Differential Diagnosis and Management of Common Medical Conditions - Prof. PURDUL, Exams of Nursing

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NURS 6550 FINAL EXAM 1 – QUESTION AND

ANSWERS

QUESTION 1

1. Mr. Jeffers was admitted 2 days ago for a carotid endarterectomy. A Foley catheter was inserted intraoperatively and remains in place. His urine output has declined markedly despite continued IV fluid infusion. Today his morning labs reveal a BUN of 19 mg/dL and a creatinine of 2 mg/dL. A leading differential includes: A. Foley lodged in the urethra causing post-renal failure B. Decreased renal perfusion causing prerenal failure C. Age-related decreased eGFR causing prerenal failure D. Post-surgical rhabdomyolysis causing intrarenal failure Answer:  D. Post-surgical rhabdomyolysis causing intrarenal failure During surgery, muscles and injured. This can result into rhabdomyolysis, which is the breakdown of muscles to release proteins. The excess proteins causes an increased level of creatinine. Mr. Jeffers is from surgery (post-surgical) and his creatinine levels are above normal. The normal creatinine levels range from 0.6mg/dl to 1.2mg/dl. Thus, the most likely differential is: Post-surgical rhabdomyolysis causing intrarenal failure. 1 points QUESTION 2
2. Janet is admitted with symptomatic tachycardia. Her pulse is 160 b.p.m. and she is weak, diaphoretic, and anxious. Physical examination reveals a 5’4” 107 lb black female who is awake, alert, and oriented, anxious, with moist skin and racing pulse. Her blood pressure is 140/100 mm Hg. Temperature and respiratory rate are within normal limits. The patient admits to having a “thyroid condition” but she never followed up on it when she was advised to see an endocrinologist. The AGACNP anticipates a diagnosis of: A. Hashimoto’s thyroiditis B. Cushing’s syndrome C. Grave’s disease D. Addison’s disease 1 points

Answer:

C. Grave's disease

QUESTION 3

1. Systemic lupus erythematosis (SLE) is a multiorgansystem autoimmune disorder that can prevent with a wide variety of manifestations. Which clinical triad should prompt an evaluation for SLE? A. Fever, normal white count, elevated sedimentation rate B. Hyperkalemia, hyponatremia, low blood pressure C. Leukocytosis, hyperglycemia, hypokalemia D. Joint pain, rash, fever 1 points QUESTION 4
2. A patient presents with profound vertigo of acute onset yesterday. She can barely turn her head without becoming very vertiginous; she is nauseous and just doesn’t want to move. This morning when she tried to get out of bed she felt like she was pushed back down. The vertigo is reproducible with cervical rotation. The patient denies any hearing loss or tinnitus, she has no fever or other symptoms. The AGACNP knows that the most helpful intervention will probably be: A. Meclizine B. Diazepam C. Bed rest D. Epley’s maneuvers 1 points

Answer:

 D. Epley's maneuvers

The patient is likely suffering from benign paroxysmoly positioning vertigo. This is indicated by

inability to turn her head and to get up from the lying position in bed. The best intervention for

benign paroxysmal positioning vertigo is Epley's maneuvers. These maneuvers effectively clear

the inner ear to relieve symptoms of vertigo

QUESTION 5

1. Mrs. Mireya is an 85-year-old female who is admitted for evaluation of acute mental status change from the long term care facility. She is normally ambulatory and participates in lots of facility activities. Today a nursing assistant found her in her room, appearing confused and disconnected from her environment. When she tried to get up she fell down. Her vital signs are stable excepting a blood pressure of 90/60 mm Hg. The AGACNP knows that the most likely cause of her symptoms is:

A. Osteoarthritis B. Drug or alcohol toxicity C. Hypotension D. Urosepsis 1 points QUESTION 6

1. A patient with SIADH would be expected to demonstrate which pattern of laboratory abnormalities? A. Serum Na+ 119 mEq/L, serum osmolality 240 mEq/L, urine Na+ of 28 mEq/L, urine osmolality of 900 mOsm/kg B. Serum Na+ 152 mEq/L, serum osmolality 315 mEq/L, urine Na+ of 5 mEq/L, urine osmolality of 300 mOsm/kg C. Serum Na+ 121 mEq/L, serum osmolality 290 mEq/L, urine Na+ of 7 mEq/L, urine osmolality of 850 mOsm/kg D. Serum Na+ 158 mEq/L, serum osmolality 251 mEq/L, urine Na+ of 20 mEq/L, urine osmolality of 420 mOsm/kg

Answer:

Syndrome of inappropriate anti diuretic hormone is characterized by

dilutionalhyponatremia.Serum sodium levels lower than 130mmol/L and urine osmolality less

than 100mmol/L.Urine sodium is less than 30mmol/L.Serum level of sodium is likely to be 121

1 points QUESTION 7

1. Sean is a 29-year-old male who presents to the emergency department for evaluation and treatment of foreign body in the eye. Ophthalmic anesthesia is achieved and removal is attempted unsuccessfully with a moist cotton tipped swab. A wet fluorescein stain is applied to the lower eyelid, and a corneal abrasion ruled out but the AGACNP notes a positive Seidel sign. This indicates: A. Penetration of the cornea with resultant aqueous leak B. A rust ring remnant due to metal foreign body C. An elevated intraocular pressure D. Paradoxical pupil dilation in response to light 1 points

Answer:

 A. Penentration of the cornea with resultant aqueous leak

A positive Seidel sign indicates a leakage from the anterior chamber into the cornea. It is used to

diagnose corneal disorders such as corneal perforation and corneal degeneration.

The AGACNP should therefore suspect Penentration of the cornea with resultant aqueous

leak as indicated by the positive Seidel sign.

QUESTION 8

1. Mrs. Lowen is an 82-year-old female who comes to the emergency department for evaluation of a fever of 102.9° F. She complains of a headache in the right side of her temple and some right-sided jaw pain. A urinalysis, chest radiograph, complete blood count (CBC) and 12-lead ECG are all non- contributory. A comprehensive metabolic panel is significant only for a slightly elevated BUN and creatinine. The AGACNP appreciates distinct right temple tenderness to percussion. Which laboratory test is necessary to support the suspected diagnosis? A. An erythrocyte sedimentation rate B. A white blood cell differential C. Two sets of blood cultures D. Echocardiography

Answer:

 A. An erythrocyte sedimentation rate

Mrs. Lowen's most likely diagnosis is temporal arteritis,also known as, giant cell arteritis. The

disease presents with one-sided temporal headache accompanied with jaw pain, fatigue and

tenderness at the temples. The main diagnostic tests for temporal arteritis are erythrocyte

sedimentation rate and C-reactive protein levels

1 points QUESTION 9

1. Ms. Schiebel, a 31-year-old female who is brought to the emergency department by police after being arrested for disruptive behavior in a public establishment. The differential diagnosis includes drug and alcohol ingestion/toxicity, central nervous system disease, severe trauma, and psychotic illness; ultimately the alcohol and toxicology screen as well as head imaging are negative. When considering psychotic illness, the AGACP knows that this is a physiologic imbalance that typically involves an excess of: A. Serotonin B. Norepinephrine

C. Acetylcholine D. Dopamine

Answer:

 B. Norepinephrine

Since Mr. Schiebel has been arrested for disruptive behavior, he most likely suffers from maniac

behavioural disorder. Mania is a physiological imbalance disorder characterized by excessively

high levels of norepinephrine.

1 points QUESTION 10

1. Mr. Lincoln is a 55-year-old male who was admitted for management of sepsis secondary to pneumonia. He has declined rapidly, and today chest radiography demonstrates a diffuse, bilateral “white-out” appearance. His paO2 is 55 mm Hg. In order to increase his oxygenation the AGACNP knows that which of the following interventions is indicated? A. Increased FiO B. Increased respiratory rate C. Increased tidal volume D. Increased PEEP

Answer:

 C. Increased tidal volume

Tidal volume refers to the maximum amount of air that can be inhaled or exhaled during

breathing. When the amount of tidal volume increases, the amount of oxygen that is inhaled into

the lungs also increases. This results into an increase in the diffusion gradient and a subsequent

increase in the rate of diffusion of oxygen into the lungs. Therefore, the patient's (Mr. Lincoln's)

oxygenation will improve and his paO2 will rise/improve when his tidal volume is increased

1 points QUESTION 11

1. A 29-year-old female patient presents with a complaint of palpitations. Physical examination reveals an essentially healthy female with no significant medical history and no maintenance medications; the only thing she can report is that she had a head cold a week or so ago. The vital signs include a blood pressure of 139/90 mm Hg, pulse of 105 b.p.m, respiratory rate of 16 b.p.m. and a temperature of 98.6° F. The only abnormal finding on physical examination is diffuse anterior neck tenderness with thyroid palpation. The AGACNP considers which medication for symptom control? A. Ibuprofen

B. Pseudoephedrine C. Propranolol D. Methimazole

Answer:

Excessive thyroid hormone causes thyrotoxicosis which is characterized by increased basal

metabolic rate,increased appetite and emotional lability .Hyperactivity of the thyroid gland

causes its enlargement. Management of this condition is by anti thyroiddrugs.An example is

methimazole which is a thioamide that acts by inhibiting thyroid peroxidase they also block

coupling of iodotyrosines.

1 points QUESTION 12

1. Jennifer is an 18-year-old homeless female who was found unresponsive. She was admitted to the hospital for management of severe bleeding after a spontaneous abortion escalated to a uterine hemorrhage. An underlying infection and dehydration were corrected and nutritional supplements were started. Her volume status is stable, morning labs were all within normal limits and she is to be discharged today. When the AGACNP enters the room to prepare the patient for discharge, she finds her agitated, pale, and diaphoretic with vital signs to include a pulse of 105 bpm, respirations of 24 bpm, blood pressure of 110/76 mm Hg and a temperature is 97.9° F. The most appropriate action would be to: A. Order a CBC to assess for recurrent bleeding B. Request and abdominal CT to assess for bleeding C. Evaluate the patient for anxiety/panic attack D. Prescribe alprazolam 1 mg now

Answer:

 D. Prescribe alprazolam 1 mg now

Alprazolam is a benzodiazepine used to treat anxiety and panic attacks. Jennifer seems to be

having a panic attack since her respiratory rate and pulse are elevated. Her blood pressure is

however within the normal range, which rules out bleeding. If she was bleeding, then her blood

pressure would be below normal. It is important to immediately give her alprazolam then later

on after she has calmed down, evaluate her for anxiety disorders.

1 points QUESTION 13

1. Physical examination findings in a patient with pneumothorax is likely to reveal:

A. Increased tactile fremitus B. Low grade temperature C. Hyperresonance to percussion D. Egophany

Answer:

 C. Hyperresonance to percussion

In pneumothorax, the lung is collapse and air is trapped within the pleural cavity. The presence

of trapped air in the pleural cavity increases the resonance heard during percussion. It is the

trapped air that causes Hyperresonance to percussion of the lungs during physical examination

of patients with pneumothorax.

1 points QUESTION 14

1. Mr. Parker brings his 73-year-old wife to a clinic appointment because he is worried about her. She has a long history of hypertension and dyslipidemia, but he says she has taken medication for years and everything has been OK. His concern today is that for a long time she has been very forgetful, and he has tried to help her by keeping a strict routine around the house. Over the past few months, she just seems more and more forgetful, does not seem interested in doing anything, and now seems to be forgetting how to do simple everyday tasks. Yesterday she could not figure out which dollar bills to use at the store to pay the cashier. The AGACNP knows Mrs. Parker should first be screened for: A. Depression B. A brain tumor C. Hypothyroidism D. Adrenal dysfunction

Answer:

 C. Hypothyroidism

Hypothyroidism is associated with both hypertension and dyslipidemia. It is known to cause

difficulty in concentration and memory problems. Mrs. Parker has a medical history of

hypertension and dyslipidemia. She also presents with memory problems. It is therefore

important to screen her for hypothyroidism which is a likely diagnosis from her medical history.

1 points QUESTION 15

1. M.R. is a 40-year-old female who has a known history of peptic ulcer disease. She has been admitted through the emergency room with a diagnosis of GI bleeding—she is vomiting dark blood and

had a nasogastric tube placed. When attached to low intermittent suction it initially drained 400 cc of dark brown/black drainage, but now it is starting to drain lighter red colored blood. The AGACNP knows that immediate priorities of care include: A. Ensuring hemodynamic stability B. Beginning a parenteral proton pump inhibitor C. Beginning gastric lavage D. Ordering a gastrointestinal consult

Answer:

 A. Ensuring haemodynamic stability

The emergency care for patients should start with: Assessing airway, breathing and circulation.

Hemodynamic stability is part of circulation. Thus, the immediate priorities of care for the

patient, from the options given, is Ensuring haemodynamic stability.

1 points QUESTION 16

1. A patient with sharp, stabbing chest pain directly over the precordium has a 12-lead ECG that demonstrates concave ST-T wave elevations in leads II, III, avR, avL, avF, and all six precordial leads. The AGACNP expects which physical finding? A. A grade IV/VI systolic murmur with radiation to the axilla B. A split S2 that increases with inspiration C. A pericardial friction rub D. An S4 heart sound

Answer:

 C. A pericardial friction rub

A sharp, stabbing, chest pain associated with concave SS-T wave elevations in leads II, III, avR,

avL, avF and all the six pericardial leads, suggest a diagnosis of pericarditis. Acute pericarditis is

diagnosed by the presence of a pericardial friction rub. The AGACNP should therefore expect A

pericardial friction rub, since the patient most likely has pericarditis.

1 points QUESTION 17

1. J.Q. is a 45-year-old male who had gastric bypass surgery 18 months ago. A CBC reveals a macrocytic anemia with aHgb of 9.8 g/dL, HCT of 30%, MCV of 115 and RDW of 19%. The AGACNP suspects which type of anemia?

A. Iron deficiency B. Sickle cell anemia C. Pernicious anemia D. Anemia of chronic disease

Answer:

 C. Pernicious anaemia

In the stomach, food mixes with intrinsic factor which increases the absorption of vitamin B12 in

the ileum. However, in patients with gastric bypass, food does not get into the stomach, thus, the

food does not mix with intrinsic factor. Subsequently, there will be decreased absorption of

vitamin B12. Inadequate levels of vitamin B12 causes pernicious anaemia. This type of anaemia

(pernicious anaemia) presents with low haemoglobin count, low hematocrit and an elevated

MCV. Since J.Q has a medical history of gastric bypass surgery, low haemoglobin count, low

hematocrit and an elevated MCV, the AGACNP suspects pernicious anaemia.

1 points QUESTION 18

1. Megan K. is a 21-year-old female who presents complaining of irritated eyes. She says this happens a couple of times a year and this time it is really a problem. Both eyes are itchy and red and she has a lot of stringy discharge, especially at the end of the day. Her visual acuity is 20/25 OS, OD, and OU with her glasses on. Physical exam reveals injected conjunctiva bilaterally but there is no photophobia. Pupils are equal, round, briskly reactive, and accommodate. The AGACNP knows that immediate treatment should include ophthalmic application of: A. Steroids B. Antihistamine C. Antibiotic D. Cycloplegic

1 points Answer:

 C. Antibiotic

Megan most likely has bacterial conjuctivitis. Conjunctivitis is often recurrent and occurs

bilaterally. The diagnosis of conjunctivitis is supported by Megan's red itchy eyes, bilaterally,

which occurs on-and-off. The stringy discharge indicates that the infection is bacterial. Thus, the

immediate treatment should include antibiotic therapy.

QUESTION 19

1. Ellen is a 61-year-old female who presents with a chief complaint of neck pain. The history of present illness reveals that Ellen felt as though a bug bit her behind the neck a few days ago. A day or two later it started to hurt, and when she began to pick at it she felt drainage come out. She is here now for evaluation. Physical exam reveals an 8 cm x 8 cm draining abscess in the right post auricular region with posterior cervical lymphadenopathy. Ellen has a temperature today of 101.9° F. The AGACNP knows that in addition to incision and drainage of the abscess, effective management must include: A. Systemic antibiotics B. Tetanus immune globulin C. Tetanus toxoid D. Antipyretics

Answer:

 A. Systemic antibiotics

Ellen's body temperature is high; she has a fever which suggests an infection. This means that the

infection has infiltrated into her systemic circulatory system. Also, the lympadenopathy suggests

that her lymphatic system is affected. Thus, it is important to give her systemic antibiotics in

addition to performing an incision and drainage.

QUESTION 20

1. A 13-year-old male presents with a chief complaint of ear drainage. The patient and his mother both indicate that the patient has not had any pain or any systemic complaints, but the pus-like discharge from the ear is very persistent. According to Mom they went to a retail clinic two weeks ago and the patient was prescribed both oral antibiotics and ear drops, but it didn’t help. Physical exam of the ear reveals a painless pinna; otoscope exam reveals only a large amount of mucopurulent drainage —the tympanic membrane could not be visualized. The AGACNP knows the diagnosis is most likely: A. Acute otitis media B. Acute otitis externa C. Cholesteatoma D. Otitis media with effusion

Answer:

 A. Acute Otitis Media

Middle ear infections such as acute otitis media do not respond to antibiotics or eardrops. They

often resolve on their own.

Acute otitis media presents with pus-like discharge and a painless pinna. The associated muco-

purulent discharge is known as otorrhea.

QUESTION 21

1. A 71-year-old male patient with lung cancer is admitted for treatment of sepsis related to his chemotherapy-induced immunosuppression. He seems to be improving from an infectious perspective, but during today’s assessment the AGACNP appreciates coarse rales in the lung fields, a blood pressure of 140-100 mm Hg, a bounding pulse, and trace pretibial edema. The urine output via Foley catheter has only been 100 mL in the last 8 hours. Suspicious for syndrome of inappropriate antidiuretic hormone (SIADH), the AGACNP orders a basic metabolic panel anticipating which of the following abnormalities? A. Hypokalemia B. Hypocalcemia C. Hyponatremia D. Hypochloremia

Answer:

 C. Hyponatremia

From the physical assessment findings (edema and bounding pulse) and the low urine output, the

patient seems to having acute renal failure. The syndrome of inappropriate antidiuretic hormone

(SIADH) causes increased production of ADH. The excess ADH produced causes more water to

be reabsorbed along the kidney tubules. As water is reabsorbed, it dilutes the intracellular

sodium, thereby causing hyponatremia. The AGACNP should thus anticipate hyponatremia.

QUESTION 22

1. A crescendo-decrescendo systolic murmur best appreciated at the second intercostal space, right sternal border with radiation to the carotid artery is most likely an indicator of: A. Aortic stenosis B. Aortic regurgitation C. Tricuspid stenosis D. Tricuspid regurgitation

Answer:

 A. Aortic stenosis

Stenosis of the aortic valve produces a crescendo/decrescendo systolic murmur that can be

appreciated by auscultating the second intercoastal space, right sternal border. The murmur can

sometimes radiate to the carotid artery.

QUESTION 23

1. The AGACNP knows that diagnostic findings consistent with rheumatoid arthritis include: A. Soft tissue swelling of the metacarpals B. Radiographic joint space narrowing C. Heberden’s nodes D. Subungal hemorrhages

Answer:

Correct answer is :

A. Soft tissue swelling of metacarpals.

Rheumatoid arthritis is an autoimmune disorder that involve the body immune system attacking

the joint lining resulting to inflammed joint lining, swollen and painful joint. The condition

causes symmetrical joint swelling that persist over a long period of time. The most commonly

joints are proximal interphalangeal and metacarpophalangeal joints of hands, wrist, feet joints,

shoulder, elbow, knees and ankle.

On examination the soft tissue swelling of metacarpals can be seen by use of scanning device

such as x-ray.

QUESTION 24

1. C.T. is a 39-year-old female who presents for evaluation of what she thinks is her “rosacea acting up.” She has a history of acne rosacea and has medicated on and off for years with tetracycline and topical metronidazole. Today however she presents with a pronounced red/purple area on her left cheek extending to the nasal border. It is very warm to the touch. The borders of the affected area are very well defined and raised. C.T. also has a temperature of 100.7° F and a generalized headache. The AGACNP appreciates tender submandibular and cervical lymphadenopathy. The likely diagnosis is: A. Complex rosacea B. Cellulitis C. Erysipelas D. Allergic reaction

Answer:

 A. Complex rosacea

Since C.T has a medical history of rosacea, she is most likely experiencing a recurrence of the

infection. Rosacea is characterized with fever, and red/purples lesions which feel warm to touch.

The complex rosacea forms well defined, raised lesion. The complicated form if the infection,

which appears to be what C.T has, is known as rosacea fulminans. It is a complex form of

rosacea.

QUESTION 25

1. Mr. Lopez is a 51-year-old male patient who is being treated for T2DM. His HgbA1c is 15.6% and initial management will include aggressive attempts for weight reduction as his body mass index (BMI) is
2. He says he is unable to participate in any meaningful exercise because he very often has back pain; he has had it for years and has tried all sort of over the counter medicines with little relief. He describes it as a profound ache that occurs across the lower part of his back bilaterally; it does not travel down either leg. The physical inspection is normal, but he has significant paraspinal tenderness to palpation bilaterally. He cannot identify any injury or accident that preceded the pain. The history and physical exam is noncontributory. The AGACP knows that the likely diagnosis is: A. Lumbar radiculopathy B. Ankylosing spondylitis C. Lumbar sacral strain D. Degenerative disk disease

Answer:

 D. Degenerative disk disease

A degenerative disc presents with local pain and tenderness, along the spine, that does not radiate

to any region or respond to over the counter pain killers. It is worth noting that type 2 Diabetes

mellitus causes degeneration of the lumbar intervertebral disc. Since Mr. Lopez has a medical

history of type 2 diabetes mellitus, and his back pain is localized in his lower back, the most

likely diagnosis lumbar intervertebral disc degeneration.

In lumbar radiculopathy, the pain radiates to the lower limbs while in ankylosing spondilytis, the

pain is from the neck to the lower back. Lumbar sacral strain affects both the lumbar and sacral

regions.

QUESTION 26

1. A patient presents with acute onset of vesicular lesions on her vulva. They are surrounded by areas of redness and they hurt. The patient says that she has even more of them now then she did when she woke up this morning. There is also inguinal lymphadenopathy. The AGACNP is suspicious for: A. Human papilloma virus B. Primary syphilis C. Gonorrhea

D. Herpes simplex virus

Answer:

 D. Herpes Simplex Virus

The Herpes Simplex Virus infection has an acute onset. It presents with painful vesicular lesions

that progress rapidly. The type 2 herpes simplex virus affects the genitalia, including the vulva. It

can also affect the surrounding lymphnodes (such as the inguinal lymphnodes) and cause

inguinal lymphadenopathy.

QUESTION 27

1. Classic radiographic features of osteoarthritis include: A. Soft tissue swelling B. Joint deformity C. Bone mineral loss D. Joint space narrowing

Answer:

Answer is D (Joint space narrowing)

The specific and significant radiographic feature of the Osteoarthritis are Osteophyte formation,

Joint space narrowing , subchondral sclerosis and cysts.

QUESTION 28

1. Mrs. Sandoval is a 72-year-old female who presents with a chief complaint of transient verbal confusion. She was speaking with her friend on the phone this morning when she suddenly couldn’t get words out. Her friend went over to her home and found Mrs. Sandoval awake, alert, and oriented, responding appropriately with non-verbal gestures, but she could not properly articulate her thoughts. By the time she arrived at the office this had passed, although during the examination she appeared to have infrequent difficulty finding a single word. The patient denies any contributory medical history, but a 12-lead ECG in the office reveals atrial fibrillation with a ventricular response of 91 b.p.m. The blood pressure is 140/94 mm Hg; remaining vital signs are normal. The AGACNP knows that management should include: A. Antiplatelet therapy B. Anticoagulation C. Blood pressure control D. Speech therapy

Answer:

 C. Blood pressure control

High blood pressure (hypertension) involves a systolic pressure of 140 or more and a diastolic

pressure of 90 or more. Since Mrs. Sandoval's blood pressure is a systolic pressure of 140 and

diastolic pressure of 94, then she has high blood pressure. Thus, blood pressure control should be

part of her management.

QUESTION 29

1. C.L. is a 48-year-old female who presents complaining of activity intolerance. She is usually very active and fit^. She jogs regularly and typically does 4-5 miles a day. About a week ago she became so tired she had to stop, and lately she has become aware of becoming easily fatigued while going up and down stairs. She admits that she thinks she is beginning menopause—she is having a lot of bleeding with her periods, and her periods seem to be more frequent. A complete blood count (CBC) reveals the following results: Hgb 10.1 g/dL Hct 30% MCV 75 fL RDW 21% The AGACNP orders which of the following laboratory test to confirm the suspected diagnosis? A. Vitamin B B. Folate C. Ferritin D. Hemoglobin electrophoresis

Answer:

 C. Ferritin

From C.L's medical history, the suspected diagnosis is iron-deficiency anaemia. She looses

excess blood during periods and this cause iron deficiency anaemia. Patients with iron deficiency

anaemia have low haemoglobin count and low hematocrit levels. Iron deficiency anaemia is also

characterized by easy fatiguability and activity intolerance. To asses a patient for iron deficiency

anaemia, their ferritin levels should be assessed. Ferritin levels below 30microgram/L confirm a

diagnosis of iron deficiency anaemia.

QUESTION 30

1. Kevin H. is a 61-year-old male who presents for treatment of profound anxiety. He has been treated on and off for years—most recently he was taking escitalopram 20 mg p.o. daily, and although

he does admit to some improvement, he still cannot function appropriately thoughout the day. He has been counseled about poor work performance and is concerned about losing his job, but he is just so worried all of the time he cannot concentrate on work. The AGACNP knows that the most appropriate action is to: A. Increase the dose of escitalopram to 40 mg daily B. Refer Kevin for a psychiatric consultation C. Stop escitalopram and begin venlafaxine D. Discuss therapeutic expectations with Kevin

Answer:

 B. Refer Kevin for a psychiatric consult

Kevin's treatment for anxiety disorder seems to have failed. Increasing the dose of escitalopram

to 40mg daily is likely to cause damage to his liver. Escitalopram should also not be stopped

immediately when changing treatment to venlafaxine. It should instead be reduced first to 10mg

daily then tapered off gradually. Since the AGACNP has not specialized in psychiatric disorders,

instead of discussing the therapeutic expectations with Kevin, he/she should Refer Kevin for a

psychiatric consult.

QUESTION 31

1. When examining a patient with a skin presentation suggestive of necrotizing fasciitis, the AGACNP knows that the most important and sensitive diagnostic test is: A. A complete blood count B. Plain film radiographs C. The finger test D. CT scan

Answer:

 C. The finger test

An AGACNP should perform the finger test when they are suspecting necrotizing fasciitis.

During the finger test, local anaesthesia is applied on the affected skin, then an incision of 2cm is

made on the skin, to the depth of the deep fascia. A gentle, probing maneuver is then done using

the index finger. If the skin dissects with minimal resistance, then the finger test is said to be

positive. A positive finger test indicates the diagnosis of necrotizing fasciitis.

QUESTION 32

1. While evaluating a patient with abdominal pain, the AGACP knows that when the pain is described as coming in waves or cycles, with periods of relief in between, the cause likely centers around: A. Peristalsis of bowel B. Disorders of pelvic organs C. Organ inflammation D. Hyperacidity

Answer:

 A. Peristalsis of bowel

Peristalsis of the bowel occurs in intermittent waves. During each wave/cycle of peristalsis, there

can be an accompanying pain which could indicate that the peristaltic process is the central cause

if the pain.

It is therefore right to suspect peristalsis of the bowel as a cause of pain that comes in waves,

with intermittent periods of relief, since this is the pattern of peristaltic movements.

QUESTION 33

1. Which of the following findings is not typically associated with testicular torsion? A. Acute pain B. Edema C. High riding testis D. Dysuria QUESTION 34
2. 152: When completing this exam, did you comply with Walden University’s Code of Conduct including the expectations for academic integrity? Yes No 1 points QUESTION 35
3. While preparing to perform an incision and drainage on a 7 cm fluctuant abscess on a patients posterior thorax, the AGACNP knows that the most important part of the procedure is: A. Immediate coverage with antistaphylococcal antibiotics

B. Maintaining sterility with topical betadine and drapes C. Breaking up loculations and aggressive irrigation D. Proper injection of local anesthetic

Answer:

 A. Immediate coverage with antistaphylococcal antibiotics

When draining an abscess, the infective organism can infiltrate into the surrounding tissue and

blood to cause a systemic infection. It is thus important to cover the patient with

antistaphylococcal antibiotics so as to protect them from sepsis in case the bacteria infiltrates

into the blood. This is the most important procedure when preparing the patient for incision and

drainage of a fluctuant abscess.

QUESTION 36

1. A patient is being evaluated with significant nausea, fatigue, and a general sense of feeling unwell; mild jaundice is noted on physical examination. Transaminases are markedly elevated and a hepatitis screening is done. Results are as follows:

• HbsAb
• anti-HAV IgM

• anti-HCV The correct interpretation of these findings is: A. The patient has acute hepatitis A B. The patient has acute hepatitis B C. The patient has chronic hepatitis B D. The patient has acute hepatitis C

Answer:

The correct interpretation of these findings is:

C. The patient has chronic hepatitis B.

Chronic hepatitis B represents with the following features:

Nausea, fatigue, malaise, general sence of feeling unwell, juandice as clinical symptoms.

There is increase in serum transaminase, elevated bilirubin, positive hepatitis B surface antigen

(HBsAg), presence of hepatitis B e antigen (HBeAg), HBV DNA, and also immunoglobulin M

antibody to hepatitis B core antigen positive (IgM anti-HBc).

Acute hepatitis B is mostly clinically asymptomatic and the body eliminates it without the patient

experiencing any symptoms. The symptoms of hepatitis B will only be realized after it progress

to chronic phase in most patients.

QUESTION 37

1. When treating a patient with an unknown overdose or toxicity, the AGACNP knows that all of the following should be administered except: A. Dextrose 50% B. Thiamine 100 mg C. Nalaxone 0.4 mg D. Ativan 4 mg

Answer:

 D. Antivan 4mg.

Patients with overdose or toxicity often have a decline in functionality of body systems, for

instance, an abnormally low blood pressure or respiratory rate. Antivan has an effect of

suppressing the respiratory center and the cardiovascular system. Thus it will case further

decrease in the rate of respiration and blood pressure. It should therefore not he given to patients

with overdose or toxicity.

However, dextrose 50%,_thiamine and nalaxone can be administered to improve the health status

of patients with overdose or toxicity.

QUESTION 38

1. The AGACNP is evaluating 29-year-old female who presents by ambulance and is unresponsive. There is no witness and no history available; the patient is not wearing any sort of medic alert bracelet. While assessing for toxicity or overdose, the patient is found to have vital signs as follows: Temp of 96.2° F, pulse of 48 b.p.m., respirations of 10 b.p.m., and blood pressure of 84/50 mm Hg. The patient’s pupils are constricted, but do react briskly to light to 1 mm. The AGACNP suspects which type of substance? A. Cholinesterase inhibiting drugs B. Stimulants such as MDMA C. Anticholinergics D. Ethanol or opiates

Answer:

 D. Ethanol or opiates

Ethanol and opiates toxicity trigger the parasympathetic nervous system which resulted into

constriction of the pupil, lower blood pressure, lower pulse and lower respiratory rate.

This particular patient has all of these symptoms (constriction of the pupil, lower blood pressure,

lower pulse and lower respiratory rate), thus, the AGACNP should suspect Ethanol or opiates

toxicity.

QUESTION 39

1. The AGACNP knows that the one class of pain medication that is effective to some extent for all forms of pain is: A. NSAIDs B. Antidepressants C. Antiepileptics D. Opiates

Answer:

 D. Opiates

Opiates are often used for the management of chronic pain. However, they can also be used for

acute pain. They are generally effective, to some extent, to all forms of pain.

NSAIDs are only effective for acute pain and not chronic pain. Antidepressants and

antiepileptics are not pain killers.

QUESTION 40

1. K.P. is a 76-year-old male admitted for antibiotic management of urosepsis. His medical history is significant for a CVA with resultant right-sided hemiparesis. He is nonverbal, maintained on enteral nutritional support and has an indwelling Foley catheter. The AGACNP knows that which of the following bacteria is the primary treatment target for this patient’s urosepsis? A. Proteus mirabilis B. Pseudomonas aeruginosa C. Staphylococcus aureus D. Streptococcus pneumoniae

Answer:

 A. Proteus mirabilis

Proteus mirabilis is a common cause of catheter-associated urinary tract infections. Infections

by Proteus mirabilis often complicate into bacteremia.

K.P. has an indwelling Foley's catheter which predisposes him to Proteus mirabilis. The

urosepsis that he suffers from indicates that he has bacteremia. Since both catheters and

bacteremia are associated with Proteus mirabilis infection, K.P most likely suffers from Proteus

mirabilis infection. This infection should thus be the primary treatment target.

QUESTION 41

1. A patient is admitted for a COPD exacerbation and placed on mechanical ventilation. His settings are as follows: FiO2 of 40%, TV of 700mL, SIMV of 12. His morning ABG reveals a pH of 7.37, paCO2 of 51 mm Hg, paO2 of 84 mm Hg and HCO3 of 30 mm Hg. The AGACNP knows that the appropriate response is to: A. Leave the ventilator settings as is B. Increase the SIMV to 16 b.p.m. C. Increase the FiO2 to 50% D. Repeat the ABG in one hour

Answer:

 A. Leave the ventilator setting as is

The pH of 7.37 suggests that the patient has alkalosis. Since the PaCO2 and HCO3 are elevated,

it shows that the alkalosis is compensated. Thus, the patient has compensated respiratory

alkalosis. Treatment is administer to patients with compensated respiratory alkalosis, only if their

pH rises above 7.5. For this particular patient, the pH is 7.37; thus, the AGACNP should Leave

the ventilator setting as is.

QUESTION 42

1. All of the following are required for a diagnosis of systemic inflammatory response syndrome (SIRS) except: A. White blood cell count < 4000 or > 12,000 cells/uL B. Heart rate > 90 b.p.m. C. Respiratory rate > 20 b.p.m. or paCO2 < 32 mm Hg D. Two sets of positive blood cultures

Answer:

 D. Two sets of positive blood cultures

The criteria for the diagnosis of systemic inflammatory response syndrome includes any 2 or

more of the following:

 White blood cell count <4,000 or > 12,000 cells/uL or >10% of band cells

 A heart rate of more than 90 beats per minute.

 A respiratory rate of more than 20 breaths per minute or paCO2 less than 32mmHg

 A temperature that is more than 38 degrees Celsius or less than 36 degrees Celsius.



The option that is not required for a diagnosis of systemic inflammatory response syndrome is:

D. Two sets of positive blood cultures

QUESTION 43

1. J.T. is a 41-year-old female patient who presents with a chief complaint of “heartburn.” She says that it doesn’t really seem to be related to meals or food—it occurs at random times. She does note, when asked, that it seems to happen a lot at night and occasionally wakes her up. Her only other symptom complaint is an occasional cough. It does not produce mucus, and she admits to assuming it was a “nervous” cough. The next appropriate action for the AGACNP would be to: A. Order an H. pylori test B. Request a GI consult for endoscopy C. Order a proton pump inhibitor 30 minutes before breakfast D. Request a 72-hour diet history

Answer:

 B. Request a GI consult for endoscopy

The hurtburn is most likely due to GERD (Gastro-eosophageal reflux disease). It occurs at night

because when the patient is horizontally lying on bed, the esophageal sphincter allows reflux of

gastric/stomach contents back into the esophagus. This could make the hydrochloric acid from

the stomach to cause ulceration of the esophageal mucosal lining. The patient thus presents with

a hurtburn. It is therefore important to do an endoscopy so as to asses the esophagus for any

ulceration and to examine the functionality of the esophageal sphincter.

Since the hurtburn is not related to the meals taken, it most likely is not caused by dietary factors.

QUESTION 44

1. Your patient has diabetes insipidus (DI). Anticipated physical assessment findings include: A. Dry skin, tachycardia, hypertension B. Weak pulse, dry skin, decreased skin turgor C. Thin hair, thready pulse, dry mucous membranes D. Hypothermia, jugular venous distention, bradycardia

Answer:

 B. Weak pulse, dry skin, decreased skin turgor

In diabetes insipidus, the patient excretes a lot of dilute urine. The excess urine excreted means

that the body is loosing a lot of water, resulting into dehydration. Clinical presenting features of

dehydration include: a weak pulse, dry skin and decreased skin turgor. These features are likely

to be present during the physical assessment of a patient with diabetes insipidus.

QUESTION 45

1. The AGACNP is beginning medical management of a patient newly diagnosed with T2DM. The patient has a BMI of 39 and has been unsuccessful in making significant diet and lifestyle changes over the last six months. Other than her weight, her physical examination is essentially within normal limits. Her HgbA1c is 9.5%. A basic metabolic panel is within normal limits. The medication of choice to begin therapy will be: A. A sulfonyurea B. A meglitinide C. A biguanide D. An incretin mimetic

Answer:

C. A biguanide

This patient specifically has difficulty with diet and lifestyle changes so the first line of

treatment would be a biguanide such as metformin. They work by preventing the liver

from converting fats and amino acids to glucose.

QUESTION 46

1. Felty’s syndrome is a condition of immune neutropenia seen sometimes in patients with: A. Polymyalgia rheumatica B. Giant cell arteritis C. Systemic lupus erythematosus D. Rheumatoid arthritis

Answer:

The correct answer is

Question 46

D. Rheumatoid arthritis

Felty's syndrome (FS) is categorized by the triumvirate of seropositive rheumatoid arthritis

(RA) coupled with the destructive splenomegaly, neutropenia and joint involvement. For

this reason, Felty's syndrome is a condition of the immune neutropenia seen sometimes in

patients with rheumatoid arthritis

Reference

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4296472/

QUESTION 47

1. When treating a patient for the profound cough of acute bronchitis, the AGACNP knows that the most appropriate pharmacotherapy consists of: A. An opiate based cough suppressant B. Oral prednisone C. A first generation-antihistamine combination D. An inhaled anticholinergic

Answer:

ANSWER

An opiate based cough suppressant

 Bronchitis is a component of chronic obstructive pulmonary disease. In acute

exacerbation, patients present with profound cough and severe difficulty in breathing due

to the obstructive nature of the disease

 Recommendations in the management of the disease in the acute settings aims at

1. Cough management where Central cough suppressants (eg, codeine and

dextromethorphan) are most appropriate for short-term symptomatic relief of

coughing in acute and chronic bronchitis

2. Pain management where NSAIDs are recommended for mild to moderate pain

3. Bronchodilators (eg, ipratropium bromide and theophylline) recommended for control of

bronchospasm, dyspnea, and chronic cough in stable patients with chronic bronchitis

QUESTION 48

1. Mr. Truman is transferred to the emergency department by ambulance. His wife called 911 this morning because he was acting “funny” when he woke up. Both the patient and his wife went to bed last night at approximately 10:30 and everything was normal. This morning he could not communicate orally and seemed confused about how to ambulate. Upon arrival to the emergency department his vital signs are as follows: Temperature 100.9° F, pulse 89 b.p.m., respirations 14 b.p.m. and blood pressure 168/94 mm Hg. A non-contrast CT scan of the head reveals thrombotic CVA. The AGACNP know that immediate management of this patient should include: A. Thrombolytics

B. IV vasodilators C. Aspirin D. Antiepileptics QUESTION 49

1. Your patient is complaining of profound nausea and vomiting that started at bedtime last night and kept him awake all night long. Early this morning he started having abdominal cramping and explosive diarrhea. Based upon the character of symptoms you are suspicious of infection with Staphylococcus aureus. To assess risk for exposure to this organism, you ask the patient about which meal? A. Breakfast yesterday B. Lunch yesterday C. Dinner yesterday D. Bedtime snack yesterday

Answer:

Question 49

C. Dinner yesterday

The symptoms of Staphylococcus aureus are usually experienced 2-4 hours after eating.

The onset of the symptoms is marked by a feeling of nausea. Since the first symptoms begin

2-4 hours after eating, we will be concerned with dinner yesterday. This is because of

experienced nausea at bedtime. This means he took the meal 2-4 hours ago. This may not

be a bedtime snack considering the time that the symptoms started. Severe abdominal pain

and diarrhea can be experienced 8 hours after eating. Early this morning the patient

started having abdominal pain meaning the meal of concern is yesterday's dinner and not

the snack

Reference

https://academic.oup.com/femsre/article/36/4/815/520403

QUESTION 50

1. D.R. is a 54-year-old male patient who was admitted for the management of cellulitis and treated with parenteral antibiotics. He has not been responding as well as anticipated. During today’s exam the AGACNP appreciates a couple of changes. All of the following indicate the need for immediate surgical evaluation except: A. Skin anesthesia B. Violaceous bullae