ANCCAdult-Gerontological Primary Care NP Questions – Set 211 Jan 2014

  1. Elevated sedimentation rate, positive antinuclear antibody, elevated C-reactive protein, and a “butterfly” rash across the cheeks and bridge of the nose are most likely indicative of: antinuclear
  2. Systemic lupus erythematosus
  3. Psoriatic giant cell arteritis
  4. Giant cell arteritis
  5. Myasthenia gravis.

No single laboratory test can diagnose systemic lupus erythematosus, and early symptoms may be vague, varied, and intermittent. Patients present with rashes, specifically a “butterfly” rash across the bridge of the nose. Arthralgias, anemia, edema, and photosensitivity are among a myriad of symptoms.

  1. You suspect that your 82-year-old patient has decreased gastric acid secretion. This may cause:
  2. Calcium malabsorption
  3. Anemia of chronic disease
  4. Iron deficiency anemia
  5. Pernicious anemia

Pernicious anemia is an autoimmune condition linked to heredity. Onset is usually after age 40 years. It is characterized by macrocytic anemia, low serum B12 level, atrophic gastritis, achlorhydria, and an autoimmune disease such as immunoglobulin A.

  1. An 82-year-old patientpresents complaining of constipation for the past 2 months. The patient denies any gastrointestinal symptoms, and his examination is unremarkable. What conservative treatment should be initiated?
  2. Bowel stimulants such as sodium phosphate (Fleet enema)
  3. Magnesium salts (milk of magnesia)
  4. Bowel lubricants such as mineral oil
  5. Bulking agents such as polycarbophil (FiberCon)

Bulk-forming agents are safe in the treatment of constipation, increasing the stool bulk with minimal adverse effects. Bowel stimulants and bowel lubricants are indicated for short-term use only and may bind with fat-soluble vitamins and decrease the absorption of some medications. Magnesium salts causes several drug interactions and are contraindicated with patients with renal impairment. Patient instructions should stress the importance of drinking adequate amounts of water and other fluids in conjunction with bulking agents.

  1. Mr. M., a 42-year-old male, presents with sudden onset, severe mid-epigastric pain with associated nausea and vomiting. He admits to a history of alcohol abuse. His labs reveal elevated lipase and amylase levels. You suspect:
  2. Cholecystitis
  3. Acute pancreatitis
  4. Gastritis
  5. Acute Appendicitis

A sudden onset of severe epigastric pain, nausea, and vomiting accompanied by elevated lipase and amylase levels is consistent with acute pancreatitis. The patient with a history of alcohol abuse is at high risk for developing pancreatitis.

  1. Mrs. C., age 78, presents with recent facial drooping, left-sided weakness, and aphasia. Her treatment will depend on the following diagnostic test:
  2. Serum troponin level
  3. MRI of the brain
  4. Angiogram
  5. CT of the head

A CT scan must be immediately performed to determine whether the patient is likely having an ischemic or hemorrhagic stroke. This will determine if the patient will require immediate thrombolytic therapy. Survival is improved if intervention is introduced within 3 hours of the onset of symptoms. An MRI and an angiogram are both not immediate diagnostic tools, and serum troponin is the cardiac marker for myocardial infarctions.

  1. Dana, age 26, has been diagnosed with asthma, and her peak flow meter reading is in the yellow zone. This indicates the following:
  2. She is at 80-100% of her personal best peak flow measurement.
  3. She should seek medical help immediately.
  4. Her asthma is under control.
  5. Her asthma is getting worse, and she should use her quick-relief medication.

The yellow zone of the peak flow meter indicates that the patient is within 50-79% of her optimal best and that her asthma is getting worse.

  1. A lifestyle risk factor for developing breast cancer is:
  2. Participating in contact sports.
  3. Being a smoker.
  4. Being overweight.
  5. Low-fat diet.

Being overweight is a risk factor for developing breast cancer after menopause. There is a direct link between elevated estradiol levels, obesity, and breast cancer.

  1. You assess Cullen’s sign in you 72-year-old patient who fell down a flight of eight stairs. Cullen’s sign is indicative of:
  2. Appendicitis
  3. Pancreatitis
  4. Ventral hernia
  5. Intra-abdominal bleeding

Intra-abdominal bleeding may track toward the skin and present as bruising around the umbilicus. The appearance of such a pattern of bruising is Cullen’s sign.

  1. All elderly patients with epistaxis should be referred to an ENT specialist:
  2. Whenever anterior packing is used.
  3. When posterior bleeding is visualized.
  4. With every bleeding episode.
  5. For silver nitrate cauterization.

Most epistaxis is self-limiting ad can be treated in primary care. Referral to an ENT specialist is indicated when posterior bleeding is visualized, anterior packing is difficult to place, and there is bleeding into the throat.

  1. The Gardasil vaccine is indicated to prevent the incidence of the human papillomavirus (HPV). The series of vaccines is currently indicated for which age?
  2. 6-12 years
  3. 26-50 years
  4. All ages
  5. 9-26 years

The prevalence of HPV is in the 15-to-25-year-old age group. The Gardasil vaccine is indicated for ages 9-26 at present.

  1. The preferred treatment for mild persistent asthma consists of:
  2. High-dose inhaled steroid.
  3. Oral corticosteroid.
  4. Low-acting beta-agonist.
  5. Low-dose inhaled steroid.

The preferred treatment for mild persistent asthma is a low-dose inhaled steroid. Intermittent asthma is treated with short-acting bronchodilators. Treatment for moderate persistent asthma includes inhaled corticosteroids and long-acting bronchodilators. Treatment for severe asthma includes long-acting bronchodilators and inhaled corticosteroids and may include oral corticosteroids.

  1. Treatment for the patient with peptic ulcer disease caused by Helicobacter pylori (H. pylori) includes:
  2. Lansoprazole, amoxicillin, and clarithromycin (Prevpac)
  3. Maalox 30 cc before meals.
  4. Omeprazole (Prilosec).
  5. Clarithromycin (Biaxin).

When treating H. pylori, a combination of proton-pump inhibitor and two antibiotics is indicated for eradication therapy.

  1. A 76-year-old man is being treated with timolol eyedrops for glaucoma. What oral medication that he is taking would cause you concern?
  2. Ranitidine (Zantac) for GERD
  3. Atenolol (Tenormin) for hypertension
  4. Aspirin for myocardial infarction prevention
  5. Alprazolam (Xanax) for anxiety

Atenolol is a beta blocker. Timolol is a beta-adrenergic blocker. The combination may cause or worsen cardiac conditions such as chronic heart failure, reactive airway diseases, and delirium.

  1. The NP examines a 62-year-old woman with rhinorrhea for the past 2 weeks, frontal headache, halitosis, and facial pain and dizziness when bending over. The practitioner suspects:
  2. Acute sinusitis
  3. Allergic rhinitis
  4. Migraine headache.
  5. Acute nasopharyngitis.

Acute sinusitis presents with facial pressure, tenderness, and dizziness that worsen when bending forward. It may also include a headache and halitosis. Upper respiratory infections resolve in 7 days and do not exhibit facial pain and pressure. Migraine headaches will not present with rhinorrhea or sinus tenderness.

  1. Ken, age 36, presents with painful swallowing, sore throat, fever, and swollen glands. On exam, he has a fever of 101⁰F, exudative posterior pharyngitis, and anterior cervical lymphadenopathy. You suspect that he has the following:
  2. Infectious mononucleosis.
  3. Acute epiglottitis
  4. Acute suppurative pharyngitis
  5. Viral influenza

Acute suppurative pharyngitis is a bacterial infection with symptoms of painful swallowing, sore throat, fever, swollen glands, exudative posterior pharyngitis, and anterior cervical lymphadenopathy. Epiglottitis incidence in adults is rare. Patient does exhibit stridor, hoarseness, trismus, or drooling. Mononucleosis can be considered if a bacterial infection is not diagnosed.

  1. An adult male presents with a sore throat, difficulty swallowing, and mouth pain. You observe white curd-like plaques in the mouth and on the tongue and pharynx. What course of treatment would you prescribe?
  2. Refer to an ENT specialist for evaluation
  3. Prescribe amoxicillin 500 mg by mouth three times a day for 10 days.
  4. Recommend consuming only clear liquids for few days
  5. Prescribe antifungal medication and encourage HIV screening

Sore throat, difficulty swallowing, and mouth pain with white curd-like plaques in the mouth and on the tongue and pharynx are indicative of candidiasis and require antifungal, not antibacterial, medication. These symptoms could be signs of HIV.

  1. The pathogen that most commonly causes community-acquired pneumonia (CAP) in the elderly is:
  2. Pneumococcus.
  3. Mycoplasma pneumonia.
  4. Haemophilus influenzae.
  5. Moraxella catarrhalis

Pneumococcus is the predominant pathogen CAP in the elderly population. Mycoplasma pneumonia is common in those aged 35-50, and Haemophilus influenzae is common in smokers.

  1. Legal authority over advanced practice nursing practice in under the auspices of:
  2. State board of nursing
  3. Certification authorities
  4. Federal laws
  5. The American Medical Association

Each state’s board of nursing defines NP roles and governs practice regulations for safe and competent advanced practice registered nurses.

  1. Ann, age 68, presents with a 3-day history of nausea, vomiting, cramping, diffuse abdominal pain, and watery diarrhea. You suspect:
  2. Ulcerative colitis.
  3. Cholecystitis.
  4. Gastroenteritis.
  5. Appendicitis.

Gastroenteritis is self-limiting with a normal physical exam. Pain is commonly diffuse in nature, with possible hyperactive bowel sounds. Care is supportive and caution must be taken in the elderly to avoid dehydration.

Differential:

Appendicitis – (RLQ) right lower quadrant pain

Cholecystitis – (RUQ) right upper quadrant pain, usually after a fatty meal.

Colitis – mild pain in the lower quadrant, with bloody diarrhea.

  1. A 58-year-old female has been diagnosed with GERD, and the NP is providing the patient with instructions regarding condition-specific lifestyle changes. These include:
  2. Avoiding all milk products.
  3. Avoiding eating meals late at night.
  4. Avoiding foods high in fiber.
  5. Avoiding acetaminophen (Tylenol).

Eating meals late at night and then lying down afterwards increases the likelihood of gastric reflux. Acetaminophen is not usually a medication that triggers GERD. Milk products and food high in fiber are not common triggers for GERD.

  1. A 78-year-old woman has early bilateral senile cataracts. Which of the following situations would most likely pose the greatest difficulty?
  2. Reading the newspaper.
  3. Reading road signs while driving
  4. Following extraocular movements
  5. Distinguishing between primary colors

Reading the newspaper could be made easier by increasing the light in the room and using stronger prescription glasses. Distinguishing between primary colors is a problem, but reading road signs while driving would pose the greatest difficulty because size of print and amount of light cannot be adjusted.

  1. An elderly patient presents with bloody diarrhea, flatulence, and fever. Laboratory results show leukocytosis. Your diagnosis is:
  2. Duodenal ulcer.
  3. Irritable bowel syndrome
  4. Liver cirrhosis.
  5. Diverticulitis.

Leukocytosis is due to colon inflammation and infection. Irritable bowel syndrome can be diagnosed based on severity of abdominal pain, bowel habits, alternating diarrhea and constipation, flatulence, abdominal pain, and distention. Duodenal ulcer symptoms range from none to burning epigastric pain, nausea, and vomiting.

  1. The primary care provider’s responsibility to his/her patient:
  2. Is the coordination of his/her patient’s care.
  3. Dictates care of his/her patient that is provided by specialist.
  4. May involve disregarding hospital protocol not sited to his/her patient’s care.
  5. Is relinquished when a patient is referred to another provider.

The primary care provider’s responsibility to his or her patient is to ensure quality of care and practice competency, as outlined by the American Association of Colleges of Nursing and the National Organization of Nurse Practitioners, in the core competencies for NP practice.

  1. A 27-year-old female presents with complaints of urgency, frequency, and dysuria of 28 hours duration. She denies fever, chills, hematuria, flank pain, vaginal discharge, or previous UTI. She is not sexually active, takes no meds, and has no significant past medical history. Physical exam reveals slight suprapubic tenderness. No costovertebral angle tenderness. Urine dipstick is positive for nitrates, large bacteria, and many white blood cells. She is diagnosed with a UTI. What bacteria is the most common cause of UTIs?
  2. Staphylococcus aureus
  3. Proteus mirabilis
  4. Staphylococcus epidermidis
  5. Escherichia coli (E. coli)

In the healthy adult population, E. coli is the most common causative agent for urinary tract infections. Staph infection would only occur as contaminants from lack of asepsis with urological procedures. Proteus is uncommon in the healthy young adult patient.

  1. Which of the following is true about mitral valve prolapse?
  2. It commonly causes premature death.
  3. It is related to rheumatic fever.
  4. Maneuvers that decrease volume is the heart will make the click inaudible.
  5. Many people have asymptomatic mitral valve prolapse.

Mitral valve prolapse is a systolic murmur that is usually benign in nature.

  1. A patient presents with chest pain unrelieved by nitroglycerine, and EKG changes were noted in transport. The immediate treatment for this patient would include:
  2. Clopidogrel (Plavix), pacemaker, amiodorone (Cordorone), and oxygen.
  3. Oxygen, heparin, serum cardiac enzymes, and clopidogrel (Plavix).
  4. Aspirin, heparin, oxygen, and serum brain natriuretic peptide (BNP).
  5. Morphine, oxygen, nitroglycerine, and aspirin (MONA).

Nitroglycerine is indicated to dilate the coronary arteries, oxygen and morphine decrease cardiac consumption, and aspirin prevents platelet aggregation.

  1. Prescribing NPs should be aware of the difference between the schedules of controlled substances. Which of the following about Schedule I-IV drugs is accurate?
  2. Schedule III drugs have more potential for abuse than do substances in Schedules II or IV, and abuse may lead to high physical and/or psychological dependence.
  3. Schedule IV drugs have a high potential for abuse but are accepted for medical use under strict medical supervision.
  4. Schedule II drugs have a high potential for abuse, which may lead to severe psychological or physical dependence.
  5. Schedule I drugs have no currently accepted medical use in the United States but are safe for use under medical supervision.

Because Schedule II drugs have a high potential for abuse, which may lead to severe psychological or physical dependence, NPs need to have knowledge about federal regulations and be well versed in laws regarding prescribing controlled substances in their own state.

  1. The NP who suspects a patient has temporal arteritis knows that blood results will show:
  2. Elevated sedimentation rate
  3. Decrease calcium.
  4. Decreased white blood cells.
  5. Elevated potassium.

Elevated sedimentation rate indicates inflammation in the body and can be an indicator of giant cell arteritis.

  1. What cancer is associated with Epstein-Barr virus?
  2. Prostate cancer
  3. Leukemia
  4. Burkitt’s lymphoma (BL)
  5. Ovarian cancer

BL is an aggressive non-Hodgkin lymphoma associated with Epstein-Barr virus that initially presents as a tumor in the jaw. Each year, it affects approximately 1,200 people in the United States. Fifty-nine percent of all people affected are adults. Incidences of BL in immunosuppressed patients is high, with 30-40% associated with HIV infection.

  1. Which of the following is consistent with the visual problems associated with macular degeneration?
  2. Peripheral vision loss
  3. Blurring of near vision
  4. Loss of central vision field
  5. Difficulty with distant vision

Conditions that affect the macula (a portion of the retina of the eye) affect central vision most.

  1. Pyelonephritis is differentiated from cystitis by which of the following clinical presentations?
  2. Dysuria and suprapubic tenderness
  3. Fever, flank pain, and nausea
  4. Hematuria and urgency
  5. Frequency and burning

Pyelonephritis is a serious systemic urinary tract infection that includes symptoms that are systemic, such as fever, nausea, and flank pain.

  1. A 60-year-old male reports large amounts of bloody urine on three occasions over the past month. He denies frequency, urgency, fever chills, or pain. A urine dipstick test is negative. He takes vitamin E, Tenormin, and Tums. Subsequent evaluation should include:
  2. Intravenous pyelogram (IVP)
  3. Cystoscopy.
  4. Blood urea nitrogen/creatinine.
  5. Urinalysis and urine culture and sensitivity.

Blood urea nitrogen/creatinine measures the amount of nitrogen present in the blood and how well the kidneys are functioning. Based on the results, a need for more invasive procedures will be considered. Cystoscopy is an invasive examination for visualization of the lining of the bladder to evaluate where the bleeding may be occurring. An IVP is an invasive examination of the Kidneys, bladder, ureters, and urethra used to identify diseases and structure of the urinary tract. A urinalysis evaluates physical, chemical, and microscopic aspects of urine to identify disease. A urinalysis and a urine culture and sensitivity test identify organisms in the urinary tract and the antibiotics to which they are sensitive.

  1. A 28-year-old female patient presents with a several-month history of bloody diarrhea. You would suspect the following:
  2. Diverticulosis.
  3. Ulcerative colitis.
  4. Colon cancer.
  5. Crohn’s disease.

Given the age of the patient, one would suspect ulcerative colitis because bloody diarrhea is the hallmark sign of the disease. Crohn’s disease patients present with nonbloody diarrhea and systemic symptoms. Diverticulosis is a chronic disease, and bloody diarrhea is uncommon. The probability of this patient having colon cancer is how; however, further history and diagnostics should be obtained.

  1. When prescribing medications for an elderly patient, NPs must remember that dosing may need to be altered because:
  2. Liver function increases with age, so bioavailability of medications is decreased.
  3. The elderly have greater fat stores, so bioavailability of fat-soluble medications is decreased.
  4. Plasma levels may reflect aging effects of decreased drug clearance or impaired absorption.
  5. Vitamin supplements are more completely absorbed.

Plasma levels may reflect aging effects of decreased drug clearance or impaired absorption in elderly who have compromised kidney or liver function as well as altered metabolism resulting from increased fat stores, decreased lean tissue, and decreased hydration, all of which alter absorption, metabolism, distribution, and excretion of medications.