Test Bank For Radiation Protection in Medical Radiography, 9th Edition by Mary Alice Statkiewicz S

Test Bank For Radiation Protection in Medical Radiography, 9th Edition by Mary Alice Statkiewicz Sherer, AS, RT(R), FASRT, Paula J. Visconti, PhD, DABR, E. Russell Ritenour, PhD, DABR, FAAPM, FACR and Kelli Welch Haynes, RT (R), FASRT Chapter 1-16 With Unit 3

Chapter 01: Introduction to Radiation Protection Sherer: Radiation Protection in Medical Radiography, 9th Edition MULTIPLE CHOICE 1. Consequences of ionization in human cells include

1. creation of unstable atoms.

2. production of free electrons.

3. creation of highly reactive free molecules (called free radicals) capable of producing substances poisonous to the cell.

4. creation of new biologic molecules detrimental to the living cell.

5. injury to the cell that may manifest itself as abnormal function or loss of function.

6. production of low-energy x-ray photons. a. 1, 2, 3, and 4 only b. 2, 3, 4, and 5 only c. 3, 4, 5, and 6 only d. All the options ANS: D 2. Which of the following is a form of radiation that is capable of creating electrically charged

particles by removing orbital electrons from the atom of normal matter through which it passes? a. Ionizing radiation b. Nonionizing radiation c. Subatomic radiation d. Ultrasonic radiation ANS: A 3. Regarding exposure to ionizing radiation, patients who are educated to understand the medical

benefit of an imaging procedure are more likely to a. assume a small chance of biologic damage but not suppress any radiation phobia they may have. b. cancel their scheduled procedure because they are not willing to assume a small chance of biologic damage. c. suppress any radiation phobia but not risk a small chance of possible biologic damage. d. suppress any radiation phobia and be willing to assume a small chance of possible biologic damage.

ANS: D 4. The millisievert (mSv) is equal to a. 1/10 of a sievert. b. 1/100 of a sievert. c. 1/1000 of a sievert. d. 1/10,000 of a sievert.

ANS: C 5. The advantages of the BERT method are

1. BERT does not imply radiation risk; it is simply a means for comparison.

2. BERT emphasizes that radiation is an innate part of the environment.

3. BERT provides an answer that is easy for the patient to comprehend. a. 1 and 2 only b. 1 and 3 only c. 2 and 3 only d. All the options ANS: D 6. If a patient asks a radiographer a question about how much radiation he or she will receive

from a specific x-ray procedure, the radiographer can a. respond by using an estimation based on the comparison of radiation received from the x-ray to natural background radiation received. b. avoid the patient‘s question by changing the subject. c. tell the patient that it is unethical to discuss such concerns. d. refuse to answer the question and recommend that he or she speak with the referring physician.

ANS: A 7. Why should the selection of technical exposure factors for all medical imaging procedures

always follow ALARA? a. So that referring physicians ordering imaging procedures do not have to accept responsibility for patient radiation safety. b. So that radiographers and radiologists do not have to accept responsibility for patient radiation safety. c. Because radiation-induced cancer does not appear to have a fixed threshold, that is, a dose level below which a person would have no chance of developing this disease. d. Because radiation-induced cancer does have a dose level at which individuals would have a chance of developing this disease.

ANS: C 8. The cardinal principles of radiation protection include which of the following? a. Time b. Distance c. Shielding d. All the options

ANS: D 9. In a hospital setting, which of the following professionals is expressly charged by the hospital

administration with being directly responsible for the execution, enforcement, and maintenance of the ALARA program? a. Assistant administrator of the facility b. Chief of staff c. Radiation Safety Officer d. Student radiologic technologist ANS: C 10. Why is a question concerning the amount of radiation a patient will receive during a specific

x-ray procedure difficult to answer?

1. Because the received dose is specified in a number of different units of measure.

2. Because the scientific units for radiation dose are normally not comprehensible by a patient.

3. Because the patient should not receive any information about radiation dose. a. 1 and 2 only b. 1 and 3 only c. 2 and 3 only d. All the options ANS: A 11. X-rays are a form of which of the following kinds of radiation? a. Environmental b. Ionizing c. Internal d. Nonionizing ANS: B 12. What unit is used to measure radiation exposure in the metric International System of Units? a. Coulomb per kilogram b. Milligray c. Millisievert d. Sievert ANS: A 13. What organization was founded in 2007 that continues their pursuit to raise awareness of the

need for dose reduction protocols by promoting pediatric-specified scan protocols to be used for both radiology and non-radiology users of CT? a. U.S. Food and Drug Administration b. Alliance for Radiation Safety in Pediatric Imaging c. American Registry of Radiologic Technologists d. The Joint Commission ANS: B 14. Which of the following provides the basis for determining whether an imaging procedure or

practice is justified?

a. b. c. d.

ALARA concept BERT method Diagnostic efficacy NEXT program

ANS: C 15. Which of the following is a method of explaining radiation to the public? a. ALARA b. BERT c. ORP d. NEXT ANS: B 16. Radiology departments or individual radiologic technologists can ―pledge‖ to image gently.

The pledge includes which of the following? a. Make the image gently message a priority in staff communications each year. b. Review the protocol recommendations and, when necessary, implement adjustments to practice processes. c. Communicate openly with parents. d. All of the options.

ANS: D 17. In a team approach to patient care, various participants

1. assume responsibility for their areas of expertise.

2. emphasize the importance of communication throughout the team.

3. rotate as the person in charge of the team. a. 1 and 2 only b. 1 and 3 only c. 2 and 3 only d. All the options ANS: A 18. Which of the following radiation quantities is intended to be the best overall measure of the

biologic effects of ionizing radiation? a. Exposure b. Effective dose c. Absorbed dose d. There is no radiation quantity that is intended to be the best overall measure of the biologic effects of ionizing radiation.

ANS: B 19. Typically, people are more willing to accept a risk if they perceive that the potential benefit to

be obtained is a. greater than the risk involved. b. equal to the risk involved. c. less than the risk involved. d. typically, people are not willing to accept risk no matter how great the benefit may

be.

ANS: A 20. Which of the following statements below is true? a. It appears that no safe dose level exists for radiation-induced malignant disease. b. The ALARA principle establishes a dose level for radiation-induced malignancy. c. The BERT method establishes a dose level for radiation-induced malignancy. d. The NEXT program and reference values establish a dose level for

radiation-induced malignancy.

ANS: A 21. The ALARA principle provides a method for comparing the amount of radiation used in

various health care facilities in a particular area for specific imaging procedures. This information may be helpful to many a. accrediting bodies. b. advisory groups. c. radiation standards organizations. d. regulatory agencies.

ANS: D 22. The term as low as reasonable achievable (ALARA) is synonymous with the term a. background equivalent radiation time (BERT). b. equivalent dose (EqD). c. diagnostic efficacy. d. optimization for radiation protection (ORP).

ANS: D 23. Diagnostic efficacy includes

1. determining if an imaging procedure is justified.

2. producing optimal quality images with the least radiation exposure to the patient.

3. adhering to radiation safety guidelines.

4. revealing the presence or absence of disease in a patient. a. 1, 2, and 3 only b. 1, 2, and 4 only c. 2, 3, and 4 only d. All the options ANS: D 24. Which of the following are required by The Joint Commission for CT?

1. Annual education of staff in dose reduction techniques 2. Minimum qualifications for medical physicists 3. Documentation of CT radiation doses 4. Management of CT protocols to minimize radiation dose a. 1 and 2 only b. 1 and 3 only c. 2 and 4 only d. All the options

ANS: D 25. Effective protective actions take into consideration

1. both human and environmental physical determinants.

2. technical elements.

3. procedural factors. a. 1 and 2 only b. 1 and 3 only c. 2 and 3 only d. All of the options ANS: D

Chapter 02: Radiation: Types, Sources, and Doses Received Sherer: Radiation Protection in Medical Radiography, 9th Edition MULTIPLE CHOICE 1. If ionizing radiation from natural sources grows larger because of accidental or deliberate

human actions such as mining radioactive elements, the sources are termed a. artificial sources. b. enhanced natural sources. c. extraterrestrial sources. d. human-made sources.

ANS: B 2. Electromagnetic radiation travels or propagates through space in the form of a wave but can

interact with matter as a particle of energy called a photon. This dual nature is referred to as a. wave attenuation capability. b. wave-particle interchange ability. c. wave-particle duality. d. wave-particle phenomena.

ANS: C 3. Which of the following statements concerning the 1979 nuclear reactor accident at TMI-2 is

not true? a. Many excess cancer deaths have been predicted to occur in the 2 million people living within 50 miles of the plant at the time of the accident. b. TMI-2 has been dormant since the accident in 1979. c. The average dose received by the exposed population living within a 10-mile radius of the TMI nuclear power station at the time of the accident was determined to be 0.08 mSv, which is well below the average annual background level. d. The pressurized water reactor underwent an accidental loss of coolant, leading to severe overheating of the highly radioactive reactor core that resulted in a partial meltdown and significant radiation leak.

ANS: A 4. Terrestrial radiation includes which of the following sources? a. Long-lived radioactive elements such as uranium-238, radium-226, and

thorium-232 that are present in variable quantities in the crust of the Earth b. Radioactive fallout from nuclear weapons tests in which detonation occurred

above ground c. The sun and beyond the solar system d. Airport surveillance systems and electron microscopes ANS: A 5. The Environmental Protection Agency (EPA) recommends that action be taken to reduce

elevated levels of radon in homes to a concentration less than a. 200 pCi/L of air.

b. 135 pCi/L of air. c. 47 pCi/L of air. d. 4 pCi/L of air.

ANS: D 6. Cosmic radiation occurs in which two forms? a. Solar and human-made b. Artificial and galactic c. Natural background and artificial d. Solar and galactic ANS: D 7. As a result of technologic advances since the 1970s and strict regulations imposed within the

United States by the FDA regarding consumer products containing radioactive material, the radiation exposure of the general public from such produces may now be considered a. substantial. b. moderate. c. very slight. d. negligible.

ANS: D 8. Through which of the following routes can radon enter houses?

1. Crawl spaces under the living areas 2. Floor drains and sump pumps 3. Porous cement block foundations a. 1 and 2 only b. 1 and 3 only c. 2 and 3 only d. All the options ANS: D 9. Removal and storage of contaminated water from the Fukushima Daiichi Nuclear Power Plant

continues to be a major concern because a. there is still immediate danger of another earthquake. b. there is still immediate danger of another tsunami. c. there is still immediate danger from explosions. d. the amount of contaminated water can still increase.

ANS: D 10. When exposed to high radon levels in the home, which of the following groups of people have

the highest risk of developing lung cancer? a. Teenagers b. Adults from 20 to 30 years of age c. Nonsmokers d. Smokers ANS: D

11. Which of the following helps shield the global population from exposure to essentially all

high-energy, bombarding cosmic rays? a. Clouds b. Fog c. Atmosphere and magnetic field of the Earth d. Smog ANS: C 12. Which of the following radiation exposures is considered by the Environmental Protection

Agency to be the second leading cause of lung cancer in the United States? a. Annual PA and Lateral chest x-rays b. Cosmic ray exposure c. Radon exposure d. A fluoroscopic examination of the upper gastrointestinal system ANS: C 13. Which of the following are forms of electromagnetic radiation?

1. Microwaves 2. Visible light 3. X-rays 4. Gamma rays 5. Ultraviolet radiation a. 1, 2, and 3 only b. 2, 3, and 4 only c. 3, 4, and 5 only d. All the options ANS: D 14. What is the most common unit of measure of equivalent dose? a. Coulomb per kilogram b. Milligray c. Millisievert d. MicroLiter ANS: C 15. In the electromagnetic spectrum, higher frequencies are associated with a. longer wavelengths and lower energies. b. longer wavelengths and higher energies. c. shorter wavelengths and lower energies. d. shorter wavelengths and higher energies.

ANS: D 16. Which of the following radiation quantities use the same unit of measure? a. Effective dose and equivalent dose b. Exposure and effective dose c. Absorbed dose and equivalent dose d. All of the above

ANS: A 17. A flight on a typical commercial airliner results in an equivalent dose rate of a. 0.001 to 0.005 mSv/hr. b. 0.005 to 0.01 mSv/hr. c. 0.02 to 0.04 mSv/hr. d. 0.05 to 0.09 mSv/hr.

ANS: B 18. The first decay product of radium is a. cesium. b. radon. c. strontium. d. x-ray.

ANS: B 19. When spread over the inhabitants of the United States, fallout from nuclear weapons tests and

other environmental sources along with other human-made radiations contributes a. only a small portion of 0.1 mSv to the equivalent dose of each person. b. a dose of approximately 1.5 mSv to the equivalent dose of each person. c. a dose of approximately 3.2 mSv to the equivalent dose of each person. d. a dose of approximately 6.3 mSv to the equivalent dose of each person.

ANS: A 20. What is the total average annual radiation equivalent dose for estimated levels of radiation

exposure for humans? a. 2.3 mSv b. 3.1 mSv c. 5.5 mSv d. 8.2 mSv ANS: C 21. The mass of an alpha particle is approximately a. two times the mass of a hydrogen atom and a negative charge of minus 2. b. four times the mass of a hydrogen atom and a positive charge twice that of an

electron. c. six times the mass of a hydrogen atom and a negative charge of minus 1. d. eight times the mass of a hydrogen atom and a positive charge four times that of an

electron.

ANS: B 22. What is the half-life of radon-220? a. 54.5 seconds b. 8 days c. 2 years d. 1622 years

ANS: A 23. Which of the following sources of radiation is human-made?

1. Atmospheric fallout from nuclear weapons testing 2. Cosmic radiation from the sun and beyond the solar system 3. Nuclear power plant accidents as a consequence of natural disasters a. 1 and 2 only b. 1 and 3 only c. 2 and 3 only d. All the options ANS: B 24. Two cGy equals a. 2 Gy. b. .2 Gy. c. .02 Gy. d. .002 Gy. ANS: C 25. Of the two sources of ionizing radiation listed below, which source remains fairly constant

from year to year? a. Human-made b. Natural ANS: B

Chapter 03: Interaction of X-Radiation with Matter Sherer: Radiation Protection in Medical Radiography, 9th Edition MULTIPLE CHOICE 1. Particles associated with electromagnetic radiation that have neither mass nor electric charge

and travel at the speed of light are a. ions. b. negatrons. c. positrons. d. x-ray photons.

ANS: D 2. Although coherent scattering is most likely to occur ____________, some of this unmodified

scattering occurs throughout the diagnostic range and can result in small amounts of radiographic fog. a. at less than 10 keV b. between 30 keV and 60 keV c. between 60 keV and 90 keV d. above 100 keV ANS: A

3. Which of the following is not a type of interaction between x-radiation and biologic matter? a. Compton scattering b. Bremsstrahlung c. Pair production d. Photoelectric absorption ANS: B 4. The symbol Z indicates a. atomic number of an atom. b. atomic weight of an atom. c. fluorescent yield. d. the number of vacancies in an atomic shell.

ANS: A 5. In photoelectric absorption to dislodge an inner-shell electron from its atomic orbit, the

incoming x-ray photon must be able to transfer a quantity of energy a. less than the energy that holds the atom together. b. 10 times as great as the energy that holds the atom together. c. as large as or larger than the amount of energy that holds the electron in its orbit. d. equal to or greater than 1.022 MeV, regardless of the energy that holds the electron in its orbit.

ANS: C 6. Which of the following interactions between x-ray photons with matter involve a

matter–antimatter annihilation reaction? a. Compton scattering b. Coherent scattering c. Pair production d. Photoelectric absorption ANS: C 7. The probability of occurrence of photoelectric absorption _________ as the energy of the

incident photon decreases and the atomic number of the irradiated atoms _________. a. increases markedly; decreases b. decreases markedly; increases c. increases markedly; increases d. stays the same; increases ANS: C 8. Which of the following terms refers to the radiation that occurs when an electron

spontaneously drops down from an outer shell of an ionized atom to fill a vacancy in an inner shell of that atom? a. Characteristic photon, or characteristic x-ray b. Bremsstrahlung c. Photoelectric radiation d. Primary radiation

ANS: A 9. Fluorescent radiation is also known as a. characteristic radiation. b. coherent scattering. c. Compton scattering. d. unmodified scattering.

ANS: A 10. What is the effective atomic number of compact bone? a. 5.9 b. 7.4 c. 7.6 d. 13.8 ANS: D 11. Which of the following is not another term for coherent scattering? a. Characteristic b. Classical c. Elastic d. Unmodified ANS: A 12. Which of the following are by-products of photoelectric absorption? a. Photoelectron and Compton-scattered electron b. Low-energy scattered x-ray photon and characteristic photon c. Low-energy scattered x-ray photon and Compton-scattered electron d. Photoelectron and characteristic photon ANS: D 13. Which two interactions between x-radiation and matter may result in the production of

small-angle scatter? a. Photoelectric absorption and Compton scattering b. Coherent scattering and Compton scattering c. Photoelectric absorption and pair production d. Coherent scattering and pair production ANS: B 14. Which of the following particles is considered to be a form of antimatter? a. Electron b. Positron c. X-ray photon d. Scattered x-ray photon ANS: B 15. Which of the following interactions results in the conversion of matter into energy? a. Classical scattering

b. Photoelectric absorption c. Modified scattering d. Annihilation reaction ANS: D 16. Compton scattering is synonymous with a. coherent scattering. b. incoherent scattering. c. photoelectric absorption. d. photodisintegration.

ANS: B 17. During the process of coherent scattering, an incident low-energy x-ray photon interacts with a. a single inner-shell electron, ejecting it from its orbit. b. a single outer-shell electron, ejecting it from its orbit. c. an atom and may transfer its energy by causing some or all of the electrons of the

atom to momentarily vibrate and radiate energy in the form of electromagnetic waves. d. a scattered photon of lesser energy, annihilating it.

ANS: C 18. What is the term for the number of x-rays emitted per inner-shell vacancy during the process

of photoelectric absorption? a. Characteristic absorption b. Classical gain c. Fluorescent yield d. Modified pair production ANS: C 19. Which of the following results in all-directional scatter? a. Classical interaction b. Coherent interaction c. Photoelectric interaction d. Compton interaction ANS: D 20. Annihilation radiation is used in which of the following modalities? a. Computed tomography b. Digital mammography c. Positron emission tomography d. Computed radiography ANS: C 21. The x-ray photon energy required to initiate pair production is a. 0.511 keV. b. 1.022 keV. c. 0.511 MeV.

d. 1.022 MeV. ANS: D 22. If two anatomic structures have the same density and atomic number but one is twice as thick

as the other, the thicker structure will absorb a. the same number of x-ray photons. b. twice as many x-ray photons. c. four times the number of x-ray photons. d. eight times the number of x-ray photons.

ANS: B 23. Since the density of air is approximately _________________ than that of soft tissue, a given

volume of air will interact with far fewer x-ray photons than adjacent regions of soft tissue, thereby permitting more radiation to reach the image receptor. a. 1000 times smaller b. 1000 times larger c. 100 times smaller d. 100 times lager ANS: A 24. When an inner electron is removed from an atom in a photoelectric interaction, thus causing

an inner-shell vacancy, the energy liberated when this vacancy is filled can be transferred to another electron of the atom, thereby ejecting that electron, instead of emerging from the atom as characteristic radiation. What is this electron called? a. Auger electron b. Compton electron c. Edison electron d. Sievert electron ANS: A 25. X-rays are carriers of a. disease. b. electrons. c. fluorescent properties that make them visible. d. human-made electromagnetic energy.

ANS: D

Chapter 04: Radiation Quantities and Units Sherer: Radiation Protection in Medical Radiography, 9th Edition MULTIPLE CHOICE 1. Who was the first American radiation worker to die from radiation-induced cancer in October

of 1904? a. Thomas A. Edison b. Wilhelm C. Roentgen c. Clarence Madison Dally

d. Marie Curie ANS: C 2. Which of the following are early tissue reactions of ionizing radiation that were experienced

by early radiation workers?

1. Diffuse redness of skin 2. Blood disorders 3. Organ atrophy 4. Intestinal disorders a. 1, 2, and 3 only b. 2, 3, and 4 only c. 1, 2, and 4 only d. All of the options ANS: C 3. 0.2 Gy equals a. 2 mGy. b. 20 mGy. c. 200 mGy. d. 2000 mGy. ANS: C 4. The total kinetic energy released in a unit mass (kilogram) of air and expressed in metric units

of joules per kilogram is a. absorbed dose. b. air kerma. c. effective dose. d. equivalent dose.

ANS: B 5. Which of the following is essentially the sum total of air kerma over the exposed area of the

patient‘s body surface? a. Absorbed dose b. Dose area product c. Effective dose d. Equivalent dose ANS: B 6. The whole-body TEDE regulatory limit for exposed personnel is _____________ and

______________ for the general public. a. 0.05 Sv; 0.001 Sv b. 0.15 Sv; 0.015 Sv c. 0.25 Sv; 0.025 Sv d. 0.5 Sv; 0.1 Sv ANS: A

7. As the intensity of x-ray exposure of the air volume increases, the number of electron–ion

pairs produced a. also increases. b. decreases considerably. c. decreases slightly. d. remains the same.

ANS: A 8. What do radiation weighting factors take into consideration? a. The overall risk of exposure to humans from ionizing radiation b. Both the internal and external dose measurements c. The fact that some types of radiation are more efficient at causing biologic damage

than other types of radiation for a given dose d. All of the options ANS: C 9. 1 gray equals a. 10 J/kg. b. 100 J/kg. c. 100 cGy. d. 1000 cGy. ANS: C 10. In the SI system, an energy absorption of 1 J/kg of matter in the irradiated object equals which

of the following? a. 10 Sv b. 5 C/kg c. 1 mSv d. 1 Gy ANS: D 11. Cataract formation, fibrosis, reduced fertility, and sterility are classified as a. early tissue reactions of ionizing radiation. b. late tissue reactions of ionizing radiation. c. hereditary effects of ionizing radiation. d. stochastic effects of ionizing radiation.

ANS: B 12. Which of the following types of ionizing radiation produce virtually the same biologic effect

in body tissue for equal absorbed doses? a. X-rays, beta particles, and gamma rays b. Alpha particles, beta particles, and gamma rays c. X-rays, neutrons, and gamma rays d. X-rays, alpha particles, and fast neutrons ANS: A

13. What theory relates the ionization produced in a small cavity within an irradiated medium or

object to the energy absorbed in that medium as a result of its radiation exposure? a. Air kerma b. Bragg-Gray c. Committed dose d. Tissue kerma ANS: B 14. If 400 people receive an average effective dose of 0.25 Sv, what is the collective effective

dose? a. 100 person-Sv b. 200 person-Sv c. 800 person-Sv d. 1600 person-Sv ANS: A 15. For x-ray and gamma ray photons with energies up to 3 million electron volts (MeV), which

of the following radiation quantities may be defined as the measure of the total electrical charge of one sign, either all pluses or all minuses, per unit mass that these two types of radiation generate in dry air (i.e., nonhumid) at standard temperature and pressure (760 mm Hg or 1 atmosphere at sea level and 22° C)? a. Absorbed dose b. Equivalent dose c. Exposure d. Collective effective dose ANS: C 16. Which of the following formulas is used to calculate effective dose? a. EfD = (D  WR)1 + (D  WR)2 + (D  WR)3 b. EfD = D  WR  WT c. EfD = D ÷ WR  WT d. All of the options ANS: B 17. Alpha particles have a radiation weighting factor (WR) that is numerically equal to a. 1. b. 5. c. 10. d. 20.

ANS: D 18. Which of the following units of measure are not SI units? a. Roentgens b. Coulombs per kilogram, grays, sieverts c. Rads and rems d. Roentgens and rads and rems

ANS: D 19. How is dose area product usually specified? a. In coulomb per kilogram b. In ergs per gram c. In subunits of millisievert d. In units of mGy-cm2 ANS: D 20. What instrument can be calibrated to read air kerma? a. Amp meter b. Coulomb counter c. Standard, or free-air, ionization chamber d. Voltmeter ANS: C 21. Which of the following is the SI unit of electrical current? a. Ampere b. Coulomb per kilogram c. Erg d. Sievert ANS: A 22. Beta particles are actually a. gamma rays. b. high-speed electrons. c. protons. d. x-rays.

ANS: B 23. Among physicians, cancer deaths attributed to x-ray exposure were reported as early as a. 1910. b. 1930. c. 1937. d. 1945.

ANS: A 24. In therapeutic radiology what SI units are now routinely used to specify absorbed dose? a. Coulomb per kilogram and roentgen b. Air kerma and microgray c. Gray and centigray d. Sievert and millisievert ANS: C 25. Who discovered x-rays on November 8, 1895? a. Thomas A. Edison b. Clarence Madison Dally

c. Louis Harold Gray d. Wilhelm Conrad Roentgen ANS: D

Chapter 05: Radiation Monitoring Sherer: Radiation Protection in Medical Radiography, 9th Edition MULTIPLE CHOICE 1. Three different filters are incorporated into the detector packet of the optically stimulated

luminescence dosimeter. Of what are these filters made? a. Aluminum, tin, and copper b. Aluminum, tin, and lead c. Zinc, copper, and barium d. Zinc, copper, and lead ANS: A 2. What is the maximum period of time that a thermoluminescent ring dosimeter (TLD) may be

worn as a personnel device? a. 1 hour b. 1 week c. 1 month d. 3 months ANS: D 3. What do optically stimulated luminescence dosimeters, thermoluminescent ring dosimeters,

and personnel direct ion storage dosimeters have in common? a. These devices are all used for area monitoring. b. These devices all use the same sensing material to detect ionizing radiation. c. These devices are all used for personnel monitoring. d. Each of these devices can only be used for personnel monitoring for a maximum of 6 months.

ANS: C 4. Which of the following instruments is called a cutie pie? a. survey meter b. Ionization chamber-type survey meter c. Optically stimulated luminescence dosimeter d. Proportional counter ANS: A 5. Which of the following instruments generally has a check source of a weak, long-lived

radioisotope located on one side of its external surface to verify its constancy daily? a. Personnel direct ion storage dosimeter b. Proportional counter c. survey meter d. Ionization chamber-type survey meter

ANS: C 6. Which of the following devices contains an aluminum oxide detector? a. Personnel direct ion storage dosimeter b. Optically stimulated luminescence dosimeter c. Proportional counter d. Thermoluminescent ring dosimeter ANS: B 7. When the sensing material contained in the thermoluminescent ring dosimeter is irradiated,

which of the following occurs? a. The protons in the crystalline lattice structure of the LiF molecule absorb energy and are excited to a higher energy level or bands. b. The neutrons in the crystalline lattice structure of the LiF molecule absorb energy and are excited to a higher energy level or bands. c. Some of the electrons in the crystalline lattice structure of the LiF molecule absorb energy and are excited to higher energy levels or bands. d. The electrons freed from the LiF molecule are trapped at a lower energy level or bands.

ANS: C 8. Because of the OSL dosimeter‘s sensitivity down to as low as 10 µSv for x-ray and gamma

ray photons in the energy range 5 keV to 40 MeV, it is an excellent and practical monitoring device for a. employees working in high-radiation environments and for non-pregnant workers. b. employees working in low-radiation environments and for pregnant workers. c. members of the general public not occupationally employed. d. pregnant employees working in high-radiation environments.

ANS: B 9. The effective atomic number (Zeff) of lithium fluoride (LiF) is equal to a. 5.9. b. 6.4. c. 7.0. d. 8.2.

ANS: D 10. Which of the following are advantages of the personnel direct ion storage dosimeter?

1. Instant access to reports 2. No waiting time for mailing dosimeters 3. Lightweight and durable 4. Can be dropped or scratched with little chance of harm to the device a. 1, 2, and 3 only b. 1, 2, and 4 only c. 2, 3, and 4 only d. All of the options ANS: D

11. How is the readout for a personnel direct ion storage dosimeter obtained? a. By hand processing in specific chemical solutions b. By measuring the amount of light emitted from its sensing material c. Through a physical connecting device such as a universal serial bus (USB) or via

wireless connection d. By heating the sensing material in the device to a specific temperature ANS: C 12. Which of the following are disadvantages of the TLD ring dosimeter? a. Thermoluminescence readings will be lost if not carefully recorded. b. The readout process destroys information stored in the TLD ring dosimeter, thus

preventing the ―read‖ from serving as a permanent legal record of exposure. c. Calibrated dosimeters must be prepared before-hand and read with each group of

TLDs as they are processed. d. All of the options.

ANS: D 13. Which component(s) of the Geiger-Muller survey meter alerts the operator to the presence of

ionizing radiation? a. The shield covering the probe‘s sensitivity chamber b. An audio amplifier and speaker c. The metal that encloses the counter‘s gas-filled tube d. The meter scale ANS: B 14. Which of the following is not a requirement that radiation survey instruments must meet? a. They must all be equally sensitive in the detection of all types of ionizing

radiation. b. They should be able to detect all common types of ionizing radiation. c. They should be calibrated annually to ensure accurate operation. d. They should interact with ionizing radiation similarly to the method human tissue

reacts, permitting dose to be determined more accurately.

ANS: A 15. Medical physicists use ionization chambers, connected to electrometers to perform the annual

standard measurements required by state, federal, and health care accreditation organizations for radiographic and fluoroscopic devices. These annual measurements include 1. x-ray output in Gy or mGy. 2. fluoroscopic radiation entrance rates in mSv/min or R/min.

3. kVp setting accuracy.

4. exposure time exactness.

5. half-value layers, or beam quality. a. 1, 2, and 3 only b. 1, 3, and 4 only c. 2, 3, and 5 only d. All of the options

ANS: D 16. When changing employment, what must a radiation worker convey to his/her new employer? a. A list of all fluoroscopic procedures performed daily b. A list of all radiographic procedures performed daily c. Data pertinent to accumulated permanent equivalent dose to be placed on file d. A report of all procedures performed when ―on call‖ after regular hours ANS: C 17. The personnel direct ion storage dosimeter provides an instant read-out of dose information

when connected to a computer via a connector such as a (an) a. universal serial bus (USB). b. charge-coupled device. c. electrometer. d. ionization chamber.

ANS: A 18. The front of the white paper packet of the optically stimulated luminescence (OSL) dosimeter a. may be color coded to facilitate correct usage and placement of the dosimeter on

the body of occupationally exposed personnel. b. must not have any type of printing on it. c. must be radiopaque. d. must never be exposed to ionizing radiation.

ANS: A 19. Three different filters are incorporated into the detector packet of the optically stimulated

luminescence (OSL) dosimeter. These filters are respectively made of 1. aluminum.

2. copper.

3. molybdenum.

4. rhenium tungsten.

5. tin. a. 1, 2, and 3 only b. 1, 2, and 4 only c. 1, 2, and 5 only d. 2, 4, and 5 only ANS: C 20. An ionization chamber connected to an electrometer is a device that can measure a. electromagnetic force. b. tiny electric currents with high precision and accuracy. c. potential difference. d. voltage in an x-ray machine circuit.

ANS: B 21. Which of the following personnel monitoring devices can be used to provide an immediate

exposure readout for a radiation worker?

a. b. c. d.

Personnel direct ion storage dosimeter Optically stimulated luminescence dosimeter without an in-house reader Thermoluminescent ring dosimeter All of the options

ANS: A 22. Which of the following is a disadvantage of the optically stimulated luminescence dosimeter? a. Exposure not determinable on the day of occurrence without an in-house reader b. Mechanical shock can cause false high reading c. No permanent, legal record of exposure d. Not cost-effective for large numbers of personnel ANS: A 23. Whenever the letter ―M‖ appears under the current monitoring period or in the cumulative

columns of a personnel monitoring report, it signifies that a (an) a. mistake has been made in recording the equivalent dose. b. equivalent dose higher than the minimum measurable radiation quantity was recorded during that time. c. equivalent dose below the minimum measurable radiation quantity was recorded during that time. d. maximal equivalent dose has been exceeded during that time.

ANS: C 24. The optically stimulated luminescence (OSL) dosimeter is ―read out‖ by using a (an) a. densitometer. b. ionization chamber. c. thermoluminescent analyzer. d. laser light at selected frequencies.

ANS: D 25. Some of the advantages of the optically stimulated luminescence (OSL) dosimeter are

1. can be used for up to 1 year.

2. lightweight, durable, and easy to carry.

3. integrated, self-contained, preloaded packet. a. 1, and 2 only b. 1, and 3 only c. 2, and 3 only d. All of the options ANS: D

Chapter 06: Overview of Cell Biology Sherer: Radiation Protection in Medical Radiography, 9th Edition MULTIPLE CHOICE 1. In general, which of the following can human cells do?

1. Move, grow, react, and protect themselves

2. Repair damage and regulate life processes 3. Reproduce a. 1 and 2 only b. 1 and 3 only c. 2 and 3 only d. All of the options ANS: D 2. Inorganic materials are compounds that a. contain only very small amounts of carbon. b. contain moderate amounts of carbon. c. contain large amounts of carbon. d. do not contain carbon.

ANS: D 3. Antibodies are protein molecules created by specialized cells in the bone marrow called a. B lymphocytes. b. R lymphocytes. c. megakaryocytes. d. oocytes.

ANS: A 4. The steps, or rungs, of the DNA ladder-like structure consist of complementary chemicals that

are a. b. c. d.

acetic acids. fatty acids. pairs of nitrogenous bases. sugar–phosphate compounds.

ANS: C 5. Which of the following are compounds called purines? a. Adenine and cytosine b. Adenine and guanine c. Adenine and thymine d. All of the options ANS: B 6. The much smaller structures that are building blocks of nucleic acids are called a. carbohydrates. b. fatty acids. c. nucleotides. d. polysaccharides.

ANS: C 7. Which of the following serves as a prototype for messenger RNA (mRNA)? a. Deoxyribonucleic acid (DNA) b. Nitric acid (HNO3)

c. Potassium (K) and sodium (Na) d. Transfer RNA (tRNA) ANS: A 8. The cell components that contain the centrioles are the a. centrosomes. b. Golgi apparatus and mitochondria. c. lysosomes. d. ribosomes.

ANS: A 9. What do the highly organized enzymes in the inner membranes of the mitochondria break

down? a. Carbohydrates b. Fats c. Proteins d. All of the options ANS: D 10. During which of the following subphases of mitosis do the centrioles migrate to opposite sides

of the cell and begin to regulate the formation of the mitotic spindle? a. Anaphase b. Metaphase c. Prophase d. Telophase ANS: C 11. In the human body mineral salts are necessary for

1. proper cell function.

2. creation of energy.

3. conduction of impulses along nerves. a. 1 and 2 only b. 1 and 3 only c. 2 and 3 only d. All of the options ANS: D 12. Which of the following can cause an increase in cellular activity that in turn causes

biochemical reactions to occur more rapidly to meet the needs of the cell in stressful situations? a. Acetic acids b. Enzymes c. Hormones d. Nucleic acids ANS: B 13. How many different amino acids are involved in protein synthesis in humans?

a. b. c. d.

7 15 22 39

ANS: C 14. A nucleotide is formed from a nitrogen-containing organic base, a ________________

molecule, and a phosphate molecule. a. three-carbon sugar b. five-carbon sugar c. seven-carbon sugar d. nine-carbon sugar ANS: B 15. Cytosine bonds only with a. adenine. b. guanine. c. nitrogen. d. thymine.

ANS: B 16. Which of the following are major tasks of the cytoplasm?

1. Accepts and builds up unrefined materials and assembles from these materials new substances such as carbohydrates, lipids, and proteins.

2. Breaks down organic materials to produce energy.

3. Packages substances for distribution to other areas of the cell or to various sites in the body through the circulation.

4. Eliminates waste products. a. 1, 2, and 3 only b. 1, 3, and 4 only c. 2, 3, and 4 only d. All of the options ANS: D 17. Which of the following is/are considered to be acellular tissue? a. Bone b. Fat c. Muscle d. Hair and nails ANS: D 18. Adenine bonds only with a. cytosine. b. guanine. c. hydrogen. d. thymine.

ANS: D 19. What should the constant core temperature of the human body be? a. 28° C b. 37° C c. 43° C d. 57° C ANS: B 20. Lysosomes are sometimes referred to as ―suicide bags,‖ because their enzymes break down

and digest not only proteins and certain carbohydrates but also will do the same to the cell itself should the lysosome‘s surrounding membrane rupture. Exposure to radiation may induce such a rupture. When this occurs what will happen to the cell? a. It will multiply spontaneously. b. It will divide very rapidly. c. It is likely to die. d. There will not be any effect on the cell.

ANS: C 21. What is any chemical reaction in which atoms lose electrons called? a. Synthesis b. Oxidation c. Osmosis d. Metabolism ANS: B 22. During mitosis, which phase of the cellular life cycle is the actual DNA synthesis period? a. G1 b. G2 c. M d. S ANS: D 23. During what phase of mitosis are the centromeres severed followed by the sister chromatids

moving apart and are then subsequently pulled toward opposite poles of the mitotic spindle? a. Prophase b. Metaphase c. Anaphase d. Telophase ANS: C 24. What is a highly coiled strand that is one of two duplicated portions of DNA in a replicated

chromosome that appears during cell division identified as? a. A centrosome b. A centromere c. A chromatid d. A curl

ANS: C 25. Fraternal twins may also be referred to as a. dizygotic twins. b. monozygotic twins. c. polyzygotic twins. d. trizygotic twins.

ANS: A

Chapter 07: Molecular and Cellular Radiation Biology Sherer: Radiation Protection in Medical Radiography, 9th Edition MULTIPLE CHOICE 1. A biologic reaction is produced by 4 Gyt of a test radiation. It takes 16 Gyt of 250-kVp x-rays

to produce the same biologic reaction. What is the relative biologic effectiveness (RBE) of the test radiation? a. 2 b. 4 c. 8 d. 12 ANS: B 2. Which of the following is/are considered low-LET radiation(s)? a. X-rays b. Alpha particles c. X-rays and gamma rays d. Alpha particles and gamma rays ANS: C 3. The radiation dose required to produce mitotic death is a. less than the dose needed to produce apoptosis in slowly dividing cells or

nondividing cells. b. more than the dose needed to produce apoptosis in slowly dividing cells or nondividing cells. c. the same as the dose needed to produce apoptosis in slowly dividing cells or nondividing cells. d. non-existent because mitotic death cannot be produced in slowly dividing cells or nondividing cells as a result of exposure to ionizing radiation.

ANS: A 4. Because the genetic information to be passed on to future generations is contained in the strict

sequence of nitrogenous bases, the loss or change of a base in the DNA chain represents a (an) a. aneuploidy. b. bleb. c. covalent cross-link. d. mutation.

ANS: D 5. Because the master molecule is unique in any given cell, no similar molecules in the cell are

available to replace it; if a critical location on the master molecule is a target receiving multiple hits from ionizing radiation, the master molecule may be inactivated. If this occurs, what is the consequence for the affected cell? a. Loss of all intracellular fluid. b. Increased pressure on the cell membrane leading to immediate rupture. c. Disruption of cell chemistry only. d. Normal cell function will cease, and the cell will die.

ANS: D 6. Which of the following curves illustrates the radiation sensitivity of a particular type of cell? a. Cell specialization curve b. Cell extrapolation curve c. Dose–response curve d. Cell survival curve ANS: D 7. Which of the following groups of cells is least radiosensitive? a. Adult nerve cells b. Nerve cells in an embryo-fetus c. Lymphocytes d. Immature spermatogonia ANS: A 8. OH* + OH* = __________. a. H2O b. HOH+ c. HOH– d. H2O2 ANS: D 9. Which of the following humans is most radiosensitive? a. A mature adult b. An embryo-fetus during the first trimester of pregnancy c. A fetus during the third trimester of gestation d. A 5-year-old child ANS: B 10. When free radicals previously produced by the interaction of radiation with water molecules

act on a molecule such as DNA, the damaging action of ionizing radiation is indirect in the sense that the radiation is not the immediate cause of injury to the macromolecule. What is the immediate cause of this damage? a. Excitation of the atoms of the biologic macromolecules b. Enzymes released from biologic macromolecules c. The recombining of a positively charged water molecule with an electron

d. The free radicals produced by the interaction of radiation with water molecules ANS: D 11. The normal white blood cell count for an adult ranges from a. 1000 to 5000/mm3 of blood. b. 3000 to 6000/mm3 of blood. c. 5000 to 10,000/mm3 of blood. d. 7000 to 15,000/mm3 of blood.

ANS: C 12. One micron (m) = __________. a. 10–6 m b. 10+6 m c. 10–3 m d. 10+3 m ANS: A 13. A periodic blood count is not recommended as a method for monitoring occupational

radiation exposure because a. biologic damage from ionizing radiation cannot be determined from a blood test. b. biologic damage has already been sustained when an irregularity is seen in the blood count. c. a blood count is a relatively insensitive test that is unable to indicate doses of less than 10 cGyt accurately. d. Both B and C. ANS: D 14. Based on current data, which of the following would be considered a safe radiation dose for

the gonads of both males and females? a. 5 Gyt b. 3 Gyt c. 1 Gyt d. 0 Gyt ANS: D 15. Which of the following statements is true concerning patients who receive radiation exposure

from a routine radiographic procedure such as a chest x-ray? a. Patients are expected to sustain appreciable damage to either the blood or the blood-forming organs as a consequence of the examination. b. Patients are not expected to sustain appreciable damage to either the blood or the blood-forming organs as a consequence of the examination. c. Patients are expected to sustain some damage to either the blood or the blood-forming organs as a consequence of the examination. d. Patients are expected to sustain total damage to either the blood or the blood-forming organs as a consequence of the examination, resulting in fatality.

ANS: B

16. The term apoptosis is synonymous with a. programmed cell death. b. meiosis. c. mitosis. d. point mutation.

ANS: A 17. Which of the following gonadal radiation doses may cause permanent sterility in a male

human? a. 0.01 Gyt b. 1.0 Gyt c. 2.0 Gyt d. 5.0 or 6.0 Gyt ANS: D 18. Which of the following groups of cells is most radiosensitive? a. Lymphocytes b. Adult nerve cells c. Erythrocytes d. Muscle cells ANS: A 19. Direct action may occur after exposure to any type of radiation, but it is much more likely to

occur after exposure to a. low-LET radiation such as x-rays. b. low-LET radiation such as gamma rays. c. high-LET radiation such as alpha particles. d. nonionizing radiation such as microwaves.

ANS: C 20. When LET increases, the chance of a significant biologic response in the radiosensitive DNA

macromolecule a. also increases. b. decreases considerably. c. decreases slightly. d. remains constant, not increasing or decreasing.

ANS: A 21. Neutrophils play an essential role in a. initiating the circulation of blood through the human body. b. initiating blood clotting. c. fighting infection. d. preventing hemorrhage.

ANS: C 22. The radiosensitivity of ova

a. b. c. d.

remains constant throughout the lifetime of the germ cell. varies considerably throughout the lifetime of the germ cell. varies slightly throughout the lifetime of the germ cell. is insignificant because the germ cell is not radiosensitive.

ANS: B 23. Which of the following tissues contain cells that do not divide?

1. Epithelial tissue 2. Muscle tissue 3. Nervous tissue in an adult a. 1 and 2 only b. 1 and 3 only c. 2 and 3 only d. All of the options ANS: C 24. Which of the following is a category of white blood cell that is essential in fighting

infections? a. Granulocytes b. Lymphocytes c. Neutrophils d. Thrombocytes ANS: A 25. If bone marrow cells have not been destroyed by exposure to ionizing radiation, they can a. become insensitive to future exposures from ionizing radiation. b. overpopulate and become radioresistant. c. remain in circulating blood indefinitely. d. repopulate after a period of recovery.

ANS: D

Chapter 08: Early Tissue Reactions and Their Effects on Organ Systems Sherer: Radiation Protection in Medical Radiography, 9th Edition MULTIPLE CHOICE 1. If a person receives radiation exposure sufficient to cause the gastrointestinal syndrome,

fatality occurs primarily as a result of a. convulsive seizures. b. catastrophic damage to the epithelial cells that line the gastrointestinal track. c. edema in the cranial vault. d. meningitis.

ANS: B 2. For persons with hematopoietic syndrome, survival time shortens as a. the radiation dose decreases. b. the radiation dose increases.

c. the radiation dose remains the same. d. there is no survival time for persons with the hematopoietic syndrome.

ANS: B 3. Which of the following is not a form of acute radiation syndrome? a. Carcinogenic syndrome b. Hematopoietic syndrome c. Gastrointestinal syndrome d. Cerebrovascular syndrome ANS: A 4. The term LD 50/30 signifies the whole-body dose of radiation that can be lethal to a. 50% of the exposed population within 30 days. b. 30% of the exposed population within 50 days. c. 50% of the exposed population within 50 days. d. 30% of the exposed population within 30 days.

ANS: A 5. Some local tissues suffer immediate consequences from high radiation doses. Examples of

such tissues include 1. bone marrow.

2. male and female reproductive organs.

3. skin. a. 1 and 2 only b. 1 and 3 only c. 2 and 3 only d. All of the options ANS: D 6. Atrophy refers to a. aging of the skin from radiation exposure. b. shrinkage of organs and tissues after a high radiation dose is received. c. necrosis of the hypodermis from radiation exposure. d. wrinkling of the skin from radiation exposure.

ANS: B 7. What determines the rate of production of chromosome aberrations?

1. The total radiation dose given to a somatic cell 2. The total radiation given to a genetic cell 3. The period of time in which radiation dose was delivered a. 1 and 2 only b. 1 and 3 only c. 2 and 3 only d. All of the options ANS: D 8. In female oogonia, the ovarian stem cells

a. b. c. d.

divide and reduce in number only during fetal development. multiply to millions of cells only during fetal development. are not present during fetal life. are present only in very small numbers during fetal life.

ANS: B 9. The correct order of development for the female germ cell from the stem cell phase to the

mature cell is a. ovum, mature follicle, corpus luteum, primordial follicle. b. corpus luteum, primordial follicle, mature follicle, ovum. c. primordial follicle, ovum, corpus luteum, mature follicle. d. primordial follicle, mature follicle, corpus luteum, ovum.

ANS: D 10. Which of the following are classified as early tissue reactions of ionizing radiation? a. Erythema, cataract formation, and cancer b. Nausea, epilation, and intestinal disorders c. Male and female sterility, embryologic defects, and cancer d. Blood disorders, fever, and genetic effects ANS: B 11. The prodromal stage of acute radiation syndrome is actually the a. beginning stage. b. latent period. c. manifest illness period. d. recovery period.

ANS: A 12. Research has shown that repeated radiation injuries have a a. cumulative effect. b. quadratic effect. c. sigmoidal effect. d. threshold effect.

ANS: A 13. The hematopoietic form of acute radiation syndrome is also called the a. Auger syndrome. b. bone marrow syndrome. c. cerebrovascular syndrome. d. cytogenetic syndrome.

ANS: B 14. Organ and tissue response to radiation exposure depends on factors such as

1. radiosensitivity.

2. reproductive characteristics.

3. growth rate. a. 1 and 2 only

b. 1 and 3 only c. 2 and 3 only d. All of the options ANS: D 15. A term that is synonymous with loss of hair is a. atrophy. b. desquamation. c. epilation. d. radiodermatitis.

ANS: C 16. A single absorbed dose of 2 Gyt can cause a radiation-induced skin erythema within a. 1 hour after irradiation. b. 6 hours after irradiation. c. 12 hours after irradiation. d. 24 to 48 hours after irradiation.

ANS: D 17. In 1898, after suffering severe burns attributed to accumulated radiation exposure, this Boston

dentist began investigating the potential hazards of radiation exposure and became the first known determined advocate of radiation protection was a. Marie Curie. b. Clarence Madison Dally. c. Wilhelm Conrad Roentgen. d. William Herbert Rollins.

ANS: D 18. The correct order of development of the male germ cell from the stem cell phase to the mature

cell is a. spermatogonia, spermatocyte, spermatid, sperm. b. spermatocyte, spermatogonia, spermatid, sperm. c. spermatid, spermatogonia, spermatocyte, sperm. d. sperm, spermatid, spermatogonia, spermatocyte.

ANS: A 19. Chromosomal damage can be caused by a. low radiation doses only. b. high radiation doses only. c. both low and high radiation doses. d. none of the options.

ANS: C 20. During cardiovascular or other therapeutic interventional procedures that use high-level

fluoroscopy for extended periods, the effects of ionizing radiation on the skin are at most a. nonexistent. b. minimal.

c. moderate. d. significant.

ANS: D 21. Moist and dry desquamation can be caused by a. high radiation doses. b. low radiation doses. c. radiation doses received during routine diagnostic imaging procedures. d. radiation dose received during annual testing of diagnostic imaging equipment.

ANS: A 22. Early tissue reactions are a. common in diagnostic imaging. b. not common in diagnostic imaging. c. a result of irradiation of acellular tissue. d. a result of Grenz rays in a diagnostic x-ray beam.

ANS: B 23. Data from epidemiologic studies of human populations exposed to doses of ionizing radiation

sufficient to cause acute radiation syndrome have been obtained from 1. atomic bomb survivors of Hiroshima and Nagasaki.

2. Marshall Islanders who were inadvertently subjected to high levels of fallout during an atomic bomb test in 1954.

3. nuclear radiation accident victims, such as those injured in the 1986 Chernobyl disaster.

4. patients who have undergone radiation therapy. a. 1, 2, and 3 only b. 1, 3, and 4 only c. 2, 3, and 4 only d. All of the options ANS: D 24. Grenz rays were once used to treat and successfully cure a. acute radiation syndrome. b. cancer. c. lupus disease. d. skin diseases such as ringworm.

ANS: D 25. During the major response stages of acute radiation syndrome after the prodromal stage and a

period of false calm that may last for several days, the stage when symptoms that affect the hematopoietic, gastrointestinal, and cerebrovascular systems occurs, this stage is called a. the latent period. b. manifest illness. c. the cytogenic syndrome. d. recovery.

ANS: B

Chapter 09: Stochastic Effects and Late Tissue Reactions of Radiation in Organ Systems Sherer: Radiation Protection in Medical Radiography, 9th Edition MULTIPLE CHOICE 1. Radiation-induced cataracts in humans follow a ______ dose–response relationship. a. nonthreshold, nonlinear b. nonthreshold, linear c. threshold, linear d. threshold, nonlinear ANS: D 2. Among the atomic bomb survivors, the number of people living with leukemia has

_______________ since the late 1940s and early 1950s. However, the occurrence rates of other radiation-induced malignancies continued to ___________ since the late 1950s and early 1960s. a. slowly declined; escalate b. increased rapidly; decrease c. increased slowly; decrease d. rapidly declined; decrease ANS: A 3. To assess the magnitude and severity of late effects on the exposed population from the 1986

nuclear power station accident at Chernobyl a. follow-up is not necessary because the radiation received by the entire exposed population was fatal. b. minimal follow-up is only necessary because the exposed population did not receive sufficient radiation exposure to cause severe late effects. c. short-term follow-up studies are necessary. d. long-term follow-up studies are necessary.

ANS: D 4. Which of the following late effects caused by exposure to ionizing radiation is considered to

be most significant? a. Cataract formation. b. Embryologic or birth defects. c. Cancer. d. None; all the options are considered to be of equal significance.

ANS: C 5. The human body can incorporate radium into bone because it is chemically similar to a. calcium. b. potassium. c. phosphorus. d. sodium.

ANS: A 6. During the 1950s and 1960s, the Navajo people of Arizona and New Mexico who mined

uranium for fuel for nuclear weapons and power plants developed lung cancer years after their exposure. This provides an example of which of the following? a. Early tissue reactions b. Late stochastic effects c. Late tissue reactions d. Late genetic effects ANS: B 7. Laboratory experiments with mice conclude that cataracts may be caused by doses of ionizing

radiation as low as a. 0.1 Gyt. b. 0.01 Gyt. c. 0.5 Gyt. d. 0.05 Gyt. ANS: A 8. In which of the following human populations is the risk for causing a radiation-induced cancer

not directly measurable? a. All patients in diagnostic radiology subjected to a radiation dose below 0.1 Sv. b. Chernobyl radiation accident victims living in contaminated villages. c. Atomic bomb survivors. d. Both B and C. ANS: A 9. Mutations in genes and DNA that occur at random as natural phenomena are called a. carcinogenic mutations. b. sporadic mutations. c. spontaneous mutations. d. stochastic mutations.

ANS: C 10. Existing data on radiation-induced genetic effects in humans a. prove conclusively that radiation causes major genetic effects. b. prove conclusively that radiation causes only minor genetic effects. c. are both contradictory and inconclusive. d. prove conclusively that radiation does not cause genetic effects.

ANS: C 11. When a prediction is made that the number of excess cancers will increase as the natural

incidence of cancer increases with advancing age in the population, the risk is considered to be a. absolute. b. excess. c. quadratic.

d. relative.

ANS: D 12. What is the mean value of the radiation doubling dose for humans, as determined from studies

of the children of the atomic bomb survivors of Hiroshima and Nagasaki? a. 1.00 Sv b. 1.56 Sv c. 3.00 Sv d. 5.67 Sv ANS: B 13. Genetic effects from exposure to ionizing radiation occur as a result of radiation-induced

damage to the DNA molecule in which of the following? a. Sperm of a man b. Ova of a woman c. Somatic cells of men and women d. Both A and B ANS: D 14. What do agents such as specific chemicals, viruses, and ionizing radiation have in common? a. Nothing. b. They can increase the frequency of mutations in only those members of the

population who are already genetically impaired. c. They are all mutagens that can increase the frequency of mutations. d. They always cause spontaneous abortions during the first trimester of pregnancy.

ANS: C 15. Which of the following are sources of low-level radiation exposure?

1. X-rays and radioactive materials used for diagnostic purposes 2. Employment-related exposure in medicine and industry 3. Natural background radiation a. 1 and 2 only b. 1 and 3 only c. 2 and 3 only d. All of the options ANS: D 16. During the preimplantation stage of development, the fertilized ovum divides and forms a

ball-like structure containing undifferentiated cells. If this structure is irradiated with a dose in the range of 0.05 to 0.15 Gyt which of the following will result? a. Congenital abnormalities b. Delayed bone growth c. Embryonic death d. Microcephaly ANS: C

17. After the Chernobyl disaster in 1986, an attempt was made to prevent thyroid cancer in

Poland and some other countries, resulting from the accidental overdose of iodine-131.

Physicians administered ______________________ to children as a harmless substitute to inhibit the gland‘s uptake of iodine-131. a. potassium bromide b. sodium chloride c. sodium bicarbonate d. potassium iodide ANS: D 18. Epidemiologic studies are of significant value to radiobiologists who use the information from

these studies to formulate dose–response curves for making predictions of the risk of ____________ in human populations exposed to low levels of ionizing radiation. a. cancer b. cataract formation c. genetic effects d. spontaneous abortions ANS: A 19. Radiation-induced genetic abnormalities are caused by unrepaired damage to a. all stem cells in the human body. b. DNA molecules in the sperm or ova of an adult. c. epithelial cells in the human body. d. somatic cells in the human body.

ANS: B 20. Some mutations in genetic material occur spontaneously, without a known cause. In humans,

a hereditary disorder is present in approximately _________ of all live births in the United States. a. 10% b. 20% c. 25% d. 30% ANS: A 21. Currently, evidence of radiation-induced hereditary effects has not been observed in persons

employed in diagnostic imaging or in patients undergoing radiologic examinations. Even with this information, it is still recommended that a. irradiation of gonadal tissue should never be allowed in any medical study. b. all radiation exposure be maintained as low as reasonably achievable (ALARA). c. both A and B. d. alternative procedures be substituted for x-ray procedures whenever diagnostic information must be obtained.

ANS: B 22. Radium decays with a half-life of a. 8 days.

b. 50 years. c. 500 years. d. 1622 years.

ANS: D 23. The term linear nonthreshold relationship implies that the biologic response to ionizing

radiation is a. directly proportional to the dose all the way down to levels approaching zero. b. inversely proportional to the dose all the way down to levels approaching zero. c. directly proportional to the square of the dose all the way down to levels approaching zero. d. inversely proportional to the square of the dose all the way down to levels approaching zero.

ANS: A 24. Genetic mutations at the molecular level are called a. chromatid mutations. b. chromosome mutations. c. molecular mutations. d. point mutations.

ANS: D 25. Studies of postpartum patients treated with ionizing radiation for relief of mastitis are a group

of individuals in whom the results of radiation exposure to healthy breast tissue via scattered radiation indicate that radiation a. can cause breast cancer. b. cannot cause breast cancer. c. can cause breast enlargement. d. can cause breast shrinkage.

ANS: A

Chapter 10: Dose Limits for Exposure to Ionizing Radiation Sherer: Radiation Protection in Medical Radiography, 9th Edition MULTIPLE CHOICE 1. Which of the following terms involves a random effect of ionizing radiation? a. Early tissue reactions b. Change in white blood cell count c. Reddening of the skin d. Stochastic event ANS: D 2. Upper boundary safe radiation exposure limits for occupationally exposed persons are

associated with risks that are similar to those encountered by employees in other industries that are generally considered to be reasonably safe. These industries include 1. manufacturing.

2. trade.

3. government. a. 1 and 2 only b. 1 and 3 only c. 2 and 3 only d. All of the options ANS: D 3. Which of the following agencies was previously known as the Atomic Energy Commission? a. FDA b. ICRP c. NCRP d. NRC ANS: D 4. Which of the following are functions and/or responsibilities of the United States Occupational

Safety and Health Administration (OSHA)?

1. Functions as a monitoring agency in places of employment, predominantly in industry 2. Regulates occupational exposure to radiation through Part 1910 of Title 29 of the U.S. Code of Federal Regulations (29 CFR 1910) 3. Responsible for regulations concerning an employee‘s ―right to know‖ with regard to hazards in the workplace a. 1 and 2 only b. 1 and 3 only c. 2 and 3 only d. All of the options ANS: D 5. Which of the following groups is run by the government of Japan, primarily to study Japanese

atomic bomb survivors? a. National Research Council Committee on the Biological Effects of Ionizing Radiation b. International Commission on Radiological Protection c. Radiation Effects Research Foundation d. Nuclear Regulatory Commission ANS: C 6. Epidemiologic studies of atomic bomb survivors exposed in utero have provided conclusive

evidence of a dose-dependent increase in the incidence of severe intellectual disability for fetal doses higher than approximately a. 0.1 Sv. b. 0.2 Sv. c. 0.3 Sv. d. 0.4 Sv. ANS: D

7. Determine the cumulative effective dose (CumEfD) limit to the whole body of an

occupationally exposed person who is 46 years old. a. 4.6 mSv b. 46 mSv c. 460 mSv d. 4600 mSv ANS: C 8. Revised concepts of the risks of radiation exposure have brought about changes in NCRP

recommendations for limits on exposure to ionizing radiation over a number of decades.

Because many conflicting views exist on assessing the risk of cancer induction from low-level radiation exposure, the trend has been to a. create more rigorous radiation protection standards. b. reduce rigorous radiation protection standards. c. eliminate radiation protection standards. d. leave radiation protection standards the same as they have been for the last 20 years.

ANS: A 9. The primary function of the Nuclear Regulatory Commission (NRC) is to a. inspect imaging facilities. b. oversee the nuclear energy industry. c. regulate imaging facilities. d. all of the options.

ANS: B 10. The effective dose (EfD) limiting system is a. a method used by the Nuclear Regulatory Commission to determine whether users

of radioactive substances are in compliance with the provisions of their license. b. a method used by the Federal Drug Administration to conduct an ongoing product

radiation control program. c. the current method for controlling the risk of biologic damage to radiation workers

and the general public from radiation exposure. d. responsible for the development of the radiation hormesis theory.

ANS: C 11. The ALARA concept adopts an extremely conservative model concerning the relationship

between a. health care education and radiation research. b. ionizing and nonionizing radiation. c. ionizing radiation and potential risk. d. radiation dose and health care spending.

ANS: C 12. If a certain dose of radiation produces a skin burn, a higher dose of radiation will cause the

skin burn to be more severe; however, a dose below the threshold level for skin burn will a. demonstrate this effect to a much greater degree.

b. demonstrate this effect to moderate degree. c. demonstrate this effect to a lesser degree. d. not demonstrate the effect.

ANS: D 13. The United Nations Scientific Committee on the Effects of Atomic Radiation (UNSCEAR)

evaluates human and environmental ionizing radiation exposures from a variety of sources, including 1. radioactive materials.

2. radiation-producing machines.

3. radiation accidents. a. 1 and 2 only b. 1 and 3 only c. 2 and 3 only d. All of the options ANS: D 14. Which of the following are responsibilities of a health care facility‘s administrative personnel

to ensure an active and detailed radiation safety program?

1. Delegate operational funds in the budget for the radiation safety program 2. Oversee the development of policies and procedures the radiation safety program 3. Provide the equipment needed for starting and for continuing the radiation safety program a. 1 and 2 only b. 1 and 3 only c. 2 and 3 only d. All of the options ANS: D 15. The essential concept underlying radiation protection is that a. any organ in the human body is vulnerable to damage from exposure to ionizing

radiation. b. only critical organs in the human body are vulnerable to damage from exposure to

ionizing radiation. c. only the reproductive organs in the male and female human are vulnerable to

damage from exposure to ionizing radiation. d. no organ in the human body is vulnerable to damage from radiation exposure to

ionizing radiation.

ANS: A 16. The cumulative effective dose (CumEfD) limit does not include

1. exposure acquired as a consequence of a radiation worker‘s undergoing medical imaging procedures.

2. radiation exposure from natural background radiation.

3. radiation exposure received while radiographers perform imaging procedures on patients. a. 1 and 2 only b. 1 and 3 only c. 2 and 3 only

d. All of the options ANS: A 17. Which of the following statements is true? a. Medical imaging personnel almost always receive equivalent doses that are close

to the annual occupational effective dose limit. b. Medical imaging personnel always receive equivalent doses that are close to the

annual occupational effective dose limit. c. Medical imaging personnel hardly ever receive equivalent doses that are close to

the annual occupational effective dose limit. d. Medical imaging personnel absolutely never receive equivalent doses that are close

to the annual occupational effective dose limit.

ANS: C 18. Occasional exposure for the purpose of education and training is permitted, provided that

special care is taken to ensure that the annual effective dose limit of ____________ is not exceeded for persons under the age of 18 years. a. 0.5 mSv annually b. 1 mSv annually c. 2 mSv annually d. 3 mSv annually ANS: B 19. The effective dose (EfD) occupational limit for the lens of the eye is a. 5 mSv. b. 15 mSv. c. 50 mSv. d. 150 mSv. ANS: B 20. The responsibility for maintaining radiation monitoring records for all personnel and for

providing counseling for individuals who receive monitor readings in excess of allowable limits belongs to the a. director of human resources of a health care facility. b. designated radiation safety officer of a health care facility. c. hospital administrator. d. radiologic technologist in charge of quality control.

ANS: B 21. To provide a low-exposure cut-off level so that regulatory agencies may consider a level of

effective dose as being of negligible risk, an annual negligible individual dose (NID) of ________________ per source or practice has been set. a. 0.001 mSv/year b. 0.01 mSv/year c. 0.1 mSv/year d. 1.0 mSv/year

ANS: B 22. A radiation safety officer in a health care facility must have sufficient authority,

organizational freedom, and management prerogative to 1. identify radiation safety problems.

2. initiate, recommend, or provide corrective action.

3. stop unsafe operations involving by-product material.

4. verify implementation of corrective actions. a. 1, 2, and 3 only b. 1, 3, and 4 only c. 2, 3, and 4 only d. All of the options ANS: D 23. To define ALARA, health care facilities usually adopt investigation levels, defined as level I

and level II. In the United States, these levels are traditionally _______ to ______ the applicable regulatory standards. a. one twentieth; one tenth b. one tenth; three tenths c. three tenths; one half d. one half; seven tenths ANS: B 24. Working in conjunction with their partners in other agencies, the FDA intends to take action

to 1. promote safe use of medical imaging devices.

2. support informed clinical decision.

3. increase patient awareness. a. 1 and 2 only b. 1 and 3 only c. 2 and 3 only d. All of the options ANS: D 25. Effective dose (EfD) limits may be specified for a. whole-body exposure. b. partial-body exposure. c. exposure of individual organs. d. all of the options.

ANS: D

Chapter 11: Equipment Design for Radiation Protection Sherer: Radiation Protection in Medical Radiography, 9th Edition MULTIPLE CHOICE 1. All digital imaging devices are subject to certain artifacts such as

1. aliasing.

2. moirè patterns.

3. contouring. a. 1 and 2 only b. 1 and 3 only c. 2 and 3 only d. All of the options ANS: D 2. The protective tube housing serves as a shield against _____________________ entering the

x-ray tube, thereby preventing electric shock while also facilitating the cooling of the x-ray tube. a. the high voltage b. the low voltage c. lose inherent filter particles d. collimator components ANS: A 3. If the luminance of the collimator light source is sufficient, the localizing light beam will be

able to satisfactorily outline the margins of the radiographic beam on the area of clinical interest on a. infants only. b. children only. c. teenagers and adults only. d. patients of all skin pigmentations.

ANS: D 4. When using digital fluoroscopy systems, making use of the last image hold feature can a. be an effective dose reduction technique. b. eliminate the need to collimate the primary beam. c. eliminate the need for body or part immobilization. d. lead to a 50% reduction of technical exposure factors.

ANS: A 5. What is the purpose of radiographic beam filtration? a. To reduce exposure to the patient‘s skin and superficial tissues by absorbing most

of the higher-energy photons from the heterogeneous beam b. To reduce exposure to the patient‘s skin and superficial tissues by absorbing most

of the lower-energy photons from the heterogeneous beam c. To reduce exposure to the patient‘s skin and superficial tissues by absorbing all of

the higher-energy photons from the homogeneous beam d. To reduce exposure to the patient‘s skin and superficial tissues by removing all the

lower-energy photons from the homogeneous beam ANS: B 6. Most fluoroscopic examinations employ a range of _____________ kVp for adult patients,

depending on the body area being examined. a. 30 to 60

b. 60 to 75 c. 75 to 110 d. 110 to 140 ANS: C 7. When performing a mobile radiographic procedure, to reduce the radiation exposure to the

patient, the radiographer must use a minimal source-skin distance of at least a. 15 cm. b. 30 cm. c. 38 cm. d. 45 cm.

ANS: B 8. When a fluoroscopic image is electronically amplified by the use of an image intensification

system, which of the following benefits results?

1. Increased image brightness 2. Saving of time for the radiologist 3. Patient dose reduction a. 1 and 2 only b. 1 and 3 only c. 2 and 3 only d. All of the options ANS: D 9. Current federal standards limit entrance skin exposure rates of general-purpose intensified

fluoroscopic units with maximum technique factors engaged to a maximum of ________________, as measured at the tabletop using an average phantom, with the image intensifier entrance surface at a prescribed 30 cm above the tabletop. a. .88 mGya/min b. 1.8 mGya/min c. 88 mGya/min d. 888 mGya/min ANS: C 10. During a fluoroscopic examination, a resettable cumulative timing device measures the x-ray

beam-on time and sounds an audible alarm or in some cases temporarily interrupts the exposure after the fluoroscope has been activated for what length of time? a. 1 minute b. 3 minutes c. 5 minutes d. 10 minutes ANS: C 11. During interventional procedures, high-level control fluoroscopy is employed, resulting in a

_______________________ or entrance dose rate to the patient to allow the examination of smaller and lower-contrast objects that are not ordinarily discerned during standard fluoroscopy.

a. b. c. d.

higher entrance exposure rate lower entrance exposure rate negligible entrance exposure rate none of the options because smaller and lower-contrast objects cannot be examined by fluoroscopy during interventional procedures

ANS: A 12. When obtaining a dorsoplantar projection of a foot, which of the following types of filters

should be used to provide a greater uniform density of the anatomy? a. Bilateral wedge filter b. Trough filter c. Thoraeus filter d. Wedge filter ANS: D 13. Digital radiography systems offer several advantages over computed radiography. Some of

these include 1. lower dose.

2. ease of use.

3. immediate imaging results.

4. manipulation of the image. a. 1, 2, and 3 only b. 1, 2, and 4 only c. 2, 3, and 4 only d. All of the options ANS: D 14. Total filtration of _______________________ for fixed x-ray units operating above 70 kVp is

the regulatory standard. a. 1.0-mm aluminum equivalent b. 1.5-mm aluminum equivalent c. 2.0-mm aluminum equivalent d. 2.5-mm aluminum equivalent ANS: D 15. In digital radiography the number of different shades of gray that can be stored in memory

and displayed on a computer monitor is termed a. contrast matrix. b. grayscale. c. shadows. d. pixels.

ANS: B 16. In standard image intensification fluoroscopy, an x-ray beam half-value-layer (HVL) of 3 to

4.5 mm aluminum is considered acceptable when kVp ranges from a. 50 to 60. b. 60 to 70.

c. 70 to 80. d. 80 to 100.

ANS: D 17. Digital radiography images can be accessed a. at only one workstation at a time, thereby decreasing convenience for physicians

providing patient care. b. at no more than two workstations at a time, thereby decreasing convenience for physicians providing patient care. c. at several workstations at the same time, thus making image viewing very convenient for physicians providing patient care. d. digital images cannot be accessed at any workstations by physicians.

ANS: C 18. When an exposed computed radiography imaging plate is ready to be processed, an imaging

reading unit is used to scan the photostimulable phosphor imaging plate with a. an argon-neon laser beam. b. a cesium-nitrogen laser beam. c. a helium-neon laser beam. d. a neon-lithium laser beam.

ANS: C 19. Computed radiography, because of its higher exposure latitude, makes grid use on the

pediatric population a. absolutely necessary for all radiographic examinations. b. less necessary than was previously believed. c. necessary only for extremity examinations. d. unnecessary for any examination.

ANS: B 20. Fluoroscopic devices are capable of subjecting the patient, the equipment operator, and other

personnel near the fluoroscopic equipment to substantial doses of ionizing radiation. These devices include 1. C-arm fluoroscopes.

2. fluoroscopes on stationary equipment with HLC mode used for interventional procedures.

3. biplane interventional fluoroscopic systems. a. 1 and 2 only b. 1 and 3 only c. 2 and 3 only d. All of the options ANS: D 21. Of the following procedures, which involve extended fluoroscopic time?

1. Biliary drainage 2. Stent and filter placement 3. Urinary or biliary stone removal a. 1 and 2 only

b. 1 and 3 only c. 2 and 3 only d. All of the options ANS: D 22. Luminance is determined by measuring the concentration of light a. at only one particular point on the field of view. b. over a particular field of view. c. at only one particular point on the field of view and then squaring the number. d. over a particular field of view and then squaring the number.

ANS: B 23. When generator settings are changed from one mA and time combination to another, the most

that linearity can vary is a. 0%. b. 10%. c. 20%. d. 50%.

ANS: B 24. The control panel, where technical exposure factors are selected and visually displayed for the

equipment operator, must be located a. at the foot end of the radiographic examining table. b. at the head end of the radiographic examining table. c. behind a suitable protective barrier that has a radiation-absorbent window that permits observation of the patient during any procedure. d. behind any regular wall that has a regular glass window that permits observation of the patient during any procedure.

ANS: C 25. Which of the following materials is commonly used in the tabletop of a radiographic

examination table to make the tabletop as radiolucent as possible so that it will absorb only a minimal amount of radiation, thereby reducing the patient‘s radiation dose? a. Carbon fiber material b. Formica c. Granite d. Slate ANS: A

Chapter 12: Management of Patient Radiation Dose During Diagnostic X-Ray Procedures Sherer: Radiation Protection in Medical Radiography, 9th Edition MULTIPLE CHOICE

1. Any image that must be repeated because of human or mechanical error during the production

of the initial image is considered to be a repeat image. What effect does a repeat image have on the radiation dose received by the patient? a. The patient receives no additional radiation dose. b. The patient‘s skin and possibly the gonads, if they were in the included imaged area, receive a double radiation dose. c. The patient‘s critical organs receive a radiation dose that is 10 times greater than the initial radiation dose. d. The patient‘s superficial tissues only receive a radiation dose that is four times as great as that of the original radiation dose.

ANS: B 2. During a radiographic examination, which of the following combinations of technical

exposure factors reduce patient radiation dose? a. Lower kVp, higher mAs b. Higher kVp, lower mAs c. Higher kVp, higher mAs d. Lower kVp, lower mAs ANS: B 3. When a pregnant patient must undergo a radiographic procedure, which of the following

practices will minimize radiation exposure? a. Selecting random technical exposure factors for the part of the body to be imaged and not collimating the primary x-ray beam to ensure full coverage of the image receptor. b. Opening the x-ray beam collimator shutters as wide as possible to ensure complete coverage of the image receptor. c. Not collimating the radiographic beam to include only the anatomic area of interest and shielding the lower abdomen and pelvis when this area needs to be included in the area to be imaged. d. Selecting technical exposure factors that are appropriate for the part of the body to be imaged and precisely collimating the radiographic beam to include only the anatomic area of interest while shielding the lower abdomen and pelvis when this area does not need to be included in the area to be imaged.

ANS: D 4. According to the American College of Radiology (ACR), abdominal radiologic examinations

that have been requested after full consideration of the clinical status of a patient, including the possibility of pregnancy, need a. not be postponed or selectively scheduled. b. to be postponed or selectively scheduled. c. to be postponed and scheduled at least 10 days after the start of the next menstrual period. d. to be postponed and scheduled 10 days before the end of the next menstrual period.

ANS: A

5. The reason for discontinuing patient gonadal shielding and fetal shielding in diagnostic

radiology is based on research that the use of such shielding may jeopardize the benefits of the radiologic examination because a. shields are now made of aluminum that will absorb less radiation. b. the gonads and embryo-fetus are relatively radioresistant. c. an incorrectly placed shield within the collimated x-ray beam when an automatic collimator is used, can result in the lead in the shield obscuring anatomic information or interfering with the AEC system. d. shields in the primary x-ray beam do not absorb radiation.

ANS: C 6. Specific area shielding may be selectively used during some x-ray procedures to protect which

of the following?

1. Lens of the eye 2. Breast 3. Upper extremities 4. Lower extremities a. 1 and 2 b. 1 and 3 c. 3 and 4 d. All of the options ANS: A 7. ________________________ are the sensing devices most often used to measure skin dose

directly. a. Thermoluminescent dosimeters b. A sequence of aluminum equivalent filters of varying thicknesses c. Lead-impregnated filters d. Molybdenum and rhodium filters ANS: A 8. Which of the following procedures results in the lowest radiation effective dose to the patient? a. Abdominal fluoroscopy b. Digital pelvic radiography c. Dual energy X-ray absorptiometry d. Digital abdominal radiography ANS: C 9. According to the U.S. Public Health Service, the genetically significant dose (GSD) for the

population of the United States is approximately a. 1.00 mSv. b. 0.80 mSv. c. 0.40 mSv. d. 0.20 mSv. ANS: D 10. Which of the following must always be the first step in protection of the reproductive organs?

a. Adequate and precise collimation of the radiographic beam to include only the

anatomy of interest b. Use of gonadal shielding c. Use of a mobile protective shielding device d. Use of digital imaging equipment ANS: A 11. Motion controlled by will is classified as voluntary motion. Lack of such control may be

attributed to which of the following?

1. The patient‘s age 2. Breathing patterns or problems 3. Physical discomfort 4. Fear of the examination 5. Mental instability a. 1, 2, 3, 4 b. 2, 3, 4, 5 c. 1, 3, 4, 5 d. 1, 2, 3, 4, 5 ANS: D 12. When a properly calibrated automatic exposure control (AEC) is not employed to obtain a

uniform selection of technical x-ray exposure factors, well-managed imaging departments? a. Estimate technical exposure factors for all radiographic examinations. b. Have the radiologist determine and set up all technical exposure factor charts. c. Use technique charts borrowed from another imaging facility. d. Make use of standardized technique charts that have been established for each x-ray unit in that facility.

ANS: D 13. Neglecting to use standardized technique charts necessitates estimating the technical exposure

factors, which may result in 1. poor-quality images.

2. repeat examinations.

3. additional and unnecessary exposure of the patient. a. 1 and 2 b. 1 and 3 c. 2 and 3 d. All of the options ANS: D 14. Reducing the field size to the anatomic features of interest not only reduces patient exposure

but also a. increases completed image quality by decreasing scatter. b. decreases completed image quality by increasing scatter. c. increases completed image quality by increasing scatter. d. decreases completed image quality by decreasing scatter.

ANS: A

15. Because multiple bony areas span the entire body, the radiation dose absorbed by the organ

called bone marrow a. can be accurately measured by a direct method. b. cannot be measured by a direct method; it can only be estimated. c. is not of concern during any diagnostic radiography examinations. d. can only be measured to a small degree by a direct method.

ANS: B 16. Which of the following are reasons for unacceptable images?

1. Patient mispositioning 2. Incorrect centering of the radiographic beam 3. Patient motion during the radiographic exposure 4. Incorrect collimation of the radiographic beam a. 1, 2, 3 b. 2, 3, 4 c. 1, 3, 4 d. All of the options ANS: D 17. After some decades of experience with modern digital x-ray equipment and as a result of

improvements in dosimetry estimates of the efficacy of shielding with modern equipment and techniques, professional and scientific societies are a. abandoning the use of collimation of the x-ray beam and gonadal shielding in diagnostic radiology. b. eliminating collimation of the x-ray beam in diagnostic radiology. c. increasing the use of collimation of the x-ray beam in diagnostic radiology to eliminate the need for collimation. d. modifying shielding practices in diagnostic radiology to discourage the use of patient gonadal shielding and fetal shielding.

ANS: D 18. A blotchy radiographic image that results when an insufficient quantity of x-ray photons

reaches the image receptor is called a. quantum noise, or mottle. b. random photon displacement. c. spatial resolution. d. photon abrasions.

ANS: A 19. Which of the following are involuntary motions that cannot be willingly controlled?

1. Chills 2. Tremors 3. Muscle spasms 4. Pain 5. Active withdrawal a. 1, 2, 3, 5

b. 2, 3, 4, 5 c. 1, 2, 3, 4 d. All of the options ANS: D 20. Which of the following is frequently a problem in diagnostic pediatric radiography? a. Lack of availability of appropriate pediatric immobilization devices b. Lack of patience on the of the radiographer when imaging children c. Finding imaging equipment that can accommodate pediatric imaging d. Patient motion ANS: D 21. In the event that a pregnant patient is inadvertently irradiated a. the radiographer performing the examination should perform the calculations

necessary to determine fetal dose. b. the imaging department manager should perform the calculations necessary to determine fetal dose. c. the radiation safety officer or the medical physicist should perform the calculations necessary to determine fetal dose. d. the administrator of the hospital or imaging facility should perform the calculations necessary to determine fetal dose.

ANS: C 22. Studies of groups such as the atomic bomb survivors of Hiroshima have shown that damage to

the newborn is unlikely for doses below a. 5 Gy. b. 2 Gy. c. 0.5 Gy. d. 0.2 Gy. ANS: D 23. Essentially all diagnostic medical procedures result in fetal exposures ______________, so

that _______________________. a. greater than 5 Gy; the risk of abnormality is large b. greater than 1 Gy; the risk of abnormality is large c. of less than 0.5 Gy but greater than 0.01 Gy; the risk of abnormality is small d. of less than 0.01 Gy; the risk of abnormality is very small ANS: D 24. Of the following radiologic procedures, which is (are) considered nonessential?

1. A chest x-ray examination automatically scheduled on admission to the hospital 2. Lumbar spine x-ray examination as part of a pre-employment physical 3. Whole-body computed tomography (CT) screening a. 1 and 2 b. 1 and 3 c. 2 and 3 d. All of the options

ANS: D 25. Analysis of an imaging department‘s repeat rate

1. provides valuable information for process improvement.

2. helps minimize patient exposure.

3. improves overall performance of the department. a. 1 and 2 b. 1 and 3 c. 2 and 3 d. All of the options ANS: D

Chapter 13: Special Considerations on Safety in Computed Tomography Sherer: Radiation Protection in Medical Radiography, 9th Edition MULTIPLE CHOICE 1. With higher radiation exposure to the patient during a computed tomography examination,

there is a. a decreased associated cancer risk because the radiation is more penetrating. b. an increased associated cancer risk. c. a negligible associated cancer risk because the radiation is less penetrating. d. an extremely large cancer risk.

ANS: B 2. Which of the following is not typically used during a CT scan? a. A tightly collimated x-ray beam b. Direct patient shielding c. Filtered back projection d. All of the options ANS: B 3. In CT because of higher effective energy of the x-ray beam, both ____________ and

_______________ interactions contribute substantially to the image. a. coherent; photodisintegration b. classical; pair production c. photoelectric; Compton d. Compton; photodisintegration ANS: C 4. Which of the following are relevant dose parameters in CT?

1. CT dose index (CTDI) 2. CTDIw 3. CTDIVOL 4. Dose length product (DLP) a. 1, 2, and 3 only b. 2, 3, and 4 only

c. 1, 3, and 4 only d. All of the options ANS: D 5. DLP represents the product of the CTDIVOL and the irradiated scan length. In what unit of

measure is it usually expressed? a. mGy-cm b. mSv-cm c. mGy-mSv d. mSv-mRa ANS: A 6. Which of the following terms are synonymous?

1. Automatic exposure control 2. Iterative reconstruction 3. Tube current modulation a. 1 and 2 only b. 1 and 3 only c. 2 and 3 only d. All of the options ANS: B 7. A miscentering of ________ can produce as much as __________% increase in patient dose. a. 2 cm; 50 b. 2 cm; 25 c. 1 cm; 75 d. 1 cm; 60 ANS: B 8. Which of the following terms are synonymous in relation to computed tomography?

1. Diagonal 2. Helical 3. Spiral a. 1 and 2 only b. 1 and 3 only c. 2 and 3 only d. All of the options ANS: C 9. For routine head and body computed tomography examinations, effective doses fall into

which of the following effective dose ranges? a. 1 to 10 mSv b. 20 to 30 mSv c. 40 to 50 mSv d. 60 to 70 mSv ANS: A

10. Computed tomography images of the plane of the body perpendicular to the long axis of a

patient are termed a. axial images. b. helical images. c. semi-axial images. d. spiral images.

ANS: A 11. The entrance exposure from a CT examination may be compared with the entrance exposure

received during which of the following procedures? a. Screening mammography b. A routine radiographic series of the lumbar spine with five projections c. A routine radiographic series of the paranasal sinuses with four projections d. A routine fluoroscopic examination ANS: D 12. Tube current modulation in CT scanning can a. increase patient dose significantly. b. increase patient dose only slightly. c. help to reduce patient dose. d. not affect patient dose.

ANS: C 13. Verifying that the center of the patient coincides with the center of the CT gantry is a

significant part of dose reduction strategies that is under the control of the a. CT technologist. b. hospital or imaging facility administrator. c. ordering physician. d. patient.

ANS: A 14. Filtering refers to changing the projection data before doing the back projections to remove

the a. b. c. d.

blurriness. contrast. grayness. scattered radiation.

ANS: A 15. Effective mAs in Computed Tomography is simply the ratio of applied mAs to a. CTDIVOL. b. irradiated scan length. c. selected pitch. d. iterative reconstruction.

ANS: C

16. The number of data channels being used in the z-axis direction and the effective detector

thickness of each data channel is known as a. channel configuration. b. data resolution. c. detector configuration. d. prospective gating.

ANS: C 17. In the human heart, blood flows into the left atrium from the a. superior vena cava. b. inferior vena cava. c. mitral valves. d. four pulmonary veins.

ANS: D 18. In CT when a series of adjacent slices is obtained, some radiation will also scatter from the

slice being made into the adjacent slices. What is this radiation called? a. Forward scatter b. Backscatter c. Interslice scatter d. Side scatter ANS: C 19. In spiral image acquisition, the patient table moves during the acquisition so that a a. single-dimension image is obtained. b. three-dimensional data set is obtained. c. four-dimensional data set is obtained. d. six-dimensional data set is obtained.

ANS: B 20. Lower tube current is used in anatomic regions where there is ____________ attenuation

because the anatomy is ____________ or _________ dense. a. increased; thicker; more b. decreased; thicker; more c. increased; thinner; less d. decreased; thinner; less ANS: D 21. In the early 2000s various publications calculated individual and population risks of cancer

from CT based upon risk estimates from studies of which of the following groups of people? a. Atomic bomb survivors b. Early radiologists and radiographers c. Patients undergoing treatment for thyroid cancer d. The general public who were exposed to natural background radiation ANS: A

22. In computed tomography the dose at the edge of a beam does not decrease to _________

immediately. a. 15 cGy b. 10 cGy c. 5 cGy d. 0 (zero) ANS: D 23. ______________ is the ratio between the movement or advancement of the patient couch and

the x-ray beam collimator dimension. a. Dose distribution b. Iterative reconstruction c. Pitch d. Tube current modulation ANS: C 24. The movement or advancement of the patient couch during a CT scan is known as a. optimization. b. iterative reconstruction. c. tube current modulation. d. table increment.

ANS: D 25. To keep the patient‘s radiation dose ALARA, for both initial and follow-up examinations, the

image acquisition should a. always be made in a different cardiac phase. b. always be made in the same cardiac phase. c. at three-second intervals. d. at six-second intervals.

ANS: B

Chapter 14: X-Ray Breast Imaging: Methods and Radiation Safety Aspects Sherer: Radiation Protection in Medical Radiography, 9th Edition MULTIPLE CHOICE 1. The age recommendation for screening mammography is controversial because a. younger women do not get breast cancer. b. mammography is less accurate in the detection of breast cancer in younger women

and is likely to result in many false-positive readings, leading to unnecessary biopsies in that population. c. mammography is more accurate in the detection of breast cancer in younger women and will most likely result in very accurate positive readings, making biopsies unnecessary in that population. d. breast cancer cannot be diagnosed from screening mammography in younger women.

ANS: B

2. For rhodium x-ray tube targets, only _____________ filters are used. a. aluminum b. molybdenum c. rhodium d. tin ANS: C 3. During a screening mammography, __________________ between the breast and the support

plate of the mammographic x-ray machine can noticeably reduce the degree of pain experienced by a sensitive patient. a. a latex pillow b. a thin lead apron c. some radiopaque cushioning d. some radiolucent cushioning ANS: D 4. During mammography, a lower patient dose per exposure will be obtained when there is a. less tissue to penetrate thereby reducing the amount of incident x-radiation that

will be used to create the image. b. more tissue to penetrate thereby reducing the amount of incident x-radiation that will be used to create the image. c. less tissue to penetrate thereby reducing the amount of incident gamma radiation that will be used to create the image. d. more tissue to penetrate thereby reducing the amount of incident gamma radiation that will be used to create the imager.

ANS: A 5. Which of the following procedures will lower the percentage of false-positive readings caused

by very dense breasts and consequently permit a more effective x-ray screening of younger women? a. Computed Tomography b. Digital Tomosynthesis c. Routine Screening Mammography d. Ultrasound ANS: B 6. The Digital Breast Tomography image creation technique uses the same algorithms as those

for a. b. c. d.

Computed Tomography.

Digital Fluoroscopy.

Magnetic Resonance Imaging.

Computed Radiography.

ANS: A

7. In newer digital mammography systems, __________ targets with ___________ or

__________ filtration are replacing molybdenum x-ray tube targets with molybdenum or rhodium filtration. a. tin; aluminum; lead b. rhodium; aluminum; beryllium c. tungsten; rhodium; silver d. silver; cesium; tungsten ANS: C 8. Breast positioning for Digital Breast Tomography is ______________ for conventional digital

mammography. a. completely different than is used b. only slightly different than is used c. the same as is used d. less important than the positioning that is used ANS: C 9. Digital Breast Tomography has the ability to overcome anatomical ______________ by

adding depth resolution to a mammogram. a. structure dislocation b. irregularities c. positioning errors d. noise ANS: D 10. For mammography molybdenum filters allow a(n) _________________ than rhodium filters. a. higher energy window b. lower energy window c. equal energy window d. comparable energy window ANS: B 11. Depending on the desired fineness of z-axis resolution, Digital Breast Tomography images

may be reconstructed as 1. thin planes.

2. coronal reconstructions.

3. slabs. a. 1 and 2 only b. 1 and 3 only c. 2 and 3 only d. All of the options ANS: B 12. Expanding the angular sweep of the x-ray tube during Digital Breast Tomosynthesis permits

_____________ or ____________ reconstruction slices. a. finer; thinner b. finer; thicker

c. shorter; longer d. wider; thicker ANS: A 13. Performing a 3D mammogram along with a standard mammogram can result in about

_________ more breast cancer found for every ____________ women screened when compared with a standard mammogram alone. a. one; 10 b. one; 100 c. one; 1,000 d. one; 10,000 ANS: C 14. For Digital Breast Tomography the concept of lesion conspicuity is used to objectively

quantify radiographic a. source-to image receptor distance. b. angular sweep. c. x-ray tube angulation. d. observational error.

ANS: D 15. In mammography maintaining and enhancing subject contrast is a. not important. b. minimally important. c. of paramount importance for all patients. d. only important for patients with dense breasts.

ANS: C 16. Digital mammography units with the ability to enhance contrast with image gray-level

manipulation offer a. substantial improvement for patients with small breasts. b. substantial improvement for patients with microcalcifications in small breasts. c. substantial improvement for patients with dense breasts. d. poor quality images for patients with dense breasts and microcalcifications.

ANS: C 17. During mammography, axillary projections should be done only on request of the a. ordering physician. b. patient. c. radiologist. d. technologist performing the examination.

ANS: C 18. If step-and-shoot motion is employed in Digital Breast Tomography, the gantry must come to

a complete stop at each angular location before delivering x-rays; otherwise vibrations will a. blur the image. b. create a double image.

c. completely remove the image from the image receptor. d. sharpen the image.

ANS: A 19. The parameter that has been chosen for both standard and 3D mammography to estimate and

represent effective dose in x-ray breast imaging is the a. cumulative effective dose. b. bone marrow dose. c. mean adipose dose. d. mean glandular dose.

ANS: D 20. The x-ray spectrum used for tomosynthesis is generally similar to that employed in standard

digital mammography, and the selected _____________ depends on the thickness and density of the compressed breast. a. source-to-image-receptor-distance b. filtration of the x-ray beam c. peak kilovoltage d. milliamperage ANS: C 21. Artifacts present in Digital Breast Tomography are primarily due to

1. patient motion.

2. the method of image acquisition.

3. imperfect z-axis or depth resolution. a. 1 and 2 only b. 1 and 3 only c. 2 and 3 only d. All of the options ANS: D 22. ______________ takes the place of glass in the window of the low-kVp producing

mammographic x-ray tube. a. Aluminum b. Beryllium c. Plastic d. Tin ANS: B 23. The introduction of full-field digital mammography (FFDM) was the primary breakthrough

that enabled the widespread usage of a. Digital Breast Tomography. b. 2D Mammography. c. Gamma Ray Mammography. d. Quantum Ion Mammography.

ANS: A

24. Protocols founded upon ____________________ which takes into account breast surface area

will be a more realistic guide to better and less uncomfortable mammograms. a. the presence of microcalcifications b. breast adipose tissue c. compression pressure d. the quantity of breast glandular tissue ANS: C 25. Which of the following groups advocate annual mammography screening or mammography

screening at least every other year?

1. American College of Radiology 2. American Cancer Society 3. American Medical Association a. 1 and 2 only b. 1 and 3 only c. 2 and 3 only d. All of the options ANS: D

Chapter 15: Management of Imaging Personnel Radiation Dose During X-Ray Procedures Sherer: Radiation Protection in Medical Radiography, 9th Edition MULTIPLE CHOICE 1. Which of the following x-ray procedures increases the radiographer‘s risk of exposure to

ionizing radiation compared to general diagnostic radiography performed in an x-ray room?

1. Mobile C-arm fluoroscopy 2. Interventional procedures that use high level control fluoroscopy 3. Mobile radiographic examinations a. 1 and 2 only b. 1 and 3 only c. 2 and 3 only d. All of the options ANS: D 2. Occupational exposure of the radiographer can be kept as low as reasonably achievable

(ALARA) through individual monitoring and other protective measures and the use of protective devices. Therefore, because exposure from radiation-related jobs will not alter the ______________________, radiation workers may receive a larger equivalent dose than members of the general population. a. mean glandular dose b. genetically significant dose c. bone marrow dose d. tissue tolerance dose ANS: B

3. Which of the following are radiation-shielding design considerations?

1. The mean energy of the x-rays that will strike the barrier 2. Whether the barrier is of a primary or secondary nature 3. The workload of the unit 4. The use factor of the unit 5. The occupancy factor behind the barrier a. 1, 2, 3, and 4 only b. 1, 3, 4, and 5 only c. 2, 3, 4, and 5 only d. All of the options ANS: D 4. Whenever scattered radiation decreases, the radiographer‘s exposure a. decreases. b. increases slightly. c. increases considerably. d. remains the same.

ANS: A 5. Which of the following adjustments in technical exposure factors decreases the production of

scattered radiation during routine radiographic procedures? a. Decrease kVp and increase mAs in compensation b. Decrease kVp and decrease mAs c. Increase kVp and decrease mAs in compensation d. Increase kVp and increase mAs ANS: C 6. During which of the following x-ray examinations should a radiographer always wear a

thyroid shield? a. Fluoroscopy and x-ray special procedures b. Routine mobile radiographic procedures c. General diagnostic radiographic procedures performed in an x-ray room d. During all digital radiography procedures and computed radiography procedures performed in an x-ray room ANS: A 7. While standing behind the control-booth barrier, a radiographer makes a radiographic

exposure. The x-rays scattered from the patient‘s body should ____________________. a. not have enough energy remaining that will reach behind the control-booth barrier. b. scatter only once before reaching any area behind the control-booth barrier. c. scatter a minimum of 2 times before reaching any area behind the control-booth barrier. d. scatter a minimum of 10 times before reaching any area behind the control-booth barrier.

ANS: C 8. Which of the following is another term for use factor (U)?

a. b. c. d.

Workload factor Occupancy factor in controlled and uncontrolled areas Beam direction factor Protective barrier thickness consideration factor

ANS: C 9. The annual effective dose limit for individual members of the general population not

occupationally exposed is ___________ for continuous or frequent exposures from artificial sources other than medical irradiation and natural background and ____________ for infrequent annual exposure. a. 1 mSv; 5 mSv b. 3 mSv; 7 mSv c. 5 mSv; 9 mSv d. 50 mSv; 25 mSv ANS: A 10. A protective curtain, or sliding panel, with a minimum of 0.25-mm lead equivalent, should

normally be positioned between the fluoroscopist and the patient to intercept which of the following types of radiation? a. Primary radiation b. Scattered radiation above the tabletop c. Exit or image-formation radiation d. Direct radiation ANS: B 11. If the intensity of the x-ray beam is inversely proportional to the square of the distance from

the source, how does the intensity of the x-ray beam change when the distance from the source of radiation and a measurement point is tripled? a. It increases by a factor of 3 at the new distance. b. It increases by a factor of 9 at the new distance. c. It decreases by a factor of 9 at the new distance. d. It decreases by a factor of 3 at the new distance.

ANS: C 12. For primary radiation, what is the term that represents a portion of beam-on time that the x-ray

beam is directed at a primary barrier during the week? a. Occupancy factor b. Workload factor c. Distance factor d. Use factor ANS: D 13. The maximum weekly permitted equivalent dose for a controlled area must not exceed a. 1 mSv. b. 100 mSv. c. 20 mSv. d. 2 mSv.

ANS: A 14. When a radiologic technologist declares her pregnancy to her employer, which of the

following is appropriate? a. The employer terminates her employment until after her child is born. b. She is able to continue her employment but is not permitted to perform any radiologic procedures during the remainder of her pregnancy. c. The employer requires her to take a leave of absence until after the completion of the first trimester of the pregnancy and then return to her normal duties. d. She continues to perform her duties without interruption of employment, provided that she has received radiation safety counseling and follows established radiation safety practices.

ANS: D 15. Which part(s) of a diagnostic x-ray unit should not be touched while a radiographic exposure

is in progress? a. Control panel b. Exposure switch c. Radiographic table d. Tube housing, collimator, and high-tension cables ANS: D 16. When doors to radiographic and fluoroscopic rooms are closed during radiation exposures, a

substantial degree of protection is provided for persons in areas adjacent to the room door.

This is because in most facilities room doors have attenuation for diagnostic energy x-ray equivalent to that provided by _______ mm of lead. a. 0.2 b. 0.4 c. 0.6 d. 0.8 ANS: D 17. When the time spent in a higher radiation area is reduced or limited, occupational exposure a. is also reduced. b. is increased slightly. c. remains the same. d. is increased considerably.

ANS: A 18. Compared to general diagnostic radiography performed in an x-ray room, imaging personnel

receive the highest occupational exposure during which of the following procedures? a. Fluoroscopy b. Mobile radiography c. X-ray special radiographic procedures d. All of the options ANS: D

19. If the peak energy of the x-ray beam is 100 kVp, a protective lead apron must be the

equivalent to at least which of the following measures? a. 0.25-mm thickness of lead b. 0.5-mm thickness of lead c. 1.0-mm thickness of lead d. 1.5-mm thickness of lead ANS: A 20. For C-arm devices with similar fields of view, the dose rate to personnel located within a

meter of the patient is ____________ the dose rate to personnel from ______________. a. comparable to; routine fluoroscopy. b. far greater than; high-level control fluoroscopy. c. significantly less than; routine fluoroscopy. d. comparable to; high-level control fluoroscopy.

ANS: A 21. Scattered radiation to the lens of the eyes of diagnostic imaging personnel can be substantially

reduced by the use of protective eyeglasses fitted with optically clear lenses that contain a minimal lead equivalent protection level of a. 0.001 mm. b. 0.05 mm. c. 0.35 mm. d. 1.50 mm.

ANS: C 22. _______________ is essentially the radiation output weighted time that the unit is actually

delivering radiation during the week. a. Control designation b. Occupancy c. Use factor d. Workload ANS: D 23. To ensure that the lifetime risk of occupationally exposed persons remains acceptable, an

additional recommendation is that the lifetime effective dose in mSv should not exceed a. the occupationally exposed person‘s age in years. b. 5 times the occupationally exposed person‘s age in years. c. 10 times the occupationally exposed person‘s age in years. d. 20 times the occupationally exposed person‘s age in years.

ANS: C 24. Secondary radiation includes

1. leakage radiation.

2. primary radiation.

3. scatter radiation. a. 1 and 2 only b. 1 and 3 only

c. 2 and 3 only d. All of the options ANS: B 25. Who should determine the exact shielding requirements for a particular imaging facility? a. Administrator of the facility b. Medical physicist c. Radiologist d. Radiographer ANS: B

Chapter 16: Radioisotopes and Radiation Protection Sherer: Radiation Protection in Medical Radiography, 9th Edition MULTIPLE CHOICE 1. The isotopes used in brachytherapy are characterized by a. very short half-lives. b. half-lives that are exactly the same in terms of multiple days, months, or years. c. relatively long half-lives that are measured in terms of multiple days, months, or

years and, except for a few of them, by relatively high energy emissions. d. half-lives that remain constant for all eternity.

ANS: C 2. Iodine-125 (125I53) has been used quite extensively since 2000 in the form of

titanium-encapsulated cylindrical seeds to give a tumoricidal radiation equivalent dose to a. malignant brain tumors. b. malignant breast tumors. c. malignant lung tumors. d. cancers that are confined within the prostate gland.

ANS: D 125

3. Tellurium-125 ( Te52) has a. 125 protons and 125 neutrons. b. 75 protons and 63 neutrons. c. 52 protons and 73 neutrons. d. 45 protons and 58 neutrons.

ANS: C 4. What is the half-life of Technetium-99m? a. 6 hours b. 3 hours c. 6 minutes d. 3 minutes ANS: A

5. In __________, a neutron transforms itself into a combination of a proton and an energetic

electron. a. alpha decay b. beta decay c. gamma decay d. x-ray absorption ANS: B 6. Considering the design of the medical imaging suites listed below, which suite requires

shielding for the highest energy photons? a. CT suite b. PET-CT imaging suite c. Digital mammography suite d. Digital fluoroscopy suite ANS: B 7. While a patient receiving Iodine-131 (131I53) therapy is hospitalized, a large, _________,

movable lead shield can be positioned between the patient and any attending personnel for protection. a. up to 25-mm or 1-inch-thick b. up to 50-mm or 2-inch-thick c. up to 75-mm or 3-inch-thick d. up to 150-mm or 6-inch-thick ANS: A 8. Diagnostic techniques in nuclear medicine typically make use of ___________ radioisotopes

as radioactive tracers. a. long-lived b. short-lived c. very weak d. potentially lethal ANS: B 9. Each Fluorine-18 (18F) nuclear transformation by positron decay yields two highly penetrating

_________ photons. a. 250 keV b. 472 keV c. 511 keV d. 777 keV ANS: C 10. Of the following four choices, the design of a _______________ imaging suite will usually

require the most lead shielding? a. diagnostic x-ray b. computed radiography c. computed tomography d. PET-CT

ANS: D 11. Any radioactive material that is attached to or associated with dust particles or in liquid form

and is found on various surfaces is referred to as a. radioactive contamination. b. a radioactive dispersal device. c. radioactive fallout. d. radioactive syndrome.

ANS: A 12. The actual long-term health effects of a ―dirty bomb‖ are likely to be a. catastrophic. b. maximal. c. minimal. d. nonexistent.

ANS: C 13. During a radiation emergency, the dose limit for individuals engaging in lifesaving activities

is a. b. c. d.

50 mSv per event.

100 mSv per event.

250 mSv per event.

500 mSv per event.

ANS: C 14. During a radiation emergency, if the dose rate exceeds ____________, emergency personnel

should await specific instructions from radiation experts on how to proceed. a. 0.1 Sv/hr b. 0.5 Sv/hr c. 1.0 Sv/hr d. 5.0 Sv/hr ANS: A 15. If enough explosives are used to spread radioactive material over a broad area, then

radioactivity is a. extremely hazardous and may be much higher than background levels. b. moderately hazardous and may be higher than background levels. c. slightly hazardous and may be only slightly higher than background levels. d. diluted and may not be much higher than background levels.

ANS: D 16. Gamma rays differ from x-rays a. because they are a form of electromagnetic radiation and x-rays are not. b. because x-rays are a form of electromagnetic radiation and gamma rays are not. c. only in the method of how they are produced. d. only because they are of much lower energy.

ANS: C 17. A solid encapsulated radioactive source a. can be handled with the hands without any protective covering of the hands. b. can be handled with the hands at any time as long as vinyl gloves are worn. c. can only occasionally be handled with the hands as long as vinyl gloves are worn. d. is never to be touched directly with the hands; instead long tongs which add

distance should be used.

ANS: D 18. At the conclusion of a brachytherapy or diagnostic radionuclide procedure, any residual

isotope a. is to be returned to its shielded container. b. is to be returned to its unshielded container. c. is thrown directly into a regular trash can for disposal. d. is dumped into any regular sink and washed down the drain.

ANS: A 19. Radioiodide tablets that dissolve in the bloodstream permit an escape of some radioactivity

through 1. the pores of the skin.

2. urination.

3. vomiting in some special cases. a. 1 and 2 only b. 1 and 3 only c. 2 and 3 only d. All of the options ANS: D 20. The National Library of Medicine and the National Institute of Health maintain a website that

contains a wealth of information on dealing with radiation emergencies. It contains which of the following?

1. Both basic and advanced methods for decontamination 2. Methods to reduce exposure 3. Specific medical emergency procedures for various situations a. 1 and 2 only b. 1 and 3 only c. 2 and 3 only d. All of the options ANS: D 21. A becquerel (Bq) is defined as a. 1000 disintegrations per second. b. 100 disintegrations per second. c. 10 disintegrations per second. d. 1 disintegration per second.

ANS: D

22. Monoclonal antibodies (MAB) are antibodies that preferentially bind always to a specific a. part of an antigen that is recognized by the antibody. b. part of an amino acid that is recognized by the antibody. c. carbohydrates. d. hormone.

ANS: A 23. The success of radioimmunotherapy depends on the selective accumulation of a. an abundance of amino acids at affected areas. b. cytotoxic radioisotopes at affected areas. c. hormones at affected areas. d. malignant cells at the affected areas.

ANS: B 24. If surface contamination from radioactive material is suspected, personnel, when working

with patients, should wear 1. gowns.

2. masks.

3. gloves. a. 1 and 2 only b. 1 and 3 only c. 2 and 3 only d. All of the options ANS: D 25. Potassium iodide can be administered to block further uptake of radioactive iodine in the a. thymus gland. b. thyroid gland. c. pancreas. d. spleen.

ANS: B

Chapter 3. Health Promotion

Multiple Choice

1. Which of the following is a primary prevention measure for a 76-year-old man newly diagnosed with a testosterone deficiency?

A. Calcium supplementation B. Testicular self-examination C. Bone density test D. Digital rectal examination

Answer: A Feedback: Primary prevention refers to efforts to prevent disease from occurring. In this case, calcium supplementation is an example of primary prevention.

Chapter: Chapter 3, Health Promotion Page: 26 Difficulty: Moderate

2. Which of the following is an example of secondary prevention in a 50-year-old woman?

A. Yearly mammogram B. Low animal fat diet C. Use of seat belt D. Daily application of sunscreen

Answer: A Feedback: Secondary prevention consists of early screening and detection of disease, such as having a yearly mammogram.

Chapter: Chapter 3, Health Promotion Page: 26

Difficulty: Moderate

3. Which of the following is an example of tertiary prevention in a patient with chronic renal failure?

A. Fluid restriction B. Hemodialysis 4 days a week C. High-protein diet D. Maintenance of blood pressure at 120/80

Answer: B Feedback: Tertiary prevention is the restoration of health after illness or disease has occurred. Undergoing hemodialysis to treat chronic renal failure is an example of tertiary prevention.

Chapter: Chapter 3, Health Promotion Page: 26 Difficulty: Moderate

4. Immunizations are an example of which type of prevention?

A. Primary B. Secondary C. Tertiary D. Quaternary

Answer: A Feedback: Immunizations are an example of primary prevention. They seek to prevent the occurrence of disease.

Chapter: Chapter 3, Health Promotion Page: 28 Difficulty: Moderate

5. The nurse is speaking to a patient regarding endemic diseases. Which of these choices describes an endemic statistic?

A. The typical incidence of influenza in a country B. The surprise outbreak of malaria in new regions C. Higher levels of Ebola in a country when compared to the previous year D. Abnormal outbreak of measles in pockets of a country

Answer: A Feedback: Because influenza rates are occurring at the same frequency as expected based on past history, this is an example of an endemic disease.

Chapter: Chapter 3, Health Promotion Page: 36 Difficulty: Moderate

6. The nurse is reviewing old and current trends in disease history. Which of these would be considered an example of a sporadic outbreak?

A. The number of people diagnosed with rabies virus in 2017 B. The number of people diagnosed with chlamydia in Texas over a 1-month period C. The number influenza cases diagnosed from 1918 to 1919 D. The number of common cold cases diagnosed in Washington between October 2016 and March 2017

Answer: A Feedback: A sporadic outbreak occurs when there are occasional cases of an event unrelated in space or time. The best example of this is the number of people diagnosed with rabies virus in 2017.

Chapter: Chapter 3, Health Promotion Page: 36 Difficulty: Moderate

7. Which accurately defines incidence rate?

A. The number of old cases of a disease at a point in time B. The number of cases of a disease at a point in time divided by the percentage of the population at a point in time C. The number of total cases of a disease diagnosed at a point in time D. The number of new cases of a disease diagnosed at a point in time

Answer: D Feedback: The incidence rate is the number of new cases of a disease diagnosed at a point in time.

Chapter: Chapter 3, Health Promotion

Page: 35 Difficulty: Easy

8. What describes a pandemic?

A. An event more than epidemic magnitude affecting a single community or country over a long period of time B. An event of epidemic magnitude affecting a single community or country in a short period of time C. An event of epidemic magnitude affecting multiple communities and countries in a short period of time D. An event less than epidemic magnitude affecting multiple communities and countries over a long period of time

Answer: C Feedback: A pandemic is defined as the presence of an event in epidemic proportions affecting many communities and countries in a short period of time.

Chapter: Chapter 3, Health Promotion Page: 36 Difficulty: Easy

9. Which test of health literacy can be completed quickly and provide results comparable to more time-consuming tests?

A. Test of Functional Health Literacy in Adults (TOFHLA) B. Patient Health Questionnaire (PHQ-9)

C. Rapid Estimate of Adult Literacy in Medicine-Short Form (REALM-SF) D. Newest Vital Scale (NVS)

Answer: D Feedback: The NVS can provide results comparable to more time-consuming literacy tests such as the TOFHLA or REALM-SF. Chapter: Chapter 3, Health Promotion Page: 29 Difficulty: Easy

10. The nurse is working with a 65-year-old patient who was recently diagnosed with hypertension. The patient is concerned about their optimal health with their new diagnosis. Which nursing action is necessary for health promotion with the patient?

A. Discussing appropriate stress management techniques B. Sharing with the patient how to increase sodium consumption C. Discussing with the patient exercises that increase heart rate D. Emphasizing the importance of avoiding flu vaccinations

Answer: A Feedback: Applying appropriate stress management techniques will help keep blood pressure within normal limits. This is the primary goal of managing hypertension.

Chapter: Chapter 3, Health Promotion Page: 25 Difficulty: Moderate

Chapter 5. Evidence-Based Care

Multiple Choice

1. What is the goal of nursing research?

A. Make decisions regarding nursing education based on published literature B. Determine topics that could develop nursing knowledge C. Gather information from published literature to make decisions about application to clinical practice D. Conduct studies to develop a body of nursing knowledge

Answer: D Feedback: Nursing research focuses on human responses to health and illness situations; as such, the goal of nursing research is to conduct studies to develop a unique body of nursing knowledge that is key to building evidence-based practice in our discipline.

Chapter: Chapter 5, Evidence-Based Practice Page: 56 Difficulty: Easy

2. Which is the most important question to ask in evidence-based practice?

A. Who funded the research?

B. How will the findings be used?

C. Is this a randomized controlled trial?

D. What theory is being utilized?

Answer: B Feedback: When evaluating research to be used in evidence-based practice, it is important to ask how the findings will be used. It is also important to consider what constitutes evidence.

Chapter: Chapter 5, Evidence-Based Practice Page: 57 Difficulty: Easy

3. Nursing research should be utilized by A. Nurses at the bedside B. Advanced practice nurses C. Nurse researchers D. Nurses at all levels of practice

Answer: D Feedback: Nurses at all levels of practice should use research to improve patient outcomes.

Chapter: Chapter 5, Evidence-Based Practice Page: 56 Difficulty: Easy

4. A clinical guideline may be found useful if the guideline was A. Published 2 to 3 years ago B. Created using one group C. Authored by a relatively unknown source

D. Funded by an anonymous source

Answer: A Feedback: Guidelines must be current. This means the guideline must have been created or revised in the past 2 to 3 years to be considered useful.

Chapter: Chapter 5, Evidence-Based Practice Page: 63 Difficulty: Easy

5. Practice guidelines are designed to A. Be inflexible B. Be utilized in every circumstance C. Provide a reference point for decision making D. Define the scope of work

Answer: C Feedback: Guidelines are intended to provide a reference point and general direction for decision making.

They are not meant to be interpreted as rigid criteria that must be followed regardless of the context.

Chapter: Chapter 5, Evidence-Based Practice Page: 59 Difficulty: Moderate

6. Which of the following is an example of determining whether a crucial element of a guideline is applicable to your patients?

A. There are no intended specific patients in the guideline.

B. You are a primary care provider and the guidelines were written for primary care providers.

C. Your patients have a markedly lower prevalence of a condition than the patients in the guideline.

D. You are a pediatric oncologist and the guidelines were written for geriatric specialists.

Answer: B Feedback: Clinical guidelines written for a primary care provider would be most applicable to a primary care provider. The key criteria to consider when assessing applicability of guideline recommendations are (1) who the guidelines are written for and whether they suit the intended purpose, (2) how closely the individual patient characteristics match those of the patients defined in the guidelines, and (3) whether the guideline is appropriate for the setting and environmental conditions.

Chapter: Chapter 5, Evidence-Based Practice Page: 64 Difficulty: Easy

7. Which of the following would be considered the research design for Level I evidence?

A. Single, well-designed randomized controlled trial B. Systematic review of randomized controlled trial studies C. Well-designed controlled trials without randomization D. Systematic reviews of descriptive or qualitative studies

Answer: B Feedback: Level I evidence includes systematic reviews and meta-analyses of randomized controlled trials.

Chapter: Chapter 5, Evidence-Based Practice Page: 59 Difficulty: Easy

8. Which of the following would be considered the research design for Level II evidence?

A. Single descriptive or qualitative study B. Well-designed case control or cohort studies C. Single, well-designed randomized clinical trial D. Systematic review of randomized clinical trial studies

Answer: C Feedback: A single, well-designed randomized clinical trial is considered Level II evidence.

Chapter: Chapter 5, Evidence-Based Practice Page: 59 Difficulty: Easy

9. Which of the following would be considered the research design for Level III evidence?

A. Well-designed controlled trials without randomization B. Systematic reviews of descriptive or qualitative studies C. Systematic review of randomized clinical trial studies D. Opinion of authorities and expert committees

Answer: A Feedback: Well-designed controlled trials without randomization are classified as Level III evidence.

Chapter: Chapter 5, Evidence-Based Practice Page: 61 Difficulty: Easy

10. Which of the following would be considered the research design for Level IV evidence?

A. Single descriptive or qualitative study B. Opinion of authorities and expert committees C. Systematic review of randomized clinical trial studies D. Well-designed case control or cohort studies

Answer: D Feedback: Level IV evidence consists of well-designed case control or cohort studies.

Chapter: Chapter 5, Evidence-Based Practice Page: 61 Difficulty: Easy

11. Which of the following would be considered the research design for Level V evidence?

A. Systematic review of randomized clinical trial studies B. Well-designed controlled trials without randomization C. Systematic reviews of descriptive or qualitative studies D. Single descriptive or qualitative study

Answer: C Feedback: Systematic reviews of descriptive or qualitative studies are classified as Level V evidence.

Chapter: Chapter 5, Evidence-Based Practice Page: 62 Difficulty: Easy

12. Which of the following would be considered the research design for Level VI evidence?

A. Systematic reviews of descriptive or qualitative studies B. Opinion of authorities and expert committees C. Well-designed case control or cohort studies D. Single descriptive or qualitative study

Answer: D Feedback: A single descriptive or qualitative study is considered Level VI evidence.

Chapter: Chapter 5, Evidence-Based Practice Page: 62 Difficulty: Easy

13. Which of the following would be considered the research design for Level VII evidence?

A. Well-designed controlled trials without randomization B. Opinions of authorities and expert committees C. Well-designed case control or cohort studies D. Single descriptive or qualitative study

Answer: B Feedback: Opinions of authorities and expert committees are considered Level VII evidence.

Chapter: Chapter 5, Evidence-Based Practice Page: 62 Difficulty: Easy

Section 1. Neurological Problems

Multiple Choice

1. Which statement about confusion is true?

A. Confusion is a disease process.

B. Confusion is always temporary.

C. Age is a reliable predictor of confusion.

D. Polypharmacy is a major contributor to confusion in older adults.

Answer: D Feedback: Although age is not a reliable predictor of confusion, older adults are at increased risk for confusion because of polypharmacy. Confusion is a symptom, rather than a disease process, and it can be temporary or permanent.

Chapter: Chapter 6, Common Neurological Complaints Page: 73 Difficulty: Moderate

2. Which of the following indicates a diagnosis of dementia?

A. Onset after an infection B. Abrupt onset over a week C. Difficulty with long-term memory D. Hard time finding words

Answer: D Feedback: Dementia affects language ability and can make it difficult for a person to find the right words.

Chapter: Chapter 6, Common Neurological Complaints Page: 75 Difficulty: Moderate

3. Which diagnostic tool is used to differentiate between focal onset and generalized onset epilepsy?

A. Electroencephalogram (EEG) B. Computed tomography (CT) C. Magnetic resonance imaging (MRI) D. Positron emission tomography (PET) scan

Answer: A Feedback: An EEG can help differentiate between focal onset and generalized onset epilepsy. CT and MRI are used to evaluate for a structural lesion, such as a hemorrhage or tumor, as the cause of the seizure.

Chapter: Chapter 7, Seizure Disorders Page: 94 Difficulty: Moderate

4. Which of the following is a potential trigger for migraines?

A. Taking an ibuprofen for muscle pain B. Eating potato chips C. Drinking a glass of merlot wine

D. Drinking a cup of green tea

Answer: C Feedback: Alcohol, and red wine in particular, can be a migraine trigger for some people.

Chapter: Chapter 6, Common Neurological Complaints Page: 80 Difficulty: Moderate

5. A patient with epilepsy has been taking antiepileptics but the seizures are not well controlled. What is the appropriate action by the clinician?

A. Immediately wean the patient off the antiepileptics.

B. Increase the medication dosage.

C. Refer the patient to a neurologist for a second opinion.

D. Continue with the current regimen and reevaluate in 3 months.

Answer: C Feedback: If the seizures are not controlled with adequate doses and levels of the medication, the clinician should refer the patient to a neurologist for a second opinion and possible combination therapy.

Chapter: Chapter 7, Seizure Disorders Page: 100 Difficulty: Moderate

6. Which is a hallmark of an absence seizure?

A. Inability to stand B. A blank stare

C. Involuntary voiding of urine D. Uncontrollable muscle spasms

Answer: B Feedback: A person experiencing an absence seizure generally has a blank stare and will stop whatever activity they were engaged in.

Chapter: Chapter 7, Seizure Disorders Page: 95 Difficulty: Moderate

7. Which person fits the classic description of a patient with multiple sclerosis (MS)?

A. A teenage male B. A 65-year-old male C. A 25-year-old female D. A 60-year-old female

Answer: C Feedback: MS typically begins in young adulthood, rather than during adolescence or older adulthood.

Chapter: Chapter 10, Infectious and Inflammatory Neurological Disorders Page: 138 Difficulty: Moderate

8. Which finding is associated with a poorer prognosis for a patient with MS? A. Onset before age 35

B. Acute onset of first symptoms C. Optic neuritis D. Polysymptomatic onset

Answer: D Feedback: Polysymptomatic onset is an indicator of poorer prognosis. Other poor prognostic indicators include late onset, chronic progressive course, motor symptoms, and vertigo.

Chapter: Chapter 10, Infectious and Inflammatory Neurological Disorders Page: 138 Difficulty: Moderate

9. Over the course of 3 years, a patient has had two MS flares. The patient‘s primary complaints during the episodes are bilateral tingling and pain in their legs, depression, and numbness in their right hand with complete recovery in between occurrences. Which MS classification fits their disease process?

A. Clinically isolated syndrome B. Relapsing-remitting C. Primary progressive D. Secondary progressive

Answer: B Feedback: This patient has relapsing-remitting MS. They experience acute attacks but have full recovery between episodes.

Chapter: Chapter 10, Infectious and Inflammatory Neurological Disorders Page: 138 Difficulty: Moderate

10. A patient with MS is complaining of new onset ―electric tingling‖ in both their arms. Which medication specifically treats these acute exacerbations?

A. Lemtrada B. Aubagio C. Zanaflex D. Depo-Medrol

Answer: D Feedback: Methylprednisolone (Depo-Medrol) is used to treat acute exacerbations of MS. Chapter: Chapter 10, Infectious and Inflammatory Neurological Disorders Page: 141 Difficulty: Moderate

11. Which of the following is a risk factor for developing Alzheimer‘s disease (AD)?

A. Having a masters or doctoral degree B. Long-term use of nonsteroidal anti-inflammatory drugs C. Down‘s syndrome D. History of neurologic disease

Answer: C Feedback: Those with Down‘s syndrome have a higher risk of developing AD. Other risk factors include being a person of color, having a lower educational or occupational level, having a family history, and having a head injury or vascular disease.

Chapter: Chapter 8, Degenerative Disorders Page: 105 Difficulty: Moderate

12. Which drug for AD should be administered beginning at the time of diagnosis?

A. Cholinesterase inhibitors B. Anxiolytics C. Antidepressants D. Atypical antipsychotics

Answer: A Feedback: Treatment with cholinesterase inhibitors should be considered at the time of diagnosis, taking into account expected therapeutic benefits and potential safety issues.

Chapter: Chapter 8, Degenerative Disorders Page: 108 Difficulty: Moderate

13. The health-care provider is treating a patient who was hit in the head with a frying pan. Which condition should the provider suspect?

A. Intraparenchymal hemorrhage B. Subdural hematoma C. Epidural hematoma D. Subarachnoid hemorrhage

Answer: B Feedback: Subdural bleeding is usually caused by blunt trauma that knocks the brain against the skull, such as might occur after being hit in the head with a frying pan.

Chapter: Chapter 9, Cerebrovascular Accident (Stroke)

Page: 118 Difficulty: Moderate

14. Which hematoma occurs along the temporal cranial wall and results from tears in the middle meningeal artery?

A. Epidural hematoma B. Subdural hematoma C. Subarachnoid hematoma D. Intraparenchymal hemorrhage

Answer: A Feedback: Epidural hematomas, which result from severe head injuries, are most common along the temporal cranial wall and result from tears in the middle meningeal artery.

Chapter: Chapter 9, Cerebrovascular Accident (Stroke) Page: 118 Difficulty: Moderate

15. Which of the following must be completed prior to administering tPA (tissue plasminogen activator)?

A. Full body MRI B. Head x-ray C. Head CT D. Head MRI

Answer: C

Feedback: It is important to differentiate between a hemorrhagic and ischemic stroke before administering tPA. A CT scan during the first few hours of symptoms can aid with this determination.

Chapter: Chapter 9, Cerebrovascular Accident (Stroke) Page: 121 Difficulty: Moderate

16. Which cranial nerve (CN) is affected in a patient with a cerebrovascular accident who has difficulty chewing?

A. CN V B. CN VII C. CN IX D. CN X

Answer: A Feedback: Abnormalities in CN V can result in difficulty chewing.

Chapter: Chapter 9, Cerebrovascular Accident (Stroke) Page: 119 Difficulty: Moderate

17. Which of the following has been linked to a delay in treatment for stroke?

A. Patient has stroke symptoms at work.

B. Patient experiences stroke during the day.

C. Patient lives with a family member.

D. Patient calls their primary care provider (PCP) at first sign of stroke.

Answer: D Feedback: At the first signs of a stroke, the patient or someone with the patient should immediately call 911. Calling the PCP first can lead to delays in treatment.

Chapter: Chapter 9, Cerebrovascular Accident (Stroke) Page: 125 Difficulty: Easy

18. When a patient has a carotid bruit, which of the following should the PCP gather from the patient history?

A. History of hemophilia B. History of peripheral vascular occlusive disease C. History of seizure disorder D. History of sickle cell anemia

Answer: B Feedback: In caring for a patient with asymptomatic carotid bruit, the provider should begin with a thorough history for the presence of coronary and peripheral vascular occlusive disease.

Chapter: Chapter 9, Cerebrovascular Accident (Stroke) Page: 120 Difficulty: Moderate

19. Which patient is most likely experiencing a cluster headache?

A. A 20-year-old woman who reports ―intense‖ headaches before her menstrual cycle B. A 35-year-old woman who reports recurring headaches that do not prevent her from working C. A 60-year-old man who reports headaches that are worse upon lying flat

D. A 45-year-old man awakened in the middle of the night by a severe unilateral headache

Answer: D Feedback: A severe unilateral headache that occurs at night is typical of a cluster headache. Cluster headaches are also most common in middle-aged men. Therefore, the 45-year-old man is most likely experiencing a cluster headache.

Chapter: Chapter 6, Common Neurological Complaints Page: 80 Difficulty: Moderate

20. A patient diagnosed with myasthenia gravis (MG) has been prescribed symptomatic treatment with an anticholinesterase. What side effect should the patient be warned of?

A. Osteoporosis B. Gastrointestinal irritability C. Sweating D. Glaucoma

Answer: B Feedback: A major side effect of anticholinesterase agents is gastrointestinal irritability.

Chapter: Chapter 10, Infectious and Inflammatory Neurological Disorders Page: 138 Difficulty: Moderate

21. Inattention and a sleep–wake cycle disturbance are the hallmark symptoms of A. Dementia

B. AD C. Parkinson‘s disease (PD) D. Delirium

Answer: D Feedback: Inattention and a sleep–wake cycle disturbance are the hallmark symptoms of delirium.

Chapter: Chapter 6, Common Neurological Complaints Page: 75 Difficulty: Moderate

22. Which type of meningitis is more benign, self-limiting, and caused primarily by a virus?

A. Purulent meningitis B. Chronic meningitis C. Aseptic meningitis D. Herpes meningitis

Answer: C Feedback: Aseptic meningitis is primarily caused by a virus and is more benign. Treatment is generally supportive.

Chapter: Chapter 10, Infectious and Inflammatory Neurological Disorders Page: 126 Difficulty: Easy

23. A patient has been diagnosed with meningitis caused by a Streptococcus pneumoniae infection.

Which of the following treatments would be appropriate?

A. Cefotaxime B. Isoniazid C. Acyclovir D. Amphotericin

Answer: A Feedback: Cefotaxime is appropriate to treat meningitis caused by the bacteria Streptococcus pneumoniae. Isoniazid is used to treat meningitis caused by tuberculosis. Acyclovir can be used for herpes simplex virus or varicella-zoster virus. Amphotericin is used to treat fungal infections.

Chapter: Chapter 10, Infectious and Inflammatory Neurological Disorders Page: 126 Difficulty: Moderate

24. Which of the following should be started promptly if viral encephalitis is suspected?

A. Oral amoxicillin B. IV acyclovir C. IV ampicillin D. Oral acyclovir

Answer: B Feedback: All patients suspected of having viral encephalitis should be promptly started on treatment with IV acyclovir while awaiting further work-up. This approach reduces both morbidity and mortality in HSV encephalitis.

Chapter: Chapter 10, Infectious and Inflammatory Neurological Disorders Page: 131 Difficulty: Moderate

25. What is usually the first sign or symptom that a patient would present with that would make you suspect herpes zoster?

A. A stabbing pain on one small area of the body B. A vesicular skin lesion on one side of the body C. A pain that is worse upon awakening D. A lesion on the exterior ear canal

Answer: B Feedback: Herpes zoster is characterized by a unilateral vesicular rash along a dermatome, most commonly a thoracic or lumbar dermatome.

Chapter: Chapter 10, Infectious and Inflammatory Neurological Disorders Page: 132 Difficulty: Moderate

26. At what point do most patients with Guillain-Barré‘s syndrome (GBS) reach the stage of greatest weakness?

A. Within 1 to 2 days B. Within 2 to 3 weeks C. Within 2 months D. Within 3 months

Answer: B Feedback: Most individuals with GBS reach the stage of greatest weakness within the first 2 to 3 weeks after the symptoms appear, and 90% will reach this point by the third week.

Chapter: Chapter 10, Infectious and Inflammatory Neurological Disorders

Page: 137 Difficulty: Moderate

27. Gabby, aged 22, has Bell‘s palsy on the right side of her face. Her mouth is distorted, and she is concerned about permanent paralysis and pain. What do you tell her?

A. ―This is a short-term condition, and most patients recover without treatment.‖ B. ―Unfortunately, you‘ll probably have a small amount of residual damage.‖ C. ―Don‘t worry, I‘ll take care of everything.‖ D. ―You may have a few more episodes over the course of your lifetime but no permanent damage.‖

Answer: A Feedback: The patient should be told that Bell‘s palsy is usually a short-term and benign condition and that the condition often resolves without treatment.

Chapter: Chapter 10, Infectious and Inflammatory Neurological Disorders Page: 137 Difficulty: Moderate

28. A patient is presenting with chorea (dancelike movements). This symptom is indicative of which disease?

A. Dementia B. PD C. Wilson‘s disease D. Huntington‘s disease

Answer: D

Feedback: Chorea is the cardinal clinical manifestation of Huntington‘s disease.

Chapter: Chapter 8, Degenerative Disorders Page: 113 Difficulty: Moderate

29. Which sign would a health-care provider expect to see in a patient with parkinsonism-plus disorder?

A. Resting tremor B. Bradykinesia C. Rigidity D. Postural instability

Answer: D Feedback: Although postural instability is a feature of parkinsonism, it is not part of the diagnostic criteria for PD because it is typically a later manifestation, and its presence early in the disease process suggests a parkinsonism-plus disorder.

Chapter: Chapter 8, Degenerative Disorders Page: 112 Difficulty: Moderate

30. Which of the following is a sign or symptom of a migraine?

A. Light sensitivity B. Nonpulsatile pain C. Nasal stuffiness D. Bandlike pain

Answer: A Feedback: During a migraine attack, patients will commonly experience sensitivity to lights as well as other stimuli, such as noises and smells.

Chapter: Chapter 6, Common Neurological Complaints Page: 80 Difficulty: Easy

31. Carotid endarterectomy should be considered only for symptomatic patients with greater than what percentage of stenosis?

A. Greater than 25% B. Greater than 50% C. Greater than 75% D. Only for 100% occlusion

Answer: B Feedback: Carotid endarterectomy is established as effective for symptomatic patients with 70% to 99% internal carotid artery stenosis. It should never be considered for symptomatic patients with less than 50% stenosis.

Chapter: Chapter 9, Cerebrovascular Accident (Stroke) Page: 123 Difficulty: Moderate

32. Which activity is part of the Functional Activities Questionnaire?

A. Asking the patient to solve a Rubik‘s cube

B. Determining if the patient can drive on the highway C. Asking the patient about a news event from the current week D. Seeing if the patient can keep their home clean

Answer: C Feedback: The Functional Activities Questionnaire is a measure of functional ability. It assesses 10 functional areas, including knowledge about what is going on in the world.

Chapter: Chapter 8, Degenerative Disorders Page: 106 Difficulty: Moderate

33. About 90% of all headaches are A. Tension B. Migraine C. Cluster D. Without pathological cause

Answer: D Feedback: The vast majority of headaches are primary headache disorders without pathological causes.

Chapter: Chapter 6, Common Neurological Complaints Page: 79 Difficulty: Easy

34. Which statement is true regarding driving and patients with a seizure disorder?

A. Once diagnosed with a seizure disorder, patients must never drive again.

B. After being seizure free for 6 months, patients may drive.

C. Each state has different laws governing driving for individuals with a seizure disorder.

D. These persons may drive but never alone.

Answer: C Feedback: Each state has different laws governing the granting of driver‘s licenses for individuals with a seizure disorder that will dictate a period of time patients must refrain from driving after having a seizure. At the federal level, the U.S. Department of Transportation has regulations that bar anyone with a history of seizures from being licensed to drive in interstate trucking.

Chapter: Chapter 7, Seizure Disorders Page: 101 Difficulty: Moderate

35. Julie has relapsing-remitting MS. She has not had a good response to interferon. Which medication might help given intravenously once a month?

A. Glatiramer acetate B. Natalizumab C. Fingolimod D. Glucocorticoids

Answer: B Feedback: Natalizumab is another treatment option for relapsing-remitting MS. It is administered via infusion every 28 days.

Chapter: Chapter 10, Infectious and Inflammatory Neurological Disorders Page: 142 Difficulty: Difficult

36. Freezing, or ―motor block,‖ is a cardinal feature of A. PD B. AD C. A cerebrovascular accident (CVA) D. Bell‘s palsy

Answer: A Feedback: Freezing is a cardinal feature of PD. It is transient and typically occurs when the patient begins to walk, attempts to turn while walking, or approaches a destination.

Chapter: Chapter 8, Degenerative Disorders Page: 112 Difficulty: Moderate

37. Patients with PD commonly experience muscle rigidity. When that rigidity has a ratchetlike quality, it is known as A. Spinothalamic dysfunction B. Ratcheting C. Cogwheeling D. Hand tremors

Answer: C Feedback: Cogwheeling is a term used to describe a ratchetlike quality to the rigidity commonly found on examination in patients with PD. It is caused by an underlying tremor.

Chapter: Chapter 8, Degenerative Disorders Page: 111

Difficulty: Easy

38. Which condition is characterized by the impaired ability to learn new information along with a cognitive disturbance in either language, function, or attention?

A. GBS B. PD C. AD D. Delirium

Answer: C Feedback: Patients with AD experience a decline in memory and learning, which makes it difficult to learn new information. They also experience a decline in at least one additional cognitive domain: language (aphasia), executive function, learned motor function (apraxia), visuospatial, or attention.

Chapter: Chapter 8, Degenerative Disorders Page: 104 Difficulty: Moderate

39. What is the most common type of seizure in adults with epilepsy?

A. Absence seizures B. Myoclonic seizures C. Tonic-clonic seizures D. Focal-impaired awareness seizures

Answer: D

Feedback: Focal-impaired awareness seizures are the most common type of seizure in adults with epilepsy. Typically, patients appear awake, although they are not aware of their surroundings and do not respond appropriately to others.

Chapter: Chapter 7, Seizure Disorders Page: 94 Difficulty: Moderate

40. Which is a contraindication for receiving IV thrombolytic therapy following an ischemic CVA? A. It has been 4 hours since symptom onset.

B. The patient has a platelet count of less than 100,000/mm3.

C. The patient experienced head trauma in the prior 6 months.

D. The patient‘s blood pressure is greater than 140/90 mm Hg.

Answer: B Feedback: IV thrombolytic therapy should not be administered if the patient‘s platelet count is less than 100,000/mm3. Other contraindications include head trauma in the prior 3 months or untreated hypertension with blood pressure exceeding 185/110 mm Hg. Although previously a 3-hour ―rule‖ was accepted, evidence shows that IV thrombolytic therapy is effective within 3 to 4.5 hours after symptom onset.

Chapter: Chapter 9, Cerebrovascular Accident (Stroke) Page: 123 Difficulty: Moderate

41. When administered at the beginning of an attack, oxygen therapy may help which kind of headache?

A. Tension B. Migraine

C. Cluster D. Stress

Answer: C Feedback: Oxygen administered via a nonrebreathing facial mask at 7 to 15 L/min at the beginning of a cluster headache attack provides relief within 15 minutes for most patients.

Chapter: Chapter 6, Common Neurological Complaints Page: 87 Difficulty: Moderate

Section 2. Skin Problems

MULTIPLE CHOICE

1. A patient presents with alopecia areata with well-circumscribed patches of hair loss on the crown of their head. How do you respond when they ask you the cause?

A. ―You must be under a lot of stress lately.‖ B. ―It is hereditary. Did your father experience this also?‖ C. ―The cause is unknown, but we suspect it is due to an immunological mechanism.‖ D. ―We‘ll have to do some tests.‖

Answer: C Feedback: Alopecia is considered an autoimmune disease and may be genetic in etiology with an environmental trigger.

Chapter: Chapter 11: Common Skin Complaints, Alopecia Page: 147 Difficulty: Medium

2. A patient presents with a sudden onset of 102°F fever, emesis, tingling in the hands and feet, fatigue, and weakness. What is the potential diagnosis of this presentation?

A. Urticaria B. Toxic shock syndrome C. Scabies D. Pediculosis

Answer: B Feedback: Gram-positive bacterial infections such as Staphylococcus aureus (the causative agent of toxic shock syndrome) present with systemic symptoms such as fever, malaise, and an erythematous rash.

Chapter: Chapter 11: Common Skin Complaints, Rash Page: 156 Difficulty: Easy

3. Which of the following describes a bullae?

A. It results from a defect in the dermoepidermal junction.

B. It interfaces between the epidermis and the dermis.

C. It is a small crusty plaque.

D. It is a dime-sized purulent pustule on the buttocks.

Answer: A Feedback: A defect in the dermoepidermal junction results in the separation of the epidermis and dermis and the formation of bullae.

Chapter: Chapter 11: Common Skin Complaints, Rash Page: 156 Difficulty: Easy

4.Which is a potential cause for a total loss of skin color in patchy areas of the body?

A. Zidovudine B. Chlorpromazine C. Vitiligo D. Addison‘s disease

Answer: C Feedback: Vitiligo is the total loss of skin color in patchy areas of the body.

Chapter: Chapter 11: Common Skin Complaints, Vitiligo Page: 151 Difficulty: Easy

5. When looking under the microscope to diagnose an intravaginal infection, you see a cluster of small, oval-to-round shapes. What do you suspect they are?

A. Spores B. Leukocytes C. Pseudohyphae D. Epithelial cells

Answer: A

Feedback: Under the microscope, spores appear as small, round-to-ovoid shapes.

Chapter: Chapter 13: Mucocutaneous Fungal Infections, Diagnostic Tests Page: 188 Difficulty: Easy

6. Tinea unguium is also known as A. Onychomycosis B. Tinea versicolor C. Tinea manuum D. Tinea corporis

Answer: A Feedback: Onychomycosis (tinea unguium) is a benign superficial infection of the toenails and fingernails.

Chapter: Chapter 13: Mucocutaneous Fungal Infections, Onychomycosis Page: 174 Difficulty: Easy

7. A patient presents with impetigo that has been diagnosed as infected with Staphylococcus. The clinical presentation is pruritic tender, red vesicles surrounded by erythema with a rash that is ulcerating.

Her recent treatment has not been adequate. Which type of impetigo is this?

A. Bullous impetigo B. Staphylococcal scalded skin syndrome (SSSS) C. Nonbullous impetigo D. Ecthyma

Answer: D Feedback: Group A Streptococcus is the primary etiological agent for a rare, severe ulcerative form of impetigo known as ecthyma.

Chapter: Chapter 14: Bacterial Skin Infections, Pathophysiology Page: 191 Difficulty: Medium

8. A patient has necrotizing fasciitis of his left lower extremity. Pressure on the skin reveals crepitus due to gas production by which anaerobic bacteria?

A. S aureus B. Clostridium perfringens C. Streptococcus pyrogenes D. Streptococcus

Answer: B Feedback: Several kinds of bacteria have been implicated in necrotizing fasciitis, including S aureus, C perfringens, Bacteroides fragilis, and Aeromonas hydrophila. Pressure on the skin may reveal crepitus due to gas production by the anaerobic bacteria C perfringens.

Chapter: Chapter 14: Bacterial Skin Infections, Box 14-1 Types of Cellulitis Page: 200 Difficulty: Medium

9. When using the microscope to diagnose an intravaginal infection, you see something translucent and colorless. What do you suspect?

A. A piece of hair or a thread

B. Hyphae C. Leukocytes D. Spores

Answer: B Feedback: Under the microscope, hyphae appear as long translucent tubes with septa denoting separating sections.

Chapter: Chapter 13: Mucocutaneous Fungal Infections, Onychomycosis Page: 175 Difficulty: Easy

10. A patient has a verruca plana and is using tretinoin cream. Which of the following is true? . It should be applied at bedtime over the entire area that is affected.

B. It should be applied twice daily for 1 week.

C. It is not normal to have a fine scaling when using this medication.

D. It is not normal to have erythema when using this medication.

Answer: A Feedback: Tretinoin cream should be applied to involved areas at bedtime once or twice daily and may require weeks to months of treatment. The treatment can be adjusted to elicit fine scaling and mild erythema.

Chapter: Chapter 15: Viral Skin Infections, Table 15-1 Treatment of Warts Page: 207 Difficulty: Medium

11. Which type of cellulitis is a streptococcal infection of the superficial layers of the skin that does not involve the subcutaneous layers?

A. Necrotizing fasciitis B. Periorbital cellulitis C. Erysipelas D. ―Flesh-eating‖ cellulitis

Answer: C Feedback: Erysipelas is a streptococcal infection of the superficial layers of skin that does not involve the subcutaneous layers, unlike more typical cellulitis.

Chapter: Chapter 14: Bacterial Skin Infections, Box 14-1 Types of Cellulitis Page: 200 Difficulty: Easy

12. A patient presents with a cauliflowerlike wart in her anogenital region. You suspect it was sexually transmitted and discuss that A. HPV 16 and 18 usually cause anogenital warts.

B. Penetrative intercourse is necessary to transmit anogenital warts.

C. Anogenital warts are transmitted genital to genital.

D. OTC home-based cryotherapy is a good choice for treatment.

Answer: C Feedback: Anogenital warts are usually transmitted by genital-to-genital contact, but penetrative intercourse is not necessary for transmission.

Chapter: Chapter 15: Viral Skin Infections, Epidemiology and Causes Page: 205 Difficulty: Medium

13. You are prescribing a low-dose topical corticosteroid for a patient with atopic dermatitis. Which would be a good choice?

A. Betamethasone dipropionate 0.05% B. Hydrocortisone base 2.5% C. Halcinonide 0.1% D. Desonide 0.05%

Answer: B Feedback: A hydrocortisone base or acetate is low potency at 1%, 1.85%, 2%, and 2.5% to treat atopic dermatitis.

Chapter: Chapter 16: Dermatitis, Box 16-1 Potency of Topical Corticosteroids Page: 221 Difficulty: Medium

14. A patient has a rubbery, smooth, round mass on his chest that is compressible and has a soft-to-very-firm texture. What do you diagnose this as?

A. A lipoma B. A nevi C. A skin tag D. A possible adenoma

Answer: A Feedback: The mass has characteristics consistent with a lipoma. One other symptom is irritation.

Chapter: Chapter 17: Skin Lesions, Table 17.1 Other Skin Lesions

Page: 252 Difficulty: Easy

15. Which of the following statements is accurate regarding removal of a seborrheic keratosis lesion using snip excision?

A. Do not use lidocaine as it may potentiate bleeding.

B. Pinch the skin taut together.

C. Use gel foam to control bleeding.

D. This should be performed by a dermatologist only.

Answer: C Feedback: To control the bleeding during a snip excision, you can use pressure, gel foam, styptics, or aluminum chloride.

Chapter: Chapter 17: Skin Lesions, Therapeutic Procedure 17.1: Removal of Seborrheic Keratoses Page: 253 Difficulty: Easy

16. The B in the ABCDEs of assessing skin cancer represents: A. Biopsy B. Best practice C. Boundary D. Border irregularity

Answer: D

Feedback: A stands for asymmetry, B stands for border (irregularity), C stands for color (variegation), D stands for diameter (greater than 6 mm), and E stands for evolving (changing in color, shape, or size).

Chapter: Chapter 11: Common Skin Complaints, Skin Cancer Page: 152 Difficulty: Easy

17. A patient has been diagnosed with Herpes Simplex Virus, Type 2 (HSV2) genital herpes and is wondering what to expect. Which of the following is a credible teaching point?

A. HSV1 genital herpes occurs more frequently than HSV2 genital herpes.

B. The HSV lesions will never occur near the initial infection site.

C. Burning and tingling at the site of initial infection can signal recurrence.

D. Each recurrent HSV infection will be worse than the initial infection.

Answer: C Feedback: A patient may experience the beginning of symptoms in the future, such as tingling or burning at the site of previous lesions, and they can be prescribed antivirals.

Chapter: Chapter 15: Viral Skin Infections, Management Page: 214 Difficulty: Medium

18. Prevalence of psoriasis is highest in which cultural group?

A. Scandinavians B. African Americans C. Asians

D. Native Americans

Answer: A Feedback: Prevalence is highest among Scandinavians, with rates slightly higher in northern rather than southern Sweden.

Chapter: Chapter 16: Dermatitis, Epidemiology and Causes Page: 228 Difficulty: Easy

19. The most common precancerous skin lesion found in people of European descent is A. Skin tags B. Actinic keratosis C. Melanomas D. Basal cell lesions

Answer: B Feedback: Actinic keratosis, also called solar keratosis or senile keratosis, is the most common precancerous skin lesion found in lighter-skinned (white) patients.

Chapter: Chapter 17: Skin Lesions, Actinic Keratosis Page: 254 Difficulty: Easy

20. A middle-aged adult presents with a wide, diffuse area of erythematous skin on his lower left leg that is warm and tender to palpation. There is some edema involved. You suspect A. Necrotizing fasciitis

B. Kaposi‘s sarcoma C. Cellulitis D. A diabetic ulcer

Answer: C Feedback: The typical lesion of cellulitis is a wide, diffuse area of erythematous skin that is warm and tender to palpation.

Chapter: Chapter 14: Bacterial Skin Infections, Cellulitis Page: 199–200 Difficulty: Medium

21. Which description is the most likely for tinea versicolor?

A. There are round, hypopigmented macules on the back.

B. There are red papules on the face.

C. There are crusted plaques in the groin area.

D. There are white streaks on the neck.

Answer: A Feedback: In adults, the usual sites for tinea versicolor are on the back, upper chest, arms, and sometimes neck and face. Tinea versicolor displays as hypopigmented spots.

Chapter: Chapter 13: Mucocutaneous Fungal Infections, Tinea Versicolor Page: 183 Difficulty: Medium

22. A patient is ordered systemic antifungals for a bad tinea infection. You instruct the patient that antifungals may cause A. Renal failure B. Skin discoloration C. Breathing difficulties D. Hepatotoxicity

Answer: D Feedback: For all patients who are on systemic antifungals, physician consultation is recommended because systemically absorbed antifungal drugs can cause hepatotoxicity.

Chapter: Chapter 13: Mucocutaneous Fungal Infections, Management Page: 183 Difficulty: Medium

23. Which of the following is a strong risk factor associated with increased melanoma risk?

A. Patient had a 15-mm nevi.

B. Patient has a history of multiple blistering sunburns in their teenage years.

C. Patient‘s uncle had melanoma.

D. Patient is of African American descent.

Answer: B Feedback: Excessive outdoor exposure to ultraviolet (UV) radiation, such as having five or more sunburns, doubles the risk for melanoma.

Chapter: Chapter 17: Skin Lesions, Environmental History Page: 257 Difficulty: Easy

24. Which statement is true regarding chloasma, the ―mask of pregnancy‖?

A. It is caused by a decrease in the melanocyte-stimulating hormone (MSH) during pregnancy.

B. This condition only occurs on the face.

C. Exposure to sunlight will even out the discoloration.

D. It is caused by increased levels of estrogen and progesterone.

Answer: D Feedback: Chloasma may have a hormonal basis due to increased levels of estrogen, progesterone, and MSH during pregnancy.

Chapter: Chapter 11: Common Skin Complaints, Melasma and Chloasma Page: 152 Difficulty: Easy

25. A patient presents with xerosis. What do you tell the patient about this condition?

A. Daily hot baths can help to soothe the skin.

B. A strong deodorant can improve the condition.

C. It can be a side effect of depigmentation creams.

D. It is uncommon in the elderly.

Answer: C Feedback: The side effects of depigmentation creams may include redness, swelling, pruritus, or xerosis.

Chapter: Chapter 11: Common Skin Complaints, Vitiligo Page: 151 Difficulty: Easy

26. Which medication used for scabies is safe for children 2 months and older?

A. Permethrin cream B. Lindane C. Crotamiton lotion and cream D. Ivermectin

Answer: A Feedback: Permethrin cream is prescribed to treat scabies and is safe in pregnant and lactating women and children 2 months and older.

Chapter: Chapter 12: Parasitic Skin Infestations, Drugs Commonly Prescribed 12.1: Scabies Page: 166 Difficulty: Easy

27. Which of the following statements about performing cryosurgery for actinic keratosis is true?

A. It is better to slightly overfreeze the area, so you only have to do it once.

B. Using liquid nitrogen, freeze each lesion for at least 30 seconds.

C. Every lesion should be biopsied after using liquid nitrogen.

D. The ―freeze balls‖ should be approximately one-and-a-half times as wide as they are deep.

Answer: D Feedback: The ―freeze balls‖ should be approximately 1.5 times as wide as they are deep. Freezing lasts for 10 to 15 seconds, it is better to under freeze the area, and any lesion that does not respond to liquid nitrogen must be biopsied.

Chapter: Chapter 17: Skin Lesions, Therapeutic Procedure 17.2: Cryosurgery for Actinic Keratoses

Page: 255 Difficulty: Easy

28. A patient presents with a very dark color on his right pinkie finger. What is the health-care provider‘s next care step?

A. Referring the patient to a dermatologist for a nail biopsy B. Watchful waiting C. Discussing that the condition is benign and the patient can ignore it D. Following up in 2 weeks to see if there is any change

Answer: A Feedback: Differential diagnoses of nail pigmentation change include acral melanoma, and if acral melanoma is suspected, referral to a dermatologist for a nail biopsy and definitive diagnosis is imperative.

Chapter: Chapter 11: Common Skin Complaints, Skin Cancer Page: 153 Difficulty: Medium

29. Which statement regarding necrotizing fasciitis is true?

A. The hallmark of this infection is its slow and steady progression.

B. Once the border of the infection is ―established,‖ it does not spread.

C. This is a medical emergency and gangrene can develop.

D. The lesion is most dangerous because it is painless.

Answer: C

Feedback: Necrotizing fasciitis progresses rapidly, and gangrene can present in just a few hours.

Chapter: Chapter 14: Bacterial Skin Infections, Box 14-1 Types of Cellulitis Page: 200 Difficulty: Easy

30. Which of these patients is most likely to have acne and resultant scarring?

A. A 15-year-old European American boy B. A 17-year-old Hispanic American girl C. A 20-year-old Asian American woman D. A 21-year-old African American man

Answer: B Feedback: The average age of onset acne is 16 years for Hispanic Americans, and this demographic has the highest incidence of acne and resultant scarring.

Chapter: Chapter 17: Skin Lesions, Pediatric/Adolescent Considerations: Acne Vulgaris Box Page: 242 Difficulty: Medium

31. A 20-year-old Hispanic American man presents with multiple noninflammatory comedones on his chest and back with four small papules on his right upper arm. Which diagnosis is accurate?

A. Mild acne B. Moderate acne C. Severe acne D. Nodulocystic acne

Answer: A Feedback: In mild acne, lesions are primarily noninflammatory comedones. The location of the comedones may vary, but they can be found on the face, chest, back, and upper outer arms.

Chapter: Chapter 17: Skin Lesions, Mild Acne Page: 240 Difficulty: Medium

32. A 40-year-old woman presents with inflammatory papules on her face, facial flushing when she drinks a glass of wine, telangiectasias, and dry eyes. Which of the following conditions is the most likely diagnosis?

A. Acne vulgaris B. Hot tub folliculitis C. Rosacea D. Perioral dermatitis

Answer: C Feedback: Rosacea can be accompanied by dry eyes, can include telangiectasis, and includes a tendency for easy flushing in response to alcohol.

Chapter: Chapter 17: Skin Lesions, Differential Diagnosis Page: 249 Difficulty: Medium

33. A patient complaining of a pruritic erythematous rash on her face and hands that became apparent this morning comes into the clinic. Which of the following questions would help determine if she has contact dermatitis?

A. ―Do you have a history of itchy rashes?‖

B. ―Do you have any food allergies?‖ C. ―Do you have a history of rosacea?‖ D. ―Have you used any new face wash or soap?‖

Answer: D Feedback: When a patient has a rash, one question to ask that is focused on the patient‘s history of skin treatment is: Have you recently used any new skin care products, cosmetics, topical creams or lotions, shampoos, soaps, or clothing detergents?

Chapter: Chapter 11: Common Skin Complaints, Focus on History: Rash Page: 154 Difficulty: Medium

34. A 70-year-old patient presents with a poorly defined, pink, scaling rash on his face and scalp.

When he asks what he can expect from this condition, you say A. ―If your rash is itchy, the itching may be worse when you are hot and sweaty.‖ B. ―This is probably a one-time rash and should not come back.‖ C. ―This condition does not run in families, so your children are not at risk of developing it.‖ D. ―This rash is most common in people who have poor hygiene, so you will have to shower at least once a day.‖

Answer: A Feedback: Dermatitis is used to describe an undefined rash. Heat and sweat may be aggravating factors for atopic dermatitis.

Chapter: Chapter 16: Dermatitis, Epidemiology and Causes Page: 216 Difficulty: Medium

35. A patient presents with a fingerlike, flesh-colored projection emanating from a broad base on her mouth. Which of the following is the most likely diagnosis?

A. Plantar wart B. Flat wart C. Verruca vulgaris D. Digitate wart

Answer: D Feedback: Digitate warts are fingerlike, flesh-colored projections that protrude from a narrow or broad base and are usually on the face.

Chapter: Chapter 15: Viral Skin Infections, Objective Page: 206 Difficulty: Easy

36. A patient is seeing her health-care provider for a follow-up visit for impetigo. Which of the following teaching points should the provider discuss?

A. Fingernails that are kept short can prevent the spread of impetigo.

B. Impetigo can be prevented in the future by wearing a face mask.

C. If a patient has impetigo in the future, they should clean everything in their home with bleach.

D. Impetigo is spread by blood, so the patient should avoid donating blood.

Answer: A Feedback: Keeping fingernails short is recommended for patients because it can reduce the likelihood of bacterial spread to other parts of the body.

Chapter: Chapter 14: Bacterial Skin Infections, Patient Education: Impetigo

Page: 193 Difficulty: Medium

37. A patient complaining of a ―bumpy‖ rash on her neck that is nonpruritic comes to the health- care provider. She was recently on a ski trip and went in a hot tub. What is the most likely diagnosis?

A. HSV-2 B. Folliculitis C. Acne vulgaris D. Actinic keratosis

Answer: B Feedback: Folliculitis infects the hair follicles, leading to erythematous papules and pustules (bumps).

Exposure to wet environments, such as hot tubs, contributes to Pseudomonas aeruginosa infection, which predisposes to folliculitis.

Chapter: Chapter 14: Bacterial Skin Infections, Folliculitis, Epidemiology and Causes Page: 194 Difficulty: Medium

38. What is the best treatment option for a patient with a single furuncle on their buttock with no surrounding cellulitis?

A. Systemic antibiotics B. Cold compress to the site C. Incision and drainage D. Watchful waiting

Answer: C Feedback: Fluctuant furuncles are ideally treated with incision and drainage.

Chapter: Chapter 14: Bacterial Skin Infections, Management Page: 199 Difficulty: Easy

39. A patient presents with an extremely pruritic lesion that is round to a half circle in his genital area.

Which of the following is the most likely diagnosis?

A. Tinea cruris B. Tinea pedis C. Tinea versicolor D. Tinea manuum

Answer: A Feedback: The typical patient with tinea cruris is an obese adult man who complains of a pruritic rash on the groin.

Chapter: Chapter 13: Mucocutaneous Fungal Infections, Tinea Cruris Page: 180 Difficulty: Medium

40. Which of the following is true of scabies?

A. It is more common in those of European descent.

B. It is transmitted through blood.

C. It is associated with hygiene.

D. It is transmitted through close personal contact.

Answer: D Feedback: Close personal contact is the major mode of transmission for scabies, although casual contact such as nursing care may be sufficient for transmission to occur.

Chapter: Chapter 12: Parasitic Skin Infestations, Epidemiology and Causes Page: 163 Difficulty: Easy

41. Which of the following is true of pediculosis?

A. Pruritus occurs before the sensitivity to the head louse.

B. Patients can be asymptomatic or have few symptoms in the first 2 weeks following exposure.

C. In a patient‘s first infection, they will develop symptoms within 24 to 48 hours.

D. It is transmitted through droplets.

Answer: B Feedback: Pediculosis infestation may be asymptomatic or cause few symptoms in the first 2 weeks after exposure. In individuals who have never before been exposed to a lice infestation, it can take several weeks before developing clinical symptoms.

Chapter: Chapter 12: Parasitic Skin Infestations, Pathophysiology Page: 167 Difficulty: Easy

42. How might a rash appear on a patient with a darker skin tone?

A. As a dark brown area B. As a light pink area

C. As a bright red area D. As a deep purple area

Answer: A Feedback: Instead of a pink-to-red color like in people with lighter skin tones, a rash in a person with darker skin might appear as a dark brown color.

Chapter: Chapter 11: Common Skin Complaints, Rash Page: 157 Difficulty: Easy

43. Which of the following is the most common appearance of Paget‘s disease?

A. Poorly defined red raised plaque on one nipple B. Scattered white papules on the nipples bilaterally C. Oval-shaped erythematous scaling plaque with sharp margins on one nipple D. Raised silvery white patches on the nipples bilaterally

Answer: C Feedback: The usual location of the rash of mammary Paget‘s disease is on only one nipple. The skin lesion appears as an oval-shaped, erythematous scaling plaque with sharp margins.

Chapter: Chapter 11: Common Skin Complaints, Paget‘s Disease Page: 157 Difficulty: Easy

44. A patient presents with a rash on their torso that is erythematous in appearance, with papulovesicular lesions that ooze and crust. The patient denies pain or pruritis. What is the most likely diagnosis?

A. Atopic dermatitis B. Shingles C. Candida D. Scabies

Answer: A Feedback: Early in its presentation, atopic dermatitis is erythematous in appearance, with papulovesicular lesions that may ooze and crust. In its later stages, the rash becomes a red-purple color, dries, and develops scaling and lichenification, which is exacerbated by scratching resulting from its highly pruritic nature.

Chapter: Chapter 16, Dermatitis Page: 215 Difficulty: Medium

45. A 24-year-old woman presents to the health-care provider‘s office with severe acne. The provider notices she is overweight and has some facial hair. The patient states during the history that she also has irregular periods but thinks it is all due to her weight. What differential diagnosis should the health-care provider investigate?

A. Adrenal gland cancer B. Polycystic ovarian syndrome (PCOS) C. Hirsutism D. Diabetes

Answer: B. Feedback: If an endocrine disorder such as PCOS is suspected (e.g., in a hirsute, overweight female patient with moderate-to-severe acne and amenorrhea or irregular menses), an evaluation for excessive androgen production should be performed.

Chapter: Chapter 17, Skin Lesions

Page: 242 Difficulty: Moderate

46. What is a common presentation in a man with balanitis?

A. Burning with urination B. Painful erection C. Itching of the glans D. White film on the penis

Answer: C Feedback: The typical presentation of balanitis is a sexually active adult man who complains of a reddish rash and itching on the glans penis. It is sometimes accompanied by penile burning after intercourse, although no burning is usually felt with urination.

Chapter: Chapter 13, Mucocutaneous Fungal Infections Page: 173 Difficulty: Moderate

47. Which drug may interact with oral systemic antifungals?

A. Warfarin B. Metoprolol C. Isoniazid D. Amoxicillin

Answer: A

Feedback: Drug interactions may occur with many oral systemic antifungals that are available by prescription when given with warfarin (Coumadin), phenytoin (Dilantin), or rifampin.

Chapter: Chapter 13, Mucocutaneous Fungal Infections Page: 179 Difficulty: Moderate

48.The borders in cellulitis are A. Flat and diffuse B. Distinct and raised C. Pink and jagged D. Red and round

Answer: A Feedback: The red borders seen in cellulitis are flat and diffuse, compared with the distinct raised border seen with an erysipelas infection.

Chapter: Chapter 14, Bacterial Skin Infections Page: 200 Difficulty: Difficult

49. Which class of medications is the standard of care for severe acne?

A. Oral antibiotics B. Topical steroids C. Retinoid creams D. Vitamin A

Answer: A Feedback: Oral antibiotics are the standard of care in the management of moderate-to-severe acne and treatment-resistant forms of inflammatory acne. P. acnes is a biofilm-forming organism, and topical treatment is recommended along with oral antibiotics.

Chapter: Chapter 17, Skin Lesions Page: 246 Difficulty: Moderate

50. Which of the following is a side effect of oral minoxidil?

A. Hypertension B. Hypotension C. Dermatitis D. Decreased libido

Answer: B Feedback: At higher doses, oral minoxidil is a vasodilator and is used to treat hypertension. Topical minoxidil has not been found to cause lowering of systolic or diastolic blood pressure or pulse rate.

Finasteride can cause sexual side effects.

Chapter: Chapter 11, Common Skin Complaints Page: 150 Difficulty: Moderate

51. Which class of drugs has a potential side effect of hyperpigmentation?

A. NSAIDS B. ACE inhibitors

C. Opioids D. Oral glycemics

Answer: A Feedback: Many classes of drugs have been implicated in hyperpigmentation, including antimalarials, chemotherapeutics, anticoagulants, antimicrobials, anticonvulsants, antipsychotics, antiretrovirals, NSAIDs, and heavy metals. Specific drugs that are known to cause diffuse hyperpigmentation (melanosis) include amiodarone, zidovudine, minocycline, clofazimine, psoralens, and cyclophosphamide.

Chapter: Chapter 11, Common Skin Complaints Page: 152 Difficulty: Moderate

Section 3. Eye Problems

MULTIPLE CHOICE

1. An acutely presenting, erythematous, tender lump within the eyelid is called A. Blepharitis B. Hordeolum C. Chalazion D. Iritis

Answer: B

Feedback: A hordeolum, also known as a stye, is an acute, erythematous, tender lump within the eyelid.

Chapter: Chapter 19, Lid and Conjunctival Pathology Page: 272 Difficulty: Easy

2. A granulomatous infection of a Meibomian gland that presents as a painless swelling on the eyelid is called A. Iritis B. Chalazion C. Viral conjunctivitis D. Nuclear cataracts

Answer: B Feedback: A chalazion is a granulomatous inflammation of a blocked meibomian gland that presents as a painless swelling on the eyelid.

Chapter: Chapter 19, Lid and Conjunctival Pathology Page: 272 Difficulty: Easy

3. A patient presents with edematous and erythematous lid margins. Closer visual inspection with a Wood‘s lamp reveals scaling. Which of the following conditions could be the diagnosis?

A. Hordeolum B. Chalazion C. Blepharitis

D. Iritis

Answer: C Feedback: Blepharitis is an inflammation of the eyelids and their margins. Lid margins are typically edematous and erythematous, and closer visual inspection with a magnifying glass or Wood‘s lamp may reveal scaling, erythema, or crusting.

Chapter: Chapter 19, Lid and Conjunctival Pathology Page: 271 Difficulty: Moderate

4. The clinician is seeing a patient complaining of red eye. The clinician suspects conjunctivitis. The presence of mucopurulent discharge suggests which type of conjunctivitis?

A. Viral conjunctivitis B. Keratoconjunctivitis C. Bacterial conjunctivitis D. Allergic conjunctivitis

Answer: C Feedback: In bacterial conjunctivitis, signs and symptoms include itching, either bilaterally or unilaterally, with a moderate amount of mucopurulent (yellow-green) discharge that occurs more unilaterally. Viral conjunctivitis occurs bilaterally and has minimal exudate, itching, excessive tearing, and a sensation that something is in the eye. Allergic conjunctivitis occurs bilaterally with intense itching, moderate tearing, and no exudate. Keratoconjunctivitis is caused by a systemic disease process and involves T cells.

Chapter: Chapter 19, Lid and Conjunctival Pathology Page: 282 Difficulty: Moderate

5. Which is appropriate patient education to provide regarding bacterial conjunctivitis?

A. The patient should continue to go to their job as a day care teacher.

B. The patient should make sure to practice proper hand washing.

C. The patient should touch their eyes to apply medication.

D. The patient will be infectious for only 24 hours after diagnosis of bacterial conjunctivitis.

Answer: B Feedback: The spread of conjunctivitis may be prevented by effective hand washing, avoiding touching the eyes, and not sharing towels or washcloths.

Chapter: Chapter 19, Lid and Conjunctival Pathology Page: 284 Difficulty: Moderate

6. What information in the patient‘s history would lead the provider to diagnose a corneal abrasion?

A. Patient‘s mother had a corneal abrasion.

B. Patient wears glasses.

C. Patient complains, ―I feel like something is in my right eye.‖ D. Patient complains, ―My eyes feel so dry.‖

Answer: C Feedback: Signs and symptoms of corneal abrasion include sharp pain, foreign body sensation, photophobia, conjunctival hyperemia, and acute profuse tearing.

Chapter: Chapter 19, Lid and Conjunctival Pathology Page: 278 Difficulty: Moderate

7. Which subtype of cataracts is characterized by significant nearsightedness and a slow indolent course?

A. Nuclear B. Cortical C. Posterior D. Immature

Answer: A Feedback: Nuclear cataracts are centrally located opacifications, characterized by significant nearsightedness and a slow, indolent course. Cortical cataracts are peripheral, asymmetric radial opacities that typically cause worse glare symptoms than other types of cataracts. Subcapsular cataracts can be anteriorly or posteriorly located and are commonly associated with acute angle-closure glaucoma and corticosteroid use, respectively. They typically progress faster than the other forms—over months rather than years. Immature cataracts are the start of cataracts but do not significantly affect vision.

Chapter: Chapter 20, Visual Disturbances and Impaired Vision Page: 288 Difficulty: Easy

8. Which of the following produces a slow and painless visual field loss that usually begins peripherally?

A. Posterior cataracts B. Open-angle glaucoma C. Immature cataracts D. Macular degeneration

Answer: B

Feedback: Open-angle glaucoma produces a slow and painless visual field loss that usually begins peripherally.

Chapter: Chapter 20, Visual Disturbances and Impaired Vision Page: 290 Difficulty: Easy

9. Which of the following is TRUE regarding dietary supplements and cataracts?

A. High doses of vitamin E prevent the progression of cataracts.

B. Low doses of vitamin C increase age-related cataract development.

C. There is no evidence that concretely proves the benefit of high-dose vitamin E to prevent cataracts.

D. Weekly lutein prevents the formation of cataracts.

Answer: C Feedback: A Cochrane review found no evidence supporting high doses of vitamin E, vitamin C, or beta carotene in preventing the formation or progression of cataracts.

Chapter: Chapter 20, Visual Disturbances and Impaired Vision Page: 290 Difficulty: Moderate

10. A 65-year-old man presents to the clinician with complaints of increasing bilateral peripheral vision loss, poor night vision, and frequent prescription changes that started 6 months previously. Recently, he has also been seeing halos around lights. The clinician suspects chronic open-angle glaucoma. Which of the following statements is true concerning the diagnosis of chronic open-angle glaucoma?

A. The presence of increased intraocular pressure (IOP) measured by tonometry is definitive for the diagnosis of open-angle glaucoma.

B. The clinician can definitively diagnosis open-angle glaucoma based on the subjective complaints of the patient.

C. Physical diagnosis relies on gonioscopic evaluation of the angle by an ophthalmologist.

D. Early diagnosis is essential in order to reverse any damage that has occurred to the optic nerve.

Answer: C Feedback: Physical diagnosis of chronic open-angle glaucoma relies on gonioscopic evaluation of the anterior chamber angle by an ophthalmologist.

Chapter: Chapter 20, Visual Disturbances and Impaired Vision Page: 293 Difficulty: Difficult

11. Acute angle-closure glaucoma involves a sudden severe rise in IOP. Which of the following ranges represents normal IOP? A. 0 to 7 mm Hg B. 10 to 21 mm Hg C. 22 to 40 mm Hg D. 40 to 80 mm Hg

Answer: B Feedback: Traditionally, normal IOP is between 10 and 21 mm Hg. Chapter: Chapter 20, Visual Disturbances and Impaired Vision Page: 293 Difficulty: Moderate

12. Which of the following education points is essential to provide to the patient with glaucoma?

A. Their medication may have adverse effects.

B. Only the patient can instill eye drops.

C. Eye infections are common and are not a concern.

D. Eye exams must happen monthly.

Answer: A Feedback: It should be noted that occasionally, localized or systemic reactions to the medication may occur, and the patients should be instructed in what to look for.

Chapter: Chapter 20, Visual Disturbances and Impaired Vision Page: 294 Difficulty: Moderate

13. With regards to the relationship between diabetes and diabetic retinopathy, which of the following is TRUE? A. Diabetic retinopathy only occurs in patients with type 1 diabetes.

B. Diabetic retinopathy is always the first sign that a patient has diabetes.

C. The longer the patient has had diabetes, the more likelihood that they will develop retinopathy.

D. Diabetic retinopathy only occurs in patients with type 2 diabetes.

Answer: C Feedback: The longer a patient has had diabetes mellitus, the greater the likelihood that they will develop retinopathy. Diabetic retinopathy can happen in either type 1 or 2 diabetes and is a long- term complication of the disease.

Chapter: Chapter 20, Visual Disturbances and Impaired Vision Page: 295 Difficulty: Moderate

14. As diabetic retinopathy progresses, the presence of ―cotton wool‖ spots can be detected. Cotton wool spots refer to A. Microvascular infarctions B. Blood vessel proliferation C. Venous beading D. Retinal hemorrhage

Answer: A Feedback: Microvascular infarcts present as cotton wool spots.

Chapter: Chapter 20, Visual Disturbances and Impaired Vision Page: 295 Difficulty: Easy

15. A patient with proliferative retinopathy (PDR) related to diabetes should see their ophthalmologist how often?

A. Monthly B. Every 2 months C. Every 3 to 4 months D. Annually

Answer: C Feedback: Patients with PDR should be seen at least every 3 to 4 months.

Chapter: Chapter 20, Visual Disturbances and Impaired Vision Page: 296

Difficulty: Easy

16. Who of the following is a patient with risk factors for macular degeneration?

A. 50-year-old African American man B. 65-year-old Caucasian woman C. 40-year-old Asian man D. 90-year-old Hispanic woman

Answer: B Feedback: Caucasian race, female gender, and age older than 60 years are a few of the highest risk factors for macular degeneration.

Chapter: Chapter 20, Visual Disturbances and Impaired Vision Page: 296 Difficulty: Moderate

17. A patient was diagnosed with gradual floaters that the provider determined did not require treatment. What is a common complaint when a patient has benign floaters?

A. ―In my right eye I see little dots when I stare in the direction of the sun.‖ B. ―In both eyes I see bright white dots that block my vision when I am in a black room.‖ C. ―I can‘t see in my left eye when I look into a bright room.‖ D. ―When I am in a dark room a big white dot blocks my field of vision in my left eye.‖

Answer: A Feedback: Floaters are often seen when looking at a bright background.

Chapter: Chapter 18, Common Eye Complaints

Page: 269 Difficulty: Moderate

18. A patient is complaining of seeing ―flashing lights.‖ What is the provider‘s next step?

A. Send the patient to ophthalmology immediately to evaluate for macular degeneration.

B. Tell the patient that it is normal to see flashing lights occasionally.

C. Send the patient to ophthalmology immediately to evaluate for a retinal tear or detachment.

D. Tell the patient that they can wait to be seen by ophthalmology for 1 month.

Answer: C Feedback: Any patient who complains of seeing flashing lights should be evaluated immediately for retinal tear or detachment.

Chapter: Chapter 18, Common Eye Complaints Page: 269 Difficulty: Moderate

19. A patient presents with tearing in her right eye that is worse in the morning along with itching this morning. What is the most likely cause in the provider‘s differential diagnosis?

A. Dry eye B. Blepharitis C. Diabetic retinopathy D. Cataract

Answer: B

Feedback: The presentation of itching that is worse in the morning suggests blepharitis, an inflammation of the eyelid.

Chapter: Chapter 19, Lid and Conjunctival Pathology Page: 271 Difficulty: Moderate

20. Which of the following medications used in the treatment of glaucoma works by constricting the pupils to open the angle and allow aqueous fluid to escape?

A. Pilocarpine B. Timolol C. Brinzolamide D. Acetazolamide

Answer: D Feedback: In acute angle-closure glaucoma, medications are administered during the acute attack to rapidly lower IOP. Acetazolamide (Diamox) and IV mannitol with a topical miotic, such as pilocarpine, may be administered, followed by a more definitive laser peripheral iridotomy to create an alternate pathway for aqueous to flow into the anterior chamber.

Chapter: Chapter 20, Visual Disturbances and Impaired Vision Page: 294 Difficulty: Moderate

21. What eye disorder is the leading cause of blindness worldwide?

A. Cataracts B. Diabetic retinopathy C. Glaucoma D. Blepharitis

Answer: A Feedback: Cataracts are the leading cause of blindness worldwide. The World Health Organization has estimated that more than 20 million people are blind due to cataracts and that cataracts are responsible for more than 70 million cases of vision impairment and blindness worldwide.

Chapter: Chapter 20, Visual Disturbances and Impaired Vision Page: 288 Difficulty: Easy

22. Which of the following occurs in dry eye syndrome?

A. Tear film stability B. Itching C. Mucopurulent drainage D. Damage to the ocular surface

Answer: D Feedback: Dry eye syndrome is a multifactorial disease of the tear film that results in discomfort, visual disturbance, and tear film instability with potential damage to the ocular surface. The failure or insufficiency of tears does not provide enough lubrication to the surface of the eye.

Chapter: Chapter 18, Common Eye Complaints Page: 267 Difficulty: Moderate

23. What patient education should be provided to a patient with age-related macular degeneration?

A. Using low light will help with reading.

B. Recognition early will not prevent vision loss.

C. Looking at an Amsler grid will detect subtle vision changes.

D. Safety should be monitored due to peripheral vision loss.

Answer: C Feedback: Macular degeneration causes central vision loss and difficulty seeing in low light. Recognizing symptoms early can prevent blindness and progression of the disease. Use of an Amsler grid will help detect subtle vision changes for prompt intervention.

Chapter: Chapter 20, Visual Disturbances and Impaired Vision Page: 300 Difficulty: Moderate

Section 4. Ear, Nose, and Throat Problems

MULTIPLE CHOICE

1. Which of the following is an example of sensorineural hearing loss (SNHL)?

A. Perforation of the tympanic membrane B. Otosclerosis C. Cholesteatoma D. Presbycusis

Answer: D Feedback: The most common cause of SNHL is age-related hearing loss, termed presbycusis. The degeneration of delicate inner ear structures over time contributes to the loss of hearing as we age.

Chapter: Chapter 22, Hearing and Balance Disorders Page: 310 Difficulty: Easy

2. The clinician is assessing a patient complaining of hearing loss. The clinician places a tuning fork over the patient‘s mastoid process, and when the sound fades away, the fork is placed without restriking it over the external auditory meatus. The patient is asked to let the clinician know when the sound fades away. This is an example of which type of test?

A. Weber test B. Schwabach test C. Rinne test D. Auditory brainstem response (ABR) test

Answer: C Feedback: In conducting a Rinne test, a vibrating tuning fork is placed on the mastoid process. When the sound fades away, the fork is promptly placed (without restriking it) over the external auditory meatus.

Chapter: Chapter 22, Hearing and Balance Disorders Page: 313 Difficulty: Moderate

3. A patient presents to the clinician complaining of ear pain. On examination, the clinician finds that the patient has tenderness on traction of the pinna as well as when applying pressure over the tragus.

These findings are classic signs of which condition?

A. Otitis media (OM) B. Meniere‘s disease C. Tinnitus D. Otitis externa (OE)

Answer: D

Feedback: Pain caused by OE is exacerbated by pulling the pinna or earlobe or by applying pressure to the tragus.

Chapter: Chapter 23, Inflammatory and Infectious Disorders of the Ear Page: 314 Difficulty: Moderate

4. In which of the following scenarios would OM be considered chronic?

A. Patient has had repeated episodes of acute OM (AOM) followed by continuous or intermittent otorrhea lasting for more than 3 months.

B. Patient has had severe pain and intermittent otorrhea lasting for 2 months.

C. Patient has had repeated episodes of AOM followed by continuous or intermittent otorrhea lasting for more than 1 month.

D. Patient has had severe pain and continuous otorrhea lasting for 3 months.

Answer: A Feedback: Chronic OM typically presents with a history of repeated bouts of AOM, followed by a period of continuous or intermittent otorrhea lasting for more than 3 months.

Chapter: Chapter 23, Inflammatory and Infectious Disorders of the Ear Page: 342 Difficulty: Moderate

5. Which of the following is helpful in evaluating patients with OM with effusion?

A. Lumbar puncture B. Magnetic resonance imaging (MRI) C. Computed tomography (CT) scan

D. Ultrasound

Answer: C Feedback: Conventional sinus x-ray films and CT scans (which can reveal mucosal thickening in the middle ear space) may be helpful in evaluating patients with effusion, particularly patients with recurrent infection.

Chapter: Chapter 23, Inflammatory and Infectious Disorders of the Ear Page: 344 Difficulty: Easy

6. Which of the following treatments is appropriate for a patient who has AOM and has an allergy to penicillin?

A. Augmentin 875 mg two times daily for 10 days B. Suprax 400 mg daily for 7 days C. Amoxicillin 500 mg every 8 hours for 10 days D. Zithromax 500 mg on day 1, and then 250 mg daily for 4 days

Answer: D Feedback: Zithromax 500 mg on day 1, and then 250 mg daily for 4 days is an appropriate alternative treatment of AOM in adults with a penicillin allergy.

Chapter: Chapter 23, Inflammatory and Infectious Disorders of the Ear Page: 347 Difficulty: Moderate

7. Which immunoglobulin (Ig) mediates the type 1 hypersensitivity reaction involved in allergic rhinitis (AR)?

A. IgA B. IgE C. IgG D. IgM

Answer: B Feedback: AR results from IgE-mediated type I hypersensitivity to airborne irritants affecting the eyes, nose, sinuses, throat, and bronchi.

Chapter: Chapter 24, Inflammatory and Infectious Disorders of the Nose, Sinuses, Mouth, and Throat Page: 351 Difficulty: Easy

8. Fluctuations and reductions in estrogen may be a contributing factor in which type of rhinitis?

A. Vasomotor rhinitis B. Rhinitis medicamentosum C. Atrophic rhinitis D. Viral rhinitis

Answer: B Feedback: Fluctuations and reductions in estrogen levels associated with menses, hormonal birth control preparations, pregnancy, and menopause may all predispose to nonallergic rhinitis (NAR). Rhinitis medicamentosa is a form of NAR that results from rebound nasal congestion secondary to medication overuse.

Chapter: Chapter 24, Inflammatory and Infectious Disorders of the Nose, Sinuses, Mouth, and Throat Page: 351 Difficulty: Easy

9. Sinusitis is considered chronic when there are episodes of prolonged inflammation with repeated or inadequately treated acute infection lasting greater than A. 4 weeks B. 8 weeks C. 12 weeks D. 16 weeks

Answer: C Feedback: Chronic sinusitis occurs with episodes of prolonged inflammation with repeated or inadequately treated acute infection, with symptoms lasting longer than 12 consecutive weeks.

Chapter: Chapter 24, Inflammatory and Infectious Disorders of the Nose, Sinuses, Mouth, and Throat Page: 365 Difficulty: Easy

10. Which of the following antibiotics provides the best coverage in acute or chronic sinusitis when gram-negative organisms are suspected?

A. Penicillin V B. Amoxicillin C. Levofloxacin D. Clindamycin

Answer: C Feedback: For documented gram-negative infection, a fluoroquinolone (e.g., levofloxacin, moxifloxacin) should be prescribed.

Chapter: Chapter 24, Inflammatory and Infectious Disorders of the Nose, Sinuses, Mouth, and Throat

Page: 374 Difficulty: Moderate

11. Which of the following can prevent chronic sinusitis?

A. Patients in the same household with sinusitis should all use the same nasal spray.

B. Respiratory infections should be treated after a week of symptoms.

C. A dehumidifier should be used during sinusitis attacks.

D. Surgery should be done to correct anatomical blockages of the sinus ostia.

Answer: D Feedback: Chronic sinusitis can be prevented by sinus surgery to remove damaged mucosal tissue or to correct anatomical obstructions of the sinus ostia.

Chapter: Chapter 24, Inflammatory and Infectious Disorders of the Nose, Sinuses, Mouth, and Throat Page: 376 Difficulty: Moderate

12. Which type of stomatitis results in necrotic ulceration of the oral mucous membranes?

A. Vincent‘s B. Allergic C. Aphthous D. Herpetic

Answer: A Feedback: Vincent‘s stomatitis causes necrotic ulceration of the interdental gingival papillae and oral mucous membranes.

Chapter: Chapter 24, Inflammatory and Infectious Disorders of the Nose, Sinuses, Mouth, and Throat Page: 384 Difficulty: Easy

13. Which type of stomatitis is caused by continual exposure to chewing tobacco?

A. Aphthous B. Herpetic C. Nicotinic D. Allergic

Answer: C Feedback: Tobacco smoking and chewing (―dipping snuff‖) can clearly lead to nicotinic stomatitis.

Chapter: Chapter 24, Inflammatory and Infectious Disorders of the Nose, Sinuses, Mouth, and Throat Page: 384 Difficulty: Easy

14. The presence of hairy leukoplakia in a person with no other symptoms of immune suppression is strongly suggestive of which type of infection?

A. Herpes simplex virus type 2 B. HIV C. Pneumonia D. Syphilis

Answer: B

Feedback: The presence of hairy leukoplakia strongly suggests HIV infection in an individual with no other signs of immune suppression.

Chapter: Chapter 24, Inflammatory and Infectious Disorders of the Nose, Sinuses, Mouth, and Throat Page: 385 Difficulty: Easy

15. Which of the following conditions leads to erythematous patches with bluish-white centers on the lingual and buccal mucosa (Koplik‘s spots)?

A. Syphilis B. Roseola paramyxovirus infection C. Parotitis D. HIV

Answer: B Feedback: Measles (roseola paramyxovirus infection) leads to erythematous patches with bluish- white centers on the lingual and buccal mucosa, known as Koplik’s spots.

Chapter: Chapter 24, Inflammatory and Infectious Disorders of the Nose, Sinuses, Mouth, and Throat Page: 385 Difficulty: Easy

16. Heart valve damage resulting from acute rheumatic fever is a long-term sequelae resulting from infection with which of the following pathogens?

A. Coxsackievirus B. Cytomegalovirus C. Francisella tularensis

D. Group A streptococcus

Answer: D Feedback: Group A streptococcus is the most important cause of pharyngitis because it may lead to the most serious complications, including heart valve damage that may occur many years after systemic infection, known as acute rheumatic fever.

Chapter: Chapter 24, Inflammatory and Infectious Disorders of the Nose, Sinuses, Mouth, and Throat Page: 393 Difficulty: Moderate

17. Which of the following is a disorder of infectious etiology?

A. Tonsillitis B. Kawasaki‘s syndrome C. Pharyngitis related to allergies D. Pemphigus

Answer: A Feedback: Tonsillitis is almost exclusively a disorder of infectious etiology.

Chapter: Chapter 24, Inflammatory and Infectious Disorders of the Nose, Sinuses, Mouth, and Throat Page: 393 Difficulty: Easy

18. A patient presents with the following signs and symptoms: gradual onset of low-grade fever, marked fatigue, severe sore throat, and posterior cervical lymphadenopathy. Based on the signs and symptoms alone, which of the following conditions is most likely the cause?

A. Gonorrhea B. Mononucleosis C. Influenza D. Herpes zoster

Answer: B Feedback: Infectious mononucleosis is infamous for its gradual onset of low-grade fever, marked fatigue, and severe sore throat. Ninety percent of infectious mononucleosis cases present with posterior cervical lymphadenopathy.

Chapter: Chapter 24, Inflammatory and Infectious Disorders of the Nose, Sinuses, Mouth, and Throat Page: 393–394 Difficulty: Moderate

19. A patient presents with nonvesicular lesions that are 2 to 10 mm, symmetrical, and scattered on the oropharynx and mouth. What is their most likely diagnosis?

A. Corynebacterium diphtheriae B. Primary syphilis C. Candida infection D. Secondary syphilis

Answer: D Feedback: Secondary syphilitic nonvesicular lesions (2 to 10 mm) arise symmetrically on all parts of the oropharynx and mouth. The nonvesicular lesions of primary syphilis are 5 to 15 mm in size and appear indurated or ―healed up,‖ extending to the lips, tonsils, or tongue. Candida infections produce thin, white, nonvesicular, diffuse or patchy (3 to 11 mm) exudative ulcers on all parts of the oropharyngeal mucosa.

Chapter: Chapter 24, Inflammatory and Infectious Disorders of the Nose, Sinuses, Mouth, and Throat Page: 394 Difficulty: Moderate

20. A patient presents to the clinician with a sore throat, fever of 100.7°F, and tender anterior cervical lymphadenopathy. The clinician suspects strep throat and performs a rapid strep test that is negative.

What would the next step be?

A. The patient should be instructed to rest and increase fluid intake as the infection is most likely viral and will resolve without antibiotic treatment.

B. Because the patient does not have strep throat, the clinician should start broad spectrum antibiotics in order to cover the offending pathogen.

C. A throat culture should be performed to confirm the results of the rapid strep test.

D. The patient should be treated with antibiotics for strep throat as the rapid strep test is not very sensitive.

Answer: C Feedback: Conducting a rapid streptococcal detection test to guide antibiotic therapy is considered appropriate for any patient with two or three of the following criteria: fever greater than 100.5°F (38.1°C), tonsillar exudate, tender anterior cervical lymphadenopathy, and the absence of cough. Patients who present with sore throat and only two of the associated criteria are given the rapid streptococcal detection test first but, if the result is negative, it must be followed up by a throat culture Chapter: Chapter 24, Inflammatory and Infectious Disorders of the Nose, Sinuses, Mouth, and Throat Page: 395 Difficulty: Moderate

21. A patient is diagnosed with acute OE with fluid that is black and malodorous. Which of the following is responsible for this?

A. Fungal infection B. Staphylococcus infection C. Pseudomonas infection D. Allergic reaction

Answer: A Feedback: Fungal infections present as a fluffy white or black malodorous carpet of growth. Pseudomonas infection produces a copious green exudate. Staphylococcus infection presents as a yellow, crusting, purulent exudate. Allergic reactions are characterized by scaly, cracked, and/or weepy tissue along the outer ear and auditory canal.

Chapter: Chapter 23, Inflammatory and Infectious Disorders of the Ear Page: 336 Difficulty: Moderate

22. You have a patient who is a positive for strep on rapid antigen testing (rapid strep test). You order amoxicillin after checking for drug allergies (patient is negative), but he returns 3 days later reporting that his temperature has gone up not down (101.5°F in office). You also note significant lymphadenopathy, most notably in the posterior and anterior cervical chains, some hepatosplenomegaly, and a diffuse rash. You decide A. To refer the patient B. That he is having an allergic response and needs to be changed to a macrolide antibiotic C. That his antibiotic dosage is not sufficient and should be changed D. That he possibly has mononucleosis concurrent with his strep infection

Answer: D Feedback: If the patient fails to respond to antibiotic therapy, tests for infectious mononucleosis and streptococcal antibiotic sensitivity should be performed.

Chapter: Chapter 24, Inflammatory and Infectious Disorders of the Nose, Sinuses, Mouth, and Throat Page: 393–394 Difficulty: Moderate

23. Which of the following medications is safe to use for OM when an adult patient has a perforated tympanic membrane?

A. Chloroxylenol 1 mg, four to five drops in the affected ear 3×/day daily for 7 days B. Floxin otic 10 drops in affected ear for 7 days C. Pramoxine HCL 10 mg, four to five drops in affected ear 3×/day for 7 days D. Hydrocortisone 10 mg/mL, three drops in affected ear 3×/day for 7 days

Answer: B Feedback: Ten drops of Floxin otic in affected ear for 7 days is safe to use when an adult patient has a perforated tympanic membrane.

Chapter: Chapter 23, Inflammatory and Infectious Disorders of the Ear Page: 340 Difficulty: Moderate

24. Which of the following is the form of external otitis in which bacterial infection extends from the auditory canal into the base of the skull?

A. OM B. OE C. Necrotizing otitis D. Swimmer‘s ear

Answer: C Feedback: Necrotizing OE is a bacterial infection that extends from the skin of the auditory canal into the soft tissues, cartilage, and bone in the temporal region or base of the skull.

Chapter: Chapter 23, Inflammatory and Infectious Disorders of the Ear Page: 335 Difficulty: Easy

25. Though common as people age, what concerning disease can dysphonia be a cardinal sign for?

A. Laryngeal cancer B. Viral infection C. Bronchitis D. Lung cancer

Answer: A Feedback: Dysphonia is a cardinal sign of laryngeal cancer, which is seen most commonly in males 50 to 70 years of age, as well as in those with a history or current use of tobacco and alcohol.

Chapter: Chapter 27, Dysphonia Page: 412 Difficulty: Easy

26. A patient has dysphonia ×3 days as a result of a viral illness. Which of the following educational points is correct?

A. As smoking has no effect on dysphonia, the patient can continue to smoke.

B. The patient should continue to use their voice to exercise it.

C. The patient should take cough medication with antihistamines.

D. It should be ensured that the patient has adequate fluid intake.

Answer: D Feedback: It is recommended to maintain adequate fluid intake and ambient humidification.

Chapter: Chapter 27, Dysphonia Page: 415

Difficulty: Moderate

27. A patient complains of dull and intermittent left sided facial pain and left sided headache that is worse in the morning. Which of the following diagnoses is most likely?

A. Pharyngitis B. Temporomandibular joint dysfunction C. Temporomandibular joint disease D. Dysphonia

Answer: C Feedback: The facial pain of temporomandibular disorder (TMD) is usually unilateral, dull, and may be constant or intermittent. The typical headache of TMD is unilateral and described as a deep pain that is worse in the morning.

Chapter: Chapter 26, Temporomandibular Disorders Page: 407 Difficulty: Easy

28. A provider is examining a patient with temporomandibular joint disease (TMJ). Which of the following results would the provider expect from the exam?

A. The mandibular opening is 40 mm.

B. There are no sounds elicited from the exam.

C. The mandible deviates to the left side.

D. The patient is able to open the mouth without pain or sound.

Answer: C

Feedback: In examining TMJ, the mandible may deviate to one side or the other when opened (asymmetrical opening).

Chapter: Chapter 26, Temporomandibular Disorders Page: 408 Difficulty: Moderate

29. Which of the following medications for TMD has the warning that patients should NOT drive while taking it?

A. Flexeril B. Naprosyn C. Tylenol D. Elavil

Answer: A Feedback: Patients cannot drive while taking Flexeril because of drowsiness and tiredness side effects.

Chapter: Chapter 26, Temporomandibular Disorders Page: 409 Difficulty: Easy

30. What is the most common site of hemorrhage for epistaxis?

A. Nasopharynx B. Nostril C. Posterior nasal cavity D. Little‘s area

Answer: D Feedback: Little‘s area is the most common site of hemorrhage for epistaxis.

Chapter: Chapter 25, Epistaxis Page: 402 Difficulty: Easy

31. A patient just had epistaxis and the health-care provider is counseling them on what to do when they go home. Which of the following should be included?

A. Make sure to talk during future nose bleeds to reassure the people around you.

B. When nose bleeds occur, if you have blood in your mouth, spit it out.

C. Avoid hot liquids after a nose bleed.

D. With future nose bleeds, drinking lukewarm beverages helps blood clot.

Answer: C Feedback: Alcohol and hot liquids should be avoided after an acute attack.

Chapter: Chapter 25, Epistaxis Page: 406 Difficulty: Moderate

32. A patient presents with complaints of right hearing loss that has been getting worse and a congruent headache. What is the most likely diagnosis?

A. Acoustic neuroma B. Presbycusis C. Meniere‘s disease D. Sensorineural hearing loss

Answer: A Feedback: Acoustic neuroma (vestibular schwannoma) is a rare tumor of cranial nerve (CN) VIII, causes unilateral constant or progressive hearing loss with tinnitus, and is possibly associated with disequilibrium and vertigo. In addition, facial paralysis, headache, nausea, vomiting, and papilledema may occur due to an acoustic neuroma.

Chapter: Chapter 22, Hearing and Balance Disorders Page: 313 Difficulty: Moderate

33. Which of the following complementary therapies can help a patient with tinnitus?

A. Increasing salt intake B. Stopping smoking C. No longer listening to music D. Increasing caffeine intake

Answer: B Feedback: General measures the patient may take to minimize symptoms include stopping smoking and decreasing the intake of caffeine, chocolate, alcohol, and salt, which are suggested by some experts to exacerbate the condition.

Chapter: Chapter 22, Hearing and Balance Disorders Page: 320 Difficulty: Moderate

34. Which of the following is true of tinnitus?

A. It can only be heard by the patient.

B. It affects hearing.

C. It is caused by changes in peripheral auditory function.

D. It is a common disease.

Answer: C Feedback: Tinnitus is a symptom, not a disease. Tinnitus is most commonly caused by changes in peripheral auditory function; however, about 10% of patients with tinnitus have normal hearing. Tinnitus is characterized as either subjective or objective tinnitus. Subjective tinnitus is perceivable only by the patient, whereas objective tinnitus, most commonly caused by vascular problems, is audible by the observer as well as the patient.

Chapter: Chapter 21, Ear Nose and Throat Problems Page: 316 Difficulty: Moderate

35. Tinnitus can be treated but often does not completely resolve. What should the patient be educated on regarding tinnitus?

A. Aspirin will help with symptoms.

B. Vitamins A and C and magnesium should be taken.

C. A white noise machine should be used.

D. Biofeedback is not an approved therapy.

Answer: C Feedback: Regular relief may be obtained by masking the tinnitus with background noise from an external ―white noise‖ machine. Avoidance of risk factors, such as excessive noise; untreated insomnia; depression; anxiety; and offending (ototoxic) medications, such as aspirin-containing products and other NSAIDs, is a priority as is avoiding alcohol. Micronutrient supplements such as vitamin A, vitamin C, cyanocobalamin, nicotinic acid, magnesium, and copper do not have data from randomized controlled trials to support their use. Biofeedback may help avoid psychological problems that can develop from the near-constant feelings of distress.

Chapter: Chapter 21, Ear Nose and Throat Problems

Page: 320 Difficulty: Moderate

Section 5. Respiratory Problems

MULTIPLE CHOICE

1. A chronic cough lasts longer than A. 3 weeks B. 8 weeks C. 6 months D. 1 year

Answer: B Feedback: Cough lasting longer than 8 weeks is considered chronic.

Chapter: Chapter 28, Common Respiratory Complaints Page: 417 Difficulty: Easy

2. You are doing a cerumen extraction and touch the external meatus of your patient‘s ear. He winces and starts coughing. What is the name of this reflex?

A. Baker‘s phenomenon B. Arnold‘s reflex C. Cough reflex D. Tragus reflex

Answer: B Feedback: Checking the ears for cerumen or hairs impinging on the tympanic membrane may cause cough (Arnold‘s reflex).

Chapter: Chapter 28, Common Respiratory Complaints Page: 418 Difficulty: Moderate

3. The patient with a history of which condition should receive fungal serology testing for their chronic cough?

A. Sickle cell disease B. Multiple sclerosis C. Celiac disease D. AIDS

Answer: D Feedback: Fungal serology should be done if the patient is immunosuppressed (e.g., patients with AIDS).

Chapter: Chapter 28, Common Respiratory Complaints Page: 419 Difficulty: Moderate

4. Which of these patients should be given a decongestant?

A. Gerta, a 41-year-old woman with GERD B. Christine, a 15-year-old girl with pneumonia C. Dan, a 60-year-old man with allergic rhinitis D. Andy, a 26-year-old man with cystic fibrosis

Answer: C Feedback: Decongestants and antihistamines, alone or in combination, are indicated in cases of allergic rhinitis and postnasal drip.

Chapter: Chapter 28, Common Respiratory Complaints Page: 419 Difficulty: Moderate

5. Which of the following herbal supplements should be used cautiously in a patient with hypertension?

A. Licorice B. Horehound C. Peppermint D. Jasmine

Answer: A Feedback: Licorice preparations should be used with caution because they may increase blood pressure.

Chapter: Chapter 28, Common Respiratory Complaints Page: 419 Difficulty: Easy

6. A 25-year-old Hispanic woman is experiencing chest tightness, a feeling of suffocation, and feeling like she ―can‘t get air in.‖ She has no current history of heart or lung disease and did not exercise leading up to this attack. Which of the following is the most likely cause for this dyspnea?

A. Severe chronic anemia B. Congestive heart failure

C. Anxiety-related dyspnea D. Chronic obstructive pulmonary disease (COPD)

Answer: C Feedback: Onset of dyspnea at rest, accompanied by a sense of chest tightness, a feeling of suffocation, and an inability to ―get air in,‖ is a common presentation of anxiety-related dyspnea.

Chapter: Chapter 28, Common Respiratory Complaints Page: 420 Difficulty: Moderate

7. Which of the following scales is useful to assess the degree of dyspnea with a score of 6 to 20?

A. Borg scale B. Patient Health Questionnaire-9 scale C. Visual analog scale D. Global assessment of functioning scale

Answer: A Feedback: The Borg scale for perceived exertion with a score of 6 to 20 (6 = no exertion; 20 = very, very hard exertion) is useful in assessing the degree of dyspnea.

Chapter: Chapter 28, Common Respiratory Complaints Page: 420 Difficulty: Easy

8. A 30-year-old African American patient complains of ―coughing up blood.‖ What is a likely cause of the condition?

A. Bronchogenic carcinoma B. Pulmonary embolus with infarction C. Mitral stenosis

D. Bronchitis

Answer: C Feedback: If hemoptysis (expectoration of blood) occurs in patients aged 45 years or younger, it is likely caused by mitral stenosis, tuberculosis (TB), bronchiectasis, or a lung abscess.

Chapter: Chapter 28, Common Respiratory Complaints Page: 422 Difficulty: Moderate

9. African American patients often have a negative reaction to which of the following asthma medications?

A. Inhaled corticosteroids B. Long-term beta agonist bronchodilators C. Leukotriene receptor agonists D. Oral corticosteroids

Answer: B Feedback: Some genetic and epidemiological studies have suggested that certain individuals (especially those of African American ethnicity) have a negative reaction to long-acting beta agonist (LABA) bronchodilators such as salmeterol (Serevent), especially if used as long-term therapy.

Chapter: Chapter 31, Inflammatory Respiratory Disorders Page: 469 Difficulty: Easy

10. A78-year-old patient presents to the clinic with respiratory symptoms. Pulmonary function tests are as follows: normal total lung capacity, decreased PaO2, and increased PaCO2. On assessment, auscultation reveals coarse crackles and forced expiratory wheezes. What is the diagnosis?

A. Asthma B. Emphysema C. Chronic bronchitis D. Influenza

Answer: C Feedback: Findings for chronic bronchitis include: normal total lung capacity, a decreased PaO2, an increased PaCO2, coarse crackles during infections, and forced expiratory wheezes.

Chapter: Chapter 31, Inflammatory Respiratory Disorders Page: 478 Difficulty: Moderate

11. You are using the CURB-65 clinical prediction tool to decide whether a patient diagnosed with community-acquired pneumonia (CAP) should be hospitalized or treated at home. Which of the following risk factors would increase the patient‘s chance of CAP-associated mortality and complications?

A. Temperature of 100°F B. Respiratory rate 22 breaths per minute C. Hemoglobin 9.5 g/dL D. History of diabetes mellitus

Answer: D Feedback: Diabetes mellitus is a known risk factor for CAP-associated mortality and complications.

Chapter: Chapter 30, Infectious Respiratory Disorders Page: 448 Difficulty: Moderate

12. A 40-year-old patient with a history of diabetes mellitus, hypertension, and HIV has a tuberculin skin test (TST). What is the smallest diameter of induration that would indicate a positive result?

A. 2 mm B. 5 mm C. 8 mm D. 10 mm

Answer: B Feedback: Persons with known HIV infection and those suspected of having HIV infection should be given treatment if their reaction to the Mantoux (PPD) TBT is 5 mm or greater.

Chapter: Chapter 30, Infectious Respiratory Disorders Page: 456 Difficulty: Moderate

13. Which patient would likely have a decreased response to a TBT? A. A patient on a high-protein diet B. An adolescent patient C. A patient on long-term corticosteroid therapy D. A patient who just got over a cold

Answer: C Feedback: TB that develops during corticosteroid therapy tends to be disseminated or presents in an obscure fashion.

Chapter: Chapter 30, Infectious Respiratory Disorders Page: 460 Difficulty: Moderate

14. A patient has been started on a TB regimen. Because isoniazid (INH) may cause peripheral neuropathy, you consider ordering which of the following drugs prophylactically?

A. Pyridoxine B. Thiamine C. Probiotic D. Phytonadione

Answer: A Feedback: Isoniazid (INH or H) may cause peripheral neuropathy, so pyridoxine may be given prophylactically.

Chapter: Chapter 30, Infectious Respiratory Disorders Page: 459 Difficulty: Moderate

15. Which of the following patients is most likely to have squamous cell carcinoma?

A. Janice, a 70-year-old woman who is a nonsmoker B. Bill, a 65-year-old man with a 20-year history of smoking C. Sophie, a 30-year-old woman with a family history of lung cancer D. David, a 90-year-old man whose brother passed away from lung cancer

Answer: B Feedback: Squamous cell carcinoma is a disease associated with cigarette smoking, so the patient with a 20-year history of smoking is most likely to develop it.

Chapter: Chapter 32, Lung Cancer Page: 496 Difficulty: Moderate

16. A patient has a history of lung cancer and is experiencing new onset right side ptosis and miosis and says, ―I‘m so hot, but I‘m not sweating.‖ Which of the following conditions can be attributed to her new onset symptoms?

A. Bell‘s palsy B. Turner‘s syndrome C. Murphy‘s syndrome D. Horner‘s syndrome

Answer: D Feedback: Horner‘s syndrome consists of unilateral ptosis, miosis, and ipsilateral anhidrosis (lack of sweating due to extension of the tumor into the paravertebral sympathetic nerves).

Chapter: Chapter 32, Lung Cancer Page: 499 Difficulty: Moderate

17. A patient has been diagnosed with breast cancer staged as T1, N0, M0. What might this mean?

A. The tumor size cannot be evaluated; the cancer has not spread to the lymph nodes; and the distant spread cannot be evaluated.

B. The cancer is in situ; it is spreading into the lymph nodes but the spread cannot be evaluated otherwise.

C. The cancer is less than 3 cm in size and has not spread to the lymph nodes or other parts of the body.

D. The cancer is about 5 cm in size; nearby lymph nodes cannot be evaluated; and there is no evidence of distant spreading.

Answer: C Feedback: T1, N0, and M0 refer to a tumor that is 3 cm or less in greatest dimension, no regional lymph node metastasis, and no distant metastasis.

Chapter: Chapter 32, Lung Cancer Page: 501–502 Difficulty: Moderate

18. Your patient has decided to try to quit smoking with Chantix. You are discussing his quit date, and he will begin taking the medicine tomorrow. When should he plan to quit smoking?

A. He should stop smoking today.

B. He should stop smoking tomorrow.

C. His quit date should be in 1 week.

D. He will be ready to quit after the first 30 days.

Answer: C Feedback: Varenicline (Chantix) is a nicotinic acetylcholine receptor partial agonist used as a smoking cessation aid. It is recommended that therapy begin 1 week before a target quit date is set.

Chapter: Chapter 33, Smoking Addiction Page: 516 Difficulty: Moderate

19. Which information should be included when you are teaching your patient about the use of nicotine gum?

A. The gum must be correctly chewed to a softened state and then placed in the buccal mucosa.

B. Patients should not eat for 30 minutes prior to or during the use of the gum.

C. Initially, one piece is chewed every 30 minutes while awake.

D. Acidic foods and beverages should be encouraged during nicotine therapy.

Answer: A Feedback: Nicotine gum must be correctly chewed to a softened state (until there is a peppery taste or a tingling sensation is felt) and then placed in the buccal mucosa.

Chapter: Chapter 33, Smoking Addiction Page: 516 Difficulty: Easy

20. Which of these sputum stains would be used to test for a viral respiratory culture?

A. Gram stain B. Direct fluorescent antibody stain

C. Wright-Giemsa stain D. Acid-fast stain

Answer: B Feedback: Direct fluorescent antibody stain is used to test for a viral respiratory culture.

Chapter: Chapter 30, Infectious Respiratory Disorders Page: 445 Difficulty: Easy

21. What is the first-line recommended treatment against group A beta hemolytic streptococci (GABHS), the most common cause of bacterial pharyngitis?

A. Penicillin B. Quinolone C. Cephalosporin D. Macrolide

Answer: A Feedback: If throat cultures are positive for GABHS, penicillin should be prescribed if the patient is not allergic to penicillin.

Chapter: Chapter 30, Infectious Respiratory Disorders Page: 434 Difficulty: Easy

22. A 40-year-old woman presents with a history of asthma. She has not been treated for a while. She complains of daily but not continual symptoms, greater than 1 week and at nighttime. She has been using her rescue inhaler. Her forced expiratory volume in 1 second (FEV1) is 60% to 80% predicted.

How would you classify her asthma severity?

A. Mild intermittent B. Mild persistent C. Moderate persistent D. Severe persistent

Answer: C Feedback: Clinical features before treatment that include symptoms daily, but not continual; nighttime symptoms more than once a week, but not nightly; exacerbations that affect activity and sleep; and PEFR or FEV1 60% to 80% predicted, PFT variability greater than 30% are classified as moderate persistent.

Chapter: Chapter 31, Inflammatory Respiratory Disorders Page: 468 Difficulty: Moderate

23. A patient taking a long-acting beta agonist for asthma should have what additional medication prescribed?

A. Inhaled corticosteroid B. Leukotriene receptor antagonist C. Systemic corticosteroid D. Methylxanthines Answer: A Feedback: Long-acting beta agonists used in combination with an inhaled corticosteroid are extremely effective at improving lung function in patients with moderate to severe asthma.

Chapter: Chapter 31, Inflammatory Respiratory Disorders Page: 469 Difficulty: Moderate

24. Your patient is on Theophylline for asthma. You want to maintain serum levels between A. 0 to 5 μg/mL B. 5 to 10 μg/mL C. 5 to 15 μg/mL

D. 10 to 20 μg/mL

Answer: C Feedback: The therapeutic levels for Theophylline are generally 5 to 15 μg/mL. Chapter: Chapter 31, Inflammatory Respiratory Disorders Page: 482 Difficulty: Moderate

25. A patient with COPD has an 80% FEV1. How would you classify the severity of his COPD? A. Stage 1 mild COPD B. Stage 2 moderate COPD C. Stage 3 severe COPD D. Stage 5 very severe COPD

Answer: A Feedback: FEV1 greater than or equal to 80% predicted is classified as mild COPD. Chapter: Chapter 31, Inflammatory Respiratory Disorders Page: 478 Difficulty: Moderate

26. Most nosocomial pneumonias are caused by A. Fungi B. Viruses C. Gram-negative bacteria D. Pneumococcal pneumonia

Answer: C Feedback: Nosocomial bacterial pneumonia is most frequently caused by gram-negative organisms such as Pseudomonas aeruginosa, Klebsiella pneumoniae, Escherichia coli, Serratia, Proteus, and Enterobacter.

Chapter: Chapter 30, Infectious Respiratory Disorders Page: 442 Difficulty: Easy

27. Which of the following statements regarding the Mantoux tuberculin skin test (TST) is true?

A. Tests should be read 48 hours after the injection.

B. The size of the TST reaction is based solely on induration.

C. It is a type V T-cell mediated immune response.

D. The diameter of the induration is measured in centimeters.

Answer: B Feedback: Interpretation of the test result is based on the presence or absence of induration, which is determined by inspection and palpation. Erythema is not a factor in interpretation of the TST reaction.

Chapter: Chapter 30, Infectious Respiratory Disorders Page: 455 Difficulty: Moderate

28. Which obstructive lung disease is classified as reversible?

A. Asthma B. Chronic bronchitis C. Emphysema D. COPD

Answer: A

Feedback: Obstructive lung diseases are further classified as reversible (such as asthma) or irreversible (such as chronic bronchitis and emphysema, which are collectively grouped together as COPD).

Chapter: Chapter 31, Inflammatory Respiratory Disorders Page: 466 Difficulty: Easy

29. Which statement about adenocarcinoma of the lung is accurate?

A. It is the least common type of lung cancer, representing approximately 5% to 10% of cases.

B. It is the most prevalent carcinoma of the lungs in both sexes and in nonsmokers, representing 35% to 40% of all tumors.

C. It is more common in men than in women and occurs almost entirely in cigarette smokers.

D. It is aggressive, with rapid growth primarily in the liver and brain.

Answer: B Feedback: Adenocarcinoma, which represents 35% to 40% of all lung cancers, is the most prevalent carcinoma of the lung in both sexes and in nonsmokers.

Chapter: Chapter 32, Lung Cancer Page: 496 Difficulty: Moderate

30. Which of the following is a contributing factor of obstructive sleep apnea (OSA)?

A. Being a recovering alcoholic of 6 years B. Having a collar size of 17 inches C. Being the only person in a family who has this D. Having an extremely thin build

Answer: B Feedback: Neck (or collar) size is the best indicator of the presence of sleep apnea. Approximately 30% of snoring men with a collar size larger than 17 inches will have OSA. Chapter: Chapter 29, Sleep Apnea Page: 424 Difficulty: Moderate

31. What is the pressure needed for continuous positive air pressure (CPAP) to abolish apneas, snoring, and oxyhemoglobin desaturations in all positions and during REM sleep?

A. 5 to 20 cm H2O B. 10 to 25 cm H2O C. 15 to 25 cm H2O D. 20 to 35 cm H2O

Answer: A Feedback: The optimal CPAP pressure is determined by technologists during polysomnography. Typically, 5 to 20 cm H2O is the pressure needed to abolish apneas, snoring, and oxyhemoglobin desaturations in all positions and during REM sleep.

Chapter: Chapter 29, Sleep Apnea Page: 429 Difficulty: Easy

32. What is a procedure that can be performed in the outpatient setting for a patient with OSA? A. Mandibular advancement B. Laser-assisted uvulopalatoplasty C. Retroglossal obstruction removal D. Uvulopalatopharyngoplasty

Answer: B Feedback: Laser-assisted uvulopalatoplasty is a procedure to treat snoring in the outpatient setting.

Chapter: Chapter 29, Sleep Apnea

Page: 429 Difficulty: Moderate

33. A 3-week-old infant was recently diagnosed with influenza. Which of the following medications would be appropriate to treat the condition?

A. Liquid Oseltamivir B. Inhaled Zanamivir C. Inhaled Oseltamivir D. Liquid Zanamivir

Answer: A Feedback: Oseltamivir, either as a pill or in liquid form, is for the treatment of influenza in persons aged 2 weeks and older.

Chapter: Chapter 30, Infectious Respiratory Disorders Page: 435 Difficulty: Moderate

34. The forced vital capacity (FPV) is decreased in A. Asthma B. Chronic bronchitis C. Emphysema D. Restrictive disease Answer: D Feedback: FPV is decreased in restrictive disease.

Chapter: Chapter 31, Inflammatory Respiratory Disorders Page: 478 Difficulty: Easy

35. What is the most common cause of CAP? A. Streptococcus pneumoniae B. K pneumoniae C. Legionella pneumoniae D. P aeruginosa

Answer: A Feedback: The most common cause of CAP is the gram-positive bacteria S pneumoniae, also referred to as pneumococcal pneumonia.

Chapter: Chapter 30, Infectious Respiratory Disorders Page: 441 Difficulty: Easy

36. Which of the following patients would you expect to have a decreased response to Mantoux tuberculin skin test (TST)?

A. Julie, a 50-year-old postal worker with hypertension B. Sandy, a 40-year-old patient who recently survived a fire that left 40% of her total body surface covered in burns C. Jill, a 16-year-old cheerleader with type 1 diabetes D. Mark, a 29-year-old tennis player who currently has a cold Answer: B Feedback: Surgery, burns, mental illness, and graft-versus-host reactions are some factors that contribute to decreased response on tuberculin skin testing.

Chapter: Chapter 30, Infectious Respiratory Disorders Page: 456 Difficulty: Moderate

37. Which of the following is a possible consequence of sleep apnea?

A. Asthma B. Increased white blood cells

C. Insulin resistance D. Hyperactivity

Answer: C Feedback: Insulin resistance is a possible consequence of sleep apnea.

Chapter: Chapter 29, Sleep Apnea Page: 423 Difficulty: Easy

38. Which of the following conditions is associated with cigarette smoking?

A. Glaucoma B. Increased sperm quality C. Bladder cancer D. Eczema

Answer: C Feedback: Smoking is considered by many to be the probable cause or contributing cause of cancers of the bladder, breast, pancreas, uterus, and kidney.

Chapter: Chapter 33, Smoking Addiction Page: 512 Difficulty: Moderate

39. What would you instruct a patient who is taking TB drugs prophylactically?

A. Take them on an empty stomach to facilitate absorption.

B. Take them with aspirin (ASA) to prevent flushing.

C. Take them with ibuprofen to prevent a headache.

D. Take them with food to prevent nausea.

Answer: A Feedback: All first-line TB drugs must be taken on an empty stomach to facilitate absorption—if unable to comply, they may take the medicine with food that does not contain fat or oils (may ease nausea).

Chapter: Chapter 30, Infectious Respiratory Disorders Page: 459 Difficulty: Moderate

40. Which of the following statements regarding pulmonary function and cigarette smoking is true?

A. Cigarette smoking causes an increase in circulating immunoglobulin levels.

B. Cigarette smoking has no increased risk of COPD. C. Cigarette smoking decreases mucus production.

D. Cigarette smoking increases the risk of pneumothorax.

Answer: D Feedback: Pneumothorax is a respiratory disease associated with cigarette smoking.

Chapter: Chapter 33, Smoking Addiction Page: 509 Difficulty: Moderate

41. How much nicotine does an average cigarette contain?

A. 5 to 10 mg B. 10 to 15 mg C. 15 to 20 mg D. 20 to 25 mg

Answer: C Feedback: An average cigarette contains 15 to 20 mg of nicotine.

Chapter: Chapter 33, Smoking Addiction Page: 511 Difficulty: Easy

42. A smoker is at a primary-care visit with their provider. After the provider asks if they are willing to quit, they say they have decided to quit, have bought nicotine gum, and are interested in hearing about Chantix. Which stage of change are they in regarding their attempts at smoking cessation?

A. Precontemplation B. Action C. Maintenance D. Preparation

Answer: D Feedback: Smokers who are serious about quitting and have taken the initial steps toward cessation are in the preparation stage. ―Precontemplation‖ is not even thinking about making the change, ―action‖ is making the change, and ―maintenance‖ is continuing the change after it happens.

Chapter: Chapter 33, Smoking Addiction Page: 514 Difficulty: Moderate

43. A 60-year-old patient would like to quit smoking, but they are unsure of the benefits. Which of these is a benefit to quitting smoking that the provider should inform them of?

A. Enhanced taste and smell B. Improved hearing

C. Decreased risk of diabetes mellitus D. Decreased risk of sexually transmitted diseases

Answer: A Feedback: Nicotine is an appetite suppressant, and once its effects have cleared from the body, food will taste better. Individuals who cease smoking report more energy, enhanced taste and smell, monetary savings, freedom from addiction, feeling better about themselves, and better performance in sexual and sports activities.

Chapter: Chapter 33, Smoking Addiction Page: 520 Difficulty: Moderate

44. The barrel chest characteristic of emphysema is a result of A. Chronic coughing B. Hyperinflation C. Polycythemia D. Pulmonary hypertension Answer: B Feedback: Barrel chest results from hyperinflation of emphysematous lungs.

Chapter: Chapter 31, Inflammatory Respiratory Disorders Page: 478 Difficulty: Easy

45. Supplemental oxygen for how many hours per day has been shown to improve the mortality associated with COPD? A. 3 hours B. 6 hours C. 11 hours D. 15 hours Answer: D Feedback: The goal of therapy is to achieve a PaO2 of 60 mm Hg or SaO2 of 90%, which usually can be accomplished with 1 to 2 L of oxygen per minute for 15 hours per day.

Chapter: Chapter 31, Inflammatory Respiratory Disorders Page: 483 Difficulty: Easy

46. Which of these patients should be evaluated with serum alpha-antitrypsin levels?

A. Jamie, a 70-year-old woman with COPD with a history of smoking B. Ron, a 43-year-old man with COPD with a history of smoking C. Leslie, a 60-year-old woman with clinical emphysema and no history of smoking D. Marshall, a 55-year-old man with clinical emphysema and no family history of early-onset COPD Answer: B Feedback: Serum alpha-antitrypsin levels should be checked in patients who develop COPD at an early age (younger than 45 years), those with clinical emphysema who have not smoked, and those with a family history of early-onset COPD. Chapter: Chapter 31, Inflammatory Respiratory Disorders Page: 480 Difficulty: Moderate

47. Which ethnic group has the highest lung cancer incidence and mortality rates?

A. African American men B. Scandinavian men and women C. Western European women D. Asian men

Answer: A Feedback: In every ethnic group, men still have higher lung cancer incidence and mortality rates than women, although women are rapidly closing the gap. Both black men and women are more likely to develop and die of lung cancer than any other racial group, and black men are 30% more likely to have lung cancer than white men.

Chapter: Chapter 32, Lung Cancer Page: 495 Difficulty: Easy

48. A cough expectorant should be given A. At night

B. With minimal water C. When the cough is nonproductive D. To decrease sputum viscosity

Answer: D Feedback: Expectorants are used to decrease sputum viscosity in patients with productive cough. They should be given during the day and with increased water consumption.

Chapter: Chapter 28, Common Respiratory Complaints Page: 419 Difficulty: Easy

49. Sleep apnea is diagnosed in a patient with comorbid conditions of sleepiness during the day and hypertension with an apnea-hypopnea index (AHI) of: A. 10 B. 3 C. 15 D. 0

Answer: A Feedback: Sleep apnea is diagnosed in a patient with AHI greater than or equal to 5 and less than 14, if comorbid factors such as excessive daytime sleepiness, hypertension, stroke, or heart failure are present or with AHI greater than or equal to 15 in the absence of comorbid factors.

Chapter: Chapter 29, Sleep Apnea Page: 423 Difficulty: Moderate

50. A patient with advanced COPD in which bronchitis predominates presents with edema and cyanosis. Which is the most likely differential diagnosis?

A. Hyperinflation of the lungs B. Pneumonia C. Pulmonary hypertension D. Heart failure

Answer: C Feedback: With advanced COPD in which bronchitis predominates, pulmonary hypertension may result from chronic alveolar hypoxia, and cor pulmonale develops. These patients often present with edema and cyanosis.

Chapter: Chapter 31, Inflammatory Respiratory Disorders Page: 478 Difficulty: Moderate

Section 6. Cardiovascular Problems

MULTIPLE CHOICE

1. Which patient is a candidate for statins?

A. Jerry is a 55-year-old man with a history of syncope.

B. Christa is a 65-year-old woman with a history of myocardial infarction (MI).

C. Manny is a 75-year-old man with a 10-year cardiovascular risk of 6.5%.

D. April is an 80-year-old woman with a low-density lipoprotein (LDL) level of 180.

Answer: B Feedback: A patient is a potential candidate for statin therapy if they have a history of MI, an LDL level greater than or equal to 190 mg/dL, are 40 to 75 years of age with diabetes mellitus

(DM), or are 40 to 75 years of age with a 10-year cardiovascular risk of greater than or equal to 7.5%.

Chapter: Chapter 35, Cardiac and Associated Risk Disorders Page: 545 Difficulty: Moderate

2. Which of the following is a chest wall syndrome?

A. MI B. Angina C. Costochondritis D. Pericarditis Answer: C Feedback: Costochondritis is a musculoskeletal problem due to nonspecific inflammation of the articular joints of the chest wall.

Chapter: Chapter 35, Cardiac and Associated Risk Disorders Page: 549 Difficulty: Easy

3. Which of the following may help a clinician determine whether palpitations are caused by a potentially lethal cardiac rhythm?

A. Holter monitoring B. CBC C. Thyroid panel D. CAT scan Answer: A Feedback: Ambulatory cardiac monitoring (Holter monitoring) done until at least one event is recorded is most helpful in ascertaining the presence of a potentially lethal cardiac rhythm disturbance.

Chapter: Chapter 34, Common Cardiovascular Complaints Page: 524 Difficulty: Easy

4. A blood pressure (BP) of 150/90 is considered A. Stage 2 hypertension B. Hypertensive C. Normal in healthy older adults D. Acceptable if the patient has DM Answer: A Feedback: Systolic BP greater than or equal to 140 or diastolic BP greater than or equal to 90 is considered stage 2 hypertension.

Chapter: Chapter 35, Cardiac and Associated Risk Disorders Page: 533 Difficulty: Moderate

5. Lifestyle modifications to manage hypertension (HTN) include A. Maintaining a body mass index (BMI) of 17 B. Restricting dietary sodium to 5 grams per day C. Engaging in exercise or physical activity for 90 minutes a day D. Limiting beer intake to 24 ounces per day Answer: D Feedback: Lifestyle modifications to manage HTN include limiting alcohol consumption to no more than two drinks (1 oz or 30 mL of ethanol, e.g., 24 oz of beer, 10 oz of wine, or 3 oz of 80-proof whiskey) per day for most men and to no more than one drink per day for women and lighter-weight persons (lowers BP by 2 to 4 mm Hg). Sodium should not exceed 2.4 g per day, 30 minutes per day of exercise is recommended, and BMI 18.4 to 24.9 is ideal.

Chapter: Chapter 35, Cardiac and Associated Risk Disorders Page: 535 Difficulty: Moderate

6. Which hypertensive drug has been shown to reduce stroke?

A. Chlorthalidone B. Metoprolol C. Amlodipine D. Losartan Answer: A Feedback: Use of thiazide-type diuretics has been shown to reduce stroke and cardiovascular-related mortality and morbidity. Chlorthalidone 12.5 to 25 mg per day is the recommended first-line thiazide diuretic drug.

Chapter: Chapter 35, Cardiac and Associated Risk Disorders Page: 537 Difficulty: Moderate

7. Which high-density lipoprotein (HDL) level is considered cardioprotective?

A. Greater than 30 B. Greater than 40 C. Greater than 50 D. Greater than 60 Answer: D Feedback: A low HDL level (40 mg/dL or less) is considered a cardiovascular risk factor, whereas a high level of HDL-C (60 mg/dL or more) is considered cardioprotective.

Chapter: Chapter 35, Cardiac and Associated Risk Disorders Page: 543 Difficulty: Easy

8. Which parameter is indicative of metabolic syndrome in women?

A. Waist is 36 inches.

B. Triglyceride level is 140 mg/dL. C. BP is 128/84.

D. Fasting blood sugar (BS) is 108 mg/dL. Answer: A Feedback: Waist circumference over 35 inches is a risk factor for women with metabolic syndrome.

Chapter: Chapter 35, Cardiac and Associated Risk Disorders Page: 531 Difficulty: Moderate

9. Which type of angina do you suspect in a patient who complains of chest pain that occurs during sleep and most often in the early morning hours?

A. Stable angina B. Unstable angina C. Variant (Prinzmetal‘s angina) D. Probably not angina but hiatal hernia Answer: C Feedback: Chest pain that is cyclical and that often occurs during sleep (most common in the early morning hours) is a characteristic of variant (Prinzmetal‘s angina).

Chapter: Chapter 35, Cardiac and Associated Risk Disorders Page: 554 Difficulty: Moderate

10. Which of these patients is at a higher risk for developing deep vein thrombosis (DVT)?

A. Jerry, a 64-year-old man with a history of epilepsy B. Samantha, a 45-year-old woman undergoing a hysterectomy C. Diane, a 15-year-old woman with type 1 diabetes D. Ben, a 23-year-old man with a history of a pneumothorax Answer: B Feedback: Patients undergoing various types of surgical procedures, such as orthopedic, gynecological-obstetrical, urological, neurosurgical, and general surgical procedures, are at high risk for developing DVT and pulmonary embolism (PE).

Chapter: Chapter 37, Disorders of the Vascular System Page: 597

Difficulty: Moderate

11. A patient reports that their left leg is cool, pale, smaller than the right, and has thick toenails. Which condition may they be experiencing?

A. Peripheral artery disease B. Anemia C. Deep vein thrombosis D. PE Answer: A Feedback: With peripheral artery disease, the affected limb may be smaller as a result of muscular atrophy. The extremity may be cool and pale, and the toenails will be thickened with cornlike material (dead skin callus) under the nails.

Chapter: Chapter 37, Disorders of the Vascular System Page: 595 Difficulty: Moderate

12. In which type of arterioventricular (AV) block does the pulse rate (PR) interval lengthen until a beat is dropped?

A. First-degree AV block B. Second-degree Mobitz I AV block C. Second-degree Mobitz II AV block D. Third-degree AV block Answer: B Feedback: Mobitz type I blocks occur in the AV nodal area, with progressive lengthening of the P-R interval until a QRS complex (ventricular contraction) is dropped (missing on ECG) completely.

Chapter: Chapter 36, Arrhythmias and Valvular Disorders Page: 576 Difficulty: Difficult

13. What is the term for light-headedness, feeling faint, and muscular weakness with a cardiovascular origin?

A. Presyncope B. Vertigo C. Dizziness D. MI Answer: A Feedback: Presyncope is a state of lightheadedness, feeling faint, and muscular weakness.

Chapter: Chapter 34, Common Cardiovascular Complaints Page: 524

Difficulty: Easy

14. A delta wave on the ECG may be present in which condition?

A. Prinzmetal‘s angina B. Bundle branch block C. Wolff-Parkinson-White syndrome (WPW) D. Aortic stenosis Answer: C Feedback: A delta wave may be present in WPW syndrome.

Chapter: Chapter 36, Arrhythmias and Valvular Disorders Page: 580 Difficulty: Easy

15. Which heart sound is associated with decreased elasticity of the left ventricle in left ventricular hypertrophy (LVH)?

A. A physiologic split S2 B. A fixed split S2 C. S3 D. S4 Answer: D Feedback: Auscultation of an S4 heart sound is associated with the decreased elasticity of the left ventricle that occurs in LVH. Chapter: Chapter 35, Cardiac and Associated Risk Disorders Page: 533 Difficulty: Easy

16. A patient who goes to the dentist and must take endocarditis prophylaxis must do so because of a history of A. Severe asthma B. A common valvular lesion C. Severe hypertension D. A prosthetic heart valve Answer: D Feedback: Antibiotic prophylaxis is recommended for high-risk patients with prosthetic heart valves.

Chapter: Chapter 36, Arrhythmias and Valvular Disorders Page: 588 Difficulty: Moderate

17. Data from the Framingham Heart Study suggest that individuals who are normotensive at 55 years of age have how much lifetime risk of developing HTN? A. 65% B. 75% C. 80% D. 90% Answer: D Feedback: Data from the Framingham Heart Study suggest that even individuals who are normotensive at 55 years of age still have a 90% lifetime risk of developing HTN. Chapter: Chapter 35, Cardiac and Associated Risk Disorders Page: 529 Difficulty: Easy

18. Which pain characteristic is usually indicative of angina pectoris?

A. Fleeting B. Moving C. Diffuse D. Localized Answer: C Feedback: The discomfort of angina pectoris is classically described as a diffuse, retrosternal sensation of pain, often with radiation, and a heavy, burning sensation, usually lasting more than 1 minute but less than 10 minutes.

Chapter: Chapter 34, Common Cardiovascular Complaints Page: 523 Difficulty: Easy

19. Which of the following is the proper way to take a BP measurement?

A. Patient is in a reverse Trendelenburg position, cuff size has a bladder length of 80% and a width of 40% of arm circumference, patient has rested for 5 minutes before measurement.

B. Patient is in a sitting position, cuff size has a bladder length of 80% and a width of 40% of arm circumference, patient has rested for 5 minutes before measurement.

C. Patient is in a sitting position, cuff size has a bladder length of 80% and a width of 40% of arm circumference, patient has rested for 3 minutes before measurement.

D. Patient is in a reverse Trendelenburg position, cuff size has a bladder length of 70% and a width of 30% of arm circumference, patient has rested for 5 minutes before measurement.

Answer: B Feedback: The proper technique for BP measurement includes: cuff size has a bladder length of 80% and a width of at least 40% of arm circumference; patient in a sitting position, arm resting at level of the heart with feet on flat surface and legs uncrossed; and rest for 5 minutes before measurement.

Chapter: Chapter 35, Cardiac and Associated Risk Disorders

Page: 534 Difficulty: Easy

20. Which of the following patient complaints indicates palpitations are due to increased catecholamine production?

A. ―I feel like my heart is pounding out of my chest and I have been sitting for an hour.‖ B. ―I feel like my heart is in a vice and I can‘t breathe.‖ C. ―I feel like my heart is beating strongly after I just worked out.‖ D. ―I feel like my heart is skipping beats.‖ Answer: C Feedback: If the patient reports a sensation of a strong but regular rhythmic beating of the heart after stress or exertion, this likely indicates a normal physiological response to increased catecholamine production.

Chapter: Chapter 34, Common Cardiovascular Complaints Page: 523 Difficulty: Moderate

21. What is the most common presenting complaint in heart failure?

A. Weight loss B. Palpitations C. Syncope D. Dyspnea Answer: D Feedback: Dyspnea, or shortness of breath, is a highly subjective complaint, yet it is one of the most common cardiac symptoms.

Chapter: Chapter 34, Common Cardiovascular Complaints Page: 524 Difficulty: Easy

22. Which of the following is true of peripheral edema?

A. It is always independent of underlying disorders.

B. Peripheral edema occurs more frequently in men than in women.

C. When it involves the lower extremities, it may be caused by cardiac conditions.

D. It is the accumulation of tissue fluid within organ systems.

Answer: C Feedback: When peripheral edema involves the lower extremities, it is a symptom of an underlying disorder and may be caused by cardiac conditions, renal or hepatic disease, trauma, tumors, or inflammation.

Chapter: Chapter 34, Common Cardiovascular Complaints Page: 526

Difficulty: Easy

23. Nitroglycerine (NTG) is given for a patient having ischemic chest pain. One tablet or one spray should be used under the tongue every 5 minutes for three doses. What should be done if the pain has not been relieved after three doses?

A. 911 should be called, and the patient should be transported immediately to the emergency department.

B. One more dose of NTG may be tried.

C. The person should be given two aspirin to chew.

D. A portable defibrillator should be located to ascertain the cardiac rhythm.

Answer: A Feedback: As unstable angina is defined as chest pain of new onset, a progressive nature, or a new pattern, if rest and NTG do not relieve the chest discomfort in typical fashion, the patient must be immediately transported by ambulance to the emergency department for further evaluation and to rule out an MI. Chapter: Chapter 35, Cardiac and Associated Risk Disorders Page: 560 Difficulty: Moderate

24. For the best therapeutic effect after an MI, thrombolytics should be administered within the first 3 hours (ideally 30 minutes) of symptom onset. Studies have shown, however, that thrombolytic therapy can be of benefit up to how many hours after the initial presentation of MI symptoms?

A. 6 hours B. 8 hours C. 10 hours D. 12 hours Answer: D Feedback: For the best therapeutic effect, thrombolytics should be administered within the first 3 hours (ideally 30 minutes) of MI symptom onset, although studies have shown that thrombolytic therapy can be of benefit up to 12 hours after the initial presentation of symptoms of MI. Chapter: Chapter 35, Cardiac and Associated Risk Disorders Page: 562 Difficulty: Easy

25. When teaching post-MI patients about their NTG tablets, the clinician should stress that the tablets should remain in the light-resistant bottle in which they are packaged and should not be put in another pill box or remain in areas that are or could become warm and humid.

Once the bottle is opened, how long can the NTG last?

A. 1 month

B. 3 months C. 6 months D. Up to a year, as long as the tablets are kept in the bottle Answer: C Feedback: NTG tablets should remain in the light-resistant bottle in which they are packaged and not be put in another pillbox or placed in areas that could become warm and/or humid.

Once opened, the bottle must be dated and discarded after 6 months or the medication may decrease in effectiveness.

Chapter: Chapter 35, Cardiac and Associated Risk Disorders Page: 564 Difficulty: Moderate

26. Which of the following is abundant in the heart and rapidly rises in the bloodstream in the presence of heart failure, making it a good diagnostic test?

A. Brain natriuretic peptide B. C-reactive protein C. Serum albumin D. Erythrocyte sedimentation rate Answer: A Feedback: Brain natriuretic peptide is abundant in the heart and rapidly rises in the bloodstream in the presence of heart failure.

Chapter: Chapter 35, Cardiac and Associated Risk Disorders Page: 569 Difficulty: Easy

27. If a PE is suspected, which test should be performed?

A. Ultrasound B. Magnetic resonance imaging (MRI) C. V/Q scan D. D-dimer Answer: C Feedback: If PE is suspected, a ventilation/perfusion (V/Q) scan or a spiral (helical) computed tomography scan of the lungs and pulmonary arterial system would be indicated.

Chapter: Chapter 37, Disorders of the Vascular System Page: 599 Difficulty: Moderate

28. Which of the following doses of statins decrease LDL by up to 50% on average?

A. Pravastatin 40 mg B. Simvastatin 20 mg

C. Atorvastatin 80 mg D. Fluvastatin 40 mg Answer: C Feedback: Atorvastatin (Lipitor) 40 to 80 mg decreases LDL by up to 50% on average.

Chapter: Chapter 35, Cardiac and Associated Risk Disorders Page: 546 Difficulty: Moderate

29. Which of the following can cause hyperlipidemia?

A. High-dose diuretics B. Exercising 30 minutes every day C. Hyperthyroidism D. ARB use Answer: A Feedback: Thiazide diuretic use (high dose) is a potential cause of secondary hyperlipidemia.

Chapter: Chapter 35, Cardiac and Associated Risk Disorders Page: 545 Difficulty: Moderate

30. Which of the following complementary therapies may be helpful if a patient has orthostatic hypotension?

A. Magnesium B. Beta glucan C. Selenium D. Hawthorn Answer: D Feedback: Hawthorn is a complementary therapy for orthostatic hypotension.

Chapter: Chapter 35, Cardiac and Associated Risk Disorders Page: 551 Difficulty: Moderate

31. Which of these murmurs is also called a ―50/50 murmur‖?

A. Aortic sclerosis B. Hemic murmur C. Systolic ejection murmur D. Diastolic murmur Answer: A Feedback: An aortic sclerosis murmur is also called the ―50/50 murmur‖ because it is present in about 50% of adults older than 50 years.

Chapter: Chapter 36, Arrhythmias and Valvular Disorders Page: 588 Difficulty: Easy

32. What value on the ankle-brachial index (ABI) indicates a diagnosis of peripheral artery disease?

A. Less than 0.25 B. Less than 0.50 C. Less than 0.90 D. Greater than 1 Answer: C Feedback: If lower extremity peripheral artery disease is suspected, the ABI, a comparison of ankle blood pressure to arm blood pressure, should be calculated during the Doppler flow study, using a blood pressure cuff. The normal ratio of ankle-to-brachial pressure is more than 0.9.

Chapter: Chapter 37, Disorders of the Vascular System Page: 595 Difficulty: Moderate

33. Your patient with chronic atrial fibrillation asks what other options he has besides warfarin. You tell him A. ―There is a permanent implantable device, but you will have to continue the warfarin when you have it.‖ B. ―We could try dabigatran, but it would require more laboratory monitoring.‖ C. ―Rivaroxaban is a good alternative because it has an established antidote.‖ D. ―Apixaban is an alternative medication because it does not necessitate dose titration.‖ Answer: D Feedback: Apixaban (Eliquis) has been replacing the use of warfarin in patients specifically with nonvalvular atrial fibrillation because it does not require dose adjustments or monitoring with PT/INR. Chapter: Chapter 36, Arrhythmias and Valvular Disorders Page: 584 Difficulty: Moderate

34. After starting a patient on hypertension therapy, the Eighth Joint National Committee recommends that if the BP goal is not reached in which length of time, the initial drug should be increased or a second drug should be added?

A. 1 month B. 3 months C. 6 months D. 1 year

Answer: A Feedback: After the initiation of pharmacological treatment, the BP should be reevaluated within a month. If the target BP is not attained, up-titration of the dose of the current pharmacological agent may be required. Alternatively, the addition of a pharmacological agent from another class may be added at a low starting dose.

Chapter: Chapter 35, Cardiac and Associated Risk Disorders Page: 537 Difficulty: Moderate

35. A 65-year-old Caucasian woman has a history of osteoporosis and new-onset hypertension. Which of the following medications is appropriate as first-line treatment for hypertension?

A. Benazepril B. Hydrochlorothiazide C. Amlodipine D. Clonidine Answer: B Feedback: Hydrochlorothiazide is a first-line diuretic to treat hypertension.

Chapter: Chapter 35, Cardiac and Associated Risk Disorders Page: 538 Difficulty: Moderate

36. Which of the following antihypertensive medications is appropriate for a patient with hypertension who recently suffered an MI? A. Hydrochlorothiazide B. Furosemide C. Spironolactone D. Lisinopril Answer: D Feedback: Lisinopril is effective for patients post-MI. Chapter: Chapter 35, Cardiac and Associated Risk Disorders Page: 539 Difficulty: Moderate

37. The care provider is assessing an ECG electrical axis that shows a negative complex in lead I and a positive complex in aVF. Which type of axis deviation is described?

A. Normal B. Left C. Right D. Extreme right

Answer: C Feedback: Right axis deviation shows a negative complex in lead I and positive complex in aVF. Chapter: Chapter 35, Cardiac and Associated Risk Disorders Page: 558 Difficulty: Moderate

38. Which of the following results might you see in a physical examination of a male patient with hypertension?

A. S2 heart sound B. Distended neck veins C. Rhonchi D. Waist measurement 36 inches Answer: B Feedback: A physical examination of hypertension may show distention of neck veins.

Chapter: Chapter 35, Cardiac and Associated Risk Disorders Page: 534 Difficulty: Moderate

39. In which patient is treatment of premature ventricular contractions (PVCs) unnecessary?

A. Kelly, a 25-year-old woman with an allergy to bee stings B. Mary, a 50-year-old woman with a history of untreated anxiety C. Randy, a 45-year-old man with a history of hypotension D. Bill, a 65-year-old man with a history of angina Answer: A Feedback: Treatment of PVC is usually not needed in healthy adults because many adults experience PVCs with no untoward effects. PVCs may be related to an MI, however, in which case, it must be determined whether the PVCs are caused by a problem with oxygenation, hypotension, electrolyte disturbances, acid–base imbalance, other medications, or an increased catecholamine state from unrelieved ischemic pain or anxiety.

Chapter: Chapter 36, Arrhythmias and Valvular Disorders Page: 585 Difficulty: Moderate

40. What is the most common form of heart disease in a patient with atrial fibrillation?

A. Hypertension B. Rheumatic heart disease C. Angina D. Coronary artery disease (CAD)

Answer: D Feedback: Most patients with atrial fibrillation have some form of heart disease. The most common form is CAD, associated with heart failure.

Chapter: Chapter 36, Arrhythmias and Valvular Disorders Page: 577 Difficulty: Easy

41. Which of the following will help a provider determine whether a patient is experiencing PSVT or VT? A. An obstructed P wave B. Ability to calculate PR interval C. Frog sign D. Chvostek‘s sign Answer: C Feedback: Observation of the neck veins may help the clinician rapidly distinguish between PSVT and VT. During PSVT, the atria contract against closed AV valves, resulting in a rapid, regular expansion of the neck veins (the same mechanism as cannon waves). This physical finding has been called the ―frog sign‖ because the rapid, regular expansion of the neck veins resembles the puffing motion of a frog.

Chapter: Chapter 36, Arrhythmias and Valvular Disorders Page: 582 Difficulty: Moderate

42. Which test will definitively diagnose heart valve disorders?

A. Two-dimensional echocardiogram B. Holter monitor C. Chest x-ray (CXR) D. Cardiac catheterization Answer: A Feedback: Two-dimensional echocardiography is the definitive procedure to diagnose heart valve disorders. Additional diagnostic tests used to detect valvular lesions or structural heart changes include the ECG, CXR, and cardiac catheterization.

Chapter: Chapter 36, Arrhythmias and Valvular Disorders Page: 590 Difficulty: Moderate

43. Left atrial enlargement (LAE) is one of the earliest ECG findings associated with which disorder?

A. MI B. Hypertension C. Heart failure

D. Arrhythmias Answer: B Feedback: LAE is one of the earliest ECG findings associated with hypertension. An echocardiogram is useful to detect the presence of increased left ventricular wall thickness and hypertrophy.

Chapter: Chapter 35, Cardiac and Associated Risk Disorders Page: 535 Difficulty: Difficult

44. Treatment of atrial fibrillation is important because of the risk of stroke. Which medication should be given to slow the AV conduction and control rate to prevent a stroke?

A. Atenolol B. Dabigatran C. Lisinopril D. Warfarin Answer: A Feedback: The risk of stroke is increased in untreated atrial fibrillation after 48 to 72 hours, therefore, it is important to diagnose and treat this arrhythmia in an expeditious manner. A beta blocker or calcium channel blocker should be given to slow AV conduction and control the ventricular rate of atrial fibrillation, and the underlying cause of the arrhythmia should be determined to aid in its successful management.

Chapter: Chapter 36, Arrhythmias and Valvular Disorders Page: 577 Difficulty: Easy

45. The health-care provider is performing an ECG. The ECG shows a prolonged P-R interval with a normal rhythm. What would the health-care provider suspect from this result?

A. An idiojunctional response B. A first-degree AV block C. A second-degree AV block D. Atrial fibrillation Answer: B Feedback: A first-degree AV block is observed with a regular rhythm and only a prolonged P-R interval. A second-degree heart block occurs in the AV nodal area, with progressive lengthening of the P-R interval until a QRS complex (ventricular contraction) is dropped completely.

An idiojunctional response is when an ―escape rhythm‖ mediating independent ventricular contraction emanates from the AV junction and runs antegrade without retrograde conduction to the atria in a third degree heart block. Atrial fibrillation is an irregular heartbeat.

Chapter: Chapter 36, Arrhythmias and Valvular Disorders Page: 579 Difficulty: Moderate

46. When injured myocardial cells depolarize normally but repolarize more rapidly than normal, it causes what on an ECG? A. P waves B. ST segment changes C. PQS intervals D. Q waves Answer. B Feedback: With epicardial injury, injured cells depolarize normally but repolarize more rapidly than normal cells. This causes an elevation of the ST segment in the leads facing the areas of injury.

Chapter: Chapter 35, Cardiac and Associated Risk Disorders Page: 556 Difficulty: Moderate

47. Which test can a health-care provider order to determine and treat the underlying cause of peripheral edema?

A. HBA1C B. Brain MRI C. CXR D. V/Q scan Answer: C Feedback: A CXR film should be ordered to assess the heart and lungs.

Chapter: Chapter 34, Common Cardiovascular Complaints Page: 528 Difficulty: Moderate

48. What is the most common etiology of peripheral arterial deficiency?

A. Heart failure B. Lung cancer C. Atherosclerosis D. DM Answer: C Feedback: Atherosclerosis is the most common etiology of arterial insufficiency. Several other disorders may precipitate lower extremity ischemia, including vasculitis, radiation exposure, arterial wall dissection, and aneurysm.

Chapter: Chapter 37, Disorders of the Vascular System Page: 594 Difficulty: Easy

49. What medication dose is recommended by the American Heart Association (AHA) to treat claudication for a patient with no known heart failure?

A. Lisinopril 10 mg daily B. Cilostazol 100 mg twice daily C. Eliquis 2.5 mg twice a day D. Warfarin 2 mg every other day Answer: B Feedback: Current American College of Cardiology (ACC) and AHA guidelines recommend cilostazol (Pletal) 100 mg twice daily for the treatment of claudication. Cilostazol is a phosphodiesterase-3 inhibitor that causes vasodilation and inhibits platelet aggregation. Cilostazol may be ordered specifically to treat leg pain and cramping due to blockages from atherosclerosis in arteries of the lower extremities. Cilostazol should not be prescribed in patients with heart failure due to prior data indicating that other oral phosphodiesterase inhibitors increase mortality in this population.

Chapter: Chapter 37, Disorders of the Vascular System Page: 596 Difficulty: Moderate

50. A patient with peripheral artery disease and coronary heart disease presents to the emergency room (ER) with complaints of chronic pain, a venous ulcer on the ankle, and swelling to the left leg. P+, the extremity is cool, and Homan‘s sign is negative. What is most likely the cause of the symptoms?

A. Deep vein thrombosis B. Diabetic neuropathy C. Postphlebitic syndrome D. Thrombophlebitis Answer: C Feedback: If a clot lyses (breaks down), it can still cause irreversible valvular damage by allowing blood to reflux in the veins. The damage sets up a cycle of pooling and hypertension known as ―postphlebitic syndrome.‖ Patients with this syndrome experience chronic pain, swelling, and venous ulcers.

Chapter: Chapter 37, Disorders of the Vascular System Page: 598 Difficulty: Difficult

Section 7. Abdominal Problems

MULTIPLE CHOICE

1. A 35-year-old female patient is seen in the clinic complaining of abdominal pain. Which of the following should be included in the examination?

A. Lumbar puncture B. Family history of cardiac problems C. Contrast venography D. Pelvic exam Answer: D Feedback: All patients with abdominal pain should undergo rectal, genital, and pelvic evaluations.

Chapter: Chapter 38, Common Abdominal Complaints Page: 603 Difficulty: Moderate

2. Which of the following is a condition that results in colicky abdominal pain?

A. Peptic ulcers B. Glisson‘s capsule around the liver C. Peritoneum irritation D. Gallstones Answer: D Feedback: Abdominal pain described as colicky, which means that it comes and goes, may result from gallstones or renal stones.

Chapter: Chapter 38, Common Abdominal Complaints Page: 603 Difficulty: Easy

3. A patient comes to the office complaining of constipation. The patient lists all of the following medications. Which drug could be responsible for the constipation?

A. Multivitamin B. Magnesium hydroxide C. Pepto-Bismol D. Ibuprofen Answer: C Feedback: Bismuth-containing drugs such as bismuth subsalicylate (Pepto-Bismol) are medications that commonly cause constipation.

Chapter: Chapter 38, Common Abdominal Complaints Page: 606 Difficulty: Moderate

4. Which of the following is an appropriate strategy to manage constipation?

A. Mildly exercise after breakfast.

B. Triple the amount of fiber in the diet.

C. Drink at least 48 ounces of fluids daily.

D. Immediately begin pharmacological treatment.

Answer: A Feedback: Mild exercise after the morning meal is often helpful in stimulating peristalsis and promoting defecation.

Chapter: Chapter 38, Common Abdominal Complaints Page: 607 Difficulty: Easy

5. A patient is seen with complaints of diarrhea. Which of the following should be included in the patient‘s differential diagnosis?

A. Gastroenteritis B. Recent use of Imodium C. Lack of dietary fiber D. Decreased physical activity Answer: A Feedback: Acute viral gastroenteritis is the most common cause of diarrhea.

Chapter: Chapter 38, Common Abdominal Complaints Page: 610 Difficulty: Moderate

6. A 38-year-old man is 5 feet 8 inches tall and weighs 189 pounds. He reports that he has had intermittent heartburn for several months and takes antacids with temporary relief. He has been waking during the night with a burning sensation in his chest. Which additional information would lead you to believe that gastroesophageal reflux disease (GERD) is the cause of his pain?

A. The pain seems better when he smokes to relieve his nerves.

B. Coffee and fried foods don‘t bother him.

C. He wakes at night coughing with a bad taste in his mouth.

D. He likes to wear tight clothing.

Answer: C Feedback: The most typical symptom of GERD is heartburn, ranging in degree from mild to severe. It is usually associated with other symptoms, including regurgitation, water brash (reflex salivation), dysphagia, sour taste in the mouth in the morning, odynophagia, belching, coughing, hoarseness, or wheezing, usually at night.

Chapter: Chapter 40, Gastric and Intestinal Disorders Page: 642 Difficulty: Moderate

7. A 35-year-old female patient is seen in the clinic in the morning. She reports abrupt onset of nausea, vomiting, colicky abdominal cramps, and profuse watery diarrhea that began last night. Her vitals are: blood pressure (BP): 110/70, HR: 110, temperature: 99°F, RR: 12. She recently came back from a vacation in Switzerland, ate leftovers for dinner last night, and had a cold 2 weeks ago. Which of the following is the most probable cause of her condition?

A. Staphylococcus B. Shigella C. Rotavirus D. Entamoeba histolytica Answer: A Feedback: Abrupt onset of nausea, vomiting, colicky abdominal cramps, and profuse watery diarrhea are signs of staphylococcus.

Chapter: Chapter 39, Infectious Gastrointestinal Disorders Page: 623 Difficulty: Moderate

8. Which of the following patients should be referred to a hepatologist?

A. Patient with persistent elevation of HBsAg B. Patient with anti-HAV IgG C. Patient with IgG anti-HBs D. Patient with anti-HEV Answer: A Feedback: Persistent elevation of HBsAg indicates a chronic state, and these patients should be referred to a hepatologist.

Chapter: Chapter 39, Infectious Gastrointestinal Disorders Page: 635 Difficulty: Moderate

9. A 29-year-old patient is seen in the office with reports of pain in his chest and belly. He quit smoking 6 months ago. He has been suffering the pain for 2 weeks and gets temporary relief from Alka-Seltzer and Pepto-Bismol. The burning pain wakes him at night and radiates up to his chest. Which factor favors a diagnosis of gastric ulcer?

A. His use of Pepto-Bismol B. His age C. His use of Alka-Seltzer D. His smoking cessation Answer: C Feedback: A variety of factors can affect the development of ulcers. Aspirin (Alka-Seltzer) and other NSAIDs decrease the mucosal defense mechanisms by inhibiting prostaglandin synthesis, leaving the area vulnerable to the effects of gastric hydrochloric acid and pepsin.

Chapter: Chapter 40, Gastric and Intestinal Disorders

Page: 645 Difficulty: Moderate

10. Which of the following causes of gastrointestinal bleeding is found in the lower gastrointestinal tract?

A. Erosive esophagitis B. Duodenal ulcer C. Meckel‘s diverticulum D. Gastric ulcer Answer: C Feedback: Meckel‘s diverticulum is found in the lower gastrointestinal tract and is a cause of gastrointestinal bleeding.

Chapter: Chapter 38, Common Abdominal Complaints Page: 614 Difficulty: Easy

11. Which of the following is most effective in diagnosing acute appendicitis?

A. History and physical examination B. Sedimentation rate C. Kidney, ureter, and bladder x-ray D. Complete blood count (CBC) with differentials Answer: A Feedback: The diagnosis of acute appendicitis is made clinically and is based primarily on the patient‘s history and physical examination.

Chapter: Chapter 39, Infectious Gastrointestinal Disorders Page: 637 Difficulty: Easy

12. Which of the following is true of appendicitis?

A. Appendicitis is more common in Asian countries.

B. Family history of appendicitis does not increase a patient‘s risk of having appendicitis.

C. Appendicitis is most common between the ages of 40 and 60.

D. If appendicitis occurs in infants, it is associated with higher morbidity.

Answer: D Feedback: Appendicitis is rare in infants and in older adults and is often associated with higher morbidity within these age groups because of delayed diagnosis and intervention.

Chapter: Chapter 39, Infectious Gastrointestinal Disorders Page: 637 Difficulty: Easy

13. Which of the following is associated with celiac disease (celiac sprue)?

A. Malabsorption B. Constipation C. Rectal bleeding D. Esophageal ulceration Answer: A Feedback: Celiac disease is a malabsorption syndrome related to an immune reaction to gluten in the diet.

Chapter: Chapter 38, Common Abdominal Complaints Page: 607 Difficulty: Easy

14. A 57-year-old woman presents with diffuse abdominal pain. Which of the following statements from the provider is appropriate?

A. ―It does not matter that you feel pain not only in your stomach but also in your shoulder.‖ B. ―Does moving around worsen your pain?‖ C. ―All causes of abdominal pain necessitate a surgical referral.‖ D. ―I noticed on examination that your stomach is rigid, and you stated your pain is quite severe. It is only necessary for a nurse to see you concerning this problem.‖ Answer: B Feedback: The classic presentation of appendicitis begins with the acute onset of mild to severe colicky, epigastric, or periumbilical pain. The pain is often vague at first, but within 12 hours, it usually shifts and localizes over the RLQ and is exacerbated by walking or coughing.

Chapter: Chapter 39, Infectious Gastrointestinal Disorders Page: 637 Difficulty: Difficult

15. A 25-year-old accountant is seen in the clinic complaining of crampy abdominal pain after meals. She is often constipated and takes laxatives, which are followed by a couple of days of diarrhea. She temporarily feels better after a bowel movement. She states she is embarrassed by flatulence and has abdominal distension. She has had no weight loss or blood in her stool.

This problem has gone on for about 6 months. What should the next step be?

A. Obtain a complete history.

B. Order a barium enema.

C. Schedule a Bernstein‘s test.

D. Prescribe a trial of antispasmodics.

Answer: A Feedback: Total patient presentation and a careful history are key when evaluating abdominal pain and determining the severity of the condition. The onset, location, duration, characteris-

tics, any associated/aggravating factors, relieving factors, temporal factors, and severity, as well as what the pain means to the patient, are useful in the diagnostic reasoning.

Chapter: Chapter 38, Common Abdominal Complaints Page: 603 Difficulty: Moderate

16. A 28-year-old patient is seen in the clinic with colicky abdominal pain particularly after meals. She has frequent constipation, flatulence, and abdominal distension. Which of the data make a diagnosis of diverticulitis unlikely?

A. Her age B. Frequent constipation C. Pain after meals D. Colicky abdominal pain Answer: A Feedback: Diverticula are uncommon (less than 20%) in individuals younger than age 40, with the prevalence increasing steadily after that.

Chapter: Chapter 40, Gastric and Intestinal Disorders Page: 662 Difficulty: Moderate

17. A 28-year-old patient is seen with complaints of diarrhea. Which of the following responses to the history questions would help the primary-care provider (PCP) establish the diagnosis of irritable bowel syndrome (IBS)?

A. Feels relief after urination B. Is woken from sleep by pain C. Defecates in the middle of the night D. Has pain precipitated by eating Answer: D Feedback: Food intolerance has been identified as a trigger of symptoms in as many as 89% of patients with IBS. Chapter: Chapter 40, Gastric and Intestinal Disorders Page: 654 Difficulty: Moderate

18. Which of these is one of the most common dietary triggers of IBS? A. Gluten-free items B. Lactose C. Honey D. Meat Answer: B

Feedback: Specific foods reported to cause symptoms are legumes, vegetables, foods containing lactose, foods high in fat, stone fruits, and artificial sweeteners.

Chapter: Chapter 40, Gastric and Intestinal Disorders Page: 654 Difficulty: Easy

19. Which of the following patients has an increased risk of epigastric hernia?

A. Randall, a 45-year-old African American man with chronic obstructive pulmonary disease B. Ana Milena, a 93-year-old Hispanic woman with dyslipidemia C. Taro, a 33-year-old Asian man with hypertension D. Whitney, a 22-year-old Caucasian woman with anemia Answer: A Feedback: Epigastric hernias are much more common in men than in women and are multiple in 25% of the cases. These hernias are more common in men of all ages and in African Americans of either sex.

Chapter: Chapter 40, Gastric and Intestinal Disorders Page: 650 Difficulty: Moderate

20. A 32-year-old Hispanic woman who is 33 weeks pregnant reports that when she wipes after defecation she notices ―a red streak on the toilet paper.‖ Which of the following should be included in the differential diagnosis?

A. Gastric ulcer B. Rectal prolapse C. Diverticulitis D. Irritable bowel syndrome Answer: B Feedback: Internal hemorrhoids most often present with rectal bleeding described as bright red streaks on the toilet paper. The differential diagnosis of hemorrhoids includes polyps, carcinoma of the anus, anorectal fistula, cryptitis, papillitis, or rectal prolapse.

Chapter: Chapter 40, Gastric and Intestinal Disorders Page: 649 Difficulty: Moderate

21. A patient is diagnosed with GERD, and the endoscopic report reveals the presence of Barrett‘s epithelium. Which of the following would the PCP include in the explanation of the pathology report?

A. This is not premalignant tissue.

B. This tissue is not resistant to gastric acid.

C. This tissue supports healing of the esophagus.

D. This tissue does not have an increased risk of developing esophageal adenocarcinoma.

Answer: C Feedback: Barrett‘s epithelium is more resistant to acid, and therefore it supports esophageal healing.

Chapter: Chapter 40, Gastric and Intestinal Disorders Page: 642 Difficulty: Moderate

22. Which of the following dietary instructions should be given to a patient with GERD? A. Eliminate coffee.

B. Drink hot fluids to relieve stomach distress.

C. Recline and rest after meals.

D. Increase the amount of spicy foods.

Answer: A Feedback: Factors that precipitate or worsen the symptoms, such as reclining after eating; eating a large meal; ingesting alcohol, chocolate, caffeine, fatty or spicy foods, or nicotine; wearing constrictive clothing; or working in an occupation that involves heavy lifting, straining, or working in a bent-over position, also help establish the diagnosis of GERD. Chapter: Chapter 40, Gastric and Intestinal Disorders Page: 642 Difficulty: Moderate

23. After typical groin hernia surgery, the patient should be instructed to A. Avoid work for 3 weeks.

B. Stay in the hospital for 2 weeks.

C. Avoid heavy lifting for 4 to 6 weeks.

D. Return to normal activities after 1 month.

Answer: C Feedback: After typical groin surgery, the patient can return to normal activities, including work, after about 1 week but is instructed to avoid heavy lifting or contact sports for at least 4 to 6 weeks.

Chapter: Chapter 40, Gastric and Intestinal Disorders Page: 653 Difficulty: Moderate

24. A patient is diagnosed with giardia after a backpacking trip in the mountains. Which of the following would be an appropriate treatment?

A. Vancomycin B. Penicillin C. Metronidazole D. Bactrim

Answer: C Feedback: Treatment for giardia may include metronidazole (Flagyl) 250 mg three times daily for 5 to 7 days.

Chapter: Chapter 39, Infectious Gastrointestinal Disorders Page: 624 Difficulty: Moderate

25. A 22-year-old is seen reporting vague belly pain. This type of pain is seen at what point in appendicitis?

A. Very early B. 3 to 4 hours after perforation C. Late in inflammation D. Appendicitis never presents with vague pain Answer: A Feedback: The classic presentation of appendicitis begins with the acute onset of mild to severe colicky, epigastric, or periumbilical pain. The pain is often vague at first, but within 12 hours, it usually shifts and localizes over the RLQ and is exacerbated by walking or coughing.

Chapter: Chapter 39, Infectious Gastrointestinal Disorders Page: 637 Difficulty: Moderate

26. The nurse practitioner (NP) suspects a patient has a peptic ulcer. Which of the following items on the history would lead the NP to this conclusion?

A. Use of fish oil vitamin B. Ethanol avoidance C. Cigarette smoking D. Prednisone use Answer: C Feedback: Genetics, blood type, personality type, and cigarette smoking may play a role in the development of peptic ulcer disease.

Chapter: Chapter 40, Gastric and Intestinal Disorders Page: 645 Difficulty: Moderate

27. A 30-year-old biracial Asian and Caucasian woman who has never been pregnant presents at the clinic. Her body mass index (BMI) is 22, and her history includes anemia, epilepsy, and bee sting allergy. Which of the following parts of her patient history would increase her risk of cholelithiasis?

A. Nulliparity B. Bee-sting allergy

C. BMI 22 D. Female gender Answer: D Feedback: Women are at a higher risk for cholelithiasis.

Chapter: Chapter 41, Gallbladder and Pancreatic Disorders Page: 679 Difficulty: Moderate

28. A patient is seen in the clinic with right upper quadrant pain that is radiating to the middle of the back. The NP suspects acute cholelithiasis. The NP should expect which of the following laboratory findings?

A. Decreased alanine aminotransferase B. Elevated alkaline phosphatase C. Decreased indirect bilirubin D. Decreased white blood cells Answer: B Feedback: Alkaline phosphatase is elevated two to four times greater than normal levels in patients diagnosed with cholelithiasis.

Chapter: Chapter 41, Gallbladder and Pancreatic Disorders Page: 680 Difficulty: Moderate

29. Which of the following are included in the Ranson‘s criteria for assessing the severity of pancreatitis at the time of diagnosis?

A. Blood glucose 180 mg/dL B. Age 45 years old and older C. Base deficit greater than 4 mEq/L D. Serum LDH greater than 25 IU/L Answer: C Feedback: Ranson‘s criteria for assessing the severity of pancreatitis includes a base deficit greater than 4 mEq/L at admission or at time of diagnosis.

Chapter: Chapter 41, Gallbladder and Pancreatic Disorders Page: 683 Difficulty: Moderate

30. A 36-year-old African American woman has chronic pancreatitis. Which of the following is necessary to manage her condition?

A. One alcoholic drink a week maximum B. NSAIDs, which are the only analgesic appropriate for pain relief C. Treatment of serum glucose levels of 200 to 250 mg/dL

D. A low-fat diet of less than 50 g of fat per day Answer: D Feedback: For patients diagnosed with chronic pancreatitis, malabsorption is managed with a low-fat diet (less than 50 g/day).

Chapter: Chapter 41, Gallbladder and Pancreatic Disorders Page: 687 Difficulty: Moderate

31. Which of the following diagnostic tests is ordered for a cecal volvulus bowel obstruction?

A. Barium enema B. Colonoscopy C. Endoscopy D. Magnetic resonance imaging (MRI) Answer: A Feedback: For both cecal and sigmoidal volvulus, a barium enema is done to reveal the precise location of the obstruction.

Chapter: Chapter 40, Gastric and Intestinal Disorders Page: 661 Difficulty: Easy

32. Which of the following is part of the treatment plan for the patient with IBS? A. High fiber diet B. A discussion in which it is said that the goal of treatment is to cure their disease C. Daily laxatives D. A conversation about their expected shorter life span Answer: A Feedback: Patients with IBS are encouraged to increase their fiber intake to 25 to 30 g per day.

Chapter: Chapter 40, Gastric and Intestinal Disorders Page: 657 Difficulty: Easy

33. A 35-year-old Caucasian woman presents with weakness, anorexia, weight loss, and fatigue. Her history is significant for inflammatory bowel disease (IBD), Hashimoto‘s thyroiditis, and cigarette smoking. Which of the following piece of her history leads the clinician to believe she has primary sclerosing cholangitis?

A. Age B. Gender C. IBD D. Smoker

Answer: C Feedback: Liver function tests may be helpful in screening for primary sclerosing cholangitis and other liver problems associated with IBD. Chapter: Chapter 40, Gastric and Intestinal Disorders Page: 667 Difficulty: Moderate

34. What would you instruct a patient with Wilson‘s disease in regard to their diet?

A. Avoid calcium-containing foods.

B. Increase protein intake with peanut butter.

C. Limit shrimp intake.

D. Increase iron intake by eating liver.

Answer: C Feedback: Patients diagnosed with Wilson‘s disease should be instructed to consume a low-iron diet that eliminates foods such as red meat, and they should avoid alcohol, vitamin C, raw shellfish, and any supplement containing iron.

Chapter: Chapter 42, Cirrhosis and Liver Failure Page: 698 Difficulty: Moderate

35. A male patient has cirrhosis and now presents with altered mental status after increasing protein intake because he was trying to increase muscle mass. Which of the following diseases would the clinician be concerned about?

A. Hepatopulmonary syndrome B. Hepatic encephalopathy C. Hepatorenal syndrome D. Spontaneous bacterial peritonitis Answer: B

Feedback: The diagnosis of hepatic encephalopathy is made clinically and often follows an event such as increased dietary protein. Physical examination findings include an altered mental status such as personality (mood) changes, decreased reaction time, and intellectual deterioration.

Chapter: Chapter 42, Cirrhosis and Liver Failure Page: 697 Difficulty: Moderate

36. What instruction would be given to a patient following a hernia repair?

A. Heat can be used for swelling.

B. Ecchymosis needs immediate attention.

C. If pain persists after a few days, see your PCP. D. Take aspirin for pain.

Answer: C Feedback: Pain that persists for more than a few days after hernia repair suggests impending wound infection. Analgesics can be taken for pain, ice is used for swelling, and ecchymosis is expected after surgery.

Chapter: Chapter 40, Gastric and Intestinal Disorders Page: 653 Difficulty: Moderate

37. Steatohepatitis is a reversible condition caused by A. Inflammation B. Hepatitis C. Liver cancer D. Gallstones Answer: A Feedback: Fatty liver is a reversible condition where large vacuoles of triglycerides accumulate in the hepatocytes. The accumulation of fat in the liver causes an inflammatory reaction in the liver called ―steatohepatitis,‖ which is a precursor to cirrhosis.

Chapter: Chapter 42, Cirrhosis and Lover Failure Page: 690 Difficulty: Moderate

38. Depleting iron stores through weekly phlebotomies is performed for what disorder?

A. Chronic cirrhosis B. Precirrhosis hemochromatosis C. Stage 3 liver cancer D. Wilson‘s disease Answer: B Feedback: If treatment is initiated before cirrhosis ensues, hemochromatosis can be controlled with weekly phlebotomies of 1 unit (500 mL) of blood, which contains approximately 250 mg of iron.

Chapter: Chapter 42, Cirrhosis and Liver Failure Page: 697 Difficulty: Moderate

39. Ascites related to hepatic congestion is initially treated with A. Paracentesis B. Sodium restriction C. Fluid restriction

D. Antihypertensives Answer: B Feedback: Ascites is initially managed with sodium restriction and diuretics; however, over time this is usually ineffective, and most patients will require large-volume paracentesis or shunting for symptomatic relief.

Chapter: Chapter 42, Cirrhosis and Liver Failure Page: 698 Difficulty: Moderate

40. A patient with acute cholelithiasis has been rehydrating and is on gastrointestinal (GI) rest.

He is not a surgical candidate. The patient starts to vomit, and his mild case becomes more severe. What would the next step in treatment be?

A. Ceftriaxone B. Ibuprofen C. Bile salts D. Ciprofloxacin Answer: D Feedback: Management of acute cholecystitis includes rehydration with IV fluids, antibiotics, analgesics, and GI rest. If vomiting is persistent, a nasogastric tube is inserted. A second or third generation cephalosporin (i.e., ceftriaxone 1 g IV every 24 hours) is started once the diagnosis is made. If the patient has a severe case or is septic, then a fluoroquinolone (ciprofloxacin 400 mg IV every 12 hours) plus metronidazole should be added to the antibiotic coverage.

Chapter: Chapter 41, Gallbladder and Pancreatic Disorder Page: 681 Difficulty: Moderate

Section 8. Renal Problems

MULTIPLE CHOICE

1. A patient is seen in the clinic with a chief complaint of hematuria. To make a differential diagnosis, which of the following questions should be asked?

A. ―Do you have a history of liver disease?‖ B. ―What medications are you currently taking?‖ C. ―Have you noticed swelling in your ankles?‖ D. ―Do you have an autoimmune condition?‖ Answer: B

Feedback: The patient‘s drug and food intake history should be assessed to rule out these substances as causative agents. The drugs involved may be prescribed, over the counter, herbal or vitamin supplements, or recreational in nature.

Chapter: Chapter 43, Common Urinary Complaints Page: 703 Difficulty: Moderate

2. The result of the patient‘s 24-hour urine for protein was 4.2 g/day. The clinician should take which of the following actions?

A. Repeat the test.

B. Refer to a nephrologist.

C. Measure the serum protein.

D. Obtain a blood urea nitrogen (BUN) and creatinine.

Answer: B Feedback: Persistent proteinuria that is not classified as functional proteinuria requires a further workup, beginning with a 24-hour measurement of urine protein and creatinine levels. If the excretion rate is more than 3.0 to 3.5 g per day, the patient by definition has nephrotic syndrome and must be referred to a nephrologist.

Chapter: Chapter 43, Common Urinary Complaints Page: 703 Difficulty: Moderate

3. The health-care provider is speaking with a female patient who has urinary incontinence.

She has had this condition for a number of years, she is 5 feet 5 inches, and she weighs 140 pounds. Which of the following should the health-care provider be aware of?

A. It is uncommon that women have this condition.

B. Most patients should wait 3 months for follow-up after diagnosis.

C. Because she has a regular body mass index, she probably has a positive body image.

D. The patient may be suffering from depression and may need a psychiatric consult.

Answer: D Feedback: There seems to be a strong association between urinary incontinence and major depression.

Chapter: Chapter 44, Urinary Tract Disorders Page: 706 Difficulty: Moderate

4. A patient is seen in the clinic with hematuria confirmed on microscopic examination. The clinician should inquire about the ingestion of which of these substances that might be the cause of hematuria?

A. NSAIDs B. Rhubarb

C. Vitamin A D. Red meat Answer: A Feedback: Beta lactam antibiotics, sulfonamides, NSAIDs, rifampin, ciprofloxacin, allopurinol, cimetidine, and phenytoin can all cause nephritis, which can result in destruction of nephrons and subsequently lead to impaired renal function and hematuria.

Chapter: Chapter 43, Common Urinary Complaints Page: 703 Difficulty: Moderate

5. A 27-year-old woman presents with a chief complaint of burning and pain on urination. She has no previous history of urinary tract infection (UTI). What are some additional symptoms consistent with a diagnosis of lower UTI? A. Thick green discharge B. Fever, chills, costovertebral angle (CVA) tenderness C. Blood in urine and frequency D. Foul-smelling discharge, perineal itch Answer: C Feedback: The most frequently reported symptoms of lower UTI in both male and female patients are dysuria, urinary frequency or urgency, nocturia, hematuria, low back or suprapubic pain, UI, and cloudy, foul-smelling urine.

Chapter: Chapter 44, Urinary Tract Disorders Page: 715 Difficulty: Moderate

6. Which of the following patients is most likely to have urge incontinence?

A. Mary, a 35-year-old woman with a history of four vaginal deliveries B. Devon, a 40-year-old man with a history of multiple sclerosis C. Dan, a 67-year-old man with a history of diabetes mellitus D. Cheryl, a 95-year-old woman who takes Norpace daily Answer: B Feedback: Urge incontinence can be caused by UTI; vaginitis; bladder stones; bladder tumors; prostate problems; stroke; dementia; multiple sclerosis; Parkinson‘s disease; spinal cord transection; cortical, subcortical, or suprasacral central nervous system (CNS) lesions; and medications such as diuretics and narcotics.

Chapter: Chapter 44, Urinary Tract Disorders Page: 708 Difficulty: Moderate

7. A 30-year-old patient presents with pain on urination. The urine microscopy of clean catch urine shows greater than 10 leukocytes/mL, and a dipstick is positive for nitrites. What is the probable diagnosis?

A. Lower UTI B. Chlamydia infection C. Candidiasis D. Pyelonephritis Answer: A Feedback: Findings on urinalysis that are associated with lower UTI include cloudy appearance; alkaline pH; hematuria; elevated levels of nitrites; leukocyte esterase (detecting pyuria of greater than 10 leukocytes per high power field [hpf]); bacterial overgrowth; and urinary sediments of red blood cells (RBCs), white blood cells (WBCs), and mucus.

Chapter: Chapter 44, Urinary Tract Disorders Page: 716 Difficulty: Moderate

8. A patient presents with CVA tenderness and a several-day history of high fever, chills, and dysuria. Which of the following diagnoses is most likely given the above information?

A. Pyelonephritis B. Cystitis C. Renal calculi D. Bladder tumor Answer: A Feedback: Patients with upper UTI usually show signs of sepsis such as fever and chills, have WBC casts in the urine (reflecting the passage of neutrophils through the renal tubules), or experience flank and CVA tenderness on examination characteristic of pyelonephritis.

Chapter: Chapter 44, Urinary Tract Disorders Page: 716 Difficulty: Moderate

9. Which of the following Macrobid doses is appropriate to treat a lower UTI? A. 200 mg bid × 14 days B. 100 mg bid × 5 days C. 500 mg daily × 8 days D. 800 mg daily × 2 days Answer: B Feedback: 100 mg two times daily × 5 to 7 days of Macrobid is an appropriate dose to treat a lower UTI. Chapter: Chapter 44, Urinary Tract Disorders Page: 717 Difficulty: Moderate

10. A patient is seen in the office complaining of severe flank pain and hematuria. The clinician should assess this patient for which risk factor for poststreptococcal glomerulonephritis?

A. Hypertension B. Constipation C. Tubal ligation D. Diabetes Answer: A Feedback: Hematuria accompanied by hypertension, edema, and a sore throat or a skin infection may be indicative of poststreptococcal glomerulonephritis.

Chapter: Chapter 43, Common Urinary Complaints Page: 722 Difficulty: Moderate

11. A patient is diagnosed with urge incontinence. Before prescribing Detrol LA, the provider should question the patient about which of these contraindications to this medication?

A. Diarrhea B. Parkinson‘s disease C. Closed-angle glaucoma D. Breast cancer Answer: C Feedback: Closed-angle glaucoma is a contraindication to prescribing Detrol LA. Chapter: Chapter 44, Urinary Tract Disorders Page: 711 Difficulty: Moderate

12. A female patient is diagnosed with overactive bladder (OAB). Which of the following instructions should be given to this woman?

A. ―Limit the amount of water that you drink.‖ B. ―Eliminate caffeine from your diet.‖ C. ―Wear panty liners.‖ D. ―Don‘t attempt pregnancy.‖ Answer: B Feedback: OAB is caused by many factors, including disorders of the lower urinary tract, ingestion of alcohol or caffeine, use of a variety of prescribed drugs, and neurological conditions.

Chapter: Chapter 44, Urinary Tract Disorders Page: 712 Difficulty: Moderate

13. A 34-year-old patient was treated for a UTI and has not responded to antibiotic therapy.

Which of the following actions should be taken next?

A. Send a urine specimen for microscopy and evaluate for fungal colonies.

B. Increase the dose of antibiotic.

C. Order a cystoscopy.

D. Order a different antibiotic.

Answer: A Feedback: Fungi, particularly Candida species, may also be causative agents in a complicated UTI that fails to respond to antibiotic therapy, especially in the presence of an indwelling catheter. Candiduria may be asymptomatic, and fungal structures should be sought on urine microscopy because fungal colonies may be more difficult to elaborate under standard urine culture conditions, in turn leading to delays in treatment.

Chapter: Chapter 44, Urinary Tract Disorders Page: 715 Difficulty: Moderate

14. Which of the following are predisposing factors for pyelonephritis?

A. Pregnancy B. Dehydration C. Smoking D. Alkaline urine Answer: A Feedback: The incidence and risk of developing pyelonephritis are increased in patients with predisposing factors, including anatomical abnormalities such as ureterovesical reflux, urinary obstruction, stress incontinence, multiple or recurrent UTIs, renal disease, kidney trauma, pregnancy, prostatic enlargement, and metabolic disorders such as diabetes mellitus.

Chapter: Chapter 44, Urinary Tract Disorders Page: 721 Difficulty: Easy

15. Which of the following types of proteinuria is associated with Hodgkin‘s disease?

A. Tamm-Horsfall proteinuria B. Tubulointerstitial area involvement C. Altered glomerular capillary permeability D. Bence Jones proteinuria Answer: D Feedback: Bence Jones proteinuria may be associated with Hodgkin‘s disease.

Chapter: Chapter 43, Common Urinary Complaints Page: 704 Difficulty: Easy

16. When proteinuria is detected in a low-risk patient with no previous diagnosis, which laboratory testing should be ordered in addition to Bence Jones proteins?

A. Serum nonfasting glucose B. Lipid panel C. Hemoglobinopathy D. CSF lumbar puncture Answer: B Feedback: When proteinuria is identified in a low-risk (nondiabetic or nonpregnant) patient, the urine should be tested for Bence Jones proteins via electrophoresis, the presence of which suggests multiple myeloma. In addition, a full serum chemistry panel should be done, including a fasting blood sugar, a lipid profile, urine culture and sensitivity, and a complete blood count with differential.

Chapter: Chapter 43, Common Urinary Complaints Page: 705 Difficulty: Moderate

17. A 27-year-old patient comes to the clinic reporting red-tinged urine. The clinician performs a urine dipstick and finds that the protein is 2+. Which of the following from the patient‘s history is related to this finding?

A. He is training for a marathon.

B. He recently broke a toe.

C. He began taking Lexapro 2 weeks ago.

D. He works in an office setting.

Answer: A Feedback: The age, sex, and activity level of the patient with hematuria should be considered during the assessment. For example, long-distance runners and other athletes can have rates of hematuria as high as 18%.

Chapter: Chapter 43, Common Urinary Complaints Page: 702 Difficulty: Moderate

18. Which of the following is true regarding the cause of isolated hematuria?

A. It is usually caused by anemia.

B. It can be due to bleeding in the urethra.

C. It can be due to hemoglobinopathies.

D. It is usually due to sickle cell disease.

Answer: B Feedback: Isolated hematuria may be due to bleeding anywhere from the renal pelvis to the urethra.

Chapter: Chapter 43, Common Urinary Complaints

Page: 703 Difficulty: Easy

19. Which of the following medications may be linked to dysuria?

A. Vitamin A B. Mirena C. Paxil D. Gabapentin Answer: C Feedback: Selective serotonin reuptake inhibitors such as citalopram (Celexa), escitalopram (Lexapro), paroxetine (Paxil), fluoxetine (Prozac), and sertraline (Zoloft) may cause dysuria.

Chapter: Chapter 43, Common Urinary Complaints Page: 701 Difficulty: Easy

20. A 42-year-old woman is seen in the clinic with fever, chills, vomiting, and severe dysuria.

She is diagnosed with acute pyelonephritis. How should this patient be managed?

A. 3-day course of oral antibiotics B. Hospitalization C. Encouragement of cranberry juice intake D. 6-week course of antibiotics Answer: B Feedback: Hospitalization may be indicated, depending on the patient‘s ability to maintain adequate fluid intake and to tolerate oral antibiotics, along with the severity of the symptoms and evidence of bacteremia. Hospitalization of patients who are pregnant, vomiting, or dehydrated should be strongly considered.

Chapter: Chapter 44, Urinary Tract Disorders Page: 723 Difficulty: Moderate

21. A patient is seen with a sudden onset of flank pain accompanied by nausea, vomiting, and diaphoresis. In addition to nephrolithiasis, which of the following should be added to the list of differential diagnoses?

A. Pancreatitis B. UTI C. Prostate tumor D. Gastroesophageal reflux disease Answer: A Feedback: The differential diagnosis for nephrolithiasis includes a variety of diseases and conditions, including appendicitis, diverticulitis, acute peritonitis, mesenteric adenitis, pancre-

atitis, ileus, peptic ulcer disease, abnormalities of the fallopian tubes and ovaries including ovarian cysts, ectopic pregnancy, gallbladder disease, and abdominal aneurysms.

Chapter: Chapter 44, Urinary Tract Disorders Page: 726 Difficulty: Moderate

22. Which of the following instructions should be given to the patient with nephrolithiasis?

A. Take ibuprofen, 600 mg every 8 hours.

B. Take Tums for stomach upset.

C. Drink more black tea.

D. Increase intake of vegetables, like spinach.

Answer: A Feedback: Oral NSAIDs in dosages of 600 to 800 mg three times daily or oral narcotics such as hydrocodone-acetaminophen (Vicodin, Lortab), acetaminophen-codeine (Tylenol #3), or oxycodone-acetaminophen (Percocet) are often necessary.

Chapter: Chapter 44, Urinary Tract Disorders Page: 726 Difficulty: Moderate

23. Which of the following medications will reduce urinary excretion of nephrolithiasis-forming substances?

A. Furosemide B. Triamterene C. Calcium supplement D. Hydrochlorothiazide Answer: D Feedback: Certain drugs help to reduce urinary excretion of stone-forming substances. Thiazide diuretics (e.g., hydrochlorothiazide) reduce calcium excretion.

Chapter: Chapter 44, Urinary Tract Disorders Page: 726 Difficulty: Moderate

24. A patient has been prescribed Ceclor for a UTI. Which of the following side effects should they be made aware of?

A. Emesis B. Abdominal discomfort if taken without food C. Nausea D. Flatulence Answer: C Feedback: Nausea is one of the possible side effects of Ceclor.

Chapter: Chapter 44, Urinary Tract Disorders Page: 718 Difficulty: Moderate

25. A patient is seen in the clinic and diagnosed with stage I renal cancer. The provider should refer the patient to a nephrologist for initial treatment. Which of these treatments may the nephrologist suggest for the patient?

A. Chemotherapy B. Nephrectomy C. Palliative treatment D. Radiation Answer: B Feedback: Treatment of renal cancer requires immediate specialist referral to a urologist or surgical oncologist, often with additional consultation by a medical oncologist or nephrologist, depending on the patient‘s renal function. Treatment for a renal neoplasm is primarily surgical with a partial or total nephrectomy.

Chapter: Chapter 45, Kidney and Bladder Disorders Page: 744 Difficulty: Easy

26. A patient has just had a total nephrectomy for renal cell carcinoma. Which of the following follow-up strategies is appropriate?

A. Computed tomography (CT) scan of abdomen and renal fossa in 3 to 6 months B. Magnetic resonance imaging (MRI) of abdomen and kidneys in 2 to 4 months C. X-ray of abdomen and renal fossa in 6 to 8 months D. No follow-up is necessary Answer: A Feedback: For follow-up of patients with a total nephrectomy, a CT scan of the abdomen and renal fossa should be done in 3 to 6 months.

Chapter: Chapter 45, Kidney and Bladder Disorders Page: 744 Difficulty: Easy

27. An 86-year-old woman is seen in the clinic for recurrent hematuria. The provider suspects bladder cancer. Which of the following data from the history are considered a risk factor for this type of cancer?

A. History of alcoholism B. Sedentary lifestyle C. Obesity D. 65-year smoking history

Answer: D Feedback: There is a significant correlation between bladder tumors and risk factors including cigarette smoking.

Chapter: Chapter 45, Kidney and Bladder Disorders Page: 745 Difficulty: Moderate

28. A 40-year-old woman presents to the clinic with reports of dull and achy flank pain and hematuria. She also notes, ―I think I have a mass in my stomach.‖ She works in a chemical plant and has a sedentary lifestyle. Which of the following parts of her history lead the clinician to believe she may have renal cell carcinoma?

A. Age B. Gender C. Works in chemical plant D. Sedentary lifestyle Answer: C Feedback: Risk factors for renal cell carcinoma include obesity; exposure to asbestos, cadmium, and/or gasoline; the use of phenacetin (of which acetaminophen is a major metabolite), NSAIDs, aspirin-containing analgesics; and chronic hemodialysis for acquired polycystic kidney disease.

Chapter: Chapter 45, Kidney and Bladder Disorders Page: 742 Difficulty: Moderate

29. Which of the following diagnostic tests would be ordered for a patient suspected of having bladder cancer?

A. Kidneys, ureter, bladder x-ray B. Cystoscopy with biopsy C. MRI D. Urine tumor marker (NMP22) Answer: B Feedback: Cystoscopic evaluation can be used to confirm the suspected diagnosis, determine the location of the tumor, and aid in staging of the tumor.

Chapter: Chapter 45, Kidney and Bladder Disorders Page: 745 Difficulty: Easy

30. A patient has bladder cancer that has grown into the fatty tissue surrounding the bladder and vagina. The cancer has not spread to distant sites or lymph nodes. What is an appropriate treatment option?

A. Palliative care only

B. External beam radiation therapy C. Chemotherapy only D. Radical cystectomy and lymph node resection Answer: D Feedback: Radical cystectomy and lymph node resection are a treatment option for stage 3 bladder cancer.

Chapter: Chapter 45, Kidney and Bladder Disorders Page: 746 Difficulty: Moderate

31. The patient is diagnosed with acute renal failure (ARF). Which of the following data obtained from the history should alert the provider that this is a case of prerenal azotemia?

A. Taking lisinopril B. Having a history of nephrolithiasis C. Taking gentamicin for a recent infection D. Having an ureteral obstruction Answer: A Feedback: Prerenal azotemia is any condition that leads to an overall decrease in renal perfusion. Etiologies in this group include hypovolemia, renovascular disease, liver disease with portal hypertension, decreased cardiac output, systemic vasodilation, renal vasoconstriction, and impairment of renal autoregulation of blood flow, which is often associated with drugs such as ACE inhibitors (including lisinopril) or NSAIDs. Chapter: Chapter 45, Kidney and Bladder Disorders Page: 729 Difficulty: Moderate

32. A female patient presents to the clinic saying, ―I do not feel like I want to eat.‖ She also notes she is experiencing lethargy, nausea, headache, and muscle cramps. She ―did not go to the bathroom a lot‖ yesterday. Which of the following stages of acute kidney injury (AKI) is this patient in?

A. Initiating B. Oliguric C. Diuretic D. Recovery Answer: A Feedback: The initiating stage begins when the kidney is injured. Decreased urine volume and other signs and symptoms of renal impairment may then become evident, which may include anorexia, lethargy, nausea, headache, muscle cramps, and fatigue.

Chapter: Chapter 45, Kidney and Bladder Disorders Page: 732 Difficulty: Moderate

33. A patient has chronic kidney disease (CKD), and their glomerular filtration rate (GFR) is 33 mL/min per 1.73 m2 of body surface area (BSA). Which of the stages does this patient‘s GFR fall under, as defined by the Third National Health and Nutrition Examination Survey?

A. Stage 1 B. Stage 2 C. Stage 3 D. Stage 4 Answer: C Feedback: A glomerular filtration rate of 30 to 44 mL/min per 1.73 m2 of BSA falls under stage 3b of CKD. Chapter: Chapter 45, Kidney and Bladder Disorders Page: 740 Difficulty: Moderate

34. Which of the following examination findings should be expected in a patient with CKD? A. Weak, thready pulse B. Auscultatory crackles C. Hypotension D. Pleural friction rub Answer: B Feedback: Peripheral neuropathy and altered mental status may be present in patients diagnosed with CKD, along with peripheral edema and ascites from severe proteinuria and the resulting hypoalbuminemia, as well as auscultatory crackles in the lungs and a pericardial rub.

Chapter: Chapter 45, Kidney and Bladder Disorders Page: 738 Difficulty: Easy

35. Which of the following strategies is useful when managing hypertension in a patient with CKD? A. Keep hemoglobin A1c (HbA1c) of less than 7.5%.

B. For a patient with proteinuria of more than 1 g/day, target blood pressure (BP) is 135/85 mm Hg. C. Avoid systolic BP less than 100 mm Hgc. D. For a patient with proteinuria of less than 1 g/day, goal BP is no more than 130/80 mm Hg. Answer: D Feedback: Glucose levels and hypertension must be strictly controlled in diabetic patients, with a target HbA1c of less than 7%. For any patient with proteinuria of more than 1 g per day, the target BP is 125/75 mm Hg; for a patient with proteinuria of less than 1 g per day, the goal is a BP of no more than 130/80 mm Hg. Chapter: Chapter 45, Kidney and Bladder Disorders

Page: 739 Difficulty: Easy

36. A patient has CKD and their creatinine levels are 12 mg/dL. The patient would like to know what to expect next. What does the provider tell her?

A. Due to her advanced renal failure, her survival time without intervention is 100 to 150 days.

B. She does not require intervention and she will require dialysis once her creatinine levels reach 15 mg/dL. C. She will require dialysis in the next year.

D. She will be placed on the transplant list once her creatinine levels are greater than 16 mg /dL. Answer: A Feedback: In patients with advanced renal failure (creatinine levels greater than 10 mg/dL), mean survival time without intervention (e.g., dialysis or transplantation) is only 100 to 150 days.

Chapter: Chapter 45, Kidney and Bladder Disorders Page: 742 Difficulty: Moderate

37. A patient comes into urgent care reporting severe flank pain, abdominal distention, and a fever. BP and heart rate are elevated. You suspect nephrolithiasis. What test would you order to confirm the diagnosis?

A. Urinalysis B. Serum chemistry C. MRI D. Ultrasound Answer: A Feedback: A CBC, urinalysis, and serum chemistry should be ordered to start a through workup. Renal calculi are diagnosed with ultrasound or more invasive tests that confirm stones and can observe renal structures to check for blockages.

Chapter: Chapter 44, Urinary Tract Disorders Page: 726 Difficulty: Moderate

38. What is the most accurate way to obtain urine protein levels?

A. Urine dipstick B. 24-hour urine collection C. Serum GFR ratio D. Creatinine level

Answer: B Feedback: The most accurate way to quantify the amount of protein in the urine is with a 24-hour urine collection.

Chapter: Chapter 43, Common Urinary Complaints Page: 704 Difficulty: Easy

39. A patient comes in for a CT with contrast. They have no allergies. What would the healthcare provider monitor for after the use of contrast?

A. Constipation B. Intrarenal azotemia C. Portal hypertension D. Myocardial infarction Answer: B Feedback: AKI includes intrarenal azotemia. Intrarenal azotemia includes disorders that affect the renal parenchyma itself, such as glomerulonephritis (GN), acute tubular necrosis (ATN) (often caused by ischemic insult or nephrotoxic drugs such as aminoglycosides), interstitial nephritis (often an allergic reaction to various drugs or transfusion reactions), toxic injury (from alcohol, cocaine, heavy metals, solvents and fuels, chemotherapy drugs, bowel preparations containing phosphate, and contrast dyes), and tubular obstruction.

Chapter: Chapter 45, Kidney and Bladder Disorders Page: 730 Difficulty: Difficult

40. AKI is usually asymptomatic until the GFR falls to A. 40% of normal B. 35% of normal C. 20% of normal D. 10% of normal Answer D Feedback: Symptoms of AKI are not usually present until the GFR falls to approximately 10% to 15% of normal.

Chapter: Chapter 45, Kidney and Bladder Disorders Page: 732 Difficulty: Easy

41. An 80-year-old man is taking tamsulosin for overflow incontinence. What education would you provide related to this medication?

A. Limit water intake.

B. Change positions slowly.

C. Use mouth rinse.

D. Take at night.

Answer: B Feedback: Tamsulosin is an adrenergic blocking agent and is used primarily in men with enlarged prostates. Orthostatic hypotension and dizziness are side effects. Patients should be instructed to change positions slowly to prevent falls.

Chapter: Chapter 44, Urinary Tract Disorders Page: 711 Difficulty: Moderate

Section 9. Gender-Related Health Problems

MULTIPLE CHOICE 1. Which of the following is a correct recommendation of when to begin prostate screening?

A. Men with no symptoms of prostate cancer and who are in good health should start screening at age 60.

B. Asian American men should start screening at age 45.

C. Men who have had a brother diagnosed with prostate cancer before the age of 65 should start screening at 45.

D. Caucasian men should start screening at age 55.

Answer: C Feedback: Prostate screening discussions start at age 50 with exams beginning at age 55 for males who are in good health, have no symptoms, and have a life expectancy of greater than 10 years. High-risk individuals should start screening at age 40, or if a family member was diagnosed with prostate cancer before the age of 65 screening should start at age 45.

Chapter: Chapter 50, Prostate Disorders Page: 844 Difficulty: Moderate

2. A 63-year-old man is seen in the clinic with a chief complaint of nocturia. Which of the following is the most common sign of prostatic problems in men with nocturia?

A. Psychogenic nocturia B. Urethral polyp C. Irritative posterior urethral lesion D. Benign prostatic hypertrophy (BPH) Answer: D Feedback: Irritative symptoms of BPH include nocturia, urinary frequency, urgency, dysuria, and urge incontinence. Because symptoms are usually not specific to BPH and may have other causes, a complete workup is necessary.

Chapter: Chapter 50, Prostate Disorders Page: 834 Difficulty: Moderate

3. A 76-year-old man is seen in the office for complaints of urinary tract infection (UTI). The clinician should explore which of these causes of UTI in men?

A. Urethral polyps B. Epididymitis C. SSRI medication D. Prostatodynia Answer: B Feedback: Sexually active men with UTIs most commonly present with epididymitis. Prostatitis, immunosuppression, and urethral constrictor can also be risk factors.

Chapter: Chapter 51, Penile and Testicular Disorders Page: 854 Difficulty: Moderate

4. A 14-year-old boy is seen with complaints of severe testicular pain. The clinician suspects testicular torsion. Which of the following is the appropriate action?

A. Refer to urologist immediately.

B. Obtain a computed tomography (CT) scan.

C. Instruct the patient to elevate the scrotum.

D. Prescribe ibuprofen.

Answer: A Feedback: Testicular torsion is a medical emergency. The patient should be referred to the emergency department and a urologist immediately. Manual reduction may be performed by external rotation. Relief of pain occurs with reduction. Surgical exploration is performed after reduction. Absence of cremasteric reflex and a ―bell clapper deformity‖ along with pain that does not get better with elevation are the presenting findings of testicular torsion.

Chapter: Chapter 51, Penile and Testicular Disorders Page: 856 Difficulty: Moderate

5. An 82-year-old man is seen in the primary care office with complaints of dribbling urine and difficulty starting his stream. Which of the following should be included in the list of differential diagnoses?

A. Prostatodynia B. Lupus disease C. Trichomoniasis infection D. Fungal infection Answer: A Feedback: Prostatodynia symptoms are weak urine stream, constant dribbling, incomplete emptying, and other symptoms of bladder obstruction. Trichomoniasis presents like prostatitis, epididymitis, or urethritis in males. Fungal infections and lupus do not present with urinary symptoms.

Chapter: Chapter 50, Prostate Disorders Page: 840 Difficulty: Moderate

6. Which of the following would be an appropriate treatment for a patient with mild BPH? A. Refer to urologist for surgery.

B. Prescribe a trial of tamsulosin.

C. Recommend cranberry supplements.

D. Have a period of watchful waiting.

Answer: D Feedback: Patients with mild-to-moderate symptoms, minimal postvoid residue, and no objective changes in the urinary tract only require monitoring. This is conservative management of BPH. Watchful waiting is also done if BPH does not affect quality of life. Cranberry supplements help prevent UTIs and the other answers are aggressive treatments.

Chapter: Chapter 50, Prostate Disorders Page: 837 Difficulty: Easy

7. A 30-year-old man is seen with a chief complaint of loss of libido. Which of the following laboratory tests would help establish a diagnosis?

A. Testosterone level B. Prostate-specific antigen (PSA) C. Nocturnal penile tumescence and rigidity D. Follicle stimulating hormone (FSH) level Answer: A Feedback: Testosterone levels range 300 to 1100 ng/dL in men between 18 and 69. Low testosterone levels cause low libido, erectile dysfunction, and decreased mental alertness. Low levels also put patients at risk for cardiovascular issues and diabetes. PSA is a test for the prostate, FSH is for sperm production, and nocturnal penile tumescence and rigidity are symptoms, not a laboratory test.

Chapter: Chapter 46, Common Reproductive System Complaints Page: 756 Difficulty: Easy

8. Peter is a 40-year-old man with a recent diagnosis of low testosterone. Which of the following counseling points is correct regarding low testosterone?

A. Testosterone deficiency is due to hypergonadism.

B. Abstaining from cigarette smoking has no effect on testosterone.

C. Controlling your blood sugar may improve your testosterone levels.

D. Stress has no effect on testosterone levels.

Answer: C Feedback: Lowest levels of free testosterone are associated with diabetes. Therefore, controlling diabetes can increase testosterone. Stress, hypogonadism, and cigarette smoking lower testosterone levels.

Chapter: Chapter 46, Common Reproductive System Complaints Page: 756 Difficulty: Easy

9. Which of the following should be considered in a patient presenting with erectile dysfunction?

A. Diabetes mellitus B. Hypertension C. Wellbutrin D. UTI Answer: A Feedback: Low testosterone is associated with diabetes. Low testosterone levels cause erectile dysfunction. None of the other answers cause erectile dysfunction.

Chapter: Chapter 46, Common Reproductive System Complaints Page: 756 Difficulty: Easy

10. A 35-year-old man presents with complaints of painful erections, and he notices his penis is crooked when erect. What is the most likely diagnosis?

A. Peyronie‘s disease B. Damage to the pudendal artery C. Scarring of the urethra D. Testicular torsion Answer: A Feedback: Peyronie‘s disease does present with painful erections and a crooked or bent penis.

It is caused by localized fibrotic thickening of the corpus cavernosa. Testicular torsion causes pain in the testes.

Chapter: Chapter 51, Penile and Testicular Disorders Page: 850 Difficulty: Easy

11. The patient with BPH is seen for follow-up. He has been taking finasteride (Proscar) for 6 months. The clinician should assess this patient for which of these side effects?

A. Erectile dysfunction B. Glaucoma C. Hypotension D. Headache

Answer: A Feedback: Erectile dysfunction, decreased ejaculation volume, and reduced libido are side effects of finasteride.

Chapter: Chapter 50, Prostate Disorders Page: 838 Difficulty: Moderate

12. Which of the following is an aerobic gram-negative bacteria involved in prostatitis?

A. Streptococcus faecalis B. Pseudomonas C. Staphylococcus D. Diphtheroids Answer: B Feedback: Pseudomonas is a gram-negative bacteria. The other choices are all gram-positive bacteria.

Chapter: Chapter 50, Prostate Disorders Page: 840 Difficulty: Easy

13. The 56-year-old man with chronic prostatitis should be treated with levofloxacin for how long?

A. 3 to 7 days B. 14 to 21 days C. 4 to 6 weeks D. 6 to 12 weeks Answer: C Feedback: Chronic prostatitis is treated with levofloxacin for 4 to 6 weeks. Acute prostatitis is treated with levofloxacin for 5 days. If an antibiotic class other than a fluoroquinolone is effective, they should be used to prevent antibiotic resistance.

Chapter: Chapter 50, Prostate Disorders Page: 842 Difficulty: Easy

14. John presents with complaints of a ―weird feeling that hurts‖ in his buttocks. He notes that he often feels urgency to urinate and defecate, but ―nothing comes out‖ when he tries. Which of the following diagnoses is most likely?

A. UTI B. Prostatitis C. Erectile dysfunction D. Peyronie‘s disease

Answer: B Feedback: Prostatitis presents with tenesmus, pain, persistent desire to empty bowel and bladder, and involuntary and ineffective straining. Peyronie‘s disease presents with painful and crooked erections. UTIs cause pain, burning, a decreased amount of urine, and more frequent urination. Erectile dysfunction is any change in erection.

Chapter: Chapter 50, Prostate Disorders Page: 840 Difficulty: Easy

15. A 46-year-old man presents with urinary hesitancy and low back pain. He has no history of UTI. Digital rectal examination (DRE) reveals a normal prostate. He is not a long-distance runner. Which of the following would lead you to a diagnosis of prostatodynia versus prostatitis?

A. Long-distance runners are more likely to have prostatodynia than prostatitis.

B. Prostatodynia presents with signs and symptoms of prostatitis, but without inflammation.

C. Prostatodynia usually has a bacterial origin, whereas prostatitis has a relation to internal urethral sphincter problems.

D. Patients with prostatodynia usually do not have a history of recurrent UTIs, whereas patients with prostatitis do.

Answer: B Feedback: Prostatodynia is asymptomatic noninflammatory prostatitis with inflammatory infiltrates, pain, or difficulty urinating.

Chapter: Chapter 50, Prostate Disorders Page: 840 Difficulty: Difficult

16. A 23-year-old sexually active man is seen in the clinic with unilateral painful testicular swelling, and he is diagnosed with epididymitis. In order to prescribe the correct drug, the clinician must understand that which of these is the most common causative organism?

A. Escherichia coli B. Staphylococcus aureus C. Chlamydia trachomatis D. Pseudomonas aeruginosa Answer: C Feedback: The cause of epididymitis in young sexually active men is usually chlamydia (C trachomatis) or gonorrhea. The other causative agents listed are more prevalent in men above age 35.

Chapter: Chapter 51, Penile and Testicular Disorders Page: 840 Difficulty: Moderate

17. Carl is a 24-year-old man who presents with scrotal pain that radiates to his flank. It manifested 3 hours ago. He also complains of pain at the tip of his penis, cloudy urine, and urethral discharge. Which of the following conditions is most likely?

A. Testicular torsion B. Epididymitis C. Prostatodynia D. Prostatitis Answer: B Feedback: Epididymitis presents with scrotal pain that can radiate to the flank, pain in the tip of the penis, urethral discharge, and UTI symptoms. Testicular torsion is extreme pain in the testes. Prostatitis and prostatodynia are conditions involving an enlarged prostate with pain more toward the rectum.

Chapter: Chapter 51, Penile and Testicular Disorders Page: 854 Difficulty: Moderate

18. Which test is used to confirm a diagnosis of epididymitis?

A. Urinalysis B. Gram stain of urethral discharge C. Complete blood cell count with differential D. Ultrasound of the scrotum Answer: D Feedback: An ultrasound confirms the diagnosis of epididymitis. Elevated white blood cells (WBCs) in the urinalysis can diagnose urethritis, pyuria, or leukocytosis. A gram stain can show diplococci consistent with Neisseria gonorrhoeae.

Chapter: Chapter 51, Penile and Testicular Disorders Page: 855 Difficulty: Easy

19. Treatment for epididymitis includes which of the following?

A. Warm sitz baths B. Scrotal elevation C. Masturbation D. Heat application Answer: B Feedback: Initial treatment is bedrest, elevation of the scrotum, and ice packs.

Chapter: Chapter 51, Penile and Testicular Disorders Page: 855 Difficulty: Easy

20. Which of the following information is indicative of testicular torsion?

A. Absent cremasteric reflex B. Pain relieved on testicular elevation C. Testicle very low in the scrotum D. Swollen scrotum with ―red dot sign‖ Answer: A Feedback: Absent cremasteric reflex, pain, swelling, a blue dot sign when the skin is pulled taut, and a ―bell clapper‖ appearance to the testes are all indicative of testicular torsion. The testes are high in the scrotal sac with torsion. Pain is relieved with elevation with epididymitis.

Chapter: Chapter 51, Penile and Testicular Disorders Page: 856 Difficulty: Easy

21. A 60-year-old man presents with an enlarged scrotum. The clinician uses a penlight to transilluminate the scrotum. In a patient with a hydrocele, what would the clinician expect to find?

A. The scrotum will be dark.

B. The scrotum will appear light pink or yellow.

C. The scrotum will appear milky white.

D. The internal structures will be clearly visible.

Answer: B Feedback: A hydrocele is an accumulation of peritoneal fluid that is light pink or yellow. A dark scrotum could be a hematoma. With a hernia internal structures may be visible and a milky appearance could indicate infection.

Chapter: Chapter 51, Penile and Testicular Disorders Page: 857 Difficulty: Moderate

22. During a DRE on a 75-year-old man, the clinician suspects the patient has prostate cancer.

What physical finding should make the clinician suspicious?

A. A nodular and unusually firm gland B. A smooth gland C. A tender gland D. A boggy gland Answer: A Feedback: The prostate should feel smooth and boggy and be nontender. Asymmetry, a nodule, pain, or hardness can indicate cancer.

Chapter: Chapter 50, Prostate Disorders Page: 835 Difficulty: Moderate

23. A patient presents complaining of pain and enlarged testes that feel like ―a bag of worms.‖ Which diagnosis should the provider most likely to assess for?

A. Prostate cancer B. Varicocele C. Hydrocele D. Testicular cancer Answer: B Feedback: A varicocele will feel like a bag of worms because of tortuous and engorged blood vessels. A hydrocele will illuminate pink or yellow. With testicular cancer a nodule will be present.

Chapter: Chapter 51, Penile and Testicular Disorders Page: 859 Difficulty: Easy

24. Which of the following is a complementary therapy for BPH? A. Red raspberry leaf tea B. Saw palmetto C. Black cohosh D. Vitamin A Answer: B Feedback: Saw palmetto is a complementary therapy for BPH. It inhibits 5--reductase and mimics finasteride.

Chapter: Chapter 50, Prostate Disorders Page: 838 Difficulty: Moderate

25. A 78-year-old man is diagnosed with C2 prostate cancer, and he asks the clinician what that means. In order to answer the patient, the clinician must have which understanding of the Jewett rating system?

A. The cancer involves the seminal vesicles.

B. There is metastatic disease to regional lymph nodes.

C. The cancer is confined to the capsule.

D. There is metastasis to distant organs.

Answer: A Feedback: According to the Jewett rating system, C2 indicates the cancer involves the seminal vesicles. C1 indicates cancer beyond the prostatic capsule. D1 indicates metastatic disease to regional lymph nodes. D2 indicates metastasis to distant organs.

Chapter: Chapter 50, Prostate Disorders Page: 843 Difficulty: Easy

26. A 58-year-old patient has been receiving leuprolide as treatment for prostate cancer. The clinician should instruct the patient about which of these side effects?

A. Cold flashes B. Hot flushes C. Increased libido D. Testicular torsion Answer: B Feedback: Leuprolide blocks FSH and luteinizing hormone and has side effects of hot flashes, low libido, erectile dysfunction, gynecomastia, and, rarely, anemia.

Chapter: Chapter 50, Prostate Disorders Page: 845 Difficulty: Moderate

27. A 22-year-old male is seen in the clinic because he found a hard lump in his testicle when performing testicular self-examination. Which of the following risk factors leads the clinician to suspect potential testicular cancer?

A. Age of 65 years old B. Prior cryptorchidism C. Family history of colon cancer D. Living in a city Answer: B Feedback: Cryptorchidism is the only cause-effect risk factor for testicular cancer. Having a family history of testicular cancer could confer greater risk. A higher SES, living in a rural area, and being unmarried are also risk factors.

Chapter: Chapter 51, Penile and Testicular Disorders Page: 860 Difficulty: Moderate

28. What is the treatment of choice for a patient diagnosed with testicular cancer?

A. Radical orchidectomy B. Lumpectomy C. Radiation implants D. Chemotherapy Answer: A Feedback: Orchidectomy is the treatment of choice for testicular cancer. If the cancer has metastasized, then chemotherapy will be started after orchidectomy.

Chapter: Chapter 51, Penile and Testicular Disorders Page: 857 Difficulty: Moderate

29. A patient with testicular cancer is being followed after completing treatment 1 year ago.

He has been symptom-free with no evidence of disease. How often should he have a CT scan?

A. Every month B. Every 3 to 4 months C. Every 6 to 12 months D. Every year Answer: B Feedback: The National Comprehensive Cancer Network recommends ultrasound every 3 to 4 months after competing treatment. In years 2 to 3, ultrasound should be done every 6 to 12 months. After 3 years an ultrasound can be done annually. There are no recommendations for monthly ultrasounds after completing treatments.

Chapter: Chapter 51, Penile and Testicular Disorders Page: 864 Difficulty: Moderate

30. Tyler is a 16-year-old boy who the clinician is counseling on sexually transmitted infections (STIs). Which statement made by the clinician is correct?

A. ―Untreated gonorrhea can lead to many health problems, including a syndrome that affects your entire body called ‗disseminated gonococcal infection.‘‖ B. ―Most STIs are untreatable, and, if contracted, you will have potentially fatal health complications.‖ C. ―Though STIs are treatable, gonorrhea isn‘t and always results in permanent penile damage.‖ D. ―The only untreatable STI is chlamydia, and it is also the most common.‖ Answer: A Feedback: Untreated gonorrhea can lead to many health problems, including a syndrome that affects the entire body called ―disseminated gonococcal infection.‖ STIs are treatable, including gonorrhea and chlamydia.

Chapter: Chapter 52, Sexually Transmitted Infections Page: 872 Difficulty: Moderate

31. The clinician is seeing Jalissa, a 17-year-old patient, for a well woman‘s exam. She mentions that she has been depressed and has been yo-yo dieting because she feels insecure about her body. She marked ―no‖ to whether she feels safe in her home on her intake form, and mentions she is worried about getting STIs from her boyfriend of 3 months. Which of the following is the correct way to interact with the patient, based on her history?

A. ―Unfortunately, the time allotted for your well woman exam does not allow time to talk about depression today.‖

B. ―I know you said you are concerned about your body image, but your weight looks good to me.‖ C. ―You mentioned on your intake form that you do not feel safe in your home. Why is that?‖ D. ―You‘ve been dating your boyfriend for 3 months, but you haven‘t had an STI screening yet? That‘s not safe.‖ Answer: C Feedback: The statement, ―You mentioned on your intake form that you do not feel safe in your home. Why is that?‖ is open ended, asks for more information, and also tells the patient the provider was listening and concerned. Saying there is no time to discuss depression or that she should not be concerned about her weight is dismissive and does not promote a caring professional relationship. Implying the patient is irresponsible for not having an STI screening is not therapeutic, rather it is punitive.

Chapter: Chapter 47, Common Reproductive Issues Page: 760 Difficulty: Easy

32. Which of these patients needs a cervical cancer screening?

A. Lisa, a 45-year-old patient who has ASCUS and had a human papillomavirus (HPV)-positive Pap 1 month ago B. April, a 26-year-old patient who had a negative Pap with negative HPV 1 year ago C. Sondra, a 66-year-old patient who had a negative Pap with negative HPV 11 years, 6 years, and 1 year ago D. Gillian, a 33-year-old patient who had a negative Pap with negative HPV 5 years ago Answer: D Feedback: Cervical cancer screening is recommended every 5 years starting at age 25 and ending at age 65.

Chapter: Chapter 47, Common Reproductive Issues Page: 761 Difficulty: Moderate

33. Which of the following is true of the intrauterine device (IUD)?

A. The IUD is 95% effective at preventing pregnancy.

B. The IUD has an inhibitory effect on sperm capacitation.

C. The IUD cannot be inserted at menses.

D. The IUD can only be inserted in women with multiparity.

Answer: B Feedback: The IUD is 99% effective in preventing pregnancy. It is inserted during menses and inhibits sperm capacitation. Multiparity is not a requirement.

Chapter: Chapter 47, Common Reproductive Issues Page: 761 Difficulty: Moderate

34. Alice has been diagnosed with breast cancer. Its TNM staging is T2, N1, M0. She would like to know what this means. Which statement made by the clinician is accurate?

A. ―Your tumor is 4 cm and has metastasized to a moveable lymph node but has not metastasized to another location.‖ B. ―Your tumor is 5.5 cm and has not metastasized to lymph nodes or anywhere else.‖ C. ―Your tumor is 1.5 cm and has metastasized to a moveable lymph node but has not metastasized to another location.‖ D. ―Your tumor is 3 cm, has metastasized to a moveable lymph node, and has only metastasized to supraclavicular lymph nodes.‖ Answer: A Feedback: ―T‖ stands for tumor size, so T2 indicates a tumor between 2 and 5 cm. ―N‖ stands for nodes, so N1 means one lymph node is affected. ―M‖ is metastasis, so M0 stands for no metastasis.

Chapter: Chapter 48, Breast Disorders Page: 803 Difficulty: Moderate

35. A 23-year-old sexually active woman presents for her first Pap smear. Her history includes nulligravida, age at first intercourse 14, and more than 10 sexual partners. Which of the following conditions should the clinician be particularly alert for during her examination?

A. HPV B. Endometrial hyperplasia C. Vaginismus D. Polycystic ovarian syndrome Answer: A Feedback: HPV is a sexually transmitted infection. Risk factors for HPV and other STIs are intercourse at an early age, multiple sexual partners, and being between the age of 15 and 24.

Nothing about the patient suggests endometrial hyperplasia, vaginismus, or polycystic ovarian syndrome.

Chapter: Chapter 52, Sexually Transmitted Infections Page: 871 Difficulty: Moderate

36. A 20-year-old woman is seen in the clinic because her partner was found to have gonorrhea. Which of the following is the treatment of choice for gonorrhea?

A. Ceftriaxone B. Doxycycline C. Acyclovir D. Metronidazole Answer: A

Feedback: Ceftriaxone and azithromycin are the drugs of choice for gonorrhea. Doxycycline treats lymphogranuloma, acyclovir treats genital herpes, and metronidazole treats bacterial vaginosis.

Chapter: Chapter 52, Sexually Transmitted Infections Page: 870 Difficulty: Easy

37. A 24-year-old woman presents to the clinic with dysuria, dyspareunia, and a mucopurulent vaginal discharge. Her partner was recently treated for nongonococcal urethritis. What sexually transmitted disease has she most probably been exposed to?

A. Gonorrhea B. HPV C. Chlamydia D. Trichomonas Answer: C Feedback: Vaginal discharge related to chlamydia is mucopurulent. Discharge with gonorrhea is purulent yellow or green, HPV has no vaginal discharge, and trichomonas discharge is diffuse, frothy, malodorous, and yellow or green.

Chapter: Chapter 52, Sexually Transmitted Infections Page: 870 Difficulty: Difficult

38. A 45-year-old woman is seen in the clinic with a report of a vaginal discharge. The clinician identifies clue cells on the vaginal smear. Which of the following diagnoses is associated with this finding?

A. Trichomonas B. Bacterial vaginosis C. HPV D. Herpes simplex virus Answer: B Feedback: Clue cells are noted on a vaginal swab in bacterial vaginosis. PCR serology is used to diagnose herpes simplex. Protozoa and WBCs are present in a wet mount in trichomonas.

HPV can be diagnosed with visualization of lesions.

Chapter: Chapter 52, Sexually Transmitted Infections Page: 873 Difficulty: Difficult

39. Which of the following medications is the treatment of choice for trichomonas?

A. Metronidazole B. Ceftriaxone C. Diflucan

D. Doxycycline Answer: A Feedback: Metronidazole treats trichomonas. Ceftriaxone treats syphilis and gonorrhea.

Doxycycline treats urethritis, syphilis, chlamydia, and lymphogranuloma venereum. Diflucan treats yeast.

Chapter: Chapter 52, Sexually Transmitted Infections Page: 869 Difficulty: Moderate

40. A 58-year-old woman presents with a breast mass. Which of the following responses by the clinician would be most appropriate?

A. ―It is probably just a cyst because that is the most common breast mass.‖ B. ―We will order a mammogram and ultrasound to help establish a diagnosis.‖ C. ―We will go ahead and schedule you for a biopsy because that is the only way to know for sure.‖ D. ―Because your lump is painful, it is most likely not cancer.‖ Answer: B Feedback: Any breast lump needs a definitive diagnosis before any recommendations can be given. Ordering a mammogram and ultrasound is most appropriate.

Chapter: Chapter 48, Breast Disorders Page: 794 Difficulty: Moderate

41. Tina is an 18-year-old woman who would like to start using the transdermal contraceptive patch. Which of the following instructions should the clinician discuss with Tina?

A. Obesity can decrease the effectiveness of the patch.

B. The patch should be applied to the buttocks or breasts.

C. The patch is changed every 10 days.

D. If a patch becomes detached for less than 24 hours, it cannot be reapplied.

Answer: A Feedback: Because of drug metabolism, obesity can affect the effectiveness of the patch. It should never be applied to the breast, should be changed every 7 days, and should be replaced as soon as possible if detached.

Chapter: Chapter 47, Common Reproductive Issues Page: 766 Difficulty: Moderate

42. A 26-year-old woman is seen with complaints of irregular vaginal bleeding. Which of the following tests should be the first priority?

A. Pregnancy test

B. Pelvic ultrasound C. Endometrial biopsy D. Platelet count Answer: C Feedback: Endometriosis can cause irregular bleeding so a biopsy should be taken to determine pathology. If a female is pregnant menses would stop. Platelets would not relate to abnormal vaginal bleeding, and an HGB and RBC would determine anemia. Ultrasounds assess the structure of the organs.

Chapter: Chapter 46, Common Reproductive System Complaints Page: 750 Difficulty: Easy

43. A 42-year-old woman presents to the clinic with complaints of painful intercourse for the last month. Which of the following should be explored as the likely cause of her dyspareunia?

A. Menopause B. Dehydration C. Excess progesterone D. Excess lubrication Answer: A Feedback: With age, vaginal dryness occurs, causing painful intercourse. This is exacerbated with menopause.

Chapter: Chapter 46, Common Reproductive System Complaints Page: 756 Difficulty: Easy

44. A 36-year-old woman is seen with complaints of vaginal itching, burning, and discharge.

On potassium hydroxide (KOH) wet mount of vaginal discharge, the clinician notices hyphae.

Which of the following treatments would be appropriate?

A. Fluconazole B. Estrogen vaginal cream C. Metronidazole D. Doxycycline Answer: A Feedback: The symptoms are consistent with candidiasis. Treatment is with fluconazole.

Chapter: Chapter 46, Common Reproductive System Complaints Page: 758 Difficulty: Easy

45. A 21-year-old woman is seen in the clinic requesting birth control pills. Which of the following tests is essential before prescribing any oral contraceptive?

A. Pregnancy test B. Complete blood cell count C. Thyroid-stimulating hormone (TSH) D. Urine dip for protein Answer: A Feedback: A pregnancy test is recommended before starting any form of birth control. A complete blood count would determine things like anemia or infection. A TSH shows thyroid issues and a urine dip for protein could determine diabetes. None of these latter three tests would be necessary before starting birth control pills.

Chapter: Chapter 46, Common Reproductive System Complaints Page: 765 Difficulty: Easy

46. A 40-year-old woman is seen for her yearly examination. She is single and not in a monogamous relationship. Her social history includes smoking cigarettes ―occasionally‖ and drinking about two beers a day. Her body mass index (BMI) is 25. She is requesting birth control. Which of the following methods would be most effective for this patient?

A. Transdermal contraceptive patch B. Oral contraceptive C. Condom D. Vaginal contraceptive sponge Answer: C Feedback: A condom would be most effective. The effectiveness of the patch would be altered due to the high BMI. Smoking and increased age are contraindications with oral contraceptives because of risks. Sponges will not protect against STIs. Chapter: Chapter 47, Common Reproductive Issues Page: 765 Difficulty: Moderate

47. A 44-year-old patient with breast cancer is prescribed tamoxifen by her surgeon. She is complaining about hot flashes. Which of the following responses by the clinician would be most appropriate?

A. ―You must be entering menopause.‖ B. ―The hot flashes are a result of the antiestrogenic effects of tamoxifen.‖ C. ―Tamoxifen use has no increased incidence of hot flashes.‖ D. ―The drug will have no effect on vaginal lubrication.‖ Answer: B Feedback: Tamoxifen can cause hot flashes. There must be more investigation into if menopause is occurring, and because the patient is younger and on tamoxifen, the comment regarding menopause is not best. Tamoxifen does increase incidence of hot flashes. Vaginal lubrication is not part of the patient‘s question.

Chapter: Chapter 47, Common Reproductive Issues

Page: 776 Difficulty: Moderate

48. A 32-year-old woman is seen in the clinic because she has been unable to get pregnant after 12 months of unprotected sex. In order to determine the cause of the infertility, the clinician should ask her about which of these possible causes?

A. Pelvic inflammatory disease (PID) B. Oral contraceptive use for 15 years C. Early menarche D. Diet low in soy protein Answer: A Feedback: PID can cause scar tissue that inhibits transport of sperm to the ovum or ovum to the uterus. The other responses do not affect infertility.

Chapter: Chapter 52, Sexually Transmitted Infections Page: 872 Difficulty: Moderate

49. When assessing a woman for infertility, which of the following tests should be done first?

A. Hysterosalpingogram B. Magnetic resonance imaging (MRI) C. Analysis of partner‘s sperm D. Estrogen level Answer: C Feedback: Semen analysis is the single most important diagnostic study and should be done early in evaluation and always before a costly or invasive exam on the woman. Estrogen levels fluctuate through a cycle monthly. An MRI could confirm other pathology, and a hysterosalpingogram can show if the fallopian tubes are blocked.

Chapter: Chapter 47, Common Reproductive Issues Page: 774 Difficulty: Moderate

50. A 15-year-old girl is seen in the clinic because she has not yet had her first period. Which of the following questions would help the clinician determine the cause?

A. ―Are you sexually active?‖ B. ―How long have you been underweight?‖ C. ―Was your mother pregnant with you when she was of advanced maternal age?‖ D. ―Have you noticed any changes in your moods lately?‖ Answer: B Feedback: Primary amenorrhea associated with being underweight occurs because of neuroendocrine dysfunction related to low body fat. The other answers are not appropriate.

Chapter: Chapter 49, Vaginal, Uterine, and Ovarian Disorders Page: 809 Difficulty: Moderate

51. What is the most common cause of secondary amenorrhea?

A. Pregnancy B. Pituitary failure C. Inadequate estrogen levels D. Genetic disorders Answer: A Feedback: Secondary amenorrhea is most commonly caused by pregnancy or other things that cause anovulation, such as neuroendocrine function. Genetic disorders and pituitary failure are causes of primary amenorrhea. Low estrogen levels can affect ovulation and menses, but pregnancy is the most common cause of amenorrhea.

Chapter: Chapter 49, Vaginal, Uterine, and Ovarian Disorders Page: 809 Difficulty: Moderate

52. A 22-year-old woman is diagnosed with premenstrual syndrome. Which of the following lifestyle changes should the clinician suggest to help minimize the patient‘s symptoms?

A. At least 4 cups of green tea daily B. Regular exercise C. Vitamin A supplements D. A diet high in iron Answer: B Feedback: Exercise and diet are lifestyle changes. A diet high in iron and green tea does not affect premenstrual syndrome. Taking vitamin A can alleviate symptoms but it is not a lifestyle change.

Chapter: Chapter 47, Common Reproductive Issues Page: 781 Difficulty: Moderate

53. A 45-year-old woman is seen in the clinic complaining of painful menstruation. Which of the following pelvic pathologies is the most common cause of secondary dysmenorrhea?

A. Cervical cancer B. Endometriosis C. STIs D. Uterine fibroid Answer: B

Feedback: Secondary dysmenorrhea is caused by a physical condition. Endometriosis is the best response because it is a cause and a risk factor. STIs are a risk factor but not a cause.

Uterine fibroids and cervical cancer can cause abnormal bleeding but they are not associated with menstruation.

Chapter: Chapter 49, Vaginal, Uterine, and Ovarian Disorders Page: 812 Difficulty: Moderate

54. A 26-year-old woman tells the clinician that she has endometriosis, because she has frequent pelvic pain. The clinician also should consider which of these differential diagnoses?

A. Diverticulitis B. Cholelithiasis C. Kidney stones D. Ovarian cysts Answer: D Feedback: Ovarian cysts cause pelvic pain. Diverticulitis causes abdominal pain and bloating; cholelithiasis causes nausea, vomiting, and pain in the right upper quadrant; and kidney stones usually cause flank pain.

Chapter: Chapter 49, Vaginal, Uterine, and Ovarian Disorders Page: 813 Difficulty: Easy

55. Which of the following would be appropriate treatment for a woman with mild endometriosis?

A. Oral contraceptives B. Leuprolide acetate injections C. Nafarelin nasal spray D. Hysterectomy Answer: A Feedback: Oral contraceptives along with pain relievers such as NSAIDs are treatments of symptoms for mild endometriosis. The other answers treat moderate-to-severe cases.

Chapter: Chapter 49, Vaginal, Uterine, and Ovarian Disorders Page: 816 Difficulty: Moderate

56. A 45-year-old woman is seen in the clinic with abnormal uterine bleeding and pain during intercourse. The clinician should consider which of the following diagnoses?

A. Postmenopausal syndrome B. Infertility C. Mittelschmerz D. Polyp

Answer: D Feedback: Polyps can cause pain and bleeding. Mittelschmerz causes pain with ovulation. Infertility is usually not physically painful. Postmenopausal syndrome causes more behavioraltype changes.

Chapter: Chapter 49, Vaginal, Uterine, and Ovarian Disorders Page: 823 Difficulty: Moderate

57. A 48-year-old woman is seen in the clinic with complaints of prolonged heavy menstrual periods. She is pale and states she can no longer exercise. Pelvic exam reveals a single, very large mass. Which of the following diagnostic tests should the clinician order first?

A. Transvaginal ultrasound (TVUS) B. Endometrial biopsy C. MRI D. Abdominal CT scan Answer: A Feedback: A TVUS is used most often for diagnosing leiomyoma, as it will show uterine structures. Endometrial biopsy is more invasive than a TVUS and would not be ordered first.

MRI and CT scans are more expensive than a TVUS and would not be ordered first.

Chapter: Chapter 49, Vaginal, Uterine, and Ovarian Disorders Page: 818 Difficulty: Moderate

58. Dorothy is a 45-year-old woman who complains of a mass in her left breast, dull nipple pain, tenderness of the left nipple, and pasty left nipple discharge. Which of the following conditions should the clinician most suspect?

A. Intraductal papilloma B. Hamartomas C. Duct ectasia D. Fibroadenoma Answer: C Feedback: Duct ectasia symptoms include breast mass, nipple pain or tenderness, and nipple discharge. Intraductal papilloma has sanguineous-to-serosanguineous drainage. With hamartomas and fibroadenomas, the mass is in breast tissue not breast ducts.

Chapter: Chapter 48, Breast Disorders Page: 803 Difficulty: Difficult

59. A 45-year-old woman is seen because of irregular menstrual periods. Her FSH level is 48 mIU/mL, and her luteinizing hormone (LH) level is elevated. She asks the clinician what this means. Which would be the best response?

A. ―You are approaching menopause.‖ B. ―You have a hormonal imbalance.‖ C. ―Your FSH is normal, but your pituitary is making too much LH.‖ D. ―There is an imbalance between your ovaries and pituitary.‖ Answer: A Feedback: High FSH and LH levels develop in perimenopause. These hormones are excreted by the ovaries and pituitary, but both are increased as a woman approaches menopause.

Chapter: Chapter 47, Common Reproductive Issues Page: 784 Difficulty: Difficult

60. Which of the following tests is essential for a 46-year-old woman who the clinician suspects is perimenopausal?

A. Pregnancy B. Estrogen level C. Progesterone level D. LH level Answer: A Feedback: Pregnancy tests are the least expensive and quickest way to rule out a cause of amenorrhea. The other exams can be done to show perimenopause but are more expensive and invasive.

Chapter: Chapter 47, Common Reproductive Issues Page: 791 Difficulty: Moderate

61. A 60-year-old woman is seen for an annual checkup. Her obstetric history reveals para 6, gravida 6. She reports that she went through menopause at age 45. Her grandmother died at age 80 of colon cancer, and her father died of lung cancer. What in her history would be a risk factor for ovarian cancer?

A. Her numerous pregnancies B. Her age at menopause C. Her father‘s history of lung cancer D. Her grandmother‘s history of colon cancer Answer: D Feedback: Risk factors for ovarian cancer are advanced age; mother, grandmother, or sister with history of ovarian breast or colon cancer; father or brother with colon cancer; nulliparous; and early menarche or late menopause.

Chapter: Chapter 49, Vaginal, Uterine, and Ovarian Disorders Page: 827

Difficulty: Difficult

62. Which of the following medications is an oral estrogen product for women with menopause?

A. Provera 2.5 mg B. Estrace 0.01% C. Alora 0.025 mg D. Premarin 0.3 mg Answer: D Feedback: Premarin is an oral estrogen pill. Provera is an oral progesterone product, not estrogen. Estrace 0.01% is a cream. Alora is transdermal.

Chapter: Chapter 47, Common Reproductive Issues Page: 789 Difficulty: Easy

63. Which of the following is an alternative treatment for breast tenderness with premenstrual syndrome?

A. Evening primrose oil 250 mg orally up to 3 times daily 2 to 3 days before menses B. Black cohosh 40 to 200 mg orally daily C. Vitamin B complex 50 mg orally daily D. Jasmine essential oil aromatherapy Answer: A Feedback: Evening primrose oil can help with premenstrual syndrome. Black cohosh and B complex help relieve symptoms with menopause. Jasmine helps with decreased sexual desire.

Chapter: Chapter 47, Common Reproductive Issues Page: 783 Difficulty: Moderate

64. A 47-year-old woman presents with reports of pain with intercourse, intense itching ―down there,‖ and states that ―it looks different down there.‖ She denies bleeding and foul odor. Which of the following diagnoses should the clinician consider most likely?

A. Atrophic vaginitis B. Trichomoniasis C. Candidiasis D. Vulvar lichen sclerosis Answer: D Feedback: In vulvar lichen sclerosis there are changes such as hyperkeratosis and thinning of the epidermis that cause a change in appearance.

Chapter: Chapter 46, Common Reproductive System Complaints Page: 758

Difficulty: Moderate

Section 10. Musculoskeletal Problems

MULTIPLE CHOICE 1. One of the initial steps in assessing patients with musculoskeletal complaints is to determine whether the complaint is articular or nonarticular in origin. Which of the following is an example of an articular structure?

A. Bone B. Synovium C. Tendons D. Fascia Answer: B Feedback: Articular structures include the synovium, synovial fluid, articular cartilage, intra-articular ligaments, joint capsule, and juxta-articular bone.

Chapter: Chapter 53, Common Musculoskeletal Complaints Page: 881 Difficulty: Easy

2. You have detected the presence of crepitus on examination of a patient with a musculoskeletal complaint. Additionally, there is limited range of motion (ROM) with both active and passive movement. These findings suggest that the origin of the musculoskeletal complaint is A. Articular B. Inflammatory C. Nonarticular D. Noninflammatory Answer: A Feedback: Disorders of articular structures are characterized by deep or diffuse pain, limited ROM on active and passive movement, swelling (caused by synovial proliferation, effusion, or bony enlargement), crepitation, instability, ―locking,‖ or deformity.

Chapter: Chapter 53, Common Musculoskeletal Complaints Page: 881 Difficulty: Moderate

3. Which of the following signs or symptoms indicates an inflammatory etiology to musculoskeletal pain?

A. Decreased C-reactive protein B. Hyperalbuminemia C. Morning stiffness D. Weight gain

Answer: C Feedback: Inflammatory disorders are identified by the presence of all or some of the four cardinal signs of inflammation (erythema, warmth, pain, or swelling); systemic symptoms (fatigue, weight loss, morning stiffness, fever); or laboratory evidence of inflammation (elevated ESR or CRP, anemia of chronic disease, hypoalbuminemia, or thrombocytosis).

Chapter: Chapter 53, Common Musculoskeletal Complaints Page: 885 Difficulty: Easy

4. Which of the following statements concerning the musculoskeletal examination is true?

A. The uninvolved side should be examined initially and then compared to the involved side.

B. The part of the body that is causing the patient pain should be examined first.

C. When possible, the patient should not be asked to perform active ROM exercises to avoid causing pain.

D. Radiographs should always be obtained prior to examination so as not to cause further injury to the patient.

Answer: A Feedback: During a musculoskeletal examination, the uninvolved side should be examined and compared with the involved side.

Chapter: Chapter 53, Common Musculoskeletal Complaints Page: 879 Difficulty: Easy

5. You are performing muscle strength testing on a patient presenting with musculoskeletal pain and find that the patient has complete ROM but cannot move the extremity above gravity. Which numeric grade of muscle strength would you give this patient?

A. 1 B. 2 C. 3 D. 4 Answer: B Feedback: In a strength examination of musculoskeletal disorders, a score of 2/5 indicates the patient can actively move the extremity but cannot move it above gravity.

Chapter: Chapter 53, Common Musculoskeletal Complaints Page: 880 Difficulty: Moderate

6. A 55-year-old woman presents with tightness, pain, and limited movement in her right shoulder. She denies any history of trauma. Her examination reveals a 75% reduction in both active and passive ROM of the right shoulder. The patient also is experiencing tenderness

with motion and pain at the deltoid insertion. Her medical history is significant for type 1 diabetes mellitus and hypertension. Her social history reveals that she is a secretary and that she is right-handed. Based on her examination and medical history, you suspect adhesive capsulitis, or ―frozen shoulder.‖ Which clue in the history supports this diagnosis?

A. She has a history of hypertension.

B. Her affected shoulder is also her dominant arm.

C. She has a history of type 1 diabetes.

D. Her work as a secretary predisposes her to repetitive motions.

Answer: C Feedback: Type 1 diabetes has a high correlation with adhesive capsulitis.

Chapter: Chapter 55, Soft-Tissue Disorders Page: 946 Difficulty: Moderate

7. Fred has been diagnosed with a trigger finger of the ring finger. Which of the following management strategies is the most effective?

A. Surgical removal of the tendon sheath B. NSAIDs C. Local anesthetic injection into the tendon sheath D. Splinting Answer: C Feedback: The most effective therapy for trigger finger is local anesthetic and corticosteroid injection into the tendon sheath, plus a modification of activities for about a month.

Chapter: Chapter 55, Soft-Tissue Disorders Page: 945 Difficulty: Moderate

8. A 35-year-old woman has been recently diagnosed with carpal tunnel syndrome. She has two young children and asks the clinician what the chances are that they also will develop carpal tunnel syndrome. Which of the following responses would be correct regarding the risk of developing carpal tunnel syndrome?

A. Carpal tunnel syndrome commonly occurs in families. Genetic factors are thought to account for about one-half the risk of developing carpal tunnel.

B. People with occupations that require repeated flexion extension of the wrist, use of hand tools that require forceful gripping, or use of hand tools that vibrate are at risk for developing carpal tunnel.

C. An underlying musculoskeletal disorder must be present for a person to develop carpal tunnel.

D. Carpal tunnel syndrome only occurs in the presence of a hormonal imbalance.

Answer: B

Feedback: The greatest risk for carpal tunnel syndrome is found in occupations that require repeated flexion or extension of the wrist, use of hand tools that require forceful gripping, or use of hand tools that vibrate.

Chapter: Chapter 55, Soft-Tissue Disorders Page: 943 Difficulty: Moderate

9. Which of the following statements is true regarding the treatment of carpal tunnel syndrome?

A. The goal of treatment is to prevent flexion and extension movements of the wrist.

B. Splints are not used in carpal tunnel syndrome, because they restrict complete movement of the fingers and wrist.

C. Corticosteroid injections are encouraged in the treatment of carpal tunnel syndrome.

D. Treatment that encourages fluid retention, to keep the joints lubricated, is an emphasis of treatment.

Answer: A Feedback: The goal of treatment is to prevent the sustained flexion of the wrist or compression of the carpal tunnel.

Chapter: Chapter 55, Soft-Tissue Disorders Page: 942 Difficulty: Easy

10. A 25-year-old patient has been diagnosed with low back strain based on his history of localized low back pain and muscle spasm. His neurological examination is normal. As the health-care provider, you explain to the patient that low back pain is a diagnosis of exclusion.

Which of the following symptoms would alert the provider to the more serious finding of a herniated nucleus pulposus or ruptured disc?

A. Morning stiffness and limited mobility of the lumbar spine B. Unilateral radicular pain symptoms that extend below the knee and are equal to or greater than the back pain C. Fever, chills, and elevated erythrocyte sedimentation rate D. Pathologic fractures, severe night pain, weight loss, and fatigue Answer: B Feedback: Unilateral radiculopathy is frequently accompanied by low back pain. If a patient has back pain with radiculopathy, the leg pain is typically far worse than the back pain, and, most often, the pain radiates from the buttock to the posterior or posterolateral leg, following a dermatomal distribution to below the level of the knee, possibly to the ankle or foot.

Chapter: Chapter 54, Spinal Disorders Page: 923 Difficulty: Moderate

11. The clinician has instructed a 23-year-old patient with low back strain to use NSAIDs to manage symptoms of pain and discomfort. Which of the following statements would be most appropriate when teaching about the use of NSAIDs? A. ―You should start with the lowest dose that is effective in managing your pain as well as complementary therapies, because long-term use of NSAIDs can result in gastrointestinal (GI) disorders such as ulcers and hemorrhage.‖ B. ―You should start with the lowest dose that is effective in managing your pain to avoid developing tolerance to the medication.‖ C. ―You should take the maximum recommended dose of NSAIDs so that you will not need to take narcotics to control your pain.‖ D. ―It is important to take NSAIDs on an empty stomach in order to increase absorption.‖ Answer: A Feedback: The lowest effective dose of NSAIDs should be maintained to control pain. Complementary therapies should be started as well to avoid long-term NSAID use. Prolonged use of NSAIDs can cause renal failure, hepatotoxicity, and GI ulcer disease and can exacerbate existing cardiac disease.

Chapter: Chapter 54, Spinal Disorders Page: 913 Difficulty: Moderate

12. A 30-year-old woman has recently been diagnosed with a herniated disc at the level of L5-S1. She is currently in the emergency room with suspicion of cauda equina compression.

Which of the following is a sign or symptom of cauda equina compression?

A. Gastrocnemius weakness B. A reduced or absent ankle reflex C. Numbness in the lateral foot D. Saddle area anesthesia Answer: D Feedback: Cauda equina compression is characterized by bilateral lower extremity weakness and by anesthesia, or paresthesia, of the perineum and buttocks (saddle anesthesia).

Chapter: Chapter 54, Spinal Disorders Page: 929 Difficulty: Moderate

13. Which of the following statements is true concerning the management of a client with a herniated disc?

A. Muscle relaxants and narcotics can be used to control moderate pain but should be discontinued after 3 weeks of use.

B. An epidural injection is helpful in reducing leg pain that has persisted for at least 3 weeks after the herniation occurred.

C. Intolerable pain for more than a 3-month period is an indication for surgical intervention.

D. Most disc hernias require opioids for long-term pain relief.

Answer: C Feedback: Relative indications for surgical intervention include intractable and intolerable pain, typically after at least 4 to 6 weeks of conservative management. Symptoms from a disc herniation will have a substantial improvement within 2 weeks of symptom onset. Nearly 90% of disc herniations resolve without residual problems at 3 months. The core of effective nonsurgical management consists of medication, physical therapy, home exercises, traction, spinal manipulation, and epidural steroid injections. Opioids are not recommended for long-term use.

Chapter: Chapter 54, Spinal Disorders Page: 925 Difficulty: Easy

14. A 16-year-old boy presents to the emergency room after hurting his knee in a football game. He describes twisting his knee and then being unable to extend it completely. He tells the clinician that he heard a pop when the injury occurred and has been experiencing localized pain. The clinician suspects a meniscal tear. Which test would be most appropriate to assess for the presence of a meniscal tear?

A. Valgus stress test B. McMurray circumduction test C. Lachman test D. Varus stress test Answer: B Feedback: The McMurray and Apley tests are indicated in diagnosing meniscal tears.

Chapter: Chapter 53, Common Musculoskeletal Complaints Page: 904 Difficulty: Moderate

15. The clinician suspects that a client has patellar instability. In order to test for this, the client is seated with the quadriceps relaxed, and the knee is placed in extension. Next, the patella is displaced laterally and the knee flexed to 30°. If instability is present, this maneuver displaces the patella to an abnormal position on the lateral femoral condyle, and the client will perceive pain. Testing for patellar instability in this way is known as A. Apprehension sign B. Bulge sign C. Thumb sign D. Lachman sign Answer: A Feedback: Apprehension sign is used to test patellar instability and includes the following steps: have the patient supine with the quadriceps relaxed; the knee is extended with 30° of flexion; displace the patella laterally and then medially; with instability, this maneuver excessively displaces the patella to an abnormal position on the lateral femoral condyle; and the patient may perceive pain and become apprehensive.

Chapter: Chapter 53, Common Musculoskeletal Complaints Page: 905 Difficulty: Moderate

16. A 65-year-old man has recently been diagnosed with osteoarthritis (OA). The patient explains to the clinician that his first choice would be to use complementary therapies to control his condition and asks what therapies are most effective in treating OA. What would be the most appropriate response from the clinician?

A. ―Complementary therapies should be considered only if surgical interventions are not successful.‖ B. ―I am unfamiliar with the available complementary therapies for OA and prefer to discuss more mainstream treatments, such as NSAIDs and physical therapy, to manage your condition.‖ C. ―I would be happy to discuss all the treatment options available to you. Complementary therapies, such as acupuncture, acupressure, and tai chi, are being studied for use in the treatment of OA, and acupuncture can be used and is safe and well tolerated.‖ D. ―It would be crazy to use complementary therapies to treat such a serious condition.‖ Answer: C Feedback: For long-term pain management of OA, consultation with a pain management specialist for collaborative management may be beneficial; the use of alternative treatments, including massage therapy, acupuncture, or acupressure, can further enhance pain management and promote a feeling of relaxation and well-being.

Chapter: Chapter 56, Osteoarthritis and Osteoporosis Page: 966 Difficulty: Moderate

17. A 28-year-old man presents to the health-care provider with lower back pain that began 3 days ago. The pain is worse when he stands or bends, and it is somewhat relieved when he sits. The clinician performs the straight-leg raise test and it is negative. Plain film x-ray is positive for straightening of the vertebral curve. Which diagnosis is most likely?

A. OA B. Spinal stenosis C. Scoliosis D. Muscle strain Answer: D Feedback: With low-back pain caused by muscle strain, pain increases when standing or bending and decreases when sitting, the straight-leg raise test would be negative, and an x-ray would show straightening of vertebral curve with muscle spasm.

Chapter: Chapter 54, Spinal Disorders Page: 912 Difficulty: Moderate

18. A clinician has performed a synovial fluid analysis and the results are as follows. Visual analysis: turbid and yellow; viscosity: decreased, 52,000 white blood cells (WBCs) per mm3; PMNs: 75%; protein: 5 g/dL. Which of the following conditions could this result be attributed to?

A. Rheumatoid arthritis B. OA C. Gout D. Septic arthritis Answer: D Feedback: Septic arthritis would show as turbid, gray, or yellow in a visual analysis, viscosity would be decreased, WBCs per mm3 would be greater than 50,000, PMNs would be 70% to 90%, and protein would be 3 to 7 g/dL. Chapter: Chapter 53, Common Musculoskeletal Complaints Page: 883 Difficulty: Moderate

19. Estrogen works to prevent osteoporosis in which of the following ways?

A. By increasing the erosive activity of osteoclasts B. By promoting osteoclastogenesis C. By inhibiting osteoclast apoptosis D. By increasing the activity of osteoblasts Answer: D Feedback: Estrogen has been shown to mediate transforming growth factor- secretion by osteoblasts.

Chapter: Chapter 56, Osteoarthritis and Osteoporosis Page: 969 Difficulty: Moderate

20. Which of the following tests is considered the gold standard for definitively diagnosing osteoporosis?

A. Bone alkaline phosphatase levels B. Urinary N-telopeptide assay C. Bone mass density (BMD) measurement by densitometry D. Magnetic resonance imaging (MRI) Answer: C Feedback: BMD measurement by densitometry is currently considered the gold standard diagnostic test for definitively diagnosing either osteopenia or osteoporosis.

Chapter: Chapter 56, Osteoarthritis and Osteoporosis Page: 970 Difficulty: Easy

21. What is the recommended daily calcium intake for men 70 years and younger?

A. 500 mg/day B. 750 mg/day C. 1,000 mg/day D. 1,500 mg/day Answer: C Feedback: The recommended daily calcium intake for men 70 years and younger is 1,000 mg daily.

Chapter: Chapter 56, Osteoarthritis and Osteoporosis Page: 973 Difficulty: Easy

22. A 60-year-old woman has been diagnosed with osteoporosis. She is very concerned about the risk of breast cancer associated with hormone replacement therapy and is wondering what other treatments are available to her. The clinician explains that bisphosphonates are another class of drugs used in the prevention and treatment of osteoporosis. What teaching should the clinician provide in regard to taking bisphosphonates?

A. Bisphosphonates can result in hypercalcemia, so calcium intake should be decreased while taking this class of drugs.

B. There is potential for upper GI irritation, so these medications are contraindicated in people with abnormalities of the esophagus or delayed esophageal emptying.

C. This class of drugs can be taken at any time of the day without regard to meals.

D. This class of drugs should be taken with orange juice to increase absorption.

Answer: B Feedback: Esophageal disorders such as achalasia, esophageal stricture, esophageal varices, and Barrett‘s esophagus are a contraindication to all bisphosphonate therapy.

Chapter: Chapter 56, Osteoarthritis and Osteoporosis Page: 973 Difficulty: Moderate

23. Which of the following medications is appropriate to treat Paget‘s disease?

A. Boniva B. Fosamax C. Reclast D. Forteo Answer: C Feedback: Zoledronic acid (Reclast, Zometa) is approved for prevention and treatment of postmenopausal osteoporosis, glucocorticoid osteoporosis, osteoporosis in men, and treatment of Paget‘s disease.

Chapter: Chapter 56, Osteoarthritis and Osteoporosis

Page: 973 Difficulty: Moderate

24. Which of the following statements concerning fibromyalgia is true?

A. Muscle pain that is caused by the development of trigger points within the muscle cannot occur concurrently with fibromyalgia.

B. A cause of myalgia can be fibromyalgia.

C. Bursitis cannot coexist with pain from fibromyalgia.

D. Fibromyalgia is an inflammatory musculoskeletal disorder.

Answer: B Feedback: Common causes of myalgia include fibromyalgia and polymyalgia rheumatica.

Chapter: Chapter 53, Common Musculoskeletal Complaints Page: 883 Difficulty: Easy

25. One of the most frequent presenting signs/symptoms of osteoporosis is A. Goiter B. Abnormal serum calcium C. Elevated urine biochemical markers D. Bone fracture Answer: D Feedback: Chief clinical manifestations of osteoporosis are vertebral and hip fractures, although fractures can occur at any skeletal site.

Chapter: Chapter 56, Osteoarthritis and Osteoporosis Page: 967 Difficulty: Easy

26. A patient is seen in the office with reports of pain and point tenderness in the area of the elbow. The pain has increased following a day of gardening 1 week ago. A physical finding that differentiates the diagnosis and is most consistent with lateral epicondylitis (tennis elbow) is A. Ecchymosis, edema, and erythema over the lateral epicondyle B. Pain at the elbow that radiates into the forearm and pain and weakness when gripping objects C. Inability to supinate and pronate the arm D. Inability to flex or extend the elbow against resistance Answer: B Feedback: Common complaints of tennis elbow are associated with pain in the lateral elbow that radiates into the forearm. There is pain and weakness when gripping objects (―coffee cup‖ sign).

Chapter: Chapter 53, Common Musculoskeletal Complaints Page: 900 Difficulty: Moderate

27. A 70-year-old woman fell 2 weeks ago and developed immediate pain in her left elbow on the lateral epicondyle. She thought she just bruised it, but is now worried because it has not improved. She has used Tylenol and ice at home, and that has helped slightly. During your examination, you find she has moderate swelling and ecchymosis, but no overtly obvious deformity. Her ROM is uncomfortable and severely diminished due to the pain. No crepitus is heard or felt. Her fingers are warm, her pulse is strong, and capillary refill is less than 2 seconds. If you suspect lateral epicondylitis, what would you do?

A. Make an immediate referral for an orthopedic surgical evaluation without further assessment.

B. Tell her that it takes time for these bruises to improve, so she should be patient.

C. Prescribe a splint for her left wrist and begin corticosteroid injections.

D. Send her to the emergency room for reduction of this obvious wrist fracture.

Answer: C Feedback: Corticosteroid injections and wrist splinting may be considered in some cases and have been shown to be effective for short-term relief of lateral epicondylitis.

Chapter: Chapter 53, Common Musculoskeletal Complaints Page: 900 Difficulty: Moderate

28. A 43-year-old woman is being evaluated for a wrist injury. The clinician is assessing for median nerve compression by having the patient maintain forced flexion of her wrist for 1 minute with the dorsal surface of each hand pressed together. Which of these tests did the clinician just perform?

A. Allen‘s test B. Phalen‘s test C. Tinel‘s sign D. Finkelstein‘s test Answer: B Feedback: Phalen‘s test is performed through the following procedure: have the patient maintain forced flexion of the wrist for 1 minute or more, with the dorsal surface of each hand pressed together. If the patient complains of pain, numbness, or paresthesias in fingers, the test is considered positive.

Chapter: Chapter 53, Common Musculoskeletal Complaints Page: 901 Difficulty: Moderate

29. In which of these athletes is posterior impingement syndrome most commonly seen?

A. Cross country runner B. Swimmer C. Soccer player D. Ballet dancer Answer: D Feedback: Posterior impingement syndrome is commonly seen in ballet dancers.

Chapter: Chapter 53, Common Musculoskeletal Complaints Page: 905 Difficulty: Easy

30. The clinician is assessing diffuse hip pain. How should the clinician begin the examination?

A. The range of motion examination will begin with an assessment of the motion that causes pain.

B. Physical examination of the hip must first assess its position at rest.

C. The patient should move the hip prior to radiographic studies to determine whether they are necessary.

D. Flexion and extension of the affected hip‘s extremity should only be performed with the knee straight.

Answer: B Feedback: Physical examination of the hip must first assess position at rest, especially if there has been an injury.

Chapter: Chapter 53, Common Musculoskeletal Complaints Page: 903 Difficulty: Moderate

31. A patient visits the health-care provider with a report that walking and prolonged standing cause pain and weakness in her legs and buttocks. She expresses that she has short-term relief when she leans on the shopping cart. When she sleeps on her back, she sometimes wakes up in the night in pain. Which of the following diagnoses is most likely?

A. Multiple sclerosis B. Herniated lumbar disc C. Lumbar spinal stenosis D. Cervical spondylosis Answer: C Feedback: For patients with lumbar spinal stenosis, walking or prolonged standing is a common cause of pain and weakness in the legs and buttocks, and the patient may obtain short-term relief of leg pain from neurogenic claudication by leaning forward (manifested as ―stooping‖). When grocery shopping, the patient will lean or hang over the cart, often referred to as a ―positive shopping cart sign.‖ Chapter: Chapter 54, Spinal Disorders Page: 926–927

Difficulty: Moderate

32. Which of the following is a risk factor for overuse syndrome?

A. Body mass index <18 B. Hypothyroidism C. Rheumatoid arthritis D. Cardiac disease Answer: C Feedback: Poor cardiovascular or musculoskeletal conditioning, underlying cardiovascular disease, arthritis (OA or RA), gout, and stress may all contribute to the development of overuse syndrome.

Chapter: Chapter 55, Soft-Tissue Disorders Page: 938 Difficulty: Easy

33. Which diagnostic test is the gold standard for patients who have tendonitis and have failed conservative treatment?

A. Plain x-ray films B. MRI C. Computed tomography (CT) scan D. Surgical exploration Answer: B Feedback: MRI is the diagnostic gold standard for tendonitis but should be reserved for patients who have failed conservative treatment or have weakness of the extremity.

Chapter: Chapter 55, Soft-Tissue Disorders Page: 939 Difficulty: Easy

34. A tailor presents with pain at the base of her right thumb on abduction and extension. She also complains of pain on the radial side of her right wrist with lifting. Which of these diagnostic tests will help to determine if she has de Quervain‘s tenosynovitis?

A. Allen‘s test B. Phalen‘s maneuver C. Tinel‘s sign D. Finkelstein‘s test Answer: D Feedback: The confirmation test for de Quervain‘s tenosynovitis is Finkelstein‘s test.

Chapter: Chapter 55, Soft-Tissue Disorders Page: 943 Difficulty: Moderate

35. Which of the following should be included in teaching a patient taking Prolia?

A. This medication is an oral pill daily.

B. This medication decreases the risk of infection.

C. It is contraindicated in the event of hypocalcemia.

D. A drug holiday every 8 months is recommended.

Answer: C Feedback: History of hypocalcemia is a contraindication for bisphosphonate therapy, including denosumab (Prolia).

Chapter: Chapter 56, Osteoarthritis and Osteoporosis Page: 973 Difficulty: Moderate

36. A 67-year-old woman has a BMD reading more than 1 SD below the young adult reference mean. What is her diagnosis?

A. Normal BMD B. Osteopenia C. Osteoporosis D. Severe osteoporosis Answer: B Feedback: Diagnostic findings for osteopenia include: BMD > 1 SD below young adult reference mean (21).

Chapter: Chapter 56, Osteoarthritis and Osteoporosis Page: 970 Difficulty: Moderate

37. Most ankle pain is a result of injury that results in A. Tendon flexion B. Ligament damage C. Tendonitis D. Weak ankle inversion Answer: B Feedback: Most ankle pain is the result of ankle injury that results in ligamental damage (a sprain).

Chapter: Chapter 53, Common Musculoskeletal Complaints Page: 905 Difficulty: Moderate

38. One intervention that can be used for plantar fasciitis is wearing shoes with

A. Roomy toes B. Arch supports C. Heels D. No heel backing Answer: B Feedback: Plantar fasciitis includes subcalcaneal pain that is alleviated with supportive arches.

This can often radiate to the arch of the midfoot while the person is running, walking, or even simply standing. The pain is often worse in the morning with the first step out of bed. Plantar fasciitis findings typically include tenderness along the medial plantar aspect of the calcaneus, with forced dorsiflexion of the digits increasing the pain.

Chapter: Chapter 53, Common Musculoskeletal Complaints Page: 906 Difficulty: Moderate

39. A patient with spinal stenosis is referred to a home physical therapist to relieve symptoms.

Which exercises are best for a patient with spinal stenosis?

A. Spine bilateral twisting B. Spine extension C. Lumbar flexion D. External hip rotation Answer: C Feedback: A physical therapy program that focuses on flexibility and core strengthening to improve overall conditioning, as well as improving flexion of the spine, is ideal. Flexion of the spine increases intraspinal volume, thereby decreasing pain. Examples of lumbar flexion exercises include exercising on all fours, arching the back, or assuming the fetal position. Exercises that extend the spine should be avoided because they will likely initiate symptoms of spinal stenosis.

Chapter: Chapter 54, Spinal Disorders Page: 928 Difficulty: Difficult

40. A patient comes into the emergency room with shoulder pain with active ROM, lateral arm pain, and an increase of pain when raising their hand above their head. The patient states they were doing a lot of tree trimming in the yard 4 days ago. They noticed pain that day, but it has not gotten any better. You diagnose tendonitis in stage 2 healing. What treatment would you suggest?

A. Ice packs for 15 minutes duration B. Heat after any exercise C. Protection of the shoulder D. Corticosteroid injections Answer: B

Feedback: In the second stage of healing, the objective is to gradually introduce stress and apply modalities to increase collagen production, size, cross-linking, and alignment. Heat is effective after 48 hours in the acute phase and in the chronic phase. After the acute phase of the healing process, heat is useful in improving blood flow, relieving muscle spasms, and decreasing tissue stiffness, allowing greater ease of deformation.

Chapter: Chapter 55, Soft Tissue Disorders Page: 940 Difficulty: Difficult

Section 11. Endocrine and Metabolic Problems

MULTIPLE CHOICE

1. A patient is 66 inches in height, weighing 200 lbs, and newly diagnosed with type 2 diabetes mellitus (T2DM). The A1C is 7.1%. What is the best initial treatment?

A. No treatment at this time B. Diet and exercise C. Diet, exercise, and metformin D. Diet, exercise, and exogenous insulin

Answer: C Feedback: Lifestyle management is an important part of treatment for T2DM and comprises nutrition therapy, activity prescriptions for exercise, decreased prolonged sitting, and, in older adults, training in balance and flexibility. The ADA and AACE recommend metformin (Glucophage) if there are no contraindications.

Chapter: Chapter 59, Diabetes Mellitus Page: 1031–1033 Difficulty: Moderate

2. The clinician suspects that a patient seen in the office has hyperthyroidism. Which test should the clinician order on the initial visit?

A. Sensitive thyroid-stimulating hormone (TSH) assay and T4 B. Free T4 and serum calcium C. Nuclear scintigraphy with radiolabeled iodine (123I) D. Magnetic resonance imaging

Answer: A Feedback: The initial screening tests for suspected hyperthyroidism are a serum TSH assay to detect suppressed thyrotropin levels in the setting of elevated thyroid hormones, as well as measurement of T4 and T3 levels.

Chapter: Chapter 58, Glandular Disorders Page: 988 Difficulty: Moderate

3. Which statement made by a patient with type 1 diabetes indicates successful teaching regarding general guidelines for exercise?

A. “I will not exercise if my blood sugar is 315.”

B. “I should just check my blood glucose after exercise.”

C. “I should eat more carbohydrates if my blood glucose is less than 200.”

D. “I will exercise when my urine ketones are positive but blood sugar is 260.”

Answer: A

Feedback: Patients with type 1 diabetes should avoid physical activity if fasting glucose is more than 250 mg/dL and ketosis is present or if the glucose level is more than 300 mg/dL, regardless of whether ketosis is present.

Chapter: Chapter 59, Diabetes Mellitus Page: 1025 Difficulty: Moderate

4. A male patient with type 1 diabetes comes to the clinic complaining of feeling nervous and clammy. He states that he took his insulin this morning but was late for work and did not eat breakfast. Which action should the clinician take first?

A. Administer glucagon subcutaneously.

B. Have him drink 4 ounces of juice.

C. Call 911.

D. Ask him about his usual eating habits.

Answer: B Feedback: Examples of appropriate foods to rapidly raise blood sugar include one-half cup of any fruit juice (with no additional sugar added), 6 ounces of regular soda (not diet or sugarless), 1 cup of milk, or glucose tablets.

Chapter: Chapter 59, Diabetes Mellitus Page: 1023 Difficulty: Moderate

5. A patient with type 2 diabetes comes to the clinic after reading about metformin in a magazine. Which condition would be a contraindication to taking metformin?

A. Ulcerative colitis B. Inflammatory bowel disease C. Chronic obstruction pulmonary disease D. Renal disease

Answer: D Feedback: The ADA and AACE recommend metformin (Glucophage) if there are no contraindications, such as renal disease or abnormal creatinine clearance, acute myocardial infarction, or septicemia.

Chapter: Chapter 59, Diabetes Mellitus Page: 1033 Difficulty: Moderate

6. A 25-year-old patient presents to the clinic with fatigue, cold intolerance, weight gain, and constipation for the past 3 months. On physical examination, the clinician notices muscular stiffness, coarse, dry hair, and a delay in relaxation in deep tendon reflexes. Which test should be ordered next?

A. Serum calcium B. TSH C. Electrolytes D. Urine specific gravity

Answer: B

Feedback: Classic early symptoms of hypothyroidism include fatigue, dry skin, slight weight gain, cold intolerance, constipation, and heavy menses; later symptoms include very dry skin, coarse hair, loss of lateral eyebrows, alopecia, hoarseness, continued weight gain, slight impairment in mental ability, depression, decreased libido, and hypersomnia. The diagnosis of hypothyroidism is made by measuring serum TSH, and both TSH and FT4 levels should be used to monitor treatment.

Chapter: Chapter 58, Glandular Disorders Page: 996 Difficulty: Moderate

7. The clinician has been doing diabetic teaching for a patient with type 1 diabetes with no retinopathy. Which statement by the patient would indicate that teaching has been effective?

A. “As long as I don’t need glasses, I don’t have to worry about going blind.”

B. “I know I need to have my eyes checked every 2 years.”

C. “My primary doctor will check my eyes.”

D. “I will begin to see my eye doctor when my vision gets blurry.”

Answer: B Feedback: The ADA recommends that adults with type 1 DM (T1DM) should be seen by an ophthalmologist or optometrist and have a dilated comprehensive eye examination within the first 5 years of diagnosis. If there is no retinopathy at the first evaluation, an eye examination should be done every 2 years.

Chapter: Chapter 59, Diabetes Mellitus Page: 1038 Difficulty: Moderate

8. A 64-year-old man with type 2 diabetes presents to the clinic with the complaint of “my feet feel like they are on fire.” He has a loss of vibratory sense and +1 Achilles reflex. Which of the following would be an appropriate treatment?

A. Tricyclic antidepressants B. Angiotensin-converting enzyme inhibitors C. Aspirin D. Insulin

Answer: A Feedback: Peripheral neuropathy may result in pain, loss of sensation, and muscle weakness, and the feet and ankles are affected most often. Nonopioid analgesics, calcium channel blockers, narcotic analgesics, tricyclic antidepressants, antiarrhythmics, and local anesthetics are frequently prescribed.

Chapter: Chapter 59, Diabetes Mellitus Page: 1038 Difficulty: Moderate

9. A patient is prescribed radioactive iodine (RAI) for thyroid disorder and asks the clinician how the drug works. The clinician’s response should include what information?

A. RAI prevents the peripheral conversion of T4 to T3.

B. RAI binds free T4.

C. RAI destroys thyroid tissue.

D. RAI reduces freely circulating iodine.

Answer: C Feedback: RAI concentrates in overactive thyroid cells, where it emits radiation, causing inflammation and the ultimate destruction of the pathological cells.

Chapter: Chapter 58, Glandular Disorders Page: 991 Difficulty: Moderate

10. A patient is diagnosed with hypothyroidism. Which electrocardiogram change should the clinician observe as a manifestation of the disease?

A. Sinus bradycardia B. Atrial fibrillation C. Supraventricular tachycardia D. U waves

Answer: A Feedback: The patient with hypothyroidism may have facial puffiness, periorbital edema, dry and thick skin, dry and coarse hair, brittle nails, slow speech, bradykinesia, hoarseness, an enlarged tongue, bradycardia, mild diastolic hypertension, psychological disorders, and pitting edema of the lower extremities.

Chapter: Chapter 58, Glandular Disorders Page: 996 Difficulty: Moderate

11. What abnormal laboratory finding would the clinician observe in a patient with untreated Graves’ disease?

A. Elevated TSH B. Decreased T3 C. Decreased TSH receptor antibody test D. Elevated antithyroglobulin antibodies

Answer: D Feedback: In Graves’ disease, antithyroglobulin and antimicrosomal antibodies are elevated.

Chapter: Chapter 58, Glandular Disorders Page: 989 Difficulty: Easy

12. The clinician prescribes glipizide (Glucotrol) for a diabetic patient. Which statement made by the patient would indicate teaching has been effective?

A. “I’ll take my pill before breakfast.”

B. “I know to take my Glucotrol at bedtime.”

C. “It is important to take my medication right after I eat.”

D. “Because I only like to eat two meals a day, I can take the pill between my meals.”

Answer: A Feedback: Therapy with sulfonylureas (such as glipizide) should be initiated at the lowest possible dose and usually begins with a once-daily dose before breakfast.

Chapter: Chapter 59, Diabetes Mellitus Page: 1036

Difficulty: Moderate

13. A male patient with diabetes asks the clinician why he needs to check his blood sugar at home even when he feels good. Which response by the clinician would be most appropriate?

A. “Control of glucose will help postpone or delay complications.”

B. “Regularly checking blood sugar will help you.”

C. “Monitoring glucose will promote a sense of connectedness.”

D. “Because you know it is the right thing to do for your disease.”

Answer: A Feedback: Used properly, self-monitoring of blood glucose levels is the most practical mechanism to maintain glucose levels as close to normal as possible and to prevent the most common complication of DM therapy—hypoglycemia. The correct answer gives the reason why it is important to monitor blood sugar levels; the other responses are correct but do not provide therapeutic communication and are dismissive of the education that is needed.

Chapter: Chapter 59, Diabetes Mellitus Page: 1014 Difficulty: Moderate

14. The clinician sees a patient who has a body mass index (BMI) of 32.4 kg/m2. How would the clinician classify this patient?

A. Overweight B. Obesity class 1 C. Obesity class 2

D. Obesity class 3

Answer: B Feedback: BMI of 30 to 34.9 kg/m2 is classified as obesity class 1.

Chapter: Chapter 60, Metabolic Disorders Page: 1048 Difficulty: Moderate

15. A patient presents in the clinic with pain, tenderness, erythema, and swelling of his left great toe. The clinician suspects acute gout. Which of the following should the clinician expect in the initial test results for this patient?

A. Elevated uric acid level B. Elevated blood urea nitrogen C. Decreased urine pH D. Decreased C-reactive protein

Answer: A Feedback: Overproduction and/or underexcretion of uric acid with tissue deposition of monosodium urate crystals is the metabolic disorder underlying gout. Most individuals (90%) with gout have inappropriate underexcretion of uric acid.

Chapter: Chapter 60, Metabolic Disorders Page: 1055 Difficulty: Easy

16. Which blood test would confirm a diagnosis of DM? A. A1C 5.5% B. Fasting plasma glucose level of 120 mg/dL C. Oral glucose tolerance test (OGTT) 250 mg/dL (2-hour level) D. Random plasma glucose level 175 mg/dL

Answer: C Feedback: Two-hour plasma glucose level of 200 mg/dL or higher during an OGTT with a 75-g glucose load can be used to diagnose DM. Chapter: Chapter 59, Diabetes Mellitus Page: 1018 Difficulty: Easy

17. A vegetarian patient with gout asks the clinician about foods to avoid. The clinician should advise the patient to avoid which of the following foods?

A. Rice B. Carrots C. Spinach D. Potatoes

Answer: C Feedback: Purine-rich foods (such as beans, peas, lentils, oatmeal, spinach, asparagus, cauliflower, and mushrooms) typically trigger gout.

Chapter: Chapter 60, Metabolic Disorders

Page: 1055 Difficulty: Moderate

18. The clinician should question the patient with suspected gout about use of which of these medications?

A. Antihypertensives B. Thiazide diuretics C. Cardiac glycosides D. Potassium supplements

Answer: B Feedback: Secondary causes of gout include other disease processes and medications, such as thiazide diuretics, that result in an overproduction or underexcretion of uric acid.

Chapter: Chapter 60, Metabolic Disorders Page: 1055 Difficulty: Moderate

19. The clinician finds numerous nodules on the thyroid of a 85-year-old woman. The clinician suspects thyroid cancer. Which data would be most significant for this patient?

A. A history of enlarged tonsils in the 1940s B. Recent exposure to mumps C. Vegetarian diet D. Allergy to iodine

Answer: A Feedback: Until the 1950s, radiation treatments were given to children as treatment for an enlarged thymus, enlarged tonsils, and acne. Studies have estimated that one-third of patients who received radiation therapy to the head and neck will develop a thyroid nodule, and one-third of those patients will later develop a thyroid malignancy.

Chapter: Chapter 58, Glandular Disorders Page: 1003 Difficulty: Moderate

20. Which of the following is essential for diagnosing thyroid cancer?

A. Fine needle aspiration (FNA) biopsy B. Thyroid ultrasound C. Computed tomography (CT) scan D. Magnetic resonance imaging

Answer: A Feedback: FNA biopsy is usually successful in differentiating benign from cancerous lesions of the thyroid gland and has 83% sensitivity and 92% specificity for thyroid cancer.

Chapter: Chapter 58, Glandular Disorders Page: 1004 Difficulty: Easy

21. Which of the following is a common sign of T2DM? A. Anorexia B. Recurrent yeast infection C. Fluid overload D. Decreased

high-density lipoprotein cholesterol

Answer: B Feedback: The typical patient with T2DM is often obese, with a history of dyslipidemia, hypertension, and CAD. Abnormal healing and an increased occurrence of infection, especially yeast infection, may also be present.

Chapter: Chapter 59, Diabetes Mellitus Page: 1029 Difficulty: Easy

22. Which laboratory test result is diagnostic for hypoglycemia?

A. A1C 7.0% B. Fasting blood sugar of 75 mg/dL C. Glucose level 43 mg/dL D. Random glucose level 64 mg/dL

Answer: C Feedback: Hypoglycemia is defined as a plasma glucose less than 54 mg/dL, although the glucose alert value is typically set at less than 70 mg/dL. Chapter: Chapter 59, Diabetes Mellitus Page: 1037

Difficulty: Easy

23. Which medication for T2DM would be contraindicated during pregnancy?

A. Insulin B. Metformin (Glucophage) C. Glipizide (Glucotrol) D. Acarbose (Precose)

Answer: C Feedback: Sulfonylureas (such as Glucotrol) are not recommended for use during the third trimester of pregnancy or for women who are planning a pregnancy.

Chapter: Chapter 59, Diabetes Mellitus Page: 1039 Difficulty: Easy

24. A 35-year-old woman presents with symptoms of hypoglycemia. She has no history of DM. Which condition should be included in the differential diagnosis?

A. Peripheral vascular disease B. Pheochromocytoma C. Cushing’s disease D. Acromegaly

Answer: B Feedback: Differential diagnoses that share many of the same signs and symptoms of hypoglycemia include generalized anxiety disorder, panic attacks, hyperventilation, pheochromocytoma, drug or alcohol intoxication, transient ischemic attack, cerebrovascular accident, and psychosis.

Chapter: Chapter 59, Diabetes Mellitus Page: 1045 Difficulty: Moderate

25. Which action would the clinician take to elicit Chvostek’s sign?

A. Check serum level of glucose after drinking a glass of juice.

B. Tap the facial nerve below the zygomatic arch anterior to the earlobe.

C. Press into the lower quadrant of the abdomen and release quickly.

D. Pump a blood pressure cuff 20 mm Hg above the patient’s systolic pressure.

Answer: B Feedback: Chvostek’s sign is an abnormal unilateral spasm of the facial muscle when the facial nerve is tapped below the zygomatic arch anterior to the earlobe.

Chapter: Chapter 57, Common Endocrine and Metabolic Complaints Page: 979 Difficulty: Easy

26. The clinician should examine which area for gynecomastia (GM)?

A. Woman’s vagina B. Man’s breast C. Man’s penis D. Woman’s ovaries

Answer: B Feedback: GM is the enlargement of glandular breast tissue in individuals assigned male at birth, resulting in increased breast size.

Chapter: Chapter 57, Common Endocrine and Metabolic Complaints Page: 980 Difficulty: Easy

27. Which slightly elevated laboratory result would the clinician observe in a patient with idiopathic hirsutism?

A. Free testosterone B. Luteinizing hormone (LH)/follicle-stimulating hormone (FSH) C. Serum calcium D. Albumin

Answer: A Feedback: Slightly elevated levels of serum androgens (free testosterone) are found in 40% of women with idiopathic hirsutism.

Chapter: Chapter 57, Common Endocrine and Metabolic Complaints Page: 981 Difficulty: Easy

28. The clinician is assessing for the most common cause of increased neck size. What would the clinician examine?

A. Salivary glands B. Lymph nodes C. Thyroid D. Trachea

Answer: C Feedback: The most common cause of increased neck size is an enlarged thyroid gland.

Chapter: Chapter 57, Common Endocrine and Metabolic Complaints Page: 982 Difficulty: Easy

29. Which word is a component of the “3 Ps” of DM? A. Pain B. Paresthesia C. Pallor D. Polyphagia

Answer: D Feedback: The 3 Ps of DM are polydipsia, polyphagia, and polyuria.

Chapter: Chapter 57, Common Endocrine and Metabolic Complaints Page: 983 Difficulty: Easy

30. A woman presents with new-onset hoarseness with hemoptysis. Which condition should the clinician focus on during the examination?

A. Hyperthyroidism B. Pheochromocytoma C. Cushing’s syndrome D. Thyroid cancer

Answer: D Feedback: The major symptom of thyroid cancer is a lump or nodule in the neck, which is usually painless, but patients may also complain of a tight or full feeling in the neck, difficulty breathing or swallowing, hoarseness, hemoptysis, and swollen lymph nodes. In particular, the new onset of hoarseness with hemoptysis is strongly suggestive of a malignant growth.

Chapter: Chapter 58, Glandular Disorders Page: 1004 Difficulty: Moderate

31. A patient presents to the clinic with a “buffalo hump,” weight gain, easy bruising, and hyperpigmentation. Which initial diagnostic test should the clinician order?

A. 1 mg overnight dexamethasone suppression test (DST)

B. Abdominal CT scan C. RAI uptake testing D. Early-morning salivary cortisol

Answer: A Feedback: The overnight DST assists in the confirmation of hypercortisolemia. In this test, the patient ingests 1 mg of dexamethasone (Decadron) orally at 11:00 p.m., and the plasma cortisol level is measured at 8:00 the next morning (when physiological cortisol levels are typically highest).

Chapter: Chapter 58, Glandular Disorders Page: 1008 Difficulty: Moderate

32. The clinician suspects a patient has Addison’s disease. Which clinical manifestation would the clinician observe upon a physical examination?

A. Moon face B. Central obesity C. Hyperpigmentation D. Myxedema coma

Answer: C Feedback: Hyperpigmentation is typically seen in Addison’s disease (as both ACTH and corresponding melanocortin levels are low).

Chapter: Chapter 58, Glandular Disorders Page: 1012

Difficulty: Moderate

33. A patient with type 1 diabetes is exhibiting Kussmaul respirations, anorexia, fatigue, and increased thirst. Which condition should the clinician manage?

A. Hypoglycemia B. Somogyi effect C. Diabetic ketoacidosis (DKA) D. Hyperosmolar hyperglycemic syndrome

Answer: C Feedback: Kussmaul respirations, anorexia, fatigue, and increased thirst are initial signs of DKA. Chapter: Chapter 59, Diabetes Mellitus Page: 1020 Difficulty: Moderate

34. A patient has hyperosmolar hyperglycemic syndrome. Which laboratory findings would the clinician observe?

A. Plasma bicarbonate 8 mEq/L B. Blood glucose level 40 mg/dL C. Serum osmolality 420 mOsm/kg D. Blood pH 7.20

Answer: C Feedback: Serum osmolality greater than 400 mOsm/kg is one of the clinical presentations of hyperosmolar hyperglycemic syndrome.

Chapter: Chapter 59, Diabetes Mellitus Page: 1029 Difficulty: Moderate

35. Which question asked by the clinician reflects the most frequent cause of DKA? A. “How often are you taking the insulin?”

B. “Have you experienced an infection recently?”

C. “What type of diet have you been following?”

D. “Is there any reason you don’t like taking your medications?”

Answer: B Feedback: Underlying infection is the most common cause of DKA. Chapter: Chapter 59, Diabetes Mellitus Page: 1020 Difficulty: Moderate

36. A patient with type 1 diabetes has DKA. Which first-line treatment should the clinician prescribe?

A. NPH insulin

B. Regular insulin C. IV normal saline D. Thiazolidinedione

Answer: B Feedback: First line of treatment for DKA is regular insulin.

Chapter: Chapter 59, Diabetes Mellitus Page: 1020 Difficulty: Moderate

37. A nondiabetic patient has idiopathic hypoglycemia. Which dietary instruction should the patient be educated on?

A. Follow a low-protein, high-carbohydrate diet.

B. Allow caffeine at each meal.

C. Avoid nuts and seeds.

D. Eat six small meals a day.

Answer: D Feedback: In patients with pseudohypoglycemia or idiopathic hypoglycemia in which a cause cannot be identified, treatment consists primarily of dietary modifications. A high-protein, low-carbohydrate diet divided into six small meals per day often relieves symptoms.

Chapter: Chapter 59, Diabetes Mellitus Page: 1045 Difficulty: Moderate

38. The clinician is using the HALT acronym to help a patient identify overeating triggers.

What does the “T” represent?

A. Tired B. Tense C. Temper D. Threats

Answer: A Feedback: The HALT acronym stands for hungry, angry, lonely, and tired.

Chapter: Chapter 60, Metabolic Disorders Page: 1052 Difficulty: Easy

39. A patient weighs 350 lbs and is on a weight loss program. After 6 months, which ideal weight in pounds should the clinician observe?

A. 335 B. 325 C. 315 D. 305

Answer: C

Feedback: Weight management should be directed toward an initial goal of decreasing the patient’s weight by 5% to 10% over 6 months, which has been shown to improve the risk factor profile associated with obesity.

Chapter: Chapter 60, Metabolic Disorders Page: 1052 Difficulty: Moderate

40. Which instruction should the clinician include in patient teaching regarding management of obesity?

A. Occasionally skipping meals is acceptable.

B. Try to use nonstick cookware when baking or frying.

C. High-intensity physical activity is recommended.

D. Exercise for about 100 minutes per week.

Answer: B Feedback: Many patients are unaware of techniques to reduce fat in their diet by cooking methods alone, including, for example, the use of nonstick cookware that removes the need to use fat or grease in the pan.

Chapter: Chapter 60, Metabolic Disorders Page: 1054 Difficulty: Easy

41. A patient has metabolic syndrome. The patient is at increased risk for which condition?

A. Anxiety disorder B. Gallbladder disease C. DM D. Hyperparathyroidism

Answer: C Feedback: Metabolic syndrome is defined as a constellation of risk factors including hypertension, hyperlipidemia, insulin resistance, and overweight/obesity that significantly increase an individual’s risk of cardiovascular disease and DM. Chapter: Chapter 60, Metabolic Disorders Page: 1051 Difficulty: Easy

42. A 45-year-old man presents with throbbing podagral pain and tophi in the ear pinnae.

Which medication should the clinician prescribe for this acute attack?

A. Colchicine (Colcrys) B. Probenecid (Benemid) C. Allopurinol (Zyloprim) D. Pegloticase (Krystexxa)

Answer: A Feedback: Pharmacological treatment for an acute attack includes NSAIDs, colchicine (if the onset of symptoms is less than 36 hours), and corticosteroids.

Chapter: Chapter 60, Metabolic Disorders Page: 1059

Difficulty: Moderate

43. What can occur if serum calcium levels drop by 2 to 3 mg/dL? A. Hair and nail growth B. Excessive eating C. Menstrual irregularities D. Spontaneous spasms of lower extremities

Answer: D Feedback: In severe hypocalcemia, spontaneous spasms may also occur in the lower extremities and feet.

Chapter: Chapter 57, Common Endocrine and Metabolic Complaints Page: 979 Difficulty: Easy

44. When would GM need to be referred to an endocrinologist?

A. When pain is present B. When it occurs with a chronic disease C. When it is present for a year D. When a 13-year-old starts to develop sex characteristics

Answer: B

Feedback: GM requires investigation and referral to an endocrinologist when it presents before or after puberty and cannot be associated with physiological aging, as a result of a drug side effect, is chronic, does not resolve within 2 years after puberty, occurs in the presence of abnormal serum levels of free testosterone and LH, or when it is accompanied by the abnormal presence or the absence of secondary sex characteristics (undermasculinization or small asymmetrical testes).

Chapter: Chapter 57, Common Endocrine and Metabolic Complaints Page: 980 Difficulty: Moderate

45. A 36-year-old woman presents with concerns of coarse hair growth on her chin, abdomen, and back. The health-care provider suspects hirsutism. Which test should be ordered to determine the underlying cause?

A. TSH B. HBA1C C. Estrogen levels D. Ultrasound of the neck

Answer: A Feedback: Evaluation of free and total testosterone, androstenedione, 17-hydroxyprogesterone, urine 17-hydroxycorticosteroids, TSH, prolactin, LH, FSH, and dehydroepiandrosterone sulfate (DHEA-S) levels will provide insights into possible causes of hirsutism and the need for further evaluation.

Chapter: Chapter 57, Common Endocrine and Metabolic Complaints Page: 981 Difficulty: Moderate

46. A patient presents with symptoms of thyrotoxicosis factitia. What important health history information would be necessary?

A. “What were you doing this morning before the symptoms started?”

B. “How much of your thyroid medication have you taken in the last 3 days?”

C. “When did you see your health-care provider last?”

D. “Where do you live?”

Answer: B Feedback: Thyrotoxicosis factitia is a form of thyrotoxicosis in which a patient takes excessive amounts of either T4 or T3. This condition should be considered in a patient with access to hormone supplements or with psychiatric problems. An excess of dietary iodine may also precipitate symptoms of hyperthyroidism, as the exogenous iodine acts as a rich substrate for thyroid hormone overproduction.

Chapter: Chapter 58, Glandular Disorders Page: 985 Difficulty: Moderate

47. Older adults with hyperthyroidism are often misdiagnosed with A. Hypothyroidism B. Iodine deficiency C. Failure to thrive D. Dementia

Answer: C Feedback: Signs of thyrotoxicosis are associated with the various forms of hyperthyroidism and range from overt manifestations in young adults with an acute onset to subtler presentations in older adults. Often, an older adult will present with signs and symptoms typically diagnosed as a failure to thrive.

Chapter: Chapter 58, Glandular Disorders Page: 988 Difficulty: Easy

48. A patient arrives at the emergency department experiencing cardiovascular complications of hyperthyroidism. They also have a history of asthma and hypertension. What would the drug of choice be for the cardiac symptoms?

A. Dobutamine B. Diltiazem C. Captopril D. Atenolol

Answer: D Feedback: Patients experiencing tachycardia, palpitations, or tremors benefit from the introduction of a beta blocker, such as Atenolol, during the initiation of therapy. Beta blockers provide effective, short-term relief of hyperadrenergic symptoms. Use of a beta blocker is contraindicated in patients with COPD, bronchospasm, or uncompensated heart failure.

Chapter: Chapter 58, Glandular Disorders Page: 990 Difficulty: Difficult

49. Which of the following is a long-term management strategy in patients with hyperthyroidism?

A. Thyroid function tests should be monitored every other year.

B. Initial treatment follow-up should be done at 6 months if the patient is symptomatic.

C. After completion of radioiodine ablative therapy, thyroid function tests should be performed annually if stable.

D. Therapy with antithyroid medications should continue for 3 to 24 months.

Answer: D Feedback: General guidelines for long-term follow-up include monitoring thyroid function tests at least twice a year; evaluating initial treatment at 1 month and 6 months or more frequently if the patient is symptomatic; continuing therapy with antithyroid medications for 3 to 24 months and after radioiodine ablative therapy; and performing thyroid function tests at 4 to 6 weeks, 12 weeks, 6 months, and annually thereafter, if stable.

Chapter: Chapter 58, Glandular Disorders Page: 992 Difficulty: Difficult

50. Patients with hypothyroidism should be cautioned about the use of which medications because of increased sensitivity?

A. ACE inhibitors B. Analgesics C. Herbal supplements D. Antivirals

Answer: B Feedback: Because of increased sensitivity to certain medications in hypothyroid patients, patients should be cautioned against the use of analgesics and sedatives. Even in small dosages, these medications can cause severe somnolence and respiratory depression.

Chapter: Chapter 58, Glandular Disorders Page: 1002 Difficulty: Moderate

Section 12. Hematological and Immunological Problems

MULTIPLE CHOICE

1. A 70-year-old patient has just been diagnosed with leukemia. They are reporting bone and joint pain. Which type of leukemia is most likely the culprit?

A. Acute lymphoblastic leukemia (ALL) B. Acute myelogenous leukemia (AML) C. Chronic myelogenous leukemia (CML) D. Chronic lymphocytic leukemia (CLL)

Answer: D Feedback: CLL is more prevalent among adults older than 60 years of age.

Chapter: Chapter 62, Hematological Disorders Page: 1094 Difficulty: Moderate

2. Which type of bone marrow transplant is obtained from an identical twin?

A. Xenograft B. Autologous C. Allogeneic D. Syngeneic

Answer: D Feedback: Syngeneic transplantation is marrow donated by an identical twin.

Chapter: Chapter 62, Hematological Disorders Page: 1100 Difficulty: Easy

3. During treatment for anaphylaxis, which site is used for the initial injection of epinephrine?

A. Antecubital vein B. Abdomen C. Upper lateral thigh D. Deltoid

Answer: C Feedback: The first step of treatment for anaphylaxis is to administer aqueous epinephrine 1:1,000 dilution 0.3 to 0.5 mg (0.3–0.5 mL) intramuscularly into the upper lateral thigh.

Chapter: Chapter 63, Immunological Disorders Page: 1105 Difficulty: Easy

4. After the initial treatment for anaphylaxis, which medication should be added to prevent late-phase anaphylactic reactions?

A. Albuterol B. Diphenhydramine C. H2 blocker D. Corticosteroid

Answer: D Feedback: After the initial treatment for anaphylaxis, add corticosteroids (IV or PO) to prevent late-phase anaphylactic reactions.

Chapter: Chapter 63, Immunological Disorders Page: 1105 Difficulty: Easy

5. Which of the following disease-modifying antirheumatic drug is a folic acid antagonist?

A. Methotrexate (Rheumatrex) B. Etanercept (Enbrel) C. Rituximab (Rituxan)

D. Anakinra (Kineret)

Answer: A Feedback: The DMARD methotrexate is a folic acid antagonist.

Chapter: Chapter 63, Immunological Disorders Page: 1122 Difficulty: Easy

6. Which statement about HIV postexposure prophylaxis (PEP) for health-care workers is the most accurate?

A. PEP treatment regimens contain two antiretroviral medications.

B. PEP should be started within 72 hours of exposure.

C. PEP follow-up requires renal function tests at 6 weeks after beginning PEP. D. PEP will prevent potential hepatitis C infection, if present.

Answer: B Feedback: PEP should be initiated within 72 hours of exposure and is unlikely to be effective if started later.

Chapter: Chapter 64, Infectious Disorders Page: 1154 Difficulty: Easy

7. For which patient would the clinician recommend annual HIV testing?

A. One who is in a mutually monogamous relationship that engages in anal sex.

B. One who is a migrant worker.

C. One who is diagnosed with viral hepatitis.

D. One who is pregnant with a second child from another male.

Answer: C Feedback: Individuals who were diagnosed or treated for viral hepatitis or TB are at higher risk of HIV infection and should be offered HIV testing at least once a year.

Chapter: Chapter 64, Infectious Disorders Page: 1153 Difficulty: Easy

8. A patient with HIV has just had a routine viral load test done. The results show a falling viral load. What does this indicate?

A. A favorable prognostic trend B. Disease progression C. The need to be more aggressive with the patient’s medications D. Drug resistance mutations

Answer: A Feedback: Viral load monitoring can establish the prognosis of a patient with HIV infection.

Rising viral load indicates disease progression; falling viral load indicates a favorable prognostic trend.

Chapter: Chapter 64, Infectious Disorders

Page: 1160 Difficulty: Moderate

9. A patient with atrial fibrillation is taking warfarin (Coumadin) and has an international normalized ratio (INR) of 4.0 with no active bleeding. How should the clinician manage this patient?

A. Stop for 1 week, and then repeat the INR. B. Withhold 1 or more days of anticoagulant therapy then repeat INR. C. Decrease the dose immediately.

D. Slowly increase the dose over 3 days.

Answer: B Feedback: If the INR is above the therapeutic target (between 2.0 and 3.0), the clinician should consider withholding 1 or more days of anticoagulant therapy.

Chapter: Chapter 61, Common Hematological and Immunological Complaints Page: 1063 Difficulty: Moderate

10. A patient with severe iron deficiency anemia is eating ice chips. Which term should the clinician use to document this finding?

A. Cheilosis B. Anorexia C. Hypochromasia

D. Pica

Answer: D Feedback: Pica is considered an objective finding associated with severe iron deficiency. Pica is identified as an eating disorder of craving for food substitutes, such as clay, dirt, ice chips, or cotton.

Chapter: Chapter 62, Hematological Disorders Page: 1070 Difficulty: Moderate

11. What is the most common cause of microcytic anemia?

A. Anemia of chronic disease B. Sideroblastic anemia C. Iron-deficiency anemia D. Pernicious anemia

Answer: C Feedback: Iron deficiency is straightforward to identify and remains the most common cause of microcytic anemia.

Chapter: Chapter 62, Hematological Disorders Page: 1067 Difficulty: Easy

12. Which symptom is the cardinal subjective symptom of sickle cell crisis?

A. Pain B. Nausea C. Light headedness D. Palpitations

Answer: A Feedback: Subjective findings of sickle cell anemia are associated with the severity of the anemia and manifest predominantly with pain when there is a crisis.

Chapter: Chapter 62, Hematological Disorders Page: 1085 Difficulty: Easy

13. Which phrase describes rheumatoid arthritis (RA)?

A. Localized synovial joint destruction B. Chronic exocrine dysfunction C. Systemic inflammatory disease D. Antibody-mediated cellular cytotoxicity response

Answer: C Feedback: RA is a chronic, progressive, systemic inflammatory disease.

Chapter: Chapter 63, Immunological Disorders Page: 1113 Difficulty: Easy

14. Which blood test is a nonspecific method and most helpful for evaluating the severity and course of the inflammatory process of RA? A. Erythrocyte sedimentation rate B. White blood cell count C. Polymorphonuclear cells D. C-reactive protein (CRP)

Answer: D Feedback: The CRP blood test is a nonspecific method for evaluating the severity and course of the inflammatory process in RA. Chapter: Chapter 63, Immunological Disorders Page: 1124 Difficulty: Easy

15. Infectious mononucleosis results from an acute infection with which of the following?

A. Epstein-Barr virus (EBV) B. Acute HIV infection C. Guillain-Barré D. Hepatitis

Answer: A

Feedback: The majority (90%) of infectious mononucleosis cases are caused by infection with EBV. Chapter: Chapter 64, Infectious Disorders Page: 1139 Difficulty: Easy

16. Which condition is the most common cause of generalized musculoskeletal pain in women ages 20 to 55?

A. Chronic fatigue syndrome (CFS) B. Anemia C. Fibromyalgia syndrome (FMS) D. Sports-related injuries

Answer: C Feedback: FMS is considered the most common cause of generalized musculoskeletal pain in females aged 20 to 55 years.

Chapter: Chapter 63, Immunological Disorders Page: 1125 Difficulty: Easy

17. After returning from visiting his grandchildren in Connecticut, a 59-year-old patient reports a flulike illness, including fever, chills, and myalgia. He reports having discovered a rash or red spot that grew in size on his right leg. Which disease should the clinician be considering?

A. Rubella B. Lyme disease C. FMS D. Shingles

Answer: B Feedback: A characteristic expanding bull’s-eye rash (erythema migrans) is typical, and positive serological markers against the causative agent (Borrelia burgdorferi) distinguish Lyme disease from RA. Chapter: Chapter 63, Immunological Disorders Page: 1116 Difficulty: Moderate

18. Dryness of the eyes and mouth is typical of which condition?

A. Sjögren’s syndrome B. Allergic reaction C. Hypothyroidism D. Sideroblastic anemia

Answer: A Feedback: Dry mouth and dry eye manifestations (sicca symptoms) are commonly seen in Sjögren’s syndrome.

Chapter: Chapter 63, Immunological Disorders Page: 1128 Difficulty: Easy

19. Exposure to ultraviolet (UV)-B and UV-A rays is a triggering factor for acute exacerbations of which condition?

A. RA B. Gout C. Systemic lupus erythematosus (SLE) D. Sjögren’s syndrome

Answer: C Feedback: Although not causative of SLE, several triggering factors for acute exacerbations have been identified. These include exposure to UVB and UVA light rays.

Chapter: Chapter 63, Immunological Disorders Page: 1132 Difficulty: Easy

20. What is the current goal of treatment for a patient with HIV infection?

A. Viral suppression to undetectable levels B. Complete eradication of the virus C. Limitation of contact with uninfected individuals D. Total abstinence

Answer: A

Feedback: The goal of HIV therapy is to render the patient’s HIV viral load so low that it cannot be measured by the test being used (i.e., below the level of detection).

Chapter: Chapter 64, Infectious Disorders Page: 1162 Difficulty: Easy

21. Which test would the clinician use to initially screen for HIV? A. Western blot B. Enzyme-linked immunosorbent assay C. HIV-1/2 antigen/antibody combination immunoassay D. Nucleic acid amplification testing

Answer: C Feedback: The Centers for Disease Control (CDC) now recommends screening for HIV using an antigen/antibody combination immunoassay, most of which detect both HIV-1 and -2.

Chapter: Chapter 64, Infectious Disorders Page: 1149 Difficulty: Easy

22. Which laboratory test would the clinician order to monitor for a significant side effect from tenofovir disoproxil fumarate (TDF)?

A. Urine protein B. Allele genetic testing

C. Sodium level D. Hemoglobin

Answer: A Feedback: Patients on TDF or TAF should be monitored routinely with tests of creatinine clearance (calculated), serum phosphorus, and urinary protein (proteinuria).

Chapter: Chapter 64, Infectious Disorders Page: 1162 Difficulty: Moderate

23. Which drug category of antiretroviral (ARV) therapy is generally effective in crossing the blood–brain barrier and may be useful in managing HIV-associated dementia?

A. Nucleoside reverse transcriptase inhibitors (NRTI) B. Protease inhibitors C. Integrase inhibitors D. Nonnucleoside reverse transcriptase inhibitors (NNRTI)

Answer: D Feedback: The NNRTIs are generally effective in crossing the blood–brain barrier and may be useful in managing HIV-associated dementia.

Chapter: Chapter 64, Infectious Disorders Page: 1161 Difficulty: Easy

24. Spontaneous bruising may be seen with platelet counts below what level?

A. 100,000 cells/mL B. 75,000 cells/mL C. 50,000 cells/mL D. 30,000 cells/mL

Answer: D Feedback: Spontaneous bruising may be seen with platelet counts less than 30,000 cells/mL, particularly on the arms and legs.

Chapter: Chapter 61, Common Hematological and Immunological Complaints Page: 1063 Difficulty: Easy

25. Which type of fatigue may improve with exercise after awakening?

A. Functional B. Acute C. Persistent D. Anemia associated

Answer: A Feedback: Functional fatigue is more typically characterized by fatigue on awakening that may improve after exercise.

Chapter: Chapter 61, Common Hematological and Immunological Complaints

Page: 1064 Difficulty: Easy

26. Which assessment finding presents with early rheumatoid disease?

A. Pain and swelling in both small and large peripheral joints B. Rigid joints with diminished range of motion C. Joint swelling and immobility on rising in the morning D. A cardiac rub with pulmonary friction rub

Answer: C Feedback: Joint swelling and immobility on rising, which abate or diminish throughout the day, characterize early rheumatoid disease.

Chapter: Chapter 63, Immunological Disorders Page: 1115 Difficulty: Easy

27. Which test is diagnostic of RA? A. Rheumatoid factor (RF) B. Erythrocyte sedimentation rate C. CRP D. Anticitrulline-containing peptide titers

Answer: A Feedback: The preferred initial test for diagnosis of RA is measurement of peripherally circulating RF. Chapter: Chapter 63, Immunological Disorders Page: 1116 Difficulty: Easy

28. What is the mainstay of management for infectious mononucleosis?

A. Antivirals B. Supportive care C. Corticosteroids D. Isolation

Answer: B Feedback: The mainstay of management of infectious mononucleosis is supportive care.

Chapter: Chapter 64, Infectious Disorders Page: 1142 Difficulty: Easy

29. CFS tends to occur in which individuals?

A. Active, highly functional adults B. Depressed middle-aged adults

C. Individuals with a depressed immune system D. Individuals who are hypochondriacs

Answer: B Feedback: CFS has been widely recognized in persons with comorbid psychiatric illness, because nearly two-thirds of CFS patients meet criteria for depression or anxiety disorders.

Chapter: Chapter 63, Immunological Disorders Page: 1124 Difficulty: Easy

30. What is the bull’s-eye rash of Lyme disease called?

A. Erythema infectiosum B. Viral exanthem C. Erythema migrans D. Morbilliform exanthem

Answer: C Feedback: A characteristic expanding bull’s-eye rash (erythema migrans) is typical with Lyme disease.

Chapter: Chapter 63, Immunological Disorders Page: 1116 Difficulty: Easy

31. Keratoconjunctivitis sicca is a classic sign of which condition?

A. SLE B. Sjögren’s syndrome C. FMS D. Lyme disease

Answer: B Feedback: Pooling of lymphocytes and plasma cells in the lacrimal glands causes the characteristic dry eye conjunctivitis of Sjögren’s syndrome, called “keratoconjunctivitis sicca.”

Chapter: Chapter 63, Immunological Disorders Page: 1129 Difficulty: Easy

32. A person of which descent is four times more likely to develop SLE than a person of European descent?

A. African B. East Asian C. Hispanic D. Middle Eastern

Answer: A Feedback: Persons of African descent are four times more likely to develop SLE compared with those of European descent.

Chapter: Chapter 63, Immunological Disorders Page: 1132 Difficulty: Easy

33. An older adult patient has an infection. The clinician should assess for which clinical manifestation?

A. Fever B. Dementia C. Confusion D. Ecchymosis

Answer: C Feedback: Symptoms more commonly indicative of an infection include malaise, fatigue, decreased appetite, decreased mentation, delirium, or confusion.

Chapter: Chapter 61, Common Hematological and Immunological Complaints Page: 1064 Difficulty: Moderate

34. Which factor should the clinician consider when trying to determine the cause of lymphadenopathy?

A. Prothrombin time B. Marital status C. Patient’s age

D. Blunt trauma

Answer: C Feedback: The differential diagnosis of lymphadenopathy depends on the location of nodal involvement, patient characteristics, and associated findings. Neck masses, for example, involve a differential that is based on nodal abnormalities manifesting in specific locations of the neck, the age of the patient, and associated comorbidities or risk factors such as tobacco use.

Chapter: Chapter 61, Common Hematological and Immunological Complaints Page: 1065 Difficulty: Moderate

35. A patient has a fever of 104.2°F (40.1°C). Which condition should the clinician be considering as the etiology of the fever?

A. Urinary tract infection B. Infectious hepatitis C. Tuberculosis D. Pancreatitis

Answer: D Feedback: Fevers in excess of 104°F (40°C) tend to be associated with pancreatitis, pyelonephritis, and intracranial pathology (e.g., bacterial meningitis).

Chapter: Chapter 61, Common Hematological and Immunological Complaints Page: 1065 Difficulty: Moderate

36. In which area would the clinician evaluate a tender point in a patient with suspected FMS? A. Fifth rib B. Trapezius C. Maxillary D. Midforearm

Answer: B Feedback: Diagnostic criteria for fibromyalgia include pain that exists in at least 11 of 18 tender points on digital palpation, such as the trapezius.

Chapter: Chapter 63, Immunological Disorders Page: 1126 Difficulty: Moderate

37. A patient has CFS. Which strategy should the clinician consider to manage this patient?

A. Bedrest B. High-impact exercise C. Thermal biofeedback D. Cognitive behavioral therapy

Answer: D

Feedback: The two therapies that have been shown to be beneficial in terms of symptom relief and increased function (albeit not curative) are cognitive behavioral therapy, which changes beliefs and behaviors that are barriers to recovery, and graded exercise.

Chapter: Chapter 63, Immunological Disorders Page: 1127 Difficulty: Moderate

38. Which classic rash should the clinician assess for in a patient with SLE? A. Butterfly B. Bull’s-eye C. Ringworm D. “Slapped” cheeks

Answer: A Feedback: Malar rash—bilateral butterfly formation across the cheeks and nasal bridge—should be assessed for in a patient with SLE. Chapter: Chapter 63, Immunological Disorders Page: 1133 Difficulty: Moderate

39. Which blood cell is excessively elevated in a person who has absolute polycythemia?

A. Platelets B. Neutrophils

C. Red blood cells (RBCs) D. All types of blood cells

Answer: C Feedback: There is an elevated RBC count in absolute polycythemia.

Chapter: Chapter 62, Hematological Disorders Page: 1089 Difficulty: Easy

40. Which treatment would the clinician recommend for a patient who has relative polycythemia?

A. Rehydration B. Antihistamines C. Weekly phlebotomies D. Referral to hematologist

Answer: A Feedback: Relative polycythemia is associated with dehydration; therefore, the key objective is to rehydrate the patient.

Chapter: Chapter 62, Hematological Disorders Page: 1091 Difficulty: Moderate

41. Which behavior would the clinician advise the patient with sickle cell anemia to avoid?

A. Becoming overhydrated B. Taking folic acid supplements C. Becoming physically overtaxed D. Taking rest periods during the day

Answer: C Feedback: Self-care behaviors that may prevent sickle cell crises should be reinforced regularly. These include adequate hydration, folic acid supplementation, avoidance of situations that tax the patient’s physical and emotional stamina, and adequate sleep and rest as part of everyday activities.

Chapter: Chapter 62, Hematological Disorders Page: 1088 Difficulty: Moderate

42. The clinician must differentiate chronic vitamin B12 deficiency anemia from folate deficiency anemia. Which action should the clinician initially take?

A. Obtain a complete blood count.

B. Assess for peripheral neuropathy.

C. Inspect for smooth surface on tongue.

D. Determine the size of the RBCs.

Answer: B Feedback: Patients may have complaints consistent with peripheral neuropathy that typically

do not occur in folate deficiency but are part of the symptom constellation associated with chronic vitamin B12 deficiency.

Chapter: Chapter 62, Hematological Disorders Page: 1081 Difficulty: Moderate

43. Which finding from bone marrow aspiration is typical in a patient with CML? A. Schistocytes B. Howell-Jolly bodies C. Hemoglobin S gene D. Philadelphia chromosome

Answer: D Feedback: CML is most commonly associated with the development of the Philadelphia chromosome in a hematopoietic stem cell that commits to the myeloid lineage.

Chapter: Chapter 62, Hematological Disorders Page: 1096 Difficulty: Easy

44. How long would the clinician inform a school-aged patient to rest after onset of infectious mononucleosis?

A. 4 days B. 10 days

C. 2 weeks D. 4 weeks

Answer: D Feedback: Young, school-aged patients must be warned of the dangers of contact sports and rough-housing for at least 4 weeks after the onset of symptoms because splenic rupture predominantly occurs within 3 weeks of symptom onset and may also occur in the absence of frank splenomegaly (50% of splenic rupture cases).

Chapter: Chapter 64, Infectious Disorders Page: 1142 Difficulty: Moderate

45. A patient presents with symptoms of infectious mononucleosis. Which laboratory chemistry test should the clinician order?

A. Viral load B. Hemoglobin A1c C. Western blot assay D. Heterophile antibody test

Answer: D Feedback: Often the diagnosis of infectious mononucleosis can be made with clinical symptoms and with results from a complete blood count (CBC), serum chemistries, and a heterophile antibody test (Monospot).

Chapter: Chapter 64, Infectious Disorders Page: 1141 Difficulty: Moderate

46. The advanced practice registered nurse (APRN) is providing a community health program for the prevention of Lyme disease. Which information should be included?

A. Safe sex practices B. Hiking precautions C. Smoking cessation D. Vaccination schedules

Answer: B Feedback: People should be encouraged to avoid foliage (where ticks may reside), especially at the ankle level and along wooded paths and to walk in the center of the path to avoid low-lying brush. Hikers should wear clothing that can prevent ticks from attaching to the skin.

Chapter: Chapter 64, Infectious Disorders Page: 1147 Difficulty: Moderate

47. What is the most common laboratory abnormality encountered in primary care?

A. Anemia B. Hyperkalemia C. Hyponatremia D. Pancytopenia

Answer: A Feedback: Evaluation of anemia is extremely common in clinical practice and is one of the most common laboratory abnormalities encountered in the primary care setting. “Anemia” can mean any one of several problems that involve suboptimal RBC numbers or functions.

Chapter: Chapter 62, Hematological Disorders Page: 1066 Difficulty: Moderate

48. A patient presents with symptoms of fatigue, sallow coloring, tachypnea and tachycardia.

You order routine blood work. Which finding is consistent with the patient’s symptoms?

A. BNP of 90 B. HGB below 10 C. TSH of 4.3 D. Potassium of 5.5

Answer: B Feedback: When hemoglobin drops below 10 g/dL (approximately 30% Hct), many patients present with a facial mask of fatigue, sallow-colored skin, pale mucous membranes, tachycardia, and tachypnea at rest. A TSH of 4.3 could indicate hypothyroidism, a BNP of 90 is within normal limits, and a 5.5 potassium indicates hyperkalemia.

Chapter: Chapter 62, Hematological Disorders Page: 1070 Difficulty: Difficult

49. A type 3 immune response on the Gell-Coombs classification system indicates: A. Poison ivy B. Food and drug allergy C. Anaphylaxis D. TB induration of 10

Answer: B Feedback: According to the Gell-Coombs classification system, there are four basic types of immune responses to allergens (collectively termed “hypersensitivity responses”), categorized by whether they are dependent on circulating antibodies (types 1 to 3) or only on cellular immune components (type 4). Type 1 immune responses are considered classic allergic hypersensitivity reactions. However, type 3 immune responses often underlie what are termed “drug and food allergies,” whereas type 4 immune reactions mediate contact dermatitis, which is a pathological response to certain skin irritants, such as the allergens in poison ivy and poison oak.

Chapter: Chapter 63, Immunologic Disorders Page: 1104 Difficulty: Moderate

50. A patient had been diagnosed with Lyme disease and went through the proper rounds of antibiotic therapy as treatment. They present to the health-care provider with complaints of headache, fatigue, and malaise. Which action would the provider take?

A. Retest for another Lyme infection.

B. Provide another round of antibiotic therapy.

C. Instruct the patient that symptoms often persist for a year or more after treatments.

D. Send the patient for acute care because the symptoms are worse since treatment.

Answer: C Feedback: Symptoms may persist after appropriate antibiotic treatment, as some Lyme disease symptoms such as headache, fatigue, and malaise commonly take months or years to resolve after treatment.

Chapter: Chapter 64, Infectious Disorders Page: 1146 Difficulty: Moderate

Section 13. Psychosocial Problems

MULTIPLE CHOICE 1. The effectiveness of benzodiazepines in treating anxiety disorders suggests that which of the following neurotransmitters plays a role in anxiety?

A. Acetylcholine B. Gamma-aminobutyric acid (GABA) C. Dopamine D. Serotonin Answer: B Feedback: Changes in neurotransmission, GABA inhibitory and glutamate excitatory, processes have been associated with general anxiety disorder. Benzodiazepines enhance GABA and GABA A receptors.

Chapter: Chapter 70, Anxiety Disorders and Post-traumatic Stress Disorder Page: 1276 Difficulty: Difficult

2. The criteria for diagnosing generalized anxiety disorder (GAD) in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, 5th edition (text revision) state that excessive worry or apprehension must be present more days than not for at least A. 1 month

B. 3 months C. 6 months D. 12 months Answer: C Feedback: The main diagnostic criterion for GAD is that excessive anxiety and worry predominate for 6 months. Anxiety is excessive and interferes with functioning in one or more areas of one’s life, and the frequency, duration, and intensity of the anxiety and worry are out of proportion that the feared event is likely to occur.

Chapter: Chapter 70, Anxiety Disorders and Post-traumatic Stress Disorder Page: 1275 Difficulty: Moderate

3. A patient presents to the clinician after experiencing four episodes in the last month of sweating, palpitations, chest pain, nausea, and shaking. Each episode lasted about 10 minutes. The patient is now becoming very fearful of future events and has been reluctant to leave the house. The clinician suspects panic disorder but wants to rule out any possible medical causes. Which of the following medical conditions can mimic the symptoms of a panic attack?

A. Pheochromocytoma B. Hyperthyroidism C. Cardiac arrhythmias D. All of the above Answer: D Feedback: Panic symptoms can be caused by several other conditions, such as pheochromocytoma, hyperthyroidism, and cardiac arrhythmias.

Chapter: Chapter 70, Anxiety Disorders and Post-traumatic Stress Disorder Page: 1283 Difficulty: Moderate

4. Which of the following is considered first-line treatment for panic disorders?

A. Benzodiazepines B. Selective serotonin reuptake inhibitors (SSRIs) C. Tricyclic antidepressants D. Cognitive behavioral therapy (CBT) Answer: D Feedback: CBT is a first-line treatment for panic disorder. Useful adjuncts are self-help books and programs. Patients who receive CBT have shown remission and long-term benefits. CBT can also be used to reduce and withdrawal medications.

Chapter: Chapter 70, Anxiety Disorders and Post-traumatic Stress Disorder

Page: 1275 Difficulty: Moderate

5. Which of the following symptoms is not part of the diagnostic criteria for post-traumatic stress disorder (PTSD)?

A. Hypersomnolence B. Blunted feelings C. Loss of interest in significant activities D. Intrusive recurrent recollections of the event Answer: A Feedback: Symptoms of PTSD are hyperarousal and increased reactivity that can lead to destructive behaviors, avoidance, alterations in cognition or mood, and flashbacks. Individuals with PTSD will often avoid things that make them remember the traumatic event because the thoughts can be intrusive, and they avoid and disengage.

Chapter: Chapter 70, Anxiety Disorders and Post-traumatic Stress Disorder Page: 1286 Difficulty: Moderate

6. Which of the following neuroendocrine abnormalities is implicated in depression?

A. Decrease in adrenal size B. Hypersecretion of cortisol C. An exaggerated response of thyrotropin (TRH) to infusion of thyroid-releasing hormone D. Increased inhibitory response of glucocorticoids to dexamethasone Answer: B Feedback: A correlation between cortisol excretion and depression is one of the oldest observations in biological psychiatry. Decreased adrenal size results in Addison’s disease. Increasing inhibitory response of glucocorticoids affects depression. TRH affects the thyroid.

Chapter: Chapter 69, Mood Disorders Page: 1241 Difficulty: Easy

7. The clinician has chosen to prescribe an SSRI instead of a tricyclic antidepressant (TCA) for a patient fitting the diagnostic criteria for depression. Which of the following is not true concerning SSRIs in comparison to TCAs? A. SSRIs are more effective than TCAs. B. SSRIs take less time to work than TCAs.

C. SSRIs have a more favorable side-effect profile than TCAs. D. SSRIs are not lethal in overdose.

Answer: A Feedback: SSRIs are not more effective than TCAs; however, they have fewer side effects and are not lethal if overdosed.

Chapter: Chapter 69, Mood Disorders Page: 1244 Difficulty: Moderate

8. After discontinuing fluoxetine, how long must a person wait before starting a monoamine oxidase inhibitor (MAOI)?

A. 2 weeks B. 3 weeks C. 4 weeks D. 5 weeks Answer: D Feedback: Risk of serotonin syndrome increases if a patient is prescribed SSRI and MAOI. Wait 2 weeks after discontinuance of an SSRI to start an MAOI; wait 5 weeks after discontinuance of fluoxetine. Wait 2 weeks after discontinuing MAOI before starting an SSRI. Chapter: Chapter 69, Mood Disorders Page: 1245 Difficulty: Easy

9. It is important to educate patients with depression and their family members about reporting signs of increasing depression and suicidal thoughts. This is especially true during which time period?

A. Prior to the antidepressant reaching therapeutic levels B. As the mood lifts in response to antidepressant treatment C. During dosage or medication adjustments D. After the patient reveals suicidal thoughts or plans Answer: B Feedback: Patients may experience and increase in suicidal thoughts and urges during the first few weeks of treatment. Dosages and medications may need to be adjusted regularly.

Suicidal thoughts should be monitored at any time before, during, or with discontinuation of medications. Once therapeutic levels of antidepressants occur mood should improve and stabilize.

Chapter: Chapter 69, Mood Disorders Page: 1245–1247 Difficulty: Moderate

10. A patient is experiencing extrapyramidal side effects from his antipsychotic medications.

The clinician would most likely take which of the following approaches to treating these side effects?

A. Give the patient a “drug holiday” until the symptoms resolve and then restart the medication.

B. Switch the patient to a different antipsychotic.

C. Treat the patient with anticholinergics.

D. Treat the patient with anticonvulsants.

Answer: C Feedback: Anticholinergics are prescribed to counteract extrapyramidal side effects when an antipsychotic medication is working and cannot be changed or removed. Anticonvulsants are not used for extrapyramidal side effects. A drug holiday may be detrimental to the patient and should only be done with exceptional monitoring.

Chapter: Chapter 68, Schizophrenia Spectrum and Other Psychotic Disorders Page: 1233 Difficulty: Moderate

11. Following suicide, what kind of support is provided for family of the victim?

A. Referral for CBT B. Prescription of a mood stabilizer C. Structured clinical interviews D. Postvention Answer: D Feedback: Postvention is any intervention strategy that occurs following an event, such as suicide. It attempts to minimize the negative impact and ensure that survivors of suicide have adequate services and support available to them.

Chapter: Chapter 69, Mood Disorders Page: 1269 Difficulty: Easy

12. The clinician is educating a 20-year-old patient about the effects of marijuana. The patient stated that she has been smoking for years and believes the use does not interfere with her life. What is the potential long-term sequelae of marijuana use that the clinician should educate this patient about?

A. Memory impairment B. Sexual dysfunction C. Dry mouth

D. Pancreatitis Answer: A Feedback: Long-term effects of cannabis use are impairments to cognition, memory, and learning functions. Declined IQ scores have been reported in adolescents and young adults.

Chapter: Chapter 67, Substance-Related and Addictive Disorders Page: 1216 Difficulty: Easy

13. Drugs of misuse increase which neurotransmitter?

A. GABA B. Acetylcholine C. Dopamine D. Serotonin Answer: C Feedback: The way the brain signals pleasure is through the release of dopamine. Drugs of misuse cause more dopamine to be released, causing more dopamine release than nondrug rewards. Drugs of misuse release so much dopamine it causes the reward to increase in velocity and efficiency. After a while the drug becomes less rewarding and more needs to be consumed to get the same reward.

Chapter: Chapter 67, Substance-Related and Addictive Disorders Page: 1210 Difficulty: Easy

14. What blood alcohol concentration (BAC) corresponds with the signs of stupor and confusion?

A. 0.05 B. 0.1 C. 0.2 D. 0.3 Answer: C Feedback: BAC at 0.2 causes stupor, disorientation, memory loss, and blackouts. BAC 0.3 causes loss of consciousness, tachycardia, irregular breathing, and loss of bladder control.

BAC 0.1 causes slurred speech, slowed reaction time, and judgement and coordination impairment. BAC 0.05 causes mild sedation, slowed reaction time, and decreased inhibition.

Chapter: Chapter 67, Substance-Related and Addictive Disorders Page: 1214 Difficulty: Easy

15. Rapid eye movement (REM) sleep occurs how frequently during non-REM sleep?

A. Every 30 to 40 minutes B. Every 60 to 80 minutes C. Every 90 to 100 minutes D. Every 180 to 200 minutes Answer: C Feedback: Typically, non-REM sleep is punctuated with a REM cycle every 90 to 100 minutes.

The first REM cycle is the shortest at about 10 minutes. Later REM cycles tend to last 15 to 40 minutes.

Chapter: Chapter 72, Other Psychiatric Disorders Page: 1311 Difficulty: Easy

16. Which of the following is a laboratory finding commonly found in patients with anorexia nervosa?

A. Hypophosphatemia B. Hypermagnesmia C. Leukocytosis D. Decreased TRH Answer: A Feedback: Hypokalemia, hypophosphatemia, and hyponatremia along with fluid imbalances are associated with anorexia nervosa. Anorexia can cause low white counts not high. Hypermagnesemia can occur in kidney disease. Thyroid hormones are not altered with anorexia.

Chapter: Chapter 72, Other Psychiatric Disorders Page: 1306 Difficulty: Moderate

17. Which of the following is the only drug used to treat bulimia that is approved by the U.S. Food and Drug Administration?

A. Sertraline B. Fluoxetine C. Citalopram D. Imipramine Answer: B Feedback: Fluoxetine is the only approved drug to treat bulimia nervosa that has been shown effective in decreasing binge eating episodes. Fluoxetine and other SSRIs are similarly used with good effects in individuals with binge eating disorder.

Chapter: Chapter 72, Other Psychiatric Disorders Page: 1310 Difficulty: Moderate

18. Which of the following would be important to monitor in a child receiving methylphenidate for treatment of attention deficit-hyperactivity disorder (ADHD)?

A. Liver function B. Vision C. Growth parameters D. Renal function Answer: C Feedback: Stimulants can cause weight loss and lack of appetite. Growth should be monitored during treatment for ADHD. In rare cases, methylphenidate can cause liver toxicity.

Chapter: Chapter 66, Neurodevelopmental Disorders Page: 1192 Difficulty: Moderate

19. It is important for the clinician to discuss the long-term effects of sexual assault with survivors. Which of the following is the most common long-term effect of sexual assault?

A. Depression B. Obsessive-compulsive disorder C. Substance abuse D. PTSD Answer: D Feedback: PTSD is the most common long-term effect of sexual assault. Sexual assault survivors may be the largest single group of individuals with PTSD. Depression, substance abuse, and obsessive-compulsive disorder can also occur at higher rates in sexual abuse survivors.

Chapter: Chapter 73, Sexual Assault Page: 1325 Difficulty: Moderate

20. Women are at the highest risk for developing peripartum depression for up to how long after childbirth?

A. 1 to 3 weeks B. 1 month C. 3 to 6 months D. 7 months to 1 year

Answer: A Feedback: Peripartum depression usually occurs 1 to 3 weeks after delivery, but it can occur during pregnancy or up to 4 weeks after delivery.

Chapter: Chapter 69, Mood Disorders Page: 1240 Difficulty: Moderate

21. Which is the most prevalent psychiatric condition in the United States?

A. Depression B. Anxiety C. Substance-related addictions D. Gambling addiction Answer: B Feedback: Anxiety disorders are frequently encountered in primary care. They occur in about 31% of adults and adolescents.

Chapter: Chapter 70, Anxiety Disorders and Post-Traumatic Stress Disorder Page: 1274 Difficulty: Moderate

22. What is recorded as a clinical category two of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, 5th edition (text revision)?

A. Clinical disorder or focus of clinical attention B. Personality or environmental problems C. Environmental and psychosocial stressors D. Global assessment of functioning Answer: C Feedback: The first category of the Diagnostic and Statistical Manuel of Mental Disorders combines the psychiatric disorder with known medical conditions, category two identifies the applicable environmental and psychosocial stressors, and category three provides a global assessment of functioning.

Chapter: Chapter 65, Common Psychosocial Complaints Page: 1176 Difficulty: Difficult

23. Which of the following may be used to evaluate a person’s suicide risk?

A. CAGE B. SANE C. SAD PERSONAS

D. DIGFAST Answer: C Feedback: The mnemonic SAD PERSONAS can be used to screen for suicide risk. A SANE assessment is for sexual assault, CAGE is used for substance abuse, and DIGFAST helps screen for mania or bipolar disorder.

Chapter: Chapter 69, Mood Disorders Page: 1266 Difficulty: Easy

24. What is the essential feature of bipolar I? A. Hyperactivity B. Mania C. Depression D. Anxiety Answer: B Feedback: Mania must be present with bipolar I. Depression and hypomania can also occur.

Mania is more than hyperactivity and anxiety. Mania is described as excessive excitement, ideas of grandeur, elation, distraction, restlessness, flight of ideas, difficulty sleeping, and more.

Chapter: Chapter 69, Mood Disorders Page: 1252 Difficulty: Easy

25. Bipolar disorder requires differential diagnosis from all of the following except: A. Substance abuse B. Neurological disorders C. Cluster B personality disorders and depression D. Obsessive-compulsive disorder Answer: D Feedback: Substance abuse and cluster B personality disorder can mimic symptoms of bipolar, such as mood swings, erratic behavior, emotional disruptions, and so forth. Other causes of the symptoms must also be ruled out.

Chapter: Chapter 69, Mood Disorders Page: 1251–1253 Difficulty: Moderate

26. All benzodiazepines are associated with

A. Potential anterograde amnesia B. Dopamine-related movement disorders C. Serotonin syndrome D. Xerostomia and agitation Answer: A Feedback: All benzodiazepines are schedule IV controlled substances with risk for building tolerance and dependence and are subject to increased state and federal regulations. All benzodiazepines are associated with potential anterograde amnesia, central nervous system (CNS) depression, and paradoxical reactions. SSRIs are associated with serotonin syndrome.

Antipsychotics are associated with dopamine-related movements.

Chapter: Chapter 70, Anxiety Disorders and Post-traumatic Stress Disorder Page: 1279 Difficulty: Moderate

27. Which medication is used as a first-line treatment in the management of bipolar disorder?

A. Gabapentin B. Lamotrigine C. Carbamazepine D. Topiramate Answer: C Feedback: Carbamazepine, valproic acid, and lithium are all first-line treatment in managing bipolar disorder. They can be used singularly or in combination with each other.

Chapter: Chapter 69, Mood Disorders Page: 1260 Difficulty: Moderate

28. HITS is a validated instrument used to identify intimate partner violence. What does “HITS” stand for?

A. Hit, injured, threatened, scared B. Hurt, insult, threaten, scream C. Humiliated, isolated, tortured, scarred D. Harm, injury, terror, shame Answer: B Feedback: HITS stands for “hurt, insult, threaten, scream.”

Chapter: Chapter 65, Common Psychosocial Complaints Page: 1183 Difficulty: Easy

29. Emotional dysregulation is common in A. Children with obsessive-compulsive disorder B. Adults with schizophrenia C. Adults with ADHD D. Children with tic disorders Answer: C Feedback: Emotional dysregulation in adults with ADHD is common. It can occur across the lifespan and in some instances can lead to comorbid conditions.

Chapter: Chapter 66, Neurodevelopmental Disorders Page: 1188 Difficulty: Moderate

30. The stooped posture, motor slowness, and minor cognitive impairments of patients with major depressive disorders are similar to the signs of disorders of the basal ganglia, such as A. Parkinson’s disease B. Stevens-Johnson syndrome C. Endocrine disease D. Huntington’s disease Answer: A Feedback: The stooped posture of patients with depression, motor slowness, and minor cognitive impairments are like the signs of disorder of the basal ganglia, such as those found in Parkinson’s disease and other subcortical dementias. Stevens-Johnson syndrome is a disorder that affects the skin and mucous membranes. Huntington’s disease occurs when the nerve cells in the brain break down over time. Endocrine diseases affect hormonal functions such as adrenal insufficiency or a thyroid or pituitary disorder.

Chapter: Chapter 69, Mood Disorders Page: 1241 Difficulty: Moderate

31. Which of the following statements is true of mental health in the United States?

A. Patients with mental illness are provided with the care and resources they need in the community.

B. Mental health care is one of the least costly services to provide.

C. One in five Americans experience a mental health disorder annually.

D. Mental health issues are easy for families to deal with.

Answer: C

Feedback: Mental health disorders affect one in five individuals annually. They are one of the costliest conditions in health care. Individuals with mental health issues do not always have available the community resources they need. Mental health often puts a heavy emotional burden on families.

Chapter: Chapter 65, Common Psychosocial Complaints Page: 1173 Difficulty: Easy

32. Suicide plans are assessed for all of the following except A. Specificity B. Possibility C. Availability D. Lethality Answer: B Feedback: It is imperative that the health-care provider ask an individual if they have any specific plans for committing suicide and assess the availability of lethal methods. Assessing possibility is not performed; rather, if an individual states they may be suicidal the threat must be taken seriously.

Chapter: Chapter 69, Mood Disorders Page: 1267 Difficulty: Moderate

33. What is the reduction in life expectancy among those with mental illness?

A. 15 to 21 years B. 10 to 20 years C. 5 to 7 years D. 3 to 6 years Answer: B Feedback: A shorter life expectancy, varying by 10 to 20 years, has been reported for patients with mental health disorders. Most of this early mortality is attributed to acute and chronic comorbid medical conditions such as heart, pulmonary, and infectious diseases.

Chapter: Chapter 65, Common Psychosocial Complaints Page: 1174 Difficulty: Easy

34. Which of the following is a potential adverse reaction to clozapine (Clozaril)?

A. Prolonged QT interval B. Hyperprolactinemia

C. Postural hypotension D. Myocarditis Answer: D Feedback: Clozapine is an atypical antipsychotic that can cause cardiac complications, such as myocarditis in rare cases. Other antipsychotics are noted to cause a prolonged QT interval.

Chapter: Chapter 68, Schizophrenia Spectrum and Other Psychotic Disorders Page: 1235 Difficulty: Moderate

35. Each of the following antidepressants does not have significant liver CYP P450 interaction effects?

A. Paroxetine B. Fluoxetine C. Fluvoxamine D. Olanzapine Answer: D Feedback: Paroxetine and fluoxetine have strong inhibition of the CYP P450 system. Fluvoxamine inhibits the CYP P450 system and has high potential for drug-to-drug interaction.

Olanzapine does not affect the CYP P450 system interactions.

Chapter: Chapter 69, Mood Disorders Page: 1244 Difficulty: Difficult

36. What term describes random quick jerking movements that flow from joint to joint?

A. Dystonia B. Chorea C. Myoclonus D. Compulsions Answer: B Feedback: The statement describes chorea. Dystonia is muscle contractions that cause twisting or abnormal postures. Myoclonus is muscle jerking or twitching. A compulsion is the urge to behave in a certain way.

Chapter: Chapter 66, Neurodevelopmental Disorders Page: 1202 Difficulty: Easy

37. Instead of reporting symptoms of body dysmorphic disorder (BDD) to the primary-care provider, patients often request which of the following?

A. Referrals to plastic surgeons, orthodontists, or dermatologists B. Antidepressant medications C. Nutritional counseling services D. Unnecessary laboratory tests Answer: A Feedback: Hallmark presentation of BDD is a preoccupation with one or more perceived physical defects or flaws, often not visible or only slightly so to others. Poor insight is common, so nutritional counseling and laboratory tests will not be asked for. Treatment consists of high doses of SSRIs or CBT. Chapter: Chapter 71, Obsessive-Compulsive and Related Disorders Page: 1299 Difficulty: Moderate

38. Which substance is one of the most used addictive substances of adolescents?

A. Opioids B. Cocaine C. Tobacco D. Methamphetamines Answer: C Feedback: Tobacco, alcohol, and marijuana are the most used substances among teens and adolescents.

Chapter: Chapter 67, Substance-Related and Addictive Disorders Page: 1210 Difficulty: Easy

39. What is a common adverse reaction for children prescribed risperidone for autism-associated irritability?

A. Gynecomastia B. Parkinsonian-like syndrome C. Bradycardia D. Rebound hypertension Answer: B Feedback: Parkinsonian-like syndrome is common in children taking risperidone for autism.

Rebound hypertension and bradycardia can occur with clonidine. Bradycardia can also occur with guanfacine. Antipsychotics and tricyclic antidepressants can cause gynecomastia.

Chapter: Chapter 66, Neurodevelopmental Disorders Page: 1198

Difficulty: Difficult

40. What is the advantage of guanfacine over clonidine for the treatment of ADHD? A. Tapering off is not required on discontinuation.

B. Therapeutic effect is instantaneous.

C. There is a wider range of available dosages.

D. Patients experience less sedation and longer duration of action.

Answer: D Feedback: The advantages of guanfacine over clonidine are less sedation and longer duration of action.

Chapter: Chapter 66, Neurodevelopmental Disorders Page: 1191 Difficulty: Moderate

41. What is a differential diagnosis of autism spectrum disorder?

A. Speech sound disorder B. Duchenne muscular dystrophy C. Structural brain malformations D. Wilson’s disease Answer: A Feedback: Speech sound disorder is a differential diagnosis for autism spectrum disorder.

Duchenne muscular dystrophy and structural brain malformations are differential diagnoses for intellectual disorders. Wilson’s disease is a differential diagnosis for tic disorders.

Chapter: Chapter 66, Neurodevelopmental Disorders Page: 1197 Difficulty: Easy

42. Which intervention has been shown to diminish feelings of isolation, improve coping skills, and decrease the need for hospitalization in schizophrenia?

A. CBT B. Peer-delivered services C. Family-based therapy D. Assertive community treatment (ACT) model of care Answer: B Feedback: Services delivered by trained peers have been shown to diminish feelings of isolation and improve coping skills that support recovery. For patients with persistent positive symptoms, CBT has been found helpful in the reduction of both symptoms and relapse rates

while improving function and quality of life. Patients who have experienced a high incidence of relapse may benefit from an assertive community treatment (ACT) team approach. The ACT approach foregoes the constraints of timed clinic appointments, and instead team members meet patients at their home or at shelters or community locations and spend more time on individualized support. Family support and encouragement are crucial for patients who may be hesitant to accept treatment.

Chapter: Chapter 68, Schizophrenia Spectrum and Other Psychotic Disorders Page: 1236 Difficulty: Difficult

43. What is the likely result of the over prescription, over supply, and over production of opioids?

A. Opioid use B. Opioid abuse C. Opioid dependence D. Opioid resistance Answer: B Feedback: Opioid abuse has resulted from over prescription. Individuals can become dependent on opioids if they are overused. Opioid use is okay for specific conditions but overuse and over prescribing should not be done in order to prevent abuse. Opioid resistance results from tolerance to opioids and the need for more drug to get the effects.

Chapter: Chapter 67, Substance-Related and Addictive Disorders Page: 1211 Difficulty: Easy

44. What is a consequence of heavy alcohol consumption?

A. Increased risk of panic disorder B. Increased risk of dyslipidemia and cardiomyopathy C. Increased risk of brain overstimulation D. Increased risk of thyroid disorders Answer: B Feedback: Heavy alcohol consumption can cause dyslipidemias, cardiomyopathy, hypertension, stroke, and arrhythmias as cardiac effects. Alcohol is a depressant and can lower brain activity and cause memory lapses. Alcohol use does not affect the thyroid. Heavy drinking often impairs judgment and can cause accidents.

Chapter: Chapter 67, Substance-Related and Addictive Disorders Page: 1214 Difficulty: Moderate

45. Repetitive movements like hand-flapping are often demonstrated by people with which disorder?

A. Autism B. Alcoholism C. ADHD D. Parkinson’s disease Answer: A Feedback: Autism patients exhibit deficits in social interactions and repetitive, restrictive ranges of interests or behaviors, including hand-flapping.

Chapter: Chapter 66, Neurodevelopmental Disorders Page: 1195 Difficulty: Easy

46. What prenatal factor could increase the risk for ADHD? A. Exposure to lead B. Zinc deficiency C. Maternal allergies D. CNS infections Answer: A Feedback: Prenatal exposure to lead, toxins, and tobacco; child abuse; low birth weight; and genetic factors are all risk factors for ADHD. Chapter: Chapter 66, Neurodevelopmental Disorders Page: 1188 Difficulty: Moderate

47. If stimulant drugs are not tolerated or are contraindicated for the treatment of ADHD, what medication may produce a therapeutic effect?

A. Daytrana B. Vyvanse C. Warfarin D. Atomoxetine Answer: D Feedback: Atomoxetine (Strattera) is a selective norepinephrine reuptake inhibitor (SNRI), which is used if stimulant drugs are not tolerated or are contraindicated (active substance abuse, tics, comorbid anxiety, or mood lability). Daytrana and Vyvanse are stimulant drugs for ADHD. Warfarin is a blood thinner drug.

Chapter: Chapter 66, Neurodevelopmental Disorders Page: 1192

Difficulty: Moderate

48. What is the presentation of a complex motor tic?

A. Simultaneous shoulder shrugs and head turns B. Eye blinks and extension of extremities C. Throat clearing and finger raising D. Barking, screaming, and snorting Answer: A Feedback: A complex motor tic is purposeful or elaborate movement, such as simultaneous shoulder shrugs and head turns. Eye blinks are simple motor tics. Throat clearing and screaming are vocal tics, not motor.

Chapter: Chapter 66, Neurodevelopmental Disorders Page: 1202 Difficulty: Easy

49. What is the most prevalent psychiatric comorbidity of ADHD? A. Antisocial personality disorder B. GAD C. Oppositional defiant disorder D. Social phobias Answer: C Feedback: Individuals commonly have oppositional defiant disorder along with ADHD. Chapter: Chapter 66, Neurodevelopmental Disorders Page: 1188 Difficulty: Moderate

50. What severity level of intellectual disability is demonstrated by a child whose language and academic skills markedly lag behind peers, who misperceives social cues, and who has a simpler spoken language than their peers?

A. Mild B. Moderate C. Severe D. Profound Answer: B Feedback: In moderate intellectual disability, language and academic skills markedly lag behind peers and ongoing support is needed into adulthood to manage day-to-day tasks. In the social domain, spoken language is simpler than that in peers, individuals may misperceive

social cues, and they have limited decision-making abilities. In the practical domain, individuals can manage ADLs and household tasks by adulthood with support and need considerable support in employment.

Chapter: Chapter 66, Neurodevelopmental Disorders Page: 1200 Difficulty: Moderate

51. Which of the following is true regarding sexual assault?

A. The perpetrators often do not know their victims.

B. Voyeurism is not assault because the perpetrator does not touch the victim.

C. Not all sexual assault is rape.

D. Older women are the most common victims.

Answer: C Feedback: It is true that not all sexual assault is rape. It is more common for the perpetrator to know their sexual assault victims. Voyeurism is a form of sexual assault. Young unmarried women of lower socioeconomic status are the most common victims.

Chapter: Chapter 73, Sexual Assault Page: 1320 Difficulty: Moderate

52. Adolescent sexual assault victims are at higher risk of which mental health problems? A. Schizophrenia B. Factitious disorders C. Eating disorders D. Bipolar disorder Answer: C Feedback: Adolescent victims of sexual assault are at greater risk of developing self-harm behaviors, like self-mutilation and eating disorders.

Chapter: Chapter 73, Sexual Assault

Page: 1321 Difficulty: Moderate

53. A benefit of having a SANE RN working in an emergency department (ED) and caring for sexual assault victims is that A. The victim has contact with one practitioner.

B. The victim will not have to make a statement to police.

C. The SANE RN can delegate evidence collection to a team member.

D. The SANE RN can make sure no medications are prescribed to the victim until all interviews are complete and evidence is collected.

Answer: A Feedback: Benefits to having a SANE RN is that they are specially trained in providing crisis intervention, offering sexual assault-related medications, and collecting forensic evidence.

The sexual assault victim is therefore seen by one practitioner instead of multiple practitioners for care.

Chapter: Chapter 73, Sexual Assault Page: 1323 Difficulty: Easy

54. What medication(s) should be offered after a sexual assault?

A. Acetaminophen B. Azithromycin and ceftriaxone

C. Sertraline D. Lorazepam

Answer: B Feedback: Empiric treatment with azithromycin or doxycycline and ceftriaxone for gonorrhea and chlamydia that may have been transmitted during the assault should be offered.

Chapter: Chapter 73, Sexual Assault Page: 1323 Difficulty: Easy

55. A sexual assault victim comes into the ED a few hours following the assault. The survivor is complaining of pain, bruising, and being scared of having an STI. The SANE RN is consulted to perform an interview and physical exam on the survivor. Which of the following is a priority during the physical exam portion of the ED visit?

A. The exam will limit the number of providers seen by the patient to two.

B. The survivor will be allowed to control the exam as much as possible.

C. The RN will ask the survivor to complete a breathalyzer test.

D. The door will remain cracked open so the survivor can escape if needed.

Answer: B Feedback: All of the procedures during the exam should be explained to the survivor so that they can control the exam as much as possible to decrease trauma. Only one provider will see the patient: the SANE RN. A breathalyzer test is inappropriate to ask of the survivor. The exam should be performed in private away from others for safety, trust, and confidentiality.

Chapter: Chapter 73, Sexual Assault Page: 1324 Difficulty: Moderate

56. The nurse is caring for an individual who comes into the ED for a severe burn to their arm. The patient is of foreign descent, and the nurse becomes suspicious that the patient is being labor trafficked. What would the nurse be concerned about with this patient?

A. That the victim would not be honest because of fear of deportation B. That the nurse would offend the patient C. That the nurse will need to identify the action, means, and purpose of human trafficking D. That the smuggler will retaliate against the nurse

Answer: A Feedback: Individuals who are human trafficked or labor trafficked are often fearful when they seek health care that they will be deported. The nurse must be alert for possible trafficking victims so that intervening can occur so that the patient does not go back to unsafe living and working conditions. It is difficult to identify individuals who are labor trafficked, and the smugglers often have minimal risk of criminal penalty for committing the crime. Retaliation should not be of concern upon reporting a suspicion of labor trafficking.

Chapter: Chapter 74, Human Trafficking Page: 1327 Difficulty: Moderate

57. Which of the following is defined as the collaboration with community resources to empower individuals to determine their own futures?

A. Crisis intervention B. Trauma-informed approach C. SANE practices D. Multiple health-care worker approach

Answer: B Feedback: The trauma-informed approach is defined as collaboration with community resources to empower individuals to determine their own futures. It will not only ensure the patient remains in charge of their care but also will maximize comfort and result in a better experience throughout care.

Chapter: Chapter 74, Human Trafficking Page: 1329 Difficulty: Easy

58. What is the most valuable resource for health-care providers or victims of human trafficking?

A. Preservation of forensic evidence B. Local law enforcement agency C. National Human Trafficking Hotline D. Department of Homeland Security

Answer: C Feedback: The National Human Trafficking Hotline is the most valuable resource. The hotline provides a live person 24/7 to talk to who is experienced and trained in human trafficking and can provide multiple area resources.

Chapter: Chapter 74, Human Trafficking Page: 1331 Difficulty: Easy

59. A 23-year-old woman is seen in the ED reporting nausea, abdominal pain, and headaches, as well as symptoms of a urinary tract infection. Upon assessment the patient seems fearful, and bruising on her back and upper arms is found. The patient appears thin, and clothes and hair are unkempt. The patient denies any abuse and states she fell and is thin because her stomach hurts. The patient’s boyfriend is waiting in the lobby. What would be the most appropriate intervention for the health-care provider at this time?

A. Call the police due to a suspicion of sex trafficking.

B. Report the findings to the National Human Trafficking Hotline.

C. Provide information at the patent’s level of understanding.

D. Request that the patient’s boyfriend leave the hospital premises.

Answer: C Feedback: It is important that the nurse remain nonjudgmental and provide the patient with resources and education that are appropriate. “Planting the seed” is important so that the patient knows they can return or seek help elsewhere. A safe, caring environment needs to be fostered. Victims often deny the abuse, so calling the police during this visit is not appropriate and can be dangerous for the victim.

Chapter: Chapter 74, Human Trafficking Page: 1329 Difficulty: Moderate

60. During initial treatment, it is most important for victims of trafficking to understand that A. Their abuser can return at any time.

B. They are safe, which is the priority.

C. They will need to go to the police station.

D. Resources are scarce but the best will be done.

Answer: B Feedback: Initially, victims need to know that their safety is the priority. Initial treatment consists of crisis intervention, physical examination, and psychiatric evaluation. Although the other answers may also be true, initially the victim needs to know they are safe so that they will continue to seek help and be able to recover.

Chapter: Chapter 74, Human Trafficking Page: 1331 Difficulty: Moderate Section 14. Urgent Care Problems

MULTIPLE CHOICE

1. Which type of heat-related illness involves a core body temperature of at least 104°F and may present with hot dry skin, acute mental status changes, absent sweat, and tachypnea?

A. Heat cramps B. Heat syncope C. Heat exhaustion D. Heat stroke

Answer: D Feedback: Heat stroke is characterized by a core body temperature of 104°F (40°C) or higher.

Clinical presentation may include hot, dry skin, decreased level of consciousness, tachycardia, tachypnea, decreased urinary output, hypotension, seizures, nausea and vomiting, decerebrate posturing, diarrhea, and dilated, nonresponsive pupils.

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Difficulty: Easy

2. Using the rule of nines, what percentage would be correct for burns on the front of both legs?

A. 9% B. 18% C. 24% D. 36%

Answer: B Feedback: When burns are scattered on the body, a rule of thumb is that the size of the patient’s palm is equal to approximately 1% total body surface area (TBSA). According to the rule of nines, burns on the front of both legs would account for approximately 18% TBSA. Chapter: Chapter 75: Common Injuries Page: 1359 Difficulty: Moderate

3. Which drug commonly prescribed for burns is active against a wide spectrum of microbial pathogens and is the most frequently used agent for partial- and full-thickness thermal injuries?

A. Clotrimazole cream (Lotrimin) B. Mafenide acetate (Sulfamylon) C. Silver nitrate D. Silver sulfadiazine (Silvadene)

Answer: D Feedback: Silver sulfadiazine (Silvadene) is active against a wide spectrum of microbial pathogens. It is the most frequently used agent for partial- and full-thickness thermal injuries.

Chapter: Chapter 75: Common Injuries Page: 1361 Difficulty: Easy

4. A sunscreen with a sun-protection factor of at least what number will block most harmful ultraviolet radiation?

A. 4 B. 8 C. 10 D. 15

Answer: D Feedback: A patient should always wear sunscreen when outdoors on a sunny day. A sunscreen with sun protection factor of at least 15 will block most harmful ultraviolet radiation.

Chapter: Chapter 75: Common Injuries Page: 1363 Difficulty: Easy

5. Which clinical feature is a late sign of increased intracranial pressure?

A. Dilated, nonreactive pupils B. Altered level of consciousness C. Loss of judgment D. Amnesia

Answer: A Feedback: Late signs of increased intracranial pressure are dilated, nonreactive pupils, unresponsiveness to verbal or painful stimuli, abnormal posturing patterns, increased systolic blood pressure, decreased pulse rate, and changes in respiratory rate and pattern.

Chapter: Chapter 75: Common Injuries Page: 1367 Difficulty: Easy

6. What number represents normal neurological function on the Glasgow Coma Scale?

A. 7 B. 9 C. 10 D. 15

Answer: D Feedback: A score of 15 on the Glasgow Coma Scale is normal. Less than 7 indicates a coma.

Chapter: Chapter 75: Common Injuries Page: 1366 Difficulty: Easy

7. Which diagnostic test is the best to diagnose a subdural hematoma?

A. Complete blood count B. Positron emission tomography C. Magnetic resonance imaging (MRI) D. Computed tomography (CT) scan

Answer: C Feedback: MRI can show brain tissue that is displaced away from the skull, which is a key finding of a subdural hematoma.

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8. Patients with a spontaneous pneumothorax should be counseled that up to what percentage may experience a reoccurrence at some point?

A. 15% B. 25% C. 30% D. 60%

Answer: C Feedback: Thirty to fifty percent of patients with a history of a primary spontaneous

pneumothorax will have a recurrence of this condition.

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9. Most adult poisonings are A. Intentional and self-inflicted B. Accidental C. Caused by someone wishing to do harm to the person D. Of unknown cause

Answer: A Feedback: In the adolescent population, trauma and intentional self-harm are the first and second leading causes of death, and most adolescent and adult poisonings are self-inflicted and secondary to intentional ingestion.

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10. Which method is used to remove heavy metals, such as lead, from the body?

A. Chelation B. Dialysis C. Gastric lavage

D. Bowel irrigation

Answer: A Feedback: Chelation therapy is used for the removal of heavy metals, such as lead.

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11. If a previously frostbitten area becomes frostbitten again after it has healed, what might occur?

A. The area may have permanent tissue damage.

B. The area will be super sensitive.

C. The area will be prone to a repeat frostbite.

D. The area is as susceptible as any other area.

Answer: A Feedback: If a previously frostbitten area becomes frostbitten again after it has healed, permanent tissue damage can occur, resulting in necrosis of that body part.

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12. About 75% of wounds occur in which population?

A. Boys in their mid-to-late teens B. Men in their early 20s C. Women in their mid-40s D. Toddlers between 18 and 30 months

Answer: B Feedback: Almost 75% of patients with wounds are men, with an average age in the early 20s.

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13. Which solution should be used to irrigate lacerated tissue over a wound on the arm?

A. Diluted povidone-iodine solution B. Hydrogen peroxide (H2O2) C. Saline solution infused with an antibiotic D. Saline irrigation or soapy water

Answer: D Feedback: Saline irrigation or even soapy water is preferred to a dilute povidone-iodine solution because povidone-iodine can be irritating and cytotoxic to lacerated tissue.

Hydrogen peroxide can be irritating to the wound. The most effective way to decrease bacterial count is with high-pressure steam.

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14. Which type of burn injury results in destruction of the epidermis including most of the dermis, yet the epidermal cells lining the hair follicles and sweat glands remain intact?

A. Superficial burns B. Superficial partial-thickness burns C. Deep partial-thickness burns D. Full-thickness burns

Answer: C Feedback: Deep partial-thickness (or second-degree) burns involve the epidermis and upper layer of dermis, but epidermal cells lining the hair follicles and sweat glands remain intact.

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15. Which carboxyhemoglobin (COHb) level correlates with the clinical symptoms of confusion, lethargy, and ST-segment depression on the electrocardiogram (ECG)?

A. Less than 10% B. 20% COHb C. 30% COHb D. 40% to 60% COHb

Answer: C

Feedback: A 30% COHb level typically correlates with confusion, lethargy, and ST-segment depression on the ECG. Chapter: Chapter 75: Common Injuries Page: 1358 Difficulty: Moderate

16. Which animal causes the greatest percentage of mammalian bites?

A. Dogs B. Cats C. Humans D. Rodents

Answer: A Feedback: Dogs inflict approximately 90% of all mammalian bites, with an overall infection rate of 15% to 20%.

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17. Which arthropod bite can contain cytotoxic and hemolytic toxins that may destroy tissue?

A. Tick B. Brown recluse spider

C. Wasp D. Stinging caterpillar

Answer: B Feedback: Brown recluse spider venom is chiefly cytotoxic, but it also contains hemolytic toxins that can destroy tissue.

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18. What condition is sometimes confused with anaphylaxis from an insect sting?

A. Heat stroke B. Toxic syndrome C. Vasovagal reaction D. Inflammatory response

Answer: C Feedback: Anaphylaxis from an insect sting may be confused with a vasovagal reaction, which is a disorder of central vasoregulation caused by increased parasympathetic tone mediated by the vagus nerve.

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19. A delayed serum sickness–type reaction in response to multiple bee, wasp, or fire ant stings can be managed with which of the following?

A. A corticosteroid such as prednisone (Deltasone), 60 to 100 mg, tapered over 2 weeks B. An oral antihistamine, such as hydroxyzine, for 2 weeks C. An H2 blocker such as cimetidine, for 1 week D. 0.1 mg (1 mL of 1:10,000 solution epinephrine) in 10 mL of normal saline administered as a slow IV push over 10 minutes

Answer: A Feedback: Delayed serum sickness–type reactions in response to multiple bee, wasp, or fire ant stings can be managed with a corticosteroid such as prednisone (Deltasone), 60 to 100 mg, tapered over 2 weeks.

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20. Which term describes air entering into the cerebrospinal fluid (CSF)–filled spaces within the head after an injury?

A. Pneumocephalus B. Hemotympanum C. Battle’s sign D. Raccoon sign

Answer: A Feedback: Head injuries like basilar skull fractures can cause leakage of CSF and be an entry

point for bacteria, leading to meningitis and/or pneumocephalus (air entry into the CSF-filled spaces within the head).

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21. CSF may leak through the cribriform plate region of the skull following a head injury and cause which of the following?

A. Ear CSF otorrhea B. Leakage of CSF from the eye C. Nasal CSF rhinorrhea D. Leakage of CSF from the mouth

Answer: C Feedback: One clinical manifestation of a basilar skull fracture is the leakage of CSF through the cribriform plate of the skull causing nasal CSF rhinorrhea.

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22. What condition is characterized by a brief loss of consciousness, then a brief “lucid” moment, followed by momentary unconsciousness minutes after the injury?

A. Concussive hematoma

B. Bleeding dyscrasias C. Subdural hematoma D. Epidural hematoma

Answer: D Feedback: Epidural hematomas are typically characterized by the patient losing consciousness briefly, followed by a brief lucid moment when the patient may be awake and talking, and then a return to a period of altered consciousness as the size of the epidural hematoma increases, becoming increasingly symptomatic and possibly progressing to coma.

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23. A patient with a basilar skull fracture may experience an impaired downward gaze or diplopia from which affected cranial nerve (CN)?

A. CN II B. CN III C. CN IV D. CN V

Answer: C Feedback: Alteration of the function of the CN IV or trochlear nerve results in an impaired downward gaze and diplopia.

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24. A patient who sustains blunt chest trauma and/or penetrating chest trauma must have which of the following imaging examinations?

A. Upright anterior/posterior and lateral chest x-ray B. Supine anterior/posterior and lateral chest x-ray C. Upright bilateral chest x-ray D. Supine anterior/posterior chest x-ray

Answer: A Feedback: Any patient who has sustained blunt and/or penetrating chest trauma must have upright posterior/anterior and lateral chest x-rays to rule out pneumothorax or hemothorax.

Chapter: Chapter 75: Common Injuries Page: 1370 Difficulty: Moderate

25. What is the priority intervention if a suspected pneumothorax is discovered in the primary care setting?

A. Emergency medical services (EMS) should be activated.

B. Support cardiovascular and respiratory status as needed.

C. Administer supplemental oxygen to reabsorb the pneumothorax.

D. Initiate stabilizing treatments, including emergency chest tube placement.

Answer: A

Feedback: If a primary care practitioner suspects that a patient presenting to a primary care setting has a pneumothorax and/or a hemothorax, EMS should be activated, then the patient’s respiratory and cardiovascular status should be evaluated and supported as needed, and, finally, the patient should be transported to the emergency department immediately.

Chapter: Chapter 75: Common Injuries Page: 1370 Difficulty: Moderate

26. Hepatic necrosis with jaundice may occur after ingesting massive doses of which medication?

A. Phenobarbital B. Diazepam C. Ritalin D. Acetaminophen

Answer: D Feedback: Acetaminophen poisoning signs and symptoms vary from asymptomatic to severe nausea and vomiting 24 to 48 hours postingestion, hepatic necrosis with jaundice, hepatic encephalopathy, renal failure, and possible death.

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27. Pink, cherry red tissues and skin may result from which type of poisoning?

A. Arsenic B. Lead C. Carbon monoxide D. Strychnine

Answer: C Feedback: The signs and symptoms of carbon monoxide poisoning are deep respirations and pink (cherry red) tissues and skin.

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28. In which type of burn is the injury more extensive than it appears, and the cardiac conduction system may be affected, leading to sudden death or arrhythmias?

A. Chemical B. Electrical C. Radiation D. Thermal

Answer: B Feedback: Electrical burn injuries are usually more extensive than they appear. The cardiac conduction system may be affected, leading to sudden death or arrhythmias.

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Difficulty: Moderate

29. A toddler presents to the emergency department with a live insect trapped in his ear canal causing a lot of distress. What should be your first step?

A. Remove the insect with tweezers.

B. Immobilize the insect with 2% lidocaine.

C. Sedate the toddler with diazepam.

D. Shine a light in the ear for the insect to “find its way out.”

Answer: B Feedback: The initial therapy is to immobilize the insect. This can be done by placing 2% lidocaine in the external ear canal, which will terminate the movement of the insect.

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30. What is the most important discharge instruction to provide for a patient with a laceration injury to their lower leg?

A. Recommend isometric exercises to prevent a deep vein thrombosis (DVT).

B. Recommend cleansing the wound every 4 hours to prevent an infection.

C. Keep the leg elevated at waist level to prevent any edema.

D. Keep the leg completely immobile to prevent extension of the laceration.

Answer: A Feedback: For lower extremities, patients should be advised to do isometric exercises to prevent DVT while wearing a splint.

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31. Cerebellar function may be assessed by performing which examination/test?

A. Gag reflex B. Pupillary response C. Romberg test D. Apley’s test

Answer: C Feedback: The Romberg test is a cerebellar function test that looks for stability and pronator drift.

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32. In the epithelialization phase of wound healing, the wound will have only what percentage of its normal tensile strength at 3 weeks?

A. Less than 15%

B. 15% to 20% C. 25% to 40% D. Greater than 50%

Answer: B Feedback: The epithelialization phase begins within hours of tissue injury and involves the migration of cells at the wound edges from one side of the incision to the other. Typically, the wound will have only 15% to 20% of its normal tensile strength at 3 weeks and 60% by 4 months.

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33. Which of the following statements is true about antibiotic prophylaxis for most recent, clean wounds?

A. Antibiotics are not indicated.

B. Antibiotics should always be ordered for a wound.

C. Antibiotics need to be ordered for at least 2 weeks.

D. Antibiotics should be ordered only if sutures are in place.

Answer: A Feedback: Antibiotic prophylaxis for most wounds is not indicated. The risk of infection of a clean, recently injured wound in a well-vascularized area is low (only 3% to 5%).

Chapter: Chapter 75: Common Injuries Page: 1339 Difficulty: Easy

34. Why do benzodiazepines have less potential for toxicity than barbiturates?

A. They cause decreased neuronal activity, depressed central sympathetic tone, and inhibit cardiac contractility.

B. They increase ligand affinity and the frequency of ion channel opening, but not the duration of time the channel remains open.

C. They act directly on inhibitory gamma-aminobutyric acid (GABA) receptors.

D. They increase the average opening time of chloride ion channels.

Answer: B Feedback: Benzodiazepines increase ligand affinity and the frequency of ion channel opening, but not the duration of time that the channel remains open. Given this mechanistic difference, benzodiazepines have less potential for toxicity than barbiturates due to their saturable effects.

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35. A patient presents to the emergency department with delirium, dilated pupils bilaterally, and hypoactive bowel sounds. Skin is flushed and dry; mucous membranes are dry. Upon admission, a urinary catheter was inserted with no output. These clinical manifestations describe which common toxidrome?

A. Cholinergic B. Sedative-hypnotic C. Anticholinergic

D. Sympathomimetic

Answer: C Feedback: The clinical manifestations of anticholinergic toxidrome include: elevated blood pressure, heart rate, and temperature, delirium, mydriasis, hypoactive bowel sounds, flushed and dry skin, urinary retention, and dry mucous membranes.

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36. Which systemic condition affects a person’s ability to sweat?

A. Hypotension B. Typhoid fever C. Miliaria D. Cystic fibrosis

Answer: D Feedback: Cystic fibrosis affects the ability to sweat.

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37. What is true about an acclimatized person?

A. Aldosterone secretions are diminished.

B. Heat dissipation is impeded.

C. Cardiac output increases.

D. Aerobic muscle metabolism decreases.

Answer: C Feedback: Cardiac output increases with acclimatization, as does aerobic muscle metabolism, which is more efficient metabolically. As the heart muscle responds to higher ambient temperatures, cutaneous circulation increases with peripheral vasodilation, augmenting head dissipation.

Chapter: Chapter 76: Toxic and Environmental Exposures Page: 1385 Difficulty: Easy

38. If no clinical decompensation is noted when evaluating a poisoned patient, what should the health-care provider do next?

A. Evaluate for signs of trauma and central nervous system (CNS) involvement.

B. Evaluate the airway, breathing, and circulation.

C. Order a basic metabolic panel and liver function test panel.

D. Obtain a urine sample for a toxicology screen.

Answer: A Feedback: Barring clinical decompensation, evaluation for signs of trauma and CNS involvement should subsequently commence.

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Difficulty: Easy

39. What should be used to alkalinize urine to a pH of greater than 7.0?

A. Dextrose B. Sodium bicarbonate C. Activated charcoal D. Ipecac syrup

Answer: B Feedback: Sodium bicarbonate administration is used to alkalinize urine to a pH of greater than 7.0.

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40. Immersion foot (trench foot) is a differential diagnosis for what condition?

A. Hyperthermia B. Necrosis C. Frostbite D. Erythema pernio

Answer: C Feedback: Differential diagnoses for frostbite include frostnip, chilblains (erythema pernio),

immersion (trench) foot, and hypothermia.

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41. What is the aim of gastrointestinal (GI) decontamination for poisoned patients?

A. Evacuating toxins from the stomach before they can be absorbed B. Neutralizing the poison by inducing vomiting and diarrhea C. Restricting the amount of xenobiotic from reaching the systemic circulation D. Absorbing the toxins that have reached systemic circulation

Answer: C Feedback: In a toxic ingestion, the xenobiotic must first dissolve in the GI tract before it can be absorbed and enter the systemic circulation. Therefore, GI decontamination aims to restrict the amount of xenobiotic that reaches the systemic circulation.

Chapter: Chapter 76: Toxic and Environmental Exposures Page: 1381 Difficulty: Moderate

42. Which of the following is not a differential diagnosis of heat stroke?

A. Cerebrovascular accident B. CNS infections C. Diabetic ketoacidosis

D. Alcohol intoxication

Answer: D Feedback: Alcohol intoxication is a differential diagnosis of hypothermia.

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43. A patient comes into the emergency department with an extensive chainsaw wound on the right lower leg. After stabilizing the patient and checking for circulation, what assessment should be done?

A. Check sensation on all extremities.

B. Check sensation on the affected leg.

C. Check for any foreign bodies in the wound.

D. Check the entire length of the wound for depth.

Answer: B Feedback. Any extremity that has sustained a wound injury should be evaluated first for distal circulation and sensation. Then assess for other things.

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44. The health-care provider is examining a wound and notices that underlying muscular fascia is damaged. What should the provider do?

A. Repair the damaged fascia.

B. Send the patient for an MRI. C. Close the wound with steri strips.

D. Clean the wound so it will heal on its own.

Answer: A Feedback: Examination for injuries to underlying muscular fascia is required. If a large defect is found, the fascia must be closed to prevent herniation of the muscle in the future.

Chapter: Chapter 75, Common Injuries Page: 1334 Difficulty: Moderate

45. A patient is brought into the clinic after a poisoning by an unknown substance. What is the priority?

A. Assessing for injury and trauma B. Assessing for CNS abnormalities C. Assessing airway, breathing, and circulation D. Obtaining an ECG

Answer: C Feedback: Evaluation of the patient who is poisoned begins with the primary survey: airway,

breathing, and circulation (ABC). Barring clinical decompensation, evaluation for signs of trauma and CNS involvement should subsequently commence. Furthermore, individuals with a reported toxic ingestion or overdose should undergo an ECG, as specific findings can suggest exposure to certain agents.

Chapter: Chapter 76, Toxic and Environmental Exposures Page: 1380 Difficulty: Easy

46. What test should be performed if the health-care provider suspects a joint violation after a knee injury has occurred?

A. A synovial fluid aspiration B. An x-ray C. A saline load D. An MRI

Answer: C Feedback: A saline-load test can be performed to accurately determine whether a joint violation has occurred.

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47. Which technique is appropriate for application of 2-octylcyanoacrylate tissue adhesive?

A. Apply the tissue adhesive along the approximated wound edges.

B. Apply topical antibiotics to the area.

C. Allow 15 seconds in between application at every 1 cm.

D. Secure adhesive tape to approximated edges to keep wound closed.

Answer: C Feedback: For 2-octylcyanoacrylate tissue adhesive application, the skin must be clean and dry. The wound is approximated with sterile fingers or tissue forceps, taking care not to injure the tissue with the forceps. Once the wound is well approximated, with the fingers at least 1 cm away, the adhesive is applied in concentric circles, allowing 15 seconds between applications. The patient should be advised not to scrub the adhesive and not to apply any antibiotic ointment to the wound, because this can dissolve the adhesive. Adhesive tape should also not be placed directly over the site.

Chapter: Chapter 75, Common Injuries Page: 1339 Difficulty: Moderate

48. Ordering prophylactic antibiotics would be appropriate for which wound?

A. A deep wound with approximated edges B. A wound that is 8 hours old C. A wound with a retained foreign body D. A wound closed with 2-octylcyanoacrylate tissue adhesive

Answer: C Feedback: Crush injuries, dirty wounds, jagged wounds, wounds with devitalized tissue, wounds that are more than 12 to 19 hours old, bite wounds (from cats, dogs, and especially

from humans [particularly if they are meat eaters]), wounds with retained foreign bodies, and wounds closed with subcutaneous stitches are all types of wounds for which prophylactic antibiotic is recommended.

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49. A patient presents to the emergency department after camping in the mountains. Their lower left extremity is edematous and red with vesicles containing clear fluid. The patient also complains of numbness. What degree frostbite would the patient have?

A. First degree B. Second degree C. Third degree D. Fourth degree

Answer: B Feedback: In second-degree frostbite (full-thickness injury), the patient may show erythema, substantial edema, vesicles with clear fluid, blisters that desquamate and form blackened eschar, numbness, and vasomotor disturbances in severe cases.

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50. Which of the following statements by the patient would indicate understanding of the education provided post wound closure?

A. “I can shower right away.”

B. “Vitamin E will help my wound heal.”

C. “Red streaks or drainage may mean an infection.”

D. “I can expect severe pain as the wound heals.”

Answer: C Feedback: The patient should be taught to monitor the wound for signs of infection, including red streaks extending from the wound (angioedema) and any purulent discharge from the wound (infection).

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Chapter 77. Primary Care of Adolescents MULTIPLE CHOICE 1. During adolescence, it is imperative that the health-care provider A. Talk to the adolescent‘s parent or guardian only because adolescents are minors.

B. Discuss the same health promotion topics with each adolescent.

C. Educate the adolescent on issues to become a productive adult.

D. Implement acute care intervention for better health.

Answer: C Feedback: Adolescents need attention and care from health-care providers during these formative years to develop into productive adults. Education should be individualized and come from a public health perspective. Discussion and education should be provided to the adolescent because they are developing from dependence to independence.

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2. A 16-year-old patient is contemplating giving into peer pressure by going to an end of the school year party where alcohol and marijuana will be present. The adolescent knows that going to the party and getting caught could lead to not getting into the college that they want to attend. The adolescent is thinking from which theoretical perspective?

A. Erickson B. Freud

C. Fowler D. Piaget Answer: D Feedback: Piaget‘s theory is formulated on the basis that adolescents move from concrete to abstract thinking, or A = B and B = C so A = C. In the example, the adolescent is moving into the abstract with an understanding of how the party could affect future plans. Erickson‘s theory is based on Freud. Erickson‘s theory is formulated from psychosocial development stages in which one stage needs to be resolved before moving to another stage. Fowler‘s theory is one that is based on moral development.

Chapter: Chapter 77, Primary Care of Adolescents Page: 1394 Difficulty: Moderate

3. The health-care provider is counseling a 20-year-old transgender adolescent. The adolescent states they know who they are and are happy but feel disconnected and socially isolated from their peers. According to Erickson, which stage is the adolescent having difficulty with?

A. Intimacy versus isolation B. Identity versus role confusion C. Autonomy versus shame and guilt D. Industry versus inferiority Answer: A Feedback: Intimacy versus isolation is the stage that this adolescent is having difficulty with and needs to overcome. The adolescent has a sense of and is accepting of their own identity, but they are searching for an intimate connection. Identity versus role confusion is not appropriate due to the adolescent knowing who they are and accepting themselves, as well as being 20 years old. Autonomy versus shame and guilt is a stage for toddlers, and industry versus inferiority is the stage for school age individuals.

Chapter: Chapter 77, Primary Care of Adolescents Page: 1394 Difficulty: Moderate

4. When an adolescent needs to overcome a crisis in the intimacy versus isolation stage of Erickson‘s theory, the health-care provider should A. Discuss ways to connect with others.

B. Instruct the adolescent to give things time and they will resolve.

C. Refer the adolescent to an inpatient psychiatric ward.

D. Ignore this part of the visit.

Answer: A Feedback: Discussion should focus on the need for the adolescent to be comfortable with their sexual identity and how to connect with others to promote an intimate relationship. Although things may get better, answer B is dismissive of the adolescent‘s concerns. The adolescent is in a normal stage of developmental and there is no need for psychiatric referral. No part of the

visit should be ignored by the health-care provider because adolescence is a formative time, and the goal is to promote productive adults.

Chapter: Chapter 77, Primary Care of Adolescents Page: 1394 Difficulty: Moderate

5. It is recommended that adolescents visit their health-care provider A. A total of three times from ages 11 to 21 B. Only if they need a sport physical or an acute issue arises C. Once a year and a complete physical exam three times from ages 11 to 21 D. Only if ill Answer: C Feedback: Bright Futures recommends that adolescents visit their health-care provider once a year with complete physical exam during the ages of 11 to 14, 15 to 17, and 18 to 21. Adolescents can also be seen for sports physicals and episodic care as needed.

Chapter: Chapter 77, Primary Care of Adolescents Page: 1394 Difficulty: Easy

6. When discussing sensitive issues with the adolescent, the health-care provider keeps things confidential. The only time the provider must reveal part of the conversation to the patient‘s parent or guardian is when the adolescent A. Is doing something risky B. Plans to take action against the parent‘s wishes C. Discusses a desire to harm self or others D. Requires an expensive prescription Answer: C Feedback: The health-care provider can ask the parents or guardian to leave the room when sensitive information will be discussed with the adolescent. The health-care provider must inform the adolescent that the information will be held confidential unless the adolescent divulges information about harming themselves or others. In that case, the parents or guardian must be notified.

Chapter: Chapter 77, Primary Care of Adolescents Page: 1395 Difficulty: Easy

7. The health-care provider is assessing a 13-year-old girl at an annual well visit. During the puberty assessment it is noted that the patient has secondary mounds of breast tissue, started menarche 6 months ago, and pubic hair is filling in. Which stage of the Tanner scale is this patient in?

A. II

B. III C. IV D. V Answer: C Feedback: Assessing puberty using Tanner staging is important to make sure the adolescent is reaching milestones. Every adolescent goes through the same order of stages of pubertal growth but at different ages. Tanner stage IV is indicative of ages 11 to 13, where secondary mounds appear above breast tissue, pubic hair becomes adultlike but is not fully distributed, and menarche starts.

Chapter: Chapter 77, Primary Care of Adolescents Page: 1396 Difficulty: Moderate

8. What anticipatory guidance topics would the health-care provider discuss with the middle adolescent?

A. Adult responsibilities B. Peer pressure C. Pregnancy prevention D. Increased freedoms Answer: D Feedback: Anticipatory guidance is providing guidance on issues before they arise. Anticipatory guidance on increased freedoms and responsibilities such as working and driving are done with the middle adolescent. Anticipatory guidance on peer pressure, sex, preventing STIs, and pregnancy are done in early adolescence. Anticipatory guidance about adult responsibilities is done in late adolescence.

Chapter: Chapter 77, Primary Care of Adolescents Page: 1400 Difficulty: Moderate

9. The 17-year-old patient worried about sleep tells the health-care provider that they are very dedicated to earning good grades. They are also involved in baseball and the track team and have a part time job on the weekend. The patient states they often feel overwhelmed by their schedule, and after practice and homework, they start to wind down at about 10:00 p.m. by watching mindless videos on their smartphone until 11:30 p.m., then they can fall asleep.

What recommendation would the provider make first to promote 8 hours of sleep a night?

A. Give up their part time job.

B. Practice mindfulness to dispel anxiety about grades.

C. Avoid watching videos before bed.

D. Pick only one extracurricular activity to participate in.

Answer: C

Feedback: Discussion about how blue light before bed affects sleep is the priority. Discussion about giving up some extracurricular activities or work can be done if the adolescent is open.

Mindfulness activities for anxiety may be helpful but are not the first recommendation.

Chapter: Chapter 77, Primary Care of Adolescents Page: 1399 Difficulty: Moderate

10. A 15-year-old patient has filled out the pediatric assessment checklist before an annual visit. Upon review of the checklist, the health-care provider notices that the patient is experiencing sadness and anxiety and has been bullied on social media after expression of liking a peer. What would be the most appropriate intervention?

A. Instruct them to delete social media accounts.

B. Prescribe Prozac.

C. Refer to counseling.

D. Report the bullying to the police.

Answer: C Feedback: The most appropriate intervention would be to refer the adolescent to a counselor.

The patient is not describing depression or feeling like they will harm themselves or others.

The police do not need to be involved, although social media accounts should be monitored by an adult.

Chapter: Chapter 77, Primary Care of Adolescents Page: 1403 Difficulty: Easy

Chapter 78. Sports Physicals

MULTIPLE CHOICE

1. Which statement is TRUE regarding sports physicals?

A. The sports physical as a screening tool changes and updates yearly.

B. They are meant to exclude athletes who are not in shape from participation in sports.

C. The sports physical is a formal requirement, and it is done annually.

D. They are only done prior to junior year to determine participation in high school sports.

Answer: C Feedback: For some, the preparticipation physical evaluation (PPE) is an annual formal requirement before participation in school or other organized sports.

Chapter: Chapter 78, Sports Physicals Page: 1406 Difficulty: Easy

2. A teen is receiving a sports physical to participate in cross-country running. She receives her exam from a single provider, who is examining all of the athletes one after the other in the nurse‘s office at school. Which of the following is a problem with this exam format for sports physicals?

A. It is expensive, and her school will have to use a large amount of its budget to fulfill the sports physical requirement.

B. It lacks individual attention that could increase the risk of insufficient medical history.

C. It is disorganized, and the athletes may have the potential for inadequate integration of findings.

D. It lacks privacy, and the students may feel that their medical information is not being kept confidential.

Answer: B Feedback: This is an example of the assembly line or mass examination format. It is cheaper and quicker, but it lacks individual attention, causes possible communication problems, increases the risk that insufficient medical history is taken, and lacks continuity.

Chapter: Chapter 78, Sports Physicals Page: 1407 Difficulty: Medium

3. A 16-year-old football player has an appointment for his sports physical. He had a head hit yesterday while playing with friends and went to the emergency room. He was discharged with a diagnosis of a concussion. Today he feels dizzy, has noise sensitivity, and had trouble sleeping last night. Which of the following options is best for the clinician to pursue?

A. Complete a formal Balance Error Scoring System (BESS) and neuropsychologic testing before clearing him to play.

B. Clear him to play, because the emergency room discharged him, and these symptoms are normal after a head hit.

C. Clear him to play in a week when his symptoms will subside.

D. Refuse to clear him because he had a concussion and should not be playing football at all anymore.

Answer: A Feedback: Because this athlete has a concussion and postconcussion symptoms, the best option is to complete a formal BESS and neuropsychologic testing to determine when he can return to play.

Chapter: Chapter 78, Sports Physicals Page: 1409 Difficulty: Medium

4. The clinician is seeing a 15-year-old swimmer for a sports physical. During examination, the swimmer notes she has had difficulty breathing while swimming over the last 3 days. Which of the following options is best for the clinician to pursue?

A. Clear her to participate in swimming, as it is common to have some days of difficulty on exertion, especially if she has not been as active the week before.

B. Refer her to the sports trainer prior to clearing her so she can work on her form and have less difficulty on exertion.

C. Complete a workup for pulmonary hypertension, anemia, asthma, and cardiovascular issues prior to clearing her for participation.

D. Send her to the emergency room immediately, as this is very concerning and needs to be urgently addressed.

Answer: C Feedback: Although this may just be poor conditioning, the best option is to suspect and complete a workup for pulmonary hypertension, anemia, asthma, and cardiovascular issues before she participates.

Chapter: Chapter 78, Sports Physicals Page: 1409

Difficulty: Medium

5. Which of the following is the most common cause of cardiac death in athletes?

A. Hypertrophic cardiomyopathy B. Supraventricular tachycardia C. Atrial flutter D. Conduction block

Answer: A Feedback: Hypertrophic cardiomyopathy is a major risk factor for sudden cardiac death (SCD) in athletes. It is believed to account for up to 35% of SCDs. Chapter: Chapter 78, Sports Physicals Page: 1409 Difficulty: Easy

6. A teen boy is 6 feet 6 inches tall. He has a thin build, pectus carinatum, and flexible joints. Which of the following tests should the clinician perform?

A. Chest x-ray to evaluate for signs of potential pneumothorax B. Abdominal computed tomography (CT) scan to assess for stomach distention C. Magnetic resonance imaging (MRI) to evaluate for scoliosis of the spine D. Echocardiography to assess for signs of aortic root dilatation

Answer: D

Feedback: There are signs that the patient has Marfan‘s syndrome. Echocardiography is recommended for boys and men taller than 6 feet who have two or more physical manifestations of Marfan‘s syndrome.

Chapter: Chapter 78, Sports Physicals Page: 1413 Difficulty: Medium

7. The clinician has discovered that an athlete who plays soccer has scabies. Which of the clearance options is appropriate at this time?

A. Unrestricted clearance B. Clearance if he promises to refrain from contact with the other players during the game C. Clearance after completion of treatment for scabies D. Disqualification

Answer: C Feedback: Contagious skin lesions, such as scabies, disqualify an athlete until they are corrected.

Chapter: Chapter 78, Sports Physicals Page: 1413 Difficulty: Medium

8. Which of the following should be gathered from a family history during a sports physical?

A. History of attention deficit-hyperactivity disorder (ADHD) B. History of heart disease C. History of broken bones D. History of cancer

Answer: B Feedback: A family history of premature SCD can put athletes at an increased risk of SCD themselves.

A family history of heart disease would include SCD and help screen for cardiovascular risk.

Chapter: Chapter 78, Sports Physicals Page: 1409 Difficulty: Medium

9. Which of the following sports would be appropriate for a patient with sickle cell disease?

A. Football B. Boxing C. Archery D. Wrestling

Answer: C Feedback: Patients with sickle cell disease are frequently recommended to participate in low-intensity activities.

Chapter: Chapter 78, Sports Physicals Page: 1410 Difficulty: Medium

10. The clinician is examining the skin of an athlete who would like to be cleared to play beach volleyball. What is the clinician‘s most important focus point when looking at her skin?

A. Color of her skin, to see if she is easily sunburned B. Acne, to see if she has sensitivity to perspiration

C. Freckles, to assess if she potentially has a melanoma D. Contagious diseases, such as tinea, boils, impetigo, or herpes

Answer: D Feedback: Contagious legions such as tinea, boils, impetigo, or herpes will disqualify the athlete until corrected.

Chapter: Chapter 78, Sports Physicals Page: 1413 Difficulty: Easy

11. What is the correct way for the clinician to check for hamstring flexibility?

A. Have the patient sit on the exam table and touch his toes.

B. Have the patient stand up straight and flex 45 forward at the waist.

C. Have the patient sit on the exam table and twist from side to side.

D. Have the patient stand up straight and flex 90 forward at the waist.

Answer: D Feedback: To assess for hamstring flexibility, the patient should stand up straight, flex forward at the waist, extend back, bend laterally, and then rotate to both sides. Discomfort in the lower extremities with range of motion of the back may be a sign of tight hamstring muscles.

Chapter: Chapter 78, Sports Physicals Page: 1413 Difficulty: Easy

12. What condition would an athlete who participates in an aesthetic sport, such as figure skating, be at risk for?

A. Bulimia B. Drug abuse C. Asthma D. Presyncope

Answer: A Feedback: Athletes in aesthetic sports like figure skating are at risk for eating disorders such as anorexia and bulimia.

Chapter: Chapter 78, Sports Physicals Page: 1410 Difficulty: Easy

13. A runner who has type 1 diabetes is receiving their sports physical. Which of the following instructions is appropriate to provide to the athlete?

A. Do not drink much water before the race so that there is more glucose in your blood.

B. You may want to look into participation in scuba diving, as it can be beneficial for pulmonary health.

C. You need to closely monitor your diet, insulin, and blood glucose before, after, and during exercise.

D. Make sure to load up on carbohydrates before activity so your blood sugar does not drop during exercise.

Answer: C Feedback: Athletes with a medical history of diabetes should have a good understanding of caloric intake/expenditure and glycemic control before, during, and after exercise. These athletes need to pay close attention to blood glucose, hydration, insulin, and diet. Although athletes with diabetes can participate in most sports, certain activities are considered high risk because of the consequences if the athlete experiences hypoglycemia. These sports include rock climbing, scuba diving, and skydiving.

Chapter: Chapter 78, Sports Physicals

Page: 1409 Difficulty: Moderate

14. Which of the following is the goal of a preparticipation sports physical?

A. To disqualify athletes from a sport for medical reasons B. To require as a means to not hold schools liable if an athlete gets hurt C. To promote safe sports participation D. To keep the sports playing field fair

Answer: C Feedback: The main goal for performing the preparticipation sports physical is to promote safe sports participation. It is not meant as a means to exclude athletes from participation.

Chapter: Chapter 78, Sports Physicals Page: 1406 Difficulty: Moderate

15. Which is a main focus of the neuromuscular exam portion of the preparticipation sports physical?

A. Strength B. Muscle size C. Coordination D. Symmetry

Answer: D Feedback: A key component of the neuromuscular examination is symmetry. This includes symmetry in range of motion, muscle strength, sensation, and reflexes.

Chapter: Chapter 78, Sports Physicals Page: 1411 Difficulty: Easy

Chapter 79. Primary Care of Patients Who are Transgender MULTIPLE CHOICE

1. What is the best strategy for determining the correct way to address a transgender patient during a patient–provider‘s initial encounter?

A. Use the gender indicated on the electronic health record.

B. Use only second-person (you/your) pronouns.

C. Ask new patients how they want to be addressed.

D. Refer to their government-issued identification.

Answer: C Feedback: It is important to build up a trusting therapeutic relationship. Asking a transgender individual how they want to be addressed shows caring and that you want to improve patient outcomes. It is important to not be biased or dismissive of differences and not to assume that the gender indicated on official forms, including government ones, is correct.

Chapter: Chapter 79, Primary Care of Patients Who are Transgender Page: 1418 Difficulty: Easy

2. Which mental health issue is most common in a transgender individual?

A. Stress B. Psychopathy C. Dysphoria D. Body dysmorphic disorder Answer: C Feedback: Dysphoria, depression, and anxiety are the common mental health issues experienced by transgender individuals.

Chapter: Chapter 79, Primary Care of Patients Who are Transgender Page: 1419 Difficulty: Easy

3. A trans woman has undergone full gender-affirming surgery and is on hormonal therapy.

Which screening should be performed for this patient?

A. Breast B. Digital rectal C. Testicular D. Pelvic Answer: B Feedback: The prostate is not removed during gender-affirming surgery. Therefore, a trans woman should continue to have her prostate checked through a digital rectal exam or with PSA laboratory testing. The other exams listed would not be appropriate due to the surgical intervention.

Chapter: Chapter 79, Primary Care of Patients Who are Transgender Page: 1422 Difficulty: Moderate

4. What is the laboratory testing interval recommendation for a trans male patient taking testosterone transdermal 1.6% daily?

A. Yearly B. Every 6 to 8 months for 2 years then yearly C. Every 3 months for the first year then yearly D. Every month for 3 months then every 3 months for a year Answer: C Feedback: Laboratory testing for individuals taking testosterone is done every 3 months for the first year then once or twice a year thereafter while on the medication.

Chapter: Chapter 79, Primary Care of Patients Who are Transgender Page: 1420 Difficulty: Easy

5. A trans man is taking testosterone and has undergone a mastectomy and hysterectomy.

What is this patient most at risk for?

A. Cardiovascular disease B. Osteoporosis C. Cancer D. Chronic obstructive pulmonary disease (COPD) Answer: A Feedback: Both trans men and trans women are at increased risk of cardiovascular disease due to the sex/hormonal link to cardiac issues. When hormone therapy is implemented the risk of cardiovascular disease increases. Trans women are more at risk of osteoporosis. Cancer and COPD do not have increased risk in the transgender population.

Chapter: Chapter 79, Primary Care of Patients Who are Transgender Page: 1421

Difficulty: Difficult

Chapter 80. Primary Care of Veterans MULTIPLE CHOICE 1. What is the largest integrated health-care system in the United States?

A. Veterans Health Administration (VHA) B. Center for Medicare and Medicaid services (CMS) C. Community networks D. Private organizations Answer: A Feedback: The VHA is the largest, most integrated health-care system in the United States, with more than 300,000 care providers and a wide range of services.

Chapter: Chapter 80, Primary Care of Veterans Page: 1424 Difficulty: Easy

2. Which VHA program assists veterans in receiving care for service-related conditions outside of the VHA network?

A. Veterans Integrated Service Network (VISN) B. Veterans Choice Program C. Light Electronic Action Framework (LEAF) D. Veterans Health Administration facilities Answer: B Feedback: The Veterans Choice Program allows veterans who receive VHA benefits to see a nonveteran provider if it is a hardship to get to a VHA facility. The VISN and veteran health-care facilities are both VHA health-care systems. The LEAF program is a web application to assist VHA facilities by digitizing processes to get services to veterans faster.

Chapter: Chapter 80, Primary Care of Veterans Page: 1424 Difficulty: Moderate

3. Which of the following will allow non-VHA providers to provide better veteran-centric care?

A. Understanding that military culture is no different from the dominant culture B. Advising all veterans that they must receive care through a VHA provider C. Asking for military service history to allow prompting of veteran-centric screening tools D. Referring all veteran patients to counseling services as a matter of course Answer: C

Feedback: Only about 20% of nonveteran providers ask about military history. If military history is documented, then appropriate screening tools specific to the needs of veterans can be prompted. Not all veterans have VHA benefits, and they do have special needs because of military culture, deployments, separation, combat, and other service-related issues.

Chapter: Chapter 80, Primary Care of Veterans Page: 1425 Difficulty: Moderate

4. A patient seeing the primary care provider states that he has recently separated from his military service, and he has been having outbursts, anger, and stress with reintegration into civilian life. His mental health is putting a strain on his marriage, and he wants help. What would be the most important intervention for this patient?

A. Instruct the patient that it will take time to reintegrate into civilian life.

B. Have the patient read his discharge papers because all military personnel, when separated from the service, are screened for mental health and substance use disorders (SUDs).

C. Provide a mental health referral for counseling for post-traumatic stress disorder (PTSD), depression, and SUD. D. Prescribe antianxiety medications to improve that patient‘s symptoms.

Answer: C Feedback: Military personnel upon separation are screened for mental health and SUDs; however, this screening and referral are often inadequate. It is important that the health-care provider be familiar with the issues service people have when they integrate back into civilian life and refer them as needed for mental health services. Although medications may be helpful, a referral to a mental health provider should be done before medications are ordered.

Chapter: Chapter 80, Primary Care of Veterans Page: 1425 Difficulty: Moderate

5. During the Gulf War, many military personnel were exposed to environmental hazards that led to development of which condition?

A. Diabetes B. Chronic fatigue C. Chronic respiratory illness D. Cancer Answer: B Feedback: Exposure to asbestos, chemical-biological agents, and depleted uranium during the Gulf War led to chronic fatigue, joint pain, and cognitive deficits termed ―Gulf War Illness‖ (GWI). Cancers and diabetes are more prevalent in Vietnam veterans, and chronic respiratory issues are more prevalent in Iraq and Afghanistan war veterans.

Chapter: Chapter 80, Primary Care of Veterans Page: 1427–1428 Difficulty: Moderate

6. A veteran of Operation Enduring Freedom is seeking care for joint pain, a nonhealing wound, and a recurring fever. What differential diagnosis should the health-care provider investigate?

A. GWI B. Hepatitis C. Agent Orange exposure D. Infectious disease Answer: D Feedback: Veterans often return with delayed presentation of infectious agents. Any recurring fever and nonhealing wounds should have a workup done for infectious disease, especially if the veteran was deployed to Southwest Asia, as in Operation Enduring Freedom.

Chapter: Chapter 80, Primary Care of Veterans Page: 1428 Difficulty: Difficult

7. A 62-year-old veteran presents to the health-care provider with whole body fatigue, fever/chills, and a loss of appetite. Upon examination, the patient has multiple areas of enlarged lymph nodes, noticeable shortness of breath with clear lung sounds, and is cachectic in appearance. What would you start to investigate as a diagnosis with this patient?

A. Hodgkin‘s lymphoma B. Lung cancer C. Diabetes D. B-cell leukemia Answer: A Feedback: The age of the patient suggests this is a Vietnam veteran who was likely exposed to Agent Orange. Agent Orange has been shown to cause severe illness, such as Hodgkin‘s lymphoma, prostate and lung cancers, ischemic heart disease, and diabetes. The patient‘s symptoms are consistent with Hodgkin‘s lymphoma likely related to Agent Orange exposure.

Chapter: Chapter 80, Primary Care of Veterans Page: 1428 Difficulty: Difficult

8. The VHA has made a priority of screening, treatment, and curing of which chronic illness that disproportionately affects veterans?

A. GWI B. Hepatitis C C. HIV D. Hodgkin‘s lymphoma Answer: B Feedback: The VHA has made hepatitis screening, treatment, and cure a major priority. Veterans are disproportionately affected due to lifestyle issues, Vietnam-era service, health-care utilization, demographic factors, transfusions, and IV drug use. The other illnesses listed af-

fect veterans and are treated by the VHA but are not listed as a major priority for screening, treatment, and cure.

Chapter: Chapter 80, Primary Care of Veterans Page: 1429 Difficulty: Easy

9. To diagnosis a veteran with PTSD, which of the following needs to be present?

A. Symptoms must be present for more than 3 months.

B. Other potential causes have been treated first.

C. Significant impairment of occupational relationships has occurred.

D. Diminished health-care utilization has occurred.

Answer: C Feedback: PTSD is diagnosed when symptoms are present for more than 1 month, other disorders such as SUD and depression are ruled out, and PTSD symptoms significantly impair social and occupational relationships. Veterans with PTSD have higher rates of health-care utilization.

Chapter: Chapter 80, Primary Care of Veterans Page: 1430 Difficulty: Moderate

10. The health-care provider is caring for a veteran who reports feeling emotionally disengaged, has trouble sleeping, is hypervigilant, has been drinking more, and feels like they want to self-harm. Upon questioning, the veteran states that they were traumatized by their unit but never made a formal complaint and left the military when their tour was up. Which would the health- care provider further investigate?

A. Suicide risk B. PTSD C. Military sexual trauma (MST) D. Traumatic brain injury (TBI) Answer: C Feedback: The symptoms and problems this veteran is stating are related to MST. Although depression and suicide should also be investigated, these would stem from the MST. There is no indication of TBI or PTSD in the veteran‘s statements. Key phrases about MST are the symptoms described and being traumatized by the unit but not filing a formal complaint. Veterans are often concerned about stigma and retaliation, and so they do not file formal complaints.

Chapter: Chapter 80, Primary Care of Veterans Page: 1430 Difficulty: Difficult Chapter 81. Primary Care of the Patient With Cancer MULTIPLE CHOICE

1. What is the most persistent and common side effect in the acute phase of cancer treatment?

A. Pain B. Fatigue C. Nausea D. Peripheral neuropathy Answer: B Feedback: Fatigue is the most common and persistent side effect that occurs in the acute phase but can last throughout the long-term effect phase. Nausea and peripheral neuropathy occur in the long-term effect phase. Pain can be experienced but it should be treated and relieved. Exercise is the best way to combat fatigue in the acute phase.

Chapter: Chapter 81, Primary Care of the Patient With Cancer Page: 1439 Difficulty: Easy

2. A 55-year-old patient was treated for lung cancer with an alkylating agent 5 years ago. The patient is seeing the health-care provider for their yearly physical and screening. What is this patient most at risk for due to previous cancer treatment?

A. Burns B. Leukemia C. Mental status changes D. Cachexia Answer: B Feedback: Chemotherapy-induced leukemia can occur 2 to 5 years after treatment. Solid mass tumor risk declines 10 years after completion of alkylating treatment. Burns are common with radiation therapy cachexia and any mental fog should resolve after treatment ends.

Chapter: Chapter 81, Primary Care of the Patient With Cancer Page: 1442 Difficulty: Difficult

3. A patient comes in with recurrent infections, both viral and bacterial, some causing severe illness, and reports getting the flu even after getting the vaccine. The patient states they are taking Rituximab. What is most likely causing the patient‘s health concerns?

A. Hyperthyroidism B. Decreased luteinizing hormone C. Lack of immunoglobin A D. Loss of B-cell function Answer: D Feedback: Immunotherapy (Rituximab) causes loss of B-cell function. B cells create antibodies that attack bacteria and viruses and provide immunity to protect individuals from infection.

Immunoglobin A is a blood protein that helps to prevent infections. The thyroid produces TSH, which affects metabolism. Luteinizing hormone plays a role in sexual development and regulates the menstrual cycle.

Chapter: Chapter 81, Primary Care of the Patient With Cancer Page: 1444 Difficulty: Difficult

4. According to the American Cancer Society (ACS), it is paramount that after cancer treatment optimal health be maintained. Which of the following is listed in these recommendations?

A. Eating more red meat to gain muscle and weight B. Drinking 2 glasses of red wine daily for its beneficial effects on the cardiovascular system C. Getting any recommended vaccines and maintaining a vaccination schedule D. Exercising one time a week for an hour to alleviate fatigue Answer: C Feedback: Getting appropriate vaccines and maintaining a vaccination schedule is recommended for optimal health by the ACS. Other recommendations are to limit the amount of red and processed meats and consume a plant-based diet as well as limiting alcohol consumption.

It is recommended that individuals exercise three times a week for 30 minutes.

Chapter: Chapter 81, Primary Care of the Patient With Cancer Page: 1445 Difficulty: Difficult

5. A laboratory test is positive for the tumor biomarker HE4. What cancer is this biomarker indicative of?

A. Ovarian B. Breast C. Colon D. Thyroid Answer: A Feedback: HE4 is a biomarker for ovarian cancer, as well as ATFCA15-3, CA 125, and CEA. Breast cancer biomarkers are CA15-3, CA 27-29, and CEA. Colon cancer biomarkers are CA 19-9 and CEA, and thyroid cancer biomarkers are calcitonin and thyroglobulin.

Chapter: Chapter 81, Primary Care of the Patient With Cancer Page: 1441 Difficulty: Easy Chapter 82. Primary Care of Older Adults

MULTIPLE CHOICE

1. Which of the following is true regarding old age?

A. It is always defined as an adult aged 65 and older.

B. The human life cycle is consistent throughout the world.

C. Old age is not a definite biological state.

D. The life expectancy in the United States exceeds all other countries.

Answer: C Feedback: Old age is not a definite biological state, as the chronicle age denoted as ―old age‖ varies culturally and historically.

Chapter: Chapter 82, Primary Care of Older Adults Page: 1448 Difficulty: Easy

2. Which of the following is of particular importance when caring for an older adult?

A. Emphasizing episodic health needs instead of chronic health needs B. Taking time to examine potential poverty as financial resources dwindle over time C. Providing an integrated-care approach designed around the needs of the provider, so they can coordinate care for the patient D. Providing care while paying the minimal cost so that standards are met

Answer: B Feedback: Nearly one in 10 older adults (8.9% or 4.8 million) live below the poverty level.

Chapter: Chapter 82, Primary Care of Older Adults Page: 1449 Difficulty: Moderate

3. A 77-year-old woman presents to the clinic for an annual wellness examination. Which subcategory of the older population does she fit into, based on her age?

A. Young-old B. Old C. Old-old D. Oldest-old

Answer: B Feedback: Older adults are categorized as young-old (65 to 75 years), old (76 to 85 years), and old-old (80 to 85 years and older).

Chapter: Chapter 82, Primary Care of Older Adults Page: 1448 Difficulty: Moderate

4. What is the key to increasing physical activity in older adults?

A. Motivating them B. Performing a physical so the older adult can exercise at the gym C. Belonging to a fitness center D. Owning home fitness equipment

Answer: A Feedback: Patients need to be reassured that expensive equipment or fitness memberships are not necessary to increase physical activity; motivation is the key.

Chapter: Chapter 82, Primary Care of Older Adults Page: 1457 Difficulty: Easy

5. Which of the following is especially important for ensuring the safety of older adults?

A. Removing firearms from the home due to the high rate of depression in older adults

B. Making sure the hot water heater is set below 130oF C. Encouraging yearly tests to assess their ability to drive safely D. Assessing fall risk and history of falls

Answer: D Feedback: Falls among older adults constitute the most common cause of traumatic injury. Each year, 800,000 older adults (one in five) are hospitalized because of a fall, most often because of a hip or head fracture.

Chapter: Chapter 82, Primary Care of Older Adults Page: 1462 Difficulty: Moderate

6. Which vaccine is recommended for adults over 65 years of age and is administered every 10 years?

A. Hepatitis B B. Tetanus-diphtheria toxoids with acellular pertussis vaccine (Tdap) C. Pneumococcal D. Zostavax

Answer: B Feedback: Tdap is administered as a once-in-a-lifetime booster to every adult. After this, a tetanus-diphtheria (Td) booster is recommended every 10 years.

Chapter: Chapter 82, Primary Care of Older Adults Page: 1460 Difficulty: Moderate

7. What does one of the ―Is‖ stand for in the mnemonic DELIRIUM, which is used to assess causes for delirium in an older patient?

A. Infection B. Identity crisis C. Influenza D. Internal injury

Answer: A Feedback: An easy way to remember the causes of delirium in the older adult is the mnemonic DELIRIUM: Drugs, Electrolyte imbalance, Lack of drugs (withdrawal, uncontrolled pain), Infection, Reduced sensory input (vision or hearing loss), Intracranial (e.g., cerebral vascular accident or subdural hematoma), Urinary retention or fecal impaction, and Myocardial/pulmonary.

Chapter: Chapter 82, Primary Care of Older Adults Page: 1461 Difficulty: Easy

8. Clinicians should ask older adults about their end-of-life (EOL) plans when they are A. Recovering from surgery B. Receiving an emergency procedure C. Undergoing an outpatient procedure D. Demonstrating confusion

Answer: C Feedback: Older adults should be asked about their EOL preparations at annual office visits, when entering the hospital, or when undergoing an outpatient procedure.

Chapter: Chapter 82, Primary Care of Older Adults Page: 1465 Difficulty: Moderate

9. Which of the following is an age-related change to the integumentary system?

A. Increased body odor B. Decreased heat loss C. Moistness D. Decreased hair production

Answer: B Feedback: Decreased vascularity is an integumentary system change that manifests as atrophy of sweat glands/decreased sweat production, decreased body odor, decreased heat loss, and dryness.

Chapter: Chapter 82, Primary Care of Older Adults Page: 1451 Difficulty: Easy

10. Which of the following is a cardiovascular age-related change?

A. Faster heart rate B. Increased sensitivity to changes in blood pressure C. Increased cardiac responsiveness to stress D. Reduced stroke volume

Answer: D Feedback: One cardiovascular age-related change is that heart valves thicken and become fibrotic. This yields reduced stroke volume, and cardiac output may be altered.

Chapter: Chapter 82, Primary Care of Older Adults Page: 1451

Difficulty: Easy

11. Which of the following is an age-related laboratory change?

A. Increase in erythrocyte sedimentation rate B. Decreased blood urea nitrogen C. Increase in hematocrit D. Decrease in urine protein

Answer: A Feedback: One hematologic age-related change is erythrocyte sedimentation rate. The normal value for men and boys is 0 to 20, the normal value for women and girls is 0 to 30. These numbers significantly increase with age.

Chapter: Chapter 82, Primary Care of Older Adults Page: 1452 Difficulty: Easy

12. Which clinical recommendation is grade A, meaning it has consistent, good-quality, patient-oriented evidence?

A. There are benefits to initiating aspirin use for primary prevention of cardiovascular disease and colorectal cancer in adults aged 70 or older.

B. There are benefits to asking adults about tobacco use, advising them to stop using tobacco, and providing Food and Drug Administration (FDA)-approved pharmacotherapy for cessation.

C. There are benefits to screening for impaired visual acuity in older adults.

D. There are benefits to completing a screening mammography in women aged 75 years or older.

Answer: B

Feedback: The USPSTF recommends clinicians ask about tobacco use, advise cessation, and provide behavioral interventions and U.S. FDA-approved pharmacotherapy for cessation for adults who use tobacco.

Chapter: Chapter 82, Primary Care of Older Adults Page: 1454 Difficulty: Easy

13. What does the first S stand for in the SPICES Geriatric Syndrome Markers?

A. Sciatica B. STIs C. Sleep disturbances D. Sexual problems

Answer: C Feedback: SPICES is a mnemonic for: Sleep disturbances, Problems with eating or feeding, Incontinence, Confusion, Evidence of falls, and Skin breakdown.

Chapter: Chapter 82, Primary Care of Older Adults Page: 1461 Difficulty: Easy

14. Which question will help identify older adults who are at risk for falls?

A. ―Have you fallen in the past 2 years?‖ B. ―Do you feel unsteady when you are sitting?‖ C. ―Does your caregiver worry about you falling?‖ D. ―Do you worry about falling?‖

Answer: D Feedback: ―Do you worry about falling?‖ is one question that is used to identify older adults who are at risk for falls. If the answer is ―yes,‖ the STEADI program provides step-by-step instruction for further assessment, intervention, and treatments.

Chapter: Chapter 82, Primary Care of Older Adults Page: 1462 Difficulty: Moderate

15. Which of the following adverse events is linked to polypharmacy in the older adult?

A. Dyspepsia B. Insomnia C. Polyuria D. Syncope

Answer: D Feedback: Polypharmacy in older adults has been linked to an increase in adverse events, including falls, confusion, extrapyramidal symptoms, and syncope.

Chapter: Chapter 82, Primary Care of Older Adults Page: 1462 Difficulty: Moderate

Chapter 83. Pain Management

MULTIPLE CHOICE

1. Which of the following statements is TRUE regarding pain?

A. If a patient complains of pain but has no physical signs, they are most likely exhibiting drug-seeking behaviors.

B. Acute pain is more intense and severe than chronic pain.

C. Pain is a subjective experience related to actual or potential tissue damage.

D. Nociceptive pain represents a normal response to injury of tissue.

Answer: D Feedback: Nociceptive pain represents a normal response to tissue injury. This type of pain is divided into two categories: somatic pain and visceral pain.

Chapter: Chapter 83, Pain Management Page: 1471–1472 Difficulty: Difficult

2. Which of the following would be a cause of neuropathic pain?

A. Bone metastases B. Poststroke pain C. Musculoskeletal inflammation D. Postsurgical incisional pain

Answer: B Feedback: Neuropathic pain is caused by lesions to the peripheral nervous system, as in diabetic neuropathy, postherpetic neuralgia, or lumbar radiculopathy, or a lesion of the central nervous system (CNS), such as poststroke pain, multiple sclerosis, or what could be acquired in conditions such as HIV neuropathy.

Chapter: Chapter 83, Pain Management Page: 1472

Difficulty: Easy

3. Which antiepileptic medication is an effective treatment for nerve pain?

A. Amitriptyline B. Codeine C. Methadone D. Gabapentin

Answer: D Feedback: Anticonvulsant medications like gabapentin have been used for the treatment of neuropathic pain. These medications block voltage-gated calcium or sodium channels and have been shown to suppress spontaneous neural discharge postulated to play a role in neuropathic pain disorders.

Chapter: Chapter 83, Pain Management Page: 1477 Difficulty: Moderate

4. Which type of pain arises from muscle joints and cutaneous tissue?

A. Somatic pain B. Neuropathic pain C. Visceral pain D. Nociceptive pain

Answer: C Feedback: Visceral pain is pain arising from organs and smooth muscle. It is more diffuse and

cramplike and is characterized as a poorly localized discomfort.

Chapter: Chapter 83, Pain Management Page: 1472 Difficulty: Easy

5. Which type of receptor is a specialized neuron that detects a noxious stimulus and then conducts it to the CNS? A. Tactile corpuscle B. Ion channel linked receptor C. Nociceptor D. Chemoreceptor

Answer: C Feedback: Nociceptors are sensory receptors that respond to noxious stimuli; they are specialized neurons that detect a noxious stimulus and then conduct it to the CNS. Chapter: Chapter 83, Pain Management Page: 1469 Difficulty: Easy

6. Which process of somatosensory perception can be either facilitated or inhibited to stop the progression of pain up the CNS? A. Modulation B. Transduction C. Perception D. Transmission

Answer: A Feedback: Modulation of pain stimulus can be facilitated or inhibited to stop the progression up the CNS. Transduction is the basis of creating a chemical event that progresses to an electrical event.

Transmission is the process by which, as the stimulus progresses, the action potential depolarizes the neuron, allowing for the release of chemicals that facilitate the pain stimulus of the afferent primary neuron to the dorsal horn of the spinal cord. Perception occurs in the cerebral cortex and involves the process by which neural activity in the pain transmission pathway results in the subjective sensation of pain.

Chapter: Chapter 83, Pain Management Page: 1470 Difficulty: Moderate

7. A patient is recovering from abdominal surgery. Which type of pain are they most likely to be experiencing a few days postoperatively?

A. Neuropathic B. Mixed C. Somatic D. Chronic

Answer: B Feedback: Pain that arises from inflammation as a response to an injury is called ―mixed‖ pain type.

This type of pain also has adaptive and protective functions. It occurs in response to tissue damage, for instance, after a surgical procedure. Inflammatory pain will create an environment where the patient will avoid physical contact and manipulation of the painful site.

Chapter: Chapter 83, Pain Management Page: 1472 Difficulty: Moderate

8. The health-care provider should include which type of factor when using the Circle of Caring model when assessing a patient‘s pain?

A. Environmental B. Organizational C. Psychological D. Financial

Answer: C Feedback: The Circle of Caring model is made up of biological, psychological, and social factors: cultural, economic, social support, spirituality, ethnicity, education, and access to care/stigma.

Chapter: Chapter 83, Pain Management Page: 1474 Difficulty: Easy

9. NSAIDs have side effects of A. Liver toxicity B. Cardiovascular events C. Adrenal insufficiency D. Bleeding disorders

Answer: B Feedback: NSAIDs have adverse effects on the cardiovascular system, the gastrointestinal system, and the renal system.

Chapter: Chapter 83, Pain Management Page: 1475–1476 Difficulty: Moderate

10. A 70-year-old patient is visiting their health-care provider. The patient has osteoarthritis and is taking Tylenol 500 mg two tabs twice a day. They tell the provider that they are not moving around much because of the pain. Which would be the next step in pain control for this patient?

A. Prescribe Tylenol with codeine.

B. Tell the patient they will just have to deal with the pain.

C. Order physical therapy.

D. Provide outpatient counseling.

Answer: C Feedback: Physical therapy is a complementary therapy that should be tried to reduce the patient‘s pain before more medications are prescribed. Codeine is a weak opioid that often causes adverse events in the older adult population. Outpatient counseling is not indicated, and pain issues need to be addressed in the older adult population.

Chapter: Chapter 83, Pain Management Page: 1475 Difficulty: Difficult

Chapter 84. Palliative and End-of-life Care

MULTIPLE CHOICE

1. Which drug is considered the MOST effective medication for pain in terminally ill patients?

A. Codeine B. Hydrocodone C. Morphine D. Hydromorphone

Answer: C Feedback: Hospice and palliative care treatments near the end of life often use medication to relieve pain and suffering, including morphine. Health-care providers can provide support, reduce unwanted symptoms, and enhance the patient‘s ability to cope with and through their illness by giving them access to medications and treatments.

Chapter: Chapter 84, Palliative and End-of-Life Care Page: 1493 Difficulty: Moderate

2. Unlike palliative care, inpatient hospice provides A. Emotional support B. Care to patients at end of life only C. Spiritual services D. Combined knowledge and skill

Answer: B Feedback: General inpatient hospice care is utilized for individuals whose symptoms cannot be managed in their current location or during the last few days of their life.

Chapter: Chapter 84, Palliative and End-of-Life Care Page: 1491 Difficulty: Easy

3. Which of the following is the best description of dyspnea?

A. An oxygen saturation of less than 90% B. Respiratory rate greater than 24 C. A psychological state resulting in the feeling of air hunger

D. A subjective feeling of breathlessness

Answer: D Feedback: Dyspnea is a subjective feeling of breathlessness, a sensation of labored or difficult breathing, which contributes to severe disability and impaired quality of life.

Chapter: Chapter 84, Palliative and End-of-Life Care Page: 1499 Difficulty: Easy

4. A scopolamine patch is one drug of choice to manage which condition?

A. Copious secretions B. Cough C. Anxiety D. Effusion

Answer: A Feedback: The R of BREATHES stands for Rales/crackles, secretions. If secretions are copious, a provider might consider a scopolamine patch every 72 hours.

Chapter: Chapter 84, Palliative and End-of-Life Care Page: 1501 Difficulty: Easy

5. The health-care provider is providing end-of-life care to an elderly patient with a history of heart failure. The patient complains of dyspnea. What is often the first-line treatment for this condition?

A. Oxygen B. Benzodiazepines C. Opioids D. Nonpharmacological solution

Answer: A Feedback: The American Thoracic Society supports the use of invasive or noninvasive mechanical ventilatory supports such as the use of oxygen to address dyspnea when appropriate.

Chapter: Chapter 84, Palliative and End-of-Life Care Page: 1499 Difficulty: Moderate

6. The Patient Self-Determination Act (PSDA) of 1991 requires that health-care providers A. Provide education about advance directives.

B. Move patients into hospice care when they have a terminal diagnosis.

C. Focus on the prognosis above all.

D. Implement necessary life-sustaining procedures.

Answer: A Feedback: The U.S. government continued to promote hospice and palliative care concepts by establishing the PSDA in 1991, requiring health-care providers discuss advance care planning with patients during the admission process.

Chapter: Chapter 84, Palliative and End-of-Life Care Page: 1489 Difficulty: Moderate

7. Which statement is true of palliative care?

A. There needs to be a prognosis of 6 months or less of life.

B. It is only provided at the end of life.

C. Curative treatments can be provided.

D. All medications except those for symptom management need to be discontinued.

Answer: C Feedback: Individuals receiving palliative care services can continue curative treatments, therapies, and trials. The Medicare hospice benefit requires that patients forgo many aggressive and curative treatments for their terminal diagnosis, and it typically does not cover therapies (physical/occupational). Hospice care is provided with a prognosis of 6 months or less and medications are discontinued except those that provide symptom management.

Chapter: Chapter 84, Palliative and End-of-Life Care Page: 1491 Difficulty: Moderate

8. Which advance directive provides for a DNR order that follows the patient across health-care settings and to their home?

A. Living will B. Power of attorney C. My Five Wishes D. Physician‘s orders for life sustaining treatment (POLST)

Answer: D Feedback: POLST forms follow the patient across all health-care settings and to their home. It is a form that is discussed with the patient and signed by the physician. The first section on the MOST/POLST form addresses cardiopulmonary resuscitation (CPR). The health-care provider asks whether the individual wishes to have chest compressions and breathing resuscitation commenced if their heart stops beating or they stop breathing.

Chapter: Chapter 84, Palliative and End-of-Life Care Page: 1494 Difficulty Moderate

9. A patient receiving chemotherapy for a cancer diagnosis reports nausea and vomiting. Which would be the best medication to relieve these symptoms?

A. Scopolamine B. Ondansetron C. Prochlorperazine D. Metoclopramide

Answer: B Feedback: Ondansetron works well for nausea and vomiting related to chemotherapy treatment.

Chapter: Chapter 84, Palliative and End-of-Life Care Page: 1502 Difficulty: Moderate

10. Which of the following can be used as a nonpharmacological intervention for a patient receiving palliative care who has developed delirium?

A. Moving the patient closer to the nurse station B. Having visitors always visit to decrease behaviors C. Providing soft music and lights in a quiet room to reduce anxiety D. Having the patient walk around the unit

Answer: C Feedback: Interventions that may be helpful for a patient with delirium include restoration of fluid and electrolyte balance, consistency in the living space, supportive techniques such as elimination of unnecessary stimuli, and provision of a safe environment, measures that reduce anxiety.

Chapter: Chapter 84, Palliative and End-of-Life Care Page: 1504

Difficulty: Moderate

Chapter 85. Ethical and Legal Issues of a Caring-Based Practice

MULTIPLE CHOICE

1. Which statement about the American Nurses Association Code of Ethics is accurate?

A. Each state’s legal requirements exceed those of the Code.

B. A primary purpose of the Code is to show physicians that nurses are professional.

C. Nurses, with input from physicians, formulated the Code for all nurses.

D. The Code sets forth the values and ethical principles that guide clinical decisions.

Answer: D Feedback: The Code sets forth the values and ethical principles that guide the clinical decisions of all nurses. It provides a framework within which nurses and advanced practice registered nurses can make ethical decisions and be held accountable for those decisions.

Chapter: Chapter 85, Professional Codes Page: 1514 Difficulty: Moderate

2. Which ethical principle reflects respect for all persons and their self-determination?

A. Autonomy

B. Beneficence C. Justice D. Veracity

Answer: A Feedback: The first ethical principle is autonomy, which deals with personal liberty of action and self-determination, along with respect for all persons as individuals.

Chapter: Chapter 85, Autonomy Page: 1516 Difficulty: Easy

3. The clinician is using the mnemonic ETHICAL to solve a practice dilemma. What does the A represent?

A. Accountability B. Autonomy C. Assess D. Act

Answer: D Feedback: The ETHICAL mnemonic represents: Examine the data, Think about which person(s) should be making the decision, Humanize the options by constructing a decision tree, Incorporate the ethical principles, legal statutes, standards of care, and so on, Choose an option, Act, and Look back and evaluate.

Chapter: Chapter 85, Resolution Guidelines Page: 1519

Difficulty: Easy

4. In an outpatient setting, what is the most common reason for a malpractice suit?

A. Breach of confidentiality B. Failure to diagnose correctly C. Medication-related errors D. Lack of informed consent

Answer: B Feedback: Approximately one-third of the malpractice cases brought against general practitioners are due to failure to diagnose in a timely manner. These cases usually involve cancer, particularly cancer of the breast.

Chapter: Chapter 85, Malpractice Page: 1525 Difficulty: Moderate

5. Which type of liability insurance covers only situations in which the incident occurred and the claim was made while the policy was in effect?

A. Claims-made policy B. Occurrence policy C. An employment coverage policy D. A “tail policy”

Answer: A Feedback: A claims-made policy covers only situations in which the incident occurred and the claim was made when the policy was in effect. It is wise to also have a “tail policy” with a claims-made policy.

Chapter: Chapter 85, Malpractice Page: 1525 Difficulty: Easy

6. Which insurance plan was the first to allow members to choose nurse practitioners (NPs) as their primary care provider and pay them the same rate as physicians for the same care?

A. Blue Cross/Blue Shield plan B. Medicare/Medicaid plan C. Oxford Health plan D. United Health Insurance plan

Answer: C Feedback: In 1997, when the Oxford Health plan allowed members to choose NPs as their primary care providers and paid them the same rate as physicians for the same care, APRNs were finally recognized as independent practitioners who could provide quality care.

Chapter: Chapter 85, Collaboration Page: 1526 Difficulty: Easy

7. What is the primary rationale in the ETHICAL mnemonic for using a decision tree to analyze ethical dilemmas?

A. Shows the best solution B. Explains the ethical principles C. Delineates the legal parameters D. Allows all options to be considered

Answer: D Feedback: The third step of the ETHICAL mnemonic is to humanize the options by constructing a decision tree. This tree allows all the options and their consequences to be considered.

Chapter: Chapter 85, Resolution Guidelines Page: 1519 Difficulty: Moderate

8. What is the best action to take to avoid a lawsuit?

A. Obtain good liability insurance.

B. Work with a collaborating physician.

C. Follow documentation principles.

D. Maintain open communication.

Answer: D Feedback: Ongoing, person-centered communication remains the best way for providers to diminish the risk of a costly judgment or settlement against them.

Chapter: Chapter 85, Malpractice

Page: 1525 Difficulty: Moderate

9. What is the purpose of the Nurse Practice Act? A. Establishing what care the practitioner can provide B. Promoting cost-effective care C. Protecting the nurse after licensure D. Determining exceptions to credentialing

Answer: A Feedback: The circumscribed actions and duties that are allowable in the profession are termed the “scope of nursing practice,” which is defined and guided by each state in the Nurse Practice Act and by common law.

Chapter: Chapter 85, Relationship Between Ethics and Law Page: 1521 Difficulty: Moderate

10. Which phrase describes deontology?

A. The greatest amount of happiness or the least amount of harm for the greatest number B. The consideration of consequences with the calculation of benefits C. The belief that the ends justify the means D. The principle of universalizability

Answer: D Feedback: Deontology literally means “from being.” The concept involves the notion that there are specific duties we have as rational beings that cannot be breached without incurring moral evil, and this encompasses the principle of universalizability.

Chapter: Chapter 85, Deontology Page: 1515 Difficulty: Easy

11. Which element is a primary focus of health-care reform?

A. Illness management B. Fee-for-service C. Disease prevention D. Bankruptcy reduction

Answer: C Feedback: The need for affordable health care is evident in the United States, and there is a shift from illness management (fee-for-service) care to prevention and wellness with reimbursement based on patient outcomes.

Chapter: Chapter 85, The Patient Protection and Affordable Care Act of 2010 Page: 1527 Difficulty: Moderate

12. Which ethical principle and concept are most congruent?

A. Veracity – fairness B. Nonmaleficence – do no harm C. Beneficence – keeping promises D. Justice – truth telling

Answer: B Feedback: The third ethical principle is nonmaleficence, or the idea that a health-care provider should, above all, “do no harm,” which is mentioned in the Hippocratic Oath.

Chapter: Chapter 85, Nonmaleficence Page: 1517 Difficulty: Easy

13. The Joint Commission (TJC) mandates that all health-care organizations have which component in place?

A. A mechanism for the consideration of ethical issues B. A standing ethics committee C. A resident parish nurse D. A lawyer who is knowledgeable about ethics

Answer: A Feedback: The Standards of TJC state that an organization should have in place “a mechanism for the consideration of ethical issues arising in the care of patients and to provide education to caregivers and patients on ethical issues in health care.”

Chapter: Chapter 85, Institutional Ethics Committees

Page: 1520 Difficulty: Easy

14. What is the relationship between ethics and law?

A. Ethical codes are legally binding.

B. What one ought to do is the “legal aspect.”

C. Legal actions may be both ethical and unethical.

D. There is no relationship between the law and ethics.

Answer: C Feedback: There is an overlap between the two concepts, but actions that are ethical are not always legal, whereas actions that are illegal are sometimes ethical.

Chapter: Chapter 85, Relationship Between Ethics and Law Page: 1521 Difficulty: Moderate

15. Which statement accurately describes the APRN’s scope of practice?

A. Regulation of the APRN’s practice ensures public understanding.

B. This delineates the permissible duties of APRN professional practice.

C. It expands the APRN’s practice outside each state’s Nurse Practice Act provisions.

D. Each APRN defines his or her own aspect of practice to be included in a protocol.

Answer: B Feedback: The circumscribed actions and duties that are allowable in the profession are termed the “scope of nursing practice,” which is defined and guided by each state in the Nurse Practice Act and by common law.

Chapter: Chapter 85, Relationship Between Ethics and Law Page: 1521 Difficulty: Moderate

16. Which condition must be present to establish malpractice?

A. The APRN must be paid for the services in question.

B. The provider must have a duty to the patient.

C. The clinician must act in a similar manner as a prudent person.

D. The plaintiff must prove an indirect link between harm and breach of duty.

Answer: B Feedback: There are three conditions that must be met to establish malpractice: the provider must have a duty to the patient, the standard of care must be deviated from or breached, and harm or damages must occur as a result of the duty and a breach of the standards of care.

Chapter: Chapter 85, Malpractice Page: 1524 Difficulty: Easy

17. Which requirement regarding prescriptive privilege is granted to APRNs in all states?

A. Additional medication training for controlled substances B. Need for countersignatures by physicians C. Statutory independent prescribing authority D. Certification in prescription drug administration

Answer: C Feedback: All states grant statutory independent prescribing authority to APRNs, including authority to prescribe controlled substances.

Chapter: Chapter 85, Prescriptive Authority Page: 1523 Difficulty: Moderate

18. Which scenario would constitute an ethical dilemma?

A. An APRN discusses a patient’s status with their significant other at the bedside.

B. An APRN instructs a patient to use the call button before they get up from the chair and applies a reminder alarm to their shirt.

C. An APRN loudly informs a patient in the dining room that they have soiled themselves and they must go get cleaned up.

D. An APRN advocates for the patient who does not want a painful procedure.

Answer: C Feedback: It is becoming more difficult to practice ethically in health care today for many reasons, including dehumanizing procedures, technological advances that affect the quality

of life, and the potential for unauthorized sharing of confidential information and violations of privacy because of easy access to data banks. In the examples, the correct answer leads to dehumanizing care and can violate ethical principles.

Chapter: Chapter 85, Ethical and Legal Practices of a Caring-Based Practice Page: 1513 Difficulty: Moderate

19. Which philosophical skill does the health-care provider need to acquire in order to practice ethically?

A. Instinctively convincing patients of what’s best for their health B. Saving health-care facilities money C. Documenting a patient’s health history D. Understanding the patient’s opposing view about diet

Answer: D Feedback: To apply ethics, there are three basic philosophical skills that clinicians need to foster or acquire. First, the clinician must develop an ability for in-depth questioning, not just taking information at face value. Next, the clinician must develop the ability to understand different points of view and make a reasonable, empathetic effort to understand another person’s opposing viewpoint. Finally, the clinician must not be afraid to argue a point logically.

Chapter: Chapter 85, Ethical and Legal Practices of a Caring-Based Practice Page: 1513 Difficulty: Difficult

20. Which example describes beneficence?

A. Declining to care for a tuberculosis patient because of possibly exposing other patients you are caring for B. Not telling a patient with dementia who is waiting for her husband that he died 10 years previous C. Running into an intensely burning building to save a pet D. Not telling the patient they are terminal because it is not your job

Answer: B Feedback: Beneficence is the provision of benefits and a balancing of harms and benefits and requires positive action. One must purposefully choose the right action, not merely by omission, and do what is in the best interest of the patient. Positive beneficence requires personal risk-taking. Not telling the patient with dementia that her husband has already died rationally balances the harm and benefit of telling a dementia patient about the death so that they grieve all over again. It is of benefit to the dementia patient and also does not cause harm.

Chapter: Chapter 85, Ethical and Legal Practices of a Caring-Based Practice Page: 1517 Difficulty: Moderate

Chapter 86. Quality & Value-Based Payment: Making an Economic Impact on Health Care

MULTIPLE CHOICE

1. The cost of care provided by an APRN is approximately A. Three-fourths that of a physician

B. One-third that of a physician C. One-half that of a physician D. One and one-half that of a physician

Answer: C Feedback: The cost of care provided by an APRN is approximately one-half of that of an internal medicine physician and a quarter of that of a specialty physician.

Chapter: Chapter 86, Quality & Value-Based Payment: Making an Economic Impact on Health Care Page: 1531 Difficulty: Moderate

2. What replaced the Sustainable Growth Rate (SGR) formula?

A. Advanced Alternate Payment Model (APM) B. Merit-Based Incentive System (MIPS) C. Medicare Access and CHIP Reauthorization D. Medicare Quality Payment Program (QPP)

Answer: D Feedback: The Medicare Access and CHIP Reauthorization Act‘s (MACRA‘s) final rule was released on October 15, 2016. This historic legislation repealed the SGR formula, creating a Centers for Medicare and Medicaid (CMS) QPP. Chapter: Chapter 86, Quality & Value-Based Payment: Making an Economic Impact on Health Care Page: 1538 Difficulty: Easy

3. The Current Procedural Terminology (CPT) and payment fee values are applicable only to CMS

services and are regulated and paid by the regional CMS carriers. How does this impact managed care organizations (MCOs)?

A. MCOs are the only groups able to adjust standard payment rules.

B. MCOs can independently determine whether to utilize certain CPT code rules and/or the reimbursement values for the payment year.

C. MCOs can create personalized CPT codes.

D. MCOs must continue to use modifiers.

Answer: B Feedback: The CPT and payment fee values are applicable only to CMS services and are regulated and paid by the regional CMS carriers. MCOs can independently determine whether to use certain CPT code rules and/or the reimbursement values for the payment year.

Chapter: Chapter 86, Quality & Value-Based Payment: Making an Economic Impact on Health Care Page: 1542 Difficulty: Moderate

4. All medical practices are required by the CMS to adopt a certified electronic medical record software system for documenting and billing for medical services. Why is this so critical?

A. Electronic software allows CMS to audit the performance of all medical practices.

B. Electronic filing protects patient information as required by the Health Insurance Portability and Accountability Act. C. Electric billing and automated electronic filing sets make timely transition to new provider fee schedule rates possible.

D. Medical record software eliminates the possibility for duplicate bills and overcharging patients.

Answer: C Feedback: Electronic billing and automated electronic filing sets make timely transitions to new PFS rates possible. This schedule provides a payment rate based on a state and local base rate multiplied by the Resource-Based Relative-Value Scale (RBRVS).

Chapter: Chapter 86, Quality & Value-Based Payment: Making an Economic Impact on Health Care

Page: 1543 Difficulty: Moderate

5. All health-care practices should develop a compliance plan. Compliance plans offer practice safeguards that prevent which of the following?

A. Malpractice claims B. Conflict-of-interest claims C. Health Insurance Portability and Accountability Act violations D. Occupational Safety and Health Administration violations

Answer: B Feedback: Compliance plans designate compliance officers who examine and identify antikickback efforts, conflict-of-interest disclosures, and identification of questionable business practices.

Chapter: Chapter 86, Quality & Value-Based Payment: Making an Economic Impact on Health Care Page: 1547 Difficulty: Easy

6. What is the focus in performance-based health care?

A. Lower cost B. Quality outcomes C. Fast service D. Customer satisfaction

Answer: B Feedback: In discussions on performance-based health care, quality outcomes are the focus.

Chapter: Chapter 86, Quality & Value-Based Payment: Making an Economic Impact on Health Care Page: 1530 Difficulty: Easy

7. Which individual would qualify for the Tricare program?

A. The adult child of a retired police officer B. The spouse of a retired veteran C. A person with a disability D. The child of an honorably discharged veteran

Answer: B Feedback: To be eligible for Tricare, a member must be a husband or wife of an active or retired service member, a child under 21 years of an active military member, or unmarried or older than 21 years of age with a disabled family member. Dependents can remain on Tricare until they are 65 years of age and/or are eligible for Medicare.

Chapter: Chapter 86, Quality & Value-Based Payment: Making an Economic Impact on Health Care Page: 1535 Difficulty:

8. Which statement is true of Accountable Care Organizations (ACOs)?

A. They provide coordinated, high-quality, affordable care.

B. They provide lower-level care to decrease cost.

C. They provide care outside of a network.

D. They provide care in a face-to-face format only to improve quality.

Answer: A Feedback: ACOs are groups of providers, hospitals, and outpatient care facilities that come together to coordinate patient care, seeking to offer high-quality care at a lower cost.

Chapter: Chapter 86, Quality & Value-Based Payment: Making an Economic Impact on Health Care Page: 1537 Difficulty: Moderate

9. Many states are adopting the APRN consensus model to align A. Payment, perception, and probability B. Certification, licensure, and accreditation C. Theory, model of care, and quality D. Quality, quantity, and quantification

Answer: B Feedback: States individually are addressing the issue of adopting the APRN Consensus Model, a uniform model supported by the American Nurses Credentialing Center to align licensure, accreditation, and certification in practice. Adoption of the APRN Consensus Model by all state boards of nursing would move health care forward and make movement of nurses from state to state seamless.

Chapter: Chapter 86, Quality & Value-Based Payment: Making an Economic Impact on Health Care Page: 1540 Difficulty: Easy

10. A health-care provider is seeing a patient for a medical condition. In order to get reimbursed correctly from the patient‘s insurance, the provider must provide the correct A. Diagnosis B. Time of care provided

C. Current procedural terminology (CPT) D. Documentation of all supplies used during the visit

Answer: C Feedback: CPT codes provide a universal nomenclature, allow assignment of uniform descriptors for services, offer the ability to review practices, and assign reimbursement rates for each service code.

Chapter: Chapter 86, Quality & Value-Based Payment: Making an Economic Impact on Health Care Page: 1540 Difficulty: Easy

11. After a patient saw the physician for an acute care illness in the office, the nurse practitioner (NP), working with the physician, provided care to the patient for some treatments the physician recommended. This type of care is billed as A. Medicare B. Incident to C. Fee for service D. The NP‘s national provider identifier

Answer: B Feedback: ―Incident to a physician‘s professional service‖ permits nonphysician practitioners to offer related services or needed care under the direct supervision of a physician. This does not mean that the physician needs to be in the room, but they must be in the same suite or office. The services are related to the course of treatment resulting from an initial visit with the physician and administered by a nonphysician.

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12. Quality metrics and core values that track outcomes are reported by health-care organizations.

Which organization requires reporting of preventive indicators, inpatient quality indicators, patient safety indications, and pediatric quality indicators?

A. CMS B. Health Plan Employer Data and Information Set (HEDIS) C. Agency for Health Care Research and Quality (AHRQ) D. Affordable Care Act (ACA)

Answer: C Feedback: Quality metrics and core values reported are presented/required by various sources. AHRQ reporting focuses on preventive, inpatient quality indicators, patient safety indications, and pediatric quality indicators. CMS focuses on the quality measures affecting Medicare and Medicaid patients and requires providers to identify goals that demonstrate effective, safe, efficient, patient-centered, equitable, and timely care. The HEDIS is a set of standardized performance measures identified as indicators for consumers so that they can evaluate the quality and cost aspects of health-care delivery.

Chapter: Chapter 86, Quality and Value-Bases Payment: Making an Economic Impact Page: 1545 Difficulty: Moderate

Chapter 87. Primary Care Approaches to Behavioral Health

MULTIPLE CHOICE

1. One benefit of motivational interviewing (MI) is A. It assumes that ambivalence is a normal part of the change process.

B. It can be utilized during routine office visits.

C. It is a therapeutic technique that is not necessarily time intensive.

D. All are benefits of MI.

Answer: D Feedback: MI asserts that ambivalence is a normal, nonpathological component of the change process. Clinicians assist patients in addressing ambivalence by exploring intrinsic motivation, values, and goals. The basic principles of MI promote respect for individual autonomy and belief that the patient is an expert on their own behavior.

Chapter: Chapter 87, Primary Care Approaches to Behavioral Health Page: 1554 Difficulty: Moderate

2. Which is not a basic principle of MI? A. People often continue behaviors with negative consequences for reasons unknown to the provider.

B. The patient is the expert on their own behavior.

C. Providers are obligated to inform each patient of the negative consequences of their behaviors.

D. Helping patients understand ambivalence for change is often more powerful than direct instruction.

Answer: C Feedback: The basic principles of MI are to promote respect for individual autonomy and the belief that the patient is an expert on their own behavior. The provider focuses on reflective listening and supporting the patient’s self-care behaviors.

Chapter: Chapter 87, Primary Care Approaches to Behavioral Health Page: 1554 Difficulty: Moderate

3. Which statement is true regarding mental health?

A. Depression decreases as chronic disease develops.

B. Depression is more common than hypertension.

C. It is out of the scope of practice for APRNs to provide care for mental health issues.

D. If depression is recognized and treated, health-care costs rise.

Answer: B Feedback: Psychiatric diagnoses are more common than hypertension and diabetes mellitus combined. Depression and cardiovascular disease, on their own, are two of the leading causes of death and disability worldwide. When these two conditions are comorbid, patients can be left with even worse health outcomes, loss of function, and exponentially increasing health-care costs. An increasing prevalence of mental health concerns are being managed in primary care.

Chapter: Chapter 87, Primary Care Approaches to Behavioral Health Page: 1551 Difficulty: Moderate

4. Which psychotherapeutic skill can the health-care provider use during short visits to assess mental health?

A. Reflective listening B. Inkblot test C. PQH-9 test D. Rejecting negative emotions

Answer: A Feedback: Cognitive behavioral skills building (CBSB) and MI techniques can be used even in brief, focused assessments. Techniques such as reflective listening, validating emotions, and encouraging patient empowerment are easily used during short office visits.

Chapter: Chapter 87, Primary Care Approaches to Behavioral Health Page: 1555 Difficulty: Moderate

5. Which statement is true about stress?

A. It is always negative.

B. It has harmful effects on the brain.

C. It always results in negative outcomes.

D. It is short term.

Answer: B Feedback: Stress is typically viewed negatively, but stress does not always result in adverse outcomes. It is the prolonged activation of the stress response in the body, namely the hypothalamic-pituitary-adrenal (HPA) axis, catecholamines, and cytokines, that leads to wear and tear on our regulatory systems. Researchers have more recently defined this as “toxic stress.” Toxic stress can be harmful to the brain in many ways.

Chapter: Chapter 87, Primary Care Approaches to Behavioral Health Page: 1552 Difficulty: Moderate

6. Which of the following is one of the three main components of the Mindstrong Program?

A. Psychoeducation B. Self-monitoring C. Cognitive restructuring D. Relaxation

Answer: C Feedback: The three main components of the Mindstrong Program are reducing negative thoughts (cognitive restructuring), increasing pleasurable activities (behavioral activation), and improving assertiveness and problem-solving skills (homework assignments).

Chapter: Chapter 87, Primary Care Approaches to Behavioral Health Page: 1553 Difficulty: Moderate

7. What is the goal of health coaching?

A. To help the patient cope effectively B. To provide a skill that is billable C. To encourage the patient to return to the health-care provider D. To eliminate stress

Answer: A Feedback: Skillfully employed, the professional therapeutic persona and health coaching can decrease stress and enable patients to cope more effectively. Although health coaching is billable, ethically this should not be why it is used as an intervention. Stress can never be

eliminated. Health-care providers want patients to be independent, have independent coping skills, and not rely on the health-care provider.

Chapter: Chapter 87, Primary Care Approaches to Behavioral Health Page: 1553 Difficulty: Difficult

8. An adolescent comes to see the health-care provider for a depression follow-up visit. The patient is on an antidepressant, but she reports she still feels like she is a “burden” and “can’t do anything right and screws things up.” The provider would employ which concept of cognitive behavioral therapy (CBT) to help this patient?

A. Increase pleasurable activities.

B. Reduce negative thoughts.

C. Listen actively.

D. Improve assertiveness and problem solving.

Answer: B Feedback: The premise of CBT is that there is a connection among our thoughts, feelings, and behaviors. Individuals develop automatic thoughts, based on our life experiences, and these thoughts shape our feelings, which shape our behaviors. Importantly, positive thoughts can lead to positive feelings and behaviors, and alternatively, negative thoughts can lead to negative feelings and behaviors.

Chapter: Chapter 87, Primary Care Approaches to Behavioral Health Page: 1553 Difficulty: Moderate

9. Which concept of CBT uses roleplay to show the patients different outcomes of a difficult situation?

A. Increasing pleasurable activities.

B. Reducing negative thoughts.

C. Improving assertiveness and problem solving.

D. Using psychoeducation.

Answer: C Feedback: Roleplay with the patient improves assertiveness and problem solving by showing the variety of ways actual situations can go. By planning for a wide range of outcomes, the patient can practice ways they can behave and react, and the health-care provider can help to examine evidence of inaccurate or unhelpful thoughts with the patient.

Chapter: Chapter 87, Primary Care Approaches to Behavioral Health Page: 1553 Difficulty: Moderate

10. What is the gold standard for treatment of behavioral health concerns?

A. MI B. CBT C. Medication D. Psychoeducation

Answer: B Feedback: The gold standard of treatment for many behavioral health concerns is CBT.

Chapter: Chapter 87, Primary Care Approached to Behavioral Health Page: 1553 Difficulty: Easy

11. A woman in her mid-20s comes in to see the health-care provider because she has been feeling down and uses food to cope with these negative feelings. The provider wants to help change the patient’s negative behaviors by discussing the motivations that cause her to overeat when feeling down. Which technique is the health-care provider using?

A. CBT B. MI C. Health history D. Adverse childhood experiences (ACEs) study

Answer: B Feedback: Health-care providers assist patients in exploring intrinsic motivation, values, and goals related to a negative behavior. The basic principles of MI promote respect for individual autonomy and the belief that the patient is an expert on their own behavior.

Chapter: Chapter 87, Primary Care Approached to Behavioral Health Page: 1554 Difficulty: Moderate

12. There is a link between ACEs and A. Liver disease

B. Hypothyroidism C. Diabetes D. GERD

Answer: A Feedback: There is a dose-response relationship between the number of ACEs and adult health risk behaviors and disease, meaning the more ACEs a person experienced, the worse their total health outcomes. Unsurprisingly, there was a strong relationship between ACEs and mental health symptoms, but more surprising was the link between number of ACEs and cardiovascular disease, cancer, lung disease, skeletal fractures, and liver disease.

Chapter: Chapter 87, Primary Care Approached to Behavioral Health Page: 1552 Difficulty: Moderate

13. When using CBT with adolescents, the decreasing negative thoughts (cognitive restructuring) concept of the intervention should be changed to A. Stop, think, listen B. Slow, steady, step C. Catch, check, change D. Look, listen, love

Answer: C Feedback: Many concepts from CBT can be easily adapted for pediatric populations. Rather than calling it “cognitive restructuring,” the health-care provider can help the adolescent catch, check, and change their thoughts. Rather than calling it “homework,” which often has a negative connotation in adolescent populations, it can be called “skills building.”

Chapter: Chapter 87, Primary Care Approach to Behavioral Health Page: 1553 Difficulty: Moderate

14. Which of the following is a category of the ACE study?

A. Hunger B. Isolation C. Abuse D. Illness

Answer: C Feedback: Abuse, neglect, and household dysfunction are the three categories of the ACE study.

Chapter: Chapter 87, Primary Care Approaches to Behavioral Health Page: 1552 Difficulty: Easy

Chapter 88. Putting Caring Into Practice: Caring for Self

MULTIPLE CHOICE

1. The World Health Organization (WHO) defines self-care as

A. An important global activity for all health-care providers B. A set of deliberate actions that all individuals, families, and communities should engage in to maintain good health C. Essential to efficacious advanced practice nursing (APRN) practice D. An awareness by the APRN of their self-care behaviors as related to diet, activity, and mental attitude

Answer: B Feedback: The WHO defines self-care as “a deliberate action that individuals, family members, and the community should engage in to maintain good health.”

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2. Nurse theorist Dorothea Orem defines self-care activities as A. Attainment of professional self-development goals B. The ability to persevere through hardship C. Attainment of balance and harmony in one’s life D. Actions that are performed independently by an individual to promote and maintain well-being throughout life

Answer: D Feedback: Orem defines self-care as comprising those activities performed independently by an individual to promote and maintain well-being throughout life.

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Difficulty: Easy

3. Self-care and personal development are built into the standards of practice of A. The American Holistic Nurses Association B. The American Nurses Association C. The American Association of Nurse Practitioners D. The American Academy of Nursing

Answer: A Feedback: The American Holistic Nurses Association’s Standards of Holistic Practice require the integration of self-care and personal development activities into one’s life.

Chapter: Chapter 88, Putting Caring Into Practice: Caring for Self Page: 1558 Difficulty: Easy

4. There are many pressures inherent in primary care practice today for APRNs. These pressures include A. Use of the electronic medical record B. Lower reimbursement rates than physicians C. The team approach to care D. Availability of medical information on the internet

Answer: B

Feedback: Reimbursement rates for NP services are often less than the rates for physician providers who provide the same care.

Chapter: Chapter 88, Putting Caring Into Practice: Caring for Self Page: 1559 Difficulty: Moderate

5. A new era of health care leads to A. Greater opportunity for independent practice, yet increased legal risk in accountability for patients B. Lowered reimbursement for all health-care services and providers C. Decrease in status for health-care providers D. No ability to individualize care

Answer: A Feedback: The changing face of health-care dictates the need for flexibility as we approach a new era in health care. APRNs have more opportunity to work independently, yet they experience increased risk of legal action.

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6. Compassion fatigue is another side effect of today’s health-care delivery system. This term means

A. The APRN feels sudden guilt and distress when they cannot rescue or save an individual, such as when bad health habits persist despite the best efforts of the APRN. B. The APRN feels burnout that happens over time related to the need to see increasing numbers of patients in busy primary care practices.

C. The APRN feels dissatisfaction that may persist over time, even when the APRN transfers to a new and different setting.

D. Patients’ problems and circumstances can be so overwhelming that the APRN needs to set severe boundaries to maintain safe function.

Answer: A Feedback: Compassion fatigue occurs when a caregiver cannot rescue or save an individual from harm, leading to feelings of guilt and distress. Compassion fatigue appears suddenly, and resolution may be uncertain and variable.

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7. Another term used, “burnout,” is differentiated by A. Numbness of feelings leading to substance abuse B. How novice APRNs feel at the end of the day in primary care C. Feelings of aloneness, desperation, and despair D. A gradual response to the inability to achieve one’s goals with patients in the work setting

Answer: D Feedback: Burnout occurs when a person cannot achieve their goals, which results in “frustration, a sense of loss of control, increased willful efforts, and diminishing morale” (Valent, 2002, p 27). Burnout arises and declines more slowly than compassion fatigue.

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8. Which statement about APRNs is true?

A. APRNs are often sensitive to patients’ deficiencies but not their own.

B. APRNs always respond appropriately to patients, families, and team members.

C. APRNs are well-equipped from their APRN educational programs to care for themselves.

D. Relicensure in some states mandates continuing education units in self-care.

Answer: A Feedback: Focusing on personal and professional shortcomings does not lead to optimal health. Nurse practitioners are often able to understand and accept the deficiencies of others, yet they hold themselves to unattainable standards.

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9. Emotional intelligence is defined as A. Being highly attuned to the needs of others B. The ability to engage in self-care C. Being able to recognize and understand the meaning of emotions and how they affect other people

D. The holistic integration of self-care and self-development practices

Answer: C Feedback: Emotional intelligence is the ability of the person to recognize emotions, understand the meaning of the emotions, and realize how the emotions affect other people.

Chapter: Chapter 88, Putting Caring Into Practice: Caring for Self Page: 1561 Difficulty: Easy

10. APRNs need to develop their own self-care management plans. Two key elements of self-care management plans are A. Vacations and keeping up with new knowledge and developments in medicine B. Resilience and positive intentionality C. Family support and a healthy diet D. Being physically and emotionally “fit”

Answer: B Feedback: Two overarching principles of a self-care management plan are resilience and positive intentionality. These concepts are interrelated and can enhance the success of self-care practices.

Chapter: Chapter 88, Putting Caring Into Practice: Caring for Self Page: 1561 Difficulty: Easy

11. The term “resilience” implies A. The ability to look to a higher power to get you through a crisis B. A response to difficult and adverse circumstances through positively adjusting to stressors C. That the APRN can weather any emergency D. Learning to set appropriate boundaries

Answer: B Feedback: Resilience has been defined as the ability to keep functioning in the face of continued stress, difficult work conditions, or trauma. Resilience can be seen as a strategy for responding to difficult or adverse situations by positively adjusting to stressors.

Chapter: Chapter 88, Putting Caring Into Practice: Caring for Self Page: 1561 Difficulty: Easy

12. Qualities associated with resilience include A. Hope, self-efficacy, and positivity B. Stick-to-it-ness, belief in a higher power C. Education, self-regulation, and use of activity to decrease stress D. Ability to take vacations and the availability of support systems and a secure work environment

Answer: A Feedback: Resilience can be associated with hope, positivity, and self-efficacy.

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Difficulty: Easy

13. Ruya, a 42-year-old experienced APRN, is orienting a new APRN to the Minute Clinic, where she has worked for more than 5 years. Ruya loves her work and was concerned when the new APRN, Alex, expressed his dissatisfaction with this setting. “I hate the idea of being here on my own, with no backup and support after orientation” was one of Alex’s concerns.

Alex confessed that this was the only job he could find. Ruya felt good in her independent role and felt she had worked to create a positive atmosphere for her patients at all times.

She derived joy and satisfaction from her ability to do this for her patients. Ruya found Alex’s endless complaints debilitating. Ruya demonstrates resilience by using which of the following strategies?

A. Ruya distances Alex by listening to him as little as possible.

B. Ruya openly shares her positive feelings about the work environment and takes a risk by sharing with Alex that she finds his endless complaining draining.

C. Ruya speaks privately with their supervisor, Pamela, stating that she does not think Alex can be successful in this environment.

D. Ruya requests that Alex be assigned to a different APRN for orientation.

Answer: B Feedback: Ruya positively adjusted to the stressor Alex created. Ruya demonstrated resilience by encouraging a positive attitude and attempting to further develop a positive working relationship with Alex.

Chapter: Chapter 88, Putting Caring Into Practice: Caring for Self Page: 1561 Difficulty: Difficult

14. When an APRN expresses their hopeful feelings towards their job and requests that a new coworker refrain from expressing their own pessimistic feelings, which qualities of resilience does the APRN demonstrate?

A. Protecting their own positive attitude by lessening their contact with a negative person B. Showing the ego strength to admit failure in their ability to orient a new coworker, who is a destructive person C. Protecting the organization by sharing the new coworker’s deficiencies with their supervisor D. Asserting their positive approach and basic optimism by initiating an honest discussion with the new coworker and having the emotional insight to recognize the new coworker’s negative effect

Answer: D Feedback: Factors of resilience in health-care professionals include: laughter/humor, self-reflection, beliefs/spirituality, and professional identity. Ruya’s positive attitude and self-efficacy are also aspects of resilience.

Chapter: Chapter 88, Putting Caring Into Practice: Caring for Self Page: 1561 Difficulty: Difficult

15. According to nurse theorist Jean Watson, a focus on positive intentionality—holding caring thoughts, loving kindness, and open receptivity—enhances caring energy, which leads to healing. How can the APRN bring this to their practice?

A. Spiritual readings, centering oneself before patient encounters, and engaging in behaviors that help build positive energy B. Review of materials on primary care before going into the work environment to increase one’s confidence, leading to caring energy C. Travel to sacred places

D. Helping the poor and homeless—volunteering at a domestic violence shelter, for example—in addition to one’s regular practice

Answer: A Feedback: Positive intentionality is a form of focused consciousness and energy. Focusing on positive intentionality in thoughts and actions enhances caring energy, which leads to healing and improved health.

Chapter: Chapter 88, Putting Caring Into Practice: Caring for Self Page: 1561 Difficulty: Difficult