NR-511 Week 4 Midterm Exam Concept Review (NP Cafe)

CONFIDENTIAL ©2017 Chamberlain University LLC. All rights reserved. Your textbook is the standard. Use tonight’s information as a guide to help you focus on what to study. To extensively learn the information ...

CONFIDENTIAL ©2017 Chamberlain University LLC. All rights reserved. Your textbook is the standard. Use tonight’s information as a guide to help you focus on what to study. To extensively learn the information, use your book. This presentation cannot be used to support any of your chosen answers on the exam. • 100 questions • Multiple-choice • Study guide • Concepts: – Dermatological disorders – ENT disorders – Mouth disorders – Gastrointestinal – Primary care basics – APN business essentials – Documentation • Assess • Diagnosis • Treat • Who is at risk • What are the risk factors for the condition to develop into something else. Ask yourself, what does this question want me to do? Define, prioritize, diagnose, treat, plan • Actinic keratosis • Fungal infections • Pruritus • Dermatitis – candida albicans common – Tinea versicolor – Balanitis (penis) – Tinea corporis *ring worm – pityriasis rosea & alba – Atopic dermatitis – Keratosis pilaris (goose/chicken) – Seborrheic dermatitis - dandruff – Tinea pedis – Tinea cruis (jock-itch) • Bacterial infections – Cellulitis and folliculitis • Rash • Pigment Changes • Urticaria (hives) • Alopecia • Seborrheic keratosis – benign, autosomal dominant trait, biopsy • Lipoma • Nevi (moles) • Skin tag (acrochordons) CONFIDENTIAL ©2017 Chamberlain University LLC. All rights reserved. 5 • Viral infections – Erythema infectiosum (fifth disease)/ roseola **slap face** • Human herpes, light pink erythematous macules and papules on face, neck and extremities, 1-3 days – Varicella rash (chicken pox) & herpes zoster (shingles) – Warts (HPV) – Rubeola (measles) – very sick, high fever, red mucosal membranes, skin is reddish purple, macular papular rash – Rubella – skin rash, macules and papules, rose pink – Hand, foot and mouth disease – contagious, vesicles on hands feet and mouth sores • Assess: – Inspection: the question may provide a description of the rash; flesh colored, hard, sand-paper like Diagnose: Based on presentation Treat: most often cryotherapy Who is at risk? Sun exposure What is the risk of it developing into something else? Pre-cancerous lesion that can progress to a squamous cell carcinoma Do I need to refer the patient? To dermatologist to help prevent its progression • Assess: papular rash, satellite lesions • Diagnose: based on presentation; common type: candida albicans • Treat: antifungal cream, pill; keep area as dry as possible; favors moisture, warmth and poor air circulation (consider the location of the rash – Ex) Groin, breast, armpit Who is at risk? Can be opportunistic (immunocompromised patients); look at patient’s age; older, younger (could be diaper rash); diabetics, antibiotic therapy What is the risk of it developing into something else? Not likely Do I need to refer the patient? Only if no improvement Common Types of Fungal Infections-Consider appearance and distribution Bacterial Skin Infections: Warm, Red, Painful without sharply demarcated border • Cellulitis: is a spreading infection of the epidermis and subcutaneous tissue that usually begins after a break in the skin • Folliculitis: bacterial infection of the hair follicle; papules are characteristic of folliculitis Viral Skin Infections • Erythema infectiosum (fifth disease): erythematous, warm rash; gives the appearance of slapped cheeks: Sore throat, slight fever, upset stomach, headache, fatigue, and itching are among other symptoms. Usually resolves on its own • Varicella rash (chicken pox): is contagious 48 hours before the onset of the vesicular rash, during the rash formation and during the several days it takes the vesicles to dry up; characteristic rash appears 2-3 weeks after exposure • Warts: caused by the human papillomavirus; most warts recur despite treatment. Contrary to popular opinion, warts do not have roots; the underside of a wart is smooth and round. Abrading the skin can spread the virus; vigorous rubbing, shaving, and nail biting, can do the same Skin Inflammations: • Pityriasis rosea: is a common, self-limiting, usually asymptomatic eruption with a distinct initial lesion. This “herald patch,” which appears suddenly and without symptoms, usually is on the chest or back. Secondary lesions appear 1 to 2 weeks later while the herald patch remains. The collarette scaling is another classic symptom of pityriasis rosea. The lesions usually resolve spontaneously in 4 to 12 weeks without scarring. Outbreaks have been known to occur in close quarters like military barracks and dormitories. • Pityriasis alba- hypopigmentation CONFIDENTIAL ©2017 Chamberlain University LLC. All rights reserved. 12 Skin inflammations: Urticaria (hives) • Hives: Look at the location of the rash; the first step is to determine the need for epinephrine; Look for respiratory symptoms, difficulty breathing, hoarseness; look at location of rash; is it on the neck, around the face, etc.; if it is, epinephrine must be administered. • Sometimes all choices may seem correct; in that case, the question is prompting you to prioritize your NP actions. Look for what should be done first. • Cholinergic urticaria: Cholinergic urticaria are hives or wheals that are pruritic and occur on the trunk and arms following exercise, anxiety, elevated body temperature, hot baths and showers. • Treated with antihistamines • History taking is important in determining rash development • Poison Ivy, poison oak, poison XXX: a form of contact dermatitis, is not contagious and it cannot be spread from one area of the body to another by touching it. • Latex sensitivity • Seborrheic dermatitis = dandruff like (lots of sebum) – Malassezia furfur *more pink in color – Selenium sulfide, ketoconazole, zinc pyrithione, shampoos – Topical corticosteroids (hydrocortisone, betamethasone) • Impetigo – gram pos staph streptococcus, honey-colored crust, mainly in children, sores of mouth nose nose hands feet face • Herpes zoster (shingles) - older patients, trunk area, small vesicles on erythematous base • Pruritic and papule • Keratosis pilaris: mildly pruritic that looks like “gooseflesh.”; the rash appears as small, pinpoint, follicular papules on a mildly erythematous base. Is a benign condition that resolves by adulthood CONFIDENTIAL ©2017 Chamberlain University LLC. All rights reserved. 15 • Consider allergy • Atopic triad: asthma, eczema and allergic rhinitis (ArEA) • This can be important during history taking to get a clear picture of what is going on with the patient. • RAST may be done to identify antigen-specific mast cell activation or to quantify levels of antigen-specific IgE,The RAST is usually available to primary-care practitioners, whereas scratch testing is typically done only by board-certified allergists. However, interpretation of RAST results requires specialized knowledge of the specificity and sensitivity of the assay because false positives are not uncommon. Thus, the RAST should not be used as a general atopic screening tool. RAST panels include antigen-specific IgE levels but also contain antigen-specific IgG and IgM levels, which are not helpful in the diagnosis of atopic disease and are therefore prone to misinterpretation. • Alopecia areata: systemic cause of alopecia; non-scarring hair loss of rapid onset, the pattern of which is most commonly sharply defined round or oval patches. • Trichotillomania: Non-scarring, non-systemic causes of alopecia include trichotillomania, trauma, bacterial or local fungal infections, and radiation to the head. • Minoxidil (Rogaine) is a vasodilator and may stimulate vertex hair growth. • Finasteride – androgenetic baldness Dermatology: Parasitic infections • Pediculosis (LICE) • Client education is essential when treating pediculosis. Clients should be informed that itching may continue for up to a week after successful treatment because of the slow resolution of the inflammatory reaction caused by the lice infestation. • Otitis externa (Swimmer’s ear): A classic sign of acute otitis externa is tenderness on traction of the pinna and/or pain on applying pressure over the tragus. There is typically an erythematous ear canal, and usually a history of recent swimming. Using ear drops made of a solution of equal parts alcohol and vinegar in each ear after swimming is effective in drying the ear canal and maintaining an acidic environment, therefore preventing a favorable medium for the growth of bacteria, the cause of swimmer’s ear. • Acute otitis media: ear infection; Diagnosis of acute otitis media is made by otoscopic examination. The tympanic membrane will appear red and bulging with or without visible effusion. Light reflex is usually diminished or absent. Mobility is decreased (not increased). The external auditory canal is red and erythematous in AOE the treatment of choice for AOM for otherwise healthy children who attend daycare or received antibiotics within the last month is Amoxicillin 80-90mg/kg/day • Note: If a child with otitis media with effusion has a change in the hearing threshold greater than 25 dB and has notable speech and language delays, more aggressive treatment is indicated. When the child’s hearing examination reveals a change in the hearing threshold, it is extremely important that the provider evaluate the child’s achievement of developmental milestones in speech and language. Any abnormal findings warrant referral. • Sensorineural loss comes from exposure to loud noises, inner ear infections, tumors, congenital and familial disorders, and aging. Sensorineural loss comes from exposure to loud noises, inner ear infections, tumors (acoustic neuromas), congenital and familial disorders, Meniere's disease, medications, trauma, certain diseases and aging. • Conductive hearing loss: Presbycusis; In conductive hearing loss, bone conduction is greater than air conduction, so the patient will report the bone conduction sound longer than the air conduction sound. Serous otitis media can result in conductive hearing loss. The etiology of conductive loss includes ear infection, presence of a foreign body, perforated drum, and otosclerosis of the ossicles • In the Weber test, a vibrating tuning fork is placed on the top of the head equidistant from the patient's ears. In the normal patient, the Weber tuning fork sound is heard equally loud in both ears. In a patient with conductive hearing loss the Weber tuning fork sound is hear louder in "bad" ear. In sensorineural hearing loss, the tuning fork is heard louder in the "good" ear. Ear Disorders • Meniere’s disease – inner ear (controls hearing and balance) • The triad of symptoms associated with Meniere's disease include progressive hearing loss, tinnitus and vertigo • cause is unknown • Abnormal fluid in the ear Eye Disorders: Conjunctivitis-various causes-Viral or bacterial • The causative organism of viral conjunctivitis is adenovirus. It can present with or without cold symptoms. Patients complaint of itchy, red eyes and may have clear to no discharge. Preauricular lymph node swelling and tenderness is hallmark for viral conjunctivitis. • Skin vesicles (if present) and a corneal infection with a “dendrite” appearance are hallmark characteristics of HSV-1 or HSV-2 conjunctivitis. • It is important to teach the patient how to put drops in and advise to avoid touching the tip of the bottle to any conjunctival or skin surface. Women should be instructed to throw away all eye makeup products due to contamination and to start with new products when the infection clears. Likewise, disposable contact lens wearers will need to discard the contacts, refrain from wearing any during treatment, and start with a new pair when clinical symptoms resolve. Bacterial conjunctivitis is very contagious, so the patient should stay home from work or school until 24 hours of antibiotic treatment or as soon as clinical improvement (decreased redness and discharge) is noted. • See Table 19.1 for medications used to treat conjunctivitis CONFIDENTIAL ©2017 Chamberlain University LLC. All rights reserved. 24 Eye Disorder: Blepharitis • Blepharitis is an inflammation around the eyelid margins that is caused by staphylococcal infection at the lash base and dysfunctional Meiobian glands. CONFIDENTIAL ©2017 Chamberlain University LLC. All rights reserved. 25 • Bright red blood in a sharply defined area surrounded by normal-appearing conjunctiva indicates subconjunctival hemorrhage. Risk factors include valsalva type maneuvers, blood-thinners, diabetes and HTN. The condition is self-limiting and resolves on it's own. Patients with visual changes or with more extensive hemorrhage should be referred to an ophthalmologist or ER. • Fluorescein stain is done to detect abrasions or foreign objects in the cornea. • Eye scratch ENT Disorders: **Sinusitis • Invasive complications such as infection of an adjacent cranial structure (mastoiditis, meningitis, etc.) require a referral to a specialist. • With ethmoid sinus problems, the pain is felt behind the eye and high on the nose. • The maxillary sinus is the largest of the paranasal sinuses and is the most commonly affected sinus. There is usually pain and pressure over the cheek. Inability to transilluminate the cavity usually indicates a cavity filled with purulent material. Discolored nasal discharge, as well as a poor response to decongestants, may also indicate sinusitis. • If a patient has a URI for at least 7 days, the presence of 2 or more of the following signs and symptoms will confirm the diagnoses of sinusitis: – colored nasal drainage – poor response to decongestants – facial or sinus pain (especially if aggravated by postural change) – Headache – Viruses may produce all of the clinical manifestations described, however, patients who meet the 7-day criteria are more likely to have bacterial rather than a viral URI. • Fatigue, sore throat, and low-grade fever. • Nasal and throat mild erythema • Edematous, enlarged tonsils bilaterally, with erythema of the pharyngeal wall and tonsillar exudates. • Inflamed posterior cervical lymph nodes. • This presentation could be a viral pharyngitis; however, with posterior cervical lymphadenitis, you would suspect mononucleosis. • A symptom cluster of severe throat pain with difficulty swallowing, copious oral secretions, respiratory difficulty, stridor, and fever BUT without pharyngeal erythema or cough is indicative of epiglottitis. • In a pediatric client with acute epiglottitis, a number of symptoms can indicate that airway obstruction is imminent: stridor, restlessness, nasal flaring, as well as the use of accessory muscles of respiration. • Tonsil grading is important • Grade 3 indicates the tonsils are touching the uvula. Tonsils are enlarged to 2, 3, or 4 with an acute infection. • Most cases of acute laryngitis are due to viruses with H. influenza being frequently identified. Viral illnesses are best treated with supportive care. Antibiotics are ineffective and increase the risk of antibiotic resistance. Throat disorders: Peritonsilar Abcess • Peritonsilar cellulitis and abscess are acute pharyngeal infections most common among adolescents and young adults. • Infection is virtually always unilateral and is located between the tonsil and the superior pharyngeal constrictor muscle. • Symptoms include gradual onset of severe unilateral sore throat, odynophagia, fever, otalgia, and asymmetric cervical adenopathy. Trismus, similar to lock jaw or "hot potato" voice (speaking as if a hot object was in the mouth), is common. A toxic appearance (e.g., poor or absent eye contact, failure to recognize parents, irritability, inability to be consoled or distracted, drooling, severe halitosis, tonsillar erythema, and exudates can also be observed. • In patient's with a peritonsilar abscess, there is more of a discrete bulge, with deviation of the soft palate and uvula. Patients should be referred to the emergency room immediately as maintaining airway patency and preventing sepsis is of concern. • Painless, white, slightly raised patches in a client’s mouth are typically caused by candidiasis (thrush). • Approximately 90% of oral cancers are squamous cell carcinoma (SCC), which is seen typically on the lip or lateral part of the tongue, usually as a lesion that is white, red, or mixed white and red. SCCs are characterized by painless, firm lesions with indurated borders. • Allergic rhinitis results from immunoglobulin E (IgE)- mediated type I hypersensitivity to airborne irritants affecting eyes, nose, sinuses, throat, and bronchi. • The symptoms of allergic rhinitis are similar to those of viral rhinitis but usually persist and are seasonal in nature. When assessing the nasal mucosa, you will observe that the turbinates are usually pale or violaceous (violet color) because of venous engorgement. • Constant periumbilical pain shifting to the right lower quadrant; vomiting following the pain; a small volume of diarrhea; • Fecalith: most common cause—stone made of feces typically found in the colon • no systemic symptoms, such as a headache, malaise, or myalgia; • a mild elevation of the white blood cell count with an early left shift; and white blood cells (WBCs) or red blood cells (RBCs) in the urine are indications of appendicitis. • The WBC count becomes high only with gangrene or perforation of the appendix. The urine may have WBCs or RBCs if the bladder is irritated and ketonuria if there is prolonged vomiting. • Obturator sign: is elicited when, with the patient’s right hip and knee flexed, the examiner slowly rotates the right leg internally, which stretches the obturator muscle. Pain over the right lower quadrant (RLQ) is considered a positive sign. • Crohn disease show’s transmural inflammation, granulomas, focal involvement of the colon with some skipped areas, and sparing of the rectal mucosa. the inflammation extends deeper into the intestinal wall. Crohn's disease can involve all or any layer of the bowel wall and any portion of the GI tract from the mouth to the anus. Any portion of the GI tract can be affected but 80% of patients have small bowel involvement. In advanced disease, perianal lesions, fistulas, strictures and obstructions are common in CD. Folic acid and serum levels of most vitamins, including A, B complex, C, and the fat-soluble vitamins, are decreased in Crohn’s disease as a result of malabsorption. Sed rate, bilirubin and liver enzymes are increased. • Ulcerative colitis is a disease only of the colon. While it is not the first treatment choice, total colectomy is a treatment option that can completely resolve this problem. • In UC, the mucosal surface of the colon is inflamed. This ultimately results in friability, erosions, and bleeding. It most often occurs in the rectosigmoid areas but can involve the entire colon. In Crohn's disease, Patients with UC are more at risk for colon perforation and should be followed closely by a surgeon. Gastrointestinal Disorders: GERD • Symptoms occur at night with regurgitation; heartburn is classic for GERD (mild to severe). Dysphagia is frequently a prominent symptom of GERD. It is usually associated with other symptoms, including regurgitation, water brash (reflex salivation), sour taste in the mouth in the morning, odynophagia, belching, coughing, hoarseness, or wheezing, usually at night. • If patient has been treated with diet modifications and 6 weeks of omeprazole without improvement of symptoms, the next step is an endoscopy • a biopsy can be done and sent for H pylori at that time. • Diverticular disease has been shown to be significantly increased with a low fiber diet and diet that is high in fat and red meats. Obesity is associated with a higher risk for diverticular disease. • Clients with GERD should be instructed to avoid coffee, alcohol, chocolate, peppermint, and spicy foods; eat smaller meals; stop smoking; remain upright for 2 hours after meals; elevate the head of the bed on 6- to 8-in blocks; and refrain from eating for 3 hours before retiring. • Antidiarrheals (Lomotil), laxatives, antispasmodics (Bentyl), Tricyclic antidepressants, SSRIs (Prozac), and medications to increase the intestinal fluid secretion and improve fecal transit (Linzess) are all used to treat IBS. • Depressants have anti-pain and gut-slowing qualities • Patients with diverticulitis may present with bleeding not associated with pain or discomfort. When the diverticula become inflamed, there are usual signs and symptoms of infection-fever, chills, and tachycardia. Patients typically present with localized pain and tenderness in the LLQ of the abdomen with associated anorexia, nausea and vomiting. • CT scan with contrast may sometimes be done to r/o if the gynecologic etiology (such as ovarian cyst or tumor) as well as bowel pathology such as abdominal abscess • Botulism: gastrointestinal illness associated with descending neurological symptoms (double vision) after eating canned food • Traveler’s diarrhea: E coli is the most common pathogen responsible for traveler’s diarrhea. • Associated with H. pylori infection • Amoxicillin, clarithromycin, and omeprazole (Prilosec) for 2 weeks. • PUD  CAP • Data collection: e.g. subjective • Documentation: e.g. OLDCART best reflects HPI • Determining the level of complexity of a visit: risk, data and diagnosis • Common Procedural Terminology (CPT) codes are recognized universally and can be used to track healthcare data. • Medicare: Medicare Part A covers hospital services only. Medicare Part B covers provider and outpatient services. • Third-party payers (supplement): The term indemnity insurer refers to an insurer that pays for the medical care of the insured but does not provide that care. • Read each question carefully to determine what is being asked: – Am I being asked to know a definition – Ami I being asked to prioritize – Am I being asked to diagnose or plan – This will help you to know what type of choice to look for • Don’t rush-you have plenty of time • Read the question, then read the choices, then read the question one more time before you make your final selection CONFIDENTIAL ©2017 Chamberlain University LLC. All rights reserved. 47