Final Flashcards

Question

Which complimentary regimen would be most beneficial in slowing the rate of functional decline in a patient with moderate to severe Alzheimer disease being treated with Aricept 10 mg PO and Memantine 10 mg PO BID? A. Memory Drills B. Vitamin E 100 IU PO BID C. 30 mins Aerobic Exercise Three Times Weekly D. Axona PO 40 mg Daily After Dinner

Answer 1

C. 30 mins Aerobic Exercise Three Times Weekly

Answer 2

A. C albicans

Answer 3

C. Unilateral in the periorbital area

Answer 4

A. Pseudomonas aeruginosa

Answer 5

b. Hyperkalemia

Answer 6

B. This vaccine is recommended by the CDC for children starting at 11-12 years old for prevention against seven types of HPV which are linked to cancer. Your daughter will need three doses of the vaccine to complete her HPV series.

Answer 7

B. Topical mupirocin

Answer 8

C. Educate that treatment can take up to 8-12 weeks to see results. Continue using the cream as prescribed and reevaluate in 3 months.

Answer 9

B) Ulcerative colitis

Answer 10

Formoterol is a long-acting beta agonist (LABA) that is used to treat COPD. The mechanism of action is to relax the smooth muscle by stimulating beta2 -adrenergic receptors which causes vasodilation in the bronchioles. LABAs are used for initial treatment for COPD. LABA duration of action is 12 hours or greater which exceeds SABA (short acting beta agonists). Formoterol is to be given twice daily and is showed to improved FEV, lung volumes, dyspnea and number of exacerbations. Side effects includes resting tachycardia, hypokalemia and tremors. Theophylline is in a class called xanthines. It is considered 4th line treatment for COPD. It relaxes the smooth muscle by inhibiting phosphodiesterase which breaks down nucleotides. This medication has a small therapeutic index and must be given in large doses which is why it is not used as often. Fluticasone is an inhaled corticosteroids used to treat moderate to severe COPD. This medication is normally used with a LAMA or LABA if 2 or more exacerbations occur. Albuterol is a short acting beta agonist and is in the same class as ipratropium. This is also optional to use a first-time treatment if the patient is experiencing sob. Therefore, in this scenario this medication would not be appropriate.

Answer 11

c) Echocardiogram Rationale: An echo can differentiate HFpEF from HFrEF. It can evaluate the size and function of the atria and ventricles. In addition, it can assess the valves for abnormalities and ventricular wall motion to detect old MI, pleural effusion, and pericardial thickening or effusion from pericarditis and can evaluate cardiac output and pulmonary artery pressures.

Answer 12

B. Screen for chlamydia and gonorrhea with a NAAT All sexually active females that are 25 years old or younger should be screened for chlamydia and gonorrhea annually using a nucleic acid amplification test (NAAT). A Pap smear should be conducted for the first time at age 21 and be repeated every three years. Screening for HPV is not advised before the age of 30

Answer 13

Pap smear. Even though the patient identifies as male, they still have female body parts. Since the patient still has female body parts, it is important to include female health promotion such as a pap smear. Bone density screening isn’t recommended until age 65. PSA lab draw is recommended for males with prostates. A colonoscopy isn’t recommended until age 45.

Answer 14

HCTZ. First-line treatment for hypertension in African Americans is with a calcium channel blocker or a diuretic. Clonidine is typically used for hypertensive urgencies or emergencies. African Americans are more likely to develop angioedema related to Lisinopril use. Also, ACE inhibitors and ARBs have been shown to be less effective in the African American population; therefore, these are reserved for second-line or combined treatment options.

Answer 15

d. Explain the importance of taking the Symbicort every day and only using the ProAir as needed Asthma is characterized by wheezing, shortness of breath, and cough with symptoms often being worse at night. Long-term controller medications are used daily to decrease inflammation of airways, prevent symptoms, and decrease risk of exacerbations. Examples of maintenance therapies include long-acting beta-adrenergic agonists (salmeterol, formoterol, and olodaterol), inhaled corticosteroids (budesonide, flunisolide, fluticasone, mometasone, triamcinolone), combined medications (budesonide/formoterol, fluticasone/salmeterol, fluticasone/vilanterol, mometasone/formoterol). Short-acting medications are used for sudden onset of symptoms such as cough, wheezing, or shortness of breath. Examples of reliever medications include short-acting beta-agonists (albuterol, levalbuterol), anticholinergics (ipratropium HFA, ipratropium with albuterol), systemic corticosteroids (methylprednisolone, prednisolone, prednisone). Uncontrolled asthma for long periods of time can lead to irreversible airway damage which causes higher mortality rates.

Answer 16

A. 6 months of trying to conceive Fertility decreases after age 35 in women. A woman who is 35 or older can be considered infertile after 6 months of actively trying to conceive. Infertility workup (including STI panel, substance abuse, timing of intercourse, and ovarian reserve/hormone labs) should be considered in this population to pinpoint course of treatment

Answer 17

B. Doxycycline 100mg by mouth twice daily for 7 days 100mg Doxycycline is the preferred treatment in non-pregnant patients. Alternate treatments in the case of allergy or pregnancy are 1 gram azithromycin by mouth once or 500mg of levofloxacin by mouth once daily for 7 days; since neither of those is an option,100mg of doxycycline is the most appropriate in this scenario.

Answer 18

A.) It is recommended that patients take these products within 72 hours of unprotected intercourse. Emergency contraception is the only contraceptive method designed to prevent pregnancy from occurring after unprotected sex. It is recommended that patients take these products within 72 hours of unprotected sex as the product loses its’ effectiveness with the more time that passes. EC is 90% effective if used within the first 24 hours and is available for sale OTC to adolescents aged 17 or older.

Answer 19

s B. Echocardiogram is the most useful test in establishing diagnosis of heart failure. It can recognize the abnormal heart function and determine whether or not left ventricular function is preserved. ECG may reveal some nonspecific cardiac abnormalities, but does not confirm the diagnosis of heart failure. Cardiac stress test is mostly useful in confirming diagnosis of angina in patients with intermittent chest pain. Chest X-ray may reveal cardiomegaly and abnormal vasculature but does not determine if ventricular function is within normal limits

Answer 20

c. Transfer the patient to the emergency department STAT for respiratory distress possibly due to epiglottitis. A sudden onset of high fever, dysphagia and excessive drooling are key symptoms of Epiglottis. Other symptoms may include a muffled voice, retractions, and cyanosis. The “sniffing dog” position is a key indicator of respiratory distress with the neck hyperextended and chin upward to open the airway. Epiglottitis is a medical emergency, and the patient should be transferred to a hospital as soon as possible to prevent airway obstruction. Symptoms may be similar in those with croup; however, croup usually presents with a barking cough and no drooling.

Answer 21

a. “Your fasting morning serum testosterone level was 240 ng/dL, which is low. We should consider initiating testosterone therapy.” Serum testosterone reference ranges are based on non-fasting morning specimens when testosterone levels are highest. Fasting specimens or those drawn later in the day may be misleading. Serum testosterone levels are considered low if a non-fasting morning testosterone level is less than 240ng/dL and is confirmed with a second test. Testing for LH levels will help differentiate between hypergonadotropic hypogonadism (LH is high) and hypogonadotropic hypogonadism or normal aging (LH is low or normal). Serum PRL helps screen for pituitary/hypothalamic lesions. Obesity may contribute to low testosterone, and bariatric surgery can be an effective means of weight loss. Significant weight loss can help normalize testosterone levels. Serum free testosterone levels are low if they are less than 35pg/mL for men ages 16-69 and less than 30pg/mL for men older than 70.

Answer 22

B. Serum TSH, free T4 For primary hypothyroidism, TSH and free T4 are the most sensitive. Assessing serum TSH and free T3 is performed for hyperthyroidism. In patients with thyroid nodules, thyroid ultrasounds should be ordered as ultrasound can be done to monitor growth and differentiate between thyroid nodules and a multinodular goiter.

Answer 23

D. Gynecomastia is enlargement of the breast and is normal in adolescences and it usually disappears by age 17. Gynecomastia is enlargement of the breast which normal which occurs at the peak of sexual maturity and disappears by age 17 if occurs after 17 it warrants further assessment. A. Gynecomastia is normal not abnormal is adolescences males. B. Incorrect. Age 15 is to earlier to assess for problem enlarge stated in above providers worry after age 17 years. C. Incorrect Gynecomastia is abnormal in adolescences males and requires a watch and wait approach is incorrect it should disappear by age 17 years old.

Answer 24

A) discontinue statin therapy immediately and order creatine kinase, urinalysis, CBC, CMP and ECG. The patient has the three classical signs of rhabdomyolysis. Patients taking high-intensity statins or combination therapy are at higher risk. Statin medication should be stopped completely and not reduced if rhabdomyolysis is suspected. Rhabdomyolysis can cause acute renal failure however more information is needed to determine renal status.

Answer 25

a. older children living in areas with a high percentage of homes that were built before the 1950's. Rationale: Since older homes were painted with lead based paints, it is imperative to assess children who live in those homes or areas where most of the homes were built before the 1950's.

Answer 26

B A. Fibroadenoma of the breast is a common benign condition. These lesions are typically 1-5cm, relatively mobile, nontender, rubbery to palpation and often discrete and round or oval in shape. Ultrasound can rule out fluid filled cysts and definitive diagnosis can usually be made with a core needle biopsy. Stable fibroadenomas do not require intervention. B. Fibrocystic condition of the breast is the most frequent abnormality of the breast. Characteristic findings include painful breast masses that are often multiple and bilateral. Fluctuation in size and tenderness is often mediated by estrogen changes in the menstrual cycle, and it is most common in women 30-50 years of age. Specific subtypes of fibrocystic conditions of the breast are associated with higher rates of breast cancer than then average population, so patients with fibrocystic condition of the breast are advised to perform SBE regularly and report masses or changes to their health care provider. C. Breast carcinoma is often a nontender, single, poorly defined mass. Risk factors include positive family history (BRCA 1, 2, others), childbirth after 30, and nulliparity. The general population is no longer recommended to perform regular SBE. D. Patients with fibrocystic condition of the breast are encouraged to perform SBE regularly.

Answer 27

A. Infant sits alone for short periods The correct answer is A. Between 6-8 months the infant sits alone, reaches with one hand, imitates bye-bye, and babbles. Building towers of 3-4 cubes is an activity observed in an 18- month-old. Pointing to a desired object and giving toys on request is a behavior observed in a one-year-old.

Answer 28

D: Viral Croup The correct answer is D. Rationale: A new onset of stridor in the presence of an upper respiratory illness or fever is the hallmark characteristic of croup that generally affects children between the ages of 6 months and 5 years of age. Croup is distinguished by a “seal-like barking” cough, stridor, hoarseness, and difficulty breathing that worsens at night. Croup is differentiated from epiglottis by the absence of drooling and positional breathing (tripoding). Peritonsillar abscess is ruled out by the absence of a sore throat and the classic “hot potato” voice. Bacterial tracheitis is ruled out by the non-toxic appearance of the patient with the ability to maintain his airway and low-grade fever.

Answer 29

A. Unintentional Injury Cultural and environmental factors pose the greatest threats to adolescent life, not organic factors. Unintentional injury is the leading cause of death among adolescents aged 15-19 making up 38.5% of all causes of adolescent death. Suicide is the second leading cause of death, homicide is the third, and cancer is the fourth leading cause of death among adolescents. Motor vehicle crashes are the leading cause of unintentional injury death making up 52% of all adolescent deaths caused by unintentional injury. Poisoning is the second leading cause of unintentional injury death and prescription drug overdose is the third leading cause of unintentional injury death among adolescents.

Answer 30

A. The Palmar grasp typically disappears at 4 months of age. He is developmentally appropriate for his age. Newborns are born with the Palmar grasp, and it typically disappears around 4 months of age. The provider knows this developmental milestone and can reassure the mother. The infant does not need to be evaluated further because this is normal development. The reflex will not reappear in a week or two. The provider should never dismiss parental concerns but instead should educate on all aspects of growth and development.

Answer 31

C. Hospital records and the mother confirm visible jaundice appeared after 24 hours of age. In physiologic jaundice, the peak bilirubin should not exceed 15 mg/dl. Excessive hyperbilirubinemia is classified as levels greater than 17. A level of 22-25 indicates need for intervention such as exchange transfusion. A lethargic infant who is not interested in feeding could be a sign of acute bilirubin encephalopathy. Physiologic jaundice appears after 24 hours of age, peaks on day of life 3-4, and resolves by 1 week in the full-term infant. Hereditary spherocytosis leads to hemolysis and subsequent hyperbilirubinemia. A peripheral blood smear is used to diagnose this condition.

Answer 32

D. E. coli According to Papadakis and McPhee (2020), coliform bacteria are responsible for the majority of uncomplicated UTIs with E Coli being the most common pathogen

Answer 33

B. Chronic hypertension Chronic hypertension is diagnosed before 20 weeks’ gestation, given this patient is 18 weeks, this would be considered a chronic condition. This is not considered pregnancyinduced given it was diagnosed before 20 weeks gestation, and it is not considered severe preeclampsia because she is negative for severe features such as headache, blurred vision, and right upper quadrant pain, and she is negative for proteinuria. Older, obese, African American females are at increased risk for chronic hypertension.

Answer 34

a. Trichomoniasis Petechial hemorrhages also known as strawberry cervix along with green, frothy, malodorous discharge and vaginal itching are seen in over 50% of females with trichomonas. The appearance of flagellated protozoa on wet prep are diagnostic of trichomonas, culture and NAAT are also available if there is unclear diagnosis

Answer 35

d. Breast cancer Breast cancer usually presents as a firm, non-tender mass that has poorly defined margins due to infiltration to the surrounding tissues. The most common anatomic region of the breast for breast cancer is the upper lateral quadrant, consisting of 60% of most cases.

Answer 36

C) Nonbacterial Chronic Prostatitis/Chronic Pelvic Pain Syndrome a) Acute Bacterial Prostatitis yields positive cultures of urine and prostatic secretions b) Chronic Bacterial Prostatitis yields positive cultures of urine and prostatic secretions c) Nonbacterial Chronic Prostatitis/Chronic Pelvic Pain Syndrome yields negative cultures of urine and prostatic secretions d) Acute Epididymitis of non-STI origin yields a positive urine culture result

Answer 37

Asthma is the presumptive diagnosis in this scenario. Chest tightness, cough, shortness of breath, and episodic wheezing are all characteristic of asthma. Common physical exam findings are atopic dermatitis, expiratory wheezing, nasal mucosal swelling or polyps. ABGs may be normal in a patient with asthma exacerbation therefore should not be the initial diagnostic test to rule in/out this diagnosis. Although albuterol would likely help to alleviate this patient’s symptoms and will likely be included in the treatment plan, it would not help to identify the cause in this scenario. Chest radiograph are not indicated in asthmatics as they are typically normal. In cases where pneumonia is suspected, chest x-ray would be necessary. Evaluation and diagnosis of asthma should include spirometry as this test helps to determine the extent of airflow obstruction

Answer 38

B. Amoxicillin 80-90 mg/kg/day in two divided doses for 5 to 7 days. Croup is an inflammatory disorder of the upper airways typically occurring following a viral upper respiratory infection. The traditional seal like-barking cough is due to edema and inflammation of the subglottic space. The goals of treatment are supportive and to reduce upper airway inflammation. In this case, antibiotics would be a completely inappropriate therapy and not beneficial based on the pathophysiology of the disease.

Answer 39

A. Decreased or absent femoral artery pulses Coarctation of the aorta involves stenosis of the aorta, usually the aortic arch between right and left subclavian arteries. Inadequate arterial blood supply to the lower extremities causes decreased or absent femoral artery pulses. Blood pressure readings are also typically inconsistent between both upper extremities. With coarctation of the aorta, lower extremity blood pressures are LOWER, than upper extremity blood pressures, not HIGHER. Jaundice and acrocyanosis are physiologic findings of newborns within the first few days to a week.

Answer 40

- Fibrocystic breast disease is a common condition that causes the breast tissue to be lumpy or feel like a rope. Hormone changes during the women’s menstrual cycle can cause the breasts to become lumpy, swollen, sensitive or tender. In order to confirm fibrocystic breast disease, an ultrasound and biopsy will be done. Mammograms are not indicated for women under 30 years old due to the breast tissue being too radiodense to result in an accurate evaluation.

Answer 41

B: Step up her asthma treatment one step by adding a daily low dose inhaled corticosteroid This patient’s asthma is not well controlled as she is not meeting three asthma control components. Her asthma is affecting daily activities, causing nighttime awakenings and she is using her rescue inhaler more than 2 times a week. The patient needs to step up to the next step, in her particular case this would be Step 2- adding an ICS. When treating asthma, it is important to find the lowest effective step, which is why stepping up 2 steps in treatment is not suggested at this time. The patient should continue to monitor asthma components and return to the clinic to see if her asthma is controlled after adding the ICS.

Answer 42

D. Make an appointment with a cardiologist for further work-up Patient is experiencing stable angina pectoris; a chest pain occurs with physical exertion and relieves when rested. To rule out any other complications, it is best to refer the patient to the cardiology for further cardiac work up.

Answer 43

D. *Initiate amlodipine 5 mg tab po daily and follow up in four weeks with updated BP logs Blood pressure less than 130/80 mm Hg is recommended for patients being treated with antihypertensive drugs. African Americans (AA) respond better to calcium channel blocker drugs such as amlodipine and diuretics, which this patient is currently on. Calcium channel blockers are superior to beta blockers in AA patients in controlling BP and should be followed up in four to six weeks post initiation to assess BP (Sutters, 2021).

Answer 44

C. Left sided heart failure : Tetralogy of Fallot is usually diagnosed in childhood and includes symptoms of a ventricular septal defect, right ventricular stenosis, right ventricular hypertrophy, and a dilated aorta. Left sided heart failure includes symptoms of shortness of breath especially on exertion, a nonproductive cough worse when lying flat, and paroxysmal nocturnal dyspnea. Right sided heart failure includes symptoms of retention of fluid, ascites, hepatic congestion, loss of appetite, nausea, and edema. Rhematic fever is rare after age 40 and occurs after an infection causing carditis, arthritis, and erythema marginatum.

Answer 45

A. Metformin will improve the frequency of ovulation, contraception should be prescribed for sexually active teens

Answer 46

A. TSH- 4.5, Free T4-3.5, T3-2.2 Hypothyroidism primarily affects females more significantly after 40 years old. Hypothyroidism affects all major body systems. It can cause hair loss, apathy, myalgia, lethargy, dry skin, constipation, intolerance to the cold, receding hairline, facial and eyelid edema, brittle nails and hair, anorexia, menstrual disturbances, weight gain, and bradycardia. The best screening test for hypothyroidism is TSH. The TSH should be within 0.4-4.0. Other labs directly related to the thyroid are Free T4 (which should be >4.0) and T3 (which should be <3.0). A hypothyroid patient will have a high TSH and a low free T4. A hyperthyroid patient will have a low TSH, a high free T4, and a high T3. The answer would be A since the TSH is above 4.0 (4.5), the free T4 is below 4.0 (3.5), and the T3 is not high. The patient is also having symptoms related to hypothyroidism. B would be incorrect because even though the TSH is elevated, the T4 and the T3 are also elevated. C would not be corrected because the labs all correlate with hyperthyroidism (low TSH, high T4, and T3). D would not be correct because the TSH is low, the T4 is high, but the T3 is low.

Answer 47

B. Ciprofloxacin

Answer 48

B. An increase in FEV1/FVC by 12% after inhaling a short-acting bronchodilator Rationale: To evaluate for asthma, spirometry (forced expiratory volume in 1 second (FEV1), forced vital capacity (FVC), and FEV1/FVC) is compared previously to after the administration of a SABA (short-acting beta-agonist). The results will determine airflow obstruction and if it is reversible. An increase of 12% or more after inhaling a SABA is significant for reversibility. The diagnosis of asthma is supported by this 12% increase.

Answer 49

b. 12 months Infertility is defined as the inability to conceive after a year of practicing normal sexual activities.

Answer 50

B. This is an expected developmental pattern. It could take up to 2 years for a child to achieve nighttime continence after achieving daytime control. : Enuresis is the repeated urination into the bed at night or into clothing during the day by a child that is developmentally and chronologically older than 5 years old. If the child was chronologically and developmentally older than 5 years old, this would be considered enuresis and a UA with culture should be obtained. Most children achieve nighttime control within 2 years of daytime control, this child is developmentally on track. No intervention nor medication needs to be initiated for this child. DDAVP is a treatment option for children diagnosed with enuresis who have had no improvement with behavioral strategies. Scolding and shaming a child will affect the child’s self-esteem and not help with achieving nighttime continence

Answer 51

A- Gestational HTN is diagnosed in a pregnant patient when they have two elevations of 140/90 or above past 20 weeks’ gestation. Option B is incorrect as the patient was past 20 weeks’ gestation with both elevations. Options C and D are incorrect as patient has not had any other associated symptoms mentioned or seizure.

Answer 52

C: BNP BNP is an extremely strong prognostic indicator for heart failure status. BNP is given off from the heart ventricles when ventricle filling pressure is high. It is most sensitive and valuable in patients in the acute heart failure setting. Blood counts such a CBC may reveal an anemia which is non-specific and a poor indicator of heart failure status. EKG would be important to evaluate for secondary arrythmias but is not entirely specific or sensitive to heart failure itself. Chest xray may reveal findings in heart failure such as cardiomegaly, which is indeed important, however, this is poor prognostic indicator for heart failure primarily as patients can have chronic

Answer 53

C: Losartan The most common side effects for calcium channel blockers (amlodipine) include constipation, bradycardia, and peripheral edema. This would be contraindicated in the patient’s baseline bradycardia and peripheral edema. The most common side effects of beta blockers (metoprolol) include worsening of bronchospasm in asthmatics and SA and AV node depression resulting in bradycardia. This would be contraindicated in the patient’s baseline bradycardia and potentially exacerbate asthma. Methyldopa is not prescribed as a first line antihypertensive and is only now utilized in females with hypertension during pregnancy. Angiotensin receptor blockers are commonly used as popular first line antihypertensives and improve cardiovascular health in patients with chronic conditions such as diabetes mellitus. Losartan also has shown significant reduction in stroke and death by MI.

Answer 54

A. Progestin only pills Progestin only oral contraceptive pills are ideal for women who have contraindications to estrogen. This includes women aged >35 y/o who smoke, women who are currently breastfeeding, women with hypertension, migraines, systemic lupus, mental retardation, or sickle cell anemia.

Answer 55

D. Ginkgo may increase your risk of bleeding especially while taking warfarin. Let’s discontinue this OTC supplement. Rationale: Gingko biloba is modernly used for management of age related memory loss, dementia and even early stages of Alzheimer’s. Gingko may have some blood thinning properties therefore it is not recommended to be used in combination with anticoagulants or antiplatelet as it increases the risk of adverse events.

Answer 56

d. Elevated thyroid-stimulating hormone (TSH), low free T4 Rationale: The patient lab results diagnosing the patient with hypothyroidism will show elevated TSH and lowT4 levels. The normal range for TSH is 0.4-4.0 milli-international units/L, T4 ranges from 5.0 to 12.0, and an average total T3 level in the adult ranges from 80-220. In hypothyroidism, the patient’s TSH will be greater than 4.0, free T4 is low, and T3 is low. In subclinical hypothyroidism, the patient’s TSH is greater than 4, free T4 is normal, and T3 is normal. In hyperthyroidism, the TSH is less than 0.4, and free T4 and T3 are high. Subclinical hyperthyroidism presents the patient’s TSH of less than 0.4 and normal free T4 and T3 levels. Therefore, high free T4, Elevated TSH, normal free T4, and High free T4 are all incorrect answer choices.

Answer 57

D. in women beginning at age 21 In otherwise healthy women, screening for cervical cancer should begin at age 21. These recommendations are applicable to women with a cervix regardless of their sexual history or, HPV vaccination status.

Answer 58

C. CMP, prolactin, estradiol, LH, FSH, testosterone, serum beta-hCG, and TSH Rationale: Glandular gynecomastia can often be the first sign in older men of a serious disorder. Checking the liver, BUN and creatinine should be included. Further endocrine labs include LH, FSH, free testosterone, serum testosterone, TSH, and FT4 help to distinguish between primary hypogonadism (high LH and low serum testosterone), secondary hypogonadism (low or normal LH and low serum testosterone) or an androgen resistance. Elevated estradiol levels may indicate testicular tumors, liver disease, or adrenal tumors.

Answer 59

D. Dengue fever Dengue fever presents in three phases. Following incubation, the febrile phase consists of high fever, malaise, arthralgia, retro-orbital eye pain, maculopapular rash, conjunctival injection, petechiae, and epistaxis. Dengue may progress to severe infection with plasma leakage, pleural effusions, and hemorrhage. Retro-orbital eye pain is not seen with chikungunya virus. Covid-19 commonly presents with cough, fever, and shortness of breath. Smallpox presents with fever, severe headache, and a maculopapular rash with vesicles or pustules.

Answer 60

A. Rheumatic Fever Rhematic fever is more common in girls and African Americans, and the age group at highest risk are 5–15-year-olds. It is preceded by group A strep, which the child had 3 weeks prior. To diagnose Rheumatic Fever, the Jones criteria is use. The patient must have 2 major or 1 major and 2 minor manifestations, as well as evidence supporting a recent strep infection. The patient has a major manifestation of Erythema Marginatum (Rash), as well as two minor criteria (fever ≥38.5 and prolonged PR interval). In addition, the diastolic murmur can be indicative of aortic insufficiency, which is seen in rheumatic carditis (a second major criteria).

Answer 61

2. Stop the statin 1-2 months before pregnancy is attempted Rationale: Statin medication should be stopped 1 to 2 months before pregnancy is attempted in all women with hypercholesterolemia. Also, they should stop the statin medication as soon as they discover they are pregnant.

Answer 62

The correct answer is Pericarditis. The stem exemplifies all aspects of pericarditis including the presentation of sudden onset of mid sternal chest pain that is described as stabbing and sharp; worsened by deep breathing and coughing; alleviated by leaning forward. Elevated ST segments seen on ECG, high-pitched, scratchy friction rub and grunting respirations are all findings associated with Pericarditis. Dilated Cardiomyopathy commonly presents with children having a decreased activity tolerance, tachypnea, diaphoresis and failure to thrive. Myocarditis would present with signs of heart failure such as rapid and weak pulse, gray/pale skin, difficulty feeding in infants, exercise intolerance and edema soon after a viral illness. Acute Myocardial Infarction is not the answer in this case based upon the aggravating and alleviating factors along with the physical exam findings.

Answer 63

3. Asbestosis: The nurse practitioner would screen the patient for occupational pulmonary disease. The patient will then have a pulmonary work up to confirm diagnosis. Influenza is a viral infection that can cause illness but does not cause clubbing of the fingers. Anemia is not the correct answer the symptoms are pertinent negatives. There is nothing in the question that points to a diagnosis of hypertension.

Answer 64

c. Mitral valve prolapse Patients who experience mitral valve prolapse have crisp mid-systolic clicks that are best heart over the left apex with the patient laying in the left lateral position. Patients with Marfan syndrome have a collagen abnormality that results on degeneration of the mitral valve leaflets resulting in mitral valve regurgitation and further mitral valve prolapse. Patients with mitral valve prolapse in the absence of severe mitral valve regurgitation frequently presents asymptomatic, although they can present with chest pain, fatigue, dyspnea, and palpitations. An echocardiogram is warranted.

Answer 65

B; Homan’s sign is a test that practitioners would obtain to rule out DVT in the presence of other clinical signs (e.g., history of DVT). The test is performed with the patient’s knee extended on the table and the clinician passively dorsiflexes the affected foot. If pain is reproducible on the posterior calf, it is said to be a positive Homan’s sign and could indicate the presence of a DVT.

Answer 66

C. At age 1, if Hg is 10-11 mg/dL, it is safe to closely monitor and recheck in one month According AAP guidelines, if a child’s hemoglobin is between 10-11mg/dL at the 12-month wellness visit, it is recommended to either monitor closely or empirically start iron supplementation at 3-6mg/kg/day. Since the patient is asymptomatic, the best answer is to monitor the patient closely and not wait to follow up in 6 months.

Answer 67

C) anterior cruciate ligament injury The Lachman and anterior drawer tests are specific to ACL injuries. An audible pop, immediate swelling, instability and difficulty bearing weight are common presentations of ACL injuries. ACL injuries are common with sporting injuries among young adolescents and adults.

Answer 68

C) rotator cuff tear Rotator cuff tears present with pain upon overhead movements, difficulty lifting the affected arm with limited active range of motion, and weakness with resisted strength testing. Rotator cuff tears are commonly caused by falling on an outstretched arm.

Answer 69

A- Anorexia Nervosa Patients with restriction of energy relates to low body weight, strong fear of gaining weight or being fat even when the patient is under weight, and visual disturbances is all characteristics of Anorexia Nervosa. Usually, the patient is in denial that they are having these problems. Some signs and symptoms of these are bradycardia, dizziness, light-headiness, prolonged QTc, brittle skin and nails, delayed gastric emptying, constipation, malnutrition and may other symptoms.

Answer 70

C- Order a CT scan/MRI This scenario reveals “shaken baby” syndrome. Any baby younger than 2 that you suspect shaken baby should have a further examination of head trauma or other head injury. Sometimes head injuries can be missed if practioner aren’t considering physical abuse as a diagnosis because they can present with no visible findings on examination. But a finding of retinal hemorrhages in an infant without a medical condition should raise concern for head trauma. Retinal hemorrhages are not commonly seen after cardiopulmonary resuscitation either. If suspected head trauma a computed tomography or magnetic resonance imaging should be done to rule in or out a subdural hemorrhage. Coagulation studies and complete blood cell count are useful if patient presents with several bruises.

Answer 71

c. Start the patient on 50mcg of Levothyroxine once daily The appropriate treatment for hypothyroidism is synthetic levothyroxine. It is important to educate the patient to take this medication on an empty stomach with an 8 oz glass of water preferably first thing in the morning. While that is an appropriate prescription of Vitamin D3 and Vitamin D3 can cause fatigue this patient’s vitamin D3 level is within normal limits and is not required for a hypothyroidism diagnosis. Calcitriol is prescribed for hypoparathyroidism/ Acute Hypocalcemia. Propranolol ER is prescribed for hyperthyroidism.

Answer 72

b. Regular Insulin based on a sliding scale While there are several medications approved for type 2 diabetes, Trulicity, Januvia, and Glyburide are examples, there is only one medication that is approved for the treatment of Type 1 diabetes whether pregnant or not, Insulin.

Answer 73

C. Lung cancer There are more lung cancer deaths than colorectal, prostate, and breast cancer combined. Lung cancer is the leading cause of cancer deaths in both men and women in the United States. The most common cause of lung cancer is tobacco use. However, there are other factors that contribute to the development of lung cancer including: tobacco smoke, radon, asbestos, diesel exhaust, arsenic, iron oxide, nickel, and industrial carcinogens.

Answer 74

A. PSA The current screenings for prostate cancer include DRE, PSA, and transrectal ultrasound. Prostate cancer may manifest as nodules on the prostate that can be felt on DRE. However, patient’s rarely present with symptom and prostate cancer detection rates are higher with PSA than DRE. When using DRE alone most cancers are already advanced when they are detected, stage T3 or greater. Transrectal ultrasound should not be the first line screening tool due to cost and low specificity. PSA testing increases the detection rate of prostate cancer by approximately 3% compared to 1.5% using DRE alone.

Answer 75

D. Lachman Test The correct answer is D, a positive Lachman Test. This test has an 84-87% sensitivity and 93% specificity for an ACL injury. It is done by having the patient lie supine, flexing the knee about 20 degrees, and holding the distal femur on the lateral side and the proximal tibia on the medial side with the opposite hand. Then pull the tibia anteriorly. If there is a greater anterior translation of the tibia when compared to the other side, this indicates an ACL injury. A positive McMurray test is a finding for a meniscus injury. A positive Thessaly test indicates a meniscus injury. A positive Valgus Stress test is likely to indicate a medial collateral ligament injury.

Answer 76

B. Januvia (Sitagliptin) The correct answer is Januvia (sitagliptin), a DPP-4. DPP-4s are moderate efficacy, weight neutral, and has the possible side effect of pancreatitis. Ozempic (semaglutide), a GLP-1, is a once-weekly injection. Jardiance (empagliflozin), a SGLT2 inhibitor, has a major side effect of UTIs, genital mycotic infections, and dehydration. Humalog (Lispro) is a short-acting insulin given subcutaneously and has an increased cost due to the additional supplies needed to monitor glucose.

Answer 77

D. Abstinence of friends The role of the NP is to identify patients at increased risk of advancing from substance use to abuse. There is a link to the amount of risk factors a patient possesses and their risk to advance to substance abuse. A few of the risk factors include Genetic predisposition, depression, ADHD, academic failure, economic deprivation, availability of substances. A few protective factors include abstinence of friends, nurturing parenting style, and goal oriented.

Answer 78

A. Glasgow Coma Scale (GCS) The recommended initial examination of Glasgow Coma Scale (GCS) gives insight into the severity of the injury and aids in predicting outcomes. Those with low GCS are linked to unfavorable outcomes. Although imaging may be recommended depending on the mechanism of injury, patient presentation, and history of present illness, it is not the initial assessment that would be conducted.

Answer 79

b. adjustment disorder with depressed mood In adjustment disorder with depressed mood, depression may occur in response to an attributable stressor or adverse life event such as a divorce, death, or financial loss. This disorder occurs within 3 months of the stressor and causes impaired social or occupational operation. Persistent depressive disorder is a chronic depressive disruption over a period of two or more years with symptoms that are milder and longer lasting. Major depressive disorder consists of physical, mood, and cognitive symptoms occurring at any time in life. Diurnal variation with improvement as the day progresses is common.

Answer 80

d. Atomoxetine Stimulants are the most commonly prescribed and most effective medications for the treatment of ADHD. Side effects may include anorexia, weight loss, insomnia, headache, tachycardia, and irritability. When stimulant medications are not well tolerated or are ineffective, non-stimulant medications may be used as an alternative. Nonstimulants such as atomoxetine, selective noradrenergic reuptake inhibitors, and central adrenergic receptor agonists are FDA approved for ADHD treatment in children.

Answer 81

b. Nicotine gum and transdermal nicotine patches are recommended for smoking cessation in teens. Adolescent patients may exhibit symptoms of nicotine dependence in as little as 4 weeks. Replacement therapy improves rates of smoking cessation and reduces withdrawal symptoms. Nicotine gum and transdermal nicotine patches may be used as replacement therapies for teens.

Answer 82

A. Asian culture When speaking to those of Arabian and Asian culture it is disrespectful to maintain direct eye contact. In the Latino and Western culture, lack of eye contact is found to be disrespectful. The Muslim culture avoids physical contact between genders.

Answer 83

B. Cultural competence Cultural competency is an ongoing, lifelong process that requires the provider to continuously self-assess and develop skills and behaviors that are respectful and responsive to the patients’ beliefs and culture.

Answer 84

C. Pulmonary embolism The Wells score/criteria checks for clinical risk probability and separates patients into a low, intermediate, or high chance, or pulmonary embolism likely or unlikely groups. The variables included are signs/symptoms of a DVT, another diagnosis is less likely, HR >100 bpm, immobilization greater than 3 days, previous PE/DVT, hemoptysis, and cancer.

Answer 85

B. Edema The essentials for diagnosis of PAD are cramping pain/tiredness in calf when exercising, reduced pedal and popliteal pulses, pain in the feet at rest that is relieved by dependency, and foot ulcers. Low blood flow chronically contributes to loss of hair. Pallor on elevation is separate from rubor related to erythema.

Answer 86

A. Methotrexate Rheumatoid arthritis is cause by a systemic wide inflammation. The mainstay drug to treat this disorder is a group of drugs called DMARDs. These drugs play a key role in the treatment of RA. The correct answer is Methotrexate. Methotrexate helps to decrease the systemic inflammation; this drug is usually well tolerated.

Answer 87

The correct answer is “The test results are wrong, and I don’t have osteoporosis”. Osteoporosis is a condition where the bone matrix is lost. This predisposes patients to fractures. Some risk factors for osteoporosis include aging, alcoholism, hormone deficiency, low physical activity, smoking, and some medications. All the options shows that the patient has an understanding except for option 3.

Answer 88

D. Cream cheese MAOI’s are used as third-line meds for depression and panic disorders. This is due to the side effects, dietary limitations and medication interactions. Fermented foods such as wine, bologna, salami, cheese (except cottage and cream cheese), sauerkraut, soy sauce should be avoided while on this medication. Meperidine, dextromethorphan, pseudoephedrine and phenylpropanolamine are a few medications to abstain from during use

Answer 89

D. TSH 5.9 IU/L, FT4 2.1 mcg/dL Common signs/symptoms of hypothyroidism include weight gain, lethargy, weakness, constipation, menorrhagia, cold intolerance, depression. On physical exam you would find low heart rate, high blood pressure, thin nails, and peripheral edema. Some uncommon symptoms of hypothyroid include decreased appetite, decrease taste/smell, dysphagia, cervicalgia, amenorrhea. Lab findings would show an elevated TSH level (>4) and a low or normal FT4 (0.9-2.4).

Answer 90

A. ABI For diagnostic purposes, ABI should be less than 0.9 for PAD. If ABI is less than 0.4, critical ischemia of the limb should be suspected. If further evaluation is indicated, CTA would be the next step. When screening in patients with claudication, CT without contrast, x-ray, and MRI are not indicated.

Answer 91

D. History of heparin-induced thrombocytopenia Treatment as an outpatient for a DVT has some contraindications the provider will need to keep in mind. Outpatient management is contraindicated if the DVT is in the vein of the upper extremity, common femoral, iliac, or inferior vena cava. Patients who had a gastrointestinal bleed within the last two weeks, peptic ulcer disease which is active should be treated in the inpatient setting. The provider should also know contraindications for outpatient treatment of a DVT include a spinal cord injury or spinal surgery within the last 10 days, comorbid conditions, metastasis of the brain, active bleeding, and low platelet counts. Patient with a weight of less than 55 kg in men and 45 kg in women should be treated in the hospital. Patients with a creatinine clearance of less than 30 mL/min, history of heparin-induced thrombocytopenia (HITT), and those who are unable to self-administer injectable medications or follow a medication schedule/follow instruction provided should also be treated as an inpatient.

Answer 92

B. TIBC, iron level, and ferritin Anemia with low MCV can be many things. However, the clue of craving ice leads to a differential diagnosis of iron deficiency anemia. To confirm this diagnosis labs for iron should be ordered (TIBC, iron level and ferritin).

Answer 93

C. Heparin Induced thrombocytopenia A decrease in platelet count of 50% or more is thrombocytopenia. When the patient is on heparin (day 5-14 of use) when platelet count is found to be decreased then it most likely heparin induced thrombocytopenia and requires further work up and discontinuation of heparin.

Answer 94

A. Delirium Depression may manifest in older adults as physical complaints like fatigue other than depressed mood. Dementia is a progressive decline of intellectual function. Acquired deficit in one or more cognitive domains severe enough to cause impairment of function. Delirium is an acute, fluctuating disturbance of consciousness, associated with a change in cognition or development of perceptual disturbances. It is the pathophysiologic consequence of an underling general medical condition, such as infection, coronary ischemia, hypoxemia, or metabolic derangement. Urinary incontinence is an involuntary loss of urine.

Answer 95

A. Asbestos exposure Mesotheliomas are primary tumors arise from the surface lining of the pleura (80% of cases) or peritoneum (20% of cases) Numerous studies have confirmed the association of malignant pleural mesothelioma with exposure to asbestos. The lifetime risk to asbestos workers of developing malignant pleural mesothelioma is as high as 10%. The latent period between exposure and onset of symptoms ranges from 20 to 40 years. The clinician concerned that a patient has mesothelioma should inquire about asbestos exposure through mining, milling, manufacturing, shipyard work, insulations, brake linings, building, construction and demolition, roofing materials, and other asbestos products (pipes, textiles, paints, tiles, gaskets panels).

Answer 96

D. Rapid weight gain from sedentary lifestyle Frailty is a very important indicator for quality of life and longevity in the geriatric population. While there is no specific tool for assessing frailty, there are multiple elements that contribute to increasing frailty. All of the following except for rapid weight gain are indicators of frailty. Most older adults begin to lose weight as they age.

Answer 97

B. Bell Palsy Bell’s palsy is simply facial paralysis sometimes associated with differences in taste. If the patient were to have any other neurologic symptoms, that could be a sign of an ischemic event and the patient would need emergent care. The cause of Bell’s palsy is not fully understood and can sometimes be brought on by viral infection such as herpes zoster.

Answer 98

C. Anemia The Bright Futures Medical Screening Reference Table recommends screening for anemia at 12 months of age. Autism Spectrum Disorder Screening is usually first done at 18 months of age. BMI screening begins at 24 months. Hearing is screened when the child is a newborn, and then routine hearing screening begins at age 4, unless the parent expresses concern about the child’s hearing. Furthermore, according to Wang et al. (2021), risk factors for iron deficiency anemia in children include prematurity, low birth weight, breast-feeding exclusively beyond 4 months of age without iron supplementation, and lead exposure.

Answer 99

D. Prescribe 25 mg quetiapine every 12 hours as needed to help quiet the patient when they become agitated. The best approach to managing behavior problems in the patient with dementia is through non-pharmacological interventions. Patients may act out when they are in pain or have discomfort due to fecal impaction or urinary retention, but they usually cannot verbalize the problem. Pharmacologic treatment should be reserved for situations in which the patient is a potential harm to themselves or others, or when the behavior causes the patient significant distress.

Answer 100

C. Fluoxetine SSRI’s are recommended as first line therapy in GAD. Although a short course of benzodiazepines may offer short-term relief, they are not recommended for long-term use.

Answer 101

A. Perform a general psychosocial assessment to assess for substance abuse Attention deficit/hyperactivity disorder is a common comorbid condition in adolescent substance abuse. Truancy and failing grades are behaviors that could be linked to substance abuse, thus screening through general psychosocial assessment is recommended.

Answer 102

d. “You sound overwhelmed. Do you have thoughts of harming yourself or taking your own life?” Screening for depression and suicidal ideations are important when working with the adolescent population. While several answers may be good responses to the patient’s statement, only D addresses suicidal thoughts. With the rates of suicide high in young people, it is important to take all statements like this seriously. Most people who attempt suicide give clues to indicate their distress. It is important for an FNP to be direct with the patient when assessing a patient’s suicidal thoughts and intent.

Answer 103

a. SSRIs may cause elevated blood pressure, elevated heart rate and several skin problems. When prescribing an SSRI to a child or adolescent, all the statements above except for A are important to keep in mind. Most antidepressants including SSRIs take several weeks to reach a therapeutic level. By combining an SSRI with CBT, better outcomes are seen within the first 12 weeks of treatment. The most common side effects of SSRIs include headache, GI upset, nausea, irritability, sedation and insomnia, and SSRIs do carry the black box warning for increased suicidal risk. Elevated blood pressure, elevated heart rate and skin problems such as erythema multiforme and Steven Johnson’s syndrome, however, are side effects seen with SNRIs.

Answer 104

A.) A sensitive D-dimer (result: positive) and ultrasound of BLEs According to the “Risk stratification of adults referred for ultrasound to rule out DVT,” being recently bedridden for > 3 days due to major surgery within 4 weeks and swelling of the entire leg adds up to 2. This means that a sensitive D-dimer is to be performed, and if positive, and ultrasound also needs to be obtained.

Answer 105

D.) Since he has a confirmed diagnosis of COVID-19, send him to the nearest hospital for further testing and management of possible thromboembolism. For best practice purposes and patient safety, all patients with COVID-19 and signs and symptoms of possible thromboembolism should have radiographic testing performed and be managed in the hospital setting.

Answer 106

B. TSH The patient’s symptoms match the most common clinical presentation of hypothyroidism. TSH is the single best screening tool for thyroid disorder and thus should be considered the most appropriate next step for diagnosis.

Answer 107

D. Acanthosis nigricans Because PCOS can cause metabolic disorder/insulin resistance, acanthosis nigricans can be assessed in many PCOS patients. Common symptoms of PCOS are weight gain, oily/acne prone skin, and hirsutism, therefore the other options are not appropriate choices.

Answer 108

A. tobacco Cancer is the second most common cause of death in the U.S. Death rates from cancer are declining due to prevention, detection, and treatment. Tobacco is the most common preventable cause of cancer death (30% of all cancer deaths in the U.S. are directly related to tobacco). For Americans who do not use tobacco, the most common modifiable risk factors are nutrition and physical activity. Recommendations to reduce cancer risk include being physically active, maintaining a healthy weight, consuming a diet high in whole grains, fruits, and vegetables, lowering consumption of trans fats, limiting ETOH use, and avoiding excessive sun exposure.

Answer 109

B. intermittent fevers, bruising, and leg pain Older children with brain tumors often have nonspecific presenting features but can commonly present with school failure, personality changes, headache, visual disturbances, seizures, focal neurologic deficits (due to supratentorial tumors that older children commonly have). Presenting complaints of a patient with acute lymphoblastic leukemia include signs and symptoms related to decreased bone marrow production (red blood cells, white blood cells, platelets) and leukemic infiltration of sites outside of the bone marrow. Intermittent fevers are common (because of reduced cytokines caused by leukemia itself or infection due to leukopenia). Bruising and pallor are common reasons patients present (due to low platelets and low hemoglobin). Approximately one fourth of children complain of bone pain (especially legs, vertebral bodies, and spine). Most children with Wilms Tumor (nephroblastoma) present with increasing size of abdomen or an asymptomatic abdominal mass as an incidental finding by a parent or health care provider. Lymphoma is caused by malignant proliferation of lymphoid cells and usually in association from lymphoid tissues (lymph nodes, thymus, and spleen), but can also involve the bone marrow. Children with Hodgkin lymphoma commonly present with painless cervical lymphadenopathy. Nodes feel firm, rubbery, may be discrete or matted together. Nodes are not fixed to surrounding tissue. Lymph node growth size varies and nodes may wax and wane in size over weeks to months.

Answer 110

c. Have them hold the next 2 doses of Warfarin and recheck their INR on day 3 If the INR is greater than 5.0 but less than 9.0 have the patient hold the next 1-2 doses. You would also monitor them more closely and resume therapy at a lower dose when the INR is back at therapeutic range.

Answer 111

D. to prevent further ligament or joint damage Range of motion should be limited with suspected shoulder dislocation to prevent further ligament and joint damage.

Answer 112

d. Confirm with the doctor which dose he wanted before allowing the patient to leave In the U.S., one of the leading causes of death is medical errors. Many of these errors occur due to the lack of communication among the healthcare team. Research indicates that less than 2 in 10 clinicians will speak up, even if the patient’s safety is at risk. As nurse practitioners it is imperative to lead by example, even if that means questioning the decisions of those with more experience or education.

Answer 113

b. “As a patient you have the right to choose what medical care you receive. Do you understand the risks of not receiving the blood transfusion?” To deliver patient centered care, providers must be aware of their values and understand that patients may not share the same beliefs. Patients have the right to decide what medical treatments they do or do not receive. Being aware of the values of others includes understanding that patients may choose other treatment options besides what Western medicine recommends.

Answer 114

d. Counsel on participating in a regular exercise program Osteoarthritis is the most common form of joint disease and occurs with aging. Women develop osteoarthritis more frequently, and about ninety percent of all people develop osteoarthritis in weight-bearing joints by age 40. Onset is usually insidious, and better with rest. Osteoarthritis does not cause inflammation; therefore, an ESR lab is not indicated. Initial treatment for mild to moderate osteoarthritis is participation in a regular exercise program, like walking or hydrotherapy. Surgery is only warranted if severe restrictions occur. NSAIDs are the first line medical management for osteoarthritis. Opioids are not indicated for long-term treatment.

Answer 115

a. Lachman test The Lachman test is 93% specificity for an ACL injury. McMurray and Thessaly tests are both used to confirm a meniscus injury. A Spurling test is done to rule out a neck injury.

Answer 116

d. Empagliflozin- SGLT-2 inhibitor Second generation sulfonylureas (glyburide, glipizide, gliclazide, glimepiride) should be used cautiously in patients with CVD and elderly, because prolonged hypoglycemia could be very dangerous. GLP-1 receptor agonists such as liraglutide are administered sub-Q and have been associated with increased risk of pancreatitis. He would not poke his finger to check his sugar so it is unlikely he would be willing to inject himself daily. DPP-4 inhibitors like Saxagliptin, can increase the risk of heart failure. Empagliflozin decreases risk of cardiovascular disease, especially related to heart failure. Effects such as weight loss, lower blood pressure, and diuresis are seen.

Answer 117

b. GI upset The maximum dosage of metformin is 2550 mg, but there is minimal benefit above 2000 mg. Start with a low dose and increase gradually. Take with food to reduce GI upset (anorexia, nausea, vomiting, abdominal discomfort, diarrhea), which occurs in 20% of patients. GI side effects are often dose-related, occur when starting therapy, and are typically temporary. 3–5% of patients require discontinuation due to ongoing diarrhea. ER metformin tends to have fewer side effects than IR

Answer 118

A. Leg swelling PAD is when there is a decrease in blood flow to peripheral arteries that is usually caused by atherosclerosis. Poor growth to toenails, shiny skin, hair loss on legs are all symptoms associated with PAD. Leg swelling is associated with PVD, not PAD.

Answer 119

C. Being underweight Smoking, taking oral contraceptives, and pregnancy can increase the risk of developing a DVT. Obesity increases the risk for developing a DVT, while being underweight is not considered to be a risk factor.

Answer 120

A. Palliative care Comfort care, also known as palliative care, is aimed at providing relief to a patient through symptom and pain management to keep the patient as comfortable as possible. The goal of this treatment is not to cure the patient but keep the patient free of pain. Palliative care is not always hospital based. Aggressive treatment is not considered palliative care. Therapeutic is a type of care that focuses on a specific treatment for a diagnosis.

Answer 121

B. It prevents the progression of growth and replication of cells Noncancerous cells can also be damaged during chemo. External radiation treats an exposed area with high-energy rays, while internal radiation uses implanted agents.

Answer 122

C. The lab results are indicative of diabetes mellitus Hemoglobin A1C is a diagnostic test for type 1 and type 2 diabetes. An HbA1c that is 6.5% or greater is indicative of diabetes mellitus. An HbA1c of 5.7-6.4% is considered prediabetes. The diagnosis of diabetes mellitus is recommended to be confirmed with a repeated HbA1c. A fasting blood glucose test that is between 100-125 mg/dL suggests impaired glucose tolerance. A fasting blood glucose test that shows a level of 126 mg/dL or greater on more than one occurrence confirms the diagnosis of diabetes mellitus.

Answer 123

D. Discontinue glipizide and consider sitagliptin Sulfonylureas medications need working pancreatic B cells to create their effect on the blood sugar. One huge adverse effect is hypoglycemia. Hypoglycemia can happen specifically in the elderly as their renal clearance decreases with older age. Sulfonylureas should be prescribed carefully in the elderly population. Sitagliptin is a DPP-4 inhibitor with a low hypoglycemic risk. The main side effect is susceptibility to upper respiratory infections.

Answer 124

A. Patient Health Questionnaire-2 (PHQ-2) The PHQ-2 is highly sensitive for detecting major depression in persons over the age of 65. Positive responses to the PHQ-2 should be followed up with a more comprehensive, structured interview such as the PHQ-9. Evaluation of depression should include a full review of medications, relationships, and lifestyle. The Mini-Cog is used to detect dementia in the early stages. The Montreal Cognitive Assessment is a tool to assist health care professionals in the detection of mild cognitive impairment and Alzheimer’s Disease. The CAM Questionnaire is used to quickly identify delirium in patients.

Answer 125

B. Utilize the prescribing cascade to achieve desired effect of a drug Clinicians should be aware of the “prescribing cascade” in which a medication is prescribed to counter the side effect of another medication. Clinicians should always consider “deprescribing” if the original indication is unclear or the patient is having side effects (D) and should always use clinical tools such as the AGS Beers Criteria List for identifying high-risk medications for adults (A). Medication reconciliation should occur at each visit to reinforce medication adherence (C).

Answer 126

A) Cellulitis Cellulitis is a diffuse, spreading infection of the dermis and subcutaneous tissue. It can be caused from a trauma or a lesion. Most commonly caused by gram - positive cocci, especially group A beta-hemolytic streptococci and S. aureus. Symptoms include edema, erythema, and pain. Once the bacteria have invaded the skin the presentation of symptoms is usually between 6 – 36 hours. As the progression of symptoms occurs, the risk for septicemia increases. The patient will become sicker with fever, chills, and malaise, and usually requires hospital admission for IV antibiotics. However, if caught early, oral antibiotics is sufficient.

Answer 127

C) Chronic venous insufficiency Patients that are obese, have a history of DVT, leg trauma or surgery are at increased risk for chronic venous insufficiency. Venous insufficiency occurs when the valves in the veins become incompetent. They do not allow blood to flow back to the heart, it then flows backward and pools in the feet and ankles, causing swelling and pressure in the veins. The muscles assist with pumping blood back to the heart and when the valves are not functioning, the muscles get fatigued and sore, causing pain.

Answer 128

C. Vitamin B12 Vitamin B12 comes from all products made from animals. Therefore, vitamin B12 deficiency from diet alone is rare. However, vegans and vegetarians commonly have B12 deficiency if they have been strict in avoiding animal products for many years. B12 deficiency often presents with neurologic symptoms including paresthesia, brain fog, balance issues, and vision changes. Folate deficiency is like B12 deficiency however patients do not have neurological signs and symptoms. Generally once supplementation is started in patients with B12 deficiency, neurological symptoms tend to improve.

Answer 129

D. 3-6 more months By 3 weeks, the patient’s hematocrit level increased by 50%. By 2 months, her hematocrit level should be within normal range. However, iron supplementation should be continued for at least 3-6 months after hematocrit levels have returned to baseline to fill iron stores.

Answer 130

A) “Open can” test A positive “Open can” test assesses for supraspinatus tendon strength. Pain is elicited when the affected shoulder is abducted at 90 degrees with slight forward flexion around 45 degrees, indicating rotator cuff injury. Carpal tunnel syndrome provocative testing includes Phalen test. Pain or paresthesia to the median nerve when the affected wrist is flexed 90 degrees for 60 seconds is a positive sign. Anterior drawer test is to rule out ankle injuries. Shoulder dislocation testing includes Load and shift test to determine shoulder instability. A positive sign is a feeling of instability and pain in the affected arm when abducted and externally rotated.

Answer 131

D) Worsening pain with back extension and relieved by sitting. Walking elicits neurogenic claudication symptoms. Back pain that progresses to bowel or bladder incontinence, perianal numbness, and bilateral leg weakness is suggestive of cauda equina syndrome. This is a medical emergency requiring surgery and a delay in care could result in lifelong disability. In a herniated lumbar disk, pain is localized in the back area at the affected disk level and increases with back flexion or sitting long periods of time. Cancer must be ruled out for back pain that is unrelieved, occurs all day and night, lasting over six weeks, and with weight loss. Spinal stenosis pain is relieved by sitting and worse with back extension. Symptoms may include pain with walking after several minutes in both legs that is relieved by sitting.

Answer 132

A. Adhesive capsulitis (frozen shoulder) Adhesive capsulitis (frozen shoulder) occurs from minimal or no trauma. It is commonly seen in patients aged 40 to 65. Patients typically presents with shoulder pain and limited external rotation. Strength is usually normal. Frozen shoulder occurs in 3 different phases: inflammatory, freezing and thawing. The inflammatory phase last 4-6 months. Pts will have a lot of pain during this phase so make sure to r/o recent trauma, fractures or tears. The freezing phase last 4-6 months and becomes stiff even though pain has improved. The thawing phase can take up to a year while the shoulder regains its motion. Treatment are NSAIDS and Physical therapy during the freezing phase. Frozen shoulder takes time to heal. Remind your patients of this. Shoulder dislocation is the shoulder ball out of its socket. It can occur from trauma such as a fall. Pt will complain of difficulty pushing a door. ED referral is needed to reduce the shoulder. Rotator cuff tears occur from falls or pulling on arms. Pt will have pain at night when laying on affected extremity. This requires surgical intervention. Subacromial impingement syndrome is shoulder pain with overhead motion and pain at night if the patient sleeps on it, pain with putting on a jacket or bra. They will lack full active ROM.

Answer 133

C. Hip dysplasia Metatarsus adductus is a foot deformity that has inward deviation of the forefoot. It is the most common deformity. Newborns will most likely have hip dysplasia. Therefore, careful examination of the hip is indicated. Genu varum (bowleg) is a normal finding through age 3. It changes from varum to genu valgus until age 8. This can occur d/t rickets or skeletal dysplasia. Pts will have a higher risk for osteoarthritis. Femoral anteversion occurs due to internal rotation of the hip. An osteotomy may be needed for correction. A slipped capital femoral epiphysis occurs mostly in obese males during adolescence. It is caused by displacement of the femoral epiphysis due to issues with the growth plate. The child is usually unable to bear weight on affected limb.

Answer 134

d. Binge eating is a disorder that starts in adulthood and high school children do not need to worry about it. Studies show that most adults with binge eating disorder develop the symptoms during adolescence. All the other options are essentials of diagnosis and typical features of binge eating disorder.

Answer 135

a. Sexual Abuse Sexual abuse is defines as engaging of a dependent, developmentally immature children in any sexual activities that they do not fully understand and to which they cannot give consent, or any activities that violate the laws of the society for example incest, sexual assault, rape, and pedophilia. Sexual abuse involves fondling, oral-genital-anal contact, all forms of intercourse and penetration, exploitation, prostitution of children and including children in pornography.

Answer 136

B. Acute lymphoblastic leukemia One of the most common malignancies of childhood, Acute lymphoblastic leukemia accounts for almost 25% of all cancers in children under 15. The diagnosis of leukemia is normally straight forward when blood counts show leukemic blasts and multiple cytopenias.

Answer 137

C. Tumor lysis syndrome Tumor lysis syndrome happens when cancer cells are broken down quickly in the body and the contents are released into the blood. It includes hyperphosphatemia, hyperkalemia, and hyperuricemia.

Answer 138

B. Administering prophylactic anticoagulants after surgery It is important to initiate VTE prophylaxis and interventions to prevent development of blood clots. Patients are at most risk after major orthopedic surgeries, immobilization, and previous history of a stroke or malignancy. Due to pain or area of surgery, patients are more likely to avoid movement or deep breathing. This puts them at a higher risk of coagulopathy and stasis of blood. ICDs are an important device to utilize as the patients are not likely to walk as often as required for adequate circulation. It is also important to make sure the patient is appropriately hydrated with IV or intake of water.

Answer 139

C. Warfarin (Coumadin) INR needs to be within a therapeutic range, usually between 2-3. Once it has been stabilized, levels should be checked every 6 weeks. Dietary restriction of leafy green vegetables should also be monitored as this can alter the effectiveness of the medication.

Answer 140

B. Lachman’s test A. McMurphy’s point test is to evaluate a patient’s gallbladder. B. Lachman’s test evaluates possible ligament tears in a patient’s knee. C and D are both tests to evaluate a patient’s shoulder injury.

Answer 141

A. “He was doing well on his pureed diet, so I increased him to a regular diet for the first-time last night.” A. Many stroke patients have dysphagia after their stroke and their diet should only be progressed by the speech therapist. B. Home health is a positive therapy for a patient after a CVA. C. Patients that have dysphagia can take their medications crushed to assist in swallowing. D. Patient should be sitting up right during all meals and feedings.

Answer 142

c. MRI Rotator cuff tears will not show up on x-rays. Ultrasound will only help assess the structures of the shoulder and allow a quick comparison between a healthy shoulder and one with an injury. MRI is the best method to confirm a dx of cuff tear

Answer 143

a. Go back to stage 2 light exercise such as walking until symptom free 24hrs. If any symptoms are experienced during any step the patient needs to drop back to the previous step that they were symptom free

Answer 144

D. “If you take estrogen hormone replacement therapy you must take a progestin hormone to prevent thickening of the uterine lining”.

Answer 145

d. INR > 9

Answer 146

C. Atorvastatin 80 mg once daily by mouth if tolerated. Patients with peripheral artery disease should be started on a high-dose statin. Nitroglycerin is utilized when a patient is suffering from angina and has a maximum of 3 doses. Simvastatin, while being of the appropriate drug class, does not have an appropriate dosing in this scenario as it would also need to be a high dosage. A treatment of “no medication” would not meet the needs of the patient and put them at potential risk for future health detriments.

Answer 147

A. Rivaroxaban cannot be used as a monotherapy and must be preceded by 5- 10 days of parenteral anticoagulation. The Pulmonary Embolism Severity Index (PESI) provides a simplified scoring system to evaluate patient risk factors, such as age greater than 80, cancer, and chronic cardiopulmonary disease. A patient with a PESI score of 1 or greater is considered high-risk. Ischemic stroke IS an absolute contraindication and administering thrombolytic therapy could put the patient at risk for intracranial hemorrhage. Catheter directed therapy is an option for intermediate and high-risk patients with an acute pulmonary embolism after systemic thrombolysis fails or as an alternative to systemic thrombolysis. The correct answer is A, as Rivaroxaban CAN be used as a monotherapy, and so can apixaban. Oral anticoagulants, such as dabigatran and edoxaban would require the preceding parenteral anticoagulation.

Answer 148

A. Behavioral Therapy For children diagnosed with ADHD younger than age 6, behavioral therapy is the first line of treatment. Though stimulants are the most effective and most prescribed medication and they are very effective, but in this case since the patient is 5 years old, Behavioral therapy would be the first choice of treatment. Exposure therapy is more effective in the treatment of OCD, PTSD, and Phobias.

Answer 149

D. Dyskinesia Symptoms of idiopathic intracranial hypertension consists of headache, diplopia, and other visual disturbances due to papilledema and abducens nerve dysfunction. Other symptoms such as tinnitus may occur. Dyskinesia is the involuntary muscle movements that are often seen in condition such as Parkinson’s; and is not a known symptom of idiopathic intracranial hypertension.

Answer 150

A. Amitriptyline Amitriptyline has shown modest efficacy. NSAIDs are generally ineffective. Opioids and corticosteroids are ineffective and should not be used to treat fibromyalgia.

Answer 151

C. The patient with no clinical signs of symptoms of PE and pain is controlled Most patients with DVT alone may be treated as outpatient given that the risk of bleeding is quite low and that they have good follow-up. Intermediate-risk patients (such as sub-massive PE) have early PE-related mortality of up to 15%. These patients should be admitted to a higher level of inpatient care. Patients with persistent hemodynamic instability are classified as high-risk patients (having a massive PE) and have an early PE-related mortality of more than 15%. These patients should be admitted to an ICU.

Final Flashcards

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