Unit 2 Flashcards
(450 cards)
1
Q
A 2 mo old is diagnosed with CAP. What treatment plan should the NP institute?
A
admit to hospital
2
Q
If in fact a bacterium is the cause of pneumonia in a child, what is the likely organism?
A
S. pneumoniae
3
Q
Bacterial pneumonia is MORE common in kids?
A
false, VIRAL
4
Q
Most common cause of CAP in children is?
A
RSV
5
Q
How is pertussis diagnosed?
Best if done when?
A
Rapid antigen (PCR) by nasal swab or nasal aspirate (best if done in 1st 3wks of cough)
6
Q
What causes Pertussis?
A
Bordetella pertussis
7
Q
According to the 2015 AAP, the following ARE NOT recommended for treatment of bronchiolitis.
A
routine RSV testing, CXR, albuterol, corticosteroids, ABXs, Ribavirin
8
Q
How is RSV identified?
A
viral nasal swab
9
Q
Bronchiolitis usually affects what age group?
A
< 2 years old
10
Q
____________ is the most common cause of bronchiolitis?
A
RSV
11
Q
Epiglottitis is usually caused by what organism?
A
H. INFLUENZA B (HiB)
12
Q
What is epiglottitis?
A
sever form of croup
13
Q
If patient’s croup signs and symptoms are moderate to severe.
How should the NP proceed with treatment?
A
humidified O2, dexamethasone IM x1, nebulized racemic epi;
s/s should improve in 10-30min; if not – admit to hospital
14
Q
A patient present with mild symptoms of croup. How should the NP proceed with treatment?
A
oral hydration, minimal handling, dexamethasone (0.15mg/kg IM), can d/c from ED if symptoms improve in <3hr
15
Q
Croup is usually cause by what?
A
virus
16
Q
Croup is usually preceded by a ______________?
A
URI
17
Q
What age group is usually affected by croup?
A
6mo-5 years
18
Q
What are the 1st line tx for bronchiolitis in children?
A
supportive measures
19
Q
What is the most common cause of croup?
A
Parainfluenza
20
Q
Which virus causes the “summer cold”?
A
enterovirus
21
Q
Which abx effectively treats atypical pathogens in pneumonia?
A
clarithromycin
22
Q
When treating a health 3 yr. old patient for PNA, the NP realizes that the MOST likely cause is?
A
respiratory VIRUS
23
Q
Aspiration of a FB can mimic the symptoms of what condition?
A
croup
24
Q
According to guidelines for ABX therapy:
1. Don’t test for or initiate abx therapy for ____ unless pneumonia is suspect
A
bronchitis
25
According to guidelines for ABX therapy:
1. Test patient with symptoms suggesting group-A strep by ______;
2. treat with abx ONLY with confirmed ___
1. rapid antigen test or culture
2.strep
pharyngitis
26
According to guidelines for ABX therapy: Acute rhinosinusitis should only receive abx if symptoms persist ___, high fever and purulent nasal drainage + face pain >___days;
worsening symptoms lasting __days
>10 days
3 days
5 days
27
What patient can receive RIV4 (recombinant) vaccine?
18 yr and older, reactions to egg or who required epi or another emergency medical intervention
28
What patient can receive the IIV3 vaccine?
>65 yr (inactivated virus at higher dose)
29
What patient can receive the IIV4 vaccine?
6 mo and older (inactivated virus; includes healthcare workers)
30
What patient can receive the LAIV4 vaccine?
Contraindications:
2yr-49yr old patients without contraindications
(CANNOT BE GIVEN: <2 yr old, pregnancy, 18yr old on aspirin therapy, healthcare
personnel, person in close contact w/high risk groups, asthma,
50yr or older (they receive IIV3), immunocompromised, use of antiviral med in
past 48hr (Tamiflu)
31
T or F: The CDC still does not recommend use of LAIV for 2019-2020 season
False; this year, they have resumed recommending LAIV as a suitable option in age-appropriate patients.
32
T of F: The CDC did NOT recommend use of LAIV for 2015-2017
True; concerned that it wasn’t effective in preventing flu past 2 years
33
Patient presents with abrupt onset of unilateral or bilateral spasmodic pain of variable intensity over the lower ribs or upper
abdomen; HA, fever, decreased thoracic excursion. what’s your diagnosis?
Pleurodynia secondary to coxsackievirus
(normal CXR, 1-week duration)
THIS IS DISEASE OF THE MUSCLES!
Give potent
analgesic agents, teach chest splinting
34
Patient presents with acute onset of fever and posterior pharyngeal GRAYISH WHITE VESICLES that quickly form ULCERS
LINEARLY ALONG POSTERIOR PALATE, + abdominal pain, 4-5 day duration. what’s diagnosis?
herpangina secondary to coxsackie virus
35
Patient presents with vesicles / papules on tongue, oral mucosa, hands, feet, 1-2 weeks duration, fever sore throat, hand foot and
mouth: when fever goes down - a rash can appear simulating roseola
hand foot and mouth disease secondary to coxsackie virus
36
Patient presents with febrile, pharyngitis with NONULCERATIVE YELLOW-WHITE PAPULES ALONG POSTERIOR PALATE
1-2 wk duration
acute lymphonodular pharyngitis secondary to coxsackie virus
37
Patient presents with sore throat, abdominal discomfort, 3-4 day duration, VESICLE / PAPULES on pharynx WITHOUT
EXUDATE. what is the diagnosis?
acute febrile pharyngitis secondary to enterovirus
38
___ severe infections in young children (sepsis and meningitis) before the age of 2-5yr; transmission is fecal-oral or from
respiratory secretions; summer-fall outbreaks
Parechovirus (HPeV)
39
How do you treat adenovirus?
no specific treatment exists; let it run its course / supportive therapy
40
How is adenoviruses diagnosed?
viral culture (results in <48hr) or PCR
41
<4 yr old with short-lived diarrhea. What’s your diagnosis?
enteric adenovirus (type 40/41)
42
Patient presents with FB sensation, photophobia, swelling of conjunctiva/eyelids - what's your diagnosis?
____ secondary to ___virus
Epidemic Keratoconjunctivitis secondary to adenovirus
43
Patient presents with fever, pharyngitis, and conjunctivitis – what’s your diagnosis?
This has NO ____ resp. symptoms
Pharyngoconjunctival Fever (secondary to adenovirus) – THIS HAS NO LOWER RESPIRATORY SYMPTOMS
44
Most common adenovirus disease?
pharyngitis
45
_____: < 2 yr old; winter and spring (daycare); DROPLET TRANSMISSION; incubation 3-10 days; URI symptoms; antigen detection,
PCR, culture (depends on type)
Adenovirus
46
___ <5 yr old, occurs late autumn-early spring; cough sore throat, acute wheezing; PCR of resp
secretions; no treatment available; duration is shorter in ___ than RSV symptoms
Human Metapneumovirus Infection (hMPV):
47
How is parainfluenza diagnosed?
based on clinical symptoms *barking seal cough*; PCR<24hr result
48
What is the incubation period for parainfluenza (croup cause)?
2-7 days
49
Parainfluenza: most often affects what age? When do you often see an outbreak?
<5yr old; fall outbreak
50
What treatment is given to a patient with the common cold?
supportive care; (<2 yr. old: hydration, humidified air, suctioning; >2 yr. old: PO antihistamines, decongestants, cough suppressants);
vitC, zinc, topical decongestants – not shown to improve symptoms
51
T of F: antibiotics can prevent complications of the common cold and limit duration of purulent rhinitis
False; ANTIBIOTICS WILL NOT PREVENT COMPLICATIONS OF THE COMMON COLD and DO NOT LIMIT
DURATION OF PURULENT RHINITIS!
52
With the common cold (generally speaking), how long do you expect to see symptoms for?
5-7 days
53
The common cold, what is most often the cause?
depends on seasons;
1. rhinoviruses: colder months
2. adenoviruses: all seasons
3. RSV: late fall-early spring (jan-feb peak)
4. influenza virus: fall-winter
5. enterovirus: summer cold
54
Few days – 16 weeks of age
watery, mucopurulent, to blood-tinged discharge and conjunctival injection
Pneumonia (complication): onset 2-12 weeks with staccato cough, afebrile,
tachypnea
Dx: conjunctival/resp specimen
systemic abx are required: AZITHROMYCIN
TEST THE MOTHER AND MOTHERS PARTNER
*Erythromycin ointment post-birth DOES NOT PREVENT THIS
CHLAYMDIA TRACHOMATIS
55
s. pneumoniae
AOM, sinusitis, pneumonia, meningitis
clinical findings correlate with what their underlying condition is
sepsis: high fever, >15,000 WBC
pneumonia: above symptoms + tachypnea, localized chest pain, localized/diffuse rales
pneumococcal meningitis: fever + high WBC, irritability, lethargy, neck stiffness (older kids)
Diagnosis / Treatment dependent on underlying cause
sepsis: mild - ceftriaxone; severe: add vanc
pneumonia: infants >1mo = ampicillin, PCN G, cefs; mild pneumonia >1mo: amoxicillin
pneumococcal meningitis: vanc+cefotaxime
PNEUMOCOCCAL PNEUMONIA
56
h. influenzae
acute epiglottitis, septic arthritis, cellulitis
DROPLET ISOLATION
Prevention of h.influenzae: HiB vaccine series
Diagnosis / Treatment dependent on underlying cause
Requires hospitalization and 3rd generation cephs (cefotaxime / ceftriaxone)
h. influenzae meningitis: vancomycin + cephalosporin IV for 10 days; dexamethasone (given
immediately after dx, continue for 4 days to reduce incidence of hearing loss)
*Pregnant women CANNOT receive Rifampin to reduce colonization of HiB
H. Influ
57
Bordetella pertussis
Insidious onset with 3 stages (catarrhal, paroxysmal, convalescent)
HIGHLY COMMUNICABLE
prodromal catarrhal stage: (1-3 weeks) mild cough, WITHOUT FEVER
paroxysmal stage: persistent staccato, paroxysmal cough ending w/ high-pitched inspiratory whoop
convalescent stage: slowly resolving cough over weeks-months
ELEVATED WBCs
Dx: PCR or culture nasopharyngeal secretions
Start tx in prodromal phase (if you can)
Infants <1mo: AZITHROMYCIN r/t risk of PYLORIC STENOSIS
Infants >1mo: clarithromycin
Prevention: vaccinations (immunity wanes @ 5-10 yr post-vaccine)
DTaP (infants/children) / Tdap (preteens, teens, adults
*High suspicion of pertussis: treat & don’t wait till results come back!
Pertussis
58
```
(an enterovirus)
1-____ Older children
Incubation: 3-4 day
sore throat + abdominal
discomfort + VESICLE /
PAPULES on pharynx
WITHOUT EXUDATE
```
Acute Febrile
| Pharyngitis
59
```
(an enterovirus)
1-____ Coxsackievirus
1-2 wks duration
Febrile + pharyngitis with
YELLOW-WHITE papules
WITHOUT ULCERS linearly
along posterior palate
Supportive treatment
```
Acute Lymphonodular
| Pharyngitis
60
```
(an enterovirus)
1-____ Coxsackievirus A
4-5 duration
Acute fever + GRAYISHWHITE
vesicles WITH
ULCERS linearly along
posterior palate, uvula, tonsillar
pillars + abd pain +
dysphagia/drooling
```
Herpangina
61
```
(an enterovirus)
1-____ Coxsackievirus
1-2 week duration
Vesicles/red papules on
tongue, hands, feet +
fever, sore throat
fever goes down à
roseola-like rash appears
```
Hand Foot and Mouth
62
```
(an enterovirus)
1-____ Coxsackievirus B
1 week duration
Abrupt onset
unilateral or bilateral pain
(spasmodic/variable intensity) over the
lower ribs or upper abdomen + fever +
decreased thoracic excursion
analgesics, chest splinting
```
Pleurodynia
| “muscle disease”
63
```
VIRAL RESPIRATORY ILLNESS (PEDIATRICS)
1. _______Organism/season dependent
Rhinovirus: colder months
Adenoviruses: all seasons
RSV: late fall-early spring
Influenza: fall-winter
Enterovirus: summer
Incubation: 5-7 days
URI symptoms + low grade fever
NO ANTIBIOTICS
<2yr: hydration, humified air
>2yr: PO antihis, decon, cough suppr.
```
common cold
64
VIRAL RESPIRATORY ILLNESS (PEDIATRICS)
1. _______< 2 yr old (daycare)
winter and spring
DROPLET
Incubation: 3-10 days
URI symptoms (pharyngitis*)
Dx: antigen detection, PCR, culture (depends on type)
Pharyngoconjunctival Fever: fever, pharyngitis, and conjunctivitis
Epidemic Keratoconjunctivitis: FB sensation, photophobia, swelling of conjunctiva/eyelids
Enteric Adenovirus (40/41): <4 yr old with short-lived diarrhea
no specific treatment exists; supportive therapy
adenovirus
65
VIRAL RESPIRATORY ILLNESS (PEDIATRICS)
1. _______before the age of 2-5yr + severe infection
summer-fall outbreaks
sepsis and meningitis*
transmission: fecal-oral, respiratory secretions
PARECHOVIRUSES (HPeV)
66
```
VIRAL RESPIRATORY ILLNESS (PEDIATRICS)
1. _______<5 yr old
late autumn-early spring
Duration: shorter in hMPV than RSV
cough sore throat, acute wheezing
PCR (resp secretions)
no treatment available
```
HUMAN METAPNEUMOVIRUS (hMPV)
67
VIRAL RESPIRATORY ILLNESS (PEDIATRICS)
1. _______H. influenzae (H1N1-A; B)
late fall-mid spring
Incubation: 2-7 days
Acute illness duration 2-5 days (several weeks in young children)
DROPLET TRANSMISSION
SYMPTOMS DEPENDENT ON AGE GROUP
Older children (same as adults): high fever, severe myalgia, HA, chills
Young children: GI symptoms
Infants (same as old people): sepsis-like illness, apnea, AMS, lethargy
Reye Syndrome (protracted vomiting, irrational behavior during flu season; varicella/ influenza
type B)
nasal swab / PCR test
supportive care + Tamiflu (5-day course given within 48 hr of symptom onset)
influenza
68
VIRAL RESPIRATORY ILLNESS (PEDIATRICS)
1. _______early spring (jan-feb peak)
3-7 days duration (fever won’t correlate w/resp symptoms)
Recent URI + wheezing, cough, tachypnea, difficulty feeding, prolonged expiration
CXR: hyperinflation
nasal swab
symptomatic treatment; resp isolation; good handwashing; cohort RSV with RSV
*Ribavirin only needed for immunocompromised kids
*<6mo old w/elevated WBC and prominent cough – MUST RULE OUT
PERTUSSIS
NO NEED FOR: abx, decongestants, expectorants, albuterol, or systemic
corticosteroids (unless asthmatic or premature infant)
RSV
69
```
VIRAL RESPIRATORY ILLNESS (PEDIATRICS)
1. _______<5 yr old
fall season
Incubation: 2-7 days
Barking seal cough
Dx: clinical symptoms; PCR
Manage croup symptoms
```
Parainfluenza
70
According to current recommendations per AAP for bronchiolitis, what testing should not be done?
no viral nasal swab for routine rsv testing (unless on palivizumab for prophylaxis);
CXR (unless respiratory distress is present);
albuterol/salbutamol and corticosteroids, antibiotics (only given if bacterial infection is strongly suspected)
71
A 5-year-old patient presents to your clinic with insidious onset of fever and dry cough, that has progressed to rales, chest pain, and
fever.
CXR reveals bronchopneumonic infiltrates in middle/lower lobes and a small pleural effusion.
What is the likely diagnosis for
this patient?
Mycoplasma pneumonia (>5-YEAR-OLD;
M. pneumoniae organism – incubation period is 2-3 wks long with slow onset of
symptoms;
NORMAL WBC w/diff, supportive measures + azithromycin 5 days)
72
A 3yr old patient with recent diagnosis of bacterial CAP comes to clinic for follow-up. Patient is favors lying on his left side,
complaining of chest pain. What is the complication of bacterial CAP you suspect in this child?
parapneumonic effusion and empyema (<5 YEARS OLD, meniscus or layering fluid on lateral decubitus CXR, s.pneumoniae
organism; dullness to percussion on affected side; child prefers lying on affected side; high WBC with left shift; needs IV abx)
73
In a pediatric patient diagnosed with viral CAP, what is your treatment of choice?
depends on underlying cause
+ PO abx to cover co-existent bacterial pneumonia
(rsv: supportive measures; influenza: Tamiflu
within 48hr of symptom onset for 5 days;
Relenza only given to ages 5 and older)
74
In a pediatric patient diagnosed with bacterial CAP, what is your treatment of choice?
Amoxicillin, 5-10 days (empiric tx aimed at S. pneumoniae)
75
```
The FNP has determined the patient can do outpatient treatment. What is the required follow-up time for this patient?
A: 12-24 hours
B: 1-5 days
C: 4 weeks
D: 6 weeks
```
1-5 days
76
```
The patients who require hospitalization with CAP include which of the following? SELECT ALL THAT APPLY!
A: all infants <3mo old
B: hypoxemia
C: effusion on CXR
D: poor feeding
```
All of the above (all infants <3mo for abx (IV or PO), any child with apnea, hypoxemia, poor feeding, effusion of CXR, moderate or
severe respiratory distress, or clinical deterioration on treatment)
77
What treatment should be provided for all pediatric patients with CAP (viral and bacterial)?
supportive measures (antipyretics, increase fluids, O2 if hypoxic)
78
T or F: Bacterial CAP will present with normal or slightly elevated WBC?
False, this is seen in viral CAP (Bacterial CAP has WBC elevated with left shift, a low WBC (<5000) can be on ominous finding in
bacterial pneumonia = overwhelming infection)
79
a ___ WBC of ____ can be on ominous finding in
| bacterial pneumonia = overwhelming infection
low, <5,000
80
In a pediatric patient with viral CAP, what radiological findings do you expect to see?
Perihilar streaking
increased interstitial markings
hyperinflation
81
In a pediatric patient with bacterial CAP, what radiological findings do you expect to see?
lobar infiltrates "consolidation"
82
T of F: CXR cannot distinguish viral from bacterial, but you will some differences in presentation
true
83
What type of patient is at HIGHEST risk for bacterial CAP?
1-I
2-M
3-A
immunocompromised, malnourished, aspiration
84
What is the MOST common bacterial cause of CAP in children?
S. pneumoniae
| bacterial usually follows viral lower respiratory tract infection
85
A patient presents to your clinic with temp 39C, tachypnea, and unilateral crackles on the left side. What is HIGH on your
differential diagnosis?
bacterial pneumonia (assess for AOM, sinusitis, epiglottitis, meningitis)
86
_____:
RSV (viral cause)
< 2 YEAR OLD
Current bacterial pneumonia
URI à tachypnea, rapid shallow breathing à poor feeding à
crackles, nasal flaring, hypoxia
CXR: non-specific hyperinflation, increased interstitial markings
1st line tx: Supportive treatment (outpatient)
Ribavirin ONLY FOR SEVERLY ILL KIDS
BRONCHIOLITIS
87
_____: Gram-negative bacteria
Child has underlying medical condition
Fever, cough, respiratory distress in @ risk patient
Decreased breath sounds limited to right upper lobe
CXR acute: lobar consolidation/atlectasis, generalized
interstitial infiltrates
CXR chronic: perihilar infiltrates
1st Line Acute tx: IV Clindamycin
aspiration pneumonia
88
_____:S. pneumoniae
<5 YEAR OLD
Current bacterial pneumonia
Chest pain, fever, will lie on affected side
Lateral Decubitis XR: meniscus or layering fluid
Elevated WBC with left shift
IV abx and DRAIN FLUID
PARAPNEUMONIC EFFUSION / EMPYEMA
89
_____: M. pneumoniae
> 5 YEAR OLD
SLOW ONSET Fever, dry cough
PROGRESSES to sputum production
CXR: Bronchopneumonic infiltrates middle/lower lobes
Normal WBC w/diff
Supportive measures + IV abx Azithroymcin
MYCOPLASMA PNEUMONIA
90
_____: BACTERIAL CAP VIRAL CAP (most common)
S. pneumoniae
Fever >39C, tachypnea, cough
Crackles, decreased breath sounds over areas of consolidation
Infiltrates, hilar adenopathy, pleural effusion
Coinfection: AOM, sinusitis, pericarditis, epiglottitis
Elevated WBC
Supportive measures + Amoxicillin 5 days
BACTERIAL CAP
91
_____: RSV / parainfluenza / influenza A or B
URI prodrome (fever, coryza, cough, hoarseness)
Wheezing or rales
Myalgia, malaise, headache (older children)
Normal WBC
Supportive measures + PO abx (cover co-infection) +
treat underlying cause
viral CAP (most common)
92
What is the treatment of tracheitis?
Order IV abx to cover S. aureus, H. influenzae and REFER for ICU ADMIT!
[Needs direct visualization of the airway to perform debridement; intubation;
humidification, frequent suctioning]
93
What are the typical lab findings in a patient with bacterial tracheitis?
Elevated WBC with left shift;
lateral neck XR show normal epiglottis with
severe subglottic and tracheal narrowing;
irregularity of contour of proximal tracheal
mucosa
94
If untreated, bacterial tracheitis will progress to what?
SUDDEN RESPIRATORY ARREST! If suspected, REQUIRES IMMEDIATE
| INTERVENTION!
95
In bacterial tracheitis, what KEY symptom would set this apart from epiglottitis or croup?
This patient would be unresponsive to standard croup treatment
96
tracheitis pt- After intubation, what should be obtained?
blood cultures + initiate IV abx to cover H influenza and Streptococcus species (ceftriaxone or equiv. cephalosporin)
97
The FNP has made the diagnosis of epiglottitis. What is your immediate expected intervention? SELECT ALL THAT APPLY!
A: have the child lay down on the examination table, awaiting transport to ED
B: minimal handling to protect the airway
C: visually inspect airway
D: consult for intubation of the patient
B, D
98
In a pediatric patient with suspected epiglottitis, should diagnostic imaging be ordered to confirm diagnosis?
Determined by patient presentation (do not delay securing an airway for someone with impending respiratory collapse to obtain
CXR)
99
In a pediatric patient with suspected epiglottitis, should diagnostic imaging be ordered to confirm diagnosis?
Determined by patient presentation (do not delay securing an airway for someone with impending respiratory collapse to obtain
CXR)
100
A 4-year-old presents to your clinic with 120HR, 39.9C temp, and muffled voice. This patient is sitting on the exam table leaning
forward with nose in the air. What differential diagnosis should be ruled out?
A 4-year-old presents to your clinic with 120HR, 39.9C temp, and muffled voice. This patient is sitting on the exam table leaning
forward with nose in the air. What differential diagnosis should be ruled out?
101
```
What sign(s) could differentiate epiglottitis from viral croup? SELECT ALL THAT APPLY!
A: high fever
B: inspiratory stridor
C: cough
D: drooling
```
A, D (epiglottitis has high fever, NO COUGHING, drooling, muffled voice, and dysphagia)
102
A patient with viral croup (stridor at rest, retractions, air hunger, and cyanosis) would
require what treatment plan?
administer humidified O2 (decreasing O2 sat), neb racemic epi (0.5ml of 2.25% solution diluted in sterile saline – delivers rapid
onset within 10-30min), 1 dose of dexamethasone 0.6mg/kg IM; if recurrent epi tx is needed à MUST ADMIT TO HOSPITAL FOR
OBSERVATION AND CONTINUED NEB TX PRN
103
A patient with viral croup (barking cough and no stridor at rest) would be
appropriate for what type of treatment plan?
Supportive therapy (oral hydration, no tests or procedures);
1 single dose of
dexamethasone 0.15mg/kg PO or 0.6mg/kg IM
(improve symptoms and permits early d/c
form ED;
patient can be discharged from ED if symptoms resolve in <3hr
104
In a patient with atypical presentation of viral croup (absence of the classic barking
seal cough + other symptoms present in croup), the FNP should order a CXR. What
findings would you expect to see?
steeple sign without irregularities (indicates subglottic narrowing)
105
T or F: Diagnostic imaging should be ordered to diagnose a patient with viral croup
False (classic presentation of croup does not require CXR)
106
What is the MOST COMMON causative organism in viral croup?
#1 parainfluenza virus
(also, RSV, rhinovirus, adenovirus, influenza A/B,
M.pneumoniae)
107
What is the CHARACTERISTIC FINDING of a patient with viral croup that has
progressed?
barking seal cough, inspiratory stridor, and retractions at rest
108
During a follow-up appt for an 8-month-old with recent URI, you note the patient has inspiratory stridor and a barky cough. When
assessing the patients ears with the otoscope, the patient begins to cry, and the stridor is worsened. What diagnosis is HIGHEST on
your differential?
```
Viral croup (early signs: no stridor at rest, with mild stridor when agitated; examine patient when they are quiet and relaxed to best
judge difficulty of breathing)
```
109
A 2-year-old girl presents to the emergency room with fever, cough, runny nose, stridor and difficulty breathing. Temperature is 101, RR 30,
there is audible stridor and a barky cough. The chest is clear, and the child does not look toxic.
What other history is important?
Nature of the onset? Was it sudden or gradual? What was the child doing when the symptoms started?
a. Acute onset of stridor is suggestive of what? Foreign Body Aspiration
2. Has the child had a recent URI? Viral Croup
3. What is the immunization history? Epiglottitis (most cases are caused by H. flu)
4. Is there a past history of croup Spasmodic croup (some children have recurrent bouts of croup)
5. Is there a history of prior intubation? Subglottic stenosis (if child has been intubated, they may have residual changes)
110
```
___6mo – 5 yr old
recent URI
Fall or early winter
onset
Parainfluenza virus
Barking seal cough
XR: Steeple sign
```
viral croup
111
```
___ H. influenzae (unimmunized kids)
Non-typeable H.influenzae
(immunized kids)
3 D’s: drooling, dysphagia,
distress; NO COUGH
Sniffing dog position
XR: Thumbprint sign
```
epiglottitis
-REFER for ADMIT to ICU!
Intubation
-Order blood cultures + initiate IV abx to cover H influenza
(ceftriaxone or equiv. cephalosporin)
112
____S. aureus
1-3 days of viral (rhinorrhea, low-grade fever, cough, sore
throat)
Progresses (high fever, COUGH, acutely worsening
STRIDOR)
Prefers to lie flat
UNRESPONSIVE TO STANDARD CROUP THERAPY!
Elevated WBC with left shift [NEW INFECTION – bands]
Lateral Neck XR: Normal epiglottis with severe subglottic and
tracheal narrowing
bacterial tracheitis
-REFER for ADMIT to ICU!
Intubation
-Order blood cultures + initiate IV abx to coverS. aureus
(ceftriaxone or equiv. cephalosporin)
113
```
Without prompt treatment of a lower airway obstruction, what complications could occur? SELECT ALL THAT APPLY!
A: empyema
B: bronchiectasis
C: lung abscess
D: recurrent pneumonia
```
B, C, D
risk justifies an AGGRESSIVE approach to suspected FB in suspicious cases)
114
Following removal of lower airway FB, what is the recommended treatment
b-adrenergic neb treatments + Chest PT (helps to clear mucus or treat bronchospasm)
115
A patient presents to your clinic with sudden onset of wheezing on expiration, diminished breath sounds on the right side, and mild
respiratory distress. You suspect lower airway FB aspiration and order a CXR, which is normal. What is your next intervention?
Admit to hospital for evaluation and treatment (NORMAL CXR CANNOT RULE OUT FB!)
116
What is an important diagnostic study that can be performed to visualize the affected area / FB in lower airway FB aspiration?
inspiratory and forced expiratory CXR (+forced expiratory study: unilateral hyperinflation, mediastinal shift AWAY from affected
side; complete obstruction: atelectasis and related volume loss)
117
What past medical history should lead the FNP to suspect lower airway FB aspiration?
chronic cough, persistent wheezing, or recurrent pneumonia
118
A patient presents to your clinic with sudden onset of wheezing on expiration, diminished breath sounds on the right side, and mild
respiratory distress. What diagnosis is HIGHEST on your differential?
Lower airway FB aspiration
119
Blind finger sweeps in an infant or child is a good alternative if the parents do not know how to perform CPR
False; this can push FB further into airway (Open airway by jaw thrust – if FB can be visualized – carefully remove with fingers or
instrument)
120
A 10 yr old child is rushed in by his mother who states 30 minutes PTA, they were eating food when he began to choke. This patient is
currently unresponsive What do you suspect and what is your treatment?
COMPLETE obstruction with airway collapse; immediately begin CPR
121
A 5 yr old child presents to your clinic with cyanosis with marked distress. Patient is awake and alert. What do you suspect and what
is your treatment?
COMPLETE obstruction; perform Heimlich maneuver (abdominal thrusts)
122
A 1 yr old child presents to your clinic with cyanosis with marked distress. Patient is awake and alert. What do you suspect and what
is your treatment?
COMPLETE obstruction; place patient face down deliver 5 rapid blows to the back, roll patient over and deliver an additional 5
rapid chest thrusts (repeat until obstruction is relieved)
123
What is the treatment of a partial airway obstruction of the upper airway?
allowing choking subject to use his/her own cough reflex to remove object
124
What is considered the GOLD STANDARD for diagnosis of upper airway FB aspiration?
REFER! Requires rigid bronchoscopy
125
```
Without prompt treatment of an upper airway obstruction, what complications could occur? SELECT ALL THAT APPLY!
A: loss of consciousness
B: tachycardia
C: diaphragm paralysis
D: seizures
```
A, D (THINK IMPENDING RESPIRATORY ARREST! Bodies functions are slowing and shutting down – progressive cyanosis, LOC,
seizures, bradycardia, cardiac arrest)
126
Stridor: Low-pitched noisy breathing when the infant/child breathes IN - ____ airway obstruction
upper
127
Wheezing: High-pitched noise when the infant/child breathes OUT = ___ airway obstruction
lower
128
A mother rushes her 7-month-old daughter to your ED stating that she cannot breathe. Upon exam, you note stridor with ability to
vocalize. What diagnosis is HIGHEST on your differential?
Partial Foreign Body Obstruction (Aspiration)
129
What age group is HIGHEST risk for extrathoracic FB aspiration?
6 mo-3 yr
130
Wheezing on expiration = ____ airway obstruction, diminished breath sounds on 1 side
CXR forced expiratory (normal CXR doesn’t exclude FB from diagnosis)
Admit to hospital for treatment
Neb tx with chest PT after removal of object
LOWER
131
____ obstruction of upper airway
-Stridor with ability vocalize
Inspiratory stridor = UPPER AIRWAY
Allowing patient to use cough reflex to expel object
If that doesn’t work – BRONCHOSCOPY (NO BLIND SWEEPS)
partial
132
____ obstruction of upper airway
-Cyanosis with marked distress, cannot vocalize or cough
1yr or less, awake = 5 rapid blows to back/5 chest thrusts, repeat
>1yr old, awake = Heimlich maneuver
Any age, unconscious = CPR!
complete
133
What is the treatment plan for a patient with ALTE?
What is the treatment plan for a patient with ALTE?
134
What is MOST important for the FNP to obtain from parents of patient with suspected ALTE?
```
Careful history (duration of event, measures taken to resuscitate the infant, infant’s recovery from event à help determine severity +
Physical Exam)
```
135
```
The MOST frequently identified problems leading to an ALTE is?
A: respiratory
B: neurological
C: cardiovascular
D: GI
```
D (GI (50%), neurologic (30%), respiratory (20%), cardiovascular (5%), and metabolic / endocrine (<5%); also, can be caused by
non-accidental trauma)
136
T or F: ALTE is a specific diagnosis
False (50% remain unexplained and referred to as apnea of infancy)
137
T or F: any history of initiation of CPR for an ALTE increases the risk of SIDS
true
138
ALTEs infants are slightly younger than SIDs infants
true
139
T or F: ALTEs are due to an insidious onset of change in an infant’s breathing, appearance, or behavior
False (acute unexpected change – patient will go apneic, appear cyanotic or pallor, limpness in muscle tone, choke or gag)
140
While providing teaching to a new mother, you as the FNP should include what in your education/discharge teaching?
A: place all infants on the stomach to sleep
B: co-sleeping is not preferred
C: bundle your child to sleep
D: breast feeding, and bottle feeding have the same risks
B (supine sleep position, no co-sleeping, no extra blankets/pillows/soft objects in crib, use form fitted sheet only; breast feeding is
better than formula feeding; maternal smoking or drug use cessation; infant over-heating. The FNP must SCREEN ALL INFANTS for
SUID risk factors, and be mindful of the childcare setting, where risk factors may not be recognized or addressed)
141
```
Should the FNP suspect SUID, what is the MOST consistent finding he/she should be looking for?
A: emaciated appearance
B: ligature marks on the body
C: intrathoracic petechiae
D: cyanosis
```
C (Intrathoracic petechiae and mild inflammation / congestion of the respiratory tract: brainstem gliosis, extramedullary
hematopoiesis, increase in peri-adrenal brown fat à suggests infant had intermittent or chronic hypoxia before death)
142
What is NOT a risk factor for SUIDs?
recent immunizations
143
What age does SUID peak and at what time of day do most deaths occur?
2-4mo old, most deaths occur at night
144
```
What are often the determined causes of death in a patient with SIDS? SELECT ALL THAT APPLY!
A: suffocation
B: ingestion
C: cardiac arrest
D: trauma
```
all of the above (infection, ingestion, metabolic diseases, cardiac arrhythmias, trauma, accidental suffocation and strangulation –
unsafe sleep surfaces)
145
What is the MOST important part of the exam to explain cause of death in a patient with SIDS?
postmortem autopsy
146
What are group is affected by SIDS?
< 1year old
147
What is the 1st line treatment for OSA?
adenotonsillectomy
148
What must be performed in all cases suspected of OSA to diagnosis this condition?
polysomnogram (PSG)
149
A 7yr old patient presents to your clinic with poor school performance over the last 6 months. His mother states she is concerned that
he may have ADHD. What also must be part of your differential diagnosis / work-up for this patient?
OSA
150
What age group is affected by central sleep apnea at increased elevations?
infants/children
151
What is a common cause of airway obstruction in ages 2-7 yr old?
tonsillar hypertrophy
152
```
What symptoms should signal to the provider that OSA is present in a child?
A: infrequent nighttime arousals
B: habitual snoring
C: shallow breathing
D: rapid weight gain
```
B (loud habitual snoring, witnessed apnea, labored breathing, frequent nighttime arousals)
153
What are some common risk factors for OSA?
1
2
3
1. craniofacial abnormalities,
2. neuromuscular dx
3. drugs (hypnotics, sedatives, anticonvulsants
154
T of F: OSA is a result of lack of effort to breathe
False (lack of effort to breathe is central sleep apnea; OSA is cessation of breathing due to attempt to breathe through an obstructed
airway)
155
___lack of effort to breathe
central sleep apnea
156
___cessation of breathing due to attempt to breathe through an obstructed
airway
OSA
157
T or F: A child has markedly enlarged tonsils with dysphagia and recurrent tonsillitis. This patient requires a STAT PSG to confirm
sleep disordered breathing followed by adenotonsillectomy.
False (this patient meets criteria for surgery WITHOUT PSG)
158
In a healthy child, an adenotonsillectomy without PSG is recommended if what criteria are present? SELECT ALL THAT APPLY!
A: labored breathing with daytime fatigue
B: ADHD and weight gain
C: habitual snoring and sleepwalking
D: enlarged tonsils and increased frequency of urination
A: labored breathing with daytime fatigue
C: habitual snoring and sleepwalking
D: enlarged tonsils and increased frequency of urination
(nighttime symptoms: habitual snoring + gasping, pauses, labored breathing, night terrors, sleepwalking, secondary
enuresis; daytime symptoms: unrefreshed sleep, ADHD, emotionally labile, temperamental behavior, poor weight gain, daytime fatigue;
Enlarged tonsils)
159
```
What common co-morbid conditions warrant a PSG when suspecting sleep apnea? SELECT ALL THAT APPLY!
A: Obesity
B: Sickle cell
C: Autism
D: Myasthenia Gravis
```
A, B, D (Also, down syndrome, craniofacial abnormalities, any neuromuscular disease)
160
What diagnostic results from the PSG would be abnormal and warrant further investigation?
more than 1 apneic or hypopnea event per hour with duration of at least 2 respiratory cycles
161
What diagnostic results from the PSG would signal to the FNP there is clinically significant OSA?
children with apnea-hypopnea index >5 events per hour
162
In order to properly diagnose and manage uncomplicated childhood obstructive sleep apnea syndrome, what must the FNP do?
screen all children for snoring
163
How must obstructive sleep apnea be diagnosed?
polysomnogram (PSG)
164
Sleep disordered breathing is an umbrella term for what types of patients?
snoring, mouth breathing, pauses in breathing
165
When an FNP wants to differentiate croup from epiglottitis, what should the FNP order?
Lateral neck radiographs
(useful in assessing the size of adenoids and tonsils, and seeing the “thumbprint sign” associated with
epiglottitis)
166
When a foreign body is suspected, what should the FNP order?
Forced expiratory radiographs (shows focal air trapping and shift of mediastinum to the contralateral side)
167
When pleural fluid is suspected in the pediatric patient, what should the FNP order?
Lateral decubitus radiographs
| helps in determining the extent and mobility of the fluid
168
When ordering CXR in pediatric patients, what should your order consist of?
both frontal and lateral views
169
What is the FOUNDATION of investigating the pediatric thorax?
Chest X-ray
170
What risk factors should you educate a mother of a patient with asthma? SELECT ALL THAT APPLY!
A: limit outdoor activities during high ozone levels
B: pet dander can exacerbate asthma symptoms
C: household flea infestations can increase asthma attacks
D: black mold is the only mold that requires remediation
Answer: A & B (household cockroach infestation, and all mold requires remediation)
A: limit outdoor activities during high ozone levels
B: pet dander can exacerbate asthma symptoms
171
```
What are the extrapulmonary signs of intrinsic pulmonary disease in pediatric patients? SELECT ALL THAT APPLY!
A: cyanosis
B: altered mental status
C: clubbing
D: decreased PO2
```
A: cyanosis
B: altered mental status
C: clubbing
(cyanosis, AMS, signs of respiratory insufficiency including growth failure, clubbing and osteoarthropathy)
172
What is the MOST valuable examination finding in an older pediatric patient with pneumonia?
unilateral crackles
173
```
In children with respiratory illness, which finding(s) have good diagnostic accuracy in detecting hypoxemia? SELECT ALL THAT
APPLY!
A: tachypnea
B: inconsolable
C: respiratory effort
D: color
```
ALL
174
What must be assessed and reviewed at each clinical visit for asthma?
delivery technique of inhaled medications
175
In a patient <4 mo of age, what medication delivery technique MUST BE USED?
pressurized metered dose inhaler (pMDI) or similar spacer
176
What medication is appropriate to use in CF patients?
nebulized antibiotics
177
What medication is important to use to control inflammation?
Inhaled corticosteroids / Cromones; (controllers)
178
What medication is important to use to during acute bronchospasms (rescue medication)?
SABA (short-acting B-agonists (relievers)
179
```
What critical component of the pediatric physical exam will aid in detecting pulmonary disease?
A: palpation
B: auscultation
C: inspection
D: percussion
```
inspection
| -RR and work of breathing
180
Patient presents with sickle cell crisis. What lab would you expect to be elevated?
increased bili
181
A patient’s EKG has peaked t waves and a prolonged PR interval. What lab do you suspect is causing this?
Hyerkal
182
What drug specifically relies on the regulation of sodium?
lithium
183
Patient presents to clinic saying they cannot get enough of licorice - you expect what lab to be off?
hypokalemia
184
What lab is expected to be elevated in children (considered normal) but not in adults?
____
have more ___ than ___
ALP
| rapid bone growth; have more lymphocytes than neutrophils
185
If your creatinine is high - your GFR will be?
low
186
If this was elevated it would warrant checking for multiple myeloma?
total protein
187
Most specific lab for the kidneys?
CR
188
What level will jaundice be visible?
>3 total bili
189
Which WBC aids with healing and blood clotting?
basophils
190
Patient is having allergic rx. What WBC is elevated?
Eosinophils
191
What’s the strongest WBC that kills/digest FB?
monocytes
192
What WBC is the 1st line of defense:
Poly neutrophils
193
What is the earliest indicator of infection (WBC)?
bands
194
A patient presents to your clinic c/o anxiety and appears tachypneic. What lab would be most affected by this patient’s presentation?
Chloride (decreased Co2 (hyperventilation) = increase CL)
195
A patient is having an acute pancreatitis attack. When would you expect amylase to rise, peak, and return to normal?
2hr
12-48hr
3-4 days
196
A patient presents to your clinic to discuss the results of his PSA screening. You are concerned as this test result is 45.
What are your
differential diagnoses?
1-prostate manipulation
2-prostate cancer
3-prostate biopsy
197
If a patient with cirrhosis presents to the ED and their ETOH level is 324 - What would you expect their liver panel to look like?
low ALT/AST
high ALP
198
What lab would indicate your patient is dehydrated?
Elevated BUN, high albumin
199
What lab is dependent on albumin? What would this cause the lab to be?
Calcium (50% is bound to albumin); In a patient with chronic alcoholism, you would expect the calcium to be low (Think, if you are
malnourished you don’t drink milk - you drink alcohol; hence why alcoholics – in addition to their blood being thinner – would be at any even
more increased risk of bleeding)
200
What would you expect the albumin level to be in a patient with chronic alcoholism?
low
201
What is the term for elevated BUN & CREATININE?
Azotemia
202
In an overwhelming infection, what would the WBCs look like (the #)?
<5,000
203
What important prevention method should be used in pertussis?
Dtap
204
At what age should all patients receive a pneumococcal vaccine?
65
205
In efforts to prevent CAP, all patients should receive what vaccine?
Flu vaccine, annually (dosing schedule determined by age)
206
T or F: FluMist LAIV4 is approved for the 2017-2018 Flu season?
T or F: FluMist LAIV4 is approved for the 2019-2020 Flu season?
false
true
207
hat vaccine should be given at EACH pregnancy, regardless of prior vaccination history?
Tdap
208
How should a pediatric patient with CAP be treated outpatient?
Viral: oral abx to cover co-existing bacterial – amoxicillin 50-90mg/kg/day BID
If child is >5 yr – give macrolide
(Because there is
greater concern for mycoplasma pneumonia)
209
If a 5 yr old patient has influenza, can zanamivir be given?
Yes! Patients 5 and older
210
The patient cannot take a macrolide to treat their pertussis. What can be given if patient is >2 mo of age?
bactrium
211
Why is azithromycin the BEST choice for an infant <1 mo to treat pertussis?
Less risk of pyloric stenosis
212
Pertussis can be treated with what abx?
<1mo _
>1mo _,_,or _
Macrolides (if <1 mo – azithromycin;
if >1mo – azithromycin, clarithromycin, erythromycin)
213
In patients that have received abx in the past 3 months, choose a regimen that includes an abx from what a ____________ drug class?
different
214
When the provider chooses a resp fluoroquinolone, what does you suspect the NP is trying to prevent?
ABX resistance
215
A patient comes in with PNA, has co-morbidities, and has received abx recently. How would you treat this patient?
Respiratory fluoroquinolones OR Macrolide + Beta Lactam
216
What is the 1st line treatment of CAP in children?
Amoxicillin, duration 5-10 days
217
A pregnant woman contracts the flu. Which antiviral is appropriate?
Oseltamivir
218
You need to treat a 2 yr old child who is clinically stable for CAP, but in an outpatient setting. What antimicrobial is appropriate?
Amoxicillin
219
T or F: A rescue inhaler is intended for long-term maintenance?
False; rescue only – not maintenance
220
An otherwise healthy patient with no abx use in the past 3 months comes to your clinic and diagnosed with CAP.
What is the
treatment you would choose?
1-
2-
3-
Azithromycin, Clarithromycin, Doxycycline
221
What class of drugs is used for relief of acute symptoms related to bronchospasm? Note: every patient should have one of these**
SABA (Albuterol)
222
How would you treat CAP in an otherwise healthy patient who HAS recently taken abx?
Respiratory fluoroquinolones (i.e. Levofloxacin)
223
How would you treat CAP in an otherwise healthy patient who has not recently received abx?
Azithromycin
224
A patient present to your clinic with bronchitis but has a sulfa allergy. Which abx is safe to use?
Amoxicillin
225
When would you do a CXR on a bronchitis patient?
Suspected pneumonia
226
How do you diagnose bronchitis?
clinical exam
227
A 65-yr. old patient presents for persistent, productive cough. You note that he is a smoker. The upper airways are clear after you
have him . He has a fever and also complains of copious sputum with symptoms lasting 10 days. What is his likely diagnosis?
Bacterial Bronchitis
228
What treatment is appropriate for a patient with Legionnaires disease?
(macrolides) azithromycin PO, clarithromycin, or a fluoroquinolone “acins” (cipro, levo, moxi, gemi) for 10-14 days
229
What tx is NOT used for Legionnaires disease?
ERYTHROMYCIN IS NOT USED BECAUSE IT IS NO LONGER EFFECTIVE AGAINST THIS GRAM-NEGATIVE BACTERIA
230
```
What KEY lab finding is present in Legionnaires Disease versus other pneumonia?
A: elevated CK
B: decreased WBC
C: decreased sodium
D: elevated LFTs
```
C: hyponatremia (<130 – low Na+ levels are a common feature of patients with community-acquired pneumonia when caused by Legionella
pneumophila. Legionella produces an interstitial disease that can destroy the JG apparatus, so you can't secrete renin. Without renin, you
can't make aldosterone, so you get a type IV renal tubular acidosis and can't reabsorb Na+)
231
What transmission sources are responsible for legionnaires disease?
contaminated water sources (Showerheads / faucets), air conditioning cooling towers
232
```
Who is MOST at risk of contracting Legionnaires disease?
A: 42 yr old with COPD
B: 30 yr old with hx of TB
C: 56 yr old, former smoker
D: 72 yr old with CKD
```
C
233
```
What part of a patient’s recent history would signal to the FNP to consider a diagnosis of meningitis?
A: URI
B: AOM
C: strep throat
D: mononucleosis
```
Answer: B
AOM
(Also, sinusitis)
234
What is the initial treatment of a patient diagnosed with meningitis?
REFER FOR HOSPITAL ADMIT! Initiate IV ceftriaxone + IV dexamethasone (reduces long-term symptoms of hearing loss
235
What is treatment for epiglottitis?
IV Ceftriaxone (patient is at HIGH RISK for laryngeal obstruction – thus requires more aggressive treatment)
236
A patient presents with ABRUPT ONSET HIGH FEVER and c/o severe sore throat. Upon physical exam, you note the patients
throat to be mildly beefy red with no exudate. What is the patients most likely diagnosis?
epiglottitis (abrupt onset of high fever, drooling, inability to handle secretions; complaint of severe sore throat despite unimpressive
exam of pharynx)
237
What is the treatment for a seriously ill patient with multilobe pneumonia?
IV Ceftriaxone
238
What is the treatment for beta-lactamase strains?
Augmentin PO
239
What is the treatment for sinusitis, otitis, and URIs?
Amoxicillin PO
240
What is the most common cause of sinusitis, otitis, bronchitis, epiglottitis, pneumonia, cellulitis, arthritis, meningitis, and endocarditis
in adults?
H. influenza
241
What is the appropriate treatment for pertussis?
1. class or __
2. 4 examples
antibiotics – MYCINS (erythromycin, azithromycin, clarithromycin, or Bactrim)
242
What is the best prevention for pertussis?
```
DTaP vaccine (11-18 yr. old whose received DTP/DTaP should receive a SINGLE dose of either Tdap product; >64 yr needs a
single dose of Tdap; during EACH PREGNANCY, receive a single dose of Tdap regardless of previous vaccine hx)
```
243
The FNP knows the gold standard to diagnosing a patient pertussis is?
nasopharyngeal culture (Bordet-Gengou agar)
244
What is the typical lab / diagnostic findings suggestive of pertussis?
A: PO2 <90%
B: WBC >15,000-20,000
C: Patchy opacities and lobar consolidation (CXR)
D: gram + bacteria (blood cultures)
B - WBC >15,000-20,000
| patchy opacities/lobar consolidation is pneumonia; pertussis is a gram-negative bacteria
245
In adult patients, what must be part of your differential when a cough has been present for more than 2 weeks?
pertussis
246
BORDETELLA PERTUSSIS
What is the typical symptom presentation in stage 3 (Convalescent)?
1- begins __ weeks after onset with __
begins 4 weeks after onset with decrease in frequency / severity of paroxysms of cough
247
BORDETELLA PERTUSSIS
What is the typical symptom presentation in stage 2 (Paroxysmal)?
bursts of rapid, consecutive coughs followed by deep, high-pitched inspiration (inspiratory whoop)
248
BORDETELLA PERTUSSIS
What is the typical symptom presentation in stage 1 (Catarrhal)?
insidious onset of lacrimation, sneezing, coryza, anorexia, malaise, hacking night cough that becomes day cough
249
Stage 3 of pertussis is called what?
Convalescent
250
Stage 2 of pertussis is called what?
Paroxysmal
251
Stage 1 of pertussis is called what?
Catarrhal
252
Approximately how long do symptoms last and what is unique about symptom progression?
Answer: last about 6 weeks, occur in 3 consecutive stages; cough that is intermittent and turns paroxysmal
253
How is pertussis transmitted between humans?
droplet
254
T or F: infants are reservoirs of pertussis whereas adults / adolescents are most affected
False, infants are most affected whereas adults/adolescents are reservoirs
255
False, infants are most affected whereas adults/adolescents are reservoirs
7-17 days
256
A 16-month-old infant presents to clinic with c/o sneezing, decreased appetite, and hacking cough that began at night but is now
occurring during the day. What is high on your diagnosis differential of this patient?
A: RSV
B: Legionnaires disease
C: Pertussis
D: Epiglottitis
Pertussis
257
```
Which of the following is cause(s) to admit a patient for pneumococcal pneumonia? SELECT ALL THAT APPLY!
A: cannot maintain oral intake
B: exacerbation of HF
C: suspected endocarditis
D: multilobular disease
```
all
258
What is the BEST prevention against pneumococcal pneumonia?
pneumococcal vaccines
259
```
What 3 complications could result from pneumococcal pneumonia?
A: pleuritis and pleural effusion
B: pneumothorax and pericarditis
C: pleural effusion and pericarditis
D: empyema and lung abscess
```
C
| pleural effusion, empyema, pneumococcal pericarditis à tamponade
260
T or F: the patient must be monitored following treatment as pneumococcal pneumonia is increasingly resistant to PCN
true
261
What is the treatment for pneumococcal pneumonia?
empiric abx – Amoxicillin PO (uncomplicated cases) – if patient has allergy to PCN, “mycins”
262
What laboratory test could provide rapid results and early diagnosis for S. pneumoniae?
rapid urinary antigen test
263
A patient presents with signs/symptoms of pneumococcal pneumonia (uncomplicated). What must be the FNPs first intervention
regarding treatment?
start empiric abx treatment
264
```
What patient population(s) have the highest mortality rate with pneumococcal pneumonia? SELECT ALL THAT APPLY!
A: elderly
B: premature infants
C: bilateral pneumonia
D: COPD
```
also ___
elderly, billat pneumonia, COPD
&
hypoxemia, bacteremia, extrapulmonary complications
265
```
What risk factors are associated with pneumococcal pneumonia. SELECT ALL THAT APPLY!
A: HIV+
B: ETOH abuse
C: smoking
D: CHF
E: sickle cell
```
also
1
2
3
A, B, C, E
Also,
asthma
splenectomy
hematologic disorders
266
T or F: pneumococcal pneumonia is the most common cause of HAP
False; pneumococcal pneumonia is the most common cause of CAP
267
Pneumococcal pneumonia is what type of gram bacteria?
gram + diplococci
268
A patient presents with productive cough, fever, dyspnea, and bronchial breath sounds x5 days What is the most likely diagnosis for
this patient?
Early sign is?
pneumococcal pneumonia (EARLY SIGN = BRONCHIAL BREATH SOUNDS!)
269
T or F: Along with hand washing and sterilizing equipment prevention measures, there is an adenovirus vaccine.
True, however – it is strictly for military use (not for general public)
270
What is the treatment regimen for adenovirus infections?
symptomatic, treat underlying cause; good hand hygiene
271
What lab findings will determine the adenovirus serotypes?
antigen detection assays
272
What main factors determine how severe adenovirus infections will be?
youth, chronic underlying conditions, recent transplant, and serotypes 5 and 21
273
```
What are some illnesses caused by adenovirus? SELECT ALL THAT APPLY!
A: gastritis
B: common cold
C: conjunctivitis
D: pharyngitis
E: acute otitis media
```
A: gastritis
B: common cold
C: conjunctivitis
D: pharyngitis
(Also, pneumonia, acute respiratory distress, epidemic keratoconjunctivitis, acute hemorrhagic cystitis (kids), GU ulcers,
appendicitis, intussusception, hepatitis, rhabdomyolysis)
274
What is the typical incubation period for adenovirus infections?
4-9 days (4=A, 9=D – adenovirus)
275
What is the KEY determining factor that could distinguish between influenza and adenovirus?
adenovirus occurs throughout the year, versus influenza outbreak times are fall and winter
276
Who are the most common individuals that contract adenovirus infections?
infants, young kids, and military recruits
277
A patient exposed to avian flu presents to your office worried about what will happen. What is your next action? SELECT ALL
THAT APPLY!
A: Prescribe oseltamivir 75mg PO BID for 5 days
B: Refer patient to ED for hospital admission due to need for droplet isolation
C: Perform a RT-PCR assay test
D: Instruct patient to monitor self for 10 days after known exposure
A & D (further educate the patient to seek prompt medical attention if new fever or respiratory symptoms develop)
278
A recent outbreak of Avian Flu has been documented in your area. When discussing this information with your patients in clinic, a
56-yr. old male requested an appointment with your office to obtain a vaccine against this. What should you do?
Return the patients phone call to inform him that there is no specific vaccine against Avian Flu, however the patient could schedule
an appointment to receive the yearly flu vaccine as this will help prevent a coinfection of seasonal flu with avian flu
279
What is the 1st line drug for avian flu?
oseltamivir 75mg PO BID for 5 days (given immediately, but no later than 48hr of onset); patients need to be HOSPITALIZED and
RECEIVE TREATMENT FOR 10 days
280
T or F: With severe illness and confirmed cases of mild disease, treatment must be started within 48hr of diagnosis
False, treatment should begin IMMEDIATELY!
281
What is REQUIRED from the FNP to do following a RT-PCR assay test?
must forward all results to public health authorities for further testing
282
What is the MOST specific test to detect avian flu?
RT-PCR assays
283
A patient presents to your clinic with Avian Flu. In addition to the symptoms of cough and fever, what symptom would indicate
subtype H7N9 as the cause?
A: shortness of breath and wheezing
B: red, diffuse rash on face
C: bilateral eye injection and drainage
D: decreased ability to handle secretions
C -bilateral eye injection and drainage
(aggressive course of illness; fever à lower resp. symptoms (cough/dyspnea) + conjunctivitis) “9-7 = 2 Nasty eyes”
284
```
A patient presents to your clinic with Avian Flu. In addition to the symptoms of cough and fever, what symptom would indicate
subtype H5N1 as the cause?
A: purulent eye drainage
B: mild gastroenteritis
C: lymphadenopathy
D: exudative tonsillitis
```
B -mild gastroenteritis
H5N1: aggressive course of illness; fever à lower resp. symptoms (cough/dyspnea) + GI) “5-piece mcNugget for 1 person”
285
```
A patient presents to your clinic with flu-like symptoms. What KEY distinguishing factor would direct the FNP to assume a diagnosis
of avian flu?
A: onset of symptoms began 48 hr. ago
B: recent travel to Africa (last 6 days)
C: hunting trip 9 days ago
D: recent poultry consumption
```
C hunting trip 9 days ago
(hx of exposure to dead/ill birds or live poultry markers in prior 10 days, recent travel to Southeast Asia/Egypt, contact with
known case = HOW YOU DISTIGUISH FROM REGULAR INFLUENZA; there is NO RISK of contracting avian flu after consumption of
poultry products)
286
What is the 1st line treatment for influenza if initiated within 48 hr. of symptom onset?
Tamiflu (75mg PO BID for 5 days)
287
```
What factors should be considered and warrant administration of Zanamivir (Relenza) antiviral therapy? SELECT ALL THAT
APPLY!
A: acute illness
B: onset of illness >48hr
C: asthma
D: pregnancy
```
A & D (zanamivir is CONTRAINDICATED in asthma patients due to bronchospasm; therapy should be initiated within 48 hr of
symptom onset)
288
What is the standard of treatment for any patient with influenza?
supportive care
289
What is a complication that can occur with kids diagnosed with Type B Influenza after having taken aspirin?
Reye syndrome
290
```
In determining whether a patient should be hospitalized with influenza, what is NOT a factor that should be considered?
A: secondary pneumonia
B: hypoxemia
C: pregnancy
D: persistent fever with cough
```
D (fever can last 1-7 days; recurrent fever >4 days plus elevated WBCs would be grounds for admission; extrapulmonary
complications like pneumonia is grounds for admission (flu complicated by pneumonia you can almost bet they have hypoxemia)
291
What is the MOST appropriate lab to order to detect and diagnose influenza?
rapid flu swab
292
What is the MOST common bacterial organism responsible for secondary bacterial infection in a patient with influenza?
pneumococcal pneumonia (staph pneumonia = the MOST serious)
293
What should the FNP suspect if a patient diagnosed with the flu has recurrent fever >4 days with productive cough and an elevated
WBC >10,000?
suspect secondary bacterial infection
294
Approximately how long should the patient diagnosed with influenza expect their fever to last?
1-7 days (w/coryza, non-productive cough, sore throat)
295
What is the typical incubation period for influenza?
1-4 days
296
Which type of influenza is exclusive to humans only?
B and C
297
What are the common outbreak times for Influenza?
fall or winter
298
In the elderly presenting with flu-like symptoms, what symptoms are expected?
A: substernal soreness and chills
B: lassitude without respiratory symptoms
C: malaise, cough, and hoarseness
D: diarrhea and fever
B lassitude without respiratory symptoms
| confusion, lassitude, without respiratory symptoms
299
```
In a child presenting with type B flu symptoms, what symptoms are expected?
A: runny and stuffy nose, cough
B: confusion without fever
C: abdominal pain, vomiting, diarrhea
D: wheezing and shortness of breath
```
Answer: C (children have GI complaints)
300
In an unvaccinated adult, what symptoms would be seen when flu is suspected?
A: fever, chills, HA
B: altered mental status with respiratory symptoms
C: nausea, vomiting, abdominal pain
D: shortness of breath and BLE swelling
Answer: A
301
What two symptoms could a patient >4yr old present with during flu season, and you suspect the cause as flu?
presence of fever >38.2 and cough
302
How is influenza transmitted?
droplet
303
What are some preventative measures that can be taken to contain RSV / prevent further spreading of disease?
rapidly diagnose RSV
hand washing
contact isolation;
administer pneumonia vaccine
-(to help decrease secondary viral infections
in kids)
304
T or F: RSV vaccine should be administered to children <2 years old and >65 yr old
False, there is no RSV vaccine
305
As an FNP, you know the treatment for RSV is?
supportive care (hydration, humidified air, ventilatory support – if needed)
306
What is a lab test that can detect RSV rapidly?
rapid nasal swab
| viral antigen identification of nasal washings
307
What is the average incubation period for RSV?
5 days
308
T or F: RSV is a leading cause of hospitalizations in young children
true
309
In addition to premature infants, who else is at risk for contracting RSV?
elderly, immunodeficiency, following lung/BM transplant
310
What is a common risk factor for RSV in children?
age
311
```
What are the common outbreak times for RSV?
A: January – Mid-March
B: Mid-October – Early January
C: November – February
D: October – March
```
B
312
What age group is most at risk of contracting RSV?
<5 and older than 65 yr. old
313
A 2-year-old patient presents with low-grade fever, wheezing with periods of apnea, and increased mucous secretion. What is a likely
diagnosis?
Respiratory Syncytial Virus (RSV)
314
___Mid-October to Early January
<5 yr & >65 yr
5-day symptom onset
Wheezing / periods of apnea
RSV
315
___Fall or Winter
1-4 day symptom onset
1-7 day symptom duration
influenxa
316
___HISTORY DEPENDENT
Exposure to dead poultry within
10 days of symptoms
EPIDEMIC IS CONCERN
avian flu
317
___Year round
| 4-9 day symptom onset
adenovirus
318
A patient presents to your clinic with profound hypoxia and a normal chest x-ray in absence of lung disease. What is your
intervention?
2- risk of __
REFER – High suspicion for PE
319
A patient is found to have recurrent thromboembolisms despite receiving adequate blood thinner therapy. As an FNP you know you
need to do what?
Patient needs a __
A patient is found to have recurrent thromboembolisms despite receiving adequate blood thinner therapy. As an FNP you know you
need to do what?
320
```
What are ABSOLUTE contraindications to alteplase?
A: active internal bleeding
B: stroke within past 2 months
C: uncontrolled HTN
D: trauma/surgery within past 6 weeks
```
A, B
321
```
What are the MAJOR CONTRAINDICATIONS of alteplase?
A: GI bleed 3 months ago
B: stroke within past 2 months
C: uncontrolled HTN
D: trauma/surgery within past 6 weeks
```
C, D
322
Target INR for warfarin is?
2-3
323
What medication therapy should be instituted for an established PE?
alteplase (EMERGENCY DRUG FOR LIFE-THREATENING PE!)
324
What is the major complication from treatment of PE?
hemorrhage
325
What is the appropriate duration of therapy for patients with PE?
No standard – need to consider patients age, potentially reversible risk
factors, likelihood and potential consequences of hemorrhage, and preferences of continued therapy (Recommendation: 3 months of
anticoagulation after 1st episode provoked by sx or transient nonsurgical risk factor; Extended therapy used for an unprovoked episode with a
low-moderate risk of bleeding)
326
A patient with cancer presents to clinic with a DVT. What medication would you order for them to go home on?
an effective drug is LMWH – recommended for patients’ w/cancer (LMWH reduced the risks of recurrent VTE by 40% with no
difference in major bleeding)
327
Patient is determined to have a DVT. What medication regimen is appropriate for this patient?
Heparin Anticoagulation therapy (standard regimen) followed by 6 months of PO warfarin
328
A patient presents with chest pain worse with inspiration, dyspnea. Patient reports recent birth control use. The highest diagnosis on
your differential would be what?
C (hx of venous thrombus in lower extremity MUST important indicator leading to diagnosis)
329
```
The FNP knows the most prevalent risk factors that could result in an embolus traveling to the lung include:
A: Orthopedic surgery
B: Vaginal Birth
C: IV Drug use
D: Untreated Strep Throat
E: VP shunt
F: all of the above
```
Answer: all of the above [air (neuro sx, central venous cath); amniotic fluid (active labor), fat (long bone fx), foreign bodies (talc injection
drug users), parasite eggs (schistosomiasis), septic emboli (acute infectious endocarditis), tumor cells (renal cell carcinoma)]
330
T or F: Thrombus from deep veins in the upper extremities is the most common cause of pulmonary embolism
F (deep veins in the LOWER extremities; (thrombi confined to calf propagate proximally to popliteal / iliofemoral veins à break off
à embolize to pulmonary circulation)
331
What is an inherited disorder that presents as a risk factor for PE?
D (factor V Leiden is a mutation of one of the clotting factors in the blood. This mutation can increase your chance of developing
abnormal blood clots, most commonly in your legs or lungs)
332
Patient presents with unilateral calf pain x3 days, increased pain with walking. Left leg appears mildly swollen. Patient appears short
of breath with a HR of 115. Patient denies hemoptysis or chest pain. Patient reports no additional medical history, no recent travel.
Using the Wells Score, what result would you get? According to the Wells criteria – what clinical probability of PE does this score
indicate?
Dvt symptoms (3.0)
PE likely diagnosis (3.0)
HR >100 (1.5) = >6.0 (high probability) – Wells Criteria, Modified Wells Criteria =
>4.0 PE likely
333
Patient presents with unilateral calf pain x3 days, increased pain with walking. Left leg appears mildly swollen. Patient appears short
of breath with a HR of 115. Patient denies hemoptysis or chest pain. Patient reports no additional medical history, no recent travel.
Using the same patient presentation above (resulting in a Wells Score of 4.5, could you utilize the PERC (Pulmonary embolism ruleout
criteria) protocol?
No. PERC is for patients with a Modified Wells score of <4 who meet additional criteria to rule out PE. This patient does not meet
criteria therefore, PE cannot be ruled out without additional testing
334
Patient presents with unilateral calf pain x3 days, increased pain with walking. Left leg appears mildly swollen. Patient appears short
of breath with a HR of 115. Patient denies hemoptysis or chest pain. Patient reports no additional medical history, no recent travel.
Using the same patient presentation above (resulting in a Wells Score of 4.5, could you utilize the PERC (Pulmonary embolism ruleout
criteria) protocol?
***What laboratory test would be appropriate to order at this point on this patient?
Answer: CT scan (not a D-Dimer)
CT scan (not a D-Dimer)
335
When assessing a patient for suspected PE - you wanted to begin by utilizing the
Wells Criteria
(a tool that helps to
stratify the probability risk of a PE results are scored either high, moderate, low).
Modified Wells Criteria utilizes the same
questions and is scored as PE likely >4 or PE unlikely <4.
336
Wells criteria >4 means PE is
likely
337
In the case of a patient who is scored >4 Modified Wells Criteria, you DO NOT NEED to order a
In the case of a patient who is scored <4 Modified Wells Criteria, you ORDER A
d-dimer
338
```
What is the 1st line treatment for obstructive sleep apnea? SELECT ALL THAT APPLY
A: weight loss
B: strict avoidance of ETOH
C: CPAP
D: Uvulopalatopharyngoplasty (UPPP)
```
A, B, C (nasal CPAP is curative in many patients)
339
```
What labs would you obtain on a patient with suspected obstructive sleep apnea?
A: Hgb/Hct
B: Chem7
C: TSH
D: ABG
```
C – TSH (hypothyroidism may contribute to obstructive sleep apnea through enlargement of the tongue (called macroglossia) or
disruption of the muscles that control the upper airway. Finally, patients with hypothyroidism are at risk for obesity, another factor that
contributes to obstructive sleep apnea)
340
What is the MOST prominent clinical findings on physical exam that indicates a patient most likely has obstructive sleep apnea?
bullneck
341
```
differential diagnosis of obstructive sleep apnea needs to be confirmed. What is the MOST accurate/gold standard diagnostic test
that will confirm this diagnosis?
A: EEG
B: Home use nocturnal pulse ox
C: Otorhinolaryngologic exam
D: Polysomnography
```
Polysomnography
342
A 59-yr. old male presents to the clinic complaining of morning sluggishness despite sleeping all night. While examining this patient,
he appears to be dozing off. What is the likely diagnosis for this patient?
OSA
343
What is the best treatment for to improve hypercapnia and hypoxemia in Obesity-Hypoventilation Syndrome?
weight loss
344
A patient presents to clinic with blunted ventilatory drive and compensates by voluntarily hyperventilating to maintain PO2 / PCO2
levels. This condition co-exists with obstructive sleep apnea. What is your diagnosis?
Obesity-Hypoventilation Syndrome
345
```
The FNP knows common risk factors for recurrence of spontaneous pneumothorax include (SELECT ALL THAT APPLY):
A: Smoking
B: Swimming
C: Alcohol Use
D: Flying on an airplane
```
A, D
346
The FNP has determined the pneumothorax is large and progressive. What intervention should the FNP employ?
REFER! Needle decompression is needed to prevent tension pneumothorax
347
If a pneumothorax is considered small and stable, what treatment should the FNP provide?
```
Symptomatic treatment (treat cough, pain; and consider serial CXR every 24hr – however, observation alone may be appropriate
(many spontaneously resolve as air is absorbed from pleural space; provide O2 to increase rate of absorption)
```
348
The FNP ordered a chest x-ray to diagnose a pneumothorax. The chest x-ray would demonstrate what findings to confirm this
diagnosis?
demonstrating the outer margin of the visceral pleura (and lung) – known as the pleural line – separated from the parietal pleura (and
chest wall) by a lucent gas space devoid of pulmonary vessels.
349
What diagnostic study should the FNP order when suspecting a pneumothorax?
Chest X-ray (adequate, inexpensive, and rapid results)
350
```
What would be a key finding in a small pneumothorax?
A: hypotension
B: tachycardia
C: hypoxemia
D: EKG changes
```
TACHYCARDIA
351
```
What is an emergency complication that can occur from a spontaneous pneumothorax?
A: lung abscess
B: empyema
C: tension pneumothorax
D: shock
```
C (mediastinal shift, cyanosis, hypotension – signs of tension pneumothorax – EMERGENCY! REFER!)
352
A patient present with acute onset of unilateral chest pain, shortness of breath, and unilateral chest expansion. Auscultation reveals
hyperresonance and diminished breath sounds on the left side. What do you suspect is the cause?
A: Left-sided pneumonia
B: Empyema
C: Left-sided Pleural Effusion
D: Left-sided Pneumothorax
D
353
___KEY symptom is acute onset of UNILTERAL chest pain and chest expansion
with hyperresonance
Spontaneous Pneumothorax:
354
___KEY piece of information that determines how you treat is knowing if this patient is
IMMUNOCOMPROMISED. If they are, you must OBTAIN A SPUTUM CX to determine treatment
Infiltrates on x-ray:
355
___KEY symptom is chest pain (more diffuse) with dyspnea + dullness to percussion
Pleural effusion:
356
___the KEY symptom is localized pain worse with a deep breath (no changes with percussion)
Pleuritis
357
___KEY symptom that isn't with other diseases is cough with FOUL-SMELLING SPUTUM!
Anaerobic:
358
___KEY symptom is tachypnea, fever, inspiratory crackles
CAP
359
T or F: observation is appropriate for symmetrical bilateral effusions secondary to heart failure
True (90% of transudative is heart related. bilateral wouldn’t throw the trachea in one direction. and a lot self-resolve)
360
What should the FNP do for any atypical pleural effusions or failure for an effusion to resolve?
REFER
361
It is determined the patient has a small hemothorax. What is the most appropriate intervention as the FNP taking care of this
patient?
close observation for small and improving on CXR (all other cases – REFER!)
362
It is determined the patient has an empyema (exudative pleural effusion). What is the most appropriate intervention as the FNP
taking care of this patient?
REFER! needs cultures, and for the effusion to be DRAINED!
363
A patient is determined to have a transudative pleural effusion. What is the most appropriate treatment for this patient?
treat underlying condition
364
A patient presents with dyspnea, chest pain (esp. with deep breaths), and fever. Past medical history includes CHF. What do you
suspect is the cause? On this patient you order a chest x-ray – results were inconclusive. What diagnostic study could be ordered and
why?
CT SCAN
| can detect as little as 10ml of fluid
365
The FNP knows with any new pleural effusion with no clinically apparent cause - what must their next intervention be?
REFER! Diagnostic thoracentesis
366
IF you have an elevated amylase level in your pleural fluid, what could be the cause?
1
2
3
pancreatitis, adenocarcinoma of lung/pancreas, esophageal rupture
367
Fluid aspirate is collected and sent for analysis. The lab results show – ratio of pleural fluid protein to serum protein >0.5, pleural
fluid LD to serum protein >0.5. You suspect the cause is exudative or transudate effusion?
exudative (Exudates have a higher protein concentration (130 g/l) due to an increase in capillary permeability and/or impaired
lymphatic drainage)
368
```
What intervention employed by the FNP would allow the distinction of what type of effusion is present?
A: Chest x-ray
B: Blood cultures
C: CT scan
D: Fluid aspirate
```
D (appearance of fluid helps to identify the type of effusion – send to lab for protein, glucose, LD, WBC w/diff analysis)
369
```
The two umbrella categories of pleural effusions are:
A: exudate and transudate
B: transudate and pleuritic
C: empyema and exudate
D: none of the above
```
A
370
```
What is the MOST common cause of pleural effusions in patients?
A: bacterial pneumonia
B: cancer
C: heart failure
D: viral infection
```
HF
371
Patient presents with chest pain worse with breathing and dyspnea - you have diagnosed this patient with pleural effusion. What do
you expect to hear upon auscultation and percussion during your exam?
dullness to percussion; decreased/absent breath sounds over effusion
372
What complication occurs with pleuritis that requires immediate referral?
Large pleural effusion (REFER for diagnostic / therapeutic tx)
373
A 43-yr. old female with no past medical history presents to your clinic complaining of localized sharp pain WORSE WITH
COUGHING or DEEP BREATHS. On exam, patient is breathing 16RR/min, shallow, and guarding chest from pain.
In this patient, what would be the most appropriate treatment recommendations?
Treat the underlying condition; administer pain medications (NSAIDs – reduce INFLAMMATION OF THE PLEURAL LINING;
most often Indomethacin is used; control cough with codeine or other opioid)
374
A 43-yr. old female with no past medical history presents to your clinic complaining of localized sharp pain WORSE WITH
COUGHING or DEEP BREATHS. On exam, patient is breathing 16RR/min, shallow, and guarding chest from pain. What diagnosis
is HIGHEST on your differential?
A: Pleural effusion s/p pneumonia
B: Spontaneous pneumothorax
C: Pleuritis s/p viral infection
D: Simple rib fracture s/p fall
C (inflammation of the pleural lining that occur in young health adults due to viral infection, pneumonia, or simple rib fracture)
375
In an immunocompromised patient with pneumonia, what is the MOST appropriate treatment?
begin empiric abx (based on severity of pulmonary infection, underlying disease, risk of empiric therapy, local expertise and
experience w/ diagnostic procedures)
376
An HIV+ patient presents to your clinic with 3 days of cough, low-grade fever, and dyspnea. Your differential diagnosis includes pneumonia.
What would be a REQUIRED intervention to definitively diagnose this patient with pneumonia?
A: Chest x-ray
B: Medication reconciliation
C: Obtain WBC and blood cultures
D: Sputum culture
D Sputum cx (immunocompromised patients include HIV+, WBC <1000, current/recent chemo, taking MORE THAN 5mg/day of
prednisone – these types of patients that contract pneumonia often have atypical causes; expectorated sputum for bacteria, fungi,
mycobacteria, Legionella, P jirovecii = important, may help preclude need for expensive diagnostic procedures)
377
```
The patient wants to know how long treatment for anaerobic pneumonia will be continued for. Your answer is? SELECT ALL THAT
APPLY.
A: Will not self-resolve, must REFER
B: 5-7 days
C: 4-6 weeks
D: Until chest x-ray improves
```
C, D
378
```
The FNP is determining the tx for a patient with anaerobic pneumonia. The FNP knows the 1st line for this is what?
A: Levaquin
B: Amoxicillin
C: Clindamycin
D: Ceftriaxone
```
C (1st line: Clindamycin IV q8hr – switch to PO with improvement OR amoxicillin-clavulanate/Augmentin q12hrs)
379
```
The FNP knows that with the presence of purulent pleural fluid accompanying either lung abscess or necrotizing pneumonia – this
would indicate what complication?
A: Pleural effusion
B: Hemothorax
C: Empyema
D: Transudate
```
C EMPYEMA
| “purulent” – REFER! order ultrasound and consult for drainage
380
The FNP is reviewing the chest x-ray of a patient suspected to have anaerobic pneumonia. The film is noted to have a thick-walled
solitary cavity surrounded by consolidation and air-fluid level present. What do you suspect?
A: Pleural effusion
B: Hemothorax
C: Tuberculosis
D: Lung abscess
D (air-fluid level is key; must exclude TB, mycosis, cancer, infarction, granulomatosis with polyangiitis)
381
If you were to culture the bacteria in anaerobic pneumonia, what is the GOLD STANDARD for obtaining this specimen?
A: Sputum expectorated from patient
B: CPT facilitated by respiratory therapist
C: Bronchoscopy
D: Blood cultures x2
C (normal flora in mouth would skew results from expectorated sputum)
382
T or F: With this type of pneumonia, anaerobic pneumonia, patients will seek care a couple days after symptoms begin
False (due to the nonspecific nature of the symptoms in anaerobic pneumonia, most will present late in the course of illness, once the
pneumonia has progressed to necrotizing pneumonia, lung abscess, empyema)
383
CAP: For all patients, we treat until the patient has been afebrile and clinically stable for at least 48 hours and for a minimum of
five days. Patients with mild infection generally require five to seven days of therapy. Patients with severe infection or chronic
comorbidities generally require
7-10 DAYS
384
CAP vs. pneumococcal pneumonia: Treating patients with a macrolide will USUALLY cover s. pneumonia, the most common
cause, but will also cover mycoplasma, another common cause. There are some strains of s. pneumonia that are resistant to
macrolides, and if you are treating a patient in a region where there is known high resistance to macrolides, then EMPIRIC
treatment is with a f
fluoroquinolone OR a macrolide PLUS a beta-lactum (such as high dose amoxicillin) is recommended.
385
Pediatric Outpatient TX of CAP: or a child under 5, __ IS FIRST LINE. Also It is also first line in > 5yr, unless you suspect __
amoxicillin
mycoplasma
386
A patient with recent PNA asks, “When will I get rid of this cough?” The appropriate response by the NP is?
Cough and fatigue may last up to 4 weeks
387
A 60-yr. old patient presents with fatigue, SOB, high fever, and purulent sputum. He is not a smoker. On physical exam, his lungs DO
NOT clear after coughing several times. What is the MOST likely diagnosis?
pneumonia
388
A patient presents with pneumonia. What would you expect to see on CXR?
Infiltrates and lung consolidation
389
A score of “1-2” using the CURB-65 means what?
Admit to hospital, but no ICU is needed
390
A score of “3+” using the CURB-65 calculator means what?
ICU admit
391
A score of “0” using the CURB-65 calculator means what
Outpatient tx with close follow-up
392
Utilizing CURB-65, what does each letter represent?
C-confusion to person, place, time – confused elderly
U-urea (BUN) >7 – dehydration secondary to pneumonia (high BUN level is one of the components of both the CURB-65 score and PSI. BUN
levels show a decrease in renal perfusion and indirectly predict the severity of pneumonia. The patients who have pneumonia are usually
dehydrated that results from increase of BUN excretion from the kidneys.)
R-resp rate >30min - tachypneic
B-blood pressure <90/60 – hypotensive (impending shock)
A-age >65yr – old, same age as vaccination of pneumonia
393
```
What is the typical antibiotic treatment duration for adults with CAP?
A: 3-5 days
B: 7-10 days
C: 3 days of IV abx
D: 5 days
```
D (a minimum of 5 days of therapy and continue abx until pt. is afebrile for 48-72hr)
394
A 35-yr. old patient with hx of recent corticosteroid use reports to your clinic and is diagnosed with CAP. You check the eMAR and
determine this patient has received azithromycin 4 wks ago. What is the recommended outpatient abx choice?
A: clarithromycin
B: amoxicillin
C: clindamycin
D: levaquin
D any patient w/ risk of drug resistance receives a respiratory fluoroquinolone or a macrolide + b-lactam (Drug resistance factors =
abx <90 days, >65yr old, comorbid illness, immunosuppression, exposed to a child in daycare
395
A 65-yr. old, previously healthy patient reports to your clinic and is diagnosed with CAP. You check the eMAR and determine this
patient has received no abx within the last 90 days. What is the recommended outpatient abx choice?
A: clarithromycin
B: amoxicillin
C: clindamycin
D: levaquin
A (macrolides)
396
ients chest x-ray shows cavitary opacities. What do you suspect and what is your intervention?
TB; REFER TO ED IMMEDIATELY – requires airborne isolation and TB work-up
397
A patient’s chest x-ray shows SIGNIFICANT pleural fluid collections. What do you anticipate concerning the patient’s condition and
what should be your intervention?
anticipate impending airway compromise; REFER! may require thoracentesis
398
A patient schedules an appointment with you regarding a persistent cough for 3 weeks. You look in the medical record and see his last
visit was the diagnosis of CAP. What is your intervention for this patient?
A: Order a repeat CXR to evaluate current treatment
B: Order repeat labs to evaluate for persistent infection
C: Schedule an appointment 4 weeks from today
D: Perform a rapid flu swab to evaluate for flu
C (cough and fatigue may last up to 4 weeks; routine CXR not needed if patient is improving)
399
What is the MOST important prevention technique for pneumonia?
pneumonia vaccine
400
```
What patient would you vaccinate with PCV13?
A: asthma
B: diabetes
C: sickle cell
D: alcoholic
```
C
401
```
What clinical prediction rule can help guide the decisions concerning whether to admit or treat a patient with CAP outpatient?
A: Pneumonia Severity Index
B: Modified Wells Score
C: CURB-65
D: CIWA score
```
C
402
```
What patient would you vaccinate with PCV13?
A: asthma
B: diabetes
C: sickle cell
D: alcoholic
```
C (PCV13 = immunocompromised, renal failure, HIV, cochlear implants, CSF leaks, sickle cell, cancer, organ transplant –
immunocompromised or blood disorders (inc. cancer); PPSV23: these are people that did stuff in their life to get the diagnoses they have
(smokers, chronic heart / lung / liver disease, asthma, DM, alcoholic, any one in long-term care facility)
403
NEED __ VACCINE: these are people that did stuff in their life to get the diagnoses they have
(smokers, chronic heart / lung / liver disease, asthma, DM, alcoholic, any one in long-term care facility)
PPSV23
404
If you were to obtain a CXR on a patient suspected to have CAP, what findings would be present and confirm your suspicion of this
diagnosis?
A: pleural fluid accumulation in dependent zones
B: Infiltrates in dependent zones with multiple cavitation
C: pulmonary opacities
D: deep sulcus sign
C pulmonary opacity on chest x-ray (clearing of opacities can take 6wks or longer; quicker in young, non-smokers with 1 lobe
involved)
405
During your initial work-up for patient with CAP, you order a rapid nasal swab to detect Influenza. Your patient questions why this
is necessary. Your response is?
A: Most often, influenza is the cause
B: A positive test will determine treatment
C: Influenza could complicate CAP disease progression
D: I need to obtain this test to report to Health Department
B
406
```
The FNP wishes to confirm the presence of S. pneumoniae as the causative organism for the patients' CAP. What lab test could be
employed to confirm?
A: rapid nasal antigen swab
B: sputum gram stain
C: urinary antigen test
D: sputum culture
```
C (a specific and rapid result of S. pneumoniae; pneumococcal urine antigen test (UAT) is an assay commonly used to identify
pneumococcal antigens excreted into the urine to increase the rate of specific microbiological diagnosis over conventional culture methods)
407
```
If the adult patient had CAP caused by a virus - what is the MOST common viral organism?
A: RSV
B: adenovirus
C: parainfluenza virus
D: influenza
```
D: influenza
408
```
What is the MOST common bacteria that causes CAP in adults?
A: S pneumoniae
B: M pneumoniae
C: H pneumoniae
D: C pneumoniae
```
A
409
55 yr. old patient presents to your clinic with dyspnea, fever, and inspiratory crackles heard on auscultation. You suspect CAP. Your
next intervention would be?
A: Order blood work, EKG, CXR
B: Order PFTs
C: Order spirometry test with PRN bronchodilator
D: Order PO antibiotics
D (only hospitalized patients require diagnostic testing; if the patient is treated outpatient – empiric abx is almost always effective in
this population without the need for diagnostic tests)
410
```
A 65yr old patient presents with CAP. What is the most likely cause?
A: bacterial
B: viral
C: fungal
D: trauma
```
A
411
```
What is the MOST sensitive sign in the elderly presenting with pneumonia?
A: tachypnea
B: low-grade fever
C: mental status change
D: inspiratory crackles
```
A
412
Because this occurs often in the elderly: it’s important to note the differences in how they would present. Same symptoms - dyspnea,
tachypnea, inspiratory crackles. What additional symptoms or change in timing would be seen? SELECT ALL THAT APPLY
A: cough with or without sputum
B: low temperature
C: subacute onset of symptoms
D: acute change in mental status
B, D (fever is often low in the elderly, mental status change)
413
So, in a patient with restrictive lung dysfunction, what results would be reflected after obtaining a spirometry test?
reduced FVC
414
After administering a bronchodilator to this patient, you repeat spirometry testing 15 minutes later. The results are low FEV1/FVC
ratio. What do you suspect the cause of this is?
COPD (obstructive disorder that would NOT improve with bronchodilator; asthma would improve – although spirometry is used in
hospital to prevent pneumonia – but in the case of using it as a diagnostic tool, it is being used to see if your lung issue is obstructive or
restrictive; repeating the test after bronchodilator, allows you to further pinpoint WHAT type of obstructive disease they have)
Explanation: Restrictive conditions are defined by inhalation that fills the lungs far less than would be expected in a healthy person.
These patients have a difficult time filling the lungs completely in the first place, and can be due to intrinsic factors (e.g. stiff lungs);
extrinsic factors, such as when pressure from an enlarged abdomen limits the expansion of the lungs; or neurological factors, such as
muscular dystrophy, where damage to the nervous system interferes with movements necessary to draw air into the lungs.
415
The results obtained on your patient show low FEV1/FVC ratio. You've determined the cause is obstructive. What should you do to
assess if this is reversible
If obstruction is evident (low FEV1/FVC) – repeat spirometry 10-20 mins after inhaled bronchodilator to help assess if dx is
reversible
416
You are evaluating a patient in clinic for a follow-up appointment. You order spirometry testing on this patient. The co-morbid
condition you would expect this patient to have would be?
C (spirometry is measuring lung volumes to assess the presence or severity of obstructive/restrictive pulmonary dysfunction;
expressed in FEV and FVC)
417
FEV (forced expiratory volume): how much air is the person exhaling during a forced breath
FEV1: the amount of air exhaled during 1st breath
FVC: the total amount of air exhales during the entire test
So, in a patient with obstructive dysfunction, what would you expect the FEV1 / FVC ratio to be?
Both decreased (reduced airflow rates seen in asthma, COPD, bronchiectasis, bronchiolitis, upper airway obstruction, CF)
Explanation: Obstruction can occur when inflammation and swelling cause the airways to become narrowed or blocked, making it
difficult to expel air from the lungs. This results in an abnormally high volume of air being left in the lungs (increased residual
volume). Increased residual volume, in turn, leads to both the trapping of air and hyperinflation of the lungs—changes that
contribute to a worsening of respiratory symptoms.
418
How do you measure your patients PFTs to establish if they are normal or not?
A – measured against predicted values derived from large studies of healthy subject (vary with age, gender, height, weight, ethnicity)
419
```
What patient would NOT be appropriate to order PFTs on?
A: chronic bronchitis
B: acute asthma exacerbation
C: patient awaiting surgery
D: new onset of SOB on exertion
```
B (PFTs are contraindicated in acute severe asthma, resp. distress, angina aggravated by testing, pneumothorax, ongoing
hemoptysis, active TB)
420
What indication would warrant the FNP to order PFTs? (what are you assessing for)
A: assess the presence of obstructive/restrictive pulmonary dysfunction
B: see how much air a person can inhale/exhale
C: assess the type and extent of lung dysfunction
D: none of the above
C (assess type and extent of lung dysfunction, causes of dyspnea/cough, early detection of lung dysfunction, follow-up response to
therapy)
421
```
As an FNP, you wish to measure a patients' airflow rates and gas exchange. What test would you order?
A: spirometry
B: ABG
C: Cardiac stress test
D: PFTs
```
D
422
What lung sounds are considered normal when heard over suprasternal notch (large, visible dip in between the neck and the two
collarbones)?
tracheal or bronchial (louder – higher pitched, hollow quality, louder on expiration)
423
Patient presents to your clinic with a history of DM uncontrolled. Their breathing is deep and rapid. What is this called and what
does this signify?
Answer: Kussmaul respirations; suspect DKA
424
You are making rounds in the hospital and are visiting the neuro ICU. A patient you are assessing is noted to have a rhythmic
breathing pattern with regular periods of apnea. What is this called? And what do you suspect the cause is?
Cheyne-Stokes respirations; suspect increased ICP, cardiac failure, renal failure, overdose on narcotics
425
What are some causes of digital clubbing that you may encounter as an FNP in an outpatient setting?
lung abscess, empyema, bronchiectasis, CF, cirrhosis, Graves’ disease
426
BLE edema is an indirect measurement of what?
```
pulmonary HTN (Why? Because if the fluid is not being pumped by the heart correctly you know it is backing up. Backing up in the
heart goes from left side to lungs to right side. if the fluid continues collecting in legs and the right side of the heart is failing - you’re going to
expect increased pressures in the lungs = pulmonary HTN)
```
427
What is NOT a reliable indicator of hypoxemia?
Cyanosis (get arterial PO2 or HgB saturation measured)
428
Patient presents with brief, nonmusical sounds that have a crisp poppy quality heard during auscultation. What do you suspect?
Fine crackles
429
Patient presents with lower-pitched popping sounds heard on auscultation. This sound is longer in duration. What do you suspect?
What is MOST often the cause
Coarse crackles; most often caused by CHF or pneumonia
430
You are assessing a patient and note dullness on percussion. What do you suspect could be the cause?
lung consolidation, pleural effusion
431
A patient presents with lower-pitched snorous respirations. What do you suspect?
What intervention could you perform immediately
to test your theory?
Rhonchi; often caused by secretions in large airways; seen in patients with pneumonia, chronic bronchitis, CF, and COPD. ask the
patient to cough – should clear
432
A patient presents with a high-pitched musical respiration. What does this signify? What could be the cause?
wheezing; bronchospasms (acute asthma attack), mucosal edema (allergic reaction), excessive secretions (from narrowed airway);
POWERFUL INDICATOR OF OBSTRUCTIVE LUNG DISEASE
433
Globally diminished lung sounds are predictive of what?
significant airflow obstruction
434
If you hear bronchial lung sounds over the periphery of lung - is this normal or abnormal
abnormal; suspect consolidation
435
In a patient with tracheal deviation - what do you suspect the cause is?
Tension pneumo – REFER
436
You are assessing a patient and note hyperresonance on percussion. What do you suspect could be the cause?
Hyperresonant sounds may be heard when percussing lungs hyperinflated with air (COPD, acute asthma attack). An area of
hyperresonance on one side of the chest may indicate a pneumothorax.
437
A patient presents with unilateral volume loss on the right side when inspecting their CXR film. What could be the cause?
pleural effusion, atelectasis, empyema
438
If a patient’s chest expands but the abdomen collapse on inspiration - what could be the physiological cause?
weakness of diaphragm (neuromuscular diseases)
439
When a patient displays an increased work of breathing, you would expect them to be using accessory muscles. However, a patient at
rest who is using accessory muscles - what is this a sign of?
Sign of significant pulmonary impairment
440
A patient presents to your clinic with hx of polycythemia. The patient appears cyanotic but there is no apparent respiratory distress
noted (sitting comfortably, respirations even and unlabored, AAOX4). What do you suspect is going on?
This is a normal finding in this patient. (Polycythemia vera is a slow-growing blood cancer in which your bone marrow makes too
many red blood cells – increased hemoglobin concentration; therefore, minimal dips in O2 will appear cyanotic in these patients)
441
A patient presents to the clinic with anemia. The patient appears very short of breath. What are two indicators of hypoxemia that
would not be accurate/present in this patient? To determine the extent of hypoxemia in this patient, what labs or studies would you
order?
pulse ox and cyanosis; order hgb/hct (see their blood levels and extent of anemia); ABG (to assess degree of hypoxemia); (Patients
who have anemia do not develop cyanosis until the oxygen saturation (also called SaO2) falls below normal hemoglobin levels. Patients with
lower hemoglobin or anemia say with hemoglobin of 6 g/dL, the saturation has to drop as low as 60% before cyanosis becomes clinically
apparent)
442
What is the physiological cause of cyanosis in patients?
increased amounts of UNSATURATED HgB in capillary blood
443
Concerning the rate of an adult patient, if their respiratory rate goes up - what is this called and what do you expect to happen to
their tidal volume
tachypnea; decreased Tidal Volume
444
Normal breathing: is 12-20rr, symmetrical chest expansion, and what sounds should you hear over periphery of the chest wall?
vesicular (gentle, rustling heard throughout inspiration – fades in expiration
445
In an adult, the primary muscle of respiration is?
Diaphragm, with chest/abdominal wall expands simultaneously
446
What are you assessing for during the percussion portion of the adult resp exam?
identify any dull areas or consolidation
447
What areas of the patient are you going to palpate during a respiratory exam?
Trachea (is it deviated?) posterior chest wall (fremitus during spoken words?), anterior chest wall (cardiac impulse)
448
Why is it important for you as the FNP to inspect for extrapulmonary signs of pulmonary disease?
directs your exam, gives you more details about what is going on with the patient
449
A normal respiratory rate in an adult?
12-20
450
Adult physical exam: What are the four things you assess and in what order?
observe pattern of breathing, inspect (extrapulmonary signs of pulm, disease), palpate, percussion, auscultate
