ANCC STUDY GUIDE 2023, Quizzes of Nursing

Download ANCC STUDY GUIDE 2023 and more Quizzes Nursing in PDF only on Docsity! Erythema infectiosum (A), or fifth disease, is a viral illness caused by the human parvovirus B19. It is characterized by a classic slapped-cheek appearance and a lacy exanthem. Most infections occur in children aged 5– 15, but the disease can develop at any age. Patients often present about 1 week after exposure to the virus with mild prodromal symptoms that may include headache, fever, sore throat, pruritus, runny nose, abdominal pain, and joint pain. Patients may be symptom free for about 7–10 days after the initial prodrome, after which the infection progresses to the development of the classic slapped-cheek appearance and an erythematous maculopapular rash that presents in a classic lacy, reticular pattern. The rash will appear on the arms, extensor surfaces, and trunk, sparing the palms and soles. Pruritus is rare. Adults are more likely to develop symmetrical polyarthropathy after the initial prodrome. The diagnosis is made clinically in patients who present with classic symptoms, so confirmation is often unnecessary. For patients who present atypically or in patients who are pregnant at risk for fetal transmission, infection can be confirmed through serologic testing. Since erythema infectiosum is a benign and self-limited disease, treatment is symptomatic. Fluids and rest are imperative. NSAIDs can relieve fever, malaise, headache, and joint pain. Oral and topical antihistamines can help with pruritus. Infected children should be isolated, especially from individuals who have chronic anemia or immunosuppression or who are pregnant. Why are the other choices incorrect? Hand, foot, and mouth disease (B) presents as a vesicular eruption of the mouth that may also involve the palms of the hands, soles of the feet, buttocks, and genitalia. Lesions may be painful, and patients may also present with a fever. Roseola (C) presents characteristically with an acute high fever and a morbilliform rash that appears on the trunk after several days. It typically presents in patients younger than 24 months. Patients with rubella (D) present with a low-grade fever, followed by a maculopapular rash that initially starts on the face and neck and spreads to the trunk and extremities. Patients will also have enlargement of the posterior auricular and suboccipital lymph nodes. The suspected causative atypical pathogen of this patient’s diagnosis of community-acquired pneumonia (CAP) is Mycoplasma pneumoniae. This patient’s presentation is consistent with M. pneumoniae because of the extrapulmonary manifestations of arthralgias and rash. Her age of 15 years old and dormitory living are also risk factors for developing M. pneumoniae infection. Another atypical organism that causes CAP in adolescents is Chlamydophila pneumoniae. Atypical organisms, such asM. pneumoniae and C. pneumoniae, can cause extrapulmonary manifestations that may include hemolysis and CNS involvement (A). Extrapulmonary manifestations occur in about 5–10% of patients and are caused by the formation of cold agglutinin antibodies. Examples of CNS involvement are cranial nerve palsies, encephalitis, aseptic meningitis, cerebellar ataxia, and ascending paralysis. M. pneumoniae rarely affects children < 5 years old but is most common in older children and young adults aged 5–20 years old. Other risk factors include smoking, immunosuppression, and any type of close community housing. Other extrapulmonary manifestations seen in atypical pneumonia are arthralgias, rash, cervical adenopathy, congestive heart failure, and cardiac dysrhythmias. M. pneumoniae is treated empirically with macrolides. Why are the other choices incorrect? M. pneumoniae is not the most common etiology in all age groups (B). Streptococcus pneumoniae is the most common bacterial cause of pneumonia in children overall. Penicillin is not the most appropriate treatment for M. pneumoniae infection (C) because it is not effective. A macrolide is the most appropriate treatment option. The formation of cold agglutinins is not a positive confirmatory test (D), as cold agglutinins are only present in 50% of infections, and they are neither sensitive nor specific. Testing is not routinely recommended or diagnostic. Group A Streptococcus (GAS) is the most common cause of bacterial pharyngitis in children between 5 and 15 years old. Symptoms in children ≥ 3 years of age include sore throat, fever, abdominal pain, headache, nausea, and vomiting. Physical exam findings of GAS include exudative tonsillopharyngitis, enlarged tonsils, palatal petechiae, cervical lymphadenopathy, and scarlatiniform rash. Penicillin (D) is the treatment of choice for GAS. Schlatter disease (B) is osteochondrosis of the tibial tubercle apophysis. Physical exam findings usually include prominence and tenderness of the tibial tubercle and pain with resisted knee extension. A quadriceps muscle strain (C) may cause knee pain and an altered gait but would not cause limitation of internal rotation of the hip. Urticaria, commonly known as hives, is a skin condition characterized by raised areas of erythema and edema that are pruritic. It can be acute (resolving within 6 weeks) or chronic (lasting > 6 weeks). Acute urticaria can be triggered by a recent illness, medications, intravenous contrast, recent travel, introduction of new foods, hygienic products (e.g., detergents, creams, and lotions), pregnancy, sun or cold exposure, exercise, and alcohol ingestion. Management of urticaria focuses on alleviating symptoms and avoiding exposure to known causes. In most cases, urticaria will resolve spontaneously within a few days or weeks. Less sedating antihistamines that block histamine H1 receptors, such as loratadine (Claritin) (B), are preferred over more sedating antihistamines, such as diphenhydramine (Benadryl). In refractory cases, histamine H2 blockers or short courses of glucocorticoids can be added to the regimen. Urticarial lesions on the skin are described as blanchable, raised wheals that can be linear, circular, or serpiginous and can occur anywhere on the skin. The wheals are transient and can migrate or combine to form larger areas of erythema and edema. Patients may also have dermatographism, which is a condition in which light pressure, such as scratching, can cause raised marks. Laboratory testing is only necessary in patients with chronic or recurrent urticaria, as acute cases can be diagnosed clinically. A CBC, erythrocyte sedimentation rate, TSH, and antinuclear antibody should be evaluated to rule out underlying disease. Rare complications of acute urticaria include angioedema of the lips, tongue, or larynx and acute bronchospasm, which can be life threatening. IM epinephrine can be used to treat angioedema, and nebulized albuterol (ProAir HFA) can be used for acute bronchospasm. Patients with chronic or recurrent urticaria should be referred to a dermatologist, allergist, immunologist, or rheumatologist for further workup. Why are the other choices incorrect? IM epinephrine (A) should only be administered to patients with symptoms of angioedema and airway compromise. Prednisone (C) in short courses can be given in refractory cases but is not first line. Tacrolimus (Progaf) (D) is a topical calcineurin inhibitor used for the treatment of atopic dermatitis when topical steroids are contraindicated or not preferred. A 24-year-old woman with endometriosis presents to the office with a report of frequent headaches for the past year. She reports a severe pulsating headache above and behind her right eye with light sensitivity and nausea. The headache occurs 12 days per month. She currently takes naproxen (Aleve) with good relief. She would like to start a preventative medication. She is currently taking norethindrone acetate and ethinyl estradiol (Loestrin). Which of the following medications would be most appropriate to initiate? Correct A. Amitriptyline 25 mg oral nightly Incorrect B. Erenumab (Aimovig) 70 mg SC once monthly Incorrect C. Topiramate (Topamax) 25 mg oral nightly Incorrect D. Valproate (Depakote) 500 mg oral once daily Review Previous QuestionReview Next Question Correct answer explanation Migraine headache is characterized by a pulsatile headache that is typically unilateral. It may be accompanied by nausea, vomiting, and photophobia. Preventative therapy is typically considered in patients who have more than four headaches per month lasting longer than 12 hours. Initial preventative treatment includes a tricyclic antidepressant, such as amitriptyline 25 mg oral nightly (A). Other options include beta-blockers, such as propranolol (Hemangeol), or antiseizure agents, such as topiramate (Topamax). The appropriate treatment regimen should be selected based on the patient’s age, comorbidities, and use of other medications. If the initial drug choice is not effective, it is recommended that the patient try an alternative drug class. Migraine is more commonly seen in women than men and in patients who have a positive family history of migraine headache. Migraines can be triggered by stress, menstruation, barometric pressure changes, odors, wine, and certain foods, among many other possible triggers. Diagnosis of migraine is based on clinical history and physical examination. A distinction should be made regarding whether the patient has an accompanying aura, which is characterized by focal neurological symptoms. Neuroimaging should be considered if the patient has abnormal physical examination findings or other atypical headache features. Why are the other choices incorrect? Erenumab (Aimovig) 70 mg SC once monthly (B) is not indicated as a first- line agent for migraine prevention due to the high cost and limited long-term safety data. Topiramate (Topamax) 25 mg oral nightly (C) is used as a first- line treatment for migraine prevention. However, it should be used cautiously in young women who take estrogen-based oral contraceptives, as it can decrease the serum concentration of estrogen and cause contraceptive failure. Valproate (Depakote) 500 mg oral once daily (D) is a reasonable treatment option for migraine, particularly in patients with a concurrent seizure disorder. However, it is not recommended in people of childbearing age, as it is teratogenic. It can additionally be poorly tolerated due to unpleasant side effects of weight gain, tremor, and hair loss. A 38-year-old man presents to the clinic for pain with swallowing for 1 week. He states that he has been unable to eat solid foods because it is too painful, and now it is becoming painful when swallowing liquids. He has a history of HIV. Which of the following is the most likely diagnosis? Incorrect to a larger, circular patch with central clearing, erythema, and a scaly border. Itching may be the only reported symptom, and the lesions are most commonly found on the trunk or extremities. Tinea corporis is typically treated with topical antifungal medications, such as clotrimazole cream (Lotrimin) (A). Alternative treatments include systemic antifungals, such as itraconazole (Sporanox) and terbinafine. Tinea corporis is most commonly caused by Trichophyton rubrum and Microsporum organisms. Transmission may occur through close contact with an infected individual, pet, or contaminated soil or the sharing of clothing items. Adolescents and young adults are the most commonly infected, but other risk factors for infection include a history of chronic fungal infections, hyperhidrosis, immunodeficiency, and diabetes mellitus. The diagnosis of tinea corporis is typically based on physical assessment findings and a clinical history. However, if necessary, the diagnosis can be confirmed by a potassium hydroxide evaluation, which will show pseudohyphae with budding yeast formations. Patients should be advised to keep the skin clean and dry and avoid close contact or sharing of clothing items until the infection is eradicated. Why are the other choices incorrect? Mupirocin cream (Centany) (B) is a type of topical antibiotic, not antifungal, used for the treatment of impetigo or folliculitis. Nystatin ointment (C) is not effective against dermatophytosis, such as tinea corporis, but is effective at treating Candida  infections. Selenium sulfide lotion (D) is an antifungal medication commonly used to treat fungal infections that cover a larger surface area, such as tinea versicolor. A 38-year-old woman presents to the clinic with a 4-day history of productive cough, fever, chills, and dyspnea. She does not smoke cigarettes and has not used any antibiotics within the past 3 months. Her temperature is 102.4°F, oxygen saturation is 95%, HR is 104 bpm, and BP is 106/78 mm Hg. On examination, crackles are noted at her lung bases bilaterally. Which of the following is the first-line pharmacotherapy for this patient’s suspected condition? Correct A. Amoxicillin 1 g three times daily for 5 days Incorrect B. Azithromycin (Zithromax) 500 mg once daily for 3 days Incorrect C. Levofloxacin (Levaquin) 750 mg once daily for 5 days Incorrect D. Penicillin 500 mg twice daily for 7 days Review Previous QuestionReview Next Question Correct answer explanation Community-acquired pneumonia (CAP) is an acute infection of the pulmonary parenchyma that is acquired outside of health-care settings. Typical symptoms include fever, malaise, dyspnea, pleuritic chest pain, cough, and sputum production. Symptoms of CAP can range from mild to severe, requiring hospitalization. Risk factors for CAP include older age, cigarette smoking, viral respiratory infections (e.g., influenza, COVID-19), and comorbid chronic conditions (e.g., COPD, alcohol use disorder). The diagnosis should be confirmed by chest radiography or U/S. According to the ATS/IDSA guidelines, the first-line outpatient antibiotic treatment for low-risk patients is high-dose amoxicillin (A). The most common pathogens associated with CAP are Streptococcus pneumoniae and respiratory viruses. Testing for specific bacteria is generally not necessary in the outpatient setting. Monotherapy with macrolide antibiotics (e.g., azithromycin [Zithromax]) is no longer routinely recommended due to high rates of resistance by S. pneumoniae. Patients with comorbid conditions or recent parenteral antibiotic use will require combination therapy for coverage of additional pathogens (e.g., Haemophilus influenzae, Moraxella catarrhalis, and methicillin- susceptible Staphylococcus aureus). For patients with confirmed influenza virus, antiviral treatment is warranted. Patients with severe symptoms may require hospitalization. Why are the other choices incorrect? Azithromycin (Zithromax) 500 mg once daily for 3 days (B) is not considered first-line for CAP due to high rates of antibiotic resistance. However, it may be used if local pneumococcal resistance is < 25%. Levofloxacin (Levaquin) 750 mg once daily for 5 days (C) is not considered first-line for low-risk patients with CAP. Penicillin 500 mg twice daily for 7 days (D) is not an effective treatment for CAP. A 49-year-old woman presents to the clinic with dizziness for 1 day. She describes the dizziness as a sensation of the room spinning with any sudden movement of her head and causing nausea. A focused neurologic examination reveals no abnormalities. The nurse practitioner notes a torsional, upbeating nystagmus when the patient is quickly placed in a supine position with her head turned to the right. During this maneuver, she reports severe dizziness and nausea. Which of the following is the best next step in caring for this patient? Incorrect A. Initiate meclizine (Antivert) 25 mg every 6 hours Correct B. Initiate the Epley maneuver Incorrect C. Obtain MRI of the brain Incorrect D. Benign paroxysmal positional vertigo (BPPV) is a common form of vertigo associated with canalithiasis or calcium debris within the posterior semicircular canal. Episodes of BPPV typically last less than 60 seconds and are triggered by certain head movements, such as rolling over in bed. In addition to vertigo, patients may experience nausea and vomiting. Patients with BPPV typically do not experience hearing loss or neurological symptoms. When the nurse practitioner takes a history, symptoms of vertigo (e.g., sensation of motion when not moving) should be differentiated from the feelings of lightheadedness or faintness that occur with orthostatic hypotension. Diagnosis of BPPV is made by clinical history and the Dix- Hallpike maneuver (B). The Dix-Hallpike maneuver is a series of movements used to elicit vertigo and nystagmus in patients with BPPV. The presence of vertigo with or without nystagmus during the Dix-Hallpike maneuver confirms the diagnosis. Treatment for BPPV involves particle repositioning maneuvers, such as the Epley maneuver, which repositions the calcium debris from the semicircular canal into the vestibule. This maneuver can be repeated until achieving relief of symptoms. Alternatively, patients can be given exercises for self- treatment at home, such as the Brandt-Daroff exercises. Why are the other choices incorrect? A CMP (A) is not required for the diagnosis of BPPV, as BPPV can be diagnosed clinically. The Epley maneuver (C) is a treatment, rather than a diagnostic tool, for BPPV. Head CT (D) is not indicated for the diagnosis of BPPV. A head CT may have been of use if there were neurologic symptoms present. A 40-year-old man presents to the clinic with reports of left eyelid swelling and eye pain. He was treated in the clinic 2 weeks ago for acute sinusitis. His temperature is 102.1°F, and the physical examination is notable for a swollen and erythematous left eyelid. He reports pain with extraocular movements. His visual acuity is unaffected. Which of the following is the most appropriate treatment for the suspected diagnosis? Incorrect A. Ciprofloxacin ophthalmic 0.3% ointment (Ciloxan) Incorrect B. High-dose oral amoxicillin-clavulanate (Augmentin) Correct C. Intravenous vancomycin and ceftriaxone Incorrect D. Oral cephalexin (Keflex) and warm compresses Review Previous QuestionReview Next Question Correct answer explanation Orbital cellulitis is an infection of the extraocular muscles and periorbital fat. It does not involve the globe of the eye. Bacterial rhinosinusitis is the most common cause of orbital cellulitis. Staphylococcus aureus and streptococci are the most frequently identified pathogens in orbital cellulitis. Patients with orbital cellulitis require immediate empiric intravenous antibiotics to prevent the spread of infection and optic nerve damage, which may lead to loss of vision. This patient should be referred to the ED for treatment with intravenous vancomycin and ceftriaxone (C), which constitute the preferred regimen for orbital cellulitis. Cefotaxime is an appropriate alternative to ceftriaxone. Patients with uncomplicated orbital cellulitis who respond well to intravenous antibiotics can be switched to oral therapy after their fever has resolved and significant clinical improvement is noted, typically in 3–5 days. Distinguishing orbital cellulitis from preseptal cellulitis is essential because orbital cellulitis is potentially vision and life threatening. While orbital cellulitis affects the extraocular muscles and periorbital fat, preseptal cellulitis only involves the anterior soft tissue. Orbital cellulitis and preseptal cellulitis both cause ocular pain and eyelid erythema and swelling, but only orbital cellulitis causes painful eye movements, proptosis, and ophthalmoplegia. Fever is more common in orbital cellulitis. CT imaging is used to confirm clinically suspected orbital cellulitis. An urgent ophthalmology consult should be obtained. Otolaryngology is often also consulted. Why are the other choices incorrect? Ciprofloxacin ophthalmic 0.3% ointment (Ciloxan) (A) is a recommended treatment for bacterial conjunctivitis in patients who wear contact lenses. It is not an appropriate treatment option for orbital cellulitis. High-dose oral amoxicillin-clavulanate (Augmentin) (B) and oral cephalexin (Keflex) and warm compresses (D) are not effective for the treatment of orbital cellulitis, which requires parenteral antibiotics. A 60-year-old woman presents to the clinic for evaluation of abdominal pain. She reports a burning pain in the epigastrium that worsens after eating. Nausea and lack of appetite are associated with the pain. She has a stressful, labor-intensive job, and she suffers from intermittent back pain, but she is otherwise healthy. She was taking naproxen (Aleve) daily for back pain for approximately 1 month, but she discontinued daily use 2 weeks ago and is currently using the medication only as needed. Which of the following treatments will most effectively promote mucosal healing? Incorrect A. Aluminum hydroxide Incorrect B. Famotidine (Pepcid) Correct C. Omeprazole (Prilosec) Incorrect D. Non-alcohol-related fatty liver disease (NAFLD) is the most prevalent chronic liver disease in the United States. The two categories of NAFLD are non- alcohol-related fatty liver (NAFL) and non-alcohol-related steatohepatitis (NASH). NAFL is characterized by hepatic steatosis without notable inflammation, while NASH is associated with liver inflammation. Conditions associated with NAFLD include central obesity (B), type 2 diabetes, metabolic syndrome, hyperlipidemia, insulin resistance, and hypertension. Patients with NAFLD are typically asymptomatic, although some patients may report fatigue, right upper quadrant abdominal pain, and malaise. The physical examination may reveal hepatomegaly. Signs of portal hypertension may be associated with advanced liver fibrosis or cirrhosis. Aspartate aminotransferase (AST) and alanine transaminase (ALT) are two liver enzymes that are elevated in the setting of liver damage. Patients with NAFLD may have mild to moderate elevations in AST and ALT. The degree of elevation is not a reflection of the degree of liver inflammation or damage. While liver imaging studies (MRI, U/S, CT) may aid in diagnosis, the most accurate test that measures the degree of liver inflammation and scarring is a liver biopsy. Management of NAFLD consists of diet, exercise, and weight loss. Treatment of hyperlipidemia, hypertension, and other comorbidities is also crucial, as they play a role in the development of liver inflammation. Patients who also have diabetes should have appropriate control of blood glucose and consume a low-carbohydrate diet. Patients with elevated liver function tests on two separate testing dates should be referred to a gastroenterologist or hepatologist. Patients and families should understand the significant risk for the development of cirrhosis and liver failure if lifestyle modifications are not made. Why are the other choices incorrect? BMI of 16 kg/m2 (A) is considered to indicate an underweight patient and is not a common finding of NAFLD. A low-grade fever (C) is often seen with acute hepatitis infections. Needle track marks (D) are associated with injectable drug use. A 64-year-old woman presents to the clinic with nausea and vomiting for 1 week. She states that she feels full early into eating her meals and becomes bloated. The patient has a history of osteoporosis and type 2 diabetes mellitus. Which of the following physical assessment findings is consistent with the suspected diagnosis? Incorrect A. Abdominal rigidity Incorrect B. Absent bowel sounds Correct C. Epigastric tenderness Incorrect D. Murphy sign Review Previous QuestionReview Next Question Correct answer explanation Gastroparesis is defined as delayed gastric emptying of contents without the presence of a mechanical obstruction. The cardinal symptoms of gastroparesis include nausea, vomiting, bloating, belching, early satiety, and upper abdominal pain. The most common disease associated with gastroparesis is diabetes mellitus (DM). Patients with diabetes mellitus have abnormalities in multiple areas in the gastric-emptying process, including reduced frequency of antral contractions and abnormal postprandial proximal gastric accommodation and contraction. Physical examination may reveal epigastric tenderness (C) or distention on palpation. Patients with suspected gastroparesis should initially undergo an upper gastrointestinal endoscopy and CT enterography to rule out a mechanical obstruction. The gold standard for diagnosis of gastroparesis is scintigraphy, a technique that evaluates gastric emptying of solids. Initial treatment of gastroparesis is management of the underlying cause. Patients with DM should optimize glycemic control because acute hyperglycemia is associated with slowed gastric emptying. Dietary modifications include decreasing the amount of acidic, spicy, fatty, and roughage-based foods (e.g., fresh fruits and vegetables). Patients who continue to have symptoms despite dietary modification may need pharmacologic management with a prokinetic agent, such as metoclopramide (Reglan). Why are the other choices incorrect? Abdominal rigidity (A) is a sign of peritonitis. Patients with peritonitis often appear acutely ill and have severe abdominal pain. Absent bowel sounds (B) could indicate a small bowel obstruction. Patients with suspected small bowel obstruction should be referred to the ED. The Murphy sign (D) is positive when the patient has pain when the nurse practitioner palpates the right upper quadrant during inspiration. It is a sign of acute cholecystitis. A 77-year-old man presents to the clinic with reports of persistent foot pain. The pain is worse in the morning with his first steps and gradually improves with activity. He was evaluated in the clinic 2 months ago for this pain and was instructed to try shoe inserts and exercise therapy. The patient states that he has tried these measures without relief. The physical examination reveals tenderness of the medial calcaneal tubercle and several areas of point tenderness upon dorsiflexing the patient’s toes. Which of the following is the best next step in treatment? Incorrect A. Corticosteroid injection Correct B. NSAID therapy Incorrect C. Opioid therapy effect of some medications is dizziness or lightheadedness. It is important to exclude any possible life-threatening conditions that could cause dizziness. It is important for the nurse practitioner to take a thorough patient history and conduct a medication review for possible aggravating agents. A comprehensive neurological exam, including orthostatic vitals, should also be conducted during the office visit. Why are the other choices incorrect? Cogwheel rigidity (A) is described as a stiffness in the limbs, and the presence or absence would be assessed if the caregiver suspected that the patient displayed signs of parkinsonism, such as a change in facial appearance or gait or a resting tremor. The Dix-Hallpike maneuver (B) assesses for the presence of nystagmus with position changes and would be performed in the office if the clinician suspected that the dizziness was secondary to a vestibular lesion. This patient had a normal neurological exam, so this answer is incorrect. EEG (D) is a test to exclude a seizure disorder but would not be necessary on initial presentation with a negative neurological exam. An 81-year-old woman presents to your office with a 6-month history of poor sleep and constant feelings of sadness. She also reports a loss of interest in social activities at the assisted living facility where she lives. She reports no suicidal ideation or hallucinations. On the Geriatric Depression Scale, she identifies with four of the five depressive responses and scores 16 out of 27 on the Patient Health Questionnaire-9. She has a 20-year history of hyperlipidemia, seizure disorder, hypothyroidism, and chronic low back and knee pain. Her physical examination is unremarkable. Laboratory studies reveal a normal TSH level. What is the most appropriate treatment for this patient’s suspected diagnosis? Incorrect A. Amitriptyline Incorrect B. Bupropion (Wellbutrin) Correct C. Duloxetine (Cymbalta) Incorrect D. Trazodone Review Previous QuestionReview Next Question Correct answer explanation Selective serotonin reuptake inhibitors (SSRIs) are considered first-line treatment for late-life depression. They are typically well-tolerated and easy to use with an acceptable safety profile. Serotonin and norepinephrine reuptake inhibitors (SNRIs) are considered second-line agents. However, they have the added benefit of treating comorbid pain. These two types of medications both work to inhibit reabsorption of serotonin (SSRI and SNRIs) and norepinephrine (SNRI). Of the treatment options presented for the patient in the above vignette, the SNRI duloxetine (Cymbalta) (C) is the most appropriate treatment choice. Psychotherapy is often very beneficial, either alone or in conjunction with pharmacotherapy, when more severe forms of depression are present. All patients should also be counseled on nonpharmacological treatment options, such as counseling and bright light therapy. Major depressive disorder is diagnosed if a patient meets the criteria defined by the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). The DSM-5 defines depression as a period lasting at least 2 weeks in which the individual experiences a depressed mood or loss of interest and pleasure in most activities most of the day for nearly all days. To be diagnosed with depression, the person must also experience at least four additional symptoms, including loss of appetite, weight loss, decreased psychomotor activity, difficulty making decisions, difficulty concentrating, decreased energy, feelings of worthlessness, feelings of guilt, thoughts of death, or suicidal ideation. Risk factors of depression include comorbid psychiatric and general medical disorders, a history of trauma, chronic pain, certain medications, and low socioeconomic status. Screening tools, such as the Geriatric Depression Scale and Patient Health Questionnaire-9, are used to screen for and aid in the diagnosis of depression. Screening tools are often used first and, if positive, should then prompt a clinical diagnostic interview to formally establish the diagnosis of depression. Why are the other choices incorrect? Tricyclic antidepressants, such as amitriptyline (A), are no longer considered first- or second-line agents for the treatment of late-life depression due to their potentially serious side effects, including cardiac dysrhythmias, urinary retention, and narrow-angle glaucoma. The atypical antidepressant bupropion (Wellbutrin) (B) is often used in the treatment of depression but is not considered first-line therapy. It may also aid in smoking cessation and is contraindicated in any patient with a history of seizure disorder. The serotonin modulator trazodone (D) is rarely used solely as an antidepressant but is often used for its sedating side effects to aid in sleep. A 94-year-old man presents to the clinic for a follow-up on his Alzheimer disease. The nurse practitioner discusses advanced care planning with the patient. Which of the following components of the patient’s medical history most likely necessitates an assessment of decision-making capacity in this patient? Incorrect A. Depression Incorrect B. Lack of a support system Incorrect C. Medical noncompliance Correct vignette, the patient has had an anaphylactic reaction to a penicillin drug and uncertainty surrounding tolerance of cephalosporins. For this reason, a third-line agent, such as doxycycline (Vibramycin) (D), would need to be used. Most episodes of rhinosinusitis encountered in the primary care setting are viral in origin. Diagnosis of both viral and bacterial sinusitis can be made on the physical examination alone. Radiographic imaging, including CT imaging of the sinuses, is more sensitive than a physical exam, but it is costly and not recommended for routine diagnosis. When patients present with absence of severe symptoms and < 10 days of illness, they should first be offered supportive care for symptom management (e.g., saline irrigation, antipyretics, and anti-inflammatories). Empiric antibiotics can be started in those with symptoms concerning for bacterial sinusitis. The typical duration of treatment is 5–7 days. Why are the other choices incorrect? Given this patient’s known anaphylactic reaction, amoxicillin-clavulanate (Augmentin) (A) should be avoided. Azithromycin (Zithromax) (B) is not recommended for the treatment of bacterial sinusitis. Since the patient’s tolerance of cephalosporins is unknown, cefdinir (C) should not be prescribed. Note: Any and all references to trademarks or registered companies are for educational purposes only and are not inclusive of all possible names. Blueprint Test Preparation is in no way endorsing or promoting any product in these educational materials. The nurse practitioner is working in a clinic that commonly sees patients with opioid dependence. The nurse practitioner is concerned about contributing to the opioid epidemic that the community faces. Which of the following is the best method for the nurse practitioner to use in determining whether it is safe to prescribe a controlled substance? Incorrect A. Call the patient’s pharmacy Incorrect B. Order a drug screening test Incorrect C. Perform a medication reconciliation Correct D. Review prescription drug monitoring programs Review Previous QuestionReview Next Question Correct answer explanation With rising numbers of prescriptions for opioids and other controlled substances, there has also been an uptick in prescription drug misuse. Some patients require these medications, and typically, they should still be prescribed in these situations. One of the best methods for safe prescription of controlled substances in the United States is reviewing prescription drug monitoring programs (D) before prescribing. Prescription drug misuse is a problem commonly seen with opioid, stimulant, and sedative prescriptions. Prescription numbers for these medications increased exponentially between 2000 and 2010, leading to overall increased episodes of prescription drug misuse. Limiting exposure to these medications and exhausting all other means of management before using them are the most important steps in preventing misuse. However, many situations require these medications, and they can be used safely. Prescription monitoring programs (PMPs) should always be used at the time of prescription for any controlled substance. PMPs are online databases that list all controlled substance prescriptions for each patient. Each US state has its own PMP. These programs are not all-inclusive. For example, methadone prescribed through opioid treatment programs is not included. Reporting errors can occur, and any discrepancies should be verified with the pharmacy listed on the PMP. Why are the other choices incorrect? Calling the patient’s pharmacy (A) does not provide enough information, as patients can use multiple pharmacies. Ordering a drug screening test (B) is useful for monitoring patients on chronic opioids but has little utility with initial prescriptions. Performing a medication reconciliation (C) will not provide accurate enough information. A 66-year-old man presents for a follow-up appointment for cellulitis. He was seen 5 days ago for right lower extremity cellulitis and was started on cephalexin (Keflex). At the current visit, the erythema of his right leg has spread past the prior line of demarcation, and he now has a large central area of fluctuance that is draining pus. You perform a bedside incision and drainage and send a sample for culture. The patient reports a prior allergic reaction to trimethoprim-sulfamethoxazole (Bactrim). Which of the following medications would be the best to prescribe for this patient? Incorrect A. Cefadroxil Incorrect B. Cefdinir Incorrect C. Dicloxacillin Correct D. Linezolid (Zyvox) Review Previous QuestionReview Next Question Correct answer explanation thrombus formation. This process causes coronary artery occlusion, ischemia, necrosis, infarction, and death. Diagnosis is verified by ECG changes, specifically ST elevation in contiguous leads, which are associated with an anatomical area of the heart. In the primary care setting, treatment of patients with coronary artery disease (CAD) is aimed at MI and stroke prevention. This treatment typically includes daily aspirin, beta-blockers, nitrates, calcium channel blockers, angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, or dyslipidemia therapy. Why are the other choices incorrect? While initiation of a beta-blocker and referral to a cardiologist (B) are likely necessary aspects of the future care of this patient, these measures should occur after reperfusion therapy. Stress testing (C) often involves physical exertion and is not appropriate in the setting of an ST elevation MI. Stress testing is used in stable patients for risk assessment and evaluation of CAD in a controlled environment. Troponin I and T levels (D) are important in the evaluation of myocardial injury, but this test alone is not the most important next step in the primary care setting. Any delay in further testing can increase the risk of mortality. A 3-year-old girl presents to the clinic with her mother for fever and congestion that began 1 day ago. On physical exam, the tympanic membranes are bulging and erythematous bilaterally, and nasal congestion is noted. The patient has a documented IgE-mediated allergic response to penicillin. Which of the following is the most appropriate therapy? Incorrect A. Amoxicillin Correct B. Azithromycin (Zithromax) Incorrect C. Cefdinir Incorrect D. Doxycycline (Vibramycin) Review Previous QuestionComplete Review Correct answer explanation Acute otitis media (AOM) is a bacterial infection of the middle ear, often precipitated by an upper respiratory infection. Symptoms include fever, otalgia, difficulty sleeping, and difficulty hearing. Physical exam findings of AOM include a bulging tympanic membrane (TM) and signs of inflammation (e.g., fever, erythema of the TM), and perforation of the TM may be noted. Azithromycin (Zithromax) (B) is the preferred treatment for AOM in patients with an IgE-mediated allergic reaction to penicillin. AOM is a clinical diagnosis based on the findings on otoscopic exam of a bulging TM or perforation of the TM with purulent drainage. AOM can be differentiated from AOM with effusion because AOM with effusion has a retracted or neutral TM. Amoxicillin and amoxicillin-clavulanate (Augmentin) are the preferred treatment options for AOM in patients without a known penicillin allergy. The duration of therapy is 5–7 days if the TM is intact, there is no history of recurrent AOM, and the patient is ≥ 2 years of age. The duration of therapy is 10 days for patients with a history of recurrent AOM or in the presence of a ruptured TM. Alternative treatments for patients with mild non-IgE-mediated reactions to penicillin include cefdinir and ceftriaxone. In addition to azithromycin (Zithromax), alternative treatments for patients with IgE-mediated allergic reactions to penicillin include clindamycin (Cleocin) and clarithromycin. Instructions should be given to use ibuprofen (Motrin) or acetaminophen (Tylenol) for pain relief. Patients should be instructed to return to the clinic if symptoms do not improve or worsen after 48–72 hours of treatment. Why are the other choices incorrect? Amoxicillin (A) is the recommended treatment for AOM, but it would not be appropriate for this patient, who has an IgE-mediated allergic reaction to penicillin. Cefdinir is indicated for treatment of AOM in patients with mild non-IgE-mediated reactions to penicillin. Doxycycline (Vibramycin) (D) is not indicated for the treatment of AOM. A 12-year-old boy presents for his annual well-child examination. The nurse practitioner notes on examination that there is enlargement of his testes and scrotum with subtle changes in scrotal texture. He also has sparse pubic hair growth at the base of the penis. Which of the following is the appropriate assessment and plan for this patient? Correct A. Tanner stage 2; continue to check yearly at well-child examinations Incorrect B. Tanner stage 2; refer to endocrinology Incorrect C. Tanner stage 3; continue to check yearly at well-child examinations Incorrect D. Tanner stage 3; refer to endocrinology Review Previous QuestionReview Next Question Correct answer explanation Tanner stage 2 is defined as the development of the first signs of puberty, which in boys include enlargement of the testes and scrotum, reddening of the scrotum and changes in its texture, and sparse pubic hair growth with slightly pigmented hair at the base of the penis. The patient in the vignette above is in Tanner stage 2, and the nurse practitioner should continue to check yearly at well-child examinations (A). For boys, Tanner stage 2 pubertal development at any time after the age of 9 is considered normal and does not require intervention other than continuing to check his pubertal development at yearly examinations. A 12-year-old boy presents to your office with right knee pain for the past week. On examination, he has a BMI of 29 kg/m2. He walks with a mildly antalgic gait, with the right foot slightly externally rotated compared with the left. He has no tenderness to palpation in the right lower extremity, and the knee range of motion appears symmetric. The right hip has decreased range of motion with internal rotation, flexion, and abduction. Which of the following is the most likely diagnosis in this patient? Incorrect A. Legg-Calve-Perthes disease Incorrect B. Osgood-Schlatter disease Incorrect C. Quadriceps muscle strain Correct D. Slipped capital femoral epiphysis Review Previous QuestionReview Next Question Correct answer explanation Slipped capital femoral epiphysis (SCFE) (D) is defined as displacement of the proximal femoral epiphysis relative to the metaphysis. SCFE is most commonly seen in adolescents, with an onset of 10–16 years old for boys and 10–14 years old for girls. It typically occurs at the time of the growth spurt, and it is more common in boys. Obesity is a significant risk factor. Patients usually present with dull, aching knee, thigh, or groin pain and altered gait. Physical activity aggravates the pain. Physical examination findings may include an externally rotated lower extremity, decreased range of motion at the hip, and abnormal gait. Physical exam of the knee is often normal. The diagnosis of SCFE is made by plain radiographs, which demonstrate that the femoral epiphysis has slipped or is displaced, medially and posteriorly, appearing like ice cream slipping off a cone. Children with a diagnosis of SCFE should be immediately admitted to the hospital and placed on bed rest to prevent further displacement. Treatment is surgical, typically fixation with a screw across the physis, with or without reduction. After surgery, patients are to use crutches for 6–8 weeks. The prognosis depends on the severity of the slip. Patients with a history of SCFE are at an increased risk of osteoarthritis. Why are the other choices incorrect? Legg-Calve-Perthes disease (A) is a condition of unknown etiology resulting in avascular necrosis of the hip. It typically presents in children 4–8 years old. Children present with hip pain and a limp with insidious onset. Osgood- Schlatter disease (B) is osteochondrosis of the tibial tubercle apophysis. Physical exam findings usually include prominence and tenderness of the tibial tubercle and pain with resisted knee extension. A quadriceps muscle strain (C) may cause knee pain and an altered gait but would not cause limitation of internal rotation of the hip. A 27-year-old woman presents to the clinic for reevaluation of her headaches. She describes them as a constant pressure on both sides of her head that usually lasts several hours. She reports no associated symptoms. She is currently taking naproxen (Aleve) and acetaminophen (Tylenol) three to four times per week, which seem to control her headaches well. Which of the following is the most appropriate next step? Incorrect A. Advise her to continue her current treatment and schedule an appointment if anything changes Incorrect B. Instruct patient to keep a headache journal Correct C. Prescribe amitriptyline Incorrect D. Prescribe sumatriptan (Imitrex) Review Previous QuestionReview Next Question Correct answer explanation The patient’s clinical presentation is consistent with tension headaches. These headaches are a type of primary headache that present with bilateral, non throbbing pressure and pain of mild to moderate intensity, typically without other associated symptoms. A primary headache means there is no disease process causing the headache. NSAIDs and acetaminophen (Tylenol) can be used in combination for abortive therapy but should be limited to twice weekly dosing to avoid rebound headaches. A prophylactic medication, such as amitriptyline (C), should be added to decrease the need for abortive therapy with NSAIDs. Diagnosis is made by clinical impression. Neuroimaging is not usually indicated unless a patient presents with atypical symptoms or abnormalities on examination. Often there may be overlap with features of other types of headaches, including migraine, which may be a diagnostic challenge. The goal of treatment is to limit the number and frequency of headaches. When prescribing amitriptyline, the nurse practitioner should be aware of the side effect profile, including anticholinergic effects, such as constipation, xerostomia, blurred vision, and urinary retention. Additionally, amitriptyline is associated with increased risk of bleeding, ECG changes, CNS depression, and serotonin syndrome. When discontinuing this medication, patients need to be advised to taper to avoid withdrawal symptoms. A 24-year-old man presents to the clinic with left eye pain and redness since this morning. He states that he does not remember injuring his eye, but he is a contact lens wearer and reports that he infrequently cleans his contacts and keeps them in place overnight at times. He removed his contacts this morning without difficulty and states that he has clouding of his vision in the left eye. He is unable to hold his eyelid open due to pain. The physical A. Eosinophilic esophagitis Correct B. Esophageal candidiasis Incorrect C. GERD Incorrect D. Sjögren syndrome Review Previous QuestionReview Next Question Correct answer explanation The most common cause of odynophagia in patients with HIV is esophageal candidiasis (B). Odynophagia, which is a painful sensation when swallowing food or liquids, is the hallmark symptom. Other symptoms may include abdominal pain, heartburn, diarrhea, melena, nausea, vomiting, and weight loss. Esophageal candidiasis is almost always caused by Candida albicans but may also be caused by herpes simplex or cytomegalovirus. It is an opportunistic infection, and patients who develop esophageal candidiasis typically have impaired immunity, including those with HIV/AIDS, solid organ transplants, or hematologic malignancies and those receiving cytotoxic chemotherapy or immunosuppressive drugs. It may also occur in those with uncontrolled diabetes or those treated with systemic corticosteroids, radiation therapy, or systemic antibiotic therapy. The clinical exam reveals thrush on the esophageal mucosa, visualized as white plaques or exudates. Diagnosis may be confirmed with an upper endoscopy. An oral antifungal agent is the treatment of choice, although intravenous antifungals may be necessary if patients cannot tolerate oral intake. Why are the other choices incorrect? Eosinophilic esophagitis (A) is a chronic, immune-mediated disease triggered by allergens or environmental factors. GERD (C) is a disorder characterized by the reflux of stomach contents into the esophagus, causing heartburn. Sjögren syndrome (D) can cause impaired peristalsis and xerostomia, which may cause some difficulty with swallowing. A 38-year-old woman presents to the clinic with a 4-day history of productive cough, fever, chills, and dyspnea. She does not smoke cigarettes and has not used any antibiotics within the past 3 months. Her temperature is 102.4°F, oxygen saturation is 95%, HR is 104 bpm, and BP is 106/78 mm Hg. On examination, crackles are noted at her lung bases bilaterally. Which of the following is the first-line pharmacotherapy for this patient’s suspected condition? Correct A. Amoxicillin 1 g three times daily for 5 days Incorrect B. Azithromycin (Zithromax) 500 mg once daily for 3 days Incorrect C. Levofloxacin (Levaquin) 750 mg once daily for 5 days Incorrect D. Penicillin 500 mg twice daily for 7 days Review Previous QuestionReview Next Question Correct answer explanation Community-acquired pneumonia (CAP) is an acute infection of the pulmonary parenchyma that is acquired outside of health-care settings. Typical symptoms include fever, malaise, dyspnea, pleuritic chest pain, cough, and sputum production. Symptoms of CAP can range from mild to severe, requiring hospitalization. Risk factors for CAP include older age, cigarette smoking, viral respiratory infections (e.g., influenza, COVID-19), and comorbid chronic conditions (e.g., COPD, alcohol use disorder). The diagnosis should be confirmed by chest radiography or U/S. According to the ATS/IDSA guidelines, the first-line outpatient antibiotic treatment for low-risk patients is high-dose amoxicillin (A). The most common pathogens associated with CAP are Streptococcus pneumoniae and respiratory viruses. Testing for specific bacteria is generally not necessary in the outpatient setting. Monotherapy with macrolide antibiotics (e.g., azithromycin [Zithromax]) is no longer routinely recommended due to high rates of resistance by S. pneumoniae. Patients with comorbid conditions or recent parenteral antibiotic use will require combination therapy for coverage of additional pathogens (e.g., Haemophilus influenzae, Moraxella catarrhalis, and methicillin- susceptible Staphylococcus aureus). For patients with confirmed influenza virus, antiviral treatment is warranted. Patients with severe symptoms may require hospitalization. Why are the other choices incorrect? Azithromycin (Zithromax) 500 mg once daily for 3 days (B) is not considered first-line for CAP due to high rates of antibiotic resistance. However, it may be used if local pneumococcal resistance is < 25%. Levofloxacin (Levaquin) 750 mg once daily for 5 days (C) is not considered first-line for low-risk patients with CAP. Penicillin 500 mg twice daily for 7 days (D) is not an effective treatment for CAP. A 55-year-old man presents to the clinic with a 2-year history of urinary hesitancy, a slow urinary stream, and nocturia every night. He reports worsening symptoms, and the nocturia interferes with his sleep, causing daytime drowsiness. He is married and sexually active. Current medications are rosuvastatin (Crestor) and a multivitamin. The physical exam reveals an enlarged prostate that is nontender and smooth. Results from urinalysis and urine culture are both normal, and serum prostate-specific antigen is 0.9 ng/mL. Which of the following is the best next step in management? Correct paroxysmal positional vertigo (BPPV). Typical symptoms are described as a brief, often < 1 minute, spinning sensation elicited with movement of the head. Nausea and, at times, vomiting may accompany the episodes of vertigo. Hearing loss and tinnitus are typically absent. The diagnosis is made based on a consistent history and examination. Provocation testing, such as the Dix-Hallpike maneuver, is used to confirm the diagnosis. Particle repositioning maneuvers are the standard treatment of choice in BPPV. The Epley and Semont maneuvers are the two most commonly used. The goal is to reposition the head to allow debris to migrate out of the semicircular canal and back into the utricular cavity. The Epley maneuver consists of a series of movements similar to those of the Dix-Hallpike maneuver. The patient is asked to assume a supine position with the head turned and progress through a series of supine head movements, holding each position for at least 30 seconds. In severe, refractory forms, surgery can be performed to alleviate the vertigo by way of occluding the posterior canal or transecting the posterior ampullary nerve. BPPV is a common cause of vertigo in the outpatient setting and increases in incidence with age. It is estimated to be seven times more likely in adults > 60 years old. The cause of BPPV is related to solid particulate matter, called otoconia, that collects within the semicircular canal of the inner ear. Most otoconia are composed of calcium carbonate crystals and are believed to originate from the utricular sac. The semicircular canals sense angular and linear motion of the head and relay this information to the CNS, allowing for our interpretation of motion and maintenance of balance. When debris collects within the semicircular canal, there is a disruption in the endolymph, causing the sensation of spinning or vertigo. The Dix-Hallpike maneuver is performed by asking the patient to sit upright and turn their head to one side. The nurse practitioner then has the patient quickly lie flat with the head off the edge of the table. The patient is next asked to sit upright, and the maneuver is repeated with the head turned in the opposite direction. A positive test is present if nystagmus is noted. Why are the other choices incorrect? Meclizine (Antivert) 25 mg every 6 hours (A) is often prescribed in conjunction with particle repositioning maneuvers but should not be used alone as therapy in a patient with BPPV. Obtaining an MRI of the brain (C) would be warranted in cases of atypical symptoms or abnormal examination findings. It is not indicated in the workup of routine, uncomplicated BPPV. Ondansetron (Zofran) (D) is not indicated in the treatment of BPPV. The nausea associated with BPPV is better managed with a vestibular suppressant, such as meclizine (Antivert). A 40-year-old woman presents to the primary care clinic reporting dizziness and head spinning that occurs when she makes certain movements, such as rolling over in bed. These symptoms started 3 months ago and last approximately 30 seconds at a time. She reports no hearing loss, lightheadedness, syncope, pain, nausea, or vomiting. Which of the following is the most appropriate tool to diagnose this patient’s suspected condition? Incorrect A. CMP Correct B. Dix-Hallpike maneuver Incorrect C. Epley maneuver Incorrect D. Head CT Review Previous QuestionReview Next Question Correct answer explanation Benign paroxysmal positional vertigo (BPPV) is a common form of vertigo associated with canalithiasis or calcium debris within the posterior semicircular canal. Episodes of BPPV typically last less than 60 seconds and are triggered by certain head movements, such as rolling over in bed. In addition to vertigo, patients may experience nausea and vomiting. Patients with BPPV typically do not experience hearing loss or neurological symptoms. When the nurse practitioner takes a history, symptoms of vertigo (e.g., sensation of motion when not moving) should be differentiated from the feelings of lightheadedness or faintness that occur with orthostatic hypotension. Diagnosis of BPPV is made by clinical history and the Dix-Hallpike maneuver (B). The Dix-Hallpike maneuver is a series of movements used to elicit vertigo and nystagmus in patients with BPPV. The presence of vertigo with or without nystagmus during the Dix-Hallpike maneuver confirms the diagnosis. Treatment for BPPV involves particle repositioning maneuvers, such as the Epley maneuver, which repositions the calcium debris from the semicircular canal into the vestibule. This maneuver can be repeated until achieving relief of symptoms. Alternatively, patients can be given exercises for self-treatment at home, such as the Brandt-Daroff exercises. Why are the other choices incorrect? A 40-year-old man presents to the clinic with reports of left eyelid swelling and eye pain. He was treated in the clinic 2 weeks ago for acute sinusitis. His temperature is 102.1°F, and the physical examination is notable for a swollen and erythematous left eyelid. He reports pain with extraocular movements. His visual acuity is unaffected. Which of the following is the most appropriate treatment for the suspected diagnosis? Incorrect A. Ciprofloxacin ophthalmic 0.3% ointment (Ciloxan) Incorrect B. High-dose oral amoxicillin-clavulanate (Augmentin) Correct C. Intravenous vancomycin and ceftriaxone Incorrect D. Oral cephalexin (Keflex) and warm compresses Review Previous QuestionReview Next Question Correct answer explanation offending medication, suspicion of drug-induced liver injury should be high in those with acutely elevated liver enzymes with a recent addition of potentially hepatotoxic medications. Symptoms of drug-induced liver injury are similar to those with other acute liver diseases and include fatigue, nausea, pruritus, jaundice, low-grade fever, and right upper quadrant pain. The mainstay treatment of drug-induced liver injury is withdrawal of the offending medication. Most patients will experience complete recovery after the offending medication is withdrawn. Why are the other choices incorrect? Atrial fibrillation recurrence (A) is a possible differential diagnosis for fatigue, but this diagnosis will not explain the elevation in liver enzymes. Hepatic steatosis (C) is a possible differential diagnosis for an elevation in liver enzymes. However, in the vignette above, the patient had unremarkable liver enzymes prehospitalization with an acute elevation after amiodarone (Pacerone) treatment. Viral hepatitis infection (D) is also a possible differential diagnosis for the elevation in liver enzymes, but the patient in the vignette above does not have any significant identified risk factors for viral hepatitis. What is the recommended daily dose of vitamin D for older individuals at moderate to high risk for falls, according to the AGS and the Institute of Medicine? Incorrect A. 1,000–1,200 units/day Incorrect B. 1,200–1,400 units/day Incorrect C. 600–800 units/day Correct D. 800–1,000 units/day Review Previous QuestionReview Next Question Correct answer explanation Falls are common in older adults. Among the most feared outcomes of falls are fractures, as they can threaten the patient’s future ability to care for themselves. Supplementation of vitamin D has been suggested in the past as a means to prevent both falls and fractures from falls. The suggested initial dosing range for individuals at risk for falls is 800–1,000 units/day (D). Among patients with an underlying vitamin D deficiency or those with osteoporosis, the daily dose may be titrated as needed to optimize bone health. When considering vitamin D supplementation to prevent falls, it is most important to consider the patient’s risk for vitamin D deficiency. Those who should be considered for screening of vitamin D deficiency include individuals with lack of sun exposure, those without dietary intake of vitamin D, and those with malabsorption issues. It should also be considered in those with underlying balance issues, who have experienced past falls, or who are at greater risk for falls. The use of vitamin D supplementation is recommended by both the AHRQ and the AGS. However, its overall benefit has been debatable. Environmental modifications, home safety, and regular exercise are all additional preventive measures that should be considered in those at risk for falls. Why are the other choices incorrect? Higher dose ranges, including 1,000–1,200 units/day (A) and 1,200–1,400 units/day (B), may be used in those with underlying osteoporosis or vitamin D deficiency, but they are not necessary for fall prevention. A dose of 600– 800 units/day (C) is less than the recommended dose for fall prevention. A 60-year-old man without a significant medical history presents to the clinic with nasal congestion. He reports that, over the past 2 weeks, he has had persistent nasal congestion, facial pressure, and cloudy nasal drainage. His symptoms have not improved with use of acetaminophen (Tylenol) and other supportive care measures. On physical exam, he is febrile with a temperature of 100.8°F, and he has significant bilateral maxillary sinus tenderness. He reports a prior anaphylactic reaction to a penicillin drug and is uncertain whether he has taken cephalosporins in the past. Which of the following medications would be best to prescribe for the suspected diagnosis? Incorrect A. Amoxicillin-clavulanate (Augmentin) Incorrect B. Azithromycin (Zithromax) Incorrect C. Cefdinir Correct D. Doxycycline (Vibramycin) Review Previous QuestionReview Next Question Correct answer explanation Bacterial sinusitis is rare but should be considered in patients with protracted symptoms lasting longer than 10 days, those who are immunocompromised, and those with more severe symptoms, including fever, purulent nasal drainage, nasal obstruction, and severe facial pain. Most treatment of bacterial sinusitis is empiric, with Streptococcus pneumoniae and Haemophilus influenzae being the typical pathogens of concern. Amoxicillin-clavulanate (Augmentin) is the first-line agent for bacterial sinusitis. If patients have a penicillin allergy and are unable to tolerate cephalosporins, a third-line agent may need to be used. In the above vignette, the patient has had an anaphylactic reaction to a penicillin drug and uncertainty surrounding tolerance of cephalosporins. For this reason, a third-line agent, such as doxycycline (Vibramycin) (D), would need to be used. Most episodes of rhinosinusitis encountered in the primary care setting are A 6-month-old female infant presents with her parent for a rash on the scalp that has been present for the past 3 weeks. She is eating well and having normal wet diapers. She has had no fever or congestion. There is no family history of asthma or eczema. Your exam shows a well-appearing, alert infant with vital signs within the normal limits for her age and erythematous plaques with yellow scales on the scalp. Which of the following is the most likely diagnosis? Incorrect A. Atopic dermatitis Incorrect B. Psoriasis Correct C. Seborrheic dermatitis Incorrect D. Tinea capitis Review Previous QuestionReview Next Question Correct answer explanation Seborrheic dermatitis (C) is associated with inflammation from Malassezia species. Seborrheic dermatitis is more commonly known as cradle cap in infants, as it will typically affect the apex and frontal areas of the scalp. Seborrheic dermatitis affects areas with greater numbers of sebum glands, including the scalp, intertriginous areas, face, and external ears. The rash associated with seborrheic dermatitis is described as erythematous plaques with greasy-looking, yellowish scales or hypopigmented, scaly patches. The rash is the primary clinical feature of seborrheic dermatitis, and it may be mildly pruritic, but otherwise, the patient will have no other symptoms. The diagnosis of seborrheic dermatitis is clinical, and no additional testing is needed. Seborrheic dermatitis will often resolve without intervention in several weeks to months. It is unlikely the patient will have symptoms beyond 12 months of age. Treatment for seborrheic dermatitis consists of using an emollient (e.g., petroleum, baby oil) for several hours to soften the scales, followed by brushing with a soft-bristled brush, and frequent shampooing with baby shampoo. In more extensive cases, topical steroids (e.g., hydrocortisone) or ketoconazole 2% cream or shampoo can also be used. Why are the other choices incorrect? Atopic dermatitis (A) can appear similar to seborrheic dermatitis initially, but it usually has a waxing and waning course, can be severely pruritic, and is associated with a family history of asthma, eczema, or allergic rhinitis. Psoriasis (B) can appear similar to seborrheic dermatitis but is less common in infants and typically involves the extensor surfaces. Tinea capitis (D) presents as scaly dermatitis frequently accompanied by hair loss, and it is rare in infants. A 3-year-old boy presents with a 1-day history of right ear pain that began after swimming lessons. The patient’s mother states that he has a history of frequent ear infections and broke out in hives approximately 1 month ago after taking amoxicillin. On physical exam, the nurse practitioner notes a bulging tympanic membrane with erythema and displaced landmarks. Which of the following is the most appropriate treatment for the patient’s suspected condition? Incorrect A. Cefdinir Incorrect B. Erythromycin (Erythrocin) Incorrect C. Penicillin G benzathine (Bicillin) Correct D. Trimethoprim-sulfamethoxazole (Bactrim DS) Review Previous QuestionReview Next Question Correct answer explanation Acute otitis media (AOM), or suppurative otitis media, is an infection of the middle ear, which often causes otalgia, otorrhea, and hearing loss. Typical otoscopic findings include a bulging, fluid-filled tympanic membrane (TM) that may be red, opaque, or yellow in color. The cone light reflex and bony landmarks may also be displaced or absent. Recurrent cases of AOM are treated with antibiotic therapy unlike the initial observation. In the setting of an IgE-mediated reaction to penicillin, such as anaphylaxis or hives, second- line treatment options include azithromycin (Zithromax), clarithromycin, and trimethoprim-sulfamethoxazole (Bactrim DS) (D). By the age of 3, approximately 50–85% of children will have at least one occurrence of AOM. The incidence is higher in children due to the anatomy of the eustachian tube, which is shorter than in adults and allows microorganisms to enter the middle ear from the nasopharynx. Additional risk factors include recent upper respiratory infection, allergic rhinitis, daycare attendance, and exposure to tobacco smoke. The most common causative organisms of AOM are Streptococcus pneumoniae, nontypeableHaemophilus influenzae, and Moraxella catarrhalis. Diagnosis is made clinically based on the patient’s history and physical exam findings. However, in recurrent or chronic cases, tympanocentesis can be performed to obtain cultures and help guide treatment. Repeat otoscopic evaluation should be performed approximately 1 month after completion of antibiotics to ensure resolution. Chronic AOM can result in TM perforation, conductive hearing loss, cholesteatoma, and mastoiditis. Patients with resistant or recurrent infections should be referred to an otolaryngologist for surgical evaluation. Why are the other choices incorrect? Otoscopic exam of the right ear reveals purulent drainage, and the tympanic membrane is poorly visualized. Physical exam of the left ear does not elicit any pain, and the tympanic membrane is intact and pearly-gray in color. The nurse practitioner has high suspicion of perforation in the right ear. Which of the following should be administered as the most appropriate next step? Incorrect A. Amoxicillin 90 mg/kg/day in divided doses twice daily for 7 days Correct B. Ciprofloxacin-hydrocortisone otic solution (Cipro HC), three drops to the affected ear twice daily for 7 days Incorrect C. Clarithromycin 15 mg/kg/day in divided doses twice daily for 10 days Incorrect D. Neomycin-polymyxin B-hydrocortisone otic solution, four drops to the affected ear four times daily for 7 days Review Previous QuestionReview Next Question Correct answer explanation Ear pain, purulent discharge, pruritus, hearing loss accompanied by erythema, and edema of the ear canal are characteristic of otitis externa.Ciprofloxacin-hydrocortisone (Cipro HC), three drops to affected ear twice daily for 7 days (B), is recommended for patients presenting with moderate otitis externa with a nonintact tympanic membrane (TM) because it does not have the potential for ototoxicity. This regimen is also considered first line for patients with moderate otitis externa with an intact TM. Topical fluoroquinolones are administered twice daily and are generally more expensive than other first-line agents, such as neomycin- polymyxin-hydrocortisone otic solution, but they may be preferred when medication adherence is a concern. Otitis externa most often occurs in children and adolescents but is common in all ages, especially during the summer months or in patients who participate in water activities. Swimming, trauma to the ear canal, and use of hearing aids or earbuds all increase the risk of acquiring otitis externa. Moisture and breakdown of the skin disrupt natural defenses that protect against the overgrowth of harmful bacteria in the ear. Pseudomonas aeruginosa is a common pathogenic organism responsible for otitis externa. While less common, fungal infections including Candida may also cause otitis externa. The diagnosis is made clinically. Assessment of the integrity of the TM is an important aspect of treatment. Topical antibiotics should be avoided in patients presenting with mild otitis externa due to minimal additional benefits. A combination of a corticosteroid and an antiseptic agent, such as acetic acid-hydrocortisone, is recommended for treatment of mild disease. A combination of topical and oral antibiotics may be necessary for patients with severe otitis externa, especially if there is cellulitis extending outside the ear. The nurse practitioner should reassess patients 1–2 weeks following initiation of treatment to ensure completion of medication regimens and resolution of symptoms. Some patients may require wick placement to aid in the administration of topical therapy and should be monitored closely by an otolaryngologist. Fungal infection may develop following treatment of bacterial otitis externa, which warrants a referral to an otolaryngologist. Patients who are immunocompromised or have a history of diabetes are at greater risk for more serious complications, such as preauricular cellulitis or malignant external otitis, and they should be referred to the ED for close monitoring and treatment. Why are the other choices incorrect? Amoxicillin 90 mg/kg/day in divided doses twice daily for 7 days (A) is first- line treatment for children older than 2 presenting with acute otitis media (AOM) with an intact TM. Clarithromycin 15 mg/kg/day in divided doses twice daily for 10 days (C) may be prescribed for patients with a penicillin allergy presenting with AOM and a perforated TM. Patients with a mild non-IgE- mediated penicillin allergy may be prescribed cephalosporins. Neomycin- polymyxin B-hydrocortisone otic solution (D) has the potential for ototoxicity and should be avoided in this patient due to the suspected perforated TM. A 23-year-old woman presents to the clinic for a well visit. She reports no significant history. She smokes an average of 10 cigarettes daily. She has been sexually active since 17 years of age, with five lifetime partners. She usually uses condoms and has never used any additional contraceptive method. She tells the nurse practitioner that she recently heard about HPV. She has never been vaccinated for HPV and would like to know how she should be screened for the virus. Which is the most appropriate screening recommendation for this patient today, based on the USPSTF guidelines? Incorrect A. Colposcopy Correct B. Cytology testing alone Incorrect C. HPV cotesting with cytology Incorrect D. HPV testing alone Review Previous QuestionReview Next Question Correct answer explanation Based on the USPSTF recommendation, the 23-year-old woman in this vignette should be screened at this time with cytology testing alone (B). The USPSTF recommends screening women for cervical cancer at ages 21–29 every 3 years with cytology testing alone. Women ages 30–65 can be tested every 3 years with cytology alone, every 5 years with HPV testing alone, or every 5 years with HPV cotesting. HPV infection is a risk factor for cervical, oral, and anogenital cancers. Cervical cancer mortality has dramatically declined with the increased use of report instability or locking of the knee. Patellar dislocation (D) is usually secondary to severe hyperextension or a fall onto a bent knee. It typically manifests as a lateral dislocation, which can be visually observed as a noticeable deformity. References A 21-year-old woman presents with a report of coughing, malaise, and fever that has worsened over the past 2 weeks. The cough is productive of scant yellow sputum, with associated shortness of breath and chest soreness. On physical examination, she has a fever of 100.6°F, and her lungs are clear to auscultation. A chest radiograph reveals patchy consolidations. The nurse practitioner suspects community-acquired pneumonia caused by Mycoplasma pneumoniae.Which of the following antibiotics provides coverage for this pathogen? Incorrect A. Amoxicillin Correct B. Azithromycin (Zithromax) Incorrect C. Ciprofloxacin (Cipro) Incorrect D. Clindamycin (Cleocin) Review Previous QuestionReview Next Question Correct answer explanation The macrolide antibiotic azithromycin (Zithromax) (B) is recommended for empiric treatment of community-acquired pneumonia (CAP). Mycoplasma pneumoniae  is an atypical pathogen often responsible for CAP in children and younger adults. Because the causative organism is typically unconfirmed at the time of diagnosis, it is important to treat it with an antibiotic that provides empiric coverage. The woman in this vignette presents with a gradual worsening of coughing, fever, and malaise. This condition correlates with suspected CAP caused by M. pneumoniae, which has a slow incubation period of 2–3 weeks and causes less severe symptoms thanStreptococcus pneumoniae, which is the most common cause of CAP. In addition to treatment of pneumonia, azithromycin (Zithromax) is approved for COPD exacerbations, Mycobacterium avium complex infections, and sexually transmitted infections (e.g., Haemophilus ducreyi and Chlamydia trachomatis). A common side effect is GI upset (e.g., loose stools, nausea, or vomiting). Additionally, it has been associated with a prolonged QT interval and should be used with caution in patients with a prolonged QT interval or other cardiac conduction abnormalities. While it crosses the placenta, it is a safe antibiotic option for patients who are pregnant. Why are the other choices incorrect? Amoxicillin (A), ciprofloxacin (Cipro) (C), and clindamycin (Cleocin) (D) do not provide coverage for atypical pneumonia pathogens, such as M. pneumoniae. A 30-year-old woman presents to the clinic with reports of tiny papules and pustules, primarily on her cheeks and chin, associated with episodes of facial flushing and increased skin temperature. These symptoms worsen when she eats spicy foods. On examination, tiny pustules are noted on both cheeks. Which of the following pharmacologic agents can be used to treat this patient’s condition? Incorrect A. Topical benzoyl peroxide Incorrect B. Topical corticosteroids Correct C. Topical metronidazole (Metrogel) Incorrect D. Topical permethrin (Elimite) Review Previous QuestionReview Next Question Correct answer explanation Rosacea is a chronic skin condition characterized by facial erythema, small and superficial dilated blood vessels or telangiectasias, papules, pustules, and swelling. Persistent facial erythema and recurrent episodes of facial flushing are characteristic features of rosacea. Exacerbating factors include exposure to extremes of temperature, sun exposure, hot beverages, spicy foods, alcohol, exercise, psychological feelings (especially anger, rage, or embarrassment), and certain drugs. If persistent facial erythema does not improve sufficiently with behavioral modifications, pharmacologic interventions, such as topical metronidazole (Metrogel) (C) formulations, should be considered. Rosacea most commonly occurs in adults > 30 years of age and affects women more than men. It occurs more in patients with skin phototypes I or II, including patients who always burn with sun exposure and never or minimally tan. Differential diagnoses include acute cutaneous lupus erythematosus, seborrheic dermatitis, and sun-damaged skin. The diagnosis of rosacea is made clinically, and testing is typically not warranted. Skin biopsy findings are nonspecific and are not usually indicated. Other treatments include ivermectin cream (Soolantra) applied once daily and topical clindamycin (Cleocin). Additional treatment options available for patients who do not improve with initial therapy include laser therapy, light therapy, topical brimonidine (Mirvaso), and sulfur-sodium sulfacetamide- containing topical agents. Rosacea is a chronic condition and will require lifelong treatment. Why are the other choices incorrect? Topical benzoyl peroxide (A) is an antimicrobial primarily used in the treatment of acne vulgaris. Topical corticosteroids (B) are used in many different dermatologic conditions, such as contact dermatitis, but are not indicated in the treatment of rosacea. Topical permethrin (Elimite) (D) is a Correct answer explanation Statins, such as atorvastatin (Lipitor), have the strongest evidence for the prevention of atherosclerotic cardiovascular disease events and are first-line pharmacotherapy for hyperlipidemia. Statins should be maximized if well tolerated in patients with persistent hyperlipidemia, so the nurse practitioner should increase atorvastatin (Lipitor) to 40 mg oral once daily (C). Hyperlipidemia is a disorder of lipoprotein metabolism defined by elevated levels of total cholesterol, LDL cholesterol, or triglycerides in adults. Hyperlipidemia may be acquired or familial. Risk factors for hyperlipidemia include obesity, diabetes mellitus, excess alcohol consumption, cigarette smoking, cholestatic liver disease, and hypothyroidism. Management of hyperlipidemia may include lipid-lowering drugs and lifestyle modifications. Secondary options in therapy include fibrates, ezetimibe (Zetia), bile acid sequestrants, proprotein convertase subtilisin-kexin type 9 (PCSK9) inhibitors, nicotinic acid, and omega-3 fatty acids. Why are the other choices incorrect? Adding alirocumab (Praluent) 75 mg subcutaneous injection once weekly (A) is not the most appropriate next step due to the medication’s cost and lack of long-term safety data. Statin therapy should be maximized before considering PCSK9 inhibitors. Adding fenofibrate (Tricor) 130 mg oral once daily (B) is not the most appropriate next step for the patient in this scenario. However, it may be considered after maximizing statin therapy. No change in medication is necessary (D) is incorrect because the LDL level is not at the goal. A 35-year-old woman presents to her primary care nurse practitioner with two episodes in the last month of feeling like the room is spinning. The episodes lasted 30 minutes and resolved without intervention. She also reports buzzing in her left ear and difficulty hearing. On exam, transient nystagmus unrelated to position is noted. The Rinne test demonstrates bilateral air conduction greater than bone conduction, and the Weber test reveals lateralization to the right ear. An MRI of the brain is performed with no significant results. Which of the following is the most likely diagnosis? Incorrect A. Benign paroxysmal positional vertigo Correct B. Ménière disease Incorrect C. Vestibular neuritis Incorrect D. Vestibular schwannoma Review Previous QuestionReview Next Question Correct answer explanation Ménière disease (B) is a condition characterized by episodic vertigo, tinnitus, and hearing loss or aural fullness. The spinning sensation may lead to nausea and vomiting, imbalance, and disequilibrium. Episodes may last from 20 minutes to 24 hours. The Rinne test will typically show bilateral air conduction greater than bone conduction. The Weber test will lateralize to the unaffected ear. The initial hearing loss in Ménière disease is sensorineural to low tones, but the loss is typically progressive and will eventually affect all frequencies in the affected ear. Ménière disease is most commonly thought to be caused by an abnormal fluctuation of the fluid in the inner ear (i.e., endolymphatic hydrops). The diagnosis is made based on the following criteria: two or more spontaneous episodes of vertigo, audiometric documentation of sensorineural hearing loss in the affected ear, fluctuating aural symptoms (e.g., distorted hearing, tinnitus, or fullness), and symptoms that do not better suggest another diagnosis. Otoscopic examination and diagnostic imaging findings are typically normal. Lifestyle changes to avoid triggers are recommended. Triggers may include high salt intake, caffeine, nicotine, and alcohol. Medical management of acute episodes may include benzodiazepines (e.g., diazepam) and antiemetics (e.g., promethazine [Phenergan] or ondansetron [Zofran]) as needed. Long-term therapy may include diuretics to decrease fluid in the inner ear (e.g., hydrochlorothiazide-triamterene [Maxzide]). Why are the other choices incorrect? Benign paroxysmal positional vertigo (A) is the most common cause of vertigo, but it is typically triggered by head movements and is not associated with hearing loss. Vestibular neuritis (C) is thought to be viral in origin, affects the eighth cranial nerve, and presents as severe vertigo without hearing loss. Vestibular schwannoma (D), also known as acoustic neuroma, typically presents with unilateral sensorineural hearing loss without vertigo, and compression of cranial nerve VIII will be noted on MRI. A 55-year-old man presents to your office with reports of swelling, stiffness, and mild pain in the proximal interphalangeal joints in his third and fourth fingers for the past few months. He reports his hands are much stiffer in the morning, but they seem to loosen with movement. He takes ibuprofen (Motrin), but it has not resolved this issue. Laboratory testing reveals a positive rheumatoid factor and anti-cyclic citrullinated peptide antibodies. Which of the following is the best treatment for the suspected diagnosis? Incorrect A. Acetaminophen (Tylenol) Correct B. Methotrexate (Trexall) Incorrect C. Naproxen (Aleve) Incorrect D. Prednisone A history of hyperkalemia (A), a history of lymphoma (B), and a history of myocardial infarction (D) are not considered contraindications to ciprofloxacin (Cipro) use. A 70-year-old woman with a history of diabetes and chronic kidney disease presents to the clinic for a cough. She reports that, over the past 3 days, she has developed a cough that has been productive of tan sputum. It has been accompanied by low-grade fevers and mild shortness of breath. On physical examination, she has crackles in her right lower lung lobe. Which of the following is the best empiric medication regimen for this patient? Correct A. Amoxicillin-clavulanate (Augmentin) and azithromycin (Zithromax) Incorrect B. Amoxicillin-clavulanate (Augmentin) and levofloxacin (Levaquin) Incorrect C. Azithromycin (Zithromax) Incorrect D. Doxycycline (Vibramycin) Review Previous QuestionReview Next Question Correct answer explanation Four to five million Americans are diagnosed with community-acquired pneumonia (CAP) each year. CAP can be either bacterial or viral, with Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis the most common bacterial causes. Coughing with or without sputum production, fever, and dyspnea are the most frequent clinical manifestations of CAP. Patients will typically present with fever and inspiratory crackles or rhonchi on lung examination. Pulmonary opacities seen on chest X-ray or CT scan can be used to confirm the diagnosis. Empiric treatment of CAP is based on location and underlying comorbid medical conditions. The patient in the above vignette is in the outpatient setting and has comorbid medical conditions of diabetes and chronic kidney disease. Empiric outpatient CAP regimens for patients with comorbid medical conditions are monotherapy with a respiratory fluoroquinolone or dual therapy with amoxicillin-clavulanate (Augmentin) and azithromycin (Zithromax) (A). Patients with CAP who have comorbid medical conditions or recent antibiotic exposure in the past 90 days require treatment for beta-lactamase- producing organisms. Dual therapy with amoxicillin-clavulanate (Augmentin) and azithromycin (Zithromax) is the preferred empiric regimen for these patients. It offers coverage against both beta-lactamase producers and atypical organisms (e.g., Legionella). In cases of allergy or prolonged QT intervals, doxycycline (Vibramycin) is an acceptable alternative to azithromycin (Zithromax). Levofloxacin (Levaquin) and other respiratory fluoroquinolones can be used as monotherapy but should be restricted to situations in which other regimens are not feasible secondary to increased side effect profiles, including risk of Clostridioides difficile colitis. Why are the other choices incorrect? Amoxicillin-clavulanate (Augmentin) and levofloxacin (Levaquin) (B) are an unnecessarily broad regimen. Levofloxacin (Levaquin) can be used as a monotherapy. Azithromycin (Zithromax) (C) and doxycycline (Vibramycin) (D) as monotherapies are too narrow and do not offer adequate beta- lactamase coverage. A 67-year-old woman presents to the clinic with reports of left-sided facial pain. She reports the pain as severe, burning, and sharp. She was evaluated in the clinic 4 months ago for herpes zoster located over her left jaw, and she completed treatment with valacyclovir (Valtrex). Despite using capsaicin cream and ibuprofen (Motrin), she has not experienced any relief. The physical examination reveals no abnormalities or skin findings. Which of the following is the best next treatment option for the suspected diagnosis? Incorrect A. Duloxetine (Cymbalta) Correct B. Gabapentin (Neurontin) Incorrect C. Nortriptyline (Pamelor) Incorrect D. Tramadol (Ultram) Review Previous QuestionReview Next Question Correct answer explanation Herpes zoster is a result of the varicella-zoster virus (VZV), which also causes varicella (i.e., chickenpox). Acute herpes zoster, or shingles, typically presents with a painful rash that is self-limited. Treatment with antivirals within the first 72 hours is the mainstay of treatment, but some patients continue to experience pain for several months after resolution of the rash. This condition is called postherpetic neuralgia. Gabapentin (Neurontin) (B) or pregabalin (Lyrica) is considered the first-line therapy for patients with moderate to severe pain. The reactivation of VZV causes acute herpes zoster, which involves inflammation of the peripheral nerve, dorsal root, and dorsal root ganglion. As the immune system weakens with age or immunocompromised states, the virus can travel along the nerves and cause nerve inflammation, resulting in ongoing pain without tissue damage. The likelihood of developing postherpetic neuralgia increases with age > 60, severe pain with acute herpes zoster, and a severe rash with acute herpes zoster. Postherpetic neuralgia typically presents as pain that does not go away, but sometimes, the pain can suddenly reappear months to years after the initial shingles