NURS 6540 Final Review: Advanced Practice Care of Frail Elders, Exams of Nursing

Download NURS 6540 Final Review: Advanced Practice Care of Frail Elders and more Exams Nursing in PDF only on Docsity! NURS 6540 FINAL REVIEW ADVANCED PRACTICE CARE OF FRAIL ELDERS ALL CHAPTERS 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. 4. Heart disease, cancer, and diabetes combined are the most common morbidities in older patients. 7. A gerontological patient is being examined for a report of pain in the shoulder. The nurse practitioner completes a thorough systemic examination because: 1. Older patients with one morbidity often express difficulties in general. 2. Arthritis of the shoulder is accompanied by other neurological symptoms. 3. Older patients with arthritis often experience pain in lower extremities. 4. The patient may not report significant signs and symptoms. - 7. Answer: 1 Page: 5 Feedback 1. Older patients with late-onset rheumatoid arthritis experience joint involvement more often in the larger joints, such as the shoulder, and they also experience systemic symptoms such as fever, malaise, weight loss, and depression. 2. Older patients may express symptoms in any other physical systems. 3. Patients more often experience arthritis in smaller joints. 4. A thorough examination will detect objective indicators. 8. The nurse practitioner performs a thorough systemic examination of a patient who reports diarrhea and pain in the upper left quadrant of the abdomen. One possible diagnosis would be: 1. Hirschsprung's disease 2. Pancreatitis 3. Appendicitis 4. Gastrointestinal inflammatory bowel disease (GIBD) - 8. Answer: 4 Page: 5 Feedback 1. Hirschsprung's disease is an obstruction of the colon in infancy. 2. Diarrhea is not associated with pancreatitis. 3. Appendicitis is more common in younger patients than in older patients. 4. GIBD is manifested differently in a bimodal pattern. 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 Page: 5 Feedback 1. As a patient ages, this correlates with more medications having been ordered. 2. Patients with multimorbidity are known to have a treatment burden in terms of understanding and self- care management of their conditions. 3. Patients with multimorbidity are known to have a treatment burden in terms of understanding and self- care management of their conditions. 4. This burden entails affording complex drug regimens. 5. Though cognitive ability may be a factor, there is much more to consider when noncompliance is an issue. 1. A patient asks the nurse practitioner what is meant by health promotion. Which of the following is the nurse practitioner's best response? Health promotion: 1. Includes activities that an individual performs proactively to increase health and well-being. 2. Is a process of keeping track of immunizations. 3. Includes a set of programs that help people cope with the disease. 4. Includes strategies that prolong life. - 1. Answer: 1 Page: 6 Feedback 1. Health promotion includes not only preventive and health-protective measures, but also actualization of one's health potential 2. Immunizations are only one part of health promotion. 3. Health promotion occurs before the onset of disease. 4. Quality of life is the important focus of health promotion, not a prolongation of life. 2. The nurse practitioner knows that health promotion is accomplished on a broader scale by: 1. Maintaining current health services. 2. Maintaining federal legislation regarding health care at the current level. 3. Encouraging healthy lifestyle and healthy public policy formulation. 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. 10. While counseling a patient about physical activity, the nurse practitioner considers which of the following? Select all that apply. 1. A physical activity prescription that is individualized to the patient. 2. Active hobbies that the patient enjoys. 3. Alternative activities such as yoga or tai chi. 4. Armchair activities for the frail older adult. 5. Patient's ability to pay for involvement in activities. - 10. Answer: 1, 2, 3, 4 Page: 7 10. Answer: 1, 2, 3, 4 Page: 7 Feedback 1. Each person is unique and may not respond the same to exercise. 2. Hobbies are enjoyable and give pleasure, while at the same time increasing activity. 3. Stretching routines are done slowly and to the level of endurance. 4. When the frail older person cannot ambulate, they can move other parts of their body such as core, arms, head, and neck. They may also do non-weight-bearing movements of legs and feet. 5. Movement, activity, and exercise can be done anywhere, anytime the individual desires. There is no need to join a group. 11. Nutrition counseling is part of health promotion. The nurse practitioner considers a teaching plan that includes which of the following information? Select all that apply. 1. Level of involvement in community activities. 2. Baseline information on current dietary intake. 3. Current activity patterns. 4. Current height and weight. 5. Health status information. - 11. Answer: 2, 3, 4, 5 Page: 7, 8 Feedback 1. Active involvement in community activities does not reflect what the older person is eating. 2. The nurse practitioner needs the current state of nutrition to develop a plan for increasing or maintaining positive nutrition. 3. 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. Barriers are things that prevent or hinder patients from exercising. 2. Incentive is one kind of patient facilitator, like family support. 3. Positive self-efficacy is another kind of patient facilitator, like family support. 4. Facilitators are things that help a patient desire exercise and health promotion, so these are facilitators. 4. The American College of Sports Medicine (ACSM) has designed programs to incorporate exercise into every patient encounter. Which of the following is the correct phrase for this program? 1. Back to Exercise 2. Health and Wellness 3. Exercise is Medicine 4. Exercise is Wellness - 4. Answer: 3 Page: 20 Feedback 1. Back to Exercise is not the correct phrase for the program the ACSM designed. 2. Health and Wellness is not the correct phrase for the program the ACSM designed. 3. Exercise is Medicine is the correct phrase for the program the ACSM has designed to incorporate discussion of exercise into patient encounters. 4. Exercise is wellness is not the correct phrase for the program the ACSM designed. 5. Which of the following should nurse practitioners suggest to counter common patient excuses for not exercising? 1. Join a gym. 2. Find an exercise "buddy." 3. Take a 10-minute walk every day. 4. Go to the YMCA. - 5. Answer: 3 Page: 20 Feedback 1. Joining a gym is not the best suggestion to counter excuses not to exercise because having to go to the gym may become another excuse. There may also be financial and transportation issues adding to the reasons not to exercise. 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 Goal setting and self-monitoring by the patient is very effective in persuading the patient to adopt a healthy lifestyle. 3. Recommending the purchase of exercise equipment to use at home may not be the best approach for different reasons, such as financial ability. 4. Informing patients about the resources that are available in the community for group exercise is a valuable adjunct to counseling. 5. Though not listed as something that could promote exercise, giving the patient illustrations for the exercise could be helpful when it is demonstrated and explained. 13. The goal of increasing physical activity is to promote a healthy lifestyle. Which of the following options help reduce the risk of injuries? Select all that apply. 1. Choosing physical activities that are appropriate for their current fitness level and health goals. 2. Remaining under the care of a health-care provider if they have chronic conditions or symptoms. 3. Choosing to do physical activities their friends are doing. 4. Enlisting spousal supervision and support. 5. Hiring a personal trainer. - 13. Answer: 1, 2 Page: 22 Feedback 1. Choosing to do types of physical activities that are appropriate for a patient's current fitness level and health goals helps reduce the risk of injuries. 2. Being under the care of a health-care provider if a patient has chronic conditions or symptoms helps reduce the risk of injuries. 3. Choosing to do types of physical activities one's friends are doing is not the best option in reducing risk for injuries because of differences in physical ability or medical conditions. 4. Being under the supervision of one's spouse for support is a good facilitator, but it is not the best option in reducing the risk for injures because a spouse may not understand the impact of physical activity on physical and medical conditions. 5. A personal trainer may not have the proper training for more complicated conditions. 14. The AHA Council on Nutrition, Physical Activity, and Metabolism identified patient facilitators to increasing physical activity in older adults. Which of the following is an example of patient facilitators? Select all that apply. 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. 7. In conducting a CGA, the nurse practitioner looks for any impairments in communication with the patient. The assessment includes: 1. Interviewing prior to the physical examination. 2. Asking questions of the accompanying family member. 3. Reading the history forms provided by the patient after the examination. 4. Observing physical impairments. - 7. Answer: 1 Page:26 Feedback 1. Interviewing begins before the physical examination and continues throughout the examination. 2. Permission from the patient must be obtained before discussing anything with the family member. 3. When forms about the history of the patient are brought in, the nurse practitioner should review them before the examination. 4. Observation alone will not provide adequate information about communication impairments. 8. When an assessment is conducted, which of the following needs to be recorded when a new concern is identified? Select all that apply. 1. Location and radiation. 2. Quantity and quality. 3. Aggravating and alleviating. 4. Signs and symptoms. 5. Effect on financial status. - 8. Answer: 1, 2, 3, 4 Page:27 Feedback 1. A comprehensive assessment includes the location and radiation of the symptom. 2. A comprehensive assessment includes the quantity and quality of the symptom. 3. A comprehensive assessment includes aggravating and alleviating factors. 4. Associated signs and symptoms are included in a comprehensive assessment. 5. Financial concerns are considered after the findings of the assessment are understood. 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 1. Geriatric assessments can be challenging for the health-care provider due to delay of recognition and/or reporting of symptoms by the patient. Which of the following best describes what is used by health-care providers to address this differential? 1. Clinical decision-making tools. 2. When symptoms were noticed. 3. Change in function and impact of symptoms. 4. Symptoms from comorbidities. - 1. Answer: 3 Page: 34 Feedback 1. Using clinical decision-making tools can be complicated because of different factors, such as patient denial of symptoms and their occurrences. 2. Using the time symptoms were noticed as the basis for assessment cannot be deemed an effective tool due to inaccuracies regarding the report of when symptoms first occurred. 3. Change in function as a measure of the impact of a symptom on the patient is an effective means of sorting out the differential. 4. Comorbidities can result in a delayed or atypical presentation. 2. Which of the following terms refers to conditions that have multiple underlying factors and may involve multiple organs? 1. Multifaceted syndrome 2. Aging syndrome 3. CFM syndrome 4. Geriatric syndrome - 2. Answer: 4 Page: 34 Feedback 1. Multifaceted syndrome is not the correct term, although conditions reflect the many contributing aspects to health care. 2. Aging syndrome is not the correct term, although aging may be a contributing factor to the condition. 3. CFM syndrome is not the correct term, although conditions may have cognitive, functional, and mobility impairments. 4. 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. Feedback 1. Use of medications should be considered in formulating diagnostic possibilities. 2. Precipitating factors should be included in the assessment process as main descriptors to guide the diagnosis. 3. Character of symptoms are necessary descriptors to guide the diagnosis. 4. Family history, although helpful, is a secondary factor in the assessment process. 5. Social history would not provide helpful information for this physical condition. 11. When a patient is suffering from constipation, the clinician evaluates the etiology and contributing factors. Which of the following diagnoses are being ruled out in these evaluations? Select all that apply. 1. DVT 2. Fecal impaction 3. IBS 4. Botulism toxin 5. Bowel incontinence - 11. Answer: 2, 3 Page: 35, 37 Feedback 1. DVT is a condition that produces unilateral lower extremity swelling and tenderness. 2. Fecal impaction is a differential diagnosis, so it needs to be ruled out. 3. IBS is a differential diagnosis that is being ruled out. 4. Botulism toxin is sometimes used for treatment of conditions arising from symptoms of chest pain, such as esophageal spasms. 5. Fecal or bowel incontinence is the inability to control bowel movements, causing stool (feces) to leak unexpectedly from the rectum. 12. Dizziness is an imprecise word used by patients to describe various subjective conditions. Care must be taken to establish what the patient means by dizziness in order to determine a diagnosis. Which of the following etiologies could be the cause of dizziness? Select all that apply. 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 3. This is a result of the nurse practitioner addressing it further rather than the reason for addressing it. 4. A professional cannot assume abuse without good reason. 4. The nurse practitioner assesses a patient's skin and finds an infectious lesion on the lower leg. The lesion is considered a secondary lesion. The nurse practitioner explains that a secondary lesion is one that: 1. Arises from changes to a primary lesion. 2. Is a complication of an underlying disease. 3. Is difficult to treat. 4. Is a normal sign of aging. - 4. Answer: 1 Page: 97 Feedback 1. Secondary lesions (infections) arise from changes to the primary lesion. 2. Secondary lesions are not necessarily the result of an underlying disease. 3. Secondary lesions can be treated with medications or surgery. 4. Secondary lesions arise as a condition not normal to aging. 5. Ms. Rose, 88 years old, comes to the nurse practitioner with a complaint about a growth on her hand. She wants to have a biopsy done. The nurse practitioner asks the following question: 1. Have you injured your hand recently? 2. Are you using a different detergent? 3. Has this growth changed, bled, or is it painful? 4. Has this growth made it difficult to put on your rings? - 5. Answer: 3 Page: 97 Feedback 1. An injury would not stimulate growth. 2. A reaction to a detergent would more likely be a rash. 3. Lesions that warrant biopsy are those that have changed, bleed, or are painful. 4. 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. If the wound is grossly contaminated and the patient's last tetanus booster was 5 to 10 years ago, the practitioner should consider giving another booster at this time. 13. A 59-year-old female was admitted to the hospital for malaise, headache, fever, and flu-like symptoms. She has a decreased appetite and is having trouble sleeping. After a couple of days, she complains to the nurse practitioner of itching, burning, and tingling pain around her waist. The nurse practitioner advises the nursing staff to observe for vesicles for a few days. The patient asks why she is so sick. What would be the nurse practitioner's best response? Select all that apply. 1. We are not certain at this point, however, these symptoms often occur before a break-out of herpes zoster. 2. You have some very general systemic symptoms, so we are waiting for more specific symptoms to appear. 3. Because you had chicken pox as a child, and you now have a depressed immune system, the chance of developing herpes zoster is high. 4. These symptoms are probably a strong case of influenza. 5. Herpes zoster is more common in people 55 years old and older. - 13. Answer: 1, 3 Page: 106 Feedback 1. Patients usually experience itching, burning, or tingling pain at the site 4 to 5 days before the eruption appears. 2. Although there are general systemic symptoms, there is also itching, burning, and pain in the waist, which is leading to a herpes zoster diagnosis. 3. The patient has initial contact with VZV in the form of chicken pox. Individuals who are immunosuppressed are more likely to develop herpes zoster. 4. Herpes zoster is characterized by pain along the dermatomes and vesicles, which is not symptomatic of influenza. 5. This infection is most common in adults over 55 years old. The risk of herpes zoster increases with age. 14. Mrs. Person, 82 years old, comes to the well clinic to see a nurse practitioner for a bump on her ear. This growth has been there for almost a year but has recently grown. The area around the growth appears inflamed. Why would the nurse practitioner suggest a biopsy? Select all that apply. 1. The growth is elevated and increasing in size. 2. The ear has high exposure to the sun. 3. There is inflammation around the growth. 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. Chalazion is an eye condition that presents a sterile mass on the eyelid that is painless and has no reddening. It is caused by an inflammation and obstruction of a meibomian gland of the upper or lower eyelid. Chalazion can interfere with vision at times and develops a rubbery consistency. 6. Oral cancer is a malignant tumor presented by a nonhealing sore in the mouth or lip that causes difficulty chewing or swallowing. Which of the following statements applies to an oral cancer diagnosis? 1. It cannot be prevented. 2. It involves unexplained lymph node swelling in the head and neck area. 3. It is three times more likely in women than men. 4. It involves unexplained lymph node swelling in the axillary area. - 6. Answer: 2 Page: 141 Feedback 1. The most important way to control oral cancer is the combination of early diagnosis and timely and appropriate treatment. Preventions include lifestyle changes, periodic checkups, and protection from sun exposure. 2. Unexplained lymph node swelling in the head and neck area is one of the symptoms of oral cancer. Additionally, a nonhealing sore in the mouth or lip and difficulty chewing or swallowing are also symptoms. 3. Men are almost three times more likely to develop oral cancer than women. 4. Unexplained lymph node swelling in the head and neck area is a symptom, but lymph node swelling in the axillary area is not. 7. A 67-year-old female patient comes in for an office visit presenting symptoms of nasal congestion, itching, and sneezing and is diagnosed with rhinitis. Which of the following is true about the types of rhinitis? 1. Allergic rhinitis (AR) is a condition of adulthood and is more common in the older adult. 2. AR develops when the body's respiratory system becomes sensitized and overreacts to something in the environment. 3. Nonallergic rhinitis (NAR) is most common between ages 10 and 39, declining after age 40. 4. NAR is a condition of adulthood and is more common in the older adult. - 7. Answer: 4 Page: 147 Feedback 1. 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 membrane, middle ear fluid, damage to the ossicles from trauma or infection, middle ear tumors, temporal bone fractures, injuries related to trauma, and congenital problems are some of the causes. 4. Cerebral neoplasia is a brain tumor that may affect body organs; however, it is not a primary etiology that leads to hearing loss. 5. Aphasia is a loss of ability to understand or express speech caused by brain damage. 14. There is no specific diagnostic test for hordeolum or chalazion unless it becomes recurrent. Which of the following may be a differential diagnosis for these conditions? Select all that apply. 1. Orbital cellulitis 2. Contact dermatitis 3. Acute dacryocystitis 4. Strabismus 5. Amblyopia - 14. Answer: 1, 2, 3 Page: 138 Feedback 1. Orbital cellulitis is an infection of the soft tissues of the orbit posterior to the orbital septum. It is most often caused by extension of infection from adjacent sinuses, or by direct infection accompanying local trauma or contiguous spread of infection from the face or teeth. 2. Contact dermatitis is a red, itchy rash caused by direct contact with a substance or an allergic reaction to it. The rash isn't contagious or life threatening, but it can be very uncomfortable. 3. Acute dacryocystitis is an infection of the tear (lacrimal) sac usually due to a blockage in the tear (nasolacrimal) duct. The patient presents with pain, redness, and edema around the lacrimal sac. 4. Strabismus is a visual problem in which the eyes are not aligned properly and point in different directions. 5. Amblyopia is the medical term used when the vision in one of the eyes is reduced because the eye and the brain are not working together properly. The eye itself looks normal, but it is not being used normally because the brain is favoring the other eye. This condition is also sometimes called lazy eye. Many people make the mistake of saying that a person who has a crossed or turned eye (strabismus) has a lazy eye, but lazy eye (amblyopia) and strabismus are not the same condition. Strabismus can cause amblyopia. 15. The most common diagnostic test for AR is skin testing that involves scratching the surface of the skin with a single stylus for each allergen. Which of the following are possible if further testing is needed? Select all that apply. 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). An S3 in an individual more than 50 years old is usually pathological and reflects an increased filling rate, indicating heart failure or mitral regurgitation. 4. This condition may cause an S4, which, in the absence of other findings, is considered normal in older adult persons. 8. The nurse practitioner identifies a late cardiac murmur in an older adult patient. A student nurse asks what condition this suggests. The nurse practitioner responds that this kind of murmur is most often due to which of the following? Select all that apply. 1. Weakening valves 2. Papillary muscle dysfunction 3. Mitral annular calcification 4. Heart blockage 5. Mitral stenosis - 8. Answer: 2, 3 Page: 153 Feedback 1. An apical late systolic murmur occurs frequently in older persons, resulting from floppy valves that become regurgitant over time. 2. One of the two most common causes of mitral regurgitation is papillary muscle dysfunction. 3. One of the two most common causes of mitral regurgitation is mitral annular calcification. 4. Diastolic murmurs, which are almost always pathological in older persons, may be caused by heart blockage. 5. Diastolic murmurs, which are almost always pathological in older persons, may be caused by mitral stenosis. 9. Ms. Jameson, 72 years old, comes to the clinic with concerns about her breathing. She states that she is having trouble with mucus collection and difficulty coughing it out. The nurse practitioner suggests which of the following? Select all that apply. 1. As you get older, the tissue in your lungs is not as flexible to aid in exhaling. 2. The muscles that help to inhale become stronger as you age. 3. The body contains less water as you age, and the mucus begins to dry out. 4. As you get older, there is an increase in the exchange of gases between the lungs and the blood vessels. 5. The cough reflex is normal, but the mucus is too thick. - 9. Answer: 1, 3 Page: 154 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. Heart failure classification is based on risk, cardiac structural changes, symptom presentation, and functional impairment. 4. Progressive lower extremity and abdominal symptoms (pain, distention, nausea) related to hepatic enlargement are symptoms suggestive of right ventricular failure or systemic venous congestion. 5. Asymptomatic means without symptoms of disease. Geriatric patients with severe heart failure may be asymptomatic, but in this case, the patient does have symptoms. 1. In the assessment for peripheral vascular disorders, the clinician should begin with which of the following after the general history and physical examination? 1. Auscultation of the carotid arteries bilaterally. 2. Palpation of the carotid arteries bilaterally. 3. Inspection of the carotid arteries bilaterally. 4. Order diagnostic testing. - 1. Answer: 1 Page: 215 Feedback 1. The clinician should begin with auscultation of the carotid arteries bilaterally because cardiac murmurs will usually radiate into the carotid arteries. 2. After auscultation of the carotid and subclavian arteries, the clinician should proceed to palpation of the brachial, radial, and ulnar arteries. 3. After auscultation and palpation, careful inspection should be performed of the distal fingers and the nail beds. 4. Diagnostic testing is usually ordered when areas of concern are found. 2. Which of the following conditions is signaled by symptoms of swelling of the affected body part, usually the limb, because of impaired flow of lymph fluid? 1. Abdominal aortic aneurysm (AAA) 2. Venous ulcers 3. Peripheral vascular disease (PVD) 4. Lymphedema - 2. Answer: 4 Page: 218 Feedback 1. 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. 10. AAA is mostly atherosclerotic in nature, but can also be caused by trauma, infection, and inflammation. Which of the following is a true statement regarding the tendency to develop AAA? Select all that apply. 1. There is no dominant ethnic group that develops AAA. 2. Caucasians have a higher risk of developing AAA. 3. Women have a higher risk of developing AAA. 4. There is a familial history associated with AAA development. 5. AAA is the 13th leading cause of death in the United States. - 10. Answer: 1, 4, 5 Page: 216 Feedback 1. There is no dominant ethnic group that develops AAA, but there is a familial history associated with AAA development. 2. There is no dominant ethnic group that develops AAA. 3. Onset occurs around age 50 years for men and 60 years for women. Incidence steadily increases with age and peaks at age 80 years. AAA is five times more likely in men than in women. 4. There is no dominant ethnic group that develops AAA, but there is a familial history associated with AAA development. 5. According to studies, AAAs are the 13th leading cause of death in the United States. Mortality rates for ruptured aneurysms are 70% to 90% compared with 5% operative mortality for elective open surgical repair, and 2% to 3% for endovascular stent AAA exclusion. 11. In treating AAA, arterial monitoring is recommended. Which of the following IV antihypertensive agents should be used to rapidly and consistently maintain blood pressure in the mean arterial pressure ranges? Select all that apply. 1. Nicardipine 2. Sertraline 3. Esmolol 4. Nitroglycerin 5. Carbidopa - 11. Answer: 1, 3, 4 Page: 217 Feedback 1. 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. 3. Mrs. M.W. asks the nurse practitioner what she is listening to in her belly and what it means. The nurse practitioner tells her that she is listening to determine: 1. That her bowels are moving properly. 2. If the blood vessels are not circulating blood. 3. Circulation and bowel function. 4. A diagnosis of her symptoms. - 3. Answer: 3 Page: 226 Feedback 1. Studies have refuted the usefulness of auscultation when differentiating between patients with normal bowel sounds versus those with pathological bowel sounds. 2. Other sites to auscultate for bruits during an abdominal examination include the iliac arteries and the femoral arteries. 3. To auscultate for bruits during an abdominal examination, include the iliac arteries and the femoral arteries. When auscultating bowel sounds, take the time to listen for the presence of bowel sounds. 4. Nurse practitioners should not rely on auscultation alone for diagnostic purposes. 4. Mr. Person comes to the health-care clinic with a presenting symptom of not urinating as much as usual. The nurse practitioner assesses Mr. Person by asking which of the following? 1. How much do you drink per day? 2. Is your urine a clear yellow color? 3. Do you experience urgency and frequency of urination? 4. What medications have you taken recently or are you currently taking? - 4. Answer: 4 Page: 228 Feedback 1. Patients may have nausea, vomiting, and diarrhea, leading to volume depletion. 2. The patient may have noticed a change in his urine consistency or color. 3. The patient may have symptoms directly resulting from alterations in kidney function, such as decreased to no urine output. 4. 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 2. While there has been limited evidence to suggest that making lifestyle changes (such as avoiding tight, restrictive clothing to decrease abdominal pressure) counteracts the symptoms of GERD, nurse practitioners should encourage patients to adopt this strategy. 3. The patient should avoid smoking and ingestion of fatty foods, coffee, chocolate, mints, citric juices, alcohol, and large quantities of fluids with meals. 4. Patients should avoid eating a meal for at least 3 hours before becoming recumbent. 5. Important to the management of GERD are the lifestyle changes or nonpharmacological measures that patients need to incorporate along with the medication regimen. These include avoidance of smoking, alcohol, and food products such as chocolate, mints, spicy or acidic foods, and caffeine. 12. Lucy is 65 years old and has been coping with irritable bowel syndrome-diarrhea (IBS-D) for over 10 years. She has tried various treatments with minimal effectiveness. She asks the nurse practitioner if there is anything else that might be helpful to control this diarrhea. The nurse practitioner suggests which of the following? Select any that apply. 1. Antispasmodics 2. Caffeinated beverages 3. Antidiarrheal medications 4. Eluxadoline,75 mcg, twice daily with food 5. Rifaximin - 12. Answer: 4, 5 Page: 267 Feedback 1. Antispasmodics are not recommended for treatment of IBS-D in older adults because of the anticholinergic side effects of these medications. 2. Foods that may exacerbate IBS-D should be avoided (e.g., caffeinated beverages). 3. Antidiarrheal medications are not beneficial in treating global IBS-D symptoms. 4. A newer agent recently approved for the treatment of IBS-D is a combination mu-opioid receptor agonist and delta-opioid receptor antagonist called eluxadoline in doses of 100 mcg and 75 mcg to be given twice a day with food. This has been shown effective in improving both diarrhea and abdominal pain symptoms associated with IBS-D. 5. Early studies point to the use of rifaximin, an antibiotic, for consideration of the treatment of IBS without constipation and can be considered for use with patients who have not had success with other treatments. 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. 5. Mr. Angulo is an 89-year-old patient who was recently an inpatient for pneumonia and was bedridden for 1 week. He is now presenting dysuria, suprapubic tenderness accompanied by fever, and increased confusion. Based on his recent history, which of the following conditions may be developing? 1. Cystitis 2. Distended bladder 3. Prostate stones 4.Subacute prostatitis - 5. Answer: 1 Page: 289 Feedback 1. Symptoms are indicative of cystitis, and because the patient was bedridden and may have had placement of a catheter, this increases the likelihood. 2. Distended bladder is less likely to be the condition the patient is developing, given the history and symptoms. 3. Prostate stones are less likely to be the condition the patient is developing, given the history and symptoms. 4. Subacute prostatitis is less likely to be the condition the patient is developing, given the history and symptoms. 6. Which of the following statements is true for untreated symptomatic cystitis? 1. Untreated symptomatic cystitis can lead to pneumonia. 2. Untreated symptomatic cystitis can resolve on its own. 3. Untreated symptomatic cystitis can lead to pyelonephritis, sepsis, shock, and death. 4. Untreated symptomatic cystitis can lead to prostatic cancer, vaginitis, and sepsis. - 6. Answer: 3 Page: 291 Feedback 1. Pneumonia is a complication in the respiratory system. 2. Treatment is indicated to resolve cystitis. 3. Untreated symptomatic cystitis can lead to pyelonephritis, sepsis, shock, and death. 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. 5. Ethnicity is a nonmodifiable risk factor, along with age and family history. 14. Which of the following are the main laboratory clinical manifestations of cystitis? Select all that apply. 1. White blood cell (WBC) count 2. Bacteriuria 3. Pyuria 4. Fungi 5. E. coli - 14. Answer: 2, 3 Page: 289 Feedback 1. WBCs, also called leukocytes or leucocytes, are the cells of the immune system that are involved in protecting the body against both infectious disease and foreign invaders. Increased or decreased WBC count can indicate infection but is not the main laboratory clinical manifestation of cystitis. 2. Bacteriuria is the presence of bacteria in urine and is one of the main laboratory clinical manifestations of cystitis. 3. Pyuria is the presence of pus in the urine and is one of the main laboratory clinical manifestations of cystitis. 4. The presence of fungi does not lead to a diagnosis of cystitis. 5. The presence of E. coli is not a main laboratory clinical manifestation of cystitis. E. coli is a bacterium found in the environment, foods, and intestines of people and animals. 15. Marie, 63 years old, is presenting with symptoms of postmenopausal bleeding and is diagnosed with endometrial cancer. Other than gender and age, which of the following can be contributing factors in the development of endometrial cancer? Select all that apply. 1. Diabetes 2. Use of tamoxifen 3. Use of hormonal contraception 4. Obesity 5. Lynch syndrome - 15. Answer: 1, 2, 4, 5 Page: 292, 293 Feedback 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.