Medical Emergencies and Clinical Classifications: A Comprehensive Guide, Exams of Nursing

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FNP ANCC BOARDS EXAM

ACTUAL Questions and

Answers GRADED A+ 2024

What percentage of intussusception cases present without the full classic triad of symptoms? - ANS-⅓ of patients do not pass blood or mucus or develop abdominal mass Name and quantify GINA's 4 clinical classifications of asthma severity - ANS-intermittent= FEV1 >80% predicted mild persistent = FEV1>80% predicted moderate persist=FEV1 60 - 80% predict severe persist= FEV1 <60% predicted MTTS - ANS-Medial Tibial Stress syndrome/fracture AKA shin splints; common in run/jump sports. Typically correlates with sudden increase in training. Focal pain and tenderness @ the medial tibia present with both. Tx: RICE. Pain at rest = likely fracture; get an MRI as plain film will not show stress fx. Refer to ortho if fx present. span of normal adult liver in cm - ANS- 6 to 15 cm in midclavicular line.

Typically <12cm in MDL but up to 15cm is normal. Next steps for pregnant primigravida with low AFP, low estriol and high hCG - ANS-Order ultrasound to eval for down's syndrome as these are classic findings. Dose of Tetanus Immune Globulin (TIG) - ANS- 250 units IM How many doses of Tdap or Td IM needed for protection after clean minor wounds. - ANS-Three doses needed. If <3, unknown, or >10 years since last dose give dose of Tdap or Td for clean minor wounds. No need to give TIG. Non-"clean" minor wounds given both of these if unknown tetanus hx or <3 doses of Tdap/Td. - ANS-Tdap or Td IM & TIG Dirty wounds (puncture, crush injury, soil, saliva, feces, dirt, avulsions, missiles, burns, frostbite) - ANS-If <3 doses Tdap or Td give both Tdap and TIG 250 units. If 3 doses in past, but none in the last 5 years then given Tdap or Td. No need to give TIG If 3 or > doses in the past When to switch from DTap to Tdap in children - ANS-Age 7 or

given Tdap

A woman becomes pregnant and received Tdap during her last pregnancy 1 year ago. When should she receive her next dose. - ANS-Tdap is recommended for each pregnancy. "Getting Tdap between 27 through 36 weeks of pregnancy is 78% more effective at preventing whooping cough in babies younger than 2 months old (CDC)". A person with a hx of anaphylaxis to neomycin should avoid which immunizations (IZ)? - ANS-IPV, MMR, varicella A person with a hx of anaphylaxis to neomycin should avoid which immunizations (IZ)? - ANS-IPV, vaccinia (smallpox) A person with a hx of anaphylaxis to bakers yeast should avoid which immunizations (IZ)? - ANS-Hepatitis B A person with a hx of anaphylaxis to gelatin should avoid which immunizations (IZ)? - ANS-varicella zoster (zostavax) and MMR Epinephrine needs to be on hand for potential anaphylaxis r/t immunization rxn. What other interventions/meds should

be considered during anaphylaxis? - ANS-Supine, 911, give epinephrine: 7.5-15kg: give 0.1 mg IM x 15 to <30 kg: give 0.15mg IM; may repeat in 5 - 15 min x

30 kg or Adult: Epipen 0.3mg/0.3mL IM; may repeat in 5 - 15 min H1/H2 blocker po (diphenhydramine, ranitidine) IV access for fluids, Oxygen. Anticipate ED might give glucagon (if on beta blocker), systemic corticosteroids, bronchodilators s/s anaphylaxis - ANS-Skin: pruritus, urticaria, angioedema Resp: dyspnea, wheezing (bronchospasm), stridor

End-organ dysfunction: hypotension, collapse, syncope, incontinence PCV- 13 - ANS-Prevnar. Greater protection, Narrower coverage. Pneumococcal conjugate. PCV23 - ANS-lesser protection, broader coverage Which type of vaccine boosts immune response better? conjugate vs. polysaccharide - ANS-conjugate (example: prevnar) Live attenuated (weaned) vaccines - ANS-MMR, Varicella and intranasal Flu-mist. Zostavax is also live. Shingrix is NOT live. When is rotavirus vaccine contraindicated? - ANS-SCID (severe combined immunodeficiency) or hx intussusception Precautions after rotavirus - ANS-hand washing!; viral shed in stool in first week post-vaccination

Shingrix: timing and dosing - ANS-=/> 50 y/o, 2 doses, 2nd dose two to six months after 1st dose. Under age 50 y/o gets shingles; think immunocompromise vs. stress. What month does the CDC release a new vaccination schedule each year? - ANS-Feb What s/s are associated with leukemia? - ANS-fever, wt loss, fatigue, bone pain, bleeding, bruising. What bloodwork should be obtained in suspected leukemia?

• ANS-WBCs >20,000 (think through common causes of leukocytosis: infection, stress, inflammation) --> get a peripheral smear (AKA manual diff) if WBCs >20,000 and with associated anemia; thrombocytopenia; thrombocytosis; enlarged liver, spleen, or lymph nodes; or constitutional symptoms. Which 2 chronic childhood diagnoses are associated with ALL and AML? - ANS-Downs syndrome and neurofibromatosis

What are 3 main risk factors for leukemia - ANS-radiation (equivalent to 2 to 3 CTs), toxin /household pesticide exposure in utero/early childhood. Acute Leukemia: ALL or AML cancer and symptoms/PE findings - ANS- 2 types: Acute Lymphoblastic Leukemia or Acute Myelogenous Leukemia. BLASTs on peripheral smear/bone aspiration in both ALL and AML. AML also presents with Auer rods on peripheral smear. Acute leukemia can also present with leukopenia, combined with anemia or thrombocytopenia Children: fever, lethargy, bleeding, potentially spinal or long bone pain. enlarged spleen, liver, lymphandenopathy. Adults (typically young): fever, fatigue, wt loss. May have anemia related symptoms (chest pain, SOB)

Chronic Leukemia - ANS-Presents in adulthood. predominant cell is mature but does not function normally, CML (chronic myelogenous leukemia) and CLL (chronic lymphocytic leukemia) Look for hepatosplenomegaly and splenomegaly. ; some adults are asymptomatic. WBCs 20,000 to 100, Which type of leukemia presents with the Philadelphia chromosome (BCR-ABL1 fusion gene)? - ANS-Chronic myelogenous leukemia Which type of leukemia is most likely to present in older adults >/= 65y/o? - ANS-CLL (chronic lymphocytic leukemia) In suspected leukemia, what lab work other than CBC should you obtain? - ANS-Serum electrolyte and creatinine levels, LFTs, and coagulation studies. If the patient appears ill or is febrile, the physician should evaluate for infection with urinalysis, urine culture, blood cultures, and chest radiography.

The next step in diagnosis involves a peripheral blood smear and usually a bone marrow specimen (an aspirate or core biopsy). Normal results for TIBC are... - ANS- 250 to 450 mcg/dL for men and women. A normal platelet count ranges - ANS-150,000 to 450, platelets per microliter of blood. Non-Hodgkin's Lymphoma (NHL) s/s - ANS-enlarged lymph nodes, fatigue, weight loss and fever More than 67 types of non-Hodgkin lymphoma; more common than Hodgkins. Impacts lymphocytes. Most cases present >/= 55 y/o, can present in children. typically diagnosed at a later stage than non-hodgkins, NO Reed-Sternberg cells are identified. Hodgkin's Lymphoma s/s - ANS-enlarged lymph nodes, fatigue, weight loss , fever, night sweats

Impacts lymphocytes. Median age 39y/o, often diagnosed in early stage, arise in upper body (neck, chest, armpits, groin). Reed-Sternberg cells are present. The main difference between leukemia and lymphoma - ANS-In leukemia, the cancer cells are mainly in the bone marrow and blood. In lymphoma they tend to be in lymph nodes and other tissues. NT-proBNP (N-Terminal-ProBNP) normal ranges - ANS-No diagnosis of HF: Less than 125 pg/mL for patients aged 0-74 years Less than 450 pg/mL for patients aged 75 - 99 years In heart failure, the following NT-proBNP levels could mean your heart function is unstable: Higher than 450 pg/mL for patients under age 50

Higher than 900 pg/mL for patients age 50 and older what level of serum lead is indicative for lead poisoning? - ANS-↑ lead level (> 5 μg/dL) on venous blood sample. chelation at 40 - 45mcg/dL. peripheral blood smear: microcytic hypochromic anemia. basophilic stippling of RBCs. high iron, high ferritin, low TIBC Normal ESR - ANS-men 10 - 22, women 10 - 29 Classification of ǪTc prolongation - ANS-normal men ≤ ms; women ≤450 ms; borderline men 431-450 ms; women 451 - 470 ms; abnormal men ≥451 ms; women ≥471 ms. What intraoccular pressure correlates with glaucoma? - ANS-Tonometry measuring 22mmHg or greater. Normal range 10 - 21mmHg When does the anterior fontanel close - ANS- 12 - 15 months

When does the posterior fontanel close - ANS- 3 months What snellen chart result requires a referral to an ophthalmologist? When is the soonest one can test with the snellen chart? - ANS-20/40, 6 y/o Myesthenia gravis- pathophysiology & 1st s/s - ANS- antibodies (immune proteins produced by the body's immune system) block, alter, or destroy the receptors for acetylcholine at the neuromuscular junction, which prevents the muscle from contracting. This is most often caused by antibodies to the acetylcholine receptor itself, but antibodies to other proteins, such as MuSK (Muscle-Specific Kinase) protein, also can impair transmission at the neuromuscular junction. 1st s/s might be ptosis weakness after exercise, better after rest. typically 20 - 40 y/o women dip percentages of white blood cell types from most to least. - ANS-Neutrophils - (40-60%)

Lymphocytes - (20-40%) Monocytes - (2-8%) Eosinophils - (1-4%) Basophils - (0.5-1%) Parkinson's disease --path and typical meds. - ANS- Problem: lack of dopamine Motor symptoms (rocks a lots to get out of chair): tx is to increase dopamine with Levodopa. Amantadine, Pramipexole Non-motor symptoms: treat with anticholinergics to alleviate tremor (resting) and rigidity. trihexyphenidyl, benztropine Myerson sign (Glabella tap reflex) Common in which Dz? - ANS-Parkinson's dz. They will blink every time you tap over the bridge of the nose.

Alzheimer's disease pathophysiology, s/s, most commonly prescribed meds - ANS-Lack of Acetylcholine aphasia, apraxia, agnosia. Donepezil (Aricept) is approved to treat all stages of the disease. It's taken once a day as a pill. Galantamine (Razadyne) is approved to treat mild to moderate Alzheimer's. ... Rivastigmine (Exelon) is approved for mild to moderate Alzheimer's disease. The philadelphia chromosome is associated with what disease? - ANS-Philadelphia chromosome (Ph): The chromosome abnormality that causes chronic myeloid leukemia (CML). DM II criteria - ANS- 2 hr post OGTT 75gm load blood glucose

/=200mg/dL, random plasma glucose >/=200mg/dL, fasting plasma glucose >/=126mg/dL, HgA1c >/= 6.5% Independent variable - ANS-being manipulated in the study; it is not affected by the other variables in the study.

Dependent variable - ANS-the variable that changes depending on the manipulation of the independent variable in a study Name the triad of intussusception - ANS-currant jelly stools, sausage-like mass, pain. What percentage of intussusception cases present without the full classic triad of symptoms? - ANS-⅓ of patients do not pass blood or mucus or develop abdominal mass Name and quantify GINA's 4 clinical classifications of asthma severity - ANS-intermittent= FEV1 >80% predicted mild persistent = FEV1>80% predicted moderate persist=FEV1 60 - 80% predict severe persist= FEV1 <60% predicted MTTS - ANS-Medial Tibial Stress syndrome/fracture AKA shin splints; common in run/jump sports. Typically correlates with sudden increase in training. Focal pain and tenderness @ the medial tibia present with both. Tx: RICE. Pain at rest = likely fracture; get an MRI as plain film will not show stress fx. Refer to ortho if fx present.

span of normal adult liver in cm - ANS- 6 to 15 cm in midclavicular line. Typically <12cm in MDL but up to 15cm is normal. Next steps for pregnant primigravida with low AFP, low estriol and high hCG - ANS-Order ultrasound to eval for down's syndrome as these are classic findings. Ddx syncope - ANS-arrhythmia, vasovagal, hypoglycemia, orthostatic hypotension, sz, accidental fall, etc. Somogyi effect - ANS-High glucose upon waking caused by a hypoglycemic event at 2 or 3am which induces glucagon release Are the ovaries sensitive to deep palpation upon bimanual exam? - ANS-The ovaries may be sensitive but NOT painful upon deep palpation. If unilateral adnexal pain is accompanied by CMT and purulent endocervical discharge then suspect PID.

Where are bouchard's nodes and what are they associated with? - ANS-PIP; noted in both OA and RA Polycythemia vera might present with tenderness in which location? - ANS-burning pain hands/feet. It's considered a myeloproliferative neoplasm. Increased erythrocytes (erythrocytosis) and might precent with increased WBCs and platelets as well. When to consider an MRI - ANS-visualization of soft tissues (Cancer, brain, cartilage, muscles, inflammation), tissues with high water content. stress fx Can someone with a cochlear implant have an MRI? - ANS-It depends. Plan ahead and get info from the manufacturer so that patient is prepared. Bacillus anthracis prophylaxis - ANS-Ciprofloxacin or Levofloxacin for 60 days and anthrax vaccine adsorbed (BioThrax) gram + rod after spore contact r/t infected animals or contaminated animal products (hide, wool, hair) or raw animal products. - ANS-Cutaneous anthrax:

GI anthrax Respiratory anthrax Injection anthrax Bell's palsy pain - ANS-may present with ipsilateral eye, jaw, ear or post auricular pain. increased sensitivity to sound on the affected side is possible. HA and decreased taste may accompany the condition. valacyclovir and prednisone for 1 week. s/s pregnancy induced HTN - ANS-facial, UE edema, blurred vision, proteinuria and HAs mean age to ride a bike with training wheels - ANS- 5 to 6 y/o Hegar's sign - ANS-softening of the lower portion of uterus; probable sign of pregnancy

What is contraindicated in placenta previa? - ANS-pelvic exams, rectal exams or TVUS. avoiding activities that might cause contractions, including having sex, douching, using tampons, or engaging in activities that can increase your risk of bleeding, such as running, squatting, and jumping. symptoms of placenta previa - ANS-bright red blood in the 2nd trimester or later WITHOUT pain Atypical PNA radiological pattern includes... Atypical PNA etiologies include... - ANS-Patchy inflammatory changes, often confined to the pulmonary interstitium. Atypical bacterial etiologies such as Mycoplasma pneumoniae, Chlamydophila pneumoniae and Legionella pneumophilia. Viral and fungal pathogens may also create the radiological and clinical picture of atypical pneumonia. Vitamin supplementation of should be recommended for all breastfed infants on their 1st PCP visit

• ANS-400 IU/day of Vitamin D; decreases the risk of rickets. recommend OTC multivitamin supplement or vitamin D supplement.

after TIA (resolution of symptoms within minutes to 2 hrs) what is the approximate risk of stroke? - ANS- 10 - 20% of patients will have a stroke in 90 days. cluster HA ocular symptoms. also list the typical length of HA. - ANS-miosis (constriction), ptosis, tearing. 15- 180 minutes. What risk is associated with MAOIs and aged/fermented foods (high in tyramine) - ANS-HTN crisis Metformin Contraindications/Precautions - ANS-renal, hepatic, ETOH, conditions r/t hypoxia (cardiac/pulmonary), sepsis/dehydration (r/t risk of lactic acidosis), advanced age. What is myxedema? - ANS-"Myxedema is a term generally used to denote severe hypothyroidism. Myxedema is also used to describe the dermatologic changes that occur in hypothyroidism and occasionally hyperthyroidism. In this setting, myxedema refers to deposition of mucopolysaccharides in the dermis, which results in swelling of the affected area. When skin changes occur in hyperthyroidism, mostly Graves disease, it's called pretibial myxedema"- Medscape

What tool should be utilized to diagnose fibromyalgia? - ANS-Widespread Pain Index (American College of Rheumatology) What WPI score and SS scale score is diagnostic for fibromyalgia? - ANS-A patient is diagnosed with fibromyalgia if the following three conditions are met: The WPI score is 7 or higher and the SS scale score is 5 or higher or the WPI is 3 - 6 and the SS scale score is 9 or higher The symptoms have been present at a similar level for at least 3 months The patient does not have another disorder that would otherwise explain his or her pain treatment for polymyalgia rheumatic - ANS-low dose prednisone for 3 month to 3 years as this is a self-limiting illness 3rd trimester pregnancy normal cardiac changes - ANS- systolic ejection murmur d/t increased stroke volume d/t increased cardiac output/higher basal heart rate, laterally displaced apical impulse, louder S1 and S2.

advice for two consecutive days of missing oral contraceptive pills - ANS-2 pills today, 2 pills tomorrow, continue the pack and use of condoms to prevent pregnancy and STIs How does one distinguish between an abd wall mass vs. an intra-abdominal mass? - ANS-abd wall mass (typically a hernia) will become more prominent with tensing the abd wall muscles. If it is an intra-and mass it will be pressed down and become more obvious upon tensing the abd muscles. Relative contraindication for COC - ANS-depression Absolute contraindications for COC - ANS-hepatoma of the liver, hx embolic episodes, undiagnosed vaginal bleeding. referrals to specialists or rehab are considered what type of relationship? - ANS-Collaborative How many wet diapers should a full-term infant have per 24 hrs? - ANS- 6 to 10 diapers

Most common childhood cancer - ANS-ALL (acute lymphoblastic leukemia) Is TLC (total lung capacity) higher or lower in COPD? - ANS- Conventionally, lung hyperinflation is said to exist when the total lung capacity (TLC) is >120% of the predicted value. Marked elevation of the TLC usually means that increased lung compliance, as a result of emphysema, is a primary determinant of lung hyperinflation. testing for celiac dz - ANS-tTG (tissue transglutimase IgA antibody) also consider antigliadin IgA and IgG Which other conditions is celiac dz associated with? - ANS- Downs, turn, williams syndromes; DMI, autoimmune thyroid dz, etc. Is elevated ALP a normal finding in pregnancy and teens? - ANS-Yes.

If bilirubin is 10mg @ 3d old is it okay to monitor? - ANS-Yes, if feeding adequately and 8-10 wet diapers/day. RTC in 1 week for recheck. In what conditions is GGT (gamma glutamyl transaminase) elevated? - ANS-Bile duct obstruction, cholangitis cholecystitis, alchohol abuse. Gastrinomas are... - ANS-tumors in the intestines, pancreas or lymph nodes near the pancreas that produce excessive gastrin. Gastrin increases stomach acid which leads to ulcers in stomach or duodenum. What is clindamycin's drug class? - ANS-lincomycin antibiotic; associated with CDAD (Clostridium difficile- associated diarrhea). Name 2 other med classes associated with CDAD (diarrhea up to 10 weeks without fever). r/o pseudomembranous colitis - ANS-cephalosporins and fluroquinolones What populations are fluroquinolones contraindicated? - ANS-Children and pregnancy.

What to give an elderly patient who was incidentally placed on cimetidine (beers list) and had subsequent neuropsychiatric changes? - ANS-Physostigmine Name additional rationales for avoiding benadryl in the elderly besides risk of confusion. - ANS-It may worsen glaucoma, increase HTN and thickened secretions may be another precaution in the the patient with lung dz. Is an allergy to SULFA drugs a contraindication for sulfonylureas? (glipizide, glyburide, glimepiride) - ANS-NO Prior to starting atypical antipsychotics what lab tests should be obtained? What AE will you monitor for? - ANS- fasting blood glucose, fasting lipid profile, weight. These meds will increase lipid profile and increase risk of obesity, hyperglycemia and DMII. Watch for hypotension and sedation. 1st line drug class for OCD (obsessive-compulsive disorder)

• ANS-SSRI