ANCC Exam with 100% Correct Answers, Exams of Nursing

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ANCC Exam with 100% correct answers 2024 WITH 200 REAL EXAM QUESTIONS AND CORRECT ANSWERS (100% CORRECT ANSWERS GRADED A+ Types of prevention - answer-primary- car restraints, bicycle helmets, immunizations secondary- prevent for those with RF-pap, mammo tertiary-mgmt of established disease- meds, lifestyle Primary - answer-Preventing the health problem, most cost effective form of healthcare **IMMUNIZATIONS, ensuring adequate illumination at home (preventing falls) Secondary - answer-Detecting disease in early asymptomatic stages, screenings -Early cause finding of asymptomatic disease via the use of a screening test Ex. highly abnormal mammo not final word Tertiary - answer-Minimizing negative disease induced outcomes, potentially viewed as a failure of primary prevention Ex- rehab, PT, OT Who should not receive influenza vaccine - answer-4 mon old born at 32 weeks gestation receive flu- 6 mon and older can give during pregnancy/lactation give children 2x- 4 months apart MMR - answer-preggers can't receive (no varicella, or zoster, smallpox, flu mist, rotavirus), but lactation OK! its live but weakened give again to those born after 1957 Give to 6-11 month who are travelling outside US May treat and have an innocent flat pink rash 2 doses ( at 12-15 mon and 4-6 years) Tetanus - answer-can get from soil, a depth of the wound is important Preggers- get a tdap in her thirst trimester to pass onto the unborn child (pertusis is a bad outcome!), family members need to be up to date- can cause lockjaw T-dap- 1 at 11-64 and then booster every 10 dTap-five doses M.catarrhalis (gram neg)- also produces beta-lactamase, can get better without antibiotic Need abnormal ear drum (bulging TM) + pain (otalgia)/rubbing/tugging ear tx- Acetaminophen and otic drops help with ST Watchful waiting- 6 months or older, with non-severe illness, unilateral, fever <102.2, otalgia <48 <6 months-begin antibiotic!! if allergy-Cefdinir], RF: pacifier use for 10 months, feedings in the supine, smoke exposure, day care, <2- 10 days 2-6 yrs- 7 days >6 yrs- 5 days 1st line- Amox 90 BID, Amox clav BID With PCN allergy- **Cefdinir (Cephlosporins) Group A strep (GABHS) - answer-Streptococcus pyogenes, risk for rheumatic fever and Glomerulo., peritonsillar abscess, tx- amox then try macrolide if doesnt't improve GOLD STANDARD IS THROAT CULTURE indoor allergen - answer-dust mites (perennial), pets, cockroaches, mold spores Acute Bacterial rhinosinusitis - answer-S.penumoniae**, RF-viral infection, allergies, tobacco use, 1st line is Augmentin, penicillin allergy-Cefdinir 2nd line- if not better...Clindamycin and Cefixime Mono - answer-30-50 days ago was infected before sxs, give prednisone not amox (rash), at least 50% present with spleen enlargement, wait 1 month to go back to sports Anterior and posterior cervical lymph Pharyngitis with exudate right and left upper quadrant abdominal tendernes Hepatomegaly in 10% of cases Splenomegaly in 50% of cases Asthma flare - answer-FEV1/Peak expiratory flow rate- drops early (even before patient notices) and good indication of severity of asthma S3 - answer-systolic dysfunction or early diastolic, common in HF (dyspnea, crackles, tachycardia- 3 adject/s3), marker of ventricular overload- best heard with bell S4 - answer-diastolic dysfunction, common in poorly-controlled hypertension, recurrent myocardial ischemia, unstable angina Systolic Murmurs - answer-Mitral (rad to axilla) Mitral Benign is- negative hx Regurgitation Valve lower grade Physiologic Prolapse no radiation Aortic (rad to neck) PMI WNL Stenosis (harsh) softens w. position change Systolic Diastolic Murmurs - answer-Mitral Stenosis (Rumble) Atrial Regurg (blowing) Diastolic Aortic stenosis - answer-young man, exercise tolerance, harsh systolic murmur, softer when changing position, radiation to the neck (assume it came out of AORTIC VALVE) LVH, congenital defect Identify the problem Assess published research Design the innovation Evaluate the situation Decide whether to use the innovation Utilization review - answer-the process of evaluating the appropriateness of inpatient hospitalization. Proof of the medical necessity for the patient's hospitalization is done mainly through chart reviews and is part of the utilization review process. A claim can be denied under this process if the reviewer and the payer do not agree with the decision for hospitalization. Payment could be denied to the healthcare facility if utilization review does not deem the treatment necessary. Avoid accidental burn injuries in home - answer-home hot water set at no more than 120 (takes 5 mins in length to cause 3rd degree burn) second degree burns- moist, red skin with peeling borders third degree- you debrided Community/herd immnity - answer-Describes the state in which a sufficient proportion of a pop is immune through vaccination or prior illness- even individuals that aren't vaccinated (infants, immunocompromised) are offered some protection because everyone Active Immunity - answer-In response to an antigen, presence of an antibody produced in the host (waiting to protect you, 1 month from getting the dose, but LIFELONG=BETTER) Passive Immunity - answer-Immunity conferred by an antibody produced in another host, acquired naturally by an infant from mother (onset is within hours of getting dose but time limited only 6- 9 months) Treatment of analphylaxis - answer-Immediately administer EPI then administer Benadryl then call 911 Pneumonia vaccine - answer-Not contra in immunosupressed, does not protect against most pneumonia-causing pathogens (just s.pneumococcal), *can give during antimicrobial therapy Flumist - answer-Only for 2-49 and not in presence of airway disease Immune globulin (passive) - answer-concentration solution of antibodies derived from pooled donated blood product (SAFE!) Gardasil - answer-Quadrivalent vaccine- 6, 11, 16, 18 6 and 11-wart virus 16 and 18- malignancy virus Males- get 9-26, get three dose series Hep B vaccine - answer-previously unvaccinated adults with DM should be vaccinated immediately upon diagnosis (because can be in group type settings/lancets/equipment not cleaned) PPD and MMR - answer-IF MMR vaccine is given on the previous day or earlier, the PPD TST should be delayed for at least one month (false positive) Elderly with RF - answer-Given PPSV23 (Pneumovax) 1 year ago, should be given a dose of PCV13 (Prevnar) today- gives an additional boost Live virus - answer-MMR, Varicella, FluMist, Zoster Contra-Pregnancy, Immuno/HIV only less than 200, Rotavirus- oral vaccine given to infants Restating - answer-"You said that you got angry when your boyfriend came home last last night" keyword- YOU 78 y/o woman with fatigue, spoon-shaped nails, and lab results MCV low, RDW incr - answer-Microcytic hypochromic anemia --> examples erosive gastritis menorrhagia so answer is GI blood loss ...then look at Ferritin because its probably IDA Iron maximum absorbs - answer-on an empty stomach Hemic murmur - answer-happens with anemia, dehydration, pregnancy goes away with tx 68 y/o woman with peripheral numbness, oral irritation, macrocyctic - answer-Pernicious anemia cause is Vit 12 deficiency 65 y/o woman with RA with poor control who is on DMARDS - answer-Anemia of chronic disease Types of anemia - answer-Iron deficiency anemia-micro, RDW high, Folate deficiency anemia-macro Alpha thalassemia minor- micro Beta thalassemia minor- micro, pale cells Meditarrean HGB HCT 10:30 12:36 15:45 Normocytic (MCV-80-96, RDW= 11.5-14.5) MCHC: 32-36 - answer-MCV=NL MCHC=NL RDW=NL normochromic anemia with NL RDW Most common etiology: acute blood loss or anemia or chronic disease 1) Acute blood loss or GI bleed 2) Lupus Microcytic (MCV<80) high RDW - answer-MCV low, MCHC low, RDW high hypochromic anemia with elevated RDW** Most common etiology: 1) Iron deficiency anemia- Low ferritin, high TIBC 2) erosive gastritis, menorrhagia Microcytic (MCV<80) NL RDW - answer-MCV low, MCHC low, RDW NL Hypochromic anemia with NL RDW** Most common etiology: 1) Alpha thalassemia minor (asian, african) 2) beta thalassemia minor (African, middle eastern, Mediterranean) Macrocytic (MCV>96) high RDW - answer-MCV high, MCHC NL, RDW high Normochromic anemia with elevated RDW Most common etiology: 1) Pernicious anemia 2) Dietary induced Vit B12 deficiency (numbness of fingertips and oral irritation***)- most common Common ADE from oral decongestants*** - answer-An increase in Blood Pressure because they are alpha-adrenergic agonists DO NOT use in hypertensive 29 y/o woman with allergic rhinitis who is a home daycare provider - answer-THINK NOT SEDATIVE do not give Chlorpheniramine -mine but can give nasal spray, oral loratadine nasal congestion---> 1st line is decongestant 75 y/o male with 60 packyear, COPD, firm, non-tender node - answer- Think malignancy- Squamous Cell carcinoma Next step...biopsy 90% of oral cancers are SCC Dx: FEV1:FVC ration <0.70 CNI Olfactory - answer-Smell CNII Optic - answer-Vision CNIII Oculomotor - answer-Eyelid and eyeball movement CNIV Trochlear - answer-Innervates superior oblique, turns eye downward and laterally CNV Trigeminal - answer-Chewing, face and mouth, touch and pain CNVI Abducens - answer-Turns eye laterally CNVII Facial - answer-Controls most facial expressions, secretion of tears and saliva, taste CNVIII Acoustic - answer-Hearing, equilibrium, sensation CNIX Glossopharyngeal - answer-Taste, sense carotid, blood pressure CNX Vagus - answer-Senses aortic blood pressure, slows heart rate, stimulates digestive organs, taste CNXI Spinal accessory - answer-Controls trapezius and sternoclei., controls swallowing movements CNXII Hypoglossal - answer-Controls tongue movements Angle Closure Glaucoma - answer-Increased IOP Funduscopic--> see a deeply-cupped optic disc Acanthosis Nigicans - answer-CHeck hemoglobin A1c hyperpigmented plaques with a velvet-like appearance at the nape of the neck and axillary region (worsens after puberty cause thats when the hyperinsulinemia Found on Groin folds, over knuckles, elbows Tx--> losing weight Hypothyroidism - answer-RF: down syndrome, post parttum Normal values- TSH= 0.5-4 distinguish between benign and malignancy- biopsy Subclinical Hypothyroidism - answer-Elevated TSH with NL free T4 Recheck TSH in 6 months AACE treatment of patients with TSH >5 (also indicated if pregnant) Thyroid nodules - answer-Order US, get TSH Hot- benign, and treat RAI to ablate vs. Cold- fine-needle aspiration biopsy, uncommon headaches - answer-Migraines younger- more boys after puberty- more girls Get HA when hungry unilateral- cluster and migraine nasal stuffiness with conjunctival injection- cluster tension- pressing, not pulsating, bilateral, more common in males- tx the triptans, nonsteroidal anti-inflammatory drugs (NSAIDs) and oxygen. Don't give women with migraine with aura a contraceptive with estrogen like BC because *** Prophylactic migraine treatment- 1st line is beta blocker propranolol**, Topamax, **TCAs-amitriptyline, Elavil Abortive-Cafergot, NSAIDs, Imitrex beta blockers - answer-Used in Acute coronary syndrome, reduce myocardial oxygen demand, reduce the effects of circulating catecholamines Migraine therapy - answer-55 y/o woman with angina pectoris Don't give ergotamine, almotriptan Can give Ibuprofen Supplements- Magnesium, butterbew, feverfew Duodenal Ulcers - answer-Caused by H.Pylori Would treat with an antimicrobial therapy WBC response - answer-Bacterial- high neurophils (around 60%) vs. VIral- high lymphs (around 30%) Blumberg's sign - answer-gently by deeply palpating an area of abdominal tenderness, then rapidly releasing the pressure/rebound tenderness (late sign) Markle's sign - answer-Stand on tip toes then let the body weight gall quickly onto heels, increases pain with maneuver, good with children (early sign) Duodenal ulcer - answer-abdominal pain described as burning, gnawing pain about 2-3 h PC. Relief with foods, antacids. Awakening at 1-2AM with symptoms Objective: tender at epigastrium, LUQ, slightly hyperactive bowel sounds Hepatitis A - answer-fecal contaminated water sxs: clay colored stools, dark colored urne, joint pains, nausea, fever, maliase 7 Incubation-28 days Hepatitis C - answer-most commonly transmitted from sharing of needles, blood transmission More horizontal> vertical transmission RF: antimicrobial therapy in the previous 3 months, exposure to children in day care, age older than 65 Likely causative organisms in CAP include - answer-S. pneumoniae and select respiratory viruses COPD old man with CAP - answer-Give levo 5 days 7 day course of clarithomycin (macrolides)- no doesnt cover DRSP and its a CYP inhibitor Amox-Clav- doesn't treat atypicals Cefpodoxime- doesn't treat atypicals CURB-65 - answer-BUN greater than 19 RR greater than 30 BP <90/60 Age >65 Score <1 = outpatient, >1 = inpatient Most common pathogen implicated in acute bronchitis - answer- Respiratory virus give person relief from the cough Atrovent/albuterol, prednisone 3-5 days (gets rid of lower airway inflammation) small percentage bacterial- then prescribe macrolide or tetracycline Tx- Anticholinergics for uncomplicated bronchitis Asthma - answer-Core defect chronic airway inflammation Spirometry is needed to make dx of asthma- FEV1 Peak flow is used to monitor asthma inhaled corticosteroids- stop release of at least 8 inflammation mediators (only 20% of the dose of the inhaled cort. is systemically absorbed Visit frequency- well controlled-3-6 months, not well controlled 2- 6weeks SABA- albuterol (can't relieve inflammation, just bronchospasm PCPs are not well-versed in - answer-Inhaled corticosteroids and SSRIs Anticholinergics for asthma (Muscarinic antagonists) - answer- Atrovent/ipratropium bromide- short acting Spiriva/tiotropium bromide- long acting used in COPD, for prevention of bronchospasm Asthma/COPD - answer-PE: Hyperresonance, decreased tactile fremitus, wheeze (expiratory first, inspiratory later), low/flattened diaphragms, increased AP diameter For asthma flares- give 5 day course of oral prednisone (don't give injectables!) COPD- high pressure on right side of heart can result in afib, chronic obstruction (FEV1:FVC <0.70 post bronchodilator confirms persistent airflow limitation oxygen therapy- >15 hours ** consider CXR only with fever and/or low SaO2 to help rule out concomitant pneumonia -Best course for flare--> Doxy with a short course oral corticosteroid Alpha-1 Antitrypsin Deficiency screening - answer-perform when COPD develops in patients of caucasian decent under 45 years with a strong family hx of COPD Hemoglobin A1c - answer-<6% goal with no CVD (newly dx 26 y/o with DM2) Low- LDL goes down by 1/4 Statins- LDL lowering effect Fish oil- can't switch too only can decrease TG LDL goal for >60 male with DM and hx of ACS 2 years ago- <70 STDS - answer-syphilis- primary-chance is painless, seconday- rash on palms and soles (injectable penicillin) HPV- 6, 11- warts 16, 18, 31, 33- malignancy History of pelvic inflammatory disease- more likely to get ectopic pregnancy, ceftriaxone + doxy with or without metronidazole, tubal thickening with ot without free pelvic fliod, increase in ESR, CRP, leukocytosis STI diagnosis - answer-BV- clue cells, metronidazole oral or topical, Clindamycin cream (+whiff test, mobiluncus bacteria, cells with large amounts of bacteria coating surface) candida vulvovagintis- Pseudohyphae, clotrimazole cream nongonococcal cervicitis/vaginitis- WBCs, doxy Trich- yellow-green discharge, strawberry spots on cervix- treat with Metronidazole or Tinidazole **Penile discharge less commonly seen Chlamydial- mucopurulent discharge and firable cervix UTI - answer-Acute uncomplicated UTI cystitis- TMP/SMX and no allergy BID x 3 days, if resistance or sulfa allergy then Macrobid 100mg BID x 5 d, Pyridium Acute uncomplicated pyelonephritis moderately ill- Cipro 500mg BID x 7 d In children- antimicrobial tx for 7 to 14 days, suprapubic aspiration, renal bladder US, cause is vesicoureteral reflex, manifests as unexplained fever Bladder cancer - answer-Not- report of recent-onset intermittent acute urinary retention Yes to cause bladder cancer- textile worker for 25 years (exposure to dyes), cigarette user, painless gross hematuria Menopausal findings - answer-flattening of the vaginal rugae vaginal pH= 5.6 high scant white vaginal discharge worrisome if ovary palpable on bimanual exam- can be ovarian cancer Don't start post-menopausal hormonal therapy if having unexplained vaginal bleeding Male STIs - answer-Epididymitis- infla of epididymis and testes tx- <35 (cause is gonorrhea/chlam).... Ceftriaxone 250 mg IM as a single dose + doxy 100 BID x 10 d .....>35 (cause is enterobact.) Ciprofloxacin 500 mg QD or levo 750 mg QD X 10 d OR MUMPS sxs: irritative voiding, penile discharge, scrotal swelling, epididyymoorchitis Acute bacterial prostatitis (STD!) <35 ...same tx, >35....same tx- need a gram negative, fever, irritable voiding, perineal pain, boggy DRE, Lower back pain!- dx. urine culture phimosis (foreskin cannot be pulled back to expose the glans) vs paraphimosis (retracted foreskin that cannot be brought forward to cover the glans) Celexa/ citalopram- CV effects, low dose for adults Lexapro/escitalopram- (no Drug-drug), best for OLD Paxil/paroxetine (anticholinergic, drug interactions) SNRI- better for anxious and/or resistant depression, associated with focus Effexor, Cymbalta, Pristiq SDRI- Wellbutrin- add on therapy, dopamine-joy Anxiolytics- benzos- will not let you forget how worrie dyou are but will reduce hyperviligance Box warning risk <24- suicidal risk TCAs- most neuro and cardio toxic!! such as Notriptyline*** Delirium - answer-Drugs-anticholinergic (TCA, antihistamines, antipsychotics) Emotional, electrolyte (hyponatremia- kidneys lose Na) Low PO2 Infection-UTI, CAP Retention of urine or feces, reduced sensory input Ictal or postictal state- alcohol withdrawal Undernutrition- b12, dehydration Metabolic, myocardial problems Subdural hematoma- mild head trauma Dementia - answer-Aricept and Namenda- cholinesterase inhibitors can cause nausea and diarrhea 40% also have depression Elderly- drug interactions/ADE - answer-Nitrofurantoin/Macrobid- lack of efficacy in renal function CrCl <60 Amitriptyline-Elavil- risk of orthostatic hypotension Ambien- falls and fracture risk Diclofenac/Voltaren- promotes fluid retention Zoloft/SSRIs- risk of hyponatremia **over 80- NO METFORMIN, glipizide better than glyburide (long half life), poor hydration-risk of hyperkalemia Falls/accidents - increased with loss of touch/sensation!!! Gout - answer-triggers are use of thiazide diuretic, consumption of organ meats, alcohol consumption NOT intake of acidic foods MSK - answer-Meniscal tear- McMurrays, Apleys Ankle instability- Talar Tilt Carpal Tunnel Syndrome- Tinel's sign (tap), Phalen's (acroparathesia- numbness), RF: DM ACL- Lachman's test Lumbar nerve root compression- Straight leg Cervical root compression- Spurlings Rotator cuff- drop arm De Quervain's tenosynovitis- Finkelstein's Lumbar spinal stenosis - answer-Improvement with flex forward position, bilateral leg numbness, report of back worsening with standing Will have pedal pulses Reactive arthritis (Reiter's syndrome) - answer-knee pain, readness and tearing in the eye, no fever, urinary meatus reddened **can't see, can't pee, can't climb a tree diagnostics- Urinary PCR testing for gono and chlamydia tx. with antibiotics Lumbar sacral strain vs Lumbar radiculopathy - answer-LSS- spasm, irritation, neuro WNL Healthy full term newborn - answer-at least 8 wet diapers, 4 or more bowel movements with breast feeding, loose up to 10% of birth weight in the first week of life and back to birth weight by 2 weeks Vision range- 8 to 12 inches (think about how far baby is from mom on breast), defensive blink present at birth (if not...wonder if can see), bluish scleral tint noted, eyes are light/glare sensitive visual preference for the human face, hear high-pitched, reacts to the cry of other neonates, well-developed sense of smell (bonds with caregivers) Baby safety - answer-PUT baby on back/face up position, supervised tummy time, Baby At 2 months - answer-can lift self on 2 arms, responds 2 sounds, smiles when smiled 2 Baby at 4 months - answer-reaches 4 a toy or other object, smiles 4 fun, rolls form tummy to back Baby at 6 months - answer-Looks like the number 6 when sitting up, rolls from back to tummy and back separation anxiety (6-8 months) 5-6 months first teeth 5-7 YEARS permanent teeth (first molar) Baby at 8 months - answer-Transfer objects from hand to hand with ease Peek-a-boo Tooth eruption- first teeth (6****-10 months)- lower central are 1st to come in central incisor (8-12 months) Baby at 6-9 months - answer-Starts to crawl 9 to 11 months - answer-Peek a boo 10 to 12 months - answer-Temper tantrums Baby at 12 months - answer-stand tall like the number 1 and walks with two legs Pulling to a stand, cruising, and waving bye-bye are milestones of a 12-month-old Baby at 18 months - answer-Name single word objects, says no a lot like a 18 yo, acts like an 18 yo coping work that adults 1) IMITATE 2) Time out- 18 to 24 months 3) Toilet- 18 monts Listening to a story, stacking 3-4 blocks, throwing a ball and naming objects are accurate milestones for an 18-month-old along with using a vocabulary of 15 words walking quickly, running stiffly, walking backwards and imitating word Baby at 2 years - answer-walk up to second floor with help, 2 word sentences, 2 step commands, 2 block tower with ease 2-year-old kicks a ball, imitates adults and has vocabulary of 30 words. Baby at 3 years - answer-tricycle, 3 block, three word sentences, draw a circle Baby at 5 years - answer-5 word sentences, draw a square Names best friend Baby at 4 years - answer-4 word sentences, 4 block tower, draw cross Simple abstract problem solving (4.5) life (before 1 month), post feeding projectile vomitting with baby eager to eat again, olive shaped abdominal mass V I- currant jelly stools, onset colicky/severe, saysage shaped abdominal mass, 1st year of life Abdominal US Infant that throws up all the time - answer-common problem would be GI tract immaturity allowing reflux Time out- child - answer-18-24 hours- 2.5 years Timer- for a minute that they are old (2 years, 2 mins) Milestone in childhood at 3.5 years - answer-People outside the home, percentage of speech should be 100% intelligable 4.5 year old child - answer-Can verbalize cold, hungry, tired, can draw a person with no torso, knows first and last name abstract problem solving Prevnair- PCV13 - answer-Makes kids fussy and mildly febrile Pre-term infants - answer-immunizations based on birth age, don't get a smaller dose! Pre-medicating baby prior to immunization - answer-FALSE- because acetaminophen and nsaids have prostaglandin affects and minimizes the effectiveness MCV4/Menactra- Meningitis vaccine - answer-Two doses are recommended for adolescents 11 through 18 years of age Developmental red flags - answer-1st days of life- do hearing testing By 6 months- no big smiles or other warm, joyful By 9 months- no sharing of sounds, smiles, facial expre. By 12 mon- lack response in name, no babbling/baby talk, no pointing/showing, reaching, waving By 16 mon- no spoken words by 24 mon- no meaningful two work phrases that don't involve imitating or repeating **AAP screening for autism at 18-24 mon old Down Syndrome/Trisomy 21 - answer-Infant with flat facial profile, hypotonia, hyperflexible joints, a single palmar crease in both hands, and Brushfield spots (grayish brown spots in the peripheral of the iris), seen immediately *Cerebral palsy not seen for a couple of weeks Car safety infants - answer-Rear facing car seats till 2 years of age 2 years and older- forward facing seat with a harness School aged- belt-positioning booster seat Front seat- taller than 4' 9'' Tanner stages - answer-1 (think pinky finger) 2- earliest changes, puberty (2 years for menses) 3- growth spurt onset (think middle finger is longest) 4- growth spurt speaks 5- adult Topical antibiotics- Clinda, Erythromycin, dapson doxy, mino, azithro (3 months of continuous therapy) BC pills- reduction in androgen levels, decreased sebum production Accutane- cystic acne when nothing else has worked- most potent teratogenicity, need to monitor for suicidal thoughts, ipledge Worsens- androgens, picking at face, sebaceous oil production but no chocolate Acne roseacea- found on chin and forehead Adolescent death - answer-Leading cause: accidental injury Alcohol leading choice, binge drinking depression screening starting at age 12 ADULT DEATH - answer-leading cause is heart disease Legal rights of adolescent patient - answer-contraception pregnancy STIs Substance abuse Mental health Risk factors for type 2 diabetes - answer-Obesity, ethnicity (NA, AA, pacific islander), personal history of PCOS/gestational DM, small for gestational age at birth, acanthosis nigricans, htn, dyslipidemia **Not hx od DMT1 Initiate at age 10 or onset of puberty (tanner stage2) q 3 years Multisystem disease (acute febrile rash-producing illness) - answer- scarlet fever- rash feels like sandpaper (fine, raised, pink), GABHS, anterior cervical lymph**, exudative pharyngitis, rash develops in 2 days then peels, tx- amox, azithro Roseola- peaks 6-24 months of age (less than 2**), high fever spike caused by herpes virus**, 3-7 period of fever, when develops rash/fever goes away Rubella posterior cervical and postauricular lymph., rash lasting 3 days, sore throat, nasal discharge (*vaccine preventable disease) mild symptoms, maculopapular rash- starts on face and spreads down trunk! Measles/Rubeola- *acute presentation with conjunctivitis, Koplik spots(oral mucosa, only in 1/3 cases though), rash that looks sunburned- may coalesce (notify public health), pharyngitis usually mild without exudate (*vaccine preventable disease) can cause pneumonia and encephalitis infectious mononucleosis - answer-anterior and posterior cervical lymph (diffused) right and left upper quadrant abdominal tenderness fatigue "shaggy" white purple exudative pharyngitis dx: Heterophil antibody test (MONOSPOT) Incubation: 20-50 days Avoid with mono: amoxicillin! Avoid contact sports for 1 month acute febrile rash-producing illness in younger kids - answer- Coxsackie's virus- fever, malaise, sore throat, anorexia, 1-2 days later lesion on hands/feet/and mouth, duration of illness 2-7 days Kawasaki disease- fever >104 lasting >5 days, strawberry tongue, bilateral conjunctivitis, cervical lymph, hands and feet with peeling skin/swollen palms and soles--> can cause coronary artery obstruction, tx: immune globulin IDA in children microcytic Hypochromic If baby has high pitched cry, difficult to console, **does not regard his mother's face --> initiate an eval for sepsis and consider for inpatient admission - CAP: tachypnea, atypical pathogen treat with Clarithromycin, dx: CXR Sepsis - answer-CBC with WBC diff- bacterial or viral shift Blood culture- bacteremia UA- culture and sensitivity LP for CSF analysis- bacterial (neutrophil), viral (lymphocytes) CXR- dx of pneumonia Stool culture- shigella Women- early warning signs acute MI - answer-**unusual fatigue, sleep disturbance, SOB, indigestion during ACS-SOB, weakness, unusual fatigue PMI - answer-should be at 5th ICS MCL- displaced means increased LV volume (moves laterally)--> left ventricular hypertrophy, poorly controlled htn Big wave- "S" and "R"- equals big left ventricular Unable to palpate- move to LLD position Conditions- body builder/thick chest wall, obesity, COPD Hypertropic Cardiomypathy - answer-ventricular septum is thick and asymmetrical- sudden cardiac death Elderly- early warning signs acute MI - answer-Dyspnea, neuro symptoms- confusion ACS in elderly with any new acute illness STEMI vs non-STEMI - answer-STEMI- Q waves NSTEMI- no Q waves Physiologic split S2 - answer-innocent, increases on inspiration, found in adults <30, just make a note ASD - answer-child presentation can range from well to HF, full sports participation with correction, easy fatigue COC (combined oral contraceptives) - answer-checking BP, don't need a pregnancy test unless indicated (had sex recently, menses <7 days), sunday start after menses or can start that day (back up for 7 days), uninterrupted use can minimize headache frequency and severity Not recommended- smoking if <35 its a relative contra if >35 absolute contra >40, hx of lipid disorder= category 2 headaches continuation= category 2 HTN- adequately= cat 3 Migraine with focal aura is bad poorly controlled= cat 4 --> can use progestin only Hepatic adenoma= cat 4 Rifampin- lowers use of COC Acne Vulgaris- COC decreases androgens Category 4- gastric bypass surgery-can't use COC because medication is not absorbed Post-partum- don't give COC for 2-3 weeks because in a thrombotic state can give POP IUD - answer-Cooper/Paraguard- 10 years Mirena- 5 years Skyla- 3 years Category 2- 45 y/o nulliparous, 33y/o with HIV Citalopram - answer-CV issues- QT elongation, do not exceed 20mg/day for older adult Ethical Principles - answer-Benevolence (help people in need) Nonmaleficence (duty to do no harm, minimizing pain) Autonomy (self right), avoiding paternalism- can't say that you will withdraw care if they do not obey--> you need to document well in the record that they are making an informed decision (listed the pros and cons) Autonomy - answer-Multi-drug resistant TB- under court under, if refuse treatment, can be detained till received therapy THREAT TO OTHERS- autonomy revoked Decision making is cognitively impaired--> healthcare proxy Utilitarisnism - answer-Best done for the greatest amount of people (large pop) Allocated healthcare- primary prevention services Veracity - answer-Must be truthful avoid deception, report known lapses of standard of care to the appropriate authority/proper agencies Informed decision - answer-can say yes or no, ask questions about the therapeutic procedure ect, process the information (stay away from answer choices that say recommending...go for pros/cons or having them verbalize that choice) HCP--> must disclose all information benefits/risks ** if you are not doing to the procedure such as removal of gallbladder so not obligated, that would be the surgeon's job Components of Compentency - answer-Ability to communicate a choice Understand the relevant information Appreciate the healthcare consequences of the situation To reason about tx. choices Only a court can declare a person incompetent Under 18--> if STI, BC, treatment of substance abuse (tobacco cession) DON'T NEED PARENTS...but want care of skin then YES Advanced Directive - answer-Methods of decision making for patients who cannot communicate wishes, appointed person makes decisions based upon the patient's past wishes and values Ex. Living Will--> Five wishes document- who the pt. wants to make health care decisions and what kind of treatment, how comfortable the patient wants to be (sedative meds) --> does not apply to meds and therapy to prevent suffering How pt. wants people to treat the person what patient wants loved ones to know (pt. can rip it up at any time) Not legally binding Healthcare Proxy - answer-or surrogate or attorney-in-fact a person chosen in a advance by individual to make healthcare decisions in the event that a patient becomes unable to do so who needs one? --> 18 years, would need to speak for patient in case of general anesthesia, or any health care problem when unable to comprehend situation Spouse- de-facto proxy (if no one else is appointed) Cultural Issues - answer-Cultural sensitivities- don't assign value (better or worse, right or wrong) Cultural knowledge- awareness of different beliefs, values Damages- permanent or substantial damages to the patient **If you see an accident- no legal duty to help Intentional tort- when you breach privacy Medicaid - answer-The largest payor for nursing care facility Improvishment is one of the requirements for eligibility Medicaid eligibility changes between states (some are more liberal, some are at minimal federal mandate) Can have medicare with medicaid- poor older person Dental care for medicaid till 21 HIPAA (health insurance portability and accountability act) - answer- national standard for EMR and national identifiers for employers, providers, and health plans(medicare, medicaid, blue cross, clearinghouses) (not just maintaining privacy) Covered entity- HCP who use EMR-NP, physicians hospitals, labs Formats- paper, electronic, and oral **minimum amount of information is used or disclosed whenever possible Right to access their health information, can have certain items removed You can decline to take care of people who will not release their PHI (protected health information) Expiration date is not required but often added No consent- ER treatment, consent is inferred, communication barriers --> need to document that you attempted to obtain consent You can call a person's name in the waiting room Can leave message with patient/or person who answers the phone but KEEP IT LIMITED If requesting a copy of medical records- can charge a "reasonable fee" for the service ($50 or less) Private insurance plans may reimburse for NP services even if not mandated by state law. In some states, the insurance code may be interpreted rigidly to exclude reimbursement of NPs. Failure to comply with HIPAA - answer-The office of civil rights of the department of health and human services enforces civil violations Department of justice for criminal crimes If information is transmitted on the provider's behalf or by the provider's agency, the HIPAA rules apply. They also apply to "business associates" of healthcare providers. Research - answer-Power analysis-math calculate used to determine the minimum sample size to detect an effect--> will tell you how likely you can generalize your results to the population power: determination of statistical significance (allow for error), sample size (a priori), effect size (post hoc) Power of 80%-general standard Confidence interval- margin of error, range in which the response is likely to be accurate Confidence level- how sure you can be that your results are accurate. 95% confidence- your results are a reliable indicator Sample size- calculate based upon a desired confidence level Coding- ICD (international classification of diseases)-10-code; code the symptoms and dx (more precise, better for insurers) E&M- evaluation and management, get paid CPT (current procedural terminology), get paid- services provided, E&M, surgery and anesthesia, lab, radiology, pathology (5th number- level of complexity) 99213- cough and cold- ICD- cough, acute URI, rhinorhea Diagnostic tests - answer-diagnostic tests include: tissue biopsies, cultures and CT scans. NOT LABS Infant derm - answer-Hemangioma- benign tumor of endothelium (rapid growth first days of life to six months)--> shrinks 3-6 months- tx. watchful waiting, oral propranolol (glow growth), corticosteroids Port-wine stains-(disorder of dermal capillaries- a/w genetic disorders)-born at birth, stay stable in size, blanchable(vascular)- THEY DO NOT REGRESS- tx. laser which lightens Mongolian spot- blue-black grey macular lesions- most common in asian, native american, african, european--> disappear during childhood, no tx Milia- resolves spontaneously, enlarged sebaceous glands Miliaria or "Prickly heat"-when infants overheat Erythema Neonatorum Toxicum-appears first 48 hours resolves 5-7, rash that progresses to pustular lesion, resolves spontaneously, LESIONS LOOK LIKE FLEA BITES Erythema Infectiosum- fiery red facial rash and myalgia for the past week Erythema Multiforme- milder form of Stevens-Johnson syndrome that produces pink-to-red targetlike lesions, wheals, and blisters Eczema- degradation of mast cells, important to apply lubrication Atopic Dermatitis-imparied epidermal layer, allowing irritants into dermis, decreased water content, from birth to 2 years on the face***! tx- eliminate triggers, hydrate, control itch Acne Neonaturum- stimulation of sebaceous glands form maternal or infant androgens revoles (1-2 months)- low does benzoyl Seb dermatitis- cradle cap--> yeast and overstimulation of sebum production, greasy with yellow scales, tx-emollient, ketoconazole 2% Insect bite - answer-Erysipelas- subtype of cellulitis involving upper tissue involvement cause by beta strep Federal drug enforcement agency - answer-state level authorization dictates the ability of NP to obtain a federal DEA number Majority of NPs are eligible to obtain a federal DEA number Insurance policy- Types of malpracticet - answer-Claims made policy- injury occurs within the policy period and the claim is filled during the period the policy is in effect Occurrence-based policy- covers any claim that results from an incident that occurs during the term of the policy, regardless of how long it takes before the claim is made Tail Coverage- additional or supplemental insurance that covers the provider for incident that occur during the term of claims made policy but are not brought forward until after the policy has expired Interval coverage Licensure vc. Certification - answer-Licensure- to protect the public by ensuring a minimum level of professional competence- an agency of state government grants! Certification- a non-gov agency or association certifies that individual licensed to practice as a professional has met certain predetermined standards specified by that profession for a practice Countertransference refers to transfer- ence of feelings from therapist to patient. Confidentiality - answer-requires that the provider discuss confidentiality issues with patients. They must establish consent, and clarify any questions about disclosure of information. Cardiac meds - answer-triple therapy with an ACEI/ARB, CCB, and thiazide type diuretics would precede use of a BB, AA, or other alternative agent JNC-6 <140/90 with CKD and DM Microalbuminuria- a/w ischemic heart disease African Americans- better use diuretics or CCBs CKD- use ACEI or an ARB (but not together) Nondihydropyridine CCBs (verapamil, diltiazem)- P450 3A4 inhibitors! contra with severe left ventricular dysfunction, 2nd or 3rd degree Heart block ACEI and ARBs - answer-used in treatment of HF, hyperkalemia seen with use of potassium sparing diuretic such as Spirolactone in advancing renal disease or in poor hydration state Also long term use of BB in HF Digoxin- positive inotropic Asthma - answer-chronic airway inflammation with superimposed bronchospasm, hyperresonance on thoracic percussion, CXR would show hyperinflation No beta blockers- propranolol, should not have morning sputum production-BAD Prednisone- taper is not needing if 7 days or less Use of LABAs is a/w small incr. risk in asthma death, also the use of two or more SABA--> limit to 2 or fewer days/wk Asthma Meds - answer-SABA: albuterol (3-5 mins), levalbuterol- better tolerated because of greater bronchodilation at a reduced dose Anticholinergic: SAMA: Ipratropium bromide/Atrovent- inhibits muscarinic cholinergic receptors (additive benefits to albuterol) LAMA: Spiriva ICS: Fluticasone (flovent), Budesinide (Pulmicort)- improvement seen in 2-8 days- SE hoarseness, candida, small risk of delayed growth in children Leukotriene modifiers: Montelukast (Singular), Zafirlukast (Accolate)- add on to ICS LABA- Salmeterol **Should not be used alone, only with ICS Mast cell stabilizers-Cromolyn but not used, and Theophylline not used bc of D-D interactions Xolair- humanized monoclonal antibody, moderate to severe persistent allergic asthma uncontrolled on ICS-IgE COPD - answer-FEv1 /FVC ratio equal to or less than 0.70 after properly timed SABA use GOLD COPD guidelines- all have SABA Exacerbations caused by viruses, do not use antimicrobial therapy Vaccines- Pneumococcal 65 and older, and < than if RF: smoker, asthma, and COPD Gallbladder - answer-Murphy's sign, dx- ALT/AST, leukocytosis RF: >50, female, obesity, hyperlipid, rapid weight loss, preggers, diet with high glycemic index pain 1 hour after eating, sometimes radiating to the tip of the scapula, Collin's sign, N/V Diverticulitis - answer-sigmoid colon, presentation is few or no symptoms** but when acute cramping, diarrhea, and leukocytosis, long term, low fiber diet is a RF! Intervention- high fiber diet, antibiotics- metronidazole and ciprofloxacin H. Pylori infection - answer-Dx: Antibody testing, urea breath test, fecal antigen test Standard-dose PPI* BID (esomeprazole is QD), clarithromycin 500 mg BID, amoxicillin 1000 mg BID Peptic Ulcer Disease - answer-Nsaid- Cox 1- maintenance of gastric protective mucosal layer, Cox2- the inflammatory response/pain Celebrex- cox 2 inhibitors- increased risk of CV Other RF: >60, hx of previous PUD, previous use of H2RA, cigarette smoking, cardiac disease, alcohol use Duodenal ulcers- worsen after 2 hours after meal, more common than gastric, BENIGN Gastric- immediately after meals, can be MALIGNANT Dx:GI endoscopy, stool antigen, H.pylori-urea breath test H2RAs-ranitidine, famotidine, cimetidine/Tagamet (inhibits CP450) PPIs-Omeprazole (prilosec), Iansoprazole (prevacid)- alter proton pump- Se- reduced absorption of iron, B12, risk of fracture Misoprostol- prostaglandin analog designed for gastric protection with NSAID GERD - answer-use of estrogen, COC, CCB, nicotine- decrease in lower esophageal sphincter pressure RF: trigger foods, obesity --> tx. weight loss Bernstein's test- to measure the lower esophageal sphincter (LES) tone Esophageal Cancer - answer-SCC- upper part of eso Adenocarcinoma- junction of eso and stomach (most common-50%) IBS - answer-Spastic colon-alteration in small and large bowel motility Rome III criteria Loperamide- antispasmodics Bentyl-anti-cholinergics Prokinetic-Reglan Lubiprostone- for constipation Tenesmus- incomplete bowel emptying that distressing Differentials- Celiac disease IBD - answer-Crohn's- any part of the GI tract, skip lesions, Ulcers seen in both cases, but grandulomas only in Crohn's UC- colon only, risk of c.diff sxs: elevated CRP, ESR, leukocytosis Anemia-common problem Tx- Aminosalicylates, Mesalamine -narrowing of joint space, incr density of subchondral bone, bone cysts and osteophytes, only 50% of radio findings have symptoms RA: RF: female, age 20-40, hands, wrists, ankles, toes RF factor, ESR/CRP, anti-CCP, normocytic, normochromic tx methotrexate plus oral NSAIDs SE: infections DMARDs ***Category X SLE: joint pain and swelling, fatigue, facial rash- 1st line is hydroxychloroquine (systemic CS) plus NSAIDs anemia, proteinuria, positive ANA, more common in African- American and Latina women (think SELENA GOMEZ) Reactive Arthritis- dactylitis, enthesitis, cervicitis, prostatitis uveitis, conjunctivitis, positive HLA-B27 tx. CS, doxy for 7 days Fibromyalgia-mechanism unknown-stress, dec tolerance of perfume , common in women, a/w RA and SLE, joint swelling, can be identified by pressing, 11 points/18 total, physical activity aimed at flexibility, tx with Pregabalin, trazadone for sleep,- follow up in 1 month JRA- salmon colored maculo-papular rash, fever spikes, splenomagley Sarcoidosis - answer-20-40, F>M, AA, fever, fatigue, anorexia, arthralgias, pulmonary, derm, ocular dx. biopsy MIld tx with NSAIDs, CS, mod/severe-DMARDs Sports participation clearance - answer-HTN- use of ACEI, ARBs, CCB- no effect on exercise tolerance osteoporosis - answer-more than 2.5 SD below average bone mass for women who are younger than 35 1200mg ca for women >50 biphosphonate therapy (Fosamax)- atypical fractures with LT use, take with glass of water, remain upright after taking RF: estrogen deficiency, common in postmenopausal women hip wrist and spinal fractures = most common DEXA, Selective estrogen receptor modulator- help preserve bone density Calcitonin-risks outweighs benefits MSK cont - answer-tendonitis- swimming, throwing football/baseball, result of a macroscopic or partial tear of the tendon reduced ROM- joint stiffness, pain is acute when squeezed MRI of shoulder PVD - answer-Raynaud's: RF: women, smoking, ages 15-45, secondary- scleroderma, vibrating tools, beta blockers *do not use hot water- risk of burn- CCB and ACEI can be used as vasodialtors DVT: unilateral leg edema, if low risk than compression stockings, need a duplex US to confirm, 1st line: heparin (longer half life)- protamine sulfate warfarin- vit K (2.0-3.0)- need to check INR Preventing thromoembolism- LMWH Thrombophlebitis- RF: travel, varicose veins, trauma, hx of prior, use of COC tx: warm packs, compression hose, NSAIDs, LMWH Lower extremity occlusion disease- poor capillary return, blanching of foot with elevation, absent dorsalis pedis and tibial pulses Cilostazol- impairs platelet aggregation contra HF No beta blockers Venous- brown pigmentation, wound debridement Cushing - answer-Addison/Adrenal insufficiency- fatigue, poor appetite, weight loss, salt craving, hypotension, hyper pigmentation- inadequate amount of Mineralcortiocoid hormones- aldosterone Tx- CS replacement therapy, need sodium!-tell athletes, crisis- administer hydrocortisone Cortisol- maintains glucose, suppresses immune response, helping body respond to stress Cushing disease vs syndrome- disease is a benign pituitary tumor, tx- surgical intervention Syndrome- excess cortisol from oral CS to treat RA or from asthma, Lupus- would gradually tapering Disease tx- either surgery or RAI therapy Meds to control cortisol- Mifepristone, mitotane ketoconazole, aminoglutethimide standard of care - answer-the reasonable and ordinary care, skill, and diligence that would be given by practitioners in good standing, in the same geographic area, in the same general type of practice in similar cases. Therefore, FNPs are held to the standard of care of a reasonable and diligent FNP. Balanced Budget Act - answer-The nurse practitioner can receive direct payments at 80% of the lesser of either the actual charge or 85% of the fee schedule amount of the same service if provided by a physician. This Act did not change the "incident to" rule and does not have anything to do with hospital privileges. Standards of Professional Nursing Practice - answer-Standard 14 reads: "The registered nurse evaluates her or his own nursing practice in relation to professional practice standards and guidelines, relevant statutes, rules and regulations."-the competency for the nurse practitioner to participate in peer review as appropriate The right to practice as a nurse practitioner is derived from the AMA or the Department of Health. Legal authority is granted by the state. Cognitive domain - answer-domain includes communication, the receptive and expressive language. It also includes perception, thinking, information processing and memory. Marketing a NP - answer-the four Ps include: product, price, place, and promotion. four major factors influencing healthcare delivery services - answer- payers (including individual healthcare consumers); insurers; providers; and suppliers. Patients who receive the healthcare services are not considered a factor. Renal Failure - answer-Precipitating factors: anaphylaxis, infection, myocardial infarction (acute) vs. chronic which is DM, high blood pressure, polycystic, pyelonephritis Prerenal Azotemia- kidneys hypoperfused Postrenal Azotemia- obstruction to urine flow Persistent proteinuria Acute glomerulonephritis-edema, RBC casts, proteinuria, post-strep Acute interstitial nephritis- allergic reaction Acute tubular necrosis- hypotension, nephrotoxins BUN and Cr - answer-Normal BUN-7 to 20 Normal serum creatinine range for men is 0.5-1.5 mg/dL. The normal range for women is 0.6-1.2 mg/dL. (arises from skeletal muscle) Renal failure--> both are increased anemia of a chronic disease- normocytic, normochromic anemia Acute glomerulonephritis - answer-Usually occurs 1-2 weeks after bacterial pharyngitis infection dx- kidney biopsy sxs: Edema, urine is darkly colored and foamy- "cola" colored, htn- acute condition can develop as a result of infection, immune disease, or vasculitis