NR 509 Final Exam 2022 with complete solutions

Know that in a 47-year-old man ED is usually ___________ rather than testosterone - ANSWER psychologic Erectile dysfunction may be from psychogenic causes, especially if - ANSWER early morning erection is preserved. ...

Know that in a 47-year-old man ED is usually ___________ rather than testosterone - ANSWER psychologic Erectile dysfunction may be from psychogenic causes, especially if - ANSWER early morning erection is preserved. it may also reflect decreased testosterone, decreased blood flow in the hypogastric arterial system, impaired neural innervation, and diabetes When performing a breast exam, know what abnormal masses should do when the arm - ANSWER may be fixed to skin or underlying tissues (may cause dimpling of skin or retraction when arms are lifted over head or hands are pressed against hips) Fibroadenoma and cysts mobility - ANSWER very mobile/mobile Know that a high proportion of breast masses are noted during ________ - ANSWER BSE Breast stage 1 - ANSWER preadolescent- elevation of nipple only Breast stage 2 - ANSWER breast bud stage- elevation of breast and nipple as a small mound; enlargement of areolar diameter breast stage 3 - ANSWER further enlargement of elevation of breast and areola, with no separation of their contours breast stage 4 - ANSWER projection of areola and nipple to form a secondary mound above the level of breast breast stage 5 - ANSWER mature stage- projection of nipple only; areola has receded to general contour of the breast (although in some individuals the areola continues to form a secondary mound) Know where pain is located with pancreatitis: acute - ANSWER epigastric, may radiation straight to the back of other areas of the abdomen; 20% with severe sequelae of organ failure Know where pain is located with pancreatitis: chronic - ANSWER epigastric, radiating to back Know how hepatitis A is transmitted - ANSWER Transmitted through fecal-oral route. Fecal shedding followed by poor handwashing contaminates water and foods leading to infection of household and sexual contacts Stress incontinence - ANSWER the urethral sphincter is weakened so that transient increases in intra-abdominal pressure raise the bladder pressure to levels that exceed urethral resistance. Causes include childbirth and surgery, postmenopausal atrophy of the mucosa, and urethral infection. May follow prostate surgery in men. urge incontinence - ANSWER detrusor contractions are stronger than normal and overcome the normal urethral resistance. The bladder is typically small. Mechanisms: Decreased cortical inhibition of detrusor contractions from stroke, brain tumor, dementia, and lesions of the spinal cord above sacral level. Also hyperexcitability of sensory pathways ie: bladder infections, tumors, and fecal impaction. Deconditioning of voiding reflexes ie: frequent voluntary voiding at low bladder volumes. overflow incontinence - ANSWER detrusor contractions are insufficient to overcome urethral resistance, causing urinary retention. The bladder is typically flaccid and large, even after an effort to void. Mechanisms: obstruction of the bladder outlet ie: BPH or tumor. Weakness of the detrusor muscle associated with peripheral nerve disease at S2-4 level. Impaired bladder sensation that interrupts the reflex arc ie: diabetic neuropathy. functional incontinence - ANSWER the patient is functionally able to reach the toilet in time because of impaired health or environmental conditions. Mechanism: problems in mobility resulting from weakness, arthritis, poor vision, or other conditions. Also environmental factors such as an unfamiliar setting, distant bathroom facilities, bed rails, or physical restraints. Incontinence secondary to medications - ANSWER drugs may contribute to any type of incontinence listed. Ex: sedatives, tranquilizers, anticholinergics, sympathetic blockers, and potent diuretics Know where lymph nodes should be with strep - ANSWER · Strep throat àstreptococcal pharyngitis, bacterial infection that may cause a sore, scratchy throat · Common childhood infection has a classic presentation of erythema of the posterior pharynx and palatal petechiae · Enlarged swollen cervical lymph nodes -> superficial cervical lymph nodes Superficial cervical -> superficial to the sternocleidomastoid What vaccines are safe during pregnancy - ANSWER tdap, flu, Pneumococcal, meningococcal, Hepatitis B, rho gam *NOT MMR, polio, or varicella Know what to be concerned about if you note an irregular rectal mass - ANSWER · Any masses with irregular borders suspicious for rectal cancer A tender purulent reddened mass with fever or chills suggests an anal abscess. Abscesses tunneling to the skin surface from the anus or rectum may form a clogged or draining ano-rectal fistula. Fistulas may ooze blood, pus, or feculent mucus. Consider anoscopy or sigmoidoscopy for better visualization. Know what HPV Vac protects against - ANSWER · Prevents infection from HPV subtypes 16, 18, 6 & 11 which cause 90 % of genital warts · The bivalent vaccine prevents infection from subtypes 16 and 18. · Recommended for prevention of cervical, vulvar, and vaginal cancers and precancers in females as well as anal cancer, precancers, and genital warts in both female and males · Vaccinated women should still get cervical cancer screening because vaccines do not prevent all HPV subtypes · Condoms do not eliminate the risk of cervical HPV infection Recommended for those with compromised immune systems including HIV Know what a 3-year-old can do in regard to jumping and balancing - ANSWER · Climbs well, runs easily · Pedals a tricycle · Walks up and down stairs, one foot on each step Know where to place measuring tape when measuring uterus in a pregnant patient - ANSWER · Measure the fundal height if gestational age is >20 weeks - fundus should reach the umbilicus · Place tape measure on pubic symphysis and place the "zero" end of the tape measure when you can firmly feel that bone. · Extend the tape measure to the very top of uterine fundus and note the number of cm measured. o Subject to error between 16-36 weeks · Number should roughly equal the number of weeks of gestation o If fundal height is >4cm than expected -multiple gestation, large fetus, extra amniotic fluid, uterine leiomyoma o If fundal height is < 4cm than expected - low-level amniotic fluid, missed abortion, intrauterine growth retardation, or fetal anomaly The _______ _______ occupies most of the anterior cardiac surface - ANSWER right ventricle Know what bleeding between periods is called - ANSWER Abnormal uterine bleeding, Intermenstrual bleeding Know types of vaginosis - ANSWER Trichomonal vaginitis, Candidal Vaginitis, Bacterial vaginosis miliaria rubra - ANSWER Scattered vesicles on an erythematous base, usually on the face and trunk, result from obstruction of the sweat gland ducts; disappears spontaneously within weeks Know the characteristics of a breast cyst - ANSWER Usually soft to firm, round, mobile and often tender. Most common between the ages of 25-50 Know the signs of peritonitis - ANSWER When tender area is palpated for guarding, early voluntary guarding may be replaced by involuntary muscular rigidity and signs of peritoneal inflammation. There may also be RLQ pain on quick withdrawal or deferred rebound tenderness. Know where pain is with diverticulitis - ANSWER LLQ Know what position to have pt in to listen for mitral stenosis - ANSWER Left lateral decubitus Know what to ask in regards to cardiovascular review of systems (pick the one that belongs) - ANSWER Ask questions related to: chest pain, palpitations, shortness of breath, swelling (edema), syncope Know how a bartholin's gland infection presents - ANSWER Acutely, the gland appears as a tense, hot, very tender abscess. Possible labial swelling. Look for pus emerging from the duct or erythema around the duct opening. Chronically, a nontender cyst is felt that may be large or small. Know where pain is with appendicitis - ANSWER RLQ pain or pain that migrates from the periumbilical region, combined with abdominal wall rigidity on palpation is suspicious for appendicitis Know how syphilis presents genitally - ANSWER Female: syphilitic chancre- firm, painless ulcer from primary syphilis, forms approx. 21 days after exposure to Treponema pallidum. It may remain hidden and undetected in the vagina and heals regardless of treatment in 3-6 weeks. Secondary syphilis (Condyloma lantum)- large raised, round or oval, flat-topped gray or white lesions point to condylomata lata. These are contagious and, along with rash and mucus membrane sores in the mouth, vagina, or anus are manifestations of secondary syphilis. Male: Primary syphilis: small red papule that becomes a chancre, a painless erosion up to 2 cm in diameter. Base of chancre is clean, red, smooth, and glistening; borders are raised and indurated. Chancre heals within 3-8 weeks. Know the signs of proctitis - ANSWER Anorectal pain, itching, tenesmus, or discharge or bleeding from infection or rectal abscess suggest proctitis. Know what causes dark, bloody emesis - ANSWER Hematemesis may accompany esophageal or gastric varices, Mallory-Weiss tears, or peptic ulcer disease. Know what causes an S3 heart sound - ANSWER In children and young adults, a third heart sound (S3) may arise from rapid deceleration of the column of blood against the ventricular wall. In an older adult, an S3 usually indicates a pathologic change in ventricular compliance. Know the signs of thrombophlebitis - ANSWER Local swelling, redness, warmth, and a subcutaneous cord signal superficial thrombophlebitis (an emerging risk factor for DVT). Know what chalazion is - ANSWER A subacute nontender, usually painless nodule caused by a blocked meibomian gland. May become acutely inflamed, but unlike a stye, usually points inside the lid rather than on the lid margin. Know what the lungs do with age - ANSWER Chest wall becomes stiffer and harder to move (decrease in chest wall compliance), respiratory muscles may weaken, and the lungs lose some of their elastic recoil. Lung mass and the surface area for gas exchange decline, and residual volume increases as the alveoli enlarge. An increase in closing volumes of small airways predisposes to atelectasis and risk of pneumonia. Diaphragmatic strength declines. Know what diastasis recti is - ANSWER As tension on the abdominal wall increases with advancing pregnancy, the rectus abdominus muscles may separate at the midline, called diastasis recti. If diastasis is severe, especially in multiparous women, only a layer of skin, fascia, and peritoneum may cover the anterior uterine wall, and fetal parts may be palpable through this muscular gap. Identify the macula in the eye - ANSWER Know the sequence of the abdomen - ANSWER Inspect, auscultate, percuss, palpate (first palpate lightly, then deeply). Assess the liver and spleen by percussion then palpation. Try to palpate the kidneys. Palpate the aorta and its pulsations. If you suspect kidney infection, percuss posteriorly over the costovertebral angles. Senile (Actinic) Pupura - ANSWER Know the signs of epididymitis - ANSWER Acute epididymitis: an acutely inflamed epididymis is indurated, swollen, and notably tender, making it difficult to distinguish from the testis. The scrotum may be reddened and the vas deferens inflamed. Know what to do if you cannot feel a testicle in the scrotum of a newborn - ANSWER If you feel a testis up in the inguinal canal, gently milk it downward into the scrotum. Need to differentiate between undescended testes (in the inguinal canals) and highly retractile testes. Know the sign factors of prostate cancer: age - ANSWER rare in ages below 40 but incidence rates begin increasing rapidly after age 50. Median age at diagnosis is 66. Know the sign factors of prostate cancer: ethnicity - ANSWER African American men have the highest incidence and mortality rates. Compared to white men, a higher percentage of African American men are diagnosed with prostate cancer before age 50. They are also more likely to present with advanced-stage cancer. Know the sign factors of prostate cancer: family hx - ANSWER Genetics appear to play an important role in prostate cancer risk. For men with one affected first degree relative (father, brother) risk of developing prostate cancer increases two fold. For men with 2 or 3 affected first degree relatives, risk increases 5-11 fold. The BRCA1 and BRCA2 mutations also appear to confer increased risk of prostate cancer. Know the sign factors of prostate cancer: other risk factors - ANSWER Agent Orange exposure among Vietnam veterans, diets high in animal fat, obesity, and cigarette smoking. BPH is NOT a risk factor. Know what chicken pox looks like (will be a description) - ANSWER Chickenpox is a highly contagious disease caused by the varicella-zoster virus (VZV). It can cause an itchy, blister-like rash. The rash first appears on the chest, back, and face, and then spreads over the entire body, causing between 250 and 500 itchy blisters. (CDC) Know the signs of candida vaginitis - ANSWER (YEAST INFECTION) Discharge that is white and curdy, may be thin but typically thick, not malodorous. Often accompanied by pruritis, vaginal soreness, pain on urination (from skin inflammation) and dyspareunia. Vulva and surrounding skin are often inflamed and sometimes swollen to a variable extent. The vaginal mucosa is often reddened with tenacious patches of white discharge. Know to screen for depression with vague complaints and negative work-up - ANSWER Know when to order ABI (ankle-brachial index) - ANSWER Order with findings of diminished or absent pulses (present in peripheral arterial disease (PAD) Know which lymph node group is most commonly involved in breast cancer - ANSWER central nodes (axillary) Know the Risk Factors for PAD - ANSWER 1. Age greater than or equal to 50 with a hx of DM or smoking 2. Leg symptoms with exertion 3. Nonhealing wounds Also: smoking, diabetes, obesity (BMI >30), high blood pressure, high cholesterol, increasing age (especially over 50), family hx of PAD, heart dis, or stroke. Know what Condylamata Acuminata is - ANSWER Genital warts- single or multiple papules or plaques of variable shapes; may be round, acuminate (pointed), or thin and slender. May be raised, flat, or cauliflower like (verrucous). Caused by HPV, usually strains 6 & 11. Incubation usually weeks to months. Infected contact may have had no visible warts. Occasionally cause itching and pain. May disappear without treatment. Can arise on penis, scrotum, groin, thighs, or anus (in males). Know the differentials for epigastric pain - ANSWER GERD, pancreatitis, and perforated ulcers, myocardial ischemia Know what a bounding pulse is on a number scale 0-3 - ANSWER bounding= 3+ Know what an 8-month-old child should be able to do in regards to standing, using words, and vocalizing what he wants - ANSWER Can pull up to stand, say "mama" and "dada" and indicates wants by vocalizing and pointing Know what brief test you can do to assess memory - ANSWER Serial 7's: poor performance may result from delirium, the late stages of dementia, intellectual disability, anxiety or depression. Also need to consider educational level. Spelling backward New learning activity: 3 to 4 word recall- give the patient 3 words and have them repeat them so that you know they heard them. Then ask them to recall the words 3-5 minutes later. Delirum - ANSWER acute, worse at night, lasts hours to weeks, disrupted sleep, general illness and/or drugs present, disturbed LOC, hesitant/slow/rapid/incoherant speech, disorganized thought process, immediate and recent memory impaired, delusions common Dementia - ANSWER insidious, slowly progressive, lasts months to years, fragmeted sleep, general illness often absent, LOC usually normal, difficulty finding words, flat, depressed, recent memory and new learning impaired