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Family and Adult-Gero Nurse Practitioner Certification Questions Book (3rd Edition)
Correct Answer: C Question is missing the following lab values:
LDL Cholesterol = 140 mg/dL
HDL Cholesterol = 35 mg/dL
Glycosylated Hemoglobin (Hgb A1c) = 9.2%
Question is missing the following lab values:
WBC = 6 thousand cells x 106uL
RBC = 4.0 x 106 cells/mL
Hemoglobin = 10.8 grams/dL
Hematocrit = 32.4%
MCH = 21 pg
Rationale should read:
This patient probably has Bell’s palsy. This is an acute unilateral event that affects the facial nerve (CN VII) and forehead muscles. Sometimes this results in smoothing of the forehead on the affected side. Stroke must always be considered in the differential in a patient who has these complaints. Stroke may spare the muscles of the forehead. Early treatment with oral steroids like prednisone (60 mg/d and tapered over 10 days) should be started within 72 hours of the onset of symptoms. This has been found to decrease the risk of permanent facial paralysis. Oral antiviral agents may be added in severe acute cases of Bell’s palsy but studies are inconclusive as to their benefit.
A pregnant patient in her second trimester is found to have positive leukocytes and positive nitrites in a second voided urine specimen. She is asymptomatic. This patient should be prescribed:
Doxycycline (Doryx).
Trimethoprim-sulfamethoxazole (Bactrim DS).
No medication, symptoms will resolve spontaneously.
Nitrofurantoin (Macrobid).
This patient has asymptomatic bacteriuria. In pregnant women, this should be confirmed with a second voided urine before prescribing medication. Asymptomatic bacteriuria during pregnancy increase the risk of pyelonephritis and has been associated with preterm birth and low birth weight infants, as well as other negative outcomes. Therefore, she should be treated empirically with antimicrobial therapy. Nitrofurantoin (Macrobid) is the best choice listed for this patient. Nitrofurantoin should be used cautiously in the first trimester, when other options are not available. It is contraindicated in at 38-42 weeks due to the possibility of hemolytic anemia in the neonate. Other options include beta-lactams (e.g. Penicillins, Cephalosporins). The shortest course possible should be prescribed Doxycycline (Doryx) and trimethoprim-sulfamethoxazole (Bactrim DS) are not considered safe during pregnancy and should be avoided.
Question and choices should read:
According to the DSM-5 criteria, which criterion is NOT part of the diagnostic criteria for anorexia nervosa?
Significantly low weight
Distorted perception of body weight
Muscle wasting is NOT part of the diagnostic criteria for anorexia nervosa. It is, however, considered a medical complication which can occur in many organ systems of the patient with anorexia nervosa. A few other medical complications may include muscle wasting, seizures, anemia, electrolyte imbalances, osteoporosis, amenorrhea, and hypotension. According to the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), the diagnosis of anorexia nervosa requires: a restriction of energy intake that leads to a low body weight, given the patient’s age, sex, developmental trajectory, and physical health. Significantly low weight is defined as a weight that is less than minimally normal or, for children and adolescents, less than that minimally expected; an intense fear of gaining weight or becoming fat, or persistent behavior that prevents weight gain, despite being underweight, and; a distorted perception of body weight and shape, undue influence of weight and shape on self-worth, or denial of the medical seriousness of one’s low body weight.
A male patient complains of dysuria. His urinalysis is positive for nitrites, leukocyte esterase, and bacteria. What medication should be given and for how many days?
The most effective way to decrease neural tube defects is to prescribe folic acid. For a woman with normal risks, how much is needed daily prior to becoming pregnant?
A 50-year-old non-pregnant female presents for an annual exam. She complains of fatigue and weight gain. She has the following lab results. What should the NP order next?
TSH 7 mlU/L (0.4-3.8 mlU/L)
The patient presents with an elevated TSH as well as symptoms suggestive of hypothyroidism. In the presence of an elevated serum TSH, the next step is to repeat the TSH measurement along with a serum free T4. If the TSH remains elevated and the serum free T4 is low, this is consistent with primary hypothyroidism, and replacement therapy would be initiated. If the serum TSH is still high but the serum free T4 value is within the normal range, this indicates subclinical hypothyroidism. Replacement of T4 is generally not initiated in subclinical hypothyroidism until the TSH is > 10. There is no indication (i.e. nodule or thyromegaly) in this scenario to justify the need for a thyroid ultrasound. Hypothyroidism may be associated with an increased risk of cardiovascular disease, including hyperlipidemia. However, this would not be helpful in determining a diagnosis of hypothyroidism.
A patient with meningitis may experience a positive Kernig or Brudzinski sign. A positive Kernig sign will elicit pain with knee extension when flexing the patient’s hip 90 degrees. A positive Brudzinski sign causes flexion of the patient’s hips and knees when flexing the neck. Patients who have septic bursitis or septic arthritis will not have a positive Kernig sign. HIV-positive patients are more likely to exhibit pneumonia secondary to pneumocystis infection, but he has no respiratory symptoms.
A pregnant patient, in her first trimester, is found to have a urinary tract infection. What is the appropriate course of action?
Prescribe TMP/SMX (Bactrim DS)
Prescribe ciprofloxacin (Cipro)
Prescribe Amoxicillin-clavulanate (Augmentin)
Prescribe no antibiotic
A nurse practitioner is taking care of a patient who has chronic perennial allergic rhinitis. The patient has health insurance. The NP has become aware that the patient is not using her prescribed allergy medication. Instead, the patient is giving the medication to her husband because he does not have insurance. What should the NP do?
Prescribe the medication only once more.
Only prescribe the medication if the patient promises to use it.
Stop prescribing the medication for the patient.
Continue to prescribe the medication.
A pregnant patient with urinary frequency is found to have a UTI. The most appropriate treatment choice for this patient is:
Cefpodoxime (Vantin) for 7 days.
Ciprofloxacin (Cipro) for 3 days.
Amoxicillin for 10 days.
Doxycycline (Doryx) for 5 days.
No corrections to rationale.
The most recent evidence-based guidelines (ATS/IDSA Clinical Guideline on Community Acquired Pneumonia, October, 2019) recommend amoxicillin (strong recommendation) 1 gram three times daily for initial treatment of uncomplicated pneumonia in outpatients who are otherwise healthy and have not had recent antibiotic exposure. Azithromycin and doxycycline are listed as conditional recommendations first line to treat this patient. Fluoroquinolones are commonly used first line in patients who have comorbidities or who have had recent antibiotic exposure, or recent contact with the healthcare system.
In 2016, FDA eliminated pregnancy categories for prescription medications. Over-the-counter medications still contain the pregnancy categories A-X. Amoxicillin-clavulanate (Augmentin), cephalexin (Keflex) (e.g. Beta-lactam antibiotics) and Nitrofurantoin (Macrobid) are considered probably safe for use during pregnancy. It provides coverage for the most common urinary tract pathogens. Bactrim is a folic acid antagonist and may be associated with an increased risk of congenital malformations. Ciprofloxacin is a fluoroquinolone (old category C) and may not be safe during pregnancy. Use of this medication during pregnancy may increase the risk of fetal harm (impaired bone and cartilage formation in the fetus). However, it may be given if the benefits outweigh the risks. A pregnant patient with bacteriuria is at high risk for the development of pyelonephritis and preterm labor if bacteriuria is left untreated.
The nurse practitioner has an ethical duty to the prescriber/patient relationship to treat the patient accordingly. The nurse practitioner exhibits beneficence and non-maleficence by prescribing the patient the medication and getting her assurance that she will use the medication for her own symptoms. If the NP abruptly stops prescribing the medication for the patient, then maleficence and a breach of duty is evident. The patient has a diagnosis of chronic perennial allergic rhinitis of which she needs medication. The legally defensible action of the nurse practitioner is to treat the patient, educate her on the risks and benefits of the medication and the risks of sharing her medications with others. Should the NP knowingly prescribe the medication, possibly even prescribing more than is warranted to “help” the patients husband, then the NP has violated veracity, standards of practice, and ethics in prescribing and is now medically liable. The NP has now knowingly diverted medications to someone in whom an assessment and diagnosis has not been made.
Medication safety during pregnancy is of utmost concern. In 2016, FDA eliminated pregnancy categories letter categories: A,B,C,D, and X. Cefpodoxime (Vantin) is a beta-lactam with a broad spectrum of coverage and is considered safe during pregnancy. The optimal duration of treatment of acute cystitis during pregnancy is uncertain, however, the shortest course of the safest antibiotic is best to minimize the risk of exposure to the fetus. Amoxicillin is probably as safe as nitrofurantoin but has a lower efficacy against typical urinary tract pathogens. Doxycycline is associated with fetal tooth discoloration and so it should be avoided. Ciprofloxacin is not recommended during pregnancy due to potential problems with bone and cartilage formation.
Question and answer choices should read:
A 24-year-old college student who does not smoke is diagnosed with pneumonia. He is otherwise healthy and does not need hospitalization at this time. Which antibiotic represents the best choice for treatment for him?
A 19-year-old female presents with a temp of 100.8°F and lower abdominal pain that began about 12 hours ago. She denies vaginal discharge. Which choice below is the least likely cause of her symptoms?
A diagnosis of Type 2 diabetes mellitus can be made:
following fasting glucose values of 126 and 130 mg/dL on different days.
if glucose values of 110, 119, and 115 mg/dL are observed on different days.
with Hgb A1C of 6.3%.
if risk factors plus a family history of diabetes are present.
The most recent evidence-based guidelines (ATS/IDSA Clinical Guideline on Community Acquired Pneumonia, October, 2019) recommend amoxicillin (strong recommendation) 1 gram three times daily for initial treatment of uncomplicated pneumonia in outpatients who are otherwise healthy and have not had recent antibiotic exposure. Azithromycin and doxycycline are listed as conditional recommendations first line to treat this patient. Sulfamethoxazole-Trimethoprim and cefdinir are not evidence-based choices and thus should not be used. Fluoroquinolones, like levofloxacin are commonly used first line in patients who have comorbidities or who have had recent antibiotic exposure, or recent contact with the healthcare system.
This child’s platelet count is decreased. The term used to describe this is thrombocytopenia. Acute lymphocytic leukemia (ALL) is often characterized by low platelet count and other red or white cell abnormalities. The peak incidence occurs between 2-5 years of age. The most common presenting signs of ALL are bleeding, fever, and lymphadenopathy. Idiopathic thrombocytopenia (ITP) is the most common type found in children between the ages of 2-4 years and is preceded by a recent (less than 4 weeks) upper respiratory infection. The nonblanchable rash over the joints probably represents petechiae, a common manifestation of thrombocytopenia and can be seen with both ITP and ALL. Nosebleeds and bleeding gums, especially with brushing of teeth, are also common with thrombocytopenia; however if the thrombocytopenia is mild, there may no presenting symptoms. The CBC is otherwise normal in ITP, unlike ALL. The underlying cause is unknown, hence the name idiopathic. Septic arthritis would be characterized by an elevated white count. Von Willebrand's disease (VWD) is a common autosomal dominant bleeding disorder that may include easy bruising or prolonged bleeding, but is characterized by a normal platelet count.
The three most common causes of bacterial diarrhea in the US are Salmonella, Campylobacter, and Shigella. When bacterial gastroenteritis is suspected, a stool specimen could be ordered for confirmation. All three pathogens are identifiable with culture if present. Pts with Shigella develop diarrhea, fever, and stomach cramps starting a day or two after exposure and will usually resolve in 5-7 days. Shigella is very contagious and is shed continuously in the stool during active illness and for weeks after symptoms have resolved. Enterovirus produces a viral form of diarrhea. Yersinia produces the deadly disease called bubonic plague. E. coli is a typical colonic pathogen.
A 67-year-old patient with COPD presents an immunization record that reflects having last received the pneumococcal immunization (PPSV23) when he was 60 years old. Which statement below reflects the current standard of practice recommended by CDC for this patient?
Discuss PCV13 vaccination with patient.
He should receive the pneumococcal immunization every 5 years after age 65.
He should receive PPSV23 only.
He does not need the immunization.
The CDC recommends shared decision making for this patient with COPD. The NP should discuss PCV13 vaccination with the patient. If the patient and provider decide together that PCV13 is appropriate, it should be administered, then followed by one dose of PPSV23 at least 1 year later. If the NP and the patient decide against the PCV13 vaccine, one dose of PPSV23 should be administered now. If the PPSV 23 immunization was given prior to age 65 years, 5 years should elapse before another PPSV23 vaccine is given.
A 7-year-old boy who was previously unimmunized received his first tetanus, diphtheria, and acellular pertussis (TDaP), Hepatitis A, Hepatitis B, inactivated polio (IPV), measles, mumps, and rubella (MMR), and Varicella vaccinations one month ago. He returns today for his second series of immunizations. He should receive:
Hepatitis A, Hepatitis B, TDaP, Hib, IPV, and MMR
Hepatitis B, TDaP, IPV, MMR, and Varicella
IPV only
Hepatitis B, TD, IPV, and MMR
The minimum length of time between Hepatitis B, DTaP/DT, IPV, and MMR is 1 month or 4 weeks. Therefore, he can receive all of these today. Children ages 7 through 10 who aren't fully vaccinated against pertussis, including children never vaccinated or with an unknown vaccination status, should get a single dose of the TDaP vaccine and follow-up with TD 4 weeks later. Note, if the child is unable to tolerate the pertussis component of the TDaP, he can receive the DT instead at the same intervals. The minimum length of time between varicella immunizations is 3 months if he is younger than 13 years of age and the second dose of Hepatitis A is not due until 6 months later. HIB is not administered to children older than 59 months (5 years).
The chest circumference is not routinely measured at well-child visits, but is assessed if there is concern about the circumference of either the head or the chest. An exception to this observation can occur in premature infants where the head grows very rapidly. Normally, the head exceeds the chest circumference by 1-2 cm from birth until 6 months. Between 6 and 24 months the head and chest circumference should be about equal and by 2 years of age the chest should be larger than the head. The chest circumference is measured at the nipple line.
The preferred treatment for this child will be determined based on your suspicion of the causative organism. Without a sputum culture, you will be treating this patient empirically. This child does not likely have a viral pathogen as they usually have a gradual onset, so the cause is likely bacterial. With suspected bacterial causes, treatment is recommended to prevent symptom progress to the development of moderate to severe respiratory distress. Then your next step in the treatment of this child is to determine if the bacterial pathogen is typical or atypical. As both typical and atypical can have abrupt onset with fever in children >5 years of age, that is difficult to do based on symptoms alone. Your best course is to treat the most common typical pathogen in this age group, which is Streptococcus pneumonia. Because this child has asthma and uses an inhaled steroid daily, Streptococcus pneumoniae should be suspected. The drug of choice for empiric treatment of S. Pneumoniae is Amoxicillin because of its efficacy, cost, and tolerability. Dosing is 90 mg/kg per day in 2 or 3 divided doses with a maximum of 4 g/day. A higher dose is suggested due to concerns for antibiotic-resistant S. pneumoniae. If the child is not improving in 3-4 days, then you may want to consider treating for an atypical pathogen. Azithromycin is the drug of choice if atypical pathogens are suspected. Doxycycline is not an appropriate choice because it has poor Strep coverage and it is contraindicated in children younger than 8 years.