Geriatric Medicine: Comprehensive Care for Older Adults, Exams of Nursing

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CURRENTLY TESTING SOLUTIONS NR601 Final

EXAM WITH ACTUAL CORRECT DETAILED ANSWERS

You know the following statements regarding the pain of acute coronary syndrome are true except: a. May last longer than 20min b. May radiate to arms, back, neck, jaw c. Present atypically more often in men than women d. May be retrosternal or poorly localized - ANSWER-C You are reviewing a pt chart before the exam. You note that the pt is using topical capsaicin. You know that topical capsaicin is often used for tx of: a. Diabetic neuropathy b. Stress recution c. All answers are appropriate d. Depression - ANSWER-A You order bilat wrist XR on a 69yo man c/o pain in both wrists for 6wks not related to known trauma. You suspect elderly onset rheumatoid arthritis. To guide tx, you look for which radiographic finding? a. Symmetric joint space narrowing

b. Soft tissue swelling c. Subluxation of joints d. Joint erosions - ANSWER-D The leading cause of disability worldwide is: a. Depression b. Lung Ca c. Heart dz d. DM - ANSWER-A RD, 65yo African American female presents for annual physical. You are reviewing VS and objective data prior to exam. Which would raise suspicion for osteoporosis? a. Wt loss of 5lbs b. 1in decrease in ht c. Hair loss d. Decreased appetite - ANSWER-B In differentiating OA from chronic gout, pseudogout, or septic arthritis, the most valuable diagnostic study would be: a. CBC b. CRP c. Synovial fluid analysis d. ESR - ANSWER-C 52yo Caucasian woman comes in for annual exam. She has mitral valve prolapse, no symptoms. PE reveals clear/equal breath sounds, midsystolic click. You know her stage of HF is:

a. A b. B c. D d. C - ANSWER-B (Stage B) Symptoms of depression distinct to elderly include: a. Loss of pleasure in usual activities b. Lack of emotions c. Flat affect d. Appetite/wt disturbances - ANSWER-B LB presents w/following hx and presentation: h/o MI 5yrs ago, currently has SOB, cough, 2+ pitting edema. Tx will be based on LB's stage of HF, which is: a. D b. C c. A d. B - ANSWER-B (Stage C) You ordered a CBC for pt you suspect has PMR. Which 2 findings are common in pt's with PMR? a. Normochromic, normocytic anemia and thrombocytosis b. Macrocytic, hyperchromic anemia and leukocytopenia c. Neutropenia and hypochromic, normocytic anemia d. Microcytic, hypochromic anemia and reticulocytopenia - ANSWER-A An example of secondary prevention you could recommend/order for elderly would be to:

a. Provide foot care for DM pt b. Check for fecal occult blood c. Administer tetanus shot d. Wear seat belts - ANSWER-B ACC 2017 Guidelines for High BP in adults discusses screening/management of other CVD risk factors for hypertensive pts. According to the guideline, basic testing for primary HTN includes fasting BGL, CBC, lipids, BMP, TSH, UA, EKG w/optional echo, uric acid, and urinary albumin-to-creatinine ratio. a. True b. False - ANSWER-A When you recommend exercise for sedentary older adult, which of the following pieces of advice should be considered for all types of exercise? a. Focus only on one type of exercise for the first few months b. Only use equipment recommended by physical trainers c. Only group exercise is beneficial to someone who has not been active in a long time d. Start low and go slow - ANSWER-D You're reviewing CXR report on 56yo male who presented w/increasing SOB. You suspect COPD. you know the dx can be made with a high degree of accuracy if 2 of the following criteria are met:

1. Flattening of diaphragm w/blunting of costophrenic angle on PA film
2. Upper zone redistribution of pulmonary blood flow (cephalization)
3. Abnormally enlarged retrosternal space
4. Signs of interstitial edema - ANSWER-1 and 3 You have completed the first follow up visit for a new COPD pt who is in stable condition. The pt asks how often he needs to follow up for COPD. You state that stable COPD pts should return for follow up eval:

a. Yearly b. Monthly c. Every 3-6mo d. Every 2mo - ANSWER-C When examining the spine of an older adult, you notice a curvature with a sharp angle. This is referred to as a: a. Pectus excavation b. Scoliosis c. Kyphosis d. Lordosis - ANSWER-C (more specifically, this is called a Gibbus, which is a specific condition in regards to kyphosis, but Gibbus wasn't an option) An effective exercise therapy for RA is: a. Yoga and/or Pilates b. Walking 20min daily c. Bicycle riding d. Water exercise programs - ANSWER-D Pt education for COPD is essential. You know that COPD education includes all of the following except: a. Increased risk for DM b. Daily exercise c. Healthy diet d. Smoking cessation - ANSWER-A

The prevalence of depression in nursing home residents is __________ greater than adults living in the community. a. 5 times b. 3-4 times c. 2-3 times d. 1-2 times - ANSWER-B Which of the following statements about OA is true? a. The metacarpal phalangeal joints are commonly involved. b. Prolonged morning stiffness is common. c. It is a systemic inflammatory illness d. It affects primarily weight-bearing joints - ANSWER-D 55yo woman presents with somatic complaints. You suspect anxiety. You know that somatic symptoms of anxiety include: a. All answers are appropriate b. Palpitations, CP, tachycardia c. Fatigue, insomnia, diaphoresis d. Diarrhea, nausea, vomiting - ANSWER-A You know that the gold standard for COPD dx is: a. Spirometry b. Dyspnea, chronic cough w/sputum production c. Irreversible airflow limitation

d. Decreased breath sounds, wheezes at lung bases - ANSWER-A The best evidence rating drugs to consider in a post MI pt include: a. ASA, ACE/ARB, BB, aldosterone blockage b. Long-acting nitrates, warfarin, ACE, ARB c. ASA, plavix, nitrates d. ACE, ARB, CCB, ASA - ANSWER-A 2017 HTN guidelines categorize a healthy 54yo African American woman with a BMI of 23 and consistent BP readings of 120-128/76-78 as: a. Normal BP b. HTN stage 1 c. Elevated BP d. HTN stage 2 - ANSWER-C ACC 2017 guidelines for high BP in adults, adults w/stage 1 HTN and high ASCVD risk should be managed w/both nonpharm and antihypertensive drug therapy. You know the pt should return for a follow up appointment which includes BP check in: a. 3wks b. 1wk c. 1mo d. 2wks - ANSWER-C Mrs. G, 65yo Caucasian, presents for her annual physical. Chart review reveals she smokes 1PPD, drinks 2 beers every evening since she retired. She does not exercise, likes to sit and knit. As part of health maintenance, DEXA was ordered. You have received results, T-score of - 2.0, which is consistent with:

a. Normal result b. Osteopenia c. At risk for fragility fracture d. Osteoporosis - ANSWER-B The purpose of Beers Criteria is to: a. Define Type A reactions b. All answers are appropriate c. Define changes in drug metabolism in elderly d. Improve quality and safety when prescribing meds - ANSWER-D Which best describes pain associated w/OA? a. Pain is persistent and motion can be limited in affect joint b. Dull and primarily affected by exposure to cold/barometric pressure c. Constant burning and throbbing w/acute onset d. Begins upon arising and after prolonged wt bearing and/or use of the joint - ANSWER-A RV is 58yo African American male w/poorly controlled HTN. He hasn't been compliant w/meds, only takes Rx when he has a bad HA or feels like his pressure is high. You know that tx goals include prevention of target organ damage. During your eval you will assess for evidence of: a. Blood clotting disorders b. L ventricular hypertrophy c. Insulin resistance d. Lipid abnormalities - ANSWER-B 59yo woman presents w/following: h/o MI, new onset SOB, especially w/exertion, an occasional rapid fluttering heartbeat and swollen feet. You know this pt's stage of HF is:

a. Stage A b. Stage B c. Stage D d. Stage C - ANSWER-D (stage C) IW is 65yo man who is new to your practice. He has h/o COPD, CAD, HTN, T2DM. He has had no immunizations since his discharge from the military at 25yo. Childhood dz's include chickenpox, measles, mumps, and German measles. He presents for dz management visit. Which immunizations would you recommend for him? a. Influenza, pneumococcal, PPD, Hep B b. Tdap, pneumococcal, influenza, Zostavax c. Hep B, influenza, pneumococcal, Hep A d. MMR, influenza, pneumococcal, Zostavax - ANSWER-B You're working with an older male w/a long h/o ETOH abuse and 30yr h/o smoking. In recommending an intervention for him, your responsibility is to: a. Make him abandon his own health practices and follow your recommendations b. ID the barriers he will encounter c. Register him for local intervention program and secure payments d. Promote positive change in lifestyle changes - ANSWER-D OA of the cervical and lumbar spine causes pain that is related to all of the following except: a. Bone spur formation b. Pressure of the ligaments c. Crystal deposition d. Reactive muscle spasm - ANSWER-C

55yo Caucasian man follows up w/you after referral to cardio. He reports that he thinks the med is causing a cough and sometimes he has dyspnea. Which of the following meds was most likely prescribed? a. Metolazone b. Enalapril c. Amlodipine d. Irbesartan - ANSWER-B Mrs. F is a 65yo Caucasian who presents for her annual exam. Chart review reveals she smokes 1PPD, drinks 2 beers/day since retirement. She doesn't exercise but likes to sit and knit. You know the nonmodifiable risk factor for OA is: a. ETOH consumption b. Tobacco use c. Age d. Sedentary lifestyle - ANSWER-C You review a CXR report on 56yo male who c/o increasing SOB. You suspect HF. You know the dx can be made with a high degree of accuracy if 2 of the following criteria are met:

1. Flattening of the diaphragm w/blunting of the costrophrenic angle on PA film
2. Upper zone redistribution of pulmonary blood flow (cephalization)
3. Abnormally enlarged retrosternal space
4. Signs of interstitial edema - ANSWER-2 and 4 All of the following statements are true regarding anxiety except: a. Common in older adults

b. Often co-occurs w/depression c. Is a normal part of aging d. More common in females - ANSWER-C Postmenopausal woman w/osteoporosis is taking a bisphosphonate daily by mouth. What action info statement would indicate the pt understood your instructions? a. Take med when up in AM w/glass of OJ to increase absorption b. Take med w/full glass of water when up in AM 30min before other food and meds c. Take med at bedtime w/full glass of water d. Take med sitting up with a meal to avoid GI distress - ANSWER-B KK, 53yo man, presents w/concerns about low energy, lack of joy. You assess him using SIG-E-CAPS. You know the C stands for: a. Catatonia b. Concentration c. Cognition d. Control - ANSWER-B Which best describes the pain associated w/RA? a. Constant, burning, throbbing w/acute onset b. Begins early in the AM, gradually improves throughout day c. Begins after prolonged wt bearing and/or use of joint d. Dull and primarily affected by exposure to cold and barometric pressure - ANSWER-B Pt presents w/neuropathic pain. You know the most effective meds include:

a. Opioids & tramadol b. Gabapentin c. Tramadol d. Topical lidocaine e. Opioids f. Gabapentin and topical lidocaine - ANSWER-F According to 2017 Guidelines for HTN in adults, recommended BP goal for 68yo Asian American woman w/no h/o DM and a h/o CKD is: a. <150/ b. <120/ c. <140/ d. <130/80 - ANSWER-D You see a new pt for acute care visit. She is 68yo Caucasian who is dx'd w/PMR. You prescribe corticosteroids and will continue tx until the condition has resolved. You look over her records and note it has been 2yrs since her last exam and labs/diagnostic tests. In prioritizing your health maintenance management plan, your orders today should include: a. DEXA and updating vax b. Recommending increased dietary intake of Calcium and vit D c. Ordering once a year bisphosphonate and PPI d. Participate in a fall prevention program - ANSWER-A JK, 60yo woman, returns for eval of management plan for insomnia. You saw her 2wks ago, dx'd primary insomnia and recommended melatonin. JK reports she is taking it nightly, avoiding caffeine/ETOH, and is falling asleep but not staying asleep. She wakes up after about 4hrs and cannot return to sleep. Next step is: a. Zolpidem 5mg PO HS #7 w/no refills

b. Eszopiclone 1mg PO HS #30 w/5 refills c. Ramelteon 8mg PO HS #21 w/no refills d. Zolpidem 5mg PO HS #30 w/3 refills - ANSWER-A CC, 62yo male, new to your practice. Previously dx'd w/Stage B HF. According to week 2 HF lecture, you'll look for the following med classes to ensure appropriate tx of HF: a. ACE/ARB, statin, BB b. ACE/ARB c. BB - ANSWER-A JM, 68yo males, presents for physical. He has T2DM x5yrs, smokes 1/2PPD, BMI 30. No other hx, no current complaints. According to AHA/ACC guidelines, JM is Stage A. Tx goals include: a. Control symptoms b. Heart healthy lifestyle c. Diuresis to relieve symptoms of congestion d. Prevent further cardiac remodeling - ANSWER-B Lifestyle modifications for managing HTN include all of the following except: a. DASH diet b. Wt reduction c. HCTZ d. Physical activity - ANSWER-C PG is a 58yo Caucasian man w/stable mental health dx of schizophrenia who presents for yearly physical. He takes aripiprazole for. You know the labs and assessments should be ordered to assess for cardiometabolic changes related to his meds except for:

a. Waist circumference b. Glucose c. Cholesterol d. AST/ALT - ANSWER-D Which organism that can be prevented by vax is most often responsible for infectious "outbreak" in nursing homes? a. Influenza A b. Haemophilus influenza c. Mycobacterium tuberculosis d. Streptococcus - ANSWER-A Justification for ordering CBC, TSH, serum B12 for a pt you suspect may have clinical depression is: a. Overlapping symptoms w/anemia, thyroid dysfunction, nutritional deficiencies b. Rule out vascular dz c. Differentiate between depression and anxiety d. Determine the cause of sadness - ANSWER-A 65yo woman w/BMI 29, 15yr h/o HTN, on HCTZ 25mg for years w/excellent response. Follow up visit: reports that for last 1-2mo, she has been thirsty, increased urination. Last fasting BGL was 118. What action should you take next? a. Plan to recheck BGL as scheduled at yearly physical b. Check POC glucose now, since she has just eaten breakfast c. Educate that the diuretic is causing the increased thirst d. Order fasting BGL - ANSWER-D 48yo female presents for annual exam. A1C is 6.2%. You interpret this result as:

a. Prediabetes b. T2DM c. T1DM d. Normal - ANSWER-A Foot problems are a major concern for diabetics due to vascular insufficiency and neuropathy. Part of the annual exam for detection of neuropathy should include: a. Monofilament testing b. Assess for loss of temp sensation c. Physical exam of feet d. POC glucose - ANSWER-A Pt with BPH is seen for follow-up, has been taking finasteride (Proscar) for 6mo. You should assess for which side effect: a. Glaucoma b. Headache c. Ejaculatory dysfunction d. HTN - ANSWER-C Pt is prescribed metformin (Glucophage). Three days later, he c/o nausea and stomach cramping. How should you respond? a. D/C med immediately b. Reassure pt that this is anticipated side effect c. Double the dosage and have pt return in 1 wk d. Order chem 7 to check for lactic acidosis - ANSWER-B

According to ADA guidelines, which of the following are appropriate screening tests for T2DM? a. Fasting plasma glucose b. 2-hour OGTT c. HgbA1C d. All of the above - ANSWER-D Which dx should be considered in a pt presenting with erectile dysfunction? a. HTN b. DM c. Atherosclerosis d. All of the above - ANSWER-D Which would be an appropriate tx for pt with minimal symptoms of BPH? a. Watchful waiting b. Refer to urology for surgery c. Prescribe trial of tamsulosin d. Recommend cranberry supplements - ANSWER-A Lifestyle approaches to postmenopausal symptom management include: a. Avoiding sugar, caffeine, chocolate, ETOH b. Sleeping more than 8hrs per night c. Decreasing levels of physical activity d. More than 1000 iu/day of Vit E - ANSWER-A

59yo female c/o pain when she urinates. She has been seen three times for this in the last 3mo. Each time, dx'd with UTI, given abx. She carefully followed instructions, but has no relief of symptoms. Last UA: WBC: 2- 3 RBC: 0- 2 Epithelial cells: few Nitrite: neg Leuk: neg Which should be done next? a. Perform pelvic exam b. Reassure the pt that she has asymptomatic bacteriuria and does not need abx c. Obtain clean catch urin for UA and C&S d. Order pelvic ultrasound - ANSWER-A Which pt should be screened for DM? a. 47yo Caucasian male w/HTN b. 45yo female on disability from back injury, unable to exercise c. Hispanic man, BMI 26 d. Overweight middle-aged African American woman w/fam h/o T2DM e. All of the above - ANSWER-E According to the GU presentation, #1 risk factor for urinary incontinence is: a. Uncontrolled DM b. Obesity c. Aging

d. Smoking and caffeine intake - ANSWER-C Which med can blunt the signs of hypoglycemia in diabetics? a. Beta blockers b. ARBs c. CCBs d. Diuretics - ANSWER-A What is a sign of insulin resistance that can present in African American pts? a. Seborrheic Nigricans b. Psoriasis Nigricans c. Bullemic Nigricans d. Acanthosis Nigricans - ANSWER-D All of the following pts have a risk of adverse reaction from Metformin except: a. Pts w/alcoholic disorder b. Pts w/BMI > c. Pts w/hypoxia d. Pts w/renal dz - ANSWER-B Pt presents with sudden, compelling desire to pass urine that is difficult to prevent. This type of incontinence is cause by: a. Impaired mobility b. Detrusor overactivity c. Urethral hypermobility

d. Weakness of the pelvic floor muscle - ANSWER-B 55yo woman w/BMI of 28, has 20yr h/o primary HTN, has been on HCTZ 25mg for years w/excellent response. During this follow up visit, she reports that for the last 6mo she has felt thirsty all of the time even though she drinks at least 10 glasses of water/day. Previous fasting BGL was 136. No further testing was done at that time. You check random BGL now, is 210. What is the next appropriate step? a. Order 3hr OGTT b. Order another random BGL in 2wks c. Order A1C d. Prescribe metformin XR 500mg PO - ANSWER-D Acanthosis Nigricans is associated with all of the following except: a. Colon cancer b. Tinea versicolor c. Obesity d. DM - ANSWER-B 66yo dx'd with acute prostatitis, afebrile w/out severe pain, deemed appropriate to be managed outpt. An appropriate initial treatment option for mild case is: a. Septra x6wks b. Cipro x10-14 days c. Bactrim x14 days d. Levaquin x3wks - ANSWER-B 55yo Caucasian man w/T2DM presents as new pt. Take metformin 500mg BID. Labs reveal albuminuria and A1C was 7%. He's current on eye/foot exams. BP today is 136/84. According to 2017 ACC Guidelines, the most appropriate med for his current status is:

a. Furosemide b. Amlodipine c. Lisinopril d. Clonidine - ANSWER-C Urinary incontinence is defined as: a. Sudden, compelling desire to pass urine that is difficult to prevent. b. Urination occurs more frequently during the day than what would be considered normal c. Continuous loss of urine or leakage of urine d. Unintentional voiding, loss, or leakage of urine - ANSWER-D How does women's anatomy make them more susceptible to UTIs? a. Their urethras are shorter b. There's a longer distance between urethra and anus c. Women tend to get UTIs when pregnant d. Asymptomatic UTIs do not resolve themselves w/out tx - ANSWER-A 76yo man seen for c/o UI. You should explore which of these causes of UI in men? a. UTI b. Sildenafil c. Urethral polyps d. All of the above - ANSWER-A Male pt with BMI of 30 presents with c/o fatigue, increased hunger, wt gain despite exercise. You suspect prediabetes. Initial testing to confirm can include:

a. Fasting plasma BGL b. A1C c. OGTT d. All of the above - ANSWER-D Mr. X returns to office for follow-up of first line tx of UI. He reports continued UI despite compliance w/first line measures. PE and lab findings today are normal. You initiate 2nd line tx and prescribe: a. Morabegron b. Solifenacin c. Oxybutynin d. Doxazosin - ANSWER-D The percentage of FVC expired in one second is: a. FEV1 b. TLC c. FVC d. FEV1/FVC ratio - ANSWER-D Aging process causes what normal physiological changes in the heart? a. Dilation of R ventricle occurs w/sclerosis of pulmonic and tricuspid valves b. Hypertrophy of R ventricle c. Heart valve thickens and becomes rigid, secondary to fibrosis and sclerosis d. Cardiology occurs along w/prolapse of mitral valve and regurgitation - ANSWER-C MJ presents with h/o structural damage w/current s/s of HF. Tx will be based on MJ's stage of HF, which is:

a. C b. A c. D d. B - ANSWER-A (stage C) 65yo Caucasian female presents with h/o mitral valve stenosis, PE unremarkable. You know the stage of HF is: a. D b. A c. B d. C - ANSWER-C (stage B) 65yo man presents for eval of CP and L-sided shoulder pain, begins after strenuous activity, including walking. Characterized by dull, aching, 8/10 during activity, otherwise 0/10. Began few months ago, intermittent, aggravated by exercise, relieved by rest. Occasional nausea. Pain is retrosternal, radiating to L shoulder, affects QOL by limiting activity. Pain is worse today, did not go away with rest. BP 120/80, HR 72 regular. Normal heart sounds, S1/2, no murmurs. Which of the following diff dx would be most likely? a. Afib b. Coronary artery dz w/angina pectoris c. Esophagitis d. Musculoskeletal chest wall syndrome w/radiation - ANSWER-B Best way to diagnose structural heart dz non-invasively is: a. CXR b. Heart cath c. Echo

d. EKG - ANSWER-C Chronic pain can have major impact on pt's ability to function and have profound impact on overall QOL. Ongoing pain may be linked to: a. Depression b. Sleep disturbance c. Decreased socialization d. All of the above - ANSWER-D Beers criteria are appropriate for use in evaluating use of certain meds in pts: a. >70yo b. >50yo c. >65yo d. >60yo - ANSWER-C Pt presents w/increasing SOB, cough w/occasional white sputum, fatigue. As part of the plan, you order labs. You know the likelihood of HF is low if BNP is: a. >400 b. <100 c. 100- 200 d. 200- 400 - ANSWER-B All of the following are true about lab values in older adults except: a. Normal ranges may not be applicable for older adults. b. Abnormal findings are often due to physiological aging

c. Reference ranges are preferable d. Reference values are not necessarily acceptable values - ANSWER-B According to 2017 ACC HTN guidelines, the recommended BP goal for 65yo African American woman w/a h/o HTN and DM and no h/o chronic kidney dz is: a. <130/80 b. <120/80 c. <140/80 d. <140/90 - ANSWER-A Pathophysiology of HF is due to: a. Incomplete closure of tricuspid valve b. Impaired atrial filling c. Normal ventricular function d. Inadequate cardiac output to meet metabolic and O2 demands of the body - ANSWER-D 60yo woman w/30-pack year hx presents for eval of persistent, daily cough w/increased sputum production, worse in the AM, occurring over past 3mo. She says, "I have the same thing year after year." Which of the following choices would you consider strongly in your critical thinking process? a. Acute bronchitis b. Chronic bronchitis c. Seasonal allergies d. Bronchial asthma - ANSWER-B 68yo man presents for physical, has had T2DM x5yrs, diet controlled. BMI 32. H/o HTN, smoker 10cigs/day x20yrs. Fam h/o CAD, CABG x4 for father, now deceased; CHF, T2DM, HTN for mother. He is asymptomatic today, exam is normal, EKG NSR. According to AHA/ACC guidelines, he is at risk for what stage of HF?

a. Stage C b. Stage D c. Stage B d. Stage A - ANSWER-D (stage A) Volume of air a pt is able to exhale for total duration of the test during maximal effort is: a. FVC b. TLC c. FEV1/FVC ration d. FEV1 - ANSWER-A According to 2017 ACC HTN guidelines, normal BP is: a. <130/90 b. <120/80 c. <140/80 d. <140/90 - ANSWER-B Functional abilities are best assessed by: a. Family report of function b. Comprehensive head-to-toe exam c. Observed assessment of function d. Self-report of function - ANSWER-C Aortic regurgitation requires medical tx for early s/s of HF with: