LEIK FNP Practice Questions & Answers. Exam predictor questions, Graded A

LEIK FNP Practice Questions & Answers. Exam predictor questions, Graded A 2. All of the following are infections that affect mostly the labia and vagina except: A) Bacterialvaginosis B) Candidiasis C) Trichomonia ...

LEIK FNP Practice Questions & Answers. Exam predictor questions, Graded A 2. All of the following are infections that affect mostly the labia and vagina except: A) Bacterialvaginosis B) Candidiasis C) Trichomoniasis D) Chlamydia trachomatis - ✔✔D) Chlamydia trachomatis Infections that commonly affect the labia and vagina include bacterial vaginosis, candidiasis, and trichomoniasis. Chlamydia trachomatis commonly affects the cervix, endometrial lining , fallopian tubes, and pelvic cavity. 124. Which of the following viral infections is associated with occasional abnormal forms of lymphocytes during an acute infection? A) Cytomegalovirus (CMV) B) Epstein-Barr virus (EBV) C) Human papilloma virus (HPV) D) Coxsackie virus - ✔✔B) Epstein-Barr virus (EBV) A test for an acute infection of the Epstein-Barr virus will show abnormal forms of lymphocytes. 411. Which of the following is the most common cause of nongonococcal urethritis? A) Escherichia coli B) Chlamydia trachomatis C) Neisseria gonorrhoeae D) Mycoplasma - ✔✔B) Chlamydia trachomatis The most common cause of nongonococcal urethritis is Chlamydia trachomatis. A 4-year-old boy is brought in by his mother for a wellness visit. His mother tells the family nurse practitioner that he had a bad case of chickenpox 1 year ago. Which of the following immunizations are indicated? A) IPV, Hib (hemophilus influenzae type B), hepatitis B B) IPV, Hib, MMR C) DTaP, IPV, MMR, hepatitis B D) DTaP, IPV - ✔✔D) DTaP, IPV DTap and IPV would be due for this 4-year-old child. A 10-year-old boy complains of a sudden onset of scrotal pain when he woke up that morning. He is also complaining of severe nausea and vomiting. During the physical examination, the nurse practitioner finds a tender, warm, and swollen left scrotum. The cremasteric reflex is negative and the urine dipstick is negative for leukocytes, nitrites, and blood. The most likely diagnosis is: A) Acute epididymitis B) A severe salmonella infection C) Testicular torsion D) Acute orchitis - ✔✔C) Testicular torsion Testicular torsion signs and symptoms include sudden onset of unilateral scrotal pain, nausea, vomiting, and abdominal pain. Acute epididymitis causes fever, chills, nausea, and unilateral pain and is most com- monly seen in sexually active men. Unilateral scrotal pain does not occur with Salmonella infection. Acute orchitis is often based on having a recent mumps infec- tion or parotitis with testicular edema. A 10-year-old male who was recently accepted into his school's soccer team has a history of exerciseinduced asthma. The child wants to know when he should take his albuterol inhaler. The nurse practitioner would advise the patient: A) Premedicate himself 20 minutes prior to starting exercise B) Wait until he starts to exercise before using the inhaler C) Premedicate 60 minutes before starting exercise D) Wait until he finishes his exercise before using his inhaler - ✔✔A) Premedicate himself 20 minutes prior to starting exercise Exercise-induced asthma is best controlled by using the Proventil inhaler (bronchodilator) approximately 20 minutes prior to exercise, to prevent vasospasm of the bronchioles and shortness of breath with exercise. These bronchodilators usually last approximately 4 hours. They also work quickly to open up the bronchioles if an acute attack/shortness of breath occurs A 12-year-old girl is complaining of a 2-week history of facial pressure that worsens when she bends over. She complains of tooth pain in her upper molars on the right side of her face. On physical exam, her lung and heart sounds are normal. Which of the following is the most likely diagnosis? A) An acute dental abscess B) Chronic sinusitis C) Acute sinusitis D) Severe allergic rhinitis - ✔✔C) Acute sinusitis Signs/symptoms of acute sinusitis includes headache, facial pain that worsens with bending over, eye/ear pressure and pain, aching in upper jaw/teeth, reduced smell and taste, cough (especially at night due to the nasal drainage), sore throat, bad breath, and fatigue. A 12-year-old male's peak expiratory flow results indicate 60 to 80% of the predicted range. How would you classify his asthma? A) Mild intermittent asthma B) Mild persistent asthma C) Moderate persistent asthma D) Severe asthma - ✔✔C) Moderate persistent asthma Asthma classifications: Intermittent: normal FEV between exacerbations, FEV > 80%; mild persistent, FEV > 80%; moderate persistent, FEV 60-80%; severe persistent, FEV < 60%. A 13-year-old adolescent female is brought in by her mother for a sports physical. The mother reports that the teen's last vaccines were given at the age of 6 years. Which of the following vaccines is recommended by the CDC for this patient? A) Td and HPV vaccines B) Tdap, MCV4, and the HPV vaccines C) DTap and the flu vaccine D) DT and MCV4 vaccines - ✔✔B) Tdap, MCV4, and the HPV vaccines Vaccine questions usually are not this complicated, but there are several lessons that can be learned with this question. The 2012 CDC recommendations for the ages 13 to 18 years are the Tdap catch-up (if did not receive at age 11-12 years), HPV or Gardasil catch-up (if did not receive at age 11-12 years), and the MCV4 or meningococcal conjugate vaccine (Menactra). Only one dose of Tdap is recommended (lifetime). Thereafter, the Td form of the vaccine is indicated every 10 years. A 13-year-old boy wants to be treated for his acne. He has a large number of closed and open comedones on his face. The patient has been treating himself with OTC benzoyl peroxide and salicylic acid topical products. Which of the following would be recommended next? A) Retinoic acid (Accutane) B) Tetracycline C) Retin A 0.25% gel D) Wash face carefully with medicated soap at bedtime - ✔✔C) Retin A 0.25% gel Topical agents are the first-line treatment for acne vulgaris. Retin A 0.25% gel would be the next step. Oral preparations would then be offered for the next step (tetracycline), and Accutane would be the final step of therapy. A 13-year-old male is brought in by his mother for a physical exam. During the genital exam, the nurse practitioner notices that the patient is at Tanner Stage II. Which of the following is the best description of this Tanner stage? A) The penis is growing more in length than in width and the testicles become larger with darker scrotal skin and the pubic hair is starting to curl B) The penis is growing more in width than in length with darker scrotal skin and more numerous pubic hairs that are darker, curly, and coarser C) The testicles become larger and the skin of the scrotum starts to become darker with straight, fine, countable hairs on the genitals and the axilla D) The testicles, penile width and length are all developing quickly - ✔✔C) The testicles become larger and the skin of the scrotum starts to become darker with straight, fine, countable hairs on the genitals and the axilla Tanner Stage II is when the testicles start to grow. The scrotal skin becomes thicker and starts to get darker (hyperpigmentation). The pubic hair is of a fine texture and straight and there are few countable hairs on the genitals and the axilla. A 13-year-old patient has a throat culture that is positive for strep throat. She reports that her younger brother was recently diagnosed with strep throat and treated. The patient has a severe allergy to penicillin and reports that erythromycin makes her very nauseated. Which of the following antibiotics is the best choice? A) Azithromycin (Zithromax) B) Cephalexin (Keflex) C) Cefuroxime axetil (Ceftin) D) Levofloxacin (Levaquin) - ✔✔A) Azithromycin (Zithromax) If the patient has a severe penicillin allergy, there is a 10% chance of cross-reactivity to cephalosporins (especially first generation). Because the patient is a child, the levofloxacin is contraindicated. Nausea is a com- mon adverse reaction to erythromycin (it is not an allergic reaction). The best option is to use azithromycin because of its minimal GI adverse effects. Azithromycin has fewer drug interactions compared with other macrolides. A 14-year-old female who is sexually active is brought in by her mother for an immunization update. According to the mother, her daughter had 1 dose of hepatitis B vaccine. Which of the following vaccines would you administer at this visit? A) Td and hepatitis B B) DTaP (diphtheria, tetanus, acellular pertussis) and hepatitis B C) Hepatitis B only D) MMR (measles, mumps, rubella) and Td - ✔✔A) Td and hepatitis B The CDC recommends Td and hepatitis B for 14-year-old females. It is recommended for her to continue the hepatitis series, which includes a total of 3 injections. A 14-year-old female with amenorrhea is tested for pregnancy and has a positive result. The patient tells the NP that she is seriously considering terminating the pregnancy. She tells the NP that she wants to be referred to a Planned Parenthood clinic. The NP's personal beliefs and religious beliefs are pro-life. Which of the fol- lowing is the best action for the NP? A) The nurse practitioner should tell the patient about her personal beliefs and advise her against getting an abortion B) The NP advises the patient that an NP peer who is working with the NP can help answer her questions more thoroughly C) The NP should excuse herself from the case D) The nurse practitioner should refer the patient to an obstetrician - ✔✔B) The NP advises the patient that an NP peer who is working with the NP can help answer her questions more thoroughly In general, discussing personal beliefs is considered unprofessional behavior. Respecting the patient's right to choose is an example of supporting patient autonomy. A 14-year-old is brought in by his mother who reports that her child has been complaining for several months of recurrent bloating, stomach upset, and occasional loose stools. She reports that her son has difficulty gaining weight and is short for his age. She has noticed that his symptoms are worse after eating large amounts of crackers, cookies, and breads. She denies seeing blood in the child's stool. Which of the following conditions is most likely? A) Amebiasis B) Malabsorption C) Crohn's colitis D) Celiac disease - ✔✔D) Celiac disease Celiac disease is also known as celiac sprue. Patients should avoid foods containing gluten, which causes malabsorption (diarrhea, gas, bloat- ing, abdominal pain, etc.). Foods to avoid are wheat, rye, and barley. Oats do not damage the mucosa in celiac disease. Antigliadin IgA and IgG are elevated in almost all patients (90%). A 14-year-old teen is worried that she has not started to menstruate like most of her friends. During the gynecological examination, the nurse practitioner tells the mother, who is in the room with the patient, that her daughter is starting Tanner Stage II. What are the physical exam findings during this stage? A) Breast buds and some straight pubic hair B) Fully developed breasts and curly pubic hair C) Breast tissue with the areola on a separate mound with curly pubic hair D) No breast tissue and no pubic hair - ✔✔A) Breast buds and some straight pubic hair Tanner Stage II in females includes breast buds and few straight, fine pubic hairs. A 15-month-old child who is eating and behaving normally is found to have a high fever. After a few days, the fever resolves and the infant breaks out in a maculopapular rash. This is a description of which of the following conditions? A) Erythema infectiosum B) Roseola infantum C) Fifth disease D) Scarlet fever - ✔✔B) Roseola infantum The signs/symptoms of roseola infantum include high fever for a few days with a maculopapular rash occuring after the fever breaks. Fifth disease is a lacy-appearing rash that usually begins on the face and moves to the extremities and trunk. It is known by the "slapped cheek " appearance at onset. Erythema infectiosum is the same as Fifth disease. Scarlet fever is a red rash that feels like sandpaper that usually begins on the neck and trunk and spreads to the extremities. Patients will have other symptoms such as fever, sore throat, and beefy red tongue. This is caused by the Group A Streptococcus bacterium. A 15-month-old infant is in your office for a well baby check. The mother denies history of chickenpox infection. Which of the following immunizations is indicated at this visit? A) DTaP, Hib, IPV, hepatitis B B) DTaP, Hib, PCV, IPV, MMR C) MMR, hepatitis B, varicella D) DTaP, IPV, MMR, varicella - ✔✔D) DTap, IPV, MMR, varicella Immunizations for a 15-month-old child include DTap, IPV, MMR, and varicella vaccine. A 15-year-old basketball player who is 6 ft tall is seen for complaints of painful lumps on his knees. Upon inspection, the nurse practitioner notes a bonelike growth on the upper tibia midline below the kneecap on both knees. The patient has full range of motion with no joint tenderness, redness, or swelling. Which of the following conditions is best described? A) Osteosarcoma of the tibia B) Juvenile rheumatoid arthritis C) Osgood- Schlatter disease D) Paget's disease of the bone - ✔✔C) Osgood-Schlatter disease Osgood-Schlatter disease is characterized by having pain over the tibial tuberosity with palpation of a bony mass over the anterior tubercle of one or both knees. Exercise worsens the pain A 15-year-old female who attends a public school is referred to the nurse practitioner by one of her teachers. The teen has been missing school and is falling behind in her schoolwork. After closing the exam room door, the nurse practitioner starts to interview the teen, asking about her moods, her appetite, her sleep, whether she any plan of hurting herself or others, and other questions. What is the level of health prevention that the nurse practitioner is performing? A) Primary prevention B) Secondary prevention C) Tertiary prevention D) Dropout prevention program - ✔✔B) Secondary prevention The nurse practitioner is evaluating the teenager for major depression. Because the teenager already has the disease (depression), it is a screening "test." All screening tests/labs (mammography, Pap smears, etc.) are secondary prevention activities. A 15-year-old White male is brought in by his father for a physical exam. He is concerned that his son is "too short" for his age. The father reports that when he was the same age, he was much taller. His son wants to try out for the football team, but the father is concerned because his son might be "too short" to join. Which of the follow- ing physical exam findings is worrisome? A) Small smooth testicles with no pubic or facial hair B) Smooth testicles with rugated scrotum that is a darker color than his normal skin color C) Smooth testicles with coarse and curly pubic hair D) Straight pubic and axillary hair with a long thin penis - ✔✔A) Small smooth testicles with no pubic or facial hair Small, smooth testicles with no pubic or facial hair (Tanner Stage I) is a worrisome finding at the age of 14 years because it signifies that the boy is not in the pubertal stage yet. The average age of onset of puberty among boys is 12 years (range 10 to 14 years). The maximum growth spurt in boys occurs about 2 years after the onset of puberty. Boys start about 1 year later than girls and continue to grow until their early 20s (college). A 16-year-old complains of a severe sore throat for 3 days along with a generalized rash and fever. The skin has the texture of fine sandpaper. This best describes: A) Kawasaki's disease B) Scarlet fever C) German measles D) Rubeola - ✔✔B) Scarlet fever Scarlet fever is a bacterial infection caused by the group A Streptococcus infection. The patient will exhibit sore throat, high fever, and a fine sandpaper rash, which is characteristic of scarlet fever. A 16-year-old male with a recent history of a cat bite is brought in by his father. The bite occurred about 2 hours before the visit. The nurse practitioner evaluates the wound and notes 2 small puncture wounds. There is no redness or purulent discharge. The father reports that the teenager received a tetanus booster when he was 12 years old. Which of the following is the correct action to take? A) Clean the wound with soap and water and apply topical antibiotic and a bandage B) Because the wound is clean and does not appear infected, there is no need for antibiotics C) Give the patient a tetanus booster using the Tdap form of the vaccine D) Clean the wound with soap and water and prescribe Augmentin 500mg PO BID x 10 days for the patient - ✔✔D) Clean the wound with soap and water and prescribe Augmentin 500 mg PO BID x 10 days for the patient Cat wounds are more likely to become infected compared with dog bites; in addition, this patient's bite is located on an extremity. These facts justify the prescription of Augmentin 500 mg PO BID x 10 days for the patient. A 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. It is not swollen or reddened. The most likely diagnosis is: A) Chronic orchitis B) Chronic epididymitis C) Testicular torsion D) Varicocele - ✔✔D) Varicocele Palpation of varicose veins, known as "bag of worms" in the scrotum, is a classic symptom of a varicocele. Chronic epididymitis and chronic orchi- tis are caused by a bacterial infection and commonly have burning, frequency, and pain. Testicular torsion is an emergent condition in which the testicle becomes twisted, interrupting the blood supply to the testis; to avoid damage, the condition must be corrected within 6 hours. A 17-year-old high school student is considering her birth control options. She wants to know more about Seasonale. Which of the following statements is false? A) Taking Seasonale results in only 4 periods per year B) Her period will occur within the 7 days when she is on the inert pills C) It is a progesterone-only method of birth control and does not contain estrogen D) Take 1 tablet daily for 84 consecutive days followed by 7 days of inert pills - ✔✔C) It is a progesterone-only method of birth control and does not contain estrogen Seasonale is an extended-cycle form of birth control. It contains both levonorgestrel and ethinyl estradiol. There are 84 pink tablets (active) and 7 white pills (inert). In general, more spotting (breakthrough bleeding) is experienced with extended-cycle pills during the first few months of use (compared with the monthly birth control pills). A 19-year-old female has recently been diagnosed with acute hepatitis B. She is sexually active and is monogamous. She reports using condoms inconsistently. What would you recommend for her male sexual partner who was also tested for hepatitis with the following results: HBsAg (−), anti-HBs (−), antiHCV (−), anti-HAV (+)? A) A hepatitis B vaccination B) Hepatitis B immunoglobulin C) Hepatitis B vaccination and hepatitis B immunoglobulin D) No vaccination is needed at this time - ✔✔C) Hepatitis B vaccination and hepatitis B immunoglobulin Hepatitis B vaccination is given for long-term prophylaxis treatment to prevent hepatitis B infection. Hepatitis B immunoglobulin is given for prevention of hepatitis B infection when the person has been directly exposed to the hepatitis B infection. The immnoglobulin is not a vaccine and does not protect against long-term prophylaxis. A 19-year-old male athlete complains of acute knee pain after a football game. The nurse practitioner elicits McMurray's sign, which is positive on the patient's injured knee. This is a test for: A) Meniscal injury B) Inflammation of the knee joint C) Osteophytes of the knee joint D) Tenosynovitis - ✔✔A) Meniscal injury With an acute knee injury, the knee should be assessed using McMurray's sign. A positive McMurray's sign indicates a meniscal injury. Inflammation of the knee, osteophytes, and tenosynovitis would not elicit a positive McMurray's sign. A 19-year-old student who is on a prescription of Triphasil is being seen for an annual gynecologic exam in the college health center. The nurse practitioner has obtained the Pap smear and is about to perform the bimanual exam. She gently removes the plastic speculum from the vagina. While the NP is performing the bimanual vaginal exam, the patient complains of slight discomfort during deep palpation of the ovaries. Which of the following is a true statement? A) The uterus and the ovaries are both very sensitive to any type of palpation B) The fallopian tubes and ovaries are not sensitive to light or deep palpation C) The ovaries are sensitive to deep palpation but they should not be painful D) The uterus and the ovaries are not important organs of reproduction - ✔✔C) The ovaries are sensitive to deep palpation but they should not be painful The ovaries are usually slightly sensitive to deep palpation, but they should not be painful. Unilateral adnexal pain accompanied by cervical motion tenderness and purulent endocervical discharge is suggestive of PID. A 21-year-old female who is complaining of random palpitations is diagnosed with mitral valve prolapse (MVP). Her echocardiogram (EKG) reveals redundant and thickened leaflets. You note a Grade III/VI systolic murmur with an ejection click during physical examination. You would recommend: A) Endocarditis prophylaxis for most dental and urologic procedures B) Endocarditis prophylaxis is not necessary C) Lifetime anticoagulation therapy with warfarin sodium D) Endocarditis prophylaxis for dental procedures only - ✔✔B) Endocarditis prophylaxis is not necessary Prophylaxis treatment for endocarditis is no longer recommended for MVP. A 21-year-old woman complains of left-sided pelvic pain accompanied by dyspareunia. During the gynecological exam, the nurse practitioner notices green cervical discharge. The patient mentions a new onset of a painful and swollen left knee and denies a history of trauma. This best describes: A) Septic arthritis B) Reiter's syndrome C) Chondromalacia of the patella D) Disseminated gonorrheal infection - ✔✔D) Disseminated gonorrheal infection Symptoms of PID with painful, swollen joints of extremities indicate disseminated gonorrheal infection. Untreated disseminated gonorrhea can lead to septic arthritis. Symptoms may be mild from slight joint pain and no fever to severe joint pain with high fever. PID symptoms do not occur with septic arthritis, Reiter's syndrome, or chondromalacia of the patella. A 22-year old is going on a 5-day cruise for her honeymoon. She reports a history of severe motion sickness. Which of the following medicines can be prescribed for motion sickness? A) Dimenhydrinate (Dramamine) B) Metochlopramide (Reglan) C) Ondansetron (Zofran) _ D) Scopolamine patch (Transderm Scop) - ✔✔D) Scopolamine patch (Transderm Scop) Scopolamine patch (Transderm Scop) is a prescription medicine that is used for motion/sea sickness. It is a small, circular patch that is placed behind the ear and is effective for 3 days. Advise the patient to apply it 4 hours before the trip to be effective. Because the question is asking about a "prescribed" med, answers with OTCs such as Dramamine are incorrect. Zofran is indicated for cancer-related nausea and vomiting (chemo, radiation, surgery). A 22-year-old male is brought to an urgent care center by his anxious mother. She reports that her son returned from a camping trip 2 days ago with a high fever and bad headache. Apparently, the patient had complained to her of a painful and stiff neck along with nausea shortly after he arrived. According to the mother, her son started breaking out in a rash the day before, some of which is turning a dark red to purple color. During the physical exam, the nurse practitioner evaluates the patient for Kernig's sign, which is positive. Which of the following conditions is most likely? A) Stevens-Johnson syndrome B) Meningococcemia C) Rocky Mountain spotted fever D) Erythema multiforme - ✔✔B) Meningococcemia Kernig's maneuver is performed by flexing both hips and legs and having the patient straighten the legs against resistance, testing for men- ingitis. A positive test indicates meningitis. Other characteristics of meningitis include high fever, headache, stiff neck, and nausea/vomiting. A 22-year-old male presents to the urgent care clinic with burns caused by a hot oil spill while frying food. He denies facial involvement, dyspnea, or weakness. During the physical exam, the nurse practitioner notices bright red skin with numerous bullae on the right arm and hand and bright red skin on the right thigh and the right lower leg. On a pain scale of 1-10, he reports the pain as 8. Based on the Rule of Nines, what is the TBSA of this patient's burns? A) 36% B) 27% C) 18% D) 9% - ✔✔B) 27% This patient has a TBSA of 27% and should be referred to the emergency department as soon as possible. Check the "ABCs" and monitor the patient for shock. Do not puncture bullae. A 25-year-old female presents with an onset of severe right-sided pelvic pain for the past 48 hours. She reports small amounts of vaginal bleeding. The pain is aggravated by jumping or any movement that jars her pelvis. The best initial intervention is which of the following? A) Follicle-stimulating hormone (FSH) B) Serum quantitative pregnancy test C) Pelvic ultrasound D) CBC with white cell differentials - ✔✔B) Serum quantitative pregnancy test Severe right-sided pain with vaginal bleeding in a 25-year-old patient requires an evaluation for pregnancy, by performing a serum quantitative pregnancy test. Ectopic pregnancy and/or miscarriage should be ruled out. A 25-year-old male who was involved in a car accident is brought in to the local emergency department. He reports wearing a seat belt and was the driver of the vehicle. The patient is complaining of pain on his right leg. The skin is intact, but the right foot is abducted slightly. The right knee is tender and swollen. Which of the following tests is/are the best choice for evaluating for possible fractures and joint damage? A) Plain radiographs of the right hip and knee B) Ultrasound with a CT scan of the right leg C) Plain radiograph of the right hip and leg with an MRI of the knee joint D) Radiograph of the right hip and knee with special view of the hip - ✔✔C) Plain radiograph of the right hip and leg with an MRI of the knee joint The stem is asking for two things " . . . evaluating for possible fractures joint damage." Plain x-rays are the first exam ordered for suspected or obvious bony fractures. An MRI scan is the best test for any type of joint pathology (swollen right knee). A 25-year-old male with schizophrenia comes in for a routine annual physical. He is a heavy smoker and has a BMI of 28. The patient has been on olanzapine (Zyprexa) for 10 years. Regarding the patient's prescription, which of the following laboratory tests is recommended for monitoring for adverse effects of atypical antipsychotics? A) Fasting blood glucose, fasting lipid profile, and weight B) Urinalysis, serum creatinine, 24-hour urine for protein and creatinine clearance C) Liver function tests only D) CBC with differential, liver function tests, weight - ✔✔A) Fasting blood glucose, fasting lipid profile, and weight Patients on atypical antipsychotics commonly gain weight and are at risk for obesity, hyperglycemia, and type 2 diabetes. Zyprexa will increase lipids (cholesterol, LDL, and triglycerides). Atypical antipsychotics also increase the risk of death among frail elders and older adults living in nursing homes A 25-year-old woman complains of dysuria, severe vaginal pruritis, and a malodorous vaginal discharge. Pelvic examination reveals a strawberry-colored cervix and frothy yellow discharge. Microscopic exam of the discharge reveals mobile organisms that have flagella. The correct pharmacologic therapy for the condition is: A) Metronidazole (Flagyl) B) Ceftriaxone sodium (Rocephin) C) Doxycycline hyclate (Vibramycin) D) Clotrimazole (Gyne-Lotrimin) - ✔✔A) Metronidazole (Flagyl) Trichomoniasis symptoms include dysuria, severe vaginal pruritis, and malodorous vaginal discharge. Wet prep will show trichomonads that are pear-shaped and have several flagella (whiplike tails) at one end. CDC recommendation for treatment is metronidazole. A 25-year-old woman's last menstrual period was 6 weeks ago. She is complaining of nausea with vomiting in the morning and fatigue. Her breasts feel bloated. The nurse practitioner suspects that she is pregnant. Her symptoms would be considered: A) Positive signs of pregnancy B) Probable signs of pregnancy C) Presumptive signs of pregnancy D) Possible signs of pregnancy - ✔✔C) Presumptive signs of pregnancy Presumptive signs of pregnancy are symptoms experienced by the woman, such as amenorrhea, breast tenderness, nausea/ vomiting, fatigue, and increased urinary frequency. A 28-year-old male nurse of Hispanic descent reports a history of a cold that resolved 2 weeks ago except for a dry cough and pain over his right cheek that worsens when he bends down. The patient denies fever. He tells the employee health nurse practitioner that he is very allergic to both cephalexin (Keflex) and erythromycin. The vital signs show that the patient's temperature is 99.2 degrees Fahrenheit, a pulse of 72 beats per minute, and a respiratory rate of 12 breaths per minute. Which of the following conditions is most likely? A) Acute sinusitis B) Acute bronchitis C) Fever secondary to the previous viral URI (upper respiratory infection) D) Munchausen's syndrome - ✔✔A) Acute sinusitis Acute sinusitis symptoms include cough, facial pain, and low-grade fever. A 28-year-old male nurse tells the employee health nurse practitioner that he was treated for a UTI twice the previous year. The patient denies fever, flank pain, or urethral discharge during the visit. Which of the following is the best follow-up for this patient? A) Refer the patient to a urologist B) Prescribe the patient ofloxacin (Floxin) for 2 weeks instead of 1 week C) Advise the patient that he needs to void every 2 hours when awake D) Refer the patient to the local ED, because he has a very high risk of sepsis - ✔✔A) Refer the patient to a urologist It is recommended that frequent UTIs in males be referred to a urologist for evaluation and treatment. A 28-year-old multipara who is at 32 weeks of gestation presents to your office complaining of a sudden onset of small amounts of bright red vaginal bleeding. She has had several episodes and appears anxious. On exam, her uterus is soft to palpation. Which of the following is most likely? A) Placenta abruptio B) Placenta previa C) Acute cervicitis D) Molar pregnancy (hydatidiform mole) - ✔✔B) Placenta previa Placenta previa occurs when abnormal implantation of the placenta occurs. A common symptom of placenta previa is painless, bright red bleeding. A 28-year-old student is seen in the school health clinic with complaints of a hacking cough that is productive of small amounts of sputum and a runny nose. He does not take any medications, denies any allergies, and has no significant medical history. Physical examination reveals a low-grade temperature of 99.9 degrees Fahrenheit, respirations of 16/min, a pulse of 90 beats per minute, and diffuse fine crackles in the base of the lungs. A chest radiograph (x-ray) shows diffuse infiltrates on the lower lobe of the right lung. The total white blood cell count is 10,500/uL. What is the most likely diagnosis? A) Streptococcal pneumonia B) Mycoplasma pneumonia C) Acute bronchitis D) Legionnaires disease - ✔✔B) Mycoplasma pneumonia Mycoplasma pneumonia is the organism most com- monly seen in children and young adults. It is easily spread from droplets, from sneezing and coughing, in close proximity. Diagnosis is based on symptoms and x-ray results of infiltrates in lower lobes. A 30-year-old chef complains of pruritic hives over her chest and arms but denies difficulty swallowing or breathing. She reports a family history of allergic rhinitis and asthma. Which of the following interventions is most appropriate? A) Perform a complete and thorough history B) Prescribe an oral antihistamine such as diphenhydramine 25 mg PO QID C) Give an injection of epinephrine 1:1000 intramuscularly stat D) Call 911 - ✔✔A) Perform a complete and thorough history Prior to prescribing medications, a complete and thorough history must be performed to determine possible causes of hives. The patient denied difficulty with swallowing and breathing, so there was no medical emergency to require calling 911. A 30-year-old female complains of having no period for the last 12 weeks. She is sexually active and has been using condoms inconsistently. The patient has a his- tory of irregular menstrual cycles and severe dysmenorrhea. The urine pregnancy test result is positive. Which of the following is a true statement regarding this pregnancy? A) The fundus of the uterus should be at the level of the symphysis pubis B) The cervix should be dilated about 0.5 in. at this time of gestation C) "Quickening" starts during this period D) Hegar's sign is present during this period of pregnancy - ✔✔A) The fundus of the uterus should be at the level of the symphysis pubis At 12 weeks gestation, the fundus of the uterus should be located approximately at the symphysis pubis. A 30-year-old female who is sexually active complains of a large amount of milk- like vaginal discharge for several weeks. A microscopy slide reveals a large amount of squamous epithelial cells that have blurred margins. Very few white blood cells are seen. The vaginal pH is at 6.0. What is most likely? A) Trichomonas infection B) Bacterial vaginosis C) Candidal infection D) A normal finding - ✔✔B) Bacterial vaginosis Bacterial vaginosis is a bacterial infection of the vagina. Signs and symptoms include copious off-white to gray discharge with foul odor without vaginal erythema or irritation. Wet prep will show positive for clue cells. When performing a wet prep, the "whiff test" will be positive for a strong "fishy" odor when vaginal discharge is mixed with one drop of KOH. A 30-year-old male patient refuses to take his afternoon dose of pills. The nurse tells him of the possible consequences of his action, but the patient still refuses to cooperate. Which of the following is the best course for the nurse to follow? A) Document in the patient's record his behaviors and the action taken by the nurse B) Reassure the patient that he will be fine after taking the medicine C) Document only the patient behavior D) Document only the nurse's action - ✔✔A) Document in the patient's record his behaviors and the action taken by the nurse If a patient is non-compliant, documentation of the patient behavior and the actions taken by the nurse both must be documented. A 30-year-old male with a history of gout is walking to the examination room and the nurse practitioner notices that he is limping. When the patient sits down, the nurse practitioner notes that the metatarsophalangeal joint of the great toe is very swollen and is bright red. The patient reports that he was attending a party the night before and drank. The patient is requesting a prescription to treat his painful toe. The nurse practitioner prescribes the patient indomethacin (Indocin) 50 mg TID PRN and colchicine. Regarding colchicine, which of the following instructions is correct? A) Take 1 pill every hour to every 2 hours until relief is obtained or adverse gastrointestinal effects occur, such as abdominal pain, nausea, or diarrhea B) Take 1 pill every hour until relief is obtained up to 24 hours C) Take 1 pill every 4 to 6 hours until the pain is relieved D) Take 2 to 3 pills QID until relief is obtained or adverse GI effects occur, such as abdominal pain, nausea, or diarrhea - ✔✔A) Take 1 pill every hour to every 2 hours until relief is obtained or adverse gastrointestinal effects occur, such as abdominal pain, nausea, or diarrhea Colchicine acts as an anti-inflammatory and helps to suppress gouty attacks. It is usually taken as 1 tablet (0.6 mg) every 1 to 2 hours until relief is obtained (or adverse gastrointestinal effects occur, such as abdominal pain, nausea, or diarrhea). Prescribe the patient only 10 tablets at a time (do not refill) during a flare-up. The maximum dose is 6 mg/day. Many patients will develop GI adverse effects even before the pain is relieved. Colchicine can also be taken daily in small amounts for prophylaxis. A 30-year-old primigravida is diagnosed with a possible threatened abortion. The result of the urine pregnancy test is positive. Which of the following statements is true regarding a threatened abortion? A) Vaginal bleeding and cramping are present, but the cervix remains closed B) Vaginal bleeding and cramping are present along with a dilated cervix C) The fetus and placenta are all expelled D) The products of conception and the placenta remain inside the uterus along with a dilated cervix - ✔✔A) Vaginal bleeding and cramping are present, but the cervix remains closed Threatened abortion is defined as vaginal bleeding and cramping with- out the presence of cervical dilation. A 35-year-old male has a history of an upper respiratory viral infection 4 weeks ago. He reports that he started feeling short of breath and now complains of sharp pain in the middle of his chest that seems to worsen when he lies down. The patient's physical exam is within normal limits with the exception of a precordial rub on auscultation. The most likely diagnosis would be: A) Pulmonary embolism B) Dissecting aneurysm C) Pericarditis D) Esophageal reflux - ✔✔C) Pericarditis Pericarditis is inflammation of the sac around the heart. Common signs/symptoms include chest pain over the center/left side of the chest; shortness of breath, especially with lying down; low-grade fever; weakness; fatigue; dry cough; and abdominal or leg swelling. Pericardial rub may be auscultated. A 35-year-old male presents complaining of the acute onset of episodes of dizziness with nausea that started a few days after he got over a cold. The patient describes it as the sensation of the room moving or of the room spinning. It is worsened by sudden head movement. During the episodes, he gets very nauseated. He also has tinnitus with hearing loss in his right ear. The patient is a type 2 diabetic and is on a prescription of metformin 500 mg PO BID and an ACE inhibitor. The blood glucose during the visit is 80 mg/dL. Which of the following conditions is most likely? A) Vasovagal presyncopal episode B) Ménière's disease C) Atypical migraine D) Hypoglycemia - ✔✔B) Ménière's disease The classic triad of symptoms of Ménière's disease are vertigo, tinnitus, and hearing loss. The condition can resolve spontaneously or may be chronic. BPV has similar symptoms except that it does not cause hearing loss. Vertigo is due to the dysfunction of the labyrinthine system. Differential diagnoses are many (Ménière's, acute labyrinthitis, acoustic neuroma, etc.). Vasovagal syncope does not cause hearing loss or tinnitus, nor is it episodic. A 35-year-old primigravida who is at 28 weeks of gestation is expecting twins. What would you would expect her alpha fetoprotein (AFP) values to be? A) Normal B) Higher than normal C) Lower than normal D) None of the above - ✔✔B) Higher than normal Alpha fetoprotein is produced in the fetal and maternal liver. Higher levels of alpha fetoprotein are commonly seen in multiple gestations due to the growing fetuses and enlargement of the livers. A 35-year-old sexually active male presents with a 1-week history of fever and pain over the left scrotum. It is accompanied by frequency and dysuria. The scrotum is edematous and tender to touch. He denies flank pain, nausea, and vomiting. He reports that the pain is lessened when he uses scrotal support briefs. His urinalysis shows 2+ blood and a large number of leukocytes. What is the most likely diagnosis? A) Acute urinary tract infection B) Acute pyelonephritis C) Acute orchitis D) Acute epididymitis - ✔✔D) Acute epididymitis Acute epididymitis is the infection presented here. Scrotal edema and pain with palpation do not occur in UTI or pyelonephritis. Acute orchitis symptoms include testicular pain and edema, are usually associated with the mumps, but do not have frequency and dysuria. A 35-year-old smoker is being evaluated for birth control choices. The patient has a history of PID along with an embolic episode after her last pregnancy. Which of the following methods of birth control would you recommend? A) Condoms and the vaginal sponge (Today Sponge) B) Estrogen patches C) Intrauterine device D) Depo-Provera (depot medroxyprogesterone) - ✔✔A) Condoms and the vaginal sponge (Today Sponge) Contraindications for hormonal contraception include: Migraine headaches; cigarette smoking or obesity in women older than 35 years; history of thromboembolic disease; hypertension or vascular disease if over 35 years of age; systemic lupus erythematosus with vascular disease, nephritis, or antiphospholipid antibodies; breastfeeding (may use progestin-only pills); hypertriglyceridemia; CAD; CHF; and strokes. A 35-year-old woman is complaining of gradual weight gain, lack of energy, and amenorrhea. The urine pregnancy test is negative. The CBC shows a hemoglobin of 13.5 g and MCV 84. The nurse practitioner suspects that the patient may have hypothyroidism. The TSH is 10 mU/L. Which of the following is the next step in the evaluation? A) Check the thyroid profile B) Check the total T3 and T4 levels C) Check for antithyroid peroxidase antibodies D) Recheck the TSH in 4 to 6 months - ✔✔A) Check the thyroid profile The upper limit of the serum TSH level is about 5.0 mU/L (range of 0.5 to 5.0). With an elevated TSH of 10, it is important to rule out hypothyroidism. The next step in this patient's evaluation is to order a thyroid profile test. Serum assays measure bound and unbound (free) forms of thyroxine (T4) and triiodothyronine (T3). Classic findings of hypothyroidism are a low total T4, low T3-resin uptake (THBI), and low free T4 index. A 38-year-old multigravida who is at 32 weeks of gestation calls the family nurse practitioner complaining of bright red vaginal bleeding. There is no watery dis- charge. She complains that her uterus feels hard and is very painful. Which of the following conditions is most likely? A) Placenta previa B) Placenta abruptio C) A molar pregnancy D) An ectopic pregnancy - ✔✔B) Placenta abruptio Abruptio placenta symptoms are bright red vaginal bleeding, board-like uterus on palpation, and pain. However, there can be concealed hemorrhage and the patient may not have vaginal bleeding. Placenta previa is painless bleeding. Ectopic and molar pregnancy would not progress to 32 weeks gestation A 39-year-old migrant worker presents to the clinic 2.5 days after a purified protein derivative (PPD) test. What minimum size of induration would be considered posi- tive for this patient? A) 3 mm B) 5 mm C) 10 mm D) 15 mm - ✔✔C) 10 mm The PPD is administered on the volar aspect of the lower arm and read 48 hours after the test is given. The PPD result must have induration and measure 10 mm or greater to be positive in a low-risk patient. Induration (firmness with palpation) must be present. If the site has erythema but no induration, result would be negative. Color is not important. A 40-year-old cashier complains of periods of dizziness and palpitations that have a sudden onset. The EKG shows P waves before each QRS complex and a heart rate of 170 beats/minute. A carotid massage decreases the heart rate to 80 beats/min. These best describe: A) Ventricular tachycardia B) Paroxysmal atrial tachycardia C) Atrial fibrillation D) Ventricular fibrillation - ✔✔B) Paroxysmal atrial tachycardia Signs/symptoms of paroxysmal atrial tachycardia include rapid, regular heart rate that begins and ends very quickly. The atria are beating at a very fast rate, but it is not life-threatening. Ventricular tachycardia is usually associated with heart disease, occurs when the ventricles are beating rapidly and inefficiently, and can lead to death if not treated. Atrial fibrillation is an irregular heartbeat that can be life threatening if not treated. Ventricular fibrillation occurs when the heartbeat is rapid and chaotic, and death will occur if the condition is not treated. A 40-year-old female is positive for anti-hepatitis C virus (HCV). Which test is appropriate for follow-up? A) HCV RNA B) HCV antibodies C) HCV core antigen D) Hepatitis C surface antigen - ✔✔A) HCV RNA HCV RNA is performed following a positive anti-hepatitis C virus test. A 40-year-old male complains to the nurse practitioner of severe stabbing pains behind his left eye for the past 2 days. It is accompanied by some nasal congestion and rhinorrhea, which is clear in color. The patient denies pharyngitis and fever. Which of the following conditions is most likely? A) Migraine headache with aura B) Cluster headache C) Tic douloureux D) Cranial neuralgia - ✔✔B) Cluster headache Signs/symptoms of cluster headaches include severe stabbing pain behind the eyes, with nasal congestion and rhinorrhea. Migraine head- aches with aura include visual changes, such as blind spots or flashing lights that appear before the onset of the headache. Trigeminal neuralgia (tic douloureux) is a unilateral headache from compression or inflammation of the trigeminal nerve (cranial nerve 5). A 40-year-old nurse complains of a new onset of back pain secondary to her job on the medical-surgical floor of a hospital. She reports lifting some obese patients while working the previous night shift. She reports to the worker's compensation clinic where she was referred. She describes the pain as starting in her right but- tocks area and radiating down the back of her thigh. It becomes worse when she sits down for long periods. You would suspect: A) Sciatica B) Acute muscle spasm C) Cauda equina syndrome D) Acute muscle strain - ✔✔A) Sciatica Sciatica is defined as pain that begins in the buttock area and radiates down one leg. Other symptoms include weakness and tingling sensation. Acute muscle spasm and strain do not cause tingling down the leg. Cauda equina syndrome is an emergent issue, in which there is neurological involvement and patient complaints of weakness and loss of bladder and bowel control. A 40-year-old White female with a BMI (body mass index) of 32 complains of col- icky pain in the right upper quadrant of her abdomen that gets worse if she eats fried food. During the physical exam, the nurse practitioner presses deeply on the left lower quadrant of the abdomen. After releasing her hand, the patient complains of pain on the right side of the lower abdomen. What is the name of this finding? A) Rebound tenderness B) Rovsing's sign C) Murphy's sign D) Psoas test - ✔✔B) Rovsing's sign Rovsing's sign is referred pain to the opposite side of the abdomen after release of palpation. A 40-year-old woman is in the office complaining of palpitations and some light headedness for the past 6 months. These are random episodes. The nurse practitioner notices a mid-systolic click with a late systolic murmur that is best heard in the apical area during auscultation of the chest. The NP would suspect: A) Atrial fibrillation B) Sinus arrhythmia C) Mitral stenosis D) Mitral valve prolapse - ✔✔D) Mitral valve prolapse Mitral valve prolapse occurs when the mitral valve does not close all the way, causing a late systolic murmur heard best in the apical area during auscultation of the chest. Symptoms patients may experience at times include palpitations and dizziness. A 44-year-old female who is undergoing treatment for infertility complains of not having a menstrual period for a few months. The night before, she started spotting and is now having cramp-type pains in her pelvic area. Her blood pressure (BP) is 160/80, the pulse rate is 110, and she is afebrile. Her labs reveal a mild anemia with mild leukocytosis. On pelvic exam, the uterine fundus is found above the symphy- sis pubis. The cervical os is dilated at 3 cm. Which of the following is most likely? A) Inevitable abortion B) Threatened abortion C) Incomplete abortion D) Acute pelvic inflammatory disease - ✔✔A) Inevitable abortion Inevitable abortion is defined as vaginal bleeding with pain and cervical dilation and/or effacement. Threatened abortion is defined as vaginal bleeding with absent or minimal pain and a closed, long, and thick cervix. Incomplete abortion is moderate to diffuse vaginal bleeding, with the passage of tissue and painful uterine cramping or contractions. Acute pelvic inflammatory disease is a sudden onset of inflammation and pain that affects the pelvic area, cervix, uterus, and ovaries, which is caused by infection. A 44-year-old patient with Down syndrome starts to develop impaired memory and difficulty with his usual daily life routines. He is having problems functioning at the job that he has done for the past 10 years. The physical exam and routine labs are all negative. The vital signs are normal. His appetite is normal. The most likely diagnosis is: A) Tic douloureux B) A stroke C) Alzheimer's disease D) Delirium - ✔✔C) Alzheimer's disease Delirium is an acute decline in mental status and is temporary. Common causes are fever, shock, drugs, alcohol, and dehydration. Alzheimer's disease is a permanent change to the brain that causes short-term memory loss, agnosia, apraxia, and aphasia. In this case, the patient's physical exam is normal; however, he is having memory loss and difficulty working and carrying out his normal tasks A 45-year-old gardener is seen as a walk-in patient in a private clinic. He reports stepping on a nail that morning. His last tetanus vaccine was 7 years ago. Which of the following vaccines is recommended? A) DTaP B) DT C) Td D) Tdap - ✔✔D) Tdap The CDC recommends that 1 of the tetanus boosters be replaced with the Tdap (once in a lifetime). Thereafter, the Td form of the vaccine is indicated every 10 years. The DTaP (diphtheria-tetanusacellullar pertussis) and DT (diphtheria-tetanus) forms of the tetanus vaccine are not given after the age of 7 years. Puncture wounds are at higher risk for tetanus because Clostridium tetani bacteria are anaerobes (deep puncture wounds are not exposed to air compared with superficial wounds). A 45-year-old man fell asleep while smoking in his bedroom and started a fire. According to the patient, he refused to go to the emergency department because he had only minor burns. About 12 hours later, he presents to a walk-in urgent care center complaining of a new cough that is productive of saliva with clear mucus with small carbonaceous black particles. His brows appear singed. Which of the following is the priority when evaluating this patient? A) Perform a medical history, including prescription, OTC, and herbal medicines B) Assess the patient for respiratory distress C) Evaluate the patient for asthma and atopy D) Use the Rule of Nines to evaluate the total body surface area (TBSA) - ✔✔B) Assess the patient for respiratory distress Assess the patient for respiratory distress ASAP. Follow the "ABCs" and assess the patient for any lifethreatening symptoms. Smoke inhalation lung injury is the main cause of death in thermal burn victims. A 48-year-old woman is told by a physician that she is starting menopause. All of the following are possible findings except: A) Hot flashes B) Irregular menstrual periods C) Severe vaginal atrophic changes D) Cyclic mood swings - ✔✔C) Severe vaginal atrophic changes As women reach menopause, changes that may occur include hot flashes, irregular menstrual periods, and cyclic mood swings. Vaginal changes, such as dryness and thinning, may also begin to occur A 50-year-old woman of Irish descent presents with history of lethargy, feeling weak, nausea, anorexia with diarrhea and abdominal pain. The woman's skin appears tanned, but she denies prolonged sun exposure. During physical exam, the skin appears tan with hyperpigmentation of the nipple area, the gums, and the lips. The electrolyte panel reveals hyperkalemia and hyponatremia. She reports craving salty foods. Which of the following is most likely? A) Addison's disease B) Cushing's disease C) Metabolic syndrome D) Cutaneous drug reaction - ✔✔A) Addison's disease Addison's disease is also known as primary adrenal insufficiency. The most common cause of damage to the adrenal cortex (the outer layer of the gland) is autoimmune destruction. The adrenal cortex produces glucocorticoids (cortisol) and mineralocorticoids (aldosterone). Aldosterone regulates sodium retention and potassium excretion through the kidneys (affects blood pressure). Electrolyte abnormalities are high potassium and low sodium. In primary disease (Addison's), serum cortisol is low, ACTH is high, and serum aldosterone is low. If the patient is not treated, severe stress (illness, accident) may cause an adrenal crisis ("Addisonian" crisis), which can be fatal. A 53-year-old crossing guard complains of twisting his right knee while working that morning. The knee is swollen and tender to palpation. The nurse practitioner diagnoses a Grade II sprain. The initial treatment plan includes which of the following? A) Application of cold packs the first 24 hours followed by applications of low heat at bedtime B) Elevation of the affected limb and intermittent applications of cold packs for the next 48 hours C) Rechecking the knee in 24 hours and isometric exercises D) The application of an Ace bandage to the affected kne - ✔✔B) Elevation of the affected limb and intermittent applications of cold packs for the next 48 hours Elevation of the injured knee above the heart will reduce the amout of swelling that can occur. Use of ice packs immediately after the injury is most effective and will reduce swelling in the tissue. Ice the affected area for 15 minutes at a time intermittently to prevent frostbite and further damage to tissue. Allowing 30-45 minutes between icings of the limb is recommended. A 55-year-old female with a history of migraine headaches has recently been diagnosed with Stage II hypertension. Her EKG strips reveal second-degree heart block. The chest x-ray is normal. Which of the following drugs should this patient avoid? A) ACE inhibitors B) Angiotensin receptor blockers C) Diuretics D) Calcium channel blockers - ✔✔D) Calcium channel blockers Common side effects of calcium channel blockers include headaches, edema of the lower extremities, and heart block or bradycardia. Contraindications for calcium channel blockers include second- or thirddegree AV block, bradycardia, and congestive heart failure. A 55-year-old male patient describes to you an episode of chest tightness in his substernal area that radiated to his back while he was jogging. It was relieved immediately when he stopped. Which of the following conditions does this best describe? A) Angina pectoris B) Acute myocardial infarction C) Gastroesophageal reflux disease D) Acute costochondritis - ✔✔A) Angina pectoris Symptoms of angina pectoris include a pressing, squeezing, or crushing pain, usually in the chest or back, arms, neck, or ear lobes. Weakness, fatigue, and shortness of breath and pain radiating in the arms, shoulders, jaw, neck, and/or back may also occur. Angina pectoris is most commonly brought on by physical exertion, but can also be triggered by stress and other stressors to the body. A 55-year-old nurse brings her mother, who is 82 years of age, to the emergency department of a local hospital. She reports she found her mother on the floor when she checked on her that morning. Her mother was awake and oriented, but needed help getting up. Her mother states that she thinks she passed out. She is being evaluated by a physician who orders an EKG and x-rays of both hips. Regarding laboratory testing, which of the following is important to perform initially? A) Urinalysis B) Serum electrolytes C) Blood glucose D) Hemoglobin and hematocrit - ✔✔C) Blood glucose Checking the blood glucose is indicated for patients with syncopal and near syncopal episodes. The NP has performed a thorough history of the incident (diabetic, rapid onset or slow, position, provocation), medical history, health history, and the medications. A 55-year-old woman who has type 2 diabetes is concerned about her kidneys. She has a history of 3 urinary tract infections within the past 8 months. She denies dysuria and frequency at this visit. Which of the following is the best initial course to follow? A) Recheck the patient's urine and order a urine for culture and sensitivity B) Order an IVP (intravenous pyelogram) C) Advise the patient to follow up with a urologist D) Evaluate the patient for a possible kidney infection - ✔✔A) Recheck the patient's urine and order a urine for culture and sensitivity A urinary tract infection is defined as the presence of 100,000 organisms per mL of urine in asymptomatic patients or greater than 100 organisms per mL or urine with pyuria (more than 7 WBCs/mL) in a symptomatic patient A 55-year-old woman who is on a prescription of clindamycin for a dental infection presents to the nurse practitioner with complaints of watery diarrhea for the past 4 days. She complains of abdominal cramping and bloating with diarrheal stools up to 10 times a day. She denies seeing blood or pus in her stool. There is no history of recent travel. The patient has been taking over-the-counter medicine with no relief. The nurse practitioner suspects that the patient has a mild case of Clostridium difficile colitis. Which of the following antibiotics is indicated for this infection? A) Ciprofloxacin (Cipro) 400 mg PO BID x 7 days B) Metronidazole (Flagyl) 500 mg PO TID x 10 days C) Levofloxacin (Levaquin) 750 mg PO daily x 7 days D) Trimethoprim-sulfamethoxazole (Bactrim DS) 1 tablet PO BID x 10 days - ✔✔B) Metronidazole (Flagyl) 500 mg PO TID x 10 days First-line treatment for a mild case of Clostridium difficile colitis is metronidazole (Flagyl) 500 mg PO TID x 10 days. Discontinuation of the offending antibiotic (if possible) or switching to another antibiotic class is recommended. The role of probiotic supplementation is controversial. Complications are pseudomembranous colitis, toxic megacolon, and fulminant colitis. A 56-year-old man complains of episodes of lancinating pain that shoots up to his right cheek when he eats or drinks. He has stopped drinking cold drinks because of the pain. Which of the following is most likely? A) Trigeminal neuralgia B) Cluster headache C) Acute sinusitis D) Sinus headache - ✔✔A) Trigeminal neuralgia Pain shooting up the right cheek with food or drink is seen with trigeminal neuralgia. A 56-year-old mechanic is brought to your office complaining of heavy pressure in the substernal area of his chest that is radiating to his jaw. The pain began while he was lifting up a tire. He now appears pale and is diaphoretic. His blood pressure is 100/60 mm Hg, and his pulse rate 50. What is the most appropriate action? A) Perform a 12-lead EKG B) Dial 9-1-1 C) Administer a morphine injection for pain D) Observe the patient in the office - ✔✔B) Dial 9-1-1 Heavy chest pressure in the substernal area, radiating to the jaw, diaphoresis, low BP, and bradycardia are signs of cardiac distress and 9-1-1 should be called immediately for transfer to the emergency department. A 60-year-old female truck driver presents to the outpatient urgent care clinic of a hospital complaining of the worsening of her low back pain the past few days. She describes the pain as "sharp and burning" and points to the left buttock. She reports that the pain started on the mid-buttock of the left leg and recently started to go down the lateral aspect of the leg toward the top of the foot. During the physical exam, the ankle jerk and the knee jerk reflex is 1+ on the affected leg and 2+ on the other leg. The pedal, posterior tibialis, and popliteal pulses are the same on both legs. Which of the following tests should the nurse practitioner consider for this patient? A) Order both a plain radiograph and computed tomography (CT) scan of the spine as soon as possible B) Write a prescription for ibuprofen 800 mg PO QID with a muscle relaxant and advise the patient to follow up with her primary care provider within 3 days C) Refer the patient to an orthopedic surgeon D) Ordering an imaging study of the spine is premature because the majority of low back pain cases resolve within 10 to 12 weeks - ✔✔A) Order both a plain radiograph and computed tomography (CT) scan of the spine as soon as possible The patient has a severe case of sciatica that is worsening quickly (may progress to cauda equina). In addition, older age and an abnormal neurologic exam are red flags for potentially serious underlying pathology (osteoporosis fracture, cancer, infection, spondylolisthesis). Because the patient's symptoms are worsening, a CT scan is the best choice. A plain radiograph can only detect bony pathology, but a CT scan can detect nerve root compression, herniated disc, cancer, and spinal stenosis (narrowing of the spinal canal). In addition, the patient needs to follow up with a neurologist as soon as possible. A 62-year-old female complains of chronic severe low back pain. She also reports mild episodes of fecal incontinence and numbness to her lower legs over the past week. You would suspect which of the following? A) Fracture of the lower spine B) A herniated disc C) Cauda equina syndrome D) Ankylosing spondylitis - ✔✔C) Cauda equina syndrome Cauda equina syndrome is a surgical emergency. Signs and symptoms include a change in bowel and bladder control (incontinence). Acute pressure on the sacral nerve root causes inflammatory and ischemic changes to the nerve and can lead to permanent nerve damage. A 62-year-old male with chronic obstructive pulmonary disease (COPD) complains to the nurse practitioner that his prescription of ipratropium bromide (Atrovent) is not working. He reports that he still feels short of breath even after using it 4 times a day for 3 months. Which of the following actions is the next step for the nurse practitioner? A) Increase the patient's dose of ipratropium bromide (Atrovent) to 3 inhalations QID B) Continue the ipratropium bromide and start the patient on oxygen by nasal cannula C) Continue ipratropium bromide (Atrovent) and add albuterol (Ventolin) inhaler 2 inhalations QID D) Start the patient on oxygen by nasal cannula at bedtime and PRN during the daytime - ✔✔C) Continue ipratropium bromide (Atrovent) and add albuterol (Ventolin) inhaler 2 inhalations QID Treatment of COPD starts with an anticholinergic (ipratropium bromide). The next step is to add a shortacting beta-2 agonist (albuterol) A 63-year-old patient with a 10-year history of poorly controlled hypertension presents with a cluster of physical exam findings. Which of the following indicate target organ damage commonly seen in hypertensive patients? A) Pedal edema, hepatomegaly, and enlarged kidneys B) Hepatomegaly, AV nicking, bibasilar crackles C) Renal infection, S3, neuromuscular abnormalities D) Glaucoma, jugular vein atrophy, heart failure - ✔✔B) Hepatomegaly, AV nicking, bibasilar crackles With long-term, uncontrolled hypertension, organ damage may occur. Organs commonly affected include: brain (stroke), eyes (retinopathy, AV nicking, bleeding, blindness), heart (heart dis- ease, left ventricular hypertrophy, MI, and/or CHF), and kidneys (renal failure, proteinuria). A 65-year-old Hispanic woman has a history of type 2 diabetes. A routine urinalysis reveals a few epithelial cells and is negative for leukocytes, nitrites, and protein. Which of the following would you recommend next? A) Order a urine for C&S B) Order a 24-hour urine for microalbumin C) Because it is negative, no further tests are necessary D) Recommend a screening IVP (intravenous pyelogram) - ✔✔B) Order a 24-hour urine for microalbumin Epithelial cells are cells that are present on the inside lining of the organs. Few epithelial cells can be normal; however, with her history of type 2 diabetes, a 24-hour urine for microalbumin should be ordered to assess kidney function. A 65-year-old woman's bone density result shows severe demineralization of cortical bone. All of the following pharmacologic agents are useful in treating this condition except: A) Raloxifene (Evista) B) Calcitonin (Miacalcin) C) Medroxyprogesterone (Depo-Provera) D) Calcium with Vitamin D - ✔✔C) Medroxyprogesterone (Depo-Provera) Common treatments for osteoporosis include calcium and Vitamin D, Evista, Miacalcin, and bisphosphonates. Depo- Provera is a type of contraception. A 67-year-old female with a 50 pack/year history of smoking presents for a routine annual physical examination. She complains of being easily short of breath and is frequently fatigued. Physical examination reveals diminished breath sounds, hyperresonance, and hypertrophied respiratory accessory muscles. Her CBC results reveal that her hematocrit level is slightly elevated. Her pulmonary function test (PFT) results show increased total lung capacity. What is the most likely diagnosis for this patient? A) Bronchogenic carcinoma B) COPD (chronic obstructive pulmonary disease) C) Chronic bronchitis D) Congestive heart failure - ✔✔B) COPD (chronic obstructive pulmonary disease) Common complaints and signs/symptoms of COPD include shortness of breath, fatigue, chronic cough, wheezing, difficulty performing tasks and speaking, pursed-lip breathing, digital clubbing, diminished breath sounds, use of accessory muscles, and polycythemia due to chronic hypoxia. Pulmonary function tests/ spirometry include forced expira- tory volume, forced vital capacity, and FEV1/FVC ratios. A 67-year-old retired clerk presents with complaints of shortness of breath and weight gain over a 2- week period. A nonproductive cough accompanies her symptoms. The lung exam is positive for fine crackles in the lower lobes with no wheezing. The exam is positive for egophony. Which of the following conditions is most likely? A) Acute exacerbation of asthma B) Left-heart failure C) Right-heart failure D) Chronic obstructive pulmonary disease - ✔✔B) Left-heart failure Signs and symptoms of left-heart failure include tachypnea, labored breathing, and rales or crackles in the lower bases of the lungs, which can develop into pulmonary edema. A 68-year-old woman complains of leaking a small amount of urine whenever she sneezes, laughs, and/or strains. The problem has been present for many months. The patient denies dysuria, frequency, and nocturia. The urine dipstick test is neg- ative for white blood cells, red blood cells, ketones, and urobilinogen. What is the name of this condition? A) Urge incontinence B) Overflow incontinence C) Urinary incontinence D) Stress incontinence - ✔✔D) Stress incontinence