NURS 6560 Advanced Practice Care of Adults in Acute Care Settings II FINAL EXAM. WALDEN UNIVERSITY N

WALDEN UNIV 6560 FINAL EXAM (GRADED A) NURS 6560 FINAL EXAM (GRADED A The AGACNP is reviewing a chart of a head-injured patient. Which of the following would alert the AGACNP for the possibility that the patient is over hydrated, thereby increasing the risk for increased intracranial pressure?

BUN = 10 Shift output = 800 ml, shift input = 825

ml

Unchanged

weight Serum osmolality = 260

A patient who has been in the intensive care unit for 17 days develops hypernatremic hyperosmolality. The patient weighs 132 lb (59.9 kg), is intubated, and is receiving mechanical ventilation. The serum osmolality is 320 mOsm/L kg H2O. Clinical signs include tachycardia and hypotension. The adult-gerontology acute care nurse practitioner's initial treatment is to: reduce serum osmolality by infusing a 5% dextrose in 0.2% sodium chloride solution reduce serum sodium concentration by infusing a 0.45% sodium chloride solution replenish volume by infusing a 0.9% sodium chloride solution replenish volume by infusing a 5% dextrose in water solution.

A 16-year-old male presents with fever and right lower quadrant discomfort. He complains of nausea and has had one episode of vomiting, but he denies any diarrhea. His vital signs are as follows: temperature 101.9°F, pulse 100 bpm, respirations 16 breaths per minute, and blood pressure 110/70 mm Hg. A complete blood count reveals a WBC count of 19,100 cells/µL. The AGACNP expects that physical examination will reveal: + Murphy’s sign + Chvostek’s sign + McBurney’s sign + Kernig’s sign

Myasthenia gravis is best described as: An imbalance of dopamine and acetylcholine in the basal ganglia Demyelination of peripheral ascending nerves

Demyelination

in

the

central

nervous

system An autoimmune disorder characterized by decreased neuromuscular activation

Mrs. Coates is a 65-year-old female who is on postoperative day 1 following a duodenal resection for a bleeding ulcer. She had an uneventful immediate postoperative course, but throughout the course of day 1 she has complained of a mild abdominal discomfort that has progressed throughout the day. This evening the AGACNP is called to the bedside to evaluate the patient for persistent and progressive discomfort. Likely causes of her symptoms include all of the following except: Colic due to return of peristalsis Leakage from the duodenal stump Gastric retention Hemorrhage

Mrs. Coates is a 65-year-old female who is on postoperative day 1 following a duodenal resection for a bleeding ulcer. She had an uneventful immediate postoperative course, but throughout the course of day 1 she has complained of a mild abdominal discomfort that has progressed throughout the day. This evening the AGACNP is called to the bedside to evaluate the patient for persistent and progressive discomfort. Likely causes of her symptoms include all of the following except: Colic due to return of peristalsis Leakage from the duodenal stump Gastric retention Hemorrhage

When a patient is hospitalized with a possible stroke, the AGACNP recognizes that the stroke most likely resulted from a subarachnoid hemorrhage when the patient’s family reports that the patient: Has

a

history

of

atrial

fibrillation Was unable to be aroused in the morning Had been complaining of a headache before losing consciousness Has had several brief episodes of mental confusion and right arm and leg weakness

You are asked to see a 29 year old female complaining of abdominal pain. She states she is experiencing

constant RUQ pain that radiates to her back. The pain is not relieved by bowel movements, over the counter antacids or food. Review of initial labs shows elevated amylase and lipase and you diagnose her with acute pancreatitis. Which test will you order next to determine the underlying cause of her pancreatitis? serum

cholesterol

level

blood

toxicology right upper quadrant ultrasound endoscopy

Jake is a 32-year-old patient who is recovering from major abdominal surgery and organ resection following a catastrophic motor vehicle accident. Due to the nature of his injuries, a large portion of his jejunum had to be resected. In planning for his recovery and nutritional needs, the AGACNP considers that: He will probably be able to transition to oral nutrition but will have lifetime issues with diarrhea His absorption

procedure

has

put

him

at

significant

risk

for

B12

problems

Most jejunum absorption functions will be assumed by the ileum Enteral nutrition will need to be delayed for 3 to 6 months to facilitate adaptation

A 32-year-old man comes to the clinic because he has had pain in the back for the past 24 hours. The patient says he first noticed the pain when he awoke in the morning and had difficulty getting out of bed. He had been playing flag football the day before the pain began but did not sustain any injuries during the game.

Acetaminophen has provided only minimal relief of the patient's pain. On physical examination, pain is elicited on palpation of the back on the left, lateral to the region of L2-L5. Full range of motion is noted in vertebral flexion, extension, lateral rotation, and lateral bending, with some hesitancy because of pain on the left side.

Which of the following is the most appropriate initial step?

Anti-inflammatory and muscle relaxant therapy Epidural injection of a corticosteroid MRI of the lumbar spine Strict bed rest and application of moist heat to the lower back

On postoperative day 7 following hepatic transplant, the patient evidences signs and symptoms of acute rejection, confirmed by histologic examination. The AGACNP knows that first-line treatment of acute rejection consists of: Cyclosporine Azathioprine Methylprednisolone Sirolimus

H. W. is a 33-year-old female who is being evaluated after a fall from a tree. Anteroposterior and lateral radiographs of the thoracolumbosacral spine are significant for transverse process fractures at T6 and T7. The AGACNP knows that treatment for this likely will include: Observation Hyperextension casting Jewett brace Surgical intervention

Acute hepatitis A is usually diagnosed by: By the constitutional symptoms Within

2

weeks

of

exposure Detection of IgM-Anti-HAV Jaundice

A 30-year-old male patient presents for evaluation of a lump on his neck. He denies pain, itch, erythema, edema, or any other symptoms. He is ^concerned because it won't ^ go away. He says, ―I noticed it a few months ago, then it seemed to disappear, and now it is back.‖ The AGACNP proceeds with a history and physical exam and concludes which of the following as the leading differential diagnosis?

Subclinical infection Non-Hodgkin's lyphoma Catscratch

disease

Syphilis

P. E. is a 61-year-old female who presents for a postoperative visit following a gastric resection after a perforation of peptic ulcer. She reports feeling better, although it is taking longer than she expected. However, she says she is feeling better each day, her appetite is returning, and her incision is healing well. She is being discharged from surgical care and advised to continue her routine health promotion follow-up with her primary care provider. As part of her surgical discharge teaching, the AGACNP counsels P. E. that as a result of her gastric resection she will need lifelong follow-up of: Blood group substances Electrolytes Vitamin B12 Gastric pH

T. O. is a 31-year-old male patient who is transported to the emergency department via emergency services. He was in a multivehicle accident and was trapped in a crushed car for more than 3 hours. On examination, his right lower extremity is found to be tensely swollen, with 3+ nonpitting edema. The lower leg is profoundly

painful with passive range of motion. Given the history and physical findings, the AGACNP recognizes that treatment centers around: Fasciotomy Thrombolytics Surgical reduction Casting

While consulting on a patient who is admitted with a chief complaint of abdominal pain, the AGACNP notes that the initial assessment described the pain as ―colicky.‖ This means that the pain: Is a result of gas in the bowel

Is

intestinal

in

origin Is characterized by pain-free intervals s sharp, intense, and nonradiating

All of the following are expected findings in a patient with a T10 fracture except: Paraplegia Fecal

retention

Priapism Inability to move fingers

T. O. is a 44-year-old female patient who presents for evaluation of sudden, severe upper abdominal pain. She is clear about the onset, which was profound and occurred approximately one hour ago. She denies that the onset had any relationship to food or eating, and she denies nausea or vomiting. On examination, she is lying on her right side with her hips and knees flexed to draw her knees to her chest. Vital signs are stable, but examination reveals involuntary guarding. The abdomen is painful and tympanic to percussion in all quadrants. CBC reveals a white blood cell count of 15,600/µL. The AGACNP suspects: Dissecting

aortic

aneurysm

Acute

pancreatitis Perforated peptic ulcer Mallory-Weiss tear

The AGACNP is covering an internal medicine service and is paged by staff to see a patient who has just pulled out his ET tube. After the situation has been assessed, it is clear that the patient will go into respiratory failure and likely die if he is not reintubated. The patient is awake and alert and is adamant that he does not want to be

reintubated. The AGACNP is concerned that there is not enough time to establish a DNR—the patient needs to be reintubated immediately and already is becoming obtunded. Which ethical principles are in conflict here?

Veracity

and

beneficence

Beneficence

and

nonmalfeasance Autonomy

and

beneficence

Justice and autonomy

In myelodysplastic syndromes, the primary indications for splenectomy include: Major

hemolysis

unresponsive

to

medical

management Severe symptoms of massive splenomegaly Sustained leukocyte elevation above 30,000 cells/µL Portal hypertension

Which of the following situations constitute a positive screening after a PPD (purified protein derivative) skin test for tuberculosis?

A patient without risk factors who has a 13mm PPD skin test A patient with HIV who has a 3mm PPD skin test A

homeless

patient

with

a

9mm

PPD

skin

test A patient with intravenous drug abuse (IVDA) who has an 11mm PPD skin test A healthcare worker who has a 6mm PPD skin test

When the patient with jaundice is evaluated, a careful history and physical exam often can help differentiate prehepatic, hepatic, and posthepatic causes. When the patient reports dark discoloration of the urine and light discoloration of the stool, the AGACNP is most suspicious for: Viral

hepatitis

Chronic alcoholism Extrahepatic obstruction Cholestasis

Jack R. is a 63-year-old male who is being seen today on rounds after being admitted for profound upper abdominal pain, nausea, and vomiting. He had markedly elevated serum amylase and lipase; he was diagnosed with pancreatitis and admitted for pain management and bowel rest. Today he feels better, but he is upset

because he knows that pancreatitis is known as the ―alcoholic’s disease.‖ He makes it clear that he is a religious man and that his religion forbids alcohol; he says he has never had an alcoholic drink in his life. The AGACNP reassures Jack that approximately 40% of cases of pancreatitis are caused by

as well as a variety of other

things, and that he will have a thorough diagnostic evaluation. hyperlipidemia gallstone

disease

genetic predisposition hypercalcemia In neurogenic shock, patients are subjected to an abnormal dilation of venules and arterioles in response to failure of the autonomic nervous system. Treatment for neurogenic shock may include all of the following except: Trendelenburg Intravenous fluids Vasodilators Vasoconstrictors

Which of the following is a true statement with respect to the use of corticosteroids in posttransplant patients? High-dose initial steroids are tapered to off over a period of 4 to 6 weeks posttransplant There is a strong interest in developing corticosteroid-free posttransplant protocols Better results are demonstrated in corticosteroid-free protocols for second-transplant recipients Evidence supports corticosteroid-free rejection protocols The comprehensive serologic assessment of a patient with Cushing’s syndrome is likely to produce which constellation of findings?

Low potassium, high glucose, high white blood cell count High sodium, polycythemia, low BUN Low sodium, low potassium, high BUN High sodium, high chloride, high RBCs

A patient admitted for management of sepsis is critically ill and wants to talk with a hospital representative about donating her organs if she dies. She has a fairly complex medical history that includes traumatic brain injury, breast cancer, and dialysis-dependent renal failure. The patient is advised that she is ineligible to donate due to her: Renal failure Traumatic

brain

injury

Systemic

infection Breast cancer

Elmer is a 61-year-old male who is admitted vomiting bright red blood. He has no known medical history— he has not been in the health care system for most of his adult life. He has lost a lot of volume, and his vital signs are borderline unstable with a blood pressure of 88/58 mm Hg, pulse of 118 bpm, respiratory rate of 12 bpm, and a temperature of 97.6°F. The AGACNP recognizes that the leading differentials include all of the following except: Peptic ulcer Portal hypertension Gastritis Zollinger-Ellison syndrome

T. S. is a 31-year-old female who is admitted following a catastrophic industrial accident. She had multiple injuries, and after a 10-day hospital stay that included several operations and attempts to save her, she is declared brain dead. She had an organ donor notation on her driver’s license. Which of the following circumstances precludes her from serving as a liver donor?

Encephalopathy Hepatitis C infection A long history of alcohol use Biliary cirrhosis

M. N. is a 61-year-old male who is referred to the emergency department by a local retail clinic. M. N. has not had regular health care at any time in his adult life; he says he doesn’t know when he last saw a doctor. His daughter finally talked him into going to the local retail health clinic when his abdomen became so distended that he couldn’t pull his pants up. M. N. says that he has put on some weight over the last few weeks but he has not felt ill. He admits to drinking > 4 drinks of whiskey daily; he says he smokes 2 packs of cigarettes a day and is not very active. He has lived alone since his divorce 20 years ago. Physical examination reveals an adult male who is chronically ill in appearance and appears older than stated age. His vital signs are within normal limits, and physical examination is significant only for obvious ascites. Paracentesis and subsequent analysis of the fluid reveals an ascites LDH to serum LDH ratio of 0.8. The AGACNP knows that this ratio is highly suspicious for: Pancreatic disease Cirrhosis Cancer

Autoimmune hepatitis The AGACNP is treating a patient with ascites. After a regimen of 200 mg of spironolactone daily, the patient demonstrates a weight loss of 0.75 kg/day. The best approach to this patient’s management is to: Continue the current regimen D/C the spironolactone and begin a loop diuretic

Add

spironolactone

a

loop

Proceed

diuretic to

to

the

large-volume

paracentesis

The AGACNP knows that following bilateral total adrenalectomy, the patient will require: Prednisone 15 mg qam and 10 mg qpm Tapering of IV hydrocortisone, beginning with 100 mg IV q8h on postoperative day 1 Initial fludrocortisone replacement, tapered off once maintenance hydrocortisone dose is achieved Individualized replacement of corticosteroid, mineralocorticoid, and androgen hormones

Josh is a 14-year-old male patient who presents for evaluation of blurred vision. His only significant injury is that over the weekend he was playing baseball and was hit in the side of the head by a flying ball. The hit was hard enough to knock him down, but he did not lose consciousness and had no remarkable symptoms. Now on Wednesday he presents with a dull headache that seems to be getting worse, and his mom wants to have him evaluated. Neurologic examination reveals a sluggish pupillary response. CT scan of the head reveals a 1 cm epidural hematoma. The AGACNP knows that the best approach to management would be: Cautious observation An osmotic diuretic Surgical consultation Emergency evacuation

Mary W. is a 39-year-old female who presents with persistent abdominal discomfort. She denies actual pain but says she has this persistent sense of fullness in her abdomen that feels like it would go away if she could have a bowel movement. This finding is known as: Somatic pain Gas stoppage sign Small

bowel

obstruction

Large

bowel obstruction

Tim is an 20 year old junior at Notre Dame and injured his right knee during an intramural football game and comes to the ER complaining of severe pain. Tim tells you that he was setting up to pass the football when he was tackled and he immediately felt his knee "pop" and buckle as he fell. You, as the AGACNP, know the most important information to obtain from Tim is: Insurance information Family history Social history What exactly was he doing when he got hurt

Mrs. Nguyen is an 84-year-old female who suffered a fall in her long-term care facility. After assessing possible reasons for her fall, a physical examination is performed to look for injuries. Mrs. Nguyen has significant pain in her left upper arm and limited range of motion in her left shoulder; a shoulder trauma series is ordered to evaluate for which type of injury that frequently occurs in these circumstances?

Shoulder dislocation Scapular fracture Proximal humerus fracture Nursemaid’s elbow

A general principle in surgical oncology is that the best approach to curative surgery in a fixed tumor requires: En bloc resection Adjuvant

therapies

Neoadjuvant

therapies

Elective

lymph

node

dissection Intracranial pressure monitoring is instituted for a patient with a head injury. The patient’s arterial blood pressure is 92/50 mm Hg, and her intracranial pressure is 18 mm Hg. Using these values to calculate the patient’s cerebral pressure (CPP) the AGACNP determines: The CPP is adequate for normal cerebral blood flow The CPP is high and that ischemia and neuronal death are imminent The blood pressure should be increased to prevent cerebral hypoxia Lowering the patients blood pressure will reduce the intracranial pressure, increasing cerebral blood flow

Mr. Jefferson is a 59-year-old male who presents to the emergency department complaining of severe abdominal pain. His medical history is significant for dyslipidemia, and he takes 40 mgof simvastatin daily. He admits to drinking 6 to 10 bottles of beer nightly and to smoking 1½ packs of cigarettes a day. He denies any history of chest pain or cardiovascular disease. He was in his usual state of good health until a couple of hours ago, when he developed this acute onset of severe pain in the upper abdomen. He says that he tried to wait it out at home but it was so bad he finally came in. His vital signs are as follows: temperature 99.1°F, pulse 129 bpm, respirations 22 breaths per minute, and blood pressure 137/84 mm Hg. The abdomen is diffusely tender to palpation with some guarding but no rebound tenderness. The AGACNP anticipates that which of the following laboratory tests will be abnormal?

A complete blood count and RBC differential Liver

function

enzymes Serum amylase, lipase, and glucose A basic metabolic panel

A. S. is a 31-year-old male who complains of gastric discomfort that he notices mostly on an empty stomach; for example, if he works late and does not have the opportunity to eat, he notices that it happens. It feels better when he eats something or even if he just take TUMS®. Physical examination reveals a generally healthy adult male with normal vital signs. There is a bit of mild discomfort with deep palpation to the epigastrum, but otherwise the abdominal exam is normal. The AGACNP know that the most useful laboratory analyses will include: Helicobacter pylori antibodies Chest radiography A white blood cell differential Vitamin B12

The AGACNP is rounding on a patient following splenectomy for idiopathic thrombocytopenia purpura. On postoperative day 2, a review of the laboratory studies is expected to reveal: Increased MCV Increased Hgb Increased platelets Increased albumin Carolyn C. has a history of Crohn’s disease and has been managed with immunologic agents, with moderate success. Today she presents with severe abdominal pain that comes and goes in waves; it started shortly after she ate a little bit of cottage cheese and crackers. This has never happened before with her Crohn’s disease. She

has difficulty localizing the pain but seems to indicate the general area of the umbilicus. She had one episode of diarrhea this morning.

Abdominal examination is nonspecific, producing mild tenderness on palpation. Plain abdominal films reveal a dilated small bowel with air fluid levels. The AGACNP suspects: Perforated small bowel Ulceration through the thickness of small bowel Small bowel obstruction Gastroenteritis

A 30 year old female nurse comes to your office with complaints of epigastric pain that awakens her at night.

She admits to being under a lot of stress at work and takes 2400 mg of ibuprofen for menstrual cramps and low back pain 5-6 times a week, especially after heavy lifting. She smokes a pack of cigarettes a day. Her physical exam is unremarkable but she does have positive heme stools. She is referred for an upper endoscopy which reveals a duodenal ulcer. Given this history,what is the most likely etiology of her ulcer?

Non steroidal anti-inflammatory drug use Stress related ulcerations Heliobacter

pylori

infection

Cigarette

smoking

An open fracture is considered an orthopedic emergency. Emergency room management of open fracture must include: Immediate covering with iodine-soaked gauze Ceftriaxone

and

tetanus

prophylaxis

Proximal and distal exploration of the wound Removal of all bone fragments

Grant Pass is a 20 year old downhill skier for the U. S Olympic team. He was on a practice run in Salt Lake City and caught a ski tip on a mogul and became airborn and crashed into the padded barriers on the side of the course. He was momentarily stunned, but was walking around unassisted and was conversant when the ski patrol paramedics arrived. The paramedics placed him on a backboard and began to slowly ski down to the end of the course where an ambulance was waiting to take him to the local trauma center. When Grant was placed in the ambulance, the paramedics noted that Grant was somnolent and not responsive to verbal commands.

They noted that his left pupil was dilated and sluggish to respond to light. Based on the above information, you, as the ACNP in the ER, suspect that Grant suffered which of the following?

Basilar skull fracture Subdural hematoma Epidural hematoma Contra-coup injury

Mrs. Maroldo is an 81-year-old female who presents for evaluation of pain in her left lower quadrant. She has had this pain before and says she usually takes antibiotics and it goes away. However, this time it seems worse, and she has had it for 4 days even though she says she started taking her leftover antibiotics from the last episode. She denies any nausea or vomiting but says she simply isn’t hungry. She had a little diarrhea yesterday but no bowel movements today. She has a temperature of 100.9°F and a pulse of 104 bpm, respirations of 20 breaths per minute, and a blood pressure of 94/60 mm Hg. She has some discomfort to deep palpation in the left lower quadrant. The AGACNP suspects: Irritable bowel syndrome Inflammatory

bowel

disease Diverticulitis Appendicitis

T. G. is a 48-year-old female who presents with biliary colic. She has had previous episodes but has resisted operation because she is afraid of anesthesia. Today her physical exam reveals a clearly distressed middle-aged female with right upper quadrant pain, nausea, and vomiting. Which of the following findings suggests a complication that requires a surgical evaluation?

A

temperature

of

101.5°F A leukocyte count of 18,000/µL A palpable gallbladder A positive Murphy’s sign

Tim is an 20 year old junior at Notre Dame and injured his right knee during an intramural football game and comes to the ER complaining of severe pain. Tim tells you that he was setting up to pass the football when he was tackled and he immediately felt his knee "pop" and buckle as he fell. What physical exam tests would you perform to confirm your differential diagnosis?

Talar

tilt

test Tinel's test Valgus/varus

stress

test

McBurney's test

The AGACNP rounds on his brain injury patient and recognizes the development of progressive bradycardia, hypertension, and irregular respiratory pattern. This is known as Cushing’s triad and suggests: Uncal herniation Increased

intracranial

pressure

Brainstem

compression

Subarachnoid

hemorrhage

Justin F. is seen in the emergency department with an 8-cm jagged laceration on the dorsal surface of his right forearm. He says he was working with his brother-in-law yesterday morning building a deck on the back of his home. A pile of wooden planks fell on top of him, and he sustained a variety of cuts and superficial injuries. He cleaned the wound with soap and water but didn’t want to go to the emergency room because he didn’t want to risk being in the waiting room for hours. He wrapped up his arm and went back to work, and then took a normal shower and went to bed last night. This morning the cut on his arm was still flapping open, and he realized he needed sutures. The appropriate management of this patient includes: Proper cleansing and covering of the laceration, along with oral antibiotic therapy Local anesthesia, cleansing, and wound exploration for foreign bodies Local anesthesia, cleansing, and suture repair Cleansing, covering, antibiotic therapy, and tetanus prophylaxis

A 49 year old female is seen for sudden onset severe abdominal pain 10/10. On further questioning you learn that she has experienced epigastric pain for several months after eating, which has resulted in an 11 pound weight loss. She does not take any other medications. On physical exam you note she has a low grade fever of 100.1, HR 124, RR 25 and BP is 116/72. The abdomen is rigid and there are no bowel sounds. Abdominal plain film shows free air under the diaphragm. What is your diagnosis? ruptured

gallbladder

ruptured

spleen perforated duodenal ulcer ascites

R. R. is a 71-year-old female who presents with left lower quadrant pain that started out as cramping but has become more constant over the last day. She reports constipation over the last few days but admits that for as long as she can remember she has had variable bowel habits. Her vital signs are normal, but physical examination reveals some tenderness in the left lower quadrant. What is the leading diagnosis for this patient?

Diverticulitis Crohns Disease Appendicitis Irritable small bowel disease

B. T. is a 49-year-old male who has been admitted for the management of an episode of diverticulitis. This is his fifth hospitalization this year, and in previous hospitalizations he has had both abscess and stricture as a consequence of his disease. His treatment this hospitalization should include: Extended-spectrum antibiotics Surgical consultation for colectomy Expectant

treatment

with

nonabsorbable

antibiotics Colonoscopy

Sara S. is a 41-year-old patient who has just had a bone marrow transplant. The AGACNP knows that which medication will be used to decrease her risk of graft-versus-host reaction?

Immune

globulin

Cyclosporine Prophylactic antibiotics

Systemic

corticosteroids

The AGACNP is receiving report from the recovery room on a patient who just had surgical resection for pheochromocytoma. He knows that which class of drugs should be available immediately to manage hypertensive crisis, a possible consequence of physical manipulation of the adrenal medulla?

Alpha-adrenergic antagonists

Beta-

adrenergic

antagonists

Intravenous

vasodilators

Arteriolar dilators

A 41-year-old male physician has a 6-week history of persistent painful, swollen, and stiff proximal interphalangeal joints, wrists, and ankles. Using a step wise progression model, which would be the first diagnostic test the AGACNP would order?

Radiography of hand and wrist Check HLA –B27 Hepatitis

B serology testing

Rheumatoid factor and anti-nuclear antibody Joint aspirate for microcrystals

Mr. S., a 49-year-old male, is brought to the emergency room by his roommate who relates that the patient has been vomiting bright red blood for two days. He has a history of alcohol abuse. Current vital signs are as follows: Temp 99.2o F, heart rate 110 bpm (sinus tachycardia), blood pressure 90/60 mm Hg, resp 32 bpm. He

is alert but lethargic and denies current abdominal pain. Which of the following is not indicated in the initial management of this patient?

Immediate IV access Laboratory

screening,

type

and

crossmatch Endoscopy Crystalloid infusion

A 38-year-old patient presents with symptoms of L5 nerve root impairment that have been ongoing for 3 weeks despite conservative

treatment.

All

of

the

following statements

regarding

this

case

are

true

EXCEPT: Normal findings on plain radiographs should be followed up with a CT Scan or MRI immediately The L5 level is one of the most likely levels for disk herniation Sensory findings may include diminished pain on the dorsum of the distal region of the foot Motor findings may include weakness on extension of the great toe Tendon reflexes are expected to be normal at the knee and ankle

R. R. is a 71-year-old female who presents with left lower quadrant pain that started out as cramping but has become more constant over the last day. She reports constipation over the last few days but admits that for as long as she can remember she has had variable bowel habits. Her vital signs are normal, but physical examination reveals some tenderness in the left lower quadrant. Which diagnostic test is most likely to support the leading differential diagnosis?

CT scan with IV, oral, and rectal contrast CBC with WBC differential Colonoscopy Barium enema A patient with chronic hepatic encephalopathy is being discharged home. Discharge teaching centers upon longterm management strategies to prevent ammonia accumulation. Teaching for this patient includes instruction about: Lactulose taken 20 g PO daily Spironolactone taken 100 mg PO daily Protein intake of 50 g daily Zolpidem taken 10 mg PO qhs.

Ms. Carpenter is a 28-year-old female who presents in significant pain; she indicates that the discomfort is in the right lower quadrant. The discomfort is colicky in nature and has the patient in tears. Which of the following associated findings increases the index of suspicion for ureteral colic?

Temperature > 102°F White blood cell count > 14,000 cells/µL Vomiting Hematuria

A 32-year-old patient who underwent an open splenectomy for a ruptured spleen is preparing for discharge.

An adult- gerontology acute care nurse practitioner reviews the potential complications with the patient. The nurse practitioner emphasizes which instruction to the patient?

Continue

antibiotics

for

14

days

Follow up with primary care provider for vaccinations No international travel for five years No weight lifting restrictions

When evaluating a patient with acute pancreatitis, which of the following physical or diagnostic findings is an ominous finding that indicates a seriously ill/potentially moribund patient?

Severe epigastric pain with radiation to the back Abdominal

guarding

and

rigidity Grey Turner sign Obturator sign

Ted is a 22 year old male who fell on his right shoulder 2 days ago during a martial arts class. He is complaining of inability to sleep on his right side and has pain whenever he tries to use his arm. He denies any sensory changes in his hand. Nothing seems to make it better, even the ibuprofen he has been taking several times a day.

Physical exam reveals limited ROM in shoulder with ecchymosis and tenderness over anterior and posterior coracorclavicular and acromioclavicular joints.

Based on the radiograph below, what is your working diagnosis at this time? NO PICTURE SHOWN: ac

separation

rotator cuff tear humerous fracture cervical neck injury

K. W. is a 50-year-old woman who presents for surgical resection of the liver for treatment of metastatic colon

cancer. Preoperatively, the surgeon tells her that he is planning to remove 50 to 75% of her liver. The patient is concerned that she will not be able to recover normal liver function with that much removed. The AGACNP counsels her that: Such a high-volume resection is utilized only in people with markedly compromised hepatic function Major regeneration occurs within 10 days, and the process is complete by 5 weeks Liver function will probably recover to 50% baseline, but that is enough for normal function Up to 95% of the liver can be removed without any apparent consequence to the patient

Joshua is a 31-year-old man who presents for evaluation of acute numbness and tingling and decreased strength in his arms. It happened rather suddenly this afternoon and has never happened before. The lower extremities do not appear to be affected. While performing the history the AGACNP asks specific questions about the risk of: Cervical radiculopathy Hyperextension injury Panic attack Poison ingestion

The AGACNP is taking report on a head injured patient. The report includes scoring on the Glasgow Coma Scale of E2 M3 V5. How would you interpret this information?

The

patient’s

eyes

open

to

sound,

they

are

orientated

are

able

to

obe y

commands The patient’s eyes open to pressure, they can utter some words but do not form sentences, and they are able to localise to trapezius pinch.

The patient’s eyes open spontaneously; they are orientated and able to obey commands The patient's eyes do not respond, they are confused and do not follow commands.

L. S. is a 49-year-old female with a history of colorectal cancer for which she has had surgical resection and

chemotherapy. She presents with profound abdominal pain. She has not vomited, and she is not certain when she had her last normal bowel movement; her bowel habits have been irregular for some time. A CBC demonstrates a mild microcytic anemia but is otherwise normal; her WBC differential is normal. Results of a metabolic panel support minor volume contraction but show no significant electrolyte abnormalities.

Abdominal radiographs demonstrate dilation of the proximal colon, air fluid levels, and a complete absence of air in the rectum. The AGACNP diagnoses the patient with: Perforated colon Paralytic

ileus

Complete bowel obstruction Intestinal volvulus

Tim is an 20 year old junior at Notre Dame and injured his right knee during an intramural football game and comes to the ER complaining of severe pain. Tim tells you that he was setting up to pass the football when he was tackled and he immediately felt his knee "pop" and buckle as he fell. Which of the following diagnostics would the AGACNP order first?

Plain radiographs MRI of his knee CT scan Diagnostic arthroscopy

Jane S. is a 35-year-old female patient who is at 30 weeks gestation. She is being followed regularly for prenatal care and has always been healthy; she just had an office visit and was told everything was fine. Tonight she presents to the emergency room complaining of significant pain in the upper abdomen. Her vital signs reveal a temperature of 98.4°F, pulse of 110 bpm, respirations of 20 breaths per minute, and blood pressure of 144/90 mm Hg. A urinalysis reveals proteinuria, and a metabolic panel is significant for increased transaminases. Her hemogram is normal, but the CVC reveals platelets of 85,000. The AGACNP knows that which of the following must be evaluated as a cause of her abdominal pain?

HELLP syndrome Placental abruption Spontaneous hepatic rupture Preterm labor

A 52-year-old male comes to the clinic in preparation for an overseas trip next year. He has already searched the internet and knows that Hepatitis A and Hepatitis B are endemic in the country that he will be visiting.

What will you recommend to this patient?

No immunizations are needed. It is highly unlikely that he’ll be exposed to hepatitis since he’s traveling with a tour group.

Recommend Hepatitis C IgG to prevent getting an acute illness.

Recommend two doses of Hepatitis A and 3 doses of Hepatitis B vaccine.

Recommend one dose of Hepatitis A and Hepatitis B vaccine.

Mr. Warner is a 64-year-old male who presents with multiple skin lesions scattered about his head, neck, shoulders, and arms. They range in size from 3 mm to 1.2 cm. They do not hurt, burn, or itch, but they are rough to palpation—like sandpaper. Mr. Warner has a history of basal cell carcinoma × 3 and wants to know if these

are also skin cancer. The AGACNP tells him that these lesions may be precancerous and are known as: Solar lentigo Bowen’s disease Actinic keratoses Atopic dermatitis

Brad Berry, a 30-year-old male, presents to the ED with the chief complaint of a red, hot, swollen, painful right knee. He first noticed the problem last night, and feels it has gotten worse over the past 14 hours.Your medical history reveals that Mr. Berry denies problems with any other joints or recent injury to his right knee. He is not sexually active and currently is attending seminary school. He denies urethral discharge or urinary symptoms, recent rash, IV drug use, chronic illness, or recent camping. His temperature is 102.2 F. Physical exam reveals normal general survey, cardiorespiratory and abdominal examination. The right knee is markedly swollen with + fluid wave. There are no inguinal lymph nodes palpated.Which of the following would be the first diagnostic test for the AGACNP to order?

Right knee AP, lateral, and sunrise view radiograph Right knee joint synovial fluid examination Serum rheumatoid factor Serum erythrocyte sedimentation rate

The AGACNP screens a new admit patient for liver disease. Elevations of all of the following would confirm your suspicion that this patient has liver disease, EXCEPT unconjugated bilirubin conjugated bilirubin urine bilirubin aspartate aminotransferase

N. C. is a 60-year-old female with primary hyperaldosteronism. She has been referred to your service for surgical management. Anticipated findings on clinical history would include: Palpitations, headaches, and sweating Polyuria, weakness, and paresthesias Dry skin, straie, and unplanned weight loss Early satiety, tremors, and fatigue

Janice is a 32-year-old female who presents for evaluation of abdominal pain. She has no significant medical or surgical history and denies any history of ulcers, reflux, or gastritis. However, she is now in significant pain and is afraid something is ―really wrong.‖ She describes what started out as a dull discomfort in the upper part of

her stomach a few hours ago but has now become more profound and centered on the right side just under her ribcage. She has not vomited but says she feels nauseous. Physical exam reveals normal vital signs except for a pulse of 117 bpm. She is clearly uncomfortable, and palpation of the abdomen reveals tenderness with deep palpation of the right upper quadrant. The AGACNP orders which imaging study to investigate the likely cause?

Abdominal radiographs CT scan of the abdomen with contrast Right upper quadrant ultrasound A HIDA scan

The AGACNP knows that early diagnostic findings consistent with rheumatoid arthritis include: Soft tissue swelling of the metacarpals Radiographic joint space narrowing Heberden's

nodes

Subungal hemorrhages

The ethical principle of veracity refers to: Telling the patient the truth Ensuring that the patient gets what he deserves

The

patient’s

right

to

self

determination The duty to do no harm

Mr. Huckabee is a 51-year-old male who had a CT scan of the abdomen to evaluate refractory left lower quadrant discomfort. The scan reported an incidental finding of cholelithiasis with calcified gallbladder.

While counseling Mr. Huckabee about the results, the AGACNP advises that the appropriate approach to these findings is: No further evaluation indicated A surgical evaluation To treat with oral emulsification agents To follow annually with ultrasound

Mr. Miller is a 56-year-old male who is being managed for portal hypertension. The AGACNP knows that of the many causes of portal hypertension, alcoholic liver disease typically is the cause when the patient has: Elevated

hepatic

vein

pressures

Elevated

transaminases

Decreased

prothrombin time Decreased alkaline phosphatase

Neoadjuvant chemotherapy treatment for cancer is given to facilitate surgical resection. When the outcomes of cancer therapies are evaluated, the terms complete response and partial response often are used. Partial response means that: 50% of the patients treated with a given regimen demonstrate remission 50% of the patients treated survive to the 5-year point The tumor mass has reduced by > 50% In 50% of cases, the tumor converts from unresectable to resectable

In a patient with a perforated duodenal ulcer, the most likely source of peritonitis is amylase gastric contents liver

enzymes

breaking

down

the

mesentry blood

Ms. Teller presents with a chief complaint of weight loss. She reports an unplanned 10 lb weight loss over the last 5-6 months. She has no significant medical history, but review of systems reveals bilateral shoulder discomfort and some impaired range of motion -- she has trouble pulling clothing over her head. Over the last few months she has generalized upper body stiffness, but seems to get better after an hour or so of activity.

When considering a diagnosis of polymyalgia rheumatica, laboratory assessment may be expected to reveal: An erythrocyte sedimentation rate (ESR) of 75 mm/hr A microcytic, hypochromic anemia Elevated

liver

function

enzymes Positive antinuclear antibodies

M. R. is a 52-year-old female who presents complaining of significant abdominal pain, which she rates as 8 to 9 on a 1 to 10 scale. The pain has been going on for a matter of hours, and she is afraid it won’t go away on its own. She denies any nausea or vomiting, and she cannot remember precisely when her last bowel movement occurred; probably it was a few days ago. She reports that she is ―always‖ constipated. On physical examination, she is tachycardic but otherwise has normal vital signs; her abdomen is tensely rigid, but no point tenderness to

palpation is appreciated. The entire abdomen percusses as tympanic—there is no distinct dullness over the upper quadrants. Bowel sounds are present but hypoactive and intermittent. There is rebound tenderness to palpation.

The AGACNP suspects: Perforated

bowel

Peritonitis Ischemic

bowel

Intestinal abscess A patient with suspected Cushing’s syndrome is being evaluated to establish the diagnosis and cause. Patients with an adrenal tumor typically will demonstrate: Low ACTH and low cortisol Low ACTH and high cortisol High ACTH and low cortisol High ACTH and high cortisol

A 25-year-old medical student is stuck with a hollow needle during a procedure on a patient known to have hepatitis B viral infection but who is HIV-negative. The student’s baseline laboratory studies include serology: HBsAG negative, total Anti-HBc negative, IgM Anti-HBc -, Anti-HBs +. Which of the following is true regarding this medical student’s hepatitis status?

Prior vaccination with hepatitis B vaccine.

Acute infection with hepatitis B virus.

The student was vaccinated for hepatitis B, but is not immune.

A 55-year-old man with a past medical history of hypertension and hyperlipidemia presents to your office with an acute onset of fevers, chills, dysuria, urinary frequency and right CVA tenderness. On exam he appears to be moderately ill, with a temperature of 39.3°C, pulse of 105/min and a blood pressure of 115/60mmHg. His cardiopulmonary and abdominal exam are negative. A urine dip in the office reveals 2+ blood, 2+ leukocytes and negative nitrates. Of the following tests, which is most likely to lead to the correct diagnosis?

Urine

culture

Renal ultrasound Blood cultures CT scan of the abdomen

S. R. is a 51-year-old male patient who is being evaluated for fatigue. Over the last few months he has noticed a marked decrease in activity tolerance. Physical examination reveals a variety of ecchymoses of unknown origin.

The CBC is significant for a Hgb of 10.1 g/dL, an MCV of 72 fL and a platelet count of 65,000/µL; the remainder of the CBC is normal. Coagulation studies are normal, but bleeding time is prolonged. The AGACNP recognizes that initial management of this patient will include: Splenectomy Monoclonal antibody therapy such as rituximab Prednisone 60 mg daily until platelets normal Avoidance of elective surgery and nonessential medications

Elliot is a 47-year-old male who is being treated for throat cancer with combination therapy that includes radiation. He is asking questions about what adverse effects he may anticipate. The AGACNP advises Elliot that the most significant toxic effects in the acute / early postradiation period are: A product of mucositis and include yeast superinfection, desquamation, and pain Nephrotic syndrome and organ failure More commonly permanent than toxic effects of other cancer treatments Atrophy and burn, with subsequent dysfunction of the area surrounding targeted tissues

The AGACNP knows that when evaluating a patient with suspected acute pyelonephritis, which of the following is not a common feature?

Pyuri a Fever CVA

tenderness

Gross hematuria

G. D. is a 13-year-old male patient who has a history of recurrent fever and flank pain. His parents traditionally are not believers in the health care system, and he has not been seen by a health care provider for many years.

Today he has fever, chills, and costovertebral angle tenderness. Urinalysis reveals findings consistent with acute urinary infection. The AGACNP treats the patient for pyelonephritis and considers which study to evaluate for vesicoureteral reflux?

Bilateral renal ultrasound CT scan of the abdomen and pelvis Voiding

cystourethrograpy

Radioisotope scanning

Maxine is being seen in follow-up after removal of an aldosteronoma. The AGACNP expects specifically that

which of the following aldosterone-related abnormalities will be cured?

Hypertension Hyponatremi a Hypokalemia Hypoglycem ia

Acute hepatitis B is diagnosed by: Presence of HAV-IgM Detection

of

HbsAg

Anti-

HBc-IgM B and C

A 19-year-old woman presents to your office with a 3-day history of dysuria and foul-smelling urine. She also notes some suprapubic pressure and noted some chills and she thinks she had a fever yesterday. She reports no vaginal bleeding or discharge and reports no nausea or vomiting. She denies any significant past medical history. On exam she has a temperature of 38°C, a pulse of 105/min and a blood pressure of 120/75mmHg. Her abdominal exam reveals some suprapubic tenderness. Her back exam reveals no costovertebral angle tenderness. Urine dip demonstrates 2+ leukocytes. What should be done next?

Admit the patient for empiric intravenous antibiotic therapy Start empiric oral antibiotic therapy Admit the patient for intravenous hydration therapy Check a urine culture and await results Check a CT of her abdomen/pelvis

Brad Berry, a 30-year-old male, presents to the ED with the chief complaint of a red, hot, swollen, painful right knee. He first noticed the problem last night, and feels it has gotten worse over the past 14 hours.Your medical history reveals that Mr. Berry denies problems with any other joints or recent injury to his right knee. He is not sexually active and currently is attending seminary school. He denies urethral discharge or urinary symptoms, recent rash, IV drug use, chronic illness, or recent camping. His temperature is 102.2 F. Physical exam reveals normal general survey, cardiorespiratory and abdominal examination. The right knee is markedly swollen with + fluid wave. There are no inguinal lymph nodes palpated. In your immediate consideration of differential diagnoses for Mr. Berry's knee problem, which of the following would be the least likely?

Trauma

Septic arthritis Rheumatoid arthritis Acute gout

The AGACNP is evaluating a 79-year-old male in the emergency department. He is extremely anxious and requires significant reassurance that he is not going to die. He subsequently rules in for an anterolateral myocardial infarction. His daughter asks you not to tell the patient the truth. She is afraid that it will compound his anxiety, agitate him, and worsen his condition. The patient becomes upset and demands to be told precisely what his condition is. The most appropriate action would be to: Answer the patient’s question truthfully Consult the attending physician Ask the daughter to leave the bedside Tell the patient you do not have any information

Mrs. Knickerson is a 77-year-old female admitted for management of urinary tract infection. Her complete blood count reveals a white blood cell differential as follows: Total leukocyte count 57,000 cells/uL, neutrophils of 16%, lymphocytes 77%, monocytes 3%, eosinophils 3% basophils 1%. The AGACNP is suspicious for: Urosepsis Immunosuppressio n Drug-induced leukocytosis Chronic lymphocytic leukemia

A 54-year-old man with a history of metastatic lung cancer comes to the office because he had sudden onset of pain in the lower back and both legs 24 hours ago. Which of the following findings would indicate that a lumbar disk herniation rather than a cauda equina syndrome is the cause of his pain?

Saddle

anesthesia

Bilateral weakness of legs Impotence Pain radiating to one buttock Urinary incontinence The Ranson’s Criteria of Severity is a morbidity and mortality index used to predict risk in patients with acute pancreatitis. A Ranson score of 3 indicates: Endoscopic sphincterotomy Surgical intervention

Severe disease Peritoneal lavage