AHA-EXAM 4 Flashcards
1
Q
The extension of the patient’s head against the examiner’s hand is a test of?
A
Sternocleidomastoid muscle strength
2
Q
Grades of muscle strength? What grade is: Normal muscle strength?
A
1-5?
5=nl
3
Q
Sx of bursitis?
A
inflammation of this structure adjacent to a joint leads to limitation with motion, point tenderness and swelling
4
Q
Paget disease ?
A
Excessive bone resorption and bone formation
5
Q
LEGG-CALVE-PERTHES DISEASE
A
Avascular necrosis of the femoral head
6
Q
D/C from nipple- how to determine the # of ducts?
A
Compress the nipple and examine with a magnifier
7
Q
Paget dz in breast vs eczema differential?
A
The response to steroids (eczema)
8
Q
Mastectomy rand malignancy recurrence?
A
Recurrence is possible and may be at the scar site. DO BREAST EXAM AND MAMMOGRAM YEARLY STILL & FOCUS ON THE SITE SCAR SITE
9
Q
Male with enlarged breast tissue (Gynecomastia)
A
QUESTION USE OF DRUGS (MARIJUANA)
10
Q
fibrocystic changes in breast sx?
A
Lumps before menstrual cycles
11
Q
sentinel nodes location to palpate with a mass finding
A
supraclavicular fossa
12
Q
What is the cause of a Peau d’orange appearance to the skin of the breast?
A
Edema from a blocked lymph drainage
13
Q
Inverted niplle finding, ask about?
A
how long they had their nipple inverted
14
Q
the ant axillary nodes are located at?
A
along the lower border of the pectoralis major
15
Q
Retention cyst?
A
breast mass w/ inflammation of the sebaceous glands in the areola
16
Q
breast mass that is firm, irregular w/ an area of discoloration
A
fat necrosis
nonmalignant
17
Q
expected finding in a 68 yr female at her yearly exam
A
granular feel to breast tissue
18
Q
Montgomery tubercles
A
nontender and nonsuppurative bumps seen on the areola
19
Q
3 most common breast lumps?
A
fibroadenoma-benign solid tumors usually in women <30 years of age.
fibrocystic breast changes-heterogenous group of nonproliferative changes of stromal/glandular elements that includes cysts, nodularity, nipple discharge, breast tenderness. usually in women 30-50yrs of age.
breast carcinoma
20
Q
6 nodes accessible to palpation -breast?
A
upraclavicular Midaxillary Lateral axillary Anterior axillary Subclavicular nodes
21
Q
Changes in breast tissue with age?
A
<25-stromal and lobular tissue. Fibroadenomas common.
25-40-cyclic mastalgia and nodularity.
>40-begin to involute. cysts and duct ectasia common.
>50-increased risk of cancer.
22
Q
Galactorrhea, meds to ask?
A
phenothiazines
23
Q
Mastitis
A
clogged milk ducts
24
Q
Fibrocystic dz
A
enlarged ducts
25
2-3 cm subareolar duct lesion?
intraductal papillomas
26
NL finding in a 28 yr old pregnant ?
dilated subcutaneous veins
27
Radiculitis
a type of dz manifests with burning pain
28
A type of dz that manifests as a heavy throbbing and aching pain?
Ovarian tumor pressing on the bowel
29
puberty by race?
Mexicans enter puberty later than blacks and earlier than whites
30
The appearance of secondary sex charact. in a 8 yr old followed by a sexual maturation can indicate?
tumor
brain tumor or a lesion in the hypothalamus may activate the gonads axis triggering the secretion of growth hormones, sex hormones and leads to early sexual maturation
31
what inhibits the pituitary from releasing the growth hormone
Somatostatin
| inhibits both GHGH and TSH
32
What age the lymphatic tissue development reach its peak
at 10-12 yrs
33
used to record deep tendon reflexes?
The incremental grading
34
pt with hx of depression, experience anger, fear. what regulates anger ?
The lumbic system: mediates the patterns of behavior that determine survival (aggression, affection, fear)
the expression of emotion and behaviors is mediated between the limbic system and the frontal lobe
35
Delirium vs dementia?
Dementia is the impairment of the cognition that is not reversible and is chronic in progression
delirium is instant and is usually related to a secondary issue that is usually reversible by fixing the causative issue.
Def: Delirium is impaired cognition, consciousness, mood and behavioral dysfunction of acute onset. Disordered perceptions, decreased attention span, suspiciousness and fear with motor and sensory excitement are objective characteristics found in delirium.
36
what test is used to evaluate the pt's menta; function with changes in cognition per family complaint?
what score is indicative of dementia?
The Isaac Set Test measures a patient's mental functioning. Their ability to respond demonstrates executive functioning, alertness, attention span, and recent memory. A score less than 15 is associated with dementia.
37
Which is a major difference between Alzheimer disease and vascular dementia?
--> Etiology
Dementia is a chronic, slowly progressive disorder of failing memory, cognitive impairment, behavioral abnormalities, and personality changes that often begins after age 60 years and usually related to structural diseases. Vascular dementia is a type of dementia related to acute or embolic strokes or cerebral hemorrhages due to hypertension. Up to 70% of Alzheimer dementia is caused by the presence of senile plaques, and neurofibrillary tangles with abnormal amyloid processing or deposits.
38
Hormones secretes by ant vs post pituitary ?
ant-FSH
| post-LH
39
Hormones resp. for softening the pelvic cartilage and strengthening the pelvic ligaments in pregnancy?
Relaxin and Progesterone
40
name of bluish cervix from increase vascularity?
| can be a sign of?
Chadwick sign
| pregnancy?
41
Name of soft cervix from inc vascularity?
Goodell sign
42
Polymenorrhea?
| Oligomenorrhea?
1-Short period of period < 19-21
| 2- longer period> 35
43
term for cervix pointing ant vs post?
A=Retroverted
P=Anteverted
think opsite!
44
+ Allis sign?
Infant supine, both knee flexed, feet flat on the exam table and the femur aligned, BUT ONE KNEE IS HIGHER THAN THE OTHER KNEE.
45
factor to hyperextension to knee?
Weak quadriceps
| nl= 130
46
group successible to subluxation?
Infants/ toddlers
47
What is tested when head of pt is extended against your hand using pressure?
Sternocleidomastoid muscle stregth
48
To test for rotator cuff prob?
Neer test
49
NL plantar flexion?
45 Degree
50
what is tested w/ straight leg test?
Lumber nerve root irritation assoc w/ herniation at the level L4-L5-S1!!
+ with tenderness or limited ROM
51
Gower sign?
Generalized weakness when rising from a sitting position by placing her hands on legs and pushing the trunk up
52
Hawkins test to test for?
Rotator cuff injury
53
Faber test for?
Hip
54
test for cerebral function?
Rapid sequence of finger to thumb
55
Pt c/o feeling as of the whole room is spinning.
| You suspect?
Inner ear dysfunction affecting the acoustic nerve
56
To assess the peripheral nerve sensory function, the NP asks the pt to?
close eyes and place a vibrating tuning fork on the pt's ankle and ask to indicate what is felt
57
Acroparesthesia during pregnancy is NL? true or false?
T
58
Foot drop during pregnancy. why? explain
d/t lumbosacral plexopathy.
Occurs when the lumbosacral trunk, and sometimes the superior gluteal and obturator nerves, is compressed between the maternal pelvic rim and the fetal head (a conduction nerve block), leading to motor deficits in a lower extremity
59
A patient presents with a bilaterally symmetric intention tremor of the hands that she describes as "worse when I'm stressed and better when I have a cocktail." How would you document this tremor?
Essential tremors.
| worsens with stress and temporarily improve with ETOH
60
what finding is consistent with when upper motor neuron disease affecting the face? vs lower motor neuron dz?
Movement of the affected side occurs with emotion but not volition!
In lower neuron dz: total paralysis of the affected side of the face.
eg: Bell's palsy is a temp acute paralysis or weakness of one side of the face.
*When the upper motor neurons are affected, as in a stroke or brain attack, voluntary movements are paralyzed, but emotional movements are spared.
61
Cerebellum function
control reflexive muscle tone, equilibrium, and posture
62
CN VII: in addition to make various faces , what is the other function?
The sensory component of cranial nerve VII (Facial) mediates taste sensation from the anterior 2/3 of tongue. Smell is mediated by the Olfactory nerve (CN I). Balance is mediated by the Vestibulocochlear nerve (CN VIII). Pain from the face and head is mediated by the Trigeminal nerve (CN V).
63
Babinsky: + sign and until when?
A positive Babinski sign, fanning of the toes and dorsiflexion of the great toe, is expected until the infant is 16 to 24 months of age.
64
clonus : reflex grade #?
hyperactive 4,5???
65
meningeal irritation?
+brudzinski and kernig
66
Goniometer
used to accurately measure the angle of a joint and is used when "ROM" is beyond normal limits
67
Temporomandibular and temporalis / masester muscles are assessed at:
1- just ant to the tragus of the ear, the fingertips are placed inside the joint space as the patient opens and closes the mouth..
2- Having the patient to bite down and clench their teeth is the method for evaluating the strength of the temporalis and masseter muscles. Cranial nerve V is tested with this same maneuver.
68
When a patient abducts an arm and the ipsilateral scapula becomes more prominent (winged), this usually means that:
injury to the nerve of the ant serratus muscle.
If the long thoracic nerve is damaged or bruised, it can cause paralysis of the serratus anterior muscle and winging of the scapula, or shoulder blade. This is not a symptom of a fractured clavicle or trapezius muscle separation. A dislocated shoulder would result in a hollowing effect
69
Dislocated shoulder is suspected when:
Asymmetric contours to the shoulder with a hollowing in the socket are symptoms of a shoulder dislocation.
70
Carpal tunnel would result in?
Reduced aBDuction of the thumb.
Median nerve compression, as in carpal tunnel syndrome, results in a positive Tinel sign, positive Phalen test, reduced abduction of the thumb, and sparing of palm tingling.
71
Thomas test?
detect flexion contractures of the hip.
The Thomas test requires the patient to lie supine, with one leg stretched out flat and the other raised and bent in toward the chest. If the patient is unable to keep the extended leg flat on the table, this is an indicator of a hip flexion contracture.
72
mcMurray test
the examiner should place the patient in a supine position with a hand on the patient's completely flexed knee and the foot flat on the table at the buttocks, and then grasp and evert the foot and extend the knee (The next step is to turn the ankle outward while applying a valgus stress and then extend the knee)
73
Test to detect a hip dislocation during the first year of life?
Barlow-Ortolani.
At every examination during an infant's first year of life, the Barlow-Ortolani maneuver is performed. This test involves stabilizing the pelvis and flexing one hip and knee to 90 degrees. It detects hip dislocation, which is signified by a clicking noise with the maneuver.
74
A 3-year-old is brought to the clinic complaining of a painful right elbow. He is holding his right arm slightly flexed and pronated and refuses to move it. The mother states that symptoms started right after his older brother had been swinging him around by his arms. This presentation supports a diagnosis of:
Radial head subluxation, AKA nursemaid's elbow!
75
Temporary disorder that is experienced by pregnant women during the 3rd trimester d/t fluid retention?
Carpal tunnel, the fluid retention causes pressure and inflammation at the MEDIAL nerve!!
76
Bowed tibias and shortened thorax in an adult may be indicative that they have?
Paget disease.
| In addition they may have asymmetric skull and are susceptible to fractures.
77
key difference b/t RA and OA?
Fatigue and weakness is uncommon in OA
78
another sign suggestive to hip dislocation in infant less than 12 mo?
what is the test that will confirm the hip dislocation ?
Allis sign: shows unequal leg lengths.
| To confirm: Barlow-Ortolani maneuver
79
7 yr who begins to limp and complains of persistent uip pain may have ?
Constant hip pain with a limp in a young child is indicative of Legg-Calvé-Perthes disease. This condition results in avascular necrosis of the femoral head caused by an inadequate blood supply.
80
Contracture of the palmar fascia of one or multiple fingers is called ?
Dupuytren contracture
81
Dowager hump is the hallmark of
OA
| d/t vertebral compression and kyphotic bowing of the spine
82
Cardinal signs of RA?
Hallmark signs of rheumatoid arthritis are gradual onset of stiffness for 1 hour after rising, sleep disturbance, joint tenderness, and medium to fine crepitus.
83
To test the instability of the lateral and the medial collateral ligaments
Varus and valgus
84
Trendelenburg?
to dtect weak hip abductor muscles.
Ask the patient to stand and balance first on one foot and then on the other. Observe from behind, note any asymmetry or change in the level of the iliac crests. When the iliac crest drops on the side of the lifted leg, the hip abductor muscles on the weight baring side are weak
85
femoral stretch test
or hip extention test is used to detect inflammation of the nerve root at L1, L2, L3 , sometimes L4.
Have the patient lie prone and extend the hip. No pain is expected. The presence of pain on extension is a positive sign of nerve root irritation.
86
Test performed to assess shoulder rotator cuff impingement or tear
Neer test
| Harkins test
87
When the spine is assessed in a newborn and a separation of one vertebrae is noted, you suspect?
Bifid defect
88
Cerebral ataxia
Pt's feet wide apart as he walks and his hip sways as he staggers and lurches .
89
Amini-cog of 3 indicates
neg screen for dementia!
| see grading criteria for dementia
90
3 characteristics fir ADD
1-Inattention/distractability
2-Impulsiveness
3-Hyperactivity
All occurring at developmentally inappropriate level observed in at least 2 settings (home, school, work) with clear evidence of clinical impairment in social academic or occupational functioning.
Can exist with varying degrees in each. Affects self-regulation and executive functions.
91
3 types of ADD?
Combined presentation (inattention + hyperactivity/impulsivity)
- Predominantly inattentive
- Predominantly hyperactive/impulsive
92
DX FOR DEPRESSION:
```
use SIG.E.CAPS
S-Sleep
I-Interest (loss of)
G-Guilt (renumination)
E-Energy (lack of)
C-Concetration (lack of)
A-Appetite
P-Psychomotor
S-Suicidal
```
93
SCREENING FOR DEPRESSION: COMMONLY USED>
Beck Depression Inventory
| PHQ-9-brief self administered screening tool
94
WELL'S CLINICAL DECISION RULE
Active cancer (treatment within 6 months) +1
Paralysis, paresis, immobilization of LE +1
Bedridden >3 days due to surgery within 4 weeks +1
Localized tenderness along deep veins +1
Entire leg swollen +1
Unilateral calf swelling >3 cm (below tibial tuberosity) +1
Unilateral pitting edema +1
Collateral superficial veins +1
Alternative diagnosis as likely or more likely than DVT -2
95
WELL'S CLINICAL DECISION RULE- SCORING?
Well's score >3
- high risk of DVT
- consider imaging legs
Well's score 1-2
- moderate risk of DVT
- consider blood test (d-dimer)
Well's score 0
- low risk of DVT
96
Hepatic osteodystrophy
Abnormal development of bone due to bile suppression and hepatic disease
Higher risk
- older age
- high alcohol/drug use
S/S
- bone pain, skeletal deformity, muscle weakness and wasting
- wasted muscles, small extremities, distended stomach
Osteomalacia: Softening of bone due to vitamin D deficiency
- caused by liver not metabolizing everything properly
- seen a lot on x-ray in high weight bearing bones
Osteoporosis: porous bone
- most prevalent bone disease in the world
Skin Changes
Skin color: greyish skin, jaundice seen in very severe, late stage disease
Pruritus: itchiness, especially in hand/thenar eminence
Spider angiomas: seen a lot on nose and cheeks (picture of skin redness)
Liver palms: palms of hands get very red and itchy
Neurological Symptoms
Confusion
- primary symptom
Sleep disturbances
Muscle tremors
Hyperactive reflexes
Asterixis sign
- inability to maintain wrist extension with arm extension
- flap forward into wrist flexion with arm extension
Bilateral carpal tunnel
- build up of ammonia affects tendon sheaths
97
Arthralgia
Relationship between gut inflammation and joint inflammation
- antigens cross from gut and cause inflammation elsewhere
- joint pain can occur 3-4 weeks after GI impairment
Usually asymmetric, migratory, and oligoarticular (1-2 joints)
Accompanying S/S
- fever
- skin rash
- malaise
- eye inflammation
- symptoms may not occur with GI symptoms
Enthesitis = inflammation of tendons, bony insertions (patellar tendon and costovertebral joints common)
98
Reactive artralgia
Inflammatory spinal pain or synovitis
- can be caused by C-diff, flu, acute illness
- can turn into chronic arthritis due to disuse --> bony growths, contractures, etc.
Asymmetrical presentation in the LE
- migratory
- 1-2 joints
Can be triggered by infection in distal site (hand/foot)
Usually resolves in 3-12 months, but if untreated and favored --> chronic arthritis
Risk factors
- 20-40 years; M>F
- +family history
- IBD
- urethritis, cervicitis, diarrhea within 1 month of onset of S/S
- alternating buttock pain
- enthesopathy
- sacrolilitis
Sponydyloarthropathy family
- ankylosing spondylitis
- psoriatic arthritis
- enteropathic arthritis
- juvenile ankylosing spondylitis
- genetic component!
99
Psoas/ Obturator abscess
S/S
- fever
- night sweats
- lower abdominal, pelvic, back pain
- referred pain to hip, medial thigh, groin, knee
```
Screening tests
- heel tap
tapping on heel very hard --> +ipsilateral R/L lower quadrant pain
- hop test
hopping on one leg --> +ipsilateral R/L lower quadrant pain
- muscle test
psoas test
- palpation
```
100
Uterine fibroids
ibroids
- usually due to increase in estrogen
(estrogen replacement therapy, estrogen with menstruation cycle, BC pills)
Pain can be coordinated with menstruation
Fibroid flare up typically during menstruation
S/S
- hip, low back, sacral/pelvic pain
- abnormal bleeding
101
ENDOMETRIOSIS
Misplaced tissues adhere outside the uterus
- can go anywhere (rectum, colon, bladder)
- keeps everything tight and stuck together --> pain
Pain is there all the time, not associated with menstrual cycle
Risk factors
- age 30-50
- have kids later in life
- do not have kids
- periods >7 days
- cycle <28 days
- first menses <12 years
- family history
- low BMI
- chronic disease
S/S
- hip, low back, sacral/pelvic pain
- abnormal bleeding
- trouble getting pregnant
102
Polymyalgia Rheumatica
S/S
- low grade fever
- weight loss
- malaise/fatigue
- depression
- temporal arteritis = inflammation of temporal arteritis HA, fatigue, fever, loss of vision
Diagnosis
- age
- bilateral aching in 2 of 3 areas (UE, LE, torso)
- 1 month duration
- prompt response to corticosteroids
Risk Factors
- W>M
- age >55
- caucasian
103
Ankylosing Spondylosis
Risk Factors
- SI, spine, larger joints affected
- stiffness >3 months in male <40 years
S/S
- stiffness
- pain worse in morning
- pain improves with activity
104
Psoriatic arthritis
Variant of RA
S/S
- brittle nail beds
- sausage fingers
- joint pain, swelling, redness
105
SLE
S/S
- classic butterfly rash on cheeks
- discoid rash = looks like ringworm, can be on scalp
- symmetrical arthralgia/arthritis in small joints (wrist, hands, knees)
- peripheral neuropathy
Risk Factors
- W>M
- age 15-40
- African, Hispanic, Asian descent
106
RA
```
S/S
- Remember SERIOUS
¬ S = swelling in 1 or more joints
¬ E = early morning stiffness
¬ R = recurring pain and tenderness in any joint
¬ I = inability to move a joint normally
¬ O = obvious redness and warmth in a joint
¬ U = unexplained weight loss or fever
¬ S = symptoms >2 weeks
```
Risk Factors
- 20-40 years
- W>M
107
Lyme dz
early Infection S/S
- red rash
- flu-like symptoms
- migratory musculoskeletal pain
- neurologic symptoms (severe HA, numbness, pain, weakness of extremities, impaired coordination, cognitive dysfunction/memory loss/mood changes/sleep disturbances)
Less Common S/S
- eye problem (conjunctivitis)
- heart abnormalities and myocarditis
Late Infection S/S
- chronic or intermittent arthritis
- encephalopathy (sleep and mood disturbances)
- neurocognitive dysfunction
- peripheral neuropathy
108
MS
S/S
- unilateral vision impairment
- paresthesias
- ataxia/unsteadiness
- vertigo
- fatigue
- muscle weakness
- bowel/bladder dysfunctions
- speech impairment
- optic neuritis
- nystagmus
- spasticity/hyperreflexia
- Babinski's sign
- absent abdominal reflexes
- dysmetria/intention tremotr
- labile/changed mood
- Lhermitte's sign
Risk Factors
- W>M
- family history of MS
- age 20-40 (peak onset age is 30)
109
Sjorgen's dz
Systemic chronic inflammatory disorder characterized by lymphocytic infiltrates in exocrine organs
S/S
- dry mouth
- dry eyes
- parotid gland enlargement
- arthralgia
- arthritis
- Raynaud phenomenon
- myalgia
- pulmonary disease
- GI disease
- leukopenia
- anemia
- xeroderma
- urticaria
Risk Factors
- W>M
- age >50
110
Ankylosing Spondylitis
Early Stage S/S
- intermittent LBP (non-traumatic, insidious onset, relieved by activity, >3 months)
- scaroilitis (inflammation, pain, tenderness of SI)
- spasm of paravertebral muscles
- loss of normal lumbar lordosis
- intermittent, low grade fever
- fatigue
- anorexia/weight loss
- anemia
- painful, limited cervical ROM
Advanced Stage S/S
- constant LBP
- loss of normal lumbar lordosis
- ankylosis of SI and spine
- muscle wasting in shoulder and pelvic girdles
- dorsocervical kyphosis
- decreased chest expansion
- arthritis involving peripheral joints (hips and knees)
- hip flexion in standing
Extraskeletal S/S
- cauda equina
- iritis/iridocyclitis (inflammation or iris)
- conjunctivitis
- enthesitis
- carditis
- pericarditis/pulmonary fibrosis
- prostatitis
111
DDD
intervertebral discs lose height and hydration --> unable to cushion and provide mobility between vertebrae
Aggravating factors:
- sitting for extended periods of time
- rotating, bending, or lifting
Relieving Factors:
- frequent position changes
- lying down
- staying active
112
Sacral Stress Fracture
```
Sacral Stress Fracture
Stress Fracture S/S
- aching/deep pain
- pain increases with activity and improves with rest
- muscle weakness
- compensatory gait
- localized pain
- pain with WB
- pain reproduced with heel strike or hop test
- possible localized swelling
```
113
Patellar tendinitis
Patellar Tendonitis
S/S
- anterior knee pain over the patella tendon
- pain made worse with jumping, landing or running activity and sometimes with prolonged sitting
- gradual onset of pain; usually related to an increase in sport activity
- localized tenderness over the patella tendon
- morning stiffness in tendon
- thickened tendon
114
Thoracic fx
```
Thoracic Spine Compression Fracture
S/S
- pain in back, arms, or legs
- numbness and/or weakness in UE/LE (if SC is involved)
- loss of height
```
115
Carpal tunnel?
| bilat?
S/S
- paresthesia/tingling/numbness in median nerve distribution (thumb, middle, index, radial half of ring finger)
Bilateral = hepatic disease!
- build up of ammonia affects tendon sheaths
116
Psych: what type of pts are not appropriate to manage in the primary care setting? need referral !!
Patients with newly identified symptoms who do not present imminent risk should be referred for a mental health evaluation
117
A 70-year-old male patient comes to see his family nurse practitioner complaining of vague aches and pains and forgetfulness over the past 3 months. His wife shares with the nurse practitioner that he is snapping at family members, no longer likes to go out for weekly family dinners, and is not interested in sex. He has a history of diabetes but his labs are normal. He scores a 28/30 on his Folstein Mini Mental Status Exam (MMSE). What does the family nurse practitioner suspect?
Major Depressive Disorder
Alzheimer’s disease
Major Neurocognitive Disorder
Complications of diabetes
1. Major Depressive Disorder
In older adults, symptoms of depression often include physical aches and pains not caused by a medical condition, memory difficulties or personality changes, and social withdrawal. Dementia would be considered if the patient showed signs of cognitive decline, such as a low score on the MMSE. A score of 23 or lower indicates cognitive impairment.
118
A 37-year-old female patient requests a prescription for antidepressant medication. She reports low energy, poor self-esteem, overeating behaviors, difficulty making decisions, and feeling hopeless. When asked how long her symptoms have been occurring, she states, "I’ve always been this way." The nurse practitioner suspects which of the following?
Borderline Personality Disorder
Major Depressive Disorder
Persistent Depressive Disorder
Bipolar Disorder
3. Persistent Depressive Disorder
The symptoms of persistent depressive disorder occur for at least two years, with no more than 2 months without symptoms.
119
A 28-year-old new mom returns four weeks after being prescribed escitalopram for postpartum depression by her family nurse practitioner. She reports that she feels better than she has ever felt, does not feel tired after several sleepless nights up with the baby, and has re-connected with previous friends to chat in her free time. She notes that her husband thinks she’s doing well, too, because she has been so sensual. The family nurse practitioner does which of the following?
Continues the current dosage of escitalopram?
Decreases the dosage of escitalopram?
Advises the new mom that she is responding to oxytocin and should pace herself as hormone levels readjust?
Suspects Bipolar Disorder and discontinues the medication?
4. Suspects Bipolar Disorder and discontinues the medication
Symptoms of mania include increased energy, decreased need for sleep, more talkative than usual, and excessive interest in pleasurable activities. Antidepressants may trigger symptoms of mania when underlying mood disorders are present. While oxytocin increases in the immediate postpartum period, as it drops off, new moms are more likely to experience symptoms of depression.
120
A 19-year-old male college student expresses concerns about being unable to talk to others, avoidance of joining activities he likes, fear of speaking in class, and avoiding approaching professors. His grades are poor due to concentration and lack of participation. His diagnosis is which of the following?
Generalized Anxiety Disorder
Social Anxiety Disorder
Attention Deficit Hyperactivity Disorder
Antisocial Personality Disorder
2. Social Anxiety Disorder
Social Anxiety Disorder is characterized by intense anxiety and distress around the fear situation, recognition that the fear is unreasonable or excessive, and social, academic, or occupational impairment related to avoidance of activities associated with the fear.
121
Which of the following stress-relieving activities would be difficult for a patient with agoraphobia?
Listening to relaxing music
Going to a friend’s house
Deep breathing
Caring for a pet
2. Going to a friend’s house
People with agoraphobia fear being in situations where escape can be difficult or embarrassing and they often avoid leaving home.
122
A 51-year-old newly established female patient has changed providers three times in the past year due to feelings that her medical care is inadequate. She has been in to see the family nurse practitioner twice in the past month. At each visit, she shares that she has spent long hours researching her health concerns and is very anxious about her undiagnosed illness, despite reassurances from the FNP that her medical workup is normal. The FNP does which of the following?
Schedules regular, noninvasive visits
Schedules the patient with a specialist for further evaluation
Begins antidepressant medication
Encourages the patient to limit stressful daily activities
1. Schedules regular, noninvasive visits
The patient is experiencing Somatic Symptom Disorder, characterized by disproportionate or excessive health anxiety and body vigilance that continues for 6 or more months. Treatment should include regular noninvasive medical assessments, acceptance of physical symptoms rather than a goal of symptom resolution, and encouraging the patient to remain active and limit the effect of the target symptom on daily functioning.
123
During a well-child visit, the mother of a 17-month-old shares concerns that her daughter is not yet pointing to objects to ask for what she wants and is very difficult to comfort. The family nurse practitioner takes which of the following as the next step?
Assures the mother that this is typical for a child of her age
Administers the M-CHAT
Administers the ASQ
Schedules a visit in 6 months to see if the child has improved communication
2. Administers the M-CHAT
Early signs of Autistic Disorder may include deficits and social and communication skills, including not being comforted by others and not pointing or responding to pointing. The M-CHAT may be utilized for toddlers aged 16–30 months. While the FNP may call the child back in 6 months, early intervention is of primary importance and a referral is indicated if a child scores high on developmental screening.
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A 12-year-old male who has been diagnosed with Autistic Spectrum Disorder comes to see the family nurse practitioner because he is experiencing increased anxiety since beginning middle school. Previously, he liked school and was earning average grades. He is in a general education classroom with a good support system for social skills and transitions. The FNP finds that his heightened anxiety impacts his functioning in which of the following ways?
He has started hitting his classmates.
He refuses to go to class.
He feels hopeless about his ability to complete his assignments.
He believes his teachers are out to get him.
2. He refuses to go to class.
Anxiety in a child with Autistic Disorder may lead to school avoidance, a drop in grades, or increased social isolation.
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A 20-year-old college student is home for the summer and schedules an appointment to see his family nurse practitioner because he is concerned about ADHD. He was previously an A student in high school but notices that lately he is unmotivated, has trouble concentrating, and has experienced a decline in grades. The family nurse practitioner:
Suspects depression and requests the student complete a PHQ-9.
Suspects depression and prescribes an antidepressant.
Suspects malingering and calls his mother.
Suspects malingering and orders a random urine drug screen.
1. Suspects depression and requests the student complete a PHQ-9.
While a person with ADHD may have difficulty initiating work and completing tasks, a person with depression is more likely to experience decreased motivation and related functional impairment.
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The parents of a 14-year-old child with a history of Tourette’s syndrome are asking about his prognosis? Which is the most appropriate response?
This is a chronic disorder that you will likely experience throughout your lifetime.
Tics typically wax and wane so you are likely to experience tics throughout your lifetime during stressful periods.
Most commonly, tics begin to decrease in adolescence. Most people are symptom-free in adulthood, although other people will experience tics throughout their lifetime.
Tics will improve considerably with medication that is both safe and effective.
3. Most commonly, tics begin to decrease in adolescence. Most people are symptom-free in adulthood, although other people will experience tics throughout their lifetime.
Tics typically begin to decrease in adolescence. This is important to inform both children and parents of the prognosis and that there is a chance the child will not experience tics in adulthood.
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The FNP is seeing a 24-year-old patient who is requesting another prescription for hydrocodone since she lost the previous one. The FNP is concerned about potential abuse. Which of the following is an important first step in the intervention?
Request that the patient complete a urine drug screen to test levels of opioid in the urine. Inform her that she cannot receive another prescription today.
Explain to the patient that this is a highly addictive drug and ask if she believes she is beginning to struggle with a dependence on hydrocodone.
Discontinue the medication and offer her an alternative therapy without abuse potential.
Complete the CRAFFT questionnaire.
2. Explain to the patient that this is a highly addictive drug and ask if she believes she is beginning to struggle with a dependence on hydrocodone.
The therapeutic alliance is important, and exploring the issue in an honest, non-threatening context is the most effective approach. While a urine toxicology screen and follow-up regarding other potential problems with substance abuse or misuse is important, the first step is exploring the situational context with the patient.
128
Which of the following patients presenting with psychosis would warrant further screening for schizophrenia?
A 19-year-old male presenting with grossly disorganized speech, flat affect, and who appears suddenly suspicious of family and friends.
A 20-year-old male with a history of severe mood disturbances, presenting with rapid speech and grandiosity, telling the office personnel that he has been appointed to solve the country’s immigration problem.
A 44-year-old female who is suspicious that her coworkers are trying to sabotage her employment after discovering a hand-written note in her employer’s office.
A 35-year-old male with treatment-resistant depression who has begun to experience auditory hallucinations.
A 19-year-old male presenting with grossly disorganized speech, flat affect, and who appears suddenly suspicious of family and friends.
This patient is presenting with both positive and negative symptoms typical of schizophrenia. The 20 year old male with rapid speech and grandiosity more accurately reflects a patient experiencing a manic episode of bipolar. A 44-year-old female who is suspicious that her coworkers are trying to sabotage her requires further investigation but does not necessarily reflect paranoid ideation. A 35-year-old male with treatment-resistant depression requires further follow-up, but because psychosis is a symptom of severe depression, depression with psychotic features is more likely.
129
Which information is accurate regarding screening for intimate personal violence (IPV)?
Typically, IPV occurs in heterosexual relationships.
Poverty is stressful, so providers should monitor for IPV more carefully when working with low-income families.
IPV occurs in all ages and ethnicities, without regard to socioeconomic status.
IPV is particularly problematic in same-sex relationships.
3. IPV occurs in all ages and ethnicities, without regard to socioeconomic status.
IPV occurs in all ages and ethnicities, without regard to socioeconomic status. IPV is present in all ages, sexual orientation, and ethnicities.
130
The NP is seeing a 23-year-old female with Borderline Personality Disorder who reports that she wishes she were dead because her boyfriend just ended a short but intense relationship with her. What is the most appropriate response?
Perform a careful risk assessment even if it appears that she is trying to gain attention and has no plan or intention to harm herself.
Recognize that suicidal ideation and impulsivity are very common in patients diagnosed with Borderline Personality Disorder. Validate her feelings and screen her carefully for intention, plan, and other self-injurious behavior.
Acknowledge her feelings but give little attention to her "acting out" and suicidal threats.
Inform her family of her threats so she can be monitored at home. Give emergency numbers in case suicidality increases.
2. Recognize that suicidal ideation and impulsivity are very common in patients diagnosed with Borderline Personality Disorder. Validate her feelings and screen her carefully for intention, plan, and other self-injurious behavior.
Recognize that suicidal ideation and impulsivity are very common in patients diagnosed with Borderline Personality Disorder is the most appropriate therapeutic response. It is important to validate the patient’s feelings while also screening for suicidality. The choices that assume that the patient is not at risk is a potentially false assumption. Informing her family is important, but only after responding therapeutically to the patient and then assessing for risk.
131
A patient presents for his follow-up appointment. He has a stable job as a software programmer and is well groomed with proper hygiene with no symptoms of psychosis. The patient reports that he is suspicious that the office staff has been reading his medical chart. You ask him why he believes this and he responds with, "The HIPAA Confidentiality stuff is just a smoke screen for the government to know our business." When the nurse practitioner attempts to refute this, he becomes angry and hostile. The nurse practitioner would screen for which of the following personality disorders?
Paranoid Personality Disorder
Social Anxiety Disorder
Schizophrenia
Schizoid Personality Disorder
1. Paranoid Personality Disorder
This patient is presenting with signs of paranoid personality disorder, including suspicion, anger, and hostility.
132
The "SAL" for suicide risk assessment screens for which three important domains?
Specificity, Availability, and Lethality
| This is the only correct choice for utilizing the SAL acronym for suicide risk assessment.
133
Shoulder dislocation
asymmetry in 1 shoulder, has hollow s in rounding contour
134
Injury to the nerve of Ant serratus muscle
Winged scapula w/ outward prominence
135
Gouty tophi or RA
SubQ nodules along the pressure points of the ulnar surface
136
Olecranon bursa
fluid filled sac= cushion
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Olecranon bursitis
swelling and tenderness of the bursa
suspect epicondylitis tendonitis: boggy soft fluctuant swelling with tenderness and lst epicondyle or along the groove of the olecranon process and epicondyle. there will be an increase of pain with pronation and supination of the elbow.
138
breast cancer
> 35, unilat, nontender fixed and lump is irregular and not discrete, may have d/c
Trio Trx: US, MRI, Mammogram
139
cysts
< 35, single or multiple.
| Round or elliptical, soft or fluctuant, mobile
140
FIBROADENOMA
younger adolescents.
| single sharply circular and mobile lumps
141
abscess
Hx of mastitis, single irreg chronic mass and non-tender
142
fat necrosis
trauma, single smooth well defined fluctuant consistency
143
tennis elbow
injury to the lat epicondylitis, causes decrease in grip strength.
144
Radicular pain: clinical lumbar instability
Clinical lumbar instability identified by the way people with proximal weakness stands up from the floor: may bend the top half of his body toward
145
Nocturnal muscle spasm/cramps
SEEN IN ELDERLY AND PREGNANT WOMEN... IMPORTANT !!!!!
Pregnant women and older adults commonly experience nocturnal leg cramps resulting from imbalances of fluids, hormones, minerals, or electrolytes or dehydration.
***A particular concern with the older adults is that this may be a sign of intermittent claudication.
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Fasciculations?
**Fasciculations can often be visualized as muscle twitching or dimpling under the skin, but they usually do not generate sufficient force to move a limb. They may represent a benign condition or occur as a manifestation of motor neuron disease or peripheral nervous system diseases.
147
When DDH tests (Barlow and Ortolani) show a false negative ?
THINK ABOUT THE REASON BOTH TESTS ARE TESTING
?!!!
The examination for DDH is positive when either the Ortolani or Barlow sign is positive. It is important to remember that if the hip is already completely dislocated and cannot be moved back into the socket, both maneuvers will be negative.
