Question Review Flashcards
A middle aged patient presents with increasing difficulty breathing and sputum production. The nurse practitioner notes that this patient was recently diagnosed with COPD and he has been getting some relief with the use of his Albuterol inhaler. The nurse practitioner decides to add ipratropium (Atrovent) to the patient’s treatment plan. Which of the following conditions in the patient’s history would not require that a different medication be used?
a.BPH
b. glaucoma
c. peptic ulcer dz
d. pancreatitis
Correct Answer: Pancreatitis
Rationale: Ipratropium (Atrovent) belongs to a class of drugs called short acting muscarinic antagonists. This drug class is notorious for having anticholinergic side effects, which exacerbate many known conditions.
Anticholinergics have a wide array of side effects such as dry mouth, blurry vision, urinary hesitancy and constipation. In BPH, anticholinergics would worsen the symptoms of urinary hesitancy. In acute-angle closure glaucoma, anticholinergics can induce this condition to occur again and it is considered to be a medical emergency. In peptic ulcer disease, anticholinergics slow down the process of gastric emptying, therefore exacerbating any current ulcers. Anticholinergics are often used in cases of pancreatitis due to their ability to slow down the secretion of pancreatic enzymes as well as gastric acid.
A 72 year old female presents to the clinic after having jaw pain while eating lunch this afternoon. She states she’s been especially tired and has had some blurry vision recently and attributes this to a nagging headache near her left eye. After performing a thorough physical assessment, which of the following steps should the nurse practitioner take next?
a. Refer to ED for CT scan
b. Refer to ophthalmologist for biopsy
c. prescribe sumatriptan
d. order inflammatory markers (ESR/CRP)
Correct Answer: Refer to an ophthalmologist for a biopsy
Rationale: Jaw claudication, or pain in the jaw with chewing, headache, and blurry vision is suspicious for temporal arteritis. We would want to refer this patient for a temporal artery biopsy as this is the only way to make a definitive diagnosis
A 19 year old female patient presents with worsening migraines over the last two months. She has tried preventative Metoprolol (Lopressor) in the past without success and is now looking for an alternative treatment. Her past medical history is significant for bulimia recovery as well as major depressive disorder. Which of the following preventative migraine treatments would be the least appropriate to prescribe to this patient?
a. Rizatriptan
b. amitriptyline
c. sumatriptan
d. Topiramate (topamax)
Correct Answer: Topiramate (Topamax)
Rationale: Topiramate would be the least desirable preventative option for this patient due to her history of having an eating disorder.
Topiramate has the potential for weight loss to occur, which could have negative impacts upon her eating disorder recovery process. In addition, the question asked about preventative treatments, and the drugs listed from the triptan drug class are considered to be abortive treatments instead.
COPD exacerbation. Which of the following criteria is not an indication to start this patient on antibiotics?
A. increased cough
b. increased sputum volume
c. increased sputum purulence
d. increased dyspnea
Correct Answer: Increased cough
Rationale: An increased cough in a COPD patient is not an indication to start antibiotics, as they frequently have flare ups. Additionally, the majority of upper respiratory infections are self-limiting as they are viral. Increased dyspnea, sputum volume, and/or sputum purulence could require antibiotics due to concern for possible bacterial infection.
A 32 year old factory worker has been having progressive issues with dyspnea. The patient appears short of breath in the office and you note mild wheezing upon auscultation. There is no change in spirometry values pre and post administration of a bronchodilator. You suspect a possible airway condition such as COPD. What test would the nurse practitioner be most likely to order?
A. FMR1 DNA test
B. Alpha-1 antitrypsin level
C. Sweat chloride test
D. Allergan Specific IgE levels
Correct Answer: Alpha-1 antitrypsin level
Rationale: Abnormal values on spirometry often indicate problems with the airway such as asthma or chronic obstructive pulmonary disease. In asthma, the restriction is often reversible after administration of a bronchodilator. With COPD, the damage is already done and therefore the obstruction is unchanged. With COPD, our FEV1/FVC ratio will be decreased and any value >70% (or 0.7) is diagnostic. Whenever we have a younger patient diagnosed with COPD, we are suspicious of an alpha-1 antitrypsin deficiency. Ordering serum IgE allergen levels could be beneficial in a patient with severe allergies and asthma. A sweat chloride test is used to screen for cystic fibrosis - however, CF is most commonly diagnosed in the first few years of life.
A 47 year old premenopausal female patient reports to the clinic today with complaints of new breast leakage. She states that she has not had breast leakage since she breastfed her last child almost fifteen years ago. You suspect a potential diagnosis of galactorrhea as her physical exam is benign. Which of the following tests would be inappropriate for further confirmation of this diagnosis?
A. TSH
B. Prolactin level
C. Pregnancy test
D. Breast Ultrasound
Correct Answer: Breast ultrasound
Rationale: Primary hypothyroidism can lead to both hyperprolactinemia and galactorrhea simultaneously. Prolactinomas are another potential cause of galactorrhea.
A pregnancy test would be appropriate as she is premenopausal.
A breast ultrasound or mammogram could be utilized if this was suspected to be pathologic in nature, but given the benign physical exam that is unlikely.
Papilledema is described as a
sudden onset of vision changes including blurred vision or double vision, flickering, or loss of vision lasting seconds at a time.
Methotrexate (Trexall) is
- commonly used for conditions such as rheumatoid arthritis.
Use of methotrexate (Trexall) causes the body to excrete folic acid in large amounts.
Supplementation is necessary to prevent megaloblastic anemia, low platelets, and white blood cells because red blood cells cannot be produced with an insufficient amount of folic acid.
More common symptoms include fatigue, paresthesias, headache, and muscle weakness.
Vitamin B should not be used in combination with folic acid because it is a man made derivative of folate (vitamin B-9) and extreme levels can cause folic acid toxicity
A 65 year old post-menopausal woman presents today with increasing abdominal discomfort and pelvic pain. The nurse practitioner performs a pelvic and vaginal exam, and is able to palpate the patient’s right ovary. Which of the following would be the most appropriate plan of care for this patient?
A. Oder a trans-vag US asap
B. Refer for colposcopy
C. Prescribe Premarin
D. Return in 2 weeks for FU
Correct Answer: Order a intravaginal ultrasound as soon as possible
Rationale: A palpable ovary in a post-menopausal woman should always be considered an abnormal finding and possibly indicative of ovarian cancer.
Therefore, an intravaginal ultrasound should be ordered and the patient should also likely be referred to their gynecologist for further evaluation.
A colposcopy is performed for abnormal pap smear results, and Premarin is a drug used to treat hot flashes in menopausal women.
In a young adult male patient with increasing skin hyperpigmentation and worsening fatigue, a diagnosis of Addison’s disease is suspected. Which of the following labs would be unlikely to see in a patient with this condition?
A. Sodium 129
B. Potassium 5.5
C. BUN 21
D. Glucose 134
D. Glucose 134
In patients with Addison’s disease, it is common to see issues with
-hyponatremia (normal 135-145),
-hyperkalemia (normal 3.5-5), and increases in blood urea nitrogen
-(BUN) (normal 10-20).
It is more typical to see issues with hypoglycemia than hyperglycemia, and their glucose levels can decrease to below 50 mg/dL inadvertently.
The nurse practitioner is reviewing the pap-smear results for a 21-year old patient. The report notes that there are atypical squamous cells and can not exclude high-grade squamous intraepithelial cells (ASC-H). Which of the following is the best plan of action for this patient?
A. come back next year
B. Reflex HVP
C. refer for colposcopy
D. return in 3 years as this is not a problem.
Correct Answer: Refer for colposcopy
Rationale: When cytology results come back as atypical squamous cells that can not exclude high-grade intraepithelial changes, regardless of age, we refer for a colposcopy.
This is because high-grade changes in the intraepithelial cells can indicate pre-cancerous cells. A colposcopy can visualize the cervix and collect biopsies if needed, which can help diagnose early cervical cancer, which is key to treatment and
survival.
A three year old presents to the clinic today with her mother. She states that the child had this new rash “pop up” after she recovered from an upper respiratory infection approximately a week and a half ago. On the physical exam, you note petechiae on her lower legs as well as some mild bleeding in her gums. Otherwise, the exam is benign and you also note there is no splenomegaly present. What is the most likely cause of these symptoms?
Correct Answer: Immune Thrombocytopenia (ITP)
Rationale: The key factor in this question is that the child is recovering from a recent respiratory infection. The average age of diagnosis for Immune Thrombocytopenia in children is two to six years old. It is also noted specifically that there is no splenomegaly which is characteristic of ITP.
First line treatment for benign prostatic hypertrophy is:
generally the alpha blocker class which includes_________ and ________.
A 5-alpha reductase inhibitor like __________could be a good second line option.
Tadalafil (Cialis) is used for ______
Alendronate (Fosamax) is used for ______
terazosin (Hytrin) and tamsulosin (Flomax)
–These have a first time dose effect of orthostatic hypotension and this patient should be educated to take the first dose at night when he goes to bed to lower the risk of falls
finasteride (Proscar)
–These work by reducing the size of the prostate over time, but may take up to 6 months to see full effect.
Tadalafil (Cialis) is used for erectile dysfunction.
Alendronate (Fosamax) is used for osteoporosis.
In order to help confirm a suspicion of Cushing Syndrome, several diagnostic tests may be ordered. Which of the following diagnostic tests would be the most inappropriate to order for further investigation of this condition?
A. 24 hr urinary free cortisol test
B. Serum midnight plasma cortisol level
C. Dexamethasone suppression screening test
d. ACTH stimulation test
Correct Answer: Adrenocorticotropic hormone (ACTH) stimulation test
Rationale: An ACTH test is typically used to help diagnose adrenal insufficiency which presents in cases of Addison’s disease, not Cushing’s disease or Cushing Syndrome.
In Cushing’s, there is too much cortisol present.
Cortisol typically decreases at midnight, but will remain increased in a patient with this condition.
Steroids such as Dexamethasone can be used to try to suppress cortisol secretion, but cortisol levels remain unchanged in Cushing’s patients.
A child presents to the office with complaints of hip pain. Which of the following assessment findings would support the diagnosis of Legg-Calve-Perthes disease over Slipped Capital Femoral Epiphysis or other hip pathology?
A
An adolescent who has had mild hip pain for 6 weeks and a widened growth plate of the affected hip is found on x-ray
B
A 10 year old with an effusion found in the hip on ultrasound and with a negative Trendeleburg’s test
C
A 5 year old who has had hip and knee pain for several weeks and the x-ray reveals necrosis of the femoral head
D
A child who has hip pain in the joint accompanied by a fever and white blood cells are present in the join fluid
Correct Answer: A 5 year old who has had hip and knee pain for several weeks and the x-ray reveals necrosis of the femoral head
Rationale: Legg-Calve-Perthes disease is characterized by osteonecrosis of the capital femoral epiphysis and occurs in prepubescent children. It may be accompanied by hip pain and a limp.
Radiographs will reveal osteonecrosis of the femoral head in Legg-Calve-Perthes.
The Trendeleburg test is performed by having a patient stand on one foot and assess if the pelvis stays horizontal or if it tilts.
A positive Trendeleburg test (if a tilt is seen), is associated with both Legg-Calve-Perthes and slipped capital femoral epiphysis.
Slipped capital femoral epiphysis is when the bone slips through the growth plate and occurs more often in growing adolescents.
A widened physis will be seen on x-ray.
Septic arthritis of the hip joint would cause hip pain and fever along with evidence of infection in the joint fluid.
An elderly male patient who presented with a resting tremor is diagnosed with Parkinson’s disease. The patient reports that he is also having difficulty zipping up the zipper on his winter coat. Which of the cardinal symptoms of Parkinson’s disease does this behavior represent?
A. Postural instability
B. Bradykinesia
C. Rigidity
D. Tremor
Correct Answer: Bradykinesia
Rationale: Bradykinesia is simply the slowing of movement in those with Parkinson’s disease. This can impact the patient’s ability to perform basic daily tasks such as zipping a zipper. Other signs and symptoms of bradykinesia specifically include slower speech, difficulty initiating movements, and less facial expressions.
You are seeing a patient in the office today for a medication reconciliation. He has a past medical history of hypertension, asthma, and obesity. Based on this information, which herbal supplement would warrant further discussion with the patient today?
A. CoQ 10
B. St Johns Wort
C. Echinacea
D. Kava Kava
Correct Answer: Echinacea
Rationale: Although Echinacea is known to be used for its immune boosting properties, it can actually make asthma symptoms worse and cause exacerbations. Due to this, Echinacea should be avoided in patients with a history of asthma.
A 56 year old male patient with a history of gout and peripheral arterial disease presents to the clinic today to discuss his recent lab work. His most recent lipid panel is as follows: Total Cholesterol: 254 mg/dL
Triglycerides: 165 mg/dL
LDL: 143 mg/dL
HDL: 41 mg/dL
Which of the following labs would be inappropriate to draw prior to initiating atorvastatin?
A. CK level
B. LFT’s
C. Hgb- A1C
D. BUN/Creatnine
Correct Answer: Blood urea nitrogen/Creatinine
Rationale: There is no indication to check a BUN and creatinine prior to starting this patient on a HMG-CoA Reductase Inhibitor. Prior to starting atorvastatin, the nurse practitioner should get a baseline CK level as well as assess the patient’s current muscle pain in case the patient were to develop rhabdomyolysis. HMG-CoA Reductase Inhibitors can also affect the liver and may cause drug-induced hepatitis. High intensity statins can increase a patient’s hemoglobin A1C overtime.
A patient presents to the office today with complaints of feeling unusually tired, a headache, and mild muscle aches. He reports that he has had some pain and swelling in his cheek and jaw area that began two days ago as well. Upon further assessment, the nurse practitioner notes that there is parotid gland swelling present. Which of the following is the most likely diagnosis for this patient?
Correct Answer: Mumps
Rationale: Parotid gland swelling is a key symptom of mumps. Typically, this will occur a few days after symptom onset. The first signs and symptoms of mumps include headache, loss of appetite, muscle aches, fatigue, and fever.
You are seeing a 25 week pregnant woman who received a positive result on her gestational diabetes screening. You are educating her on the treatment plan and importance of strict blood sugar control when she asks what the consequences of gestational diabetes might include. What risks are you going to educate this patient on as the nurse practitioner? Select all that apply by choosing three of the following answer choices.
a. macrosomia
b. cervical insufficiency
c. placental abruption
d. pre-e
e. polyhydraminos
Correct Answer: Macrosomia / Preeclampsia / Polyhydramnios
Rationale: Gestational diabetes presents risk for both short and long term complications. Short term complications in addition to these include a large for gestational age infant, gestational hypertension, stillbirth, or neonatal morbidity. Long term complications for the mother include the increased risk of developing type 2 diabetes while the infant is at an increased risk for obesity and diabetes later in life as well
Pulsus paradoxus occurs when there is a decrease in blood pressure by greater than 10 mmHg specifically on inhalation. Which of the following is not a possible cause of this phenomenon?
cardiac tamponade
status asthmaticus
ischemia stroke
severe hypovolemia
Correct Answer: Ischemic stroke
Rationale: Pulsus paradoxus occurs when there is not enough circulation present throughout the body, and tends to present during serious conditions. Cardiac causes include cardiac tamponade and pericarditis. Pulmonary causes include severe COPD exacerbations, pulmonary embolism, obstructive sleep apnea, status asthmaticus, etc. Severe hypovolemia can also create this pressure change due to lack of circulation.
The nurse practitioner is examining the results of a wet mount for a patient suspected to have a vulvovaginal candidiasis infection. Which of the following on a wet mount would indicate that this is the likely differential?
A. Flagellated organisms
B. Pseudohyphae
C. Clue cells
D. Overgrowth of squamous epithelial cells
Correct Answer: Pseudohyphae
Rationale: Vulvovaginal candidiasis, commonly referred to as a yeast infection,
is one of the most common causes of vaginal irritation and discharge. It can be identified
by pseudohyphae, spores, and bud cells present on a wet mount. Patients also
commonly describe a chunky white vaginal discharge and intense itching. Flagellated
organisms are seen with Trichomoniasis infections, and clue cells are seen with bacterial
vaginosis.
A 45 year old female returns to the clinic for a follow up on the clusters of erythematous, warm to the touch pustules. They are tender to palpation on her arm and her trunk. She declined oral antibiotics at the last visit and has been utilizing mupirocin (bactroban) without improvement. Which of the following would be the most appropriate medication for the nurse practitioner to prescribe today?
A. Cephalexin (Keflex)
B. Bactrim
C. Clindamycin
D. Rifampin
Correct Answer: Cephalexin (Keflex)
Rationale: This patient is presenting with persistent folliculitis that has not responded to topical mupirocin (bactroban) treatment. Cephalexin (keflex) or penicillins can be utilized to treat severe cases of folliculitis, especially if the patient is not responding to mupirocin (bactroban).
Which of the following assessment findings would be an abnormal finding on a digital rectal exam?
A. large, rubbery prostate
B. Prostate 2-3 cm in size but wider at the top
C. mucosal walls are smooth within the rectum
D. sphincter is reactive to stimulation
Correct Answer: A large, rubbery prostate
Rationale: A digital rectal exam is used to assess the prostate in male patients. A normal prostate is smooth, firm, and nontender. Any deviation from this including enlargement, rubbery feel, or a boggy, warm prostate, warrants further investigation.
