EXAM PREP DIRECT QUESTIONS AGNP Flashcards
An asthmatic male patient complains of a sudden onset of itching and coughing after taking two aspirin tablets for a headache in the waiting room. The patient’s lips and eyelids are becoming swollen. The patient complains of feeling hot. Bright-red wheals are noted on his chest and arms and legs. Which of the following is the best initial intervention to follow?
A. Call 911.
B. Check the patient’s BP, pulse, and temperature.
C. Give an injection of aqueous epinephrine 1:1,000 (1 mg/mL) 0.5 mg IM into the vastus lateralis muscle immediately.
D. Initiate a prescription of a potent topical steroid and a Medrol Dose Pack.
Correct Answer: Option C
C. Give an injection of aqueous epinephrine 1:1,000 dilution (1 mg/mL) 0.5 mg IM into the vastus lateralis muscle immediately.
Best Clues
* The quick onset of symptoms, such as angioedema, after taking aspirin is a clue.
* The classic signs and symptoms of anaphylaxis described in this case should be noted.
* Severe anaphylactic episodes occur almost immediately or within 1 hour after exposure.
Notes
1. Treatment of anaphylaxis (in primary care):
If only one clinician is present: Give an injection of epinephrine 1:1,000 dilution 0.3 to 0.5 mg intramuscularly stat, and then call 911. May repeat dose within 5 minutes in case of poor response.
2. ED treatment medications: Administer epinephrine IM, 100% oxygen by face mask, an antihistamine (H1 antagonist) such as diphenhydramine (Benadryl), an H2 antagonist such as ranitidine, a bronchodilator such as albuterol (short-acting beta-2 agonist), and systemic glucocorticosteroids such as prednisone.
3. Patients with an atopic history (asthma, eczema, allergic rhinitis) with nasal polyps are at higher risk for aspirin and nonsteroidal anti-inflammatory drug (NSAID) allergies.
4. Anaphylaxis is classified as a type I IgE-dependent reaction.
5. Biphasic anaphylaxis occurs in up to 23% of cases (symptoms recur within 8–10 hours after initial episode). This is the reason why these patients are prescribed a Medrol Dose Pack and a long-acting antihistamine after being discharged from the ED.
6. The most common triggers for anaphylaxis in children are foods. Medications and insect stings are the most common triggers in adults.
An 18-year-old woman with allergic rhinitis presents for primary care. She is sexually active with a male partner and is one year post coitarche; During that time she had to sexual partners. An example of primary prevention activity for this patient is:
A. Screening for sexually transmitted infection (STI)
B. Counseling about safer sexual practices
C. Prescribing therapies for minimizing allergy
D. Obtaining a liquid based pap test
Correct:
C. Counseling about safer sexual practices
The goal of primary prevention is to prevent a disease or injury before it happens. Educating the patient about safer sexual practices is important in reducing the risk for sexually transmitted diseases.
Incorrect:
Screening for STI’s and performing a pap test are part of secondary prevention measures to potentially detect/identify already established diseases. Prescribing medication’s to minimize allergy can be a part of the patient management for allergic rhinitis and is considered tertiary prevention measure.
When a critical portion of a population is immunized against a contagious disease, most members of the group, even the unamused, are protected against the disease because there is little opportunity for an outbreak. This is known as ________ immunity.
A. Passive
B. Humoral
C. Epidemiological
D. Community
Correct:
D. Community
In herd or community immunity, a significant portion of a given population has immunity against the infectious agent; the likelihood that the susceptible portion of the group would become infected is minimize.
Incorrect:
Passive immunity is provided when a person receives select antibodies produced in another host, usually via the administration of IG. Humoral immunity is an aspect of immunity mediated by antibodies in the body fluids (or humors). Epidemiological immunity is not a defined term.
An 18-year-old female student presents in the college health clinic complaining of a strong odor in her vagina. She reports that she had an abortion about 3 weeks ago and recently completed her prescription of antibiotics. The NP performs a vaginal speculum exam and notes a large amount of gray to off-white discharge coating the patient’s vaginal walls. It has a milk-like consistency. During microscopy, the slide reveals mature squamous epithelial cells with numerous bacteria on the cell surface and borders. The vaginal pH is 6.0. Which of the following conditions is most likely?
A. Trichomoniasis
B. BV
C. Candida vulvovaginitis
D. Hormonal changes
Correct Answer: Option B
B. BV
IV. Question Dissection
Best Clues
* The vaginal pH is alkaline (pH of 6.0).
- Rule out Candida because it is classified as a yeast organism (not a bacteria).
- Rule out Trichomonas because it is a protozoan or unicellular flagellated organism.
- The odor and discharge are not due to hormonal changes in an 18-year-old.
Notes
1. BV has an alkaline pH (vagina normally has an acidic pH of 3.5–4.5). BV is the only vaginal condition with an alkaline pH for the exam.
2. BV is not considered an STD (it is caused by an imbalance of vaginal bacteria). The sex partner does not need to be treated. It is a vaginosis (not a vaginitis).
3. BV does not cause inflammation (the vulvovagina will not be red or irritated). The microscopy slide will have very few WBCs and a large number of clue cells.
4. The vaginal discharge in Candida infection is a white color with a thick and curdlike consistency. It frequently causes redness and itching in the vulvovagina because of inflammation.
5. The microscopy in candidiasis will show a large number of WBCs, pseudohyphae, and spores (“spaghetti and meatballs”).
6. Candida yeast is a normal flora of the GI tract and in some women’s vaginas.
7. Trichomonas infection (or trichomoniasis) vaginal discharge is copious, bubbly, and green in color. It causes a lot of inflammation, resulting in itching and redness of the vulvovagina. It is considered to be an STI. The sex partner also needs treatment.
8. PCR testing is now available for trichomonas and vaginal candida infections. For trichomonas, a urine specimen (males or females) is used. For vaginal candida, a vaginal swab is used.
A previously healthy 30-year-old complains of an acute onset of fever and chills accompanied by a productive cough with purulent sputum and a loss of appetite. The patient denies receiving an antibiotic in the previous 3 months. The NP diagnoses CAP. The Infectious Diseases Society of America (IDSA) and the American Thoracic Society (ATS) treatment guidelines recommend which of the following as the preferred first-line treatment for this patient?
A. Macrolides
B. Antitussives
C. Cephalosporins
D. Fluoroquinolones with gram-positive bacteria activity
A. Macrolides
According to the IDSA and the ATS treatment guidelines, outpatient treatment of CAP in healthy patients (no comorbidities) involves the macrolides (azithromycin, clarithromycin, or erythromycin).
Which of the following antibiotics is the preferred treatment for healthy adults diagnosed with uncomplicated CAP?
A. Azithromycin (Zithromax Z-Pak 250 mg) 500 mg on day 1, then 250 mg daily for 4 days
B. Dextromethorphan with guaifenesin (Robitussin DM) 1 to 2 teaspoons PO QID as needed
C. Cephalexin (Keflex) 500 mg PO QID × 10 days
D. Levofloxacin (Levaquin) 500 mg PO daily × 7 days
A. Azithromycin (Zithromax Z-Pak 250 mg) 500 mg on day 1, then 250 mg daily for 4 days
According to the IDSA and the ATS treatment guidelines, outpatient treatment of CAP in healthy patients (no comorbidities) involves the macrolides (azithromycin, clarithromycin, or erythromycin).
The following is an example of a question about a common side effect:
Which of the following are possible side effects that may be seen in a patient who is being treated with hydrochlorothiazide for hypertension?
A. Dry cough and angioedema
B. Swollen ankles and headache
C. Hyperuricemia and hyperglycemia
D. Fatigue and depression
C. Hyperuricemia and hyperglycemia
Example A is caused by angiotensin-converting enzyme (ACE) inhibitors. L
What is the most common type of gynecological cancer?
A. Uterine cancer
B. Cervical cancer
C. Breast cancer
D. Ovarian cancer
** Correct Answer: Option A**
A. Uterine cancer
Best Clues
- This question is based on your recall of facts that you memorized (rote memory).
- Rule out breast cancer because it is not considered a gynecological cancer.
Notes
There may be a question about the gynecological cancers. These types of cancers are located in the pelvis (labia, vagina, uterus, fallopian tubes, ovaries).
Breast cancer is not classified as a gynecological cancer.
A 45-year-old female patient complains of a sore throat. Upon examination, the NP notices a bony growth midline at the hard palate of the mouth. The patient denies any changes or pain. It is not red, tender, or swollen. She reports a history of the same growth for many years without any change. Which of the following conditions is most likely?
A. Torus palatinus
B. Geographic tongue
C. Acute glossitis
D. Leukoplakia
Correct Answer: Option A
A. Torus palatinus
Best Clues
* The description of a chronic bony growth located midline in the hard palate indicates torus palatinus.
- Rule out glossitis, geographic tongue, and hairy leukoplakia because they are all located on the tongue and not on the hard palate (roof of the mouth).
Notes
A torus palatinus is a benign growth of bone (an exostosis) located midline on the hard palate and covered with normal oral skin. It is painless and does not interfere with function.
A “geographic tongue” has multiple fissures and irregular smoother areas on its surface that make it look like a topographic map. The patient may complain of soreness on the tongue after eating or drinking acidic or hot foods.
Leukoplakia is not a benign variant. It appears as a slow-growing white plaque that has a firm to hard surface that is slightly raised on the tongue or inside the mouth. It is considered a precancerous lesion. It is due to chronic irritation of the skin or precancerous changes on the tongue and inside the cheeks. Its causes include poorly fitting dentures, chewing tobacco (snuff), and using other types of tobacco. Refer the patient for a biopsy because it can sometimes become malignant.
Oral hairy leukoplakia (OHL) of the tongue is a painless white patch (or patches) that appears corrugated. It is usually located on the lateral aspects of the tongue (or other areas inside the mouth) and is associated with HIV and AIDS infection. It is caused by Epstein–Barr virus (EBV) infection of the tongue. It is not considered a premalignant lesion.
What is the USPSTF screening recommendation for ovarian cancer?
A. Annual bimanual pelvic exam with pelvic ultrasound
B. Pelvic and intravaginal ultrasound
C. Intravaginal ultrasound with CA-125 tumor marker
D. The USPSTF does not recommend routine screening of women for ovarian cancer (Grade D)
Correct Answer: Option D
D. The USPSTF does not recommend routine screening of women for ovarian cancer (Grade D)
Best Clues
- Do not “overread” the question. Assume that the question is asking about routine screening of the general population.
- Transvaginal ultrasound and CA-125 are not used for routine screening.
- Although the bimanual pelvic exam is “low tech,” it is being used as a distractor.**
Notes
The USPSTF (2018) is against routine screening for ovarian cancer
Table 1. USPSTF Screening Guidelines
**Disease: ** Breast cancer (2018)
Screening Test: Baseline mammogram at age 50 years
Screen every 2 years until age 74 years (biennial)
After age 75 years (insufficient evidence)
Disease: Cervical cancer (2018)
Screening Test: Baseline Pap smear/cytology at age 21 years (do not screen younger)
Screen every 3 years until age 65 years; at age 30–65 years, another option is to screen every 5 years using hrHPV testing alone or in combination with cytology (cotesting).
Disease: Lung cancer (2013)
Screening Test: Aged 55–80 years with 30 pack-year history of smoking or quit smoking up to 15 years previously
Annual screening with LDCT
Disease: Hysterectomy (no cervix)
Screening Test: Do not screen (if no history of precancer or cervical cancer).
Disease: Prostate cancer (2018)
Screening Test: Aged 55–69 years, PSA-based screening should be individualized; ≥70 years, against prostate cancer screening.
Disease: Testicular cancer (2011)
Screening Test:Routine screening is not recommended.
Disease: Colorectal cancer (2016)
Screening Test: Baseline screening at age 50 years
Use high-sensitivity fecal occult blood test (yearly) or sigmoidoscopy (every 5 years) or colonoscopy (every 10 years) from age 50 to 75 years; aged 76–85 years, individualize.
Disease: Skin cancer (2016)
Screening Test: Current evidence insufficient to assess benefits/harms of visual skin exam.
Educate fair-skinned persons to avoid sunlight (10 a.m.–3 p.m.) and use sunblock ≥SPF 15.
Disease: Tobacco smoking (2020)
Screening Test: Ask all adults about tobacco use, advise them to stop smoking, and provide behavioral interventions/pharmacotherapy (if not pregnant) for smoking cessation.
Disease: Fall prevention in community-dwelling older adults (2018)
Screening Test: Adults aged ≥65 years, exercise interventions to prevent falls in adults at increased risk; against vitamin D supplementation.
Disease: Ovarian cancer (2018)
Screening Test: Routine screening is not recommended.
High-risk (BRCA mutation, family history of breast/ovarian cancer) are screened by specialist; refer for genetic counseling.
Disease: Abdominal aortic aneurysm (2019)
Screening Test: One-time screening (men aged 65–75 years) for cigarette smokers or those who have quit.
Screening test is ultrasound of abdomen.
hrHPV, high-risk human papillomavirus; LDCT, low-dose computed tomography; SPF, sun protection factor; USPSTF, U.S. Preventive Services Task Force.
A 65-year-old female smoker presents with a history of Barrett’s esophagus and gastroesophageal reflux disease (GERD). The patient reports that her gastroenterologist’s prescription for esomeprazole (Nexium) 40 mg daily ran out a few days ago. She is complaining of severe heartburn and a sore throat. During the physical exam, the NP notes an erythematous posterior pharynx without tonsillar discharge and mild dental enamel loss on the rear molars. What is the best initial action for the NP to follow?
A. Refer the patient to an oncologist for a biopsy to rule out esophageal cancer.
B. Give the patient a refill of her proton-pump inhibitor (PPI) prescription and advise her to schedule an appointment with her gastroenterologist.
C. Recommend that the patient take over-the-counter (OTC) ranitidine (Zantac) twice a day until she can be seen by her gastroenterologist.
D. Switch the patient’s prescription to another brand of PPI because her symptoms are not improving.
Correct Answer: Option B
B. Give the patient a refill of her proton-pump inhibitor (PPI) prescription and advise her to schedule an appointment with her gastroenterologist.
Best Clues
* Rule out option A because the patient is already under the care of a gastroenterologist.
- OTC ranitidine (Zantac) is not potent enough to control the symptoms of erosive esophagitis. A PPI is the preferred treatment for erosive esophagitis.
- Do not switch the patient to another brand of PPI. Her worsening symptoms are due to rebound caused by abrupt cessation of PPI.
- The best initial action in this case is to refill the PPI prescription because the patient is fully symptomatic (erosive esophagitis) until she can see her gastroenterologist.
Notes
1. The patient’s severe symptoms are caused by the sudden discontinuation of the high-dose PPI (rebound type of reaction).
2. Barrett’s esophagus is the “precancerous” lesion of esophageal cancer. It is best managed by a gastroenterologist (not an oncologist).
3. Patients diagnosed with Barrett’s esophagus typically have endoscopic examinations with biopsy by a gastroenterologist annually (or every 6 months for high-grade lesions).
4. Patients with Barrett’s esophagus are treated with high-dose PPIs for a “lifetime.”
5. The first-line treatment of mild, uncomplicated GERD is lifestyle changes (e.g., avoid eating 3–4 hours before bedtime, dietary changes, weight loss if overweight).
1. If a patient is at high risk for esophageal cancer (aged 50 years or older, smoker, chronic GERD for decades), consider referral to a gastroenterologist for an upper endoscopy.*
A 14-year-old boy is brought in by his mother for a physical exam. Both are concerned about his breast enlargement. The teen denies breast tenderness. On physical exam, the NP palpates soft breast tissue that is not tender. No dominant mass is noted. The skin is smooth, and there is no nipple discharge with massage. The teen has a body mass index (BMI) of 29. Which of the following statements is correct?
A. Advise the mother that the patient has physiologic gynecomastia and should return for a follow-up exam.
B. Order an ultrasound of both breasts to further assess the patient’s breast tissue development.
C. Reassure the mother that the patient’s breast development is within normal limits.
D. Educate the mother that her son has pseudogynecomastia.
Correct Answer: Option D
D. Educate the mother that her son has pseudogynecomastia.
Best Clues
* The boy is very overweight (BMI 29) and is almost obese.
* The clinical breast exam does not show palpable breast tissue. Instead, the breast palpation reveals soft fatty tissue.
* It is wrong to “reassure” a patient or family member in the exam (poor therapeutic communication technique).
Notes
1. Physiologic gynecomastia physical exam findings will show disklike breast tissue that is mobile under each nipple/areola; the breast may be tender, and the breast can be asymmetrical (one breast larger than the other).
2. A BMI of 25 to 29.9 is considered overweight. Obesity is a BMI of 30 or higher.
3. Overweight to obese males are at highest risk for pseudogynecomastia.
TANNER STAGES
Girls
Stage I: Prepubertal pattern
Stage II: Breast bud and areola start to develop.
Stage III: Breast continues to grow with nipples/areola (one mound/no separation).
Stage IV: Nipples and areola become elevated from the breast (a secondary mound).
Stage V: Adult pattern
Boys
Stage I: Prepubertal pattern
Stage II: Testes and scrotum start to enlarge (scrotal skin starts to get darker/more rugae).
Stage III: Penis grows longer (length) and testes/scrotum continues to become larger.
Stage IV: Penis become wider and continues growing in length (testes are larger with darker scrotal skin and more rugae).
Stage V: Adult pattern
Which of the following foods are known to have high potassium content?
A. Low-fat yogurt, soft cheeses, and collard greens
B. Aged cheese, red wine, and chocolate
C. Potatoes, apricots, and Brussels sprouts
D. Black beans, red meat, and citrus juice
Correct Answer: Option C
C. Potatoes, apricots, and Brussels sprouts
Best Clues
* First, look at the answer options for inconsistencies in the list of foods.
* Rule out option A because it is inconsistent and these foods do not contain high levels of potassium: low-fat yogurt and soft cheeses (calcium) with collard greens (vitamin K).
* Rule out option B because these foods have a high tyramine, not potassium, content.
* Rule out option D because it is inconsistent. Although citrus juices are high in potassium, both black beans and red meat are not (iron).
* If options A, B, and D are incorrect, then the only one left is option C (potatoes, apricots, and Brussels sprouts). A large number of fruits and vegetables are rich in potassium and vitamins.
*
Notes
1. Foods with a high tyramine content can cause dangerous food–drug interactions with MAOI inhibitors (e.g., isocarboxazid [Marplan], phenelzine [Nardil], and tranylcypromine [Parnate]).
2. Foods and supplements containing stimulants, such as caffeine and ephedra, are best avoided by patients with hypertension, arrhythmias, high risk for MI, hyperthyroid disease, albuterol use, amphetamine use, and so on.
3. If one of the food choices in an answer option is incorrect, rule out this option because all of the foods on the list have to be correlated.
Examples of Food Groups
Gluten (avoid with celiac disease/celiac sprue): Wheat (including spelt and kamut), rye, barley (breads, cereals, pasta, cookies, cakes)
Gluten free (safe carbohydrates): Corn, rice, potatoes, quinoa, tapioca, soybeans
Plant sterols and stanols (reduce cholesterol, LDL, triglycerides): Sterol-fortified spreads (Benecol spread), sterol-fortified foods, wheat germ, sesame oil
Monounsaturated fats/fatty acids (decrease risk of heart disease):
Olive oil, canola oil, some nuts (almonds, walnuts), sunflower oil/seeds
Mediterranean diet, which is high in monounsaturated fats
Saturated fats or trans fats (increase risk of heart disease): Lard, beef fat (fatty steak), deep-fried fast foods
*Omega-3 or fish oils (decrease risk of heart disease): *Fatty cold-water marine fish (salmon), fish oils, flaxseed oil, and krill oil
Magnesium (decreases BP, dilates blood vessels): Some nuts (almonds, peanuts, cashews), some beans, whole wheat; also found in laxatives, antacids, milk of magnesia
Potassium (helps decrease BP): Most fruits (especially apricot, banana, orange, prune juice), some vegetables
Folate (decreases homocysteine levels and fetal neural tube defects): Breakfast cereals fortified with folate, green leafy vegetables (i.e., spinach), liver
Iron (treats iron-deficiency anemia): Beef, liver, black beans, black-eyed peas
*Vitamin K (should control intake if on anticoagulants): *Green leafy vegetables (kale, collard greens, spinach), broccoli, cabbage
High sodium content (increases water retention, can increase BP): Cold cuts, pickles, preserved foods, canned foods, hot dogs, chips
Calcium (helps with osteopenia and osteoporosis, helps decrease BP): Low-fat dairy, low-fat milk, low-fat yogurt, cheeses
**
Common Disorders Associated With Certain Foods**
Celiac disease
Lifetime avoidance of gluten-containing cereals such as wheat, rye, and barley is necessary.
Gluten free: Rice, corn, potatoes, peanuts, soybeans, meat, dairy, all fruits/vegetables; most people with celiac disease can eat oats.
Hypertension
Maintain an adequate intake of calcium, magnesium, and potassium.
Calcium: Low-fat dairy, low-fat yogurt, cheeses
Magnesium: Wheat bread, nuts (almonds, peanuts, cashews), some beans
Potassium: Most fruits (apricot, banana, oranges, cantaloupes, raisins), green vegetables
Avoid high-sodium foods: Cold cuts, pickles, preserved foods, canned foods, preservatives
Migraine headaches and MAOIs (Marplan, Nardil, and Parnate)
High-tyramine foods: Aged cheeses/meats, red wine, fava beans, draft beer, fermented foods
Anticoagulation therapy (e.g., warfarin sodium or Coumadin)
Avoid eating large amounts of leafy green vegetables (kale/collard greens, spinach, cabbage, broccoli) and cooking with canola oil (high in vitamin K); use other oils instead. High levels of vitamin K decrease the effects of warfarin sodium.
A 16-year-old boy presents to a community clinic accompanied by his grandmother, who reports that he fell off his bike this morning. The patient now complains of a headache with mild nausea. The patient’s grandmother reports that he was not wearing a helmet. The health history is uneventful. Which of the following statements is indicative of an emergent condition?
A. The patient complains of multiple painful abrasions that are bleeding on his arms and legs.
B. The patient complains of a headache that is relieved by acetaminophen (Tylenol).
C. The patient makes eye contact occasionally and answers with brief statements.
D. The patient is having difficulty with following normal conversation and answering questions.
Correct Answer: Option D
D. The patient is having difficulty with following normal conversation and answering questions.
Best Clues
* History of recent trauma that is followed by a headache with nausea.
* The patient did not wear a bicycle helmet.
Notes
1. Any recent changes in LOC, even one as subtle as difficulty with normal conversation, should ring a bell in your head.
2. Notice the words “normal conversation.” Do not overread the question and ask yourself what they mean by “normal conversation.” Take it at face value.
3. Changes in LOC on the test are usually subtle changes. Signs to watch for include difficulty answering questions, slurred speech, apparent confusion, inability to understand instructions/conversation, being sleepy/lethargic, and so forth.
4. Even though the patient is bleeding, note that he has “abrasions,” which are superficial.
5. The behavior described in option C is considered “normal” for an adolescent male (or female).
