Questions 6

A 42-year-old male patient presents to your clinic with acute flank pain that started suddenly in the middle of the night accompanied with nausea and vomiting. The pain radiates into his abdomen. The urinalysis shows 2+ hematuria and a pH of 5.0. The findings are likely associated with: 1. Struvite Stone 2. Acute Pyelonephritis 3. Uric Acid stone 4. Acute Cystitis

3 The normal pH of a urinalysis is 5.8-6.2. Nephrolithiasis presents with acute flank pain that will sometimes radiate into the abdomen or groin with nausea and vomiting. A pH of <5.5 is often indicative of a uric acid stone. Acute Pyelonephritis and acute cystitis will show leukocytes and bacteria as well as hematuria on the urinalysis.

The FNP knows that all of the following are normal findings in the newborn except: A. The infant has flaccid upper extremities while lying undisturbed B. The infant grasps the FNP's fingers when they are placed in his hand C. The infant startles when his head is lowered suddenly D. The infant sucks on his pacifier when it is placed in his mouth

A A newborn should exhibit a sucking reflex, palmar grasp, and Moro reflex when stimulated. A newborn's resting tone should have flexion of the upper and lower extremities

Which patient would have the greatest risk for Intimate Partner Violence? a. 31-year-old female who is getting divorced from her husband and has visited the ER 7 times in the past month. b. 39-year-old female who is married and pregnant. c. 45-year-old female who is homeless and has a history of drug abuse. d. 67-year-old female who is widowed and dating younger men.

A According to McNamara and Walsh (2020), "Risk factors for abuse include being young (under age 35 years); being pregnant; being single, divorced, or separated; alcohol or drug abuse in the victim or the partner; smoking; and being poor." In this question, the patient going through a divorce with frequent ER visits has the greatest risk for intimate partner violence (IPV).

A 17-year-old female patient presents to the clinic with a complaint of painful vaginal ulcerations for 3 days. She became sexually active last year and has since had several partners. A PCR test of her ulcerations reveals HSV-2. This is her first outbreak. To reduce symptoms, you give? a. Acyclovir 400mg po TID x 7-10 days b. Valacyclovir 500mg po daily X 30 days c. Rocephin 250mg IM injection d. Metronidazole 500mg po BID X 7 days

A Acyclovir 400mg po TID X 7-10 days can be used within the first 5 days of a patient's primary infection to decrease the duration and severity of symptoms the HSV infection. Other options include, Acyclovir 200mg po 5 times a day for 7-10 days; Famciclovir 250mg TID for 7-10 days; Valacyclovir 1g po BID for 7-10 days

Adam, a 56-year-old, black male, presents to your office today for a hypertension follow up. He reports he is taking his medication as prescribed, but he has yet to quit smoking. Adam is on dual hypertensive therapy with 10mg amlodipine and 50mg hydrochlorothiazide once daily. His VS in the office are BP 164/98; HR 82; ASCVD Risk 29.6%. What is the most appropriate next step for Adam? A. Add Losartan 25mg daily and encourage smoking cessation B. Start Adam on 21g Nicotine transdermal and have him maintain home blood pressure monitoring for 2 weeks and then follow up in the clinic. C. Add Lisinopril 10mg daily D. Start Adam on 150mg Wellbutrin daily

A In patients with uncontrolled hypertension, already on dual therapy, it is appropriate to initiate a third antihypertensive medication for better controL

You are the on-call FNP in a pediatric practice and receive a call from the parent of infant, Thomas, who was born yesterday at a local birthing center. Mom had spontaneous rupture of membranes, and labored for a total of 17 hours before delivering via uncomplicated vaginal delivery. APGAR score immediately after birth was 6. He immediately latched onto mother's breast, and mom and baby were discharged from the center 6 hours after birth. Mom is concerned that Thomas is very sleepy. Which of the following findings are least consistent with bacterial sepsis in a newborn < 3 days of age? A. Wide-spread vesicular rash B. Decreased APGAR scores without notable fetal distress C. Poor feeding and lethargy D. Hypotonia and temperature instability

A Infants < 3 days old who have bacterial sepsis present with clinical findings of hypotonia, temperature instability, respiratory distress (secondary to pneumonia), lethargy, and poor feeding. Oftentimes, bacterial sepsis at this age is associated with bacterial meningitis, with group B beta-hemolytic streptococci and E. Coli being the most frequent culprits. Diagnosis of bacterial sepsis can be made after obtaining cultures from blood, urine, CSF, and endotracheal secretions (if available).

A 45-year-old male patient presents with right shoulder pain. Upon exam, pain is worse with reaching the right arm up or back. His pain is also worse at night. What does the advance practice nurse suspect as a first differential diagnosis? a. Rotator cuff injury b. Shoulder dislocation. c. Adhesive capsulitis D. Carpal Tunnel syndrome

A Over 40-year-old patients are more at risk for rotator cuff injury. Pain is also worse at night or with overhead abduction activities or posterior reach upon physical exam.

Maria finished primary therapy for breast cancer last week. When educating her about follow up care how often should she be told to schedule follow up visits? A. Every 6 mo for the first 2 yrs, then annually thereafter. B. Every 6 mo for 1 yr, then every other year. C. Annually for life D. Annually for 5 years

A Patients should be monitored long term to detect recurrences while observing the opposite breast for secondary primary carcinoma. During the first 2-5 years local and distant recurrences are most likely to occur. Most patients should be examined every 6 mo for the first 2 years, then annually thereafter

A 50 year old female presents to the clinic with heart palpitations and dizziness. The patient has a heart rate is 48 and the EKG reveals "sawtooth" pattern of atrial activity. What heart rhythm does this patient have? A) Atrial flutter B) Ventricular tachycardia C) Atrial fibrillation D) Premature ventricular beats

A Patients with atrial flutter commonly present with heart palpitations, fatigue, or dizziness. "Sawtooth" pattern is typically seen on an EKG of patients in atrial flutter due to the atrial activity. Atrial rates can be 250-350 beats/min, but the patient may present with bradycardia because only transmission of every second, third, or fourth impulse goes through the AV node to the ventricles. Ventricular tachycardia can also have symptoms of palpitations, dizziness, and also dyspnea. On rare occasion this rhythm may be asymptomatic. The patient may or may not have a pulse with this rhythm and the EKG would reveal a fast, wide QRS complex. Symptoms of atrial fibrillation may include palpitations, exertional shortness of breath, and fatigue. This rhythm is also very irregular with a rapid ventricular rate. Premature ventricular contractions are characterized by wide QRS complexes that are different from the patient's normal beats, and they are usually not preceded by a P wave. The patient typically is asymptomatic, but may feel occasional heart palpitations.

Pubertal gynecomastia in adolescent males is typically a result of which hormone imbalance? A) Estrogen and androgens B) Estrogen and testosterone C) Androgen and testosterone D) Testosterone and leptin

A Pubertal gynecomastia attributed to a transient imbalance of estrogens used to stimulate proliferation of the breast tissue and androgens used to antagonize this effect. Leptin levels seen higher in healthy, nonobese male teenagers with gynecomastia when compared with control groups

A three-year-old child with no known health problems presents to the clinic for her well-child visit. Mom is questioning what exams will be performed today. The practitioner's response would include all of the following except which exam? A. Head circumference B. Blood Pressure C. Visual Acuity D. Ht/Wt

A Routine head circumference measures may cease if circumferential growth has been steady for the first 2 years of life. Blood pressure screening at well-child visits starts at age 3 years. Starting after age 3, formal testing of visual acuity should be done if possible. Height and weight should be plotted for children who can stand upright from ages 2-20.

A 61-year-old male presents to the clinic to follow up from having an ER visit. He was diagnosed with atrial fibrillation during the visit. Which medication was he most likely discharged home on for rate control? a. Diltiazem b. Amlodipine c. Losartan d. HCTZ

A The first line agent for rate control in atrial fibrillation is usually a beta-blocker or calcium channel blocker

Each antihypertensive agent is paired correctly with its class EXCEPT: A. Verapamil--Angiotensin-Converting Enzyme (ACE) Inhibitor B. Valsartan--Angiotensin II Receptor Blocker C. Metoprolol--Beta-Adrenergic Blocker D. Amlodipine--Calcium Channel Blocker

A Verapamil is a Calcium Channel Blocker (CCB). Other drugs match their classes correctly.

A 44 year-old Male comes into your office with complaints of suprapubic pain, dysuria, and a fever. His urinalysis shows leukocytes, bacteriuria, and hematuria. You order a complete blood count and it shows leukocytosis and a left shift. What medical condition should be ruled out on this patient? A. Epididymitis B. Acute Bacterial Prostatitis C. Pancreatitis D. Acute Pyelonephritis

B In acute prostatitis a complete blood count will show leukocytosis and left shift. The UA will show bacteria, leukocytes, and hematuria. The patient will havie varying degrees of pain, fever, and dysuria.

A mother brings her newborn to the office for a well child checkup. She states she started noticing the newborn sweating while breastfeeding and will sometimes fall asleep while trying to eat. What other symptoms would be a concern for potential heart failure in a newborn? A. Weight gain B. Irritability C. Vomiting D. Fever

B

Norma is a 46 year old female, presenting to her PCP for management of her chronic hypertension. In triage, she jokes that she was so nervous for her appointment that she stopped at a coffee shop for a cup of coffee. What would be your next action? A. Advise Norma that patients with hypertension should not ingest coffee B. Advise patient to sit quietly for 30 minutes before taking vital signs C. Reschedule Norma's appointment because her vital signs will not be accurate today D. Place patient in Trendelenburg's position before taking vital signs

B Per McAfee and Papadakis (2020) Readings should be taken after the patient has been resting comfortably, back supported in the sitting or supine position, for at least 5 minutes and at least 30 minutes after smoking or coffee ingestion.

When performing health supervision visits, at what ages should the nurse practitioner include a formal autism specific screening? a. At every visit b. 18 and 24 months c. 12 and 24 months d. 24 and 36 months

B A formal autism screening should be part of universal screenings of the 18-month and 24-monthold child. With early recognition of autism, patients can receive early intervention. It is important for the provider to follow these patients closely to insure they have the proper referrals, evaluations, and focused therapies they need.

Breast cancer screening recommendations for a 45-year-old transgender man who has not undergone a mastectomy should include which of the following? a. Screening for breast cancer is not recommended in transgender men who have not undergone a mastectomy. b. Yearly mammograms are recommended to screen for breast cancer. c. Mammograms should be scheduled every 5 years after the age of 45 to screen for breast cancer in transgender men who have not undergone a mastectomy. d. Screening for breast cancer in transgender men who have not undergone a mastectomy is recommended only if he uses masculinizing hormone therapy.

B According to Papadakis and McPhee, breast cancer screening for transgender men who have not undergone a mastectomy should be performed based on the guidelines for cisgender women. It is unknown if breast cancer screening for transgender men who have had a mastectomy is necessary and there are limitations in place for screening the small amounts of residual breast tissue.

Eve presents to the office for her annual women's exam. She reports that she and her husband are actively trying to get pregnant. She requests a pregnancy test. A review of medications shows Eve takes 10mg of lisinopril daily. The pregnancy test is positive. As her NP, what should you do next? A. Congratulate Eve on her pregnancy and refer her to an OB-GYN B. Discontinue Lisinopril and start 30mg Nifedipine C. Develop a plan for follow up with scheduled prenatal visits D. Start Eve on 250mg Methyldopa

B Angiotensin-converting enzyme inhibitors are contraindicated in pregnancy

A 21 y/o female presents to GYN clinic with c/o pruritus, vaginal irritation and discharge. She reports that she desires STD testing after finding out her current partner has been involved with 2 additional partners during their relationship. Upon exam the NP observes vaginal erythema and copious yellow-green malodorous discharge. The cervix has multiple red speckled lesions upon inspection. What would be your highest differential as the NP provider for this patient? a. Bacterial Vaginosis b. Trichomonas Vaginalis c. Chlamydia d. PID

B Bacterial Vaginosis is associated with thin, white or gray, malodorous discharge; fishy odor and is not sexually transmitted so this diagnosis would not be correct. Chlamydia often has an asymptomatic presentation. In the symptomatic patient discharge is odorless, cloudy, white, or mucoid. The cervix may be friable, and the patient may report postcoital or intermenstrual bleeding so Chlamydia would not be correct in this patient. Patients with PID often present with fever, chills, lower abdominal pain, and cervical motion tenderness. The patient does not have this presentation so PID would not be correct. A common risk factor for Trichomonas Vaginalis is having multiple partners. The presentation of Trichomonas Vaginalis is associated with complaints of pruritis, malodorous yellow or green copious discharge. Vaginal erythema with red cervical lesions may be present which is called "strawberry cervix." The red lesions are caused by protozoal flagellate indicative of Trichomonas Vaginalis. The patient has all the signs and symptoms of the presentation for Trichomonas Vaginalis so this diagnosis would be high on the differential.

A well-appearing 22mo boy is seen in clinic today with his mother who states, "Sometimes I think he can't hear me." No abnormalities are noted on otoscopic exam. The FNP knows the most appropriate next step is: A) Proceed with in-office audiometry screening B) Refer to audiology C) Reassess at 24mo well check D) Assure mother inattention to sound is a normal finding for this age group

B Conventional audiometry screening requires the cooperation of the child and is not initiated until age 4. All hearing concerns under age 4y require audiology referral. Not appropriate to delay intervention for potential hearing loss. This is not a normal finding and parental concerns should be considered and investigated.

John, a 55-year-old Caucasian male, presents to your clinic to follow-up on his recent labs. He has a history of psoriasis, diabetes mellitus type 2, hyperlipidemia, obesity and hypertension. His most recent fasting triglyceride level was 360. He has made lifestyle modifications for the past 4 months and continues to take his high intensity statin. Which of the following is indicated for John? a. Have him increase his cruciferous vegetable intake and follow-up in one month b. Start Icosapent Ethyl and follow-up in three months with repeat labs c. Add Ezetimibe to his medication regimen d. Refer him to cardiology

B Elevated fasting triglycerides can lead to further complications such as pancreatitis. It is imperative to treat hypertriglyceridemia to mitigate additional complications. Triglyceride lowering agents are indicated in a patient who has established CVD with controlled LDL on a statin. Icosapent ethyl is the current recommended agent for the treatment of elevated triglycerides.

A 55 year old female comes into your clinic for a wellness visit. She states has been having occasional chest heaviness and shortness of breath after going for her morning walk. On exam, you auscultate and find the patient has a S3 heart sound during early diastole. What is this finding typically associated with in the older adult population? A. Aortic Stenosis B. Congestive Heart Failure C. Left Ventricular Hypertrophy D. Mitral Regurgitation

B Exertional dyspnea is the most common complaint of CHF and an S3 heart sound heard during the physical exam is most likely related to Congestive Heart Failure. Aortic stenosis is consistent with a finding of a midsystolic ejection murmur, not S3. LVH is usually associated with an S4 heart sound heard on late diastole, not S3. Mitral regurgitation is associated with a loud blowing and high-pitched holosystolic murmur, not an S3 heart sound.

If a 19 yo female presents to the clinic with yellowish-green discharge, dysuria, and a positive NAAT. What would you plan to administer? a. Acyclovir b. Ceftriaxone plus Azithromycin c. Metronidazole d. Doxycycline plus ceftriaxone

B Gonorrhea presents in mucous membranes with exudate and secretions. Women normally present with burning when voiding and yellowish-green urethral discharge. The treatment for uncomplicated gonorrhea is single doses of ceftriaxone IM and Azithromycin 1 gm orally. The combination treatment was recommended after the increase in efficacy and potential delaying resistance to cephalosporins

You are an NP working in a clinic with a big population of adolescents. You want to be able to assess their psychosocial history. Using the acronym HEADSS assessment tool, you understand it stands for what? A) Home and Education; Experience and Employment; Activities; Drugs; Sexuality/Relationships; Suicide/Depression B) Home and Environment; Education and Employment; Activities; Drugs; Sexuality/Relationships; Suicide/Depression C) Health and Environment; Education and Employment; Activities; Drugs; Sexuality/Relationships; Suicide/Depression D) Home and Environment; Education and Employment; Abuse; Drugs/Sexual Encounters; Relationships; Suicide/Depression

B Healthcare providers caring for adolescents need to be able and willing to obtain a developmentally appropriate psychosocial history. Ideal situation would be to obtain information while adolescent is alone. This may require flexibility to obtain this after parent/guardian has stepped out of the exam room (Hay, 2020)

A 17 yo male patient with a recent diagnosis of Rheumatic fever and on bed rest is seen at the clinic today. Vital signs are HR of 70, NSR on ECG, T: 99.1F. and Sed rate 20mm/hr. The patient wants to know if he can be off bed rest. What is the most appropriate response by NP? A. You can end the bed rest since you only have low grade fever and are still taking Aspirin. B. The bed rest will end when your temperature remains below 99.0 F without taking Aspirin. C. The bed rest will end when you stop feeling sick and stop taking Aspirin. D. The bed rest will end after 3 weeks.

B In patients with rheumatic fever, the bed rest does not end until the fever is controlled without antipyretics, and heart rate, ECG and sediment rate return to baseline. Salicylates are preferred since they act on the fever, joint pain, and edema.

A mother brings her 7-day old in for her newborn visit. The FNP knows that all of the following is important information to gather except: A. Newborn's exposure to second or third hand smoke B. Paternal blood type C. Method of delivery of the newborn D. Family history of congenital abnormalities

B It is important to gather a complete newborn medical history at the first appointment which includes the mother's obstetric history, antepartum and intrapartum obstetric history, and maternal and paternal medical and genetic history. This includes a thorough history of delivery such as how long membranes were ruptured, type of delivery, forceps or vacuum usage, APGAR scores, and resuscitation needed. Obstetric history should include mother's age, number of pregnancies, outcomes of pregnancies, and mother's blood type. Medical and genetic history should include history of congenital anomalies, tobacco/substance abuse, medical conditions, and significant social history. Paternal medical and genetic history should be obtained but knowing the father's blood type is not necessary

Paul, a 63-year-old male stockbroker, presents to your clinic complaining of increased fatigue, difficulty performing strenuous activities, decreased sexual drive and difficulty maintaining an erection. Paul is overweight and takes only Crestor for hyperlipidemia. His serum testosterone level is decreased at 110 ng/dl and luteinizing hormone (LH) is slightly decreased. The nurse practitioner diagnoses Paul with hypogonadotropic hypogonadism and knows there are several causes. Which is not a cause of acquired hypogonadotropic hypogonadism: A. Obesity (BMI >30) B. Increased emotional stress C. Normal aging D. Marijuana use

B Men with acquired hypogonadism can have many symptoms including decreased libido, erectile dysfunction, poor morning erections, hot sweats, depression, fatigue, not able to perform vigorous activity, and headache. Decreased testosterone and normal to decreased LH are seen in hypogonadotropic hypogonadism and can be caused by normal aging, alcohol use, chronic illness, certain drugs (spironolactone, prior androgens, marijuana), obesity, and can be idiopathic

A 17-year-old gymnast presents to the clinic for evaluation of irregular menses. Her history reveals use of diet pills and disordered eating. The NP knows that which further testing would confirm the diagnosis of female athlete triad disorder: A. Thyroid gland ultrasound B. DEXA scan C. Electrocardiogram D. CBC, CMP, TSH

B The diagnosis of female athlete triad disorder is confirmed by evidence of menstrual irregularities, disordered eating, and a low bone mineral density. EKGs and labs such as a CBC, CMP, and TSH may reveal abnormalities but are not diagnostic. There is no need for a thyroid ultrasound in this condition.

A 36 y.o. patient presents to the office today for abnormal uterine bleeding. The patient was seen 2 weeks ago and started on oral contraceptives. The patient states: "I've just been really weak and dizzy. I feel like I'm going to pass out." When asked about how heavy the blood flow is, the patient states "I've been soaking through an overnight pad every 2 hours for the past 2 days." VS are: Temp 97.9 Pulse 110 BP 86/50 Respirations 22 SpO2 99% on RA. The NP should do which of the following: a. Refer to OB/GYN b. Admit to the hospital c. Tell the patient to take naproxen and come back tomorrow d. Do nothing, she's fine

B Patients who are hemodynamically unstable should be admitted to the hospital for further treatment. The pt is hypotensive and symptomatic, therefore she needs admission to the hospital for further workup.

Primary prevention of sexually transmitted infections in youth includes all the following EXCEPT: A. Sex Education Classes B. Treating partners for STI C. Providing condoms D. Discussing proper use of lubrication

B Primary prevention focuses largely on education and risk-reduction techniques. Secondary prevention requires identifying and treating STIs before infected individuals transmit infection to others

The FNP is treating a 47-year-old male for hypogonadism. All of the following can be a direct effect of testosterone replacement therapy except a. Improved mood b. Improved sleep apnea c. Increased hematocrit d. Improved exercise endurance

B Symptoms of hypogonadism include erectile dysfunction, decreased libido, fatigue, depression, poor morning erection, decreased ability to perform vigorous physical activity. Benefits of testosterone therapy include increased muscle strength, increased physical performance, improved sense of well-being, overall mood, sexual desire, and erectile function. Risks of therapy include erythrocytosis, hyperlipidemia, and aggravation of sleep apnea.

A patient presents with complaints of neck pain. The advance practice nurse would like to perform the Spurling test to assess nerve root pain. When would this be contraindicated? a. Pain has persisted for 6 months. b. Known history of trauma c. Patient has tingling to right hand d. Patient has already completed physical therapy

B The Spurling test is a physical exam to assess for nerve pain originating in the cervical spine. The exam is done by having the patient turn his/her head toward the affected side and placing a downward pressure. If there is nerve root involvement within the cervical spine, the symptoms will be recreated. The Spurling test is contraindicated in patients with a known history of trauma

A 12-month-old child presents complaining of a cough and low-grade fever. The parent states 2 days before the symptoms began the child had a stuffy nose and drainage. Physical exam reveals a barking cough, stridor with agitation that is absent with rest. No excessive drooling or retractions are noted. All vaccines are up to date. What is the most likely diagnosis of this child's condition? a. Epiglottis b. Viral Croup Syndrome c. Lower airway foreign body aspiration d. Pertussis

B The hallmark sign of croup syndrome is a barking cough. While epiglottis, a severe form of croup, should be considered the child's lack of drooling rules this diagnosis out as the most likely cause of the child's condition. The hallmark sign of pertussis is a whooping cough, and it is uncommon in children that are a vaccinated with DTaP.

Mrs. Simpson is a 50-year-old patient with a history of rheumatoid arthritis, diabetes, hyperlipidemia, and preeclampsia. She has been on a high-intensity Atorvastatin for 6 months and tolerating it well. A review of her labs shows the following: LDL 107, HDL 42, Triglycerides 151, and Total Cholesterol 210. What is the best next step in her care? A. Obtain creatinine kinase and liver enzyme levels to monitor for rhabdomyolysis. B. Recommend the addition of Ezetimibe to her regimen. C. Recommend the addition of Gemfibrozil to her regimen. D. Obtain liver enzymes and high-sensitivity C-reactive protein to monitor for rhabdomyolysis

B The patient has a history of Diabetes in addition to rheumatoid arthritis and preeclampsia, which are two risk-enhancing factors for cardiovascular risk. The goal for this patient's LDL level should be less than 70. Since she is already on a maximum dose statin, the next medication that should be added is Ezetimibe (Papadakis, et. al, 2020, p. 1283).

The following are considered health disparities among lesbian and bisexual women: childhood sexual abuse, depression and ______? A. Decreased incidence of chlamydial infections B. Cardiovascular disease C. HIV D. Lung cancer

B There are health disparities across the lifespan that exist between lesbian and bisexual women when compared to heterosexual women. These disparities include childhood physical abuse in the home, childhood sexual abuse, substance abuse, chlamydial infection as teens and young adults, depression, asthma, CVD, disabilities, and sexual assault.

The NP is performing a routine prenatal visit on a 19 year old female. This NP notices bruising on the patient's forearms and asks the patient about it. The patient states "oh my boyfriend had a little too much to drink 3 nights ago and got a little violent with me. He's under a lot of stress lately though because he is the only one who works and we are behind on all of our bills." The NP understands that the following are known factor(s) that increase the patient's risk of intimate partner violence." (Select all that apply). a. Female b. Young age (18-24 y.o.) c. Being pregnant d. Being heterosexual

B, C IPV happens in all cultures, races, socioeconomical backgrounds, and relationships. However, it is found more commonly in women, lesbian/gay/transgender relationships, being young (18-24 y.o.), being pregnant, being single/divorced/separated, member of ethnicity groups such as Native American, multiracial, or non-Hispanic black, coexisting mental illness

Which of the following patients is a candidate for a high intensity statin? a. Nina, a 68-year-old female, whose LDL is 120 b. Steven, a 50-year-old male, with lung cancer whose HDL is 30 c. Barry, a 49-year-old male, with DM2 whose LDL is 200 d. Sally, a 25-old-female, with anxiety whose LDL is 100

C A high-intensity statin is indicated in patients who meet the following criteria: • Presence of ASCVD • Adults with LDL ≥ 190 • Ages 40-75 with ≥ 7.5% 10-year ASCVD risk and LDL 70-189 • Adults 40-75 with diabetes High-intensity statins are Atorvastatin 40-80mg daily and Rosuvastatin 20-40mg daily.

During an annual wellness visit, the ECG of the patient shows atrial fibrillation (AFib) with a heart rate of 101. The NP understands that the pattern of the heart rhythm on the ECG will appear A. Regularly irregular. B. Regularly regular. C. Irregularly irregular. D. Irregularly regular

C AFib presents as irregular irregular heart rhythm on the ECG because of the rapid ventricular rate and irregular rhythm.

A 4-month-old patient arrives at your rural clinic with his new foster mother who is now caring for him because of neglect issues. The child is less than 25th-percentile in both height and weight. His foster mother is very concerned as she was told he was 4 weeks premature and says he is very hungry, but simply exhausts himself trying to eat. She is concerned about his breathing because he sometimes "pants" when he is excited. Your assessment reveals a rough, machine-like murmur across the anterior lungs. ECG appears normal. What type of murmur do you suspect and what does this imply for treatment? a. Atrial Septal Defect-the child will need immediate cardiology referral for surgery b. Atrioventricular Septal Defect-this is common and will close on its own c. Patent Ductus Arteriosus-Order an echocardiogram while waiting on Cardiology referral as medication or surgery are possible treatments d. Pulmonary Valve Stenosis-Begin weigh-based indomethacin treatment

C ASV is usually asymptomatic. If symptomatic, it is often electively corrected between ages 1-3 years (p. 574-575). AVSD is often inaudible (p.577-578). PVS may have a click-like sound and requires surgical or cardiac catheterization with ballooning to widen the narrowed pathway (p. 580-581). Patent Ductus Arteriosus has a distinct, mechanical like murmur. Depending on the child's size and the duct opening, medication or surgery may be recommended (p. 578-579). In a rural clinic, it may be some time for both Echocardiograms and pediatric cardiology appointments. Ordering an ECHO in the waiting period for a specialist can reduce time to treatment if more information is available at the time of presentation.

A 21-year-old bisexual female presents to the clinic for a wellness exam. In regards to safe sexual practices and the prevention of sexually transmitted infections, what should the nurse practitioner include in the education? a. The human papillomavirus (HPV) vaccine is critical in the prevention of cervical cancer, but cannot be administered after the age of 21. b. The herpes simplex virus (HSV) cannot be transmitted between women. c. The CDC recommends annual Chlamydia trachomatis and Neisseria gonorrhea screening yearly until the age of 25 in sexually active females, regardless of sexual orientation. d. HIV cannot be transmitted sexually between women, so it is not important for women who have sex with women to be tested for HIV.

C According to Papadakis and McPhee, the recommendation by the CDC, regardless of sexual orientation, is to be screened for Chlamydia trachomatis and Niesseria gonorrhea from the age of the first sexual encounter until the age of 25 years for all women. The herpes simplex virus (HSV) can be transmitted sexually between women, so the same precautions regarding transmission should be provided to lesbian, bisexual, and heterosexual women and there should be no sexual contact during the prodromal phase that may precede a genital herpes outbreak. Viral genotype analysis has determined that HIV can be transmitted sexually between women. The HPV vaccine is critical in the prevention of cervical cancer and the FDA has approved and expanded the age to 45-years-old

A 23-year-old male homosexual patient presents to clinic to establish care with the NP. Which immunization titers would be most important to check for this patient considering his sexual orientation? A. Hepatitis C B. Varicella C. Hepatitis A and Hepatitis B D. RPR

C According to the CDC, it is recommended that MSM be screened for chronic hepatitis B infection at least once in their life and be vaccinated against hepatitis A and B. Annual hepatitis C screening is only recommended for HIV infected MSM.

Which of the following statements should NOT be included when educating an adolescent male about his Chlamydia diagnosis? a. First line treatment of this infection is Azithromycin 1 gram as a single dose b. Both the infected patient and their partner need to be treated even if they are asymptomatic. c. He is at less risk of reinfection than a female so he does not need to be retested after completing treatment. d. Common signs and symptoms of Chlamydia in males are dysuria, urethritis, and epididymitis.

C Adolescent males and females are at increase risk for reinfection within several months of their initial infection because of failure of contacts to received treatment or the initiation of sexual activity with a newly infected partner. Because of this increase risk, all infected females and males should be retested approximately 3 months after treatment

You are the FNP caring for a 15-year-old here for her annual exam. She has disclosed to you that she smokes marijuana. With the aim to promote positive change, you respond in the following way: A. "You need to stop smoking, don't you realize the negative impacts it will have on your health?" B. "Marijuana is a gate-way drug and if you keep smoking you may end up addicted to other drugs." C. "Have you ever wanted to quit smoking? On a scale from 0-10 how ready are you to stop smoking?" D. "We will have to have you come back every 4 weeks for routine drug tests."

C Adolescents respond well to motivational interviewing which includes asking open ended questions to gage how ready the adolescent is to make a change. This method is more effective in addressing substance abuse and other unhealthy behaviors in this patient population. Lecture-type teaching has not proven to be as effective in adolescents. Routine drug testing is not indicated in the primary care setting.

A mother brings in her 3 yr old son for a well visit. She is very excited as she reports that she just inherited her grandmother's 100 yr old farmhouse. She laughs as she reports that her son likes it so much, that he has been chewing on the window sill by the front door. The nurse practitioner recognizes that an appropriate screening would be to screen for? a. Iron deficiency b. Dyslipidemia c. Lead poisoning d. Anemia

C Although lead base paint has been banned since 1977, it is still the primary source of childhood exposure to lead. The CDC has recommended universal screenings at ages 1 and 2 yrs old. In communities with a large percentage (>27 % of older homes built before 1950) the CDC recommends targeted screenings in older children

A 68-year-old female comes in for a routine physical. She has not had a physical in over 10 years and asks for some information regarding a bone density test. Which of the following would NOT be correct regarding a bone density scan? A. A bone density test is recommended at age 65 and older for post-menopausal women and those with an increased risk of osteoporosis and osteomalacia. B. The dual energy x-ray absorptiometry (DXA) scan cannot differentiate between osteoporosis and osteomalacia. C. A T-score of < -2.5 is considered normal. D. The test is performed by scanning the lumbar spine, hip, and distal radius

C Bone density reporting is represented by a T score. T score > or = -1.0: Normal. T score -1.0 to -2.5: Osteopenia (low bone density). T score < -2.5: Osteoporosis. T score < -2.5 with a fracture severe osteoporosis.`

A 3-year-old is brought to clinic for well child exam. During assessment you notice an early systolic murmur at the left sternal border that is short and vibratory. You notice when the child is sitting the murmur diminishes. You diagnose the murmur as a Still's murmur. What education can you provide to the child's parent? A. This type of murmur usually resolves following surgery B. The child will need to be on medication for the rest of their life C. Still's murmur is innocent and usually resolves as the child gets older D. This type of murmur is rare and should be evaluated immediately by specialist

C C - Still's murmur is a very common innocent murmur heard in early childhood especially between the ages of 2 and 7 years old. The murmur typically resolves on its own without intervention.

A patient presents to the office with hypogonadism. Which of the following chronic conditions could the patient have and still receive testosterone replacement therapy? A. Untreated sleep apnea B. Prostate cancer C. Asthma D. Heart failure

C Testosterone to treat hypogonadism should not be given to men with active prostate cancer. It can aggravate sleep apnea through CNS effects. It can worsen heart failure symptoms. There are no associated risk factors of using testosterone with a history of asthma

What is the most common bacterial STI in the United States among adolescents and young adults? a. Gonorrhea b. HPV c. Chlamydia d. Trichomonas

C C. trachomatis is most common in the United Stated for bacterial infections. There were over 1.05 million cases reported to the CDC in 2017. The cases were reported in the adolescent and young adult population representing 63% of the chlamydial cases

A father brings his son, Tommy, who is 6 years old into clinic for a sick visit. The father tells the nurse practitioner that Tommy is having nighttime urine incontinence and he and his wife are getting upset because they are having to change the sheets frequently and fear the bed is going to be ruined. As a NP what do you ask and or tell the father? A. Tell Tommy to stop urinating in bed, 6-year-olds don't do that. B. Educate dad that encopresis is more common in boys than girls. C. Ask dad how many times a week Tommy wets the bed and how long has it been going on for, this sounds like enuresis. D. Encourage dad to purchase or take away toys as rewards and or punishment depending on Tommy's behavior with bed wetting.

C Enuresis is defined as repeated urination into the clothing during the day and into the night by a child who is chronologically and developmentally older than 5 years. It is more common in boys than girls. Repeated urinary incontinence must occur at least twice a week for 3 months. Monosymptomatic enuresis reflects a delay in achieving nighttime continence and reflects a delay in the maturation of the urologic and neurologic systems. Treatment involves education and avoidance of being judged and shaming the child.

A patient comes in with complaints of nonspecific symptoms including weight gain and fatigue. She states she has also been feeling down. Blood work shows an elevated TSH and decreased FT4. The NP knows that the patient is exhibiting A. Hyperthyroidism B. Depression C. Hypothyroidism D. Hyperprolactinemia

C Hypothyroidism is characterized by a group of nonspecific symptoms including fatigue, intolerance to cold, changes in weight, constipation, depression, menorrhagia, dry skin, hoarseness, bradycardia, and delayed deep tendon reflexes. Laboratory findings for hypothyroidism include a low FT4 and elevated TSH.

A 6yo female arrives today for her well check. She does not wear glasses or contacts. The nurse performs the patient's vision screening and records the results as 20/20 combined, 20/20 in the right, 20/30 in the left. How does the APN proceed? A) No action needed since combined vision is normal B) Reassess in 6mo C) Refer to ophthalmology D) Perform a cover test to assess for strabismus

C Minimum visual acuity for ages 3-5y is 20/40, for 6y and over it is 20/30. Even if visual acuity is within normal range, a discrepancy of 2 or more lines between eyes requires a referral to ophthalmology. While visual acuity does improve with age, a two line discrepancy requires a referral to ophthalmology. While not incorrect to do, strabismus will have already been screened for and hopefully corrected. If strabismus were present you would also refer to ophthalmology

A 70-year-old male presents to the clinic. Upon auscultation of the heart at the right second intercostal space, a high-pitched mid-systolic sound is heard and is also present when auscultating the carotid arteries. This murmur would be documented as which? a. Mitral Stenosis b. Mitral Regurgitation c. Aortic Stenosis d. Aortic Regurgitation

C Mitral stenosis is a diastolic rumble best heard near the apex. Mitral regurgitation is holosystolic murmur heard best near the apex and can transmit to the axilla. Aortic stenosis is loudest at the right second intercostal space and can also be heard in the carotid arteries. Aortic regurgitation is a low-pitched diastolic murmur heard best at the left sternal border in the third to fourth interspace

A new mother brings her newborn in for his newborn visit. She states she has a history of iron deficiency and questions the practitioner on what she can do to lower her son's risk for iron deficiency. Which of the following would be the best response? A. Encourage cow's milk, at least 30 oz per day once the child is 1 B. Avoid ground up meats after age 6 months C. Avoid low-iron formula during infancy D. Start the infant on nonfortified formula at 1 month old

C Risk factors for iron deficiency include preterm or low-birth-weight births, multiple pregnancy, iron deficiency in the mother, use of non-fortified formula or cow's milk before age 12 months, and an infant diet that is low in iron-containing foods. Primary prevention of iron deficiency should be achieved through dietary means, including feeding ground up meats and iron-containing cereals by age 6 months, avoiding low-iron formula during infancy, and limiting cow's milk to 24 oz per day in children 1-5 years.

In developing a treatment plan for Paul, the nurse practitioner is considering prescribing a topical testosterone gel such as Androgel 1% topical gel. What finding would be contraindicated for testosterone replacement in this patient? A. Hypertension B. Obesity C. Prostate cancer D. Over 60-years-old

C Testosterone replacement is contraindicated in active breast and prostate cancer. It should also not be given to men with heart failure or untreated sleep apnea. Testosterone replacement is not contraindicated in hyperlipidemia but should be used with caution because it can increase the lipid profile. Should also be used cautiously in BPH, elderly patients, renal and hepatic disease, diabetes mellitus and obesity

A 16y female comes to you for follow-up appointment following an Urgent Care visit for a sinus infection. Her prior medical history includes mild asthma and seasonal allergies. She uses an albuterol rescue inhaler and she takes over the counter allergy medication, but could not remember the name. She was given a "Z-pak" for her sinus infection. She reports her breathing is fine, facial pressure improving, and nasal congestion is clearing, but she feels very weak and nearly fainted this morning when loading books into the car. In your assessment, her vital signs are 110/68, 72HR, 18RR, 97.6'F, 98%RA and her presentation has a regular cardiac rhythm and clear lungs to osculation. As a prudent FNP, what would you do next? a. Advise patient to take an additional day off school as she is underestimating the impact of the infection and needs rest and time to allow antibiotics to work. b. Order a complete metabolic, blood chemistry panel, and drug screen. c. Order an EKG d. Schedule a Pulmonary Function Test

C The patient has been stable with only a PRN inhaler for asthma and she denied respiratory symptoms. Her vitals and assessment do not show signs of a systemic infection. While her labs may demonstrate elevated WBC or electrolyte abnormalities, her weakness and syncope are most often cardiac in nature. Unless the patient demonstrates signs of drug use, her age alone is not a cause for drug screening. Multiple medications including albuterol, pseudoephedrine, and azithromycin can prolong QT which presents as weakness syncope, especially in females (pp. 565-566). An EKG, available immediately in most office settings, can provide measurable data aide in diagnosis

You are interviewing a 65 year old male patient in your clinic who reports a sudden onset of heart palpitations this morning with fatigue and states that he started feeling very short of breath while walking and keeps feeling like he might pass out. Vital signs in the clinic are as follows; HR 116, BP 92/54, Temp. 98.8 F, Sp02 92%, RR 24. You order a 12 lead ECG and see that his ventricular rate is rapid and his rhythm is very irregular with indistinguishable or absent P waves. What new-onset rhythm are these findings most likely associated with? A. Atrial Flutter B. Supraventricular Tachycardia C. First Degree Heart Block D. Atrial Fibrillation

D A. Fib is the only rhythm listed in which the rhythm is very irregular and the ventricular rate is rapid. New-onset Afib is often associated with palpitations, exertional SOB and presyncope. Atrial Flutter is incorrect because it is associated with a rapid and regular rhythm with a 2-1 or 3-1 ratio of p waves to qrs complexes, which is not how this patient is presenting. Supraventricular Tachycardia is incorrect because the rate would be much higher, over 150bpm, and would be a regular rhythm. First degree heart block clinical manifestation is usually benign and does not usually produce symptoms, making it incorrect for this patient.

A 67-year-old woman comes to the clinic today for an annual exam. She had a bone density scan at her OB/GYN clinic last month and her T score was 2.0. What would be your plan for this patient? a. Tell the patient she has osteoporosis, and she needs to start using a walker or cane immediately to decrease her risk for falls. b. Set up a repeat bone density scan to confirm results. c. Prescribe the patient 800 International Units of Vitamin D to take daily. d. Educate the patient on eating a calcium rich diet and incorporating regular weight bearing exercises in her lifestyle

D According to McNamara and Walsh (2020), "Dietary calcium is the preferred route for calcium intake because calcium supplements have been associated with an increased risk of myocardial infarction, although there has not been an increase in either cardiovascular or all-cause mortality. Calcium supplements, if they are taken, can be given as either calcium citrate or calcium carbonate and should be combined with vitamin D. Regular weight-bearing exercise has also been associated with an increase in bone density, although the effect is lost when the exercise is not continued." So, in this question, educating the patient and focusing on lifestyle changes would be most beneficial according to the text.

Mr. Ellis is a 45-year-old male who presents for a review of his labs. His vitals are 131/82, HR 67, temp 36.7, RR 18, O2 sat 100%, BMI 32. He has no noted past medical history. In reviewing his labs, you note the following lipid profile: LDL 198, HDL 40, Triglycerides 145, and Total Cholesterol 199. According to AHA/ACC guidelines, what is the priority recommendation? A. Educate him on a DASH diet and return in 3 months to recheck his labs. B. Reassure him that his labs are all within normal limits, but he needs to decrease his BMI. C. Calculate the 10-year CVD risk to see if he requires statin therapy. D. Prescribe high-intensity statin therapy

D According to the AHA/ACC guidelines, patients who present with an LDL of greater than 190 should automatically begin on a high intensity statin. There is no need to calculate the 10-year CVD risk. Dietary guidelines should be provided for the patient, but it is the Mediterranean Diet that has been shown to reduce LDL levels by 5-10%, and the patient would need a greater reduction than this alone could provide (Papadakis, et. al, 2020, p. 1282).

Which of the following physical exam findings of the female breast would be an atypical characteristic of breast carcinoma? A. Bloody nipple discharge in a non-pregnant patient who is not breastfeeding B. Axillary lymphadenopathy C. Multiple breast tissue nodules that change in size and is associated with serous nipple discharge D. A fixated breast mass and unilateral nipple discharge

D All of the following are characteristic physical exam findings in a female breast that are typical for breast carcinoma (A, B, & D). However, the description in C is characteristic of a typical finding in a female breast with a fibrocystic condition.

A 35-year-old with a medical history that includes hypertension and sickle cell disease, both are well controlled, is being seen for her annual wellness exam and desires to start oral contraceptives to control the bleeding that she has noticed between her menstrual cycles over the past 2 months. The NP knows that an absolute contraindication for OCPs is: A. The patient's age B. Hypertension C. Sickle Cell Disease D. Undiagnosed abnormal vaginal bleeding

D Although using OCPs with conditions such as hypertension and sickle cell may cause adverse effects, some OCPs can be used with caution which is why they are both relative contraindications. Age alone is not a contraindication to OCP use. The reason of the bleeding between menstrual cycles must be diagnosed and treated, if possible, before initiation of OCPs

A 25-year-old Caucasian female presents to the primary care clinic with complaints of multiple, nontender lumps to her left breast tissue. The patient states she noticed the lumps 1 week ago while performing a self-breast exam. After a thorough history and physical examination, you decide to: A. Order a breast MRI B. Order a mammogram C. Refer patient to a Breast Surgical Oncologist D. Order a breast ultrasound

D Being that the patient is less than 30 years of age, it is likely that the breast tissue is relatively dense, in which case an ultrasound would be a better diagnostic test to evaluate a breast mass/lesion. The ultrasound will determine if the mass/lesion is a cyst or a solid tumor. If the lesion is thought to be suspicious, a biopsy of the tissue is then performed.

A 56 year old male presents to your clinic with complaints of breast swelling and tenderness. You suspect medication induced gynecomastia. Which one of his medications could cause gynecomastia? A. Zoloft B. Plavix C. Aspirin D. Spironolactone

D Drug induced gynecomastia resolves after the offending drug is removed. Spironolactone is one of the drugs that can induce gynecomastia due to its anti-androgen mechanism of action.

A 33-year-old African American female presents with complaints of reoccurring bilateral tender breast masses. The patient reports the masses seem to be larger and more painful before her menstrual cycle. The nurse practitioner knows the most likely diagnosis is: A. Fibroadenoma of the breast B. Fat necrosis C. Carcinoma of the breast D. Fibrocystic condition

D Fibrocystic condition is primarily seen in women ages 30 - 50, characterized by painful breast masses that fluctuate in size and are worse immediately prior to menstruation. Fibrocystic condition is the most frequently diagnosed breast lesion, often presenting with multiple masses and affecting both breasts. Fibroadenomas of the breast and carcinomas of the breast are typically one-sided, non-tender, and do not fluctuate in size. Fat necrosis is rare, typically seen after trauma or fat injection, and often presents with associated nipple retraction/skin dimpling

. A 35 yo female presents to clinic with a painful transient mass on her left breast for the past several months. The pain worsens during her premenstrual cycle with serous nipple discharge. A mammogram and US showed a Fibrocystic Condition. What is the first line of treatment for this diagnosis? A. Biopsy B. Hormone therapy C. Decrease caffeine consumption D. Avoid trauma to the breast and wear a good supportive brassiere during the night and day

D Fibrocystic condition is the most common frequent lesion of the breast. Common in women 30- 50 years of age. Exacerbations of pain, tenderness, and cyst formation may occur at any time until menopause, except in patients receiving hormonal replacement. Women should be advised to examine their own breasts regularly especially after menstruation.

A mother asks whether she should get her child vaccinated against HPV. The nurse practitioner educates her that the HPV vaccine will decrease risk for all the following EXCEPT: A. Anal and oropharyngeal cancers B. cervical cancer C. genital warts in both males and females D. bacterial sexually transmitted infections

D HPV vaccination prior to exposure decreases risk for cervical cancer and cervical dysplasia in females. It decreases risk of genital warts in both males and females, along with risk of anal and oropharyngeal cancers. HPV vaccination does not decrease risk of bacterial sexually transmitted infections

A 13-year-old girl presents for a sports physical for school. She is an active soccer player and has no medical history. She is concerned that she has not had an onset of menarche yet and all of her friends have. You assess her SMR to be stage 3 with no abnormal findings on physical exam. The next appropriate step would be to: A. Order a wrist X-ray of her non-dominant hand to assess for delayed growth. B. Order FSH and LH levels to test for hypogonadism. C. Refer to OBGYN for initiation of an oral contraceptive. D. Provide reassurance to the patient that the onset of menarche occurs at different ages and is influenced by nutrition, ethnicity, and genetics

D It is a normal finding for menarche to occur anywhere from 9-15 years. Since this patient has secondary sex characteristics it is not necessary to pursue further diagnostic testing at this time. If there is no menses by 15 years with secondary sex characteristics present, consider further work up. An oral contraceptive is not indicated in this patient.

A 32-year-old male presents to clinic complaining of decreased libido, erectile dysfunction, fatigue, and new onset headaches. His past medical history includes depression, obesity, chronic pain, and 25 pack year smoking. He is taking Elavil q HS and Percocet prn. Serum testosterone is 125ng/mL and free testosterone is 31pg/mL. Repeat labs confirm hypogonadotropic hypogonadism. What is the next best step in managing this patient? a. Counsel the patient to lose weight. b. Start testosterone replacement and recheck serum testosterone level in 1 month. c. Tell him his Elavil is likely causing his fatigue. d. Order an MRI of the pituitary/hypothalamus to rule out a mass lesion.

D Men with hypogonadotropic hypogonadism should have an MRI of the pituitary/hypothalamus if one of the following signs/symptoms are present: serum testosterone less than 150ng/mL, elevated serum prolactin level, other pituitary hormone deficiencies, or symptoms of a space-occupying lesion

Which of the following findings are NOT consistent with coarctation of the aorta? A. Grade I or II systolic murmur B. Lack of bilateral femoral pulses C. Blood pressure discrepancy between upper and lower extremities D. Diminished brachial pulses

D Murmurs may be auscultated in infants with CoA whose PDA remains open. Any murmur necessitates careful evaluation of pulses and blood pressure. Femoral and brachial pulses should be palpated simultaneously. If there is question of presence of femoral pulses, blood pressure should be obtained in all 4 extremities. In coarctation of the aorta, systolic blood pressures are higher in the right upper extremity in comparison to the lower extremities. An infant with severe heart failure secondary to the PDA closing may have diminished pulses throughout, but not specifically the brachial pulses alone.

RSV is the most common cause of bronchiolitis, a serious acute respiratory illness in younger children and infants. Which of the following patients is most at risk for a severe or life-threatening RSV infection? a. 4-year-old child with history of asthma b. 7-month-old healthy infant c. 18-month-old born prematurely at 33 weeks gestation d. 5-month-old with congenital heart disease

D Patients at risk for life-threatening RSV infections include children less than 24 months of age who were born prematurely, children less than 24 months of age with severe pulmonary conditions, CHD, neuromuscular disease, or are immunocompromised. By this C & D are both correct. However, infants are at highest risk for hospitalization in the first 5 months of life and infants with chronic lung disease and congenital heart disease are at an even higher risk for hospitalization according to the AAP. Thus, a 5- month-old with CHD is at higher risk for a more severe RSV infection than an 18-month-old born prematurely.

Which of the following medications is highly recommended for a patient that has had an acute coronary syndrome? a. Thiazide diuretic b. Losartan c. Furosemide d. Atorvastatin

D Patients that have had an acute coronary syndrome are recommended to be on an high-dose statin

A patient presents to the clinic with compliant of chest pain. Which of the following statements would alert the nurse practitioner that the patient's chest pain is cardiac related? A) "I feel a stabbing pain in my chest when I take a deep breathe." B) "It hurts when I press on the left side of my chest." C) "I have this burning pain in my chest after I eat large meals." D) "I have been having tightness in my chest with exercise.

D Pleuritic chest pain usually increases during respirations. Pain during palpation is usually related to the musculoskeletal system. Esophageal and gastrointestinal disorder such as gastrointestinal reflux disease can cause chest pain. Cardiac ischemia causes chest pain that is often described as dull or aching. Ischemic pain can also be described as pressure, tightness, or squeezing.

A 37-year-old Caucasian female is currently breast feeding and desires to start birth control. She has a past medical history of HTN, smoking, and breast cancer. Which method of contraception should the NP recommend? a. Progestin Only Pill b. Combined Oral Contraceptives c. Depo Provera d. Copper IUD (Paragard)

D Progestin only pills are indicated for breastfeeding moms. There is a decreased risk of blood clots with progestin only pills. Progesterone only pills are indicated for women over 35 with a history of HTN, smoking, or migraines but are contraindicated in breast cancer so the progestin only pill would not be an option. Combined oral contraceptives contain estrogen and progesterone and are contraindicated in smokers over 35, history of HTN, and breast cancer so this method would not be acceptable. Depo Provera is a hormonal contraceptive and is contraindicated in breast cancer so this choice would not be acceptable. The copper IUD is hormone free. It can be safely given to breast feeding moms, women over 35 with a history of HTN, smoking, and breast cancer. The copper IUD would be an acceptable contraceptive option for this patient.

A teen mom brings her 3-year-old son to a well child check. She is visibly exhausted and very emotional and states that she can't handle her son's behavior and asks for a referral to a behavior specialist. When asked to explain his behavior she states that he throws himself on the ground, kicks, screams, and hits when he gets frustrated. What is your next best action as the provider? A. Agree with the mom that her son's behavior is not appropriate for his age, and she should take him to a behavior specialist. B. Instruct the mom to walk away from her child when he shows these behaviors, it will teach him that she doesn't approve of these behaviors. C. Educate the mom that this is a completely normal behavior for this age, and she should just remain patient and support him. D. Ask mom how often these behaviors are occurring throughout the week

D Temper tantrums are common between 12 months and 4 years of age. These tantrums can be very exhausting to parents and family members. When tantrums occur out in public it can be very embarrassing to parents and family members and often results in parents not bringing their children into public. Common behaviors of temper tantrums include throwing him or herself on the floor, kicking, screaming, or hitting/ swinging. During the ages of 12 months to 4 years of age temper tantrums occur once a week in about 50- 80% of all children, only 5-20% of children have frequent temper tantrums which require referrals to psychologists.

Which factor is the leading cause of illness and preventable death in the United States? a. Hypertension b. Obesity c. Diabetes d. Smoking

D although hypertension, obesity, and diabetes are all modifiable risk factors that contribute to illness and preventable death in the United States, smoking is the leading cause.