Medical Case Studies: Diagnosis and Treatment of Various Conditions, Exams of Nursing

Download Medical Case Studies: Diagnosis and Treatment of Various Conditions and more Exams Nursing in PDF only on Docsity! CMN 577 Unit 5 (75 Questions and Answers) Best graded A+ A 55-year-old male presents to the office with his wife for evaluation of the patient's left arm tremors. The symptoms are increased when he gets upset. The wife has noticed that the patient's movements are slowed, "It seems as if he's shuffling his feet when he walks". The Nurse Practitioner knows these are signs of: a. Huntington Disease b. Parkinson's Disease c. Dementia d. Bell's Palsy - SOLUTION * b. Parkinson's Disease Rationale: According to Papadakis and McPhee (2015), In Parkinson's Disease, tremor is commonly confined to one limb and is exacerbated by emotional stress. The disease is also manifested by slowed voluntary movements and gait is characterized by shuffling steps. Page 988 A twenty-five-year-old college student presents to the outpatient clinic today with complaints of a "bug in my ear." The FNP is able to visualize the insect with an otoscope. The next best action is to: a. Use a cotton tipped applicator to remove the insect. b. Use an aqueous solution to irrigate the ear c. Fill the ear with lidocaine prior to removing. d. Apply heat to the ear to make the bug crawl out. - SOLUTION *c. Fill the ear with lidocaine prior to removing. Rationale: Lidocaine helps to immobilize insect for easier removal. A 46-year-old male presents to the office with complaints of the room "spinning", noting that these symptoms last several seconds after he rolls over to get out of bed in the mornings. He denies symptoms of the 'spinning' otherwise. Which of the following would be the best initial treatment? a. Prescribe steroid dose pack b. Valsalva maneuver c. Hall Pike d. Epley Maneuver - SOLUTION *d. Epley Maneuver Rationale: Benign Paroxysmal Positioning Vertigo (BPPV) is recognized by positional changes, most often described as spinning or dizziness that occurs with head position changes such as rolling over in bed. This is caused by loose, freely moving otoconia located in the semicircular canal. Treatment includes the Epley maneuver which can cause the otoliths to settle back into place. Source: (Lustig & Schindler, 2015) (page 211 in McPhee 2015) A mom brings her 6 year old who is complaining with headache and sore throat for 2 days. Temperature on arrival is 102.1 F orally. Examination reveals tonsillar erythema and edema and soft palate petechiae. What is your first best action? a. Start Amoxicillin immediately b. Perform rapid strep throat culture c. Have patient gargle with warm salty water d. Refer to ENT specialist - SOLUTION *b. Perform rapid strep throat culture Rationale: None listed Which of the following statements is true regarding the treatment of patients with HIV-associated nephropathy? a. A patient with ESRD, who is otherwise in good health, is a potential candidate for renal transplant. b. Calcium channel blockers are the best choice to control blood pressure c. HAART has not been shown to slow progression in these patients d. Serum blood values can be used for diagnosis - SOLUTION * a. A patient with ESRD, who is otherwise in good health, is a potential candidate for renal transplant. Rationale: In McPhee & Papadakis (2015), Watnick and Dirkx note several key points for the treatment of patients with HIV-associated nephropathy. Kidney biopsy is needed to locate a focal segment of glomerulosclerosis pattern of injury with glomerular collapse. Studies have shown that HAART d. Seborrheic dermatitis - SOLUTION * b. Pityriasis rosea Rationale: The SOLUTION is (b). Pityriasis rosea is a common, mild, inflammatory disease, more common in females. Itching is common. The lesions are oval, fawn colored plaques with a center that has a crinkled appearance. It often resembles a Christmas tree. Seborrheic dermatitis consists of dry scales and underlying erythema commonly found on the face. Impetigo presents with superficial blisters filled with purulent material that crust over when ruptured. Plaque psoriasis are red, sharply defined margins with silvery scales. A 60-year-old male patient complains of pain along his right side that started approximately 48 hours ago. Yesterday he noticed a 'rash' along the same area. The examination reveals scattered, grouped vesicles distributed unilaterally along the mid posterior thoracic T7 dermatome. The nurse practitioner suspects: What do you suspect? a. Herpes Zoster (shingles) b. Eczema c. Contact Dermatitis d. Actinic Keratoses - SOLUTION *a. Herpes Zoster (shingles) Rationale: The SOLUTION is (a). Herpes Zoster is an acute vesicular eruption due to the varicella virus. This usually occurs in adults. Pain is usually present about 2 days prior to rash eruption. The lesions consist of deep-seated vesicles distributed along a dermatome, commonly found along the trunk or face. Eczema does not follow a dermatome. Contact dermatitis is often in an area of contact with a suspicious agent and followed by vesicles and bullae. Actinic Keratosis are hyperpigmented flesh colored lesions on areas of high sun exposure A six year old patient presents with tea colored urine, 14 days after having a group A streptococcal infection of the throat. The nurse practitioner correctly diagnoses these renal symptoms as: a) Proteinuria b) Post infectious glomerulonephritis c) Membranous nephropathy d) Pyuria - SOLUTION *b) Post infectious glomerulonephritis Rationale: Lum (2014), p. 757-758. The NP should know that post infectious glomerulonephritis (GN) usually follows an acute streptococcal pharyngitis infection. Other symptoms may include edema, or hypertension, but rarely fever. Typical post-streptococcal GN usually has no specific treatment. The underlying infection should be identified and treated. Children usually make a full recovery from this type of acute kidney injury. The NP correctly identifies hematuria as more than _____ red cells per high power field, documented on two or more separate occasions. a. Two b. Three c. Five d. Ten - SOLUTION *b. Three Rationale: Watnick and Dirkx (2015), p. 891. Rationale: Usually detected incidentally by urine dipstick or clinically after an episode of macroscopic hematuria. Diagnosis is confirmed via microscopy. Hematuria in patients more than 40 years of age is a concern for malignancy. What dermatologic lesion is considered to be premalignant? a. seborrheic keratoses b. blue nevi c. lichen planus d. actinic keratoses - SOLUTION *d. actinic keratoses Rationale: -Seborrheic keratoses are not premalignant they are benign lesions (Papadakis et al., 2015). -Blue nevi are typically considered benign lesions (Papadakis et al., 2015). -Lichen planus is benign (Papadakis et al., 2015). *Actinic keratoses are the only lesions in question considered premalignant (Papadakis et al., 2015). Which of the following is *not* a sign of acute appendicitis? a. Positive McMurray test b. Psoas sign c. Obturator signn d. Tenderness at McBurney Point - SOLUTION *a. Positive McMurray test Rationale: *The McMurray test is used for evaluating the knee (Papadakis et al., 2015). -A positive psoas sign or obturator sign are suggestive of appendicitis and warrant further evaluation (Papadakis et al., 2015). -Pain at McBurney point is indicative of appendicitis (Papadakis et al., 2015). Papadakis, M. A., McPhee, S. J., & Rabow, M. W. (2015). Current medical diagnosis & treatment Which of the following is an effective intervention for the PRIMARY prevention of hypertension? a. Initiation of antihypertensive medication. b. Performing weekly blood pressure readings. c. Following the DASH diet d. Participation in learning activities aimed at health promotion activities such as weight loss and exercise. - SOLUTION *d. . Participation in learning activities aimed at health promotion activities such as weight loss and exercise. Rationale: : Participation in health promotion education regarding weight loss and exercise is an effective primary preventative strategy for hypertension. These interventions can deter the onset or acquisition of hypertension (Pignone & Salazar, 2015). . - SOLUTION , Which of the following is not a contraindication of the MMR vaccine for children? a. High dose corticosteroid therapy. b. Anaphylactic egg or Neomycin allergy. c. Order plain films of the abdomen d. Order ondansetron 8 mg every 8 hours as needed for nausea. - SOLUTION *a. Start a clear liquid diet, monitor for further signs and symptoms, and return for recheck in 3 days. Rationale: Patients with diverticulitis without peritoneal signs and mild symptoms can be managed outpatient on a clear liquid diet. Broad- spectrum antibiotics are regularly prescribed but current research shows that these medications are not useful in uncomplicated diverticulitis. Typically patients experience marked improvements in 3 days and their diet can be advanced as tolerated. After all symptoms have subsided, a diet high in fiber is recommended. (McQuaid, 2014). McQuaid, K. (2014) Gastrointestinal Disorders. In Papadakis, M., McPhee, S,. Rabow, M, (Eds), Current Medical Diagnosis and Treatment, 2015. Retrieved October 16,2015 from http://accessmedicine.mhmedical.com/content.aspx?bookid=1019&S ectionid=57668607. A parent tells the NP she is worried her 6 year old daughter will be injured while having a seizure episode. She explains the last time her daughter had a seizure she bit her tongue, saliva pooled in her mouth, and she appeared not to breathe. Which statement is an appropriate response to reassure the patient's mother? a. Turn her to her side to prevent her from swallowing her saliva. b. It is very common to turn blue from lack of oxygen. c. Hug her and hold her down to prevent injury. d. To protect her tongue place a toothbrush handle between her teeth. - SOLUTION *a. Turn her to her side to prevent her from swallowing her saliva. Rationale: To protect a child having a seizure from injury, prevent aspiration by placing them on the side, resist restraining and placing an object in clenched teeth which may cause more harm and choking; it is uncommon for patient's having seizures to turn blue from lack of oxygen. (Kedia, Knupp, Schreiner, Yang, & Moe, 2014, p. 793). A 30 year old female patient presents to the clinic complaining of generalized numbness, tingling, diplopia, feeling unsteady and urinary urgency for 10 days. She reports no significant medical history and this is the first time experiencing these symptoms. What is the most likely diagnosis? a. Myasthenia Gravis b. Guillian Barre syndrome c. Transient Ischemic Attack d. Multiple Sclerosis - SOLUTION * d. Multiple Sclerosis Rationale: Multiple sclerosis typically presents under the of age 55 with common initial presentation of weakness, numbness, tingling, unsteadiness in limbs, paraparesis, retrobulbar optic neuritis, diplopia, disequilibrium, sphincter disturbance such as urinary urgency or hesitancy (Aminoff & Kerchner, 2015, p. 1000). What are the three most common organisms that require antibiotic coverage in treatment of acute bacterial rhinosinusitis? a. Streptococcus pneumoniae, Mycoplasma pneumoniae, Staphylococcus aureus b. Staphylococcus aureus , Haemophilus influenzae, Beta-Hemolytic Streptococcus c. Streptococcus pneumoniae, Staphylococcus epidermis, Beta-hemolytic Streptococcus d. Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis - SOLUTION *d. Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis Rationale: Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis are the most common bacterial causes of acute bacterial rhinosinusitis. Lustig, L.R., & Schindler, J.S. (2015). Ear, Nose, & Throat Disorders. In Papadakis, M.A. & McPhee, S.J. (Eds.), Current medical diagnosis & treatment (54th ed.) (pp.XX-XXX). New York, NY: McGraw Hill Education. The first line treatment for acute bacterial rhinosinusitis in a patient who has not taken antibiotics within the past 90 days include all of the following EXCEPT: a. Amoxicillin b. Levofloxacin c. Trimethoprim-sulfamethoxazole d. Doxycycline - SOLUTION *b. Levofloxacin Rationale: All medications are viable options for first-line medications except Levofloxacin, which is only a first-line option after recent antibiotic use. Lustig, L.R., & Schindler, J.S. (2015). Ear, Nose, & Throat Disorders. In Papadakis, M.A. & McPhee, S.J. (Eds.), Current medical diagnosis & treatment (54th ed.) (pp.XX-XXX). New York, NY: McGraw Hill Education. A 58 year old African American who drinks 3 twelve ounce beers a day and is obese has questions about his risk for cirrhosis. He has tried to limit his alcohol intake because he knows that it is associated with cirrhosis. He is up to date with his Hepatitis A & B, pneumococcal, and annual influenza vaccines. You instruct the patient in order to further decrease his risk of cirrhosis: a. He should limit his intake of coffee and tea. b. His race reduces his risk for cirrhosis. c. He should discontinue taking his levothyroxine because it can increase his risk for cirrhosis. d. Higher coffee and tea intake will reduce his risk of cirrhosis. - SOLUTION * d. Higher coffee and tea intake will reduce his risk of cirrhosis. Rationale: The patient's race increases his risk of cirrhosis. Mexican Americans and African Americans have a higher frequency of cirrhosis. It is not levothyroxine, but propylthiouracil that can result in acute or chronic hepatitis. A higher coffee and tea intake will reduce his risk of cirrhosis. Therefore, D is the SOLUTION. A a 68 year old obese male presents to establish care. His initial BP is 154/92. He has not seen a provider in the past 10 years. His initial labs are: Rationale: Impetigo presents with macules, pustules, and superficial erosions, filled with honey colored, sticky crusts, usually on the face but also on other areas of the body. It is contagious and is caused by staphylococci or streptococci. A 68-year-old male presents to your clinic for his 3-month check-up. The patient complains of frequent "Charlie horses" at night that wakes him up from sleep over the last week. The patient's serum K+ is 3.1mEq/L. During the last week, the patient has also experienced GI symptoms including diarrhea and vomiting after being exposed to a virus by his granddaughter. He is currently taking losartan, metformin, and atorvastatin. Which of the following is the best plan of care for this patient? a. If the patient increases dietary intake of potassium containing foods such as bananas, dark leafy greens, and avocados and returns in one week for repeat labs, his K+ will return to normal. b. Instruct patient to take oral potassium over the next 5 days and return in one week to recheck potassium level. c. Admit patient to receive intravenous potassium. d. Refer patient to nephrology. - SOLUTION *b. Instruct patient to take oral potassium over the next 5 days and return in one week to recheck potassium level. Rationale: A. "Dietary potassium is almost entirely coupled to phosphate, rather than chloride-and is therefore not effective in correcting potassium loss associated with chloride depletion from diuretics or vomiting." (Papadakis & McPhee, 2015, p. 870) *B. "Oral potassium supplementation is the safest and easiest treatment for mild to moderate deficiency" (Papadakis & McPhee, 2015, p. 870) C. "Intravenous potassium is indicated for patients wth sever hypokalemia and for those who cannot take oral supplementation" (Papadakis & McPhee, 2015, p. 870). Severe hypokalemia is <2.5 mEq/L (Papadakis & McPhee, 2015, p. 807) D. "Patients with unexplained hypokalemia, refractory hyperkalemia, or clinical features suggesting alternate diagnosis (eg, aldosteronism or hypokalemic periodic paralysis) should be referred for endocrinology or nephrology consultation" (Papadakis & McPhee, 2015, p. 807) A 23-year-old male presents with clear rhinorrhea and sneezing associated with eye pruritus, irritation, and tearing. He is diagnosed with allergic rhinitis and prescribed intranasal corticosteroids. Which of the following is important for the APN to explain to the patient? a. This is an incorrect diagnosis; allergic rhinitis consists of greenish-yellow nasal discharge. b. Flunisolide 25mcg BID per nostril is the first line therapy concerning intranasal corticosteroids c. Antihistamines and H1 receptor agonists are preferred over intranasal corticosteroids for the treatment of allergic rhinitis and the prevention of developing recurrent acute or chronic sinusitis. d. Educating the patient on compliance, proper delivery technique, and maintaining consistent use especially in the first 2 weeks is essential to intranasal corticosteroid effectiveness. - SOLUTION *d. Educating the patient on compliance, proper delivery technique, and maintaining consistent use especially in the first 2 weeks is essential to intranasal corticosteroid effectiveness. Rationale: A. "Purulent yellow-green nasal discharge or expectorant" is an essential of diagnosis for Acute Bacterial Rhinosinusitis (Sinusitis) (Papadakis & McPhee, 2015, p. 214). B. "All intranasal corticosteroids are equally effective" (Papdakis & McPhee, 2015, p. 218). C. "Intranasal corticosteroids are critical in treating patients prone to recurrent acute bacterial rhinosinusitis or chronic rhinosinusitis" (Papadakis & McPhee, 2015, p. 218). *D. "Probably the most critical factor is compliance with regular use and proper introduction into the nasal cavity" (Papadakis & McPhee, 2015, p. 218). "Patients should be reminded that there might be a delay in onset of relief of 2 or more weeks (Papadakis & McPhee, 2015, p. 218) A patient presents with lab values that include: ALT = 78 and AST = 198. Which of the following is the most likely cause of these abnormal liver function tests? a. Daily Acetaminophen use b. ETOH abuse c. viral hepatitis d. statin use - SOLUTION *b. ETOH abuse Rationale: Abnormal LFTs can be caused by acetaminophen, statins, and viral hepatitis but is more commonly seen in alcoholic liver disease. In alcoholic liver disease, both ALT and AST are with the AST being > than the ALT by a factor of 2 or greater. (Essentials of Diagnosis on page 676, Papadakis & McPhee). When is it appropriate for the FNP to refer a patient with GERD for an upper endoscopy? a. At initial diagnosis of GERD b. After 4-8 weeks of successful control of symptoms with a proton pump inhibitor (PPI) c. After 8 weeks of H2 antagonist therapy with lack of response d. After no response to twice daily proton pump inhibitor over an 8 week period - SOLUTION *d. After no response to twice daily proton pump inhibitor over an 8 week period Rationale: An upper endoscopy should be considered if symptoms persist after 4-8 weeks of empiric proton pump inhibitor therapy to identify complications of GERD and other conditions. (Papadakis & McPhee page 591 under B. Special Examinations). d. Instruct the patient's mother to keep her daughter out of school until her symptoms have resolved and use cool compresses for eye discomfort. - SOLUTION *d. Instruct the patient's mother to keep her daughter out of school until her symptoms have resolved and use cool compresses for eye discomfort. Rationale: According to Current diagnosis & treatment: Pediatrics (Braverman, 2014, p. 466)-The child's symptoms are most consistent with viral conjunctivitis, which presents with redness in one or both eyes and a clear, watery discharge. The lack of itching and persistent, prolonged course distinguishes viral from allergic conjunctivitis, which often has a stringy or ropey watery discharge as well. *d. This condition is usually self-limited and resolves with symptomatic treatment. However, viral conjunctivitis is very contagious and child should not return to school until symptoms have completely resolved. Also instruct parent to adhere to strict hand hygiene. A 34-year-old with a history of asthma presents to the office complaining of increased shortness of breath and coughing; the symptoms wake her up about 2-3 times per month, and reports having to use her rescue inhaler at least 1-2 times per week. What should the FNP add to this patient's existing treatment regimen based on her current symptoms? a. ProAir HFA (albuterol) 90mcg/spray, Sig: 2 puffs inhaled q 4-6 hours prn wheezing or shortness of breath b. Serevent Diskus (salmeterol) 50 mcg/actuation DPI, Sig: 1 puff inhaled q 12 hours daily c. Prednisone 40 mg/day divided BID x 5 days d. Pulmicort Flexhaler 200 mcg/actuation DPI, Sig: 2 puffs inhaled BID daily - SOLUTION *d. Pulmicort Flexhaler 200 mcg/actuation DPI, Sig: 2 puffs inhaled BID daily *Rationale: According to Current Medical Diagnosis & Treatment 2015, pgs. 242-246 (Chestnutt & Prendergast, 2015, p. 242-246) Based on this patient's symptoms her asthma is classified as mild and persistent, therefore requiring step 2 treatment; the addition of a low dose ICS, in addition to her existing SABA rescue inhaler. The only correct choice from the options provided would be *d. Pulmicort is an ICS recommended daily low adult doses: 180-600mcg). None of the other choices are ICS. A-is a SABA (which she is already using); B-is a LABA (not recommended at Stage 2); C-Oral CCS-recommended for exacerbations. A mastectomy and radiation of the breast to remove localized cancer is an example of which of the following preventative medicine options? a. Tertiary b. Secondary c. Primary d. Elective - SOLUTION * a. Tertiary Rationale: None given Which risk factor is considered a modifiable risk factor regarding coronary disease and stroke? a. occasional EOTH use (< 2 glasses wine every month) b. Age c. Family History of early coronary disease d. Tobacco abuse - SOLUTION *d. Tobacco abuse Rationale: None given A patient presents with complaints of left sided, pulsatile head pain accompanied by nausea and photophobia. What type of headache would the nurse practitioner suspect this patient is experiencing? a. Tension b. Migraine c. Cluster d. musculoskeletal - SOLUTION *b. Migraine Rationale: None given A 2-month old patient presents to your clinic for his check up and vaccinations. The patient will receive his first Rotarix 1 vaccination today for prevention of rotavirus. When will the patient's second dose of Rotarix 1 be due? a. 8 months b. 4 months c. 6 months d. 9 months - SOLUTION *b. 4 months Rationale Question 47: There are two vaccines for Rotavirus: RV5 and RV1. RV5 is a three dose series at 2, 4, and 6 months of age while RV1 is a two dose series that is administered at 2 and 4 months of age. For both vaccines, the minimum age for dose 1 is 6 weeks and the maximum age for dose 2 is 14 weeks and 6 days. The minimum interval between doses is 4 weeks. All doses should be administered by 8 months and 0 days of age. What is the most important cause of preventable morbidity and early mortality? a. Low dose (81 mg) aspirin dosed each day b. Cigarette smoking c. Systolic blood pressure control d. routine physical activity - SOLUTION *b. Cigarette smoking Rationale: Cigarette smoking remains the most important cause of preventable morbidity and early mortality. The leading causes of death from smoking were: cardiovascular diseases, chronic obstructive pulmonary disease, and lung cancer. Cigarettes are responsible for 1 in 4 deaths each year. (Papadakis and McPhee, 2015 p. 7) At what age should the NP start regular blood pressure screenings at well- child visits? a. 2 years b. 3 years c. 4 years d. 5 years - SOLUTION *b. 3 years Rationale: According to Hay, Levin, Deterding, and Abzug (2014), blood pressure screenings at well-child visits start at age 3 years (pp. 255). What two findings are critical in establishing a diagnosis of acute otitis media? a. Edema and erythema of the external auditory canal b. Erythema of external auditory canal and severe ear pain c. Retracted and white TM d. Bulging TM and middle ear effusion - SOLUTION *d. Bulging TM and middle ear effusion b. Acute Bacterial Rhinosinusitis, PO NSAIDS, nasal decongestant, nasal corticosteroid c. Common cold, nasal irrigation, oral decongestant, nasal corticosteroid d. Pharyngitis, Penicillin, nasal decongestant, Acetaminophen (Tylenol) - SOLUTION *b. Acute Bacterial Rhinosinusitis, PO NSAIDS, nasal decongestant, nasal corticosteroid Rationale: The NP recognizes the signs and symptoms of Acute Bacterial Rhinosinusitis and prescribes the appropriate therapy. According to Papadakis & McPhee (2015) "All study groups note a number of major symptoms, including purulent nasal drainage, nasal obstruction or congestion, facial pain/pressure, altered smell, cough, and fever." (p. 214) "Eighty percent of patients with acute bacterial rhinosinusitis improve symptomatically within 2 weeks without antibiotic therapy." (Papakadis & McPhee, 2015, p. 215) A 62 year old male patient presents to the clinic with unilateral resting tremor, muscle rigidity, bradykinesia, and postural instability. The nurse practitioner recognizes that this patient will benefit most from which drug? a. Aricept b. Sinemet c. Namenda d. Haldol - SOLUTION * b. Sinemet Rationale: The nurse practitioner should recognize that the clinical symptoms of unilateral resting tremor, muscle rigidity, bradykinesia, and postural instability characterize Parkinson disease, a common disorder that includes male sex and age as risk factors. Sinemet (a combination of levadopa and carbidopa) is generally used to control clinical features, however the drug does not stop progression. A 12 year old female patient is having recurring migraines. The nurse practitioner understands that this age group can have which of the(se) medications to treat acute migraines? a. Almotriptan b. Acetaminophen c. Rizatriptan d. All of the above - SOLUTION *d. All of the above Rationale: The nurse practitioner should understand that a 12 year old child can be treated for migraines with simple analgesics like acetaminophen as well as specific migraine medications. It is important to understand that the two migraine medications the FDA approved for adolescents are almotriptan for adolescents ages 12-17 and rizatriptan for ages 6-17. In this case, the 12 year old child would be able to get any 3 of the medications listed. Psoriasis typically has ____ and ____ appearance. a. dry scales and underlying erythema b. well demarcated erythematous skin and silvery scales c. ring shaped and scaly border d. erythema and central clearing - SOLUTION *b. well demarcated erythematous skin and silvery scales Psoriasis is silvery scales on bright red, well-demarcated plaques, usually on knee, elbows, and scalp (Berger, 2015, p. 105). Which of the following conditions is considered a differential diagnosis for suspected warts? a) squamous cell carcinoma b) pemphigus c) varicella zoster d) chancre - SOLUTION *a.) squamous cell carcinoma Rationale: Some lesions warty in appearance are actually hypertrophic actinic keratosis or squamous cell carcinoma (Berger, 2015, p. 140). A 76 year old female presents to your clinic with complaints of "the worst headache of my life." She is accompanied by family who provide the history as the patient is confused and lethargic. The family states the patient has been complaining of headaches and neck discomfort for 2 days. The patient is positive for nuchal rigidity on exam. The next step is: a. Administer Acyclovir 10mg/kg IV now and admit to the hospital for 23 hour monitoring. b. Send the patient to Emergency Department for immediate neuro consult, CT with angiography, and lumbar puncture, including CSF studies. c. Order outpatient CSF studies and return in one week for follow up. d. Initiate triptan therapy, follow up CBC, CMP, and ESR, then return in one week. - SOLUTION *b. Send the patient to Emergency Department for immediate neuro consult, CT with angiography, and lumbar puncture, including CSF studies. Rationale: The abrupt onset of the 'worst headache in my life" is a key feature of subarachnoid hemorrhage. It is often accompanied by nuchal rigidity and obtundation. (Amnioff and Kerchner, 2015, p.975 A ten year old male presents to the clinic, accompanied by his mom. Mom provides the history, noting that the patient has periods of staring off into space, occurring on a daily basis, but only lasting a few seconds. The FNP knows that all of the following regarding this type of seizure are true *except*: a. The seizures last between three to ten seconds with 10-200 episodes in a day. b. Episodes are often triggered by hyperventilation. c. First line treatment is ethosuxamide. d. A lumbar puncture is diagnostic for seizure activity. - SOLUTION *d. A lumbar puncture is diagnostic for seizure activity. Rationale: Lumbar puncture cannot diagnose seizures, only rule out other underlying problems. Which of the following should you avoid for treatment of acute viral rhinosinusitis? a. Nasal saline irrigation b. Oral decongestants c. Intranasal decongestants d. Intranasal corticosteroids - SOLUTION *c. Intranasal decongestants rationale: Intranasal decongestants such as oxymetazoline or phenylephrine are rapidly effective but should not be used more than few days to prevent rebound congestion. Withdrawal of thedrug after prolonged use leads to rhinitis medicamentosa (page 214). c. Educate the patient that smoking does not contribute to GERD symptoms d. Educate the patient to elevate the head of bed while sleeping - SOLUTION *d. Educate the patient to elevate the head of bed while sleeping Rationale: For mild intermittent symptoms patients should eat smaller meals, loose weight, eliminate smoking and acidic foods, avoid lying down within 3 hours after meals, and elevate HOB when lying down to enhance esophageal clearance and decrease reflux (Mcphee (2015), pg 593). An elderly women presents to your clinic with complaints of vision loss, severe eye pain, and seeing "halos around lights." Examination reveals no discharge, a cloudy cornea, and dilated pupils. The provider knows these symptoms are most likely consistent with: a. Acute angle-closure glaucoma b. Acute conjunctivitis c. Corneal trauma d. Acute anterior uveitis - SOLUTION *a. Acute angle-closure glaucoma Rationale: (Table 7.1) Symptoms consistent with acute angle-closure glaucoma are blurred vision, severe pain, moderately dilated pupils, elevated IOP, no noted discharge, and a cloudy cornea (Mcphee ,2015, pg 166). Acute angle-closure glaucoma is seen more commonly in an older age group and is described as "halos around lights." (pg 175). The nurse practitioner is educating a patient who has a new diagnosis of celiac disease. Which of the following foods is not gluten free? A. Jelly B. Soy sauce C. Brown rice D. Honey - SOLUTION *B. Soy sauce Rationale: According to our McPhee textbook on page 617, celiac is defined as a disorder caused from an immunologic response to gluten. On page 619, it explains that removing foods that have gluten, such as soy containing foods, significantly improve/resolve symptoms. A first-time mom brings her daughter in for her 6 month check-up. The mother states she is concerned with the amount of spit-up her daughter has been having and inquires about reflux. As the NP, you educate the mother that all of the following factors may trigger reflux in infants *except*: A. Frequent large-volume feedings B. Upright positioning C. Small stomach capacity D. Short esophageal length - SOLUTION *B. Upright positioning Rationale: On p. 651 of our Pediatric textbook, clinical findings associated with infants with gastroesophageal reflux are listed. Answer choices A, C, and D are all factors that indeed contribute to reflux. Answer choice B can actually resolve reflux. On p. 652, the text states erect positioning can resolve reflux. Which one of the statements is *not* true regarding trigeminal neuralgia? a) Women are more commonly affected than men. b) Presents as the sudden onset of facial pain due to the dysfunction of the facial nerve (CN7). c) Pain may be aggravated by touch, chewing, and/or cold air. d) Treatment may include anticonvulsants, radiofrequency rhizotomy and/or gamma radiosurgery. - SOLUTION *b) Presents as the sudden onset of facial pain due to the dysfunction of the facial nerve (CN7). Rationale: Trigeminal neuralgia is restricted to the trigeminal nerve (CN5), and is triggered by compression of the nerve root. This can include the ophthalmic (V1), maxillary (V2), and mandibular (V3) branches (Papadakis, McPhee, & Rabow, 2015, pg. 958). Papadakis, M. A., McPhee, S. J., & Rabow, M. W. (Eds.). (2015). Nervous System Disorder. Current medical diagnosis & treatment 2015 (54th ed., pp. 958-959). New York, NY: McGraw Hill Education. Which of the following statements is true regarding chronic kidney disease? a) CKD is often classified by an abnormal GFR persisting for at least 3 months. b) Hypotension is one of the most common complications of CKD. c) CKD is not considered a stand-alone risk factor for cardiovascular disease. d) Computed tomography scanning supports the diagnosis of CKD. - SOLUTION *a) CKD is often classified by an abnormal GFR persisting for at least 3 months. Rationale: B ) Hypertension not hypotension is one of the most common complications of CKD (Papadakis, McPhee, & Rabow, 2015, pg. 901). C) CKD IS an independent risk factor for CVD (Papadakis, McPhee, & Rabow, 2015, pg. 901). C) US, not CT scan supports the diagnosis of CKD (Papadakis, McPhee, & Rabow, 2015, pg. 902). Papadakis, M. A., McPhee, S. J., & Rabow, M. W. (Eds.). (2015). Kidney Disease. Current medical diagnosis & treatment 2015 (54th ed., pp. 900-903). New York, NY: McGraw Hill Education. What is considered the gold standard for diagnosis of a UTI in a child? a) Renal ultrasound b) Voiding cystourethrogram (VCUG) c) Urine culture d) CBC - SOLUTION *c) Urine culture Rationale: The gold standard for diagnosing a UTI in a child is a urine culture (Hay, Levin, Deterding, Abaug, pg. 704). Hay, W., Levin, M., Deterding, R., & Abzug, M. (2014). Current diagnosis & treatment (22nd ed., pp. 774). New York, NY: McGraw-Hill Medical. Which of the following is *not* true about malignant melanoma? a. It has the highest mortality rate of all skin cancers b. Tumor thickness is the most important prognostic factor c. Clinical features may include irregular borders and diameter >6mm d. It is the most common of all skin cancers - SOLUTION * d. It is the most common of all skin cancers Rationale: The leading cause of death in skin disease is malignant melanoma, in addition, tumor thickness is the most important factor when