NRNP 6540 FINAL EXAM PREP ( ADVANCED PRACTICE CARE OF ADULTS) ANSWERED 20232024, Exams of Nursing

Download NRNP 6540 FINAL EXAM PREP ( ADVANCED PRACTICE CARE OF ADULTS) ANSWERED 20232024 and more Exams Nursing in PDF only on Docsity! NRNP 6540 FINAL EXAM PREP ADVANCED PRACTICE CARE OF OLDER ADULTS ANSWERED 2023/2024 1. The nurse practitioner is examining an 85-year-old man with reports of abdominal pain, weakness, and loss of appetite. Which is the most likely condition to be tested for and ruled out? 1. Neoplasms and carcinomas 2. Partial seizure 3. Sarcopenia 4. Hirschsprung's disease - 5. Selected answer: 1Page: 4 Feedback 1. Certain diseases, such as neoplasms and carcinomas, are more common in the elderly, and an understanding of the epidemiology is critical in the interpretation. 2. Partial seizure is more common in early old age. 3. Sarcopenia is more common in early old age. 4. Hirschsprung's disease is most common in infancy. 6. For individuals over 65 years old, the most common morbidities are related to: 1. Heart disease, arthritis 2. Respiratory problems, cancer 3. Diabetes, stroke 4. All of these are common morbidities. - 6. Selected answer: 4 Feedback 1. Heart disease is one of the common morbidities. 2. Cancer is common in the general population; however, specific types are more common in the older patient. 3. Diabetes is common in patients over 40 years of age. 3. Many factors can influence the health of elders, including changes in the immune system. 4. Viruses and other infections are not the only considerations for infections. 5. Biochemical individuality is important in detecting asymptomatic abnormalities in older adults. Significant homeostatic disturbances in the same individual may be detected through serial laboratory tests, even though all individual test results may lie within normal limits of the reference interval for the entire group. 11. An older woman is seen in the ambulatory clinic for a routine checkup. The patient asks about results of her blood work compared to last year's results. How is it best for the clinician to respond? Select all that apply. 1. They are likely to be the same if you have had no diseases since then. 2. Blood work results may be different just because of your aging process. 3. Your results may be different because the body changes with disease and medications you are taking. 4. Blood work is not a reliable indicator of health because many things can affect your health that may not show up in the results of your blood work. 5. There is likely no significant difference as your body remains stable in its functioning. - 11. Selected answer: 2, 3 Page: 4, 5 Feedback 1. Biochemical individuality variation is often much smaller than variation within the larger group. 2. The aging process and decline in organ function may affect the health of elders. 3. Disease, nutrition, and medications affect the health of elders. 4. Although abnormal laboratory findings are often attributed to old age, rarely are they true aging changes. 5. Many factors can influence laboratory value interpretation in the elderly, including the physiological changes with aging, the prevalence of chronic disease, changes in nutritional and fluid intake, lifestyle (including activity), and the medications that are taken. 12. An elderly couple is discussing health concerns with the nurse practitioner. The couple is concerned that each of their individual blood studies show different results. One set of test results shows a significant decrease in blood sugar, but the test results of the partner does not show an equal decrease. Their physician does not seem concerned, and the couple is wondering why. How is it best for the nurse practitioner to respond? Select all that apply. 1. Studies show that each person's pattern of chemical make-up is different. 2. There is no difference between one person's range of blood results and that of any other person. 3. Each person's chemical make-up is the same as that of others of the same gender and age group. 4. Many factors affect an individual's chemical make-up. 5. Ranges of the values provided by the laboratory are correct for any age. - 12. Selected answer: 1, 4Page: 2, 3 Feedback 1. Individuals experience smaller variations in laboratory work than from the others in the same age group. 2. There are wider variations of laboratory results within a group of older people. 3. Laboratory values are determined by more than age and gender. 4. Laboratory values may vary as a result of nutrition, activity, and emotional status. 5. The reference values presented for the older adult cohort are not necessarily correct for the individual due to biochemical individuality. 13. Adam, 70 years old, is admitted for possible myasthenia gravis (MG). The nurse practitioner knows that MG is commonly seen in women between 20 and 40 years old. Adam, however, is experiencing an ocular form of MG, has dysphonia, and does not have any thymus abnormalities. Adam asks why the nurse is concerned about MG since he is older and this is a "young person's disease." Which of the following are the best answers? Select all that apply. 1. We need to assess for anything, just in case. 2. Some diseases show up in two different age and gender groups. 3. Older people often experience weakness, and we must rule out other conditions. 4. Your insurance will cover this, and we want to rule out as much as possible. 5. Signs and symptoms of illness are the same for each disease regardless of age. - 13. Selected answer: 2, 3Page: 5 Feedback 1. Ordering more tests than needed violates the principle of "Do no harm." 2. MG is bimodal and can be found in younger women, as well as in both men and women. 3. Knowledge of the bimodality of age onset of certain disease conditions will aid the nurse practitioner in avoiding misdiagnosis or delay in diagnosis due to lack of recognition. 4. There should be a need for ordering a test and value attributed to the results. 5. The manifestations of illness and disease in the elderly can be very different, even if the underlying pathological process is the same as in younger individuals. 14. Mrs. Smith is 75 years old and has had type 2 diabetes for 30 years. She sees her nurse practitioner on a regular basis. Mrs. Smith asks the nurse practitioner why her treatment has not been changed, even though her laboratory values are seemingly out of normal range. Which of the following answers are best? Select all that apply. 1. A decision to make changes must be based on a pattern and not on one set of laboratory results. 2. The normal range charts are based on patients younger than 75 years. 3. Currently, it is too expensive to change your treatment. 4. Comparing new results with your prior results gives a more accurate picture. 5. Normal values for laboratory tests differ as one gets older. - 14. Selected answer: 1, 4, 5Page: 3 Feedback 1. Blood studies are more valuable when assessing for an increase or decrease in values. 2. It is not helpful to use aging as an explanation for possible abnormal results. 3. If a change in treatment is appropriate, the least expensive alternative should be sought. 4. Significant disturbances in the same individual may be detected through serial laboratory tests. 5. The clinician must determine whether a value obtained reflects a normal aging change, a disease, or the potential for disease. 15. Mr. Adams is 90 years old. In the last few months he appears unable to comply with the health- care plan developed by the nurse practitioner. The nurse practitioner considers which of the following reasons for noncompliance when updating his home care plan? Select all that apply. 1. Polypharmacy 2. Treatment burden 3. Attending multiple appointments 4. Affording complex drug regimens 5. Cognitive ability only - 15. Selected answer: 1, 2, 3, 4 3. There is no reason to use these botanicals when opioids are proven effective. 4. This botanical is not on the Medicare list of approved medications. - 4. Selected answer: 2Page: 6 Feedback 1. Although this botanical may not be approved by the U.S. Food and Drug Administration (FDA), its cost will depend on the distributor. 2. Medicare will only pay for A and B level recommendations that meet the USPSTF stringent evidence guidelines, leaving other beneficial interventions without coverage. 3. Opioids are not recommended for older patients. 4. It is important to use only prescribed and approved medications/treatments. 5. When a patient is seen by a nurse practitioner, the care plan is developed keeping which of the following objectives in mind? 1. Increasing the use of the emergency department for injuries from falls. 2. Maintaining the patient living in his or her home. 3. Increasing safety checks in the home. 4. Increasing use of the Welcome to Medicare visit. - 5. Selected answer: 4Page: 6 Feedback 1. The objective is to decrease the use of the emergency department for falls. 2. There are many factors involved in the decision for an older adult to remain in the home. 3. Although it is useful to conduct home safety checks, they are not part of the Healthy People 2020 objectives. 4. The Healthy People 2020 program has set specific objectives for prevention in older adults; use of the Welcome to Medicare visit is one of those objectives. 6. The focus of advanced nurse practitioners is primary care. This is defined as activities that focus on: 1. Preventing the occurrence of a disease or condition. 2. Treating an illness after symptoms appear. 3. Enabling the patient to recover and convalesce. 4. Enriching the patient's appreciation of life. - 6. Selected answer: 1Page: 7 Feedback 1. Primary preventive strategies focus on immunization, well-checks, and other health maintenance activities. 2. Secondary preventive strategies focus on prevention and treatment of illness. 3. Tertiary preventive strategies focus on rehabilitation. 4. Nurse practitioners focus on the wellness-illness continuum. 7. A health promotion topic included in the nurse practitioner visit is physical activity. Which of the following would be a good recommendation for the 75-year-old male? Select all that apply. 1. Skydiving 2. Horseback riding 3. Swimming 4. Dancing 5. Whatever the patient is willing and able to do - 7. Selected answer: 3, 4, 5Page: 7 Feedback 1. Skydiving is risky for older patients who may have cardiovascular issues. 2. Horseback riding could be risky for an older person who may have neurological or orthopedic issues. 3. Swimming is a good option if the patient is willing. 4. Dancing is a good option if the person is able. 5. When recommending physical activity, the person's functional abilities and desires need to be considered. 8. Understanding that the current life expectancy is 79 years, the nurse practitioner plans a patient's health promotion while considering which of the following? Select all that apply. 1. Patient's health beliefs and goals. 2. Present levels of function. 3. Benefit of treatment. 4. Patient's involvement in a religious community. 5. Primary disease or condition affecting the patient. - 8. Selected answer: 1, 2, 3Page: 6 Feedback 1. The nurse practitioner develops a collaborative plan that includes consideration of the patient's health beliefs and goals. 2. The nurse practitioner considers present and anticipated levels of function. 3. Risks need to be considered in light of benefits offered by interventions. 4. The nurse practitioner may consider whether the patient is connected to a religious community but cannot prescribe or recommend any specific plan. 5. Many disorders in older adults encompass multiple risk factors that involve several systems and interventions to achieve outcomes; this presents a challenge when measuring and synthesizing evidence, and reporting outcomes. 9. As the nurse practitioner is teaching about the need for more exercise, the patient says that it takes away too much energy needed for other activities. The nurse practitioner explains that the benefits of exercise include which of the following? Select all that apply. 1. Increased flexibility. 2. Increased muscle mass. 3. Maintenance of optimal weight. 4. Lower blood pressure. 5. Decreased urinary output. - 9. Selected answer: 1, 2, 3, 4Page: 7 Feedback 1. The health benefits of regular physical activity are well documented and include flexibility. 2. Exercise increases muscle tone and mass. 3. Exercise uses calories from stored fat and allows for weight loss. 4. Exercise strengthens the cardiac muscle and thereby lowers blood pressure. 5. Exercise does not affect urinary output. Feedback 1. Older adults are less likely to practice safe sex and use condoms. 2. Older people may be at increased danger from STIs because of the decreased perception of risk. 3. Current sexual history may determine the need for continued screening for STIs, HPV, and cervical cancer. 4. Encounters may be with fellow travelers, locals, or commercial sex workers. 5. Using the patient's sexual history, explore patient needs, preferences, and medical or psychological obstacles to sexual expression. 14. Mary, 72 years old, goes to the pharmacy to pick up her prescriptions. The pharmacist asks if she has had her immunizations. Mary replies, "I had all my childhood shots, so I do not need any now." What should the nurse practitioner teach her about senior immunizations? Select all that apply. 1. Because the immune system may be weakened in older persons, immunizations are suggested. 2. Persons over the age of 50 years should have a yearly influenza vaccine. 3. The new Shingrix vaccine will help protect her from shingles. 4. The side effects of immunizations outweigh the benefits of immunizations. 5. The pneumococcal vaccine is given as a one-time dose. - 14. Selected answer: 1, 2, 3Page: 12 Feedback 1. The older person is susceptible to organisms that cause infection due to decreased immunity, nutrition, hydration, and other factors. 2. The influenza virus mutates each year and an updated version of the vaccine is needed to provide immunity. Influenza vaccine is now recommended annually for all adults over 50 years old, unless contraindicated. 3. Recently released Shingrix has been found to be more effective than the Zostavax, which was given previously. 4. Side effects are most often mild and localized. Viruses can cause serious or even lethal conditions. 5. Pneumococcal vaccine is recommended as follows: Administer one-time dose to PCV13-naïve adults at age 65 years, followed by a dose of PPSV23 12 months later. 15. Mr. and Mrs. Jones are preparing to take a trip to Europe. The nurse practitioner includes the following teaching about taking care of their health while gone. Select all that apply. 1. Shorter airplane flights provide more chance to ambulate and relieve pressure on the back and legs. 2. Generally speaking, the air in Europe is cleaner than the air in the United States, so you should have no problems with your respiratory conditions. 3. Plan to fill your prescriptions when you are in a larger city. 4. Depending on the specific areas you will visit, certain immunizations may be needed. 5. You will most likely function as well when traveling as when at home. - 15. Selected answer: 1, 4Page: 12, 13 Feedback 1. Long flights in cramped areas increase the risk of thromboembolic events. 2. Increased air pollution is a significant problem in many countries and affects pulmonary function. 3. The medications needed may not be available in some countries in Europe. Medicare does not cover medications filled outside of the United States. 4. Some areas of the world continue to see cases of yellow fever, malaria, and other diseases. When going to a vulnerable area, proper immunizations are required. 5. Some of the physiological and psychosocial changes that can occur with aging pose special risks during travel. How a patient functions at home may not be indicative of how well he or she will function in an unfamiliar environment. 1. Mrs. Keating is a 70-year-old woman suffering from arthritis. She is seeing the nurse practitioner for her regular checkup. For a person with chronic degenerative conditions, which of the following should the nurse suggest for health promotion? 1. Take herbal supplements. 2. Increase physical activity. 3. Take Aleve. 4. Get a massage. - 1. Selected answer: 2Page: 19 Feedback 1. Although there may be some herbal supplements that can help with arthritis, this is not the best suggestion because it does not promote increased physical activity. 2. Increased physical activity in older adults promotes wellness and quality of life. 3. Medication may be helpful for relief of symptoms but does not necessarily promote increased physical activity, which can help lead to better health. 4. Massage may provide temporary relief for arthritic joints, but physical activity is what can help lead to better health. 2. Many adults find reasons or barriers for not being able to exercise. Which of the following is an example of a patient barrier? 1. Good health, no functional limitations. 2. Insurance incentive. 3. High body mass index (BMI). 4. Frequent contact with prescriber. - 2. Selected answer: 3Page: 20 Feedback 1. Good health, no functional limitations is an example of a patient facilitator because it is not counterintuitive to pursuing good health. 2. Insurance incentive is an example of a patient facilitator because it provides incentive for the patient. 3. High BMI is an example of a patient barrier because it is something that may seem insurmountable to a patient. 4. Frequent contact with the prescriber is an example of a patient facilitator because it provides accountability in the pursuit of good health. 3. Mr. Osorio is a 65-year-old male who recently retired because of a medical condition. He has good family support and is very motivated to start a wellness program to prevent worsening of his condition. These factors are an example of: 1. Barriers 2. Incentives 3. Positive self-efficacy 4. Facilitators - 3. Selected answer: 4Page: 20 Feedback 1. Feedback 1. Depression, interpersonal loss, significant life event changes, and functional limitations are not choices that one makes so are not excuses. 2. Patient facilitators are things that encourage a patient to do what is needed for good health. 3. These examples are not the result of what one doesn't know. 4. These are examples of patient barriers because they discourage a patient from a desire to promote health. 8. Which of the following is the focus of additional studies about the relationship between physical activities and cognitive changes? 1. Diet and supplements 2. Provider and patients 3. Social support and patients 4. Medical conditions and medications - 8. Selected answer: 1Page: 19 Feedback 1. Diet and supplements are the focus of these additional studies. 2. Although provider and patient relationship is important, these are not the focus of these additional studies. 3. Although a patient's social support is important, it is not the focus of these additional studies. 4. Medical conditions and medications should be considered in physical activity, but it is not the focus of these additional studies. 9. With the recognition that baby boomers will increase the over 65 population exponentially, guidelines for increasing physical activity in older adults have been issued. Which of the following programs is dedicated to health promotion in older adults? Select all that apply. 1. The Healthy People 2020 initiative 2. The Center for Medicare and Medicaid 3. The American Medical Association 4. The National Institute on Aging 5. The American Heart Association (AHA) - 9. Selected answer: 1, 2, 4Page: 19 Feedback 1. The Healthy People 2020 initiative has several sections dedicated to health promotion for older adults. 2. The Center for Medicare and Medicaid has programs to promote wellness and quality of life in older adults. 3. The American Medical Association promotes the art and science of medicine and the betterment of public health. 4. The National Institute on Aging has programs to promote wellness and quality of life in older adults. 5. The AHA publishes the scientific guidelines for cardiopulmonary resuscitation and emergency cardiovascular care, which form the foundation of lifesaving protocols used by health-care professionals, companies, and hospitals in the United States and throughout the world. 10. Mr. Fekjar is diagnosed with unstable angina. Which of the following is a contraindication for exercise therapy and prevents patients from joining an exercise program? Select all that apply. 1. Uncontrolled hypertension 2. Fibromyalgia 3. Unstable aortic aneurysm 4. Chondromalacia 5. Hypoxemia - 10. Selected answer: 1, 3Page: 20 Feedback 1. Uncontrolled hypertension is a medical contraindication for exercise therapy. 2. Fibromyalgia is a condition in which exercise therapy is useful for health promotion. 3. Unstable aortic aneurysm is a medical contraindication for exercise therapy. 4. Chondromalacia is an orthopedic condition in which exercise therapy is useful for health promotion. 5. Low oxygen saturation or hypoxemia is a below-normal level of oxygen in the blood, specifically in the arteries. Hypoxemia is a sign of a problem related to breathing or circulation, and may result in various symptoms, such as shortness of breath and dizziness during exercise. Though it is not a contraindication for exercise therapy, its symptoms could be a barrier. 11. Which of the following may be included in the healthy lifestyle counseling during the initial Welcome to Medicare visit? Select all that apply. 1. Level of physical activity assessment. 2. Physical therapy consultation. 3. Referral to an herbalist. 4. Referral to a health coach. 5. Referral to an acupuncturist. - 11. Selected answer: 1, 2, 4Page: 20 Feedback 1. Current level of physical activity is assessed during the initial Welcome to Medicare visit. 2. Physical therapy consultation may be recommended for patients with disabilities or functional limitations. 3. Referral to an herbalist is not part of the initial Welcome to Medicare visit. 4. Referral to a health coach may be recommended to patients during the initial Welcome to Medicare visit to keep them engaged. 5. Referral to an acupuncturist is not part of the initial Welcome to Medicare visit. 12. Incorporating exercise into patients' lifestyles can be effectively achieved by including which of the following in your discussions with patients? Select all that apply. 1. Talking about the importance of exercise. 2. Encouraging goal setting and self-monitoring by the patient. 3. Recommending the purchase of exercise equipment to use at home. 4. Informing the patient about resources that are available in the community for group exercise. 5. Giving an illustration of the exercises. - 12. Selected answer: 2, 4Page: 21 Feedback 1. Handing a program or exercise prescription to the patient is more effective than just talking about it. 2. Having an exercise "buddy" may make the activity fun but will not necessarily reduce risk of injuries, especially if the buddy does not understand the concepts of exercises and physical activity physiology. 1. Mr. and Mrs. Smith are both 75 years old and are seeing their nurse practitioner for their annual checkups. Mrs. Smith wonders why they each have trouble digesting different foods. It is inconvenient for her to fix different meals that they both can tolerate. The nurse practitioner explains that: 1. Men have more difficulty digesting vegetables. 2. Women have more difficulty digesting dairy products. 3. Men and women have different enzymes in their gastrointestinal tracts. 4. Organ systems progress differently for each person regardless of age. - 1. Selected answer: 4Page: 26 Feedback 1. There are no gender differences in types of food digested. 2. People of either gender may have an intolerance to dairy. 3. People of either gender have the same types of enzymes in their digestive systems. 4. People age at different rates, and within each person organ systems age at different rates. 2. The nurse practitioner conducts a comprehensive geriatric assessment of the older individual because: 1. Health of older people is affected by several factors. 2. A focused assessment will provide depth of specific information. 3. A comprehensive assessment will provide more subjective information. 4. A comprehensive assessment will result in a list of current and prior medications taken. - 2. Selected answer: 1 Page: 26 Feedback 1. A comprehensive approach to geriatric assessment is recommended because the physical health of the older adult is inextricably related to functional ability, psychosocial health, and a safe and enabling environment. 2. A focused assessment will provide a limited amount of information about the whole person. 3. A comprehensive assessment will provide both objective and subjective information. 4. A list of medications is only one component of a comprehensive assessment. 3. The nurse practitioner knows that conducting a comprehensive geriatric assessment (CGA) is more beneficial for which of the following groups? 1. People between 60 and 70 years old. 2. People over 70 years old. 3. People classified as vulnerable older adults. 4. People over 55 years old. - 3. Selected answer: 3Page: 26 Feedback 1. People between 60 and 70 years old are likely to be healthy. 2. People over 70 years old have a variety of levels of health. 3. Vulnerable older adults and frail older adults will benefit most from a CGA because of lower physiological reserves and higher risk of iatrogenic complications. 4. People over 55 years old may not be considered the appropriate age for a CGA. 4. A family member comes into the clinician's office with her older mother, the patient. In the process of the examination, the nurse practitioner identifies the patient as "frail older adult." The family member asks what that means. The nurse practitioner explains that this refers to: 1. Someone who is prone to pathological fractures. 2. An older person already exhibiting signs of decline. 3. An older person who has lost height and is under 5 feet tall. 4. An older person being susceptible to infections. - 4. Selected answer: 2Page: 26 Feedback 1. Frailty is not defined by only one symptom. 2. Frailty, or signs of declining health, can occur at any age. 3. Frailty is not related to the size of the patient. 4. Infections can be treated at any age. 5. Jane, 83 years old, comes to the clinic with her daughter for a geriatric assessment. The daughter asks about the necessity of this comprehensive assessment. The clinician explains that a CGA is a multidimensional process to: 1. Identify care needs and plans of care for older people. 2. Acquire information about past medical conditions. 3. Determine which diagnostic tests are necessary. 4. Satisfy requirements of Medicare. - 5. Selected answer: 1Page: 26 Feedback 1. The CGA is a multidimensional, interdisciplinary, and diagnostic process to identify needs and plan outcomes. 2. The CGA includes information from medical history, as well as the current assessment. 3. The CGA helps identify diagnostics, treatments, and other plan-of-care strategies. 4. The CGA is not a requirement of Medicare. 6. Mary Jane is seeing a nurse practitioner for a CGA and asks which parts of her life will be examined. The nurse practitioner says the domains of the CGA include: 1. Internal organ health. 2. Social habits. 3. Physical and psychological health, as well as other facets of life. 4. History of family illness. - 6. Selected answer: 3Page: 27 Feedback 1. The CGA includes more than internal health. 2. Learning about social habits is not the only component in determining health. 3. Domains of CGA include physical health, psychological health, socio-environmental supports, mobility, functional status, and a measure of the quality of life. 4. Although family health history provides information about genetics, the CGA is complete and includes current health status in several domains. Measuring the blood pressure after John gets up will show a drop if he experiences hypostatic hypotension. 3. Jumping in place is not a normal activity and is risky for older people. 4. Breathing deeply does not affect blood pressure significantly. 5. Mobility can be screened with the Timed Get Up and Go Test. This test involves observing for unsteadiness as the patient gets up from a chair without using the arms, walks 10 feet, turns around, walks back, and resumes a seated position. 11. In conducting a physical assessment of an older person, the nurse practioner assesses which of the following? Select all that apply. 1. Pulse oximetry 2. Weight 3. Color of hair 4. Functional assessment 5. Presence of pain - 11. Selected answer: 1, 2, 4, 5Page: 27, 28 Feedback 1. Pulse oximetry provides a reading of oxygen saturation for the end tissues. 2. Measuring weight provides information about nutrition and fluid status. 3. Hair color is not directly associated with health status. 4. The ability to function for ADLs is crucial to the health of an older person. 5. Pain is the fifth vital sign and provides information about underlying conditions. 12. Mrs. Parsons is 75 years old and is anticipating renewing her driver's license. The nurse practitioner conducts an eye examination and is concerned to find which of the following? Select all that apply. 1. Visual acuity better than 20/20. 2. Visual acuity worse than 20/40. 3. Abnormality in the six cardinal fields of gaze. 4. Ability to gaze downward. 5. Absence of nystagmus. - 12. Selected answer: 2, 3,5 Page: 28 Feedback 1. An acuity of 20/20 is normal. Better than that is good. 2. Visual acuity of worse than 20/40 suggests weakness in the ability to see. 3. Abnormality in cardinal fields of gaze may indicate a neurological condition. 4. Ability to gaze downward is normal. 5. Abnormality in the six cardinal fields of gaze with nystagmus or lack of a downward gaze may reveal neurological disease. 13. Bertha is an 85-year-old grandmother who has multiple morbidities. Family members report that Bertha is not eating much and does not seem as active as usual. They want the nurse practitioner to order tests to identify what is happening to her. The nurse practitioner considers which of the following before ordering any tests? Select all that apply. 1. Will the test results alter any of the diagnoses that she is currently addressing? 2. Will the results alter management of her health regimen? 3. What is the cost/benefits ratio? 4. Is the test the least invasive? 5. Is this testing acceptable to the patient? - 13. Selected answer: 1, 2, 3, 4,5 Page:28 Feedback 1. One of the considerations in ordering tests for diagnostic purposes is whether the test result will alter the diagnosis. 2. One of the considerations in ordering tests for diagnostic purposes is whether the test result will alter management of a condition. 3. The cost and benefits need to outweigh the risks. 4. Less invasive testing alleviates negative reactions to invasive procedures. 5. Evidenced-based practice includes the consideration of the patient's wishes. 14. In assessing functionality, the nurse practitioner first considers activities of daily living (ADLs), which include which of the following? Select all that apply. 1. Basic self-care. 2. Mobility. 3. Continence. 4. Ability to cook a meal. 5. Ability to interact with others within the community. - 14. Selected answer: 1, 2, 3Page:30,31 Feedback 1. The ability to bathe and dress oneself is a basic daily need. 2. The ability to move around and walk safely is a basic daily need. 3. The ability to maintain urinary and bowel control is a basic daily need. 4. It is not a basic daily need to be able to cook. It is possible to eat food that does not require cooking. 5. Industrial ADLs measure community interactions within the home and outside the home. 15. The nurse practitioner performs a holistic assessment on an older patient. One component of this assessment is spirituality. Which of these options is appropriate to use to assess any spiritual needs? Select all that apply. 1. Use the HOPE assessment tool: source of Hope, a participant in an Organized religious group, Personal spirituality, Effect of spirituality on health care. 2. Ask the patient, "Are you at peace?" 3. Call a chaplain to conduct the assessment. 4. Wait until a sign of distress appears and then evaluate the source. 5. Administer the FICA assessment of spiritual needs. - 15. Selected answer: 1, 2, 5Page:31 Feedback 1. HOPE is an acceptable assessment tool for spiritual distress. 2. Asking a direct question that is not directed at a specific faith or religion is appropriate. 3. Chaplains are helpful, but the nurse practitioner can make a basic assessment of a patient. 4. An early assessment can help to avoid distress by implementing comfort measures early. 5. FICA (Puchalski & Romer, 2000): Faith or belief, Importance or influence, Community Address is an acceptable assessment tool. Anti-Parkinson's drugs, calcium supplements, and NSAIDs typically do not cause headaches. Headache, however, may be a signal symptom for other neurological conditions. 4. Anti-Parkinson's drugs, calcium supplements, and NSAIDs typically do not cause chest pain. Chest pain may be a signal symptom for some cardiac conditions. 5. Which of the following statements best describes "cough"? 1. It is a sign of a life-threatening condition. 2. It is often isolated to the respiratory system. 3. It is often isolated to the immune system. 4. It is often associated with acid reflux. - 5. Selected answer: 2 Page: 43 Feedback 1. Cough is often associated with conditions that are not life threatening. 2. Cough is often isolated to the respiratory system. 3. Cough may be a secondary symptom associated with the immune system. 4. Cough is unlikely to be associated with acid reflux. 6. Tina is a 60-year-old female presenting symptoms of coughing, shortness of breath, and purulent sputum. She is being treated with antibiotics, use of a nebulizer, and oral steroids. Which of the following conditions could be her diagnosis? 1. Bacterial pneumonia 2. Acute bronchitis 3. Chronic bronchitis 4. GERD - 6. Selected answer: 3Page: 44 Feedback 1. Her symptoms are not typical of bacterial pneumonia, which is a common lung infection where the lungs' air sacks become inflamed. Signal symptoms may be fever as high as 105°F, along with profuse sweating, bluish lips and nails, and confusion. 2. Antibiotics should not be used with acute bronchitis because it is viral. 3. Chronic bronchitis is a condition that presents with symptoms of coughing, shortness of breath, and purulent sputum, and is often treated with antibiotics, use of a nebulizer, and oral steroids. 4. GERD is a gastrointestinal condition that may be associated with coughing but is treated with an antihistamine and decongestant. 7. Reduction of pain is the main goal for patients suffering from acute joint pain. The mnemonic PRICE is a helpful reminder of the treatment when this occurs. What does the "E" in PRICE stand for? 1. Elevation 2. Emergency 3. Elastic 4. Electrical - 7. Selected answer: 1Page: 73 Feedback 1. Elevating the joint above heart level may help reduce pain and swelling. 2. This is not part of the mnemonic. 3. This is not part of the mnemonic, although the "P" does stand for protection with a brace or wrap. 4. This is not part of the mnemonic. 8. A patient complains of dry, irritated, and itchy skin that has not been relieved with over-the-counter medications. On examination, the patient is also found to present cholestasis and jaundice. From which of the following conditions may the patient be suffering? 1. Lice 2. Scabies 3. Pruritus 4. Lichenification - 8. Selected answer: 3 Page: 77 Feedback 1. Lice may cause itching in the scalp but is generally localized. 2. Scabies may cause itching of the skin but is generally localized. 3. Pruritus is an unpleasant, irritating, or itching sensation on the surface of the skin that may lead to a desire to scratch. Inflammation results from activation of the immune response. 4. Lichenification is the result of continued scratching and causes thickening of the skin. 9. Mr. Thomas noticed tremors in his right hand 2 years ago and attributed this to his elbow injury from a fall. The tremors have gradually worsened, and he now has tremors under his lip, some gait problems, and occasional stomach spasms. His wife has recently noticed these things and suggested he have a medical consultation. Which of the following reasons might Mr. Thomas have had for ignoring these symptoms? Select all that apply. 1. Fear of loss of independence 2. Fear of doctors 3. Symptoms do not interfere with functions 4. Attributes symptoms to the aging process 5. Lack of transportation - 9. Selected answer: 1, 3,4 Page: 34 Feedback 1. Fear of loss of independence may result in older adults not seeking medical help for illnesses. 2. Fear of doctors is usually not a factor. 3. If symptoms do not interfere with one's ability to function, sometimes medical help will not be sought. 4. If an individual has a feeling that his symptoms are simply the results of aging, he may not feel there is a reason to seek medical help. 5. Not having transportation to get to the medical provider is not a factor because many facilities now have transportation services for patients who need it. 10. Mrs. Lee is experiencing moderate pain in her right leg and having difficulty sitting down on and standing up from a chair. She reports no other symptoms. Which of the following should be included in the assessment? Select all that apply. 1. Thorough medication history 2. Precipitating factors 3. Character of symptom 4. Family history 5. Social history - 10. Selected answer: 1, 2, 3Page: 34 Fractured humerus is an injury to the bone in the arm and does not necessarily cause joint pain. 5. A muscle strain is the stretching or tearing of muscle fibers. The tearing of the muscle can also damage small blood vessels, causing local bleeding (with or without bruising) and pain (caused by irritation of the nerve endings in the area). Pain is in the muscle and surrounding tissue rather than in the joint. 14. Which of the following are the focus questions when assessing patients with pruritus? Select all that apply. 1. Did it come on suddenly or gradually? 2. How do you characterize the sensation? 3. What did you eat yesterday? 4. Is there anything that makes it worse or better? 5. What is the consistency of your bowel movements? - 14. Selected answer: 1, 2, 4Page: 77 Feedback 1. Symptoms of pruritis can begin gradually or suddenly, and can include a prickling, crawling, burning, or stinging sensation. 2. Having the patient characterize the sensation may help determine if the diagnosis is pruritus, as a feeling of prickling, crawling, burning, or stinging are associated with this disease. 3. Pruritus is not the result of foods you've eaten. 4. Knowledge of what makes it feel worse or better can help with treatment planning. 5. Consistency of bowel movement is not particularly associated with pruritus unless there is an underlying condition that is causing anal itching. 15. Wandering in older adults can occur with disorientation or cognitive impairment and is characterized as locomotion in a seemingly aimless pattern. From which of the following conditions can wandering arise? Select all that apply. 1. Pneumonia 2. Delirium 3. Mood disorder 4. Dementia 5. Vertigo - 15. Selected answer: 2, 4Page: 88 Feedback 1. Pneumonia is a lung infection that can make an individual very sick but does not cause wandering. It often clears up in 2 to 3 weeks. 2. Delirium is a condition that causes extreme confusion and changes in cognition, which can cause wandering. 3. Mood disorder is a mental disorder but does not cause wandering. 4. Dementia is a condition that causes individuals to experience looseness of thought and confusion, which can cause wandering. 5. Vertigo is a sensation of whirling and loss of balance, associated particularly with looking down from a great height, or caused by disease affecting the inner ear or the vestibular nerve. Vertigo does not cause wandering. 1. Mrs. Williams is 76 years old and comes in to have a wound checked on her right leg. She fell a month ago and the wound has not healed. She is concerned that something is wrong. The nurse practitioner examines the wound and sees that it has been cleaned properly and has no signs of infection. The edges are approximated, but the skin around the wound is red and tender to touch. The best response regarding Mrs. Williams' concern is: 1. Wound healing for older people may take up to four times longer than it does for younger people. 2. Let us talk about what you are eating. 3. Had you come in earlier, I would have ordered medicine that would have healed that right up. 4. I will order an antibiotic to prevent infection. - 1. Selected answer: 1 Page: 96 Feedback 1. Skin renewal turnover time increases to approximately 87 days in older adults, compared with 20 days during youth. 2. The perceived extended healing time is not related to diet. 3. This is false hope, as there is no medication that will heal this wound quickly. 4. Prophylactic antibiotics are not appropriate when there are no signs or symptoms of infection. 2. The nurse practitioner is conducting patient rounds in a long-term care facility. As she talks with Mrs. Jones, she notices that her arms and elbows are excoriated and the skin is shearing. The nurse practitioner explains to the staff that Mrs. Jones needs frequent assessment of her skin and protection provided to prevent skin breakdown because: 1. Her lack of activity causes the skin to tear. 2. Fat has redistributed to the abdomen and thighs, leaving bony surfaces in areas such as the face, hands, and sacrum. This can result in injury. 3. She has lost weight and is in jeopardy of falling. 4. She picks at herself and causes skin breakdown. - 2. Selected answer: 2Page: 96 Feedback 1. Lack of activity alone does not cause skin breakdown. 2. Fat is redistributed to the abdomen and thighs, leaving bony surfaces, such as the face, hands, and sacrum, exposed to potential injury, especially skin tears from shearing, friction forces and pressure ulcer development. 3. Although losing weight may be a risk factor for falling, it is not directly related to skin breakdown. 4. There is no evidence that she is picking at herself, as there is nothing reported anywhere else on her arms. 3. Mr. James is 91 years old. His daughter notices that he has bruises and lacerations on his arms and reports this to the nurse practitioner, who tells her that older people bruise easily due to their fragile blood vessels. The skin lacerations happen because he has thin skin. Even so, the nurse practitioner assures the daughter that she will investigate further to ensure that he is getting proper care. She says this because she understands that: 1. These markings on the patient's skin are part of aging skin. 2. Bruises and lacerations can indicate inadequate care. 3. The daughter needs assurance that her father is okay. 4. The patient is being abused. - 3. Selected answer: 2Page: 97 Feedback 1. Markings on the skin may be signs of aging, a disease, or maltreatment. 2. Poorly healing wounds or chronic pressure ulcers may signal a problem not only with the patient but with the caregiver's ability to provide adequate care. Welts, lacerations, burns, and distinctive markings may indicate a need for intervention. The fact that the patient smokes is not the issue; safety is the issue. 8. The nurse practitioner is conducting a safety class with community-living older adults. Which of the following should she include in her teaching of risks of burns for this population? Select all that apply. 1. Thinner skin. 2. Less vascularity. 3. Diminished nerve function. 4. A weakened immune system. 5. The burden of various comorbidities leading to enhanced wound healing and reepithelialization after burn injury. - 8. Selected answer: 1, 2, 3, 4 Page: 98 Feedback 1. As one ages, there are significant changes in the skin, which becomes thinner, providing a less effective barrier to external stimuli. 2. With aging, there are fewer appendages and decreased vascularity. 3. Thinner skin and diminished nerve function often result in a higher incidence of deeper burns. 4. Advanced age results in a weakened immune system. 5. Along with the burden of various comorbidities, the fragility of older skin leads to delayed wound healing and reepithelialization after burn injury. 9. Mr. Edwards is 76 years old and received a burn on his leg when he dozed off and dropped his cigarette. The nurse practitioner examines his leg for the degree of burn and classifies it as second degree with some third degree in the center. Mr. Edwards asks what that means and why it hurts so much. What is the best answer? Select all that apply. 1. It means that this is a serious, deep burn in the center, and a less deep burn around the sides. 2. It hurts because the nerve endings are exposed in the second-degree area. 3. It means that the burn is advancing and getting worse. 4. It hurts because the nerves are destroyed. 5. It hurts because the nerves in the second-degree areas are exposed to the outside and are stimulated. - 9. Selected answer: 1, 2 Page: 98 Feedback 1. Deep dermal burns extend further into the dermis; third-degree burns involve the full dermis, extending into the subcutaneous tissue. 2. In these burns there is pain from exposed nerve endings, but by the second day, pain is often described more as pressure. 3. The first step in treatment is to stop the burn. 4. Destroyed nerves do not register pain. 5. Superficial dermal burns involve the dermis and are characterized by blisters. The underlying tissue is pink, moist, and hypersensitive to touch. 10. Mrs. Thomas is 82 years old and burned her hand while cooking. The nurse practitioner assesses second- and third-degree burns over approximately half of the back of her hand. The nurse practitioner chooses which of the following for initial treatment? Select all that apply. 1. Administer appropriate pain medication. 2. Rinse with cool tap water. 3. Clean with a strong detergent. 4. Remove any loose tissue but allow the blisters to remain. 5. Diagnose as first- and third-degree burns. - 10. Selected answer: 1, 2, 4Page: 100 Feedback 1. After administration of appropriate pain medication, wound management can begin. 2. Burn wounds should be immediately doused in cool tap water to disperse any remaining heat in the tissue. 3. Detergents and antibacterial soaps are not indicated. Burn wounds should be cleaned with mild soap and rinsed. 4. For small surface area burns, it is good to remove any loose tissue during cleansing and allow intact blisters to remain. 5. First-degree burns do not exhibit blisters, and third-degree burns do not exhibit pain. 11. Mr. Watson,75 years old, comes to the urgent care center with complaints of fever, fast heartbeat, a swollen gland under his right arm, and redness in his upper left arm that has hurt for 2 to 3 days. The patient says that he has had the redness in his arm for months without any difficulty. The nurse practitioner suspects which of the following? Select all that apply. 1. Influenza 2. Upper respiratory infection 3. Cellulitis of upper left arm 4. Necrotizing fasciitis 5. Lymphangitis - 11. Selected answer: 3Page: 103 Feedback 1. Influenza is systemic and not localized in any one area. 2. The patient has no respiratory symptoms. 3. Signs of cellulitis include worsening of erythema, edema, tenderness, and pain that has occurred for a few days. Symptoms are usually sudden. Systemic symptoms which indicate serious toxicity include fever, hypotension, and tachycardia. 4. Necrotizing fasciitis exhibits diffuse swelling of an arm or leg with bullae. 5. Systemic symptoms that indicate serious toxicity include fever, hypotension, tachycardia, leucocytosis, lymphadenopathy, and lymphangitis. 12. The treatment for cellulitis includes which of the following? Select all that apply. 1. Patients with mild cellulitis may be given oral antibiotics. 2. One drug of choice is dicloxacillin, 500 mg four times a day. 3. Treatment is dependent on the culture of the cells affected. 4. The drug of choice is given for a minimum of 3 days. 5. Administration of a tetanus booster injection. - 12. Selected answer: 1, 2Page: 103 Feedback 1. Oral antibiotics are sufficient for mild cellulitis and IV antibiotics for organisms such as MRSA. 2. There are several drugs effective with cellulitis; dicloxacillin is one of them. 3. Treatment of MRSA should be guided by wound culture results, but not cellulitis. 4. The drug of choice is typically given for 7 days. 5. NRNP 6540 Advanced Practice Care Of Older Adults NEW 2023 APPROVED EXAM 5. Newer agents are more likely to cure tinea pedis than the older generation of antifungals, including clotrimazole, which is fungistatic, whereas terbinafine is fungicidal. 1. Which cranial nerve should be assessed in the examination for disorders of the face? 1. Cranial nerve III 2. Cranial nerve V 3. Cranial nerve VII 4. Cranial nerve IX - 1. Selected answer: 3Page: 127 Feedback 1. Cranial nerve III: oculomotor. This nerve is also known as the common ocular motor nerve. It controls eye movement and is also responsible for pupil size. It originates in the midbrain. 2. Cranial nerve V: trigeminal. This nerve's function is to carry sensitive information to the face and convey information for the chewing process. The sensory fibers convey sensations of touch, pain, and temperature from the front of the head, including the mouth and the meninges. 3. Cranial nerve VII: facial. This nerve should be assessed in the examination for disorders of the face. It consists of several nerve fibers that perform different functions, like ordering the muscles of the face to create facial expressions, as well as sending signals to the salivary and lacrimal glands. 4. Cranial nerve IX: glossopharyngeal. This nerve's influence lies in the tongue and pharynx. It collects information from the taste buds (tongue) and sensory information from the pharynx. 2. Which of the following medical specialists deals with the diagnosing of visual impairments and conditions? 1. Ophthalmologist 2. Optometrist 3. Otolaryngologists 4. Podiatrist - 2. Selected answer: 1Page: 129 Feedback 1. An ophthalmologist is a medical doctor who specializes in eye and vision care. An ophthalmologist diagnoses and treats all eye diseases, performs eye surgery, and prescribes and fits eyeglasses and contact lenses to correct vision problems. NRNP 6540 Advanced Practice Care Of Older Adults NEW 2023 APPROVED EXAM 2. An optometrist is an eye doctor who has earned the doctor of optometry (OD) degree. Optometrists examine eyes for both vision and health problems, and correct refractive errors by prescribing eyeglasses and contact lenses. 3. Otolaryngologists are physicians trained in the medical and surgical management, and treatment of patients with diseases and disorders of the ear, nose, and throat, and related structures of the head and neck. 4. A podiatrist is a medical doctor devoted to the study and medical treatment of disorders of the foot, ankle, and lower extremities. 3. Which of the following conditions is signaled by bleeding from the nose? 1. Rhinitis 2. Telangiectasia 3. Retinopathy 4. Epistaxis - 3. Selected answer: 4Page: 130 Feedback 1. Rhinitis is inflammation of the nose. Symptoms of rhinitis include runny nose (rhinorrhea), nasal itching, nasal congestion, and sneezing. 2. Telangiectasia, also known as spider veins, are small dilated blood vessels near the surface of the skin or mucous membranes. These dilated blood vessels can develop anywhere on the body but are commonly seen on the face around the nose, cheeks, and chin. 3. Retinopathy is a disease of the retina that results in impairment or loss of vision. 4. Epistaxis is a condition signaled by bleeding from the nose and is the result of a spontaneous rupture of a blood vessel in the anterior septum. Causes include, but are not limited to, trauma, irritation or inflammation of the nasal mucosa, a septal defect, or paranasal tumors. 4. Mr. Jones, a 70-year-old male, visits the urgent care and presents symptoms of unilateral eye pain, visual blurring with halos around lights, red eye, and photophobia. He also reports nausea and vomiting. Visual acuity shows a loss in the affected eye. He is immediately referred for a complete ophthalmic examination. Which of the following conditions may Mr. Jones be experiencing? 1. Acute glaucoma 2. Conjunctivitis 3. Hyphema 4. Uveitis - 4. Selected answer: 1Page: 132 Feedback 1. Symptoms for acute glaucoma include unilateral eye pain, visual blurring with halos around lights, conjunctival injection, and photophobia. This requires immediate referral for a complete ophthalmic examination. 2. Symptoms for chronic glaucoma include tunnel vision, night blindness, and halos around lights. The treatment goal is to minimize the progression of the disease and preserve vision. 3. Hyphema is defined as the presence of blood within the aqueous fluid of the anterior chamber. The blood may cover most or all of the iris and the pupil, blocking vision partially or completely. The most common cause of hyphema is trauma. 4. Uveitis is a form of eye inflammation. It affects the middle layer of tissue in the eye wall (uvea). Symptoms include eye redness; eye pain; light sensitivity; blurred vision; dark, floating spots in the field of vision (floaters); and decreased vision. Possible causes of uveitis are infection, injury, or an autoimmune or inflammatory disease. 5. Which of the following is the correct term for the eye condition that presents a sterile mass on the eyelid that is painless and has no reddening? 1. Blepharitis 2. Entropion 3. Hordeolum 4. Chalazion - 5. Selected answer: 4Page: 138 Feedback 1. Blepharitis is an inflammation of the eyelids, usually resulting in redness, swelling, and itching. 2. Entropion is the inward turning of the upper or lower eyelid so that the lid margin rests against and rubs the eyeball. 3. Hordeolum is an acute, purulent area of inflammation in the meibomian gland, commonly called a stye. It typically contains bacteria and can occur internally or externally at the lid margin. Not all styes are sterile. 4. 1. Palpating bones of the head for any anatomical irregularities should be included in the inspection and examination of the face, head, and scalp. 2. Inspecting the skin is not a part of this examination, however, cranial nerve VII, the facial nerve, should be assessed at this time, noting any facial asymmetry, weakness, drooping of the lower eyelid, and unilateral paralysis. Cranial nerve VIII is the auditory and vestibular nerve, responsible for balance and orientation in space and auditory function. 3. Areas of uniform alopecia should be noted, along with discovery of any nits or seborrhea. 4. Inspecting the patient's features includes examination of facial expressions, presence of tremor, edema, or facial drooping. 5. Thoracic outlet syndrome is a group of disorders that occur when blood vessels or nerves in the space between your collarbone and your first rib (thoracic outlet) are compressed. This can cause pain in the shoulders and neck, and numbness in the fingers. 10. When looking for disorders, which of the following parts of the body should be inspected in the examination of the head, face, and neck? Select all that apply. 1. Sinuses 2. Neck 3. Lungs 4. Skin 5. Cervical spine - 10. Selected answer: 1, 2Page: 128 Feedback 1. The sinuses should be inspected and palpated, noting any gross tenderness or inflammation. 2. Inspection should include looking for symmetry, masses, scars, tracheal position, deviation, and other things. 3. Inspection of the lungs is only possible by performing diagnostic testing and not possible by sight and touch. 4. Inspection of the skin, although important, is not a focus in the examination for head, face, and neck disorders. 5. The cervical spine, or neck, begins at the base of the skull and through a series of seven vertebral segments connects to the thoracic, or chest, region of the spine. It houses the spinal cord, which sends messages from the brain to control all aspects of the body. This is not evaluated in examination of the head, face, and neck. 11. Eye health education should be provided to maintain or minimize visual problems. Which of the following should be included in patient education? Select all that apply. 1. The importance of protecting the eyes from sunlight. 2. Eye examinations should be performed every 5 years. 3. Eating more protein with meals will help eye health. 4. Information on age-related visual changes 5. The importance of wearing eye goggles when swimming. - 11. Selected answer: 1, 4Page: 129 Feedback 1. The importance of protecting the eyes from sunlight with UV-blocking sunglasses should be included in the patient eye health education. 2. Recommending periodic eye examinations every 2 years should be included in the patient eye health education. 3. The patient should be instructed to maintain a nutritionally balanced diet including green, leafy vegetables. 4. Because age-related changes do occur with vision, giving patients this information will help them be aware of what to look for. 5. Though not generally a part of patient education, the recommendation to wear eye goggles when swimming may be helpful to minimize eye irritation from chlorine, salt water, or any other contaminants. 12. Nosebleeds are generally minor and nonrecurring, but when a patient is seen for this, a consultation with an ear, nose, and throat (ENT) specialist is indicated when which of the following conditions occurs? Select all that apply. 1. Bleeding that is not controlled after 15 minutes of compression. 2. Second episode occurs within 1 week. 3. Itching sensation after the bleeding stops. 4. Sneezing after the bleeding stops. 5. Massive bleeding. - 12. Selected answer: 1, 2, 5Page: 131 Feedback 1. Most nosebleeds do not require medical attention; however, the individual should seek medical attention if a nosebleed lasts longer than 15 minutes, or if it occurs after an injury. This may be a sign of a posterior nosebleed, which is more serious. 2. If a second episode occurs within 1 week, a consultation with an ENT specialist is indicated, as it may have underlying conditions associated with the recurrence of symptoms such as sinusitis, septal hematoma/perforation, or mucosal pressure necrosis. 3. Dry air is the most common cause of nosebleeds. Living in a dry climate and using a central heating system can dry out the nasal membranes, which are tissues inside the nose. This dryness causes crusting inside the nose. Crusting may itch or become irritated if the nose is scratched or picked, and it can bleed. 4. Sneezing is an allergic reaction and can also dry out the nasal membranes and cause nosebleeds. Frequent nose blowing is another cause of nosebleeds. 5. ENT consultation is indicated when there is evidence of massive bleeding that cannot be stopped, as there can be a large amount of blood loss. 13. Hearing loss is a decreased ability or inability to hear. The loss may involve the external, middle, or inner ear and can be unilateral or bilateral. Which of the following etiologies may result in hearing loss? Select all that apply. 1. Sensorineural 2. Vascular occlusive disease 3. Conductive 4. Cerebral neoplasia 5. Aphasia - 13. Selected answer: 1, 3Page: 136 Feedback 1. A lesion in the organ of Corti or in the central pathways, including the cranial nerve VIII and auditory cortex, causes sensorineural hearing loss. Presbycusis, noise-induced hearing loss, and ototoxic drug- related hearing loss all are sensorineural. 2. Vascular occlusive disease is predominantly a disease of the lower extremities and not an etiology of hearing loss. 3. Conductive hearing loss is caused by a lesion involving the outer and middle ear to the level of the oval window. Various structural abnormalities, cerumen impaction, perforation of the tympanic 2. The nurse practitioner knows that risk factors for coronary artery disease (CAD) include atherosclerosis. The nurse practitioner includes teaching on these factors that can be remediated to help prevent CAD: 1. Low blood pressure. 2. Age. 3. Advanced age and male gender. 4. Cholesterol levels and smoking. - 2. Selected answer: 4Page: 152 Feedback 1. One major remediable risk factor for CAD is high blood pressure. 2. Aging cannot be remedied, though it is a risk for CAD. 3. These two most important risk factors for atherosclerosis cannot be remedied. 4. Along with high blood pressure, cholesterol levels and smoking can be remedied. 3. Mr. Thomas comes in for a health examination with his nurse practitioner. When the nurse practitioner measures his blood pressure, the systolic is 150 mm and the diastolic is 80 mm. When Mr. Thomas asks if that is a good pressure for him, the nurse practitioner responds: 1. It is normal for your age. 2. Isolated hypertension is usually identified by a systolic blood pressure (SBP) higher than 160 mm Hg. 3. When evaluating blood pressure, a higher diastolic blood pressure (DBP) is risky. 4. There is a risk of a cardiovascular event for you with an SBP of 150 mm Hg. - 3. Selected answer: 2Page: 175 Feedback 1. Normal blood pressure is less than 120/less than 80.The SBP rises with age. 2. Isolated systolic hypertension is defined as an SBP greater than 160 mm Hg and a DBP of less than 90 mm Hg. 3. Cardiovascular disease in the geriatric age group is of greater possibility where there are systolic elevations rather than diastolic elevations. 4. The risk of experiencing a cardiovascular event is two to three times higher in those with significant hypertension (SBP over 160 mm Hg). 4. A 58-year-old man is being seen by his nurse practitioner for a cardiac work-up. His cholesterol is 320 mg/d. The nurse practitioner includes teaching about lowering his cholesterol by discussing blood levels and dietary choices. The nurse practitioner says which of the following? 1. Your cholesterol level is above normal for your age and we need to address how to lower it. 2. We will discuss food choices that will raise your LDL levels. 3. We will discuss food choices that will lower your HDL levels. 4. The effects of high cholesterol levels will not be a factor in cardiac disease after you turn 60 years old. - 4. Selected answer: 1 Page: 181 Feedback 1. The normal cholesterol level is less than 200 mg/d. 2. Efforts are often indicated to lower LDL levels. 3. Efforts are often indicated to raise HDL levels for cardiac protection. 4. The risk of the effects of an elevated cholesterol level persists from middle age to extreme old age. 5. Mr. Borden is 79 years old and lives with his daughter. The daughter provides excellent care for her father and wants to know which changes in his heart and circulatory system are due to aging and which are due to lifestyle choices. The nurse practitioner replies: 1. The size of the heart increases with age. 2. The left ventricle hypertrophies in response to increasing in age. 3. The activity of the heart decreases in its ability to deal with stress, as well as to provide physical strength as one ages. 4. The patient's diet affects the ability of the heart to balance blood pressure. - 5. Selected answer: 3Page: 153 Feedback 1. The size of the heart remains essentially unchanged, although some increase in left ventricular wall thickness has been demonstrated even in older individuals who do not have cardiovascular disease. 2. Left ventricular hypertrophy is usually due to increased cardiac demand, most likely caused by an increase in peripheral resistance. 3. Structural and physiological changes in the aging cardiovascular system cause decreased capacity to endure stresses and a decline in ability pertaining to physical activity performance. 4. Baroreceptors become less sensitive with age, and the response to changes in blood pressure is often blunted. 6. The nurse practitioner sees a patient in the emergency department with reports of chest pain and nausea. To analyze the patient's condition, what further information is needed? 1. Whether there has been constipation. 2. A description of the pain. 3. Information regarding last food intake. 4. Information regarding urinary difficulties. - 6. Selected answer: 2Page: 153 Feedback 1. Constipation is not included in the major signs or symptoms of CAD. 2. Ask the following about chest pain: Precipitating/Palliating factors, Quality, Radiation, Severity, and Timing (PQRST). 3. Chest pain may be presented as heartburn or indigestion, particularly if the patient also has gastroesophageal reflux disease (GERD). GERD needs to be ruled out. 4. There are no associated urinary symptoms with chest pain. 7. The nurse practitioner and a student are examining the apical pulse of an 82-year-old man. The student perceives that there is an S4 sound. The nurse practitioner interprets that this is likely: 1. An early ventricular filling. 2. Heart blockage. 3. Mitral regurgitation. 4. Normal, due to the man's age. - 7. Selected answer: 4Page: 153 Feedback 1. The early diastolic filling is reduced in healthy older adult persons, resulting in an end-diastolic volume maintained by an increase in atrial contribution to left ventricular filling. 2. A change in the loudness of S1, accompanied by a slow heart rate, may indicate heart blockage. 3. 1. Infections can lead to an occurrence of asthma. 2. Experiencing strong emotions like anger can trigger an asthma episode. 3. As you get older, you are more likely to experience difficulty breathing. 4. Symptoms of asthma may include a runny nose or postnasal drip. 5. There is no need to follow up with your doctor unless your symptoms get worse. - 11. Selected answer: 1, 2,4 Page: 155 Feedback 1. Symptoms may occur in conjunction with a respiratory infection, weather changes, or contact with environmental allergens. 2. Symptoms may occur in conjunction with strong emotional reactions, animal fur, mold, or exercise. 3. Older adults are less likely to sense dyspnea related to airway obstruction. 4. Other symptoms may include rhinorrhea with postnasal drip. 5. Regular monitoring 1 to 3 months after initiation of treatment, and then every 3 to 12 months depending on the level of control and severity. Patients should be seen within 1 week after an asthma exacerbation, and within 2 to 6 weeks when changes are made in the stepwise management. 12. The nurse practitioner implements an approved plan of care proposed in the National Asthma Education and Prevention Program Expert Panel Report-3 (NAEPP-EPR-3) for an older adult patient with asthma. This includes which of the following? Select all that apply. 1. Completion of the assessment and monitoring, as this is not an ongoing process. 2. Patient, family, and professional education so as to create a partnership in asthma management. 3. Control of comorbidities. 4. Monitoring of appropriate use of medications. 5. Use of a standardized asthma care plan. - 12. Selected answer: 2, 3,4 Page: 156 Feedback 1. Asthma is a chronic health problem, just like hypertension and diabetes. Regular chronic maintenance visits are required for optimal management. 2. The NAEPP-EPR-3 (2007) has identified four components of asthma management, which includes educating the patient, family, and professionals for partnership in asthma management. 3. The NAEPP-EPR-3 (2007) has identified four components of asthma management, one of which is the control of comorbidities and environmental factors affecting asthma. 4. The NAEPP-EPR-3 (2007) has identified four components of asthma management, which includes pharmacotherapy. 5. Treatment in older adults may need to be individualized based on comorbidities. 13. Sam is 64 years old and has been feeling weak, lightheaded, and slightly nauseous. He goes to the urgent care center where the nurse practitioner initiates an assessment. Which of the following suggest an arrhythmia? Select all that apply. 1. Chest x-ray showing an increased size of the left atria. 2. History of alcohol drinking. 3. Lack of family history of any acute heart conditions. 4. No history of heart pounding, racing, or skipping beats. 5. Palpitations and syncope. - 13. Selected answer: 1, 2Page: 161 Feedback 1. An age-related factor associated with tachyarrhythmias is increased left atrial size. 2. Drugs that can cause an arrhythmia include digitalis and other antiarrhythmics, aminophylline, and alcohol. 3. The family history of sudden cardiac death may indicate a predisposing factor for rhythm disorder, such as hypertrophic obstructive cardiomyopathy, congenital prolonged QT syndrome, or the presence of an aberrant conduction pathway. 4. In the history, the patient may describe sensations that accompany abnormal cardiac rhythm, such as pounding, racing, or skipped beats. 5. Older adults are less likely to complain of palpitations and more likely to present with manifestations of heart failure or hypoperfusion (i.e., impaired mental function, dizziness, syncope). There appears to be a peak in syncopal episodes above age 65 years in both men and women. 14. Ms. Alma, 69 years old, seeks medical advice because she is having trouble breathing. She is experiencing dyspnea, chronic cough with sputum production, decreased activity tolerance, and wheezing. She states that she had not been near anyone with any upper respiratory infections and wonders why this is happening. The nurse practitioner asks which of the following questions? Select all that apply. 1. Have you ever smoked cigarettes? 2. Have you ever worked in a factory or foundry? 3. How long have you experienced these symptoms? 4. Do you have any past history of respiratory difficulties? 5. Have your symptoms increased as you've gotten older? - 14. Selected answer: 1, 2, 3, 4, 5Page: 164, 165 Feedback 1. The most significant risk factor for chronic obstructive pulmonary disease (COPD) is cigarette smoking. 2. Occupational/industrial gases or fumes, and indoor/outdoor air pollution are all contributing risk factors for COPD. 3. Advancing age is a factor, with symptoms often presenting after the age of 40 to 50 years old. Individuals aged 65 to 74 years and 75 years and older have the highest incidence of COPD. 4. Inadequate lung growth and development during childhood contribute to risk factors for COPD. 5. Advancing age is a risk factor for COPD, although the evidence is unclear if healthy aging leads to COPD or if it is a result of the cumulative sum of exposures throughout life. 15. John is 80 years old and is experiencing the following: weight gain, tachycardia, neck vein distention, and cognitive impairment. The nurse practitioner assesses for which of the following to support a diagnosis of heart failure? Select all that apply. 1. Laterally displaced point of maximum impulse of apical pulse. 2. Rales in bilateral lower lobes not due to atelectasis or ascites. 3. Functional impairment. 4. Increase in appetite and alertness. 5. Asymptomatic. - 15. Selected answer: 1, 2, 3Page: 171 Feedback 1. Signs that suggest heart failure include weight gain, tachycardia, S3 or S4 heart sound, and laterally displaced point of maximum impulse. 2. Signs that suggest heart failure include rales in bilateral lower lobes that are not due to atelectasis, positive hepatojugular reflux, and ascites. 3. A reading of 100 to 120 mm Hg is too high. 2. A reading of 90 to 120 mm Hg is too high. 3. Good arterial pressure for those with AAA should fall between 60 and 70 mm Hg. 4. A reading of 80 to 100 mm Hg is too high. 5. Which medical specialist is the best referral for patients with symptomatic AAA? 1. Vascular surgeon 2. Neurosurgeon 3. Cardiologist 4. Internist - 5. Selected answer: 1 Page: 217 Feedback 1. A vascular surgeon is a specialist who is highly trained to treat diseases of the vascular system. 2. A neurosurgeon is a physician who specializes in the diagnosis and surgical treatment of disorders of the central and peripheral nervous system. 3. A cardiologist is a doctor who specializes in the study or treatment of heart diseases and heart abnormalities. 4. Internists are specialists who apply scientific knowledge and clinical expertise to the diagnosis, treatment, and compassionate care of adults across the spectrum, from health to complex illness. 6. Anne is a 50-year-old post-mastectomy patient diagnosed with secondary lymphedema. Based on her surgical history, which of the following may be the contributing factor to the lymphedema? 1. Gynecological cancer 2. Breast cancer 3. Urological cancer 4. Infection - 6. Selected answer: 2Page: 218 Feedback 1. Gynecological cancer is a contributing factor for secondary lymphedema, but it is not the best option for this scenario because of Anne's history. 2. Breast cancer is the best option and is a contributing factor for secondary lymphedema in Anne's case because of the previous mastectomy. 3. Urological cancer is a contributing factor for secondary lymphedema, but it is not the best option for this scenario because of Anne's history. 4. Infection is a contributing factor for secondary lymphedema, but it is not the best option for this scenario because of Anne's history. 7. PVD is a disease that alters blood flow to or from the extremities and vital organs other than the heart. According to studies, which of the following remains the most important risk factor for PVD? 1. Smoking 2. Hypertension 3. Family history 4. Hypercoagulopathy - 7. Selected answer: 1Page: 219 Feedback 1. Smoking remains the most important risk factor to PVD. 2. Hypertension is an associated risk factor to PVD. 3. A strong family history of the disease is an associated risk factor to PVD. 4. Hypercoagulopathy is an associated risk factor to PVD. 8. Which of the following differential diagnoses should be considered with the diagnosis of peripheral arterial disease (PAD)? 1. Marfan syndrome 2. Atelectasis 3. Raynaud's phenomenon 4. Carpal tunnel syndrome - 8. Selected answer: 3Page: 219, 220 Feedback 1. Marfan syndrome is a genetic disorder that affects the body's connective tissue. It is not related to the diagnosis of PAD. 2. Atelectasis is a condition where some, or all, of the air-filled sacs (alveoli) inside the lungs collapse, thereby reducing the lungs' capacity to deliver oxygen to the body. It is not related to the diagnosis of PAD. 3. Raynaud's phenomenon is a type of vascular disease characterized by a pale to blue to red sequence of color changes of the digits, most commonly after exposure to cold, and should be considered with the diagnosis of PAD. Buerger's disease is also a differential diagnosis for this disease. 4. Carpal tunnel syndrome is a common condition that causes pain, numbness, and tingling in the hand and arm. It is not related to the diagnosis of PAD. 9. Patient education is very important for individuals who have AAA. The patient and their family should be taught the importance of follow-up and the management of which of the following? Select all that apply. 1. Hypertension 2. Hypercholesterolemia 3. Smoking 4. Chondromalacia 5. Pain - 9. Selected answer: 1, 2, 3, 5 Page: 220, 221 Feedback 1. Education about hypertension management is important for patients with AAA. Antihypertensive agents are used to reduce tension on the vessel wall in patients with AAAs who have elevated blood pressure. 2. Patients with AAA need to learn about control of hypercholesterolemia (also called high cholesterol). Hypercholesterolemia is characterized by high serum cholesterol levels and premature coronary atherosclerosis. Hypercholesterolemia is one of the factors promoting the arteriosclerotic process and is a major cause of aortic aneurysm. 3. Smoking cessation should be considered by patients with AAA. Smoking appears to increase the risk of aortic aneurysms. Smoking can be damaging to the aorta and weaken the aorta's walls. 4. Chondromalacia is a pain in the knee and has no relationship to AAA. 5. Pain is the most common symptom of an AAA. Pain associated with an AAA may be in the abdomen, chest, lower back, or groin area. The pain may be severe or dull. Sudden, severe pain in the back or abdomen may mean the aneurysm is about to rupture. 13. Devon visits the urgent care facility for sudden symptoms of pain to his lower extremity. The initial diagnosis is acute arterial ischemia. Aside from pain, which other symptoms may arise from this diagnosis? Select all that apply. 1. Pulselessness 2. Paresthesia 3. Pallor 4. Purulence 5. Paralysis - 13. Selected answer: 1, 2, 3, 5Page: 219 Feedback 1. Pulselessness is a symptom for acute arterial ischemia. Checking pulses is notoriously unreliable. Arterial Doppler signals should be checked in anyone with suspected acute limb ischemia. 2. Paresthesia is present in over 50% of cases. Sensory nerves are smaller than motor nerves and more sensitive to ischemia so tend to be affected first. 3. Pallor is especially useful in comparison to the opposite limb; it is also useful to check venous filling. Acutely ischemic limbs are classically white rather than blue. Chronic critically ischemic limbs may appear pink due to compensatory vasodilation, the so-called sunset foot. 4. Purulence is not a symptom that may arise from acute arterial ischemia diagnosis. 5. Paralysis is a poor prognostic sign and indicates an element of irreversible ischemia. 14. Treatment to slow the progression of PAD should include which of the following? Select all that apply. 1. Immobilization 2. Pharmacological 3. Surgical 4. Conservative 5. Heat - 14. Selected answer: 2, 3, 4Page: 220 Feedback 1. Immobilization does not slow the progression of PAD. 2. Pharmacological treatment is provided with conservative treatment and used to slow the progression of PAD. 3. Surgical treatment of PAD involves revascularization of the affected extremity and is used to slow the progression of PAD. 4. Conservative treatment involves modification of risk factors, including smoking. It also includes blood pressure and diet implementations to slow the progression of PAD. 5. Heat is not a treatment used to slow the progression of PAD. 15. Sharon is a 70-year-old patient with venous ulcers to her right lower extremity. She has a history of multiple pregnancies and surgeries, and has a sedentary lifestyle. Which of the following may be possible contributing factors to her diagnosis given her history? Select all that apply. 1. Obesity 2. Reduced mobility 3. History of breast cancer 4. Degenerative disease 5. Parkinsonism - 15. Selected answer: 1, 2Page: 221 Feedback 1. Obesity, or being overweight, can increase the risk of developing a venous leg ulcer, as this increases the pressure in the leg veins. 2. Decreased or reduced mobility in the ankle contributes to the diagnosis of venous leg ulcer. 3. History of breast cancer is not a contributing factor to venous leg ulcer. 4. Degenerative disease is not a contributing factor to venous leg ulcer. 5. Parkinsonism is not a contributing factor to venous leg ulcer. 1. Mrs. M. W. comes into the primary care office for her regular yearly checkup. The nurse practitioner begins the assessment by asking if there are concerns Mrs. M. W. has that need to be addressed. The patient says that she has been experiencing periodic episodes of abdominal cramps and diarrhea that just comes and goes. The nurse practitioner continues the assessment with which of the following? 1. Asking about the sequence of events and events that triggered each episode. 2. Conducting a complete neurological examination. 3. Collecting a urine specimen. 4. Evaluating abdominal pain. - 1. Selected answer: 1Page: 225 Feedback 1. Determining the sequence of events that triggered each symptom and inquiring about precipitating factors such as a meal, position of the body, use of caffeine, or alcohol and smoking will lead to a differential diagnosis. 2. Information regarding episodes of anorexia, dyspepsia, dysphagia, heartburn, nausea, regurgitation, vomiting, painful or difficult defecation, diarrhea, tenesmus, or constipation can be clustered to form a differential diagnosis. 3. The physical examination is often unremarkable, and laboratory findings may not provide diagnostic information because the presentation of illness in an older adult is usually subdued. 4. Ask about the severity of pain by having the patient rate her pain on a scale of 1 to 10. Realize, however, that in older adults, pain may be blunted despite the underlying pathology. 2. Part of the abdominal examination the nurse practitioner will conduct is the assessment of skin color. As the nurse practitioner assesses the abdominal skin, the findings include which of these signs that are concerning? 1. Generalized pinkness. 2. Bluish discoloration on the flanks. 3. Yellow tint around the lower left quadrant. 4. Blue in the upper left quadrant. - 2. Selected answer: 2Page: 226 Feedback 1. Pinkness is normal for a Caucasian patient. 2. If the bluish discoloration is on the flanks, this is known as Grey Turner's sign and is often indicative of retroperitoneal bleeding, as with pancreatitis. 3. Jaundice in the area of the umbilicus is known as Ransohoff's sign and is a result of a ruptured common bile duct. 4. If a bluish discoloration is detected around the umbilicus, this is known as Cullen's sign, which is often found in patients with bleeding in the peritoneum. Mild leukocytosis with increased band formation is the most common abnormality seen in laboratory studies; however, white blood cell counts may not be elevated in the older adult. 3. Elevation in lipase, amylase, and elevated liver function tests would prompt further evaluation for gallstone pancreatitis; however, laboratory values may be normal. 4. Real-time ultrasonography of the gallbladder and biliary tree is the diagnostic procedure of choice for both acute and chronic cholecystitis, showing gallstones, thickening of the gallbladder wall, and (if the common bile duct is obstructed) dilation of the biliary tract. 7. Kefka Jones, 60 years old, has diabetes and is now having urinary tract symptoms. The nurse practitioner orders a glomerular filtration rate (GFR) from a urine sample. Which of the following would indicate a stage 1 chronic kidney disease (CKD)? 1. GFR greater than or equal to 120mL/min. 2. GFR greater than or equal to 90 mL/min with other symptoms. 3. GFR of 45 to 59 mL/min. 4. GFR less than 15 mL/min. - 7. Selected answer: 2Page: 236 Feedback 1. GFR of 120 mL/min is not a criterion for stages of CKD. 2. Stage 1 is when GFR is greater than or equal to 90 mL/min with other evidence of CKD damage. 3. Stage 3a is GFR 45 to 59 mL/min. 4. Stage 5 is GFR less than 15 mL/min or on dialysis. 8. Jose Mirrare is a 65-year-old male who is being treated for cirrhosis of the liver. Which of the following does the nurse practitioner include in his discharge teaching? Select all that apply. 1. Eliminate all alcohol consumption. 2. Attend an alcohol treatment program. 3. Do not self-medicate with over-the-counter (OTC) medications, including herbal products. 4. Eat three large meals of a balanced diet containing 4 to 5 mg protein/kg body weight per day. 5. Be cautious when driving, as you have encephalopathy. - 8. Selected answer: 1, 2, 3Page: 236, 237 Feedback 1. Chronic alcohol consumption, combined with a poor nutritional intake, contributes to cirrhosis. Drug- induced cirrhosis can occur in patients taking large doses of vitamin A, Aldomet, isoniazid, and methotrexate. Certain infectious diseases (tertiary syphilis, brucellosis, schistosomiasis) have predisposed patients to a risk of developing cirrhosis. 2. Recommend an alcohol treatment program and provide the telephone number for the nearest chapter of Alcoholics Anonymous. 3. Patients should be requested not to self-medicate with OTC medications, including herbal products. 4. Patients with cirrhosis should eat small, frequent meals of a balanced diet containing 1 to 1.5 mg protein/kg body weight per day, unless contraindicated by advanced disease. 5. Patients with encephalopathy should not be driving. 9. Ms. Jenny is 80 years old and is diagnosed with Clostridium difficile-associated diarrhea (CDAD). As she discusses her condition with her nurse practitioner, she asks how she obtained this disease. The nurse practitioner tells her which of the following? Select all that apply. 1. It used to be hospital-acquired only disease, but now this infection is in the community. 2. Risk factors include antibiotic exposure, being an older adult, and church or synagogue exposure. 3. Inflammatory bowel disease and compromised immunity can lead to CDAD. 4. Lesser known risk factors include prior hospitalization within several months and a state of malnourishment of the body. 5. The source of CDAD is currently unknown. - 9. Selected answer: 1, 3, 4Page: 242 Feedback 1. CDAD is no longer a hospital-acquired infection only, as outpatient incidences are rising. 2. Risk factors include antibiotic exposure, older adults, and health-care facility exposure. 3. The presence of inflammatory bowel disease and compromised immunity also play a role in increasing the risk for CDAD. 4. Lesser-known risk factors include intensive care admission, prior hospitalization within several months, ventilatory support, enteral feedings, use of histamine blockers and proton pump inhibitors, and malnourished states. 5. Bacterial spores are spread via the fecal-oral route and thrive on surfaces such as toilets, hospital equipment, and door handles. These spores have the potential to survive for months, even in harsh circumstances. 10. A patient who is an 80-year-old female comes to the emergency department with complaints of a low-grade fever and left lower quadrant pain aggravated by movement. She also reports that the pain is precipitated by eating and describes a colicky pain in the right side of the abdomen. Which diagnostic tests does the nurse practitioner order? Select all that apply. 1. A total body CT scan 2. Abdominal x-rays 3. CBC, amylase, lipase 4. Urinalysis 5. Sigmoidoscopy - 10. Selected answer: 2, 3, 4Page: 250 Feedback 1. Patients should be scheduled for a CT scan of the abdomen and pelvis. CT scans performed with oral, IV, and rectal contrast can enhance the accuracy of the diagnostic image. 2. Initially, plain abdominal radiographs can be ordered. 3. A CBC, amylase, lipase, urinalysis, complete C-reactive protein, and sedimentation rate need to be ordered to distinguish diverticulitis from other causes of acute abdominal pain. 4. Urinalysis may reveal sterile pyuria due to adjacent colonic irritation. 5. Sigmoidoscopy, colonoscopy, and barium enema are usually avoided during acute diverticulitis because these tests may cause further perforation or leakage of bowel contents. 11. Bill James, 67 years old, is being seen in the clinic for complaints of regurgitation, pyrosis, hoarseness, chronic cough, and atypical chest pain. The nurse practitioner suspects gastroesophageal reflux disease (GERD). As home-going instructions are developed, the nurse practitioner includes which of the following? Select any that apply. 1. Raise the head of the bed 2 inches. 2. Avoid tight, restrictive clothing. 3. Avoid smoking and ingestion of fatty foods. 4. Avoid eating a meal for at least 20 minutes before becoming recumbent. 5. Avoid caffeine and acidic foods. - 11. Selected answer: 2, 3, 5Page: 262 Feedback 1. Patients with reflux esophagitis should be instructed to raise the head of the bed 4 to 6 inches with shock blocks or use a foam wedge that can be placed at the head of the bed. Feedback 1. Overweight or obese patients with NAFLD should consider a weight-loss program. It has been shown that weight loss and exercise reduce liver enzyme levels and steatosis. 2. Treatment for hyperlipidemia (atorvastatin, gemfibrozil) has been shown to improve liver enzymes and liver steatosis. 3. The hepatitis A and B vaccine should be given to patients without serological evidence of immunity. 4. Patients with NAFLD should avoid alcohol consumption. 5. Weight loss should not exceed 1 to 2 pounds a week. Patients should avoid rapid weight loss. 15. Dan is 70 years old and has been having frequent bouts of kidney stones. They are painful, and he has had one procedure done for nephrolithiasis. Dan asks the nurse practitioner if there is anything he can do to prevent these. He says his brother also has them, so he wonders if it is just familial. How does the nurse practitioner respond? Select all that apply. 1. Increase the amount of fluids you drink daily. 2. Avoid eating foods such as dairy, spinach, and nuts. 3. Some medications can contribute to stone formation. 4. Kidney stones are not familial. 5. Report signs of possible urinary tract infections to a physician for treatment. - 15. Selected answer: 1, 2, 3, 5Page: 270 Feedback 1. A major contributing factor to the development of calculi is decreased fluid intake leading to a high concentration in urine. 2. Certain food substances that augment the formation of kidney stones include dairy products, chocolate, green leafy vegetables (calcium oxalate stones), and eggs, fish, poultry, peanuts, and wheat (cystine stones). 3. Certain medications, such as triamterene, indinavir, acetazolamide, acyclovir, and sulfa can contribute to the development of nephrolithiasis. 4. Family history has also been found to contribute to stone formation, as well as increased oxalate absorption. 5. Chronic urinary tract infections may be precursors to struvite stone formation. 1. The genitourinary and reproductive systems undergo many age-related changes. Which of the following statements is true about these changes? 1. The older male patient undergoes more gradual changes than does the older female patient. 2. The older female patient undergoes more gradual changes than does the older male patient. 3. Older male and female patients undergo the same changes. 4. The older male patient undergoes less gradual changes than those of the older female patient. - 1. Selected answer: 1 Page: 281 Feedback 1. This statement is correct. Older male patients undergo more gradual changes than those of older female patients. 2. Older male patients undergo more gradual changes than those of older female patients. 3. Older male patients undergo more gradual changes than those of older female patients. 4. Older male patients undergo more gradual changes than those of older female patients. 2. Lucy is a 56-year-old woman experiencing itching, discomfort, and bleeding after intercourse. Which of the following conditions may be developing in the patient? 1. Atrophic vaginitis 2. Vaginal cancer 3. Fibroadenoma 4. Cystitis - 2. Selected answer: 1Page: 282 Feedback 1. Atrophic vaginitis presents symptoms of itching, discomfort, and bleeding after intercourse. 2. Vaginal cancer presents symptoms of a watery vaginal discharge, a lump or mass in the vagina, painful urination, frequent urination, constipation, and pelvic pain. 3. Fibroadenoma is a solid, noncancerous breast lump. 4. Cystitis presents with symptoms of change in urination: dysuria, frequency, urgency, and change in urine character. It also can include suprapubic tenderness and mental status changes. 3. Which of the following is the single most signal symptom for possible breast cancer? 1. Nipple retraction 2. Breast discharge 3. Breast mass 4. Breast redness - 3. Selected answer: 3Page: 286 Feedback 1. Other than a mass in the breast, there are no other early signal symptoms. 2. Other than a mass in the breast, there are no other early signal symptoms. 3. Breast mass is the only early signal symptom of breast cancer. 4. Other than a mass in the breast, there are no other early signal symptoms. 4. Which of the following conditions presents nonproliferating lesions and does not affect future cancer risk? 1. Atypical lobular hyperplasia 2. Fat necrosis 3. Radial scar 4. Papilloma - 4. Selected answer: 2Page: 287 Feedback 1. Atypical lobular hyperplasia is a proliferating lesion with atypia and has an increase in cancer risk of four to five times. 2. Fat necrosis is a nonproliferating lesion and does not affect future cancer risk. 3. Radial scar is a proliferating lesion without atypia and has an increase in cancer risk of approximately one to two times. 4. Papilloma is a proliferating lesion without atypia and has an increase in cancer risk of approximately one to two times. 9. A nurse practitioner is performing an annual checkup for a female patient. In the physical examination of the breast, for which of the following should the nurse practitioner assess? Select all that apply. 1. Temperature 2. Symmetry 3. Dimpling 4. Lumps 5. Size - 9. Selected answer: 2, 3, 4Page: 280 Feedback 1. Although changes in temperature may signal abnormalities, it is secondary to the physical examination of the breast. 2. Asymmetry can present any abnormalities that contribute to breast conditions. 3. Dimpling or puckering of the skin on the breast is important to recognize, as these may be signs of breast cancer or other breast conditions. 4. A lump on the breast is important to recognize, as this is the single early sign of breast cancer. Lumps may also be indicative of other breast conditions. 5. Size alone is not important, but asymmetry in size is important to recognize, as it may be a sign of breast cancer or other breast conditions. 10. During a breast examination, the patient should be asked if she has which of the following? Select all that apply. 1. Breast pain 2. Breast atrophy 3. Breast rash 4. Breast trauma 5. Proper support - 10. Selected answer: 1, 3, 4Page: 280, 281 Feedback 1. A patient should be asked if she is experiencing any breast pain and should point out the location. Description of the pain is also important. 2. Breast atrophy is an observation to be made by the nurse practitioner and not a question to be asked of the patient. 3. A patient should be asked if she has observed any rash on or around the breast. Also ask about onset, location, and sensations of the rash. 4. Patients should be asked if there was any breast trauma, as this could lead to injury of the breast. 5. Asking about the use of proper support may be helpful for some individuals, but it is not generally a question that is asked during the breast examination. 11. When other symptoms are presented with atrophic vaginitis, a biopsy is used as the diagnostic test to rule out which of the following diagnoses? Select all that apply. 1. Urinary tract infection (UTI) 2. Sexually transmitted infection (STI) 3. Squamous cell hyperplasia 4. Lichen sclerosis 5. Lichen planus - 11. Selected answer: 3, 4, 5Page: 282 Feedback 1. UTI presents with the symptom of pain with urination and is usually treated with an antibiotic. No biopsy is indicated to diagnose. 2. STIs present symptoms of pruritis, burning, and a thick white discharge. No biopsy is indicated to diagnose. 3. Squamous cell hyperplasia presents symptoms of pruritus, which results in scratching and inflammatory changes in squamous cells of the vulvar area. These are seen on a biopsy. 4. Lichen sclerosis presents with whitish lesions on the vulva and squamous cells. A biopsy is needed to diagnose. 5. Lichen planus shows papular, purple lesions that are pruritic and thought to be immunological in origin. A biopsy is needed to diagnose. 12. Jessie is a 54-year-old patient with a history of atrophic vaginitis. Which of the following should be included in her patient education? Select all that apply. 1. Use of over-the-counter (OTC) medications for pain and discomfort. 2. Use of water-soluble lubricants. 3. Benefits of regular sexual activity. 4. Identifying and addressing age-related changes. 5. Benefits of sexual-aid stimulators. - 12. Selected answer: 2, 3, 4Page: 283, 284 Feedback 1. First-line therapies to alleviate atrophic vaginitis symptoms include vaginal lubricants and moisturizers, plus regular sexual activity. 2. The use of water-soluble lubricants may alleviate symptoms. 3. Regular sexual activity can be beneficial in alleviating symptoms. 4. Knowledge of age-related changes is beneficial for understanding and alleviating the symptoms of atrophic vaginitis. 5. The use of a stimulator with sexual activity is not typically discussed with patients diagnosed with atrophic vaginitis. 13. Breast cancer is more prevalent in the female gender, with a median age of 61 years. Which of the following are modifiable risk factors that may contribute to the diagnosis of breast cancer? Select all that apply. 1. Postmenopausal obesity 2. Alcohol intake 3. Early menarche 4. Menopause hormone therapy 5. Ethnicity - 13. Selected answer: 1, 2, 4Page: 285 Feedback 1. Addressing postmenopausal obesity by encouraging healthy eating and exercise can reduce the risk factor of breast cancer. 2. Minimizing alcohol intake can help reduce the risk of developing breast cancer. 3. Early menarche is a nonmodifiable risk factor of breast cancer. 4. Menopause hormone therapy is a modifiable risk factor for breast cancer. Patients need to be informed about the risk of using combined estrogen and progestin menopause hormone therapy. Feedback 1. The nurse practitioner is seeking symptoms that form a pattern, and in the thorough examination to do that, she will find any abnormalities or areas of concern. 2. Medications will be taken into consideration after examination findings. 3. A goal of the nurse practitioner in gathering information from the older adult is to try and determine if there is a pattern of symptoms. 4. In an adult over 65 years old who is not presenting any musculoskeletal issues, this type of examination may not be necessary. 3. Mrs. Wilbur reports the presence of pain in her lower and upper back. The nurse practitioner responds by doing which of the following? 1. Determining where the pain is coming from. 2. Ignoring any history of injury. 3. Ruling out the presence of anything inflammatory. 4. Determining that this pain does not affect activities of daily living (ADLs), as the patient came in independently. - 3. Selected answer: 1 Page: 305 Feedback 1. Initially, the nurse practitioner will need to determine if the presenting symptoms arise from the joints, tendons, muscles, or periarticular structures, such as bursae. 2. Past trauma may now be manifesting itself as an articular degeneration. Because patients who have had a structural deformity or amputation typically place excessive strain on the joints for years, as older individuals they may now experience degeneration of the bone and surrounding musculature. 3. Inflammatory and noninflammatory conditions can coexist in patients. 4. It is important to ask questions and determine how the pain and stiffness are affecting function and quality of life, regardless of how it appears. 4. When assessing a patient with a possible musculoskeletal condition, it is important to: 1. Know how much sleep the patient gets per night. 2. Be aware that older patients report any and all pains. 3. Determine ROM in all limbs. 4. Not refer to past injuries or conditions. - 4. Selected answer: 3Page: 306 Feedback 1. The amount of sleep the patient gets may be affected by pain, but knowing this will not affect the diagnosis. 2. It is important to remember that within the current cohort of older adults, a stoic attitude toward pain may be displayed despite the presence of an acute or chronic musculoskeletal condition. 3. Patients presenting with a functional limitation should be asked to demonstrate active ROM. Active ROM should be performed smoothly and effortlessly. 4. Ask if the patient has experienced any severe trauma in the past that may now be manifesting itself as an articular degeneration. 5. Mr. Cummins, a 69-year-old Caucasian male, presents with an inability to move his right arm sufficiently. The nurse practitioner tells him that she will perform a physical examination and order tests to rule out which of the following? 1. Gout 2. Rheumatoid arthritis (RA) 3. Muscle weakness from a systemic condition 4. Osteoarthritis (OA) - 5. Selected answer: 3Page: 307 Feedback 1. Because gout is an inflammatory disease that results in deposits of sodium urate crystals in the joints, periarticular tissues, and kidneys, and because the patient is only having a problem with one joint, it is not likely that gout is the diagnosis. 2. RA is a chronic systematic inflammatory process evidenced by symmetrical polyarthritis; it is the most common inflammatory arthropathy. 3. To determine if a patient is having true muscle weakness, the patient should perform against the examiner's resistance. One side should be compared to the other and a numerical value for tested muscle strength recorded. Flexor and extensor muscles should be tested for strength. 4. OA encompasses both symptoms and the structural remodeling of articular cartilage with inflammation of synovitis and ligament. 6. Mrs. Cameron is a 72-year-old woman who comes to see her nurse practitioner for pain in her right thigh. The nurse practitioner assesses that Mrs. Smith has bruises on her thigh and muscle weakness distally, near the knee. The nurse practitioner suspects which of the following? 1. Musculoskeletal lesions 2. Tendon rupture 3. Gout 4. Arthritis - 6. Selected answer: 2Page: 306 Feedback 1. Patients with presentation of soft tissue syndromes should be asked about the origin of the presentation of bruising. The pain may be related to an event. 2. Ecchymosis in the area of a joint may be indicative of tendon rupture. 3. Gout is polyarticular in older adults. 4. Arthritis is an ongoing synovial membrane attack that results in synovial proliferation; pannus formation; and destruction of bone, cartilage, and ligaments, leading to joint damage and deformity. 7. The nurse practitioner calls Mr. Smith to come into the examining room. As he is coming in, the nurse practitioner observes his gait to assess for musculoskeletal conditions. One abnormal sign is: 1. Unbalance in gait. 2. Lack of a lurch. 3. Symmetrical leg movement. 4. Ability to sit in and get out of a chair without using arms. - 7. Selected answer:1 Page: 306 Feedback 1. An unbalanced gait is abnormal and a risk for falling. 2. Note if the patient is having difficulty in shifting weight from one leg to the other and instead relies on shoulder movement from side to side. This is called a lurch and is abnormal. 3. Observe for any limping or asymmetrical leg.