Final exam questions 2

Question 1

21. Arrhythmia, mental confusion, and muscle weakness in children is caused by a deficiency of which mineral?
    a. Calcium
    b. Chloride
    c. Magnesium
    d. Potassium

Answer 1

d. Potassium

Rationale: Potassium causes muscle weakness, mental confusion, and arrhythmias.

Question 2

22. A mother brings her 7-year-old son into the clinic for their well child visit. The mother asks the NP how much fluid her son should be taking in daily. Her son weighs 30kg at today’s visit. How much fluid should this patient be taking in daily?
    a. 1000 mL
    b. 1200 mL
    c. 1500 mL
    d. 1700 mL

Answer 2

d. 1700 mL

Rationale: A child weighing 30kg would require 1700 mL/day.

To calculate the daily fluid intake of a child based on their weight, the NP would use the following formula:

• For a body weight of 3-10kg, use 100 mL/kg.
• For a body weight of 11-20kg, use 1000 mL/kg + 50mL/kg for each kg >10kg.
• For a body weight > 20kg, use 1500 mL/kg + 20mL/kg for each kg > 20kg.

Question 3

23. A 12-year-old male patient presents to your clinic today with mother who reports for the past week he has been expecting muscle weakness, tingling all over his body that is worse in his feet and hand and muscle spasms throughout the day. You obtained a 12-lead ECG in the office which revealed peaked T waves and widening QRS. What electrolyte abnormality would you suspect based on symptoms and ECG findings?
    a. Hypokalemia
    b. Hyperkalemia
    c. Hyponatremia
    d. Hypercalcemia

Answer 3

b. Hyperkalemia

Rationale:

Elevated potassium is characterized by muscle weakness, paresthesia, tetany, ascending paralysis, and cardiac arrhythmia including elevated T wave, widening QRS complex, sinus bradycardia, or sinus arrhythmia.

Hypokalemia has similar symptoms, but ECG changes include shallow T wave and ST depression.

Hyponatremia symptoms include confusion, decreased tendon reflex, headache, and orthostatic hypotension.

Hypercalcemia symptoms include lethargy, confusion, nausea, vomiting, palpations, and increased thirst.

Question 4

24. A 31-year-old male presents to the clinic for c/o fever of 101, nausea and vomiting, and decreased urine output for 3 days. Patient reports he just finished penicillin for a bacterial infection. On exam, the NP notices a maculopapular rash. Urinalysis reveals pyuria and hematuria. The NP knows this to be expected in:
    a. Pyelonephritis
    b. Acute Kidney Injury
    c. Interstitial Nephritis
    d. Glomerulonephritis

Answer 4

c. Interstitial Nephritis

Rationale: Interstitial Nephritis is recognized by fever, acute kidney injury, transient maculopapular rash, pyuria, and hematuria. 70% of all cases are caused by drugs (PCN, sulfonamides, Rifampin, cephalosporins, PPI’s,
phenytoin, allopurinol, or NSAID’s.

Question 5

25. Normal electrolyte losses occur primarily through which of the following?
    a. Urinary tract
    b. Stool
    c. Skin
    d. Emesis

Answer 5

a. Urinary tract

Rationale: Of the above, the urinary tract is the best answer when considering normal primary electrolyte
loss. See Hay (2020, pg. 706), “to a lesser degree, electrolytes are lost through stool and skin”, and emesis does not qualify as a normal route for electrolyte loss.

Question 6

26. The causes of hypokalemia are typically attributed to which system?
    a. Renal
    b. Gastrointestinal
    c. Pulmonary
    d. Cardiac

Answer 6

a. Renal

Rationale: Volume depletion results in an increase in plasma aldosterone which stimulates excretion of K+ from the kidneys.

Question 7

27. A 54-year-old male patient presents to the clinic for his annual exam. When reviewing his routine lab results, you notice hypermagnesemia. As the nurse practitioner you know someone can have elevated magnesium from what?
    a. History of small bowel bypass surgery
    b. Chronic use of antacids
    c. History of alcohol abuse
    d. Chronic use of loop diuretic

Answer 7

b. Chronic use of antacids

Rationale: Chronic use of antacids is a common cause of hypermagnesemia. History of small bowel bypass surgery, history of alcohol abuse, and chronic use of loop diuretics would have increased risk of low magnesium

Question 8

28. When assessing a patient with signs of hypocalcemia you tap their facial nerve and notice the facial muscles contract in response to the tapping. This test is known as the:
    a. Chvostek sign
    b. Murphy’s sign
    c. Chadwick sign
    d. Trousseau sign

Answer 8

a. Chvostek sign

Rationale: Excitation of muscle and nerve cells in the cardiovascular and neuromuscular systems are seen in patients with hypocalcemia.

Chvostek sign is a classic finding in hypocalcemia and is performed by tapping the facial nerve around the cheek, then seeing the muscles of the face twitch.

Trousseau sign is also a test performed when a patient has hypocalcemia, but involves a carpal spasm with the occlusion of the brachial artery using a BP cuff.

Question 9

29. A young male patient is brought into the ER due to acute onset of altered mental status. Ambulance driver reports that the patient had confusion on their arrival, and he has become more lethargic on the ride to the ER. Ambulance driver also reports that the patient is a frequent patient of theirs due to drug use. On arrival, respiratory rate is 8, and he is lethargic. Labs are obtained, and the lab results show a low arterial pH, increased PCo2, and HCO3 is elevated. What is the probable diagnosis and treatment for this patient?
    a. Respiratory Alkalosis due to opioid overdose; Administer trial of Naloxone IV.
    b. Respiratory Alkalosis with treatment directed at his anxiety.
    c. Respiratory Acidosis due to COPD; Administer albuterol nebulizer treatment.
    d. Respiratory Acidosis due to opioid overdose; Administer trial of Naloxone IV.

Answer 9

d. Respiratory Acidosis due to opioid overdose; Administer trial of Naloxone IV.

Rationale: According to Papadakis and McPhee (2020), respiratory acidosis is classified as low arterial pH
with an increased PCo2. The HCO3 is elevated, but it does not make the pH return to normal. It can be
caused by acute respiratory failure with opioid overdose or by chronic conditions such as COPD or asthma.
Papadakis and McPhee (2020) recommend a trial of Naloxone IV when there is no obvious cause for
hypoventilation.

Question 10

30. 13-year-old Jessica presents to the Emergency Department with her mother, stating that she cannot breathe, can’t feel her fingers and thinks she is having a panic attack. Vital signs are: T-98.9, HR-115, RR-32, BP-136/90, O2-100% RA. ABG results were pH 7.47, pCO2 25, HCO3 21. What is the likely cause for her respiratory alkalosis?
    a. Hypoventilation
    b. Hyperventilation
    c. Diarrhea
    d. Hyperemesis

Answer 10

b. Hyperventilation

Rationale: Respiratory alkalosis occurs when hyperventilation results in a decrease in Pco2 and an increase in systemic pH.

Hypoventilation results in respiratory acidosis due to increase of Pco2.

Diarrhea would cause loss of buffering bicarbonate, resulting in metabolic acidosis.

Hyperemesis would result in metabolic alkalosis due to the loss of strong acid (gastric juice) from excessive vomiting.

Question 11

31. A 13 y.o male with a medical history of intermittent asthma presents to the clinic c/o of the following: symptoms that last 3 days/week, minor limitation in normal activity, and waking up at least once/week for the past month. The pt. states he has been using his PRN SABA at least once a day, 3 days during the week. Keeping these symptoms in mind, what classification of asthma severity should the NP recognize this as to best tailor treatment?
    a. Intermittent
    b. Mild
    c. Moderate
    d. Severe

Answer 11

b. Mild

Rationale: Based off the classification of asthma severity in 12 years of age and above, mild persistent asthma is
classified as: symptoms greater than, or equal to 2 days/week but not every day, nighttime awakenings 3-
4x/mo., using SABA more than 2 days/week but not daily and no more than once a day, and minor
limitations in normal activity.

Question 12

32. A 34-year-old female with no known past medical history presents to your clinic with a complaint of fever, non-productive cough and shortness of breath. After a workup she is diagnosed with bacterial pneumonia. She has no recent history of hospitalization or antimicrobial use. What is the most common causative agent of her pneumonia?
    a. Klebsiella pneumoniae
    b. Pneumocytis jirovecci
    c. Streptococcus pneumoniae
    d. Pseudomonas aeruginosa

Answer 12

c. Streptococcus pneumoniae

Rationale: [C] S. pneumoniae is responsible for approximately two-thirds of all cases of community acquiredpneumonia.

Other common pathogens include H. influenzae, Mycoplasma pneumoniae, and C. pneumoniae.

[A] K. pneumoniae is a common etiology for hospital acquired pneumonia.

[B] P. jirovecci is more common in immunocompromised individuals.

Question 13

33. Your 18-year-old male patient was diagnosed with asthma three years ago and was prescribed an albuterol inhaler. Today he presents to your clinic reporting worsening symptoms over the past two weeks. He reports having to use his inhaler about three times weekly. He also reports that he is awakened by symptoms about every week. What is the best treatment plan for this patient?
    a. Add a low dose Fluticasone MDI to the patients current regimen
    b. Add tiotropium and discontinue albuterol
    c. Add formoterol to the patient’s current regimen
    d. Provide reassurance to the patient and have him continue the albuterol as needed

Answer 13

a. Add a low dose Fluticasone MDI to the patients current regimen

Rationale: The patient was previously on step 1. His symptoms indicate that he is not well controlled and requires a step up in treatment. Step 2 recommends adding a low dose inhaled corticosteroid.

[B] It is inappropriate to discontinue the patient’s SABA. Further, addition of a LAMA is inappropriate in this phase of treatment.

[C] The addition of a LABA is an option in step 3 of treatment, not step 2.

[D] This patient’s symptoms indicate that his asthma is not well-controlled. He requires pharmacological intervention at this point

Question 14

34. Your patient was diagnosed with mild persistent asthma last year. She is currently taking budesonide 180 mcg inhalation daily. She is complaining of symptoms at least 3 days a week, wakening up 2x/week due to her asthma, and some limitation with her daily activity. She reports she has used her albuterol inhaler 4 times this week. What medication(s), if any, would you consider adding to her regimen?

a. None, the patient’s asthma is well controlled
b. Increase budesonide to 1200 mcg (high dose ICS) and formoterol 20 mcg every 12 hours
c. Formoterol 20 mcg inhaled every 12 hours
d. Budesonide 1200 mcg and scheduled Albuterol daily

Answer 14

c. Formoterol 20 mcg inhaled every 12 hours

Rationale: This patient was diagnosed with mild persistent asthma and is on step 2 of the recommended
treatment for mild persistent asthma. Her complaints show that she is not well controlled: symptoms >2
days/week, nighttime awakenings 1-3x/week, some limitation with physical activity, and SABA use >2 days
week). If asthma is not well controlled, it is advised to step up 1 step and reevaluate in 2-6 weeks. Step 3
consists of a low-dose ICS + LABA OR a medium-dose ICS.

Question 15

35. Jeff, a 65-year-old male, presents to the clinic for evaluation of a productive cough, and shortness of breath with exertion increasing over the last 2 weeks. VS are 140/89, 99, 20, O2 sats 95%. PMHX is HTN, Obesity, and a 1 pack a day smoker for over 25 years. What is the most likely diagnosis that a novice NP would anticipate?
    a. CHF
    b. COPD
    c. Pneumonia
    d. Covid

Answer 15

b. COPD

Rationale: The most important factor contributing to COPD is the patient’s history of cigarette smoking.

Pneumonia and covid may present with the same symptoms but also include fever and malaise.

CHF would also present with orthopnea and peripheral edema.

Question 16

36. A 55-year male comes in wheezing, with a dry cough, respiratory rate 35 bpm, and nasal flaring. He is alert and oriented but appears irritable. For 3 days, he has had chest tightness, shortness of breath at rest, and having to take pauses when using simple words. What type of pulmonary disorder and level of severity is this patient experiencing?

a. Asthma exacerbation, Respiratory Arrest Imminent
b. COPD, Severe Exacerbation
c. Asthma, Severe Exacerbation
d. COPD, Moderate Exacerbation

Answer 16

c. Asthma, Severe Exacerbation

Rationale: COPD and Asthma symptoms are often similar, however there are a few things that sets them
apart.

The pulmonary disorder this patient is experiencing is a Severe Asthma Exacerbation.

COPD can be ruled out because the patient has a dry cough. Patients with COPD are more likely to have a productive cough.

The level of severity is distinguishable (severe from imminent respiratory arrest) based on the fact
that the patient is still awake, alert, and oriented, able to lie flat but being upright is better, and wheezing is
still present.

In an imminent arrest, there will be no wheezing, patient will be slightly confused, and probably
won’t be able to hold a conversation. Remember, this patient is still communicating with you!

Question 17

37. A 65-year-old male comes in coughing, and you notice his thick, tan sputum. His nailbeds are cyanotic with clubbing, he has 2+ edema bilaterally, and he’s rhonchus on auscultation. On chart review, his BMI is 48, HGB 18, and paCO2 is 55. What pulmonary disorder and ventilation-perfusion results would you suspect?

a. Bronchitis (Blue Bloater); Increase V/Q areas to low perfusion
b. Bronchitis (Blue Bloater); Increase perfusion to low V/Q areas
c. Emphysema (Pink Puffer); Low V/Q perfusion to low ventilation
d. Emphysema (Pink Puffer); High ventilation to high V/Q areas

Answer 17

b. Bronchitis (Blue Bloater); Increase perfusion to low V/Q areas

Rationale: In the advanced stages of COPD; patients often suffer from bronchitis and/or emphysema. Based
on the above signs, symptoms and labs, this patient has bronchitis. In bronchitis, patients tend to have a
chronic productive cough, higher concentrated hemoglobin, elevated CO2 levels, and are often overweight.

On diagnostic testing, these patients have increase perfusion to low V/Q area in comparison to those with
emphysema who has increased ventilation to high V/Q area due to dead space.

Question 18

38. The strongest predisposing factor of asthma is?
    a. Obesity
    b. Smoking
    c. RSV during infancy
    d. Atopy

Answer 18

d. Atopy

Rationale: Atopy is a genetic immune response that predisposes a patient to allergic diseases. This causes
the body to produce immunoglobulin E (IgE), which responds to the environmental substances that may
trigger an allergic response.

Common conditions related to atopy include asthma, allergic rhinitis, and eczema.

Question 19

39. A 58-year-old male presents for his annual physical. He states that he is very concerned about developing dementia and is wondering about risk factors that he may have. You tell him that these may include all the following except:
    a. Family History
    b. Obesity
    c. A significant head injury
    d. Male gender

Answer 19

d. Male gender

Rationale: Risk factors for dementia include family history, diabetes mellitus, hypertension, cigarette
smoking, sleep deprivation, vitamin D deficiency, hearing loss, and obesity. Dementia is more prevalent in
women, but this may be due to their longer life expectancy.

Question 20

40. A 40-year-old female presents to your clinic with her mother. Her mother is 78 years old and is on several daily medications for some chronic conditions. Her daughter is concerned she has developed dementia. Daughter states that her mother started acting funny two days ago. She started getting confused and taking about people who had already died. She is having a very hard time paying attention and following conversations. As an APRN your thoughts are?
    a. Check her medications and urine sample, this is delirium not dementia
    b. Start Memantine- to help with advance dementia
    c. Start Acetylcholinesterase inhibitor like donepezil
    d. Start an antidepressant

Answer 20

a. Check her medications and urine sample, this is delirium not dementia

Rationale: Delirium is distinguished from dementia by the onset.

Delirium onset is acute, fluctuating, includes
hallucinations, and deficits in attention and not memory. In elderly patients, delirium is by drugs like:
anticholinergic agents, hypnotics, opioids, antihistamines, steroids and NSAIDs. Delirium can also come from urinary tract infections.

Memantine and Acetylcholinesterase are drugs used for Alzheimer’s and not delirium.

Antidepressants should be considered, because new incidence of depression can present like dementia, which needs further evaluation and history.

Question 21

41. All of the following acetylcholinesterase inhibitors have been used to improve cognitive function effectively in mild to moderate Alzheimer’s patients EXCEPT.
    a. Donepezil (Aricept)
    b. Rivastigmine (Exelon)
    c. Galantamine (Razadyne)
    d. Memantine (Namenda)

Answer 21

d. Memantine (Namenda)

Rationale: Memantine is a NMDA antagonist used to treat SEVERE Alzheimer and dementia with Lewy bodies.

Question 22

42. Ms. McGhee is a 80 y/o new established patient to your office. She has multiple PMH and take a ton of medications as her son reports. As her NP, what medications should you review?
    a. All prescribed drug, OTCs and supplements she’s currently taking
    b. All her prescribed medications
    c. All of OTCs and supplements to avoid adverse drug events
    d. Whatever Ms. McGhee brings to your office

Answer 22

a. All prescribed drug, OTCs and supplements she’s currently taking

Rationale: A is correct answer. There is greater incidence of hospitalizations in elderly population due to
adverse drug events. Therefore, it is important to review all medications and supplements during each visit
for each patient.