Final Flashcards
Which of the following is listed as one of the DSM-5 criteria for opioid use disorder?
More than 5 visits to the ER for opioid prescription
Unsuccessful attempts to limit or control opioid use
Taking prescription opioids for reasons other than controlling pain
Frequent insomnia requiring use of sleeping aid or sedative
Unsuccessful attempts to limit or control opioid use
-Opioids are often taken in larger amounts or over a longer period of time than
intended.
-There is a persistent desire or unsuccessful efforts to cut down or control opioid
use.
-Recurrent opioid use resulting in failure to fulfill major role obligations at work,
school or home.
Using the DSM criteria, you identify opioid use disorder (OUD). You discuss your diagnosis with your patient. Which of the following would be an appropriate initial step?
Stop all opioids and offer non-opioid pain medication
Admit to the hospital for management of opioid withdrawal
Continue to prescribe medication and refer for psychosocial treatment
Assess readiness to quit and document last opioid use
Assess readiness to quit and document last opioid use
Determine if the patient is ready and willing to start treatment for their opioid use. If the patient is not ready to stop, share your concerns about their ongoing opioid use, the risk of overdose, medical complications, and offer harm-reduction techniques (e.g. a naloxone kit).
You obtain a POCT positive for heroin on your patient you are treating with opioids. When you walk back into the room, your patient tells you they used heroin recently. Do you send a confirmation sample to the laboratory?
Yes
No
No. Test will remain positive for several days and patient already confirmed using heroin.
Next focus on the patient’s well-being and safety. Discuss the risks associated with taking heroin with other opioids and provide protective interventions (e.g. naloxone).
Which of the following opioid risk assessment tools could be used in practice?
A. Current Opioid Misuse Measure (COMM)
B. Opioid Risk Tool (ORT)
C. Patient Medication Questionnaire (PMQ)
D. All of the above
All of the above
Assessment requires the providers use a standardized systematic approach to all patients who will be receiving (or are at risk of misusing) opioids.
-The COMM is a 17-question patient assessment tool designed to identify ADRB’s during chronic opioid therapy. Each of the 17 items is scored 0–4 points. Total score can range from 0–68. A score of ≥9 is suggestive of current ADRB with 77% sensitivity and 66% specificity.
-ORT is a 5-question screening tool designed for use in adults to assess the risk for opioid abuse or ADRB. A score is given for a range of responses on each of the 5 items and the total used to predict for low, moderate or high risk for ADRB.
-The PMQ is a 26-question assessment tool using 0–4 point scale to assess for ADRB in patients already taking opioid medications for pain. Scores can range from 0–104. In the derivation study, a score <25 is considered low risk for opioid misuse, 25–30 indicates problematic use, and >30 close monitoring and consideration of titrating the patient off opioids.
Which of the following is most associated with neuropathic pain:
A. Shooting, tingling
B. Aching, stabbing
C. Poorly localized cramping
D. Localized dull ache
Shooting, tingling
Neuropathic pain experience may vary from person to person but often include the following:
-shooting, burning, or stabbing pain
-tingling and numbness, or a “pins and needles” feeling
-spontaneous pain, or pain that occurs without a trigger
Which of the following is an example of a non-opioid adjuvant medication for pain?
Gabapentin starting at 300 mg at bedtime
Tramadol 50 mg every 6 hours as needed for pain
Meperidine 50 mg every 4 hours
Codeine 15 mg every 6 hours as needed for pain
Gabapentin starting at 300 mg at bedtime
Drug Class: Anticonvulsant - GABA Analogs
Gabapentin has FDA approval for:
-Postherpetic neuralgia
-Adjunctive therapy in the treatment of partial seizures with or without secondary generalization in patients over the age of 12 years old with epilepsy, and the pediatric population, 3 to 12 year-olds with a partial seizure
-Moderate to severe restless leg syndrome (RLS) moderate to severe
Which of the following is NOT an alarm symptom in peptic ulcer disease?
Unintentional weight loss
Anemia
Epigastric discomfort 2-3 hours after eating
Swallowing difficulty (dysphagia) or odynophagia (painful swallowing)
Epigastric discomfort 2-3 hours after eating
Alarm symptoms for PUD include the following:
* Unintentional weight loss
* Progressive dysphagia
* Overt gastrointestinal bleeding
* Iron deficiency anemia
* Recurrent emesis
* Over age 55 and/or family history of upper gastrointestinal malignancy
Which of the following are the main risk factors for peptic ulcer disease?
H. pylori and NSAID use
Gastric malignancies
Omeprazole and acetaminophen use
Decreased gastric motility
H. pylori and NSAID use
-H. pylorus is a gram-negative bacillus that is found within the gastric epithelial cells. This bacterium is responsible for 90% of duodenal ulcers and 70% to 90% of gastric ulcers.
-Nonsteroidal anti-inflammatory drugs use is the second most common cause of PUD after H. pylori infection. NSAIDs block prostaglandin synthesis that normally protects the gastric mucosa.
In GERD, without any alarm symptoms, what is an appropriate initial plan:
Endoscopy
8-week trial of PPI
Referral to surgery for diagnosis and possible anti-reflux surgery
Omeprazole 20 mg BID, bismuth subsalicylate 525 mg q6h, metronidazole 250mg every 6h, tetracycline 500 mg every 6h.
8-week trial of PPI
-Lifestyle modifications include weight loss, tobacco smoking cessation, reduction is alcohol intake, avoiding late evening meals, and elevation of the head of the bed.
-PPIs block acid production in the stomach, providing relief of symptoms and promote healing. The goal is to use the shortest course of treatment possible to relieve symptoms and promote healing of PUD.
-First-line treatment for H. pylori-induced PUD is a triple regimen comprising two antibiotics and a proton pump inhibitor. Pantoprazole, clarithromycin, and metronidazole, or amoxicillin are used for 7 to 14 days.
The nurse practitioner knows that Crohn’s disease affects:
Colon only
Anywhere from the mouth to the anus
Anywhere from the stomach to the anus
The large intestines
Anywhere from the mouth to the anus
-Crohn’s disease most commonly occurs in the small intestine and the colon, but can affect any part of the GI tract (from the mouth to the anus).
-Crohn’s Disease is characterized by “skip” lesions and will extend through the layers of the intestinal mucosa
What is the most common cause of melena?
Upper GI bleeding
Gastroesophageal reflux disease
GI malabsorption disease
Colon cancer
Upper GI bleeding
Melena refers to black stools that occur as a result of upper GI bleeding.
Melena often results from damage to the upper GI tract lining (PUD, NSAIDs, and tumors), swollen blood vessels (varices), or bleeding disorders (hemophilia and thrombocytopenia).
Which of the following should the nurse practitioner consider a diagnosis GERD:
A patient presenting with heartburn and regurgitation
A patient with epigastric pain as their only symptom
A patient with complaints of burping and bloating
A patient with nausea and vomiting
A patient presenting with heartburn and regurgitation
Which of the following are considered first line medication for GERD:
Omeprazole
Esomeprazole
Pantoprazole
All of the above
All of the above
-For patients with classic GERD symptoms of heartburn and regurgitation who have no alarm symptoms, we recommend an 8-week trial of empiric PPIs once daily before a meal (strong recommendation, moderate level of evidence).
-We recommend attempting to discontinue the PPIs in patients whose classic GERD symptoms respond to an 8-week empiric trial of PPIs (conditional recommendation, low level of evidence).
Your patient has recently been diagnosed with GERD. You recognize there is a need for further patient education when she tells you:
She is going to quit smoking
She will have a small snack just prior to bedtime
Patients diagnosed with GERD should avoid eating meals within 2–3 hours of bedtime.
She is going to elevate her head of bed with cinderblocks
All of the above
She will have a small snack just prior to bedtime
Pain in the left lower quadrant of the abdomen is associated with the diagnosis of:
A. Crohn disease
B. Peptic ulcer disease
C. Diverticulitis
D. Cholelithiasis
Diverticulitis
A sudden pain in the lower left side of the abdomen is the most common symptom diverticulitis. Other symptoms may include:
* Nausea
* Vomiting
* Fever
* Bloating or increased flatus
* Constipation
In a patient who presents in your clinic with a complaint of chest discomfort, what is the priority diagnosis to eliminate?
A. Peptic ulcer disease
B. Cardiac conditions
C. Gastroesophageal reflux disease
D. Diverticulosis
Cardiac conditions
Always rule out the differential diagnosis that may cause the patient the greatest harm and that can become a medical emergency (MI, PE, GI perforation). Patient experiencing cardiac symptoms should be transferred to a higher level of care if you are unable to complete the appropriate medical work up in your clinical setting.
In a patient presenting with abdominal pain, bloating, and diarrhea described as small volumes of loose stool for longer than 6 months, which of the following list of differential diagnoses is most appropriate?
Irritable bowel disease, celiac disease, and lactose intolerance
Irritable bowel disease, toxic megacolon, and endometriosis
Gastroesophageal reflux disease, irritable bowel syndrome, and lactose intolerance
Irritable bowel syndrome, diverticulosis, and colon cancer
Irritable bowel disease, celiac disease, and lactose intolerance
-Symptoms of IBS include cramping, abdominal pain, bloating, gas, diarrhea and constipation.
-IBS and lactose intolerance can sometimes have similar symptoms, such as diarrhea, bloating, and gas. However, symptoms of lactose intolerance only occur when you consume dairy products.
-Celiac disease is an autoimmune condition, triggered by the exposure of the body to gluten, that damages damage the lining of the bowel and may impair the body’s ability to absorb important nutrients.
-Common symptoms of megacolon include constipation, bloating, and abdominal pain .
-Symptoms of colon cancer may include the following:
-A change in bowel habits (diarrhea, constipation, or narrowing of the stool) that lasts for more than a few days
-A feeling of incomplete emptying after a bowel movement
-Rectal bleeding with bright red blood
-Blood in the stool (dark brown or black)
-Cramping or abdominal discomfort
-Weakness and fatigue
-Unexplained weight loss
Which of the following is a true statement?
All individuals over the age of 19, with suspected irritable bowel syndrome, should undergo colonoscopy
All individuals with suspected irritable bowel syndrome should be tested for food allergies
All individuals should have a careful review of their clinical history with a focus on key symptoms, a physical exam, and minimal diagnostic testing in order to diagnose irritable bowel syndrome
All individuals with suspected irritable bowel syndrome should be routinely tested for parasitic infections
All individuals should have a careful review of their clinical history with a focus on key symptoms, a physical exam, and minimal diagnostic testing in order to diagnose irritable bowel syndrome
A positive diagnostic strategy for IBS involves a careful history (allergies, medical, surgical, social, and family), physical examination, and the use of a standard definition to make a diagnosis, with limited diagnostic tests.
-serologic testing be performed to rule out celiac disease in patients with IBS and diarrhea symptoms.
-Two fecal-derived markers of intestinal inflammation, fecal lactoferrin (FL) and fecal calprotectin (fCal) are safe, noninvasive, generally available, and can identify IBD with good accuracy.
-Colonoscopy is not recommended unless patient has other alarm symptoms that require further evaluation.
Which of the following is a true statement?
Advise patients with a history of diverticulitis to avoid nuts and seeds
If a colonoscopy is to be obtained, wait until about 6-8 weeks after resolution of symptoms of diverticulitis
If the patient has undergone a CT for diagnosis of diverticulitis, a follow-up colonoscopy is not needed to exclude colonic neoplasm
In a patient with established cardiovascular disease and a history of diverticulosis, avoid aspirin
If a colonoscopy is to be obtained, wait until about 6-8 weeks after resolution of symptoms of diverticulitis
Colonoscopy is the most useful method of determining the presence and extent of diverticulosis and can be vital to the diagnosis and management of diverticular diseases.
Diverticular disease can increase the difficulty of colonoscopy due to luminal narrowing, angulations, colon spasm, and difficulty with insufflation.
Current treatment guidelines recommend diagnostic colonoscopy (generally 6-8 weeks following improvement of an episode of acute diverticulitis) in patients who have not had a high-quality colonoscopy in the last 1-2 years.
Which of the following increases a person’s risk for colorectal cancer?
A. Familial polyposis
B. Daily aspirin use
C. Daily caffeine intake
D. Plant-based diet
A. Familial polyposis
About 1 in 4 colorectal cancer patients have a family history of colorectal cancer.
The most common types of hereditary colorectal cancer are the following:
-Lynch syndrome (Hereditary Non-polyposis Colorectal Cancer, HNPCC)
-a subset of Lynch syndrome called Muir-Torre syndrome (MTS)
-MUTYH-associated polyposis syndrome (MAP syndrome)
-Familial adenomatous polyposis (FAP)
You are seeing a patient with a chief complaint of four months of intermittent GI irritation. They tell you that they have stomach burning about 2-3 hours after eating a meal. The burning stays localized to the upper abdomen. They do not feel that what they eat makes any difference. This presentation is most associated with which of the following?
A. Peptic ulcer disease
B. Cholecystitis
C. GERD
D. Angina
A. Peptic ulcer disease
Epigastric pain usually occurs within 15-30 minutes following a meal in patients with a gastric ulcer.
Pain due to a duodenal ulcer tends to occur 2-3 hours after a meal, when the GI tract is empty and no food to buffer the acid.
You are seeing a patient with a chief complaint of four months of intermittent GI irritation. They tell you that they have retrosternal burning that migrates up their neck shortly after eating large meals. They can get a sour taste in their mouth, especially if they lay down or bend over after a meal. This presentation is most associated with which of the following?
A. Peptic ulcer disease
B. Cholecystitis
C. GERD
D. Angina
C. GERD
Heartburn is the most common GERD symptom and is described as substernal burning sensation rising from the epigastrium up toward the neck. Regurgitation is the effortless return of gastric contents upward toward the mouth, often accompanied by an acid or bitter taste.
You are asked to see a patient in a nursing home who complains of pain that started in the periumbilical region and migrated to the right lower quadrant. After the pain started, they developed nausea and vomiting. On physical exam the right lower quadrant is tender to touch. What is the most likely diagnosis?
A. Cholecystitis
B. Appendicitis
C. Peptic ulcer disease
D. Pancreatitis
B. Appendicitis
Acute appendicitis (AA) is among the most common causes of lower abdominal pain leading patients to attend the emergency department.
Appendicitis starts with pain around the umbilicus and progresses to the right lower abdomen or pelvis in a few hours.
Other symptoms may include:
-Nausea, vomiting, fever, tachycardia, and foul breath
-Constipation is a common and occasionally diarrhea
-Frequent urination (contact with inflamed appendix and the bladder)
You are asked to see a patient in the infusion center who is receiving treatment for Crohn disease. The patient reports intermittent crampy periumbilical abdominal pain with nausea and vomiting. Physical exam reveals orthostatic hypotension and tachycardia, abdominal distention and high-pitched “tinkling” bowel tones. Which is the most likely diagnosis?
A. Peptic ulcer disease
B. GERD
C. Appendicitis
D. Small bowel obstruction
D. Small bowel obstruction
A small bowel obstruction is a partial or complete blockage of the small intestine, which can be caused by adhesions, hernia, malignant tumors, and inflammatory bowel disorders.
Patients presenting with abdominal pain, nausea, abdominal distention, vomiting, and/or obstipation/constipation, should be evaluated for a small bowel obstruction (SBO).
Examine the abdomen for signs of distention, pain, masses, non-reducible hernias, surgical scars, or tenderness.
Dysphagia and unintentional weight loss are classic signs of which diagnosis?
A. Peptic ulcer disease
B. GERD
C. Esophageal carcinoma
D. Inflammatory bowel disease
C. Esophageal carcinoma
The most common symptoms of esophageal cancer are:
-Difficulty swallowing
-Chest pain
-Unintentional weight loss
-Hoarseness
-Chronic cough
-Vomiting
-Bone pain
-Melena due to bleeding from esophagus
It is recommended that patients with long-standing GERD (> 5 years) undergo evaluation for Barrett’s esophagus.
True
False
True
Barrett’s esophagus occurs as the result of persistent reflux of stomach acid into the lower esophagus, which can damage the inner lining of the esophagus. This causes the squamous cells that normally line the esophagus to be replaced with gland cells that are more resistant to stomach acid.
The risk of esophageal cancer in patients with Barrett’s esophagus is approximately 0.5 percent per year (or 1 out of 200). However, periodic endoscopies may be required to monitor for early signs of dysplasia.
All diverticulitis must be treated with antibiotics.
True
False
False
Diverticulitis can be uncomplicated or complicated. Uncomplicated diverticulitis involves thickening of the colon wall and peri-colonic inflammatory changes. Complicated diverticulitis additionally includes the presence of abscess, peritonitis, obstruction, stricture and/or fistula.
-Antibiotic treatment can be used selectively rather than routinely in immunocompetent patients with mild acute uncomplicated diverticulitis.
-Antibiotic treatment is advised in patients with uncomplicated diverticulitis who have comorbidities or are frail, who present with refractory symptoms or vomiting, or who have a CRP >140 mg/L or baseline white blood cell count > 15 × 109 cells per liter.
-Antibiotic treatment is advised in patients with complicated diverticulitis or uncomplicated diverticulitis with a fluid collection or longer segment of inflammation on CT scan.
When antibiotic treatment is necessary, the regimen usually includes broad spectrum agents with gram-negative and anaerobic coverage.
In the outpatient setting, treatment of mild uncomplicated diverticulitis most commonly includes either a combination of an oral fluoroquinolone and metronidazole or monotherapy with oral amoxicillin-clavulanate.
The duration of treatment is usually 4–7 days but can be longer.
Gross rectal bleeding is most likely to be caused by early-stage colorectal cancer.
True
False
False
Bleeding often occurs with late stage colorectal cancers.
Common causes of rectal bleeding include:
* Anal fissure
* Constipation
* Hemorrhoids
* Diverticular disease
* Trauma or foreign body
Which of the following best describes migraine type headaches?
A. Most commonly seen in men starting in their 20s. Usually unilateral and occurring around the eye and associated with ipsilateral conjunctival injection, lacrimation, nasal congestion or rhinorrhea.
B. Throbbing, often unilateral, associated with photophobia and/or phonophobia or nausea, and vomiting. More common and more severe in women, headache can last 4-72 hours.
C. A common type of headache. Generally described as bilateral and squeezing. Nausea is absent and pain is relieved with OTC analgesics. Not associated with any disability.
D. Occurs in the morning, often in patients with diabetes with recent medication or diet changes or in individuals with obesity and daytime somnolence.
B. Throbbing, often unilateral, associated with photophobia and/or phonophobia or nausea, and vomiting. More common and more severe in women, headache can last 4-72 hours.
Migraines are a common disorder that affects 12 to 15 percent of the general population. Migraines are most common in woman and in those aged 30 to 39. Migraine without aura is the most common type, accounting for approximately 75 percent of cases. Migraines also tend to run in families.
a- cluster headache
c- tension headache
d- medical associated (hypoglycemia, OSA)
Which of the following are considered red flag symptoms in patients with headache? (select all that apply)
A. Systemic symptoms: fever, rash, myalgia, unexplained weight loss
B. Current or history of neoplasm (cancer)
C. Neurological deficit (seizures or cognitive changes)
D. New onset in patients >50 years old
A. Systemic symptoms: fever, rash, myalgia, unexplained weight loss
B. Current or history of neoplasm (cancer)
C. Neurological deficit (seizures or cognitive changes)
D. New onset in patients >50 years old
Although 80% to 90% of headaches are primary headaches, it’s important to recognize the red flags of a secondary headache. Secondary headaches are caused by an underlying illness, medication or other factors, such as a brain tumor, blood clot, stroke, change in brain pressure or toxic exposure. Providers can use the mnemonic “SNOOP4” to remember the red flags of secondary headache.
-Systemic symptoms (fevers, sweats)
-Neurological symptoms ( weakness in one arm or leg, numbness, or any visual changes)
-Onset is sudden (thunderclap headache, which comes on suddenly at a maximum 10/10)
-Progression ( a clear progression of becoming more severe or more frequent)
-Papilledema (welling of the optic nerve on a fundoscopic exam, can be an indication of increase in ICP)
-Positional or Precipitated by Valsalva maneuver (pressure issue or a problem related to a mass)
-Pregnancy (evaluated for pituitary or vascular abnormalities)
Correct!
Which is most associated with the diagnosis of migraine?
A. Mild pain severity
B. Aggravated by or causes avoidance of routine physical activity
C. Temporal artery tenderness in elderly patients
D. Stiff neck
Aggravated by or causes avoidance of routine physical activity
The clinical features that appear to be most predictive of migraine include nausea, photophobia, phonophobia, and exacerbation by physical activity
a- migraine in mod-severe
c- giant cell arteritis
d- hemorrhage or meningeal irritation
Which of the following would you expect to see prescribed for abortive treatment in migraine with moderate to severe pain and no nausea or vomiting?
A. Propranolol 20 mg BID
B. Gabapentin 100 mg TID
C. Sumatriptan 50 mg by mouth, can repeat if no improvement in 2 hours
D. Valproate 250 mg BID, can increased by 250 mg/day every 3 days
C. Sumatriptan 50 mg by mouth, can repeat if no improvement in 2 hours
Treatment for moderate to severe migraine attacks not associated with vomiting or severe nausea are treated with oral migraine-specific agents as first-line therapy, including oral triptans and the combination of sumatriptan-naproxen.
Oxygen would be appropriate in which type of headache.
A. Migraine
B. Tension headache
C. Primary cough headache
D. Cluster headache
D. Cluster headache
Oxygen (100 %) is administered via a nonrebreathing facial mask with a flow rate of at least 12 L/minute with the patient in a sitting, upright position. The inhalation should continue for 15 minutes to prevent the attack from returning, although the pain may subside as soon as five minutes after starting oxygen.
Oxygen is generally safe and without side effects. However, patients with severe chronic obstructive pulmonary disease should not be treated with inhaled oxygen because of the risk for developing severe hypercapnia.
Which of the following represents the classic presentation of nephrolithiasis?
A. Renal colic and hematuria
B. Flank pain, fever, and pyuria
C. Colic with abdominal tenderness
D. Flank pain with a unilateral vesicular eruption of a rash
A. Renal colic and hematuria
The most characteristic symptoms of nephrolithiasis are pain, hematuria, nausea, and vomiting.
The classic presentation of pain in patients with nephrolithiasis is severe ureteral colic. This pain is often of abrupt onset and intensifies over time into an excruciating, severe flank pain that resolves with stone passage or removal.
b- pyelonephritis
c- diverticulitis or appendicitis
d- herpes zoster
You are working in college health center seeing a 20-year-old female patient with new onset hematuria and unilateral flank pain that comes in waves. What diagnostic test should the NP order first?
A. CT of abdomen without contrast
B. CT of the abdomen with contrast
C. Abdominal ultrasound
D. hCG, urine
D. hCG, urine
Begin by ruling out possible pregnancy. Signs of ectopic pregnancy include the following:
* Abdominal pain
* One sided pelvic pain
* Bleeding
* Dizziness/fainting
