APEA ONLY Flashcards
Which of the following symptoms would be a clinical manifestation noted during the tertiary stage of syphilis?
a. A single painless lesion, chancre, on the genital area
b. Absence of symptoms
c. Rash marked by red or reddish-brown, penny-sized lesions over the palms and soles
d. Poor muscle coordination
d. Poor muscle coordination
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Which stage of syphilis includes findings of a symmetrical, reddish-pink, non-itchy rash on the trunk and extremities, including the palms and soles of the feet?
a. Primary
b. Secondary
c. Latent
d. Tertiary
b. Secondary
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Which type of virus causes oral and genital lesions through sexual contact?
a. Chancroid
b. Herpes simplex virus (HV-1)
c. Herpes zoster
d. Syphilis
b. Herpes simplex virus (HV-1)
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Which sexually transmitted disease (STD) is caused by infection with a protozoan parasite?
a. Chlamydia
b. Genital herpes
c. Trichomoniasis
d. Syphilis
c. Trichomoniasis
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Which stage of syphilis is described as having serologic proof of infection without symptoms of disease?
a. Primary
b. Secondary
c. Latent
d. Tertiary
c. Latent
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A chancre is defined as a:
a. group of small scattered vesicles
b. painless ulceration
c. papule of many shapes
d. non-tender penile indurated nodule
b. painless ulceration
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Which gynecological assessment finding includes a fish-like odor with white vaginal discharge on physical presentation and clue cells on microscopic exam?
a. Chlamydia
b. Gonorrhea
c. Trichomoniasis
d. Bacterial vaginosis (BV)
d. Bacterial vaginosis (BV)
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Which sexually transmitted disease (STD) in men causes a yellowish discharge from the penis, accompanied by itching and burning?
a. Chlamydia
b. Gonorrhea
c. Trichomoniasis
d. Syphilis
b. Gonorrhea
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Which sexually transmitted disease (STD) can lead to serious neurological conditions if left untreated?
a. Chlamydia
b. Gonorrhea
c. Trichomoniasis
d. Syphilis
d. Syphilis
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What is the most commonly reported sexually transmitted disease (STD) in the United States?
a. Human immunodeficiency virus (HIV)
b. Syphilis
c. Chlamydia
d. Gonorrhea
c. Chlamydia
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Which of the following is NOT considered a sexually transmitted disease (STD)?
a. Chlamydia
b. Gonorrhea
c. Trichomoniasis
d. Bacterial vaginosis (BV)
d. Bacterial vaginosis (BV)
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Which is NOT a type of diagnostic test for human immunodeficiency virus (HIV)?
a. Antibody test
b. Combination antibody and antigen test
c. Cluster of differentiation 4 (CD4)
d. Nucleic acid tests (NATs)
c. Cluster of differentiation 4 (CD4)
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Which sexually transmitted disease (STD) is known as a ‘silent’ infection and often lacks abnormal physical examination findings?
a. Syphilis
b. Chlamydia
c. Trichomoniasis
d. Bacterial vaginosis
b. Chlamydia
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Hairy leukoplakia may be associated with:
a. Acquired immunodeficiency syndrome (AIDS)
b. Addison’s disease
c. Cushing’s disease
d. Diabetes
a. Acquired immunodeficiency syndrome (AIDS)
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What is the sexually transmitted disease (STD) caused by infection with Haemophilus ducreyi and characterized by painful necrotizing genital ulcers?
a. Herpes simplex virus
b. Chancroid
c. Syphilis
d. Herpes zoster
b. Chancroid
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When examining the external genitalia of a female patient, excoriations and itchy, small, red maculopapulares were noted. These lesions may be suggestive of:
a. Genital herpes
b. Pediculosis pubis
c. Chlamydia trachomatis
d. Genital warts
b. Pediculosis pubis
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What type of cells are found on the wet mount slide of a patient with bacterial vaginosis (BV)?
a. Lactobacilli
b. Yeast cells
c. Clue cells
d. White blood cells
c. Clue cells
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What cluster of differentiation 4 (CD4) lab result suggests that a patient with human immunodeficiency virus (HIV) has developed acquired immunodeficiency syndrome (AIDS)?
a. 150 cells/mm3
b. 300 cells/mm3
c. 500 cells/mm3
d. 650 cells/mm3
a. 150 cells/mm3
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What is the gold standard method for diagnosing bacterial vaginosis (BV)?
a. Bimanual examination
b. Urine culture
c. Gram stain
d. Rectal examination
c. Gram stain
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Which genital infection can cause cervicitis, pelvic inflammatory disease (PID), tubal factor infertility, and ectopic pregnancy in women if untreated?
a. Chlamydia
b. Syphilis
c. Trichomoniasis
d. Bacterial vaginosis (BV)
a. Chlamydia
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Which of the following signs and symptoms are consistent with genital warts?
a. Pain or itching in the genital area and the presence of small, red papules or vesicles
b. Small, flesh-colored or grey lesions and itching in the genital area
c. Presence of vaginal or penile discharge
d. Painful bowel movements, anal itching, and painful or swollen testicles or abnormal menstrual bleeding.
b. Small, flesh-colored or grey lesions and itching in the genital area
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Which of the following signs and symptoms are consistent with genital warts?
a. Pain or itching in the genital area and the presence of small, red papules or vesicles
b. Small, flesh-colored or grey lesions and itching in the genital area
c. Presence of vaginal or penile discharge
d. Painful bowel movements, anal itching, and painful or swollen testicles or abnormal menstrual bleeding.
b. Small, flesh-colored or grey lesions and itching in the genital area
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During palpation of the abdomen, right lower quadrant pain is elicited by applying pressure to the left side of the abdomen. This technique elicited a positive:
a. Psoas sign.
b. Rovsing’s sign.
c. Murphy’s sign
d. Obturator sign
b. Rovsing’s sign.
**APEA Gastroenterology
Examination of the abdomen reveals a small midline protrusion in the linea alba. This finding is consistent with an:
a. Incisional hernia
b. Epigastric hernia
c. Umbilical hernia
d. Inguinal hernia
b. Epigastric hernia
**APEA Gastroenterology
Indicators of oropharyngeal dysphagia include all of the following symptoms except:
a. Drooling
b. Nasopharyngeal regurgitation
c. Cough
d. Vomiting
d. Vomiting
**APEA Gastroenterology
A feeling of constantly needing to pass stool is termed:
a. Constipation
b. Tenesmus
c. Obstipation
d. Acholic
b. Tenesmus
**APEA Gastroenterology
Sarcopenia is:
a. Cancer of the muscle sheath
b. Loss of lean body mass and strength with aging
c. Atrophy of voluntary muscles
d. Loss of bone production
b. Loss of lean body mass and strength with aging
**APEA Gastroenterology
On auscultation of the abdomen, rushes of high-pitched sounds are audible and coincide with abdominal cramps. These findings are most consistent with:
a. An adynamic ileus
b. Intestinal obstruction
c. Peritonitis
d. Ulcerative colitis
b. Intestinal obstruction
**APEA Gastroenterology
A patient visits the nurse practitioner for complaints of passing bloody stools over the past few weeks. He denies abdominal pain or fever. Further questioning reveals that when he passes stool, he notices blood dripping in the toilet. These symptoms could be consistent with:
a. Hemorrhoids
b. Colon cancer
c. Ischemic colitis
d. Adenomatous polyps
a. Hemorrhoids
**APEA Gastroenterology
Of the five percussion notes, which one produces a drum-like sound heard over air filled structures during the abdominal examination?
a. Tympany
b. Dullness
c. Flatness
d. Hyperresonance
a. Tympany
**APEA Gastroenterology
When performing a rectal exam, a purulent bloody discharge mixed with fecal matter is oozing from the rectum. This finding is most consistent with a:
a. Rectal carcinoma
b. Anorectal fistula
c. Anal abscess
d. Genital wart
b. Anorectal fistula
**APEA Gastroenterology
When performing a rectal exam, if a tender, purulent, reddened mass is palpated, consider an anal abscess, especially in the presence of fever and chills. Abscesses tunneling to the skin surface from the anus or rectum may form a clogged or draining anorectal fistula. Fistulas may ooze blood, pus, or feculent mucus. Rectal carcinoma may present with pain along with bleeding from the rectum and changes in bowel habits. Genital warts present as tiny growths and may increase in size to that of a pea. They are usually non-tender and are not associated with rectal discharge.
A 55-year-old patient visits with the nurse practitioner for an annual exam. Stool sample revealed hematochezia. The patient is otherwise asymptomatic. This finding could be associated with:
a. Hemorrhoids
b. Pancreatic cancer
c. Ischemic colitis
d. Adenomatous polyps
d. Adenomatous polyps
**APEA Gastroenterology
Blood in the stools, hematochezia, is often the only symptom seen with adenomatous polyps. Although adenomatous polyps are benign, they are the most common cause of colorectal cancer. Lower abdominal pain accompanied by fever or shock in older adults could be consistent with ischemic colitis. Generally, the abdomen is soft on palpation. Hemorrhoids typically present with noticeable blood on the tissue paper, surface of stool, or dripping in the toilet. Colon cancer can cause bloody stool but usually presents with changes in bowel habits and weight loss.
Bowel sounds may be decreased in the presence of:
a. Diarrhea
b. Early intestinal obstruction
c. Peritonitis
d. Ulcerative colitis
c. Peritonitis
**APEA Gastroenterology
Pain of duodenal or pancreatic origin may be referred to the:
a. Right shoulder
b. Retrosternal area
c. Right posterior chest
d. Back
Back
**APEA Gastroenterology
Referred pain of duodenal or pancreatic origin may be perceived in the back. Referred pain from the biliary tree may be perceived in the right shoulder or the right posterior chest. Heartburn may be associated with retrosternal pain.
When examining the buttocks and rectum, a small tuft of hair surrounded by a halo of erythema was observed at the sacral area. This finding is most likely:
a. An external hemorrhoid
b. A pilonidal cyst
c. A genital wart
d. A normal finding
b. A pilonidal cyst
**APEA Gastroenterology
Pilonidal cyst is a fairly common, probably congenital, abnormality located in the midline superficial to the coccys or the lower sacrum. The opening may exhibit a small tuft of hair surrounded by a halo of erythema. Although Pilonidal cysts are generally asymptomatic, they may drain, form abscesses, or secondary sinus tracts.
An enlarged liver with a smooth tender edge may suggest:
a. Cirrhosis
b. Right-sided heart failure
c. Hepatocellular carcinoma
d. Hematochromatosis
b. Right-sided heart failure
**APEA Gastroenterology
An enlarged liver with a smooth, tender edge suggests inflammation, as in hepatitis, or venous congestion, as in right-sided heart failure. Cirrhosis, hematochromatosis (increased amount of iron in the blood), and lymphoma produce an enlarged liver with a firm, non-tender edge. An enlarged liver that is firm or hard and has an irregular edge or surface suggests hepatocellular carcinoma
Palpation of the liver reveals an enlargement that is firm with an irregular edge. This finding may be suggestive of:
a. Cirrhosis
b. Hepatocellular carcinoma
c. A normal variation in the shape of the liver
d. A downward displacement of the liver by a low diaphragm
b. Hepatocellular carcinoma
**APEA Gastroenterology
An enlarged liver that is firm or hard and has an irregular edge or surface suggests hepatocellular carcinoma. There may be one or more nodules. The liver may or may not be tender. With cirrhosis, the liver is enlarged with a firm, non-tender edge.
Helminths can be transmitted by:
a. The bite of a blood-sucking insect
b. Venom injected through a stinger
c. Casual contact
d. Body fluids
a. The bite of a blood-sucking insect
**APEA Gastroenterology
Helminths are worm-like organisms living in and feeding on living hosts, receiving nourishment and protection while disrupting their hosts’ nutrient absorption, causing weakness and disease. They are transmitted via fecal-oral ingestion, ingestion of infected pork, via sexual contact, and through skin penetration. Examples of helminths are tapeworms, pinworms, and hookworms. Venom is transmitted by arachnids and insects. Casual contact and body fluids are not modes of transmission for helminths
An infant weighed 8 pounds at birth. According to the principles of normal growth and development, how much should he weigh at 12 months of age?
a. 16 pounds
b. 24 pounds
c. 29 pounds
d. 32 pounds
b. 24 pounds
**APEA Gastroenterology
Normal infants double their birth weight at 6 months and triple their birth weight at one year of age.
A 9-month-old who has been a healthy, thriving infant presents with poor appetite, two episodes of vomiting, three bloody stools with mucus and knees drawn to the abdomen with screaming. These are clinical manifestations of:
a. Celiac disease
b. Intussusception
c. Pyloric stenosis
d. Intestinal parasites
b. Intussusception
**APEA Gastroenterology
Intussusception generally occurs in children without a history of chronic GI problems. Pain progresses from colicky-like, intermittent discomfort to a more constant, intense pain. Vomiting may occur and the child may pass “currant jelly-like” stools due to the blood/mucus from inflammation secondary to intussusception. These are classic signs of intussusception. The other choices do not present with these symptoms.
When performing a rectal exam, a reddish, moist, protruding mass is noted at the anal opening. This finding is most likely a(n):
a. A prolapsed internal hemorrhoid
b. An external hemorrhoid
c. A rectal polyp
d. An anal abscess
a. A prolapsed internal hemorrhoid
**APEA Gastroenterology
Internal hemorrhoids are enlargements of the normal vascular cushions located above the pectinate line. They are not usually visible but may become visible if prolapse occurs after defecation. They would appear in the anal canal as reddish, moist, protruding masses. External hemorrhoids are dilated hemorrhoidal veins that originate below the pectinate line and are covered with skin. They present as tender, swollen, bluish, ovoid masses at the anal margin. A tender, purulent, reddened mass palpated in the rectum would be consistent with an anal abscess, especially in the presence of fever and chills. Rectal polyps are typically located in the rectum and, if palpated, feel soft to touch.
Stool that appears bloody, mucoid, or with pus, may indicate:
a. Constipation
b. A lesion in the sigmoid colon
c. Hemorrhoid
d. Crohn’s disease
d. Crohn’s disease
**APEA Gastroenterology
Crohn’s disease usually presents with blood, mucus, or puss in the stool. Thin, pencil-like stool occurs in an obstructing “apple-core” lesion of the sigmoid colon. Constipation produces hard, dry stool. In the presence of hemorrhoids, the stool may appear blood streaked.
Which type of hepatitis is most commonly transmitted from infected mothers to infants at the time of birth?
a. Hepatitis A
b. Hepatitis B
c. Hepatitis C
d. Hepatitis D
b. Hepatitis B
**APEA Gastroenterology
Hepatitis A is typically contracted via ingestion of food or water contaminated with the virus. Hepatitis C and D usually occur as a result of parenteral contact with body fluids infected with the virus. Hepatitis B can be transmitted from mothers to infants at time of birth or from a family member to the infant early in childhood.
Spider angiomas, palmar erythema, and Terry’s nails can be associated with:
a. Chronic renal failure
b. Leukemia
c. Liver disease
d. Infective endocarditis
c. Liver disease
**APEA Gastroenterology
Jaundice, spider angiomas and other telangiectasias, palmar erythema, Terry’s nails, pruritis, purpura, and caput medusae are skin conditions associated with liver disease.
A patient is experiencing a dull achy pain in the epigastric area with eating. This type of pain is consistent with:
a. A gastric ulcer
b. A duodenal ulcer
c. Pancreatitis
d. Dumping syndrome
a. A gastric ulcer
**APEA Gastroenterology
Pain associated with peptic ulcers is dull and achy and usually occurs with eating. With a duodenal ulcer, the pain is relieved by eating. Dumping syndrome is usually seen following gastric surgery when the pylorus is bypassed. Depending on the time following ingestion of food, symptoms can include GI cramping, diarrhea, syncope, tachycardia, sweating, and high-pitched bowel sounds. Pancreatitis pain is caused by edema and inflammation and may be referred posteriorly because of its retro peritoneal position
When percussing the right upper quadrant of the abdomen, a dull medium-pitched sound is heard. The area being percussed is probably the:
a. Spleen
b. Liver
c. Right kidney
d. Bladder
b. liver
**APEA Gastroenterology
The liver is located in the RUQ below the right costal margin. The five percussion notes include: tympany, dullness, flatness, resonance, and hyperresonance. Tympanic or tympanitic, are drum-like sounds heard over air-filled structures during the abdominal exam. Hyperresonant (pneumothorax) sound similar to percussion of puffed up cheeks. Normal resonance/resonant is the sound produced by percussing a normal chest. A dull (consolidation) sound is similar to percussion of a mass such as a liver. Stony dull or flat sounds are produced on percussion from the pleximeter with no contribution from the underlying area.
If a patient describes his stool as thin and “pencil-like”, this could be associated with:
a. Constipation
b. A lesion in the sigmoid colon
c. Hemorrhoids
d. Crohn’s disease
b. A lesion in the sigmoid colon
**APEA Gastroenterology
Peritoneal inflammation produces abdominal pain and tenderness. What technique can be used to assess a tender abdomen suspected to be secondary to peritoneal inflammation?
a. Gentle palpation over the painful area
b. Ask the patient to cough prior to palpation
c. Listen for a bruit prior to palpation
d. Listen for normal bowel sounds after percussing the abdomen
b. Ask the patient to cough prior to palpation
**APEA Gastroenterology
Abdominal pain and tenderness are usually associated with muscle spasms and suggest inflammation of the peritoneum. Before palpating the abdomen, ask the patient to cough because if coughing increases the abdominal pain this suggests inflammation. Deep palpation is not recommended with inflammation. When assessing for rebound tenderness, do it firmly and quickly. A bruit would not denote inflammation but it would denote arterial obstruction. Bowel sounds would be decreased and eventually absent in the presence of peritonitis or in an adynamic ileus.
Stools that appear black, tarry, and sticky are referred to as:
a. Acholic
b. Melena
c. Hematochezia
d. Steatorrhea
b. Melena
**APEA Gastroenterology
Acholic refers to pale or clay-colored stools. A term used to describe red blood in the stool is hematochezia. Steatorrhea refers to the presence of excess fat in the stool.
A patient presents with complaints of black, tarry stools for the last week. This symptom is seen in conditions related to the:
a. Descending colon
b. Ascending colon
c. Rectum
d. Transverse colon
b. Ascending colon
**APEA Gastroenterology
If blood occurs in the stool in right-sided colon cancers or gastric ulcers, the stool will be black and tarry. Bright red blood is more characteristic of left-sided colon cancer or rectal hemorrhoids.
A 30-year-old male presents with generalized abdominal pain. With flexion of the legs at the hip, an increase in his abdominal pain is noted. This finding elicited a positive:
a. Psoas sign
b. Rovsing’s sign
c. Murphy’s sign
d. Obturator sign
a. Psoas sign
**APEA Gastroenterology
Flexion of the leg at the hip causes the psoas muscle to contract. If there is an increase in abdominal pain, this is a positive psoas sign. This is consistent with an inflamed appendix.
Pain in the right lower quadrant during left-sided pressure is a positive Rovsing’s sign. This can be positive with appendicitis.
A sharp increase in tenderness is a positive Murphy’s sign, and consistent with acute cholecystitis.
Right hypogastric pain constitutes a positive obturator sign, from irritation of the obturator muscle by an inflamed appendix.
An enlarged liver with a firm, non-tender edge may be suggestive of:
a. Cirrhosis
b. Right-sided heart failure
c. Hepatocellular carcinoma
d. Hepatitis
a. Cirrhosis
**APEA Gastroenterology
A 30-year-old patient complains of frequent belching, pain in the area below the sternum mostly after earing, and increased salivation. These symptoms are often seen in patients who have:
a. Peptic ulcers
b. Cancer of the stomach
c. Esophageal varices
d. Gastroesophageal reflux
d. Gastroesophageal reflux
**APEA Gastroenterology
GERD symptoms include dyspepsia, frequent belching with a sour taste, chest pain after eating or lying down, straining or lifting, increased salivation, and history of high stress levels.
A patient presents with right upper quadrant and upper abdominal pain. Acute cholecystitis is suspected because the pain radiates to the:
a. Epigastric area
b. Lower abdomen
c. Back
d. Right scapula area
d. Right scapula area
**APEA Gastroenterology
Acute cholecystitis presents with right upper quadrant and upper abdominal pain radiating to the right scapular area. It is usually steady and aching. Pain in the epigastric area could be associated with peptic ulcer or dyspepsia. Cancer of the stomach can present with epigastric pain. Acute mechanical colon obstruction presents with pain in the lower abdomen.
Risk factors associated with Hepatitis B include all of the following except:
a. Having multiple sex partners
b. Body piercing with unclean equipment
c. Travelers to endemic areas
d. Being incarcerated
c. Travelers to endemic areas
**APEA Gastroenterology
Exposure to infected blood in ANY situation can be a risk. International travelers to endemic areas is consistent with risk factor for Hepatitis A, not Hepatitis B.
When performing a rectal exam, a tender, purulent, reddened mass was noted at the anal opening. This finding is most consistent with a:
a. Rectal carcinoma
b. Anorectal fistula
c. Anal abscess
d. Genital wart
c. Anal abscess
**APEA Gastroenterology
If a tender, purulent, reddened mass is palpated, consider anal abscess, especially in the presence of fever and chills.
Abscesses tunneling to the skin surface from the anus or rectum may form a clogged or draining anorectal fistula. Fistulas may ooze blood, pus, or feculent mucus.
Rectal carcinoma may present with pain but is not usually accompanied by fever. Other symptoms may include bleeding from the rectum and changes in bowel habits.
Genital warts present as tiny growths and may increase in size to that of a pea. They are usually non-tender.
The most appropriate position for the patient when performing a rectal exam and one that allows for optimal examination is the:
a. Knee-chest position
b. Lateral decubitus position
c. Right side lying position
d. Supine position
b. Lateral decubitus position
**APEA Gastroenterology
Left side-lying position (Lateral decubitus) is satisfactory for rectal exam and allows good visualization of the perianal and sacrococcygeal areas.
Abdominal percussion is performed to assess:
a. Local inflammation
b. Generalized tenderness
c. Density of tissues and organs
d. Size and placement of the kidneys
c. Density of tissues and organs
**APEA Gastroenterology
A patient was instructed to point to the location of his pain. He pointed to just below the sternoclavicular notch which likely indicates:
a. Diabetic gastroparesis
b. Esophageal dysphagia
c. Oropharyngeal dysphagia
d. Esophageal varices
b. Esophageal dysphagia
**APEA Gastroenterology
Pain associated with diabetic gastroparesis is located in the upper abdomen. The pain associated with oropharyngeal dysphagia is usually located in the cervical neck region. Esophageal varices may be retrosternal.
A patient complains of severe epigastric pain that radiates to the posterior trunk and entire abdomen. This type of pain can be suggestive of:
a. Appendicitis
b. Stomach cancer
c. Acute pancreatitis
d. Biliary colic
c. Acute pancreatitis
**APEA Gastroenterology
Inflammation of the pancreas is poorly localized in the abdomen, therefore can be epigastric and may radiate to the posterior trunk.
Biliary colic, sudden obstruction of the cystic or common bile ducts by a gallstone is characterized by pain in the epigastric or right upper quadrant and may radiate to the right scapula or shoulder.
Pain in the periumbilical area that radiates to the right lower quadrant is usually seen in patients who have appendicitis. Stomach cancer presents with pain in the patient’s epigastric area.
When percussing a protuberant abdomen, tympany is audible. This is consistent with all of the following conditions except:
a. Intestinal obstruction
b. Increased intestinal gas production
c. A large solid tumor
d. A paralytic ileus
c. A large solid tumor
**APEA Gastroenterology
A solid mass gives a dull sound on percussion.
Atypical respiratory symptoms associated with gastroesophageal disease (GERD) may include all of the following except:
a. Coughing
b. Wheezing
c. Aspiration pneumonia
d. Rhinitis
d. Rhinitis
**APEA Gastroenterology
Respiratory symptoms associated with GERD may include coughing, wheezing, asthma, aspiration pneumonia.
When performing an examination of the rectal area, a linear tear at the anal opening was observed. This could be indicative of:
a. A hemorrhoid
b. An anal fissure
c. A syphilitic chancre
d. A genital wart
b. An anal fissure
**APEA Gastroenterology
A linear crack or tear suggests an anal fissure from large hard stools, inflammatory bowel disease, or sexually transmitted diseases.
When performing a rectal exam, a firm mass with an irregular border is palpated approximately two inches inside the rectum. This finding could be indicative of:
a. Rectal carcinoma
b. A syphilitic chancre
c. Rectal abscess
d. Genital wart
a. Rectal carcinoma
**APEA Gastroenterology
Syphilitic chancre appears as a firm, painless ulcer and suggests the chancre of primary syphilis. A tender, purulent, reddened mass palpated in the rectum would be consistent with an anal abscess, especially in the presence of fever and chills. Genital warts present as tiny growths and may increase in size to that of a pea and are usually non-tender and not associated with anal discharge.
Risk factors associated with Hepatitis A include all of the following except:
a. Travelers to endemic areas
b. Male-male partners
c. Persons with chronic liver disease
d. Exposure to needle sticks
d. Exposure to needle sticks
**APEA Gastroenterology
Risk factors for Hep A: Traveling internationally to endemic areas, eating food or drinking water contaminated with HAV, male-male partners, and persons with chronic liver disease.
Being exposed to needlesticks on the job is a risk usually associated with Hepatitis B
A patient presents with complaints of burning sensation in the sternal area. He states it is aggravated by alcohol, chocolate, and coffee. This finding is:
a. Odynophagia
b. Dyspepsia
c. Dysphagia
d. Heartburn
d. Heartburn
**APEA Gastroenterology
Heartburn is a rising retrosternal burning pain or discomfort. Can be aggravated by chocolate, coffee, alcohol, onions, tomato sauce, or bending over or lifting.
Dyspepsia is chronic or recurrent discomfort or pain centered in the upper abdomen.
Odynophagia is pain on swallowing and could be associated with esophagitis, peptic strictures, or Barrett’s esophagus.
Dysphagia is difficulty swallowing and can be associated with some of the same conditions as odynophagia
Signs and symptoms associated with diabetic gastroparesis may include all of the following except:
a. Vomiting of undigested food
b. Weight loss
c. Diarrhea
d. Erratic glucose levels
c. Diarrhea.
**APEA Gastroenterology
Diabetic gastroparesis occurs as a result of damage to the vagus nerve (controls the movement of food through the digestive system). Signs and symptoms associated with diabetic gastroparesis may include vomiting of undigested food, weight loss, erratic glucose levels, and gastroesophageal reflux. Diarrhea is not associated with this condition.
A 35-year-old male visits the nurse practitioner for complaints of a fullness in his lower abdomen. He states that he noticed it a few days ago when he was working out at the gym. At times it feels like a round lump in his groin. Examination reveals a protrusion under the skin near the right groin area. This finding could be suggestive of:
a. Incisional hernia
b. Epigastric hernia
c. Umbilical hernia
d. Inguinal hernia
d. Inguinal hernia
**APEA Gastroenterology
When there is a sudden obstruction caused by a gallstone in the common bile duct or the cystic duct, the pain is usually felt in the:
a. Epigastric area with radiation to the back.
b. The periumbilical area with radiation to the right lower quadrant
c. Epigastric or right upper quadrant with radiation to the right scapula and shoulder.
d. Left lower quadrant
c. Epigastric or right upper quadrant with radiation to the right scapula and shoulder.
**APEA Gastroenterology
A is more indicative of peptic ulcers or dyspepsia. B is more indicative of appendicitis. D is more indicative of diverticulitis.
Which one of the following symptoms is seen in infants with pyloric stenosis?
a. Gross distension of the abdomen
b. Distended superficial veins
c. Ascites
d. Visible peristalsis
d. Visible peristalsis
**APEA Gastroenterology
In pyloric stenosis, visible peristalsis is seen because the stomach works to empty itself but the lumen is obstructed by the hyperplasia and hypertrophy of the pyloric muscle. The stomach is empty, not distended, due to repeated vomiting of feedings. Distended superficial veins and ascites have no relationship with pyloric stenosis, they are observed in biliary atresia.
When assessing a preschooler’s mouth, the number of deciduous teeth seen should be:
a. Up to 10
b. 11 to 15
c. 16-20
d. Up to 32
c. 16-20
**APEA Gastroenterology
Children get their first 20 deciduous teeth between the ages of 6 months and 5 years. Permanent teeth begin to erupt around 6 years of age when the deciduous teeth begin to fall out. All 32 permanent teeth usually erupt by late adolescence.
A patient presents with chest pain and moves his hand from the neck to the epigastrium. This gesture could be suggestive of:
a. Costochondritis
b. Angina pectoris
c. Gastroesophageal reflux
d. Bronchitis
c. Gastroesophageal reflux
**APEA Gastroenterology
Patient gestures may indicate the etiology of some types of chest pain. A clenched fist over the sternum may suggest angina pectoris. A finger pointing to a tender area on the chest wall may suggest musculoskeletal pain. A hand moving from the neck to the epigastrium may suggest GERD.
A patient complains of an unpleasant abdominal fullness after a light meal. This complaint may be consistent with:
a. Diabetic gastroparesis
b. Peptic ulcer
c. Gastritis
d. Gastrocolic fistula
a. Diabetic gastroparesis
**APEA Gastroenterology
Complaints of unpleasant abdominal fullness after a light or moderate meal, or the inability to eat a full meal is often seen in patients with diabetic gastroparesis, gastric outlet obstruction, gastric cancer, early satiety in hepatitis, or those taking anticholinergic medications.
Which of the following symptoms are indicators of dehydration in a four-year-old child?
a. Weight gain and absence of tears
b. Thirst and urine specific gravity of 1.038
c. Heart rate of 120 bpm and sunken fontanels
d. Urine specific gravity of 1.010 and clear, yellow urine
b. Thirst and urine specific gravity of 1.038
**APEA Gastroenterology
A patient presents with complaints of bright red stools over the past weeks. This symptom could be consistent with:
a. Cancer of the ascending colon
b. Cancer of the sigmoid colon
c. Gastric ulcers
d. Small bowel obstruction
b. Cancer of the sigmoid colon
**APEA Gastroenterology
A positive obturator sign would elicit pain in the:
a. right hypogastric area
b. left lower quadrant
c. flank area
d. right lower quadrant
a. right hypogastric area
**APEA Gastroenterology
Assessment of the obturator sign is performed by flexing. By flexing the patient’s right thigh at the hip with knees bent, rotating the leg internally at the hip. If this causes pain in the right epigastric area, then the obturator sign is positive. Hypogastric pain occurs as the obturator muscle rubs an inflamed appendix.
Which of the following assessment findings is a result of the presence of a stone in the common bile duct?
a. Elevated cholesterol levels
b. Right upper quadrant pain
c. Steatorrhea
d. Jaundice
d. Jaundice
**APEA Gastroenterology
Obstruction of the common bile duct results in reflux of bile into the liver, thus, producing jaundice. Although nausea and right upper quadrant pain would occur, jaundice is the result of the obstruction. Steatorrhea is the presence of excessive fat in the stool and can be seen in patients with Crohn’s disease but is not present in cholelithiasis. Elevated cholesterol levels are not indicative of an obstructed common bile duct.
Lower abdominal pain accompanied by fever or shock in older adults could be consistent with:
a. Hemorrhoids
b. Colon cancer
c. Ischemic colitis
d. Adenomatous polyps
c. Ischemic colitis
**APEA Gastroenterology
When examining the abdomen, which of the following symptoms would be suggestive of appendicitis?
a. Pain localized halfway between the umbilicus and the right iliac crest
b. Pain in the left lower quadrant
c. Presence of borborygmus sounds
d. Pain radiating from the mid abdomen to the back.
a. Pain localized halfway between the umbilicus and the right iliac crest
**APEA Gastroenterology
A positive response over McBurney’s point, the area located halfway between the umbilicus and the right iliac crest, would be highly suspicious for appendicitis. Positive rebound tenderness may also be present. Pain in the left lower quadrant could be suggestive of diverticulitis. Pain radiating from the abdomen to the back could be related to a peptic ulcer, perforation, or even pancreatitis.
A 40-year-old female presents with generalized abdominal pain and nausea. During the abdominal exam she exhibits inspiratory arrest with deep palpation of the upper right quadrant of the abdomen. This maneuver exhibits a positive:
a. psoas sign
b. Rovsign’s sign
c. Murphy’s sign
d. Obturator sign
c. Murphy’s sign
**APEA Gastroenterology
Inspiratory arrest with deep palpation of the RUQ constitutes a positive Murphy’s sign and is consistent with acute cholecystitis.
Flexion of the leg at the hip resulting in increased abdominal pain is positive psoas sign and is consistent with inflamed appendix
Pain in RLQ that occurs with palpation of the RLQ is Rovsing’s sign and is consistent with appendicitis.
A positive obturator sign occurs when the obturator muscle rubs inflamed appendix and produces right hypogastric pain.
Percussion of the abdomen should be avoided when:
a. Trying to determine if the bladder is full
b. Trying to detect the size of an abdominal organ
c. Assessing for feces-filled intestines
d. An abdominal aneurysm is suspected.
d. An abdominal aneurysm is suspected
**APEA Gastroenterology
Bowel sounds may be increased in the presence of:
a. An adynamic ileus
b. Early intestinal obstruction
c. Peritonitis
d. Constipation
b. Early intestinal obstruction
**APEA Gastroenterology
Bowel sounds may be increased in the presence of diarrhea or early intestinal obstruction
Bowel sounds are decreased, then absent in adynamic ileus and peritonitis.
They are decreased in constipation.
Ecchymosis of the abdominal wall is usually seen with persons with:
a. Cushing’s disease
b. Hepatic cirrhosis
c. Colorectal cancer
d. Intraperitoneal hemorrhage
d. Intraperitoneal hemorrhage
**APEA Gastroenterology
Ecchymosis of the abdominal wall is seen in intraperitoneal or retroperitoneal hemorrhage.
Pink-purple striae may indicate Cushing’s syndrome.
Dilated veins may indicate hepatic cirrhosis or inferior vena cava obstruction.
Colorectal cancer does not exhibit ecchymosis.
Pain of biliary tree origin may be referred to the:
a. Right shoulder
b. Retrosternal area
c. Left posterior chest
d. Back
a. right shoulder
**APEA Gastroenterology
When performing a digital rectal exam, a soft, pedunculated lesion is palpated. This finding is most likely:
a. A prolapsed internal hemorrhoid
b. An external hemorrhoid
c. A rectal polyp
d. An anal abscess
c. A rectal polyp
**APEA Gastroenterology
Rectal polyps are typically located in the rectum and if palpated, feel soft to touch and may be pedunculated (attached to the base tissue by means of a stalk).
When inspecting the abdomen of a 60-year-old male, dilated veins were noted especially in the mid and upper abdomen. This condition is associated with:
a. Cushing’s disease
b. Hepatic cirrhosis
c. Colorectal cancer
d. Intraperitoneal hemorrhage
b. Hepatic cirrhosis
**APEA Gastroenterology
When the scrotum is transilluminated in a 4-month-old boy, it lights up brightly. This finding may be consistent with:
a. Normal scrotal findings
b. An inguinal hernia
c. Cryptochidism
d. A hydrocele
d. A hydrocele
A hydrocele is defined as swelling in the scrotum that lights up on transillumination. Inguinal hernia and cryptorchidism are diagnosed using palpation of the scrotum and testicle and are not associated with fluid collection. Swelling of the scrotum and collection of serous fluid are not normal findings.
**APEA Men’s Health
What is the most common non-skin cancer in America?
a. Uterine cancer
b. Bladder cancer
c. Cervical cancer
d. Prostate cancer
d. Prostate Cancer
**APEA Men’s Health
A 26-year-old man with a past medical history of sickle cell disease arrives at the office with complaints of a penile erection that has lasted 4 hours. He is experiencing symptoms of:
a. Low flow priapism
b. Peyronie disease
c. Acute balanitis
d. Side effect of opioids
a. Low flow priapism
**APEA Men’s Health
Low flow priapism is common in sickle cell patients. Priapism is a penile erection lasting more than 4 hours without stimulation. Peyronie disease, acute balanitis, and opioid side effects result in an inability to achieve or difficulty maintaining an erection.
During assessment of a 3-month-old boy, an incomplete descent of the left testicle into the scrotum is noted. The practitioner understands that:
a. Testicles should descend by 6 months of age
b. Testicles will not spontaneously descend
c. An abdominal ultrasound should be ordered.
d. A referral to a pediatric urologist is indicated.
a. Testicles should descend by 6 months of age
**APEA Men’s Health
Male infants with cryptorchidism experience incomplete descent of one or both testicles into the scrotum. Urology evaluation should be considered if the testicle is not descended by 6 months of age. Orchiopexy surgery is not performed until symptoms persist after 1 year. 75% of full-term and 95% of premature cryptorchid testes descent spontaneously by 1 year of age.
A 30-year-old man is seen in the clinic for complaints of scrotal irritation, bilateral testicular pain, and enlarged lymph nodes in the groin that began 2 weeks after having unprotected intercourse. The subjective history describes:
a. Epididymitis
b. Testicular torsion
c. Urinary tract infection
d. Idiopathic sacral edema
a. Epididymitis
**APEA Men’s Health
Epididymitis is commonly caused by a sexually transmitted infection (STI) and presents as scrotal irritation, bilateral testicular pain, and enlarged lymph nodes. Urinary tract infections (UTIs) include symptoms associated with urination and do not usually feature testicular or scrotal involvement. Testicular torsion causes acute, unilateral testicular pain. Idiopathic sacral edema presents as swelling of the scrotum with fluid accumulation. It presents as unilateral erythema of the scrotal skin.
A 40-year-old male states that he felt “something” above his left testis. On examination, a painless cyst is noted above the left testicle. Transillumination is positive. This is consistent with a:
a. Varicocele of the spermatic cord
b. Spermatocele of the epididymis
c. Torsion of the spermatic cord
d. Prostatitis
b. Spermatocele of the epididymis
**APEA Men’s Health
A painless, movable cystic mass just above the testicle suggests a spermatocele or an epididymal cyst. Both transilluminate and are difficult to distinguish clinically.
An acutely inflamed epididymis is tender and swollen and may be difficult to distinguish from the testicle. Additionally, the scrotum may be reddened and the vas deferens inflamed. Coexisting urinary tract infection, or prostatitis, supports the diagnosis.
Varicocele refers to varicose veins of the spermatic cord, usually found on the left. It feels like a soft “bag of worms” upon palpation of the scrotum.
Torsion, or twisting, of the testicle on its spermatic cord produces an acutely painful, tender, and swollen organ that is retracted upward in the scrotum. The scrotum becomes red and edematous. There is no associated urinary infection.
When screening for bladder cancer in a primary care setting, the test that would be LEAST appropriate is:
a. Microscopic urinalysis
b. Urine cytology
c. Cystoscopy
d. Dipstick for hematuria
c. Cystoscopy
**APEA Men’s Health
Cystoscopy would be completed by a urologist, not in the PCP setting.
A 30-year-old man who has a history of heart disease will present with which symptom related to the development of arteriosclerosis?
a. Hypogonadism
b. Erectile dysfunction
c. Enlarged prostate
d. Urinary incontinence
b. Erectile dysfunction
APEA Men’s Health
Hypogonadism is caused by changes in testosterone. Prostate enlargement occurs in most older men and is not specifically related to heart disease. Urinary incontinence is a symptom associated with enlarged prostate and is not specific to atherosclerotic changes.
Which examination finding is defined as a congenital ventral displacement of the meatus on the penis?
a. Balanitis
b. Posthitis
c. Phimosis
d. Hypospadias
d. Hypospadias
**APEA Men’s health
Balanitis is an inflammation of the glans of the penis.
Posthitis is an inflammation of the foreskin.
Phimosis is a congenital narrowing of the opening of the foreskin so that it cannot be retracted
When examining the scrotum in a young male child, test the cremasteric reflex by:
a. Scratching the medial aspect of the thigh
b. Having the child lie down and palpate the femoral pulse
c. Gently pulling the penis downward
d. Palpating the area above the symphysis pubis
a. Scratching the medial aspect of the thigh
**APEA Men’s Health
To elicit the cremasteric reflex: examine child when he is relaxed and have him sit crossed legged on the table. Palpate the scrotum. The child can also blow into a balloon, this would cause an increase in intra-abdominal pressure and stimulate the reflex. The cremasteric reflex can be tested by scratching the inside of the child’s thigh.
When assessing for the presence of a direct inguinal hernia in a man, the practitioner should palpate for a distinct bulge while instructing the patient to:
a. Hold a breath
b. Lift one leg
c. Cough
d. Bear down
c. Cough
**APEA Men’s Health
The prostate is assessed by:
a. A digital rectal examination (DRE)
b. A formal urinalysis
c. Testicular palpation and cough
d. Palpation of the left lower quadrant
a. A digital rectal examination (DRE)
**APEA Men’s Health
A 33-year-old male presents for examination because of a scrotal complaint. The exam reveals the presence of 2 testicles and palpable tissue resembling a “bag of worms” over the left testicle. When in the supine position with the scrotum elevated, the “bag of worms” disappears. This condition is suggestive of a:
a. Varicocele of the spermatic cord
b. Spermatocele of the epididymis
c. Torsion of the spermatic cord
d. Prostatitis
a. Varicocele of the spermatic cord
**APEA Men’s Health
Varicocele refers to varicose veins of the spermatic cord, usually found on the left. It feels like a soft “bag of worms” upon palpation of the scrotum.
An acutely inflamed epididymis is tender and swollen and may be difficult to distinguish from the testicle. The scrotum may be reddened and the vas deferens inflamed. Epididymitis occurs usually in adults, who are infected with Chlamydia. Coexisting UTI or prostatitis support the diagnosis.
A painless, movable cystic mass just above the testicle suggests a spermatocele or an epididymal cyst. Both transilluminate.
Torsion, or twisting, of the testicle on its spermatic cord produces an acutely painful, tender, and swollen organ that is retracted upward in the scrotum. The scrotum becomes red and edematous. There is no associated urinary infection.
When examining the prostate gland, the examiner should inform the patient that this procedure may:
a. Cause him to urinate
b. Prompt an urge to defecate
c. Prompt an urge to urinate
d. Cause him to cough
c. Prompt an urge to urinate
**APEA Men’s Health
When palpating the prostate gland during the rectal exam, the prostate feels tender, swollen, “boggy” and warm. This finding is consistent with:
a. A normal prostate gland
b. Acute bacterial prostatitis
c. Benign prostatic hyperplasia
d. Carcinoma of the prostate
b. Acute bacterial prostatitis
**APEA Men’s Health
As palpated through the anterior rectal wall, the normal prostate is a rounded, heart-shaped structure, somewhat rubbery and non-tender. It measures approximately 2.5 cm long.
In a patient with BPH, the gland feels enlarged and increases with age. BPH is present in more than 50% of men by 50 years of age.
Carcinoma of the prostate gland is suggested by an area of hardness in the gland. A distinct hard nodule that alters the contour of the gland may or may not be palpable. However, as the cancer enlarges, the prostate feels irregular and may extend beyond the confines of the gland.
Undescended testicle(s) in a young male is termed:
a. Testicular torsion
b. Epispadias
c. Hydrocele
d. Cryptorchidism
d. Cryptorchidism
**APEA Men’s Health
Epispadias is present when the urethral orifice is located on the dorsal surface of the glans or shaft of the penis.
A hydrocele denotes fluid in the scrotal sac.
Testicular torsion occurs when the spermatic cord (from which the testicle is suspended) twists, reducing the testicle’s blood supply resulting in ischemia of that testicle. This is a medical emergency.
When palpating the prostate gland during the rectal exam, the prostate feels enlarged and non-tender. This finding is consistent with:
a. A normal prostate gland
b. Acute bacterial prostatitis
c. Benign prostatic hyperplasia
d. Carcinoma of the prostate.
c. Benign prostatic hyperplasia
**APEA Men’s Health
As palpated through the anterior rectal wall, the normal prostate is a rounded, heart-shaped structure, somewhat rubbery and non-tender. It measures approximately 2.5 cm long.
In a patient with BPH, the gland feels enlarged and increases with age. BPH is present in more than 50% of men by 50 years of age.
Carcinoma of the prostate gland is suggested by an area of hardness in the gland. A distinct hard nodule that alters the contour of the gland may or may not be palpable. However, as the cancer enlarges, the prostate feels irregular and may extend beyond the confines of the gland.
During pregnancy, which hormone promotes endometrial growth that supports the early embryo?
a. Progesterone
b. Human chorionic gonadotropin (HCG)
c. Estrogen
d. Human placental lactogen
c. Estrogen
**APEA Pregnancy
Estrogen promotes endometrial growth that supports the early embryo. This hormone appears to stimulate prolactin output in the anterior lobe of the pituitary gland, which readies breast tissue for lactation. Estrogen also contributes to the hypercoagulable state that puts pregnant women at higher risk for thromboembolic events.
During pregnancy, as the skin over the abdomen stretches to accommodate the fetus, this purplish mark may appear. This finging is:
a. Hegar’s sign
b. Chadwick’s sign
c. Striae gravidarum
d. Linea nigra
c. Striae gravidarum
**APEA Pregnancy
As the skin over the abdomen stretches to accommodate the fetus, purplish striae gravidarum “stretch marks” may appear.
Linea nigra is a brownish black pigmented vertical stripe along the midline skin.
Hegar’s sign is the palpable softening of the cervical isthmus, the portion of the uterus that narrows into the cervix.
Increased vascularity throughout the pelvis during pregnancy gives the vagina a bluish color, known as Chadwick’s sign.
A form of milk produced by the mammary glands during the late pregnancy is referred to as:
a. Witch’s milk
b. Colostrum
c. Breast milk
d. Lactating milk
b. Colostrum
**APEA Pregnancy
After 24 weeks gestation, auscultation of more than one fetal heart tone (FHT) in different locations with varying rates suggests:
a. Decelerations
b. Fetal distress
c. Intrauterine growth restriction
d. Multiple gestation
d. Multiple gestation
**APEA Pregnancy
When performing a pelvic exam on a pregnant woman, a larger speculum may be needed because of:
a. Increased vascularity of the vagina
b. Vaginal wall relaxation
c. Increased vascularity of the cervical structures
d. Swelling in the vaginal cavity
b. Vaginal wall relaxation
**APEA Pregnancy
During pregnancy, which hormone results in increased blood viscosity?
a. Human chorionic gonadotropin (HCG)
b. Estrogen
c. Progesterone
d. Erythropoietin
d. Erythropoietin
**APEA Pregnancy
Erythropoietin increases during pregnancy, which raises erythrocyte mass resulting in increased blood viscosity
When should an oral glucose tolerance test be performed during pregnancy?
a. Initially, when the pregnancy is confirmed
b. 8 weeks
c. 24 weeks
d. 30 weeks
c. 24 weeks
**APEA Pregnancy
Oral glucose tolerance test is used to screen for gestational diabetes between 24-28 weeks of pregnancy. It may also be used when the disease is suspected, even though fasting blood glucose level is normal.
During pregnancy, which hormone is responsible for increasing insulin resistance and hyperglycemia associated with gestational diabetes?
a. Progesterone
b. Human chorionic gonadotropin (HCG)
c. Estrogen
d. Human placental lactogen
d. Human placental lactogen
**APEA Pregnancy
Normal changes in the breast and nipples during pregnancy include all of the following except:
a. A marked venous pattern on the breast
b. Darkened nipples
c. Mastitis
d. Darkened areola
c. Mastitis
**APEA Pregnancy
When might fundal height in a pregnant woman most accurately predict gestational age?
a. 10 weeks gestation
b. 14 weeks gestation
c. 18 weeks gestation
d. 40 weeks gestation
c. 18 weeks gestation
**APEA Pregnancy
Uterine fundal height measured in centimeters correlates with gestational age between 18-34 weeks. Fundal height is measured in centimeters from symphysis pubis to top of uterus. This is known as McDonald’s rule.
Upon cervical examination of the pregnant woman, cervical erosion, erythema, and irritation are noted. These findings could be suggestive of:
a. Cervical cancer
b. A non-pregnant state
c. Cervicitis
d. Bacterial vaginosis
c. Cervicitis
**APEA Pregnancy
Cervical erosion, erythema, discharge, or irritation might suggest cervicitis and warrants investigation for sexually transmitted infections (STIs).
A pink cervix suggests a non-pregnant state.
B/P readings greater than 140 mm HG systolic and greater than 90 mm HG diastolic prior to pregnancy, before 20 weeks gestation, or beyond 12 weeks postpartum is:
a. Gestational hypertension
b. Preeclampsia
c. Chronic hypertension
d. Primary hypertension
c. Chronic hypertension
**APEA Pregnancy
Chronic HTN occurs when systolic BP >140 or diastolic BP >90 documented prior to pregnancy, before 20 weeks gestation, or beyond 12 weeks postpartum.
Gestation HTN refers to elevated BP detected after 20 weeks gestation in the absence of proteinuria.
Pre-eclampsia occurs in a woman who was previously normotensive but now has new onset hypertension with either proteinuria or end-organ damage.
Primary hypertension, formerly known as essential hypertension, is a disorder which is associated with elevated blood pressure and an unidentifiable cause.
During pregnancy, what sound may be auscultated at the second or third intercostal space at the sternal border due to increased blood flow through the vessles?
a. Diastolic murmur
b. Systolic murmur
c. Venous hum
d. Bruit
c. Venous hum
**APEA Pregnancy
A venous hum, or continuous mammary souffle, that occurs during pregnancy is due to increased blood flow through normal vessels. The mammary souffle is commonly heard during late pregnancy or lactation. It is heard loudest in the second or third intercostal space at the sternal border, and is typically both systolic and diastolic, though only the systolic component may be audible.
Inaudible fetal heart tones (FHT) may indicate:
a. Extra amniotic fluid
b. Severe fetal morbidity
c. Earlier gestation than expected
d. Intrauterine growth restriction
c. Earlier gestation than expected
**APEA Pregnancy
Lack of audible fetal heart tones (FHT) may indicate earlier gestation than expected, fetal demise, false pregnancy, or observer error.
Inability to locate the FHT should always be investigated with ultrasound.
When performing the third Leopold maneuver on a pregnant woman, the fetal head is the presenting part. This finding is referred to as the:
a. Vertical lie
b. Transverse lie
c. Face presentation
d. Vertex presentation
d. Vertex presentation
**APEA Pregnancy
When performing the third Leopold maneuver on a pregnant woman, the fetal head is the presenting part. This finding is referred to as the vertex or cephalic presentation. Additionally, if the cephalic prominence is on the same side as the small parts, then the fetus is in vertex presentation. If the cephalic prominence is on the same side as the back, then the head is extended and the fetus is in face presentation. The top of the uterus (fundus) is palpated to establish which end of the fetus (fetal pole) is in the upper part of the uterus. If either the head or buttocks (Breech) of the fetus is in the fundus, then the fetus is in vertical lie. Otherwise the fetus is most likely in transverse lie.
If regular uterine contractions occur prior to 37 weeks gestation, this could be:
a. A normal finding
b. Preterm labor
c. Preeclampsia
d. Supine hypotensive syndrome
b. Preterm labor
**APEA Pregnancy
Before 37 weeks, regular uterine contractions with/without pain and bleeding are abnormal findings and may suggest preterm labor.
During the examination of a pregnant woman, knee and ankle deep tendon reflexes appear hyperreflexic. This finding could be suggestive of:
a. Hypertension
b. Gestational diabetes
c. Preeclampsia
d. An embolus
c. Preeclampsia
**APEA Pregnancy
During the vaginal examination of a pregnant woman in her first trimester, an adnexal mass with tenderness is palpated. This finding could be consistent with:
a. Multiple gestation
b. A fibroid tumor
c. An ectopic pregnancy
d. A false pregnancy
c. An ectopic pregnancy
**APEA Pregnancy
Adnexal tenderness or masses identified early in gestation require ultrasound evaluation to rule out ectopic pregnancy.
An enlarged uterus may indicate multiple gestation or a fibroid tumor.
During pregnancy, which hormone is secreted by the corpus luteum and placenta to promote ligamentous laxity in the sacroiliac joint and pubic symphysis for passage of the fetus?
a. Human chorionic gonadotropin (HCG)
b. Estrogen
c. Human placental lactogen
d. Relaxin
d. Relaxin
**APEA Pregnancy
Inflamed and overgrown gingiva during pregnancy is:
a. A common finding during pregnancy
b. Suggestive of anemia
c. Suggestive of periodontal disease
d. Indicative of poor nutrition
a. A common finding during pregnancy
**APEA Pregnancy
Gingival inflammation and swelling is common during pregnancy because of hormonal shifts that occur. Consequently, meticulous oral hygiene is important in pregnant women.
Adequate daily dietary intake of folic acid in pregnancy is:
a. 300 mcg
b. 400 mcg
c. 800 mcg
d. 1000 mcg
b. 400 mcg
**APEA Pregnancy
The daily suggested intake levels of folic acid are as follows:
Men older than 13 years = 400 mcg.
Women older than 13 years = 400-600 mcg.
Pregnancy all ages = 400-600 mcg.
Breastfeeding women of all ages = 500 mcg.
The cervical opening or shortening noted during a bimanual examination prior to 37 weeks gestation, may indicate:
a. Ectopic pregnancy
b. Preterm labor
c. Leiomyomata
d. Cervical erosion
b. Preterm labor
**APEA Pregnancy
When examining the pregnant patient, conjunctival pallor may indicate:
a. Leukemia
b. Anemia
c. Preeclampsia
d. Hypertension
b. Anemia
**APEA Pregnancy
Which substance used during pregnancy accounts for one third of all low-birth-weight infants, placental abruption, and preterm labor?
a. Illicit drugs
b. Alcohol
c. Tobacco
d. Prescription drugs
c. Tobacco
**APEA Pregnancy
When should all pregnant women be screened for human immunodeficiency virus (HIV)?
a. Routine screening is not recommended
b. At the first prenatal visit
c. During the second trimester
d. During the third trimester
b. At the first prenatal visit
**APEA Pregnancy
The CDC recommends screening all pregnant women for HIV at the first prenatal visit. During the third trimester, women at high risk for acquiring HIV infection should be rescreened.
Weight gain should be monitored during pregnancy. For a pregnant woman whose BMI is <18.5, the total weight gain should be:
a. 11-20 lbs
b. 15-25 lbs
c. 25-35 lbs
d. 28-40 lbs
d. 28-40 lbs
**APEA Pregnancy
Weight gain should be closely monitored during pregnancy, as both excessive and inadequate weight gain are associated with poor birth outcomes. BMI of <18.5 should gain 28-40 lbs.
BMI of 18.5-24.9 should gain 25-35 lbs
BMI of 25-29.9 should gain 15-25 lbs
BMI >30 should gain 11-20 lbs
During pregnancy, dyspnea accompanied by increased respiratory rate, cough, rales, or respiratory distress raises concerns of:
a. Preeclampsia
b. Hypertension
c. Peripartum cardiomyopathy
d. Cocaine use
c. Peripartum cardiomyopathy
**APEA Pregnancy
These symptoms raise concerns of possible infection, asthma, pulmonary embolus, or peripartum cardiomyopathy.
Weight gain should be monitored during pregnancy. For a pregnant woman whose BMI is 30, the total weight gain should be:
a. 11-20 lbs
b. 15-25 lbs
c. 25-35 lbs
d. 28-40 lbs
a. 11-20 lbs
**APEA Pregnancy
Weight gain should be closely monitored during pregnancy, as both excessive and inadequate weight gain are associated with poor birth outcomes. BMI of <18.5 should gain 28-40 lbs.
BMI of 18.5-24.9 should gain 25-35 lbs
BMI of 25-29.9 should gain 15-25 lbs
BMI >30 should gain 11-20 lbs
In pregnant women, between 10-18 weeks gestation, fetal heart tones (FHT) can be auscultated along the:
a. Woman’s back
b. Woman’s upper left quadrant
c. Midline of the woman’s lower abdomen
d. Upper left quadrant
c. Midline of the woman’s lower abdomen
**APEA Pregnancy
After 18 weeks, the FHT are best heard over the back or chest and depends on fetal position
Pregnant women should avoid unpasteurized dairy products such as soft cheese, raw eggs, and delicatessen meats because of the risk of:
a. Ingesting large amounts of mercury
b. Ingesting large amounts of vitamin A
c. Contracting toxoplasmosis
d. Contracting botulism
c. Contracting toxoplasmosis
**APEA Pregnancy
These foods should be avoided in pregnancy due to the risk of Listeria, Salmonella, and toxoplasmosis
What is the standard instrument used to auscultate fetal heart tones?
a. Stethoscope
b. Doppler
c. Prenatal monitor
d. Ultrasound
b. Doppler
**APEA Pregnancy
When should a vaginal swab for Group B streptococcus be obtained in a pregnant woman?
a. Initially, when the pregnancy is confirmed
b. 12-18 weeks
c. 24-30 weeks
d. 35-37 weeks
d. 35-37 weeks
**APEA Pregnancy
A vaginal swab for group B streptococcus should be done between 35-37 weeks gestation. Group B streptococcus can normally be found in 15-45% of all healthy adult women. It can commonly be found in the intestine, vagina, and rectal area. Most women who are carriers will not have any symptoms. However, under certain circumstances, infection of both the mother and/or the newborn can develop.
Normal findings of the vaginal wall of a pregnant woman include all of the following except:
a. Bluish color
b. Deep rugae
c. Leukorrhea
d. Lochia
d. Lochia
**APEA Pregnancy
Lochia is a term given to the substance that is discharged from the uterus, through the vagina after childbirth. It consists of blood, mucus, and placental tissue.
The normal fetal heart rate (FHR) range is:
a. 60-90 bpm
b. 90-110 bpm
c. 120-160 bpm
d. 140-180 bmp
c. 120-160 bpm
**APEA Pregnancy
New onset hypertension with proteinuria or end-organ damage is:
a. Gestational hypertension
b. Preeclampsia
c. Chronic hypertension
d. Primary hypertension
b. Preeclampsia
**APEA Pregnancy
Chronic HTN occurs when systolic BP >140 or diastolic BP >90 documented prior to pregnancy, before 20 weeks gestation, or beyond 12 weeks postpartum.
Gestation HTN refers to elevated BP detected after 20 weeks gestation in the absence of proteinuria.
Pre-eclampsia occurs in a woman who was previously normotensive but now has new onset hypertension with either proteinuria or end-organ damage.
Primary hypertension, formerly known as essential hypertension, is a disorder which is associated with elevated blood pressure and an unidentifiable cause.
Weight gain should be monitored during pregnancy. For a pregnant woman whose BMI is 25-29.9, the total weight gain should be:
a. 11-20 lbs
b. 15-25 lbs
c. 25-35 lbs
d. 28-40 lbd
b. 15-25 lbs
**APEA Pregnancy
Weight gain should be closely monitored during pregnancy, as both excessive and inadequate weight gain are associated with poor birth outcomes. BMI of <18.5 should gain 28-40 lbs.
BMI of 18.5-24.9 should gain 25-35 lbs
BMI of 25-29.9 should gain 15-25 lbs
BMI >30 should gain 11-20 lbs
Weight gain should be monitored during pregnancy. For a pregnant woman whose BMI is 18.5-24.9, the total weight gain should be:
a. 11-20 lbs
b. 15-25 lbs
c. 25-35 lbs
d. 28-40 lbs
c. 25-35 lbs
Weight gain should be closely monitored during pregnancy, as both excessive and inadequate weight gain are associated with poor birth outcomes. BMI of <18.5 should gain 28-40 lbs.
BMI of 18.5-24.9 should gain 25-35 lbs
BMI of 25-29.9 should gain 15-25 lbs
BMI >30 should gain 11-20 lbs
Which of the following sexually transmitted disease (STD) screening tests is NOT routinely recommended during pregnancy?
a. Syphilis
b. Gonorrhea
c. Hepatitis B
d. Genital herpes (HSV-2)
d. Genital herpes (HSV-2)
**APEA Pregnancy
Evidence does not support routine genital herpes (HSV-2) serologic testing among asymptomatic pregnant women. The CDC recommends screening for syphilis, gonorrhea, and hepatitis B at the first prenatal visit for all pregnant women.
During pregnancy, if fundal height is 4 centimeters larger than expected, consider all of the following except:
a. Large for gestational age infant
b. Extra amniotic fluid
c. Uterine leiomyoma
d. Fetal anomaly
d. Fetal anomaly
**APEA Pregnancy
If fundal height is >4 cm larger than expected, consider multiple gestation, a large fetus, extra amniotic fluid, or uterine leiomyoma.
If fundal height is >4 cm smaller than expected, consider low level of amniotic fluid, missed abortion, intrauterine growth restriction, or fetal anomaly.
All of these conditions should be investigated by ultrasound.
If fetal movement cannot be perceived after 24 weeks gestation, all of the following may be considered except:
a. Fetal demise
b. False pregnancy
c. An error in calculating gestational age
d. A normal finding
d. A normal finding
If fetal movement cannot be perceived after 24 weeks, consider error in calculating gestational age, fetal death or severe morbidity, or false pregnancy.
Confirm fetal health and gestational age with an ultrasound.
Facial edema in a pregnant woman after 20 weeks gestation could be:
a. A normal finding
b. Suggestive of preeclampsia
c. Renal failure
d. Heart failure
b. Suggestive of preeclampsia
A five percent weight loss during the first trimester due to vomiting would be considered:
a. Normal weight loss
b. Mild weight loss
c. Moderate weight loss
d. Excessive weight loss
d. Excessive weight loss
**APEA Pregnancy
Weight loss in excess of 5% of pre-pregnancy weight is considered excessive, representing hyperemesis gravidarum, and may lead to adverse pregnancy outcomes.
When performing a third Leopold maneuver on a pregnant woman, the cephalic prominence is on the same side as the back. This finding is referred to as the:
a. Vertical lie
b. Transverse lie
c. Face presentation
d. Vertex presentation
c. Face presentation
**APEA Pregnancy
When performing the third Leopold maneuver on a pregnant woman, the fetal head is the presenting part. This finding is referred to as the vertex or cephalic presentation. Additionally, if the cephalic prominence is on the same side as the small parts, then the fetus is in vertex presentation. If the cephalic prominence is on the same side as the back, then the head is extended and the fetus is in face presentation. The top of the uterus (fundus) is palpated to establish which end of the fetus (fetal pole) is in the upper part of the uterus. If either the head or buttocks (Breech) of the fetus is in the fundus, then the fetus is in vertical lie. Otherwise the fetus is most likely in transverse lie.
Which substance used during pregnancy accounts for the leading cause of preventable intellectual disability?
a. Illicit drugs
b. Alcohol
c. Tobacco
d. Prescribing drugs
b. Alcohol
**APEA Pregnancy
Fetal alcohol syndrome, the neurodevelopmental sequela of alcohol exposure during fetal development, is the leading cause of preventable intellectual disability in the United States.
When performing the first Leopold maneuver on a pregnant woman, if the fetal buttocks and head are not easily palpated at the fundus, the fetus is said to be in:
a. Vertical lie
b. Transverse lie
c. Face presentation
d. Vertex presentation
b. Transverse lie
**APEA Pregnancy
When performing the third Leopold maneuver on a pregnant woman, the fetal head is the presenting part. This finding is referred to as the vertex or cephalic presentation. Additionally, if the cephalic prominence is on the same side as the small parts, then the fetus is in vertex presentation. If the cephalic prominence is on the same side as the back, then the head is extended and the fetus is in face presentation. The top of the uterus (fundus) is palpated to establish which end of the fetus (fetal pole) is in the upper part of the uterus. If either the head or buttocks (Breech) of the fetus is in the fundus, then the fetus is in vertical lie. Otherwise the fetus is most likely in transverse lie.
In the third trimester of pregnancy, which position affords the greatest comfort by reducing the weight of the uterus on the abdominal vessels?
a. Left side lying
b. Right side lying
c. Supine
d. Semi-sitting with knees bent
d. Semi-sitting with knees bent
**APEA Pregnancy
Murmurs audible during pregnancy may suggest:
a. Preeclampsia
b. Hypertension
c. Anemia
d. Pulmonary embolus
c. Anemia
**APEA Pregnancy
Murmurs audible during pregnancy may suggest anemia however, benign systolic murmurs can be heard in women after the first trimester.
During pregnancy, which hormone is produced by the placenta and supports progesterone synthesis in the corpus luteum?
a. Progesterone
b. Human chorionic gonadotropin (HCG)
c. Estrogen
d. Human placental lactogen
b. Human chorionic gonadotropin (HCG)
**APEA Pregnancy
Human chorionic gonadotropin (HCG) is produced by the placenta and supports progesterone synthesis in the corpus luteum, effectively preventing the early embryo from being lost to menstruation
During pregnancy, a patient’s fundal height measured 26 centimeters. This would suggest that the gestational age was:
a. 13 weeks
b. 26 weeks
c. 30 weeks
d. 36 weeks
b. 26 weeks
**APEA Pregnancy
During pregnancy, which hormone increases tidal volume and alveolar minute ventilation, lowers esophageal sphincter tone, and relaxes tone in the uterus and bladder?
a. Progesterone
b. Human chorionic gonadotropin (HCG)
c. Estrogen
d. Human placental lactogen
a. Progesterone
**APEA Pregnancy
Progesterone affects numerous body systems. Rising progesterone leads to increased tidal volume and alveolar minute ventilation, though respiratory rate remains constant. Respiratory alkalosis and subjective shortness of breath result from these changes. Lower esophageal sphincter tone results from rising levels of estradiol and progesterone, contributing to gastroesophageal reflux. Progesterone relaxes tone in the ureters and bladder, causing hydronephrosis and an increased risk of bacteriuria.
What is the importance of prenatal care?
a. Determines gestational age
b. Estimates expected date of delivery
c. Optimizes health and minimizes risk for mother and fetus
d. Obtain family history
c. Optimizes health and minimizes risk for mother and fetus
**APEA Pregnancy
During pregnancy, if fundal height is 4 centimeters smaller than expected, consider:
a. Large for gestational age infant
b. Extra amniotic fluid
c. Uterine leiomyoma
d. Intrauterine growth restriction
d. Intrauterine growth restriction
**APEA Pregnancy
If fundal height is >4 cm larger than expected, consider multiple gestation, a large fetus, extra amniotic fluid, or uterine leiomyoma.
If fundal height is >4 cm smaller than expected, consider low level of amniotic fluid, missed abortion, intrauterine growth restriction, or fetal anomaly.
All of these conditions should be investigated by ultrasound.
During pregnancy, the Leopold maneuvers assist in determining all of the following except:
a. Fetal position with the maternal abdomen
b. Readiness for vaginal birth
c. Adequacy of fetal growth
d. Cervical effacement
d. Cervical effacement
**APEA Pregnancy
Leopold maneuvers are used to determine the fetal position within the maternal abdomen beginning in the second trimester. Accuracy is greatest after 36 weeks gestation. These exam findings can help ascertain the adequacy of fetal growth and the readiness for vaginal birth. Since these maneuvers are performed on the maternal abdomen, cervical effacement is not included with these maneuvers. To determine cervical effacement, a vaginal exam would be performed.
Which of the following is NOT a condition associated with hyperthyroidism in pregnancy?
a. Miscarriage
b. Premature birth
c. Gestational diabetes
d. Preeclampsia
c. Gestational diabetes
**APEA Pregnancy
During pregnancy, a brownish black pigmented vertical stripe along the midline of the abdomen may appear. This finding is:
a. Hegar’s sign
b. Chadwick’s sign
c. Striae gravidarum
d. Linea nigra
d. Linea nigra
**APEA Pregnancy
As the skin over the abdomen stretches to accommodate the fetus, purplish striae gravidarum “stretch marks” may appear.
Heger’s sign is the palpable softening of the cervical isthmus, the portion of the uterus that narrows into the cervix.
Increased vascularity throughout the pelvis during pregnancy gives the vagina a bluish color, known as Chadwick’s sign.
During pregnancy, which supplement is recommended to decrease the risk of neural tube defect.
a. Vitamin B12
b. Iron
c. Folic acid
d. Calcium
c. Folic acid
**APEA Pregnancy
During pregnancy, a palpable softening of the cervical isthmus is noted. This finding is:
a. Hegar’s sign
b. Chadwick’s sign
c. Striae gravidarum
d. Linea nigra
a. Hegar’s sign
**APEA Pregnancy
Linea nigra is a brownish black pigmented vertical stripe along the midline skin of the abdomen
As the skin over the abdomen stretches to accommodate the fetus, purplish striae gravidarum “stretch marks” may appear.
Heger’s sign is the palpable softening of the cervical isthmus, the portion of the uterus that narrows into the cervix.
Increased vascularity throughout the pelvis during pregnancy gives the vagina a bluish color, known as Chadwick’s sign.
Hypertension that occurs after 20 weeks gestation in the absence of proteinuria is:
a. Gestational hypertension
b. Preeclampsia
c. Chronic hypertension
d. Primary hypertension
a. Gestational hypertension
**APEA Pregnancy
Chronic HTN occurs when systolic BP >140 or diastolic BP >90 documented prior to pregnancy, before 20 weeks gestation, or beyond 12 weeks postpartum.
Gestation HTN refers to elevated BP detected after 20 weeks gestation in the absence of proteinuria.
Pre-eclampsia occurs in a woman who was previously normotensive but now has new onset hypertension with either proteinuria or end-organ damage.
Primary hypertension, formerly known as essential hypertension, is a disorder which is associated with elevated blood pressure and an unidentifiable cause.
Which one of the following symptoms would be seen in a 39-week gestational age patient who was suspected of having HELLP syndrome?
a. Decreased liver enzymes, low platelet count, and nausea
b. Vomiting, flu-like symptoms, and platelet count <100,000
c. Flu-like symptoms, low platelet count, and decreased liver enzymes
d. Hypotensive, malaise, and elevated platelet count >100,000
b. Vomiting, flu-like symptoms, and platelet count <100,000
**APEA Pregnancy
HELLP syndrome is a life-threatening pregnancy complication usually considered to be a variant of pre-eclampsia. Both conditions usually occur during the later stages of pregnancy, or sometimes after childbirth. Its characteristics are:
H: Hemolysis
EL: Elevated liver enzymes
LP: Low platelet count
Increased vascularity throughout the pelvis during pregnancy gives the vagina a bluish color. This sign is:
a. Hegar’s sign
b. Chadwick’s sign
c. Quickening sign
d. Leopold’s sign
b. Chadwick’s sign
**APEA Pregnancy
Linea nigra is a brownish black pigmented vertical stripe along the midline skin of the abdomen
As the skin over the abdomen stretches to accommodate the fetus, purplish striae gravidarum “stretch marks” may appear.
Heger’s sign is the palpable softening of the cervical isthmus, the portion of the uterus that narrows into the cervix.
Increased vascularity throughout the pelvis during pregnancy gives the vagina a bluish color, known as Chadwick’s sign.
During the last trimester of pregnancy, the supine position causes the uterus to overlie the vertebral column and compress the descending aorta and inferior vena cava. This position causes the patient to become faint and dizzy resulting in:
a. A hypertensive crisis
b. Supine hypotensive syndrome
c. Preeclampsia
d. Gestational hypertension
b. Supine hypotensive syndrome
**APEA Pregnancy
Irregular brownish patches around the forehead, cheeks, nose, and jaw noted during pregnancy are:
a. Pallor
b. Nevi
c. Chloasma
d. Hirsutism
c. Chloasma
**APEA Pregnancy
Chloasma, or Melasma, is also known as the “mask of pregnancy” and is considered a normal finding.
When performing the Leopold maneuver on a pregnant woman, if the buttocks are easily palpated at the fundus, the fetus is said to be in:
a. Cephalic longitudinal (vertical) lie
b. Transverse lie
c. Breech longitudinal (vertical) lie
d. Oblique presentation
a. Cephalic longitudinal (vertical) lie
**APEA Pregnancy
When performing the third Leopold maneuver on a pregnant woman, the fetal head is the presenting part. This finding is referred to as the vertex or cephalic presentation. Additionally, if the cephalic prominence is on the same side as the small parts, then the fetus is in vertex presentation. If the cephalic prominence is on the same side as the back, then the head is extended and the fetus is in face presentation. The top of the uterus (fundus) is palpated to establish which end of the fetus (fetal pole) is in the upper part of the uterus. If either the head or buttocks (Breech) of the fetus is in the fundus, then the fetus is in vertical lie. Otherwise the fetus is most likely in transverse lie.
Symptoms on initial assessment of a pregnant woman with preeclampsia are: BP 158/100, Urinary output 50 ml/hour, Lungs clear upon auscultation, +1 urine protein on dipstick, and edema of the hands, ankles, and feet. On assessment an hour later, which one of the following symptoms would indicate worsening of preeclampsia?
a. Blood pressure 158/104
b. Urinary output of 20 ml/hour
c. Reflexes 2+
d. Platelet count of 150,000
b. Urinary output of 20 ml/hour
The decrease in urine output is an indication of a decrease in glomerular filtration rate (GFR), which indicates a loss of renal perfusion. There is not a significant rise in blood pressure, the reflexes are normal at 2+, and the platelet count is normal, though at the lower end. The assessment finding of greatest concern is the decreased urine output.
Menopause is diagnosed in a woman who has experienced amenorrhea for:
a. 6 months
b. 12 months
c. 18 months
d. 24 months
b. 12 months
**APEA Women’s Health
Menopause is diagnosed when no menstruation has occurred for 12 consecutive months, with no other identified biological of physiological cause.
When preparing to perform a pelvic exam in an older female, vaginal atrophy is noted. Due to this finding, the speculum:
a. Should not be used
b. Should be a larger size
c. Should be a smaller size
d. Should be completely dry
c. Should be a smaller size
**APEA Women’s Health
Performing a pelvic exam in an older woman, the nurse practitioner should separate the labia, press downward on the introitus to relax the levator muscles, and gently insert the speculum after moistening it with warm water or a water-soluble lubricant. If there is severe vaginal atrophy, a gaping introitus, or an introital stricture from estrogen loss, the size of the speculum may need to be adjusted to a smaller size.
If urethritis or inflammation of the paraurethral glands is suspected in a female patient, the index finger should be inserted into the vagina and:
a. Milk the urethra gently from the outside inward
b. Milk the urethra gently from the inside outward
c. Massage the urethral meatus with the other hand
d. Massage the pelvic floor muscles in a clockwise fashion
b. Milk the urethra gently from the inside outward
**APEA Women’s Health
When performing this procedure, note any discharge from or about the urethral meatus. If present, it should be cultured.
Upon examination of the vagina, a tense, hot, very tender abscess with labial swelling is noted. This finding is most consistent with a:
a. Cystocele
b. Urethral caruncle
c. Rectocele
d. Bartholin gland infection
d. Bartholin gland infection
**APEA Women’s Health
A Bartholin gland infection appears as a tense, hot, very tender abscess with labial swelling over the area of the Bartholin gland.
A cystocele is a bulge of the upper 2/3 of the anterior vaginal wall and the bladder above it. It results from weakened supporting tissues.
A urethral caruncle is a small, red, benign tumor visible at the posterior part of the urethral meatus.
A rectocele is a herniation of the rectum into the posterior wall of the vagina, resulting from a weakness or defect in the endopelvic fascia.
Upon examination of the vagina, a bulge is noted in the lower posterior wall of the vagina. This finding is most consistent with:
a. Cystocele
b. Cystourethrocele
c. Rectocele
d. Bartholin’s gland infection.
c. Rectocele
**APEA Women’s Health
A Bartholin gland infection appears as a tense, hot, very tender abscess with labial swelling over the area of the Bartholin gland.
A cystocele is a bulge of the upper 2/3 of the anterior vaginal wall and the bladder above it. It results from weakened supporting tissues.
When the entire anterior vaginal wall, together with the bladder and urethra, is involved in the bulge, a cystourethrocele is present.
A rectocele is a herniation of the rectum into the posterior wall of the vagina, resulting from a weakness or defect in the endopelvic fascia.
When discussing the female anatomy, the introitus is also known as the:
a. Uterus
b. Vaginal canal
c. Vaginal opening
d. Cervical os
c. Vaginal opening
**APEA Women’s Health
The vaginal mucosa lies in transverse folds called the:
a. Fornices
b. Rugae
c. Corpus
d. Fornix
b. Rugae
**APEA Women’s Health
The vaginal mucosa lies in transverse folds called rugae.
The fornices (pleural of fornix) are used to describe the three recesses of the vagina: anterior, posterior, and lateral fornices.
Corpus refers to the body of the uterus.
Fornix refers to the upper third of the vagina when it terminates into a cuplike shape near the cervix.
When performing a bimanual exam of the vagina, the examiner should lubricate the index and middle fingers of a gloved hand. From a standing position, the fingers should be inserted into the vagina while exerting pressure primarily:
a. Anteriorly
b. Posteriorly
c. Toward the “4 o’clock” position
d. Toward the “8 o’clock” position
b. Posteriorly
**APEA Women’s Health
A 35-year-old female presents with complaints of swelling of her right breast. Findings reveal edema of the lower portion of her right breast. The skin appears thickened with enlarged pores. This condition is consistent with:
a. Paget’s disease
b. The peau d’orange sign
c. Nipple deviation
d. Skin dimpling
b. The peau d’orange sign
**APEA Women’s Health
Edema of the skin is caused by a lymphatic blockade. It appears as thickened skin with enlarged pores, commonly termed the peau d’orange (orange peel) sign. It is often seen first in the lower portion of the breast or areola and is considered a visible sign of breast cancer.
Upon examination of the vagina, the entire anterior wall, together with the bladder and urethra create a bulge. This condition is most consistent with a:
a. Prolapse of the urethral mucosa
b. Urethral caruncle
c. Cystocele
d. Cystourethrocele
d. Cystourethrocele
**APEA Women’s Health
When the entire anterior vaginal wall, together with the bladder and urethra, is involved in the bulge it is a cystourethrocele.
A cystocele is a bulge of the upper 2/3 of the anterior vaginal wall and the bladder above it. It results from weakened supporting tissues.
A prolapsed urethral mucosa forms a swollen red ring around the urethral meatus.
A urethral caruncle is a small, red, benign tumor visible at the posterior part of the urethral meatus.
When do the ovaries become non-palpable after menopause?
a. One year
b. Two years
c. Three to five years
d. Six to ten years
c. Three to five years
**APEA Women’s Health
To palpate the uterus during a bimanual exam, the examiner would lubricate the index and middle fingers of one hand and insert them into the vagina. The other hand would be placed on the abdomen:
a. Near the symphysis pubis while pressing downward and elevating the cervix and uterus with the other hand
b. About midway between the umbilicus and symphysis pubis while elevating the cervix and uterus with the other hand
c. Just above the umbilicus while pressing downward and elevating the cervix and uterus with the other hand
d. Just below the umbilicus while pressing downward and elevating the cervix and uterus with the other hand.
b. About midway between the umbilicus and symphysis pubis while elevating the cervix and uterus with the other hand
**APEA Women’s Health
To palpate the uterus: one hand is placed on abdomen midway between umbilicus and symphysis pubis. The other hand is in vagina and elevates the cervix and uterus. Press the abdominal hand in and down, trying to grasp the uterus between the two hands.
Upon examination of the vagina, a small, red, benign tumor is noted at the posterior part of the urethral meatus. This finding is most consistent with a:
a. Prolapse of the urethral mucosa
b. Urethral caruncle
c. Cystocele
d. Cystourethrocele
b. Urethral caruncle
**APEA Women’s Health
A prolapsed urethral mucosa forms a swollen red ring around the urethral meatus.
A urethral caruncle is a small, red, benign tumor visible at the posterior part of the urethral meatus.
A cystocele is a bulge of the upper 2/3 of the anterior vaginal wall and the bladder above it. It results from weakened supporting tissues.
When the entire anterior vaginal wall, together with the bladder and urethra, is involved in the bulge it is a cystourethrocele.
The findings of mucopurulent endocervical discharge and cervical motion tenderness on pelvic examination are strongly suggestive of:
a. Pelvic inflammatory disease (PID)
b. Pyelonephritis
c. Nephrolithiasis
d. Urethritis
a. Pelvic inflammatory disease (PID)
Abdominal or pelvic pain and fever are the most common clinical findings in patients with pelvic inflammatory disease (PID), although dysuria may also be present. The findings of mucopurulent endocervical discharge or cervical motion tenderness on pelvic examination are strongly suggestive of PID.
Cervical motion tenderness and endocervical discharge are not found with pyelonephritis, nephrolithiasis, or urethritis
To palpate an indirect inguinal hernia in a woman, have her stand and palpate in the labia majora and:
a. Palpate the external floor muscles in a clockwise position
b. Apply pressure against the anterior and lateral walls of the vagina
c. In the rectum
d. Palpate upward to just lateral to the pubic tubercles
d. Palpate upward to just lateral to the pubic tubercles
**APEA Women’s Health
When performing an examination of the external genitalia of a female patient, a small, firm, round cystic nodule in the labia is identified. This lesion is most consistent with:
a. A syphilitic chancre
b. An epidermoid cyst
c. Condylomata acuminata
d. Genital herpes
b. An epidermoid cyst
**APEA Women’s Health
A small, firm, round cystic nodule in the labia suggests an epidermoid cyst. They appear yellowish in color with a dark punctum marking the blocked opening of the gland.
A syphilitic chancre appears as a firm, painless ulcer and suggests the chancre of primary syphilis. Because most chancres in women develop internally, they often go undetected.
Genital warts, or condylomata acuminata, are warty lesions on the labia and within the vestibule resulting from infection with HPV.
Genital herpes appears as shallow, small, painful ulcers on red bases.
If performed correctly and in a timely fashion, which one of the following is most definitive for the diagnosis of breast cancer?
a. Breast tissue sample
b. Digital mammogram
c. Self-breast examination
d. Clinical breast exam
a. Breast tissue sample
**APEA Women’s Health
The other three options are indicative of screening tests and not always diagnostic of cancer.
An ulcerated vulvar lesion in an elderly woman may indicate:
a. Condylomata acuminata
b. A syphilitic chancre
c. Vulvar cancer
d. Ovarian cancer
c. Vulvar cancer
**APEA Women’s Health
To assess pelvic floor muscle strength during the bimanual vaginal exam, have the patient squeeze around the inserted fingers for as long as possible. To consider full strength, snug compression should last for:
a. 1 second
b. 2 seconds
c. 3 seconds
d. at least 5 seconds
c. 3 seconds
**APEA Women’s Health
When performing a bimanual vaginal exam, a smooth and rather compressible non-tender lesion is palpated over the right ovary. This finding is most consistent with:
a. Ovarian cancer
b. An ovarian cyst
c. A right tubal pregnancy
d. A tubo-ovarian abscess
b. An ovarian cyst
**APEA Women’s Health
An ovarian cyst tends to be smooth and compressible and if uncomplicated, non-tender.
Ovarian tumors appear more solid and often nodular.
A right tubal pregnancy does not typically present with an ovarian lesion.
A tubo-ovarian abscess is difficult to palpate and typically presents with severe pain and purulent vaginal discharge.
A gynecological infection characterized by itching, burning, and vaginal discharge that is typically cheesy in texture and white in color is:
a. Trichomoniasis
b. Bacterial vaginosis (BV)
c. Yeast infection
d. Gonorrhea
c. Yeast infection
**APEA Women’s Health
A vaginal yeast infection is characterized by itching, burning, soreness, pain during intercourse and/or urination, and vaginal discharge that is typically cheesy in texture and white in color.
Trichomoniasis, bacterial vaginosis, and gonorrhea do not have symptoms of vaginal itching or classic presentation of a cheesy white discharge
The first sign of puberty in females is:
a. Appearance of body odor
b. Increased energy and appetite
c. Occurrence of first menses
d. Appearance of breast buds
d. Appearance of breast buds
**APEA Women’s Health
Breast buds are the first sign of puberty in girls. Body odor comes later as the apocrine glands develop. Menses first occurs about 1 year following the appearance of breast buds.
Increased energy and appetite do not relate to the signs of puberty
The cessation of menses sometime after menarche is termed:
a. Primary amenorrhea
b. Secondary amenorrhea
c. Menorrhagia
d. Hypomenorrhea
b. Secondary amenorrhea
**APEA Women’s Health
When performing a bimanual vaginal exam, a nodule on the anterior uterine surface could suggest a (an):
a. Ovarian cyst
b. Myoma
c. Pregnancy
d. Pelvic inflammatory disease
b. Myoma
**APEA Women’s Health
The shiny, pink area located around the cervical os is known as:
a. A retention cyst
b. The columnar epithelium
c. Squamous epithelium
d. The endocervix
c. Squamous epithelium
**APEA Women’s Health
There are two types of epithelia that cover the cervix: A shiny, pink squamous epithelium, which resembles the vaginal epithelium. And the Deep, red columnar epithelium, which is continuous with the endocervical lining. These two epithelia meet at the squamocolumnar junction. When this junction is at or inside the cervical os, usually only the squamous epithelium is seen. A ring of columnar epithelium is often visible to a varying extent around the os.
A retention cyst appears as a translucent nodule on the cervical surface.
The endocervix is the mucous membrane lining the canal of the cervix.
Urethritis in a female patient may arise from all of the following organisms except:
a. Neisseria gonorrhoeae
b. Herpes simplex
c. Chlamydia trachomatis
d. Campylobacter
d. Campylobacter
***APEA Women’s Health
Campylobacter is associated with bacterial infections of the GI tract and commonly produce diarrhea
Retraction of the nipple and areola suggest:
a. A cystic breast
b. An underlying breast mass
c. A fibroadenoma
d. A normal finding in most women
b. An underlying breast mass
**APEA Women’s Health
When performing a vaginal exam with a speculum, the use of the lower blade as a retractor during bearing down could expose an anterior wall defect such as a:
a. Rectocele
b. Cystocele
c. Bartholin gland infection
d. Prolapse of the urethral mucosa
b. Cystocele
**APEA Women’s Health
Use of lower blade during bearing down helps expose anterior vaginal wall defects such as cystoceles.
Use of the upper blade helps expose rectoceles.
Prolapse of the urethral mucosa and Bartholin gland infection can be visualized without the use of the speculum
Upon examination of the cervix, a yellow drainage is visible around the cervical os. This finding is most likely suggestive of:
a. Candidal vaginitis
b. Cervical polyp
c. Carcinoma of the cervix
d. Mucopurulent cervicitis
d. Mucopurulent cervicitis
**APEA Women’s Health
Mucopurulent cervicitis produces purulent, yellow drainage from the cervical os, usually from Chlamydia trachomatis, Neisseria gonorrhoeae, or herpes infection.
Candidal vaginitis produces a white and curd-like, thin discharge from the vagina and does not originate from the cervix.
Typically a cervical polyp does not produce a cervical discharge.
Carcinoma of the cervix begins in an area of metaplasia and usually does not produce a mucopurulent cervical discharge.
When performing a rectal exam on a female, a hard nodular rectal “Shelf” is palpable at the tip of the examiner’s finger. This finding is suggestive of:
a. An ovarian cyst
b. Metastatic tissue in the rectouterine pouch
c. Rectal polyp
d. Carcinoma of the rectum
b. Metastatic tissue in the rectouterine pouch
**APEA Women’s Health
Widespread peritoneal metastases from any source may develop in the area of the peritoneal reflection anterior to the rectum. A firm to hard nodular rectal “Shelf” may be just palpable with the tip of the examining finger. In a woman, this shelf of metastatic tissue develops in the rectouterine pouch, behind the cervix and the uterus.
Rectal polyps and carcinoma of the rectum, if palpable, are typically located in the lower section of the rectum.
To palpate the ovaries, a bimanual pelvic examination would be more appropriate
When examining the cervix, a bright, red, soft and fragile lesion is noted on the cervical surface. This finding is consistent with:
a. A retention cyst
b. An epidermoid cyst
c. A syphilitic chancre
d. A cervical polyp
d. A cervical polyp
**APEA Women’s health
A cervical polyp usually arises from the endocervical canal, becoming visible when it protrudes through the cervical os. It is bright red, soft, and fragile.
A small, firm, round cystic nodule in the labia suggests an epidermoid cyst.
A retention cyst appears as a translucent nodule on the cervical surface.
A small, firm, round cystic nodule in the labia suggests an epidermoid cyst.
A syphilitic chancre appears as a firm, painless ulcer and suggests the chancre of primary syphilis
During examination of the vagina, a bulge in the upper two-thirds of the anterior vaginal wall is noted. This symptom is most consistent with:
a. Prolapse of the urethral mucosa
b. Urethral caruncle
c. Cystocele
d. Cystourethrocele
c. Cystocele
**APEA Women’s Health
A cystocele is a bulge of the upper 2/3 of the anterior vaginal wall and the bladder above it. It results from weakened supporting tissues.
When the entire anterior vaginal wall, together with the bladder and urethra, is involved in the bulge it is a cystourethrocele.
A urethral caruncle is a small, red, benign tumor visible at the posterior part of the urethral meatus.
A prolapsed urethral mucosa forms a swollen red ring around the urethral meatus.
A 45-year-old female presents to the nurse practitioner with complaints of postcoital bleeding (greater than spotting) unrelated to the menstrual cycle. What is the most likely cause?
a. Endometriosis
b. Cervical cancer
c. Early pregnancy
d. Menopause
b. Cervical cancer
**APEA Women’s Health
Postcoital bleeding suggests cervical polyps, cervical cancer, or in an older woman, atrophic vaginitis.
Postcoital bleeding is not usually noted in patients with endometriosis, early pregnancy, or menopause
Chronic pelvic pain may be secondary to all of the above except:
a. Sexually transmitted diseases
b. Sexual abuse
c. Fibroids
d. Peptic ulcer disease
d. Peptic ulcer disease
**APEA Women’s Health
Chronic pelvic pain (CPP) refers to pain of at least 6 months duration that occurs below the umbilicus. While gynecologic etiologies are common, CPP may be secondary to conditions in the urinary tract, GI tract, musculoskeletal system, and in the setting of mental health issues. Peptic ulcer disease affects the upper GI tract and produces symptoms above the umbilicus.
A female patient has a history of a retroverted uterus. This condition refers to:
a. The normal position of the uterus and cervix
b. A tilting backward of the uterus and cervix
c. A backward angulation of the uterus in relation to its cervix
d. The cervix being located at the introitus and the uterus in the vaginal canal
b. A tilting backward of the uterus and cervix
**APEA Women’s Health
Retroversion of the uterus refers to a tilting backward of the entire uterus, including both body and cervix. It is a common variant occurring in approximately 20% of women.
A backward angulation of the uterus in relation to its cervix is referred to as retroflexion of the uterus.
When the cervix is located at the introitus, and the uterus is in the vaginal canal, this is consistent with a third-degree uterine prolapse
Upon examination of the cervix, an irregular cauliflower-like growth was noted around the cervical os. This finding is most suggestive of:
a. Venereal warts
b. A cervical polyp
c. Carcinoma of the cervix
d. Genital herpes
c. Carcinoma of the cervix
**APEA Women’s Health
Carcinoma of the cervix begins with an area of metaplasia. In its earliest stages, it cannot be distinguished from a normal cervix. In later stages, an extensive, irregular, cauliflower-like growth may develop.
Warty lesions on the labia and within the vestibule suggest condyloma acuminatum, genital warts.
A cervical polyp usually arises from the endocervical canal, becoming visible when it protrudes through the cervical os. It is bright red, soft, and fragile.
Genital herpes appears as shallow, small, painful ulcers on red bases and are typically noted on the vulva
In which of the following situations would it be difficult for the examiner to palpate an ovary during the bimanual vaginal exam?
a. A slender woman
b. A woman who is anxious
c. A relaxed woman
d. A one year postmenopausal woman
b. A woman who is anxious
**APEA Women’s Health
Normal ovaries are usually tender to palpation but could pose difficulty in some women. They are usually palpable in slender, relaxed women but are difficult or impossible to feel in women who are obese or anxious. Three to five years after menopause, ovaries are atrophic and usually non-palpable
When performing a bimanual vaginal exam, a solid, nodular-like lesion is palpated over the right ovary. This finding is most consistent with:
a. Ovarian cancer
b. An ovarian tumor
c. A right tubal pregnancy
d. A tubo-ovarian abscess
b. An ovarian tumor
**APEA Women’s Health
Ovarian tumors appear more solid and often nodular upon palpation.
Ovarian cancer is relatively rare and usually presents at an advanced stage with symptoms of pelvic pain, increased abdominal size, and urinary tract symptoms.
An ovarian cyst tends to be smooth and compressible and if uncomplicated, non-tender.
A right tubal pregnancy does not typically present with an ovarian lesion.
A tubo-ovarian abscess is difficult to palpate and typically presents with severe pain and purulent vaginal discharge.
In a female diagnosed with a third-degree uterine prolapse, the cervix:
a. Is located in its normal position
b. Has slipped but is well within the vagina
c. Is located in the introitus
d. And vagina are outside the introitus
d. And vagina are outside the introitus
**APEA Women’s Health
Uterine prolapse occurs in progressive stages. The uterus becomes retroverted and descends down the vaginal canal to the exterior.
In first degree prolapse, the cervix is still well within the vagina.
In second degree prolapse, the cervix is at the introitus.
In third-degree prolapse (procidentia), the cervix and vagina are outside the introitus
When performing a breast exam, a mobile mass becomes fixed when the arm relaxes. This suggests that the mass is:
a. Cystic
b. Attached to the rib or intercostal muscle
c. Non-malignant
d. Attached to the pectoral fascia
b. Attached to the rib or intercostal muscle
**APEA Women’s Health
A mobile mass that becomes fixed when the arm relaxes is attached to the ribs and/or intercostal muscles.
If fixed then the hand is pressed against the hip, it is attached to the pectoral fascia.
The most common cause of sexual problems in females are related to:
a. Lack of sexual desire
b. Inadequate vaginal lubrication
c. Psychosocial factors
d. Pelvic disorders
c. Psychosocial factors
**APEA Women’s Health
During a speculum exam of the cervix the speculum is maintained in an open position by:
a. Sliding the speculum along the posterior wall of the vagina
b. Rotating and adjusting the speculum until it cups the cervix
c. Gently tightening the thumb screw on the speculum
d. Rotating the speculum into a horizontal position while maintaining pressure posteriorly
c. Gently tightening the thumb screw on the speculum
**APEA Women’s Health
The other procedures are related to inserting the speculum, not to maintaining an open position.
The most important risk factor for cervical cancer is:
a. Failure to undergo screening
b. Multiple sexual partners
c. Long-term use of oral contraception
d. Persistent infection with high-risk human papillomavirus (HPV) subtypes
d. Persistent infection with high-risk human papillomavirus (HPV) subtypes
**APEA Women’s health
The most important risk factor for cervical cancer is persistent infection with HPV subtypes, especially HPV 16 or HPV 18. These two subtypes cause approximately 70% of cervical cancers, usually over the course of many years. Although the other choices pose a risk for developing cervical cancer, HPV infection is the most important risk factor.
Upon examination of the vagina, a swollen red ring is noted around the urethral opening. This finding is most consistent with a:
a. Prolapse of the urethral mucosa
b. Urethral caruncle
c. Cystocele
d. Cystourethrocele
a. Prolapse of the urethral mucosa
**APEA Women’s Health
A prolapsed urethral mucosa forms a swollen red ring around the urethral meatus.
A urethral caruncle is a small, red, benign tumor visible at the posterior part of the urethral meatus.
A cystocele is a bulge of the upper 2/3 of the anterior vaginal wall and the bladder above it. It results from weakened supporting tissues.
When the entire anterior vaginal wall, together with the bladder and urethra, is involved in the bulge it is a cystourethrocele.
A female patient presents with a profuse, yellowish, green vaginal discharge that is malodorous. This vaginal discharge is most consistent with:
a. Candidal vaginitis
b. Bacterial vaginosis
c. Trichomonal vaginitis
d. Gonorrhea
c. Trichomonal vaginitis
**APEA Women’s health
Trichomonas vaginalis causes trichomonal vaginitis. Presenting symptoms include a profuse, yellowish/green vaginal discharge that is malodorous.
Candidal vaginitis produces a white and curd-like thin discharge that is rarely malodorous.
With bacterial vaginosis, the discharge can be gray or white, thin, malodorous (fishy), and not usually profuse.
The discharge associated with gonorrhea is usually thick and bloody
The most common cause of acute pelvic pain in women is:
a. Ruptured ovarian cysts
b. Appendicitis
c. Pelvic inflammatory disease
d. Mittelschmerz
c. Pelvic inflammatory disease
**APEA Women’s health
Causes of post-menopausal bleeding typically include all of the following except:
a. Endometrial cancer
b. Hormone replacement therapy
c. Atrophic vaginitis
d. Uterine polyps
c. Atrophic vaginitis
**APEA Women’s Health
Typically, with atrophic vaginitis patients are more likely to experience postcoital bleeding as opposed to post-menopausal bleeding
A female patient presents with a white and curd-like thin vaginal discharge. This discharge is most consistent with:
a. Candidal vaginitis
b. Bacterial vaginosis
c. Trichomonal vaginitis
d. Gonorrhea
a. Candidal vaginitis
**APEA Women’s health
Trichomonas vaginalis causes trichomonal vaginitis. Presenting symptoms include a profuse, yellowish/green vaginal discharge that is malodorous.
Candidal vaginitis produces a white and curd-like thin discharge that is rarely malodorous.
With bacterial vaginosis, the discharge can be gray or white, thin, malodorous (fishy), and not usually profuse.
The discharge associated with gonorrhea is usually thick and bloody
When performing the bimanual vaginal exam, uterine enlargement is noted. This enlargement could suggest:
a. A malignancy
b. Retroversion of the uterus
c. Retroflexion of the uterus
d. Pelvic inflammatory disease
a. A malignancy
**APEA Women’s health
Uterine enlargement may suggest pregnancy, uterine myomas (fibroids), or malignancy
Retroversion or retroflexion of the uterus, and pelvic inflammatory disease do not present with enlargement of the uterus
Primary dysmenorrhea results from:
a. Endometriosis
b. Increased prostaglandin production during the luteal phase of the menstrual cycle
c. Pelvic inflammatory disease
d. Endometriosis in the muscular layers of the uterus
b. Increased prostaglandin production during the luteal phase of the menstrual cycle
**APEA Women’s health
Endometriosis, adenomyosis (endometriosis in the muscular layers of the uterus), pelvic inflammatory disease, and endometrial polyps are secondary causes
A woman complains of infrequent menses with intervals greater than 35 days. This condition is termed:
a. Oligomenorrhea
b. Polymenorrhea
c. Metrorrhagia
d. Menorrhagia
a. Oligomenorrhea
**APEA Women’s health
When performing a vaginal exam with a speculum, the use of the upper blade as a retractor could expose a:
a. Rectocele
b. Cystocele
c. Bartholin gland infection
d. Prolapse of the urethral mucosa
a. Rectocele
**APEA Women’s health
Use of the lower blade as a retractor during bearing down helps expose anterior vaginal wall defects such as cystoceles.
Use of the upper blade as a retractor helps expose rectoceles.
The other two can be visualized without the use of a speculum
Examination of a female patient’s right breast reveals a retraction of the nipple and areola. This finding is consistent with:
a. Breast cancer
b. Mastitis
c. Paget’s disease of the breast
d. Fibrocystic breast disease
a. Breast cancer
**APEA Women’s health
Retraction of the nipple and areola are suggestive of an underlying tumor.
Mastitis is an inflammation of the breast tissue.
Paget’s disease is an uncommon form of breast cancer that starts with a scaly, eczema-like lesion that may week, crust, or erode.
Fibrocystic breast disease findings include lumps, thickening and swelling in the breast tissue, and becomes prominent immediately before onset of menses.
In a female diagnosed with a first-degree uterine prolapse, the cervix is:
a. Is located in its normal position
b. Has slipped but is well within the vagina
c. Is located in the introitus
d. And vagina are outside the introitus
b. Has slipped but is well within the vagina
**APEA Women’s health
Uterine prolapse occurs in progressive stages. The uterus becomes retroverted and descends down the vaginal canal to the exterior.
In first degree prolapse, the cervix is still well within the vagina.
In second degree prolapse, the cervix is at the introitus.
In third-degree prolapse (procidentia), the cervix and vagina are outside the introitus
A twenty-year-old female complains of a milky discharge bilaterally from her breasts. This suggests:
a. A normal finding in women in their early twenties
b. Pregnancy or elevated prolactin level
c. Brease disease
d. Breast cancer
b. Pregnancy or elevated prolactin level
**APEA Women’s health
A female patient presents with a gray, thin, malodorous (fishy) vaginal discharge. These symptoms are most consistent with:
a. Candidal vaginosis
b. Bacterial vaginosis
c. Trichomonal vaginitis
d. Gonorrhea
b. Bacterial vaginosis
**APEA Women’s health
Trichomonas vaginalis causes trichomonal vaginitis. Presenting symptoms include a profuse, yellowish/green vaginal discharge that is malodorous.
Candidal vaginitis produces a white and curd-like thin discharge that is rarely malodorous.
With bacterial vaginosis, the discharge can be gray or white, thin, malodorous (fishy), and not usually profuse.
The discharge associated with gonorrhea is usually thick and bloody
Indications for performing a rectovaginal exam include all of the following except to:
a. Palpate a retroverted uterus
b. Assess pelvic pathology
c. Assess an inguinal hernia
d. Screen for colorectal cancer in women over 50
c. Assess an inguinal hernia
**APEA Women’s health
The rectovaginal examination has three primary purposes:
1- To palpate a retroverted uterus, the uterosacral ligaments, cul-de-sac, and adnexa;
2- To screen for colorectal cancer in women 50 years or older
3- To assess for pelvic pathology
Daughters of women who took Diethylstilbestrol (DES) during pregnancy are at a high risk for developing all of the following abnormalities except:
a. Columnar epithelium covering most or all of the cervix
b. A slit-like cervical os
c. Vaginal adenosis
d. A circular collar or ridge of tissue between the cervix and the vagina
b. A slit-like cervical os
**APEA Women’s health
A slit-like cervical os is a normal variation
In female patients with dyspareunia, superficial pain is most likely related to all of the following except:
a. Local inflammation
b. Atrophic vaginitis
c. Pressure on a normal ovary
d. Inadequate lubrication
c. Pressure on a normal ovary
**APEA Women’s health
In females, dyspareunia (painful intercourse) can occur at the vaginal opening, occurring at the start of intercourse, or when the partner is pushing deeper. It is important to differentiate the pain to determine the etiology.
Superficial pain suggests local inflammation, atrophic vaginitis, or inadequate lubrication.
Deeper pain may be from pelvic disorders or pressure on a normal ovary
A woman complains of experiencing uterine bleeding between expected menstrual cycles. This condition is termed:
a. Oligomenorrhea
b. Polymenorrhea
c. Metrorrhagia
d. Menorrhagia
c. Metrorrhagia
**APEA Women’s health
Metrorrhagia refers to intermenstrual bleeding.
Polymenorrhea occurs when there are fewer than 21-day intervals between menses
Oligomenorrhea is infrequent bleeding with menses occurring at greater than 35-day intervals, or 4-9 menstrual cycles per year.
Menorrhagia refers to excessive or prolonged menstrual flow occurring at regular intervals
When examining the cervix, a translucent nodule is noted on the cervical surface. This finding is consistent with:
a. A retention cyst
b. An epidermoid cyst
c. A syphilitic chancre
d. A cervical polyp
a. A retention cyst
**APEA Women’s health
A retention cyst appears as a translucent nodule on the cervical surface.
A small, firm, round cystic nodule in the labia suggests an epidermoid cyst.
A syphilitic chancre appears as a firm, painless ulcer and suggests the chancre of primary syphilis. Because most chancres in women develop internally, they often go undetected.
A cervical polyp usually arises from the endocervical canal, becoming visible when it protrudes through the cervical os. It is bright red, soft, and fragile.
A 29-year-old woman with systemic lupus erythematosus (ALE) complains of facial swelling. She has been on prolonged course of corticosteroids. On assessment, moon face appearance is noted. She has most likely developed:
a. Cushing syndrome
b. Addison’s disease
c. Sjogren syndrome
d. Syndrome X
a. Cushing syndrome
**APEA Endocrine
A patient has an enlarged thyroid gland with an audible bruit. The examiner should suspect:
a. Hypothyroidism
b. A thyroid malignancy
c. Hyperthyroidism
d. Thyroiditis
c. Hyperthyroidism
**APEA Endocrine
In hyperthyroidism, there is often a localized or continuous bruit audible over the lateral lobes of the thyroid gland.
Myxedema is a symptom commonly found in patients diagnosed with:
a. Addison’s disease
b. Hypothyroidism
c. Thyroid nodule
d. Adrenal insufficiency
b. Hypothyroidism
**APEA Endocrine
Myxedema is a deposition of mucopolysaccharides in the dermis that results in swelling of the affected area, giving the skin a waxy appearance. One manifestation of myxedema in the lower limb is pretibial myxedema, a hallmark of Graves’ disease, an autoimmune form of hyperthyroidism. Myxedema can also occur in Hashimoto’s thyroiditis and other longstanding forms of hypothyroidism.
Myxedema is not associated with Addison’s disease, thyroid nodule, or adrenal insufficiency
When a patient presents with myxedema coma, which one of the following groups of symptoms may be present?
a. Hypothermia, thickening of the tongue, and disorientation
b. Dehydration, tachycardia, and tachypnea
c. Diarrhea, hyperactive peristalsis, and abdominal distention
d. Seizures, hyperthermia, and conjunctivitis
a. Hypothermia, thickening of the tongue, and disorientation
**APEA Endocrine
Myxedema coma is a loss of brain function as a result of severe, longstanding low level of thyroid hormone in the blood (hypothyroidism). Myxedema coma is considered a life-threatening complication of hypothyroidism and represents the far more serious side of the spectrum of thyroid disease.
Symptoms include: hypothermia, significant edema, thickening of the tongue, difficulty breathing, constipation, and severe mental changes including hallucinations, disorientation, seizures, and ultimately deep coma
A patient presents with sweating, tremors, palpitations, hunger, and confusion. This patient is most likely experiencing:
a. A syncopic event
b. Hypoglycemia
c. Postural hypotension
d. Hypocapnia
b. Hypoglycemia
**APEA Endocrine
Hypoglycemia symptoms: sweating, tremors, palpitations, hunger, headache, abnormal behavior, confusion.
Syncope could present with nausea, vomiting, dizziness, and possible fainting.
Postural hypotension usually occurs after one stands up. Usually there are no prodromal symptoms. The BP returns to normal when the patient lies down.
Hypocapnia is decreased carbon dioxide and symptoms include dyspnea, palpitations, chest discomfort, numbness and tingling in the hands and around the mouth lasting for several minutes. Consciousness is maintained.
Hyperpigmentation of the skin and mucous membranes can be seen in patients with:
a. Acquired immunodeficiency syndrome (AIDS)
b. Addison’s disease
c. Cushing’s disease
d. Diabetes
b. Addison’s disease
**APEA Endocrine
Addison’s disease: Hyperpigmentation
AIDS: Hairy leukoplakia
Cushing’s: Striae, skin atrophy, purpura, ecchymosis, telangiectasias, acne, moon facies, buffalo hump, or hypertrichosis.
Diabetes: Necrobiosis lipoidica diabeticorum, diabetic bullae, diabetic dermopathy, granuloma annulare, acanthosis nigricans, candidiasis, neuropathic ulcers, eruptive xanthomas, and PVD.
Which of the following is NOT considered a benign tumor of the pituitary gland?
a. Craniopharyngioma
b. Prolactinoma
c. Gonadotropin-secreting adenoma
d. Thyrotropin-secreting adenoma
a. Craniopharyngioma
**APEA Endocrine
Craniopharyngiomas develop in the area of the brain near the pituitary gland and are derived from pituitary gland embryonic tissue. They are most common in children and in adults in their 50s and 60s. Almost all pituitary tumors are benign glandular tumors called pituitary adenoma. Examples include prolactin-producing adenomas (prolactinomas), gonadotropin-and growth hormone-secreting adenomas, and thyrotropin-secreting adenomas
Examination of the hair reveals a sparse amount with a coarse appearance. This finding may be seen in patients who have:
a. Hypothyroidism
b. Hyperthyroidism
c. Type 2 diabetes
d. Celiac disease
a. Hypothyroidism
**APEA Endocrine
Sparse, coarse, and thin hair is more characteristic of hair seen in patients with hypothyroidism.
Fine, silky hair may be seen in patients who have hyperthyroidism
In celiac disease and type 2 diabetes, alopecia may be seen
Symptoms of underdeveloped ovaries, web-like neck, and short stature are associated with:
a. Polycystic ovarian syndrome (PCOS)
b. Prolactinemia
c. Klinefelter syndrome
d. Turner syndrome
d. Turner syndrome
Turner Syndrome: Short stature, delayed growth, low-set ears, web-like neck, and in girls, underdeveloped ovaries.
PCOS: Infertility, unwanted hair growth, weight gain, fatigue
Prolactinoma: infertility, irregular menstrual periods, acne, and unwanted hair growth.
Klinefelter: Hypogonadism, gynecomastia in late puberty, elevated urinary gonadotropin levels, and behavioral concerns in boys
A 20-year-old with acanthosis nigricans should be evaluated for:
a. Acute renal failure
b. Diabetes mellitus
c. Alcohol-induced cirrhosis
d. Hypothyroidism
b. Diabetes mellitus
**APEA Endocrine
Acanthosis nigricans is a skin condition characterized by dark velvety patches in the body folds and creases. It is typically noted in patients who are obese or who have diabetes.
A common symptom noted in patients who have a thyroid goiter is:
a. A frequent cough
b. Decreased oral secretions
c. Fatigue
d. Gastric reflux
a. A frequent cough
**APEA Endocrine
Because of the anatomic relationship of the thyroid gland to the trachea, larynx, superior and inferior laryngeal nerves, and esophagus, abnormal growth may cause a variety of compressive syndromes. These symptoms may include: wheezing, cough, globus hystericus, dysphagia, and vocal cord dysfunction and hoarseness.
Compression of the venous outflow results in facial plethora and dilated neck and upper thoracic veins. Other symptoms include waking up from sleep with a sensation of being unable to breathe or feeling that food is stuck in the throat.
Striae, skin atrophy, and purpura may be associated with:
a. Acquired immunodeficiency syndrome (AIDS)
b. Addison’s disease
c. Cushing’s disease
d. Diabetes
c. Cushing’s disease
**APEA Endocrine
Addison’s disease: Hyperpigmentation
AIDS: Hairy leukoplakia
Cushing’s: Striae, skin atrophy, purpura, ecchymosis, telangiectasias, acne, moon facies, buffalo hump, or hypertrichosis.
Diabetes: Necrobiosis lipoidica diabeticorum, diabetic bullae, diabetic dermopathy, granuloma annulare, acanthosis nigricans, candidiasis, neuropathic ulcers, eruptive xanthomas, and PVD.
A sweat test is used to help diagnose:
a. Graves’ disease
b. Hypothyroidism
c. Cystic fibrosis
d. Crohn’s disease
c. Cystic fibrosis
**APEA Endocrine
A sweat test measures the amount of sodium and chloride in sweat and is used to assist in diagnosing cystic fibrosis. Patients with cystic fibrosis have 2-5 times the normal amount of sodium and chloride in their sweat.
Hypofunctioning of the thyroid gland would lead to all the following disorders except:
a. Myxedema
b. Grave’s disease
c. Hypothyroidism
d. Hashimoto’s thyroiditis
b. Grave’s disease
**APEA Endocrine
Disorders related to hypofunctioning of the thyroid gland include primary hypothyroidism, myxedema, Hashimoto’s thyroiditis, iodine deficiency, and myxedema coma.
A common clinical term used to refer to women with an excess growth of terminal hair in a male pattern is:
a. Androgenic alopecia
b. Alopecia
c. Hirsutism
d. Vellus hair
c. Hirsutism
**APEA Endocrine
Although hirsutism is broadly defined as excess hair, the common clinical use of the term refers to women with excess growth of terminal hair in a male pattern.
Vellus hair is short, thin, slight-colored, and barely noticeable thin hair that develops on most of the body during childhood.
Androgenic alopecia is a genetically determined disorder characterized by the gradual conversion of terminal hairs into indeterminate, and finally vellus hairs.
Alopecia is a condition in which hair is lost from some or all areas of the body. It often results in bald spots.
Thyrotoxicosis is most commonly associated with:
a. Hyperthyroidism
b. Hypothyroidism
c. Thyroid nodules
d. Non-toxic goiter
a. Hyperthyroidism
**APEA Endocrine
Hyperthyroidism occurs due to excessive production of thyroid hormone by the thyroid gland. Thyrotoxicosis is a result of high levels of thyroid hormones and therefore includes hyperthyroidism.
A thyroid nodule is an abnormal growth of thyroid cells that forms a lump within the thyroid gland. The majority are benign.
A non-toxic goiter is a diffuse or nodular enlargement of the thyroid gland that does not result from an inflammatory or neoplastic process and is not associated with abnormal thyroid function
Which hemoglobin A1C level is typically used to diagnose type 2 diabetes?
a. 0.05
b. 0.055
c. 0.06
d. 0.065
d. 0.065
**APEA Endocrine
Hemoglobin A1C levels between 5.7%-6.4% are reflective of impaired glucose metabolism. Type 2 diabetes is diagnosed when the A1C is 6.5% or greater
Which of the following is NOT associated with Hashimoto’s thyroiditis?
a. Weight loss
b. Cold intolerance
c. Hair loss
d. Decreased sweating
a. Weight loss
**APEA Endocrine
Cold intolerance, hair loss, and decreased perspiration are associated with Hashimoto’s hypothyroidism. Weight loss is usually noted in patients with hyperthyroidism.
Bilateral exophthalmos suggests:
a. The presence of a goiter
b. Hashimoto’s thyroiditis
c. Grave’s disease
d. Hypothyroidism
c. Grave’s disease
**APEA Endocrine
Exophthalmos is an abnormal protrusion of the eye. When it presents bilaterally, it is suggestive of Grave’s disease, a form of hyperthyroidism. Unilateral exophthalmos may be due to Grave’s disease or to a tumor or inflammation of the orbit.
A common arrhythmia associated with hyperthyroidism is:
a. First-degree heart block
b. Atrial fibrillation
c. Ventricular tachycardia
d. Sinus bradycardia
b. Atrial fibrillation
**APEA Endocrine
Hyperthyroidism is associated with atrial fibrillation, systolic murmur, and cardiac failure.
Hypothyroidism is associated with sinus bradycardia, mild hypertension (diastolic), and narrowed pulse pressure.
Supraventricular tachycardia may be associated with hyperthyroidism, however, ventricular tachycardia is not.
A six-year-old has a history of diabetes mellitus type 1 and is now experiencing cellulitis of the right lower leg. The child presents with deep, rapid, and unlabored respirations, fruity odor, and dry skin. These are symptoms of:
a. Hypoglycemia
b. Sepsis
c. Stevens Johnson Syndrome
d. Ketoacidosis
d. Ketoacidosis
**APEA Endocrine
These are signs of diabetic ketoacidosis (DKA) and can occur in diabetic patients with infections. DKA is characterized by elevated blood glucose (usually higher than 240 mg/dl) and ketonuria. The respiratory pattern is consistent with Kussmaul breathing and are signs of hyperglycemia.
Women with hyperthyroidism often experience:
a. Oligomenorrhea
b. Normal menstruation
c. Amenorrhea
d. Menorrhagia
a. Oligomenorrhea
**APEA Endocrine
When auscultating the enlarged thyroid with a stethoscope, a bruit is suggestive of:
a. A carotid aneurysm
b. A normal finding
c. Hyperthyroidism
d. A thyroid malignancy
c. Hyperthyroidism
**APEA Endoctine
A systolic or continuous bruit auscultated with a stethoscope over an enlarged thyroid may be heard in hyperthyroidism. This is not a normal finding.
A bruit is not usually associated with a thyroid malignancy
Symptoms of Graves’ disease include:
a. Weight gain
b. Bradycardia
c. Anemia
d. Proptosis
d. Proptosis
**APEA Endocrine
Proptosis is defined as a bulging of the eyes, which is a symptom of hyperthyroidism or Graves’ disease.
Weight gain, bradycardia, and anemia are associated with hypothyroidism
A 13-year-old girl presents with complaints of insomnia and hyperactivity along with gradual weight loss despite a good appetite. She has warm, flushed, and moist skin and unusually fine hair. These manifestations are indicative of which one of the following conditions?
a. Hypothyroidism
b. Hyperthyroidism
c. Cushing’s syndrome
d. Addison’s disease
b. Hyperthyroidism
**APEA Endocrine
Symptoms of hyperthyroidism in children may include: anxiousness, irritability, nervousness, poor/restless sleet, increased activity/fidgeting, hyperactivity, increased appetite with or without weight loss, increased number of bowel movements per day, decreased/poor school performance, difficulty concentrating that may be diagnosed as “late-onset” attention deficit disorder, and a feeling of a “lump” in the throat.
During assessment of the thyroid, a fixed, firm, non-tender large mass is noted. These findings describe:
a. A cyst
b. A nodule
c. A goiter
d. Hyperplasia
b. A nodule
**APEA Endocrine
Thyroid nodule: Fixed, firm, non-tender large mass
Thyroid cyst: Fluid-filled
Goiter: causes visible swelling at the base of the neck
Hyperplasia: abnormal increase in the volume of a tissue or organ caused by the formation and growth of new normal cells.
Based on a one-step 2-hour glucose tolerance test (GTT) with 75 grams of oral glucose, a positive result for gestational diabetes is a blood sugar of at least:
a. 120 mg/dL
b. 160 mg/dL
c. 180 mg/dL
d. 200 mg/dL
b. 160 mg/dL
**APEA Endocrine
Gestational diabetes mellitus (GDM) may be diagnosed between 24-28 weeks of pregnancy based on a fasting one-step or two-step glucose tolerance test (GTT).
In one-step GTT, the patient receives 75 grams of oral glucose and plasma glucose is measured at 1 and 2 hours. GDM is diagnosed if:
1- Fasting blood glucose is >92 mg/dL.
2- 1-hour blood glucose is >180 mg/dL
3- 2-hour blood glucose is >153 mg/dL
In two-step GTT, 50 gm of glucose is administered to the non-fasting patient. If the lood glucose is 130 mg/dL or higher, then a second test is performed fasting and 100 gm of glucose is administered. The patient is diagnosed with GDM if:
1- Fasting blood glucose is >95 mg/dL
2- 1-hour blood glucose is >180 mg/dL
3- 2-hour blood glucose is >155 mg/dL
4- 3-hour blood glucose is >140 mg/dL
The presence of pubic hair in girls between the age of 5 and 8 years is termed:
a. Hypertrichosis
b. Thelarche
c. Adrenarche
d. Adrenal hyperplasia
c. Adrenarche
**APEA Endocrine
Adrenarche is the early presence of pubic hair in girls aged 5-8 years.
Hypertrichosis is an abnormal amount of hair growth over the body.
Thelarche is the onset of female breast development
Adrenal hyperplasia is the excess production of male sex hormones that results in short height, early puberty, and in females, abnormal genital development
The most common cause of death in children diagnosed with cystic fibrosis is:
a. Heart failure
b. Respiratory failure
c. Liver failure
d. Renal failure
b. Respiratory failure
**APEA Endocrine
The appearance of breast development in girls before the age of 8 years is termed:
a. Amenorrhea
b. Gynecomastia
c. Adrenarche
d. Precocious puberty
d. Precocious puberty
**APEA Endocrine
Puberty that begins before age 8 in girls and before age 9 in boys is considered precocious puberty.
Amenorrhea is the absence of menstruation.
Gynecomastia is the swelling of breast tissue in boys or men
Adrenarche is the early presence of pubic hair in girls aged 5-8 years old.
Children with type 1 diabetes mellitus usually present with which one of the following symptoms?
a. Obesity
b. High cholesterol levels
c. Polyuria
d. Hypoglycemia
c. Polyuria
**APEA Endocrine
The classic symptoms of DM1 are polyuria, polydipsia, polyphagia, and unexplained weight loss.
Obesity and elevated cholesterol are more consistent with DM2
Hyperfunctioning of the thyroid gland could lead to all of the following disorders except:
a. Grave’s disease
b. Thyrotoxicosis
c. Myxedema
d. Toxic goiter
c. Myxedema
**APEA Endocrine
Hyperfunctioning of the thyroid gland leads to a hypermetabolic state causing an increase in metabolic function, increased oxygen consumption by tissues, and heat production. Disorders include: Grave’s disease, toxic goiter, thyroid storm (thyrotoxicosis).
Myxedema is seen in hypofunctioning of the thyroid gland
When assessing the thyroid gland, the nurse practitioner palpates for abnormalities while asking the patient to:
a. Cough
b. Turn the neck
c. Stick out tongue
d. Swallow water
d. Swallow water
**APEA Endocrine
Proper posterior assessment of the thyroid is performed by palpating between the cricoid cartilage and the suprasternal notch. One hand is used to slightly retract the sternocleidomastoid muscle, the other hand palpates the thyroid. The patient is asked to swallow a sip of water during palpation while the examiner feels for the upward movement of the thyroid gland. Abnormalities include asymmetry, masses, erythema, or deviation of the trachea.
A 30-year-old woman is taking phenytoin (Dilantin) for seizures. She has recent hair loss and anorexia but is craving salty foods. Her lab results show abnormally low cortisol levels. These symptoms suggest:
a. Hyperparathyroidism
b. Addison’s disease
c. Anorexia nervosa
d. Celiac disease
b. Addison’s disease
**APEA Endocrine
Addison’s disease, also known as primary adrenal insufficiency and hypocortisolism, is a long-term endocrine disorder in which the adrenal glands do not produce adequate steroid hormones. Classic symptoms include fatigue, anorexia, chronic diarrhea, salt craving, mucosal pigmentation, and hair loss. Lab tests for adrenal function shows a subnormal rise in cortisol levels.
A finding NOT identified in boys diagnosed with Klinefelter syndrome is:
a. A low testosterone level
b. Micro-orchidism
c. Gynecomastia
d. A high sperm count
d. A high sperm count
**APEA Endocrine
Klinefelter syndrome is a chromosomal condition that affects male physical and cognitive development. S/Sx vary among patients. Low testosterone levels, micro-orchidism, gynecomastia, facial hair, baldness, and low sperm count are all associated with Klinefelter syndrome.
A hormonal disorder in adults resulting from the overproduction of growth hormones is known as:
a. Gigantism
b. Prolactinoma
c. Acromegaly
d. Congenital adrenal hyperplasia
c. Acromegaly
**APEA Endocrine
Gigantism refers to abnormally high linear growth due to the excessive action of insulin-like growth factor 1 (IGF-1) while the epiphyseal growth plates are open during childhood. Acromegaly is the same disorder of excess IGF-1 but occurs after the growth plate cartilage fuses in adulthood. Excessive growth hormone is almost always caused by a non-cancerous (benign) pituitary tumor.
A prolactinoma is a benign tumor (adenoma) of the pituitary gland that produces excessive prolactin resulting in decreased levels of some sex hormones. The term congenital adrenal hyperplasia (CAH) encompasses a group of autosomal recessive disorders, each of which involves a deficiency of an enzyme involved in the synthesis of cortisol, aldosterone, or both.
A general term for an enlarged thyroid is:
a. Exophthalmos
b. A goiter
c. Lymphadenopathy
d. Acromegaly
b. A goiter
**APEA Endocrine
A butterfly-shaped gland located in the middle of the neck below the larynx and above the clavicles is the:
a. Parathyroid
b. Thyroid gland
c. Hypothalamus gland
d. Thymus gland
b. Thyroid gland
**APEA Endocrine
Fruity breath odor correlates with assessment for:
a. Salicylate toxicity
b. Diabetic ketoacidosis
c. Urinary tract infection
d. Acute pancreatitis
b. Diabetic ketoacidosis
**APEA Endocrine
Hyperplasia of the thyroid gland is caused by a deficiency of:
a. Phosphorus
b. Iron
c. Magnesium
d. Iodine
d. Iodine
**APEA Endocrine
Hyperplasia of the thyroid gland (goiter) results from an iodine-deficient diet, which causes overgrowth of the thyroid gland
A life-threatening symptom of parathyroid hormone (PTH) deficiency, hypoparathyroidism, is:
a. Dystonia
b. Myoclonia
c. Tetany
d. Choria
c. Tetany
**APEA Endocrine
A lack of PTH leads to decreased blood levels of calcium (hypocalcemia) and increased levels of blood phosphorus (hyperphosphatemia). Muscle cramps involving the lower back, legs, and feet are common in patients with hypoparathyroidism and hypocalcemia.
Tetany develops if hypocalcemia is severe. In some patients, laryngospasm and bronchospasm may be life threatening
A significant increase in 24-hour urine volume that exceeds 3 liters is called:
a. Polyuria
b. Dysuria
c. Urgency
d. Frequency
a. Polyuria
**APEA Urology
Which one of the following is NOT a cause of vaginitis?
a. Yeast infection
b. Herpes simplex virus (HSV)
c. Trichomoniasis
d. Bacterial vaginosis (BV)
b. Herpes simplex virus (HSV)
**APEA Urology
Approximately 90% of all cases of vaginitis are thought to be attributed to 3 causes: Bacterial vaginosis, vaginal candidiasis (or vulvovaginal candidiasis), and trichomonas vaginalis infection (trichomoniases.
Herpes simplex virus does not cause vaginitis
When testing for pyelonephritis, the exam technique of percussing the back over the kidney that produces flank pain is called:
a. Murphy’s sign
b. Psoas sign
c. Pasternacki’s sign
d. Rovsing’s sign
c. Pasternacki’s sign
**APEA Urology
Costovertebral angle tenderness (CVA), also known as Pasternacki’s sign (Murphy’s punch or Goldflam’s sign) is a medical test in which findings of pain are elicited by percussion of the back over either kidney when infection is present.
Murphy’s sign assesses for cholecystitis. It is positive if deep palpation in the subcostal area occurs when a patient with gallbladder disease takes a deep breath and ceases inspiration.
Psoas sign indicates irritation to the iliopsoas group of hip flexors in the abdomen, and consequently indicates that the inflamed appendix is retrocecal in orientation.
Rovsing’s sign indicates peritoneal irritation. If palpation of the left lower quadrant of a person’s abdomen increases the pain felt in the right lower quadrant, the patient is said to have a positive Rovsing’s sign and may have appendicitis
What is the average urine pH level?
a. 4.5
b. 6
c. 7
d. 8
b. 6
**APEA Urology
The average urine pH is 5-6
Acidic urine pH is 4.5-5.5
Alkaline urine pH is 6.5-8
Which one of the following conditions is not related to polyuria?
a. Lithium toxicity
b. Hyperkalemic nephropathy
c. Uncontrolled diabetes
d. Hypogonadism
b. Hyperkalemic nephropathy
**APEA Urology
Kidney diseases such as hypokalemic nephropathy, lithium toxicity, uncontrolled diabetes, and disorders of the posterior pituitary and hypothalamus (ex. Hypogonadism) cause polyuria.
Which one of the following patient positions would be least beneficial to examine the genitals of a young female child?
a. Have the child sit on her parent’s lap with the parent holding the child’s knees apart
b. Have the child lie supine in the frog-leg position
c. Have the child sit crossed legged on the examination table
d. Position the child in the knee-chest position
c. Have the child sit crossed legged on the examination table
**APEA Urology
Having the child sit crossed-legged would not expose the genitals. This position is useful when examining the male child and eliciting the cremasteric reflex
A form of urinary incontinence that is characterized by the involuntary release of urine from a full-bladder in the absence of any need to urinate is called:
a. Stress incontinence
b. Urge incontinence
c. Overflow incontinence
d. Functional incontinence
c. Overflow incontinence
**APEA Urology
This condition occurs in people who have a blockage of the bladder outlet (BPH, prostate cancer, or narrowing of the urethra) or when the muscle that expels urine from the b ladder is too weak to empty the bladder normally.
A 65-year-old woman complains that when she feels the urge to urinate, she has to go immediately or else she urinates “on herself”. She has become homebound because she wants to stay close to the bathroom. This condition is termed:
a. Functional incontinence
b. Overflow incontinence
c. Urge incontinence
d. Stress incontinence
c. Urge incontinence
**APEA Urology
One cause of proctitis could be related to:
a. Gastritis
b. Frequent anal intercourse
c. Cirrhosis
d. Pancreatitis
b. Frequent anal intercourse
**APEA Urology
Proctitis is inflammation of the lining of the rectum leading to rectal pain, bleeding, and a continuous sensation to defecate. Causes may include: inflammatory bowel disease, sexually transmitted infections, radiation therapy, and frequent anal intercourse
Patients with prior hypospadias surgery who develop slow and painful urination as well as prostatitis are experiencing symptoms of:
a. Neurogenic bladder
b. Urethral stricture
c. Benign prostatic hyperplasia (BPH)
d. Prostate cancer
b. Urethral stricture
**APEA Urology
A urethral stricture may occur in patients who have undergone hypospadias surgery and experience voiding symptoms such as urinary retention and straining to void.
Neurogenic bladder symptoms include urinary retention and/or incontinence associated with other underlying chronic neurologic conditions (multiple sclerosis) or after spinal cord injury.
BPH symptoms include daytime frequency, nocturia, urinary incontinence, and terminal dribbling.
Prostate cancer is usually asymptomatic but can sometimes present with storage, voiding, or irritative symptoms
A 40-year-old male complains of right flank pain. His temperature is 102 F. These symptoms may be characteristic of:
a. Renal calculi
b. Acute pyelonephritis
c. Urethritis
d. Prostatitis
b. Acute pyelonephritis
**APEA Urology
Kidney pain in the flank area and groin that is accompanied by fever and chills is consistent with acute pyelonephritis.
Renal or ureteral colic usually presents with a sudden onset of pain in the flank area, abdomen, or groin. Chills and fever do not generally accompany urinary calculi.
In men, painful urination without frequency or urgency suggests urethritis
Acute prostatitis presents with frequency, urgency, and dysuria
Which one of the following symptoms would be least indicative of acute glomerulonephritis?
a. Hematuria
b. Polyruria
c. Proteinuria
d. Hypertension
b. Polyruria
**APEA Urology
Acute glomerulonephritis symptoms include hematuria. This is a universal finding even if it is microscopic. Gross hematuria is reported in 30% of pediatric patients, often manifesting as smoky, coffee, or cola-colored urine. Oliguria is seen. Hypertension, proteinuria, and edema (peripheral or periorbital) is reported in approximately 85% of pediatric patients. Edema may be mild (involving only the face) to severe, bordering on a nephrotic appearance. Headache may occur secondary to hypertension. Confusion may occur secondary to malignant hypertension in as many as 5% of patients. Shortness of breath, or dyspnea on exertion may occur secondary to heart failure or pulmonary edema. It is usually uncommon, particularly in children.
Possible flank pain secondary to stretching of the renal capsule may occur.
A 50-year-old male describes difficulty emptying his bladder. On exam, a distended bladder is noted following urination. This finding may be associated with:
a. Functional incontinence
b. Overflow incontinence
c. Urge incontinence
d. Stress incontinence
b. Overflow incontinence
**APEA Urology
Overflow incontinence is associated with a neurological or anatomical obstruction from pelvic organs or the prostate which limits bladder emptying and causes a distended bladder.
Stress incontinence is commonly seen in women and arises from decreased intraurethral pressure. This condition is noted when a patient coughs, sneezes, or laughs.
In urge incontinence, urgency is followed by immediate involuntary leakage due to uncontrolled detrusor contractions that overcome urethral resistance. Following an urge to void, there is an involuntary loss of urine.
Functional incontinence usually arises from cognitive impairment, musculoskeletal problems, or immobility
Symptoms of proctitis may include all of the following except:
a. Left-sided abdominal pain
b. Rectal pain
c. Suprapubic pain
d. Tenesmus
c. Suprapubic pain
**APEA Urology
Proctitis is inflammation of the lining of the rectum leading to rectal pain, bleeding, and a continuous sensation to defecate (tenesmus). Additional symptoms may also include left-sided abdominal pain, diarrhea, pain with bowel movements, and a feeling of fullness in the rectum.
Suprapubic pain is not generally associated with proctitis.
Glomerulonephritis can cause:
a. Nephrotic syndrome
b. Diabetic nephropathy
c. Polycystic kidney disease
d. Pyelonephritis
a. Nephrotic syndrome
**APEA Urology
Glomerulonephritis can lead to nephrotic syndrome, which is the loss of a large amount of protein in the urine that leads to sodium and fluid retention in the body. Complications of nephrotic syndrome include hypertension, hyperlipidemia, and peripheral edema
Benign prostatic hypertrophy begins in the:
a. Second decade of life
b. Third decade of life
c. Fourth decade of life
d. Fifth decade of life
b. Third decade of life
**APEA Urology
In men, proliferation of prostate epithelial and stromal tissue, termed BPH, begins in the third decade. Symptoms occur in only about half of men with enlargement. Hyperplasia continues to increase prostate volume until the seventh decade, then appears to plateau. These changes are androgen dependent
An infection or irritation of the bladder that leads to pain on urination is called:
a. Polyuria
b. Dysuria
c. Urgency
d. Incontinence
b. Dysuria
**APEA Urology
A useful mnemonic for elucidating causes of incontinence in the older adult is:
a. STOOL.
b. DIAPERS.
c. DRIP.
d. URINE
b. DIAPERS.
**APEA Urology
DIAPERS:
Delirium
Infection
Atrophic urethritis/vaginitis
Pharmaceuticals
Excess urine output from conditions like hyperglycemia or heart failure
Restricted mobility
Stool impaction
OR
DDRRIIPP
Delirium
Drug side effects
Retention of feces
Restricted mobility
Infection of urine
Inflammation
Polyuria
Psychogenic
Which of the following symptoms is NOT associated with nephrotic syndrome?
a. Proteinuria
b. Hyperlipidemia
c. Lower leg edema
d. Hyperalbuminosa
d. Hyperalbuminosa
**APEA Urology
Chronic bladder pain syndrome (BPS) that causes symptoms of urinary urgency, frequency, and hesitancy is also known as:
a. Interstitial cystitis
b. Endometriosis
c. Urinary tract infection
d. Pelvic inflammatory disease
a. Interstitial cystitis
**APEA Urology
Symptoms of fever, chills, flank pain, costovertebral angle tenderness (CVA), and vomiting suggest:
a. Pelvic inflammatory disease (PID)
b. Pyelonephritis
c. Nephrolithiasis
d. Urethritis
b. Pyelonephritis
**APEA Urology
Which of the following substances is found in the urine of a child suspected of having post streptococcal glomerulonephritis?
a. Blood and protein
b. Bacteria and ketones
c. Glucose and white blood cells
d. Casts and mucous threads
a. Blood and protein
**APEA Urology
With post-streptococcal (strep) glomerulonephtiris, a child may have a recent strep infection (pharyngitis or impetigo). Proteinuria is secondary to altered glomerular structure and functioning. Gross hematuria causes the urine to be tea-colored.
Bacteria, white blood cells, and mucus can be seen with urinary tract infections.
Glucose and ketones present in the urine may be associated with diabetes
In renal adaptation of the newborn, which one of the following statements is correct?
a. The kidneys have an inability to concentrate urine and adapt to fluid and electrolyte stress
b. In the nephrons of the kidneys, long tubules enhance the effectiveness of tubular reabsorption
c. The kidneys are fully capable of concentrating urine and maintaining fluid and electrolyte balance
d. The kidneys have the ability to increase the production of antidiuretic hormone (ADH) effectively
a. The kidneys have an inability to concentrate urine and adapt to fluid and electrolyte stress
**APEA Urology
In the neonate the kidneys are structurally complete but physiologically immature. The glomeruli have an inability to filter and concentrate urine, therefore glucose and amino acids escape and there is decreased ability to remove uric acid crystals which give the reddish appearance to the urine. There is an inability to adapt to fluid and electrolyte stress leading to loss of bicarbonate and poor reabsorption. This puts the neonate at increased risk of metabolic acidosis. The tubules are short/narrow which causes a problem with reabsorption. The nephrons function well within a month.
ADH inhibits diuresis and the immature kidney causes an increased risk for dehydration
In men, painful urination without frequency or urgency suggests:
a. Cystitis
b. Urethritis
c. Constipation
d. Acute prostatitis
b. Urethritis
**APEA Urology
Cystitis would present with frequency and urgency.
Constipation does not usually present with urinary tract symptoms.
Acute prostatitis presents with frequency, urgency, and dysuria.
A whitish sebaceous secretion that collects between the glans penis and foreskin or in the vulva is known as:
a. Candida
b. Smegma
c. Leukorrhea
d. Leukocoria
b. Smegma
**APEA Urology
Candida appears as a white substance usually causing vaginal itching
Leukorrhea refers to thick whitish or yellowish vaginal discharge commonly seen during pregnancy
Leukocoria is an abnormal white reflection from the retina of the eye and its presence could indicate retinoblastoma or a congenital cataract
On opthalmoscopic exam of the older adult, there is an increased cup-to-disc ratio. This finding is suggestive of:
a. Cataracts
b. Macular degeneration
c. Open angle glaucoma
d. Blindness
c. Open angle glaucoma
**APEA ENT
The cup-to-disc ratio compares the diameter of the “cup” portion of the optic disc with the total diameter of the optic disc. In glaucoma, an increase in intraocular pressure will damage the delicate nerve fibers and produces additional cupping of the optic disc. As glaucoma worsens, the cup enlargens until it occupies most of the disc area.
A teenager complains of itching and burning of his eye. Examination reveals an erythematous eyelid margin with crusting and clear mucus discharge. These findings are consistent with:
a. Conjunctivitis
b. A chalazion
c. A corneal ulcer
d. Blepharitis
d. Blepharitis
**APEA ENT
Blepharitis is an inflammation of eyelid margin, glands, and lash follicles. It presents with red-rimmed eyes, burning, itching of the eyelid margins, and mucous discharge with crusting and scaling of lid margins.
Conjunctivitis is inflammation of the conjunctiva. It presents with erythematous conjunctiva and frequent discharge.
Chalazion is a granulomatous eyelid cyst or nodule.
Corneal ulcer of a local necrosis of the cornea caused
A condition that involves optic nerve damage and visual field changes is termed:
a. Retinoblastoma
b. Cataracts
c. Glaucoma
d. Pterygium
c. Glaucoma
**APEA ENT
Glaucoma is a leading cause of blindness in the United States. Glaucoma is a condition that produces optic nerve damage and visual field changes. The risk of glaucoma increases with age but can occur in anyone in any age group.
Retinoblastoma is a rapidly developing tumor and is the most common malignant tumor of the eye in children.
A cataract is an opacity of the lens and may be seen through the pupil
Pterygium is a triangular thickening of the bulbar conjunctiva that grows slowly across the outer surface of the cornea and may interfere with vision but does not cause blindness.
The Rinne hearing test allows the examiner to screen for:
a. Sensorineural hearing loss
b. Conductive hearing loss
c. General hearing loss
d. Bilateral hearing loss
b. Conductive hearing loss
**APEA ENT
The Rinne hearing test is used primarily for evaluated hearing in one ear as compared to the other ear. It compares the perception of sound transmitted by air conduction to those sounds transmitted by bone conduction through the mastoid. Therefore, it screens for conductive hearing loss.
The patient complains of seeing floating spots. This is consistent with:
a. Macular degeneration
b. A detached retina
c. Glaucoma
d. Cataracts
b. A detached retina
**APEA ENT
A detached retina is the separation of the sensory layer of the retina from the choroid layer. Initially, the patient is aware of the presence of floaters or floating spots, and/or flashing lights.
Macular degeneration is the degeneration of the macular area of the retina with a loss of central vision and intact peripheral vision.
In patients who have glaucoma, there is damage to the optic nerve and a loss of peripheral vision, the appearance of halos around lights, and difficulty focusing on near objects.
Mydriasis is a term used to describe:
a. The shape of the pupils
b. Constriction of the pupils
c. Dilation of the pupils
d. Symmetry of the pupils
c. Dilation of the pupils
**APEA ENT
Miosis refers to constriction of the pupils.
Mydriasis refers to dilation of the pupils.
Findings following assessment of a person’s eye gaze include both eyes moving in the same direction simultaneously. This condition is most consistent with:
a. A conjugate gaze
b. Left cranial nerve III (oculomotor) paralysis
c. Cranial nerve IV (trochlear) paralysis
d. Cranial nerve VI (abducens) paralysis
a. A conjugate gaze
**APEA ENT
Conjugate, or normal gaze, the normal movement of the two eyes appears simultaneously in the same direction to bring something into view.
With a left cranial nerve VI paralysis, a person’s gaze would include eyes conjugate when looking to the right, esotropia (one or both eyes turn inward) in the left eye when looking straight ahead, and esotropia is maximum in the left eye when looking to the left.
With a left cranial nerve III paralysis, upward, downward, or inward movements are impaired.
The left eye is unable to look down when turned inward in a left cranial nerve IV paralysis.
An eight-year-old complains of itching in the right ear and an increase in pain when the pinna is pulled or the tragus is palpated. Examination reveals slight redness in the ear canal with a clear odorless fluid. This could be suggestive of:
a. Otitis media
b. Otitis externa
c. Mastoiditis
d. A tympanic membrane rupture
b. Otitis externa
**APEA ENT
Otitis externa (swimmer’s ear) is an infection or inflammation of the external ear or the ear canal. Symptoms include itching and tragal pain. The external canal may have a discharge.
Otitis media is a middle ear infection and usually the tympanic membrane is bulging with fluid or pus behind it.
Mastoiditis is an infection of the mastoid process (temporal bone adjacent to the middle ear).
A ruptured tympanic membrane is usually secondary to infection that causes pus and fluid to build-up behind the eardrum and as the pressure increases, the eardrum may rupture. Ear pain decreases when the membrane ruptures and the discharge can be pus, blood, or a clear fluid
A patient presents with findings of pain, warmth, redness, and swelling below the inner canthus toward the nose. Tearing is present and when pressure is applied to the lacrimal sac, purulent discharge from the puncta is noted. This is suggestive of:
a. Blepharitis
b. Dacryocystitis
c. A hordeolum
d. A chalazion
b. Dacryocystitis
**APEA ENT
Dacryocystitis is an infection and blockage of the lacrimal sac and duct. Symptoms include pain, warmth, redness, and swelling below the inner canthus toward the nose. Tearing is usually present and when pressure is applied to the lacrimal sac, a purulent discharge from the puncta can be noted.
Blepharitis: Red, scaly, greasy flakes and thickened, crusted lid margins. Symptoms include burning, itching, tearing, foreign body sensation, and some pain.
Hordeolum is an infection usually secondary to localized staphylococcal infection of the hair follicles at the lid margin.
On examination of the tympanic membrane, a red bulging ear drum is detected. This is consistent with:
a. Acute otitis externa
b. Chronic otitis externa
c. Acute otitis media
d. A serous effusion
c. Acute otitis media
**APEA ENT
Acute Otitis Media: red, bulging tympanic membrane may be found
Acute otitis externa: Canal may be swollen, narrow, moist and pale with tenderness on touching. The ear drum is intact.
Chronic otitis externa: Skin of canal may be thickened, red, and pruritic. The ear drum is usually unaffected.
Serous effusion: the ear drum appears amber and there usually is no bulging of the eardrum.
On ophthalmoscopic examination, glaucomatous cupping appears:
a. Pink and hyperemic
b. Yellowish orange to creamy pink
c. Pale
d. White
c. Pale
**APEA ENT
Glacomatous cupping: A pale disc with a backward depression is characteristic of glaucomatous cupping.
Papilledema: Pink and hyperemic disc
Normal disk: yellowish-orange to creamy pink and the vessels are tiny with disc margins that appear sharp
Optic atrophy: death of the optic nerve fibers leads to loss of the tiny disc vessels giving a white appearance.
Ophthalmoscopic examination of a 30-year-old with a history of an eye injury 3 years ago reveals a superficial grayish-white opacity in the right cornea. This may be indicative of a:
a. Corneal arcus
b. Corneal scar
c. Pterygium
d. Cataract
b. Corneal scar
**APEA ENT
Corneal scar: Superficial grayish-white opacity in the cornea
Corneal arcus: thin grayish-white arc noted on the lower end of the cornea. This is common during normal aging but can be seen in younger people and may be suggestive of dyslipidemia.
Pterygium: triangular thickening of the bulbar conjunctiva that grows slowly across the outer surface of the cornea
Cataract: opacity of the lens visible through the pupil
Where in the mouth would reddened areas, nodules, or ulcerations that are suspicious of malignancy be present?
a. Mucous membranes
b. Tongue
c. Gums
d. Palate
b. Tongue
**APEA ENT
Reddened areas, nodules, or ulcerations noted on the sides and undersurface of the tongue and the floor of the mouth would be suggestive of cancer. Cancer of the tongue is the second most common cancer of the mouth, the lip is number one.
Performance of the Weber and Rinne tests to assess for hearing loss is best performed using tuning fork with a frequency of:
a. 256 Hz
b. 512 Hz
c. 800 Hz
d. 1000 Hz
b. 512 Hz
**APEA Ent
Tuning forks with a lower frequency may be better felt than heard, while tuning forks at higher frequency tend to lose vibratory energy quickly and are difficult to activate for them to be heard with moderate or severe sensorineural impairment. A tuning fork with a frequency of 512 Hz is the most effective in assessing for air and bone conduction of hearing
A term used to describe drainage from the nose is:
a. Rhinitis
b. Rhinorrhea
c. Cerumen
d. Otorrhea
b. Rhinorrhea
**APA ENT
Rhinitis refers to inflammation in the nose
Cerumen is the medical term for earwax
Otorrhea refers to ear discharge
Leukoplakia was noted during an exam of the mouth. This symptom may be:
a. A normal finding
b. Precancerous
c. Associated with periodontal disease
d. Consistent with gingivitis
b. Precancerous
**APEA ENT
Leukoplakia are thickened white patches located on any area of the mouth. These patches cannot be rubbed off. Most are not serious but some can be considered precancerous. Therefore, they should be evaluated. These lesions are not considered normal findings. Periodontal disease usually includes an infection of the gums and may involve the teeth. Generally, the infection causes redness and swelling but not white patches.
When administering ear drops to a 6-year-old, the pinna should be pulled:
a. Downward
b. Downward and back
c. Upward
d. Upward and back
d. Upward and back
**APEA ENT
To examine the ears of an infant it is usually necessary to pull the auricle backward and downward. In the older child, the external ear is pulled backward and upward.
A 57-year-old man with a history of diabetes complains of difficulty hearing on the telephone and muffled sounds while watching the television at a low volume. He should be further evaluated for:
a. Acoustic neuroma
b. Granulomatous disease
c. Cholesteatoma
d. Presbycusis
d. Presbycusis
**APEA ENT
Presbycusis is the most common type of sensorineural hearing loss caused by the natural aging of the auditory system. It occurs gradually and initially affects the ability to hear higher-pitched (higher frequency) sounds. It also muffles the sounds of voices.
Acoustic neuroma is a rare condition that develops from direct effects on the main nerve or from a tumor pressing on adjacent nerves or brain structures. It causes symptoms of dizziness, loss of balance, and facial numbness.
Cholesteatoma and granulomatous disease present with physical symptoms of infectious ear drainage.
Gingival hyperplasia could be seen in all the following conditions except:
a. Those patients undergoing phenytoin (Dilantin) therapy
b. Adolescents with nickel braces
c. In patients diagnosed with diabetes
d. In adults with leukemia
c. In patients diagnosed with diabetes
**APEA ENT
Gingival hyperplasia describes erythematous, swollen gums that are over grown. This condition can be seen in some patients during pregnancy or puberty, or those with leukemia. It is associated with certain medications: phenytoin, cyclosporine, and calcium antagonists. This condition is not characteristically seen in diabetes.
A softening of the skin at the angles of the mouth which may be due to nutritional deficiency is commonly referred to as:
a. Actinic cheilitis
b. Herpes simplex
c. Angular cheilitis
d. Leukoplakia
c. Angular cheilitis
**APEA ENT
Angular cheilitis begins with softening of the skin at the angle of the mouth with subsequent development of fissures. This condition may be seen in patients who have nutritional deficiencies or ill-fitting dentures.
Actinic cheilitis typically results from excessive exposure to sunlight and generally affects the lower lip. The lip becomes slightly everted, scaly, somewhat thickened, and loses its red color.
Herpes simplex presents with recurrent and painful vesicles on the lips and surrounding areas.
Leukoplakia appears as thickened white patches anywhere in the oral mucosa
A swollen deviated uvula may be associated with a:
a. Vagus nerve lesion
b. Peritonsillar abscess
c. Person who smokes cigarettes
d. A normal finding in the elderly population
b. Peritonsillar abscess
**APEA ENT
Presence of swelling of the uvula with a deviation may be a strong indication of a peritonsillar abscess or parapharyngeal abscess.
A deviated uvula with no evidence of swelling may be due to a vagus nerve (CN X) lesion. CN X innervates the uvula. Peritonsillar abscess and smoking may be associated with a swollen uvula but not associated with deviations of the uvula. A deviated uvula is not a common finding in the elderly but may be present if a person experiences a stroke.
A person who has been blind since birth presents for a physical exam. Expected findings of the pupillary reaction when light is shown would be:
a. Constriction of both pupils
b. Dilation of both pupils
c. No reaction from either pupil
d. It depends
d. It depends
**APEA ENT
It depends on the type of blindness. Pupillary reaction is controlled by the muscles which are innervated by nerves. As long as there is no damage to the nerve or the muscle, the pupil will still contract or dilate.
Miosis is a term used to describe:
a. The shape of the pupils
b. Constriction of the pupils
c. Dilation of the pupils
d. Symmetry of the pupils
b. Constriction of the pupils
**APEA ENT
When examining the pupils, the left pupil is noted to be fixed and dilated to light and near accommodation. This condition may be suggestive of:
a. A tonic pupil
b. Oculomotor nerve (CN III) paralysis
c. Horner’s syndrome
d. Argyll Robertson pupils
b. Oculomotor nerve (CN III) paralysis
**APEA ENT
Oculomotor cranial nerve (CNIII) paralysis: dilated pupil is fixed to light and near accommodation. Ptosis and lateral deviation of the eye are usually present.
Tonic Pupil (Adele’s pupil): When the pupil is large, regular, and usually unilateral and the reaction to light is severely reduced and slowed, or even absent.
Horner’s syndrome: affected pupil reacts briskly to light and near effort but the pupil is small.
Argyll Robertson: pupil appears small, irregular shaped and accommodate but do not react to light.
A six-year-old child presents with sore throat, difficulty swallowing, and a temperature of 102 F. Findings reveal lymphadenopathy and pharyngeal erythema. This is probably:
a. Sinusitis
b. Exudative tonsillitis
c. Pharyngitis
d. The flu
c. Pharyngitis
**APEA ENT
Pharyngitis is caused by swelling between the tonsils and the larynx secondary to either viral or bacterial infections. The most common bacterial pharyngeal infections in children are caused by group A beta-hemolytic strep.
A patient with sinusitis is more likely to present with nasal congestion, nasal discharge, headache, and an absence of fever.
Exudative tonsillitis presents with tonsillar exudate. There is no mention of this in the question stem.
Influenza infection typically presents with cough, headache, and body aches.
A man with a history of long-term use of chewing tobacco presents with a mouth lesion that is suspicious for malignancy. Oral assessment findings describe:
a. A smooth circular pustule lesion on the base of the gum
b. A soft, solitary papule lesion located apical to the molar
c. A small, shallow, sore lesion at the base of the gums
d. An ulcerated lesion with indurated margins on the lateral tongue
d. An ulcerated lesion with indurated margins on the lateral tongue
**APEA ENT
Oral malignant lesions: usually present as ulcerated with indurated margins. They are not usually circular or smooth
Dental abscess presents as a soft, solitary papule located apical to the molar.
Canker sore is a small, shallow sore at the base of the gum
A gradual loss of vision with a change in color and size of the optic disc is referred to as:
a. Macular degeneration
b. Glaucoma
c. Cataracts
d. Retinoblastoma
b. Glaucoma
**APEA ENT
Glaucoma: change in the color and size of the optic disc resulting in a gradual loss of vision.
Macular degeneration: loss of vision in the central visual fields because of damage to the retina. Peripheral vision remains intact
Cataracts: usually appear as cloudiness or opacity in the lens.
Retinoblastoma- rapidly developing cancer of the retina and an absent red reflex is noted on opthalmoscopic exam
With transillumination of the frontal sinuses, a dim red glow is observed on the forehead. This dim red glow would be indicative of:
a. Thickened mucosa or secretions in the frontal sinuses
b. Clear frontal sinuses
c. An absent frontal sinus
d. A developmental absence of both frontal sinuses
b. Clear frontal sinuses
**APEA ENT
Dim red glow would suggest a normal finding. An absence of this red glow could be suggestive of a thickened mucosa or the presence of secretions or lesions in the frontal sinuses. Absence of the red glow could also indicate the absence of the frontal sinuses
A cyclist sustained an avulsion of the upper central incisor. If he is unable to position the tooth in the socket until he is able to be seen by a dentist, he should:
a. Transport the tooth in a cup of lukewarm tap water
b. Place the tooth between the molars and the inside of the cheek
c. Rinse the tooth and transport it in a clean, dry cloth
d. Not rinse the tooth but transport it in a clean dry cloth
b. Place the tooth between the molars and the inside of the cheek
**APEA ENT
Saliva, saline, milk, and culture medias are physiologic medias for storing the tooth until it can be reimplanted. Tap water is avoided because the hypotonic environment causes rapid cell lysis and increased inflammation on reimplantation.
All of the following diseases may be associated with the appearance of a strawberry tongue except:
a. Scarlet fever
b. Folic acid and B-12 deficiencies
c. Rubeola
d. Kawasaki syndrome
c. Rubeola
**APEA ENT
Five medical reasons for the appearance of strawberry tongue: Kawasaki disease, scarlet fever, folic acid and vitamin B12 deficiencies, bacterial toxic shock syndrome, and a geographic tongue.
Rubeola does not present with a strawberry tongue. Koplik’s spots are diagnostic of rubeola and they appear as clustered white lesions on the buccal mucosa.
In patients who have allergic rhinitis, the nasal mucosa appears:
a. Erythematous
b. Pale
c. Green
d. Yellow
b. Pale
**APEA ENT
Rhinitis is inflammation of the nasal mucosa and the mucosa appears somewhat redder than the oral mucosa.
With allergic rhinitis, it appears pale, bluish, or a darker red than normal.
In viral rhinitis, it tends to appear erythematous and swollen
A yellow or green color may be due to the appearance of exudate in the nasal cavity
When a person shifts gaze from a near object to a far object, the pupils:
a. Dilate
b. Constrict
c. Remain unchanged
d. Depends
a. Dilate
**APEA ENT
Upon examination of the right tympanic membrane, a cone of light was visible at the four o’clock mark. This would be interpreted as:
a. A perforation of the ear drum
b. An acute otitis media
c. A normal eardrum
d. Tympanosclerosis
c. A normal eardrum
**APEA ENT
The normal eardrum or tympanic membrane appears pinkish gray. The handle and short process of the malleus and the cone of light are all clear and visible. The cone of light fans anteriorly and downward from the umbo putting it in the four-o-clock position.
A perforation in the eardrum would appear as a hole in the membrane and the cone of light would be absent.
In acute otitis media, the eardrum appears red with loss of landmarks and may or may not have a bulge.
Tympanosclerosis is a deposit of hyaline material within the layers of the tympanic membrane that sometimes follow a severe episode of otitis media. It appears as a chalky white patch with irregular margins.
Ophthalmoscopic examination of the retina reveals AV tapering. This appears as if the:
a. Vein “winds” down on either side of the artery
b. Vein is twisted on the distal side of the artery
c. Vein crosses beneath the artery
d. Vein stops abruptly on either side of the artery
a. Vein “winds” down on either side of the artery
**APEA ENT
When the arterial walls lose their transparency, changes appear in the arteriovenous crossings.
Decreased transparency of the retina probably contributes to AV nicking and AV tapering.
In tapering, the vein appears to taper or “wind” down either side of the artery.
In AV nicking, the vein appears to stop abruptly on either side of the artery.
In the normal eye, the vein appears to cross beneath the artery
With banking, the vein appears to be twisted on the distal side of the artery and forms a dark wide knuckle appearance.
Examples of sudden, painful, unilateral visual loss include all the following except:
a. Retinal detachment
b. Corneal ulcer
c. Traumatic hyphema
d. Acute glaucoma
a. Retinal detachment
**APEA ENT
If a patient reports sudden, unilateral visual loss that is painless, vitreous hemorrhage from diabetes or trauma may be considered. It could also be caused by macular degeneration, retinal detachment, retinal vein occlusion, or central retinal artery occlusion.
If the loss is painful, causes may be associated with the cornea and anterior chamber. Examples include corneal ulcer, uveitis, traumatic hyphema, and acute glaucoma
Ectropion is defined as:
a. An inward turning of the lower eyelid
b. An outward turning of the lower eyelid
c. Drooping of the eyelid
d. A retracted eyelid with a wide-eyed stare
b. An outward turning of the lower eyelid
**APEA ENT
Ectropion exhibits an outward turning of the lower eyelid exposing the palpebral conjunctiva. This condition is more common in the elderly.
Entropion exhibits an inward turning of the lower eyelid with irritation to the conjunctiva and lower cornea. This condition is more common in the elderly.
Ptosis presents as drooping of the eyelid caused by damage to the oculomotor nerve, myasthenia gravis, or damage to the sympathetic nervous system.
Lid retraction and exophthalmos is a condition that appears as a wide-eyed stare and suggests retracted eyelids. This condition could be suggestive of hyperthyroidism
On examination of the pupils, both are round but the right pupil appears larger than the left and reacts much slower to light. This condition may be indicative of:
a. A tonic pupil
b. Oculomotor nerve (CNIII) paralysis
c. Horner’s syndrome
d. Argyll Robertson pupils
a. A tonic pupil
**APEA ENT
Oculomotor cranial nerve (CNIII) paralysis: dilated pupil is fixed to light and near accommodation. Ptosis and lateral deviation of the eye are usually present.
Tonic Pupil (Adele’s pupil): When the pupil is large, regular, and usually unilateral and the reaction to light is severely reduced and slowed, or even absent.
Horner’s syndrome: affected pupil reacts briskly to light and near effort but the pupil is small.
Argyll Robertson: pupil appears small, irregular shaped and accommodate but do not react to light.
When the corneal reflex is stimulated by shining the light in the right eye, the right eye blinks. The left eye:
a. Does not blink
b. Blinks
c. Turns inward
d. Turns outward
b. Blinks
**APEA ENT
The corneal reflex is the blink reflex and is an involuntary blinking of the eyelids. When the corneal reflex is stimulated, stimulation should elicit both a direct and consensual response of the opposite eye
Assessment of a patient’s visual acuity resulted in 20/200 using the Snellen eye chart. This means that:
a. At 200 feet the patient can red printed information that a person with normal vision could read at 20 feet.
b. At 20 feet the patient can read printed information that a person with normal vision could read at 200 feet.
c. The patient has normal visual acuity
d. The patient may not be able to read so he should be tested with the picture or “E” eye charts
b. At 20 feet the patient can read printed information that a person with normal vision could read at 200 feet.
**APEA ENT
A 30-year-old patient presents with a moderate “Aching” in his right eye. Findings reveal a small and irregular shaped right pupil. The cornea appears cloudy with a slight erythematous area around the corneal limbus. There is no ocular discharge noted. These findings are consistent with:
a. Acute iritis
b. Corneal injury
c. Corneal infection
d. Acute angle closure glaucoma
a. Acute iritis
**APEA ENT
Acute iritis: moderate aching deep within the eye. The pupils are small and irregular and vision is decreased and photophobia is present. The cornea is clear or slightly cloudy with injection confined to the corneal limbus. This is considered an emergency and is usually related to Herpes zoster infection of tuberculosis.
Corneal injury or infection usually presents with watery or purulent ocular discharge and severe eye pain.
Acute angle closure glaucoma: pain is severe, aching, and deep but the pupils are dilated and fixed and the cornea appears steamy or cloudy. If an increase in intraocular pressure is present in conjunction with these findings, this would be an emergency situation
Findings following assessment of a person’s left eye gaze include impaired movements when attempting to look upward, downward, or inward. This condition is most consistent with:
a. A conjugate gaze
b. Left cranial nerve III (oculomotor) paralysis
c. Cranial nerve IV (trochlear) paralysis
d. Cranial nerve VI (abducens) paralysis
b. Left cranial nerve III (oculomotor) paralysis
**APEA ENT
Which of the paranasal sinuses are accessible to clinical examination?
a. Ethmoidal sinuses
b. Sphenoidal sinuses
c. Frontal sinuses
d. Vestibular sinuses
c. Frontal sinuses
**APEA ENT
Examination of the nose and paranasal sinuses reveal local tenderness, pain, fever, and rhinorrhea. These symptoms are suggestive of:
a. Chronic sinusitis of the frontal and maxillary sinuses
b. Allergic rhinitis
c. Upper respiratory infection
d. Acute sinusitis of the frontal and maxillary sinuses
d. Acute sinusitis of the frontal and maxillary sinuses
**APEA ENT
When a light bean shines into one pupil causing pupillary constriction in that eye, the term used is:
a. Indirect reaction to light
b. Consensual reaction to light
c. Optic radiation
d. Direct reaction to light
d. Direct reaction to light
**APEA ENT
What visual acuity constitutes legal blindness?
a. Visual acuity of 20/80 or worse bilaterally
b. Visual acuity of 20/200 or worse in the better eye with corrected lens
c. Visual acuity of 20/200 in the better eye without corrected lens
d. Visual acuity of 20/100 with corrected lens
b. Visual acuity of 20/200 or worse in the better eye with corrected lens
**APEA ENT
If a patient complains of seeing flashing lights across the field of vision, this could be:
a. A normal response if around bright lights
b. A retinal detachment
c. Detachment of the vitreous from the retina
d. Lesion in the visual pathways
c. Detachment of the vitreous from the retina
**APEA ENT
Flashing lights or new vitreous floaters suggest detachment of vitreous from the retina. A detached retina would present with a sudden loss of vision. With a lesion in the visual pathway, one may visualize fixed defects such as a scotoma. At any rate, this is not a normal finding even if the person was around bright lights.
Actinic chelitis is a condition of the lower lip most commonly seen in:
a. Dark-skinned males who work in coal mines
b. People of all races with nutritional deficiencies
c. People with a history of intestinal polyps
d. Fair-skinned men who work outdoors
d. Fair-skinned men who work outdoors
**APEA ENT
A patient complains of a sore tongue. Findings reveal a smooth and erythematous tongue. This condition is termed:
a. Gingivitis
b. Stomatitis
c. Glossitis
d. Candidiasis
c. Glossitis
**APEA ENT
A 60-year-old patient presents with severe, deep left eye pain. Findings reveal dilated and fixed left pupil and the cornea is cloudy. There is no ocular discharge noted. These findings are most likely consistent with:
a. Acute iritis
b. Corneal injury
c. Corneal infection
d. Acute angle closure glaucoma
d. Acute angle closure glaucoma
**APEA ENT
With acute angle closure glaucoma, the pain is described as severe, aching, and deep. The pupils are dilated and fixed and the cornea appears steamy or cloudy. If increase in intraocular pressure is present, this would be an emergency situation.
Acute iritis presents with a moderate aching pain deep within the eye. The pupils are small and irregular and vision is decreased and photophobia is usually present. The cornea is clear or slightly cloudy with injection confined to the corneal limbus. This is considered an emergency and is usually related to Herpes zoster infection or tuberculosis.
Corneal injury or infection usually presents with watery or purulent ocular discharge and the pain is severe
One cause of nasal septum perforation may be:
a. Nasal polyps
b. Intranasal use of cocaine
c. Cystic fibrosis
d. Chronic sinusitis
b. Intranasal use of cocaine
**APEA ENT
The ethmoidal sinuses:
a. Are located between the eyes
b. Are located above the eyes
c. Surround the nasal cavity
d. Are located behind the sphenoid sinuses
a. Are located between the eyes
**APEA ENT
Paranasal sinuses include the maxillary, frontal, ethmoidal, and sphenoidal sinuses. The ethmoidal sinuses are between the eyes, the frontal sinuses are above the eyes. The maxillary sinuses are located around the nasal cavity. The sphenoidal sinuses lie just behind the ethmoidal sinuses.
Redness, bleeding, pain, and swelling of the gums is most likely:
a. Stomatitis
b. Gingivitis
c. Leukoplakia
d. Aphthous ulcers
b. Gingivitis
**APEA ENT
All of the following are examples of causes of sensorineural hearing loss in children except:
a. The presence of cerumen impaction
b. Prolonged use of tobramycin
c. Maternal history of herpes infection
d. Congenital rubella syndrome
a. The presence of cerumen impaction
**APEA ENT
Sensorineural hearing loss involves problems with the transmission of sound from the inner ear to the 8th cranial nerve. It is a permanent condition that usually affects both ears. Sensorineural hearing loss can be present at birth or as a result of conditions acquired later in life. Examples include: Prolonged exposure to loud noise, infection, severe head injury, medication exposure, and some inherited diseases.
A condition in which the eyes are not properly aligned with each other is termed:
a. Hyperopia
b. Myopia
c. Strabismus
d. Astigmatism
c. Strabismus
**APEA ENT
Strabismus (heterotropia) is a condition in which the eyes are misaligned. “cross-eyed”, “wall eye” or “lazy eye” are all associated with strabismus.
Hyperopia (farsightedness) occurs when light rays focus posterior to the retina.
Myopia (Nearsightedness) occurs when light rays focus anterior to the retina
Astigmatism- light rays do not focus correctly on the retina. This causes blurriness.
Causes of sensorineural hearing loss include all of the following except:
a. Aging
b. Loud noises over prolonged periods of time
c. Perforated tympanic membrane
d. Acoustic neuroma.
c. Perforated tympanic membrane
**APEA ENT
A perforated tympanic membrane is an example of a cause of a conductive hearing loss.
Sensorineural hearing loss involves disorders of the cochlear nerve, cochlea, and an interruption in the neuronal impulse transmission to the brain. Causes include: exposure to loud noises, inner ear infections, acoustic neuroma, aging, and congenital and/or familial disorders.
A forty-five-year-old female complains of frequent attacks of dizziness accompanied by a sense of fullness in the right ear, headache, nausea, reduced hearing in the right ear. This patient may need further workup for:
a. Otosclerosis
b. Meniere’s disease
c. Paget’s disease
d. Mastoiditis
b. Meniere’s disease
**APEA ENT
Meniere’s Disease: disorder of the middle ear with excessive endolymphatic fluid accumulation in the membranous labyrinth. It may be due to malabsorption or a blocked endolymphatic duct. Symptoms include recurrent attacks of dizziness, a sense of fullness in the ears with roaring or ringing tinnitus. There is gradual but progressive sensorineural hearing loss. It usually occurs in adults around forty years of age.
Otosclerosis is a disorder of the labyrinthine capsule where abnormal bone growth occurs around the ossicles leading to a reduction of sound transmission to the inner ear.
Paget’s disease results in abnormal bone destruction or growth of bone. It is also a malignant disease of the breast.
Mastoiditis is an infection of the mastoid process.
Which of the following screening tests for hearing loss can detect both sensorineural and conductive hearing loss?
a. Weber test
b. Rinne test
c. Whispered voice test
d. Bilateral hearing loss
a. Weber test
**APEA ENT
The weber hearing screening test can detect unilateral conductive hearing loss (middle ear hearing loss) and unilateral sensorineural hearing loss (inner ear) hearing loss.
In order to visualize the opening of Stensen’s duct, examine the:
a. Dorsal surface of the tongue
b. Area beneath the mandible at the angle of the jaw
c. Buccal mucosa opposite the second molar
d. Small openings along the sublingual fold under the tongue.
c. Buccal mucosa opposite the second molar
**APEA ENT
The largest salivary gland is the parotid gland and it lies within the cheeks in front of the ear extending from the zygomatic arch down to the angle of the jaw. Its duct, Stensen’s duct, runs forward to an opening on the buccal mucosa opposite the second molar. If blood comes out through the Stensen’s duct when it is palpated, this could suggest parotid cancer. If pus is expelled, it suggests suppurative parotitis. With mumps, the orifice of the Stensen duct appears erythematous and enlarged.
The submandibular gland is the size of a walnut. It lies beneath the mandible at the angle of the jaw.
Wharton’s duct runs up and forward to the floor of the mouth and opens at either side of the frenulum.
The smallest, the almond-shaped sublingual gland, lies within the floor of the mouth under the tongue. It has many small openings along the sublingual fold under the tongue.
A localized Staphylococcal infection of the hair follicles at the lid margin is suggestive of:
a. A hordeolum
b. Blepharitis
c. A chalazion
d. Dacryocystitis
a. A hordeolum
**APEA ENT
Hordeolum: Localized staphylococcal infection of the hair follicles at the lid margin. (Stye). Symptoms include a painful, red, and swollen pustule at the lid margin. Rubbing the eyes can cause cross-contamination and development of another hordeolum.
Blepharitis: Red, scaly, greasy flakes and thickened, crusted lid margins are consistent with blepharitis.
Chalazion is a chronic inflammatory lesion that develops when a meibomian gland becomes obstructed. It produces a beady nodule on the lid.
Dacryocystitis represents an infection of the lacrimal sac and duct
Examination of the nasolacrimal duct reveals a mucopurulent discharge from the puncta. This finding is suggestive of:
a. Conjunctivitis
b. An obstructed nasolacrimal duct
c. Dacryocystitis
d. Pinguecula
b. An obstructed nasolacrimal duct
**APEA ENT
Obstructed nasolacrimal duct would present with a mucopurulent discharge from the puncta of the eye.
Conjunctivitis is an inflammation of the conjunctiva and findings include red, burning, and itchy eyes.
Dacryocystitis represents an infection of the lacrimal duct and the lacrimal sac, the area between the lower eyelid and the nose. It presents as a painful, red, and tender area around the eye, especially near the nose.
Pinguecula- harmless yellowish triangular nodule noted in the bulbar conjunctiva on either side of the iris. This finding may be seen in aging or in patients who are exposed chronically to dust
A 40-year-old male was umpiring a little league baseball game when he was hit in the face with flying debris. He presents with decreased vision and severe pain in the left eye. Findings reveal watery, left ocular discharge. The pupils are normal in appearance and the cornea is slightly cloudy with areas of corneal erythema. These findings are most consistent with:
a. Acute iritis
b. Corneal injury
c. Corneal infection
d. Acute angle closure glaucoma
b. Corneal injury
**APEA ENT
When comparing veins and arteries in the eyes of older adults, the arteries appear:
a. Bright red
b. Widened
c. Less brilliant
d. Curvy
c. Less brilliant
**APEA ENT
In older adults, the fundi lose their youthful shine and light reflections. The arteries look narrowed, pale, straight, and less brilliant than in young or middle adults
Examination of the eye reveals a painful, erythematous, and tender area around the nose and lower eyelid. This condition is most likely:
a. Conjunctivitis
b. An obstructed nasolacrimal duct
c. Dacrocystitis
d. Pinguecula
c. Dacrocystitis
**APEA ENT
Dacryocystitis represents an infection of the lacrimal duct and the lacrimal sac, the area between the lower eyelid and the nose. It presents as a painful, red, and tender area around the eye, especially near the nose.
Conjunctivitis is an inflammation of the conjunctiva and findings include red, burning, and itchy eyes.
Obstructed nasolacrimal duct would present with a mucopurulent discharge from the puncta of the eye.
Pinguecula- harmless yellowish triangular nodule noted in the bulbar conjunctiva on either side of the iris. This finding may be seen in aging or in patients who are exposed chronically to dust
A reduction in vision in one or both eyes causing loss of binocular vision is termed:
a. Strabismus
b. Amblyopia
c. Cataracts
d. Macular degeneration
b. Amblyopia.
**APEA ENT
Amblyopia results from anything that causes visual deprivation to the eye, including congenital cataracts, untreated strabismus, and refractive errors. With amblyopia, there is a reduction in vision in one or both eyes causing loss of binocular vision.
Cataracts are visualized by a cloudiness or opacity in the lens.
Macular degeneration is defined as degeneration of the macular area of the retina
A 60-year-old was concerned about a yellowish colored lesion above her right eyelid. Findings revealed a slightly raised yellowish, well circumscribed plaque along the nasal area of her right eyelid. This finding is most consistent with:
a. A pinguecula
b. A chalazion
c. Episcleritis
d. Xanthelasma
d. Xanthelasma
**APEA ENT
Pinguecula- harmless yellowish triangular nodule noted in the bulbar conjunctiva on either side of the iris. This finding may be seen in aging or in patients who are exposed chronically to dust
Chalazion is a chronic inflammatory lesion that develops when a meibomian gland becomes obstructed. It produces a beady nodule on the lid.
Episcleritis- an ocular inflammation of the episcleral vessels
Xanthelasma- Slightly raised, yellowish, well-circumscribed plaques appearing along the nasal areas of one or both eyelids, consistent with lipid disorders.
A patient presents with complaints of earache, blood-tinged discharge from the ear, and hearing loss. Findings reveal painful hemorrhagic vesicles on the tympanic membrane and the ear canal. These findings and symptoms are suggestive of:
a. Tympanosclerosis
b. Serous effusion
c. Otitis media with purulent effusion
d. Bullous myringitis
d. Bullous myringitis
**APEA ENT
Bullous myringitis: viral infection characterized by painful hemorrhagic vesicles on the tympanic membrane and/or in the ear canal. Hearing loss, blond-tinged discharge from the ear, and an earache are classic symptoms.
Tympanosclerosis is a deposit of hyaline material within the layers of the tympanic membrane that sometimes follow a severe episode of otitis media. It appears as a chalky white patch with irregular margins.
Otitis media with purulent effusion is usually bacterial and the eardrum is red and the landmarks are not visible.
Otitis media with serous effusion is usually viral and amber fluid can be seen behind the eardrum
All of the following symptoms in a 10-month-old would be indicative of acute otitis media (OM) except:
a. Nausea, vomiting, and possibly diarrhea
b. Increased mobility of the tympanic membrane
c. Persistent crying and irritability
d. Reluctance to suck a bottle
b. Increased mobility of the tympanic membrane
**APEA ENT
The hallmark of acute otitis media (AOM) is the recent onset of a middle ear infection manifesting one or more of the following signs or symptoms: Otalgia (tugging or rubbing of the ear in children <2 years), fever, irritability, anorexia, nausea, vomiting, diarrhea, rhinitis or purulent discharge in the ear canal accompanied by decreased mobility of the tympanic membrane (TM)
A patient presents with complaints of burning, itching, tearing, and some pain in the eye. Findings reveal red, scaly, greasy flakes and thickened, crusted lid margins. This would be suggestive of:
a. A chalazion
b. Blepharitis
c. A hordeolum
d. Dacryocystitis
b. Blepharitis
**APEA ENT
Blepharitis: Red, scaly, greasy flakes and thickened, crusted lid margins are consistent with blepharitis.
Chalazion is a chronic inflammatory lesion that develops when a meibomian gland becomes obstructed. It produces a beady nodule on the lid.
Hordeolum: Localized staphylococcal infection of the hair follicles at the lid margin. (Stye). Symptoms include a painful, red, and swollen pustule at the lid margin. Rubbing the eyes can cause cross-contamination and development of another hordeolum.
Dacryocystitis represents an infection of the lacrimal duct and the lacrimal sac, the area between the lower eyelid and the nose. It presents as a painful, red, and tender area around the eye, especially near the nose.
On otoscopic examination, the cone of light can be visualized:
a. At the 1 o’clock to 2 o’clock position of the left tympanic membrane
b. At the 4 o’clock to 5 o’clock position of the left tympanic membrane
c. At the 7 o’clock to 8 o’clock position of the left tympanic membrane
d. At the 12 o’clock position of the left ear tympanic membrane
c. At the 7 o’clock to 8 o’clock position of the left tympanic membrane
**APEA ENT
Ptosis is defined as:
a. An inward turning of the lower eyelid
b. An outward turning of the lower eyelid
c. Drooping of the eyelid
d. A retracted eyelid with a wide-eyed stare
c. Drooping of the eyelid
**APEA ENT
A deviated uvula without swelling may be suggestive of a:
a. Vagus nerve lesion
b. Peritonsillar abscess
c. Person who smokes cigarettes
d. A normal finding in the elderly population
a. Vagus nerve lesion
**APEA ENT
A deviated ulna with no evidence of swelling may be due to a vagus nerve (CN X) lesion. CN X innervates the ulna.
A deviated ulna with swelling may be a strong indication of a peritonsillar abscess or parapharyngeal abscess.
Peritonsillar abscess and smoking may be associated with a swollen uvula but not with deviations of the uvula.
A deviated uvula is not a common finding in the elderly but may be seen after a stroke
A sixty-year-old complains of a progressive bilateral hearing loss over the past four months. He has difficulty understanding spoken words and has become sensitive to loud noises. These symptoms are consistent with:
a. Otosclerosis
b. Mastoiditis
c. Presbycusis
d. Meniere’s disease
c. Presbycusis
**APEA ENT
Presbycusis is the most common type of sensorineural hearing loss caused by the natural aging of the auditory system. Most common hearing problem in people over age 50. It occurs gradually and initially affects the ability to hear higher-pitched (higher frequency) sounds. It also muffles the sounds of voices. Patients may have a hard time hearing what others are saying or may become sensitive to loud noises. Hearing loss is usually bilateral.
Mastoiditis is an infection of the mastoid process (temporal bone adjacent to the middle ear) and generally results from inadequately treated otitis media.
Otosclerosis is a sensorineural hearing loss because of reduced sound transmission to the middle ear.
Meniere’s disease is a disorder of the middle ear due to impaired absorption of endolymph
Raised or flat, deep, purple-colored lesions noted in the mouth may be suggestive of:
a. Koplik’s spots
b. Kaposi’s sarcoma
c. Torus palatinus
d. Fordyce spots
b. Kaposi’s sarcoma
Kaposi’s sarcoma: A low-grade vascular tumor associated with human herpes virus 8. Associated with flat or raised, deep purple-colored lesions of the mouth. Approximately 1/3 of patients with Kaposi’s sarcoma have lesions in the oral cavity. Other sites that could be affected include the gastrointestinal tract and the lungs.
Koplik’s spots: Frequently seen in the early stage of measles (Roseola) and appear as small, white specks that resemble grains of salt on a red background on the buccal mucosa.
Torus palatinus: develops as a bony growth in the hard palate and is common in adults.
Fordyce spots: granules appear as yellow spots in the buccal mucosa or on the lips. They are considered normal sebaceous glands.
When a 512 Hz tuning fork is placed over the mastoid bone and then held next to the ear canal with recordings of how long sound was heard in each ear, this is known as the:
a. Absolute bone conduction test
b. Pure tone audiometry test
c. Weber test
d. Rinne test
d. Rinne test
**APEA ENT
Opthalmoscopic examination of the fundus reveals blood anterior to the retina and obscuring retinal vessels. These findings are consistent with:
a. Superficial retinal hemorrhages
b. Preretinal hemorrhages
c. Microaneurysms
d. Deep retinal hemorrhages
b. Preretinal hemorrhages
**APEA ENT
Deep retinal hemorrhages: appear as small, rounded, slightly irregular red spots and are sometimes called dot or blot hemorrhages. They occur in a deeper layer of the retina than flame-shaped hemorrhages. Diabetes is a common cause.
Preretinal hemorrhages lie anteriorly between the retina and the vitreous and are typically larger than retinal hemorrhages. These hemorrhages obscure any underlying retinal vessel.
Superficial retinal hemorrhages appear as small, linear, flame-shaped, red streaks in the fundus and are seen in hypertension, papilledema, and occlusion of the retinal vein.
Microaneurysms present as tiny, round, red spots commonly seen in and around the macular area. These are classic in diabetic retinopathy.
Round or oval shaped lesions surrounded by erythematous mucosa and noted on an area of the oral mucosa may be:
a. Leukoplakia
b. Aphthous ulcers
c. Koplik’s spots
d. Ulcerative gingivitis
b. Aphthous ulcers
**APEA ENT
Leukoplakia appears as thickened white patches anywhere in the oral mucosa
Aphthous ulcers: (Canker sore) can appear anywhere on the buccal mucosa or tongue. They usually appear as round or oval ulcers, can be white or yellowish gray in color, and are surrounded by a halo of reddened mucosa. They are usually painful.
Koplik’s spots: Frequently seen in the early stage of measles (Roseola) and appear as small, white specks that resemble grains of salt on a red background on the buccal mucosa.
Ulcerative gingivitis is a painful form of gingivitis that is characterized by the development of ulcers in the interdental papillae. If untreated they can become necrotizing along the gum margins and appear as erythematous ulcers.
A fine, rhythmic oscillation of the eyes is termed:
a. Presbyopia
b. Nystagmus
c. Strabismus
d. Proptosis
b. Nystagmus
**APEA ENT
On ophthalmoscopic examination, optic atrophy appears:
a. Pink and hyperemic
b. Yellowish orange to creamy pink
c. Pale
d. White
d. White
**APEA ENT
Papilledema: Pink and hyperemic disc
Normal disk: yellowish-orange to creamy pink and the vessels are tiny with disc margins that appear sharp
Optic atrophy: death of the optic nerve fibers leads to loss of the tiny disc vessels giving a white appearance.
Glacomatous cupping: A pale disc with a backward depression is characteristic of glaucomatous cupping.
A toddler with a suspected hearing loss would:
a. Exhibit little or no babbling or vocalization sounds
b. Likely communicate through gestures
c. Display poor school performance
d. Need to watch television with the volume on high
b. Likely communicate through gestures
An infant with hearing loss: does not startle to loud noises, arouses to touch and not noise, does not turn head in response to sounds, and has little or no babbling or vocalization.
A toddler with hearing loss: would communicate with gestures, exhibits little or no intelligible speech, and does not respond to surrounding noises.
A school-aged child with hearing loss: would sit close to the television with the volume on high, may have poor school performance, speech problems, and inability to correctly respond unless directly in front of the speaker’s face.
To palpate for sinus tenderness, press up on the frontal sinuses from under the bony brows, then:
a. Press down on the ethmoid sinus
b. Press up on the maxillary sinus
c. Palpate around the orbit
d. Observe the turbinates
b. Press up on the maxillary sinus
**APEA ENT
A patient complains of seeing specks that obscure his line of vision when he looks in certain direction. This impairment could be caused by:
a. Vitreous floaters
b. Retinal detachment
c. Macular degeneration
d. Scotomas
d. Scotomas
**APEA ENT
Scotomas, or fixed defects: lesions appear in the retina or visual pathways of a certain area of the field of vision.
Vitreous floaters: moving specks or strands. Specks can be seen throughout the visual fields.
A detached retina is the separation of the sensory layer of the retina from the choroid layer. Initially, the patient is aware of the presence of floaters or floating spots, and/or flashing lights.
Macular degeneration is the degeneration of the macular area of the retina with a loss of central vision and intact peripheral vision.
When assessing extraocular movements:
a. Use the Snellen eye chart
b. Use the ophthalmoscope to view the fundus
c. Include the cardinal directions of gaze
d. Shine a penlight into the pupils
c. Include the cardinal directions of gaze
**APEA ENT
The maxillary sinuses:
a. Are located between the eyes
b. Surround the nasal cavity
c. Are located above the eyes
d. Are located behind the ethmoidal sinuses
b. Surround the nasal cavity
**APEA ENT
Ophthalmoscopic examination of the retina reveals AV banking. This appears as if the:
a. Vein tapers down on either side of the artery
b. Vein is twisted on the distal side of the artery
c. Vein crosses beneath the artery
d. Vein stops abruptly on either side of the artery
b. Vein is twisted on the distal side of the artery
**APEA ENT
When the arterial walls lose their transparency, changes appear in the arteriovenous crossings. Decreased transparency of the retina probably contributes to AV nicking and AV tapering.
AV nicking: The vein appears to stop abruptly on either side of the artery.
AV tapering: The vein appears to taper down either side of the artery.
Normal eye: Vein appears to cross beneath the artery
AV banking: Vein appears to be twisted on the distal side of the artery and forms a dark wide knuckle appearance
A condition of the sclera that appears as localized ocular inflammation of the episcleral vessels is most likely:
a. Scleroderma
b. Episcleritis
c. Conjunctivitis
d. Pinguecula
b. Episcleritis
**APA ENT
Episcleritis: condition of the sclera when the vessels appear movable over the scleral surface. The appearance may be nodular or show only redness and dilated vessels. This condition can be seen in rheumatoid arthritis, Sjogren’s syndrome, and herpes zoster.
Scleroderma: Characterized by thickened, hardened skin. It may be accompanied by multisystem involvement.
Conjunctivitis is an inflammation of the conjunctiva and findings include red, burning, and itchy eyes.
Pinguecula- harmless yellowish triangular nodule noted in the bulbar conjunctiva on either side of the iris. This finding may be seen in aging or in patients who are exposed chronically to dust
Ophthalmoscopic examination of the fundus reveals small, rounded, slightly irregular red spots embedded in the retina. These findings are consistent with:
a. Superficial retinal hemorrhages
b. Preretinal hemorrhages
c. Microaneurysms
d. Deep retinal hemorrhages
d. Deep retinal hemorrhages
**APEA ENT
Deep retinal hemorrhages: appear as small, rounded, slightly irregular red spots and are sometimes called dot or blot hemorrhages. They occur in a deeper layer of the retina than flame-shaped hemorrhages. Diabetes is a common cause.
Preretinal hemorrhages lie anteriorly between the retina and the vitreous and are typically larger than retinal hemorrhages. These hemorrhages obscure any underlying retinal vessel.
Superficial retinal hemorrhages appear as small, linear, flame-shaped, red streaks in the fundus and are seen in hypertension, papilledema, and occlusion of the retinal vein.
Microaneurysms present as tiny, round, red spots commonly seen in and around the macular area. These are classic in diabetic retinopathy.
A 50-year-old patient complains of being unable to read the hymnal at church. This describes:
a. Hyperopia
b. Myopia
c. Presbyopia
d. Astigmatism
c. Presbyopia
**APEA ENT
Presbyopia may begin in the 5th or 6th decade. Symptoms include diminished ability to focus on near objects.
Hyperopia (farsightedness): occurs when light rays focus posterior to the retina.
Myopia (nearsightedness): occurs when light rays focus anterior to the retina.
Strabismus (heterotropia): a condition in which the eyes are misaligned. Cross-eyed, wall-eye, or lazy eye are all associated with strabismus.
Which disorder of the eye can be detected with the cover-uncover and the Hirschberg test?
a. Amblyopia
b. Conjunctivitis
c. Strabismus
d. Cataracts
c. Strabismus
**APEA ENT
Strabismus (heterotropia): a condition in which the eyes are misaligned. Cross-eyed, wall-eye, or lazy eye are all associated with strabismus. Can be detected with the cover-uncover and the Hirschberg test. With the cover-uncover test, eye muscle weakness is seen as eye deviation when the eye is uncovered. With Hirchberg’s test, an asymmetric light reflex indicates a deviation.
Surgical perforation of the tympanic membrane to allow drainage of middle ear secretions is termed:
a. Otosclerosis
b. A myringotomy
c. A tympanocentesis
d. A tympanoplasty
b. A myringotomy
**APEA ENT
Myringotomy: Surgical perforation of the tympanic membrane to allow drainage of the middle ear secretions and to relieve pain and pressure from a bulging ear drum.
Otosclerosis: abnormal bone growth that occurs around the ossicles.
Tympanocentesis: Procedure where a fine needle is inserted into the tympanic membrane to relieve pressure, pain, and to drain secretions, or to obtain a culture of the fluid.
Tympanoplasty: Surgical reconstruction of the ossicles and tympanic membrane to help restore hearing.
The whispered voice test allows the examiner to screen for:
a. Low-frequency hearing loss
b. High frequency hearing loss
c. General hearing loss
d. Conductive hearing loss
c. General hearing loss
**APEA ENT
Sudden, bilateral and painful vision loss is rare but can be associated with:
a. Cholinergics
b. Anticholinergics
c. Steroids
d. Radiation exposure
d. Radiation exposure
**APEA ENT
Sudden, bilateral vision loss that is painful: Can result from exposure to chemicals or radiation
Sudden, bilateral vision loss that is painless: Can result from certain medications including cholinergics, anticholinergics, and steroids.
When examining the conjunctiva and sclera, have the patient look upward and then:
a. Cover one eye while visualizing the sclera and conjunctiva of the uncovered eye.
b. Depress both lower lids with your thumbs, exposing the sclera and conjunctiva
c. Look for excessive tearing or dryness in the conjunctiva sac
d. Note the position of the lids in relation to the eyeballs and color of the sclera
b. Depress both lower lids with your thumbs, exposing the sclera and conjunctiva
**APEA ENT
Sudden visual loss suggests:
a. Retinal detachment
b. Hyperopia
c. Macular degeneration
d. Hyperglycemia
a. Retinal detachment
If a patient reports a change in vision and states that the vision loss was sudden, this is suggestive of retinal detachment, vitreous hemorrhage, or occlusion of the central retinal artery. Immediate ophthalmology consultation is needed.
Macular degeneration is the degeneration of the macular area of the retina with a loss of central vision and intact peripheral vision.
Hyperopia (farsightedness): occurs when light rays focus posterior to the retina.
Hyperglycemia can cause blurring, but not a loss of vision.
All of the following are examples of causes of sensorineural hearing loss in children except:
a. The presence of cerumen impaction
b. Prolonged use of tobramycin
c. Maternal history of Herpes infection
d. Congenital rubella syndrome
a. The presence of cerumen impaction
**APEA ENT
A disease that may present as indigestion, but is precipitated by exertion and relieved by rest is most likely:
a. Gastroesophageal reflux
b. Inflammatory bowel disease
c. Angina
d. Aortic stenosis
c. Angina
**APEA Cardiovascular
Absent or diminished pulses in the wrist could be indicative of:
a. Varicosities
b. Right-sided heart failure
c. Venous insufficiency
d. Arterial occlusive disease
d. Arterial occlusive disease
**APEA Cardiovascular
Absent or diminished pulses at the wrist are found in arterial occlusive disease such as acute embolic occlusion, in Buerger’s disease, or thromboangiitis obliterans.
Varicosities, venous insufficiency, and right-sided heart failure are consistent with venous conditions.
The patient has had an internal pacemaker in place for five years. Pacemaker failure is being considered because over the past few days, the patient has been experiencing episodes of:
a. Hiccoughs
b. Chest pain
c. Wheezing
d. Hypertension
a. Hiccoughs
**APEA Cardiovascular
Pacemaker failure is uncommon. Most malfunctions are caused by electrode dislocation, poor contact, or interference by other tissues. Symptoms include dizziness, lightheadedness, hiccoughs, sudden changes in heart rate, electric shock feeling in the chest. Chest pain is usually absent. Wheezing and hypertension are not specifically characteristic of pacemaker malfunction.
A patient complains of a tight, bursting pain in the calf that increases with walking. Elevation of the leg sometimes relieves the pain. These symptoms may be consistent with:
a. Intermittent claudication
b. Raynaud’s disease
c. Deep vein thrombosis
d. Superficial Thrombophlebitis.
c. Deep vein thrombosis
**APEA Cardiovascular
DVT: Venous disorder. Patient often describes the pain as tight and bursting around the affected area. The pain may be accompanied by swelling and tenderness.
Raynaud’s disease: Usually affects the distal portions of the fingers and causes pain especially with exposure to cold or stress.
Intermittent claudication: Episodic muscular ischemia induced by exercise. Due to atherosclerosis of large or medium-sized arteries. The pain is usually associated with the calf muscles, but also may be in the buttock, hip, thigh, or foot depending on the level of obstruction. Rest usually stops the pain within a few seconds.
Symptoms of orthostatic hypotension include all of the following except:
a. Syncope
b. Unsteadiness
c. Visual blurring
d. Respiratory rate greater than 30
d. Respiratory rate greater than 30
**APEA Cardiovascular
Orthostatic hypotension: Occurs in 20% of older adults and in up to 50% of frail nursing home residents. Common when first arising in the morning. Symptoms include lightheadedness, weakness, unsteadiness, visual blurring, and in 20-30% of patients syncope occurs.
A patient describes chest pain as persistent, sharp, and knife-like. these symptoms are more characteristic of:
a. Myocardial infarction
b. Costochondritis
c. Pericarditis
d. Dissecting aortic aneurysm
c. Pericarditis
**APEA Cardiovascular
Persistent, Sharp, and knife-like pain: Characteristic of pericarditis and pleuritic pain.
Pressing, squeezing, tight, heavy, and occasionally burning: Characteristic of myocardial infarction
Stabbing, sticking, dull, or aching pain: Characteristic of costochondritis
Ripping and tearing pain: Dissecting aortic aneurysm
A heart rate of 100-180 beats per minute in an adult is considered:
a. Normal sinus rhythm
b. Sinus tachycardia
c. Supraventricular tachycardia
d. Ventricular tachycardia
b. Sinus tachycardia
**APEA Cardiovascular
Rates that exceed 180 beats per minute are usually supraventricular. Normal sinus rhythm is a measurement of the heart’s electrical activity, not mechanical activity. Ventricular tachycardia is rapid and chaotic ventricular activity.
When palpating the carotid pulse, it is important to:
a. Place the fingers on the upper third of the neck
b. Palpate both carotids simultaneously
c. Position the patient in the lying or sitting positions
d. Position the patient’s chin on the chest
c. Position the patient in the lying or sitting positions
**APEA Cardiovascular
The carotid artery should be palpated gently and while the patient is sitting or lying down. The patient’s chin should be elevated to allow easy palpation and yet not enough to tighten the neck muscles. Stimulating its baroreceptors with low palpation can provoke severe bradycardia or cause cardiac arrest in some sensitive persons. Carotid arteries should never be palpated at the same time, this may limit blood flow to the head possibly leading to fainting or cerebral ischemia. Carotid pulse is palpable between the anterior border of the sternocleidomastoid muscle, above the hyoid bone and lateral to the thyroid cartilage
Characteristic symptoms of chronic arterial insufficiency may include which one of the following?
a. Persistent leg pain
b. Petechiae leading to brown pigmentation noted over the feet
c. Feet warm to touch
d. Feet appear pale on elevation and dusky red on dependency
d. Feet appear pale on elevation and dusky red on dependency
**APEA Cardiovascular
Arterial insufficiency: Skin becomes pale on elevation and a dusky red color on dependency. Skin is cool to touch. Intermittent claudication symptoms (intermittent pain).
Venous insufficiency: Persistent leg pain is noted. Skin color appears normal or may be cyanotic on dependency. Petechia occur initially, then progress to brown pigmentation. Feet are usually warm to the touch.
The four classic structural defects of Tetralogy of Fallot include:
a. Tricuspid atresia, atrial septal defect, pulmonary stenosis, and left ventricular hypertrophy
b. A ventricular septal defect, an overriding aorta, pulmonary stenosis, and right ventricular hypertrophy
c. Dextroposition of the aorta, ventricular septal defect, aortic stenosis, and patent ductus stenosis
d. An atrial septal defect, ventricular septal defect, pulmonary atresia, and the aorta arising from the right ventricle
b. A ventricular septal defect, an overriding aorta, pulmonary stenosis, and right ventricular hypertrophy
**APEA Cardiovascular
While auscultating the patient’s heart, a medium, soft murmur is audible. It is pansystolic and heard loudest at the apex with radiation to the left axilla. These findings are consistent with:
a. Tricuspid regurgitation
b. Mitral regurgitation
c. A ventricular septal defect
d. An innocent murmur
b. Mitral regurgitation
**APEA Cardiovascular
Tricuspid regurgitation: Audible loudest at the left sternal border with radiation to the right sternal border, xiphoid area, or to the left midclavicular line. Produces a blowing sound and is pansystolic.
Mitral regurgitation: Pansystolic, harsh murmur. Heard loudest at the apex with radiation toward the left axilla. The intensity of the murmur can be soft or if there is an atrial thrill it can be loud.
Ventricular Septal Defect: High pitch and is usually heard throughout systole.
Innocent murmur: Heard loudest at mid systole near the second to fourth intercostal spaces between the left sternal border and the apex. Usually decreases or disappears when sitting.
The ankle-brachial index is a screening test used to assess a person’s risk for:
a. Deep vein thrombosis
b. Peripheral artery disease
c. Venous insufficiency
d. Thromboangiitis obliterans
b. Peripheral artery disease
**APEA Cardiovascular
A widened pulse pressure greater than or equal to 60 in an older patient is a risk factor for cardiovascular disease, stroke, and:
a. Emboli
b. Systolic hypertension
c. Renal disease
d. Orthostatic hypertension
c. Renal disease
**APEA Cardiovascular
When auscultating heart sounds arising from the aortic valve in an adult patient, place the stethoscope:
a. Near the apex of the heart between the 5th and 6th intercostal spaces in the mid-clavicular line
b. Between the 2nd and 3rd intercostal spaces at the right upper sternal border
c. Between the 2nd and 3rd intercostal spaces at the left sternal border
d. Between the 3rd, 4th, 5th, and 6th intercostal spaces at the left lower sternal border
b. Between the 2nd and 3rd intercostal spaces at the right upper sternal border
**APEA Cardiology
To auscultate the heart sounds arising from the pulmonic valve in an adult patient, place the stethoscope:
a. Near the apex of the heart between the 5th and 6th intercostal spaces in the mid-clavicular line
b. Between the 2nd and 3rd intercostal spaces at the right upper sternal border
c. Between the 2nd and 3rd intercostal spaces at the left sternal border.
d. Between the 3rd, 4th, 5th, and 6th intercostal spaces at the left lower sternal border
c. Between the 2nd and 3rd intercostal spaces at the left sternal border.
**APEA Cardiology
When auscultating the heart of a 55-year-old patient, a loud murmur with a thrill is audible in the right second intercostal space that radiates to the carotid arteries. Also noted is a crescendo-decrescendo pitch audible at the apex. The murmur is heard best with the patient sitting and leaning forward. This finding is consistent with:
a. Pulmonic stenosis
b. Tricuspid regurgitation
c. Mitral regurgitation
d. Aortic stenosis
d. Aortic stenosis
**APEA Cardiovascular
Aortic Stenosis: Murmur is audible loudest in the right second intercostal space and radiates to the carotid arteries, down the left sternal border, or the apex. There is a crescendo-decrescendo pitch audible at the apex. The murmur is heard best with the patient sitting and leaning forward.
Pulmonic Stenosis: soft intensity murmur with a crescendo-decrescendo pitch. It is loudest at the 2nd or 3rd intercostal spaces and radiates to the left shoulder and neck.
Tricuspid regurgitation: Audible loudest at the left sternal border with radiation to the right sternal border, xiphoid area, or to the left midclavicular line. Produces a blowing sound and is pansystolic. The intensity may increase with inspiration.
Mitral regurgitation: Pansystolic, harsh murmur. Heard loudest at the apex with radiation toward the left axilla. The intensity of the murmur can be soft or if there is an atrial thrill it can be loud.
A sudden, tearing, sharp pain that begins in the chest and radiates to the back or into the neck is usually associated with:
a. Angina pectoris
b. A myocardial infarction
c. An aortic dissection
d. Pericarditis
c. An aortic dissection
**APEA Cardiology
Aortic Dissection: Ripping and tearing pain. Sudden, sharp pain that radiates to the back or into the neck.
Myocardial Infarction: Pressing, squeezing, tight, heavy, and occasionally burning. Retrosternal type pain that often radiates up to the neck, shoulder, and jaw and down to the ulnar aspect of the left arm.
Angina: Exertional pain.
Pericarditis: Persistent, Sharp, and knife-like pain. May radiate to the tip of the shoulder and to the neck.
A condition that presents with symptomatic limb ischemia upon exertion is termed:
a. Neurogenic claudication
b. Intermittent claudication
c. Atherosclerotic peripheral vascular disease
d. Raynaud’s disease
c. Atherosclerotic peripheral vascular disease
**APEA Cardiology
Raynaud’s disease: Usually affects the distal portions of the fingers and causes pain especially with exposure to cold or stress.
Neurogenic Claudication: Pain with walking or prolonged standing, radiating from the psinal area into the buttocks, thighs, lower legs, or feet.
Intermittent claudication: Episodic muscular ischemia induced by exercise. Due to atherosclerosis of large or medium-sized arteries. The pain is usually associated with the calf muscles, but also may be in the buttock, hip, thigh, or foot depending on the level of obstruction. Rest usually stops the pain within a few seconds. Pain or cramping in the legs that occurs with exertion.
Atherosclerotic peripheral vascular disease: Symptomatic limb ischemia with exertion.
Pain with walking or prolonged standing, radiating from the spinal area into the buttocks, thighs, lower legs, or feet, may be seen with:
a. Neurogenic claudication
b. Intermittent claudication
c. Atherosclerotic peripheral vascular disease
d. Raynaud’s disease
a. Neurogenic claudication
**APEA Cardiovascular
Raynaud’s disease: Usually affects the distal portions of the fingers and causes pain especially with exposure to cold or stress.
Neurogenic Claudication: Pain with walking or prolonged standing, radiating from the spinal area into the buttocks, thighs, lower legs, or feet.
Intermittent claudication: Episodic muscular ischemia induced by exercise. Due to atherosclerosis of large or medium-sized arteries. The pain is usually associated with the calf muscles, but also may be in the buttock, hip, thigh, or foot depending on the level of obstruction. Rest usually stops the pain within a few seconds. Pain or cramping in the legs that occurs with exertion.
Atherosclerotic peripheral vascular disease: Symptomatic limb ischemia with exertion.
Pain or cramping of the legs that occurs during exertion and is relieved by rest is termed:
a. Neurogenic claudication
b. Intermittent claudication
c. Atherosclerotic peripheral vascular disease
d. Raynaud’s disease
b. Intermittent claudication
–APEA Cardiovascular
Raynaud’s disease: Usually affects the distal portions of the fingers and causes pain especially with exposure to cold or stress.
Neurogenic Claudication: Pain with walking or prolonged standing, radiating from the spinal area into the buttocks, thighs, lower legs, or feet.
Intermittent claudication: Episodic muscular ischemia induced by exercise. Due to atherosclerosis of large or medium-sized arteries. The pain is usually associated with the calf muscles, but also may be in the buttock, hip, thigh, or foot depending on the level of obstruction. Rest usually stops the pain within a few seconds. Pain or cramping in the legs that occurs with exertion.
Atherosclerotic peripheral vascular disease: Symptomatic limb ischemia with exertion.
A bruit heard in the epigastric area with both systolic and diastolic components is suggestive of:
a. Renal artery stenosis
b. Aortic regurgitation
c. Femoral artery occlusion
d. An aortic aneurysm
a. Renal artery stenosis
**APEA Cardiovascular
Pulmonic Stenosis: soft intensity murmur with a crescendo-decrescendo pitch. It is loudest at the 2nd or 3rd intercostal spaces and radiates to the left shoulder and neck.
Renal Artery Stenosis: A bruit heard in the epigastric area, upper quadrants, or in the costovertebral region that has both systolic and diastolic components.
Aortic regurgitation: Could be evidenced by the presence of S2, S2, and a diastolic murmur.
Aortic Aneurysm: A pulsation visible or palpable in the epigastrium could be consistent with aortic aneurysm
Presence of a heart murmur in a child would be considered organic if the child:
a. Is 18-months-old and was recently diagnosed with anemia
b. Was a 3-year-old, afebrile and diagnosed with an upper respiratory infection
c. Was a 10-month-old who presents with a temperature of 103 F
d. Was a 2-year-old with a congenital heart defect
d. Was a 2-year-old with a congenital heart defect
**APEA Cardiovascular
A heart murmur is classified an organic murmur if there is an anatomic cardiac defect with or without a physiologic abnormality.
If a murmur was heard and the child presents with fever or anemia, the murmur is considered a non-organic or physiologic. The 3-year-old with the upper respiratory infection without fever would be an example of an innocent murmur since there is an absence of an anatomic or physiological condition.
A patient complains of a sharp, knife-like pain that begins in the chest and radiates to the tip of the shoulder and to the neck. This type of chest pain is suggestive of:
a. Pericarditis
b. An aortic dissection
c. Angina pectoris
d. A myocardial infarction
a. Pericarditis
**APEA Cardiovascular
Pericarditis: Persistent, Sharp, and knife-like pain. May radiate to the tip of the shoulder and to the neck.
Myocardial Infarction: Pressing, squeezing, tight, heavy, and occasionally burning. Retrosternal type pain that often radiates up to the neck, shoulder, and jaw and down to the ulnar aspect of the left arm.
Aortic Dissection: Ripping and tearing pain. Sudden, sharp pain that radiates to the back or into the neck.
Angina: Exertional pain.
To assess the murmur of aortic insufficiency, position the patient:
a. Supine
b. Sitting leaning forward
c. Supine with head elevated 30 degrees and turned partly to the left side
d. Standing
b. Sitting leaning forward
**APEA Cardiovascular
A patient describes chest pain as pressing, squeezing, and tight, lasting between 1-3 minutes. These symptoms are more characteristic of:
a. Myocardial infarction
b. Costochondritis
c. Pericarditis
d. Dissecting aortic aneurysm
a. Myocardial infarction
**APEA Cardiovascular
Pericarditis: Persistent, Sharp, and knife-like pain. May radiate to the tip of the shoulder and to the neck.
Myocardial Infarction: Pressing, squeezing, tight, heavy, and occasionally burning. Retrosternal type pain that often radiates up to the neck, shoulder, and jaw and down to the ulnar aspect of the left arm.
Costochondritis: Stabbing, sticking, dull, or aching pain
Aortic Dissection: Ripping and tearing pain. Sudden, sharp pain that radiates to the back or into the neck.
A twelve-month-old has a history of heart failure related to his congenital heart defect. He is receiving Aldactone (Spironolactone), enalapril (Vasotec), furosemide (Lasix), and acetaminophen (Tylenol). The infant’s potassium level is 3.1 mEq/l. Which medication is most likely decreasing his potassium level?
a. Aldactone (Spironolactone)
b. Furosemide (Lasix)
c. Enalapril (Vasotec)
d. Acetaminophen (Tylenol)
b. Furosemide (Lasix)
**APEA Cardiovascular
Loop diuretics can produce decreased potassium levels. Potassium is WNL between 3.5-5.3. 3.1 is a low value. The other medications are not known for excessive potassium losses.
A disparity between the brachial and femoral pulses in a 4-month-old could indicate:
a. An atrial septal defect (ASD)
b. Tetralogy of Fallot
c. Coarctation of the aorta (COA)
d. Tricuspid atresia (TA)
c. Coarctation of the aorta (COA)
**APEA Cardiovascular
In coarctation of the aorta (COA), there is a disparity of pulses between the upper and lower extremities due to the narrowing of the descending aorta resulting in decreased blood flow to the lower extremities.
In older adults, the presence of heart sound S4 suggests:
a. Hypertension
b. Heart failure
c. An aortic aneurysm
d. Aortic stenosis
a. Hypertension
**APEA Cardiovascular
An S4 heart sound occurs when the atria contract and force blood into a left ventricle that is non-compliant. This can be the result of diastolic heart failure, hypertension, infarction, or others. It is known as the “atrial gallop” and is always an abnormal finding.
What heart sounds are heard during auscultation of a man with Marfan syndrome who has a known mitral valve prolapse:
a. An opening snap
b. A mid-systolic click
c. A fat blowing pitch
d. A fourth heart sound (S4)
b. A mid-systolic click
**APEA Cardiovascular
Mitral valve prolapse: Mid-systolic click.
Mitral stenosis: Opening snap
Aortic stenosis: Flat blowing pitch or a fourth heart sound (S4)
The great saphenous vein enters the deep venous system by way of the:
a. Inferior vena cava
b. Iliac vein
c. Popliteal vein
d. Femoral vein
d. Femoral vein
**APEA Cardiovascular
The great saphenous vein originates on the dorsum of the foot, joins the femoral vein of the deep venous system below the inguinal ligament
When percussing the chest in a patient who has left sided heart failure, the sound emanated would be:
a. Resonant
b. Dull
c. Tympany
d. Diffusely hyperresonant
a. Resonant
**APEA Cardiovascular
With left sided heart failure, increased pressure in the pulmonary veins causes congestion and interstitial edema. Percussed sounds emitted would most likely be resonant. Consolidation in the lungs produces a dull sound on percussion. Tympany (low-high pitched musical sound) is usually audible when percussing a distended abdomen or when a pneumothorax is present. Chronic obstructive lung disease produces diffusely hyperresonant sound on percussion.
A pediatric patient presents with erythema marginatum, chorea, and a heart murmur. These symptoms are consistent with:
a. Kawasaki disease
b. Rheumatic heart disease
c. Infectious endocarditis
d. Sickle cell disease
b. Rheumatic heart disease
**APEA Cardiovascular
Classic symptoms of rheumatic heart disease include: Erythema marginatum, chorea, murmur, joint pain, and shortness of breath. These are usually preceded by history of a recent streptococcal infection.
Kawasaki disease presents with unexplained fever for five days along with 4/5 of these symptoms: Bilateral non-purulent conjunctivitis, cervical lymphadenopathy, edema of the hands and/or feet, strawberry tongue, and a macular rash.
Endocarditis presents with fever, lethargy, petechiae, neurological involvement, Janeway lesions and Osler’s nodes.
Sickle cell disease may present with several symptoms: chronic hemolytic anemia, delayed growth and development, renal and neurological dysfunction, and retinopathy
The hemodynamic changes resulting from structural defects in children can lead to heart failure. The most common reason for these changes is related to:
a. Volume and pressure overload resulting in increased cardiac output
b. Volume and pressure overload resulting in decreased cardiac output
c. Increased heart rate increasing cardiac output
d. Decreased blood volume
b. Volume and pressure overload resulting in decreased cardiac output
**APEA Cardiovascular
A patient complains of pain in the arch of the foot sometimes relieved by rest. Occasionally, he experiences intermittent pain in the toes, especially at rest. Exercise aggravates the pain in the arch. History reveals he smokes approximately a half pack of cigarettes per day. These symptoms may be consistent with:
a. Intermittent claudication
b. Raynaud’s disease
c. Deep venous thrombosis
d. Thromboangiitis obliterans
d. Thromboangiitis obliterans
**APEA Cardiovascular
DVT: Venous disorder. Patient often describes the pain as tight and bursting around the affected area. The pain may be accompanied by swelling and tenderness.
Thromboangiitis obliterans (Buerger’s disease): inflammatory and thrombotic occlusions of small arteries and also of veins, usually occurring in smokers. Symptoms include intermittent claudication especially in the arch of the foot and pain at rest in the toes or fingers. Other symptoms may include distal coldness or cyanosis.
Raynaud’s disease: Usually affects the distal portions of the fingers and causes pain especially with exposure to cold or stress.
Intermittent claudication: Episodic muscular ischemia induced by exercise. Due to atherosclerosis of large or medium-sized arteries. The pain is usually associated with the calf muscles, but also may be in the buttock, hip, thigh, or foot depending on the level of obstruction. Rest usually stops the pain within a few seconds. Pain or cramping in the legs that occurs with exertion.
The amplitude of the pulse in a patient in cardiogenic shock would most likely appear:
a. Bounding
b. Thready
c. Normal
d. As a bruit
b. Thready
**APEA Cardiovascular
The amplitude of the pulse correlates with pulse pressure. Small, thready, or weak pulses occur in patients in cardiogenic shock. Bounding pulses are seen in patients in aortic insufficiency. A bruit is not typically associated with pulse amplitude, but is associated with stenosis or turbulent arterial blood flow.
When auscultating the heart for aortic insufficiency, ask the patient to:
a. Lie supine and inhale
b. Exhale while sitting
c. Turn to the left side and breath deeply
d. Sit up, lean forward, exhale
d. Sit up, lean forward, exhale
**APEA Cardiovascular
In older adults, the presence of heart sound S3 suggests:
a. Hypertension
b. Heart failure
c. An aortic aneurysm
d. Aortic stenosis
b. Heart failure
**APEA Cardiovascular
S3: Suggests dilation of the left ventricle from heart failure or cardiomyopathy. S3 is produced when blood strikes a compliant left ventricle. It commonly accompanies fluid overload. It may be normal in children or pregnant women
A male patient states that he has difficulty breathing when he is lying down but when he sits up, it improves. This is a classic description of:
a. Eupnea
b. Dyspnea
c. Orthopnea
d. Paroxysmal noctural dyspnea
c. Orthopnea
**APEA Cardiovascular
A patient suspected of having chronic venous insufficiency may present with:
a. Calf asymmetry
b. A brownish discoloration just above the malleolus
c. Absent right pedal pulse
d. Decreased femoral pulse
b. A brownish discoloration just above the malleolus
**APEA Cardiovascular
A three-week-old infant presents with a generalized lacy, reticulated blue discoloration of the skin. This is suggestive of:
a. Mongolian spots
b. Harlequin color changes
c. Acrocyanosis
d. Cutis marmorata
d. Cutis marmorata
**APEA Cardiovascular
Cutis Marmorata: marbled or mottled look about the skin of a newborn caused by the uneven distribution of blood flow about the skin. The cause is due to both the immature vascular and neurologic systems in the newborn.
Mongolian spots are blue-gray spots that are flat, “bruise-like” areas of skin. Usually confined to the back and buttocks.
Acrocyanosis is a bluish discoloration of the hands, feet, and lips. The phenomenon is considered normal to newborns because of immature circulation and underdeveloped capillaries.
Widened pulse pressure (PP) is defined as systolic BP:
a. Dropping 20 mm Hg within 3 minutes of standing
b. Minus diastolic blood pressure
c. Dropping 10 mm Hg within 5 minutes of sitting
d. Minus apical heart rate
b. Minus diastolic blood pressure
**APEA Cardiovascular
Men between the ages of 40-64 years should be screened yearly for:
a. Hypertension
b. Prostate cancer
c. Hyperlipidemia
d. Diabetes mellitus
a. Hypertension
**APEA Cardiovascular
Causes of orthostatic hypotension in older adults may include all of the following except:
a. Diabetes
b. Cardiovascular disorders
c. Medications
d. Impaired visual acuity
d. Impaired visual acuity
**APEA CArdiovascular
A patient presents with chest pain that radiates to the left side of the neck and down the left arm when he chops wood. This type of pain could be suggestive of:
a. An early onset myocardial infarction
b. Angina pectoris
c. Costochondritis
d. A dissecting aneurysm
b. Angina pectoris
**APEA Cardiovascular
When assessing the heart rate of a healthy 13-month-old child, which one of the following sites is the most appropriate for this child?
a. Apical pulse at the 5th intercostal space right midclavicular line
b. Apical pulse between the 3rd and 4th intercostal space in the left midclavicular line
c. Apical pulse to the right of the midclavicular line in the 3rd intercostal space
d. Apical pulse in the 5th intercostal space left midclavicular line
b. Apical pulse between the 3rd and 4th intercostal space in the left midclavicular line
**APEA Cardiovascular
To assess aortic pulsations in patients with carotid obstruction, assess the pulse using the:
a. Temporal artery
b. Brachial artery
c. Femoral artery
d. Popliteal artery
b. Brachial artery
**APEA Cardiovascular
When screening a patient for peripheral arterial disease (PAD), one risk factor would include a history of:
a. Smoking
b. An implantation of a temporary internal pacemaker
c. Dysrhythmias
d. Peripheral edema
a. Smoking
**APEA Cardiovascular
Right atrial pressure can be determined by:
a. Palpating the carotid pulse
b. Identifying the pulsations of the right jugular vein
c. Analyzing the arterial blood gases
d. Assessing for dependent edema
b. Identifying the pulsations of the right jugular vein
**APEA Cardiovascular
By placing the ball of the examiner’s hand firmly on the chest, the examiner would be checking for:
a. Bruits
b. S1 and S2
c. Heaves
d. Thrills
d. Thrills
**APEA Cardiovascular
A patient with cirrhosis develops portal hypertension as indicated by the presence of:
a. Splenomegaly
b. Bleeding gums
c. Jaundice
d. Muscle wasting
a. Splenomegaly
**APEA Cardiovascular
To auscultate the tricuspid valve heart sounds in an adult patient, place the stethoscope:
a. Between the 2nd and 3rd intercostal spaces at the right upper sternal border.
b. Near the apex of the heart between the 5th and 6th intercostal spaces in the mid-clavicular line
c. Located between the 2nd and 3rd intercostal spaces at the left sternal border
d. Between the 3rd, 4th, 5th, and 6th intercostal spaces at the left lower sternal border.
d. Between the 3rd, 4th, 5th, and 6th intercostal spaces at the left lower sternal border.
**APEA Cardiovascular
Mitral Point: near the apex of the heart between the 5th and 6th intercostal spaces in the mid-clavicular line
Aortic Point: Between the 2nd and 3rd intercostal spaces in the right upper sternal border (RUSB).
Pulmonic point: between the 2nd and 3rd intercostal spaces at the left sternal border (LUSB)
Tricuspid point: between the 3rd, 4th, 5th, and 6th intercostal spaces at the left lower sternal border (LLSB)
When auscultating the point of maximal impulse (PMI), apex of the heart, in an adult, the stethoscope is placed at the:
a. Third intercostal space to the left of the midclavicular line
b. Fifth intercostal space to the left of the midclavicular line
c. Fourth intercostal space to the right of the midclavicular line
d. Fifth intercostal space to the right of the midclavicular line
b. Fifth intercostal space to the left of the midclavicular line
**APEA Cardiovascular
A patient complains of some pain in the distal portions of her fingers on both hands. She states that it tends to occur more frequently with exposure to cold. These symptoms are consistent with:
a. Intermittent claudication
b. Raynaud’s disease
c. Deep vein thrombosis
d. Superficial thrombophlebitis
b. Raynaud’s disease
**APEA Cardiovascular
Raynaud’s disease: Usually affects the distal portions of the fingers and causes pain especially with exposure to cold or stress.
Intermittent claudication: Episodic muscular ischemia induced by exercise. Due to atherosclerosis of large or medium-sized arteries. The pain is usually associated with the calf muscles, but also may be in the buttock, hip, thigh, or foot depending on the level of obstruction. Rest usually stops the pain within a few seconds. Pain or cramping in the legs that occurs with exertion.
DVT: Venous disorder. Patient often describes the pain as tight and bursting around the affected area. The pain may be accompanied by swelling and tenderness.
In order to bring the ventricular apex closer to the chest wall when assessing the point of maximal impulse (PMI), ask the patient to:
a. Lie supine
b. Sit up
c. Turn to the left side
d. Lean forward
c. Turn to the left side
**APEA Cardiovascular
In order to assess for variscosities in the lower extremities, position the patient:
a. lying supine
b. Standing
c. Sitting facing forward
d. Squatting facing the examiner
b. Standing
**APEA Cardiovascular
When assessing a 3-year-old African American child, the most likely cause of black, dusky mucous membranes is related to:
a. Jaundice
b. Pallor
c. Erythema
d. Cyanosis
d. Cyanosis
**APEA Cardiovascular
When performing a cardiovascular assessment on a healthy 2-year-old child:
a. Expect to hear a swooshing sound during diastole
b. Place the stethoscope over the fifth intercostal space to the left of the mid-clavicular line
c. Auscultate the heart sounds in all four cardiac areas
d. Expect to hear an S4 sound
c. Auscultate the heart sounds in all four cardiac areas
**APEA Cardiovascular
In cardiac assessments of children, heart sounds should be auscultated in all 4 cardiac areas: Aortic, pulmonic, tricuspid, and mitral areas.
In children younger than 7 years old, the point of maximum impact (PMI) is auscultated at the 3rd of 4th intercostal spaces.
A third heart sound (S3) is audible in a forty-five-year old. This S3 sound may be:
a. Normal for this age group
b. A sign of valvular heart disease
c. A sign of heart disease
d. Associated with a jugular venous hum
b. A sign of valvular heart disease
**APEA Cardiovasular
A patient complains of increased pain in the calf muscles and buttocks especially after walking or riding his bicycle. He states that the pain stops after he sits still for about 2-3 minutes. This condition may be associated with:
a. Intermittent claudication
b. Raynaud’s disease
c. Deep venous thrombosis
d. Superficial thrombophlebitis
a. Intermittent claudication
**APEA Cardiovascular
When auscultating the heart, a scratchy, continuous murmur is audible during atrial systole and ventricular systole and diastole. This finding may be indicative of a:
a. Pericardial friction rub
b. Venous hum
c. Patent ductus arteriosus
d. Ventricular septal defect
a. Pericardial friction rub
**APEA Cardiovasular
Pericardial friction rub: Scratchy, scraping sound with a high pitch. Best heard with the diaphragm and are associated with friction from cardiac movement in the pericardial sac. If they are heard in atrial systole and ventricular systole and diastole, then the diagnosis is made.
Venous hum: benign sounds resulting from turbulence in the jugular veins. They can produce a humming or roaring sound and are heard best wit hthe bell of the stethoscope during diastole. Venous hums are common in children and may be present in patients who have anemia or hyperthyroidism.
Patent ductus arteriosus: harsh, machine-like sound, loudest during late systole.
Ventricular septal defect: high pitch and is usually heard throughout systole.
A characteristic finding in the elderly population is:
a. The increase in diastolic blood pressure after the sixth decade
b. A tendency toward developing postural hypertension
c. The development of heart rhythm changes leading to syncope
d. The susceptibility to hyperthermia
c. The development of heart rhythm changes leading to syncope
**APEA Cardiovascular
Which of the following symptoms would necessitate the need for further evaluation of the newborn?
a. Blue hands and feet within an hour after birth
b. Blood glucose level of 45 mg/dl
c. Dusky cyanotic when crying
d. Deep sleep one hour after birth
c. Dusky cyanotic when crying
**APEA Cardiovascular
When auscultating the apex of the heart in an 8-year-old, the bell of the stethoscope should be placed at the:
a. Third intercostal space lateral to the midclavicular line
b. Fifth intercostal space to the left of the midclavicular line
c. Fourth intercostal space lateral of the midclavicular line
d. Fifth intercostal space to the right of the midclavicular line
b. Fifth intercostal space to the left of the midclavicular line
**APEA Cardiovascular
Breath sounds consisting of a full inspiratory and expiratory phase with the inspiratory phase usually being louder and normally heard over the trachea and larynx are considered:
a. Bronchial
b. Abnormal
c. Bronchovesicular
d. Vesicular
a. Bronchial
**APEA Respiratory
Bronchial breath sounds consist of a full inspiratory and expiratory phase with the inspiratory phase usually being louder. They are normally heard over the trachea and larynx.
Bronchovesicular breath sounds consist of a full inspiratory phase with a shortened and softer expiratory phase. They are normally heard over the hilar region (center of the lungs near the heart).
Vesicular breath sounds consist of a quiet, wispy inspiratory phase followed by a short, almost silent expiratory phase. They are heard over the periphery of the lung field.
Stridor heard louder in the neck than over the chest wall indicates:
a. An obstruction in the alveoli
b. An obstruction in the main bronchus
c. A partial obstruction in the larynx
d. An obstruction in the bronchioles
c. A partial obstruction in the larynx
**APEA Respiratory
A wheeze that is entirely or predominately inspiratory is termed stridor. It is often louder in the neck than over the chest wall and indicates a partial obstruction of the larynx or trachea and is considered an emergency.
An obstruction in the alveoli or bronchioles are generalized wheezes heard throughout the chest.
With an obstruction in the main bronchus, the wheeze would be persistent and more localized
The line that extends through the inferior angle of the scapula when the arms are at the sides of the body is the:
a. Mid vertebral line
b. Scapular line
c. Midclavicular line
d. Mid-spinal line
b. Scapular line
**APEA Respiratory
When performing a respiratory assessment on a 4-year-old child, further evaluation is warranted in the presence of:
a. The use of the abdominal muscles
b. Eupneic respirations
c. Supraclavicular retractions
d. Vesicular sounds in the chest periphery
c. Supraclavicular retractions
**APEA Respiratory
A 4-year-old has diaphragmatic breathing so using the abdominal muscles would be normal. Eupneic respirations is a term for normal breathing. Vesicular sounds in the chest periphery is considered normal for this age group.
The lower tip of the scapula is located:
a. Near the fourth rib
b. Around the seventh or eighth rib
c. Midway between the ninth and tenth rib
d. At the angle just above the twelfth rib
b. Around the seventh or eighth rib
**APEA Respiratory
A patient presents with a productive cough. Which one of the following descriptions of the mucus is correct?
a. Mucoid sputum is green, white, or pale yellow
b. Tenacious sputum is consistent with patients who have cystic fibrosis
c. Foul-smelling sputum is present in bronchitis
d. Large volumes of purulent sputum are present in patients who have asthma
b. Tenacious sputum is consistent with patients who have cystic fibrosis
**APEA Respiratory
Purulent sputum is yellow or green.
Mucoid sputum is translucent, white, or gray.
Foul-smelling sputum is present in anaerobic lung abscess
Tenacious sputum is present in patients who have cystic fibrosis.
Large volumes of purulent sputum are present in bronchiectasis or lung abscess
Adventitious breath sounds, such as crackles, are:
a. Low-pitched, dry, grating sounds heard on inspiration and expiration
b. Continuous, high-pitched, and musical heard on inspiration and expiration
c. Continuous, low-pitched and prolonged and heard on expiration
d. Popping, frying sounds, may be low or high-pitched and usually heard on inspiration
d. Popping, frying sounds, may be low or high-pitched and usually heard on inspiration
**APEA Respiratory
Crackles: Coarse, medium, or fine. Usually produce a popping, frying sound. Coarse crackles are low-pitched while fine crackles are high-pitched. Course sounds are heard on inspiration and sometimes expiration. Medium crackles are heard in the middle of inspiration. Fine crackles are heard at the end of inspiration.
Rhonchi: Continuous, low-pitched. Heard on expiration.
Wheezes: Continuous high-pitched and musical.
Pleural friction rub: Dry, grating sound
Retractions are observed in all the following areas except the:
a. Supraventricular area
b. Hilar area
c. Intercostal area
d. Costal marginal area
b. Hilar area
**APEA Respiratory
Retractions are a pulling inward of the soft tissue and are associated with respiratory difficulty. Usually retractions are noted in the supraventricular, intercostal, and costal margin areas of the chest.
When percussing the lower posterior chest, begin by:
a. Standing on the side rather than directly behind the patient
b. Having the patient lie supine on the examining table
c. Carefully palpating any area that has reported pain
d. Using the ball or the ulnar surface of the hand
a. Standing on the side rather than directly behind the patient
**APEA Respiratory
Breath sounds heard on chest over the hilar region are:
a. Bronchial
b. Abnormal
c. Bronchovesicular
d. Vesicular
c. Bronchovesicular
**APEA Respiratory
Respiratory effort in the neonate is initiated at birth as a result of:
a. An increase in the PO2 and a decrease in PCO2
b. The continued functioning of the foramen ovale
c. Chemical, thermal, and mechanical factors
d. Drying off the infant
c. Chemical, thermal, and mechanical factors
**APEA Respiratory
Several factors influence respiration: Breathing is initiated by a lack of oxygen and a high level of carbon dioxide in the blood stream. This stimulates the respiratory center in the medulla of the brain. Initiation of respiration is aided by the compression of the chest wall during the birth process, the cool air on the wet face, and the general handling of the body and limbs. A healthy baby cries almost immediately, but he has to breathe to be able to cry. With the first breath, the blood vessels in the lung expand. Spontaneous breathing is now established. Pulmonary venous return to the heart increases. This results in left arterial pressure exceeding right arterial pressure. Right to left shunting through the foramen ovale is reduced.
A 48-year-old woman states that she began smoking about 10 cigarettes per day at 20 years of age. How should this subjective history be documented?
a. 10 pack year history
b. 14 pack year history
c. 18 pack year history
d. 20 pack year history
b. 14 pack year history
**APEA Respiratory
The anterior surface landmark on the thorax that is denoted by a hollow U-shaped depression just above the sternum and between the clavicles is termed the:
a. Sternum
b. Suprasternal notch
c. Substernal nodule
d. Spinous process
b. Suprasternal notch
**APEA Respiratory
When trying to differentiate between hemoptysis or blood-streaked material, which one of the following observations is correct?
a. Hemoptysis is seen frequently in infants, children, and adolescents with allergic rhinitis
b. Blood originating in the stomach is usually brighter than blood originating from the respiratory tract
c. Hemoptysis is common in children with cystic fibrosis
d. Blood-streaked material often originates from the gastrointestinal tract
c. Hemoptysis is common in children with cystic fibrosis
**APEA Respiratory
A deviated trachea could be caused by all of the following except:
a. Pneumothorax
b. Pneumonectomy
c. Pneumonia
d. Atelectasis
c. Pneumonia
**APEA Pneumonia
Tracheal deviation results from unequal intrathoracic pressure within the chest cavity. When the deviation occurs, the trachea will follow the direction of less pressure. Tracheal deviation can be caused by pneumothorax, atelectasis, pleural effusion, some cancers within the pleural cavity, and pleural fibrosis.
Pneumonia is not associated with tracheal deviation
To document chest findings located at the lowermost portion of the lungs, which one of the following terms would be used?
a. Lower lung fields
b. Visceral pleura
c. Parietal pleura
d. Bases of the lungs
d. Bases of the lungs
The bases of the lungs refers to the lowermost portion of the lungs
The visceral surface refers to the pleural space that covers the outer surface of the lungs. The parietal pleura lines the inner rib cage and the upper surface of the diaphragm
Pain from pleurisy may be referred to the:
a. Right shoulder
b. Retrosternal area
c. Epigastric area
d. Back
c. Epigastric area
**APEA Respiratory
Referred pain is defined as pain that is felt in more distal sites than the initial pain site. Pain from pleurisy or inferior wall myocardial infarction may be referred to the epigastric area.
Pain from the biliary tree may be perceived in the right shoulder or the right posterior chest.
Referred pain of duodenal or pancreatic origin may be referred to the back.
Heartburn may be associated with retrosternal burning pain
When auscultating breath sounds, use the diaphragm of the stethoscope by placing it initially on the:
a. Anterior chest at the nipple line
b. Lateral surface of the chest near the axilla
c. Posterior chest at the cervical 7 level
d. Anterior chest in the upper sternal area
c. Posterior chest at the cervical 7 level
**APEA Respiratory
To auscultate all the lung fields, begin by placing the diaphragm of the stethoscope on the posterior chest and listen from the apices (cervical 7 level) to the bases located around thoracic 10 level. Then listen laterally from the axilla to the 7th or 8th ribs, then repeat the entire assessment from the anterior chest.
A patient who walked into the examination room, may be observed to be sitting and leaning forward in his chair. Lips were pursed during exhalation and arms are supported on the table. This position could be consistent with patients who have:
a. Pneumonia
b. Chronic obstructive pulmonary disease
c. Asthma
d. Croup
b. Chronic obstructive pulmonary disease
**APEA Respiratory
People who have COPD experience shortness of breath and dyspnea. Breathing with pursed lips and use of abdominal muscles help reduce shortness of breath and dyspnea. Leaning forward while seated and having arms supported on the table facilitate breathing.
Diminished breath sounds should be interpreted as:
a. Suggestive of chronic pulmonary disease
b. Suggestive of severe respiratory failure
c. An abnormal finding warranting further evaluation
d. A normal finding
c. An abnormal finding warranting further evaluation
**APEA Respiratory
To locate the twelfth rib, palpate:
a. Anteriorly at the costal margin
b. Between the spine and the lateral chest
c. At the tip of the scapula
d. Below the eleventh spinous process
b. Between the spine and the lateral chest
**APEA Respiratory
Palpate midway between the spine and the lateral chest to identify its free tip. As you palpate toward the vertebral column, you may lose contact with the twelfth rib because it is deep to the quadratus lumborum muscle
On auscultation of the chest, if the patient says “ninety-nine” and it is clearly heard, this is indicative of:
a. A normal sounding chest
b. Lung density in the area
c. Consolidation or compression in the area
d. Of inflammation in the area
b. Lung density in the area
**APEA Respiratory
Bronchophony: indicates density and usually repeating the words ninety-nine produces that sound. If the word is clearly heard it is indicative of lung density in the area
Egophony: saying ee-ee-ee-ee, is indicative of consolidation or compression in the area. It will sound like Ay for an abnormal finding
Whispered pectoriloquy: Whispering one-two-three. More faint than bronchophony, you can hear the words over areas of consolidation.
Increased anteroposterior diameter of the chest, pursed-lipped breathing, and dyspnea with talking suggest:
a. Pneumonia
b. Lung cancer
c. Bronchitis
d. COPD
d. COPD
**APEA Respiratory
A 37-year-old female has audible stridor. This type of stridor is consistent with:
a. Bronchiectasis
b. Pulmonary fibrosis
c. Cystic fibrosis
d. A foreign object lodged in the upper trachea
d. A foreign object lodged in the upper trachea
**APEA Respiratory
The middle section of the thoracic cavity containing the esophagus, trachea, heart, and great vessels is the:
a. Mediastinum
b. Pleural cavity
c. Visceral cavity
d. Pericardium
a. Mediastinum
**APEA Respiratory
Mediastinum: The middle section of the thoracic cavity containing the esophagus, trachea, heart, and great vessels.
Pleural cavities: right and left pleural cavities are on either side of the mediastinum and those contain the lungs.
Visceral pleura: encloses the lung
Pericardium: surrounds the heart
A 3-year-old presents with a history of fever and cough over the past 24 hours. Findings on exam reveal: temperature of 102 F, apical heart rate of 157 bpm, and respiratory rate of 40 breaths per min. Tachypnea in this child is most likely related to:
a. Paradoxical respirations
b. The child’s febrile state
c. The child’s age
d. An airway obstruction
b. The child’s febrile state
**APEA Respiratory
In children, heart and respiratory rates will increase with fever. For every degree of fever the respiratory rate will increase 3-4 breaths/minute and the heart rate will increase 8-10 beats per minute
A condition associated with a chronic cough that produces copious amounts of purulent sputum is most likely:
a. Tracheobronchitis
b. Chronic bronchitis
c. Bronchiectasis
d. Laryngitis
c. Bronchiectasis
**APEA Respiratory
Tracheobronchitis: Acute viral illness that presents with a burning retrosternal discomfort and a dry cough.
Laryngitis: Acute, mild illness often associated with viral nasopharyngitis and hoarseness. The initial cough is dry and non-productive but may become productive over time.
Chronic bronchitis: Cough is characteristically productive with mucoid to purulent sputum and may be blood-tinged.
Bronchiectasis: produces a chronic cough with sputum that is copious and foul-smelling. It may be blood-tinged.
When percussing the posterior chest, which one of the following techniques would be omitted?
a. When comparing two areas on the chest, use the same percussion technique in both areas
b. Percuss one side of the chest then the other at each level
c. Percuss the areas over the scapulae
d. If a louder note is needed, apply more pressure with the pleximeter finger
c. Percuss the areas over the scapulae
**APEA Respiratory
A 65-year-old man presents with complaints of daytime sleepiness, unrestful sleep, and loud snoring. These symptoms are MOST consistent with:
a. Narcolepsy
b. Nocturnal asthma
c. Obstructive sleep apnea (OSA)
d. Chronic obstructive pulmonary disease
c. Obstructive sleep apnea (OSA)
**APEA Respiratory
OSA: Presents as daytime sleepiness, unrestful sleep, and loud snoring.
Narcolepsy: Presents with symptoms of cataplexy, sleep paralysis, hypnogogic hallucinations, and excessive daytime sleepiness.
Nocturnal asthma: Symptoms include chest tightness, shortness of breath, cough, and wheezing.
COPD: Symptoms include nighttime wheezing, coughing, chest tightness, morning phlegm and cough
The palpation technique used to assess respiratory expansion of the chest is placing the hands on the eighth or tenth ribs posteriorly with the thumbs close to the vertebrae, sliding the hand medially and grasping a small fold of skin between the thumbs. Then:
a. Ask the patient to cough and note chest expansion
b. Ask the patient to take a deep breath and note any delay in expansion during inhalation
c. Have the patient hold his breath for 15 seconds and note chest expansion
d. Have the patient exhale forcefully noting expansion on expiration
b. Ask the patient to take a deep breath and note any delay in expansion during inhalation
**APEA Respiratory
During this assessment the thumbs should move evenly away from the vertebrae during inspiration and there should be no delay in expansion
When inspecting the chest for respiratory effort, which one of the following is not part of the inspection?
a. Overall patient appearance
b. Contour and movement of the chest
c. Color of the skin, nail beds, and lips
d. Assessment for tactile fremitus
d. Assessment for tactile fremitus
**APEA Respiratory
An acute viral illness that presents with a burning retrosternal discomfort and a dry cough is suggestive of:
a. Tracheobronchitis
b. Chronic bronchitis
c. Bronchiectasis
d. Laryngitis
a. Tracheobronchitis
**APEA Respiratory
Tracheobronchitis: Acute viral illness that presents with a burning retrosternal discomfort and a dry cough.
Laryngitis: Acute, mild illness often associated with viral nasopharyngitis and hoarseness. The initial cough is dry and non-productive but may become productive over time.
Chronic bronchitis: Cough is characteristically productive with mucoid to purulent sputum and may be blood-tinged.
Bronchiectasis: produces a chronic cough with sputum that is copious and foul-smelling. It may be blood-tinged.
When percussing the right upper posterior area of the chest, a dullness replaces the resonance sound usually heard in the lung. This sound would be suggestive of:
a. Lobar pneumonia
b. Emphysema
c. Asthma
d. Pneumothorax
a. Lobar pneumonia
**APEA Respiratory
If dullness replaces resonance, consider a lung with fluid or solid tissue replacing the air. Examples include: pleural effusion, hemothorax, lobar pneumonia, or empyema.
Emphysema, asthma, and a pneumothorax produce hyperresonance when the lungs are percussed.
Breath sounds consisting of a full inspiratory phase and a shortened and softer expiratory phase normally audible over the hilar region of the chest are termed:
a. Vesicular
b. Bronchial
c. Bronchovesicular
d. Rhonchi
c. Bronchovesicular
**APEA Respiratory
Bronchial breath sounds consist of a full inspiratory and expiratory phase with the inspiratory phase usually being louder. They are normally heard over the trachea and larynx.
Bronchovesicular breath sounds consist of a full inspiratory phase with a shortened and softer expiratory phase. They are normally heard over the hilar region (center of the lungs near the heart).
Vesicular breath sounds consist of a quiet, wispy inspiratory phase followed by a short, almost silent expiratory phase. They are heard over the periphery of the lung field.
When examining a patient for chest expansion, begin by:
a. Hyperextending the examiner’s middle finger of the left hand (pleximeter finger) and pressing its distal interphalangeal joint firmly on the surface to be examined.
b. Placing the thumbs of the examiner at about the level of the tenth ribs with the fingers loosely grasping and parallel to the lateral rib cage.
c. Positioning the examiner’s right forearm close to the chest surface with the hand cocked upward.
d. Standing on the side rather than directly behind the patient
b. Placing the thumbs of the examiner at about the level of the tenth ribs with the fingers loosely grasping and parallel to the lateral rib cage.
**APEA Respiratory
A patient who presents with a long history of cigarette smoking exhibits a dry to productive cough with dyspnea and weight loss. These symptoms could be consistent with:
a. A pulmonary embolus
b. Asthma
c. A neoplasm of the lung
d. Chronic obstructive pulmonary disease
c. A neoplasm of the lung
**APEA Respiratory
One of the anterior thoracic landmarks is costal angle. It is located:
a. Where the manubrium and body of the sternum intersect
b. Where the right and left costal margins form an angle where they meet at the xiphoid process
c. Where the suprasternal notch and the sternum form an angle
d. At the angle where the ninth and tenth ribs are fuses
b. Where the right and left costal margins form an angle where they meet at the xiphoid process
**APEA Respiratory
Which one of the following infants should be seen immediately by the nurse practitioner?
a. A two-week-old infant with nasal congestion and a respiratory rate of 64 breaths/minute
b. A one-week-old infant with a diaper rash and a respiratory rate of 44 breaths/minute
c. A one-month-old infant with an axillary temperature of 99 degrees Farenheit
d. A three-week-old breastfed infant who has had two loose stools today.
a. A two-week-old infant with nasal congestion and a respiratory rate of 64 breaths/minute
**APEA Respiratory
Normal respiratory function is a high priority in the newborn. Nasal congestion and increased respiratory rate are the beginning signs of respiratory distress. Any situation in which respiratory function is impaired should be assessed immediately. Diaper rash can be treated at home and does not necessitate immediate care. It is not unusual for breast fed infants to have loose stools after each feeding. A temperature of 99 F is within normal limits for an infant
The line that bisects the center of each clavicle at a point halfway between the palpated sternoclavicular and acromioclavicular joints is the:
a. Midsternal line
b. Midclavicular line
c. Midvertebral line
d. Midscapular line
b. Midclavicular line
**APEA Respiratory
To document chest findings located below the scapulae, which one of the following terms would be used?
a. Infraclavicular
b. Supraclavicular
c. Interscapular
d. Infrascapular
d. Infrascapular
**APEA Respiratory
Factors that aggravate costochrondritis may include:
a. Hypertension
b. Emotional stress
c. Swallowing cold foods
d. Movement of the chest, trunk, and arms
d. Movement of the chest, trunk, and arms
**APEA Respiratory
To document chest findings located between the scapulae, which one of the following terms would be used?
a. Infraclavicular
b. Supraclavicular
c. Interscapular
d. Infrascapular
c. Interscapular
**APEA Respiratory
The midaxillary line:
a. Extends from the anterior axillary fold where the pectoralis major muscle inserts
b. Continues from the posterior axillary fold where the latissimus dorsi muscle inserts
c. Runs down from the apex of the axilla and lies between and parallel to the anterior and posterior lines
d. Extends through the inferior angle of the scapula when the arms are at the sides of the body
c. Runs down from the apex of the axilla and lies between and parallel to the anterior and posterior lines
**APEA Respiratory
Which technique best determines whether the tissues in the chest are air-filled, fluid-filled, or solid?
a. Auscultation
b. Palpation
c. Inspection
d. Percussion
d. Percussion
**APEA Respiratory
The hilar region of the lungs describes:
a. The area around the heart
b. The base of the lungs
c. The posterior chest
d. The upper, anterior area of the chest
a. The area around the heart
**APEA Respiratory
The area around the heart near the center of the lungs describes the hilar region. The hila are structures consisting of the major bronchi and pulmonary veins and arteries. Hilar lymph nodes are not normally visible on chest x-ray
A 65-year-old obese man with a past medical history of hypertension complains of increased fatigue during the day. The practitioner orders a polysomnogram to test for:
a. Congestive heart failure (CHF)
b. Gastroesophageal reflux disease (GERD)
c. Obstructive sleep apnea (OSA)
d. Chronic obstructive pulmonary disease (COPD)
c. Obstructive sleep apnea (OSA)
**APEA Respiratory
The angle of Louis is a useful place to start counting ribs. This landmark is located:
a. On the manubrium and body of the sternum
b. Near the xiphoid process
c. Just above the sternum
d. Between the two scapulae
a. On the manubrium and body of the sternum
**APEA Respiratory
The sternal angle or the “angle of Louis” is the articulation of the manubrium and body of the sternum. It is continuous with the second rib. This angle is a useful place to start counting ribs, which helps localize respiratory finding horizontally
Breath sounds auscultated over the periphery of the lung fields are quiet and wispy during the inspiratory phase followed by a short, almost silent expiratory phase. These breath sounds are considered:
a. Vesicular
b. Bronchovesicular
c. Bronchial
d. Crackles
a. Vesicular
**APEA Respiratory
Bronchial breath sounds consist of a full inspiratory and expiratory phase with the inspiratory phase usually being louder. They are normally heard over the trachea and larynx.
Bronchovesicular breath sounds consist of a full inspiratory phase with a shortened and softer expiratory phase. They are normally heard over the hilar region (center of the lungs near the heart).
Vesicular breath sounds consist of a quiet, wispy inspiratory phase followed by a short, almost silent expiratory phase. They are heard over the periphery of the lung field.
When palpating the thorax, a crackling, popping noise under the skin is heard. On auscultation, a sound similar to hair being rubbed between the fingers is noted. These symptoms could be consistent with:
a. Pneumonia
b. Hemothorax
c. Pneumothorax
d. Bronchitis
c. Pneumothorax
**APEA Respiratory
Subcutaneous emphysema is the condition described in the question. This can be caused by pneumothorax because this condition allows air to be introduced into the tissue.
Hemothorax refers to blood in the chest and crepitus is not associated with this condition
Pneumonia and bronchitis do not produce subcutaneous emphysema
Orthopnea is typically associated with all of the following conditions except:
a. Left ventricular hypertrophy
b. Pulmonary embolus
c. Mitral stenosis
d. Obstructive lung disease
b. Pulmonary embolus
**APEA respiratory
**Orthopnea is defined as dyspnea that occurs when the patient is lying down and improves when the patient sits or stands up. It is generally seen in patients with mitral stenosis, left ventricular hypertrophy, and in obstructive lung disease. With a pulmonary embolus, the dyspnea is sudden and uncomfortable in any position.
Breath sounds heard over the periphery of the lung fields are:
a. Bronchial
b. Abnormal
c. Bronchovesicular
d. Vesicular
d. Vesicular
**APEA Respiratory
When testing for corneal reflex, an absent blink reflex is noted. This finding may be suggestive of a lesion in which cranial nerve?
Cranial nerve VII
Nerves V and VII are the Trigeminal or facial nerves.
Intention Tremors appear with movement and:
Worsen as the target gets closer.
Tremors are rhythmic oscillatory movements. Intention tremors, absent at rest, appear with movement and often worsen as the target gets closer. Causes include disorders of cerebellar pathways as in MS or diseases of the cerebellum.
When assessing anal reflexes, the NP strokes the four quadrants of the anus with a cotton swab. A loss of anal reflex is noted. This finding could be suggestive of a pathologic lesion in which segmented level of the spine?
Sacral 2, 3, and 4
The NP instructs the patient to close his eyes and then grasps his big toe and moves the toe up or down asking the patient to correctly identify the direction of the movement. This is an example of identifying:
Proprioception or position sensation in the big toe.
Glasgow coma scale assesses:
Motor Response
Based on Motor responsiveness, verbal performance, and eye opening to appropriate stimuli, the Glasgow Coma Scale was designed and should be used to assess the depth and duration of coma and impaired consciousness.
When assessing coordination of muscle movement, four areas of the nervous system function in an integrated way. These areas include the motor, cerebellar, the vestibular, and the sensory systems. Which system coordinates head movements?
Motor System
Cerebellar System
Vestibular System
Sensory System
Vestibular System
A progressive disorder of the nervous system that affects movement is known as:
Delirium
Functional impairment
Parkinson’s Disease
Alzheimer’s Disease
Parkinson’s Disease
A rhythmic oscillatory movement of a body part resulting from the contraction of opposing muscle groups is:
Dystonia
Bradykinesia
a Tremor
a Seizure
A Tremor
Resting tremors refer to those tremors that disappear:
At rest
With voluntary movement
When the affected part is actively maintaining a posture
When the target gets closer
with voluntary movement
When assessing plantar reflexes, the NP strokes the lateral aspect of the sole from the heel to the ball of the right foot. Absence of movement of the big toe is noted. This finding could be suggestive of a pathologic lesion in which segmented level of the spine?
Thoracic 8, 9, and 10
Thoracic 10, 11, 12
Lumbar 5 and Sacral 1
Sacral 2, 3, and 4
Lumbar 5 and Sacral 1
During this type of seizure activity, the patient loses consciousness suddenly, sometimes with a cry, and the body stiffens into tonic extensor rigidity. Breathing stops, and the person becomes cyanotic. A clonic phase of rhythmic muscular contraction follows. This type of seizure activity is referred to as a:
Focal seizure with impairment of consciousness
Jacksonian seizure
Focal seizure that become generalized
Grand mal seizure
Grand mal seizure
What is an example of a disease or condition that appears in a dermatomal pattern?
Fibromyalgia
Shingles
Diabetic Neuropathy
Referred pain
Shingles
A band of skin innervated by the sensory root of a single spinal nerve is a dermatome.
Which of the following symptoms may be associated with a tumor of the eighth cranial nerve?
Dizziness
Inability to close the eyes
Loss of the sense of smell
Inability to taste sour things
Dizziness
Symptoms indicative of shaken baby syndrome are related to:
Poor nutrition and lack of parental bonding
Vaso-Occlusive crisis and cerebral infarction
Uncontrollable cerebral edema and hypoxia
Microcephaly and premature closures of the cranial sutures
Uncontrollable cerebral edema and hypoxia
Can lead to symptoms of blindness, inability to perform previously learned milestones and very flaccid muscle tone.
Symptoms of a migraine headache can include throbbing, nausea or vomiting, duration of one day, and be unilateral and/or disabling. How many of these symptoms should be present to classify the headache as a migraine?
One of the five
Two of the five
Three of the five
Four of the five
Three of the five
The patient experiences a sudden loss of consciousness with falling without movements and injury may occur. This type of a seizure is consistent with:
A myoclonic seizure
An absent seizure
A myoclonic atonic seizure
A focal seizure with impairment of consciousness.
A myoclonic atonic seizure.
A form of aphasia in which the person has difficulty speaking and understanding words and is unable to read or write is termed:
Broca’s Aphasia
Anomic Aphasia
Wernicke’s Aphasia
Global Aphasia
Global Aphasia
Broca’s aphasia, speech is confluent, slow, with few words, and laborious effort. With anomic aphasia, the person has word-finding difficulties and because of the difficulties the person struggles to find the right words for speaking and writing.
Uncontrolled electrical activity in the brain, which may produce minor physical signs, thought disturbances, or disturbed motor activity is:
Dystonia
Bradykinesia
Tremor
Seizure
Seizure
An older adult presenting with signs of undernourishment, slow motor performance, and loss of muscle mass or weakness suggests:
Depression
Frailty
Parkinson’s Disease
Alzheimer’s Disease
Frailty
When assessing the cranial nerves, the nurse practitioner insturcats the patient to stick out his tongue and move it from side to side. This maneuver would be used to assess which cranial nerve?
Cranial Nerve V
Cranial Nerve VII
Cranial Nerve IX
Cranial Nerve XII
Cranial Nerve XII- Hypoglossal Nerve.
Which choice is least likely to be an example of asymmetric weakness?
The right Shoulder
The right hand
Both arms
On the right side of the face
Both Arms
There are 4 different patterns of weakness: Proximal, distal, symmetric, and asymmetric.
With the adult patient lying supine, the nurse practitioners flexes the patient’s neck while observing the hips and knees. Flexion of both hips and knees was noted. This is a positive:
Brudzinski’s Sign
Kernig’s Sign
Nuchal Rigidity Sign
Babinski’s Sign
Brudzinski’s Sign
When assessing the cranial nerves, the nurse practitioner instructs the patient to raise both eyebrows, frown, and smile. These maneuvers would be assessing which cranial nerve?
Cranial Nerve IV
Cranial Nerve V
Cranial Nerve VI
Cranial Nerve VII
Cranial Nerve VII
Other maneuvers could include having the patient puff out cheeks, show upper and lower teeth, and closing both eyes tightly without opening them when the examiner tries to.
One maneuver used to assess coordination is to observe the patient:
Dorsiflexing the ankle
Walking heel-to-toe in a straight line
Squeezing the examiner’s fingers
Counting to 10 backwards
Walking heel-to-toe in a straight line
When eliciting deep tendon reflexes in the biceps, the NP notes an abnormal reflex in the right biceps. This abnormality is probably consistent with a pathological lesion in which segmented level of the spine?
Cervical 5 and 6
Cervical 6 and 7
Lumbar 2, 3, and 4
Sacral 1
Cervical 5 and 6
The segmented levels of the deep tendon reflexes are: ankle: Sacral 1
Knee: Lumbar 2, 3, 4
Supinator and biceps: Cervical 5 and 6
Triceps: Cervical 6 and 7
While assessing cranial nerve, the NP touches the cornea lightly with a wisp of cotton. This maneuver assesses which cranial nerve?
Cranial Nerve II
Cranial Nerve IV
Cranial Nerve V
Cranial Nerve X
Cranial Nerve V
Disorders of speech fall into three groups that affect all fo the following except the:
Voice
Articulation of speech
Written Language
Comprehension of language
Written Language
A patient is unable to identify the smell of an orange. This inability could reflect an abnormaility in cranial nerves:
I
II
III
VIII
I - Olfactory
When assessing the abdominal cutaneous reflexes, the nurse practitioner strokes the lower abdomen, the localized twictch is absent. This finding could be suggestive of a pathologic lesion in which segmented level of the spine?
Thoracic 8, 9, and 10
Thoracic 10, 11, and 12
Lumbar 5 and Scral 1
Sacral 2, 3, and 4
Thoracic 10, 11, and 12
When evaluating a patient for weakness of the upper extremities, bilateral proximal limb weakness without sensory loss is noted. This finding could be suggestive of:
Alcohol Myopathy
Polyneuropathy
Myositis
Neuromuscular Junction Disorders
Alcohol Myopathy
Can also occur due to glucocorticoids and inflammatory muscle disorders like myositis and dermatomyositis
A teenager presents with signs of being gleeful, somewhat drowsy, and unable to focus. On examination, BP 90/65, pupils constricted, and speech slurred. These symptoms are consistent with:
Opiod Intoxication
An amphetamine overdose
An overdose of benzodiazepines
Marijuana Usage
Opioid Intoxication
Which developmental area is predominantly affected by lead poisoning?
Nutrution
Communication
Cognition
Mobility
Cognition
A 40-year old male presents with complaints of headaches. History reveals headaches that occurred daily for about 4-6 weeks. He had relief for 6 months but now there are recurring. These are most likely:
Tension headaches
cluster headaches
migraine headaches
sinus headaches
Cluster Headaches
Cluster headaches are more common in men than woman
Which diagnosis describes people often found to be criminals, who habitually violate the rights of others without remorse?
a. Histrionic
b. Antisocial
c. Borderline
d. Narcissistic
b. Antisocial
**APEA Psychiatry
Antisocial personality disorder is characterized by habitual and pervasive disregard for or violation of the rights and considerations of others without remorse.
Borderline personality disorder is defined as a pervasive pattern of instability with interpersonal relationships, self-image, and affect, as well as marked impulsivity.
Histrionic personality disorder is characterized by patterns of attention-seeking, often dramatic behavior to gain the approval of others.
Narcissistic personality disorder is described as a long-term pattern of abnormal behavior characterized by exaggerated feelings of self-importance, and excessive need for admiration, and a lack of understanding of others’ feelings
The most common cause of viral encephalitis in children is:
Herpes Simplex Virus Type II
Picornavirus
Enteroviruses
Herpes Simplex Virus Type I
Herpes Simplex Virus Type I
Which of the following is NOT a symptom associated with the formal diagnosis of attention-deficit hyperactivity disorder (ADHD) in a child?
a. Difficulty organizing tasks and activities
b. Inability to play or engage in leisure activities quietly
c. Exhibiting symptoms of insomnia, restless sleep, and occasional noctambulism
d. Inability to follow through on instructions and failure to finish schoolwork
c. Exhibiting symptoms of insomnia, restless sleep, and occasional noctambulism
**APEA psychiatry
ADHD is a brain disorder marked by an ongoing pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development. Six or more of the symptoms must persist for at least 6 months, to a degree that is inconsistent with developmental level and that negatively impacts social and academic/occupational activities. Some of the symptoms of ADHD include: difficulty organizing tasks and activities, inability to quietly play or engage in leisure activities, inability to follow instructions, and failing to finish schoolwork.
A patient presents with hisotry of Temp. 102 with a headache and pink papules on the upper chest several hours ago. Petechiae and ecchymosis are noted on the trunk. These skin lesions may be indicative of:
Leukemia
Meningococcemia
Neurofribromatosis
Hemorrhagic Pancreatitis
Meningococcemia
A flat affect can be an identifiable finding in an older adult who has:
a. Dementia
b. Delirium
c. Depression
d. Alcoholism
c. Depression
**APEA psychiatry
Flat affect occurs in depression, Parkinson’s disease, or Alzheimer’s disease
Which one of the following choices would NOT be recommended for effective communication for an older adult?
a. Allow time for open ended questions and reminiscing
b. Use brief screening instruments
c. Face the patient and speak in high tones
d. Adjust pace and content of the interview to the stamina of the patient
c. Face the patient and speak in high tones
**APEA psychiatry
Low tone should be used rather than a high tone.
The personality disorder characterized by patterns of attention-seeking, often dramatic behavior to gain the approval of others is:
a. Histrionic
b. Antisocial
c. Borderline
d. Narcissistic
a. Histrionic
**APEA psychiatry
Antisocial personality disorder is characterized by habitual and pervasive disregard for or violation of the rights and considerations of others without remorse.
Borderline personality disorder is defined as a pervasive pattern of instability with interpersonal relationships, self-image, and affect, as well as marked impulsivity.
Histrionic personality disorder is characterized by patterns of attention-seeking, often dramatic behavior to gain the approval of others.
Narcissistic personality disorder is described as a long-term pattern of abnormal behavior characterized by exaggerated feelings of self-importance, and excessive need for admiration, and a lack of understanding of others’ feelings
Higher level self-care functioning activities are referred to as:
a. Activities of daily living
b. Instrumental activities of daily living
c. Necessary activities of daily living
d. Required activities of daily living
b. Instrumental activities of daily living
**APEA psychiatry
ADLs consist of basic self-care abilities: bathing, dressing, toileting, transferring, continence, and feeding.
Higher level functions are referred to as the instrumental activities of daily living (IADLS) and include: using the telephone, shopping, preparing food, laundry, and taking medicine
At what age is it considered normal for a child to pick up objects using the palm of the hand only?
2 months
6 months
12 months
18 months
6 months
At 9 months the child uses the thumb and pointer finger to pick up objects and this is called the pincer grasp. A 12-month old would be able to use the entire hand and fingers to pick up items. At 2 years old, Children have full dexterity and movement.
The 10-minute geriatric screener is a tool used to assess:
a. Smoking habits
b. Alcohol consumption
c. Functionality
d. Dementia
c. Functionality
**APEA psychiatry
10-minute screener is a tool used for functional assessment in the older adult. It assesses: vision, hearing, leg mobility, urinary incontinence, nutrition and weight loss, memory, depression, and physical disability.
What geriatric condition is characterized by normal alertness but progressive global deterioration of cognition in multiple domains?
Delirium
Cognitive impairment
Parkinson’s Disease
Alzheimer’s Disease
Alzheimer’s Disease
Including short term memory, but with sparing of memory for remote events, subtle language errors, visuospatial perceptual difficulties, and changes in executive function, or the ability to perform sequential tasks such as instrumental activities of daily living.
A multifactorial geriatric condition or syndrome characterized by an age-related lack of adaptive physiological capacity occurring in the absence of identifiable illness is known as:
a. Delirium
b. Cognitive impairment
c. Functional impairment
d. Frailty
d. Frailty
**APEA psychiatry
Frailty: A multifactorial geriatric condition or syndrome characterized by an age-related lack of adaptive physiological capacity occurring in the absence of identifiable illness.
Delirium: Serious disturbance in a person’s mental abilities that results in a decreased awareness of one’s environment and confused thinking. In the older adult, it is defined as a geriatric syndrome or condition occurring as a temporary state of confusion and may be the first clue to infection or problems with medications.
Cognitive impairment: intermediate stage between the expected cognitive decline of normal aging and the more serious decline of dementia.
Functional impairment: A health condition in which the normal function of a part of the body is less than full capacity. One of the defining characteristics of functional impairments is that the reduction in physical or mental capacity is sufficient to interfere with managing day-to-day tasks.
A 25-year-old with the mental age of a toddler, who exhibits limited language skills and can be trained in very basic activities of daily living, such as dressing, hygiene, and feeding, would be classified as:
a. Mildly mentally retarded
b. Severely mentally retarded
c. Moderately mentally retarded
d. Profoundly mentally retarded
b. Severely mentally retarded
**APEA psychiatry
Mild mental retardation: Person is educable with a mental age of 8-12 years old.
Moderate mental retardation: Trainable with a mental age of 3-7 years and an IQ of 35-55.
Severe mental retardation: Person has an IQ between 25-40, limited communication, capable of learning certain self-care activities, and the mental age of a toddler.
Profound mental retardation: IQ less than 20, the mental age of an infant, and requires complete custodial care.
With the adult patient lying supine the NP srokes the lateral aspect fo the sole from the heel to the ball of the foot with the end of an applicator stick. Dorsiflexsion of the big toe was noted. This is positive:
Brudzinski’s sign
Kernig’s sign
Nuchal rigidity sign
Babinski’s sign
Babinski’s sign
When assessing the cranial nerves, the NP uses the tongue blade to gently stimulate the back of the throat on each side. A unilateral absence of the gag reflex is noted. This finding could be suggestive of a unilateral lesion in which cranial nerve?
Cranial Nerve V
Cranial Nerve VII
Cranial Nerve IX
Cranial Nerve XII
Cranial Nerve IX
Unilateral absence of the gag reflex suggests a lesion of CN IX or X. The glossopharyngeal and vagus nerves.
Mood disorders include all of the following except:
a. Bipolar disorder
b. Seasonal affective disorder (SAD)
c. Schizoaffective disorder
d. Agoraphobia
d. Agoraphobia
**APEA psychiatry
A mood disorder is defined as a prolonged emotional state that affects a person’s life and personality.
All of the examples listed are included except agoraphobia, a fear of being in a public place where escape may not be possible or help not available, is considered a phobic disorder.
A patient who is being evealuated for frequent headaches, mentions that the headache worsensd with coughing, sneezing, or when changing positions. Increasing pain with these maneuvers may be suggestive of:
A brain tumor
A migraine
Seizure Activity
A Subarachnoid Hemorrhage
A brain Tumor
May also present with Nausea and Vomiting
Which one of the following questions is NOT asked in the CAGE questionnaire?
a. Have you ever felt you needed to cut down on your drinking?
b. Have you ever been found guilty of driving under the influence of alcohol?
c. Have people annoyed you by criticizing your drinking
d. Have you ever felt you needed a drink first thing in the morning?
b. Have you ever been found guilty of driving under the influence of alcohol?
**APEA psychiatry
Which one of the following senses is most often affected in patients on long-term antibiotic therapy
Touch
Taste
Smell
Hearing
Hearing
Antibiotics can be ototoxic.
A form of aphasia in which the speech is confluent, slow, with few words and laborious effort and inflection and articulation are impaired but words are meaningful, is termed:
Broca’s aphasia
Anomic aphasia
Wernicke’s aphasia
Global aphasia
Broca’s aphasia
Small grammatical words are often dropped as well.
Social phobia, panic disorder, and selective mutism are all classified under the DSM-5 category of:
a. Depressive disorders
b. Anxiety disorders
c. Obsessive-compulsive disorders
d. Trauma and stressor-related disorders
b. Anxiety disorders
**APEA Psychiatry
Anxiety disorders: This includes separation anxiety disorder, selective mutism, specific phobia, social phobia, panic disorder, agoraphobia, and generalized anxiety disorder.
An intermediate stage between the expected cognitive decline of normal aging and the more serious decline of dementia is known as:
a. Delirium
b. Cognitive impairment
c. Functional impairment
d. Frailty
b. Cognitive impairment
**APEA psychiatry
Frailty: A multifactorial geriatric condition or syndrome characterized by an age-related lack of adaptive physiological capacity occurring in the absence of identifiable illness.
Delirium: Serious disturbance in a person’s mental abilities that results in a decreased awareness of one’s environment and confused thinking. In the older adult, it is defined as a geriatric syndrome or condition occurring as a temporary state of confusion and may be the first clue to infection or problems with medications.
Cognitive impairment: intermediate stage between the expected cognitive decline of normal aging and the more serious decline of dementia.
Functional impairment: A health condition in which the normal function of a part of the body is less than full capacity. One of the defining characteristics of functional impairments is that the reduction in physical or mental capacity is sufficient to interfere with managing day-to-day tasks.
Which one of the following is at the HIGHEST risk for suicide?
a. A 32-year-old Asian woman
b. A 15-year-old Hispanic girl
c. An 86-year-old black man
d. A 52-year-old white man
d. A 52-year-old white man
**APEA psychiatry
A mental health condition is characterized by over-the-top behavior such as emotional outbursts, noisy displays of temper, compulsive attention-seeking and self-centered actions is:
a. Histrionic
b. Antisocial
c. Borderline
d. Narcissistic
a. Histrionic
**APEA psychiatry
Antisocial personality disorder is characterized by habitual and pervasive disregard for or violation of the rights and considerations of others without remorse.
Borderline personality disorder is defined as a pervasive pattern of instability with interpersonal relationships, self-image, and affect, as well as marked impulsivity.
Histrionic personality disorder is characterized by patterns of attention-seeking, often dramatic behavior to gain the approval of others.
Narcissistic personality disorder is described as a long-term pattern of abnormal behavior characterized by exaggerated feelings of self-importance, and excessive need for admiration, and a lack of understanding of others’ feelings
During which part of the routine office visit should a person be asked questions related to physical and sexual abuse?
a. While obtaining the subjective health history of sexually transmitted diseases (STDs)
b. Physical and sexual abuse history is not obtained during routine office visits
c. During the physical exam, when others are asked to leave the room
d. While the patient is in the waiting room completing the written abuse questionnaire
c. During the physical exam, when others are asked to leave the room
**APEA psychiatry
Which of the following symptoms would be consistent with Attention Deficit Hyperactivity Disorder (ADHD)
a. Child refuses to cooperate with parents or teachers and often defies authority
b. Child unable to sit still in the desk and often blurts out the answer before the teacher finishes asking the question
c. Child is very social and always talking to the other children in class
d. Child has difficulty reading and often memorizes the stories when read to him.
b. Child unable to sit still in the desk and often blurts out the answer before the teacher finishes asking the question
**APEA psychiatry
Symptoms of ADD or ADHD are inattention, daydreaming, inability to stay focused or follow multiple steps in directions/instructions. These children commonly engage in risk taking and so accidents are common. Other symptoms include constant motion without purpose, hyperactivity, impulsivity, poor school performance and poor self-esteem. The other choices are more consistent with conduct disorder and oppositional defiant disorder (ODD). The child who is social is acceptable behavior for the age group.
Anticipatory guidance for the family of a pre-adolescent with a cognitive impairment should include information about:
a. Institutional placement
b. Sexual development
c. Environmental stimulation
d. Self-care activities
b. Sexual development
**APEA psychiatry
Pre-adolescents who have a cognitive dysfunction may have normal sexual development without age appropriate emotional and cognitive abilities. It is important to assist the family and child through this developmental stage. Pre-adolescence does not require the child to be institutionalized. By the time a child reaches pre-adolescence, the family should have received instructions on ways to encourage and reinforce self-care activities and strategies to enhance the environment to encourage growth and development.
During the mental status exam, a 45-year-old woman is easily distractible and seems to have difficulty responding to each question. This is an assessment of:
a. Perception
b. Attention
c. Orientation
d. Thought process
b. Attention
**APEA psychiatry
The mental status exam assesses attention, memory, orientation, perception, thought process, thought content, insight, judgment, affect, mood, language, and cognitive function. Attention is described as the ability to focus or concentrate over time on a particular stimulus or activity. An inattentive person is easily distractible and may have difficulty giving a history or responding to a question. Perception is the sensory awareness of an object in the environment. Orientation is awareness of identity, place, and time. Thought process is the logic and relevance of the patient’s thought as it leads to selected goal.
Basic self-care activities are referred to as:
a. Activities of daily living
b. Instrumental activities of daily living
c. Necessary activities of daily living
d. Required activities of daily living
a. Activities of daily living
**APEA psychiatry
What geriatric condition is characterized by reduction in physical or mental capacity sufficient to interfere with managing day-to-day tasks.
a. Delirium
b. Cognitive impairment
c. Functional impairment
d. Frailty
c. Functional impairment
**APEA psychiatry
Frailty: A multifactorial geriatric condition or syndrome characterized by an age-related lack of adaptive physiological capacity occurring in the absence of identifiable illness.
Delirium: Serious disturbance in a person’s mental abilities that results in a decreased awareness of one’s environment and confused thinking. In the older adult, it is defined as a geriatric syndrome or condition occurring as a temporary state of confusion and may be the first clue to infection or problems with medications.
Cognitive impairment: intermediate stage between the expected cognitive decline of normal aging and the more serious decline of dementia.
Functional impairment: A health condition in which the normal function of a part of the body is less than full capacity. One of the defining characteristics of functional impairments is that the reduction in physical or mental capacity is sufficient to interfere with managing day-to-day tasks.
Which one of the following findings is not typical in a patient who has delirium?
a. Cerebral dysfunction confirmed on electroencephalogram (EEG)
b. Multiple examinations identify fluctuations in the level of consciousness
c. Alternating periods of confusion with periods of coherence
d. Intact attention and concentration
d. Intact attention and concentration
**APEA psychiatry
Delirium: Acute, abrupt-onset confusional state characterized by the symptoms listed below as well as disorientation, disturbed perception, and emotional disturbances. Serious disturbance in a person’s mental abilities that results in a decreased awareness of one’s environment and confused thinking. In the older adult, it is defined as a geriatric syndrome or condition occurring as a temporary state of confusion and may be the first clue to infection or problems with medications.
Which behavior is NOT an observation of a patient’s affect?
a. Dysphoric mood
b. Flat facial expression
c. Labile demeanor
d. Soft tone of voice
a. Dysphoric mood
**APEA psychiatry
Affect, mood, language, and cognitive function are observed assessments that make up the mental status examination. Affect is a fluctuating pattern of observable behaviors that express feelings or emotions through tone of voice, facial expressions, and demeanor. Mood is a separate assessment of the mental status examination that observes a more pervasive emotion that describes a person’s perception of the world. Language is a complex symbolic system for comprehending words and cognitive function.
Which mental health disorder is characterized by reoccurring thoughts, feelings, images, and sensations that lead to repetitive behaviors?
a. Major depressive disorder (MDD)
b. Generalized anxiety disorder (GAD)
c. Obsessive-compulsive disorder (OCD)
d. Somatic symptom disorder (SSD)
c. Obsessive-compulsive disorder (OCD)
**APEA psychiatry
OCD: Anxiety disorder that causes unwanted repeated thoughts, feelings, images, and sensations (obsessions) and prompts patients to engage in behaviors or mental acts in response to these thoughts or obsessions.
MDD: characterized by an overwhelming feeling of sadness, isolation, and despair lasting 2 weeks or longer.
GAD: Characterized by persistent and excessive worry about a number of different things. People with GAD may anticipate disaster and may be overly concerned about money, health, family, work, or other issues. Patients with GAD find it difficult to control their worry. Somatic symptom disorder (SSD) causes extreme anxiety about physical symptoms such as pain or fatigue. The person has intense thoughts, feelings, and behaviors about the symptoms that interfere with daily life.
Which of the following statements made by a parent would alert the nurse practitioner to suspect autism spectrum disorder?
a. He is negative, disobedient and defiant
b. He acts very impulsively and speaks out of turn
c. He seems to be speaking less and less
d. He can’t sit still for a short story
c. He seems to be speaking less and less
**APEA psychiatry
Communication difficulties are common in the child with autism spectrum disorder. They often speak very little or lose language abilities if early interventions are not started that encourage and build language/communication abilities. The other choices are consistent in children with Attention Deficit Hyperactivity Disorder (ADHD).
Extreme anxiety about physical symptoms (ie. pain or fatigue) that causes intense thoughts and behaviors that interfere with daily life is classified as:
a. Major depressive disorder (MDD)
b. Generalized anxiety disorder (GAD)
c. Obsessive-compulsive disorder (OCD)
d. Somatic symptom disorder (SSD)
d. Somatic symptom disorder (SSD)
**APEA psychiatry
Somatic symptom disorder (SSD): occurs when a person feels extreme anxiety about physical symptoms such as pain or fatigue. The person has intense thoughts, feelings, and behaviors related to the symptoms that interfere with daily life.
The personality disorder characterized by symptoms of instability with self-image, affect, and marked impulsivity is:
a. Histrionic
b. Antisocial
c. Borderline
d. Narcissistic
c. Borderline
**APEA psychiatry
Borderline personality disorder: a pervasive pattern of instability with interpersonal relationships, self-image and affect, as well as marked impulsivity.
A seven-year-old is suspected of having conduct disorder. Which one of the following topics should the nurse practitioner include in the assessment history?
a. Stuttering
b. Animal abuse
c. Worrying excessively about mother
d. Refusing to perform chores.
b. Animal abuse
**Animal abuse is often seen in children who display conduct disorder behaviors and would be a topic of concern if the child was abusing animals. Stuttering, worrying excessively about mother, and refusing to perform chores fall into other behavioral disorders.
When obtaining information from an adolescent who has likely been sexually abused, the most appropriate action initially is to:
a. Notify the parent
b. Call child protective services
c. Ask open-ended questions
d. Tell the adolescent that his/her story will be believed
c. Ask open-ended questions
**APEA psychiatry
The goal of palliative care is to:
a. Initiate discussions for end-of-life decisions
b. Relieve pain
c. Avoid elder abuse
d. Relieve suffering and improve quality of life
d. Relieve suffering and improve quality of life
**APEA psychiatry
It is imperative to assess for suicidality and bipolar disorder in patients suspected of experiencing:
a. Delirium
b. Autism spectrum disorder
c. Depression
d. Attention deficit disorder
c. Depression
**APEA psychiatry
Depression is more common in individuals with significant medical conditions, including several neurologic disorders (dementia, epilepsy, multiple sclerosis, and Parkinson disease). Patients who present with depression may actually have bipolar disorder and so screening should always take place. Patients who are depressed may be suicidal. Consequently, in order for appropriate treatment to occur, appropriate diagnosis must occur.
Which one of the following statements is true of Munchausen Syndrome by Proxy?
a. The injury is self-inflicted as the patient is seeking attention from others
b. Under the supervision of adults other than the abuser, the patient does not exhibit symptoms
c. The caregiver is usually not involved in the abusive behavior
d. The abuser’s behavior reflects a serious psychological disturbance and once the behavior is recognized, the behavior resolves.
b. Under the supervision of adults other than the abuser, the patient does not exhibit symptoms
**APEA psychiatry
If the patient is removed from the caregiver, the symptoms usually resolve and the patient’s condition improves. Self-inflicted injuries are consistent with Munchausen Syndrome. By proxy means someone is inflicting the injury on the victim. The caregivers are most likely the ones involved and the caregiver/abuser’s behavior requires long-term psychiatric treatment and also includes removing the patient from the abuser.
Assessment findings of Russell’s sign is NOT indicative of:
a. Anorexia nervosa
b. Body dysmorphic disorder
c. Bulimia Nervosa
d. Binge eating disorder
b. Body dysmorphic disorder
**APEA psychiatry
Russell’s sign is defined as calluses on the knuckles or back of the hand due to repeated self-induced vomiting over long periods of time. The condition generally arises from the patient’s knuckles making contact with the incisor teeth during the act of inducing the gag reflex at the back of the throat with their finger and is associated with bulimia nervosa, anorexia nervosa, and binge eating disorder. Body dysmorphic disorder (BDD) is a debilitating disorder characterized by obsessions and compulsions relating specifically to perceived appearance
Symptoms of Sundown syndrome may include:
a. Alternating patterns of hyperactivity
b. Impairment in recent and remote memory
c. Cyclic alternating periods of coherence with periods of confusion
d. Vivid and terrifying dreams and nightmares
c. Cyclic alternating periods of coherence with periods of confusion
**APEA psychiatry
Sundown symptoms become evident around sunset each day. Medically, it refers to nocturnal delirium, and is associated with increased disorientation, confusion and agitation in late afternoon. The other symptoms are associated with delirium but not with sundown syndrome.
What is the leading cause of serious injury among U.S. women of reproductive age?
a. Alcohol and illicit drug use
b. Motor vehicle accidents
c. Suicide
d. Intimate partner and domestic violence
d. Intimate partner and domestic violence
**APEA psychiatry
**Intimate partner and domestic violence is the leading cause of serious injury and the second leading cause of death among U.S. women of reproductive age. The U.S preventive services task force recommends routine screening of all women of childbearing age for intimate partner violence and referring those who screen positive to intervention services.
A soldier states that since returning from active duty 2 months ago, he is experiencing sleep disturbance, irritability, low energy, and difficulty with concentration. These findings are consistent with:
a. Adjustment disorder
b. Panic disorder
c. Post-traumatic stress disorder
d. Depression
c. Post-traumatic stress disorder
**PTSD is a constellation of maladaptive symptoms that persist beyond 30 days after exposure to a traumatic event, for example military combat or physical assault. Adjustment, panic, and depression are symptoms related to PTSD
A serious disturbance in a person’s mental abilities that results in a decreased awareness of one’s environment and confused thinking is referred to as:
a. Delirium
b. Cognitive impairment
c. Functional impairment
d. Frailty
a. Delirium
**APEA psychiatry
An example of an alcohol assessment screening tool is the:
a. Kessler 6
b. PHQ-9
c. CAGE
d. A-SSRS
c. CAGE
**APEA psychiatry
The CAGE assessment is a quick questionnaire to help determine if an alcohol assessment is needed. If a person answers yes to two or more questions, a complete assessment is advised. The Kessler 6 and Kessler 10 are mental health screening tools used with a general adult population. Patient Health Questionnaire (PHQ-9) is the most common screening tool to identify depression. The Colombia-Suicide Severity Scale (C-SSRS) is a questionnaire used for suicide assessment
Higher level self-care functioning activities are referred to as:
a. Activities of daily living
b. Instrumental activities of daily living
c. Necessary activities of daily living
d. Required activities of daily living
With the patient lying supine, the NP places her hands behind the patient’s head while flexing his neck forward until his chin touches his chest. Neck stiffness with resistance to flexion is noted. This is positive:
Brudzinski’s Sign
Kernig’s Sign
Nuchal Rigidity
Babinski’s Sign
Nuchal Rigidity
The term used to describe involuntary muscle spasms and twisting limbs is:
Dystonia
Bradykinesia
Akinesia
Dyskinesia
Dystonia
Symptoms of a subdural Hematoma include:
Noticeable bleeding between the dura and skull on X-Ray
Appropriate responses to questions
Noticeable bleeding between the dura and the cerebrum on X-ray
Absent retinal hemorrhages
Noticeable bleeding between the dura and the cerebrum on X-ray
When assessing coordination of muscle movement, four areas of the nervous system function in an integrated way. These areas include the motor, cerebellar, the vestibular, and the sensory systems. Which system coordinates a steady posture?
Motor system
Cerebellar system
Vestibular system
Sensory System
Cerebellar System
An abnormal or unpleasant sense of touch is termed?
Dysarthria
Dysesthesia
Metatarsalgia
Paresthesia
Dysesthesia
An example of tandem walking is having the patient:
Walk across the room
Walk heel-to-toe
Walk on the toes, then on the heels
Walk with a shallow knee bend
Walk heel-to-toe
Having the patient shrug his shoulders and elicit neck movements tests Cranial Nerve:
VI
VIII
IX
XI
XI
Spinal accessory nerve.
The term used to describe a distortion of any sense, especially that of touch, is:
Absence of sensation
Weakness
Dysesthesia
Paresthesia
dysesthesia
Dysesthesia: distortion of any sense, especially that of touch.
Absence of sensation is the inability to feel pain or sensation when touched.
Paresthesia is a sensation of tingling, tickling, prickling, pricking, or burning of a person’s skin
Involuntary rhythmic, repetitive, bizarre movements that chiefly involve the face, mouth, jaw, and tongue are known as:
Facial tics
Dystonic Movements
Athetoid Movements
Oral Facial Dyskinesias
Oral Facial Dyskinesias
Grimacing, pursing the lips, protrusions of the tongue, opening and closing of the mouth, and deviations of the jaw.
The inability to hop in place on each foot could be suggestive of a:
Cerebellar Dysfunction
Corticospinal tract weakness
Proximal tract weakness
Weakness of the quadriceps
Cerebellar Dysfunction
Winging of the scapula can be noted in patients with all of the following conditions except:
Liver disease
Injury to the long thoracic nerve
Muscular dystrophy
Weakness of the serratus anterior muscle
Liver disease
Normally, the scapula lie close to the thorax.
With the adult patient lying supine the NP practitioner flexes the patient’s leg at both the hip and the knee and then straightens the knee. Pain and increased resistance to extending the knee is noted. This is a positive:
Brudzinski’s Sign
Kernig’s Sign
Nuchal Rigidity
Babinski’s Sign
Kernig’s Sign
A discriminative sensation that describes the ability to identify a number drawn in the hand when the patient’s eyes are closed is:
Graphesthesia
Stereognosis
Two point discrimination
Astereognosis
Graphesthesia
A patient is asked to visually follow a finger through the cardinal fields of gaze. Which cranial nerves are being assessed?
I
II, IV
III, IV, VI
V, VI, VII
III, IV, VI
Oculomotor, Trochlear, and abducens
A patient complains of experiencing symptoms of nausea, diaphoresis, and pallor triggered by a fearful or unpleasant event. These symptoms are most likely associated with:
Subarachnoid Hemorrhage
Stroke
Neurocardiogenic Syncope
Vasovagal Syncope
Vasovagal Syncope
By placing the patient in the supine position, the NP raises the patient’s relaxed and straightened leg while flexing the leg at the hip, then dorsiflexes the foot. This maneuver is known as:
Kernig’s Sign
The straight leg raise
The plantar Response
The ankle reflex
The straight leg raise
When evaluating the six cardinal gazes, a loss of conjugate movements is noted when the patient looks to his left. This finding could be consistent with damage to which cranial nerve?
Cranial Nerve II
Cranial Nerve IV
Cranial Nerve V
Cranial Nerve VII
Cranial Nerve IV
When assessing the patient’s sense of position, instruct the patient to first stand with his feet together and eyes open, then instruct him to close both eyes for 30-60 seconds. If he loses his balance with his eyes closed, this is:
Considered a normal finding
Suggestive of ataxia related to dorsal column disease
Suggestive of Cerebellar ataxia
Corticospinal track damage
Suggestive of ataxia related to dorsal column disease
This is also known as Positive Romberg Test suggestive of ataxia
An indication that there is a malfunction of a ventriculoperitoneal (VP) shunt in an older child would be the presence of a:
Headache upon awakening
Temperature greater than 100.8
Noticeable increase in activity
Bulging Fontanels
Headache upon awakening
Headache and projectile vomiting are associated with shunt malfunction as well as signs of increased intracranial pressure.
When evaluating a patient for weakness of the upper extremities, bilateral distal weakness is noted. This could be suggestive of:
Alcohol Myopathy
Polyneuropathy
Myositis
Neuromuscular Junction disorders
Polyneuropathy
Happens in diabetes
Assessment findings in an infant with increased intracranial pressure would include:
Increased Hunger
Drowsiness
Papilledema
Blurred Vision
Drowsiness
Increased ICP includes drowsiness, separated sutures on the skull, bulging fontanel, and vomiting.
When eliciting deep tendon reflexes in the knee, the NP notes an abnormal reflex in the right knee. This abnormality is probably consistent with a pathological lesion in which segmented level of the spine?
Cervical 5 and 6
Cervical 6 and 7
Lumbar 2, 3, and 4
Sacral 1
Lumbar 2, 3, and 4
On examination of the adult patient, symptoms of flexed posture, tremor, rigidity, and shuffling gait are observed. These findings are consistent with:
Drug-Induced reaction
Functional impairment
Parkinson’s disease
Depression
Parkinson’s disease
An infant presents with an inappropriately increasing head circumference and hydrocephalus confirmed by CT scan. In addition to these findings, which one of the following would also be consistent with hydrocephalus?
A soft, low-pitched cry
Ability to be comforted easily
Tense bulging fontanels
Appropriately increasing weight
Tense bulging fontanels
An infant with newly diagnosed hydrocephalus present with a shrill and high-pitched cry.
On Examination of the feet, the NP observes a deep infected lesion on the plantar surface of the left foot. The patient denies pain to touch. He has a history of diabetes. This lesion is most likely:
Plantar Wart
Corn
Callus
Neuropathic Ulcer
Neuropathic Ulcer
It is painless due to diminished or absent pain sensation as seen in diabetic neuropathy.
A form of aphasia where articulation is good but sentences lack meaning is referred to as:
Broca’s aphasia
Anomic Aphasia
Wernicke’s aphasia
global aphasia
Wernicke’s aphasia
Speech is fluent, often rapid, voluble, and effortless.
When assessing an elderly patient for delirium, the recommended instrument with the best supportive data is the:
Delirium Rating Scale
Confusion Assessment Method
Mini Mental State Examiniation
Delirium superimposed on dementia algorithm
Confusion Assessment Method
Provides the best supportive data for bedside use and takes 5 minutes to complete.
A band of skin innervated by the sensory root of a single spinal nerve is termed a:
Peripheral nerve field
Dermatome
Synapse
Asterixis
Dermatome
On physical exam, the soft palate does not rise, there is an absent gag reflex, and the patient complains of taste abnormalities. This requires further evaluation of the:
Hypoglossal Nerve XIII
Facial Nerve VII
Glossopharyngeal Nerve IX
Trigeminal Nerve
Glossopharyngeal Nerve IX
This never assesses swallowing, salivation, taste perception and voice quality
During this type of seizure activity, the patient appears confused. Automatisms include automatic motor behaviors such as chewing, lip smacking, walking about, and unbuttoning clothes. This type is referred to as:
Focal Seizure with impairment of consciousness
Jacksonian Seizure
Focal seizure that become generalized
Grand mal seizure
Focal Seizure with impairment of consciousness
The term used to describe skin that is red over the entire body is:
a. Eschar
b. Erythroderma
c. Excoriation
d. Exfoliation
b. Erythroderma
**Dermatology
Erythroderma occurs when a skin condition affects the whole body or nearly the whole body, resulting in a red appearance all over.
Eschar: Dark-colored adherent crust of dead tissue found on some ulcers
Excoriation: Scratch mark or surface injury penetrating the dermis.
Exfoliation: peeling skin
Which stage of pressure ulcer is consistent with a partial thickness loss of the dermis presenting as a shallow opening ulcer with a red pink wound bed, without slough?
a. Stage I
b. Stage II
c. Stage III
d. Stage IV
b. Stage II
**Dermatology
The term asteatosis refers to:
a. Skin that appears weather beaten, thickened, yellowed, and deeply furrowed
b. Skin that is dry, flaky, rough, and often itchy
c. Raised yellowish lesions that feel greasy and velvety or warty
d. Painful vesicular lesions in a dermatomal distribution
b. Skin that is dry, flaky, rough, and often itchy
**Dermatology
Asteatosis: skin appears dry, flaky, rough, and itchy
Sun Damage: Skin appears weather beaten, thickened, yellowed, and deeply furrowed.
Seborrheic keratoses: appear as raised, yellowish lesions that feel greasy, velvety, or warty.
Herpes zoster: Painful vesicular lesions in a dermatomal distribution
Which stage of pressure is consistent with findings on dermatologic examination of a full thickness tissue loss and subcutaneous fat visible with mild slough on the right hip?
a. Stage I
b. Stage II
c. Stage III
d. Stage IV
c. Stage III
**Dermatology
When examining the skin, multiple areas of circumscribed elevations of the skin filled with serous fluid measuring approximately 0.5 cm were noted. These types of lesions could be seen in:
a. Second degree burns
b. Acne or impetigo
c. Psoriasis or athlete’s foot
d. Herpes simplex or varicella
d. Herpes simplex or varicella
**Dermatology
When the examiner lifts a fold of skin and notes how quickly it returns to place, the examiner is assessing skin:
a. Mobility
b. Turgor
c. Moisture
d. Temperature
b. Turgor
**Dermatology
When assessing the skin, silvery, scaly papules or plaques are noted on the extensor surface of both arms. This could be associated with:
a. Hypothyroidism
b. Hyperthyroidism
c. Psoriasis
d. Scleroderma
c. Psoriasis
**Dermatology
Psoriasis: presents as silvery, scaly papules or plaques, mainly on the extensor surfaces of the skin.
Scleroderma: skin is thickened, taut, and shiny
A patient presents with a full thickness tissue loss with exposed bone and tendon and eschar of the left hip. Which stage of pressure ulcer development is this?
a. Stage I
b. Stage II
c. Stage III
d. Stage IV
d. Stage IV
**Dermatology
On examination, a white discoloration appearing on nails was noted. This is consistent with:
a. Paronychia
b. Onycholysis
c. Leukonychia
d. Psoriasis
c. Leukonychia
**Dermatology
Leukonychia: white discoloration appearing on nails. Most common cause is injury to the base of the nail (the matrix) where the nail is formed.
Psoriasis of the nails: may appear as small pits in the nail
Paronychia: red, swollen, tender inflammation of the nail folds.
Onycholysis: separation of the nail plate from the nail bed. The nail may crumble or break with loosening of the nail plate, usually beginning at the distal edge and progressing proximally.
A yellowish hue imparted to the skin, mucous membrane, or eye is termed:
a. Carotenemia
b. Scleroderma
c. Cafe-au-lait
d. Jaudice
d. Jaudice
**Dermatology
An infant presents with a rash in the diaper area. Which description likely indicates candidal diaper rash?
a. Red, moist, maculopapular patch with poorly defined borders in diaper area
b. Bright red, moist patches with sharply demarcated borders, some loose scales noted in the diaper area.
c. Moist, thin-roofed vesicles with a thin, erythematous base noted in the diaper area
d. Erythematous and symmetric rash noted in the diaper area
b. Bright red, moist patches with sharply demarcated borders, some loose scales noted in the diaper area.
**Dermatology
Candidiasis: characteristic rash appearing with bright red, moist patches with sharply demarcated borders, with some loose scales noted in the diaper area.
Diaper Dermatitis: Red, moist, maculopapular patch with poorly defined borders in diaper area.
Impetigo: Moist, thin-roofed vesicles with a thin, erythematous base.
Hives: erythematous and symmetric and can be generalized over the body, including the diaper area.
When assessing the skin, it is noted to be very dry and cool to touch. This could be associated with:
a. Hypothyroidism
b. Hyperthyroidism
c. Psoriasis
d. Scleroderma
a. Hypothyroidism
Hyperthyroid skin: Velvety appearance and is usually warm to the touch
Hypothyroid skin: Dry, rough skin that is cool to the touch
Psoriasis: presents as silvery, scaly papules or plaques, mainly on the extensor surfaces of the skin.
Scleroderma: skin is thickened, taut, and shiny
When assessing the skin, it is noted to be thickened, taut, and shiny in appearance. This could be associated with:
a. Hypothyroidism
b. Hyperthyroidism
c. Psoriasis
d. Scleroderma
d. Scleroderma
**APEA Dermatology
Psoriasis: presents as silvery, scaly papules or plaques, mainly on the extensor surfaces of the skin.
Scleroderma: skin is thickened, taut, and shiny
Hyperthyroid skin: Velvety appearance and is usually warm to the touch
Hypothyroid skin: Dry, rough skin that is cool to the touch
Which model is used to designate risk factors for melanoma?
a. ABCDE
b. HARMM
c. BCRAT
d. NHANES
b. HARMM
**Dermatology
The National Melanoma/Skin Cancer Screening Program of the American Academy of Dermatology validates the HARMM model for designating risk factors for melanoma.
H- History
A- Age
R- Regular dermatologist absent
M- Mole changing
M- Male gender
ABCDE nomenclature: method used in recognizing characteristics of possible melanomas.
A- Asymmetry
B- Borders
C- Color
D- Diameter
E- Evolution
BCRAT is the breast cancer risk assessment tool.
NHANES: National Health and Nutrition Examination Survey. Used to predict diabetes prevalence
Purple patches or macules on backs of the hands and forearms of the elderly would be suggestive of:
a. Elder abuse
b. Actinic purpura
c. A bleeding disorder
d. Injury from falls
b. Actinic purpura
**Dermatology
Actinic purpura: skin on the backs of the hands and forearms appears thin, fragile, loose, and transparent. There may be purple patches or macules, termed actinic purpura that fade over time. These spots and patches come from blood that has leaked through poorly supported capillaries and spread within the dermis.
A 45-year-old male presents with a skin lesion that has a smooth, slightly scaly, or pebbly surface, with an irregular edge. Further evaluation reveals a dark brown 2.5 cm lesion. This is most likely a:
a. Basal cell carcinoma
b. Melanoma
c. Squamous carcinoma
d. Dysplastic nevus
d. Dysplastic nevus
**Dermatology
Dysplastic Nevus: type of mole that looks different from a common mole. It may be bigger than a common mole, and its color, surface, and border may be different. It is usually more than 5 millimeters wide and can have a mixture of several colors, from pink to dark brown. Usually, it is flat with a smooth, slightly scaly, or pebbly surface, and it has an irregular edge that may fade into the surrounding skin.
Basal Cell Carcinoma: Usually arises in sun-exposed areas and classically appears as pearly erythematous, translucent papules, but may also be subtle red macules or exhibit other morphologies.
Squamous Cell Carcinoma: Crusted hyperkeratotic lesions with a rough surface or flat, reddish patches with an inflamed or ulcerated appearance.
Melanomas: arise from the pigment-producing melanocytes in the epidermis. These melanocytes give skin its color and appear as dark, raised, asymmetric lesions with irregular borders.
The term used to describe dark-colored adherent crust of dead tissue around an ulcer is:
a. Eschar
b. Erythroderma
c. Excoriation
d. Exfoliation
a. Eschar
***Dermatology
Erythroderma occurs when a skin condition affects the whole body or nearly the whole body, resulting in a red appearance all over.
Eschar: Dark-colored adherent crust of dead tissue found on some ulcers
Excoriation: Scratch mark or surface injury penetrating the dermis.
Exfoliation: peeling skin
If a lesion is described as annular, it appears:
a. Circular and begins in center and spreads to periphery
b. As if the lesions run together
c. As distinct, individual lesions that remain separate
d. With concentric rings of color in the lesions
a. Circular and begins in center and spreads to periphery
**Dermatology
Annular Lesions: described as circular lesions that begin in the center and spreads to the periphery as with tinea and ringworm lesions.
Confluent lesions: appear as if the lesions run together and are characteristic of hives.
Discrete lesions: Appear as distinct, individual lesions that remain separate as in acne.
Target lesions: Resemble the iris of the eye and appear with concentric rings of color in the lesions. These are seen in erythema multiforme
A child presents with erythematous papules and vesicles, that are weeping, oozing, and crusty. These lesions are located over the forehead, wrists, elbows, and the backs of the knees. With which of the following conditions are these symptoms associated?
a. An allergic reaction to something
b. Atopic dermatitis
c. Contact dermatitis
d. Psoriasis
b. Atopic dermatitis
**Dermatology
Atopic Dermatitis: presents with erythematous papules and vesicles with weeping, oozing, and crusts. Lesions usually appear in characteristic areas: the scalp, forehead, cheeks, forearms, wrists, elbows, and backs of knees. Paroxysmal and severe pruritus can be present. There is usually a family and/or personal history of allergies.
An allergic reaction to something usually presents with a generalized rash that resembles hives. Erythematous and symmetric rash.
Contact dermatitis: Associated with a reaction in the area that the object touched. Erythema becomes evident initially, followed by swelling, wheals (or urticaria), or maculopapular vesicles, scales. This is often accompanied by intense pruritus.
Psoriasis: presents as silvery, scaly papules or plaques, mainly on the extensor surfaces of the skin.
A slow, persistent fungal infection of fingernails and toenails is:
a. Paronychia
b. Onychomycosis
c. Leukonychia
d. Psoriasis
b. Onychomycosis
**Dermatology
Paronychia: Red, swollen, tender inflammation of the nail folds.
Onychomycosis: slow, persistent fungal infection of fingernails and toenails causing change in color, texture, and thickness. The nail may crumble or break with loosening of the nail plate, usually beginning at the distal edge and progressing proximally.
Leukonychia: White discoloration appearing on nails. The most common cause is injury to the base of the nail (the matrix) where the nail is formed.
Psoriasis of the nails: May appear as small pits in the nail.
A six-year-old child presents with a few small vesicles that are honey-colored and weeping around the left nare. These lesions are consistent with:
a. Impetigo
b. Varicella
c. Herpes simplex
d. Shingles
a. Impetigo
**Dermatology
Impetigo: Moist, thin-roofed vesicles with a thin, erythematous base. Appear as red crusty lesions on the face, especially around a child’s nose and mouth. The lesions burst and develop honey-colored crusts.
Varicella: Characteristic of papules, vesicles, and crusted lesions occurring simultaneously.
Herpes Simplex: On the lips and mouth appear as small vesicles or blisters and are termed “fever blisters” or “cold sores”.
Shingles: Appear as vesicles or blisters in clusters along the entire path of the nerve or in certain areas supplied by the nerve.
On examination of the feet, the nurse practitioner observes a painless thickening of the skin under the ball of the foot. It is tender to direct pressure. This lesion is most likely a:
a. Plantar wart
b. Corn
c. Callus
d. Neuropathic ulcer
c. Callus
**Dermatology
Callus: usually develops on the soles of the feet where the skin is thick and is exposed to constant pressure. It is tender to direct pressure
Plantar wart: Hyperkeratotic lesion caused by human papillomavirus and is usually seen in the sole of the foot. Characteristically, small dark spots give a stippled appearance to a wart and normal skin lines stop at the wart’s edge. Tenderness occurs if pinched side to side.
Corn: Painful conical thickening of skin that results from recurrent pressure on normally thin skin and characteristically occur over bony prominences such as the fifth toe.
Neuropathic ulcer: Appears as a deep, infected, and indolent lesion on the sole of the foot. It is painless due to diminished or absent pain sensation as seen in diabetic neuropathy
On examination of the feet, the nurse practitioner observes a painful thickening of the skin on the bony prominence of the left fifth toe. This lesion is most likely a:
a. Plantar wart
b. Corn
c. Callus
d. Neuropathic ulcer
b. Corn
**APEA dermatology
Callus: usually develops on the soles of the feet where the skin is thick and is exposed to constant pressure. It is tender to direct pressure
Plantar wart: Hyperkeratotic lesion caused by human papillomavirus and is usually seen in the sole of the foot. Characteristically, small dark spots give a stippled appearance to a wart and normal skin lines stop at the wart’s edge. Tenderness occurs if pinched side to side.
Corn: Painful conical thickening of skin that results from recurrent pressure on normally thin skin and characteristically occur over bony prominences such as the fifth toe.
Neuropathic ulcer: Appears as a deep, infected, and indolent lesion on the sole of the foot. It is painless due to diminished or absent pain sensation as seen in diabetic neuropathy
Asymmetry, irregular borders, variations in color, diameter greater than 6 mm, and elevation represent the “ABCDEs” of:
a. Benign nevi
b. Basal cell carcinoma
c. Malignant melanoma
d. Skin tumors
c. Malignant melanoma
**Dermatology
An example of a macule is:
a Psoriasis
b. Impetigo
c. Petechia
d. A nevus
c. Petechia
**Dermatology
Macule: Small, flat spot measuring no larger than 1 cm. Examples are a freckle and petechiae.
Papule: Raised above the level of skin. Example: Nevus
Crust: dried residue of pus, serum, or blood. Example: Impetigo
Scale: Thin flake of exfoliated epidermis. Dandruff, dry skin, and psoriasis are examples.
Pressure ulcers, decubitus ulcers, develop over all of the following body parts except the:
a. Sacrum
b. Gluteus maximus
c. Ischial tuberosities
d. Greater trochanters
b. Gluteus maximus
**Dermatology
Skin conditions such as pruritis, hyperpigmentation, and calciphylaxis may be seen in patients who have:
a. Diabetes
b. Chronic renal failure
c. Hyperthyroidism
d. Liver disease
b. Chronic renal failure
Skin conditions in chronic renal failure include: Pallor, xerosis, pruritus, hyperpigmentation, uremic frost, calciphylaxis, “half & half” nails.
The term used to refer to skin that is peeling is:
a. Eschar
b. Erythroderma
c. Excoriation
d. Exfoliation
d. Exfoliation
**Dermatology
A raised, crusted border with central ulceration on the helix is identified. This lesion needs further evaluation because it is most likely:
a. A basal cell carcinoma
b. A squamous cell carcinoma
c. Cutaneous cyst
d. Chondrodermatitis nodularis helicus
b. A squamous cell carcinoma
**Dermatology
Cutaneous Cyst: Benign, closed sac that lies in the dermis, forming a dome shaped lump.
Chondrodermatitis Nodularis Helicis: a condition with painful nodules that develop on the rim of the helix (where there is no subcutaneous tissue). This develops as a result of repetitive mechanical pressure or environmental trauma (sunlight). They are small, indurated, dull red, poorly defined, and painful.
Basal Cell Carcinoma: Red raised nodule with a lustrous surface and telangiectatic vessels with or without ulceration. Usually arises in sun-exposed areas and classically appears as pearly erythematous, translucent papules, but may also be subtle red macules or exhibit other morphologies.
Squamous Cell Carcinoma: Raised, crusted border with central ulceration on the lesion. Crusted hyperkeratotic lesions with a rough surface or flat, reddish patches with an inflamed or ulcerated appearance.
An inflammation of the proximal and lateral nail folds represents:
a. Paronychia
b. Onychomycosis
c. Psoriasis
d. Leukonychia
a. Paronychia
**Dermatology
Paronychia: Red, swollen, tender inflammation of the nail folds. Acute paronychia is usually secondary to a bacterial infection. Chronic paronychia is often secondary to a fungal infection from a break in the cuticle in those who perform “wet” work.
Onychomycosis: A slow, persistent fungal infection of fingernails and toenails causing change in color, texture, and thickness. The nail may crumble or break with loosening of the nail plate, usually beginning at the distal edge and progressing proximally.
Leukonychia: A white discoloration appearing on the nails. The most common cause is injury to the base of the nail (the matrix) where the nail is formed.
Psoriasis of the nails may appear as small pits in the nails.
Transverse depressions of the nail plates, usually bilateral, resulting from temporary disruption of proximal nail growth from systemic illness is termed:
a. Terry’s nails
b. Beau’s lines
c. Mees’ lines
d. Pitting nails
b. Beau’s lines
**APEA Dermatology
Beau’s Lines: Deep grooved lines that run from side-to-side on the fingernail. They appear as transverse depressions of the nail plates, usually bilateral, resulting from temporary disruption of proximal nail growth from systemic illness, such as severe illness, cold stress in the presence of Reynaud’s disease, and trauma.
Terry’s Nails: The nail plate turns white with a ground-glass appearance, a distal band of reddish brown, and obliteration of the lunula.
Mees’ lines present as curving transverse white bands that cross the nail parallel to the lunula. They arise from the disrupted matrix of the proximal nail, vary in width, and move distally as the nail grows out. These lines are seen in arsenic poisoning, heart failure, Hodgkin’s disease, chemotherapy, carbon monoxide poisoning, and leprosy.
Pitting nails present as punctate depressions of the nail plate caused by defective layering of the superficial nail plate by the proximal nail matrix. They may be associated with psoriasis, but are also seen in Reiter’s syndrome, sarcoidosis, alopecia areata, and localized atopic or chemical dermatitis.
Ticks can transmit and cause:
a. Impetigo, staph infections, and psoriasis
b. Candidiasis, scabies, and tinea capitis
c. Rocky Mountain spotted fever, Lyme disease, tularemia
d. Lice, roundworms, and hookworms
c. Rocky Mountain spotted fever, Lyme disease, tularemia
**APEA dermatology
A dark, raised, asymmetric lesion with irregular borders may be:
a. A comedone
b. Actinic keratosis
c. A melanoma
d. Actinic purpura
c. A melanoma
**APEA dermatology
An adolescent is being examined for acne and findings revealed several closed comedones. These findings are also termed:
a. whiteheads
b. blackheads
c. pustules
d. cysts
a. whiteheads
**APEA Dermatology
A patient is observed to have pressure related alteration of intact skin along with changes in temperature, consistency, sensation, and color. Which stage of pressure ulcer is consistent with this?
a. Stage I
b. Stage II
c. Stage III
d. Stage IV
a. Stage I
**APEA Dermatology
Depigmented macules appearing on the face, hands, feet, and other parts of the body due to the lack of melanin are termed:
a. Tinea versicolor
b. Vitiligo
c. Cafe-au-lait spots
d. Tinea corporis
b. Vitiligo
**APEA dermatology
When examining the left ear, a raised nodule behind the ear is noted to have a lustrous surface with visible telangiectatic vessels in the center. This lesion needs further evaluation because it is most likely:
a. Squamous cell carcinoma
b. A cutaneous cyst
c. Basal cell carcinoma
d. Tophi
c. Basal cell carcinoma
**APEA dermatology
Cutaneous Cyst: Benign, closed sac that lies in the dermis, forming a dome shaped lump.
Basal Cell Carcinoma: Red raised nodule with a lustrous surface and telangiectatic vessels with or without ulceration. Usually arises in sun-exposed areas and classically appears as pearly erythematous, translucent papules, but may also be subtle red macules or exhibit other morphologies.
Squamous Cell Carcinoma: Raised, crusted border with central ulceration on the lesion. Crusted hyperkeratotic lesions with a rough surface or flat, reddish patches with an inflamed or ulcerated appearance.
Tophi: Deposits of uric acid crystals secondary to gout and appear as hard nodules in the helix or antihelix
To assess skin temperature, the examiner would use the:
a. Palmar surface of the hand
b. Dorsal surface of the hand
c. Fingertips
d. Oral thermometer
b. Dorsal surface of the hand
**APEA dermatology
Lesions that develop within hair follicles produce papules that become erythematous, and painful are termed:
a. Vesicles
b. Furuncles
c. Nevi
d. Ulcers
b. Furuncles
**APEA dermatology
Vesicles: Also known as blisters. Small lesions filled with a clear fluid.
Furuncles: Also known as boils. Painful lesions that develop within hair follicles. They usually begin as papules on the skin, then develop a white or soft center.
Nevi/Nevus: Moles. Pigmented area on the epidermis.
Ulcers: Occurs on the skin or a mucous membrane accompanied by the disintegration of tissue.
A patient has a papule with an ulcerated center on the lower lid and medial canthus of the eye. This is consistent with:
a. Dacryocystitis
b. A hordeolum or stye
c. A chalazion
d. A basal cell carcinoma
d. Basal cell carcinoma
**APEA dermatology
Basal Cell Carcinoma of Eyelid: Uncommon. Occurs most often on the lower lid and medial canthus. It looks like a papule with an ulcerated center. Metastasis is rare but should be referred for removal.
Dacrocystitis: An infection and blockage of the lacrimal sac and duct
Hordeolum: Often secondary to localized staphylococcal infection of the hair follicles at the lid margin.
Chalazion: beady nodule protruding on the lid.
A reddish blue, irregularly shaped, solid and spongy mass of blood vessels that may be present at birth and enlarge during the first 10-15 months is characteristic of a:
a. Cavernous hemangioma
b. Strawberry mark
c. Telangiectasia
d. Port-wine stain
a. Cavernous hemangioma
**APEA dermatology
Cavernous Hemangioma: Appears as a reddish blue, irregularly shaped, solid and spongy mass of blood vessels. It may be present at birth, may enlarge during the first 10-15 months, and will not involute spontaneously
Strawberry Mark: A type of hemangioma that has a raised bright red area with well-defined borders about 2-3 cm in diameter. It does not blanch with pressure.
Telangiectasia: Caused by vascular dilation and are permanently dilated blood vessels that are visible on the skin surface.
Port-Wine Stain: A large, flat, macular dark red or purplish patch covering the scalp or face, frequently along the distribution of cranial nerve V and intensifies with crying, exertion, or exposure to heat or cold.
The assessment findings of the integumentary system of an 80-year-old that would warrant further evaluation would include:
a. Several brown macular spots on the hands and arms
b. Ecchymoses on both forearms
c. Seborrheic keratoses on the scalp
d. Cherry angiomas on the trunk
b. Ecchymoses on both forearms
**APEA dermatology
Ecchymoses in the elderly is not a sign of aging and should be evaluated for injury or abuse.
Brown macular spots, age spots, on the hands are related to sun exposure
Seborrheic keratoses: thickened lesions on the skin that range from tan to brown to black with a clear border and develop on the trunk but can also occur on the hands, feet, face, and scalp. Not considered harmful
Cherry angiomas: Common type of skin lesion that first occurs in early adulthood and continues with age. These round lesions typically develop on the trunk, hands, and feet. They range from bright to dark red and are asymptomatic with no reported clinical consequences.
When the term rubor is used in describing the skin, it means that the appearance is:
a. Elastic
b. Dusky red
c. Excoriated
d. Excessively dry
b. Dusky red
**APEA dermatology
A child has a maculopapular, blotchy rash and on examination of his mouth, red eruptions with white centers on the buccal mucosa are visualized. These eruptions are called:
a. Rubella spots
b. Aphthous ulcers
c. Pastia’s spots
d. Koplik spots
D. Koplik spots
**APEA dermatology
Koplik Spots: Seen with measles. They are small, white spots (often on a reddened background that occur on the inside of the cheeks early in the course of red measles, rubeola.
Pastia’s Spots: Pink or red lines that are formed of confluent petechiae found in skin creases and are seen in patients who have scarlet fever.
Aphthous ulcers are recurrent small, round, or ovoid ulcers with circumscribed margins, erythematous haloes, and yellow or gray floors occurring in the mouth
The patient has recently sustained an injury to the upper thigh. Examination reveals an irregular shaped purplish blue lesion that does not blanch with pressure and does not exhibit pulsatility. This would be considered:
a. Petechia
b. Ecchymosis
c. Purpura
d. A spider vein
b. Ecchymosis
**APEA dermatology
Ecchymosis: Purple or bluish purple area that fades to green, yellow, and brown with time. It is generally larger than petechia and can be round, oval, or take on an irregular shape. It does not blanch with pressure and does not pulsate. These lesions are termed bruises and occur secondary to trauma.
Petechia and purpura are deep red or reddish purple and fade with time.
Spider vein: Bluish in color and mostly seen on the legs near veins
A 45-year-old male presents with a skin lesion that has a smooth, slightly scaly, or pebbly surface, with an irregular edge. Further evaluation reveals a dark brown 2.5 cm lesion. This is most likely a:
a. Basal cell carcinoma
b. Melanoma
c. Squamous carcinoma
d. Dysplastic nevus
d. Dysplastic nevus
**APEA dermatology
A small child sustained burns to the posterior trunk and posterior surface of both arms. According to the “Rule of Nines” for small children, what percentage of the total body surface area was involved?
a. 9%
b. 18%
c. 27%
d. 32.5%
c. 27%
**APEA dermatology
When a patient complains of joint pain as progressing from one joint to another, the examiner should consider this pattern of involvement as migratory. This type of involvement would most likely be observed in a patient who has:
a. Gout
b. Rheumatic fever
c. Bursitis
d. Osteomyelitis
B. Rheumatic fever
**APEA Orthopedics
Gout: Usually involves one joint and typically affects the first toe.
Migratory pattern. Pain migrates from joint to joint or steadily spreading from one joint to multiple joints. Examples of this type of joint pain migration is seen in patients who have rheumatic fever or gonococcal arthritis.
Bursitis: Consistent with extra-articular pain that occurs in inflammatory conditions
Osteomyelitis: Usually presents suddenly with a swollen joint and pain. This is more commonly seen in children.
On examination of the shoulder, tenderness is noted just below the tip of the acromion with pain on abduction and rotation and loss of smooth movement. This finding could be suggestive of:
a. Septic arthritis
b. Subacromial bursitis
c. Synovitis
d. Rotator cuff tear
b. Subacromial bursitis
**APEA Orthopedics
When performing a musculoskeletal examination, the nurse practitioner instructs the patient to move his arm in front of himself and overhead. This motion of the shoulder girdle would be an example of:
a. Adduction
b. Abduction
c. Flexion
d. Extension
c. Flexion
**APEA Orthopedics
A dislocation of the elbow joint caused by the sudden pull on the extended pronated forearm is referred to as:
a. Golfer’s elbow
b. Tennis elbow
c. Nursemaid’s elbow
d. Quarterback elbow
c. Nursemaid’s elbow.
**APEA Orthopedics
Golfer’s Elbow: Medial epicondylitis. Also known as pitcher’s elbow. Tenderness over the median epicondyle
Lateral Epicondylitis: Tennis Elbow or Quarterback Elbow. Tenderness with or without effusion over the olecranon process and the lateral epicondyle.
Nursemaid’s Elbow: A dislocation of the elbow joint caused by the sudden pull on the extended pronated forearm
A defect in the gastrocnemius and soleus muscles with tenderness and swelling could be suggestive of:
a. Osteoarthritis
b. Fibromyalgia Syndrome
c. Achilles tendinitis
d. A ruptured Achilles tendon
d. A ruptured Achilles tendon
**APEA orthopedics
Ruptured Achilles Tendon: A defect in the gastrocnemius and soleus muscles with tenderness and swelling
Achilles Tendinitis: Tenderness and thickening of the tendon above the calcaneus, sometimes with a protuberant posterolateral bony process of the calcaneus.
Fibromyalgia and osteoarthritis do not usually exhibit tenderness and swelling in these muscles
Restrictions of internal and external rotation of the hip are sensitive indicators of:
a. Lumbar lordosis
b. Arthritis
c. Scoliosis
d. Kyphosis
b. Arthritis
**APEA orthopedics
Tenderness over the sacroiliac joint is commonly noted in patients with:
a. Arthritis
b. Spondylolisthesis
c. Ankylosing spondylitis
d. Thoracic kyphosis
c. Ankylosing spondylitis
**APEA orthopedics
When performing a spinal exam, the nurse practitioner noted the appearance of poor posture and a “hump” appearance of the upper back. This finding could be suggestive of:
a. A spinal compression
b. Scoliosis
c. A vertebral fracture
d. Thoracic kyphosis
d. Thoracic kyphosis
**APEA orthopedic
Thoracic kyphosis: Presents with back pain and stiffness as well as a curvature of the thoracic spine
Scoliosis: Presents with lateral curvature of the spine
Vertebral fracture: Vertebral tenderness
Spinal compression: Back pain, muscle weakness, bowel or bladder impairment
To test the thumb for abduction, ask the patient to:
a. Move his thumb across his palm and touch the base of the fifth finger.
b. Move his thumb from the base of the fifth finger and then as far away from the palm as possible.
c. Touch the thumb to each of the other fingertips
d. Place the fingers and thumbs in the neutral position with the palm up and them move the thumb anteriorly away from the palm.
d. Place the fingers and thumbs in the neutral position with the palm up and them move the thumb anteriorly away from the palm.
**APEA orthopedic
Abduction: Place the fingers and thumbs in the neutral position with the palm up and moving the thumb anteriorly away from the palm assesses abduction.
Flexion: Ask the patient to move thumb to touch the base of the fifth finger
Extension: Ask the patient to move thumb from the base of fifth finger, across the palm, and then as far away from the palm as possible.
Opposition: Touching the thumb to each of the other fingers
Adduction: Moving the thumb back to its neutral position assesses adduction
With the patient in the dorsal decubitus position, have him slowly extend the knee while maintaining the varus stress and external rotation. If a snap on the medial joint line is palpated, this may indicate a positive test for a:
a. Lateral collateral ligament (LCL) tear
b. Medial collateral ligament (MCL) tear
c. Posterior cruciate ligament (PCL) tear
d. Medial meniscal tear
d. Medial meniscal tear
**APEA Orthopedic
Lateral collateral ligament (LCL) tear: Assessed with the Adduction (Varus) Stress Test.
Medial collateral ligament (MCL) tear: Assessed with the Abduction (Valgus) Stress Test
Posterior cruciate ligament (PCL) tear: Tested with the Drawer Sign
Medial meniscal tear: Test by placing patient in dorsal decubitus position. Have them slowly extend the knee while maintaining the varus stress and external rotation. If a snap on the medial joint line is palpated, this may be a positive test. (McMurray Test)
Contracture of the sternocleidomastoid muscle could result in lateral deviation and rotation of the head. This is suggestive of:
a. Arthritis
b. Torticollis
c. Spondylolisthesis
d. Thoracic kyphosis
b. Torticollis
**APEA Orthopedic
Passive flexion, valgus stress, and internal rotation of the lower leg, evaluates the:
a. Medial meniscus
b. Lateral meniscus
c. Lateral collateral ligament (LCL)
d. Posterior cruciate ligament (PCL)
A. Medial meniscus
**APEA orthopedic
The medial and lateral meniscus are crescent-shaped cartilage in the knee joint. These ligaments rest between the femur and the tibia. The medial meniscus is located on the inside, or medial, side of the knee. McMurray Test: Passive flexion, valgus stress, and internal rotation of the lower leg evaluates the medial meniscus. The McMurray test performed with passive flexion, varus stress, and external rotation of the lower leg evaluates the lateral meniscus.
When testing hand grip strength on a patient, the nurse practitioner asks the patient to squeeze which finger(s)?
a. Index finger
b. Second and third fingers
c. Third and fourth fingers
d. Entire hand
b. Second and third fingers
**APEA orthopedic
Physical signs associated with cervical radiculopathy from nerve root compression include:
a. Weakness in the triceps and finger flexors and extensors
b. Decreased cervical range of motion
c. Neck flexion with resulting sensation of electrical shock radiating down the spine
d. Local neck muscle tenderness
a. Weakness in the triceps and finger flexors and extensors
**APEA Orthopedics
Cervical Radiculopathy: from nerve root compression. Physical signs include weakness in the triceps and finger flexors and extensors.
Cervical myelopathy: from cervical cord compression. Physical signs include hyperreflexia, clonus at the wrist, knee, or ankle, gait disturbances, and a positive Lhermitte’s sign (neck flexion with resulting sensation of electrical shock radiating down the spine).
Mechanical neck pain: local neck muscle tenderness.
A small, tuberculated eminence, curved a little forward, and giving attachment to the radial collateral ligament of the elbow-joint is referred to as the:
a. Dorsal epicondyle of the humerus
b. Ventral epicondyle of the humerus
c. Lateral epicondyle of the humerus
d. Anterior epicondyle of the humerus
c. Lateral epicondyle of the humerus
A 64-year-old man complains of worsening pain that radiates from the right buttock to the posterior upper thigh. This is a common complaint associated with:
a. Osteoporosis
b. Degenerative disc disease (DDD)
c. Sciatica
d. Cauda equina
c. Sciatica
Sciatica is characterized as a constant pain in one side of the buttock that radiates to the leg. The pain worsens while sitting.
Osteoporosis: Patients with osteoporosis have no symptoms until bone fracture occurs.
Degenerative disc disease (DDD): Chronic lower back or neck pain and spasms.
Cauda equina: Lower back pain, weakness, numbness of lower extremities, and possible loss of bladder control.
With the patient standing and the examiner sitting in the chair, the examiner should observe:
a. Alignment of the legs and feet
b. The abdomen
c. The rectum
d. The axillary lymph nodes
a. Alignment of the legs and feet
On examination of the foot, the nurse practitioner notes acute inflammation of the first metatarsophalangeal joint. This finding could be consistent with:
a. Achilles tendinitis
b. Gout
c. A ligamentous injury
d. Rheumatoid arthritis
b. Gout
The nerve that provides sensation to the dorsal web of the thumb and index finger is the:
a. Ulnar nerve
b. Radial nerve
c. Median nerve
d. Flexor retinaculum
b. Radial nerve
**APEA Orthopedics
Radial Nerve: Innervates the dorsal web space of the thumb and index finger.
Ulnar Nerve: Innervates half of the fourth digit and the entire fifth digit.
Median Nerve: Provides sensation to the palm and palmar surface of most of the thumb, second and third fingers, and half of the fourth digit.
When performing a spinal exam, the patient complains of vertebral tenderness. This finding could be suggestive of:
a. A spinal compression
b. Sacroiliitis
c. A vertebral fracture
d. Thoracic Kyphosis
c. A vertebral fracture
**APEA Orthopedics
A six-year-old male complains of ankle pain and difficulty walking but denies any recent injuries. Findings reveal ankle tenderness, decreased mobility and range of motion. The patient’s temperature is 102 degrees F. These findings are consistent with:
a. A fractured ankle
b. Early onset of Paget’s Disease
c. Osteomyelitis
d. Osteoporosis
c. Osteomyelitis
When examining the foot of a patient, the nurse practitioner notes a bony projection along the edge of the right calcaneus with minimal pain and tenderness to touch. This could be suggestive of:
a. A bone spur
b. Plantar fasciitis
c. A ligamentous injury
d. Tibial tendinitis
a. A bone spur
Which one of the following conditions can plantar fasciitis be associated?
a. Achilles tendinitis
b. An ankle fracture
c. A ligamentous injury
d. Rheumatoid arthritis
d. Rheumatoid arthritis
When examining the elbow for range of motion, the nurse practitioner instructs the patient to turn his palm upward. This motion is an example of:
a. Extension
b. Flexion
c. Supination
d. Pronation
c. Supination
When performing an examination of a painful left hip on an adult, there is a palpable bogginess over the area. This finding is referred to as:
a. Edema
b. Tissue tenderness
c. Crepitus
d. Synovitis
d. Synovitis
Blue sclera, weak muscles, and increased joint flexibility during a newborn assessment may be suggestive of:
a. Marfan’s syndrome
b. Muscular dystrophy
c. Osteogenesis imperfecta
d. Retinopathy of the newborn
c. Osteogenesis imperfecta
On examination of a six-week-old infant, developmental hip dysplasia (DDH) is suspected. If DHH is present, it might be evidenced by:
a. Symmetrical gluteal folds
b. Limited abduction of the affected leg
c. Limited adduction of the affected leg
d. Lordosis
b. Limited abduction of the affected leg
Olecranon bursitis may be caused by all of the following except:
a. Gout
b. Trauma
c. Frozen shoulder
d. Osteoarthritis
c. Frozen shoulder
After attempting to elicit the Moro reflex in a newborn, the nurse practitioner identifies absence of movement of the left arm. The next assessment would be to:
a. Perform the Ortolani maneuver
b. Elicit the Babinski reflex
c. Examine the clavicle
d. Check the brachial pulses
c. Examine the clavicle
What test is performed when the nurse practitioner instructs the patient to hold his wrist in flexion for 60 seconds while pressing the backs of his hands together to form right angles?
a. Finkelstein’s test
b. Tinel’s test
c. Phalen’s test
d. Thumb abduction
c. Phalen’s test
The Lachman Test is used to assess the instability of the
a. Anterior cruciate ligament (ACL)
b. Posterior cruciate ligament (PCL)
c. Lateral collateral ligament (LCL)
d. Medial collateral ligament (MCL)
a. Anterior cruciate ligament (ACL)
Anterior Cruciate Ligament (ACL): Lachman Test is used to assess instability. The knee is passively held in 30 degrees of flexion and the patient is asked to relax. With one hand, the distal femur is stabilized and with the other hand a gentle anterior force on the proximal tibia is applied. Comparison with the contralateral knee is essential.
Women who wear high-heeled shoes with narrow toe boxes are at risk for developing all of the following forefoot abnormalities except:
a. Hallux valgus
b. Metatarsalgia
c. Achilles tendinitis
d. Morton’s neuroma
c. Achilles tendinitis
The nurse practitioner instructs the patient to bend forward and try to touch his toes. This maneuver would elicit:
a. Flexion of the lumbar spine
b. Extension of the lumbar spine
c. Lateral movement of the lumbar spine
d. Rotation of the lumbar spine
a. Flexion of the lumbar spine
Stiffness in a joint and limited motion after inactivity is commonly referred to as
a. Pseudoclaudication
b. Gelling
c. Diffuse idiopathic hyperostosis
d. Sciatica
b. Gelling
Vasculitis on the extremities and an erythematous to salmon-colored rash over the trunk are skin lesions that may be attributed to:
a. Scleroderma
b. Rheumatoid arthritis
c. Systemic Lupus Erythematosus (SLE)
d. Thrombocytopenic purpura
b. Rheumatoid arthritis
A decrease in the amount of density in a bone is referred to as:
a. Osteopenia
b. Osteoporosis
c. Osteomyelitis
d. Osteoarthritis
a. Osteopenia
Metatarsalgia is a term used to describe:
a. Inflammation of the metatarsophalangeal joint
b. Pain in the metatarsals and the phalanges
c. Pain and tenderness in the metatarsals
d. Pain at the junction of the tibia and the talus
c. Pain and tenderness in the metatarsals
Metatarsalgia: Term used to describe pain and tenderness in the metatarsals. Activities such as running and jumping and wearing ill-fitting shoes can cause this condition
A condition resulting from a forceful throwing motion and causing the shoulder to “slip out of the joint” when the arm is abducted and externally rotated is known as:
a. Acromioclavicular arthritis
b. Adhesive capsulitis
c. Anterior dislocation of the humerus
d. Frozen shoulder
c. Anterior dislocation of the humerus
A normal finding in the musculoskeletal assessment of a 3-year-old child would be presence of:
a. A C-shaped spine
b. Genu varum
c. Genu Valgum
d. Club foot
c. Genu Valgum
Genu-Valgum: “Knock Knees”: Normal for children around age 3, usually not treated unless it continues after age 7, then a night brace may be used.
Genu Varum: “Bow legged”: Normal in infants because of their folded position in the mother’s womb. Legs begin to straighten once the child starts to walk (about 12-18 months)
When observing for thenar atrophy of the hands, a typical observation is:
a. Furrowing in the spaces between the metacarpals
b. Thenar eminences appear full
c. The hypothenar eminences would appear convex
d. The spaces between the metacarpals would be slightly depressed.
a. Furrowing in the spaces between the metacarpals
To test the anterior and lateral deltoid, pectoralis major, coracobrachialis and biceps brachii muscles, the nurse practitioner would have the patient perform which shoulder movement?
a. Adduction
b. Abduction
c. Flexion
d. Extension
c. Flexion
Tenderness over the scapulohumeral muscle group with the inability to abduct the arm above the shoulder level would be consistent with all of the following conditions except:
a. Sprains
b. Tears
c. Tendon rupture of the rotator cuff
d. Synovitis of the glenhumeral joint
d. Synovitis of the glenhumeral joint
When examining the ankle and foot, the nurse practitioner moves the proximal phalanx of each toe up and down. This maneuver assesses the:
a. Talocalcaneal joint
b. Tibiotalar joint
c. Transverse tarsal joint
d. Metatarsophalangeal joint
d. Metatarsophalangeal joint
Tenderness at cervical vertebrae 1 - 2 (C1-2) in a patient with rheumatoid arthritis suggests possible risk for:
a. Scoliosis
b. Subluxation
c. Kyphosis
d. Ankylosing spondylitis
b. Subluxation
Tenderness at cervical vertebrae 1-2 (C1-2) in a patient with rheumatoid arthritis suggests possible risk for subluxation and high cervical cord compression. This condition would need prompt attention.
The nurse practitioner instructs the patient to move his extended fingers so that each touches its nearest finger. This motion assesses the fingers and thumbs for:
a. Adduction
b. Abduction
c. Flexion
d. Extension
a. Adduction
The hamstring muscles flex the knee and are located on the:
a. Anterior aspect of the thigh
b. Posterior aspect of the thigh
c. Medial aspect of the thigh
d. Lateral aspect of the thigh
b. Posterior aspect of the thigh
When grading muscle strength, a grade of two would indicate:
a. No muscular contraction detected
b. Barely detectable trace of contraction
c. Active movement of the body part with gravity eliminated
d. Active movement against gravity with some resistance.
c. Active movement of the body part with gravity eliminated
While evaluating the thumb, ask the patient to point his thumb upward as the nurse practitioner applies downward resistance. This maneuver tests:
a. Finkelstein’s test
b. Tinel’s test
c. Phalen’s test
d. Thumb abduction
d. Thumb abduction
A patient experienced a neck injury yesterday and presents to the nurse practitioner with aching paracervical pain and stiffness. Other complaints include dizziness, malaise, and fatigue. These findings may be associated with:
a. Mechanical neck pain
b. Mechanical neck pain with whiplash
c. Cervical radiculopathy
d. Cervical myelopathy
b. Mechanical neck pain with whiplash
Mechanical Neck Pain with Whiplash: Paracervical pain and stiffness begins the day after injury and may be accompanied by occipital headaches, dizziness, and malaise.
Mechanical Neck Pain: Aching pain in the cervical paraspinal muscles and ligaments with associated muscle spasm, stiffness, and tightness in the upper back and shoulder, lasting up to 6 weeks.
Cervical Radiculopathy: Nerve root compression is the etiology. Symptoms may include sharp burning or tingling pain in the neck and one arm with associated paresthesias.
Cervical myelopathy (Cervical cord compression): The neck pain is associated with bilateral weakness and paresthesias in both upper and lower extremities.
When screening for scoliosis, assessment should include:
a. Measuring and comparing the length of the child’s legs
b. Obtaining x-rays of the spine
c. Observing the back while the child is bending forward
d. Asking the child to touch the thigh to the abdomen
c. Observing the back while the child is bending forward
A patient complains of shooting pain below the knee radiating into the lateral leg and calf. This type of low back pain is referred to as:
a. Radicular low back pain
b. Mechanical low back pain
c. Lumbar spinal stenosis
d. Pseudoclaudication pain
a. Radicular low back pain
Sciatica (Radicular low back pain) is characterized as a constant pain in one side of the buttock that radiates to the leg. The pain worsens while sitting. Shooting pains below the knee, into the lateral leg or posterior calf. It may be accompanied by paresthesias and/or weakness in the affected leg. Mechanical low back pain: Often arises from muscle and ligament injuries or age-related intervertebral disc or facet disease. Common symptoms include aching pain in the lumbosacral area that radiates to the upper leg. Common risk factors include heavy lifting, poor conditioning, and obesity.
Lumbar Spinal Stenosis (Pseudoclaudication): Refers to pain in the back or legs with walking that improves with rest, lumbar flexion, or both.
When describing muscle strength, the term paraplegia means:
a. Impaired strength
b. Absence of strength
c. Paralysis of all four extremities
d. Paralysis of the legs
d. Paralysis of the legs
Joint pain that is localized and involves one joint, would be documented as:
a. Polyarticular joint pain
b. Extra-articular joint pain
c. Monoarticular joint pain
d. Radicular pain
c. Monoarticular joint pain
A patient complains of a sharp burning pain in the neck and right arm with associated paresthesia’s and weakness. These symptoms may be associated with:
a. Mechanical neck pain
b. Mechanical neck pain with whiplash
c. Cervical radiculopathy
d. Cervical myelopathy
c. Cervical radiculopathy
Cervical Radiculopathy: from nerve root compression. Physical signs include weakness in the triceps and finger flexors and extensors.
Cervical myelopathy: from cervical cord compression. Physical signs include hyperreflexia, clonus at the wrist, knee, or ankle, gait disturbances, and a positive Lhermitte’s sign (neck flexion with resulting sensation of electrical shock radiating down the spine).
Mechanical Neck Pain with Whiplash: Paracervical pain and stiffness begins the day after injury and may be accompanied by occipital headaches, dizziness, and malaise.
Mechanical Neck Pain: Aching pain in the cervical paraspinal muscles and ligaments with associated muscle spasm, stiffness, and tightness in the upper back and shoulder, lasting up to 6 weeks.
When performing a musculoskeletal examination, the nurse practitioner instructs the patient to move his arm behind himself. This motion of the shoulder girdle would be an example of:
a. Adduction
b. Abduction
c. Flexion
d. Extension
d. Extension
SHOULDER ROM
Adduction: Patient crosses arm in front of their body.
Abduction: Patient moves arms away from the body laterally and overhead
Flexion: Move arm forward in front and overhead. Tests the anterior and lateral deltoid, pectoralis major, coracobrachialis and biceps brachii muscles.
Extension: Patient moves arm behind themself
To palpate the medial meniscus, slightly internally rotate the tibia and palpate the medial soft tissue along the:
a. Lateral joint line of the knee
b. On either side of the patella
c. Upper edge of the tibial plateau
d. Top of the patella
c. Upper edge of the tibial plateau
Medial Meniscus: Palpate by slightly internally rotating the tibia and palpating the medial soft tissue along the upper edge of the tibial plateau.
Lateral Meniscus: Palpated on the lateral joint line by placing the patient’s knee in slight flexion.
Tibiofemoral joint: Palpate by facing the patient’s knee and placing the thumbs in the soft tissue depressions on either side of the patellar tendon.
A popliteal or “baker’s” cyst arises from:
a. Excessive running
b. Fibromyalgia
c. Excessive kneeling
d. Trauma
d. Trauma
Popliteal or “Baker’s” cyst: Arises from distention of the gastrocnemius semimembranous bursa from underlying arthritis or trauma.
Anserine bursitis arises from running, valgus knee deformity, fibromyalgias, and osteoarthritis
Prepatellar bursitis “housemaid’s knee” arises from excessive kneeling.
When grading muscle strength, a five would indicate:
a. No muscular contraction detected
b. Barely detectable trace of contraction
c. Active movement of the body part with gravity eliminated
d. Active movement against full resistance without fatigue
d. Active movement against full resistance without fatigue
The gastrocnemius and soleus muscles are located by palpating the:
a. Anterior surface of the lower leg
b. Anterior surface of the upper leg
c. Posterior surface of the upper leg
d. Posterior surface of the lower leg
d. Posterior surface of the lower leg
Which of the following symptoms would be suggestive of lumbar spinal stenosis?
a. Calf wasting
b. Thich pain after 30 seconds of lumbar extension
c. Absent ankle jerk
d. Loss of normal lumbar lordosis
b. Thich pain after 30 seconds of lumbar extension
A decrease in the degree of density in a bone that results in fragile bones is referred to as:
a. Osteopenia
b. Osteoporosis
c. Osteomyelitis
d. Osteoarthritis
A decrease in the degree of density in a bone that results in fragile bones is referred to as:
Osteopenia: Condition of bone that makes it slightly less dense than normal bone but not as severe as in osteoporosis.
Osteomyelitis: Usually presents suddenly with a swollen joint and pain. This is more commonly seen in children. Usually caused by Staphylococcus. Typical symptoms include elevated temperature, chills, restlessness, severe bone pain unrelieved by analgesics or rest. There is usually swelling, redness and warmth at the site.
Osteoporosis: Characterized by a severe decrease in the density of bone, decreasing its strength and resulting in fragile bones. Leads to abnormally porous bone that is compressible, like a sponge. Usually seen in adults, not known to produce bone pain.
Osteoarthritis: A term used to describe degenerative joint disease
Flexion contracture of the knee suggests hamstring tightness or:
a. Quadriceps tightness
b. Limb paralysis
c. Prepatellar bursitis
d. Quadriceps weakness
b. Limb paralysis
Flexion Contracture: Inability to extend fully. Seen in hamstring tightness or limb paralysis.
Swelling over the patella: Suggests prepatellar bursitis.
Stumbling or “giving way” of the knee during the heel strike phase of gait suggests quadriceps weakness or abnormal patellar tracking.
Genu varum refers to:
a. Toeing inward or outward of the feet
b. Bow leggedness
c. Knock knees
d. Club foot
b. Bow leggedness
Genu-Valgum: “Knock Knees”: Normal for children around age 3, usually not treated unless it continues after age 7, then a night brace may be used.
Genu Varum: “Bow legged”: Normal in infants because of their folded position in the mother’s womb. Legs begin to straighten once the child starts to walk (about 12-18 months)
Upon examination of the left shoulder, the patient complains of a dull, aching pain when attempting active or passive range of motion and localized tenderness with external rotation. These symptoms could be suggestive of:
a. A complete rotator cuff tear
b. Adhesive capsulitis
c. Rotator cuff tendinitis
d. Calcific tendinitis
b. Adhesive capsulitis
**APEA Orthopedics
Adhesive capsulitis, or frozen shoulder, refers to fibrosis of the glenohumeral joint capsule redulting in a dull aching pain in the shoulder. It progresses to restriction of active and passive range of motion and tenderness with external rotation.
Complete rotator cuff tear: Active abduction and forward flexion at the glenohumeral joint are severely impaired. The characteristic shrug of the shoulder is noted with a positive arm drop on the affected side.
Rotator Cuff Tendonitis: Reports of sharp “catches” of pain, grating, and weakness in the shoulder when lifting the arm overhead are symptoms suggestive of rotator cuff tendonitis or impingement syndrome.
Calcific tendonitis: involves the supraspinatus tendon and is associated with deposition of calcium salts. This results in disabling attacks of shoulder pain severely limiting motions due to the pain.
Prepatellar bursitis arises from:
a. Excessive running
b. Excessive kneeling
c. Arthritis
d. Fibromyalgia
b. Excessive kneeling
**APEA orthopedics
Prepatellar bursitis “housemaid’s knee” arises from excessive kneeling.
Popliteal or “Baker’s” cyst: Arises from distention of the gastrocnemius semimembranous bursa from underlying arthritis or trauma.
Anserine bursitis arises from running, valgus knee deformity, fibromyalgias, and osteoarthritis
When performing a musculoskeletal examination, the nurse practitioner instructs the patient to move his arm in front of his body. This motion of the shoulder girdle would be an example of:
a. Adduction
b. Abduction
c. Flexion
d. Extension
c. Flexion
**APEA orthopedic
Adduction: Patient crosses arm in front of their body.
Abduction: Patient moves arms away from the body laterally and overhead
Flexion: Move arm forward in front and overhead. Tests the anterior and lateral deltoid, pectoralis major, coracobrachialis and biceps brachii muscles.
Extension: Patient moves arm behind themself
When inspecting the shoulder and shoulder girdle, the rounded lateral aspect of the shoulder appears flattened. This finding could be associated with:
a. Anterior shoulder dislocation
b. Scoliosis
c. Atrophy of the supraspinatus muscle
d. Rotator cuff tear
a. Anterior shoulder dislocation
**APEA orthopedic
When examining the elbow, swelling over the olecranon process is noted. This finding could be suggestive of:
a. Synovitis
b. Bursitis
c. Osteomyelitis
d. Arthritis
b. Bursitis
**APEA orthopedics
The nerve that provides sensation to the palm and palmar surface of most of the thumb, second and third fingers, and half of the fourth digit is the:
a. Ulnar nerve
b. Radial nerve
c. Median nerve
d. Flexor retinaculum
c. Median nerve
**APEA orthopedic
Medial Nerve: Provides sensation to the palm and palmar surface of most of the thumb, second and third fingers, and half of the fourth digit.
Ulnar Nerve: Innervates half of the fourth digit and the fifth digit.
Radial nerve: innervates the dorsal web space of thumb and index finger.
Tenderness over the patellar tendon or inability to move the knee, suggests:
a. Crepitus around the tendon
b. A degenerative patella
c. A partial or complete patellar tendon tear
d. Synovial thickening over the knee joint
c. A partial or complete patellar tendon tear
**APEA orthopedic
Tenderness over the patellar tendon or inability to extend the knee suggests a partial or complete tear of the patellar tendon.
Pain and crepitus over the patella suggest roughening of the patellar undersurface that articulates with the femur.
Pain and compression and patellar movement during quadriceps contraction is noted with a degenerative patella.
Swelling above and adjacent to the patella suggests synovial thickening or effusion of the knee joint.
When assessing a patient with complaints consistent with carpal tunnel syndrome, which one of the following symptoms is unlikely?
a. Dropping objects
b. Inability to twist lids off jars
c. Tingling of the first three digits of the hand
d. Numbness of the last two digits of the hand
d. Numbness of the last two digits of the hand
**APEA orthopedic
Decreased spinal mobility in the lumbar region could be suggestive of:
a. Dupuytren’s contracture
b. Torticollis
c. Osteoarthritis
d. Kyphosis
c. Osteoarthritis
**Orthopedic
Dupuytren’s contracture affects the hands.
Torticollis would present a lateral deviation and rotation of the head.
Kyphosis affects the thoracic spine.
The forward slippage of one vertebrae resulting in spinal cord compression is referred to as:
a. Arthritis
b. Spondylolisthesis
c. Sacroiliitis
d. Thoracic kyphosis
b. Spondylolisthesis
**Orthopedics
Passive flexion, varus stress, and external rotation of the lower leg evaluates the:
a. Medial meniscus
b. Lateral meniscus
c. Lateral collateral ligament (LCL)
d. Posterior cruciate ligament (PCL)
b. Lateral meniscus
**APEA orthopedics
Upon examination of the left shoulder, the left arm is at the patient’s side. The elbow is flexed 90 degrees and the patient is instructed to supinate the forearm against the nurse practitioner’s resistance; increased pain in the bicipital grove results. This finding confirms:
a. Supraspinatud tendinitis
b. Bicipital tendinitis
c. Rotator cuff tendinitis
d. Calcific tendinitis
b. Bicipital tendinitis
**APEA Orthopedics
A thickened nodule overlying the flexor tendon of the 4th finger and possibly the 5th finger near the distal palmar crease is suggestive of:
a. Trigger finger
b. Dupuytren’s contracture
c. Thenar atrophy
d. A ganglion
b. Dupuytren’s contracture
Physical signs associated with mechanical neck pain include:
a. Weakness in the triceps and finger flexors and extensors
b. Decreased cervical range of motion
c. Neck flexion with resulting sensation of electrical shock radiating down the spine
d. Local neck muscle tenderness
d. Local neck muscle tenderness
**APEA orthopedics
Mechanical Neck Pain with Whiplash: Results in decreased range of motion, perceived weakness of the upper extremities, and paracervical tenderness.Paracervical pain and stiffness begins the day after injury and may be accompanied by occipital headaches, dizziness, and malaise.
Mechanical Neck Pain: Local neck muscle tenderness. Aching pain in the cervical paraspinal muscles and ligaments with associated muscle spasm, stiffness, and tightness in the upper back and shoulder, lasting up to 6 weeks.
Cervical Radiculopathy: Weakness in the triceps and finger flexors and extensors. Caused by nerve root compression. Symptoms may include sharp burning or tingling pain in the neck and one arm with associated paresthesias.
Cervical myelopathy (Cervical cord compression): Physical signs include hyperreflexia, clonus at the wrists, knee, or ankle, gait disturbances, and positive Lhermitte’s sign (neck flexion resulting in a sensation of electrical shock radiating down the spine. The neck pain is associated with bilateral weakness and paresthesias in both upper and lower extremities.
When performing a spinal exam, the nurse practitioner notices unequal heights of the iliac crests. This finding could be suggestive of:
a. Spina bifida
b. Lordosis
c. Kyphosis
d. unequal leg lengths
d. Unequal leg lengths
**APEA orthopedics
When evaluating a patient who complains of thumb pain, the nurse practitioner would test thumb movement by instructing the patient to place his thumb in the palm and then move the wrist toward the midline in ulnar direction. This maneuver is commonly known as:
a. De Quervaain’s test
b. Finkelstein’s test
c. Tinel’s test
d. Phalen’s test
b. Finkelstein’s test
**APEA Orthopedics
When inspecting the shoulder and shoulder girdle, an elevation of the right shoulder was noted. This finding could be associated with:
a. Anterior shoulder dislocation
b. Scoliosis
c. Atrophy of the supraspinatus muscle
d. Rotator cuff tear
b. Scoliosis
**APEA orthopedics
Asymmetry: Shoulder asymmetry could be indicative of scoliosis.
Rounded lateral aspect of the shoulder appears flattened in an anterior dislocation
Atrophy of the supraspinatus and infraspinatus with increased prominence of the scapular spine can appear within 2-3 weeks of a rotator cuff tear.
Restricted abduction of the hip in an adult is common in hip:
a. Bursitis
b. Tendinitis
c. Muscle spasm
d. Osteoarthritis
d. Osteoarthritis
**APEA orthopedics
To palpate the trochanteric bursa, position the patient:
a. One one side, hip flexed, and externally rotated
b. One one side, hip flexed, and internally rotated
c. One one side, hip extended, and externally rotated
d. One one side, hip extended, and internally rotated
b. One one side, hip flexed, and internally rotated
**APEA orthopedic
Crepitus with flexion and extension of the knee suggests:
a. Tendinitis
b. Osteoarthritis
c. Rheumatoid arthritis
d. Fibromyalgia
b. Osteoarthritis
**APEA orthopedics
Which one of the following ligaments of the foot is most at risk of injury from inversion?
a. Anterior talofibular ligament
b. Deltoid ligament
c. Calcaneofibular ligament
d. Posterior talofibular ligament
a. Anterior talofibular ligament
**APEA orthopedics
The three ligaments of the foot with higher risk for injury are the:
1- Anterior talofibular ligament: Most at risk from injury from inversion (heel bows inward) injuries
2- Calcaneofibular ligament
3- Posterior talofibular ligament
Which nerve in the arm is located in the ventral forearm and is just medial to the brachial artery in the antecubital fossa?
a. Median nerve
b. Ulnar nerve
c. Radial nerve
d. Brachial plexus
a. Median nerve
**APEA orthopedics
The median nerve is located on the ventral forearm and is just medial to the brachial artery in the antecubital fossa.
The ulnar nerve runs posteriorly in the ulnar groove between the medial epicondyle and the olecranon process.
The radial nerve originates in the axilla and travels down the arm in a shallow depression (radial groove) on the surface of the humerus.
The brachial plexus runs from the spine through the neck, the axilla, and into the arm.
When examining the medial and lateral meniscus, a click along the medial joint with valgus stress, external rotation, and leg extension suggests a probable tear of the:
a. Anterior portion of the medial meniscus
b. Anterior portion of the lateral meniscus
c. Posterior portion of the lateral meniscus
d. Posterior portion of the medial meniscus
d. Posterior portion of the medial meniscus
**APEA orthopedics
On examination of the feet, the nurse practitioner notes dusky red swelling extending beyond the margin of the metatarsophalangeal joint of the right great toe. It is hot on palpation and the patient states it is painful to touch. These findings are suggestive of:
a. Cellulitis
b. Acute gouty arthritis
c. Acute tenosynovitis
d. A felon
b. Acute gouty arthritis
**APEA orthopedic
Gout: Usually involves one joint and typically affects the first toe. The metatarsophalangeal joint of the great toe is the initial site of attack in 50% of the episodes of acute gouty arthritis. It is characterized by a very painful and tender, hot, dusky red swelling that extends beyond the margin of the joint. It is easily mistaken for cellulitis, however with cellulitis the dermis and subcutaneous tissue is involved as opposed to the joint.
The nurse practitioner instructs the patient to lie supine, bend his knee, and turn is lower leg and foot away from midline. This maneuver would assess hip:
a. Abduction
b. Extension
c. External rotation
d. Internal rotation
d. Internal rotation
**APEA orthopedics
The nurse practitioner instructs the patient to bend backward as far as possible. This maneuver would elicit:
a. Flexion of the lumbar spine
b. Extension of the lumbar spine
c. Lateral movement of the lumbar spine
d. Rotation of the lumbar spine
b. Extension of the lumbar spine
**APEA orthopedics
The area located between the olecranon process and the skin is known as the:
a. Olecranon fossa
b. Olecranon bursa
c. Acromion process
d. Olecranon
b. Olecranon bursa
**APEA orthopedic
The nurse practitioner instructs the patient to place one hand behind his back and touch his shoulder blade. This shoulder movement elicits:
a. Extension
b. Flexion
c. Internal rotation
d. External rotation
c. Internal rotation
**APEA orthopedic
Flexion: Move arm forward in front and overhead. Tests the anterior and lateral deltoid, pectoralis major, coracobrachialis and biceps brachii muscles.
Extension: Patient moves arm behind themself
Internal rotation: Instruct the patient to place one hand behind their back and touch their shoulder blade.
External rotation: Ask patient to raise arm to shoulder, bend elbow, and rotate forearm toward ceiling
The medial and lateral menisci:
a. Connects the medial femoral epicondyle to the medial condyle of the tibia
b. Flex the knee
c. Cushion the action of the femur on the tibia
d. Extend the knee
c. Cushion the action of the femur on the tibia
**APEA orthopedics
Which nerve in the arm runs posteriorly in the ulnar groove between the medial epicondyle and the olecranon process?
a. Median nerve
b. Ulnar nerve
c. Radial nerve
d. Brachial plexus
b. Ulnar nerve
**APEA orthopedics
The median nerve is located on the ventral forearm and is just medial to the brachial artery in the antecubital fossa.
The ulnar nerve runs posteriorly in the ulnar groove between the medial epicondyle and the olecranon process.
The radial nerve originates in the axilla and travels down the arm in a shallow depression (radial groove) on the surface of the humerus.
The brachial plexus runs from the spine through the neck, the axilla, and into the arm.
When examining the foot of a patient, the nurse practitioner notes tenderness of the posterior medial malleolus. This could be suggestive of:
a. A bone spur
b. Plantar fasciitis
c. A ligamentous injury
d. Tibial tendinitis
d. Tibial tendinitis
**APEA orthopedics
Tibial tendinitis: Tenderness along the posterior medial malleolus.
Bone spurs: may be present on the calcaneus as bony projections and may cause numbness, tenderness, or pain.
Localized tenderness on examination of the ankle joint could be suggestive of arthritis, infection of the ankle, or ligamentous injury.
Focal heel tenderness on palpation of the plantar fascia suggests plantar fasciitis.
Thenar atrophy suggests:
a. An ulnar nerve disorder
b. A median nerve disorder
c. A radial nerve disorder
d. A superficial branch of the radial nerve
b. A median nerve disorder
**APEA orthopedics
Thenar atrophy suggests a median nerve disorder such as carpal tunnel syndrome. This is evidenced by muscle wasting in the palm of the hand.
When assessing a 3-month-old for development dysplasia of the hips (DDH), which one of the following symptoms would be suspicious of dysplasia?
a. Limitation of adduction of the affected extremity, shortening of the femur, and a negative Ortolani’s sign
b. Limitation of abduction of the affected extremity, shortening of the femur and positive Ortolani’s sign
c. Limitation of adduction of the affected extremity, Trendelenburg’s sign and symmetry of gluteal folds
d. Limitation of abduction of the affected extremity, asymmetry of gluteal folds, and lengthening of the femur on the affected side.
b. Limitation of abduction of the affected extremity, shortening of the femur and positive Ortolani’s sign (it clicks when maneuvered)
**APEA orthopedics
When examining the elbow for range of motion, the nurse practitioner instructs the patient to turn his palms downward. This motion is an example of:
a. Extension
b. Flexion
c. Supination
d. Pronation
d. Pronation
**APEA orthopedic
The posterior drawer sign is used to assess instability of the:
a. Anterior cruciate ligament (ACL)
b. Posterior cruciate ligament (PCL)
c. Lateral collateral ligament (LCL)
d. Medial collateral ligament (MCL)
b. Posterior cruciate ligament (PCL)
**APEA orthopedic
Inspection of the hip begins with careful observation of a patient’s gait. A patient’s foot moves forward without bearing weight. This is known as the:
a. Swing phase of gait
b. Stance phase of gait
c. Push off phase of gait
d. Heel strike phase of gait
a. Swing phase of gait
**APEA orthopedics
Two phases of gait: Stance and swing. Swing phase occurs when the foot moves forward and does not bear weight. The stance phase occurs when the foot is on the ground bearing weight.
Stumbling or “giving way” of the knee during the heel strike phase of gait suggests:
a. Hamstring tightness
b. Limb paralysis
c. Prepatellar bursitis
d. Quadriceps weakness
d. Quadriceps weakness
**APEA orthopedics
Flexion Contracture: Inability to extend fully. Seen in hamstring tightness or limb paralysis.
Swelling over the patella: Suggests prepatellar bursitis.
Stumbling or “giving way” of the knee during the heel strike phase of gait suggests quadriceps weakness or abnormal patellar tracking
The nurse practitioner suspects rotator cuff tear in a patient who is unable to:
a. Squeeze the examiner’s left hand with his right hand
b. Flex his elbow
c. Touch his left scapula with his right hand
d. Supinate his left wrist
c. Touch his left scapula with his right hand
**APEA orthopedics
A 35 year old female patient presents to the nurse practitioner with complaints of pain in the joints of both hands accompanied by stiffness, especially in the morning with tenderness and warmth to touch. Examination reveals swelling of the synovial tissue and limitation of motion. These findings are consistent with:
a. Osteoarthritis
b. Rheumatoid arthritis
c. Gouty arthritis
d. Polymyalgia rheumatica
b. Rheumatoid arthritis
**APEA orthopedic
OA usually affects a single joint with brief stiffness in the early morning and after a period of inactivity. Gouty arthritis often affects the big toe, less often the dorsa of foot, ankles, knees, and elbows. The swelling is usually around the joint and accompanied by extreme tenderness, erythema, and very warm to the touch.
Polymyalgia rheumatica affects the muscles rather than the joints.
On examination of the left wrist, the nurse practitioner notes a slightly tender .75 cm swelling along the joint capsule during flexion of the wrist. This finding could be suggestive of:
a. A rheumatoid nodule
b. A ganglion cyst
c. Chronic tophaceous gout
d. Osteoarthritis
b. A ganglion cyst
**APEA orthopedic
Ganglion cyst: ganglia are cystic, round, usually non-tender swellings along tendon sheaths or joint capsules, frequently at the dorsum of the wrist. Flexion of the wrist makes ganglia more prominent. Extension tends to obscure them.
Upon examination of the foot and ankle, the nurse practitioner notes point tenderness over the posterior aspect of the right malleolus. Additionally, the patient is unable to bear weight after 4 steps. This finding is most consistent with:
a. Achilles tendinitis
b. An ankle fracture
c. A ligamentous injury
d. Rheumatoid arthritis
b. An ankle fracture
**APEA orthopedic
When performing an examination of a painful left wrist in an adult, there is a palpable crunching sound during flexion. This finding is referred to as:
a. Edema
b. Tissue tenderness
c. Crepitus
d. Synovitis
c. Crepitus
**APEA orthopedic
Synovitis: A term used to describe a palpable bogginess or doughiness over a joint area.
Crepitus: An audible or palpable “crunching” during movement of tendons or ligaments over bone or areas of cartilage loss. This may occur painlessly in joints but is more significant when associated with symptoms or signs.
Edema: The build-up of excess fluid in surrounding tissues.
Tissue Tenderness: Term used to describe an area that is sensitive to tough, usually related to trauma.
When examining the knee, which of the following symptoms could be indicative of a positive Adduction (Varus) Stress Test?
a. Pain in the lateral joint line
b. Pain in the medial joint line
c. Pain in the anterior joint line
d. A click along the medial joint line
a. Pain in the lateral joint line
**APEA orthopedic
Lateral collateral ligament (LCL) tear: Assessed with the Adduction (Varus) Stress Test. To perform the test, the knee is held in 30 degrees of flexion. With one hand on the medial side of the knee and one hand on the ankle, an adduction force is gently applied. If pain is noted in the lateral joint line, this could be indicative of a lateral collateral ligament tear. When tenderness extends more to the proximal or distal joint line, the collateral ligament may be the cause of pain instead of the meniscus.
When assessing the knee, the examiner instructs the patient to sit and swing his lower leg away from midline. This motion would assess knee:
a. Flexion
b. Extension
c. Internal rotation
d. External rotation
d. External rotation
**APEA orthopedic
Flexion: Patient bends their knee
Extension: Patient straightens leg
Internal rotation: Have the patient swing lower leg toward midline while sitting
External rotation: Instruct the patient to swing leg away from midline while sitting.
When examining the foot of a patient, the nurse practitioner notes localized tenderness over the ankle joint. This could be suggestive of:
a. A bone spur
b. Plantar fasciitis
c. A ligamentous injury
d. Tibial tendinitis
c. A ligamentous injury
**APEA orthopedic
Tibial tendinitis: Tenderness along the posterior medial malleolus.
Bone spurs: may be present on the calcaneus as bony projections and may cause numbness, tenderness, or pain.
Localized tenderness on examination of the ankle joint could be suggestive of arthritis, infection of the ankle, or ligamentous injury.
The nerve that provides sensation to half of the fourth digit and fifth digit is the:
a. Ulnar nerve
b. Radial nerve
c. Median nerve
d. Flexor retinaculum
a. Ulnar nerve
**APEA orthopedic
Radial Nerve: Innervates the dorsal web space of the thumb and index finger. Originates in the axilla and travels down the arm in a shallow depression (radial groove) on the surface of the humerus.
Ulnar Nerve: Innervates half of the fourth digit and the entire fifth digit. Runs posteriorly in the ulnar groove between the medial epicondyle and the olecranon process. The ulnar nerve runs posteriorly in the ulnar groove between the medial epicondyle and the olecranon process.
Median Nerve: Provides sensation to the palm and palmar surface of most of the thumb, second and third fingers, and half of the fourth digit. Located on the ventral forearm and is just medial to the brachial artery in the antecubital fossa.
The flexor retinaculum is a ligament
A patient reports sharp “catches” of pain, grating, and weakness in the right shoulder when lifting the arm overhead. These symptoms could be suggestive of:
a. A complete rotator cuff tear
b. Adhesive capsulitis
c. Rotator cuff tendinitis
d. Calcific tendinitis
c. Rotator cuff tendinitis
**APEA orthopedic
Adhesive capsulitis, or frozen shoulder, refers to fibrosis of the glenohumeral joint capsule resulting in a dull aching pain in the shoulder. It progresses to restriction of active and passive range of motion and tenderness with external rotation.
Complete rotator cuff tear: Active abduction and forward flexion at the glenohumeral joint are severely impaired. The characteristic shrug of the shoulder is noted with a positive arm drop on the affected side.
Rotator Cuff Tendonitis (impingement): Reports of sharp “catches” of pain, grating, and weakness in the shoulder when lifting the arm overhead are symptoms suggestive of rotator cuff tendonitis or impingement syndrome.
Calcific tendonitis: involves the supraspinatus tendon and is associated with deposition of calcium salts. This results in disabling attacks of shoulder pain severely limiting motions due to the pain.
Acromioclavicular arthritis usually arises from prior direct injury to the:
a. Glenohumeral joint
b. Shoulder girdle
c. Rotator cuff
d. Subacromial bursa
b. Shoulder girdle
**APEA orthopedic
Where the head of the humerus articulates with the shallow glenoid fossa of the scapula is known as the:
a. Glenohumeral joint
b. Sternoclavicular joint
c. Acromioclavicular joint
d. Manubrium joint
a. Glenohumeral joint
Glenohumeral joint: where the head of the humerus articulates with the shallow glenoid fossa of the scapula. This joint is deeply situated and not normally palpable.
Acromioclavicular joint: Lies at the lateral end of the clavicle and articulates with the acromion process of the scapula. The convex medial end of the clavicle articulates with the concave hollow in the upper sternum to form the sternoclavicular joint.
There is no manubrium joint, it is a broad upper part of the sternum.
Which of the following symptoms is associated with iron deficiency anemia?
a. Atrophic glossitis
b. Oral candida
c. Melanoglossia
d. Transient lingual papillitis
a. Atrophic glossitis
**APEA hematology
Atrophic glossitis: Occurs when a large number of papillae are lost, resulting in changes to the tongue’s color and texture. This type of glossitis typically turns the tongue dark red and is a symptom of iron deficiency anemia.
Oral candida: White paste on the tongue. Most common type of oral candida is Candida albicans fungus.
Melanoglossia: a medical condition in which the tongue is blackened. Usually caused by a bacterial infection or allergic reaction.
Transient lingual papillitis is a common painful inflammatory condition affecting one or several fungiform papillae on the tongue.
The nurse practitioner differentiates physiologic jaundice from pathologic jaundice by assessment of the:
a. Degree of jaundice of the skin
b. Timing of the onset of the jaundice
c. Maternal history of drugs/medications
d. Level of bilirubin in the blood
b. Timing of the onset of the jaundice
**APEA hematology
Physiologic Jaundice: Identified after 24 hours
Pathologic Jaundice: Identified before the infant is 24 hours of age.
The fetus produces more red blood cells (RBCs) than the normal adult or child has, with a hematocrit of up to 60% being normal. At birth, structural and functional changes take place which enable the fetus to breathe room air, bringing the baby’s paO2 up to the normal child-adult range. Thus, the excess RBCs are no longer needed for O2 carrying capacity, and they begin to break down. This is a normal, physiologic change that occurs at birth
Patients who develop pica have a deficiency in:
a. Folic acid
b. Lead
c. Magnesium
d. Iron
d. Iron
**APEA hematology
Pica is characterized by an appetite for substances that are non-nutritive, such as ice, starch, or clay. This finding is associated with iron-deficiency anemia. Pica is considered an eating disorder in the DSM-5 criteria
An example of a vaso-occlusive crisis of the pulmonary vasculature seen in patients with sickle cell anemia is:
a. Acute chest syndrome
b. Pulmonary embolism
c. Pneumonia
d. Pulmonary edema
a. Acute chest syndrome
**APEA hematology
Acute Chest Syndrome: A vaso-occlusive crisis of the pulmonary vasculature commonly seen in patients with sickle cell anemia. It is often precipitated by a respiratory infection and symptoms include: fever, cough, excruciating pain, sputum production, shortness of breath, or low oxygen levels.
Hemophilia type A is a deficiency of factor:
a. VIII
b. IX
c. XI
d. IV
a. VIII
**APEA hematology
Hemophilia is an inherited disorder in which a person lacks adequate clotting factors. Type A is lacking of clotting factor VIII (90% of cases). Type B is lacking clotting factor IX. Type C is lacking clotting factor XI
Which ethnicity is associated with glucose-6-phosphate-dehydrogenase (G-6-PD) deficiency?
a. American Indian
b. Black
c. Asian
d. Hispanic
b. Black
Glucose-6-phosphate-dehydrogenase (G-6-PD) deficiency is a condition in which red blood cells break down when the body is exposed to certain drugs (aspirin, antimalaria drugs) or the stress of infection. G-6-PD is most prevalent in people of Mediterranean and African descent, and specifically common in Saudi Arabian, African, and black patients.
A symptom of severe hemorrhagic shock (Class IV) does NOT include:
a. Tachycardia
b. Hypotension
c. Tachypnea
d. Hypertension
d. Hypertension
**APEA hematology
Class IV (severe) hemorrhagic shock: Refers to a medical condition in which rapid fluid loss results in multiple organ failure due to inadequate circulating volume and subsequent inadequate perfusion. Symptoms of severe hemorrhagic shock include tachycardia, hypotension, decreased or no urinary output, loss of consciousness, cold and pale skin, and tachypnea.
An assessment finding in a patient diagnosed with von Willebrand disease is:
a. Hypopigmentation
b. Cafe au lait spots
c. Ecchymosis
d. Hyperpigmentation
c. Ecchymosis
**APEA hematology
Von Willebrand disease is a group of congenital bleeding disorders caused by a deficiency of the protein von Willebrand factor (vWF). Defective vWF interaction between platelets and the vessel wall impairs primary hemostasis. Symptoms include: bruising (ecchymosis), menorrhagia, recurrent epistaxis, petechiae, and hemorrhage.
On assessment, which one of the following symptoms would be noted as a compensatory response to chronic hypoxia?
a. Pulmonary hypertension
b. Dehydration
c. Hematocrit (HCT) of 55%
d. Hemoglobin (Hgb) of 8.5 g/dL
c. Hematocrit (HCT) of 55%
**APEA hematology
With chronic hypoxia, the body attempts to improve tissue oxygenation by producing additional red blood cells and thereby increasing the oxygen carrying capacity of the blood. This condition is termed polycythemia. Clubbing is a classic symptom of chronic hypoxia. Lab values denoting increased RBC such as HCT of 55-60% would be indicative of polycythemia.
Pulmonary hypertension is a clinical consequence of increased pressure in the pulmonary arteries and is seen in children with congenital heart defects but it is not a direct result of hypoxia. Dehydration can occur rapidly in children with cyanotic heart defects, however it is not a compensatory mechanism of chronic hypoxia. Anemia may develop as a result of poot tissue oxygenation secondary to decreased blood viscosity not increased as in polycythemia.
The blood lead level that requires further testing and monitoring in children is:
a. 3 mcg/dL
b. 5 mcg/dL
c. 7 mcg/dL
d. 9 mcg/dL
b. 5 mcg/dL
**APEA hematology
In children, a blood lead level of 5 mcg/dL or 0.24 Umol/L or greater requires further testing and monitoring. The source of lead must be found and removed. A lead level greater than 45 mcg/dL or 2.17 Umol/L in a child’s blood usually indicates the need for chelation.
The tonsillar lymph node is located:
a. At the angle of the mandible
b. In front of the ear
c. At the base of the skull posteriorly
d. Superficial to the mastoid process
a. At the angle of the mandible
**APEA hematology
The supraclavicular lymph nodes are located:
a. Along the anterior edge of the trapezius
b. Deep in the angle formed by the clavicle and the sternomastoid muscle
c. Superficially to the sternomastoid muscle
d. Midway between the angle and the tip of the mandible
b. Deep in the angle formed by the clavicle and the sternomastoid muscle
**APEA hematology
Which of the following foods contains the LEAST amount of folic acid?
a. Dairy
b. Green leafy vegetables
c. Liver
d. Fruits
a. Dairy
**APEA hematology
Foods high in folic acid include green leafy vegetables, meat from animal sources, fruits, nuts, liver, and foods containing yeast. Dairy foods such as cheese, milk, and yogurt do not contain folic acid unless they have been specifically fortified to include this vitamin.
The posterior auricular lymph node is located:
a. At the angle of the mandible
b. In front of the ear
c. At the base of the skull posteriorly
d. Superficial to the mastoid process
d. Superficial to the mastoid process
**APEA hematology
Which one of the following does NOT produce anemia of chronic disease?
a. Systemic lupus
b. Rheumatoid arthritis
c. Osteomyelitis
d. Osteoporosis
d. Osteoporosis
**APEA hematology
Mild to moderate normochromic, normocytic anemia is associated with chronic disease. Anemia has been identified as a risk factor for osteoporosis, however, osteoporosis does not cause anemia.
Anemia of chronic disease is associated with diseases such as systemic lupus, rheumatoid arthritis, and osteomyelitis.
The preauricular lymph node is located:
a. At the angle of the mandible
b. In front of the ear
c. At the base of the skull posteriorly
d. Superficial to the mastoid process
b. In front of the ear
**APEA hematology
Enlargement of which lymph nodes would be suggestive of metastasis from a thoracic or abdominal malignancy?
a. Tonsillar
b. Anterior cervical chain
c. Submandibular
d. Supraclavicular
d. Supraclavicular
**APEA hematology
Supraclavicular: The supraclavicular lymph nodes are located: Deep in the angle formed by the clavicle and the sternomastoid muscle. Enlargement, especially on the left, would be suggestive of metastasis from a thoracic or abdominal malignancy.
A possible assessment finding in patients taking oral iron supplements for anemia is:
a. Steatorrhea
b. Hematochezia
c. Constipation
d. Beeturia
c. Constipation
**APEA hematology
Constipation is a common side effect of iron supplements. Iron causes dysbiosis (microbes imbalance) which slows peristalsis. This results in longer bowel retention, which causes more water uptake and leads to dry feces, resulting in constipation.
Steatorrhea is a greasy, foul-smelling stool associated with cystic fibrosis. Hematochezia is a passage of fresh blood through the anus and is commonly associated with lower gastrointestinal bleeding. Beeturia is red-colored feces after consuming beets. It occurs due to insufficient metabolism of red pigment.
A patient who presents with joint pain and an accompanying butterfly rash on the face is suggestive of:
a. Gonococcal arthritis
b. Systemic lupus erythematosus
c. Fifth’s disease
d. Acute rheumatic fever
b. Systemic lupus erythematosus
**APEA hematology
Some joint disorders can be linked to organ systems outside the musculoskeletal system. A patient who presents with joint pain and an accompanying butterfly rash on the face could have SLE. Gonococcal arthritis may have an accompanying rash on the distal extremities. The rash may appear as papules, pustules, or vesicles on reddened bases. In fifth’s disease, the rash appears as a “slapped” cheek. Acute rheumatic fever may be preceded by a sore throat and progress with musculoskeletal involvement.
Which one of the following statements is true about immunity?
a. Passive immunity develops in response to an infant receiving immunizations
b. Infants acquire active immunity from the mother which lasts 6-7 months
c. Infants acquire active immunity in response to infections and immunizations
d. Maternal antibodies that pass to the infant ensure active immunity up to 12 months age.
c. Infants acquire active immunity in response to infections and immunizations
**APEA hematology
Infants acquire long-term active immunity from exposure to certain diseases (antigens) and vaccines. Active immunity develops in response to immunizations. The infants passive immunity is acquired from the mother and dissipates around 6 months of age.
The axillary lymph nodes drain lymphatic fluid from all of the following areas except the:
a. Breasts
b. Upper part of the abdominal wall
c. Upper part of the back
d. Anterior chest wall
d. Anterior chest wall
**APEA hematology
Axillary lymph node: Drainage areas include the breast, upper part of the abdominal wall, the upper part of the back, pectoral region, and upper limbs.
Anterior pectoral nodes: drained the anterior chest and much of the lymphatic fluid from the breast
The anterior cervical lymph node chain is located anterior and:
a. Midway between the angle and the tip of the mandible
b. Superficial to the mastoid process
c. Superficial to the sternomastoid muscle
d. At the angle of the mandible
c. Superficial to the sternomastoid muscle
**APEA hematology
A child with sickle cell anemia presents with a history of sudden onset of rapid breathing with left upper quadrant (LUQ) tenderness upon palpation. The child is most likely experiencing a (an):
a. Aplastic crisis
b. Sequestration crisis
c. Vaso-occlusive crisis
d. Hemarthrosis crisis
b. Sequestration crisis
**APEA hematology
Sequestration occurs when RBC’s are trapped or sequestered in the spleen causing it to enlarge; therefore, there would be tenderness in the LUQ and the child may have tachypnea as well.
Aplastic crisis occurs when RBC production is decreased. Symptoms include pallor, decreased hemoglobin and decreased RBSc.
Vaso-occlusion usually involves pain but no increase in spleen size.
Hemiarthrosis is usually seen in hemophilia and where there is joint involvement, but not spleen involvement.
In which of the following situations would a one-year-old child be at risk for lead poisoning?
a. Ceiling tiles have just been replaced in the child’s home
b. Refinishing of all painted woodwork has occurred recently in the child’s home
c. The family moved into a twenty-year-old brick house
d. The family moved from a trailer home to a new apartment complex
b. Refinishing of all painted woodwork has occurred recently in the child’s home
**APEA hematology
Painted woodwork may contain lead, especially in older homes and during refinishing, the paint would have to be scraped off placing it in easy reach of a one year old.
A finding suggestive of an inflamed lymph node would be one that is:
a. Hard and fixed
b. Tender and movable
c. Shotty and movable
d. Non-tender and fixed
b. Tender and movable
**APEA hematology
Small, mobile, discrete, non-tender (shotty) nodes are frequently identified as normal findings.
Nodes that are tender suggest inflammation.
Hard and fixed nodes suggest malignancy
Which situation would put the patient at the LEAST risk for developing lead toxicity?
a. Being a plumber
b. Residing in a home built before 1988
c. Having a history of gout
d. Living near a busy highway
b. Residing in a home built before 1988
**APEA hematology
Risks for lead toxicity may include occupation as a plumber, having a history of gout, living near a busy highway or hazardous waste dump, and residing in a home built before 1978.
The tonsillar, submandibular, and submental nodes drain the lymphatic fluid from portions of the:
a. Palpebral conjunctiva and the skin adjacent to the ear within the temporal region
b. Eyelids, the conjunctiva, and the skin and mucous membranes of the nose and cheek
c. Mouth, throat, and face
d. Posterior part of the temporoparietal region
Mouth, throat, and face
**APEA hematology
An indication that there is a malfunction of a ventriculoperitoneal (VP) shunt in an older child would be the presence of a:
a. Headache upon awakening
b. Temperature greater than 100.8 degrees Fahrenheit
c. Noticeable increase in activity
d. Bulging fontanels
a. Headache upon awakening
**Headache and projectile vomiting are associated with shunt malfunction as well as signs of increased intracranial pressure. Fever can be associated with shunt infection.
A patient presents with symptoms of influenza during influenza season. He has not received the immunization against influenza. What should be used to help diagnose influenza in him?
a. A nasal culture
b. A nasal swab
c. CBC
d. Based on symptoms
b. A nasal swab
**Respiratory
Influenza is diagnosed based on the results of a flu swab and the patient’s clinical presentation. A patient with influenza usually demonstrates influenza A (the most predominant strain during an outbreak) or influenza B (the strain identified occasionally during flu season but more often throughout the rest of the year) if he is infected.
A 24-year-old presents with fever, rhinorrhea, and paroxysmal, high-pitched cough. This is:
a. Bronchiolitis
b. Croup
c. Pertussis
d. Epiglottitis
c. Pertussis
**Respiratory
Pertussis is also called “whooping cough”. This is a highly communicable respiratory disease caused by Bordetella pertussis. There are three recognized stages of pertussis: the catarrhal phase, the paroxysmal phase, and convalescence. More adults than children have contracted pertussis in the last decade. Since the outbreak of pertussis in Iowa in 2005, diminished titers were recognized and adolescents are being given a booster with TdaP at 11-12 years of age.
Patients with asthma:
a. All wheeze
b. All cough
c. Can cough or wheeze
d. Have dyspnea
c. Can cough or wheeze
**Respiratory
The second leading cause of cough in adults is asthma. Cough due to asthma is often accompanied by episodic wheezing or dyspnea, though some patients with asthma only cough. This is termed “cough variant asthma”. The clinical presentation of asthma varies but hyper-responsiveness of the airways is a typical finding.
A 78-year-old adult who has a 50 pack year smoking habit asks the nurse practitioner about the benefits of quitting “at my age”. What should the nurse practitioner reply?
a. There is little benefit because you’ve smoked for so much for so long
b. This would help decrease your risk of developing COPD
c. This will decrease your risk of all cause mortality 5 years after stopping
d. Your heart will benefit minimally from quitting smoking
c. This will decrease your risk of all cause mortality 5 years after stopping
**Respiratory
Smoking cessation at any age is beneficial to the person engaging in smoking cessation. Data demonstrates that after 5 years of smoking cessation, there is a significant decrease in the risk of death from coronary disease, cancer, and COPD.
A patient received the pneumonia immunization at age 60 years. He is 65 years old and presents to your clinic today. What recommendation should be made about the pneumococcal immunization.
a. He should receive another one today
b. He does not need another one today
c. He needs to get one annually starting at age 65 years
d. He should get it every 5 years
a. He should receive another one today
**Respiratory
This patient should receive another one today because he is 65 years old and at least 5 years has elapsed since his last one. The CDC does not recommend immunizing this patient every 5 years. Two immunizations are available, PCV13 and PPSV23. He needs both, but PCV13 should be administered today. PPSV23 should be administered at least 1 year later.
A patient has received a prescription for lisinopril. Which side effect most commonly occurs with this medication?
a. Dry cough
b. Angioedema
c. Hyperuricemia
d. Itching
a. Dry cough
**Respiratory
A common side effect of ACE inhibitors is dry cough. Though estimates vary, 5-20% of patients who receive ACE inhibitors develop a cough. Angiotension converting enzyme is believed to be responsible for metabolism of bradykinin in the lungs. Bradykinin is thought to be responsible for the cough because it induces production of arachidonic acid metabolites and nitric oxide. These substances may promote cough. The cough associated with ACE inhibitors appears to be a class effect.
A patient with cough and fever is found to have infiltrates on chest x-ray. What is his likely diagnosis?
a. Pneumonia
b. Acute bronchitis
c. Tuberculosis
d. Pneumonitis
a. Pneumonia
**Respiratory
The finding of infiltrates on CXR, in conjunction with clinical findings of fever and cough, should direct the examiner to consider pneumonia as the diagnosis. Other common clinical findings with pneumonia include chest pain, dyspnea, and sputum production. Though not common, some patients with pneumonia exhibit gastrointestinal symptoms like nausea, vomiting, and diarrhea
A patient who has asthma presents with chest tightness, wheezing, coughing, and fever. He has wheezing and diminished breath sounds in the upper right lobe. His cough is non-productive, and he denies nasal symptoms. Which symptom is most likely related to pneumonia?
a. Fever
b. Coughing
c. Wheezing
d. Chest tightness
a. Fever
**Respiratory
The presence of fever should trigger the practitioner to consider pneumonia. The other symptoms are most likely secondary to asthma. Coughing may be due to asthma and pneumonia
Which of the following characteristics is always present in a patient with COPD?
a. Productive cough
b. Obstructed airways
c. Shortness of breath
d. Hypercapnia
b. Obstructed airways
**Respiratory
COPD is characterized by obstructed airways. The obstruction is NOT completely reversible even with medication use. Productive cough is likely present in patients with chronic bronchitis but not necessarily emphysema. Shortness of breath does not have to be present (or perceived in patients with COPD). Hypercapnia is more prevalent in patients with emphysema since air trapping occurs.
A patient with asthma uses one puff twice daily of fluticasone and has an albuterol inhaler for PRN use. He requests a refill on his albuterol inhaler. His last prescription was filled 5 weeks ago. What action by the NP is appropriate?
a. Refill the albuterol only
b. Prescribe a longer acting bronchodilator, continue the steroid
c. Increase the dose of the inhaled steroid, refill the albuterol
d. Prescribe a long acting bronchodilator and increase the steroid
c. Increase the dose of the inhaled steroid, refill the albuterol
**Respiratory
The patient is using his short-acting bronchodilator excessively if he needs a refill of his inhaler in only 5 weeks. Inhalers typically contain 200 puffs. They should be used two or fewer times per week. His inhaled steroid dose should be increased and his albuterol inhaler should be refilled. In fact, he should not be without a prescription for the albuterol. Consideration could be given to prescribing a long-acting bronchodilator and increasing the steroid, but this is not the best choice because this does not include a refill of the albuterol and this patient cannot be without access to a rescue inhaler.
Mycoplasma pneumoniae is:
a. A diagnosis of exclusion
b. An uncommon respiratory pathogen
c. Only identifiable on CXR
d. A disease with extrapulmonary manifestations
d. A disease with extrapulmonary manifestations
**Respiratory
Mycoplasma is an atypical pathogen and produces atypical pneumonia. It can be difficult to diagnose because symptoms can be varied and involve multiple body systems (extrapulmonary manifestations). Infection with Mycoplasma may present with a normal white blood cell count, maculopapular rash, GI symptoms, tender joints and aches, and, though rare, cardiac rhythm disturbances. Respiraotyr symptoms may not be pronounced. On CXR there are some unique findings (peribronchial pattern) with Mycoplasma. These include thickened bronchial shadow, streaks of interstitial infiltration, and atelectasis. These are more likely to occur in the lower lobes.
A 6-year-old child who has moderate persistent asthma is diagnosed with pneumonia after CXR and laboratory studies. He developed a sudden onset of fever with chills. He is in no distress. What is the preferred treatment for him?
a. Supportive measures, it is probably viral
b. Amoxicillin
c. Azithromycin
d. Doxycycline
b. Amoxicillin
**Respiratory
The preferred treatment for this child will be based on your suspicion of the causative organism. Without a sputum culture, you will be treating this patient empirically. This child does not likely have a viral pathogen because viral infections usually have a gradual onset. The cause is likely bacterial. When bacterial cause is suspected, treatment is recommended to prevent symptom progression. In this case, the child could develop moderate to severe respiratory distress. Your next step in the treatment of this child is to determine whether the bacterial pathogen is typical or atypical. Both typical and atypical pathogens can cause an abrupt onset of fever in children >5 years old. Thus, making this determination is difficult based on symptoms alone. Your best course is to treat the most common typical pathogen in this age group, shich is streptococcus pneumoniae. The drug of choice is Amoxicillin.
The major laboratory abnormality noted in patients who have pneumococcal pneumonia is:
a. Eosinophilia
b. Leukocytosis
c. Gram stain positive
d. Leukopenia
b. Leukocytosis
**Respiratory
An increased white count is typical in patients with bacterial pneumonia such as pneumococcal pneumonia. Eosinophils can be increased in patients who develop pneumonia secondary to exposure to a very irritating substance like a toxic gas. Gram stain can demonstrate gram-positive or negative pathogens. Leukopenia is an ominous finding, especially in older patients. This indicates a poor prognosis because it means that the immune system is not responding to a potentially fatal pathogen.
Which of the following is NOT part of the differential for a patient who complains of cough?
a. Heart failure
b. Reflux disease
c. Asthma
d. Obesity
d. Obesity
**Respiratory
Which of the following medications should be used cautiously in a patient who has asthma?
a. Timolol ophthalmic drops
b. Naproxen
c. Lisinopril
d. Amlodipine
a. Timolol ophthalmic drops
**Respiratory
Timolol is a beta-blocker. This class of medications can precipitate bronchoconstriction in patients who have asthma. Even though timolol is being administered in the eye, it is absorbed through mucous membranes and can exert systemic effects. Beta blockers should be avoided in patients with asthma and used cautiously in patients with COPD. The other medications listed have no specific contraindications for patients with asthma.
A 24-year-old college student who does not smoke is diagnosed with pneumonia. He is otherwise healthy and does not need hospitalization at this time. What antibiotic represents the best choice for treatment for him?
a. Cefdinir
b. Levofloxacin
c. Sulfamethoxazole-Trimethoprim
d. Amoxicillin
d. Amoxicillin
**Respiratory
The most recent evidence-based guidelines recommend amoxicillin 1 gram TID for initial treatment of uncomplicated pneumonia in outpatients who are otherwise healthy and have not had recent antibiotic exposure. Azithromycin and doxycycline are listed as conditional recommendations first line to treat this patient. Sulfamethoxazole-Trimethoprim and Cefdinir are not evidence-based choices and thus should not be used. Fluoroquinolones, like levofloxacin are commonly used first line in patients who have comorbidities or who have had recent antibiotic exposure, or recent contact with the healthcare system.
How should a 20-year-old college age student who presents with cough, night sweats, and weight loss be screened for TB?
a. A chest x-ray
b. A TB skin test
c. A sputum specimen
d. CDC questionnaire about symptoms
b. A TB skin test
**Respiratory
Mantoux test first. A CXR is performed after a positive skin test. A sputum specimen is used for diagnosis, not screening. A questionnaire is used for screening patients who have had a history of a positive TB skin test.
The chest circumference of a 12-month-old is:
a. Routinely measured on well-child visits
b. 1-2 cm larger than head circumference
c. Smaller than head circumference
d. Equal to head circumference
d. Equal to head circumference
**Respiratory
The chest circumference is not routinely measured at well-child visits, but is assessed if there is concern about the circumference of either the head or the chest. An exception to this observation can occur in premature infants where the head grows very rapidly. Normally, the head exceeds the chest circumference from birth until 6 months. Between 6-24 months the head and chest circumference should be about equal and by 2 years of age the chest should be larger than the head. The chest circumference is measured at the nipple line.
The most common cause of pneumonia in an otherwise healthy 3-year-old child is:
a. S. pneumonia
b. S. aureus
c. Mycoplasma
d. A viral infection
d. A viral infection
**Respiratory
In children who are 6 months to 5 years of age, the most common cause of pneumonia is a viral pathogen. Rarely are studies performed to identify viral pathogens, however one of the most common viral pathogens is respiratory syncytial virus (RSV). S. pneumoniae is a common cause of pneumonia in very young children, it is also implicated in older adults as a causative agent in pneumonia. In young and middle adults, Mycoplasma is a common pathogen.
Mild persistent asthma is characterized by:
a. Limitation in activity due to bronchoconstriction
b. Symptoms occurring more than twice weekly
c. Wheezing and coughing during exacerbations
d. Shortness of breath with exercise
b. Symptoms occurring more than twice weekly
**Respiratory
Mild persistent asthma is characterized by symptoms that occur more than twice weekly but not daily; or 3-4 nocturnal awakenings per month due to asthma. It is treated with an inhaled steroid daily and a bronchodilator PRN for exacerbations. If symptoms occur more than twice weekly, therapy should be stepped up. Generally, a long-acting bronchodilator is added to the steroid when therapy is stepped up.
The most common sequela of influenza in older adults is:
a. Sinusitis
b. Hepatitis
c. Pneumonia
d. Bronchitis
c. Pneumonia
**Respiratory
More than 90% of deaths associated with influenza occur in older adults. Pneumonia is the most common cause of death and most common reason for hospital admission in older patients with influenza. Annual influenza immunization is recommended for all adults in the United States
Breath sounds auscultated over the periphery of the lung fields are quiet and wispy during the inspiratory phase followed by a short, almost silent expiratory phase. These breath sounds are considered:
a. Vesicular
b. Bronchovesicular
c. Bronchial
d. Crackles
a. Vesicular
**Respiratory
The three normal breath sounds are vesicular, bronchovesicular, and bronchial. Vesicular breath sounds consist of a quiet, wispy inspiratory phase followed by a short, almost silent expiratory phase. They are heard over the periphery of the lung fields. Bronchial breath sounds consist of a full inspiratory and expiratory phase with the inspiratory phase usually being louder. They are normally heard over the trachea and larynx. Bronchovesicular breath sounds consist of a full inspiratory phase with a shortened and softer expiratory phase. They are normally heard over the hilar region. Crackles are adventitious sounds heard in the lungs and may be due to abnormalities in the lungs.
An 80-year-old has Stage 3 COPD. He is most likely to have concomitant:
a. Anxiety or depression
b. Thyroid disease
c. Diabetes
d. Obesity
a. Anxiety or depression
**Respiratory
About 40% of older patients who have COPD have concomitant anxiety and/or depression. It should be treated because it affects the overall management of COPD. COPD is characterized by airflow limitation and dyspnea. This may contribute to feelings of chronic anxiety. Additionally, many chronic diseases are associated with depression. This is the case with COPD.
A patient with pneumonia reports that he has rust-colored sputum. What pathogen should the nurse practitioner suspect?
a. Mycoplasma pneumoniae
b. Chlamydophila pneumoniae
c. Staphylococcus aureus
d. Streptococcus pneumoniae
d. Streptococcus pneumoniae
**Respiratory
Clinical descriptions of mucus do not really help in clinical decision-making regarding pneumonia, but certain clinical characteristics are associated with specific types of pneumonia. Strep pneumonia, also known as pneumococcal pneumonia, is associated with rust-colored sputum.
Scant or watery sputum is associated with atypical pathogens like Mycoplasma and Chlamydophila pneumonia.
Thick, discolored sputum may be associated with bacterial pneumonia.
A 44-year-old nonsmoker is diagnosed with pneumonia. He is otherwise healthy and does not need hospitalization at this time. Which antibiotic can be used for empirical treatment of pneumonia according to the most recent Infectious Diseases Society of America/American Thoracic Society guidelines?
a. Erythromycin
b. Levofloxacin
c. Azithromycin
d. Amoxicillin
d. Amoxicillin
**Respiratory
Amoxicillin (strong recommendation) 1 gram three times daily for initial treatment of uncomplicated pneumonia in outpatients who are otherwise healthy and have not had recent antibiotic exposure. Azithromycin and doxycycline are listed as conditional recommendations first line to treat this patient. Fluoroquinolones are commonly used first line in patients who have comorbidities or who have had recent antibiotic exposure or recent contact with the healthcare system.
Which of the following may be used to diagnose COPD?
a. Chest radiograph or lung CT scan
b. CT scan of the chest or spirometry
c. Pulmonary function tests or spirometry
d. Arterial blood gases or peak flow rate
c. Pulmonary function tests or spirometry
**Respiratory
Spirometry or pulmonary function tests (PFTs) are essential to diagnose COPD. The most important measures are the FEV1 (forced expiratory volume in one second) and FVC (forced vital capacity). Chest radiograph has a poor sensitivity in diagnosing COPD. Only about half of patients with moderately severe COPD can be diagnosed using chest radiography alone. CT scan is able to identify emphysema, but not chronic bronchitis. Arterial blood gases demonstrate hypoxia, but a specific cause is not able to be determined from this test alone.
Mr. Smith has smoked for 45 years. Which of the following medications may worsen one of his diseases?
a. Amlodipine
b. Multivitamin with iron
c. Vitamin B12
d. Propanolol
d. Propanolol
**Respiratory
Propranolol is a nonselective beta blocker and might be potentially more harmful in a patient who has COPD than a cardioselective beta blocker. Nonselective beta blockers can exert their effect on the beta receptors in the lungs. This could produce shortness of breath and would be described as a drug-disease interaction.
A healthy 7-year-old child is diagnosed with atypical pneumonia. He is febrile but not in distress. What is the preferred treatment for him?
a. Supportive measures, it is probably viral
b. Amoxicillin, doses 80-90 mg/kg/d
c. Azithromycin
d. Doxycycline
c. Azithromycin
**Respiratory
Streptococcus pneumonia is the most common bacterial pathogen in all age groups. Atypical pathogens such as Mycoplasma pneumoniae and Chlamydia pneumoniae are common in children >5 years of age who present with abrupt onset of symptoms including malaise, cough, sore throat and headache, but are not ill enough for hospitalization. The initial, preferred antibiotic to treat atypical community acquired pneumonia is a macrolide antibiotic (i.e. azithromycin). Alternative options include levofloxacin and doxycycline if the patient cannot take a macrolide. Amoxicillin would be an appropriate choice for the patient with pneumonia related to S. pneumonia.
The most common cause of atypical pneumonia in adults is:
a. Streptococcus pneumoniae
b. Mycoplasma pneumoniae
c. Chlamydophila pneumoniae
d. Staphylococcus aureus
b. Mycoplasma pneumoniae
**Respiratory
In patients who have atypical pneumonia, Mycoplasma is the most common pathogen. M. Pneumoniae is so named because of its atypical appearance on CXR. This organism is responsible for “walking pneumonia” that is prevalent in a young adult population. This accounts for about 15% of pneumonia and is transmitted via respiratory droplet
The most common cause of pneumonia in people of all ages is:
a. S. pneumoniae
b. Group A Strep
c. S. Aureus
d. Mysoplasma sp.
a. S. pneumoniae
**Respiratory
Streptococcus pneumoniae (s. pneumo) is the most common pathogen in community-acquired pneumonia worldwide. It is more common in age extremes (the very young and very old) and during winter months.
A 6-year-old being treated for community-acquired pneumonia (CAP) has been taking azithromycin in therapeutic doses for 72 hours. His temperature has gone from 102 F to 101 F. What should be done?
a. Continue the same dose and monitor his status
b. Increase the dose to high-dose azithromycin
c. Change antibiotics to a penicillin
d. This is probably viral, stop the antibiotic
c. Change antibiotics to a penicillin
**Respiratory
Improvement should be seen within 24-48 hours if on appropriate antibiotic therapy. Azithromycin treats atypical pathogens like Mycoplasma and Chlamydia, but it has poor strep coverage.
Which medication below is contraindicated in an asthma patient because it may increase risk of sudden death if used alone?
a. Short-acting bronchodilator
b. Long-acting bronchodilator
c. Inhaled steroid
d. Leukotriene blocker
b. Long-acting bronchodilator
**Respiratory
LABA can be used to treat asthma when it is used in combination with an inhaled steroid. Otherwise, it is contraindicated d/t increased risk of sudden death.
A 20-year-old college age student has a positive TB skin test. What choice listed below provides definitive diagnosis of tuberculosis?
a. A chest x-ray
b. A TB skin test
c. A sputum specimen
d. Questionnaire about symptoms
c. A sputum specimen
**Respiratory
Screening for TB is performed with a skin test known as the Mantoux.
CXR is typically performed after a positive skin test, but is not diagnostic since TB can affect organs other than the lungs.
A sputum specimen is used for definitive diagnosis.
A questionnaire is used for screening patients who have a history of positive TB skin test.
“Good control” of asthma is measured by the number of times weekly a patient uses a rescue inhaler. What choice below indicates “good control”?
a. Six times monthly at nighttime
b. Once weekly
c. Not more than three times weekly
d. Not more than once daily and once nightly
b. Once weekly
**Respiratory
Good asthma management is characterized by using SABA (rescue medication) no more than twice weekly during daytime or twice monthly at nighttime.
Using SABA 2 times weekly necessitates use of prophylactic medications such as inhaled steroids and possible use of long-acting bronchodilators in conjunction with inhaled steroids
A 67-year-old patient with COPD presents an immunization record that reflects having last received the pneumococcal immunization (PPSV23) when he was 60 years old. Which statement below reflects the current standard of practice recommended by CDC for this patient?
a. Discuss PCV13 vaccination with the patient
b. He should receive the pneumococcal immunization every 5 years after age 65
c. He should receive PPSV23 only
d. He does not need the immunization
a. Discuss PCV13 vaccination with the patient
**Respiratory
The CDC recommends shared decision making for the patient with COPD. The NP should discuss PCV13 vaccination with the patient. The patient and provider should decide together if PCV13 is appropriate. If administered, it should be followed by one dose of PPSV23 at least 1 year later.
If the patient and provider decide against the PCV13 vaccine, one dose of PPSV23 should be administered now.
If the PPSV23 immunization was given prior to age 65 years, 5 years should elapse before another PPSV23 vaccine is given
An 18-month-old child is diagnosed with bronchiolitis. His respiratory rate is 28 breaths per minute. Which choice below is most appropriate for patient management?
a. Antipyretics
b. Nebulized bronchodilators
c. Inhaled steroids
d. Antibiotics
a. Antipyretics
**Respiratory
Bronchiolitis is a viral infection and antibiotics would be inappropriate. Fever commonly accompanies bronchiolitis.
M. Pneumoniae and C. pneumoniae are respiratory pathogens that:
a. Are spread via direct contact
b. Associated with immunosuppression
c. Cause atypical pneumonia
d. Transmitted via direct contact
c. Cause atypical pneumonia
**Respiratory
These two organisms are common causes of pneumonia. They are called atypical pathogens because they produce atypical pneumonia. They are transmitted via respiratory droplets from the nose and throat of infected people. Prolonged close contact is probably needed for transmission to occur. Patients are usually contagious for 10 days or so. Most commonly, these infections occur in younger patients, but all ages may be affected. Generally, the atypical pathogens are eradicated with macrolide antibiotics or tetracyclines
What disease is usually managed with a short-acting or long-acting inhaled anticholinergic medication?
a. COPD
b. Asthma
c. Bronchitis
d. Bronchiectasis
a. COPD
**Respiratory
First-line treatment for patients with COPD who have intermittent symptoms of shortness of breath is an anticholinergic medication because it improves lung function. Alternatively, a short-acting beta agonist may be used. Anticholinergic medications are not used as a lone agents to manage symptoms of asthma; inhaled steroids usually are. Bronchitis is a viral infection that is self-limited and usually does not require an inhaled medication. Bronchiectasis is a disease in which the respiratory tubules are permanently enlarged. Symptoms include chronic production of purulent mucous.
A 65-year-old patient has COPD. She receives a prescription for an albuterol inhaler. What medication information should be provided to this patient?
a. Use this early in the morning
b. This may cause constipation
c. This may cause tachycardia
d. Rinse your mouth well after using
c. This may cause tachycardia
**Respiratory
SABAs stimulate the beta receptors in the lungs and in the heart. This helps the patient breathe better because it produces bronchodilation, but it potentially can produce arrhythmias or angina because beta receptors in the heart can become stimulated too.
The dose for a patient with underlying cardiac problems is half the dose (and used with caution).
Common side effects of these agents are jitteriness, tremor, nervousness, and potentially hypokalemia if used on a regular basis
A 75-year-old female with emphysema who has been treated with inhaled steroids for many years should:
a. Be screened for osteoporosis
b. Have oxygen at home for exacerbations
c. Use anticholinergics and beta agonists instead of inhaled steroids
d. Be screened for periodontal disease
a. Be screened for osteoporosis
**Respiratory
Older females are at higher risk than others for osteoporosis. This female patient, who has used inhaled steroids, is at increased risk for osteoporosis. Additionally, she probably has emphysema because she smoked (or still smokes). If she is Asian or Caucasian, she has still another risk factor.
Ipratropium is very widely used in the treatment of COPD. Which of the following statements about ipratropium is correct?
a. It slows the progression of COPD
b. It decreases parasympathetic tone and produces bronchodilation
c. It has anti-inflammatory actions and reduces bronchoconstriction
d. It is less effective than a beta agonist in producing bronchoconstriction
b. It decreases parasympathetic tone and produces bronchodilation
**Respiratory
Ipratropium is the most widely studied anticholinergic medication used to treat patients with COPD. It produces its helpful effects by reducing cholinergic tone in the lungs. It may be used with a beta agonist if shortness of breath is present. However, beta agonists increase side effects like tachycardia and tremor and do not improve efficacy.
An example of a short-acting beta agonist (SABA) is:
a. Levalbuterol
b. Salmeterol
c. Mometasone
d. Beclomethasone
a. Levalbuterol
**Respiratory
Examples of SABAs are albuterol or levalbuterol. They provide rapid dilation of the bronchioles and can give immediate relief for shortness of breath; hence the term for this class of medications is rescue medications.
Salmeterol is a long-acting beta agonist. These should never be used without an inhaled steroid to treat a patient with asthma.
Mometasone and beclomethasone are steroids commonly used to treat asthma
Which patient might be expected to have the worst FEV1?
a. An asthma patient in the green zone
b. A 65-year-old with emphysema
c. A 60-year-old with pneumonia
d. A patient with bronchiolitis
b. A 65-year-old with emphysema
**Respiratory
FEV1: Forced expiratory volume in 1 second. This is the volume of air that is forcibly exhaled in the first second of exhalation after a deep breath. Patients with emphysema are not able to do this efficiently because their alveoli are stretched, and mostly contain trapped air. FEV1 is used to assess airway obstruction.
A 6-year-old with sore throat has coryza, hoarseness, and diarrhea. What is the likely etiology?
a. Group A Streptococcus
b. H. parainfluenzae
c. Viral etiology
d. Mycoplasma
c. Viral etiology
**Respiratory
This constellation of symptoms is typical of a viral infection. Group A streptococcus is usually not accompanied by coryza (inflammation and irritation of the mucous membrane of the nose).
H. parainfluenzae is not a common cause of pharyngitis.
Mycoplasma usually is associated with lower respiratory tract infections
The pneumococcal immunization in infants has:
a. Decreased the episodes of acute otitis media due to H. flu
b. Shifted the pathogenesis to fewer cases of S. pneumoniae
c. Eradicated acute otitis media due to S. pneumoniae
d. Improved the prognosis of acute otits media
b. Shifted the pathogenesis to fewer cases of S. pneumoniae
**Respiratory
The heptavalent pneumococcal conjugate vaccine (PCV13), Prevnar, protects children from 13 types of pneumococcal bacteria. It has reduced the incidence of ear infections caused by S pneumo and has reduced the incidence of recurrent ear infections and tube placement by 10-20%. The pathogenesis of acute otitis media has shifted to more cases of H. influenzae, but this organism is less likely to become resistant.
An adult has upper respiratory symptoms and cough for the past 14 days. What should be considered?
a. H. influenza
b. S. pneumoniae
c. Viral agents
d. Pertussis
d. Pertussis
**Respiratory
Pertussis should always be considered in adults who present with acute cough of greater than 5 days duration. The incubation period for pertussis is about 7-10 days. Patients who present with URI symptoms for 1-2 weeks. The classic paroxysmal cough usually begins in the second week of the illness. The duration of symptoms and cough are about 3 months even when treated with antibiotics. This is highly infectious and is a reportable disease.
Which choice below would be the best choice for an 80-year-old patient whose blood pressure is 172/72 mm Hg?
a. Chlorthialidone
b. Amlodipine
c. Monopril
d. Acebutolol
b. Amlodipine
**Cardiovascular
This patient has isolated systolic hypertension. According to many learned authorities, this is best treated with a long-acting calcium channel blocker, particularly the ones that end in “pine”. These belong to the class of calcium channel blockers termed dihydropyridines.
Thiazide diuretics are not potent enough to decrease this patient’s blood pressure into normal range, and its effect is not additive when combined with calcium channel blockers.
A characteristic of an ACE inhibitor-induced cough is that it:
a. Is mildly productive
b. Is worse at nighttime
c. Usually begins within 2 weeks of starting therapy
d. Is more common in men
c. Usually begins within 2 weeks of starting therapy
**Cardiovascular
The cough associated with use of an ACE inhibitor is typically dry and nonproductive. It is more common in women than men and is thought to be due to the buildup of bradykinin. Bradykinin is partly degraded by ACE (angiotensin converting enzyme). Degradation of bradykinin and conversion of antiotensin I to angiotensin II by ACE occurs in the lung. When degradation is impaired, bradykinin can accumulate and cough can ensue.
Which test below is most cost-effective to screen for abdominal aortic aneurysm?
a. CT of the abdomen
b. MRI of the abdomen
c. Abdominal ultrasound
d. Two-hand palpation test
C. Abdominal ultrasound
**Cardiovascular
While an abdominal aortic aneurysm (AAA) might be detected by multiple modalities, including a plain film of the abdomen, it is most cost effectively and efficiently identified using ultrasound. The sensitivity and specificity for AAA identification with ultrasound is nearly 100%. Both CT and MRI are very accurate in identifying AAA, but they are both more expensive than ultrasound.
Which laboratory abnormality may be observed in a patient who takes lisinopril?
a. Decreased INR
b. Decreased calcium level
c. Increased potassium level
d. Increased ALT/AST
c. Increased potassium level
**Cardiovascular
Lisinopril is an ACE inhibitor. This medication causes retention of potassium. A potassium level should be measured about 1 month after initiating therapy and after each dose change. The other laboratory values are not specific to changes that can take place when a patient takes an ACE inhibitor.
Which patient could be expected to have the highest systolic blood pressure?
a. A 21-year-old male
b. A 50-year-old perimenopausal female
c. A 35-year-old patient with Type 2 diabetes
d. A 75-year-old male
d. A 75-year-old male
**Cardiovascular
Nearly 25% of the US population has hypertension. The greatest incidence is in older adults because of changes in the intima of vessels as aging and calcium deposition occur. Males of any age are more likely to be hypertensive than females of the same age. African-American adults have the highest incidence in the general population. Among adolescents, African-Americans and Hispanics have the highest rates. Hypertension occurs in 5-10% of pregnancies
Which study would be most helpful in evaluating the degree of hypertrophy of the atrium or ventricle?
a. Chest x-ray
b. Electrocardiography
c. Echocardiography
d. Doppler ultrasound
c. Echocardiography
**Cardiovascular
Echocardiography is of greatest value when evaluating valves, chamber size, cardiac output, and overall function of the myocardium. It is noninvasive and allows specific measurement of chamber size and thickness of the myocardium.
The chest film is important in identification of chamber enlargement, but its primary importance is in assessment of the pulmonary vasculature.
Electrocardiography (ECG) provides information about the heart’s conduction system and identifies cardiac rhythm, though ventricular enlargement can be identified on ECG.
Doppler ultrasound identifies intracardiac flow velocities and can assist in quantifying the severity of regurgitation or stenosis.
Warfarin treatment is greatly influenced by a patient’s food and medication intake. Which group listed can potentially decrease INR (International Normalized Ratio) in an outpatient who takes warfarin?
a. Alcohol and an aspirin
b. Flu vaccine and ketoprofen
c. Naproxen and celecoxib
d. Sucralfate and cholestyramine
d. Sucralfate and cholestyramine
**Cardiovascular
The drugs listed in choice D will decrease INR in patients who take warfarin concurrently. Sucralfate and calcium carbonate decrease absorption of warfarin. The drugs listed in the other choices will increase INR. Major interactions can occur with celecoxib, ketoprofen, and naproxen. These three NSAIDs are commonly taken by older adults, so this should be part of education with a patient who takes warfarin
How often should blood pressure be measured in a child who is 3 years old?
a. Blood pressure measurement should begin at age 6 years, then every other year.
b. It should be measured every other year.
c. It should be measured annually
d. It should be measured only at well child visits
c. It should be measured annually
**Cardiovascular
Beginning at 3 years of age, blood pressure is measured annually. It continues to be measured annually through adulthood. Prior to age 3 years, blood pressure is not routinely measured. BP is assessed in all four extremities at birth to assess for coarctation of the aorta, patent ductus arteriosus (PDA), other cardiovascular abnormalities, or significant murmurs. If BP is only assessed at well-child visits for older children, it will not occur annually.
A patient who has mitral valve prolapse (MVP) reports chest pain and frequent arrhythmias. In the absence of other underlying cardiac anomalies, the drug of choice to treat her symptoms is:
a. Lisinopril
b. Metoprolol
c. Amlodipine
d. Chlorthalidone
b. Metoprolol
**Cardiovascular
Beta blockers like metoprolol are indicated to alleviate atrial or ventricular arrhythmias associated with mitral valve prolapse. However, long-term effectiveness of beta blockers is uncertain. Most patients with MVP who do not have symptoms of arrhythmias or ectopy at rest usually do not require further evaluation. However, they should be monitored at least annually for a change in their condition.
Mr. Brown is a 45-year-old African American male has the following lab values. What should the nurse practitioner do next?
LDL: 180 mg/dL.
HDL: 37 mg/dL.
Total Cholesterol: 250 mg/dL.
Triglycerides: 140 mg/dL
a. Prescribe a statin daily
b. A thyroid stimulating hormone level
c. A second measurement to confirm diagnosis
d. A stress test done
b. A thyroid stimulating hormone level
**Cardiovascular
If a patient’s lipids are elevated, a TSH should be performed. If the TSH is elevated, it may be a secondary cause of hyperlipidemia. It is considered safe practice to NOT treat elevated lipid levels until the TSH level has decreased to at least 10 mU/L. If the lipids are still elevated, consideration should be given to treatment.
An older adult who has hypertension also has osteoporosis. Which antihypertensive agent would have the secondary effect of improving her osteoporosis?
a. A thiazide diuretic
b. A calcium channel blocker
c. An ACE inhibitor
d. A beta blocker
a. A thiazide diuretic
**Cardiovascular
Thiazide diuretics have the secondary effect of increasing serum calcium by decreasing fluid. This makes more calcium available for absorption. This would not be used to treat a patient with osteoporosis, but this mechanism of action could be helpful as an adjunct for patients who are receiving other forms of treatment for osteoporosis. The other agents listed would have no effect on osteoporosis. Calcium channel blockers impede movement of calcium into cells. This has no effect on available serum calcium.
In older adults, the three most common ailments are:
a. Hearing loss, vision loss, hypertension
b. Hearing loss, hypertension, arthritis
c. Depression, vision loss, hypertension
d. Arthritis, hearing loss, depression
b. Hearing loss, hypertension, arthritis
**Cardiovascular
Hypertension and arthritis are the two most common ailments in older adults. Hearing loss occurs in half to almost 2/3 of older adults. The most common form is known as presbycusis. There is no consensus for the frequency of screening for hearing loss in older patients, but minimally, it should be grossly evaluated at each visit and screened more thoroughly if deficits are observed. Blood pressure should be screened annually, but it is usually screened at each visit. Arthritis is not routinely screened.
The major difference between varicose veins and arteriosclerosis is the:
a. Limbs affected
b. Gender affected
c. Vessels affected
d. Degree of pain
c. Vessels affected
**Cardiovascular
Varicose veins and arteriosclerosis are very different disease processes. While differences can be found in the gender affected, the major difference between the two diseases is the vessel affected. Arteriosclerosis affects the arteries, varicose veins affect the veins. While there is a predilection for the lower extremities in varicose veins, peripheral artery disease (PAD) is most common in the lower extremities too. Varicose veins are especially common in women 2:1; PAD is more common in men 2:1 after age 70 years. Pain is a subjective measure.
Which choice below characterizes a patient who has aortic regurgitation?
a. Long asymptomatic period followed by exercise intolerance, then dyspnea at rest
b. An acute onset of shortness of breath in the fifth or sixth decade
c. Dyspnea on exertion for a long period of time before sudden cardiac death
d. A long asymptomatic period with sudden death usually during exercise
a. Long asymptomatic period followed by exercise intolerance, then dyspnea at rest
**Cardiovascular
The natural course of aortic regurgitation (AR) is that the patient has a long asymptomatic period with slowing of activities but remains essentially asymptomatic. Shortness of breath develops with activity and finally, shortness of breath at rest. The left ventricle eventually fails unless the aortic valve is replaced.
The usual clinical course of mitral valve prolapse:
a. Is benign
b. Results in sudden cardiac death
c. Results in chronic heart failure
d. Is associated with multiple episodes of emboli
a. Is benign
**Cardiovascular
The usual course of mitral valve prolapse (MVP) is benign, and most patients who have MVP are asymptomatic. A murmur may be present and is best auscultated with the diaphragm of the stethoscope over the cardiac apex. In a minority of patients, symptoms of heart failure or sudden death may occur. When heart failure results, it is usually a result of mitral regurgitation. Embolization may occur, but, this is not common or usual in the majority of patients.
Three of the following medications warrant monitoring of potassium levels. Which one does NOT?
a. Fosinopril
b. Candesartan
c. Hydrochlorothiazide
d. Amlodipine
d. Amlodipine
**Cardiovascular
Amlodipine is a calcium channel blocker and its use does not warrant monitoring potassium levels. Fosinopril is an ACE inhibitor and candesartan is an ARB. Both warrant monitoring potassium levels because both have the potential to produce hyperkalemia, especially in patients who have renal impairment or heart failure. Hydrochlorothiazide has the potential to produce hypokalemia, so, it too warrants monitoring of potassium levels.
A 77-year-old patient has had an increase in blood pressure since the last exam. The blood pressure readings are provided. If medication is to be started on this patient, what would be a good first choice?
LAST EXAM…….TODAY’s EXAM
BP: 144/90……..168/88
HR: 70……68
Resp: 18……….18
Temp: 98.1………97.9
a. ACE inhibitor
b. Beta blocker
c. Calcium channel blocker
d. Thiazide diuretic
c. Calcium channel blocker
**Cardiovascular
This patient is 77 years old and should have a goal blood pressure of <150/90 mmHg according to JNC8. A thiazide diuretic is not a good first choice in this patient because it will not be potent enough to decrease blood pressure by about 20 points to get him to goal. A long-acting calcium channel blocker is appropriate for patients who have isolated systolic hypertension and will be more likely to get this patient to goal pressure than HCTZ. Beta blockers are no longer recommended first line for uncomplicated hypertension. ACE inhibitors are very effective in patients who are high renin producers. Older patients tend to produce lower amounts of renin.
A patient with hypertension describes a previous allergic reaction to a sulfa antibiotic as “sloughing of skin” and hospitalization. Which medication is contraindicated in this patient?
a. Ramipril
b. Metoprolol
c. Hydrochlorothiazide
d. Verapamil
c. Hydrochlorothiazide
**Cardiovascular
This patient’s allergy to “sulfa” sounds like Stevens-Johnson Syndrome, a potentially life-threatening allergic reaction. Hydrochlorothiazide has a sulfonamide ring in its chemical structure, generally referred to as “sulfa”. This sulfonamide ring can initiate an allergic reaction in patients with sulfa allergy. Since the patient’s allergic reaction to sulfa was so serious, other sulfonamide medications should be completely avoided until consultation with an allergist. The other medications can be used without concern in the presence of a patient with a sulfa allergy because there is no sulfonamide component.
You are managing the warfarin dose for an older adult with a prosthetic heart valve. Which situation listed requires that warfarin be discontinued now?
a. INR of 3, some bleeding
b. INR of 8, no significant bleeding
c. INR of 6, no significant bleeding
d. INR of 2 with minimal bleeding
b. INR of 8, no significant bleeding
**Cardiovascular
INR is a good measure of the clotting status in an outpatient who takes an oral anticoagulant like warfarin. When warfarin is overdosed and INR climbs, or when warfarin is overdosed because of food or medication that produces deleterious side effects, warfarin doses may be omitted or discontinued until the INR is in a more acceptable range. Generally, one or two doses may be omitted before rechecking INR and resuming warfarin or decreasing the dose.
A 74-year-old who retired as a store clerk last year would like to start an exercise program. She tells the nurse practitioner that she would like to start walking 15-20 minutes daily. Which statement is correct regarding the patient?
a. She should have a stress test prior to initiating a walking program
b. She should have an EKG performed in the clinic today
c. She does not need any testing because she is asymptomatic
d. She should have labs and EKG performed prior to starting
c. She does not need any testing because she is asymptomatic
**Cardiovascular
The obvious risk of starting a new exercise program is the risk of cardiac events. Evidence does not support routine EKG or cardiac testing in patients who are asymptomatic. She should be told about symptoms to watch for and to stop immediately if chest pain or shortness of breath develops.
Screening for abdominal aortic aneurysm should take place:
a. Once for all males aged 65-75 who have ever smoked
b. Once for all men and women who have hypertension
c. Annually after age 75 years for males and females
d. Only if the patient has smoked and has hypertension
a. Once for all males aged 65-75 who have ever smoked
**Cardiovascular
The prevalence of abdominal aortic aneurysm (AAA) is greater in men than women. American Heart Association and USPSTF recommend screening males once between ages 65-75 years if they have ever smoked. Smoking increases the risk of AAA. The USPSTF does not recommend routinely screening for AAA in women or screening for AAA in men who have never smoked. Screening may be considered in men aged 65-75 years if they have a first-degree relative who required repair of AAA.
A 50-year-old patient with hypertension has taken hydrochlorothiazide 25 mg daily for the past 4 weeks. How should the nurse practitioner proceed?
BP went from 155/95 to 145/90
HR went from 69 to 66
a. Wait 4 weeks before making a dosage change
b. Increase the hydrochlorothiazide to 50 mg daily
c. Add a drug from another class to the daily 25 mg hydrochlorothiazide
d. Stop the hydrochlorothiazide and start a drug from a different class
c. Add a drug from another class to the daily 25 mg hydrochlorothiazide
**Cardiovascular
The recommended target blood pressure, according to JNC 8 for this 50-year-old patient is <140/90 mmHg. The current plan has not allowed this patient to meet this goal so it is not acceptable to continue current dose. Increasing HCTZ dose will only result in increased potassium loss, not further decrease in blood pressure
A patient will be screened for hyperlipidemia via a serum specimen. He should be told:
a. To fast for 12-14 hours
b. To fast for 6-8 hours
c. That black coffee is allowed
d. A nonfasting state will not affect the results
a. To fast for 12-14 hours
**Cardiovascular
Serum total and HDL cholesterol is fine to measure fasting or nonfasting but triglyceride levels will elevate 3-4 hours after eating and there may be several peaks during a 12-hour period.
A patient with mitral regurgitation (MR) has developed the most common arrhythmia associated with MR. The intervention most likely to prevent complications from this arrhythmia is:
a. Immediate referral for a pacemaker
b. Anticoagulation
c. Beta blocker administration
d. Valve replacement
b. Anticoagulation
**Cardiovascular
The most common arrhythmia associated with mitral regurgitation (MR) is atrial fibrillation. Anticoagulation with warfarin will help prevent arterial embolism that can result in stroke or myocardial infarction. Atrial fibrillation occurs because the fibers in the atrium are stretched as the atrium dilates. The stretch results in conduction defects, notably atrial fibrillation.
In order to reduce lipid levels, statins are most beneficial when taken:
a. Once daily in the AM
b. Always with food
c. With an aspirin in the evening
d. In conjunction with diet and exercise
b. Anticoagulation
**Cardiovascular
Benazepril should be discontinued immediately if:
a. Dry cough develops
b. Pregnancy occurs
c. Potassium levels decrease
d. Gout develops
b. Pregnancy occurs
**Cardiovascular
ACE inhibitors are contraindicated during pregnancy because of teratogenic effects on the renal system of the developing fetus.
ACE inhibitors may cause increased potassium levels, not decreased.
Gout is not exacerbated by ACE inhibitor use
A patient with aortic stenosis has been asymptomatic for decades. On routine exam, he states that he has had some dizziness associated with activity but no chest pain or shortness of breath. The best course of action for the nurse practitioner is to:
a. Monitor closely for worsening of his status
b. Refer to cardiology
c. Order a CBC, metabolic panel and UA
d. Assess his carotid arteries for bruits
b. Refer to cardiology
**Cardiovascular
In patients with known aortic stenosis who have been asymptomatic, one should be alert for symptoms that will precede angina, heart failure, and syncope. Dizziness precedes syncope in these patients and so this is an early indication that the patient is becoming symptomatic. Once symptoms develop, there is a rapid downhill course. Therefore, dizziness, chest discomfort, or exercise intolerance are important symptoms to assess in previously asymptomatic patients who have AS. This patient should be referred to cardiology.
A child’s resting heart rate is expected to be between 60-100 beats per minute once he reaches:
a. 4 years of age
b. 6 years of age
c. 10 years of age
d. 12 years of age
c. 10 years of age
**Cardiovascular
Age 4-6: average HR between 60-140, by age 10 it is more close to an adult normal which is 60-100 beats per minute.
The carotid arteries are auscultated for bruits because:
a. A bruit is indicative of an impending stroke
b. A bruit is indicative of carotid stenosis
c. This is indicative of generalized atherosclerosis
d. This is reflective of stroke risk
c. This is indicative of generalized atherosclerosis
**Cardiovascular
Asymptomatic bruits in the carotid area are more indicative of atherosclerotic disease than increased stroke risk. A symptomatic bruit requires immediate attention. Patients with carotid artery disease are more likely to die of cardiovascular disease than cerebrovascular disease.
According to the National Heart, Lung, and Blood Institute, which characteristic listed below is a coronary heart disease risk equivalent: that is, which risk factor places the patient at a CHD risk similar to a history of CHD?
a. Hypertension
b. Cigarette smoking
c. Male age >45 years
d. Diabetes mellitus
d. Diabetes mellitus
**Cardiovascular
Ramipril has been initiated at a low dose in a patient with heart failure. What is most important to monitor in about 1 week?
a. Heart rate
b. Blood pressure
c. EKG
d. Potassium level
d. Potassium level
**Cardiovascular
ACE inhibitors work in the kidney in the renin angiotensin aldosterone system and can impair renal excretion of potassium in patients who have normal kidney function. In patients who have impaired renal blood flow and/or function, the risk of hyperkalemia is increased. Common practice is to monitor potassium, BUN, and Cr at about 1 week after initiation of an ACE inhibitor and with each increase in dosage in a patient who has heart failure and who receives an ACE inhibitor.
The lipid particle with the greatest atherogenic effect is:
a. cholesterol
b. HDL
c. LDL
d. triglycerides
c. LDL
LDL cholesterol promotes atherosclerosis via several different mechanisms. Consequently, LDL cholesterol tends to be the primary target when patients are treated pharmacologically for elevated lipid levels. Low HDL levels and elevated triglyceride levels can accelerate atherogenesis.
An otherwise healthy two-year-old presents with a heart rate that varies with inspiration and expiration. Which statement is true?
a. The child has ingested too much caffeine.
b. A cardiology referral is prudent.
c. This is a normal exam.
d. There is a need for an echocardiogram.
c. This is a normal exam.
Sinus arrhythmia occurs when an irregular heart rate increases with inspiration and decreases with respiration and is considered normal in children. There is no need for an echo or referral to a cardiologist nor should the child be evaluated for caffeine intake.
The diagnosis of mitral valve prolapse can be confirmed by:
a. physical examination.
b. electrocardiography.
c. echocardiography.
d. chest X-ray.
c. echocardiography.
The best means to identify mitral valve prolapse (MVP) is with echocardiography. It will identify bulging of either, or both, of the leaflets (anterior or posterior) into the left atrium. Approximately 2% of the US population is identified to have MVP. A chest X-ray will not enable visualization of the mitral leaflets. Electrocardiography identifies the heart’s electrical activity. A physical exam may provide great clues to MVP, but in the absence of definitive mid to late systolic clicks, a diagnosis cannot be confirmed.
A 50-year-old patient with hypertension has taken hydrochlorothiazide 25 mg daily for the past 4 weeks. How should the nurse practitioner proceed?
a. Wait 4 weeks before making a dosage change.
b. Increase the hydrochlorothiazide to 50 mg daily.
c. Add a drug from another class to the daily 25 mg hydrochlorothiazide.
d. Stop the hydrochlorothiazide and start a drug from a different class.
c. Add a drug from another class to the daily 25 mg hydrochlorothiazide.
The recommended target blood pressure, according to JNC 8, for this 50-year-old patient is <140/90 mmHg. The current plan has not allowed this patient to meet this goal, so it is not acceptable to continue the current dose. Increasing the hydrochlorothiazide to 50 mg daily will not result in a decrease in blood pressure, only an increase in potassium loss. Adding a drug from a different medication class is a good choice because the combined effects of antihypertensive medications nearly always produce a decrease in blood pressure and both drugs can be maintained in low doses to minimize side effects.
The correlation between blood pressure and age greater that 60 years is that as age increases:
a. diastolic blood pressure increases.
b. systolic blood pressure decreases.
c. blood pressure remains about the same.
d. diastolic blood pressure decreases.
d. diastolic blood pressure decreases.
As age increases (>60 years), systolic blood pressure tends to increase, but diastolic blood pressure tends to decrease. This is evidenced by the observation of isolated systolic hypertension, seen almost exclusively in the older population. This results in a widening pulse pressure, a predictor of cardiovascular events in older adults. The pulse pressure is calculated by subtracting the diastolic blood pressure from the systolic blood pressure. Measurements greater than 60-70 points indicate “stiffening” of the vessels. Stiffening commonly occurs as aging occurs.
A child’s resting heart rate is expected to be between 60 and 100 beats per minute once he reaches:
a. 4 years of age.
b. 6 years of age.
c. 10 years of age.
d. 12 years of age.
c. 10 years of age.
Normal heart rate varies with age. Generally, as the heart becomes more efficient, the rate begins to decrease. This occurs with age. 4- and 6-year old children can be expected to have normal heart rates between 60 and 140 beats per minute. By age 10 years, the usual heart rate more closely approximates that of an adult, 60-100 beats per minute.
How often should blood pressure be measured in a child who is 3 years old?
a. Blood pressure measurement should begin at age 6 years, then every other year.
b. It should be measured every other year.
c. It should be measured annually.
d. is should be measured only at well child visits.
c. It should be measured annually.
Beginning at 3 years of age, blood pressure is measured annually. It continues to be measured annually through adulthood. Prior to age 3 years, blood pressure is not routinely measured. Blood pressure is assessed in all four extremities at birth to assess for coarctation of the aorta, patent ductus arteriosus (PDA), other cardiovascular abnormalities, or significant murmurs. If blood pressure is only assessed at well-child visits for older children, it will not occur annually.
A patient will be screened for hyperlipidemia via a serum specimen. He should be told:
a. to fast for 12-14 hours.
b. to fast for 6-8 hours.
c. that black coffee is allowed.
d. a nonfasting state will not affect the results.
a. to fast for 12-14 hours.
Serum total and HDL cholesterol can be measured in fasting or nonfasting patients. There are very small and clinically insignificant differences in these values whether fasting or not. The primary effect of eating on a patient’s lipid values is elevation of the triglyceride levels. The maximum elevation of triglyceride levels occurs at 3-4 hours after eating, but there may be several peaks during a 12-hour period. Therefore, the most accurate triglyceride levels will be obtained following a 12-hour fast.
The usual clinical course of mitral valve prolapse:
a. is benign.
b. results in sudden cardiac death.
c. results in chronic heart failure.
d. is associated with multiple episodes of emboli.
a. is benign.
The usual course of mitral valve prolapse (MVP) is benign, and most patients who have MVP are asymptomatic. A murmur may be present and is best auscultated with the diaphragm of the stethoscope over the cardiac apex. In a minority of patients, symptoms of heart failure or sudden death may occur. When heart failure results, it is usually a result of mitral regurgitation. Embolization may occur, but, this is not common or usual in the majority of patients.
Which choice below would be the best choice fo an 80-year-old patient whose blood pressure is 172-72 mm Hg?
a. Chlorthalidone
b. Amlodipine
c. Monopril
D. Acebutolol
b. Amlodipine
This patient has isolated systolic hypertension. According to many learned authorities, this is best treated with a long-acting calcium channel blocker, particularly the ones that end in “pine.” These belong to the class of calcium channel blockers termed dihydropyridines. Thiazide diuretics are not potent enough to decrease this patient’s blood pressure into normal range, and its effect is not additive when combined with calcium channel blockers.
In older adults, the three most common ailments are:
a. hearing loss, vision loss, hypertension.
b. hearing loss, hypertension, arthritis.
c. depression, vision loss, hypertension.
d. arthritis, hearing loss, depression.
b. hearing loss, hypertension, arthritis.
Hypertension and arthritis are the two most common ailments in older adults. Hearing loss occurs in half to almost 2/3 of older adults. The most common form is known as presbycusis. There is no consensus for the frequency of screening for hearing loss in older patients, but minimally, it should be grossly evaluated at each visit and screened more thoroughly if deficits are observed. Blood pressure should be screened annually, but it is usually screened at each visit. Arthritis is not routinely screened.
The carotid arteries are auscultated for bruits because:
a. a bruit is indicative of an impending stroke.
b. a bruit is indicative of carotid stenosis.
c. this is indicative of generalized atherosclerosis.
d. this is reflective of stroke risk.
c. this is indicative of generalized atherosclerosis.
Asymptomatic bruits in the carotid area are more indicative of atherosclerotic disease than increased stroke risk. A symptomatic bruit requires immediate attention. Patients with carotid artery disease are more likely to die of cardiovascular disease when cerebrovascular disease. The Framingham heart Study found that patients with an asymptomatic carotid bruit were at increased risk of stroke, but the majority of strokes occurred in an area away from the carotid artery. The overall risk of stroke was insignificant when an asymptomatic carotid bruit was identified.
A 77-year-old patient has had an increase in blood pressure since the last exam. The blood pressure readings are provided. If medication is to be started on this patient, what would be a good first choice?
a. ACE inhibitor
b. Beta blocker
c. Calcium channel blocker
d. Thiazide diuretic
c. Calcium channel blocker
This patient is 77 years old and should have a goal blood pressure of <150/90 mmHg according to JNC8. A thiazide diuretic is not a good first choice in this patient because it will not be potent enough to decrease blood pressure by about 20 points to get him to goal. A long-acting calcium channel blocker is appropriate for patients who have isolated systolic hypertension and will be more likely to get this patient to goal pressure than HCTZ. Beta blockers are no longer recommended first line for uncomplicated hypertension. ACE inhibitors are very effective in patients who are high renin producers. Older patients tend to produce lower amounts of renin.
A patient who has mitral valve prolapse (MVP) reports chest pain and frequent arrhythmias. In the absence of other underlying cardiac anomalies, the drug of choice to treat her symptoms is:
a. lisinopril.
b. metoprolol.
c. amlodipine.
d. chlorthalidone.
b. metoprolol.
Beta blockers like metoprolol are indicated to alleviate atrial or ventricular arrhythmias associated with mitral valve prolapse. However, long–term effectiveness of beta blockers is uncertain. Most patients with MVP who do not have symptoms of arrhythmias or ectopy at rest usually do not require further evaluation. However, they should be monitored at least annually for a change in their condition.
A characteristic of an ACE inhibitor-induces cough is that it:
a. is mildly productive.
b. is worse at nighttime.
c. usually begins within 2 2eeks of starting therapy.
d. is more common in men.
c. usually begins within 2 2eeks of starting therapy.
The cough associated with use of an ACE inhibitor is typically dry and nonproductive. It is more common in women than men and is thought to be due to the buildup of bradykinin. Bradykinin is partly degraded by ACE (angiotensin converting enzyme). Degradation of bradykinin and conversion of angiotensin I to angiotensin II by ACE occurs in the lung. When degradation is impaired, bradykinin can accumulate and cough can ensue.
Which choice below characterizes a patient who has aortic regurgitation?
a. Long asymptomatic period followed by exercise intolerance, then dyspnea at rest
b. An acute onset of shortness of breath in the fifth or sixth decade
c. Dyspnea on exertion for a long period of time before sudden cardiac death
d. A long asymptomatic period with sudden death usually during exercise
a. Long asymptomatic period followed by exercise intolerance, then dyspnea at rest
The natural course of aortic regurgitation (AR) is that the patient has a long asymptomatic period with slowing of activities but remains essentially asymptomatic. Shortness of breath develops with activity and finally, shortness of breath at rest. The left ventricle eventually fails unless the aortic valve is replaced.
Three of the following medications warrant monitoring of potassium levels. Which one does NOT?
a. Fosinopril
b. Candesartan
c. Hydrochlorothiazide
d. Amlodipine
d. Amlodipine
Amlodipine is a calcium channel blocker and its use does not warrant monitoring potassium levels. Fosinopril is an ACE inhibitor and candesartan is an ARB. Both warrant monitoring potassium levels because both have the potential to produce hyperkalemia, especially in patients who have renal impairment or heart failure. Hydrochlorothiazide has the potential to produce hypokalemia, so, it too warrant monitoring of potassium levels.
A patient with aortic stenosis has been asymptomatic for decades. On routine exam, he states that he has had some dizziness associated with activity but no chest pain or shortness of breath. The best course of action for the nurse practitioner is to:
a. monitor closely for worsening of his status.
b. refer to cardiology.
c. order a CBC, metabolic panel and UA.
d. assess his carotid arteries for bruits.
b. refer to cardiology.
In a patient with known aortic stenosis (AS) who has been asymptomatic for decades, one should be alert for symptoms that will precede angina, heart failure, and syncope. Dizziness precedes syncope in these patients and so this is an early indication that the patient is becoming symptomatic from his AS. Once symptoms develop, there is a rapid downhill course. Therefore, dizziness, chest discomfort, or exercise intolerance are important symptoms to assess in previously asymptomatic patients who has AS. This patient should be referred to cardiology.
Mr. Brown a 45-year-old African American male has the following lab values. What should the nurse practitioner do next?
LDL 180 mg/dL
HDL 37 mg/dL
Cholesterol, Total 250 mg/dL
Triglycerides 140 mg/dL
a. Prescribe a statin daily
b. A thyroid stimulating hormone (TSH) level
c. A second measurement to confirm diagnosis
d. A stress test done
b. A thyroid stimulating hormone (TSH) level
If a patient’s lipids are elevated, a TSH should be performed. If the TSH is elevated, it may be a secondary cause of hyperlipidemia. It is considered safe practice to NOT treat elevated lipid levels until the TSH level has decreased to at lest 10 mU/L. If the lipids are still elevated, consideration should be given to treatment.
An older adult who has hypertension also has osteoporosis. Which antihypertensive agent would have the secondary effect of improving her osteoporosis?
a. A thiazide diuretic
b. A calcium channel blocker
c. An ACE inhibitor
d. A beta blocker
a. A thiazide diuretic
Thiazide diuretics have the secondary effect of increasing serum calcium by decreasing fluid. This makes more calcium available for absorption. This would not be used to treat a patient with osteoporosis, but this mechanism of action could be helpful as an adjunct for patients who are receiving other forms of treatment for osteoporosis. The other agents listed would have no effect on osteoporosis. Calcium channel blockers impede movement of calcium into cells. This has no effect on available serum calcium.
You are managing the warfarin dose for an older adult with a prosthetic heart valve. Which situation listed requires that warfarin be discontinued now?
a. INR of 3, some bleeding
b. INR of 8, no significant bleeding
c. INR of 6, No significant bleeding
d. INR of 2 with minimal bleeding
b. INR of 8, no significant bleeding
INR is a good measure of the clotting status in an outpatient who takes an oral anticoagulant like warfarin. When warfarin is overdosed and INR climbs, or when warfarin is overdosed because of food or medication that produces deleterious side effects, warfarin doses may be omitted or discontinued until the INR is in a more acceptable range. Generally, one of two doses may be omitted before rechecking INR and resuming warfarin or decreasing the dose.
A patient has had poorly controlled hypertension for more than 10 years. Indicate the most likely position of his point of maximal impulse (PMI):
a. 5th Intercostal space (ICS) midclavicular line (MCL).
b. 8th ICS MCL.
c. 5th ICS, left of MCL.
d. 6th ICS, right of MCL.
c. 5th ICS, left of MCL.
The PMI or apical impulse is produces when the left ventricle moves anteriorly and touches the chest wall during contraction. This is normally found at the 5th intercostal space, midclavicular line. Certain conditions and diseases like heart failure or cardiomyopathy may account for this; or left ventricular hypertrophy from prolonged hypertension can displace the apical impulse. The displacement usually occurs left and laterally from is usual location. Thus, 5th ICS, left of midclavicular line. Conditions like pregnancy may displace the apical impulse upward and to the left.
A common side effect of thiazide diuretics is:
a. prostatitis.
b. erectile dysfunction.
c. fatigue.
d. hyperkalemia.
b. erectile dysfunction.
Several studies have demonstrated that erectile dysfunction (ED) is associated with use of thiazide diuretics, specifically chlorthalidone. When ED was evaluated in patients taking chlorthalidone, acebutolol, amlodipine, enalapril, and doxazosin (medications from major antihypertensive drug classes), the thiazide diuretic chlorthalidone had the greatest incidence of ED. The other drugs in the study were no more likely to cause ED than a placebo. however, a common complaint of men on antihypertensive medications is ED. This should always be evaluated as a side effect of antihypertensive treatment.
Which patient could be expected to have the highest systolic blood pressure?
a. A 21-year-old male
b. A 50-year-old perimenopausal female
c. A 35-year-old patient with Type 2 diabetes
d. A 75-year-old male
d. A 75-year-old male
Nearly 25% of the US population has hypertension. The greatest incidence is in older adults because of changes in the intima of vessels as aging and calcium deposition occur. Males of any age are more likely to be hypertensive than females of the same age. African American adults have the highest incidence in the general population. Among adolescents, African Americans and Hispanics have the highest rates. Hypertension occurs in 5-10% of pregnancies.
The most common indicator of end-organ damage in adolescents with hypertension is:
a. left ventricular hypertrophy.
b. seizure.
c. renal dysfunction.
d. renal artery damage.
a. left ventricular hypertrophy.
The most common manifestation of end-organ damage in hypertensive adolescents is left ventricular hypertrophy (LVH). According to the National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents, as many as 41% of children who have hypertension have LVH identifiable on ECG.
According to the National Heart, Lung and Blood Institute, which characteristic listed below is a coronary heard disease (CHD) risk equivalent; that is, which risk factor places the patient at a CHD risk similar to a history of CHD?
a. Hypertension
b. Cigarette smoking
c. Male age > 45 years
d. Diabetes mellitus
d. Diabetes mellitus
In determining whether a patient should be treated for hyperlipidemia, a patient’s risk factors must be determined. After assessing fasting lipids, specifically LDLs, CHD equivalents must be identified. These are diabetes, symptomatic carotid artery disease, peripheral artery disease, abdominal aortic aneurysm, and multiple risk factors that confer a 10-year risk of CHD > 20%. Major CHD risk factors are elevated LDL cholesterol, cigarette smoking, hypertension, low HDL cholesterol, family history of premature CHD [in male first-degree relatives (FDR) < 55 years; female FDR, 65 years], and age (men >45 years, women >55 years). Patients with 2 or more risk factors should have a 10-year risk assessment performed and be treated accordingly.
Which item below represents the best choice of antihypertensive agents for the indicated patient?
a. Beta blocker for a 38-year-old diabetic patient
b. ACE inhibitor for a patient on a K+ sparing diuretic
c. Lisinopril in a 35-year-old Caucasian male
d. Diuretic in a patient with history of gout
c. Lisinopril in a 35-year-old Caucasian male
An ACE inhibitor is a preferred initial medication choice in a nonblack patient according to JNC8. Beta blockers may mask the signs and symptoms of hypoglycemia in patients who have diabetes and so are not preferred. ACE inhibitors decrease potassium loss and so should not be routinely used in patients who are on potassium=sparing diuretics because hyperkalemia may result. Diuretics can produce hyperuricemic states due to fluid loss. Therefore, they should be avoided in patients with history of gout.
At what age should initial blood pressure screening take place?
a. 3 years
b. 4-6 years
c. 6 years
d. 6-10 years
a. 3 years
Blood pressure should be measured immediately after birth and anytime a cardiac problem is suspected. After this time, blood pressure screening should begin at 3 years of age and then, annually. A pediatric blood pressure table must be used because normal blood pressure varies with age, gender, and height. A pediatric blood pressure table will display the maximum systolic and diastolic blood pressure expected for the child. Taller and heavier children will have higher blood pressures.
What choice below would be beneficial to a 76-year-old who takes daily oral steroids for COPD and now takes a daily aspirin for primary prevention of myocardial infarction?
a. Screen for infection with H. pylori
b. Daily proton pump inhibitor (PPI)
c. Antacids PRN heartburn
d. Daily use of low dose famotidine
b. Daily proton pump inhibitor (PPI)
Aspirin does increase the risk of gastrointestinal bleeding, especially if it is given in combination with oral steroids. Most learned authorities and ACOVE (Assessing Care of Vulnerable Elders) agree that when two or more risk factors for GI bleed are present, aspirin should not be added without some form of protection for the GI tract (misoprostol or a daily PPI). In considering all the risks for GI bleed, the most significant ones are age >75 years, history of GI bleeding, warfarin use, daily NSAID use, and chronic steroid use.
An ACE inhibitor is specifically indicated in patients who have:
a. hypertension, diabetes with proteinuria, heart failure.
b. diabetes, hypertension, hyperlipidemia.
c. asthma, hypertension, diabetes.
d. renal nephropathy, heart failure, hyperlipidemia.
a. hypertension, diabetes with proteinuria, heart failure.
ACE inhibitors have numerous indications. Three are indicated in the first choice. ACE inhibitors are also indicated in patients who have renal insufficiency. However, ACE inhibitors can worsen renal insufficiency, so the patients must be monitored closely with lab tests for BUN, Cr, and potassium. Diabetes without proteinuria is not a specific indication for ACE inhibitors use, though they are used by some healthcare providers in this way. This is an off-label use.
The major difference between varicose veins and arteriosclerosis is the:
a. limbs affected.
b. gender affected.
c. vessels affected.
d. degree of pain.
c. vessels affected.
Varicose veins and arteriosclerosis are very different disease processes. While the differences can be found in the gender affected, the major difference between the two diseases is the vessel affected. Arteriosclerosis affects the arteries, varicose veins affect the veins. While there is a predilection for the lower extremities in varicose veins, peripheral artery disease (PAD) is most common in the lower extremities too. Varicose veins are especially common in women 2:1; PAD is more common in men 2:1 after age 70 years. Pain is a subjective measure.
The nurse practitioner is caring for an independent 74-year-old female who had acute coronary syndrome (ACS) about 6 weeks ago. What medications should be part of her regimen unless there is a contraindication?
a. ASA and beta blocker
b. ACE and beta blocker
c. ACE, ASA, and beta blocker
d. ACE, ASA, beta blocker, and statin
d. ACE, ASA, beta blocker, and statin
After a myocardial event, an aspirin, ACE inhibitor, beta blocker, and statin should be dosed daily. The aspirin will provide anticoagulation; the ACE inhibitor, statin and beta blocker are associated with reduced morbidity and mortality if given soon after ACS.
Screening for abdominal aortic aneurysm should take place:
a. once for all males aged 65-75 who have ever smoked.
b. once for all men and women who have hypertension.
c. annually after age 75 years for males and females.
d. only if the patient has smoked and has hypertension.
a. once for all males aged 65-75 who have ever smoked.
The prevalence of abdominal aortic aneurysm (AAA) is greater in men than women. American Heart Association and USPSTF recommend screening males once between ages 65-75 years if they have ever smokes. Smoking increases the risk of AAA. The USPSTF does not recommend routinely screening for AAA in women or screening for AAA in men who have never smokes. Screening may be considered in men aged 65-75 years if they have a first-degree relative who required repair of AAA.
Which medication listed below could potentially exacerbate heart failure in a susceptible patient?
a. Metoprolol
b. Furosemide
c. Insulin
d. Acetaminophen
a. Metoprolol
Metoprolol is a cardioselective beta blocker that decreases heart rate. A patient who has acute heart failure will compensate by increasing heart rate to maintain cardiac output (CO). Metoprolol impairs the patient’s ability to increase heart rate when needed to maintain cardiac output (CO=stroke volume x heart rate). Consequently, the use of beta blockers in patients with heart failure should be monitored carefully. Furosemide may actually improve shortness of breath in a patient with heart failure. Insulin and acetaminophen have no direct effect on cardiac output in a patient with heart failure.
Which mitral disorder results from redundancy of the mitral valve’s leaflets?
a. Acute mitral regurgitation
b. Chronic mitral regurgitation
c. Mitral valve prolapse
d. Mitral stenosis
c. Mitral valve prolapse
Mitral valve prolapse (MVP) is the most common adult murmur. It is best heard with the diaphragm of the stethoscope over the cardiac apex. It is a result of redundancy of the mitral valve leaflets and subsequent degeneration of the mitral tissue. The posterior leaflet is more commonly affected than the anterior leaflet. The valve’s annulus becomes enlarged in conjunction with elongation of the chordae tendineae.
Benazepril should be discontinues immediately if:
a. dry cough develops.
b. pregnancy occurs.
c. potassium levels decrease.
d. gout develops.
b. pregnancy occurs.
Benazepril is an ACE inhibitor and this class of drugs is contraindicated during pregnancy because of teratogenic effects on the renal system of the developing fetus. Dry cough is an aggravating side effect that occurs in some patients who take ACE inhibitors, but discontinuation is elective. ACE inhibitor use is associated with increased potassium levels, not decreased levels. Gout is not exacerbated by ACE inhibitor use.
Which medications could potentially exacerbate heart failure (HF)?
a. Naproxen
b. Furosemide
c. Atorvastatin
d. Aspirin
a. Naproxen
Naproxen is an NSAID. NSAIDs cause sodium retention and thus, water retention. A single dose of naproxen is unlikely to produce HF symptoms, but repeated subsequent doses are very likely to produce water retention sufficient to cause edema and possible shortness of breath in susceptible people. The other medications lister are unlikely to have any direct effect on cardiac output in a patient who has HF.
A patient with poorly controlled hypertension and history of myocardial infarction 6 years ago presents today with mild shortness of breath. He takes quinapril, ASA, metoprolol, and a statin daily. What symptom is NOT indicative of heart failure?
a. Fatigue
b. Headache
c. Orthopnea
d. Cough
b. Headache
Fatigue is a common symptom in cardiac patients, and it can represent a worsening of many cardiac diseases, such as coronary artery disease, heart failure, or valvular dysfunction. Orthopnea and cough, especially nocturnal, are classic symptoms of worsening heart failure. Headache is a nonspecific symptom and is not typical of heart failure.
Classic symptoms of deep vein thrombosis (DVT) include:
a. swelling, pain, redness.
b. calf complaints, pain with walking, history of exercise.
c. swelling, pain, and discoloration in lower extremity.
d. warmth, edema, and relief of pain with walking.
c. swelling, pain, and discoloration in lower extremity.
Swelling, pain, and discoloration from impaired blood flow are the classic symptoms. Choice A could describe infection, like cellulitis, and is not classic for DVT. Redness is an inconsistent sign of DVT as is a positive Homan’s sign. A history of exercise actually decreases the risk of DVT. Pain secondary to DVT is not relieved by walking. The lower extremities are the most likely location of DVT, but symptoms don’t always correlate with location of the thrombosis. Patients must be asked about history, family history of DVT, and precipitation conditions.
Which laboratory abnormality may be observed in a patient who takes lisinopril?
a. Decreased INR
b. Decreased calcium level
c. Increased potassium level
d. Increased ALT/AST
c. Increased potassium level
Lisinopril is an ACE inhibitor. This medication causes retention of potassium. A potassium level should be measured about 1 month after initiating therapy and after each dose change. The other laboratory values are not specific to changes that can take place when a patient takes an ACE inhibitor.
Warfarin treatment is greatly influenced by a patient’s food and medication intake. Which group listed can potentially decrease INR (International Normalized Ratio) in an outpatient who takes warfarin?
a. Alcohol and an aspirin
b. Flu vaccine and ketoprofen
c. Naproxen and celecoxib
d. Sucralfate and cholestyramine
d. Sucralfate and cholestyramine
The drugs listed in choice D will decrease international normalized ratio (INR) in patients who take warfarin concurrently. Sucralfate and calcium carbonate decrease absorption of warfarin. The drugs listed in the other choices will increase INR. Major interactions can occur with celecoxib, ketoprofen, and naproxen. These three NSAIDs are commonly taken by older adults, so this should be part of education with a patient who takes warfarin.
A patient with hypertension has been diagnosed with gout. Which home medication may have contributed to this episode of gout?
a. Lisinopril
b. Amlodipine
c. Furosemide
d. Allopurinol
c. Furosemide
Gout is characterized by hyperuricemia. Uris acid levels are increased when a patient consumes any medication that results in less circulating fluid volume, specifically, any diuretic. Diuretics such as furosemide will produce hyperuricemia and thus increase the risk of gout in susceptible patients. Diuretics should be avoided when possible in patients who have a history of gout.
A 74-year-old who retired as a store clerk last year would like to start an exercise program. She tells the nurse practitioner that she would like to start walking 15-20 minutes daily. Which statement is correct regarding the patient?
a. She should have a stress test prior to initiating a walking program.
b. She should have an EKG performed in the clinic today.
c. She does not need any testing because she is asymptomatic.
d. She should have labs and EKG performed prior to starting.
c. She does not need any testing because she is asymptomatic.
The obvious risk of starting a new exercise program is the risk of cardiac events. Evidence does not support routine EKG or cardiac testing in patients who are asymptomatic. She should be told about symptoms to watch for and to stop immediately if chest pain or shortness of breath develops. A 74-year-old who retires last year will benefit from any type of exercise. She will develop improved conditioning, reduce her risk of many chronic diseases including cardiovascular disease, reduce the risk of falls, and decrease functional limitations. Exercised for older adults fall into four categories: aerobic, muscle strengthening, flexibility and balance.
In order to reduce lipid levels, statins are most beneficial when taken:
a. once daily in the AM.
b. always with food.
c. with an aspirin in the evening.
d. in conjunction with diet and exercise.
d. in conjunction with diet and exercise.
Statins are used to reduce elevated levels of lipids in conjunction with modifications in diet and exercise. The timing of statin dosing and indication with food (or not) is specific to each statin. Many patients who take statins are also candidates for aspirin as primary or secondary prevention, but aspirin is not beneficial in reducing lipid levels. Statins are correctly taken once daily but not necessarily in the AM.
A patient taking an ACE inhibitor should avoid:
a. strenuous exercise.
b. potassium supplements.
c. protein-rich meals.
d. grapefruit juice.
b. potassium supplements.
An ACE inhibitor potentially can produce hyperkalemia because its mechanism of action is to spare potassium in the renin angiotensin aldosterone system. If potassium is taken in the form of potassium supplements, the effect will be additive and the risk of hyperkalemia can be great.
A patient taking candesartan for treatment of hypertension should avoid:
a. strenuous exercise.
b. potassium supplements.
c. protein-rich meals.
d. grapefruit juice.
b. potassium supplements.
An ARB like candesartan potentially can produce hyperkalemia because its mechanism of action is to spare potassium in the renin angiotensin aldosterone system. If potassium is taken in the form of potassium supplements, the effect will be additive and the risk of hyperkalemia will be great.
Older adults have a unique blood pressure pattern. Which blood pressure reading below reflects this pattern?
a. 100/50 mmHg
b. 140/100 mmHg
c. 160/60 mmHg
d. 160/100 mmHg
c. 160/60 mmHg
Nearly 2/3 of all older adults who are hypertensive have isolated systolic hypertension, i.e., the systolic blood pressure is elevated, the diastolic is normal. This probably occurs because the vessels stiffen as people age and a higher systolic is required to move blood through stiffened vessels. Elevated systolic blood pressure is an important risk factor for cardiovascular disease and stroke in older adults.
Older adults have a unique blood pressure pattern. Which blood pressure reading below reflects this pattern?
a. 100/50 mmHg
b. 140/100 mmHg
c. 160/60 mmHg
d. 160/100 mmHg
c. 160/60 mmHg
Nearly 2/3 of all older adults who are hypertensive have isolated systolic hypertension, i.e., the systolic blood pressure is elevated, the diastolic is normal. This probably occurs because the vessels stiffen as people age and a higher systolic is required to move blood through stiffened vessels. Elevated systolic blood pressure is an important risk factor for cardiovascular disease and stroke in older adults.
A congenital heart abnormality often discovered during the newborn period is coarctation of the aorta. How is this assessed?
a. By comparing right and left femoral pulses
b. By comparing right and left pedal pulses
c. By comparing upper and lower extremity blood pressures
d. By auscultating an audible bruit in the carotid arteries
c. By comparing upper and lower extremity blood pressures
Coarctation is frequently missed on initial assessment. This disorder is characterized by elevated blood pressures in the upper extremities and diminished blood pressures in the lower extremities. It can be assessed by measuring and comparing blood pressures in the upper and lower extremities.
A decrease in blood pressure can occur in men who take sildenafil (Viagra) and:
a. ibuprofen.
b. trimethoprim-sulfamethoxazole.
c. levothyroxine.
d. any antihypertensive medication.
d. any antihypertensive medication.
Any antihypertensive medication could have an additive effect with sildenafil (or another medication in this class). Caution is advised and sildenafil should only be used if the male has stable blood pressure. A specific drug-drug interaction to be aware of is the one that can occur with sildenafil and alpha blockers like tamsulosin, alfuzosin, prazosin, doxazosin, or terazosin. This combination of medications may increase the risk of symptomatic hypotension because the effect of these two drugs is additive.
Which study would be most helpful in evaluating the degree of hypertrophy of the atrium or ventricle?
a. Chest X-ray
b. Electrocardiography
c. Echocardiography
d. Doppler ultrasound
c. Echocardiography
Echocardiography is of greatest value when evaluating valves, chamber size, cardiac output, and overall function of the myocardium. It is noninvasive and allows specific measurement of chamber size and thickness of the myocardium. The chest film is important in identification of chamber enlargement, but its primary importance is in assessment of the pulmonary vasculature. Electrocardiography (ECG) provides information about he heart’s conduction system and identifies cardiac rhythm, though ventricular enlargement can be identified on ECG. Doppler ultrasound identifies intracardiac flow velocities and can assist in quantifying the severity of regurgitation or stenosis.
An immune response to Group A Streptococcal infections involving the heart is:
a. Kawasaki syndrome.
b. rheumatic fever.
c. hemolytic disease.
d. pericarditis.
b. rheumatic fever.
Rheumatic fever is the correct answer. The immune response involves not just the heart, but can affect the joints, skin, and central nervous system. 0.1-0.3% of untreated or undertreated infections involving Group A beta hemolytic Strep can result in rheumatic fever. More often than not, this involves an infection in the upper airways. The most common age group affected is 5-15 years. however, the residual effect of rheumatic fever is realized into the later decades of life.
A young child has an audible murmur. The nurse practitioner describes it as a grade 4 murmur. How should this be managed?
a. The child should be monitored for other abnormal findings.
b. The child should be referred to cardiology.
c. An EKG should be performed.
d. The nurse practitioner should palpate to see if a thrill is present.
b. The child should be referred to cardiology.
The child should be referred to pediatric cardiology. A grade 4 designation for a murmur indicates that a murmur is loud and has a thrill associated with it. The finding of a thrill (characteristic of a grade 4 murmur) is always an abnormal finding and requires a referral. A thrill can be palpated with the examiner’s hand over the anterior chest in the area of the point of maximal impulse (PMI).
Which hypertensive patient is most likely to have adverse blood pressure effects from excessive sodium consumption?
a. 21-year-old Asian American male
b. 35-year-old menstruating female
c. 55-year-old post menopausal female
d. 70-year-old African American male
d. 70-year-old African American male
Two groups of patients typically experience adverse blood pressure effects from consumption of sodium greater than 2,000 mg daily. Those patients considered to be most sodium sensitive are elderly patients and African American patients. Thus, choice d is the best choice listed.
Which test below is most cost-effective to screen for abdominal aortic aneurysm?
a. CT of the abdomen
b. MRI of the abdomen
c. Abdominal ultrasound
d. Two-hand palpation test
c. Abdominal ultrasound
While an abdominal aortic aneurysm (AAA) might be detected by multiple modalities, including a plain film of the abdomen, it is most cost effectively and efficiently identified using ultrasound. The sensitivity and specificity for AAA identification with ultrasound is nearly 100%. Both CT and MRI are very accurate in identifying AAA, but they are both more expensive than ultrasound.
A patient with hypertension describes a previous allergic reaction to a sulfa antibiotic as “sloughing of skin” and hospitalization. Which medication is contraindicated in this patient?
a. Ramipril
b. Metoprolol
c. Hydrochlorothiazide
d. Verapamil
c. Hydrochlorothiazide
This patient’s allergy to “sulfa” sounds like Stevens-Johnson Syndrome, a potentially life-threatening allergic reaction. Hydrochlorothiazide has a sulfonamide rind in its chemical structure, generally referred to as “sulfa.” This sulfonamide ring can initiate an allergic reaction in patients with sulfa allergy. Since the patient’s allergic reaction to sulfa was so serious, other sulfonamide medications should be completely avoided until consultation with an allergist. The other medications can be used without concern in the presence of a patient with a sulfa allergy because there is no sulfonamide component.
A patient who has diabetes presents with pain in his lower legs when he walks and pain resolution with rest. When specifically asked about the pain in his lower leg, he likely will report pain:
a. in and around the ankle joint.
b. in the calf muscle.
c. radiating down his leg from the thigh.
d. pain in his lower leg which waxes and wanes.
b. in the calf muscle.
This patient’s symptoms are typical of arteriosclerosis. The term used to describe this patient’s symptom is intermittent claudication. When there is compromised arterial blood flow in the lower legs, a common complaint is reproducible pain in a specific group of muscles. The pain occurs because there is an incongruence between blood supply and demand. This produces pain that causes a patient to stop exercising in order to obtain pain relief.
How often should lipids be screened in patients who are 65 years and older if they have lipid disorders or cardiovascular risk factors?
a. Annually
b. Every other year
c. Every 3 years
d. Every 5 years.
a. Annually
Screening should take place annually for patients who have coronary artery disease and other risk factors like diabetes, peripheral artery disease, or prior stroke. These patients are at very high risk and annual screening is economically justified. In a setting of low-risk patient who does have any of the above mentioned risk factors, United States Preventive Services Task Force recommends screening every 5 years.
Which of the following medications may have an unfavorable effect on a hypertensive patient’s blood pressure?
a. Lovastatin
b. Naproxen
c. Inhaled fluticasone
d. Amoxicillin
b. Naproxen
Naproxen is an NSAID. NSAIDs produce sodium retention and hence, water retention. This produces many systemic effects, such as an increase in blood pressure, lower extremity edema, increased workload on the heart, and inhibition of prostaglandin syntheses. Patients with hypertension and heart failure should use NSAIDs cautiously. Lovastatin, fluticasone, and amoxicillin would not be expected to increase or decrease blood pressure.
Which class of medication is frequently used to improve long-term outcomes in patients with systolic dysfunction?
a. Loop diuretics
b. Calcium channel blockers
c. ACE inhibitors
d. Thiazide diuretics
c. ACE inhibitors
ACE inhibitors are commonly used in patients with systolic dysfunction because they reduce morbidity and mortality, i.e. these medications alter prognosis. They also improve symptoms of fatigue, shortness of breath, and exercise intolerance. Lop and thiazide diuretics improve symptoms, but do not alter long-term prognosis with heart failure. Beta blockers should be used in conjunction with ACE inhibitors and diuretics, but not as solo agents. Beta blockers can potentially worsen heart failure, so their use in patients with heart failure should be monitored carefully. Despite this fact, beta blockers decrease morbidity and mortality associated with heart failure.
Mrs. Brandy is having contrast dye next week for a heart catheterization. What drug does NOT need to be stopped prior to her catheterization?
a. Naproxen
b. Furosemide
c. Metformin
d. Losartan
d. Losartan
Naproxen and furosemide should be stopped for 24 hours prior to the catheterization. Metformin should be stopped 48 hours prior to the catheterization. Furosemide is stopped because it contributes to volume depletion. NSAIDs like naproxen are withheld because of the impact on renal prostaglandin production. Metformin has been implicated in lactic acidosis when combines with contract dye in an impaired kidney.
A patient taking an angiotensin receptor blocker (ARB) should avoid:
a. strenuous exercise.
b. potassium supplements.
c. protein-rich meals.
d. grapefruit juice.
b. potassium supplements.
An ARB potentially can produce hyperkalemia because its mechanism of action is in the renin-angiotensin-aldosterone system, where potassium is spared. If potassium is taken in the form of potassium supplements, the effect will be additive and the risk of hyperkalemia can be great.
A 75-year-old has isolated systolic hypertension. She started on amlodipine 4 weeks ago. She states that since then, she has developed urinary incontinence. What is the nurse practitioner’s assessment?
a. This is unrelated to her new medication.
b. Is is coincidental.
c. She may have underlying urinary tract pathology.
d. It is probably related to amlodipine.
d. It is probably related to amlodipine.
Amlodipine is a long-acting calcium blocker (CCB). Calcium is responsible for muscle contraction. Sometimes CCBs worsen or produce urinary incontinence by impairing detrusor contraction. A lower dose of calcium channel blocker could be tried, a different class could be tried, or as a last resort, incontinence products could be used.
A patient with mitral regurgitation (MR) has developed the most common arrhythmia associated with MR. The intervention most likely to prevent complications from this arrhythmia is:
a. immediate referral for a pacemaker.
b. anticoagulation.
c. beta blocker administration.
d. valve replacement.
b. anticoagulation.
The most common arrhythmia associated with mitral regurgitation (MR) is atrial fibrillation. Anticoagulation with warfarin will help prevent arterial embolism that can result in stroke or myocardial infarction. Atrial fibrillation occurs because the fibers in the atrium are stretched as the atrium dilates. The stretch results in conduction defects, notable, atrial fibrillation.
Mrs. Jones is an 85-year-old who has average blood pressures of 170/70 mmHg. Which agent would be a good starting medication to normalize her blood pressure?
a. Fosinopril
b. Losartan
c. Amlodipine
d. Hydrochlorothiazide
c. Amlodipine
This patient has isolated systolic hypertension (ISH), common in older adults. Long-acting calcium channel blockers (CCB), specifically those with the suffix “pine,” and thiazide diuretics, are recommended for starting treatment in patients with ISH. Amlodipine is probably a better choice in this patient because she needs a substantial decrease in her systolic blood pressure. Thiazide-type diuretics produce an average decrease of 2-8 points in the systolic blood pressure. The CCBs are more potent and a more significant decrease in blood pressure could be expected.
Pharmacologic treatment for children who have hypertension should be initiated for:
a. those who are obese.
b. Stage 1 hypertension.
c. diabetics with hypertension.
d. asymptomatic Stage 1 or Stage 2 hypertension.
c. diabetics with hypertension.
Pharmacologic treatment should be initiated for children who have both hypertension and diabetes, symptomatic hypertension, hypertension >95th percentile, when end-organ damage is present. Obesity is a risk factor, but it is not a sole indicator of treatment.
A patient who takes HCTZ 25 mg daily has complaints of muscle cramps. He probably has:
a. hypocalcemia.
b. hypomagnesemia.
c. hypokalemia.
d. hypercalcemia.
c. hypokalemia.
HCTZ is a thiazide diuretic that is potassium-wasting. Patients can become hypokalemic and experience side effects of this. A common one is muscle cramps.
A medication that may produce exercise intolerance in a patient who has hypertension is:
a. hydrochlorothiazide.
b. amlodipine.
c. metoprolol.
d. fosinopril.
c. metoprolol.
Metoprolol is a cardioselective beta blocker. It can produce bradycardia that is responsible for exercise intolerance. As a patient exercises, a concomitant increase in heart rate allows for an increase in cardiac output. If the heart rate is not able to increase because of beta blocker influence, neither can the cardiac output. The patient will necessarily slow down his physical activity. Choices a and d have no direct effect on heart rate. Amlodipine is a calcium channel blocker that does not decrease heart rate.
Most hypertension in preadolescents and children is:
a. obesity-related.
b. primary hypertension.
c. secondary hypertension.
d. endocrine-related.
c. secondary hypertension.
Secondary hypertension is more common in preadolescence, with most cases caused by renal disease. Primary or essential hypertension is more common in adolescents and has multiple risk factors, including obesity and a family history of hypertension.
A common, early finding in patients who have chronic aortic regurgitation (AR) is:
a. an hypertrophied left ventricle.
b. atrial fibrillation.
c. pulmonary congestion.
d. low systolic blood pressure.
a. an hypertrophied left ventricle.
The left ventricle enlarges as blood regurgitates from the aorta. Atrial fibrillation is not typical or usual in aortic regurgitation (AR), since neither atrium is affected. Pulmonary congestion is seen later in the pathogenesis of AR. The blood pressure in patients with AR is characterized by an elevated systolic and decreased diastolic pressure. This is termed a wide pulse pressure.
A 75-year-old patient with longstanding hypertension takes an ACE inhibitor and a thiazide diuretic daily. He has developed dyspnea on exertion and peripheral edema over the past several days. This probably indicates:
a. worsening hypertension.
b. development of heart failure (HF).
c. noncompliance with medication.
d. acute myocardial infarction.
b. development of heart failure (HF).
The symptoms of dyspnea on exertion and peripheral edema are symptoms of HF. Long standing hypertension is a risk factor for HF. Acute myocardial infarction would result in acute symptoms, not development of symptoms over the past several days. Noncompliance with medication and fluid or sodium excess might result in peripheral edema and development of heart failure.
Which antibiotic should be used with caution if an older patient has cardiac conduction issues?
a. Amoxicillin-clavulanate
b. Trimethoprim-sulfamethoxazole
c. Ciprofloxacin
d. Macrodantin
c. Ciprofloxacin
Quinolones such as ciprofloxacin and levofloxacin are often used to treat urinary tract infections, especially in older adults. All of the quinolones have been implicated in possible QT interval prolongation. Knowing this should cause prescribers to use care, especially when using these or other quinolones in adults who have underlying conduction defects. This is especially the case if a patient is concurrently taking other drugs that can prolong the QT interval.
Many factors can contribute to the risk of congenital heart disease. Which maternal disease carries a higher risk of transposition of the great vessels (TGA), ventricular septal defect (VSD), and hypertrophic cardiomyopathy?
a. Hypothyroidism
b. Diabetes
c. Lupus
d. Hypertension
b. Diabetes
Maternal diabetes increases the risk of the above names diseases. Congenital infections like cytomegalovirus, herpesvirus, rubella, or coxsackie virus can increase the risk of many cardiac structural abnormalities. TORCH is an acronym used to describe five maternal infections that are deleterious to the fetus. The acronym TORCH stands for Toxoplasmosis, Other (syphilis), Rubella, Cytomegalovirus (CMV), Herpes simples virus (HSV).
Pharmacologic treatment for older adults with hypertension should be initiated:
a. only if there is a life expectancy of 10 years or more.
b. for any type of hypertension.
c. without regard to lifestyle modifications.
d. only for those who are symptomatic.
b. for any type of hypertension.
Hypertension management has been found to be beneficial in preventing stroke and cardiac events in all ages. Treatment should begin without regard to age. Older adults are more likely to exhibit isolated systolic hypertension. This has been found to be a strong predictor of cardiac and cerebral events if not managed appropriately.
Which infant feeding behavior is least likely related to congenital heart disease (CHD)?
a. Limited intake of volume of milk.
b. Feedings that take “a long time” to complete.
c. Feedings that are interrupted by sleeping.
d. Infants that burp frequently when feeding.
d. Infants that burp frequently when feeding.
Infants who burp frequently probably are swallowing too much air with feeding. This is likely not related to congenital heart disease. Some red flags associated with feeding that should prompt the examiner to assess for congenital heart disease include feedings interrupted by choking, gagging, or vomiting. Some infants have rapid breathing with feeding or a persistent cough or wheeze. These should be assessed and CHD should be considered.
A child received a burn on his chest from a cup of hot coffee. On examination, the injured area appeared moist, red to ivory white in color, and features blisters. It is painful to touch. this burn would be classified as a:
a. superficial thickness burn.
b. superficial partial thickness burn.
c. deep partial thickness burn.
d. full thickness burn.
b. superficial partial thickness burn.
Types of burn injuries are chemical, electric, radiation, or thermal. They are classified by the depth of damaged skin. Symptoms of superficial partial thickness burns include: moist areas that are red to ivory white in color, immediate blister formation and painful to touch (pain receptors are intact). Superficial thickness burns appear erythematous without blisters and usually have local pain. Deep partial thickness burns have a dry, waxy, whitish appearance and resemble full thickness burns. Sometimes grafts are needed. Full thickness burns involve the destruction of all skin elements with coagulation of subdermal plexus, muscle, and or tendons.
A patient will be taking oral terbinafine for fingernail fungus. The NP knows that:
a. this will cure her infection 95% of the time.
b. a topical antifungal will work just as well when the nail matrix is involved.
c. terbinafine is an inhibitor of the CYP 2D6 enzymes.
d. toenail fungus resolves faster than fingernail fungus after treatment.
c. terbinafine is an inhibitor of the CYP 2D6 enzymes.
Many oral antifungal agents inhibit the 3A4 or 2D6 enzymes in the cytochrome P450 system. This is why they must be used with extreme caution (or not used) in patients who consume medications that need 3A4 or 2D6 enzymes for metabolism. And, liver enzymes must be monitored in patients who take oral antifungal medications and discontinued if elevations are >2.5 times the upper limits of normal. No oral agent has a 95% cure rate for fingernail fungus (tinea unguium). This can be a difficult infection to clear even if oral antifungal agents are utilized. A topical antifungal agent typically will not clear the infection if the nail matrix is involved. There is anecdotal evidence that menthol ointments or bleach may cause resolution when used topically. Generally, resolution of fingernail fungus occurs more rapidly than toenail fungus because toenails grow at slower rates than fingernails.
The nurse practitioner is examining a 3-month-old infant who has normal development. She has identified an alopecic area at the occiput. What should be done?
a. Order a TSH
b. Order a hydrocortisone cream
c. Suspect child abuse
d. Encourage the caregiver to change the infant’s head position
d. Encourage the caregiver to change the infant’s head position
In a normally developing infant, an alopecic area at the occipital area generally develops because the infant has been placed in the supine position during sleeping and waking hours. Prolonged pressure on the occipital area can restrict hair growth. This is normal and will resolve when the infant begins to have better head control and movement; and she begins to have less pressure on the occipital area. Sometimes coarse, dry hair can be indicative of hypothyroidism; not necessarily alopecia.
A 9-year-old has been diagnosed with chickenpox. A drug that should be avoided in him is:
a. penicillin.
b. aspirin.
c. ibuprofen.
d. sulfa.
b. aspirin.
Aspirin should always be avoided in the case of viral infections in children and adolescents. The incidence of Reye syndrome is increased if aspirin is given. This is especially true with varicella and influenza infections. The typical constellation of symptoms occurs during a bout of chickenpox and includes nausea, vomiting, headache, excitability, delirium, and combativeness with progression to coma. Since aspirin use has declined sharply, Reye syndrome has too.
The lesions seen in a patient with folliculitis might be filled with:
a. blood.
b. pus.
c. fluid.
d. serous fluid.
b. pus.
Folliculitis is a superficial inflammation of hair follicles usually caused by bacteria. As a superficial infection, it involves only the epidermis. When this occurs, there are usually numerous pustular lesions. The composition of pus is dead white cells and other cellular debris.
A patient presents to the minor care area of the emergency department after being bitten by a dog. The patient states that the dog had a tag around his neck and had been seen roaming around the neighborhood for days before the patient was bitten. The dog did not exhibit any odd behavior. How should this be managed?
a. If the bites are only minor, do not mention rabies prophylaxis to the patient.
b. Give the patient tetanus immunization only. Don’t call animal control.
c. Clean the wounds, provide tetanus and rabies prophylaxis.
d. Report the bite to animal control and administer appropriate medical care.
d. Report the bite to animal control and administer appropriate medical care.
All 50 states require reporting of animal bites to animal control or the state’s appropriate authority for reporting animal bites. It sounds unlikely that the dog could be infected with rabies, but rabies prophylaxis must be considered after all history and information has been gathered.
Patients with atopic dermatitis are likely to exhibit:
a. itching.
b. asthma and allergic bronchitis.
c. nasal polyps and asthma.
d. allergic conjunctivitis and wheezing.
a. itching.
Atopic dermatitis is diagnosed on clinical presentation and includes evidence of pruritic skin. It is recurrent and often begins in childhood. For decades the “atopic triad” has been used to refer to patients with atopic dermatitis, asthma, and allergic rhinitis. This has recently been called into question. A similar triad, knows as Samter’s triad, consists of asthma, aspirin sensitivity, and nasal polyps. Samter’s triad is not the same as the atopic triad.
Which of the following areas of the body has the greatest percutaneous absorption?
a. Sole of the foot
b. Scalp
c. Forehead
d. Genitalia
d. Genitalia
Genitalia have the highest percutaneous absorption across the entire body. this is important because low-potency creams will act with greater potency in this area. Low-potency creams/lotions should be used initially for treating skin conditions involving the genitalia. The sole of the foot has the lower percutaneous absorption, followed by the scalp, forehead, and genitalia. Therefore, the sole of the foot will require more potent vehicles to enhance absorption.
A patient with a primary case of scabies was probably infected:
a. 1-3 days ago.
b. 1 week ago.
c. 2 weeks ago.
d. 3-4 weeks ago.
d. 3-4 weeks ago.
The incubation period for scabies is about 3-4 weeks after primary infection. Patients with subsequent infections with scabies will develop symptoms in 1-3 days. The classic symptom is itching that is worse at night, couples with a rash that appears in new areas over time.
The primary therapeutic intervention for patients who present with hives is:
a. steroids.
b. antihistamines.
c. calcium channel blockers.
d. topical steroid cream.
b. antihistamines.
The primary cause of pruritus associated with hives is histamine release. Histamine is released from mast cells with other substances of anaphylaxis. Antihistamines are the primary therapeutic intervention. Topical steroid use is not helpful. Calcium channel blockers (nifedipine) are used as a “last resort” for refractory cases of urticaria. Steroids do not inhibit mast cell degradation and so are less helpful than thought. Steroids can be used for persistent attacks of acute urticaria if antihistamines are not helpful.
A 71-year-old female presents with a vesicular rash that burns and itches. Shingles is diagnosed. An oral antiviral:
a. should be started within 72 hours of the onset of symptoms.
b. must be started within 96 hours of the onset of the rash.
c. can be started at any time after appearance of the rash.
d. will nearly eliminate the risk of postherpetic neuralgia.
a. should be started within 72 hours of the onset of symptoms.
This patient has been diagnosed with shingles. This can produce a painful neuritis. Shingles is treated with an oral antiviral agent, preferably within 72 hours of onset of the symptoms. Treating shingles with an oral antiviral agent shortens the severity and duration of shingles. It may also help decrease the incidence of post-herpetic neuralgia.
Which of the following antibiotics may increase the likelihood of photosensitivity?
a. Amoxicillin
b. Cephalexin
c. Ciprofloxacin
d. Azithromycin
c. Ciprofloxacin
Many medications can produce a phototoxic reaction when a patient is exposed to sunlight. Antibiotics are especially notable for this. Common antibiotics associated with photosensitivity are tetracyclines, sulfa drugs, and fluoroquinolones. Ciprofloxacin is a fluoroquinolone. Amoxicillin and cephalexin are beta lactam antibiotics. Azithromycin is a macrolide antibiotic. Other common medication/classes that increase photosensitivity are hydrochlorothiazide, diltiazem, selective serotonin reuptake inhibitors, antihistamines, ibuprofen, and naproxen.
A 3-year-old female had a fever of 102° F for the last 3 days. Today she wode up from a nap and is afebrile. She has a maculopapular rash. Which statement is true?
a. This child probably has measles.
b. The rash will blanch.
c. This is a streptococcal rash.
d. This could be Kawasaki disease.
b. The rash will blanch.
This describes a patient with roseola or exanthem subitum. This is a common viral exanthem found in young children caused by human herpes virus 6. It is characterized by high fever for 3 days followed by the abrupt cessation of fever and the appearance of a maculopapular rash. This usually resolved in a few days. The child may return to school or daycare when he has been fever-free for 24 hours.
A skin lesion that is a solid mass is described as a:
a. macule.
b. papule.
c. vesicle.
d. bullae.
b. papule.
A papule is an elevated solid mass up to 1.0 cm. in diameter. A macule is flat and small, like a freckle. A vesicle is filled with a serous fluid and less than 1.0 cm in diameter. A bullae is fluid filled and larger than 1.0 cm in diameter.
A topical treatment for basal cell carcinoma is:
a. sulfacetamide lotion.
b. 5-fluorouracil.
c. tetracycline lotion.
d. trichloroacetic acid.
b. 5-fluorouracil.
Several treatments exist for basal and squamous cell carcinoma. The majority are simple procedures like cryotherapy, electrodessication, surgical excision, and a topical treatment like 5-fluorouracil (5-FU). The other agents listed are not used to treat basal or squamous cell carcinoma. 5-FU works by inhibiting DNA synthesis. It is effective if used for superficial basal cell carcinomas. It is available in cream and solution and is usually applied twice daily for 3-6 weeks.
A patient has used a high-potency topical steroid cream for years to treat psoriasis exacerbations when they occur. She presents today and states that this cream “just doesn’t work anymore.” What word describes this?
a. Rebound effect
b. Tachyphylaxis
c. Tolerance
d. Lichenification
b. Tachyphylaxis
Tachyphylaxis is the word used to describe when a medication becomes progressively less effective after repetitive administration. This is particularly true of topical glucocorticoids, bronchodilators, nitroglycerine, and antihistamines when they are overused. The rebound effect describes a condition in which initial clinical improvement occurred, but worsening has occurred. Lichenification refers to a thickening of the skin. Drug-free intervals are important to prevent tachyphylaxis.
A 6-year-old has been diagnosed with Lyme disease. Which drug should be used to treat him?
a. Doxycycline
b. Amoxicillin
c. Azithromycin
d. Cephalexin
b. Amoxicillin
Amoxicillin, doxycycline, and cefuroxime have all been shown to have equivalent efficacy for treatment of Lyme disease. However, because this patient is 6 years old, he should not be given doxycycline as a first line treatment unless the other regimens are contraindicated. Macrolides like azithromycin should not be used first line because they are poorly effective at eradicating infection. They may be used in patients who are intolerance of penicillins and cephalosporins and who cannot take doxycycline. first-generation cephalosporins like cephalexin are poorly effective and should not be used.
The American Cancer Society uses and ABCDE mnemonic to help patients develop awareness of suspicious skin lesions. What does the “B” represent?
a. Bleeding
b. Black
c. Border
d. Benign
c. Border
The mnemonic is helpful when looking at skin lesions, but it is primarily used for patient education. The “A” represents asymmetry (asymmetrical lesions are worrisome), “B” is border (irregular borders), “C” is color (colored lesions have more melanin and may be associated with malignant melanoma), “D” is diameter (larger than a pencil eraser [6 mm] is concerning), and “E” represent enlarging or elevated (lesions that are actively enlarging are growing; elevated lesions are concerning).
A 40-year-old female patient presents to the clinic with multiple, painful reddened nodules on the anterior surface of both legs. She is concerned. These are probably associated with her history of:
a. deep vein thrombosis
b. phlebitis.
c. ulcerative colitis.
d. alcoholism.
c. ulcerative colitis.
These nodules describe erythema nodosum. These are most common in women aged 15-40 years old. They are typically found in pretibial locations and can be associated with infections agents, drugs, or systemic inflammatory disease like ulcerative colitis. They probably occur as a result of a delayed hypersensitivity reaction to antigens. It is not unusual to find polyarthralgia, fever, and/or malaise that precede or accompany the skin nodules.
An example of a premalignant lesion that develops on sun-damaged skin is:
a. actinic keratosis.
b. basal cell carcinoid.
c. squamous cell carcinoma.
d. molluscum contagiosum.
a. actinic keratosis.
Actinic keratoses (AK) are a result of solar damage to the skin. They are most common on the face, bald scalp, and forearms. Patients who present with AK usually have multiple of them. A characteristic that helps identification of AK is an area of erythema that surrounds the lesion. AK is sometimes easier felt than seen.
A microscopic examination of the sample taken from a skin lesion indicates hyphae. What type of infection might this indicate?
a. Bacterial
b. Viral
c. Parasitic
d. Fungal
d. Fungal
Under microscopic exam, hyphae are long, thin and branching and indicate dermatophytic infections. Hyphae are typical in tinea pedis, tinea cruris, and tinea corporis.
When can a child with chickenpox return to daycare?
a. 24 hours after he is fever-free
b. 48 hours after he is fever-free
c. After all lesions have crusted
d. When he no longer itches
c. After all lesions have crusted
Chickenpox is highly contagious and can be spread via respiratory secretions from an infected person or by direct contact from the vesicle fluid from lesions on the skin or mucus membranes. The usual incubation period is about 2 weeks but can be as long as 21 days or as short at 10 days. The greatest period of infectivity is 48 hours prior to the onset of the rash and until all the skin lesions have crusted over.
What finding is most characteristic of shingles?
a. Pain, burning, and itching
b. Single dermatome affected
c. Presence of grouped vesicles
d. Presence of rash and crusting
b. Single dermatome affected
Shingles is herpes zoster. It characteristically affects a shingle dermatome. Grouped vesicle on an erythematous base may occur in some patients with shingles, but this is not unique to shingles. In fact, it is typical in many viral infections. Crusting may be seen with shingles, chicken pox, or impetigo. Pain, burning, and itching are symptoms that some patients have with shingles, but not all patients report itching with shingles.
A patient presents with small vesicles on the lateral edges of his fingers and intense itching. On close inspection, there are small vesicles on the palmar surface of the hand. What is this called?
a. Seborrheic dermatitis
b. Dyshidrotic dermatitis
c. Herpes zoster
d. Varicella zoster
b. Dyshidrotic dermatitis
This dermatitis is intensely pruritic and involves the palms and soles and lateral aspects of the fingers. Over a couple of weeks, the vesicles desquamate. Recurrences are common. Seborrheic dermatitis affects only hairy areas of the body. The vesicles might raise suspicion of a viral infection, but this is not present in this case.
The agent commonly used to treat patients with scabies is permethrin. How often should it be applied to eradicate scabies?
a. Once
b. Once daily for 3 days
c. Twice daily for 3 days
d. Once daily for 1 week
a. Once
A single whole-body application of permethrin is usually successful in eradicating infection with scabies. It is applied over the entire body from the neck down. The lotion is left on and then showered off 8-12 hours later. All contact must be treated at the same time and all potential fomites (bed linen, mattresses, cloth furniture, etc.) must be treated as well. Permethrin can be sprayed on cloth fomites, or the fomite can be bagged for several days, washed, and dried in a washing machine and dryer. Ironing clothes after washing them is acceptable.
Wat is the proper technique to safely removed a tick from a human?
a. Pull it off with tweezers
b. Use petroleum jelly
c. Use isopropyl alcohol
d. Use a hot match
a. Pull it off with tweezers
Use tweezers to pull it off. If tweezers are not available, protected fingers should be used. The person removing the tick should take care NOT to crush the tick because it may contain infectious organisms. After the tick is removed, the skin should be washed well with soap and water. If mouth parts remain after the tick has been removed, they should NOT be removed. They will be expelled on their own and removed of these parts may cause significant skin trauma. The area should be monitored for 30 days for erythema migrans.
A patient reports that he found a tick on himself about 2 weeks ago. He presents today with a red circle and a white center near where he remembers the tick bite. He did not seek treatment at that time. Today he complains of myalgias and arthralgias. Which laboratory test can be used to help diagnose Lyme disease?
a. CBC
b. Lyme titer
c. ELISA
d. Skin scraping
c. ELISA
A detailed history should always precede testing for Lyme disease. The red circle with the white center is likely erythema migrans (EM). EM is the characteristic skin lesion of Lyme disease (and other illnesses) and usually occurs within 1 month following the tick bite. Many learned authorities, including the Infections Diseases Society of America, conclude that individuals should not be screened/tested for Lyme disease unless they have a high probability of having Lyme disease. In this case, historical features coupled with physical exam support the diagnosis, and thus screening. The most common initial serologic test for screening is an ELISA. If it is positive, it should be confirmed with a Western blot. Unfortunately, there are a large number of false positives and so a confirmation should be performed.
Impetigo is characterized by:
a. honey-colored crusts.
b. silvery scales.
c. marble-like lesions.
d. wheals with pus.
a. honey-colored crusts.
Impetigo is a superficial bacterial infection of the skin characterized by honey-colored crusts. Another form of impetigo is characterized by the presence of bullae. These infections are treated with topical antibiotics, good hygiene, and frequent hand washing. It is usually caused by Staphylococcus or Group A Streptococcus.
A 23-year-old male appears in clinic with the following nonpruritic lesion on his trunk. He first noticed this about 3 days ago. The lesion is probably:
a. scabies.
b. eczema.
c. a herald patch.
d. psoriasis.
(Image is similar to ring-worm)
c. a herald patch.
Pityriasis rosea is a viral rash that is common in older children and young adults. It typically begins with a herald patch, a single round pink or salmon-colored, nonpruritic plaque on the chest, neck, or back. It is often mistaken for ringworm prior to the eruption of the Christmas tree pattern rash. The rash occurs within 1-2 weeks after the appearance of the herald patch. Scabies typically presents as a pruritic eruption characterized by small, erythematous, nondescript papules. Its prominent clinical feature is pruritus. Most cases of eczema initially occur by the age of five years, but can manifest in adults as an area os pruritic, thickened (lichenified), and excoriated skin in the flexural area. Psoriasis may present as silvery scales or plaques.
Mr. Johnson is a 74-year-old who presents with a pearly-domes, nodular-looking lesion on the back of the neck. It does not hurt or itch. What is a likely etiology?
a. Basal cell carcinoma
b. Squamous cell carcinoma
c. Malignant melanoma
d. Actinic keratosis
a. Basal cell carcinoma
Basal cell’s classic description is “a pearly-domes nodule with a telangiectatic vessel”. It is commonly found on sun-exposed areas like the head or neck. Sending the patient to dermatology (since these represent skin cancer) best treats these lesions. Sometimes these lesions can be treated with a topical agent like 5-fluorouracil if they are superficial; others require surgical removal.
A 68-year-old female adult with pendulous breasts complains of “burning” under her right breast. The nurse practitioner observes a malodorous discharge with mild maceration under both breasts. What is this?
a. Intertrigo
b. Impetigo
c. Tinea corporis
d. Shingles
a. Intertrigo
This is not unusual in adults with pendulous breasts. Intertrigo is common in areas between skin folds, under the breasts, between the scrotum and inner thigh, or between the toes. These are moist lesions that can be easily treated if the skin can be separated from touching the adjoining skin and the area can be kept dry. A topical powder with an antifungal would likely resolve this if used twice daily for 7-14 days. A diagnosis of diabetes should be considered if this is resistant to treatment or if it recurs.
A patient has 10 cm of well demarcated erythema on his lower leg that is raised and warm to touch. He had an abrupt onset of lower leg pain, and fever that began 36 hours ago. What is this?
a. Cellulitis
b. Erysipelas
c. Impetigo
d. An allergic reaction
b. Erysipelas
Erysipelas is characterized by an acute onset of symptoms as described in this scenario. Fever and chills are common. Patients with cellulitis tend to have a more gradual course, with development of symptoms over several days. The erythema noted in erysipelas is well demarcated and raised above the level of the skin. This elevation reflects that the more superficial dermis is involved.
A patient who is 62 years old asks if she can get the herpes zoster (shingles) vaccine. She has never had shingles but states that she wants to make sure she doesn’t get it. What should the nurse practitioner advise?
a. The immunization will protect you from acquiring shingles.
b. You are not old enough to receive the immunization.
c. The immunization is offered only to those who have had shingles.
d. you are eligible to receive it but you still may get shingles.
d. you are eligible to receive it but you still may get shingles.
Patients must be at least 50 years old to receive the recombinant zoster vaccine (Shingrix). Shingrix provides strong protection against acquiring herpes zoster (shingles) and against developing postherpetic neuralgia (PHSN), which is a complication of herpes zoster infection. in an immunocompetent patient, 2 doses of Shingrix administered 2-6 months apart is more than 90% effective at preventing shingles and PHN. According to the Advisory Committee on Immunization Practices (ACIP), protection level remains at about 5% for at least 4 years after vaccination. Despite the vaccine’s high rate of effectiveness, there is a chance that patients may develop shingles after immunization. The risk of developing complication (e.g., PHN) from shingles increases with age and with immunocompromise. The vaccine may be offered regardless of whether the patient has a prior history of shingles. It may also be offered if the patient received Zostavax, which is no longer available in the U.S.
A patient has been in the sun for the past few weeks and has developed darkened skin and numerous 3-6 mm light-colored, flat lesions on his trunk. What is the likely etiology?
a. Tinea corporis
b. Tinea unguium
c. Tinea versicolor
d. Human papilloma virus
c. Tinea versicolor
Tinea versicolor is typically visualized during the spring and summer months when a patient has become darkened after sun exposure. the areas that are infected do not tan and so become very noticeable. The chest and back are common areas to observe tinea versicolor. There can be 100 or more in some infections. This can be treated with topical selenium sulfide or an oral antifungal agent.
An oral antifungal agent is commonly used to treat tinea unguium. The difficulty in treating an older adult with this infection is:
a. absorption of the medication.
b. applying the medication twice daily.
c. tolerability of the medication.
d. relative ineffectiveness of oral agents.
c. tolerability of the medication.
The most efficacious agents used to treat toenail fungus are the oral antifungal agents. They must be taken daily for 8-16 weeks (or longer) for adequate length of treatment. Additionally, the real difficulty lies in the ability of the older adult’s liver to handle this medication. Oral antifungal agents require great amounts of the liver’s resources for metabolism. A topical agent or toenail removal may be a better choice for an older adult.
A child with a sandpaper-textured rash probably has:
a. rubeola.
b. Strept infection.
c. varicella.
d. roseola.
b. Strept infection.
Streptococcal infections can present as a sandpaper-textured rash that initially is felt on the trunk. Rubeola, measles, produces a blanching erythematous “brick-red” maculopapular rash that begins on the back of the neck and spreads around the trunk and then extremities. Varicella infection produces the classic crops of eruptions on the trunk that spread to the face. The rash is maculopapular initially and then crusts. Roseola produces a generalized maculopapular rash preceded by 3 days of high fever.
Which recommendation below reflect CDC’s recommendation for administration of the recombinant zoster vaccine?
a. It should be given to immunocompetent adults age 50 and older.
b. It should be given to immunocompetent adults age 65 and older.
c. it can be given regardless of immune status at age 50.
d. It can be given regardless of immune status at age 60.
a. It should be given to immunocompetent adults age 50 and older.
CDC’s recommendation for the recombinant zoster vaccine (Shingrix) is for administration in immunocompetent adults aged 50 years and older. Shingrix is an inactivated (not live) vaccine and while not contraindicated in patients who are immunocompromised, it is not currently recommended by the Advisory Council on Immunization Practices (ACIP). It should not be administered during an acute outbreak of shingles, but can be administered as soon as the acute phase has resolved. Shingrix is given in a two-dose series, with the second dose administered in 2 to 6 months. If it has been longer than 6 months from the first dose; just give the second dose, there is no need to restart the series. there is no need to screen the patient for a prior history of varicella nor to obtain serologic testing for antibodies.
A 4-year-old has been diagnosed with measles. The nurse practitioner identifies Koplik’s spots. These are:
a. spots on the skin that are pathognomonic for measles.
b. red rings found on the tongue that have a white granular area inside the ring.
c. found on the inside of the cheek and are granular.
d. blanchable areas on the trunk and extremities.
c. found on the inside of the cheek and are granular.
Koplik’s spots are found in the oral cavity, especially on the buccal mucosa opposite the first and second molars. the spots are white and granular and are circled by an erythematous ring. The spots are pathognomonic for measles. The exanthem associated with measles is typical described as cranial to caudal in progression. The lesions become confluent and last for approximately 4 days before fading begins.
A patient is found to have koilonychia. What laboratory test would be prudent to perform?
a. Liver function tests
b. Complete blood count
c. Hepatitis B surface antigen
d. Arterial blood gases
b. Complete blood count
koilonychia is the term that describes spoon-shaped nails. Spoon-shaped nails may be present in patients who have longstanding iron deficiency anemia. A CBC should be performed to assess for anemia. The most common symptoms of iron deficiency anemia are weakness, headache, irritability, fatigue, and exercise intolerance.
A “herald patch” is a hallmark finding in which condition?
a. Erythema infectiosum
b. Pityriasis rosea
c. Seborrheic keratosis
d. Atopic dermatitis
b. Pityriasis rosea
Pityriasis rosea (PR) is a self-limiting exanthematous skin disorder characterized by several unique findings. It is more common in young adults. A characteristic finding is the “herald” or “mother” patch found on trunk. This looks like a ringworm and precedes the generalized “Christmas tree” pattern rash. The lesions associated with the rash are salmon-colored and oval in shape. Most cases clear in 4-6 weeks, but the plaques may last for several months.
A patient has suspected scarlet fever. He likely has a sandpaper rash and:
a. negative throat swab.
b. a positive rapid Strept test.
c. diarrhea with abdominal cramps.
d. petechiae on the trunk.
b. a positive rapid Strept test.
A patient with scarlet fever (scarlatina) has a common childhood disease that is characterized by sore throat, fever, and a scarlet “sandpaper” rash. The causative organism is Group A beta hemolytic Streptococcus pyogenes. The patient’s rapid Strep test will likely be positive. Diarrhea with abdominal cramps is not specific to scarlet fever. Petechiae represent an extravasation of blood under the skin and are not present with scarlet fever unless some other disease process is present. Petechiae should be considered to be a serious finding.
a patient has a “herald patch” and is diagnosed with pityriasis rosea. Where is the “herald patch” most commonly found?
a. On the affected limb
b. On the chest
c. Close to the scalp
d. Behind one of the ears
b. On the chest
The herald patch associated with pityriasis rosea is most commonly found on the trunk. It precedes the generalized Christmas tree pattern rash that is easily noted on the rest of the body. Because it appears round and has a darkened center, it looks like a ringworm. In fact, it is commonly mistaken for ringworm until the Christmas tree pattern rash appears. It would be unusual to identify the herald patch on a body part other than the trunk, but there are case reports of this.
A wound has the following characteristics; partial thickness loss of dermis, a shallow open ulcer with red/pink bed, and no evidence of sloughing. What stage of pressure ulcer does this describe?
a. Stage I
b. Stage II
c. Stage III
d. Stage IV
b. Stage II
Stage I is characterized by intact skin and nonblanchable redness of a localized area (usually over a bony prominence). Compared to adjacent tissue. the area may be painful, firm, soft, warmer or cooler. Stage II is characterized by partial-thickness loss of dermis presenting as a shallow open ulcer or a re-pink wound bed, absent sloughing. It may also present as an intact or open/ruptured serum-filled blister. Stage III is characterized by full-thickness tissue loss with or without visible subcutaneous fat; bone, tendon, and muscle are not exposed. Sloughing may be present but does not obscure the depth of tissue loss. The depth varies by anatomical location. Stage IV is characterized by full-thickness tissue loss with exposed bone, tendon, or muscle. Sloughing or eschar may be present on some parts of the wound bed. The depth varies by anatomical location.
A 28-year-old has thick, demarcated plaques on her elbows. Which features are suggestive of psoriasis?
a. Scaly lesions on the scalp
b. Pruritus around the lesions
c. A scaly border around the plaques
d. Silvery scales that are mildly pruritic
d. Silvery scales that are mildly pruritic
There are many different presentations of psoriasis. Plaque psoriasis, which is described in this question, is usually found in a symmetrical distribution on the scalp, elbows, knees, and/or back. The size of the lesions ranges from 1-10 cm in diameter. The plaques may be asymptomatic, but pruritis is a common finding. Scaly lesions found on the scalp are not specific to psoriasis and could be seborrheic dermatitis. A scaly border around the plaque could describe the lesions associated with pityriasis rosea.
The most common place for basal cell carcinoma to be found is the:
a. scalp.
b. face.
c. ear.
d. anterior shin.
b. face.
The most common presentation of basal cell carcinoma (BCC) is on the face. This is probably because BCC occurs secondary to sun damage. The most common sun exposure occurs on the face. In fact, 70% of BCC occurs on the face; 15% occurs on the trunk.
A patient who is at high risk for skin cancer should:
a. examine his skin monthly for changes.
b. be examined by a dermatologist quarterly.
c. use emollients regularly.
d. eat foods high in vitamin A.
a. examine his skin monthly for changes.
Patients should be examined periodically for evidence of skin cancer by a professional examiner (NP, MD or PA). The frequency and type of examination depends on the risk level, and personal and family history of the patient. However, a patient should examine his own skin regularly for changes. Once he has begun to examine his skin, research demonstrates that he will identify early changes and can make his provider aware of them.
A patient with eczema asks for a recommendation for a skin preparation to help with xerosis. What should the NP respond?
a. Use a petroleum-based product
b. Use a hypoallergenic lotion
c. Use any hypoallergenic product
d. No particular product is better than another
a. Use a petroleum-based product
Xerosis is dry skin. It is common in patients who have eczema. Using thick creams or ointments can prevent xerosis. Lotions should be avoided because they have high water content that promotes evaporation of water from the skin. Hypoallergenic refers to the allergenicity of a product. This is not related to the water content of products.
Which test is NOT suitable to diagnose shingles if the clinical presentation is questionable?
a. Tzanck preparation
b. Polymerase chain reaction (PCR)
c. Direct fluorescent antibody (DFA)
d. Complete blood count (CBC)
d. Complete blood count (CBC)
Herpes viruses are the causative agents in shingles, chickenpox, genital herpes, and oral fever blister. Diagnosis is usually made on clinical presentation. However, in questionable cases, lab tests may be employed. A Tzanck preparation is a rapid test used to diagnose infections due to herpes viruses. Cell taken from a blister’s fluid are smeared on a slide and stained with a Wright’s stain, or the fluid can be used for other methods of testing. DFA is the most common test employed for shingles diagnosis because it can be rapidly performed and offers results in about 90 minutes. PCR may be performed on skin scraping, serum or blood for herpetic diagnosis. CBC may indicate a patient with a viral infection, but it is nonspecific for herpetic infections.
An example of a first-generation cephalosporin used to treat a skin infection is:
a. cephalexin.
b. cefuroxime.
c. cefdinir.
d. cefaclor.
a. cephalexin.
Two common first-generation cephalosporins used to treat skin and skin structure infections are cephalexin and cefadroxil. These are taken two to four times daily and are generally well tolerated. These antibiotics provide coverage against Staphylococcus and Streptococcus, common skin pathogens.
Topical 5-fluorouracil (5-FU) is used to treat:
a. atopic dermatitis.
b. hepatitis.
c. thalassemia.
d. basal cell carcinoma.
d. basal cell carcinoma
5-FU is a topical agent that can be used to treat basal cell carcinoma (BCC). it is most effective on rapidly proliferating cells. This treatment should only be used on superficial BCCs. If it is used on more invasive BCC, the cure rate is significantly lower. Therefore, 5-FU should be used only on superficial BCCs in noncritical locations. It is does as a 5% formulations twice daily for 3-6 weeks.
An adolescent takes isotretinoin for nodulocystic acne. She is on oral contraceptives. Both were prescribed by the dermatologist. The adolescent presents to your clinic with a sinus infection. her temperature is 99.5° F and her blood pressure is 160/100 mmHg. How should this be managed?
a. Call the dermatologist to report the elevated BP
b. Treat the sinus infection and recheck the BP in one week
c. Discontinue the isotretinoin today
d. Discontinue the oral contraceptive today
a. Call the dermatologist to report the elevated BP
The nurse practitioner is responsible for treated the sinus infection but has also become aware of a potentially harmful situation involving the elevated blood pressure and oral contraceptive use. The safest and most professional action is to call the dermatologist to discuss your concerns regarding the elevated BP and concomitant oral contraceptive use since this potentially increases the risk of stroke in this adolescent. Care and processional courtesy should be exercised when discontinuing a medication that another provider has initiated. Professional courtesy is extended to the prescriber by calling them prior to discontinuing a medication they have ordered.
A 70-year-old is diagnosed with multiple cherry angiomas. The nurse practitioner knows that:
a. this is mature capillary proliferation more common in young adults.
b. an angioma occurs as a single lesion.
c. these may bleed profusely if ruptured.
d. these are precursors of skin malignancies.
c. these may bleed profusely if ruptured.
Cherry angiomas are mature capillary proliferations that are more common in middle-aged and older adults. They blanch with pressure and are usually 0.1-0.4 cm in diameter. They are commonly found on the trunk as multiple lesions. Because they are a proliferation of capillaries, they will bleed significantly if they rupture. The bleed is not life threatening, but in older adults who take aspirin, the bleeding will be worse. Pressure should be held over the ruptured area until bleeding stops. These are not precursors of skin malignancies.
Which of the following skin lesions in an older adult is a premalignant condition?
a. Xanthelasma
b. Chalazion
c. Hordeolum
d. Actinic keratosis
d. Actinic keratosis
Actinic keratosis is a premalignant condition of the skin and is considered an evolving carcinoma in situ. It is a precursor of squamous cell carcinoma. The lesion are usually multiple in occurrence and sit on an erythematous base. They appear dry, scaly, and flat and are usually secondary to sun damaged skin. Thus they are found on sun-exposed areas. The most common sites are the face, ears, lateral forearms, and tops of hands.
A skin lesion fluoresces under a Wood’s lamp. What microscopic finding is consistent with this?
a. Clue cells
b. Scabies
c. Hyphae
d. Leukocytes
c. Hyphae
A Wood’s lamp emits ultraviolet light when turned on. If an area fluoresces under Wood’s lamp illumination, a fungal (and sometimes bacterial) infection should be suspected. Hyphae are associated with fungal infections. The test is most effectively performed in a darkened room so the fluorescence can be more easily identified. Deodorant, soap, and makeup may also fluoresce. About one-third of hyphae fluoresce.
The nurse practitioner examines a patient who has had poison ivy for 3 days. She asks if she can spread it to her family members. The nurse practitioner replies:
a. “Yes, but only before crusting has occurred.”
b. “Yes, the fluid in the blister can transmit it.”
c. “No, transmission does not occur from the blister’s contents”
d. “No, you are no longer contagious.”
c. “No, transmission does not occur from the blister’s contents”
The skin reaction seen after exposure to poison ivy (or any other skin irritant), takes place because of contact with the offending substance. In the case of poison ivy, the harmful exposure occurs from contact with oil from the plant. The eruptions seen are NOT able to transmit the reaction to other people unless oil from the plant remains on the skin and someone touches the oil. The fluid found in the blisters is NOT able to transmit poison ivy to anyone; only the oil from the plant can do that. After oil has touched the skin, some time must pass for the reaction to occur. Therefore, reaction times vary depending on skin thickness and quantity of oil contacting the skin.
A patient with a positive history of a tick bite about 2 weeks ago and erythema migrans has a positive ELISA for Borrelia burgdorferi. The Western blot is positive. How should he be managed?
a. He should receive doxycycline for Lyme disease.
b. He should receive penicillin for Rocky Mountain spotted fever (RMSF)
c. He does not have Lyme disease or RMSF.
d. He needs additional testing to confirm Lyme disease.
a. He should receive doxycycline for Lyme disease.
The first serologic test for Lyme disease is the ELISA. If this is positive, it should be confirmed. In this case, it was confirmed by a Western blot and it is positive. This patient can be diagnosed with Lyme disease. The appropriate treatment for erythema migrans is doxycycline, amoxicillin, or cefuroxime for 21 days. All three medications were found to be of equal efficacy.
A patient calls your office. He states that he just came in from the woods and discovered a tick on his upper arm. He states that he has removed the tick and the area is slightly red. What should he be advised?
a. No treatment is needed.
b. He should receive a prescription for doxycycline.
c. He needs a topical scrub to prevent Lyme disease.
d. He should come to the office for a ceftriaxone injection.
a. No treatment is needed.
Many factors must be present for a patient to develop Lyme disease from a tick bite. First, the tick must belong to lxodes species. The tick must have been attached for at least 48 hours before disease can be spread. Time of year and stage of organism development affect transmission. There is no need for prophylactic treatment in this case because the tick has not been present long enough, though many patients will feel antibiotics are necessary. He could be checked to ensure that the entire tick has been removed.
A 60-year-old patient is notes to have rounding of the distal phalanx of the fingers. What might have caused this?
a. Coronary artery disease
b. Hepatic cirrhosis
c. Lead toxicity
d. Iron deficiency anemia
b. Hepatic cirrhosis
Rounding of the distal phalanx describes clubbing. Clubbing of fingers is most often associated with chronic hypoxia as seen in cigarette smokers and patients with COPD or lung cancer. Other causes are cirrhosis, cystic fibrosis, pulmonary fibrosis and cyanotic heart disease.
A patient has been diagnosed with scabies. What is the medication of choice to treat this?
a. Permethrin
b. Coal tar
c. Ketoconazole
d. Mupirocin
a. Permethrin
Scabies is eradicated by using permethrin and good hygiene. All household and personal contact must be treated simultaneously, and meticulous care must be exercised to prevent transmission by cross contamination. All clothing, stuffed animals, linens, mattresses, and cloth furniture must be treated to prevent further transmission.
A patient is diagnosed with tinea pedis. A microscopic examination of the sample taken from the infected area would likely demonstrate:
a. hyphae.
b. yeasts.
c. rods or cocci.
d. a combination of hyphae and spores.
a. hyphae.
Under microscopic exam, hyphae are long, thin and branching, and indicate dermatophytic infections. Hyphae are typical in tinea pedis, tinea cruris, and tinea corporis. Yeasts are usually seen in candidal infections. Cocci and rods are specific to bacterial infections.
A skin disorder has a hallmark finding of silvery scales. What word below describes this common condition?
a. Chronic
b. Infectious
c. Contagious
d. Acute
a. Chronic
“Silvery scales” describes the hallmark finding in psoriasis. This is a chronic condition. It is not infectious, contagious, or acute. There are several variants, but “silvery scales” is the most common form.
A patient exhibits petechiae on both lower legs but has no other complaints. How should the NP proceed?
a. Refer to hematology
b. Order a CBC
c. Order blood cultures
d. Stop aspirin and reassess in 1 week
b. Order a CBC
The presence of petechiae on the lower legs (or anywhere on the body) should prompt the NP to consider a problem that is related to a low platelet count. A CBC should be checked to assess the platelet count and for any evidence of anemia from blood loss. If the platelet count is found to be low, referral to hematology should be done. Blood cultures are of no value in this patient, who is otherwise asymptomatic.
The most common form of skin cancer is:
a. squamous cell carcinoma.
b. basal cell carcinoma.
c. malignant melanoma.
d. cutaneous carcinoma.
b. basal cell carcinoma.
Skin cancers are divided into two major groups: nonmelanoma and melanoma skin cancer. Basil cell carcinoma is considered nonmelanoma skin cancer and is the most common form of skin cancer in the US. It is most common in 40- to 60-year-olds, but can occur at any age if the skin is regularly exposed to sunlight or ultraviolet radiation. Basal cell carcinoma grows slowly, and if not treated it can spread to surrounding areas of tissue or bone.
A pregnant mother in her first trimester has a 5-year-old who has Fifth Disease. What implication does this have for the mother?
a. She does not have to worry about transmission to the fetus.
b. She may get a mild case of Fifth Disease.
c. There is a risk of fetal death if she becomes infected.
d. The mother should have a fetal ultrasound today.
c. There is a risk of fetal death if she becomes infected.
Pregnant mother should avoid exposure to patients with known Fifth disease. However, the risk of transmission is very low. She should avoid exposure to aplastic patients who are infected because they are highly contagious. Infection during pregnancy is associated with 10% risk of fetal death. There is no need for an ultrasound today. This pregnant patient does not have evidence of disease. She should be monitored for a rash which could indicate infection.
The term caput succedaneum refers to:
a. cradle cap.
b. atopic dermatitis.
c. scalp edema.
d. asymmetric head shape.
c. scalp edema.
Caput succedaneum is a common finding in newborns. It is a result of pressure over the presenting part. This results in some ecchymosis of the scalp. While this may be disturbing to new parents who observe this in their newborn, it will resolve in a few days and is harmless.
A 15-year-old male has worked this summer as a lifeguard at a local swimming pool. he complains of itching in the groin area. He is diagnosed with tinea cruris. The nurse practitioner is likely to identify:
a. swelling of the scrotum.
b. macular lesions on the penis.
c. well marginated half-moon macules on the inner thigh.
d. maceration of the scrotal folds with erythema of the penis.
c. well marginated half-moon macules on the inner thigh.
Tinea cruris, “jock itch” is common during warm months and in humid areas. It is a fungal infection that affects the scrotum and inner thighs, but never affects the penis and is never evidence by scrotal swelling. He is probably at increased risk because he is working as a lifeguard and may wear damp or wet swim trunks during work. He should be treated with a topical antifungal cream, advised to dry off after swimming, and to put on dry swim trunks.
A patient has had right upper quadrant pain that has lasted for the past 3 days, but the pain has become acute in the past 12 hours. He has low-grade fever. Which lab test(s) will be elevated if he has pancreatitis?
a. CBC
b. Serum amylase
c. ALT and AST
d. CRP
A patient has the following lab values. This indicates that he:
(image has: Neg HBsAg, Neg anti-HBc, and Pos anti-HBs)
a. has acute hepatitis B and needs immunization.
b. has chronic hepatitis B.
c. is immune to hepatitis B.
d. needs immunization to hepatitis B.
c. is immune to hepatitis B.
This patient is immune to hepatitis B because he has a positive hepatitis B surface antibody. He does not need immunization. his immunity is due to immunization because he has a negative core antibody. The finding of a positive surface antibody and a negative core antibody in this patient indicates immunity from hepatitis B from innumization. If his immunity had been derived from infection, his core antibody would have been positive.
In a patient with end-of-life physical pain, constipation commonly occurs. What is the most common cause of this?
a. Decreased activity
b. Decreased fluids
c. Opioid use
d. General slowing of body processes
c. Opioid use
Opioids can cause severe constipation. At end of life, this can be a significant cause of discomfort for the patient. Measures for relief of constipation should be instituted.
A patient has been diagnosed with hepatitis A. The most common reported risk factor is:
a. drinking contaminated water.
b. homosexual activity.
c. international travel.
d. eating contaminated food.
c. international travel.
Traveling internationally is the most common risk factor. Hepatitis A (HAV) is spread via the fecal-oral route (and is highly contagious), though most people have no recollection of eating or drinking contaminated food/drink. Mexico, Central and South America are countries with the highest reported rates of HAV. Other risk factors are contract with infected family or close contact and homosexual activity among men. Hepatitis A has declined since vaccination in the US has become widespread.
A patient is 86 years old and functions independently. He has hypertension, hyperlipidemia, BPH, and flair-ups of gout. His last colonoscopy was at age 76 years. What should he be advised about having a colonoscopy?
a. Colonoscopy is the preferred method for screening in older adults
b. Colonoscopy is ill advised in older adults
c. It is not advised in this patient at this time
d. Screening is not necessary after age 80 years
c. It is not advised in this patient at this time
Prior to any screening test such as colonoscopy, consideration must be given to the patient’s overall health status, colorectal cancer risk, and desire to pursue treatment if cancer or disease is diagnosed. The United States Preventive Services Task Force, American College of Physicians, and American College of Gastroenterology do no recommend screening an 86-year-old for colorectal cancer. As a general rule, patients with a life expectancy of less that 5-10 years should forego colorectal cancer screening via colonoscopy. Colonoscopy enables the examiner to visualize the entire colon and is a superior screening tool for colorectal cancer, but there are significant risks of bleeding and perforation in older adults. Additionally, the colon prep can produce massive shifts in electrolytes that can increase the likelihood of arrhythmias, heart failure, weakness, and falls.
What medication may be used to treat GERD if a patient has tried over-the counter ranitidine without benefit?
a. Calcium carbonate
b. Prescription-strength ranitidine
c. Cimetidine
d. Pantoprazole
d. Pantoprazole
If a patient has been diagnosed with GERD and he is symptomatic on an H2 blocker like ranitidine, a proton pump inhibitor (PPI) should be considered. An example of a proton pump inhibitor is pantoprazole. Relief of symptoms after using a PPI does not indicate a benign condition. This patient could have esophageal erosions, Barrett’s esophagitis, or esophageal cancer. He should be screened for risk factors for these conditions and then a discussion to refer this patient to gastroenterology can be made.
A patient with diarrhea has a stool specimen positive for WBCs. What is a likely etiology?
a. A viral infection
b. A malignancy
c. Parasitic infection
d. Occult blood
a. A viral infection
When WBCs are found in stool specimens, it is indicative of infection or inflammation. In the case of a patient with symptoms suggestive of an infections etiology, bacterial or viral infections should be considered. When considering a differential diagnosis and no infection etiology is likely, Crohn’s disease or ulcerative colitis could be considered.
A 63-year-old male has been your patient for several years. He is a former smoker who takes simvastatin, ramipril, and an aspirin daily. his blood pressure and lipids are well controlled. He presents to your clinic with complaints of fatigue and “just not feeling well” for the last few days. His vital signs and exam are normal, but his liver enzymes are elevated. His hepatitis panel is negative for infections hepatitis. What is the most likely cause of his elevated liver enzymes?
a. He has received a generic version of simvastatin
b. He is an alcoholic in denial
c. Daily grapefruit consumption for the past 10 days
d. Rare liver toxicity from a usual dose of simvastatin
c. Daily grapefruit consumption for the past 10 days
Grapefruit is a potent inhibitor of the cytochrome P450 enzyme system. Statins and calcium channel blockers are two infamous drug interactions that occur with grapefruit and grapefruit juice. Because they inhibit metabolism of the statin, the patient continues to have statin in circulation because he cannot significantly metabolize the medication. When the next day’s dose is taken, its effect is coupled with the effect of the previous day’s dose. The effect is cumulative. Hepatoxicity can quickly develop. The simvastatin must be stopped immediately! The liver enzymes must be followed until they return to normal; which could take weeks, months or even longer.
An infant is diagnosed with diaper dermatitis. Satellite lesions are visible. This should be treated with a:
a. moisture barrier like zinc oxide
b. Topical antifungal agent
c. Topical antibacterial agent
d. Low potency steroid cream
B. Topical antifungal cream
The finding of satellite lesions associated with diaper dermatitis indicates a candidal infection. This patient will be most effectively treated with a topical antifungal agent, allowing the lesions to be exposed to air for periods of time (like during a nap)
