Laboratory Abnormalities and Clinical Findings in Various Medical Conditions, Exams of Nursing

Download Laboratory Abnormalities and Clinical Findings in Various Medical Conditions and more Exams Nursing in PDF only on Docsity! 1 Acute Care Exam 1 Week 1 – EENT A primary care provider notes painless, hard lesions on a patient’s external ears that expel a white crystalline substance when pressed. What diagnostic test is indicated? Rheumatoid factor Endocrine studies Biopsy of the lesions Uric acid chemical profile A patient has painful oral lesions and the provider notes several white, verrucous lesions in clusters throughout the mouth. What is the recommended treatment for this patient? Oral hygiene measures Nystatin oral suspension Surgical excision Oral acyclovir A patient has sore throat, a temperature of 38.5° C, tonsillar exudates, and cervical lymphadenopathy. What will the provider do next to manage this patient’s symptoms? Prescribe empiric penicillin Perform a rapid antigen detection test Refer to an otolaryngologist Order an antistreptolysin O titer A 61 year old male presents with a 12 hour history of extremely painful left red eye. The patient complains of blurred vision, haloes around lights, and vomiting. It began yesterday evening. On exam, the eye is red, tender and inflamed. The cornea is hazy and pupil reacts poorly to light. The most likely diagnosis in this patient is: 2 Macular degeneration Acute angle glaucoma Increased intracranial pressure Detached cornea A patient has recurrent epistaxis without localized signs of irritation. Which laboratory tests may be performed to evaluate this condition? (Select all that apply.) CBC with platelets 5 Metronidazole Clindamycin What are factors associated with acute suppurative parotitis? (Select all that apply.) Anticholinergic medications Diabetes mellitus Radiotherapy Hypervolemia Allergies A 39 year old has a sudden onset of painful right red eye. He reports sensitivity to light and the sensation of a foreign body, though his history for a foreign body is negative. He does not wear contact lenses. How should the NP manage this? Observe for 24 hours if visual acuity is normal Treat for bacterial conjunctivitis Treat for viral conjunctivitis Refer to ophthalmology No clear diagnosis can be made from signs/symptoms, but there are several red flags. collectively the red flags necessitate a referral. There is no mention of eye discharge necessary for conjunctivitis. Red flags present point more towards active corneal process although glaucoma should also be a differential. A 17-year-old has a complaint of ear pain. If he has otitis externa, which complaint is most likely/most common? Concurrent URI Fever Difficulty hearing TV Tragal pain 6 A patient has an initial episode otitis external associated with swimming. The patient’s ear canal is mildly inflamed and the tympanic membrane is not involved. Which medication will be ordered? Cipro HC Neomycin Fluconazole Vinegar and alcohol 7 A patient has gingival inflammation with several areas of separate ulceration and a small amount of purulent discharge. What is required to diagnose this condition? Culture and sensitivity Tzank smear Physical examination Microscopic exam of oral scrapings A patient reports tooth pain in a lower molar and the provider notes a mobile tooth with erythema and edema of the surrounding tissues without discharge. Which is the initial course of action by the provider? Recommend oral antiseptic rinses and follow up in one week Perform an incision and drainage of the edematous tissue Prescribe amoxicillin and refer to a dentist in 2 to 3 days Refer to an oral surgeon for emergency surgery A patient presents to your clinic with a painless red eye. Her vision is normal, but her sclera has a blood red area. What is this termed? Conjunctivitis Glaucoma Acute iritis Subconjunctival hemorrhage Which physical examination finding suggests viral rather than bacterial parotitis? Unilateral edema of parotid glands Enlargement and pain of affected glands Gradual reduction in saliva production Clear discharge from Stensen’s duct 10 Tinnitus Hearing loss A patient who has acute suppurative parotitis has been taking amoxicillin-clavulanate for 4 days without improvement in symptoms. The provider will order an antibiotic for Methicillin-resistant S. aureus. Which other measure may be helpful? Discouraging chewing gum 11 Topical corticosteroids Cool compresses Surgical drainage A NP preforms a fundoscopic exam. He identifies small areas of dull, yellowish-white coloration in the retina. What might these be? Cotton wool spots Hemorrhages Exudates Microaneurysm The provider sees a child with a history of high fever and sore throat. When entering the exam room, the provider finds the child sitting in the tripod position and notes stridor, drooling, and anxiety. What is the initial action for this patient? Administer empiric intravenous antibiotics and steroids Obtain an immediate consultation with an otolaryngologist Perform a thorough examination of the oropharynx Have the child lie down and administer high-flow, humidified oxygen A patient reports ear pain after being hit in the head with a baseball. The provider notes a large perforated tympanic membrane. What is the recommended treatment? Prescribe analgesics and follow up in 1 to 2 days Order antibiotic ear drops if signs of infection occur Refer the patient to an otolaryngologist for evaluation Reassure the patient that this will heal without problems Papilledema is noted n a patient with a headache. What is the importance of papilledema in this patient? it is not related to the headache 12 this is a common finding in patients with headache it is an incidental finding in patient with migraines It could be an important finding in this patient A patient has seasonal rhinitis symptoms and allergy testing reveals sensitivity to various trees and grasses. What is the first-line treatment for this patient? Intranasal steroids 15 Anterior cervical lymphadenopathy is common This usually begins as a viral infections Pain is normal in the affected eye It produces blurred vision in the affected eye An adolescent has fever, chills, and a severe sore throat. On exam, the provider notes foul-smelling breath and a muffled voice with marked edema and erythema of the peritonsillar tissue. What will the primary care provider do? Perform a rapid strep and throat culture Refer the patient to an otolaryngologist Prescribe empiric oral antibiotics Evaluate for possible epiglottitis Which patient may be given symptomatic treatment with 24 hours follow-up assessment without initial antibiotic therapy? A 4 year old, afebrile child with bilateral otorrhea A 6 month old with fever of 39.2° C, poor sleep and appetite and bulging TM A 36 month old with fever of 38.5° C, mild otalgia, and red, non-bulging TM A 5 year old with fever of 38.0° C, severe otalgia, and red, bulging TM A patient has nasal congestion, fever, purulent nasal discharge, headache, and facial pain and begins treatment with amoxicillin-clavulanate. At a follow-up visit 10 days after initiation of treatment, the patient continues to have purulent discharge, congestion, and facial pain without fever. What is the next course of action for this patient? A referral to an otolaryngologist A trial of azithromycin A CT scan of the paranasal sinuses A second course of amoxicillin-clavulanate 16 A patient reports several episodes of acute vertigo, some lasting up to an hour, associated with nausea and vomiting. What is part of the initial diagnostic workup for this patient? Auditory brainstem testing Electrocochleography Vestibular testing Audiogram and MRI 17 A patient has two palpable, tender, left preauricular nodes that are about 0.5cm in diameter. What condition might this be associated with? Ear infection Conjunctivitis Ulceration on the tongue Sore throat A kindergarten teacher was diagnosed with acute streptococcal pharyngitis. On exam, her throat is bright red color with no tonsillar exudate, and clear mucus is seen on the lower nasal turbinates. The urinalysis shows a large amount of white blood cells and is positive for nitrates. The patient has a significant sulfa allergy and thinks she is also allergic to penicillin. Which with the following is the best treatment choice? Levofloxacin Amoxicillin–clavulanic acid Trimethoprim–sulfamethoxazole Clarithromycin During routine physical exam of an elderly woman, a triangular thickening of the bulbar conjunctiva on the temporal side is noted to be encroaching on the cornea. She denies any eye pain or visual changes. Which of the following is most likely? Corneal arcus Pterygium Chalazion Pinguecula Group A strep pharyngiitis: Can be accompanied by abdominal pain Group A strep is usually accompanied by multiple symptoms with abrupt onset. GI symptoms are common such as nausea, vomiting, no abdominal pain. Inflamed uvula is not common 20 A patient presents to your clinic with a painless red eye. Her vision is normal, but her sclera has a blood red area. What is this termed? 1. Acute iritis 2. Conjunctivitis 21 3. Subconjunctival hemorrhage 4. Glaucoma During a routine physical examination, a provider notes a shiny, irregular, painless lesion on the top of one ear auricle and suspects skin cancer. What will the provider tell the patient about this lesion? It is benign and will not need intervention. Immediate surgery is recommended. This is most likely malignant. A biopsy should be performed. A patient with allergic rhinitis develops acute sinusitis and begins treatment with an antibiotic. Which measure may help with symptomatic relief for patients with underlying allergic rhinitis? Oral mucolytics Intranasal steroids Saline solution rinses Topical decongestants A 32-year-old patient is a newly diagnosed diabetic. She has developed a sinus infection. Her symptoms have persisted for 10 days. 6 weeks ago, she was treated with amoxicillin for a URI. It cleared without incident. Which be recommended today? Prescribed amoxicillin–clavulanate today Prescribed amoxicillin again Prescribe a decongestant and an antihistamine Do not prescribe an antibiotic, only a decongestant as indicated [Rationale: Amoxicillin is not indicated when a beta-lactamase producing organism and suspected, this is the case as patient took antibiotics 6 weeks ago. Amoxicillin–clavulanate is a good choice as it covers a beta-lactamase producers. And bacteria etiology is suspected as symptoms have persisted for 10 days. A decongestant can be added, however this does not substitute antibiotics in this case] A patient has been taking amoxicillin for treatment of a dental abscess. In a follow-up visit, the provider notes edema of the eyelids and conjunctivae. What is the next action? 22 Hospitalize the patient for an endodontist consultation Suggest using warm compresses to the eyes for comfort Recommend follow up with a dentist in 2 to 3 days Prescribe amoxicillin clavulanate for 10 to 14 days 25 Otitis externa Ear pain when pinna is pulled or tragus is pushed is indicative of otitis externa. Clear fluid is not indicative of pus formation such as with ruptured tympanic membrane. A patient is suspected of having vestibular neuritis. Which finding on physical examination is consistent with this diagnosis? Vertigo with changes in head position Facial palsy and vertigo Fluctuating hearing loss and tinnitus Spontaneous horizontal nystagmus A 20-year-old male of Hispanic descent who reports a history of a cold that resolved 2 weeks ago except for a dry cough and pain over his right cheek that worsens when he bends down. The patient denies fever. The patient tells you that he is very allergic to Keflex and erythromycin. Vital signs are stable except temperature is 99.2°F. Which showed the following conditions is most likely? Fever secondary to previous viral URI Hay fever Acute bronchitis Acute sinusitis Acute otitis media can be best diagnosed by identifying which otic characteristic(s)? Cloudy, bulging TM with impaired mobility Opacity and erythema of the tympanic membrane Decreased mobility of the tympanic membrane Marked redness of the tympanic membrane Cloudy, bulging TM with impaired mobility is the best predictor for AOM. Decreased mobility of TM can be a result of fluid behind the TM, as in middle ear effusion. 26 A patient complains of otalgia and difficulty hearing from one ear. The provider performs an otoscopic exam and notes a dark brown mass in the lower portion of the external canal blocking the patient’s tympanic membrane. What is the initial action? Ask the patient about previous problems with that ear. During an eye exam of a 50 year old hypertensive patient who is complaining of an onset of a severe headache, you find that the borders of the disc margins on both eyes are blurred. What is the name of this clinical finding? 27 Papilledema. A provider is recommending a cerumenolytic for a patient who has chronic cerumen buildup. The provider notes that the patient has dry skin in the ear canal. Which preparation is FDA approved for this use? Carbamide peroxide Mineral oil Hydrogen peroxide Liquid docusate sodium A patient reports a sudden onset of sore throat, fever, malaise, and cough. The provider notes mild erythema of the pharynx and clear rhinorrhea without cervical lymphadenopathy. What is the most likely cause of these symptoms? Viral pharyngitis Infectious mononucleosis Allergic pharyngitis Group A streptococcus A 93 year old demented adult has been recently treated for an upper respiratory infection but drainage from the right nostril persists. What should the NP suspect? Presence of foreign body Allergic rhinitis Unresolved URI Dental caries The NP preforms a fundoscopic exam on a patient who has recently been diagnosed with hypertension. What is the significant of AV nicking? This is indicative of long-standing hypertension This is a normal variant This is indicative of retinal detachment 30 A 22 year old tall, thin and athletic man comes into your primary care clinic complaining of pain with breathing and progressively worsening shortness of breath. In order of sequence, what will be your next steps? -Obtain more history, auscultate the lungs and send pt to the ER for a stat CXR and further evaluation. -Obtain more history, and immediately send him to the ER 31 A patient reports coughing up a small amount of blood after a week of cough and fever. The patient has been previously healthy and does not smoke or work around pollutants or irritants. What will the provider suspect as the most likely cause of this patient’s symptoms? Infection Patients with pneumonia reports that he has rust-colored sputum. With pathogen should the nurse practitioner suspect? Streptococcus pneumoniae Clinical description of mucus does not really help and clinical decision making regarding pneumonia, but certain clinical characteristics are associated with specific types of pneumonia. Scant or watery sputum is associated with atypical pathogens like mycoplasma and clamydophila. Thick, discolored sputum may be associated with bacterial pneumonia. A young adult patient without a previous history of lung disease has an increased respiratory rate and reports a feeling of “not getting enough air.” The provider auscultates clear breath sounds and notes no signs of increased respiratory effort. Which diagnostic test will the provider perform initially? Complete blood count A 65-year-old patient who has not had an influenza vaccine is exposed to influenza and comes to the clinic the following day with fever and watery, red eyes. What will the provider do initially? Observe for improvement or worsening for 24 hours Begin treatment with an antiviral medication Administer LAIV influenza vaccine Perform a nasal swab for RT-PCR assay Which patient might be expected to have the worst FEV1? Patient with bronchiolitis A controlled asthma patient 32 A 65 her old with emphysema A 60-year-old with pneumonia Forced expiratory volume in 1 second (FEV1)is the worst in patients with obstructive disease such as emphysema. An FEV1 should not be performed in patients with pneumonia and bronchiolitis because they would have diminished respiratory capacity related to the infection 35 What does peak flow meter measure? Peak flow capacity Oxygen saturation Exercise capacity Expiratory flow A patient comes to an emergency department with chest pain. The patient describes the pain is sharp and stabbing and reports that it has been present for several weeks. Upon questioning, the examiner determines that the pain is worse after eating. The patient reports getting relief after taking a friend’s nitroglycerin during one episode. What is the most likely cause of this chest pain?orrect! Esophageal pain Pleural pain Cardiac pain Aortic dissection pain A previously healthy patient develops influenza which is confirmed by RT-PCR testing and begins taking an antiviral medication. The next day, the patient reports increased fever and cough without respiratory distress. The patient’s lungs are clear and oxygen saturations are 97% on room air. What will the provider recommend? Empiric antibiotics to treat a possible secondary infection Referral to a specialist for evaluation and treatment Correct! Symptomatic treatment with close follow up in clinic Admission to the hospital for treatment of complications Hemoptysis can be confuse with other bleeding disorder. To narrow down your differential diagnosis, it is important to evaluate and obtain these pertinent data regarding your patient's history of: (Choose all that apply) sequence of birth number of soda intake per day Correct! occupational and environmental exposures travel history 36 A patient is seen in clinic for an asthma exacerbation. The provider administers three nebulizer treatments with little improvement, noting a pulse oximetry reading of 90% with 2 L of oxygen. A peak flow assessment is 70%. What is the next step in treating this patient? Admit to the hospital with specialist consultation Prescribe an oral corticosteroid medication 37 Give epinephrine injections and monitor response Administer three more nebulizer treatments and reassess What is the most common complication of influenza? Bacterial pneumonia Cough Bronchitis You Answered Viral pneumonia A patient develops acute bronchitis and is diagnosed as having influenza. Which medication will help reduce the duration of symptoms in this patient? Oseltamivir Whoever put this answer its incorrect the correct answer is Azithromycin The most common cause of bloody expectorant in primary care are due to the following: GERD and esophagitis Acute bronchitis and Pneumonia URI and Asthma AAA and varices Buttaro, Chapter 108 Hemoptysis, pg 471 40 Which method of treatment is used for traumatic pneumothorax? 1. Placement of small-bore catheter 2. Needle aspiration of the pneumothorax 3. Observation for spontaneous resolution 4. Tube thoracostomy 41 A patient who has undergone surgical immobilization for a femur fracture reports dyspnea and chest pain associated with inspiration. The patient has a heart rate of 120 beats per minute. Which diagnostic test will confirm the presence of a pulmonary embolism? 1. CT angiography 2. Electrocardiogram 3. D-dimer 4. Arterial blood gases A patient has a cough and fever and the provider auscultates rales in both lungs that do not clear with cough. The patient reports having a headache and sore throat prior to the onset of coughing. A chest radiograph shows patchy, nonhomogeneous infiltrates. Based on these findings, which organism is the most likely cause of this patient’s pneumonia. 1. Tuberculosis 2. S. pneumoniae 3. Mycoplasma 4. TrueA virus A high school athlete reports recent onset of chest pain that is aggravated by deep breathing and lifting. A 12-lead electrocardiogram in the clinic is normal. The examiner notes localized pain near the sternum that increases with pressure. What will the provider do next? 1. Prescribe an antibiotic 2. Recommend an NSAID 3. Order a chest radiograph 4. Refer to a cardiologist A patient who has asthma calls the provider to report having a peak flow measure of 75%, shortness of breath, wheezing, and cough, and tells the provider that the symptoms have not improved significantly after a dose of albuterol. The patient uses an inhaled corticosteroid medication twice daily. What will the provider recommend? 1. Taking an oral corticosteroid 2. Administering two more doses of albuterol 3. Going to the emergency department 4. Coming to the clinic for evaluation 42 The following requires immediate intervention and hospitalization (choose all that apply) 1. Primary spontaneous pneumothorax (PSP) 45 A patient reports shortness of breath with activity and exhibits increased work of breathing with prolonged expirations. Which diagnostic test will the provider order to confirm a diagnosis in this patient? Blood cultures Spirometry Arterial blood gases Ventilation/perfusion scan Mycoplasma pneumoniae is: Only identifiable on chest x-ray A disease with extrapulmonary manifestations Of diagnosis of exclusion And on common respiratory pathogens Mycoplasma is an atypical pathogen that produces atypical pneumonia. It is often difficult to diagnose because symptoms are varied often involving extrapulmonary symptoms such as GI symptoms, myalgia and arthralgia, rash. Chest x-ray may have some unique findings with mycoplasma but it is not the only way to diagnose it What is the most common cause of pneumonia and people of all ages?Correct! S. pneumoniae Group A Strep S. aureus Mycoplasma sp. Which clinical sign is especially worrisome in a patient with a pulmonary embolism? Abnormal lung sounds Hypotension Dyspnea Tachycardia 46 You have an elderly patient with a history of a myocardial infarction with residual paresthesia, and dysphagia. Your patient was brought in by his caretaker in the nursing home. The patient presents with one week of fever, productive cough and malaise. Besides his presentation, you suspect pneumonia due to his risk factors. (Choose all that apply) lack of proper housing Diminished gag reflex that can prevent entry of particles, mucus and food debris into the lungs Inadequate nutrition 47 possible compromise airway filtration and humidification from his h/o CVA You see a college student in college health clinic. She complains of abrupt onset of sore throat, nasal congestion, runny nose, and malaise. Vital signs show temperature of 99.8°F, otherwise normal physical exam reveals an erythematous throat, swollen nasal turbinates, and rhinitis. The NP suspect viral URI. Although the following treatments are appropriate except: Pseudoephedrine Saline nasal spray Oral prednisone Ibuprofen Week 3 – Endocrinology A 20-year-old female patient with tachycardia and weight loss but no optic symptoms has the following laboratory values: decreased TSH, increased T3, and increased T4 and free T4. A pregnancy test is negative. What is the initial treatment for this patient? Beta blocker medications A patient who is obese has recurrent urinary tract infections and reports feeling tired most of the time. What initial diagnostic test will the provider order in the clinic at this visit? C-peptide level Hemoglobin A1C Random serum glucose Thyroid studies 50 Cognitive impairment Chvostek’s sign Renal calculi Lef t ventricular hypertrophy Perioral paresthesias Which thyroid stimulating hormone (TSH) level indicates hyperthyroidism? 2.4 uIU/L 0.4 uIU/L 51 0.2 uIU/L 4.2 uIU/L Some of the hallmark characteristics of hyperosmolar hyperglycemic state are: Blood glucose over 1000 mg/dL Slow onset (over days) Higher prevalence in type 1 diabetics Negative ketones The patient comes into the clinic complaining of weight gain and brings in a nonfasting glucose log indicating glucose ranging from 110-170 mg/dL. This patient: Has impaired fasting glucose Should have a hemoglobin A1c performed Has normal blood glucose values Should continue to monitor glucose at home A postpartum woman develops fatigue, weight gain, and constipation. Laboratory values reveal elevated TSH and decreased T3 and T4 levels. What will the provider tell this patient? A thyroidectomy will be necessary. She will need lifelong medication. This condition may be transient. She should be referred to an endocrinologist. A 76-year-old obese patient has fatigue, thirst, and frequent urination. She was asked to measure a.m. fasting glucose value for one week. The values range from 142-1 75 mg/dL. She is now back to your clinic due to persistent symptoms, this patient: Should have a hemoglobin A1C performed for diagnosis 52 Can be diagnosed with type 2 diabetes Has prediabetes Has impaired fasting glucose Impaired fasting glucose can be diagnosed when to fasting glucose readings are between 100-125 mg/dL. The conjunction of classic symptoms of hyperglycemia with a fasting blood glucose over 126 mg/dL consistently is diagnostic for diabetes. A1c is not required to diagnose diabetes in this case, but can be done to establish a baseline. Untreated hyperglycemia may lead to all of the following complications except: 55 In order to determine how much T4 replacement of patient needs to reestablish a euthyroid state, the nurse practitioner considers: Patient's body weight A patient who has diabetes has a blood pressure of 140/90 mm Hg and significant >2mg/dL albuminuria. Which initial action by the primary care provider is indicated for management of this patient? 1. Referring to an ophthalmologist 2. Consulting with a nephrologist 3. Prescribing an antihypertensive medication 4. Limiting protein intake Which thyroid stimulating hormone (TSH) level indicates hyperthyroidism? 1. 0.4 2. 4.2 3. 0.2 4. 2.4 A patient who is obese has recurrent urinary tract infections and reports feeling tired most of the time. What initial diagnostic test will the provider order in the clinic at this visit? 1. Thyroid studies 2. Hemoglobin A1c 3. Random serum glucose 4. C-peptide level Mr. Smith, an overweight 48-year-old male with undiagnosed type 2 diabetes mellitus presents to your clinic. Which symptom is least likely associated with type 2 diabetes mellitus? 1. Constipation 2. Impetigo 3. Fatigue 4. Athlete’s foot 56 A 52-year-old presents with thirst and frequent urination today. His glucose is 352. How should this be managed today? 1. Start metformin 2. Have him return tomorrow to recheck his blood glucose 3. Start metformin plus pioglitazone 4. Start insulin 57 A postpartum woman develops fatigue, weight gain, and constipation. Laboratory values reveal elevated TSH and decreased T3 and T4 levels. What will the provider tell this patient? 1. This condition may be transient 2. She should be referred to an endocrinologist 3. A thyroidectomy will be necessary 4. She will need lifelong medication A patient who is obese has recurrent urinary tract infections and reports feeling tired most of the time. What initial diagnostic test will the provider order in the clinic at this visit? 1. Random serum glucose 2. Hemoglobin a1c 3. Thyroid studies 4. c-peptide Excessive thirst and volume of dilute urine may be a symptom of: 1. Diabetes insipidus 2. Viral gastroenteritis 3. Urinary tract infection 4. hypoglycemia A 45-year-old female patient has fatigue for the past 3 months and a 10 pound weight gain. She previously had regular menses occurring about every 30 days, but in the last 3 months her menses have varied. She has high TSH. It was repeated one week later and found to be even higher. Would explain this finding? 1. Hypothyroidism 2. Subclinical hypothyroidism 3. Perimenopause 4. Transient hypothyroidism Mr. Jones, brings his obese 15 year old son in to see you. You examine the 15-year-old and identify acanthosis nigricans. This probably indicates: 60 Repeat TSH plus free T4 Patient presents with elevated TSH as well as possible symptoms of hypothyroidism. A repeat of TSH and free T4 should be done to determine presence and degree of hypothyroidism. Replacement therapy is generally not initiated until the TSH is greater than 10 and direct measurement of serum T4 is obtained. there is no nodule or other indications in this scenario for an ultrasound. 61 In order to determine how much T4 replacement of patient needs to reestablish a euthyroid state, the nurse practitioner considers: The TSH level A 20-year-old female patient with tachycardia and weight loss but no optic symptoms has the following laboratory values: decreased TSH, increased T3, and increased T4 and free T4. A pregnancy test is negative. What is the initial treatment for this patient? Beta blocker medications 62 A patient who is obese has recurrent urinary tract infections and reports feeling tired most of the time. What initial diagnostic test will the provider order in the clinic at this visit? 65 Increase levothyroxine dose This patient has a low T4 with elevated TSH and hence needs an increase in levothyroxine. Dyslipidemia is common finding when TSH exceeds 10. The NP should first treat hypothyroidism and then proceed with repeat of lipid testing. A 50-year-old female presents for her annual exam. She complains of fatigue and weight gain. She has a following lab results. What should the NP order? TSH 7 (normal 0.4-3.8) Repeat TSH plus free T4 Patient presents with elevated TSH as well as possible symptoms of hypothyroidism. A repeat of TSH and free T4 should be done to determine presence and degree of hypothyroidism. Replacement therapy is generally not initiated until the TSH is greater than 10 and direct measurement of serum T4 is obtained. there is no nodule or other indications in this scenario for an ultrasound. Acanthosis nigricans is associated with all of the following disorders except: Tinea versicolor Acanthosis nigricans is a benign skin condition that is a sign of insulin resistance. It is rarely associated with some types of adenocarcinoma of the GI tract. Tinea versicolor is a superficial infection of the skin that is caused by fungi A 45-year-old female patient has fatigue for the past 3 months and a 10 pound weight gain. She previously had regular menses occurring about every 30 days, but in the last 3 months her menses have varied. She has high TSH. It was repeated one week later and found to be even higher. Would explain this finding? Hypothyroidism 66 The patient's TSH is high on 2 occasions, along with symptoms, this was certainly lead to a diagnosis of hypothyroidism. A postpartum woman develops fatigue, weight gain, and constipation. Laboratory values reveal elevated TSH and decreased T3 and T4 levels. What will the provider tell this patient? She will need lifelong medication. You Answered 67 She should be referred to an endocrinologist. This condition may be transient. A thyroidectomy will be necessary. A patient who is obese has recurrent urinary tract infections and reports feeling tired most of the time. What initial diagnostic test will the provider order in the clinic at this visit? Thyroid studies Hemoglobin A1C C-peptide level Random serum glucose Which findings are part of the 2009 diagnostic criteria for metabolic syndrome? (Select all that apply.) Elevated waist circumference Decreased plasminogen activator inhibitor 1 levels HDL cholesterol </= 40 mg/dL Fasting plasma glucose ≧100 mg/dL Triglycerides ≧150 mg/dL Mr. Smith, an overweight 48-year-old male with undiagnosed type 2 diabetes mellitus presents to your clinic. Which symptom is least likely associated with type 2 diabetes mellitus? Athlete's foot Fatigue Constipation Impetigo 70 A 45-year-old patient who has hypothyroidism and takes levothyroxine. Based on the following lab results, how should the nurse practitioner proceed? TSH 32.7 (normal 0.4-3.8) Free T4 0.09 (normal 0.8-2.8) LDL 190mg/dL Total cholesterol 260mg/dL 71 Encourage lifestyle modifications Increase levothyroxine dose Decrease levothyroxine dose Begin statin therapy This patient has a low T4 with elevated TSH and hence needs an increase in levothyroxine. Dyslipidemia is common finding when TSH exceeds 10. The NP should first treat hypothyroidism and then proceed with repeat of lipid testing. The patient has a TSH value of 13.1 today. The nurse practitioner had decided to initiate replacement therapy with levothyroxine 88 µg daily. When should the NP recheck the patient's TSH level? 4 weeks 6 weeks 10 weeks 2 weeks Symptoms of hypothyroidism can improve post levothyroxine therapy within 2-3 weeks; however steady TSH concentration are not achieved for at least 6 weeks. TSH can then be monitored annually unless the patient asymptomatic. Which laboratory values representing parathyroid hormone (PTH) and serum calcium are consistent with a diagnosis of primary hyperparathyroidism? Inappropriate secretion of PTH along with hypercalcemia Week 4 – Cardiovascular (CV) An adult patient reports frequent episodes of syncope and lightheadedness. The provider notes a heart rate of 70 beats per minutes. What will the provider do next? 72 Evaluate the patient’s orthostatic vital signs Which are causes of secondary hypertension? (Select all that apply.) Nonsteroidal anti-inflammatory drugs Sleep apnea 75 Mr. Smith is a 72-year-old patient takes warfarin for chronic atrial fibrillation. His INR today is 4. The nurse practitioner should: Stop the warfarin today and repeat INR tomorrow. INR range for atrial fibrillation is usually 2-3 for chronic atrial fibrillation. Stopping warfarin for 4 days with certainly decrease INR, but his overkill, and would put patient at risk for thromboembolism when INR is subtherapeutic. Vitamin K is not necessary for patients who are not bleeding due to high INR, or whose INR is less than 8. Which are causes of secondary hypertension? (Select all that apply.) Oral contraceptives Isometric exercises Increased salt intake ct! Sleep apnea ! Nonsteroidal anti-inflammatory drugs The AHA recommends early CPR and AED use for adult victims of cardiac arrest outside of a hospital setting because most victims have which arrhythmia? Atrial fibrillation ct! Ventricular fibrillation Atrial flutter Ventricular tachycardia A patient with poorly controlled hypertension and history of myocardial infarction 6 years ago presents today with mild shortness of breath. He takes quinapril, aspirin, metoprolol, and statin daily. What symptom is not indicative of heart failure?Correct! Headache Cough Orthopnea Fatigue Headache is a nonspecific symptom and is not typical for heart failure. All the other symptoms are classic for worsening heart failure. 76 A 28-year-old has a grade 3 murmur. Which characteristic indicates a need for referral? A fixed split An increase in splitting with inspiration Split S2 with inspiration wered 77 Changes in intensity with position changes A split this created because of closure of valves. For example, and S2 is created by closure of an aortic and pulmonic valve. Normal these split with inspiration and almost never with expiration. Splits should never be fixed. This could indicate pathology such as atrial septal defect, pulmonic stenosis, or possibly mitral regurgitation. A health care provider in a clinic finds a patient in a room, unresponsive and pale. Which possible signs should be used to identify the need to initiate cardiopulmonary resuscitation (CPR)? Correct! Assessment of gasping breaths or not breathing Determination of pulselessness or bradycardia An African-American patient who is being treated with a thiazide diuretic for chronic hypertension reports blurred vision and shortness of breath. The provider notes a blood pressure of 185/115. What is the recommended action for this patient? Admit to the hospital for evaluation and treatment A patient reports sustained, irregular heart palpitations. What is the most likely cause of these symptoms? Atrial fibrillation A patient taking atorvastatin for newly diagnosed dyslipidemia complains of fatigue, weakness, muscle aches in his lower back, arms, legs for the past 3 days. It has not improved with rest. How should this be managed initially? 80 A child with a history of asthma is brought to the clinic with a rapid heart rate. A cardiac monitor shows a heart rate of 225 beats per minute. The provider notifies transport to take the child to the emergency department. What initial intervention may be attempted in the clinic?ect! Using a vagal maneuver or carotid massage Giving a beta blocker 81 Providing a loading dose of digoxin Administration of intravenous adenosine A 43-year-old Hispanic male presents to clinic for uncomplicated lower leg cellulitis. During her exam, you notice an audible diastolic murmur best heard in the mitral listening point. he does not have any significant cardiovascular symptoms. The murmur is probably: Acute mitral regurgitation Chronic mitral regurgitation Mitral stenosis Mitral valve prolapse A 35-year-old man has a history of an upper respiratory viral infection 4 weeks ago. He reports that he started feeling dyspnea and now complains of sharp pain in the middle of the chest that is worse when he lies down. Physical exam is within normal limits with the exception of pericardial rub on auscultation. The most likely diagnosis would be: Pulmonary embolism Esophageal reflux Pericarditis Pneumonia A patient reports abdominal and back pain with anorexia and nausea. During an exam, the provider notes a pulsatile abdominal mass. What is the initial action? Ultrasound of the mass to determine size Immediate referral to a thoracic surgeon Scheduling an MRI to evaluate for aortic disease Ordering computerized tomography angiography A young female patient has known mitral valve prolapse. During a routine health maintenance exam, the provider notes an apical systolic murmur and a midsystolic click on auscultation. The patient denies chest pain, syncope, or palpitations. What will the provider do? 82 Continue to monitor the patient every 3 years Reassure the patient that these findings are expected Consult with the cardiologist to determine appropriate diagnostic tests Admit the patient to the hospital for evaluation and treatment 85 A 40-year-old woman comes to the medical office complaining of palpitations and some lightheadedness for the past 6 months. These are and him episodes. You notice a midsystolic click with late systolic murmur that is best heard in the apical area during auscultation of the chest. You would suspect: Atrial fibrillation Sinus arrhythmia Mitral stenosis Mitral valve prolapse MVP occurs when the mitral valve does not close all the way, causing a late systolic murmur heard best in the apical area during auscultation. Following a normal S1, the valve suddenly prolapses, resulting in a midsystolic click. Classic symptoms of deep vein thrombosis include: Swelling, pain, discoloration in lower extremity A 75-year-old patient has aortic stenosis is presenting with symptoms of worsening stenosis. You know that to most common symptoms of worsening stenosis include: Shortness of breath and syncope Patient with diabetes presents with pain in his lower legs when he walks and pain resolution with rest. When specifically asked about pain in his lower leg, he likely will report pain: In the calf muscle In or around the ankle joint Pain in the lower leg that waxes and wanes Radiating down his leg from the thigh 86 The patient's symptoms are typical of claudication related to arteriosclerosis. This usually produces pain in specific muscle group where ischemia occurs. Commonly this is seen in the calf muscle. A patient has a cardiac murmur that peaks in midsystole and is best heard along the left sternal border. The provider determines that the murmur decreases in intensity when the patient changes from standing to squatting and increases in intensity with the Valsalva maneuver. Which cause will the provider suspect for this murmur? Mitral valve prolapse Aortic stenosis Tricuspid regurgitation 87 Hypertrophic cardiomyopathy A patient is diagnosed with PAD and elects not to have angioplasty after an angiogram reveals partial obstruction in lower extremity arteries. What will the provider recommend to help with relief of symptoms in this patient? Walking to the point of pain each day Statin therapy with clopidogrel Daily aspirin therapy to prevent clotting Walking slowly for 15 to 20 minutes twice daily An elderly woman has been taking digoxin for 10 years. Her EKG is showing a new onset of atrial fibrillation. Her pulse is 64 bpm. She denies any significant cardiovascular symptoms. Which of the following interventions is most appropriate? Discontinued digoxin and order another 12-lead EKG Order a serum TSH, digoxin level, electrolyte panel Order an electrolyte panel and digoxin level Order a digoxin level and decrease her digoxin dose by half while waiting for results An adult patient reports frequent episodes of syncope and lightheadedness. The provider notes a heart rate of 70 beats per minutes. What will the provider do next? 1. Monitor patient’s heart rate while the patient is bearing down 2. Evaluate the patient’s ortho vital signs 3. Order an electrocardiogram and exercise stress test A patient reports sustained, irregular heart palpitations. What is the most likely cause of these symptoms? 1. Anemia 2. Extrasystole 3. Atrial Fibrillation 90 A patient is diagnosed with PAD and elects not to have angioplasty after an angiogram reveals partial obstruction in lower extremity arteries. What will the provider recommend to help with relief of symptoms in this patient? 91 1. Daily aspirin therapy to prevent clotting 2. Statin therapy with clopidogrel 3. Walking to the point of pain each day 4. Walking slowly for 15 to 20 minutes twice daily A patient reports recurrent chest pain that occurs regardless of activity and is not relieved by rest. The provider administers a nitroglycerin tablet which does not relieve the discomfort. What is the next action? 1. Administer a second nitroglycerin tablet 2. Prescribe a calcium channel blocker medication 3. Give the patient a beta blocker medication 4. Start statin therapy and refer the patient to a cardiologist An elderly woman has been taking digoxin for 10 years. Her EKG is showing a new onset of atrial fibrillation. Her pulse is 64 bpm. She denies any significant cardiovascular symptoms. Which of the following interventions is most appropriate? 1. Order an electrolyte panel and digoxin level 2. Order a serum TSH, digoxin level, electrolyte panel 3. Order a digoxin level and decrease her digoxin dose by half while waiting for results 4. Discontinued digoxin and order another 12-lead EKG A patient taking atorvastatin for newly diagnosed dyslipidemia complains of fatigue, weakness, muscle aches in his lower back, arms, legs for the past 3 days. It has not improved with rest. How should this be managed initially? 1. Ask about nighttime muscle cramps 2. Check liver enzymes first 3. Stop atorvastatin immediately 92 4. Order a CPK level A 70 year old male patient complains of a bright red colored spot that has been present in his left eye for 2 days. He denies eye pain, visual changes, or headaches. He ha a new onset cough from a recent URI. The only medicine he is taking is aspirin 1 tablet daily. 95 Apply ice to the injured site to prevent airway occlusion A patient has recurrent sneezing, alterations in taste and smell, watery, itchy eyes, and thin, clear nasal secretions. The provider notes puffiness around the eyes. The patient’s vital signs are normal. What is the most likely diagnosis for this patient? Correct! Allergic rhinitis Acute sinusitis Chronic sinusitis Viral rhinitis A patient diagnosed with strep throat received a prescription for azithromycin. She has not improved in 48 hours. What course of action is acceptable? Different macrolide antibiotic should be prescribed Correct! Penicillin or cephalosporin with beta-lactamase coverage should be considered The patient should wait another 24 hours for improvement That antibiotics should be changed to a first generation cephalosporin Improvement with antibiotics and strep throat should generally occur within 48 hours. Initial macrolide therapy would be a poor choice as there is high rates of strep resistance to macrolide antibiotics. penicillin antibiotics are generally first-line A 93 year old demented adult has been recently treated for an upper respiratory infection but drainage from the right nostril persists. What should the NP suspect? Unresolved URI Dental caries Allergic rhinitis Correct! Presence of foreign body 96 There are 2 clinical clues in this question. First the pt has continued drainage despite treatment. Second, the drainage is unilateral. Unilateral drainage from a nostril should prompt the examiner to visualize turbinates. 97 During routine physical exam of an elderly woman, a triangular thickening of the bulbar conjunctiva on the temporal side is noted to be encroaching on the cornea. She denies any eye pain or visual changes. Which of the following is most likely? Corneal arcus Chalazion Correct! Pterygium Pinguecula Which method of treatment is used for traumatic pneumothorax? Tube thoracostomy Observation for spontaneous resolution Correct! Needle aspiration of the pneumothorax Placement of a small-bore catheter A 22 year old tall, thin and athletic man comes into your primary care clinic complaining of pain with breathing and progressively worsening shortness of breath. In order of sequence, what will be your next steps? Obtain more history, order a stat CXR and have patient return to clinic Immediately auscultate the lungs and send for CXR Correct Answer Obtain more history, and immediately send him to the ER Correct! Obtain more history, auscultate the lungs and send pt to the ER for a stat CXR and further evaluation. Dyspnea, tachypnea and pleuritic CP are classic presentation of a pulmonary emboli. If your pt is complaining of calf or thigh leg pain, you should suspect compartment syndrome peripheral neuropathy with fracture Correct!