Old patient

Question 1

A geriatric patient appears to have soft wartlike skin lesions that appear “pasted on”. Mostly seen on the back and trunk. Benign. What is it?

Answer 1

Seborrheic Keratoses

Question 2

A geriatric patient appears in the clinic. They appear to have bright, purple-colored patches with well-demarcated edges. Located on the extensor surfaces of the forearms and hands after a minor trauma. Lesions eventually resolve over several weeks, but residual brown appearance can occur when hemosiderin deposits in the tissue. Benign. What is it?

Answer 2

Senile Purpura

Question 3

A geriatric patient appears in the clinic with tan- to brown-colored macules with a “moth-eaten” border on the dorsum of the hands and forearms caused by sun damage. More common in light-skinned individuals. Benign. What is this called?

Answer 3

Liverspots

Lentigines

Question 4

A patient with a history of PVD appears in the clinic with dry and scaly, ulcerated, neovascularized, and bronzed (from hemosiderin deposition on the lower legs and ankles? What is this called?

Answer 4

Stasis Dermatitis

Question 5

A geriatric patient appears in the clinic with flat or thickened plaque with color varying from skin-colored to red, white, or yellow. It appears scaly or have a horny surface and is found on sun-damaged skin. What is this called?

Answer 5

Actinic Keratosis (Solar Keratosis)

Condition is secondary to sun exposure and has the potential for malignancy. It is a precancerous form of squamous cell carcinoma.

Question 6

A patient comes in the clinic with opaque grayish-to-white ring with a sharp outer border and an indistinct central border at the periphery of the cornea. What is the called? What do we need to monitor for?

Answer 6

Arcus Senilis (Corneal Arcus)

• associated with contralateral carotid artery disease
• Develops gradually and is not associated with visual changes
• Caused by deposition of lipids.
• *In patients younger than 40 years, can be a sign of elevated cholesterol. Check fasting lipid profile. **

Question 7

A patient appears in the clinic with cloudiness and opacity of the lens of the eye(s) or its envelope. No red Reflex. The color of the lens is white to grey.

The patient reports gradual onset of decrease night vision, sensitivity to glare of car lights, halos around lights, blurry vision, and double vision.
What is it?

Answer 7

Cataracts

There are three types (nuclear, cortical, and posterior capsular).

Question 8

You suspect glaucoma. How do you test for them?

Answer 8

Visual fields and tonometer

Question 9

A geriatric patient comes into the clinic with loss of central visual fields results in loss of visual acuity and contrast sensitivity. Patient has drusen bodies. What is suspected? How to test for it?

Answer 9

Macular Degeneration

Amsler grid to evaluate central-vision changes

Question 10

A patient is diagnosed with presbycusis?

What is it? What should be included in the education of this disease?

Answer 10

Sensorineural hearing loss

• High-frequency hearing is lost first
• Presbycusis starts at about age 50 years.
• There are degenerative changes of the ossicles, fewer auditory neurons, and atrophy of the hair cells resulting in sensorineural hearing loss.

Question 11

A patient appears to the clinic with tenesmus, rectal pain, and diminished-caliber stools (ribbonlike stools). What is suspected?

Answer 11

Rectal cancer

Refer to GI

Question 12

An older patient presents with acute onset of severe eye pain, severe headache, and nausea and vomiting. The eye(s) is(are) reddened with profuse tearing. Complains of blurred vision and halos around lights. What is the plan of care? What is suspected?

Answer 12

Open Angle Closure Glaucoma

CALL 911 do not delay treatment
the ER will check IOP

Question 13

When should the NP screen for lung cancer?

Answer 13

Patient with a history of smoking with the last 15 years and at the age of 55-80 years of age.

LDCT

Question 14

A NP suspects lung cancer in a patient. What is the work-up?

Answer 14

Order chest radiograph (e.g., nodules, lesions with irregular borders, pleural effusion).
The next imaging exam needed is a CT scan.
Baseline labs include complete blood count (CBC), chemistry panel, liver enzymes, bilirubin, creatinine.

Refer patient to a pulmonologist for bronchoscopy and tumor biopsy.
Gold Standard DX: Lung biopsy

Question 15

When should colorectal cancer be screen?

Answer 15

Start at age 50 years with baseline colonoscopy (repeat every 7–10 years; abnormal findings dictate more frequent evaluation),

Sigmoidoscopy (every 5 years)

A high-sensitivity fecal occult blood test (FOBT; annually).

A DNA-based screening FOBT (Cologuard) is now available in place of the screening colonoscopy, but it is only for average-risk individuals with no prior history of abnormal colonoscopy findings and/or no family history of colon cancer.

Question 16

An older adult who presents with a change in bowel habits with hematochezia or melena and/or abdominal pain. The patient with unexplained iron-deficiency anemia. The patient may report anorexia and unintentional weight loss. Patients with rectal cancer can present with tenesmus, rectal pain, and diminished-caliber stool. What is the suspect dx?

Answer 16

colon cancer

GI referral

Question 17

What is multiple myeloma?

Answer 17

Cancer of the bone marrow that affects the plasma cells of the immune system (production of monoclonal immunoglobulins).

Question 18

What the cardinal s/s of multiple myeloma.

Answer 18

CRAB
Calcium increase
Renal insufficiency
Anemia
Bone Disease

Question 19

An older-to-elderly adult who complains of bone pain with generalized weakness. The bone pain located on the central skeleton (chest/back/shoulders/hips/pelvis), worsens with movement, and rarely occurs at night. The patient presents with anemia. What does the NP suspect or should rule out? What is the work up?

Answer 19

Suspect multiple myeloma.
Check for CRAB s/s
Work up include Baseline labs include CBC, FOBT, chemistry panel, and UA.

Refer patient to a hematologist.

Question 20

What lifestyle factors contribute to constipation?

Answer 20

Constipation are immobility, low-fiber diet, dehydration, milk intake, and ignoring the urge to have bowel movement.

Question 21

What medication can contribute to constipation?

Answer 21

Drugs that cause constipation are iron supplements, beta-blockers, calcium channel blockers, antihistamines, anticholinergics, antipsychotics, opiates, and calcium-containing antacids.

Question 22

What is the treatment plan for constipation ?

Answer 22

Education and behavior modification (bowel retraining). Teach “toilet” hygiene such as going to the bathroom at the same time each day; advise not to ignore the urge to defecate.

Dietary changes such as eating dried prunes and/or drinking prune juice. Increase intake of fruit and vegetables.
Ingest bulk-forming fibers (25–35 g/day) once daily. Do not take with medication (will absorb drugs). Take with full glass of water (can cause intestinal obstruction).

Increase physical activity, especially walking.

Increase fluid intake to 8 to 10 glasses/day (if no contraindication).

Consider laxative treatment (Table 1). Avoid daily use of laxatives (except for fiber supplements) and chronic treatment with laxatives.

Question 23

The NP’s patient need bowel retraining. What is included in the education?

Answer 23

Choose time of the day patient prefers for bowel movements. Usually in mornings about 20 to 40 minutes after eating breakfast.

Spend about 10 to 15 minutes on the toilet each day at the same time. Avoid straining.

Question 24

What is the most common neurogenerative dementia?

Answer 24

The most common cause of neurodegenerative dementia in elderly is Alzheimer’s disease (60%–80%)

Question 25

What is the most common non-degenerative dementia?

Answer 25

The most common cause of non-neurodegenerative dementia is vascular dementia (CVA).

Question 26

A patient is suspected to have dementia. What is the initial workup to rule-out other diseases?

Answer 26

Ruling out secondary causes is done by ordering laboratory tests for syphilis, vitamin B12 deficiency, thyroid-stimulating hormone (TSH), syphilis (only if high clinical suspicion based on sexual history or travel).

MRI is preferred over CT when scan of the brain is indicated.

Question 27

The nurse has to do a cognitive test. What is included on the Mini-Mental State Examination (MMSE)

Answer 27

A brief screening exam to assess for cognitive impairment.

High sensitivity and specificity.

Score range is 0 to 10 (severe), 10 to 20 (moderate), 20 to 25 (mild), 25 to 30 (questionable significance; mild deficits).

Question 28

Mini-Mental State Examination (MMSE): Perform test MMSE

Answer 28

1. Orientation to time and place
   Ask about year/season/date/day/monthWhere are we now? Name state (county, town/city, hospital, floor)
2. Short-term memory
   Name three unrelated objects and instruct the patient to recite all three words

3.  Attention and calculation
Serial 7s (ask the patient to count backward from 100 by sevens)

4. Alternative: Instruct the patient to spell world backward
5. Recall
   Say to the patient, “Earlier I told you the names of three things. Can you tell me what they were?”
6. Language
   Show the patient two simple objects (e.g., pencil, coin); instruct patient to name them.Instruct the patient to repeat the phrase “No ifs, ands, or buts.”Give the patient one blank piece of paper. Instruct patient to “take the paper in your right hand, fold it in half, and put
   it on the floor.”Write on the paper “Close your eyes.” Instruct the patient to read and do what it says.
7. Complex commands
   Writing a sentence: Instruct the patient to make up and write a sentence about anything.

   Copying a design: Use a questionnaire with a picture of two pentagons that intersect.

Question 29

A patient is experiencing delirium. What does the NP check for to find the cause?

Answer 29

Check Prescription medications (opioids, sedatives, hypnotics, antipsychotics, polypharmacy)

Check Substance abuse (alcohol, heroin, hallucinogens), plants (jimsonweed, salvia)

Cehck Drug–drug interactions, adverse reactions, psychiatric illness

Check for Abrupt drug withdrawal (alcohol, benzodiazepines, drugs)

Check Preexisting medical conditions, ICU patients with sensory overload

Cehck for Infections, sepsis (UTI and pneumonia most common infections)

Check Electrolyte imbalance, heart failure, renal failure

Question 30

What are the three A for Alzheimer’s?

Answer 30

Three As: Aphasia, apraxia, agnosia

Aphasia (difficulty expressing and understanding language)

Apraxia (difficulty with gross motor movements such as walking)

Agnosia (inability to recognize familiar people or objects)

Question 31

What’s the treatment for a MMSE 10–26 score?

Answer 31

Mild to moderate

Cholinesterase inhibitor drug class (increases longevity of acetylcholine)

Donepezil (Aricept), rivastigmine (Exelon), galantamine, or N-methyl-d-aspartate (NMDA) receptor agonist memantine (Namenda) PO daily to BID

Question 32

You patient scored MMSE <17 . What is the treatment plan?

Answer 32

Moderate-to-advanced dementia

Add memantine (10 mg BID) to cholinesterase inhibitor or use memantine alone.

Question 33

How to treat severe dementia?

Answer 33

Severe dementia (MMSE <10): Continue memantine or discontinue drug.

Improvement within 3 to 6 months. Stop if no longer effective.

Question 34

What are the s/s of Parkinson?

Answer 34

The classic three symptoms are tremor (worse at rest), muscular rigidity, and bradykinesia.

Parkinson’s dementia is common (up to 40%).

Depression is common (up to two-thirds of all patients).

Question 35

What is the first line drug for Parkinson Disease? What is included in the education?

Answer 35

first-line drug: Carbidopa–levodopa (Sinemet) TID (dopamine precursor)

Start at low doses. Sinemet 25/100 mg (half tablet) PO BID to TID with meal or snack to avoid nausea. Titrate up slowly to control symptoms.

Sudden withdrawal or dose reductions of levodopa or dopamine agonists (e.g., bromocriptine, ropinirole) may be associated (rarely) with akinetic crisis or parkinsonism-hyperpyrexia syndrome (fever, autonomic dysfunction, muscular rigidity, altered mental status).

Adverse effects: Motor fluctuations (wearing-off phenomenon), dyskinesia, dystonia, dizziness, somnolence, nausea, headache. Eventually will develop tardive dyskinesia (treat with benztropine, amantadine, others).

Question 36

Treatment for tardive dyskinesia (extrapyramidal symptoms) are the following:

Answer 36

Administer anticholinergics: Benztropine (Cogentin).
Administer amantadine (Symmetrel/Osmolex ER): Antiviral (treats type A influenza) and dopamine agonist.