NR 509 Final Exam BEST STUDYING MATERIAL WITH VERIFIED ANSWERS LATEST VERSION UPDATED, Exams of Nursing

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NR 509 Final Exam BEST STUDYING

MATERIAL WITH VERIFIED ANSWERS

LATEST VERSION UPDATE 2024- 2025

A 75-year-old female in generally good health presents to a new primary care provider after she recently moved to a new city. She takes no prescribed medications, but she has been told in the past that her blood pressure was borderline elevated and might require treatment at some time in the future. Which of the following findings during the physical examine is consistent with the normal aging process and not a sign of cardiovascular disease? a. A narrowed pulse pressure with increased systolic and diastolic components b. A widened pulse pressure with increased systolic pressure (up to 140) and decreased diastolic pressure c. An unchanged pulse pressure with equal increases in both systolic and diastolic pressures d. A drop in systolic pressure of 25 mm Hg when rising from a supine to standing position e. An isolated increase in systolic blood pressure to >150 mm Hg b. A widened pulse pressure with increased systolic pressure (up to 140) and decreased diastolic pressure A 66-year-old recently retired restaurant worker presents to his primary care provider with a concern about hearing loss. He relates a history of difficulty distinguishing voices in crowded settings when significant background noise exists, which hastened his retirement. Which of the following is true about this patient's experience with hearing and the aging process? a. His experience is consistent with the normal aging process. b. Any hearing impairment that causes functional decline warrants formal testing and evaluation. c. Early age-related hearing loss initially affects lower-pitched sounds. d. Decreased hearing acuity associated with aging is formally known as hypoacusis. e. Age- related declines in hearing does not begin until age ≥75 years. b. Any hearing impairment that causes functional decline warrants formal testing and evaluation. Medications carry both risks and benefits for older patients. Although the risks of polypharmacy (the use of many medications at once) are very well known, many older patients take many medications for a variety of conditions. Which of the following best describes medication prescribing and utilization in the older adult population?

a. Although older patients take more medications than younger adults, their rate of hospitalization for drug-related adverse reactions is the same. b. Older patients rarely take or have adverse effects from sleep medications. c. Only half of all older patients take at least one drug daily. d. Individuals age >65 years account for 30% of all prescribed drugs. e. Medications prescribed for known indications are not considered to be a modifiable risk factor for adverse events. d. Individuals age >65 years account for 30% of all prescribed drugs. Which of the following is true about the presentation of pain in the older adult? a. Older patients are more likely to report pain symptoms than younger patients. b. The prevalence of pain is greater in community-dwelling older adults compared to those living in nursing homes. c. The American Geriatrics Society (AGS) prefers the term "persistent pain" over the term "chronic pain." d. Pain is often overtreated in the aging population due to overreporting and exaggeration of symptoms. e. The majority of pain complaints in this population are due to cardiac or gastrointestinal (GI) syndromes. c. The American Geriatrics Society (AGS) prefers the term "persistent pain" over the term "chronic pain." Concerning alcohol consumption in older adults, which of the following is true? a. The CAGE screening for alcohol abuse retains the same sensitivity and specificity it has for younger populations. b. The detection of alcohol abuse is higher in older patients than younger patients due to more frequent ambulatory interactions with health care providers. c. Symptoms and signs of alcohol abuse are more overt and easier to notice during outpatient encounters in older patients than in younger patients. d. Alcohol alone does not cause cognitive impairment in older patients. e. Alcohol consumption is responsible for 10% of all hospitalizations in patients age >65 years. a. The CAGE screening for alcohol abuse retains the same sensitivity and specificity it has for younger populations. An 80-year-old woman who lives alone at home presents with concerns about maintaining her independent living status. She continues to drive and care for herself and her pet dog but reports two falls over the past 4 months. During one fall, she struck her head, causing a bruise over the right eye. She attributes these episodes to environmental factors: Once she tripped over a rug, and once she misjudged the depth of the curb while crossing the street. Which of the following would be the best approach to this patient?

a. Advise the patient to be more careful and attentive to her surroundings and provide reassurance that two episodes is not a cause for concern. b. Advise her that she may require a walker or a cane to provide better balance. c. Advise her that falls are associated with aging and that no preventive measures have proven effective. d. Perform a comprehensive assessment of fall risk d. Perform a comprehensive assessment of fall risk and plan preventive interventions. A 44-year-old female mathematician presents to clinic with a complaint of a mass in the right breast. Her partner noticed this mass 2 days ago, and the patient feels guilty because she has only had one mammogram and does not engage in breast self-examination (BSE) on any regular basis. She has no family history of breast cancer, and her prior mammogram was ordered as a routine screening test at age 43 years after a brief discussion with her primary care provider. After a thorough investigation reveals a benign cyst, what advice should be given to this patient about screening for breast cancer in her age group? a. BSE is well evidenced, and all recommending agencies agree that it should be taught and reinforced. b. Clinical breast examination (CBE) is superior to BSE and should be a routine part of annual examinations starting at age 30 years. c. This patient was in compliance with the c. This patient was in compliance with the U.S. Preventive Services Task Force (USPSTF) recommendations for her age group and risk factors prior to her current complaint. A 42-year-old female website developer presents for an annual preventive examination with questions about breast cancer screening. She is concerned about the radiation exposure associated with mammography and is interested in magnetic resonance imaging (MRI) as a possible alternative for routine screening. She is otherwise healthy with no family history of breast, ovarian, or colon cancer. Which of the following is true about MRI as a screening modality for breast cancer in the general population? a. Breast cancer screening by MRI has been well studied in the general population. b. Sensitivity of screening for breast cancer increases with breast MRI at the expense of specificity. c. This patient is an ideal candidate for screening via breast MRI based on current evidence. d. Women at low lifetime risk of breast cancer (<20%) are recommended to undergo screening MRI. e. Known BRCA1 or B b. Sensitivity of screening for breast cancer increases with breast MRI at the expense of specificity.

A 35-year-old G0P0 woman presents to clinic with a complaint of bilateral nipple discharge. This discharge started several weeks ago and has occurred at irregular intervals since that time. She does not complain of local tenderness, redness, fever, or any other systemic symptoms aside from slightly irregular periods over the last few months. On examination, she is able to express a small amount of discharge, which is sent to the laboratory and found to be consistent with breast milk but without any signs of blood or pus. Screening laboratories are also sent, which reveal a normal blood count, metabolic panel, thyroid- stimulating hormone, and human chorionic gonadotropin (HCG) level. Further laboratories are still pending. Which of the following is the most likely diagnosis? a. Mastitis b. Ductal carcinoma in situ c. Paget disease of the breast d. Occult pregnancy e. Prolactinoma e. Prolactinoma A 22-year-old G0P0 undergraduate student presents to clinic after finding a breast mass on breast self-examination (BSE) at home. The mass is nontender without skin changes, erythema, or overlying swelling. She has heard that most breast cancers are found by patients themselves, and she is very concerned that she may have breast cancer. Which of the following is true about BSE and self- detection of breast cancer? a. Most masses that women find at home and bring to a provider's attention turn out to be malignant. b. This patient is more likely to find a fibroadenoma than a cancer on self- examination. c. The most likely breast mass this patient is likely to find in herself is an abscess complicating underlying mastitis. d. Because of this patient's age, breast masses should not be pursued with imaging and diagnosis because the risk of cancer is so low. e. BSE is universally recommended b b. This patient is more likely to find a fibroadenoma than a cancer on self-examination. A 48-year-old female psychologist presents to clinic with concerns about her breast cancer risk after an age-matched cousin was recently diagnosed with this disease. This cousin is the third family member on her father's side in as many years to be diagnosed with breast cancer, including the patient's own father, who had surgery and subsequent treatment 3 years ago for breast cancer. The patient has little other knowledge of her family history, only that her grandparents independently arrived from Eastern Europe near the end of World War II and were among very few members of their family that survived the war. The patient has read about testing for the breast cancer genes (BRCA1 and BRCA2) and desires

further information about whether this would be appropriate for her. Which of the following is true about this patient's indications for BRCA testing? a. Her familial lineage is irrelevan d. This patient carries several risk factors that together justify BRCA testing. CHAPTER 18: Breasts & Axillae A 68-year-old former paleontologist presents to clinic with concerns about her breast cancer risk. Her mother developed the disease in her 50s and died from it in her 60s. A younger cousin developed the disease a few years ago before the age of 50 years, but this individual was not tested for the BRCA1 and BRCA2 genes. In addition, the patient suffered from lymphoma in her 20s and had radiation to the chest. She did take hormone replacement therapy for a few years before data emerged that this may contribute to breast cancer risk. She has had several abnormal mammograms in her 50s for persistently dense breasts with subtle findings, but follow-up biopsies never showed any malignant pathology. Which of the following is true regarding magnetic resonance imaging (MRI) screening of this patient? a. No agency recommends breast MRI for a patient such as this one, who has moderately but not e c. Regardless of recommendations, the high sensitivity of breast MRI comes at the expense of markedly decreased specificity (i.e., the ability to rule out disease in healthy breasts). CHAPTER 18: Breasts & Axillae A 66-year-old female museum curator presents for a routine annual examination. On examination, a notably enlarged supraclavicular lymph node is appreciated on the right side. The lymph node is nontender and feels firm and rubbery. She denies any localized or systemic symptoms such as breast lumps, fevers, or night sweats. She has been taking conjugated estrogen tablets for 9 years since menopause, though she has not taken progestin compounds since she had a hysterectomy for heavy bleeding at age 45 years. Which of the following is true about this presentation of lymphadenopathy? a. Breast cancer always presents with axillary lymphadenopathy because the lymphatics of the breast uniformly drain into the axilla. b. Supraclavicular nodes are generally considered benign and require no further evaluation or follow-up. c. Supraclavicular nodes are found along the anterior edge of the trapeziu e. Metastatic breast cancer cells may spread directly into the infraclavicular and then supraclavicular nodes without first causing notable changes in the axillary nodes. A 24-year-old graphic designer presents to clinic with a concern for a breast mass. A rubbery, mobile, nontender mass is palpated in the right breast as described by the patient, which is consistent with a firbroadenoma. In describing

the location of the mass, the examiner notes that it is 3 cm proximal to and 3 cm to the left of the nipple. Which of the following would be the most appropriate way to report this finding? a. "Rubbery, mobile, nontender mass located in right breast, in the 10:30 position from the nipple" b. "Rubbery, mobile, nontender mass located in right breast, in the lower outer quadrant" c. "Rubbery, mobile, nontender mass located in right breast, in the upper inner quadrant" d. "Rubbery, mobile, nontender mass located in the left breast, upper outer quadrant" e. "Rubbery, mobile, nontender mass located in right breast, in the 1:30 position from the nipple" a. "Rubbery, mobile, nontender mass located in right breast, in the 10:30 position from the nipple" A 54-year-old female dietician presents for a routine annual examination. On review of systems, she reports that she has had many breast findings over several years, including one biopsy with normal pathology. She feels that her breasts have become far less lumpy since she underwent menopause 3 years ago. Which of the following is true regarding changes in the breasts with menopause? a. Transformation of breasts to primarily fatty tissue with menopause decreases the sensitivity and specificity of mammograms. b. Estrogen in hormone replacement therapy (HRT) has no effect on breast density after menopause. c. Glandular tissue of the breast atrophies with menopause, primarily due to decrease in the number of lobules. d. Breast density has no genetic component and is entirely due to estrogen dose from endogenous and exogenous sources over the lifetime. e. Mammography performs most poorly i c. Glandular tissue of the breast atrophies with menopause, primarily due to decrease in the number of lobules. CHAPTER 19: Abdomen An overweight 26-year-old public servant presents to the Emergency Department with 12 hours of intense abdominal pain, light-headedness, and a fainting episode that finally prompted her to seek medical attention. She has a strong family history of gallstones and is concerned about this possibility. She has not had any vomiting or diarrhea. She had a normal bowel movement this morning. Her βhuman chorionic gonadotropin (β - hCG) is positive at triage. She reports that her last period was 10 weeks ago. Her vital signs at triage are pulse, 118; blood pressure, 86/68; respiratory rate, 20/min; oxygen saturation, 99%; and temperature, 37.3ºC orally. The clinician performs an abdominal exam prior to her

pelvic exam and, on palpation of her abdomen, finds involuntary rigidity and rebound tenderness. What is the most likely diagnosis? a. Ruptured tubal (or ectopic) pregnancy b. Acute cholecystitis c. R a. Ruptured tubal (or ectopic) pregnancy A 63-year-old janitor with a history of adenomatous colonic polyps presents for a well visit. Basic labs are performed to screen for diabetes mellitus and dyslipidemia. Electrolytes and liver enzymes were also measured. His labs are all normal expect for moderate elevations of aspartate aminotransferase, alanine aminotransferase, γ - glutamyl transferase, and alkaline phosphatase as well as a mildly elevated total bilirubin. He presents for a follow-up appointment and the clinician performs an abdominal exam to assess his liver. Which of the following findings would be most consistent with hepatomegaly? a. Liver span of 11 cm at the midclavicular line b. Liver span of 8 cm at the midsternal line c. Dullness to percussion over a span of 11 cm at the midclavicular line d. Dullness to percussion over a span of 8 cm at the midsternal line e. Liver palpable 3 cm below the right costal margin, mid clav e. Liver palpable 3 cm below the right costal margin, mid clavicular line, on expiration A 63-year-old underweight administrative clerk with a 50-pack-year smoking history presents with a several month history of recurrent epigastric abdominal discomfort. She feels fairly well otherwise and denies any nausea, vomiting, diarrhea, or constipation. She reports that a first cousin died from a ruptured aneurysm at age 68 years. Her vital signs are pulse, 86; blood pressure, 148/92; respiratory rate, 16; oxygen saturation, 95%; and temperature, 36.2ºC. Her body mass index is 17.6. On exam, her abdominal aorta is prominent, which is concerning for an abdominal aortic aneurysm (AAA). Which of the following is her most significant risk factor for an AAA? a. Female gender b. History of smoking c. Underweight d. Family history of ruptured aneurysm e. Hypertension b. History of smoking CHAPTER 19: Abdomen A 76-year-old retired man with a history of prostate cancer and hypertension has been screened annually for colon cancer using high sensitivity fecal occult blood testing (FOBT). He presents for followup of his hypertension, during which the clinician scans his chart to ensure he is up to date with his preventive health

care. He has a positive FOBT on one occasion at age 66 years and subsequently went for a colonoscopy. Internal hemorrhoids and sigmoid diverticuli were found on colonoscopy. He has no first-degree relatives with a history of colorectal cancer or adenomatous polyps. What are the U.S. Preventive Services Task Force (USPSTF) screening recommendations for this patient? a. Do not screen routinely b. Continue annual FOBT screening until age 80 years c. Continue annual FOBT screening until age 85 years d. Repeat colonoscopy this year e. Sigmoidoscopy every 5 years with FOBT every 3 year a. Do not screen routinely CHAPTER 19: Abdomen An otherwise healthy 31-year-old accountant presents to an outpatient clinic with a 3-year history of recurrent crampy abdominal pain that lasts for about 1- 2 weeks each episode and is associated with onset of constipation. She describes infrequent, small hard stool that she finds very difficult to pass. She has tried to increase dietary fiber and water intake, but usually this is not sufficient and she resorts to over-the-counter laxatives, which she finds upset her stomach but do resolve the constipation. Symptoms typically gradually resolve with bowel movements. Which of the following is the most likely physiological mechanism for her constipation? a. A large, firm fecal mass in the rectum b. Decreased fecal bulk c. Functional change in bowel movement d. Spasm of the external sphincter e. Impairment of autonomic innervations c. Functional change in bowel movement A 23-year-old woman comes to the respirology clinic for follow-up of her chronic sinusitis and bronchiectasis that is associated with a rare congenital condition called Kartagener syndrome. The preceptor notes that she has situs inversus and asks for a physical exam. Which of the following descriptions best fits with findings on the abdominal exam? a. Tympany to percussion in the right upper quadrant, dullness to percussion of the left upper quadrant b. Protuberant abdomen that has scattered areas of tympany and dullness; stool is felt on palpation c. Liver dullness in the right upper quadrant that is displaced downward by the low diaphragm due to chronic obstructive pulmonary disease d. Dullness to percussion of the left lower anterior chest wall roughly at the anterior axillary line

e. A change in percussion from tympany to dullness in the left lower anterior chest wall on inspiration a. Tympany to percussion in the right upper quadrant, dullness to percussion of the left upper quadrant CHAPTER 19: Abdomen An otherwise healthy 28-year-old lawyer presents to the Emergency Department with a 1-day history of severe abdominal pain. The emergency physician suspects appendicitis and general surgery is consulted. The resident believes the patient has signs of peritonitis on exam. Which of the following physical exam findings supports peritonitis? a. Voluntary contraction of the abdominal wall that persists over several examinations b. Pressing down onto the abdomen firmly and slowly and withdrawing the hand quickly produces pain c. Abdominal pain that increases with hip flexion d. Localized pain over McBurney point, which lies 2 inches from the anterior superior iliac spinous process on a line drawn from the umbilicus e. Pain with internal rotation of the right hip b. Pressing down onto the abdomen firmly and slowly and withdrawing the hand quickly produces pain CHAPTER 19: Abdomen A 58-year-old man with a history of diabetes and alcohol addiction has been sober for the last 10 months. He presents with a 4-month history of increasing weakness, recurrent epigastric pain radiating to his back, chronic diarrhea with stools 6-8 times daily, and weight loss of 18 lb over 4 months. What is the mechanism of his most likely diagnosis? a. Helicobacter pylori infection b. Inflammation of the gallbladder c. Inflammation of colonic diverticulum d. Reduced blood supply to the bowel e. Fibrosis of the pancreas e. Fibrosis of the pancreas CHAPTER 19: Abdomen A 46-year-old executive who is obese and otherwise healthy presents to a family medicine clinic with a 3-month course of recurrent severe abdominal pain that usually resolves on its own after a few hours. Her last episode was prolonged lasting 6 hours, and she is frustrated that she has had to leave or miss work on three separate occasions. She would like a diagnosis and the problem fixed. Which symptoms or signs would be most suggestive of a diagnosis of biliary colic?

a. Exacerbating factor includes alcohol intake b. Positive McBurney point tenderness c. Poorly localized periumbilical pain d. Vomiting of bile e. Associated right shoulder pain e. Associated right shoulder pain CHAPTER 20: Male Genitalia A 67-year-old electronics technician with a history of hypertension and type 2 diabetes presents for his yearly physical examination and complains of progressively worsening erectile dysfunction (ED). While counseling him, the clinician mentions that multiple processes must take place to achieve an erection. Which of the following structures would be most affected by vascular deficiencies related to his preexisting medical conditions and is likely contributing to his symptoms? a. Corpora cavernosa b. Ejaculatory duct c. Epididymis d. Seminal vesicle e. Vas deferens a. Corpora cavernosa CHAPTER 20: Male Genitalia A 29-year-old graduate student states that he is able to achieve an erection and ejaculate during sexual intercourse; however, he does not experience any pleasurable sensation of orgasm. He is otherwise healthy and is not on any medications. What is the most likely cause of his problem? a. Androgen insufficiency b. Endocrine dysfunction c. Peyronie disease d. Psychogenic e. Sexually transmitted infection (STI) d. Psychogenic CHAPTER 20: Male Genitalia Multiple processes must take place in order for a male to sustain an erection. Various cues stimulate sympathetic outflow from higher brain centers to the T11- L2 levels of the spinal cord and parasympathetic outflow from S2 to S4 reflex arcs. Local vasodilatation within the penis erectile tissue results from increased levels of which of the following? a. Follicle-stimulating hormone (FSH) b. Gonadotropin-releasing hormone (GRH) c. Luteinizing hormone (LH)

d. Nitric oxide (NO) and cyclic guanosine monophosphate (cGMP) e. Testosterone d. Nitric oxide (NO) and cyclic guanosine monophosphate (cGMP) CHAPTER 20: Male Genitalia The human papillomavirus (HPV) can cause genital warts in males and females as well as cervical cancer in females. Vaccination against HPV is available and should be offered to males between what ages? a. 6-9 months b. 1-3 years c. 5-7 years d. 9-21 years e. 30-50 years d. 9-21 years CHAPTER 20: Male Genitalia A 32-year-old male complains of a painless, cystic mass just above his left testicle. During the physical examination, a strong flashlight is placed behind the scrotum through the area in question and transillumination is noted. What is the most likely diagnosis? a. Direct hernia b. Indirect hernia c. Spermatocele d. Testicular tumor Varicocele c. Spermatocele CHAPTER 20: Male Genitalia A 25-year-old graduate student presents to the clinic complaining of scrotal pain, which has been increasing over the past 2 days. He is sexually active and has had unprotected intercourse with multiple partners in the past couple of weeks. On examination, some mild to moderate swelling of the scrotum on the right and tenderness with palpation of the right testicle are notes. What is the most likely diagnosis? a. Acute epididymitis b. Hydrocele c. Primary syphilis d. Spermatocele e. Testicular cancer a. Acute epididymitis CHAPTER 20: Male Genitalia A 32-year-old elementary teacher requests a workup for infertility. He and his wife

have been trying to conceive for the last 2 years. He reports that his wife has been evaluated and does not appear to have any infertility issues. The overall examination does not reveal any significant abnormalities. He is of average height and weight and has normal secondary sex characteristics of the genitalia. Of the following, which would be most likely be abnormal and causing male infertility? a. 5α - Dihydrotestosterone b. 5α - Reductase c. Follicle-stimulating hormone (FSH) d. Luteinizing hormone (LH) e. Thyroid-stimulating hormone (TSH) c. Follicle-stimulating hormone (FSH) CHAPTER 20: Male Genitalia While performing a physical examination on male patients, it is possible to palpate multiple structures in relation to the inguinal canal and related hernias. Which of the following is not palpable during an external examination of the abdominal wall or inguinal region? a. External inguinal ring b. Internal inguinal ring c. Pubic tubercle d. Anterior superior iliac spine e. Direct inguinal hernia b. Internal inguinal ring CHAPTER 20: Male Genitalia A 20-year-old college student presents for his annual physical examination. He recently became sexually active and is inquiring about the best means of preventing sexually transmitted infections (STIs). Of the following, which would be the most effective means of prevention? a. Early withdrawal b. Male condoms c. Spermicides d. Diaphragms e. Cervical caps b. Male condoms CHAPTER 20: Male Genitalia A 21-year-old college student presents to the student health clinic for a full physical examination. He is generally healthy; however, he reports that he has had sexual intercourse with multiple partners in the past couple of months. He noticed a small lesion on the shaft of his penis a few days ago. While performing the examination, he unwillingly achieves an erection. How should the clinician

proceed at this point? a. Stop the examination immediately. b. Have him return to see another provider. c. Explain this is a normal response and finish the examination. d. Tell him the examination cannot proceed until the erection subsides. e. Assume that he is malingering. c. Explain this is a normal response and finish the examination. CHAPTER 21: Female Genitalia A 45-year-old driver's education instructor presents to the clinic for heavy periods and pelvic pain during her menses. She reached menarche at age 13 years and has had regular periods except during her pregnancies. She is a G4P3013 and does not use birth control as her husband has had a vasectomy. She states this has been going on for about a year but seems to be getting worse. Her last period was 1 week ago. On bimanual exam, a large midline mass halfway to the umbilicus is palpated. Each adnexal area is nonpalpable. Her rectal exam is normal. Her body mass index (BMI) is 27. What is the best explanation for her physical finding? a. Large colonic stool b. Ovarian mass c. Fibroids d. 4-Month pregnancy e. Bartholin gland enlargement c. Fibroids CHAPTER 21: Female Genitalia A 32-year-old G0 woman comes for evaluation on why she and her husband have been unable to get pregnant. Her husband has been married before and has two other children, ages 7 and 4 years. The patient relates she began her periods at age 12 and has been fairly regular ever since. She began oral contraceptive pills from when she got married until last year, when she began to try for a pregnancy. Before this she had regular cycles for 10 years. She has had a history of five prior partners. She relates she was once treated for a severe genital infection when she was in college. Based on this patient's history, what is the best explanation for her infertility? a. Prior pelvic inflammatory disease (PID) b. Prior Bartholin gland infection c. Prior herpes infection d. Metabolic disorder with subsequent hormonal irregularities leading to anovulation e. Secondary amenorrhea a. Prior pelvic inflammatory disease (PID)

CHAPTER 21: Female Genitalia A 24-year-old retail clerk presents to the clinic for an annual exam. Her last Pap was 3 years ago and was normal. She is a G0 and is currently not sexually active although she has had two lifetime partners. She is on oral contraceptive pills for cycle control and has no medical problems. Based on guidelines, the clinician proceeds to perform a Pap smear and places the speculum. There are two layers of cells, squamous and columnar. Where is the most important area to obtain cells for a Pap smear? a. Zona reticularis b. Transformation zone c. Squamous zone d. Columnar zone e. Linea nigra b. Transformation zone CHAPTER 21: Female Genitalia A 35-year-old grade school teacher presents for her annual exam. Her last Pap smear was 4 years ago and normal. She is a G1P1 with a 6-year-old child. She has had four lifetime partners but only one partner in the last 12 years. Otherwise she has no complaints. A speculum exam is done followed by a bimanual examination during which a rectovaginal mass is palpated. Which of the following exam findings would be most reassuring that this is not a colonic mass? a. No cervical motion tenderness b. No pus from the os c. The mass dents with digital pressure d. Both adnexa are nontender e. The perineum has no lesions c. The mass dents with digital pressure CHAPTER 21: Female Genitalia A 21-year-old college student presents for her first annual exam. She has been sexually active for 1 year and has had two partners. She is not aware of having had any sexually transmitted diseases (STIs). She is using condoms for birth control and STI prevention but admits to not always using them regularly. Her last menses was 2 weeks ago. On speculum exam, an unusual appearance is noted, which is diagnosed as warts. What is the best description for these lesions? a. Several shallow ulcers with a red base b. Translucent nodules c. Raised friable or lobed lesions d. Bright red, soft lesion arising from the cervical canal e. Strawberry cervix (small red granular spots or petechiae)

c. Raised friable or lobed lesions CHAPTER 21: Female Genitalia A 23-year-old female comes to the clinic to discuss her birth control options. Although she has been sexually active since age 16 years, she has been with one partner for the last year. She has decided to discontinue condoms and would like a different birth control option. She has not had a pelvic exam for 2 years. She had a normal Pap smear that year and negative sexually transmitted infection (STI) testing. Her last menstrual period was 2 days ago. She states that she is still spotting. She also states that she last had sex with her boyfriend 1 week ago, so the clinician elects to postpone her speculum exam. What is the best explanation for the decision to postpone her exam? a. She is on her menses. b. She has only one current partner and does not need STI testing c. She had a normal Pap smear within the last 3 years. d. She should not be sexually active. e. She has been using condoms a. She is on her menses. CHAPTER 21: Female Genitalia An 18-year-old high school senior presents to the clinic complaining of a vaginal discharge. She states that it is thick and yellow and that she has had some recent pelvic pain. She is sexually active and is not using any type of birth control or sexually transmitted infection (STI) prevention. She denies any burning with urination, nausea, vomiting, or diarrhea. She has had some fever and chills with a temperature up to 101.5ºF. Her last menstrual period was last week. After a physical exam, she is diagnosed with pelvic inflammatory disease (PID). Visualization of purulent discharge in which of the following areas would best support a diagnosis of PID? a. Cervical os b. Posterior fornix c. Anterior fornix d. Skene gland opening e. Bartholin gland opening a. Cervical os CHAPTER 21: Female Genitalia A 27-year-old G0 bus driver presents to the clinic complaining of an itchy vaginal discharge for the last week. She reached menarche at age 12 years, became sexually active at age 18 years, and has had a total of five sexual partners. She has been with her current partner for 1 month. She is on oral contraceptive pills and does not use condoms as she is allergic to latex. Her last menstrual period was 3 weeks ago. She is not having any pelvic pain, fever, nausea, or vomiting. Her vitals are normal with a body mass index of 22. The clinician places the metal

medium Graves speculum in the vagina but cannot find the cervix. What is the best next maneuver to visualize the cervix? a. Replace the speculum with a larger one (large Graves). b. Withdraw the speculum and do a bimanual exam to find the cervix. c. Withdraw the speculum slightly and reposition it on a different slope d. Replace the c. Withdraw the speculum slightly and reposition it on a different slope CHAPTER 21: Female Genitalia A 63-year-old office worker comes to the clinic for her women's health exam. Her last Pap smear was 5 years ago and was normal. She is married and has been with the same sexual partner for the last 35 years. After performing the majority of the exam, the clinician decides to do a speculum exam to collect cytology for Pap smear. What is the correct position to have the patient in for her speculum exam? a. Sitting b. Supine c. Prone d. Trendelenburg e. Lithotomy e. Lithotomy CHAPTER 21: Female Genitalia A 68-year-old retired patient presents to the clinic complaining about feeling like something is falling out of her vagina. She is a G6P6007 and had all her children vaginally, even the twins. She went through menopause at age 55 years, and, for the last few months, she has felt this falling sensation. On exam, an anterior bulge in the vaginal wall is apparent when she bears down. Weakness in which muscle would best account for the anterior bulge in the vaginal wall? a. Levatori ani b. Anal sphincter c. Pubis symphysis d. Ischiocavernosus muscle e. Bulbocavernosus muscle a. Levatori ani CHAPTER 22: Anus, Rectum, & Prostate A 49-year-old male nurse experiences fecal incontinence after a motor vehicle accident that left him paralyzed below the waist. He asks his rehabilitation physician about the control of this function in a person without his injuries. Which of the following is true regarding the muscle control of the anal sphincter? a. The internal anal sphincter is under voluntary control, whereas the external

anal sphincter is under involuntary control. b. The internal anal sphincter is under involuntary control, whereas the external anal sphincter is under voluntary control. c. Both internal and external anal sphincter are under voluntary control. d. Both internal and external anal sphincter are under involuntary control. Control of the anal sphincters is variable between individuals. b. The internal anal sphincter is under involuntary control, whereas the external anal sphincter is under voluntary control. CHAPTER 22: Anus, Rectum, & Prostate A 62-year-old male who is undergoing evaluation for possible prostate cancer strongly declines a rectal examination, stating that, "Some trainee once did that and it hurt badly." Which of the following is true about the innervation of the anus and rectum that may explain this patient's experience of discomfort? a. The rectum contains primarily somatic nerves, whereas the anal canal contains primarily visceral nerves, making the rectum the most likely source of this patient's discomfort. b. The rectum contains primarily somatic nerves, whereas the anal canal contains primarily visceral nerves, making the anus the most likely source of this patient's discomfort. c. Proximal to the dentate line, the lower gastrointestinal tract is innervated primarily by somatosensory nerves, making the proximal reach of the examination the most likely site of this patient's pain d. The anal canal d. The anal canal has a rich somatosensory innervation, making poorly directed examinations painful in this area. CHAPTER 22: Anus, Rectum, & Prostate A 54-year-old male with a strong family history of breast and prostate cancer presents to his primary care provider to discuss prostate screening. His father died at age 73 years from prostate cancer that was not detected on routine digital rectal examinations (DREs), and he would like to minimize his chance of a similar occurrence. Which of the following is true regarding the anatomy and screening of the prostate by DRE? a. All three lobes of the prostate are palpable on DRE. b. The seminal vesicles are palpable distal to the prostate on DRE. c. The median lobe of the prostate is located anterior to the urethra and is not palpable on DRE. d. The median sulcus divides the lateral lobes from the median lobe and is palpable on DRE. e. A prostate of 5 cm diameter without palpable nodes or masses represents a normal prostate examination. c. The median lobe of the prostate is located anterior to the urethra and is not palpable on DRE.

CHAPTER 22: Anus, Rectum, & Prostate A third-year medical student rotating on the internal medicine service performs a digital rectal examination (DRE) on a 56-year-old female patient. The patient has been admitted for suspicion of a myocardial infarction, and confirmation that there is no blood in the stool is required before anticoagulation can be started. The student reports that the fecal occult blood test was negative but notes that he palpated a structure through the anterior rectum that he could not identify. The attending physician confirms normal anatomy and reviews with the student that the most likely identity of the structure palpable is which of the following? a. Sacrum b. Pectinate line c. Uterine fundus d. Prostate e. Cervix e. Cervix CHAPTER 22: Anus, Rectum, & Prostate A 45-year-old female executive reports to her primary care provider that she has recently experienced a change in the patterns of her bowel movements. She expresses a great concern as her family history includes a maternal aunt who died of colon cancer at age 49 years; her mother has had colonoscopies every 3 years with numerous adenomatous polyps removed. Which of the following historical elements would be the most concerning for colon cancer in this patient? a. Long-term history of hemorrhoids b. Recent history of black, tarry stools c. Remote history of anal pruritus d. New-onset anal fissure e. Recent onset of small-caliber stools e. Recent onset of small-caliber stools CHAPTER 22: Anus, Rectum, & Prostate A 49-year-old customer service representative presents to his gastroenterologist for follow-up of his long-standing inflammatory bowel disease (IBD). He was diagnosed with ulcerative colitis (UC) at age 37 years and has had irregular care for this condition since then. His sole colonoscopy was done at the time of diagnosis 12 years ago. His only relevant family history is of prostate cancer in his father; his mother and sisters are healthy. Which of the following is true about recommended screening for colon cancer in this patient? a. The patient should begin screening for colon cancer 10 years prior to the age of onset of his father's prostate cancer. b. The patient should undergo colonoscopy for his bowel condition, which

confers risk of colon cancer. c. The patient is due for routine age-based colon cancer screening by colonoscopy regardless of his risk factors. d. The patien b. The patient should undergo colonoscopy for his bowel condition, which confers risk of colon cancer. CHAPTER 22: Anus, Rectum, & Prostate A 49-year-old male with well-controlled HIV undergoes a proctoscopic examination as routine screening for anal cancer. The patient is asymptomatic and specifically denies complaints of frequent urination (frequency), large volume of urination (polyuria), or repeated urination at night (nocturia). Under direct visualization, the clinician observes a clear, circumferential demarcation of proximal versus distal tissue. This demarcation was not palpable on digital rectal examination (DRE) prior to proctoscopy. What is the most likely origin of this finding? a. Pathological constriction of the anal canal b. Normal anatomy of the mucosal surface c. Carcinoma d. Valve of Houston External anal sphincter b. Normal anatomy of the mucosal surface CHAPTER 22: Anus, Rectum, & Prostate A 34-year-old female reports anal pain with defecation. She notes incidentally to this complaint that she has developed episodic abdominal discomfort and sores in her mouth. Anoscopic examination reveals anal fissures that appear to be her source of pain. Which of the following underlying conditions is the clinician most likely to find? a. Inflammatory bowel disease (IBD) b. Lymphogranuloma venereu c. Human papillomavirus (HPV) d. Gonorrhea cervicitis e. Primary syphilis a. Inflammatory bowel disease (IBD) CHAPTER 22: Anus, Rectum, & Prostate A 53-year-old African American advertising agent presents for discussion of his prostate cancer risk and possible screening for this disease. His father was diagnosed at age 82 years with prostate cancer but died recently at age 87 years from a myocardial infarction before the disease progressed. Family history also reveals that his mother died of ovarian cancer when he was age 10 years, and two of his maternal aunts had breast cancer. Which of the following is true about risk and screening for prostate cancer?

a. The incidence of prostate cancer does not rise until age >65 years, thus this patient needs no screening at this time. b. Prostate cancer is always an aggressive neoplasm, thus the risks of overdiagnosis with screening is outweighed by the benefits of early case-finding. c. This patient is at an elevated risk of prostate cancer due to his family history, thus screening c. This patient is at an elevated risk of prostate cancer due to his family history, thus screening modalities should be discussed between the patient and provider. CHAPTER 22: Anus, Rectum, & Prostate A 64-year-old retired architect presents to his primary care provider with a magazine article about prostate cancer screening that states, "You should talk to your doctor about the ups and downs of prostate cancer screening." The patient hands this to the clinician and states, "Tell me about the ups and down of prostate screening." Which of the following is true about prostate cancer screening? a. Regardless of sensitivity and specificity of testing modalities, screening for prostate cancer should always be ordered due to the malignant nature of the disease. b. The prostate-specific antigen (PSA) effectively differentiates aggressively malignant prostate tumors from indolent cases. c. The prostate-specific antigen (PSA) cut-off of 4.0 ng/ml is virtually 100% specific for aggressive prostate cancer. d. Setting normal cut-offs for prostate-specific antigen (PSA) testing relies on d. Setting normal cut-offs for prostate-specific antigen (PSA) testing relies on balancing the risk of overdiagnosis with the risk of underdiagnosis. CHAPTER 23: Musculoskeletal System A thin, 58-year-old patient complains of lower back pain for years. On examination, the clinician finds that the patient has tenderness over the sacroiliac area. Which of the following conditions is most consistent with this physical sign? a. Osteoporosis b. Ankylosing spondylitis c. Malignancy d. Infection e. Torticollis b. Ankylosing spondylitis CHAPTER 23: Musculoskeletal System During an evaluation of an athletic 30-year-old patient, the clinician conducts an active range of motion evaluation at the neck. Which muscle is being assessed when the patient is asked to flex the neck?

a. Splenius capitis b. Trapezius c. Splenius cervicis d. Sternocleidomastoid (SCM) e. Sacrospinalis d. Sternocleidomastoid (SCM) CHAPTER 23: Musculoskeletal System An obese 50-year-old patient presents with a long history of back trouble. What structure in the spine supports the body's weight? a. Vertebral arch b. Intervertebral disk c. Transverse process d. Vertebral body e. Spinous process d. Vertebral body CHAPTER 23: Musculoskeletal System A 31-year-old day care worker presents with a worsening stiff, painful neck. On inspection, the patient's head is laterally deviated toward the shoulder and rotated. At this point of the examination, what is the most likely diagnosis? a. Torticollis b. Spondylolisthesis c. Osteoarthritis (OA) d. Thoracic kyphosis e. Ankylosing spondylitis a. Torticollis CHAPTER 23: Musculoskeletal System A young adult patient presents to the clinic stating that something is wrong as he looks in the mirror and sees that his shoulders are uneven. He fractured his left arm 8 weeks ago and remains in a cast. He noticed the uneven shoulders over the last week. Upon inspection, his shoulder heights are unequal and there is winging of the scapula. As the examination continues, which of the following maneuvers would confirm a likely diagnosis? a. Assess his ability to touch his toes b. Assess the lateral bending movement of his neck c. Compare the strength of his trapezia muscles d. Assess his ability to extend his back Check for listing of his trunk c. Compare the strength of his trapezia muscles

CHAPTER 23: Musculoskeletal System During a musculoskeletal examination, the clinician instructs the patient to look over one shoulder, and then the other shoulder. This action assesses the movement of which muscle(s)? a. Scalenes b. Sternocleidomastoid (SCM) c. Splenius capitis d. Prevertebral muscles e. Splenius cervicis b. Sternocleidomastoid (SCM) CHAPTER 23: Musculoskeletal System During a musculoskeletal examination of the spine, what is the action(s) of the erector spinae muscle group? a. Rotation of the spine b. Extension of the spine c. Flexion of the spine d. Lateral bending of the spin e. Rotation and lateral bending of the spine b. Extension of the spine CHAPTER 23: Musculoskeletal System The clinician is seeing a middle-aged patient who has a diagnosis of lumbar spinal stenosis. The patient's history is consistent with this diagnosis as he has pain in the back with walking that improves with rest. Which physical sign(s) are most consistent with his diagnosis? a. Hyperreflexia of the lower limb b. Pelvic tilt or drop c. Thoracic kyphosis d. Positive straight-leg raise e. Flexed forward posture with lower extremity weakness e. Flexed forward posture with lower extremity weakness CHAPTER 23: Musculoskeletal System The clinician is seeing a 58-year-old patient with a diagnosis of arthritis. The patient complains of pain in his knees, hips, hands, wrists, neck, and low back. Based on which joints are involved, the patient most likely has which joint problem? a. Osteoarthritis (OA) b. Rheumatoid arthritis (RA) c. Psoriatic arthritis

d. Gout e. Polymyalgia rheumatica a. Osteoarthritis (OA) CHAPTER 23: Musculoskeletal System A 62-year-old patient with rheumatoid arthritis (RA) complains of increased joint stiffness. What characteristic(s) are consistent with her diagnosis of RA? a. Stiffness follows joint activity. b. Joint distribution is asymmetrical. c. Swelling of the synovial tissue is seen in joints and tendon sheaths. d. It most frequently involves the first metatarsophalangeal joint. e. Tophi are found in the subcutaneous tissue. c. Swelling of the synovial tissue is seen in joints and tendon sheaths. CHAPTER 24: Nervous System A 55-year-old woman with a headache explains to the clinician that she has had headaches before, but this one is unusual because of some new symptoms. Which of the following symptoms would prompt an immediate investigation? a. The headache is similar in nature to prior ones she has had for decades but more severe. b. The patient had a car accident and minor head trauma about 3 months ago. c. The patient also has developed fever and night sweats and thinks she lost some weight. d. The headache comes and goes. e. The patient lost her glasses. c. The patient also has developed fever and night sweats and thinks she lost some weight. CHAPTER 24: Nervous System In the case of a middle-aged female with a pounding headache, what is an effective question to ask the patient? a. Does the patient have any aura prior to the headaches? b. How old is the patient? c. Is she feeling stressed? d. Does she think she is losing her memory? e. Has she ever seen anyone with a stroke? a. Does the patient have any aura prior to the headaches? CHAPTER 24: Nervous System A 35-year-old female patient has had migraines for much of her adult life. Ather regular checkup, she is healthy, takes no medications except oral contraceptive pills (OCPs), exercises, and has a steady job. Her only complaint is that her migraines seem to have become worse, and, for the past few weeks, she has

been waking up at night with headache and also nausea. Which of the following is the best course of action? a. Reassure her that this is a common pattern with migraines. b. Order studies to evaluate potential transient ischemic attacks (TIAs) because she is on OCPs. c. Take a further history and perform a very careful neurological examination. d. Treat her for sinusitis. e. Prescribe a strong medication for her migraines. c. Take a further history and perform a very careful neurological examination. CHAPTER 24: Nervous System An 82-year-old grandmother presents to the Emergency Department in the care of her extended family with new-onset speech impairment. According to family members, the patient awoke with this symptom as well as difficulty in understanding questions or following commands. Her past medical history is remarkable for atrial fibrillation but no other notable conditions. On examination, her speech is verbose but poorly comprehensible and lacks meaning. She is unable to follow simple commands. Which of the following best describes her speech disorder? a. Dysphonia with expressive deficit b. Dysarthria c. Wernicke aphasia d. Global aphasia e. Broca aphasia c. Wernicke aphasia CHAPTER 24: Nervous System A 74-year-old bus driver is delivered to the hospital via emergency transport after an astute passenger noted that the patient exhibited drooping facial features and slurred speech. The patient was diagnosed rapidly with ischemic (nonhemorrhagic) stroke, and urgent intervention lead to a near complete recovery from his symptoms. The astute passenger was thanked and congratulated for recognizing the signs of acute stroke; this individual credited this recognition to a public safety awareness campaign that outlined the critical public health need to recognize strokes early. Which of the following statements is true for risks and rapid recognition of suspected strokes? a. Atrial fibrillation is not a risk factor for ischemic stroke in individuals age ≥75 years. b. Hypertension is the leading risk factor for both ischemic and hemorrhagic stroke. c. Obesity with normal glucose tolerance is n b. Hypertension is the leading risk factor for both ischemic and hemorrhagic stroke.

CHAPTER 24: Nervous System A 70-year-old male presents to the Emergency Department accompanied by his wife, who is concerned that he has experienced a stroke. She states that he awoke with drooping of the right side of his mouth. He has a history of hypertension and diet-controlled diabetes, but no history of prior transient ischemic attacks (TIAs), strokes, or neurologic deficits. Physical examination reveals a wellnourished, right-handed male, who has an obvious flattening of the right nasolabial fold at rest. He is unable to close his right eye, wrinkle his forehead, or raise his eyebrows. The remainder of the neurologic examination is symmetric with intact strength and normal deep tendon reflexes. Based on this history and physical examination, which of the following statements is true? a. The patient most likely has a central upper motor neuron lesion involving cranial nerve (CN) VII (the facial nerve). b. The d. The patient most likely has an isolated peripheral lower motor neuron (LMN) lesion involving cranial nerve (CN) VII, the facial nerve. CHAPTER 24: Nervous System In longstanding and poorly controlled hypertension, white matter tracts in the brain are subjected to ateriolosclerotic effects. Which one of the following is most vulnerable to this process? a. Thalamus b. Basal ganglia c. Internal capsule d. Diencephalon Reticular activating system c. Internal capsule CHAPTER 24: Nervous System A 14-year-old student comes with her family to the urgent care center, having been hit in the right eye with a plastic baseball during a family reunion. She complains of a painful, watery, red right eye and sensitivity to light. She has normal visual acuity in both eyes, no diplopia, and can open and close her eyes normally. The pupils are unequal in size, 3 mm in diameter on the left, 5 mm in diameter on the right. Which cranial nerve (CN) would be implicated as the cause of the photosensitivity complaint and the pupillary asymmetry? a. CN II b. CN III c. CN IV d. CN V e. CN VI b. CN III