Midterm

Question 1

An example of appropriate secondary prevention for a 55-year-old man with type 2 diabetes mellitus is:

A. Ordering an HbA1C
B. Teaching back on insulin injection
C. Ordering colonoscopy for cancer screening
D. Influenza vaccine

Answer 1

C. Ordering colonoscopy for cancer screening

Primary prevention is intervening before a health event happens. Secondary prevention is screening to identify a disease before signs and symptoms appear. Tertiary prevention is trying to slow or stop disease progression.

Question 2

USPTF recommends screening adults age 35-70 years who are overweight or obese for abnormal blood glucose.

True
False

Answer 2

True

USPTF recommends screening for prediabetes and type 2 diabetes in adults aged 35-70 who are overweight (BMI ≥25) or have obesity (BMI ≥30). Evidence on the optimal screening interval for adults with an initial normal glucose test result is limited, but studies suggest that screening every 3 years may be a reasonable approach.

Question 3

An example of appropriate tertiary prevention for a 78-year-old woman with COPD is:

A. Obtaining a pap smear.
B. Ordering home oxygen therapy for hypoxia.
C. Administering pneumococcal vaccine.
D. Ordering abdominal aortic aneurysm screening.

Answer 3

B. Ordering home oxygen therapy for hypoxia.

Primary prevention is intervening before a health event happens. Secondary prevention is screening to identify a disease before signs and symptoms appear. Tertiary prevention is trying to slow or stop disease progression.

Question 4

Which of the following individuals should be vaccinated with PPSV23 today?

A. 67-year-old received his PCV 15 one year ago
B. 41-year-old with moderate persistent asthma, with no vaccinations prior
C. 50-year-old woman with a sedentary lifestyle
D. 48-year-old who is a cigarette smoker and received PCV 20 this past Fall

Answer 4

A. 67-year-old received his PCV 15 one year ago

For those who have never received any pneumococcal conjugate vaccine, CDC recommends PCV15 or PCV20 for adults 65 years or older and adults 19 through 64 years old with certain medical conditions or risk factors. If PCV15 is used, this should be followed by a dose of PPSV23 one year later, a minimum interval of 8 weeks can be considered in certain circumstances. If PCV20 is used, a dose of PPSV23 is NOT indicated.

Question 5

Which of the following is true in a 30-year-old adult who has no documentation of prior MMR vaccination?

A. It is contraindicated in anyone with a history of egg allergy.
B. Order rubella, measles, and mumps titers.
C. Revaccination of an already vaccinated person is associated with significant allergic reactions.
D. Administer two doses of MMR vaccine, 28 days apart.

 

Answer 5

D. Administer two doses of MMR vaccine, 28 days apart.

Adults who do not have presumptive evidence of immunityLinks to an external site. should get at least one dose of MMR vaccine. Certain adults may need 2 doses. Adults who are going to be in a setting that poses a high risk for measles or mumps transmission should make sure they have had two doses separated by at least 28 days. These adults include: 
-students at post-high school education institutions
-healthcare personnel
-international travelers

Question 6

Which of the following would be appropriate for a 65-year-old man who has a 35 pack-per-year smoking history who quit three years ago? Select all that apply:

A. Order routine screening mammography
B. Order abdominal aortic aneurysm screening
C. Order low-dose CT for lung cancer screening
D. Order routine osteoporosis screening

Answer 6

B. Order abdominal aortic aneurysm screening

The USPSTF recommends 1-time screening for abdominal aortic aneurysm (AAA) with ultrasonography in men aged 65 to 75 years who have ever smoked.

B. Order abdominal aortic aneurysm screening

The USPSTF recommends annual screening for lung cancer with low-dose computed tomography (LDCT) in adults aged 50 to 80 years who have a 20 pack-year smoking history and currently smoke or have quit within the past 15 years. Screening should be discontinued once a person has not smoked for 15 years or develops a health problem that substantially limits life expectancy or the ability or willingness to have curative lung surgery.

Question 7

All women planning or capable of becoming pregnant should take a daily supplement with 0.4-0.8 mg of folic acid.

True
False

Answer 7

True

Half of all pregnancies in the United States are unplanned.  Daily folic acid supplementation in the periconceptional period can prevent neural tube defects. The USPSTF recommends that all people who are planning or capable of pregnancy take a daily supplement containing 0.4 to 0.8 mg (400 to 800 µg) of folic acid.

Question 8

Which woman should be offered routine osteoporosis screening? Select all that apply:

A. Women age 65 and over
B. Women under age 65 whose 10-year fracture risk is greater than that of a 65-year-old, white woman without additional fracture risks
C. Women age 40 and over
D. Women under age 60 whose 10-year fracture risk is greater than that of a 60-year-old, white woman without additional fracture risks

 

Answer 8

A. Women age 65 and over

The USPSTF recommends screening for osteoporosis with bone measurement testing to prevent osteoporotic fractures in women 65 years and older. The USPSTF recommends screening for osteoporosis with bone measurement testing to prevent osteoporotic fractures in postmenopausal women younger than 65 years who are at increased risk of osteoporosis, as determined by a formal clinical risk assessment tool.

B. Women under age 65 whose 10-year fracture risk is greater than that of a 65-year-old, white woman without additional fracture risks

The USPSTF recommends screening for osteoporosis with bone measurement testing to prevent osteoporotic fractures in women 65 years and older. The USPSTF recommends screening for osteoporosis with bone measurement testing to prevent osteoporotic fractures in postmenopausal women younger than 65 years who are at increased risk of osteoporosis, as determined by a formal clinical risk assessment tool.

Question 9

The nurse practitioner should stop screening average risk women older than 65 years old for cervical cancer who have had 2 consecutive negative cytology plus HPV test results within the last 10 years, with the most recent negative results within the last five year.

True
False

Answer 9

True

The USPSTF recommends against screening for cervical cancer in women older than 65 years who have had adequate prior screening and are not otherwise at high risk for cervical cancer. Adequate prior screening as 3 consecutive negative cytology results or 2 consecutive negative co-testing results within 10 years before stopping screening, with the most recent test occurring within 5 years. Once screening has stopped, it should not resume in women older than 65 years, even if they report having a new sexual partner.

Question 10

Which of the following is true:

A. Clinicians should offer screen for colorectal cancer in average-risk adults starting at age 45.
B. Clinicians should stop routine screening for colorectal cancer in adults at age 70.
C. Colorectal cancer screening with fecal immunochemical testing or high-sensitivity guaiac-based fecal occult blood testing should be done every 5 years.
D. Colorectal cancer screening with flexible sigmoidoscopy should be done every 10 years.

 

Answer 10

A. Clinicians should offer screen for colorectal cancer in average-risk adults starting at age 45.

The USPSTF recommends offering colorectal cancer screening starting at age 45 years. In adults aged 76 to 85 years, the age at which the balance of benefits and harms of colorectal cancer screening becomes less favorable and screening should be stopped varies based on a patient’s health status. High-sensitivity gFOBT or FIT screening interval is every year, flexible sigmoidoscopy every 5 years, flexible sigmoidoscopy every 10 years with FIT every year, and colonoscopy screening every 10 years. 

Question 11

Which of the following is true:

A. Adults who have previously had Zostavax vaccine do not need to receive the Shingrix vaccine.
B. Shingrix is a two-dose vaccine that should be separated by 2-6 months.
C. Healthy adults over the age of 60 are eligible for Shingrix.
D. Shingrix should not be administered if your patient has already had shingles.

 

Answer 11

B. Shingrix is a two-dose vaccine that should be separated by 2-6 months.

Shingrix (recombinant zoster vaccine) is recommended by the Centers for Disease Control and Prevention (CDC) for adults age 50 and older and in adults 19+ with a weakened immune system. Shingrix is a nonliving vaccine made of a virus component. It’s given in two doses, with 2-6 months between doses. People who have had shingles in the past and people who have received varicella (chickenpox) vaccine are recommended to get recombinant shingles vaccine. There is no specific amount of time you need to wait before administering Shingrix to patients who have had herpes zoster. However, you should not give Shingrix to patients who are experiencing an acute episode of herpes zoster. The vaccine is also recommended for people who have already gotten another type of shingles vaccine, the live shingles vaccine (Zostavax). Zostavax is no longer available in the US.

Question 12

USPTF recommends screening for high blood pressure in those ages 18 and above and recommends obtaining measurement outside of the clinical setting for diagnostic confirmation.

True
False

 

Answer 12

True

The USPSTF recommends screening for hypertension in adults 18 years or older with office blood pressure measurement (OBPM). The USPSTF recommends obtaining blood pressure measurements outside of the clinical setting for diagnostic confirmation before starting treatment.

Question 13

USPTF recommends screening with resting and/or exercise electrocardiography to prevent cardiovascular events in adults at low risk and asymptomatic for cardiovascular disease.

True
False

 

Answer 13

False

The USPSTF recommends against screening with resting or exercise electrocardiography (ECG) to prevent cardiovascular disease (CVD) events in asymptomatic adults at low risk of CVD events.

Question 14

T.B is a 39 year-old person with a vagina and cervix. T.B. has a BMI of 31 kg/m2. T.B. has not seen any provider in the last seven years. Which of the following should the family nurse practitioner offer T.B.? Select all that apply:

A. Screen for prediabetes/diabetes with A1C, or fasting plasma blood glucose, or 3-hour plasma glucose during 75 g OGTT, or random plasma glucose.
B. Cervical cancer screening
C. Folic acid 0.4 to 0.8 mg daily.
D. Consider discussing if HPV vaccination if T.B. is likely to benefit

 

Answer 14

A. Screen for prediabetes/diabetes with A1C, or fasting plasma blood glucose, or 3-hour plasma glucose during 75 g OGTT, or random plasma glucose.
B. Cervical cancer screening
C. Folic acid 0.4 to 0.8 mg daily.
D. Consider discussing if HPV vaccination if T.B. is likely to benefit

The USPSTF recommends screening for prediabetes and type 2 diabetes in adults aged 35 to 70 years who have overweight or obesity (BMI ≥30). For women aged 30 to 65 years, the USPSTF recommends screening every 3 years with cervical cytology alone, every 5 years with high-risk human papillomavirus (hrHPV) testing alone, or every 5 years with hrHPV testing in combination with cytology (cotesting). The USPSTF recommends that all people who are planning or capable of pregnancy take a daily supplement containing 0.4 to 0.8 mg (400 to 800 µg) of folic acid. CDC recommends HPV vaccination for children at ages 11 or 12 years to protect against HPV infections that can cause some cancers later in life. Vaccination can be started at age 9 and is recommended through age 26 years for those who did not get adequately vaccinated when they were younger. For adults ages 27 through 45 years, clinicians can consider discussing HPV vaccination with people who are most likely to benefit. HPV vaccination does not need to be discussed with most  adults over age 26 years.

Question 15

Your patient is an 80-year-old woman with pre-diabetes, stage II hypertension, and mild cognitive impairment. She lives in senior housing and lives a very active lifestyle including volunteer work at the local public library and is part of a knitting circle that donates blankets to the local hospital for newborns and patients who are actively dying as part of their comfort kit. Which of the following should be considered in screening for breast cancer for her?

A. Mammography has not been shown to decrease breast cancer mortality.
B. Screening annually decreases the 10-year risk of false-positive results by 50%.
C. Consider her 10-year life expectancy when weighing risks and benefits of breast cancer screening.
D. Regardless of health and function, all older adults benefit from surgery, chemotherapy, and radiation.

 

Answer 15

C. Consider her 10-year life expectancy when weighing risks and benefits of breast cancer screening.

The USPSTF recommends biennial screening mammography for women aged 50 to 74 years. Women who place a higher value on the potential benefit than the potential harms may choose to begin biennial screening between the ages of 40 and 49 years. Of all of the age groups, women aged 60 to 69 years are most likely to avoid breast cancer death through mammography screening. Mammography screening may potentially continue to offer a net benefit after age 74 years among women with no or low comorbidity. In individuals 75+ most guidelines encourage a person-specific shared-decision making approach that factors overall health and life expectancy. 

Question 16

You are working in college health center. Your patient is a 19-year-old woman who became sexually active with male partners at the age of 15. Which of the following is the most appropriate action for the nurse practitioner to recommend?

A. Pap test with co-testing.
B. Chlamydia and gonorrhea screening.
C. Advise against HPV vaccination, as she is already sexually active.
D. Advise for tetanus vaccine every 5 years.

Answer 16

B. Chlamydia and gonorrhea screening.

Question 17

Tobacco is the largest single preventable cause of illness and premature death in the US.

True
False

Answer 17

True

Smoking is the leading cause of preventable death. Worldwide, tobacco use causes more than 7 million deaths per year. If the pattern of smoking all over the globe doesn’t change, more than 8 million people a year will die from diseases related to tobacco use by 2030. (from the CDC)

Question 18

All men over the age of 50 should be screened for prostate cancer with an annual PSA.

True
False

 

Answer 18

False

For men aged 55 to 69 years, the decision to undergo periodic prostate-specific antigen (PSA)-based screening for prostate cancer should be an individual one. The USPSTF recommends against PSA-based screening for prostate cancer in men 70 years and older. The American Urological Association recommends against routine screening in men over the age of 70 + or any man with less than a 10-15 year life expectancy. The AUA says that some men over the age of 70 with excellent health may benefit from prostate cancer screening.

Question 19

Which of the following is true about the medical homes that provide care? Select all that apply:

A. Medical homes provide chronic care.
B. Medical homes provide primary care.
C. Is patient centered.
D. Is committed to quality and safety.

 

Answer 19

A. Medical homes provide chronic care.

The primary care medical home is accountable for meeting the majority of each patient’s physical and mental health care needs, including prevention and wellness, acute care, and chronic care. The primary care medical home is patient-centered, providing health care that is relationship-based with an orientation toward the whole person. The primary care medical home demonstrates a commitment to quality and quality improvement by ongoing engagement in activities such as using evidence-based medicine and clinical decision-support tools to guide shared decision making with patients and families, engaging in performance measurement and improvement, measuring and responding to patient experiences and patient satisfaction, and practicing population health management. Sharing robust quality and safety data and improvement activities publicly is also an important marker of a system-level commitment to quality.

B. Medical homes provide primary care.

The primary care medical home is accountable for meeting the majority of each patient’s physical and mental health care needs, including prevention and wellness, acute care, and chronic care. The primary care medical home is patient-centered, providing health care that is relationship-based with an orientation toward the whole person. The primary care medical home demonstrates a commitment to quality and quality improvement by ongoing engagement in activities such as using evidence-based medicine and clinical decision-support tools to guide shared decision making with patients and families, engaging in performance measurement and improvement, measuring and responding to patient experiences and patient satisfaction, and practicing population health management. Sharing robust quality and safety data and improvement activities publicly is also an important marker of a system-level commitment to quality.

C. Is patient centered.

The primary care medical home is accountable for meeting the majority of each patient’s physical and mental health care needs, including prevention and wellness, acute care, and chronic care. The primary care medical home is patient-centered, providing health care that is relationship-based with an orientation toward the whole person. The primary care medical home demonstrates a commitment to quality and quality improvement by ongoing engagement in activities such as using evidence-based medicine and clinical decision-support tools to guide shared decision making with patients and families, engaging in performance measurement and improvement, measuring and responding to patient experiences and patient satisfaction, and practicing population health management. Sharing robust quality and safety data and improvement activities publicly is also an important marker of a system-level commitment to quality.

D. Is committed to quality and safety.

The primary care medical home is accountable for meeting the majority of each patient’s physical and mental health care needs, including prevention and wellness, acute care, and chronic care. The primary care medical home is patient-centered, providing health care that is relationship-based with an orientation toward the whole person. The primary care medical home demonstrates a commitment to quality and quality improvement by ongoing engagement in activities such as using evidence-based medicine and clinical decision-support tools to guide shared decision making with patients and families, engaging in performance measurement and improvement, measuring and responding to patient experiences and patient satisfaction, and practicing population health management. Sharing robust quality and safety data and improvement activities publicly is also an important marker of a system-level commitment to quality.

Question 20

Which of the following is the best definition of family:

A. Family is defined as people residing in the same household.
B. Family is defined as people bonded by marriage or common DNA.
C. Family is who the person says it is.
D. Family is defined by either blood or adoption.

Answer 20

C. Family is who the person says it is.

Definitions of family can differ. The definition has major impact on people’s lives and can impact access to health and life insurance, educational, recreational, and mental health services. A definition that is inclusive of unmarried couples, long-term foster families, estranged/non-custodial parents, etc. can all test the definitions that use DNA, living in the same residence, legal marriage, etc. to define families. 

Question 21

In considering the impact of family on health care, the FNP is aware that:

A. The family has a significant impact on the health and well-being of its individual members
B. Family members develop according to an established pattern
C. Family is considered only in cases of chronic illness
D. The family structure is a consistent and statis phenomenon.

Answer 21

A. The family has a significant impact on the health and well-being of its individual members

Question 22

Which of the following are considered first-line pharmacological therapy for stage 1 hypertension? Select all that apply:

A. Thiazide diuretics
B. Calcium channel blockers
C. ACE inhibitors
D. ARBs

Answer 22

A. Thiazide diuretics
B. Calcium channel blockers
C. ACE inhibitors
D. ARBs

Initial first-line therapy for stage 1 hypertension includes thiazide diuretics, CCBs, and ACE inhibitors or ARBs.

Question 23

Two first-line antihypertensives are recommended in stage 2 hypertension and if the average blood pressure is greater than 20/10 above the target blood pressure.

True
False

Answer 23

True

Two first-line drugs of different classes are recommended with stage 2 hypertension and average BP of 20/10 mm Hg above the BP target. 

Question 24

In an otherwise healthy adult, under the age of 60 years, anti-hypertensive pharmacological management should be considered when BP is:

A. > 140/90
B. > 130/80
C. >120/70
D. >100/60

Answer 24

A. > 140/90

Normal BP is defined as <120/<80 mm Hg; elevated BP 120-129/<80 mm Hg; hypertension stage 1 is 130-139 or 80-89 mm Hg, and hypertension stage 2 is ≥140 or ≥90 mm Hg. Prior to labeling a person with hypertension, it is important to use an average based on ≥2 readings obtained on ≥2 occasions to estimate the individual’s level of BP. Out-of-office and self-monitoring of BP measurements are recommended to confirm the diagnosis of hypertension and for titration of BP-lowering medication. Use of BP-lowering medication is also recommended for primary prevention of CVD in adults with no history of CVD and with an estimated 10-year ASCVD risk <10% and a SBP ≥140 mm Hg or a DBP ≥90 mm Hg.

Question 25

In a patient who is black and has elevated blood pressure, but is otherwise healthy, which class of antihypertensive should the NP consider?

A. Ace Inhibitor
B. ARB
C. Calcium channel blocker
D. Beta Blocker

Answer 25

C. Calcium channel blocker

In African American adults with hypertension but without HF or CKD, including those with DM, initial antihypertensive treatment should include a thiazide-type diuretic or CCB. Two or more antihypertensive medications are recommended to achieve a BP target of <130/80 mm Hg in most adults, especially in African American adults, with hypertension.

Question 26

Individuals with chronic kidney disease and diabetes are at increased risk for cardiovascular events.

True
False

Answer 26

True

Question 27

In a patient with hypertension and stage 3 chronic kidney disease, which class of antihypertensives should the NP consider?

A. Ace Inhibitor
B. Vasodilator
C. Calcium channel blocker
D. Beta Blocker

Answer 27

A. Ace Inhibitor

For most patients with chronic kidney disease, BP goal should be <130/80 mm Hg (JNC 8). In those with stage 3 or higher CKD or stage 1 or 2 CKD with albuminuria (>300 mg/day), treatment with an ACE inhibitor is reasonable to slow progression of kidney disease. An ARB is reasonable if an ACE inhibitor is not tolerated. KDIGO 2021 Blood Pressure in CKD Guideline suggests that adults with high BP and CKD be treated to a target systolic blood pressure (SBP) of <120 mm Hg. 

Question 28

In addition to an ACEI or ARB, in HFrEF, which drug would the NP select to manage hypertension?

A. Diltiazem
B. Naproxen
C. Verapamil
D. Metoprolol succinate

Answer 28

D. Metoprolol succinate

Avoid non-dihydropyridine CCB (diltiazem, verapamil) in HFrEF. NSAIDs can raise blood pressure. Preferred BBs are metoprolol succinate, bisoprolol, and carvedilol.

Question 29

All people identified with elevated blood pressure should employ healthy heart lifestyle modifications.

True
False

Answer 29

True

1 kg weight loss can reduce SBP by 1 mmHg. Heart health eating, like DASH dietary pattern can reduce SBP by 11 mmHg. Reducing dietary sodium by 25% or 1,000 mg/day to reduce SBP by 5 mmHg. Increasing dietary potassium (e.g., 4 to 5 servings of fruits and vegetables/day). A structured exercise program of 150 min. aerobic activity/week can reduce SBP by 5 mmHg. Reduce alcohol intake to one (women) or two (men) standard drink(s) per day to reduce blood pressure.

Question 30

George Jonas is a 65-year old man who is new to your practice. He has a history of hypertension. Mr. Jonas takes Tums for occasional heartburn and Tumeric for osteoarthritis in his knee. Otherwise, he has no other health history and is lifelong non-smoker and non-drinker. Which of the following would the nurse practitioner consider for his care: select all that apply:

A. Order PCV20 or PCV15 followed by PPSV23 within one year
B. Calculate a 10-year risk of ASCVD
C. Order routine abdominal aortic aneurysm screening
D. SBP treatment goal of <130 mm Hg

Answer 30

A. Order PCV20 or PCV15 followed by PPSV23 within one year.

For those who have never received any pneumococcal conjugate vaccine, CDC recommends PCV15 or PCV20 for adults 65 years or older. 

B. Calculate a 10-year risk of ASCVD

A precise estimation of the absolute risk for a first ASCVD event is desirable when making treatment recommendations for a specific individual.

D. SBP treatment goal of <130 mm Hg

For adults with confirmed hypertension, without additional markers of increased CVD risk, a BP target of less than 130/80 mm Hg may be reasonable. 

Question 31

When possible, an out of office blood pressure reading should be obtained for the diagnosis of hypertension.

True
False

Answer 31

True

Prior to diagnosing a person with hypertension, it is important to use an average based on ≥2 readings obtained on ≥2 occasions to estimate the individual’s level of BP. Out-of-office and self-monitoring of BP measurements are recommended to confirm the diagnosis of hypertension.

Question 32

Which patient should the nurse practitioner prioritize initiating anti-hypertensive pharmacological therapy today?

A. A 39-year-old with the following blood pressure readings: 153/89 (office) and 145/90 (home reading average).

B. An 82-year-old with Parkinson’s disease dementia who lives in a memory care unit and has the following blood pressure readings: 143/89 (office) and 140/85 (SNF average readings).

C. A 46-year-old with the following blood pressure reading: 129/70 (office)

D. A 61-year old with the following blood pressure reading: 141/82

Answer 32

A. A 39-year-old with the following blood pressure readings: 153/89 (office) and 145/90 (home reading average).

Adults with stage 2 hypertension should be evaluated by a primary care provider within 1 month of initial diagnosis, and be treated with a combination of nonpharmacologic therapy and 2 antihypertensive drugs of different classes with repeat BP evaluation in 1 month. In low-risk adults with elevated BP or stage 1 hypertension with low ASCVD risk, BP should be repeated after 3-6 months of nonpharmacologic therapy. In octogenarians, evaluation for adding medications to lower blood pressure requires a more robust assessment that will include functional and frailty assessments.  

Question 33

What is the most common presenting symptom in arrhythmias?

A. Palpitations
B. Syncope
C. Cough
D. Headache

Answer 33

A. Palpitations

Palpitations are a common complaint in primary care and can be associated with very benign or life-threatening arrhythmias. Symptoms will guide the clinical actions of the NP.  Syncope is associated with hemodynamically significant arrhythmias. Arrhythmias can have unusual presenting symptoms like tinnitus and abdominal pain.

Question 33

USPTF recommends individual decision-making regarding low-dose aspirin in adults age 40-59 with a 10% or greater CVD risk for the primary prevention of cardiovascular disease and are not at increased risk for GI bleeding or have a life expectancy of under ten years.

True
False

Answer 33

True

Question 34

Which of the following would be an indication for immediate referral to the emergency room in a patient presenting with a newly discovered atrial tachycardia:

A. CHA2DS2-VASc score of 2
B. Fatigue
C. Blood pressure 83/45
D. Palpitations

 

Answer 34

C. Blood pressure 83/45

Initial triage of this patient should be for clinical stability. Patients who are hemodynamically or clinically unstable should not be evaluated in the primary care office. The NP is looking for things like hypotension, shortness of breath, chest pain suggestive of coronary ischemia, shock, and/or decreased level of consciousness. Palpitations are frequently reported in atrial tachycardia. Palpitations are usually benign, but should be investigated to make sure they are not part of a life-threatening arrhythmia. CHA2DS2-VASc score, is used in estimating the risk of stroke in non-rheumatic atrial fibrillation, this prediction tool helps clinicians in deciding on oral anticoagulation and risk for bleeding in patients. 

Question 35

Non-fasting plasma lipid levels are acceptable in most patients when assessing baseline LDL-C levels for screening.

True
False

Answer 35

True

Testing can be done on fasting or non-fasting individuals. In some patients it is inconvenient to have them fast, and waiting can lead to inaction. The NP wants to consider person-specific indicators that may guide them towards fasting, like a family history of hyperlipidemia. In adults who are 20 years of age or older and in whom an initial nonfasting lipid profile reveals a triglycerides level of 400 mg/dL or higher (‡4.5 mmol/L) repeat lipid profile in the fasting state should be performed for assessment of fasting triglyceride levels and baseline LDL-C

Question 36

Which statement is correct:

  

A, High-intensity statin therapy typically lowers LDL-C levels by >50%. An example of high-intensity statin therapy is Simvastatin 10 mg.

B. Niacin and fibrates typically lower LDL-C levels by 30-40%.

C. In the United States, hypertension accounts for more ASCVD deaths than any other modifiable risk factor

D. The most common type of cardiovascular disease in people with T2DM is stroke.

Answer 36

C. In the United States, hypertension accounts for more ASCVD deaths than any other modifiable risk factor

In the United States, hypertension accounts for more ASCVD deaths than any other modifiable risk factor. 20 mm Hg higher SBP and 10 mm Hg higher DBP were each associated with a doubling in the risk of death from stroke, heart disease, or other vascular disease. The most common cardiovascular disease in people with T2DM is coronary heart disease. Niacin is not addressed in current guidelines and is difficult to use because of flushing, hepatotoxicity, etc. Fibrates mildly increase LDL-C, they are mostly used to lower serum triglyceride level for preventing pancreatitis.  Moderate intensity Simvastatin is 20 to 40 mg once daily in the evening and reduces LDL-C by 30% to 49%. 

Question 37

Which of the following is a red flag finding peripheral artery disease?

A. Exertional leg symptoms
B. Impaired walking function
C. Resting pain in leg(s) that is worse when laying in bed
D. Cramping in leg during walking

Answer 37

C. Resting pain in leg(s) that is worse when laying in bed

Lower extremity pain is the predominant symptom in patients with PAD and is due to varying degrees of ischemia. Patients with PAD may complain of pain in the calf, thigh, or buttock brought on with activity and relieved with rest (ie, intermittent claudication), atypical leg pain, or constant pain (ie, ischemic rest pain). Chronic extremity ischemia is long-standing and is typically located in the forefoot and often aggravated by elevation and relieved by dependency, this should be evaluated by a vascular team.

Question 38

The diagnostic test for lower extremity PAD is resting ankle-brachial index (ABI).

True
False

Answer 38

True

For many patients, a history of risk factors or symptoms of PAD, in combination with physical examination findings, is sufficient to establish a diagnosis of PAD. For patients with atypical symptoms, or a pulse examination that is equivocal, the ankle-brachial index (with or without exercise) is diagnostic for arterial obstruction if ≤0.9. 

Question 39

In addition to healthy lifestyle interventions, statins are the cornerstone of lipid therapy.

True
False

Answer 39

True

The statins are considered a first-line drug therapy for dyslipidemias. Statin therapy is usually well tolerated and safe. Instead of the label statin intolerance, the current guidelines prefer the term, statin-associated side effects, because the large majority of patients are able to tolerate statin re-challenge with an alternative statin or alternative regimen, such as reduced dose or in combination with non-statins. Muscle symptoms are the most common adverse effects reported by statin users.

Question 40

Which of the following statements is true? Select all that apply:

A. Nonpharmacological therapy is the preferred therapy for adults with elevated BP and an appropriate first-line therapy for adults with stage 1 hypertension who have an estimated 10-year ASCVD risk of <10%. 

B. Initiate two antihypertensive agents (dual therapy) if diastolic is >20 mmHg or diastolic > 10 mmHg above goal.

C. In older adults use clinical judgement in BP lowering considering things like patient-specific functional levels and frailty

D. The patient evaluation in hypertension care should intentionally assess for target organ damage.

 

Answer 40

A. Nonpharmacological therapy is the preferred therapy for adults with elevated BP and an appropriate first-line therapy for adults with stage 1 hypertension who have an estimated 10-year ASCVD risk of <10%. 

Nonpharmacological interventions are effective in lowering BP, with the most important interventions being weight loss for overweight or obese patients with a heart healthy diet such as)Links to an external site., the DASH (Dietary Approaches to Stop Hypertension) diet, sodium reduction, potassium supplementation, increased physical activity, and a reduction in alcohol consumption. Men should be limited to no more than 2 and women no more than 1 standard alcohol drink(s) per day. The usual impact of each lifestyle change is a 4-5 mm Hg decrease in SBP and 2-4 mm Hg decrease in DBP; but diet low in sodium, saturated fat, and total fat and increase in fruits, vegetables, and grains may decrease SBP by approximately 11 mm Hg. Older adults should be evaluated for function and frailty in the decision to start anti-hypertensives and set target BP. 

B. Initiate two antihypertensive agents (dual therapy) if diastolic is >20 mmHg or diastolic > 10 mmHg above goal.

Single-drug therapy is unlikely to attain goal blood pressure in patients whose blood pressures are more than 20/10 mmHg above goal. In such patients, initial combination therapy using two drugs is recommended. 

C. In older adults use clinical judgement in BP lowering considering things like patient-specific functional levels and frailty.

 Older adults should be evaluated for function and frailty in the decision to start anti-hypertensives and set target BP. 

D. The patient evaluation in hypertension care should intentionally assess for target organ damage.

Certain comorbidities may affect clinical decision-making in hypertension. These include ischemic heart disease, HF with reduced ejection fraction, CKD (including renal transplantation), cerebrovascular disease, AF, PAD, DM, and metabolic syndrome. Guidelines generally recommends use of BP-lowering medications for secondary prevention of CVD in patients with clinical CVD (CHD, HF, and stroke) and an average BP ≥130/80 mm Hg and for primary prevention of CVD in adults with an estimated 10-year ASCVD risk of ≥10% and an average SBP ≥130 mm Hg or an average DBP ≥80 mm Hg.  

Question 41

Which of the following is most likely the cause of secondary hypertension?

A. Obstructive sleep apnea
B. Cushing’s syndrome
C. Cortication of the aorta
D. Hypothyroidism

Answer 41

A. Obstructive sleep apnea

Secondary hypertension should be considered when there is a severe elevation of BP, pharmacologically resistant hypertension, sudden onset of hypertension, increased BP in patients with hypertension previously controlled on drug therapy, onset of diastolic hypertension in older adults, and target organ damage disproportionate to the duration or severity of the hypertension. Obstructive sleep apnea is associated with resistant hypertension, snoring, fitful sleep, breathing pauses during sleep, and daytime sleepiness. OSA is relatively common with a prevalence of 25-50%. Cushing’s syndrome (rapid weight gain, especially with central distribution, proximal muscle weakness, depression, hyperglycemia) and hypothyroidism (Dry skin, cold intolerance, constipation, hoarseness, weight gain) are not as common. Aortic coarctation (BP higher in upper extremities than in lower extremities, absent femoral pulses, continuous murmur over patient’s back, chest, or abdominal bruit) has a prevalence of < 0.1%. 

Question 42

Which of the following is not considered routine, or basic laboratory tests in primary hypertension?

A. Fasting blood sugar
B. Uric acid
C. Lipid profile
D. Complete blood count

Answer 42

B. Uric acid

Laboratory measurements should be obtained for all patients with a new diagnosis of hypertension to facilitate CVD risk factor profiling, establish a baseline for medication use, and screen for secondary causes of hypertension. Fasting blood glucose, complete blood count, lipid profile, serum creatinine with eGFR, serum sodium, potassium, calcium, thyroid-stimulating hormone, and urinalysis can all be helpful. Uric acid is helpful when investigating monosodium urate (MSU) crystal deposition diseases, such as gout or uric acid renal disease.

Question 43

Match the patient to the preferred antihypertensive dual therapy medication:

A. Patient who is black
B. Patient with heart failure and reduced ejection fraction
C. Patient with chronic kidney disease with proteinuria

1.  Treat with a beta blocker and an ACEI or ARB             
2. ACEI or ARB plus a thiazide diuretic or a calcium channel blocker 
3. At least one agent should be a calcium channel blocker or thiazide diuretic.  

 

             

Answer 43

A. Patient who is black
          3. At least one agent should be a calcium channel blocker or thiazide diuretic.             

B. Patient with heart failure and reduced ejection fraction
            1.  Treat with a beta blocker and an ACEI or ARB             

C. Patient with chronic kidney disease with proteinuria
               2. ACEI or ARB plus a thiazide diuretic or a calcium channel blocker 

Question 44

You are seeing a 65-year-old patient with a chief complaint of a productive cough with purulent mucus, but no blood is noted. Your patient reports these symptoms have been ongoing for a few weeks, but they felt like they were starting to get better. However, two days ago they report a sudden onset of symptoms including fatigue, fever, chills, rigors, and dyspnea. They also report a pain in the chest with deep inhalations. What is the most likely diagnosis?

A. Asthma
B. COPD
C. Community acquired pneumonia
D. Common cold

Answer 44

C. Community acquired pneumonia

Community acquired pneumonia classically presents with acute onset fever, cough (with or without sputum production), and shortness of breath, pleuritic chest pain may be present. Classic signs and symptoms of asthma are intermittent dyspnea, cough, wheezing, and shortness of breath with an identifiable trigger. COPD (emphysema, chronic bronchitis, and chronic obstructive asthma) is an umbrella term for limited airflow. Over 200 viruses have been associated with the common cold (mild upper respiratory illness), the symptoms are; cough, nasal discharge, nasal obstruction, and a dry or “scratchy throat.” If there is a fever, it should be low-grade and you should not find lower respiratory signs likes rales.

Question 45

COPD is a disease of the lungs, so a simple validated tool that measures breathlessness is sufficient for symptom assessment.

True
False

 

Answer 45

False

COPD is considered to be a disease that is more complex than simple breathlessness. A comprehensive assessment of symptoms is now recommended using an evidence-based tool such as the COPD Assessment Test or the COPD Control Questionnaire. A comprehensive symptom assessment tools will ask about things like mood and sleep.

Question 46

You are seeing a 68-year-old patient with a chief complaint of a cough. The cough started a few years ago and is productive. The patient is a current smoker and has increased dyspnea with exertion. They deny fevers, chills, night sweats, edema, and unintentional weight loss. What is the most likely diagnosis?

A. Pertussis
B. COPD
C. Community acquired pneumonia
D. Common cold

Answer 46

B. COPD

Question 47

What is the most important intervention for the nurse practitioner in COPD?

A. Smoking cessation counseling and offer to prescribe assistive drug therapy

B. Obtaining serial FEV1 measurements for clinical monitoring

C. Pulse oximetry

D. Ensuring that they are started on an inhaler

Answer 47

A. Smoking cessation counseling and offer to prescribe assistive drug therapy

Question 48

Which of the following is consistent with COPD at all grades of the disease?

A. Dyspnea at rest
B. Dyspnea with exertion
C. FEV1 : FVC ratio < 0.70 post-bronchodilator
D. Hypoxemia

Answer 48

C. FEV1 : FVC ratio < 0.70 post-bronchodilator

Question 49

Your patient has chronic bronchitis. Which of the following is true?

A. Influenza vaccine reduces serious illness and death in patients with COPD

B. Individuals with COPD should not receive pneumococcal vaccine until age 65

C. Individuals age 50-80 who have a 20 pack per year smoking history and currently smoke or have quit within the last 15 years should have a chest x-ray for lung cancer screening

D. Medications for COPD have been shown to effectively modify the long-term decline in lung-function

Answer 49

A. Influenza vaccine reduces serious illness and death in patients with COPD

Question 50

Which of the following is the drug of choice for rapid relief from bronchoconstriction?

A. Fluticasone/Umeclidinium/Vilanterol DPI (Trelegy Ellipta) 100 mcg/62.5 mcg/25 mcg/inhalation 1 inhalation/day

B. Fluticasone propionate HFA MDI 44 mcg/puff 2 puffs BID

C. Salmeterol DPI (Serevent Diskus) 50 mcg/inhalation 1 inhalation BID

D. Levalbuterol HFA MDI 45 mcg/puff 1-2 puffs every 4-6 hours PRN

Answer 50

D. Levalbuterol HFA MDI 45 mcg/puff 1-2 puffs every 4-6 hours PRN

Question 51

Mr. C is a 55-year-old man who presents in your clinic today with a chief complaint of right hip pain. His pain symptoms began about 2-3 years ago. He wakes up feeling “stiff” and then moves about and feels better within minutes. He notices that the discomfort is worse with more walking or activity. He tells you that by the end of the day he “can really tell how much walking I did that day.” He describes the pain as a dull ache and says it gets better when he rests. Denies constitutional complaints. What is the most likely diagnosis?

A. Rheumatoid arthritis
B. Systemic lupus
C. Osteoarthritis
D. Gout

Answer 51

C. Osteoarthritis

Question 52

Inhaled bronchodilators are essential in COPD symptom management.

True
False

Answer 52

True

Question 53

A 70-year-old man is in your office this morning with a complaint of sudden onset of pain in his right big toe. He noticed the pain starting at about 4 AM. He has never had anything like this happen before. He denies any trauma to his foot and reports no falls. His temperature is 100.4 F. His right MTP joint is red, warm, and swollen. What is the most likely diagnosis?

 A. Rheumatoid arthritis
B. Systemic lupus
C. Osteoarthritis
D. Gout

Answer 53

D. Gout

Question 54

You are seeing a 25-year-old patient with a chief complaint of cough. Their cough is unproductive, intermittent, associated with wheezing, shortness of breath, and chest tightness. They recently moved into a new home and has started taking Zyrtec for their allergies. They also have a PMH significant for eczema. What is the most likely diagnosis?

A. Asthma
B. COPD
C. Community acquired pneumonia
D. Common cold

Answer 54

A. Asthma

Question 55

Which of the following is not an appropriate therapy use in the management of osteoarthritis in the knee:

A. Methotrexate 10 mg once weekly
B. Diclofenac 1% topical gel. Apply 4g to affected knee up to 4 times per day
C. Weight loss, if indicated
D. Tai Chi class at the local senior center

Answer 55

A. Methotrexate 10 mg once weekly

Methotrexate is a disease-modifying antirheumatic drug (DMARD). It is one of a group of drugs that changes the course of RA and can slow its effect on the joints. The Food and Drug Administration approved the drug as a first-line treatment for RA.

Question 56

You are seeing an 81-year-old patient in her adult family home. She tells you her hands hurt. You ask where and she points to her DIP joint in both hands. You notice bony enlargement of both DIPs and enlargement of the PIPs. The joints are hard and cool to the touch. She tells you she has a hard time turning doorknobs. What is the most likely diagnosis?

A. Rheumatoid arthritis
B. Systemic lupus
C. Osteoarthritis
D. Gout

Answer 56

C. Osteoarthritis

Question 57

Mrs. B is a 77 year-old patient of yours who comes to clinic today complaining of left knee pain. She had left knee arthroplasty done 12 months ago, but unfortunately had a complicated hospital course and thus has only returned home from her post-operative rehab two weeks ago. The onset of pain was sudden without any preceding event or trauma. She has a fever. The knee is painful to touch and is red, swollen and warm. The pain is at rest and also with movement and weight bearing. She has a past medical history of diabetes mellitus type 2, obesity, obstructive sleep apnea, and COPD. Which working diagnosis needs to be prioritized in this case?

A. Rheumatoid arthritis
B. Prosthetic joint infection
C. Gout
D. Patellofemoral syndrome

Answer 57

B. Prosthetic joint infection

Question 58

Which of the following is recommended in the diagnosis of community acquired pneumonia in adults?

A. Obtain a sputum culture

B. Prescribe corticosteroids

C. Obtain routine follow-up chest x-ray after treatment

D. Start empiric antibiotic treatment in clinically suspected and radiographically supported cases

Answer 58

D. Start empiric antibiotic treatment in clinically suspected and radiographically supported cases

Question 59

In an addition to clinical judgement, use a validated prediction tool, such the Pneumonia Severity Index (PSI) to determine need for hospitalization in community acquired pneumonia in adults.

True
False

Answer 59

True

Question 60

You have diagnosed your patient with community acquired pneumonia. Your patient has COPD. Which antibiotic regimen is the most appropriate?

A. Amoxicillin 1 g three times a day, for 10 days

B. Amoxicillin/clavulanate 875 mg/125 mg twice daily and Azithromycin 500 mg on day one and then 250 mg/day, for a minimum of 5 days

C. Azithromycin 500 mg daily, for 3 days

D. Nitrofurantoin 100 mg twice daily and Vancomycin 100 mg four times a day

Answer 60

B. Amoxicillin/clavulanate 875 mg/125 mg twice daily and Azithromycin 500 mg on day one and then 250 mg/day, for a minimum of 5 days

Question 61

In a patient with established COPD, when should a chest x-ray be obtained?

A. Routinely in all patients

B. When work of breathing is increased

C. When there is clinical suspicion for pneumonia

D. When there is mucus with cough

 

Answer 61

C. When there is clinical suspicion for pneumonia

Question 62

In patients with severe resting hypoxemia, the use of long-term oxygen administration (> 15 hours/day) is associated with increased survival in patients with COPD.

True
False

Answer 62

True

Question 63

Pulmonary rehabilitation reduces re-hospitalizations in patients who have had a recent exacerbation.

True
False

Answer 63

True

Question 64

The physical findings of significant orbital inflammation, tachycardia, myxedematous changes in the pretibial area, onycholysis in the fourth and fifth fingernail, hyperactive DTRs, a diffusely enlarged, smooth thyroid gland and thyroid bruits are most associated with which diagnosis?

A. Subacute thyroiditis
B. Hashimoto thyroiditis
C. Wolff-Parkinson-White Syndrome
D. Graves’ disease

 

Answer 64

D. Graves’ disease

Graves’ disease is an autoimmune disorder where the immune system attacks the thyroid. It occurs in about 1% of all Americans and is more common in women and people under the age of 40. Graves’ is one disorder that may result in hyperthyroidism. Symptoms range from mild to severe; enlarged thyroid gland, bulging eyes, thick and red skin often on shins or tops of the feet, fast/irregular heartbeat/palpitations, anxiety/irritability,  trembling hands, unintentional weight loss, heat sensitivity/hot flashes/perspiration, loss of scalp hair, loose frequent stools, change in menstrual cycle, skin changes, increased risk of miscarriage, loss of calcium from bones, sleep disturbance, There are three treatments for Graves’ disease: anti-thyroid drugs, radioiodine, or surgery.

Hashimoto’s thyroiditis (chronic autoimmune thyroiditis) is the most common cause of hypothyroidism in iodine-sufficient parts of the world. It can happen at any age, but is most common in women and older adults. While it eventually causes hypothyroidism, Hashimoto’s can initially lead to goiter and hyperthyroidism and then leads to hypothyroidism. Symptoms of hypothyroidism are variable but include; fatigue, cold intolerance, depression, weight gain, constipation, dry skin, myalgia, memory problems, puffy face, enlargement of the tongue, and menstrual irregularities. On physical exam you may find goiter, bradycardia, diastolic hypertension, delated DTRs.

Sub-acute thyroiditis is a transient, temporary cause of hypothyroidism. It is thought to be a post-viral inflammatory process. It is most common in young adulthood and middle age. Patient may have a history of recent URI. On palpitation the thyroid is slightly-moderately enlarged, asymmetrical, and tender to touch. Can have fever, fatigue, malaise, anorexia, and myalgia. But the neck pain and thyroid tenderness is a differentiating feature.

Wolffe-Parkinson-White syndrome is an infrequently found congenital heart problem that impacts the heart’s electrical system.  Symptoms include palpitations, lightheadedness/dizziness, syncope/pre-syncope, chest pain, and sudden cardiac arrest. 

Question 65

Select the diagnosis that best fits the following complaints: Nervousness, heat intolerance, unintentional weight loss, and palpitations.

A. Hyperthyroidism
B. Hypothyroidism
C. Type 2 Diabetes
D. Infectious mononucleosis

Answer 65

A. Hyperthyroidism

Hyperthyroidism classic presentation includes heat intolerance, tremor, palpitations, anxiety, weight loss, increased frequency of bowel movements, and shortness of breath. You may notice goiter on physical exam and skin changes such as loosening of the nails from the nail bed or softening of the nails, lid lag, atrial fibrillation (esp. in older adults), behavioral or personality changes. 

Hypothyroidism symptoms are variable but include; fatigue, cold intolerance, depression, weight gain, constipation, dry skin, myalgia, memory problems, puffy face, enlargement of the tongue, and menstrual irregularities. On physical exam you may find goiter, bradycardia, diastolic hypertension, delated DTRs.

Type 2 diabetes mellitus is the most common type of diabetes in adults. It is hyperglycemia due to insulin resistance and progressive impairment of insulin secretion. The majority of people are asymptomatic at diagnosis, without the classic symptoms of hyperglycemia; polyuria, polydipsia, nocturia, blurred vision,  and weight loss. 

Infectious mononucleosis is a widely spread Epstein-Barr virus. The classic triad is; fever, tonsillar pharyngitis, and lymphadenopathy. On exam you may see splenomegaly and rash. 

Question 66

Which of the following is NOT a true statement.

A. For most cases of mild to moderate hypothyroidism in an otherwise healthy adult under the age of 60, the initial dose is 1.6 mcg/kg/day

B. Elderly patients may need a higher starting dose of levothyroxine

C. Hypothyroidism generally has a more subtle presentation than hyperthyroidism

D. Normalization of clinical and metabolic end-points, such as menstrual cycles, are an indicator of euthyroid state

 

Answer 66

B. Elderly patients may need a higher starting dose of levothyroxine

Hypothyroidism is an underactive thyroid gland. It can present with very subtle symptoms. Untreated hypothyroidism can lead to many health problems like obesity, joint pain, infertility, and heart disease. Levothyroxine is a synthetic hormone (T4). Initial dosing is 1.6 mcg/kg/day. In adults over the age of 60, the initial dose is 25-50 mcg/day. It has a long-half life, so steady state concentrations are not achieved until about 6 weeks after treatment is started or is adjusted. Symptoms usually start to improve within two weeks, but recovery can take several months. Patient should take the medication consistently in the morning on an empty stomach, at least 30-60 minutes before food. Or consistently take at night 3-4 hours after last meal. Do not take levothyroxine within 4 hours of calcium or iron containing products, aluminum hydroxide, and bile acid sequestrants. 

Question 67

Marsha is 67-years-old with end-stage COPD who has been on chronic high-dose oral corticosteroids for the past few years. She recently started home remedy regimen of essential oils and micro-dosing various minerals. She stopped all prescribed medications. What condition is the nurse practitioner most concerned about for Marsha?

A. Myxedema crisis
B. Hypoparathyroidism
C. Adrenal insufficiency
D. Diabetes insipidus

 

Answer 67

C. Adrenal insufficiency

Chronic high-dose glucocorticoid therapy suppresses the hypothalamic-pituitary-adrenal function. Resulting adrenal insufficiency symptoms include fatigue, weakness, body aches, joint pain, nausea, loss of appetite, and lightheadedness. As a general rule, tapering is not needed when steroids are used for less than 3 weeks. When adrenal insufficiency is a concern (chronic or frequent steroid bursts), reduce the doses by 10%-20% every 1-2 weeks or slower for patients who have been on steroids for years or frail or has Cushingoid signs. You can also consider an ACTH stimulation test to check adrenal recovery before stopping. A myxedema crisis is very severe hypothyroidism that leads to changes in mental status, hypothermia, and other symptoms. It is the slowing of function in multiple organs and is a medical emergency. Hypoparathyroidism happens when the parathyroid gland is destroyed. This leads to decreased parathyroid hormone and development of hypocalcemia.  Central diabetes insipidus is characterized by polyuria and is due to a decrease in anti-diuretic hormone. 

Question 68

Kendra, age 23, is preparing for her radioactive iodine therapy for Graves’ disease. Which test should she have before treatment?

A. Serum sodium
B. HbA1C
C. Beta human chorionic gonadotropin
D. Serum nicotine

Answer 68

C. Beta human chorionic gonadotropin

Radioiodine is a popular and effective treatment for Graves’ hyperthyroidism. Pregnancy and breastfeeding are absolute contraindications to radioiodine therapy. It should not be given for 6-12 weeks after breastfeeding is stopped. It is recommended that people who can get pregnant have a negative pregnancy test within 48 hours prior to treatment with radioiodine. 

Question 69

Which of the following is a true statement:

A. For older, frail adults a target HbA1C of <6%

B. Most patients will have a target HbA1C <7%

C. Statin therapy is contraindicated for people with type 2 diabetes

D. Obtain urinary albumin in every person with type 2 diabetes every 5 years

 

Answer 69

B. Most patients will have a target HbA1C <7%

An A1C goal for many nonpregnant adults of <7% (53 mmol/mol) without significant hypoglycemia is appropriate. Less stringent A1C goals (such as <8% [64 mmol/mol]) may be appropriate for patients with limited life expectancy or where the harms of treatment are greater than the benefits.

ASCVD is the leading cause of morbidity and mortality for people with diabetes. ASCVD is defined as coronary heart disease, cerebrovascular disease, or peripheral arterial disease. For patients of all ages with diabetes and ASCVD, high-intensity statin therapy should be added to lifestyle therapy. In adults not taking statins or other lipid-lowering therapy, it is reasonable to obtain a lipid profile at the time of diabetes diagnosis, at an initial medical evaluation, and every 5 years thereafter if under the age of 40 years, or more frequently if indicated.

Urinary albumin and eGFR should be assessed in patients with with type 2 diabetes at least annually. For patients with type 2 diabetes and CKD, consider use of an SGLT2 inhibitor additionally in patients with an eGFR ≥25 mL/min/1.73 m2 and urinary albumin ≥300 mg/g creatinine. SGLT2 inhibitors are recommended to reduce CKD progression and CV events.

Question 70

In a patient needing a second agent for their type 2 diabetes and they have established heart failure, which is the best choice?

A. GLP-1 agonist: liraglutide or semaglutide

B. SGLT2 inhibitor: empagliflozin or canagliflozin

C. DPP-4 inhibitor: saxagliptin

D. Thiazolidines: rosiglitazone

Answer 70

B. SGLT2 inhibitor: empagliflozin or canagliflozin

SGLT2 inhibitors are considered pillars of care in diabetes with heart failure. In CREDENCE trial, Canagliflozin (SGLT2) was associated with decreased risk for HF hospitalization and DECLARE-TIMI trial showed correlation with Dapagliflozin (SGLT2) and reduced HF hospitalizations.

Saxagliptin and Alogliptin (DPP-4 inhibitors) are associated with new or worsening heart failure, both are associated with increased risk of HF-related admissions. In the LEADER trial, Liraglutide (GLP-1 receptor agonist) did not reduce HF-related hospitalization. Rosiglitazone (thiazolidinediones) may exacerbate or cause congestive heart failure, it is not recommended for use in patients with symptomatic heart failure and its initiation is contraindicated in patients with NYHA class III or IV heart failure. 

Question 71

In a patient needing a second agent for their type 2 diabetes and they have established kidney disease with albuminuria, which is the best choice?

A. Sulfonylurea: Chlorpropamide

B. SGLT2 inhibitor: empagliflozin or canagliflozin

C. DPP-4 inhibitor: saxagliptin

D. Thiazolidines: rosiglitazone

Answer 71

B. SGLT2 inhibitor: empagliflozin or canagliflozin

Current guidelines from Kidney Disease Improving Global Outcomes (KDIGO) recommends that lifestyle therapy is the cornerstone of management for patients with T2D and CKD. In addition, metformin and SGLT2 inhibitor should be used in combination as first-line treatment for all or nearly all patients with an eGFR > 30 ml/min per 1.73 m2. For patients with type 2 diabetes and diabetic kidney disease, use of a sodium–glucose co-transporter 2 inhibitor in patients with an estimated glomerular filtration rate ≥25 mL/min/1.73 m2 and urinary albumin ≥300 mg/g creatinine is recommended to reduce chronic kidney disease progression and cardiovascular events.

A GLP-1 is recommended as additional line for glycemic control. 

Question 72

In a patient needing a second agent for their type 2 diabetes and they have established atherosclerotic heart disease, which is the best choice?

A. GLP-1 agonist: liraglutide or semaglutide

B. Sulfonylurea: tolbutamide

C. DPP-4 inhibitor: saxagliptin

D. Thiazolidines: rosiglitazone

Answer 72

A. GLP-1 agonist: liraglutide or semaglutide

In patients with type 2 diabetes and established ASCVD or multiple risk factors for ASCVD, a GLP-1 receptor agonist with demonstrated CV benefit is recommended to reduce the risk of major adverse cardiovascular events (MACE).

In patients with type 2 diabetes and established ASCVD, multiple ASCVD risk factors, or diabetic kidney disease (DKD), an SGLT2 inhibitor with demonstrated CV benefit is recommended to reduce the risk of MACE and/or HF hospitalization. Tolbutamide is associated with higher CV mortality. Rosiglitazone is associated with increased LDL.

Question 73

When trying to avoid hypoglycemia, which of these should the nurse practitioner not include in the treatment regimen?

A. GLP-1 (ex: liraglutide)

B. DPP-4 inhibitor (ex: sitagliptin)

C. Sulfonylureas (ex: glyburide)

D. Biguanides (ex: metformin)

Answer 73

C. Sulfonylureas (ex: glyburide)

Sulfonylureas decreases blood glucose concentrations by stimulating the release of insulin from pancreatic beta-cells thereby lowering blood glucose concentrations. 

GLP-1 inhibitors, DPP-4 inhibitors, and biguanides all have low risk of hypoglycemia when used as monotherapy.

Question 74

All patients with type 2 diabetes should be screened at diagnosis and then annually for for diabetic neuropathy through medical history and clinical tests. Which of the following will not prevent of slow the progression of diabetic nephropathy?

A. Glycemic control
B. Control of blood pressure
C. Use of opioids
D. Smoking cessation

Answer 74

C. Use of opioids

Glycemic control has a modest impact on the development of neuropathy in type 2 DM. Lifestyle interventions are considered essential care in prevention and slowing the progression of diabetic neuropathy. Up to 50% of diabetic peripheral neuropathy may be asymptomatic. If not recognized and if preventive foot care is not implemented, patients are at risk for injuries to their insensate feet. Neuropathic pain can be severe and can impact quality of life, limit mobility, and contribute to depression and social dysfunction. First line pain management includes pregabalin, duloxetine, or gabapentin, but do not directly alter the disease course. 

Question 75

A nurse practitioner is starting their patient on Metformin, which of the following is appropriate for patient teaching?

A. There is a risk for gastrointestinal side effects like diarrhea, nausea, flatulence, and abdominal discomfort with this medication

B. There is a high risk for hypoglycemia with metformin

C. You will need to check your blood sugars three times a day

D. It is associated with weight gain

Answer 75

A. There is a risk for gastrointestinal side effects like diarrhea, nausea, flatulence, and abdominal discomfort with this medication

The most common adverse reaction with metformin is GI upset (abdominal discomfort, diarrhea, flatulence, and nausea). Administer with a meal (to decrease GI upset). Immediate release tabs tend to have worse GI symptoms than extended release. Risk for hypoglycemia is low with metformin and the drug is associated with weight loss. Obtain HbA1c twice yearly in stable patients and quarterly in unstable patients.

Question 76

Your patient is 29 years old and has a BMI of 19.6. She has adopted lifestyle changes and you have tried oral hypoglycemics without much success. Which of the following is an appropriate next step?

A. Order HbA1C and fasting LDL

B. Order islet cell antibody with reflex to glutamic acid decarboxylase antibody

C. Increase home glucose testing to four times a day

D. Start on 81 mg of daily aspirin

Answer 76

B. Order islet cell antibody with reflex to glutamic acid decarboxylase antibody

Type 1 diabetes and type 2 diabetes are heterogeneous diseases in which clinical presentation and disease progression may vary considerably. T2DM is managed very differently from T1DM, making differentiation of  T1DM versus T2DM very important. Type 1 diabetes (due to autoimmune β-cell destruction, usually leading to absolute insulin deficiency, including latent autoimmune diabetes of adulthood). Type 2 diabetes (due to a progressive loss of adequate β-cell insulin secretion frequently on the background of insulin resistance).

Clinically, you will use clinical presentation and history in your differential. Sometimes you will use laboratory data to help you differentiate the diagnosis. T1DM is suggested by the presence of circulating, islet-specific pancreatic autoantibodies against glutamic acid decarboxylase 65 (GAD65), the 40K fragment of tyrosine phosphatase (IA2), insulin, and/or zinc transporter 8 (ZnT8), while high fasting insulin and C-peptide levels suggest T2DM. 

Question 77

Your patient, Mr. L has an HbA1C of 6%. According to ADA, when should you check the HbA1C again?

A. In six months
B. In one year
C. Every two years
D. Every 5 years

Answer 77

A. In six months

Assess glycemic status (A1C or other) at least two times a year in patients who are meeting treatment goals (and who have stable glycemic control). Monitor glycemic status at least quarterly and as needed in patients whose therapy has recently changed and/or who are not meeting glycemic goals. 

Question 78

Ms. W is in clinic today because she had her blood pressure read by at a community health event by the local EMS service. Her readings were 168/90 and 163/91. Today in clinic, her average reading is 162/87. Ms. W is on Metformin 1000 mg BID and Empagliflozin 25 mg daily. What is the best initial treatment for her elevated blood pressure?

A. Lisinopril 5 mg daily and Chlorthalidone 12.5 mg daily

B. Lisinopril 5 mg daily

C. Lisinopril 5 mg daily and Losartan 25mg once daily

D. Losartan 25 mg once daily

 

Answer 78

A. Lisinopril 5 mg daily and Chlorthalidone 12.5 mg daily

Normal BP is defined as <120/<80 mm Hg; elevated BP 120-129/<80 mm Hg; hypertension stage 1 is 130-139 or 80-89 mm Hg, and hypertension stage 2 is ≥140 or ≥90 mm Hg. In diabetes mellitus (DM) and hypertension, antihypertensive drug treatment should be initiated at a BP ≥130/80 mm Hg with a treatment goal of <130/80 mm Hg. Two first-line drugs of different classes are recommended with stage 2 hypertension and average BP of 20/10 mm Hg above the BP target.  In adults with DM and hypertension, all first-line classes of antihypertensive agents (i.e., diuretics, ACE inhibitors, ARBs, and CCBs) are useful and effective. ACE inhibitors or ARBs are renal protective and may be considered in the presence of albuminuria. Chlorthalidone (12.5-25 mg) is the preferred diuretic because of long half-life and proven reduction of CVD risk. When possible, patients found to have elevated blood pressure (≥140/90 mmHg) should have blood pressure confirmed using multiple readings, including measurements on a separate day, to diagnose hypertension.

Question 79

The blood test with the highest specificity and sensitivity in the evaluation of hyperthyroidism is:

A. Free T4 (Thyroxine)
B. T3 (Triiodothyronine)
C. TSH (Thyroid stimulating hormone)
D. Thyroperoxidase (TPO) antibodies

Answer 79

C. TSH (Thyroid stimulating hormone)

The diagnosis of hyperthyroidism is based upon thyroid function tests. In patients in whom there is a clinical suspicion of hyperthyroidism, the best initial test is serum TSH. All patients with primary hyperthyroidism have a low TSH. The serum TSH concentration alone cannot determine the degree of biochemical hyperthyroidism; serum free T4 and T3 are required to provide this information. However, in laboratories utilizing serum TSH assays with detection limits of 0.01 mU/L (third generation), most patients with overt hyperthyroidism have values <0.05 mU/L.

Question 80

Select the diagnosis that best fits the following complaints: fatigue, constipation, dry skin, and cold intolerance.

A. Hyperthyroidism
B. Hypothyroidism
C. Diabetes type 2
D. Mononucleosis

 

Answer 80

B. Hypothyroidism

Common symptoms of hypothyroidism include fatigue, cold intolerance, weight gain, constipation, dry skin, myalgia, and menstrual irregularities. The classic symptoms of hyperthyroidism include heat intolerance, tremor, palpitations, anxiety, weight loss despite a normal or increased appetite, increased frequency of bowel movements, and shortness of breath. Goiter is commonly found on physical examination. Type 2 diabetes is the most common type of diabetes in adults, it is commonly diagnosed from routine laboratory work, but the classic symptoms of hyperglycemia are; polyuria, polydipsia, nocturia, blurred vision, and weight loss. Mononucleosis is characterized by a triad of fever, tonsillar pharyngitis, and lymphadenopathy.

Question 81

When starting a patient on levothyroxine, clinical improvement can be seen within two weeks days and then typically levels off in about 4-6 weeks.

True
False

Answer 81

True

A patient will likely notice symptom improvements within 2-3 weeks of starting levothyroxine, but they do not achieve steady state until about 6 weeks post-initiation or dosage adjustment. In patients whose symptoms improve following initiation of therapy or after dose adjustment, you can then measure TSH response at 6 weeks and adjust dose as/if indicated. Once TSH levels are at goal, you can recheck levels at 4 to 6 months and then annually if they remain within the goal range. In people being treated with levothyroxine, the clinician is alert to heart rate, BP, new/worsening cardiac symptoms (eg, chest pain, palpitations, edema), clinical signs of hypo- and hyperthyroidism; bone mineral density (particularly with long-term use in postmenopausal people).

Question 82

Metformin is considered first line medication in Type 2 Diabetes

True
False

 

Answer 82

True

Metformin should be started at the time type 2 diabetes is diagnosed, unless contraindicated. Treatment is in combination with lifestyle modifications. The clinician should consider additional agents in circumstances, such as the patient has established or increased risk of cardiovascular or renal complications. Metformin is also indicated in the treatment of prediabetes in select patients, those with BMI ≥35 kg/m2, age <60 years, and patients with prior gestational diabetes mellitus, in whom lifestyle interventions fail to improve glycemic indices. 

Question 83

Metformin is contraindicated when GFR < 30 mL/min

True
False

Answer 83

  True

When eGFR is  30 to 45 mL/minute/1.73 m2, initiation of metformin is generally not recommended.  For patients who are currently on Metformin and tolerating well, metformin may be continued at a reduced dose up to a maximum of 500 mg twice daily with close monitoring of kidney function. At eGFR <30 mL/minute/1.73 m2 metformin is contraindicated.

Question 84

Which of the following is true about USPTF guidelines for screening for abnormal blood glucose? Select all that apply:

A. Ages 40-70 years old who are overweight or obese

B. People who are pregnant should be screened for diabetes at gestational week 24 or after

C. Limited to those with a 1st degree family member with kidney disease

D. Attempt lifestyle modifications before screening

Answer 84

A. Ages 40-70 years old who are overweight or obese

B. People who are pregnant should be screened for diabetes at gestational week 24 or after

The USPSTF recommends screening for prediabetes and type 2 diabetes in adults aged 35 to 70 years who have overweight or obesity. Screen for prediabetes and type 2 diabetes, and offer or refer patients with prediabetes to effective preventive interventions.

The USPTF recommends screening for gestational diabetes in asymptomatic pregnant persons at 24 weeks of gestation or after and screen adults aged 35 to 70 years for pre-diabetes and diabetes who are overweight or obese. The recommendations include referring appropriately for treatment and are not limited by family history. 

Question 85

When adding insulin to the treatment of type 2 diabetes, the nurse practitioner needs to stop the metformin.

True
False

 

Answer 85

False

Question 86

Which classes of antihyperglycemic medications are associated with weight loss? Select all that apply:

A. Thiazolidinediones
B. SGLT-2 Inhibitors
C. Sulfonylureas
D. GLP-1 RAs

Answer 86

B. SGLT-2 Inhibitors

SGLT-2 inhibitors promote renal excretion of glucose. SGLT-2 inhibitors decrease weight and blood pressure.

D. GLP-1 RAs

Glucagon-like peptide (GLP-1) receptor agonists are incretin hormones in which weight loss is common. Weight loss may be due, in part, to the effects of GLP-1 slowed gastric emptying.

Question 87

Advanced practice providers should avoid prescribing glyburide to older adult patients.

True
False

 

Answer 87

True

Glimepiride and glyburide are both on the Beer’s list of potentially harmful drugs in elderly because of prolonged, severe hypoglycemia.

Question 88

When the clinical diagnosis of hyperthyroidism is strongly suspected, the nurse practitioner may initially order a serum TSH and free T4

True
False

Answer 88

True

Question 89

When is consultation with an endocrinologist recommended when treating a person with hypothyroidism? Select all that apply:

A. Pregnancy or planning conception

B. Presence of goiter or nodule noted in the thyroid gland

C. Unable to achieve a hyperthyroid state with treatment regimen

D. Presence of other endocrine diseases

Answer 89

A. Pregnancy or planning conception

Hypothyroidism can have adverse effects on pregnancy outcomes. The diagnosis and/or management of thyroid disease in pregnancy requires an understanding of the changes in thyroid physiology and thyroid function tests that accompany pregnancy. Increased metabolic needs take place during pregnancy and changes occur in thyroid physiology reflected in altered function tests. Women with preexisting hypothyroidism who are planning to become pregnancy should have their thyroid hormone dose optimized preconception. Complications may occur and close monitoring is required. Thereby in treatment of a person with hypothyroidism a consultation with endocrinologist is recommended.

B. Presence of goiter or nodule noted in the thyroid gland

Clinical manifestations in a person with a goiter may be asymptomatic. Large goiter symptoms may be more severe resulting in obstruction due to progressive compression of the trachea or sudden enlargement secondary to hemorrhage into a nodule. Factors during assessment determine management. Thyroid nodules may be benign or suspicious for malignancy. Thyroid nodules commonly require periodic monitoring over intervals to assess for growth and/or worrisome features suggestive of malignancy. 

D. Presence of other endocrine diseases

The presence of other endocrine diseases often require an endocrinology consultation. Endocrinologists diagnose and treat complex conditions (e.g. metabolic, hormonal, diabetes, thyroid, infertility, growth, pituitary). Some conditions may go undetected, mimic other disorders, or rare but serious complications (e.g. tumor, malignancy).