Acute Care Exam 2 with complete solutions

A patient develops acute diarrhea and then comes to clinic two weeks later reporting profuse watery, bloody diarrheal stools 6 to 8 times daily. The provider notes a toxic appearance with moderate dehydration. Which test ...

A patient develops acute diarrhea and then comes to clinic two weeks later reporting profuse watery, bloody diarrheal stools 6 to 8 times daily. The provider notes a toxic appearance with moderate dehydration. Which test is indicated to diagnose this cause? Stool collection for 24-hour stool pH Qualitative and quantitative fecal fat C. difficile toxin Wright stain of stool for white blood cells - ANSWER C. difficile toxin A patient reports anal pruritis and occasional bleeding with defecation. An examination of the perianal area reveals external hemorrhoids around the anal orifice as the patient is bearing down. The provider orders a colonoscopy to further evaluate this patient. What is the treatment for this patient's symptoms? Referral for possible surgical intervention A high-fiber diet and increased fluid intake Daily laxatives to prevent straining with stools Infiltration of a local anesthetic into the hemorrhoid - ANSWER A high-fiber diet and increased fluid intake A patient has sudden onset of right upper quadrant and epigastric abdominal pain with fever, nausea, and vomiting. The emergency department provider notes yellowing of the sclerae. What is the probable cause of these findings? Acute acalculous cholecystitis Infectious cholecystitis Common bile duct obstruction Chronic cholelithiasis - ANSWER Common bile duct obstruction An 83 year old is diagnosed with diverticulitis. The most common complaint is Rectal bleeding Bloating and crampiness Left lower quadrant pain Frequent belching and flatulence - ANSWER Left lower quadrant pain A patient's CBC demonstrated anemia. Which diagnosis is likely based on this patient's laboratory values? MCV 74.1 fL (normal 80-95) MCH 24 pg (normal 27-31) MCHC 33% (normal 32-69) RDW 12% (normal 11-14.5) iron deficiency anemia anemia of chronic disease vitamin B12 deficiency anemia thalassemia - ANSWER thalassemia A patient has fever, nausea, vomiting, anorexia, and right upper quadrant abdominal pain. An ultrasound is negative for gallstones. Which action is necessary to treat this patient's symptoms? Hospitalization for emergent treatment Empiric treatment with antibiotics Supportive care with close follow-up Prescribing ursodeoxycholic acid - ANSWER Hospitalization for emergent treatment A patient has both occasional "coffee ground" emesis and melena stools. What is the most probably source of bleeding in this patient? Upper GI Hepatic Lower GI Rectal - ANSWER Upper GI An adult patient has intermittent, crampy abdominal pain with vomiting. The provider notes marked abdominal distention and hyperactive bowel sounds. What will the provider do initially? Prescribe an antiemetic and recommend a clear liquid diet for 24 hours Obtain upright and supine radiologic views of the abdomen Schedule the patient for a barium swallow and enema Admit the patient to the hospital for consultation with a surgeon - ANSWER Obtain upright and supine radiologic views of the abdomen What choice below is most commonly associated with pancreatitis? Appendicitis and renal stones Hypertriglyceridemia and cholecystitis Gallstones and alcohol abuse Viral infection and cholecystitis - ANSWER Gallstones and alcohol abuse What medication may be used to treat GERD if a patient has tried over the counter ranitidine without benefit? Prescription strength ranitidine Calcium carbonate Prescription strength ranitidine Pantoprazole - ANSWER Pantoprazole A 30-year-old woman has right upper quadrant abdominal pain, nausea, and vomiting. Which diagnostic test will the provider order? Abdominal ultrasound MRI of the abdomen Abdominal CT with contrast Plain abdominal radiographs - ANSWER Abdominal ultrasound Which medications may increase the prevalence of GERD? (Select all that apply.) Calcium antagonists Aspirin Oral contraceptives Hormone replacements Benzodiazepines - ANSWER Calcium antagonists Aspirin Benzodiazepines What is the best treatment for H. pylori-related peptic ulcer disease? H2RA, bismuth, metronidazole, and tetracycline for 10 to 14 days PPI, amoxicillin, and clarithromycin for 10 days PPI and clarithromycin for 14 days H2RA and clarithromycin for 14 days - ANSWER PPI and clarithromycin for 14 days An 8-month-old girl is brought by her grandmother to see the nurse practitioner because of intermittent, random episodes of vomiting, abdominal bloating, currant jelly stools, and irritability with poor appetite. The infant is stranding in the 10th percentile on the growth chart and appears lethargic. During the abdominal exam, a sausage like mass is palpated on the right side of the abdomen. The infant's presentation is highly suggestive of which condition? Lactose intolerance Intussusception Inflammatory bowel disease Irritable bowel syndrome - ANSWER Intussusception The classic triad of intussusception is currant jelly stools, a sausage like mass, and pain. A sausage-shaped abdominal mass may be palpated on the right side of the abdomen. A patient is in the clinic with a 36 hrs history of diarrhea and moderate dehydration. Interventions should include: IV rehydration Oral rehydration with gatorade or tea Resumption of usual fluid intake Oral rehydration with an electrolyte replenishment solution - ANSWER Oral rehydration with an electrolyte replenishment solution All of the following are true statements about diverticula except: Most diverticula in the colon are infected with gram negative bacteria Supplementing with fiber, such as psyllium (Metamucil), is recommended Diverticula are located in the colon A low fiber diet is associated with the condition - ANSWER Most diverticula in the colon are infected with gram negative bacteria A patient has a history of diverticular disease and asks what can be done to minimize acute symptoms. What will the practitioner recommend to this patient? Taking an anticholinergic medication Consuming a diet high in fiber Avoiding saturated fats and red meat Using bran to replace high-fiber foods - ANSWER Consuming a diet high in fiber A patient has a recent episode of vomiting and describes the vomitus as containing mostly gastric juice. What does this symptom suggest? Small bowel obstruction Gastritis Peptic ulcer Bile duct obstruction - ANSWER Peptic ulcer A patient present with abdominal pain and has the following laboratory findings. Would does this mean? HBsAg positive anti-HBc positive IgM Anti-HBc positive anti-HBs negative He has immunity to hepatitis B More data is needed He has no immunity to hepatitis B He has acute hepatitis B - ANSWER He has acute hepatitis B A positive hepatitis B surface antigen and a positive IgM means that this patient has acute hepatitis B. The first serological marker to be positive is the surface antigen. It can become positive as soon as 3-4 weeks after exposure to hepatitis B. Positive IgM indicates acute infection. A patient who has been taking an NSAID for osteoarthritis pain has newly diagnosed peptic ulcer disease. What is the initial step in treating this patient? Discontinue the NSAID Order prostaglandin therapy Prescribe a proton pump inhibitor Recommend an H2 receptor antagonist - ANSWER Discontinue the NSAID Which is the most common cause of pancreatitis in the United States? Hyperlipidemia Ethyl alcohol Trauma Gallstones - ANSWER Gallstones Most patient who have an acute hepatitis B infection: Have varied clinical presentations Are acutely ill Are females Develop subsequent cirrhosis - ANSWER Have varied clinical presentations Which description is more typical of a patient with acute cholecystitis? The patient is ill appearing and febrile The elderly patient is more likely to exhibit Murphy's sign The patient rolls from side to side on the exam table Most are asymptomatic until a stone blocks the bile duct - ANSWER The patient is ill appearing and febrile A patient with acute cholecystitis usually c/o abd pain in upper right quadrant or epigastric pain. Many also have nausea. The patient lies still on the exam table as this condition is associated with peritoneal inflammation that is worse with movement. Elderly are less likely to exhibit Murphy's sign. Asymptomatic patients have cholelithiasis. A patient is in clinic for evaluation of sudden onset of abdominal pain. The provider palpates a pulsatile, painful mass between the xiphoid process and the umbilicus. What is the initial action? Schedule the patient for an aortic angiogram Perform an ultrasound examination to evaluate the cause Transfer the patient to the emergency department for a surgical consult Order a CBC, type and crossmatch, electrolytes, and renal function tests - ANSWER Transfer the patient to the emergency department for a surgical consult A patient has intermittent left-sided lower abdominal pain and fever associated with bloating and constipation alternating with diarrhea. The provider suspects acute diverticulitis. Which tests will the provider order? (Select all that apply.) Stool for occult blood CT scan of abdomen and pelvis Rigid sigmoidoscopy Plain abdominal radiographs Barium enema examination - ANSWER Stool for occult blood CT scan of abdomen and pelvis Extreme tenderness and involuntary guarding at McBurney's point is a significant finding for possible: Acute gastroenteritis Acute appendicitis Acute diverticulitis Acute cholecystitis - ANSWER Acute appendicitis A 24 year old female with pain and tenderness in the right lower abdominal quadrant. Pelvic exam and UA are normal. WBC is elevated. Urine pregnancy test is negative. What is part of the differential diagnosis? UTI Pelvic inflammatory disease Ectopic pregnancy Appendicitis - ANSWER Appendicitis Which factors increase the risk of renal stones? (Select all that apply.) Excess antacid use Vitamin D excess Strenuous exercise Snow skiing Surgical menopause - ANSWER Excess antacid use Strenuous exercise Surgical menopause A pregnant woman at 30 weeks gestation has proteinuria. What will the provider do next? Reassure her that this normal at this stage of pregnancy Evaluate her blood pressure Monitor serum glucose for gestational diabetes Perform a 24-hour urine collection - ANSWER Evaluate her blood pressure A patient who has diabetes has symptoms consistent with renal stones. Which type of stone is most likely in this patient? Uric acid Citrate Oxalate Cysteine - ANSWER Uric acid A 50-year-old male patient reports that he has a sensation of scrotal heaviness. He reports that the sensation is worse at the end of the day. He denies pain. What is likely etiology of these symptoms? Strangulated hernia Inguinal hernia Epididymitis Hydrocele - ANSWER Inguinal hernia Inguinal hernias are common in males. typical symptom reported by man with an inguinal hernia is scrotal heaviness, especially at the end of the day. If pain is severe, it may indicated strangulated hernia. This is a medical emergency. Epididymitis can produce scrotal pain, not usually heaviness. Hydrocele results in fluid in the scrotum. A female patient who is 45-year-old states that she is having urinary frequency. She describes episodes of "having to go right now" and not being able to wait. Her urinalysis results are within normal limits. What this part of the differential? Stress incontinence Asymptomatic bacteriuria Lupus Diabetes - ANSWER Diabetes Patients with diabetes can present with polyuria. In assessment of patient's risk factors should be done with strong consideration even to checking glucose level. Other possible diagnoses include urge incontinence and vaginitis. A urinalysis would show bacteriuria. A 3-month-old male infant has edema and painless swelling of the scrotum. On physical examination, the provider is able to transilluminate the scrotum. What will the provider recommend? A short course of empiric antibiotic therapy Observation and reassurance that spontaneous resolution may occur A Doppler ultrasound to evaluate the scrotal structures Immediate referral to a genitourinary surgeon for repair - ANSWER Observation and reassurance that spontaneous resolution may occur An asymptomatic pregnant woman has a positive leukocyte esterase and positive nitrites on a urine dipstick screening. What will the provider do next? Admit to the hospital Obtain a urine culture Prescribe trimethoprim-sulfamethoxazole Order a renal ultrasound - ANSWER Obtain a urine culture A patient has acute renal colic, nausea, and vomiting and a urinalysis reveals hematuria, but is otherwise normal. A radiographic exam shows several radiopaque stones in the ureter which are less than 1 mm in diameter. What will the primary provider do initially to manage this patient? Order a narcotic pain medication and increased oral fluids Obtain a consultation with a urology specialist Prescribe desmopressin and a corticosteroid medication Prescribe nifedipine and hospitalize for intravenous antibiotics - ANSWER Order a narcotic pain medication and increased oral fluids 17-year-old boy reports feeling something on his left scrotum. On palpation, soft and movable blood vessels that feel like "a bag of worms" are noted underneath the scrotal skin. The testicle is not swollen or reddened. The most likely diagnosis is: Testicular torsion Varicocele Chronic orchitis Chronic epididymitis - ANSWER Varicocele Palpation of varicose veins, described as "a bag of worms", is a classic symptom of varicocele. The daughter of an elderly, confused female patient reports that her mother is having urinary incontinence several times each day. What will the provider do initially? Perform a bladder scan to determine distention and retention Tell the daughter that this is expected given her mother's age and confusion Obtain a urine sample for urinalysis and possible culture Order serum creatinine and blood urea nitrogen tests - ANSWER Obtain a urine sample for urinalysis and possible culture An adolescent male reports severe pain in one testicle. The examiner notes edema and erythema of the scrotum on that side with a swollen, tender spermatic cord and absence of the cremasteric reflex. What is the most important intervention? Immediate referral to the emergency department Doppler ultrasound to assess testicular blood flow Prescribing anti-infective agents to treat the infection Transillumination to assess for a "blue dot" sign - ANSWER Immediate referral to the emergency department A 20-year-old male has epididymitis. His most common complaint will be: Scrotal pain Burning with urination Penile discharge Testicular pain - ANSWER Scrotal pain The most common complaint for epididymitis is scrotal pain. Usually develops over a period of days. Burning with urination is possible if the underlying cause is a urinary tract infection. However, this is more common in older males. Testicular pain is not a common complaint with epididymitis. Penile discharge may occur with gonorrhea or Chlamydia infections. A 16-year-old female patient is being treated for her first UTI. She had an allergic reaction with hives after taking sulfa as a child. Which of the following antibiotics would be contraindicated? Trimethoprim-sulfamethoxazole Cephalexin Nitrofurantoin Ampicillin - ANSWER Trimethoprim-sulfamethoxazole A young adult male reports a gradual onset 3/10 dull pain in the right scrotum and the provider notes a bluish color showing through the skin on the affected side. Palpation reveals a bag of worms on the proximal spermatic cord. What is an important next step in managing this patient? Consideration of underlying causes of this finding Referral to an emergency department for surgical consultation Reassurance that this is benign and may resolve spontaneously Anti-infective therapy with ceftriaxone or doxycycline - ANSWER Consideration of underlying causes of this finding A 30-year-old male patient has a positive leukocyte esterase and nitrites on a random urine dipstick during a well patient exam. What type of urinary tract infection does this represent? Unresolved Uncomplicated Isolation Complicated - ANSWER Complicated An older male patient reports gross hematuria but denies flank pain and fever. What will the provider do to manage this patient? Obtain a urine culture Monitor blood pressure closely Refer for cystoscopy and imaging Perform a 24-hour urine collection - ANSWER Refer for cystoscopy and imaging A male patient complaints of dysuria. His urinalysis is positive for nitrates, leukocytes, and bacteria. What medication should be given and for how many days? Ciprofloxacin for 3 days Nitrofurantoin for 14 days Doxycycline for 7 days Trimethoprim-sulfamethoxazole for 7-10 days - ANSWER Trimethoprim-sulfamethoxazole for 7-10 days A patient's recent blood work indicates acute kidney injury. You know that acute kidney injury can be caused from: Heart failure exacerbation GERD Increase in metoprolol dose atrial fibrillation - ANSWER Heart failure exacerbation Heart failure exacerbation and cause decreased perfusion to the kidneys, leading to acute kidney injury. Changes in medications or nephrotoxic can cause acute kidney injury, metoprolol is not one of them. While patients with atrial fibrillation can have decreased cardiac output, it is often compensated to preserve renal perfusion The provider is evaluating a patient for potential causes of urinary incontinence and performs a postvoid residual (PVR) test which yields 30 mL of urine. What is the interpretation of this result? The patient may have overflow incontinence. The patient probably has a UTI. This represents incomplete emptying. This a normal result. - ANSWER This a normal result. A female patient reports hematuria and a urine dipstick and culture indicate a urinary tract infection. After treatment for the UTI, what testing is indicated for this patient? Voiding cystourethrogram 24-hour urine collection to evaluate for glomerulonephritis No testing if hematuria is resolved Bladder scan - ANSWER No testing if hematuria is resolved A physically independent 75 year old was diagnosed with mild cognitive impairment 6 months ago. She resides in an assisted living facility. she is in clinic today for scheduled visit. Her adult daughter reports that about 2 weeks ago her mother had an episode of urinary incontinence, but no episode since then. She is found to have asymptomatic bacteriuria. How should this be managed? Repeat the urinalysis in 7 days Repeat the urinalysis in 4 weeks Treat her today with one dose of an antibiotic Monitor her for symptoms of urinary tract infection - ANSWER Monitor her for symptoms of urinary tract infection Approximately 30-50% of older females living in institutions have asymptomatic bacteriuria. No data support treatment of patients to prevent future problems or complications. In fact, asymptomatic bacteriuria is not usually treated unless the patient is pregnant, immunocompromised, or is undergoing a urinary procedure. A pregnant patient has asymptomatic bacteriuria. What is the likely pathogen? Escherichia coli Staph aureus Klebsiella No pathogen - ANSWER Escherichia coli Of pregnant patient with asymptomatic bacteriuria should be treated with antibiotics because she is at high risk of developing pyelonephritis and/or preterm labor. The most common pathogen is Escherichia coli. The provider is counseling a patient who has stress incontinence about ways to minimize accidents. What will the provider suggest initially? Voiding every 2 hours during the day Referral to a physical therapist Increasing fluid intake to dilute the urine Taking pseudoephedrine daily - ANSWER Voiding every 2 hours during the day A patient with urolithiasis is more likely to: Demonstrate RBC casts Have chills and fevers Be of male gender Have frequent UTIs - ANSWER Be of male gender Males are more likely than females to have urolithiasis. There is no increased incidence of stone formation among patients with frequent UTIs. Patients with your urolithiasis may exhibit fever and chills of infection if associated with a very large stone, but this is not the usual case. RBC casts are formed in the renal tubules, this generally indicates glomerular injury, not urolithiasis. A pregnant patient is found to have a urinary tract infection. What is the appropriate course of action? Prescribe nitrofurantoin Prescribe ciprofloxacin Prescribe TMP/SMX Prescribe no antibiotics - ANSWER Prescribe nitrofurantoin Nitrofurantoin is considered probably safer to use during pregnancy. It provides coverage for most common UTI pathogens. TMP/SMX is a full of acid antagonist and may be associated with increased risk of congenital malformation. Ciprofloxacin is not to be used first line for any simple UTI, and may not be safe during pregnancy. In some occasions it could still be given if benefits outweigh risks. An adolescent male reports severe pain in one testicle. The examiner notes edema and erythema of the scrotum on that side with a swollen, tender spermatic cord and absence of the cremasteric reflex. What is the most important intervention? Prescribing anti-infective agents to treat the infection Immediate referral to the emergency department Transillumination to assess for a "blue dot" sign Doppler ultrasound to assess testicular blood flow - ANSWER Immediate referral to the emergency department If cervical stenosis is met when performing IUD insertions, which of the following should be used to overcome resistance? 12 - 15 cm 3 - 6 cm 9 - 12 cm 6 - 9 cm - ANSWER 6 - 9 cm A 45 year old diabetic female presents with c/o vaginal itching and discharge that began after douching post-menstruation approximately one week ago. Upon exam, you find thick, white discharge with a curd-like consistency and erythema generally in the vuvlvogavinal region. Under a wet mount you see the following below (budding, branching hyphae). Which of the following is an appropriate treatment for this patient? No treatment needed Rocephin (Ceftriaxone) 250mg IM x 1 and Azithromycin 1 g PO x 1 Diflucan (Fluconazole) 150mg PO x 1 Flagyl (Metronidazole) 500mg PO BID x 7 days - ANSWER Diflucan (Fluconazole) 150mg PO x 1 What is included in your treatment plan for #4? Flagyl (Metronidazole) 2g PO x 1 of patient only and no report to the county Rocephin (Ceftriaxone) 250mg IM with partner treatment and report to the county Flagyl (Metronidazole) 2g PO x 1 with partner treatment and report to the county Rocephin (Ceftriaxone) 250mg IM of patient only and no report to the county - ANSWER Flagyl (Metronidazole) 2g PO x 1 with partner treatment and report to the county Syphilis may present as: Discharge Painful lesions Dysuria A rash - ANSWER A rash Secondary syphilis can present as a rash, more commonly on the palms of the hands or soles of the feet. Lesions are usually painless. It usually does not produce significant dysuria or discharge. A 19-year-old student who is on prescription combined oral contraceptive pills is being seen for lower GI pain. The nurse practitioner has obtained a Pap smear and is about to perform the bimanual exam. She gently remove the plastic speculum from the vagina. While the NP is performing the bimanual vaginal exam, the patient complaints of slight discomfort during palpation of the ovaries. Which with the following is a true statement?