NURS 6550 Midterm Exam Questions and Answers (Graded A), Exams of Nursing

Download NURS 6550 Midterm Exam Questions and Answers (Graded A) and more Exams Nursing in PDF only on Docsity! Question 1 1 out of 1 points The AGACNP is caring for a patient who is quite ill and has developed, among other things, a large right sided pleural effusion. Thoracentesis is sent for pleural fluid analysis. While evaluating the fluid analysis, the AGACNP knows that a fluid identified as a(n) is the least worrisome type. Response Feedback: Question 2 “A” is the correct answer. A transudate is essentially just water and can occur as a consequence of increased hydrostatic pressure in the pulmonary vessels. It typically implies that the some condition has produced an imbalance in colloid-hydrostatic pressures, such as CHF or hypoalbuminemia. While it can represent a serious problem, it may also represent a transient imbalance. Conversely, “B” is not correct as an exudate has more protein in it and implies a condition characterized by protein leaking from vessels, such as a malignancy or some serious systemic stressor. “C” is not correct—a chyliform effusion is characterized by fat and indicates a pathology causing massive triglyceride degradation. “D” is not correct as a hemorrhagic effusion is blood and typically means traumatic injury. 1 out of 1 points Differentiating vertigo from near-syncope and ataxia is one of the goals of history-taking when a patient presents as “dizzy.” The AGACP knows that vertigo is the problem when the patient reports the primary symptom as: Response Feedback: “A” is the correct answer. Dizzy is a layperson’s term and can mean many different things to patients and health care providers. When the patient identifies the primary symptom as a sense of spinning this supports vertigo, which is usually an inner ear problem. This versus ataxia which is neurologic or near-syncope which may be cardiac, neurological, or neurocardiogenic. “B” is not correct—this may occur with vertigo, but when it is the primary symptom it is most likely ataxia and neurological causes should be considered. “C” is not correct as coincident nausea is not specific and can occur with any of these complaints. “D” is not correct as it is also not specific; while ataxia cannot occur when supine near-syncope can. Question 3 1 out of 1 points Mr. Banks has been admitted for surgical resection of a metastatic tumor, during surgery it is discovered that he has widespread, diffuse metastasis throughout the abdomen. Surgery is no longer an option, and his oncologist says that chemotherapy is unlikely to produce any meaningful benefit. Mr. Banks is concerned that his sons will not support a transfer to comfort care. The AGACNP advises that he: Response “B” is the correct answer. If there is any concern about disagreement Feedback: among family members, or any concern at all that a patient’s wishes will not be carried out, the best action is to ensure that there is a clearly defined legally executed document. “A” is not correct. Living wills are not legally enforceable documents and when dissention arises among family members they may not be carried out. “C” is not correct - while the patient should arrange for his care as long as he is capable of doing so, if questions arise at such a time that he is not capable of answering his next of kin will need to do so. “D” is not correct -- identifying the proxy is not enough without assigning legal rights and responsibilities. While “A,” “C,” and “D” should all be done and will support his care, the only way to ensure that one’s wishes are carried out is to ensure that a legally enforceable direction is in place. Question 4 1 out of 1 points Mr. Wilkerson is a 77-year-old male who is being evaluated and treated for his cardiogenic pain. His vital signs are as follows: Temperature of 99.1° F, pulse of 100 bpm, respirations of 22 bpm, and blood pressure of 168/100 mm Hg. A 12-lead ECG reveals deep ST segment depression in leads V3-V«. The AGACNP recognizes which of the following as a contraindication to rTPA therapy? Response Feedback: “D” is the correct answer. rTPA is not indicated in patients with ST segment depression; this is not a ST elevation MI. “A” is not correct as age > 80 is a relative contraindication. “B” is not correct as a temperature of 99.1° F is an expected response to myocardial necrosis, and “C” is not correct—the blood pressure is not prohibitive until > 180/110 mm hg. Question 5 A 71-year-old patient is recovering from a particularly severe exacerbation of 1 out of 1 points chronic obstructive pulmonary disease. He has been in the hospital for almost two weeks and was on mechanical ventilation for 7 days. While discussing his discharge plan he tells Question 10 context of the rest of the examination. 0 out of 1 points Because of the commonly recognized adverse effects of atypical antipsychotics, annual laboratory assessment for patients taking these medications should include a: Response Feedback: Question 11 “C” is the correct answer. The atypical antipsychotics such as olanzapine (Zyprexa), clozapine (Clozaril), and quetiapine (Seroquel) are classically associated with dyslipidemia and annual lipid panels should be performed in patients of all ages who take these medications. “A” is incorrect—this is the appropriate annual screening tool for patients on lithium due to lithium-related iodine suppression of the thyroid gland. There are no specific indications for “B” and “D” unique to patients taking atypical antipsychotics. Those laboratory assessments should only be ordered as indicated by any other significant patient history. 1 out of 1 points K.R. presents for an evaluation of eye discomfort. He works in a fabricating shop for a custom automobile restoration company and while working he felt like something flew into his eye. He was wearing eye protection at the time but still has the sensation that something is there. Physical examination is significant for some tearing and he reports a persistent sense of something in his eye. Which of the following is not indicated in the diagnostic evaluation? Response Feedback: Question 12 “B” is the correct answer. The patient’s history is consistent with a metal injury and so an MRI should be avoided. “A” may or not be indicated as the history progresses, but there is no contraindication to it should the examiner determine the need to rule out an abrasion. “C” and “D” are both mechanisms to visualize behind the cornea which may be necessary if a penetration injury (which may occur with a high-velocity injury) is suspected. 0 out of 1 points D.E. is a 41-year-old female who had lumbar surgery two days ago to repair a ruptured nucleus pulposus. She has been doing well postoperatively but today is complaining of resting fatigue and some shortness of breath at rest. In ruling out a pulmonary embolus the AGACNP first orders a: Response Feedback: Question 13 “B” is the correct answer. The D-dimer is a highly sensitive serology and is the least invasive mechanism by which a pulmonary embolus may be ruled out; a negative D-dimer virtually eliminates pulmonary embolus from the differential diagnosis. “A” is not correct—while it can be used to make the diagnosis it is more invasive and less specific than other options. “D” is not correct—there is no indication that the patient is on warfarin, and in any event it would not be used to rule in or out pulmonary embolus “C” is not accurate when after surgery, as it will be positive after surgery. 1 out of 1 points Mr. Nixon is being treated with unfractionated heparin infusion for acute pulmonary embolus. In order to avoid a potentially fatal complication of heparin infusion, the AGACNP monitors: Response Feedback: Question 14 “D” is the correct answer. An uncommon but potentially serious consequence of heparin infusion is heparin-induced thrombocytopenia. Some patients make autoantibodies in response to exogenous heparin that activate their own platelets. When this occurs, heparin must be immediately discontinued and thrombin inhibitors started. “A” is not correct—this is not affected by heparin, but is monitored in those on Coumadin. “B” is not correct—this is also unaffected by heparin, but monitored on Coumadin. “C” is not correct—this is monitored to assess therapeutic efficacy, but not for complications. 1 out of 1 points While assessing a patient with a known psychiatric history, the AGACNP knows that the primary difference between a psychotic and neurotic disorders is: Response Feedback: “B” is the correct answer. Patients with psychotic disorders are characterized by a distinct alteration in their perception of reality which may be manifest by visual or auditory hallucinations or impaired thought processes. Neurotic disorders, while many times very serious, are seen in patients who remain aware and interactive with the reality. “A” is incorrect as neurotic disorders may be characterized by a tendency or actual act of harm, such as the self- mutilating actions classic of a borderline personality, suicide by a depressed patient, or even murder or torture committed by an antisocial personality. While dangerous, none of those disorders include a dis-connect from reality as part of the presentation. “C” is incorrect as antipsychotic medications are used to manage a variety of neurotic disorders such as depression or oppositional defiant disorder. “D” is incorrect as lack of conscience and remorse is typical of antisocial personalities. Question 15 0 out of 1 points L.T. is an 85-year-old male who is admitted for evaluation of profound diarrhea that has produced significant dehydration. He also complains of being very tired lately, and feeling like he is going to vomit all of the time. His vital signs are significant for a pulse of 41 b.p.m. and a blood pressure of 90/60 mm Hg. A gastrointestinal evaluation including stool for blood, white blood cells, and ova and parasites is negative. He insists that he has not started any new medications or made any diet changes; the only thing new is that he got new eye drops for his glaucoma. The AGACNP correctly assumes that his new eye drops are: Response “B” is the correct answer. The accelerated GI motility and Feedback: bradycardia are cholinergic adverse effects. Ophthalmic medications are readily absorbed into systemic circulation. All of these medications are used to treat glaucoma and may cause class-related adverse effects, but cholinergic drops are the only ones shown that will slow heart rate and accelerate GI motility. Question 16 1 out of 1 points Janice is a 19-year-old female who presents to the emergency department via ambulance. She is pale, diaphoretic, agitated, and convinced she is having a stroke. Her vital signs include a temperature of 98.9° F, pulse of 114 beats per minute, respirations of 32 breaths per minute, and a blood pressure of 110/74 mm Hg. Diagnostic evaluation is negative and Janice is diagnosed with an acute panic attack. The initial treatment of choice is: Response “A” is the correct answer. A panic anxiety attack requires immediate Feedback: intervention with a short acting benzodiazepine for immediate symptom control. A calm environment would be helpful, but is not adequate alone to manage acute episodes characterized by physical symptoms. Oxygen is not indicated in the absence of organic Response “A” is the correct answer. While SSRIs, beta adrenergic antagonists, Feedback: and even centrally acting antiadrenergic agonists (clonidine) are all used as first line agents depending upon symptom presentation, patients who have more severe symptoms and do not respond to initial treatments often require management with atypical antipsychotics. This patient has been treated with an SSRI, reports no improvement, and has been arrested for his behavior; these circumstances are a clear indication for escalation to the nest level of therapy. Question 22 1 out of 1 points Mrs. Salter is an 81-year-old lady who presents for evaluation of near-syncopal episodes. Her 12-lead ECG, complete blood count, and comprehensive metabolic panel are all essentially normal. A urinalysis shows some trace protein but is otherwise normal. A 24- hour rhythm monitor demonstrates rare premature ventricular contractions. Mrs. Salter has been in good health and had her first episode at her aerobics class. She only gets lightheaded when she exerts herself. Her heart auscultates for a grade III/VI systolic crescendo-decrescendo murmur at the second intercostal space, right sternal border. The AGACP considers that the likely cause of the syncope is: Response Feedback: “C” is the correct answer. This is the classic murmur of aortic stenosis, which impedes cardiac output and as it progresses will produce a symptomatic decrease in carotid perfusion. “A” is not correct as there is no sign or symptom of seizure activity. “B” is not correct—the rare PVC is not likely to cause syncope. “D” is not correct—a blood pressure is not given and the proteinuria could come from any variety of causes. 0 out of 1 points A patient with anterior epistaxis has been treated with 20 minutes of direct pressure to the cartilaginous portion of the nose. Following pressure the patient is instructed to gently blow the nose. Expected findings in the patient who has been successfully treated include all of the following except a: Response “C” is the correct answer. If bleeding is successfully stopped with 20 Feedback: minutes of directed pressure, there will be residual blood and clot formation. This is evacuated either by gentle suction or having the patient gently blow. Residual blood and formed clot may present as a sudden gush of dark blood or discharge with or without a clot— these are all typical expected findings. However, if bleeding is not stopped, it will continue as a bright red steady trickle. When this occurs, more invasive measures are indicated. Question 23 0 out of 1 points Kevin is a 14-year-old male who presents for evaluation of a fever of 102.5° F and significant right ear pain. He appears quite ill and says he feels nauseous. Otoscopic evaluation reveals pain to palpation, a very erythematous and bulging tympanic membrane with bullous myringitis. The AGACNP knows that antibiotic therapy must be selected to cover: Response “D” is the correct answer. Streptococcus pneumoniae is the most Feedback: common bacteria that infects the head and neck in immunocompetent persons, and is the primary treatment target when treating otitis media, bacterial sinusitis, and bacterial pharyngitis. “A” is not correct—while likely on broken skin and soft tissue, it is not common in the ear, nose, or throat unless specific risk factors exist. “B” is not correct—this is much more likely in an immunocompromised patient or a patient on mechanical ventilation. “C” is not correct—it is the second most common organism, but strep is the primary treatment target. Question 25 1 out of 1 points Who among the following patients is at greatest risk for a pulmonary embolus? Response “C” is the correct answer. The primary risk factor for pulmonary Feedback: embolus is deep vein thrombosis, for which primary risks are polycythemia and stasis. “A” is not correct—the concentration of estrogen in most hormonal contraception is so low that it barely increases risk above that of the general circulation. Of the millions of women on hormonal contraception, only a handful develop DVT/PE. “B” is not correct—this patient is likely to have problems bleeding rather than clotting. “D” is not correct—while smoking is a risk factor for many things DVT is not among them. Question 26 1 out of 1 points Mrs. Birdsong is an 85-year-old female who has been admitted for surgical repair of a hip fracture. She is in remarkably good spirits and is quite talkative. She readily answers all of the questions on her intake assessment, and readily acknowledges information provided during her room orientation. Later while talking with the patient's son the AGACNP learns that the patient has had significant cognitive impairment for a few years. She has virtually no short term memory, but compensates by confabulating. Her son says she is generally very happy as long as there is no change in her day to day routine. This history is most consistent with which form of dementia? Response “C” is the correct answer. Alzheimer’s dementia is statistically the Feedback: most common form of dementia and is characterized by a long trajectory that progresses to include confabulation. Additionally, patients with this form of dementia are very reliant upon routine and may be distressed when it is disrupted. “A” is not correct; Lewy body dementia characteristically progresses much more quickly and produces an angry demeanor. “B” is incorrect because vascular dementia typically produces a more depressive affect and is not characterized by confabulation; additionally, patients with vascular dementia often have a medical history consistent with vascular risk factors. “D” is not correct as there is no apparent history of Parkinson’s disease. Question 27 1 out of 1 points Mrs. Radovich is an 80-year-old female with a variety of chronic medical conditions which are reasonably well controlled. She generally enjoys a good quality of life and is active with her family. Today her only concern is that she is having problems with her vision. She notices that while trying to look at pictures of her great grandchildren she can’t seem to focus on their faces. She also reports increased trouble reading—she cannot seem to see the words that she is looking at, and her reading glasses do not help. Further evaluation of Mrs. Radovich should include assessment with: Response “D” is the correct answer. An Amsler grid is used to assess central Feedback: vision and is used to assess symptoms of macular degeneration, an age-related disease that decreases central vision. “A” is not correct, a slit lamp assesses the anterior chamber of the eye and does not especially help in evaluation of macular symptoms. “B” is not correct as this assesses visual acuity and would not be especially helpful with the complaint is loss of central vision. “C” is not correct —a Wood’s lamp is an alternate light source used to visualize corneal abrasions. Question 28 0 out of 1 points RJ. is a 55-year-old female who presents with acute onset left sided facial pain and an inability to move the left side of her face. She cannot smile, raise her eyebrow or even close her left eye, The immediate approach to this patient should include: Response “A” is the correct answer. This is the classic presentation of Bell’s bleeding. She appears to have stabilized hemodynamically, but today she had a temperature of 101.9° F and chest radiography demonstrates a diagnosis of pneumonia. The AGACNP knows that the diagnostic evaluation for hospital acquired pneumonia for all patients must include: Response Feedback: Question 34 “A” is the correct answer. At a minimum, the American Thoracic Society/Infectious Disease Society of America (ATS/IDSA) guidelines suggest induced sputum, arterial blood gas, and blood cultures for all patients with nosocomial pneumonia (acquired after a hospitalization of > 72 hours). “B” is not correct—neither viral cultures nor CT of the chest are routinely mandated for all patients, although they may be necessary in selected circumstances. “C” is not correct thoracentesis is only indicated for large effusions or any effusion in which the patient appears toxic. Similarly, bronchoscopy is not routinely indicated but may be useful in some circumstances. “D” is not correct as thoracentesis, as previously noted, is not routinely indicated. 0 out of 1 points Most psychosocial theories of aging center around the core concept that successful aging requires acceptance of a series of changes or losses that predictably occur later in the life span. The theory that specifically addresses coming to terms with the inevitability of death is known as: Response Feedback: Question 35 “B” is the correct answer. Levinson’s work has been widely interpreted, and it is the only one of the developmental theories that specifically calls upon the older adult to accept the inevitability of death in order to achieve emotional harmony later in life. Other theorists, including those in “A,” “C,” and “D” focus more on the required adjustments to change in physical appearance, change in income, change in relationships, and loss of professional identity. 0 out of 1 points All of the following conditions are risk factors for pulmonary embolus except: Response Feedback: “C” is the correct answer. A factor VIII deficiency is hemophilia, in which patients have a decreased ability to clot and are at risk for pathologic bleeding. Conversely, “A” and “D” are not correct as protein C and protein S, activated by the products of clotting, ultimately inhibit the clotting cascade. Deficiencies in protein C and S result in an inability to inhibit clotting and are at risk for pathologic clotting. Factor V is a clotting factor that is inhibited by the activated protein C and protein S complex. “B” is not correct— when patients have a mutation of factor V, it is insensitive to the inhibiting properties of protein C and S and clotting cannot be stopped appropriately—resulting in increased risk of clotting. Question 36 1 out of 1 points A patient is diagnosed with acute descending aortic aneurysm and hypertension should be immediately started on which medication pending surgical evaluation? Response “A” is the correct answer. Beta adrenergic antagonists decrease the Feedback: force of contraction therefore decreasing shear force exerted on the dissection. “B” is not correct, intravenous vasodilators are not used initially although are a second option to reduce systolic blood pressure but . “C” and “D” are not correct as other medical management strategies have not demonstrated improved outcomes. Ultimately these patients will require surgical intervention. Question 37 0 out of 1 points Jason is a 27-year-old with a long history of intermittently controlled asthma. He is currently prescribed Advair daily with albuterol as needed for symptoms. Today he presents to the emergency department with cough and wheezing and difficulty catching his breath. His FEV, is 51% at the time of presentation. He is given alternating albuterol and ipratropium nebulizer treatments along with oral prednisone. After one hour his FEV; has increased 65%. The appropriate disposition for Jason at this point is: Response . a Feedback: “B” is the correct answer. The EPR-3 guidelines for management of asthma in the urgent and emergency care setting indicate that if the FEV; remains below 70% after one hour of emergency care that the patient should be admitted. “A” is not correct—he does not have an indication for intubation as his FEV, is improving and is not approaching the 40% that would indicate intubation. “C” is not correct—he has already been assessed and treated for one hour and at this point admission is indicated. “D” is not correct—he cannot be discharged to home unless his FEV; is > 70% Question 38 1 out of 1 points A patient in the intensive care unit suddenly becomes tachypneic and dyspneic. The physical examination reveals pale, cool, clammy skin and an arterial blood gas demonstrates hypocapnea and hypoxia. Pulmonary artery pressure demonstrates a pattern consistent with obstructive shock. The AGACNP knows that which of the following causes of this presentation is most likely? Response “D” is the correct answer. Pulmonary embolus, cardiac tamponade, Feedback: and pneumothorax are the most common causes of obstructive shock. The obstructive shock, along with the remaining classic symptom presentation, makes pulmonary embolus very likely. “A” is not correct—the septic patient would demonstrate pulmonary artery pressures consistent with distributive shock. “B” is not correct—the patient with congestive heart failure would demonstrate vascular congestion and cardiogenic shock. “C” is not correct—this patient would demonstrate intravascular hypovolemic shock. Question 39 0 out of 1 points Mr. Bowers is an 81-year-old male who is being terminally extubated at the request of his family due to the presence of a large subdural hematoma with a shift; the patient is Not initiating respirations on his own and the prognosis is very poor. After he is extubated he begins to initiate his own respirations and 24 hours later has not expired yet. The decision is made to leave him in the hospital on a general medical floor rather than transfer to another facility for hospice. Which of the following is the best indicator that the patient’s death is imminent? Response “A” is the correct answer. Patient may survive in hospice care for Feedback: days or even weeks after all support, including food and fluids, are withdrawn. “B,” “C,” and “D” can occur for weeks in patients who manage to sustain cardiopulmonary function. However, when there is no urine being produced, the combination of volume contraction and electrolyte and metabolic imbalance will cause death very quickly. The cessation of urine output is the strongest marker of the answer choices provided to predict imminent cardiac arrest. Question 40 0 out of 1 points A patient is newly admitted to your service for open reduction and internal fixation of the left hip. She seems very down, and as you talk with her you realize that her mood is not just related to her hip fracture. Which of the following symptoms would not be consistent with major depressive disorder? Response “D” is the correct answer. Major depressive disorder is not Feedback: diagnosed when the symptoms may be attributed to bereavement over a loss of < 2 months duration. Conversely, “A,” “B,” and “C” are all consistent with a diagnosis of major depressive disorder. Feedback: of location (aortic, pulmonic, tricuspid, and mitral valves) and timing (systolic or diastolic). The murmur of mitral regurgitation occurs when the mitral valve is closed, which is a systolic event—therefore “C” and “D” are not correct. The mitral valve is best auscultated at the fifth intercostal space, midclavicular line, which makes “A” incorrect. “B” is the only answer choice that represents the mitral valve location during systole. Question 46 1 out of 1 points A patient with minor head trauma presents for evaluation. Which of the following findings should be followed up with a CT scan to rule out orbital fracture? Response “C” is the correct answer. Even with minor head trauma, > one half Feedback: of all patients with a black eye will have orbital fracture; the presence of periorbital ecchymosis is an indication to CT scan the orbit. “A” is not correct—a positive Romberg test is more consistent with cerebellar dysfunction. “B” is not correct—it may be related to any number of etiologies or no identifiable ones, but there is no specific link to orbital fracture. “D” is not correct—in the setting of head injury bleeding from the ear’s is more consistent with increased intracranial pressure. Question 47 0 out of 1 points Mrs. Forbes is a 69-year-old lady being discharged from the hospital after complications following a cosmetic surgical procedure. She is basically in good health. She has a history of hypothyroidism for which she takes levothyroxine daily, and mild osteoarthritis which is controlled with only prn nonsteroidal use. Her blood pressure is 148/90 mm Hg. The AGACNP knows that in accordance with the most current guidelines published in JNC 8 the appropriate action is to: Response “C” is the correct answer. Absent chronic kidney disease or diabetes, Feedback: any adult > 60 years old has goal blood pressure of 150/90 mm Hg. This patient is at goal and should just proceed with normal health promotion. “A” is not correct—there is no indication for drug therapy. “B” is not correct—we are not given the patient’s weight, and given her age lack of comorbid kidney disease or diabetes, weight reduction is not indicated in response to her blood pressure. “D” is no correct—while these are the three first line drugs for hypertension and would be indicated if drug therapy were needed, this patient does not require any medication at this time Question 48 0 out of 1 points When assessing driver safety in the older adult, the AGACNP considers that: Response “B” is the correct answer. Mental status is only one part of driver Feedback: safety; older adults may have a normal mental status but be at risk due to poor vision, decreased hearing, decreased neck mobility, or decreased ability to quickly assimilate and respond to complex stimuli. “A” is not true, MMSE as an isolated correlate with road accidents is not reported. “C” is not true, dementia is not a condition that requires reporting, although the clinician does have a responsibility to counsel drivers when there is a safety concern. “D” is not true—driving to slowly can lead to accidents; if an older adult is not comfortable with the speed limit he or she should not be driving on the road. Question 49 0 out of 1 points The nursing staff calls to tell you that your 81-year-old male patient is having an acute change in mental status. He is a basically healthy man who was admitted three days ago for inpatient antibiotic management of community acquired pneumonia. His daughter is at the bedside and she is very distraught because she has never seen him like this. She is asking for medication to make him stop acting disoriented. Upon examination the patient is lying in bed, appears calm and happy, but does not recognize his daughter as anyone he knows. He is talking as if he is at home and has company. The AGACNP instructs the daughter that: Response “C” is the correct answer. Medication is not indicated for a patient Feedback: who is delirious but calm and in no distress or danger; determining the underlying cause is the priority of care. “A” is not correct as gentle reality orientation is an important part of delirium management. Using reality props, such as a large clock, large calendar, etc., are often used in inpatients units designed for the geriatric patient. “C” is not correct—after three days of antibiotic therapy, the infection should be improving and any delirium at this point does not likely have its origin in a successfully treated infection. “D” is not correct as he may or may not have head imaging, but less invasive and expensive diagnostic tools will be used first. Question 50 0 out of 1 points While discharging a patient following her myocardial infarction, you offer some patient education about medically supervised cardiac rehabilitation. The patient expresses fear of rehab because she was on her treadmill when she had her infarction and now she is afraid of making it happen again. She doesn’t understand how the rehab can force her to exercise her heart but not make her have another cardiac event. The AGACNP explains that the patient will be monitored and that her goal heart rate will be: Response Feedback: Question 51 “B” is the correct answer. There are three phases of cardiac rehab— phase I begins in the hospital immediately upon acute treatment and involves getting out of bed and ambulating. Phase II is the medically supervised programs that most insurances pay for in which the patient’s heart is reconditioned. Phase III is essentially the rest of the patient’s life—30 minutes of moderately strenuous activity at least 5 days a week. In phase II rehab, the goal heart rate is calculated to be 10 beats per minute below the rate of ischemic change. This allows the heart to be exercised without endangering the patient. “A” is not correct—the goal does not increase over the period of phase II, although it may change over phase III. “C” is not correct, the heart must be exercised significantly above resting or there will be no improvement. “D” is not correct—the patient is not medicated to change target heart rate. 0 out of 1 points During physical examination of a 51-year-old African-American female you appreciate a decrease in her peripheral vision. The rest of her eye examination is within normal limits and she is symptom free. This presentation is consistent with: Response Feedback: Question 52 “D” is the correct answer. Painless loss of peripheral vision is consistent with open angle glaucoma and this patient is from a high risk group (African-American population). “A” is incorrect because macular degeneration is a disease of central vision change/loss. “B” is incorrect—increased intraocular pressure is consistent with glaucoma but not intracranial pressure. “C” is incorrect— dacrocystitis is an acute inflammation of the lacrimal apparatus and presents as an acute abscess at the medial aspect of the eye and nasal border. 1 out of 1 points Mr. Moffett is a 66-year-old male with a long history of lower extremity edema. All other causes of lower extremity edema have been ruled out and his overall symptom presentation and history are strongly supportive of chronic venous insufficiency. Today he presents with increased itching of both lower legs. Physical exam reveals 2-3+ pitting edema and trophic hyperpigmentation. The AGACNP know that treatment should Bowers oxygenated and he required very high FIO2s and PEEP. The AGACNP knows that the primary concern with FIO,s > 60% is: Response Feedback: Question 58 “B” is the correct answer. It is well established that when a patient is sustained on an FIO) > 60% there is an increased risk of oxygen conversion to oxygen free radical and causing damage to the lung parenchyma. While the patient should never be compromised, FIO2s > 60% should only be maintained when essential to keep the patient out of respiratory failure. “A” is not correct—high levels of oxygen are not independently correlated with ventilator dependence. “C” is not correct as acid-base balance is more a consequence of rate and volumes resulting in increased or decreased CO: retention. “D” is not correct. While high volumes of gas can lead to pneumothorax in patients with decreased compliance, oxygen concentration is not the primary issue. 0 out of 1 points Acute respiratory distress syndrome (ARDS) occurs when an overwhelming systemic insult results in which maladaptive physiologic response? Response Feedback: Question 59 “A” is the correct answer. Patients with ARDS develop and increase in the permeability of the alveolar capillary membrane, which allows protein and other intravascular solutes to leak out of the pulmonary vessels into the alveoli resulting in decreased ability to ventilate the alveoli and ultimately right to left shunting. “B” is not correct—a decrease in this barrier would actually inhibit leakage from capillary to alveoli. “C” and “D” are not correct—pulmonary hydrostatic pressure is not an issue in ARDS, it is a factor in pulmonary edema when increased vascular congestion results in an increase in hydrostatic pressure and ultimately water leaking into the alveoli. 0 out of 1 points Acute respiratory distress syndrome is characterized by which abnormality of ventilation and perfusion? Response Feedback: “B” is the correct answer. A shunt occurs when blood flows from the right side of the heart to the left side of the heart without any contact with aerated alveoli as occurs in ARDS. “A” is not correct—dead space occurs when the alveoli are inflated but no venous blood comes into contact with it—this is the case in pulmonary emboli in which emboli block the vessel and the inflated alveoli are wasted “C” is not correct—this is not a ventilation or perfusion problem; increased retrosternal airspace occurs with the long term retention seen in COPD. “D” is not correct—ARDS results in fibroproliferation which will decrease compliance. Question 60 0 out of 1 points George Schulz is a 69-year-old male who presents for evaluation of acute foot pain. It is so painful that he cannot walk on it without assistance. At first he denies any significant medical history, but then reveals that he has been diagnosed with dyslipidemia and hypertension but stopped taking his medications because he couldn’t afford it. Pulses are not palpable but are audible by Doppler. The extremity is pale and shiny with decreased hair growth, suspecting peripheral arterial disease, the AGACNP expects which additional finding? Response “D” is the correct answer. When patients have severe arterial Feedback: disease, the microcirculation tries to compensate with widespread dilation and the foot will turn bright red when placed in a dependent position. “A” is not correct—this is more consistent with venous insufficiency as increased venous pressure moves fluid into the interstitial. “B” is not correct—this is also consistent with venous disease and the distended interstitium stimulates melanocytes which increases pigmentation. “C” is not correct, this is more consistent with neuropathy as is seen in diabetes. Question 61 0 out of 1 points G.T. is a 40-year-old male who is under your case for long term management of secondary osteoarthritis. Today he asks if he can take a medication for anxiety. Further assessment reveals that he is in a relationship that has been very stressful; his girlfriend wants very much to get married and start a family, and he does not. He admits that he no longer feels they are compatible and acknowledges that he needs to end this relationship. He is sure that this is the source of his anxiety. The best approach would be to: Response “B” is the correct answer. G.T. freely acknowledges that his Feedback: relationship is the source of his anxiety. SSRI therapy corrects only neurotransmitter abnormalities; it will not improve anxiety that is related to interpersonal relationships. A short acting benzodiazepine is only appropriate during acute anxiety circumstances and is not indicated as an intervention for typical day-to-day personal issues. Couples’ therapy is unlikely to help when G.T. clearly acknowledges major life goal differences as well as a desire to end the relationship. Question 62 1 out of 1 points During the physical examination of a 31-year-old female, the AGACNP appreciates a bifurcate uvula. The most appropriate action would be to: Response Feedback: Question 63 “C” is the correct answer. A bifurcate uvula (a uvula that is split in two or forked) is a normal variant in a small percentage of the population. It has no clinical significance. “A” is not correct as there is no indication for ENT evaluation. “B” is not correct because a bifurcate uvula is not among the anatomical risk factors for sleep apnea, and “D” is not correct—stimulation will not cause spasm. Stimulation is a concern when epiglottitis is suspected. 0 out of 1 points During routine immigration screening a 29-year-old male patient from Mexico has a positive purified protein derivative (PPD) test at 17 mm induration. He reports no known history of tuberculosis (TB) infection or exposure, or vaccination with the BCG vaccine. Chest x-ray is negative for any evidence of TB exposure. The AGACNP knows that the appropriate next step is to: Response Feedback: Question 64 “B” is the correct answer. Patients who have a + PPD but negative chest radiography are considered exposed but not infected, and the Centers for Disease Control (CDC) and Prevention recommend a prophylactic regimen; while isoniazid (INH) and vitamin B6 are the classic combination other regimens do exist. “A” is not correct—the negative chest radiography makes this a non-reportable event. “C” is not correct—sputum cultures are collected when the chest radiograph is positive. “D” is not correct—the patient may ultimately elect not to take prophylactic therapy and be discharged from care, but before that decision is made prophylactic therapy should be offered and considered. 1 out of 1 points Clinical diagnostic criteria for acute respiratory distress syndrome (ARDS) include all of the following except: Response Feedback: “D” is the correct answer. Hypoxemia may be due to any number or respiratory abnormalities and in itself is not among criteria for ARDS; however hypoxemia that is refractory to high oxygen flow concentrations is an anticipated clinical finding. “A,” “B,” and “C” are all among the clinical diagnostic criteria for ARDS—it is virtually always acute in onset, occurring over a matter of hours; chest radiography demonstrates classic characteristic bilateral indicated at this point. “B” is the appropriate action for BPPV— many patients get measurable relief of symptoms by doing Epley’s maneuvers to reposition otoliths. “C” is not correct—the coincident nausea is often very strong and antiemetic’s are often given for up to one week; if symptoms do not begin to improve at that point further investigation is warranted. “D” is not correct as a textbook evaluation of vertigo includes an assessment of nystagmus to complete the physical examination and differentiate the more common peripheral vertigo from central vertigo. Question 70 0 out of 1 points A 36-year-old female presents complaining of left leg swelling. She describes the onset as acute over the last day or two, and says it feels "tight and throbbing." She denies any significant medical history and says the only medication she takes is oral contraception, which she has taken since she was 15 years old. The AGACNP first orders: Response “B” is the correct answer. The D-dimer is a highly sensitive blood Feedback: test that suggests activation of the clotting cascade. It requires only venipuncture and is less invasive and less expensive than other tests for deep vein thrombosis. A negative D-dimer essentially rules out a DVT and the diagnostic evaluation can proceed to rule out other differentials. “A” is not correct—it is not ordered first, but rather follows a positive D-dimer to confirm the presence of a DVT. c" is not correct—a venogram of the affected extremity may be ordered when clinical suspicion is very high and the Doppler inconclusive, but it is not an initial test. “D”A comprehensive metabolic panel may be ordered, but it does not contribute to the diagnosis and is indicated to rule DVT in or out. Question 71 0 out of 1 points The primary neurotransmitter implicated in post-traumatic stress disorder (PTSD) is: Response “C” is the correct answer. There are several theories that implicate Feedback: the role of catecholamine’s such as dopamine and serotonin, as well as secondary stress hormones such as cortisol, but these most of these are not uniformly accepted in terms of the neurobiology of PTSD. Conversely, norepinephrine is universally accepted as a key neurotransmitter in both initial neurological response to an extreme stressor and the subsequent PTSD attacks. Increased exposure to norepinephrine at the time of initial stressor is linked to the development of PTSD, and norepinephrine is an integral component of the symptoms of subsequent attacks. Question 72 1 out of 1 points Mr. Avila is an 82-year-old male being counseled about the risks and benefits of his upcoming abdominal surgery. While considering risk factors for atelectasis, pneumonia and other pulmonary complications, the AGACNP advises that the greatest risk comes from: Response “A” is the correct answer. Among all the choice listed here, cigarette Feedback: smoking confers the highest risk for poor outcomes. “B” is incorrect —while major abdominal procedures do have a link to pulmonary complications, it is not as big a risk as smoking. “C” is not correct— age alone is a risk factor for systemic complications, but it does not confer any specific independent risk for pulmonary complications— the middle aged smoker may be at higher risk that the elderly non- smoker. “D” is not correct—an FVC just under normal does not have any strong correlation with poor pulmonary outcomes. Question 73 1 out of 1 points The female AGACNP is practicing with a cardiology group and sees patients one day a week in the outpatient office. A 49-year-old female presents for follow-up after her admission for infective endocarditis. She is recovering well, and says that she is going to be more proactive about her health. She admits to not having had any of her regular health screenings for years, and asks if she can have her Pap performed at this office. The AGACNP: Response “C” is the correct answer. A cardiology practice should not be Feedback: managing a woman’s gynecological health. Performing a Pap smear includes accountability for knowing and implementing proper screening, interpretation, guidance, and follow-up. Regardless of whether or not the AGACNP has been trained to perform a Pap, it is not typically within the scope of practice for a cardiology practice, and is no more appropriate than a gynecology practice managing the patient’s cardiac health. Therefore “A,” “B,” and even “D” are not correct answers. In isolated circumstances specialty providers will assume the role of primary care provider, and when that occurs policies and standards are in place to ensure that the providers have a competency in all levels of care they provide. Question 74 0 out of 1 points The AGACNP is seeing a patient who was transferred from the correctional facility for evaluation. He has a profound purulent discharge from his right eye. The conjunctive is erythematous and there is mild photosensitivity. The inmate denies any real eye pain, just says that it is extremely uncomfortable. Treatment for this patient is likely to include: Response “B” is the correct answer. This presentation is most likely descriptive Feedback: of gonococcal conjunctivitis, which needs to be treated either with IM Rocephin and referred to ophthalmology. “A” is incorrect as eye irrigation is not indicated and would likely be uncomfortable while doing no good. “C” is not correct as a topical (or systemic) macrolide would be ineffective against gonorrhea. “D” is not indicated as ophthalmic steroids are only indicated for acute inflammatory ocular conditions. Question 75 0 out of 1 points Ms. Ewing is a 78-year-old female who lives in a long term care facility because her dementia has progressed to the point at which her family cannot provide the necessary safety measures at home. In addition to her absent short term memory she has developed some affective changes and most recently is demonstrating sexual disinhibition. While considering management options, the AGACNP knows that all of the following are medications are options for the management of disinhibition except: Response “D” is the correct answer. Testosterone will increase sex drive and is Feedback: used therapeutically to do so, thus it is not indicated to suppress sexual disinhibition. “A” is used to capitalize on the well- documented adverse effect of decreased libido. “B” is used as is has antiandrogenergic properties that may counter testosterone. “D” is thought to be successful primarily to its general sedative properties. Question 76 1 out of 1 points A patient recently had a nasal packing inserted for management of refractory epistaxis. One week later he presents with fatigue, a headache “inside of his nose” and a feeling generally unwell. The AGACNP considers: Response “C” is the correct answer. These symptoms are consistent with Feedback: bacterial sinusitis, which most often occurs as the consequence of some antecedent irritation or inflammation of the sinuses. Nasal packing, nasal instrumentation, viral infection, and allergic inflammation are common causes. “A” is not correct as hematomas are not likely because the pressure packing left in place typically Question 82 blood of the lung parenchyma of the pulmonary veins. Hyperlucency means that there is more air, less tissue, or less vein perfusion—or a combination. “A,” “B,” and “C” are all conditions characterized by increased air in the lung or pleural space. Conversely, atelectasis is a condition of consolidated/underinflated alveoli, which presents as less air resulting in consolidation. 0 out of 1 points When evaluating a patient with epistaxis, which of the following signs or symptoms is suggestive of a more serious etiology and posterior packing? Response Feedback: Question 83 “B” is the correct answer. If the patient reports a sense of swallowing blood, that indicates that blood is flowing into the nasopharynx. This is suggestive of a posterior bleed that will be inaccessible by anterior packing, and posterior packing is required to stop the bleeding. All patients with epistaxis should be asked if they are swallowing blood, “A” is not correct—this is not unusual in virtually all patients who present to a supervised care setting for management of nosebleed and is often stabilized with a packing. “C” and “D” are not correct—the appreciation of the presence or absence of clots does not provide any diagnostic cues to the location of the bleed. 1 out of 1 points R.M. is a 15-year-old male who presents to the emergency department with his mother. Mom says he has been complaining that his throat hurts so badly he cannot even swallow saliva. According to Mom R.M. is not the type to complain, but he is in so much pain with his throat he is almost crying. He has no significant medical history and takes no daily medications. He has no allergies of which his mother is aware. Upon physical examination he is febrile with a temperature of 102.4° F and he is a bit tachycardic, but other vital signs or normal. Inspection of the throat is basically unremarkable—the AGACNP does not appreciate any abscesses, edema, or exudate; there may be some slight erythema. The AGACNP becomes suspicious that the patient: Response Feedback: A” is the correct answer. The pain of epiglottitis is typically inconsistent with the physical examination because the epiglottis is not readily visualized on physical exam of the throat. This is a medical emergency and needs attention by a rapid responder who is trained to intubate patients with epiglottitis. Neither “B” nor “D” are not correct - given his mother’s report and his elevated temperature, it is not likely that he is lying or exaggerating his symptoms. “C” is not correct as this presentation is not consistent with any known recreational drug effect or toxicity. Question 84 1 out of 1 points Mr. Stossel is a 66-year-old male patient who was admitted for management of acute anterior wall myocardial infarction. Over a period of hours he has developed acute shortness of breath, coarse rales to auscultation, and Kerley B lines on chest radiography. Arterial blood gas reveals a pH of 7.34, pCO: of 30 mm Hg, and paO: of 59 mm Hg. The AGACNP anticipates which of the following findings on physical examination? Response cep: _ , ; ; Feedback: ‘B” is the correct answer. The clinical scenario described is acute pulmonary edema as consequence of acute myocardial infarction. At this point the physical findings will be consistent with acute cardiopulmonary congestion, such as an S; heart sounds which implies acute left ventricular overload. “A,” “C,” and “D” are all findings that develop later, when the right side of the heart and venous circulation become affected. At this point, the acute congestion is typically confined to the left ventricular and pulmonary venous tree. Question 85 1 out of 1 points According to the revised criteria in DSM-V, the primary difference between panic attacks and panic disorder is that: Response “A” is the correct answer. Panic disorder is characterized by Feedback: unexpected attacks that occur suddenly without any external provocation or cues; panic attacks (without panic disorder) may be expected and occur in response to an identified situation, e.g., airplane travel. Significant revisions were made to the diagnostic criteria for panic attacks, panic disorder, and agoraphobia in DSM- V, the first major revision to the DSM in 20 years. As a result, “B” is incorrect because both attacks and disorder include physical symptoms such as palpitations. “C” is incorrect as the diagnostic criteria for panic disorder is that it must have occurred for at least one month. “D” is incorrect because panic is now a diagnosis completely separate from agoraphobia. Question 86 1 out of 1 points Mr. Wilson is a 71-year-old male who has been treated with prn short acting anticholinergics for his COPD. Last week he developed an exacerbation that required a 4 day hospitalization for support and stabilization. He was discharged on a five day course of prednisone and now presents for follow-up. The AGACNP knows that his outpatient medication regimen should be adjusted to include: Response “B” is the correct answer. In accordance with GOLD guidelines, Feedback: patients who have had an exacerbation of COPD should be started on a long acting bronchodilator, either anticholinergic or beta agonist, if they are not already on one. “A” is not correct—a daily inhaled corticosteroid is used only for patients with a documented FEV; < 50%. “C” is not correct—this is an alternative to a long acting bronchodilator but the single long acting form is preferred. “D” is not correct—daily oral corticosteroids are not routinely recommended for any stage of COPD. Question 87 1 out of 1 points J.T. is a 26-year-old female patient being evaluated for eye discharge. She says that for the last few days she has developed this sticky, string-like discharge in both eyes. She denies any pain or visual changes, but does admit to a sense of "something in my eyes" and that her eyes itch a lot. Physical examination reveals injected conjunctiva, rope-like discharge bilaterally; pupil response is equal and brisk in both eyes. Which factor in the patient’s history would be supportive of the most likely diagnosis? Response “A” is the correct answer. The fact that both eyes present with the Feedback: same symptoms, itch, and have rope-like discharge all support a diagnosis of allergic conjunctivitis—a history of allergies supports this. “B” is incorrect because chemical injury is more likely to produce pain and visual abnormality. “C” is incorrect—dry eye syndrome can be uncomfortable, but in extreme states would present as iatrogenic corneal abrasion which is acutely painful and does not itch. “D” is incorrect as high trajectory foreign bodies, such as metal or wood shavings from a machine shop, would more likely present as comeal abrasion or foreign body. Question 88 1 out of 1 points What is the primary difference in patient management between high risk non-ST elevation myocardial infarction (MI) and the low risk non-ST elevation MI patient? Response “A” is the correct answer. Glycoprotein IIb/IIIa inhibitors such as Feedback: abciximab, eptifibatide, and tirofiban are medications that inhibit the activated platelet from aggregation and adhesion. Their greatest benefit has been demonstrated in patients in high risk non-ST elevation patients and/or who are undergoing PCI. These drugs are the primary difference in the management of low risk vs high risk patient; the risk of bleeding is not outweighed by benefit in the low Question 95 patient with acute coronary syndrome. Morphine may not always be used—the general guideline is to administer to any patient who does not get pain relief with three doses of nitroglycerin—but it should be considered and administered if appropriate. 1 out of 1 points Mr. Sloane is a 36-year-old male patient who presents for treatment of eye pain. He has no significant medical history and does not take any daily or over-the-counter medications. His only recent history is nighttime allergies for which he takes occasional diphenhydramine with good relief. He has had some throbbing in his eye for the last few days on and off but just ignored it; today he says it is flat out painful and he had to come to the emergency department. The eye is throbbing and painful, and he reports generalized decreased vision. The pupil is dilated to 5 mm and non-reactive to light. The eye conjunctiva is reddened. The next step in the diagnostic evaluation should be: Response Feedback: Question 96 “A” is the correct answer. This is a classic presentation of acute angle closure glaucoma, the patient likely had an underlying anatomic abnormality that was exacerbated by the anticholinergic properties of diphenhydramine. Assessment of intraocular pressure via tonometry must be performed and if elevated will confirm diagnosis. Once elevated pressure is confirmed, the condition will be treated. “B” and “C” are not correct—the first diagnostic evaluation must be tonometric pressure; if pressure is normal, acute angle closure glaucoma is ruled out and then imaging may be indicted depending upon the differential diagnoses. “D” is not correct; if glaucoma is confirmed than ophthalmology will be consulted. 1 out of 1 points The AGACNP counsels a patient with recurrent epistaxis that the most common cause of nose bleeding is: Response Feedback: “A” is the correct answer. Statistically most nose bleeding is cause by the irritation of nose picking, and patients of all ages should be evaluated for this when presenting with a complaint of recurrent nose bleed. “B,” “C,” and “D” are also causes and are all part of the differential diagnosis and will guide the history of present illness, but “A” is most common and the first thing to be considered; similarly, while patients may not realize or acknowledge that this is a factor, if no cause is identified, counseling about the avoidance of nose picking may ultimately result in improvement of symptoms. Question 97 0 out of 1 points The geriatric depression scale (GDS) is a commonly used tool to diagnose depression in the elderly population. It comes in a variety of forms for maximal utility. When administering the geriatric depression scale to patients, the AGACNP recognizes that it is extremely important to: Response “B” is the correct answer. All forms of the GDS require one word Feedback: “yes/no” answers; the tool cannot be scored with more ambiguous or scaled scoring. “A” is incorrect—the tool helps establish a diagnosis of depression, and then the etiology will be pursued. “C” is not correct, in fact the one word answer format, different from most tools that use “1 to 5” scaled scoring, allows the tool to be used in those with more significant cognitive impairment. “D” is not correct as the tool can evaluate change after initiation or change in drug therapy. Question 98 1 out of 1 points Ventilator-acquired pneumonia (VAP) is a significant problem impacting morbidity, mortality and the cost of inpatient health care. Data-supported mechanisms to reduce the risk for VAP include all of the following except: Response “B” is the correct answer. Strategies both pre and post intubation to Feedback: reduce the likelihood of VAP have been extensively studied, and there are numerous data-supported strategies including those presented in choices “A,” “C,” and “D” above. Conversely, while “B” has been proposed as a possible strategy, data are conflicted. Endotracheal tube cuff biofilm formation and bacterial colonization are proposed mechanisms by which ventilator acquired pneumonia occurs, and there are several strategies in use to target this, such as antibiotic impregnated, chlorhexidine coated and silver coated endotracheal tubes. Cost and effectiveness data continue to emerge. Question 99 0 out of 1 points Absolute contraindications to thrombolytic therapy in the patient having an acute myocardial infarction include all of the following except: Response “PD” is the correct answer. A history of hemorrhagic ophthalmic Feedback: condition is a relative contraindication; a risk benefit analysis must be considered and thrombolytics may be used. Conversely, “A,” “B,” and “C” above are all absolute contraindications to Question 100 thrombolytic therapy. 1 out of 1 points Which of the following is not a true statement with respect to risk for or occurrence of elder abuse? Response Feedback: “D” is the correct answer. There are a variety of theories regarding the etiology of caregiver abuse, and a common theme is that the greater the stressors and/or burden on the caregiver, the greater the likelihood of some form of caregiver abuse, whether psychological, physical, or neglect. Otherwise "healthy" people can become abusive if the demands placed upon them are great enough; this is one of the reasons that respite care is so important. “A,” “B,” and “C” are true statements. Caregiver stress is a risk factor, the cycle of learned violence suggests that those subjected to violence are at greater risk of becoming violent, and the greater the physical and/or mental impairment of the patient, the higher the risk for an abusive situation.