NSG 6420 Predictor Question Bank | Updated Fall 2025

Typed Pre-Predictor 1) A 15 years old high school student with a mild sore throat and low-grade fever that has persisted for about 3 weeks. She reports general malaise, fatigue, and loss of appetite. The NP suspects m ...

Typed Pre-Predictor 1) A 15 years old high school student with a mild sore throat and low-grade fever that has persisted for about 3 weeks. She reports general malaise, fatigue, and loss of appetite. The NP suspects mononucleosis. Which of the following is the LEAST appropriate intervention? a. Palpate the lymph nodes and spleen b. Examine the posterior oropharynx for petechiae c. Obtain a CBC, throat culture, and heterophil antibody test. d. Obtain an urinalyses and serum for LFTs and amylase Explanation: mononucleosis is a symptomatic infection caused by the Epstein-Bar virus. Common is people 15-24 years of age. Common signs and symptoms following incubation period (1-2 months) include fatigue, chills, malaise, anorexia, white tonsillar exudates and lymphadenopathy or posterior cervical region. Splenomegaly can be present. A maculopapular or occasionally a petechial rash occurs in less than 15% of patients. A diagnosis is usually made using the Monospot. In addition, neutropenia and lymphocytosis are usually detected in the CBC. 2) A 32 years old male patient complaint of urinary frequency and burning on urination for 3 days. Urinalyses reveals bacteriuria and positive nitrites. He denies any past hx. Of urinary tract infections. The initial treatment should be: a. trimethoprim-sulfamethoxazole (Bactrim, Sulfatrim) for 7-10 day b. ciprofloxacin (Cipro) for 3-5 days c. Trimethoprim-Sulfamethoxazole for 3 days d. 750 mg ciprofloxacin as a one-time dose Explanation: trimethoprim-sulfamethoxazole (TMPS) is usually n appropriate medication to treat urinary tract infections in most patients. In the case of community resistance to TMPS >20%^, another medication should be substituted. In men, the appropriate length of time is 7-10 days. Women may be treated for 3 days for uncomplicated UTI 3) Which agent is most effective for the treatment of nodulocystic acne? a. Benzoyl peroxide (Benzac) b. Retinoic acid (Retin A) c. Topical tetracycline d. Isotretinoin) Explanation: Isotretinoin (Accutane) is a systemic agent indicated for treatment with severe inflammatory acne. Guidelines for its use must be clearly understood by the patient. A woman of childbearing age must use an effective method of contraception because isotretinoin is teratogenic. There are many restrictions in prescribing this medication because of the teratogenic effects is given during pregnancy. Therefore, it is a pregnancy category X. 4) An 18 y/o woman is taking a combined hormonal oral contraceptive. She should be instructed to use a backup method for the prevention of pregnancy a. Throughout the week of placebo pills b. If prescribed topiramate (Topamax) for the treatment of migraines. 1c. If prescribed amoxicillin/clavulanate (Augmentin) for a sinus infection d. if she forgets to take a single dose of the contraceptive Explanation: Anticonvulsant including phenytoin (Dilantin), carbamazepine (Tegretol), primidone (Mysoline), topiramate (Topamax) and oxcarbazepine (Trileptal) reduce the effectiveness of contraceptives. Depo-medroxyprogesterone acetate injections or levonorgestrelreleasing intrauterine devices would be a better method of contraceptive for patients taking anticonvulsants. Most commonly used antibiotics have not been proven to reduce the effectiveness of contraceptives. Rifampin is an exception, and additional …. Be used by women taking this drug and using oral contraceptives, transdermal, or vaginal ring preparations. Additional backup contraception should be used if taking antifungal agents. No additional protection is needed thought the week of placebo pills. Missing one single dose of contraceptive does not require additional protection, missing more than one doses does. 5) A 44 years old female patient has diabetes. Her total cholesterol (TC) is 250 mg/dl (6.5 mmol/L), LDL= 190 mg/dL (4.94 mmol/L), HDL= 25 mg/dL (65 mmol/L), and triglycerides= 344 mg/dL (8.94 mmol/L). What agent have the greatest effect on improving her lipid profile and reducing morbidity and mortality associates with dyslipidemia? a. Niacin (Niaspan) b. Atorvastatin c. Omega 3 fatty acids d. Fenofibrates Explanation: First and foremost, it is essential to educate individuals on a heart-healthy lifestyle. LDL-C is one of the major culprits in the development of atherosclerotic heart disease. The target level of LDL-C is between 50 to 70mg/dl to prevent plaque formation in the blood vessels. Guidelines strongly recommend statin therapy because they primarily lower LDL-C levels, but they also have the secondary effects of lowering triglyceride and increasing HDL-C levels. 6) A 30 years old female comes into a clinic with classic signs and symptoms of appendicitis. The NP fails to refer the patient to a surgeon. The appendix ruptures and the woman die. This is an example of a. Failure of diligence b. Professional liability c. Negligence d. Malpractice Explanation: malpractice, a negligence tort, occurs when a health care professional’s actions fall bellow the appropriate standard of care and hurts the patient. In this case the patient came with sings and symptoms indicating appendicitis and the NP failed to refer the patient.. 7) A NP has recently been hired to work in a fast track facility. The NP employer asked if she has “a problem prescribing medications for emergency contraception.” The NP replies affirmatively. This is: a. Grounds for dismissal b. An ethical dilemma for the NP 2c. Illegal according to the standards of nursing d. Patient abandonment. Explanation: in this instance, the NP has a difference of opinion with her employer based on her religious or moral belief about providing emergency contraception. This situation is an example of an ethical dilemma. Failure to participate in the provision of care to the patient based on the NP’s beliefs is neither against the law nor a violation of the standards of practice 8) A patient presents with pruritic lesions on both knees. There are visible silver scales. How Should this condition be managed? a. Topical antifungal cream or ointment b. Oral antibiotics c. Topical corticosteroids cream d. Topical anti-fungal/ steroid cream Explanation: Psoriasis is characterized by erythematous papules, as well as itchy, red, precisely defined plaques with silvery scales. Auspitz sings is another common finding. Topical agents containing tar and salicylic acid may be used. Topical steroids, such as betamethasone, may also be ordered. 9) Antidepressant discontinuation syndrome is less likely if the patient a. Is male b. Is less than 35 y/o c. Has taken an SSRI with a short half life d. Gradually tapers SSRI use Explanation: Antidepressant discontinuation syndrome is most often seen in the primary care office in association with SSRI discontinuation, because SSRIs are the most commonly prescribed class of antidepressant medications. Interruption of treatment with an anti-depressant medication is sometimes associated with an antidepressant discontinuation syndrome; in early reports it was referred to as a “withdrawal reaction. Symptoms of antidepressant discontinuation syndrome can include flu-like symptoms, insomnia, nausea, imbalance, sensory disturbances, and hyperarousal. Tapering is recommended by experts. 10) Patient with benign prostatic hyperplasia (BPH) should be taught to avoid which one of the following drug classes? a. Alpha adrenergic antagonist b. Anti-androgen agents c. Tricyclic antidepressant (TCA) d. Sulfonamides Explanation: tricyclic antidepressant should not be used by men with benign prostatic hyperplasia because of the increased risk of urinary retention secondary to the anticholigergic effects of TCAs. 11) Which of the following is the best response to a woman who has just admitted she is a victim of spousal abuse? a. What was if you did to make him angry? 3b. You must seek refuge immediately c. I am concerned about your safety d. I am going to call a shelter for you Explanation: The first step is to establish trust in the therapeutic relationship. without trust future collaboration, intervention and client outcome cannot be accomplished to facilitate appropriate and safe behavior. The experience of abuse is a traumatic psychological crisis that must be addressed as such. The healthcare providers must emphasize the fact that the victim has not done anything wrong and they must also emphasize the fact that the victim's life and the lives of their children can be in danger if the abuse is not addressed. It will not disappear with a lack of action. An order of protection against the perpetrator is often recommended. 12) For which patient group does the US Preventive Services Task Force recommend routine screening for asymptomatic bacteriuria a. pregnant woman b. Children c. Patients with diabetes d. patients over the age of 70 Explanation: an increased incidence of bacteriuria is found in all the population listed. However, bacteriuria in pregnant women increases the mother…..Also increased is the risk of a pre-term delivery, which then increases perinatal and fetal morbidity and mortality. The recommended it…. 13) What diabetic complications result from hyperglycemia? 1. Retinopathy 2. Hypertension resistant to treatment 3. Peripheral neuropathy 4. Accelerated atherosclerosis a. 1,2,3 b. 2,3,4 c. 1,3,4 d. 1,2,4 explanation: Complications of untreated or uncontrolled hyperglycemia over a prolonged period of time include: Microvascular complications: Retinopathy, Nephropathy, Neuropathy Macrovascular complications: Coronary artery disease, Cerebrovascular disease, Peripheral vascular disease 14) A 6 y/o presents w/ complaints of sore throat and fever for 2 days. He has multiple vesiculated ulcerations on his tonsils and uvula. There are no other remarkable findings. What is the most likely diagnosis? a. Viral pharyngitis b. Herpangina c. Epiglottitis d. Tonsillitis 4Explanation: Herpangina is a viral infection common in toddlers and young children caused by Coxsackie virus. The clinical findings of numerous, small (1-2 mm) ulcerations on the tonsils and uvula are typical of herpangina. The ulcerations can be very painful but usually resolve in 7 to 10 days. Treatment is symptomatic. 15) A patient has Kawasaki syndrome. Which characteristics would be UNUSUAL? a. Age > 15 years b. Fever > 101 F (38.3 C) c. Exudative pharyngitis d. Painful rash explanation: Kawasaki disease is an acute febrile vasculitis syndrome that evolves inflammation of the blood vessels. This condition often causes cardiac complication in children by damaging the coronary arteries is most prevalent in children of Asian ethnicity. Diagnosis of Kawasaki disease requires presentation of fever and 4 of the following criteria: bilateral bulbar conjunctival injection, oral mucous membrane changes, peripheral extremity changes, polymorphous rash, and cervical lymphadenopathy. 16) According to the JNC 8 guideline hypertension in a 40 y/o can be diagnosed when blood pressure exceeds a. 140/90 b. 130/90 c. 125/85 d. 150/100 Explanation: According to JNC 8 guidelines, hypertension is a sustained elevation of systolic BP greater than or equal to 140 mmHg or diastolic BP greater or equal than 90mmHg, taken from 2 or more readings on 2 different occasions after an initial screening. 17) A 48 y/o female complains of pain and stiffness in her right hip and knee that is mild on awakening in the morning, get worse as the day progresses and is relived with hot baths and ibuprofen. Crepitus is palpated on range of motion of the knee. Signs of inflammation are notably absent. What is the most likely diagnosis? a. Rheumatoid arthritis (RA) b. Gout c. Osteoarthritis (OA) d. Osteoporosis Explanation: Rheumatoid arthritis is characterized by several joint deformities, usually bilaterally symmetrical. RA is characterized by inflammatory processes, while OA is not. RA and OA are chronic conditions. Gout is characterized by acute exacerbations related to a defect in purine metabolism, increased uric acid production, or decreased uric acid excretion. 18) A 7-year old female patient presents with severe injuries that are inconsistent with the explanation given for them. The nurse practitioner questions the mother about abuse. She admits that her husband, the child’s father, beat the child. How should the nurse practitioner proceed? a. Inform the mother that the abuse must be reported to child protection authorities. b. Counsel the mother that if it happens again it will be reported to child protection service. c. Ask the child what she did to cause the punishment 5d. Refer the family to the National Domestic Violence hotline. Explanation: An awareness of all the unique presentations of child abuse, subjective or objective, physical, sexual, or neglect, is essential for NPs. Objective findings, such as broken bones, burns, and bruises, may be as a result of an intentional injury from physical abuse or from an unintentional injury as a result of neglect. Both must be considered. Repeated visits to the emergency department, frequent or suspicious injuries, or bilateral or multiple healing fractures are often indicators of physical abuse. Once the diagnosis of child abuse has been made, the primary role of the NP is to ensure the child is safe. If the NP suspect that a child is undergoing abuse, it’s critical to report it—and to continue reporting each separate incidence if it continues to recur. 19) A 1-month-old presents with reported recurrent diarrhea, screaming, and drawing up of the legs followed by periods of lethargy. On physical examination, a “sausage-like” mass in the upper right quadrant of the distended abdomen. Which of the following is the most likely diagnosis? a. Intussusception b. Volvulus c. Crohn’s disease d. Foreign body in the GI tract explanation: Intussusception is one of the most common causes of abdominal obstruction in children prior 2 years of age; is best described as a portion of the intestine which telescopes into a more distal intestinal segment. The classic triad of intussusception include crampy (intermittent, also known as colicky) abdominal pain, vomiting, and bloody stools. The patient may pull up his knees with crying. The patient may develop vomiting with bilious emesis. Progressive lethargy/altered level of consciousness and pallor is common. The etiology of this lethargic presentation is not known, but it tends to occur in younger infants. As intussusception progresses, a palpable, sausage-shape mass may develop. Some hypothesize that this is due to release of endogenous opioids or endotoxins released from ischemic bowel. Intussusception in a child presenting with lethargy is often difficult to diagnose since other causes of lethargy such as dehydration, hypoglycemia, sepsis, toxic ingestion, post-ictal state, etc., must also be considered. Ultrasound is the preferred diagnostic test. Enemas is considered the first line of treatment prior surgery. Volvulus occurs more frequently in middle-aged and elderly men. Cronos’s is most often diagnosed between 13 – 30 years of age. 20) A middle-aged female complains of insomnia, night sweats, feeling intensely hot, emotional lability, extreme nervousness and impatience. The LEAST likely cause of her symptoms is a. Thyrotoxicosis b. Menopausal vasomotor instability c. Alcohol or another drug withdrawal d. New onset type 2 diabetes mellitus Explanation: New onset diabetes produces elevated serum glucose levels less than 200 mg/dL (7.0 mmol/L) and usually no clinical signs or symptoms. At higher levels, the patient may report lethargy, fatigue, weakness, weight loss, and polydipsia, polyuria, and/or polyphagia. Complaints of insomnia, night sweats, feeling intensely hot, emotional lability, and extreme nervousness may 6be caused by thyroxine excess, menopausal instability, or withdrawal from alcohol or other drugs of addiction. 21) Which of the following indicated need for further evaluation? a. A 7 y/o girl with vaginal bleeding b. A 7 years old girl with no true pubic hair c. A 12 years old boy with sparse, slightly pigmented pubic hair d. A 12-year-old girl with breast buds explanation: In newborn girls, withdrawal bleeding may occur as a normal response to maternal estrogen leaving the infant’s uterine lining. Vaginal bleeding after the first few weeks of life and before puberty is considered abnormal. Early vaginal bleeding can indicate trauma, foreign bodies (toilet paper is the most common), vulvovaginitis, hemangiomas, benign polyps, precocious puberty, or sexual abuse. 22) A young couple is being seen by the NP for preconception counseling. They express a wish for pregnancy within the next 3 month and are very eager to know what they can do now to “make the baby as healthy as possible”. Which of the following should the NP encourage to decrease the chance of neural tube defect in the fetus? a. Maternal alpha-fetoprotein level b. Folic acid 0.4 mg daily c. Rubella vaccine today d. Vitamin E 400 IU daily Explanation: Supplementation with folic acid decreases the development of neural tube defects, such as spina bifida and anencephaly. Folic acid plays an essential role in neural tube closure. Neural tube development/closure takes place in the fist 4 weeks of embryonic life (6 weeks’ gestation). U.S. Public Health Service and the CDC recommend that all women of childbearing age consume 0.4 mg of folic acid daily to prevent tube defects. 23) A patient with a past history of documented coronary arterial blockage less than 70% complains of chest pain several time p…. which is relived with nitroglycerin. Which is the most appropriate initial action for the NP? a. Refer to a cardiologist as soon as possible b. Prescribe long-acting nitroglycerin c. Order treadmill stress test d. Prescribe an ACE inhibitor and re-evaluate in 24 to 48 hours Explanation: The patient has at least a 70% occlusion of a major coronary artery. For a patient to be considered for CABG, the coronary arteries to be bypassed must have approximately a 70% occlusion (60% if in the left main coronary artery). 24) A 3 y/o has enlarged, warm, tender cervical lymph nodes, indicating: a. Infection proximal to the nodes b. A possible cancer diagnosis c. Shorty nodes, a common normal variant in children d. An infectious process distal to the nodes explanation: size of lymph nodes is important. Nodes > 1 cm are significant and should be asses carefully. Nodes > 5 cm are almost always neoplastic. Tenderness of a node usually suggest 7inflammation. Cancerous nodes frequently are larger, non-tender, and stone-like in consistency. Nodes are pea-sized, non-tender, mobile, discrete and reflect pre-existent infection. 25) The NP examines a 2-month-old with unequal gluteal and thigh skin folds. What should the NP do next? a. Send the infant for x-ray of the hips b. Send the infant for ultrasound of the hips c. Perform Ortolani and Barlow test d. Examine the infant for unequal arm length Explanation: Gluteal and thigh skin fold asymmetry may indicate congenital hip dysplasia. Xray studies are not useful before 3 months-of-age because the femoral head has not completely ossified. 26) A very active 35 years old male has painful hemorrhoid, but he does not want hemorrhoidal surgery at this time. His diet has been indiscriminate as his job requires frequent travel. The most appropriate recommendation is for him to select food that are: a. Low in fiber such as milk and other dairy products b. High in simple carbohydrates such as white bread and mashed potatoes c. High in fiber such as bran, complex carbohydrates and fresh fruit d. High protein such a meat, poultry and fish Explanation: Hemorrhoid disease is the most common reason patients seek evaluation by a colon and rectal surgeon. The majority of hemorrhoids can be managed nonoperatively with medical management or office-based procedures. Patients should benefit from minimizing straining and avoiding constipation. Bulking of the stool facilitates this and can be accomplished by increasing dietary fiber and fluid intake. Stool softeners may also be used. 27) Correct instructions to give new parent who are transporting their newborn infant is a. A rear-facing infant car seat secured in the backseat is required until the infant weight 20 lbs. b. The infant car set may be secured in the back or front seat, but must rear-facing c. The infant car seat may be front facing when the infant is 1 year old d. A rear or front-facing infant car seat must be secured in the back seat until the infant weight 20 lbs. Explanation: The American Academy of Pediatrics (AAP) recommends that infants and toddlers ride in a rear-facing seat until they are 2 years old or until they have reached the maximum weight and height limits recommended by the manufacturer 28) A 13 y/o pt. complains that he fell while running during football practice. Now his knee hurts and sometimes “lucks”. The NP conducts McMurrays test. Which of the following is TRUE about this test? a. An audible or palpated “click” is positive for a torn meniscus b. A various stress is applied to the flexed knee c. The straight leg is internally rotated with the patient supine and flat d. The knee is grasped with the examiner’s fingers placed laterally. Explanation: Mac Murray’s test is conducted while the patient is in the supine position. The NP places the distal hand on the foot and raises the knee slowly, keeping the foot and knee externally 8rotated with the proximal hand resting on the join line. The knee is flexed and then quickly straightened. If an audible or palpable click occurs during the this test, the outcome is positive for medial meniscal injury. 29) A 20 y/o male patient complains of “scrotal swelling”. He states his scrotum feels heavy but denies pain. On examination, the NP notes transillumination of the scrotum. What is the most likely diagnosis? a. Hydrocele b. Orchitis c. Testicular torsion d. Indirect inguinal hernia Explanation: Hydrocele is common in newborns and usually disappears without treatment within the first year. Older men can develop hydroceles, sometimes due to inflammation or injury. Hydroceles are usually painless, but may become large and inconvenient. An ultrasound may be needed to diagnose the condition. 30) A 15 y/o male has a hx of cryptorchidism which was surgically repaired. Because of this information, it is essential for the NP to teach him about a. Testicular self-examination b. Protection of the testes during sports activities c. Risk of testicular torsion d. Practicing safer sex Explanation: Cryptorchidism, even with surgical repair, is associated with increased risk for testicular cancer. 31) A pt. present with classic symptoms of gastroesophageal reflux diseases’ (GERD). He is instructed in lifestyle modification, and drug initialed. Two month later, he returns and report that he still has symptoms. The next steps are to. a) Refer for surgical interventions such as partial or complete fundoplication. b) Refer for endoscopy, namometry, and/or PH testing c) Repeat the 8*-week course of drug therapy while continuing lifestyles modifications. d) Review proper proton pump inhibitor dosing time and adherence with the patient. Explanation: poor adherence is an importance cause of inadequate acid suppression and refractory GERD. Determining adherence to proton pump inhibitor (PPI) therapy and superficially timing in relation to meals, should be sought first alarm features such as iron deficiency anemia, unexplained weight loss, and persistent vomiting would precipitate the need for further diagnostic testing. Diagnostic testing procedures should proceed any surgical intervention like fundoplication. 32) A 51 –year- old post-menopausal female, request guidance regarding osteoporosis risk. The NP would be correct to recommend all of the following EXCEPT a. Moderate weight bearing exercise 3 times per week b. 1200 – 1500 mg calcium daily c. Avoidance of alcoholic beverages d. Weight loss 9Explanation: the recommended calcium intake is 1,200 mg – 1500 mg a day. Regular weightbearing and muscle-strengthening exercise reduce the risk of falls and fractures. Moderate alcohol intake has no known negative effect on bone and may even be associated with slightly higher bone density and lower risk of fracture in postmenopausal women. However, alcohol intake of more than two drinks per day for women or three drinks a day for men may be detrimental to bone health, increases the risk of falling and requires further evaluation for possible alcoholism. In addition, Risk factors for osteoporosis include age greater than 65, white or Asian ethnicity, cigarette smoking, inactive lifestyle, low weight and postmenopausal estrogen deficiency including premature menopause. 33) According to Erickson, the developmental task of the elderly adult is: a. Intimacy VS isolation b. Ego integrity VS despair c. Industry VS self-doubt d. Trust Vs mistrust explanation: 34) Moderate weight loss, particularly of visceral adipose tissue in patients with type 2 diabetes mellitus may have all of the following beneficial effects EXCEPT: a. Improved insulin sensitivity b. Increased glucose uptake and utilization by the cells c. Increase lean muscle mass’ d. Improved lipid profile Explanation: Regular, consistent exercise is an essential part of diabetes and prediabetes management. The ADA recommends that people with diabetes perform at least 30 minutes, 5 10days/wk of a moderate-intensity aerobic physical activity. The ADA also encourages people with type 2 diabetes to perform resistance training 3Xwk in the absence of contraindications. Exercise contributes to weight loss, which further decreases insulin resistance. The therapeutic benefits of regular physical activity may result in a decreased need for diabetes medications to reach target blood glucose goals. Regular exercise may also help reduce triglyceride and low-density lipoprotein (LDL) cholesterol levels, increase high-density lipoprotein (HDL), reduce BP, and improve circulation. Patients who use insulin, sulfonylureas, or meglitinides are at increased risk for hypoglycemia when they increase physical activity. 35) A 12 y/o presents with eat pain or 36 hours duration. The NP diagnoses acute otitis media because the a. Tympanic membrane is bulging and glossy with tiny bubbles visible posteriorly b. Tympanic membrane is retracted against boy landmarks c. Bony landmarks are obscured, and the tympanic membrane is mildly erythematous, dulls and immobile. d. Canal is narrowed, erythematous, and exquisitely tender with speculum contact Explanation: Serous otitis media typically presents with a flat or bulging and tympanic membrane with a fluid line and/or tiny bubbles visible posteriorly. The tympanic membrane may be immobile and retracted against the bony landmarks when the eustachian tube is swollen or congested as with the common cold or allergies. Narrowing of the external canal with erythema and extreme tenderness of the canal wall is indicative of otitis externa. 36) The NP should instruct the mother of an infant with thrush to: a. Take oral nystatin since she is breastfeeding b. Stop breast feeding until the thrush has resolved c. administer antifungal medication to the infant prior to feeding d. sterilized pacifiers and bottle nipples explanation: Most bouts of oral thrush occur for no apparent reason. However, regularly sterilization of pacifiers, bottles-feed and other mouth toys used by the baby may help to prevent some bouts. 37) A 26 y/o patient, 18 weeks pregnant with twins, has been healthy and has followed recommendations of her nurse midwife. She is in the office to discuss results of her maternal serum alpha-fetoprotein (MSAFP) test. which show elevation in this particular pregnancy? a. Elevated MSAFPO is an indicator of Down Syndrome b. Low MSAFP is expected at 18 weeks’ gestation c. Neural tube defects are highly probable d. Elevated MSAFP is an expected finding Explanation: elevated maternal serum alfa Protein is expected when a woman is pregnant with twins. An elevation can also be an indication of a miscalculated due date. Low levels can indicate Down Syndrome 1138) The hallmark of neurofibromatosis (von Recklinghousen disease) present in almost 100% of patients is: a. Acoustic neuroma b. Astrocytoma of the retina c. Distinctive osseous lesion d. Café au lait spots Explanation: Von Recklinghausen disease is also known as neurofibromatosis. It is characterized by multiple neurofibromas, or tumors, forming that vary in shape, size, and location. Neurofibromatosis type 1 and neurofibromatosis are differentiated by clinical features. They both include benign tumors of the nerve tissue (neurofibromas). Only neurofibromatosis type 1 (90%) has prominent clinical features, such as cafe-au-lait pigmentation. Neurofibromatosis type 2 consists of neurofibromas only without clinical features. 39) The NP correctly teaches an elderly patient with pernicious anemia that food sources of B12 include a. Red meat, poultry, fish, eggs, dairy products b. Canned and frozen fruit c. Whole grain breads, cereals and pastas d. Fresh vegetables explanation: Pernicious anemia is a type of vitamin B12 anemia. VB12 can be found in foods such as meat, poultry, shellfish, eggs, and dairy products. A special protein, called intrinsic factor (IF), helps the intestines absorb vitamin B12. This protein is released by cells in the stomach. When the stomach does not make enough intrinsic factor, the intestine cannot properly absorb vitamin B12. 40) An 18-year-old female applying for college admission present to the health clinic because evidence of rubella vaccination is required for admission. She says, “don’t remember ever getting that shot” She has negative serologic evidence of rubella antibody. The NP should: a. Tell her that her serologic evidence demonstrates that she is immune to the rubella and that she probably has the disease as a child b. Administer the vaccination after a negative pregnancy test and advise the patient that she must not get pregnant for 28 days c. Tell her that she needs the immunization and can get today if her pregnancy test is negative d. Administer the rubella vaccination after a negative pregnancy test and advise her not to get pregnant for at least 6 months. Explanation: Due to this very small chance of illness, the Centers for Disease Control and Prevention (CDC) recommend waiting 28 days after getting the MMR vaccine before trying to get pregnant. 41) A 45 y/o obese pre-menopausal female complains of indigestion, flatulence, RUQ pain and epigastric “crampy pain”. Symptoms are exacerbated by high-fat meal. What is the most likely diagnosis? a. Hepatitis 12b. Chronic cholecystitis c. Acute pancreatitis d. Myocarditis Explanation: The “typical” patient with chronic cholecystitis is “female, fat, fertile, and (over) 40” years of age. Myocarditis produces retrosternal pain that is not related to diet. The pain of pancreatitis radiates to the back. The pain of hepatitis is non-specific upper quadrant pain. 42) A 16 y/o male presents w/ mild sore throat, fever, fatigue, posterior cervical adenopathy, and palatine petechia. With for this patient, what drug would be the LEAST appropriate to prescribe? a. Ibuprofen b. Erythromycin c. Ampicillin d. Doxycycline Explanation: Mono can be managed with supportive care, including NSAIDs, and warm sailing gargles. patients with strep throat should be prescribed penny ceiling or every throw myosin instead of amoxicillin or ampicillin because amoxicillin and ampicillin often cause a rash in mono patients. 43) A characteristic of delirium that is typically absent in dementia is a. Acute onset of confusion in a previously alert and oriented patient b. Gradual loss of short-term memory c. Loss of language skills d. Long term memory gaps filled in with confabulation Explanation: Delirium is acute confusional state, is potentially a reversible cognitive impairment that often has a physiological cause; physiological causes include electrolyte imbalances, cerebral anoxia (an absence of oxygen); hypoglycemia; medication effects; tumors; subdural hematoma; and cerebral infection, infarction, or hemorrhage. Dementia is a generalized impairment of intellectual functioning that interferes with social and occupational functioning. It is an umbrella term that includes Alzheimer's disease, Lewy body disease, frontal-temporal dementia, and vascular dementia. 44) It is imperative that the NP teach patients taking oral contraceptives to report any of the danger signs of complications. Which of the following would be the LEAST concern to the NP? a. Lower leg pain b. Upper abdominal pain c. Chest pain d. Weight gain Explanation: Common side effects of OCP includes: bleeding between periods, nausea, breast tenderness, headaches and weight gain. The symptoms often subside after a few months of use. Lower Leg pain can be indicative of- DVT. Other major complication can include the liver, gallbladder or the cardiac organ. 45) Which of the following oral medications should be avoided in a child under 8 years of age? 13a. Cephalexin (Keflex) b. Tetracycline c. Rifampin d. Metronidazole (flaggyl) Explanation: Children younger than 8 years old should not take tetracycline. Deposition in the bone and primary dentition occurs during calcification in growing children. This causes discoloration and hypoplasia of the teeth and a temporary stunting of growth. 46) Which of the following descriptions of Denver II Developmental Screening Test is most accurate? a. Applicable to children from birth to 2 years; evaluates four major categories of development: motor, intellectual, emotional, and language to determine whether a child is within normal range for various behaviors or is developmentally delayed b. Applicable to children from birth to 5 years; evaluates four major categories of development: motor, vision, hearing and psychosocial to determine whether a child is normal or developmentally compromised c. Applicable to children from age 6 months to 6 years; evaluates 4 major categories of development: intellectual, verbal, social and memory to determine IQ and aptitude d. Applicable to children from birth to 6 years; evaluates four major categories of development: gross motor, fine motor-adaptive, language, and personal social to determine whether a child is within normal range for behaviors or is developmentally delayed. Explanation: The Denver Developmental Screening Test (DDST) is a screening test for cognitive and behavioral problems in children from birth until the age of 6 The purposes of the DDST and Denver II are to screen children or possible developmental problems and to verify suspected problems with an objective measure. The Denver II screens general development in four areas: Social – Personal: Aspects of socialization inside and outside the home – eg, smiling. Fine motor function – Adaptive: Eye/hand co-ordination, problem solving and manipulation of small objects – eg, grasping and drawing. Language: Production of sounds, and ability to recognize, understand and use language – eg, ability to combine words Gross motor functions: Motor control, sitting, walking, jumping, and overall large muscle movements. 47) A 12-month-old has conjunctivitis in his right eye with a mucopurulent discharge. The mother asks if the child can forego for antibiotic eye drops because he does not’s like drops in his eyes. The NP replies that: a. If untreated, conjunctivitis may permanently damage the cornea b. Conjunctivitis is usually caused by a virus. Let’s wait a few days c. If no one else at the daycare has it, we can wait a few days. d. An oral antihistamine may be prescribed instead of eye drops. Explanation: Pink eye does not normally cause loss of vision, especially when treatment is administered in a timely manner. However, if bacterial conjunctivitis is serious and left untreated, it may damage the eye permanently, leading to loss of vision. 1448) which oral hypoglycemic agent would be safest for an elderly patient if hypoglycemia is a major concern? a. Tolbutamide (orinase) b. Glipizide (Glucotrol) c. Metformin (Glucophage) d. Chlorpropamide (diabinese) Explanation: When used alone, metformin typically does not cause hypoglycemia and is usually weight neutral or causes modest weight loss. Given the low risk of hypoglycemia, metformin has an important role in elderly patients with diabetes, as long as patients are selected appropriately to avoid the risk of lactic acidosis. 49) the components of the Denver II Developmental screening test are: a. Personal/social, fine motor, gross motor, language b. Intelligence, motor performance, language development c. Vocabulary, clarity of speech, abstract thinking d. Problem-solving, speech, gross motor, fine motor Explanation: The Denver II Developmental Screening Test is the most widely used tool to assess early childhood development and rates the categories of personal–social, fine motor– adaptive, language, and gross motor skills. The nurse should explain to the parent before administering the test that this test does not measure intelligence but of the child's level of development or ability to perform age-appropriate tasks. DDST II Assesses: Gross motor function Language development Fine motor-adaptive skills Personal-social skills 50) A patient has been taking fluoxetine (prozar) since being diagnosed with major depression 7 month ago. She reports considerable empowerment in her symptoms and her intention to discontinue the medication what should be the NP’s recommendation? a. Advice the patient to stop the antidepressant medication b. Question the patient to determine if the self-assessment is correct before advising her to discontinue the medication c. Recommend that the patient continue the antidepressant medication for at least 4 more month d. Discuss with the patient that need to take the antidepressant medication indefinitely Explanation: Anxiety Treatment Clinical guidelines for managing MDD also recommend that patients should maintain antidepressant use for at least 6–9 months after full symptom remission and that patients with some risk factors. 51) for the general adult population, total dietary fat intake should be no more than what percent of total calories? a) 10% 15b) 20% c) 30% d)40% Explanation: Clinical trials suggest that heart disease mortality rates un the US could be lowered by 5 to 20% if all Americans restricted their fat intake to less than 30% of total daily calories, 7% from saturated fat. 52) A 30 y/o female patient is being seen by the NP for the first time. She is seeking advice from the NP about becoming pregnant. She is currently taking an oral contraceptive. She gives a hx of having hydatidiform molar pregnancy 2 years ago. An appropriate plan of care for this a. patient should include b. Delaying pregnancy for 1 more year c. Measuring serum chorionic gonadotropin level d. Discontinuing oral contraceptive e. Recommending permanent sterilization Explanation: A Women should be instructed to use birth control for 1 year after treatment for a hydatidiform mole. Pregnancy raises hCG levels which increases the risk for choriocarcinoma. 53) which of the following is NOT a goal for treatment for the patient with cystic fibrosis? a. Prevent intestinal obstruction b. Provide adequate nutrition c. Promote clearance of secretions d. Replace water soluble vitamins Explanation: most patients with cystic fibrosis have insufficient release of pancreatic enzymes. This results in malabsorption of the fat-soluble vitamins….meconium ileus , resembles appendicitis in these patients 54) A 24 y/o female taking oral contraceptive has missed her last 2 pills. What should the NP advise her to do to minimize her risk of pregnancy? a. Take today’s dose and do not miss any more during this month b. Double today’s dose and use a barrier method for the rest of this month c. Double today’s dose and tomorrow’s dose and use a barrier method for the rest of this month d. Stop the pills and restart a new pill pack in one week. Explanation: If 2 pills are missed on consecutive days, the next 2 days’ dosage should be double, and a barrier method recommended for the remainder of the cycle 55) Which red blood cell (RBC) index is most useful for differentiating types of anemias? a. Mean corpuscular volume (MCV) b. Mean corpuscular hemoglobin concentration (MCHC) c. Hematocrit (HCT d. Platelet count Explanation: The MCV is the most useful value in the RBC indices to help determine the type of anemia you may have. Your doctor will see if your MCV is low, normal, or high to help determine what is causing your anemia. 1656) what is a Tzanck test used to diagnosed? a. Mastoiditis b. Trichomoniasis c. Hyphema d. Herpes virus Explanation: Tzanck prep is the only test in this list which is diagnostic for herpes simplex. KOH prep is used to diagnose candidal and bacterial vaginosis. Gram stain is used to help distinguish Gram positive and Gram negative organisms. The Papanicolaou (Pap) smear is used to screen for cervical dysplasia and cancer. 57) a 40 y/o female with hx. Of frequent sun exposure present with multicolored lesion on her back it has irregular borders and is about 11 mm in diameter. What should the NP suspect? a. Squamous cell carcinoma b. Malignant melanoma c. Common Nevis d. Basal cell carcinoma Explanation: ABCDE RULE Another commonly used tool for early detection of melanoma is the ABCDE acronym (Asymmetry, Border irregularity, Color variation, Diameter >6mm and Evolution or history of change) introduced to alert patients and health professionals to the diagnosis of melanoma. 58) a 16 y/o sexually active female presents to the clinic. She has never had vaccinations for hepatitis A or B. She has had one MMR immunization, and her last tetanus vaccination was 4 years ago. which vaccination would be contraindicated without further testing? a. Hepatitis B b. Hepatitis A c. MMR d. Tetanus Explanation: Patient should have a pregnancy test before MMR vaccine. The MMR vaccine is contraindicated during pregnancy because it contains live, attenuated viruses that pose a theoretical risk to the fetus 59) following the finding of prostate gland abnormalities on DRE, The NP orders appropriate labs. When preparing to review with the patient, the NP knows all of the following are true EXCEPT a. Normal PSA is 10 mg/ml or less b. PSA is elevated in the presence of malignant prostate epithelium c. PSA is elevated in the presence of BPH d. Positive serum acid phosphatase reflects malignancy of the prostate gland with bone metastasis. Explanation: The effect of digital rectal examination (DRE) on serum PSA levels is still debatable. ... Although, there was a statistically significant increase in serum PSA levels 30 min after DRE, the clinical significance of this increase in PSA values with a mean difference of 0.4 ng/ml remains to be clarified. 1760) in which of the following presentations is further diagnostic testing NOT warranted? a. Bilateral gynecomastia in a prepubertal male of average weight; Tanner stage 1 b. Bilateral gynecomastia in a 13 y/o male with normal testicular size and volume c. Recent onset gynecomastia in a 20-year-old male with breast tenderness d. Unilateral breast mass which is 5 centimeters in diameter Explanation: Gynecomastia is the benign enlargement of male breast glandular tissue and is the most common breast condition in males. Pubertal gynecomastia usually begins at age 10-12- years-old and peaks at ages 13-14.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3987263/ 61) a 59 years old post-menopausal woman has atrophic vaginitis. She has a hx. Of breast cancer at age 40 years. What is the appropriate initial treatment for this patient? a. Oran conjugated estrogens b. Oral medroxyprogesterone aetate c. Topical medroxyprogesterone aetate d. Topical conjugate estrogen cream Explanation: PREMARIN (conjugated estrogens) Vaginal Cream is a mixture of estrogens indicated for: Treatment of Atrophic Vaginitis and Kraurosis Vulvae Treatment of Moderate to Severe Dyspareunia, a Symptom of Vulvar and Vaginal Atrophy, due to Menopause. https://www.pfizermedicalinformation.com/en-us/premarin-vaginal-cream 62) Advances in obstetric and neonatal care have a. Helped to identify the cause of cerebral palsy b. Demonstrated the cerebral palsy is a direct result of birth asphyxia c. Has no effect on the incident of cerebral palsy d. Resulted in a dramatic decrease in the incidence of cerebral palsy Explanation: Cerebral palsy is a common, non-progressive, encephalopathy that is believed to be from a defect in the developing brain. Improvements in perinatal care have not affected the incidence. 63) which of the following physical modalities recommended for treatment of rheumatic arthritis provides the most effective long-term pain relief? a. Superficial and deep heat b. Application of cold c. Transcutaneous electrical nerve stimulation (TENS) d. Exercise Explanation: exercise is most consistently effective in reducing the pain associated with rheumatoid arthritis. Exercise improve blood flow, cartilage health, range of motion. Exercise can also improve self-efficacy. Patients with RA should be cautioned to limit joint range of motion, and/or splint affected joints during acute…..Heat, cold, and TENS application can also have a role in pain relief. 64) The NP is counseling a 25 y/o sexually active male patient about condom use, which of the following statement is INCORRECT a. Adequate lubrication is needed to prevent damage to the condom b. Roll the condom over an erect penis before any sexual contact 18c. Make sure the condom is tight against the head of the penis d. Withdraw while the penis is erect, so that the condom stays in place Explanation: Condoms come in all different types and sizes. Condoms that are too tight can choke off blood supply, which contributes to erectile dysfunction. And if you choose a condom that’s too big, it can slip off during intercourse, which not only defeats the purpose of wearing the condom but can also undo an erection. 65) a patient with moderate persistent asthma will probably be most effectively managed with daily a. Oral leukotriene blockers b. Short and long acting bronchodilators c. Inhaled steroids and long acting bronchodilators d. Oral steroids and short acting bronchodilators Explanation: People with moderate persistent asthma are not well controlled on low doses of inhaled corticosteroids. A combination of this drug and long-acting inhaled beta2 agonists provides improved control compared with doubling of the maintenance dose of inhaled corticosteroids. https://www.ncbi.nlm.nih.gov/pubmed/16935690 66) diagnosis of systemic lupus erythematosus (SLE) is made a. On the basis of demonstrable anti-nuclear antibodies (ANA) b. Considering symptom complex with confirmation by laboratory test c. Using renal function studies and rheumatoid factor for confirmation d. On the basis of renal or cutaneous biopsy Explanation: The American College of Rheumatology has proposed the revised criteria for diagnosis of systemic lupus erythematosus (SLE) abnormalities associated with disease. At least four of these criteria are required to make the diagnosis. Laboratory test…. 67) which of the following would not be considered a developmental red flag to a NP assessing a 4 y/o? a. Persistent fear of going to sleep b. Missing speech sounds c. Fire-setting d. An imaginary friend Explanation: The parents need to understand that the child's behavior is not uncommon. Imaginary friends are common in the preschool-age child. The child's behavior is not abnormal. The child does not have a deep-set psychological need. The child is not at risk for social isolation. 68) A 44 y/o patient complains of stuffiness and soreness in his hands, hips and knees. There is noticeable PIP and DIP joint enlargement in his hands.. The NP suspects arthritis. All of the following questions are helpful in differentiation between rheumatoid arthritis (RA) and osteoarthritis (OA) EXCEPT a. on the joint of your fingers never feel particularly warm or hot? b. tell me about your usual energy level 19c. does the soreness and stiffness get better or worse as the day progresses? d. Have you noticed decreased joint movement or flexibility? Explanation: Limited range of joint motion is characteristic of both types of arthritis. The soreness and stiffness associated with OA improves as the day progresses and joint range of motion improves with the performance of daily activities. Joint pain and stiffness associated with RA worsens with use. Loss of energy, malaise, and easy fatigability are constitutional symptoms associated with RA. RA is an inflammatory disease of the joints and flare-ups are characterized by very warm and erythematous joints relieved by anti-inflammatory medications such as NSAIDs and glucocorticosteroids 69) An adult presents w/ tinea corpus. What comment by the patient would be the LEAST likely explanation of how he acquired this disease? a. "I trap animals" b. "my wife has this also" c. "I have diabetes" d. "I live in the Northern US" Explanation: A ringworm infection can be spread in many direct and indirect ways, including: Person to person, Pet/animal to person, Inanimate item to person: It’s possible to get ringworm through indirect contact with objects, including hair of an infected person, bedding, clothing, shower stalls, and floors, Soil to person, having a weak immune system. https://www.healthline.com/health/tinea-corporis 70) Acute rheumatic fever is diagnosed using the modified Jones criteria. Which is NOT a major criterion in the Jones System? a. Jaundice b. Carditis c. Polyarthritis d. Subcutaneous nodules Explanation: One of the major criteria for diagnosis of acute rheumatic fever using the Jones System is polyarthritis, the most common finding. This usually responds to aspirin therapy within 48 hours. Another common finding is carditis. Other major criteria which are far less common include erythema marginatum and subcutaneous nodules. 71) A pt is taking an ACE inhibitor for the blood pressure control. The NP decides to add a diuretic which of the following is the best choice? a. a thiazide diuretic b. a loop diuretic c. a potassium-sparing diuretic d. Fitness bar Explanation: A ringworm infection can be spread in many direct and indirect ways, including: Person to person, Pet/animal to person, Inanimate item to person: It’s possible to get ringworm through indirect contact with objects, including hair of an infected person, bedding, clothing, shower stalls, and floors, Soil to person, having a weak immune system. 2070) Acute rheumatic fever is diagnosed using the modified Jones criteria. Which is NOT a major criterion in the Jones System? e. Jaundice f. Carditis g. Polyarthritis h. Subcutaneous nodules Explanation: One of the major criteria for diagnosis of acute rheumatic fever using the Jones System is polyarthritis, the most common finding. This usually responds to aspirin therapy within 48 hours. Another common finding is carditis. Other major criteria which are far less common include erythema marginatum and subcutaneous nodules. 71) A pt is taking an ACE inhibitor for the blood pressure control. The NP decides to add a diuretic which of the following is the best choice? e. a thiazide diuretic f. a loop diuretic g. a potassium-sparing diuretic h. Fitness bar Explanation: First-line and later-line treatments should now be limited to 4 classes of medications: thiazide-type diuretics, calcium channel blockers (CCBs), ACE inhibitors, and ARBs. 72) which of the following drugs classes would be most effective in decreasing elevated triglycerides levels (650 mg/dL)? a. bile acid sequestrants b. nicotinic acid c. fibrates d. statins Explanation: Classes of medications that are appropriate for the management of major triglyceride elevations include fibric acid derivatives, niacin, and omega-3 fatty acids. 73) the mother of a 16 y/o high school student athlete is concerned that her daughter has not had a menstrual period yet. on physical examination, the NP finds normal growth and development including appropriate secondary sexual characteristics what is the most appropriate NP action? a. refer to a endocrinolist b. order a pelvic ultrasound c. attempt progesterone challenge d. prescribe oral contraceptive Explanation: Normal age for menarche is between nine and 17. Since this patient has secondary sexual characteristics and normal anatomy, she should be offered reassurance that she is normal and her menses will probably start soon. 74) factors known to be associated with early sexual activity include. a. early development of secondary sex characteristics, living in an urban area, and easy access to contraceptives 21b. legalized abortion, frequent viewing of adult television and movies, and lack of church affiliation c. lower socioeconomic status, use of tobacco, alcohol or other drugs, and single parent household d. exposure to sex education information at school Explanation: Factors found to be associated with early sexual activity are lower socioeconomic status, use of tobacco, alcohol, or other drugs, and belonging to a single parent household. 75) the finding which is most consistent with a diagnosis of benign prostatic hyperplasia is digital palpation of prostatic gland that is a. enlarged, symmetrical, semi firm and non-tender b. enlarged, symmetrical, boggy and exquisitely tender c. asymmetrical and nodular d. exquisitely tender with absence of median sulcus Explanation: During the digital rectal exam, the practitioner palpates the prostate, noting its size, shape, and consistency and any nodules or tenderness. The normal prostate is rubbery and nontender. With BPH, the prostate feels symmetrically enlarged, firm, slightly elastic, and smooth. A distinct, hard nodule may signal a malignancy. 76) The NP correctly diagnoses iron deficiency anemia in a female patient whose lab report reveals a. an increase reticulocyte count b. a mean corpuscular volume (MCV) > 100 c. hemoglobin (hgb) 140 mg/dL (140 g/L) d. an increased total iron binding capacity (TIBC) Explanation: A total iron binding capacity value above 450 mcg/dL usually means that there's a low level of iron in your blood. This may be caused by a lack of iron in the diet, increased blood loss during menstruation, pregnancy, or a chronic infection. 77) Strabismus is observed in a 13-month-old child. The most appropriate action for the NP to take a. refer the patient to an ophthalmologist b. patch the child affected eye c. follow the child closely for 2 more month d. teach the patient and parent, eye muscle exercises Explanation: Strabismus can also be an indicator of severe eye and health problems. As it can indicate poor vision, it may in rare cases be the first sign of childhood cataract, glaucoma, or tumors of the eye, optic nerve, orbit or brain, such as retinoblastoma, glioma, or rhabdomyosarcoma. 78) giving appropriate patient education by the primary care provider, poor compliance with medical recommendations is most often due to: a. willful disobedience b. vision and/or hearing deficits c. anxiety d. limited cognitive ability 22Explanation: In the National adult Literacy Survey, 75% of Americans with chronic or mental health problems scored in the lowest 2 out of 5 …. Literacy. Among the elderly, minorities, and lo income groups, 2/5 cannot read the simple brochure. Most patients are not likely to volume….. 79) the physical exam findings in an infant are most effected by which item listed below? a. what was the Apgar score at one minute? b. is the child breast of bottle fed? c. are the immunizations current? d. what was the gestational age at birth? Explanation: Gestational age is the most important predictor of growth impairment, followed by birth weight and length standard deviation scores. https://www.sciencedirect.com/topics/nursingand-health-professions/gestational-age 80) Babies should begin oral iron supplementation: a. when they are able to eat iron enriched cereal b. 2 months of age c. 4-6 months d. any time after their teeth have erupted Explanation: Recommends giving breastfed infants 1 mg/kg/day of a liquid iron supplement until iron-containing solid foods are introduced at about 6 months of age. 81) the most common cause of cerebral palsy is a. unknown b. intra-partial hypoxia c. in utero infection d. intraventricular hemorrhage Explanation: in approx. 70% of cases, neither cause (s) nor risk factors can be identified as correlates to cerebral palsy 82) A patient with diabetes bring his glucose dairy from the past 7 days for the NP to review and evaluate what changes should be made? DAY 1234567 AM 67, 52, 61, 48, 39, 68, 70 PM138, 161, 148, 168, 171, 142, 176 a. increase the PM dose of NPH insulin b. increase the PM dose of regular insulin c. decrease the PM dose of NPH insulin d. decrease the PM dose of regular insulin Explanation: NPH Human Insulin which has an onset of insulin effect of 1 to 2 hours, a peak effect of 4 to 6 hours, and duration of action of more than 12 hours. 83) which of the following patient is at highest risk of suicide? a. 65 y/o female b. 70 y/o male c. 35 y/o white divorce male d. 42 y/o single mother 23Explanation: There is a common perception that suicide rates are highest among the young. However, it is the elderly, particularly older white males that have the highest rates. And among white males 65 and older, risk goes up with age. White men 85 and older have a suicide rate that is six times that of the overall national rate. 84) a 17 y/o male is brought into the clinic by his mother who says that is there are no medical consequences or risk known, she will allow her son to get a possible. How should the NP respond? a. tattoos distort one’s body image resulting in high possible of depression b. tattoos and body piercing are possible sources of hepatitis C infection if there is a common use of contaminated needles. c. the tattoo should be applied to an area that will not be exposed to sun to avoid increase risk of skin cancer d. the only medical consequence of tattoos is the scarring associated with removal. Explanation: Sharing personal care items that may have come in contact with another person’s blood, such as razors or toothbrushes. Having sexual contact with a person infected with the hepatitis C virus. Getting a tattoo or body piercing in an unregulated setting 85) A diagnostic finding of Hodgkin’s lymphoma is the presence of: a. granulocytopenia b. reed Sternberg cells c. lymphoblast d. Howell -lolly bodies Explanation: He or she will diagnose classical Hodgkin's lymphoma if abnormal cells called Reed-Sternberg cells are found within the lymph node. Removing a sample of bone marrow for testing. A bone marrow biopsy and aspiration procedure involve inserting a needle into your hipbone to remove a sample of bone marrow. 86) A child with type 1 diabetes mellitus brings in a glucose dairy indicating consisted morning hyperglycemia. How you differentiate the Somogy effect from the dawn phenomenon? a. experiment with a smaller insulin dose in the evening b. increase the insulin dose and liberalize the child's diet c. check HbA1C today and again in 3 months d. instruct the parent to monitor the blood glucose at 3 am Explanation: Dawn phenomenon is an early morning rise in plasma glucose. It indicates a need for increased insulin. The Somogyi effect is a rise in plasma glucose in response to hypoglycemia. It is usually accompanied by weight gain and hunger and is corrected by decreasing the evening insulin dose. A series of 3 early morning measurements of blood glucose will help differentiate between the 2 conditions. 87) practitioners working with physically active girls need to be aware of the "female athlete triad" in order to develop an effective pain for prevention, recognition and treatment. the components of the female athlete triad are: a. distorted body image, low self-esteem, and generalized anxiety. b. stress fractures, osteoarthritis and plantar fasciitis c. eating disorders, amenorrhea and osteoporosis 24d. iron deficiency anemia, steroid abuse and bradycardia. Explanation: The female athlete triad is a medical condition observed in physically active females involving three components: 1) low energy availability with or without disordered eating, 2) menstrual dysfunction, and 3) low bone density. An individual does not need to show clinical manifestations of all three components of the female athlete triad simultaneously to be affected by the condition. Consequences of these clinical conditions may not be completely reversible, so prevention, early diagnosis, and intervention are critical. 88) palpable thyroid nodule is benign. How does it feel on palpation? a. smooth b. hard c. non-tender d. fixed Explanation: Clinically, thyroid enlargement may be smooth and diffuse or nodular with the nodules being either single or multinodular. A smooth, diffuse enlargement is indicative of benign thyroid disease, although rarely anaplastic carcinoma or lymphoma may present this way. 89) A 53 y/o postmenopausal female with a 38 BMI and gastric esophageal reflux disease, takes a daily calcium supplement for protection against osteoporosis. All of the following are appropriate teaching points for this patient, except a. take the calcium supplement with milk to facilitate absorption b. the addition of HRT may further decrease osteoporosis risk c. take an OTC calcium containing antacid to increase calcium intake d. avoid caffeine containing beverages. Explanation: Taking calcium paired with vitamin D seems to be more beneficial for bone health than taking calcium alone. Antacids contain calcium, but do not contain vitamin D. So if you choose antacids as a calcium source, you may want to consider taking a separate vitamin D supplement. Discuss your options with a health care provider. 90) A 65 y/o immunocompetent man with no underlying medical condition presents in midOctober and request the "flu and pneumonia shots" Records show he received the influenza and PCV13 ten month ago. The NP recommends that he a. receive the PCV13 and influenza vaccine today, and return in January for the PPS23 b. should return in January to receive both the influenza and PPSV23 c. receive the influenza vaccine at this time and return in January for the PPSV23 d. receive the PPSV23 and the influenza vaccine today and again in January Explanation: For adults who have not received any pneumococcal vaccine previously, PCV13 should be given before PPSV23. If the primary indication for vaccination is age ≥65 years, PPSV23 should be given ≥1 year after PCV13. For adults between ages 19 and 64 years who require both vaccines, PPSV23 can be given ≥8 weeks after PCV13. 91) when discussing treatment option with a patient. The NP would be correct to say that surgery can be curative for: a. ulcerative colitis 25b. irritable bowel syndrome c. crohn's disease d. inflammatory bowel disease Explanation: Ulcerative colitis (UC) is an inflammatory bowel disease that mainly affects the lining of the large intestine (colon). This autoimmune disease has a relapsing-remitting course, which means that periods of flare-ups are followed by periods of remission. The symptoms typically associated with UC — such as cramping, bloody diarrhea, and inflammation of the bowel — can be stopped with surgery 92) A patient has developed blood clot in his lower extremity and is receiving warfarin (Coumadin) therapy. Which outpatient laboratory measurement best measures the therapeutic effect of warfarin? a. International normalized ratio b. activated clotting time c. PT d. PTT Explanation: Therapeutic INR for a patient with a medical heart valve is 3.5 to 4.5. A patient with chronic atrial fibrillation requires a therapeutic INR of 2.0 to 3.0. 93) A female patient asks, "how do I calculate my ideal body weight?" The NP appropriately answers: a. Starts with 100 pounds, and add 5 pounds for every inch in height over five feet b. add 6 pounds to every inch over 5 feet, then add 100 pounds c. start with 100 pounds, and add 10 pounds for every inch in height over five feet d. multiply your height in inches times 2 Explanation: The height weight formula is a quick method of that remaining ideal weight. females allow 100 lbs for the first five feet of height plus 5 pounds for each additional inch. Males allow 106 pounds For the first five feet plus 6 pound for each additional inch. this method can only be used as an estimate because it does not account for body composition or age. 94) which term most accurately describes the prostate gland of patient with prostate cancer? a. hard b. rubbery c. boggy d. spongy Explanation: Adenocarcinoma of the prostate typically begins in the posterior lobe. The gland may be large, asymmetrical, or hard; or the cancer may be too small to palpate. Occasionally, there will be induration of a lateral lobe with obliteration of the lateral 95) Ideally, ante-partum care should begin: a. as soon as the pregnancy is identified b. at 6 weeks gestations c. with preconception counselling d. in the first trimester 26Explanation: traditionally, ante-partum care began as soon as the pregnancy was identified. The new recommendation is to evaluate nutritional and psychosocial needs, and asses’ medical problems before pregnancy occurs. 96) which of the following must be present for the diagnosis of bacterial vaginosis? a. presence of clue cells b. vaginal pH <4.0 c. presence of pseudo hyphae on HPF d. negative amine test Explanation: Demonstration of clue cells on a saline smear is the most specific criterion for diagnosing BV. Clue cells are vaginal epithelial cells that have bacteria adherent to their surfaces. 97) The patient Self Determination Act of 1991 requires all health care agencies receiving Medicare or Medicaid funds to give patients written information about their rights to make decisions regarding their medical care. A document which declares in advance what type of medical care a person wants ... he provided or withheld should he or she be unable to express his or her wishes is called: a. an advance directive b. a durable power of attorney c. informed consent d. a right to die statement explanation: The PSDA requires all health care agencies (hospitals, long-term care facilities, and home health agencies) receiving Medicare and Medicaid reimbursement to recognize the living will and power of attorney for health care as advance directives. 98) Thalassemia should be included in the differential diagnosis of an infant with microcytic anemia when the infant’s parents are of what ethnicity? a. Italian b. Swedish c. Japanese d. European Explanation: Thalassemia can affect both men and women. Certain ethnic groups are at greater risk: Alpha thalassemia most often affects people who are of Southeast Asian, Indian, Chinese, or Filipino descent. Beta thalassemia most often affects people who are of Mediterranean (Greek, Italian and Middle Eastern), Asian, or African descent. 99) What is the earliest age that MMR immunization can be administered? a. 2 months b. 4 months c. 6 months d. 1 year Explanation: Both vaccines are administered by the subcutaneous route. The minimum age for both MMR and MMRV is 12 months of age. The typical age for the second dose of either 27vaccine is at 4 to 6 years of age. The maximum age MMRV for administration is 12 years of age. It should not be administered to anyone 13 years of age or older. 100) A male patient with chronic atrial fibrillation takes a genetic brand of Coumadin (Warfarin). He should report all of these to his health care provider EXCEPT a. Brand name substitution for his genetic warfarin b. On missed dose of warfarin c. Chest pain or weakness d. Blood in his urine Explanation: If you miss a dose of this medicine, take it as soon as possible. However, if it is almost time for your next dose, skip the missed dose and go back to your regular dosing schedule. Do not double doses. 101) which of the following is not an appropriate treatment for chronic bacterial prostatitis (CBP)? a) Doxycycline (Vibramycin) b) Ciprofloxacin (Cipro) c) Trimethoprim/sulfamethoxazole (Bactrim DS) d) Nitrofurantoin (Macrobid) Explanation: Appropriate treatment of chronic bacterial prostatitis include fluoroquinolones, sulfonamides, tetracyclines, an microlights .... drop entry into the prostate is limited. fluoroquinolone's and sulfonamides achieve the highest concentration In the tissue; tetracyclines and microlights can also reach therapeutic levels in the prostate. nitrofuran towing is avoided in men with prostatitis because of concern about poor tissue penetration and poor efficacy. there is also a risk of pulmonary an hepatic adverse effect with prolonged use. recurrences of chronic bacterial prostatitis are common in warrant a 2nd …. Duration. The antibiotics of choice are the fluoroquinolones (eg, ciprofloxacin, Trimethoprim/sulfamethoxazole. Trimethoprim/sulfamethoxazole, Azithromycin. It has good penetration into the prostate and is active against gram-positive bacteria, Fosfomycin. Fosfomycin achieves reasonable tissues. 102) A new patient presents to the NP clinic stating she wants a second opinion. She started propiluracil (PTU, Propyl Thyracil) 75 mg 3 times a day a week ago as therapy for newly diagnosed Grave’s disease. She still feels irritable and jittery. How should the NP response? a) Obtain a serum TSH and serum T4 today b) Increase the PTU dose to 100 mg 3 times a day c) Recommend radioactive therapy d) Inform the patient that improvement requires 2 – 2 weeks. Explanation: Propylthiouracil should have some effect on your symptoms around three to four weeks after treatment starts. Your thyroid hormone levels should be stabilized within four to eight weeks. 103) A 15 y/o patient has a complaint of vaginal discharge. She is sexually active with multiple partners. Which of the following symptoms should lead the NP to suspect pelvic inflammatory disease (PID)? a. A report of dyspareunia 28b. A complaint of low back pain c. A yellow vaginal discharge d. Cervical motion tenderness (CMT) Explanation: Cervical motion tenderness or cervical excitation is a sign found on a gynecological pelvic examination suggestive of pelvic pathology. Classically, it is present in the setting of pelvic inflammatory disease (PID) or ectopic pregnancy and is of some use to help differentiate PID from appendicitis. 104) Which of the following is NOT a component of the fetal biophysical profile? a) Gestational age estimate b) Fetal breathing c) Amniotic fluid volume d) Fetal movements Explanation: There are 5 components in the fetal biophysical profile: fetal heart acceleration, fetal breathing, fetal movements, fetal tone, and amniotic fluid volume measurement. 105) Which murmur is associated with radiation to the neck? a. Pulmonic stenosis b. Aortic stenosis c. Hypertrophic obstructive cardiomyopathy d. Mitral valve insufficiency Explanation: The classic murmur of aortic stenosis is a high-pitched, crescendo-decrescendo (diamond shaped), midsystolic murmur located at the aortic listening post and radiating toward the neck. The radiation of the AS murmur is often mistaken for a carotid bruit. 106) When examining a pregnant patient, where should the fundal height be at 22 weeks? a) Slightly above the symphysis pubis b) At the level of the umbilicus c) Midway between the symphysis pubis and the umbilicus d) Above the umbilicus Explanation: Between 18 and 32 weeks, there is good correlation between fundal height and gestational age of the fetus. The expected heights are: 10-12 weeks: fundus slightly above the symphysis pubis 16 weeks: fundus midway between the symphysis pubis and umbilicus 20 weeks: fundus at the level of umbilicus 28 weeks: fundus 3 fingerbreadths above the umbilicus 36 weeks: fundus just below the xiphoid process 107) Education of women with fibrocystic breast disease should include which of the following statement a. Fibrocystic breast disease is often a precursor of breast cancer b. Annual mammography is recommended beginning at age 40 c. Caffeine may trigger breast pain d. Oral contraceptives are not useful in the treatment of this disease 29Explanation: avoidance of all methylxanthines (e.g. coffee, tea, chocolate) has been shown to reduce breast pain in women precursor of malignancy. Mammography is recommended once at age 35 years, at least every 1-2 years apart .... contraceptives may help reduce cyclic pain and swelling. 108) An 18 y/o college student lives in the dormitory. He has been treated for scabies infestation with permethrin (Nix). He was asymptomatic for 2 weeks but now complains again of itching and skin burrows. How should the NP proceed? a. Retreat with a different scadicide b. Refer him to a physician for treatment c. Tell him that itching can last 2-4 weeks after infection is clear d. Retreat him with primethrin and have him launder all of his bedding and clothing. Explanation: Permethrin cream (Elimite). Permethrin is a topical cream that contains chemicals that kill scabies mites and their eggs 109) An 83 y/o has heart failure (HF) . He takes Prinivil (lisinopril), metoprolol (Lopressor), ASA, and low dose furosemide every morning. After assessing the patient today, the NP determines that he is having a mild exacerbation of HF (heart failure) the LEAST likely cause of this a. Three skipped doses of the Prinivil b. Daily doses of ibuprofen for arthritis in his knees. c. Atrial fibrillation d. Consumption of antacid, calcium carbonate 3X yesterday Explanation: It is unlikely that this patient HF exacerbati0on is due to consumption of antacids yesterday especially not calcium carbonate because it is relatively lower in sodium. Missed doses of his ACE inhibitor can lead to an exacerbation, as can consumption of Ibuprofen or any NSAID. NSAIDs cause the patient to retain sodium, and thus fluid. This increases the workload of the heart. Atrial fibrillation can lead to an exacerbation of HF. 80% of humans cardiac ….. is attributable to the “atrial kick”. Is ….. because the patient is in a-fib, HF can result. A …… increase in his ……. reduces the process ………..causing his symptoms. 110) Antibiotic administration has been demonstrated to be of little benefit in the treatment of which of the following disease process? a) Chronic sinusitis b) Acute bronchitis c) Bacterial pneumonia d) Lobar pneumonia Explanation: Antibiotics are powerful medicines that treat bacterial infections. But acute bronchitis is usually caused by a viral infection 111) Which of the following is a medication or medication class that does NOT have dizziness or vertigo as potential adverse side effect? a. Aminoglycosides antibiotics 30b. high dose salicylates c. central acting antihypertensive d. meclizine (Antivert) Explanation: dizziness is associated with sensation of body movement when there is no body movement occurring (i.e., the person is spinning, and the person is still, and the room is spinning. There is no associated muscle weakness or visual disturbance with either of there condition. …..ingestion, hypotension, inner or middle ear pathology, and positional vertigo. Dizziness is and adverse reaction associated with certain…. High dose salicylates. Vertigo is associated with certain inner ear pathology such as labyrinthitis and Meniere’s disease. Meclizine is a long… chronic vertigo. 112) The NP CORRECTLY teaches an insulin dependent patient the signs and symptoms of early hypoglycemia, which include a. Facial flushing and dilated pupils b. Frequent urination and abdominal pain c. Diplopia and irregular pulse d. Blurred vision, pallor and perspirations Explanation: Early signs Sweating, Racing heartbeat, Flushed face, Anxiety, Hunger pangs Late Signs: Headaches, Dizziness, Lightheadedness, Confusion, Difficulty speaking, Seizures Coma. 113) The most effective treatment for a non-infective bursitis included a. Systemic antibiotic therapy effective against penicillin-resistant staphylococcus aureus b. Rest, an intra-articular corticosteroid injection, and a concomitant oral NSAID c. A tapering regimen of oral corticosteroid therapy d. Frequent active range of joint motion Explanation: The affected joint should be rested. A sling, cane, or splint may be helpful. A longacting corticosteroid injected into the bursa along with an oral NSAID should be effective in relieving the inflammation and pain on bursitis. 114) Tunner’s syndrome present exclusively in a. Male infant b. Female infant c. African American infants d. Asian infants Explanation: Turner syndrome, a condition that affects only females, results when one of the X chromosomes (sex chromosomes) is missing or partially missing. Turner syndrome can cause a variety of medical and developmental problems, including short height, failure of the ovaries to develop and heart defects. 115) Once a competent patient is identified as a victim of domestic violence a. Recommend join counseling sessions for the pair b. Suggest resources that will help the victim to develop survival skills c. Refer the abuser for individual psychological counseling 31d. Insist that the victim leave the abusive environment immediately Explanation: Domestic violence survivors are at a high risk of developing post-traumatic stress disorder, substance abuse or stress-related mental health conditions. Learning to cope with residual emotional pain and fears is essential to healing. 116) A 60 y/o female patient complains of sudden unilateral, stabbing, surface pain in the lower part of her face lasting a few minutes, subsiding and then returning. The pain is triggered by touch or temperature extremes. Physical examination is normal. The patient had a negative dental examination. CT scan is normal. Erythrocyte sedimentation rate (ESR) is normal. Which of the following is the most likely diagnosis? a. Trigeminal neuralgia b. Temporal arteritis c. Parotiditis d. Bell’s palsy Explanation: Symptoms of trigeminal neuralgia include an acute onset of sharp, stabbing pain to one side of the face. It tends to begin at the angle of the jaw and radiate along the junction lines; The pain is severe and described as an electric shock. It may be made worse by light touch, chewing, or cold exposure in the mouth. In the midst of an attack, affected individuals shield their face trying to protect it from being touched. 117) A 45-year-old pre-menopausal female complains of indigestion, flatulence RUQ and epigastric “crampy pain” that radiates to the right scapula. Symptoms are exacerbated by a high fat meal. What is the most likely diagnosis? Chronic cholecystitis Explanation: the “typical” with chronic cholecystitis is “female, fat, ….. and ……40” year of age. Myocarditis produces retrosternal pain that is not related to diet. The pain of pancreatitis radiates to the back. The pain of ….and is near specific upper quadrant pain 118) Sings and symptoms of anemia, regardless of the specific cause or type, include all of the following EXCEPT: a. Weakness, dizziness , fatigue b. Shakiness and jitteriness. c. Dyspnea on exertion d. Shakiness or …..ness Explanation: Regardless of the cause or type anemia may often be mistaken for depression. All of the patient’s mental functions may be …. Generalized malaise, sluggishness, forgetfulness, lethargy, syncope, pallor, and problems associated with decreased tissue oxygenation. There is no associated nervousness or anxiety. 119) Advance directives are: Documents that guide medical decision making in the event an individual becomes incompetent or unable to convey his wishes. 32Explanation: a document which designate authority to make health care decisions is a health care proxy or durable power of attorney, which is only one example of a type of advance directive. Another type of advance directive is a living will, which usually states the patient’s wishes not to receive life-prolonging treatment. Advance directives refer to several different kinds of documents that guide medical decision making. They ate recognized in some, but not all states. 120) The CAGE, MAST and AUDIT questionnaires to detect problem drinking should be used: a. To detect early problems and hazardous drinking b. As supplements to the standard patient history c. As a diagnostic tool for the early detection of problem drinking d. To determine the level and pattern of alcohol use Explanation: standard screening instrument such as CAGE, AUDIT, and MAST should be used only as a supplement to the…. Development. 121) Which of the following scenarios in a 75 y/o patient would be inappropriately managed in an outpatient setting (i.e. the patient should be referred for a hospital admission? a. Secondary hypertension b. Unstable angina c. Orthostatic hypotension d. Vasovagal syncope Explanation: Patients with unstable angina nearly always require hospitalization for monitoring, coronary artery lesion treatment, and/or medication management. The other situations do not warrant hospitalization and could be managed safety and effectively in the outpatient setting. Malignant hypertension is more likely to result in hospitalization than secondary hypertension. 122) An adult female present with a hordeolum. A topical antibiotic is prescribed. Which of the following instructions is NOT appropriate for the nurse practitioner to give the patient? a. Apply warm, moist compresses several times per day b. Do not use soap near the affected eyelid c. Do not wear eye makeup and discard all used eye makeup d. Do not rub your eyes Explanation: Good peri-orbital hygiene should prevent recurrence of the hordeolum. 123) The cornerstone of treatment for stress fracture of the femur or metatarsal stress fracture is Absolute rest from activities which may further stress the bone Explanation: absolute rest from aggravating activities is essential until healing has occurred. 124) Group A Beta hemolytic streptococcal (GABHS) pharyngitis is most common in which age group? a. Under 3 years of age b. Preschool children c. 6 to 12 years of age d. Adolescent 33Explanation: Group A strep pharyngitis can occur in people of all ages. It is most common among children 5 through 15 years of age. It is rare in children younger than 3 years of age. The most common risk factor is close contact with another person with group A strep pharyngitis. Physical exam findings including cervical lymphadenopathy, pharyngeal inflammation, and tonsillar exudate, sore throat, temperature greater than 100.4°F (38°C) 125) Which of the following is NOT a component of CAGE questionnaire? a. Have you ever felt the need to cut down on drinking? b. Have you gotten into fights when drinking? c. Have you ever taken a morning eye opener? d. Have you ever felt annoyed by criticism of drinking? Explanation: Have you ever felt you needed to Cut down on your drinking? No. Yes. +1. Have people Annoyed you by criticizing your drinking? No. Yes. +1. Have you ever felt Guilty about drinking? No. Yes. +1 Have you ever felt you needed a drink first thing in the morning (Eye-opener) to steady your nerves or to get rid of a hangover? No. Yes. +1 126) A 62 years old female has been diagnosed with osteoporosis. She refuses hormone replacement therapy as well as new medication shown to increase bone density. Important education for this patient should include: a. Information about joint replacement surgery b. The need for annual bone density studies c. The benefits of increasing calcium intake and daily weight bearing exercise d. A list of occupational therapists in the community Explanation: Nonpharmacologic interventions include calcium and vitamin D supplementation, weight-bearing exercise, muscle strengthening, and fall prevention. Pharmacologic options include: the bisphosphonates, estrogen therapy, raloxifene, salmon calcitonin, and the anabolic agent teriparatide. 127) The NP wants to assess intactness of a patient cerebral function. Which of the following clinical test will provide information relative to cerebral function? a. Kinesthesia b. Sterogenesis c. Romberg d. Graphesthesia Explanation: Romberg’s test is a commonly performed test during the neurological examination to evaluate the integrity of dorsal columns of the spinal cord. The Romberg test is a test of proprioception. This test is performed by asking the patient to stand, feet together with eyes open, then with eyes closed. The patient with significant proprioceptive loss will be able to stand still with eyes open because vision will compensate for the loss of position sense but will sway or fall with their eyes closed because they are unable to keep their balance. Graphesthesia is the ability of the patient to identify characters that are written on the skin using a dull pointed object. The examiner demonstrates the test by writing single numbers on the palm 34of the hand while the patient is watching. The patient then closes their eyes and identifies numbers that are written by the examiner Stereognosis is the ability to identify objects that are placed in the hand when the eyes are closed. The patient is given common objects and asked to identify them without looking at them. The inability to do this called astereognosis and indicates parietal lobe dysfunction. Kinanesthesia is the awareness of motion of the human body (motion sense). Sense of movement refers to the ability to appreciate joint movement, including the duration, direction, amplitude, speed, acceleration and timing of movements. 128) The most appropriate medications for elderly patients a. Are highly protein-bound b. May be dose once daily c. Have a narrow therapeutic index d. Have anticholinergic effect Explanation: Particular care must be taken in determining drug doses when prescribing for older adults. An increased volume of distribution may result from the proportional increase in body fat relative to skeletal muscle with aging. Decreased drug clearance may result from the natural decline in renal function with age, even in the absence of renal disease. Larger drug storage reservoirs and decreased clearance prolong drug half-lives and lead to increased plasma drug concentrations in older people. 129) A 66 y/o female presents to your clinic. She states that yesterday evening she has chest pain for 20-30 minutes. Which finding most strongly correlates with myocardial infarction? a. ST segment depression of EKG b. Elevated troponin levels c. Elevated CK-MB d. Elevated CK Explanation: An ECG is the 1st test ordered for suspected MI. ECG changes indicative of MI include: Picked T wave, ST elevation or Q wave development. Post MI, a patient may exhibit elevated CK-MB, myoglobulin and troponins. Troponin I is always specific to myocardial necrosis. 130) The NP is evaluating a 35 y/o female nurse. She has a history of hospitalization for hepatitis B infection 2 years ago. Her laboratory test demonstrates positive HBsIg. The nurse practitioner would most likely diagnose: a. Chronic hepatitis B infection b. Acute hepatitis B infection c. Recovered hepatitis B infection d. Recent hepatitis B vaccination Explanation: Presence of hepatitis B surface antigen at this time indicates chronic infection with hepatitis B. Lab studies indicating a positive surface antigen on 2 separate occasions at least 6 months apart indicate chronic infection. Immunization produces positive hepatitis B antibodies in most instances. Hepatitis B surface antigen would not be present in a person who has recovered from hepatitis B infection. This case would not be an acute episode because of the history of hepatitis B infection 2 years prior. 35131) A 55 y/o male patient complains of blood in his urine for the past 2 weeks. He denies dysuria. Urinalyses is positive for red blood cells and negative for leukocytes and nitrates. The initial evaluation of this patient should include: a. Magnetic resonance imaging (MRI) b. Cystoscopy c. Bladder biopsy d. Renal ultrasonography 132) A good sunscreen lotion or sunblock may contain all of the following components. Which provides the LEAST protection against the sun’s harmful rays? a. Zinc oxide b. Benzophenones c. Para-aminobenzoic acid (PABA) d. Lanolin Explanation: the most common sunscreens contain chemical filters. These products typically include a combination of two to six of the following active ingredients: oxybenzone, avobenzone, octisalate, octocrylene, homosalate and octinoxate. Mineral sunscreens use zinc oxide and/or titanium dioxide. 133) When examining 5 years old the NP knows that this is an appropriate age to teach the child about: a. Washing his hands before eating b. Not allowing anyone to touch his private parts without permission c. The importance of balanced meals so that he can grow tall and strong d. Getting his preschool immunizations Explanation: Anticipatory guidance by the NP should include an explanation about not allowing anyone to touch his private parts without permission. This is the age of sexual exploration for the child. 134) A mother presents with her 12-year-old son who has chills, fever, headache, malaise, and myalgias. On examination the NP finds an erythematous lesion, 7.5 cm diameter, with annular edges and central clearing. The boy first noticed the lesion when he was preparing to go back home from a 2-week summer camp in the mountains. Of the following, which is the most likely diagnosis? a. Pityriasis rosea b. Impetigo c. Lyme disease (erythema migrans) d. Tinea corporis Explanation: Lyme disease is caused by the bacterium Borrelia burgdorferi and rarely, Borrelia mayonii. It is transmitted to humans through the bite of infected blacklegged ticks. Typical symptoms include fever, headache, fatigue, and a characteristic skin rash called erythema migrans. 36135) A NP is holding a prenatal nutrition class for a group of patients. Considering knowledge about cultural variations, which of the following women may be at increased risk for inadequate calcium intake? a. A 30-year-old orthodox Jew b. A 35 years-old Caucasian c. A 27 years-old Native American d. A 24 years-old Hispanic Explanation: While anyone can develop osteoporosis, Caucasian and Asian women are at higher risk than those of African American and Hispanic descent. 136) Which behavior would NOT be expected of a 2 y/o? a. Kicking a ball b. Running around a corner without falling down c. Riding a tricycle d. Climbing on a chair and standing up to reach and object Explanation: Stand on tiptoes. Kick a ball. Start to run. Climb on and down from furniture without help. Walk up and down stairs while holding on. Throw a ball overhand. Carry a large toy or several toys while walking. 137) A 49 years-old Hispanic female has a blood pressure of 145/95 mmHg during a routine annual evaluation. She has no previous history of hypertension. She takes a statin for dyslipidemia. How should the NP proceed with this patient? a. The patient’s blood pressure should be checked in about 2-4 weeks b. The patient should be started on 25 mg HCTZ (hydrochlorothiazide) once daily in the morning c. She should be diagnosed with hypertension today and lifestyle modifications should be initiated d. The statin should be stopped because it may be the cause of elevated blood pressure Explanation: Diagnosis of hypertension should be confirmed at an additional patient visit, usually 1-4 weeks after the first measurements. If white-coat hypertension is suspected. Treatment recommendation for specific patient population African American Patients should be treated with diuretics and calcium channel blockers first Those with chronic kidney disease aged 18-75 years should be prescribed an ACE inhibitor or an ARB Differences in ARB agents and diuretics:  Losartan (Cozaar): weakest ARB, may require twice a day dosing  Valsartan (Diovan), Telmisartan (Micardis), irbesartan (Avapro), candesartan (Atacand), Olmesartan (Benicar) are all genetics (except ebardi) can be used every day.  More Potent ARB include Olmesartan and azilsartan  Chlorthalidone is more potent than HCTZ 37For HTN that is difficult to control:  Make sure the Pt. is on Na restricted diet of 1500 -2000mg/day and NOT taking OTC NSAIDs or drinking excess alcohol  If the patient is already on ACE/ARB w/thiazide diuretic and SBP remains uncontrolled, 1st try changing the ACE inhibitor to an ARB; if the pt. is on losartan change to a more potent once daily  If the Pt. is no B-Blockers change for a vasodilating B-Blocker.  Add dihydropyridine Calcium Chanel Blocker. Do not use Nifedipine with LV systolic dysfunction  Add aldosterone Blocker if BP remains uncontrolled  Change HCTZ to chlorthalidone (more potent thiazide) For elevated isolated systolic BP  Use ARB, a thiazide diuretic and or dihydropyridine calcium channel blocker 138) A 37 y/o female patient with a history of a single episode of depression and frequent complaints of PMS is being treated for hypothyroidism. Today she complains of poor concentration and fatigue. Initially the NP should: a. Provide information about PMS b. Perform a TSH c. Resume her antidepressant medication d. Question her further Explanation: 139) When a patient presents with symptoms of acute gallbladder disease, what is the appropriate a. Order abdominal x-rays b. Order abdominal ultrasound c. Refer the patient to a surgeon for evaluation d. Prescribe a second-generation cephalosporin Explanation: Ultrasound testing uses sound waves to take images of the gallbladder. It is the gold-standard to look for gallstones because it is simple and non-invasive. ... Computed tomography (CT): This test uses X-rays to construct detailed images of the abdominal organs. 140) The client with iron deficiency anemia should be advised to take the iron supplement a. With milk to avoid stomach upset b. With milk of magnesia at bedtime to avoid constipation c. On an empty stomach between meals d. For 30 days to 6 weeks 141) A 2-week-old infant presents with projectile vomiting, weight loss, dehydration, constipation and history of insatiable appetite. An olive shaped mass is palpable to the right epigastrium. The NP, suspecting pyloric stenosis, refers the infant for an upper GI series. The expected finding is: a. Double bubble pattern, secondary to air in the stomach, and a distended duodenum 38b. Dilated loops of bowel c. Bowel loops of varying width, with a grainy appearance d. The “sling sign,” indicating a narrow and elongated pyloric canal Explanation: Pyloric stenosis is the narrowing of the lower portion of the stomach (pylorus) that leads into the small intestine. The muscles in this part of the stomach thicken, narrowing the opening of the pylorus and preventing food from moving from the stomach to the intestine. 142) Which of the following diagnostic assessment must be considered before developing any plan of care for a 27-year-old female presenting to a family practice clinic? a. Pregnancy test b. Family social history c. Hematocrit and hemoglobin d. Blood pressure 143) An 8 y/o is sent home from school with mucopurulent discharge from his eye. He is brought to the NP for treatment. What is the most appropriate intervention? a. Cromolyn sodium (opticrom, Nalcrom) ophthalmic solution for 4 days b. Doxycycline (vibramycin) orally for 10 days. c. Bacitracin/polymyxin (Polisporin) ophthalmic solution for 7 to 10 days. d. No pharmacologic interventions are needed because this will resolve overnight without treatment. Explanation: acute mucopurulent conjunctivitis is the most common type of acute bacterial conjunctivitis. It is characterized by marked conjunctival hyperemia and mucopurulent discharge. Although, acute bacterial conjunctivitis is usually self-limited and does not cause any serious harm, there are several justifications for treatment. These include decreasing patient morbidity by shortening the course of the disease, reducing person-to-person spread, lowering the risk of sight-threatening complications such as corneal ulceration, and eliminating the risk of more widespread extraocular disease. Cultures should be obtained in certain patients, including young children and debilitated persons. However, empiric treatment with a topical medication is a safe and cost-effective approach in most patients with clinically mild acute bacterial conjunctivitis. Usual Pediatric Dose for Ocular Infection: Apply to the affected eye(s) every 3 to 4 hours for 7 to 10 days. For the treatment of superficial ocular infections involving the conjunctiva and/or cornea due to organisms susceptible to this drug; for the topical treatment of superficial infections of the external eye and its adnexa (including conjunctivitis, keratitis, keratoconjunctivitis, blepharitis, blepharoconjunctivitis) due to susceptible bacteria. 144) The NP would be correct to tell a 27 y/o newly diagnosed hypertensive patient that: a. The older you are, the more difficult is to control blood pressure with medication b. Lifestyle modifications such as losing excess weight, exercising, limiting salt and alcohol intake, and reducing stress will help to maintain a normal blood pressure c. For about 10 to 20 percent of people with primary hypertension, the cause is unknown d. Isolated systolic hypertension is typical of young adults who are drug abusers 39Explanation: High blood pressure can often be prevented or reduced by eating healthily, maintaining a healthy weight, taking regular exercise, drinking alcohol in moderation and not smoking. Healthy diet Cut down on the amount of salt in your food and eat plenty of fruit and vegetables. 147) A 50 years old patient has abnormal vaginal bleeding with heavy periods and intermenstrual watery discharge with a small amount of blood. What is the most likely diagnosis? a. Uterine fibroids b. Normal perimenopause c. Endometrial cancer d. Cervical cancer Explanation: In women with postmenopausal bleeding, likely causes of uterine pathology should be evaluated. in early menopause the most common etiology of bleeding is atrophy of the endometrium or vaginal mucosa. if the patient has been postmenopausal and bleeding occurs, the most common causes are polyps, fibroids an endometrial hyperplasia. Non-pharmacological interventions include lifestyle modifications like dietary modifications, exercise, avoiding stress, and minimizing alcohol consumption. 148) Which choice below is NOT a symptom of COPD? Fully reversible airflow Explanation: COPD is characterized by airflow that is not fully reversible. Asthma patients have reversible flow disease. 149) Therapeutic international normalized ratio (INR) for a patient taking warfarin (Coumadin) for chronic atrial fibrillation is expected to be: Increased Explanation: Warfarin is expected to increase the INR in a patient who is taking it. Therapeutic levels vary according to the reason anticoagulation is needed. Therapeutic INR for a patient with a medical heart valve is 3.5 to 4.5. A patient with chronic atrial fibrillation requires a therapeutic INR of 2.0 to 3.0. 150) A healthy 50-year-old patient presents to the clinic for a routine physical examination. He has no significant personal or family history of clinical heart disease. What should be part of his CV assessment? Blood pressure only Explanation: The Guide to Clinical Preventive Services, a Report of the U.S. Preventive Services Task Force, does not recommend screening with electrocardiogram (ECG) for asymptomatic men or women at age 50; or screening for asymptomatic AAA until age 65 years. BP screening should take place annually for all adults. Routine x-ray is not recommended for asymptomatic adults. Carotid auscultation is not recommended routinely because of its poor sensitivity and specificity for carotid artery disease. Routine screening should be based on patient history, patient risk factors, and likelihood of development of clinical disease based on patient risk factors. 40151) The NP is initiating levothyroxine (Synthroid) for primary hypothyroidism in a 71-yearold female. The usual starting dose of levothyroxine is 50 (0.05 mg) to 100mcg (0.100mg) per day. What would be the most appropriate initial therapy in this patient? 25 mcg (0.025 mg) per day Explanation: A principle of pharmacotherapeutics in the elderly is “start low and go slow.” In older patients, 25 mcg per day is usual starting dose. Larger doses may precipitate tachycardia and chest pain. 152) An example of an indirect role of the nurse practitioner is: Educator, administrator, or researcher, influencing the delivery of direct care. Explanation: NP’s have traditionally delivered direct patient care. Since there are increasing numbers of nurse practitioners who are prepared at the graduate level of education, there is increasing need for indirect roles such as educator, administrator, consultant, and researcher. 153) In July 1996, the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC) issued which of the following recommendations for the use of the live attenuated varicella vaccine? Varicella vaccine has been approved for routine use in all healthy children age 12 months to 12 years. Explanation: Varicella virus vaccine has been approved for use in healthy children age 12 months to 12 years. Children in this age group should receive one 0.5 ml dose of the vaccine subcutaneously. Serologic testing is not warranted. Vaccination is not necessary for children who have a reliable history of varicella. Persons 13 years-of-age and older should be. Given two 0.5 ml doses of the vaccine, 4 to 8 weeks apart. 154) A patient presents with a furuncle in his right axilla. The NP should prescribe an oral antibiotic and: frequent warm moist compresses. Explanation: Warm moist compresses may provide some relief from pain and promote draining. 155) Which of the following signs and symptoms is typical of hyperthyroidism? Heat intolerance Explanation: Frequent stools, heat intolerance, weight loss, and anxiety or nervousness are indicative of hyperthyroidism function. Constipation, cold intolerance, weight gain, lethargy, and impaired concentration are indicative of hypothyroid function. 156) What is the most common chronic condition in the elder population in the U.S? Arthritis Explanation: The most frequently occurring chronic conditions among the elderly are arthritis (48%), HTN (36%), heart disease (32%) and hearing deficits (32%), cataracts (17%), and diabetes mellitus (11%). 157) A 7-year-old male presents with a painless limp, antalgic gait, muscle spasm, mildly restricted hip abduction and internal rotation, proximal thigh atrophy, and slightly short stature. The most likely diagnosis is: Legg-Calve-Perthes disease. 41Explanation: These are the classic signs and symptoms of Legg-Calve-Perthes disease, a local, self-healing disorder. The mean age of presentation is 7 years. Justification for treatment is prevention of secondary osteoarthritis and femoral head deformity. 158) A 73-year-old presents with a very sore, glossy, smooth, beefy-red tongue. This clinical presentation most likely reflects: Pernicious anemia, due to insufficient intrinsic factor Explanation: Hypothyroidism is associated with an enlarged tongue (macroglossia). Cracked corners of the mouth (cheilosis), is common in the elderly, particularly when the patient is without teeth or dentures. The treatment is application of a topical lubricant at regular intervals. Insufficient production of intrinsic factor by the gastric mucosa decreases vitamin B-12 absorption, causing pernicious anemia. This anemia commonly presents with a very sore, smooth, beefy-red tongue. 159) All patients with renal calculi should be taught that the best prevention is: Increased fluid intake Explanation: Vigorous fluid therapy around the clock is beneficial for all forms of renal calculi. Fluid intake should be sufficient to assure urinary output of 2 to 3 liters per day. Protein intake should be restricted with calcium stones. Alkalization of the urine is beneficial with uric acid stones. 160) A patient complains of “very puffy feet” since beginning a new medication 3 months ago. There is no underlying physiological cause for this condition. Which medication is most likely causing the problem? Nifedipine (Procardia, Adalat) Explanation: Mild to moderate peripheral edema is associated with arteriolar vasodilation and not necessarily due to left ventricular dysfunction. It is most commonly seen in patients taking felodipine and nifedipine. 161) The diagnosis of human papilloma virus (HPV) infection in males is usually made by: Clinical appearance Explanation: Appearance of human papilloma virus is usually sufficient for diagnosis in male or females. The presence of cervical HPV is diagnosed via Pap smear. Viral culture is not useful for diagnosing HPV. Tzanck smear is used to diagnose herpes infections. Application of potassium hydroxide (KOH) to the lesion is used to diagnose fungal infection. 162) A patient that has 20/80 vision acuity can see: At 20 feet what a person with normal vision can see at 80 feet. Explanation: Visual acuity is screened by using the Snellen eye chart Vision of 20/20 is considered normal. “Legally blind” is defined as 20/200 vision in the better eye with corrective lenses. A person with 20/40 has better vision that a person with 20/60 or 20/80 vision. 163) The reason beta-adrenergic blockers should be avoided in patients with diabetes is because they may: Mask symptoms of hypoglycemia 42Explanation: Beta blockers may mask the peripheral signs of hypoglycemia like jitteriness and tachycardia. However, beta blockers will not mask diaphoresis. Therefore, diabetics on beta blockers should be taught to look for this specific symptom as a possible indication of hypoglycemia. 164) A 73-year-old patient has HTN, CHF, and atrial fibrillation. The patient’s adult daughter phones the NP to report that her mother has been nauseated for several days and has vomited for the past 18 hours. She is confused but has no other neurological deficits. The NP should: Arrange for immediate transfer to the emergency department Explanation: Digoxin is a drug commonly used in the treatment regimen for congestive heart failure. Anorexia, nausea, and vomiting are signs and symptoms of digitalis toxicity. Atrial fibrillation predisposes this patient to embolism and stroke is a possibility. The nausea, vomiting, and confusion may be an indication of increasing intracranial pressure. If she is taking warfarin (Coumadin), her INR should be checked. 165) A 27-year-old female patient with epilepsy is well controlled with phenytoin (Dilantin). She requests information about contraception. The NP should instruct her that: The effectiveness of an oral contraceptive may be reduced Explanation: The effectiveness of oral contraceptives may be reduced when taken concomitantly with phenytoin, carbamazepine, phenobarbital, or primidone. A higher dose estrogen oral contraceptive may be more effective. The lowest effective dose of a single anticonvulsant is the most desirable medical treatment, especially when considering teratogenicity of this drug class. The patient should be educated the increased incidence of congenital anomalies in infants born to mothers taking anticonvulsant medication. 166) An 18-year-old female applying for college admission presents to the health clinic because evidence of rubella vaccination is required for admission. She says, “I don’t remember ever getting that shot.” She has negative serologic evidence of rubella antibody. The NP should: Administer the vaccination after a negative pregnancy test and advise the patient that she must not get pregnant for 28 days. Explanation: Administration of rubella vaccination during pregnancy is absolutely contraindicated because of the possible teratogenic effects of rubella on the developing fetus. The earlier in the pregnancy the fetus is exposed, the greater the potential for congenital anomalies. Regardless of the actual time of gestational development in which the fetus is exposed, the infant may be chronically ill. 167) A 44-eyar-old patient has a dark multi-colored mole on his back which is about eight millimeters in diameter and has an irregular border. The NP should: Refer the patient to a surgeon or dermatologist for biopsy Explanation: Malignant melanomas tend to have an irregular border, color variation, and size greater than 6 millimeters in diameter. This patient should be referred for biopsy. Putting on sunscreen is a good habit but will not address the current problem. 168) The typical description of a tension headache is: Bilateral, occipital, or frontal tightness or fullness, with waves of aching pain 43Explanation: Tension HA are usually bilateral and located in the occipital and/or frontal areas. They are described as constant fullness with waves of aching pain. Tension HA may be triggered by emotional stress or worry. The recommended therapy is acetaminophen or aspirin. 169) A 48-year-old female presents with a chief complaint of insomnia. On further investigation, she reports fatigue, nervousness and agitation during the daytime, and feeling hot most of the time. Which of the following would NOT be included in the differential diagnoses? Parkinson’s disease Explanation: The patient’s complaints are characteristics of menopause, hyperthyroidism, and anxiety disorder. Appropriate work-up would include CBC, serum FSH, serum TSH and T4, and fasting glucose. Parkinson’s disease presents insidiously with social isolation, apathy, passivity, confusion, and blunted or flat affect which may be misdiagnosed as depression. 170) Which of the following medications is useful in the treatment of patients with chronic emphysema? Ipratropium (Atrovent) Explanation: Anticholinergic such as ipratropium and long-acting bronchodilators are very effective in the treatment of emphysema. Epinephrine, cromolyn, and zafirlukast do not have a role in the treatment of emphysema. 171) A 4-year-old female complains of leg pain at night which resolves by morning. This has lasted for the past 4 months. The NP should tell the patient’s mother that: These are growing pains that last from 1 to 2 years. This is a common complaint in this age group Explanation: Growing pains, typical in 3 to 5-year-old children present at night and do not involve joints. Acetaminophen along with heat and massage at bedtime may be helpful. 172) A common finding associated with temporal arteritis is: Severe headache Explanation: Temporal arteritis is almost exclusively a disease of the elderly. Symptoms include headache, scalp tenderness, and visual disturbances. 173) Persons with Thalassemia should avoid: Iron replacement therapy Explanation: Person with thalassemia should avoid iron replacement therapy due to the risk of iron overload. 174) Which of the following is LEAST likely to be the cause of ophthalmia neonatorum? Hemophilus influenza Explanation: Bacterial conjunctivitis caused by H. influenza is most likely to present in preschoolers and teenagers. All the other choices are likely causing of ophthalmia neonatorum, a form of conjunctivitis in the newborn period. Silver nitrate reaction is the causative factor in 10% of neonates. 175) Two siblings, 4-years-old and 8-years-old, present with impetigo. The older sibling has multiple lesions over the arms and legs, and some are confluent. The younger sibling has 3 minor 44lesions on one leg. The most appropriate intervention is to advise the mother to wash the lesions thoroughly and: Apply a topical antibacterial ointment to the lesions on both children and administer an oral antibiotic to the older child. Explanation: When impetigo lesions are few and minor, a topical antibiotic (e.g., mupirocin) is sufficient. Multiple lesions, particularly when they are confluent, usually require an oral antibiotic as well. Keeping the lesions covered with clothing reduces further trauma by scratching and reduces transmission of this highly communicable disease. 176) Screening for increased intra-ocular pressure or early glaucoma is: Best performed by an eye specialist Explanation: There is currently no reliable method for primary care practitioner to screen efficiently for glaucoma. Accurate screening is best performed by an eye specialist with access to specialized equipment. 177) Which of the following accurately describes the appropriate use of influenza vaccine? Influenza vaccine should be given annually to all persons 65 years or older, and to person 6 month or older, who are in chronic care facilities, or who suffer chronic cardiopulmonary disorders, metabolic disorder, hemoglobinopathies, or immunosuppression Explanation: Influenza vaccine should be administered annually to all person’s age 65 years and older, and to person 6 moths of age or older. Influenza vaccine is also recommended for those who suffer from renal dysfunction, and for health care providers caring for high risk patients. 178) A NP is examining the gluteal folds of a 6-month-old and notices a 7 to 8 cm bluish discoloration in the sacral area. The NP should: Consider this a normal finding Explanation: bluish discoloration found in the sacral or gluteal area is usually indicative of a hyper-pigmented nevus commonly referred to as a Mongolian spot. There is often a family history of nevi. 179) What medication would be best to relieve symptomatic wheezing in a patient who has asthma? Short-acting bronchodilator Explanation: The most rapid relief for this patient will be achieved by nebulizing a short-acting bronchodilator, termed a “rescue” medication. Relief can be achieved in 1-5 minutes. Longacting bronchodilators usually take 15-20 minutes to achieve bronchodilation. Methylxanthines are not usually used for relief of asthma symptoms. 180) Strabismus is observed in a 13-month-old child. The most appropriate action for the NP to take is to: Refer the patient to an ophthalmologist Explanation: Any ocular deviation seen beyond 6 months-of-age is considered abnormal and the patient should be referred to an ophthalmologist for evaluation. 45181) Which of the following findings would raise the NP suspicious of bulimia in a 17-yearold female? Scar on her knuckles Explanation: Scars on the knuckles from induced vomiting are often found on persons with bulimia nervosa. Hypokalemia may be present. Persons with anorexia nervosa are commonly emaciated, but those with bulimia nervosa are usually normal weight. Frequent vomiting causes erosion of dental enamel. 182) A new patient presents to the NP clinic stating she wants a second opinion. She started propylthiouracil (PTU) 75mg 3 times a day a week ago as therapy for newly diagnosed Grave’s disease. She still feels irritable and jittery. How should the NP respond? Inform the patient that improvement requires 2-3 weeks Explanation: Because anti-thyroid drugs block the synthesis of thyroid hormone, but do not interrupt the release of stored hormone, clinical improvement is delayed for 2 to 3 weeks. A euthyroid state can usually be expected in 4 to 6 weeks. 183) Health Maintenance Organization (HMOs) and Preferred Provider Organizations (PPOs) are: Managed care systems Explanation: Managed care systems are intended to integrate delivery of health care with financing of health care. This is typically done through a series of contracts with health care providers, diagnostic groups, and other support services. 184) Which of the following is a microcytic hypochromic anemia? Iron deficiency anemia Explanation: Iron deficiency anemia is a microcytic and hypochromic anemia. Folic acid is a macrocytic normochromic anemia. Pernicious (vitamin B-12 deficiency) anemia is a macrocytic, megaloblastic, and normochromic anemia. The anemia of chronic disease is normocytic and normochromic. 185) Which drug class is associated with elevated serum lipid levels? Thiazide diuretics Explanation: Thiazide diuretics given in a higher dose are associated with elevated serum lipids and glucose. In lower doses, these elevations are less likely. 186) A 16-year-old presents for a sports physical for football. The NP auscultates a diastolic murmur. It is a grade II/IV. He has no history of a murmur. The patient denies symptoms. What is the most appropriate action for the NP? Refer this patient to a cardiologist Explanation: A diastolic murmur is ALWAYS considered abnormal, even if not accompanied by any physical symptoms. Diastolic murmurs tend to be soft (I-III/IV are common) because the heart is resting during diastole. This patient should not be allowed to practice football until he is evaluated by a cardiologist. He will need an echocardiogram as part of initial treatment. 46187) The NP is performing a routine assessment of a 47-year-old female who wants to lose weight. She has truncal obesity with relatively slender forearms and lower legs. Her BMI is 38. Upon review of her history, physical examination, and laboratory reports, the NP diagnoses “Syndrome X.” This diagnosis is based on the previous findings plus all of the following EXCEPT: Cardiac arrhythmias Explanation: Common features of Syndrome X include truncal obesity, HDL equal to or less than 35, triglycerides equal to or greater than 250, hyperinsulinemia, insulin resistance, and HTN. Cardiac pathology is not part of the clinical presentation of Syndrome X. 188) Which of the following is NOT a form of diaper dermatitis? Acrodermatitis enteropathica Explanation: Diaper rash collectively can encompass one or several dermatoses. There are many types: friction, irritation, allergic, atopic, seborrheic, and candida. Typically, candida infections are beefy red with satellite lesions. Acrodermatitis enteropathica is a dermatitis due to zinc deficiency. 189) Which of the following diseases is NOT acquired trans placentally? Tuberculosis Explanation: Tuberculosis is not transmitted trans placentally but may be transmitted in the early newborn period if the mother has active untreated disease. Rubeola, toxoplasmosis, and varicella are all transmitted trans placentally and have teratogenic potential. 190) A 2-week-old infant presents with projectile vomiting, weight loss, dehydration, constipation, and history of insatiable appetite. An olive-shape mass is palpable to the right of the epigastrium. The NP, suspecting pyloric stenosis, refers the infant for an upper GI series. The expected finding is: The “string sign” indicating a narrow and elongated pyloric canal Explanation: Pyloric stenosis is due to a hypertrophied pyloric muscle. It is diagnosed by clinical signs and symptoms along with narrowing and elongation of the pyloric canal (evidenced by upper GI series as the classic “string sign”). Intervention is correction of fluid and electrolyte imbalances followed by surgical repair. 191) Which of the following is an example of secondary prevention? Annual mammography for women age 40 years and older Explanation: Secondary prevention consists of early diagnosis and treatment of a disease that is already present. 192) An 80-year-old Caucasian female has heart failure (FH). Which symptom below is an early indication of failure? Weight gain Explanation: Early signs of HF include weight gain (the most sensitive indicator), S3 gallop, dyspnea on exertion, peripheral edema. Moderate signs include nocturnal cough, tachycardia. Late signs include ascites, frothy sputum, and hypotension. 47193) A patient presents to the NP with complaints of diarrhea and malaise which started at 2:00 am the morning of the visit. After history and examination, the nurse practitioner advises the patient that the problem should be self-limiting. If the diarrhea does not resolve, when should the NP advise the pt to return? 3 days Explanation: Diarrhea without systemic symptoms and fever should resolve in 3 days. If does not, laboratory studies and further testing may be necessary to identify the causative organism. 194) A mother presents with a 3-year-old who has croup. The plan for home care would appropriately include: a cool mist vaporizer Explanation: Cool mist helps reduce inflammation and swelling as well as loosen secretions. Warm mist and hot steam aggravate pulmonary inflammation and swelling. 195) An early sign of multiple sclerosis (MS) is: Acute monocular vision loss Explanation: Acute monocular vision loss may be seen in 15% to 20% of patients with MS. Memory loss and personality changes appear later in the course of the disease. Loss of consciousness is not usually associated with MS. 196) The mother of a 6-month-old infant asks about the use of an infant walker. The most appropriate response is to: Discourage the use of walkers and encourage parental holding and floor play Explanation: Baby walkers are a significant cause of injuries in young children. Their use should be discouraged, and parental holding and floor play should be encouraged instead. 197) Which of the following is LEAST likely to be the cause of ophthalmia neonatorum? Hemophilus influenza Explanation: Bacterial conjunctivitis caused by H. influenza is most likely to present in preschoolers and teenagers. All the other choices are likely causing of ophthalmia neonatorum, a form of conjunctivitis in the newborn period. Silver nitrate reaction is the causative factor in 10% of neonates. 198) An 18-year-old female applying for college admission presents to the health clinic because evidence of rubella vaccination is required for admission. She says, “I don’t remember ever getting that shot.” She has negative serologic evidence of rubella antibody. The NP should: Administer the vaccination after a negative pregnancy test and advise the patient that she must not get pregnant for 28 days. Explanation: Administration of rubella vaccination during pregnancy is absolutely contraindicated because of the possible teratogenic effects of rubella on the developing fetus. The earlier in the pregnancy the fetus is exposed, the greater the potential for congenital anomalies. Regardless of the actual time of gestational development in which the fetus is exposed, the infant may be chronically ill. 48199) A 19-year-old sexually active female is being counseled by the NP about contraception. The NP is accurate when she tells the patient that a diaphragm: Increases the incidence of UTI Explanation: Use of a diaphragm for contraception is associated with an increased incidence of UTI. The arching spring type is easier to properly place than the flat spring type. The diaphragm can be inserted up to 6 hours before intercourse. The risk of contracting a sexually transmitted disease is decreased with diaphragm use. 200) A 2-week-old infant is brought to the NP clinic after a difficult delivery. The mother says the infant fusses when handled or picked up. On physical examination, the NP notes decreased movement of the right arm during the Moro reflex, and crepitus on palpation of the right clavicle. The diagnosis is fracture of the clavicle. The recommended management is: Instructions to the parents to handle the neonate gently. Explanation: A frequent complication of a difficult birth is fracture of the clavicle. Neonates generally require only gentle handling of the arm and shoulder for 3 to 5 weeks. Older children may require a sling. X-rays are not usually necessary. 201) A 4-year-old presents to the clinic with circumoral pallor and an intense red eruption on both cheeks which appeared last night. The child has low grade fever but no other symptoms. What is the most likely diagnosis? Fifth disease Explanation: The eruptive rash of Fifth disease appears on the cheeks and forehead and looks like the child has been slapped; hence, the name, “slapped cheek” disease. This is a viral infection that stars on the face, but by the next day appears as a maculopapular rash on the extremities. It finally spreads to the trunk and distal extremities leaving a lace-like appearance. A prodrome with malaise and fever occurs occasionally. 202) The most effective intervention (s) to prevent stroke is (are): Smoking cessation and treatment of hypertension Explanation: According to the U.S. Preventive Services Task Force, the most important modifiable risk factors for stroke are hypertension and smoking. Improved treatment of hypertension has resulted in greater than 50% age-adjusted reduction in stroke. 203) A 30-years-old female has varicose veins. These are: Usually diagnosed on clinical presentation Explanation: Varicose veins are not congenital, but are due to development of faulty valves, usually at the saphenofemoral junction. They are more common during and after pregnancy. Women become symptomatic during menses. No special diagnostic studies are needed to diagnose varicose veins; they are evident by inspection. However, diagnostic studies are conducted prior to any surgical treatments. 204) A 3-year-old has worn a new pair of plastic sandals at the beach. When her mother takes them off, she notices that the straps of the sandals have left red marks and the child complains of itching and burning in the area of redness. What is the most likely diagnosis and how should the nurse practitioner manage the problem? Contact dermatitis; the mother should not allow the child to wear theses sandals again. 49Explanation: This is a case of classic contact dermatitis. When the skin is exposed to an irritant, the stratum corneum is disrupted, the underlying epidermis is injured, and an inflammatory reaction ensues. Plastic is a common precipitant of this kind of reaction. The child should avoid exposure to known skin irritants. 205) Which of the following is NOT a symptom of irritable bowel syndrome? Weight loss Explanation: Irritable bowel syndrome (IBS) is characterized by cramping abdominal pain with painful constipation and /or diarrhea. Bleeding, fever, weight loss, and persistent severe pain are indicative of other problems. 206) After a thorough examination, a 2-month-old infant is diagnosed with infantile colic. What should be included in the initial education of the mother about this condition? Instruct the mother on appropriate feeding techniques. Then reinforce efforts to claim and comfort the infant. Explanation: There is no “cure” for infantile colic. The situation can only be managed until it resolves on its own. Effective management includes appropriate feeding technique, calming strategies, and patient support. Dicyclomine (Antispas), hyoscyamine (Lesvin), and simethicone (Mylicon) have indications for treatment of infantile colic. 207) Of the following signs and symptoms of heart failure (HF), the earliest clinical manifestation is: Weight gain Explanation: The earliest and most sensitive clinical indicator of HF is weight gain. A patient with HF should be instructed to weigh himself daily to note changes in his weight. The best time of day to weigh is early morning. The other clinical manifestations listed will present after the weight gain. Another early, clinical manifestation of CHF not listed above is fatigue. 208) After a thorough history, physical examination, and laboratory tests, a patient is diagnosed with irritable bowel syndrome. Which of the following initial treatment plans is currently considered most effective? A low-fat, tyramine-free, caffeine free, high fiber diet, along with a daily diary, and attention to psychosocial factors Explanation: Irritable bowel syndrome can be diagnosed with careful history and physical examination, along with complete blood count (CBC) to assess for anemia, and a biochemical profile and urinalysis, for general information. Invasive procedures should be avoided unless age or family history indicates risk. A low-fat, tyramine free, caffeine free diet, along with a daily diary and stress reduction are mainstays of therapy. Unresponsive patients should be referred to a gastroenterologist. Selective serotonin reuptake inhibitors (SSRI) may worsen symptoms by their excitatory effect on the bowel. 209) A 2-week old African American male infant has ecchymotic-like marks over his lower back and upper buttocks. The most appropriate intervention is to: Reassure the infant’s mother that this is a normal finding 50Explanation: Mongolian spots are normal variants in non-Caucasian infants (particularly African American and Asian infants). They appear as “bruised” areas on the lower back and buttocks and usually fade spontaneously. 210) An elderly patient is taking an effective dose of doxepin (Sinequan) for treatment of agitated depression with insomnia. Constipation has become a significant problem, even though the patient has been vigilant about maintaining adequate hydration and uses bulk laxatives frequently. Which of the following is the course of action most likely to be successful? Stop the doxepin and initiate trazodone (Desyrel) Explanation: Fluoxetine tends to contribute to insomnia. A daily enema may cause fluid and electrolyte imbalance. Trazodone is a good alternative. It is a sedating antidepressant with properties similar to doxepin, but without anticholinergic effects. Constipation often accompanies depression and should be treated. 211) Which of the following is NOT true about Carpal Tunnel Syndrome? Phalen’s and Tinel’s signs are negative Explanation: Phalen’s and Tinel’s signs are positive and diagnostic of Carpal Tunnel Syndrome. Another hallmark feature is nighttime awakening with symptoms. Symptoms follow the distribution of the median nerve which innervates the first 3 fingers and the thumb-side half of the 4th finger. There is no involvement of the 5th finger. 212) A 17-year-old female presents with painful vesicular lesions on her vulva. Which of the following would be the most definitive diagnostic test? Tzanck prep Explanation: Tzanck prep is the only test in this which is diagnostic for herpes simplex. KOH prep is used to diagnose candida and bacterial vaginosis. Gram stain is used to help distinguish Gram positive and Gram-negative organisms. The Papanicolaou (Pap) smear is used to screen for cervical dysplasia and cancer. 213) Which of the following findings are usually associated with atopic dermatitis in infants? Positive family history Explanation: Atopic dermatitis is a familial disorder with unknown etiology. It is intensely pruritic. In infants it presents on the cheeks, forehead, scalp, trunk or extremities. It is often associated with asthma and allergy. 214) Today, a patient is diagnosed with iron deficiency anemia and started on a daily iron supplement. In order to best assess the adequacy of supplementation, the NP would appropriately order a follow-up: b. Hemoglobin level 1 one month Explanation: One month after iron supplementation, a hemoglobin or hematocrit should be measured to assess response to therapy. If this value is not increased in 1 month, consideration must be given to other sources of iron loss like GI or menstrual bleeding. The serum ferritin level, an indicator of tissue iron stores, should be increased and near normal after 4-6 months of supplementation. The reticulocyte count wound be expected to increase be 10 days or less but would not specifically assess the effects of iron supplementation. 51215) Appropriate nutritional guidance for the pregnant patient is: b. Increase caloric intake by 300 Cal/day and add iron and folic acid supplementation Explanation: Recommendation during pregnancy include well-balanced and nutritious meals and snacks, an additional 300 calories per day, and supplemental folic acid, iron and calcium. 216) An 8-month-old male presents with hemarthrosis of both knees and hematuria. The parents give no history of trauma but say “he has always bruised easily.” The most likely diagnosis is: A type of hemophilia Explanation: Hemophilia is usually diagnosed within the first year of life. It commonly presents with hemarthrosis, bleeding into soft tissue, hematuria, and prolonged bleeding times. 217) At 3 years old female with palpable right upper quadrant abdominal mass, anemia, and fever is been evaluated for wilms tumor. Which of the following diagnostic test would be the most useful a) intravenous polygram b) flat an erect xray of the abdomen c) abdominal ultrasound d) Voiding sistourethrogram Explanation: Abdominal ultrasound gives the best information about extensiveness of the tumor. Flat and erect x-rays of the abdomen may show linear calcifications, but are not as helpful as ultrasound. Intravenous pyelogram is rarely useful and voiding cystourethrogram is not indicated in the evaluation of Wilms' tumor. 218) Which class of drugs increases a patient's risk of developing rhabdomyolysis ? a) anti hypertensives b) thiazide diuretics c) the statin d) anticoagulant Explanation: The higher the dose of statins, the higher the risk of rhabdomyolysis becomes. The risk also increases if certain drugs — including cyclosporine (Sandimmune) and gemfibrozil (Lopid) — are taken in combination with statins. An overdose of aspirin or diuretics may cause an electrolyte imbalance and muscle injury. Alcohol and illegal drugs such as amphetamines, opiates, ecstasy, and LSD can also cause muscle injury. Trauma to the muscles, such as a crushing injury, electrical shock, or severe burns, can cause rhabdomyolysis. 219) When, in childhood, do the frontal sinus is usually present? a) 2 to 3 years b) 4 to 6 years c) 10 to 11 years d) Birth 52Explanation: frontal sinuses usually appear as early as 5 to 6 years of age but they may be asymmetrical or absent. Infants are born with ethmoid sinuses. Sphenoid sinuses may be identified radiographically by 9 years of age. 220) Which of the following is an example of Piaget’s concrete logical operation? a) A 4 years old child insist that a bowl of clay has more ones it is shaped into a snake b) a 5 years old child demonstrate their ability to read a paragraph to decode the words c) a 7 years old maintains that a bowl of clay wait the same amount after it has been shaped into a snake d) an 8 years old child must recalculate basic mathematic facts each time he attempts to solve a word problem Explanation: This period spans the time of middle childhood—it begins around age 7 and continues until approximately age 11—and is characterized by the development of logical thought. Conservation is the understanding that something stays the same in quantity even though its appearance change 221) A 23 years old college student present to the campus health clinic with a generalized rash on the trunk deletions are oriented in a Christmas tree pattern and are mildly pruritic. she describes around ringworm that that appeared about one week ago coma but now how has disappeared. What is this patient's diagnosis and how should be treated? a) Tinea corporis: treat with a topical antifungal cream for 10 to 14 days b) secondary syphilis: treat with penicillin c) viral exanthem: not specific treatment is needed except rest and fluids d) Pityriasis rosea: treat with a topical anti pruritic Explanation: Pityriasis rosea is a self-limited, inflammatory disorder of the skin possibly caused by human herpesvirus types 6, 7, or 8 or drugs. An initial 2- to 10-cm herald patch is followed by centripetal eruption of oval papules and plaques with a slightly raised and scaly border, typically appearing along skin lines. Diagnose based on clinical appearance and distribution. Treat with antipruritic drugs as needed and possibly topical corticosteroids and/or sunlight. Pityriasis rosea during the first 15 wk of pregnancy is associated with premature birth or fetal demise. Pregnant women should be offered antiviral therapy, even though this has not proved to reduce obstetric complications. Definition of Viral Exanthem: Viral exanthema is a widespread skin rash triggered by a viral infection. These rashes are more common in children than adults. 222) The nurse practitioner is caring for a 19 years old female college student with iron deficiency anemia secondary to heavy menstrual bleeding. An appropriate initial treatment for this patient is: a) intramuscular iron dextran b) a daily oral multi vitamin with iron c) oral ferrous sulfate d) increase intake of dietary iron Explanation: With iron deficiency anemia, iron stores of the body must be replenished as well as the underlying cause corrected. A daily iron supplement is used initially. The most common form is ferrous sulfate. Intramuscular iron dextran is usually not needed but may be required in 53the presence of a malabsorption disorder, inflammatory bowel disease, intolerance to oral iron, or blood loss too great to be compensated by oral iron. 223) The initial management of an adult with hypertension should include: evaluation for underlying causes explanation: approximately 5% of patients with hypertension in the US half secondary hypertension coma that is, it is secondary to something. Patient history, physical exam, and laboratory tests should be completed to identify patients who might have underlying causes (secondary hypertension ). underlying causes include some forms of renal disease, medications (oral contraceptives), adrenal hypertension, Acromegaly and hypercalcemia . 224) Which of the following statements about medication in a 45 years old patient with diabetes is correct? daily aspirin therapy should be recommended for the secondary prevention of a cardiovascular disease. Explanation: daily aspirin therapy for the secondary prevention of cardiovascular disease is recommended for patients with diabetes. The use of as the primary prevention, specially in low risk patients, is not routinely recommended. ACE inhibitors are especially beneficial right after albuminurea is present. Even if blood pressure is normal, an ace inhibitor may be used for renoprotection. The initiation of statin the dependent on cardiovascular risk or the presence of cardiovascular disease. ACE inhibitors may not be required with all patients with d…. 225) A 25 years old female has a history of frequent candidal vaginal infections in the past year. She is in a monogamous sexual relationship and uses an intrauterine for contraception. of the following, which is the most likely underlying condition for disposing her to recurrent candida vaginitis? a) hyperthyroidism b) diabetes mellitus c) trichomoniasis d) pregnancy Explanation: Diabetes mellitus (DM) is a metabolic disorder that predisposes individuals to fungal infections, including those related to Candida sp., due to a immunosuppressive effect on the patient 226) It is recommended that the therapeutic management of children with juvenile rheumatoid arthritis shoot include a) avoidance of exercise b) immunosuppressing agents c) ophthalmologists examination at least annually d) avoidance of aspirin therapy Explanation: Children with systemic in polyarticular JRA should have an annual ophthalmological examination. Those with pauci-articular JRA should be examine 4 time a year. 54227) Stress urinary incontinence is: a) associated with the normal aging process b) may be caused by anti cholinergic or anti depressant medication c) due to the truther muscle instability d) might be aggravated by caffeine or alcohol Explanation: stress urinary incontinence is not expected as a result of the normal aging process. The primary problem is sphincter incompetence ingestion of caffeine or alcohol decreases sphincter control. Anticholinergic and antidepressant medication are causative factor overflow incontinence. Detrusor muscle instability is the primary underlying problem causing urge incontinence. 228) Which immunization is contraindicated in an immunedeficiency individual? 1. Varicella, 2. IPV, 3. MMR, 4. HBV a) 4 b) 1,3 c) 1, 3, 4 d) all of the above Explanation: People who are immunocomprised are at risk of adverse events or vaccine-related disease if they receive a live vaccine. Live vaccines include:  BCG (bacille Calmette–Guérin) vaccine  Japanese encephalitis vaccine  MMR (measles-mumps-rubella) vaccine  rotavirus vaccine  oral typhoid vaccine  varicella vaccine  yellow fever vaccine  zoster vaccine 229) Enlargement of the scrotum and testis with little change in the size of the penis characterizes which Tanner stage sexual development ? a) Tanner 1 b) Tanner 2 c) Tanner 3 d) timer 5 55230) the most commonly recommended method for prostate cancer screening in a 55 y/o man is: Prostate-specific antigen (PSA) testing alone Explanation: a prostate-specific antigen (PSA) test is the most commonly recommended method for prostate cancer screening. For patient should … informed decision about whether to 56undergo testing. Digital rectal exam (DRE) for prostate cancer screening alone or in combination PSA is not recommended. 231) a 75 y/o patient is well controlled on timolol maleate (timoptic) for chronic open-angle glaucoma. Prescribing propranolol (Inderal) for this patient may precipitate: a) Hyperglycemia b) Elevated intraocular pressure c) Bradycardia d) Hypotension ? Explanation: Ophthalmic timolol may cause serious adverse effects, such as symptomatic bradycardia, various conduction disorders in the heart, orthostatic hypotension, syncope and falls, all of which can be particularly troublesome in the frail elderly. Patients may experience excessively low blood pressure or reductions in heart rate. 232) A patient presents with periorbital erythema and edema, fever, and nasal discharge. The nurse practitioner should a) start aggressive antibiotic therapy b) start treatment with steroid c) recommend cool compresses and oral antibiotic d) order sinus xray Explanation: This question describes periorbital Cellulitis. this might be seen in children from ethmoid sinusitis. very orbital satellite any children lead to meningitis or cavernous sinus thrombosis. this patient should be aggressively treated with intramuscular or intravenous and possible surgical consultation. 233) which of the following is appropriate to teach a patient who is using a daily nitrate agent for treatment of chronic angina? A daily 12 hour nitrate free. Is important to prevent tolerance Explanation: continuous 24 hour coverage increases tolerance to the effect of nitrate. A daily 12 hour nitrate free period important to prevent these potential problem. 234) Prescriptive authority for APRN is might be exercise by given a verbal medication order tool a pharmacist explanation: an example of exercising prescriptive authority is given a verbal order to a pharmacy or writing an order for a prescription medication. prescriptive authority rules and relations vary from state to state. prescriptive authority is granted only to those APRNS who meet the requirements of the governing body for the state in which the APRN practices. 235) All of the following are included in the differential diagnosis of hyperthyroidism except: hypersomnia Explanation: plumber's disease is a form of hyperthyroidism due to a single hyperfunctioning (hot nodule) Thyroid adenoma. Half of the cases Alpha hyperthyroidism in adults over 60 years of age are due to multi nodular Gotier (Which might have been previously present, but it 57euthyroid, for…years). Thyrotoxicosis, also refer to as thyroid storm, is a potentially fatal complication of excess thyroid hormone production. 236) A patient with uncontrolled primary hypertension present with a complain of frequent headaches. Headaches which might be attributed to the patients blood pressure elevation are typically described as: Occipital, presenting on awakening in the morning. Explanation: Uncontrolled primary hypertension is usually a symptomatic. However, the headache associated with elevated blood pressure is typically occipital an present an awakening in the morning. other symptoms which might be associated with uncontrolled primary hypertension include tachycardia, palpitations, tinnitus an fatigue. if target organ damage has occurred, signs and symptoms my present that can be attributed to target organ pathology. 237) Upon ophthalmoscopic examination of a 70 year old patient, the nurse practitioner observed dark spots against a retina. what diagnosis is this finding most consistent with? cataract Explanation: a cataract opacity is seen as a dark disruption of the red reflex on ophthalmoscopic exam. 238) The intervention known to be most effective in the treatment of severe depression, with or without psychosis, is: Electroconvulsive therapy (ECT) Explanation: Electroconvulsive therapy (ECT)is generally the most effective, most rapid treatment for severity depressed or acutely suicidal patients. ECT is the treatment of choice for psychotic depression and is also useful for the patient with poor response to medication. 239) Her mother has been breastfeeding her infant since giving birth 6 weeks ago. Her right breast is engorged, erythematous, hot to touch, and very painful. she says the problem began 48 hours earlier. she has been feeding exclusively with the left breast. the nurse practitioner diagnosis acute mastitis and recommends all of the following except : discontinue breastfeeding from the affected breast and wearing a bra until the pain and engorgement have resolved Explanation: Application of moist heat provides comfort, increases blood flow to the breast, and facilitate the let down reflex. ibuprofen is an appropriate anti-inflammatory analgesic. Cephalexin is safe during breastfeeding. The breast should be emptied on a regular schedule to alleviate engorgement and to continue breast milk production and a bra should be worn for support. Breastfeeding is not contraindicated with mastitis. 240) which medication or medication class used in the treatment of heart failure (HF) is NOT associated with decrease mortality? Digoxin (lanoxin) Explanation: ACE inhibitors, beta blockers, and diuretics are associated with decrease morbidity and mortality in heart failure. Digoxin has been show to reduce morbidity in patients with heart failure, but not to reduce mortality. It was previously thought that beta blockers were contraindicated in the treatment of HF and are still to be avoided in acute exacerbations of HF. Carvedilol (Coreg) and metoprolol (Top…) are beta-adrenergic blockers that have FDA. 58indications for chronic HF treatment. Diuretics reduce pre-load, reducing such symptom, shortness of breath, orthopnea, and paroxysmal nocturnal dyspnea. 241) A 19 y/o pregnant patient, at 20 weeks gestations, complains of pain in the right lower quadrant . she is afebrile and denies nausea vomiting. The most likely diagnosis is: Round ligament pain Explanation: Ask the fetus grows and the uterus rises is out of the pelvis, the strain is placed on the you train round ligament causing lower abdominal pain. this common discomfort in pregnancy is not associated with any other systemic symptoms . 242) At 23 years old female present with his scaly hypopigmented macular lesion on her trunk, shoulders, an upper arms. The lesion fluorescent under the wood lamb. appropriate treatment for this condition is: Apply selenium sulfide (Versel) lotion and allowed to dry for 10 minutes; then rinse off. Explanation: take condition described is tinea versicolor, a fungal dermatitis. the lesions will have a Golden Florescence under Woods lamp. KOH Positive for hyphae and spores. distribution of the lesions is primarily on the chest, back and shoulders and less commonly the groin an genitalia. The condition typically presents in young adults and trends to be recurrent because the causative agent, Malassezia Normal skin inhabitant 243) A child complains of “hurting a lot” with swallowing and state that his “throat feels full”. his sore throat that started 4 days ago. he is hyperextending his neck. examination reveals asymmetrical swelling of the tonsils. his uvula is deviated to the left .what is the most likely diagnosis ? Peritonsillar Abscess Explanation: This can be a complication of pharyngitis due to failure to seek treatment or a failure to treat. peritonsillar or retropharyngeal Abscess is a reason for immediate physician or emergency 244) 15 years old pregnant patient present to her first prenatal visit. on an physical examination, her uterus is approximately 24 weeks growth in size. she doesn't know when her last menstrual period was nor does she know when she might have conceived. Gestational age for this patient can most accurately be assessed by? Ultrasonography Explanation: prior to the 26th week of pregnancy, ultrasound will accurately estimate just stational age with an accuracy within days. between the 14 and 30 weeks of pregnancy, measurement of fundal height is accurate within 2 weeks of the estimated gestational age . Naegele’s would not be accurate due to the lack of this patient menstrual history. Gestational age estimation is not a component of the biophysical profile. 245) Which APRN is the exception to the graduate level preparation requirement for certification for advanced practice registered nurses? Advanced practice registered nurses who have completed an approved ducational program prior to implementation of graduate level education are considered to have met the requirements for advanced practice registered nursing. 59Explanation: Some advanced practice registered nurses in current practice have not been educated at the graduate level. Advanced practice registered nurses who have completed an accredited or approved educational program prior to implementation of graduate level education are considered to have met the educational requirement for advanced practice registered nurse (APRN) certification. 246) A 72 years old male present with fluid collected in his scrotum. He states that the size of his scrotum does not fluctuate during the course of a day. He is also likely to describe. A recent traumatic injury. Explanation: The condition described is a non-communicating hydrocele. This occurs about 1% of adult males and may be associated with infection, neoplasm, or trauma. The scrotum should translluminate if fluid is present. A solid mass will not transilluminate. The fluid may be surgically drained or monitored. 247) All of the following intervention with pediatric patient patients are appropriate EXCEPT: Pre-medicate all patient prior to all painful interventions. Explanation: Pre-medication is not warranted prior to all painful interventions. For example, pre-medication is not warranted to routine immunization, but it certainly is prior to suturing. Pain management should be an integral part of patient management. 248) Siri what is the recommendation of the US Department of Health and human resources regarding nicotine replacement therapy ? encourage the use of nicotine replacement except in the present of serious medical condition . Explanation: except in special circumstances such as pregnancy and recent myocardial infarction , every smoker should be offered nicotine replacement therapy . 6 month abstinence rates are 2 to 3 times higher for patients who use nicotine replacement as compared to placebo. 249) A patient takes Theophylline twice daily from Bronchospastic disease. today he presents with thick, discolored, tenacious sputum, fever and mild shortness of breath. what drug should he avoid? Clarithromycin (Biaxin XL) Explanation: This patient takes Theophylline, a drug Which is metabolized by the cytochrome P45O system. Biaxin XL Is also metabolized by the cytochrome P450 system. the addition of a second drug like Biaxin will slow down metabolism of the Theophylline causing the serum level to rise. Biaxin is not contraindicated in this patient but if it is prescribed, theophylline levels should be monitored closely and/or the dosage reduced. 250) Beneficiaries 21 years of age and older are allowed a specified number of outpatient visits per year. Explanation: In contrast to Medicare, Medicaid services are state specific. Each state received federal dollars to be used to take care of a group of individuals identified by each state. The individuals tend to be low income with no other payment source for medical expenses. 251) which group is considered to be high risk for the development of testicular tumors? Late adolescence through early adulthood. 60Explanation: the peak incidence of tumors of the testes is in late adolescence and early adulthood; therefore, palpation of the testes is most likely to yield valuable information at this age. 252) a 45 y/o diabetic patient has periorbital cellulitis secondary to a sinus infection. What course of action should the nurse practitioner take? Consider collaboration with a physician regarding antibiotic treatment, culture, and subsequent action. Explanation: Periorbital cellulitis signals an emergent condition which may warrant hospitalization and intravenous antibiotics. At the very least, this patient should have a culture so that the organism can be identified and appropriate antibiotic can be administered. This patient is also diabetic, which contributes to his high risk status. 253) An adult female patient is seeking information about her ideal weight. she is 5 feet 7 inches tall. using the height weight formula, what is her ideal body weight? 135 pounds. Explanation: The height weight formula is a quick method of that remaining ideal weight. females allow 100 lbs for the first five feet of height plus 5 pounds for each additional inch. Males allow 106 pounds For the first five feet plus 6 pound for each additional inch. this method can only be used as an estimate because it does not account for body composition or age. 254) The mother of a 2 years old uncircumcised male patient is concerned that she cannot retract the foreskin over the glans penis. the appropriate response by the nurse practitioner is to? reassured the mother that this is normal Explanation: phimosis refers to 4 skin that cannot be retracted over the glans penies. this is a normal finding in uncircumcised male children Anne usually resolves by eight five years . circumcision is not indicated unless there is urinary obstruction. the foreskin should never be forcibly retracted. 255) After following, the patient who should be referred for periodic colonoscopy is the patient with: extensive ulcerative colitis of long duration Explanation: patients with extensive ulcerative colitis of long duration are at risk of colorectal cancer. Colonoscopic surveillance for these patients is recommended 256) A patient complaints of a stomach pains on and off for the past month in this team win in distinguishing between a gastric and duodenal ulcer, What question is least important to ask? have you been out of the country in the past several months? Explanation: responses B&C and D are critical questions to ask patients with suspected Pepcid ulcer disease. a positive response to response b implies a GI hemorrhage. A positive response to A could imply an infectious etiology of the stomach pain and has little bearing on distinguishing between gastric and duodenal ulcer disease. 257) The first step when taking a patient history is the: introductory information 61Explanation: the steps in the patient history are introductory information (including name, age, gender, sources and reliability) chief complaint, history of present illness, past medical history, family history, social history, review of systems, and conclusions. 258) Characteristics of prescription and OTC drug use in the elder population include all of the following except: Increased tolerance to drag effect Explanation: with advancing age, patience becomes more sensitive to the effects of most drugs. Additionally, as drugs are added to a patient potential for drug interaction and slow metabolism are increased. the rule of thumb when introducing a new drug to an elderly patient medication regiment is to start low and go slow. 259) A patient has laboratory studies performed which demonstrate increased TSH, decrease free T4 and T3. which symptoms my she complain of? Hair loss Explanation: the patient's laboratory results demonstrate primary hypothyroidism. patients with hypothyroidism may exhibit lethargy, weight gain, intolerance to cold, Constipation, menstrual irregularities, course, dry skin, and hair loss from scalp and body. In extreme cases, bradycardia, hypotension, and coma can result. 260) a 16 y/o athlete complains of pain underneath his hell every time he walks. There is a verrucous surface level with the skin of the heel. What pharmacologic intervention (s) should the nurse practitioner prescribe for this patient? Salicylic acid plasters Explanation: This patient has a plantar wart, an epidermal tumor caused by a virus. Daily or every other day application of a salicylic acid plaster will help to remove a large part of the wart. Rubbing with a pumice stone will help remove a large part and also give this patient some pain relief. Total length of treatment is usually 6 to 8 weeks. 261) A 22 years old patient has a single, non tender, freely movable lump in her right breast. she denies any nipple discharge following diagnosis is this clinical presentation most consistent with: fibroadenoma Explanation: fibroadenoma usually present as single, non tender, freely mobile mass in the breast and there is usually absence of nipple discharge. fibrocystic breast disease is usually painful and there are multiple lumps present. breast cancer is typically a fixed mass with nipple discharge mine or might not be present. intraductal papilloma is characterized by serous or bloody nipple discharge. 262) Which of the following patients is least likely to exhibit secondary hypertension? a 62 years old with untreated depression Explanation: diseases an conditions which might cause secondary hypertension include Grave disease (hyperthyroidism), Cushing disease, phyochromocytoma, Coarctation of the aorta, disease of the renal parenchyma and renal artery. Hypertension might be a concequence of the sympathetic nervous system stimulation (anxiety, panic ). drop related causes of hypertension 62include cocaine use and withdrawal, alcohol withdrawal, opioid withdrawal, pseudoepinephrine contain in OTC preparations and steroids. 263) Which of the following medication is indicated for primary prevention are febrile seizures? a) phenobarbital b) Acetaminophen (Tylenol) c) aspirin d) phenytoin (Dilantin) Explanation: Antipyretic agents (Ibuprofen, Acetamnophen) on their own , have not been shown to prevent febrile seizures or their recurrent febrile seizure.” A randomized controlled trial published in 2018 suggested that rectal acetaminophen 10 mg/kg given every 6 hours may prevent febrile seizure recurrence within the same febrile episode. On the basis of risk/benefit analysis, neither long-term nor intermittent anticonvulsant therapy is indicated for children who have experienced 1 or more simple febrile seizures. In situations in which a child tends to have febrile seizures with frequent illnesses, and seizures tend to occur after the onset/recognition of fever, oral diazepam can be considered for the duration of the fever. 264) The anatomical site currently believed to be the best location for subcutaneous insulin administration is the: a) buttocks b) thigh c) Abdomen d) arms explanation: Research had demonstrated that insulin is absorbed most rapidly and consistently when injected in the subcutaneous tissue of the abdomen (with the exception of the area in a 1 inch radius around the umbilicus). 265) An 85 years old Caucasian male request screening for prostate cancer. What is the best approach to his request? a) give him objective information about the potential benefits of early detection and treatment b) tell him that screening is only done for men with life expectancy greater than 10 years c) Perform a digital rectal exam (DRE), obtain a prostatic specific antigen (PSA), an order at transrectal ultrasound (TRUS)at this time. d) perform a digital rectal exam (DRE) and PSA at this visit, reserving that TRUS for patients with abdominal DRE or PSA. Explanation: Prostate cancer screening at age 70 years includes prostate-specific antigen measurement (PSA) with or without digital rectal exam (DRE). DRE has not been found to increase overall cancer detection. Prostate cancer is typically slow growing, thus if life expectancy is < 10 years, screening is not cost-effective. The discussion regarding prostate cancer screening should take place with men who are expected to live at least 10 more years. Prostate-specific antigen (PSA) screening is controversial for men of any age but, for older men, screening may impart a risk to quality of life that may outweigh the potential advantages of diagnosis and treatment. 63266) The nurse practitioner diagnosis eczema on the cheeks of a 2 years old female. the patient's mother explained that she is embarrassed to take the child to public because her face is so red, dry, and crusted. she asked for a strong QWERTY sun cream so that eczema will clear rapidly. The nurse practitioner knows that: a) a high potency cortisone preparation applied to the face will shorten the duration of the eczema flare up. b) a high potency cortisone cream on the face will only be helpful if used in conjunction with hydrating lotion c) a high potency cortisone cream is not recommended for use in children's under 7 years of age d) A high potency cortisone cream might cause atrophy, telangectasia, purpura, or stanae if used on the face. Explanation: Topical steroids are grouped by potency into classes, from Class 1 (most potent) to Class 7 (least potent). Those in Classes 6 and 7 are usually most appropriate for children. Local side effects of topical steroids are more common and include:  Skin thinning (atrophy) and stretch marks (striae).  Easy bruising (senile purpura) and tearing of the skin (fragility).  Telangiectasia.  Perioral dermatitis (erythematous papules around the mouth).  Contact allergy to the steroid molecule itself or another ingredient 267) An adult present with tinea corporis. what comment by the patient would be the least likely explanation of how he acquired this disease? a) I trap animals b) my wife has this also c) I have diabetes d) I live in the northern US Explanation: acquisition of infection may occur by direct skin contact with an infected individual or animal, contact with fomites, or from secondary spread from other sites of dermatophyte infection (eg, scalp, feet, etc). In particular, tinea corporis in adults may result from contact with a child with tinea capitis, often acquired by contact with an infected cat or dog. Tinea corporis can also occur in outbreaks among athletes who have skin-to-skin contact, such as wrestlers. Tinea corporis often begins as a pruritic, circular or oval, erythematous, scaling patch or plaque that spreads centrifugally. Central clearing follows, while an active, advancing, raised border remains. The result is an annular (ring-shaped) plaque from which the disease derives its common name (ringworm) 268) Which of the following can result from chronic inflammation of a meibomian Gland? a) A chalazion b) uveitis c) keratitis d) a pterygium 64Explanation: A chalazion is a small, usually painless, lump or swelling that appears on your eyelid. A blocked meibomian or oil gland causes this condition. It can develop on the upper or lower eyelid 269) A 23-year-old female patient of Italian descent has been diagnosed with anemia secondary to glucose-6-phosphate dehydrogenase (G-6PD) deficiency. It is important to teach this patient to avoid: a) beef or pork liver b) fava beans c) phenylalanine d) milk and milk products Explanation: Glucose-6-phosphate dehydrogenase deficiency is a genetic disorder that occurs almost exclusively in males. This condition mainly affects red blood cells, which carry oxygen from the lungs to tissues throughout the body. In affected individuals, a defect in an enzyme called glucose-6-phosphate dehydrogenase causes red blood cells to break down prematurely. This destruction of red blood cells is called hemolysis. The most common medical problem associated with glucose-6-phosphate dehydrogenase deficiency is hemolytic anemia, which occurs when red blood cells are destroyed faster than the body can replace them. This type of anemia leads to paleness, yellowing of the skin and whites of the eyes (jaundice), dark urine, fatigue, shortness of breath, and a rapid heart rate. In people with glucose-6-phosphate dehydrogenase deficiency, hemolytic anemia is most often triggered by bacterial or viral infections or by certain drugs (such as some antibiotics and medications used to treat malaria). Hemolytic anemia can also occur after eating fava beans or inhaling pollen from fava plants (a reaction called favism). 270) A 62-year-old with Type 2 diabetes mellitus complains of increased nocturia, fatigue, and weakness. His fasting blood glucose is 110 mg/dL (6.2 mmol/L), he is slightly anemic, and his serum creatinine level is slightly elevated. All other laboratory tests and physical examination are within normal limits. What is the most likely diagnosis? a) Renal Insufficiency Explanation: Nocturia is a sign of moderate renal insufficiency due to impaired ability to concentrate urine. 271) A 12-year-old has a fasting serum cholesterol of 190 mg/dl (4.94 mmol/L). Her mother asks if this value is “ok”. The FNP responds: a) This is unacceptable. The desired level is <170 mg/dL (4.42mmol/L) Explanation: Children who have cholesterol levels greater than 170mg/dL (4.42mmol/L) are known to be at increased coronary artery disease. Total dietary intake of fats for children and adults should be < 30% of total caloric intake and < 7% should be from saturated fat. Reduction of dietary fat intake is not recommended for children <2 year-old-age. 272) The correct treatment for ankle sprain during the first 48 hours after injury includes: a) alternating heat and ice, and ankle exercises. b) resistive ankle exercises, ankle support, and pain relief. 65c) rest, elevation, compression, ice, and pain relief. d) referral to an orthopedist after x-rays to rule out fracture Explanation: For the first 48 hours, elevate (raise) the ankle higher than your heart whenever you're lying down. If your ankle is just painful and swollen, remove ankle bracelets or toe rings right away. Then try the “RICE” method to ease your symptoms. RICE stands for “rest, ice, compress, and elevate.” Here’s how it works: Rest the ankle (use crutches if needed). Ice the ankle for 20 to 30 minutes every 2 to 3 hours for the first 2 days. Compress (wrap) the ankle lightly -- not tightly -- with an elastic bandage or ankle brace. Go to the emergency room if: Pain, bruising, or severe swellin. Bleeding, numbness, or change in color of the affected area. Deformed or seems dislocated. You can't put any weight on it 273) A 52-year-old female has a firm, non-tender, one-centimeter mass in the right lower quadrant of her breast. There are no palpable axillary lymph nodes. A mammogram the month before her examination was negative. The most appropriate NP action today is to: a) reassure the patient that the mass is benign b) refer the patient to a surgeon for evaluation c) schedule an ultrasound of the breast d) plan a repeat mammogram in 6 months Explanation: the diagnostic test of choice to differentiate a solid from a fluid-filled breast mass is ultrasound. More than 90% breast masses in women in the 20s to early 50s are benign. However, they must be evaluated. Clinical breast examination is unable to differentiate fluid filled from solid masses. MRI is not used unless a history of breast cancer is present. Mammography has the potential to evaluate the presence of a mass, but not adequate in assessing ii is fluid filled or not. 274) A 25-year-old married woman is being taught the natural family planning method (NFP) of contraception by the NP. Which of the following statements by the patient demonstrates her understanding of NFP? “Cervical mucus is clear and thin during ovulation.” Explanation: Cervical mucus is abundant, clear, thin, wet, and elastic, before and during ovulation. Increase in basal body temperature indicates ovulation. Abstinence is required when basal body temperature and cervical mucus assessment indicate ovulation. Specific dates of the cycle cannot be used with confidence. Douching can interfere with the ability to assess mucus changes. 275) A significant barrier to treatment of depression in the elderly population is: The belief that depression is an inevitable part of aging Explanation: Only 10% of elderly adults who suffer from depression receive treatment. This is largely because many health care providers and elderly patients mistakenly believe depression is an inevitable and untreatable result of ageing. 276) Oral and parenteral contraceptive methods: Inhibit secretion of FSH Explanation: The estrogen and progesterone in OCPs, and parenteral progesterone, inhibit pituitary production of folic stimulating hormone (FSH). 66277) Infants born to women who smoke are at risk for. a) premature delivery b) congenital abnormalities c) low birth weight d) nicotine withdrawal symptoms Explanation: Smoking during pregnancy has been linked to increased risk for slowed fetal growth and low birth weight, stillbirth, pre-term birth, infant mortality, Sudden Infant Death Syndrome, and respiratory problems. 278) A patient is diagnosed with Bell’s Palsy. He is placed on high doses steroids. After 4 days of prednisone, the patient states that his eye still not close completely. How should the NP manage problem? a) This patient should be referred to a neurologist b) This is not unusual. He should continue the plan. c) The NP should increase the dosage of prednisone d) The patient should have a CT scan to rule out other etiologies. Explanation: Complete recovery of Bell’s palsy may be noted within 3 to 6 months, with or without treatment. Though in most of the cases, the symptoms disappear after a few months, in some cases the symptoms of Bell’s palsy may linger longer and in certain rare cases, the symptoms may last forever. 279) A 45-year-old patient voices concern about her “hot flashes” and irregular menstrual periods. What diagnostic test would be appropriate for the NP to order for confirmation of menopause or perimenopausal? A) serum follicular stimulating hormone (FSH) b) serum prolactin level c) pelvic ultrasound d) serum gonadotropin releasing hormone (GnRH) Explanation: Sometimes, elevated follicle-stimulating hormone (FSH) levels are measured to confirm menopause. When a woman’s FSH blood level is consistently elevated to 30 mIU/mL or higher, and she has not had a menstrual period for a year, it is generally accepted that she has reached menopause. 280) A 50-year-old patient with diabetes complains of pain bilaterally in her lower legs while walking. The pain disappears at rest. What else would you expect to identify on her lower extremities? a) A finding of lower extremity edema, erythema, hair growth b) Peripheral artery insufficiency c) Acanthosis nigricans d) Deep vein thrombosis (DVT) Explanation: Peripheral artery disease (also called peripheral arterial disease) is a common circulatory problem in which narrowed arteries reduce blood flow to your limbs. When you develop peripheral artery disease (PAD), your extremities — usually your legs — don't receive enough blood flow to keep up with demand. This causes symptoms, most notably leg pain when walking (claudication). 67281) A middle aged patient has a history of smoking, chronic cough, and sputum production. He reports chronic dyspnea. A diagnosis of COPD should be confirmed with: a) spirometry b) chest X-ray c) ABG’s d) alpha-1 antitrypsin deficiency Explanation: A chronic obstructive pulmonary disease (COPD) diagnosis is confirmed by a simple test called spirometry, which measures how deeply a person can breathe and how fast air can move into and out of the lungs 282) A widowed 85-years-old was recently moved from her home of 65 years to a bedroom in her daughter’s home. According to reports by family members, she is now “cantankerous,” “gets mixed up” easily, and cries for no apparent reason. Factors in the client history that are consistent with delirium may include all of the following EXCEPT: a) Insidious onset and chronic progressive course b) a new anticholinergic medication c) dehydration and/ or malnutrition d) recent changes in surroundings and routines Explanation: Delirium is a serious disturbance in mental abilities that results in confused thinking and reduced awareness of the environment. The start of delirium is usually rapid — within hours or a few days. Delirium can often be traced to one or more contributing factors, such as a severe or chronic illness, changes in metabolic balance (such as low sodium), medication, infection, surgery, or alcohol or drug intoxication or withdrawal(MAYO Clinic). Definition of cantankerous: bad-tempered, argumentative, and uncooperative. 283) Standards of practice are: Minimum levels of acceptance performance Explanation: Standards of practice describe a minimal competency level. 284) Which of the following is NOT a risk for a transient ischemic attack (TIA)? a) Age b) Hypertension c) Common migraine headache d) Smoking Explanation: Migraine is a complex and often confusing disease. The symptoms of Migraine can also be symptoms of other conditions and events including transient ischemic attack (TIA). As per Mayo clinic Risk factors you can't change: Family history. Your risk may be greater if one of your family members has had a TIA or a stroke, Age=55 and above, Sex. Men have a slightly higher risk of a TIA and a stroke, Prior transient ischemic attack, Sickle cell anemia. Some health conditions such as hypertension, high cholesterol, diabetes and other . Lifestyle choices: such as smoking , heavy drinking, physical inactivity etc.. 68285) According to the American Diabetes Association, what is the lowest fasting plasma glucose level which warrants a diagnosis of diabetes Mellitus if confirmed on a subsequent day? a)121 mg/dL (6.7 mmol/L) b)126 mg/dL (7 mmol/L) c)130 mg/dL (7.2 mmol/L) d)140 mg/dL (7.8 mmol/L) Explanation: Glucose values that equal or exceed 126 mg/dL on different days constitute a diagnosis of diabetes. Therefore, an A1C is not needed for diagnosis but may be ordered to establish a baseline for this patient. Impaired fasting glucose can be diagnosed when two glucose values are between 100 mg/dL and 125 mg/dL on different days. 286) Which of the following patients is most likely to have a diagnosis of Type 2 diabetes mellitus? a) An underweight 9-year-old with frequent staphylococcal infections, glucosuria, and ketonuria b) A 49-year-old male with impotence and HbA1C 10.0% c) A 35-year-old obese female with frequent vaginal yeast infections and 120 fasting serum glucose d) A 55-year-old female with HTN, hyperlipidemia, and 130/dL 2 hour/75 g glucose tolerance test Explanation: The risk of type 2 diabetes increases as you get older, especially after age 45. That's probably because people tend to exercise less, lose muscle mass and gain weight as they age. Diabetes mellitus (DM) is a major risk factor for the development of erectile dysfunction (ED). 287) Which of the following are the classic features of ulcerative colitis? a) Right lower quadrant pain, frequently accompanied by a palpable mass, fever, and leukocytosis b) Massive painful hematemesis, occasionally accompanied by melena c) Rapidly progressive dysphagia to solid foods, anorexia, and weight loss out of proportion to the dysphagia d) Remissions and exacerbations of bloody diarrhea, tenesmus, fecal incontinence, abdominal pain, and weight loss Explanation: ulcerative colitis is a idiopathic inflammatory condition that presents with diffuse inflammation of mucosa in the colon, affecting the rectum upward. The hallmark sign is bloody diarrhea. Patient with severe symptoms may present with severe anemia, hypovolemia and impaired nutrition due to having more than 6 bloody bowel movements per day. 288) A 37-year-old female is found to have a negative rubella titer. How long after immunization should she avoid pregnancy? a) 28 days b) 60 days c) 90 days d) 120 days Explanation: Women of childbearing age should be advised to avoid pregnancy for 28 days after immunization with an MMR. However, The CDC has collected data on women who have 69accidentally received that immunization while pregnant, Anne there has been no documented injury to offspring. the vaccine is safe for women who are breast feeding even though their rubella virus is excreted in breast milk. it is safe for young children of pregnant women to be immunized with NMR because infection is not transmitted from immunized patience. 289) Successful management of a patient with attention deficit hyperactivity disorder (ADHD) is best achieved with: a) Stimulant medication along with behavioral and family interventions b) Methylphenidate (Ritalin) in conjunction with an antihistamine c) treatment by a pediatric psychiatrist d) firm discipline and removal of offending foods from the diet Explanation: Pharmacotherapy and behavioral therapy are currently used with success in treating attention-deficit/hyperactivity disorder (ADHD) in children, adolescents, and adults. 290) Which of the following signs and symptoms are typical of hypothyroidism? a) Constipation b) Heat intolerance c) Weight loss d) Nervousness Explanation: Hypothyroidism happens when your thyroid gland doesn’t make enough hormones. This can slow down many of your body functions, including your bowels. 291) A first-time mother asks the NP how much her baby will grow in the first 3 months of life. The NP explains that the normal baby will grow. a) ½ to 1 ounce per day b) 1 to 2 ounces per week c) one inch per week d) more than 6 inches Explanation: Once your milk supply is established, your baby should gain between ½ and 1 ounce per day during the first 3 months 292) The requirement that a NP practice under the direct supervision of a physician is: a) Not a requirement in any state b) Dependent on state regulations c) Illegal, according to standards of nursing care d) A standard national requirement Explanation: The central principle underlying physician supervision of NPPs is that the physician retains ultimate responsibility of the patient care rendered when so required by state law 293) The NP correctly diagnoses iron deficiency anemia in a male patient whose lab report reveals: a) hemoglobin (Hgb) 15.0 g/dL (150g/L) b) a decreased total iron-binding capacity (TIBC) 70c)mean corpuscular volume (MCV) < 80 fL d) increased mean corpuscular hemoglobin concentration (MCHC) Explanation: In iron-deficiency anemia, red blood cells will be small in size with an MCV of less than 80 femtoliters(fl) 294) All of the following are medical emergencies which may be attributed to acute cocaine intoxication EXCEPT: a) hyperthermia leading to extreme rhabdomyolysis b) HTN with or without vasculitis causing cerebrovascular accident (CVA) c) depression of cardiac conduction and contractility resulting in arrhythmias and myocardial infarction (MI) d) decrease heart rate and vasodilation leading to hypersomnia Explanation: Cocaine is associated with both ischaemic and haemorrhagic stroke. Persistent severe hypertension in the presence of chest pain. We conclude that cocaine intoxication can cause acute rhabdomyolysis with acute renal failure, severe liver dysfunction, and disseminated intravascular coagulation. 295) A male patient presents 24 hours after having been bitten on the arm during a fight with his spouse. His wound is swollen, red. Has a discolored exudate and a 5-centimeter tissue scar. Which action by the NP is LEAST appropriate at this time? a) Administer 0.5 ml of tetanus toxoid vaccine since it has been > 5 years since his last tetanus booster b) Prescribe amoxicillin-clavulanate (Augmentin) and collect a swab specimen for culture and sensitivity c) Suture the torn tissue since 24 hours has elapsed since the injury. Provide an antibiotic ointment for use with twice a day dressing changes d) Prescribe an antibiotic ointment for application with twice a day dressing changes. Explanation: Wound closure is a source of controversy in the management of patients with human bite wounds. In general, do not close hand wounds, puncture wounds, infected wounds, or wounds more than 12 hours old. Allow such wounds to heal by secondary intention. They may be closed secondarily or revised at a later date. 296) Adolescents are at increased risk for contracting the human immunodeficiency virus (HIV) due to: a) immaturity of their immune systems b) increased sexual experimentation c) pubertal changes in body composition d) inadequate primary health care Explanation: Teenagers need to be educated about how HIV is spread and ways to prevent transmission because the virus is spread by sexual contact and intravenous drug use. Teenagers are likely to take part in these risky behaviors because of their developmental stage. 71297) A 50-year-old female complains of urinary incontinence. Which patient response supports a diagnosis of stress incontinence? a) It burns when I urinate b) I’m only incontinent at night c) I’m incontinent when I laugh, cough, or sneeze d) It’s hard to predict when I will be incontinent Explanation: Stress urinary incontinence is not expected as a result of the normal aging process. The primary problem is sphincter incompetence. The ingestion of caffeine or alcohol decreases sphincter control. Anticholinergic and antidepressant medications are causative factors related to overflow incontinence. Detrusor muscle instability is the primary underlying problem causing urge incontinence. 298) A 14-year-old female cheerleader reports gradual and progressive dull anterior knee pain, exacerbated by kneeling. She also complaints of a “sore lump on my knee.” The NP notes swelling and point tenderness at the tibial tuberosity. X-ray is negative. What is the most likely diagnosis? a) Patellar fasciitis b) Cruciate ligament tear c) Osgood-Schlatter disease d) Patellar fracture Explanation: in patients with Osgood-Schlatter disease, pain can be unilateral or bilateral. What is obvious on assessment is a swelling of the tibial tubercle. X-rays are not needed for diagnosis. Pain worsens with squatting or crouching and with contraction of the quadriceps muscle against resistance. An avulsion of the quadriceps tendon should be part of the differential for patients who exhibit severe pain. 299) The NP correctly diagnoses a 2nd degree burn injury which is described as: a) full thickness, waxy or leathery, without vesicles b) partial thickness, with erythema and edema but no vesicles c) partial thickness, with involvement of the dermis and epidermis, edema, and vesicles d) full thickness, with involvement of muscle and bone Explanation: Second degree burns or partial thickness burns are more severe than first degree burns. They affect the outer layer of skin, called the epidermis and part of the second layer of skin called the dermis. They cause pain, redness, swelling, and blistering. 300) The first sign of puberty in girls is: a) enlargement of the ovaries, uterus, and clitoris b) development of breast buds c) the occurrence of menarche d) acne resulting from stimulation of the sebaceous glands 72301) A patient presents with distorted areas and blind spots in the visual field. The painless condition was first noticed on awakening this morning. The NP would most appropriately include all of the following plan of care EXCEPT: a) refer the patient to an ophthalmologist if the condition has not resolved in 24 hours b) schedule the patient for a fluorescein angiogram and retinal exam as soon as possible c) examine the retinal filed for edema, infarcts, exudates, and retinal detachment d) screen the patient for diabetes mellitus Explanation: An eye stroke or anterior ischemic optic neuropathy is a condition in which the blood flow either becomes blocked or reduced to the font part of the optic nerve. An eye stroke can cause sudden loss of peripheral vision, distorted vision and blind spots in your vision. Prompt medical attention can prevent or limit vision loss. 302) The most accurate measure of diabetes control is: a) micro and macro vascular complications b) insulin sensitivity c) early morning glucose levels d) HbA(1C) Explanation: The current Gold Standard for diabetes screening is the glycohemoglobin test (Hgba1c). It is a general gauge of diabetes control that specifies an average blood glucose level over a few months. It measures glucose that sticks to hemoglobin inside the red blood cells. 303) A 70-year-old patient presents with left lower quadrant (LLQ) abdominal pain, a markedly tender palpate abdominal wall, fever, and leukocytosis. Of the following terms, which correctly describes the suspected condition? a) Diverticulosis b) Diverticula c) Diverticulitis d) Diverticulum 73Explanation: Diverticulitis is an inflammation or infection of the pouches formed in the colon (diverticula). Can last several days or weeks. Common ages are 35-50. Requires lab test and imaging. 304) At what age does vision normally become approximately 20/20? a) 6 weeks b) 4 months c) 3 to 4 years d) 6 years Explanation: 4-6 years of age, child recognizes and recites the alphabet, ready to read, has complete depth perception, and should have 20/20 vision. 305) Salmeterol (Serevent) in combination with an inhaled steroid is prescribed for a patient with moderate persistent asthma. What is the most important teaching point about salmeterol? a) It is not effective during an acute asthma attack b) It may take 2-3 weeks to begin working c) This drug works within 10 minutes d) This drug may be used by patients 6 years and older Explanation: This medication is not to be used to treat intense flare-ups or shortness of breath. A rescue inhaler will be needed. 306) At what age is screening most helpful in detecting scoliosis? a) 4 to 6 years b) 8 to 10 years c) 12 to 14 years d) 18 to 20 years Explanation: girls should be screened twice at 10-12 yrs of age and boys ages 13-14 307) A first time mother asks the NP when she should start feeding her baby cereal. The NP replies: a) not before 4 to 6 months-of-age b) at 2 months of age if the baby is taking 20 ounces of milk per 24 hours day c) when the baby does not sleep through the night d) as soon as the baby begins teething Explanation: The Academy of Pediatrics does not recommend introducing cereal and other solid foods until 4-6 months of age. Before that, only breast milk or formula. 308) Which symptoms is NOT typical in a female during the peri-menopausal period? a) Vasomotor instability b) Paresthesia c) Increased vaginal lubrication d) Disturbed sleep patterns Explanation: Females in the peri-menopausal period have decreased vaginal lubrication which results in itching, discharge, bleeding, and increased risk of urethritis. Vasomotor instability ("hot 74flashes" and "hot flushes") is the most common symptom during this period. Other symptoms include nervousness, palpitations, depression, and headache. 309) An 85-year-old is diagnosed with shingles. The patient states that she became “miserable”. What is the pharmacologic interventions should the NP offer this patient? a) NSAIDs for pain and fever b) Topical capsaicin cream (Zostrix) to lesions 4 times a day for 21 days c) Oral acyclovir (Zovirax) for 7 to 10 days, NSAIDs, and topical capsaicin d) Acetaminophen, Burrow’s solution compresses and mupirocin Explanation: Medications include, antiviral drug, NSAIDS, analgesic or nerve pain medication. Capasaicin can relieve topical pain 310) The mechanism by which nurses are held accountable for practice, based on the quality of nursing care in a given situation with established standards of practice, is: a) outcome criteria b) process criteria c) peer review d) quality assurance Explanation: evaluation of scientific, academic, or professional work by others working in the same field. 311) A patient taking levothyroxine is being over-replaced. What condition is he at risk for: a) Osteoporosis b) Diarrhea c) Bipolar disorder d) Periorbital puffiness Explanation: Symptoms of levothyroxine being over-replaced will be: Increased pulse and bp, anxiety, nervousness, diarrhea, difficulty sleeping, feeling that your heart is racing/skipping beats, unexplained weight loss, increased appetite. 312) What prophylaxis medication is recommended for the patient under 35-years-of-age with…. a) ethambutol (Etibi) b) Streptomycin c) pyrazinamide (Tebrzid) d) isoniazid (INH) 313) The infant 1 to 6 months-of-age with a diagnosis of developmental hip dysplasia is correctly treated with: a) closed reduction of the hips b) surgical open reduction followed by pelvic and/or femoral…. c) a variety of adduction orthoses d) the Pavlik harness 75Explanation: Pavlik harness: Specially designed to gently position your baby’s hips so they are aligned. 314) A 25-year-old hypertensive patient has a BMI of 16. His BP is 165/110. There is an audible bruit in his left upper abdomen quadrant. He probably has: a) essential HTN b) secondary HTN c) isolated systolic HTN d) whitecoat HTN Explanation: There may be renal artery stenosis or renovascular hypertension. An abdominal bruit may be heard in the epigastric region. It may radiate to one side. A bruit indicates narrowing of the artery which may cause secondary HTN as a result. 315) A female patient believes that she was exposed to HIV through sexual intercourse several months ago. She asks for “the test for AIDS”. Which statement is NOT correct? a) The ELISA is used for screening, but may yield a false negative this soon after exposure b) the Western blot is an immunofluorescence assay and is used to confirm a possible ELISA c) either blood or saliva can be used for screening d) She should refrain from all sexual intercourse until the results of the test are known Explanation: ELISA is the initial screening test for HIV. The Western blot is then ordered for confirmation of a positive ELISA. Rapid plasma reagin (RPR) is the screening test for syphilis. CD4 cell count is used to monitor the immune status of HIV-positive patients. 316) The most appropriate first-line drug treatment for African American patients diagnosed with HTN is: a) a calcium channel blocker (CCB), demonstrates by research to be the most effective antihypertensive drug class for this population b) an angiotensin converting enzyme inhibitor (ACE-I), because African Americans are typically high renin producers c) an angiotensin converting enzyme inhibitor (ACE-I), because African Americans are typically low renin producers d) a beta-adrenergic blocker (beta-blocker), demonstrated by research to be the most effective first-line treatment for all ethnic populations. Explanation: African American Patients should be treated with diuretics and calcium channel blockers first 317) The NP knows that the frail elderly is at high risk for malnutrition. Indicators of malnutrition in this population include all of the following EXCEPT: a) hunger and increased appetite b) glossitis c) delayed wound healing d) cachexia 76318) Which drugs below would be expected to produce the least amount of hypokalemia? a) Furosemide (Lasix) b) Hydrochlorothiazide (HCTZ) and spironolactone (Aldactone) c) Spironolactone (Aldactone) d) Hydrochlorothiazide (HCTZ) Explanation: Potassium-sparing diuretics such as spironolactone, amiloride, and triamterene all have the potential to cause hyperkalemia. This risk is increased when used in association with potassium supplements and salt substitutes, as previously noted. The risk of hyperkalemia with spironolactone increases threefold if used with potassium supplements. The use of concurrent loop diuretics does not guarantee that hyperkalemia will not occur 319) A 25-years-old overweight patient presents with a complaint of dull achiness in his groin and history of palpable lump that “comes and goes”. On physical examination, the NP does not detect a scrotal mass. The scrotum does not transluminate. Considering these finding what is the most likely diagnosis? a)Testicular torsion b) Epididymitis c) Inguinal hernia d) Varicocele Explanation: An inguinal hernia is characterized by herniation of bowel or omentum into the scrotum. It typically present with the scrotal pain and scrotal mask or scrotal swelling. Abdominal or growing pain with a scrotal mass is a common presentation. bowel sounds might be audible in the scrotum. 320) Acute idiopathic thrombocytopenia purpura (ITP) is most commonly seen in childhood following: a) trauma b) glucocorticosteroid therapy c) aspirin ingestion d) acute infection Explanation: Often, the child may have had a virus or viral infection about three weeks before developing ITP. It is believed that the body, when making antibodies against a virus, "accidentally" also made an antibody that can stick to the platelet cells. The body recognizes any cells with antibodies as foreign cells and destroys them. That is why ITP is also referred to as immune thrombocytopenic purpura. 321) Which of the following drug classes may potentiate hyperkalemia in a patient taking a potassium-sparing diuretic or potassium supplement? a) Thiazide diuretic b) Angiotensin-converting enzyme inhibitor c) Beta-adrenergic blocker d) Calcium channel blocker Explanation: ACE inhibitors work in the kidney in the renin angiotensin aldosterone system and can impair renal excretion of potassium in patients with normal kidney function. In patients with impaired renal blood flow and/or function, the risk of hyperkalemia is increased. Common 77practice is to monitor potassium, BUN, and Cr at about one week after initiation of an ACE inhibitor and with each increase in dosage in a patient who has heart failure and who receives an ACE inhibitor. 322) The major health risk(s) associated with oral contraceptive therapy is (are): a) dysmenorrhea b) cardiovascular events c) infertility d) ovarian cancer Explanation: 323) A 35-year-old women with prior history of extreme nervousness has been treated with diazepam (Valium) for 4 weeks. She shows improvement. Today her pulse is 112 bpm and BP is 130/92 mmHg. She is 5’4”and weight 105 pounds. What is the diagnosis? a) anxiety b) somatization c) Cushing’s syndrome d) hyperthyroidism 324) Of the following characteristics, which are most closely associated with risk for becoming an abusive parent? a) older, following the example set by the previous generation b) young, isolated, with unreasonable expectations of the child c) working full time, feeling pressure to perform multiple duties d) single, working part time, living with parents, attending trade school Explanation: Parents with a lack of social support, a tendency toward depression, multiple stress factors, and a history of abuse are at risk for abusing their own children. Abusive parents often have unrealistic expectations of a child's developmental abilities. 325) A 55-year-old male patient presents with dysuria, urgency, perineal pain, and temperature of 101 degrees. What is most likely diagnosis? a) Cystitis b) Epididymitis c) Urethritis d) Prostatitis Explanation: Findings of acute bacterial prostatitis include fever, chills, in low back pain, as well as the dysuria, increased urgency or frequency of urination an nocturia. epididymitis usually uppers with scrotal edema and pain. 326) Licensure is: a) another term for certification b) contingent on certification c) used to establish minimal competence d) necessary for reimbursement 78Explanation: Licensure is the process by which boards of nursing grant permission to an individual to engage in nursing practice after determining that the applicant has attained the competency necessary to perform a unique scope of practice. Licensure is necessary when the regulated activities are complex and require specialized knowledge and skill and independent decision making. The licensure process determines if the applicant has the necessary skills to safely perform a specified scope of practice by predetermining the criteria needed and evaluating licensure applicants to determine if they meet the criteria. 327) A patient with no significant medical history has varicose veins. She complains of “aching legs.” The intervention that will provide greatest relief for her complaint is to: a) wear support stocking b) avoid prolonged sitting c) elevate her legs periodically d) take two aspirin for pain Explanation: the intervention that will provide the greatest relief for this patient is elevating her legs periodically. This will facilitate venous return. Use of support stockings will prolong the length of time she is able to stand in place, but will not provide relief after her legs begin aching. Support stockings should be applied prior to getting out of bed. 328) an 8-year-old presents to the health clinic with history of acute onset severe sore throat and respiratory rale. The child’s history is positive for fever and pharyngitis for 2 days. What is the most likely diagnosis? a) Mononucleosis b) Asthma c) respiratory syncytial virus (RSV) d) Epiglottitis Explanation: It is unlikely that this child has respiratory syncytial virus (RSV) because of his age and history of pharyngitis. Mononucleosis is rarely accompanied by respiratory distress. Asthma can cause a rapid onset of respiratory distress, but it is not frequently accompanied by stridor and is usually accompanied by cough. With a 2 day history of pharyngitis and fever, it is more likely an infectious condition such as epiglottitis. 329) A mother who has diabetes mellitus wants to breast-feed her infant. The NP should: a) explain that breast-feeding is contraindicated, because anti-diabetic medication is secreted in the breast milk, putting the infant at risk for hypoglycemia b) explain that breast-feeding is unwise, because it places excess physiological stress on the mother c) support the mother decision and recommend more frequent monitoring of blood sugar d) encourage bottle-feeding, as breast-feeding would cause the serum glucose to be too erratic Explanation: Milk production takes a lot of energy, and breast milk is loaded with lactose.. When nursing the baby, the mother’s blood sugar levels may dip by up to 25% causing hypoglycemia. Monitoring the blood sugar more often and snaking before breastfeeding can prevent hypoglycemia. 79330) The treatment of choice for recurrent herpes simplex II infection is: a) topical acyclovir b) soaks with Burrow’s solution c) oral acyclovir d) nonsteroidal anti-inflammatory agents Explanation: Patients who have six or more recurrences of genital herpes per year can be treated with one of the following regimens: acyclovir, 400 mg PO twice daily; valacyclovir, 1 g PO daily; or famciclovir, 250 mg PO twice daily. These regimens are effective in suppressing 70 to 80 % of symptomatic recurrences. 331) A NP is examining a 2-month-old infant. What question is most important to ask: a) Does the infant have siblings? b) Has the umbilical cord stump fallen off yet? c) Was the infant full-term at birth? d) Has the baby had a PKU test? 332) Which of the following liver enzyme values indicative of alcohol-related hepatitis? a) ALT:AST ratio >2.0 b) AST:ALT ratio > 2.0 c) ALT and AST equally elevated d) ALT and AST equally decreased Explanation: The normal AST/ALT ratio in healthy subjects is 0/8. In patients with alcoholic hepatitis, the usual ratio (AST:ALT) IS 2:1. When ALT is very elevated, infectious hepatitis must be considered. Normally, both AST and ALT are less than 40 IU/AL. 333) Which of the following is TRUE concerning sensitivity and specificity? a) Assessment techniques must be highly sensitive and highly specific to be useful b) Sensitivity relates to the reliability of a technique to give a positive result when the finding is present. Specificity relates to the reliability of a technique to successfully rule out a finding c) Sensitivity relates to the reliability of a technique to successfully rule out a finding. Specificity relates to the reliability of a technique to give a positive result when the finding is present. d) A test of high sensitivity will fail to determine a finding in many patients. A test of high specificity tends to produce false positive results Explanation: Sensitivity the test's ability to detect people who DO HAVE disease. Specificity how well does the Test do at correctly identify people who is disease FREE. 334) Which antibiotic is demonstrated to be the most effective treatment for community acquired pneumonia (CAP) in young adults with co-morbid conditions? a) sulfa b) clarithromycin (Biaxin) c) cefuroxime (Ceftin) d) penicillin 80Explanation: Clarithromycin is an antibiotic recommended by the American Thoracic Society for treatment of community acquired pneumonia (CAP) in young adults without co-morbid conditions. Clarithromycin provides antimicrobial activity against Streptococcus pneumoniae, the most common causative organism in CAP, and provides coverage for other less common pathogens, including Mycoplasma pneumoniae, Chlamydia pneumoniae, and Legionella pneumophlia 335) Infants with celiac disease (gluten enteropathy) are at risk for multiple complications. The most urgent complication of this disease is: intussusception or volvulus Explanation: Intussusception and volvulus are surgical emergencies. Delay releasing the invaginated or “telescoped” bowel (intussusception) or releasing the twisted bowel (volvulus) may result in tissue death and gangrene, perforation, peritonitis, and/or sepsis, and fatality. There is also a high rate of intussusception and volvulus among infants with cystic fibrosis. 336) Prescriptive authority for APRN is: Legislative and regulated at the state level Uniform for all states Governed by the state medical board Regulated by federal and state laws 81