Final Exam questions 5

Question 1

84. A 34-year-old, obese, AA male presents to the clinic c/o painful swallowing for 1 week. He denies cough or fever and reports no sick contacts. He and his male partner were both treated for chlamydia in last 6 months with confirmed treatment success. Physical exam reveals oral candida infection. Which of the following includes the most appropriate labs/diagnostic testing to pursue?
    a. HgbA1c, HIV, CBC
    b. CBC, HgbA1c, CMP, RPR
    c. HIV, RPR, HSV 1 & 2, CBC
    d. Urinalysis, CBC, RPR, HgbA1c

Answer 1

a. HgbA1c, HIV, CBC

Rationale: Commonly oral candidiasis is associated with antibiotic or corticosteroid use, poor dental hygiene or denture use, diabetes, anemia, or chemotherapy (Lustig & Schindler, 2020).

Due to the patient’s h/o obesity HgbA1c should be checked to r/o DM, and CBC to r/o anemia.

Candidiasis can be a first sign of HIV and testing should be done if no other causes are evident (Lustig & Schindler, 2020). In ruling out other common
causes of Candidiasis, and in conjunction with his history of MSM and recent h/o STD, HIV testing should
also be performed.

Question 2

85. A 36-year-old transgender woman is inquiring about hormone therapy, specifically estrogen. She admits that she is a 1/2 ppd smoker and has a BMI >35. She does not have a personal history of a DVT but is unaware of a family history because she is adopted. The clinician knows that the preferred route of therapy for her would be:
    a. Transdermal patch
    b. In pill form
    c. Injection
    d. Given her risk factors, she should be advised that she is not a candidate for hormone therapy

Answer 2

a. Transdermal patch

Rationale: Since the primary risk associated with estrogen therapy is DVT, a transdermal patch is the preferred route for those who smoke or with risk factors for a personal history of DVT. It has also been the most studied method of hormone therapy.

Question 3

86. A 24-year-old woman presents to the clinic for a yearly well-person exam. During the health history, the patient states she is bisexual. The NP knows this patient is at increased risk for all the following health disparities EXCEPT:
    a. Childhood physical and sexual abuse
    b. Cardiovascular disease
    c. Lower than average body mass index
    d. Depression

Answer 3

c. Lower than average body mass index

Rationale: Lesbian and bisexual women are at an increased risk for health disparities compared to heterosexual women.

These health disparities include, but are not limited to, childhood physical and sexual abuse, substance abuse, depression, sexual assault, cardiovascular disease, high body mass index, chlamydial
infections as a teen and young adult, disabilities, asthma, and other types of violence and threats outside the home.

Question 4

87. The NP knows which of the following patients is at the highest risk for developing HIV?
    a. A 19-year-old Caucasian male who has oral intercourse with men
    b. A 45-year-old Hispanic male who has receptive anal intercourse with men
    c. A 32-year-old African American male who has insertive intercourse with men
    d. A 27-year-old African American male who has receptive anal intercourse with men

Answer 4

d. A 27-year-old African American male who has receptive anal intercourse with men

Rationale: Despite representing less than 10% of the US male population, men who have sex with men (MSM) make up approximately 70% of new HIV infections.

High HIV infection rates stem from the efficient transmission of HIV through receptive anal intercourse which poses a higher risk for HIV transmission than any other sexual activities.

MSM of color are at in increased risk of HIV.

African American MSM have the highest risk for HIV (1 in 2) followed by Hispanic MSM (1 in 4) then Caucasian MSM (1 in 11).

Question 5

88. PEP exposure in Men who have sex with men should not be given after ——– hours?
    a. 72
    b. 24
    c. 48
    d. 36

Answer 5

a. 72

Rationale: PEP is not recommended if more than 72 hours have elapsed. PEP should also be taken
for 28 days. The sooner the patient takes PEP the sooner, it effective.

Question 6

89. A 20-year-old female presents to the clinic with non-odorous cottage cheese-like vaginal discharge and itching. What would be the most likely diagnosis?
    a. Trichomoniasis
    b. Bacterial vaginosis
    c. Vulvovaginal candidiasis
    d. Gonorrhea

Answer 6

c. Vulvovaginal candidiasis

Rationale: Common symptoms of vulvovaginal candidiasis (yeast infection) is pruritic and cottage cheese like vaginal discharge that has no smell.

Trichomoniasis symptoms (present in 50 %) include vaginal itching, frothy greenish-grey discharge, strong odor, and dysuria.

Bacterial vaginosis symptoms include copious
grey-white vaginal discharge with a strong fishy odor.

Gonorrhea symptoms (present in 23-57%) will present
with vaginal discharge and dysuria.

Question 7

90. A 14yo female is being seen in your clinic for her yearly checkup. Her only complaints are headaches, nausea and severe abdominal cramps during her period. Her periods are regular, slightly heavy and last 6-7 days. She is on no current prescribed medications and has not tried any OTC medications for these symptoms. What is your first line treatment?
    a. Oral contraceptive pills
    b. Ibuprofen 400-600mg Q 6 hours 2 days before until 3 days after onset of symptoms
    c. Answers a & b
    d. Pelvic imaging prior to medication initiation

Answer 7

b. Ibuprofen 400-600mg Q 6 hours 2 days before until 3 days after onset of symptoms

Rationale: Ibuprofen is always first line choice for moderate period symptoms when periods are regular. If
the ibuprofen is not effective, then initiation of oral contraceptive pills is started in an attempt to suppress
ovulation.

Question 8

91. A 16-year-old female presents for a wellness exam. Her mother has prepared her to undergo her first pelvic exam with Pap smear and she is very nervous. She denies any abdominal pain, vaginal discharge, sexual contact, and her periods are regular and do not bother her. The NP should:
    a. Ask the teen to remove her clothes and provide a drape in preparation for a pelvic exam.
    b. Allay the teen’s anxiety as early as possible in the visit by explaining that a pelvic exam is not a part of her visit today as she does not have any complaints and does not need Pap screening until age 21.
    c. Explain to the teen that the pelvic exam with Pap smear and HPV testing is an important part of screening for women.
    d. She needs an exam for wellness purposes despite absence of genitourinary and menstrual concerns

Answer 8

b. Allay the teen’s anxiety as early as possible in the visit by explaining that a pelvic exam is not a part of her visit today as she does not have any complaints and does not need Pap screening until age 21.

RATIONALE: A pelvic exam in the teen is indicated with any concerns about pelvic or abdominal pain/mass,
menstrual concerns, or vaginal discharge.

Papanicolaou screening begins at age 21 regardless of sexual activity as the risk of adverse events related to screening follow up outweighs the risk of cancer in this age group.

HPV testing begins at age 30 according to the American College of Obstetrics and Gynecology
(ACOG). The only exception is for the HIV positive teen who should be screened for HPV within one year of
starting sexual activity.

Question 9

92. Which of the following regarding primary and secondary amenorrhea in adolescents is not true?
    a. A 15-year-old female who has not had her first menstrual cycle is considered to have secondary amenorrhea.
    b. One of the main causes of primary amenorrhea is Turner Syndrome.
    c. A thin 17-year-old female started her period at age 12 and reports she has not had a period in half a year should be diagnosed with secondary amenorrhea.
    d. The initial lab workup for both primary and secondary amenorrhea includes a pregnancy test and serum LH, FSH, prolactin and TSH levels.

Answer 9

a. A 15-year-old female who has not had her first menstrual cycle is considered to have secondary amenorrhea.

Rationale: The correct answer is A.

Primary amenorrhea is when there is no menarche by age 15

Secondary amenorrhea is when there are no menses for 3 cycles or for 6 months for a patient with irregular
menses.

Question 10

93. At what age does the USPSTF recommend starting bone mineral density (BMD) screening for osteoporosis in women with no additional risk factors?
    a. 45 years old
    b. 50 years old
    c. 65 years old
    d. At the time of menopause

Answer 10

c. 65 years old

Rationale: If there are no additional risk factors, routine BMD screening is recommended starting at age 65.
The USPSTF states that screening can be done in women younger than 65 if the fracture risk is equal or
greater to the risk of a 65-year-old white woman. If there is a concern for risk, the FRAX tool can be used to calculate the 10-year risk of osteoporotic fracture.

Question 11

94. A 47-year-old woman presents to your clinic after feeling a “lump” in her left breast. After your physical examination, you did not palpate any masses or lesions in either the left or right breast. The patient is worried that it may be breast cancer. Which imaging study do you order first?
    a. Ultrasound and mammography
    b. MRI chest
    c. CT chest
    d. PET scan

Answer 11

a. Ultrasound and mammography

Rationale: Ultrasound and mammography are valuable and essential imaging studies when a patient feels
something abnormal, despite the Advanced Practice Nurse feeling no mass or lesion.

MRI should not be
used due to its false-negative rate of about 3-5%, which cannot safely rule out the possibility of cancer.

CT chest and PET scan evaluate for metastatic lesions when there are suspicious signs or symptoms present,
such as bone pain, elevated liver test, abdominal symptoms, abnormal lymph nodes, or large primary
tumors.

Question 12

95. A 35-year-old patient is in your clinic today because she recently found a small mass after noticing slight tenderness to the breast. Now, the mass cannot be palpated. She is currently having her menstrual cycle. What do you suspect?
    a. Breast cancer, she needs a biopsy STAT.
    b. A Fibrocystic condition
    c. The patient clearly is a hypochondriac and needs to be taught how to properly do monthly self-breast exams
    d. A breast abscess

Answer 12

b. A Fibrocystic condition

Rationale: With fibrocystic breast condition, a mass may be found accidentally, or found when the breast feels tender. The discomfort commonly occurs premenstrual as the cysts tend to grow in size. Rapid growth and/or disappearance is common. There may also be serous drainage from the nipple or multiple masses noted.

Question 13

96. Your non-pregnant and non-lactating female patient comes to your clinic with complaints of milky discharge from both breasts that has occurred intermittently for the past two weeks. What labs will be helpful in ruling out certain conditions in this patient?
    a. TSH and Prolactin
    b. CBC and TSH
    c. A1C and Prolactin
    d. Testosterone, CMP, and Quantitative HCG

Answer 13

a. TSH and Prolactin

Rationale: Galactorrhea is a common symptom of hyperprolactinemia which can have multiple causes.
Obtaining a prolactin level in someone presenting with milky breast discharge can help rule out
hyperprolactinemia caused by a tumor of the pituitary gland. In addition, a TSH level can help rule out
hyperprolactinemia caused by primary hypothyroidism. CBC and A1C are not necessary when evaluating hyperprolactinemia and Testosterone level is not necessary when evaluating this condition in a female patient.

Question 14

97. A 30-year-old female presents to the clinic for a Well Woman’s exam and requests more information about available options for contraception. In deciding which contraceptive types are appropriate for this patient, all the following are relative contraindications to use of oral contraceptives except:
    a. Diabetes mellitus
    b. Gallbladder disease
    c. Hypertension
    d. Migraine with aura

Answer 14

d. Migraine with aura

Rationale: Migraine with aura is an absolute contraindication to use of oral contraceptives. Use of oral contraceptives should be avoided in women experiencing an aura associated with migraine headaches, uncontrolled diabetes mellitus, and uncontrolled hypertension.

Migraine without aura, is a relative contraindication.

Question 15

98. A 45-year-old female reports to clinic for her yearly wellness exam. During the exam she states that her grandmother had breast cancer and she is wanting to know the risk factors for breast cancer. As her family care provider, you know that which of the following is a risk factor for breast cancer?
    a. Childbirth after age 25
    b. Family history of breast cancer
    c. Low dietary intake of fat
    d. Routine screening mammography

Answer 15

b. Family history of breast cancer

Rationale: Factors affecting the risk for breast cancer in a female include: their age, one who has not birthed a child, one who has birthed a child after 30 years of age, one who has a family history of breast cancer or genetic mutation of BRCA, and a prior history of breast cancer or some type of proliferative condition. ETOH consumption, a diet high in fat and the lack of exercise also increases the risk of breast cancer.

Question 16

99. You work in a rural pediatric clinic and just received a call from a mother who is concerned about her 8-year old’s behavior. He and his siblings are established patients, but he has been receiving treatment by a pediatric oncologist in a neighboring city for the past 2 years. He was recently transitioned from palliative care to end of life care. The mother states that the child seems withdrawn from the family, is not sleeping well and has been very oppositional. You explain that these are normal responses to stress in his age group and suggest which of the following interventions?

a. Allow the child to stop completing all schoolwork
b. Suggest that he eat in his room to allow for alone time
c. Allow age-appropriate control whenever possible
d. Cuddle, hold, and rock often

Answer 16

c. Allow age-appropriate control whenever possible

Rationale: School aged children understand that death is permanent and have seen death in
context. This child is experiencing a normal response to stress after learning that his end of life is
approaching. It is important to acknowledge his feelings are normal, and to allow as much control as
possible for his age. The family should work to keep as much normalcy in his routine as possible. It may be a good idea to have someone to talk to outside of the family unit that can answer concerns and fear
honestly. Psychosocial support is important to the family and the child as the end-of-life approaches.

Question 17

100. A six-year-old patient who is accompanied by her mother presents to you in the office. Recently, there was a death in their family. The child is asking questions about death and dying. All of the following are true except:
     a. Adolescent children believe death is deliberately caused
     b. At 5-6 years of age they understand universality
     c. At age 8-9 they understand personal mortality
     d. Children recognize death as a changed state by 3 years old

Answer 17

a. Adolescent children believe death is deliberately caused

Rationale: From toddler years through adolescence, the concept of death is understood but synthesized differently.

Infants have no cognitive ability to understand the concept of death.

Toddlers do not understand death however, they do recognize and understand separation. So, they will grieve in the sense that the loved one is no longer around but will not understand they have passed away. This presents as “the changed state”. It is helpful to maintain a routine with a toddler if someone passes away in the family.

Children aged 5-6, view death as a “universality”. At this cognitive stage, children can understand and apply logic. Death is synthesized through personal experience (loss of a pet or a grandparent) or watching television. Continue to maintain a routine, let them use play therapy as an outlet to express emotions, address their questions and reassure them that how they are feeling is normal.

At ages 8-9, they understand personal mortality. This age group and beyond (pre-adolescence/adolescence), are aware of death but may need some guidance as to why it happened. They have a social networking group at school whom they trust and rely on for support. When seeing patients at this age it is important to be honest and giving them a sense of control.

Question 18

101. You are discussing the option of palliative care with the family of a pediatric patient recently diagnosed with lymphoma. All of the following demonstrate understanding of palliative care except which answer?

a. “Once we agree palliative care we will no longer be able to pursue curative treatment options.”
b. “Opting for palliative care will allow us to provide pain management and improve her quality of life while going through treatment.”
c. “Adding palliative care to our care team will offer psychosocial support for us all during this difficult time.”
d. “Palliative care can help our family incorporate a sense of normalcy when we are home from the hospital.”

Answer 18

a. “Once we agree palliative care we will no longer be able to pursue curative treatment options.”

Rationale: Palliative care is offered to those patients who might have curable treatment options but may end up failing, diseases or conditions that require long term treatment to maintain a high quality of life, conditions that are progressive, and diseases that can lead to health complications. Palliative care helps to prevent and relieve symptoms associated with a disease or condition to ensure patients quality of life is maintained during treatment. Aside from maintaining that patients quality of life they aid in supporting the patient and family emotionally and psychosocially.

Question 19

102. 68-year-old female patient presents with difficulty in concentration, apprehension, sweating and hyperventilation in relation to certain situations for the past 2 years. You diagnose her with generalized anxiety disorder and know all of the following are true, except
     a. Anxiety can be self-generating since symptoms can reinforce the reaction.
     b. Anxiety disorders are some of the most common psychiatric disorders.
     c. Benzodiazepines are the best options for treatment.
     d. Psychological and somatic symptoms are both principal components of anxiety.

Answer 19

c. Benzodiazepines are the best options for treatment.

Rationale: Although benzodiazepines can be beneficial in brief acute management, antidepressants and behavioral techniques are first line treatment in order to help relieve anxiety.

Question 20

103. A patient comes in with complaints of chronic pain. They have seen many different providers, have had minimal relief with treatment, and frequently use nonspecific medications. Which of the following statements are true?
     a. A single provider should oversee a comprehensive approach involving behavioral, medical, social and psychological treatment.
     b. The pain isn’t real, it’s just in their head.
     c. Anxiety and depression should not be addressed since that’s not a component of chronic pain.
     d. Sympathy and attention is all that they need.

Answer 20

a. A single provider should oversee a comprehensive approach involving behavioral, medical, social and psychological treatment.

Rationale: a combination of approaches should be used in order to correctly identify and treat the chronic pain; this should be managed by one provider to prevent confusion. The pain is real to the patient and should be treated as such, but sympathy and attention can be positive reinforcers for the patient that can increase the behavior. Anxiety and depression are often components of chronic pain that should be addressed and treated.

Question 21

104. A mother brings in her 15-year-old son in clinic for a sport physical who has brought his mother with him. The patient’s mother asks to talk to you outside of the room and states “I believe my son is using drugs. He has not been acting like himself lately, not doing good in school, and has a really bad temper. Can you test his urine for drugs?” As a practicing provider you respond and state:
     a. “I appreciate you bringing this problem to my attention, we will have the nurse get a urine sample from him.”
     b. “He seems like a great kid. Can you give me more reasons as to why you think he is doing drugs?”
     c. “We can get a urine sample from him, but we need to get his consent first.”
     d. “He is not old enough to get a urine sample from, it has to be a blood draw.”

Answer 21

c. “We can get a urine sample from him, but we need to get his consent first.”

Rationale: The patient needs to give consent and should have the procedure explained to them, even if they are a minor. The permission of the parent is not sufficient for involuntary screening of a minor.