Missed CEA Exam questions

Question 1

Classic findings in a patient with a pheochromocytoma include which of the following?

Answer 1

Paroxysmal symptoms

Patient symptoms will be paroxysmal rather than constant due to the intermittent secretion/surge of catecholamines

Question 2

A patient is evaluated in the urgent care for complications of Type 2 diabetes due to an episode of recent life stressors. All the following are consistent with HHS except:

Answer 2

Markedly positive serum ketones

HHS presents with severe hyperglycemia with BS >600 and pts are more dehydrated.

Ketosis is more common in DKA.

Hyperosmolality is the hallmark of HHS, and the urine osmolality is typically 350-380 mOsm/mL and in DKA typically have elevated plasma osmolality.

Arterial pH is suppressed in DKA <7.3 and is >7.3 in HHS

Question 3

An elderly patient diagnosed with end-stage lung cancer has been refusing meals, opting instead for ice cream only. The family is concerned about the patient not getting enough nutrition. The NP:

Answer 3

explains loss of appetite is common at the end of life

Death is an uncomfortable topic, and must be handled tactfully. Factual re-orientation to the terminal state of a patient’s condition may be appropriate when unrealistic expectations for their longevity have been voiced. The reasonable choice in this case is to describe the normalcy of what the patient is experiencing with their loss of appetite and their terminal state. Testing the patient for depression has really no clinical bearing on this particular time nor does prescribing methylphenidate. Ordering a UA and CBC would suggest a concern of a urinary tract infection, and that is not a likely scenario to describe the patient’s existing condition. Support the patient as his advocate by helping the man enjoy the ice cream he requested.

Question 4

A 49-year-old male presents to your service with symptoms of fever 102.3, jaundice, and abdominal pain. Imagining reveals a biliary obstruction. Which diagnosis is most likely for this patient?

Answer 4

Cholangitis

The most likely cause for this patients’ symptoms is cholangitis, which has a typically presentation of fever, jaundice, and abdominal pain.

The most common cause of this is a biliary stone causing obstruction and allowing for ascending of bacteria and infection

Question 5

A 59-year-old male presents with symptoms of abdominal pain, jaundice, and weight loss which he has not been trying to lose weight. What would be a malignancy associated with these symptoms?

Answer 5

Pancreatic cancer

Pancreatic cancer, the most typically presentation includes abdominal pain, jaundice, and weight loss.

Although weight loss and abdominal pain may be present with adenocarcinoma it is unlikely to present with jaundice, and you’re unlikely to have abdominal pain or jaundice with any esophageal malignancy.

Question 6

A 19-year-old presents with a sore throat and anterior cervical adenopathy. Which causative agent would be suspected?

Answer 6

Group A beta-hemolytic Streptococcus

While this patient could easily represent strep or EBV, the differentiating factor is the location of the affected lymphadenopathy. As a generalization, posterior cervical lymphadenopathy is common of Epstein-Barr virus (EBV) and anterior cervical lymphadenopathy is more common with Group A beta-hemolytic streptococcus.

Question 7

Your patient is on rivaroxaban, a potent novel oral anticoagulant, and presents to the urgent care in no apparent distress with a right nare that is bleeding through the current self-packed gauze. This has been persistent for the past 30 minutes without any evidence of stopping. Which is the most appropriate next action?

Answer 7

Apply direct manual compression to the bridge of the nose and consult ENT

First order of operation is to assess for killer bleeds and attempt hemostasis. Direct pressure is the best option of these provided. Blind cautery would not likely be useful since the packing is in the way and should not be removed. There is no evidence to suggest a need to intubate the patient at this time.

Question 8

Your patient presents to the urgent care clinic with a swollen exudative pharynx, profound fatigue, and a very tender left upper quadrant abdomen. What is the most likely diagnosis?

Answer 8

Epstein Barr virus (EBV)

Splenomegaly in the setting of upper respiratory infection is almost always EBV. Strep pharyngitis does also have similar attributes but does not explain the splenomegaly. Pancreatitis also has left upper quadrant discomfort but does not have URI symptoms. Tonsillitis is possible except it also does not explain splenomegaly.

Question 9

An adult male presents with a 1-week history of headache and nasal congestion; assessment reveals T=103 degrees F (39.4 degrees C), periorbital swelling, and proptosis. Which is the most appropriate action?

Answer 9

Refer for hospital admission

This is suspicious for orbital cellulitis and this requires hospitalization and IV antibiotic therapy.

Question 10

Progression to Acute Myelogenous Leukemia (AML) is a risk for untreated or poorly responsive:

Answer 10

Myelodysplastic syndrome

Long-term treatment goals include supportive care, prevent disease progression and/or development of AML.

Question 11

A 78 y.o. M patient reports chronic infections, bruising, fatigue, SOB, and fevers. He has a history of rectal adenocarcinoma and completed concurrent chemotherapy/radiation earlier this year. His CBC shows Hgb 7.5, PLT 88, WBC 1.2, ANC 0.8, and peripheral smear shows dysplasia. What additional work-up would you anticipate for this patient?

Answer 11

Bone marrow biopsy and flow cytometry

Diagnosis of Myelodysplastic Syndromes involves H&P, CBC, peripheral smear, bone marrow biopsy (immunocytochemistry and flow cytometry). Diagnosis is dependent on cytopenias, dysplasia, and cytogenic abnormalities. IPSS is used to identify risk.

Question 12

A geriatric patient with anemia, back pain, osteoporosis, and elevated erythrocyte sedimentation rate should be evaluated for:

Answer 12

multiple myeloma

Multiple myeloma is a type of cancer that affects plasma cells in the bone marrow. Symptoms can include:
* Bone pain: Often in the back, hips, or ribs
* Weakness or fatigue: May be caused by anemia
* Infections: People with multiple myeloma are more likely to get infections like pneumonia, bronchitis, sinusitis, and urinary tract infections
* Kidney problems: Myeloma protein can damage the kidneys, which may lead to kidney failure
* Bruising or bleeding: High levels of protein in the blood can make it easier to bruise and cause nosebleeds
* Other symptoms: Confusion, dizziness, stroke-like symptoms, loss of appetite, weight loss, nausea, vomiting, constipation, frequent urination, and shortness of breath

Question 13

A 35-year-old woman presents with fatigue, joint pain, and a butterfly-shaped rash on her face. What is the most appropriate initial management in primary care?

Answer 13

Referral to rheumatology

As this represents a likely diagnosis of systemic lupus erythematosus (SLE), this should be managed by rheumatology to evaluate and initiate therapy when possible.

Question 14

Your patient presents with painless lymph node swelling, weight loss, night sweats, and asks what is wrong with him. Which of the following represents a most appropriate intervention to confirm a diagnosis of lymphoma?

Answer 14

Order a core needle biopsy

This question is asking for an intervention. Although examining the patient is useful, it is an evaluation tool, as is ordering routine lab work. Pulmonology is not an appropriate consultation for this patient; rather, hematology or oncology would be best suited to evaluate and work up this patient. A diagnostic needle biopsy is the most definitive intervention to gain a diagnosis for a suspected lymphoma.

Question 15

You are admitting an otherwise healthy 67-year-old female patient with a leading diagnosis of hypotension. She has a history of palmar dyshidrotic eczema who has been taking mometasone ointment for over a month. She reports stopping this medication a few days prior to admission. With this information, what is the likely diagnosis of her admission?

Answer 15

Suppression of the HPA axis causing an Addisonian crisis

Dehydration and heart failure are both possible causes but unlikely to cause this without any precipitating history. HPA axis suppression is possible from chronic use of mid to high potency steroids and her stopping of the mometasone wound indicate this may be the case with an Addisonian crisis.

Question 16

An 84-year-old patient presents with complaints of diffuse bilateral lower back pain which is made worse by standing. On exam the patient maintains a posture of forward flexing at the waist. The most likely diagnosis is?

Answer 16

Spinal stenosis

The symptoms of spinal stenosis often develop gradually over time, as the narrowing of the spinal canal progresses and exerts pressure on the nerves. Symptoms may worsen with activities that extend the spine (such as standing upright) and improve with activities that flex the spine (such as sitting or leaning forward).

Question 17

A 50-year-old woman with a history of osteoporosis presents for a routine check-up. What is the most appropriate medication to prevent further bone loss?

Answer 17

Bisphosphonates

Bisphosphonates are medications commonly used to prevent bone loss and treat osteoporosis. Bisphosphonates work by inhibiting osteoclast-mediated bone resorption, which helps to maintain or increase bone density. They bind to bone surfaces and interfere with osteoclast activity, thereby slowing down the rate of bone breakdown.

Question 18

Patients who have been in a multi-car pileup should be evaluated for which of the following elements of the secondary survey?

Answer 18

Deformities

Primary survey assessment points (airway, breathing, and circulation)
Deformities, are part of the secondary survey.

Question 19

Which of the following suggest a diagnosis of glomerulonephritis?

Answer 19

CD4 count of 50 with hematuria

HIV is a common cause of glomerulonephritis. CD4 count of 50 suggests poor HIV control and hematuria is a common finding of glomerulonephritis.

Question 20

The use of GABA-agonizing drugs is likely going to have which effect on seizure threshold?

Answer 20

Increase

When seizure threshold is elevated, less seizure activity occurs. GABA is an inhibitory neurotransmitter for seizures, so increasing its presence will raise the seizure threshold and reduce the incidence of them occurring.

Question 21

In treating a pregnant female with migraine headaches, which of the following drugs would be contraindicated?

Answer 21

Ergotamine tartrate (Migergot)

Ergotamine, like other ergot alkaloids, has vasoconstrictive properties that can potentially reduce blood flow to the placenta and affect fetal growth and development. It has been associated with an increased risk of miscarriage, preterm birth, and fetal malformations when used during pregnancy.

Question 22

A 5-year-old girl presents with fever, rash, hacking cough, and swollen, tender lymph nodes. The rash started on her face and has spread to the rest of her body. What is the most likely diagnosis?

Answer 22

Measles

Measles, also known as rubeola, is a highly contagious viral infection caused by the measles virus. The symptoms of measles typically appear in stages over a period of about 10-14 days after exposure to the virus.

Here are the common symptoms associated with measles:
1. Initial Symptoms (Prodromal Stage):
o Fever: Often high, typically begins about 10-12 days after exposure to the virus.
o Malaise: General feeling of discomfort, tiredness, and lack of well-being.
o Runny Nose: Nasal congestion and discharge.
o Cough: Dry, persistent cough.
2. Koplik Spots: These are small, white spots that may appear inside the mouth, usually on the inner lining of the cheek. They are characteristic of measles and may precede the rash by 1-2 days.
3. Rash (Exanthematous Stage):
o A characteristic red or reddish-brown rash typically begins on the face and hairline, spreading downward to the rest of the body.
o The rash consists of flat, red spots that may blend together as they spread.
o It usually lasts for about 5-7 days and fades in the order it appeared, often accompanied by fever.

Question 23

During a well-child examination of a 24 month old, premature tooth decay and inflamed gums, particularly of the maxillary incisors, are noted. The approach to this problem includes:

Answer 23

Referring the child to a dentist, assessing for bottle feeding and fluoride in local water.

Refer to a periodontist if the child has moderate to severe gum disease this ensures comprehensive care, including orthodontic evaluation if misaligned teeth are contributing to gum disease.

Question 24

The 16-year-old mother of a 2-month-old presents the infant, reporting that the child is very irritable and does not feed well. During physical examination, the child’s head drops back and the child exhibits sudden flexing of the extremities. As the flexing stops, the child cries uncontrollably. Funduscopic examination reveals retinal hemorrhages. Which of the following diagnostic tests should be ordered?

Answer 24

CT scan

Retinal hemorrhages are a characteristic finding in abusive head trauma, particularly shaking injuries. They result from the forceful shaking causing shearing and tearing of blood vessels in the retina. A CT scan is indicated in this case.

Question 25

A 25-year-old woman presents with a 2-year history of fluctuating mood states, including periods of mild depression and hypomania. These symptoms have not been severe enough to meet the criteria for major depressive or manic episodes. What is the most likely diagnosis?

Answer 25

Cyclothymic disorder Cyclothymic Disorder involves chronic mood fluctuations that include periods of hypomanic and depressive symptoms. These symptoms are less severe than those in Bipolar I or II disorders but can significantly impact daily functioning. Early diagnosis and appropriate treatment, including psychotherapy, medications, and lifestyle changes, can help manage symptoms and improve quality of life.

Question 26

An adult G0P0 patient presents with reports of breast discharge for several months. The discharge is thin, milky, and non-odorous. The patient denies any pain, masses, or skin changes of either breast. She has a history of seizures and bipolar disorder and has had a recent normal MRI. She is taking divalproex (Depakote), risperidone (Risperdal), clonazepam (Klonopin), and conjugated estrogens (Premarin Vaginal Cream). Which medication should the nurse practitioner consider changing?

Answer 26

Risperidone (Risperdal) Risperidone (Risperdal) is an atypical antipsychotic used to treat conditions such as schizophrenia, bipolar disorder, and irritability associated with autism. One of the notable side effects of risperidone is its potential to cause breast discharge, or galactorrhea.

Question 27

A geriatric female presents with 48 hours of regional burning pain on the right side of the ribs. The nurse practitioner starts drug treatment with:

Answer 27

Acyclovir (Zovirax) Antiviral medications help to reduce the severity and duration of the shingles outbreak and lower the risk of complications, such as postherpetic neuralgia.

Question 28

Anticholinergic agents such as ipratropium (Atrovent) and tiotropium (Spiriva) are used in COPD primarily to:

Answer 28

Anticholinergics block the parasympathetic nervous system's effect on the airways, causing bronchodilation.

Question 29

Which two lobes of the lung are most associated with aspiration pneumonia?

Answer 29

Right middle and right upper This is due in part to the anatomical tendency at the carina of a straighter shot towards the right middle and right lower lobes.

Question 30

Your patient presents with bradycardia, severe nausea, and substernal pain. STEMI was identified on the EKG. Which region of the heart is most likely involved?

Answer 30

Inferior Wall The inferior wall, fed by the right coronary artery is commonly associated with these symptoms. Remember right equals rate as it is the blood supply for the SA and AV nodes in most patients. Dyspepsia is common in RCA territory injury due to vagal stimulation not typical of other areas.

Question 31

Classic findings in a patient with a pheochromocytoma include what?

Answer 31

Paroxysmal symptoms Patient symptoms will be paroxysmal rather than constant due to the intermittent secretion/surge of catecholamines

Question 32

Which of the following do not represent possible causes of a prothrombotic state?

Answer 32

Inhibition of factor Xa Protein C and S are the body’s natural anticoagulants and a deficit of these would make the patient more prone to clot. Factor V Leyden is a genetic mutation that makes the blood more prone to clot. Factor X when activated (Xa) is the beginning of stable clot formation. Inhibition of this would represent an anticoagulated state. (Oral anticoagulants such as rivaroxaban and apixaban use this mechanism).

Question 33

An older adult female presents for her annual examination. She has been on antihypertensive medications for over 20 years, with good control. Laboratory values are within normal ranges. The nurse practitioner is concerned about the patient’s cardiac health risks, due her to weight and her waist circumference. According to the AHA guidelines, which of the following goals is expected for this patient?

Answer 33

Physical activity for 30 minutes daily, for a minimum of 5 days a week

Question 34

A patient arrives to the urgent care clinic after several days of crushing chest pain rated 10 out of 10 on a zero to 10 scale with associated left arm numbness and shortness of breath. The pain has lessened over the last 24 hrs to a 4 out of 10. Given the extended duration from onset to presentation, what finding would be expected on the EKG?

Answer 34

Presence of a large Q wave in areas of infarction Patients with a fully evolved myocardial infarction (MI) as this scenario is suggesting would likely have a presence of a large q wave in the area of infarction with or without the additional presence of ST elevation. P wave inversion and QT prolongation are unrelated to MI, and a normal EKG would not be expected with an acute MI that went untreated for several days.

Question 35

An 80-year-old man with a history of atrial fibrillation presents with sudden-onset unilateral leg pain and pallor. What is the most likely diagnosis?

Answer 35

Acute arterial occlusion

Question 35

Patients on levothyroxine should be monitored for signs of which one of the following:

Answer 35

Angina pectoris and dysrhythmias

Question 36

An adult male who has managed type 2 diabetes mellitus well for many years presents for a 6-month follow up. His Hgb A1c has risen from 7% to 9% over the interval. All other laboratory values are normal and his BMI is still 25. His psychiatrist recently added olanzapine (Zypreza) to the medical regimen. The nurse practitioner will most likely:

Answer 36

Begin to increase the patient’s diabetes medications incrementally A common side effect of initiation of onanzapine (Zyprexa) is increased appetite and it is evidenced by this by the patient having their A1c increase from 7 to 9%. The patient should have their diabetic mediation dose increased to help counteract this phemonemon, however a long-term strategy may include consult the psychiatrist about decreasing the dose or altering the medication as this represents a considerable health risk to the patient. As that specifically was not an option, the best option would be to augment the anti-diabetic medication regimen. Stopping the olanzapine without discussing it with the psychiatrist would potentially cause the patient to experience discontinuation syndrome.

Question 37

A 39-year-old male with type 1 DM is seen in the urgent care after a recent hospitalization for DKA. Treated with IV fluids, IV insulin, and potassium correction, His BS decreases to 120 mg/dL and is transitioned from IV insulin to Sub Q. After 6 hours he begins vomiting and ABG is done: pH 7.19, CO2 13, K+ 5.5, glucose 180. Which of the following is the most likely reason for persistent acidosis?

Answer 37

Premature discontinuation of insulin drip

Question 38

A 27-year-old woman presents with frequent headaches, galactorrhea, and amenorrhea. MRI of the brain reveals a pituitary adenoma. What is the most appropriate initial treatment?

Answer 38

Dopamine agonists Dopamine agonists are commonly used to initially counteract the effects of pituitary adenomas. Surgery or radiation may be used as an eventual destination therapy, however the question specifically asked about the initial management.

Question 39

Pheochromocytoma is best diagnosed by which of the following tests:

Answer 39

24-hour urine for catecholamines/metanephrines and plasma metanephrines

Question 40

A 42-year-old female presents with large watery frequent stools. She also reports abdominal pain and cramping, bloating and gas. The likely anatomical source of her diarrhea is where?

Answer 40

Small intestine These are all signs typically seen with small intestine diarrhea. Diarrhea of large intestinal origin often presents with frequent, regular, small volume, and often painful bowel movements

Question 41

An adult patient diagnosed with retropharyngeal abscess should be treated with which of the following antibiotics?

Answer 41

Ceftriaxone IV or IM Due to the highly anaerobic nature of most pathogens found in the enteral tract, most of which are gram negative, the standard of care for treatment of retropharyngeal abscess includes IV ceftriaxone or clindamycin.

Question 42

A patient presents with blood present in the anterior portion of their eye covering the lower half of their iris. With which of the following diagnoses is this most consistent?

Answer 42

Hyphema Hyphema is defined as red blood cells in the anterior portion of the eye between the cornea and iris. Subconjunctival hemorrhage is commonly mistaken for this and is a hemorrhage lateral to the iris in the conjunctiva of the eye. Globe rupture does not present with such specific findings unless hyphema is also included in the trauma, and acute angle glaucoma is not associated with blood in the anterior vitreous; however, hyphema may lead to this if the trabecular network were to get clogged. For this reason, close follow up is required for these patients.

Question 43

Which antibiotic is appropriate for initial treatment of sinusitis?

Answer 43

amoxicillin/clavulanic acid (Augmentin) Due to the mixed gram positive and gram negative flora that are present in the oropharynx, it would be wise to consider broad spectrum coverage with a beta lactamase inhibitor. Amoxicillin/clavulanic acid (Augmentin) does exactly this and is considered the recommendation for bacterial rhinosinusitis.

Question 44

Which of the following microorganisms are most frequently associated with acute bacterial rhino-sinusitis?

Answer 44

Streptococcus pneumoniae and Haemophilus influenzae

Question 45

The patient you just saw in urgent care is being admitted for strep viridans endocarditis. Which of the following does the prudent nurse practitioner considered the most possible source of the illness?

Answer 45

Perioral abscess seen on maxillofacial bone CT scan this admission Gumline infections are remarkably easy to introduce pathogens into the bloodstream to attack valves, cause sepsis, etc. Strep viridans is a very common oral pathogen. Scabies do not carry a risk of bacterial sepsis, nor does a recent low-grade common cold virus. Any invasive lines should be considered at risk, but the IV catheter placement is both unlikely as a source and does not fit the timing after already being admitted.

Question 46

All the following thrombocytopenic emergencies require immediate action except:

Answer 46

Scheduled surgical procedure with mild thrombocytopenia

Question 47

A patient with a known intrinsic factor autoantibody is at risk for developing which of the following conditions?

Answer 47

B12 deficiency and pernicious anemia Causes of B12 deficiency include malabsorption and intrinsic factor deficiency. Intrinsic factor deficiency is a result of gastric resection or IF autoantibody.

Question 48

A geriatric patient with anemia, back pain, osteoporosis, and elevated erythrocyte sedimentation rate should be evaluated for:

Answer 48

multiple myeloma Multiple myeloma is a type of cancer that affects plasma cells in the bone marrow. Symptoms can include: Bone pain: Often in the back, hips, or ribs Weakness or fatigue: May be caused by anemia Infections: People with multiple myeloma are more likely to get infections like pneumonia, bronchitis, sinusitis, and urinary tract infections Kidney problems: Myeloma protein can damage the kidneys, which may lead to kidney failure Bruising or bleeding: High levels of protein in the blood can make it easier to bruise and cause nosebleeds Other symptoms: Confusion, dizziness, stroke-like symptoms, loss of appetite, weight loss, nausea, vomiting, constipation, frequent urination, and shortness of breath

Question 49

Long-term immunoglobulin that is carried from generation to generation is likely which type of immunoglobulin?

Answer 49

IgG IgG is passed from maternal circulation to fetal circulation to protect for the first several months to years of life.

Question 50

What is the first-line treatment for mild systemic lupus erythematosus (SLE)?

Answer 50

Ibuprofen (Advil) While more severe SLE will require steroids for acute management and monoclonal antibody therapy or biologics (DMARDS) for chronic therapy, mild SLE can be managed with non-steroidal anti-inflammatory agents. Acetaminophen is not an NSAID and is not indicated for SLE.

Question 51

A 35-year-old woman presents with fatigue, joint pain, and a butterfly-shaped rash on her face. What is the most appropriate initial management in primary care?

Answer 51

Referral to rheumatology As this represents a likely diagnosis of systemic lupus erythematosus (SLE), this should be managed by rheumatology to evaluate and initiate therapy when possible.

Question 52

An 87-year-old patient presents with round, pruritic plaques and small vesicles on the lower legs. The most likely diagnosis is:

Answer 52

nummular eczema. The hallmark feature of nummular eczema is the presence of round or oval-shaped patches of inflamed skin. These patches are well-defined and can range in size from a few centimeters to several inches in diameter.

Question 53

Which of the following behaviors is likely to elicit rhabdomyolysis?

Answer 53

Participating in a full ironman triathlon Risks of rhabdomyolysis are highest with overuse from a massive exertion such as a full triathlon. 30 minutes of plyometric exercises or 10 minutes in a lap pool are very unlikely to cause as severe of a response. High-intensity statin therapy is infrequently associated with incidence of rhabdomyolysis, but it is quite rare; myalgia is far more common.

Question 54

A 25-year-old athlete presents with shoulder pain and difficulty with overhead activities. Physical examination suggests impingement syndrome. What is the most appropriate initial treatment?

Answer 54

Physical therapy focusing on rotator cuff strengthening

Question 55

Which of the following suggest a diagnosis of glomerulonephritis?

Answer 55

CD4 count of 50 with hematuria HIV is a common cause of glomerulonephritis. CD4 count of 50 suggests poor HIV control and hematuria is a common finding of glomerulonephritis.

Question 56

A male adult patient presents to the clinic with sudden onset of painful hematuria. The most likely diagnosis is:

Answer 56

Bladder carcinoma

Question 57

An older adult female presents with a 2-month history of incontinence. She specifically complains of an inability to make it to the bathroom without the loss of some urine most of the time, and denies incontinence due to laughing, coughing, or sneezing; she denies dysuria. Her medications include an angiotensin-converting enzyme (ACE) inhibitor. The initial plan of action for this patient would be:

Answer 57

Obtaining a urinalysis for pyuria, hematuria, and glucosuria Obtaining a urinalysis for pyuria (pus in the urine), hematuria (blood in the urine), and glucosuria (glucose in the urine) is typically done to evaluate and diagnose various medical conditions affecting the urinary tract and overall health.

Question 58

Patients with uncontrolled hypertension should be started on antihypertensive agents in addition to diet and exercise. Which medication should not be considered for a hypertensive patient with acute kidney injury with a creatinine of 3.1?

Answer 58

Lisinopril Although ACE inhibitors are recommended for patients with chronic kidney disease, they are contraindicated in acute kidney injury states as they can exacerbate worsening renal function. They should be added when the renal function has stabilized.

Question 59

A patient who presents to your clinic with an acute change in facial symmetry, inability to speak clearly and unilateral muscular weakness should be transported for evaluation immediately as treatment for embolic stroke with tPA within which timeframe?

Answer 59

Less than 4.5 hrs 4.5 hrs is considered the end of the window for tPA therapy unless otherwise contraindicated.

Question 60

Which of the following tools is most easily administered in the practice setting for assessing cognitive decline?

Answer 60

Clock drawing (mini cog) Drawing a clock involves multiple cognitive domains, including visuospatial skills, executive function (planning and organization), attention, and memory. These cognitive abilities are often affected in conditions such as dementia and Alzheimer's disease, making clock drawing a useful screening tool.

Question 61

A 78-year-old male presents with a complaint of paroxysmal dizziness associated with nausea, and a feeling that he is going to “pass out”. Neurological examination and brain imaging studies are negative. EKG is within normal limits. The next diagnostic procedure should be:

Answer 61

Cardiac event monitor Paroxysmal dizziness, which refers to sudden and transient episodes of dizziness or vertigo, can be caused by various underlying conditions. The term "paroxysmal" implies that these episodes come on suddenly and may resolve spontaneously. Certain abnormal heart rhythms, such as atrial fibrillation, can occasionally cause episodes of dizziness or lightheadedness, especially if they affect blood flow to the brain.

Question 62

In treating a pregnant female with migraine headaches, which of the following drugs would be contraindicated?

Answer 62

Ergotamine tartrate (Migergot) Ergotamine, like other ergot alkaloids, has vasoconstrictive properties that can potentially reduce blood flow to the placenta and affect fetal growth and development. It has been associated with an increased risk of miscarriage, preterm birth, and fetal malformations when used during pregnancy.

Question 63

A 5-year-old child presents with facial puffiness, decreased urine output, and dark-colored urine. The parents report that the child had a sore throat about two weeks ago. Which condition is most likely?

Answer 63

Acute glomerulonephritis (AGN) is a condition characterized by inflammation in the glomeruli, which are the tiny filters in the kidneys that help remove excess fluids and waste from the bloodstream. The symptoms of acute glomerulonephritis can vary depending on the underlying cause and the severity of kidney involvement. Common symptoms include: 1. Hematuria: Blood in the urine, which may make the urine appear pink, red, or cola-colored. 2. Proteinuria: Protein in the urine, which may cause foamy urine. 3. Edema: Swelling, typically around the eyes, face, hands, feet, and abdomen. This occurs due to fluid retention as the kidneys lose their ability to properly regulate fluid balance. 4. Hypertension: High blood pressure, which can be sudden and severe in some cases. 5. Oliguria: Decreased urine output, which may indicate reduced kidney function. 6. Fatigue: General feeling of tiredness or weakness. 7. Flank Pain: Dull pain or discomfort in the sides of the back (flank area), where the kidneys are located. 8. Fever: Low-grade fever may be present, especially if the cause of AGN is infectious. 9. Reduced Appetite: Loss of appetite and nausea may occur. 10. Joint Pain: Some individuals may experience joint pain and swelling, particularly in cases where AGN is associated with systemic conditions like lupus or vasculitis.

Question 64

A late adolescent is brought to the nurse practitioner’s office by her mother, who is concerned about her daughter’s recent weight loss and the potential of purging herself after meals. The daughter denies any self-induced vomiting, starvation or excessive activity. History reveals that the daughter was consistently in the 50th percentile for weight but is now in the 10th percentile. She does state that she jogs 5 miles a day and is in good condition. In addition to a complete blood count with differential, which of the following laboratory tests will be most helpful for further assessment?

Answer 64

Electrolytes, blood urea nitrogen (BUN)/creatinine, urinalysis Bulimia nervosa is an eating disorder characterized by episodes of binge eating followed by compensatory behaviors such as self-induced vomiting, excessive exercise, or the misuse of laxatives and diuretics. These behaviors can lead to significant medical complications, including electrolyte imbalances, renal dysfunction, and urinary abnormalities. Assessing electrolytes, BUN/creatinine, and urinalysis can provide crucial information about the physiological impacts of bulimia.

Question 65

At what age should a child typically be able to sit without support?

Answer 65

6 months Typically, a child should be able to sit without support around the age of 6 to 8 months.

Question 66

A healthy unvaccinated child is exposed to Hepatitis A. The best option for therapy is:

Answer 66

immune globulin IG is effective when given within 2 weeks (preferably within 2 weeks) of exposure to HAV. It provides temporary protection, typically lasting about 3 to 6 months.

Question 67

A 4-year-old child presents with a chronic cough, wheezing, and difficulty breathing, especially at night. On examination, you hear expiratory wheezing and observe the use of accessory muscles for breathing. What is the most likely diagnosis?

Answer 67

Asthma Asthma is a chronic condition that affects the airways in the lungs, causing them to become inflamed and narrowed in response to certain triggers. The symptoms of asthma can vary in severity and frequency from person to person, but common symptoms include: 1. Shortness of Breath: Difficulty breathing, especially during physical activity or at night. 2. Wheezing: A whistling or squeaky sound when breathing, particularly during exhalation. 3. Coughing: Often persistent, especially at night or early in the morning. Coughing may worsen with exercise or exposure to allergens or irritants. 4. Chest Tightness: A feeling of pressure or tightness in the chest, which may accompany other asthma symptoms. 5. Increased Mucus Production: The lining of the airways may produce excess mucus, leading to phlegm or congestion. 6. Symptoms that Worsen at Night or Early Morning: Asthma symptoms often tend to be more severe during sleep or upon waking up, known as nocturnal asthma. 7. Exacerbation Triggers: Symptoms may worsen or flare up in response to specific triggers such as: Allergens: Pollen, dust mites, pet dander, mold. Irritants: Smoke, strong odors, air pollution. Respiratory Infections: Colds, flu, sinus infections. Exercise: Particularly in cold or dry air. Emotional Factors: Stress or strong emotions. Weather Changes: Cold air, humidity changes. 8. Difficulty Speaking: In severe asthma attacks, talking may become difficult due to shortness of breath.

Question 68

An adult female was treated for postpartum depression with selective serotonin reuptake inhibitors (SSRIs) by another healthcare provider. The patient reports continuing lethargy and depression. Before the dose of SSRIs is increased, it is most important to obtain:

Answer 68

The thyroid-stimulating hormone (TSH) level Low TSH (thyroid-stimulating hormone) levels after pregnancy can indicate various thyroid conditions. Postpartum thyroid dysfunction is relatively common and can present in different forms.

Question 69

A 30-year-old woman presents with a 6-month history of persistent sadness, loss of interest in activities she once enjoyed, fatigue, and difficulty concentrating. She also reports changes in appetite and sleep patterns. What is the most likely diagnosis?

Answer 69

Major depressive disorder Major Depressive Disorder (MDD) is a mental health condition characterized by persistent and intense feelings of sadness, hopelessness, and a lack of interest or pleasure in nearly all activities. The symptoms can significantly interfere with an individual’s daily life, including their ability to work, sleep, study, eat, and enjoy life.

Question 70

An adult G0P0 patient presents with reports of breast discharge for several months. The discharge is thin, milky, and non-odorous. The patient denies any pain, masses, or skin changes of either breast. She has a history of seizures and bipolar disorder and has had a recent normal MRI. She is taking divalproex (Depakote), risperidone (Risperdal), clonazepam (Klonopin), and conjugated estrogens (Premarin Vaginal Cream). Which medication should the nurse practitioner consider changing?

Answer 70

Risperidone (Risperdal) is an antipsychotic medication commonly used to treat various mental health conditions such as schizophrenia, bipolar disorder, and irritability associated with autistic disorder. One of the potential side effects of risperidone is the development of breast discharge, a condition known as galactorrhea.

Question 71

A 46-year-old female found a lump in her breast this morning. History includes: no prior breast disease; G2P2 (first birth, age 22); maternal aunt diagnosed with breast cancer at age 72; last menstrual period was 2.5 weeks ago. On examination, a nurse practitioner palpates a 2-cm round, soft, mobile, tender lesion in the upper outer quadrant of the right breast. Mammogram is negative. Which of the following actions is most appropriate?

Answer 71

A right breast ultrasound is a non-invasive imaging test used to evaluate abnormalities in the breast tissue. It uses high-frequency sound waves to produce images of the inside of the breast. If a mammogram reveals an abnormality such as a lump, mass, or area of increased density, an ultrasound can provide more detailed information.

Question 72

An older adult female reports nasal congestion, clear nasal secretions, and a post-nasal drip since going through menopause. After a thorough examination reveals no significant abnormalities, the nurse practitioner diagnoses the patient with:

Answer 72

Vasomotor rhinitis Vasomotor rhinitis, also known as non-allergic rhinitis, is a condition characterized by chronic nasal congestion, runny nose, and postnasal drip that is not caused by allergies or infections. This condition can be particularly bothersome in post-menopausal women due to hormonal changes.

Question 73

A 24-year-old sexually active woman presents with lower abdominal pain, fever, and purulent cervical discharge. On pelvic examination, cervical motion tenderness is noted. What is the most likely diagnosis?

Answer 73

Pelvic inflammatory disease (PID) Cervical motion tenderness is a clinical finding characterized by pain elicited when the cervix is moved or manipulated during a pelvic examination. This tenderness can indicate underlying pelvic pathology. Lower abdominal pain, fever, abnormal vaginal discharge, pain during intercourse, and irregular menstrual bleeding and cervical motion tenderness are present with Pelvic Inflammatory Disease (PID).

Question 74

A female patient was sexually assaulted with the past 120 hours and is concerned about unwanted pregnancy. The correct prescription would be:

Answer 74

Levonorgestrel 1.5 mg as a single dose Levonorgestrel is a type of emergency contraception, commonly known as the morning-after pill. It works in the following ways: Prevention of Ovulation: - Levonorgestrel primarily works by preventing ovulation, meaning it stops the release of an egg from the ovary. Interference with Fertilization: - It may also interfere with fertilization by affecting the movement of sperm or egg. Alteration of the Uterine Lining: - Levonorgestrel can alter the lining of the uterus, making it less suitable for implantation if fertilization has already occurred.

Question 75

A 65-year-old man with a history of chronic obstructive pulmonary disease (COPD) presents with increased shortness of breath, wheezing, and a productive cough. On auscultation, you hear decreased breath sounds and wheezes. What is the most appropriate initial management?

Answer 75

Short-acting beta-agonists Short-acting beta-agonists (SABAs) are a crucial component in the management of COPD due to their rapid onset of action, effectiveness in relieving acute symptoms, and ability to improve exercise tolerance and overall quality of life. They serve as rescue medications to manage acute exacerbations and are used in conjunction with long-acting therapies to provide comprehensive symptom control. Their ease of use, availability, and flexibility in dosing make SABAs an essential tool in the treatment of COPD

Question 76

The following are side effects of albuterol use except which of the following?

Answer 76

Diarrhea Beta 2 agonism can cause tachycardia, tremors, and decreased GI motility, not diarrhea.

Question 77

The patient recently diagnosed and treated with chemotherapy and radiation for lymphoma develops shortness of breath and chest pain on the right side. He feels he is unable to take a deep breath. What diagnosis based on this history is most likely?

Answer 77

Pleural effusion Patients undergoing treatment for lymphoma commonly develop pleural effusions in response to the lysis of the tumor and the body’s response. For this reason, many patients with this diagnosis and treatment will have a silicone pleural catheter placed to allow them to drain at home.

Question 78

Your patient with a history of COPD is being evaluated in urgent care with respiratory distress. Which of the following interventions would NOT cause the patient to potentially develop worsening of respiratory acidosis?

Answer 78

Initiation of BiPAP Treatment of hypercarbia is to increase minute volume and Bipap will be design create a larger tidal volume from pressure (x resp rate = minute volume). COPD patients with a hypoxic drive should not be treated with moderate to large doses of oxygen as it may trigger apnea and use of benzodiazepines will blunt the respiratory drive and lower minute volume.

Question 79

Which of the following agents would NOT be useful in reducing pulmonary edema in a patient with cardiogenic shock?

Answer 79

Phenylephrine Phenylephrine is an afterload increasing agent and would likely exacerbate worsening of pulmonary edema in a heart with cardiogenic shock

Question 80

Your patient who has undergone right upper lobectomy for stage II adenocarcinoma does not have any nodes positive for metastasis on pathology. Which of the following stages is ruled out by the absence of positive lymph nodes?

Answer 80

Stage III Stage I and II are typically localized lesions that may have local invasion or large size to be considered stage II. Stage III suggests positive nodes and stage IV suggests distal metastasis.

Question 81

Your patient has been diagnosed with a 4.5cm ascending aortic aneurysm. Which medical imaging is considered standard of care for serial surveillance?

Answer 81

CT angiography is considered the standard of care for measuring vascular luminal dimensions with contrast. CT PE protocol is not timed properly for the aorta (it’s timed for the pulmonary artery). Although a plain film is able to catch large aneurysms at times, they are not able to provide multi-axis reconstruction needed to accurately measure the size. Transesophageal echo is not needed to accurately measure the aorta and requires the patient to undergo sedation which is unnecessary.

Question 82

A “code blue” is called on your patient in the waiting room of your urgent care. When you arrive, cardiac monitoring is applied and their rhythm appears to be normal sinus rhythm with a rate of 80. On palpation over the carotid artery, you do not feel a pulse. What is the name of this cardiac rhythm?

Answer 82

Pulseless electrical activity appears as a normal rhythm without a pulse. Idioventricular rhythm is very slow (20-40), Junctional tachycardia and WAP both without pulses are considered PEA also.

Question 83

What is the key long-term benefit of using carvedilol for patients with coronary artery disease and heart failure with reduced ejection fraction (HFrEF)?

Answer 83

Potential increase in ejection fraction EF increase is a key reason for using carvedilol over metoprolol for patients with low EF states. Libido unfortunately can be negatively impacted by any beta blocker. Cardiac output should only improve with long term use, not decrease, and beta blockers may reduce blood pressure slightly, but tha

Question 84

An older adult presents with the single complaint of bilateral pedal edema. The patient has a history of diabetes and high blood pressure and is on oral medications. Which of the following medications is the MOST likely cause of the patient's complaint?

Answer 84

Amoldipine (norvasc)

Question 85

A 60-year-old woman presents for a routine check-up. She has a history of hypertension, type 2 diabetes mellitus, and hyperlipidemia. She is currently on lisinopril, metformin, and atorvastatin. She has no new complaints. On examination, her blood pressure is 135/80 mmHg, heart rate is 72 beats per minute, and BMI is 32 kg/m². Recent laboratory tests reveal HbA1c of 7.5%, LDL cholesterol of 110 mg/dL, and creatinine of 1.1 mg/dL. What is the most appropriate management plan to optimize her care?

Answer 85

Recommend lifestyle modifications including diet and exercise Although all these are potential options to consider, the loss of weight is most likely to affect all of her issues and should be considered as the first therapy before adding additional mediations, especially as she is already on 3 agents, yet her BMI of 32 suggests she is obese.

Question 86

A patient is having increased thirst and urination. You have ruled out diabetes mellitus. After a compete history and physical you suspect diabetes insipidus. Your initial lab tests should include?

Answer 86

Plasma sodium, 24-hour urine osmolality and volume

Question 87

All the following are symptoms of hypocalcemia except:

Answer 87

Visual field deficits S/S of hypocalcemia may include tetany, paresthesia in fingers/toes, abdominal pain

Question 88

Which of the following is the most common cause of Cushing’s Syndrome?

Answer 88

ACTH-producing adenomas account for roughly 75% of Cushing’s Syndrome, 15% due to ectopic ACTH secretion, and 10-15% are from adrenal adenomas.

Question 89

An adult female presents with a 1-week history of left lower quadrant abdominal pain. T=101.2 degrees F. (38.4 degrees C) and an elevated WBC count. This is the patient’s first episode of severe abdominal pain. The nurse practitioner suspects diverticulitis. Which of the following diagnostic tests would confirm the diagnosis?

Answer 89

For patients with acute diverticulitis, CT of the abdomen will provide evidence of the pathophysiology. Evidence of diverticula will be present on a flat plate KUB x-ray, but there is not enough specificity to show that it is inflamed as with a CT scan.

Question 90

A 38-year-old male presents to the ER with complaints of abdominal pain, intermittent diarrhea, and has a positive occult blood. A stool culture is done which does not show any organism growth. His CRP and fecal calprotectin are elevated, and a colonoscopy is performed with biopsy which shows changes consistent with Crohn’s disease, which are mild. What of the following represent the first line of treatment for this illness?

Answer 90

5-ASA, Abx, and corticosteroids are typically used in the acute first line phase of treatment of Crohn's disease. With either a mono or multi therapy after the acute phase with immunomodulators and/or anti-TNF

Question 91

A patient states they do not want to have any further medical care and wishes to leave against medical advice. Unknown to you, the healthcare tech then held their arm down to get an IV catheter placed against their will. The healthcare tech is at risk of being charged with which of the following:

Answer 91

Assault refers to the risk of a harm to others, whereas battery refers to the actual act of that harm.

Question 92

A 60-year-old man presents with persistent hoarseness for the past 3 months. He has a history of smoking. What is the most appropriate next step in management?

Answer 92

Referral to ENT for laryngoscopy Suspicion of malignancy should be considered in individuals with risk factors such as smoking presenting with unexplained hoarseness lasting more than two weeks.

Question 93

An adult patient diagnosed with retropharyngeal abscess should be treated with which of the following antibiotics?

Answer 93

Ceftriaxone IV or IM Due to the highly anaerobic nature of most pathogens found in the enteral tract, most of which are gram negative, the standard of care for treatment of retropharyngeal abscess includes IV ceftriaxone or clindamycin.

Question 94

Your patient with a large bump on their cheek should be evaluated and ruled out for which cardiac complication-linked diagnosis

Answer 94

Perioral abscess Perioral abscesses are linked to complications since the bloodstream access is so easy for pathogens. The remainder do not represent any cardiac risk.

Question 95

A young adult female presents with painful swelling of the right cheek anterior to the TMJ. The diagnosis is sialadenitis. To determine the appropriate treatment for this patient, the most common infecting organism in bacterial sialadenitis is:

Answer 95

Staphylococcus aureus A salivary gland infection is also called sialadenitis and is caused by bacteria or viruses. A salivary stone or other blockage of the salivary gland duct can contribute to an acute infection. Chronic inflammation of a salivary gland can cause it to stop functioning. The most causative agent for this is staphylococcus aureus.

Question 96

Which of the following is not a common mechanism of neutrophil expenditure and resultant neutropenia?

Answer 96

Loss of circulating neutrophils in acute blood loss Neutropenia can result from three basic mechanisms: decreased production in the bone marrow, redistribution, or immune destruction.

Question 97

A patient on warfarin (Coumadin) therapy for recurrent deep vein thrombosis (DVT) is about to have lumbar spinal fusion surgery. The patient’s warfarin is put on hold starting 5 days prior to the surgery and subcutaneous enoxaparin (Lovenox) has been ordered for DVT prophylaxis until the resumption of the warfarin. The nurse practitioner knows that the patient’s postoperative warfarin dose should be restarted based on the:

Answer 97

Baseline PT and INR values The use of the patient's baseline PT/INR levels will dictate their response and timing of the resumption of warfarin postoperatively. It is important to recall that enoxaparin (Lovenox) will need to continue until the INR has resumed at their baseline therapeutic level, typically INR o 2.0 or more before stopping of the enoxaparin bridging.

Question 98

A geriatric patient with anemia, back pain, osteoporosis, and elevated erythrocyte sedimentation rate should be evaluated for:

Answer 98

Multiple myeloma is a type of cancer that affects plasma cells in the bone marrow. Symptoms can include: Bone pain: Often in the back, hips, or ribs Weakness or fatigue: May be caused by anemia Infections: People with multiple myeloma are more likely to get infections like pneumonia, bronchitis, sinusitis, and urinary tract infections Kidney problems: Myeloma protein can damage the kidneys, which may lead to kidney failure Bruising or bleeding: High levels of protein in the blood can make it easier to bruise and cause nosebleeds Other symptoms: Confusion, dizziness, stroke-like symptoms, loss of appetite, weight loss, nausea, vomiting, constipation, frequent urination, and shortness of breath

Question 99

A 78 y.o. M patient reports chronic infections, bruising, fatigue, SOB, and fevers. He has a history of rectal adenocarcinoma and completed concurrent chemotherapy/radiation earlier this year. His CBC shows Hgb 7.5, PLT 88, WBC 1.2, ANC 0.8, and peripheral smear shows dysplasia. What additional work-up would you anticipate for this patient?

Answer 99

Bone marrow biopsy and flow cytometry Diagnosis of MDS involves H&P, CBC, peripheral smear, bone marrow biopsy (immunocytochemistry and flow cytometry). Diagnosis is dependent on cytopenias, dysplasia, and cytogenic abnormalities. IPSS is used to identify risk.

Question 100

A patient is newly diagnosed with multiple sclerosis. Treatment includes prednisone with physical therapy. The nurse practitioner advises the patient to begin disease-modifying therapy:

Answer 100

To limit disease progression, disease modifying therapy (DMARDs) should be initiated as soon as possible. This is also to limit the exposure and duration of steroid therapy as this does not treat the underlying cause and it may take some time for DMARD therapy to become fully therapeutic for the patient.

Question 101

What is the first-line treatment for mild systemic lupus erythematosus (SLE)?

Answer 101

Ibuprofen While more severe SLE will require steroids for acute management and monoclonal antibody therapy or biologics (DMARDS) for chronic therapy, mild SLE can be managed with non-steroidal anti-inflammatory agents. Acetaminophen is not an NSAID and is not indicated for SLE.

Question 102

Which of the following is a true statement about squamous cell carcinoma?

Answer 102

Squamous cell carcinoma is more common to have metastasis than basal cell carcinoma. Basal cell carcinoma occurs more commonly than squamous cell carcinoma.

Question 103

Parkland formula to determine fluid administration

Answer 103

The Parkland formula for resuscitation in burns is 4ml x kg x burn % with 50% delivered to patient over first 8 hrs. For this patient 4x100x20=8000ml, of which half is to be given in the first 8 hrs.

Question 104

Which diagnostic test is commonly used to identify fungal infections of the skin?

Answer 104

A Wood's lamp emits long-wave ultraviolet light (UV-A) that causes certain substances on the skin to fluoresce. Fungi that cause superficial skin infections (dermatophytes) can sometimes fluoresce under this light.

Question 105

Your patient has presented with flank pain, CVA tenderness, frequency. Which diagnostic finding would be useful to differentiate between cystitis and pyelonephritis?

Answer 105

UA with WBC casts suggests pyelonephritis. UA with RBC suggests glomerulonephritis. Presence of hematuria is non-specific and a UC positive for proteus is not specific to either, as both cystitis and pyelonephritis could have proteus as the bacterial agent.√

Question 106

A 24-year-old female reports urinary urgency with suprapubic tenderness relieved by bladder emptying. The patient has been evaluated by urology and urogynecology. Review of laboratory reports reveal negative urinalysis and cultures, negative results for sexually transmitted infections, and an unremarkable cystoscopy. Which of the following is an appropriate plan of care?

Answer 106

Amitriptyline (Elavil) is a tricyclic antidepressant medication that is sometimes used off-label for various conditions, including the management of urinary urgency and overactive bladder symptoms.

Question 107

Your patient presents to the Urgent Care with periorbital and peripheral edema and has evidence of macroalbuminuria. Which state is described by this clinical presentation?

Answer 107

Nephrotic syndrome

Question 108

An older adult with diabetes mellitus, COPD, hypertension, and osteoarthritis develops chronic kidney disease. The most likely cause is:

Answer 108

Diabetes is a leading cause of kidney failure, medically known as end-stage renal disease (ESRD), and it is often referred to as diabetic nephropathy when discussing kidney damage specifically caused by diabetes.

Question 109

Patients with an elevated creatinine after receiving contrast from an angiogram are exhibiting which classification of renal dysfunction?

Answer 109

Intrarenal This is a classic example of intrarenal failure due to contrast induced nephropathy (CIN). In the case of otherwise healthy kindeys, CIN is a transient finding and resolves without intervention other than time and hydration. If the kidney is in a chronically damaged state, CIN can exacerbate permanent damage.

Question 110

Patients presenting to urgent care with hematuria and RBC casts in their urine should be considered for which diagnosis?

Answer 110

GN is commonly diagnosed with proteinuria, hematuria, and RBC casts in their urine. Pyelonephritis commonly has WBC casts present on urinalysis. ATN does not typically have any of these features of casts. Nephrotic syndrome tends to have proteinuria, but no RBCs or casts present.

Question 111

Interstitial cystitis

Answer 111

Symptoms of interstitial cystitis include frequent, urgent need to urinate, often with pelvic pain that ranges from mild discomfort to intense pressure. Individuals may experience pain during urination, and the bladder may feel full even after urinating. Other common symptoms include nocturia (frequent urination at night), and in severe cases, pain in the pelvis or between the vagina and anus in women or between the scrotum and anus in men.

Question 112

A 7-year-old boy presents with recurrent abdominal pain, diarrhea, and weight loss. What is the most appropriate initial test?

Answer 112

Celiac antibody test 'This test may be used to screen individuals who have symptoms suggestive of Celiac disease, such as chronic diarrhea, abdominal pain, bloating, fatigue, weight loss, or unexplained iron-deficiency anemia.

Question 113

A 6-year-old child presents with a loud, harsh, holosystolic murmur at the left lower sternal border. What is the most likely diagnosis?

Answer 113

Ventral septal defect The symptoms of VSD in a 6-year-old can range from mild to severe and may include: Heart murmur: A common finding during routine physical exams. Shortness of breath, especially during physical activity. Fatigue or difficulty feeding (in infants). Rapid breathing. Pale skin. Failure to gain weight appropriately.

Question 114

A 5-year-old presents with a 3-month history of soiling his pants. The child was successfully toilet trained at 3. What is the most likely diagnosis?

Answer 114

Encopresis is a childhood disorder characterized by the repeated passing of stool (feces) into inappropriate places, such as clothing or the floor, typically after the age of toilet training.

Question 115

Which of the following drug classes is associated with anticholinergic side effects?

Answer 115

TCAs TCAs are notoriously associated with side effects of dry mouth, urine retention, constipation, and dry eyes.

Question 116

Patients who overdose on beta blockers should be treated with which of the following agents?

Answer 116

Glucagon stimulates the beta-adrenergic system via the cAMP second messenger system even if the beta receptors are bound by beta blocker agents. This provides a “back door” into stimulating the system and improving heart rate.

Question 117

Anticholinergic agents such as ipratropium (Atrovent) and tiotropium (Spiriva) are used in COPD primarily to:

Answer 117

BRONCHODILATION

Question 118

An adult presents for a 3-month follow-up visit for intermittent asthma. The patient’s current treatment plant is albuterol (Ventolin HFA) as needed. The patient reports coughing, wheezing, and chest tightness that require inhaler use 3 days a week. The patient also reports nighttime coughing about once per week in the last month. What is the nurse practitioners BEST plan of care?

Answer 118

Fluticasone propionate (Flovent HFA) is added to asthma management for its potent anti-inflammatory effects, which help to control and prevent chronic symptoms, improve lung function, reduce the frequency and severity of exacerbations, and minimize the need for systemic corticosteroids. It is a corne

Question 119

A 25-year-old woman presents with a sudden onset of shortness of breath and pleuritic chest pain. She has no significant past medical history and takes no medications. On physical examination, her heart rate is 110 beats per minute, respiratory rate is 24 breaths per minute, and oxygen saturation is 90% on room air. What is the most likely diagnosis?

Answer 119

Pulmonary embolism (PE) is a serious medical condition that occurs when a blood clot (usually from the legs or other parts of the body) travels to the lungs and obstructs one of the pulmonary arteries. The primary symptoms of a PE can vary depending on the size of the clot and the location within the lung, but the most common symptoms include: Sudden onset of difficulty breathing, which may occur at rest or with exertion and sharp, stabbing pain that may worsen with deep breathing (pleuritic pain). The pain may also feel like pressure, fullness, or a squeezing sensation.

Question 120

A 55-year-old man with a history of smoking presents with a persistent cough and hemoptysis. A chest X-ray reveals a solitary lung nodule. What is the most appropriate next step?

Answer 120

CT scans provide high-resolution, cross-sectional images of the lungs, offering more detail than standard chest X-rays. This allows for better characterization of the nodule's size, shape, and density.

Question 121

Severity of COPD is most effectively evaluated with the use of which diagnostic test?

Answer 121

Ventilatory spirometry is the gold standard for evaluation of COPD with the use of FEV1, FVC, and the ratio of FEV1/FVC.

Question 122

An adult female presents with a 1-week history of left lower quadrant abdominal pain. T=101.2 degrees F. (38.4 degrees C) and an elevated WBC count. This is the patient’s first episode of severe abdominal pain. The nurse practitioner suspects diverticulitis. Which of the following diagnostic tests would confirm the diagnosis?

Answer 122

For patients with acute diverticulitis, CT of the abdomen will provide evidence of the pathophysiology. Evidence of diverticula will be present on a flat plate KUB x-ray, but there is not enough specificity to show that it is inflamed as with a CT scan.

Question 123

A 50-year-old man presents with fatigue, muscle weakness, and hyperpigmentation of the skin. Laboratory tests show low sodium, high potassium, and low cortisol levels. What is the most likely diagnosis?

Answer 123

Addisonian crisis The clinical traid of hypocortisolism, also known as Addisonian crisis presents with hypotension, hypothermia, and oliguria. Not all patients who exhibit adrenal insufficiency will have this in a severe state, but it is common to look for these findings to support the diagnosis. The patient may also have a recent history of steroid supplementation that was abruptly stopped or a recent stressor which caused an increase in their cortisol levels which their adrenal glands could not support such as surgery, hospitalization, infection, etc.

Question 124

A patient has been complaining of palpitations for the past week and presents to you at an urgent care clinic for evaluation. You perform a 12 lead EKG and identify atrial fibrillation with a hear rate of 122 beats per minute. What is your next order?

Answer 124

Order a stat transthoracic (2D) echocardiogram and prepare the patient for trasnport to the closest appropriate hospital for inpatient evaluation

Question 125

The most common side effect of the oral ribavirin used in the treatment of hepatitis C is:

Answer 125

Hemolytic anemia. It is important to note that ribavirin will not treat hepatitis C unless it is taken with another medication called pegylated-interferon α (PEG-IFNα). This therapy is not considered evidence based anymore due to better options now available and the considerable side effect profile of ribavirin which includes hemolytic anemia as it's most significant side effect affecting 10-15% of those taking it.

Question 126

Your 62-year-old patient with diabetes and COPD has been diagnosed with acute angle glaucoma after presenting to the clinic with complaints of acute unilateral eye pain with decreased unilateral visual acuity and a hazy cornea. Which of the following topical medications should be avoided?

Answer 126

Beta blockers Beta blockers should be avoided in COPD patients due to the risk of exacerbating bronchoconstriction.

Question 127

What is the following is not an effective strategy of treatment for verruca?

Answer 127

Shave biopsy As verruca are deeply rooted in the dermis, shave biopsy is ineffective in reaching the root. The remaining options are all considered reasonable techniques

Question 128

Your 58-year-old male patient identifies a bothersome 2cm lesion on his forehead during your admission exam which is right where his baseball caps hit and cause discomfort. You identify it as a seborrheic keratosis. Which of the following represents the most effective strategy for removal?

Answer 128

Shave biopsy Since seborrheic keratoses are topical, shave biopsy is very ideal in their removal. Punch of a 2cm lesion would be atypical and unnecessary. A local wide excision is more typical of melanoma management. Elliptical excision is unnecessary since the lesion is superficial.

Question 129

Which of the following bacteria are commonly associated with pyelonephritis?

Answer 129

Klebsiella is the only gram-negative bacteria listed. Gram negative bacteria are most associated with UTI and pyelonephritis.

Question 130

Which of the following are not associated with alcohol abuse?

Answer 130

Microcytic anemia Vitamin B12 and thiamine are commonly low in patients who abuse alcohol chronically. Macrocytic anemia is also common in this population. Microcytic anemia is more common with iron deficient states and thalassemia.

Question 131

Which of the following symptoms are not found in anti-depressant discontinuation syndrome?

Answer 131

Hypersomnia. The acronym to recall the symptoms of discontinuation syndrome is FINISH (Flu-like symptoms, insomnia, nausea, imbalance, sensory disturbances, hyperarousal).

Question 132

Patients who present with agitation, confusion, tachycardia and hypertension, dilated pupils, loss of muscle coordination, twitching muscles, muscle rigidity, diaphoresis, and diarrhea should be worked up for which of the following conditions?

Answer 132

Serotonin syndrome Serotonin syndrome accurately reflects these symptoms. The remaining items reflect near-opposite symptoms from these: pallor, bradycardia, fatigue, weakness, hypotension, constipation.

Question 133

A 40-year-old man presents with chronic cough, night sweats, and unintentional weight loss. He has a history of recent travel to a country with a high prevalence of tuberculosis. On physical examination, he has dullness to percussion and decreased breath sounds in the right upper lobe. What is the most appropriate initial test to confirm the diagnosis?

Answer 133

Sputum culture A sputum culture for acid-fast bacilli (AFB) is a diagnostic test used to detect Mycobacterium tuberculosis, the bacterium that causes tuberculosis (TB), as well as other mycobacterial infections. This test is essential for confirming the presence of tuberculosis and for identifying other mycobacterial diseases.

Question 134

Which two lobes of the lung are most associated with aspiration pneumonia?

Answer 134

Right middle and right lower This is due in part to the anatomical tendency at the carina of a straighter shot towards the right middle and right lower lobes.

Question 135

An 18-month-old child presents with a bulging, immobile tympanic membrane; T = 103°F (39.4°C). Assessment also reveals a grade II/VI systolic murmur at the left sternal border. After initiation of treatment for otitis media, the most appropriate intervention is to:

Answer 135

Reevaluate the patient in 10 days. Heart murmurs in toddlers are relatively common and can be either innocent (benign) or pathological (indicative of underlying heart conditions). Proper evaluation and monitoring are essential to determine the nature of the murmur and to ensure the child’s health and development are not adversely affected. Re-evaluating in 10 days is an appropriate next course of action.

Question 136

By what age should a child typically be able to walk independently?

Answer 136

By 15 months, most children can walk independently, although the gait may still be a bit wobbly and they may need to use their arms for balance.

Question 137

Which of the following medications does not cause beta 1 stimulation?

Answer 137

Phenylephrine only stimulates alpha 1 receptors. The remaining three all have beta receptor activity

Question 138

A grade III/VI, low-pitched, diastolic, rumbling murmur heard at the apex, and best heard in the left lateral decubitus position, is most indicative of which of the following types of valve problem?

Answer 138

Mitral stenosis

Question 139

A 33-year-old woman presents with irregular menstrual cycles, hirsutism, and obesity. Laboratory tests reveal elevated serum testosterone and LH ratio > 2:1. What is the most appropriate initial treatment?

Answer 139

These are classic symptoms of polycystic ovarian syndrome and the patient should be treated with oral contraceptives to help stabilize their estrogen and progesterone. Additionally, they may be managed on metformin and/or spironolactone for their PCOS. Oral contraceptive pills (OCPs) are often the first pharmacological treatment for polycystic ovary syndrome (PCOS) because they help manage in several ways: Menstrual irregularities: OCPs can help regulate menstrual cycles, making periods lighter and more regular. This is important because irregular ovulation can lead to endometrial hyperplasia, which is a buildup of uterine tissue that can increase the risk of uterine cancer. Androgen excess: OCPs can reduce androgen production and increase sex hormone-binding globulin (SHBG), which binds androgens. This can help reduce symptoms like acne, hirsutism (unwanted body and facial hair), and androgenic alopecia (male pattern baldness). Endometrium protection: OCPs can protect the endometrium by ensuring regular ovulation

Question 140

A patient has a 3 cm pituitary mass noted on CT. What is your next step in evaluating the patient?

Answer 140

Initial work up includes hormone testing. Cabergoline is the treatment for prolactinoma. Surgery consult is indicated when there are VF deficits and/or abutment/compression on optic nerves or chiasm or if adenoma is hyperfunctioning. Adenomas >1 cm with no VF deficit or abutment/compression of optic nerves or chiasm require a follow up MRI at 6 months.

Question 141

A 43-year-old male with past medical history significant for GERD, smoking, and obesity presents to your clinic for worsening GERD symptoms, he has been taking Protonix 40mg daily with no improvement. He had an EGD done with biopsy. Which findings would diagnose the patient with Barret's esophagus?

Answer 141

Histologic examination of biopsy specimens from that columnar epithelium must reveal intestinal metaplasia characterized with goblet cells. This would be significant of change to diagnose a patient with Barrett's esophagus

Question 142

Inability to reach the bathroom before urinating is a feature consistent with which of the following diagnoses?

Answer 142

Urge-type incontinence, also known as overactive bladder (OAB) or urgency incontinence, is a condition characterized by a sudden and strong need to urinate, often followed by involuntary leakage of urine. This type of incontinence occurs when the bladder muscle (detrusor) contracts involuntarily, leading to urgency and sometimes an inability to reach the toilet in time.

Question 143

An adult female Pap smear results reveals high-grade squamous intraepithelial lesion. What should the nurse practitioner do next?

Answer 143

Refer for colposcopy When a Pap smear reveals a high-grade squamous intraepithelial lesion (HSIL), it indicates a significant abnormality that has a higher potential to progress to cervical cancer if left untreated. The recommended next step is further evaluation through colposcopy and possibly biopsy.

Question 144

A 55-year-old man with a history of smoking presents with a persistent cough and hemoptysis. A chest X-ray reveals a solitary lung nodule. What is the most appropriate next step?

Answer 144

CT scan of the chest CT scans provide high-resolution, cross-sectional images of the lungs, offering more detail than standard chest X-rays. This allows for better characterization of the nodule's size, shape, and density.

Question 145

A 60-year-old man with a history of chronic obstructive pulmonary disease (COPD) presents with an acute exacerbation, including increased sputum production and dyspnea. He has no known drug allergies. What is the most appropriate initial antibiotic treatment?

Answer 145

Amoxicillin-clavulanate (Augmentin) is an effective antibiotic choice for the treatment of acute exacerbations of COPD due to its broad-spectrum coverage, ability to overcome beta-lactamase-mediated resistance, proven clinical efficacy, good tolerability, and flexibility in dosing. It is particularly useful in treating bacterial infections caused by common respiratory pathogens, including those that produce beta-lactamase, making it a reliable option for managing exacerbations in COPD patients.

Question 146

The use of sublingual nitrates for patients with chest pain is relatively or absolutely contraindicated in all the following scenarios except:

Answer 146

Uncontrolled hypertension Hypertension does not contraindicate the use of nitrates. Use of phosphodiesterase inhibitors such as sildenafil may cause a precipitous drop in blood pressure, as would their use with patients relying on diastolic filling pressure in RCA territory STEMI. Profound hypotension is an absolute contraindication

Question 147

As the nurse practitioner working in a primary care clinic, you have been notified from a hospitalist that your long-term patient with a history of HFrEF (heart failure with reduced ejection fraction) with an ejection fraction of 40% two years ago who is also not on optimal medical therapy has been diagnosed with a myocardial infarction this admission and received emergent placement of a drug-eluting stent to the left anterior descending artery. As the patient’s medical home who will manage this patient after discharge, which of the following would you expect to be a priority in the patient’s care for their heart failure after an acute MI?

Answer 147

Ordering a new transthoracic echocardiogram and order a Lifevest if EF is less than 35% Dual anti-platelet therapy is required for 12 months minimum post-MI. A Holter monitor does not provide any conceivable benefit for this patient as presented. The patient should have a protective mechanism such as an implantable automated cardioverter defibrillator (AICD) or a Lifevest if the EF is less than 35% due to the increased risk of sudden cardiac death with low EF states. Since most patients are not eligible for 90 days for an AICD in this state, optimizing their medication regimen and repeating an echo in 2-3 months to re-evaluate for improvement in their EF is required by most insurance companies. A baseline echo is needed at discharge to provide a baseline for improvement vs their repeat echo in 2-3 months.

Question 148

A 25-year-old woman presents with a urinary tract infection (UTI) confirmed by urinalysis. She has no allergies. What is the most appropriate first-line antibiotic treatment?

Answer 148

Bactrim Bactrim DS BID times three days for a standard uncomplicated UTI without community resistance over 20%, especially in otherwise healthy individuals where local resistance patterns support its efficacy.

Question 149

A patient with a solitary nodule in the right upper lobe with no brain or body lesions and a PET scan showing no evidence of other lesions in the body would be ruled out of which of the following stages of lung cancer?

Answer 149

Stage IV Stage IV requires evidence of distal metastasis, which this patient does not have.