NR 601 Final Exam Questions With Complete Solutions, Exams of Nursing

Download NR 601 Final Exam Questions With Complete Solutions and more Exams Nursing in PDF only on Docsity! NR 601 Final Exam An 86-year-old female comes to your office for a wellness visit. Her blood pressure is 125/70 mmHg, pulse 69 beats per min, and respiratory rate 18 breaths per min. She is well appearing and reports she is up to date on her routine vaccinations. She introduces her partner of 35 years whom she would like to make medical decisions for her in case she becomes unable to make decisions for herself. She reports that she and her partner are not married. She asks if she needs any further documentation to ensure her goals of care are followed. Which one of the following would be the most appropriate recommendation for this patient and her partner? Advise them to file an advanced directive. . An 81-year-old transgender female with history of depression and hyperlipidemia presents to your clinic for routine care. She endorses a history of smoking, currently smoking 1 pack per day, and occasionally drinks a glass of wine, although she denies illicit drug use. She reports she takes atorvastatin 20 mg and subcutaneous estrogen therapy. Counseling on smoking cessation An 84-year-old male with history of stroke without residual deficit, systolic heart failure, and type 2 diabetes presents to clinic for follow-up. He is independently living in a retirement community and still works part time on a golf course. He currently takes aspirin 81 mg, metoprolol tartrate 25 mg BID (twice a day), furosemide 20 mg BID, and lisinopril 10 mg daily. He reports his last colonoscopy was 8 years ago, with no abnormality. He reports he is sexually active with men and women, engaging in receptive oral, receptive anal, and penetrative sex. He states he has had over three sexual partners in the last year with intermittent condom use. What sexually transmitted infection testing should be offered? Urine testing, blood testing, anal swab, and oropharyngeal swab Which of the following is true about tolterodine? It has greater risk of adverse effects with its twice-daily formulation. An 82-year-old man, Mr. A, complains of worsening nocturia, occurring four times per night. His other lower urinary tract symptoms are slow stream, occasional urgency, and urgency- related leakage once weekly. Medical problems include poorly controlled hypertension, diastolic heart failure, hyperlipidemia, osteoarthritis, and prediabetes. His medications include lisinopril 20 mg daily, metoprolol succinate 75 mg daily, atorvastatin 10 mg daily, metformin 500 mg twice daily, hydrocodone- acetaminophen as needed, and aspirin 81 mg daily. Amlodipine 5 mg daily was recently added by his cardiologist. On review of systems, Mr. A complains that nocturia is causing daytime fatigue, and he is more constipated. Physical examination is or instrumental (IADL) dependencies. What treatment would you recommend? Hormonal therapy only An 86-year-old man with no ADL deficits who has stopped driving because of macular degeneration is evaluated for a urinary tract infection associated with urinary retention. The consulting urologist places a Foley catheter and sends a prostate- specific antigen (PSA) level that comes back 12 ng/mL. Three months later after the Foley has been removed and he has had a good response to tamsulosin, his PSA is still 10 ng/mL. What is the appropriate next step in managing this man's prostate problem? Repeat PSA in 6 months In which of the following patients is chemical or surgical castration likely to prolong survival? A 78-year-old man who had a radical prostatectomy and external beam radiation therapy 10 years earlier now has a PSA level of 24.5 ng/mL. A CT scan of the pelvis shows an enlarged pelvic lymph node, and a bone scan is positive in the pelvis. On admission to the hospital, an 85-year-old woman was found to have a fungating mass on her right breast. The mass is 9 cm in diameter, partially ulcerated, and associated with edema of the arm and obvious pain. The patient has no children and had lived alone until recently, when a neighbor became concerned for what appeared to be a progressive loss of memory and neglect of the house. A nephew living in another city eventually came to take care of the situation and arranged for the admission. The patient appears confused and withdrawn; her appearance is disheveled, but she seems to be independent in her ADLs. The medical history is negative for any serious illnesses. She was able to drive her own car until shortly before this admission. The nephew does not wish to authorize hospice "right now." A positron-emission tomography scan was negative for metastatic disease. In addition to determining the cause of her delirium, which of the following is the best way to address the breast mass? The mass should be biopsied to study hormone receptor and HER2/neu antigen status. A 78-year-old man has an emergency partial colectomy for lower gastrointestinal bleeding. A localized colonic adenocarcinoma is completely resected. The surgeon did not dissect lymph nodes for metastatic sampling. The patient wants to know if he should have chemotherapy. Should he? No because he can be followed with serial carcinoembryonic antigens and CT scans. An 80-year-old woman has no weight loss, no pain, and no distention but over 2 years increasingly complains of constipation despite adequate medical treatment. A colonoscopy is negative. An abdominal CT is performed. It reveals well- circumscribed pelvic masses, the largest adherent to the ovarian ligament. The best first step is: Invite her to return with a family member and have a long talk about the diagnostic and therapeutic options. An 85-year-old man with chronic obstructive pulmonary disease presents to your office with his daughter with the complaint of new onset chest pain, shortness of breath, and cough. He is clearly tachypneic and has tactile fremitus and egophany and crackles heard at the right lung base. His daughter just wants you to give him an antibiotic pill so that she can take him home. You are concerned that he might need to be hospitalized and require IV antibiotics. What statement is true? Treatment decisions for pneumonia are based on its severity, the presence of comorbid illnesses, and a prior history of MRSA or Pseudomonas respiratory infection. An 80-year-old woman that you follow in a nursing home has an acute decline in her mental status. She has a fever >100° F, but no other focal complaints or findings on physical examination except for a chronic indwelling urinary catheter. What statement is true? Fever in an older adult with an indwelling urinary catheter is an appropriate indication to start empiric antibiotic therapy. An 82-year-old woman receives oral amoxicillin-clavulate for a skin abscess on her leg. She develops new onset of frequent Mr. Roberts, a 72-year-old patient who has sought medical care on an intermittent basis in the past, complains of aching discomfort in his perineal area, urinary urgency, and frequency for the past few years. He also complains of insomnia and intermittent anxiety that he attributes to loneliness after his wife's death about a year ago. Digital rectal examination (DRE) reveals a slightly enlarged, nontender prostate with no palpable nodules. Perineal examination is normal. Bladder scan is unremarkable and postvoid residual urine volume is 50 mL. Urinalysis shows no WBCs or RBCs. Urine culture is negative. Previous treatment has included dietary modification and alpha- blocker medication. What is the most appropriate next step? Screen for depression. Mr. Hunter, a 69-year-old man, complains of urinary frequency and urgency that have increased over the past several months. There is no dysuria, hematuria, or sensation of incomplete voiding. He drinks 2 cups of coffee daily and diet cola multiple times a day. His International Prostate Symptom Score (IPSS) is 6, with a bother score of 1 indicating mild voiding symptoms with low impact on his quality of life. His medical history includes hypertension, coronary artery disease, and benign prostatic hyperplasia. Current medications are aspirin, metoprolol, and hydrochlorothiazide. Physical examination reveals normal sized prostate. Which of the following is the best next step? Lifestyle modifications Two years later Mr. Hunter reports progression of his urinary symptoms and desires "a pill to make this better." His current IPSS is 17, with a bother score of 3 indicating moderate voiding symptoms with moderate impact on his quality of life. On review of systems he notes that his vision has worsened, especially in his left eye. His ophthalmologist has recommended cataract surgery. For which of the following medications would initiation of therapy be delayed until after cataract surgery? Tamsulosin Several years later, Mr. Hunter, who is now 75 years old, seeks additional intervention for his urinary symptoms that have progressed further. He now experiences slow urinary stream, hesitancy, straining, and a feeling of incomplete emptying in addition to the previous urinary urgency and frequency. At times, he has noted blood in his urine. He has had five urinary tract infections (UTIs) in the past 2 years. His current IPSS is 24, with a bother score of 5 indicating severe voiding symptoms with high impact on his quality of life. Mr. Hunter's updated medical history includes hypertension, coronary artery disease, benign prostatic hyperplasia, cataract surgery 4 years ago, and two falls within the past year while rushing to the bathroom during the night. Current medications are aspirin, metoprolol, finasteride, and tamsulosin. Physical examination reveals an enlarged, nontender prostate, about 50 g in size without discrete nodules. Upon further evaluation, the intermittent hematuria is attributed to BPH. Postvoid residual volume is 110 mL. Uroflowmetry reveals urinary flow rate of 12 mL/s. Which of the following is the best next step in management? Perform surgical resection of prostate. The US Advisory Committee on Immunization Practices and the Centers for Disease Control currently recommend which one of the following? a. All older adults be immunized against influenza annually and that they receive at least one pneumococcal vaccination. b. All high-risk older adults should receive an additional pneumococcal vaccination 5 years or more after their first immunization. c. Older adults should receive a one-time revaccination for pneumonia if they were initially vaccinated more than 5 years previously and were less than 65 years of age at the time of the initial vaccination. d. All of these are recommended. Healthcare providers should recommend that older adults engage in which one of the following? 150 minutes of moderate intensity physical activity weekly Guidelines for the primary prevention of stroke recommend that aspirin be used in which one of the following? Individuals whose risk is high enough for the benefits to outweigh the risks redirection, calming music, and reassurance are unsuccessful. When safety of the patient and staff are in jeopardy and nonpharmacologic approaches have failed, which of the pharmacologic agents would be the best choice for treating the agitation associated with his delirium? Haloperidol A 69-year-old female presents to your office for routine primary care. Her elder sister was recently diagnosed with Alzheimer disease, and she wonders what steps she can take to reduce her own risk of developing dementia. Which of the following statements about the prevention of dementia is true? There is moderate quality evidence to suggest control of cardiovascular and metabolic risk factors, such as blood pressure, weight, and blood sugar, may reduce risk of dementia. A 78-year-old male was recently diagnosed with Alzheimer disease. He scored 23/30 on his Montreal Cognitive Assessment (MoCA) and his clinical presentation is consistent with mild disease. He returns to clinic with his family to discuss possible initiation of pharmacotherapy. You consider beginning donepezil 5 mg daily for 4 weeks, with a plan to increase to 10 mg daily if he tolerates the lower dose. Which of the following is not a common side effect of donepezil? Thrombocytopenia The remission rate of depressed patients who are 65 years and older to initial antidepressant treatment is: 30% Which of the following groups has the highest rate of suicide in older adults? White males Which of the following is not a risk factor for late-life depression? Family history of depression Which of the following is not a side effect of selective serotonin reuptake inhibitors in older adults? Increase in suicidal ideation You want to start pharmacologic treatment for depression in an older patient who is taking numerous medications. You are concerned about drug-drug interactions. Which of the following antidepressants is the least likely to cause such an interaction? Citalopram . Randall Johnson, an 80-year-old man with a history of high blood pressure and hypothyroidism, presents to your office with ongoing dizziness. He feels it has worsened since the summer months began. He states it is worst when he gets up from his chair on his front porch to stand or when he is working in his garden. If he stands still for a few minutes, the dizziness typically resolves on its own. If he tries to move too quickly, he has felt like he may pass out, but has not yet done so. He denies changes in vision or hearing. He has had no recent changes in his medication. On examination today, he is a frail-appearing older man in no acute distress. Vitals show a blood pressure of 118/71 mmHg with a pulse of 55 beats per minute. Heart and lung exams are benign. What is the most likely cause of his dizziness? Orthostatic hypotension Joyce Mitchell is a 73-year-old frail female with a history of frequent falls, who presents with rapid onset of nausea, vomiting, sweating, and horizontal nystagmus. She also reports hearing loss in the right ear. After testing and further questioning, you diagnose the patient with vestibular neuritis. What is the best initial course of treatment? Supportive care with antinausea and antivertigo medication Pedro Lopez is an 89-year-old male who presents to you with the complaint that he continuously experiences the feeling that a fall is imminent. He appears comfortable when seated, but is notably unsteady and imbalanced when erect, walking with a broad-based gait. Which of the following is not a standard treatment modality for this condition? Meclizine through the night, cried out from their rooms, woke other patients, and seriously disrupted the limited staff's ability to manage the facility. The night nurse thus asked the previous attending to prescribe medications that would help these individuals sleep through the night. What further diagnostic steps are required in the seven patients receiving atypical antipsychotics? Unless there is an underlying suspicion of obstructive sleep apnea (OSA) or other sleep disorder, these patients already meet criteria for irregular sleep-wake phase disorder, and no further diagnostic steps are required. You have recently assumed directorship of a nursing home that has a 30-bed dementia unit. The nursing home does not have an onsite pharmacist. You go to the dementia unit for patient observation and chart review. Immediately, you notice that although it is 9:00 AM, and most of the patients have been taken out of their rooms and placed in the dayroom, they are dozing in their wheelchairs. The window blinds block about half of the sunlight, and without the overhead fluorescent lighting, the room would be considered dimly lit. The nurses have just finished administering the morning medications. You begin focused chart review, concentrating on patient medications, cognitive/functional status, and comorbidities. When you are finished, you note that of the 28 patients currently living in this facility, seven of them are receiving a low-moderate dose of an atypical antipsychotic (quetiapine, olanzapine, risperidone, etc.) before bedtime, but only one of these patients has any history of recurrent visual hallucinations and delusions. All of these individuals have either moderate-to-severe dementia from Alzheimer disease or vascular/Alzheimer overlay listed among their problems. You ask the charge nurse why these patients are receiving these medications, and he replies that his counterpart on the night shift stated that many of these patients did not sleep through the night, cried out from their rooms, woke other patients, and seriously disrupted the limited staff's ability to manage the facility. The night nurse thus asked the previous attending to prescribe medications that would help these individuals sleep through the night. . What is an appropriate step in the initial management of the seven patients receiving atypical antipsychotics? Taper to discontinue the atypical antipsychotic, and create day programs that allow patients to develop a sleep deficit/need through the morning/afternoon/early evening. What aspects of sleep hygiene may make your facility more conducive for nighttime sleep? Neutralizing antiseptic smells, minimize movement of equipment through halls, maintain quiet hours where staff can speak in areas away from residents, avoid using overhead announcement systems. Which of the following statements regarding programs to increase daytime engagement in persons with dementia is true? Daytime programs are designed to maintain client wakefulness, and as such can cover a broad range of topics, including music, art, exercise, dance, and cognitive tasks (puzzles, etc.), and should be designed with patient cognitive and physical status, cultural beliefs, social support, and available staffing in mind. An 85-year-old man with newly diagnosed nonvalvular atrial fibrillation comes to the office for a follow-up. He has a history of essential hypertension, type 2 diabetes mellitus, hyperlipidemia, and stage 3B chronic kidney disease. He takes lisinopril, atorvastatin, metformin, and aspirin. He lives in an assisted living facility and uses a walker for ambulation. He has fallen twice in the past year. On physical examination, his heart rate is normal but his rhythm is irregularly irregular. His blood pressure is 135/70 mmHg. Stop aspirin and begin apixaban 5 mg twice a day. 2. A 79-year-old woman was admitted to the hospital a month ago with an acute left middle cerebral artery ischemic stroke. On examination, she had right hemiparesis, mild motor aphasia, and dysphagia. After discharge, she was transferred to a skilled nursing facility where she has been working with physical, occupational, and speech therapy. Despite initial progress, in the last 2 weeks, she has lost her appetite, and complains of insomnia and difficulty concentrating. Which would be the next best step in management? Start escitalopram 5 mg orally daily. Iatrogenic disease Which of the following is true about cultural humility? It places emphasis on power imbalances and promotes interpersonal sensitivity through partnerships with and learning from patients. Racial disparities have been a part of US healthcare for many decades. How might this impact the expectations of older Black Americans? Reluctance to participate in medical research because of unethical studies in the past. Underrepresentation of Black physicians in the geriatric workforce. Cumulative effects of differences in access to healthcare providers. D. ALL OF THESE Dementia is a relatively common condition in the geriatric population. It becomes more common as people age. Which is the most appropriate description of "personhood" as it relates to people with dementia? The ability to relate to others as people, rather than preserving cognitive independence, is an important aspect of "personhood." Immigrant families bring cultural traditions into healthcare decisions. With regard to older adults, which of the following is true? End-of-life care is particularly sensitive to cultural beliefs and should be explored carefully with the patient and family, as appropriate. Which of the following statements is true? Lack of decision-making capacity should not be presumed if the patient goes against medical advice. Which of the following statements concerning advance directives is true? A DNR order is not equivalent to a do-not-treat order. The following are components of the open disclosure of medical error, except: A best guess as to why the error occurred. Mrs. Gloth is an 84-year-old woman whom you are admitting to the nursing home. Her son takes you aside and tells you that she has metastatic ovarian cancer but has not been told the diagnosis. He asks that you not tell her, because she would "lose all hope and die." Which of the following is an appropriate response? Suggest that you discuss this further after getting to know the patient and family a little better. Dr. Smith is obtaining informed consent from Mr. Jones to perform a colonoscopy, because the patient had blood in his stool and Dr. Smith is concerned that this might indicate the presence of carcinoma of the colon. Mr. Jones is able to recite back to Dr. Smith what a colonoscopy is, how it is done, and that a colonoscopy is performed to look for cancer. He then tells Dr. Smith that he is refusing the procedure; he knows he does not have cancer because he has not experienced any bleeding. Of the following required elements for Mr. Jones's decision- making capacity, which is impaired? Appreciation George Hall is a 91-year-old man visiting his physician to receive the results of a recent computed tomography scan of his abdomen. He is cognitively intact and still works 2 days a week. He is accompanied by his daughter Eleanor. She takes the doctor aside before the appointment and says, "Please do not tell my father any bad news. It would just kill him." If the physician were to agree, which ethical principles might this violate? Autonomy Lenore White is an 80-year-old woman who smokes two packs of cigarettes per day. She is hospitalized for pneumonia because she has presenting symptoms of cough and fever. On her second day of hospitalization, she asks the nurse to please wheel her outside so she can smoke a cigarette. The nurse feels uncomfortable agreeing to this and speaks to her clinical nurse manager. What two ethical principles are in conflict? Autonomy and nonmaleficence Which sentence completion is false? The Veterans Health Administration: Provides care management only for individuals with disabilities that are service related When a Medicare beneficiary with only traditional Part A and Part B coverage is admitted to the hospital, what will he or she will have to pay out of pocket? More than $1000 deductible and 20% of all physician fees Since passage of the ACA in 2010, the following are true about payments changes except: Providers in Medicare Advantage will be paid higher fees All of the following about the Medicare Part D prescription medication benefit plan are true except: Beneficiaries have no out-of-pocket expense for each prescription filled. All of the statements about Medicare are true except: All of the funding for Medicare comes from federal taxes. All of the statements about Medicaid are true, except: The coverage provided under Medicaid is the same in every state. Mr. B is an 82-year-old enrolled in your primary care clinic panel. His medical history includes moderate dementia and probable Alzheimer disease. He requires cues to bathe and dress but is otherwise independent in his activities of daily living. He cannot manage his medications and does not drive. His wife is his primary caregiver and has been providing 24-hour care supervision since he was found wandering outside by their neighbors. During your visit today, she admits that she is "feeling stressed" and at times "overwhelmed" with her caregiving responsibilities. She wants to know what options are available to help support her taking care of him. All of the following would be appropriate for Mr. B except: Skilled nursing facility Which of the following is true about the primary functions and duties of the skilled nursing facility medical director? Participates in monitoring and improving the facility's medical care Which one of the following is most true of the capacity to make medical decisions? It includes the ability to express a choice and to weigh options. Which one of the following is most true about the staffing of a typical nursing home? CNAs provide most of the direct patient care. Subtypes of elder mistreatment include: Psychological mistreatment, Physical mistreatment, Sexual mistreatment, Financial exploitation. ALL OF THESE Risk factors for elder mistreatment include all except: Financial independence of the caregiver Barriers to detecting elder mistreatment include all except: The tendency for many older adults to falsely claim they are being abused