hesi primary 3

Question 1

The Cullen sign

Answer 1

The Cullen sign is ecchymosis noted in the periumbilical area and is indicative of intraperitoneal hemorrhage.

Question 2

The Blumberg sign

Answer 2

The Blumberg sign is acute pain elicited with the abrupt release of abdominal pressure, and is indicative of peritoneal inflammation. The Blumberg sign, also known as rebound tenderness, is positive when the pain is worsened with the abrupt release of abdominal pressure. When assessing for the Blumberg sign, palpate the painful area last, using care. In addition to the patient verbalizing pain, watch for winces, guarding, or sharp inhalations.

Although the Blumberg sign is common in appendicitis, it can be positive in any condition that causes localized or generalized peritoneal inflammation.

Question 3

The Murphy sign

Answer 3

The Murphy sign is localized tenderness over the gallbladder, commonly noted in acute cholecystitis. It is elicited by palpating the gallbladder area as the patient deeply inhales. Abrupt cessation of the inspiration is a positive finding.

Question 4

The Markle sign

Answer 4

The Markle sign is the acute right lower quadrant abdominal pain associated with the jarring heel-drop test, and is suggestive of acute appendicitis.

Question 5

glomerulonephritis

Answer 5

inflammation of the glomerulus is termed glomerulonephritis.

Clinical manifestations of glomerular disease may include foamy or cola-colored urine, nausea, vomiting, edema, and hypertension. Glomerular disease can manifest as proteinuria on the urinalysis (≥500 mg/day) and other testing may indicate declining renal function. Hematuria may also be present in glomerulonephritis.

Question 6

glomerulus

Answer 6

The glomerulus is a complex network of vasculature and nerve endings surrounding the end of the renal tubule. It serves an important role in the function of the kidneys

Question 7

thrombosed hemorrhoid.

Answer 7

A blood clot may form inside a hemorrhoidal vein which can obstruct the blood flow and cause painful swelling. This condition is known as a thrombosed hemorrhoid. This thrombosis can occur after coughing, heavy lifting, or straining at the stool. This condition has an acute onset and can cause severe pain and discomfort. On examination, the thrombosed hemorrhoid will appear as a firm, bluish, nodule covered with skin. They can be several centimeters in size.

Question 8

treatment of thrombosed hemorrhoid.

Answer 8

Small and less painful thrombosed hemorrhoids may be conservatively treated with warm sitz baths, analgesics, and ointments, however, when the patient is seen within the first 24-48 hours of onset and is experiencing severe symptoms, the most effective management for fast symptom relief is the administration of 1% lidocaine and excision and removal of the clot. A dry gauze dressing is placed for 12-24 hours after excision, and then daily sitz baths are started.

Question 9

The first-line medications for major depressive disorder are ?

Answer 9

The first-line medications for major depressive disorder are selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs). The choice between these medications depends on individual patient factors such as cost and side effects.

Question 10

SNRI examples

Answer 10

SNRI examples are venlafaxine (Effexor) and duloxetine (Cymbalta). Providers should be aware that both SNRIs and SSRIs have a suicide risk.

Question 11

SSRI examples

Answer 11

Escitalopram (Lexapro) is an effective and commonly prescribed SSRI. Providers should be aware that both SNRIs and SSRIs have a suicide risk.

Question 12

starting depression meds

Answer 12

A patient with severe depression may have enough energy to attempt suicide after starting the medication. Additionally, patients should be made aware that it may take several weeks before they experience symptom relief. Both SNRIs and SSRIs require a taper after depression remission and should not be discontinued abruptly.

Question 13

alternative for depression treatment

Answer 13

Tricyclic antidepressants (TCA) are an alternative for treatment but require caution due to their potential for cardiotoxicity and side effects (hypertension, syncope, seizures, and myocardial infarction).

Question 14

Monoamine oxidase inhibitors (MAOIs)

Answer 14

Monoamine oxidase inhibitors (MAOIs) can be effective medications for major depression, but they have more side effects and interactions (drug and food).

Question 15

genital gonorrhea symptoms

Answer 15

Up to 70% of women with genital gonorrhea are asymptomatic; if symptoms develop they usually occur by day 10 following exposure

Question 16

A positive urine culture should be treated how?

Answer 16

Urinary tract infections and asymptomatic bacteriuria commonly occur during pregnancy. A positive urine culture should be treated with antibiotics, even if the patient is asymptomatic. Untreated UTIs can cause adverse pregnancy outcomes including preterm birth and low birth weight . Clinicians should be mindful of patient allergies, history of resistance, and safety during pregnancy when selecting an antibiotic for treatment. Fosfomycin (Monurol) is a safe and effective single-dose treatment when there is no concern for pyelonephritis. Additional options for treatment include Amoxicillin-clavulanate (Augmentin), Nitrofurantoin (Macrobid), Trimethoprim-sulfamethoxazole (Bactrim), and Cephalexin (Keflex). Both Macrobid and Bactrim should be avoided during the first trimester because of fetal risks. A test of cure should be performed during pregnancy to make sure the infection has been adequately treated.

Question 17

screening for CRC

Answer 17

Patients with ulcerative colitis and Crohn’s disease (that affects at least 30% of the colon) are at an increased risk for CRC. The risk of cancer development is dependent on disease extent, age of onset, and severity. Early detection of CRC in patients with IBD is very important to reduce morbidity and mortality.
The recommendation is an initial screening colonoscopy eight years after diagnosis. Patients with ileal Crohn’s disease are not at an increased risk for the development of colorectal cancer because of the lack of colonic inflammation. There are no specific screening guidelines for patients with Crohn’s not affecting the colon.

Question 18

Almost all patients with Barrett’s esophagus are treated with

Answer 18

a proton-pump inhibitor (PPI). Research shows that reducing chronic acid exposure to the lining of the esophagus may prevent adenocarcinoma. Adherence to PPI therapy is very important for the reduction of exposure to acid and preventing chronic inflammation. PPIs are often prescribed once per day and should be taken before meals. Patient’s with Barrett’s esophagus are treated with a PPI and monitored closely via endoscopy for dysplasia. High-grade dysplasia and development of carcinoma may require other interventions such as ablative therapy or resection.

Question 19

Progestin-only contraceptives

Answer 19

come in different forms that include implants, intrauterine devices, injections, and pills. They work to thicken cervical mucus, which leads to sperm not being able to migrate as easily to the egg if ovulation has occurred. This type of contraception also slows the migration of the egg from an ovary through the fallopian tubes and thins the lining of the endometrium, which can make it difficult for an egg to implant if fertilized.

Question 20

Side effects of progestin-only contraceptives

Answer 20

Side effects of progestin-only contraceptives include unscheduled bleeding, menstrual changes, ovarian cysts, and acne.

Question 21

the benefit to progestin-only contraceptives

Answer 21

A benefit of this type of contraceptive is that it does not increase the risk of hypertension, elevated liver enzymes, or deep venous thrombosis. Another benefit is that it can help decrease a patient’s risk of developing endometrial cancer.

Question 22

Contraindications to progestin-only contraceptives

Answer 22

Contraindications to this birth control method include known pregnancy, breast cancer, undiagnosed abnormal uterine bleeding, history of bariatric surgery, or liver disease.

Question 23

Iron deficiency anemia

Answer 23

Iron deficiency anemia is a microcytic anemia with labs that include a low MCV value (less than 80 fL) and a high total iron binding capacity level.

Question 24

Patients with an iron deficiency may present with what symptoms?

Answer 24

Patients with an iron deficiency may present with symptoms of anemia (restless leg syndrome and ice cravings are common) prior to an actual drop in Hgb level. The gold standard for the diagnosis of iron deficiency is the absence of storage iron on bone marrow stains.

Although ferritin levels are often used successfully to reflect iron stores, patients with inflammatory diseases, infections, liver disease, heart failure, or cancer may have normal or elevated ferritin levels despite iron deficiency because ferritin is an acute phase reactant.

Question 25

If patient is having symptoms ex. fatigue, drowsiness, etc. but the CBC is normal.

Answer 25

Order Ferratin level. Stage 1 – Storage Depletion – Lower than expected blood ferritin levels. Ferritin is the storage form of iron, and low ferritin levels are the first sign that the body’s iron stores are compromised. Stage 2 – Mild Deficiency- During the second stage of iron deficiency, transport iron ( known as transferrin) decreases. This is often accompanied by a reduction in size of red blood cells even though hemoglobin levels remain normal. Stage 3 – Iron Deficiency Anemia – Hemoglobin begin to drop in the final stage which, depending on other blood work, may formally be defined as IDA. At this stage your red blood cells are fewer in number, smaller and contain less hemoglobin.

Question 26

formation of kidney stones.

Answer 26

A high uric acid concentration and an acidic pH causes a reaction which converts soluble urate salt into insoluble uric acid which promotes the formation of stones.The two major factors for uric acid stone formation are a persistently low pH (acidic urine) and a high uric acid concentration. The combination of these two factors causes a reaction that converts soluble urate salt into insoluble uric acid. There is a correlation between certain conditions and high uric acid production. These include myeloproliferative disorders, malignancies, psoriasis, obesity, down syndrome, and hemolytic disorders.

Question 27

The formation of uric acid stones in relation to gout

Answer 27

The formation of uric acid stones is significantly increased in patients with gout. The primary factor in this condition is persistently acidic urine. This acidic pH creates an ideal environment for uric acid overproduction and the formation of stones. Distinguishing the type of stone is important in guiding treatment. The composition of the kidney stone can be determined by chemical analysis and helical CT scan. Management of the patient with uric acid stones includes measures to cause the urine to be more alkaline, increased fluid intake, and reduction of uric acid production by reducing purine intake and the use of xanthine oxidase inhibitors.

Question 28

constipation in elderly

Answer 28

In the older adult population, chronic constipation is a relatively prevalent condition, but there are serious diseases that can cause constipation, most notably colon cancer. Once a serious disease is ruled out, fiber supplements are recommended for first-line treatment.

Question 29

pneumonia

Answer 29

Patients often present with the classical symptoms of fever, productive cough, purulent sputum, dyspnea, and pleuritic chest pain. Clinical presentation is often subacute. Findings on the clinical exam may include tachypnea, audible rales over the involved lobe or segment, increased or decreased tactile fremitus, bronchial breath sounds, egophony, and dullness on chest percussion. A chest X-ray is used to confirm the diagnosis of pneumonia.

Question 30

frostbite

Answer 30

Pallor and lack of sensation occur with first-degree frostbite. The skin may also appear red with swelling after rewarming in first-degree injuries. Erythema, edema, sloughing, and blistering are seen with second-degree frostbite. Because granulation tissue develops under the blisters, tissue loss is usually avoided. Blisters occur in third-degree frostbite but the thermal injury progresses further into the skin. Eschar often develops and tissue loss occurs. Fourth-degree frostbite is severe and may result in mummification and gangrene. The cold-induced injury extends beyond the subcutaneous tissue and into the musculature and bone.

Question 31

Cranial nerves both sensory and motor functions

Answer 31

Cranial nerves V, VII, IX, and X have both sensory and motor functions. Assessment of cranial nerve function is used to diagnose neurological disorders.

Question 32

moderate to severe persistent asthma and a confirmed reaction to an aeroallergen.

Answer 32

Omalizumab (Xolair) is an IgE antagonist given in injection form. It is approved for patients over six years of age with moderate to severe persistent asthma and a confirmed reaction to an aeroallergen. The allergy should be confirmed using a skin test or in vitro. Common aeroallergens are pollen and mold spores. This medication has a black box warning for anaphylaxis. Patients should be observed post-administration and have injectable epinephrine available. More common side effects include injection site reactions, headaches, and upper respiratory infection symptoms. include duloxetine (Cymbalta) and venlafaxine (Effexor). Each medication carries individual risks. Duloxetine is associated with an increased risk of postpartum hemorrhage. Venlafaxine is associated with an increased risk of preeclampsia, and may also increase the risk of spontaneous abortion and postpartum hemorrhage.

Question 33

There are different compositions of the stones,

Answer 33

Renal stones form in the kidneys and may move into the ureters, bladder, and urethra. Urolithiasis is the term used once the stone exits the renal pelvis and enters the remainder of the collecting system. There are different compositions of the stones, however, 80% of stones are made of calcium oxalate. The composition of the stones varies dependent on risk factors such as diet, family history, environmental factors, medications, and the individual's personal medical history. Not drinking enough fluids and an inadequate calcium intake may lead to the development of calcium stones.

Question 34

first-line treatment for adrenal insufficiency

Answer 34

Primary adrenal insufficiency (Addison disease) results in a cortisol deficiency. Symptoms may include fatigue, salt cravings, weight loss, hyperpigmentation, and gastrointestinal complaints. Oral hydrocortisone is the first-line treatment for adrenal insufficiency because it is a fast-acting mineralocorticoid. This medication can be given intravenously for an adrenal crisis. Hydrocortisone therapy is given in divided doses to mimic the pattern of natural cortisol release in the body.

Question 35

MCV

Answer 35

Mean corpuscular volume (MCV) is a laboratory value that measures the average size and volume of a red blood cell

Question 36

folic acid pregnancy

Answer 36

The daily recommended dose of folic acid during pregnancy is 0.4–0.8 mg (400–800 mcg). Increased dosing is not indicated for patients with a history of smoking, gestational diabetes, or twin pregnancy, according to the U.S. Preventive Services Task Force, the Centers for Disease Control and Prevention, and the Institute of Medicine. A history of pregnancy affected by NTDs (such as spina bifida) indicates the need for increased dosing of folic acid during pregnancy to 4 mg (4,000 mcg) per day at least 1 month before becoming pregnant and during the first 3 months of gestation.

Question 37

acute infection hep B

Answer 37

The results for an acute infection would most likely be positive HbsAg, positive anti-HBc, positive IgM anti-HBc, and negative anti-HBs.

Question 38

chronic hepatitis B

Answer 38

The results for a patient with chronic hepatitis B would most likely be positive HBsAg, positive anti-HBc, and negative IgM anti-HBc and anti-HBs.

Question 39

immunity from Hep B

Answer 39

The serology markers for immunity from vaccination would be negative HBsAg, negative anti-HBc, and positive anti-HBs.

Question 40

vertigo

Answer 40

nystagmus is an involuntary eye movement in which the eye can move up and down, side to side, or in a circle. Nystagmus may be seen with use of the Dix Hallpike maneuver in individuals with benign paroxysmal positional vertigo.

Question 41

vertigo, nystagmus, and tinnitis

Answer 41

The vestibulocochlear, cranial nerve VIII, is made up of vestibular and cochlear components. The vestibular component is responsible for maintaining balance and eye movements. Symptoms of a disorder of the vestibular component include vertigo, nystagumas, and tinnitus.

Question 42

albuminuria

Answer 42

Diabetes mellitus can cause increased protein excretion into the urine. A moderately high level of protein in the urine is called microalbuminuria or albuminuria. Albuminuria is associated with a higher cardiovascular risk and is often an indicator that nephropathy is developing. Primary prevention for this condition is glycemic control. Testing for albuminuria should be performed yearly. Albuminuria is defined as levels of albumin between 30 and 300mg/day.

Question 43

Testing for microalbuminuria

Answer 43

Testing for microalbuminuria is performed using an albumin-to-creatinine ratio in a urine sample. If a high ratio is detected, the patient should be tested two more times over the next three to six months. Diagnostic criteria for microalbuminuria require two or three samples with a high ratio.

Question 44

women considering starting HRT

Answer 44

All women considering starting HRT should be evaluated thoroughly to determine the risks of cardiovascular events and breast cancer. Particular concerns include the risk of breast cancer and adverse cardiac events (blood clot, stroke, heart attack) that can be increased with the use of HRT. Patients on HRT should be monitored closely and re-evaluated frequently to determine the need for continued therapy.

Question 45

HRT after 60

Answer 45

Professional consensus recommends that HRT not be initiated after age 60 because of the risks of vascular events

Question 46

genitourinary symptoms of menopause

Answer 46

Women with only genitourinary symptoms of menopause (GSM) should be treated with vaginal estrogen.

Question 47

HRT > 5 years?

Answer 47

The current recommendations state that HRT should be used for 5 years or less .In certain situations, HRT benefits may outweigh the risks, but this should be frequently re-evaluated and based on individual circumstances.

Question 48

Cluster headaches

Answer 48

Cluster headaches are most common in middle-aged males. They are often described as pain behind only a single eye, with the pain having periods of varying intensity and severity. They may present in clusters and then disappear for months to years. Unlike migraine headaches, there is typically no nausea or vomiting, but symptoms of cluster headaches may include nasal congestion, rhinorrhea, and tearing and redness of the affected eye. Episodes typically awaken the patient during the night and last between 15 minutes and 3 hours. Many patients report that alcohol, stress, glare, or certain foods trigger an attack.

Question 49

Posttraumatic headache

Answer 49

Posttraumatic headache occurs within a day following a head injury, and is a dull, throbbing constant headache that may be localized, generalized, or lateralized.

Question 50

Tension headaches

Answer 50

Tension headaches are generalized and nonthrobbing, with the pain most intense at the back of the head and neck

Question 51

migraine headache

Answer 51

The typical migraine headache may be lateralized or generalized, dull or throbbing, and it builds in intensity, lasting several hours.

Question 52

Folliculitis

Answer 52

Folliculitis is condition characterized by inflammation and bacterial infection of the hair follicles. It can cause widespread erythematous pustules/papules and most often arises on the face, trunk, lower extremities, and buttocks. The rash is often pruritic. Folliculitis is most commonly caused by S. aureus.

Question 53

appropriate topical treatment for folliculitis.

Answer 53

Mupirocin (Bactroban) is an appropriate topical treatment for folliculitis.

Question 54

management of irritant contact dermatitis.

Answer 54

Topical high-potency corticosteroids, such as betamethasone (Sernivo), can be utilized in the management of irritant contact dermatitis.

Question 55

hyperpigmentation treatment,

Answer 55

Hydroquinone (Musely) is a hyperpigmentation treatment.

Question 56

treatment option for psoriasis

Answer 56

Topical calcitriol (Rocaltrol) is a treatment option for psoriasis.

Question 57

antifungal treatment

Answer 57

Topical clotrimazole (Lotrimin) is an antifungal treatment

Question 58

first-line treatment for erysipelas

Answer 58

Amoxicillin is a recommended first-line treatment for erysipelas due to β‑hemolytic streptococci.

Question 59

Tinea versicolor

Answer 59

Tinea versicolor is a common infection caused by the lipophilic yeast Pityrosporum orbiculare (a normal skin flora). It is most common during years of higher sebaceous activity in adolescence and young adulthood. Excess heat and humidity can precipitate infection. Appearance is often the patient’s major concern. It is characterized by numerous small, circular, white scaling papules on the upper trunk, arms, neck, and abdomen. Lesions are hypopigmented in tanned skin and pink or fawn-colored in untanned skin. Wood’s light examination shows hypopigmented areas of infection. A potassium hydroxide examination can quickly verify the correct diagnosis.

Question 60

First-line treatment Tinea versicolor

Answer 60

First-line treatments include topical antifungals such as terbinafine, selenium sulfide shampoo (applied to the affected areas), or zinc pyrithione shampoo

Question 61

reasons older adults are more vulnerable to infections

Answer 61

It is known that older adults are more vulnerable to infections (increased morbidity and mortality) than other adults. One reason is the age-related changes in the immune system. B-cell function declines, T-cell generation slows, T-cell activation is not as efficient, and innate immunity decreases. These changes coupled with multiple comorbidities, including cardiovascular disease, diabetes mellitus, cancer, and lung disease, increase the older adult population’s vulnerability to infections. Vaccines are less effective in this population as well, which is why the high-dose influenza vaccine is recommended for older adults.

Question 62

Cushing syndrome

Answer 62

Cushing syndrome is a condition caused by an excess of cortisol. It may be caused by adrenocortical tumors or other adrenocortical diseases, but the most common cause is pharmacological use of glucocorticoids causing iatrogenic Cushing syndrome. Hyperpigmentation occurs due to an increase in adrenocorticotropin hormone (ACTH), not the increase in cortisol. "Moon" face and "buffalo hump" occur along with the progressive central obesity of Cushing. The extremities are typically spared. Hypertension in Cushing is caused by several factors and not well understood. It is suspected that cortisol may have a direct cardiotoxic effect. Striae typically occur along the areas of progressive obesity such as the abdomen, trunk, and breasts. It is a thinning and stretching of the skin that shows the underlying venous return in the dermis.

Question 63

gold standard for hypertension treatment post-MI

Answer 63

Beta blockers in combination with angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) are the gold standard for hypertension treatment post-MI. This combination of medications prevents cardiac remodeling while treating high blood pressure.

Question 64

recommended to treat genitourinary symptoms of menopause (GSM)

Answer 64

Hormone replacement therapy (HRT) is an essential tool in managing symptoms associated with menopause. Vaginal estrogen is recommended to treat genitourinary symptoms of menopause (GSM), while systemic estrogen therapy can be used if indicated to manage vasomotor symptoms including hot flashes (Bachmann, & Santen, 2021). Local estrogen therapy (vaginal estrogen) generally carries less risk than oral estrogen therapy as it is not absorbed systemically. Systemic estrogen therapy increases the risks of blood clots, heart attack, and stroke. When prescribing HRT, providers should be mindful of risks and use doses and routes that limit the risks to the patient while also optimizing symptom management.

Question 65

Long-term non-steroidal anti-inflammatory use can cause significant adverse effects throughout the systems of the body. What are they?

Answer 65

Many patients do not realize over-the-counter medications can have significant drawbacks if ingested long-term. In addition to renal, cardiovascular, and gastrointestinal effects, many other body systems are impacted. Significant hepatic injury can occur including acute liver injury. An immunologic reaction can occur leading to anaphylaxis. Integumentary complications can also develop, including the two most severe dermatologic conditions Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis. Both of these diagnoses are medical emergencies. Central nervous, hematologic, and pulmonary effects can also arise from long-term NSAID use.

Question 66

tinea pedis treatment

Answer 66

Topical antifungal therapy is the treatment of choice. Topical drugs effective for tinea pedis include azoles (ketaconazole), allylamines (terbenafine), butenafine (Mentax), ciclopirox (Loprox), and tolnaftate (Tinactin). The topical agent is usually applied once or twice a day for a period of four weeks. Oral antifungal agents are typically reserved for those who fail topical treatment.

Question 67

Depo black box warning

Answer 67

Depot medroxyprogesterone acetate carries a black box warning for bone mineral density loss and suggests that it not be continued past 2 years if other options are available. A discussion should take place with the patient regarding the risks, benefits, and alternatives. According to the ACOG, if the patient wishes to continue the medication after this discussion, it should be continued.

Question 68

hemorrhoidectomy

Answer 68

A hemorrhoidectomy is when the hemorrhoids are surgically removed. The swollen vein inside the hemorrhoid is tied off to prevent bleeding, and the hemorrhoid is excised. Surgical excision is reserved for those patients with stage III or IV hemorrhoids who have not responded to conservative treatment and for those who have acute thrombosed stage IV hemorrhoids with necrosis. Approximately 5%-10% of patients require a hemorrhoidectomy. It is the most effective treatment for hemorrhoids, however, it also carries the greatest risk of complications. Recovery time is typically 2-4 weeks, and complications include pain, impaired continence, fecal impaction, infection, and anal stricture.

Question 69

The major risk factors for a fatal asthma attack

Answer 69

The major risk factors for a fatal asthma attack are recent poorly controlled asthma and a history of a near-fatal attack. If the patient has recently been intubated, required ventilation assistance, or been admitted to intensive care, their risk is significantly higher. Other risk factors include smoking, exercise, aspirin, menstruation, food allergies, genetic links, and contraction of a respiratory virus. Illicit drug use, especially heroin and cocaine, is associated with fatal asthma attacks.

Question 70

appropriate treatment for diverticulitis.

Answer 70

Ciprofloxacin (Cipro) plus metronidazole (Flagyl) for seven to ten days is an appropriate treatment for diverticulitis.

Question 71

giant cell temporal arteritis

Answer 71

Patients with giant cell temporal arteritis typically present with a new-onset headache, increased fatigue, and weight loss, and they may have jaw claudication. The condition is frequently diagnosed in conjunction with polymyalgia rheumatica.

Question 72

treatment for giant cell temporal arteritis

Answer 72

Along with a physical examination, laboratory tests should be done to assess inflammatory markers. It is recommended that a biopsy of the temporal artery also be performed for histology to confirm the diagnosis. High-dose corticosteroids for at least 4 weeks is the first-line treatment, and the nurse practitioner should also consider a referral to a rheumatologist.

Question 73

African american vit D deficiency

Answer 73

Race has been identified as a significant risk for vitamin D deficiency, with African-American adults having the highest risk. This patient's race, obesity, and report of muscle aches raise a concern for a vitamin D deficiency and warrants screening.

Question 74

Cranial nerve IV (trochlear)

Answer 74

Cranial nerve IV (trochlear) controls the superior oblique muscle of the eye and allows for downward, outward, and inward movement of the eye.

Question 75

Cranial nerve III (oculomotor)

Answer 75

Cranial nerve III (oculomotor) innervates the pupil and lens, the upper eyelid, and eye muscles that allow for visual tracking and gaze fixation.

Question 76

Cranial nerve VI (abducens)

Answer 76

Cranial nerve VI (abducens) controls the lateral rectus muscle that is involved in outward eye movement.

Question 77

Cranial nerve VII (facial)

Answer 77

Cranial nerve VII (facial) controls the muscles of facial expression, and functions in the conveyance of taste sensation from the anterior two-thirds of the tongue.

Question 78

Excessive progesterone

Answer 78

Excessive progesterone may be caused by many conditions, including pregnancy and ovarian cancer. These conditions should be ruled out if a patient is experiencing symptoms such as decreased libido, depression, breast tenderness, increased appetite, or migraines. The appetite effects are used advantageously in progesterone analogs for individuals with cachexia or anorexia. Patients should also be asked about over-the-counter and herbal supplements, such as essential oils and sublingual progesterone supplements.

Question 79

straight leg raising test

Answer 79

The straight leg raising test is used to evaluate nerve root compression, which is suggested by this patient’s back pain and radiculopathy. The nurse practitioner will place the patient in a comfortable supine position, with the head and pelvis flat. With the knee fully extended, the affected leg should be lifted off of the examination table to the point of pain in 1 or both legs. The leg should be supported with the nurse practitioner’s hand under the heel. The angle formed by the leg when pain is felt is noted. Some patients may experience pain with an angle of 70–90 degrees due to hamstring tightness, but the pain involves only the posterior thigh, compared with sciatic pain, which can extend all the way down the leg to the foot. In the presence of sciatica or nerve root pathology, the patient will experience an intense pain shooting down the posterior thigh, often into the leg. The straight leg raising test stretches the L5 and S1 nerve roots. An abnormal straight leg raising test, which is indicated by the shooting pain in the hip and leg, suggests a pathology of the L5 or S1 nerve root.