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CASE STUDY 2: Focused Throat Exam Lily is a 20-year-old student at the local community college. When some of her friends and classmates told her about an outbreak of flu-like symptoms sweeping her campus during the past 2 weeks, Lily figured she shouldn’t take her 3-day sore throat lightly. Your clinic has treated a few cases similar to Lily’s. All the patients reported decreased appetite, headaches, and pain with swallowing. As Lily recounts these symptoms to you, you notice that she has a runny nose and a slight hoarseness in her voice but doesn’t sound congested.

To Prepare

· By Day 1 of this week, you will be assigned to a specific case study for this Case Study Assignment. Please see the “Course Announcements” section of the classroom for your assignment from your Instructor.

· Also, your Case Study Assignment should be in the Episodic/Focused SOAP Note format rather than the traditional narrative style format. Refer to Chapter 2 of the Sullivan text and the Episodic/Focused SOAP Template in the Week 5 Learning Resources for guidance. Remember that all Episodic/Focused SOAP Notes have specific data included in every patient case.

With regard to the case study you were assigned:

· Review this week’s Learning Resources and consider the insights they provide.

· Consider what history would be necessary to collect from the patient.

· Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?

· Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.

The Assignment

Use the Episodic/Focused SOAP Template and create an episodic/focused note about the patient in the case study to which you were assigned using the episodic/focused note template provided in the Week 5 resources. Provide evidence from the literature to support diagnostic tests that would be appropriate for each case. List five different possible conditions for the patient’s differential diagnosis and justify why you selected each.

Episodic/Focused SOAP Note Template – (delete information on this template and input one related to the patient in the case study above).

Patient Information:

Initials, Age, Sex, Race

S.

CC (chief complaint) a BRIEF statement identifying why the patient is here – in the patient’s own words – for instance “headache”, NOT “bad headache for 3 days”.

HPI: This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. Use LOCATES Mnemonic to complete your HPI. You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You must include the seven attributes of each principal symptom in paragraph form not a list. If the CC was “headache”, the LOCATES for the HPI might look like the following example:

Location: head

Onset: 3 days ago

Character: pounding, pressure around the eyes and temples

Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia

Timing: after being on the computer all day at work

Exacerbating/ relieving factors: light bothers eyes, Aleve makes it tolerable but not completely better

Severity: 7/10 pain scale

Current Medications: include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.

Allergies: include medication, food, and environmental allergies separately (a description of what the allergy is ie angioedema, anaphylaxis, etc. This will help determine a true reaction vs intolerance).

PMHx: include immunization status (note date of last tetanus for all adults), past major illnesses and surgeries. Depending on the CC, more info is sometimes needed
 

Soc Hx: include occupation and major hobbies, family status, tobacco & alcohol use (previous and current use), any other pertinent data. Always add some health promo question here – such as whether they use seat belts all the time or whether they have working smoke detectors in the house, living environment, text/cell phone use while driving, and support system.

Fam Hx: illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.

ROS: cover all body systems that may help you include or rule out a differential diagnosis You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe.

Example of Complete ROS:

GENERAL:  No weight loss, fever, chills, weakness or fatigue.

HEENT:  Eyes:  No visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat:  No hearing loss, sneezing, congestion, runny nose or sore throat.

SKIN:  No rash or itching.

CARDIOVASCULAR:  No chest pain, chest pressure or chest discomfort. No palpitations or edema.

RESPIRATORY:  No shortness of breath, cough or sputum.

GASTROINTESTINAL:  No anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.

GENITOURINARY:  Burning on urination. Pregnancy. Last menstrual period, MM/DD/YYYY.

NEUROLOGICAL:  No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.

MUSCULOSKELETAL:  No muscle, back pain, joint pain or stiffness.

HEMATOLOGIC:  No anemia, bleeding or bruising.

LYMPHATICS:  No enlarged nodes. No history of splenectomy.

PSYCHIATRIC:  No history of depression or anxiety.

ENDOCRINOLOGIC:  No reports of sweating, cold or heat intolerance. No polyuria or polydipsia.

ALLERGIES:  No history of asthma, hives, eczema or rhinitis.

O.

Physical exam: From head-to-toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History. Do not use “WNL” or “normal.” You must describe what you see. Always document in head to toe format i.e. General: Head: EENT: etc. 

Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines)

A.

Differential Diagnoses (list a minimum of 3 differential diagnoses).Your primary or presumptive diagnosis should be at the top of the list. For each diagnosis, provide supportive documentation with evidence based guidelines.

P. 

This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.

References

You are required to include at least three evidence based peer-reviewed journal articles or evidenced based guidelines which relates to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 6th edition formatting.

Resources for references

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.

  • Chapter 11, “Head and Neck”

         This chapter reviews the anatomy and physiology of the head and neck. The      authors also describe the procedures for conducting a physical examination      of the head and neck.

  • Chapter 12, “Eyes”

         In this chapter, the authors describe the anatomy and function of the      eyes. In addition, the authors explain the steps involved in conducting a      physical examination of the eyes.

  • Chapter 13, “Ears, Nose, and Throat”

         The authors of this chapter detail the proper procedures for conducting a      physical exam of the ears, nose, and throat. The chapter also provides      pictures and descriptions of common abnormalities in the ears, nose, and      throat.

Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health assessment and clinical diagnosis in primary care (6th ed.). St. Louis, MO: Elsevier Mosby.

Credit Line: Advanced Health Assessment and Clinical Diagnosis in Primary Care, 6th Edition by Dains, J.E., Baumann, L. C., & Scheibel, P. Copyright 2019 by Mosby. Reprinted by permission of Mosby via the Copyright Clearance Center.

 

Chapter 15, “Earache”
This chapter covers the main questions that need to be asked about the patient’s condition prior to the physical examination as well as how these questions lead to a focused physical examination.

Chapter 21, “Hoarseness”
This chapter focuses on the most common causes of hoarseness. It provides strategies for evaluating the patient, both through questions and through physical exams.

Chapter 25, “Nasal Symptoms and Sinus Congestion”

In this chapter, the authors highlight the key questions to ask about the patients symptoms, the key parts of the physical examination, and potential laboratory work that might be needed to provide an accurate diagnosis of nasal and sinus conditions.

Chapter 30, “Red Eye”

The focus of this chapter is on how to determine the cause of red eyes in a patient, including key symptoms to consider and possible diagnoses.

Chapter 32, “Sore Throat”

A sore throat is one most common concerns patients describe. This chapter includes questions to ask when taking the patient’s history, things to look for while conducting the physical exam, and possible causes for the sore throat.

Chapter 38, “Vision Loss”
This chapter highlights the causes of vision loss and how the causes of the condition can be diagnosed.

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Head and neck: Student checklist. In Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.

Credit Line: Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center.

Ball, J. W., Dains, J. E., Flynn, J. A., & Solomon, B. S., & Stewart, R. W. (2019). Head and neck: Key points. In Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.

Credit Line: Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center.

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Eyes: Student checklist. In Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.

Credit Line: Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center.

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Eyes: Key points. In Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.

Credit Line: Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center.

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Ears, nose, and throat: Student checklist. In Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.

Credit Line: Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center.

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Ears, nose, and throat: Key points. In Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.

Credit Line: Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center.

Colyar, M. R. (2015). Advanced practice nursing procedures. Philadelphia, PA: F. A. Davis.

Credit Line: Advanced practice nursing procedures, 1st Edition by Colyar, M. R. Copyright 2015 by F. A. Davis Company. Reprinted by permission of F. A. Davis Company via the Copyright Clearance Center.

Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). Philadelphia, PA: F. A. Davis.

  • Chapter 2, “The Comprehensive History and      Physical Exam” (Previously read in Weeks 1, 3, 4, and 5)

Bedell, H. E., & Stevenson, S. B. (2013). Eye movement testing in clinical examination. Vision Research 90, 32–37. doi:10.1016/j.visres.2013.02.001. Retrieved from https://www.sciencedirect.com/science/article/pii/S0042698913000217 

Rubin, G. S. (2013). Measuring reading performance. Vision Research, 90, 43–51. doi:10.1016/j.visres.2013.02.015. Retrieved from http://www.sciencedirect.com/science/article/pii/S0042698913000436  

Harmes, K. M., Blackwood, R. A., Burrows, H. L., Cooke, J. M., Harrison, R. V., & Passamani, P. P. (2013). Otitis media: Diagnosis and treatment. American Family Physicians, 88(7), 435–440.

Otolaryngology Houston. (2014). Imaging of maxillary sinusitis (X-ray, CT, and MRI). Retrieved from http://www.ghorayeb.com/ImagingMaxillarySinusitis.html

This website provides medical images of sinusitis, including X-rays, CT scans, and MRIs (magnetic resonance imaging).

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July 1, 2023
    

  

NUR6550 Final Exam

1. The Valsalva maneuver and the squat-to-stand maneuver are likely to increase the sound of a cardiac murmur associated with which of these conditions?

2. Which of the following conditions may result in lower extremity edema?

Nephrotic syndrome

Decompensated congestive heart failure

Cirrhosis

Renal failure

Deep venous thrombosis

Late-stage pregnancy

All of the above

3. Art Bakke is a 46-year-old male who is being treated for an acute myocardial infarction. He has now developed significant dyspnea at rest and, per physical exam, has coarse rales involving the lower 2/3 of the lung fields bilaterally. You suspect acute pulmonary edema due to papillary-muscle rupture and acute mitral-valve regurgitation.

Question: Which of the following physical findings would support this diagnostic hypothesis?

A palpable diastolic murmur maximal in the second intercostal space (ICS) at the left sternal border

A harsh, rumbling, diastolic murmur heard maximally in the fourth ICS at the left sternal border

A holosystolic systolic murmur heard maximally in the fifth ICS at the midclavicular line

4. The most common ECG finding in a patient with a cardiomyopathy is an ST-elevation MI.

True

False

5. Nina Martinez is a 70-year-old female who experienced an episode of acute pulmonary edema following an endovascular aneurysm repair. She was discharged on furosemide 60 mg daily and instructed to follow up with cardiology. She is now seen in the office at 2 weeks post discharge. Her metabolic panel includes the following lab values:

·          Na 126 mEq/L

·          K 4.0 mEq/L

·          Cl 93 mEq/L

·          CO2 28 mEq/L

·          BUN 40 mg/dL

·          Cr 1.3 mg/dL

Question: This patient has which of the following abnormalities as a likely consequence of diuretic overuse?

Hyponatremia

Hypokalemia

Metabolic acidosis

6. Which of the following are primary cardiomyopathy categories, as described by the World Health Organization (WHO) in 1995?

Dilated cardiomyopathy

Symbol Hypertrophic cardiomyopathy (HCM)

Symbol Restrictive cardiomyopathy

Symbol Arrhythmogenic right ventricular dysplasia

Symbol Unclassified

All of the above

7. What is the most common cause of sudden cardiac death in young people?

What is the most common cause of sudden cardiac death in young people?

Myocardial infarction

Hypertrophic cardiomyopathy

Supraventricular tachycardia

Arrhythmogenic right ventricular dysplasia; aka arrhythmogenic right ventricular cardiomyopathy (ARVC)

8. Which of the following are treatment options for a patient who presents with peripartum cardiomyopathy while still carrying the fetus? (Select all that apply.)

ACE inhibitors

Induction if stable

Emergent cesarean section if unstable

Digoxin

Nitroglycerin

9. What are the 3 major clinical complications related to cardiomyopathies?

Arrhythmias; including ventricular tachycardia and ventricular fibrillation

Thromboembolic complications; including DVT, PE, and ventricular thrombi

Acute pulmonary edema

10. Some patients with primary cardiomyopathies remain asymptomatic throughout their lifetime.

True

False

11. A 38-year -old woman comes to the emergency department complaining of a rapid heartbeat, tremors, and chest tightness. She reports earlier in the day she was feeling a migraine starting so she took a pill given to her by her friend who also experiences migraines. Her medical history reveals that she is currently taking a monoamine oxidase inhibitor for depression. Which migraine medication did she most likely take?

Acetaminophen and caffeine (Excedrin ® Migraine)

Naproxen sodium (Aleve ® )

Almotriptan (Axert ® )

Butalbital, acetaminophen and caffeine (Fioricet ® )

12. You are seeing a 68-year-old woman for treatment of an uncomplicated urinary tract infection (UTI). She has well-controlled hypertension, type 2 diabetes mellitus, and dyslipidemia and takes an angiotensin-converting enzyme inhibitor (ACEI), statin, biguanide, and low-dose aspirin (ASA). She worked in a dry cleaning facility until approximately 8 years ago. During her evaluation, she mentions that she sometimes has difficulty understanding conversation, especially in noisy environments. This is likely a:

Drug-related reaction.

Consequence of occupational chemical exposure.

Early sign of dementia.

Normal age-related change in hearing

13. While evaluating a 33-year-old female with a 2-day history of dysuria, which of the following findings in urinalysis is most suggestive of urinary tract infection (UTI) caused by a Gram-negative organism?

Nitrites

30 mg/dL protein

Epithelial cells

pH>8

14. All of the following are examples of primary prevention strategies except:

Counseling an elderly patient prior to discharge about fall risk at home and how to prevent falls through adequate illumination.

Performing a hemoglobin A1C for all patients admitted to the hospital.

Conducting a study to identify the leading cause of mortality in teenagers and how to reduce risk.

Immunizing all adults ?60 years with zoster vaccine.

15. A 23-year-old woman is being evaluated for an upper respiratory tract infection. As you prepare for auscultation, the patient states “I have a benign murmur that has been with me my whole life”. Anticipating a physiologic murmur, you would expect which of the following characteristics?

Usually obliterates S2.

Becomes softer when going from a supine to standing position.

Occurs late in systole.

Has localized area of auscultation

16. You see a 73-year-old woman with a 40 pack- year smoking history, chronic obstructive pulmonary disease (COPD) and peripheral arterial disease (PAD) who presents with an ulcer on the sole of her left foot. The ulcer has an irregular edge and pale base and a punched out appearance, with the surrounding skin white and shiny. The patient states that the pain is worse at night in bed and when the legs are elevated. The most likely diagnosis is:

Pressure ulcer

Pyoderma gangrenosum

Venous ulcer

Arterial ulcer

17. You see a 76-year-old woman living at home who is accompanied by her home care provider. She has COPD and type 2 diabetes mellitus. An example of a secondary prevention strategy is:

Administering the seasonal influenza vaccine.

Screening for physical or financial abuse/Checking her blood glucose level.

Checking her blood pressure.

Adjusting her insulin dosing regimen.

18. A 43-year-old woman is being evaluated in the emergency department with a complaint of a severe headache. She describes a unilateral, pulsing headache that was preceded by a gradual onset of paresthesia affecting the ipsilateral face and arm. The patient stated she noticed a “funny smell” prior to the symptoms starting. This description is most typical of:

Migraine with aura.

Cluster headache.

Transient ischemic attack.

Tension-type headache.

19. You see a 54-year-old man living in subsidized housing with a history of hypertension. He states that he stopped taking his blood pressure medication about 4 months ago because of costs. He is concerned because his blood pressure is high whenever he checks it, though he does not report any symptoms. His BP at this visit is 196/104 mm Hg. Upon examination of this patient, you would expect to detect an S 4 sound heard during:

Early systole.

Late systole.

Early diastole.

Late diastole.

20. 32-year-old man requires evaluation for hepatitis infection prior to taking a job as a restaurant cook. He presents with the following laboratory results:

Hepatitis A Panel Hepatitis B Panel Hepatitis C Panel

Anti-HAV Negative HBsAg Negative Anti-HCV Positive

IgM Negative Anti-HBc Negative HCV RNA Negative

IgM NegativeAnti-HBs Positive

You recognize the patient is susceptible to:

Hepatitis A and B

Hepatitis B and C

Hepatitis B only

Hepatitis A only

21.  When evaluating illness symptoms in older patients, the disease will often present differently from younger adults due to:

The likelihood of polypharmacy.

Decreased compensatory mechanisms in the elderly.

An increased physiologic response to illness in the elderly.

Presence of comorbid conditions.

22. When prioritizing risk factors for bacterial endocarditis, the nurse practitioner knows who among the following patients has the highest risk.

A 55-year-old man with 3-vessel coronary artery bypass grafts with stents.

A 23-year-old woman with mitral valve prolapse without tissue redundancy.

A 65-year-old man with nonobstructive cardiomyopathy.

A 75-year-old woman with a nonorganic prosthetic aortic valve.

23. The legal authority for NPs to perform healthcare services as defined by state law is called:

Duty of care.

Non-malfeasance.

Autonomy.

Scope of practice.

24. When developing a management plan for patients with genitourinary infections, which of the following would you most likely recommend for follow-up imaging following resolution of their infection?

A 27-year-old nonpregnant woman with acute, uncomplicated urinary tract infection (UTI). 

A 38-year-old nonpregnant woman with 2 acute, uncomplicated UTIs in the past 9 months. 

A 57-year-old man with acute bacterial prostatitis.

A 43-year-old man with type 2 diabetes mellitus and recurrent pyelonephritis.

25. The NP is called to evaluate Jane, a 43-year- old woman, who presents with a diffuse maculopapular rash that began on the trunk but now covers the entire body, including the palms and soles. The rash is not itchy but wart-like sores are present in the mouth and genital area as well as skin folds. Initial evaluation reveals generalized lymphadenopathy and a low-grade fever, and she complains of lethargy and headache. The patient reports that she had a painless genital ulcer that healed on its own about 3 weeks earlier. Which of the following is the most likely diagnosis?

Primary syphilis.

Secondary syphilis.

Genital herpes.

Gonorrhea.

26. A 27-year-old man presents with a chief concern of an abnormal mass within his left scrotum. He describes it as feeling like a “bag of worms” and is present when he is standing but disappears when he lies down. His past medical history is unremarkable and his BMI is 29 kg/m 2 . He has been in a monogamous relationship for the past 4months. The most likely diagnosis is:

Testicular torsion.

Syphilis.

Varicocele.

Testicular cancer.

27. An 18-year-old man is being evaluated for a severe exacerbation of asthma. He is currently taking an inhaled corticosteroid, a long- acting beta-agonist, and a short-acting beta-agonist on an as needed basis. The most important component of the initial assessment includes a(n):

Continuous pulse oximetry reading

Peak expiratory flow reading

Chest X-ray

Arterial Blood Gas

28. A 67-year-old man is being evaluated for shortness of breath. His medical history reveals that he experienced a myocardial infarction about 2 years ago and a history of hypertension, which is well controlled by diet.. Otherwise, his medical history is unremarkable. Which of the following would you expect to find on electrocardiogram (ECG)?

T wave inversion.

Pathologic Q wave.

ST segment elevation.

Tall R wave.

29. A 74-year-old male with asymptomatic atrial fibrillation underwent electrical cardioversion that successfully restored the heart’s rhythm. Which of the following medications can be considered for the purpose of maintaining the heart’s rhythm?

Sotalol (Betapace ® )

Digoxin (Lanoxin ® )

Dabigatran (Pradaxa ® )

Enalapri

30. A 14-year-old male is brought in for evaluation after he reportedly collapsed during a tennis match, though he quickly regained consciousness. His medical history is otherwise unremarkable. You suspect hypertrophic cardiomyopathy. Which of the following heart murmur characteristics would support the diagnosis?

Occurs late in systole.

Widely split S?.

Becomes louder when going from a supine to standing position.

Murmur follows mid-systolic click.

31. You see a 64-year-old man with an area of erythema concentrated on the left side of his neck with clusters of vesicles forming a line. He reported pain in the area a couple of days before the eruption of the lesions. He states that he recently initiated biologic therapy for rheumatoid arthritis. Which of the following is the most likely diagnosis?

Impetigo.

Herpes zoster.

Drug-related adverse reaction.

Viral exanthem.

32. An NP’s duty of care can be established:

Only in the setting of a healthcare institution (e.g., hospital, clinic, etc.).

When the NP gives professional advice or treatment in any setting.

Only when a fee is charged, either to the patient or third-party payer, for services.

Only when both the NP and patient acknowledge a patient-provider relationship.

33. In managing a 58-year- old woman who is admitted for deep vein thrombosis, caution should be used with which of the following medications due to a risk of drug-induced thrombocytopenia?

Warfarin (Coumadin®)

Clopidogrel (Plavix®)

Dabigatran (Pradaxa®)

Unfractionated heparin

34. An 84-year-old female patient is admitted from a local long-term care facility (illnes). The patient is normally awake, alert, and oriented. She resides in the LTCF because she has not fully recovered from a broken hip resulting from a fall 4 months ago; otherwise she is in relatively good health. She can walk short distances with a walker, though she primarily stays in a wheelchair. Today, however, the nursing staff found her to be acutely confused and unable to ambulate without falling. She was transferred to the emergency department for evaluation. Initial laboratory testing must include:

2 sets of blood cultures.

Serum thyroid stimulating hormone (TSH) level.

Urinalysis.

Lumbar puncture.

35. A 23-year-old college student presents with a 2-day history of severe sore throat and difficulty eating or drinking due to trouble swallowing. A physical examination reveals exudative pharyngitis and minimally tender anterior and posterior cervical lymphadenopathy. The NP suspects infectious mononucleosis and would expect which of the following laboratory findings?

Neutrophilia with reactive forms.

Thrombocytosis.

Lymphocytosis with atypical lymphocytes.

Diminished ALT/AST levels.

36. "Incident-to" services are defined as those which are "an integral, although incidental, part of the physician's personal professional services in the course of diagnosis or treatment of an injury or illness". As long as certain criteria are met, “incident to” billing is an option in all of the following settings except:

Office visits.

Hospital.

Nursing home.

Home visits.

37. A 78-year- old male is being treated for a hypoglycemic episode. He has a long history of type 2 diabetes mellitus as well as congestive heart failure and COPD. He is currently taking basal insulin with a sulfonylurea. What is the acceptable A1C goal for this patient?

≤ 6.5%

≤ 7.0%

≤ 8.0%

≤ 9.0%

38. You see a 74- year-old male who is accompanied by his granddaughter who lives with him. He has hypertension, a prior myocardial infarction, long-standing type 2 diabetes, and recently underwent a lower limb amputation secondary to diabetes. He is currently taking an ACE inhibitor, statin, low-dose aspirin, biguanide, and insulin. The granddaughter reports that since the amputation, her grandfather sometimes becomes withdrawn, irritable and moody for no apparent reason, does not want to participate in the typical activities he enjoys, and often does not appear to eat much during the day. She also states that he often complains of being tired but normally wakes up in the early morning hours. The most appropriate action is to evaluate the patient for:

Dementia.

Depression.

Delirium.

Drug interaction.

39. You see a 58-year-old man who complains of a persistent dry, hacking cough. He reports that he recently started taking a medication to treat high blood pressure. He is most likely taking a(n):

Angiotensin-converting enzyme (ACE) inhibitor

Alpha-adrenergic antagonist

Angiotensin receptor blocker

Beta-adrenergic antagonist

40. A 77-year-old woman is accompanied by her husband for evaluation. She is currently being treated with metoprolol (Lopressor ® ) for hypertension and digoxin (Lanoxin ® ) for atrial fibrillation. He reports that his wife is becoming increasingly forgetful over the past year, failing to note important family events such as birthdays, and sometimes becomes confused with driving directions to familiar locations. She has no previous psychiatric history. The most likely diagnosis is:

Parkinson’s disease.

Delirium.

Dementia.

Early stage of congestive heart failure.

41. Mrs. Conner is a 76- year-old woman living in a long-term care facility and has been bedridden with a respiratory infection for the past 4 days. She is brought in for evaluation and you note signs of dehydration as well as a section of epidermal skin loss about 3 cm in diameter on her right hip. The dermal layer appears intact. This would be considered a pressure ulcer of Stage:

1

2

3

4

42. Which of the following represents the highest level of scientific evidence when evaluating clinical research?

A randomized controlled trial.

Systematic review/ Meta-analysis of randomized controlled troals.

Observational study.

Cohort study.

43. A 64-year- old woman with chronic kidney disease presents with a chief complaint of lethargy. His hemogram is as follows:

-Hemoglobin (Hg)=9.9 g/dL (12–14 g/dL

-Hematocrit (Hct)=30% (36%–42%)

-Mean cell volume (MCV)=81 fL (80–96 fL

-Reticulocytes=0.7% (1%–2%)

These findings are most consistent with:

Iron deficiency anemia.

Anemia of chronic disease.

Folate deficiency anemia.

Thalassemia trait.

44. You see a 68-year-old woman who is being treated for moderate depression. She complains that her medication is causing symptoms of dry mouth and constipation. She is most likely taking which of the following medications?

Venlafaxine (Effexor ® )

Citalopram (Celexa ® )

Fluoxetine (Prozac ® )

Nortriptyline (Pamelor ® )

45. All of the following persons are eligible for Medicare services except:

A 74-year-old ex-smoker with COPD and high income from assets.

A 69-year-old undocumented resident in the US with atrial fibrillation.

A 62-year-old with a permanent physical disability due to a motor vehicle accident. 

A 72-year-old permanent legal resident (non-US citizen) with type 1 diabetes mellitus.

46. When initiating therapy with spironolactone for a patient who is also on an ACE inhibitor, you advise the patient to return in 5 days to check which of the following laboratory parameters?

Sodium

Calcium

Potassium

Chloride

47. When considering an end-of-life decision for a terminally ill person with Alzheimer-type dementia who can no longer communicate, all of the following can be used as an advanced directive except:

Testimony from a family member or close friend

A living will.

A “do not resuscitate” order.

A durable power of attorney for healthcare.

48. Which of the following types of clinical studies represents the lowest level of evidence used to guide medical decisions?

Clinical experience of renowned expert in field.

Non-randomized controlled study.

Observational study.

Case-control study.

49. Which of the following electrocardiogram (ECG) changes do you expect to find in a person with myocardial ischemia?calcium

Pathologic Q wave

Tall R wave

T wave inversion

ST segment elevation

50. Which of the following statements is false regarding end-of-life decision-making for a patient that is hopelessly and terminally ill?

A durable power of attorney for healthcare can be used to authorize another person to make healthcare decisions. 

A videotaped or audiotaped discussion with the patient can include advanced directives.

Advanced directives are legally binding and recognized in all 50 states.

Living wills and do not resuscitate orders are examples of advanced directives.

51. The nurse practitioner is evaluating a 19-year- old male suffering from a severe headache. He has a history of headaches that tend to occur in clusters over a few days. He has unsuccessfully tried several therapeutic modalities. A positive response to which of the following interventions supports the diagnosis of cluster headache?

Oxygen therapy.

Beta-adrenergic blockade.

Tricyclic antidepressant.

Dietary reduction of amines.

52. All of the following are required Medicare terms and conditions for paying NP services except:

The services are within the NP’s scope of practice as defined by state law.

The services performed are those for which a physician would be able to bill Medicare. The services are performed in collaboration with a physician.

Separate charges are billed for NP services and facility charges.

53. A 28- year- old male with asthma presents with a chief complaint that he has to use his rescue inhaler multiple times each day. An evaluation reveals that he has moderate-to-severe asthma and requires Step 4 treatment. An appropriate regimen would include:

Low-dose inhaled corticosteroid (ICS)

Medium-dose ICS

Medium-dose ICS plus a long-acting beta?-agonist (LABA)

High-dose ICS plus LABA plus omalizumab (Xolair ® )

54. A 62-year-old woman presents in the emergency department complaining of severe toe pain that originated overnight. She has a history of renal disease and is currently taking a thiazide diuretic. Her BMI is 37 kg/m 2 . In considering a diagnosis of acute gouty arthritis, the nurse practitioner knows that the best diagnostic indicator is:

Serum uric acid.

Joint X-ray.

Erythrocyte sedimentation rate (ESR).

Analysis of joint aspirate for urate crystals.

55. Which of the following is the most appropriate antibiotic for a 57-year-old man with acute bacterial rhinosinusitis and who has type 2 diabetes mellitus, COPD and a beta-lactam allergy?

Cephalexin (Keflex ® ).

Amoxicillin-clavulanate (Augmentin ® ).

Trimethoprim with or without sulfamethoxazole (Primsol ® , Bactrim ® ).

Levofloxacin (Levaquin ® )

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July 1, 2023
    

  

NUR6550 Final Exam

1. The Valsalva maneuver and the squat-to-stand maneuver are likely to increase the sound of a cardiac murmur associated with which of these conditions?

2. Which of the following conditions may result in lower extremity edema?

Nephrotic syndrome

Decompensated congestive heart failure

Cirrhosis

Renal failure

Deep venous thrombosis

Late-stage pregnancy

All of the above

3. Art Bakke is a 46-year-old male who is being treated for an acute myocardial infarction. He has now developed significant dyspnea at rest and, per physical exam, has coarse rales involving the lower 2/3 of the lung fields bilaterally. You suspect acute pulmonary edema due to papillary-muscle rupture and acute mitral-valve regurgitation.

Question: Which of the following physical findings would support this diagnostic hypothesis?

A palpable diastolic murmur maximal in the second intercostal space (ICS) at the left sternal border

A harsh, rumbling, diastolic murmur heard maximally in the fourth ICS at the left sternal border

A holosystolic systolic murmur heard maximally in the fifth ICS at the midclavicular line

4. The most common ECG finding in a patient with a cardiomyopathy is an ST-elevation MI.

True

False

5. Nina Martinez is a 70-year-old female who experienced an episode of acute pulmonary edema following an endovascular aneurysm repair. She was discharged on furosemide 60 mg daily and instructed to follow up with cardiology. She is now seen in the office at 2 weeks post discharge. Her metabolic panel includes the following lab values:

·          Na 126 mEq/L

·          K 4.0 mEq/L

·          Cl 93 mEq/L

·          CO2 28 mEq/L

·          BUN 40 mg/dL

·          Cr 1.3 mg/dL

Question: This patient has which of the following abnormalities as a likely consequence of diuretic overuse?

Hyponatremia

Hypokalemia

Metabolic acidosis

6. Which of the following are primary cardiomyopathy categories, as described by the World Health Organization (WHO) in 1995?

Dilated cardiomyopathy

Symbol Hypertrophic cardiomyopathy (HCM)

Symbol Restrictive cardiomyopathy

Symbol Arrhythmogenic right ventricular dysplasia

Symbol Unclassified

All of the above

7. What is the most common cause of sudden cardiac death in young people?

What is the most common cause of sudden cardiac death in young people?

Myocardial infarction

Hypertrophic cardiomyopathy

Supraventricular tachycardia

Arrhythmogenic right ventricular dysplasia; aka arrhythmogenic right ventricular cardiomyopathy (ARVC)

8. Which of the following are treatment options for a patient who presents with peripartum cardiomyopathy while still carrying the fetus? (Select all that apply.)

ACE inhibitors

Induction if stable

Emergent cesarean section if unstable

Digoxin

Nitroglycerin

9. What are the 3 major clinical complications related to cardiomyopathies?

Arrhythmias; including ventricular tachycardia and ventricular fibrillation

Thromboembolic complications; including DVT, PE, and ventricular thrombi

Acute pulmonary edema

10. Some patients with primary cardiomyopathies remain asymptomatic throughout their lifetime.

True

False

11. A 38-year -old woman comes to the emergency department complaining of a rapid heartbeat, tremors, and chest tightness. She reports earlier in the day she was feeling a migraine starting so she took a pill given to her by her friend who also experiences migraines. Her medical history reveals that she is currently taking a monoamine oxidase inhibitor for depression. Which migraine medication did she most likely take?

Acetaminophen and caffeine (Excedrin ® Migraine)

Naproxen sodium (Aleve ® )

Almotriptan (Axert ® )

Butalbital, acetaminophen and caffeine (Fioricet ® )

12. You are seeing a 68-year-old woman for treatment of an uncomplicated urinary tract infection (UTI). She has well-controlled hypertension, type 2 diabetes mellitus, and dyslipidemia and takes an angiotensin-converting enzyme inhibitor (ACEI), statin, biguanide, and low-dose aspirin (ASA). She worked in a dry cleaning facility until approximately 8 years ago. During her evaluation, she mentions that she sometimes has difficulty understanding conversation, especially in noisy environments. This is likely a:

Drug-related reaction.

Consequence of occupational chemical exposure.

Early sign of dementia.

Normal age-related change in hearing

13. While evaluating a 33-year-old female with a 2-day history of dysuria, which of the following findings in urinalysis is most suggestive of urinary tract infection (UTI) caused by a Gram-negative organism?

Nitrites

30 mg/dL protein

Epithelial cells

pH>8

14. All of the following are examples of primary prevention strategies except:

Counseling an elderly patient prior to discharge about fall risk at home and how to prevent falls through adequate illumination.

Performing a hemoglobin A1C for all patients admitted to the hospital.

Conducting a study to identify the leading cause of mortality in teenagers and how to reduce risk.

Immunizing all adults ?60 years with zoster vaccine.

15. A 23-year-old woman is being evaluated for an upper respiratory tract infection. As you prepare for auscultation, the patient states “I have a benign murmur that has been with me my whole life”. Anticipating a physiologic murmur, you would expect which of the following characteristics?

Usually obliterates S2.

Becomes softer when going from a supine to standing position.

Occurs late in systole.

Has localized area of auscultation

16. You see a 73-year-old woman with a 40 pack- year smoking history, chronic obstructive pulmonary disease (COPD) and peripheral arterial disease (PAD) who presents with an ulcer on the sole of her left foot. The ulcer has an irregular edge and pale base and a punched out appearance, with the surrounding skin white and shiny. The patient states that the pain is worse at night in bed and when the legs are elevated. The most likely diagnosis is:

Pressure ulcer

Pyoderma gangrenosum

Venous ulcer

Arterial ulcer

17. You see a 76-year-old woman living at home who is accompanied by her home care provider. She has COPD and type 2 diabetes mellitus. An example of a secondary prevention strategy is:

Administering the seasonal influenza vaccine.

Screening for physical or financial abuse/Checking her blood glucose level.

Checking her blood pressure.

Adjusting her insulin dosing regimen.

18. A 43-year-old woman is being evaluated in the emergency department with a complaint of a severe headache. She describes a unilateral, pulsing headache that was preceded by a gradual onset of paresthesia affecting the ipsilateral face and arm. The patient stated she noticed a “funny smell” prior to the symptoms starting. This description is most typical of:

Migraine with aura.

Cluster headache.

Transient ischemic attack.

Tension-type headache.

19. You see a 54-year-old man living in subsidized housing with a history of hypertension. He states that he stopped taking his blood pressure medication about 4 months ago because of costs. He is concerned because his blood pressure is high whenever he checks it, though he does not report any symptoms. His BP at this visit is 196/104 mm Hg. Upon examination of this patient, you would expect to detect an S 4 sound heard during:

Early systole.

Late systole.

Early diastole.

Late diastole.

20. 32-year-old man requires evaluation for hepatitis infection prior to taking a job as a restaurant cook. He presents with the following laboratory results:

Hepatitis A Panel Hepatitis B Panel Hepatitis C Panel

Anti-HAV Negative HBsAg Negative Anti-HCV Positive

IgM Negative Anti-HBc Negative HCV RNA Negative

IgM NegativeAnti-HBs Positive

You recognize the patient is susceptible to:

Hepatitis A and B

Hepatitis B and C

Hepatitis B only

Hepatitis A only

21.  When evaluating illness symptoms in older patients, the disease will often present differently from younger adults due to:

The likelihood of polypharmacy.

Decreased compensatory mechanisms in the elderly.

An increased physiologic response to illness in the elderly.

Presence of comorbid conditions.

22. When prioritizing risk factors for bacterial endocarditis, the nurse practitioner knows who among the following patients has the highest risk.

A 55-year-old man with 3-vessel coronary artery bypass grafts with stents.

A 23-year-old woman with mitral valve prolapse without tissue redundancy.

A 65-year-old man with nonobstructive cardiomyopathy.

A 75-year-old woman with a nonorganic prosthetic aortic valve.

23. The legal authority for NPs to perform healthcare services as defined by state law is called:

Duty of care.

Non-malfeasance.

Autonomy.

Scope of practice.

24. When developing a management plan for patients with genitourinary infections, which of the following would you most likely recommend for follow-up imaging following resolution of their infection?

A 27-year-old nonpregnant woman with acute, uncomplicated urinary tract infection (UTI). 

A 38-year-old nonpregnant woman with 2 acute, uncomplicated UTIs in the past 9 months. 

A 57-year-old man with acute bacterial prostatitis.

A 43-year-old man with type 2 diabetes mellitus and recurrent pyelonephritis.

25. The NP is called to evaluate Jane, a 43-year- old woman, who presents with a diffuse maculopapular rash that began on the trunk but now covers the entire body, including the palms and soles. The rash is not itchy but wart-like sores are present in the mouth and genital area as well as skin folds. Initial evaluation reveals generalized lymphadenopathy and a low-grade fever, and she complains of lethargy and headache. The patient reports that she had a painless genital ulcer that healed on its own about 3 weeks earlier. Which of the following is the most likely diagnosis?

Primary syphilis.

Secondary syphilis.

Genital herpes.

Gonorrhea.

26. A 27-year-old man presents with a chief concern of an abnormal mass within his left scrotum. He describes it as feeling like a “bag of worms” and is present when he is standing but disappears when he lies down. His past medical history is unremarkable and his BMI is 29 kg/m 2 . He has been in a monogamous relationship for the past 4months. The most likely diagnosis is:

Testicular torsion.

Syphilis.

Varicocele.

Testicular cancer.

27. An 18-year-old man is being evaluated for a severe exacerbation of asthma. He is currently taking an inhaled corticosteroid, a long- acting beta-agonist, and a short-acting beta-agonist on an as needed basis. The most important component of the initial assessment includes a(n):

Continuous pulse oximetry reading

Peak expiratory flow reading

Chest X-ray

Arterial Blood Gas

28. A 67-year-old man is being evaluated for shortness of breath. His medical history reveals that he experienced a myocardial infarction about 2 years ago and a history of hypertension, which is well controlled by diet.. Otherwise, his medical history is unremarkable. Which of the following would you expect to find on electrocardiogram (ECG)?

T wave inversion.

Pathologic Q wave.

ST segment elevation.

Tall R wave.

29. A 74-year-old male with asymptomatic atrial fibrillation underwent electrical cardioversion that successfully restored the heart’s rhythm. Which of the following medications can be considered for the purpose of maintaining the heart’s rhythm?

Sotalol (Betapace ® )

Digoxin (Lanoxin ® )

Dabigatran (Pradaxa ® )

Enalapri

30. A 14-year-old male is brought in for evaluation after he reportedly collapsed during a tennis match, though he quickly regained consciousness. His medical history is otherwise unremarkable. You suspect hypertrophic cardiomyopathy. Which of the following heart murmur characteristics would support the diagnosis?

Occurs late in systole.

Widely split S?.

Becomes louder when going from a supine to standing position.

Murmur follows mid-systolic click.

31. You see a 64-year-old man with an area of erythema concentrated on the left side of his neck with clusters of vesicles forming a line. He reported pain in the area a couple of days before the eruption of the lesions. He states that he recently initiated biologic therapy for rheumatoid arthritis. Which of the following is the most likely diagnosis?

Impetigo.

Herpes zoster.

Drug-related adverse reaction.

Viral exanthem.

32. An NP’s duty of care can be established:

Only in the setting of a healthcare institution (e.g., hospital, clinic, etc.).

When the NP gives professional advice or treatment in any setting.

Only when a fee is charged, either to the patient or third-party payer, for services.

Only when both the NP and patient acknowledge a patient-provider relationship.

33. In managing a 58-year- old woman who is admitted for deep vein thrombosis, caution should be used with which of the following medications due to a risk of drug-induced thrombocytopenia?

Warfarin (Coumadin®)

Clopidogrel (Plavix®)

Dabigatran (Pradaxa®)

Unfractionated heparin

34. An 84-year-old female patient is admitted from a local long-term care facility (illnes). The patient is normally awake, alert, and oriented. She resides in the LTCF because she has not fully recovered from a broken hip resulting from a fall 4 months ago; otherwise she is in relatively good health. She can walk short distances with a walker, though she primarily stays in a wheelchair. Today, however, the nursing staff found her to be acutely confused and unable to ambulate without falling. She was transferred to the emergency department for evaluation. Initial laboratory testing must include:

2 sets of blood cultures.

Serum thyroid stimulating hormone (TSH) level.

Urinalysis.

Lumbar puncture.

35. A 23-year-old college student presents with a 2-day history of severe sore throat and difficulty eating or drinking due to trouble swallowing. A physical examination reveals exudative pharyngitis and minimally tender anterior and posterior cervical lymphadenopathy. The NP suspects infectious mononucleosis and would expect which of the following laboratory findings?

Neutrophilia with reactive forms.

Thrombocytosis.

Lymphocytosis with atypical lymphocytes.

Diminished ALT/AST levels.

36. "Incident-to" services are defined as those which are "an integral, although incidental, part of the physician's personal professional services in the course of diagnosis or treatment of an injury or illness". As long as certain criteria are met, “incident to” billing is an option in all of the following settings except:

Office visits.

Hospital.

Nursing home.

Home visits.

37. A 78-year- old male is being treated for a hypoglycemic episode. He has a long history of type 2 diabetes mellitus as well as congestive heart failure and COPD. He is currently taking basal insulin with a sulfonylurea. What is the acceptable A1C goal for this patient?

≤ 6.5%

≤ 7.0%

≤ 8.0%

≤ 9.0%

38. You see a 74- year-old male who is accompanied by his granddaughter who lives with him. He has hypertension, a prior myocardial infarction, long-standing type 2 diabetes, and recently underwent a lower limb amputation secondary to diabetes. He is currently taking an ACE inhibitor, statin, low-dose aspirin, biguanide, and insulin. The granddaughter reports that since the amputation, her grandfather sometimes becomes withdrawn, irritable and moody for no apparent reason, does not want to participate in the typical activities he enjoys, and often does not appear to eat much during the day. She also states that he often complains of being tired but normally wakes up in the early morning hours. The most appropriate action is to evaluate the patient for:

Dementia.

Depression.

Delirium.

Drug interaction.

39. You see a 58-year-old man who complains of a persistent dry, hacking cough. He reports that he recently started taking a medication to treat high blood pressure. He is most likely taking a(n):

Angiotensin-converting enzyme (ACE) inhibitor

Alpha-adrenergic antagonist

Angiotensin receptor blocker

Beta-adrenergic antagonist

40. A 77-year-old woman is accompanied by her husband for evaluation. She is currently being treated with metoprolol (Lopressor ® ) for hypertension and digoxin (Lanoxin ® ) for atrial fibrillation. He reports that his wife is becoming increasingly forgetful over the past year, failing to note important family events such as birthdays, and sometimes becomes confused with driving directions to familiar locations. She has no previous psychiatric history. The most likely diagnosis is:

Parkinson’s disease.

Delirium.

Dementia.

Early stage of congestive heart failure.

41. Mrs. Conner is a 76- year-old woman living in a long-term care facility and has been bedridden with a respiratory infection for the past 4 days. She is brought in for evaluation and you note signs of dehydration as well as a section of epidermal skin loss about 3 cm in diameter on her right hip. The dermal layer appears intact. This would be considered a pressure ulcer of Stage:

1

2

3

4

42. Which of the following represents the highest level of scientific evidence when evaluating clinical research?

A randomized controlled trial.

Systematic review/ Meta-analysis of randomized controlled troals.

Observational study.

Cohort study.

43. A 64-year- old woman with chronic kidney disease presents with a chief complaint of lethargy. His hemogram is as follows:

-Hemoglobin (Hg)=9.9 g/dL (12–14 g/dL

-Hematocrit (Hct)=30% (36%–42%)

-Mean cell volume (MCV)=81 fL (80–96 fL

-Reticulocytes=0.7% (1%–2%)

These findings are most consistent with:

Iron deficiency anemia.

Anemia of chronic disease.

Folate deficiency anemia.

Thalassemia trait.

44. You see a 68-year-old woman who is being treated for moderate depression. She complains that her medication is causing symptoms of dry mouth and constipation. She is most likely taking which of the following medications?

Venlafaxine (Effexor ® )

Citalopram (Celexa ® )

Fluoxetine (Prozac ® )

Nortriptyline (Pamelor ® )

45. All of the following persons are eligible for Medicare services except:

A 74-year-old ex-smoker with COPD and high income from assets.

A 69-year-old undocumented resident in the US with atrial fibrillation.

A 62-year-old with a permanent physical disability due to a motor vehicle accident. 

A 72-year-old permanent legal resident (non-US citizen) with type 1 diabetes mellitus.

46. When initiating therapy with spironolactone for a patient who is also on an ACE inhibitor, you advise the patient to return in 5 days to check which of the following laboratory parameters?

Sodium

Calcium

Potassium

Chloride

47. When considering an end-of-life decision for a terminally ill person with Alzheimer-type dementia who can no longer communicate, all of the following can be used as an advanced directive except:

Testimony from a family member or close friend

A living will.

A “do not resuscitate” order.

A durable power of attorney for healthcare.

48. Which of the following types of clinical studies represents the lowest level of evidence used to guide medical decisions?

Clinical experience of renowned expert in field.

Non-randomized controlled study.

Observational study.

Case-control study.

49. Which of the following electrocardiogram (ECG) changes do you expect to find in a person with myocardial ischemia?calcium

Pathologic Q wave

Tall R wave

T wave inversion

ST segment elevation

50. Which of the following statements is false regarding end-of-life decision-making for a patient that is hopelessly and terminally ill?

A durable power of attorney for healthcare can be used to authorize another person to make healthcare decisions. 

A videotaped or audiotaped discussion with the patient can include advanced directives.

Advanced directives are legally binding and recognized in all 50 states.

Living wills and do not resuscitate orders are examples of advanced directives.

51. The nurse practitioner is evaluating a 19-year- old male suffering from a severe headache. He has a history of headaches that tend to occur in clusters over a few days. He has unsuccessfully tried several therapeutic modalities. A positive response to which of the following interventions supports the diagnosis of cluster headache?

Oxygen therapy.

Beta-adrenergic blockade.

Tricyclic antidepressant.

Dietary reduction of amines.

52. All of the following are required Medicare terms and conditions for paying NP services except:

The services are within the NP’s scope of practice as defined by state law.

The services performed are those for which a physician would be able to bill Medicare. The services are performed in collaboration with a physician.

Separate charges are billed for NP services and facility charges.

53. A 28- year- old male with asthma presents with a chief complaint that he has to use his rescue inhaler multiple times each day. An evaluation reveals that he has moderate-to-severe asthma and requires Step 4 treatment. An appropriate regimen would include:

Low-dose inhaled corticosteroid (ICS)

Medium-dose ICS

Medium-dose ICS plus a long-acting beta?-agonist (LABA)

High-dose ICS plus LABA plus omalizumab (Xolair ® )

54. A 62-year-old woman presents in the emergency department complaining of severe toe pain that originated overnight. She has a history of renal disease and is currently taking a thiazide diuretic. Her BMI is 37 kg/m 2 . In considering a diagnosis of acute gouty arthritis, the nurse practitioner knows that the best diagnostic indicator is:

Serum uric acid.

Joint X-ray.

Erythrocyte sedimentation rate (ESR).

Analysis of joint aspirate for urate crystals.

55. Which of the following is the most appropriate antibiotic for a 57-year-old man with acute bacterial rhinosinusitis and who has type 2 diabetes mellitus, COPD and a beta-lactam allergy?

Cephalexin (Keflex ® ).

Amoxicillin-clavulanate (Augmentin ® ).

Trimethoprim with or without sulfamethoxazole (Primsol ® , Bactrim ® ).

Levofloxacin (Levaquin ® )

default image
July 1, 2023
    

  

NUR6550 Final Exam

1. The Valsalva maneuver and the squat-to-stand maneuver are likely to increase the sound of a cardiac murmur associated with which of these conditions?

2. Which of the following conditions may result in lower extremity edema?

Nephrotic syndrome

Decompensated congestive heart failure

Cirrhosis

Renal failure

Deep venous thrombosis

Late-stage pregnancy

All of the above

3. Art Bakke is a 46-year-old male who is being treated for an acute myocardial infarction. He has now developed significant dyspnea at rest and, per physical exam, has coarse rales involving the lower 2/3 of the lung fields bilaterally. You suspect acute pulmonary edema due to papillary-muscle rupture and acute mitral-valve regurgitation.

Question: Which of the following physical findings would support this diagnostic hypothesis?

A palpable diastolic murmur maximal in the second intercostal space (ICS) at the left sternal border

A harsh, rumbling, diastolic murmur heard maximally in the fourth ICS at the left sternal border

A holosystolic systolic murmur heard maximally in the fifth ICS at the midclavicular line

4. The most common ECG finding in a patient with a cardiomyopathy is an ST-elevation MI.

True

False

5. Nina Martinez is a 70-year-old female who experienced an episode of acute pulmonary edema following an endovascular aneurysm repair. She was discharged on furosemide 60 mg daily and instructed to follow up with cardiology. She is now seen in the office at 2 weeks post discharge. Her metabolic panel includes the following lab values:

·          Na 126 mEq/L

·          K 4.0 mEq/L

·          Cl 93 mEq/L

·          CO2 28 mEq/L

·          BUN 40 mg/dL

·          Cr 1.3 mg/dL

Question: This patient has which of the following abnormalities as a likely consequence of diuretic overuse?

Hyponatremia

Hypokalemia

Metabolic acidosis

6. Which of the following are primary cardiomyopathy categories, as described by the World Health Organization (WHO) in 1995?

Dilated cardiomyopathy

Symbol Hypertrophic cardiomyopathy (HCM)

Symbol Restrictive cardiomyopathy

Symbol Arrhythmogenic right ventricular dysplasia

Symbol Unclassified

All of the above

7. What is the most common cause of sudden cardiac death in young people?

What is the most common cause of sudden cardiac death in young people?

Myocardial infarction

Hypertrophic cardiomyopathy

Supraventricular tachycardia

Arrhythmogenic right ventricular dysplasia; aka arrhythmogenic right ventricular cardiomyopathy (ARVC)

8. Which of the following are treatment options for a patient who presents with peripartum cardiomyopathy while still carrying the fetus? (Select all that apply.)

ACE inhibitors

Induction if stable

Emergent cesarean section if unstable

Digoxin

Nitroglycerin

9. What are the 3 major clinical complications related to cardiomyopathies?

Arrhythmias; including ventricular tachycardia and ventricular fibrillation

Thromboembolic complications; including DVT, PE, and ventricular thrombi

Acute pulmonary edema

10. Some patients with primary cardiomyopathies remain asymptomatic throughout their lifetime.

True

False

11. A 38-year -old woman comes to the emergency department complaining of a rapid heartbeat, tremors, and chest tightness. She reports earlier in the day she was feeling a migraine starting so she took a pill given to her by her friend who also experiences migraines. Her medical history reveals that she is currently taking a monoamine oxidase inhibitor for depression. Which migraine medication did she most likely take?

Acetaminophen and caffeine (Excedrin ® Migraine)

Naproxen sodium (Aleve ® )

Almotriptan (Axert ® )

Butalbital, acetaminophen and caffeine (Fioricet ® )

12. You are seeing a 68-year-old woman for treatment of an uncomplicated urinary tract infection (UTI). She has well-controlled hypertension, type 2 diabetes mellitus, and dyslipidemia and takes an angiotensin-converting enzyme inhibitor (ACEI), statin, biguanide, and low-dose aspirin (ASA). She worked in a dry cleaning facility until approximately 8 years ago. During her evaluation, she mentions that she sometimes has difficulty understanding conversation, especially in noisy environments. This is likely a:

Drug-related reaction.

Consequence of occupational chemical exposure.

Early sign of dementia.

Normal age-related change in hearing

13. While evaluating a 33-year-old female with a 2-day history of dysuria, which of the following findings in urinalysis is most suggestive of urinary tract infection (UTI) caused by a Gram-negative organism?

Nitrites

30 mg/dL protein

Epithelial cells

pH>8

14. All of the following are examples of primary prevention strategies except:

Counseling an elderly patient prior to discharge about fall risk at home and how to prevent falls through adequate illumination.

Performing a hemoglobin A1C for all patients admitted to the hospital.

Conducting a study to identify the leading cause of mortality in teenagers and how to reduce risk.

Immunizing all adults ?60 years with zoster vaccine.

15. A 23-year-old woman is being evaluated for an upper respiratory tract infection. As you prepare for auscultation, the patient states “I have a benign murmur that has been with me my whole life”. Anticipating a physiologic murmur, you would expect which of the following characteristics?

Usually obliterates S2.

Becomes softer when going from a supine to standing position.

Occurs late in systole.

Has localized area of auscultation

16. You see a 73-year-old woman with a 40 pack- year smoking history, chronic obstructive pulmonary disease (COPD) and peripheral arterial disease (PAD) who presents with an ulcer on the sole of her left foot. The ulcer has an irregular edge and pale base and a punched out appearance, with the surrounding skin white and shiny. The patient states that the pain is worse at night in bed and when the legs are elevated. The most likely diagnosis is:

Pressure ulcer

Pyoderma gangrenosum

Venous ulcer

Arterial ulcer

17. You see a 76-year-old woman living at home who is accompanied by her home care provider. She has COPD and type 2 diabetes mellitus. An example of a secondary prevention strategy is:

Administering the seasonal influenza vaccine.

Screening for physical or financial abuse/Checking her blood glucose level.

Checking her blood pressure.

Adjusting her insulin dosing regimen.

18. A 43-year-old woman is being evaluated in the emergency department with a complaint of a severe headache. She describes a unilateral, pulsing headache that was preceded by a gradual onset of paresthesia affecting the ipsilateral face and arm. The patient stated she noticed a “funny smell” prior to the symptoms starting. This description is most typical of:

Migraine with aura.

Cluster headache.

Transient ischemic attack.

Tension-type headache.

19. You see a 54-year-old man living in subsidized housing with a history of hypertension. He states that he stopped taking his blood pressure medication about 4 months ago because of costs. He is concerned because his blood pressure is high whenever he checks it, though he does not report any symptoms. His BP at this visit is 196/104 mm Hg. Upon examination of this patient, you would expect to detect an S 4 sound heard during:

Early systole.

Late systole.

Early diastole.

Late diastole.

20. 32-year-old man requires evaluation for hepatitis infection prior to taking a job as a restaurant cook. He presents with the following laboratory results:

Hepatitis A Panel Hepatitis B Panel Hepatitis C Panel

Anti-HAV Negative HBsAg Negative Anti-HCV Positive

IgM Negative Anti-HBc Negative HCV RNA Negative

IgM NegativeAnti-HBs Positive

You recognize the patient is susceptible to:

Hepatitis A and B

Hepatitis B and C

Hepatitis B only

Hepatitis A only

21.  When evaluating illness symptoms in older patients, the disease will often present differently from younger adults due to:

The likelihood of polypharmacy.

Decreased compensatory mechanisms in the elderly.

An increased physiologic response to illness in the elderly.

Presence of comorbid conditions.

22. When prioritizing risk factors for bacterial endocarditis, the nurse practitioner knows who among the following patients has the highest risk.

A 55-year-old man with 3-vessel coronary artery bypass grafts with stents.

A 23-year-old woman with mitral valve prolapse without tissue redundancy.

A 65-year-old man with nonobstructive cardiomyopathy.

A 75-year-old woman with a nonorganic prosthetic aortic valve.

23. The legal authority for NPs to perform healthcare services as defined by state law is called:

Duty of care.

Non-malfeasance.

Autonomy.

Scope of practice.

24. When developing a management plan for patients with genitourinary infections, which of the following would you most likely recommend for follow-up imaging following resolution of their infection?

A 27-year-old nonpregnant woman with acute, uncomplicated urinary tract infection (UTI). 

A 38-year-old nonpregnant woman with 2 acute, uncomplicated UTIs in the past 9 months. 

A 57-year-old man with acute bacterial prostatitis.

A 43-year-old man with type 2 diabetes mellitus and recurrent pyelonephritis.

25. The NP is called to evaluate Jane, a 43-year- old woman, who presents with a diffuse maculopapular rash that began on the trunk but now covers the entire body, including the palms and soles. The rash is not itchy but wart-like sores are present in the mouth and genital area as well as skin folds. Initial evaluation reveals generalized lymphadenopathy and a low-grade fever, and she complains of lethargy and headache. The patient reports that she had a painless genital ulcer that healed on its own about 3 weeks earlier. Which of the following is the most likely diagnosis?

Primary syphilis.

Secondary syphilis.

Genital herpes.

Gonorrhea.

26. A 27-year-old man presents with a chief concern of an abnormal mass within his left scrotum. He describes it as feeling like a “bag of worms” and is present when he is standing but disappears when he lies down. His past medical history is unremarkable and his BMI is 29 kg/m 2 . He has been in a monogamous relationship for the past 4months. The most likely diagnosis is:

Testicular torsion.

Syphilis.

Varicocele.

Testicular cancer.

27. An 18-year-old man is being evaluated for a severe exacerbation of asthma. He is currently taking an inhaled corticosteroid, a long- acting beta-agonist, and a short-acting beta-agonist on an as needed basis. The most important component of the initial assessment includes a(n):

Continuous pulse oximetry reading

Peak expiratory flow reading

Chest X-ray

Arterial Blood Gas

28. A 67-year-old man is being evaluated for shortness of breath. His medical history reveals that he experienced a myocardial infarction about 2 years ago and a history of hypertension, which is well controlled by diet.. Otherwise, his medical history is unremarkable. Which of the following would you expect to find on electrocardiogram (ECG)?

T wave inversion.

Pathologic Q wave.

ST segment elevation.

Tall R wave.

29. A 74-year-old male with asymptomatic atrial fibrillation underwent electrical cardioversion that successfully restored the heart’s rhythm. Which of the following medications can be considered for the purpose of maintaining the heart’s rhythm?

Sotalol (Betapace ® )

Digoxin (Lanoxin ® )

Dabigatran (Pradaxa ® )

Enalapri

30. A 14-year-old male is brought in for evaluation after he reportedly collapsed during a tennis match, though he quickly regained consciousness. His medical history is otherwise unremarkable. You suspect hypertrophic cardiomyopathy. Which of the following heart murmur characteristics would support the diagnosis?

Occurs late in systole.

Widely split S?.

Becomes louder when going from a supine to standing position.

Murmur follows mid-systolic click.

31. You see a 64-year-old man with an area of erythema concentrated on the left side of his neck with clusters of vesicles forming a line. He reported pain in the area a couple of days before the eruption of the lesions. He states that he recently initiated biologic therapy for rheumatoid arthritis. Which of the following is the most likely diagnosis?

Impetigo.

Herpes zoster.

Drug-related adverse reaction.

Viral exanthem.

32. An NP’s duty of care can be established:

Only in the setting of a healthcare institution (e.g., hospital, clinic, etc.).

When the NP gives professional advice or treatment in any setting.

Only when a fee is charged, either to the patient or third-party payer, for services.

Only when both the NP and patient acknowledge a patient-provider relationship.

33. In managing a 58-year- old woman who is admitted for deep vein thrombosis, caution should be used with which of the following medications due to a risk of drug-induced thrombocytopenia?

Warfarin (Coumadin®)

Clopidogrel (Plavix®)

Dabigatran (Pradaxa®)

Unfractionated heparin

34. An 84-year-old female patient is admitted from a local long-term care facility (illnes). The patient is normally awake, alert, and oriented. She resides in the LTCF because she has not fully recovered from a broken hip resulting from a fall 4 months ago; otherwise she is in relatively good health. She can walk short distances with a walker, though she primarily stays in a wheelchair. Today, however, the nursing staff found her to be acutely confused and unable to ambulate without falling. She was transferred to the emergency department for evaluation. Initial laboratory testing must include:

2 sets of blood cultures.

Serum thyroid stimulating hormone (TSH) level.

Urinalysis.

Lumbar puncture.

35. A 23-year-old college student presents with a 2-day history of severe sore throat and difficulty eating or drinking due to trouble swallowing. A physical examination reveals exudative pharyngitis and minimally tender anterior and posterior cervical lymphadenopathy. The NP suspects infectious mononucleosis and would expect which of the following laboratory findings?

Neutrophilia with reactive forms.

Thrombocytosis.

Lymphocytosis with atypical lymphocytes.

Diminished ALT/AST levels.

36. "Incident-to" services are defined as those which are "an integral, although incidental, part of the physician's personal professional services in the course of diagnosis or treatment of an injury or illness". As long as certain criteria are met, “incident to” billing is an option in all of the following settings except:

Office visits.

Hospital.

Nursing home.

Home visits.

37. A 78-year- old male is being treated for a hypoglycemic episode. He has a long history of type 2 diabetes mellitus as well as congestive heart failure and COPD. He is currently taking basal insulin with a sulfonylurea. What is the acceptable A1C goal for this patient?

≤ 6.5%

≤ 7.0%

≤ 8.0%

≤ 9.0%

38. You see a 74- year-old male who is accompanied by his granddaughter who lives with him. He has hypertension, a prior myocardial infarction, long-standing type 2 diabetes, and recently underwent a lower limb amputation secondary to diabetes. He is currently taking an ACE inhibitor, statin, low-dose aspirin, biguanide, and insulin. The granddaughter reports that since the amputation, her grandfather sometimes becomes withdrawn, irritable and moody for no apparent reason, does not want to participate in the typical activities he enjoys, and often does not appear to eat much during the day. She also states that he often complains of being tired but normally wakes up in the early morning hours. The most appropriate action is to evaluate the patient for:

Dementia.

Depression.

Delirium.

Drug interaction.

39. You see a 58-year-old man who complains of a persistent dry, hacking cough. He reports that he recently started taking a medication to treat high blood pressure. He is most likely taking a(n):

Angiotensin-converting enzyme (ACE) inhibitor

Alpha-adrenergic antagonist

Angiotensin receptor blocker

Beta-adrenergic antagonist

40. A 77-year-old woman is accompanied by her husband for evaluation. She is currently being treated with metoprolol (Lopressor ® ) for hypertension and digoxin (Lanoxin ® ) for atrial fibrillation. He reports that his wife is becoming increasingly forgetful over the past year, failing to note important family events such as birthdays, and sometimes becomes confused with driving directions to familiar locations. She has no previous psychiatric history. The most likely diagnosis is:

Parkinson’s disease.

Delirium.

Dementia.

Early stage of congestive heart failure.

41. Mrs. Conner is a 76- year-old woman living in a long-term care facility and has been bedridden with a respiratory infection for the past 4 days. She is brought in for evaluation and you note signs of dehydration as well as a section of epidermal skin loss about 3 cm in diameter on her right hip. The dermal layer appears intact. This would be considered a pressure ulcer of Stage:

1

2

3

4

42. Which of the following represents the highest level of scientific evidence when evaluating clinical research?

A randomized controlled trial.

Systematic review/ Meta-analysis of randomized controlled troals.

Observational study.

Cohort study.

43. A 64-year- old woman with chronic kidney disease presents with a chief complaint of lethargy. His hemogram is as follows:

-Hemoglobin (Hg)=9.9 g/dL (12–14 g/dL

-Hematocrit (Hct)=30% (36%–42%)

-Mean cell volume (MCV)=81 fL (80–96 fL

-Reticulocytes=0.7% (1%–2%)

These findings are most consistent with:

Iron deficiency anemia.

Anemia of chronic disease.

Folate deficiency anemia.

Thalassemia trait.

44. You see a 68-year-old woman who is being treated for moderate depression. She complains that her medication is causing symptoms of dry mouth and constipation. She is most likely taking which of the following medications?

Venlafaxine (Effexor ® )

Citalopram (Celexa ® )

Fluoxetine (Prozac ® )

Nortriptyline (Pamelor ® )

45. All of the following persons are eligible for Medicare services except:

A 74-year-old ex-smoker with COPD and high income from assets.

A 69-year-old undocumented resident in the US with atrial fibrillation.

A 62-year-old with a permanent physical disability due to a motor vehicle accident. 

A 72-year-old permanent legal resident (non-US citizen) with type 1 diabetes mellitus.

46. When initiating therapy with spironolactone for a patient who is also on an ACE inhibitor, you advise the patient to return in 5 days to check which of the following laboratory parameters?

Sodium

Calcium

Potassium

Chloride

47. When considering an end-of-life decision for a terminally ill person with Alzheimer-type dementia who can no longer communicate, all of the following can be used as an advanced directive except:

Testimony from a family member or close friend

A living will.

A “do not resuscitate” order.

A durable power of attorney for healthcare.

48. Which of the following types of clinical studies represents the lowest level of evidence used to guide medical decisions?

Clinical experience of renowned expert in field.

Non-randomized controlled study.

Observational study.

Case-control study.

49. Which of the following electrocardiogram (ECG) changes do you expect to find in a person with myocardial ischemia?calcium

Pathologic Q wave

Tall R wave

T wave inversion

ST segment elevation

50. Which of the following statements is false regarding end-of-life decision-making for a patient that is hopelessly and terminally ill?

A durable power of attorney for healthcare can be used to authorize another person to make healthcare decisions. 

A videotaped or audiotaped discussion with the patient can include advanced directives.

Advanced directives are legally binding and recognized in all 50 states.

Living wills and do not resuscitate orders are examples of advanced directives.

51. The nurse practitioner is evaluating a 19-year- old male suffering from a severe headache. He has a history of headaches that tend to occur in clusters over a few days. He has unsuccessfully tried several therapeutic modalities. A positive response to which of the following interventions supports the diagnosis of cluster headache?

Oxygen therapy.

Beta-adrenergic blockade.

Tricyclic antidepressant.

Dietary reduction of amines.

52. All of the following are required Medicare terms and conditions for paying NP services except:

The services are within the NP’s scope of practice as defined by state law.

The services performed are those for which a physician would be able to bill Medicare. The services are performed in collaboration with a physician.

Separate charges are billed for NP services and facility charges.

53. A 28- year- old male with asthma presents with a chief complaint that he has to use his rescue inhaler multiple times each day. An evaluation reveals that he has moderate-to-severe asthma and requires Step 4 treatment. An appropriate regimen would include:

Low-dose inhaled corticosteroid (ICS)

Medium-dose ICS

Medium-dose ICS plus a long-acting beta?-agonist (LABA)

High-dose ICS plus LABA plus omalizumab (Xolair ® )

54. A 62-year-old woman presents in the emergency department complaining of severe toe pain that originated overnight. She has a history of renal disease and is currently taking a thiazide diuretic. Her BMI is 37 kg/m 2 . In considering a diagnosis of acute gouty arthritis, the nurse practitioner knows that the best diagnostic indicator is:

Serum uric acid.

Joint X-ray.

Erythrocyte sedimentation rate (ESR).

Analysis of joint aspirate for urate crystals.

55. Which of the following is the most appropriate antibiotic for a 57-year-old man with acute bacterial rhinosinusitis and who has type 2 diabetes mellitus, COPD and a beta-lactam allergy?

Cephalexin (Keflex ® ).

Amoxicillin-clavulanate (Augmentin ® ).

Trimethoprim with or without sulfamethoxazole (Primsol ® , Bactrim ® ).

Levofloxacin (Levaquin ® )

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