Unit 3 Practice Questions Flashcards
A thin patient w/ a slight build present with constant difficulty breathing and clear mucus. A physical exam also indicates an increased chest anteroposterior diameter and hyperresonance on percussion. Given the most likely diagnosis, which class of medications is best suited for long-term tx?
a. Antibiotics
b. Anticholinergics
c. Antileukotrienes
d. Short-acting beta-2 adrenergic agonists
B. Anticholinergics
Diagnosis: emphysema. This is treated with ipratropium bromide; antibiotics treats complications; SABA may treat but ipratropium is preferred d/t greater efficacy and minima cardiac stimulation effects; antileukotrienes are not used in emphysema
Which of these manifestations is LEAST likely to present with the onset of asthma?
a. Plugging the airways by thick mucus
b. Hypertrophy of the mucus glands
c. Thinning of the epithelial basement membrane
d. Hypertrophy of smooth muscle
C. thinning of the epithelial basement membrane
Asthma presents as a result of increased responsiveness of the trachea and bronchi to stimuli, often leading to the thickening, not thinning, of the epithelial basement membrane. Other physical changes likely to produce from asthma include plugging of the airways by thick mucus and hypertrophy of both the mucus gland and smooth muscle.
Your patient was seen by a pulmonologist 2 months ago and diagnosed with asthma. The pulmonologist ordered a short acting beta-2 agonist for initial symptom relief. However, on today’s visit to your office, the patient states, “I don’t think this stuff is really working because I’m still short of breath.” You refer the patient back to the pulmonologist. Which of the following would you anticipate being the next step in the patient’s management following the latest national guidelines?
a. An antileukotriene
b. A long-acting beta-2 adrenergic agonist
c. A metered anticholinergic
d. An inhaled corticosteroid
d. an inhaled corticosteroid
By national guidelines for asthma management, a low-dose ICS is usually the first step for increased management after a SABA shows insufficient results in controlling symptoms. While an antileukotriene, such montelukast, may serve as alternative treatment at this
step, a low-dose ICS is considered to be the standard medication. Long-acting beta-2 agonists typically see use if tx with a low-dose ICS fails to manage symptoms, whereas metered anticholinergics are usually paired with a SABA for short-term sx relief, not longterm sx control.
Jackie, a 25-yo female, comes to the clinic experiencing respiratory distress and difficulty speaking. Her lungs are
hyperresonant and show hyperinflation on the x-ray. Which result would most strongly indicate that Jackie should be admitted to a hospital?
a. Forced expiratory volume is below 30%
b. Respiratory rate is 25 breaths/minute
c. Pulsus paradoxus of 8 mmHg
d. Pulse is 112 bpm
a. forced expiratory volume is below 30%
Which of these is NOT a common indoor trigger for asthma?
a. Cockroaches
b. Dust mites
c. Exercise
d. Termites
d. termites
Although termites may trigger asthma, they are not commonly considered to be an indoor trigger for the condition. Dust mites, pets, cockroaches, indoor molds, exercise, and cigarette smoke are all common indoor causes of asthma.
Upon examination, you notice that Alex, an obese 63yo male, has moderate dyspnea and purulent sputum. His lungs are normal upon percussion. Laboratory results reveal an increased hematocrit level. Given the most likely diagnosis, which of the following drugs would you be LEAST likely to prescribe for the patient’s condition?
a. Ipratropium bromide
b. Albuterol
c. Budesonide
d. Montelukast
d. Montelukast
A patient with dyspnea, purulent sputum, obesity, and an increased hematocrit level most likely has chronic bronchitis, which would not require the administration of montelukast. Mainstays of chronic bronchitis tx include anticholinergics such as ipratropium bromide, as well as beta-2 adrenergic agonists, such as albuterol. Budesonide and other corticosteroids may likewise see use improving lung function. Leukotriene receptor antagonists, such as montelukast, are not commonly used to treat chronic bronchitis, and would more likely see use in the management of asthma.
Which of the following medications is considered to be the mainstay of treatment for chronic obstructive pulmonary disease?
a. Budesonide
b. Ipratropium bromide
c. Salmeterol
d. Triamcinolone
b. Ipratropium bromide
A 52yo female patient comes to your practice with complaints of breathlessness and a cough accompanied by excessive phlegm. She produces a sputum sample, which appears clear upon inspection. You order a PFT; in reviewing the results, you find evidence indicating both an increased functional residual capacity and an increased total lung capacity. Which of the following respiratory disease would be the most likely diagnosis?
a. Acute bronchitis
b. Emphysema
c. Tuberulosis
d. Pneumonia
b. Emphysema
Victor, a stocky 40yo male, presents to the clinic with complaints of difficulty breathing and “endless amounts of gunk whenever he coughs.” During the visit, he coughs up a substantial amount of yellow phlegm. A blood test reveals an increased hematocrit level, and a physical exam detects lungs that are normal upon percussion. You order a pulmonary lab for the patient. Given the most likely condition, which of the following findings would you LEAST expect?
a. Increased forced expiratory volume in 1 second
b. Increased total lung capacity
c. Increased functional residual capacity
d. Increased residual volume
a. increased forced expiratory volume in 1 second
Least expect an increased FEV1 because that’s an indication of healthy lung functioning
In cases of asthma, the trachea and bronchi typically become more:
a. Thickened
b. Narrowed
c. Responsive
d. Hyperemic
c. Responsive
Asthma commonly results in the increased responsiveness of the trachea and bronchi to stimuli. Thickening of the epithelial basement
membrane and mucosal edema and hyperemia typically result in narrowing of the respiratory airways.
Winston, a 42yo male, is an HIV-positive patient whose TB skin test returns with an elevation of 5mm. After confirming a diagnosis of TB, you prescribe a traditional drug regimen. For what minimum period of time is Winston expected to continue his regimen?
a. 7 months
b. 8 months
c. 9 months
d. 10 months
c. 9 months
HIV-+ pts who test + for TB are expected to be treated for 9 months. In pts who are not immunocompromised and who test + for TB, the regimen may be tapered before 9 months, with 6 months standing as the traditional cut-off point.
All of the following would be consistent with a typical manifestation of severe asthma EXCEPT:
a. RR of 35
b. HR of 125
c. Pulsus paradoxus of 15 mmHg
d. WBC of 1800 eosinophils/mc
c. Pulses paradoxes of 15 mmHg
A pulsus paradoxus of 15 mmHg does not strongly indicate severe asthma; rather, it would more strongly indicate moderate asthma, which typically presents with pulsus paradoxis of 10-20 mmHg. A respiratory rate that exceeds 28 is a sign of asthma in older children. Furthermore, the patient’s pulse of 125 is consistent with the elevated pulse that typically occurs in severe cases of asthma. A WBC count that detects more than 1500 eosinophils/mcl may also indicate severe asthma.
The practitioner recognizes that all of these are expected pulmonary findings in the geriatric patient EXCEPT:
a. Total lung capacity decreases
b. Residual volume increases
c. Vital capacity decreases
d. The number of mucus-producing cells increases
a. total lung capacity decreases
A geriatric patient is likely to experience an unchanged, not decreased, total lung capacity (TLC). Patients in the geriatric population commonly experience an increase in residual volume alongside a decrease in vital capacity, meaning that TLC typically remains constant. Geriatric patients are likely to experience an increase in the number of mucus-producing cells
Common symptoms of COPD are:
cough
dyspnea
sputum production
Is a CXR needed to diagnose COPD?
NO. CXR may show hyperinflation, but PFTs are the standard for diagnosis. PFT may be able to diagnose prior to the presentation of symptoms.
What is the PFT result needed for diagnosis of COPD?
FEV1 < 0.7
Does every patient with asthma need a SABA?
YES
30yo patient with persistent asthma, what are the essential components of their care plan? (select all that apply)
a. Asthma action plan
b. Flu and pneumonia vaccine
c. Rescue inhaler
d. LABA
a. asthma action plan
b. four and pneumonia vaccine
c. rescue inhaler
T or F: Asthma patients and COPD pts both need rescue inhalers?
TRUE
Most common side effects of long-term inhaled steroid use?
a. Osteoporosis and GERD
b. Hypertension and diabetes
c. Hyperkalemia and diabetes
d. Bone demineralization (osteopenia) and cataracts
d. bone demineralization (osteopenia) and cataracts
A 12yo patient presents to the clinic with wheezing, SOB, a feeling of tightness in the chest. He is afebrile. Which of the following would be the best test to confirm diagnosis?
a. CBC
b. Blood cultures
c. PFT
d. Chest X-ray
c. PFT
T or F: USPSTF recommends screening with low-dose helical CT scans for lung cancer?
True
(Small vs large cell carcinoma – McPhee pg. 1622)
T or F: Women are more likely to be diagnosed with mesothelioma?
Answer: False
What are symptoms of TB?
Cough (3+ weeks), hemoptysis, chest pain, sputum production, weight loss, anorexia, fatigue
TB interpretation of the Mantoux test: What are some patient populations that a >10mm induration would be classified as positive?
At risk peds, lab workers, healthcare workers, IV drug users
Can you do a TST test on a pregnant woman; and when would you do it?
Yes, high risk group or showing signs / symptoms
Can IGRAs be used to differentiate between TB and LTBI?
No, IGRAs cannot differentiate between the two
How long after infection can LTBI be detected by TST or IGRAs?
2-8 weeks
T or F: Direct Observed Therapy is recommended for only high-risk populations.
False, it is recommended for ALL
What TB regimen is recommended for pregnant women? What should the NP do if the patient is unable to take regimen?
9 months of INH daily or twice weekly, give with vitamin B6; if unable to take, consult TB expert
What is the strongest predictor of asthma?
Atopy
Due to severely restricted air flow, severe asthma may present with what breathe sounds?
Absent wheezing, decreased breath sounds
How should you diagnose a 3yo with asthma? Does this process change with a 9yo being diagnosed? How?
3yo is based on s/s and exam; unable to cooperate with PFT; 9yo diagnosed based on s/s, exam, and PFT
When a patient has been diagnosed with asthma, the NP may refer them out for what additional testing?
Allergy
Increasing use of SABA greater than how many days/weeks for sx relief generally indicates inadequate control and a need to step up treatment?
> 2
How much bloody expectorant in a 24hr period is considered “massive” hemoptysis?
200mL/24hrs; 60mL/2hr
Asthma is more common in which gender as children? And which gender in adults?
Males under 14yo and female adults
LABAs provide bronchodilation for up to how many hours after a single dose.
12
What are the first line treatment agents for all patients with persistent asthma?
Low-dose ICS
A patient comes to you with the complaint that he cannot stop coughing. He has trouble speaking in sentences but manages to describe a tight feeling in his chest. A physical exam indicates his pulse is 115. The pt explains that he used his albuterol and inhaled budesonide today but is still having symptoms. Of the following, which would be the most appropriate treatment option?
a. Add oral prednisone.
b. Add an inhaled ipratropium bromide.
c. Increase the dosage of albuterol.
d. Add a regular dose of salmeterol
d. add a regular dose of salmetrol
(The patients symptoms of coughing, trouble speaking full sentences, chest tightness, and elevated pulse are most indicative of an acute asthma attack, which the patient already treats with a SABA and an ICS; if
symptoms persist, tx protocols may include increasing corticosteroid dosage, adding a LABA, such as salmeterol, or adding theophylline or antimediators. Adding oral corticosteroids, such as prednisone, would not be recommended at this stage, as oral corticosteroids are typically prescribed after treatment with ICS and LABAB has failed to control symptoms. Adding ipratropium bromide or other anticholinergic agent would typically not be beneficial because theses medication sees more use in chronic bronchitis than asthma. Additionally, increasing the dosage of SABA would not be recommended because of
overuse of the drug could reeducate its future effectiveness)
A patient with TB is being treated with a regimen of isoniazid, rifampin, pyrazinamide, and ethambutol. The patients’ condition is improving significantly and there is evidence indicating that the isolate being treated is fully susceptible to the current regimen. At this time, which change would be recommended to incorporate into the patient’s regimen?
a. Rifampin may be dropped.
b. Isoniazid may be dropped.
c. Pyrazinamide may be dropped.
d. Ethambutol may be dropped
d. ethambutol may be dropped
(If a patient with TB shows susceptibility of the isolates while on a treatment regimen of isoniazid, rifampin, pyrazinamide, and ethambutol, then ethambutol may be dropped. Pyrazinamide should be continued for at least 2 more months, and isoniazid and rifampin should be continued as daily or intermittent therapy for 4 or more months)
An HIV+ patient develops a low-grade fever. During his visit, he complains of fatigue, a reduced desire to eat, and a dry cough. He coughs in front of you, producing sputum that is tinged red. You order a cxr, which reveals a small homogenous infiltrate in the upper lobes. Given the most likely condition, what combination of drugs would be most effective for treatment?
a. Isoniazid, ipratropium bromide, pyrazinamide, ethambutol
b. Isoniazid, rifampin, pyrazinamide, theophylline
c. Isoniazid, rifampin, ethambutol, pyrazinamide
d. Isoniazid, rifampin, albuterol, ethambutol
c. Isoniazid, rifampin, ethambutol, pyrazinamide
A thin, 70yo patient with a wasted appearance comes to the clinic complaining of difficulty breathing and a cough. She states that she had to stop taking her senior water aerobics class bc she couldn’t make it through the 30 minutes without tiring out. Which of these characteristics would lead you to believe she has emphysema and not chronic bronchitis?
a. Thin and wasted habitus
b. Cough
c. Exercise intolerance
d. Dyspnea
a. Thin and wasted habitus
Kyle, a 32yo male, is HIV+. When initiating a TB skin test, which result would show the minimal amount of elevation that would indicate he is positive for TB?
a. 5mm
b. 10mm
c. 15mm
d. 20mm
a. 5mm
What baseline labs should be obtained prior to starting TB medication regimens?
LFTs (AST, ALT); CBC, serum creatinine
A prisoner has a TB skin test with a 10mm induration. What does this tell the NP?
Positive result, needs treatment
Which of the following best describes asthma?
a. Intermittent airway inflammation with occasional bronchospasm.
b. A disease of bronchospasm that leads to airway inflammation
c. Chronic airway inflammation with superimposed bronchospasm
d. Relatively fixed airway constriction
c. Chronic airway inflammation with superimposed bronchospasm
The patient you are evaluating is having a severe asthma flare. You have assessed that his condition is appropriate for office treatment. You expect to find the following on physical examination:
a. Tripod posture
b. Inspiratory crackles
c. Increased vocal fremitus
d. Hyperresonance on thoracic percussion
d. Hyperresonance on thoracic percussion
A 44yo man has a long-standing history of moderate persistent asthma that is normally well controlled by fluticasone with salmeterol (Advair) via metered-dose inhaler, one puff BID, and the use of albuterol 1-2x/week as need for wheezing. 3 days ago, he developed a sore throat, clear nasal discharge, body aches, and a dry cough. In the past 24hrs, he has had intermittent
wheezing that necessitated the use of albuterol, 2 puffs every 3hrs, which produced partial relief. Your next most appropriate action is to obtain a:
a. Chest x-ray
b. SaO2
c. Spirometry measurement
d. Sputum smear for WBCs
c. Spirometry measurement
Peak expiratory flow meters:
a. Should only be used in the presence of a medical professional
b. Provide a convenient method to check lung function at home.
c. Are as accurate as spirometry.
d. Should not be used more than once daily.
b. Provide a convenient method to check lung function at home.
Which of the following is most likely to appear on a chest x-ray of a person during an acute severe asthma attack?
a. Hyperinflation
b. Atelectasis
c. Consolidation
d. Kerley B signs
a. Hyperinflation
The cornerstone of moderate persistent asthma drug therapy is the use of:
a. Oral theophylline.
b. Mast cell stabilizers.
c. SABA
d. Inhaled corticosteroids
d. inhaled corticosteroids
Sharon is a 29yo woman with moderate persistent asthma. She is not using prescribed inhaled corticosteroids but is using albuterol PRN to relieve her cough and wheeze with reported satisfactory clinical effect. Currently, she uses about 2 albuterol metered-dose inhalers/ month and is requesting a rx refill. You consider that:
a. Her asthma is well controlled and albuterol use can continue.
b. Excessive albuterol use is a risk factor for asthma death.
c. Her asthma is not well controlled and salmeterol (serevent) should be added to relieve bronchospasm and reduce her albuterol use.
d. Her asthma has better control with albuterol than inhaled corticosteroids
b. Excessive albuterol use is a risk factor for asthma death.
In the treatment of asthma, leukotriene receptor antagonists should be used as:
a. Controllers to prevent bronchospasm.
b. Controllers to inhibit inflammatory responses.
c. Relievers to treat acute bronchospasm.
d. Relievers to treat bronchospasm and inflammation.
b. Controllers to inhibit inflammatory responses.
After inhaled corticosteroid is initiated, improvement in control is usually seen:
a. On the first day of use.
b. Within 2-8 days.
c. In about 3-4 weeks.
d. In about 1-2 months.
b. Within 2-8 days.
Compared with albuterol, levalbuterol (Xopenex) has:
a. A different mechanism of action.
b. The ability potentially to provide greater bronchodilation with a lower dose.
c. An anti-inflammatory effect similar to that of an inhaled corticosteroid.
d. A contraindication to use in elderly patients.
b. The ability potentially to provide greater bronchodilation with a lower dose.
Which of the following statements is false regarding the use of omalizumab (Xolair)?
a. Its use is recommended for pts with mild persistent asthma to prevent asthma flares.
b. The medication selectively binds to IgE to reduce exacerbations.
c. Labeled indication is for patients with poorly controlled asthma with frequent exacerbations.
d. Special evaluation is required prior to its use and ongoing monitoring is needed during use.
a. Its use is recommended for pts with mild persistent asthma to prevent asthma flares.
Subcutaneous immunotherapy is recommended for use in patients:
a. With well-controlled asthma and infrequent exacerbations.
b. With allergic-based asthma.
c. With moderate persistent asthma who are intolerant of ICS.
d. With poorly-controlled asthma who fail therapy with omalizumab.
b. With allergic-based asthma.
Is emphysema or chronic bronchitis typically associated with OSA?
Chronic bronchitis
What is the major complaint of emphysema?
Dyspnea
What is the major complaint of chronic bronchitis?
Cough
What is the preferred first line agent for COPD: SABA or ipratropium bromide?
ipratropium bromide
Should ICS alone ever be used as a first line agent for COPD?
No, 1st line are anticholinergics
What is a “coin lesion”? What does it indicate?
A solitary, pulmonary nodule. Indicates likely malignancy
Are corticosteroids and antibiotics recommended in pts with smoke inhalation?
NO
T or F: Patient with a TNM stage B cancer would benefit from surgery?
False
Papadakis, pg.1623 table 39-2 and text above it
In cases of asthma, the trachea and bronchi typically become more:
a. Narrowed
b. Hyperemic
c. Thickened
d. Responsive
d. Responsive
Which of these manifestations is least likely to present with the onset of asthma?
a. Plugging airways with thick mucus
b. Hypertrophy of the mucus glands
c. Thinning of the epithelial basement membrane
d. Hypertrophy of smooth muscle
c. Thinning of the epithelial basement membrane
What is the hallmark sign of asthma?
a. Daytime, unproductive cough
b. Reduced airway inflammation
c. Tripod positioning to assist breathing
d. Bronchoconstriction
d. Bronchoconstriction (bronchial hyperresponsiveness)
Upon physical exam of a 19yo female presenting with c/o an asthma exacerbation during exercise, you auscultate her lungs and hear:
a. Decreased airflow
b. Faint or absent breath sounds
c. Expiratory wheezes
d. Pleural friction rub
c. expiratory wheezes
Rodney, age 27, comes into your clinic. He is a non-smoker who has fall seasonal allergies. It’s October. He’s been waking up about once/week with trouble breathing, wheezing, and he’s been using his rescue inhaler about every day. How would you describe his asthma and what is the next step in management?
a. Sever, persistent, very poorly controlled; rx high dose ICS + LABA + oral steroid
b. Intermittent, well-controlled, tell him to keep doing what he is doing, but to make sure to close his windows at night
c. Mild, persistent, not-well controlled; rx low dose ICS, and continue with SABA PRN
d. Refer to pulmonology
c. Mild, persistent, not-well controlled; rx low dose ICS, and continue with SABA PRN
Mrs. Rodriguez has been your patient for 2 months. She has a history of obesity, eczema, atopic dermatitis, and asthma. She states she is having a severe asthma attack. Upon assessment, you hear no wheezing, but you hear reduced breath sounds and note prolonged expiration. Her shoulders are hunched. Based on this information, the NP assumes:
a. She cannot possibly be having an asthma attack since you could not auscultate wheezing.
b. The asthma attack has subsided and you want to discuss her weight.
c. She is quite possibly having a severe asthma exacerbation.
d. You test her gag reflex and assess her throat to make sure she is not choking on food.
c. She is quite possibly having a severe asthma exacerbation.
Katie, 42, is a new patient of yours. During the p thx, you find out that she has been on “bursts” of prednisolone for several years. You ask her what supplements she is taking, and she answers, “a multivitamin.” You ask if she has ever had a bone density screening, she says no. You know that:
a. Given her age, you are not worried about bone loss.
b. She should avoid contact sports.
c. She should be taking concurrent vitamin D and calcium supplementation and should be sent for a bone mineral density test.
d. Has been on this drug far too long and should be discontinued immediately
c. She should be taking concurrent vitamin D and calcium supplementation and should be sent for a bone mineral density test.
Bone density becomes an issue with long-term (>3months) corticosteroid therapy
T or F: Inhaled corticosteroids are the first line of rescue treatment for acute asthma exacerbations?
False, SABA
T or F: Inhaled nebulized meds are always more effective than inhaled meds from MDI?
False; you can provide a higher dose of the med, but it is more effective for pts who are unable to coordinate inhalation of meds from MDI d/t age, coordination, agitation, or severity of exacerbation (Papadakis p 253, top right-hand side of page)
T or F: LTBI radiographs are typically abnormal
False
Pt received Mantoux TB test and returned to the office 24 hrs. later with no reaction, is this a negative result?
Answer: No, needs to be 48-72 hrs.
A 4yo is being tested for TB via the Mantoux test. What induration size would indicate a positive result?
Answer: 10mm
What is the BCG vaccine? Does it affect how you test patients for TB?
Bacille Calmette-Guerin vaccine, it’s a vaccine used typically outside the US, in countries with high prevalence of TB. For them, their TB Mantoux skin tests will give a false-positive. Blood tests are not affected by the BCG vaccine.
Pt presents with night sweats, fever, fatigue, and blood in urine. What do these symptoms indicate to the NP? What could the patient potentially have?
Extrapulmonary TB (located in the kidneys); autoimmune disease
What are the CDC recommendations for sputum cultures for TB testing?
Answer: Collect at least 3 sputum’ at 8-24hr intervals, with at least 1 in the morning
What is the gold standard for confirming the diagnosis of TB?
Answer: Sputum culture
What is the preferred LTBI treatment for children age 2-11?
Answer: INH for 9 months
Which treatment is best for pregnant women positive for TB?
Answer: INH for 9 months
Should PZA be offered to treat LTBI?
NO
What are patients considered no longer infectious with TB?
3 consecutive negative sputum cultures; symptoms improving; 2 weeks of adherence to TB treatment regimen
Which drug class is never used to treat COPD?
a. LABA
b. Long-acting anticholinergic
c. Leukotriene blockers
d. Systemic steroids
c. Leukotriene blockers
Which patient might be expected to have the worst FEV!?
a. An asthma patient in the green zone
b. A 65-year-old with emphysema
c. A 60-year-old with PNA
d. Patient with bronchiolitis
b. A 65-year-old with emphysema
Which of the following is always present in a COPD pt?
a. Productive cough
b. Obstructed airways
c. SOB
d. Hypercapnia
b. Obstructed airways
A COPD patient has been using albuterol with good relief for SOB. He is using it 3-4x/d x4weeks. How should the NP manage this?
a. Encourage its use.
b. Add a LABA.
c. Tell his to use it only once daily.
d. Add an oral steroid.
b. Add a LABA.
Mild persistent asthma is characterized by:
a. Limitation in activity d/t bronchoconstriction
b. Symptoms occurring more than 2x weekly
c. Wheezing and coughing during exacerbations
d. SOB with exercise
b. Symptoms occurring more than 2x weekly
What does peak flow meter measure?
a. Exercise capacity
b. Oxygen saturation
c. Peak flow capacity
d. Expiratory flow
d. Expiratory flow
Which of the following may be used to diagnose COPD?
a. Chest X-ray or lung CT scan
b. Ct scan of chest or spirometry
c. PFTs or spirometry
d. ABGs or peak flow rate
c. PFTs or spirometry
A 60-year-old patient report chronic cough and sputum production. He has a long hx of 2nd hand exposure to his wife’s cigarette smoke. What diagnosis is most likely?
a. Lung ca
b. Emphysema
c. COPD
d. Allergic cough
c. COPD – (Sputum production distinguishes it from emphysema)
Which of the following is consistent with the NAEPP comment on the use of ICS for children with asthma?
a. The potential, but small, risk of delayed growth with ICS is well balanced by their effectiveness
b. ICS should be used only if leukotriene receptor antagonist fails
c. Permanent growth stunting is consistently noted in children using ICS
d. Leukotriene receptor antagonist is equal in therapeutic effect to the use of LABA
a. The potential, but small, risk of delayed growth with ICS is well balanced by their effectiveness
According to the NAEPP guidelines, which of the following is not a risk of asthma death?
a. Hospitalization
b. Current use of systemic corticosteroids or recent w/d from system corticosteroids
c. Difficulty perceiving airflow obstruction or its severity
d. Rural residence
d. Rural residence
Which of the following is true?
a. Most prescribers are well-versed in the relative potency of ICS and rx an appropriate dose for the pt’s clinical presentation
b. Approximately 80% of the dose of an ICS is systemically absorbed
c. A leukotriene modifier and an ICS are interchangeable clinically because both groups of medication have equivalent antiinflammatory effect
d. Little systemic absorption of mast cell stabilizers occurs with inhaled or intranasal use
e. Due to safety concerns, mast cell stabilizers are no longer available
d. Little systemic absorption of mast cell stabilizers occurs with inhaled or intranasal use
You are considering prescribing oral prednisone to a 34yo male patient with moderate persistent asthma who is having an asthma flare. Which of the following is true?
a. a taper is needed for prednisone therapy lasting >4d
b. a taper is not needed for prednisone regimens <7d
c. a taper is not needed regardless of duration of therapy
d. a taper is needed only if patient is taking a concomitant inhaled corticosteroid
b. a taper is not needed for prednisone regimens <7d
A patient who worked in construction and building destruction 20 years ago presents to your clinic with unilateral, nonpleuritic chest pain, and dyspnea. What is he at risk for based on his career history and present symptoms?
Mesothelioma
What is the immediate treatment for impaired tissue oxygenation d/t smoke inhalation?
100% oxygen
What are some risk factors for the development of bronchogenic carcinoma?
Smoking, environmental exposures (asbestos, radon gas, various metals), fam hx of lung cancer, COPD, pulmonary fibrosis
The incidence of ____ is increased in patients with silicosis?
a. PNA
b. COPD
c. TB
d. Asthma
c. TB
A lung nodule that rapidly grows in size in under 30d is most likely what?
a. Malignant
b. Benign
c. Infectious
C. Infectious
Pg. 292 states that a lung nodule with “rapid progression (doubling time less than 30d) suggests infection”
Cavitary lung lesions with thick walls are likely what?
a. Malignant
b. Benign
c. Infectious
a. Malignant
Which meds cannot be used to treat LTBI?
a. INH
b. Rifampin
c. Pyrazinamide
d. ING-rifapetine
c. Pyrazinamide
Triggers for asthma include which of the following (select all that apply)?
a. tobacco smoke
b. cold air
c. exercise
d. rapid changes in barometric pressure
e. sedentary lifestyle
a. tobacco smoke
b. cold air
c. exercise
d. rapid changes in barometric pressure
NOT E
Effective use of bronchodilator in an asthmatic would result in an increase or decrease in FEV1?
Increase
Upon diagnosis of a 58 yo male with COPD, you should also screen him for what comorbidity?
a. Diabetes
b. Asthma
c. Depression
d. GERD
c. Depression
When used in treating COPD, ipratropium bromide (Atrovent) is prescribed to achieve which of the following therapeutic
effects?
a. Increase mucociliary clearance
b. Reduce alveolar volume
c. Bronchodilation
d. Mucolytic action
c. Bronchodilation
According to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) COPD guidelines, which of the following medications is indicated for use in all COPD stages?
a. SABA
b. ICS
c. Phosphodiesterase 4 (PDE-4) inhibitor
d. Mucolytic
a. SABA
According to the GOLD COPD guidelines, the goal of inhaled corticosteroid use in severe COPD is to:
a. Minimize the risk of repeated exacerbations.
b. Improve cough function.
c. Reverse alveolar hypertrophy.
d. Help mobilize secretions
a. Minimize the risk of repeated exacerbations.
You see a 67yo man with severe (Gold 4) COPD who asks, “When should I use my home oxygen?” You respond:
a. “As needed when short of breath.”
b. “Primarily during sleep hours.”
c. “Preferably during waking hours.”
d. “For at least 15 hours a day.”
d. “For at least 15 hours a day.”
Pts with LTBI are (select all that apply):
a. Infectious
b. Not infectious
c. Have normal x-rays
d. Require isolation
e. Have negative sputum smears and cultures
b. Not infectious
c. Have normal x-rays
e. Have negative sputum smears and cultures
How many weeks after exposure to TB with the PPD test react?
a. 4-6
b. 2-8
c. 1-2
d. 10-12
b. 2-8
An admitted IV drug user presents to your clinic for PPD test, which he says is required for his group housing. You do the test; he returns in 72 hours. He has a 7mm induration. You mark this test as:
a. Positive
b. Negative
b. Negative
In a severe asthma exacerbation, with FEV1 <40%, what are 3-4 things (meds, treatments) that must be done/given; and what 2 medications should be avoided because they can worsen the exacerbation?
Oxygen, high-dose inhaled SABA, systemic corticosteroids (IV mag sulfate); do not give anxiolytics, benzos, hypnotics or
mucolytics (p261 in papa)
Name 4 of the 8 reasons to refer an asthma patient to pulmonology.
Atypical presentation comorbidities such as smoking and environmental allergies poor response to therapy not meeting goals after 6 months high dose ICS multiple rounds of prednisone
Demographically, which of the following is more likely to present with COPD?
a. 57 yo male smoker
b. 12 yo girl who never smoked
c. 42 yo male with hx of smoking, who’s quit
d. 82 yo female who never smoked
a. 57 yo male smoker
Most commonly, COPD exacerbations are precipitated by:
a. Bacterial infection
b. Viral infection
c. Fungal infection
d. Parasitic infection
b. Viral infection
Post-bronchodilator FEV1/FVC less than _____ establishes the presence of airflow obstruction?
a. 0.50
b. 0.70
c. 0.80
d. 0.40
b. 0.70
Which would be present in severe COPD? (select all that apply)
a. Marked increase in residual volume (RV)
b. Elevation of RV/ total lung capacity (TLC) ratio
c. Decrease in TLC
d. Increase in TLC
e. Hypoxemia
a. Marked increase in residual volume (RV)
b. Elevation of RV/ total lung capacity (TLC) ratio
d. Increase in TLC
e. Hypoxemia
Which of the following ECG abnormal rhythms may be present in a COPD patient? – SELECT ALL THAT APPLY!
a. Sinus brady
b. A fib
c. Coarse v fib
d. Sinus tach
e. Multifocal atrial tach
f. A flutter
b. A fib
d. Sinus tach
e. Multifocal atrial tach
f. A flutter
T or F: TB is spread more easily through children than adults?
False
A nurse for an assisted living facility has a TST result of 11mm. How would that be interpreted?
Positive
A bone marrow transplant patient has a TST result of 7mm. How would that be interpreted?
Positive
Jeanine, 32, a professional cellist for the city’s symphony orchestra, comes in and c/o severe stage fright while playing concerts. It’s so bad, she’s had to leave before some performances. She has heard some of the other performers talk about taking propranolol for performance anxiety. She has moderate persistent asthma, which is well-controlled. Can you prescribe this medication?
No, propranolol is a beta blocker and beta receptors need to be working for the smooth muscle relaxation.
Is TST contraindicated in BCG vaccinated people?
No but may create a false positive.
Randy, a 59yo male who has been smoking since he was 9, has been smoking about 4 packs/ day for the last 30 years. He returns to your office for his CT results. The report says he has a single 23mm lesion. He states he will not be going to the pulmonary oncologist because he has the chance of malignancy is about 1%. You respond by saying:
a. You are right. Watch and wait is a good plane
b. There is a 25% chance of malignancy
c. With a lesion that size, the likelihood of malignancy is 80%
d. I will order a sputum cytology test, which is specific and sensitive for malignancy to get more information.
2-5mm has a 1% chance of malignancy
c. With a lesion that size, the likelihood of malignancy is 80%
Dominique is a 39yo AA female who presents to the office with c/o malaise, fever, and dyspnea with gradual onset. She reports history of peripheral neuropathy, arthritis, and an unidentified skin condition with erythematic/purplish hardened growths on her nose, cheeks, and lips. Upon exam, you note parotid gland enlargement, hepatosplenomegaly, and lymphadenopathy. She states she had “some sort of abnormal chest x-ray report informs the urgent care a few weeks ago” but she isn’t sure if that’s related. You DDX includes:
a. Asthma
b. Pneumonia
c. Sarcoidosis
d. DM2
e. Lupus
c. Sarcoidosis
Nick, a 41yo male, non-smoker, who has worked in shipbuilding for the last 20 years, presents with c/o worsening SOB. During your exam, you assess inspiratory crackles, clubbing, and cyanosis. You are concerned he has what? What test do you send him for?
a. Asthma, PFT
b. PNA, CXR
c. TB, sputum culture
d. Asbestosis, chest CT
d. Asbestosis, chest CT
You have just gotten an NP position in the clinic for a Quarry union in Arkansas. You have been told that numerous patients of the clinic have asymptomatic silicosis. You ask if they are also screened for:
a. Lung ca
b. Asthma
c. COPD
d. TB
d. TB
When should PEF be measured? What PEF results indicated poorly controlled asthma?
Measure in the morning before bronchodilator and in the afternoon after bronchodilator; a 20% change indicates poor control
T or F: Apart from acute exacerbations, COPD is not usually responsive to oral corticosteroids?
True
T or F: Bronchial carcinoid tumors grow slow and rarely metastasize, surgical interventions are often necessary.
True
5yo c/o cough 5d/w, awakens at night 4x/month, utilizes SABA 3d/week. She was previously diagnosed with intermittent asthma. What type of control does she have? What is the recommended treatment?
Not well controlled, step up to low dose ICS and follow-up in a month
2-year-old has been having coughing and wheezing daily. He has been waking up 4x/month during the night. He has limitation when playing with other kids on the playground at daycare. He has never been diagnosed with asthma. What is his asthma severity? What is the treatment plan?
Moderate persistent; step 3: start SABA and add medium dose ICS, follow-up in 2-6 weeks
Would SAMA be helpful with exercise induced asthma?
No, SABA or LABA
What are 3 immediate treatments for severe asthma exacerbations?
Oxygen, high dose SABA, systemic corticosteroids
How long do acute urticarial lesions (hives) last?
Less than 6 weeks
Is anaphylaxis mediated by IgE antibodies?
No, anaphylatoxins may mediate it
How should the NP educate the patient about how to prevent anaphylaxis?
Educate, avoid causative agent, and carry EpiPen
What patient populations are high risk for latex allergies?
Health care workers, children with spina bifida
What is considered the gold standard for diagnosing food allergies (except in severe reactions)?
Double blind, placebo-controlled food challenge
Popular urticaria is usually caused by what?
Insects, especially mosquitoes, fleas, bedbugs
Bronchiectasis typically presents with what symptoms?
Foul smelling copious sputum that is typically blood tinged
What is the normal FEV/FVC for 60-80-year-old?
70%
3-year-old child using SABA 3x/weeks, waking up 2x/months only reporting a little limitation. What classification?
Mild persistent, not well controlled, treat with low dose ICS and SABA
4-year-old waking up 1x/month, using SABA multiple times/day. What is classification?
Severe persistent, step 3 medium dose ICS, very poor control, might need oral steroids (1-2mg/kg/day) for 3-7days
What are advanced symptoms of COPD?
Edema, cyanosis, weight loss, decrease muscle strength
What are some diet tips for a patient recently diagnosed with COPD?
Limit caffeine, small frequent meals, avoid overeating, avoid gassy foods/ carbonated drinks
What does GOLD classification indicate?
FEV1 % or severity of COPD
What does GOLD classification of 3 indicate?
FEV1 30-49%
What does GOLD classification of 4 indicate?
FEV1 <30%
What is an example of a COPD questionnaire?
mMRC (measures degree of breathing), CAT
Patient has a C rating via GOLD, what is the first-choice treatment?
ICS and either LABA or LAMA; consider adding PED-4 (roflumilast)
COPD patient has been admitted to the hospital for exacerbation once and CAT less than 10, what letter classification are they?
C- any hospital admission=C
Why might a COPD patient not be compliant with Atrovent?
Anticholinergic s/e: flushing, urinary retention, constipation, dry mouth, cognitive impairment
When do you refer COPD patients?
Persistent symptoms despite adequate management; onset co-morbidities, long-term oxygen therapy, 2+ exacerbations/year,
COPD <40yo
When do you admit COPD patients?
Hypoxia that doesn’t respond to outpatient management, AMS
COPD under 40 is likely caused by what?
DNA: alpha1 antitrypsin
Theophylline is the best choice for which population of COPD patient?
Sleep disorders
3-year-old with cough and SOB 2-3x/weeks, awakens at night with cough 1-2x/month, not using an inhaler (no current diagnosis), minor limitations. What is the severity of asthma? Treatment?
Mild persistent, step 2, SABA and low dose ICS
What would you add if the pt had atopy? Why?
Montelukast, helps with allergies and samters triad (ASA sensitivity, asthma, nasal polyps); if they have allergies, would benefit from a LTRA
Diet suggestions for an asthmatic?
Avoid sulfite-containing foods (salty)
7-year-old with intermittent asthma comes for his check up and states he wakes up less than once/month and report no activity limitations. He reports using his albuterol 4d/week. How is his control, what is the next action?
Not well, add ICS
4-year-old not waking up at night, using SABA 1x/week, has had 2 exacerbations over the last year needing corticosteroids. What severity, what are the next steps?
Not well controlled, mild persistent, add ICS
First line treatment for urticaria?
Antihistamine
Which is more likely associate with systemic complications: urticaria or angioedema?
Angioedema causes laryngoedema and hypotension
6-year-old presents to office already using SABA and low dose ICS. Uses SABA 3x/weeks, wakes up 2x/month, has required steroids 1x this year, has some limitations with activity. What are the next steps?
Low dose ICS with LABA, not well controlled; alternate: medium dose ICS
6-year-old not waking up at night, using SABA 1d/week, no limitations; what are next steps?
Nothing, continue regimen because well controlled
10-year-old, waking up 1x/week, increased SABA use to 2x/day, low dose ICS daily, some limitations, daily SOB and cough; what are next steps?
Add LABA
11-year-old with predicted FEV of 70%, what are they?
Moderate persistent, not well controlled, consider short course of systemic corticosteroids and follow-up in 2-6weeks
What should you be doing/asking each time you step up a patient?
Assess compliance/environmental changes and educate
Normal FEV1/FVC for 35-year-old patient is? What about 62-year-old?
80%; 70%
Pt complains of peripheral neuropathy with taking INH for LTBI, what can you do?
Add B6
What is the oral corticosteroid dose for a 15-year-old having an acute asthma attack?
Prednisone 1-2mg/kg/day divided BID or daily, max dose of 60mg
Signs and symptoms of mesothelioma?
Unilateral, non-pleuritic chest pain, dyspnea; mostly on the right side
4 components of asthma care in the stepwise approach?
Education, control of environmental factors and comorbid conditions, medications, assessing and monitoring
Goals of asthma therapy?
Reduce impairment and reduce risk
What do you educate the parent and patient about regarding administration of ICS?
Use a chamber, rinse mouth after use to decrease SE
Suspect _________syndrome if patient has hemoptysis and glomerulonephritis.
Goodpasteurs
What is key for effective asthma care?
Self-management education
Non-medication treatment to decrease exercise induced bronchospasm?
Longer warm-up
In asthma, at what stage can you offer subQ immunotherapy?
With suspected allergies starting at stage 2
Treatment of sarcoidosis?
Long-term prednisone 0.5-1mg/kg/d
Common cause of R middle lobe syndrome?
Foreign body
T or F: Sarcoidosis has an increased calcium level in blood and urine
True
Best test to screen for lung cancer?
Low dose helical CT scan
When do you screen for lung cancer?
Greater than 20pack years smoker, within 15 years of smoking
Which cancer is the leading cause of death?
Lung
Is small cell slow or aggressive? And what is the survival rate?
Aggressive (so is large cell), survival is 16-18w
What does TNM stand for when staging cancers?
Tumor, nodule metastasis (distant)
3 consequences of smoke inhalation?
Hypoxia, thermal injury to upper airway, and something to the lower airway
What is a single non-medication modality treatment for COPD?
Pulmonary rehab (SAMA for medication)
Example of appropriate exercise for COPD?
Purse lip breathing, walking for 20 minutes or biking
Lung institute says what new treatment shows increased QOL in 84.5% of COPD patients?
Stem cell
T or F: Men over 40 who smoke and have COPD are at risk for lung cancer?
True
T or F: Solitary pulmonary nodule or “coin lesion” that is less than 5mm in size and is seen with calcification is concerning for lung cancer
False, it’s benign
Common symptoms of COPD are?
Cough, dyspnea, sputum production
Is a chest X-ray needed to diagnose COPD?
No. CXR may show hyperinflation but PFT are the standard for diagnosis. PFT may be able to diagnose prior to the presentation of symptoms (COPD dx FEV1 < 0.7)
What is the preferred first line agent for COPD – SABA or Ipratropium Bromide?
Ipratropium Bromide
Should ICS alone every be used as a first line agent for COPD?
No.
Which drug class is never used to treat COPD?
A: LABA
B: long-acting anticholinergic
C: Leukotriene blockers
D: Systemic steroids
C (Anti Leukotriene drugs)
Which of the following is always present in a COPD patient?
A: Productive cough
B: Obstructed airways
C: SOB
D: Hypercapnia
B. Obstructed airways
A COPD patient has been using albuterol w/ good relief for SOB. He is using it 3-4 times/day x 4 weeks. How should the NP manage this?
A: Encourage its use
B: add a LABA
C: tell him to use it only once daily
D: add an oral steroid
B. add a LABA
Which of the following may be used to dx COPD?
A: Chest x-ray or lung CT scan
B: CT scan of chest or spirometry
C: PFT or spirometry
D: ABGs or peak flow rate
C: PFT or spirometry
Upon dx of 58 yo M with COPD, you should also screen him for what co-morbidity?
A: diabetes,
B: asthma
C: depression
D: GERD
C: depression
When used in tx of COPD, Ipratropium Bromide (Atrovent), is prescribed to achieve what effect?
bronchodilation
According to the GOLD COPD guidelines, which med is indicated for use in all stages?
SABA
According to the GOLD COPD guidelines, the goal of inhaled corticosteroid use in sever COPD is to?
minimize risk of repeated exacerbations
Most commonly, COPD exacerbations are precipitated by:
A: bacterial infection
B: viral infection
C: fungal infection
D: parasitic infection
A. bacterial infection
Which would be present in severe COPD? – SELECT ALL THAT APPLY!
A: Marked increase in residual volume (RV) B: elevation of RV/TLC ratio C: decrease in total lung capacity (TLC) D: increase in TLC E: hypoxemia
A: Marked increase in residual volume (RV)
B: elevation of RV/TLC ratio
C: decrease in total lung capacity (TLC)
D: increase in TLC
Answer: A, B, C, D
Which of the following ECG abnormalities may be present in a COPD patient? – SELECT ALL THAT APPLY!
A: Sinus Bradycardia B: A-fibrillation C: Coarse V-fib D: Sinus Tachycardia E: Multifocal Atrial Tachycardia F: A-Flutter
B: A-fibrillation
D: Sinus Tachycardia
E: Multifocal Atrial Tachycardia
F: A-Flutter
Answer: B, D, E, F
T or F: Bronchodilators alter the disease process and decline of COPD?
False (Oxygen can alter the disease process and decline COPD)
T or F: All COPD should be on a prophylactic antibiotics.
False. Prophylaxis is an independent decision concerning immunity and grading of COPD
T or F: USPSTF recommends screening with low dose helical CT scans for lung cancer
True
T or F: Women are more likely to be diagnosed with mesothelioma
False
“Massive” hemoptysis is typically defined as expectorating ________ per 24 hours?
200ml/24 hours 60ml/2 hours
Is emphysema or chronic bronchitis typically associated with obstructive sleep apnea?
Chronic Bronchitis
What is the MAJOR complaint of Emphysema?
Dyspnea
What is the MAJOR complaint of chronic bronchitis?
Cough
What is a “coin lesion”? What does it indicate?
Solitary pulmonary nodule that can indicate malignancy is likely
Are corticosteroids and antibiotics recommended in patients with smoke inhalation?
No
T or F: A patient with a TNM stage IIIB cancer would benefit from surgery
False
What is the major difference in presenting complaints of “pink puffers” and “blue bloaters”?
“Blue Bloaters” (bronchitis predominant) present with complaints of cough
“Pink Puffers” report dyspnea
A patient who worked in construction and building destruction twenty years ago presents to your clinic with unilateral, nonpleuritic chest pain and dyspnea. What is he at risk for based on his career history and present symptoms?
Mesothelioma
What is the immediate treatment for impaired tissue oxygenation due to smoke inhalation?
100% oxygen
What are some risk factors for the development of bronchogenic carcinoma?
smoking, environmental exposures, family hx of lung cancer, COPD, pulmonary fibrosis, and asbestos
What are the most common side effects of long term inhaled steroid use?
bone demineralization & cataracts
12-year-old patient presents to clinic with wheezing, SOB, and feeling of tightness in chest. Which would be best in determining dx?
PFTS
Increasing use of SABA or use ________ days a week for symptoms relief generally indicates inadequate control and need to step up treatment.
> 2
LABAs provide bronchodilation for up to ______ hours after a single dose.
12 hrs.
What are the first line treatment agents for all patients with persistent asthma?
Low dose ICS
What baseline labs should be obtained prior to starting TB medication regimens?
AST and ALT, LFTs, CBC, Serum Creatinine
Which patient might be expected to have the worst FEV1?
A: Patient with asthma in the green zone
B: 65 yo with emphysema
C: 60 yo with PNA
D: Patient with bronchiolitis
B. 65 yo with emphysema
What does a peak flow meter measure?
A: exercise capacity B: oxygen saturation C: peak flow capacity D: expiratory flow Answer: D
D: expiratory flow
A lung nodule that rapidly grows in size in under 30 days is most likely
A: malignant
B: benign
C: infectious
A. malignant
Cavitary lung lesions with thick walls are likely to be:
A: malignant
B: benign
C: infectious
A. malignant
T or F: It is recommended to perform a TB blood test over TST when the patient has received the BCG vaccination
True
Post-bronchodilator FEV1/FVC less than ______ establishes the presence of airflow obstruction?
A: 0.50
B: 0.70
C: 0.80
D: 0.40
B. 0.70
When should PEF be measured? What PEF results indicated poorly controlled asthma?
measure in the morning (when its lowest) before bronchodilator and in the afternoon after bronchodilator; a 20% change indicates poor control
What are symptoms of pulmonary TB?
Cough (3+ weeks), hemoptysis, chest pain, sputum production, weight loss, anorexia, fatigue
Interpretation of the Mantoux test - what are some patients populations that a >10mm induration would be classified as positive?
At risk peds, lab workers, healthcare workers, IV drug users
How long after infection can LTBI be detected by TST or IGRAs?
2-8 weeks
T or F: Direct Observed Therapy (DOT) is recommended for only high risk population groups
False, its recommended for all
What TB regimen is recommended for pregnant women? What should the NP do if the patient is unable to take regimen?
9 months of INH daily or twice weekly, give with vitamin B6. If cannot take INH, consult TB expert
A prisoner has a TB skin test with a 10mm induration. What does this tell the NP?
Positive result, needs treatment
T or F: LTBI radiographs are typically abnormal
False
Patient received a Mantoux TB test and returned to the office 24 hours later with no reaction, is this a negative result?
No. Reading of TB skin test must be read at 48-72h.
4 year old is being tested for TB via the Mantoux test. What induration size would indicate a positive result?
> or = to 10 mm
What is the BCG vaccine? Does it affect how you test patients for TB?)
Bacille Calmette-Guerin vaccine (a vaccine used typically outside the U.S., in countries with high prevalence of TB. For these folks, their TB Mantoux skin tests will give a false-positive. Blood tests are not affected by the BCG vaccine
Pt presents with night sweats, fever, fatigue, and blood in urine. What do these symptoms indicate to the NP? What could the patient potentially have?
Extrapulmonary TB, specifically located in the kidneys (due to blood in urine)
What are the CDC recommendations for sputum cultures for TB testing?
ALL suspected cases should have sputum cultured collected to include at least 3 specimens (8-24 hr. intervals, with at least one in morning)
What is the gold standard for confirming the diagnosis of TB?
sputum culture
What is the preferred LTBI treatment for children age 2-11?
INH for 9 months
Pregnant woman positive for TB – which treatment is best?
INH for 9 months
When are patients considered no longer infectious with TB?
3 consecutive negative sputum cultures, improving symptoms, and 2 weeks of adherence to TB treatment regimen
The incidence of _____ is increased in patients with silicosis?
A: PNA
B: COPD
C: TB
D: Asthma
C. TB
Which meds cannot be used to treat LTBI?
A: INH
B: Rifampin
C: Pyrazinamide
D: INH-rifapetine
C: Pyrazinamide
LTBI is characterized by which of the following? SELECT ALL THAT APPLY!
A: Infectious B: Not infectious C: Normal x-rays D: Require isolation E: Negative sputum smears & cultures
B: Not infectious
C: Normal x-rays
E: Negative sputum smears & cultures
Answer: B, C, E
How many weeks after exposure to TB will the PPD test react?
A: 4-6
B: 2-8
C: 1-2
D: 10-12
B: 2-8
An admitted IV drug user presents to your clinic for PPD test, which he says is required for his group housing. You do the test, he returns in 72 hours. He has a 7 mm induration. You mark this as
A: positive
B: negative
B: negative
A nurse for an assisted living facility has a TST result of 11mm. Is she positive or negative?
+ b/c >10mm
A bone marrow transplant patient has TST result of 7mm – positive or negative?
+b/c > or = to 5mm
You have just gotten an NP position in the clinic for a Quarry union in Arkansas. You have been told that numerous patients of the clinic have asymptomatic silicosis. You ask if they are also screened for?
A: lung cancer
B: asthma
C: COPD
D: TB
D: TB
Does every patient with asthma need a SABA?
Yes!
30 year old with persistent asthma. What are essential components of their plan of care? SELECT ALL THAT APPLY!
A: Asthma Action Plan
B: Flu and Pneumonia Vaccines
C: Rescue inhaler
D: LABA
A: Asthma Action Plan
B: Flu and Pneumonia Vaccines
C: Rescue inhaler
Answer: A, B, C
T or F: Asthma patients and COPD patients both need rescue inhalers?
True
What is the strongest predictor of Asthma?
Atopy
In _______ air flow may be so restricted that wheeze may be absent and breath sounds are diminished
Severe Asthma
How should you diagnose a 3 year old with asthma? Does this process change with an 9 year old being diagnosed? How so?
3 yr. old – based on signs, symptoms, and exam, unable to cooperate for PFT.
Yes, in a 9 yr. old – based on signs, symptoms, exam and PFT
What in addition to a PFT may a NP refer the patient out for when Asthma is suspected in a patient?
Allergy testing
What gender as children is asthma is more common? What gender in adults is asthma more common?
Children: males, under the age of 14
Adults: female
In cases of asthma, the trachea and bronchi typically become more:
A) narrowed
B) hyperemic
C) thickened
D) responsive
D) responsive
Which of these manifestations is least likely to present with the onset of asthma?
A) plugging of airways with thick mucus
B) hypertrophy of the mucus glands
C) thinning of the epithelial basement membrane
D) hypertrophy of smooth muscle
C) thinning of the epithelial basement membrane
What is the hallmark sign of asthma?
A) daytime, unproductive cough
B) reduced airway inflammation
C) tripod positioning to assist breathing
D) bronchoconstriction
D) bronchoconstriction
bronchial hyperresponsiveness
Upon your physical exam of a 19 yo F presenting with complaints of an asthma exacerbation during exercise, you auscultate her lungs and hear:
A) decreased air flow
B) faint or absent breath sounds
C) expiratory wheezes
D) pleural friction rub
C) expiratory wheezes
typical
T or F: Inhaled corticosteroids are the first line of rescue treatment for acute asthma exacerbations?
False, SABA
T or F: Inhaled nebulized meds are always more effective than inhaled meds from MDI
False
Mild persistent asthma is characterized by:
A) limitation in activity d/t bronchoconstriction
B) sx occurring more than 2x weekly
C) wheezing and coughing during exacerbations
D) SOB w/exercise
B) sx occurring more than 2x weekly
According to the NAEPP guidelines, which of the following is not a risk of asthma death?
A) hospitalization
B) current use of systemic corticosteroids or recent w/d from systemic corticosteroids
C) difficulty perceiving airflow obstruction or its severity
D) rural residence
D) rural residence
You are considering rx’ing oral prednisone to a 34yo M pt. with moderate persistent asthma who is having an asthma flare. Which of the following is true?
A) A taper is needed for prednisone therapy lasting > 4 days
B) A taper is not needed for prednisone regimens < or = 7 days
C) A taper is not needed regardless of duration of therapy
D) A taper is needed only if pt. is taking concomitant inhaled corticosteroids
Answer: B
B) A taper is not needed for prednisone regimens < or = 7 days
Triggers for asthma include which of the following:
A) tobacco smoke B) cold air C) exercise D) rapid changes in barometric pressure E) sedentary lifestyle Answer: A, B, C, D
A) tobacco smoke
B) cold air
C) exercise
D) rapid changes in barometric pressure
Answer: A,B, C, D
Effective use of a bronchodilator in an asthmatic would result in an increase or decrease in FEV1?
Increase
In a severe asthma exacerbation, with FEV1 < 40%, what are 3-4 things (meds, treatments) that must be done/given, and what 2 medications should be avoided b/c they can worsen the exacerbation?
give oxygen, high-dose inhaled SABA, systemic corticosteroids (4th one is IV mag sulfate, but that was a bonus one; Do not give anxiolytics/benzos/hypnotics or mucolytics!)
Demographically, which of the following is more likely to present with COPD?
A) 57 yo M smoker,
B) 12 yo girl who never smoked
C) 42 yo M hx of smoking, now quit
D) 82 yo F who never smoked
A) 57 yo M smoker
Would a SAMA be helpful with exercise induced asthma?
No! SABA or LABA
