ANCC Board Prep Part II

Apples (S2 heart sound)

A (aortic valve) P (pulmonic valve) S (semilunar valves)

Grading System Grade I: __ Grade II: ___ Grade III: ___ Grade IV: ____ Grade V: ___ Grade VI: ____

A very soft murmur heard only under optimal conditions A mild to moderately loud murmur Loud murmur that is easily heard once the stethoscope is placed on the chest. A louder murmur. First time that a thrill is present. A thrill is like a "palpable murmur." Very loud murmur heard with edge of stethoscope off the chest. Thrill is more obvious. Murmur is so loud that it can be heard even with the stethoscope off the chest. The thrill is easily palpated.

Rule out ____ in an older male who has a pulsatile abdominal mass that is more than __ cm in width. The next step is to order an abdominal ultrasound and CT.

AAA 3

The person at highest risk is a 70-year-old elderly White male who is a smoker (current or has quit) and has HTN. The classic initial symptoms of a severe, sharp, excruciating pain in the abdomen, flank, and/or back with a pulsatile abdominal mass occurs in only about half (50%) of patients.

ABDOMINAL AORTIC ANEURYSM

A middle-aged to older man who complains of onset of steady chest or substernal discomfort lasting more than 15 minutes that is described as squeezing, tightness, crushing, a knot in the center of the chest, heavy pressure ("an elephant sitting on my chest"), or band-like. Some report that it radiates to the inner aspect of one or both arms, shoulders, neck, and/or jaw. The pain can radiate to the back (interscapular region). It is provoked by physical exertion, emotional upset, or eating a heavy meal. The patient may be diaphoretic and complain of palpitations, shortness of breath, nausea, and/or vomiting.

ACUTE CORONARY SYNDROME

EKG changes include ST segment elevation and Q waves. Wide QRS complex on leads V2 to V4 resembles a "tombstone."

Anterior wall myocardial infarction.

____: Located at the fifth intercostal space (ICS) by the midclavicular line on the left side of the chest

Apical impulse

___ (irregularly irregular rhythm with no P waves

Atrial fibrillation

_____ is the most common cardiac arrhythmia in the United States. It is a major cause of ____ and classified as a ____.

Atrial fibrillation (AF) stroke supraventricular tachyarrhythmia

Elderly patient reports being short of breath and lightheaded with minimal exertion, which can progress to dyspnea at rest. Easily fatigued even with light exertion. Complains of feeling short of breath when lying down (orthopnea) and/or episodes of sudden awakening from sleep (recumbent position) due to severe shortness of breath, which is relieved with upright/sitting position (paroxysmal nocturnal dyspnea). Peripheral edema caused by fluid retention. Can be accompanied by poor appetite and right upper quadrant abdominal pain.

HEART FAILURE

Atrial Fibrillation and Atrial Flutter Risk Factors

HTN, CAD, ACS, stimulants, hyperthyroidism, alcohol intake ("holiday heart"), heart failure, LVH, pulmonary embolism (PE), chronic obstructive pulmonary disease (COPD), sleep apnea

Risk factors include valvular abnormalities, arrhythmias, IV drug use, and hemodialysis.

INFECTIVE ENDOCARDITIS

Grading murmurs: Be aware that the first time a thrill is palpated is at grade ___.

IV3

Motivated (S1 heart sound)

M (mitral valve) T (tricuspid valve) AV (atrioventricular valves)

Diaphragm of the Stethoscope Mid- to high-pitched tones such as lung sounds _____ _____

Mitral regurgitation Aortic stenosis

Bell of the Stethoscope Low tones such as extra heart sounds (S3 or S4) _______

Mitral stenosis

If an apical/apex murmur occurs during ___, it is mitral regurgitation (MR. ASS).

S1

If an apical/apex murmur occurs during __, it is mitral stenosis (MS. ARD).

S2

Displacement of the Point of Maximal Impulse _______ and ______: The point of maximal impulse (PMI) is displaced laterally on the chest and is larger (>3 cm) in size and more prominent. Pregnancy, _____ trimester: As the uterus grows larger, it pushes up against the diaphragm and causes the heart to shift to the left of the chest anteriorly. The result is a displaced PMI that is located slightly upward on the left side of the chest. May hear S3 heart sound during pregnancy.

Severe left ventricular hypertrophy (LVH), cardiomyopathy third

The P waves show uniform morphology, and the PP interval increases and decreases during inspiration and exhalation.

Sinus arrhythmia

A photograph of a skin lesion is included in this question. What is the diagnosis? A. Basal cell carcinoma B. Squamous cell carcinoma C. Nevus D. Melanoma

Solution: A Basal cell carcinoma This is a photograph of basal cell carcinoma, the most common type of skin cancer. Although the lesion does not have central ulceration, it contains telangiectasia with a waxy or pearly (shiny) appearance. The gold-standard diagnosis for any type of skin cancer is a biopsy of the lesion that is sent to the lab for pathological evaluation.

Which of the following is recommended treatment for erythema migrans or early Lyme disease? A. Doxycycline (Vibramycin) 100 mg PO BID × 21 days B. Ciprofloxacin (Cipro) 250 mg PO BID × 14 days C. Erythromycin (E-mycin) 333 mg PO TID × 10 days D. Dicloxacillin (Dynapen) 500 mg PO BID × 10 days

Solution: A Doxycycline (Vibramycin) 100 mg PO BID × 21 days Erythema migrans is the rash characteristic of Lyme disease, and it usually appears 7 to 10 days after a tick bite. Lyme disease is caused by Borrelia burgdorferi , a spirochete. The rash appears either as a single expanding red patch or as a central spot surrounded by clear skin that is in turn ringed by an expanded red rash (bull's-eye). The choice of antibiotic depends on bacterial sensitivity. Doxycycline 100 mg BID for 14 to 21 days is the recommended treatment of adults.

The mother of an 8-year-old boy reports the presence of a round red rash on the child's left lower leg. It appeared 1 week after the child returned from visiting his grandparents, who live in Massachusetts. During the skin exam, the maculopapular rash is noted to have areas of central clearing, making it resemble a round target. Which condition is most likely? A. Erythema migrans B. Rocky Mountain spotted fever C. Meningococcemia D. Larva migrans

Solution: A Erythema migrans Erythema migrans is a symptom of early Lyme disease. It is an annular lesion that slowly enlarges with time (days to weeks) and has central clearing. It is caused by a bite from an infected ( Borrelia burgdorferi ) blacklegged tick. If untreated, infection will spread to the joints, nervous system, and heart. Most cases of Lyme disease occur in the Northeast, mid-Atlantic states, Wisconsin, Minnesota, and northern California.

A child diagnosed with eczema was treated with over-the-counter 1% hydrocortisone ointment. During a follow-up visit, the mother reports that the rash does not seem to be improving. What level steroid should the nurse practitioner prescribe next? A.Group 6 B.Group 5 C.Group 4 D.Group 3

Solution: A Group 6 The patient is currently using a potency Group 7 (over-the-counter topical hydrocortisone, 0.5%-1.0%) for eczema. The nurse practitioner should prescribe the next level of topical steroids, a Group 6, such as desonide cream or lotion (0.05%) and then reevaluate for effectiveness. The topical steroid strengths range from 7 (least potent) to 1 (very potent). For example, a Group 5 is fluticasone propionate cream (0.05%), a Group 4 is triamcinolone acetonide cream (0.1%), and a Group 3 is amcinonide (0.1%). Children should not be prescribed topical steroids for more than 2 weeks.

An elderly male presents with complaints of severe pain on his left back and a concentrated swath of vesicles. Which diagnosis is most likely? A. Herpes zoster B. Varicella C. Tinea corporis D. Plaque psoriasis

Solution: A Herpes zoster Herpes zoster (shingles) is caused by infection with the herpes varicella-zoster virus, the same virus that causes chickenpox. It commonly causes severe, deep pain along a peripheral nerve on the trunk of the body and red, nodular skin lesions. Fever and malaise typically accompany these findings. Shingles occurs more frequently in the geriatric population. Chickenpox, also known as varicella, is a highly contagious infection caused by the varicella-zoster virus. There is a blister-like rash, which first appears on the face and trunk and then spreads throughout the body. Plaque psoriasis is a chronic autoimmune condition. It appears on the skin in patches of thick, red, scaly skin. Tinea corporis is a dermatophytosis that causes pink-to-red annular (O-shaped) patches and plaques with raised, scaly borders that expand peripherally and tend to clear centrally.

A middle-aged Black man complains of a history of outbreaks of painful large nodules and pustules on both his axillae that resolve after treatment with antibiotics. On physical examination, the nurse practitioner notices large red nodules that are tender to palpation. In addition, several pustules are present along with multiple scars on the skin. The nurse practitioner advises the patient that the condition is caused by a bacterial infection of the sweat glands in the axillae. Which of the following conditions is being described? A. Hidradenitis suppurativa B. Severe nodular acne C. Granuloma inguinale D. Cat scratch fever

Solution: A Hidradenitis suppurativa Hidradenitis suppurativa is a chronic skin condition, commonly found in the apocrine glands in the axilla and/or groin, that causes painful nodules under the skin. These abscesses tend to open and drain fluid and pus. Significant scarring of the skin may result from these outbreaks.

71.4% complete Question The nurse practitioner is assessing a 14-year-old female who is 20% underweight for her height. The nurse practitioner notes the patient has thinning hair and brittle nails as well as fine, downy body hair on her back. How will the nurse document the body hair finding on the back? A. Lanugo B. Actinic keratosis C. Russell's sign D. Telogen effluvium

Solution: A Lanugo The appearance of fine, downy body hair should be documented as lanugo, commonly associated with anorexia nervosa. Actinic keratosis is a rough, scaly patch on the skin that develops from years of exposure to the sun. It is most commonly found on the face, lips, ears, back of the hands, forearms, scalp, or neck. Russell's sign is a sign defined as calluses on the knuckles or back of the hand due to repeated self-induced vomiting over long periods of time. Telogen effluvium is a scalp disorder characterized by the thinning or shedding of hair, resulting from the early entry of hair in the telogen phase (temporary hair loss).

61.5% complete Question A red, raised serpiginous-shaped rash is noted by the nurse practitioner on the right foot of a 4-year-old child brought in for a preschool physical by the mother. The child complains of severe itch and keeps scratching the lesion. The mother reports that the child frequently plays in the yard without wearing shoes or sandals. Which of the following is most likely? A. Larva migrans B. Erythema migrans C. Tinea pedis D. Insect bites

Solution: A Larva migrans Larva migrans results from infection with the eggs of parasites (worms) that are commonly found in the intestines of dogs and cats. Children are at high risk of developing this infection if they come in contact with dirt that is contaminated with dog or cat feces. Eating foods that are grown in contaminated soil and/or raw liver are other means of transferring the infection. After the eggs hatch, the parasite can migrate to other organs of the body if left untreated.

A patient presents with fever, fatigue, headache, and joint pain. The patient has recently returned from a camping trip in the Northeast. On physical examination, the nurse practitioner notes a large macule on the patient's back with central clearing. Which diagnosis is most likely? A. Lyme disease B. Brown recluse spider bite C. Erythema infectiosum D. Rocky Mountain spotted fever

Solution: A Lyme disease The classic lesion in Lyme disease is an expanding red rash with central clearing that resembles a target. This "bull's-eye" rash (erythema migrans) appears 7 to 14 days after a bite from an Ixodes tick (deer tick) infected with the Borrelia burgdorferi bacterium. Lyme disease is accompanied by flu-like symptoms. The bite of a brown recluse spider appears as a reddened skin area that may be followed by a blister that forms at the bite site, and it leads to mild-to-intense pain and itching for 2 to 8 hours following the bite. An open sore (ulcer) with a breakdown of tissue (necrosis) develops a week or more following the bite. Erythema infectiosum is known as fifth disease and generally occurs in children. Rocky Mountain spotted fever is also a tick-borne illness with similar symptoms but has a rash that begins in the extremities and has smaller red spots or macules.

The nurse practitioner is examining an 82-year-old male patient and notes that his penile gland and foreskin are inflamed. A reddened, moist macular lesion is present on the prepuce. The patient is being treated for a urinary tract infection with amoxicillin. The nurse practitioner will: A. Obtain a swab of the lesion for a potassium hydroxide (KOH) prep B. Prepare the patient for a needle biopsy of the lesion C. Obtain a serum sample for a rapid plasma reagin test (RPR) D. Prescribe 0.05% betamethasone cream BID × 4 weeks

Solution: A Obtain a swab of the lesion for a potassium hydroxide (KOH) prep The patient has symptoms associated with balanoposthitis. Fungal infections, specifically candida infections, are commonly associated with the use of antibiotics and are the most common identifiable infectious etiology associated with balanoposthitis. Therefore, the nurse practitioner will obtain a swab of the lesion for a KOH preparation to confirm the diagnosis of a fungal infection. There is no indication the client requires a biopsy to determine the cause of the eruption. An RPR test is used to screen for syphilis; the patient does not present with a chancre-type lesion or other findings consistent with syphilis. Prior to prescribing a 0.05% betamethasone cream, the nurse practitioner will confirm the causative agent associated with the diagnosis, as it can promote the exacerbation of a fungal infection.

The nurse practitioner is assessing a 56-year-old patient and notes diffuse reddish-brown, pigmented lesions on the back, trunk, abdomen, chest, and arms. A sample of the skin scrapings on a potassium hydroxide (KOH) wet mount reveals short hyphae and budding cells. Which medication will the nurse practitioner prescribe? A. Oral fluconazole (Diflucan) B. Oral ketoconazole (Nizoral) C. Topical tacrolimus (Protopic) D. Topical selenium sulfide

Solution: A Oral fluconazole (Diflucan) Pityriasis versicolor, formerly known as tinea versicolor, is a fungal infection caused by a type of yeast that is normally present on the skin but has grown out of control. Pityriasis versicolor is diagnosed by clinical appearance and a sample of the skin scrapings placed on a KOH wet mount, which reveal short hyphae and budding cells. Because of the extent of the patient's fungal infection, oral fluconazole (Diflucan) is the primary prescribed treatment. Oral ketoconazole (Nizoral) is contraindicated in the treatment of pityriasis versicolor because of the risk of adrenal problems, liver damage, and harmful drug interactions. Tacrolimus (Protopic) is an immunosuppressant that demonstrates antimycotic action but is not the most effective in reducing the appearance of hypopigmentation associated with pityriasis versicolor. Topical selenium sulfide for a widespread case of pityriasis versicolor can be expensive and diffi cult to cover large surface areas of the infected skin.

Upon assessment of a patient, the nurse practitioner notes several small, smooth, and round papules on the abdominal area. These papules are bright red and blanchable with pressure. Which of the following is a true statement regarding the findings? A. The lesions are cherry angiomas, which are benign and require no treatment B. The lesions are lipomas, which require surgical excision C. The lesions are acrochordons, which can be treated with steroids D. The lesions are actinic keratosis, which must be biopsied

Solution: A The lesions are cherry angiomas, which are benign and require no treatment These small lesions are cherry angiomas. A cherry angioma is a smooth, cherry-red bump on the skin. Although cherry angiomas usually appear on the trunk of the body, they can occur nearly anywhere. The cause of cherry angiomas is malformed arterioles in the skin, and the growths usually appear on people over the age of 40. Lipomas are soft, fatty cystic tumors usually located in the subcutaneous layer of the skin. They can be located on the trunk and are round or oval in shape. They measure 1 to 10 cm. Acrochordons, or skin tags, are painless outgrowths of the patient's skin and therefore are the same color as the patient's skin. Actinic keratosis presents as a rough, scaly patch on the skin that develops from years of exposure to the sun. It is most commonly found on the face, lips, ears, back of the hands, forearms, scalp, or neck.

38.5% complete Question Café au lait spots look like tan to light-brown stains that have irregular borders. They can be located anywhere on the body. Which of the following is a correct statement? A. They are associated with neurofibromatosis or von Recklinghausen's disease B. They may be identified as precancerous after a biopsy C. They are more common in children with darker skin D. They are associated with Wilson's disease

Solution: A They are associated with neurofibromatosis or von Recklinghausen's disease Café au lait spots are caused by an increase in melanin content, often with the presence of giant melanosomes. They have irregular borders and vary in color from light to dark brown. Neurofibromatosis causes tumors to grow in the nervous system, and these tumors commonly cause skin changes.

A 20-year-old man is being seen for a physical exam by the nurse practitioner. He complains of pruritic macerated areas in his groin that have been present for the past 2 weeks. Which of the following is the most likely? A. Tinea cruris B. Tinea corporis C. Tinea capitis D. Tinea pedis

Solution: A Tinea cruris Tinea cruris (jock itch) is a common skin infection that is caused by a type of fungus called tinea. The fungus thrives in warm, moist areas of the body, and as a result, infection can affect the genitals, inner thighs, and buttocks. Infections occur more frequently in the summer or warm, wet climates. Tinea cruris appears as a red, itchy rash that is often ring shaped. Tinea corporis involves the body, tinea capitis involves the head, and tinea pedis involves the feet.

A 4-year-old child presents with a red, swollen, painful blister-type lesion on his lower back, fever of 101°F, and vomiting for 24 hours. His mother reports that the child was playing with a box of toys that were brought down from the attic the day before. The nurse practitioner will: A. Wash the lesion and apply antibiotic cream B. Prescribe tazarotene 0.1% cream C. Apply hydrocolloid and silver-impregnated dressings D. Prescribe doxycycline 100 mg BID × 10 days

Solution: A Wash the lesion and apply antibiotic cream The history indicates the probability that the child was bitten by a brown recluse spider living in the box from the attic, as spiders prefer dark places to hide. The bite should be washed with soap and water and then treated with an antibiotic cream. A poisonous spider bite generally will form a blister (eschar) and then ulcerate. It can take several weeks to heal. Tazarotene cream is a retinoid prescribed for psoriasis. Hydrocolloid and silver-impregnated dressings are used to treat burns. Doxycycline is first-line treatment for the tick-borne diseases Rocky Mountain spotted fever and Lyme disease, which are generally contracted outside the house.

64.3% complete Question A 49-year-old male sustains burns to both the legs, abdomen, and chest that have manifested as painful blisters. What is the total percentage of body surface area for this superficial partial-thickness burn? A. 46% B. 54% C. 72% D. 36%

Solution: B 54% The calculation is based on the rule of nines for the body surface of an adult: 9% for each arm and the head, and 18% for each leg, anterior trunk, or posterior trunk. For children, it is 9% for each arm, 14% for each leg, and 18% for anterior trunk or posterior trunk.

A bulla is defined as: A. A solid nodule <1 cm in size B. A superficial vesicle filled with serous fluid >1 cm in size C. A maculopapular lesion D. A shallow ulcer

Solution: B A superficial vesicle filled with serous fluid >1 cm in size This is a blister—a circumscribed, fluid-containing, elevated lesion of the skin, usually >5 mm in diameter.

A mother brings in her 6-year-old daughter to see the nurse practitioner (NP). She complains that the school nurse found a few nits in her daughter's hair. The mother states that the school has a "no nits" policy regarding head lice and her daughter cannot go back to school until all the nits have been removed. The child was treated with permethrin shampoo (Nix) twice about 3 months ago. During the physical exam, the NP sees a few nits that are about 2 inches away from the scalp. The child denies itchiness on her scalp. Which of the following is the best action for the NP to follow? A. Prescribe lindane (Kwell) for the child because she may have head lice that are resistant to permethrin B. Advise the mother to use a nit comb after spraying the child's hair with white distilled vinegar, wait for 15 minutes, and then rinse the hair C. Advise the mother to re-treat the child with permethrin cream instead of sha

Solution: B Advise the mother to use a nit comb after spraying the child's hair with white distilled vinegar, wait for 15 minutes, and then rinse the hair According to the Centers for Disease Control and Prevention (CDC), nits that are more than ¼ inch from the scalp are usually not viable. The child also does not have an itchy scalp. One method of removal is to soak the patient's head with distilled vinegar (and then rinse after), which will break down the protein of the nit casings, making it easy to comb them out of the hair.

A 68-year-old female presents at the primary care clinic with complaints of whitish-looking papules in the vulvar region and a nonpruritic maculopapular rash on the soles of the feet. The patient is also experiencing alopecia and lymphadenopathy. Rapid plasma reagin is 1:8. Which diagnosis is most likely? A. Lichen planus B. Condylomata lata C. Molluscum contagiosum D. Condylomata acuminata

Solution: B Condylomata lata The patient is exhibiting signs and symptoms of secondary syphilis with infectious white papules in the vulvar area that look like white warts (condylomata lata). Condylomata lata may be skin-colored, white, pink, or yellowish. Additional data for secondary syphilis diagnosis includes alopecia, lymphadenopathy, maculopapular rash on the soles of the feet, and a rapid plasma reagin result of 1:8 (normal = 1:1). Condylomata acuminata are genital warts caused by the human papillomavirus (HPV). HPV warts are usually skin-colored with tan or bluish hues. Molluscum contagiosum is a poxvirus infection that can present anywhere on the skin in children, but in adults, it is usually located in the genital area and inner thighs of young adults. The lesions have a central umbilication with a white core. Lichen planus causes red patches and plaques, but the intact tissue may appear white or gray with a lacy pattern.

An adult visits the urgent care clinic with a fever of 104.2°F, vomiting, and petechiae on the hands and feet progressing to the trunk over the past 3 days. The nurse practitioner will prescribe? A. Ceftriaxone (Rocephin) 2 g IV every 12 hours B. Doxycycline BID × 10 days C. Rifampin PO every 12 hours × 2 days D. Cephalexin (Keflex) QID × 10 days

Solution: B Doxycycline BID × 10 days The patient likely has Rocky Mountain spotted fever. Doxycycline is the first-line treatment for Rocky Mountain spotted fever, a vector-borne (commonly by ticks) disease caused by the bacterium class Rickettsia rickettsii. The treatment is based on empirical diagnosis. To avoid possible complications, treat within 5 days; do not wait for lab results. Rifampin is indicated for treating close contacts of a patient with meningococcemia. If confirmed with meningococcemia, the patient will be admitted to the hospital and started on ceftriaxone (Rocephin) 2 g IV every 12 hours and vancomycin IV every 8 to 12 hours. Cephalexin (Keflex) is the preferred medication of choice for severe cases of impetigo.

Which diagnosis describes a chronic disease of the apocrine follicles and glands, characterized by clusters of abscesses and pustules in the axilla, groin, and perianal area? A. Mulloscum contagiosum B. Hidradenitis suppurativa C. Folliculitis D. Furuncle

Solution: B Hidradenitis suppurativa Hidradenitis suppurativa is a chronic disease and recurrent inflammatory disorder of the apocrine glands that results in painful pustules, nodules, and abscesses in areas such as the axilla, groin, perianal, and mammary areas. It is more common in women; risk factors include obesity and a history of smoking. Mulloscum contagiosum is a relatively common viral infection of the skin that results in round, firm, painless bumps ranging in size from a pinhead to a pencil eraser. Folliculitis is a common skin condition in which hair follicles become inflamed. It is usually caused by a bacterial or fungal infection. At first, it may look like small red bumps or white headed pimples around hair follicles. It is not a chronic condition. A furuncle, also known as a boil, is a painful infection that forms around a hair follicle and contains pus. It is not a chronic condition.

Your female patient of 10 years is concerned about her most recent diagnosis. She was told by her dermatologist that she has an advanced case of actinic keratosis. Which of the following is the best explanation for this patient? A .It is a benign condition B. It is a precancerous lesion and needs to be followed up with her dermatologist C. It will diminish with application of hydrocortisone cream 1% BID for 2 weeks D. It is important for her to follow up with an oncologist

Solution: B It is a precancerous lesion and needs to be followed up with her dermatologist Actinic keratoses are small, raised skin lesions that result from extended sun exposure. Some actinic keratoses may develop into skin cancer; therefore, further evaluation is needed to determine if removal is required.

The nurse practitioner is checking a 75-year-old woman's breast during an annual gynecological exam. The left nipple and areola are scaly and reddened. The patient denies pain or pruritus. She has noticed this scaliness on her left nipple for the past 8 months. Her dermatologist gave her a potent topical steroid, which she used twice a day for 1 month. The patient never went back for the follow-up. She still has the rash and wants an evaluation. Which of the following is the best intervention for this patient? A. Prescribe another potent topical steroid and tell the patient to use it twice a day for 4 weeks B. Order a mammogram and refer the patient to a breast surgeon C. Advise the patient to stop using soap on her breasts when she bathes to avoid drying up the skin on her areolae and nipples D. Order a sonogram of the breast and fine-needle biopsy of the breast

Solution: B Order a mammogram and refer the patient to a breast surgeon A scaly, reddened rash on the breast that does not resolve after a few weeks of medical treatment may indicate breast cancer. She should have a mammogram performed and see a breast surgeon for evaluation and treatment. Paget's disease of the breast is a rare type of cancer involving the skin of the nipple and, usually, the areola. It may be misdiagnosed at first because its early symptoms are similar to those caused by some benign skin conditions. Most patients with Paget's disease of the breast also have one or more tumors inside the same breast, either ductal carcinoma in situ or invasive breast cancer.

A patient presents to the clinic complaining of a painful, itchy rash on the elbows and knees that appears as raised erythematous patches of silvery, scaly skin. The patient states that the rash has occurred before but resolved without treatment. For which condition should the nurse practitioner treat? A. Impetigo B. Psoriasis C. Xerosis D. Contact dermatitis

Solution: B Psoriasis Psoriasis causes rapid cell build-up on the skin, causing red, dry, itchy, raised patches covered with silvery lesions. Plaques frequently occur on the elbows and knees but can occur on other body areas. Impetigo is an infection caused by gram-positive bacteria; the lesions are small, red, and pus-filled. Impetigo occurs most frequently in small children. Xerosis is an inherited skin disorder characterized by extremely dry mucosal skin surfaces. Contact dermatitis is an inflammatory skin reaction caused by direct exposure with an irritant. It can occur as a single lesion or generalized rash.

The mother of a 12-month-old infant reports to the nurse practitioner that her child had a high fever for several days, which spontaneously resolved. After the fever resolved, the child developed a maculopapular rash. Which diagnosis is most likely? A. Fifth disease (erythema infectiosum) B. Roseola infantum (exanthema subitum) C. Varicella D. Infantile maculopapular rashes

Solution: B Roseola infantum (exanthema subitum) Roseola infantum is a common viral rash that is caused by the human herpesvirus. The most common ages of onset are between 6 months and 2 years. The rashes are maculopapular (small, round, pink colored) rashes that first appear on the trunk and then spread to the extremities.

An 18-year-old female patient is being followed up for acne by the nurse practitioner. During the facial exam, papules and pustules are noted mostly on the forehead and the chin areas. The patient has been using over-the-counter topical antibiotic gels and medicated soap daily for 6 months without much improvement. The nurse practitioner will recommend: A .Isotretinoin (Accutane) B. Tetracycline (Sumycin) C .Clindamycin topical solution (Cleocin T) D. Minoxidil (Rogaine)

Solution: B Tetracycline (Sumycin) First-line treatment for acne vulgaris includes over-the-counter medicated soap and water with topical antibiotic gels. The next step in treatment would be the initiation of oral tetracycline.

65.0% complete Question A nurse practitioner sees a fair-skinned patient who is experiencing recurrent small acne-like pustules and papules on the cheeks, nose, and chin, as well as chronic dry eyes. Which diagnosis is most likely? A. Rocky Mountain spotted fever (RMSF) B. Herpes zoster ophthalmicus C. Acne rosacea D. Actinic keratosis

Solution: C Acne rosacea The patient is presenting with acne rosacea, a chronic inflammatory disease of the cheeks, chin, and nose, with dry, reddened eyes. First-line treatment is to determine triggers such as spicy foods and alcohol. Herpes zoster ophthalmicus affects one side of the head with sudden vesicular lesions on the scalp, nose, and forehead. The patient may also report photophobia, eye pain, and blurred vision. RMSF causes a rash, an abrupt onset of a high fever, chills, severe headache, photophobia, and nausea and vomiting. A petechial rash starts on the wrists, forearms, and feet and then moves up to the trunk. RMSF is caused by the bite of a dog tick that is infected with the parasite Rickettsia ricksettsii . Actinic keratosis is more common in older to elderly adults. Numerous dry, round, and red-colored lesions do not heal and mostly occur in sun-exposed areas. They may be precancerous lesions to squamous cell carcinoma.

A patient has several well-defined, primary lesions <20 mm over the trunk and extremities. After completing a dermascopic exam, the nurse practitioner diagnoses Bowen's disease. Which treatment will the nurse practitioner recommend? A. Moh's surgery B. Radiation therapy C .Curettage and electrodessication D. Standard excision

Solution: C Curettage and electrodessication The patient has Bowen's disease, a squamous cell cancer (SCC) of the epidermis that has not invaded the dermis yet. Curettage and electrodessication is an efficient, cost-effective method with low complication rates. Surgical treatments such as a standard excision (95% removal) and Moh's surgery (100% removal) are more invasive, and there is a greater risk for complications, especially in the elderly. Radiation therapy is not indicated for low-risk lesions.

The nurse practitioner is screening a patient for melanoma using the ABCD acronym. Which lesion size is an abnormal finding? A. Diameter <2 mm B Diameter <3 mm C. Diameter >6 mm D. Diameter <4 mm

Solution: C Diameter >6 mm In the ABCDE acronym for melanoma screening, the "D" is for the diameter of a lesion. If the lesion is larger than 6 mm (1/4) with asymmetry, border irregularity, color variety, and enlargement over time, the patient should be referred to a dermatologist.

A new patient who is a 40-year-old female postal worker is being evaluated for complaints of a new-onset erythematous rash on both cheeks and the bridge of the nose, accompanied by fatigue. She reports a history of Hashimoto's thyroiditis and is currently being treated with levothyroxine (Synthroid) 1.25 mg daily. Which of the following conditions is most likely? A. Atopic dermatitis B. Thyroid disease C. Lupus erythematosus D. Rosacea

Solution: C Lupus erythematosus Classic symptoms of lupus erythematosus are butterfly rash across both cheeks and the bridge of the nose and fatigue. Risk factors include being female and 40 years old. Rosacea also has a similar rash but usually not associated with fatigue.

A 7-year-old is brought to the clinic by his mother, who is concerned about "bumps" on his trunk and armpits lasting for several weeks. There are no complaints of pain or itching, and the child is afebrile. Upon examination, the nurse practitioner notes a cluster of 2-mm papules that are flesh-colored, dome-shaped, and smooth with a central umbilication. Which diagnosis is most likely? A. Secondary milia B. Verruca vulgaris C. Molluscum contagiosum D. Folliculitis

Solution: C Molluscum contagiosum Molluscum contagiosum is a viral condition common in children spread by direct contact. The condition is self-limiting, does not produce pain or itching, and resolves over several months. Milia are keratin-filled cysts that usually occur around the nose and eyes. Verruca vulgaris (warts) are viral and appear as irregular, raised, flesh-colored growths that feel rough to the touch. Folliculitis is an inflammation of the hair follicles, which can become pus-filled sores.

A 13-year-old boy wants to be treated for his acne. He has a large number of closed and open comedones on his face. The patient has been treating himself with over-the-counter benzoyl peroxide and topical salicylic acid products. Which of the following would be recommended next? A. Isotretinoin (Accutane) B. Tetracycline C. Retin-A 0.25% gel D. Careful face washing with medicated soap at bedtime

Solution: C Retin-A 0.25% gel Topical agents are the first-line treatment for acne vulgaris. Retin-A 0.25% gel would be the next step. Oral preparations (tetracycline) would then be offered, and Accutane would be the final step.

A 72-year-old woman complains of a crusty and nonhealing small ulcer on her upper lip that she has had for several years. Which of the following will the nurse practitioner recommend? A. Triamcinolone acetonide (Kenalog) cream BID × 2 weeks B. Triple antibiotic ointment BID × 2 weeks C. Hydrocortisone 1% cream BID for 2 weeks D. A referral to a dermatologist

Solution: D A referral to a dermatologist Nonhealing ulcers of the skin are a risk for skin cancer and should be evaluated by a dermatologist for treatment.

Which skin condition is caused by elevated androgen levels? A. Tinea corporis B. Onychomycosis C. Acne rosacea D. Acne vulgaris

Solution: D Acne vulgaris Acne vulgaris is most prevalent in the adolescence stage because of elevated androgen levels, bacteria (Propionibacterium acnes), and genetic factors. Severe cystic acne causes painful, indurated cysts and abscesses on the face, back, shoulders, and chest. Tinea corporis is ringworm of the body and creates ringlike pruritic scales that slowly enlarge over the body. Onychomycosis is a fungal infection of the nail, which becomes yellowed and thickened, with scaling under the nail; it is also known as tinea unguium. Acne rosacea is a chronic inflammatory skin disorder that occurs mostly in fair-skinned people and causes small acne-like papules and pustules on the cheeks, mouth, and chin.

The nurse practitioner sees a 58-year-old female patient with complaints of abscesses and pustules in the axilla and groin and under the breasts, which burst and drain purulent green discharge. She has a history of smoking and a body mass index (BMI) of 37.1. Which diagnosis is most likely? A. Impetigo B. Carbuncles C. Shingles D. Hidradenitis suppurativa

Solution: D Hidradenitis suppurativa. Hidradenitis suppurativa is most common in women (3:1). Smoking and obesity are significant risk factors. Lesions are treated with topical antibiotics (or oral antibiotics, warm compresses, and pain medications). Institute diet changes to reduce high glycemic and dairy food intake. Refer to a dermatologist for additional treatment options. Impetigo is caused by Group B streptococcus or Staphylococcus aureus and is more common in children. Lesions form under the nose and around the mouth, and it is very contagious. Dried lesions are honey colored. Carbuncles are a collection of multiple furuncles that are treated with systemic antibiotics. The lesions of shingles present as groups of vesicles and papules with a red base, which rupture and form dermatomal, crusted lesions on one side of the body.

Which of the following conditions is associated with a positive Auspitz sign? A. Contact dermatitis B. Seborrheic dermatitis C. Systemic lupus erythematosus D. Psoriasis

Solution: D Psoriasis The Auspitz sign is simply bleeding that occurs after psoriasis scales have been removed. It occurs because the capillaries run very close to the surface of the skin under a psoriasis lesion, and removing the scale essentially pulls the tops off the capillaries, causing bleeding. Auspitz sign is also found in other scaling disorders such as actinic keratoses.

The nurse practitioner will consider referring patients with all of the following burns to the ED or a specialist, except: A. Facial burns B. Electrical burns C. Burns that involve the cartilage of the ear D. Second-degree burns on the lower arm

Solution: D Second-degree burns on the lower arm Burns are described according to the depth of injury to the dermis and are loosely classified into first, second, third, and fourth degrees. A second-degree (superficial partial thickness) burn extends into the superficial (papillary) dermis. It appears red with clear blisters, blanches with pressure, has a moist texture, and is painful to sensation. A second-degree burn takes 2 to 3 weeks to heal. First- and second-degree burns are appropriately treated by a nurse practitioner. Third-degree burns should be referred to a physician. Examples of third-degree burns include electrical burns, severe burns on the face, and burns involving cartilage, such as the ear and nose.

45.0% complete Question The nurse practitioner is conducting a health history on a 39-year-old male patient with necrotic ulcers on his arms, face, and neck. The patient reveals that he is a livestock farmer. The nurse practitioner will: A. Isolate the patient in an examination room B. Administer the anthrax vaccine adsorbed (AVA) C. Prescribe ciprofloxacin (Cipro) D. Send a blood sample to the state lab and Centers for Disease Control and Prevention (CDC)

Solution: D Send a blood sample to the state lab and Centers for Disease Control and Prevention (CDC) A patient with suspected cutaneous anthrax requires a blood test to confirm Bacillus anthracis (grampositive rods). The blood sample should be sent to the state lab and the CDC for confirmation. Because anthrax is not contagious, there is no need to isolate the patient in an examination room. The anthrax vaccine is administered to specifi c populations (18 to 65 years), such as military personnel, veterinarians, and people who work with specific animals or in slaughterhouses. Once the diagnosis is confirmed and course of antibiotics completed, the vaccine can be administered.

Acanthosis nigricans is associated with all of the following disorders, except: A. Obesity B. Diabetes C. Colon cancer D. Tinea versicolor

Solution: D Tinea versicolor Acanthosis nigricans is a benign skin condition that is a sign of insulin resistance. It appears as hyperpigmented velvety areas that are usually located on the neck and the axillae. It is rarely associated with some types of adenocarcinoma of the gastrointestinal tract. Tinea versicolor is a superficial infection of the skin (stratum corneum layer) that is caused by dermatophytes (fungi) of the tinea family. Another name for it is sunspots.

60.0% complete Question The parent of a 5-year-old states, "My child has had a rash for the past week and cannot stop scratching it." Physical assessment reveals 1-mm papules and pustules, grayish-white burrows on the child's palms and soles of the feet, and excoriated skin with honey-colored crusting on the face and neck. The nurse practitioner will prescribe: A. Topical nystatin B. Oral griseofulvin C. Oral ketoconazole (Nizoral) D. Topical permethrin (Elimite)

Solution: D Topical permethrin (Elimite) The assessment findings are consistent with scabies and require the application of a scabicide such as topical permethrin (Elimite). Topical nystatin is used to treat candidal infections. Oral griseofulvin is used to treat different fungal infections. Oral ketoconazole (Nizoral) is reserved for severe fungal infections.

An obese middle-aged man with type 2 diabetes is diagnosed with familial hypercholesterolemia. During the physical exam, the nurse practitioner notes raised, sharply demarcated yellowish patches on the inner canthi of both eyes and on the upper and lower eyelids that are symmetric and nontender. Which of the following conditions is being described? A. Psoriasis B. Warts C. Xerosis cutis D. Xanthelasma

Solution: D Xanthelasma Xanthelasma is a benign subcutaneous lesion composed of cholesterol that usually develops around the eyelids. Approximately 50% of patients with xanthelasma have hyperlipidemia. Order a fasting lipid profile. If the patient desires treatment, the lesions can be removed by laser, application of trichloroacetic acid (TCA), or surgery. Xerosis cutis is a medical term for extremely dry skin. Psoriasis lesions can occur on the eyelid area. Warts are usually not located on the inner canthus or eyelids bilaterally and are not yellow in color.

INFECTIVE ENDOCARDITIS Most commonly caused by methicillin-sensitive _____ and methicillin-resistant _____.

Staphylococcus aureus (MSSA) Staphylococcus aureus (MRSA)

Tips for Solving Questions To solve a murmur question correctly, only two pieces of information are needed: ____ ____

Timing of the murmur (systole or diastole) Location of the murmur (aortic, Erb's point, or mitral area)

S2 (Diastole) Closure of the ____ and _____ valves

aortic pulmonic

MS (Mitral Stenosis) A low-pitched diastolic rumbling murmur Best heard at the ___ of the heart Also called an opening snap (use bell of the stethoscope)

apex (or apical area)

The lower border of the left ventricle is where the _____ is generated.

apical impulse

MR (Mitral Regurgitation) A pansystolic (or holosystolic) murmur Best heard at the apex (or apical area) of the heart May radiate to the ____ Loud blowing and high-pitched murmur (use the diaphragm of the stethoscope)

axilla

Atrial Fibrillation and Atrial Flutter Medications Rate control: Use ___, ___, ___. anticoagulation in patients with abnormal or damaged heart valves and end-stage chronic kidney disease (CKD):_____

beta-blockers calcium channel blockers (CCBs) digoxin Warfarin

Diastolic murmurs are always indicative of _____ (unlike systolic murmurs).

heart disease

S3 Heart Sound Usually indicative of ____ or ____ Sounds like "___" Always considered abnormal if it occurs after the age of ___ years This can be a normal finding in children, pregnant women, and some athletes (>35 years of age)

heart failure congestive heart failure (CHF) Kentucky 40

S4 Heart Sound Increased resistance due to a stiff ___ ventricle; usually indicates ____ Sounds like "____" Best heard at the _____

left LVH Tennessee apex

S1 (Systole) Closure of the _____ and _____ valves

mitral tricuspid

Systolic Murmurs Use the "MR. ASS" (____ = systolic) mnemonic.

mitral regurgitation/aortic stenosis

Diastolic Murmurs Use the "MS. ARD" (____ = diastolic) mnemonic.

mitral stenosis/aortic regurgitation

AS (Aortic Stenosis) A midsystolic ejection murmur Best heard at the second ICS at the right side of the sternum May radiate to the ____ A harsh and noisy murmur (use diaphragm of stethoscope). Patients with aortic stenosis should avoid physical overexertion, because there is increased risk of sudden death. Refer to cardiologist. Aortic stenosis is monitored by serial cardiac sonograms with Doppler flow studies. Surgical valve replacement needed if it worsens.

neck

Physiological S2 Split Best heard over the ___ pulmonic area (or second ICS on the upper left side of sternum); caused by splitting of the aortic and pulmonic components.

pulmonic

Typical angina is usually of brief duration (2-5 minutes) and is relieved by ___ and/or ___.

rest nitroglycerin

The _____ ventricle is the chamber of the heart that lies closest to the sternum.

right

AR (Aortic Regurgitation) A high-pitched diastolic murmur (use diaphragm of the stethoscope) If AR is due to a diseased aortic valve, the murmur is located at the third ICS by the left sternal border (Erb's point). If AR is due to an abnormal aortic root, the murmur is best heard at the ____.

right upper sternal border (aortic area)

All benign murmurs occur during ___.

systole

On the exam, only the ____ murmurs radiate (to the axilla in ____ and to the neck with ____).

systolic mitral regurgitation aortic stenosis

Benign murmurs do not have a __.

thrill