NR 507 Week 4 Midterm Exam plus Midterm Study Guide Plus Rationales/ already graded A

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NR 601 midterm study guide A client is newly diagnosed with type 2 diabetes mellitus. Which diagnostic test will best evaluate the management plan prescribed for this client? Quarterly hemoglobin ... A1C After first managing the pain being experienced by the client with gout, the treatment focuses on: Preventing systemic involvement by altering the client's diet The abrupt onset of symptoms of stress or urge incontinence is most often due to a urinary tract infection True A 60-year-old woman presents with a chief complaint of uncomfortable breathing on exertion. She has had a minimally productive cough for several years that does not bother her. On further questioning, she states that her breathing gets much worse when she lies down. The most likely cause of her dyspnea is: Cardiac Which of the following drugs do not trigger or aggravate a cough? Hydrochlorothiazide Based on current demographic data, which statement identifies a predictive trend regarding the health care needs of society? More nursing services will be required to serve the needs of the population 85 years of age and older. Which diagnostic laboratory test would the nurse practitioner typically not order for the purpose of evaluating an individual's acute, unexplained weight loss? Serum Potassium It has been projected that the cultural group presenting the greatest growth rate among the older adult population will be the: Hispanic Americans Which statement made by a client recently diagnosed with diverticular disease would indicate that she needs additional teaching regarding dietary considerations? "I'll have to give up eating right before I go to bed." Ethnocentrism is defined as: a belief that one's ethnic group is superior to that of another true When diagnosed with diverticulosis, a client asks how this problem occurred. Which assessment data identifies a risk factor for diverticulosis? Maintains a diet low in fiber. A 77-year-old client being treated for glaucoma asks the nurse practitioner what causes glaucoma. The nurse bases the response on the knowledge that the increase in intraocular pressure is a result of: a breakdown in the absorption process Weight loss is frequently caused by ingestion of one or more of the following drugs. Antibiotics Digoxin Nonsteroidal anti-inflammatory drugs (NSAIDs) Theophylline A, B, and C All of the above Answer: All of the above Which of the following culturally diverse male clients will most benefit from educational material related to "Staying Healthy into your 80s" Japanese The following are true statements about bipolar disorders in older adults except "Bipolar disorder is the most commonly diagnosed psychiatric disorder in older adults." Which assessment data would not be of particular concern when attempting to manage an older adult's risk for dehydration? Chronic constipation When educating the older adult population about the risks to physical health that chronic alcohol abuse presents, the nurse practitioner is especially careful to include the: Identification of the signs and symptoms of gastrointestinal bleeding Which of the following drugs does not typically cause constipation? Magnesium-containing antacid An older adult client has been voluntarily admitted for treatment of alcohol dependency. In implementing care, the nurse plans which intervention based upon knowledge about alcohol and aging? Assessing the client for both depression and anxiety The greatest risk for injury for a client with progressed Parkinson's disease is: Falls An older adult client shares with the nurse that, "I don't know what it is but it seems that I need more light for reading or even watching television as I get older." The nurse explains that aging may cause this change due to the: Slower ability of the pupil to adjust to changes in lighting. The nurse practitioner educates that client that Healthy People 2010: offers direction for the achievement of improved quality of life across the life span Which of the following is not a common cause of constipation? hypercalcemia The nurse is teaching a health promotion class at a senior center. Which of the following statements demonstrate that the participant does not understand the topic: "We need to use caustic soaps and scrub aggressively with a wash cloth bathing to minimize bacteria on the skin." The nurse practitioner shows an understanding of appropriate influenza vaccination guidelines for a client over the age of 65 when stating: "Regardless of your physical health you really should get a yearly flu shot." The nurse shows understanding of the need to promote healthy skin in the older adult when encouraging the client to all of the following except : clean the skin with a moisturizing soap . A 78-year-old man is being evaluated in the geriatric clinic. His daughter reports that he has been very forgetful lately, and she is concerned that he might be "senile." The advanced practice nurse administers the clock drawing test and the patient draws a distorted circular shape and places the numbers all on one side of the shape. Based on his performance, the nurse concludes that the patient: needs further evaluation Tinnitus is defined as: a buzzing, clicking, or ringing in the ear Which intervention is not therapeutic when facilitating communication with a cognitively impaired older client? Use non-verbal as well as verbal cues to help get your message across to the client When best promoting a sense of well-being, the role of the nurse practitioner caring for a terminally ill client is to: help empower the client to achieve his/her potential for wellness A 68-year-old male presents with a chief complaint of episodes of lightheadedness or dizziness. He states that sweating, tachycardia, and some hand trembling are often associated with these episodes. Which one of the following questions should you ask to help confirm the diagnosis? Are these symptoms related to eating? The caregiver for an older adult with cognitive impairment is concerned about the individual's seeming disinterest in eating. Which suggestion does the nurse practitioner offer based upon a known effect of dementia on a client's nutrition? Establish a routine of when and where the individual will have their meals. A 68-year-old male presents with a chief complaint of episodic dizziness. Although not dizzy at present, he states that he has noted onset of dizzy episodes when he rolls over in bed and occasionally when he turns his head rapidly. Episodes last about 3 minutes. The most likely diagnosis is: Benign positional vertigo What information will be included in client education for an older adult who needs to manage their calcium levels? Take your 1200-1500 mgs of daily calcium spread out between your meals and snacks The nurse practitioner is developing a class on stroke prevention for a local senior citizens center. What would be an important focus when teaching stroke prevention directed at modifiable risk factors? Smoking cessation The nurse practitioner provides a client with education regarding the use of My Pyramid. What is the primary advantage of the United States Department of Agriculture's (USDA) My Pyramid to the older adult client? It's an easy method for identifying and correcting nutritional deficiencies in one's diet. An older adult recently diagnosed with depression asks, "How long will it take for the antidepressant medication to make me feel better?" The nurse practitioner correctly responds: "It can take up to 3 months for the full effects of the medication to be felt." An older man has a history of medication therapy for hypertension. Which intervention does the nurse practitioner implement when the client reports that, "I've fallen twice in 5 weeks"? Orthostatic blood pressures The nurse practitioner is caring for a client with a newly diagnosed chronic illness. In answering the client's questions, the nurse practitioner most accurately responds when basing the response on the fact that: chronic illness is lifelong, and coping can be influenced by perceived uncertainty. true In the elderly population, the fastest growing group is the age range: 85 years or older Which statement correctly describes normal changes of aging? Individual variations are enormous at every age and in every part of the body. Compared with acute pain, persistent chronic pain requires the nurse practitioner to: Educate the patient to the benefit of specific lifestyle changes An older adult is admitted to the hospital during the night after a serious fall. When you round on the patient, you note that the patient has been prescribed meperidine (Demerol) for muscle pain. The nurse practitioner: Changes this medication order as Demerol is contraindicated in older adults Of the following clients, all of whom are 65 years of age or older, the nurse practitioner anticipates that the one who will rate himself or herself as has having excellent health will be: a white female who lives independently in a senior citizen community A 75-year old resident in the nursing home has end stage dementia and experiences a 10-pound weight loss over the course of 2 months. The resident has become increasingly difficult to feed and often spits out food, pockets food, and frequently drools. The family is concerned about the resident's nutritional status. What is the initial action of the nurse practitioner? order a swallow evaluation The FANCAPES assessment tool focuses on the older adult's: ability to meet personal needs to identify the amount of assistance needed Which of the following causes of chest pain are often relieved by sublingual nitroglycerin? Esophagitis When considering Erikson's developmental stages, the task for later life is referred to as: ego integrity An older adult is currently prescribed both aspirin (81 mg) and ibuprofen daily. What instructions are most important for the nurse practitioner to provide to assure the expected outcomes for this client? Take ibuprofen 30 minutes after the aspirin so as to not interfere with its effectiveness Which assessment data does not support the medical diagnosis of coronary heart disease? Client reported an unexplained gain of 10 pounds in last 6 months. What are the 3 primary physiological changes of aging? 1. Reduced physiological reserve of most body systems, esp. cardiac, resp, renal. 2. Reduced homeostatic mechanisms that fail to adjust regulatory systems (i.e. temp control, fluid/lyte balance, etc.). 3. Impaired immunological function (infection risk is greater, autoimmune dz's more prevalent) What is the preferred amount of exercise for elderly? 30min/day 5 days/wk of moderate exercise. If trying to lose wt: 60min/day. What are PFTs? Group of tests that provide quantifiable measurement of lung function, used to dx resp abnormalities or assess progression/resolution of lung dz. What is FEV1? Forced Expiratory Volume in 1 second (80-120%) What is FVC? Forced Vital Capacity (80-120%) What is normal FEV1/FVC ratio? <0.7 (70%) What is GOLD 1 criteria? Mild FEV1 >/= 80% predicted What is GOLD 2 criteria? Moderate FEV1 50-79% predicted What is GOLD 3 criteria? Severe FEV1 30-49% predicted What is GOLD 4 criteria? Very severe FEV1 <30% predicted What are the signal symptoms of COPD? Dyspnea Chronic cough w/sputum Decreased activity tolerance Wheezing What are characteristics of COPD? Common, preventable, treatable. Characterized by persistent airflow limitation. Usually progressive, associated with enhanced chronic inflammatory response in airways and lungs to noxious particles/gases Airway fibrosis, luminal plugs, airway inflammation, increased airway resistance, small airway dz. Decreased elastic recoil of alveoli. What are risk factors for COPD? Smoking (increasing w/number of pack years) Second hand smoke Environmental pollution (endotoxins, coal dust, mineral dust) What is seen on phys exam in COPD? May be normal in early states As severity progresses: lung hyperinflation, decreased breath sounds, wheezes at bases, distant heart tones (b/c of hyperinflation, so S1/S2 sounds off in distance), accessory muscle use, pursed lip breathing, increased expiratory phase, neck vein distention. How is COPD diagnosed? Spirometry is gold standard (pre and post bronchodilator). Irreversible airflow limitation is hallmark. How is COPD treated? Bronchodilators: beta agonists (long/short), anticholinergics (long/short), or combo. What is the MOA of beta agonists? Stimulates beta-2-adrenergic receptors, increasing cyclic AMP, resulting in relaxing airways. What is the MOA of anticholinergics? Block the effect of acetylcholine on muscarinic type 3 receptors, resulting in bronchodilation. Why are long-acting beta agonists prescribed for COPD? They are for moderate airflow limitation. They relieve symptoms, increase exercise tolerance, reduce number of exacerbations, improve QOL. What are some non pulmonary diagnoses that result in COPD-type symptoms? CHF What are some Hyperventilation syndrome Panic attacks Vocal cord dysfunction Obstructive sleep apnea Aspergillosis Chronic fatigue syndrome What are signal symptoms of asthma? Wheezing Shortness of breath Cough (esp at night) Chest tightness What is chronic bronchitis? Daily chronic cough w/increased sputum for at least 3 consecutive months in at least 2 consecutive years. Usually worse on wakening. May or may not be associated with COPD. What is emphysema? Characterized by obstruction to airflow caused by abnormal airspace enlargement distal to terminal bronchioles. Chronic inflammation/remodeling, trapping air, hindering effective O2/CO2 exchange (all due to inflammatory mediators infiltrating airways). What are signal symptoms of ischemic heart dz? Chest pain Chest tightness Chest discomfort What is ischemic heart dz? Imbalance between supply and demand for blood flow to myocardium What are signal symptoms of lung CA? Cough Dyspnea Wt loss Anorexia Hemoptysis What is lung CA? Malignant neoplasm originating in parenchyma of lung/airways What are signal symptoms of MI? Prolonged CP (>20min duration) SOB Confusion Weakness Worsening HF What is an MI? Necrosis of heart tissue caused by lack of blood and O2 supply to the heart What are signal symptoms of pneumonia? Fever Chills Hypothermia New cough w/or w/out sputum Chest discomfort or dyspnea Fatigue HA Some older adults will be asymptomatic but may experience falls/confusion What is community acquired pneumonia? Acute lower resp tract infection of lung parenchyma. Can be bacterial or viral. Bacterial is most common in older adults. What are signal symptoms of a PE? Dyspnea CP on inspiration Anxiety Presentation is variable Symptoms nonspecific Some asymptomatic What is PE description? Occlusion of one or more pulmonary vessels by traveling thrombus originating from distant site. What are signal symptoms of tuberculosis? Initially asymptomatic Later: productive, prolonged cough Fatigue Low-grade fever Night sweats Poor appetite Hemoptysis Wt loss Fever/sweats are less common in elderly Symptoms in elderly are often attributed to other comorbidities What is tuberculosis? Chronic, necrotizing infection caused by slow-growing acid-fast bacillus (Mycobacterium tuberculosis). Most common cause of death related to infectious dz worldwide. What are signal symptoms of valvular heart dz? Asymptomatic in early stages Fatigue Exertional dyspnea What is valvular heart dz? Damage to valve(s) of the heart, causing cardiac dysfunction. Most prevalent types in elderly: calcific and degenerative aortic valve dz What is aortic stenosis? Abnormal narrowing of aortic valve orifice What is aortic regurgitation? Retrograde blood flow through incompetent aortic valve into L ventricle during ventricular diastole What is mitral stenosis? Abnormal narrowing of mitral valve orifice What is mitral regurgitation? Retrograde blood flow during systole from L ventricle into L atrium through incompetent mitral valve What is mitral valve prolapse? Mitral regurgitation associated with bulging of one or both mitral valve leaflets into L atrium during ventricular systole What are most common causes of VHD in elderly? Age-related degenerative calcifications Myxomatous degeneration Papillary muscle dysfunction Infective endocarditis Rheumatic dz What happens in valvular regurgitation? Portion of the ejected blood leaks back into the upstream cardiac chamber What happens in valvular stenosis? Usually results in elevated pressures in the chamber upstream from the stenosis What are signal symptoms of URI? Nasal congestion Rhinorrhea/mucopurulent discharge Sore throat Cough HA Malaise What is a URI? Most frequently called the common cold Usually caused by virus Results in nasal passage inflammation Most are self-limiting, accompanied by minor complaints Included in URI dx: acute laryngitis, acute rhinosinusitis, acute pharyngitis What are signal symptoms of restrictive lung dz? Rapid, shallow respirations Dyspnea Decreased activity tolerance Easily fatigued Nonproductive, irritating cough provoked by deep breathing/exertion What is restrictive lung dz? Heterogenous group of disorders that share common abnormal ventilatory function. Characterized by small tidal volume, rapid rate. Hallmark restrictive pattern is decreased lung volm, esp. total lung capacity and vital capacity. What is the purpose of functional assessment of the elderly? Discovers the ability to care for themselves on a daily bases What can ongoing pain be linked to in the elderly? Depression Decreased socialization Sleep disturbance Impaired cognitive function Is chronic pain a normal sign of aging? No What is polypharmacy? Broad definition, but basically too many medications for what is going on with the patient, the use of multiple pharmacies/providers. What is Stage A of HF? At high risk for heart failure but w/out structural changes/symptoms What is Stage B HF? Structural heart dz but w/out s/s of HF (still "at risk" for HF) What is Stage C HF? Structural heart dz w/prior or current s/s of HF (actually have HF) What is Stage D HF? Refractory heart failure including specialized interventions (actually have HF, need surgery, PM, etc.) What are treatment goals for Stage A HF? Heart-healthy lifestyle Prevent vascular, coronary dz Prevent LV structural abnormalities What are drugs used in Stage A HF? ACEi or ARB in appropriate pt's for vascular dz or DM Statins as appropriate What are treatment goals for Stage B HF? Prevent HF symptoms Prevent further cardiac remodeling What are drugs used in Stage B HF? ACEi or ARB as appropriate Beta blockers as appropriate In selected pt's: ICD Revascularization/valvular surgery as appropriate What are goals of Stage C HFpEF? Control symptoms Improve HRQOL Prevent hospitalization Prevent mortality ID comorbidities What is treatment for Stage C HFpEF? Diuresis to relieve s/s congestion Follow guideline-driven indications for comorbidities (HTN, AF, CAD, DM, etc.) What are treatment goals for Stage C HFrEF? Control symptoms Pt education Prevent hospitalization Prevent mortality What are drugs used in Stage C HFrEF? Diuretics for fluid retention ACEi or ARB BB Aldosterone antagonists Drugs in selected pts: Hydralazine/isosorbide dinitrate ACEi and ARB Digitalis Procedures in selected pts: CRT ICD Revascularization/valvular surgery as appropriate What are treatment goals in Stage D HF? Control symptoms Improve HRQOL Reduce hospital readmissions Establish pt's end-of-life goals What are options for Stage D HF? Advanced care measures Heart transplant Chronic inotropes Temporary or permanent MCS Experimental surgery/drugs Palliative care, hospice ICD deactivation What is the normal BNP level? <100pg/mL (indicates HF is unlikely) What is normal BP? <120/80 What is "elevated" BP? 120-129/<80 What is Stage 1 HTN? 130-139 OR 80-89 What is Stage 2 HTN? >/= 140 or >/= 90 What is recommended BP for DM? <130/80 What is recommended BP for CKD? <130/80 How should HTN be managed? Stage 2 and up should be given consideration for pharm treatment. Others can wait for lifestyle modification. What is first-line meds for non-black HTN population (including those w/DM)? Thiazide, CCB, ACEi, or ARB, either alone or in combo What is the med guideline for ASCVD for those </= 75yo? High-intensity statin (atorvastatin/Lipitor 40-80mg, rosuvastatin/Crestor 20mg) What is the med guideline for ASCVD for those >75yo? Moderate statin (atorvastatin 10mg, rosuvastatin 5mg, simvastatin/Zocor 20-40mg, pravastatin/Pravachol 40mg, lovastatin/Mevacor 40mg, fluvastatin 40mg BID) What is the guideline for meds for LDL >/= 190? High intensity statin (atorvastatin/Lipitor 40-80mg, rosuvastatin/Crestor 20mg) What is the med guideline for ASCVD for 40-75yo w/DM? Their 10yr risk is >7.5%, so high intensity statin (atorvastatin/Lipitor 40-80mg, rosuvastatin/Crestor 20mg) What is the med guideline for LDL 70-189? Their 10yr risk is <7.5%, so moderate intensity statin (atorvastatin/Lipitor 10mg, rosuvastatin/Crestor 5mg, simvastatin/Zocor 20-40mg, pravastatin/Pravachol 40mg, lovastatin/Mevacor 40mg, fluvastatin 40mgBID) What is the ASCVD med guideline for 40-75yo w/out ASCVD or DM? Their 10yr risk is >7.5%, so moderate to high intensity statin What is the purpose for Beers criteria? The American Geriatrics Society developed Beers Criteria for use of providers as a guide for medical management of geriatric pts. Goal: to improve quality and safety. Not a sub for individualized care, but should be incorporated into prescribing practices for elderly. As an NP, be familiar w/the lists to avoid prescribing potentially inappropriate meds. Why do elderly need special prescribing criteria? Age-related changes also change metabolism. Pharmacodynamics change. Pharmacokinetic changes: absorption, distribution, metabolism, elimination. Half-lives altered, which affects steady state and dosing intervals. What are potential risk factors for ADRs in elderly? 6 or more chronic dz's. 9 or more Rx or OTC meds. >12 doses per day >85yo BMI <22 Creatinine clearance <50 H/o previous ADR What are some 2015 changes in med awareness for elderly? Nitrofurantoin can be used w/creatinine clearance of 30, but should be avoided long term due to possible irreversible pulmonary fibrosis, liver tox, peripheral neuropathy. Non-benzos, benzo receptor agonist hypnotics (eszopiclone, zaleplon, zolpidem) should be avoided for insomnia regardless of duration due to associated harm. PPI should be avoided >8wks w/out justification due to possible c-diff infection, bone loss, fractures. Opioids should be avoided in those with h/o falls/fractures. T/F The meds listed in Beers Criteria are not absolutely contraindicated in elderly. True T/F The BC recommendations are graded as high, medium, low to assist w/decision making. True T/F The BC list includes dosage adjustments for kidney impairment. True T/F The BC list includes drug to drug interactions to avoid. True T/F Responsible prescribing is an important role of NP and BC can assist in determining the safest meds for geri pts. True What vaccination is recommended for people traveling to countries where dz is common? Hep A How is Hep A vax given? Two doses: initial at least 4wks before departure, second dose 6-12mo later. When is Hep B vax recommended? High-risk people (IV drug users, persons w/multiple partners) How is Hep B vax given? Initial dose 1mo later: 2nd dose 4-6mo after 2nd: 3rd dose When is Zostavax recommended? Anyone over 60yo, given as single dose Can people who have had prior episode of zoster be vaccinated? Yes When is flu vax recommended? Annually for all adults >50yo When should DTaP be given? Once in a lifetime for all adults, then Td booster every 10yrs. When is pneumococcal vax recommended? Once for 65yo and older Younger adults w/severe chronic health conditions What is primary prevention? Activities to prevent occurrence of dz or adverse health condition, including mental health. Health counseling and immunizations are examples. What is secondary prevention? Activities aimed at detection of dz or adverse health condition in asymptomatic pt who has risk factors but no detectable dz. Screening tests are examples, like mammography. What is tertiary prevention? Management of existing conditions to prevent disability and minimize complications, striving for optimal function and QOL. Pulmonary rehab for COPD is an example. What are common s/s of anxiety in elderly? Constipation Nausea HA Worrying about health, disability, finances What are phobic disorders? Anxiety from a specific feared object or situation. Person feels anxiety is excessive or unreasonable. Often leads to distress or avoiding the fear. Often lifelong, common in older adults. What is generalized anxiety disorder (GAD)? Often 20-30yrs of excessive worry about health, family, finances w/insomnia, muscle tension, restlessness, fatigue, irritability, memory problems. What is PTSD? Re-experiencing a traumatic event w/increased anxiety, avoiding thoughts of the trauma, feeling numb/uninterested, perceiving future as short. What is panic disorder? Involves recurrent, often unexpected attacks of severe anxiety w/one month of worry about future attacks and consequences. May include changes in behavior. Rare in older adults, less severe/frequent than in younger adults. Usually keeps them from leaving home. What is agoraphobia? Avoiding places where escape is difficult or embarrassing. Rare in older adults, usually does not occur w/panic attacks. What is OCD? Obsessions that cause anxiety or distress and/or compulsions that reduce anxiety. Rare in older adults. Usually lifelong. What is treatment for anxiety? Should reduce symptoms and improve function. First-line: SSRI (citalopram/Celexa, escitalopram/Lexapro, sertraline/Zoloft). For elderly, these have lowest risk of drug interactions, SE, or worsening existing conditions. Effective but not recommended due to falls/confusion: benzos (lorazepam/Ativan, alprazolam/Xanax, clonazepam/Klonopin) What are signal symptoms of depression? Feeling sad Discouraged Lack of pleasure in usual activities Unmotivated Low energy Sleep/appetite disturbances The symptoms of depression may encompass what 4 domains? Affect/mood Cognition Physiological Behavior What is treatment goal for depression? Full remission and recovery What are first-line meds for depression? SSRIs: fluoxetine (Prozac) sertraline (Zoloft) paroxetine (Paxil) citalopram (Celexa) escitalopram (Lexapro) flovoxamine (Luvox) What is transient insomnia? Lasts a few nights. Related to emotional stress. Usually resolves w/out meds when elderly adapts to or removes change. What is short-term insomnia? Similar to transient insomnia. Lasts <1mo Related to acute medical/psychological condition or to persistent situational stress. What is chronic insomnia? Lasts >1mo Results from age-related changes in sleep/chronic stressors. What is treatment for insomnia? Avoid caffeine for 12hrs before bedtime. D/C ETOH/unnecessary sleep-interrupting drugs. OTC melatonin or Rx ramelteon can be tried; if ineffective, initiate short-acting sedative- hypnotic like zolpidem (Ambien) or zaleplon (Sonata) at lowest dose before desired bedtime for 1wk or less. Suggest spacing dose to every other day to avoid SE. If benzos used, temazepam (Restoril) is relatively short-acting; if ineffective, re-eval dx and restructure treatment modalities. What are signal symptoms of polymyalgia rheumatica? New onset stiffness/aching in neck, shoulders, pelvic girdle. Unable to get out of bed in the morning w/out extreme difficulty. Difficulty lifting arms over head. What are common lab findings in polymyalgia rheumatica? Elevated ESR and CRP Normochromic, normocytic anemia Thrombocytosis What is treatment for PMR? If s/s are only of PMR and not of GCA as well, start low dose prednisone 10-20mg/day and taper dose. What are signal symptoms of rheumatoid arthritis? Morning stiffness Joint deformities Rheumatoid nodules Symmetrical inflammatory polyarthritis What are diagnostic tests for RA? Rheumatoid factor (RF) ESR CRP Erosive dz and raised RF indicate seropositive RA What is treatment for RA? Drug management is for symptom/dz control. For symptoms: Corticosteroids Analgesia NSAIDs For dz control: Corticosteroids, which can be used in combo w/traditional dz-modifying therapies What are signal symptoms of osteoarthritis? Morning stiffness <30min, improves with activity Bouchard's nodes (PIP joints) Heberden's nodes (DIP joints) Crepitus What are diagnostic tests for OA? Often dx is made w/out XR Bilat XR reveal joint space narrowing, subchondral cysts, subchondral bony sclerosis, osteophytosis resulting in proliferative bone spurs. What is treatment for OA? Multifaceted approach is maintstay. Walking. Water therapy in pts w/no evidence of inflammation. In non-inflammatory: APAP is med of choice (2.6-4g/day) What is the major difference between varicose veins and atherosclerosis? a. The limbs that are affected b. The gender that's affected c. Vessels that are affected d. The degree of pain C Vessels that are affected Pt has had poorly controlled HTN >10yrs. Indicate the most likely position of his PMI. a. 5th ICS MCL b. 8th ICS MCL c. 5th ICS left of MCL d. 6th ICS R of MCL C 43yo hispanic male has audible diastolic murmur best heard at the mitral point. No audible click. He has been monitored for 2yrs. What is the most likely murmur? a. Mitral valve prolapse b. Acute mitral regurgitation c. Chronic mitral regurgitation d. Mitral stenosis D What is osteoporosis? Skeletal disorder characterized by impaired bone strength that predisposes to increased risk of fracture. Can occur from not only bone loss but also from failure earlier in life to make sufficient bone. Primary: due to aging (increased bone resorption/reduced new bone formation) Secondary: consequence of underlying medical condition/drug What are s/s of osteoporosis? Sometimes not seen until fracture sustained spontaneously or after minimal trauma, usually in thoracic/lumbar vertebrae, hip, wrist, humerus, pelvis. With each fracture, risk of another increases exponentially. Loss of height, kyphosis development. XR: bones appear osteopenic (at least 30% loss in bone mass); spine shows loss of horizontal vertebral trabeculae, accentuating end plates, producing biconcave "codfish" vertebrae; maybe compression fracture. What are diagnostic tests for osteoporosis? XR DEXA (screen all women >65yo, hip/spine; test earlier if major risk factors present; repeat every 3-5yrs depending on degree) What is T-score of -2.5 or lower indicative of? Osteoporosis What is a T-score of -1.0 to -2.5 indicative of? Osteopenia What is a T-score of -1.0 or higher indicative of? Normal bone density What is a Z-score of <-1.5 indicative of? Secondary cause of osteoporosis What are the risk factors for osteoporosis? Previous fracture Advanced age Low body wt/BMI Maternal h/o fracture Current smoking Physical inactivity Excessive exercise resulting in amenorrhea Poor lifetime intake of calcium Endocrine disorders GI dz Chronic systemic illnesses Nutritional deficiencies Meds (steroids, anticonvulsants, thyroid hormone, SSRI, aromatase inhibitors for breast CA) Alcoholism What is the treatment for osteoporosis? Aim to prevent those that are at risk Combine diet, exercise, meds Dietary Ca/vit D Wt-bearing/strength exercises Bisphosphonates Selective estrogen receptor modulators Calcitonin PTH Denosumab Fall prevention How does chronic pain differ from acute pain? Chronic pain tends to be more multifactorial, less amenable to cure, more influenced by psychological/social factors. Typically requires continuous long-term/multidisciplenary management. Can be triggered with seemingly minor biologic stimulus or persist long after injury is healed. What is the principle goal of chronic pain treatment? Improvement in QOL/function, rather than complete elimination of pain. What is nociceptive pain? Pain from nociceptive fibers in periphery triggered by actual or potential tissue damage. Typically attributed to specific anatomic location of tissue injury. Pain is well-localized, stabbing, throbbing, achy. What is neuropathic pain? Direct neuronal injury. Burning, tingling, lancinating. Often occurs in dermatomal pattern What are treatments for nociceptive pain? Nonopioid (APAP, ibuprofen) Weak opioids (Tramadol, tapentadol) Antidepressants (TCAs, SNRIs) Opioids What are treatments for neuropathic pain? Characteristically more resistant to opioids and to pharm interventions in general than nociceptive pain. Antidepressants (TCAs, SNRIs) Anticonvulsants (gabapentin, pregabalin, carbamazepine, oxcarbazepine) Opioids Topical agents 1. The percentage of the FVC expired in one second is: a. FEV1/FVC ratio 2. The aging process causes what normal physiological changes in the heart? a. The heart valve thickens and becomes rigid, secondary to fibrosis and sclerosis. 3. A 55yo Caucasian male follows up after referral to cardiologist. He thinks his med is causing a cough and sometimes he has difficulty breathing. Which med was most likely prescribed? a. Lisinopril 4. JM is a 68yo man who presents for a physical. He has T2DM x5yrs, smokes 1/2 PPD, BMI is 30. No other previous medical dx, no current complaints. According to the AHA/ACC guidelines, JM is stage A HF. Treatment goals for him include: a. Heart healthy lifestyle 5. MJ presents with h/o structural damage with current s/s of HF. Treatment will be based on his stage of HF, which is: a. Stage C 6. 65yo Caucasian female presents with mitral valve stenosis, physical exam unremarkable. You know her stage of HF is: a. B 7. DG, 65yo man, presents for eval of CP and L-sided shoulder pain, beginning after strenuous activity, including walking. Pain is dull, aching, 8/10 during activity, otherwise 0/10. Began few mo ago, intermittent, aggravated by exercise, relieved by rest. Occasional nausea. Pain is retrosternal, radiating to L shoulder, affects QOL by limiting activity. Pain is worse today, did not go away after stopped walking. BP 120/80, HR 72 and regular. Normal heart sounds, no murmur, S1, S2. Which differential dx would be most likely? a. Coronary artery dz w/angina pectoris 8. The best way to dx structural heart dz/dysfunction non-invasively is: a. Echocardiogram 9. Chronic pain can have major impact on pt's ability to function and have profound impact on overall QOL. Ongoing pain may be linked to: a. Depression, sleep disturbance, decreased socialization 10. The Beers criteria are appropriate for use in evaluating use of certain meds in pts: a. >65yo 11. Pt presents with c/o increasing SOB, cough w/occasional white sputum, fatigue. As part of the plan you order labs. You know the likelihood of HF is low if the BNP is: a. <100 12. All of the following statements are true about lab values in older adults except: a. Normal ranges may not be applicable to older adults b. Abnormal findings are often due to physiological aging c. Reference ranges are preferable d. References values are not necessarily acceptable values a. B 13. According to the 2017 ACC HTN guidelines, the recommended BP goal for a 65yo African American woman w/a h/o HTN and DM and no h/o CKD is: a. <140/80 14. The pathophysiology of HF is due to: a. Inadequate cardiac output to meet the metabolic and O2 demands of the body 15. A 60yo woman w/30 pack yr hx, presents for eval of persistent, daily cough w/increased sputum, worse in the AM, occurring over past 3 months. She tells you, "I have the same thing year after year." Which of the following choices would you consider strongly in your critical thinking process? a. Chronic bronchitis 16. JM is a 68yo man who presents for a physical. He has T2DM x5yrs, diet controlled. His BMI is 32. He has HTN, smoker (10 cigs/day x20yrs). He denies other medical problems. Fam hx includes CAD, CABG x4 for dad, now deceased; CHF, T2DM, HTN for mom. He is asymptomatic today, exam is normal, EKG NSR. According to AHA/ACC guidelines, JM is at risk for what stage of HF? a. Stage A 17. The volume of air a pt is able to exhale for total duration of the test during maximal effort is: a. FVC 18. According to the 2017 ACC HTN guidelines, normal BP is: a. <120/80 19. Functional abilities are best assessed by: a. Observed assessment of function 20. LB is a 77yo pt w/chronic poorly controlled HTN. You know that goals include prevention of target organ damage. During your eval you will assess for evidence of: a. L ventricular hypertrophy 21. Aortic regurgitation requires medical treatment for early signs of HF with: a. ACEi 22. The volume of air in the lungs at max inflation is: a. TLC (total lung capacity) 23. Preferred amount of exercise for older adults is: a. 30min/day of aerobic activity 5 days/wk 24. The total volume of air a pt is able to exhale in the first second during max effort is: a. FEV1 25. You know the following statements regarding the pain of acute coronary syndrome are true except: a. Present atypically more often in men than women b. May be retrosternal or poorly localized c. May last longer than 20min d. May radiate to arms, back, neck, jaw a. A 26. Elderly pt presents w/new onset of feeling heart race, fatigue. EKG reveals afib w/rate >100. Pt also has a new tremor in both hands. Which of the following would you suspect? a. Hyperthyroidism 27. 62yo female c/o fatigue, lack of energy. Constipation increased, pt gained 10lbs in past 3mo. Depression is denied although pt reports lack of interest in usual hobbies. VS are WNL, skin is dry/cool. Which of the following must be included in the DD? a. Hypothyroidism 28. Mrs. Black, 87yo, has been taking 100mcg Synthroid x10yrs. She comes for routine follow-up, feeling well. HR is 90. Your first response is to: a. Order TSH 29. Which pt is most likely to have osteoporosis? 30. 80yo underweight male who smokes and has been on steroids for psoriasis 31. When evaluating the expected outcome for hypothyroid elderly pt on levothyroxine, you will: a. Assess TSH in 4-6wks 32. Postmenopausal woman w/osteoporosis is taking bisphosphonate daily PO. What action info statement would indicate she understood your instructions regarding this med? a. Take med w/full glass of water when up in the AM 30min before other food and meds 33. Primary reason levothyroxine sodium is initiated at low dose in elderly pt w/hypothyroidism is to prevent which of the following untoward effects? a. Angina and arrhythmia 34. 6mo ago an elderly pt was dx'd w/subclinical hypothyroidism. Today the pt returns and has TSH of 11 and c/o fatigue. He has taken Synthroid 25mcg daily as prescribed. What is the best course of action? a. Double the dose 35.A A fluoroquinolone (Cipro) is prescribed for a male pt w/a UTI. What should you teach him regarding this med? a. Its effectiveness is decreased by antacids, iron, or caffeine 36. Pt has been rx'd metformin (Glucophage). One wk later, he returns w/lowered BGL but c/o loose stools during the week. How should you respond? a. Reassure him that this is an anticipated SE 37. Which of the following s/s of hyperthyroidism commonly manifest in younger populations, but is notably lacking in elderly? a. Exopthalmos 38. 60yo obese male has T2DM and lipid panel of TC = 250, HDL = 32, LDL = 165. You teach him about his modifiable cardiac risk factors, which include: a. DM, obesity, hyperlipidemia 39. Diabetic pt presents w/R foot pain but denies any recent known injury. He states it has gotten progressively worse over past few months. On exam, vibratory sense, as well as sensation tested w/monofilament, was abnormal. Pt's foot is warm, edematous, misshapen. You suspect Charcot foot. What intervention is indicated? a. Referral to orthopedist 40. What is a s/s of insulin resistance that can present in African Americans? a. Acanthosis Nigricans 41. During routine exam of 62yo female, you ID xanthelasma around both eyes. What is the significance of this? a. Abnormal lipid metabolism requiring medical management 42. Mr. White is 62yo, had CKD that has been relatively stable. He also has h/o hyperlipidemia, OA, HTN. He is compliant w/meds, BP has been well controlled on CCB. Last lipids showed: TC = 201, HDL = 40, TG = 180, LDL = 98. He currently takes Crestor 20mg daily. Today his BP is 188/90 and urine dip shows significant proteinuria. He denies changes in dietary habits or med regimen. What would be the best med change at this point? a. Change CCB to ACEi 43. You are working as NP in Fast Track of ER. 76yo male presents w/LUQ pain. There can be many conditions that present as LUQ pain, but which of the following is least likely to cause pain here? a. Acute pancreatitis 44. Which is cardinal feature of failure to thrive? a. Poor nutritional status 45. Feeding gastrostomy tubes at end-of-life Alzheimer's pt's have been associated with: a. Aspiration pna 46. Which of the following nutritional indicators is not an indication of poor nutritional status in elderly? a. BMI 25 47. OA of cervical and lumbar spine causes pain related to all of the following except: a. Crystal deposition 48. In differentiating OA from chronic gout, pseudogout, or septic arthritis, the most valuable diagnostic study would be: a. Synovial fluid analysis 49. Pt's w/OA of hip and knee often have distinguishable gait described as: a. Antalgic 50. Which of the following best describes pain associated w/OA? a. Begins upon arising and after prolonged wt bearing and/or use of the joint 51. Joint effusions typically occur later in the course of OA, especially in the: 52. Knee 53. You ordered CBC for your pt you suspect has polymyalgia rheumatica (PMR). Which 2 clinical findings are common in pt's w/PMR? a. Normochromic, normocytic anemia and thrombocytosis 54. You suspect your pt has PMR and now are concerned that they may have Giant Cell Arteritis (GCA) too. Which of the following 2 symptoms are most indicative of GCA and PMR? a. Scalp tenderness and aching in shoulder and pelvic girdle 55. 63yo Caucasian pt w/PMR will begin Tx w/corticosteroids until the condition has resolved. You look over her records and it has been 2yrs since her last physical exam and any labs or diagnostic tests as she relocated and had not yet ID'd a provider. In prioritizing your management plan, your first orders should include: a. Duel-energy x-ray (DEXA) scan and updating immunizations 56. Which of the following DD for pt's presenting w/PMR can be ruled out w/a muscle biopsy? a. Polymyositis 57. In reviewing lab results for pt's w/suspected PMR, you realize there is no definitive test to dx PMR, rather clinical response to Tx. Results you would expect to see include: a. Elevated erythrocyte sed rate (ESR) >50 58. Which of the following is the most appropriate lab test for monitoring gout therapy over the long-term? a. Serum urate level 59. In providing health teaching related to dietary restrictions, you should advise a pt w/gout to avoid which of the following dietary items: a. Beer, sausage, fried seafood 60. The best method of verifying gout dx in a joint is which of the following: 61. Joint aspiration and polarized-light microscopy 62. The most appropriate first-line Tx for acute gout flare is (assuming no kidney dz or elevated bleeding risk): a. Indomethacin 50mg TID x2 days, then 25mg TID x3 days 63. You order bilat wrist XR on 69yo man c/o pain both wrists x6 wks no related to any known trauma. You suspect early onset RA. The initial XR finding in a pt w/elderly onset RA would be: a. Soft tissue swelling 64. You examine the hands of a 55yo woman w/RA and note bilat spindle shaped deformities on middle interphalangeal joints. These are known as: a. Haygarth's nodes 65.A A 72yo female has been dx'd w/gout. She also has h/o chronic HF. The most likely contributing factor to development of gout in this older female is: a. Thiazide diuretics 66. Which of the following statements about OA is true? 67. It affects primarily wt-bearing joints 68. In considering the specificity of lab data, the most reliable diagnostic test listed below would be: a. Synovial fluid analysis to differentiate between infectious versus inflammatory infusion 69. When examining the spine of an older adult you notice a curvature w/a sharp angle. This is referred to as a: a. Gibbus 70. The prevalence of depression in nursing home residents is greater than adults living in the community. a. 3-4 times 71. The majority of depressed older adults remain untreated because of: a. Misdiagnosis, social stigma, environmental barriers 72. Symptoms of depression distinct to the elderly include: a. Lack of emotions 73. The justification for ordering CBC, TSH, serum B12 for a pt you may suspect have clinical depression is: a. Because of overlapping symptoms w/anemia, thyroid dysfunction, and nutritional deficiencies 74. One major difference that is useful in the DD of dementia versus delirium is that: a. Dementia develops slowly and delirium develops quickly 75. Which of the following is the most appropriate screening tool for delirium? a. Confusion Assessment Method 76. The proposed mechanism by which diphenhydramine causes delirium is: a. Anticholinergic effects 77. The elderly are at high risk for delirium because of: a. Multisensory declines, polypharmacy, multiple medical problems 78.A A consistent finding in delirium, regardless of cause, is: a. Reduction in regional cerebral perfusion 79. Older adults w/dementia sometimes suffer from agnosia, which is defined as the inability to: a. Recognize objects 80. In late stages of dementia, a phenomenon called sun downing occurs, in which cognitive disturbances tend to: a. Become worse in the evening 81. Of the following, which one is the most useful clinical eval tool to assist in the dx of dementia? a. St. Louis University Mental Status Exam (SLUMS) 82. The cornerstone of pharmacotherapy in treating Alzheimer's is: a. Cholinesterase inhibitors 83. The comorbid psych problem w/the highest frequency in dementia is: a. Anxiety 84. When treating depression associated w/dementia, which of the following would be a poor choice and should not be prescribed? a. Amitriptyline 85. The leading COD in elderly travelers worldwide is: a. Accidents 86. Which of the following should be avoided in countries where food and water precautions are to be observed? a. Salad buffet 87. What insect precautions are not necessary to prevent insect-borne dz's in the tropics? a. Using 100% DEET on skin to prevent bites 88. An example of secondary prevention you could recommend/order for older adults would be to: a. Check for fecal occult blood 89. Ali is a 72yo man who recently came to US from Nigeria. He reports having BCG (bacille Calmette-Guerin) vax as a child. Which of the following is correct regarding a TB skin test? a. Vax hx is irrelevant; read as usual 90. Ivan is 65yo man who is new to your practice. He has h/o COPD, CAD, HTN, T2DM. He has had no immunizations since his d/c from military at 25yo. Childhood dz's include chickenpox, measles, mumps, and German measles. He presents for a dz management visit. Which of the following immunizations would you recommend for Ivan? a. Tdap, pneumococcal, influenza, Zostavax 91. Leo is a 62yo African American male who comes in for an initial visit. Personal health hx includes smoking 1 PPD since 11yo, consuming a case of beer (24 bottles) every weekend, and working as an assembler (sedentary job) for the past 10yrs. Fam Hx in first-degree relatives includes HTN, high cholesterol, MI, T2DM. Leo's BMI is 32. BP is 130/86. You order fasting glucose, lipid profile, and return visit for BP check. This is an example of: a. Secondary prevention 92.A A local chapter of NP organization has begun planning a community-based screening for HTN at a local congregate living facility. This population was selected on the basis of: a. A recognized element of high risk within this group. 93. Performing ROM exercises on a pt who has had a CVA is an example of which level of prevention? a. Tertiary 94. You demonstrate an understanding of primary prevention of falling among the elderly through which management plan? a. Provide info about meds, SE, interactions 95. An example of an active strategy of health promotion for an individual to accomplish would be: a. Beginning stress management program 96. You are working w/an older adult male w/a long h/o ETOH abuse and a 30yr h/o smoking. In recommending an intervention, your responsibility is to: a. Promote positive change in lifestyle choices 97. The 4 main domains of clinical preventive services that you will provide are: a. Counseling interventions, screening tests, immunizations, chemoprophylaxis 98. Which organism that can be prevented by immunization is most often responsible for an infectious "outbreak" in the nursing home setting? a. Influenza A 99. What is the appropriate method for TB screening of an older adult entering a nursing home? a. 5 TBU intradermal PPD injection and if negative, repeat w/same dose one week later 100. Meds known to contribute to constipation include all of the following except: a. Broad-spectrum abx 101. All of the following are considered contributors to dysphagia except: a. Smooth muscle relaxants 102. The term "geriatric syndrome" is best described as: a. Condition that has multiple underlying factors and involves multiple systems 103. The anal wink reflex is used to test: a. Sensation and pudental nerve function 104. Atypical presentation of acute coronary syndrome is: a. More common in females 105. What dz can mimic and often co-exists w/MI in elderly w/CAD? a. Esophageal dz 106. Thoracic aortic dissection presents typically as: a. Severe retrosternal CP that radiates to the back and both arms 107. Bordetella pertussis is best characterized by: a. Sub-acute cough lasting >2wks 108. Routine testing of TB should occur in all of the following vulnerable populations except: a. Hospitalized elderly 109. Which of the following statements about fluid balance in elderly is false? a. Assessment of skin turgor at the sternum is a reliable indicator of dehydration in elderly. 110. Distinguishing delirium from dementia can be problematic since they may co-exist. The primary consideration in the DD is: a. Rapid change and fluctuating course of cognitive function 111. Presbystasis is best described as: a. Age-related disequilibrium of unknown pathology characterized by gradual onset of difficulty walking 112. If dizziness has a predictable pattern associated w/it, you should first consider: a. Hypoglycemia 113. Evidence shows that the most important predictor of a fall is: a. Prior h/o a fall 114. The most cost-effective interventions used to prevent falls are: 115. Home modifications and vit D supplements 116. Chronic fatigue syndrome is best described as: 117. Fatigue lasting longer than 6mo and not relieved by rest 118. Which form of HA is bilat? 119. Tension 120. Microscopic hematuria is defined as: 121. 3 or more RBCs on 3 or mor samples of urine 122. Risk factors associated with the finding of a malignancy in a pt w/hemoptysis include all of the following except: a. Childhood asthma 123. Recent wt loss is defined as: a. Loss of >10lbs over the past 3-6mo 124. The most common cause of disability in elderly is due to: a. Arthritis 125. Lipedema is best described as: a. Bilat distribution of fat in lower extremities 126. Drug-induced pruritis is distinguished because it: a. May occur right after drug is taken or months later 127. A form of syncope that is more common in elderly than in younger adults is: a. Orthostatic hypotension 128. All of the following statements about tremor are true except: a. The most common tremor is the Parkinson tremor 129. Overflow incontinence is usually associated with: a. Bladder outlet obstruction 130. Wandering is best described as: a. Purposeful excessive ambulatory behavior 131. A key symptom of ischemic heart dz is CP. However, angina equivalents may include exertional dyspnea. Angina equivalents are important because: a. Women w/ischemic heart dz many times don't present w/CP. Some pt's may have no symptoms or atypical symptoms so dx may only be made at the time of the actual MI. 132. Which test is clinical standard for assessment of aortic stenosis? a. Echocardiogram 133. Ischemic heart dz is: a. Defined as an imbalance between O2 supply and demand. Frequently manifested as angina. Leading COD in elderly. 134. Preceding a stress test, the following lab work might include: a. CBC w/diff to differentiate ischemic heart dz from anemia. Thyroid studies to rule out hyperthyroidism. 135. On exam, what type of murmur can be auscultated w/aortic regurg? a. Austin flint 136. Which of the following statements is true regarding anti-arrhythmic drugs? a. Most anti-arrhythmics have low toxic/therapeutic ratio and some are exceedingly toxic. 137. In mitral stenosis, p waves may suggest: a. L atrial enlargement 138. Aortic regurg requires medical tx for early signs of CHF with: a. ACEi 139. The best evidence rating drugs in a post-MI pt include: a. ASA, ACEi/ARB, BB, aldosterone blockade 140. 55yo post-menopausal woman with h/o HTN c/o jaw pain on heavy exertion. No c/o CP. EKG is NSR w/out ST segment abnormalities. Your plan may include: a. Exercise stress test 141. What is the most common valvular heart dz in elderly? a. Aortic stenosis 142. Elderly may present with atypical clinical signs of pna. You need to be aware that clustering of all of the following s/s may indicate pna in the elderly except for: a. Bradycardia 143. A common auscultatory finding in CHF is: a. S3 144. The most common organism responsible for CAP in the elderly is: a. Strep pneumoniae 145. 72yo woman and her husband are driving cross-country. After a long day of driving, they stop to eat. Midway through the meal, the woman becomes very SOB w/CP and a sense of panic. Which problem is most likely? a. Pulmonary embolism 146. Exercise recommended for elderly should include activities that: a. Strengthen muscles 147. Preferred amount of exercise for elderly is: a. 30min of aerobic activity a day 5 days a week 148. Which of the following medical conditions is not considered restrictive for engaging in physical activity? a. Depression 149. The best recommendation for a pt who says they have no equipment to exercise is: a. Improvise w/recommended objects at home that can be used 150. When you recommend exercise for elderly, which of the following pieces of advice should be considered for all types of exercise? a. Start low and go slow 151. All of the following statements are true about lab values in the elderly except: a. Abnormal findings are often due to physiological aging 152. Biochemical individuality is best described as: a. Each individual's variation is often much smaller than that of a larger group 153. All the following statements about drug absorption are false except: a. Underlying chronic dz has little impact on drug absorption 154. The cytochrome p system involves enzymes that are generally: a. Inhibited or induced by drugs 155. A statement not shown to be true about pharmacodynamic changes with aging is: a. Decreased sensitivity to oral anticoagulants 156. The major impact of the physiological changes that occur w/aging is: a. Reduced physiological reserve Reduced homeostatic mechanisms Impaired immunolgoical response 157. The strongest evidence regarding normal physiological aging is available through: a. Longitudinal studies 158. Pharmacokinetic changes w/aging is reflective of: a. What the body does to the drug 159. All of the following statements are true about drug distribution in the elderly except: a. Drugs distributed in water have lower concentration 160. Men have faster and more efficient biotransformation of drugs and this is thought to be due to: a. Testosterone 161. Atypical presentation of dz in elderly is reflected by all the following except: a. MI w/CP and diaphoresis 162. Polypharmacy is best described as taking: a. Even a single med if there is not a clear indication for its use [Show More]

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