Medical Concepts and Procedures, Exams of Advanced Education

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AGACNP Review Exam With 100%

Correct Answers 2023

Tx of infectious Post-op fever - Correct Answer-#1 Supportive fluid therapy and APAP #2 Treat underlying source #3 Gram stain and C & S all invasive lines or catheters as indicated. What is the best intervention for fever of unknown origin? - Correct Answer-Nothing until the diagnosis is confirmed. Major syndromes causing fever - S/S of each and TX - Correct Answer-Serotonin syndrome - SSRI use, clonus, hyperreflexia, ataxia, mental status changes, restlessness, confusion, agitation, coma, seizure, diaphoresis, hyperthermia, mydriasis, labile bp

• tx: dantrolene sodium, clonazepam for rigor, cooling blankets Malignant Hyperthermia - happens in the OR; after succinylcholine IV then fry brain to 104 F. IVF, pack them with ice then send to PACU with Dantrolene Neuroleptic Malignant Syndrome - associated with dopamine antagonists - bradykinesia, "lead-pipe" muscle rigidity
• on anti psychotic; IVF priority to flush toxins out, and this is true to every toxic Other rando causes of fever to consider - Correct Answer-Temporal arteritis - high ESR, normal WBC, fever as high as 104!!! - HA, scalp tenderness, visual complaints. - 15% of all cases of FUO in pts > 65 years Endocarditis - consider if fever presents w/ new murmur. Also night sweats, malaise, wt loss, "sick" feeling. Pt w/ vise-like, tight, generalized HA that is most intense in the neck or back of the head, w/ no focal symptoms and that lasts for several hours. What is it / what do you do? - Correct Answer-Tension HA. No dx for this. Manage w/ OTC analgesics and relaxation. Female w/ unilateral episodic HA that is dull or throbbing, builds up gradually and lasts for several hours. Has some field defects, visual hallucinations such as stars, sparks, and zigzag lights, APHASIA, numbness, tingling, clumsiness and weakess, also n/v, and photophobia and phonophobia. What is it / what do you do? - Correct Answer- Classic Migraine (migraine with aura) (NOT COMMON MIGRAINE). This is r/t dilation and pulsation of branches of external carotid and follows the trigeminal nerve pathway. If new or different than previous HA's -- Head CT!!!

BMP, CBC, VDRL, ESR, and anything else indicated by hx and physical exam If Migraine confirmed, then.... #1 avoid triggers #2 relax/manage stress #3 Prophylactic therapy is ATTACKS > 2-3x PER MONTH (Elevil - monitor QT interval; Depakote, Inderal Tofranol, Catapres, Veramapil, Topamax, Neurontin, Methysergide, Magnesium). In ACUTE ATTACK: rest, take ASA right away (some relief), Sumitriptan 6mg SQ or 25mg PO at onset (STANDARD ABORTIVE TX), SQ may be repeated. Middle-aged male w/ unilateral, periorbital HA, no family hx of HA or migraine, but possible ETOH use. Describes pain as "severe" and reports suicidal thoughts when the pain comes on. Also causes him nasal congestion, rhinorrhea, and eye redness. What is it / what do you do? - Correct Answer-Cluster HA. No diagnostics. Eye will be red, and he will have rhinorrhea. PO meds ineffective. Give 100% o2 (so about 12-15L on non-rebreather for about 15 min). Subq Sumitriptan 6mg Inhalation Ergostat Albumin level for protein malnutrition / Albumin level for edema? - Correct Answer-< 3.5 / < 2.7 (will see falling out hair, ridged nails, muscle wasting, dry mucous membranes, slow healing). Nutritional considerations for the acutely ill: - Correct Answer-In times of physiological stress, pts caloric needs double from baseline d/t their hypercatabolic state Goal of nutritional therapy is to sustain pts existing weight, even if pt is obese Typical caloric requirement is to sustain existing weight is 30-35kcal/kg or body weight daily, so hospital patients will require 60-70 kcal/kg daily Pt getting feedings with duo tube, ND tube, NG tube, or PEG what should you watch out for? - Correct Answer-Complications of Enteral nutrition support related to the solution. -aspiration -diarrhea -emesis -GI bleeding (didn't know that, d/t PEG?) -mechanical obstruction of tube -hypernatremia (know this!!) -dehydration (know this!!)

Pt getting parenteral nutrition. What are the potential complications? What are complications related to? What is the % of which you may see them? What should you monitor for daily? - Correct Answer-Pneumothorax Hemothorax Arterial laceration Air emboli Catheter thrombosis Catheter sepsis Hyperglycemia HHNK Complications related to route of delivery Complications may occur in up to 50% of pts Monitor BMP daily What is the best assessment of TPN efficacy? A) Total protein B) Daily Weights C) Evidence of a positive nitrogen balance D) Transthyretin (Prealbumin) (From Fitzgerald book) - Correct Answer-C) positive nitrogen balance. This tells you that pt is taking in more nutrition than he needs, and it is an immediate reflection of nutrition status. You want this when you give TPN. total protein takes months to adjust to current nutrition prealbumin takes weeks to adjust to nutrition Labs for hypo / hypernatremia - Correct Answer-Urine sodium 10-20 >20 = renal salt wasting (kidney problem); <10 = renal retention to compensate for other losses. Normal Serum Osmo 275- Isotonic 284-295 (high lipids / or proteins) Hypotonic <280 (assess if hypo, euvo, or hypervolemic and tx) Hypertonic >290 (hyperglycemia) High Urine Osmo (in SIADH) > 100 Low Urine Osmo (in DI) < 100 Volume Status determined mostly by clinical status (Hypervolemic, Euvolemic, Hypovolemic)

Steps in evaluating hyponatremia - Correct Answer-1. Serum Sodium

2. Serum Osmolality
3. Volume Status / clinical status
4. Urine sodium Pt w/ recent onset of n/v/d and new onset confusion. Past hx of SZ. PE includes HR of 110, BP 110/80 supine, and 90/58 upright, poor skin turgor. Serum Na 128. What is the next step in evaluating the cause of the sodium imbalance? A) Serum Osmo B) Serum Chloride C) Urine Catecholamines D) Urine Sodium - Correct Answer-A. Serum Osmolality Serum Na 128, urine Na 8, serum osmo 280, and patient has fine crackles, edema, and ascites but is without complaints and breathing well. What is this / what do you do? What do you do if same pt becomes symptomatic w/ breathing difficulty? What do you do if he develops CNS symptoms? - Correct Answer-Hypervolemic Hypotonic Hyponatremic Asymptomatic : Restrict water Symptomatic but without CNS symptoms: NS IV w/ lasix CNS symptoms: Consider slow administration of 3% NS IV w/ lasix Serum Na 130, urine Na 12, Serum Osmo 288 What is it, what does the patient look like, and what do you do? - Correct Answer- Isotonic Hyponatremia Patient looks a little chubby, might be snacking on a cupcake or three. Or might be a big beefy guy sucking on a protein shake. In either case, body water is normal and pt is asymptomatic. This is a lab artificact d/t hyperlipidemia or hyperproteinemia. Tx: Cut down on fat, No fluid restriction needed. Serum Na 125, urine Na 23, serum osmo 274, tenting skin and dry mucus membranes. What is it? What are the causes? What do you do? - Correct Answer-Hypovolemic Hypotonic Hyponatremia Caused by: low volume and kidneys not conserving Na. D/t: Diuretic use, ACE inhibitors, Mineralocorticoid deficiency (Addison's), Nephropathies, and Cerebral Salt wasting syndrome (not the same as DI).

Treat cause (b/c urine Na is > 20) and give NS IV (b/c hypovolemic). Serum Na 122; urine Na 5; Serum Osmo 296; BP 82/40; Hr 122 altered level of consciousness What is this / what do you do? - Correct Answer-Hypertonic Hyponatremia Usually d/t HHNK (osmo will be higher with this though, like >310) but may also be d/t mannitol, sorbitol, glycerin, maltose, and radiocontrast dye

1. Tx cause
2. Tx condition
3. If hypovolemic (and will be so in HHNK) give NS IV (and insulin / fluid protocol if HHNK)
4. If hypervolemic, water restriction
5. If symptomatic, NS IV w/ loop diuretic
6. If CNS symptoms, consider 3% NS IV w/ loop diuretics Serum Na < 135; urine Na > 20; serum osmo < 280; urine osmo > 100 What is this? What else will you see in this patient? What do you do? (if Na >120, if Na 110-120, if Na <110). - Correct Answer-SIADH (low Na, low urine output but highly concentrated, dark urine b/c high urine osmo, low serum osmo, because they are peeing out all the serum Na). May have neuro changes, mild HA, decreased DTR's, hypothermia, wt gain, edema, N/V, cold intolerance (d/t low Na). Also, renal, cardiac, and thyroid function will be normal *You tx underlying cause - (tumor, head trauma, CNS d/o chronic lung d/s) *If serum Na >120 restrict fluids to 1L / monitor *If serum Na 110-120 and no neuro symptoms, restrict fluids to 500ml/ monitor *If serum Na <110 or Neuro s/s give isotonic or hypertonic saline and lasix at 1-2mEq/h and monitor Na and K losses hourly and replace. Serum Na 152; serum osmo 302. What is it? What do you do if you see these labs and pt is
7. Hypovolemic?
8. Euvolemic?
9. Hypervolemic? - Correct Answer-Hypertonic Hypernatremia - this is always hyperosmolar. Usually d/t excess water loss. Excessive Na intake is rare (so a more serious cause is suspected).
10. Severe hypernatremia w/ hypovolemia give NS followed by 1/2 NS
11. Hypernatremia w/ euvolemia give free water (D5W)

3. Hypernatremia w/ hypervolemia give D5W and loop diuretic and may need dialysis. Pt POD 1 from ORIF of femur from MVA, c/o constipation, weakness, and occasional muscle cramps during morning rounds. Later in the day his nurse calls to report multi- focal PVCs, broad T-waves and prominent U-waves on his cardiac monitor. What is the cause and what do you do? Would you do anything different if he did not have ECG abnormalities? - Correct Answer-Hypokalemia is the likely cause. K losses may be due to elevated serum epinephrine in trauma patients, as well as chronic diuretic use, GI loss, renal loss, and alkalosis. Since pt is having ECG abnormalities give him 40 mEq/L/hr IV and check q 3 hours. Same tx for pts with K < 2.5. Keep him on telemetry until he normalizes. If no ECG abnormalities and K < 2.5 do tx above. If no ECG abnormalities and K >2.5 use oral replacement. If K is not corrected following treatment then you are an idiot b/c you failed to realize that you needed to correct the magnesium first. ECG changes w/ hypokalemia - Correct Answer-Decreased amplitude, broad T waves, Prominent U waves, PVCs (multifocal), V-tach, V-fib You patient with Addisons disease is most likely to have what electrolyte abnormalities?

• Correct Answer-Hyperkalemia, Hyponatremia, Hypoglycemia You round on a patient admitted for a bleeding NSAID-induced duodenal ulcer. You are about to discharge him when the nurse reports that overnight he had multiple loose BMs, weakness, a near-fall, and ECG changes with his T wave (she forgot what his T wave was doing). What is the likely cause and what will you do about it? - Correct Answer-Hyperkalemia - causes include drugs like NSAIDS, excessive intake, renal failure, hypoaldosteronism (Addisons), and cell death. Although this pt had some tall, peaked T-waves (that eluded his poor nurse), this is not always the case since only 50% of pts with K. 6.5 have any ECG changes at all. Tx w/ exchange resins (Kayexalate) If > 6.5 or cardiac toxicity or muscle paralysis present, consider: Insulin 10 U w/ one amp D May also consider NaHCO3 gtt

What should you do for a total calcium of 1.8 mmol/L? - Correct Answer-1. Check pts serum albumin for corrected calcium level (normal total calcium 2.2-2.6mmol/L -or- 8.5- 10.5 mg/dl).

2. Check blood pH - look for alkalosis
3. If acute, IV calcium gluconate
4. If chronic, oral supplements, Vitamin D, aluminum hydroxide What are the normal ranges for total / ionized calcium? What is the difference between the two? - Correct Answer-Total calcium = 2.2-2. mmol/L (8.5-10.5 mg/dl) Ionized calcium = 1.1-1.4 mmol/L (4.5-5.5 mg/dl) Difference: Ionized calcium does not vary with albumin level. Use this to measure calcium when albumin is not within normal range. What is the relationship between Calcium and pH? - Correct Answer-Acidemia increases ionized calcium, alkalemia decreases ionized calcium What is the relationship between Potassium and pH? - Correct Answer-Inverse relationship. K+ increases 0.7mEq/L with each 0.1 drop in pH You are rounding on a patient that you have been seeing for over 1 week d/t a bilateral femur and pelvis fracture. She reports that she has no appetite, had nausea and vomiting overnight, and is constipated. She is even more irritable than you remember when you admitted her. You review that her meds include: Metoprolol, HTCZ, and levothyroxine. You review her labs and expect to see what electrolyte abnormality? What are going to do about it? - Correct Answer-Hypercalcemia. Can be elevated in hyperthyroidism, thiazide diuretic use (rarely though), prolonged immobilization (bedrest in this case), as well as hyperparathyroidism, and Vit D intoxication. Tx: Check her albumin corrected calcium/ if > 12, begin NS infusion w/ loop diuretics She may need dialysis. If cardiovascular or renal function is impaired, she may need calcitonin. Your patient's ABG's are as follows: pH 7.33; pCO2 48; HCO3 26, serum choride 110. Pt is somnolent, confused, and has sudden twitches and jerks. There is no apparent reason for this change. He was admitted for diverticulitis and is taking opioids, but at a low-dose.

What does this mean and what do you do? - Correct Answer-Respiratory Acidosis. Pt has decreased alveolar respiration explaining the increase in CO2. This is an acute situation as the HCO3 has not had a chance to compensate and serum choride is 110 (would be < 93 in chronic resp acidosis). -Narcan for all pts w/ no obvious cause 0.04-2mg -Improve ventilation - intubate if necessary -If already intubated, increase rate on ventilator. Tar burn, what do you first, and what do you do next? (Fitz & Bark) - Correct Answer-#1 Cool area #2 Use petroleum product to remove tar Your patient Nikki swears that she does not have Hepatitis B as she was successfully vaccinated as a child. What serology do you expect to be positive? - Correct Answer- Anti-HBs Hepatitis B surface antibody. The presence of anti-HBs is generally interpreted as indicating recovery and immunity from hepatitis B virus infection. Anti-HBs also develops in a person who has been successfully vaccinated against hepatitis B. (CDC) What is the screening test to order if you suspect Hep B in your patient? - Correct Answer-HBsAg This is the first test to order if HBV is suspected. A caveat is that it will remain positive in asymptomatic carriers and in chronic infection.

1. Which of the following serologies will be positive in active, chronic, and recovered HBV? HBsAG HBeAg Anti-HBc Anti-HAV Anti-HCV Anti-HBsAg Anti-HBe
2. What serology must also be positive to confer recovered infection and immunity? - Correct Answer-1. Anti-HBc

2. Anti-HBc will be coupled with Anti-HBsAg, indicating recovered status. Your patient Nikki is freaking out because she just came back from a Filipino orgy and realized that the hosts are chronic Hepatitis B carriers. What serology do you expect to see in the Filipino hosts? - Correct Answer-Chronic Hep B HBsAg, Anti-HBc, Anti-HBe, IgM, IgG You are in line at a health screening and see a handsome man. You sneak a glance at the lab printout he is holding in his hand. You read the following positive results: HBsAg, HBeAg, Anti-HAV Do you ask him out? - Correct Answer-Not unless you want to get Hep B or already have it. He is currently infected with Hep B (HBsAg), and is an active, chronic, contagious carrier (HBsAg and HBeAg), he is also either recovered or was vaccinated from Hep A (Anti-HAV) What is this: Anti-HBc, Anti-HBsAg - Correct Answer-Recovered Hep B What is the Gold standard for HCV detection? - Correct Answer-HCV RNA. This is NOT an antibody test, but tests for viral RNA. A positive result means that the virus is present.
3. Your patient was admitted for IV drug overdose, you suspect she was exposed to HCV. What enzyme immunoassay test do you order?
4. You learn that she was successfully treated for HCV in the past, what test will confirm current viremia from prior exposure? - Correct Answer-1. Anti-HCV
5. No. You will need to order the PCR (Polymerase chain reaction) test, HCV RNA Your patient works in a daycare in an impoverished immigrant neighborhood. She reports a weeks worth of flu-like symptoms: N/V, fatigue, malaise, / her labwork shows low WBC, elevated AST/ ALT, LDH, bili, alk phos, and proteinuria and bilirubinuria. What does she most likely have? What serologies do you expect to see? What do you advise her to do? - Correct Answer-Hepatitis A (transmitted via fecal-oral route, and rarely parenterally). Anti-HAV, IgM (Active Hep A)

Self-limiting d/s. She seems to be in the prodromal (pre-icteric) phase, which lasts about 2 weeks. Next, she will enter the active (icteric) phase which lasts about 2-6 weeks. She may experience wt loss, jaundice, dark urine pruritis, low grade fever...). You advise her that her blood and stool will be infective for 3-6 months. Hydrate (3-4L/day), nourish self, rest, avoid ETOH and other hepatically cleared drugs. Practice good hygiene to minimize transmission. As a healthcare worker you were immunized for Hepatitis B, you expect which serology to be positive? - Correct Answer-Anti-HBs Your patient is a healthcare worker from Uganda. She was exposed to HBV and had a complete recovery. Which positive serology is an indication of immunity due to natural infection and is not present in immunized individuals? - Correct Answer-Anti-HBc You have been treating your male patient's GERD symptoms for 6 weeks. At which point would you consider endoscopy? - Correct Answer-After 8-12 weeks of tx Normal values for Cardiac pressures: CVP PAP PCWP CO CI SVR SVO2 - Correct Answer-CVP 0-6mm Hg PAP 15-25 / 5- PCWP 6-12 mm Hg CO 4-8L/min CI 2.5-4 L/min SVR 800-1200 dynes/sec/cm- SVO2 60-80% CI 1.7; CVP 1; PCWP 5; SVR 700, SVO2 60% What condition(s) may be a cause? - Correct Answer-All values low: Anaphylactic & Neurogenic CI 1.7; CVP 7; PCWP 8; SVR 1100 What condition (s) may be a cause? What value can differentiate the two? - Correct Answer-Obstructive and/ or Cardiogenic If SVO2 was listed and was low, it would be Cardiogenic. If high, then Obstructive

CI 1.7 (low) CVP 7 (high) PCWP (High/ normal) SVR 1100 (High/ normal) Why is SVR high in Hypovolemic and Cardiogenic shock? A. Decreased O2 demand B. Increased tissue extraction of oxygen C. Compensatory peripheral arterial constriction D. Decreased peripheral vasomotor tone - Correct Answer-C. Compensatory peripheral arterial constriction. You assess your patient in the morning: CO 8; CVP 1; PCWP 5; SVR 700; SVO2 55% WBC is 25, What kind of shock does he have? What changes might you expect by the next day? A. CO 4; CVP 7; PCWP 14; SVR 700; SVO2 90% B. CO 4; CVP 1; PCWP 7; SVR 1400: SVO2 55% C. CO 8; CVP 7; PCWP 14: SVR 1400; SVO2 90% D. CO 8; CVP 1; PCWP 5; SVR 700; SVO2 55% - Correct Answer-Septic Shock High, low, low, low, low - early shock CO 8 (high) (normal 4-8) CVP 1 (low) (normal 0-6) PCWP 5 (low) (normal 6-12) SVR 700 (low) (normal 800-1200) SVO2 55% (low) (normal 60-80%) By the next day he might have: A). CO 4; CVP 7; PCWP 14; SVR 700; SVO2 90% Low, high, high, low, high - late shock

CO 4; CVP 7; PCWP 14; SVR 700; SVO2 90%

What is your priority plan? - Correct Answer-Late septic shock Plan- #1 fluid rescusitation (crystalloids) #2 Pressors #3 ABX (within 1 hour) (after blood cultures / upon diagnosis of sepsis) What is the primary #1 tx in every type of shock? What is the #2 tx in every shock? - Correct Answer-Fluids Pressors What age can you stop getting PAP exams if all previous ones have been normal? - Correct Answer-Age 65 Meningitis revaccinations indicated when? - Correct Answer-After age 18 in high-risk situations such as college dorms, military, etc, and must be five years from last vaccination. Meds for SZ

1. regular seizure 2.status
2. seizure prevention - Correct Answer-1. break seizure with Lorazepam (Ativan)
3. break status with Diazepam (Valium), if not effective then Phenytoin (Dilantin), then Fosphenytoin (cerebrex), or Phenobarbitol (Luminal).
4. seizure prevention with Phenytoin, Phenobarb, or ..... Endarterectomy indicated for: - Correct Answer-70-80% stenosis for symptomatic patients What does a high TIBC mean? - Correct Answer-That there is high available capacity on the transferrin binding sites. High TIBC in iron-deficiency anemia which kidney stones are most common after age 30? - Correct Answer-Calcium stones Calcium stones account for 80% of all stones, are frequently familial, more common in men, and have average age of onset > 30 years. Which kidney stones occur mainly in women? - Correct Answer-Struvite stones

Struvite stones result from UTIs with urease-producing bacteria. They are known as magnesium-ammonium-phosphate stones. They may grow to a large size and fill the renal pelvis and calyces Which kidney stone is the only one that is insoluble in urine? - Correct Answer-Cystine. Cystine is the only amino acid insolube in urine. Cystine stones are the most difficult to manage. Which STI is known as a well established co-factor to HIV transmission? - Correct Answer-Chrancroid In which STI are up to 10% of people also infected with syphilis and HSV? - Correct Answer-Chancroid Pt in DKA, you start NS at a rate of _____/hr for the _______ hr; then you reduce it to ______/hr. If glucose is > ________ mg/dL, use _______ after the first hour because __________. When glucose levels fall <_______ mg/dL change to _______to prevent _______. - Correct Answer-Start NS at a rate of 1000ml/hr for the 1 hr; then you reduce it to 500ml/hr. If glucose is > 500 mg/dL, use 1/2 NS after the first hour because water deficit exceeds sodium loss. When glucose levels fall < 250 mg/dL change to D51/2 NS to prevent hypoglycemia. What are the 2 indications for TPA in ACS? - Correct Answer-1. Unrelieved chest pain > 30 minutes and < 6 hours.

2. ST segment elevation > 0.1 mV in two or more contiguous leads Door to needle time in MI? A) 30 min B) 60 min C) 90 min D) 120 min - Correct Answer-A) 30 min to deliver thrombolytic therapy in MI (fibrinolytic) Door to balloon time in MI? A) 30 min B) 60 min C) 90 min

D) 120 min - Correct Answer-C) 90 min (Cardiac cath / balloon) For thrombotic strokes, fibrinoloytic therapy, if indicated, should be administered within _______ to ______ hour(s) of _______. A) 1/2 - 1 hour(s) of arrival to ED B) 1 - 1.5 hour(s) of symptom onset C) 3 - 4.5 hour(s) of arrival to ED D) 3 - 4.5 hour(s) of symptom onset - Correct Answer-D) 3 - 4.5 hour(s) of symptom onset Diagnostics for appendicitis - Correct Answer-CT or ultrasound WBC will be modestly elevated 10k-20k Will you see copious purulent sputum in emphysema? - Correct Answer-No, sputum in emphysema is mild and clear. Copious sputum can be seen in bronchitis, and pneumonia (not as copius here, but definitely purulent). Of all the shock states, which is the only one that begins with a high CO/CI? - Correct Answer-Septic shock (high CO later becomes low as shock progresses). Of all the shock states which two have high initial CVP? - Correct Answer-Cardiogenic and Obstructive Of all the shock states, which two have high SVR? - Correct Answer-Hypovolemic and Cardiogenic What is the normal cup/disk ratio? - Correct Answer-Cup should be less than 1/2 the size of the disk diameter MMSE

1. How many components?
2. What is the acronym?
3. What is max score?
4. What is score for no cognitive impairment?
5. What is the score for cognitive impairment? - Correct Answer-1. 11
6. ORArL 2,3 RWD
7. 30

8. 24 is normal

9. 0-7 severe impairment / 8-17 moderate / 18-23 mild impairment What tests are to be expected in the diagnostics of TIA? - Correct Answer-Head CT - distinguish betw ischemia, hemorrhage, and tumor MRI better than CT in detecting ischemic infarcts

Echo Carotid doppler / US Cerebral angiography What are the two most common causes of CVA? What are other common causes? - Correct Answer-1. Atherosclerotic changes

2. Chronic HTN Trauma, Aneurysm, AV malformation, Tumor What GCS score is an indication for ICP monitoring in the patient with an epidural hematoma? A) 7 or less B) 9 C) 11 D) 12 or greater - Correct Answer-A) 7 or less What is Passive immunity? - Correct Answer-Can be artificial, such as immunity conferred by the introduction of antibody proteins such as gamma globulin injections (Hep B immuno globulin, CMV, tetanus toxoid, diptheria toxoid), or natural, such as maternal immunity transferred to the fetus (Can be mom to baby). Your patient has diarrhea, abdominal distention, weakness, and flaccid paralysis. What do you suspect? - Correct Answer-Hyperkalemia. May also present with tall, peaked T waves Regarding calcium and renal failure, what can you expect to see in your patient? - Correct Answer-Either hypocalcemia or hypercalcemia What is the only electrolyte abnormality that can cause a prolonged QT interval? - Correct Answer-Hypocalcemia What pathogen is the usual cause in uncomplicated cellulitis? - Correct Answer-Strep. pyogenes (Gp A Strep) What is the most important step in GI decontamination management? A) Physical exam B) History C) Serum, gastric, and urinary toxicology screens

D) Administering activated charcoal - Correct Answer-B) History History is the first and most important step of assessment. Your patient presents to the ED with a BP of 92/76, respirations of 7/ minute, miosis, a temperature of 36.5, and he is falling asleep mid-sentence. You are unable to get an adequate history from him. After his IV and toxicology labs are drawn he becomes difficult to arouse from sleep. What is your next step? A) Oxygen support, admit to stepdown and await results of his toxicology labs B) Prophylactic intubation C) Administer an emetic D) Administer Butorphanol - Correct Answer-D) Administer Butorphanol The patient is presenting with s/s of a narcotic overdose (drowsiness, hypothermia, respiratory depression, shallow respirations, miosis, and eventually coma). Naloxone (Narcan) and Butorphanol (Stadol) are reversal agents. Emetics are contraindicated. In both malignant hyperthermia and serotonin syndrome what do you not expect to see? A) Hypothermia B) Hyperthermia C) Rigor D) Recent administration of Succinylcholine - Correct Answer-A) Hypothermia SS and MH both have hyperthermia for which cooling blankets may be ordered. Rigor may be present and is treated with Klonopin. The primary treatment for both is Dantrolene sodium (Dantrium). What direction do you expect the hemoglobin-oxygen dissociation curve to go in a patient that has severe salicylate intoxication? A) Up B) Down C) Right D) Left - Correct Answer-C) Right Salicylate (aspirin) intoxication s/s include hyperthermia and metabolic acidosis (among others) which results in a DECREASED affinity of hgb to oxygen and a shift to the RIGHT T/F Bicitra is considered conservative medical management in metabolic alkalosis? - Correct Answer-False. Bicitra 10-30cc is actually sodium citrate which is ordered for normal gap metabolic acidosis.

ST elevation in I, aVL, V5, V6 - Correct Answer-Lateral MI St elevation in II, III, aVF - Correct Answer-Inferior MI ST elevation in leads V3 and V4 - Correct Answer-Anterior MI ST elevation in leads V1, V2 - Correct Answer-Septal MI What are three major GI dx that will perforate the bowel? - Correct Answer-Ruptured diverticulum, PUD, appendicitis (less common) When would you start your pt on a statin? - Correct Answer-ASCVD LDL-C >/= 190 DM 40-75 w/LDL-C 70-189/ without ASCVD No ASCVD or DM but LDL-C 70-189 and 10-year ASCVD risk of 7.5% or higher What two conditions may present with ST elevation but are NOT due to CAD or MI? - Correct Answer-Prinzmetals angina and Pericarditis Pt presents 15 minutes after initial onset of chest pain, SOB, friction rub, ST segment elevation in all leads > 0.1 mV, and PR depression. What is the mainstay of treatment for this patient? A) nitroglycerin B) Indomethacin C) Cardiac catheterization D) TPA - Correct Answer-B) Indomethacin Patient has pericarditis. Classic presentation of CP that is relieved by sitting forward, SOB secondary to pain with inspiration, pericardial friction rub, ST elevation in all leads, and the highly indicative PR segment depression. NONE of these are present in MI. NSAIDS are mainstay of treatment in pericarditis. Ibuprofen (Advil) 400-600 mg q 6- hrs or Indomethacin (Indocin) 25-50 mg q 8 hrs x 2 weeks. If patient was having MI he would need: ASA, NTG, O2, three IVs, 12 lead EKG/ tele, morphine 2-4mg IVP, lasix if pulm edema present, 5mg metoprolol unless contraindicated, ACE, Hep or Lovenox, Cath lab or TPA revascularization if CP unrelieved after 30 min and door to needle time < 30 min. NP role development vs NP expansion into inpatient setting. What precipitated the first, and the second? - Correct Answer-NP role developed in early 1960s d/t PHYSIAN SHORTAGE IN PEDIATRICS

NP expansion into inpatient setting developed d/t MANAGED CARE, HOSPITAL RESTRUCTURING and DECREASES IN MEDICAL RESIDENCY PROGRAMS Don't get these mixed up! What has nothing to do with the historical service of NPs in primary care? A) Restructuring in managed care B) Available funding C) Resources towards preventative care education D) Federal assistance for primary care NP education - Correct Answer-A) Restructuring in managed care NPs in primary care resulted in part from availability of federal funding for preventative and primary care NP education. The total sample size in a study is: A) n B) N C) t D) p - Correct Answer-B) N = total sample size n = the number of subjects in a subgroup of subpopulation. t = t-test is a statistical test to evaluate the differences in means between two groups. p= level of significance. p < .05 represents a 5% probability that the results of a study are due to chance. When you see a p value in a study it means that there was a statistically signifanct result and that you should probably incorporate that data into your practice. If the NPs actions fail to meet the standards of care and result in actual or even potential harm to the patient, is the NP liable? - Correct Answer-Yes! The NP has a legal responsibility to meet the standards of care. Who determines the Standards of Care for NPs? - Correct Answer-American Nurses Association - "Scope and Standards of Practice". This document provides guidelines for nursing performance and delineates what it means to provide competant care. Who determines the Scope of Practice for NPs? - Correct Answer-State Nurse Practice Acts (aka the State Board of Nursing). Certified letter w/ return receipt required when dismissing pt from practice or when closing a practice? - Correct Answer-When dismissing pt from practice In obtaining informed consent pt must have competence (decisional capability) so they must be able to do these 4 things.... - Correct Answer-Ability to understand

Reason Differentiate good and bad Communicate Must have ALL of these! Which vaccines would you NOT give to an immunocompromised person? - Correct Answer-Zoster, Varicella, nasal flu vaccine, MMR, .... T/F : Order of syphilus stages is Primary, Latent, Secondary, Tertiary - Correct Answer- False Primary, Secondary, Latent, Tertiary Macrolides not routinely ordered for patients > 60 because of..... - Correct Answer-BB warning: QT prolongation MCHC - Correct Answer-32-36% normochromic Ferritin level - Correct Answer-11- (approximately. males 28-336/ females 11-306) HGB 8, MCV 110, MCHC 34, what will you order NEXT? - Correct Answer-Serum B HGB 8, MCV 110, MCHC 34, B12 (< 200pg/ml), what will you order to affirm this deficiency? - Correct Answer-Anti-IF (intrinsic factor) and Anti-parietal antibody test and Schilling test HGB 8, MCV 110, MCHC 34, what will you order to determine the CAUSE of this? - Correct Answer-Shilling test 2 major drug classes that manage HF? - Correct Answer-ACEI and Thiazides. (Anticoags if afib) Where do you want the pulse pressure in ICP? - Correct Answer-in the 70's Symptom management, maintaining electrolyte balance, and high dose parenteral therapy started ASAP (in suspected bacterial cases) w/ aqueous penicllin G, vanc with a third gen ceph until C&S available, or tx with fluoroquinolone. - Correct Answer- Meningitis Decreased glucose, WBCs present, elevated protein, cloudy fluid. What substance is likely being analyzed? A) viral CSF B) bacterial CSF C) exudatative pleural fluid

D) transudative pleural fluid - Correct Answer-B) bacterial CSF. May also present with elevated opening pressure and xanthelochromic (yellow) color. (tip, low glucose/ high protein, think bug eating glucose). Viral CSF will present with protein and glucose within normal limits. remember to do head CT too!!! protein to serum protein > 0.5 and/or LDH to serum LDH > 0.6 and/or LDH > 2/3rd ULN of serum LDH. (So basically high protein, LDH, and cream-colored). what is this? - Correct Answer-exudative pleural fluid Which of the following is NOT a type of pleural effusion? A) empyema B) exudates C) transudates D) hemorrhagic E) viral - Correct Answer-E) viral 10-20 - Correct Answer-normal urine sodium -or- normal intraoccular pressure -or- normal BUN normal or few hyaline casts - Correct Answer-prerenal granular/white casts - Correct Answer-intrarenal no urinary sediment - Correct Answer-postrenal urine sodium < 20 / FEna < 1 - Correct Answer-prerenal (think holding on to sodium, low na excretion) urine sodium > 40 / FEna > 3 - Correct Answer-intrarenal / postrenal cardiac specific labs - Correct Answer-tropinin I and CKMB methyldopa A) increases available dopamine B) helpful to alleviate tremor and rigidity C) drug of choice for pregnant patient D) tachycardia is a serious side effect - Correct Answer-C) drug of choice for pregnant patient

Methyldopa is a central alpha-2 agonist that prevents vasoconstriction, causes vasodilation, and slows the heart rate. increases available dopamine - Correct Answer-pramipexole, ropinorole, carbidopa- levodopa, amantadine T4-T6 - Correct Answer-Some trunk control Complications include autonomic dysreflexia. Autonomic dysreflexia: A) Sympathetic response to a stimulus B) Diaphoresis and flushing below the level of injury C) Characterized by hypertension, tachycardia, and headache D) Treatment includes antihypertensives and stimulus removal - Correct Answer-D) antihypertensives and stimulus removal (usually d/t a full bladder. I/O cath needed). AD is AUTONOMIC response, diaphoresis and flushing ABOVE the injury, characterized by HTN, BRADYCARDIA, HA, chills and vasoconstriction below the injury, and nausea. Which of the following would you NOT be increased in the elderly? A) CNS alpha responses B) Peripheral beta-adrenergic responses C) CNS muscarinic parasympathetic responses D) Pain tolerance - Correct Answer-B) Peripheral beta-adrenergic responses These are decreased. All the others are increased in the gero patient. Which of the following is common between both Parkinsons and Alzheimer's patients? A) Disorientation B) Rigidity C) Tremor D) Flexion posture - Correct Answer-B) Rigidity Disorientation - Alzheimers Tremor - Parkinsons Flexion posture - Alzheimers T/F Your patient is in status asthmaticus. You will be monitoring ABGs q 30min-1 hour - Correct Answer-False. Monitor ABGs q 10-20 min. Inpt management incudes O2 1-2L NC or 24-28% venti make / 7-10 days of ABX if purulent sputum. - Correct Answer-Inpt management of COPD. (clues might be the low O2 level) T/F: Admit pt with FEV1 to FVC < 70% after bronchodilator therapy? - Correct Answer- False. This is diagnostic for COPD. FEV1/FVC <0.7

T/F Peak flow is NOT used for diagnosis in asthma. - Correct Answer-True. Peak flow is used for monitoring. PFTs are used for Dx. Swallowing: A) CN IX B) CN IX / CN X C) CN X D) CN IX/ CN X / CN XII - Correct Answer-B) CN IX / CN X IX Glossopharyngeal & X Vagus Bells Palsy is CN? - Correct Answer-CN VII - Facial Pupillary constriction - Correct Answer-CN III - Oculomotor Which cranial nerve(S): EOM - Correct Answer-3,4,6 Which cranial nerves are being assessed when patient is asked to: stick out tongue, close eyes, puff out cheeks, and shrug shoulders? - Correct Answer-7 (puff cheeks and close eyes), 11 (shrug shoulders), 12 (stick out tongue) T/F Endocarditis is a cause of cardioembolic TIA - Correct Answer-True. Other cardio-embolic events that are causes of TIA are: afib, acute MI and valve disease. Ischemic events also cause TIA, these can be d/t atherosclerosis, thrombus, arterial occlusion, embolus, and intracerebral hemorrhage. T/F Approximately 2/3 of pts with TIA will experience a cerebral infarction within 5 years.

• Correct Answer-False. The number is 1/3 of TIAs will progress to CVA d/t infarct. 1mg/kg - Correct Answer-lovenox dosing 2.5 - 4 and 4-8 - Correct Answer-CI/ CO 0-6 - Correct Answer-CVP 6-12 - Correct Answer-PCWP 800-1200 - Correct Answer-SVR Which of the following is false: Distributive shock is characterized by: A) Reduced tissue perfusion B) Vasodilation and decreased intravascular volume

C) Reduced peripheral vascular resistance D) Loss of capillary integrity - Correct Answer-A) Reduced tissue perfusion - this is NOT an element of distributive shock, but is present in cardiogenic shock T/F Neurogenic shock is characterized by the loss of central vasomotor tone as a result of spinal cord injury, regional anesthesia, etc - Correct Answer-False - Not central vasomotor tone, but PERIPHERAL vasomotor tone is lost. Which of the following is NOT used in anaphylactic shock? A) Ranitidine or other H2 antagonist B) IV epi 0.3-0.5 ml 1:1000 sol C) Benedryl 25-75 mg IV or IM D) Crystalloids E) Inhaled beta agonist - Correct Answer-B) IV epi 0.3-0.5 ml 1:1000 sol - Not IV!!!!! Use epi in IM or SQ only. You NEVER push IV epi 1:1000 into a patient with a pulse. Is BP of 180/110 a contraindication to TPA? - Correct Answer-NO. You may give TPA, but BP cannot get higher than this. Dependent rubor - Correct Answer-PVD - arterial Which would not be a priority to manage in CVI? A) Weight B) DM C) Edema D) Weeping dermatitis - Correct Answer-B) DM Diabetes management is part of PVD management NOT CVI management. T/F Systemic ABX are a mainstay in the management of acute weeping dermatitis secondary to chronic venous insufficiency. - Correct Answer-False. Systemic ABX only indicated if the presence of active bacterial infection What other meds besides macrobid can be used for UTI in pregnant pt? - Correct Answer-Amoxicillin and Cephalexin Vertobasilar TIA - Correct Answer-Vertigo, ataxia, dizziness, CONFUSION, visual field deficits, weakness (think drunk person) Carotid TIA - Correct Answer-Altered LOC, aphasia, dysarthria, weakness, numbness Commonalities in vertebralbasilar/ carotid TIA - Correct Answer-weakness Management of thyroid crisis may include all but: A) PTU or Methimazole q 6 hours

B) Aspirin C) IV Sodium iodide D) IV Propranolol E) IV Lugol's solution F) Hydrocortisone - Correct Answer-B) Aspirin Should be avoided. Loss of consciousness in complex partial? - Correct Answer-yes Which two are NOT a s/s of hypocalcemia? A) Carpopedal spasm B) Constipation C) Muscle/ abdominal cramps D) Convulsions E) Chvostek's sign F) Prolonged QT interval G) Muscle weakness/ fatiguability - Correct Answer-B) Constipation G) Muscle weakness/ fatiguability These are s/s of hypERcalcemia When to start and stop mammograms? - Correct Answer-Start at approx 45-50. Finish at 75, or continue as long as in good health. normal hgb for men and women - Correct Answer-14-18 12-16 CO 3, CVP 9, PCWP 8, SVR 900, SVO2 90% - Correct Answer-Obstructive shock CO/CI low CVP high PCWP normal or low SVR normal SVO2 high T/F Pseudomonas is the most common causative organism in HAP - Correct Answer- False. Pseudomonas is the most common organism in VAP. HAP organisms are Staph aureus, Strep pneumo, and H. influenzae. These may present 48 hours after admission. Antispasmodics and interferon - Correct Answer-Classic multiple sclerosis meds. May also treated with immunosuppressives and plasmapheresis

Pancreatitis or Mesenteric Infarct? Sudden, severe abdominal pain, absent bowel sounds, elevated amylase and lipase, tachycardia, fever, N/V. - Correct Answer-Acute pancreatitis. Mesenteric infarct does not usually present with elevated lipase, or tachycardia Sudden onset of abdominal pain out of proportion to physical exam findings, fever, n/v, abdominal guarding, tenderness, and absent BS. Your first action is to... - Correct Answer-Get abdominal films to rule out free air. Pt presents with peritoneal signs, likely from mesenteric infarct. Emergent surgical intervention is the management of this. T/F Management of acute pancreatitis includes: NPO, bedrest, aggressive IV fluids, NG suction, pain control, and IV ABX. - Correct Answer-False. ABX are not part of routine management. T/F. Causes of bowel obstruction include: tumors, fecal impaction, ileus, hernia, adhesion, and volvulus. - Correct Answer-True. Bowel obstruction or Mesenteric infarct: Crampy abdominal pain, mild fever, nausea and vomiting within several hours of onset of pain, abdominal distention, hyperactive, tinkling bowel sounds. - Correct Answer- Bowel obstruction. Mesenteric infarct will not have vomiting with hours of pain onset, nor will distention or tinkling bowel sounds be present. Management following H.Pylori eradication therapy should include: A) Tapering off PPI over course of 6-8 weeks B) PPI and H2 blockers as needed until follow-up visit C) PPI for an additional 7 weeks D) Sucralfate for no more than 2 weeks - Correct Answer-C) PPI for an additional 7 weeks. (Point is to HEAL ulcer and provide SYMPTOM RELIEF) Antiulcer therapy recommended following eradication therapy for 3-7 weeks to ensure symptom relief and ulcer healing For duodenal ulcer: Omeprazole (Prilosec) 40 mg q day for 7 weeks. H2 blockers or Sucralfate can be given for 6-8 weeks. Management of viral hepatitis includes all but 2 of the following: A) Diazepam if sedation is necessary B) Rest and increasing fluids to 3-4L/ day C) Avoiding ETOH and drugs metabolized by liver