is taking metronidazole, they should avoid what?
Terbinafine, atorvastatin, simvastatin
Which 3 medications should have liver function test prior to starting?
McBurneys point: rebound tenderness-
sign for acute appendicitis
MANTRELS score [41]
Score is based on clinical characteristics of the patients. The higher the score out of a possible total of 10, the greater the chance of having acute appendicitis.
M: Migration of pain to right lower quadrant = 1 point
A: Anorexia = 1 point
N: Nausea and vomiting = 1 point
T: Tenderness in right lower quadrant = 2 points
R: Rebound tenderness = 1 point
E: Elevated temperature = 1 point
L: Leukocytosis = 2 points
S: Shift of WBC count to left = 1 point
Or use apache 2 calculator.
se headache, abdominal pain and gas
asthma patient on low-dose ICS still has symptoms, what is next step
IF LOW DOSE ICS, NEXT IS MEDIUM DOSE
intermittent asthma, day time symptom frequency, night time awakenings, tx
<2 / week day, <2 month – night, SABA
Polymyalgia rheumatica s/s, tests and tx:
Basics:
Typically a history of neck, shoulder girdle, and/or hip girdle stiffness and pain, occurring in patients age 50 years or older.
Patients complain of difficulty rising from seated or prone positions, varying degrees of muscle tenderness, shoulder/hip bursitis, and/or oligoarthritis.
More common in women.
About 15% to 20% of patients with polymyalgia rheumatica (PMR) have giant cell arteritis (GCA); 40% to 60% of GCA patients have PMR.
Diagnosis is made via history and with supportive laboratory tests indicating an elevated ESR or CRP.
Rapid improvement often occurs within 24 to 72 hours with low-dose prednisone.
s/s:
Key Factors
shoulder/hip girdle stiffness
shoulder/hip girdle pain
rapid response to corticosteroids
Other Factors
acute onset
low-grade fever
anorexia
weight loss
malaise
depression
asthenia
oligoarticular arthritis
dx:
Criteria: must have any 3 factors, or just 1 and a temporal artery biopsy positive for giant cell arteritis
Age over 65 years
Bilateral shoulder girdle pain
More than 1 hour morning stiffness
Symptom onset <2 weeks
ESR >40 mm/hour
Depression/weight loss
Upper arm tenderness, bilateral.
Tests: 1st Tests To Order
ESR
C-reactive protein (CRP)
CBC
ultrasound
Other Tests to Consider
TSH
MRI
serum protein electrophoresis
serum creatine phosphokinase
TX:
Acute
initial presentation
corticosteroid: prednisone : 10-20 mg orally once or twice daily
calcium + vitamin D + bisphosphonate
nonsteroidal anti-inflammatory drug (NSAID)
methotrexate
folic acid
tocilizumab
Ongoing
treatment-resistant or relapse or disease exacerbation
corticosteroid (increased dose)
calcium + vitamin D + bisphosphonate
methotrexate plus folic acid
tocilizumab or leflunomide
Which mitral disorder results fro redundancy of the mitral valve’s leaflets?
Mild persistent, daytime symptoms, night awakenings, tx
>2 but not daily symptoms, >2 per month, but not weekly, SABA + low dose ICS
s/s of polymyalgia rheumatica:
The lipid particle with the greatest atherogenic effect is
Mod Persistent, daytime symptom frequency, night awakenings, tx
daily daytime symptoms, night awakenings >1 per week, SABA+ICS+LABA or SABA+medium dose ICS
starts with short term memory loss
If a pt’s lipids are elevated, what would the NP do next?
s/s of hypoglycemia if patient is on a betablocker and insulin:
Staph aureus most common bacteria with people DM
Severe persistent, daytime, night awakenings, tx
symptoms throughout the day, nightly asthma symptoms- SABA, Med ICS plus LABA.
metronidazole 2 grams (flagyl)
s/s: Key Factors
vaginal discharge
dysuria
discharge adherent to vaginal mucosa
Other Factors
prior episodes
fever
pruritus
vulvodynia
vaginal dryness
vaginal bleeding
abdominal pain
dyspareunia
erythema
pale epithelium
shiny epithelium
decreased elasticity
friable epithelium
strawberry cervix
testing:
1st Tests To Order
vaginal pH
amine “whiff” test of vaginal secretions
wet mount microscopy of vaginal secretions
Gram stain of vaginal secretions
HIV test
nucleic acid amplification test (NAAT)
VDRL
serum rapid plasma regain (RPR) test
Criteria:
Bacterial vaginosis:
Vaginal pH >4.5
Whiff test
Clue cells (vaginal epithelial cells with distinctive stippled appearance in saline wet mount by being covered with bacteria)
Adherent white vaginal discharge.
enlarged fluid filled area that is subperiosteal and does not cross the suture line
Which hypochromic, microcytic anemia has elevated RDW?
What to check before starting statins
Must check LFT before starting Statin
The volume of air expired during a forced maximal expiration after a forced maximal inspiration.
Providers who do not increase therapy even if test results indicate the need.
A patient taking an ARB should avoid?
Gastic ulcer v peptic ulcer disease:
Peptic ulcer:
Usually presents as chronic, upper abdominal pain related to eating a meal (dyspepsia).
Use of nonsteroidal anti-inflammatory drugs (NSAIDs) and Helicobacter pylori infection are the most common causes.
There may be some epigastric tenderness, but often there are no other signs on physical examination.
Endoscopy is diagnostic and may show an ulcer in the stomach or proximal duodenum. H pylori infection should be sought.
In the absence of “alarm” (red flag) symptoms or signs, testing for and treating H pylori and/or empiric acid inhibition therapy is appropriate.
Most common complications are gastroduodenal bleeding and perforation, either of which may be the presenting symptom, particularly in patients taking NSAIDs.
Gastritis:
A histologic term for inflammation of the gastric mucosa.
Helicobacter pylori infection and use of nonsteroidal anti-inflammatory drugs (NSAIDs) or alcohol are the most common causes. Other causes include stress (secondary to mucosal ischemia) and autoimmune gastritis. Rare forms include phlegmonous gastritis (a rare bacterial infection).
Diagnosis is based on clinical history and characteristic histological findings. A variety of methods may be used to diagnose H pylori infection.
Presence of suspicious features suggestive of upper GI malignancy requires urgent endoscopy. These include GI bleeding, anemia, early satiety, unexplained weight loss (>10% body weight), progressive dysphagia, odynophagia, or persistent vomiting.
Treatment depends on the etiology. Options include H pylori-eradication therapy, reduction of NSAIDs or alcohol exposure, and symptomatic therapy with histamine-2 antagonists and/or proton-pump inhibitors.
If untreated, progression to peptic ulcer disease may occur. Other complications include gastric carcinoma and gastric lymphoma.
1. Patients with any form of clinical ASCVD
2. Patients with primary LDL-C levels of 190 mg per dL or greater
3. Patients with diabetes mellitus, 40 to 75 years of age, with LDL-C levels of 70 to 189 mg per dL
4. Patients without diabetes, 40 to 75 years of age, with an estimated 10-year ASCVD risk ≥ 7.5%
The primary risk factor for development of breast cancer in women of average risk is?
Who gets moderate intensity statin
ask meaning of common proverb.
child 6 yrs old amoxicillin or cefuroxime
How long should a pt be treated with atb if he has prostatits secondary to an STD?
Thiazide diuretic c/i and side effects
No satelite lesions with diaper rash:
contact dermatitis
Satelite lesions- candida infection
pulmonary rehab goals include:
Which long-acting antihistamine is sedating?
peripheral artery disease (same as PVascularD)
What are the 2 most common causes of IDA in adults?
ADHD (Attention-Deficit Hyperactivity Disorder)
Costovertebral angle tenderness (CVA)
A pt with pyelonephritis will likely have what symptom?
S4-LVH stiffening, Tennesse, late diastole. “Atrial kick/gallop”
breast dev stage 3 to 4, predominatly 4
No significant systemic effects. They are predictable.
Class effect of nasal steroids?
S3- HF, Kentucky, early diastole. Abn >35. Bell
Farsighted (objects nearby are blurry)
MVP how it sounds, when to treat and how to treat
MVP- S2 click, followed by systolic murmur. Asymptomatic. MVP with palpitations is treated with BB.
HTN meds that can cause heartburn
BB, CCB, alpha agonists. (HTN meds). EXAM
In what condition are the turbinates dark red and swollen?
monospot is a heterophile antibody test
Otitis Externa (swimmers ear)- bacterial cause and tx
Weber lateralization to which ear
Weber’s test is performed by softly striking a 512-Hz tuning fork and placing it midline on the patient’s scalp, or on the forehead, nasal bones, or teeth.
If the hearing loss is conductive, the sound will be heard best in the affected ear.
If the loss is sensorineural, the sound will be heard best in the normal ear.
The sound remains midline in patients with normal hearing
Pt: NP, I can’t hear in my left ear.
NP (wonders to herself): I wonder if it is conductive hearing loss.
There are three options:
Does Weber test and pt can hear best in left ear (affected ear) == “Sir, you have conductive hearing loss.”
Does Weber test and patient can hear best in RIGHT ear (normal ear) == “Sir, you have sensorineural hearing loss”
Hears both equally == “Sir, you do not have hearing loss.”
What skin condition is a raised reddened area with a dimpled look?
Rinne test results and interpretation
AC>BC is normal. BC>AC is conductive hearing loss
Signal the pancreas to increase insulin secretion & signals the liver to stop producing glucagon
Amox, If your patient is only PCN allergic do azithromycin or clarithromycin.
. Usually S. pneumo. (others: h influ, mor catarrhalis).
Lactic acidosis is a potential adverse side effect most commonly seen with which medication?
Koplik spots are a diagnostic indicator of
lusters sm. Size red papules w/ white centers in the buccal mucosa by lower molars -rubeola measles
a swollen, inflamed lymph node in the armpit or groin.
Where is the site for most breast tumors in women?
What is a positive prehn’s sign?
papilledema appearance and indicates what
Papilledema- optic disc swollen w/ blurred edges due to increased ICP
Which cranial nerve is most responsible for papillary constriction?
Retinal Detachment- Floaters, curtain, flashes of light. Painless.
Which type of ulcer feels better right after a patient eats?
age-related macular degeneration: how affects sight, how test
Which ECG changes would the provider see in a pt with classic angina?
Cataracts, how affect elderly eye sight
in elderly night vision issues. Opaque
acute angle closure glaucoma: what patient will see, findings on physical exam, disposition
Dependent rubor is found in what disease?
Ateriosclerotic occlusvie disease
Primary open angle glaucoma, how affects sight
What to test for with rash on hands and feet?
pityriasis rosea itchy, herald patch, xmas tree pattern,
fine, lace-like network of white lines in lichen planus
Impetigo-Gram positive. Itchy pink-red lesions, evolve into vesiculopustules that rupture
Treatment for impetigo, plus for allergies
. If bullous-large blisters. Severe- Keflex, dicloxacillin. PCN Allergic-Azithro, clinda.
acne rosacea: appearance and treatment
“contagious 48 h. before, until all lesions crusted over” low grade fever, generalized lymphadenopathy, intense itching, erythematous macules, papules develop over macules, then vesicles erupt. “initially on trunk, then scalp and face” TREATMENT supportive, antihistamines, acyclovir 20mg/kg 5xd. If given first 24 hours works best.
MRSA TREATMENT: Bactrim, doxy, mino, clinda. If sulfa allergy do not use Bactrim.
actinic keratosis: s/s, gold standard dx, tx
Eczema, s/s, mediated by which immunoglobulin, tx
(Koebner phenomenon- new psoriatic plaques form over skin trauma)
TREATMENT: Topical steroids, Tar preps (mild). For (severe) do anti-TNF, or immunologic.
Melanoma- Dark Moles, uneven texture, different colors, irregular, >6mm, could be itchy. EXAM
Lyme: name of rash, what is the rash like
DX: B. Burgdorferi via ELISA, then confirm with western blot. Increased ESR.
TREATMENT: Less than 7 Amoxicillin or cefuroxime axetil. Older than 7 Doxycycline.
Rocky mountain spotted fever: s/s
Rocky mountain spotted fever – dx
DX: PCR essay with Rickessetti Antigen
Rocky mountain spotted fever – tx
acute sinusitis
CP?
Diagnostic?
(DDx)
Pharm, NonPharm?
f/u
Recognize normal course? Refer?
– S Pneu. H. Flu. M. Cat. Viral
– Facial or upper molar pain. Nasal congestion >10d. Purulent nasal d/c or PND- awaken at night w cough. Fever (mostly w children not adults). Can be due to allergy flare-up, then boggy swollen nasal turbinate. Tender sinuses.
– H&P, Positive transillumination.
– If mild uncomplicated- topical decongestants (Afrin), Steroid and saline nasal spray, Mucolytic
– If severe, 1st: Augmentin
Alt: Levaquin, Doxy, Cefdinir, Cefin
Strep pneumo, Strep pyogenes, H flu, Staph aureus, Staph epi, oral anaerobes
acute onset of erythematous swollen eyelid w proptosis (bulging of the eyeball) and eye pain. Bad EOM exam w pain. h/o recent rhinosinusitis or URI.
Caused by bacterial infection of the orbital contents (fat and ocular muscles).
More common in children than adults.
Serious complications. Refer to ED.
Grp A Strep
Fever, Sore throat, Tonsillar exudate, absence of cough
PCN V, Amoxicillin
Alt: Azithromycin
Ibuprofen/Tylenol
Complications:
Scarlet fever- Sandpaper texture maculopapular rash that desquamates. Strawberry tongue. Sore throat that can lead to Acute Rheumatic Fever (affects the heart and valves, joints, brain)
Poststrep glomerulonephritis- abrupt onset of proteinuria, hematuria, dark-colored urine, RBC casts a/b HTN and edema
A VIRAL skin infection of the finger(s) that is caused by HERPES SIMPLEX (type 1 (ORAL) or type 2 (GENTIAL) virus infection, from DIRECT CONTACT with either a cold sore or genital herpes lesion.
Self-limited infection: ANALGESICS or nonsteroidal anti-inflammatory drugs (NSAIDs) for pain PRN.
SEVERE infections: Treat with ACYCLOVIR (Zovirax).
A 65-year-old woman presents for a follow-up examination after a new patient visit. She has not seen a healthcare provider for several years. She is a smoker and her hypertension is now adequately controlled with medication. Her mother died at age 40 from a heart attack. The fasting lipid profile shows cholesterol = 240 mg/dL, HDL = 30, and LDL = 200. In addition to starting Therapeutic Lifestyle Changes, the nurse practitioner should start the patient on:
1.bile acid sequestrant.
2. a statin drug.
3. a cholesterol absorption inhibitor.
4. low-dose aspirin.
The nurse practitioner prescribes amitriptyline (Elavil) for a patient with neuropathic pain secondary to diabetes mellitus. On follow-up, the patient complains of urine retention and dry mouth. The practitioner would:
1. discontinue amitriptyline and begin ibuprofen (Motrin).
2. refer to physical therapy.
3. start methocarbamol (Robaxin).
4. discontinue amitriptyline and begin gabapentin (Neurontin).
discontinue amitriptyline and begin gabapentin (neurontin)
A 17-year-old male with rheumatoid arthritis is being treated with an NSAID and omeprazole (Prilosec). The patient complains of headache, abdominal pain, and gas. These symptoms are most likely:
1. associated with the omeprazole.
2. related to the underlying condition.
3. the result of the NSAID.
4. caused by viral gastroenteritis.
associated with the omeprazole
A 12-year-old with sickle cell anemia has recently experienced a sickle cell crisis and presents for a follow-up examination after a recent hospitalization. It is most important to continue monitoring growth, development, and:
1. white blood cell levels.
2. fecal occult blood test.
3. hemoglobin levels.
4. urine dipsticks.
A 90-year-old female is brought to the clinic by her neighbor. She states that everything is fine, but the nurse practitioner notes that she has poor hygiene and bruises on her trunk. The neighbor is concerned that the patient often has no money to buy food, despite income from social security and a coal miner’s pension. The nurse practitioner suspects abuse. Which of the following is the nurse practitioner obligated to do next?
1. Report the case to the proper authorities.
2. Tell the neighbor to check on the woman daily and report back.
3. Document the data and report the information to risk management.
4. Call the patient’s family and inquire about the concerns.
report the case to proper authorities
osioniazid (nydrazid) for 9 months
A young child with asthma presents for follow-up evaluation. After numerous changes in medications and doses, the parents report that the child continues to have difficulty with coughing, especially during the night. Which of the following conditions would be the most likely cause of the continued asthma symptoms?
1. Vocal cord dysfunction
2. Cystic fibrosis
3. Gastroesophageal reflux
4. Allergic rhinitis
A pregnant woman with known HIV infection can reduce the risk of perinatal transmission through zidovudine (Retrovir) therapy. Based on current research, optimal therapy is to start daily dosing:
1. post amniocentesis.
2. after 14 weeks of gestation.
3. if premature rupture of membranes occurs.
4. if maternal viral loads are greater than 10,000.
The 16-year-old mother of a 2-month-old presents the infant, reporting that the child is very irritable and does not feed well. During physical examination, the child’s head drops back and the child exhibits sudden flexing of the extremities. As the flexing stops, the child cries uncontrollably. Funduscopic examination reveals retinal hemorrhages. Which of the following diagnostic tests should be ordered?
1. Skull X-rays
2. MRI
3. CT scan
4. Pet scan
A patient on warfarin (Coumadin) therapy for recurrent deep vein thrombosis (DVT) is about to have lumbar spinal fusion surgery. The patient’s warfarin is put on hold starting 5 days prior to the surgery and subcutaneous Lovenox has been ordered for DVT prophylaxis until the resumption of the warfarin. The nurse practitioner knows that the patient’s postoperative warfarin dose should be restarted based on the:
1. value of her morning Prothrombin time.
2. loading dose of 10 mg, plus the previous warfarin dose.
3. baseline PT and INR values.
4. target INR of 2.
A 3-year-old presents with a 2-day history of acute diarrhea with a total of 8 watery stools without blood or mucus, and 2 episodes of vomiting in the past 48 hours. Assessment reveals no current antibiotic therapy, dehydration <5%, soft abdomen with hyperactive bowel sounds, no masses or organomegaly; other physical findings are normal. Which of the following is the most appropriate management plan?
1. Stool culture; Immodium AD liquid.
2. No laboratory workup; instruct parents on signs and symptoms of dehydration; diet of clear liquids, advancing to bananas, rice cereal, Jell-O, and soup.
3. Start diet of clear liquids, advancing to bananas, rice cereal, Jell-O, and soup over next 72 hours; Imodium AD liquid, 1 mg/sml
4. Stool for ova and parasites; advise parents of likely sources of Giardia; prescribe furazolidone (Furoxone)
A mother presents her 12-month-old child with concern because the child does not yet say “mama” or “dada.” The mother reports that in the first months of life, the child loved listening to music and being talked to. The past medical history is negative for ear infections. The nurse practitioner should:
1. evaluate for hearing loss.
2. refer to speech therapy.
3. re-evaluate in 3 months.
4. check for cerumen impaction.
During a well-child examination of an 18-month-old, premature tooth decay and inflamed gums, particularly of the maxillary incisors, are noted. The approach to this problem includes:
1. referring the child to a dentist, assessing for bottle feeding and fluoride in local water.
2. teaching the mother to brush the child’s teeth, encouraging vitamin supplements.
3. recommending fluoride mouthwash and toothpaste, suggesting celery sticks for snacks.
4. providing fluoride treatment, teaching dental hygiene, and eating foods high in calcium.
referring the child to a dentist, assessing for bottle feeding and fluoride in local water
decreased reabsorption of sodium-glucose transporters
In pulmonary function testing, forced vital capacity represents the:
1. maximum volume of air that can be forcefully exhaled after maximum inspiration.
2. total volume of air that is exhaled after normal inspiration.
3. total volume of air that the lungs can hold, minus the expiratory reserve volume.
4. volume of air that can be forcefully exhaled in 1 second.
maximum volume of air that can be forcefully exhaled after maximum inspiration
An adult male presents as first patient of the day after awaking about 5:00 AM with indigestion and chest pressure. On checking his pulse, he found no change from previous measurements. He states that, while waiting for the nurse practitioner to arrive, he began to feel a little clammy. A 12-lead EKG records the following patterns. On the basis of these EKG readings, the diagnosis is:
1. anterior-septal acute myocardial infarction.
2. lateral acute myocardial infarction.
3. inferior acute myocardial infarction.
4. anterior acute myocardial infarction.
inferior acute myocardial infarction
During the past 24 hours, a 62-year-old has experienced abdominal pain that radiates to the back. The patient also reports several episodes of nausea and vomiting, a low-grade temperature, and a history of excessive drinking. Physical examination reveals a distended abdomen. Laboratory serum values indicate elevated alkaline phosphatase, amylase, and serum lipase. The most likely diagnosis is:
1. alcoholic liver disease.
2. acute mesenteric ischemia.
3. viral hepatitis.
4. acute pancreatitis.
An otherwise healthy adult female presents complaining of vaginal burning and itching during urination. She has a social history of two sexual partners. She denies fever or vaginal discharge, but has noted a lesion on one labium. The nurse practitioner should order all of the following EXCEPT:
1. wet mount and potassium hydroxide.
2. dark-field microscopy of fluid from the lesion.
3. nucleic acid amplification testing for gonorrhea.
4. serology for Haemophilus ducreyi.
dark-field microscopy of fluid from lesion
A 3-year-old female has been diagnosed with bacterial meningitis. She attends preschool daily at a local church day care program. The day before her diagnosis, she ate lunch with her mother at a local restaurant. For which contact(s) would chemoprophylaxis with rifampin be recommended?
1. Preschool contacts in the past 7 days
2. A friend of the patient’s sister who visited after school yesterday
3. The checkout employee at the grocery store yesterday
4. Diners at the restaurant during lunch the day the patient ate there
preschool contacts in past 7 days
more commonly affects both hips
sudden onset of painless and profuse bleeding
A 27-year-old male patient, who works as a janitor, presents with a 6-month history of an intermittent rash on his hands. History reveals itching and occasional burning. Examination reveals irregularly-distributed scaly maculopapular erythematous patches extending from the dorsum of the hand several inches up the forearms, and dry palms with no nail involvement. The most likely diagnosis is:
1. contact dermatitis.
2. scabies infestation.
3. psoriasis.
4. eczema.
A patient reports to your office, having been struck on the right cheek with a baseball bat. On examination, you notice tenderness and swelling over the cheek. The patient is unable to gaze laterally with his left eye, and he complains of double vision when he attempts to do so. This is most likely associated with:
1. retinal hemorrhage.
2. orbital rim fracture.
3. subarachnoid hemorrhage.
4. periorbital cellulitis.
A 7-year-old child presents with group A streptococcal infection confirmed by throat culture. Past history includes treatment for positive streptococcal infection with erythromycin (EryPed oral suspension) 3 weeks ago. What is the most appropriate next intervention?
1. Treat with amoxicillin for 10 days.
2. Obtain culture for all household members.
3. Treat with azithromycin (Zithromax) for 10 days.
4. Intramuscular Penicillin.
treat with amoxicillin for 10 days
A 16-year-old female adolescent is brought to the nurse practitioner’s office by her mother, who is concerned about her daughter’s recent weight loss. History reveals that the daughter was consistently in the 50th percentile for weight, but is now in the 10th percentile. The mother states that she is concerned that her daughter is purging herself after meals since she often goes to the restroom after eating and remains there for a long period of time. The daughter denies any self-induced vomiting, starvation or excessive activity. She does state that she jogs five miles a day and is in good condition. In addition to a complete blood count with differential, which of the following laboratory tests will be most helpful for further assessment?
1. Electrolytes, fasting blood sugar
2. Creatine phosphokinase, follicle-stimulating hormone (FSH)
3. Electrolytes, blood urea nitrogen (BUN)/creatinine, urinalysis
4. Electrolytes, FSH, stool for occult blood
electrolytes, blood urea nitrogen (BUN)/creatinine, urinalysis
A 2-year-old male presents for reevaluation. Two days ago, he had four episodes of vomiting and six diarrheal stools. On physical examination today, his vital signs reveal P = 120 and capillary refill of 3 seconds. The patient’s eyes are sunken and his extremities are mottled and cool to the touch. The treatment plan would include:
1. start oral electrolyte mixture every hour.
2. hospitalization for IV fluid replacement.
3. giving the child loperamide for each diarrheal stool.
4. catheterizing the child to obtain accurate urine output.
hospitalization for IV fluid replacement
A nurse practitioner places a 76-year-old patient on nifedipine (Procardia) 10 mg t.i.d. for angina. The patient is unable to remember to take the medication at the scheduled times. The practitioner should:
1. discontinue the issue with the patient’s daughter.
2. change the dose to extended release 30 mg daily.
3. reinforce the importance of taking the medication.
4. increase the dosage to 20 mg b.i.d.
change the dose to extended release 30mg daily
A pediatric male is present with his mother, who states that he is extremely restless at night and constantly scratches his anal area. Which diagnostic procedure would confirm a diagnosis of pinworm infestation?
1. The patch test
2. Examination of bed linens
3. Examination of transparent tape sample from perianal skin
4. Blood tests for anemia and eosinophilia
examination of transparent tape sample from perianal skin
Which of the following microorganisms are most frequently associated with acute bacterial rhino-sinusitis?
1. Staphylococcus aureus and Mycoplasma pneumonia
2. Staphylococcus aureus and Methicillin Resistant Staph aureus
3. Streptococcus pneumoniae and Haemophilus influenzae
4. Streptococcus pneumoniae and Pseudomonas aeruginosa
strep pneumo and haemophilus influenzae
slight increase in growth velocity
A geriatric female presents for her annual examination. She has been on antihypertensive medications for over 20 years, with good control. Laboratory values are within normal ranges. The nurse practitioner is concerned about the patient’s cardiac health risks, due her to weight and her waist circumference. According to the AHA guidelines, which of the following goals is expected for this patient?
1. Physical activity for 60 minutes daily, for a minimum of 6 days a week
2. Physical activity for 30 minutes daily, 7 days a week
3. Physical activity for 30 minutes daily, for a minimum of 5 days a week
4. Physical activity for 60 minutes daily, 7 days a week
physical activity for 30 minutes daily, for a minimum of 5 days a week
A 50-year-old male presents with bruises and abrasions on the left leg and forearm, claiming to have had a number of minor accidents at home and at work. The patient reports general feelings of depression, forgetfulness, and, despite the fact that he is regularly employed, a mounting collection of unpaid and overdue bills. In taking the patient’s history, a significant pattern of parental alcohol abuse, stroke, TIA, and MI emerges. During questioning to elicit a more thorough diagnosis, the patient becomes hostile and leaves the clinic without further treatment. The most likely explanation for this behavior is:
1. Alzheimer’s disease.
2. chronic alcoholism.
3. cancer.
4. carotid artery stenosis.
A 28-year-old patient presents with profuse yellow vaginal discharge, odor, and local irritation. She reports completing a 7-day course of oral metronidazole (Flagyl), 500 mg b.i.d. 4 weeks ago. She has had multiple recurrences over the last 18 months. Microscopic examination reveals presence of clue cells. What is the most appropriate treatment intervention?
1. Oral metronidazole (Flagyl), 500 mg b.i.d., plus metronidazole vaginal gel (MetroGel), for 5 days
2. Treat both patient and partner(s) with oral metronidazole (Flagyl), 500 mg b.i.d., for 7 days
3. Metronidazole vaginal gel (MetroGel) twice weekly for 4 to 6 months
4. Treat patient with metronidazole vaginal gel (MetroGel) b.i.d. and partner(s) with tetracycline, 250 mg q.i.d., for 7 days
Treat both patient and partner(s) with oral metronidazole (Flagyl), 500 mg b.i.d., for 7 days
An adult female who recently returned from a business trip to Japan presents for a recheck appointment. The only remarkable laboratory result is for thyroid-stimulating hormone (TSH), at 0.3 microunits/mL (normal = 0.4-6 microunits/mL). The patient reports that her neck hurts; examination reveals thyroid tenderness. Which of the following laboratory tests should the nurse practitioner order now?
1. Triiodothyronine (T3) and free thyroxine (FT4)
2. Triiodothyronine (T3) only
3. Triiodothyronine (T3) resin uptake assay
4. Triiodothyronine (T3) and free triiodothyronine (FT3)
Triiodothyronine (T3) and free thyroxine (FT4)
3-oz (85 g) weight gain over the past 2 weeks
leg, buttock or back pain precipitated by walking
A 70-year-old patient presents to the clinic complaining of dyspnea, palpitations, and fatigue. The patient reports a 2-week history of blackened stools, which the patient attributes to drinking berry juice. Assessment reveals vital signs of BP = 110/60, P = 100, R = 24; Hgb = 4.5 g/dL; Hct = 16%. What is the most appropriate immediate intervention?
1. Order serum iron, total iron-binding capacity (TIBC), and ferritin.
2. Refer to a gastroenterologist.
3. Send to the emergency room.
4. Order a complete blood count (CBC) with differential.
The symptoms of benign prostatic hypertrophy are often overlooked because the older male:
1. understands that surgery is the only cure for this condition.
2. considers urinary problems to be a normal part of aging.
3. is fearful of the side effects of additional medication.
4. is concerned that he will no longer be able to obtain an erection.
considers urinary problems to be normal part of aging
A 26-year-old female presents with abdominal distention, bloating, and intermittent crampy abdominal pain relieved by defecation. She has four to six loose stools a day when stressed. Between bouts of diarrhea, she often has constipation. Physical examination results are normal. The CBC was normal. The most likely diagnosis is:
1. diverticulitis.
2. viral gastroenteritis.
3. inflammatory bowel disease.
4. irritable bowel syndrome
A mother has just noticed that her 15-month-old, 15-kg child has recently ingested an unknown quantity of iron tablets. The mother has ipecac syrup and activated charcoal on hand. The mother should be advised to:
1. take the child to the primary care provider.
2. give ipecac per recommendation on the bottle label.
3. take the child to the emergency room.
4. give the child 30 g of activated charcoal diluted with water
A 13-year-old is concerned because she has not yet begun to menstruate. Physical examination indicates that the patient is at Tanner stage IV and is of average height and weight. Which of the following would be the most appropriate response to this patient?
1. “We’ll need to refer you to an endocrinologist for a complete workup.”
2. “We’ll need to do some tests to find out why you are not having periods.”
3. “I’ll give you some pills that will make your periods start.”
4. “Your development is exactly as expected for your age; you’ll probably begin to have periods within a year.”
A 46-year-old female found a lump in her breast this morning. History includes: no prior breast disease; G2P2 (first birth, age 22); maternal aunt diagnosed with breast cancer at age 72; last menstrual period was 2.5 weeks ago. On examination, a nurse practitioner palpates a 2-cm round, soft, mobile, tender lesion in the upper outer quadrant of the right breast. Mammogram is negative. Which of the following actions is most appropriate?
1. Reassure the patient that no further action is necessary.
2. Repeat unilateral right mammogram in 3 months.
3. Schedule a right-breast ultrasound.
4. Refer for genetic testing if the lump increases in size.
schedule a right breast ultrasound
multiple sexual partners and years of sexual activity
A 65-year-old patient being treated with digoxin (Lanoxin) for chronic heart failure (HF) presents with complaints of palpitations. Three days ago, the patient was placed on clarithromycin (Biaxin) by another provider for community-acquired pneumonia. The appropriate course of action at this point would be to:
1. increase the digoxin dosage by 25%.
2. obtain a digoxin level and change the antibiotic to azithromycin (Zithromax).
3. obtain a chest X-ray.
4. obtain a serum potassium level and perform a 12-lead EKG.
obtain a digoxin level and change the antibiotic to azithromycin (zithromax)
A 54-year-old male who is 30 pounds overweight states that he awakens at night with heartburn and the taste of hot acid in his mouth. Stress makes his condition worse, yet baking soda seems to provide some relief. Findings on examination are normal and the stool for occult blood is negative. The preliminary diagnosis(es) should be:
1. esophagitis.
2. esophageal spasm.
3. helicobacter pylori.
4. gastroesophageal reflux disease.
A late adolescent patient presents with complaints of acute-onset unilateral right eye pain, visual changes, seeing halos around lights, abdominal pain, and intermittent nausea. Physical findings include an erythematous right eye without discharge, a cloudy cornea, and a moderately dilated right pupil that is nonreactive to light. The nurse practitioner should immediately:
1. apply steroid drops to the right eye.
2. apply mydriatic drops to the eye.
3. refer to the emergency department.
4. make an appointment for him to see an ophthalmologist.
An 86-year-old patient is experiencing radiculopathy-associated lower back pain that has not improved over the past 4 weeks. The medical history includes a lumbar discectomy. The best type of imaging study for evaluating this patient would be a/an:
1. MRI.
2. spinal X-ray.
3. myelography.
4. nuclear bone scan.
A 30-month-old with a history of frequent ear infections was seen in September after a symptom-free summer. Examination revealed bilateral bulging eardrums. After two separate courses of antibiotics, fluid is noted in both ears. The parent reports speech difficulties. The most likely diagnosis is:
1. otitis media with effusion.
2. myringitis.
3. recurrent acute otitis.
4. Esutachian tube dysfunction.
A frail elderly widow presents to the senior clinic with a 3- to 4-day history of confusion that became worse the evening before but currently seems a little better, although her speech is rambling and difficult to follow. During the examination, the patient is anxious and agitated. She is on cardiac medications, an antidepressant, and insulin. The most likely diagnosis is:
1. mild stroke.
2. polypharmacy.
3. electrolyte imbalance.
4. agitated depression.