NURS 503 GI Management Exam (100% Correct Solution) | Highly Rated Paper.

GI Management 1. A 3 day-old infant weighed 8 pounds at birth. Today he weighs 7.5 pounds. How should this be managed? Assess the baby for a cardiac anomaly Add an extra feeding in the AM and PM Have the mother re ...

GI Management 1. A 3 day-old infant weighed 8 pounds at birth. Today he weighs 7.5 pounds. How should this be managed? Assess the baby for a cardiac anomaly Add an extra feeding in the AM and PM Have the mother return to re-weigh the baby in 1 week Continue feeding every 2-4 hours Correct Explanation: Babies will lose about 10% of their birth weight in the first 3-4 days of life. This baby has lost about 8 ounces; this is about 10% of his birth weight. This is an appropriate weight loss in this time. He should rapidly gain this weight back. When children begin losing weight and growth slows, one consideration should be given to congenital cardiac anomalies. There is no need for the mother to return in one week to re-weigh this infant. The infant should be asked to return for his 2 month check. 2. Which set of symptoms is most likely in a patient infected with C. difficile? Headache, diarrhea, body aches Body aches, fever, abdominal cramps Fever, headache, diarrhea Diarrhea, abdominal pain, nausea or vomiting Correct Explanation: The classic symptoms that patients with C. difficile experience are described in choice D. This patient should be treated because symptoms are present. If no symptoms or mild symptoms are present, treatment can be delayed until symptoms develop or worsen. All patients who are infected do not exhibit symptoms. They do not need treatment. 3. A healthcare provider (“the HCP”) was stuck with a needle from a patient suspected to be infected with HIV (“the patient”). A rapid HIV test was performed and was found to be positive. This means that the: healthcare provider has been infected with HIV. the patient is infected with HIV. the HIV status of the patient requires further testing. Correct the HIV status of the healthcare provider requires further testing. Explanation: The rapid HIV is always performed on the source patient (“the patient”). It is known as an ELISA (enzyme linked immunosorbent assay). In the patient suspected of being HIV positive, it is performed to establish whether or not he was positive at the time of the needle stick. In this case, it was found to be positive, but, this is a screening test, and false positives can occur. Therefore, a confirmatory test, the western blot, is routinely performed on the patient’s specimen to confirm the findings of the ELISA. The healthcare provider will usually be tested with a rapid HIV but it is done to establish HIV status at the time of the needlestick. It is not used to establish infection in the healthcare provider. The results of a rapid test can be reported in 20-40 minutes. 4. Most patients who have acute hepatitis A infection: develop fulminant disease. become acutely ill. have a self-limited illness. Correct develop subsequent cirrhosis. Explanation: Clinical presentation of patients infected with hepatitis A virus (HAV) is very variable. However, most adult patients have a self-limited, uncomplicated course. There may be mild, flu-like symptoms or there may be a more acute and severe clinical manifestation. Rarely does HAV result in hepatic failure unless there are other complicating illnesses like HIV or hepatitis B or C. In children, most are asymptomatic. 5. A patient with gall bladder disease has classic symptoms. Which symptom below is NOT classic of gallbladder disease? Intense, dull pressure in the mid abdomen Pain that radiates into the chest, back, or right shoulder blade Pain that worsens after a fatty meal Pain that occurs when the stomach empties. Correct Explanation: The pain associated with cholecystitis is usually constant and may or may not occur in relation to meals, but, it rarely occurs after the stomach has emptied (takes several hours) or with fasting. Initial pain is usual after a fatty meal. The pain is usually in the upper right quadrant but is nearly as common in the mid abdomen. The pain can mimic a myocardial infarction and so it must be treated as cardiac pain until proven otherwise. The pain is usually caused by contraction of the gallbladder after a meal. The contraction may force a stone or sludge against the gallbladder outlet. Discomfort can last for several hours. 6. Which characteristic does not describe hemorrhoids? Bleeding Burning Itching Carcinogenic Correct Explanation: Hemorrhoids are vascular structures in the anal canal. The classic symptoms of hemorrhoidal disease are bleeding, itching, burning. They are not carcinogenic; nor are they found with greater prevalence in patients with colorectal cancer. They are of equal prevalence in men and women. The most common age is 45-65 years. 7. The most common symptoms associated with gastroesophageal reflux disease (GERD) are heartburn and: cough. regurgitation and dysphagia. Correct cough and hoarseness. belching and sore throat. Explanation: The three most commonly associated symptoms of GERD are heartburn, especially post- prandial, regurgitation, and dysphagia, especially after long-standing heartburn. Other common symptoms are chest pain, nausea, and odynophagia (painful swallowing). 8. A mother presents with her one-month old infant. She reports that he cries inconsolably every evening after his first evening feeding. She asks for help. What should be done? Order stool specimens Order ranitidine for the infant’s bottle A different formula should be tried Education, parental reassurance, and encouragement Correct Explanation: This describes colic. Colic is a symptom complex characterized by episodes of inconsolable crying accompanied by apparent abdominal pain. It typically occurs between 1-3 months of age and usually in a very predictable pattern, typically in the evening after feeding. Many different approaches are tried, but medication like ranitidine is not indicated, changing formula is not indicated either. Parents need education regarding colic, comfort measures like rhythmic rocking or frequent burping, much reassurance, and encouragement. 9. A 95 year-old male has lost muscle mass as he has aged. He does not have any underlying disease that has caused this loss. What is this termed? Hypoproteinemia Sarcopenia Correct Cachexia Dithering Explanation: Sarcopenia is the term used to describe loss of muscle mass related to aging. The actual definition is a decrease in appendicular muscle mass that is measured as a two standard deviation decrease. It is associated with increased falls, disability, and impairment. In males, this is due to decreased production of testosterone. 10. A patient has a positive hepatitis B surface antibody. His core antibody is negative. This indicates: he has acute hepatitis B and needs immunization. he has chronic hepatitis B. he is immune to hepatitis B. Correct he needs immunization to hepatitis B. Explanation: This patient is immune to hepatitis B because he has a positive hepatitis B surface antibody. He does not need immunization. His immunity is due to immunization because he has a negative core antibody. The finding of a positive surface antibody and a negative core antibody in this patient indicates immunity from hepatitis B from immunization. If his immunity had been derived from infection, his core antibody would have been positive. 11. A mother of a 4 week-old infant visits your office. She states that her baby is vomiting after feeding and then cries as if he is hungry again. What should the nurse practitioner assess? His abdomen for an olive shaped mass Correct His rectum for patency. His swallowing ability The position his mother uses when she feeds him Explanation: The symptoms sound like pyloric stenosis. The most common time for this to occur is 3-6 weeks. It rarely occurs after 12 weeks of age. Babies who have episodes of projectile vomiting and who demand to be re-fed are called “hungry vomiters” and a diagnosis of pyloric stenosis should be considered. The olive shaped mass, if found, probably represents hypertrophy of the lateral edge of the rectus abdominus muscle. It is most easily felt immediately after vomiting. This diagnosis is made much earlier now than it used to be, so problems with dehydration are not as common as decades ago. 12. A patient has the following laboratory values. What does this mean? Hepatitis A: (-) IgM (-) IgG He has hepatitis A. He has immunity to hepatitis A. He has no immunity to hepatitis A. Correct More data is needed. Explanation: This patient does not have immunity to hepatitis A, as evidenced by the negative IgG. He is not currently infected, as evidenced by the negative IgM. This patient should be referred for immunization. The immunization consists of two immunizations given 6-12 months apart. They can be given to infants or adults. 13. A patient has the following laboratory value. What is the clinical interpretation? Hepatitis A: (+) IgG He has hepatitis A. He has immunity to hepatitis A. * He has no immunity to hepatitis A. More data is needed to interpret this. Explanation: This patient is immune to hepatitis because he has a positive immunoglobulin G (IgG). This signifies immunity secondary to: (1) past infection, or (2) immunization. A negative IgG signifies absence of immunity to Hepatitis A and susceptibility if exposed. 14. Most patients who have acute hepatitis B infection: are females. are acutely ill. have varied clinical presentations. Correct develop subsequent cirrhosis. Explanation: Most patients with Hepatitis B (70%) have sub-clinical hepatitis. Development of cirrhosis is rare following Hepatitis B infection unless other systemic factors are present, such as ethanol abuse, HIV infection, Hepatitis C infection, etc. There is no predilection for this disease by gender. When patients are symptomatic, they typically develop nausea, jaundice, and flu-like symptoms with fever, body aches, and fatigue. 15. Which patient has NO indication for further evaluation of his diarrhea? One with: bloody diarrhea. temperature > 101.3F. duration of illness >48 hours. watery diarrhea and fever. Correct Explanation: Diarrhea is extremely common. Evaluation of diarrhea should take place when specific criteria suggest severe illness. In addition to those listed, some conditions which indicate further work-up are: profuse watery diarrhea with signs of hypovolemia, passage of >6 unformed stools per 24 hours or a duration of illness > 48 hours, recent antibiotic use or recent hospitalization, and diarrhea in a patient > 70 years old. 16. A patient with a suspected inguinal hernia should be examined: in the prone position. standing. Correct side-lying. with patient squatting. Explanation: The patient should be examined while he is standing. He should be asked to bear down, cough, or strain during the exam. Though hernias are far more common in males, they can be found in females too. In males, the patient should be asked to stand. The examiner should put his 2nd or 3rd finger through the scrotum and into the external ring. When the patient is asked to cough, a “silky” feel will butt up against the examiner’s finger, and the hernia can be easily felt. 17. A 48 year-old patient has the following laboratory values. How should they be interpreted? HCV IgG (+), RIBA (radio immuno blot assay) (+) The patient has hepatitis C. Correct The patient does not have hepatitis C. The patient should consider immunization. The results are indeterminate. Explanation: This patient has hepatitis C. He has a positive HCV IgG. This is a positive screen for hepatitis C. The confirmatory RIBA is positive. When both the HCV IgG and RIBA are positive, the patient can be diagnosed with hepatitis C. At this time, there is no immunization for hepatitis C. 18. Hirschsprung's disease is characterized by: intermittent constipation in the first year of life. inability to absorb carbohydrates. failure to pass meconium in the first 48-hours of life. Correct chronic fecal incontinence. Explanation: Another name for this condition is aganglionic megacolon. The affected segment of colon is absent of ganglia that are responsible for producing peristalsis. The diagnosis cannot be made in the first 48-hours of life, but a suggestion of the diagnosis can be made because meconium is not passed in a timely manner. Consequently, most children are diagnosed in the neonatal period. Patients usually present with emesis, abdominal distention, and failure to pass stool. An abdominal x-ray will demonstrate distal intestinal obstruction with dilated bowel loops. The patient should be referred for surgery to remove the diseased segment of colon. 19. A 35 year-old patient has the following laboratory values. How should they be interpreted? HBsAg (-), HBsAb (-), HBcAb (-) The patient had hepatitis B. The patient has hepatitis B. The patient should consider Hepatitis B immunization. Correct The patient has had Hepatitis B immunization. Explanation: This patient has a negative hepatitis B surface antigen (HBsAg). Therefore, he does not have hepatitis B. The patient has a negative hepatitis B core antibody (HBcAb). Therefore, he has never had hepatitis B. The patient has a negative hepatitis B surface antibody (HBsAb). Therefore, he is not considered immune, and immunization should be considered. There is a remote possibility that this patient has been immunized but did not produce hepatitis B surface antibodies. If this were the case, he should consider immunization once again. The correct answer is choice C. 20. The two tests which can indicate with certainty that a patient has hepatitis B at present are: hepatitis B surface antigen and antibody. hepatitis B surface antigen and IgM. Correct hepatitis B surface antibody and core antibody. positive IgG and positive core antibody. Explanation: The earliest serologic marker that indicates acute hepatitis B infection is the hepatitis B surface antigen. It becomes positive about 2-6 weeks after infection, but before symptom onset. A positive IgM indicates acute infection at this time. The finding of a positive hepatitis B core antibody identifies with certainty, hepatitis B infection (either at present or in the past). It does not indicate timing of infection. 21. An 84 year-old presents with a stated involuntary weight loss. He states that he’s lost about 6 pounds in the last 6 or 8 weeks. What statement below is NOT part of the assessment? The weight loss should be measured today and again in the next few weeks.A laboratory evaluation should be performed. Evaluate his dietary intake. Evaluate his upper and lower extremity muscle mass. Correct Explanation: Involuntary weight loss in older adults is often due to malignancy or disease. The initial assessment of an older adult who reports involuntary weight loss is to document the weight loss. If prior measurements are part of the patient’s chart, this would be helpful. Laboratory assessment should also be performed. Consideration should be given to performing a CBC, TSH, metabolic panel. Also consider chest and abdominal x-rays. If all are normal, he should be monitored and re-weighed on the same scale for comparison. A dietary consult should be in order. However, even with negative initial findings, a significant number of patients are later found to have disease or malignancy. 22. A 20 year-old female patient presents with tenderness at McBurney’s point. Appendicitis is considered. What laboratory test would be LEAST helpful to the nurse practitioner in excluding appendicitis as part of the differential? CBC with elevated white count Correct Urinalysis with leukocytes Positive serum pregnancy Positive pelvic cultures Explanation: CBC with an elevated white count simply indicates that an infection is likely. It is not specific for the location of the infection. Urinalysis should be performed to rule out a UTI. Symptoms can mimic an appendicitis. Serum pregnancy test must be performed since this patient could have an ectopic pregnancy. Positive pelvic cultures could indicate pelvic inflammatory disease as the cause of the pain. 23. A patient had an acute onset of right upper quadrant pain that has lasted for the past 3 days. He has low-grade fever. Which lab test(s) will be elevated if he has pancreatitis? CBC Serum amylase Correct ALT and AST CRP Explanation: Serum amylase levels begin to rise 6-12 hours after pancreatic insult and remain elevated for 3-5 days. The other tests described may be abnormal but are not specific for pancreatitis. 24. A 15 year-old is about 10% below her ideal body weight. She complains of dizziness when she stands up. Laboratory studies were performed. Besides malnutrition, what else could account for her dizziness? BUN is mildly elevated Glucose = 80 mg/dL Hemoglobin = 9.6 mg/dL Correct Potassium is 3.5 meq/L Explanation: This patient does not meet the strict criteria for an eating disorder, but it should be suspected. The other laboratory values are not the cause of her dizziness with standing. This is likely due to a low hemoglobin. She needs treatment for a probable iron deficiency anemia and elicitation of history to help identify the cause of her low hemoglobin. 25. The initial step in the management of encopresis is: client and family education. Correct bowel cleansing. dietary changes. psychosocial evaluation. Explanation: Encopresis is repetitive soiling of stool by a child who is 4 years of age or older who should be potty trained. The patient and caregivers of a child with encopresis need education about the underlying cause, usually chronic constipation. The initial step is to remove negative attributions regarding soiling. The caregivers should be educated about changing the child’s chronic behavior patterns. The child should not be scolded. The next step after education is to relieve the constipation with a goal of one soft bowel movement daily. 26. A 70 year-old patient states that he had some bright red blood on the toilet tissue this morning after a bowel movement. What is the most likely cause in this patient? Hemorrhoids. Diverticulitis Correct Colon cancer Colon polyp Explanation: Nearly 1 in 3 patients in this age group with acute lower gastrointestinal bleeding have bleeding secondary to diverticulitis. Nearly 1 in 5 have colorectal cancer or polyps, though, polyps usually do not bleed. Regardless of the etiology, this patient needs referral for a colonoscopy to identify the cause of bleeding. He is at high risk for colon cancer because of his age. The appropriate recommendation is referral to gastroenterology for colonoscopy. 27. What medication may be used to treat GERD if a patient has tried over the counter ranitidine without benefit? Calcium carbonate Prescription strength ranitidine Cimetidine Pantoprazole Correct Explanation: If a patient has been diagnosed with GERD and he is symptomatic on an H2 blocker like ranitidine, a proton pump inhibitor (PPI) should be considered. An example of a proton pump inhibitor is pantoprazole. Relief of symptoms after using a PPI does not indicate a benign condition. This patient could have esophageal erosions, Barrett’s esophagitis, or esophageal cancer. He should be screened for risk factors for these conditions and then a decision to refer this patient to gastroenterology can be made. 28. A 19 year-old female presents with lower abdominal pain that began about 12 hours ago. She is febrile. She denies vaginal discharge. Which choice below is the least likely cause of her symptoms? Appendicitis Urinary tract infection Renal stone Correct Ovarian cyst Explanation: A renal stone can produce lower abdominal pain, but is unlikely to produce fever. Fever can be associated with the presence of a stone if pyelonephritis also accompanies this. However, this is not nearly as likely as the other diagnoses listed. Another diagnosis that must be considered because of her age, is pelvic inflammatory disease. In this case, a pelvic exam should be performed. 29. What medication used to treat patients who have GERD provides the fastest relief of heartburn symptoms? Calcium carbonate Ranitidine Amantadine Pantoprazole Explanation: Calcium carbonate is an antacid. It provides rapid changes in gastric pH. This provides relief that can be noticed immediately. The increase in pH lasts for about 30 minutes. Ranitidine is an H2 blocker. It provides relief in 1-2 hours. This usually lasts for about 6- 12 hours. Amantadine is an antiviral not used to treat GERD. Pantoprazole is a proton pump inhibitor. This provides relief after several hours or days of daily consumption. 30. A 14 year-old patient has an acute, painless groin swelling. What tool would yield the most information to identify the etiology of the swelling? Abdominal radiographs Ultrasound of the abdomen Ultrasound of the scrotum MRI of the scrotum Explanation: The patient has an acute swelling of the groin. Since the etiology could include several scrotal problems (inguinal hernia, hydrocele, or varicocele), an ultrasound will yield quick reliable information with a diagnostic accuracy of 93% for acute groin problems. The definitive treatment for inguinal hernia is surgical repair. 31. Mrs. Lovely, an 84 year old complains of fecal incontinence. A likely cause is: inactivity. constipation. Correct poor fluid consumption. medication related. Explanation: Underlying constipation is a common cause of fecal incontinence in older adults. However, typically it is multifactorial. Risk factors include: age > 80 years, impaired mobility, and neurologic disorders including dementia. Inactivity and poor fluid consumption may contribute to constipation but are not causes of fecal incontinence. 32. A patient has been diagnosed with Hepatitis A. The most common reported risk factor is: drinking contaminated water. homosexual activity. international travel. Correct eating contaminated food. Explanation: Traveling internationally is the most common risk factor. Hepatitis A (HAV) is spread via the fecal-oral route (and is highly contagious), though most people have no recollection of eating or drinking contaminated food/drink. Mexico, Central and South America are countries with the highest reported rates of HAV. Other risk factors are contact with infected family or close contacts and homosexual activity among men. Hepatitis A has declined since vaccination in the US has become widespread. 33. Older adults frequently complain of constipation. Which medication listed below does NOT increase chance of constipation in an older adult? Diltiazem Hydrochlorothiazide Calcium supplements Metformin Correct Explanation: Constipation is a common complaint in older adults because of mediations they routinely consume and many diseases they often have. Some other examples of medications that can cause constipation are opiate analgesics, NSAIDs, and antacids. Some diseases and conditions that can produce constipation are hypothyroidism, colon cancer, electrolyte abnormalities, immobility, change in diet due to inability to chew food properly. 34. A 3 day-old full-term infant has a bilirubin level of 16 mg/dL. How should this be managed? Monitor only Increase fluids and stop breastfeeding Increase breastfeeding Order phototherapy for the infant. Correct Explanation: There are several ways to determine how elevated the bilirubin level is. One measure is to use the Bhutani nomogram. It predicts bilirubin levels based on post-natal age. A level of 16 mg/dL is considered high intermediate. Since the bilirubin probably will rise a little more, phototherapy is probably appropriate. 35. A 45 year-old patient has the following laboratory values. How should they be interpreted? HBsAg (+), HBsAb (-), HBcAb (+) The patient has hepatitis. Correct The patient had hepatitis. The patient should consider immunization. The results are indeterminate. Explanation: This patient has a positive hepatitis B surface antigen (HBsAg). Therefore, he has hepatitis B. A positive HBcAb is found in patients who either have hepatitis now or who have had it. The surface antibody (HBsAb) would be expected to be negative in a patient with positive surface antigen (HBsAg) because these 2 markers will not be positive at the same time. 36. An elderly adult with an appendicitis is unlikely to exhibit: generalized abdominal pain. initial WBC elevation. Correct UTI symptoms. low grade fever. Incorrect Explanation: Very young children and elderly adults are not likely to have initial WBC elevations. Consequently, appendicitis can be easily missed in these populations. Generalized abdominal pain is typical initially. UTI symptoms in older adults can manifest as lower abdominal pain and is a common presentation in this age group. Low grade fever is common too. 37. Many older adults have cachexia. What characterizes this? Anorexia and weight loss Weakness and fatigue Illness and loss of muscle mass Correct Starvation and weight loss Explanation: Cachexia is common in older adults and is associated with increased mortality. It is described as a syndrome of underlying illness that is accompanied by loss of muscle mass. Illnesses associated with cachexia are malignancies, renal disease, COPD, and chronic heart failure. Other matters are associated with cachexia and may contribute to loss of muscle mass. These include loss of appetite, insulin resistance, and increased catabolism of bodily proteins. 38. A patient has been diagnosed with viral gastroenteritis. He has nausea, vomiting, and has started having lower abdominal cramps. What is the most effective intervention for him? An anti-diarrheal An anti-emetic An anti-spasmodic Oral rehydration Correct Explanation: Patients with viral gastroenteritis should be treated symptomatically. The goal of therapy is to prevent dehydration and replace electrolyte losses. Loperamide can decrease abdominal cramping and symptoms of diarrhea but should only be used in adults. Careful use or avoidance is suggested in older adults and children less than age 5 years. 39. A 40 year-old patient has the following laboratory values. How should they be interpreted? HBsAg (-), HBsAb (+), HBcAb (+) The patient had hepatitis. Correct The patient has never had hepatitis.3 The patient should consider immunization. The patient has been immunized. Explanation: This patient has a negative hepatitis B surface antigen (HBsAg). Therefore, he does not have hepatitis B. The patient has a positive hepatitis B surface antibody (HBsAb). Therefore, he is considered immune. The patient also has a positive hepatitis B core antibody (HBcAb). Therefore, he is immune because he has had hepatitis B. The correct answer is choice A. 40. Children with an inguinal hernia: have a history of an intermittent bulge in the groin. Correct are usually symptomatic. have a mass that is always present on exam. are usually irritable and often constipated. Explanation: Inguinal hernias are usually asymptomatic and absent on exam but can sometimes be elicited by increasing intraabdominal pressure such as occurs with straining or crying. The “silk sign” is infrequently appreciated but represents a silky thickening of the cord. If it is able to be palpated, it is done by placing a single finger next to the inguinal canal at the level of the pubic tubercle and gently moving the finger from side to side. Children with an incarcerated mass are often irritable but not constipated. 41. A 7 year-old male presents with encopresis. The NP might expect: constipation. Correct delayed maturation. urinary tract infection. laxative abuse. Explanation: The underlying cause of encopresis, repetitive soiling of stool by a child who is 4 years of age or older who should be potty trained, is usually chronic constipation. The ultimate goal is to reverse the constipation and establish normal bowel habits by the child. Having the patient use daily laxatives reverses constipation. Once he is able to have one soft bowel movement daily and a routine has been established, the laxatives are slowly weaned off. Attention to dietary factors must be addressed so that the child’s diet will support a daily bowel movement. 42. A patient has elevated liver enzymes. ALT = 642 U/L; AST= 150 U/L. What is the likely etiology of the elevation? Acetaminophen toxicity Alcohol abuse Hepatitis Correct Drug overdose Explanation: These liver enzymes are elevated. In looking at the numbers, the ALT is grossly elevated compared to the AST. A diagnosis of hepatitis is far more common when the ALT is elevated. AST becomes the dominant liver enzyme when the patient has consumed a substance that causes the liver to be damaged. Examples of this are found in the choices suggesting acetaminophen, alcohol, and drug abuse. 43. A patient has been prescribed metronidazole for treatment of C. difficile. What should be avoided in this patient? Excess fluids Vitamin B12 Grapefruit juice Alcohol Correct Explanation: Patients should always be cautioned against alcohol ingestion (in any form) if they take metronidazole. Alcohol can (and usually does) produce a disulfiram reaction. This is characterized by abdominal cramps, nausea, vomiting, headache, and elevated body temperature. Precautions should remain until 72 hours after the last dose of metronidazole. 44. An inguinal hernia is palpated on a male patient by an examiner. Which word below best describes what the hernia feels like when touched by the examiner? Nodular Silky Correct Firm Bumpy Incorrect Explanation: Patients should be in the standing position when examined for a hernia. They are asked to strain, cough, or bear down after the examiner has inserted his fingertip within the external ring. The word used to describe the impulse of the hernia bumping into the finger is “silky”. Nodular might be the word used to describe a prostate gland. Bumpy implies an irregular surface on some object. This is not the case with a hernia. 45. A 50 year-old with a history of consumption of 3-4 alcoholic drinks daily and weekend binges has elevated liver enzymes. Which set of enzymes is most representative of this patient? AST= 200, ALT= 75 Correct AST= 100, ALT = 90 AST=100, ALT=200 AST= 30, ALT= 300 Explanation: The normal AST/ALT ratio in healthy subjects is 0.8. In patients with alcoholic hepatitis, the usual ratio (AST:ALT) is 2:1. When the ALT is very elevated, infectious hepatitis must be considered. Normally, both AST and ALT are less than 40 IU/L. The level of elevation does not correlate with the degree of damage in the liver and has no prognostic value in patients with non-acute liver disease. 46. The most common place for indirect inguinal hernias to develop is: the internal inguinal ring. the external inguinal ring. Hesselbach’s triangle. femoral ring. Incorrect Explanation: The internal inguinal ring is the most common site for development of an indirect inguinal hernia. These can occur in men and women. Though most are probably congenital, symptoms may not be obvious until later in life. Indirect hernias are more common on the right side. Direct inguinal hernias occur through Hesselbach’s triangle. 47. A 24 year-old male has recently returned from a weekend camping trip with friends. He has ulcerative colitis and history of migraine headaches. He reports a two-day history of headache, nausea, and vomiting with weakness. Which of the following is least likely as a possible cause? Migraine headache Exacerbation of ulcerative colitis Acute gastroenteritis Norovirus Explanation: The patient presents with headache, nausea and vomiting. His symptoms could be due to migraine headache or acute gastroenteritis. Norovirus is a common cause of gastroenteritis. An exacerbation of ulcerative colitis would produce lower GI symptoms (diarrhea, flatulence, or bleeding), not nausea, vomiting, and headache. 48. A patient has the following laboratory value. What does this mean? Hepatitis B surface antigen (+) He has acute hepatitis B. Correct He has immunity to hepatitis B. He has no immunity to hepatitis B. More data is needed. Explanation: A positive hepatitis B surface antigen means that this patient has acute hepatitis B. The first serologic marker to be positive is the surface antigen. It can become positive as soon as 3-4 weeks after exposure to hepatitis B. 49. The relationship between colon polyps and colon cancer is: polyps eventually all become malignant. polyps have a slow progression to colon cancer. Correct polyps have a rapid progression to colon cancer. polyps have no relationship to colon cancer. Explanation: Colon polyps are usually very slow growing and take a long time to progress to cancer. This is the reason that a colonoscopy does not need to be repeated annually. While not all polyps grow slowly, this is the usual progression. 50. A patient has a positive anti-HCV test. This means: he has hepatitis C. he has immunity to hepatitis C. he does not have hepatitis C. more data is needed. Correct Explanation: The anti-HCV test is a screening test. A patient who has a positive screen for hepatitis C may have the disease, but more data is needed to determine this. Once the screen is positive, a confirmatory test should be performed. The confirmatory test is the RIBA (recombinant immunoblot assay). If it is positive, it indicates past or current infection with hepatitis C. If negative, the RIBA indicates that the screen was a false positive. 51. A patient asks for advice about a medication that will produce rapid relief if he is having heartburn symptoms. What should the nurse practitioner respond? Calcium carbonate Correct Ranitidine Omeprazole Sucralfate Explanation: Antacids, like calcium carbonate, produce the most rapid change in gastric pH and thus, the most rapid relief of symptoms. However, the increase in pH lasts 20-30 minutes and so, may provide only “short-lived” relief. H2 blockers, like ranitidine, and proton pump inhibitors, like omeprazole, may take many hours before relief is realized and so are not the best choices for immediate relief of symptoms. Sucralfate does not affect gastric pH or acid output. Instead, it forms a viscous, adhesive substance that adheres to the surface of gastric and esophageal ulcers. 52. LFTs should be checked initially in patients who take: niacin, atorvastatin, simvastatin. Correct naproxen, metformin, aspirin. cimetidine, pravastatin, and propanolol. ketoconazole, simvastatin, iron. Explanation: Patients who take niacin and the statins should have liver enzymes measured prior to initiation. The need for periodic monitoring of liver enzymes with the statins is no longer required. However, baseline values are prudently measured. There is no need to do this routinely with aspirin, cimetidine, propanolol, or iron in patients without risk factors. There are more than 600 commonly prescribed drugs that can produce liver enzyme elevations. Care with prescribing is always warranted. 53. A 63 year-old male has been your patient for several years. He is a former smoker who takes simvastatin, ramipril, and an aspirin daily. His blood pressure and lipids are well controlled. He presents to your clinic with complaints of fatigue and “just not feeling well” for the last few days. His vital signs and exam are normal. His hepatitis panel is negative for infectious hepatitis. What is the most likely cause of his elevated liver enzymes? He has received a generic version of simvastatin He is an alcoholic in denial Daily grapefruit consumption for the past 10 days.Correct Rare liver toxicity from a usual dose of simvastatin Explanation: Grapefruit is a potent inhibitor of the cytochrome P450 enzyme system. Statins and calcium channel blockers are two infamous drug interactions that occur with grapefruit and grapefruit juice. Because they inhibit metabolism of the statin, the patient continues to have statin in circulation because he cannot significantly metabolize the medication. When the next day’s dose is taken, its effect is coupled with the effect of the previous day’s dose. The effect is cumulative. Hepatoxicity can quickly develop. The simvastatin must be stopped immediately! The liver enzymes must be followed until they return to normal; which could take weeks, months or even longer. 54. A fecal occult blood test (FOBT) obtained during a rectal examination: should be adequate for screening of colorectal cancer. will usually detect the presence of polyps. is adequate to screen for rectal cancer only. is inadequate to screen for colorectal cancer. Correct Explanation: This is not adequate to screen for colorectal cancer. Fecal occult blood tests have a much higher sensitivity if three consecutive stool specimens are used (applying 2 samples per card for each specimen). A single specimen is inadequate for screening purposes. Since polyps do not usually bleed, the fecal occult blood test is not a good screen for polyp identification. 55. The most common reason that older adults develop peptic ulcer disease is: chronic NSAID use. H. pylori infection. Correct acetaminophen abuse. polypharmacy. Explanation: The most common reason that older adults have peptic ulcer disease is infection with H. pylori. There are many regimens approved to treat H. pylori and most are well tolerated. NSAID use is the second most common reason older patients have PUD. 56. What choice below is most commonly associated with pancreatitis? Gallstones and alcoholism Correct Hypertriglyceridemia and cholecystitis Appendicitis and renal stones Viral infection and cholecystitis Explanation: In adults, the most common causes of acute pancreatitis are gallstones and alcoholism. Pancreatitis in women is more often due to gallstones; in men, due to alcoholism. Hypertriglyceridemia can precipitate pancreatitis, but a serum amylase measurement may be normal. This can be a difficult diagnosis to make. The other conditions listed are not associated with pancreatitis. However, viral infections of the pancreas can produce pancreatitis. 57. Which imaging study of the abdomen would be LEAST helpful in diagnosing an acute appendicitis? Ultrasound CT scan MRI X-ray Correct Explanation: X-rays are usually not helpful in diagnosing appendicitis, however, some findings on radiograph can be associated with appendicitis: ileus, free air, right lower quadrant appendicolith or soft tissue density, or a deformity of the cecal outline. A CT scan is considered more accurate than an ultrasound, but ultrasound and CT are the most commonly used tests. The sensitivity and specificity with CT scan are 94 and 95% respectively. With an ultrasound, the sensitivity and specificity are 86 and 81% respectively. MRI is generally not used because it is more expensive, takes more time to complete, and is not as readily available. 58. A 6 week-old male infant is brought to the nurse practitioner because of vomiting. The mother describes vomiting after feeding and feeling a “knot” in his abdomen especially after he vomits. The child appears adequately nourished. What is the likely etiology? Gastroesophageal reflux (GER) Pyloric stenosis Correct Constipation Munchausen syndrome by proxy Explanation: This scenario is typical of an infant with pyloric stenosis. It is more common in males (88%) and usually is diagnosed before the child is 12 weeks old. The classic presentation is an infant who vomits immediately after eating. The “knot” in the abdomen is the typical “olive-shaped mass” palpable at the lateral edge of the rectus abdominus muscle in the right upper quadrant of the abdomen. The mass is best palpated immediately after vomiting. The differential should include GER, but no mass is palpable. Munchausen syndrome by proxy is the fabrication or induction of an illness in a child in order for the caregiver to receive attention. 59. A 5 year-old female’s playmate has been diagnosed with pinworms. The mother brings her child in for an exam. The 5 year-old denies rectal itching. How should the NP proceed? Reassure the mother that if the child develops symptoms, she will need to be treated. Visually assess the child’s rectum for redness or presence of worms. Have the mother collect a stool specimen and send it to the laboratory. Perform the “scotch tape” test and look at the collection under the microscope. Correct Explanation: The diagnosis of pinworms, Enterobiasis, is made by using a piece of scotch tape on a tongue depressor. It is touched against the child’s rectum. The greatest yield of eggs will occur during the nighttime or early AM. Eggs will be found here if they are present. Worms and eggs are rarely found in stool specimens, so this is not a good plan. When the scotch tape is examined under a low power microscope, the eggs will be easily visualized since they are large and bean shaped. The finding of an adult worm would confirm the diagnosis. These are large enough to be seen with the naked eye. 60. A 42 year-old patient was diagnosed with ulcerative colitis many years ago. What part of his routine health screenings should be stressed by the nurse practitioner? He should be screened at age 50 with a colonoscopy. Tetanus immunization should be given every 5 years. Pneumococcal vaccine should be administered by age 50. He should have a colonoscopy every 1-3 years. Correct Explanation: A history of ulcerative colitis or Crohn’s disease is associated with an increased risk of colorectal cancer. Recommendations vary according to organization, but generally, screening with annual colonoscopy should take place 8-10 years after diagnosis in patients with pancolitis. Screening should take place for 15 years after diagnosis in patients with colitis involving the left colon. Colonoscopy should be repeated every 1-3 years. 61. A patient is in the clinic with a 36 hour history of diarrhea and moderate dehydration. Interventions should include: oral rehydration with tea, cola, or Gatorade. IV rehydration. oral rehydration with an electrolyte replenishment solution. Correct resumption of usual fluid intake and solid food intake. Explanation: The goal in managing a patient who presents with dehydration is rehydration. This is typically done with a commercially prepared electrolyte solution. Infamously, these are poor tasting. Patients usually prefer to rehydrate with fluids like tea, cola or a sports drink. However, these usually contain too much carbohydrate, too little potassium, and too much sodium for ideal fluid replenishment. Consequently, these are avoided when rehydration is needed. These are preferred by patients because of their good taste. The oral tract is always preferred for rehydration when it can be used. Resumption of the usual fluid and solid food intake should occur AFTER rehydration has occurred. 62. A 40 year-old patient has the following laboratory values. How should they be interpreted? HBsAg (-), HBsAb (+), HBcAb (-) The patient had hepatitis. The patient has hepatitis. The patient should consider immunization. The patient has been immunized. Correct Explanation: This patient has a negative hepatitis B surface antigen (HBsAg). Therefore, he does not have hepatitis B. The patient has a negative hepatitis B core antibody (HBcAb). Therefore, he has never had hepatitis B. The patient has a positive hepatitis B surface antibody (HBsAb). Therefore, he is considered immune. The patient is immune from immunization because his hepatitis B core antibody is negative. If the core antibody had been positive, he would be considered immune from the disease. The correct answer is choice D. 63. The most common risk factor for developing hepatitis B is: homosexual activity. injecting drug use. heterosexual activity. Correct body piercings. Explanation: Hepatitis B can be contracted by any of the choices listed. However, the one with the highest likelihood of disease transmission, and the one that is most common, is heterosexual activity. 64. A patient has suspected peptic ulcer disease. Her symptoms occur a few hours after eating. She likely has a: gastric ulcer. duodenal ulcer. Correct gastric or duodenal ulcer. infection with H. pylori. Explanation: Symptoms have a poor correlation with disease found during endoscopy. However, duodenal symptoms tend to occur within 2-5 hours of eating. These patients derive relief from eating or taking antacids. This is in contrast to a patient with a gastric ulcer who has symptoms within minutes of eating. He tends to derive less relief from antacids. 65. The early signs and symptoms of appendicitis in an adult: are subtle. Correct produce marked pain in the lower right abdominal quadrant. produce symptoms in the periumbilical region only. include fever, nausea and vomiting. Explanation: The most consistent findings in adults with early presentation of acute appendicitis are very subtle and difficult to identify. Symptoms may be as vague as indigestion, flatulence, a feeling of ill-being. Initially, pain can be in the general abdomen, then become periumbilical, and finally localize to the lower right quadrant. Early symptoms are difficult to identify, especially in older adults. 66. A patient has been diagnosed with Hepatitis B. The most common reported risk factor is: drinking contaminated water. eating contaminated food. exposure to blood. sexual exposure. Correct Explanation: Hepatitis B is transmitted by blood and body fluids. While exposure to infected blood or blood products would significantly increase risk of infection in unvaccinated people, this is much less likely than becoming infected via sexual exposure or IV drug use. Hepatitis A is transmitted via fecal oral routes. Choices a and b implicate hepatitis A as the etiologic agent. 67. An older adult has suspected Vitamin B12 deficiency. Which of the following lab indices is more indicative of a Vitamin B12 deficiency? Microcytosis Macrocytosis Correct Leukocytosis Thrombocytosis Explanation: A Vitamin B12 deficiency can produce an anemia called pernicious anemia. This is most commonly found in older adults and is characterized by macrocytosis. In other words, the red cells are larger than expected. Microcytosis may be seen in iron deficiency anemia or thalassemia. Leukocytosis refers to large numbers of white cells in the blood stream. Thrombocytosis refers to an increased number of platelets in the blood stream. 68. An 83 year-old patient is diagnosed with diverticulitis. The most common complaint is: rectal bleeding. bloating and crampiness. left lower quadrant pain. Correct frequent belching and flatulence. Incorrect Explanation: Diverticular disease is more common in older adults. About 70% of patients diagnosed with diverticulitis have left lower quadrant pain. Rectal bleeding may have varied etiologies like rectal carcinoma or hemorrhoids. Bloating and cramping are often found in patients with diverticular disease (diverticulosis) but not specifically diverticulitis. Belching and flatulence are not specifically associated with diverticulosis. 69. A 37 year-old has routine blood work performed during an annual exam. He is found to have elevated liver enzymes. On exam he has a tender, enlarged liver. How should the nurse practitioner proceed? Repeat the liver enzymes today. Order a hepatitis panel. Correct Have patient return in one week for recheck. Order a CBC. Explanation: The differential for a patient with elevated liver enzymes can reflect many different etiologies. Since the liver is tender and liver enzymes are elevated, a likely etiology is hepatitis. The size and consistency of the liver should be ascertained. The spleen should be assessed. If it is palpable, it is enlarged also. Hepatitis panel should be performed and strong consideration given to referral to gastroenterology. Repeating liver enzymes might be considered if the rest of the exam was normal and the lab values were the only thing abnormal. The results of a CBC will not change the differential. The patient’s abnormal labs and exam make this urgent and waiting a week will delay diagnosis and possible treatment. 70. The most common cause of diarrhea in adults is: E. coli. salmonella. C. difficile. viral gastroenteritis. Correct Explanation: Most cases of acute gastroenteritis are viral in origin. Severe diarrhea is usually caused by bacteria. This typically lasts longer than 3 days. 71. GERD (gastroesophageal reflux disease) and physiologic reflux have similar characteristics. However, physiologic reflux: can produce mucosal injury. rarely occurs at nighttime. Correct occurs only postprandial. is always asymptomatic. Explanation: GERD is usually associated with symptoms that produce injury to the mucosa. This rarely occurs in physiologic reflux. Characteristics typical of physiologic reflux are that it occurs primarily post-prandial (like GERD), are usually asymptomatic, rarely occur nocturnally, and are usually short-lived. In contrast, GERD usually occurs nocturnally, especially when there is lower esophageal sphincter disease. 72. A 43 year-old patient who has been diagnosed with hepatitis B has the following laboratory values. How should they be interpreted based on these values? HCV IgG (-), RIBA (radio immuno blot assay) (-) The patient has hepatitis B and hepatitis C. The patient does not have hepatitis C. Correct The patient could have hepatitis C. The results are indeterminate. Explanation: This patient does not have hepatitis C. This patient has a negative hepatitis C IgG. Currently, this is the screen. The RIBA was not necessary to perform, but, it confirms that this patient has a true negative screen for hepatitis C. If the HCV IgG had been positive, the RIBA would have been necessary to perform. There is no laboratory information that helps conclude that this patient has hepatitis B, except the history in the stem of the question. 73. Which description is more typical of a patient with acute cholecystitis? The patient rolls from side to side on the exam table. The patient is ill appearing and febrile. Correct An elderly patient is more likely to exhibit Murphy’s sign. Most are asymptomatic until a stone blocks the bile duct. Incorrect Explanation: A patient with acute cholecystitis usually complains of abdominal pain in the upper right quadrant or epigastric area. Many patients complain of nausea. The patient lies very still on the exam table because cholecystitis is associated with peritoneal inflammation that is worse with movement. Elderly patients are more likely to NOT exhibit Murphy’s sign and thus, are more likely to suffer from complications of acute cholecystitis. Patients who are asymptomatic have cholelithiasis, not acute cholecystitis. 74. What are the most common signs and symptoms associated with mononucleosis? Fatigue and lymphadenopathy Correct Cough and pharyngitis Splenomegaly and fever Rash and pharyngitis Explanation: The most common symptoms associated with mononucleosis (mono) are adenopathy (100%) and fatigue (90-100%). Pharyngitis occurs in 65-85% of patients. Cough occurs less than 50%; splenomegaly occurs 50-60%; fever 80-95%. The least common symptom of mono is rash. It occurs in only 3-6% of patients. 75. A 10 year-old female presents with a three-month history of abdominal pain. She has been diagnosed with recurrent abdominal pain. During the interview the nurse practitioner is likely to elicit a finding of: nocturnal pain. change in bowel habits. school absenteeism. Correct pain relief with ibuprofen. Explanation: Recurrent abdominal pain can be diagnosed after three episodes of abdominal pain that severely affects the child’s usual activities and occurs over at least a three month period. No acute cause can be identified. Fewer than one in 10 children with recurrent abdominal pain attends school regularly. The goal in treating these children is a return to normal function and activities, not necessarily relief of pain. Caregivers must be coached to avoid reinforcement of pain behaviors with the child. 76. A patient has hepatitis B. He probably has a predominance of: leukocytes. lymphocytes. Correct neutrophils. eosinophils. Explanation: Lymphocytes tend to be the predominant white cell present during viral infections. Hepatitis B is a viral infection. The total white count will likely be decreased. This happens very often in the presence of viral infections. A bacterial infection is frequently evidenced by an elevated leukocyte count, a increased neutrophil count, and a decreased lymphocyte count. 77. A patient has a positive hepatitis B surface antibody. This means: he has acute hepatitis B. he has chronic hepatitis B. he is immune to hepatitis B. Correct he needs immunization to hepatitis B. Explanation: The hepatitis B surface antibody indicates immunity to hepatitis B virus. Specifically, if this patient comes in contact with hepatitis B virus, he will not become infected with hepatitis B. The presence of hepatitis B surface antibody indicates immunity from immunization or actual infection. It also indicates recovery if the patient was infected. 78. Which medication listed below can exacerbate the symptoms of GERD? Verapamil Correct Metformin Ferrous sulfate Ceftriaxone Explanation: Verapamil is a calcium channel blocker. Calcium is needed for muscle contraction. Since the lower esophageal sphincter is opened and closed by muscles, the contraction of these muscles will be less forceful. GERD can be exacerbated in this case. Calcium channel blockers should be avoided in patients with severe GERD or in patients in whom calcium channel blockers exacerbate GERD symptoms. 79. The most common place for indirect inguinal hernias to develop is: the internal inguinal ring. Correct the external inguinal ring. Hesselbach’s triangle. femoral ring. Explanation: The internal inguinal ring is the most common site for development of an indirect inguinal hernia. These can occur in men and women. Though most are probably congenital, symptoms may not be obvious until later in life. Indirect hernias are more common on the right side. Direct inguinal hernias occur through Hesselbach’s triangle. 80. An older patient presents with left lower quadrant pain. If diverticulitis is suspected, how should the NP proceed? Order a chest and abdominal x-ray CT scan with IV and oral contrast Correct Barium enema Ultrasound of the abdomen Incorrect Explanation: CT scan of the abdomen is the diagnostic test of choice for this patient with suspected diverticulitis. The CT scan is able to demonstrate inflammatory changes in the colonic wall, colonic diverticula, thickening of the bowel wall, fistula formation, peritonitis, and other complications associated with diverticulitis. A chest and abdominal x-rays are commonly ordered and can help exclude other causes of abdominal pain, but do not help diagnose diverticulitis. Barium enema would be contraindicated if there were a potential for perforation. Ultrasound is much less widely used than CT. 81. Which of the following is NOT part of the prescription for management of weight loss in older adults? Increase carbohydrate intake Correct Increase the calories at each meal (Incorrect) Fat is needed not CBH Increase the frequency of meals Consider liquid supplements Explanation: When treating patients with weight loss, the goal is to increase the number of calories at each meal. Fats are more heavily laden with calories than carbohydrates. Carbohydrates (and proteins) provide only 4 calories per gram; fats provide 9 calories per gram. The addition of fats will increase calories much more quickly than increasing carbohydrate intake. All of the suggestions listed above will increase caloric intake. Daytime snacks should be offered too. Consider a Vitamin B supplement because this can stimulate appetite. 82. Which of the following would be usual in a patient with biliary colic? Presence of gallstones on imaging studies Presence of gallstones and unpredictable abdominal pain Positive Murphy’s sign only Pain in upper abdomen in response to eating fatty foods Correct Explanation: Biliary colic refers to discomfort produced by contraction of the gallbladder. This occurs in response to eating. Typically, pain occurs in the upper right quadrant or chest, peaks in an hour after eating, and then remains constant and finally subsides over the next several hours. A positive Murphy’s sign is elicited when the gallbladder wall is inflamed. It can be elicited by palpating the gallbladder just beneath the liver as the patient takes a deep breath. 83. The relationship between duodenal ulcer disease and H. pylori infection is: distant. very unlikely. possible. very likely. Correct Explanation: H. pylori is a gram negative organism that is a major etiologic factor in development of duodenal ulcer disease, gastric adenocarcinoma and lymphoma of the stomach. Only about 10-15% of patients with H. pylori infection actually develop duodenal ulcer disease, but this is the largest contributor to duodenal ulcer development. Other etiologic factors in duodenal ulcer development are NSAID overuse and smoking. 84. A 26 year-old female with low-grade fever and nausea has pain at McBurney’s point. The most appropriate action by the NP is to: order a CBC and pregnancy test. Correct order an abdominal ultrasound. refer her to the emergency department. order an abdominal CT. Explanation: Patients with appendicitis usually have pain at McBurney’s point, the painful area in the lower right quadrant of the abdomen. However, because this patient is of child bearing age, pregnancy is part of the differential and must be ruled out. Once pregnancy status is determined, patient disposition can be managed. If pregnancy is ruled out, then workup for appendicitis can proceed. CT scan of abdomen has very high sensitivity and specificity for appendicitis (95 and 94% respectively) and so it is the gold standard for diagnosis of appendicitis. 85. Which of the following symptoms is typical of GERD? Chest pain Cough Sore throat Pyrosis Correct Explanation: Typical symptoms of GERD include pyrosis (heartburn). The other symptoms listed are considered atypical symptoms of GERD. Patients who present with atypical symptoms of GERD, especially if older than 50 years, should be considered for endoscopy. 86. Which choice contains 3 medications that should have liver function tests measured prior to initiation of the medications? Niacin, atorvastatin, simvastatin Correct Naproxen, metformin, aspirin Cimetidine, pravastatin, and propranolol Ketoconazole, simvastatin, iron Explanation: Patients who take niacin and the statins should have liver enzymes measured prior to initiation. The need for periodic monitoring of liver enzymes with the statins is no longer required. However, baseline values are prudently measured. There is no need to do this routinely with aspirin, cimetidine, propanolol, or iron in patients without risk factors. There are more than 600 commonly prescribed drugs that can produce liver enzyme elevations. Care with prescribing is always warranted. 87. What is true regarding overweight states in older adults? This is clearly associated with increased mortality in older adults. Mortality in the elderly related to overweight states declines over time. Correct BMI is a good way to assess nutritional states in the elderly. There are no potential metabolic or functional benefits to weight loss in the elder. Explanation: Overweight and obese states are not as important in predicting mortality in the elderly as they are in their younger counterparts. After age 65 years (some studies demonstrate after age 70), weight is less significant in decreasing risk for mortality than in younger adults. There are some benefits to weight loss in the obese elderly. One of them is better balance and decreased risk for falls. Others include less sleep apnea, decreased risk of diabetes, decreased rates of shortness of breath with respiratory and cardiac diseases. 88. 88. Which of the following is appropriate for initiation of an 8 week-old with gastroesophageal reflux? Small, frequent thickened feedings Correct Cimetidine every 6 hours Change formula to soy based Place infant on left side after eating Explanation: Two strategies should be tried initially. First, avoidance of overfeeding is recommended. Hence, small, frequent feedings. Second, milk thickening agents appear to improve symptoms in infants who experience gastroesophageal reflux (GER). Thickened feedings significantly decrease frequency of reflux in most infants. Also, caloric content is increased and this may be helpful for patients who are underweight because of persistent GER. Generally, when medications are used, proton pump inhibitors are preferred over an H2 blocker like cimetidine. Changing formula generally does not help, however, a milk-free diet may help since 40% of infants with GER are sensitive to cow’s milk protein. Thus, soy would not help. Positioning seems to be ineffective in relieving symptoms in infants. 89. Which symptom is INCONSISTENT with irritable bowel syndrome in older adults? Constipation Abdominal pain Bloating Onset after 50 years of age Correct Explanation: Irritable bowel syndrome (IBS) is common in adults and lasts into older adulthood but symptoms start prior to age 50 years. Typical symptoms of IBS are diarrhea and constipation intermittently, abdominal pain (one of the criteria for diagnosis), and bloating. Other symptoms that are inconsistent with IBS are associated weight loss, blood in the stool, rectal bleeding, nocturnal diarrhea. These are more indicative of inflammatory disease or carcinoma of the bowel. 90. A 70 year-old presents to the nurse practitioner’s office for a well exam today. What medication probably has no affect on screening for occult blood in the stool? Aspirin Clopidogrel Acetaminophen Correct Ibuprofen Explanation: The exam for occult blood is a screen for colorectal cancer. Aspirin, clopidogrel, NSAIDs, warfarin all decrease the positive predictive value of the test because they all can exacerbate bleeding if it is occurring in the colon secondary to a polyp or tumor. Ideally, the medications mentioned (except acetaminophen) would be stopped prior to the exam to increase the likelihood of test sensitivity, but this is not always possible. 91. What is the simplest screen for nutritional adequacy in elderly patients? Measure their weight Correct Measure their BMI Ask about food preferences Obtain a 72 hour food recall diary Explanation: In older adults, serial weight is the simplest screen for assessment of nutritional adequacy. Weight loss in elderly patients is associated with greater mortality than weight maintenance. 92. A 63 year-old male has been your patient for several years. He is a former smoker who takes simvastatin, ramipril, and an aspirin daily. His blood pressure and lipids are well controlled. He presents to your clinic with complaints of fatigue and “just not feeling well” for the last few days. His vital signs and exam are normal, but his liver enzymes are elevated. His hepatitis panel is negative for infectious hepatitis. What is the most likely cause of his elevated liver enzymes? He has received a generic version of simvastatin He is an alcoholic in denial Daily grapefruit consumption for the past 10 days Correct Rare liver toxicity from a usual dose of simvastatin Explanation: Grapefruit is a potent inhibitor of the cytochrome P450 enzyme system. Statins and calcium channel blockers are two infamous drug interactions that occur with grapefruit and grapefruit juice. Because they inhibit metabolism of the statin, the patient continues to have statin in circulation because he cannot significantly metabolize the medication. When the next day’s dose is taken, its effect is coupled with the effect of the previous day’s dose. The effect is cumulative. Hepatoxicity can quickly develop. The simvastatin must be stopped immediately! The liver enzymes must be followed until they return to normal; which could take weeks, months or even longer. 93. A patient with eczema asks for a recommendation for a skin preparation to help with xerosis. What should the NP respond? Use a petroleum based product Correct Use a hypoallergenic lotion Use any hypoallergenic product No particular product is better than another Explanation: Xerosis is dry skin. It is common in patients who have eczema. Using thick creams or ointments can prevent xerosis. Lotions should be avoided because they have high water content that promotes evaporation of water from the skin. Hypoallergenic refers to the allergenicity of a product. This is not related to the water content of products. 94. An elderly adult has constipation. A supplement known to cause constipation is: Vitamin A. calcium. Correct magnesium. Vitamin B-12. Explanation: Calcium does produce constipation in many patients. If this is taken as a supplement for osteoporosis or osteopenia, the patient should be encouraged to increase fluids and fiber. 95. The three most common causes of bacterial diarrhea in the US are Salmonella, Campylobacter, and: E. coli. Enterovirus. Yersinia. Shigella. Correct Explanation: Shigella will be shed continuously in the stool and should be easily identified on stool culture. When bacterial gastroenteritis is suspected, a stool specimen could be ordered for confirmation. Generally, these three pathogens are easily identified if they are present. 96. According to the American Geriatric Society, symptoms of uncomplicated reflux disease in older adults should be treated: by referring for upper GI testing. with empiric treatment. Correct ambulatory pH testing. referral to gastroenterology. Explanation: In older patients without signs of complicated GERD (choking, cough, shortness of breath, pain with swallowing or in the chest), empiric treatment is appropriate. Empiric treatment can take place using proton pump inhibitors or H2 blockers. If H2 blockers are used, famotidine and nizatidine are preferred because of their efficacy and low risk of drug-drug interactions. If symptoms of GERD persist despite initial treatment or if symptoms are severe, patients should have testing to rule out esophageal cancer, Barrett’s esophagitis, or other conditions of the esophagus and throat 97. An elderly adult has chronic constipation. How should this be managed initially? Avoid all constipating medications/foods when possible Correct Add dietary fiber and increase fluids Add sorbitol solution daily Use an oil retention enema Explanation: Initially, all medications known to cause constipation should be stopped when possible. Symptoms should be re-assessed. It is always preferable to stop a medication to correct a condition BEFORE adding a medication to correct a condition. If symptoms persist, 6-25 grams of dietary fiber should be added along with increasing fluid intake. Physical activity should be increased as tolerated. Choice 3 and 4 would be initiated if other options mentioned were not helpful. 98. What medication listed below could be used to increase appetite in an anorexic patient? Megestrol Correct Loratadine Fexofenadine Serum ferritin Explanation: Megestrol acetate has a positive effect on weight in patients who are trying to gain weight. It increases appetite and may improve quality of life. Weight gain may take up to 3 months before it is measurable. Megestrol has the potential to cause edema and so should be used cautiously (or not at all) in patients with chronic heart failure. 99. A 5 year-old has been diagnosed with pinworms. He lives with his mother. There are no other members of the household. How should his mother be managed? Reassure the mother that if she develops symptoms, she will need to be treated. Visually assess the mother’s rectum for redness or presence of worms. Have the mother collect a stool specimen and send it to the laboratory. Perform the “scotch tape” test and look at the collection under the microscope. Correct Explanation: The diagnosis of pinworms (Enterobiasis) is made by using a piece of scotch tape on a tongue depressor. It is touched against the patient’s rectum. The greatest yield of eggs will occur during the nighttime or early AM. Eggs will be found here if they are present. Worms and eggs are rarely found in stool specimens, so this is not a good plan. When the scotch tape is examined under a low power microscope, the eggs will be easily visualized since they are large and bean shaped. The finding of an adult worm would confirm the diagnosis. These are large enough to be seen with the naked eye. If the mother is symptomatic, she should be treated with or without a rectal exam. It is very likely she is infected 100. A 56 year-old male patient has been diagnosed with an inguinal hernia. What symptom would make the nurse practitioner suspect an incarcerated hernia? Swelling Change in skin color Constipation Pain Correct Explanation: A hernia is a weakened area in the muscle where loop of bowel protrudes through the abdominal wall. Normally, hernias are not frankly painful, though they may be tender. A painful hernia should be suspected as one that has become incarcerated or strangulated. Incarceration means that the hernia cannot be reduced; it is trapped. A strangulated hernia means that it is incarcerated and ischemia is present. A strangulated hernia is a surgical emergency. Emergency surgery should be performed within 4-6 hours to prevent loss of bowel. 101. A patient with diarrhea is tested for C. difficile. How soon should the enzyme immunoassay (EIA) yield results? Within 20 minutes About 24 hours Correct About 3 days Less than one week Incorrect Explanation: The enzyme immunoassay allows detection of Clostridium difficile toxin, not the organism. It is the most commonly used assay in the US because it is easy to perform, yields results in less than 24 hours. The assay has good specificity, but moderate sensitivity. More sensitive tests can be performed but they are more expensive and take longer to yield results. 102. An 83 year-old patient is diagnosed with diverticulitis. Where is her pain typically located? Epigastric area Right or left lower quadrant Left lower quadrant Correct Right lower quadrant Explanation: Diverticular disease is more common in older adults. About 70% of patients diagnosed with diverticulitis have left lower quadrant pain. Pain may be present for several days prior to the acute episode. In addition to left lower quadrant pain, bloating and cramping are commonly described by these patients. Diverticulitis occurs secondary to perforations of a diverticulum.