NURS 6531 Final Exam New 2024-2025 Version Best Studying Material with All Questions, Exams of Nursing

Download NURS 6531 Final Exam New 2024-2025 Version Best Studying Material with All Questions and more Exams Nursing in PDF only on Docsity! NURS 6531 Final Exam New 2024-2025 Version Best Studying Material with All Questions and 100% Correct Answers What is important about increased PAI-1 levels in patients? a. They cause increased insulin resistance. b. They are associated with metabolic syndrome. c. They lower the risk of hypertension. d. They predispose patients to dyslipidemia. --------- Correct Answer ---------- ANS: B Increased PAI-1 levels increase the risk of atherothrombosis. They are correlated, but do not cause insulin resistance and do not affect the relative risk of hypertension or dyslipidemia. Which medication given for patients with metabolic syndrome is most likely to lower PAI-1 levels? a. Aspirin b. Atorvastatin c. Metformin d. Niacinc --------- Correct Answer ---------- ANS: C Metformin is given not only to reduce hyperinsulinemia and lower insulin resistance, but also to lower plasma PAI-1 levels. Aspirin is given to reduce MI risk. Atorvastatin helps with dyslipidemia. Niacin may be given to lower triglycerides. A previously lucid patient with early-stage Alzheimer's disease is hospitalized after a surgical procedure and exhibits distractibility and perceptual disturbances that occur only in the late afternoon. The patient has difficulty sleeping at night and instead sleeps much of the morning. What is the likely cause of these symptoms? a. Hyperactive delirium b. Hypoactive delirium c. Sundowner syndrome d. Worsening dementia --------- Correct Answer ---------- ANS: C Patients with dementia are at increased risk of sundowner syndrome, characterized by the symptoms above and which typically appear in late afternoon and early evening. Hyperactive delirium is manifested by agitation and restlessness. Hypoactive delirium includes patients with decreased alertness, lethargy, and slowed speech. Delirium and worsening of dementia would cause symptoms around the clock, not just in the late afternoon or evening. An 80-year-old patient becomes apathetic, with decreased alertness and a slowing of speech several days after hip replacement surgery alternating with long periods of lucidity. What is the most likely cause of these symptoms? a. Anesthesia effects b. Delirium c. Pain medications d. Stroke --------- Correct Answer ---------- ANS: B An acute presentation of these symptoms is most likely delirium since they alternate with lucid periods. The other causes may contribute to delirium by intensifying it. An elderly patient has symptoms of depression and the patient's daughter asks about possible Alzheimer's disease (AD) since there is a family history of this disease. A screening evaluation shows no memory loss. What is the initial step in managing this patient? a. Order brain imaging studies such as CT or MRI. b. Perform genetic testing to identify true risk. c. Prescribe a trial of an antidepressant medication. d. Recommend a trial of a cholinesterase inhibitor drug. --------- Correct Answer ---------- ANS: C Elderly patients with depression who do not have other signs of AD may be given a trial of antidepressant medications initially in order to evaluate these symptoms. Brain imaging studies are not indicated initially. Genetic testing is not indicated. Once the degree of depression is determined and if other symptoms appear, an anticholinesterase inhibitor may be ordered. Which findings are part of the diagnostic criteria for metabolic syndrome? (Select all that apply.) a. Decreased plasminogen activator inhibitor 1 levels b. Elevated waist circumference c. Fasting plasma glucose > 100 mg/dL d. HDL cholesterol > 45 mg/dL e. Triglycerides > 150 mg/dL --------- Correct Answer ---------- ANS: B, C, E The current criteria for diagnosing metabolic syndrome include increased waist circumference, elevated fasting plasma glucose, and elevated triglycerides. According to these criteria, patients will have HDL levels <40 mg/dL. The old criteria included elevated plasminogen activator inhibitor 1 levels. Which laboratory values representing parathyroid hormone (PTH) and serum calcium are consistent with a diagnosis of primary hyperparathyroidism? a. Appropriately high PTH along with hypocalcemia b. Appropriately increased PTH and low or normal serum calcium c. Inappropriate secretion of PTH along with hypercalcemia d. Prolonged inappropriate secretion of PTH with subsequent hypercalcemia --------- Correct Answer ---------- ANS: C Primary hyperparathyroidism is characterized by the inappropriate secretion of PTH in the setting of hypercalcemia. Appropriately high PTH with hypocalcemia characterizes hypoparathyroidism. An appropriately increased secretion of PTH with low or normal serum calcium is characteristic of secondary hyperparathyroidism. Prolonged inappropriate secretion of PTH in which hypercalcemia develops is tertiary hyperparathyroidism. d. The iron is stopped when the hemoglobin increases. --------- Correct Answer ---------- ANS: C The dose for children is 3 mg/kg/day in divided doses. This child should get 60 mg/day, which is 30 mg/dose twice daily. Iron supplements are best absorbed on an empty stomach. Iron is given for at least 4 to 6 months. Hemoglobin levels will begin to increase in 1 to 2 weeks, but the iron is given until the serum ferritin increases sufficiently in 4 to 6 months. A 60-year-old female patient has recently lost weight and a physical examination reveals a beefy-red, sore tongue, with no neurological findings. Based on these clinical findings, what will the provider anticipate finding in the laboratory data? a. Decreased homocysteine levels b. Leukopenia and thrombocytopenia c. Low hemoglobin and elevated MCV d. Normal methylmalonic acid level --------- Correct Answer ---------- ANS: C Macrocytic anemia caused by vitamin B12 deficiency will have symptoms described above. Although folate acid deficiency causes macrocytic anemia, there are rarely any symptoms. Hemoglobin will be decreased and MCV will increase. Homocysteine levels will be increased. The patient with B12 deficiency will have leukopenia and thrombocytopenia with severe deficiency, characterized by neurologic findings, which this patient does not have. Methylmalonic acid level will decrease. A patient is noted to have prolonged bleeding after an intravenous needle is removed. A subsequent laboratory test reveals a prolonged activated partial thromboplastin (aPTT) time with a normal prothrombin time (PT). Based on this result, the provider may suspect alteration in function of which factor? a. Factor V b. Factor VII c. Factor VIII d. Factor X --------- Correct Answer ---------- ANS: C Factor VIII is part of the intrinsic system, which aPTT measures. The other factors are part of the extrinsic system, which is measured by PT. A male patient has a history of recurrent epistaxis. Prior to a scheduled surgery, the provider asks about a family history of bleeding disorders. The patient reports no female relatives who had excessive bleeding episodes, but states that a maternal uncle and his maternal grandfather both had postsurgical complications related to bleeding. Based on this history, which diagnosis is possible? a. Hemophilia b. Thrombocytopenia c. Thrombophilia d. Von Willebrand disease --------- Correct Answer ---------- ANS: A Hemophilia is an X-linked recessive disorder affecting only males and carried by females. A family history of maternal males with bleeding disorders should clue the provider that this disorder is likely. Thrombocytopenia is usually an acquired disorder. Thrombophilia causes clots and thrombi, not bleeding. Von Willebrand disease is an autosomal genetic disorder affecting both males and females. A patient has type 1 Von Willebrand disease (vWD). What treatment is generally effective to prevent and treat bleeding episodes in this patient? a. Coagulation factor b. Desmopressin c. Heparin d. Vitamin K --------- Correct Answer ---------- ANS: B Desmopressin may be useful in patients with type 1 vWD. Coagulation factor is used in most patients with hemophilia. Heparin is an anticoagulant. Vitamin K is used to counter warfarin overdose. A child has a recent history of leg pain, unexplained bruising, and nosebleeds. The provider notes petechiae and diffuse lymphadenopathy. A complete blood count reveals a white blood cell (WBC) of 30,000 cells/mm3 and near normal red blood cell (RBC) and platelet counts. What will the provider do next to manage this patient? a. Order coagulation studies to evaluate for coagulopathies b. Perform biochemical studies to look for hyperuricemia c. Refer to a specialist for a bone marrow aspirate and biopsy d. Repeat the complete blood count in 2 weeks --------- Correct Answer ---------- ANS: C Patients with acute lymphocytic leukemia (ALL) may have normal blood counts even when the marrow has been replaced with leukemic cells, so a bone marrow aspirate and biopsy is required for the definitive diagnosis. Coagulation and biochemical studies may be performed after the diagnosis is known to evaluate for complications. Waiting and repeating the CBC in 2 weeks is not recommended since the definitive diagnosis is made by bone marrow biopsy. A patient is suspected of having leukemia and the provider orders biochemical studies and a bone marrow aspirate and biopsy. The results include white blood cells (WBCs) greater than 200,000 cells/mm3 normal red blood cells (RBCs), hyperplastic myeloid cells, and the absence of serum leukocyte alkaline phosphatase. Which test will the provider order to confirm a diagnosis in this patient? a. Chest radiograph b. Coagulation studies c. Philadelphia chromosome test d. Serum protein electrophoresis --------- Correct Answer ---------- ANS: C The findings from the complete blood count (CBC) and bone marrow biopsy, along with a positive Philadelphia chromosome test, confirm the diagnosis of chronic myelogenous leukemia. A chest radiograph and serum protein electrophoresis may be performed to evaluate for associated symptoms. Coagulation studies are usually performed as part of the diagnostic workup for acute lymphocytic leukemia (ALL). A patient with acute myelogenous leukemia (AML) who has a high white blood cell count and diffuse lymphadenopathy is hospitalized during the induction phase of chemotherapy. What monitoring and interventions are critical to assess for complications during this phase of care for this patient? (Select all that apply.) a. Administration of sodium bicarbonate and allopurinol b. Assessment for bruising and petechiae c. Close monitoring of absolute neutrophil counts d. Daily renal function and chemistry values e. Meticulous assessment of hydration status --------- Correct Answer ---------- ANS: A, D, E This patient has a high WBC load and diffuse lymphadenopathy, so is at increased risk for acute tumor lysis syndrome (ATLS). Close monitoring of renal function, serum renal chemistry values, and hydration status is essential. Adding sodium bicarbonate and allopurinol help to minimize risk. Thrombocytopenia causing bruising and petechiae, along with neutropenia, are common complications of chemotherapy but these symptoms generally occur 7 to 10 days after initiation of therapy. A patient reports a neck mass that has been present intermittently for 5 or 6 weeks which varies in size. The provider palpates a lymph node measuring 1.25 cm. Which test will provide proper histologic diagnosis for this patient? a. Bone marrow aspirate b. Computed tomography (CT) scan with intravenous (IV) contrast c. Lymph node biopsy d. Positron emission tomography (PET) scan --------- Correct Answer ---------- ANS: C The lymph node biopsy is used to provide proper histologic diagnosis and precise classification. Bone marrow aspirate identifies the presence of dysplastic cells. PET and CT scans will identify the presence of other lesions. A 30-year-old male patient is diagnosed with Hodgkin lymphoma. Initial lab work reveals a WBC of 20 109/L, hemoglobin of 10.1 gm/dL, a serum albumin of 3 g/dL, and lymphopenia of 0.5 109/L. Staging studies identify stage III disease. What is this patient's prognostic score? a. 2 b. 3 c. 4 d. 5 --------- Correct Answer ---------- ANS: C Risk factors for lymphoma include age >45 years, male gender, serum albumin <4, Hb <10.5, stage IV disease, WBC >15, and lymphopenia <0.6. This patient has 4 risk factors. Which types of lymphomas typically have an aggressive presentation? (Select all that apply.) a. Adult T cell leukemia-lymphoma b. Burkitt lymphoma A patient reports persistent lower back pain and constipation. A digital rectal examination reveals a mass at the sacrum. What will the primary care provider do to manage this patient? a. Order spinal radiographs in 3 months b. Perform an MRI of the sacrum c. Refer the patient to an oncologist d. Schedule the patient for a biopsy --------- Correct Answer ---------- ANS: C Patients with chordoma, which is a type of sarcoma with a predilection for the sacrum, will have these symptoms and a palpable mass coming out of the sacrum. A referral to an oncologist is necessary. These tumors have a significant risk for malignancy, so waiting 3 months is not an option. The oncologist will order a CT and body scan and possibly biopsy or surgery. Which treatments may be used to manage bone pain in patients with bone tumors? (Select all that apply.) a. Bisphosphonates b. Exercise c. External beam radiation d. Massage e. Vertebroplasty --------- Correct Answer ---------- ANS: A, B, C, E Bisphosphonates can decrease pain by preventing growth and development of existing and new bone lesions. Exercise is useful to maintain function and reduce pain. External beam radiation is useful in most patients. Vertebroplasty involves injecting bone cement to stabilize bone. Massage is not recommended. The daughter of an elderly confused patient reports that her parent is having urinary incontinence several times each day. What will the provider do initially? a. Obtain a urine sample for urinalysis (UA) and possible culture b. Order serum creatinine and blood urea nitrogen tests c. Perform a bladder scan to determine distention and retention d. Tell the daughter that this is expected given her mother's age and confusion --------- Correct Answer ---------- ANS: A When incontinence occurs, UA is performed initially to exclude hematuria, pyuria, glucosuria, or proteinuria and possible infection. Serum creatinine and BUN may be performed if renal disease is suspected. Bladder scans may be performed if the UA is normal to evaluate physiologic causes. It is not correct to offer reassurance without ruling out other causes. The provider is evaluating a patient for potential causes of urinary incontinence and performs a postvoid residual (PVR) test which yields 30 mL of urine. What is the interpretation of this result? a. The patient may have overflow incontinence. b. The patient probably has a urinary tract infection (UTI). c. This is a normal result. d. This represents incomplete emptying. --------- Correct Answer ---------- ANS: C A PVR less than 50 mL is considered normal and this result does not indicate any abnormality. The provider is counseling a patient who has stress incontinence about ways to minimize accidents. What will the provider suggest initially? a. Increasing fluid intake to dilute the urine b. Referral to a physical therapist c. Taking pseudoephedrine daily d. Voiding every 2 hours during the day --------- Correct Answer ---------- ANS: D Timed voiding is useful to help minimize stress incontinence and is used initially. Increasing fluid intake will increase symptoms. PT referral may be done if other measures fail to help with exercises to strengthen the pelvic floor muscles. Pseudoephedrine is useful, but not an initial therapy. An older male patient reports urinary frequency, back pain, and nocturia. A dipstick urinalysis reveals hematuria. What will the provider do next to evaluate this condition? a. Order a PSA and perform a digital rectal exam (DRE) b. Refer for a biopsy c. Refer the patient to a urologist d. Schedule a transurethral ultrasound (TRUS) --------- Correct Answer ---------- ANS: A Patients with symptoms of potential prostate cancer should be screened with PSA and DRE. Referral to a urologist is the next step even with normal findings, since PSA is occasionally normal. The urologist may order TRUS or biopsy. An older male patient has a screening prostate-specific antigen (PSA) which is 12 ng/mL. What does this value indicate? a. A normal result b. Benign prostatic hypertrophy c. Early prostate cancer d. Prostate cancer --------- Correct Answer ---------- ANS: D A PSA greater than 10 ng/mL suggests prostate cancer. A level between 4 and 10 ng/mL may be early prostate cancer or a benign condition. A level less than 4 ng/mL is normal. A patient is diagnosed with prostate cancer and diagnostic testing reveals disease that has gone past the prostatic capsule without evidence of metastasis. The patient does not wish to undergo treatment. What will the provider tell this patient? a. Chemotherapy is indicated to provide cure for this cancer. b. Monitoring prostate-specific antigen (PSA) with regular digital rectal examination (DRE) is an acceptable option. c. Palliative radiation therapy is necessary to improve quality of life. d. This level of disease requires intervention with hormonal therapy. --------- Correct Answer ---------- ANS: B This patient has stage T2 prostate cancer which may be managed with watchful waiting which includes PSA and DRE evaluation. Chemotherapy, palliative radiation therapy, and hormonal therapy are not required. A male patient reports nocturia and daytime urinary frequency and urgency without changes in the force of the urine stream. What is the likely cause of this? a. Bladder outlet obstruction b. Lower urinary tract symptoms (LUTS) c. Prostate cancer d. Urinary tract infection (UTI) --------- Correct Answer ---------- ANS: B Lower urinary tract symptoms (LUTS) result from irritative changes in the lower tract. Bladder outlet obstruction causes hesitancy, decreased caliber and force of the urine stream, and postvoid dribbling. Diagnosis of prostate cancer and UTI require further testing and are less likely causes. A 70-year-old male reports urinary hesitancy, postvoid dribbling, and a diminished urine stream. A digital rectal exam (DRE) reveals an enlarged prostate gland that feels rubbery and smooth. Which tests will the primary care provider order based on these findings? a. Bladder scan for postvoid residual b. Prostate-specific antigen (PSA) and bladder imaging c. Urinalysis and serum creatinine d. Urine culture and CBC with differential --------- Correct Answer ---------- ANS: C The DRE reveals a prostate gland consistent with benign prostatic hyperplasia (BPH). The primary provider should order a urinalysis and creatinine to evaluate possible infection and renal function. A bladder scan is ordered at the discretion of the urologist. The prostate exam isn't consistent with prostate cancer, so PSA and bladder imaging are not necessary. Symptoms of prostatitis would indicate a need for evaluation of possible infection. A patient has been taking terazosin daily at bedtime to treat benign prostatic hyperplasia (BPH) and reports persistent daytime dizziness. What will the provider do? a. Prescribe finasteride instead of terazosin b. Recommend taking the medication in the morning c. Suggest using herbal preparations d. Switch the prescription to doxazosin --------- Correct Answer ---------- ANS: A Patients who cannot tolerate the side effect of alpha-adrenergic antagonists, the provider may initiate therapy with a 5a-reductase inhibitor such as finasteride. Terazosin should be given at bedtime to minimize these adverse effects. Herbal preparations have not been proven to be safe or effective. Doxazosin is in the same drug class as terazosin. A pregnant woman at 30 weeks gestation presents with proteinuria. What will the provider do next? a. Evaluate her blood pressure and discuss with OB/GYN b. Monitor serum glucose for gestational diabetes c. The medication's effects may last for 24 to 36 hours. d. This medication has a rapid onset and short duration of action. e. This medication may be taken once daily. --------- Correct Answer ---------- ANS: A, D Sildenafil has a rapid onset and short duration of action and should be taken on an empty stomach. Fatty foods may delay or interfere with absorption. This medication is given when sexual activity is desired and not once daily. A young adult male reports a dull pain in the right scrotum and the provider notes a bluish color showing through the skin on the affected side. Palpation reveals a bag of worms on the proximal spermatic cord. What is an important next step in managing this patient? a. Anti-infective therapy with ceftriaxone or doxycycline b. Consideration of underlying causes of this finding c. Reassurance that this is benign and may resolve spontaneously d. Referral to an emergency department for surgical consultation --------- Correct Answer ---------- ANS: B This patient has symptoms of varicocele. Because varicocele is rare on the right side, the provider should look for underlying causes of these findings. Anti infective therapy is indicated for epididymitis. Varicocele requires surgical intervention or ablation to resolve. Testicular torsion is an emergency. An adolescent male reports severe pain in one testicle. The examiner notes edema and erythema of the scrotum on that side with a swollen, tender spermatic cord and absence of the cremasteric reflex. What is the most important intervention? a. Doppler ultrasound to assess testicular blood flow b. Immediate referral to the emergency department c. Prescribing anti-infective agents to treat the infection d. Transillumination to assess for "blue dot" sign --------- Correct Answer ---------- ANS: B This patient has symptoms of testicular torsion, which is a surgical emergency. An immediate referral is warranted. Doppler US and transillumination are useful in establishing a diagnosis, but the referral is the most important. Anti-infective agents are used if epididymitis is suspected. A 3-month-old male infant has edema and painless swelling of the scrotum. On physical examination, the provider can transilluminate the scrotum. What will the provider recommend? a. A Doppler ultrasound to evaluate the scrotal structures b. A short course of empirical antibiotic therapy c. Immediate referral to a genitourinary surgeon for repair d. Observation and reassurance that spontaneous resolution may occur --------- Correct Answer ---------- ANS: D This infant has symptoms of hydrocele; these disorders often resolve spontaneously during infancy and do not require treatment unless symptoms, such as pain, occur. It is not necessary to perform other studies or refer to a surgeon. Antibiotics are not indicated, since this is not infectious. A patient diagnosed with diabetes has symptoms consistent with renal stones. Which type of stone is most likely in this patient? a. Citrate b. Cysteine c. Oxalate d. Uric acid --------- Correct Answer ---------- ANS: D Uric acid stones are more prevalent in diabetics. Citrate, cysteine, and oxalate are less common in all patients. A patient diagnosed with acute renal colic is experiencing nausea and vomiting. A urinalysis reveals hematuria but is otherwise normal. A radiographic exam shows several radiopaque stones in the ureter which are less than 1 mm in diameter. What will the primary provider do initially to manage this patient? a. Obtain a consultation with a urology specialist b. Order a narcotic pain medication and increased oral fluids c. Prescribe desmopressin and a corticosteroid medication d. Prescribe nifedipine and hospitalize for intravenous antibiotics --------- Correct Answer ---------- ANS: B Stones that are less than 1 mm in diameter will usually pass spontaneously. The provider should counsel the patient to increase fluid intake and should prescribe adequate pain medication. A consultation is not necessary unless initial measures fail. Desmopressin and corticosteroids have not been shown to be effective. Nifedipine and IV fluids may be used as a secondary option. Which factors increase the risk of renal stones? (Select all that apply.) a. Excess antacid use b. Living in a cold climate c. Obesity d. History of gout e. Vitamin D excess --------- Correct Answer ---------- ANS: A, C, D Excess antacids, obesity, and a history of gout are linked to renal stone risk. Tropical climates are also linked to renal stone development. Vitamin D excess is not a risk factor. A 30-year-old male patient has a positive leukocyte esterase and nitrites on a random urine dipstick during a well patient exam. What type of urinary tract infection does this represent? a. Complicated b. Isolation c. Uncomplicated d. Unresolved --------- Correct Answer ---------- ANS: A All urinary tract infections (UTIs) in males are considered complicated, because the infection source is not secondary to ascending infection. An asymptomatic pregnant woman has a positive leukocyte esterase and positive nitrites on a urine dipstick screening. What will the provider do next? a. Admit to the hospital b. Obtain a urine culture c. Order a renal ultrasound d. Prescribe trimethoprim-sulfamethoxazole (TMP-SMZ) --------- Correct Answer ---------- ANS: B Urine culture is the definitive test and should be obtained in all pregnant women. Admission to the hospital is usually not necessary. Renal ultrasound is used to identify abnormalities or obstructions that may be causing recurrent symptoms. TMP-SMZ is contraindicated in pregnant women. An asymptomatic female is concerned about having come into contact with sexually transmitted gonorrhea and asks about antibiotics. What will the provider recommend? a. Amoxicillin-clavulanate for 10 days b. Cultures and treatment if symptoms appear c. Empirical ceftriaxone and azithromycin d. Trimethoprim-sulfamethoxazole --------- Correct Answer ---------- ANS: C Patients with gonorrhea usually have chlamydia as well, so treatment with both ceftriaxone and azithromycin is recommended. Amoxicillin-clavulanate and TMP-SMZ are used for urinary tract infections (UTIs). The patient should be treated empirically. Females are often asymptomatic. A patient is in the emergency department with confusion and fatigue and a corrected serum calcium concentration is 10.8 mg/dL. What is the initial treatment for this patient prior to admission to the inpatient unit? a. Administration of furosemide b. Correction of potassium and magnesium levels c. Parenteral salmon calcitonin d. Rapid administration of intravenous normal saline --------- Correct Answer ---------- ANS: D To help the kidneys excrete calcium, intravenous normal saline should be given initially. Furosemide may not be effective as once thought and is used less often today. Correction of other electrolytes may be done when these imbalances are assessed. Parenteral salmon calcitonin may be used later to enhance calcium losses. A patient experiences a carpal spasm when a blood pressure cuff is inflated. Which diagnostic testing will the provider consider evaluating to determine the cause of this finding? a. Calcitriol level b. C-reactive protein c. Magnesium and vitamin D d. Protein electrophoresis --------- Correct Answer ---------- ANS: C sometimes the initial finding. TB skin testing is done to exclude tuberculosis. Serum and urine cortisol levels are evaluated with Cushing's syndrome is suspected. An obese patient 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? a. C-peptide level b. Hemoglobin A1C c. Random serum glucose d. Thyroid studies --------- Correct Answer ---------- ANS: B HbA1C, along with fasting plasma glucose or a 2-hour plasma glucose during an oral glucose tolerance test (OGTT), is diagnostic of diabetes. This patient is probably not fasting, so a glucose level will not be helpful. C-peptide levels help to distinguish type 1 from type 2 diabetes and may be performed after a diagnosis of diabetes is made and if there is uncertainty about the cause. Thyroid studies are helpful in evaluating comorbidity. A patient diagnosed with type 2 diabetes mellitus becomes insulin dependent after a year of therapy with oral diabetes medications. When explaining this change in therapy, the provider will tell the patient a. it is necessary because the patient cannot comply with the previous regimen. b. that strict diet and exercise measures may be relaxed with insulin therapy. c. the use of insulin therapy may be temporary. d. this is because of the natural progression of the disease. --------- Correct Answer ------ ---- ANS: D Even after several years of therapy for type 2 DM well controlled with oral diabetic medications, diet, and exercise, the natural progression of the disease may require patients to become insulin dependent. Patients must understand that this does not represent failure on their part. Adding insulin may cause weight gain, so continuing lifestyle measures is essential. The addition of insulin is not temporary. A patient diagnosed with diabetes has a blood pressure of 140/90 mm Hg and albuminuria. Which initial action by the primary care provider is indicated for management of this patient? a. Consulting with a nephrologist b. Limiting protein intake c. Prescribing an antihypertensive medication d. Referring to an ophthalmologist --------- Correct Answer ---------- ANS: A Patients with diabetes who have elevated blood pressure and reduced renal function should be referred to a nephrologist. Limiting protein intake and giving an antihypertensive medication may be recommended, but evaluation by a nephrologist is essential. Ophthalmology referral will be made as well to assess concurrent ocular damage. A patient recently diagnosed with type 1 diabetes mellitus is in clinic for a follow-up evaluation. The provider notes that the patient appears confused and irritable and is sweating and shaking. What intervention will the provider expect to perform once the point of care blood glucose level is known? a. Dipstick urinalysis for ketones b. Giving a rapid-acting carbohydrate c. Injection of rapid-acting insulin d. Performing a hemoglobin A1C --------- Correct Answer ---------- ANS: B This patient has signs of hypoglycemia, so a rapid-acting carbohydrate should be given once this is confirmed. Assessing for ketones is done if the patient is hyperglycemic, as is insulin administration. Hemoglobin A1C gives information about long-term and not immediate glucose control. An obese adolescent female patient reports irregular periods and excessive acne. The provider notes an increased amount of hair on her upper back, shoulders, and upper abdomen. What will the provider do, based on these findings? a. Consider treatment with oral contraceptive pills (OCPs) b. Counsel her about diet, exercise, and weight loss c. Recommend cosmetic laser hair removal d. Refer to an endocrinologist for evaluation --------- Correct Answer ---------- ANS: D All patients with suspected hirsutism should be referred to a specialist to determine the cause. OCPs, lifestyle changes, and cosmetic treatments may be part of the treatment, but the underlying causes must be determined first to ensure that a life-threatening condition is not present. A young adult woman is unable to conceive after trying to get pregnant for over 6 months. The woman reports having had irregular periods since the onset of menarche. The provider notes that the woman is overweight, has acanthosis nigricans, and an excess hair distribution. What does the provider suspect as the most likely primary cause of these symptoms? a. Congenital adrenal hyperplasia b. Cushing's syndrome c. Polycystic ovary syndrome (PCOS) d. Type 2 diabetes --------- Correct Answer ---------- ANS: C PCOS is the most likely cause of oligo- or amenorrhea, so this is the most likely cause. The other conditions are possible, but less likely. A woman who has hirsutism with acne, and oligomenorrhea will most likely be treated with which medication to control these symptoms? a. Finasteride b. Levonorgestrel c. Norgestimate d. Spironolactone --------- Correct Answer ---------- ANS: C Norgestimate is a progestin with low androgenic activity and is used to suppress testosterone and control symptoms. Finasteride, which decreases the peripheral conversion of testosterone to dihydrotestosterone (DHT), is not approved for this use. Levonorgestrel is an androgenic oral contraceptive pill (OCP) and should be avoided. Spironolactone is a second-line medication approved for this purpose. A patient has a serum potassium level of 3 mEq/L and a normal blood pressure. Which test should be performed initially to assist with the differential diagnosis? a. Plasma aldosterone b. Plasma renin activity c. Serum bicarbonate d. Serum magnesium --------- Correct Answer ---------- ANS: D Hypomagnesemia often accompanies hypokalemia indicating the importance of also obtaining a serum magnesium level. Sodium bicarbonate is occasionally used in the treatment of hyperkalemia and is most effective when hyperkalemia is a result of metabolic acidosis. Plasma aldosterone and renin activity are assessed in patients with hypokalemia who are hypertensive. A patient with normal renal function has a potassium level of 6.0 mEq/L. Which underlying cause is possible in this patient? a. Adrenocortical deficiency b. Alcoholism c. Hypertension d. Malabsorption syndrome --------- Correct Answer ---------- ANS: A Hyperkalemia without underlying renal disorder may be caused by Addison's disease, which is an adrenocortical deficiency. Alcoholism, hypertension, and malabsorption syndromes all contribute to hypokalemia. A hospitalized patient with renal failure is accidentally given parenteral potassium and has a potassium level of 7.0 mEq/L. An ECG reveals a normal QRS interval. What is the initial recommended treatment for this patient? a. Calcium chloride b. Insulin and glucose infusion c. Sodium bicarbonate d. Sodium polystyrene sulfate --------- Correct Answer ---------- ANS: B Patients with severe hyperkalemia should have IV administration of glucose and insulin to lower potassium levels quickly. If life-threatening sequelae, such as a widening QRS interval, are present, calcium chloride is given. Sodium bicarbonate is occasionally used, but should be used cautiously to prevent metabolic alkalosis. Sodium polystyrene sulfate is used when oral medications may be given. When using the 2013 ACC/AHA "Guideline on the Assessment of Cardiovascular Risk" to treat patients with hyperlipidemia, the practitioner understands that it will provide what information? a. Goals for treatment for low-density lipoprotein levels b. How to titrate statin drugs to achieve goal levels c. Use of non-statin therapy for primary prevention d. Which patients will benefit from statin therapy --------- Correct Answer ---------- ANS: D c. Musculoskeletal pain d. Nonrestorative sleep e. Renal complications --------- Correct Answer ---------- ANS: A, C, D Fibromyalgia may cause GI complaints, musculoskeletal pain, and nonrestorative sleep. Hepatosplenomegaly and renal complications are not associated with fibromyalgia. A postmenopausal female patient has a blood test that reveals hyperuricemia, although the patient has no symptoms of gout. What will the provider do initially? a. Ask the patient about medications and medical history b. Begin therapy with colchicine and an NSAID c. Recommend a low-purine, alcohol-restricted diet d. Treat for gout prophylactically to prevent a flare --------- Correct Answer ---------- ANS: A Patients without symptoms of gout but with hyperuricemia do not need treatment, since most of these patients will never have a gout flare. It is important, however, to determine the cause of this finding and correct it if possible, since it is a risk factor for gout. Certain medications and medical conditions can predispose patients to gout. Colchicine and NSAIDs are used to treat symptoms of gout. Dietary changes are not necessary and are difficult to follow. Prophylaxis for prevention of flares is for patients who have gout and who are between flares. A patient with gout and impaired renal function who uses urate-lowering therapy (ULT) is experiencing an acute gout flare involving one joint. What is the recommended treatment? a. Administration of intraarticular corticosteroid b. Discontinuing ULT while treating the flare c. Oral colchicine for 5 days d. Therapy with NSAIDs begun within 24 hours --------- Correct Answer ---------- ANS: A Intraarticular steroids are practical and beneficial when only one or two joints are involved and are safe for patients who cannot use NSAIDs or colchicine. NSIADs are contraindicated in patients with renal disease and colchicine should not be used in those with low glomerular filtration rates. It is not necessary to discontinue urate- lowering therapy during an acute attack. A patient experiences a second gouty flare and the provider decides to begin urate- lowering therapy (ULT). How should this be prescribed? a. Begin with a high-loading dose and gradually decrease. b. Start ULT during the current flare for best results. c. Start ULT in 5 weeks along with an anti-inflammatory drug. d. ULT should be suspended during future gouty flares. --------- Correct Answer ---------- ANS: C Beginning therapy with a urate-lowering drug during an acute flare will prolong the flare. Typically, ULT is begun 5 to 6 weeks after a flare and should be given with an anti- inflammatory drug, since the initial period of ULT administration is associated with flares. ULT dosing should start low and gradually increase. It is not recommended to stop ULT during future flares, but to treat those flares while continuing the ULT. A patient reports the sudden onset of pain, redness, and swelling in one knee joint but denies a fever. The provider elicits exquisite pain with manipulation of the joint and notes no decrease in pain when the joint is at rest. Which is the likely cause of this arthritis? a. Bacterial infection b. Gout c. Lyme disease d. Rheumatoid arthritis --------- Correct Answer ---------- ANS: A Septic arthritis is usually painful both with movement and at rest and is accompanied by swelling and erythema. Fever is not always present. The other causes of arthritis are not painful at rest. An adolescent patient reports intermitted pain and swelling in various joints on the right side including the knee, elbow, wrist, and ankle. A physical examination reveals tenosynovitis and a maculopapular rash. Which diagnostic tests will be most helpful in determining a diagnosis in this patient? a. Blood cultures and a complete blood count b. Cultures of the urethra, pharynx, cervix, and rectum c. Skin lesion scrapings and cultures d. Urine cultures and renal --------- Correct Answer ---------- ANS: B This patient has signs of gonococcal arthritis. Cultures of the urethra, pharynx, cervix, and rectum will be positive in 80% of patients with this infection. Blood cultures are likely to be negative. Culturing skin lesions is not helpful. Renal involvement is not part of this infection. A patient has marked swelling of a shoulder joint with erythema and severe pain. The provider suspects a bacterial cause. Which culture will be most helpful to determine the cause of these symptoms? a. Blood culture b. Synovial fluid culture c. Urethral culture d. Urine culture --------- Correct Answer ---------- ANS: B Synovial fluid culture is the most important exam for diagnosis of septic arthritis. Blood culture may be positive in only 10% of cases. Urethral culture is performed if gonococcal arthritis is suspected. Urine culture is not helpful. A patient reports severe back pain located in the lumbar spine. To evaluate whether the patient has axial pain or radicular pain, which assessment is necessary? a. Asking the patient to perform the Valsalva maneuver b. Assessing reflexes and asking about tingling or numbness c. Determining whether the pain is present with prolonged sitting d. Noting whether pain is mitigated with frequent position shifts --------- Correct Answer - --------- ANS: A Associated neurological signs are present with radicular pain and include numbness, tingling, weakness, and reflex changes. The other symptoms occur with both axial and radicular pain. A patient has an acute onset of lower back pain associated with lifting heavy objects at work. A physical examination reveals no loss of lower extremity function or neurological symptoms. What is the initial intervention for this patient? a. Magnetic resonance imaging (MRI) to evaluate soft tissue involvement b. Plain radiographs to evaluate the extent of the injury c. Traction therapy to minimize complications d. Treatment with a nonsteroidal anti-inflammatory drug (NSAID) --------- Correct Answer ---------- ANS: D NSAIDs are appropriate as first-line treatment in patients without potential complications. Radiologic studies are performed if improvement does not occur in 4 to 6 weeks. Traction may be used for patients with radicular symptoms to help resolve neurological deficits, although systematic review of research has not clearly identified a benefit to this therapy. A patient has recurrent lumbar pain which is sometimes severe. The patient reports that prescription of nonsteroidal anti-inflammatory drugs (NSAIDs) is no longer effective for pain relief. What will the provider recommend? a. Adjunctive treatment with physical therapy b. Beginning treatment with opioid analgesics c. Complementary and alternative therapies d. Referral to an interventional spine physician --------- Correct Answer ---------- ANS: D Patients with recurrent or chronic lower back pain may benefit from lumbar epidural corticosteroid injection performed by an interventional spine physician. Physical therapy is often used for acute injury if no improvement in 4 to 6 weeks. Opioid analgesics are not usually effective. An adult patient who has been taking high-dose corticosteroids reports a dull, aching pain in the groin and presents with a limp. What condition does the provider suspect, based on this history? a. Avascular necrosis of the femoral head b. Infectious arthritis of the hip c. Osteoarthritis of the hip d. Slipped capital femoral epiphysis (SCFE) --------- Correct Answer ---------- ANS: A Avascular necrosis has the symptoms listed above and is common among patients who have been taking corticosteroids. Infectious arthritis will typically be accompanied by fever and intense pain. Osteoarthritis causes progressively worsening pain with activity and improvement with rest. SCFE is common in adolescents. A patient comes to a provider with reports of unilateral arm pain and weakness with mild neck pain. The provider notes that the patient prefers holding the affected arm crossed in front of the throat. A history reveals a recent onset of sexual dysfunction. What does the provider suspect based on this history? a. Axial neck pain b. Cervical myelopathy c. Diabetic neuropathy d. Facet joint pain --------- Correct Answer ---------- ANS: B Patients with neurological symptoms have radicular neck pain, which is usually greater in one arm and involves neurological findings. Patients with concurrent lower extremity findings may have cervical myelopathy and should be evaluated immediately. Axial neck pain does not involve neurological findings. Diabetic neuropathy typically does not include neck pain. Facet joint pain is a cause of axial neck pain, associated with injuries and headaches. A provider suspects degenerative disk disease in a patient with chronic neck pain. Which diagnostic test will be performed? a. Computerized tomography (CT) b. Magnetic resonance imaging (MRI) c. Plain radiograph d. Radionuclide bone scintigraphy --------- Correct Answer ---------- ANS: B MRI is usually performed to diagnose degenerative disk disease. CT testing is used to identify bone and degenerative changes, but the exposure to radiation is high. Plain radiographs are used to identify fractures or when trauma or cancer is present. Radionuclide bone scintigraphy is used for osteomyelitis, metastatic disease, or occult fracture. A patient has chronic radicular neck pain that no longer responds to over-the-counter NSAIDs and physical therapy measures and reports having difficulty sleeping. Which medication will the provider order? a. A skeletal muscle relaxant b. A tricyclic antidepressant c. An opioid analgesic d. Gabapentin --------- Correct Answer ---------- ANS: D Gabapentin is useful for central pain syndromes and radiculopathy and can help to restore sleep. Skeletal muscle relaxants are useful for muscle spasms. A tricyclic antidepressant is useful for some chronic neck pain, although gabapentin is more specific to this patient's symptoms. Opioid analgesics should be used cautiously. A 50-year-old woman reports pain in one knee upon awakening each morning that goes away later in the morning. A knee radiograph is negative for pathology and serum inflammatory markers are normal. What will the provider tell this patient? a. A magnetic resonance imaging study is necessary for diagnosis b. That the lack of findings indicates no disease process c. To take acetaminophen 1 gram three times daily for pain d. To use a cyclooxygenase 2-selective NSAIDs to reduce inflammation --------- Correct Answer ---------- ANS: C Acetaminophen is the mainstay for initial treatment of osteoarthritis. Radiologic findings are often negative in the early stages of the disease. There are no serologic markers for OA. A COX-2-selective inhibitor has cardiovascular side effects and should not be used unless necessary. These agents are used more for pain than for inflammation. A patient who has osteoarthritis in the carpometacarpal joints of both thumbs asks about corticosteroid injections to treat symptoms. What will the provider tell this patient about this therapy? a. Corticosteroid therapy reduces inflammation and improves joint mobility b. Injections may be administered as needed up to 6 times per year c. Intraarticular injections provide significant pain relief for 3 to 4 months d. This treatment may cause a temporary increase in pain, warmth, and redness --------- Correct Answer ---------- ANS: D Intraarticular injections of corticosteroids are helpful in decreasing pain, but may cause a transient increase in pain, warmth, and redness. This therapy does not improve inflammation and joint mobility. Injections are not recommended more than 3 to 4 times per year. The duration of pain relief is variable. A 45-year-old patient has mild osteoarthritis in both knees and asks about nonpharmacologic therapies. What will the provider recommend? a. Aerobic exercise b. Glucosamine with chondroitin c. Therapeutic magnets or copper bracelets d. Using a cane or walker --------- Correct Answer ---------- Aerobic exercise helps with cardiovascular conditioning and weight reduction as well as improved range of motion, decreased pain, and strengthening of supporting structures. Randomized controlled studies have failed to demonstrate significant pain relief with glucosamine. Therapeutic magnets and copper have not been proven to be effective. A young patient with mild symptoms will not need assistive devices and should focus on conditioning. A 50-year-old patient with diabetes mellitus has a low-grade fever and pain on one foot. The provider notes erythema and swelling at the site along with several superficial skin ulcers without necrosis and suspects osteomyelitis. Which type of diagnostic study will the provider order? a. Biopsy of bone or debridement cultures b. Blood cultures and serologic markers of inflammation c. Magnetic resonance imaging of the foot d. Plain radiograph of the foot --------- Correct Answer ---------- ANS: D A patient with diabetic foot infection suspected of having osteomyelitis should have a plain radiograph to identify bony abnormality or soft tissue changes. MRI may be performed if more specific evaluation is needed or if abscess is suspected. Blood cultures are not diagnostic of osteomyelitis. Biopsy and debridement cultures increase the risk of further infection if poor healing at the site occurs. A 3-year-old child has marked pain in one leg localized to the upper tibia with refusal to bear weight. The child has a high fever and a toxic appearance. Which type of osteomyelitis is most likely? a. Chronic osteomyelitis b. Hematogenous osteomyelitis c. Osteomyelitis from a contiguous focus d. Peripheral vascular disease osteomyelitis --------- Correct Answer ---------- ANS: B Young children are more likely to have hematogenous osteomyelitis, especially with acute symptoms. Chronic osteomyelitis is more common with underlying diseases such as diabetes. Contiguous focus osteomyelitis occurs when organisms are introduced from a puncture wound, foreign body, or adjoining soft tissue infection. Peripheral vascular causes are more common in chronically ill patients. A patient has osteomyelitis related to vascular insufficiency. Which initial consultation is necessary? a. Infectious disease consultation b. Neurosurgical consultation c. Surgical consultation d. Wound care specialist consultation --------- Correct Answer ---------- ANS: C Because patients with vascular insufficiency who develop osteomyelitis may need debridement or draining of lesions, a surgical consult is necessary. Infectious disease consults are obtained for patients with resistant organisms or complex wounds. Neurosurgical consults are needed for patients with epidural abscess. Wound care consults are needed for patients with progressive or chronic wounds. A 45-year-old patient reports a recent onset of unilateral shoulder pain which is described as diffuse and is associated with weakness of the shoulder but no loss of passive range of motion. What does the provider suspect as the cause of these symptoms? a. Acromioclavicular joint disease b. Cervical radicular pain c. Glenohumeral arthritis d. Rotator cuff injury --------- Correct Answer ---------- ANS: D Rotator cuff injury is usually characterized by diffuse pain, weakness of the joint, but no change in range of motion. Acromioclavicular joint disease is associated with anterior- superior shoulder pain. Glenohumeral arthritis has similar symptoms, but with loss of range of motion. Cervical radicular pain is characterized by pain distal to the elbow. An examiner is evaluating a patient who reports unilateral shoulder pain and notes limited active and passive range of motion in the affected shoulder along with erythema and bulging on the anterior shoulder. What diagnosis is likely with this presentation? a. Acromioclavicular joint disease a. Carpal tunnel syndrome b. Palmar fibrosis c. De Quervain's Tenosynovitis d. Trigger finger --------- Correct Answer ---------- ANS: C De Quervain's tenosynovitis causes pain as described and occurs more in women between 30 and 59 years who engage in activities requiring excessive repetitive motions, such as knitting. Carpal tunnel syndrome presents with intermittent wrist pain, numbness, and tingling radiating from the palm to the thumb, index finger, middle finger, and medial aspect of the ring finger. Palmar fibrosis causes contractures, usually of the ring finger. Trigger finger causes nodules in tendons that catch on the finger pulley and impede movement. A patient reports numbness and weakness of the wrist with pain focuses on the radial aspect of the joint. During physical examination, what will the examiner do to help diagnose this condition? a. Applying press to the focus area b. Flexing the thumb while placing a finger on the metacarpophalangeal joint c. Passively extending the thumb and observe for puckering of the skin d. Placing the thumb on the palm while deviating the hand toward the ulna --------- Correct Answer ---------- ANS: A Applying pressure to the volar or radial aspect of the wrist will elicit pain in patients with a ganglion cyst which has symptoms described above. Flexing the thumb while the examiner places a finger on the metacarpophalangeal joint will elicit a pop when the digit is extended in patients with trigger finger. Puckering of the skin occurs with palmar fibrosis. Placing the patient's thumb on the palm while deviating the hand toward the ulna will elicit pain in patients with tenosynovitis. A patient has symptoms of carpal tunnel syndrome. Which diagnostic tests will help confirm this disorder? (Select all that apply.) a. Anti-nuclear antibody (ANA) b. Electromyography c. Erythrocyte sedimentation rate (ESR) d. Nerve conduction studies e. Plain radiographs --------- Correct Answer ---------- ANS: B, D While diagnosis may be made on history and physical findings, electromyography and nerve conduction studies can be helpful to confirm or exclude carpal tunnel syndrome. ANA and ESR testing are useful when rheumatoid arthritis is suspected. Plain radiographs are not useful. A patient is diagnosed with polymyalgia rheumatica (PMR) with giant cell arteritis. Which dose of prednisolone will be given initially? a. 15 mg daily b. 20 mg daily c. 30 mg daily d. 60 mg daily --------- Correct Answer ---------- ANS: D Although the usual starting dose to treat PMR is 15 to 20 mg daily, a higher dose of 60 mg daily is used when there is evidence of concomitant giant cell arteritis. A patient who is taking prednisolone 20 mg daily to treat polymyalgia rheumatica reports blurred vision. What will the provider do? a. Discontinue the medication b. Increase the prednisolone dose to 60 mg daily c. Prescribe NSAIDs to treat the inflammation d. Refer to a rheumatologist immediately --------- Correct Answer ---------- ANS: D Sudden vision loss, diplopia, and other visual disturbances may indicate giant cell arteritis (GCA) and requires immediate referral to rheumatology. The primary provider should not change the medication regimen without a consult A 60-year-old patient reports new onset of bilateral shoulder pain with morning stiffness lasting approximately 1 hour. Which will be included in initial diagnostic testing for this patient? (Select all that apply.) a. Antinuclear antibodies b. Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) c. Liver function tests (LFTs) d. Protein electrophoresis e. Serum calcitonin --------- Correct Answer ---------- ANS: B, C, D ESR, CRP, and protein electrophoresis are included in the initial diagnostic workup when polymyalgia rheumatica is suspected. ANA testing is not specific for this disorder. Serum calcitonin is not indicated. A provider performs a nail fold capillaroscopy on a patient who reports marked color changes of both hands with cold exposure and notes tortuous and dilated capillary loops. This finding is consistent with what condition? a. Polymyositis b. Primary Raynaud's phenomena c. Scleroderma d. Secondary Raynaud's phenomena --------- Correct Answer ---------- ANS: D Microvascular abnormalities like tortuous of dilated capillary loops are observed in secondary Raynaud's phenomena and capillaroscopy is used to differentiate primary from secondary Raynaud's. These findings are not present with polymyositis or scleroderma. A patient has secondary Raynaud's phenomena with severe digital ischemia. Which treatment is indicated for this patient? a. Ginkgo biloba b. Intravenous prostaglandin E1 c. Oral nifedipine d. Sildenafil as needed --------- Correct Answer ---------- ANS: B Intravenous prostaglandin E1 is reserved for patients with secondary Raynaud's phenomenon who have severe digital ischemia. Ginkgo biloba is associated with adverse effects and has not been shown to be effective. Nifedipine is used to prevent vasospasm in milder cases. Sildenafil may be used as a vasodilator in milder cases. A patient has swelling and tenderness in the small joints of both hands and reports several weeks of malaise and fatigue. A rheumatoid factor (RF) test is negative. What will the primary care provider do next? a. Begin treatment with a biologic disease-modifying anti-rheumatic (DMARD) drug b. Order radiographic tests, a CBC, and acute-phase reactant levels c. Reassure the patient that the likelihood of rheumatoid arthritis is low d. Refer the patient to an orthopedic specialist for evaluation and treatment --------- Correct Answer ---------- ANS: B The patient has signs of rheumatoid arthritis (RA); the RF test may be negative initially but will become positive in 70% to 80% of patients. The provider's next step is to order tests to confirm the diagnosis and to provide a baseline to monitor disease progress and response to treatment. DMARDs may be ordered when the disease is confirmed. The PCP may treat in consultation with a rheumatologist who will order medications and will refer the patient for physical therapy, occupational therapy, and psychotherapy. A patient is diagnosed with rheumatoid arthritis (RA) after a review of systems, confirmatory lab tests, and synovial fluid analysis. What will the provider order initially to treat this patient? a. Disease-modifying anti- rheumatic (DMARDs) drugs b. Long-term glucocorticoid therapy c. Non-pharmacological treatments d. Nonsteroidal anti-inflammatory drugs (NSAIDs) --------- Correct Answer ---------- ANS: A Treatment with DMARDs should be initiated as soon as the diagnosis of RA is established to achieve disease modification. Long-term glucocorticoid therapy is not recommended because of adverse effects. NSAIDs are not first-line drugs and increase the risk of cardiac and renal complications. NSAIDs are used as adjunctive and not first- line therapy. Which are symptoms of rheumatoid arthritis (RA) that distinguish it from osteoarthritis (OA)? (Select all that apply.) a. Extra-articular inflammatory signs b. History of injury to affected joints c. Morning stiffness of at least 1 hour d. Symmetric tender, swollen joints e. Unilateral joint involvement --------- Correct Answer ---------- ANS: A, C, D The clinical presentation of RA includes extra-articular symptoms, morning stiffness lasting at least 1 hour, and symmetric, bilateral joint involvement. OA often has a history of previous injury and is usually asymmetric and may be unilateral. This patient has a high probability of OSA without significant comorbidities or use of medications that may cause central sleep apnea, so this test, which has more limited measures than a full PSG, may be performed. Full overnight PSG is used when the cause of sleep apnea is less certain to help determine whether there is a central cause. The multiple sleep latency test is used to test EDS symptoms. Overnight pulse oximetry is not sufficiently sensitive to be a reliable screening for sleep apnea. A patient is diagnosed with mild restless leg syndrome (RLS) which occasionally interferes with sleep. Which initial treatment will be helpful? a. A continuous positive airway pressure (CPAP) devices b. A dopaminergic agonist c. Hot baths and exercise d. Supplemental iron --------- Correct Answer ---------- ANS: C Patients with mild restless leg syndrome (RLS) may benefit from massage, hot baths, exercise, and good sleep hygiene. CPAP is used for obstructive sleep apnea. Dopaminergic agonists are useful medications but have a risk of rebound or augmentation of effects. Supplemental iron is used in patients with low ferritin levels. A 35-year-old patient reports suddenly experiencing an asymmetric smile along with drooping and tearing in one eye. The patient has a history of a recent viral illness but is otherwise healthy. During the exam, the provider notes that there is unilateral full-face paralysis on the right side. What is the initial intervention for this patient? a. Perform confirmatory diagnostic tests. b. Prescribe oral corticosteroids. c. Recommend wearing an eye patch. d. Refer the patient to a neurologist. --------- Correct Answer ---------- ANS: B Steroids are highly effective and increase the probability of complete nerve recovery and should be started within 72 hours of onset. There are no confirmatory diagnostic tests, but other tests may be performed to rule out certain causes. Patients may be instructed to tape the eye closed at night, but eye patches are not recommended. A neurology referral is needed only if patients have an atypical presentation or other comorbid conditions. What is recommended to prevent ophthalmic complications in patients with Bell's palsy? a. Acupuncture b. Lubricating eye drops c. Patching of the eye d. Sunglasses --------- Correct Answer ---------- ANS: B Exposure keratitis from drying of the eye can result in blindness. Lubricating eye drops should be used every 2 hours. Acupuncture has not been sufficiently studied. Patching is not recommended. Protective eyewear to prevent moisture loss is recommended. Which symptoms may occur with Bell's palsy? (Select all that apply.) a. Alteration in taste b. Decreased hearing c. Drooling d. Inability to open the eye e. Tinnitus --------- Correct Answer ---------- ANS: A, C, E Bell's palsy may cause altered taste, drooling, and tinnitus. It causes increased sensitivity to noises and an inability to close the eye. A patient exhibits visual field defect, ataxia, and dysarthria and complains of a mild headache. A family member reports that the symptoms began several hours prior. An examination reveals normal range of motion of the neck. What type of cerebrovascular event is most likely? a. Hemorrhagic stroke b. Hypertensive intracerebral hemorrhage c. Ischemic stroke d. Transient ischemic attack (TIA) --------- Correct Answer ---------- ANS: C Patients with ischemic stroke typically do not have headache; if they do, it is milder than with hemorrhagic stroke. A TIA resolves within minutes. An elderly patient is brought to the emergency department after being found on the floor after a fall. The patient has unilateral sagging of the face, marked slurring of the speech, and paralysis on one side of the body. The patient's blood pressure is 220/190 mm Hg. What is the likely treatment for this patient? a. Carotid endarterectomy b. Close observation until symptoms resolve c. Neurosurgical consultation d. Thrombolytic therapy --------- Correct Answer ---------- ANS: C This patient has signs consistent with hemorrhagic stroke and will need consultation with a neurosurgeon to determine whether surgical intervention will be beneficial. Carotid endarterectomy is performed in patients with carotid stenosis and is used in patients with hemispheric ACVS (TIA). Patients with TIA may be observed to monitor symptoms. Thrombolytic therapy is given to patients with ischemic stroke. A previously healthy 30-year-old patient is brought to the emergency department with signs of stroke. Diagnostic testing determines an ongoing ischemic cause. The patient's spouse reports that symptoms began approximately 2 hours prior to transport. What is the recommended treatment? a. Administration of low-molecular-weight heparin b. Neurosurgical consultation for possible surgery c. Observation for complications prior to initiating tPA d. Tissue plasminogen activator (tPA) administration --------- Correct Answer ---------- ANS: D This patient meets the criteria for tPA administration and it should be begun within 4.5 hours after onset of symptoms. This patient has had symptoms for over 2 hours, so tPA should begin immediately. LMW heparin is not indicated. Neurosurgical intervention is recommended for patients with hemorrhagic stroke. A patient reports a recurrent sensation of spinning associated with nausea and vomiting. Which test will the provider order to confirm a diagnosis for this patient? a. Electroencephalogram (ECG) b. Holter monitoring and electrocardiogram c. Neuroimaging with computerized tomography (CT) d. The Hallpike-Dix positioning maneuver --------- Correct Answer ---------- ANS: D This patient has symptoms consistent with a vestibular lesion, so the provider will order a Hallpike-Dix positioning maneuver to evaluate vestibular function. If seizure activity is suspected, an electroencephalogram will be ordered. Holter monitoring and ECG are used if patients report syncope or lightheadedness. Neuroimaging with CT is used when patients possibly have a central lesion which would present with difficulty balancing. An older adult patient reports sensations of being off balance when walking but does not experience dizziness. The provider will refer this patient to which specialist for further evaluation? a. Audiologist b. Cardiologist c. Neurologist d. Otolaryngologist --------- Correct Answer ---------- ANS: C This patient has problems of balance without dizziness, suggestive of a central neural lesion and should be referred to a neurologist. Patients with vertigo are likely to have vestibular dysfunction and would be referred to an otolaryngologist and possibly an audiologist if hearing is affected. Patients with syncope or lightheadedness are more likely to have an underlying cardiac disorder and would be referred to a cardiologist. Following an upper respiratory infection, a patient begins to develop ataxia and distal paresthesias, along with oculomotor symptoms and double vision. Based on these presenting symptoms which type of Guillain-Barré syndrome (GBS) does this patient have? a. Acute inflammatory demyelinating polyradiculoneuropathy (AIDP) b. Acute motor axonal neuropathy (AMAN) c. Classic Guillain-Barré syndrome d. Miller Fisher syndrome (MFS) --------- Correct Answer ---------- ANS: D Miller Fisher syndrome has oculomotor symptoms. Patients with this type tend to peak sooner and recover more completely and quickly. Which diagnostic test helps confirm a diagnosis of Guillain-Barré syndrome (GBS) in a patient who is developing muscle weakness and paresthesias? a. Lumbar puncture b. MRI imaging c. Nerve conduction studies d. Screening for systemic infection --------- Correct Answer ---------- ANS: A A lumbar puncture is the most important confirmatory test showing albuminocytologic disassociation. MRI imaging typically is not necessary unless there is concern for spine pathology but does not diagnose GBS. Nerve conduction studies are not necessary for Dystonia, essential tremor, and Tourette's are hyperkinetic disorders. Parkinson's disease and progressive supranuclear palsy are hypokinetic disorders. A patient reports two episodes of visual disturbances and eye pain that lasted 1 to 2 days each about 2 months apart. Which diagnostic testing will the provider order initially? a. Lumbar puncture b. Magnetic resonance imaging (MRI) c. Optical Coherence Tomography (OCT) d. Visual evoked potential --------- Correct Answer ---------- ANS: B Visual disturbances and eye pain may be the only presenting symptoms and should be investigated. The MRI is the gold standard for diagnosis of multiple sclerosis (MS). The other tests may be performed if the diagnosis is unclear or if MRI is not readily available. A patient diagnosed with multiple sclerosis and begins disease modulating therapy (DMT) drugs. As part of the counseling about this therapy, the provider will tell the patient that this regimen will likely result in what outcome? a. A decreased need for other medications b. An induced long-term remission c. A reduction in the exacerbation rate d. A permanent stop of the disability --------- Correct Answer ---------- ANS: C Disease modulating therapy will reduce the rate of exacerbations of symptoms. It does not decrease the need for other medications, induce long-term remission, or stop the progression of the disease. A primary care provider suspects Parkinson's disease (PD) in a patient. Which tests may be performed to diagnose this disorder? a. Neuroimaging to identify specific midbrain lesion b. Neuromuscular studies to identify reflex function c. Presence of 2 cardinal signs which improve with levodopa d. Serum creatine phosphokinase levels --------- Correct Answer ---------- ANS: C The diagnosis of idiopathic PD is made based on clinical presentation and examination findings with 2 of 3 cardinal manifestations present which respond to dopaminergic therapy. Neuroimaging that identifies Lewy bodies is the gold standard but is performed post-mortem. Neuromuscular studies and serum laboratory studies are not useful unless excluding other causes of symptoms. A patient diagnosed with Parkinson's disease (PD) has been prescribed carbidopa- levodopa with good results but develops increased dyskinesia. Which drug will be added to this patient's regimen to help control this symptom? a. Amantadine b. Benztropine c. Ropinirole d. Tolcapone --------- Correct Answer ---------- ANS: A Amantadine is an antiviral agent that has antiparkinsonian activity. It is useful for controlling dyskinesia as adjunctive therapy to levodopa and is more effective than anticholinergic drugs. Benztropine is an anticholinergic drug that may be used for this purpose but is less effective and is more commonly used to treat antipsychotic-induced parkinsonism. Ropinirole is used as a first-line agent in patients with young-onset PD. Tolcapone is a COMT agent to prolong and potentiate the effects of levodopa to help prevent "wearing off" periods. What are common symptoms noted in patients diagnosed with Parkinson's disease? (Select all that apply.) a. Bradykinesia b. Festination c. Hyperphonia d. Rigidity e. Symmetric tremor --------- Correct Answer ---------- ANS: A, B, D Symptoms of Parkinson's disease include bradykinesia, or loss of automatic movement, festination, or an impulse to take much quicker and shorter steps, and rigidity. Hypophonia, not hyperphonia occurs. Tremors are unilateral or asymmetric. A patient with a seizure disorder has seizures which begin with a gastric sensation and a feeling of déjà vu. Which site in the brain is the seizure focus? a. Frontal b. Occipital c. Parietal d. Temporal --------- Correct Answer ---------- ANS: D Temporal sites cause epigastric and déjà vu sensations. Occipital sites causing complex partial seizures will have visual auras that may begin with eye twitching and visual hallucinations. Frontal sites cause dizziness or fear. Parietal sites cause sensory changes, such as numbness, tingling, or pain. A patient who has a seizure disorder and takes levetiracetam is brought to an emergency department as two consecutive 15-minute seizures occur. What is the priority action for this patient? a. Administer a dose of levetiracetam now and repeat in 10 minutes. b. Administer lorazepam and monitor cardiorespiratory status. c. Administer phenytoin and phenobarbital along with oxygen. d. Admit the patient to the hospital for a diagnostic work up. --------- Correct Answer ------ ---- ANS: B This patient has status epilepticus, which should be treated with benzodiazepines and close monitoring of airway, breathing, and circulation. The other interventions are not appropriate for acute seizure management. Which drug is used to treat patients with focal epilepsy and complex partial seizures? a. Carbamazepine b. Ethosuximide c. Lamotrigine d. Topiramate --------- Correct Answer ---------- ANS: A Carbamazepine is used for focal and complex partial seizures. Ethosuximide is useful for petit mal seizures in children. Lamotrigine has a wide range of effectiveness but has an increased risk for Stevens-Johnson syndrome. Topiramate is not a first-line drug because of cognitive side effects. A patient reports paroxysms of burning, shock-like pain on both sides of the face usually triggered by chewing or talking. The provider suspects trigeminal neuralgia. Based on these presenting symptoms, what testing is indicated? a. Autoimmune laboratory panel b. Inflammatory markers c. Magnetic resonance imaging (MRI) d. Plain radiographs --------- Correct Answer ---------- ANS: C Trigeminal neuralgia is a clinical diagnosis. Pain on both sides of the face raises a suspicion for multiple sclerosis and MRI is done to corroborate the presence of MS. Autoimmune laboratory pane is performed if alternative diagnoses are suspected. Inflammatory markers are not diagnostic. Plain radiographs are not indicated. A patient is diagnosed with trigeminal neuralgia and reports having paroxysms several times each day. What is the initial treatment for this patient? a. A combination of baclofen, lamotrigine, and phenytoin b. A high dose of carbamazepine with subsequent titration downward c. Botox injections or intranasal lidocaine as needed d. Low doses of anticonvulsants with gradual increase as needed --------- Correct Answer ---------- ANS: B Anticonvulsants are first-line treatments for trigeminal neuralgia - carbamazepine is started at the maximum therapeutic dose and titrated down to the lowest effective dose. Combination drug therapy is begun if the initial treatment is not effective or if the single drug regimen has intolerable side effects. Botox injections and intranasal lidocaine are used as adjuncts to anticonvulsants for acute pain relief. A patient diagnosed with trigeminal neuralgia has tried several medication regimens to control pain without success. What is the next step in management for this condition? a. Consultation with a psychiatrist b. Education about alternative treatments c. Recommending a pain center d. Referral to a neurosurgeon --------- Correct Answer ---------- ANS: D Referral to a neurosurgeon is indicated after medical therapies have been exhausted. The other options may be included in long-term care, but a neurosurgery referral is warranted. b. Begin treatment with lithium or lamotrigine c. Counsel the parent to report any symptoms of depression d. Schedule an appointment with a psychiatrist --------- Correct Answer ---------- ANS: B Patients with symptoms of mania should begin treatment with a mood stabilizer and the primary care provider should initiate treatment for an acute episode. It is not necessary to admit as an inpatient unless there is indication of harm to the self or others. The primary provider should refer for psychiatric evaluation but should begin medications as soon as possible. A patient is brought to the emergency department experiencing disorientation, confusion, and fever. The patient describes visual and auditory hallucinations. The patient's spouse states that the patient had several drinks 12 hours prior to passing out. A blood alcohol level is 0.2%. What is the recommended treatment? a. Benzodiazepines b. Intravenous fluids and rest c. Naloxone d. Phenobarbital --------- Correct Answer ---------- ANS: A This patient is showing symptoms of major alcohol withdrawal and should be treated with a benzodiazepine, which is the safest, most effective drug to treat alcohol detoxification. Without medications, the patient may develop seizures and delirium tremens or may die. Naloxone is used for narcotics. Phenobarbital is used to treat seizures. A college student is brought to the emergency department by a roommate who is concerned about symptoms of extreme restlessness, nausea, and vomiting. The provider notes elevations of the pulse and blood pressure and pupillary dilation, along with hyperactive bowel sounds. The provider suspects withdrawal from which substance? a. Alcohol b. Cocaine c. LSD d. Opioids --------- Correct Answer ---------- ANS: D This patient has symptoms consistent with opioid withdrawal, which causes restlessness, hyperactive bowel sounds, pupillary dilation, and changes in vital signs. Alcohol withdrawal involves tremors, confusion, and hallucinations. Cocaine withdrawal causes muscle tension, teeth clenching, and blurred vision. LSD symptoms cause hallucinations. A 17-year-old male is brought to the clinic by a parent who is concerned that the patient has become more isolated and withdrawn. The patient has expressed suspicions that his teachers hate him and want him to fail. What will the provider tell this parent? a. The adolescent should be evaluated by a psychiatrist. b. The adolescent should be given a trial of antipsychotic medications. c. These are common adolescent behaviors and will eventually go away. d. These signs are diagnostic for schizophrenia. --------- Correct Answer ---------- ANS: A These signs, along with a family history of psychosis, can be predictive of schizophrenia, so referral for psychiatric evaluation should be made. Unless symptoms are present longer than a month and the patient is diagnosed, antipsychotic medications are not indicated. Without evaluation, these behaviors should not be dismissed as normal. While these signs may raise concerns for schizophrenia, they are not diagnostic. A young male patient is reported to be more withdrawn from his peers than usual and has dropped out of college and quit his job within the last 5 months. The parent is concerned that the patient may have schizophrenia because a maternal uncle has the disease. What will the provider do next? a. Ask about the patient's speech and thinking patterns b. Consider treatment with antipsychotic medications c. Reassure that classic symptoms of schizophrenia are not present d. Refer the patient for inpatient psychiatric treatment --------- Correct Answer ---------- ANS: A In order to diagnose schizophrenia, one or more of the positive signs of delusions, hallucinations, or disorganized speech must be present. Unless there is a definitive diagnosis, hospitalization and treatment are not indicated. The patient has some signs of schizophrenia, so further evaluation is necessary before reassurance can be made. Which are considered "negative" symptoms of schizophrenia? (Select all that apply.) a. Auditory hallucinations b. Delusions of persecution c. Impaired self-care d. Poor school performance e. Withdrawing from peers --------- Correct Answer ---------- ANS: C, D, E Negative symptoms are those related to decrease or loss of normal functions and may include social withdrawal, impaired self-care, and poor school performance. Hallucinations and delusional beliefs are things added to normal behaviors and are considered positive symptoms of schizophrenia. Question 2. Which of the following is a potential acquired cause of thrombophilia --------- -- Correct Answer ---------- Homocysteinuria Protein C deficiency Factor V Leiden Antiphospholipid antibodies Question 3 Phalen's test, 90°wrist flexion for 60 seconds, reproduces symptoms of: ----------- Correct Answer ---------- Ulnar tunnel syndrome Carpal tunnel syndrome Tarsal tunnel syndrome Myofascial pain syndrome Question 4 Which patient would benefit most from screening for type 2 diabetes? ----------- Correct Answer ---------- A 30 year old female with unintended weight loss. A 25 year old male with family history of type 1 diabetes An obese female with recurrent vaginitis A 50 year old hyperlipidemic male Question 5 A 72 year old female patient reports a 6 month history of gradually progressive swollen and painful distal interphalangeal (DIP) joints of one hand. She has no systemic symptoms but the erythrocyte sedimentation rate (ESR), antinuclear antibody (ANA), and rheumatoid factor (RF) are all minimally elevated. What is the most likely diagnosis? ----------- Correct Answer ---------- Rheumatoid arthritis (RA) Osteoarthritis (OA) Lupus Peripheral neuropathy Question 6 A 32 year old male patient complains of urinary frequency and burning on urination for 3 days. Urinalysis reveals bacteriuria. He denies any past history of urinary tract infection. The initial treatment should be: ----------- Correct Answer ---------- Trimethoprim- sulfamethoxazole for 3 days Ciprofloxacin for 7-10 days Trimethoprim-sulfamethoxazole for 14 days Ciprofloxacin for 3 days A thymectomy is usually recommended in the early treatment of which disease? ---------- - Correct Answer ---------- Parkinson's disease Multiple sclerosis Myasthenia gravis Huntington's chorea Question 8 The diagnosis of human papilloma virus (HPV) infection in males is usually made by ---- ------- Correct Answer ---------- Clinical appearance Viral culture Tzanck smear KOH prep Question 9 The most effective intervention(s) to prevent stroke is (are): ----------- Correct Answer ---- ------ 81 mg of aspirin daily Carotid endarterectomy for patients with high-grade carotid lesions Routine screening for carotid artery stenosis with auscultation for bruits Smoking cessation and treatment of hypertension Spinal stenosis Traumatic fracture Osteoporosis Question 23 A middle-aged female presents complaining of recent weight loss. The physical exam reveals an enlarged painless cervical lymph node. The differential diagnosis for this patient's problem includes: ----------- Correct Answer ---------- Infection Toxoplasmosis Mononucleosis All of the above None of the above Question 24 An 81-year-old female is diagnosed with type 2 diabetes. When considering drug therapy for this patient, the nurse practitioner is most concerned with which of the following side effects? ----------- Correct Answer ---------- Weight gain Fracture risk Hypoglycemia Weight loss Question 25 A patient has HIV infection and is having a problem with massive diarrhea. You suspect the cause is ----------- Correct Answer ---------- cryptococcosis toxoplasmosis cryptosporidiosis cytomegalovirus Question 26 Which of the following is the most common causative organism of nongonococcal urethritis? ----------- Correct Answer ---------- Chlamydia trachomatis Ureaplasma urealyticum Mycoplasma hominis Trichonomas vaginalis Question 27 The most common symptoms of transient ischemic attack (TIA) include ----------- Correct Answer ---------- Nausea, vomiting, syncope, incontinence, dizziness, and seizure. Weakness in an extremity, abruptly slurred speech, or partial loss of vision, and sudden gait changes. Headache and visual symptoms such as bright spots or sparkles crossing the visual field. Gradual onset of ataxia, vertigo, generalized weakness, or lightheadedness Question 28 What is the first symptom seen in the majority of patients with Parkinson's disease? ----- ------ Correct Answer ---------- Rigidity Bradykinesia Rest tremor Flexed posture Question 29 A 21-year-old female presents to the office complaining of urinary frequency and urinary burning. The nurse practitioner suspects a urinary tract infection when the urinalysis reveals ----------- Correct Answer ---------- 1-4 red blood cells per high-powered field Specific gravity 1.012 Urobilinogen 10- white blood cells per high-powered field Question 30 A 26 year old female presents with elbow pain that is described as aching and burning. There is point tenderness along the lateral aspect of the elbow and painful passive flexion and extension. She reports she has been playing tennis almost daily for the past month. The most likely diagnosis is: ----------- Correct Answer ---------- Radial tunnel syndrome Ulnar collateral ligament sprain Olecranon bursitis Lateral epicondylitis Question 31 Maria, age 17, was raped when she was 13 year old. She is now experiencing sleeping problems, flashbacks, and depression. What is your initial diagnosis? ----------- Correct Answer ---------- Depression Panic disorder Anxiety Post-traumatic stress disorder Question 32 An elderly man is started on lisinopril and hydrochlorhiazide for hypertension. Three days later, he returns to the office complaining of left great toe pain. On exam, the nurse practitioner notes an edematous, erythematous tender left great toe. The likely precipitant of this patient's pain is: ----------- Correct Answer ---------- Trauma Tight shoes Arthritis flare Hydrochlorothiazide Question 33 Which of the following is a contraindication for metformin therapy? ----------- Correct Answer ---------- Insulin therapy Creatinine > 1.5 Edema None of the above Question 34 A positive drawer sign supports a diagnosis of: ----------- Correct Answer ---------- Sciatica Cruciate ligament injury Meniscal injury Patellar ligament injury Question 35 Steve, age 69, has gastroesophageal reflux disease (GERD). When teaching him how to reduce his lower esophageal sphincter pressure, which substances do you recommend that he avoid? ----------- Correct Answer ---------- Apples Peppermint Cucumbers Popsicles Question 36 A patient taking levothyroxine is being over-replaced. What condition is he at risk for? --- -------- Correct Answer ---------- Osteoporosis Constipation Depression Exopthalmia Question 37 Diabetes screening recommendations for asymptomatic adults age 45 and over include which of the following: ----------- Correct Answer ---------- HbA1C 2-hour 75 gram oral glucose tolerance test C-peptide level A and B All of the above Question 38 Dave, age 38, states that he thinks he has an ear infection because he just flew back from a business trip and feels unusual pressure in his ear. You diagnose barotrauma. What is your next action? ----------- Correct Answer ---------- Prescribe systemic antibiotics Prescribe antibiotic ear drops Prescribe nasal steroids and oral decongestants Refer him to an ear, nose, and throat specialist Question 39 Josh, age 22, is a stock boy and has an acute episode of low back pain. You order and NSAID and tell him which of the following? ----------- Correct Answer ---------- Maintain moderate bed rest for 3-4 days Call the office for narcotics if there is no relief with the NSAID in 24-48 hours Obese Question 51 Reed-Sternberg B lymphocytes are associated with which of the following disorders: ---- ------- Correct Answer ---------- Aplastic anemia Hodgkin's lymphoma Non Hodgkin's lymphoma Myelodysplastic syndromes Question 53 A 77-year-old female presents to the office complaining a sudden swelling on her right elbow. She denies fever, chills, trauma, or pain. The physical exam reveals a non- tender area of swelling over the extensor surface over the right elbow with evidence of trauma or irritation. The nurse practitioner suspects: ----------- Correct Answer ---------- Arthritis Ulnar neuritis Septic arthritis Olecranon bursitis Question 54 Establishment of a definitive diagnosis of osteomyelitis requires: ----------- Correct Answer ---------- A known causative injury such as a puncture wound, bite, or decubitus ulcer. Biopsy of culture of the pathogen from blood or bone aspirate. Visualization of purulent material draining into soft tissue. Lucent areas identified on plain x-ray. Question 55 The most accurate measure of diabetes control is: ----------- Correct Answer ---------- Avoidance of micro- and macro-vascular complications. Insulin sensitivity. Early morning glucose levels. HgbA1c Question 56 A patient has been diagnosed with generalized anxiety disorder (GAD). Which of the following medications may be used to treat generalized anxiety disorder? ----------- Correct Answer ---------- Alprazolam or diazepam Venlafaxine or buspirone Trazodone or sertraline Venlafaxine or hydroxyzine pamoate Question 57 The most common presentation of thyroid cancer is: ----------- Correct Answer ---------- Generalized enlargement of the thyroid gland. A solitary thyroid nodule. A multinodular goiter. Abnormal thyroid function tests. Question 58 Which of the following accounts for half of the bladder tumors among men and one-third in women? ----------- Correct Answer ---------- Cigarette smoke, both active and passive inhalation Chemicals from plastic and rubber Chronic use of phenacetin-containing analgesic agents Working long hours and not voiding often Question 59 You have a new patient that presents with generalized lymphadenopathy. You know that this is indicative of: ----------- Correct Answer ---------- Sjogren's syndrome Pancreatic cancer Disseminated malignancy of the hematologic system Cancer of the liver Question 60 Sally, a computer programmer, has just been given a new diagnosis of carpal tunnel syndrome. Your next step is to: ----------- Correct Answer ---------- Refer her to a hand surgeon Take a more complete history Try neutral position wrist splinting and oral NSAID Order a nerve conduction study such as am electromyography Question 61 Which drug category contains the drugs that are the first line Gold standard therapy for COPD? ----------- Correct Answer ---------- Corticosteroids Inhaled beta-2 agonist bronchodilators Inhaled anticholinergic bronchodilators Xanthines Question 62 Potential causes of septic arthritis include which of the following? ----------- Correct Answer ---------- Lyme disease Prosthetic joint infection Reiter's syndrome A and B All of the above Question 63 The nurse practitioner diagnoses epididymitis in a 24 year old sexually active male patient. The drug of choice for treatment of this patient is: ----------- Correct Answer ------ ---- Oral ciprofloxacin (Cipro) Oral doxycycline (Virbamycin) plus intramuscular ceftriaxone Oral trimethoprim-sulfamethoxazole (Bactrim DS) Intramuscular penicillin Question 64 A patient has been taking fluoxetine (Prozac) since being diagnosed with major depression, first episode, 2 months ago. She reports considerable improvement in her symptoms and her intention to discontinue the medication. What should be the nurse practitioner's recommendation? ----------- Correct Answer ---------- Advise the patient to stop the antidepressant medication Question the patient to determine if the self-assessment is correct before advising her to discontinue the medication Recommend that the patient continue the antidepressant medication for at least 4 more months Discuss with the patient the need to take the antidepressant medication indefinitely Question 65 Your patient has an elevated mean cell volume (MCV). What should you be considering in terms of diagnosis? ----------- Correct Answer ---------- Iron-deficiency anemia Hemolytic anemia Lead poisoning Liver disease Question 66 Which of the following medications increase the risk for metabolic syndrome? ----------- Correct Answer ---------- Antihistamines Proton pump inhibitors Protease inhibitors A and C All of the above Question 67 The hallmark of neurofibromatosis (von Recklinghausen's disease) present in almost 100% of patients is ----------- Correct Answer ---------- Acoustic neuroma Astrocytoma of the retina Distinctive osseous lesions Café au lait spots Question 68 The most commonly recommended pharmacological treatment regimen for low back pain (LBP) is: ----------- Correct Answer ---------- Acetaminophen or an NSAID A muscle relaxant as an adjunct to an NSAID An oral corticosteroid and diazepam (Valium) Colchicine and an opioid analgesic Question 69 A sudden rise in blood pressure due to overly efficient vasoconstriction. Emotional stress resulting in hypertension, tachycardia, and increased venous return. Question 80 A 60 year old male patient with multiple health problems presents with a complaint of erectile dysfunction (ED). Of the following, which medication is most likely to be causing the problem? ----------- Correct Answer ---------- Thiazide diuretic Insulin Famotidine (Pepcid) Albuterol Question 81 The cardinal sign of infectious arthritis is: ----------- Correct Answer ---------- Affected joint is painful at rest, with movement and weight bearing Rapid onset that wakes the patient during the night Long history of severe pain with associated joint swelling None of the above Question 82 A 75-year-old female is diagnosed with primary hyperparathyroidism and asks the nurse practitioner what the treatment for this disorder is. The nurse practitioner explains: ------- ---- Correct Answer ---------- Primary hyperparathyroidism is treated with Vitamin D restriction Primary hyperparathyroidism is treated with parathyroidectomy Primary hyperparathyroidism is treated with daily magnesium Primary hyperparathyroidism is treated with parenteral parathyroid hormone (PTH) Question 83 Which of the following is not appropriate suppression therapy for chronic bacterial prostatitis? ----------- Correct Answer ---------- Doxycycline 100 mg qd Nitrofurantoin 100 mg qd Bactrim DS qd Erythromycin qd Question 84 Who is at a higher risk for developing nephrolithiasis? ----------- Correct Answer ---------- Jack, who exercises every day and drinks copious amounts of water Mary, who watches her weight and eats a low-sodium diet Harvey, a "couch potato" who drinks a lot of no-sodium soda Bill, who runs every day and takes excessive amounts of vitamin C Question 85 Potential side effects of levofloxacin include which of the following? ----------- Correct Answer ---------- Confusion Hypoglycemia Achilles tendon rupture All of the above Question 86 A patient has just been diagnosed with Bell's palsy. He is understandably upset and has questions about the prognosis. You response should be: ----------- Correct Answer ------- --- Although most of your symptoms will disappear, some will remain but can usually be camouflaged by altering your hairstyle or growing a beard Unfortunately there is no cure but you have a mild case The condition is self-limiting and most likely complete recovery will occur With suppressive drug therapy you can minimize the symptoms Question 87 A diabetic patient is taking low-dose enalapril for hypertension. A record of the patient's blood pressure over 4 weeks ranges from 130 to 142 mmHg systolic and 75 to 85 mmHg diastolic. How should the nurse practitioner respond? ----------- Correct Answer -- -------- Change to a different class of antihypertensive medication to get better control. Increase the dosage of the current BP medication. Continue the current medication and dosage for 4 more weeks. Add a beta-blocker to the current medication regimen. What diabetic complications result from hyperglycemia? 1. Retinopathy 2.Hypertension resistant to treatment 3. Peripheral neuropathy 4.Accelerated atherogenesis ----------- Correct Answer ---------- 1, 2, 3 2, 3, 4 1, 3, 4 1, 2, 4 Question 89 Diagnostic confirmation of acute leukemia is based on: ----------- Correct Answer ---------- Bone marrow aspiration and biopsy Pancytopenia Hyperuricemia All of the above Question 90 The best test to determine microalbuminuria to assist in the diagnosis of diabetic neuropathy: ----------- Correct Answer ---------- A dipstick strip done during routine urinalysis in the office A 24-hour urine collection An early morning spot urine collection A serum albumin test Question 91 Which of the following antibiotics should not be prescribed for a pregnant woman in the 3rd trimester? ----------- Correct Answer ---------- Trimethoprim-sulfamethoxazole Erythromycin Cefuroxime Levofloxacin Question 92 Martin, a 58 year old male with diabetes, is at your office for his diabetes follow up. On examining his feet with monofilament, you discover that he has developed decreased sensation in both feet. There are no open areas or signs of infection on his feet. What health teaching should Martin receive today regarding the care if his feet? ----------- Correct Answer ---------- Wash your feet with cold water daily See a podiatrist every 2 years, inspect your own feet monthly, and apply lotion to your feet daily Go to a spa and have a pedicure monthly See a podiatrist yearly; wash your feet daily with warm soapy water and towel dry between the toes; inspect your feet daily for lesions; apply lotion to dry areas Question 93 The intervention known to be most effective in the treatment of severe depression, with or without psychosis, is: ----------- Correct Answer ---------- Psychotherapy Electroconvulsive therapy (ECT) A selective serotonin reuptake inhibitor (SSRI) A tricyclic antidepressant (TCA) Question 94 The initial clinical sign of Dupuytren's contracture is: ----------- Correct Answer ---------- Pain with ulnar deviation Painless nodule on palmer fascia Pain and numbness in the ring finger Inability to passively extend finger Question 95 Which of the following is the most common complication of the myelodysplastic syndromes ----------- Correct Answer ---------- Fatigue Cardiomyopathy Falls Bleeding Question 96