2024 NR 601 Midterm Exam New Latest Version with All Questions from Actual Past Exam, Exams of Medicine

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2024 NR 601 Midterm Exam New Latest Version with

All Questions from Actual Past Exam and 100%

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The best evidence rating drugs in a post MI pt include ---------- Correct Answer ----------- ASA, ACEi/ARB, BB, aldosterone blockade How much water should a HF patient have a day? ---------- Correct Answer --------- no need or 8-10 glasses per day What is the fist line treatment for HFpEF? ---------- Correct Answer --------- diuretics What are the criteria for diagnosing diabetes? ---------- Correct Answer --------- A1C 6.5% or >, FPG 126 or >, 2-hr PG during OGTT 200 or >, random PG 200 or greater or when classics symptoms of hyperglycemia or hyperglycemic crisis are present 55 year old post-menopausal woman with h/o HTN c/o jaw pain on heavy exertion. No c/o CP. EKG is normal sinus rhythm without ST segment abnormalities. Your plan may include ---------- Correct Answer ----------- Exercise stress test What is a T-score of - 2.5 indicative of ---------- Correct Answer ----------- Osteoporosis What is a T-score of - 1.0 to - 2.5 indicative of ---------- Correct Answer ----------- Osteopenia What is a T-score of - 1.0 or higher indicative of ---------- Correct Answer ----------- Normal bone density What is a Z-score of <-1.5 indicative of ---------- Correct Answer ----------- Secondary cause of osteporosis The term "geriatric syndrome" is best described as: --------- Correct Answer --------- Condition that has multiple underlying factors and involves multiple systems The anal wink reflex is used to test: --------- Correct Answer --------- Sensation and pudental nerve function Atypical presentation of acute coronary syndrome is: --------- Correct Answer --------- More common in females What dz can mimic and often co-exists w/MI in elderly w/CAD? --------- Correct Answer - -------- Esophageal dz

Thoracic aortic dissection presents typically as: --------- Correct Answer --------- Severe retrosternal CP that radiates to the back and both arms Bordetella pertussis is best characterized by: --------- Correct Answer --------- Sub-acute cough lasting >2wks Routine testing of TB should occur in all of the following vulnerable populations except: - -------- Correct Answer --------- Hospitalized elderly Which of the following statements about fluid balance in elderly is false? --------- Correct Answer --------- Assessment of skin turgor at the sternum is a reliable indicator of dehydration in elderly. What is nocieceptive pain ---------- Correct Answer ----------- Pain from nociceptive fibers in the periphery triggered by actual or potential tissue damage. Pain is well-localized, stabbing, throbbing, achy What is neuropathic pain ---------- Correct Answer ----------- Direct neuronal injury, burning, tingling, lancinating. Often occurs in a dermatomal pattern Treatment goals for stage A HF are ---------- Correct Answer ----------- Heart healthy lifestyle The Beer's criteria are appropriate for use in evaluating use of certain meds in patients - --------- Correct Answer ----------- >65 y/o The pathophysiology of heart failure is due to ---------- Correct Answer ----------- Inadequate cardiac output to meet the metabolic and O2 demands of the body Which of the following nutritional indicators is not an indication of poor nutritional status in the elderly ---------- Correct Answer ----------- BMI 25 What is the most common valvular heart disease in the elderly ---------- Correct Answer - ---------- Aortic stenosis Elderly may present with atypical signs of pneumonia. You may need to be aware that clustering of all of the following s/s may indicate pneumonia in the elderly except ---------

• Correct Answer ----------- Bradycardia A common auscultory finding in CHF is ---------- Correct Answer ----------- S The most common organism responsible for CAP in the elderly is ---------- Correct Answer ----------- Strep pneumoniae 72 year old woman and her husband are driving cross country. After a long day of driving, they stop to eat. Midway through the meal, the woman because very SOB with

CP and a sense of panic. Which problem is most likely ---------- Correct Answer ----------- Pulmonary embolism Exercise recommended for elderly should include activities that ---------- Correct Answer ----------- Strengthen muscles Preferred amount of exercise for elderly is ---------- Correct Answer ----------- 30 min of aerobic activity a day 5 days a week. Which of the following medical conditions is not considered restrictive for engaging in physical activity ---------- Correct Answer ----------- Depression The best recommendation for patient who says they have no equipment to exercise is -- -------- Correct Answer ----------- Improvise with recommended objects at home that can be used When you recommend exercise for the elderly which of the following pieces of advice should be considered for all types of exercise ---------- Correct Answer ----------- Start low and go slow Biochemical individuality is best described as ---------- Correct Answer ----------- Each individual's variation is often much smaller than that of a larger group All of the following statements about drug absorption are false except ---------- Correct Answer ----------- Underlying chronic disease has little impact on drug absorption The cytochrome p system involves enzymes that are generally: ---------- Correct Answer ----------- Inhibited or induced by drugs A statement not shown to be true about pharmacodynamic changes with aging is -------- -- Correct Answer ----------- Decreased sensitivity to oral anticoagulants The major impact of the physiological changes that occur w/aging is: ---------- Correct Answer ----------- Reduced physiological reserve, reduced homeostatic mechanisms, impaired immunological respons The strongest evidence regarding normal physiological aging is available through -------- -- Correct Answer ----------- Longitudinal studies Pharmacokinetic changes with aging is reflective of ---------- Correct Answer ----------- What the body does to the drug All of the following statements are true about drug distribution in the elderly except ------- --- Correct Answer ----------- Drugs distributed in water have a lower concentration

Men have faster and more efficient biotransformation of drugs and this is thought to be due to: ---------- Correct Answer ----------- Testosterone Atypical presentation of disease in elderly is reflected by all of the following exept -------- -- Correct Answer ----------- MI with CP and diaphoresis Polypharmacy is best described as ---------- Correct Answer ----------- Even a single med if there is not a clear indication for its use What is the major difference between varicose veins and atherosclerosis ---------- Correct Answer ----------- Vessels that are affected Patient has poorly controlled HTN for >10 years. Indicate the most likely position of his PMI ---------- Correct Answer ----------- 5th ICS left of MCL 43 year old Hispanic male has audible diastolic murmur best hard at the mitral point. No audible click. He has been monitored for 2 years. What is the most likely murmur ---------

• Correct Answer ----------- Mitral Stenosis The following are true statements about bipolar disorders in older adults except ---------- Correct Answer ----------- Bipolar disorder is the most commonly diagnosed psychiatric disorder in older adults. The caregiver for an older adult with cognitive impairment is concerned about the individuals seeming disinterest in eating. Which suggestion does the NP offer based upon a known effect of dementia on a clients nutrition ---------- Correct Answer ----------- Establish a routine of when and where the individual will have their meals. An older man has a hx of medication therapy for hypertension. Which intervention does the nurse practitioner implement when the client reports that, I've fallen twice in 5 weeks. ---------- Correct Answer ----------- Orthostatic blood pressures In the elderly population, the fastest growing group is the age range ---------- Correct Answer ----------- 85 years or older The percentage of the FVC expired in one second is ---------- Correct Answer ----------- FEV1/FVC ratio The aging process causes what normal physiological changes in the heart ---------- Correct Answer ----------- The heart valve thickens and becomes rigid, secondary to fibrosis and sclerosis A 55 yo Caucasian male follows up after referral to cardiologist. He thinks his med is causing a cough and sometimes he has difficulty breathing. Which med was most likely prescribed? ---------- Correct Answer ----------- Lisinopril

MJ presents with h/o structural damage with current s/s of HF. Treatment will be based on his stage of HF which is ---------- Correct Answer ----------- Stage C 65 yo Caucasian presents with mitral valve stenosis, physical exam is unremarkable. you know her stage of HF is ---------- Correct Answer ----------- Stage B The best way to diagnose structural heart disease/dysfunction noninvasively is ---------- Correct Answer ----------- Echocardiogram Chronic pain can have major impact on patients ability to function and have profound impact on overall QOL. Ongoing pain may be linked to ---------- Correct Answer ----------- Depression, sleep disturbance, decreased socialization The Beers criteria are appropriate for use in evaluating use of certain meds in patients -- -------- Correct Answer ----------- >65 y/o All of the following statements are true about lab values in older adults except ---------- Correct Answer ----------- Abnormal findings are often due to physiological aging According to the 2017 ACC HTN guidelines, the recommended BP goal for a 65y/o African American woman with a h/o HTN and DM and no h/o CKD is ---------- Correct Answer ----------- <140/ THe pathophysiology of HF is due to ---------- Correct Answer ----------- Inadequate cardiac output to meet the metabolic and O2 demands of the body The volume of air a patient to exhale for total duration of the test during maximal effort is ---------- Correct Answer ----------- FVC According it the 2017 ACC HTN guidelines, normal BP is ---------- Correct Answer -------- --- <120/ Functional abilities are best assessed by ---------- Correct Answer ----------- Observed assessment of function LB is a 77 yo with chronic poorly controlled HTN. You know that goals include prevention of target organ damage. During your eval you will assess for evidence of ----- ----- Correct Answer ----------- Left ventricular hypertrophy Aortic regurgitation requires medical treatment for early signs of HF with ---------- Correct Answer ----------- ACEi The volume of air in the lungs at max inflation is ---------- Correct Answer ----------- TLC (total lung capacity)

Preferred amount of exercise for older adults is ---------- Correct Answer ----------- 30min/day of aerobic exercise 5 days a week You know the following statements regarding th pain of acute coronary syndrome are true except ---------- Correct Answer ----------- Present atypically more often in men than women Elderly patient presents with new onset of feeling heart race, fatigue. EKG reveals Afib with rate >100. Patient also has a new tremor in both hands. Which of the following would you suspect ---------- Correct Answer ----------- Hyperthyroidism Which patient is more likely to have osteoporosis ---------- Correct Answer ----------- 80 y/o. Underweight male who smokes and has been on steroids for psoriasis Post menopausal woman with osteoporosis is taking bisphosphonate daily po. What action info statement would indicate she understood your instructions regarding this med? ---------- Correct Answer ----------- Take med with full glass of water when up in the AM 30 min before other food and meds 60 y/o obese male has T2DM and lipid panel of TC= 250 HDL=32, LDL=165. You teach him about his modifiable cardiac risk factors which include ---------- Correct Answer ------ ----- DM, obesity, hyperlipidemia OA of cervical and lumbar spine causes pain related to all of the following except ---------

• Correct Answer ----------- Crystal deposition In differentiating OA from chronic gout, pseudo gout, or septic arthritis, the most valuable diagnostic study would be ---------- Correct Answer ----------- Synovial fluid analysis Patients with OA of the hip and knee often have a distinguishable gait described as ------ ---- Correct Answer ----------- Antalgic Which of the following best describes pain associated with OA ---------- Correct Answer - ---------- Begins upon arising and after prolonged weight bearing and or use of the joint Joint effusions typically occurs later in the course of OA, especially in the ---------- Correct Answer ----------- Knee You ordered CBC for your patient you suspect has polymyalgia rheumatica. Which 2 clinical findings are common in patients with PMR ---------- Correct Answer ----------- Normochromic, normocytic anemia and thrombocytosis You suspect your patient has PMR and now are concerned that they may have Giant Cell Arteritis too. Which of the following 2 symptoms are most indicative of GCA and

PMR ---------- Correct Answer ----------- Scalp tenderness and aching in shoulder and pelvic girdle 63 yo Caucasian patient with PMR will begin tx corticosteroids until the condition has resolved. You look over her records and it has been 2 years since her last physical exam and any labs or diagnostic tests as she relocated and had not yet ID'd a provider. In prioritizing your management plan your first orders should include ---------- Correct Answer ----------- Duel energy X-ray scan and updating immunizations Which of the following DD for patients presenting with PMR can be ruled out with a muscle biopsy ---------- Correct Answer ----------- Polymyositis In reviewing lab results for patients with suspected PMR, you realize there is no definitive test to diagnose PMR, rather clinical response to treatment. Results you would expect to see include: ---------- Correct Answer ----------- ESR > Which of the following is the most appropriate lab test for monitoring gout therapy over the long-term ---------- Correct Answer ----------- Serum urate level In providing health teaching related to dietary restrictions, you should advise a patient with gout to avoid which of the following dietary items ---------- Correct Answer ----------- Beer, sausage, fried seafood The best method of verifying gout diagnosis in a joint is which of the following ---------- Correct Answer ----------- Joint aspiration and polarized light microscopy The most appropriate first line treatment for acute gout flare, assuming no kidney disease or elevated bleeding risk ---------- Correct Answer ----------- Indomethacin 50mg TID x2 days, then 25mg TID x3 days You order bilateral wrist XR on 69 yo man with c/o both wrists x6 weeks, not related to any known trauma. You suspect early RA. The initial XR finding in apatien with elderly onset RA would be ---------- Correct Answer ----------- Soft tissue swelling A 72 female has been diagnosed with gout. She also has chronic HF. The most likely contributing factor to development of gout in this older female is ---------- Correct Answer ----------- Thiazide diuretics Which of the following statements about OA is true ---------- Correct Answer ----------- It affects primarily weight bearing joints In considering the specificity of lab data, the most reliable diagnostic test listed below would be ---------- Correct Answer ----------- Synovial fluid analysis to differentiate between infectious versus inflammatory infusion

When examining the spine of an older adult you notice a curvature with a sharp angle. This is referred to as ---------- Correct Answer ----------- Gibbus The prevalence of depression in nursing home residents is __________________ greater than adults living in the community ---------- Correct Answer ----------- 3 - 4 times The majority of depressed older adults remain untreated because of ---------- Correct Answer ----------- Misdiagnosis, social stigma, environmental barriers Symptoms of depression distinct to the elderly include ---------- Correct Answer ----------- Lack of emotions The justification for ordering CBC, TSH, serum B12 for a patient you may suspect have clinical depression is ---------- Correct Answer ----------- Because of overlapping symptoms with anemia, thyroid dysfunction, and nutritional deficiencies One major difference that us useful in the DD of dementia versus delirium is that ---------

• Correct Answer ----------- Dementia develops slowly and delirium develops quickly Which of the following is the most appropriate screening tool for delirium ---------- Correct Answer ----------- Confusion Assessment Method The proposed mechanism by which diphenhydramine causes delirium is ---------- Correct Answer ----------- Anticholinergic effects The elderly are at risk for delirium because of ---------- Correct Answer ----------- Multisensory declines, polypharmacy, multiple medical problems A consistent finding in delirium regardless of cause i ---------- Correct Answer ----------- Reduction in regional cerebral perfusion Older adults with Dementia sometimes suffer from agnosia, which is defined as the inability to ---------- Correct Answer ----------- Recognize objects In late stages of dementia, a phenomenon called sun downing, in which cognitive disturbances tend to ---------- Correct Answer ----------- Become worse in the evening Of the following, which one is the most useful clinical eval tool to assist in the diagnosis of dementia ---------- Correct Answer ----------- St. Louis Mental Status Exam SLUMS The cornerstone of pharmacotherapy in treating Alzheimer's is ---------- Correct Answer - ---------- Cholinesterase inhibitors The comoribid psych problem with the highest frequency in dementia in ---------- Correct Answer ----------- Anxiety

WHen treating depression associated with dementia, which of the following would be a poor choice and should not be prescribed ---------- Correct Answer ----------- Amitriptyline Which of the following should be avoided in countries where food and water precautions are to be observed ---------- Correct Answer ----------- Salad buffet What insect precautions are not necessary to prevent insect borne diseases in the Tropics ---------- Correct Answer ----------- Using 100% DEET on skin to prevent bites An example of secondary prevention you could recommend/order for older adults would be to ---------- Correct Answer ----------- Check for fecal occult blood Ali is a 72 year old male who recent came to the US from Nigeria. He reports having BCG vax as a child. Which of the following is correct regarding a TB skin test ---------- Correct Answer ----------- Vax hx is irrelevant, read as usual A local chapter on NP organization has begun planning a community based screening for HTN at a local congregate living facility. The organization was select3d on the basis of ---------- Correct Answer ----------- A regcognized element of high risk within this group Performing ROM exercises on a patient who has had a CVA is an example of which level of prevention ---------- Correct Answer ----------- Tertiary You demonstrate an understanding of primary prevention of falling among the elderly through which management plan ---------- Correct Answer ----------- Provide info about meds, SE and interactions An example of an active strategy of health promotion for an individual to accomplish would be ---------- Correct Answer ----------- Beginning stress management program The 4 main domains of clinical preventive services that you will provide are ---------- Correct Answer ----------- Counseling interventions, screening tests, immunizations, chemoprophylaxis What is the appropriate method for TB screening of an older adult entering a nursing home ---------- Correct Answer ----------- 5 TBU intradermal PPD injection and if negative, repeat with same dose one week later The term "geriatric syndrome" is best described ---------- Correct Answer ----------- Condition that has multiple underlying factors and involves multiple systems Atypical presentation of acute coronary syndrome is ---------- Correct Answer ----------- More common in females What disease can mimic and often co-exists with MI in elderly with CAD ---------- Correct Answer ----------- Esophageal disease

Thoracic aortic dissection presents typically as ---------- Correct Answer ----------- Severe retrosternal CP that radiates to the back and both arms Bordetella pertussis is best characterized ---------- Correct Answer ----------- Sub-acute cough lasting >2 weeks Routine testing of TB should occur in all of the following vulnerable populations except - --------- Correct Answer ----------- hospitalized elderly Distinguishing delirium from dementia can be problematic since they may co-exist. The primary consideration in the DD is ---------- Correct Answer ----------- Rapid change and fluctuating course of cognitive function Evidence shows that the most important predictor of a fall is ---------- Correct Answer ---- ------- Prior history of a fall The most cost-effective interventions used to prevent falls are ---------- Correct Answer -- --------- Home modifications and vitamin D supplements Chronic fatigue syndrome is best described as ---------- Correct Answer ----------- Fatigue lasting longer than 6 months and not relieved by rest Risk factors associated with the finding of a malignancy in a patient with hemoptysis include all of the following except ---------- Correct Answer ----------- Childhood asthma The most common cause of disability in the elderly is ---------- Correct Answer ----------- Arthritis Drug-induced pruritis is distinguished because it ---------- Correct Answer ----------- May occur right after drug is taken or months later A key symptom of ischemia heart disease is chest pain. However, angina equivalents may include exertional dyspnea. Angina equivalents are important because ---------- Correct Answer ----------- Women with ischemic heart disease many times don't present with chest pain. Some patient's may have no symptoms or atypical symptoms so diagnosis may only be made at the time of the actual MI Which test is clinic standard for assessment of aortic stenosis ---------- Correct Answer -- --------- Echocardiogram Ischemic heart disease is ---------- Correct Answer ----------- Defined as an imbalance between O2 supply and demand, frequently manifested as angina, leading cause of death in the elderly

Preceding a stress test, the following lab work might include ---------- Correct Answer ---- ------- CBC with diff to differentiate ischemic heart disease from anemia, thyroid studies to rule out hyperthyroidism On exam, what type of murmur can be auscultation with aortic regurgitation ---------- Correct Answer ----------- Austin Flint Which of the following statements is true regarding anti-arrhythmic drugs ---------- Correct Answer ----------- Most anti-arrhythmic have low toxic/therapeutic ratio and some are exceeding toxic In mitral stenosis, p waves may suggest ---------- Correct Answer ----------- Left atrial enlargement Aortic regurgitation requires medical treatment for early signs of CHF with ---------- Correct Answer ----------- ACEi Which statement correctly describes normal changes of aging ---------- Correct Answer - ---------- Individual variations are enormous at every age and in every part of the body Compared with acute pain, persistent chronic pain requires in the nurse practitioner to -- -------- Correct Answer ----------- Educate the patient to the benefit of specific lifestyle changes When considering Erikson's developmental stages, the task for later life is referred to as ---------- Correct Answer ----------- Ego integrity What is the method of action of anticholinergics ---------- Correct Answer ----------- Block the effect of acetylcholine on muscarinic type 3 receptors resulting in bronchodilation What is the method of action of beta agonists ---------- Correct Answer ----------- Stimulates beta-2 adrenergic receptors, increasing cyclic AMP, resulting in relaxing airways What is tuberculosis ---------- Correct Answer ----------- Chronic, necrotizing infection caused by slow-growing acid fast bacillus (mycobacterium tuberculosis). Most common cause of death related to infectious disease worldwise What is aortic regurgitation? ---------- Correct Answer ----------- Retrograde blood flow through an incompetent aortic valve into left ventricle during ventricular diastole What is aortic stenosis ---------- Correct Answer ----------- abnormal narrowing of the aortic valve What is mitral stenosis ---------- Correct Answer ----------- Abnormal narrowing of the mitral valve orifice

What is mitral regurgitation ---------- Correct Answer ----------- Retrograde blood flow during systole from the left ventricle into the left atrium through incompetent mitral valve What is mitral valve prolapse? ---------- Correct Answer ----------- Mitral regurgitation associated with bulging of one or both mitral valve leaflets into the left atrium during ventricular systole What happens in valvular regurgitation ---------- Correct Answer ----------- Portion of the ejected blood leaks back into the upstream cardiac chamber What happens in valvular stenosis ---------- Correct Answer ----------- Usually results in elevated pressures in the chamber upstream from the stenosis What is the purpose of functional assessment of the elderly ---------- Correct Answer ----- ------ Discovers the ability to care for themselves on a daily basis How should HTN be managed ---------- Correct Answer ----------- Stage 2 and up should be given consideration for pharm treatment. Others can wait for lifestyle modification. What is first line meds for non-black HTNpopulation including those with DM ---------- Correct Answer ----------- Thiazide, CCB, ACEi or ARM either alone or in combo What is the med guideline for ASCVD for those </= 75 y/o ---------- Correct Answer ------- ---- High intensity statin, atorvastatin-Lipitor 40-80, rosuvastatin/Crestor 20mg What is the med guideline for ASCVD for those >75 y/o ---------- Correct Answer ----------

• Moderate statin (atorvastatin 10mg, rosuvastatin 5mg, simvastatin 20-40mg, pravastatin 40mg, lovastatin 40mg, fluvastatin 40mg) What is the guideline for meds for LDL>=190 ---------- Correct Answer ----------- High intensity statin (atorvastatin 40-80mg, rosuvastatin 20mg) What is the bed guideline for ASCVD for 40-75 y/o with DM ---------- Correct Answer ----- ------ Their 10 year risk is >7.5% so high intensity statin What is the med guideline for LDL 79- 189 ---------- Correct Answer ----------- Their 10 year risk is ,7.5% so moderate intensity statin What is the ASCVD med guideline for 40-75 y/o without ASCVD or DM ---------- Correct Answer ----------- Their 10 year risk is >7.5% so moderate to high intensity statin When is Zostavax recommended ---------- Correct Answer ----------- Anyone over 60, given as a single dose

What is primary prevention ---------- Correct Answer ----------- Activities to prevent occurrence of disease or adverse health condition, including mental health. What is secondary prevention ---------- Correct Answer ----------- Activities aimed at detection of disease or adverse health condition in asymptomatic patient who has risk factors but no detectable disease What is teritiary prevention ---------- Correct Answer ----------- Management of existing conditions to prevent disability and minimize complications, striving for optimal function and QOL The symptoms of depression may encompass what 4 domains ---------- Correct Answer ----------- Affect/mood, cognition, physiological, behavioral What is transient insomnia ---------- Correct Answer ----------- Lasts a few night, related to emotional issues, usually resolved without meds when elderly adapts to or removes change What is short-term insomnia ---------- Correct Answer ----------- Lasts <1 month, related to acute medical/psychological condition or to persistent situational stress What is chronic insomnia ---------- Correct Answer ----------- Lasts >1 month, results from age related changes in sleep or chronic stressors. What are some symptoms of polymyalgia rheumatica ---------- Correct Answer ----------- New onset stiffness/aching in neck, shoulders, pelvic girdle, unable to get out of bed in the morning without extreme difficulty, difficulty lifting arms above head What are common lab findings in PMR ---------- Correct Answer ----------- Elevated ESR and CRP, normochromic normocytic anemia, thrombocytosis What is the treatment for PMR ---------- Correct Answer ----------- If s.s are only of PMR and not of GCA as well, start low dose prednisone 10-20mg daily and taper dose What is osteoporosis ---------- Correct Answer ----------- Skeletal disorder characterized by impaired bone strength that predispose to increased risk of fracture Primary osteoporosis ---------- Correct Answer ----------- Due to aging, increased bone resorption reduced new bone formation Secondary osteoporosis ---------- Correct Answer ----------- Consequence of underlying medical condition/drug You examine the hands of a 55 year old woman and note bilateral spindle shaped deformities on middle interphalangeal joints. These are known as ---------- Correct Answer ----------- Haygarth's nodes

The comorbid psych problem with the highest frequency in dementia is ---------- Correct Answer ----------- Anxiety When treating depression associated with dementia, which of the following would be a poor choice and should not be prescribed ---------- Correct Answer ----------- Amitriptyline Performing ROM exercises on a patient who has had a CVA is an example of which level of prevention ---------- Correct Answer ----------- Tertiary You demonstrate an understanding of primary prevention of falling among the elderly through which management plan? ---------- Correct Answer ----------- Provide info about meds, SE and interactions An example of an active strategy of health promotion for an individual to accomplish would be ---------- Correct Answer ----------- Beginning stress management progrma You are working with an older adult male with a long history of alcohol abuse and a 30 year history of smoking. In recommending an intervention, your responsibility ---------- Correct Answer ----------- Promote positive change in lifestyle choices Which organism that can be prevented by immunization is most often responsible for an infectious "outbreak" in the nursing home setting ---------- Correct Answer ----------- Influenza A What disease can mimic and often co-exists with MI in elderly with CAD ---------- Correct Answer ----------- Esophageal Disease Thoracic aortic dissection presents typically as ---------- Correct Answer ----------- Severe retrosternal CP that radiates to the back and both arms A statement not shown to be true about pharmacodynamic changes with aging is -------- -- Correct Answer ----------- Decreased sensitivity to oral anticoagulants What are the 3 primary physiological changes of aging? --------- Correct Answer ---------

1. Reduced physiological reserve of most body systems, esp. cardiac, resp, renal.
2. Reduced homeostatic mechanisms that fail to adjust regulatory systems (i.e. temp control, fluid/lyte balance, etc.).
3. Impaired immunological function (infection risk is greater, autoimmune dz's more prevalent) What is the preferred amount of exercise for elderly? --------- Correct Answer --------- 30min/day 5 days/wk of moderate exercise.

If trying to lose wt: 60min/day. What are PFTs? --------- Correct Answer --------- Group of tests that provide quantifiable measurement of lung function, used to dx resp abnormalities or assess progression/resolution of lung dz. What is FEV1? --------- Correct Answer --------- Forced Expiratory Volume in 1 second (80-120%) What is FVC? --------- Correct Answer --------- Forced Vital Capacity (80-120%) What is normal FEV1/FVC ratio? --------- Correct Answer --------- <0.7 (70%) What is GOLD 1 criteria? --------- Correct Answer --------- Mild FEV1 >/= 80% predicted What is GOLD 2 criteria? --------- Correct Answer --------- Moderate FEV1 50-79% predicted What is GOLD 3 criteria? --------- Correct Answer --------- Severe FEV1 30-49% predicted What is GOLD 4 criteria? --------- Correct Answer --------- Very severe FEV1 <30% predicted What are the signal symptoms of COPD? --------- Correct Answer --------- Dyspnea Chronic cough w/sputum Decreased activity tolerance Wheezing What are characteristics of COPD? --------- Correct Answer --------- Common, preventable, treatable. Characterized by persistent airflow limitation. Usually progressive, associated with enhanced chronic inflammatory response in airways and lungs to noxious particles/gases Airway fibrosis, luminal plugs, airway inflammation, increased airway resistance, small airway dz. Decreased elastic recoil of alveoli. What are risk factors for COPD? --------- Correct Answer --------- Smoking (increasing w/number of pack years) Second hand smoke

Environmental pollution (endotoxins, coal dust, mineral dust) What is seen on phys exam in COPD? --------- Correct Answer --------- May be normal in early states As severity progresses: lung hyperinflation, decreased breath sounds, wheezes at bases, distant heart tones (b/c of hyperinflation, so S1/S2 sounds off in distance), accessory muscle use, pursed lip breathing, increased expiratory phase, neck vein distention. How is COPD diagnosed? --------- Correct Answer --------- Spirometry is gold standard (pre and post bronchodilator). Irreversible airflow limitation is hallmark. How is COPD treated? --------- Correct Answer --------- Bronchodilators: beta agonists (long/short), anticholinergics (long/short), or combo. What is the MOA of beta agonists? --------- Correct Answer --------- Stimulates beta- 2 - adrenergic receptors, increasing cyclic AMP, resulting in relaxing airways. What is the MOA of anticholinergics? --------- Correct Answer --------- Block the effect of acetylcholine on muscarinic type 3 receptors, resulting in bronchodilation. Why are long-acting beta agonists prescribed for COPD? --------- Correct Answer --------- They are for moderate airflow limitation. They relieve symptoms, increase exercise tolerance, reduce number of exacerbations, improve QOL. What are some non pulmonary diagnoses that result in COPD-type symptoms? --------- Correct Answer --------- CHF Hyperventilation syndrome Panic attacks Vocal cord dysfunction Obstructive sleep apnea Aspergillosis Chronic fatigue syndrome What are signal symptoms of asthma? --------- Correct Answer --------- Wheezing Shortness of breath Cough (esp at night) Chest tightness What is chronic bronchitis? --------- Correct Answer --------- Daily chronic cough w/increased sputum for at least 3 consecutive months in at least 2 consecutive years.

Usually worse on wakening. May or may not be associated with COPD. What is emphysema? --------- Correct Answer --------- Characterized by obstruction to airflow caused by abnormal airspace enlargement distal to terminal bronchioles. Chronic inflammation/remodeling, trapping air, hindering effective O2/CO2 exchange (all due to inflammatory mediators infiltrating airways). What are signal symptoms of ischemic heart dz? --------- Correct Answer --------- Chest pain Chest tightness Chest discomfort What is ischemic heart dz? --------- Correct Answer --------- Imbalance between supply and demand for blood flow to myocardium What are signal symptoms of lung CA? --------- Correct Answer --------- Cough Dyspnea Wt loss Anorexia Hemoptysis What is lung CA? --------- Correct Answer --------- Malignant neoplasm originating in parenchyma of lung/airways What are signal symptoms of MI? --------- Correct Answer --------- Prolonged CP (>20min duration) SOB Confusion Weakness Worsening HF What is an MI? --------- Correct Answer --------- Necrosis of heart tissue caused by lack of blood and O2 supply to the heart What are signal symptoms of pneumonia? --------- Correct Answer --------- Fever Chills Hypothermia New cough w/or w/out sputum Chest discomfort or dyspnea Fatigue HA Some older adults will be asymptomatic but may experience falls/confusion

What is community acquired pneumonia? --------- Correct Answer --------- Acute lower resp tract infection of lung parenchyma. Can be bacterial or viral. Bacterial is most common in older adults. What are signal symptoms of a PE? --------- Correct Answer --------- Dyspnea CP on inspiration Anxiety Presentation is variable Symptoms nonspecific Some asymptomatic What is PE description? --------- Correct Answer --------- Occlusion of one or more pulmonary vessels by traveling thrombus originating from distant site. What are signal symptoms of tuberculosis? --------- Correct Answer --------- Initially asymptomatic Later: productive, prolonged cough Fatigue Low-grade fever Night sweats Poor appetite Hemoptysis Wt loss Fever/sweats are less common in elderly Symptoms in elderly are often attributed to other comorbidities What is tuberculosis? --------- Correct Answer --------- Chronic, necrotizing infection caused by slow-growing acid-fast bacillus (Mycobacterium tuberculosis). Most common cause of death related to infectious dz worldwide. What are signal symptoms of valvular heart dz? --------- Correct Answer --------- Asymptomatic in early stages Fatigue Exertional dyspnea What is valvular heart dz? --------- Correct Answer --------- Damage to valve(s) of the heart, causing cardiac dysfunction. Most prevalent types in elderly: calcific and degenerative aortic valve dz

What is aortic stenosis? --------- Correct Answer --------- Abnormal narrowing of aortic valve orifice What is aortic regurgitation? --------- Correct Answer --------- Retrograde blood flow through incompetent aortic valve into L ventricle during ventricular diastole What is mitral stenosis? --------- Correct Answer --------- Abnormal narrowing of mitral valve orifice What is mitral regurgitation? --------- Correct Answer --------- Retrograde blood flow during systole from L ventricle into L atrium through incompetent mitral valve What is mitral valve prolapse? --------- Correct Answer --------- Mitral regurgitation associated with bulging of one or both mitral valve leaflets into L atrium during ventricular systole What are most common causes of VHD in elderly? --------- Correct Answer --------- Age- related degenerative calcifications Myxomatous degeneration Papillary muscle dysfunction Infective endocarditis Rheumatic dz What happens in valvular regurgitation? --------- Correct Answer --------- Portion of the ejected blood leaks back into the upstream cardiac chamber What happens in valvular stenosis? --------- Correct Answer --------- Usually results in elevated pressures in the chamber upstream from the stenosis What are signal symptoms of URI? --------- Correct Answer --------- Nasal congestion Rhinorrhea/mucopurulent discharge Sore throat Cough HA Malaise What is a URI? --------- Correct Answer --------- Most frequently called the common cold Usually caused by virus Results in nasal passage inflammation Most are self-limiting, accompanied by minor complaints Included in URI dx: acute laryngitis, acute rhinosinusitis, acute pharyngitis What are signal symptoms of restrictive lung dz? --------- Correct Answer --------- Rapid, shallow respirations Dyspnea Decreased activity tolerance

Easily fatigued Nonproductive, irritating cough provoked by deep breathing/exertion What is restrictive lung dz? --------- Correct Answer --------- Heterogenous group of disorders that share common abnormal ventilatory function. Characterized by small tidal volume, rapid rate. Hallmark restrictive pattern is decreased lung volm, esp. total lung capacity and vital capacity. What is the purpose of functional assessment of the elderly? --------- Correct Answer ---- ----- Discovers the ability to care for themselves on a daily bases What can ongoing pain be linked to in the elderly? --------- Correct Answer --------- Depression Decreased socialization Sleep disturbance Impaired cognitive function Is chronic pain a normal sign of aging? --------- Correct Answer --------- No What is polypharmacy? --------- Correct Answer --------- Broad definition, but basically too many medications for what is going on with the patient, the use of multiple pharmacies/providers. What is Stage A of HF? --------- Correct Answer --------- At high risk for heart failure but w/out structural changes/symptoms What is Stage B HF? --------- Correct Answer --------- Structural heart dz but w/out s/s of HF (still "at risk" for HF) What is Stage C HF? --------- Correct Answer --------- Structural heart dz w/prior or current s/s of HF (actually have HF) What is Stage D HF? --------- Correct Answer --------- Refractory heart failure including specialized interventions (actually have HF, need surgery, PM, etc.) What are treatment goals for Stage A HF? --------- Correct Answer --------- Heart-healthy lifestyle Prevent vascular, coronary dz Prevent LV structural abnormalities What are drugs used in Stage A HF? --------- Correct Answer --------- ACEi or ARB in appropriate pt's for vascular dz or DM Statins as appropriate

What are treatment goals for Stage B HF? --------- Correct Answer --------- Prevent HF symptoms Prevent further cardiac remodeling What are drugs used in Stage B HF? --------- Correct Answer --------- ACEi or ARB as appropriate Beta blockers as appropriate In selected pt's: ICD Revascularization/valvular surgery as appropriate What are goals of Stage C HFpEF? --------- Correct Answer --------- Control symptoms Improve HRQOL Prevent hospitalization Prevent mortality ID comorbidities What is treatment for Stage C HFpEF? --------- Correct Answer --------- Diuresis to relieve s/s congestion Follow guideline-driven indications for comorbidities (HTN, AF, CAD, DM, etc.) What are treatment goals for Stage C HFrEF? --------- Correct Answer --------- Control symptoms Pt education Prevent hospitalization Prevent mortality What are drugs used in Stage C HFrEF? --------- Correct Answer --------- Diuretics for fluid retention ACEi or ARB BB Aldosterone antagonists Drugs in selected pts: Hydralazine/isosorbide dinitrate ACEi and ARB Digitalis Procedures in selected pts: CRT ICD Revascularization/valvular surgery as appropriate What are treatment goals in Stage D HF? --------- Correct Answer --------- Control symptoms

Improve HRQOL Reduce hospital readmissions Establish pt's end-of-life goals What are options for Stage D HF? --------- Correct Answer --------- Advanced care measures Heart transplant Chronic inotropes Temporary or permanent MCS Experimental surgery/drugs Palliative care, hospice ICD deactivation What is the normal BNP level? --------- Correct Answer --------- <100pg/mL (indicates HF is unlikely) What is normal BP? --------- Correct Answer --------- <120/80 What is "elevated" BP? --------- Correct Answer --------- 120 - 129/<80 What is Stage 1 HTN? --------- Correct Answer --------- 130 - 139 OR 80- 89 What is Stage 2 HTN? --------- Correct Answer --------- >/= 140 or >/= 90 What is recommended BP for DM? --------- Correct Answer --------- <130/80 What is recommended BP for CKD? --------- Correct Answer --------- <130/80 How should HTN be managed? --------- Correct Answer --------- Stage 2 and up should be given consideration for pharm treatment. Others can wait for lifestyle modification. What is first-line meds for non-black HTN population (including those w/DM)? --------- Correct Answer --------- Thiazide, CCB, ACEi, or ARB, either alone or in combo What is the med guideline for ASCVD for those </= 75yo? --------- Correct Answer --------

• High-intensity statin (atorvastatin/Lipitor 40-80mg, rosuvastatin/Crestor 20mg) What is the med guideline for ASCVD for those >75yo? --------- Correct Answer --------- Moderate statin (atorvastatin 10mg, rosuvastatin 5mg, simvastatin/Zocor 20-40mg, pravastatin/Pravachol 40mg, lovastatin/Mevacor 40mg, fluvastatin 40mg BID) What is the guideline for meds for LDL >/= 190? --------- Correct Answer --------- High intensity statin (atorvastatin/Lipitor 40-80mg, rosuvastatin/Crestor 20mg)

What is the med guideline for ASCVD for 40-75yo w/DM? --------- Correct Answer --------

• Their 10yr risk is >7.5%, so high intensity statin (atorvastatin/Lipitor 40-80mg, rosuvastatin/Crestor 20mg) What is the med guideline for LDL 70-189? --------- Correct Answer --------- Their 10yr risk is <7.5%, so moderate intensity statin (atorvastatin/Lipitor 10mg, rosuvastatin/Crestor 5mg, simvastatin/Zocor 20-40mg, pravastatin/Pravachol 40mg, lovastatin/Mevacor 40mg, fluvastatin 40mgBID) What is the ASCVD med guideline for 40-75yo w/out ASCVD or DM? --------- Correct Answer --------- Their 10yr risk is >7.5%, so moderate to high intensity statin What is the purpose for Beers criteria? --------- Correct Answer --------- The American Geriatrics Society developed Beers Criteria for use of providers as a guide for medical management of geriatric pts. Goal: to improve quality and safety. Not a sub for individualized care, but should be incorporated into prescribing practices for elderly. As an NP, be familiar w/the lists to avoid prescribing potentially inappropriate meds. Why do elderly need special prescribing criteria? --------- Correct Answer --------- Age- related changes also change metabolism. Pharmacodynamics change. Pharmacokinetic changes: absorption, distribution, metabolism, elimination. Half-lives altered, which affects steady state and dosing intervals. What are potential risk factors for ADRs in elderly? --------- Correct Answer --------- 6 or more chronic dz's. 9 or more Rx or OTC meds.

12 doses per day 85yo BMI <22 Creatinine clearance <50 H/o previous ADR What are some 2015 changes in med awareness for elderly? --------- Correct Answer --- ------ Nitrofurantoin can be used w/creatinine clearance of 30, but should be avoided long term due to possible irreversible pulmonary fibrosis, liver tox, peripheral neuropathy.

Non-benzos, benzo receptor agonist hypnotics (eszopiclone, zaleplon, zolpidem) should be avoided for insomnia regardless of duration due to associated harm. PPI should be avoided >8wks w/out justification due to possible c-diff infection, bone loss, fractures. Opioids should be avoided in those with h/o falls/fractures. T/F The meds listed in Beers Criteria are not absolutely contraindicated in elderly. --------- Correct Answer --------- True T/F The BC recommendations are graded as high, medium, low to assist w/decision making. --------- Correct Answer --------- True T/F The BC list includes dosage adjustments for kidney impairment. --------- Correct Answer --------- True T/F The BC list includes drug to drug interactions to avoid. --------- Correct Answer --------- True T/F Responsible prescribing is an important role of NP and BC can assist in determining the safest meds for geri pts. --------- Correct Answer --------- True What vaccination is recommended for people traveling to countries where dz is common? --------- Correct Answer --------- Hep A How is Hep A vax given? --------- Correct Answer --------- Two doses: initial at least 4wks before departure, second dose 6-12mo later. When is Hep B vax recommended? --------- Correct Answer --------- High-risk people (IV drug users, persons w/multiple partners) How is Hep B vax given? --------- Correct Answer --------- Initial dose 1mo later: 2nd dose 4 - 6mo after 2nd: 3rd dose When is Zostavax recommended? --------- Correct Answer --------- Anyone over 60yo, given as single dose Can people who have had prior episode of zoster be vaccinated? --------- Correct Answer --------- Yes

When is flu vax recommended? --------- Correct Answer --------- Annually for all adults

50yo When should DTaP be given? --------- Correct Answer --------- Once in a lifetime for all adults, then Td booster every 10yrs. When is pneumococcal vax recommended? --------- Correct Answer --------- Once for 65yo and older Younger adults w/severe chronic health conditions What is primary prevention? --------- Correct Answer --------- Activities to prevent occurrence of dz or adverse health condition, including mental health. Health counseling and immunizations are examples. What is secondary prevention? --------- Correct Answer --------- Activities aimed at detection of dz or adverse health condition in asymptomatic pt who has risk factors but no detectable dz. Screening tests are examples, like mammography. What is tertiary prevention? --------- Correct Answer --------- Management of existing conditions to prevent disability and minimize complications, striving for optimal function and QOL. Pulmonary rehab for COPD is an example. What are common s/s of anxiety in elderly? --------- Correct Answer --------- Constipation Nausea HA Worrying about health, disability, finances What are phobic disorders? --------- Correct Answer --------- Anxiety from a specific feared object or situation. Person feels anxiety is excessive or unreasonable. Often leads to distress or avoiding the fear. Often lifelong, common in older adults. What is generalized anxiety disorder (GAD)? --------- Correct Answer --------- Often 20- 30yrs of excessive worry about health, family, finances w/insomnia, muscle tension, restlessness, fatigue, irritability, memory problems.