HESI?

In which of the following patients would an atypical presentation of appendicitis be most likely? A. 67-year-old female B. 17-year-old male C. 26-year-old female D. 45-year-old male

A. 67-year-old female In children, pregnant women, and the elderly, the presentation of appendicitis may not be typical (Old et al, 2005).

Which of the following physical findings would be expected in a patient with peritoneal irritation? A. Abdominal guarding B .Liver 2 cm below the costal margin C. Increased bowel sounds D. Engorged veins around the umbilicus

A. Abdominal guarding Peritoneal irritation would lead to guarding and possible rebound tenderness. The Iliopsoas sign is an indicator of peritoneal irritation. A liver below the costal margin may indicate hepatic inflammation, as seen in hepatitis. Increased bowel sounds might be seen in gastroenteritis. In many cases, bowel sounds would decrease in the presence of peritoneal irritation. Engorged veins around the umbilicus are seen with ascites (Kidd et al, 2003).

A patient has a history of migraine headaches for the past 2 years. The headaches have increased in frequency to 4 times a week. The FNP wants to start preventive therapy for the headaches. Which of the following is appropriate therapy? A. Amitriptyline (Elavil) B. Sumatriptan (Imitrex) C. Ergotamine D. Enalapril

A. Amitriptyline (Elavil) Prophylactic therapy of migraine is used when the patient has frequent headaches or if abortive therapy is not effective. Beta blockers, calcium channel blockers, and tetracyclic antidepressants are the most commonly used. Ergotamine and sumatriptan are abortive drugs, not prophylactic drugs. Enalapril is not appropriate for headaches (Ferri, 2006).

Which of the following best describes the expected physical exam findings in a patient with severe COPD? A. Wheezing B. Egophony C. Decreased breath sounds D. Rales

C. Decreased breath sounds When a patient has severe COPD, the FNP would expect to find decreased breath sounds from less air moving in and out because of trapped air (Judd, 2004).

A patient is brought to the clinic with a nosebleed. Which of the following objective descriptions is consistent with a posterior nosebleed? A. Blood seen in oropharynx B. Unilateral, foul-smelling nasal discharge C. Red, raw Kiesselbach triangle D. Bloody discharge from both nares

A. Blood seen in oropharynx In anterior nosebleeds, the bleeding is usually from the Kiesselbach triangle. It can be seen on examination as a red, raw area with clots present. Posterior nosebleeds usually present with blood running down the oropharynx, which can be seen on visualization of the pharynx (Kucik and Clenney,

A daughter brings in her 86-year-old mother with a concern about driving safety. Which of the following is not a concern for driving safety? A. Gets lost easily B. Drives too slowly C. Has difficulty in making left-hand turns D. Takes too long to get to destination

A. Gets lost easily Families tend to be reassured when the elder drives slowly. The most frequent traffic violations for the elderly include failure to yield, improper turning, and difficulty in entering or leaving highways. The evaluation should include vision, hearing, cognition, motor function, and review of medications (Murphy and Maxwell, 2005).

Besides abdominal or flank pain, what would the best indicator be in a patient with a kidney stone? A. Hematuria B. Urinary frequency/urgency C. pH of urine D. Fever

A. Hematuria Hematuria is generally seen in all patients with kidney stones. The other findings may not be seen in all patients with kidney stones (Portis and Sundaram, 2001).

Which of the following signs would indicate to the FNP that a patient might have an airway occlusion and needs assistance? A. Holding throat with both hands B. Coughing C. Crying D. Whispery, soft voice

A. Holding throat with both hands The ability to cough, talk, or cry indicates an incomplete occlusion of the airway. Holding the throat with both hands indicates a complete occlusion (Thomas et al, 2006).

Which of the following is not a trait found in a person suffering from PTSD? A. Hypersomnia B. Hyperarousal C. Reexperiencing D. Avoidance

A. Hypersomnia The DSM IV identifies PTSD as consisting of three clusters of symptoms: reexperiencing, avoidance, and hyperarousal. Hypersomnia is not a trait of PTSD (Miller, 2000).

A patient who has CHF and is taking an ACE inhibitor has noticed a dry, irritating cough. The FNP knows that the pathophysiology of the cough is: A. Increase in bradykinin level B. Increased irritation of the bronchi C. Interaction so that a beta blockade is produced D. Decrease in angiotension II levels

A. Increase in bradykinin level The cough from ACE inhibitors is related to the build up of bradykinen (Kidd et al, 2003).

Which of the following is not considered a tetanus prone wound? A. Laceration B. Gunshot wound C. Puncture D. Frostbite

A. Laceration All of the following wounds are considered tetanus prone: wounds contaminated with soil, feces, saliva; puncture or crushing wounds; burns, gunshot wounds, avulsions, frostbite, chronic skin ulcers. A laceration without the above risk factors is not considered tetanus prone (Talan and Gelfand, 2000).

Which of the following examination findings is consistent with the diagnosis of Hirschsprung's disease? A. Large fecal mass palpable in abdomen but no stool in rectal vault B. Large amount of stool in rectal vault C. Fluid wave of abdomen D. Hepatosplenomegaly

A. Large fecal mass palpable in abdomen but no stool in rectal vault A large mass of feces may be palpated through the abdomen, but no stool is found in the rectal vault. This is different from functional constipation in that in functional constipation, a large amount of stool is found in the rectum (Zitelli, 2002).

Which skin lesion necessitates immediate intervention? A. New 3 mm brown mole with an irregular red border that itches B. Waxy papule 3 cm in diameter that appears "stuck on" the face C. Multiple flat moles scattered along the upper back—black-brown with smooth rounded edges D. Brown mole on thigh—5 mm symmetrical, unchanged in many years

A. New 3 mm brown mole with an irregular red border that itches The lesion involving color and irregular boarders suggests malignant melanoma and requires immediate intervention (Fitzpatrick et al, 2001).

Which drug best raises HDL cholesterol? A. Nicotinic acid B. Bile acid sequestrants C. Statins D. Fibrates

A. Nicotinic acid Nicotinic acid gives the best increase in HDL cholesterol (ATP III Guidelines, 2003).

A 14-year-old girl is concerned about not having started her period. In looking over her records, the FNP notes that the patient is below the 5th percentile for height and weight and has a history of recurrent respiratory infections. Which differential diagnosis for the patient is least suspicious on the list? A. Pneumonia B. Asthma C. Turner's syndrome D. Cystic fibrosis

A. Pneumonia Recurrent respiratory infections and poor weight gain can indicate both asthma and CF. Short stature and delayed puberty are consistent with a diagnosis of Turner's syndrome. A diagnosis of pneumonia is not logical in the absence of current respiratory symptoms (Larsen et al, 1999).

A patient with asthma comes in for chest tightness. She is taking fluticasone (Flonase) and albuterol as directed and continues to have difficulty with coughing and wheezing. Her PEFR is 55% of predicted. Her medication regimen should be adjusted to include: A. Prednisone dose pack B. Zafirlukast (Accolate) C. Salmeterol (Servent) D. Theophylline

A. Prednisone dose pack Steroids should be used when the PEFR is 50% to 80% of what is predicted. The treatment should be rapid acting (NAED, 2002).

A patient comes to the office with complaints of wheezing. What associated history would best support a diagnosis of asthma? A. Recurrent skin problems since infancy B. Chronic otitis media during the first years of life C. Smokers in the home D. Older brother with seasonal allergies

A. Recurrent skin problems since infancy Atopy is the strongest predisposing factor associated with the development of asthma. Irritants and illnesses can serve as triggers for allergy attacks. A family history of allergies is not as much a support for the diagnosis as are the symptoms of the patient herself (Kidd, et al, 2003).

A college student presents to the College Clinic complaining of amenorrhea. Which factor in her history is least often associated with amenorrhea? A. Scoliosis B. Ballet dancing C. Anorexia nervosa D. Long-distance running

A. Scoliosis Excessive exercise seen in athletes and nutritional deficits seen in eating disorders are often associated with irregular menses and amenorrhea. Scoliosis is an unrelated factor (Phipps, 2004).

Education for a patient treated for a partial-thickness burn should include which of the following? A. The future use of sunscreen on the area B. Application of ice to decrease pain C. Explaining the proper way to debride blisters D. The need to return for tetanus immunization within 1 week

A. The future use of sunscreen on the area A burned area is more susceptible to injury from thermal energy in the future. Tetanus prophylaxis must be administered within 72 hours. Ice is not used because vasoconstriction may further injure the area. Blisters should remain intact until they break on their own (Fultz and Messer, 2000).

A mother brings her daughter for an eye evaluation. Which finding in the child's history is most consistent with a diagnosis of amblyopia? A. Tilting her head to one side to see better B. Tearing and tenderness of her eyes with close work C. Sitting close to the television to see D. Saying she sees the movie better when far back from the screen

A. Tilting her head to one side to see better Children with strabismus tilt their heads to minimize the effect of diplopia on their vision. This finding is consistent with a diagnosis of amblyopia. Other options are not associated (Wilson and Giddens, 2005).

A 23-year-old woman comes in with complaints of LLQ, pain, fatigue, and occasional spotting since her LMP, which was 8 weeks ago. The exam reveals closed cervical os, minimal blood in vaginal vault, uterus 8 week size, and fullness and tenderness of the left adnexa; right adnexa WNL; B/P 118/60; HR 94. Serum hCG is positive. What diagnostic test is appropriate and cost effective given these findings? A. Vaginal ultrasonography B. CT of the abdomen C. Flat plate of abdomen D. Laparoscopy

A. Vaginal ultrasonography The clinical scenario is descriptive of ectopic pregnancy; the appropriate diagnostic test is vaginal ultrasonography. CT of the abdomen is not appropriate to rule out the suspected diagnosis; flat plate of the abdomen is inappropriate since the pregnancy test is positive. Laparoscopy is an invasive technique that is unnecessary at this point in the case (Lozeau and Potter, 2003).

Which of the following comments by a patient with Osgood-Schlatter disease is consistent with the diagnosis? A. "My knee hurts all the time, even when I am not moving." B. "My knee hurts when I run or jump." C. "My knee only hurts when I twist it." D. "My knee only hurts when I try to straighten it."

B. "My knee hurts when I run or jump." OS is an overuse syndrome; the pain occurs with running, jumping, going up steps, and kneeling (Calmback et al, 2003).

A patient is being seen for hypertension. Which of the following drugs is recommended for first line therapy? A. Calcium channel blocker B. ACE inhibitor C. Nitroglycerine D. Beta blocker

B. ACE inhibitor

At what age would the FNP expect to see a child use his or her pincher grasp? A. 11 months B. 6 months C. 9 months D. 3months

C. 9 months A child normally uses a pincher grasp around the age of 9 months (Bright Futures, 2001).

Which comment by an older woman would lead the FNP to include macular degeneration in a list of differential diagnoses? A. "There is good direct vision but objects at the sides seem blurred." B. "I can't see anything in front of me but my side vision is good." C. "My eyes feel as if they have a film over them darkening my vision." D. "I see little flecks that appear to be dancing in front of my eyes."

B. "I can't see anything in front of me but my side vision is good." The central vision is affected in macular degeneration, while vision at the periphery remains clear (Kidd et al, 2003).

61. Which of the following complaints, in addition to facial pain, is most indicative of TMJ disorder? A. "My food gets caught in my throat when I swallow." B. "My husband says I grind my teeth at night." C. "I have a partial plate." D. "My teeth hurt when I chew hard candies."

B. "My husband says I grind my teeth at night." Bruxism or teeth grinding makes the symptoms of TMJ disorder worse (Kidd et al, 2003).

Visual acuity testing of a young man hoping to enter the military indicates 20/40 vision. The FNP interprets these findings to the man correctly as: A. Vision normal for a young adult male B. Ability to see from 20 feet what the normal eye sees at 40 feet C. Ability to see from 40 feet what the normal eye sees at 20 feet D. Normal vision in the right eye but inability to see beyond 40 feet in the left

B. Ability to see from 20 feet what the normal eye sees at 40 feet Visual acuity assessed with the Snellen chart requires measurement of vision from a distance of 20 feet (the numerator in the 20/40 finding). A finding of 20/40 vision indicates that the man can see from 20 feet what the normal eye can see from 40 feet away from the chart (Wilson and Giddens, 2005).

The use of 10% potassium hydroxide in wet mount slides assists in diagnosing: A. Herpes and condyloma acuminata B. Bacterial vaginosis and Candida albicans C. Gonorrhea and syphilis D. Trichomonas and Chlamydia

B. Bacterial vaginosis and Candida albicans KOH removes cellular debris from slides, allowing the hyphae and spores of Candida and the clue cells of bacterial vaginosis to be seen more clearly. KOH also provides a positive whiff test with BV by releasing amines (Kidd et al, 2003).

A man with type I diabetes asks the FNP what kind of exercises he can do. The patient had laser treatment of a partially detached retina 2 years earlier but his retinopathy is now stable. What exercise would be appropriate? A. Jogging on an indoor track B. Bicycling on a stationary bike C. Running on a treadmill D. Weight lifting that increases in intensity over time

B. Bicycling on a stationary bike Given the history of diabetic retinopathy serious enough to require laser correction, certain physical activities and exercises are contraindicated for this patient. Use of a stationary bicycle would be acceptable because it not likely to increase intraocular pressure or compromise the eye (Friberg, 2001).

A 19-year-old college student came in for an STD check. She had gone to a party where she had 6 12-oz beers and 2 shots of tequila in the first 4 hours. She is not sure how the party ended or how she got home. She is concerned she may have an alcohol problem. Which of the following screening tests would be the best to use in this situation? A. Screening for tolerance B. CAGE C. No screening test is needed; it is clear that she has a problem. D. DAST

B. CAGE CAGE or AUDIT would be the most appropriate screening tests. AUDIT is very helpful because it identifies frequency and amount of alcohol. DAST is a drug abuse screening test. Tolerance is best used in pregnant women (Colyar, 2005).

An FNP student sees a patient and reports finding annular lesions of 3 days' duration. When you enter the room with the student, you expect to see skin lesions arranged in: A. A snake-like pattern B. Circular or ring shape C. Groups of vesicles D. A pattern merging together

B. Circular or ring shape Annular lesions are round or ring shaped; a pattern merging together is reticular, while groups of vesicles are known as clustered (or dermatomal) if they follow one dermatome. A snake-like pattern of lesions is referred to as gyrate (Fitzpatrick et al, 2001).

Which of the following is an effective treatment for Ménière's disease? A. Avoidance of excessive noise B. Diuretics C. Hearing aid D. Increased salt intake

B. Diuretics The cause of Ménière's disease is excessive accumulation of endolymph in the membranous labyrinth. Diuretics decrease the pressure within the inner ear (Crummer and Hassan, 2004).

A patient has had a genital probe return with a positive Chlamydia but negative gonorrhea. The appropriate antibiotic treatment for this patient is: A. Suprax 500 mg 1 dose B. Doxycycline 100 mg BID × 7 days C. Rocephin 125 mg IM D. Cipro 500 mg × 1 dose

B. Doxycycline 100 mg BID × 7 days The first-line treatment for Chlamydia is zithromax 1 gm packet or doxycycline 100 mg. Cipro and Rocephin are treatments for gonorrhea (CDC, 2006).

Which of the following historical factors in a patient with sickle cell disease typically is the presenting symptom of a patient in crisis? A. Decreased hearing B. Extremity pain C. Nosebleeds D. Menorrhagia

B. Extremity pain Pain in the extremities is typically a presenting symptom of sickle cell crisis (Platt, A and Echman, J. Relieving the symptoms of sickle cell disease. The clinical advisor, 2/2006, pg 54,59-62,67).

An FNP reviews both the patient log of a patient with type 2 diabetes and current lab results. Which findings indicate that the target value of the particular test is being met? A. Fasting glucose 125 mg/dL B. HS glucose levels between 100 and 140 mg/dL C. Glycosylated glucose 8% on a random sample D. Glucose levels between 140 and 180 mg/dL 2 hours after heavy meal

B. HS glucose levels between 100 and 140 mg/dL The HS blood glucose matches a target level. The target levels for type 2 diabetes are FBS 80 to 120 mg/ dL (Funnel and Kruger, 2004).

An adolescent presents for a sports physical examination. He has a family history of premature cardiac death. He is non-symptomatic and appears in good health. The FNP should use which technique during the examination to help determine the presence of abnormal heart sounds? A. Have the patient lie on his left side. B. Have the the patient perform the Valsalva maneuver C. Have the patient lean forward. D. Have the patient hold his breath.

B. Have the the patient perform the Valsalva maneuver In hypertrophic cardiomyopathy a murmur may not be detected, but performing the Valsalva maneuver will accentuate the murmur if it is present (Kidd et al, 2003).

In a patient with Bell's palsy, which of the following physical exam findings is consistent with the diagnosis? A. Decreased RAMs B. Inability to puff out cheek C. Decreased ability to smell D. Positive straight leg raise

B. Inability to puff out cheek In Bell's palsy, unilateral paresis or paralysis of the facial nerve occurs. Bell's palsy symptoms include facial weakness accompanied by change in taste sensation, hyperacusis, and decreased lacrimation (Bromley, 2000).

A patient has been diagnosed with tennis elbow. This implies pain at what location? A. Olecranon B. Lateral epicondyle C. Medial epicondyle D. Epicondyle and olecranon

B. Lateral epicondyle Tennis elbow refers to pain in the lateral epicondyle. Golf elbow refers to pain in the medial epicondyle (Robinson, 2000).

78. Which of the following children need a referral because of developmental concerns? A. A boy who is not toilet trained by age 4 B. An 18-month-old child who does not use any consonants C. A 2-year-old child who uses two-word sentences D. A 5-year-old girl who does not have many friends

C. A 2-year-old child who uses two-word sentences A child who uses only two-word sentences by age 2 should be referred for evaluation (Dixon and Stein, 2006).

A woman with known fibrocystic breast changes presents with complaints of tenderness and pain in her breasts. What plan of care is appropriate? A. Use acetaminophen or ibuprofen for pain and ice packs during times of greatest tenderness. B. Limit salt intake and avoid tea, coffee, cola, and chocolate. C. Use moist heat for discomfort and reduce fluid intake. D. Take vitamin E 1500 mg daily; add vitamin B6 (pyridoxine) 1000 mg 5 days before the period.

B. Limit salt intake and avoid tea, coffee, cola, and chocolate. The only treatment option here that is appropriate for breast tenderness related to fibrocystic disease is limiting salt intake and avoiding dietary items high in methylxanthines (coffee, tea, cola, chocolate) (Kidd et al, 2003).

The FNP orders a CBC on a patient who presents with fatigue. Which of the following findings is indicative of macrocytic anemia? A. Spherocytes, fragments B. MCV >100 μm3 per cell (100 fL) C. Burr cells D. MCV <80 μm3 per cell (80 fL)

B. MCV >100 μm3 per cell (100 fL) Macrocytic anemia is diagnosed when the MCV is >100 μm3 per cell (Smith, 2000).

A 22-year-old woman has a 3-year history of recurrent, unilateral, pulsating headaches with vomiting and photophobia. The headaches, which generally last 3 hours, can be aborted by resting in a dark room. Usually she knows she is going to get a headache by the little squiggles she sees in front of her eyes. This presentation is most consistent with: A. Cluster headaches B. Migraine with aura C. Tension headache D. Migraine without aura

B. Migraine with aura Migraine with aura is found in about 20% of those with migraines. The aura is a neurological symptom that develops over 5 to 20 minutes, lasts less than 1 hour, and is accompanied or followed by migraine pain (Ferri, 2006).

A 21-year-old patient comes in with fever, malaise, and fatigue. Which of the following is the most likely diagnosis for this patient? A. Lymphoma B. Mononucleosis C. Chronic fatigue syndrome D. Tuberculosis

B. Mononucleosis Mononucleosis usually presents with fatigue, fever, and malaise. Chronic fatigue syndrome does not have fever or weight loss associated with it. TB presents with night sweats and cough. Lymphoma usually presents with a painless, enlarged lymph node (Bazeman et al, 2002).

Which of the following is the best drug to order for rapidly escalating severe pain? A. Meperidine B. Morphine C. Methadone D. Codeine

B. Morphine Codeine has higher adverse effects, while meperidine is not recommended because of neurotoxicity when it accumulates in the system. Methadone has a long half-life and can cause accumulation over 3 to 5 days (McCaffery et al, 2002).

A 54-year-old white male is being evaluated because he was found to have a low HGB (10.2) and HCT. He tells you that except for some fatigue and a 5- to 6-pound weight loss over the past 3 months he has not felt ill. You repeat the CBC and confirm that the patient has microcytic hypochromic anemia. You suspect iron deficiency. At this point, which of the following would be your best course of action? A. Admit the patient to the hospital for blood transfusion. B. Obtain more history and perform a physical exam including a DRE and test for occult blood. C. Start oral ferrous sulfate and have the patient return to see you in 4 to 6 weeks for a repeat CBC. D. Administer a CAGE questionnaire, since you suspect alcohol gastritis.

B. Obtain more history and perform a physical exam including a DRE and test for occult blood. For male patients, blood loss is the most likely cause of iron deficiency anemia. It is important at this point to obtain more information, including the source of blood loss. A bone marrow aspiration and blood transfusion is not necessary at this time (Smith, 2000).

After intense rectal itching, which of the following symptoms is most typical of pinworms in children? A. Nausea and vomiting B. Perianal excoriation C. Abdominal pain D. Diarrhea

B. Perianal excoriation Perianal excoriation is common, particularly in children. They scratch the perianal area because of all the itching (Niemer, 2000).

Which of the following rashes is found in scarlet fever? A. Rash evolving from pink macules to red papules and finally to petechiae B. Rash is bright red and maculopapular, with a fine sandpaper-like texture C. Petechial lesions distributed on the trunk and extremities D. Annular erythematous rash with scaling on the leading edge

B. Rash is bright red and maculopapular, with a fine sandpaper-like texture The rash of scarlet fever is bright red with a sandpaper texture. The annular rash is found in tinea corporis, petechial lesions are found in meningitis, and macules to red papules to petechiae describes Rocky Mountain Spotted fever (McKinnon and Howard, 2000).

A patient is complaining of having difficulty sleeping. He states that when he lies down he gets a feeling of having an electric current in his legs. This description is consistent with: A. Insomnia B. Restless leg syndrome C. Myoclonic seizure D. Chronic fatigue syndrome

B. Restless leg syndrome Patients who have RLS have a compelling urge to move their limbs, usually the legs, especially when the limbs are at rest (NHLBI, 2000).

A patient presents with hopelessness, irritability, and loss of concentration. Before making a diagnosis of depression it is important for the FNP to rule out which of the following? A. Dementia B. Substance abuse C. Family history of depression D. History of overeating

B. Substance abuse To make the diagnosis of depression, it is important to make sure that the symptoms are not caused by the physiologic effects of a substance or medical condition (Hart, 2005)

Which of the following is most helpful in terms of preventing allergic rhinitis? A. Dust daily with a moist cloth. B. Take an antihistamine before a known exposure to the allergen. C. Avoid the offending agents. D. No smoking in the house.

C. Avoid the offending agents. The most effective way to prevent allergic rhinitis is to avoid the offending allergens. All answers do help decrease allergic rhinitis; however, avoiding the allergen is the most effective (Ruckenstein, 2004).

What subjective fact from a 14-year-old girl is most consistent with a diagnosis of a binge episode in bulimia? A. "I ate two slices of pizza and a side salad for dinner." B. "The candy apples were so good at the fair that I ate two." C. "I ate two bags of marshmallows in less than an hour." D. "This morning I had an egg, grits, bacon, and toast for breakfast."

C. "I ate two bags of marshmallows in less than an hour." A binge episode associated with bulimia would be evidenced by the patient's comments about eating two bags of marshmallows in less than an hour—eating a larger amount of food than most people would in a particular interval and under similar circumstances (Kidd et al, 2003).

A patient tells the FNP that she remembers having Braxton Hicks contractions with her first baby but also states, "These feel very different, and I am only 32 weeks pregnant." Which response by the FNP would be best? A. "It's too early for contractions; come to be checked for preterm labor." B. "Second pregnancies are always a bit different; don't be concerned." C. "Tell me what you mean by 'these feel very different'." D. "Increase your fluid intake and report back later today."

C. "Tell me what you mean by 'these feel very different'." Women do perceive Braxton Hicks contractions earlier in a second pregnancy because of familiarity. The FNP needs additional information on which to make a decision for action; perhaps the woman is experiencing premature labor and needs to be evaluated. Other options are not appropriate in this situation, where preterm labor needs to be assessed (Sinclair et al, 2004).

A patient with possible osteoporosis should be treated based on which of the following DEXA test results? A. -4.0 B. -1.0 C. -2.5 D. -1.5

C. -2.5 The bone mineral density is expressed as a T score, which is derived by comparing the patient's BMD with the mean BMD for a young healthy adult of the same sex whose bone mass is at its peak. The difference between the patient's score and the norm is expressed as standard deviations above or below the mean. Each SD represents a 10% -12% difference in BMD. The American Association of Clinical Endocrinologists recommends medication for patients with a T score of < -2.5 or -2.0 if bone loss continues despite preventive intervention (American College of Endocrinologists, 2006).

At what age would the FNP expect to see a child copy a circle? A. 4 years B. 2 years C. 3 years D. 5years

C. 3 years A child normally can copy a circle at 3 years (Bright Futures, 2001).

Which finding is more suggestive of chronic fatigue syndrome than of fibromyalgia? A. Widespread and incapacitating pain B. Higher scores on Beck Depression Inventory C. Disruption of stage IV sleep that contributes to a sense of constant tiredness D. Discontinuation of work and leisure activities because of progressive immobility

C. Disruption of stage IV sleep that contributes to a sense of constant tiredness Although CFS and fibromyalgia share many common features, the distinct difference in CFS is overwhelming fatigue because of inadequate stage IV sleep. Fibromyalgia more likely presents with pain (Kidd, Robinson, and Kish, 2003).

A 2-year-old child has a sudden onset of stridor. There is no history of a viral illness, fever, or vomiting. The child's mother states that the child was well in the morning. What would be of highest suspicion on your differential diagnosis? A. Neoplastic tumor B. Epiglottitis C. FB aspiration D. Croup

C. FB aspiration This child has no other clinical symptoms that suggest croup or epiglottitis, such as fever. Neoplastic tumor is not associated with a sudden onset of stridor. Two-year-old children often place objects into their mouths; therefore they are at greater risk for accidental aspiration of FBs. In any child with a sudden onset of stridor, FB aspiration always should be considered (Kidd et al, 2003).

Which patient is at least risk for a diagnosis of blepharitis? A. Male with pronounced rosacea B. Female contact lens wearer C. Female who occasionally wears artificial eyelashes D. Female patient with seborrhea

C. Female who occasionally wears artificial eyelashes Factors that increase the likelihood of blepharitis are contact lens use, and a history of rosacea or seborrhea. Wearing artificial eyelashes on occasion does not increase the risk of blepharitis (Johnson, 2000).

Which of the following is not considered a risk factor for the development of cerebral palsy? A. Hyperbilirubinemia B. Anoxia C. Folic acid deficiency D. Placental insufficiency

C. Folic acid deficiency Anoxia, placental insufficiency, and hyperbilirubinemia are all risk factors for cerebral palsy. Folic acid deficiency is a risk factor for neural tube defects (Kiman, Smith, and Shilt, 2004).

An 11-year-old child's last tetanus vaccination was given at age 5 upon entry to kindergarten. When should the child receive a tetanus booster? A. If he gets cut, he should have a tetanus booster. B. It should be given at the 15-year well-child appointment. C. He should have a tetanus booster at this visit. D. He is up to date for tetanus.

C. He should have a tetanus booster at this visit. The age range for administration of a Td booster has been lowered from 14 to 16 years to 11 to 12 years to ensure long-lasting immunity against tetanus. Immunity to tetanus varies with age; 28% of children vaccinated 6 to 10 years before serologic testing lacked immunity as compared with 14% of those vaccinated 1 to 5 years before testing. The Td booster administered at age 11 to 12 years is the only exception to the administration of routine boosters every 10 years (Bright Futures, 2001).

John Carlisle, a 65-year-old patient of the clinic, tells the FNP that he just had a nice retirement party. He has sold hardware for 40 years in the same family-owned store, which will now be closed. The NP asks what his future plans are. Which response would justify clarification, given the expected developmental task for this age group? A. His promise to help a young neighbor develop a business plan for a small plant nursery B. His plan to teach his grandsons how to fish and build a bird house C. His plan to "lay up in a hammock under the trees all day—no more work—not even the simplest exercise" D. His determination to lose 10 pounds prior to a scheduled cruise

C. His plan to "lay up in a hammock under the trees all day—no more work—not even the simplest exercise" The loss of weight prior to a cruise could be a positive accomplishment. Plans to teach his grandchildren and to help the neighbor develop a business plan both address leaving a legacy—the developmental task of generativity; these choices provide clear evidence that this older man is using his wealth of experience and recent spare time to provide important help to younger persons to improve their own lives in some fashion. The comment related to no work—not even simple exercise deserves clarification. Not only would this change in lifestyle not be healthy, it clearly does not reflect generativity (Kidd et al, 2003).

Which of the following medications is useful in reducing proteinuria and slowing the progression of chronic renal disease? A. HCTZ B. Doxazosin (Cardura) C. Lisinopril (Zestril) D. Atenolol (Tenormin)

C. Lisinopril (Zestril) ACE inhibitors, ARBs, and nondihydropyridine calcium channel blockers are used to prevent the progression of chronic renal disease. HCTZ is not generally effective in CRF, while beta blockers and alpha blockers are not used with chronic renal failure (Ferri, 2006).

Which finding on a Tzanck smear confirms herpes? A. Intracellular nonmotile parasites B. Presence of WBCs C. Multinucleated giant cells D. Coated epithelial cells

C. Multinucleated giant cells The Tzanck smear shows multinucleated giant cells of herpes (Robinson, Kidd, and Rogers, 2000).

What is the primary difference between tender points and trigger points as objective findings in a physical examination? A. Eliciting trigger points requires use of the reflex hammer; evaluating tender points does not. B. The amount of pressure required to elicit them is different. C. Palpation of trigger points causes radiation of pain; palpation of tender points does not. D. Tender points cause radiating pain, whereas trigger points do not.

C. Palpation of trigger points causes radiation of pain; palpation of tender points does not. On physical examination, palpation of trigger points causes radiation of pain; palpation of tender points does not. The other options are false (Dunphry and Winland-Brown, 2001).

A high school girl is brought by her father to the clinic. She reports having a rash that started with a round patch on her left chest that has spread over her chest, arms, legs, and back and is itchy. The exam shows a generalized distribution of red, scaly, macular lesions that run parallel to each other. What action should the FNP take? A. Refer the patient to a dermatologist for biopsy. B. Take a photograph of the lesions and follow up in 4 weeks. C. Recommend oatmeal baths and calamine lotion for symptom relief. D. Prescribe Aristocort cream BID for 2 weeks.

C. Recommend oatmeal baths and calamine lotion for symptom relief. The description in this scenario is consistent with a diagnosis of pityriasis rosea, and the appropriate treatment is symptomatic—oatmeal baths and calamine lotion will provide relief. The condition is self limited (Fitzpatrick, 2001).

An elderly resident of a nursing home is referred to the clinic with a 2 cm ulcer on her left heel that is draining. The exam shows a cool, hairless left leg and a draining ulcer with a "punched out" appearance on the left heel. A popliteal pulse is not palpable. Which action by the FNP is best? A. Consult with the physician about the appropriate systemic vasodilator for the patient. B. Recommend elevation of the left leg and a bed cradle and sterile dressing with padding to protect the ulcerated heel. C. Refer immediately to a vascular specialist for evaluation and management. D. Order wet-to-dry dressings every 2 hours with Betadine.

C. Refer immediately to a vascular specialist for evaluation and management. Findings suggest a dermatologic condition associated with underlying peripheral vascular disease. Immediate referral is necessary because the patient is at risk of losing a limb (Kutty et al, 2003).

A patient who has had a myocardial infarction and has an ejection fraction of 35% but is able to work full time and continues to attend exercise classes three times a week has which level of NYHA classification? A. Stage II heart failure B. Stage IV heart failure C. Stage I heart failure D. Stage III heart failure

C. Stage I heart failure A patient who has no symptoms of heart failure and is able to do normal activities without symptoms is in Stage I (NYHA, 2002).

A 10-year-old girl, brought in by her grandmother whom she is visiting, has symptoms of a urinary tract infection. Which historical factor supports a diagnosis of cystitis? A. Sleeping in cotton panties B. Swimming in a chlorinated indoor swimming pool C. Taking frequent bubble baths D. Spending hours building sandcastles at the beach

C. Taking frequent bubble baths Bubble baths change the surface tension of bath water and organisms ascend more easily up the short urethra of females, predisposing to cystitis (Kidd et al, 2003).

The FNP, after consultation with the collaborating physician, is going to start a patient with seizures on medication. Which of the following information is not true regarding women of childbearing age starting on anti-epileptic drugs? A. Women who are pregnant have a higher incidence of seizures. B. The dose of oral contraceptive pills needs to be increased. C. The patient should be started on phenobarbital as first choice. D. Anti-epileptic drugs cause a higher incidence of teratogenesis.

C. The patient should be started on phenobarbital as first choice. All information regarding pregnancy and AEDs is true except the statement regarding the patient should be started on phenobarbital as first choice. Phenobarbital is not a first-line drug for seizure disorders in adults (Ferri, 2006).

A college freshman who learned the testicular examination procedure in a health class 2 days ago comes to the College Clinic "upset about my privates." Further questioning elicits the following description: the testicle "feels like the candy called gummy worms." The exam confirms that there is a palpable area in the left scrotum that is not pain. This most likely represents a diagnosis of: A. Testicular cancer B. Epididymitis C. Varicocele D. Hydrocele

C. Varicocele Varicocele is associated with varicosities, and the objective finding is similar to a "bag of worms," so the student who referred to "gummy worms" is describing accurately the sensation of palpation that would support a diagnosis of varicocele (Mullen, 2004).

Which of the following therapeutic interventions best addresses the underlying pathophysiological mechanisms of GERD? A. Antacids B. Elevation of the head of the bed C. Weight loss D. Proton pump inhibitor

C. Weight loss Proton pump inhibitors suppress acid release so that the reflux does not irritate or damage the esophageal mucosa. Antacids give rapid relief for GERD symptoms but are not curative. H2 blockers reduce the acid release but are not as effective as PPIs (Blair and Beltz, 2006).

Which factor in a patient's history places him at high risk for skin cancer? A. Job-related exposure to coal tar B. Repairman for x-ray equipment C. Work on a crew that paves highways D. Janitorial service

C. Work on a crew that paves highways The factor that places a patient at greatest risk for skin cancer is exposure to ultraviolet light; because of sun exposure, the man who works on a highway crew would be at greatest risk (Fitzpatrick et al, 2001).

At what age would the FNP generally recommend that the parents start using a time-out system for discipline? A. 18 months B. 30 months C. 12 months D. 24 months

D. 24 months Time-out forms of discipline are best started when the child is 2 years old (Bright Futures, 2001).

Which of the following patients should be referred to an ophthalmologist for treatment? A. A man with a mild corneal abrasion B. A 10-week-old with new onset conjunctivitis C. A contact wearer with allergic conjunctivitis D. A teen with conjunctivitis with a suspected cause of gonorrhea or Chlamydia

D. A teen with conjunctivitis with a suspected cause of gonorrhea or Chlamydia All cases where the cause of conjunctivitis is gonorrhea or Chlamydia should be referred to an ophthalmologist (Kidd et al, 2003).

In assessing a patient suspected of having dementia, the FNP should assess whether the patient has difficulty in which of the following? A. Reading the newspaper B. Getting dressed C. Walking down stairs D. Balancing the checkbook

D. Balancing the checkbook Difficulty getting dressed or walking may be associated with arthritis or a mobility problem. Reading the newspaper may be related to a visual problem. Inability to balance the checkbook is a sign of a problem with reasoning ability and complex cognitive tasks (indications of dementia) (Adelman et al, 2005).

100. A child has been diagnosed with Shigella and treated with ampicillin. The mother wants to know if there is anything that can be done to control the diarrhea. Which of the following actions is appropriate? A. Decrease food and fluid intake until the diarrhea is gone. B. Suggest loperamide (Imodium) to help with symptoms. C. Write a prescription for diphenoxylate with atropine (Lomotil). D. Encourage increased fluids.

D. Encourage increased fluids. Loperamide and diphenoxylate with atropine are not recommended for use in Shigella. It is important to maintain food and fluid intake in a child with Shigella. Adequate fluid intake would be important to maintain hydration (CDC, 2006).

Which of the following findings in a 70-year-old man would increase the suspicion of prostate cancer? A. Asymmetric enlargement of the gland B. Bogginess of gland noted; tender on exam C. Smooth gland with one lobe enlarged and rubbery D. Firm, distinct lesion palpable

D. Firm, distinct lesion palpable A firm, distinct palpable lesion is descriptive of prostatic malignancy and should be referred immediately (Wallace, 2004).

Which of the following is the second most prevalent bacterial pathogen in upper respiratory infections such as sinusitis? A. Mycoplasma pneumonia B. Streptococcal pneumonia C. M. catarrhalis D. H. influenza

D. H. influenza Streptococcus is the leading cause of URIs, followed by H. influenza and then M. catarrhalis (Poole and Portugal, 2005).

When the FNP is discussing safety issues with the parents of a toddler, which of the following topics does not need to be addressed? A. Safety seat use B. Choking hazards C. Water heater temperature D. Helmet use

D. Helmet use Helmets would be discussed with parents of older children. The other topics are very appropriate to the safety of the toddler (Bright Futures, 2006).

Which of the following elements in the history would make an elderly patient most susceptible to falling in the near future? A. Taking two medications at a time B. Routine activities C. Walking 2 miles 3 times a week D. Initiation of a new medication within past 2 weeks

D. Initiation of a new medication within past 2 weeks Falls occur more frequently in the elderly who have four or more medications, the initiation of new medications within 2 weeks, and certain medications that make the elderly more fall prone (Fuller, 2000).

Which of the following objective findings is pathognomonic for infectious mononucleosis? A. Throat erythematous, no exudate B. Facial edema C. Maculopapular rash D. Lymphadenopathy

D. Lymphadenopathy The localized inflammatory response produces the lymphadenopathy that is almost always present in infectious mononucleosis. If lymphadenopathy is not present, the diagnosis of mononucleosis should be questioned. Although usually present in infectious mononucleosis, the rash, facial edema, and sore throat could also occur with other illnesses (Robinson, 2000).

Which of the following actions best demonstrates that a 31-year-old woman has achieved the appropriate developmental task for her age group? A. Changing careers three times since graduating high school B. Living at home with her parents and working part time C. Living alone and spending lots of time shopping online D. Married with two sons and an active social life

D. Married with two sons and an active social life The appropriate developmental task for this age is Intimacy versus Isolation. This refers not only to physical intimacy but also to friendships, work colleagues, and parenting relationships. Marriage, family, and social activity is most reflective of the Intimacy task being met (Kidd et al, 2003).

he FNP suspects that a 6-year-old child has been abused. Which finding would increase the index of suspicion for that diagnosis? A. 2 cm scar in right lower quadrant of abdomen B. Mother's threat to punish her for punching her young brother in the exam room C. Patient is quieter than usual during this clinic visit with her mother present D. Multiple bruises on arms and face ranging from purple to yellow

D. Multiple bruises on arms and face ranging from purple to yellow Bruising in different stages of healing may indicate multiple episodes of trauma over time—a key indicator of child abuse. Bruises on the knees and lower legs are common in childhood from play injuries; bruises on arms and face would be less likely to be associated with typical injury during playtime (Garfunkel et al, 2002).

Which factor in the patient's history should cause the FNP to suspect deep vein thrombosis? A. Low fluid intake B. Regular exercise C. Occupation cashier D. Oral contraceptive pill use

D. Oral contraceptive pill use DVT should be suspected in the following circumstances: pregnancy, smoking, oral contraceptive use, older age, or clotting disorders (Fitzmaurice, Hobbs, and McManus, 2002; www.aafp.org/afp/20020801/ british.html).

When a patient complains of ear pain, the diagnoses of otitis media and otitis externa must be considered in the differential. In comparison with otitis media, otitis externa presents with: A. Fever B. Erythematous, bulging tympanic membrane C. Yellow-green nasal discharge D. Pain with movement of the tragus

D. Pain with movement of the tragus In otitis externa, movement of the pinna or tragus is usually very painful for the patient. The external ear canal is generally filled with moist-looking debris; the canal can be swollen and filled with purulent exudate, and the tympanic membrane may not be visualized (Kidd, Robinson, and Kish, 2003).

Which clinical finding is least diagnostic of ovulation for a couple attempting to use natural family planning? A. Positive ovulation on an ovulation predictor kit B. Stretchy cervical mucus C. Basal body temperature elevation D. Pasty, thick cervical mucus

D. Pasty, thick cervical mucus At ovulation, the cervical mucus becomes more liquid and more stretchable (spinbarkeit). The BBT increases slightly, which is attributable to progesterone, and ovulation is noted by an ovulation predictor kit; these indicators are all fairly reliable evidence of ovulation for women who are familiar with those body changes. A pasty, thick cervical mucus is not associated with ovulation (Hatcher et al, 2004).

A 17-year-old ballet student presents with concerns about not having a menstrual period in the past 3 months. She has been training especially rigorously for a special audition and has lost 13 pounds in the process. She is now 5'7" tall and weighs 105 pounds. The initial action by the FNP should be: A. Serum FSH B. BMI and fat percentage C. Thyroid function tests D. Pregnancy test

D. Pregnancy test Any woman of reproductive age who presents with amenorrhea should be considered pregnant until that is ruled out by diagnostic testing (Lowdermilk and Perry, 2006).

Which of the following symptoms of sinusitis is least likely to lead to a diagnosis? A. Facial pressure increased with leaning forward B. Unilateral sinus tenderness C. Past history of sinusitis D. Purulent rhinorrhea

D. Purulent rhinorrhea Purulent rhinorrhea alone is not sufficient to diagnose bacterial sinusitis; it is seen in viral illnesses such as colds. Unilateral sinus tenderness is the most indicative symptom of acute sinusitis. A past history of recurrent sinusitis is not a predictor for a bacterial infection (Alper and Hickner, 2005).

Which of the screening techniques is most sensitive for risky in pregnant women? A. Direct questions about amount of alcohol consumed B. CAGE screening C. Items about alcohol use on a questionnaire D. Questions about tolerance in history

D. Questions about tolerance in history Light drinking in pregnant women is hazardous and may not be uncovered by direct questioning or screening questionnaires. Questions about tolerance are more revealing. Two drinks per day or binge drinking is most risky during pregnancy. Women who drink three or more drinks to feel high or who can drink five drinks at a time demonstrate tolerance (Kidd et al, 2003).

Young adults may develop which kind of rash when they are infected with erythema infectiosum? A. Skin around the neck is thickened and dark brown-black B. Erythematous rash in a butterfly distribution on the face C. 2 mm to 5 mm red macules on the trunk and proximal extremities D. Reddened exanthema on hands and feet with at wrist and ankle joints

D. Reddened exanthema on hands and feet with at wrist and ankle joints Young adults may have papular-pruritic "gloves and socks" syndrome (Cunningham, 2005).

Along with pharyngitis, which of the following would make the FNP least suspicious for group A beta-hemolytic strep? A. Tonsillar lymphadenopathy B. Fever C. Red, rough rash on trunk D. Rhinorrhea

D. Rhinorrhea GABHS presents with pharyngitis, red rash of scarlet fever, fever, and nausea/vomiting. Generally there is no cough or nasal symptoms (Kidd, Robinson, and Kish, 2003).

The 7-year-old patient has a fever, along with URI symptoms. While assessing your patient's throat and mouth, you observe blue-gray spots in the center of red eruptions. The most likely diagnosis for this patient is: A. Roseola B. Rubella C. Erythema infectiosum D. Rubeola

D. Rubeola The lesions described are Koplik spots, which are pathognomonic for measles or rubeola (McKinnon and Howard, 2000).

A 7-year-old boy is brought in by his mother; there are molluscum contagiosum lesions in his genital area. This finding raises the index of suspicion about: A. Deer tick bite B. Improper cleaning after using the toilet C. Excessive masturbation D. Sexual abuse

D. Sexual abuse Molluscum contagiosum is considered a sexually transmitted infection, so finding this lesion in the genital region of a child raises a high index of suspicion. None of the other options is accurate about molluscum contagiosum (Fitzpatrick et al, 2001).

Which factor in the patient's history should cause the FNP to suspect hyperlipidemia? A. Smoking B. Obesity C. Erythematous annular patch on trunk D. Soft, yellowish plaques in the medial cantal area

D. Soft, yellowish plaques in the medial cantal area Soft, yellowish plaques in the medial canthal area are known as xanthelasma; they are findings consistent with hyperlipidemia (Ferri, 2006).

Which of the following statements is true regarding the plan of care for ADHD? A. Methylphenidate slows the release of NE. B. Treatment of ADHD increases the risk of substance abuse. C. The treatment of ADHD in adults is different from that in children. D. Stimulants increase the amount of dopamine available.

D. Stimulants increase the amount of dopamine available. Lack of dopamine has been identified as being part of the pathophysiological process of ADHD. The treatment of adults and children with ADHD is the same. Treatment of ADHD with stimulants actually reduces the risk of substance abuse by approximately 50% (Vitale, 2003).

Which of the following findings is the least suggestive that a terrorist attack has occurred? A. A credible threat has been received from a terrorist organization. B. Multiple patients with similar unexpected symptoms are presenting to different clinics. C. Numbers of dead animals and birds are being discovered in the region. D. Store owner becomes ill after throwing out a bag of white powder he found on a shelf in the store.

D. Store owner becomes ill after throwing out a bag of white powder he found on a shelf in the store. Multiple patients with similar unexpected symptoms are presenting to different clinics, numbers of dead animals and birds in the region, or receipt of a credible threat all point to terrorism. White powder from an unknown source versus a person familiar would increase the level of suspicion (Fortmeier-Saucier, 2004).

The FNP sees a 62-year-old man whose TSH level is low. Clinical findings include recent onset of palpitations, heat intolerance, and weight loss. Exam reveals heart rate of 116, mild diaphoresis, slight diffusely enlarged thyroid, and fine tremors of outstretched hands. Which additional lab test is appropriate? A. Thyroid antibodies B. T3 C. Testosterone D. T4

D. T4 The clinical scenario points to hyperthyroidism, which can be diagnosed with evidence of ↑ T4 with the ↓ TSH level. Other diagnostic tests are not appropriate for diagnosis (Orlowski, 2002).

An FNP is co-managing a teenaged girl with anorexia nervosa. Which treatment approach should be anticipated? A. Hospitalization with parenteral nutrition B. Cognitive behavioral therapy with parents and patient as joint participants C. Antidepressant therapy plus individual counseling by a psychologist D. Team approach with patient, family, and professionals from several disciplines

D. Team approach with patient, family, and professionals from several disciplines Anorexia nervosa is an extremely complex disorder best treated by a multidisciplinary team approach that includes physician, FNP, nutritionist, and mental health professionals working collaboratively with the patient and family (Fairburn and Brownell, 2002).

Expected objective findings in acute otitis media include: A. Submental lymphadenopathy B. Prominent bony landmarks on tympanic membrane C. Itchiness and cracking in the affected ear D. Tympanic membrane immobility

D. Tympanic membrane immobility An immobile TM is the hallmark of AOM. Itching and crackling in the ear is common in patients with serous otitis. The bony landmarks usually appear prominent when the TM is retracted, a condition usually seen with eustachian tube dysfunction. Usually the nodes in the anterior cervical chain are enlarged and painful (Ruckenstein, 2004).

A review of a patient chart indicates that she has been on a very low calorie diet in an attempt to lose weight. For which serious complication should the woman be evaluated? A. Elevated prothrombin time B. Gallstones C. Gastric cancer D. Ventricular arrhythmias

D. Ventricular arrhythmias Most deaths related to very low calorie diets are associated with ventricular arrhythmias or dysrhythmias (Kidd et al, 2003).

A female patient is diagnosed with blepharitis. What management, in addition to soaking the eyelids with a warm wet towel for 2 to 3 minutes, is appropriate? A. Prescription for ophthalmic steroid drops B. Administration of Benadryl C. Prescription for an oral cephalosporin D. Washing lids and lashes with dilute baby shampoo

D. Washing lids and lashes with dilute baby shampoo Crusting of the lids and lashes, much like dandruff, occurs in blepharitis. Treatment includes removal of the scales with dilute baby shampoo and warm water (Vander and Gault, 2002).