Final

Question 1

Which of the following is listed as one of the DSM-5 criteria for opioid use disorder?

More than 5 visits to the ER for opioid prescription

Unsuccessful attempts to limit or control opioid use

Taking prescription opioids for reasons other than controlling pain

Frequent insomnia requiring use of sleeping aid or sedative

Answer 1

Unsuccessful attempts to limit or control opioid use

-Opioids are often taken in larger amounts or over a longer period of time than
intended.
-There is a persistent desire or unsuccessful efforts to cut down or control opioid
use.
-Recurrent opioid use resulting in failure to fulfill major role obligations at work,
school or home.

Question 2

Using the DSM criteria, you identify opioid use disorder (OUD). You discuss your diagnosis with your patient. Which of the following would be an appropriate initial step?

Stop all opioids and offer non-opioid pain medication

Admit to the hospital for management of opioid withdrawal

Continue to prescribe medication and refer for psychosocial treatment

Assess readiness to quit and document last opioid use

Answer 2

Assess readiness to quit and document last opioid use

Determine if the patient is ready and willing to start treatment for their opioid use. If the patient is not ready to stop, share your concerns about their ongoing opioid use, the risk of overdose, medical complications, and offer harm-reduction techniques (e.g. a naloxone kit).

Question 3

You obtain a POCT positive for heroin on your patient you are treating with opioids. When you walk back into the room, your patient tells you they used heroin recently. Do you send a confirmation sample to the laboratory?

Yes
No

Answer 3

No. Test will remain positive for several days and patient already confirmed using heroin.
Next focus on the patient’s well-being and safety. Discuss the risks associated with taking heroin with other opioids and provide protective interventions (e.g. naloxone).

Question 4

Which of the following opioid risk assessment tools could be used in practice?

A. Current Opioid Misuse Measure (COMM)
B. Opioid Risk Tool (ORT)
C. Patient Medication Questionnaire (PMQ)
D. All of the above

Answer 4

All of the above

Assessment requires the providers use a standardized systematic approach to all patients who will be receiving (or are at risk of misusing) opioids.

-The COMM is a 17-question patient assessment tool designed to identify ADRB’s during chronic opioid therapy. Each of the 17 items is scored 0–4 points. Total score can range from 0–68. A score of ≥9 is suggestive of current ADRB with 77% sensitivity and 66% specificity.

-ORT is a 5-question screening tool designed for use in adults to assess the risk for opioid abuse or ADRB. A score is given for a range of responses on each of the 5 items and the total used to predict for low, moderate or high risk for ADRB.

-The PMQ is a 26-question assessment tool using 0–4 point scale to assess for ADRB in patients already taking opioid medications for pain. Scores can range from 0–104. In the derivation study, a score <25 is considered low risk for opioid misuse, 25–30 indicates problematic use, and >30 close monitoring and consideration of titrating the patient off opioids.

Question 5

Which of the following is most associated with neuropathic pain:

A. Shooting, tingling
B. Aching, stabbing
C. Poorly localized cramping
D. Localized dull ache

Answer 5

Shooting, tingling

Neuropathic pain experience may vary from person to person but often include the following:
-shooting, burning, or stabbing pain
-tingling and numbness, or a “pins and needles” feeling
-spontaneous pain, or pain that occurs without a trigger

Question 6

Which of the following is an example of a non-opioid adjuvant medication for pain?

Gabapentin starting at 300 mg at bedtime

Tramadol 50 mg every 6 hours as needed for pain

Meperidine 50 mg every 4 hours

Codeine 15 mg every 6 hours as needed for pain

Answer 6

Gabapentin starting at 300 mg at bedtime

Drug Class: Anticonvulsant - GABA Analogs

Gabapentin has FDA approval for:

-Postherpetic neuralgia
-Adjunctive therapy in the treatment of partial seizures with or without secondary generalization in patients over the age of 12 years old with epilepsy, and the pediatric population, 3 to 12 year-olds with a partial seizure
-Moderate to severe restless leg syndrome (RLS) moderate to severe

Question 7

Which of the following is NOT an alarm symptom in peptic ulcer disease?

Unintentional weight loss

Anemia

Epigastric discomfort 2-3 hours after eating

Swallowing difficulty (dysphagia) or odynophagia (painful swallowing)

Answer 7

Epigastric discomfort 2-3 hours after eating

Alarm symptoms for PUD include the following:
* Unintentional weight loss
* Progressive dysphagia
* Overt gastrointestinal bleeding
* Iron deficiency anemia
* Recurrent emesis
* Over age 55 and/or family history of upper gastrointestinal malignancy

Question 8

Which of the following are the main risk factors for peptic ulcer disease?

H. pylori and NSAID use

Gastric malignancies

Omeprazole and acetaminophen use

Decreased gastric motility

Answer 8

H. pylori and NSAID use

-H. pylorus is a gram-negative bacillus that is found within the gastric epithelial cells. This bacterium is responsible for 90% of duodenal ulcers and 70% to 90% of gastric ulcers.
-Nonsteroidal anti-inflammatory drugs use is the second most common cause of PUD after H. pylori infection. NSAIDs block prostaglandin synthesis that normally protects the gastric mucosa.

Question 9

In GERD, without any alarm symptoms, what is an appropriate initial plan:

Endoscopy

8-week trial of PPI

Referral to surgery for diagnosis and possible anti-reflux surgery

Omeprazole 20 mg BID, bismuth subsalicylate 525 mg q6h, metronidazole 250mg every 6h, tetracycline 500 mg every 6h.

Answer 9

8-week trial of PPI

-Lifestyle modifications include weight loss, tobacco smoking cessation, reduction is alcohol intake, avoiding late evening meals, and elevation of the head of the bed.
-PPIs block acid production in the stomach, providing relief of symptoms and promote healing. The goal is to use the shortest course of treatment possible to relieve symptoms and promote healing of PUD.
-First-line treatment for H. pylori-induced PUD is a triple regimen comprising two antibiotics and a proton pump inhibitor. Pantoprazole, clarithromycin, and metronidazole, or amoxicillin are used for 7 to 14 days.

Question 10

The nurse practitioner knows that Crohn’s disease affects:

Colon only

Anywhere from the mouth to the anus

Anywhere from the stomach to the anus

The large intestines

Answer 10

Anywhere from the mouth to the anus

-Crohn’s disease most commonly occurs in the small intestine and the colon, but can affect any part of the GI tract (from the mouth to the anus).
-Crohn’s Disease is characterized by “skip” lesions and will extend through the layers of the intestinal mucosa

Question 11

What is the most common cause of melena?

Upper GI bleeding

Gastroesophageal reflux disease

GI malabsorption disease

Colon cancer

Answer 11

Upper GI bleeding

Melena refers to black stools that occur as a result of upper GI bleeding.
Melena often results from damage to the upper GI tract lining (PUD, NSAIDs, and tumors), swollen blood vessels (varices), or bleeding disorders (hemophilia and thrombocytopenia).

Question 12

Which of the following should the nurse practitioner consider a diagnosis GERD:

A patient presenting with heartburn and regurgitation

A patient with epigastric pain as their only symptom

A patient with complaints of burping and bloating

A patient with nausea and vomiting

Answer 12

A patient presenting with heartburn and regurgitation

Question 13

Which of the following are considered first line medication for GERD:

Omeprazole

Esomeprazole

Pantoprazole

All of the above

Answer 13

All of the above
-For patients with classic GERD symptoms of heartburn and regurgitation who have no alarm symptoms, we recommend an 8-week trial of empiric PPIs once daily before a meal (strong recommendation, moderate level of evidence).
-We recommend attempting to discontinue the PPIs in patients whose classic GERD symptoms respond to an 8-week empiric trial of PPIs (conditional recommendation, low level of evidence).

Question 14

Your patient has recently been diagnosed with GERD. You recognize there is a need for further patient education when she tells you:

She is going to quit smoking

She will have a small snack just prior to bedtime

Patients diagnosed with GERD should avoid eating meals within 2–3 hours of bedtime.

She is going to elevate her head of bed with cinderblocks

All of the above

Answer 14

She will have a small snack just prior to bedtime

Question 15

Pain in the left lower quadrant of the abdomen is associated with the diagnosis of:

A. Crohn disease
B. Peptic ulcer disease
C. Diverticulitis
D. Cholelithiasis

Answer 15

Diverticulitis

A sudden pain in the lower left side of the abdomen is the most common symptom diverticulitis. Other symptoms may include:
* Nausea
* Vomiting
* Fever
* Bloating or increased flatus
* Constipation

Question 16

In a patient who presents in your clinic with a complaint of chest discomfort, what is the priority diagnosis to eliminate?

A. Peptic ulcer disease
B. Cardiac conditions
C. Gastroesophageal reflux disease
D. Diverticulosis

Answer 16

Cardiac conditions

Always rule out the differential diagnosis that may cause the patient the greatest harm and that can become a medical emergency (MI, PE, GI perforation). Patient experiencing cardiac symptoms should be transferred to a higher level of care if you are unable to complete the appropriate medical work up in your clinical setting.

Question 17

In a patient presenting with abdominal pain, bloating, and diarrhea described as small volumes of loose stool for longer than 6 months, which of the following list of differential diagnoses is most appropriate?

Irritable bowel disease, celiac disease, and lactose intolerance

Irritable bowel disease, toxic megacolon, and endometriosis

Gastroesophageal reflux disease, irritable bowel syndrome, and lactose intolerance

Irritable bowel syndrome, diverticulosis, and colon cancer

Answer 17

Irritable bowel disease, celiac disease, and lactose intolerance

-Symptoms of IBS include cramping, abdominal pain, bloating, gas, diarrhea and constipation.
-IBS and lactose intolerance can sometimes have similar symptoms, such as diarrhea, bloating, and gas. However, symptoms of lactose intolerance only occur when you consume dairy products.
-Celiac disease is an autoimmune condition, triggered by the exposure of the body to gluten, that damages damage the lining of the bowel and may impair the body’s ability to absorb important nutrients.
-Common symptoms of megacolon include constipation, bloating, and abdominal pain .
-Symptoms of colon cancer may include the following:
-A change in bowel habits (diarrhea, constipation, or narrowing of the stool) that lasts for more than a few days
-A feeling of incomplete emptying after a bowel movement
-Rectal bleeding with bright red blood
-Blood in the stool (dark brown or black)
-Cramping or abdominal discomfort
-Weakness and fatigue
-Unexplained weight loss

Question 18

Which of the following is a true statement?

All individuals over the age of 19, with suspected irritable bowel syndrome, should undergo colonoscopy

All individuals with suspected irritable bowel syndrome should be tested for food allergies

All individuals should have a careful review of their clinical history with a focus on key symptoms, a physical exam, and minimal diagnostic testing in order to diagnose irritable bowel syndrome

All individuals with suspected irritable bowel syndrome should be routinely tested for parasitic infections

Answer 18

All individuals should have a careful review of their clinical history with a focus on key symptoms, a physical exam, and minimal diagnostic testing in order to diagnose irritable bowel syndrome

A positive diagnostic strategy for IBS involves a careful history (allergies, medical, surgical, social, and family), physical examination, and the use of a standard definition to make a diagnosis, with limited diagnostic tests.

-serologic testing be performed to rule out celiac disease in patients with IBS and diarrhea symptoms.
-Two fecal-derived markers of intestinal inflammation, fecal lactoferrin (FL) and fecal calprotectin (fCal) are safe, noninvasive, generally available, and can identify IBD with good accuracy.
-Colonoscopy is not recommended unless patient has other alarm symptoms that require further evaluation.

Question 19

Which of the following is a true statement?

Advise patients with a history of diverticulitis to avoid nuts and seeds

If a colonoscopy is to be obtained, wait until about 6-8 weeks after resolution of symptoms of diverticulitis

If the patient has undergone a CT for diagnosis of diverticulitis, a follow-up colonoscopy is not needed to exclude colonic neoplasm

In a patient with established cardiovascular disease and a history of diverticulosis, avoid aspirin

Answer 19

If a colonoscopy is to be obtained, wait until about 6-8 weeks after resolution of symptoms of diverticulitis

Colonoscopy is the most useful method of determining the presence and extent of diverticulosis and can be vital to the diagnosis and management of diverticular diseases.
Diverticular disease can increase the difficulty of colonoscopy due to luminal narrowing, angulations, colon spasm, and difficulty with insufflation.
Current treatment guidelines recommend diagnostic colonoscopy (generally 6-8 weeks following improvement of an episode of acute diverticulitis) in patients who have not had a high-quality colonoscopy in the last 1-2 years.

Question 20

Which of the following increases a person’s risk for colorectal cancer?

A. Familial polyposis
B. Daily aspirin use
C. Daily caffeine intake
D. Plant-based diet

Answer 20

A. Familial polyposis

About 1 in 4 colorectal cancer patients have a family history of colorectal cancer.
The most common types of hereditary colorectal cancer are the following:

-Lynch syndrome (Hereditary Non-polyposis Colorectal Cancer, HNPCC)
-a subset of Lynch syndrome called Muir-Torre syndrome (MTS)
-MUTYH-associated polyposis syndrome (MAP syndrome)
-Familial adenomatous polyposis (FAP)

Question 21

You are seeing a patient with a chief complaint of four months of intermittent GI irritation. They tell you that they have stomach burning about 2-3 hours after eating a meal. The burning stays localized to the upper abdomen. They do not feel that what they eat makes any difference. This presentation is most associated with which of the following?

A. Peptic ulcer disease
B. Cholecystitis
C. GERD
D. Angina

Answer 21

A. Peptic ulcer disease

Epigastric pain usually occurs within 15-30 minutes following a meal in patients with a gastric ulcer.
Pain due to a duodenal ulcer tends to occur 2-3 hours after a meal, when the GI tract is empty and no food to buffer the acid.

Question 22

You are seeing a patient with a chief complaint of four months of intermittent GI irritation. They tell you that they have retrosternal burning that migrates up their neck shortly after eating large meals. They can get a sour taste in their mouth, especially if they lay down or bend over after a meal. This presentation is most associated with which of the following?

A. Peptic ulcer disease
B. Cholecystitis
C. GERD
D. Angina

Answer 22

C. GERD

Heartburn is the most common GERD symptom and is described as substernal burning sensation rising from the epigastrium up toward the neck. Regurgitation is the effortless return of gastric contents upward toward the mouth, often accompanied by an acid or bitter taste.

Question 23

You are asked to see a patient in a nursing home who complains of pain that started in the periumbilical region and migrated to the right lower quadrant. After the pain started, they developed nausea and vomiting. On physical exam the right lower quadrant is tender to touch. What is the most likely diagnosis?

A. Cholecystitis
B. Appendicitis
C. Peptic ulcer disease
D. Pancreatitis

Answer 23

B. Appendicitis

Acute appendicitis (AA) is among the most common causes of lower abdominal pain leading patients to attend the emergency department.
Appendicitis starts with pain around the umbilicus and progresses to the right lower abdomen or pelvis in a few hours.
Other symptoms may include:

-Nausea, vomiting, fever, tachycardia, and foul breath
-Constipation is a common and occasionally diarrhea
-Frequent urination (contact with inflamed appendix and the bladder)

Question 24

You are asked to see a patient in the infusion center who is receiving treatment for Crohn disease. The patient reports intermittent crampy periumbilical abdominal pain with nausea and vomiting. Physical exam reveals orthostatic hypotension and tachycardia, abdominal distention and high-pitched “tinkling” bowel tones. Which is the most likely diagnosis?

A. Peptic ulcer disease
B. GERD
C. Appendicitis
D. Small bowel obstruction

Answer 24

D. Small bowel obstruction

A small bowel obstruction is a partial or complete blockage of the small intestine, which can be caused by adhesions, hernia, malignant tumors, and inflammatory bowel disorders.
Patients presenting with abdominal pain, nausea, abdominal distention, vomiting, and/or obstipation/constipation, should be evaluated for a small bowel obstruction (SBO).
Examine the abdomen for signs of distention, pain, masses, non-reducible hernias, surgical scars, or tenderness.

Question 25

Dysphagia and unintentional weight loss are classic signs of which diagnosis? A. Peptic ulcer disease B. GERD C. Esophageal carcinoma D. Inflammatory bowel disease

Answer 25

C. Esophageal carcinoma The most common symptoms of esophageal cancer are: -Difficulty swallowing -Chest pain -Unintentional weight loss -Hoarseness -Chronic cough -Vomiting -Bone pain -Melena due to bleeding from esophagus

Question 26

It is recommended that patients with long-standing GERD (> 5 years) undergo evaluation for Barrett’s esophagus. True False

Answer 26

True Barrett's esophagus occurs as the result of persistent reflux of stomach acid into the lower esophagus, which can damage the inner lining of the esophagus. This causes the squamous cells that normally line the esophagus to be replaced with gland cells that are more resistant to stomach acid. The risk of esophageal cancer in patients with Barrett's esophagus is approximately 0.5 percent per year (or 1 out of 200). However, periodic endoscopies may be required to monitor for early signs of dysplasia.

Question 27

All diverticulitis must be treated with antibiotics. True False

Answer 27

False Diverticulitis can be uncomplicated or complicated. Uncomplicated diverticulitis involves thickening of the colon wall and peri-colonic inflammatory changes. Complicated diverticulitis additionally includes the presence of abscess, peritonitis, obstruction, stricture and/or fistula. -Antibiotic treatment can be used selectively rather than routinely in immunocompetent patients with mild acute uncomplicated diverticulitis. -Antibiotic treatment is advised in patients with uncomplicated diverticulitis who have comorbidities or are frail, who present with refractory symptoms or vomiting, or who have a CRP >140 mg/L or baseline white blood cell count > 15 × 109 cells per liter. -Antibiotic treatment is advised in patients with complicated diverticulitis or uncomplicated diverticulitis with a fluid collection or longer segment of inflammation on CT scan. When antibiotic treatment is necessary, the regimen usually includes broad spectrum agents with gram-negative and anaerobic coverage. In the outpatient setting, treatment of mild uncomplicated diverticulitis most commonly includes either a combination of an oral fluoroquinolone and metronidazole or monotherapy with oral amoxicillin-clavulanate. The duration of treatment is usually 4–7 days but can be longer.

Question 28

Gross rectal bleeding is most likely to be caused by early-stage colorectal cancer. True False

Answer 28

False Bleeding often occurs with late stage colorectal cancers. Common causes of rectal bleeding include: * Anal fissure * Constipation * Hemorrhoids * Diverticular disease * Trauma or foreign body

Question 29

Which of the following best describes migraine type headaches? A. Most commonly seen in men starting in their 20s. Usually unilateral and occurring around the eye and associated with ipsilateral conjunctival injection, lacrimation, nasal congestion or rhinorrhea. B. Throbbing, often unilateral, associated with photophobia and/or phonophobia or nausea, and vomiting. More common and more severe in women, headache can last 4-72 hours. C. A common type of headache. Generally described as bilateral and squeezing. Nausea is absent and pain is relieved with OTC analgesics. Not associated with any disability. D. Occurs in the morning, often in patients with diabetes with recent medication or diet changes or in individuals with obesity and daytime somnolence.

Answer 29

B. Throbbing, often unilateral, associated with photophobia and/or phonophobia or nausea, and vomiting. More common and more severe in women, headache can last 4-72 hours. Migraines are a common disorder that affects 12 to 15 percent of the general population. Migraines are most common in woman and in those aged 30 to 39. Migraine without aura is the most common type, accounting for approximately 75 percent of cases. Migraines also tend to run in families. a- cluster headache c- tension headache d- medical associated (hypoglycemia, OSA)

Question 30

Which of the following are considered red flag symptoms in patients with headache? (select all that apply) A. Systemic symptoms: fever, rash, myalgia, unexplained weight loss B. Current or history of neoplasm (cancer) C. Neurological deficit (seizures or cognitive changes) D. New onset in patients >50 years old

Answer 30

A. Systemic symptoms: fever, rash, myalgia, unexplained weight loss B. Current or history of neoplasm (cancer) C. Neurological deficit (seizures or cognitive changes) D. New onset in patients >50 years old Although 80% to 90% of headaches are primary headaches, it’s important to recognize the red flags of a secondary headache. Secondary headaches are caused by an underlying illness, medication or other factors, such as a brain tumor, blood clot, stroke, change in brain pressure or toxic exposure. Providers can use the mnemonic “SNOOP4” to remember the red flags of secondary headache. -Systemic symptoms (fevers, sweats) -Neurological symptoms ( weakness in one arm or leg, numbness, or any visual changes) -Onset is sudden (thunderclap headache, which comes on suddenly at a maximum 10/10) -Progression ( a clear progression of becoming more severe or more frequent) -Papilledema (welling of the optic nerve on a fundoscopic exam, can be an indication of increase in ICP) -Positional or Precipitated by Valsalva maneuver (pressure issue or a problem related to a mass) -Pregnancy (evaluated for pituitary or vascular abnormalities) Correct!

Question 31

Which is most associated with the diagnosis of migraine? A. Mild pain severity B. Aggravated by or causes avoidance of routine physical activity C. Temporal artery tenderness in elderly patients D. Stiff neck

Answer 31

Aggravated by or causes avoidance of routine physical activity The clinical features that appear to be most predictive of migraine include nausea, photophobia, phonophobia, and exacerbation by physical activity a- migraine in mod-severe c- giant cell arteritis d- hemorrhage or meningeal irritation

Question 32

Which of the following would you expect to see prescribed for abortive treatment in migraine with moderate to severe pain and no nausea or vomiting? A. Propranolol 20 mg BID B. Gabapentin 100 mg TID C. Sumatriptan 50 mg by mouth, can repeat if no improvement in 2 hours D. Valproate 250 mg BID, can increased by 250 mg/day every 3 days

Answer 32

C. Sumatriptan 50 mg by mouth, can repeat if no improvement in 2 hours Treatment for moderate to severe migraine attacks not associated with vomiting or severe nausea are treated with oral migraine-specific agents as first-line therapy, including oral triptans and the combination of sumatriptan-naproxen.

Question 33

Oxygen would be appropriate in which type of headache. A. Migraine B. Tension headache C. Primary cough headache D. Cluster headache

Answer 33

D. Cluster headache Oxygen (100 %) is administered via a nonrebreathing facial mask with a flow rate of at least 12 L/minute with the patient in a sitting, upright position. The inhalation should continue for 15 minutes to prevent the attack from returning, although the pain may subside as soon as five minutes after starting oxygen. Oxygen is generally safe and without side effects. However, patients with severe chronic obstructive pulmonary disease should not be treated with inhaled oxygen because of the risk for developing severe hypercapnia.

Question 34

Which of the following represents the classic presentation of nephrolithiasis? A. Renal colic and hematuria B. Flank pain, fever, and pyuria C. Colic with abdominal tenderness D. Flank pain with a unilateral vesicular eruption of a rash

Answer 34

A. Renal colic and hematuria The most characteristic symptoms of nephrolithiasis are pain, hematuria, nausea, and vomiting. The classic presentation of pain in patients with nephrolithiasis is severe ureteral colic. This pain is often of abrupt onset and intensifies over time into an excruciating, severe flank pain that resolves with stone passage or removal. b- pyelonephritis c- diverticulitis or appendicitis d- herpes zoster

Question 35

You are working in college health center seeing a 20-year-old female patient with new onset hematuria and unilateral flank pain that comes in waves. What diagnostic test should the NP order first? A. CT of abdomen without contrast B. CT of the abdomen with contrast C. Abdominal ultrasound D. hCG, urine

Answer 35

D. hCG, urine Begin by ruling out possible pregnancy. Signs of ectopic pregnancy include the following: * Abdominal pain * One sided pelvic pain * Bleeding * Dizziness/fainting

Question 36

Your patient is out of town at a convention. She calls and tells you that she started having right upper quadrant abdominal pain with radiation to her right shoulder about 12 hours ago. She has chills and believes she has fever. She had a similar episode to this about a year ago after she went to the state fair and ate a lot of fatty foods. You ask her to press on her right upper quadrant and she tells you that it hurts to press. What is the most likely diagnosis? A. Acute hepatitis B. Hemorrhoids C. Acute cholecystitis D. Cholelithiasis

Answer 36

C. Acute cholecystitis A positive Murphy's sign can be seen with acute cholecystitis.

Question 37

Which of the following is most likely to be found in acute cholecystitis? A. Palpable gall bladder B. Negative Murphy’s sign C. Elevated serum creatinine D. Vomiting

Answer 37

D. Vomiting Patients with acute cholecystitis usually present with severe and steady abdominal pain in the right upper quadrant or epigastrium, fever, and leukocytosis. A positive Murphy's sign on physical examination supports the diagnosis. Patients should remain NPO and those who are vomiting should undergo NGT placement.

Question 38

You are working in a clinic in the local high school. You are called because one of the cheerleaders took a significant fall while practicing stunts for an upcoming cheer competition. Which of the following is important history to obtain? A. The timing and exact mechanism of the injury B. The stability and progression of symptoms C. Medical history and medications D. All of the above

Answer 38

D. All of the above It is important to establish a baseline level of health by reviewing the students medical history and medications. The primary assessment of a patient with trauma in the field follows the ABCD prioritization scheme: Airway, Breathing, Circulation, Disability (neurologic status). If the patient has a head injury, is unconscious or confused, or complains of spinal pain, weakness, and/or loss of sensation, then a traumatic spinal injury should be assumed

Question 39

Which of the following is correct about asymptomatic bacteriuria in nonpregnant patients? Prescribe nitrofurantoin (Macrobid) 100 mg BID for 5 days Do not treat asymptomatic bacteriuria in nonpregnant adults Pyuria (> 10 leukocytes/microL of urine) is diagnostic for acute cystitis Recommend boric acid vaginal suppositories

Answer 39

Do not treat asymptomatic bacteriuria in nonpregnant adults. The term asymptomatic bacteriuria refers to isolation of bacteria in an appropriately collected urine specimen from an individual without symptoms of urinary tract infection. Most nonpregnant patients with asymptomatic bacteriuria should not be screened or treated for asymptomatic bacteriuria.

Question 40

You are working in a clinic in the local high school. A student comes to see you complaining of increased frequency, urgency, dysuria, and suprapubic discomfort for three days. Denies rigors, fever, flank pain, and nausea. She is not sexually active and denies concern for sexually transmitted infections. What is the most likely diagnosis? A. Acute cystitis (Uncomplicated urinary tract infection) B. Pyelonephritis (Complicated urinary tract infection) C. Atrophic vaginitis D. Cholecystitis

Answer 40

A. Acute cystitis (Uncomplicated urinary tract infection) Women categorized as having acute uncomplicated cystitis according to traditional definitions would fall under the definition of acute simple cystitis that we use here. The infection is confined to the bladder and lacks features that suggest a systemic infection * Fever (>99.9°F/37.7°C) * Chills * Rigors * Marked fatigue or malaise beyond baseline * Flank pain * Costovertebral angle tenderness

Question 41

Which symptom is central to the diagnosis of UTI? A. Urgency B. Frequency C. Incontinence D. Dysuria

Answer 41

D. Dysuria Symptoms of cystitis (dysuria, urinary urgency, and/or urinary frequency) along with fever (>99.9ºF/37.7ºC) or other signs or symptoms of systemic illness, such as chills, rigors, or acute mental status changes. In such cases, pyuria and bacteriuria support the diagnosis.

Question 42

In older adults which of the following should be on the nurse practitioner’s differential diagnosis list with the complaint of urinary incontinence? A. Stool impaction B. Hyperglycemia C. Atrophic vaginitis D. All of the above

Answer 42

D. All of the above A targeted history and physical examination can often identify the cause of UI and lead to appropriate intervention. A targeted physical would include an assessment for fluid overload, genital and rectal examination, and neurologic evaluation. Diabetes approximately doubles the risk for severe incontinence in women. Spinal cord disorders can lead to overflow urinary incontinence. Other neurologic disorders that can lead to urinary incontinence include the following: * Stroke * Parkinson disease * Normal pressure hydrocephalus

Question 43

Involuntary loss of urine during coughing is the definition for: A. Urinary urgency B. Stress incontinence C. Functional incontinence D. All of the above

Answer 43

B. Stress incontinence Stress urinary incontinence is associated with urine loss (small or large) with increases in intraabdominal pressure due to the following: * Laughing * Coughing * Sneezing

Question 44

Inability to delay voiding after sensation of bladder fullness is the definition for: A. Urinary urgency B. Stress incontinence C. Functional incontinence D. All of the above

Answer 44

A. Urinary urgency Urinary urgency (overactive bladder) is associated with frequency, small volume, and a strong urge to void with an inability to make it to the bathroom in time. * May keep the patient up at night * May worsen after taking a diuretic

Question 45

Because older adults live rather sedentary lives, they are at very low risk for traumatic brain injury and the consequences of TBI. True False

Answer 45

False Falls are the most common cause of injury in patients over the age of 65. Most head trauma in older adult patients is associated with falls.

Question 46

Which is true for the nurse practitioner caring for older adult post-TBI? A. Prescribe lorazepam for agitation and anxiety B. Limit social interaction for a calming environment C. Assess suicide ideation D. Talk therapy is not effective in older adults

Answer 46

C. Assess suicide ideation Older adult patients with severe traumatic brain injury (sustained Glasgow Coma Scale <9) have at least an 80 % likelihood of death or major disability leading to placement in a long-term care facility.

Question 47

Which of the following is associated with sepsis in the person who is over age 18? A. Altered mental state or behavior B. No urine passed in last 12-18 hours C. Heart rate 80-100 beats/minute D. Both A & B

Answer 47

D. Both A & B The signs and symptoms associated with sepsis are often nonspecific but may include the following: -Specific to an infectious source (e.g. UTI, pneumonia, or non-healing surgical wound) -Systolic blood pressure <90 mmHg, mean arterial pressure <70 mmHg -Temperature >38.3 or <36ºC -Heart rate >90 beats/min -Tachypnea (rate >20 breaths/minute) -Signs of end-organ perfusion: -Warm, flushed skin may be present in the early phases of sepsis -As sepsis progresses to shock, the skin may become cool due to redirection of blood flow to core organs (e.g. decreased capillary refill, cyanosis, or mottling) -Additional signs of hypo perfusion include -Altered mental status -Obtundation or restlessness -Oliguria or anuria. -Ileus or absent bowel sounds (end-stage)

Question 48

Who is at risk for sepsis? Select all that apply Correct! A. A 71-year-old patient B. A patient diagnosed with type 2 diabetes C. A patient diagnosed with chronic bronchitis D. A 40-year man with alcoholism and malnutrition

Answer 48

A. A 71-year-old patient -Older patients ≥65 years of age account for the majority (60 to 85 %) of all episodes of sepsis. B. A patient diagnosed with type 2 diabetes -Obesity and type 2 diabetes are associated with an increased risk of recurrent, nosocomial, and secondary infections that lead to sepsis. Individuals with obesity have a higher risk of community acquired pneumonia, biliary disease, cutaneous infections, and aspiration pneumonia during hospitalizations. C. A patient diagnosed with chronic bronchitis -Patients with COPD have been reported to be at a higher risk of developing sepsis due to the use of corticosteroids, underlying comorbidities, and possibly impaired barrier function D. A 40-year man with alcoholism and malnutrition -Alcohol has widespread effects on the immune system and patients are at an increased risk of a variety of infections.

Question 49

You are caring for a 28 year-old person with HIV infection. Their CD4 cell count is > 200 cells/microL. They received one dose of PPSV23 one year ago and no other pneumococcal immunizations. Which of the following is an appropriate plan? Give one dose of live attenuated influenza vaccine. They require no further pneumococcal vaccines. Give a second dose of PPSV23 at age 32 Give a second dose of PPSV23 at age 32 and give third dose of PPSV23 at age 65 Give a second dose of PPSV by age 33 and give third dose of PPSV23 at age 65.

Answer 49

Give a second dose of PPSV by age 33 and give third dose of PPSV23 at age 65. If the patient was younger than 65 years old when the first dose of PPSV23 was given and has not turned 65 years old yet, administer a second dose of PPSV23 at least 5 years after the first dose of PPSV23. This is the last dose of PPSV23 that should be given prior to 65 years of age.

Question 50

You are an occupational health nurse who is seeing an LPN who was had contact with a resident with infectious TB disease. The TST was 23 mm, they have no symptoms and chest x-ray was normal. Which of the following is an appropriate diagnosis? A. TB disease B. Prodromal TB disease C. Latent TB D. No signs of TB disease

Answer 50

C. Latent TB Average timeline for developing TB infection after a clinical exposure: TST conversion occurs three to eight weeks later *Health care workers with a baseline TST of 0 mm oTST ≥5 mm is considered a positive result *HCWs with a baseline TST result >0 mm but <10 mm oTST ≥10 mm is considered a positive result Latent TB infection: Mycobacterium tuberculosis, is initially suppressed by the individual's immune system *infection may remain in a prolonged, suppressed state termed "latency" *latent infection has the potential to develop into active infection at any time

Question 51

You are reviewing a positive (reactive) interferon gamma release assay (IGRA) blood test. The nurse practitioner knows: A. This is diagnostic for latent TB B. This is diagnostic for TB disease C. Additional tests are needed to determine latent TB or active TB disease D. Indicates that TB disease is not likely

Answer 51

C. Additional tests are needed to determine latent TB or active TB disease IGRAs are in vitro blood tests of cell-mediated immune response *measure T cell release of interferon-gamma following stimulation by antigens unique to Mycobacterium tuberculosis and a few other mycobacteria *IGRA results can be available in 24 to 48 hours *Cannot distinguish between latent infection and active TB disease and should not be used for diagnosis of active TB, which is a microbiologic diagnosis

Question 52

You are a nurse practitioner working in a prison. You are seeing a patient with 2-3 weeks of productive cough with blood. They have a fever, unintentionally lost 10 pounds, and report night sweats and malaise. What is the most likely diagnosis? A. Pneumonia B. COPD C. Asthma D. Pulmonary tuberculosis

Answer 52

D. Pulmonary tuberculosis The diagnosis of pulmonary TB is definitively established by isolation of M. tuberculosis from a bodily secretion or fluid (eg, culture of sputum, bronchoalveolar lavage, or pleural fluid) or tissue (eg, pleural biopsy or lung biopsy). *Cough (especially if lasting for 3 weeks or longer) with or without sputum production *Hemoptysis *Chest pain *Loss of appetite *Unexplained weight loss *Night sweats *Fever *Fatigue

Question 53

You are a nurse practitioner in correctional health. You are called by a nurse who is concerned about a possible reaction a patient is having to isoniazid. Which symptoms does not indicate an adverse reaction to isoniazid (INH): A. Vomiting B. Nasal congestion C. Tingling or burning in their toes D. Dark urine

Answer 53

B. Nasal congestion Common of side effects of INH: * Peripheral neuropathy * Hepatitis * Nausea * Vomiting * Diarrhea * Pyridoxine deficiency * Dyspepsia * Abnormal hepatic function tests * Gastrointestinal irritation

Question 54

Which of the following is an appropriate option for treating latent TB infection in non-pregnant and HIV-uninfected people? A. Isoniazid (INH) daily for 9 months B. Isoniazid (INH) and rifapentine (RPT) given in 12 once-weekly doses under directly observed treatment C. Rifampin (RIF) daily for 4 months D. All of the above

Answer 54

D. All of the above Rifamycin-based regimens: * Rifampin 10 mg/kg (600 mg maximum) orally daily for 4 months * Isoniazid 5 mg/kg (300 mg maximum) orally daily for 3 months * Rifampin 10 mg/kg (600 mg maximum) orally daily for 3 months * Isoniazid (orally once weekly for 3 months; direct observation is preferred): o15 mg/kg, rounded up to the nearest 50 or 100 mg; 900 mg maximum Isoniazid monotherapy regimens: * Isoniazid 5 mg/kg (300 mg maximum) orally daily for 9 months * Isoniazid 5 mg/kg (300 mg maximum) orally daily for 6 months * Isoniazid 15 mg/kg (900 mg maximum) orally twice weekly for 9 or 6 months

Question 55

Which of the following is at high risk for becoming infected with M. tuberculosis: People who have come to the US in the last 25 years from areas of the world where TB is common People who have unprotected sex People with prior diagnosis of hepatitis B People who live or work in congregate setting with individuals at increased risk for TB disease

Answer 55

People who live or work in congregate setting with individuals at increased risk for TB disease Close contact with an individual with smear-positive pulmonary TB is the most important risk factor for TB.

Question 56

Which of the following is most likely to be discovered in a person with colorectal cancer? A. Pernicious anemi B. Folate-deficiency anemia C. Iron deficiency anemia D. Aplastic anemia

Answer 56

C. Iron deficiency anemia Anemia may be one of the first signs of a developing malignancy.

Question 57

This treatment uses antiretroviral medication to prevent HIV infection in an HIV-negative person who has infrequent exposure to HIV. This best describes which of the following: A. Pre-exposure prophylaxis (PrEP) B. Post-exposure prophylaxis (PEP) C. HIV screening D. None of the above

Answer 57

B. Post-exposure prophylaxis (PEP) Antiretroviral drugs after a single high-risk event to stop HIV seroconversion PEP must be started as soon as possible to be effective (always within 72 hours of a possible exposure).

Question 58

This is the use of daily antiretroviral medication to prevent the acquisition of HIV in a person who is HIV negative. The primary care nurse practitioner should consider offering this treatment to those who are at risk for acquiring the virus from sex or injection drug use. This best describes which of the following: A. Pre-exposure prophylaxis (PrEP) B. Post-exposure prophylaxis (PEP) C. HIV screening D. None of the above

Answer 58

A. Pre-exposure prophylaxis (PrEP) Pre-exposure prophylaxis (or PrEP) is taken to prevent HIV infection. Highly effective for preventing HIV when taken as prescribed. * PrEP reduces the risk of getting HIV from sex by about 99%. * PrEP reduces the risk of getting HIV from injection drug use by at least 74%.

Question 59

What is the most common type of anemia? A. Anemia of chronic disease B. Iron deficiency anemia C. Vitamin B12 deficiency D. Folic acid deficiency

Answer 59

B. Iron deficiency anemia Iron deficiency affects >12 % of the world's population (especially women, children, and individuals living in under-resourced and middle-income countries).

Question 60

Which of the following is best describes patient presentation in anemia? Fatigue, exercise intolerance, poor memory, and possibly repeated infections. Weakness, fatigue, cold intolerance, constipation, weight gain, coarse skin, bradycardia, periorbital edema. Emotional liability, tremors, sweating, heat intolerance, increased freuency of bowel movements, increased appetite, weight loss, palpitations. Polyuria, polydipsia, polyphagia, polyphagia.

Answer 60

Fatigue, exercise intolerance, poor memory, and possibly repeated infections. Symptoms of anemia may include the following: * Weakness * Tiredness * Lethargy * Reduced immunity * Restless legs * Shortness of breath (especially on exertion) * Chest pain and reduced exercise tolerance (with more severe anemia) * Pica (desire to eat unusual and nondietary substances) * Mild anemia may otherwise be asymptomatic

Question 61

A 40 year-old woman presents with fatigue and difficulty concentrating for the past three months. Physical exam results are unremarkable expect for pale skin and mucosa. Lab results reveal normal WBC and platelets; Hb= 9 g/dL; MCV=75 fL/cell; Serum iron 49 µg/dL (65-176 µg/dL); Serum ferritin 9 µg/dL (20-250 µg/dL); and TIBC 420 µg/dL (250-370 µg/dL). What is the diagnosis? A. Anemia of chronic disease/inflammation B. Iron deficiency anemia C. Vitamin B12 deficiency D. This is a normal hemogram and iron study

Answer 61

B. Iron deficiency anemia Iron studies with Iron Deficiency Anemia Serum iron: Decreased Total iron-binding capacity (TIBC); transferrin: Increased Transferrin saturation (TSAT): Decreased Serum ferritin: Decreased

Question 62

In a person with positive TST, no signs or symptoms of TB, and a negative chest x-ray, are considered non-infectious. Correct! True False

Answer 62

True If the TST is documented to be positive, it should never be repeated. Once the TST is positive it will remain positive, and repeating the test has no clinical utility. A baseline chest radiography (at the discretion of the clinician) may be useful, whether or not treatment for LTBI was completed. If symptoms suggestive of active TB develop, repeat chest radiograph and other cultures should be collected.

Question 63

The purpose of treating latent TB infection is to prevent progression to TB disease. True False

Answer 63

True The goal of testing for latent TB infection (LTBI) is to identify individuals who are at increased risk for the development of active TB disease and therefore would benefit from treatment of LTBI

Question 64

Which of the following should be part of the nurse practitioner care at the initiation of care in HIV? Select all that apply A. If the person was tested anonymously, obtain an HIV antigen/antibody screen B. Obtain a CD4 count with percentages C. Order a quantitative HIV RNA level D. Obtain CD8 cell count

Answer 64

A. If the person was tested anonymously, obtain an HIV antigen/antibody screen B. Obtain a CD4 count with percentages C. Order a quantitative HIV RNA level Available tests for the diagnosis of HIV infection include those that can detect: *HIV antibody (enzyme-linked immunosorbent assays [ELISAs], HIV -1/HIV-2 differentiation assays, Western blot) oELISAs that detect antibody to HIV are used as an initial test to screen for HIV infection. More sensitive than rapid antibody tests. A positive laboratory-based test should be confirmed with either an HIV-1/HIV-2 differentiation assay or Western blot *HIV antibody and HIV antigen oThe sensitivity and specificity of the fourth-generation tests approach 100% for patients with chronic HIV infection. In addition, these tests are able to identify acute/early infection in up to 80% of patients whose HIV diagnosis would have been missed by antibody-only testing *HIV antigen *HIV RNA (qualitative or quantitative)

Question 65

USPTF recommends HIV screening for all people between the ages of 15-65, the clinician is to use clinical judgement in screening younger and older ages, and screen all pregnant women. True False

Answer 65

True HIV testing should also be incorporated into routine screening of healthy individuals in order to: *decrease the number of individuals who present at an advanced stage *enhance the detection of newly infected individuals *reduce transmission to others

Question 66

In which of the following clinical environments would it be essential for the NP to have a working knowledge of the current HIV clinical guidelines for every day clinical practice. Select all that apply: Correctional Health Facility STD-Sexual Health Clinic A Mobile Health Clinic College Campus Health Center

Answer 66

Correctional Health Facility STD-Sexual Health Clinic A Mobile Health Clinic College Campus Health Center Patients at high risk for HIV, those with signs or symptom of acute or chronic infection, as well as those with a possible exposure to HIV should be tested. The goals of the initial evaluation of an adult with HIV are to: * assess the stage of HIV disease * determine the risk for other infections * identify comorbidities that are associated with HIV infection or relevant to its treatment * select an antiretroviral regimen * establish the patient-practitioner relationship * educate the patient about the natural history and management of HIV infection.

Question 67

A rapid HIV test positive results requires further confirmation testing. Correct! True False

Answer 67

True An initial positive rapid antibody test offers only preliminary information. A laboratory-based combination antigen/antibody assay should be performed if the rapid test is positive.

Question 68

You are reviewing the CBC of a 43 year-old man who was seen in clinic for fatigue. His hematocrit is 30% and hemoglobin 10.1 g/dL. with a MCV value of ____. Select the best type of anemia based on the following potential MCV results. A. MCV 120 B. MCV 55 C. MCV 90 1. Macrocytic anemia 2. Microcytic anemia 3. Normocytic anemia

Answer 68

A. MCV 120 1. Macrocytic anemia B. MCV 55 2. Microcytic anemia C. MCV 90 3. Normocytic anemia Mean corpuscular volume (MCV) is the average volume (size) of the RBCs. Low MCV: A reduced MCV (usually < 80). Patients with possible microcytic anemia should have serum iron, TIBC/transferrin, and serum ferritin concentrations measured. Iron studies will identify iron deficiency (the most likely diagnosis for microcytic anemia) and ACD/AI in most cases. Hight MCV: An increased MCV (>100 fL) due to asynchronous nuclear maturation (megaloblastosis). Serum vitamin B12 level should be measured in all patients with unevaluated macrocytosis. Normal MCV: A normal MCV (80 to 100 fL) is the most common finding in anemic men and postmenopausal women. More challenging to evaluate than anemias with an MCV that is obviously low or high. Potential causes are numerous and an underlying condition may be less apparent

Question 69

Match the laboratory test to the appropriate definition. Each possible response will only be used once. A. MCV B. MCH and MCHC C. RDW D. Reticulocyte count 1. Number of new cells the body is releasing 2. Reflects the hemoglobin content in the RBC through color 3. RBC size 4. Variation in size between the RBCs

Answer 69

A. MCV 3. RBC size B. MCH and MCHC 2. Reflects the hemoglobin content in the RBC through color C. RDW 4. Variation in size between the RBCs D. Reticulocyte count 1. Number of new cells the body is releasing MCH: Mean corpuscular hemoglobin (MCH) is the average hemoglobin content in a RBC RDW: Red cell distribution width (RDW) is a measure of the variation in RBC size Reticulocyte count: The reticulocyte count reflects the rate of RBC production

Question 70

Match the type of anemia to the appropriate laboratory result. Each possible response will only be used once. A. Iron deficiency anemia B. B12 deficiency C. Anemia of chronic disease 1. MCV >96 2. MCV 80-95, TIBC normal or low 3. MCV <80, TIBC elevated

Answer 70

A. Iron deficiency anemia 3. MCV <80, TIBC elevated B. B12 deficiency 1. MCV >96 C. Anemia of chronic disease 2. MCV 80-95, TIBC normal or low Iron deficiency: iron is reduced and TIBC is increased, resulting in a lower transferrin saturation B12 deficiency: An MCV value >115 is more specific to vitamin B12 or folate deficiency than other conditions. Anemia of chronic disease (ACD): serum iron concentration is low, TIBC is low, and ferritin level is normal or increased -Patients with ACD may also have true iron deficiency due to the following: *acute or chronic bleeding episodes *repetitive blood draws for laboratory testing

Question 71

A finding of symptoms having no impairment on functioning and independent activities is most associated with which diagnosis? A. Mild cognitive impairment B. Alzheimer’s type dementia C. Dementia with Lewy-bodies D. Huntington’s disease

Answer 71

A. Mild cognitive impairment Mild Cognitive Impairment: * an intermediate clinical state between normal cognition and dementia * mild neurogenic disorder * mild decline in cognitive function * modest impairment in cognitive performance

Question 72

You are seeing an 81-year-old patient in assisted living who has a DM2, diastolic heart failure, HTN, osteoarthritis in knees and hips, and mild cognitive impairment. They use a wheeled walker. You have administered the Geriatric Depression Scale and your patient scored 11/15. What is the next best action? Prescribe lorazepam 0.25 mg every 6 hours as needed for depression Order physical therapy/occupational therapy Arrange for a comprehensive psychological evaluation Prescribe Memantine (Namenda) 5 mg once daily

Answer 72

Arrange for a comprehensive psychological evaluation The shortened form (GDS-S) is comprised of 15 items chosen from the Geriatric Depression Scale-Long Form (GDS-L). These 15 items were chosen because of their high correlation with depressive symptoms in previous validation studies. *> 5 points suggests depression *> 10 points always indicative of depression oComprehensive psychological assessment for depression Referral to a psychiatric specialist Depression is common in older adults and may lead to disability, malnutrition, and weight loss.

Question 73

You are caring for a 90-year-old patient who was recently treated at the local community hospital for community acquired pneumonia. Upon discharge from the hospital, she returned to her senior living center and was placed in the subacute care wing. The registered nurse is calling you this morning because the patient is suddenly talking incoherently, pulling on her IV lines, and trying to get out of bed. The nurse tells you that she recognizes her caregivers and earlier had been very quiet throughout the night. Yesterday she ate well, walked with nursing staff, and visited with friends from her regular independent living wing. What is the most likely diagnosis? A. Dementia B. Delirium C. Depression D. Anxiety

Answer 73

B. Delirium A disturbance of consciousness and altered cognition are essential components. *Develops over a short period of time oOver hours to days and typically persists for days to months *Tend to fluctuate during the course of the day oA change in the level of awareness and the ability to focus, sustain, or shift attention oMay present with memory loss, disorientation, and difficulty with language and speech Goals: *Recognizing that the disorder is present *Uncovering the underlying medical illness that has caused delirium.

Question 74

You are seeing a 78-year-old patient in the clinic who is accompanied by their son. The patient is pleasant and tells you they have no idea why they are seeing you today. The patient's son tells you that a couple of years ago the patient was stopped by the police two counties away from home and they did not know why they were there. The family was concerned and decided to limit driving to locations closer to home. However, three months ago the patient could not remember where they had parked their car and a friend brought them home. The family has also noticed increased episodes of the patient forgetting other little things. Although the family initially chalked it up to normal aging, they are now wondering if there is something more going on. What is the best working diagnosis for this patient? A. Delirium B. Dementia C. Anxiety D. Schizophren

Answer 74

B. Dementia Dementia is a disorder that is characterized by a decline in cognition involving one or more cognitive domains * learning and memory * language * executive function * complex attention * perceptual-motor * social cognition Patients with dementia often do not present with a complaint of memory loss. Family members are often delayed in recognizing the signs of dementia and frequently relate the symptoms to normal aging.

Question 75

You are seeing an 82-year-old patient in the memory care unit. He has moderate dementia with behavioral disturbances, depression, BPH, and a history of witnessed and unwitnessed falls. You stopped his metformin three months ago because of some challenging behaviors around taking his pills. His HbA1C is 8.0%. His blood pressure is 148/80. What is the next best step? A. Resume Metformin at 850 mg TID B. Start a non-insulin injectable, such as Byetta C. Start hydrochlorothiazide 25 mg daily D. No change at this time

Answer 75

D. No change at this time Metformin standard dose for glucose is 500 mg once daily then increase to 500 mg BID. The 850 mg dose would be once a day. Byetta may cause his blood glucose level to significantly decrease and cause weight loss. HCTZ may cause dizziness and is contraindicated in patients who have difficulty voiding. *Lower glucose levels, dizziness, lower B/P, and increased urgency to void may increase the patient's risk for falling and worsen symptoms of confusion. *It is best to make no changes at this time.

Question 76

The medication memantine is appropriate for use in: A. Early stage of dementia B. Middle stage of dementia C. Later stage of dementia D. B & C

Answer 76

D. B & C Pharmacologic Category: *N-Methyl-D-Aspartate (NMDA) Receptor Antagonist Use: *Treat moderate to severe dementia in adults with Alzheimer’s disease *Links to an external site.Reduces dementia symptoms *Does not cure or slow the progression of Alzheimer’s disease

Question 77

Which of the following is true about managing the care of an older adult? The nurse practitioner needs to supplement the routine history taking with additional information such as determining the need for assistive devices and/or a medical power attorney. Older adults may have complex medical and surgical histories that require an organized interview process to create a complete clinical picture. The nurse practitioner should carefully review the older adult's medication list to check for potential concerns associated with polypharmacy. All of the above

Answer 77

All of the above *Older adults with chronic conditions receive care from: -multiple providers -across multiple settings -care is often unorganized and confusing A key role of the nurse practitioner is to work with the patient and family to establish an accurate and complete clinical picture.

Question 78

Which of the following is not true about physical findings in the older adult? Older adults are often less able to mount a temperature response than younger people. Change in body temperature from typical baseline can be a more accurate indicator of an infectious process in older adults. Postural hypotension is very rare in older adults living in nursing homes. Skin is typically thinner and drier in the older adult.

Answer 78

Postural hypotension is very rare in older adults living in nursing homes. Orthostatic hypotension is more common in older adults due to the following: *impaired cardiac function (reduced baroreceptor sensitivity) *Reduced intravascular volume *end organ dysfunction *physical deconditioning *disorders that cause autonomic dysfunction: oType 2 diabetes mellitus oParkinson’s disease oSmall cell lung carcinoma Older adults are more likely to be on medications that are associated with inducing postural hypotension. * Antihypertensives * Diuretics * Alpha-adrenoceptor blockers * Insulin * Levodopa * Tricyclic antidepressants

Question 79

Assessment for gait and balance are essential parts of the physical exam of an older adult. Which screening test for gait and balance can be completed in the clinic? A. Timed Up and Go Test B. Romberg Test C. Four-Stage Balance Test D. All of the above

Answer 79

D. All of the above The Timed Up and Go (TUG) test is a performance-based measure of functional mobility that was developed to identify mobility and balance impairments in older adults. The Romberg test is a simple test used to diagnose sensory ataxia, gait, and balance disorders. The Four-Stage Balance Test is used to assess mobility and risk of falls, based on the individual's ability to hold four progressively more challenging positions.

Question 80

Which of the following is not an essential element of decisional capacity? Capable of understanding the information. Able to appreciate the consequences of the decision. The decision has to be deemed reasonable. They must be able to communicate the decision.

Answer 80

The decision has to be deemed reasonable. Patients have medical decision-making capacity if they can demonstrate understanding of the situation, appreciation of the consequences of their decision, and reasoning in their thought process, and if they can communicate their wishes. The decision does not have to be deemed reasonable/appropriate.

Question 81

Which of the following is the best definition for frailty: The culmination of loses of reserve across multiple physiologic systems. The aggregation of multiple system failures within the human body. Loss of muscle mass as part of normal aging.

Answer 81

The culmination of loses of reserve across multiple physiologic systems. Aging-related syndrome of physiological decline, characterized by marked vulnerability to adverse health outcomes. Frail older patients often present with an increased burden of symptoms including weakness and fatigue, medical complexity, and reduced tolerance to medical and surgical interventions.

Question 82

You are starting an 86-year-old patient on escitalopram for depression with anxiety. Which of the following is not standard of practice? Conduct a thorough medication review to minimize drug interactions and polypharmacy. Encourage psychotherapy in addition to pharmacological measures. Start at the highest dose and then titrate down once depression symptoms have improved. Assess falls and falls risk, antidepressants are associated with increased falls in elderly.

Answer 82

Start at the highest dose and then titrate down once depression symptoms have improved. The recommended starting dose of Lexapro is 10 mg once daily. If the dose is increased to 20 mg, this should occur after a minimum of one week.

Question 83

Which of the following is a risk factor for falls in an older adult? A. Previous falls. B. Gait and balance impairments. C. Visual impairments D. All of the above

Answer 83

D. All of the above Falls are the leading cause of injury, both fatal and nonfatal, among older adults in the United States. Falls are often due to more than one cause. Risk factors for falls include: * Past history of a fall * Lower-extremity weakness * Age * Female sex * Cognitive impairment * Balance problems * Psychotropic drug use * Arthritis * History of stroke * Orthostatic hypotension * Dizziness * Anemia

Question 84

Mild cognitive impairment always progresses to dementia. True False

Answer 84

False Mild cognitive impairment is an intermediate clinical state between normal cognition and dementia. MCI may represent a reversible condition in the setting of: * depression * a complication of certain medications * during the recovery from an acute illness Its presence indicates a greater risk of progression to dementia, but it may also * remain stable * not progress * revert to normal

Question 85

All individuals diagnosed with dementia cannot complete wills or health care directives. True False

Answer 85

False Capacity is a functional assessment made by a clinician to determine if a patient is capable of making a specific decision. Patients with dementia cannot be assumed to have impaired capacity. A patient with moderate or severe dementia may still be able to indicate a choice and show some understanding. Capacity evaluation for a patient with dementia is used to determine whether the patient is capable of the following: * giving informed consent * participating in research * managing their finances * living independently * making a will * have ability to drive * Four key components of decision-making in a capacity evaluation include: -understanding -communicating a choice -appreciation -reasoning

Question 86

Assessment of the functional status in older adults is an important part of the clinic visit because it is a strong predictor of survival prognosis. True False

Answer 86

True Functional status refers to the ability to perform activities necessary or desirable in daily life. The functional assessment can provide valuable prognostic information to direct diagnostic evaluations, treatment plans, and establish goals of care.

Question 87

During her annual physical exam your 76 y/o patient reports a significant reduction in her vision looking straight ahead, but she is still able to see things out of the corner of her eyes. Which eye disorder would be most consistent with this clinical presentation? A. Age-related Macular Degeneration (AMD) B. Cataract C. Dry Eye D. Astigmatism

Answer 87

A. Age-related Macular Degeneration (AMD) AMD is a progressive vision impairment resulting from deterioration of the central part of retina, known as macula. Central vision loss, blurred vision, and changes in color perception are also commonly noted.

Question 88

A patient presents to your office prior to undergoing cataracts surgery. He would like to know if the surgical procedure will help to improve his vision. Which of the following statements is the best response for the patient? A. The surgery will remove your cloudy lens but you may still need glasses for reading and driving at night. B. Your vision will be restored to perfect 20/20 after the cataract is removed. C. The surgery will help to restore your vision loss due to uncontrolled diabetes. D. The surgery will not cause light sensitivity or blurred vision after the procedure.

Answer 88

A. The surgery will remove your cloudy lens but you may still need glasses for reading and driving at night. Some patients may note improved vision as soon as the day after surgery. Others may not appreciate the full impact until updated glasses are prescribed one to three months after surgery. Patients usually require glasses for night driving and/or reading after cataract surgery. Improvement in vision may be limited by underlying age-related factors, diabetes, traumatic maculopathy, or glaucoma.