Test Bank for Advanced Practice Nursing in the Care of Older Adults 2E by Kennedy-Malone, Laurie & D

TEST BANK

2023

COMPLETE Elaborated Test Bank for Advanced Practice Nursing in the Care of Older Adults 2nd Edition Laurie Kennedy-Malone Lori Martin-Plank Evelyn Duffy 2023

Advanced Practice Nursing in the Care of Older Adults 2nd Edition by Laurie Kennedy-Malone , Lori MartinPlank & Evelyn Duffy ISBN-10 0803666616 ISBN-13 978-0803666610

Test bank for Advanced Practice Nursing in the Care of Older Adults 2nd Edition by Laurie Kennedy-Malone , Lori Martin-Plank & Evelyn Duffy

ISBN-10 0803666616 ISBN-13 978-0803666610

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TABLE OF CONTENTS Unit I: The Healthy Older Adult Chapter 1: Changes With Aging Chapter 2: Health Promotion Chapter 3: Exercise in Older Adults

Unit II: Assessment Chapter 4: Comprehensive Geriatric Assessment Chapter 5: Symptoms and Syndromes

Unit III: Treating Disorders Chapter 6: Skin and Lymphatic Disorders Chapter 7: Head, Neck, and Face Disorders Chapter 8: Chest Disorders Chapter 9: Peripheral Vascular Disorders Chapter 10: Abdominal Disorders Chapter 11: Urological and Gynecological Disorders Chapter 12: Musculoskeletal Disorders Chapter 13: Central and Peripheral Nervous System Disorders Chapter 14: Endocrine, Metabolic, and Nutritional Disorders Chapter 15: Hematological and Immune System Disorders Chapter 16: Psychosocial Disorders

Unit IV: Complex Illness Chapter 17: Polypharmacy Chapter 18: Chronic Illness and the APRN Chapter 19: Palliative Care and End-of-Life Care

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Link I : Test Bank - Advanced Practice Nursing in the Care of Older Adults 2nd Edition by Laurie Kennedy-Malone , Lori Martin-Plank & Evelyn Duffy - Complete, Elaborated and Latest Test Bank. ALL Chapters(1-19) Included and Updated for 2024. - Browsegrades

Advanced Practice Nursing 2e(Malone)

Chapter 1. Changes With Aging Multiple Choice Identify the choice that best completes the statement or answers the question.

1. The major impact of the physiological changes that occur with aging is: A. Reduced physiological reserve B. Reduced homeostatic mechanisms C. Impaired immunological response D. All of the above 2. The strongest evidence regarding normal physiological aging is available through: A. Randomized controlled clinical trials B. Cross-sectional studies C. Longitudinal studies D. Case control studies 3. All of the following statements are true about laboratory values in older adults except: A. Reference ranges are preferable B. Abnormal findings are often due to physiological aging C. Normal ranges may not be applicable for older adults D. Reference values are not necessarily acceptable values 4. Biochemical individuality is best described as: A. Each individual’s variation is often much greater than that of a larger group B. The unique biochemical profile of a selected population C. The truly “normal” individual—falling within average range D. Each individual’s variation is often much smaller than that of a larger group 5. Polypharmacy is best described as taking: A. More than nine medications per day B. More than five medications per day C. Even a single medication if there is not a clear indication for its use D. When a drug is given to treat the side effect of another drug 6. Pharmacokinetic changes with aging is reflective of: A. What the drug does to the body B. What the body does to the drug C. The effect at the site of action and the time and intensity of the drug

Advanced Practice Nursing 2e(Malone) D. The side effects commonly associated with the drug 7. All the following statements are false about drug absorption except: A. Antacids increase the bioavailability of digitalis B. Gastric acidity decreases with age C. Anticholinergics increase colonic motility D. Underlying chronic disease has little impact on drug absorption 8. All of the following statements are true about drug distribution in the elderly except: A. Drugs distributed in water have lower concentration B. Drugs distributed in fat have less intense, more prolonged effect C. Drugs highly protein bound have greater potential to cause an adverse drug

reaction D. The fastest way to deliver a drug to the action site is by inhalation 9. Men have faster and more efficient biotransformation of drugs and this is thought to be due to: A. Less obesity rates than women B. Prostate enlargement C. Testosterone D. Less estrogen than women 10. The cytochrome p system involves enzymes that are generally: A. Inhibited by drugs B. Induced by drugs C. Inhibited or induced by drugs D. Associated with decreased liver perfusion 11. A statement not shown to be true about pharmacodynamics changes with aging is: A. Decreased sensitivity to oral anticoagulants B. Enhanced sensitivity to central nervous system drugs C. Drug responsiveness can be influenced by patient activity level D. There is a decreased sensitivity to beta blockers 12. Atypical presentation of disease in the elderly is reflected by all the following except: A. Infection without fever B. Depression without dysphoric mood C. Myocardial infarction with chest pain and diaphoresis D. Cardiac manifestations of thyroid disease 13. Functional abilities are best assessed by: A. Self-report of function B. Observed assessment of function C. A comprehensive head-to-toe examination D. Family report of function

Advanced Practice Nursing 2e(Malone)

Chapter 2. Health Promotion Multiple Choice Identify the choice that best completes the statement or answers the question.

1. The leading cause of death in elderly travelers worldwide is: A. Cardiovascular disease B. Infections C. Accidents D. Malaria 2. Which of the following should be avoided in countries where food and water precautions are to be

observed?

A. Hot coffee B. Bottled water C. Salad buffet D. Unpeeled bananas 3. What insect precautions are not necessary to prevent insect-borne diseases in the tropics?

A. Using 100% DEET on skin to prevent bites B. Treating clothes with permetherin C. Covering up exposed skin to lessen biting surface D. Taking malaria pills as directed for areas at risk for malaria

Advanced Practice Nursing 2e(Malone) 4. An example of secondary prevention you could recommend/order for older adults would be to: A. Check for fecal occult blood B. Wear seat belts in the car C. Provide foot care for a diabetic patient D. Administer a tetanus shot 5. Ali is a 72-year-old man who recently came to the U.S. from Nigeria. He reports having BCG

(bacille Calmette-Guerin) vaccination as a child. Which of the following is correct regarding a tuberculin skin test?

A. It should not be done at all.

B. It should be read as smaller than it really is.

C. Vaccination history is irrelevant; read as usual.

D. It should be read as larger than it really is.

6. A 72-year-old woman and her husband are on a cross-country driving vacation. After a long day of

driving, they stop for dinner. Midway through the meal, the woman becomes very short of breath, with chest pain and a feeling of panic. Which of the following problems is most likely?

A. Pulmonary edema B. Heart failure C. Pulmonary embolism D. Pneumonia 7. Ivan W. is a 65-year-old man who is new to your practice. He has a history of COPD, CAD,

hypertension, and type 2 diabetes mellitus. He has had no immunizations since his discharge from the military at age 25. Childhood diseases included chickenpox, measles, mumps, and “German measles.” He presents for a disease management visit. Which of the following immunizations would you recommend for Ivan?

A. MMR, influenza, pneumococcal, Zostavax B. Influenza, pneumococcal, PPD, Hepatitis B C. Tdap, pneumococcal, influenza, Zostavax D. Hepatitis B, influenza, pneumococcal, Hepatitis A 8. Leo L. is a 62-year-old African American male who comes for an initial visit to your practice.

Personal health history includes smoking 1 pack/day since age 11, consuming a case of beer (24 bottles) every weekend, and working as an assembler (sedentary job) for the past 10 years. Family history in first-degree relatives includes hypertension, high cholesterol, heart attack, and type 2 diabetes mellitus. Leo’s BMI is 32; BP today is 130/86. You order a fasting glucose, lipid profile, and return visit for BP check. This is an example of: A. Primary prevention B. Secondary prevention C. Tertiary prevention D. Health profiling 9. A local chapter of a nurse practitioner organization has begun planning a community-based

screening for hypertension at a local congregate living facility. This population was selected on the basis of: A. A predicted decreased incidence of high blood pressure in this population B. A recognized element of high risk within this group

Advanced Practice Nursing 2e(Malone) C. Readily available treatment measures D. Achieving an administrative goal for the congregate living facility 10. Performing range of motion exercises on a client who has had a stroke is an example of which level

of prevention?

A. Primary prevention B. Tertiary prevention C. Secondary prevention D. Rehabilitation prevention 11. The nurse practitioner demonstrates an understanding of primary prevention of falling among the

elderly through which management plan?

A. Evaluate a need for assistive devices for ambulation after the client has been injured from a fall.

B. Provide resources to correct hazards contributing to falls in the home environment.

C. Reinforce the need to use prescribed eyeglasses to prevent further injury from falls.

D. Provide information about medications, side effects, and interactions.

12. An example of an active strategy of health promotion for an individual to accomplish would be: A. Maintaining clean water in the local environment B. Introducing fluoride into the water C. Beginning a stress management program D. Maintaining a sanitary sewage system 13. You are working with an older male adult with a long history of alcohol abuse and a 30-year history

of smoking. In recommending an intervention for this client, your responsibility is to: A. Make the individual abandon his own health practices and follow your recommendations B. Register the patient for a local intervention program and secure payments C. Promote positive change in lifestyle choices D. Identify the barriers that the client will encounter 14. The four main domains of clinical preventive services that the practitioner will provide are: A. Counseling interventions, screening tests, immunizations, and chemoprophylaxis B. Counseling intervention, screening tests, immunizations, and education C. Counseling interventions, transportation, screening tests, and immunizations D. Screening tests, brief psychotherapy, immunizations, andchemoprophylaxis 15. Which organism that can be prevented by immunization is most often responsible for an infectious

“outbreak” in the nursing home setting?

A. Haemophilus influenza B. Streptococcus C. Influenza A D. Mycobacterium tuberculosis 16. What is the appropriate method for tuberculosis screening of an older adult entering a nursing home?

A. 5 tuberculin units intramuscular PPD injection and if negative repeat with same

dose one week later

Advanced Practice Nursing 2e(Malone) B. 5 tuberculin units intradermal PPD injection and if negative repeat with same dose

one week later C. Chest x-ray at the same time of PPD testing D. 5 tuberculin units intradermal PPD injection and if positive repeat same dose in

one week

Advanced Practice Nursing 2e(Malone)

Chapter 3. Exercise in Older Adults Multiple Choice Identify the choice that best completes the statement or answers the question.

1. Exercise recommended for older adults should include activities that: A. Conserve energy B. Restrict flexibility C. Strengthen muscles D. Are anaerobic in nature 2. Preferred amount of exercise for older adults is: A. 10 minutes of physical activity each morning B. 30 minutes per day of aerobic activity five times a week C. Any increase in physical activity over a sedentary lifestyle D. 60 minutes per day that includes 30 minutes of aerobic activity and 30 minutes of

weight training five times a week 3. Which of the following medical conditions is not considered restrictive for engaging in physical

activity?

A. Unstable angina

Advanced Practice Nursing 2e(Malone) B. Dehydration C. Depression D. Uncontrolled tachycardia 4. The best recommendation for a patient who states they have no equipment to exercise would be: A. Sign a contract for a year’s membership to a local gym B. Borrow free weights from grandchildren C. Have a personal trainer come to the home three times a week D. Improvise with recommended objects at home that can be used 5. When the nurse practitioner recommends exercise for a sedentary older adult, which of the following

pieces of advice should be considered for all types of exercise?

A. Only use equipment recommended by physical trainers B. Start low and go slow C. Only group exercise is beneficial to someone who has not been active in a long time D. Focus only on one type of exercise for the first few months

Advanced Practice Nursing 2e(Malone)

Chapter 4. Comprehensive Geriatric Assessment Multiple Choice Identify the choice that best completes the statement or answers the question.

1. The evidence reflects that comprehensive geriatric assessment should be conducted: A. On all individuals 65 and older B. On all individuals 75 and older C. By an inter-disciplinary team of professionals D. Targeting the vulnerable and frail elderly 2. Evidence-based geriatric assessment instruments available to the clinician: A. Are largely screening instruments to detect a condition B. Largely do not exist and if they do they have limited clinical utility C. Include screening, evaluation, and measurement instruments in multiple domains D. Have applicability in the outpatient but not the inpatient setting 3. When interviewing the older adult with a suspected dementia, it is most important that: A. Mental status be evaluated first in order to determine if the patient is a reliable

historian B. The examiner use short simple questions and recognize non-verbal signs of

discomfort C. Postpone the mental status evaluation for the following visit and establish a rapport

first D. The clinician get in contact with a family member to obtain the history 4. Which is not considered a dimension of symptomatology?

A. Onset B. Physical signs C. Location D. Absence of associated symptoms 5. The best approach to taking the health history is to:

Advanced Practice Nursing 2e(Malone) A. B. C. D.

Start with an open-ended question Start with the review of systems Focus on the chief complaint Complete the history before conducting the examination

6. A review of the evidence relative to screening of the elderly reveals the highest evidence rating for: A. Vision screening B. Mammography screening C. Hearing screening D. Dementia screening 7. Assessment of vital signs in the elderly reflect: A. Errors in blood pressure measurement are rare with automated recording devices B. Shortness of breath in the elderly is rare in the older, deconditioned, and immobile

patient C. Older adults prefer a 0-10 pain rating scale D. Older adults could be septic with a temperature within normal limits 8. What statement is true about nutrition intake in the elderly?

A. Deficiencies in protein intake are common with aging.

B. Malnutrition is the most common nutritional disorder among the elderly living in

the community.

C. Increased caloric consumption is needed as one ages.

D. The serum albumin is a good reflection of protein stores.

9. What is reflective of functional decline in older adults?

A. Functional decline is synonymous with advanced age.

B. Some individuals die of “old age” but have maintained an active and healthy

lifestyle.

C. Instrumental activities of daily living are preserved longer than activities of daily

living.

D. It is always possible to prevent functional deterioration.

10. The leading cause of traumatic death in the elderly is due to: A. Motor vehicle accidents B. Pedestrian injuries C. Falls D. Burns 11. Timing of the get-and-go test enhances its sensitivity. The process should take less than: A. Thirty seconds B. Sixteen seconds C. Sixty seconds D. Ten seconds 12. A validated tool for assessing cognitive function specific to dementia is: A. Mini-cog B. Confusion assessment method C. Yesavage GDS scale

Advanced Practice Nursing 2e(Malone) D. NuDesc 13. The medical outcome study short form 36 remains the gold standard of quality of life instruments. It

measures: A. Mental and social domains B. Social domain C. Physical, mental, and social domains D. Physical domain

Advanced Practice Nursing 2e(Malone)

Chapter 5. Symptoms and Syndromes Multiple Choice Identify the choice that best completes the statement or answers the question.

1. The term “geriatric syndrome” is best described as: A. A condition that has multiple underlying factors and involves multiple systems B. A condition that has a discreet etiology that is difficult to pinpoint C. Significant progress has been made in understanding geriatric syndromes,

especially falls and delirium D. Therapeutic management of a geriatric syndrome can be accomplished once a

specific diagnosis is made 2. The anal wink reflex is used to test: A. Rectal prolapse B. Sensation and pudental nerve function C. Baseline and squeeze sphincter tone D. Fissures and fistulas 3. Atypical presentation of acute coronary syndrome is: A. Most common in Hispanic females B. More common in men C. Most common in African American men D. More common in females

Advanced Practice Nursing 2e(Malone) 4. What disease can mimic and often co-exists with myocardial infarctions in elders with coronary

artery disease?

A. Hypertension B. Esophageal disease C. Diabetic gastroparesis D. Vascular disease 5. Thoracic aortic dissection presents typically as: A. Sharp stabbing pain in the mid thorax B. Pleuretic chest pain and dyspnea C. Severe retrosternal chest pain that radiates to the back and both arms D. Unilateral pleuretic chest pain and dyspnea 6. Medications known to contribute to constipation include all of the following except: A. Stimulant laxatives B. Anticholinergic drugs C. Broad-spectrum antibiotics D. Iron 7. Bordetella pertussis is best characterized by: A. Sub-acute cough lasting greater than two weeks B. Acute cough associated with a coryzal symptom C. Chronic cough with post-nasal drip D. Non-productive acute cough 8. The routine testing of tuberculosis should occur in all of the following vulnerable populations

except: A. Nursing home residents B. Prison inmates C. Hospitalized elderly D. Immune-compromised patients 9. Which of the following statements about fluid balance in the elderly is false?

A. Total body water decreases with age.

B. Thirst response decreases as a person ages.

C. African Americans have higher rates of dehydration than white Americans.

D. Assessment of skin turgor at the sternum is a reliable indicator of dehydration in

the elderly.

10. Distinguishing delirium from dementia can be problematic since they may co-exist. The primary

consideration in the differential is: A. Performance on the Mini Mental Status Exam B. The Confusion Assessment is negative C. Rapid change and fluctuating course of cognitive function D. The presence of behavioral symptoms with cognitive impairment 11. Presbystasis is best described as: A. Impairment in vestibular apparatus that causes dizziness

Advanced Practice Nursing 2e(Malone) B. Age-related disequilibrium of unknown pathology characterized by a gradual onset

of difficulty walking C. The loss of high frequency tones with aging that can impair sensation D. A disorder of the inner ear characterized by vertigo 12. If dizziness has a predictable pattern associated with it, the clinician should first consider: A. Hypoglycemia B. Psychogenic etiology C. Cardiovascular cause D. Neurogenic cause 13. All of the following are considered as contributors to dysphagia except: A. Anticholinergics B. Drugs that increase reflux symptoms C. Inadequate intake of fluids with medications and meals D. Smooth muscle relaxants 14. Evidence shows that the most important predictor of a fall is: A. Prior history of a fall B. Cognitive impairment C. Gait and balance disturbance D. Proximal muscle weakness 15. The most cost-effective interventions used to prevent falls are: A. Use of sitters B. Use of alarms (bed, chair, monitors) C. Tai Chi exercises D. Home modifications and vitamin D supplements 16. Chronic fatigue syndrome is best described as: A. Fatigue that is constant, lasting more than three months B. Fatigue lasting longer than six months and not relieved by rest C. Fatigue that waxes and wanes over a period of three months D. Total exhaustion with inability to get out of bed 17. Which form of headache is bilateral?

A. Cluster B. Tension C. Migraine D. Acute angle closure glaucoma 18. Microscopic hematuria is defined as: A. Twenty or more RBCs on a urine sample B. Three or more RBCs on a urine sample C. Twenty or more RBCs on three or more samples of urine D. Three or more RBCs on three or more samples of urine 19. Risk factors associated with the finding of a malignancy in a patient with hemoptysis include all of

the following except:

Advanced Practice Nursing 2e(Malone) A. Male sex B. Smoking history C. Over age 40 D. Childhood asthma 20. Recent weight loss is defined as: A. loss of >10 pounds over the past 3-6 months B. loss of >2 pounds a week C. 5% weight loss in three months D. 10% weight loss in one year 21. The most common cause of disability in the elderly is due to: A. Diabetes B. Arthritis C. Heart disease D. Chronic obstructive pulmonary disease 22. Lipedema is best described as: A. Bilateral accumulation of interstitial fluid B. Bilateral distribution of fat in the lower extremities C. Fluid retention caused by a compromised lymphatic system D. Lipid molecules that break down and cause fluid retention 23. Drug-induced pruritus is distinguished because it: A. Occurs soon after a new drug is taken B. Usually is a generalized rash C. May occur right after the drug is taken or months later D. Usually involves localized circumscribed lesions 24. A form of syncope that is more common in the elderly than younger adults is: A. Vasovagal B. Carotid sinus sensitivity C. Orthostatic hypotension D. Arrhythmias 25. All of the following statements about tremor are true except: A. The most common tremor is the Parkinson tremor B. Most individuals with tremor do not seek medical attention C. Psychogenic tremor is uncommon D. Tremor is more prevalent in whites than blacks 26. Overflow incontinence is usually associated with: A. Loss of urine that occurs with urgency B. Cognitive impairment C. Weak pelvic floor muscles D. Bladder outlet obstruction 27. Wandering is best described as: A. Aimless excessive ambulatory behavior

Advanced Practice Nursing 2e(Malone) B. Purposeful excessive ambulatory behavior C. Risk-seeking behavior in the cognitively impaired D. A result of boredom in those with dementia

Advanced Practice Nursing 2e(Malone)

Chapter 6. Skin and Lymphatic Disorders Multiple Choice Identify the choice that best completes the statement or answers the question.

1. Which of the following dermatological conditions results from reactivation of the dormant varicella

virus?

A. Tinea versicolor B. Seborrheic keratosis

Advanced Practice Nursing 2e(Malone) C. Verruca D. Herpes zoster 2. An older adult male presents with pain in his right chest wall for the past 48 hours. Upon

examination, the nurse practitioner notices a vesicular eruption along the dermatome andidentifies this as herpes zoster. The NP informs the gentleman that: A. All symptoms should disappear within three days B. Oral medications can dramatically reduce the duration and intensity of his symptoms C. He has chickenpox and can be contagious to his grandchildren D. He has a sexually transmitted disease 3. A 70-year-old white male comes to the clinic with a slightly raised, scaly, pink, and irregular lesion

on his scalp. He is a farmer and works outside all day. You suspect actinic keratosis, but cannot rule out other lesions. What recommendation would you give him?

A. Ignore the lesion, as it is associated with aging.

B. Instruct him to use a nonprescription hydrocortisone cream to dry up the lesion.

C. Perform a biopsy or refer to a dermatologist.

D. Advise him to use a dandruff shampoo and return in one month if the lesion has not gone away.

4. The immunofluorescent antibody (IFA) is a laboratory test used to diagnose which of the following

disorders?

A. Tinea versicolor B. Herpes zoster C. Squamous cell carcinoma D. Human papilloma virus 5. A wound with drainage and foul odor should be cleansed with: A. Normal saline B. Hydrogen peroxide C. 20% acetic acid D. Betadine 6. A full thickness pressure ulcer is partially covered with eschar and the surrounding tissue is

reddened. Which of the following is the most appropriate treatment for this condition?

A. Apply an occlusive dressing B. Debride mechanically or chemically C. Saline moistened gauze dressings D. Vacuum-assisted wound closure 7. In examining the skin of your nursing home patient, you note a “stained glass” brownish mark on the

face. Which of the following lesions best describes a stained glass brownish mark?

A. Actinic keratosis B. Seborrhea keratosis C. Lentigo maligna D. Superficial spreading malignant melanoma

Advanced Practice Nursing 2e(Malone) 8. Patients who have an underlying tinea infection to the cellulitis should also be treated with which

one of the following?

A. An anti-fungal medication B. Topical steroids C. Oral steroids D. Zinc oxide 9. Identify the type of malignant melanoma that is associated with the Hutchinson’s sign of the cuticle

of the finger.

A. Lentigo maligna B. Acral lentiginous C. Nodular D. Superficial spreading malignant melanoma 10. A smooth round nodule with a pearly gray border and central induration best describes which skin

lesion?

A. Seborrheic keratosis B. Malignant melanoma C. Herpes zoster D. Basal cell carcinoma 11. Cellulitis is a deep skin infection involving the dermis and subcutaneous tissues. The nurse

practitioner suspects cellulitis in a 70-year-old Asian diabetic male presenting with reddened edematous skin around his nares. Which statement below will the nurse practitioner use in her decision-making process for the differential diagnosis pertaining to reddened edematous skin?

A. Cellulitis is two times more common in women B. Facial cellulitis is more common in people >55 C. There is low incidence of cellulitis in patients with diabetes D. Cellulitis is only a disease of the lower extremities of patients with known arterial insufficiency 12. An 82-year-old female has a “pimple” on his nose that occasionally bleeds and may have increased

in size in the past year. The lesion is a 0.7-cm, dome-shaped, umbilicated papule with pearly translucence. There is also a hemorrhagic crust covering the central portion. Which of the following is the most likely diagnosis?

A. Squamous cell carcinoma B. Basal cell carcinoma C. Keratocanthoma D. Sebaceous hyperplasia 13. Which of the following is generally not a first-line treatment for post herpetic neuralgia?

A. Intrathecal methylprednisolone B. Gabapentin C. 5% lidocaine patch D. Topical capsaicin 14. A nursing home resident with a Stage 4 pressure ulcer that extends to the muscle layer and has

significant undermining with heavy exudate should be treated with:

Advanced Practice Nursing 2e(Malone) A. B. C. D.

Dry gauze dressings Duoderm Chemical debridement Calcium alginate dressings

15. Which of the following descriptions accurately documents cellulitis?

A. Cool, erythematous, shiny hairless extremity with decreased pulse B. Scattered, erythematous ring-like lesions with clear centers C. Clearly demarcated, raised erythematous area of face D. Diffusely inflamed skin that is warm and tender to palpation 16. Asymmetrical bi-color lesion with irregular border measuring 8 mm is found on the right lower arm

of an adult patient. This assessment finding is consistent with: A. Melanoma B. Basal cell carcinoma C. Leukoplakia D. Senile lentigines 17. Which of the following descriptions best illustrates assessment findings consistent with tinea capitis?

A. Circular erythematous patches with papular, scaly annular borders and clear

centers B. Inflamed scaly dry patches with broken hairs C. Web lesions with erythema and scaling borders D. Scaly pruritic erythematous lesions on inguinal creases 18. A hyperkeratatotic nodule formed as the result of exposure of the foot to moisture from perspiration

is called: A. Hard corn B. Tinea pedis C. Soft corn D. Plantar warts (verrucae) 19. A 64-year-old male presents with an exacerbation of psoriasis. His social history includes 50-year

two packs a day of cigarettes and a six-pack a week of beer. He states he had a recent sore throat, which he attributes to minding his young grandson. He reports that until recently the pruritis was only minimal. His BMI is 37. Which of the following factors most likely contributed to the acute presentation of psoriasis?

A. Alcohol abuse B. Smoking C. Streptococcal infection D. Obesity 20. Treatment of complicated cellulitis of the lower extremity resulting from an anaerobe requires all of

the following except: A. Extended antibiotic medication lasting at least 7-10 days B. Topical antifungal medication C. Inquiry when last tetanus toxoid booster was given D. Elevation of limb and consideration of compression bandaging

Advanced Practice Nursing 2e(Malone)

Chapter 7. Head, Neck, and Face Disorders Multiple Choice Identify the choice that best completes the statement or answers the question.

1. A 64-year-old male presents with erythema of the sclera, tearing, and bilateral pruritus of the eyes.

The symptoms occur intermittently throughout the year and he has associated clear nasal discharge.

Which of the following is most likely because of the inflammation?

A. Bacterium B. Allergen C. Virus D. Fungi 2. One of the first-line treatments in patients with allergic rhinitis is the use of nasal corticosteroid

sprays. What is the anticipated onset of symptom relief with the use of these medications?

A. Two weeks or more B. Immediate

Advanced Practice Nursing 2e(Malone) C. 1 to 2 days D. A minimum of one week 3. The nurse practitioner knows that antihistamines work primarily through which of the following

mechanisms?

A. Vasodilatation B. Blocking leukotriene effects C. Inhibiting histamine receptor sites D. Vasoconstriction 4. Cromolyn sodium may also be used in the treatment of allergic rhinitis. What is the mechanism of

action of this medication?

A. Mast cell stabilization B. Blocking the effects of IgE C. Leukotriene inhibition D. Histamine blockade 5. Patients that have atopic disorders are mediated by the production of IGE will have histamine

stimulated as an immediate phase response. This release of histamine results in which of the following?

A. Sinus pain, increased vascular permeability, and bronchodilation B. Bronchospasm, vascular permeability, and vasodilatation C. Contraction of smooth muscle, decreased vascular permeability, and vasoconstriction D. Vasodilatation, bronchodilation, and increased vascular permeability 6. Which of the following maneuvers is used to induce symptoms of benign paroxysmal positional

vertigo?

A. The Fukuda stepping test B. The Dix-Hallpike maneuver C. Forced hyperventilation D. The head thrust test 7. You have a patient complaining of vertigo and want to know what could be the cause. Knowing

there are many causes for vertigo, you question the length of time the sensation lasts. Shetells you several hours to days and is accompanied by tinnitus and hearing loss. You suspect which of the following conditions?

A. Ménière’s disease B. Benign paroxysmal positional vertigo C. TIA D. Migraine 8. Sensory impairment (vision and hearing) in the elderly is associated with: A. Impaired quality of life B. Decreased function C. Increased mortality D. All of the above 9. Which of the following conditions is the leading cause of blindness in the United States?

Advanced Practice Nursing 2e(Malone) A. B. C. D.

Macular degeneration Diabetic retinopathy Glaucoma Cataracts

10. A slightly elevated elastic tissue deposit in the conjunctiva that may extend to the cornea but does

not cover it is known as a: A. Pterygium B. Pinguecula C. Xanthelsma D. Limbal nodule 11. A nonmodifiable risk factor for the development of cataracts is: A. Long-term exposure to ultraviolet B radiation B. High alcohol intake C. Strong family history D. Diabetes mellitus 12. Causes of sensorineural hearing loss include: A. Ototoxicity B. Ménière’s disease C. Otosclerosis D. Inner ear fistula 13. Clinical findings in patients with nonproliferation retinopathy include: A. Cotton wool spots B. Microaneursyms C. Deep hemorrhages D. Neovascularization 14. In examining the mouth of an older adult with a history of smoking, the nurse practitioner finds a

suspicious oral lesion. The patient has been referred for a biopsy to be sent for pathology. Which is the most common oral precancerous lesion?

A. Fictional keratosis B. Keratoacanthoma C. Lichen planus D. Leukoplakia 15. A gross screening for hearing is the whisper tests. Which cranial nerve is being tested when the

nurse practitioner conducts this test?

A. Cranial nerve V B. Cranial nerve VII C. Cranial nerve VIII D. Cranial nerve IV

Advanced Practice Nursing 2e(Malone)

Chapter 8. Chest Disorders Multiple Choice Identify the choice that best completes the statement or answers the question.

1. In mitral stenosis, p waves may suggest: A. Left atrial enlargement B. Right atrial enlargement C. Left ventricle enlargement D. Right ventricle enlargement 2. Aortic regurgitation requires medical treatment for early signs of CHF with: A. Beta blockers B. ACE inhibitors C. Surgery D. Hospitalization 3. A key symptom of ischemic heart disease is chest pain. However, angina equivalents may include

exertional dyspnea. Angina equivalents are important because: A. Women with ischemic heart disease many times do not present with chest pain B. Some patients may have no symptoms or atypical symptoms. Diagnosis may only be made at the time of an actual myocardial infarction

Advanced Practice Nursing 2e(Malone) C. Elderly patients have the most severe symptoms D. A & B only 4. The best evidence rating drugs to consider in a post myocardial infarction patient include: A. ASA, ACE/ARB, beta-blocker, aldosterone blockade B. Ace, ARB, Calcium channel blocker, ASA C. Long-acting nitrates, warfarin, ACE, and ARB D. ASA, clopidogrel, nitrates 5. A 55-year-old post-menopausal woman with a history of hypertension complains of jaw pain on

heavy exertion. There were no complaints of chest pain. Her ECG indicates normal sinus rhythm without ST segment abnormalities. Your plan may include: A. Echocardiogram B. Exercise stress test C. Cardiac catheterization D. Myocardial perfusion imaging 6. Preceding a stress test, the following lab work might include: A. CBC and differential to differentiate ischemic heart disease from anemia B. Liver enzymes to rule out underlying gall bladder disease C. Thyroid studies to rule out hyperthyroidism D. A & C only 7. Which test is the clinical standard for the assessment of aortic stenosis?

A. Cardiac catheterization B. Stress test C. Chest x-ray D. Echocardiography 8. What is the most common valvular heart disease in the older adult?

A. Aortic regurgitation B. Aortic stenosis C. Mitral regurgitation D. Mitral stenosis 9. On examination, what type of murmur can be auscultated with aortic regurgitation?

A. Austin flint B. Systolic ejection C. Soft S1 and a Loud S2 D. Loud S1 10. Ischemic heart disease is: A. Defined as imbalance between oxygen supply and demand.

B. Frequently is manifested as angina.

C. Leading cause of death in the elderly.

D. All of the above.

11. Which test is the clinical standard for the assessment of aortic stenosis?

A. Cardiac catheterization

Advanced Practice Nursing 2e(Malone) B. Stress test C. Chest x-ray D. Echocardiography 12. The aging process causes what normal physiological changes in the heart?

A. The heart valve thickens and becomes rigid, secondary to fibrosis and sclerosis B. Cardiology occurs along with prolapse of the mitral valve and regurgitation C. Dilation of the right ventricle occurs with sclerosis of pulmonic andtricuspid

valves D. Hypertrophy of the right ventricle 13. An older adult may present with atypical clinical signs of pneumonia. The nurse practitioner needs to

be aware that the clustering of all of the following signs and symptoms may be indicative of pneumonia in an older person except: A. Bradycardia B. Malaise C. Anorexia D. Confusion 14. Which of the following statements is true concerning anti-arrhythmic drugs?

A. Amiodarone is the only one not associated with increased mortality and it has a

very favorable side effect profile.

B. Both long-acting and short-acting calcium channel blockers are associated with an increased risk of cardiovascular morbidity and mortality.

C. Most anti-arrhythmics have a low toxic/therapeutic ratio and some are exceedingly toxic.

D. Anti-arrhythmic therapy should be initiated in the hospital for all patients.

15. Dan G., a 65-year-old man, presents to your primary care office for the evaluation of chest pain and

left-sided shoulder pain. Pain begins after strenuous activity, including walking. Pain is characterized as dull, aching; 8/10 during activity, otherwise 0/10. Began a few months ago, intermittent, aggravated by exercise, and relieved by rest. Has occasional nausea. Pain is retrosternal, radiating to left shoulder, definitely affects quality of life by limiting activity. Pain is worse today; did not go away after he stopped walking. BP 120/80. Pulse 72 and regular. Normal heart sounds, S1 and S2, no murmurs. Which of the following differential diagnoses would be most likely?

A. Musculoskeletal chest wall syndrome with radiation B. Esophageal motor disorder with radiation C. Acute cholecystitis with cholelithiasis D. Coronary artery disease with angina pectoris 16. Jose M. is a 68-year-old man who presents to your primary care practice for a physical. Jose has had

type 2 diabetes mellitus for 5 years, diet controlled. His BMI is 32. Smoker, pack per day for 25 years. He denies other medical problems. Family history includes CAD, CABG x4 for father, now deceased; CHF, type 2 diabetes mellitus, HT for mother. According to the AHA/ACC guidelines, what stage is Jose?

A. Stage A B. Stage B C. Stage C

Advanced Practice Nursing 2e(Malone) D. Stage D 17. Susan P., a 60-year-old woman with a 30 pack year history, presents to your primary care practice

for evaluation of a persistent, daily cough with increased sputum production, worse in the morning, occurring over the past three months. She tells you, “I have the same thing, year after year.” Which of the following choices would you consider strongly in your critical thinking process?

A. Seasonal allergies B. Acute bronchitis C. Bronchial asthma D. Chronic bronchitis 18. The best way to diagnose structural heart disease/dysfunction non-invasively is: A. Chest x-ray B. EKG C. Echocardiogram D. Heart catheterization 19. A common auscultatory finding in advanced CHF is: A. Systolic ejection murmur B. S3 gallop rhythm C. Friction rub D. Bradycardia 20. The organism most commonly responsible for community-acquired pneumonia in older adults is: A. Pseudomonas aeruginosa B. Staphylococcus aureus C. Proteus mirabilis D. Streptococcus pneumonia 21. A 72-year-old woman and her husband are on a cross-country driving vacation. After a long day of

driving, they stop for dinner. Midway through the meal, the woman becomes very short of breath, with chest pain and a feeling of panic. Which of the following problems is most likely?

A. Pulmonary edema B. Heart failure C. Pulmonary embolism D. Pneumonia

Advanced Practice Nursing 2e(Malone)

Chapter 9. Peripheral Vascular Disorders Chapter 9: Peripheral Vascular Disorders Multiple Choice Identify the choice that best completes the statement or answers the question.

1. The clinician should begin the peripheral vascular exam with: A. Auscultation of the carotid arteries B. Checking for peripheral edema C. Auscultation of the heart D. Palpation of the upper extremity arteries 2. Inspection of the distal nails and nail beds should be evaluated for signs of decreased perfusion.

Signs include: A. Clubbing B. Cyanosis

Advanced Practice Nursing 2e(Malone) C. Petechiae D. All of the above 3. A thorough vascular exam includes all of the following except: A. Cardiac exam B. Reproductive organ exam C. Peripheral vascular exam D. Cranial nerve exam 4. The majority of abdominal aortic aneurysms are due to: A. Trauma B. Infection C. Inflammation D. Atherosclerosis 5. The best initial screening test for abdominal aortic aneurysm is: A. Angiography B. CT scan with IV contrast C. Abdominal ultrasound D. MRI 6. The initial treatment for symptomatic abdominal aortic aneurysm involves: A. Emergency surgery B. Aggressive blood pressure control C. Watch-and-wait approach D. Cardiology consult 7. The major cause of death after an abdominal aortic aneurysm repair is: A. AAA rupture B. Hemorrhage C. Renal failure D. Myocardial infarction 8.

An early symptom of peripheral artery disease is: A. Painful cramping of muscles during walking B. Pain is worse when the legs are dependent below the level of the heart C. Pain intensifies after vigorous walking is stopped D. Ulceration or gangrene occurs at the sight of minor injury 9. The hallmark of venous stasis ulcers include all of the following except: A. Lower extremity edema B. Hyperpigmentation of the lower extremities C. Ulcers on the medial or lateral malleolus D. Copious draining ulcers 10. Exercise is an essential element of peripheral arterial disease management primarily because: A. It encourages weight loss, as being overweight is a contributing factor to PAD B. Evidence shows exercise reduces smoking C. Collateral vessels are strengthened

Advanced Practice Nursing 2e(Malone) D. It improves aerobic capacity 11. Home exercise programs for peripheral arterial disease focus on: A. Walk until pain develops then stop B. Walk through the pain then stop C. Begin at a slow speed with 10 minutes a day and build up to 30 minutes D. Walk through the pain, rest until it goes away, then resume walking 12. When should surgical options for peripheral arterial disease be considered?

A. Immediately after the diagnosis since the prognosis without revascularization is

poor B. After two weeks of pentoxifylline (Trental) therapy C. Pain is not relieved with rest D. Pain limits the patient’s lifestyle or ulceration occurs 13. All of the following are classic signs of venous insufficiency except: A. Pain B. Dependent edema C. Hemosiderosis D. Dermatitis 14. Lower leg edema associated with pain is characteristic of: A. Venous insufficiency B. Heart failure C. Deep venous thrombosis D. Diabetes 15. The most common cause of secondary lymphedema is: A. Surgery B. Cancer treatment C. Infection D. Trauma 16. The imaging gold standard for lymphedema is: A. Lymphosonogram B. Lymphoscintigraphy C. Lymphoangiogram D. CT scan 17. Known risk factors for lymphedema include all of the following except: A. Osteoarthritis B. Rheumatoid arthritis C. Obesity D. Venous ulcer disease 18. Complete decongestive physiotherapy (CDP) works by: A. Stimulating the lymph vessels B. Breaking up subcutaneous fibrous tissue C. Redirecting lymph flow

Advanced Practice Nursing 2e(Malone) D. All of the above

Advanced Practice Nursing 2e(Malone)

Chapter 10. Abdominal Disorders Multiple Choice Identify the choice that best completes the statement or answers the question.

1. Your 70-year-old patient has gastroesophageal reflux disease (GERD). After a trial of lifestyle

modifications and antacids, the patient continues to have occasional mild heartburn after occasional meals and at night. The most appropriate next action is: A. Prokinetic agents B. H2 antagonists C. Proton pump inhibitors D. Surcralfate 2. An older patient reports burning pain after ingestion of many foods and large meals. What

assessment would assist the nurse practitioner in making a diagnosis of GERD? A. Identification of a fluid wave B. Positive Murphy’s sign C. Palpable spleen D. Midepigastric pain that is not reproducible with palpation

Advanced Practice Nursing 2e(Malone) 3. The nurse practitioner is examining a 62-year-old female who has been complaining of lower

abdominal pain. Upon auscultation, bowel sounds are high pitched and tinkling. Which of the following terms describes this finding?

A. Succession splash B. Borborygmi C. Tenesmus D. Puddle sign 4. In teaching an older adult female client with end-stage renal disease her medication regimen, the

nurse practitioner must include which of the following pieces of information in the treatment plan?

A. Report any changes in the color of her stool B. Take iron supplement and elemental calcium with each meal C. Take iron supplement before meals and the calcium after meals D. Take calcium with a high phosphorus meal 5. A 62-year-old client presents with a complaint of fever, pain, and burning on urination. Difficulty

urinating with dribbling has been increasing in the past few days. He has a feeling of pressure in his groin. On examination, his prostate is tender, boggy, and warm. A stat urinalysis reveals the presence of leukocytes and bacteria. He is allergic to sulfa drugs. His weight is 70 kg and his last serum creatinine was 1.0. While awaiting the culture and sensitivity, the nurse practitioner begins empiric treatment with which of the following?

A. Trimethoprim/sulfamethroxazole DS bid x 2 weeks B. Ampicillin 250 mg PO q day for 10 days C. Nitrofurantoin 100 mg Q 12 hours for 7 days D. Ciprofloxacin 500 mg Q 12 hours for 14 days 6. A 62-year-old woman presents with a recurrent urinary tract infection. She now has a fever of 104°F

and severe costovertebral tenderness with pyuria. What is the appropriate diagnosis and intervention for this patient?

A. Septic arthritis and oral prednisolone is indicated B. Pyelonephritis and hospitalization is required C. Recurrent cystitis and 10 days of antibiotics are needed D. Pelvic inflammatory disease and 7 days of antibiotics are indicated 7. Which of the following drugs would be useful for the nurse practitioner to prescribe for an older

adult to prevent gastric ulcers when a nonsteroidal anti-inflammatory drug is used for chronic pain management?

A. Misoprostol (Cytotec) B. Cimetidine (Tagamet) C. Metronidazole (Flagyl) D. Bismuth subsalicylate (Pepto bismol) 8. A 68-year-old male reports painless rectal bleeding occasionally noted with thin pencil-like stools,

but no pain with defection. He has a history of colon polyp removal 10 years ago but was lost to follow-up. The nurse practitioner’s appropriate intervention is: A. Digital rectal exam and send home with 3 hemoccult to return B. Immediate referral to gastroenterologist and colonoscopy C. Order a screening sigmoidoscopy

Advanced Practice Nursing 2e(Malone) D. Order a colonoscopy and barium enema and refer based on results 9. Asymptomatic 1+ bacteruria is found in a nursing home resident with an indwelling catheter. The

nurse practitioner’s initial intervention includes: A. Assessing resident’s cognitive status and last change of the catheter/bag B. Prescribing prophylactic Bactrim 1 tablet at bedtime C. Ordering a urine culture and sensitivity and prescribing empiric treatment until results obtained D. Ordering an x-ray of the kidney, urine, and bladder 10. When counseling clients regarding the use of antidiarrheal drugs such as Imodium anti-diarrheal and

Kaopectate, the nurse practitioner advises patients to: A. Use all the medication B. Do not use for possible infectious diarrhea C. Use should exceed one week for effectiveness D. These drugs provide exactly the same pharmaceutical effects 11. When teaching a group of older adults regarding prevention of gastroesophageal reflux disease

symptoms, the nurse practitioner will include which of the following instructions?

A. Raise the head of the bed with pillows at night and chew peppermints when symptoms of heartburn begins B. Raise the head of the bed on blocks and take the proton pump inhibitor medication at bedtime C. Sit up for an hour after taking any medication and restrict fluid intake D. Avoid food intolerances, raise head of bed on blocks, and take a protonpump inhibitor before a meal 12. A clinical clue for suspected renal artery stenosis would be: A. Decreased urine output B. Development of resistant hypertension in a previously well-controlled patient C. Retroperitoneal pain on the affected side D. Rising BUN level with normal creatinine level 13. Helicobacter pylori is implicated as a causative agent in the development of duodenal or gastric

ulcers. What teaching should the nurse practitioner plan for a patient who has a positive Helicobacter pylori test?

A. It is highly contagious and a mask should be worn at home.

B. Treatment regimen is multiple lifetime medications.

C. Treatment regimen is multiple medications taken daily for a few weeks.

D. Treatment regimen is complicated and is not indicated unless the patient is symptomatic.

14. An obese middle-aged client presents with a month of nonproductive irritating cough without fever.

He also reports occasional morning hoarseness. What should the differential include?

A. Atypical pneumonia B. Peptic ulcer disease C. Gastroesophageal reflux D. Mononucleosis (Epstein-Barr)

Advanced Practice Nursing 2e(Malone) 15. Which of the following findings would indicate a need for another endoscopy in clients with peptic

ulcer disease?

A. Cases of dyspepsia with constipation B. Symptoms persisting after 6-8 weeks of therapy C. All clients with dyspepsia who smoke and drink alcohol D. When a therapeutic response to empiric treatment is obtained 16. A careful history of a female client with a chief complaint of intermittent diarrhea reveals that she

also experiences bouts of constipation. She has no known allergies and experienced no unintentional weight loss. What is the most likely condition?

A. Inflammatory bowel disease B. Irritable bowel syndrome C. Giardiasis D. Lactose intolerance 17. The nurse practitioner is discussing lifestyle changes with a patient diagnosed with gastroesophageal

reflux. What are the nonpharmacological management interventions that should be included?

A. Weight reduction and rest 30 minutes after each meal in the supine position B. Elevation of head of the bed 4-6 inches on blocks and weight reduction C. Encouraged to wear restrictive clothing to add support for diaphragmatic breathing D. Using oral mints to relieve gastric distress 18. In differentiating a gastric ulcer from a duodenal ulcer, you know that each type of ulcer can present

with distinct signs and symptoms. Which of the following pieces of information from the patient’s history is the least useful for you to determine that the patient has a duodenal ulcer?

A. Pain occurs on an empty stomach B. Diffuse epigastric pain C. Rarely associated with non-steroidal use D. Occurs in patients under 40 years of age 19. A 74-year-old obese female presents complaining of persistent right upper quadrant pain. She reports

that she has not had any prior abdominal surgeries. Which of the following laboratory studies would be most indicative of acute cholecystitis?

A. C-reactive protein level of 3 mg B. White blood cell count of 11,000 C. Direct serum bilirubin level of 0.3 mg/dL D. Serum amylase level of 145 U/L 20. Which of the following is not a contributing factor to the development of esophagitis in older adults?

A. Increased gastric emptying time B. Regular ingestion of NSAIDs C. Decreased salivation D. Fungal infections such as Candida

Advanced Practice Nursing 2e(Malone)

Chapter 11. Urological and Gynecologic Disorders Multiple Choice Identify the choice that best completes the statement or answers the question.

1. Which ethnic group has the highest incidence of prostate cancer?

A. Asians B. Hispanics C. African Americans D. American Indians 2. Men with an initial PSA level below 2.5 ng/ml can reduce their screening frequency to what

intervals?

A. Every 6 months B. Yearly C. Every 2 years D. Every 2 to 4 years

Advanced Practice Nursing 2e(Malone) 3. All of the following may be reasons associated with an elevated PSA besides prostate cancer except: A. Prostatitis B. Urinary tract infection C. Perineal trauma D. Digital rectal exam 4. In the diagnosis of acute bacterial prostatitis, a midstream urine culture is of benefit. To be

diagnostic, the specimen should reveal how many white blood cells per high-power field?

A. Five B. Ten C. Fifteen D. Twenty 5. In chronic bacterial prostatitis, what is the organism most commonly associated with the disease?

A. Klebsiella B. Proteus C. Pseudomonas D. Escherichia coli 6. In acute prostatitis, an exam of the prostate may find the gland to be: A. Nodular B. Cool and pliable C. Swollen and tender D. Asymmetrical 7. All of the following antimicrobials may be indicated in chronic bacterial prostatitis except: A. Ciprofloxacin B. Levofloxacin C. Trimethoprim D. Azithromycin 8. Age-related changes in the bladder, urethra, and ureters include all of the following in older women

except: A. Increased estrogen production’s influence on the bladder and ureter B. Decline in bladder outlet function C. Decline in ureteral resistance pressure D. Laxity of the pelvic muscle 9. Mr. Jones is a 68-year-old retired Air Force pilot that has been diagnosed with prostate cancer in the

past week. He has never had a surgical procedure in his life and seeks clarification on the availability of treatments for prostate cancer. He asks the nurse practitioner to tell him the side effects of a radical prostatectomy. Which of the following is NOT a potential side effect of this procedure?

A. Urinary incontinence B. Impotence C. Dribbling urine D. Selected low back pain

Advanced Practice Nursing 2e(Malone) 10. The nurse practitioner is evaluating a patient’s pelvic muscle strength by digital examination. This is

performed when: A. A male patient complains of nocturia and dribbling B. The nurse practitioner needs to confirm a cystocele or stress incontinence C. The patient reports sudden loss of large amounts of urine or urge incontinence D. The nurse practitioner suspects overflow incontinence 11. A pelvic mass in a postmenopausal woman: A. is most commonly due to uterine fibroids.

B. is always symptomatic.

C. is highly suspicious for ovarian cancer.

D. should be monitored over a period of time.

12. A 79-year-old man is being evaluated for frequent urinary dribbling without burning. Physical

examination reveals a smooth but slightly enlarged prostate gland. His PSA level is 3.3 ng/mL. The patient undergoes formal urodynamic studies, and findings are as follows: a decreased bladder capacity of 370 mL; a few involuntary detrusor contractions at a low bladder volume of 246 mL; an increased postvoid residual urine volume of 225 mL; and a slightly decreased urinary flow rate.

Which of the following is not consistent with a normal age-associated change?

A. PSA level of 3.3 ng/mL B. Decreased bladder capacity C. Involuntary detrusor contradictions D. Increased postvoid residual urine volume 13. Mrs. Smith, a 65-year-old woman presents to clinic for the first time and complains of urinary

incontinence and dyspareunia. She went through menopause 10 years ago without any hormone replacement therapy and had a hysterectomy for a fibroid. Her mother had a hip fracture at 82 years of age. The patient’s most recent mammogram was 5 years ago and no known family history of breast cancer. She is not taking any medications. Her physical examination is unremarkable except for findings consistent with atrophic vaginitis. You decide to begin topical hormone replacement therapy. Which of the following evaluations would be necessary prior to initiating hormone replacement therapy?

A. Mammogram B. Endometrial biopsy C. Bone mineral density measurement D. Papanicolaou smear 14. Mrs. L. Billings is a 77-year-old Caucasian female who has a history of breast cancer. She has been

in remission for 6 years. As her primary care provider, you are seeing her for follow-up of her recent complaint of intermittent abdominal pain of a 3-month duration and some general malaise. Given the brief history above, what will you direct your assessment at during physical examination?

A. Examination of her thyroid to rule out thyroid nodules that may contribute to her feeling fatigued.

B. Auscultation of her abdomen for abnormal bowel sounds to rule out peritonitis.

C. Thorough abdominal and gynecological exam to rule out masses and identify any tenderness.

D. A rectal examination to rule out colon cancer as a secondary site for breast cancer.

Advanced Practice Nursing 2e(Malone) 15. A 78-year-old female comes to the office because she has pain when she urinates. She has been seen

three times for this problem in the last 3 months. Each time she was told she had a UTI and was given antibiotics. She carefully followed the instructions but has had no relief of symptoms. Last UA: WBCs: 2-3/high-power field RBCs: 0-2/high-power field Epithelial cells: Few Nitrite: Negative Leuckocyte esterase: Negative Which of the following should be done next?

A. Obtain a clean catch urine for UA and urine for C&S B. Perform a pelvic examination C. Reassure the patient that she has asymptomatic bacteriuria and does not need antibiotics D. Order a pelvic ultrasound

Advanced Practice Nursing 2e(Malone)

Chapter 12. Musculoskeletal Disorders Multiple Choice Identify the choice that best completes the statement or answers the question.

1. Osteoarthritis of the cervical and lumbar spine causes pain that is related to all of the following

except: A. Bone spur formation B. Pressure of the ligaments C. Reactive muscle spasm D. Crystal deposition 2. In differentiating osteoarthritis from chronic gout, pseudogout, or septic arthritis, the most valuable

diagnostic study would be: A. Erythrocyte sedimentation rate (ESR) B. Synovial fluid analysis C. C-reactive protein analysis D. Complete blood cell count 3. Patients with osteoarthritis of the hip and knee often have a distinguishable gait described as: A. Ataxic B. Festinating

Advanced Practice Nursing 2e(Malone) C. Antalgic D. Steppage 4. Which of the following best describes the pain associated with osteoarthritis?

A. Constant, burning, and throbbing with an acute onset?

B. Dull and primarily affected by exposure to cold and barometric pressure C. Begins upon arising and after prolonged weight bearing and/or use of the joint D. Begins in the morning but decreases with activity 5. Joint effusions typically occur later in the course of OA, especially in the: A. Knee B. Elbow C. DIP joints D. Hips 6. You have ordered a CBC for your patient you suspect has polymyalgia rheumatica (PMR). Which

two clinical findings are common in patients with PMR? A. Neutropenia and hypochromic, normocytic anemia B. Normochromic, normocytic anemia and thrombocytosis C. Microcytic, hypochromic anemia and reticulocytopenia D. Macrocytic, hyperchromic anemia and leukocytopenia 7. You suspect that your patient has polymyalgia rheumatica and now are concerned that the patient

may also have Giant Cell Arteritis (GCA). Which of the following two symptoms are most indicative of GCA and PMR? A. Jaw pain and heart murmur B. Joint swelling and sudden loss of central vision bilaterally C. Hoarseness and the total inability to grasp small objects D. Scalp tenderness and aching in shoulder and pelvic girdle 8. Your 63-year-old Caucasian woman with polymyalgia rheumatica (PMR) will begin treatment with

corticosteroids until the condition has resolved. You look over her records and it has been 2 years since her last physical examination and any laboratory or diagnostic tests as she relocated and had not yet identified a health-care provider. In prioritizing your management plan, your first orders should include: A. Recommending she increase her dietary intake of Calcium and Vitamin D B. Ordering once a year bisphosphonate and a proton pump inhibitor C. Participate in a fall prevention program D. Dual-energy x-ray (DEXA) scan and updating immunizations 9. Which of the following differential diagnosis for patients presenting with polymyalgia rheumatica

(PMR) can be ruled out with a muscle biopsy?

A. Parkinson’s disease B. Polymyositis C. Late onset rheumatoid arthritis D. Giant Cell Arteritis

Advanced Practice Nursing 2e(Malone) 10. In reviewing laboratory results for patients suspected with polymyalgia rheumatica (PMR), you

realize that there is no definitive test to diagnosis PRM, rather clinical response to treatment. Results you would expect to see include: A. Elevated erythrocyte sedimentation rate (ESR) greater than 50mm per hour B. Elevated rheumatoid factor and anti-citrullinated protein antibodies (RF and ACPA) C. Decreased C-reactive protein level (CR-P) D. Elevated thyroid stimulating hormone (TSH) 11. Which of the following is the most appropriate laboratory test for monitoring gout therapy over the

long-term?

A. Erythrocyte sedimentation rate (ESR) B. Completer blood count (CBC) C. Serum urate level D. Serum albumin 12. In providing health teaching related to dietary restrictions, the nurse practitioner should advise a

patient with gout to avoid which of the following dietary items: A. Green leafy vegetables B. Beer, sausage, fried seafood C. Sugar D. Gluten and bread items 13. The best method of verifying a diagnosis of gout in a joint is which of the following: A. Radiographic examination of the joint with two views B. Ultrasound C. Palpation D. Joint aspiration and polarized-light microscopy 14. The most appropriate first-line treatment for an acute gout flare is (assuming no kidney disease or

elevated bleeding risk): A. Indomethacin 50 mg TID for 2 days; then 25 mg TID for 3 days B. Doxycycline 100 mg BID for 5 days C. Prednisolone 35 mg QD for 5 days D. Ice therapy 15. The nurse practitioner orders bilateral wrist X-rays on a 69-year-old gentleman complaining of pain

in both wrists for the past 6 weeks not related to any known trauma. The nurse practitioner suspects elderly onset rheumatoid arthritis. The initial radiographic finding in a patient with elderly onset rheumatoid arthritis would be: A. Symmetric joint space narrowing B. Soft tissue swelling C. Subluxations of the joints D. Joint erosions 16. The nurse practitioner is examining the hands of a 55-year-old woman with rheumatoid arthritis and

notes bilateral spindle shaped deformities on the middle interphalangeal joints. These are known as: A. Haygarth’s nodes

Advanced Practice Nursing 2e(Malone) B. Heberden’s nodes C. Bouchard’s nodes D. Benediction hands 17. A 72-year-old female patient has been diagnosed with gout. She also has a long history of chronic

congestive heart failure. The most likely contributing factor to the development of gout in this older female is: A. Lead intoxication B. Illegal whiskey C. Binge-eating D. Thiazide diuretics 18. Which of the following statements about osteoarthritis is true?

A. It affects primarily weight-bearing joints B. It is a systemic inflammatory illness C. The metacarpal phalangeal joints are commonly involved D. Prolonged morning stiffness is common 19. In considering the specificity of laboratory data, the most reliable diagnostic test listed below would

be: A. B. C. D.

Elevated erythrocyte sedimentation rate (ESR) to rule out inflammation CBC to rule out infection Antinuclear Antibody (ANA) test to rule out a collagen disease Synovial fluid analysis to differentiate between an infectious versus an inflammatory infusion

20. When examining the spine of an older adult you notice a curvature with a sharp angle. This is

referred to as a: A. Gibbus B. Scoliosis C. Kyphosis D. Lordosis

Advanced Practice Nursing 2e(Malone)

Chapter 13. Central and Peripheral Nervous System Disorders Chapter 13: Central and Peripheral Nervous System Disorders Multiple Choice Identify the choice that best completes the statement or answers the question.

1. An older adult patient is being evaluated following a stroke, which affected the anterior cerebral

circulatory system. Which of the following signs/symptoms would be positive in the assessment of this patient?

A. Bilateral vision disturbance and/or diplopia B. Dysarthria and speech difficulties C. Disorders in behavior and in cognition D. Motor and sensory problems on both sides of the body 2. When assessing a patient who complains of a tremor, the nurse practitioner must differentiate

essential tremor from the tremor of Parkinson’s disease. Which of the following findings are consistent with essential tremor?

Advanced Practice Nursing 2e(Malone) A. B. C. D.

The handwriting is not affected by the tremor The tremor occurs with purposeful movements The tremor occurs at rest The tremor gets worse with alcohol ingestion

3. Which of the following assessments are commonly noted in a client with Parkinson’s disease?

A. Macrographia and bradycardia B. Micrographia and bradykinesia C. Exaggeration of rapid successive movements D. Increased arm swing 4. An older adult client with a history of a seizure disorder comes into the clinic for a routine check-up.

Although seizure free, the client continues on long-term phenytoin treatment. The nurse practitioner would assess for which of the following long-term effects?

A. Lid lag and nystagmus B. Gingival hyperplasia and nystagmus C. Nystagmus and microcytic anemia D. Gingival hyperplasia and iron deficiency anemia 5. An elderly nursing home resident is maintained on phenytoin therapy for a history of a seizure

disorder. In addition to periodic serum drug concentrations, which of the following are needed for annual evaluation?

A. Complete blood count, liver function tests, and renal function tests B. Complete blood count, liver function tests, and platelet count C. Renal function and calculated creatinine clearance D. Serum albumin, liver function tests, and renal function tests 6. A 78-year-old female presents with a seizure that occurred over the weekend. In selecting the most

important diagnostics for this presentation, it is important to know that the least common site of seizures in the elderly is: A. Cerebellum B. Frontal lobe C. Temporal lobe D. Parietal lobe 7. An elderly patient has had a CVA in the anterior cerebral circulatory system (frontal lobe). What

symptoms are most likely expressed?

A. Neglect of body and difficulty organizing space B. Wernicke’s aphasia (difficulty understanding speech) C. Disorders of behavior and cognition D. Bilateral motor and sensory problem 8. The most common neurological cause of seizures in an older adult is: A. Alzheimer’s disease B. Multiple sclerosis C. Stroke D. Peripheral neuropathy

Advanced Practice Nursing 2e(Malone) 9. You are evaluating an elderly patient’s complaint of a new onset of “hand shaking” when he drinks

from a cup. The patient is euthyroid and does not drink alcohol. Which of the following signs indicate that this tremor is most likely an essential tremor rather than a Parkinson’s tremor?

A. It is characteristic of “pill rolling” and occurs at rest B. It is a moderate amplitude tremor that occurs only with movement/activity C. The tremor is also associated with slowed movements D. The tremor is accompanied by dyskinesia 10. Mr. Andrews experienced a brief onset of right-sided weakness, slurred speech, and confusion

yesterday. The symptoms have resolved. What should the nurse practitioner do?

A. Assure the patient that he will not experience the symptoms again B. Identify modifiable cardiovascular risk factors C. Do a thorough medication review and a CT scan D. Order a stat EEG and administer O2 by mask 11. An older male patient is experiencing acute onset of right-sided weakness, slurred speech, and

confusion. What should the nurse practitioner do promptly?

A. Administer an aspirin by mouth B. Evaluate for stroke and arrange transport to the hospital right away C. Do a thorough medication review and stat blood sugar D. Order an EKG and administer O2 by cannula immediately 12. An older adult female patient had a stroke. What symptoms are not usually expressed by patients

who have had a vertebrobasilar stroke?

A. Vertigo B. Ataxia C. Dysarthria D. Monocular blindness 13. When assessing an elderly client who reports a tremor, which assessment findings would be most

reliable in identifying Parkinson’s disease?

A. Any presence of tremor B. Symptoms of slowed movement, unstable angina, and tremor C. Resting tremor, slow unsteady gait, and cogwheel resistance D. Cogwheel rigidity, bradykinesia, and amnesia 14. A 78-year-old man with Parkinson’s disease is being cared for in a nursing home. The nurses

observe that he coughs at mealtime; he has the ability to still feed himself with adaptive equipment.

He has had no aspirations. Oral exam is normal, except during his swallowing assessment you note there is slight delayed elicitation. You assess that he has only mild dysphagia. You recommend which of the following as the next step in his care?

A. Consult gastroenterologist for g-tube decision B. Consult speech pathologist for video fluoroscopy C. Provide a trial of foods of differing consistency D. Require that he is fed all his meals 15. Which of the following assessment findings is commonly noted in a client with advanced

Parkinson’s disease?

Advanced Practice Nursing 2e(Malone) A. B. C. D.

Macrographia Micrographia Ataxic gait Increased arm swing

16. A middle-aged patient has been diagnosed with Parkinson’s disease. What influences the nurse

practitioner’s decision to begin pharmacological treatment for this patient?

A. Intentional tremors B. Gait instability requiring use of a cane C. Symptoms interfering with functional ability D. Medications initiated at first sign of unilateral involvement 17. An older male presents with incontinence, has a wide-based and irregular gait, and progressive

dementia. Which of the following presents with these cardinal signs?

A. Parkinson’s disease B. Normal pressure hydrocephalus C. Basilar artery CVA D. Progressive supranuclear palsy 18. In review of a nursing home patient’s chart, the nurse practitioner discovers that the neurology

consult identified that the client has a homonymous hemianopsia. Which of the following statements accurately describes these findings?

A. Partial loss of visual acuity in the ipsilateral peripheral fields B. Diplopia in the eye contralateral to the cerebral lesion C. Loss of vision in either the right or left halves of the visual fields D. Nystagmus in both eyes with asymmetrical movement 19. The Mini-Cog is a short screening tool used to assess cognition. Which of the following statements

pertaining to the test is a true statement?

A. The patient will be asked to repeat five words immediately following the directions by the practitioner.

B. The patient is asked to draw the hour and minute hands on a picture of an analog clock.

C. A score of 0-2 is a positive screen for dementia.

D. The patient is asked to recall five images from picture cards following the drawing of the clock hands.

Advanced Practice Nursing 2e(Malone)

Chapter 14. Endocrine, Metabolic, and Nutritional Disorders Multiple Choice Identify the choice that best completes the statement or answers the question.

1. An elderly client presents with a new onset of feeling her heart race and fatigue. An EKG reveals

atrial fibrillation with rate >110. The patient also has a new fine tremor of both hands. Which of the following would the nurse practitioner suspect?

A. Hypothyroidism B. Hyperthyroidism C. Congestive heart failure D. Type 2 diabetes mellitus 2. A 62-year-old female complains of fatigue and lack of energy. Constipation has increased and the

patient has gained ten pounds in the past 3 months. Depression is denied although the patient reports a lack of interest in usual hobbies. Vital signs are within normal limits and the patient’s skin is dry and cool. Which of the following must be included in the differential?

A. Hyperthyroidism

Advanced Practice Nursing 2e(Malone) B. Hypothyroidism C. Hyperparathyroidism D. Grave’s disease 3. Mrs. Black, an 87-year-old patient, has been taking 100 mcg of Synthroid for 10 years. She comes to

your office for a routine follow-up, feeling well. Her heart rate is 90. Your first response is to: A. Increase the Synthroid B. Order TSH C. Start a beta-blocker D. Order thyroid scan 4. Which patient is most likely to have osteoporosis?

A. An 80-year-old underweight male who smokes and has been on steroids for

psoriasis B. A 90-year-old female with no family history of osteoporosis who is on hormone

replacement therapy C. A 68-year-old overweight female who drinks 1-2 drinks alcohol/day D. An 82-year-old female with a normal BMI takes calcium and performs weight-

bearing exercise daily 5. When evaluating the expected outcome for a hypothyroid elderly patient placed on levothyroxine,

the nurse practitioner will: A. Assess a weekly TSH B. Assess the TSH in 4-6 weeks C. Ask the patient if the symptoms have subsided and adjust dosage accordingly D. Decrease the dosage should a cardiac event occur 6. A postmenopausal woman with osteoporosis is taking a bisphosphonate daily by mouth. What action

information statement would indicate the patient understood the nurse practitioner’s instructions regarding this medication?

A. Takes medication at bedtime with a full glass of water B. Takes medication with a full glass of water when up in a.m. 30 minutes prior to other food and medications C. Takes medication when up in a.m. with a glass of orange juice to increase absorption D. Takes medication sitting up and with a meal to avoid gastrointestinal distress 7. The primary reason levothyroxine sodium is initiated at a low dose in an elderly patient with

hypothyroidism is to prevent which of the following untoward effects?

A. Angina and arrhythmia B. Nausea and diarrhea C. Confusion and delirium D. Osteoporosis and muscle weakness 8. Six months ago an elderly patient was diagnosed with subclinical hypothyroidism. Today the patient

returns and has a TSH of 11.0 and complains of fatigue. He has taken Synthroid 25 mcg daily as prescribed. What is the best course of action for the nurse practitioner?

A. Assess further for a cause of fatigue

Advanced Practice Nursing 2e(Malone) B. Double the dose of Synthroid C. Discontinue the Synthroid D. Prescribe Liotrix (T3 & T4 combination) 9. A fluoroquinolone (Ciprofloxin) is prescribed for a male patient with a UTI. What should the nurse

practitioner teach the patient regarding taking this medication?

A. It must be taken on an empty stomach B. Its effectiveness is decreased by antacids, iron, or caffeine ingestion C. It may cause a metallic aftertaste D. Its effectiveness is not a concern and it can be taken with any medications 10. A patient has been prescribed metformin (Glucophage). One week later he returns with lowered

blood sugars but complains of some loose stools during the week. How should the nurse practitioner respond?

A. Discontinue the medication immediately B. Reassure the patient that this is an anticipated side effect C. Double the dosage of medication and have patient return in 1 week D. Order a chem. 7 to check for lactic acidosis 11. Which of the following signs of hyperthyroidism commonly manifest in younger populations, but is

notably lacking in the elderly?

A. Weight gain B. Constipation C. Bradycardia D. Exophthalmos 12. A 60-year-old obese male client has type 2 diabetes mellitus and a lipid panel of TC = 250, HDL =

32, LDL = 165. The nurse practitioner teaches the patient about his modifiable cardiac risk factors, which include: A. Advancing age, diabetes, hyperlipidemia, and male gender B. Diabetes, obesity, and hyperlipidemia C. Hyperlipidemia, smoking, and family history of heart disease D. Male with age > 45, diabetes mellitus, and hyperlipidemia 13. A diabetic patient presents with the complaint of right foot pain but denies any recent known injury.

He states it has gotten progressively worse over the past few months. On exam, vibratory sense, as well as sensation tested with a monofilament, was abnormal. The patient’s foot is warm, edematous, and misshapen. The nurse practitioner suspects Charcot foot. What intervention is indicated?

A. Warm soaks and return for follow-up in 1 week B. Referral to a pain management clinic C. Referral to an orthopedist D. Referral to a cardiologist for evaluation of peripheral vascular disease 14. What is a sign of insulin resistance that can present in African American patients?

A. Acanthosis Nigricans B. Psoriasis Nigricans C. Seborrheic Nigricans D. Bullemic Nigricans

Advanced Practice Nursing 2e(Malone) 15. During a routine physical examination of a 62-year-old female patient, the nurse practitioner

identifies xanthelasma around both his eyes. What is the significance of this finding?

A. High potential for future blindness and requires immediate referral B. None, normal variant of aging process C. Abnormal lipid metabolism requiring medical management D. Hereditary variant that is of no consequence but requires watchful waiting 16. Mr. White is 62 years old and has chronic kidney disease that has been relatively stable. He also has

a history of hyperlipidemia, osteoarthritis, and hypertension. He is compliant with his medications, and his BP has been well controlled on a calcium channel blocker. His last lipid panel showed: TC = 201, HDL = 40, TG = 180, LDL = 98. He currently takes Crestor 20 mg daily. In the office today, his BP is 188/90, and his urine dip now shows significant proteinuria. He denies any changes in his dietary habits or medication regimen. What would be the best medication change for Mr. White at this point?

A. No change—have him return in 4 weeks for a re-check of his blood pressure and urine B. Increase the dose of the calcium channel blocker for his hypertension C. Change the calcium channel blocker to an ACE-I D. Increase the dose of his Crestor and have him return in 3 months for a re-check of his BP 17. You are working as a nurse practitioner in the Fast Track of the emergency room. A 76-year-old

male presents with left upper quadrant abdominal pain. There can be many conditions that present as left upper quadrant pain, but which of the following is least likely to cause pain in the left upper quadrant?

A. Splenic abscess B. Left pyelonephritis C. Splenic rupture D. Acute pancreatitis 18. Which is a “cardinal feature” of failure to thrive?

A. Decline in toileting ability B. Gait disturbance C. Poor nutritional status D. Spiritual distress 19. Feeding gastrostomy tubes at end-of-life Alzheimer’s disease patients have been associated with: A. Prolongation of life B. Aspirational pneumonia C. Increase in skin infections D. Reversal of any clinical signs of failure to thrive 20. Which of the following nutritional indicators is not an indication of poor nutritional status in an older

person?

A. Albumin of < 3.5 g/dl B. Body mass index of 25 C. Total cholesterol < 150 mg/dl D. Loss of 10% body weight in 180 days

Advanced Practice Nursing 2e(Malone)

Chapter 15. Hematologic and Immune System Disorders Multiple Choice Identify the choice that best completes the statement or answers the question.

1. Iron Deficiency Anemia (IDA) is classified as a microcytic, hypochromic anemia. This classification

refers to which of the following laboratory data?

A. Hemoglobin and hematocrit B. Mean Corpuscular Volume (MCV) and Mean Corpuscular Hemoglobin (MCH) C. Serum ferritin and serum iron D. Total iron binding capacity and transferrin saturation 2. Initial therapy for patients with IDA is: A. Blood transfusion B. Increasing dietary intake of green leafy vegetables C. Ferrous sulfate 325 mg orally bid-tid D. Parenteral administration of Venofer

Advanced Practice Nursing 2e(Malone) 3. Mrs. G, a 70-year-old patient, presents to you with a hemoglobin of 9.4 and a decreased MCV/MCV.

You diagnose her with IDA and start her on ferrous sulfate 325 mg PO tid. The next step in your work-up would be: A. Send Mrs. G for a GI consult B. Obtain hemoglobin one week after oral therapy C. Schedule Mrs. G for an upper GI series D. Obtain stool for occult blood 4. Despite adherence to oral iron therapy of 2 weeks, your elderly patient with IDA demonstrates a

drop in his hemoglobin from 8.4 to 7.4. He is complaining of fatigue, dyspnea, and heart racing. You would change his therapy by which of the following: A. Schedule patient for outpatient parenteral iron infusion B. Switch to a different form of oral therapy C. Schedule patient for outpatient blood transfusion D. Make no changes until evaluated by GI specialist 5. You are prescribing oral iron therapy for a patient with IDA. In teaching your patient about iron

therapy, all of the following instructions should be reviewed except: A. Iron is best taken on an empty stomach one hour before meals B. Meat, fish, poultry, beans, and green leafy vegetables are good dietary sources of iron C. Adding vitamin D daily enhances absorption of iron D. Common GI side effects of iron therapy include constipation, nausea, and black stools 6. When interpreting laboratory data, you would expect to see the following in a patient with Anemia

of Chronic Disease (ACD): A. Hemoglobin <12 g/dl, Mean Corpuscular Volume (MCV) decreased, Mean Corpuscular Hemoglobin (MCH) decreased B. Hemoglobin >12 g/dl, Mean Corpuscular Volume (MCV) increased, Mean Corpuscular Hemoglobin (MCH) increased C. Hemoglobin <12 g/dl, Mean Corpuscular Volume (MCV) normal, Mean Corpuscular Hemoglobin (MCH) normal D. Hemoglobin >12 g/dl, Mean Corpuscular Volume (MCV) decreased, Mean Corpuscular Hemoglobin (MCH) increased 7. The pathophysiological hallmark of ACD is: A. Depleted iron stores B. Impaired ability to use iron stores C. Chronic uncorrectable bleeding D. Reduced intestinal absorption of iron 8. The main focus of treatment of patients with ACD is: A. Replenishing iron stores B. Providing for adequate nutrition high in iron C. Management of the underlying disorder D. Administration of monthly vitamin B12 injections

Advanced Practice Nursing 2e(Malone) 9. In addition to the CBC with differential, which of the following laboratory tests is considered to be

most useful in diagnosing ACD and IDA? A. Serum iron B. Total iron binding capacity C. Transferrin saturation D. Serum ferritin 10. Education of patient and family regarding ACD includes discussion of all of the following except: A. Early prevention of chronic conditions through healthy lifestyle measures B. Importance of adherence to the treatment plan for management of chronic

conditions C. Explaining the ACD is mainly attributed to the aging process D. Importance of regular follow-up to monitor responses to treatments 11. Symptoms in the initial HIV infection include all of the following except: A. Sore throat B. Fever C. Weight loss D. Headache 12. The primary mode of HIV transmission in the U.S. is: A. Blood transfusion B. Men having sex with men C. Heterosexual contact D. Needle sharing 13. In the older adult, which group comprises the highest rate of HIV/AIDS? A. African American women B. African American men C. Hispanic women D. Hispanic men 14. Contributing factors in HIV development in the older adult include all of the following except: A. Older adults are less likely to be tested B. Healthcare providers do not routinely ask older adults about HIV risks C. Older adults are less likely to use condoms D. Older adults are at low risk to contract HIV 15. Immune system changes that render older adults more susceptible to contracting HIV include all of

the following except: A. Hyper-responsive T cells B. Age-related thymic involution C. Depletion of naïve CD4 cells D. Decline in B cell function

Advanced Practice Nursing 2e(Malone)

Chapter 16. Psychosocial Disorders Multiple Choice Identify the choice that best completes the statement or answers the question.

1. The prevalence of depression in nursing home residents is

greater than adults living in the

community.

A. 1-2 times B. 2-3 times C. 3-4 times D. 5 times 2. The majority of depressed older adults remain untreated because of: A. Misdiagnosis B. Social stigma C. Environmental barriers D. All of the above 3. Symptoms of depression distinct to the elderly include: A. Flat affect B. Loss of pleasure in usual activities C. Appetite and weight disturbances

Advanced Practice Nursing 2e(Malone) D. Lack of emotions 4. The justification for ordering a CBC, TSH, and serum B12 for a patient you suspect may have

clinical depression is: A. To determine the cause of sadness B. Because of overlapping symptoms with anemia, thyroid dysfunction, and nutritional deficiencies C. To differentiate between depression and metabolic disorders D. To rule out vascular disease 5. One major difference that is useful in the differential diagnosis of dementia versus delirium is that: A. Dementia develops slowly and delirium develops quickly B. The initial symptoms of dementia are more severe than the symptoms of delirium C. Dementia symptoms are not associated with underlying medical conditions and

delirium symptoms usually result from underlying medical conditions D. Symptoms of delirium involve memory and attention and symptoms of dementia involve only memory 6. Which of the following is the most appropriate screening tool for delirium?

A. Lawton Scale of Instrumental Activities of Daily Living B. Confusion Assessment Method C. Folstein’s Mini-Mental Status Examination D. Montreal Cognitive Assessment 7. The proposed mechanism by which diphenhydramine causes delirium is: A. Serotinergic effects B. Dopaminergic effects C. Gabanergic effects D. Anticholinergic effects 8. The elderly are at high risk for delirium because of: A. Multisensory declines B. Polypharmacy C. Multiple medical problems D. All of the above 9. A consistent finding in delirium, regardless of cause, is: A. Dopamine deficiency B. Serotinergic toxicity C. Acetylcholine deficiency D. Reduction in regional cerebral perfusion 10. Older adults with dementia sometimes suffer from agnosia, which is defined as the inability to: A. Use language B. Understand language C. Recognize objects D. Remember events and places

Advanced Practice Nursing 2e(Malone) 11. In late stages of dementia, a phenomenon called “sun downing” occurs, in which cognitive

disturbances tend to: A. Improve as the day goes on B. Become worse toward the evening C. Fluctuate during the course of the day D. Peak mid-day 12. Of the following, which one is the most useful clinical evaluation tool to assist in the diagnosis of

dementia?

A. Folstein’s Mini-Mental Status Exam (MMSE) B. St. Louis University Mental Status Exam (SLUMS) C. Montreal Cognitive Assessment (MoCA) D. Geriatric Depression Scale (GDS) 13. The cornerstone of pharmacotherapy in treating Alzheimer’s disease is: A. Cholinesterase inhibitors B. NMDA receptor antagonist C. Psychotropic medications D. Anxiolytics 14. The comorbid psychiatric problem with the highest frequency in dementia is: A. Anxiety B. Depression C. Agitation and aggression D. Psychosis 15. When treating depression associated with dementia, which of the following would be a poor choice

and should not be prescribed?

A. Fluoxetine B. Desipramine C. Amitriptyline D. Mirtazapine

Advanced Practice Nursing 2e(Malone)

Chapter 17. Polypharmacy MULTIPLE CHOICE 1. The nurse plans to closely monitor an older adult client who is receiving multiple drugs for evidence of adequate excretion of the medications. Which two major organs affecting drug clearance from the body should be monitored when an older adult client is receiving multiple drugs? a. Kidneys and lungs b. Kidneys and pancreas c. Liver and pancreas d. Liver and kidneys ANS: D

Advanced Practice Nursing 2e(Malone)

The older adult client may experience a decrease in hepatic enzyme production, hepatic blood flow, and total liver function. These decreases cause a reduction in drug metabolism. A decrease in renal blood flow and decrease in glomerular filtration rate of 40% to 50% can also occur.

2. The nurse is aware that increased

may affect the absorption of medications.

a. gastric motility b. alkaline gastric secretion c. intestinal emptying time d. peristalsis ANS: B An increase in alkaline gastric secretions may affect the absorption of medications, because gastric motility, gastric emptying time, and peristalsis are all decreased with increased alkaline gastric secretions.

3. The older adult client is prescribed a drug that is excreted through the urine. The nurse anticipates that which laboratory test will be prescribed to evaluate renal function before administration of the medication? a. Blood urea nitrogen b. Serum albumin c. Serum electrolytes d. White blood cell count ANS: A Drug dosages are adjusted according to the older adults weight, adipose tissue, laboratory results (e.g., serum protein, electrolytes, liver enzymes, blood urea nitrogen, creatinine), and current health problems.

4. The nurse recognizes that polypharmacy is more likely to occur in an older adult client because the older client:

Advanced Practice Nursing 2e(Malone)

a. has difficulty maintaining a list of current medications. b. experiences changes in visual capability. c. experiences alterations in mental capacity. d. may obtain prescribed drugs from various providers.

ANS: D Polypharmacy is the prescription and administration of many drugs during the same period. This is more likely with the older client, who may see various healthcare providers to manage the health concerns that may accompany aging.

5. The diuretic hydrochlorothiazide (HCTZ; HydroDIURIL) is usually prescribed for the olderadult in a lower dose. The nurse recognizes that this is an attempt to prevent the older adult from experiencing a(n): a. increase in potassium loss. b. decrease in sodium loss. c. decrease in blood sugar levels. d. increase in red and white blood cell count.

ANS: A 6. The nurse notes that Cimetidine has been prescribed for anolder adult client. The nurses highest priority would be to call: a. the physician. b. the pharmacist. c. the nursing supervisor. d. Poison Control.

ANS: A

Advanced Practice Nursing 2e(Malone)

Cimetidine is not recommended for the older adult because of its side effects and multiple potential drug interactions. Famotidine, nizatidine, and ranitidine may be prescribed for the geriatric client instead of cimetidine.

7. An older adult client says that he has difficulty removing the cap from his medication bottle. He says, Thats why I dont always take my medication. The nurse should suggest that he: a. ask a neighbor to help him remove the bottle cap. b. ask the pharmacist to put the drug in a nonchildproof container. c. have a family member visit daily to prepare his medications. d. ask the healthcare provider not to prescribe drugs that come in childproof bottles.

ANS: B Childproof caps may be difficult to remove for older adults with arthritis or decreased strength or motor function.

8. A client is demonstrating signs and symptoms of disorientation. Which question by the nurse would be appropriate, related to the clients medication use? a. Are you taking any new medications? b. Do you take medications with a full glass of water? c. Do your medications make you constipated? d. Have you been diagnosed with dementia?

ANS: A A new medication may be associated with changes in sensorium or other behavioral characteristics.

This should be evaluated.

9. The nurse is caring for an older adult client and a middle-aged adult client. The nurse anticipates that the medication doses for the older adult will be

those for the middle-aged adult.

Advanced Practice Nursing 2e(Malone)

a. the same as b. less than c. slightly more than d. twice as much as ANS: B Because of changes in metabolism and excretion, doses are generally decreased to avoid accumulation and toxicity.

10. An older adult client is ordered to receive digoxin (Lanoxin). The client has decreased renal function. Which condition could indicate digoxin toxicity? a. Elevated blood pressure b. Decreased blood pressure c. Heart rate greater than 100 beats per minute d. Heart rate less than 60 beats per minute ANS: D Digoxin slows and strengthens the heart. Toxicity may be manifested by bradycardia.

11. A client takes ibuprofen to deal with the pain of arthritis. The client complains ofgastrointestinal symptoms. Which is an appropriate strategy for the nurse to teach the client? a. Take the medication on an empty stomach. b. Do not take the medication if it has side effects. c. Try to take an antacid 1 hour before the dose. d. You must take the medication anyway.

ANS: C

Advanced Practice Nursing 2e(Malone)

An antacid may decrease the gastrointestinal side effects of the NSAID. It may also impair absorption, so it must be evaluated for effectiveness.

12. A nurse is administering medication to an older adult client. The nurse is aware that the clients half-life is longer than that of middle-aged adults. What nursing intervention is indicated by this premise? a. Provide higher doses to achieve therapeutic effects. b. Assess the client for adverse reactions. c. Monitor the client for signs of accumulation. d. Provide education to the client on drug reactions.

ANS: C Because older adults may have less efficient medication elimination, monitoring for accumulation is an important component of nursing care.

13. The nurse is caring for an older adult client who complains that she has to take multiple medications at various times throughout the day. What is the most appropriate nursing intervention for the nurse to implement with this client? a. Encourage family members or friends to monitor drug regimen. b. Explain the purpose, drug action, and importance of medication. c. Develop a chart indicating times to take drugs. d. Provide time for questions; reinforce with written information.

ANS: C The nurse should help the client develop a chart indicating times to take drugs. Space should be provided to mark each drug taken. An organizer or calendar can be used to mark days and weeks.

14. The physician is recommending a benzodiazepine medication for an older adult client who has previously been treated with Valium. The nurse recognizes that which medication would be most appropriate for this client?

Advanced Practice Nursing 2e(Malone)

a. Librium b. Dalmane c. Ativan d. Equanil

A short-acting benzodiazepine, such as Ativan, would be preferable to any of the other drugs to avoid prolonged sedation and addiction.

15. Which older adult client is most likely to experience digoxin toxicity? a. 72-year-old man who is also experiencing hyperkalemia b. 74-year-old woman who is also experiencing hypokalemia c. 66-year-old woman who is also experiencing hypercalcemia d. 62-year-old woman who is also experiencing hypocalcemia

Chapter18.Chronic Illnessandthe Advanced PracticeRegistered Nurse (APRN) Multiple Choice Identify the choice that best completes the statement or answers the question.

1. All of the following statements are true about chronic disease/illness except: A. Chronic disease is defined as a condition that requires both modification by the

patient along with interaction with the provider B. The meaning of chronic illness includes the experience of thepatient and family

and provider C. Chronic illness is reversible if diagnosed and treated early D. Chronic conditions are those that last a year or longer

Advanced Practice Nursing 2e(Malone) 2. The highest number of people with multiple chronic conditions are those that are: A. Over age 85 B. Diagnosed with type 2 diabetes C. African American women over age 65 D. Diagnosed with COPD 3. Long durations of a chronic illness that are most commonly associated in both women and men are: A. Heart disease and obesity B. Diabetes and COPD C. Arthritis and dementia D. Dyslipidemia and eye disease 4. The percentage of non-institutionalized elderly over age 75 with limitations in activity due to a

chronic condition is: A. 25% B. Nearly 50% C. Over 75% D. Less than 15% 5. Which of the following statements are true?

A. Most Medicare participants have a single care provider B. Chronic kidney disease patients have better outcomes due to the dialysis benefit C. Nearly half of Medicare participants have five or more chronic diseases D. Nearly half of Medicare participants have three or more chronic diseases 6. Which statement about chronic mental disorders is false?

A. The numbers are projected to increase in the next decade B. Individuals with mental health problems actually have a decreased risk of medical

problems C. The number of older adults with addiction problems is projected to increase in the

next decade D. Nearly half of individuals with dementia are not diagnosed prior to hospitalization 7. All of the following criteria define frailty except: A. Unintentional weight loss >10 pounds in the past year B. Slow walking speed C. Stooped posture D. Self-reported exhaustion 8. All of the following are health consequences of obesity except: A. Mortality of aging B. Hypertension C. Coronary artery disease D. Sleep apnea 9. Evidence-based clinical practice guidelines may have limited applicability in the older population

because: A. They often are disease specific

Advanced Practice Nursing 2e(Malone) B. They often have complex comorbid conditions C. Both A and B D. None of the above evidence-based clinical practice guidelines are always the

standard 10. Inter-professional care is distinguished from other models of team-based care in that: A. Independent providers share information B. Expert advice is shared from one provider to another C. Different disciplines work under one leader D. Shared leadership and accountability is a primary focus 11. All of the following statements about the Chronic Care Model are true except: A. It was developed with Robert Wood Johnson Foundation funding B. It focuses exclusively on a self-management model C. It is an evidence-based policy response designed to meet the needs of the

chronically ill D. It directs quality improvement and system change for patients with chronic disease 12. The legislation signed in March 2010 with provisions for addressing chronic disease was: A. Accountable Care Organization Act B. Independence at Home Act C. Patient Protection and Affordable Care Act D. Patient Centered Medical Home Act 13. Reported outcome measures for the Patient Centered Medical Home include all of the following

except: A. Emergency room use B. Hospitalizations C. Patient/family satisfaction D. Number of primary care visits 14. Transitional care is best described as: A. A set of actions to ensure the coordination and continuity of careacross

sites/settings B. The care received in transit from one site of care to another C. A discharge-planning model D. Long-term acute care that provides the transition from hospital to long-term careor

home

Advanced Practice Nursing 2e(Malone)

Chapter 19. Palliative Care and End-of-Life Care Multiple Choice Identify the choice that best completes the statement or answers the question.

1. Hospice care differs from palliative care in that: A. It is not covered by insurance B. Supports patients and families through both the dying and the bereavement process C. It cannot be provided in the nursing home D. The majority of those admitted to hospice die within 7 days 2. Evidence reflects the primary obstacle to implementing palliative care in the long-term care setting

include all of the following except: A. Inadequate communication between decision makers B. Failure to recognize futile treatments C. Lack of advance directives D. Lack of sufficient staff 3. The most prevalent symptom in end-of-life care includes all of the following except: A. Lower extremity weakness B. Pain C. Dyspnea

Advanced Practice Nursing 2e(Malone) D. Delirium 4. Pain at the end of life is most often due to all of the following except: A. Musculoskeletal disorders B. Headache C. Cancer pain D. Neuropathic pain 5. The strongest level of evidence reflects the absolute contraindication for NSAID use exists with: A. Chronic kidney disease B. Peptic ulcer disease C. Heart disease D. Liver disease 6. The drug specific for severe opioid-induced constipation is: A. Lactulose B. Ducolax C. Mineral oil D. Methylnaltrexone 7. Pharmacological interventions for dyspnea include all of the following except: A. Antitussives B. Inhaled anesthetics C. Sedatives D. Anxiolytics 8. Delirium is typically characterized by all of the following except: A. Inattention B. Hyperactive level of psychomotor activity C. Disorganized thinking D. Altered level of consciousness 9. The first step in treating delirium is to: A. Give low-dose Haldol if the patient has psychosis B. Identify the cause C. Provide reality orientation D. Use side rails and/or wrist restraints to keep the patient safe 10. The majority of patients enrolled in hospice care die: A. In a nursing home B. In the hospital C. In an inpatient hospice facility D. At home 11. A drug that can be used to treat two very common symptoms in a dying patient (pain and dyspnea)

is: A. Morphine B. Methadone C. Gabapentin

Advanced Practice Nursing 2e(Malone) D. Lorazepam 12. The tasks of grieving include all of the following except: A. Acknowledge the reality of death B. Work through the pain of grief C. Begin to disengage D. Restructure relationships 13. The best description of complicated grief is: A. Chronic, delayed, exaggerated, masked, or disenfranchised B. Experience of shock during notification of the death C. When grief is actually experienced before the death of a loved one D. A physical illness develops soon after death of a loved one 14. All of the following statements are true about interventions in working with the bereaved except: A. Allow the active expression of grief B. There is strong evidence behind recommended interventions C. Staff attending memorial services support the family D. Provide both emotional and spiritual support 15. The highest level of evidence to support interventions at the end of life is with: A. Opioids for pain control B. Hyocsyamine for respiratory secretions C. Stimulant laxatives for treating constipation D. Opioids for dyspnea 16. The highest level of evidence with the use of adjuvant analgesics is with: A. Tricyclic antidepressants avoided due to high adverse events B. Therapeutic trials before discontinuing drugs C. Patient with fibromyalgia are candidates for adjuvant analgesics D. Neuropathic pain patients are candidates for adjuvant analgesia

Advanced Practice Nursing 2e(Malone)

Advanced Practice Nursing 2e(Malone)

Unit I: The Healthy Older Adult Chapter 1: Changes With Aging Question 1: The major impact of the physiological changes that occur with aging is: a. b. c. d.

Reduced physiological reserve Reduced homeostatic mechanisms Impaired immunological response All of the above

Instructor Explanation: The major impact of all of these physiological changes can be highlighted with three primary points. First, there is a reduced physiological reserve of most body systems, particularly cardiac, respiratory, and renal.

Second, there are reduced homeostatic mechanisms that fail to adjust regulatory systems such as temperature control and fluid and electrolyte balance.

Third, there is impaired immunological function: infection risk is greater, and autoimmune diseases are more prevalent. (Kennedy-Malone 3) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014- 01-14. VitalBook file.

Question 2: Men have faster and more efficient biotransformation of drugs and this is thought to be due to a. b. c. d.

Less obesity rates than women Prostate enlargement Testosterone Less estrogen than women

Instructor Explanation: Men have faster and more efficient biotransformation, presumably because of serum testosterone.

Conditions of increased or decreased liver perfusion alter the overall level of the drug that is absorbed and how it is metabolized. (Kennedy-Malone 5) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014- 01-14. VitalBook file.

Question 3: The cytochrome p system involves enzymes that are generally: a. b. c. d.

Inhibited by drugs Induced by drugs Inhibited or induced by drugs Associated with decreased liver perfusion

Instructor Explanation: Biotransformation occurs in all body tissues but primarily in the liver, where enzymatic activity (cytochrome P [CYP] system) alters and detoxifies the drug and prepares it for excretion. (Kennedy-

Advanced Practice Nursing 2e(Malone) Malone 5)-Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file.

Question 4: Functional abilities are best assessed by: a. b. c. d.

Self-report of function Observed assessment of function A comprehensive head-to-toe examination Family report of function

Instructor Explanation: Two well-established tools used to evaluate function in older adults are the Katz Activities of Daily Living Scale (Katz et al., 1963) and the Lawton and Brody scale for Instrumental Activities of Daily Living (Lawton & Brody, 1969). It is important to be cautious about self-report of function (rather than direct observation of function) and to ask, “Do you …?” instead of “Can you …?” in order to determine if patients actually perform the activity. (Kennedy-Malone 40)-Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 201401-14. VitalBook file.

Question 5: Iron Deficiency Anemia (IDA) is classified as a microcytic, hypochromic anemia. This classification refers to which of the following laboratory data? a. b. c. d.

Hemoglobin and Hematocrit Mean Corpuscular Volume (MCV) and Mean Corpuscular Hemoglobin (MCH) Serum ferritin and serum iron Total iron binding capacity and transferrin saturation

Instructor Explanation: RBC indices reveal an MCV (mean corpuscular volume/RBC size) that will be decreased to <80 fL in adults; MCH (mean corpuscular hemoglobin/RBC color) will show hypochromia or pale cells; RBC distribution width (RDW)/volume variation will be increased. (Kennedy-Malone page 519)-KennedyMalone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file.

Question 6:When interpreting laboratory data, you would expect to see the following in a patient with Anemia of Chronic Disease (ACD): a. b. c. d.

Hemoglobin <12 g/dl, MCV decreased, MCH decreased Hemoglobin >12 g/dl, MCV increased, MCH increased Hemoglobin <12 g/dl, MCV normal, MCH normal Hemoglobin >12 g/dl, MCV decreased, MCH increased

Instructor Explanation: Hemoglobin (Hgb): <12 g/dL (120 g/L) women <13 g/dL (130 g/L) men Rarely <10 g/dL (100 g/L) Mean corpuscular volume: 80–96 mcm3 (normocytic) Mean corpuscular hemoglobin Normochromic (normal color) RBC distribution width: normal (Kennedy-Malone page 517)-Kennedy-Malone, Laurie, Kathleen

Advanced Practice Nursing 2e(Malone) Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file.

Question 7:The pathophysiological hallmark of ACD is: a. b. c. d.

Depleted iron stores Impaired ability to use iron stores Chronic uncorrectable bleeding Reduced intestinal absorption of iron

Instructor Explanation: The pathophysiological hallmark of ACD is a disregulation of iron homeostasis, characterized by an increased uptake and retention of iron within the cells of the reticuloendothelial system (liver/spleen), resulting in decreased RBC production. Essentially, iron is present but inaccessible for use in the production of Hgb with the erythrocytes (Bross et al., 2010). A shortened RBC survival is also a contributing factor to ACD. (Kennedy- Malone page 516-517)-Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014- 01-14. VitalBook file.

Question 8 The main focus of treatment of patients with ACD is: a. b. c. d.

Replenishing iron stores Providing for adequate nutrition high in iron Management of the underlying disorder Administration of monthly vitamin B12 injections

Instructor Explanation: Treatment: Treatment of ACD focuses on management of the underlying disorder. Iron supplementation is of no benefit in ACD, except in cases of coexisting IDA. A therapeutic trial of iron supplementation of no longer than 1 month may be useful in delineating between ACD and IDA. In ACD, there would be no hematological response to iron therapy (Chen & Gandhi, 2004). (Kennedy-Malone page 518)-KennedyMalone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014- 01-14. VitalBook file.

Question 9: In addition to the complete blood count (CBC) with differential, which of the following laboratory tests is considered to be most useful in diagnosing ACD and IDA? Student Answer: a. b. c. d.

Serum iron Total iron binding capacity Transferrin saturation Serum ferritin

Instructor Explanation:

Advanced Practice Nursing 2e(Malone) Treatment: Treatment of ACD focuses on management of the underlying disorder. Iron supplementation is of no benefit in ACD, except in cases of coexisting IDA. A therapeutic trial of iron supplementation of no longer than 1 month may be useful in delineating between ACD and IDA. In ACD, there would be no hematological response to iron therapy (Chen & Gandhi, 2004).

(Kennedy-Malone page 518) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014- 01-14. VitalBook file.

Question 10 :Symptoms in the initial human immunodeficiency virus (HIV) infection include all of the following except: Student Answer: a. b. c. d.

Sore throat Fever Weight loss Headache

Instructor Explanation: Signal symptoms: The initial HIV infection is characterized by mononucleosis-like illness with fever, sore throat, lymphadenopathy, headache, and fatigue. A roseola-like rash may also develop. These initial symptoms are followed by an asymptomatic phase, which may last 10 years or more. Later, if untreated, lymphadenopathy, weight loss, myalgias, and diarrhea may develop (Cohen, Kuritzkes, & Sax, 2011). In advanced disease, malignancies and opportunistic infections occur. Co-infection with hepatitis B or C is common (25% to 30%) in IV drug users, so hepatitis symptoms may also appear (Centers for Disease Control and Prevention [CDC], 2010a). (Kennedy-Malone page 521) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file.

Question 11:Essential parts of a health history include all of the following except: Student Answer: a. b. c. d.

Chief complaint History of the present illness Current vital signs All of the above are essential history components

Instructor Explanation: Vital signs are part of the physical examination portion of patient assessment, not part of the health history.

Question 12:Which of the following clinical reasoning tools is defined as evidence-based resource based on mathematical modeling to express the likelihood of a condition in select situations, settings, and/or patients?

Student Answer:

Advanced Practice Nursing 2e(Malone) a. b. c. d.

Clinical practice guideline Clinical decision rule Clinical algorithm Clinical recommendation

Instructor

Clinical decision (or prediction) rules provide another support for clinical

Explanation: reasoning. Clinical decision rules are evidence-based resources that provide probabilistic statements regarding the likelihood that a condition exists if certain variables are met with regard to the prognosis of patients with specific findings. Decision rules use mathematical models and are specific to certain situations, settings, and/or patient characteristics. 7 Question 13:The first step in the genomic assessment of a patient is obtaining information regarding: Student Answer: a. b. c. d.

Family history Environmental exposures Lifestyle and behaviors Current medications

Instructor Explanation: A critical first step in genomic assessment, including assessment of risk, is the use of family history.

Family history is considered the first genetic screen (Berry & Shooner 2004) and is a critical component of care because it reflects shared genetic susceptibilities, shared environment, and common behaviors (Yoon, Scheuner, & Khoury 2003). 18 Question 14 Question : In autosomal recessive (AR) disorders, individuals need: Student Answer: a. b. c. d.

Only one mutated gene on the sex chromosomes to acquire the disease Only one mutated gene to acquire the disease Two mutated genes to acquire the disease Two mutated genes to become carriers

Instructor Explanation: In autosomal recessive (AR) disorders, the offspring inherits the condition by receiving one copy of the gene mutation from each of the parents.

Autosomal recessive disorders must be inherited through both parents (Nussbaum et al. 2007). Individuals who have an AR disorder have two mutated genes, one on each locus of the chromosome. Parents of an affected person are called carriers because each carries one copy of the mutation on one chromosome and a normal gene on the other chromosome. Carriers typically are not affected by the disease. 28

Advanced Practice Nursing 2e(Malone)

Question 15:In AR disorders, carriers have: Student Answer: a. b. c. d.

Two mutated genes; two from one parent that cause disease A mutation on a sex chromosome that causes a disease A single gene mutation that causes the disease One copy of a gene mutation but not the disease

Instructor Explanation: Individuals who have an AR disorder have two mutated genes, one on each allele of the chromosome.

Parents of an affected person are called carriers because each parent carries one copy of the mutation on one chromosome and a normal gene on the other chromosome. Carriers typically are not affected by the disease. In pedigrees with an AR inheritance patterns, males and females will be equally affected because the gene mutation is on an autosome. 28

Question 16:A woman with an X-linked dominant disorder will: Student Answer: a. b. c. d.

Not be affected by the disorder herself Transmit the disorder to 50% of her offspring (male or female) Not transmit the disorder to her daughters Transmit the disorder to only her daughters

Instructor Explanation: Everyone born with an X-linked dominant disorder will be affected with the disease. Transmission of the disorder to the next generation varies by gender, however. A woman will transmit the mutation to 50% of all her offspring (male or female). 29 Question 17 According to the Genetic Information Nondiscrimination Act (GINA): Student Answer: a. b. c. d.

Nurse Practitioners (NPs) should keep all genetic information of patients confidential NPs must obtain informed consent prior to genetic testing of all patients Employers cannot inquire about an employee’s genetic information All of the above

Instructor Explanation:

Advanced Practice Nursing 2e(Malone) On May 21, 2008, President George W. Bush signed the Genetic Information Nondiscrimination Act (GINA) to protect Americans against discrimination based upon their genetic information when it comes to health insurance and employment, paving the way for patient personalized genetic medicine without fear of discrimination (National Human Genome Research Institute 2012). 43 Question 18 Question : Which of the following would be considered a “red flag” that requires more investigation in a patient assessment?

Student Answer: a. b. c. d.

Colon cancer in family member at age 70 Breast cancer in family member at age 75 Myocardial infarction in family member at age 35 All of the above

Instructor Explanation: Early onset cancer syndromes, heart disease, or dementia are red flags that warrant further investigation regarding hereditary disorders.

Question 19 Your 2-year-old patient shows facial features, such as epicanthal folds, up-slanted palpebral fissures, single transverse palmar crease, and a low nasal bridge. These are referred to as: Student Answer: a. b. c. d.

Variable expressivity related to inherited disease Dysmorphic features related to genetic disease De novo mutations of genetic disease Different penetrant signs of genetic disease

Instructor Explanation: Assessing for dysmorphic features may enable identification of certain syndromes or genetic or chromosomal disorders (Jorde, Carey, & Bamshad 2010; Prichard & Korf 2008). Dysmorphology is defined as “the study of abnormal physical development” (Jorde, Carey, & Bamshad 2010, 302).

Question 20: In order to provide a comprehensive genetic history of a patient, the NP should: Student Answer: a. b. c. d.

Ask patients to complete a family history worksheet Seek out pathology reports related to the patient’s disorder Interview family members regarding genetic disorders All of the above

Instructor Explanation:

Advanced Practice Nursing 2e(Malone) Asking the patient to complete a family history worksheet prior to the appointment saves time in the visit while offering the patient an opportunity to contribute to the collection of an accurate family history.

Reviewing the family information can also help establish family rapport while verifying medical conditions in individual family members. If a hereditary condition is being considered but family medical information is unclear or unknown, requesting medical records and pathology or autopsy reports may be warranted.

Question 21 :An 86-year-old patient who wears a hearing aid complains of poor hearing in the affected ear. In addition to possible hearing aid malfunction, this condition is often due to: Student Answer: Acoustic neuroma Cerumen impaction Otitis media Ménière’s disease Instructor Explanation: Elderly clients frequently present with complaints of hardened cerumen and decreased hearing resulting from cerumen impaction aggravated by hearing aid wear.( 137-138) Conductive hearing loss is caused by a lesion involving the outer and middle ear to the level of the oval window. Various structural abnormalities, cerumen impaction, perforation of the tympanic membrane, middle ear fluid, damage to the ossicles from trauma or infection, otosclerosis, tympanosclerosis, cholesteatoma, middle ear tumors, temporal bone fractures, injuries related to trauma, and congenital problems are some of the causes.

(Kennedy-Malone 170-171)

Question 22 .Question : In examination of the nose, the clinician observes gray, pale mucous membranes with clear, serous discharge. This is most likely indicative of: Student Answer: a. b. c. d.

Bacterial sinusitis Allergic rhinitis Drug abuse Skull fracture

Instructor Explanation: When examining the nose, assess the mucosa for integrity, color, moistness, and edema/lesions and the nasal septum for patency. The turbinates should be assessed for color and size. Pale, boggy turbinates suggest allergies; erythematous, swollen turbinates are often seen with infection. Any discharge should be noted. Clear, profuse discharge is often associated with allergies. ( 128-129) Patients with seasonal allergic rhinitis report rhinorrhea, sneezing, obstructed nasal passages, and pruritic eyes, nose, and oropharynx during the spring and fall. Patients with perennial allergic rhinitis have similar

Advanced Practice Nursing 2e(Malone) symptoms associated with exposure to environmental allergens typically in their homes. Physical examination may reveal a pale, boggy nasal mucosa, injected conjunctiva, enlarged turbinates, dark discoloration or bags under the eyes, and mouth breathing; absence of pale, boggy nasal mucosa does not rule out allergic rhinitis.

(Kennedy-Malone 182-183)

Question 3:A 45 year old patient presents with ‘sore throat’ and fever for one week. After a quick strep screen you determine the patient has Strep throat. You know that streptococcal pharyngitis should be treated with antibiotics to prevent complications and to shorten the course of disease. Which of the following antibiotics should be considered when a patient is allergic to Penicillin?

Student Answer: a. b. c. d.

Amoxicillin EES (erythromycin) Bicillin L-A Dicloxacillin

Instructor Explanation:

MedU Card #1

Question 4: Presbycusis is the hearing impairment that is associated with: Student Answer: a. b. c. d.

Physiologic aging Ménière’s disease Cerumen impaction Herpes zoster

Instructor Explanation: Presbycusis is an age-related cause of gradual sensorineural hearing loss and involves diminished hairy cell function within the cochlea as well as decreased elasticity of the TM. Although the changes associated with presbycusis often start in early adulthood, the decreased hearing acuity is usually not noticed until the individual is older than 65. ( 138)Because presbycusis is gradual and insidious, hearing loss may go unnoticed until it has progressed significantly.

(Kennedy-Malone 170)

Question 5: Epistaxis can be a symptom of: Student Answer: a. b. c. d.

Over-anticoagulation Hematologic malignancy Cocaine abuse All of the above

Instructor Explanation:

Advanced Practice Nursing 2e(Malone) Cocaine abuse, which is more common than might be expected, frequently causes epistaxis. Hematologic disorders likely to cause bleeding include thrombocytopenia, leukemia, aplastic anemia, and hereditary coagulopathies. High doses of anticoagulants can cause epistaxis and bleeding from the gums. ( 142) Epistaxis results from a spontaneous rupture of a blood vessel in the nose, usually in the anterior septum in Kiesselbach's plexus (Nguyen, 2012). The bleeding may be secondary to local infections, systemic infections, drying of the nasal mucous membrane, trauma, arteriosclerosis, hypertension, or bleeding disorders. Trauma is usually the primary mechanism of disruption of the nasal mucosa. Posterior epistaxis can result in nausea and respiratory compromise. In older adults, nasal and paranasal tumors may be involved (Mäkitie, 2010). (Kennedy-Malone 168-169)

Question 6: Your patient has been using chewing tobacco for 10 years. On physical examination, you observe a white ulceration surrounded by erythematous base on the side of his tongue. The clinician should recognize that very often this is: Student Answer: a. b. c. d.

Malignant melanoma Squamous cell carcinoma Aphthous ulceration Behcet’s syndrome

Instructor Explanation: Most oral malignancies are painless until quite advanced, so patients are often unaware of the lesion unless the lip or anterior portion of the tongue is involved. The patient may become aware of the lesion if it bleeds.

Squamous cell cancer lesions vary in appearance, from the reddened patches of erythroplakia to areas of induration/thickening, ulceration, or necrotic lesions. Lesions of malignant melanoma have varied pigmentation, including brown, blue, and black. Even lesions that appear flat and smooth may be nodular, indurated, or fixed to adjacent tissue on palpation. Even though patients with squamous cell malignancies often have a history of heavy alcohol and/or tobacco use or poor dentition, these are not risk factors for malignant melanoma. In Behcet’s syndrome, the patient complains of recurrent episodes of oral lesions that are consistent with aphthous ulcers.

The number of lesions ranges from one to several; the size of the ulcers varies from less than to greater than 1 cm. Like aphthous ulcers, the lesions are well defined, with a pale yellow or gray base surrounded by erythema. The majority of patients also develop lesions on the genitals and eyes. ( 153) Tobacco use and heavy alcohol consumption, alone or synergistically, are strongly related to the development of oral cancer. Pipe smoking and sun exposure have been implicated in lip cancer.

Leukoplakia and erythroplasia are often precursors to oral cancer. Relationships between oral cancer and Epstein-Barr virus, HPV, herpes simplex virus, and immunodeficiency states also have been found (Stenson, 2011). (Kennedy-Malone 177).

Advanced Practice Nursing 2e(Malone)

Question 7:A 26 year old patient presents with cough and general malaise for 3 days. They note that their eyes have been watering clear fluid and a ‘runny nose’ since yesterday. They note they ‘feel miserable’ and demand something to make them feel better. What would be the best first plan of treatment?

Student Answer: a) b) c) d)

Saline nasal spray for congestion and acetaminophen as needed for pain.

Z-pack (azithromycin) for infection and Cromolyn nasal for congestion Hydrococone/acetaminophen as needed for pain and Guaifensin for congestion Cephalexin for infection and Cromolyn ophthalmic for congestion

Instructor Explanation: MedU Card #4

Question 8 Which of the following findings should trigger an urgent referral to a cardiologist or neurologist?

Student Answer: a) b) c) d)

History of bright flash of light followed by significantly blurred vision History of transient and painless monocular loss of vision History of monocular severe eye pain, blurred vision, and ciliary flush All of the above

Instructor Explanation: Amaurosis fugax is a monocular, transient loss of vision. It stems from transient ischemia of the retina and presents an important warning sign for impending stroke. Depending on the circumstances reported, the patient should be immediately referred to either a cardiovascular or neurological specialist. ( 108)

Question 9 Question : Dizziness that is described as "lightheaded" or, "like I'm going to faint," is usually caused by inadequate cerebral perfusion and is classified as?

Student Answer: a) b) c) d)

Presyncope Disequilibrium Vertigo Syncope

Advanced Practice Nursing 2e(Malone) Instructor Explanation: MedU Card #5

Question 10

Question :

It is important to not dilate the eye if is suspected.

Student Answer: a) b) c) d)

Cataract Macular degeneration Acute closed-angle glaucoma Chronic open-angle glaucoma

Instructor Explanation: If the patient has experienced sudden onset of eye pain, it is important not to dilate the eyes before determining whether acute closed-angle glaucoma is present because dilating the eye may increase the intraocular pressure. ( 108) Acute glaucoma, also known as angle-closure or narrow-angle glaucoma, is an obstruction to the outflow of aqueous humor from the posterior to the anterior chamber through the trabecular meshwork, canal of Schlemm, and associated structures. It results in an elevation of intraocular pressure, damaging the optic nerve and causing loss of peripheral vision, eye pain, and redness. This type of glaucoma is uncommon but may occur as a primary disease or secondary to other conditions and constitutes an ophthalmic emergency (Kennedy-Malone 161)

Question 11 Mr. GC presents to the clinic with nausea and vomiting for 2 days, prior to that time he reports occasional ‘dizziness’ that got better with change in position. He denies a recent history of URI or any history of headaches or migraines. What would the most likely diagnosis be?

Student Answer:

Vestibular neruitis

Benign paroxysmal positional vertigo Vestibular migraine Benign hypertensive central vertigo Instructor Explanation: MedU Card #9

Question 12

Advanced Practice Nursing 2e(Malone) Which of the following patients with vertigo would require neurologic imaging?

Student Answer: a) A 68-year-old woman with a history of hypertension and sudden acute onset constant vertigo. She has right nystagmus that changes direction with gaze and that does not disappear when she focuses. b) A 45-year-old man with recurrent episodes of brief intense vertigo every time he turns his head rapidly. He has no other neurologic signs or symptoms. He has a positive Dix-Hallpike maneuver. c) A 66-year-old man with recurrent episodes of vertigo associated with tinnitus and hearing loss.

His head thrust test is positive. d) A 28-year-old otherwise well woman with new onset constant vertigo with no other neurologic symptoms. On physical exam, she has unidirectional nystagmus that disappears when her gaze is fixed.

Instructor Explanation: MedU Card #11. There are multiple reasons to be concerned about a central lesion and possible infarct in this patient. Her age puts her at risk as does her hypertension. Her physical exam shows nystagmus that changes direction and that does not inhibit with focus. Both of these findings are consistent with a central lesion. She needs an urgent MRI. Question 13 A patient presents with eye redness, scant discharge, and a gritty sensation. Your examination reveals the palpable preauricular nodes, which are most likely with: Student Answer: a) b) c) d)

Bacterial conjunctivitis Allergic conjunctivitis Chemical conjunctivitis Viral conjunctivitis

Instructor Explanation: Preauricular nodes are nonpalpable and nontender in allergic conjunctivitis, usually nonpalpable in bacterial conjunctivitis, and palpable in viral conjunctivitis. ( 112)

Question 14 In assessing the eyes, which of the following is considered a “red flag” finding when associated with eye redness?

Student Answer: a) b) c) d)

History of prior red-eye episodes Grossly visible corneal defect Exophthalmos Photophobia

Advanced Practice Nursing 2e(Malone) Instructor Explanation: Red flag warnings for eye redness include pain (not discomfort or irritation), decreased vision, profuse discharge, and corneal defect grossly visible. ( 112)

Question 15 A 64-year-old male presents with erythema of the sclera, tearing, and bilateral pruritus of the eyes. The symptoms occur intermittently throughout the year and he has associated clear nasal discharge. Which of the following is most likely because of the inflammation?

Student Answer: a) b) c) d)

Bacterium Allergen Virus Fungi

Instructor Explanation: Patients with seasonal allergic rhinitis report rhinorrhea, sneezing, obstructed nasal passages, and pruritic eyes, nose, and oropharynx during the spring and fall. Patients with perennial allergic rhinitis have similar symptoms associated with exposure to environmental allergens typically in their homes. Physical examination may reveal a pale, boggy nasal mucosa, injected conjunctiva, enlarged turbinates, dark discoloration or bags under the eyes, and mouth breathing; absence of pale, boggy nasal mucosa does not rule out allergic rhinitis.

(Kennedy-Malone 182-183)

Question 16 Patients that have atopic disorders are mediated by the production of Immunoglobulin E (IgE) will have histamine stimulated as an immediate phase response. This release of histamine results in which of the following?

Student Answer: a) Sinus pain, b) Increased vascular permeability, and bronchodilation

Advanced Practice Nursing 2e(Malone) c) Bronchospasm, d) Vascular permeability, and vasodilatation Instructor Explanation: Contraction of smooth muscle, decreased vascular permeability, and vasoconstriction Vasodilatation, bronchodilation, and increased vascular permeability Rhinitis may be either allergic or nonallergic. Allergic rhinitis results as a response of the nasal mucosa to airborne allergens in atopic genetically prone individuals. This response is mediated by the production of immunoglobulin E (IgE). IgE antibodies produced in response to the initial and subsequent exposure to allergens bind to the nasal mucosa.

With repeated exposure, immediate type 1 hypersensitivity reactions may occur (Simoens & Laekeman, 2009). Antigen-specific T cells are activated through the lymphatic system in response to the antigen. The activated antigen-specific T cells activate B cells, and IgE is created in lymphoid tissue and at local tissue sites (Adelman, Casale, & Corren, 2002; Novak, 2009). The newly created antigen-specific IgE is released by plasma cells and binds to high-affinity IgE receptors located on the basophils and mast cells.

This leads to the sensitization of the cells in the tissues of the nose, lung, or skin (Adelman et al., 2002; Cirillo, Pistorio, Tosca, & Ciprandi, 2009). IgE also binds with the antigen protein, beginning degranulation of the mast cells and basophils. These actions start the allergic cascade. Mediators are released as a result of the degranulation and include histamine, proteoglycans, enzymes, leukotrienes, cytokines, and many others. The chain in the release of mediators is responsible for the immediate and late phase responses of the cells. Histamine may be fully released within 30 minutes of degranulation, whereas cytokines may be released over many hours (Adelman et al., 2002; Derendorf & Meltzer, 2008).

(Kennedy-Malone 181-182)

Question 17 You have a patient complaining of vertigo and want to know what could be the cause. Knowing there are many causes for vertigo, you question the length of time the sensation lasts. She tells you several hours to days and is accompanied by tinnitus and hearing loss. You suspect which of the following conditions?

Student Answer: a) b) c) d)

Ménière’s disease Benign paroxysmal positional vertigo Transient ischemic attack (TIA) Migraine

Instructor Explanation: Ménière's disease commonly involves a triad of symptoms—severe vertigo, tinnitus, and hearing loss ( 140)

Advanced Practice Nursing 2e(Malone) Question 18 Question : In examining the mouth of an older adult with a history of smoking, the nurse practitioner finds a suspicious oral lesion. The patient has been referred for a biopsy to be sent for pathology. Which is the most common oral precancerous lesion?

Student Answer: a) b) c) d)

Fictional keratosis Keratoacanthoma Lichen planus Leukoplakia

Instructor Explanation: The cause of most episodes of leukoplakia is not determined. However, this condition, which results in the development of white patches on the oral mucosa, is associated with an increased risk of oral squamous cell cancer. Risk factors for the development of leukoplakia include chronic/recurrent trauma to the affected site and the use of smokeless and smoked tobacco and alcohol. ( 152)

Question 19 Question : Rheumatic heart disease is a complication that can arise from which type of infection?

Student Answer: Epstein-Barr virus Diphtheria Group A beta hemolytic streptococcus Streptococcus pneumoniae Instructor Explanation: Group A beta-hemolytic streptococcal (GABHS) pharyngitis is a bacterial infection of the pharynx, commonly called strep throat. Complications of GABHS pharyngitis, although rare, include rheumatic heart disease and glomerulonephritis, and the condition requires prompt diagnosis and definitive treatment. Most patients with GABHS pharyngitis are children and youths. Other bacterial causes of pharyngitis include mycoplasmal pneumonia, gonorrhea, and diphtheria. ( 156) -580490428 0

MultipleChoice 19

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Question 20

MultipleChoice

Advanced Practice Nursing 2e(Malone) .

Question : A patient complains of fever, fatigue, and pharyngitis. On physical examination there is pronounced cervical lymphadenopathy. Which of the following diagnostic tests should be considered?

Student Answer: Mono spot Strep test Throat culture All of the above Instructor Explanation: The physical examination for sore throat should include a comprehensive assessment of the upper and lower respiratory systems, including ears, nose, mouth, throat, and lungs. The neck assessment should include, at a minimum, assessment of the cervical lymph nodes. Strep screens, throat cultures, and mononucleosis screens are common diagnostic studies used to narrow the differential diagnosis of sore throat. A CBC with differential count is helpful in determining the cause of sore throat. ( 156) 1

Question :

Susan P., a 60-year-old woman with a 30 pack year history, presents to your primary care practice for evaluation of a persistent, daily cough with increased sputum production, worse in the morning, occurring over the past three months. She tells you, “I have the same thing, year after year.” Which of the following choices would you consider strongly in your critical thinking process?

Student Answer: Seasonal allergies Acute bronchitis Bronchial asthma Chronic bronchitis Instructor Explanation: The pulmonary component includes an abnormal inflammatory response to noxious stimuli, principally tobacco, but also occupational and environmental pollutants. The hallmark of chronic bronchitis is a daily chronic cough with increased sputum production lasting for at least 3 consecutive months in at least 2 consecutive years, usually worse on awakening; this may or may not be associated with COPD (GOLD, 2011). Emphysema is characterized by obstruction to airflow caused by abnormal airspace enlargement distal to terminal bronchioles.

Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 201401-14. VitalBook file. (page 206) & , Mary J., Laurie Grubbs. Advanced Assessment Interpreting Findings and Formulating Differential Diagnoses, 3rd Edition. F.A. Davis Company, 11/2014. VitalBook file. (page 213) -576289521 0

MultipleChoice 1

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Advanced Practice Nursing 2e(Malone) Question 2 .

Question : A patient presents complaining of a 5 day history of upper respiratory symptoms including nasal congestion and drainage. On the day the symptoms began he had a low-grade fever that has now resolved.

His nasal congestion persisted and he has had yellow nasal drainage for three days associated with mild headaches. On exam he is afebrile and in no distress.

Examination of his tympanic membranes and throat are normal. Examination of his nose is unremarkable although a slight yellowish-clear drainage is noted. There is tenderness when you lightly percuss his maxillary sinus. What would your treatment plan for this patient be?

Student Answer:

Observation and reassurance

Treatment with an antibiotic such as amoxicillin Instructor Explanation: Treatment with an antibiotic such as a fluoroquinoline or amoxicillin-clavulanate Combination of a low dose inhaled corticosteroid and a long acting beta2 agonist inhaler.

MedU Card #4. According to the American Academy of Ortolaryngology —Head and Neck Surgery Foundation guidelines (2007) on sinusitis, making the distinction between a lingering viral upper respiratory infection that affects the nose and sinuses (viral rhinosinusitis) or early acute bacterial sinusitis can be difficult. It is more likely to be a viral rhinosinusitis if the duration of symptoms is less than ten days and they are not worsening. In this case, you can continue to observe the patient and reassure him that antibiotics are not necessary at this time.

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MultipleChoice 2

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Question 3 .

Question : Emphysematous changes in the lungs produce the following characteristic in COPD patients?

Student Answer: Asymmetric chest expansion Increased lateral diameter Increased anterior-posterior diameter

Advanced Practice Nursing 2e(Malone) Pectus

excavatum

Instructor Explanation: In COPD, patients commonly develop a barrel-shaped chest due to emphysematous changes in the lungs.

A barrel shape is due to an increased anterior-posterior (AP) diameter. In emphysema, there is a 1:1 ratio of AP to lateral diameter; AP diameter equals the lateral diameter. Normally the AP diameter is twice the lateral diameter. , Mary J., Laurie Grubbs. Advanced Assessment Interpreting Findings and Formulating Differential Diagnoses, 3rd Edition. F.A. Davis Company, 11/2014. VitalBook file( page 213-214) & Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014- 01-14. VitalBook file. (page 206) -576289519 0

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Question 4 .

Question : When palpating the posterior chest, the clinician notes increased tactile fremitus over the left lower lobe.

This can be indicative of pneumonia. Areas of increased fremitus should raise the suspicion of conditions resulting in increased solidity or consolidation in the underlying lung tissue, such as in pneumonia, tumor, or pulmonary fibrosis. In the instance of an extensive bronchial obstruction: Student Answer: No palpable vibration is felt Decreased fremitus is felt Increased fremitus is felt Vibration is referred to the non-obstructed lobe Instructor Explanation: Areas of increased fremitus should raise the suspicion of conditions resulting in increased solidity or consolidation in the underlying lung tissue, such as in pneumonia, tumor, or pulmonary fibrosis.

Conversely, areas of decreased fremitus raise the suspicion of abnormal fluid- or air- filled spaces, such as occurs with pleural effusion, pneumothorax, or emphysema. In the instance of an extensive bronchial obstruction, no palpable vibration is felt in the related field. , Mary J., Laurie Grubbs. Advanced Assessment Interpreting Findings and Formulating Differential Diagnoses, 3rd Edition. F.A. Davis Company, 11/2014. VitalBook file. (page 209) & Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014- 01-14. VitalBook file. (page 193)

Question 5

Advanced Practice Nursing 2e(Malone) Question : Your patient presents with complaint of persistent cough. After you have finished obtaining the History of Present Illness, you realize that the patient may be having episodes of wheezing, in addition to his cough.

The most common cause of cough with wheezing is asthma. What of the following physical exam findings will support your tentative diagnosis of asthma?

Student Answer: a) b) c) d)

Clear, watery nasal drainage with nasal turbinate swelling Pharyngeal exudate and lymphadenopathy Clubbing, cyanosis and edema.

Diminished lung sounds with rales in both bases

Instructor Explanation: MedU Card #9

Question 6 Question : Which of the following imaging studies should be considered if a pulmonary malignancy is suspected?

Student Answer:

Computed tomography (CT) scan

Chest X-ray with PA, lateral, and lordotic views Ultrasound Positron emission tomography (PET) scan Instructor

For pulmonary malignancy, chest films are often nondiagnostic, although

Explanation: diagnostic.

they may reveal a nodule, mass, or other abnormality. A CT scan of the chest is typically

, Mary J., Laurie Grubbs. Advanced Assessment Interpreting Findings and Formulating Differential Diagnoses, 3rd Edition. F.A. Davis Company, 11/2014. VitalBook file. (page 217-218) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file. (page 251) -576289516 0

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Question 7 .

Question :

MultipleChoice

Advanced Practice Nursing 2e(Malone) A 26-year-old, non-smoker, male presented to your clinic with SOB with exertion. This could be due to: Student Answer: Exercise-induced cough Bronchiectasis Alpha-1 deficiency Pericarditis Instructor Explanation: When younger patients or nonsmokers develop findings consistent with COPD, alpha-1 antitrypsin deficiency should be suspected. Currently, the American Thoracic Society (2003) recommends that all individuals with COPD or asthma with chronic obstructive changes be tested for alpha-1 antitrypsin deficiency. If alpha-1 antitrypsin deficit is suspected, a qualitative serum should be performed as a screen, followed by quantitative study, as indicated. , Mary J., Laurie Grubbs. Advanced Assessment Interpreting Findings and Formulating Differential Diagnoses, 3rd Edition. F.A. Davis Company, 11/2014. VitalBook file. (page 213) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014- 01-14. VitalBook file. (page 206) -576289515 0

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Question 8 .

Question : Upon assessment of respiratory excursion, the clinician notes asymmetric expansion of the chest. One side expands greater than the other. This could be due to: Student Answer: Pneumothorax Pleural effusion Pneumonia Pulmonary embolism Instructor Explanation: The respiratory excursion, or expansion, is determined by placing hands around the patient’s posterior rib cage with the thumbs approximately at the level of the 10th rib between the thumbs, and then asking the patient to take a deep breath and observing the movement of the hands. The motion should be symmetrical. Less than anticipated movement occurs with advanced COPD and many restrictive processes, such as interstitial lung disease. Asymmetry of movement occurs with atelectasis, lobar collapse, pneumothorax, and several other conditions.

Advanced Practice Nursing 2e(Malone) , Mary J., Laurie Grubbs. Advanced Assessment Interpreting Findings and Formulating Differential Diagnoses, 3rd Edition. F.A. Davis Company, 11/2014. VitalBook file (page 208-209) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 201401-14. VitalBook file. (pages 193 & 227) -576289514 0

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Question 9 .

Question : A 72-year-old woman and her husband are on a cross-country driving vacation. After a long day of driving, they stop for dinner. Midway through the meal, the woman becomes very short of breath, with chest pain and a feeling of panic. Which of the following problems is most likely?

Student Answer: Pulmonary edema Heart failure Pulmonary embolism Pneumonia Instructor Explanation: The problem may occur when these symptoms are attributed to aging or existing comorbidities. Dyspnea (acute onset), anxiety or apprehension, pleuritic chest pain, cough, tachypnea, and accentuation of the pulmonic component of S2 are frequently present and may be accompanied by diaphoresis, syncope, tachycardia, S3 or S4 gallop, hypoxemia, or hemoptysis .

Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014- 01-14. VitalBook file. (page 246) , Mary J., Laurie Grubbs. Advanced Assessment Interpreting Findings and Formulating Differential Diagnoses, 3rd Edition. F.A. Davis Company, 11/2014. VitalBook file (page 202) -576289513 0

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Question 10 .

Question : A cough is described as chronic if it has been present for: Student Answer: 2 weeks or more 8 weeks or more 3 months or more 6 months or more Instructor Explanation:

Advanced Practice Nursing 2e(Malone) Cough is classified as acute (less than 3 weeks in duration), subacute (lasting 3 to 8 weeks), and chronic (8 or more weeks in duration), and these distinctions help to narrow the potential differential diagnoses. , Mary J., Laurie Grubbs. Advanced Assessment Interpreting Findings and Formulating Differential Diagnoses, 3rd Edition. F.A. Davis Company, 11/2014. VitalBook file. (page 211) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014- 01-14. VitalBook file. ((page 206) -576289512 0

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Question 11 .

Question : Testing is necessary for the diagnosis of asthma because history and physical are not reliable means of excluding other diagnoses or determining the extent of lung impairment. What is the study that is used to evaluate upper respiratory symptoms with new onset wheeze?

Student Answer:

Chest X-ray

Methacholine challenge test Spirometry, both with and without bronchodilation Ventilation/perfusion scan Instructor Explanation: MedU Card #10 -576289511 0

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Question 12 .

Question : In classifying the severity of your patient presenting with an acute exacerbation of asthma. You determine that they have moderate persistent symptoms based on the report of symptoms and spirometry readings of the last 3 weeks. The findings that support moderate persistent symptoms include: Student Answer:

Symptoms daily with nighttime awakening more than 1 time a

week. FEV1 >60%, but predicted <80%. FEV1/FVC reduced 5% Symptoms less than twice a week and less than twice a week nighttime awakening. FEV1 >80% predicted. FEV1/FVC normal Symptoms more than 2 days a week, but not daily. Nighttime

Advanced Practice Nursing 2e(Malone) awakenings 3-4 times a month. FEV1 >80% predicted. FEV1/FVC normal Symptoms throughout the day with nighttime awakenings every night. FEV1< 60% predicted. FEV1/FVC reduced >5% Instructor Explanation: MedU Card #15 -576289510 0

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Question 13 .

Question : The following criterion is considered a positive finding when determining whether a patient with asthma can be safely monitored and treated at home: Student Answer: Age over 40 Fever greater than 101 Tachypnea greater than 30 breaths/minute Productive cough Instructor Explanation: Decision Rule: CURB-65 provides framework for determining whether the patient diagnosed with community-acquired pneumonia can be safely monitored and treated at home. One point is awarded for each of the following factors present: •

Confusion of new onset

•

BUN greater than 20mg/dL

•

Respiratory rate of ≥ 30 breaths/minute

•

Blood pressure is less than 90 mmHg systolic or diastolic ≤ 60 mm Hg

•

Age 65 or older

Patients scoring 3 to 5 typically require hospitalization for observation and therapy. Scores of 0 to 1 indicate likelihood that outpatient management is appropriate. A score of 2 is inconclusive. , Mary J., Laurie Grubbs. Advanced Assessment Interpreting Findings and Formulating Differential Diagnoses, 3rd Edition. F.A. Davis Company, 11/2014. VitalBook file (page 214-216)

Advanced Practice Nursing 2e(Malone) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file.( page 241) -576289509 0

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Question 14 .

Question : Medications are chosen based on the severity of asthma. Considering the patient that is diagnosed with moderate persistent asthma, the preferred option for maintenance medication is: Student Answer:

High-dose inhaled corticosteroid and leukotriene receptor

antagonist Oral corticosteroid—high and low dose as appropriate Short acting beta2 agonist inhaler and theophylline Instructor Explanation: Low dose inhaled corticosteroid and long acting beta2 agonist inhaler MedU Card #16 -576289508 0

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Question 15 .

Question : A 75-year-old patient with community-acquired pneumonia presents with chills, productive cough, temperature of 102.1, pulse 100, respiration 18, BP 90/52, WBC 12,000, and blood urea nitrogen (BUN) 22 mg/dl. He has a history of mild dementia and his mental status is unchanged from his last visit. These findings indicate that the patient: Student Answer: Can be treated as an outpatient Requires hospitalization for treatment Requires a high dose of parenteral antibiotic Can be treated with oral antibiotics Instructor Explanation:

Advanced Practice Nursing 2e(Malone) Decision Rule: CURB-65 provides framework for determining whether the patient diagnosed with community-acquired pneumonia can be safely monitored and treated at home. One point is awarded for each of the following factors present: •

Confusion of new onset

•

BUN is greater than 20mg/dl

•

Respiratory rate of ≥ 30 breaths/minute

•

Blood pressure is less than 90 mmHg systolic or diastolic ≤ 60 mm Hg

•

Age 65 or older

Patients scoring 3 to 5 typically require hospitalization for observation and therapy. Scores of 0 to 1 indicate likelihood that outpatient management is appropriate. A score of 2 is inconclusive. , Mary J., Laurie Grubbs. Advanced Assessment Interpreting Findings and Formulating Differential Diagnoses, 3rd Edition. F.A. Davis Company, 11/2014. VitalBook file (page 214-216) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file. (page 241) -576289507 0

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Question 16 .

Question : Which of the following is considered a “red flag” when diagnosing a patient with pneumonia?

Student Answer: Fever of 102 Infiltrates on chest X-ray Pleural effusion on chest X-ray Elevated white blood cell count Instructor Explanation: With pneumonia, the chest film typically reveals an area of infiltrate. It is a red flag if a pleural effusion is also visualized, in which case adequate follow-up to exclude development of an empyema is mandatory.

This often involves prompt referral to a pulmonologist for possible thoracentesis.

Cultures and Gram stains of sputum are usually not ordered for outpatients. The white blood cell count is often elevated. , Mary J., Laurie Grubbs. Advanced Assessment Interpreting Findings and Formulating Differential Diagnoses, 3rd Edition. F.A. Davis Company, 11/2014. VitalBook file. (page 214) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014- 01-14. VitalBook file. (page 240) -576289506

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Question 17 .

Question : A 23-year-old patient who has had bronchiectasis since childhood is likely to have which of the following: Student Answer: Barrel-shaped chest Clubbing Pectus excavatum Prolonged capillary refill Instructor Explanation: In bronchiectasis, there is usually a history of chronic, productive cough. Sputum is typically mucopurulent and produced in increased amounts. Other common findings include shortness of breath, wheezing, fatigue, and possibly hemoptysis. Physical examination reveals rhonchi and/or wheezing. In advanced disease, clubbing and cyanosis may be present. , Mary J., Laurie Grubbs. Advanced Assessment Interpreting Findings and Formulating Differential Diagnoses, 3rd Edition. F.A. Davis Company, 11/2014. VitalBook file (page 216) -576289505 0

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Question 18 .

Question : Your patient has just returned from a 6-month missionary trip to Southeast Asia. He reports unremitting cough, hemoptysis, and an unintentional weight loss of 10 pounds over the last month. These symptoms should prompt the clinician to suspect: Student Answer: Legionnaires' disease Malaria Tuberculosis Pneumonia Instructor Explanation: Many times, patients with active tuberculosis are essentially symptom free. Some complain of malaise and/or fevers but have no significantly disruptive

Advanced Practice Nursing 2e(Malone) complaints. When respiratory symptoms occur with tuberculosis, cough is common; the cough is nonproductive at first and is later associated with sputum production. Additionally, patients with tuberculosis may experience progressive dyspnea, night sweats, weight loss, and hemoptysis. It is important to suspect tuberculosis when the patient has travelled to a country where TB is endemic, such as Asia. , Mary J., Laurie Grubbs. Advanced Assessment Interpreting Findings and Formulating Differential Diagnoses, 3rd Edition. F.A. Davis Company, 11/2014. VitalBook file. (page 217) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014- 01-14. VitalBook file. (page 249) -576289504 0

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Question 19 .

Question : A 76-year-old patient with a 200-pack year smoking history presents with complaints of chronic cough, dyspnea, fatigue, hemoptysis, and weight loss over the past 2 months. The physical exam reveals decreased breath sounds and dullness to percussion over the left lower lung field. The chest X-ray demonstrates shift of the mediastinum and trachea to the left. These are classic signs of: Student Answer: Lung cancer Tuberculosis Pneumonia COPD Instructor Explanation: Dyspnea is the most common symptom associated with pleural effusion, but effusion may be accompanied by cough, pain, and systemic symptoms, such as malaise and fever. Abnormal physical findings become evident as the effusion increases in volume. These include decreased lung sounds, dullness over the effusion, decreased fremitus, egophony, and whispered pectoriloquy. With extremely large effusions, the mediastinum and trachea may shift to the opposite side. The exception involves effusion related to malignancy, in which case the mediastinum and trachea may be pulled toward the malignancy. , Mary J., Laurie Grubbs. Advanced Assessment Interpreting Findings and Formulating Differential Diagnoses, 3rd Edition. F.A. Davis Company, 11/2014. VitalBook file (page 217-218) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-0114. VitalBook file.(page 232) -576289503 0

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Advanced Practice Nursing 2e(Malone) Question 20 .

Question : A 24-year-old patient presents to the emergency department after sustaining multiple traumatic injuries after a motorcycle accident. Upon examination, you note tachypnea, use of intercostal muscles to breathe, asymmetric chest expansion, and no breath sounds over the left lower lobe. It is most important to suspect: Student Answer: Pulmonary embolism Pleural effusion Pneumothorax Fracture of ribs Instructor Explanation: Pneumothorax involves air in the pleural cavity. A pneumothorax can occur spontaneously in otherwise healthy individuals or be secondary to trauma or intrinsic lung disease. There is history of sudden onset of shortness of breath associated with chest pain. The patient usually presents in great distress, with tachycardia and tachypnea, and is often splinting the chest. There is decreased fremitus and increased hyperresonance on the affected side. Lung sounds are diminished or absent. The trachea may shift away from the affected side if a large pneumothorax is present. , Mary J., Laurie Grubbs. Advanced Assessment Interpreting Findings and Formulating Differential Diagnoses, 3rd Edition. F.A. Davis Company, 11/2014. VitalBook file (page 221) 1

Question :

Which of the following is the most important question to ask during cardiovascular health history?

Student Answer: Number of offspring Last physical exam Sudden death of a family member Use of caffeine Instructor Explanation: The sudden death of a family member is an important question to ask in the health history because it reveals the cardiovascular disease risk of the patient. Sudden death is usually due to an acute cardiovascular event, such as myocardial infarction, cardiac dysrhythmia, or stroke.

Family history is particularly important for cardiac assessment because CVD, HTN, hyperlipidemia, and other vascular diseases often have a familial association that is not easily ameliorated by lifestyle changes.

If there are deaths in the family related to CVD, determine the age and exact cause of death, because CVD at a young age in the immediate family carries an increased risk compared with CVD in an elderly family member. Ask about sudden death, which might indicate a congenital disease such as Marfan's syndrome. This is especially important to ask during pre-sports physicals because sudden death in athletes

Advanced Practice Nursing 2e(Malone) is often related to congenital or familial heart disease. Familial hyperlipidemia is autosomal dominant and often leads to CAD and MI at a young age. Family history of obesity and type 2 diabetes are also secondary risk factors for heart disease because the familial tendency for these is strong. Ask about smoking in the house, as secondhand smoke is a risk factor for respiratory and cardiac disease. ( 167-168) , Mary J., Laurie Grubbs. Advanced Assessment Interpreting Findings and Formulating Differential Diagnoses, 3rd Edition. F.A. Davis Company, 11/2014. VitalBook file.

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Question 2 .

Question : A key symptom of ischemic heart disease is chest pain. However, angina equivalents may include exertional dyspnea. Angina equivalents are important because: Student Answer:

Women with ischemic heart disease many times do not present

with chest pain Some patients may have no symptoms or atypical symptoms; diagnosis may only be made at the time of an actual myocardial infarction Elderly patients have the most severe symptoms A & B only Instructor Explanation: The key symptom of IHD is chest pain, but other common symptoms include arm pain, lower jaw pain, shortness of breath, and diaphoresis. These symptoms are referred to as angina equivalents and can also include fatigue or breathlessness. Some patients may have no symptoms or atypical ones so that CAD may not be diagnosed until they experience a myocardial infarction. (Kennedy-Malone 227) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file.

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Question 3 .

Question : A 55-year-old post-menopausal woman with a history of hypertension complains of jaw pain on heavy exertion. There were no complaints of chest pain. Her ECG indicates normal sinus rhythm without ST segment abnormalities. Your plan may include:

Advanced Practice Nursing 2e(Malone) Student Answer: Echocardiogram Exercise stress test Cardiac catheterization Myocardial perfusion imaging Instructor Explanation: Once all the results of the initial laboratory and ECG testing are reviewed, a pretest probability of disease can be generated and additional tests can be ordered.2 The probability of CAD can be calculated by considering the chosen noninvasive test's sensitivity and specificity.2 Selection of the proper cardiac test (see Table 115-1) for an individual depends on the person's risk stratification, age, and tolerable level of activity. The most common and least invasive test for diagnosis of CAD is the stress test, also called the exercise tolerance test (ETT) or treadmill exercise. (Buttaro 488) Buttaro, Terry, JoAnn Trybulski, Patricia Bailey, Joanne Sandberg-Cook.

Primary Care, 4th Edition. Mosby, 2013. VitalBook file.

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Question 4 .

Question : Jenny is a 24 year old graduate student that presents to the clinic today with complaints of fever, midsternal chest pain and generalized fatigue for the past two days. She denies any cough or sputum production. She states that when she takes Ibuprofen and rest that the chest pain does seem to ease off.

Upon examination the patient presents looking very ill. She is leaning forward and states that this is the most comfortable position for her. Temp is 102. BP= 100/70. Heart rate is 120/min and regular. Upon auscultation a friction rub is audible. Her lung sounds are clear. With these presenting symptoms your initial diagnosis would be: Student Answer: Mitral Valve Prolapse Referred Pain from Cholecystitis Pericarditis Pulmonary Embolus Instructor Explanation: Pericarditis Pericarditis, inflammation of the pericardium, is usually not a solo disease process but is seen in conjunction with other diseases or conditions.

Pericarditis may occur as a complication of MI (Dressler's syndrome) or coronary artery bypass surgery.

It is also more commonly seen in patients with connective tissue disorders such as rheumatoid arthritis,

Advanced Practice Nursing 2e(Malone) systemic lupus erythematosus (SLE), scleroderma, and sarcoidosis. Bacterial, viral, or fungal infections, including HIV, are risk factors for pericarditis. Pericarditis can occur with kidney failure or metastatic neoplasias or as a reaction to medication, particularly phenytoin, hydralazine, and procainamide. Rarely, it is idiopathic and the cause unknown, although a common viral infection is suspected. Cardiac tamponade can occur as a serious complication, and it is an emergency requiring immediate pericardiocentesis. Constrictive pericarditis can occur over time due to scarring of the pericardial sac.

Signs and Symptoms Unlike the symptoms associated with ACS, the pain accompanying pericarditis is sharp and stabbing; it may worsen with inspiration or when lying flat or leaning forward. Associated symptoms may include shortness of breath, fever, chills, and malaise. ( 179) , Mary J., Laurie Grubbs. Advanced Assessment Interpreting Findings and Formulating Differential Diagnoses, 3rd Edition. F.A. Davis Company, 11/2014. VitalBook file.

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Question 5 .

Question : Which symptom is more characteristic of Non-Cardiac chest pain?

Student Answer:

Pain often radiates to the neck, jaw, epigastrium, shoulder, or

arm Pain tends to occur with movement, stretching or palpation Pain usually lasts less than 10 minutes and is relieved by nitroglycerine Pain is aggravated by exertion or stress Instructor Explanation: Palpate chest wall for tenderness and swelling. Chest pain present in only one body position is usually not cardiac in origin.

(MSN 194) MSN, Jill C. C., FNP-BC. Family Practice Guidelines: Third Edition, 3rd Edition. Springer Publishing Company, 2014-02-01. VitalBook file.

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Question 6 .

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Advanced Practice Nursing 2e(Malone) Question : What is the most common valvular heart disease in the older adult?

Student Answer: Aortic regurgitation Aortic stenosis Mitral regurgitation Mitral stenosis Instructor Explanation: Age: Present in 2% to 9% of persons over age 65, aortic stenosis is the most clinically significant cardiac valve lesion (Faggiano, 2006). Isolated aortic regurgitation is rarely seen and is usually accompanied by some degree of mitral valve involvement. Mitral regurgitation is more common than mitral stenosis in elderly individuals. Mitral valve disease, commonly caused by rheumatic heart disease, is usually acquired by younger patients; however, the effects may not be seen until they are in their forties or fifties.

Mitral valve stenosis has a progressively slow course with latent symptoms over 20 to 40 years followed by rapid acceleration in later life. (Kennedy-Malone 259) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014- 01-14. VitalBook file.

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Question 7 .

Question : Jeff, 48 years old, presents to the clinic complaining of fleeting chest pain, fatigue, palpitations, lightheadedness, and shortness of breath. The pain comes and goes and is not associated with activity or exertion. Food does not exacerbate or relieve the pain. The pain is usually located under the left nipple.

Jeff is concerned because his father has cardiac disease and underwent a CABG at age 65. The ANP examines Jeff and hears a mid-systolic click at the 4th ICS mid-clavicular area. The ANP knows that this is a hallmark sign of: Student Answer: Angina Pericarditis Mitral valve prolapse Congestive heart failure Instructor Explanation: Mitral valve prolapse Sharp left anterior chest pain, generally occurring in response to stress or emotional events Chest discomfort lasting seconds to days Palpitations and dyspnea Mitral valve click may be noted in systole at left lower sternal border (Buttaro 529)

Advanced Practice Nursing 2e(Malone) Buttaro, Terry, JoAnn Trybulski, Patricia Bailey, Joanne Sandberg-Cook.

Primary Care, 4th Edition. Mosby, 2013. VitalBook file.

MVP, also termed click-murmur syndrome, is a variant of mitral regurgitation and occurs in approximately 10% of young women. MVP generally is hemodynamically insignificant and characterized by normal heart size and dynamics, although the process can progress to hemodynamically significant mitral regurgitation. Characteristically, a portion of the mitral valve balloons into the left atrium, giving rise to a midsystolic click followed by a soft grade I murmur that crescendos up to S2. It is high-pitched and is heard best at the apex or left sternal border.

Some patients with MVP have only a murmur and no click, and others have only a click and no murmur. ( 185) , Mary J., Laurie Grubbs. Advanced Assessment Interpreting Findings and Formulating Differential Diagnoses, 3rd Edition. F.A. Davis Company, 11/2014. VitalBook file.

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Question 8 .

Question : The aging process causes what normal physiological changes in the heart?

Student Answer:

The heart valve thickens and becomes rigid, secondary to

fibrosis and sclerosis Cardiology occurs along with prolapse of the mitral valve and regurgitation Dilation of the right ventricle occurs with sclerosis of pulmonic and tricuspid valves Hypertrophy of the right ventricle Instructor Explanation: The aging process can also have an adverse effect on the cardiac valves. The valves tend to become thick and stiff secondary to arteriosclerosis and atherosclerotic plaques. (Kennedy-Malone 201) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file.

During the past three decades, with the successful treatment of streptococcal pharyngitis, the etiology has shifted away from rheumatic to calcific. All such cases share a history of 20 to 30years of repetitive mechanical trauma of the blood against the valve, resulting in fibrosis, calcification, and eventually stenosis. This progress of calcification within the valve cusps is usually seen during the latter decades of life. An inflammatory process similar to that affecting the development of atherosclerotic plaques in

Advanced Practice Nursing 2e(Malone) coronaries may be a possible cause of the progression of AS. It has been noted that early lesions and calcification in AS are comparable to those found in coronary plaques.4 (Buttaro 602) Buttaro, Terry, JoAnn Trybulski, Patricia Bailey, Joanne Sandberg-Cook.

Primary Care, 4th Edition. Mosby, 2013. VitalBook file.

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Question 9 .

Question : Dan G., a 65-year-old man, presents to your primary care office for the evaluation of chest pain and leftsided shoulder pain. Pain begins after strenuous activity, including walking. Pain is characterized as dull, aching; 8/10 during activity, otherwise 0/10. Began a few months ago, intermittent, aggravated by exercise, and relieved by rest. Has occasional nausea. Pain is retrosternal, radiating to left shoulder, definitely affects quality of life by limiting activity. Pain is worse today; did not go away after he stopped walking. BP 120/80. Pulse 72 and regular. Normal heart sounds, S1 and S2, no murmurs. Which of the following differential diagnoses would be most likely?

Student Answer: Musculoskeletal chest wall syndrome with radiation Esophageal motor disorder with radiation Acute cholecystitis with cholelithiasis Coronary artery disease with angina pectoris Instructor Explanation: With a complaint of chest pain, the most life-threatening diagnosis should be ruled out first. A thorough history identifying the quality and quantity of the pain, alleviating and aggravating factors, and associated symptoms assists in raising or lowering your index of suspicion for a myocardial origin of the pain. Age, gender, weight, vital signs, family history, and medical history also assist in diagnosis.

Signs and symptoms that are suspicious for myocardial ischemia include substernal chest pain or discomfort that may radiate into the neck or left arm, diaphoresis, nausea, shortness of breath, and perhaps weakness. Chest discomfort that increases with exertion and resolves with rest or nitroglycerin can indicate myocardial ischemia. Chest discomfort that occurs in the early morning or wakes a patient at night can also be cardiac in origin. Chest discomfort or pain at rest is worrisome because it may signify ACS (unstable angina or an acute MI). Atypical symptoms such as jaw pain, fatigue, indigestion, and upper back pain are more common in women, the elderly, and patients with diabetes. ( 178-179) , Mary J., Laurie Grubbs. Advanced Assessment Interpreting Findings and Formulating Differential Diagnoses, 3rd Edition. F.A. Davis Company, 11/2014. VitalBook file

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MultipleChoice

Question 10 .

Question : A common auscultatory finding in advanced CHF is: Student Answer: Systolic ejection murmur S3 gallop rhythm Friction rub Bradycardia Instructor Explanation: Pathological S3, also called a ventricular gallop, is heard in adults and is associated with decreased myocardial contractility, HF, and volume overload conditions, as can occur with mitral or tricuspid regurgitation. The sound is the same as a physiological S3 and is heard just after S2 with the patient supine or in the left lateral recumbent position. The sound is very soft and can be difficult to hear. ( 165) , Mary J., Laurie Grubbs. Advanced Assessment Interpreting Findings and Formulating Differential Diagnoses, 3rd Edition. F.A. Davis Company, 11/2014. VitalBook file.

-572739300 0

MultipleChoice 10

-572739300

MultipleChoice

Question 11 .

Question : Your 35-year-old female patient complains of feeling palpitations on occasion. The clinician should recognize that palpitations are often a sign of: Student Answer: Anemia Anxiety Hyperthyroidism All of the above Instructor Explanation: Occasional palpitations occur physiologically in the majority of the population or as a result of other noncardiac conditions, such as anxiety, exercise, hyperthyroidism, and anemia. They can also occur with VHD, increased or decreased stroke volume, and arrhythmias. The patient may complain of palpitations or skipped beats, or an arrhythmia may be seen on EKG. Patients are often aware if their heart rate is slower or faster than normal or if it is irregular. With some arrhythmias, patients may complain only of fatigue, shortness of breath, weakness, or syncopal episodes. These are common symptoms in patients

Advanced Practice Nursing 2e(Malone) who have atrial fibrillation, and, if the ventricular response is slow, the patient may be unaware of the arrhythmia. Ask the patient about the frequency and duration of the palpitations and the presence of associated symptoms, such as loss of consciousness, lightheadedness, chest pain, shortness of breath, nausea, or vomiting. ( 173) , Mary J., Laurie Grubbs. Advanced Assessment Interpreting Findings and Formulating Differential Diagnoses, 3rd Edition. F.A. Davis Company, 11/2014. VitalBook file.

-572739299 0

MultipleChoice 11

-572739299

MultipleChoice

Question 12 .

Question : The best way to diagnose structural heart disease/dysfunction non-invasively is: Student Answer: Chest X-ray EKG Echocardiogram Heart catheterization Instructor Explanation: Echocardiography is recommended in patients with ventricular arrhythmias who are suspected of having structural heart disease (Zipes et al., 2006). An echocardiogram is used more commonly than magnetic resonance imaging (MRI) or cardiac computed tomography (CT) because it is inexpensive in comparison.

The echocardiogram is a useful tool in assessing for valvular disorders, left ventricular function and wall motion, and the ejection fraction. (Kennedy-Malone 203) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014- 01-14. VitalBook file.

-572739298 0

MultipleChoice 12

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MultipleChoice

Question 13 .

Question : During auscultation of the chest, your exam reveals a loud grating sound at the lower anterolateral lung fields, at full inspiration and early expiration. This finding is consistent with: Student Answer: Pneumonia Pleuritis Pneumothorax A and B Instructor Explanation:

Advanced Practice Nursing 2e(Malone) Adventitious Sounds Description Significance Crackles Coarse, medium, or fine; early, mid-, or late inspiratory Atelectasis, bronchiectasis, congestive heart failure, pulmonary fibrosis Rhonchi, Wheezes Low- or high-pitched; inspiratory or expiratory COPD, acute and chronic bronchitis, asthma, bronchiectasis, pneumonia Friction Rub Loud, grating; late inspiratory–early expiratory Inflamed pleura; pneumonia, pleuritis, malignancy ( 211) , Mary J., Laurie Grubbs. Advanced Assessment Interpreting Findings and Formulating Differential Diagnoses, 3rd Edition. F.A. Davis Company, 11/2014. VitalBook file.

-572739297 0

MultipleChoice 13

-572739297

MultipleChoice

Question 14 .

Question : A 75-year-old patient complains of pain and paresthesias in the right foot that worsens with exercise and is relieved by rest. On physical examination you note pallor of the right foot, capillary refill of 4 seconds in the right foot, +1 dorsalis pedis pulse in the right foot, and +2 pulse in left foot. Which of the following is a likely cause of the signs and symptoms?

Student Answer: Arterial insufficiency Femoral vein thrombus Venous insufficiency Peripheral neuropathy Instructor Explanation: Intermittent claudication is pain in the leg or foot that becomes worse with exercise and is relieved by rest. The classic signs of peripheral arterial disease include pain, pallor, weak pulse, paresthesias, and palpable coolness. The signs of venous thrombosis are erythema, ropiness, as well as warmth and tenderness along the course of the vein. Edema of the leg and Homan’s sign of the foot are also common.

Note any symptoms of intermittent claudication, such as complaints of cramping, aching, or pain in the ankle, calf, or thigh that occur with exercise and are promptly relieved with rest. ( 200) , Mary J., Laurie Grubbs. Advanced Assessment Interpreting Findings and Formulating Differential Diagnoses, 3rd Edition. F.A. Davis Company, 11/2014. VitalBook file.

-572739296

MultipleChoice 14

Advanced Practice Nursing 2e(Malone) 0

-572739296

MultipleChoice

Question 15 .

Question : Your patient complains of a feeling of heaviness in the lower legs daily. You note varicosities, edema, and dusky color of both ankles and feet. Which of the following is the most likely cause for these symptoms?

Student Answer: Femoral vein thrombosis Femoral artery thrombus Venous insufficiency Musculoskeletal injury Instructor Explanation: Chronic venous insufficiency can be a long-term complication of venous thrombosis owing to the destruction of valves in the deep veins. The calf muscle pump that returns blood from the lower legs is damaged, increasing ambulatory pressure in the calf veins. A constellation of symptoms is set up: aching or pain in the lower legs, edema, thinning and hyperpigmentation of the skin, superficial varicosities, venous stasis, and ulceration. Ankle edema is often the earliest sign.

Other causes of chronic venous insufficiency include trauma, pelvic neoplasm, and occasionally secondary to superficial venous disease. Prompt treatment of DVT with anticoagulants decreases the risk for chronic venous insufficiency. General measures for symptom management include the following: elevation of the legs intermittently during the day and at night, avoidance of prolonged sitting or standing, and support or compression stockings. Wearing an Unna boot is valuable and successful in the treatment of stasis ulcers. ( 203-204) , Mary J., Laurie Grubbs. Advanced Assessment Interpreting Findings and Formulating Differential Diagnoses, 3rd Edition. F.A. Davis Company, 11/2014. VitalBook file.

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MultipleChoice 15

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MultipleChoice

Question 16 .

Question : Your 54 year old patient, Mr. A, presents to your clinic with a 2 day history of severe shoulder pain. On initial assessment you note that in addition to shoulder findings his blood pressure on the ‘good’ arm is 162/100. You review his history and on his last visit his blood pressure was 120/70. He has a medical history of sleep apnea and has used anabolic steroids when body building as a younger adult. In addition to caring for Mr. A’s chief complaint of shoulder pain, you also: Student Answer:

Start a thiazide diuretic, discussing the importance of

adherence Discuss with him his new diagnosis of hypertension and the

Advanced Practice Nursing 2e(Malone) importance of taking medication.

Schedule a follow up appointment after pain has subsided to take additional blood pressure readings Start an ACE inhibitor because with his history he may also be diabetic.

Instructor Explanation: MedU Card #3 -572739294 0

MultipleChoice 16

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MultipleChoice

Question 17 .

Question : You decide to order labs today to help with the diagnosis and management of hypertension in Mr. A. Which of the following labs are indicated to assist in the medical management of Mr. A if he meets the diagnostic criteria for hypertension?

Student Answer:

Serum Sodium Thyroid function tests

Fasting serum cholesterol panel Complete liver function enzyme panel Instructor Explanation: MedU Card #14 -572739293 0

MultipleChoice 17

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MultipleChoice

Question 18 .

Question : Lifestyle modifications reduce blood pressure, enhance antihypertensive medication efficacy, and decrease cardiovascular risks. Which lifestyle change will decrease blood pressure the most?

Student Answer:

Physical activity

Dietary sodium reduction DASH diet Weight reduction Instructor Explanation: MedU Card # 15 -572739292

MultipleChoice 18

Advanced Practice Nursing 2e(Malone) 0

-572739292

MultipleChoice

Question 19 .

Question : Mr. A returns to your clinic and a diagnosis of hypertension is made. He is started on a diuretic and counseled on lifestyle modifications including increasing activity and smoking cessation. On his next visit you note that his blood pressure remains elevated. Before referring to a specialist you should do all of the following except: Student Answer:

Assure medications are at appropriate dose

Instructor Explanation: Identify any underlying medical condition that requires treatment Review diet with Mr. A and refer to dietician if it is diet problematic Determine he has ‘white coat’ hypertension because his home readings are also elevated MedU Card #22 -572739291 0

MultipleChoice 19

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MultipleChoice

Question 20 .

Question : Mr. A has many issues that seem to be interfering with his health outcomes. In order to negotiate and formulate a patient-centered management plan you take the time to gather more information. This can be started by asking the following question: Student Answer:

What do you think caused your hypertension and how has it

affected your life?

I see that you are 20 pounds overweight -- do you exercise? Does you wife help you to manage your diet and medication?

Instructor Explanation: Taking your blood pressure everyday is important so that I can see what happens each day. Do you do this?

MedU Card #23

Advanced Practice Nursing 2e(Malone) MIDTERM 1

Question :

Your 2-year-old patient shows facial features, such as epicanthal folds, up-slanted palpebral fissures, single transverse palmar crease, and a low nasal bridge. These are referred to as: Student Answer:

Variable expressivity related to inherited disease

Dysmorphic features related to genetic disease De novo mutations of genetic disease Different penetrant signs of genetic disease -570006493 0

MultipleChoice 39

-570006493

MultipleChoice

Question 2 .

Question : Presbycusis is the hearing impairment that is associated with: Student Answer: -570006492 0

Physiologic aging Ménière’s disease Cerumen impaction Herpes zoster

MultipleChoice 44

-570006492

MultipleChoice

Question 3 .

Question : The most common etiologic organism for community-acquired pneumonia is: Student Answer:

Streptococcus pneumoniae Beta hemolytic streptococcus Mycoplasma

Methicillin resistant staphylococcus -570006490 0

MultipleChoice 74

-570006490

MultipleChoice

Question 4 .

Question : The first step in the genomic assessment of a patient is obtaining information regarding: Student Answer: medications -570006488

Family history Environmental exposures Lifestyle and behaviors Current

MultipleChoice 33

Advanced Practice Nursing 2e(Malone) 0

-570006488

MultipleChoice

Question 5 .

Question : In examination of the nose, the clinician observes gray, pale mucous membranes with clear, serous discharge. This is most likely indicative of: Student Answer:

Bacterial sinusitis Allergic rhinitis Drug abuse

Skull fracture -570006486 0

MultipleChoice 42

-570006486

MultipleChoice

Question 6 .

Question : A cough is described as chronic if it has been present for: Student Answer: -570006484 0

2 weeks or more 8 weeks or more 3 months or more 6 months or more

MultipleChoice 70

-570006484

MultipleChoice

Question 7 .

Question : If it has been determined a patient has esophageal reflux, you should tell them: Student Answer:

They probably have a hiatal hernia causing reflux

They probably need surgery They should avoid all fruit juices Smoking, alcohol, and caffeine can aggravate their problem -570006482 0

MultipleChoice 18

-570006482

MultipleChoice

Question 8 .

Question : Which of the following findings should trigger an urgent referral to a cardiologist or neurologist?

Advanced Practice Nursing 2e(Malone) Student Answer:

History of bright flash of light followed by significantly

blurred vision History of transient and painless monocular loss of vision History of monocular severe eye pain, blurred vision, and ciliary flush All of the above -570006480 0

MultipleChoice 48

-570006480

MultipleChoice

Question 9 .

Question : A 72-year-old woman and her husband are on a cross-country driving vacation. After a long day of driving, they stop for dinner. Midway through the meal, the woman becomes very short of breath, with chest pain and a feeling of panic. Which of the following problems is most likely?

Student Answer: -570006478 0

Pulmonary edema Heart failure Pulmonary embolism Pneumonia

MultipleChoice 68

-570006478

MultipleChoice

Question 10 .

Question : Which of the following is not a contributing factor to the development of esophagitis in older adults?

Student Answer:

Increased gastric emptying time

Regular ingestion of NSAIDs Decreased salivation Fungal infections such as Candida -570006476 0

MultipleChoice 20

-570006476

Question 11 .

Question :

MultipleChoice

Advanced Practice Nursing 2e(Malone) An older patient reports burning pain after ingestion of many foods and large meals. What assessment would assist the nurse practitioner in making a diagnosis of GERD? Student Answer:

Identification of a fluid wave Positive Murphy’s sign Palpable spleen

Midepigastric pain that is not reproducible with palpation -570006474 0

MultipleChoice 2

-570006474

MultipleChoice

Question 12 .

Question : A 26-year-old, non-smoker, male presented to your clinic with SOB with exertion. This could be due to: Student Answer:

Exercise-induced cough Bronchiectasis

Alpha-1 deficiency Pericarditis -570006472 0

MultipleChoice 69

-570006472

MultipleChoice

Question 13 .

Question : Which of the following findings would indicate a need for another endoscopy in clients with peptic ulcer disease?

Student Answer:

Cases of dyspepsia with constipation

Symptoms persisting after six to eight weeks of therapy All clients with dyspepsia who smoke and drink alcohol When a therapeutic response to empiric treatment is obtained -570006471 0

MultipleChoice 15

-570006471

MultipleChoice

Question 14 .

Question : Iron Deficiency Anemia (IDA) is classified as a microcytic, hypochromic anemia. This classification refers to which of the following laboratory data?

Advanced Practice Nursing 2e(Malone) Student Answer:

Hemoglobin and Hematocrit

Mean Corpuscular Volume (MCV) and Mean Corpuscular Hemoglobin (MCH) Serum ferritin and Serum iron Total iron binding capacity and transferrin saturation -570006470 0

MultipleChoice 26

-570006470

MultipleChoice

Question 15 .

Question : A 20-year-old engineering student complains of episodes of abdominal discomfort, bloating, and episodes of diarrhea. The symptoms usually occur after eating, and pain is frequently relieved with bowel movement. She is on a “celiac diet” and the episodic symptoms persist. Physical examination and diagnostic tests are negative. Colonoscopy is negative for any abnormalities. This is a history and physical consistent with: Student Answer:

Inflammatory bowel disease Irritable bowel syndrome Giardiasis

Norovirus gastroenteritis -570006469 0

MultipleChoice 16

-570006469

MultipleChoice

Question 16 .

Question : An obese middle-aged client presents with a month of nonproductive irritating cough without fever. He also reports occasional morning hoarseness. What should the differential include?

Student Answer:

Atypical pneumonia Peptic ulcer disease Gastroesophageal reflux

Mononucleosis (Epstein-Barr) -570006468 0

MultipleChoice 14

-570006468

Question 17 .

Question :

MultipleChoice

Advanced Practice Nursing 2e(Malone) A 55-year-old post-menopausal woman with a history of hypertension complains of jaw pain on heavy exertion. There were no complaints of chest pain. Her ECG indicates normal sinus rhythm without ST segment abnormalities. Your plan may include: Student Answer:

Echocardiogram Exercise stress test Cardiac catheterization

Myocardial perfusion imaging -570006467 0

MultipleChoice 85

-570006467

MultipleChoice

Question 18 .

Question : Your 35-year-old female patient complains of feeling palpitations on occasion. The clinician should recognize that palpitations are often a sign of: Student Answer:

Anemia Anxiety

Hyperthyroidism All of the above -570006466 0

MultipleChoice 96

-570006466

MultipleChoice

Question 19 .

Question : A 75-year-old patient with community-acquired pneumonia presents with chills, productive cough, temperature of 102.1, pulse 100, respiration 18, BP 90/52, WBC 12,000, and blood urea nitrogen (BUN) 22 mg/dl. He has a history of mild dementia and his mental status is unchanged from his last visit. These findings indicate that the patient: Student Answer: Can be treated as an outpatient Requires hospitalization for treatment Requires a high dose of parenteral antibiotic Can be treated with oral antibiotics Instructor Explanation: Decision Rule: CURB-65 provides framework for determining whether the patient diagnosed with community-acquired pneumonia can be safely monitored and treated at home. One point is awarded for each of the following factors present: Confusion of new onset BUN is greater than 20mg/dl Respiratory rate of ≥ 30 breaths/minute

Advanced Practice Nursing 2e(Malone) Blood pressure is less than 90 mmHg systolic or diastolic ≤ 60 mm Hg Age 65 or older Patients scoring 3 to 5 typically require hospitalization for observation and therapy. Scores of 0 to 1 indicate likelihood that outpatient management is appropriate. A score of 2 is inconclusive. , Mary J., Laurie Grubbs. Advanced Assessment Interpreting Findings and Formulating Differential Diagnoses, 3rd Edition. F.A. Davis Company, 11/2014. VitalBook file (page 214-216) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file. (page 241) -570006465 0

MultipleChoice 75

-570006465

MultipleChoice

Question 20 .

Question : The major impact of the physiological changes that occur with aging is: Student Answer: Reduced physiological reserve Reduced homeostatic mechanisms Impaired immunological response All of the above -570006464 0

MultipleChoice 21

-570006464

MultipleChoice

Question 21 .

Question : Aortic regurgitation requires medical treatment for early signs of CHF with: Student Answer: -570006463 0

Beta blockers ACE inhibitors Surgery Hospitalization

MultipleChoice 82

-570006463

MultipleChoice

Question 22 .

Question : Which of the following symptoms is common with acute otitis media?

Student Answer:

Bulging tympanic membrane

Bright light reflex of tympanic membrane Increased tympanic membrane mobility All of the above -570006462

MultipleChoice 43

Advanced Practice Nursing 2e(Malone) 0

-570006462

MultipleChoice

Question 23 .

Question : A common auscultatory finding in advanced CHF is: Student Answer:

Systolic ejection murmur S3 gallop rhythm Friction rub

Bradycardia -570006461 0

MultipleChoice 95

-570006461

MultipleChoice

Question 24 .

Question : The best way to diagnose structural heart disease/dysfunction non-invasively is: Student Answer:

Chest X-ray EKG

Echocardiogram Heart catheterization -570006460 0

MultipleChoice 97

-570006460

MultipleChoice

Question 25 .

Question : Which disease process typically causes episodic right upper quadrant pain, epigastric pain or chest pain that can last 4-6 hours or less, often radiates to the back (classically under the right shoulder blade) and is often accompanied by nausea or vomiting and often follows a heavy, fatty meal.

Student Answer: Acute pancreatitis Duodenal ulcer Biliary colic Cholecystitis Instructor Explanation: MedU Card #7. Biliary colic typically causes right upper quadrant pain, epigastric pain or chest pain that is constant (the term "colic" is a misnomer), typically lasts 4-6 hours or less, and often radiates to the back (classically under the right shoulder blade). It is often accompanied by nausea or vomiting and often follows a heavy, fatty meal. These symptoms are a result of a stimulated gallbladder (e.g., from a fatty meal) contracting when a gallstone obstructs the outlet of the cystic duct. The hallmark of biliary colic is that the stone is mobile and eventually moves away from the outlet allowing resumption of normal gallbladder function and resolution of symptoms.

Advanced Practice Nursing 2e(Malone) -570006459 0

MultipleChoice 105

-570006459

MultipleChoice

Question 26 .

Question : Which of the following is the most common cause of heartburn- type epigastric pain?

Student Answer:

Decreased lower esophageal sphincter tone

Helicobacter pylori infection of stomach Esophageal spasm Peptic ulcer disease -570006458 0

MultipleChoice 1

-570006458

MultipleChoice

Question 27 .

Question : Jeff, 48 years old, presents to the clinic complaining of fleeting chest pain, fatigue, palpitations, lightheadedness, and shortness of breath. The pain comes and goes and is not associated with activity or exertion. Food does not exacerbate or relieve the pain. The pain is usually located under the left nipple.

Jeff is concerned because his father has cardiac disease and underwent a CABG at age 65. The ANP examines Jeff and hears a mid-systolic click at the 4th ICS mid-clavicular area. The ANP knows that this is a hallmark sign of: Student Answer:

Angina Pericarditis

Mitral valve prolapse Congestive heart failure -570006457 0

MultipleChoice 90

-570006457

MultipleChoice

Question 28 .

Question : Which of the following statements is true concerning anti- arrhythmic drugs?

Student Answer:

Amiodarone is the only one not associated with increased

mortality and it has a very favorable side effect profile.

Both long-acting and short-acting calcium channel blockers

Advanced Practice Nursing 2e(Malone) are associated with an increased risk of cardiovascular morbidity and mortality.

Most anti-arrhythmics have a low toxic/therapeutic ratio and some are exceedingly toxic.

Anti-arrhythmic therapy should be initiated in the hospital for all patients.

-570006456 0

MultipleChoice 93

-570006456

MultipleChoice

Question 29 .

Question : What is the most common valvular heart disease in the older adult?

Student Answer:

Aortic regurgitation Aortic stenosis

Mitral regurgitation Mitral stenosis -570006455 0

MultipleChoice 88

-570006455

MultipleChoice

Question 30 .

Question : Which of the following imaging studies should be considered if a pulmonary malignancy is suspected?

Student Answer:

Computed tomography (CT) scan

Chest X-ray with PA, lateral, and lordotic views Ultrasound Positron emission tomography (PET) scan -570006454 0

MultipleChoice 66

-570006454

MultipleChoice

Question 31 .

Question : Which of the following is the most important question to ask during cardiovascular health history?

Student Answer:

Number of offspring Last physical exam

Sudden death of a family member

Advanced Practice Nursing 2e(Malone) Use of caffeine -570006453 0

MultipleChoice 81

-570006453

MultipleChoice

Question 32 .

Question : The first assessment to complete related to the eyes is: Student Answer:

Eye lids Visual acuity

Extraocular movements Peripheral vision -570006452 0

MultipleChoice 49

-570006452

MultipleChoice

Question 33 .

Question : Which of the following medications are commonly associated with the side effect of cough?

Student Answer:

Beta blocker Diuretic

ACE inhibitor Calcium antagonist -570006451 0

MultipleChoice 71

-570006451

MultipleChoice

Question 34 .

Question : Patients that have atopic disorders are mediated by the production of Immunoglobulin E (IgE) will have histamine stimulated as an immediate phase response. This release of histamine results in which of the following?

Student Answer:

Sinus pain, increased vascular permeability, and

bronchodilation Bronchospasm, vascular permeability, and vasodilatation Contraction of smooth muscle, decreased vascular permeability, and vasoconstriction Vasodilatation, bronchodilation, and increased vascular permeability -570006450

MultipleChoice 56

Advanced Practice Nursing 2e(Malone) 0

-570006450

MultipleChoice

Question 35 .

Question : A nurse practitioner reports that your patient’s abdominal X-ray demonstrates multiple air-fluid levels in the bowel. This is a diagnostic finding found in: Student Answer: -570006449 0

Appendicitis Cholecystitis Bowel Obstruction Diverticulitis

MultipleChoice 5

-570006449

MultipleChoice

Question 36 .

Question : According to the Genetic Information Nondiscrimination Act (GINA): Student Answer:

Nurse Practitioners (NPs) should keep all genetic information

of patients confidential NPs must obtain informed consent prior to genetic testing of all patients Employers cannot inquire about an employee’s genetic information All of the above -570006448 0

MultipleChoice 37

-570006448

MultipleChoice

Question 37 .

Question : Which of the following would be considered a “red flag” that requires more investigation in a patient assessment?

Student Answer:

Colon cancer in family member at age 70

Breast cancer in family member at age 75 Myocardial infarction in family member at age 35 All of the above -570006447

MultipleChoice 38

Advanced Practice Nursing 2e(Malone) 0

-570006447

MultipleChoice

Question 38 .

Question : A 59-year-old patient with history of alcohol abuse comes to your office because of ‘throwing up blood”.

On physical examination, you note ascites and caput medusa. A likely cause for the hematemesis is: Student Answer: -570006446 0

Peptic ulcer disease Barrett’s esophagus Esophageal varices Pancreatitis

MultipleChoice 8

-570006446

MultipleChoice

Question 39 .

Question : A 64-year-old male presents with erythema of the sclera, tearing, and bilateral pruritus of the eyes. The symptoms occur intermittently throughout the year and he has associated clear nasal discharge. Which of the following is most likely because of the inflammation?

Student Answer: -570006445 0

Bacterium Allergen Virus Fungi

MultipleChoice 55

-570006445

MultipleChoice

Question 40 .

Question : Your patient complains of lower abdominal pain, anorexia, extreme fatigue, unintentional weight loss of 10 pounds in last 3 weeks, and you find a positive hemoccult on digital rectal examination. Laboratory tests show iron deficiency anemia. The clinician needs to consider: Student Answer:

Diverticulitis Colon cancer Appendicitis

Peptic ulcer disease 1

Question :

Which ethnic group has the highest incidence of prostate cancer?

Student Answer: Asians Hispanics African Americans

Advanced Practice Nursing 2e(Malone) American Indians Instructor Explanation: Ethnicity: African Americans have the highest incidence of prostate cancer in the world, with Asian and Hispanic men at lower risk than white men (Wilbur, 2008). Diagnosis in African Americans tends to be at a more advanced stage, and disease- specific survival is lower in this group (Prostate cancer, 2012).

(Kennedy-Malone 378) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014- 01-14. VitalBook file.

-566202526 0

MultipleChoice 1

-566202526

MultipleChoice

Question 2 .

Question : Men with an initial PSA level below 2.5 ng/ml can reduce their screening frequency to what intervals?

Student Answer: Every 6 months Yearly Every 2 years Every 2 to 4 years Instructor Explanation: Education: Review risk factors and significance of reporting family history. Encourage screening per health-care providers' recommendations and current guidelines.

CLINICAL RECOMMENDATION EVIDENCE RATING REFERENCES Screening, when completed, is recommended with PSA with or without digital rectal examination.

A Wolf et al. (2010) Screening should be conducted yearly for men whose PSA levels are ≥2.5 ng/mL. A Wolf et al. (2010) For men whose PSA is <2.5 ng/mL, screening intervals can be extended to every 2 years.

Advanced Practice Nursing 2e(Malone) A Wolf et al. (2010) A PSA level of ≥4.0 ng/mL historically has been used to recommend referral for further evaluation or biopsy. A Wolf et al. (2010) The USPSTF recommends against PSA screening for prostate cancer. C USPSTF (2012) A = consistent, good-quality, patient-oriented evidence; B = inconsistent or limited-quality, patientoriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to www.aafp.org/afpsort.xml.

(Kennedy-Malone 380) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-0114. VitalBook file.

-566202525 0

MultipleChoice 2

-566202525

MultipleChoice

Question 3 .

Question : Your 55-year-old male patient presents to your office with complaints of sudden development of severe right-sided, colicky lower abdominal pain. He cannot sit still on the examining table. The patient has previously been in good health. On physical examination, there are no signs of peritoneal inflammation. A urine sample reveals hematuria and crystalluria. Which is the next diagnostic test that should be done immediately?

Student Answer: Ultrasound of the abdomen Abdominal X-ray Digital rectal examination Spiral CT scan Instructor Explanation: The initial study can be a KUB or IVP; however, many facilities can perform a stone protocol spiral CT, a much more definitive test for the evaluation of kidney stones. CT can demonstrate filling defects. CT scan is a highly specific and sensitive test for urinary tract calculi. After the initial evaluation with CT scan, pain reliever can be administered. An IVP can be done at another time when the patient can better prepare for the test. .

-566202524

MultipleChoice 3

Advanced Practice Nursing 2e(Malone) 0

-566202524

MultipleChoice

Question 4 .

Question : The most common complication of an untreated urinary obstruction due to a ureteral calculus is: Student Answer: Ureteral rupture Hydronephrosis Kidney mass Renal artery stenosis Instructor Explanation: Hydronephrosis is swelling of the renal pelvis caused by an obstructing stone, ureteral stricture, prostatic hyperplasia, or renal or abdominal tumor that prevents the kidney from draining. The obstruction can be unilateral or bilateral, symptoms can be sudden or gradual in onset, and progressive renal damage will occur with time.

-566202523 0

MultipleChoice 4

-566202523

MultipleChoice

Question 5 .

Question : A 43-year-old male patient complains of right-sided abdominal and pain in the back in the right costovertebral angle region, fever, chills, dysuria, and nausea. On physical examination, there is 102 degree fever, tachycardia, and right costovertebral angle tenderness to percussion. The most likely condition is: Student Answer: Lower urinary tract infection Nephrolithiasis Hydronephrosis Pyelonephritis Instructor Explanation: Pyelonephritis is a bacterial infection of the renal pelvis and parenchyma, typically caused by Escherichia coli ascending from the lower urinary tract. The patient will have bilateral or unilateral flank pain, fever, chills, nausea, and vomiting, and LUTS, such as dysuria, may also be present. The patient will appear ill on presentation, with fever and tachycardia commonly noted. Palpation and/or percussion over the infected side is painful. There may be accompanying abdominal discomfort or abdominal distension.

-566202522

MultipleChoice 5

Advanced Practice Nursing 2e(Malone) 0

-566202522

MultipleChoice

Question 6 .

Question : On a physical examination for employment, a 45-year-old male shows no significant findings and takes no medications. Past medical history and surgery are unremarkable. On urinalysis, hematuria is present.

The urinalysis is repeated on another day and still reveals microscopic hematuria. It is important to recognize that painless hematuria can be diagnostic of: Student Answer: Urinary tract infection Bladder cancer Nephrolithiasis Pyelonephritis Instructor Explanation: Approximately 80% to 90% of patients with bladder cancer present with painless gross hematuria. All patients with this classic presentation should be considered to have bladder cancer until proof to the contrary. Patients should be referred to a urologist. They usually undergo cystoscopy to rule out bladder tumor. The majority of patients with bladder cancer present with no urinary tract symptoms or palpable masses.

-566202521 0

MultipleChoice 6

-566202521

MultipleChoice

Question 7 .

Question : On DRE, you note that a 45-year-old patient has a firm, smooth, non-tender but asymmetrically shaped prostate. The patient has no symptoms and has a normal urinalysis. The patient’s PSA is within normal limits for the patient’s age. The clinician should: Student Answer: Refer the patient for transrectal ultrasound guided prostate biopsy Obtain an abdominal X-ray of kidneys, ureter, and bladder Recognize this as a normal finding that requires periodic follow up Obtain urine culture and sensitivity for prostatitis Instructor Explanation:

Advanced Practice Nursing 2e(Malone) An asymmetric prostate is typically asymptomatic and not necessarily diagnostic of prostate cancer; asymmetry can be a normal finding on DRE but should be followed periodically to monitor for changes.

Age-specific reference ranges for PSA (see Table 11.4) should be used as a guide when there is no previous PSA for comparison. A prostatic nodule found on DRE necessitates a referral to a urologist or radiologist for transrectal ultrasound-guided prostate biopsy and may well be the first indication of the presence of a cancer.

-566202520 0

MultipleChoice 7

-566202520

MultipleChoice

Question 8 .

Question : Age-related changes in the bladder, urethra, and ureters include all of the following in older women except: Student Answer: Increased estrogen production’s influence on the bladder and ureter Decline in bladder outlet function Decline in ureteral resistance pressure Laxity of the pelvic muscle Instructor Explanation: Contributing factors: Estrogen-deficient states accompanying metabolic disorders and changes of normal aging create the risk of atrophic vaginitis. Changes in vaginal epithelium and pH caused by estrogen deficiency provide an environment in which pathogenic bacteria and fungi can flourish. Drugs also may alter vaginal secretions and clinical findings (Bachmann & Santen, 2011b).

Signs and symptoms: Itching, discomfort, burning, dyspareunia, and, at times, a thin blood-tinged vaginal discharge or bleeding after intercourse as the epithelium thins characterize atrophic vaginitis. As vaginal secretions decrease, vaginal dryness can be another bothersome symptom. Complaints of urinary frequency, urgency, and stress incontinence are common. On physical examination, signs include pale, dry, nonrugated vaginal walls with patches of erythema or petechiae or both. The vaginal canal is short and narrow. A watery white vaginal discharge without foul odor may be found. Estrogen deficiency can lead to loss of uterine support and subsequent uterine descensus (Tan, Bradshaw, & Carr, 2012).

(Kennedy-Malone 362) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file.

-566202519

MultipleChoice 8

Advanced Practice Nursing 2e(Malone) 0

-566202519

MultipleChoice

Question 9 .

Question : Mr. Jones is a 68-year-old retired Air Force pilot that has been diagnosed with prostate cancer in the past week. He has never had a surgical procedure in his life and seeks clarification on the availability of treatments for prostate cancer. He asks the nurse practitioner to tell him the side effects of a radical prostatectomy. Which of the following is not a potential side effect of this procedure?

Student Answer: Urinary incontinence Impotence Dribbling urine Selected low back pain Instructor Explanation: Sequelae: Complications of treatment may include incontinence, ED, mild colitis, and radiation cystitis.

After nerve-sparing prostatectomy, urinary continence returns in under 6 months in about 50% of men.

The rate of ED after external beam radiation ranges from 10% to 80%, and with brachytherapy approximately 15% to 60% (Ali & Walsh, 2011).

(Kennedy-Malone 379) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file.

-566202518 0

MultipleChoice 9

-566202518

MultipleChoice

Question 10 .

Question : Your 77-year-old patient complains of frequent urination, hesitation in getting the stream started, and nocturnal frequency of urination that is bothersome. On DRE, there is an enlarged, firm, non-tender, smooth prostate. The clinician should recognize these as symptoms of: Student Answer: Urethritis Benign prostatic hyperplasia Prostatitis Prostate cancer Instructor Explanation:

Advanced Practice Nursing 2e(Malone) BPH is an enlargement of the transition zone of the prostate gland which occurs as men age. An enlarged prostate causes symptoms that include urinary urgency, frequency, hesitation in getting the stream started, decreased caliber and force of stream, and nocturnal frequency of urination that is bothersome. This collection of symptoms has also been termed prostatism. A patient with BPH shows symmetric or asymmetric enlargement and a firm, smooth, non-tender gland.

-566202517 0

MultipleChoice 10

-566202517

MultipleChoice

Question 11 .

Question : Your 24-year-old female patient complains of dysuria as well as frequency and urgency of urination that develops the day after she uses her diaphragm. Urine culture reveals a bacterial count of 100 CFU/mL. These signs and symptoms indicate: Student Answer: Upper urinary tract infection Normal bacteriuria Lower urinary tract infection Urethritis Instructor Explanation: In women whose symptoms suggest uncomplicated UTI, a culture of greater than 102 CFU/mL of a specific bacterium is indicative of cystitis. However, this CFU number is controversial. Infectious disease specialists recommend use of 103 CFU / mL as diagnostic of UTI. In the past, a bacterial count of 105 CFU/mL was regarded as significant for UTI. UTI diagnosis relies on the patient’s subjective report of symptoms of UTI, not only the number of bacteria. Patients with asymptomatic bacteriuria can have bacterial counts as high as 10 5 CFU/mL. Asymptomatic bacteriuria is not treated. Risk factors for the development of a UTI include increasing age, recent sexual intercourse, a history of UTI, use of a diaphragm or cervical cap, and anatomic abnormalities.

-566202516 0

MultipleChoice 11

-566202516

MultipleChoice

Question 12 .

Question : A 79-year-old man is being evaluated for frequent urinary dribbling without burning. Physical examination reveals a smooth

Advanced Practice Nursing 2e(Malone) but slightly enlarged prostate gland. His PSA level is 3.3 ng/ml. The patient undergoes formal urodynamic studies, and findings are as follows: a decreased bladder capacity of 370 ml; a few involuntary detrusor contractions at a low bladder volume of 246 mL; an increased postvoid residual urine volume of 225 ml; and a slightly decreased urinary flow rate. Which of the following is not consistent with a normal age-associated change?

Student Answer: PSA level of 3.3 ng/ml Decreased bladder capacity Involuntary detrusor contradictions Increased postvoid residual urine volume Instructor Explanation: Signs and symptoms: Symptoms are lower urinary tract symptoms (LUTS), occur on a continuum, and do not necessarily reflect the degree of prostatic enlargement. The onset of symptoms is gradual and includes increased frequency of urination, nocturia, hesitancy, urgency, and weak urinary stream. These symptoms are not specific for BPH and progress gradually over a period of years.

(Kennedy-Malone 373) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014- 01-14. VitalBook file.

-566202515 0

MultipleChoice 12

-566202515

MultipleChoice

Question 13 .

Question : Mrs. L. Billings is a 77-year-old Caucasian female who has a history of breast cancer. She has been in remission for 6 years. As her primary care provider, you are seeing her for follow-up of her recent complaint of intermittent abdominal pain of a 3-month duration and some general malaise. Given the brief history above, what will you direct your assessment at during physical examination?

Student Answer: Examination of her thyroid to rule out thyroid nodules that may contribute to her feeling fatigued.

Auscultation of her abdomen for abnormal bowel sounds to rule out peritonitis.

Thorough abdominal and gynecological exam to rule out masses and identify any tenderness.

A rectal examination to rule out colon cancer as a secondary

Advanced Practice Nursing 2e(Malone) site for breast cancer.

Instructor Explanation: Signs and symptoms: Ovarian cancer may be totally asymptomatic. The woman may experience pelvic or abdominal pain or pressure, bloating, early satiety, or urinary symptoms (frequency/urgency). Because many of these symptoms are nonspecific and occur with other health conditions, they are frequently overlooked by patient and health-care professional alike (Vaughan et al., 2011).

Diagnostic tests: Pelvic examination is recommended in all sexually active women on the schedule determined by the American College of Obstetricians and Gynecologists. Rectovaginal examination may be necessary to detect ovarian enlargement. Ovarian enlargement cannot always be palpated, making pelvic examination a limited diagnostic test. (Kennedy-Malone 371) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file.

-566202514 0

MultipleChoice 13

-566202514

MultipleChoice

Question 14 .

Question : A 27-year-old male comes in to the clinic for symptoms of dysuria, urinary frequency, as well as urgency and perineal pain.

Transrectal palpation of the prostate reveals a very tender, boggy, swollen prostate. The clinician should recognize these as signs of: Student Answer: Prostatitis Prostate cancer Urethritis Benign prostatic hyperplasia Instructor Explanation: Prostatitis is an acute or chronic infection of the prostate gland. Acute bacterial prostatitis is usually the result of infection by aerobic gram- negative rods (coliform bacteria or Pseudomonas). Enterococcus faecalis, an aerobic gram-positive bacteria, can also cause prostatitis. Routes of infection are ascent from the urethra, reflux of infected urine into the prostatic ducts, direct extension of bacteria, and migration via the lymphatic and vascular system. Acute symptoms commonly include fever, low back and perineal pain, possible penis pain, urinary urgency and frequency, nocturia, dysuria, and muscle and joint aches.

Transrectal palpation of the prostate reveals a very tender, boggy, swollen prostate.

-566202513 0

MultipleChoice 14

-566202513

MultipleChoice

Advanced Practice Nursing 2e(Malone) Question 15 .

Question : Which of the following males would be at greatest risk for testicular cancer?

Student Answer:

John, a 52-year-old, married African American Attorney who

lives in Detroit, MI Jacob, a 22-year-old, homosexual male, who works as an accountant, resides in Cumming GA, and has a history of Instructor Explanation: cryptorchidism Andy, a 27-year-old, Caucasian, single male who resides in Waukesha, WI and works as a maintenance mechanic Ryan, a 34-year-old healthy, married man from Sweden, who works as a Registered Nurse in Boston, MA Malignant tumors of the testes are uncommon, usually present between the ages of 15 and 35, are slightly more common on the right side, and arise from germ cells. The greatest risk factor for the development of a testicular tumor is cryptorchidism, with an overall incidence of 7% to 10% in the patient with a history of unilateral or bilateral undescended testes. Increased screening and early detection have significantly decreased the mortality from this malignancy, but up to 10% of patients present with pain and/or constitutional or pulmonary complaints that indicate metastasis. ( 337) , Mary J., Laurie Grubbs. Advanced Assessment Interpreting Findings and Formulating Differential Diagnoses, 3rd Edition. F.A. Davis Company, 11/2014. VitalBook file.

-566202512 0

MultipleChoice 15

-566202512

MultipleChoice

Question 16 .

Question : A 43-year-old male patient complains of right-sided abdominal and pain in the back in the right costovertebral angle region, fever, chills, dysuria, and nausea. On physical examination, there is 102 degree fever, tachycardia, and right costovertebral angle tenderness to percussion. The most likely condition is: Student Answer: Hydonephrosis

Lower urinary tract infection Pyelonephritis Nephrolithiasis

Advanced Practice Nursing 2e(Malone) -566202511 0

MultipleChoice 16

-566202511

MultipleChoice

Question 17 .

Question : Which of the following disorders can cause urinary incontinence?

Student Answer: Cystocele Overactive bladder Uterine prolapse All of the above Instructor Explanation: Cystocele and prolapse of the uterus can affect pelvic floor anatomy and cause urinary changes, including incontinence and changes to the quality of the urinary stream. Overactive bladder is a cause of incontinence due to atrophic changes of the pelvic floor muscles.

-566202510 0

MultipleChoice 17

-566202510

MultipleChoice

Question 18 .

Question : Your 18 year old sexually active patient presents with sudden right sided groin pain that is sharp and constant. Inspection of his genitals reveals a swollen and erythematous right scrotum. His right testicle is exquisitely tender, swollen and has no palpable masses. Elevation of the testis results in no reduction in pain. The left scrotum and the testicle are normal. Epididymis and other scrotal contents were within normal limits. The scrotum does not transilluminate. Cremasteric reflex is present on the left side but absent on the right. There is no penile discharge, inguinal lymphadenopathy, or hernias.

Based on the history and physical exam your immediate concern is for: Student Answer:

Torsion Infection Cancer Rupture

Instructor Explanation: MedU Card #11 -566202509 0

MultipleChoice 18

-566202509

Question 19

MultipleChoice

Advanced Practice Nursing 2e(Malone) .

Question : The Prehn sign is utilized to distinguish epididymitis from testicular torsion. Epididymitis is considered when the Prehn sign is positive. When is the Prehn sign determined to be positive?

Student Answer:

Pain is relieved by lifting of the testicle.

Tenderness is limited to the upper pole of the testis.

Instructor Explanation: Lightly stroking or pinching the superior medial aspect of the thigh causes testicular retraction.

A small bluish discoloration is visible through the skin in the upper pole.

MedU Card # 6. Prehn reported that physical lifting of the testicles relieves the pain caused by epididymitis but not pain caused by testicular torsion. A positive Prehn sign is pain that is relieved by lifting of the testicle; if present this can help distinguish epididymitis from testicular torsion.

-566202508 0

MultipleChoice 19

-566202508

MultipleChoice

Question 20 .

Question : Which of the following exam findings makes the diagnosis of testicular tumor more likely?

Student Answer:

A scrotal mass that is accompanied by exquisite tenderness.

Testicular swelling is mostly fluid and transilluminates easily A testicular mass that is non-tender to palpation Dilated and tortuous veins in the pampiniform plexus Instructor Explanation: MedU Card #9. Testicular tumor presents as scrotal mass that is rarely accompanied by tenderness. The swelling is solid so should not transilluminate. A testicular tumor is usually non-tender to palpation.

1

Question :

Which ethnic group has the highest incidence of prostate cancer?

Student Answer:

Advanced Practice Nursing 2e(Malone) Asians Hispanics African Americans American Indians Instructor Explanation: Ethnicity: African Americans have the highest incidence of prostate cancer in the world, with Asian and Hispanic men at lower risk than white men (Wilbur, 2008). Diagnosis in African Americans tends to be at a more advanced stage, and disease- specific survival is lower in this group (Prostate cancer, 2012).

(Kennedy-Malone 378) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014- 01-14. VitalBook file.

-566202526 0

MultipleChoice 1

-566202526

MultipleChoice

Question 2 .

Question : Men with an initial PSA level below 2.5 ng/ml can reduce their screening frequency to what intervals?

Student Answer: Every 6 months Yearly Every 2 years Every 2 to 4 years Instructor Explanation: Education: Review risk factors and significance of reporting family history. Encourage screening per health-care providers' recommendations and current guidelines.

CLINICAL RECOMMENDATION EVIDENCE RATING REFERENCES Screening, when completed, is recommended with PSA with or without digital rectal examination.

A Wolf et al. (2010) Screening should be conducted yearly for men whose PSA levels are ≥2.5 ng/mL. A

Advanced Practice Nursing 2e(Malone) Wolf et al. (2010) For men whose PSA is <2.5 ng/mL, screening intervals can be extended to every 2 years.

A Wolf et al. (2010) A PSA level of ≥4.0 ng/mL historically has been used to recommend referral for further evaluation or biopsy.

A Wolf et al. (2010) The USPSTF recommends against PSA screening for prostate cancer. C USPSTF (2012) A = consistent, good-quality, patient-oriented evidence; B = inconsistent or limited-quality, patientoriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to www.aafp.org/afpsort.xml.

(Kennedy-Malone 380) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-0114. VitalBook file.

-566202525 0

MultipleChoice 2

-566202525

MultipleChoice

Question 3 .

Question : Your 55-year-old male patient presents to your office with complaints of sudden development of severe right-sided, colicky lower abdominal pain. He cannot sit still on the examining table. The patient has previously been in good health. On physical examination, there are no signs of peritoneal inflammation. A urine sample reveals hematuria and crystalluria. Which is the next diagnostic test that should be done immediately?

Student Answer: Ultrasound of the abdomen Abdominal X-ray Digital rectal examination Spiral CT scan Instructor Explanation: The initial study can be a KUB or IVP; however, many facilities can perform a stone protocol spiral CT, a much more definitive test for the evaluation of kidney stones. CT can demonstrate filling defects. CT scan is a highly specific and sensitive test for urinary tract calculi. After the initial evaluation with CT scan,

Advanced Practice Nursing 2e(Malone) pain reliever can be administered. An IVP can be done at another time when the patient can better prepare for the test. .

-566202524 0

MultipleChoice 3

-566202524

MultipleChoice

Question 4 .

Question : The most common complication of an untreated urinary obstruction due to a ureteral calculus is: Student Answer: Ureteral rupture Hydronephrosis Kidney mass Renal artery stenosis Instructor Explanation: Hydronephrosis is swelling of the renal pelvis caused by an obstructing stone, ureteral stricture, prostatic hyperplasia, or renal or abdominal tumor that prevents the kidney from draining. The obstruction can be unilateral or bilateral, symptoms can be sudden or gradual in onset, and progressive renal damage will occur with time.

-566202523 0

MultipleChoice 4

-566202523

MultipleChoice

Question 5 .

Question : A 43-year-old male patient complains of right-sided abdominal and pain in the back in the right costovertebral angle region, fever, chills, dysuria, and nausea. On physical examination, there is 102 degree fever, tachycardia, and right costovertebral angle tenderness to percussion. The most likely condition is: Student Answer: Lower urinary tract infection Nephrolithiasis Hydronephrosis Pyelonephritis Instructor Explanation: Pyelonephritis is a bacterial infection of the renal pelvis and parenchyma, typically caused by Escherichia coli ascending from the lower urinary tract. The patient will have bilateral or unilateral flank pain, fever,

Advanced Practice Nursing 2e(Malone) chills, nausea, and vomiting, and LUTS, such as dysuria, may also be present. The patient will appear ill on presentation, with fever and tachycardia commonly noted. Palpation and/or percussion over the infected side is painful. There may be accompanying abdominal discomfort or abdominal distension.

-566202522 0

MultipleChoice 5

-566202522

MultipleChoice

Question 6 .

Question : On a physical examination for employment, a 45-year-old male shows no significant findings and takes no medications. Past medical history and surgery are unremarkable. On urinalysis, hematuria is present.

The urinalysis is repeated on another day and still reveals microscopic hematuria. It is important to recognize that painless hematuria can be diagnostic of: Student Answer: Urinary tract infection Bladder cancer Nephrolithiasis Pyelonephritis Instructor Explanation: Approximately 80% to 90% of patients with bladder cancer present with painless gross hematuria. All patients with this classic presentation should be considered to have bladder cancer until proof to the contrary. Patients should be referred to a urologist. They usually undergo cystoscopy to rule out bladder tumor. The majority of patients with bladder cancer present with no urinary tract symptoms or palpable masses.

-566202521 0

MultipleChoice 6

-566202521

MultipleChoice

Question 7 .

Question : On DRE, you note that a 45-year-old patient has a firm, smooth, non-tender but asymmetrically shaped prostate. The patient has no symptoms and has a normal urinalysis. The patient’s PSA is within normal limits for the patient’s age. The clinician should: Student Answer: Instructor Explanation: Refer the patient for transrectal ultrasound guided prostate

Advanced Practice Nursing 2e(Malone) biopsy Obtain an abdominal X-ray of kidneys, ureter, and bladder Recognize this as a normal finding that requires periodic follow up Obtain urine culture and sensitivity for prostatitis An asymmetric prostate is typically asymptomatic and not necessarily diagnostic of prostate cancer; asymmetry can be a normal finding on DRE but should be followed periodically to monitor for changes.

Age-specific reference ranges for PSA (see Table 11.4) should be used as a guide when there is no previous PSA for comparison. A prostatic nodule found on DRE necessitates a referral to a urologist or radiologist for transrectal ultrasound-guided prostate biopsy and may well be the first indication of the presence of a cancer.

-566202520 0

MultipleChoice 7

-566202520

MultipleChoice

Question 8 .

Question : Age-related changes in the bladder, urethra, and ureters include all of the following in older women except: Student Answer: Increased estrogen production’s influence on the bladder and ureter Decline in bladder outlet function Decline in ureteral resistance pressure Laxity of the pelvic muscle Instructor Explanation: Contributing factors: Estrogen-deficient states accompanying metabolic disorders and changes of normal aging create the risk of atrophic vaginitis. Changes in vaginal epithelium and pH caused by estrogen deficiency provide an environment in which pathogenic bacteria and fungi can flourish. Drugs also may alter vaginal secretions and clinical findings (Bachmann & Santen, 2011b).

Signs and symptoms: Itching, discomfort, burning, dyspareunia, and, at times, a thin blood-tinged vaginal discharge or bleeding after intercourse as the epithelium thins characterize atrophic vaginitis. As vaginal secretions decrease, vaginal dryness can be another bothersome symptom. Complaints of urinary frequency, urgency, and stress incontinence are common. On physical examination, signs include pale, dry, nonrugated vaginal walls with patches of erythema or petechiae or both. The vaginal canal is short and narrow. A watery white vaginal discharge without foul odor may be found. Estrogen deficiency can lead to loss of uterine support and subsequent uterine descensus (Tan, Bradshaw, & Carr, 2012).

(Kennedy-Malone 362)

Advanced Practice Nursing 2e(Malone) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file.

-566202519 0

MultipleChoice 8

-566202519

MultipleChoice

Question 9 .

Question : Mr. Jones is a 68-year-old retired Air Force pilot that has been diagnosed with prostate cancer in the past week. He has never had a surgical procedure in his life and seeks clarification on the availability of treatments for prostate cancer. He asks the nurse practitioner to tell him the side effects of a radical prostatectomy. Which of the following is not a potential side effect of this procedure?

Student Answer: Urinary incontinence Impotence Dribbling urine Selected low back pain Instructor Explanation: Sequelae: Complications of treatment may include incontinence, ED, mild colitis, and radiation cystitis.

After nerve-sparing prostatectomy, urinary continence returns in under 6 months in about 50% of men.

The rate of ED after external beam radiation ranges from 10% to 80%, and with brachytherapy approximately 15% to 60% (Ali & Walsh, 2011).

(Kennedy-Malone 379) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file.

-566202518 0

MultipleChoice 9

-566202518

MultipleChoice

Question 10 .

Question : Your 77-year-old patient complains of frequent urination, hesitation in getting the stream started, and nocturnal frequency of urination that is bothersome. On DRE, there is an enlarged, firm, non-tender, smooth prostate. The clinician should recognize these as symptoms of: Student Answer:

Advanced Practice Nursing 2e(Malone) Urethritis Benign prostatic hyperplasia Prostatitis Prostate cancer Instructor Explanation: BPH is an enlargement of the transition zone of the prostate gland which occurs as men age. An enlarged prostate causes symptoms that include urinary urgency, frequency, hesitation in getting the stream started, decreased caliber and force of stream, and nocturnal frequency of urination that is bothersome. This collection of symptoms has also been termed prostatism. A patient with BPH shows symmetric or asymmetric enlargement and a firm, smooth, non-tender gland.

-566202517 0

MultipleChoice 10

-566202517

MultipleChoice

Question 11 .

Question : Your 24-year-old female patient complains of dysuria as well as frequency and urgency of urination that develops the day after she uses her diaphragm. Urine culture reveals a bacterial count of 100 CFU/mL. These signs and symptoms indicate: Student Answer: Upper urinary tract infection Normal bacteriuria Lower urinary tract infection Urethritis Instructor Explanation: In women whose symptoms suggest uncomplicated UTI, a culture of greater than 102 CFU/mL of a specific bacterium is indicative of cystitis. However, this CFU number is controversial. Infectious disease specialists recommend use of 103 CFU / mL as diagnostic of UTI. In the past, a bacterial count of 105 CFU/mL was regarded as significant for UTI. UTI diagnosis relies on the patient’s subjective report of symptoms of UTI, not only the number of bacteria. Patients with asymptomatic bacteriuria can have bacterial counts as high as 10 5 CFU/mL. Asymptomatic bacteriuria is not treated. Risk factors for the development of a UTI include increasing age, recent sexual intercourse, a history of UTI, use of a diaphragm or cervical cap, and anatomic abnormalities.

-566202516 0

MultipleChoice 11

-566202516

MultipleChoice

Advanced Practice Nursing 2e(Malone) Question 12 .

Question : A 79-year-old man is being evaluated for frequent urinary dribbling without burning. Physical examination reveals a smooth but slightly enlarged prostate gland. His PSA level is 3.3 ng/ml.

The patient undergoes formal urodynamic studies, and findings are as follows: a decreased bladder capacity of 370 ml; a few involuntary detrusor contractions at a low bladder volume of 246 mL; an increased postvoid residual urine volume of 225 ml; and a slightly decreased urinary flow rate. Which of the following is not consistent with a normal age-associated change?

Student Answer: PSA level of 3.3 ng/ml Decreased bladder capacity Involuntary detrusor contradictions Increased postvoid residual urine volume Instructor Explanation: Signs and symptoms: Symptoms are lower urinary tract symptoms (LUTS), occur on a continuum, and do not necessarily reflect the degree of prostatic enlargement. The onset of symptoms is gradual and includes increased frequency of urination, nocturia, hesitancy, urgency, and weak urinary stream. These symptoms are not specific for BPH and progress gradually over a period of years.

(Kennedy-Malone 373) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 201401-14. VitalBook file.

-566202515 0

MultipleChoice 12

-566202515

MultipleChoice

Question 13 .

Question : Mrs. L. Billings is a 77-year-old Caucasian female who has a history of breast cancer. She has been in remission for 6 years. As her primary care provider, you are seeing her for follow-up of her recent complaint of intermittent abdominal pain of a 3-month duration and some general malaise. Given the brief history above, what will you direct your assessment at during physical examination?

Student Answer:

Examination of her thyroid to rule out thyroid nodules that

may contribute to her feeling fatigued.

Auscultation of her abdomen for abnormal bowel sounds to

Advanced Practice Nursing 2e(Malone) rule out peritonitis.

Thorough abdominal and gynecological exam to rule out masses and identify any tenderness.

A rectal examination to rule out colon cancer as a secondary site for breast cancer.

Instructor Explanation: Signs and symptoms: Ovarian cancer may be totally asymptomatic. The woman may experience pelvic or abdominal pain or pressure, bloating, early satiety, or urinary symptoms (frequency/urgency). Because many of these symptoms are nonspecific and occur with other health conditions, they are frequently overlooked by patient and health-care professional alike (Vaughan et al., 2011).

Diagnostic tests: Pelvic examination is recommended in all sexually active women on the schedule determined by the American College of Obstetricians and Gynecologists. Rectovaginal examination may be necessary to detect ovarian enlargement. Ovarian enlargement cannot always be palpated, making pelvic examination a limited diagnostic test.

(Kennedy-Malone 371) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file.

-566202514 0

MultipleChoice 13

-566202514

MultipleChoice

Question 14 .

Question : A 27-year-old male comes in to the clinic for symptoms of dysuria, urinary frequency, as well as urgency and perineal pain. Transrectal palpation of the prostate reveals a very tender, boggy, swollen prostate. The clinician should recognize these as signs of: Student Answer: Prostatitis Prostate cancer Urethritis Benign prostatic hyperplasia Instructor Explanation: Prostatitis is an acute or chronic infection of the prostate gland. Acute bacterial prostatitis is usually the result of infection by aerobic gram- negative rods (coliform bacteria or Pseudomonas). Enterococcus faecalis, an aerobic gram-positive bacteria, can also cause prostatitis. Routes of infection are ascent from the urethra, reflux of infected urine into the prostatic ducts, direct extension of bacteria, and migration via the lymphatic and vascular system. Acute symptoms commonly include fever, low back and perineal

Advanced Practice Nursing 2e(Malone) pain, possible penis pain, urinary urgency and frequency, nocturia, dysuria, and muscle and joint aches.

Transrectal palpation of the prostate reveals a very tender, boggy, swollen prostate.

-566202513 0

MultipleChoice 14

-566202513

MultipleChoice

Question 15 .

Question : Which of the following males would be at greatest risk for testicular cancer?

Student Answer:

John, a 52-year-old, married African American Attorney who

lives in Detroit, MI Jacob, a 22-year-old, homosexual male, who works as an accountant, resides in Cumming GA, and has a history of cryptorchidism Andy, a 27-year-old, Caucasian, single male who resides in Waukesha, WI and works as a maintenance mechanic Ryan, a 34-year-old healthy, married man from Sweden, who works as a Registered Nurse in Boston, MA Instructor Explanation: Malignant tumors of the testes are uncommon, usually present between the ages of 15 and 35, are slightly more common on the right side, and arise from germ cells. The greatest risk factor for the development of a testicular tumor is cryptorchidism, with an overall incidence of 7% to 10% in the patient with a history of unilateral or bilateral undescended testes. Increased screening and early detection have significantly decreased the mortality from this malignancy, but up to 10% of patients present with pain and/or constitutional or pulmonary complaints that indicate metastasis. ( 337) , Mary J., Laurie Grubbs. Advanced Assessment Interpreting Findings and Formulating Differential Diagnoses, 3rd Edition. F.A. Davis Company, 11/2014. VitalBook file.

-566202512 0

MultipleChoice 15

-566202512

Question 16 .

Question :

MultipleChoice

Advanced Practice Nursing 2e(Malone) A 43-year-old male patient complains of right-sided abdominal and pain in the back in the right costovertebral angle region, fever, chills, dysuria, and nausea. On physical examination, there is 102 degree fever, tachycardia, and right costovertebral angle tenderness to percussion. The most likely condition is: Student Answer: -566202511 0

Lower urinary tract infection Pyelonephritis Nephrolithiasis Hydonephrosis

MultipleChoice 16

-566202511

MultipleChoice

Question 17 .

Question : Which of the following disorders can cause urinary incontinence?

Student Answer: Cystocele Overactive bladder Uterine prolapse All of the above Instructor Explanation: Cystocele and prolapse of the uterus can affect pelvic floor anatomy and cause urinary changes, including incontinence and changes to the quality of the urinary stream. Overactive bladder is a cause of incontinence due to atrophic changes of the pelvic floor muscles.

-566202510 0

MultipleChoice 17

-566202510

MultipleChoice

Question 18 .

Question : Your 18 year old sexually active patient presents with sudden right sided groin pain that is sharp and constant. Inspection of his genitals reveals a swollen and erythematous right scrotum. His right testicle is exquisitely tender, swollen and has no palpable masses. Elevation of the testis results in no reduction in pain. The left scrotum and the testicle are normal. Epididymis and other scrotal contents were within normal limits. The scrotum does not transilluminate. Cremasteric reflex is present on the left side but absent on the right. There is no penile discharge, inguinal lymphadenopathy, or hernias.

Based on the history and physical exam your immediate concern is for: Student Answer:

Torsion Infection Cancer Rupture

Instructor Explanation: MedU Card #11 -566202509

MultipleChoice 18

Advanced Practice Nursing 2e(Malone) 0

-566202509

MultipleChoice

Question 19 .

Question : The Prehn sign is utilized to distinguish epididymitis from testicular torsion. Epididymitis is considered when the Prehn sign is positive. When is the Prehn sign determined to be positive?

Student Answer:

Pain is relieved by lifting of the testicle.

Tenderness is limited to the upper pole of the testis.

Instructor Explanation: Lightly stroking or pinching the superior medial aspect of the thigh causes testicular retraction.

A small bluish discoloration is visible through the skin in the upper pole.

MedU Card # 6. Prehn reported that physical lifting of the testicles relieves the pain caused by epididymitis but not pain caused by testicular torsion. A positive Prehn sign is pain that is relieved by lifting of the testicle; if present this can help distinguish epididymitis from testicular torsion.

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MultipleChoice 19

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Question 20 .

Question : Which of the following exam findings makes the diagnosis of testicular tumor more likely?

Student Answer:

A scrotal mass that is accompanied by exquisite tenderness.

Testicular swelling is mostly fluid and transilluminates easily A testicular mass that is non-tender to palpation Dilated and tortuous veins in the pampiniform plexus Instructor Explanation: MedU Card #9. Testicular tumor presents as scrotal mass that is rarely accompanied by tenderness. The swelling is solid so should not transilluminate. A testicular tumor is usually non-tender to palpation.

1

Question :

When a patient presents with a skin-related complaint, it is important to first:

Advanced Practice Nursing 2e(Malone) Student Answer:

Fully inspect all skin lesions before asking the patient how the

lesion in question developed Obtain a full history about the development of the skin lesion prior to the physical examination Complete a full physical examination of the body prior to inspecting the skin lesion Examine the skin lesion without hearing a health history in order to not prejudice the diagnosis Instructor Explanation: When a patient presents with a skin-related complaint, there is an inclination to immediately examine the skin, as the lesion or change is often readily observable. However, it is crucial to obtain a history before proceeding to the examination in order to understand the background of the problem. A thorough symptom analysis is essential.

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MultipleChoice 1

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Question 2 .

Question : Which of the following dermatological conditions results from reactivation of the dormant varicella virus?

Student Answer: Tinea versicolor Seborrheic keratosis Verruca Herpes zoster Instructor Explanation: Description: Herpes zoster is an acute vesicular eruption caused by a virus histologically identical to the varicella (chickenpox) virus. Herpes zoster is human (alpha) herpes virus 3 (varicella-zoster virus [VZV]), a member of the herpes virus group.

Etiology: Recurrent VZV infection causes herpes zoster. The patient has initial contact with VZV in the form of chickenpox. The DNA virus resides within the neurons. During reactivation, the virus spreads across the sensory ganglion to other neurons, which causes a cutaneous eruption of a dermatome distribution (Fashner & Bell, 2011). Older adults have a decrease in cell-mediated immunity, which contributes to the risk of developing herpes zoster and postherpetic neuralgia (Barakzai & Fraser, 2008).

(Kennedy-Malone 132-133)

Advanced Practice Nursing 2e(Malone) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014- 01-14. VitalBook file.

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MultipleChoice 2

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Question 3 .

Question : An older adult male presents with pain in his right chest wall for the past 48 hours. Upon examination, the nurse practitioner notices a vesicular eruption along the dermatome and identifies this as herpes zoster.

The NP informs the gentleman that: Student Answer:

All symptoms should disappear within three days

Oral medications can dramatically reduce the duration and intensity of his symptoms He has chickenpox and can be contagious to his grandchildren He has a sexually transmitted disease Instructor

Treatment: Antiviral agents are recommended in the presence of

Explanation: significant pain, serious herpes zoster, or involvement near the eye. Postherpetic neuralgia is not reduced by antiviral therapy, but these agents may help with healing in the acute phase by reducing viral shredding (Cadogan, 2010). Give acyclovir, 800 mg 5 times a day for 7 to 10 days; famciclovir, 500 mg orally every 8 hours for 7 days; or valacyclovir, 1000 mg orally every 8 hours for 7 days (Fashner & Bell, 2011). These drugs must be given within 72 hours after onset of rash to be effective, and their use must be monitored in patients with reduced renal function (Tyring, Beutner, Tucker, Anderson, & Crooks, 2000).

Patients should be encouraged to stay hydrated and to avoid scratching (Cadogan, 2010). Patients with disseminated disease and those who are immunocompromised may need IV antiviral medications (Cadogan, 2010). Topical agents are also effective in treating herpes zoster. The use of cool compresses with 1:20 Burow's solution, calamine lotion, and topical lidocaine (Xylocaine) is recommended for the soothing local effect.

Analgesics may be necessary for the initial prodromal pain associated with herpes zoster. Acetaminophen is recommended initially. Tramadol, NSAIDs, and opiates can be used as recommended for severe pain.

Gabapentin is recommended for the treatment of PHN. Initial dose is 300 mg on the first day and is titrated up gradually until pain relief is safely reached. The maximum does of gabapentin is 3600 mg/day.

Pregabalin is also recommended for the treatment of postherpetic neuralgia and can be administered 50 mg 3 times a day or 75 mg twice a day. The dosage can be increased to 300 mg daily after 3 to 7 days as tolerated, followed by 150 mg every 3 to 7 days. The maximum recommended dose is 600 mg/day.

Caution is advised when prescribing gabapentin and pregabalin to older adults given the side effects of dizziness and ataxia (Christo, Hobelmann, & Maine, 2007).

Advanced Practice Nursing 2e(Malone) The secondary amine tricyclic antidepressants, nortriptyline 10 mg orally or desipramine 10 to 25 mg orally both given at bedtime, may be helpful, and it may be necessary to gradually increase the dosage until reduction of pain occurs; however, because of the anticholinergic side effects, caution is warranted (Ahmad & Goucke,2002).

The use of opioids in the treatment of PHN alone or in combination with other therapies has also been studied; greater pain relief was experienced by patients when a combined regimen was prescribed over a single agent (Gilron et al., 2005). The 5% lidocaine patch has been shown to be effective in treating the pain of PHN; 1 to 3 patches are applied in a 24- hour period. For PHN pain, capsaicin (Zostrix cream) can be applied topically. The capsaicin 8% patch can be applied by a health-care professional to the most painful skin areas (Christo et al., 2007). In cases of severe pain, a transcutaneous electrical nerve stimulator unit may be tried (Christo et al., 2007).

(Kennedy-Malone 134) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file.

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MultipleChoice 3

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Question 4 .

Question : A 70-year-old white male comes to the clinic with a slightly raised, scaly, pink, and irregular lesion on his scalp. He is a farmer and works outside all day. You suspect actinic keratosis, but cannot rule out other lesions. What recommendation would you give him?

Student Answer:

Ignore the lesion, as it is associated with aging.

Instruct him to use a nonprescription hydrocortisone cream to dry up the lesion.

Perform a biopsy or refer to a dermatologist.

Instructor Explanation: Advise him to use a dandruff shampoo and return in one month if the lesion has not gone away.

Patients may be concerned about a new, pigmented lesion or a change in an already existing one. Patients may report associated itching, burning, or pain in a mole. Superficial spreading melanoma is a flat to slightly raised pigmented lesion with irregular borders, commonly found on the backs of men and the lower legs of women. Lentigo maligna melanoma, an irregularly pigmented macula with notched borders, occurs on sun- exposed areas, especially on the faces of older adults. Nodular melanoma, brown or black papules usually located on the trunk, head, and neck, is characterized by rapid growth. Acral lentiginous melanomas, a rare melanoma subtype, is found proportionally higher in people of

Advanced Practice Nursing 2e(Malone) color. Acral lentiginous melanoma occurs on the palms, soles, fingers, and toes; a pigmented streak of the cuticle is diagnostic (Hutchinson's sign) (Bradford, Goldstein, McMaster, & Tucker, 2009; Bristow, de Berker, Acland, Turner, & Bowling, 2010). Clinical evaluation for skin cancer also includes a total body skin examination and palpation of regional lymph nodes, liver, and spleen (Rubin, 2010a).

Diagnostic tests: Skin cancer is diagnosed through biopsy. Biopsy of the suspected lesion is necessary to confirm the diagnosis via histological examination of the tissue; an adequate tissue sample should be excised, and an elliptical excision generally is necessary for larger lesions.

Excisional biopsy is recommended for any pigmented lesion (Nolen et al., 2011). (Kennedy-Malone 145) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file.

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MultipleChoice 4

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Question 5 .

Question : The appearance of a 2-10 cm. herald patch with subsequent development of parallel oval lesions on the trunk in a christmas tree distribution involving the upper arms and upper legs are common in: Student Answer: Pityriasis Rosea Shingles Psoriasis Lymes Disease Instructor Explanation: The patient is usually asymptomatic, although some complain of a prodromal period of malaise preceding the emergence of the rash. The rash is often pruritic. The first sign is typically a “herald patch,” which is a 2- to 10-cm annular pink patch that, similar to tinea, has an area of central clearing with a fine scale. The herald patch is most commonly located on the trunk. The herald patch is followed several days later by a more diffuse set of smaller pink, salmon, or fawn-colored lesions, which, at 0.5 to 1.5 cm, are much smaller than the herald patch. The distribution of the smaller lesions is described as “Christmas tree distribution” because the lesions have a slightly diagonal axis and are distributed along the skin tension lines. ( 73) , Mary J., Laurie Grubbs. Advanced Assessment Interpreting Findings and Formulating Differential Diagnoses, 3rd Edition. F.A. Davis Company, 11/2014. VitalBook file.

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Question 6 .

MultipleChoice 5 MultipleChoice

Advanced Practice Nursing 2e(Malone) Question : Mr. Fitzgerald is a 68-year-old previously healthy man with a history of significant sun exposure who presents with a progressively enlarging 18 x 16 mm erythematous pruritic oval patch on his left forearm that has been present for three to four years. Your differential would include all of the following EXCEPT: Student Answer:

Fungal skin infection Eczema

Seborrheic Keratosis Squamous cell carcinoma of the skin Instructor Explanation: MedU Card #7 -563888937 0

MultipleChoice 6

-563888937

MultipleChoice

Question 7 .

Question : What kind of lesions are caused by the herpes simplex virus?

Student Answer: Scales Vesicles Plaques Urticaria Instructor Explanation: The skin lesions of herpes consist of multiple vesicles, which cluster and are usually preceded by an area of tender erythema. The vesicles erode, forming ulcerations.

-563888936 0

MultipleChoice 7

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Question 8 .

Question : Among the following conditions, which needs to be treated with systemic antifungal agents?

Student Answer:

Tinea pedis/tinea magnum Tinea corporis/tinea cruris

Tinea capitis/Tinea unguium (onychomycosis) Tinea pedis /tinea faciale Instructor Explanation:

Advanced Practice Nursing 2e(Malone) MedU Card #9 -563888935 0

MultipleChoice 8

-563888935

MultipleChoice

Question 9 .

Question : Which lesions are typically located along the distribution of dermatome?

Student Answer: Scabies Herpes zoster Tinea Dyshidrosis Instructor Explanation: Signal symptoms: Cutaneous eruption of a dermatome distribution, burning or tingling skin sensation.

Description: Herpes zoster is an acute vesicular eruption caused by a virus histologically identical to the varicella (chickenpox) virus. Herpes zoster is human (alpha) herpes virus 3 (varicella-zoster virus [VZV]), a member of the herpes virus group.

Etiology: Recurrent VZV infection causes herpes zoster. The patient has initial contact with VZV in the form of chickenpox. The DNA virus resides within the neurons. During reactivation, the virus spreads across the sensory ganglion to other neurons, which causes a cutaneous eruption of a dermatome distribution (Fashner & Bell, 2011). Older adults have a decrease in cell-mediated immunity, which contributes to the risk of developing herpes zoster and postherpetic neuralgia (Barakzai & Fraser, 2008).

(Kennedy-Malone 132-133) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-0114. VitalBook file.

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MultipleChoice 9

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MultipleChoice

Question 10 .

Question : A smooth round nodule with a pearly gray border and central induration best describes which skin lesion?

Student Answer: Seborrheic keratosis Malignant melanoma Herpes zoster

Advanced Practice Nursing 2e(Malone) Basal cell carcinoma Instructor Explanation: There are three specific types of basal cell carcinoma: nodular, morpheaform, and superficial. Nodular BCC generally presents first as a dome-shaped, white-to-pink papule or nodule having a raised pearly border with prominent telangiectasia. BCC tumors can also have a brown to glossy black appearance (Gloster & Neal, 2006). Patients may describe this lesion as a pimple that did not heal. As the nodule enlarges, scaling, crusting, or central ulceration may become noticeable. It is important to note that the ulcerated areas can heal over with new scar tissue; however, the tumor grows deeper and the cycle of ulceration and healing begins again (Habif, 2004).

Superficial BCC often appears on the trunk and extremities. Characteristic of the superficial BCC is the presence of a well-circumscribed translucent or bright pink to red patch of skin surrounded often by telangiectasia. This type of BCC resembles other chronic skin conditions such as psoriasis, eczema, discoid lupus erythematous, and Bowen's disease. The least common type of BCC is the sclerosing or morpheaform tumor. Found on the head and neck and occasionally the trunk of the body, the lesion appears to be a hypopigmented tumor that eventually is surrounded by irregular telangiectasia with atrophic scarlike appearance (Nolen et al., 2011). (Kennedy-Malone 144-145) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014- 01-14. VitalBook file.

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MultipleChoice 10

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MultipleChoice

Question 11 .

Question : Cellulitis is a deep skin infection involving the dermis and subcutaneous tissues. The nurse practitioner suspects cellulitis in a 70-year-old Asian diabetic male presenting with reddened edematous skin around his nares. Which statement below will the nurse practitioner use in her decision-making process for the differential diagnosis pertaining to reddened edematous skin?

Student Answer:

Cellulitis is two times more common in women

Facial cellulitis is more common in people >55 There is low incidence of cellulitis in patients with diabetes Instructor Explanation: Cellulitis is only a disease of the lower extremities of patients with known arterial insufficiency Age: Cellulitis can occur at any age. Facial cellulitis is most common in people 50 years and older.

(Kennedy-Malone 128)

Advanced Practice Nursing 2e(Malone) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file.

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MultipleChoice 11

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Question 12 .

Question : Folliculitis is most commonly due to: Student Answer: Contact dermatitis Varicella zoster Dermatophytes Staphylococcal infection Instructor Explanation: Folliculitis is an inflammation of the hair follicles and is typically associated with staphylococci. Other microorganisms and causes include pseudomonas (associated with hot tubs), Candida, tinea barbae, and herpes.

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MultipleChoice 12

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MultipleChoice

Question 13 .

Question : The anti-inflammatory properties of topical corticosteroids result in part from their ability to induce vasoconstriction to the small blood vessels in the upper dermis. Of the following, which is the most potent topical corticosteroid?

Student Answer:

Hydrocortisone 2.5% Triamcinolone acetonide 0.1%

Betamethasone dipropionate 0.05% Alclometasone dipropionate 0.05% Instructor Explanation: MedU Card #8 -563888930 0

MultipleChoice 13

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Question 14

MultipleChoice

Advanced Practice Nursing 2e(Malone) .

Question : Which of the following descriptions accurately documents cellulitis?

Student Answer: Instructor Explanation: Cool, erythematous, shiny hairless extremity with decreased pulse Scattered, erythematous ring-like lesions with clear centers Clearly demarcated, raised erythematous area of face Diffusely inflamed skin that is warm and tender to palpation Signs and symptoms: Patients may complain of localized pain, fever, chills, rigors, malaise, anorexia, nausea, or headache, and, in severe cases, patients may have tachycardia, hypotension, and delirium (Nazarko, 2008b). Cellulitis most often appears on the lower extremities after a skin aberration, such as dermatitis, ulceration, trauma, or tinea pedis. Cellulitis can develop on the arms and the face as well.

Scars from previous cardiovascular surgery are common sites for recurrent cellulitis (Price, 2009).

Examine for skin temperature, note any breaks in the skin and ulcerations, and determine presence of pulses and sensation. Local erythema with edema and tenderness elicited by palpation are presenting signs of cellulitis. The skin can appear to look stretched, later taking on the appearance of an orange peel when the surface is infiltrated (Price, 2009). Depending on the organism of origin, large hemorrhagic bullae may be present. (Kennedy- Malone 128-129) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file.

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MultipleChoice 14

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MultipleChoice

Question 15 .

Question : Asymmetrical bi-color lesion with irregular border measuring 8 mm is found on the right lower arm of an adult patient. This assessment finding is consistent with: Student Answer: Melanoma Basal cell carcinoma Leukoplakia Senile lentigines Instructor Explanation:

Advanced Practice Nursing 2e(Malone) For patients with suspected melanoma, the mnemonic ABCDE guides the clinician in determining if the clinical characteristics of a suspicious lesion warrant close surveillance and/or biopsy for histological evaluation: •

Asymmetry

•

Border irregularity

•

Color variation

•

Diameter >6 mm

• Elevation of a previously flat lesion, evolving and enlarging (Halpern, Marghoob, & Sober, 2009; Rubin, 2010b).

It is important to note, however, than only one-third of melanoma cases follow the classic ABCDE pattern of development, and many forms of melanoma mimic benign lesions (Rubin, 2009).

(Kennedy-Malone 145) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014- 01-14. VitalBook file.

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MultipleChoice 15

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Question 16 .

Question : Which of the following descriptions best illustrates assessment findings consistent with tinea capitis?

Student Answer:

Circular erythematous patches with papular, scaly annular

borders and clear discharge Inflamed scaly dry patches with broken hairs Web lesions with erythema and scaling borders Scaly pruritic erythematous lesions on inguinal creases Instructor Explanation: Signs and symptoms: Dry scaling is a hallmark of each of the superficial fungal infections.

Tinea capitis presents as hair loss (alopecia). Grey patch tinea capitis often is circular in shape with the presence of many broken-off hairs and the scalp assumes a dull grey color due to the arthrospores that are formed by the fungi. Black dot tinea capitis occurs when hairs break off near the surface and give the appearance of dots. The

Advanced Practice Nursing 2e(Malone) dots may be scattered over the scalp and not form a classic round patch. A kerion is an inflammatory mass on the scalp that is painful and may include pustules and result in cervical or occipital adenopathy. (Kennedy-Malone 150) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank.

Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01- 14.

VitalBook file.

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MultipleChoice 16

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MultipleChoice

Question 17 .

Question : A patient has a tender, firm, nodular cystic lesion on his scalp that produces cheesy discharge with foul odor. This is most likely a: Student Answer: Bacterial folliculitis Basal cell carcinoma Bullous impetigo Epidermoid cyst Instructor Explanation: With an epidermoid cyst, the patient complains of a cystic lesion that produces cheesy discharge with foul odor. The lesion is sometimes tender or painful. The lesion is nodular, round and firm, and subcutaneous; thus, it is flesh colored. The most common sites include the face, scalp, neck, upper trunk, and extremities.

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MultipleChoice 17

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MultipleChoice

Question 18 .

Question : Patient presents with complaint of a “swollen node” under his arm. The area is tender and the node has progressed in size over the past few days. Which of the following should be included in your differential diagnosis?

Student Answer: Hidradenitis suppurativa Epidermoid cyst Furuncle

Advanced Practice Nursing 2e(Malone) Both

A

and

C

Instructor Explanation: Hidradenitis suppurativa involves occlusions of hair follicles, which causes a red, fluctuant tender lesion.

The site is commonly under the breast or in the axillae or groin. The clinician must differentiate this skin condition from an enlarged lymph node, which can appear similar. An enlarged lymph node is usually painless, whereas hidradenitis is usually tender. Furuncles are staphylococcal infections of hair follicles or sebaceous glands. Patients complain of pain, redness, and swelling at the affected site, commonly the axillae and groin.

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MultipleChoice 18

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MultipleChoice

Question 19 .

Question : A patient suffered a laceration of the shin three days ago, and today presents with a painful, warm, red swollen region around the area. The laceration has a purulent exudate. The clinician should recognize that the infected region is called: Student Answer: Contact dermatitis Folliculitis Hidradenitis suppurativa Cellulitis Instructor Explanation: In cellulitis, a patient often describes a history of a break in the skin from an injury, insect bite or sting, or previous procedure preceding the onset of redness, swelling, and pain at the site. The affected area is tender, swollen, reddened, and warm. Streptococcus or staphylococcal commonly causes the infection.

The lower leg is a common site, usually unilateral.

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MultipleChoice 19

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MultipleChoice

Question 20 .

Question : A woman complains of malaise and arthralgias. You note a butterfly-shaped, macular, erythematous rash across her cheeks and nose. These conditions are common in:

Advanced Practice Nursing 2e(Malone) Student Answer:

Psoriasis Lichen planus

Systemic lupus erythematosus Erythema nodosum Instructor Explanation: In systemic lupus erythematosus, the patient will have a range of symptoms relevant to the diagnosis, depending on the affected organs. There is often coexisting arthralgia and malaise. The rash is macular and erythematous. It is described as a “butterfly rash” because the distribution resembles a butterfly’s wings overlying the forehead and cheeks.

1

Question :

Which of the following best describes the pain associated with osteoarthritis?

Student Answer:

Constant, burning, and throbbing with an acute onset

Dull and primarily affected by exposure to cold and barometric pressure Begins upon arising and after prolonged weight bearing and/or use of the joint Begins in the morning and limits continued ambulation Instructor Explanation: Signs and symptoms: Complaints of morning stiffness lasting <30 minutes or stiffness that improves with activity and accompanying muscle spasms may indicate OA. Persistent pain and limitation of motion in the affected joint may be reported.

(Kennedy-Malone 402) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file.

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MultipleChoice 1

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Question 2 .

Question : Your 63-year-old Caucasian woman with polymyalgia rheumatica (PMR) will begin treatment with corticosteroids until the condition has resolved. You look over her records and it has been 2 years since her last physical examination and any laboratory or diagnostic tests as she relocated and had not yet identified a health-care provider. In prioritizing your management plan, your first orders should include:

Advanced Practice Nursing 2e(Malone) Student Answer: Instructor Explanation: Recommending she increase her dietary intake of Calcium and Vitamin D Ordering once a year bisphosphonate and a proton pump inhibitor Participate in a fall prevention program Dual-energy X-ray (DEXA) scan and updating immunizations Follow-up: Assess the patient for proximal pain, morning stiffness, resolution of constitutional symptoms, and adverse reaction to corticosteroids (Dasgupta et al., 2010). For patients with PMR, the ESR and/or Creactive protein need monitoring until the levels decrease and previously reported symptoms are alleviated. The CBC can be repeated to determine if the anemia has resolved. Initially, the patients will need to return every couple of weeks to evaluate the clinical response to therapy; this is followed by approximately an every-3-month surveillance to determine response to treatment and any adverse reactions to the long- term corticosteroids. Additional monitoring of urea and electrolytes and glucose should continue every 3 months while on corticosteroids (Dasgupta et al., 2010). Follow up on the results of the dual-energy x-ray absorptiometry scan. Consider prophylactic therapy to prevent osteoporosis with bisphosphonates with calcium and vitamin D supplementation. Patients also presenting with GCA need to be monitored in the same way, with repeated eye examinations as warranted, including examination for cataracts resulting from corticosteroid therapy (Paget & Spiera, 2006). Because patients with GCA are at risk for developing aortic aneurysm, follow-up abdominal examination for aortic aneurysm is needed.

This complication is of great concern especially with patients who are at high risk for developing aortic aneurysms such as patients who smoke, are hypertensive, and have arteriosclerotic heart disease (Unwin et al., 2006).

(Kennedy-Malone 407) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file.

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MultipleChoice 2

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MultipleChoice

Question 3 .

Question : In providing health teaching related to dietary restrictions, the nurse practitioner should advise a patient with gout to avoid which of the following dietary items: Student Answer:

Advanced Practice Nursing 2e(Malone) Green leafy vegetables Beer, sausage, fried seafood Sugar Gluten and bread items Instructor Explanation: Contributing factors: Factors associated with primary gout in men include positive family history, obesity, trauma, hypertension, hyperlipidemia, hypertriglyceridemia, diets high in purine (especially organ meats, anchovies, sardines, scallops, oatmeal), alcohol consumption (especially beer and moonshine whiskey), dietary intake of high-fructose corn syrup products, lead intoxication, dehydration, fasting (which causes ketosis), binge eating, analgesic nephropathy, nephrolithiasis, urolithiasis, and polycystic kidney disease (Choi & Curhan, 2008; Neogi, 2011) (Kennedy- Malone 394) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014- 01-14. VitalBook file.

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MultipleChoice 3

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Question 4 .

Question : A 33-year-old female reports general malaise, fatigue, stiffness, and pain in multiple joints of the body.

There is no history of systemic disease and no history of trauma. On physical examination, the patient has no swelling or decreased range of motion in any of the joints. She indicates specific points on the neck and shoulders that are particularly affected. She complains of tenderness upon palpation of the neck, both shoulders, hips, and medial regions of the knees. The clinician should include the following disorder in the list of potential diagnoses: Student Answer: Osteoarthritis Rheumatoid arthritis Fibromyalgia Polymyalgia rheumatica Instructor Explanation: In fibromyalgia, the most common symptoms are generalized pain, stiffness, and decreased ROM, with multiple-point tenderness. The diagnostic criteria currently rest on a patient reporting point tenderness in at least 11 of 18 specified sites (Fig. 14.1) in addition to the presence of widespread pain for at least 3 months. The most common tender sites are in the neck, shoulders, spine, and hips. Other common symptoms include morning stiffness, anxiety, depression, sleep disturbances, “brain fog,” and irritable bowel syndrome.

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MultipleChoice 4

-559260839

Question 5

MultipleChoice

Advanced Practice Nursing 2e(Malone) .

Question : A 46-year-old female complains of fatigue, general malaise, and pain and swelling in her hands that has gradually worsened over the last few weeks. She reports that pain, stiffness, and swelling of her hands are most severe in the morning. On physical examination, you note swelling of the metacarpophalangeal joints bilaterally. These are common signs of: Student Answer: Osteoarthritis Rheumatoid arthritis Scleroderma Sarcoidosis Instructor Explanation: RA typically affects the joints symmetrically. Symptoms may wax and wane, but the effects are cumulative and progressive. Although RA can affect any joint, it commonly affects the small joints of the hands and feet, and this is often helpful in diagnosis. There is often history of prolonged morning stiffness and fatigue. Affected joints are often tender, swollen with effusions, warm, and inflamed. The disease most commonly affects metacarpophalangeal and proximal interphalangeal joints.

-559260838 0

MultipleChoice 5

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MultipleChoice

Question 6 .

Question : Which of the following statements about osteoarthritis is true?

Student Answer: It affects primarily weight-bearing joints It is a systemic inflammatory illness The metacarpal phalangeal joints are commonly involved Prolonged morning stiffness is common Instructor Explanation: Osteoarthritis (OA), still also referred to as degenerative joint disease, is a degenerative disease of the joint cartilage. It is the leading cause of disability in older adults in the United States (Lawrence et al., 2008). OA most commonly affects the hips, knees, and cervical and lumbar spine.

Joint deformity with minimal pain is found in the DIP and PIP joints of the hand, the first carpometacarpal joint, and the first metatarsophalangeal joint (Shelton, 2013). OA is a complex active disease process involving the wearing away (degradation) and, to a lesser extent, the repair of the cartilage surface. It is now understood that there is both a mechanical (wearing away) and a biological (abnormal joint biology) part of the osteoarthritis (Ling & Rudolph, 2006). Besides the cartilage

Advanced Practice Nursing 2e(Malone) degeneration, patients often experience neurological and mechanical dysfunction (Chao & Kalunian, 2010). (Kennedy-Malone 402) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file.

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Question 7 .

Question : The most appropriate first-line treatment for an acute gout flare is (assuming no kidney disease or elevated bleeding risk): Student Answer:

Indomethacin 50 mg thrice daily for 2 days; then 25 mg thrice

daily for 3 days Doxycycline 100 mg twice daily for 5 days Prednisolone 35 mg four times a day for 5 days Ice therapy Instructor Explanation: Treatment: NSAIDs, corticosteroids, and oral colchicine are acceptable first-line options for treatment of acute gout with treatment started within 24 hours of attack onset. Management of the older adult with gout requires careful monitoring. Older adults are susceptible to renal insufficiency, may have other concomitant diseases, and experience hypersensitivity to some of the medications used to treat younger patients with gout. NSAIDs should be used cautiously in the treatment of gout in older adults who have a history of heart failure, renal failure, and gastrointestinal conditions (Fravel & Ernst, 2011). As with any NSAID, renal function must be monitored. NSAIDs can endanger existing renal function, especially when the creatinine clearance is ≤30 mL/min.

Additional concern with NSAID use in older adults is the potential for gastrointestinal bleeding due to NSAID-induced peptic ulcers. An exacerbation of hypertension can occur with excessive use of NSAIDs in older adults. Extensive use of NSAIDs can lead to fluid retention and antagonism of diuretic therapy, which may precipitate heart failure (Fravel & Ernst, 2011).

Indomethacin is effective in the treatment of acute gout; the usual dose is 25 to 50 mg orally 2 to 3 times daily until the symptoms cease, then begin to taper the dose for 5 to 7 days. Liquid indomethacin is available for patient use. Although indomethacin has been traditionally favored in the treatment of gout, there has been no research documenting the advantage to its use over other NSAIDs such as naproxen (Zychowicz et. al, 2010). As with any NSAID, renal function must be monitored. NSAIDs can endanger existing renal function, especially when the creatinine clearance is ≤30 mL/min. Cyclooxygenase-2 inhibitors may be better tolerated in older adults with history of peptic ulcer.

Colchicine can be given for acute gout attacks orally. It is most effective

Advanced Practice Nursing 2e(Malone) if given within 24 hours of an attack. The oral colchicine dose is 1.2 mg followed by a single 0.6 mg dose 1 hour later. Dose should not exceed 1.8 mg a day for an acute flare. Consensus guidelines indicate that colchicine is not to be used in patients with a creatinine clearance of <10 mL/min. (Hanlon et al., 2009).

(Kennedy-Malone 395-396) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file.

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Question 8 .

Question : A 34-year-old female presents with fever, general malaise, fatigue, arthralgias and rash for the last 2 weeks. On physical examination, you note facial erythema across the nose and cheeks. Serum diagnostic tests reveal positive antinuclear antibodies, anti-DNA antibodies, elevated C-reactive protein and erythrocyte sedimentation rate. The clinician should include the following disorder in the list of potential problems: Student Answer: Fibromyalgia Sarcoidosis Systemic lupus erythematosus Rheumatoid arthritis Instructor Explanation: SLE has many potential symptoms. The classic findings include a malar rash. Patients often have arthralgias, myalgias, fever, fatigue, Raynaud’s syndrome, and neuropathy. SLE effects depend on the organs involved and diagnosis can be difficult. A positive ANA occurs at some point in the condition in the majority of patients but is neither consistent nor specific for SLE. Positive anti-DNA and lupus erythematosus prep are also common to SLE.

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Question 9 .

Question : Your 66-year-old male patient has recently started treatment for metabolic syndrome and is currently taking the following medications: an ACE inhibitor and beta blocker for treatment of hypertension. He is also taking a statin medication, simvastatin for hyperlipidemia, and a biguanide, metformin, for type 2

Advanced Practice Nursing 2e(Malone) diabetes. The patient complains of myalgias of the legs bilaterally and blood work shows elevated serum creatine kinase. Which of the medications can cause such a side effect?

Student Answer: Beta blocker ACE inhibitor Statin medication Metformin Instructor Explanation: Myalgias are a side effect of lipid-lowering medications called “statins.” If the myalgia is related to rhabdomyolysis, the urine is often reddish-brown. When drug- induced myalgia is present, there is often eosinophilia. For rhabdomyolysis myalgia, the serum creatine kinase is significantly elevated.

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Question 10 .

Question : A 20-year-old male construction worker is experiencing new onset of knee pain. He complains of right knee pain when kneeling, squatting, or walking up and down stairs. On physical examination, there is swelling and crepitus of the right knee and obvious pain with resisted range of motion of the knee. He is unable to squat due to pain. Which of the following disorders should be considered in the differential diagnosis?

Student Answer: Joint infection Chondromalacia patella Prepatellar bursitis All of the above Instructor Explanation: Prepatellar bursitis is also called housemaid’s knee, which is common to persons whose occupation requires extended periods of kneeling, such as plumbers and carpet layers. This bursitis can also be caused by an infection. The patient complains of pain in the area inferior to and over the patella, and there is swelling and inflammation of the bursa. Chondromalacia patella is seen in young active persons of either gender. The condition is also commonly called patella-femoral syndrome and runner’s knee. The pain involves the anterior knee, often develops gradually, and is moderate in intensity. Pain can be reproduced by pressing the patella against the femoral condyles, and there is tenderness around the patella. Other maneuvers that reproduce the pain include applying pressure against the patella as the patient extends the lower leg, flexing the quadriceps, and moving the patella from side to side. Crepitus and effusion are often present.

Decision Rule in Chondromalacia Patella:

Advanced Practice Nursing 2e(Malone) Two or more of the following symptoms (pain reported on muscle contraction, squatting, or kneeling) is associated with 60% sensitivity and 85% specificity for patellofemoral pain syndrome. Of these, the one maneuver with greatest diagnostic strength is pain on resisted contraction (Cook et al., 2010).

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Question 11 .

Question : A 17-year-old male complains of severe right knee pain. He was playing football when he heard a “pop” at the moment of being tackled and his knee “gave away” from under him. On physical examination, there is right knee swelling and decreased range of motion. There is a positive anterior drawer sign. These findings indicate: Student Answer: Knee ligament injury Osgood-Schlatter disease Prepatellar bursitis Chondromalacia patella Instructor Explanation: The anterior, medial, and lateral knee ligaments are vulnerable to injury in athletic activities. The mechanism through which the anterior cruciate ligament (ACL) is typically injured involves deceleration combined with sudden turning or pivoting. The medial collateral ligament (MCL) is most prone to injury through motions that place valgus stress on the knee.

Compared with ACL and MCL injury, damage to the lateral collateral ligament (LCL) is much rarer but typically occurs when sudden varus stress is placed on the knee. The patient often relates history of an acute trauma followed by the onset of pain, swelling, and limited mobility. Often patients recall hearing or feeling a “pop” at the moment of injury and/or “give-away” sense. ACL injury is identified through a positive drawer (Fig. 14.9) and/or Lachman’s test (Fig. 14.10). Laxity of the LCL is assessed by placing varus stress on the knee with the leg both extended and flexed.

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Question 12 .

Question : A 55-year-old patient complains of lower back pain due to heavy lifting at work yesterday. He reports weakness of the left leg and paresthesias in the left foot. On physical examination, the patient has diminished ability to dorsiflex the left ankle. Which of the following symptoms should prompt the clinician to make immediate referral to a neurosurgeon?

Advanced Practice Nursing 2e(Malone) Student Answer: Straight leg raising sign Lumbar herniated disc on X-ray Loss of left sided patellar reflex Urinary incontinence Instructor Explanation: With low back pain in a patient, it is important to obtain a detailed history of the onset and progression of the pain. A thorough pain history should be completed, noting its quality, location, radiation, and intensity as well as any exacerbating and relieving factors. A thorough review of systems is necessary to identify any associated symptoms that may indicate an urgent problem. These include altered bowel and/or bladder function, fever, weight loss, and/or weakness. The physical examination should begin by noting the patient’s posture and apparent level of comfort. The standing patient should be directed through a series of maneuvers to assess the back motion, including flexion, hyperextension, lateral flexion, and rotation, as the smoothness of motion, ROM, and any obvious signs of discomfort are noted. Observe the patient walking on heels and on toes, noting any signs of weakness. Next, with the patient resting supine on the examination table, the straight leg maneuver should be performed. As the patient rests supine with both legs extended, the examiner should passively elevate one leg at a time. A positive test is indicated if the patient experiences discomfort with the initial elevation rather than once the hip has been hyperflexed beyond 50 degrees. If the results indicate nerve impingement or disk injury, further radiographic testing is then indicated.

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Question 13 .

Question : Your patient is a 43-year-old female golfer who complains of arm pain. On physical examination, there is point tenderness on the elbow and pain when the patient is asked to flex the wrist against the clinician’s resistance. These are typical signs of: Student Answer: Carpal tunnel syndrome Osteoarthritis of the wrist Epicondylitis Cervical osteoarthritis Instructor Explanation: Carpal tunnel syndrome causes a range of neurological symptoms, including pain, paresthesia, and weakness. Frequently, nighttime pain is an early symptom. There may be a swelling at the wrist related to inactivity or flexion at night. The pain and/or paresthesias typically involve the anterior aspects of wrist, medial palm, and first three digits on the affected hand.

However, pain may radiate up the forearm to the shoulder with numbness and tingling along the median nerve. Over time, hand weakness often develops. Pain and paresthesia are often relieved by the patient “shaking” the affected hand in a downward fashion; this is called the flicking sign. A positive Tinel’s sign

Advanced Practice Nursing 2e(Malone) is elicited by tapping on the median nerve at the carpal tunnel, causing pain and tingling along the median nerve. Phalen’s maneuver reproduces the pain after 1 minute of wrist flexion against resistance.

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Question 14 .

Question : Which of the following describes the pathology of De Quervain’s tenosynovitis?

Student Answer:

Irritation of a tendon located on the radial side of the wrist,

near the thumb Impingement of the median nerve, causing pain in the palm and fingers Fluid-filled cyst that typically develops adjacent to a tendon sheath in the wrist Ulnar nerve compression at the olecranon process Instructor Explanation: De Quervain’s tenosynovitis involves irritation of a tendon located on the radial side of the wrist, near the thumb. With overuse, the tissues surrounding the tendon sheath hypertrophy, causing pressure on the tendon and making it difficult to move. The pain is usually limited to the radial aspect of the wrist and area immediately around the base of the thumb. Pain increases with use of the hand, such as with gripping maneuvers. Other symptoms include swelling, decreased sensation, and limited ROM with a locking sensation with thumb motion. The Finkelstein maneuver (Fig. 14.7) is used to diagnose De Quervain’s disease. A positive test results in pain, which is often severe. Patients who can repeatedly open and close the fist with smooth thumb motion are unlikely to have De Quervain’s.

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Question 15 .

Question : What is the most common cause of hip pain in older adults?

Student Answer:

Advanced Practice Nursing 2e(Malone) Osteoporosis Osteoarthritis Trauma due to fall Trochanteric bursitis Instructor Explanation: There are many potential causes of hip pain. Among adults, the most common cause is OA with degenerative changes. In younger patients, the cause is often strain of the muscles or tendons. In comparison to other joints, the hip is often difficult to assess, in part because much of the joint and its periarticular structures lie deeper than those of other joints.

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Question 16 .

Question : A 43-year-old female was in a bicycling accident and complains of severe pain of the right foot. The patient limps into the emergency room. On physical examination, there is no point tenderness over the medial or lateral ankle malleolus. There is no foot tenderness except at the base of the fifth metatarsal bone.

According to the Ottawa foot rules, should an X-ray of the feet be ordered?

Student Answer: a. b. c. d.

Yes, there is tenderness over the fifth metatarsal No, there is not tenderness over the navicular bone Yes, the patient cannot bear weight on the foot A and C

Instructor Explanation: Bone tenderness at navicular or base of fifth metatarsal Sensitivity = 100% Specificity = 79% . And FYI:The following Ottawa rules recommend x-ray of the ankle if either one of the following conditions exist:

Question 17 38-year-old Asian male, Mr. Chen, with past medical history significant for prehypertension who has recently taken up softball presents with three to five weeks of shoulder pain when throwing overhead. Ice minimally alleviates pain. Medications: Naproxen minimally alleviates shoulder pain. Allergies: Penicillin- associated rash. Family history: Brother has rheumatoid arthritis.

Advanced Practice Nursing 2e(Malone) Which of the following musculoskeletal causes of shoulder pain would merit urgent diagnosis and management?

Student Answer: Adhesive capsulitis Septic subacromial bursitis Impingement of the supraspinatus tendon Calcific tendinopathy Instructor Explanation: MedU Card #3 Delay in recognition and treatment of a septic subacromial bursitis may lead to local tissue destruction and loss of function, extension of infection locally to deeper spaces such as bone (osteomyelitis) or more distant sites by way of bacteremia and that may progress to sepsis.

Question 18 If Mr. Chen had restricted passive as well as active ROM of the shoulder, what problems involving the shoulder might you consider?

Student Answer: a. b. c. d.

Adhesive capsulitis Rotator cuff tear Tendinopathy of the long head of the biceps Rotator cuff impingment

Instructor Explanation: MedU Card #7 A patient with loss of active and passive ROM is more likely to have joint disease; whereas a patient with loss of only active ROM is more likely to have an issue with muscle tissue.

The following joint diseases will produce restricted active and passive ROM of the shoulder: • Adhesive capsulitis, a condition common in patients with metabolic diseases such as diabetes and hypothyroidism in which there is contracture of the joint capsule • Glenohumeral arthritis, a much less common site of osteoarthritis than the primary weightbearing joints of the lower extremity

Question 19: What is the essential dynamic stabilizer of the shoulder joint?

Student Answer: a. b. c. d.

Labrum Rotator muscle group Glenohumeral ligaments Teres major muscle

Advanced Practice Nursing 2e(Malone) Instructor Explanation: MedU Card #10

Question 20 Given Mr. Chen’s repetitive overhead activities, some injury to his rotator cuff muscle group is most likely. Of the following exam findings, which one would not support the diagnosis of rotator cuff tendinopathy?

Student Answer: a. b. c. d.

Positive Apley’s Scratch test Weakness and pain with empty can testing Limited active ROM Inability to raise arm above his head

Instructor Explanation: MedU Card #15 Limited ROM with significant pain is a hallmark of the physical exam in the patient with a partial or complete rotator cuff tear. In a complete tear, the patient will likely not be able to raise his arm above his head.

Advanced Practice Nursing 2e(Malone)

Chapter 19: Palliative Care and End-of-Life Care Question 1: When assessing a patient who complains of a tremor, the nurse practitioner must differentiate essential tremor from the tremor of Parkinson’s disease. Which of the following findings are consistent with essential tremor?

Student Answer: • • • •

The handwriting is not affected by the tremor The tremor occurs with purposeful movements The tremor occurs at rest The tremor gets worse with alcohol ingestion

Instructor Explanation: Unilateral pill-rolling tremor at rest is usually the first symptom. The tremor is maximal at rest but absent during sleep and can be differentiated from essential tremor, which is absent at rest and worsens with voluntary movement. The bradykinesia of PD affects gross and fine motor movement, speech volume, swallowing, and blinking. There is generally no muscle weakness, and deep tendon reflexes are normal.

Although Alzheimer's disease can manifest with rigidity, bradykinesia, and gait disorders, no resting tremor is seen with Alzheimer's. Nonspecific secondary manifestations include cognitive dysfunction, sleep disturbances, constipation, dysphagia, blurred or double vision, nocturia, frequency, urgency, autonomic dysfunction (e.g., erectile dysfunction), dizziness, and drooling. ( 463) , Mary J., Laurie Grubbs. Advanced Assessment Interpreting Findings and Formulating Differential Diagnoses, 3rd Edition. F.A. Davis Company, 11/2014. VitalBook file.

Question 2: Which of the following statements is true concerning anti- arrhythmic drugs?

Student Answer: a.

Amiodarone is the only one not associated with increased mortality and it has a very favorable side effect profile

Advanced Practice Nursing 2e(Malone) b. c.

Both long-acting and short-acting calcium channel blockers are associated with an increased risk of cardiovascular morbidity and mortality.

Most anti-arrhythmics have a low toxic/therapeutic ratio and some are exceedingly toxic.

d.

Anti-arrhymic therapy should be initiated in the hospital for all patients.

Question 3: What is the most common cause of hip pain in older adults? a. b. c. d.

Student Answer: Osteoporosis Osteoarthritis Trauma due to fall Trochanteric bursitis

Question 4 Which patient is most likely to have osteoporosis? * Times are displayed in (G

7:00) Mountain Time (US & Canada)

Student Answer: You are beginning the examination of the skin on a 25-year-old teacher. You have previously elicited that she came to the office for evaluation of fatigue, weight gain, and hair loss. You strongly suspect that she has hypothyroidism. What is the expected moisture and texture of the skin of a patient with hypothyroidism?

Dry and smooth Dry and rough

Question 5:Joint pain and are trying to decide whether it is inflammatory or noninflammatory in nature.

Which one of ent with an inflammatory process?

Student Answer: a. b. c. d.

Tenderness Cool temperature Ecchymosis Nodules