Mod 7 Butarro Ch 185-194

Question 1

A patient has new-onset hypertension with a systolic blood pressure of 180 mm Hg. Which test will the provider order to diagnose this patient?

a. ACTH suppression testing
b. Adrenal antibody tests
c. Cortisol excretion studies
d. Fractionated metanephrine levels

Answer 1

d. Fractionated metanephrine levels

This patient may be experience signs of a pheochromocytoma adrenal tumor.
**hall mark symptoms is new sudden onset hypertension with systolic pressure >170 mm Hg.

diagnosed by a urine test that will show Fractionated metanephrine will be elevated when the diagnosis is confirmed.

Pheochromocyoma is one of the most common adrenal gland disorders treated by managing bp and surgical resection

other common adrenal disorders:
1. Addison Disease (primary adrenal insufficiency)
CAUSED BY: (autoimmune) destruction or injury of adrenal gland most common, pituitary tumors of TBIs, or high dose use of exogenous steroids
SX: hyperpigmentation and skin changes, dehydration, salt craving, weight loss, malaise, nauseam, abdominal pain, impaired memory
DX by: blood test show serum levels of ACTH High and serum cortisol levels low. may cause electrolyte problems AND adrenal antibody tests are performed as part of the evaluation for Addison’s disease.
TX: with steroids

2. Cushing Disease:
   CAUSED by suppression of the pituitary function that cased decrease in production of ACTH which then causes an over production of cortisol (tumor)
   DX serum acth low and high levels of cortisol, urine
   positive for cortisol >100mcg AND ACTH suppression testing and cortisol excretion studies are performed to diagnose an suppression testing
   SX: moon face, buffalo hump, strai, depression, weight gain, purpura, mild hypertension, dec libido, increase glucose, amenorrhea without pregnanct
   TX: fix underlying cause (like tumor)

Question 2

A patient has rapid weight gain, amenorrhea without pregnancy, and mild hypertension. Once confirmatory tests are performed, what is a possible treatment for this patient?

a. Antihypertensive therapy
b. Mineralocorticoid replacement
c. Oral hydrocortisone
d. Pituitary tumor resection

Answer 2

d. Pituitary tumor resection

This patient has symptoms of Cushing’s syndrome. When indicated, pituitary tumor resection is performed as the first choice.

Antihypertensive therapy is initiated in patients with pheochromocytoma.

Mineralocorticoids and glucocorticoids are given to patients with Addison’s disease.

Question 3

A patient has unexplained weight loss and the provider notes increased skin pigmentation on light-exposed skin folds along with darkened palmar creases. Which laboratory tests will the provider order? (Select all that apply.)

a. Serum ACTH
b. Serum cortisol
c. Serum electrolytes
d. TB skin testing
e. Urine cortisol

Answer 3

a. Serum ACTH
c. Serum electrolytes
d. TB skin testing

Addison Disease (primary adrenal insufficiency)
CAUSED BY: (autoimmune) destruction or injury of adrenal gland most common, pituitary tumors of TBIs, or high dose use of exogenous steroids
SX: hyperpigmentation and skin changes, dehydration, salt craving, weight loss, malaise, nauseam, abdominal pain, impaired memory
DX by: blood test show serum levels of ACTH High and serum cortisol levels low. may cause electrolyte problems (na and k AND adrenal antibody tests are performed as part of the evaluation for Addison’s disease.
TX: with steroids

This patient has symptoms of Addison’s disease. Serum ACTH will be elevated in patients with Addison’s disease. Hyponatremia and hyperkalemia may occur and are sometimes the initial finding.

TB skin testing is done to exclude tuberculosis typically symptoms are similar must r/o

Serum and urine cortisol levels are evaluated with Cushing’s syndrome is suspected.

Question 4

An obese patient has recurrent urinary tract infections and reports feeling tired most of the time. What initial diagnostic test will the provider order in the clinic at this visit?

a. C-peptide level
b. Hemoglobin A1C
c. Random serum glucose
d. Thyroid studies

Answer 4

b. Hemoglobin A1C

HbA1C, along with fasting plasma glucose or a 2-hour plasma glucose during an oral glucose tolerance test (OGTT), is diagnostic of diabetes.

This patient is probably not fasting, so a glucose level will not be helpful.

C-peptide levels help to distinguish type 1 from type 2 diabetes and may be performed after a diagnosis of diabetes is made and if there is uncertainty about the cause.

Thyroid studies are helpful in evaluating comorbidity.

Question 5

A patient diagnosed with type 2 diabetes mellitus becomes insulin dependent after a year of therapy with oral diabetes medications. When explaining this change in therapy, the provider will tell the patient

a. it is necessary because the patient cannot comply with the previous regimen.
b. that strict diet and exercise measures may be relaxed with insulin therapy.
c. the use of insulin therapy may be temporary.
d. this is because of the natural progression of the disease.

Answer 5

d. this is because of the natural progression of the disease.

Even after several years of therapy for type 2 DM well controlled with oral diabetic medications, diet, and exercise, the natural progression of the disease may require patients to become insulin dependent.

Patients must understand that this does not represent failure on their part.

Adding insulin may cause weight gain, so continuing lifestyle measures is essential. The addition of insulin is not temporary.

Question 6

A patient diagnosed with diabetes has a blood pressure of 140/90 mm Hg and albuminuria. Which initial action by the primary care provider is indicated for management of this patient?

a. Consulting with a nephrologist
b. Limiting protein intake
c. Prescribing an antihypertensive medication
d. Referring to an ophthalmologist

Answer 6

a. Consulting with a nephrologist

Patients with diabetes who have elevated blood pressure and reduced renal function should be referred to a nephrologist. *hypertension and albuminuria is first sign of kidney damage must see nephrologist first who will probably start them on a ARB or ACE

Limiting protein intake and giving an antihypertensive medication may be recommended, but evaluation by a nephrologist is essential.

Ophthalmology referral will be made as well to assess concurrent ocular damage.

Question 7

A patient recently diagnosed with type 1 diabetes mellitus is in clinic for a follow-up evaluation. The provider notes that the patient appears confused and irritable and is sweating and shaking. What intervention will the provider expect to perform once the point of care blood glucose level is known?

a. Dipstick urinalysis for ketones
b. Giving a rapid-acting carbohydrate
c. Injection of rapid-acting insulin
d. Performing a hemoglobin A1C

Answer 7

b. Giving a rapid-acting carbohydrate

This patient has signs of hypoglycemia, so a rapid-acting carbohydrate should be given once this is confirmed. Assessing for ketones is done if the patient is hyperglycemic, as is insulin administration. Hemoglobin A1C gives information about long-term and not immediate glucose control.

Type 1 dm more hypoglycemia more likely to happen as well as DKA Type 1 = insulin deficiency due to auto immune process taking insulin making cells in the pancreas

Question 8

An obese adolescent female patient reports irregular periods and excessive acne. The provider notes an increased amount of hair on her upper back, shoulders, and upper abdomen. What will the provider do, based on these findings?

a. Consider treatment with oral contraceptive pills (OCPs)
b. Counsel her about diet, exercise, and weight loss
c. Recommend cosmetic laser hair removal
d. Refer to an endocrinologist for evaluation

Answer 8

d. Refer to an endocrinologist for evaluation

All patients with suspected hirsutism should be referred to a specialist to determine the cause.

OCPs, lifestyle changes, and cosmetic treatments may be part of the treatment, but the underlying causes must be determined first to ensure that a life-threatening condition is not present

Question 9

A young adult woman is unable to conceive after trying to get pregnant for over 6 months. The woman reports having had irregular periods since the onset of menarche. The provider notes that the woman is overweight, has acanthosis nigricans, and an excess hair distribution. What does the provider suspect as the most likely primary cause of these symptoms?

a. Congenital adrenal hyperplasia
b. Cushing’s syndrome
c. Polycystic Ovary Syndrome (PCOS)
d. Type 2 diabetes

Answer 9

c. Polycystic Ovary Syndrome (PCOS)

PCOS is the most likely cause of oligo- or amenorrhea, so this is the most likely cause. The other conditions are possible, but less likely.

Question 10

A woman who has hirsutism with acne, and oligomenorrhea will most likely be treated with which medication to control these symptoms?

a. Finasteride
b. Levonorgestrel
c. Norgestimate
d. Spironolactone

Answer 10

c. Norgestimate

Norgestimate is a progestin with low androgenic activity and is used to suppress testosterone and control symptoms. Finasteride, which decreases the peripheral conversion of testosterone to dihydrotestosterone (DHT), is not approved for this use. Levonorgestrel is an androgenic oral contraceptive pill (OCP) and should be avoided. Spironolactone is a second-line medication approved for this purpose.

Question 11

A patient is in the emergency department with confusion and fatigue and a corrected serum calcium concentration is 10.8 mg/dL. What is the initial treatment for this patient prior to admission to the inpatient unit?

a. Administration of furosemide
b. Correction of potassium and magnesium levels
c. Parenteral salmon calcitonin
d. Rapid administration of intravenous normal saline

Answer 11

d. Rapid administration of intravenous normal saline

normal levels of CA should be 8.5 -10.5 anything >10.5 needs to be corrected or anything <8.5 needs to be corrected

this patient has ca >10.5 and treatment for hypercalcemia is maintaining fluid hydration status. that is the only way to get rid of excess ca

causes of hypercalcemia:
PTH dysfunction lead to increase levels which leads to increased bone reabsorption
secondary kidney disease CA is only excreted by urine or

sx: change in neuostatus, caridac problems, gastsro symptoms

Malignancy (tumor)= most common cause

Milk alkali syndrome: when a patient is not in renal failure hypercalcemia can be induced by high intake of milk

other caused high levels of Vitamin D or Lithium, thiazide diuretics

Question 12

A patient experiences a carpal spasm when a blood pressure cuff is inflated. Which diagnostic testing will the provider consider evaluating to determine the cause of this finding?

a. Calcitriol level
b. C-reactive protein
c. Magnesium and vitamin D
d. Protein electrophoresis

Answer 12

c. Magnesium and vitamin D

Hypocalcemia may be asymptomatic but prolonged dec ca can cause neuromuscular excitatibility and numbness and tingling ness of extremities and can lead to seizures, coma,

as evidence by increased hyperreflexia of deep tendons
+ trouseau’s signs- carpel spasm occurring after occlusion of brachial artery with bp cuff for 3 minutes
+chvosteks sign- contraction of the facial muscle in response to tapping on facial nerve against bone of anterior ear.

Because hypomagnesemia and vitamin D deficiency may cause hypocalcemia, these should be evaluated to help determine a cause.

Calcitriol levels are used to assess hypercalcemia.

Protein electrophoresis is used in the evaluation of hypercalcemia.

Question 13

A patient has low serum calcium associated with low serum albumin. What is the recommended treatment for this patient?

a. Calcium supplementation only
b. Correction of other serum electrolytes
c. Thiazide diuretics and sodium restriction
d. Vitamin D and calcium supplementation

Answer 13

b. Correction of other serum electrolytes

Patients with hypocalcemia associated with hypoalbuminemia do not require calcium replacement. Serum pH, potassium, magnesium, and phosphorus levels should be monitored and corrected if needed. Thiazide diuretics with sodium restriction may be used to lower urinary calcium excretion to allow lower dosing of calcium and vitamin D when these are given.

Question 14

A patient has a serum potassium level of 3 mEq/L and a normal blood pressure. Which test should be performed initially to assist with the differential diagnosis?

a. Plasma aldosterone
b. Plasma renin activity
c. Serum bicarbonate
d. Serum magnesium

Answer 14

d. Serum magnesium

Hypomagnesemia often accompanies hypokalemia indicating the importance of also obtaining a serum magnesium level.

Sodium bicarbonate is occasionally used in the treatment of hyperkalemia and is most effective when hyperkalemia is a result of metabolic acidosis.

Plasma aldosterone and renin activity are assessed in patients with hypokalemia who are hypertensive.

Question 15

A patient with normal renal function has a potassium level of 6.0 mEq/L. Which underlying cause is possible in this patient?

a. Adrenocortical deficiency
b. Alcoholism
c. Hypertension
d. Malabsorption syndrome

Answer 15

a. Adrenocortical deficiency

Hyperkalemia without underlying renal disorder may be caused by Addison’s disease, which is an adrenocortical deficiency. Alcoholism, hypertension, and malabsorption syndromes all contribute to hypokalemia.

Question 16

A hospitalized patient with renal failure is accidentally given parenteral potassium and has a potassium level of 7.0 mEq/L. An ECG reveals a normal QRS interval. What is the initial recommended treatment for this patient?

a. Calcium chloride
b. Insulin and glucose infusion
c. Sodium bicarbonate
d. Sodium polystyrene sulfate

Answer 16

b. Insulin and glucose infusion

Patients with severe hyperkalemia should have IV administration of glucose and insulin to lower potassium levels quickly.

If life-threatening sequelae, such as a widening QRS interval, are present, calcium chloride is given ( to help restore myocardium)

Sodium bicarbonate is occasionally used, but should be used cautiously to prevent metabolic alkalosis.

Sodium polystyrene sulfate is used when oral medications may be given.

Question 17

A high school athlete is brought to the emergency department after collapsing during outdoor practice on a hot day. The patient is weak, irritable, and confused. Serum sodium is 152 mEq/L and has dry mucous membranes and tachycardia. What is the initial approach to rehydration in this patient?

a. Hypotonic intravenous fluid replacement
b. Intravenous fluid resuscitation with an isotonic solution
c. Loop diuretics and hypotonic intravenous fluids
d. Oral water replacement

Answer 17

b. Intravenous fluid resuscitation with an isotonic solution

This patient is dehydrated and has hypernatremia because of heat exposure and sweating. Because the patient is confused, oral fluid replacement is not recommended, although it is the safest in cognitively intact patients who are able to swallow safely.

The initial fluids should correct the hypovolemia and isotonic solutions such as normal saline (0.9%) or Ringer’s lactate are given.

Hypotonic fluids are then given once vital signs and urine output have normalized in patients with hypernatremia caused by fluid loss.

Loop diuretics are added for patients who have hypernatremia caused by sodium gain.

Question 18

An elderly patient who is taking a thiazide diuretic has been ill with nausea and vomiting and
is brought to the emergency department for evaluation. An assessment reveals oliguria,
hypotension, and tachycardia and serum sodium is 118 mEq/L. What is the treatment?
a. A single infusion of hypertonic saline
b. Addition of spironolactone
c. Emergency volume repletion with 3% NaCl.
d. Fluid and dietary sodium restriction

Answer 18

c. Emergency volume repletion with 3% NaCl.

This patient has hypovolemic hyponatremia with a sodium less than 120 mEq/L and requires fluid resuscitation with 3% NaCl.

Diuretics and fluid restriction are part of treatment for hypervolemic hyponatremia.

Question 19

A patient has euvolemic hyponatremia secondary to chronic syndrome of inappropriate antidiuretic hormone (SIADH) and is hospitalized for fluid replacement. When preparing to discharge the patient home, what will be included in teaching?

a. Limiting dietary protein intake
b. Limiting fluids to 500 mL/day for several days
c. Restriction of sodium intake
d. The importance of adherence to vaptan therapy

Answer 19

b. Limiting fluids to 500 mL/day for several days

Patients with chronic hypovolemia secondary to SIADH require fluid restriction for several days. Sodium and protein are not restricted. Vaptan therapy is started for those whose serum sodium fails to normalize in 24 to 48 hours.

Question 20

When using the 2013 ACC/AHA “Guideline on the Assessment of Cardiovascular Risk” to treat patients with hyperlipidemia, the practitioner understands that it will provide what information?

a. Goals for treatment for low-density lipoprotein levels
b. How to titrate statin drugs to achieve goal levels
c. Use of non-statin therapy for primary prevention
d. Which patients will benefit from statin therapy

Answer 20

d. Which patients will benefit from statin therapy

The 2013 guidelines identify four groups of patients who will benefit from statin therapy to lower low-density lipoprotein cholesterol (LDL-C).

1. LDL > 190
2. Must have clinical ASVD
3. Pt with DM 40-75 years with LDL 70-189
4. Pt with 40-75 years of age with an estimated 10 year risk of AVSD of 7.5% or higher

Lab finding lipid panel every 5 years in adults >20yrs

• total cholesterol goal is >200 (high is >240)
• LDL below 100
• HDL >60
• triglycerides below 150

first choice drugs= statins- work to lower LDL by 21%-55% and increase HDL rare but super serious adverse reaction from statins is MYOPATHY- milkd paresthesia to severs muscle breakdown dose less that 80g/day is recommended. If pts are complaining of muscle pain they must have ck levels drawn.

drugs should be started based on ASVD risk factors and the presence of CAD

Question 21

A patient with type 2 diabetes has a low-density lipoprotein (LDL) level of 110 gm/dL. What is recommended to manage this patient?

a. Dietary and lifestyle changes to modify risk
b. Initial treatment with a low intensity statin medication
c. Prescription of a moderate or high intensity statin
d. Statin therapy until the LDL level is below 75 mg/dL

Answer 21

a. Dietary and lifestyle changes to modify risk

This patient is in one of the four groups of patients identified in current guidelines as one who would benefit from statin therapy because of type 2 diabetes.

A moderate to high intensity statin should be prescribed. Statins will be used in conjunction with dietary and lifestyle changes, but these treatments alone do not reduce risk in this patient. T

Titration of statins is not recommended, and goal levels are no longer part of the protocol.

Question 22

A patient who is taking a statin drug to treat dyslipidemia has begun a diet and exercise program. The patient reports new onset of muscle pain several weeks after beginning therapy. What is the initial action by the provider?

a. Discontinue the statin drug immediately
b. Obtain a creatine kinase level
c. Prescribe acetaminophen or ibuprofen
d. Recommend reducing exercise intensity

Answer 22

b. Obtain a creatine kinase level

A potential serious side effect of statin drugs is drug-induced myopathy. Patients who report new-onset muscle pain should have creatine kinase levels evaluated. If this is elevated, the drug should be stopped, and renal function should be evaluated. It is not safe to assume that the muscle pain is related to the exercise until CK levels are determined.

first choice drugs= statins- work to lower LDL by 21%-55% and increase HDL rare but super serious adverse reaction from statins is MYOPATHY- milkd paresthesia to severs muscle breakdown dose less that 80g/day is recommended. If pts are complaining of muscle pain they must have ck levels drawn.

Question 23

What is important about increased PAI-1 levels in patients?

a. They cause increased insulin resistance.
b. They are associated with metabolic syndrome.
c. They lower the risk of hypertension.
d. They predispose patients to dyslipidemia.

Answer 23

b. They are associated with metabolic syndrome.

metabolic syndrome is associated with an increased risk of developing cardiovascular disease, and PAI-1 overexpression may participate in this process.

Fibrinolysis is primarily regulated by plasminogen activator inhibitor type-1 (PAI-1), which prevents the escape of this potentially destructive protease system.1–3
Increased PAI-1 levels may predispose patients to the formation of atherosclerotic plaques prone to rupture with a high lipid-to-vascular smooth muscle cells ratio as a result of decreased cell migration.

Increased PAI-1 levels increase the risk of atherothrombosis. They are correlated, but do not cause insulin resistance and do not affect the relative risk of hypertension or dyslipidemia.

Question 24

Which medication given for patients with metabolic syndrome is most likely to lower PAI-1 levels?

a. Aspirin
b. Atorvastatin
c. Metformin
d. Niacin

Answer 24

c. Metformin

Metformin is given not only to reduce hyperinsulinemia and lower insulin resistance, but also
to lower plasma PAI-1 levels. Aspirin is given to reduce MI risk. Atorvastatin helps with
dyslipidemia. Niacin may be given to lower triglycerides.

Question 25

Which findings are part of the diagnostic criteria for metabolic syndrome? (Select all that apply.)

a. Decreased plasminogen activator inhibitor 1 levels
b. Elevated waist circumference
c. Fasting plasma glucose > 100 mg/dL
d. HDL cholesterol > 45 mg/dL
e. Triglycerides > 150 mg/dL

Answer 25

b. Elevated waist circumference
c. Fasting plasma glucose > 100 mg/dL
e. Triglycerides > 150 mg/dL

The current criteria for diagnosing metabolic syndrome include;
- increased waist circumference, >40 in men >35 in women
-elevated fasting plasma glucose, 100mg/dl or higher
- elevated triglycerides >150According to these criteria, —-patients with HDL levels <40 mg/dL.
- patient with elevated bp; SBP >130 DDP >85
The old criteria included elevated plasminogen activator inhibitor 1 levels.

Metabolic syndrome is a cluster of disorders characterized by insulin resistance with. hyperinsulenemia; hypertension; abdominal pain (central or visceral); obesity; and dyslipidemia consisting of hypertriglyceridemia, low HDL, and high LDL

Other include: high ck level and increased plasminogen activiatory inhibitor (PAI-1)

sx: based on risk factors: main physical symptoms is hyperkeratotic condition with acanthosis nigricans-diffuse hyperpigmented, velvety thickening of the skin that is found in the neck and axillae,

dx; screening test.

Question 26

Which laboratory values representing parathyroid hormone (PTH) and serum calcium are consistent with a diagnosis of primary hyperparathyroidism?

a. Appropriately high PTH along with hypocalcemia
b. Appropriately increased PTH and low or normal serum calcium
c. Inappropriate secretion of PTH along with hypercalcemia
d. Prolonged inappropriate secretion of PTH with subsequent hypercalcemia

Answer 26

c. Inappropriate secretion of PTH along with hypercalcemia

serum ca levels are sensed by CSR and regulated by PTH

Parathyroid disorders can affect bone, kidney, serum ca and phosperous levels.

Primary hyperparathyroidism is characterized by the inappropriate secretion of PTH (low levels) in the setting of hypercalcemia.

sx: asymptomatic but may be masked by hypoalbuminemia or vit d deficiency PTH will drop. may experience weakness, fatigue, depression, cognitive impairment, anxiety KEY; WHITE CLOUDINESS AT THE NASAL AND EMPORAL BORDERS OF CORNEA

Appropriately high PTH with hypocalcemia characterizes hypoparathyroidism. ACCOMPAINIED BY HIGH PHOSPHOROUS SX: seizures, convulsions, life threatening cardiac arrhythmia, perioral or paresthesia

tests: Chvostek and Trousseau, pts may also develop cataracts or basal ganglia calcifications an reversible parkinsons syndrom

An appropriately increased secretion of PTH with low or normal serum calcium is characteristic of secondary hyperparathyroidism. TYPICALLY IN THE SETTING OF CKD AND VIT D DEFICIENCY

Prolonged inappropriate secretion of PTH in which hypercalcemia develops is tertiary hyperparathyroidism.

Question 27

A 40-year-old patient with primary hyperparathyroidism has increased serum calcium 0.5 mg/dL above normal without signs of nephrolithiasis. What is the recommended treatment for this patient?

a. Annual monitoring of calcium, creatinine, and bone density
b. Avoidance of weight-bearing exercises
c. Decreasing calcium and vitamin D intake until values normal
d. Parathyroidectomy

Answer 27

a. Annual monitoring of calcium, creatinine, and bone density

Medical management of primary hyperparathyroidism involves close monitoring of serum calcium and creatinine and bone density screenings.

Weight-bearing exercises should be encouraged, and vitamin D and calcium intake should be adequate, not decreased.

This patient does not meet criteria for parathyroidectomy because of age less than 50 years and serum calcium less than 1 mg/dL above the upper limit of normal.

Question 28

Which findings are symptoms of hyperparathyroidism? (Select all that apply.)

a. Chvostek’s sign
b. Cognitive impairment
c. Left ventricular hypertrophy
d. Perioral paresthesias
e. Renal calculi

Answer 28

b. Cognitive impairment
c. Left ventricular hypertrophy
e. Renal calculi

Cognitive impairment, left ventricular hypertrophy, and renal calculi all occur with hyperparathyroidism. Chvostek’s sign and perioral paresthesias occur with hypoparathyroidism.

Question 29

Which thyroid-stimulating hormone (TSH) level indicates hyperthyroidism?

a. 0.2 uIU/L
b. 0.4 uIU/L
c. 2.4 uIU/L
d. 4.2 uIU/L

Answer 29

a. 0.2 uIU/L

tsh -most sensitive indicator of thyroid function
LOW TSH = HYPERTHYROIDISM <0.2 ulU/L

A TSH LESS than 0.3 uIU/L indicates hyperthyroid;
HIGH TSH greater than 4.0 uIU/L = HYPOTHYROID

between 0.3 and 4.0 uIU/L indicates euthyroid

Question 30

A patient has thyroid nodules and the provider suspects thyroid cancer. To evaluate thyroid nodules for potential malignancy, which test is performed?

a. Radionucleotide imaging
b. Serum calcitonin
c. Serum TSH level
d. Thyroid ultrasound

Answer 30

d. Thyroid ultrasound

Thyroid ultrasound evaluation should be performed for all patients with known thyroid
nodules; high-resolution sonography can clearly distinguish between solid and cystic
components. Radionucleotide imaging is not specific; many cold nodules are benign. The routine measurement of serum calcitonin levels is not useful or cost-effective. TSH levels are not specific to malignancy.

Question 31

A 20-year-old female patient with tachycardia and weight loss but no optic symptoms presents with the following laboratory values: decreased TSH, increased T3, and increased T4 and free T4. A pregnancy test is negative. What is the initial treatment for this patient?

a. Beta blocker medications
b. Radioiodine therapy
c. Surgical resection of the thyroid gland
d. Thionamide therapy

Answer 31

a. Beta blocker medications

Beta blockers should be initiated for patients with Graves’ disease to alleviate the alpha-adrenergic symptoms of the hyperthyroidism.

Radioiodine therapy is used for patients with Graves’ ophthalmopathy.

Surgical resection is performed for pregnant women who cannot be managed with thioamides or for patients who refuse radioiodine therapy.

Thioamide therapy is recommended for patients younger than 20 years old, pregnant women, those with a high likelihood of remission, and those with active Graves’ Orbitopathy.

Question 32

A postpartum woman develops fatigue, weight gain, and constipation. Laboratory values reveal elevated TSH and decreased T3 and T4 levels. What will the provider tell this patient?

a. A thyroidectomy will be necessary.
b. She should be referred to an endocrinologist.
c. She will need lifelong medication.
d. This condition may be transient.

Answer 32

d. This condition may be transient.

Postpartum hypothyroidism may be a transient condition and does not require surgical intervention, referral to a specialist, or lifelong medication unless it proves to be long-standing or refractory to treatment.

Question 33

Sadie, age 40, has just been given a diagnosis of Graves disease. She has recently lost 25lbs, she has palpitations, is very warm, and has a noticeable bulge on her neck. The most likely cause of her increased thyroid function is

a. hyperplasia of the thyroid
b. an anterior pituitary tumor
c. a thyroid carcinoma
d. an autoimmune response

Answer 33

d. an autoimmune response

Question 34

A client with type 2 dm is on the maximum three oral antibiotic agents, and the HgA1c is 8.5% today. The NP initiates basal insulin. Which of the following would be an appropriate order.

a. Insulin glargine (lantus)
b. insulin detemir (Levenir)
c. insulin aspart (novolog)
d. Regular insulin

Answer 34

a. Insulin glargine (lantus)

Question 35

Peter, age 65, has dm and wants to start an exercise program. Which type of exercise might be detrimental

a. jogging
b. swimming
c. tennis
d. dancing

Answer 35

a. jogging

Question 36

Mary, age 72, has been taking insulin for several years. She just called you because she realized that yesterday she put her short-acting insulin in the long-acting insulin box and vice versa. She just took 22 units of regular insulin when she was supposed to take only 5 units. She says that she tried to do a fingerstick to test her glucose level but was unable to obtain any blood. She states that she feels fine. What do you tell her to do first?
1.
“Keep trying to get a fingerstick and call me back with the results.”
2.
“Call 911 before you collapse.”
3.
“Drive immediately to the emergency room.”
4.
“Drink four ounces of fruit juice.”

Answer 36

4.

“Drink four ounces of fruit juice.”

Question 37

A client with diabetes on a sulfonylurea and metformin with a glycated hemoglobin (HbA1c) of 6.5% is complaining of episodes of low blood sugar. Which of the following changes would be the most appropriate?
1.
Decreasing the dosage of the metformin.
2.
Discontinuing the metformin.
3.
Increasing carbohydrate intake.
4.
Decreasing the dosage of the sulfonylurea.

Answer 37

4.

Decreasing the dosage of the sulfonylurea.

Question 38

A patients bp is 148/88 and 142/90. He says he has “white coat syndrome” the next prudent thing the FNP should do is?

a. start the patient on a beta blocker
b. start the patent on hydrochlorothiazide
c. prescribe home monitoring BP and teach the patient how to use it for a week.
d. initiate lifestyle changes and have patient follow-up in 3 months

Answer 38

c. prescribe home monitoring BP and teach the patient how to use it for a week.