SARAH MICHELLE LIVE REVIEW EXAM 2024-2025, Exams of Nursing

Download SARAH MICHELLE LIVE REVIEW EXAM 2024-2025 and more Exams Nursing in PDF only on Docsity! 1 | P a g e SARAH MICHELLE LIVE REVIEW EXAM 2024-2024 WITH ACTUAL CORRECT QUESTIONS AND VERIFIED DETAILED ANSWERS |FREQUENTLY TESTED QUESTIONS AND SOLUTIONS |ALREADY GRADED A+|BRAND NEW!!|GUARANTEED PASS |LATEST UPDATE What is a major concern with elevated calcium levels? Underlying malignancy What is going on in Type 1 DM that isn't going on in type 2 DM? There are antibodies in type 1- this is going to impact type 1 because these antibodies are destroying all of their beta cells and because of that they are going to be insulin dependent In type 1 diabetes patients, we are worried about them developing what? DKA When type 1 diabetic patients are sick, should they stop their insulin? No- continue insulin as normal What is Somogyi Effect? There is a DIP in the middle of the night in their blood glucose, before it rise in the morning What is Dawn Effect? The blood glucose steadily rises all night What is the typical cause of the Dawn Effect? Due to an increase in growth hormone, just need to increase their insulin At what HgbA1c are we going to initiate insulin? 2 | P a g e > 9% What physical exam finding may occur due to insulin resistance? Acanthosis nigricans Do type 2 diabetes patients need to take a daily aspirin? Not necessarily, if they are at increased risk of heart disease then they can take a daily aspirin What is Addison's disease? Too little cortisol What is Cushing's disease? Too much cortisol What lab values would you expect in Addison's disease? Everything is going to be low except their potassium level- hyperkalemia What lab values would you expect in Cushing's disease? Everything is going to be high except their potassium level- hypokalemia What are some signs and symptoms of Cushing's disease? Moon face Purple striae Truncal obesity What anemias are alcoholics at biggest risk for? Folate and B12 deficiency anemias What is glossitis? Beefy red tongue- common in B12 deficiency What do we need to limit in children less than 12 months of age to help prevent iron deficiency anemia? Whole milk Beside thalassemia, what is another condition that can cause you to absorb too much iron? What is the treatment? Hemochromatosis- treatment is regular phlebotomy What is polycythemia vera? How is this treated? When the body creates too many blood cells and this makes the blood very thick and viscous Treated with regular phlebotomy Patient with polycythemia Vera are at an increased risk of what? 5 | P a g e A history, physical exam, and a plan What is the Swiss Cheese Model? Risk analysis and management This is when an error happens and we go back after the fact and see where did this issue continually "fall through the cracks" or "fall through the holes." So it inadvertently reached the patient. Focuses on root cause analysis so that we can prevent this from happening to patients again in the future. What is incident to billing? How does it impact out reimbursement as NP's? This is going to be when a physician first sees the patient for a medical issue and then we see the same patient for the same diagnosis later on. We're allowed to bill at 100% for this. When typically NP's can only bill up to 85%. If any new problems develop in the visit and we're no longer seeing the patient for the same issue that was previously seen by the physician for, we can not use incident to billing. What determines your legal right to practice as a NP and also determines our scope of practice? The State Nursing Practice Act Who is going to enforce that State Nursing Practice Act? The State Board of Nursing Are we able to have collaborative agreements with people other then physicians? Yes, dentists and DO's, NOT chiropractors What is a resource we can use to improve access to care for patients? Telehealth What components do we need to ensure we ask patients about in regards to their social history? Relationship status, sexual status, who they live with, highest level of education, employment, smoking, drug, and alcohol status. New stressors or concerns, social supports, exercise, do they have access to running water and air conditioning. Who funds Medicare? Federal government What types of patients do we expect to see using this benefit? Elderly and disabled We CARE for the elderly and disabled and we AID the poor What is Medicare Part A? All of your inpatient stuff, including hospice. What is Medicare Part B? 6 | P a g e All of your outpatient needs, including diagnostic tests, second opinions, medical equipment. What is Medicare Part C? All of your advantage plans, supplemental insurances like dental and vision. What is Medicare Part D? Majority of your drug coverage, or prescription drugs. What are the 2 acts involved with Medicare Reimbursement? Which one came first? BRA came first: Budget Reconciliation Act Balanced Budget Act What is the difference between the Budget Reconciliation Act and Balanced Budget Act? The BRA allows us to get reimbursed up to 85% when seeing a patient. The Balanced Budget Act required NP's to have an NPI number whenever you charge for your care What did the HITECH Act mandate? Mandated that we all move to EMR in order to get paid. Who funds Medicaid? Federal and state government What types of patients would we expect to see using Medicaid? Those who can not afford health care insurance because they live below the poverty level. AID the poor How low does your income level have to be to be eligible for Medicaid? Currently $2000 per month in your household is the max amount in order to even be eligible for Medicaid. What is an example of a program through Medicaid? WIC Does Medicaid coverage vary from state to state? Yes, because the states have some control of it. What is CHIP? Children's Health Insurance Program- children are eligible for this even is family is not eligible for Medicaid What is primary prevention? prevention of disease before it occurs. e.g., vaccination 7 | P a g e What is secondary prevention? When we complete screenings What is tertiary prevention? After it has already happened, ex. Rehab or treatment Define veracity Telling the truth Define fidelity Loyalty Define autonomy The patient has the ability to make their own decisions. Define paternalism You are trying to decide what is best for them, because you disagree with what they chose. Define beneficence To do good- an action that is done for the benefit of others. Define non-maleficence To do no harm Define justice Fair and equal treatment for all What are some cultural considerations for Native Americans? They use shamans as healers Believe that illness is a punishment What are some cultural considerations for African Americans? Healthcare disparities and an increased lack of access to care in comparison to other ethnicities. May believe that sin can cause illness and religion is an important aspect of their care to ask them about. What are some cultural considerations for Vietnamese patients? Believe that blood loss is worse than the illness- fear those labs being drawn Oftentimes will stop prescriptions all together when they start to feel better What are some cultural considerations for Hispanics? There is an imbalance between the individual and the environment What are some cultural considerations for Chinese patients? 10 | P a g e How should we treat PUD when it is NOT due to H. Pylori? PPIs and H2 Blockers H2 blockers are not as strong as PPIs, but if we are going to have to treat patient for a longer duration, we will probably go H2 blocker route What is triple therapy for treatment of H. Pylori? 2 antibiotics + PPI for 2 weeks Clarithromycin and Amoxicillin + PPI **If PCN allergy then Flagyl What is quadruple therapy for treatment of H. Pylori? PPI, Tetracycline, Flagyl, Bismuth Salt x 2 weeks Where and how does the pancreas work? Located in LUQ Serve 2 main functions: Aids in digestion and helps regulate your blood glucose levels What causes pancreatitis? Digestive enzymes that the pancreas releases to start digestion actually digest the pancreas itself, which leads to a lot of inflammation and a lot of pain. What are some main causes of pancreatitis? Alcoholism, gallstones blocking that pancreatic duct, high calcium in the blood, or high triglycerides What labs are indicative of pancreatic function? Amylase and lipase What 2 clinical signs are associated with pancreatitis? Cullen's sign and Turner's sign What is Cullen's sign? Bluish discoloration around the belly button Cullen=Center Indicates intra-abdominal bleeding, necrotizing pancreatitis- EMERGENCY What is Turner's signs? Bluish discoloration on the patient's flank TURN the patient over to see their flank Indicates intra-abdominal bleeding, necrotizing pancreatitis- EMERGENCY What is the treatment of pancreatitis? 11 | P a g e Treat the cause, manage the symptoms in the in-between, refer if indicated Allow pancreas to rest, NPO status- pancreas is going to stop producing those digestive enzymes Pain control and hydration What is the most common cause of gastroenteritis? Viral etiology What symptoms might a patient with gastroenteritis present with? Nausea/vomiting, diarrhea, abdominal pain, weight loss, ***look for signs of overall dehydration Gastroenteritis- how do we diagnosis it? Look at overall clinical picture: Basic lab work: CBC, CMP, UA Stool studies: Stool culture, occult blood, C Dif, and stool for ova and parasites What is the basics of treatment of gastroenteritis? Hydration, manage their symptoms- antiemetics, anti-diarrheal, and BRAT diet- bananas, rice, applesauce, and toast What is treatment for Salmonella, Shigella, E. Coli, and Campylobacter? Fluoroquinolones OR Macrolides What is treatment for Giardia? Flagyl What is C. Dif? Antibiotic use disrupts the normal gut flora, which allows for C Dif to grow like crazy. A frequent, odorous diarrhea with lots of abdominal cramping. C Dif is spore that can live in the environment and it is CONTAGIOUS! What is the treatment of CDif? Discontinue whatever antibiotic that led to this occurring and start them on Vancomycin. What are some examples of PPIs? All the -prazoles Omeprazole and pantoprazole What are common indications for PPIs? First line treatment for GERD, ulcer treatment and H. Pylori treatment When should a patient take a PPI? Before first meal of the day What are some examples of H2 Blockers? 12 | P a g e All the -tidines Ranitidine, famotidine What are H2 blockers used for? First line treatment for GERD, treats ulcers What H2 blocker to be avoided when prescribing and why? Cimetidine (Tagamet) it tends to have a lot more drug drug interactions than other H2 blockers What labs are indicated when prescribing a patient H2 blocker? Why? LFTs and CBC These drugs can decrease platelet count and rarely cause liver dysfunction What is an example of an antacid? TUMS- typically used PRN and are available OTC Why are antacids not considered first line treatment? These provide symptom relief, they do not treat underlying problem. How to antacids work? Tone down the acidity for the patient which ultimately gives them relief of symptoms Antacids are most effective when taken how many minutes before a meal? 30 minutes Antacids with calcium or aluminum may cause what? Constipation- this is a consideration especially in the elderly population Antacids with magnesium may cause what? Diarrhea When should sucralafate be taken? Before meals, to allow for it to coat the stomach lining for protection How does sucralafate work? Coats the entire stomach lining. This protective coating ideally will not allow for ulcers to occur or for ones that already exist to be irritated by whatever you're about to ingest. It truly adheres to those ulcer sites to protect them. What is sucralafate typically used for? Maintenance therapy for duodenal ulcers. Typically used short-term for < 8 weeks or less. When administering Zofran, we need to use a reduced dose in what patients? 15 | P a g e What control is Lomotil? Schedule 4 What is the main difference regarding symptom relief, between Imodium and Lomotil? Lomotil provides symptom relief AND pain relief Lomotil is common prescribed to patients with what condition? Inflammatory bowel disease Why is Atropine part of Lomotils formulation? Hopes of preventing abuse because atropine is going to be highly anticholinergic Hep A: If BOTH IgM anti-HAV and IgG anti-HAV are negative, what does this mean? They are susceptible and need immunization! Hepatitis D only occurs in what population? Those who are also infected with Hepatitis B What is CKD Stage 1? GFR >90 Kidney damage with normal kidney function What is CKD Stage 2? GFR 60-89 Mild loss of kidney function What is CKD Stage 3? GFR 30-59 Usually when symptoms being, mild to severe loss of kidney function What is the top priority in patient with CKD 1, 2, or 3? BP Control What complaints will we see in patients with CKD? Fatigue, dry, itchy skin, hematuria, and edema. Eventually that urine production is going to steadily go down as they progress through these stages of CKD. What is CKD Stage 4? GFR 15-29 Severe loss of kidney function What is CKD Stage 5? 16 | P a g e End stage renal failure GFR <15 Dialysis- if not already Urine production essentially ceases Have a lot of issues with electrolyte imbalances and fluid volume overload What are typical UTI symptoms? Frequency,m urgency, pain with urination, foul smelling urine, new incontinence What are signs and symptoms of pyelonephritis? Why is this so serious? CVA tenderness, fever, chills, ill appearing Pyelonephritis increases the chance of blood stream infection What is the main symptoms of a UTI in the elderly? New onset of confusion What is our go to diagnostic test for UTI? UA to screen for possible infection- leukocytes, nitrites, hematuria What bacteria is the majority cause of UTIs? E. Coli What is UTI treatment with S/S for < 7 days? Bactrim or a Fluoroquinolone (Cipro) for 3 days Can also do Macrobid, Keflex, and Augmentin What is UTI treatment with S/S for > 7 days? Bactrim or a Fluoroquinolone (Cipro) for 7-10 days Do we treat patients that have a UA + for leukocytes/nitrites but no symptoms? The only patient that you would treat this is if they are pregnant- this would a risk for the baby, all other patient, if asymptomatic there is no need to treat What do you do if you patient that was recently treated for a UTI has a return of symptoms right after completing the antibiotics? Prescribe same antibiotic for longer Where is the prostate gland? Surrounds the urethra What is the function of the prostate gland? Helps make fluid for semen What is BPH? 17 | P a g e Benign prostatic hyperplasia- enlargement of the prostate What is the common presentation of a patient with BPH? After age 50 Urinary frequency, hesitancy, nocturnal, post-void dribbling, and weak stream DRE- what is the expected assessment of prostate gland of a patient with BPH? Non tender, enlarged, symmetrical, rubbery prostate What is first line treatment for BPH? Alpha blockers -zosin Ex. Terazosin and doxazosin What is an important first time dose effect related to alpha blockers? First time dose effect of profound orthostatic hypotension. Patient needs to be instructed to take it at bedtime so they don't pass out. What is an example of 5-alpha-reductase inhibitors? finasteride How long do 5-alpha-reductase inhibitors take to see their full effect? Up to 6 months- they are literally going to shrink the size of the prostate over time What herbal supplement is used for BPH? Saw palmetto What is acute bacterial prostatitis? Inflammation and edema of the prostate gland related to an underlying infection What are signs and symptoms of acute bacterial prostatitis? Pelvic/perineal pain, dysuria, urgency, frequency, nocturnal, flu like symptoms. How would a prostate gland appear during DRE in a patient with acute bacterial prostatitis? Warm, tender, swollen, boggy prostate (feels spongey and soft- typically indicative of inflammation) Why does prostatic massage need to be avoided in patients with acute bacterial prostatitis? Can lead to bacteremia and ultimately sepsis What is the treatment for bacterial prostatitis? UA and urine cultures and STI testing to determine underlying infection Fluoroquinolones (Levaquin) or Bactrim Symptomatic treatment: NSAIDs or Alpha blockers 20 | P a g e Medications- SSRI's, neuropathy, Parkinson's, Multiple Sclerosis, etc, Wide variety of issues If a patient can have a nocturnal erection, what cause of ED is most likely? Psychogenic What is the treatment of ED? Lifestyle modifications: smoking cessation, stress reduction, and exercise PDE-5 Inhibitors- PDE: Penis Doesn't Erect ****SAFETY: Assess cardiac- do EKG, confirm that pt is not taking Nitrate!!!!! Will bottom out patient's BP**** Cognitive Behavioral therapy What is amenorrhea? Lack of menstruation What are primary and secondary amenorrhea? Primary: No menarche by age 15- refer out Secondary: 3-6 months of amenorrhea. Pregnancy=most common cause, menopause, contraception, hormone deficiencies, thyroid disorders, eating disorders, stress, obesity, etc. Management is treating the underlying cause What is dysmenorrhea? Painful mestruation What is the difference between primary and secondary dysmenorrhea? Primary: Painful cramps NOT related to an underlying issue. The patient has normal pelvic organs and normal physical exam. Secondary: Related to an underlying issue ex. Endometriosis What is the treatment for dysmenorrhea? Analgesics, contraceptives, if not controlled then refer to GYN What is menopause? Amenorrhea is present for 12 months later in life due to the fact that the ovaries are no longer producing estrogen and progesterone. What are signs and symptoms of menopause? Occurs between 45-55 Hot flashes, mood changes, sleep changes, dry skin, thinning hair, vaginal dryness, weight gain. Strophic vaginitis, lichen sclerosis What is atrophic vaginitis? Thin and dry vaginal walls- can't lead to painful intercourse, frequent infections, and vaginal bleeding. 21 | P a g e What is the treatment for atrophic vaginitis? Vaginal lubrication or hormone creams What are potential complications related to menopause? Increased CV risk and osteoporosis What is treatment for menopause? Symptomatic treatment Herbal supplements: Ginkgo, black cohosh Hormone Replacement Therapy What are signs and symptoms of PCOS? Infertility concerns, acne, hirsutism, acanthosis nigricans, irregular menses, weight gain What is Rotterdam criteria for diagnosis of PCOS? 2 out of the 3 need to be present An ovulation, increased androgen levels, and multiple cysts What are complications related to PCOS? Diabetes, HLD, HTN, increased cancer risk What is the treatment for PCOS? Lifestyle modifications and weight loss Spironlactone Contraception Metformin What are the current routine guidelines for Pap Smears? Begin at age 21 Age 21: Every 3 years, no routine HPV testing Age 35: Every 5 years WITH routine HPV contesting Age 65: Can discontinue if has had normal previous results and not high risk What do you do for Pap smear results: ASCUS? Follow up for HPV testing What do you do for Pap Smear results: LSIL/HSIL? Refer for colposcopy What are screening guideline for mammograms? Prior to age 50: assess risk vs. benefit Age 50-74: every 2 years Age 75: Not recommended 22 | P a g e What is fibrocystic breasts? Breast lumps: firm, tender, sore, and moveable, related to menstrual cycle How does breast cancer present? Fixed, non movable lump in breast/axilla, painless, dimpling, red or flaky nipples, discharge What are risk factors for breast cancer? Age, genetics, family history, having the BRCA gene 1 and 2 mutations, menarche before age 12, menopause after age 55, not having children and a sedentary life style. Exposure to hormones through HRT can lead to breast cancer When does the neural tube close during pregnancy? 4-6 weeks What is the recommended amount of folic acid a female should take? How about if they have a history of having a child with a neural tube defect? 400 mcg 4000 mcg daily for those with history What are some examples of Category X drugs? Actutane, Statins, ACE Inhibitors, Methotrexate These medications must be discontinued prior to conception What are presumptive signs of pregnancy? Subjective signs perceived by the woman - Signs: amenorrhea, breast changes & tenderness, nausea - Symptoms: N/V, urinary freq, weight gain, fatigue, quickening (fetal movement) What are probable signs of pregnancy? Pregnancy is likely but it's not confirmatory Ex. Pregnancy test HCG Ex. Hegar's sign, Chadwick's sign, Goodell's sign What is Hegar's sign? Softening of the cervical isthmus and the blue discoloration of the uterus What is Chadwick's sign? Blueish discoloration of the cervix due to increased blood flow to the cervix and vagina around th e4th week of pregnancy What is Goodell's sign? Softening of the cervix 25 | P a g e What is preeclampsia? High blood pressure in combination of signs of damage to other organ systems. REFER! What are signs and symptoms of preeclampsia? HTN, edema, headache, epigastric pain, visuals changes, clonus, proteinuria What is placenta previa? When the placenta partially covers the cervix S/S: PAINLESS vaginal bleeding What is management for placenta previa? Pelvic rest, monitoring with US, typically resolves on own as the uterus grows What is placental abruption? EMERGENCY Placenta separates from the uterus S/S: Painful contractions and vaginal bleeding and a hard uterus What is Zika Virus? Virus spread through mosquito bites What can zika virus cause in pregnant women? Can be passed to the fetus, can cause microcephalic and brain defects What is Listeria? Food borne bacterial illness that occurs when eating high risk foods such as uncooked deli meat, anything unpasteurized, soft cheeses, etc. What happens if a pregnant woman contracts Listeria? Can be passed to the fetus and can cause serious complications: illness, miscarriage, and preterm labor How to prevent Listeria? Treated with antibiotics, hand hygiene, proper food storage and preparation, and cooking to proper temperatures What is postpartum depression? depression after giving birth- commonly occurs in the first few weeks after delivery, but can occur up to 1 year postpartum What screening tool is used for postpartum depression? Edinburgh Postnatal Depression Scale 26 | P a g e What is the treatment for postpartum depression? CBT and antidepressants What is mastitis? Inflammation of Brest tissue Warm, tender, boggy breast, fever, malaise What is the treatment for mastitis? First line: Dicloxacillin Other options: Clindamycin, Macrolides If mastitis persists despite antibiotic treatment, what is a main concern? Concern for possible breast cancer, evaluate further and refer What are the safest contraception options for breastfeeding women? Non-hormonal options IUD, Depo-Provera, Progestin-only pill When can an IUD be placed in a postpartum woman? Has to be placed within 48 hours of birth OR 4-6 weeks postpartum Why can breastfeeding mothers not take combined-contraceptive options that contain estrogen? Estrogen is known to dry up the mother's milk supply What are contraindications for combination contraceptive options? Age > 35 AND a smoker History of clot Migraines with aura Current liver disease Current cancer Uncontrolled hypertension Also: not ideal in breastfeeding women Why do we not want a woman who is > 35 AND smokes to not get a COC? Estrogen along with the increased age and smoking puts her at a serious risk for a blood clot What are the different start option your patient can use when starting their contraception pills? Quick start: takes first pill the day she receives them, no matter where she is in her cycle. She will need to use backup method for 7 days. First-day start: start the first day of her next period- no back up method needed. 27 | P a g e Sunday-start: start the pack on the Sunday following start of menses. By doing this, the woman will ideally be able to avoid having a period on the weekends. Back up method needed. What should your patient do if they miss one active COC pill? Take it as soon as possible, continue taking others on schedule. What should your patient do if they miss 2 active pills? Take most recent pill ASAP, discard other missed pills. Continue taking rest of pack on schedule while using a back up method. What are some advantages to COC? Improved and regular cycle control Less ovarian cysts Can help with dysmenorrhea symptoms Helps with acne and endometriosis Decreased risk of endometrial/ovarian cancer As soon as you stop taking, you can get pregnant What are some disadvantages of COC? Clot risk due to estrogen Breast tenderness, Nausea, Breakthrough bleeding- these symptoms typically subside after 2-3 cycles What are other combination opinions for contraception? Nuvaring and Ortho-Evra patch Describe use of the Nuvaring Keep in place for 3 weeks, then remove for one week If it falls out, be sure to reinsert ASAP Provides low and steady amounts of hormones- less ups and downs Describe use of Ortho-Vera patch Apply once a week for 3 weeks and then take off for one week for period What is the key thing to remember about the Ortho-evra combination option? Going to have the HIGHEST risk for a blood clot because it has the highest levels of estrogen in it. What are contraindications for Progestin-only contraception options? Patients with active cancers or liver issues What is important education regarding Progestin-only options? There is a CONTINUOUS need for compliance, there is no wiggle room for error with these methods Describe use of Depo-Provera 30 | P a g e What is our biggest concern with ectopic pregnancy? Possibility of rupture- REFER OUT- EMERGENT What is Nagele's Rule? LMP + 9 months + 7 days What re expectations regarding weight gain in pregnancy? If patient was normal weight BMI: expect about 25-35 lb weight gain Greater weight gain is going to be recommended if the patient was underweight previously Lower weight gain is going to be recommended if the patient was overweight What heart sound may be audible in pregnant women due to that extra fluid of pregnancy? S3 Where should the fundal height be at 12 weeks? Symphysis pubis Where should the fundal height be at 20 weeks? Umbilicus What does it mean if the mother is Rh-negative and the baby is Rh- positive? An incompatibility is present, that can affect future pregnancies. It is common during deliveries for fetal and maternal blood to mix, and so the mother can develop antibodies against that Th-positive blood type. This would mean that if she had a future pregnancy with an Rh-positive baby, those antibodies could attack. What pregnant mothers need Rhogam? When is it given? All Rh-negative mothers 28 weeks ***If the mother is Rh-negative and the baby is Rh-positive, then ANOTHER dose will be given within 72 hours of delivery When are AFP Levels checked in pregnancy? 15-20 weeks What does low AFP levels indicate? Down Syndrome What does high AFP levels indicate? Multiple gestation, neural tube defects Where is AFP made? Fetal liver 31 | P a g e When do we screen for gestational diabetes? 24-28 weeks How do we screen for gestational diabetes? One Step: 2 hour oral glucose tolerance test, and if the result is > 200 the patient has gestational diabetes Two Step: One hour glucose challenge, and if the pregnant fails the one hour, a 3 hour test will be initiated What is the treatment of gestational diabetes? First line: lifestyle modifications Second: Metformin and/or insulin- insulin is favored because it does not cross the placenta When do we screen for Group B Strep and how is it collected? 35-37 weeks Vaginal/Rectal swab If a woman screens positive for Group B Strep, what is the treatment? PCN administered during labor What is preterm labor? Labor that occurs prior to 37 weeks What are risk factors for preterm labor? Multiple gestation pregnancy, smoking, and various infection, UTIs What is preeclampsia? High blood pressure in combination of signs of damage to other organ systems. REFER! What are signs and symptoms of preeclampsia? HTN, edema, headache, epigastric pain, visuals changes, clonus, proteinuria What is placenta previa? When the placenta partially covers the cervix S/S: PAINLESS vaginal bleeding What is management for placenta previa? Pelvic rest, monitoring with US, typically resolves on own as the uterus grows What is placental abruption? 32 | P a g e EMERGENCY Placenta separates from the uterus S/S: Painful contractions and vaginal bleeding and a hard uterus What is Zika Virus? Virus spread through mosquito bites What can zika virus cause in pregnant women? Can be passed to the fetus, can cause microcephalic and brain defects What is Listeria? Food borne bacterial illness that occurs when eating high risk foods such as uncooked deli meat, anything unpasteurized, soft cheeses, etc. What happens if a pregnant woman contracts Listeria? Can be passed to the fetus and can cause serious complications: illness, miscarriage, and preterm labor How to prevent Listeria? Treated with antibiotics, hand hygiene, proper food storage and preparation, and cooking to proper temperatures What is postpartum depression? depression after giving birth- commonly occurs in the first few weeks after delivery, but can occur up to 1 year postpartum What screening tool is used for postpartum depression? Edinburgh Postnatal Depression Scale What is the treatment for postpartum depression? CBT and antidepressants What is mastitis? Inflammation of Brest tissue Warm, tender, boggy breast, fever, malaise What is the treatment for mastitis? First line: Dicloxacillin Other options: Clindamycin, Macrolides If mastitis persists despite antibiotic treatment, what is a main concern? Concern for possible breast cancer, evaluate further and refer What are the safest contraception options for breastfeeding women? 35 | P a g e When does an individual have return of fertility following removal of Mirena? A few months after removal What is emergency contraception? If taken within 72 hours of unprotected intercourse, these reduce the risk of pregnancy by 75%. The sooner the woman take it, the better the odds. NOT abortive in nature. What are common side effect of emergency contraception? N/V, and spotting until that next period What are some examples of emergency contraception? Plan B and Ella, Copper-T IUD What is a non hormonal emergency contraception option? Copper-T IUD Needs to be inserted within 7 days of unprotected intercourse, can stay in place for up to 10 years What are common uses of HRT? Manage menopause symptoms, help prevent issues with osteoporosis What are risks associated with HRT? Heart disease, blood clots, breast cancer What is the goal for HRT? Have our patient on HRT for as little as possible (ideally no more than 3-5 years) What are the 2 types of HRT? Estrogen only and Estrogen/progestin combo If a patient has an intact uterus what HRT type can she NOT have and WHY? She can not take estrogen only HRT. The progestin in the combo will help prevent endometrial hyperplasia and cancer in these women. What are some alternatives for HRT? SSRIs- especially Paxil: works well for night sweats and hot flashes Herbals: Gingko, black cohosh, evening primrose oil What work up is required prior to prescribing PDE-5 inhibitors? Cardiac work up: Lipid panel, EKG, CBC, CMP, A1c, Fasting total testosterone Verify that patient is not on nitrates 36 | P a g e What are side effects of 5a-reductase inhibitors? ED and impotence What is important regarding 5a-reductase inhibitors and pregnant patients? These are teratogenic: pregnant women should NOT handle any crushed tablets or come into contact with the semen of men who are taking this drug class, because it poses serious risk for the fetus. What is gout? A buildup of Uric acid in our patients body What are some things that can increase uric acid levels? Medications: Diuretics Renal insufficiency Obesity Foods high in purine: red meats, shell fish Alcohol How is a gout patient going to present? Painful big toe What lab work can we order to evaluate for gout? Uric acid (not always going to be elevated during an acute attack), ESR, CRP, WBCs (inflammation and stress can cause an elevation) What is treatment for gout? Lifestyle modifications: hydration, low purine diet, cut back or eliminate alcohol, weight loss, etc. Acute attack: Potent NSAIDs: Indocin or Naproxen and steroids (will decrease inflammation) Severe attack: NSAIDs, steroids and Colcrys What is maintenance therapy for gout patients? First line: Allopurinol (going to help body excrete the excess uric acid) Other options: Colcrys, Probenecid, Febuxostat What lab must be monitored if patient is on Allopurinol? CBC- because in some patient allopurinol is going to cause true bone marrow suppression Do you stop alloipurinol during an acute attack? No, patient should continue taking allopurinol during an acute attack What is osteoporosis? Disease process where the bones become more porous, predisposes patients to fractures 37 | P a g e How can osteoporosis be prevented? Weight bearing exercise Calcium 1200 mg Vitamin D 800-1000 units How is osteoporosis diagnosed? DEXA scan What are normal DEXA scan results? > -1.0 What DEXA scan results indicate osteopenia? -1.0 to -2.5 What DEXA scan results indicate osteoporosis? < -2.5 Who should be getting DEXA scan screening? All women 65 years and older, this is our post-menopausal population Younger patients with low trauma fractures How is osteoporosis treated? Calcium, Vitamin D, and weight bearing exercise First line: Biphosphonates: increase bone density (-dronate) How should biphosphonates be taken? Medication needs to be taken prior to all other meds and food on an empty stomach Instruct patient to remain upright for 30 minutes after administration to prevent severe acid reflux What is the purpose of the ACL in the knee? One of the key structures in the knee because it stabilizes the knee during rotational movements What is typical presentation of an ACL injury? Likely for patient to hear a "sudden popping" and then their knee gave away. Swelling occurs almost immediately. What is the best way to evaluate the ACL? Lachman test Anterior Drawer Sign can be used, but it is not as specific or sensitive How do you perform Lachman test? Patient should be supine Put one hand on lower thigh and one on lower leg 40 | P a g e Folic acid deficiency What is fibromyalgia? Most commonly affects women Not autoimmune or inflammatory in nature Widespread pain and tenderness What are some risk factors for fibromyalgia? RA and Lupus What are signs and symptoms of fibromyalgia? Widespread pain and tenderness throughout the body, the pain tends to move and come and go. Depression Severe fatigue Waking up un-freshed Cognitive complaints How do you diagnose fibromyalgia? There is no diagnostic test currently Diagnosis is based on symptoms- must be present for at least 3 months and there can not be an alternative explanation for the symptoms What is treatment for fibromyalgia? Physical exercise Cymbalta, Elavil, Flexeril, and Lyrica have been FDA approved What are some examples of biphosphonates? -dronate Alendronate, risedronate How do biphosphonates work? Inhibits the reabsorption of bone by the osteoclasts, which in turn increases bone density because it allows the osteoblasts to build up the bone to work more effectively. What 2 things can women take throughout their life to decrease their chances of getting osteoporosis? Calcium and vitamin D What is the maximum dosage of Tylenol daily? 3000 mg per day What organ might suffer if the patient takes too much Tylenol? Liver, can cause hepatotoxicity How do NSAIDs work? 41 | P a g e Block the COX enzyme, which inhibits the production of prostaglandins How does NSAIDs impact sodium and fluid? NSAIDs cause sodium and fluid retention which is why they are C/I in HF patients How does NSAIDs effect platelets? NSAIDs decrease activity of your body's platelets, patients will be more prone to bleeding How does NSAIDs effect gastric acid? NSAIDs increase the production of gastric acid. What organ can be harmed with administration of NSAIDs? Kidney- can worsen current kidney disease or possible cause kidney injury What are examples of DMARDs? Methotrexate, Plaquenil, Cyclosporine What labs need to be monitored for patients on DMARDs? CBC, LFTs and Renal Function What are some things to consider when prescribing gabapentin? Controlled substance- not at the federal level yet Can be sedating What are side effects of Colcrys? Lots of GI effects: N/V, abdominal discomfort Colcrys should be prescribed with caution to those with what condition? Renal impairment How is the McMurray test performed? Have the patient supine Grab the patient's heel with one hand and grab the knee with the other hand Internally and externally rotate the knee to see if there's a reproduction of pain, or if we feel clicking. A positive result is if there is clicking or pain What is Meniscal injury treatment? RICE Refer to Ortho What is osteoarthritis? Degenerative joint disease 42 | P a g e What are typical sites that OA occurs? Spine, hip, hand, foot, knee What are risk factors for OA? Age, trauma, obesity, overuse of body (athletes/occupation) What are signs and symptoms of OA? Pain that is worse with activity, but relieved with rest Morning stiffness, typically lasts less than an hour Asymmetrical with NO warmth or redness What are 2 things to look for in OA- fingers? Bouchard's nodes- PIP Heberden's nodes- DIP What diagnostic testing can assist with differentiating OA and RA? ESR, RF, X-Ray What will we see on X-Ray of an OA patient? Joint space narrowing What is the treatment of OA? Exercise/PT OTC medications: Tylenol, NSAIDs Ortho Referral- steroid injections and further treatments What is Rheumatoid Arthritis? systemic autoimmune inflammatory disease What are signs and symptoms of RA? Pain- NOT relieved by rest Stiffness for over an hour after awakening Symmetrical Warmth/redness What are clinical signs in relation to RA? Swan neck deformity Boutonniere deformity SOME cases Bouchard's nodes can be present in RA (think B for BOTH) How can you diagnose RA? Lab work: ESR, RF Refer to rheumatology for official diagnosis 45 | P a g e What is a common side effect of gabapentin? Sedation What diagnostic test is best going to diagnose appendicitis? CT Scan What is Rovsing sign? Think Reverse/Right Palpate on the LLQ and it hurts on the opposite side (RLQ) Can indicate appendicitis What is the Markle sign? When there is pain in the RLQ when the patient hops on one foot Can indicate appendicitis What is Blumberg sign? Rebound tenderness What is McBurney's point? The point that is two thirds the distance between the belly button and the anterior iliac crest, and it will be tender if you press into it, if it's a positive sign. Can indicate appendicitis What is the obturator sign? Internal rotation of the right hip at 90 degrees causes abdominal pain if it's positive Can indicate appendicitis What is the Psoas sign? When the patient raises their leg against resistance and is positive if they experience pain Can indicate appendicitis What is Murphy's sign? Palpate into the subcostal area in the RUQ, positive if pain occurs on inspiration Can indicate cholecystitis What is our go to diagnostic tool for possible cholecystitis US- need to look and see if there are any gallstones If there are no gallstones, and patient is still experiencing symptoms, then order HIDA scan What is Chvosteks sign? When we tap on the patient's face, and we have that scrunch up on one side. Indicates HYPOcalcemia 46 | P a g e What is Trousseau's sign? When you inflate the BP cuff and it draws up their arm like an involuntary contraction Indicates HYPOcalcemia When calciums levels are low, the patient is at risk for what? Seizure What conditions are US considered the go to diagnostic tool? Cholecystitis, kidney stones, abdominal aortic aneurysm How does an abdominal aortic aneurysm usually present? Pulsating mass in the abdomen When should patients start getting colonoscopies? 45-50 years old How often should a patient be getting colonoscopies? Every 10 years starting at age 45-50, with an annual fecal occult blood test as well What patients should start earlier and have more frequent colonoscopies? Those that have a personal history of colorectal cancer, or family history- especially a first degree relative Also, if they have any kind of inflammatory bowel disease like Crohn's or Ulcerative colitis And if they have any prior abdominal radiation What are some signs and symptoms that you might see in a patient who actually DOES have colorectal cancer? Ribbon shaped or pencil shaped stools Where in the colon are most colorectal cancers occurring? Where are we seeing the most polyps? The descending colon What labs can we use to distinguish between IBS and IBD? Inflammatory markers: ESR and CRP These will be elevated in IBD and will not be elevated in IBS RLQ pain can indicate? Appendicitis RUQ pain can indicate? Cholecystitis, hepatitis LUQ pain can indicate? 47 | P a g e Pancreatitis, gastritis LLQ pain can indicate? Diverticulitis How do we treat diverticulitis? Clear Liquid Diet, Antibiotics (Augmentin or Cipro or Metronidazole) What is the only definitive way to treat celiac disease? Gluten free diet What is ankylosing spondylitis? Autoimmune arthritis and a chronic inflammatory disease, affecting the spine and large joints. Also known as Bamboo spine How to patients with akylosing spondylitis present? Pain typically starts in the patient's lower back and it works up the back to their neck. What is initial diagnostic testing for akylosing spondylitis? XR When do we see snuff box tenderness? Scaphoid fracture What is another term for scaphoid fracture? Navicular fracture How do we diagnose scaphoid fracture? This fracture doesn't usually show up on X-Ray right away, if we suspect this to happen, we are going to go ahead and treat them. It's going to show up on X-Ray about 2 weeks after the initial injury. How are scaphoid fractures most caused? If patient reports they fell with their hands braced to catch them How do we treat a scaphoid fracture? Thumb spica cast Why do we need to treat a scaphoid fracture, even if it not present on X-Ray? Want to prevent osteonecrosis from occurring in the wrist What is Phalen's sign? Backwards prayer hands Indicates carpal tunnel syndrome 50 | P a g e Finkelstein test How do you perform Finkelstein test? The examiner is going to grab the thumb and perform ulnar deviation, positive test if pain occurs When do we see a strawberry cervix? Trichomoniasis What do you expect when clue cells are on the wet mount and a positive whiff test? Bacterial vaginosis What are you thinking if a patient has a friable cervix? Gonorrhea or Chlamydia Painful, burning vesicles with an erythematous base may indicate what condition? Herpes simplex What is a normal vaginal pH? 3.8-4.5 What is treatment for a patient who has gonorrhea AND chlamydia? Doxycycline and Rocephin What is treatment for a patient who has chlamydia? Azithromycin 2 a's in chlamydia, and Azithromycin starts with A What is treatment for a patient who has gonorrhea? Rocephin Lots of r's in gonorrhea- Rocephin starts with an R What is the treatment for BV? Flagyl What is the treatment for trichomoniasis? Flagyl What is the typical presentation of syphilis? First stage: painless chancre that is around for about 3-6 weeks and then goes away Second stage: See a rash on palms and soles Third stage: Neurosyphilis What is the screening test for syphilis? 51 | P a g e RPR What is the confirmatory test for diagnosis of syphilis? FTA-ABS How do we treat syphilis? IM PCN specifically Bicillin PCN VK Anytime a female of childbearing age is having GU complaints, what should we order? Hcg urine pregnancy test Patients with down syndrome will be at a higher risk for what 3 things? Alzheimers, hypothyroidism, and cervical spine instability Are down syndrome patients able to play sports? As long as they are cleared prior with a C-Spine XR and it does not show any instability When does placenta abruption typically occur? Third trimester Should a breastfeeding mother with mastitis stop breastfeeding? No What colposcopy results indicate that something more serious is going on? CIN 2 and 3 What is the typical treatment for genital warts? TCA Acid HRT increases risk of what type of cancer? Ovarian cancer Patient with PCOS are at higher risk for what condition? Insulin resistance- may develop diabetes, HLD, and certain types of cancer What is galactorrhea? Milky discharge that's able to be expressed from the breast What lab should be drawn when a patient presents with galactorrhea? Prolactin level to see if this is caused from a prolactinoma What is the PSA cutoff before we refer a patient out? 52 | P a g e 4 RBC casts indicates what condition? Glomerulonephritis WBC casts indicate what condition? Pyelonephritis What should you order if a patient is having recurrent UTIs? Kidney US What is our immediate concern when a patient has erectile dysfunction? Cardiac disease In the geriatric population, what are some expected changes to see regarding skin and hair? Atrophy of the skin Dry and thin skin (much more fragile) Thin, gray hair Hair grows slower What are some skin and hair conditions that may occur in the geriatric population? Seborrheic keratosis, actinic keratosis, lentigines (liver spots or sunspots), and alopecia In the geriatric population, what are some expected changes to see regarding GI? Decreased sense of taste Dry mouth /receding gums Diminished ability to absorb vitamins Bowel transmit time is slower What are some GI conditions that may occur in the geriatric population? Constipation and increased risk of GI cancers (especially colon) In the geriatric population, what are some expected changes to see regarding vision changes? Presbyopia What are some vision conditions that may occur in the geriatric population? Cataracts, arcus senilus, glaucoma, and macular degeneration In the geriatric population, what are some expected changes to see regarding cardiac? Arteriosclerosis S4 sound may be normal (unless they have heart disease) Left ventricle becomes more thick Heart valves may have calcium deposits 55 | P a g e 1. Instruct patient to remember 3 words 2. Instruct patient to draw a clock to a specific time 3. Ask the patient to recall the original 3 words What medication can lead to B-12 deficiency? Metformin A new graduate nurse practitioner has a patient presents with a hearing complaint. The patient states that they have had decreased hearing on the right side for the last month that is continuing to get worse. The NP completes both the Rinne and Weber tests. If the patient has Ménière's disease, what would be the expected finding on the Weber test? 1. AC is 2 times longer than BC 2. BC is 2 times longer than AC 3. The tuning fork lateralizes to the right ear 4. The tuning fork lateralizes to the left ear 4. The tuning fork lateralizes to the left ear What are common signs and symptoms of Meniere's Disease? Vertigo, tinnitus, ear pressure, nystagmus What is our biggest worry for a Meniere's Disease patient? There is a possibility for a potential, permanent hearing loss. What is rhinitis meidcamentosa? Drug-induced rebound nasal congestion, this can happen after use of nasal decongestants like Afrin. These nasal decongestants should ideally not be used for greater than 3-5 days because of this risk. What is herpes keratitis? This is an infection of the cornea due to herpes simplex virus How is herpes keratitis diagnosed? By examining the eye under a black lamp and visualized the cornea, in herpes keratitis, fern like lines will be seen on the cornea A child that has a history of mononucleosis is at increased risk for development for what cancer later in life? And why? Hodgkin's Lymphoma and Burkitt's Lymphoma, this is due to the exposure of the Epstein-Barr virus What types of patients will be at a higher risk of pneumonia? Patient with chronic lung diseases: asthma, COPD, cystic fibrosis. Why are cough suppressants not helpful in pneumonia patients? 56 | P a g e Because we WANT them to get that gunk out, we do not want them to hold it in their lungs, an expectorant would be a better option for these patients. When should a follow up chest X-Ray be completed after treatment of pneumonia? Around 8 week mark What is COPD? Chronic Obstructive Pulmonary Disease. This is a chronic condition that is made up of chronic bronchitis and emphysema. It is a progressive inflammatory lung disease that makes it hard for the patients to breathe, because the chronic bronchitis leads to mucous build up and the emphysema portion destroys areas of the lungs. What signs and symptoms are common in COPD patients? Chronic cough Sputum production Dyspnea- difficulty breathing What signs and symptoms are specific to B12 deficiency anemia? Neurological symptoms, paresthesia (numbness and tingling in hands and feet), unsteady gait, memory issues Beefy red tongue What diet can result in B12 deficiency? Vegan- oral supplements can be used for treatment What surgery can result in B12 deficiency? Gastric surgery- patient will lose intrinsic factor that is required to absorb B12- these patients will require life long IM B12 injections What patient population is lupus commonly seen? Women of childbearing age- ages 15-45, African Americans are going to be at higher risk What is the diagnostic criteria for Lupus? Must have 4/11 diagnostic criteria: Malar rash Discoid rash Photosensitivity Oral/nasal ulcers Non-erosive arthritis Cardio-pulmonary complaints Renal complaints Neurological concerns 57 | P a g e Immunological disorders + ANA test Hematologic disorders What is Sjogren's Syndrome and what is the treatment? Dry eyes and dry mouth- treatment revolves around symptom management- artificial tears, hard candies, etc. Common in lupus patients What is a major concern for lupus patients? How do we monitor this? Impact on the kidneys- Lupus nephritis Be on the look out for glomerularnephritis as well as proteinuria These patients will require routine UA for assessment of their kidneys and protect them What is the function of the thyroid? Viral hormone gland Metabolism regulation- impacts every SINGLE cell within the body Proper growth and development across the entire lifespan What produces TSH? Pituitary gland What is the function of TSH? Tells your thyroid when to produce and release those critical thyroid hormones- T3 and T4. What disorders include hypothyroidism? Iodine deficiency, Hashimoto's, or thyroiditis A presence of thyroid peroxidase antibodies indicates that? Hypothyroidism is caused by an autoimmune process of some sort What are some signs and symptoms of hypothyroidism? Weight gain, constipation, dry skin, cold intolerance, fatigue, course hair, facial puffiness, thick tongue, and maybe some cardiac side effects What patient education must be included regarding Synthroid administration? Must be taken on an empty stomach before other medications What are signs and symptoms of a myxedema coma? Low body temperature, edema, confusion, lethargy, tongue thickening, difficulty breathing What medications can precipitate myxedema coma? Lithium or amiodarone