NRNP 6540 FINAL EXAM-with 100% verified solutions-2023-2024, Exams of Health sciences

Download NRNP 6540 FINAL EXAM-with 100% verified solutions-2023-2024 and more Exams Health sciences in PDF only on Docsity! NRNP 6540 FINAL EXAM-with 100% verified solutions-2023-2024 1. Mrs. Smith, 75 years old, reports that she is weak, has difficulty urinating, and is dehydrated. Although she is afebrile, the nurse conducts a thorough physical examination, including urinalysis and complete blood count (CBC). The total assessment is necessary because: 1. All body systems interact, and symptoms could indicate a variety of diagnoses. 2. The symptoms are vague and may be signs of aging. 3. There may be other signs or symptoms more indicative of the condition. 4. Mrs. Smith may not be reporting all significant information. - 1. Answer: 1 Page: 2 Feedback 1. The clinician must be aware that all the systems interact and, in doing so, can increase the older person's vulnerability to illness/disease. 2. The nurse must not attribute symptoms only to the aging process. 3. There may be comorbidities accompanying this condition. 4. Assumptions of not reporting properly may not be true. 2. A patient with renal disease has blood work drawn, and the results show an increase in serum creatinine. The nurse practitioner needs to know which of the following laboratory values before ordering medications? 1. CBC 2. Culture and sensitivity of the urine 3. Creatinine clearance 4. Uric acid levels - 2. Answer: 3 Page: 3 Feedback 1. A CBC will not evaluate kidney function for a patient with renal disease. 2. A culture and sensitivity test reflects the presence of an infection and the antibiotic to which the organism is sensitive. 3. The calculation of creatinine clearance provides an estimation of renal function. 4. Uric acid level is elevated in the presence of gout. 3. Which of the following statements is true regarding diagnostic testing? 1. A test is ordered for a specific purpose. 2. A test is the most invasive available. 3. There is no need to discuss results with the patient. 4. If a test is needed, it should be ordered regardless of risk to the patient. - 3. Answer: 1 Page: 3 Feedback 1. The nurse practitioner should have a plan for the use of each test result value obtained. 2. When considering which laboratory tests to order, it is worth remembering the doctrine primum no nnocere—first, do no harm. 3. Once laboratory tests are available for review, tests results should be discussed with the patient, with abnormal test results interpreted for the aging individual and addressed with the patient and caregivers. 4. Any risks involved in laboratory testing must be considered concerning the patient's clinical condition and weighed against the test's expected benefits. 4. Janey, 25 years old, may experience arthritis differently than 65-year-old Mrs. Johnson because: 1. The body undergoes physiological changes with aging. 2. A healthy body does not experience significant changes as one gets older. 3. Older patients do not feel any systemic symptoms, such as malaise and weight loss. 4. Even though the same joints are usually affected, age makes it feel different. - 4. Answer: 1 Page: 5 Feedback 1. Knowledge of the bimodality of age onset of certain disease conditions will aid the advanced practice nurse in avoiding misdiagnosis or delay in diagnosis due to lack of recognition. 2. Symptoms of rheumatoid arthritis may be different depending on the age of the patient. 9. A 70-year-old man is seeing a nurse practitioner because he is feeling weak and dizzy. The nurse practitioner is discussing a care plan with him and makes which of the following statements? Select all that apply. 1. I want to order a test for your heart to evaluate its function. 2. I will perform a thorough examination of your functional abilities. 3. I will order a blood sugar test to check for diabetes. 4. Many older people feel this way. It is to be expected. 5. I will assess you for the presence of other conditions. - 9. Answer: 1, 2, 3, 5 Page: 2, 3 Feedback 1. A complete assessment will help differentiate signs of aging from disease. 2. All systems interact and can affect an existing condition. 3. Identifying underlying conditions will avoid undertreatment. 4. Attributing symptoms to aging can contribute to depression in an older person. 5. There are changes in the sympathetic response which contribute to the orthostasis and falls, as well as lack of hypoglycemic response. 10. The nurse practitioner is leading a class of seniors over age 65 years and is teaching about nutritional needs. One of the men asks why, even though he eats correctly according to the standards presented, he still feels weaker than he did 10 years ago. He also wonders why he gets more infections than he used to. Which of the following are helpful answers? Select all that apply. 1. I suggest that you exercise a little more than you are currently doing. 2. Some people experience a decrease in reserve energy. 3. For some people, the immune system weakens. 4. More viruses are being spread throughout the community. 5. I suggest that you see your primary caregiver for extensive testing. - 10. Answer: 2, 3, 5 Page: 2, 3 Feedback 1. Improved nutrition may not be the factor affecting health of elders. 2. Many factors can influence the health of elders, including lifestyle and medications. 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. 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. Answer: 1, 4 Page: 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. Answer: 2, 3 Page: 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. 4. Encouraging the advancement of alternative health therapies. - 2. Answer: 3 Page: 6 Feedback 1. Current health policies are ever-changing to improve services for citizens. 2. Federal legislation is being proposed to increase health services. 3. The World Health Organization has determined that healthy lifestyle promotion works best when coupled with supportive environments, community action, and healthy public policy formation. 4. This does not include preventive and health-protective measures, nor actualization of one's health potential. 3. Mr. Thomas comes in for a health examination appointment with his nurse practitioner. He asks why nurse practitioners are qualified to conduct these evaluations. Which of the following is the nurse practitioner's best response? The nurse practitioner: 1. Is concerned about health and not disease. 2. Saves the physician time in the office. 3. Can assess for minor conditions and refer to the doctor for other conditions. 4. Is prepared to assess health holistically. - 3. Answer: 4 Page: 6 Feedback 1. The nurse practitioner is concerned about health promotion, disease prevention, and early diagnosis. 2. The nurse practitioner may spend more time with the patient than the doctor is able to. 3. The nurse practitioner is prepared to diagnose and plan treatment for many conditions. 4. The nurse practitioner brings a holistic orientation to health and wellness development and possesses knowledge of developmental tasks and the wellness-illness continuum. 4. Mrs. Williams, 80 years old, asks her nurse practitioner to order a new alternative therapy for her. Mrs. Williams believes that this botanical supplement will provide pain relief for her fibromyalgia. The nurse practitioner explains that this therapy is likely not covered by Medicare because: 1. The botanical is expensive and not approved for use. 2. Medicare only covers treatments that are approved according to the stringent guidelines of the U.S. Preventive Services Task Force (USPSTF). 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. Answer: 2 Page: 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. Answer: 4 Page: 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. Answer: 1 Page: 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. Answer: 3, 4, 5 Page: 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. Knowing how much activity the person has affects the need for calories and nutrients. 4. Knowing the current height and weight aids in determining the body mass index, which is an indicator of normal weight or overweight. 5. Before initiating counseling about diet, obtain baseline information on other health status information. 12. A major concern for older adults is safety. The nurse practitioner addresses safety issues when assessing the following. Select all that apply. 1. Presence of a gun in the home. 2. Fear of falling. 3. Strength of the patient. 4. Presence of rugs and other hazards in the home. 5. Urinary incontinence. - 12. Answer: 1, 2, 3, 4, 5 Page: 8 Feedback 1. Possession of a firearm combined with depression, caregiver stress, irreversible illness, or decline in functional abilities can invite self-inflicted injury, suicide pacts, or other acts of violence. 2. Fear of falling causes a person to walk guardedly and unevenly. 3. Potential recommendations include exercise programs to build strength. 4. Rugs, furniture, and pets can become obstacles for the older person to stumble over. 5. Urinary incontinence, day or night, causes the person to rush to the bathroom and increases the risk of falling. 13. Albert is 72 years old and complains of burning upon urination. He has recently returned from a vacation to another country. The nurse practitioner conducts a physical examination and observes that there is a white discharge from his penis. What does the nurse practitioner include in the treatment plan? Select all that apply. 1. Teaching on safe sex practices. 2. Teaching about the incidence of contracting sexually transmitted infections (STIs), even at an older age. 3. Teaching that frequent testing and screening is needed if he continues to be sexually active. 4. Assuring the patient that while traveling there are limited opportunities for sexual encounters. 5. There is no need to assess an older patient's sexual preferences and practices. - 13. Answer: 1, 2, 3 Page: 8 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. Answer: 1, 2, 3 Page: 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. Answer: 1, 4 Page: 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. Answer: 2 Page: 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. 2. Finding an exercise "buddy" may be helpful but still may impose the excuse of not being able to find one. 3. Taking a 10-minute walk every day is the best suggestion. With this suggestion a patient cannot make the excuse of not having time or equipment. 4. Going to the YMCA is not the best suggestion to counter excuses for the same reasons as joining a gym is not the best suggestion. 6. Older adults who have chronic conditions and are considering an increase in their physical activity should: 1. Start slowly, using lower weights with high repetitions. 2. Consult with a personal trainer. 3. Consult a health-care provider to help set physical activity goals that are realistic and safe. 4. Start with low repetitions but heavier weights. - 6. Answer: 3 Page: 21 Feedback 1. Starting slowly with low weights and high repetitions may be a good start but must be monitored or initiated by an appropriate medical professional for instruction in proper use. 2. A consultation with a personal trainer is not the best option because some trainers may not be familiar with chronic conditions. 3. Consulting a health-care provider for physical activity goals that are realistic and safe is the best option. 4. Starting with low repetitions but heavier weights is not a good way to start an exercise program because it may result in injury. 7. Challenges to increasing physical activity are different for everyone. For instance, some patients may be experiencing depression or loss, some may have had significant life changes, and others may be dealing with functional limitations. As relates to increasing physical activity, these are examples of what? 1. Patient excuses 2. Patient facilitators 3. Patient ignorance regarding what to do 4. Patient barriers - 7. Answer: 4 Page: 20 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. Answer: 1 Page: 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. Answer: 1, 2, 4 Page: 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. Answer: 1, 3 Page: 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 1. Frequent contact with prescriber. 2. Planned program. 3. Making time. 4. Purchasing new equipment. 5. Ignorance of exercise. - 14. Answer: 1, 2 Page: 20 Feedback 1. Frequent contact with a prescriber has been seen to be a patient facilitator. 2. A planned program has resulted in facilitation toward health motivation. 3. Making time is a patient choice rather than a facilitator toward making changes. 4. Purchasing new equipment is not an example of a patient facilitator and may not be doable for all patients. 5. Ignorance of what to do is not a patient facilitator but a barrier to increasing physical activities. 15. To perform physical activity safely and reduce the risk of injuries and other adverse events, which of the following are advisable? Select all that apply. 1. Start fast to get acclimated to the activities. 2. Use their instincts. 3. Use appropriate protective gear. 4. Follow rules and policies. 5. Have an exercise "buddy." - 15. Answer: 3, 4 Page: 21 Feedback 1. Starting fast could actually increase the possibility of injury. 2. There is no guarantee that instincts are correct. 3. Using appropriate protective gear is recommended to reduce the risk of injuries. 4. Rules and policies are made to inform and protect, therefore, following them will help to reduce the risk of injuries. 5. 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. Answer: 4 Page: 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. 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. Answer: 3 Page: 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. Answer: 2 Page: 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. 9. After examining Adam, who is 79 years old, the nurse practitioner uses which of the following criteria to adjust Adam's medications? Select all that apply. 1. The Beers Criteria published in 1991 2. Medication Appropriateness Index 3. STOPP/START Criteria 4. HHS Guide to Geriatric Medications 5. Hospital formulary - 9. Answer: 2, 3 Page: 27 Feedback 1. The Beers Criteria, 1991, was revised in 2015. Other criteria were also developed to address weaknesses found in the original Beers Criteria. 2. The Medications Appropriateness Test was developed to address some of the weak areas of the Beers Criteria. 3. The STOPP/START Criteria were developed to determine when medications should be added and when another might be discontinued for an older patient. 4. The HHS Guide to Geriatric Medications does not guide in medication prescribing. 5. Hospital formulary provides a list of medications carried within that hospital. 10. While examining John, who is 80 years old, the nurse practitioner observes that as he rises from the chair he pauses and holds on to the rail. Asking John if this happens often, he replies, "Yes, I get lightheaded and feel like I will fall." The nurse practitioner decides to conduct testing for orthostatic hypotension. This test includes which of the following? Select all that apply. 1. Having the patient lie down for 5 minutes, then measuring blood pressure and pulse. 2. Having the patient stand and wait a minute, then measuring blood pressure and pulse. 3. Having the patient jump in place for 2 minutes and then lie down. 4. Having the patient breathe deeply five times and then stand up. 5. Having the patient get up from his chair without using his arms, walk two to three steps, then back up to his chair and sit down. - 10. Answer: 1, 2 Page:27 Feedback 1. Obtaining baseline blood pressures is important to assess any changes. 2. 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. Answer: 1, 2, 4, 5 Page: 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. 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. 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. Geriatric syndrome is the term that refers to the conditions that have multiple underlying factors that may involve multiple organs. 3. Mrs. Rizzo is an 80-year-old Caucasian female who is presenting symptoms of chest pain, weakness, and lightheadedness. Which of the following may be a possible differential diagnosis of her symptoms? 1. Ischemic colitis 2. Spinal cord compression 3. Diabetic neuropathy 4. Costochondritis - 3. Answer: 4 Page: 38, 39 Feedback 1. Ischemic colitis is a possible differential diagnosis for fecal incontinence. 2. Spinal cord compression is a possible differential diagnosis for fecal incontinence. 3. Diabetic neuropathy is a possible differential diagnosis for fecal incontinence. 4. Costochondritis is the possible differential diagnosis for her symptoms of chest pain, weakness, and lightheadedness. 4. Steven is a 65-year-old male diagnosed with Parkinson's disease. He is taking anti- Parkinson's drugs, calcium supplements, and NSAIDs for his joint pain. Which of the following conditions could be caused by his medications? 1. Constipation 2. Hematuria 3. Headache 4. Chest pain - 4. Answer: 1 Page: 41 Feedback 1. Anti-Parkinson's drugs, calcium supplements, and NSAIDs are all known to cause constipation. 2. In older adult patients, the most common causes of hematuria are malignancy or benign prostatic hyperplasia. 3. 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. 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. Answer: 3 Page: 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. Answer: 1 Page: 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. 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. 1. Medications 2. Otolaryngologic conditions 3. Exercise 4. Psychiatric conditions 5. Hypothyroidism - 12. Answer: 1, 2, 4 Page: 51 Feedback 1. Some medications can cause dizziness. 2. Otolaryngologic conditions can result in symptoms of dizziness. 3. Exercise does not usually result in dizziness unless it is associated with other pathologies. 4. Psychiatric conditions can produce symptoms of dizziness. 5. Hypothyroidism (underactive thyroid) is a condition in which the thyroid gland doesn't produce enough of certain important hormones. Signs and symptoms of this condition may include fatigue, increased sensitivity to cold, constipation, dry skin, and weight gain, but not dizziness. 13. Joint pain is a condition that is caused by joint damage or injury that can interfere with movement. From which of the following etiologies may joint pain arise? Select all that apply. 1. Bursitis 2. Muscle spasm 3. Gout 4. Fractured humerus 5. Muscle strain - 13. Answer: 1, 3 Page: 72 Feedback 1. Bursitis is an inflammation of the fluid-field pads called bursa within the joint that can cause joint pain. 2. Muscle spasm is a condition that affects the muscles due to injury and does not necessarily cause joint pain. 3. Gout is a form of arthritis that causes joint pain. 4. 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. Answer: 1, 2, 4 Page: 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. Answer: 2, 4 Page: 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. 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 The ability to put on her ring is not the problem. 6. A 60-year-old male enters the burn center for triage and treatment due to a burn he received at a campfire. His left arm has an area that is erythematous and painful, and another area has a blister. What does the nurse practitioner record as the degree of burn? 1. First degree 2. Second degree 3. First and second degree 4. Second and third degree - 6. Answer: 3 Page: 98 Feedback 1. First-degree burns involving the epidermis are erythematous and painful but do not blister. 2. Second-degree burns involve the dermis and are characterized by blisters. 3. The patient presents with erythematous skin, painful with blisters, which indicates both first- and second-degree burn areas. 4. In third-degree burns there is no sensation when the wound is pinpricked. 7. The nurse practitioner is concerned with primary prevention strategies. How can the nurse practitioner implement primary prevention strategies for an 80-year-old male patient who smokes? 1. Review home fire safety protocols, including the proper use of smoke alarms, and discuss smoking cessation. 2. Inform him that if he does not stop smoking, the nurse practitioner cannot see him again. 3. Have a conference with his family about his smoking. 4. Plan a family meeting with the patient to discuss benefits of his smoking cessation. - 7. Answer: 1 Page: 115, 116 Feedback 1. Primary prevention includes educational programs designed to educate the public on safety. For example, the individual smoking in bed would hopefully benefit from smoking cessation programs in the community, as well as instruction in safety precautions. 2. Threatening refusal of care is not ethical. 3. The patient is at risk, not the family. 4. 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. 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. 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. Answer: 1, 2, 4 Page: 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. 4. The patient is 82 years old and reports having lived in the south of the United States for many years. 5. There is no concern about familial tendencies. - 14. Answer: 1, 2, 3, 4 Page: 118 Feedback 1. Signs of malignancy include elevation; the original lesion may also have enlarged in size. 2. Common locations for skin cancers are the scalp, ears, lower lip, and dorsal side of the hands. 3. Signs of malignancy include inflammation of the lesion. 4. The incidence of all types of skin cancers increases with age and the degree and intensity of sun exposure. 5. Certain genetic predispositions can contribute to the development of skin cancer, and there is a familial tendency to develop melanoma. 15. The nurse practitioner is making patient rounds in a long-term care facility and is visiting Mr. Smith, 95 years old, who has a large amount of fungus growing from his toenails. The staff nurse asks what can be done to help alleviate this nail fungus. What does the nurse practitioner advise? Select all that apply. 1. Wash and completely dry the feet and toes daily. 2. Keep the patient's feet cool and dry. 3. Use aluminum acetate solution (Burow's solution). 4. Have the patient wear occlusive footwear. 5. Use clotrimazole (ointment, cream, or lotion). - 15. Answer: 1, 2, 3 Page: 123 Feedback 1. The key to prevention of recurrence is to keep the area dry. Use a hairdryer to thoroughly dry the area after bathing. 2. The key to prevention of all types is to keep the skin cool and dry. 3. The use of aluminum acetate solution (Burow's) and the application of antifungal or absorbent powder have all been shown to prevent recurrence. 4. Avoiding occlusive footwear, wearing absorbent materials, and practicing good hygiene offer the best primary prevention. 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. Answer: 3 Page: 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. Answer: 1 Page: 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. 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. Answer: 4 Page: 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 AR is a condition of adulthood that declines in diagnosis after age 40. 2. AR develops when the body's immune system, not the respiratory system, becomes sensitized and overreacts to something in the environment that typically causes no problem in most people. 3. NAR is a condition of adulthood and is more common in the older adult. 4. NAR could be related to physiological changes in the older adult, as well as interactions from medications. 8. For which of the following evaluations should the patient be referred when sleep impairment is involved with chronic rhinitis? 1. Obstructive sleep apnea 2. Pharmacological therapy 3. Acupuncturist evaluation 4. Massage therapy - 8. Answer: 1 Page: 148 Feedback 1. Patients with chronic rhinitis may be referred for evaluation of obstructive sleep apnea in the presence of sleep-disordered breathing. 2. Pharmacological therapy is directed at control of the specific patient symptoms. 3. Acupuncture evaluation may be helpful to improve sleep, but may not be helpful in treating rhinitis. 4. Massage therapy may be helpful to improve sleep, but it is not helpful in treating rhinitis. 9. Evaluation for head and neck disorders should be performed with a systemic and thorough examination, including inspections of the face, head, and scalp. This includes which of the following? Select all that apply. 1. Palpating bones of the head for any anatomical irregularities. 2. Inspecting skin for any inflammation. 3. Inspecting the scalp and hair for any balding patterns. 4. Inspecting patient's features for any abnormalities. 5. Assessing for thoracic outlet syndrome. - 9. Answer: 1, 3, 4 Page: 127 Feedback 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. Answer: 1, 2 Page: 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. Answer: 1, 4 Page: 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. Answer: 1, 2, 5 Page: 131 1. Skin prick testing 2. CT scan 3. Blood test 4. MRI 5. Myelogram - 15. Answer: 1, 2 Page: 148 Feedback 1. Skin prick testing is a next step, but intradermal testing may be needed if results are negative. 2. CT scan should not be used in the absence of recurrent infection. 3. Blood test is a not common diagnostic testing for AR. 4. MRI is a not common diagnostic testing for AR. 5. A myelogram is a diagnostic imaging test generally done by a radiologist. It uses a contrast dye and x- rays or CT scan to look for problems in the spinal canal. 1. A patient comes to the health-care provider office for a checkup. The nurse practitioner notes that the patient is 67 years old and is presenting symptoms of dizziness, orthopnea, and edema. The nurse practitioner begins a focused assessment of the: 1. Cardiovascular system. 2. Respiratory system. 3. Neurological system. 4. Reproductive system. - 1. Answer: 1 Page: 152 Feedback 1. Key symptoms of cardiovascular assessment include dizziness, syncope, orthopnea, angina, edema, and claudication. 2. Edema is not commonly found in respiratory conditions. 3. Dizziness is a symptom in various conditions besides neurological conditions. 4. Dizziness, orthopnea, and edema have no direct connection with the reproductive system. 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. Answer: 4 Page: 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. Answer: 2 Page: 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. 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. Answer: 3 Page: 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. Feedback 1. The aging process is characterized by a loss of elasticity and flexibility in collagen and elastin tissue components, which impedes the normal expiratory recoil of the lung. 2. A part of aging is the weakening of inspiratory muscles. 3. The concurrent decrease in body water composition dries mucous membranes. 4. Loss of elastin also affects the alveoli and the basement membrane of the capillary wall, where gas exchange occurs. A thickening occurs in both areas, limiting the amount of diffusion. 5. Because of decreased muscular strength, the cough reflex is not as forceful or as effective. This is one of the changes that occurs gradually as one ages and is hardly noticeable unless a physiological challenge or stress arises. 10. The nurse practitioner is seeing patients in the respiratory clinic. An 85-year-old woman comes in with concerns about having difficulty breathing. When considering asthma, the nurse practitioner asks which of the following questions? Select all that apply. 1. Do you feel out of breath during the day? 2. Do you have a cough, especially at night? 3. Do you feel a tightness in your chest? 4. May I listen for wheezing in your breathing? 5. Do you feel any dyspnea? - 10. Answer: 1, 2, 3, 4 Page: 155 Feedback 1. Chronic inflammation is associated with airway hyperresponsiveness that leads to breathlessness. 2. Chronic inflammation is associated with airway hyperresponsiveness that leads to coughing, particularly at night or early in the morning. 3. Chronic inflammation is associated with chest tightness. 4. Chronic inflammation is associated with airway hyperresponsiveness that leads to recurrent episodes of wheezing. 5. Older adults are less likely to sense dyspnea related to airway obstruction. 11. The nurse practitioner is preparing discharge instructions for a 79-year-old man with newly diagnosed asthma. Which of the following are important instructions to include? Select all that apply. 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. 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. 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. Answer: 1, 2 Page: 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. AAA presents the signal symptoms of persistent or intermittent pain in the middle or lower abdomen, radiating to the lower back. 2. Venous leg ulcers present signal symptoms of swelling that subside with elevation of lower extremities, eczematous skin changes, dull ache in lower extremities, and presence of varicosities. 3. PVD is a disease that alters blood flow to or from the extremities and vital organs other than the heart. It presents signal symptoms of pain, intermittent claudication of the feet, and tissue loss in affected leg/arm. 4. Lymphedema presents the signal symptoms of swelling of the affected body part, usually the limb, because of impaired flow of lymph fluid. 3. In the initial screening for a diagnosis of AAA, which of the following is the best screening test? 1. CT scan 2. Complete blood count (CBC) 3. Ultrasound in the abdominal area 4. Angiography - 3. Answer: 3 Page: 216 Feedback 1. CT screening is indicated when surgery is planned. 2. CBC may be a secondary screening when surgery is planned. 3. Ultrasound in the abdominal area is the best initial screening test for AAA. 4. Angiography screening is indicated when surgery is planned. 4. Mrs. Prentiss is diagnosed with symptomatic AAA. The initial treatment is aggressive blood pressure control. At which of the following readings should mean arterial pressure be maintained? 1. Between 100 and 120 mm Hg. 2. Between 90 and 120 mm Hg. 3. Between 60 and 70 mm Hg. 4. Between 80 and 100 mm Hg. - 4. Answer: 3 Page: 217 Feedback 1. 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. 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. Answer: 2 Page: 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. Answer: 1 Page: 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. Answer: 3 Page: 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. Nicardipine is an IV antihypertensive agent that should be used to rapidly and consistently maintain blood pressure in mean arterial pressure ranges. 2. Sertraline is used to treat depression, panic attacks, obsessive compulsive disorder, post-traumatic stress disorder, and social anxiety disorder. 3. Esmolol is an IV antihypertensive agent that should be used to rapidly and consistently maintain blood pressure in mean arterial pressure ranges. 4. Nitroglycerin is an IV antihypertensive agent that should be used to rapidly and consistently maintain blood pressure in mean arterial pressure ranges. 5. Carbidopa is a medication used with a combination to treat symptoms of Parkinson's disease or Parkinson-like symptoms. 12. Lymphedema is characterized by swelling of the extremity. Which of the following symptoms are also presented with lymphedema? Select all that apply. 1. Overall lethargy 2. Aching in the affected area 3. Restricted range of motion 4. Purulence 5. Cellulitis - 12. Answer: 2, 3, 5 Page: 218 Feedback 1. Lethargy, or tiredness, is a state with a lack of energy and enthusiasm and not generally presented with lymphedema. Lethargy has been reported by people with multiple sclerosis, rheumatoid arthritis, hepatitis C, high blood pressure, and depression. 2. Lymphedema usually develops gradually over time and the swelling can be mild, moderate, or severe. Swelling, aching, discomfort, and fatigue in the affected limb may become present. 3. Restricted range of motion is a symptom presented with lymphedema due to the swelling in the affected limb. 4. Purulence is not presented with lymphedema. 5. Cellulitis is a sudden, noncontagious infection of the skin, characterized by redness, swelling, and heat, and is accompanied with pain and tenderness. Patients with lymphedema are particularly susceptible to cellulitis because the lymphatic system is damaged or overloaded and does not function adequately to fight infection. 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. Answer: 1, 2, 3, 5 Page: 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. Answer: 2, 3, 4 Page: 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. Answer: 1, 2 Page: 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. Specific questions regarding the use of medications that can cause renal injury, including NSAIDs and antihypertensive medications, such as ACE inhibitors and angiotensin receptor blockers, as well as recent antibiotic use, need to be asked of the patient. 5. J. T. is a 69-year-old Caucasian male who presents with dysuria. During the examination, he asks the nurse practitioner if there is a chance he has cancer. The nurse practitioner tells him that before she can determine what is causing the problem she will need to perform a physical examination and order which of the following diagnostic tests? 1. Computed tomography (CT) scan of the abdomen and pelvis 2. IV pyelogram 3. Urine dipstick and cytology 4. Ultrasound - 5. Answer: 1 Page: 230 Feedback 1. CT scans should include both the abdomen and pelvis; scans need to be done with and without contrast, and they should include delayed images to identify defects in the collecting system. 2. CT scan is replacing the IV pyelogram as the procedure of choice. 3. Urine dipstick, cytology, and screening for tumor-specific molecular markers in the urine are not recommended for screening asymptomatic patients due to low specificity, low sensitivity, and cost, respectively. 4. Although CT scan provides better visualization of tumors than ultrasound, it may miss tumors less than 1 cm in size. 6. Jane Smith is a 70-year-old Caucasian woman who comes to see her nurse practitioner for pain in her abdomen. The nurse practitioner is aware that Mrs. Smith is obese and has diabetes. Which of the following is a definitive diagnostic test for cholecystitis? 1. A flat plate of the abdomen. 2. Complete blood count (CBC). 3. Lipase, amylase, and liver function tests. 4. Real-time ultrasonography of the gallbladder and biliary tree. - 6. Answer: 4 Page: 232 Feedback 1. A flat plate of the abdomen will not provide the information that a real-time ultrasound will. 2. 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. Answer: 2 Page: 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. Answer: 1, 2, 3 Page: 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. Answer: 1, 3, 4 Page: 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. 13. Mark is 60 years old. He reports a swelling in his right side, loss of weight, and a slight discoloration of his skin. The nurse practitioner conducts a history and physical examination and orders which of the following to rule out cancer of the liver? Select all that apply. 1. CBC to identify anemia. 2. Serum alkaline phosphatase, AST, ALT for liver damage. 3. Ultrasound to identify any enlargement. 4. Magnetic resonance imaging (MRI). 5. Radiology for lesions found in the liver. - 13. Answer: 1, 2, 3, 4, 5 Page: 269 Feedback 1. Patients with liver disease may have mild anemia and electrolyte disturbances. 2. Serum alkaline phosphatase, AST, ALT, and gamma-glutamyl transpeptidase (GGT) are often abnormal in a nonspecific pattern. 3. Identification of a liver nodule that is smaller than 1 cm should be reimaged with an ultrasound in 3 months. 4. Nodules that are larger than 1 cm should be reimaged with contrast-enhanced MRI. Nodules that demonstrate arterial hypervascularity and venous or delayed phase washout are consistent with hepatocellular carcinoma (HCC). Those nodules that do not demonstrate arterial hypervascularity and venous or delayed phase washout should be reimaged with another contrast-enhanced study such as a CT scan or MRI. 5. Lesions that demonstrate arterial hypervascularity and venous or delayed phase washout are diagnostic for HCC. Lesions that do not demonstrate arterial hypervascularity and venous or delayed phase washout should undergo percutaneous biopsy. 14. Thom is 60 years old and has been treated for nonalcoholic fatty liver disease (NAFLD) for over 10 years. He still suffers from fatigue, abdominal pain, and an enlarged liver. The nurse practitioner discusses which of the following home-care plans to assist him in adjusting to his disease? Select all that apply. 1. Monitor weight and stay within optimal weight limits. 2. Avoid anti-lipid medications, such as atorvastatin. 3. Obtain a hepatitis A and B vaccine, if not immune. 4. May drink alcohol socially, but not daily. 5. If obese, set a goal for rapid weight loss. - 14. Answer: 1, 3 Page: 272 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. Answer: 1, 2, 3, 5 Page: 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. 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. Answer: 1 Page: 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. Untreated symptomatic cystitis does not lead to prostatic cancer or vaginitis, but it can lead to sepsis. 7. Women developing ovarian cancer may be asymptomatic, making it hard to detect until the condition has worsened. Which of the following is the best initial diagnostic tool for suspected ovarian cancer? 1. Transvaginal ultrasonography 2. Pelvic examination 3. Laparoscopy 4. Complete blood count (CBC) - 7. Answer: 1 Page: 294 Feedback 1. Transvaginal ultrasonography is the best initial study for suspected ovarian cancer. 2. Pelvic examination gives limited diagnostic results, as ovarian enlargement cannot always be palpated. 3. Laparoscopy is performed after a histopathological tissue report has been confirmed. 4. A CBC is also part of the initial evaluation, but secondary to transvaginal ultrasonography. 8. Prostate cancer is the most common and leading cause of cancer death in men. Which of the following statements is true about prostate cancer? 1. There is usually a sudden onset of pain in the early stages. 2. Asian men are at highest risk for developing prostate cancer. 3. Development of prostate cancer has been linked with prior vasectomy. 4. There are usually no symptoms with early disease. - 8. Answer: 4 Page: 299 Feedback 1. There are usually no symptoms with early disease. 2. African Americans have the highest incidence of prostate cancer in the world, with Asian and Hispanic men at lower risk than white men. 3. No link has been determined with prior vasectomy. 4. Once symptoms occur, there is usually progression of the disease. 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. Answer: 2, 3, 4 Page: 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. Answer: 1, 3, 4 Page: 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. Answer: 3, 4, 5 Page: 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. 1. Diabetes has been correlated with endometrial carcinoma. 2. Use of tamoxifen in postmenopausal women is a risk factor for endometrial carcinoma. 3. Use of hormonal contraception is a negative risk factor for endometrial carcinoma. 4. Obesity is a contributing factor in the development of endometrial cancer. 5. Women who have Lynch syndrome, which is an autosomal dominant genetic condition causing hereditary nonpolyposis colorectal cancer, are at high risk for endometrial malignancies. 1. The nurse practitioner is serving in a clinic dedicated to patients over age 65 years. The nurse practitioner observes several common characteristics in the posture of elderly patients. Which of the following is common? 1. Increase in the length of the trunk in relationship to the upper extremities. 2. Head tips backward. 3. Disappearance of bony prominences. 4. Increase in the range of motion (ROM). - 1. Answer: 2 Page: 305 Feedback 1. Aging often brings about a decrease in height, resulting from a decrease in the length of the trunk with respect to the length of the extremities. 2. An older person may tilt the head backward to compensate for the bend in the thoracic spine, producing the typical posture of those in this age group. 3. Because of the loss of subcutaneous fat caused by aging, bony prominences became more noticeable. 4. Without continued use, muscles stiffen and ROM becomes impaired as an older person continues to age. 2. While conducting a thorough examination of the musculoskeletal system, the patient asks why such detail is necessary. Which of the following is the nurse practitioner's best response? 1. I don't want to miss any signs of something serious. 2. The purpose of conducting this examination is to regulate your medications. 3. I am looking for symptoms that form a pattern. 4. This is routine for all patients over 65 years of age. - 2. Answer: 3 Page: 305 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. 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. Answer: 3 Page: 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. Answer: 3 Page: 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.