PC1 GI Quiz Questions

Mr. G 39-yr-old • Sx: dysuria, frequency, urgency, malaise and perineal pain x 5 days. No fever. • Hx: Unprotected sex with new partner 2 wks. ago. • PMH: none • Meds: none • NKDA • DX Acute prostatitis What labs? What tx? When to f/u?

-labs: UA culture, GC &chlamydia -tx: Ceftriaxone 250 mg IM x1 and Doxycycline 100 mg BID x 10 days. -f/u: 10 days

Crohn's disease, which can affect any part of the gastrointestinal tract from the mouth to the rectum, carries a higher risk if the colon is involved. Colonoscopy with random biopsies every ______ years is recommended beginning ______ years after the irritable bowel disease began.

1-2 8-10

Risk factors for anal cancer include the following (choose all that apply): A. Human papillomavirus (HPV) infection B. Smoking C. Condyloma acuminatuma D. history of cystic fibrosis E. More than 4 alcoholic drinks per week F. Lymphogranuloma venereum G. Chronic fistulas

A, B, C, F, G

Janet's laboratory results are as follows: HBsAG - positive anti HBc - positive IgM anti HBc - negative anti HBs - negative Anti-HAV - positive Anti-HCV - nonreactive AST - 56 unit/L (0-40) ALT - 98 unit/L (0-40) These findings are most consistent with which of the following? Choose all that apply. A. Chronic hepatitis B B. Evidence of hepatitis B infection immunity C. Evidence of hepatitis A immunity D. Acute hepatitis B infection E. Evidence of hepatitis C infection

A, C HBsAG - positive (evidence of hepatitis B infection - the next three tests are consistent with chronic hepatitis; the patient presents with no symptoms which would be unusual if acute hep B. ) anti HBc - positive IgM anti HBc - negative anti HBs - negative Anti-HAV - positive (indicates immunity to hep A) Anti-HCV - nonreactive (no evidence of past or present HCV)

Gina is a 44 y/o pt is here for a follow-up you suspect viral hepatitis based on her history and presenting symptoms. Which lab indicates viral hepatitis? A. ALT elevated, AST normal B. PT elevated C. ALP elevated D. ALT normal, AST elevated

A. ALT>AST in viral hepatitis; other LFT elevations are not associated with hepatitis.

In 2020, approximately how many cases of Chlamydia trachomatis infections were reported in the United States? A. 1,600,000 B. 725,000 C. 4,750,000 D. 250,000

A. 1,600,000

During a DRE on a 75-year-old man, the clinician suspects the patient has prostate cancer. What physical finding should make the clinician suspicious? A. A nodular and unusually firm gland B. smooth gland C. tender gland D. boggy gland

A. A nodular and unusually firm gland Rationale: Patients with suspected prostate cancer will have a nodular and unusually firm gland. A tender or boggy gland is related to prostatitis. A smooth gland would be a normal finding.

It is recommended that health care professionals consider IBS if a patient reports: A. Abdominal pain or discomfort, bloating, or a change in bowel habit consistently for 6 months. B. Nausea and vomiting associated with postprandial fullness and bloating. C. Acute, cramping with intermittent abdominal pain that's duration is less than 1 month. D. Intermittent epigastric pain associated with bloating, feeling of fullness, and increased eructation.

A. Abdominal pain or discomfort, bloating, or a change in bowel habit consistently for 6 months. It is recommended that health care professionals consider IBS if a patient reports Abdominal pain or discomfort, bloating, or a change in bowel habit consistently for 6 months. (Buttaro, 699)

Which of the following is true about solitary rectal ulcer syndrome? A. Associated lesions may be solitary or multiple and ulcerated or nonulcerated B. Lesions are typically located in the posterior rectal wall extending 10-12 cm from anal verge. C. A common precipitating factor is frequent episodes of diarrhea. D. There is rarely passage of blood or mucous.

A. Associated lesions may be solitary or multiple and ulcerated or nonulcerated The syndrome is poorly named because associated lesions may be solitary or multiple and ulcerated or nonulcerated; they range from mucosal erythema to ulcers to small mass lesions. Lesions are typically located in the anterior rectal wall within 10 cm of the anal verge. Affected patients have straining during defecation, a sense of incomplete evacuation or pelvic fullness, and sometimes passage of blood and mucus by rectum.

At what age should a discussion about family history and colorectal cancer (CRC) screening with the primary care physician begin? A. Before 40 years old B. After 45 years old C. Between 50 and 55 years old C. After 60 years old

A. Before 40 years old Family history and screening discussions should start before age 40 years with the primary care physician. This allows for the identification of patients with risk factors that warrant earlier screening and helps prepare average-risk patients to begin screening when recommended.

A 24-year-old man presents to a clinic with a diffuse macular and papular rash on his chest, back, hands, and feet. He had two new male sexual exposures approximately 6 weeks ago. He now has a positive Venereal Diseases Research Laboratory (VDRL) test with a titer of 1:256. He had a negative syphilis test about 3 months ago. He has no other symptoms and his neurologic examination is normal. He has no known antibiotic allergies. What treatment is indicated? A. Benzathine penicillin G 2.4 million units IM in a single dose B. Benzathine penicillin G 2.4 million units IM weekly for 3 total doses C. Ceftriaxone 250 mg IM in a single dose plus azithromycin 1 g orally in a single dose D. Doxycycline 200 mg twice a day for 3 days

A. Benzathine penicillin G 2.4 million units IM in a single dose

Which one of the following is not a common cause of obstruction of the appendix which leads to appendicitis? A. Blunt trauma to abdomen. B. Hardened feces (fecalith) C. Inflammatory process such as bacteria or viruses. D. Foreign bodies such as vegetable or fruit seeds

A. Blunt trauma to abdomen. Hardened feces, inflammatory process such as bacteria, viruses, or parasites, or foreign bodies such as vegetable or fruit seeds are all potential causes of obstruction of the appendix. Strictures or neoplasms are also potential causes. Blunt trauma to the abdomen is not a common cause of appendicitis. There have been some exceedingly rare reported cases, but trauma is not a common cause.

A 23-year-old woman is diagnosed with gonococcal cervicitis based on purulent discharge and Gram's stain findings. Results for chlamydia are pending. She has an intrauterine device for birth control, and a urine pregnancy test in the clinic is negative. Which one of the following regimens is recommended? A. Ceftriaxone 500 mg IM in a single dose plus oral doxycycline 100 mg twice daily for 7 days B. Ciprofloxacin 500 mg orally in a single dose plus azithromycin 1 g orally in a single dose C. Ceftriaxone 125 mg IM in a single dose plus doxycycline 100 mg twice daily for 7 days D. Cefixime 400 mg orally in a single dose plus doxycycline 100 mg twice daily for 3 days

A. Ceftriaxone 500 mg IM in a single dose plus oral doxycycline 100 mg twice daily for 7 days

Successful treatment for an adult patient with Helicobacter pylori-induced peptic ulcer disease requires therapy with which regimen? The patient has no known drug allergies and has never taken a macrolide. A. Clarithromycin, amoxicillin, and omeprazole (Prilosec) for 14 days. B. Bismuth (Pepto-Bismol), cephalexin (Keflex), and metronidazole (Flagyl) for 10 days. C. Amoxicillin, bismuth (Pepto-Bismol), metronidazole (Flagyl), and cimetidine (Tagamet) for 10 days. D. Clarithromycin, tetracycline, cephalexin (Keflex), and lansoprazole for 14 days.

A. Clarithromycin, amoxicillin, and omeprazole (Prilosec) for 14 days. Patients with gastric or duodenal ulcers caused by H. pylori can be successfully treated with triple-drug therapy: a proton-pump inhibitor (PPI; bid for all except esomeprazole, which is qd), clarithromycin, and amoxicillin or metronidazole for 14 days (eradication rates 70%-85%). An alternative regimen approved by the U.S. Food and Drug Administration is a quadruple regimen with a (qd or bid) histamine 2 receptor antagonist (bid), metronidazole, bismuth, and tetracycline for 10-14 days (eradication rates 75%-90%). Treatment should continue with a PPI for at least 2-4 weeks after to promote healing of the ulcer. After completion of H. pylori therapy, it is recommended that testing is done with the stool antigen for H. pylori at 8 weeks to ensure eradication of the infection. The PPI would need to be stopped for 2 weeks before testing the stool because there can be false-negative results. Other treatment regimens have been suggested, but eradication rates can vary. Cephalosporins are not included in any recommended regimens for H. pylori.

The family nurse practitioner knows that in patients with ulcerative colitis that involves the entire colon (universal or pancolitis), careful surveillance of the colon is required because of an increased risk of: A. Colon cancer. B. Diverticulosis. C. Ischemic colitis. D. Irritable bowel syndrome.

A. Colon cancer. Colorectal cancer (CRC) risk in patients with left-sided and universal ulcerative colitis increases by 0.5%-1% per year after the eighth year of disease. Ulcerative colitis limited to the proctosigmoid region carries less of a risk. Crohn's disease, which can affect any part of the gastrointestinal tract from the mouth to the rectum, carries a higher risk if the colon is involved. Colonoscopy with random biopsies every 1-2 years is recommended beginning 8-10 years after the irritable bowel disease began. Diverticulosis is common in the general population but is less common in ulcerative colitis and is not a risk factor for CRC. Ischemic colitis occurs when a mesenteric artery is temporarily blocked and the colon at the splenic flexure develops ischemia from lack of blood flow. There is no higher risk of ischemic colitis for patients with ulcerative colitis. Irritable bowel syndrome is common in the general population and in patients with ulcerative colitis, but it is a disorder of brain-gut interaction and does not increase risk of colon cancer.

A 45-year-old patient presents with a CC of generalized abdominal pain. Her physical exam is remarkable for LLQ tenderness. At this time, which of the following should be considered in the DDx? A. Endometriosis B. Yersinia enterocolitica infection C. Appendicitis D. GERD

A. Endometriosis For female patients and especially those presenting with LLQ pain, endometriosis should be in your list of DDx. A yersinia enterocolitica infection is one of the bacteria that causes gastroenteritis which presents as diffuse abdominal pain. Appendicitis is associated with RLQ pain and GERD epigastric pain.

Gastroesophageal reflux disease (GERD) requires a referral to gastroenterology when the patient reports: A. Eructation and burning accompanied by periodic difficulty swallowing. B. Persistent epigastric burning that is worsened when supine. C. Epigastric burning accompanied by extraesophageal symptoms. D. Symptoms not relieved by a daily prescription-strength PPI.

A. Eructation and burning accompanied by periodic difficulty swallowing. "Alarm" symptoms in GERD that warrant further evaluation include dysphagia (difficulty swallowing), odynophagia (painful swallowing), gastrointestinal bleeding, unexplained weight loss, and persistent chest pain.

Which of the following is part of the treatment plan for the patient with IBS? A. High-fiber diet B. A discussion that the goal of treatment is to cure their disease C. Daily laxatives D. A conversation about their expected shorter life span

A. High-fiber diet Diets high in fiber are beneficial regardless of predominant bowel habit. Patients are encouraged to increase their fiber intake to 20 to 30 grams per day. Patients with IBS are often dissatisfied with treatment because no organic cause of their symptoms can be found and therefore a goal of treatment being a cure is unrealistic. Daily or long-term use of laxatives is not recommended only intermittent use. Patients with IBS do not have a shorter life span.

Which one of the following is most effective in diagnosing acute appendicitis? A. History and physical B. Sedimentation rate C. Kidney, ureter, and bladder x-ray (KUB) D. CBC with diff

A. History and physical Diagnosis of acute appendicitis is made clinically and is based primarily on the patient's history and physical exam. Labs such as sedimentation rate and CBC with diff are not diagnostic and are nonspecific, so they must be used in combination with data from H&P. No radiologic exam is of diagnostic importance early in appendicitis, but might become more important as appendicitis progresses.

A 19-year-old man is evaluated in the clinic with a purulent urethral discharge. A Gram's stain is performed on a sample of the discharge. Which one of the following is most consistent with a diagnosis of gonorrhea? A. Intracellular gram-negative diplococci B. Abundant white blood cells with no visible organisms C. Extracellular gram-positive cocci in chains D. Extracellular gram-negative rods in rows

A. Intracellular gram-negative diplococci

A 47-year-old male presents with chronic nausea and vomiting. Vital signs are unremarkable. Physical exam is only pertinent for mild tenderness to palpation in the epigastric region. Laboratory reports were unremarkable and an esophagogastroduodenoscopy was normal. A stable isotope (13Cspirulina) breath test showed delayed rates of emptying at all time points up to 240 minutes. Which pharmacologic agent would be the most appropriate to start? A. Metoclopramide B. Haloperidol C. Nortriptyline D. Relamorelin

A. Metoclopramide In patients with idiopathic and DG, pharmacologic treatment should be considered to improve GE and GP symptoms, considering benefits and risks of treatment. The guideline suggests treatment with metoclopramide over no treatment for management of refractory symptoms. Domperidone is available for treatment of GP under a special program administered by the FDA.. While tricyclic antidepressants may be considered in causes of refractory nausea and vomiting, caution must be exercised as some of these drugs may exhibit anticholinergic effects which could work to slow down gastric transit Current data do NOT support the use of ghrelin agonists (relamorelin) for management of GP (strong recommendation, moderate quality of evidence). Current data do NOT support the use of haloperidol for treatment of GP (conditional recommendation, low quality of evidence).

Which of the following patients is eligible to begin CRC screening at age 40 with colonoscopy as the preferred screening methodology? A. Patient who has a father with CRC diagnosed at age 50 B. Patient who has no personal or family history of polyps or CRC C. Patient who has a maternal uncle who had CRC at age 70 years D. Patient who has no personal history of CRC but has an aunt who had polyps at age 75 years

A. Patient who has a father with CRC diagnosed at age 50 Based on several different guidelines, the current recommendation is for a patient to begin screening with colonoscopy at age 40 or 10 years before the age at diagnosis of the affected relative, for patients with CRC diagnosed before age 60 in a first-degree relative (parents or siblings).

Which one of the following most accurately describes recommendations for chlamydia screening in asymptomatic females? A. Perform annual screening in sexually active females 24 years or younger and in older women who are at increased risk for chlamydial infection B. Perform annual screening in sexually active females 15-20 years of age and in older women who have a prior history of a sexually transmitted disease C. Perform one-time screening in all sexually active females 25-30 years of age D. Perform one-time screening in all sexually active females 21-25 years of age

A. Perform annual screening in sexually active females 24 years or younger and in older women who are at increased risk for chlamydial infection

What is the treatment of choice for a patient diagnosed with testicular cancer? A. Radical orchiectomy B. Lumpectomy C. Radiation implants D. Chemotherapy

A. Radical orchiectomy Rationale: Treatment of choice for patients with testicular cancer is a radical orchidectomy. The other options are incorrect and not a reasonable option for a good long-term prognosis.

The nurse practitioner is evaluating a 57-year-old female who complains of an intermittent burning in the middle of her chest. The patient says that it isn't really painful, but it's just "not right" and it is happening a few times a week - enough that she feels it needs to be evaluated. Further discussion reveals that the discomfort seems to happen when she gets to work in the morning, and sometimes again after dinner when she is trying to relax. She denies any nausea, vomiting, or eructation, or bleeding. Her review of systems is significant only for a 10 lb (4.5 kg) weight loss in the last 4 months that she says concerns her a bit because she wasn't trying to lose weight. Stool is heme negative. The appropriate action on the part of the nurse practitioner would be to: A. Refer to gastrointestinal for endoscopic evaluation. B. Order a daily proton pump inhibitor (PPI) and have the patient follow-up in 4 weeks C. Suggest that the patient begin treatment with omeprazole (Prilosec-OTC) prn. D. Explore psychosocial causes of symptoms related to job anxiety.

A. Refer to gastrointestinal for endoscopic evaluation. The course of GERD is usually straightforward. However, "alarm" symptoms in GERD that warrant further evaluation include dysphagia (difficulty swallowing), odynophagia (painful swallowing), gastrointestinal bleeding, unexplained weight loss, and persistent chest pain. The development of iron-deficiency anemia as a result of chronic low volume GI blood loss in the presence of GERD symptoms is a rare but worrisome finding. A component of the additional evaluation is referral to gastroenterology for upper endoscopy. These alarm findings can be indicative of erosive esophagitis or esophageal cancer; upper endoscopy can clarify the diagnosis and provide, if required, a vehicle of esophageal biopsy.

A 72-year-old man comes to the office for evaluation. For 5 years, he has taken tamsulosin 0.4 mg/d for lower urinary tract symptoms associated with BPH. DRE reveals an asymmetric prostate with a hard nodule in the left lower lobe. The remainder of the examination is normal. Urinalysis is normal. His PSA level is 9.5 ng/mL. Which of the following is the most appropriate next step? A. Referral to urologist B. Bone scan C. CT pelvis D. MRI pelvis E. Measurement of free PSA

A. Referral to urologist

Which one of the following medications would be contraindicated in a patient taking vardenafil (Levitra) for ED? A. Tamsulosin (Flomax) B. Lisinopril C. Simvastatin (Zocor) D. Meloxicam (Mobic)

A. Tamsulosin (Flomax) Oral agents for ED such as Viagra, Levitra, Cialis, and Stendra should be avoided in patients taking alpha blockers (e.g., tamulosin).The other medications would not be contraindicated with vasoactive drugs for ED.

Tommy, age 15, comes to the clinic in acute distress with "belly pain." When obtaining his history, the nurse practitioner (NP) finds that he fell off his bike this morning and has vomited. Upon closer examination, the NP determines the belly pain to be left-sided groin pain or pain in his left testicle. He is afebrile and reports no dysuria. Which of the following diagnoses is most likely? A. Testicular torsion B. Epididymitis C. Hydrocele D. Variocele

A. Testicular torsion Testicular torsion is a condition in which the testis twists on the spermatic cord, thereby compromising blood flow to the testicle. This is a surgical emergency. Examination usually reveals a tender scrotal mass high in the hemiscrotum, and there is frequently a reactive hydrocele around the testis, obscuring anatomical detail. The scrotum can become erythematous and edematous. The cremasteric reflex is frequently blunted on the side of the torsion.Epididymitis is usually accompanied by fever, as well as urethral discharge, and usually occurs in boys older than Tommy.Although a hydrocele may develop secondary to testicular torsion, the intense discomfort and acute onset, accompanied often by nausea, distinguish the possibility of testicular torsion.A varicocele, which usually occurs in young men, may cause pain but does not usually develop acutely.

A 30-year-old man is seen with a c/o loss of libido. Which of the following laboratory tests would help establish a diagnosis? A. Testosterone level B. Prostate-specific antigen C. Nocturnal penile tumescence and rigidity D. Prolactin level

A. Testosterone level Based on the patient's c/o loss of libido, starting with lab tests to assess his level of testosterone would be the most beneficial. Testosterone levels peak during adolescence and early adulthood and then gradually decline about 1% per year after age 30 years. The other laboratory tests would not be indicated to assess for c/o loss of libido.

A 13-year-old patient you are treating for functional constipation asks you what nonmedical therapies are helpful. Which one of the following recommendations is appropriate? A. The patient should eat five servings of fruits and vegetables per day to get the recommended amount of fiber. B. One hour or more of moderate-intensity exercise per week will improve symptoms. C. The patient should try to drink two times the normally recommended daily intake of water. D. Biofeedback has been shown to be effective in treating functional constipation.

A. The patient should eat five servings of fruits and vegetables per day to get the recommended amount of fiber. Management of constipation includes dietary modifications, behavior interventions, medications, and disimpaction if needed. Children and adolescents obtain adequate daily fiber intake from five servings of fruits and vegetables. Recommended daily fiber intake can be calculated by adding 5 g to the child's age in years.

During what decades of life of the male patient will early signs of BPH usually appear? A. Third and fourth decades B. Fourth and fifth decades C. Fifth and sixth decades D. Sixth and seventh decades

A. Third and fourth decades Rationale: The earliest histological signs of BPH usually appear in their third and fourth decades of life. Therefore obtaining a thorough history of GU symptoms and performing a prostate exam for all yearly physicals is important.

Which of the following is a true statement about rectal prolapse and procidentia? A. Transient, minor prolapse of just the rectal mucosa often occurs in otherwise normal infants. B. Mucosal prolapse in adults usually resolves in less than a week. C. The most prominent symptom of rectal prolapse and procidentia is severe rectal pain. D. The clinician should examine the patient while the patient in the lithotomy or sims position.

A. Transient, minor prolapse of just the rectal mucosa often occurs in otherwise normal infants. Transient, minor prolapse of just the rectal mucosa often occurs in otherwise normal infants. Mucosal prolapse in adults persists and may progressively worsen. The most prominent symptom of rectal prolapse and procidentia is protrusion. It may only occur while straining or while walking or standing. Rectal bleeding can occur, and incontinence is frequent. Pain is uncommon unless incarceration or significant prolapse occurs. To determine the full extent of the prolapse, the clinician should examine the patient while the patient is standing or squatting and straining.

True or false, patients with a history of undescended testicle has a 40% increased risk of developing testicular cancer? A. True B. False

A. True All male patients should be taught self-scrotal exam at puberty. This is especially important with patients with a history of undescended testicle due to 40% increased risk of testicular cancer.

For patients presenting with suspected acute prostatitis, massaging the prostate is not recommended? A. True B. False

A. True Avoid vigorous massage of the prostate in acute prostatitis. Vigorous massage can cause septicemia.

A patient with testicular cancer will often present with a hard lump or nodule on his testis that was felt during a testicular self-examination. In addition, testicular cancer usually presents as a painless enlargement of the testis. A. True B. False

A. True Rationale: Patients who present with c/o hard lump or nodule felt in testis upon self-exam will also report painless enlargement of the testis.

Prostate cancer is the most common cancer found in American men and most men do not die from it. A. True B. False

A. True Rationale: Prostate cancer is the most common cancer found in American men and ranks 3rd in the number of cancer deaths (lung and colorectal are first and second). Most men diagnosed with prostate cancer do not die from it. Sixty-seven percent of men 80 years and older have prostate cancer but only about 3% are expected to die from it.

Rectal bleeding associated with anal fissure is usually described by the patient as: A. drops of blood noticed when wiping. B. dark brown to black in color and mixed in with normal-appearing stool. C. a large amount of brisk red bleeding. D. significant blood clots and mucus mixed with stool.

A. drops of blood noticed when wiping. If rectal bleeding is noted with anal fissure, this is usually limited to drops of blood noted when wiping, not protracted bleeding.

Indirect inguinal hernias result when tissue herniates through the: A. internal inguinal ring B. external inguinal ring C. Hesselbach's triangle D. femoral ring

A. internal inguinal ring The internal inguinal ring is a common site for development of an indirect inguinal hernia.

What is the most common presentation of upper GI bleeding? A. melena B. hematochezia C. epigastric pain D. hypovolemia

A. melena Melena represents an upper GI source 85% to 95% of the time, and hematochezia from a briskly bleeding upper GI source accounts for 15% of cases.

Match the serology results with the correct interpretation. HBsAG - positive IgM anti-HBc - positive Anti HBc - positive Anti HBs - negative

Acute Hepatitis B infection

Henry is a 40 year-old man who has a past history of injection drug use, currently with 5 years of sobriety. He is unsure about his vaccine history but believes he has "some when I was a little kid." He does not have any complaints of current or recent illness. Results of recent laboratory test reveal the following: AST - 45 (0-40) ALT - 72 (0-40) You run a Hepatitis screen on him and the results are as follows: Anti HAV - negative HBsAg - negative Anti HBc - positive Anti HBs - positive Anti HCV - reactive What do these results mean? Mark all that apply. A. Chronic hepatitis B infection B. Immunity to hepatitis B due to natural infection C. Immunity to hepatitis B due to hepatitis B vaccination D. Hepatitis C infection confirmed E. Hepatitis C infection suspected, needs confirmation

B, E Anti HAV - negative (indicates no current hep A infection) HBsAg - negative (indicates not a current hep B infection) Anti HBc - positive (indicates a previous or ongoing infection; we can r/o ongoing infection because the HBsAg is negative) Anti HBs - positive (indicates recovery and immunity from hep B infection or vaccine) Anti HCV - reactive (recent exposure is suspected, need to test for HCV RNA for confirmation)

You are seeing a 4-month-old male in the clinic for his well-child exam. The mom is concerned that his right testis has not descended and is concerned the child will need surgery. The NP knows that there is no need for concern at this point. He proceeds to educate the mom that most undescended testes descend spontaneously by what age? A. 1 year B. 6 months C. 9 months D. 15 months

B. 6 months Most undescended testes will spontaneously descend by 6 months of age. If the testes have not spontaneously descended by 6 months of age, refer the patient to a pediatric urologist for laparoscopic or open orchiopexy.

A 32-year-old woman who is at 30 weeks' gestation comes to the office because she has had pain on defecation during the past week. She says she also has had pain when attempting to cleanse the anal region as well as pain when sitting. Based on these findings, which of the following types of hemorrhoid is most likely to be noted on further evaluation of this patient? A. Internal B. External C. Thrombosed D. Strangulated

B. External This type of hemorrhoid causes pain on defecation, pain with sitting, and pain on attempting to cleanse the anal region. Choice B: Internal hemorrhoids are not as painful as external hemorrhoids, and they often cause bleeding during defecation with the sensation of incomplete evacuation. Choice C: The patient's symptoms would be much more intense and would perhaps be accompanied by itching. Choice D: A thrombosed hemorrhoid would also include necrosis and ulceration of a protrusion.

A four-year-old male child has presented to your clinic with a chief complaint of abdominal pain. You recall that the classic triad for intussusception includes: A. Cramping pain in the abdomen with petechiae and purpura. B. Intermittent abdominal pain, vomiting, and bloody mucous stools. C. Progressive vomiting, projectile vomiting, and palpable "olive". D. Palpable mass in scrotum, scrotal bowel sounds, and disappearing mass.

B. Intermittent abdominal pain, vomiting, and bloody mucous stools. The classic triad for intussusception is intermittent colicky (crampy) abdominal pain, vomiting, and bloody mucous stools.

Which of these is one of the most common dietary triggers of IBS? A. Gluten-free items B. Lactose C. Honey D. Meat

B. Lactose The most common dietary triggers are lactose, fructose, sorbitol, and glutens.

Which one of the following is TRUE regarding the following definitions related to late latent syphilis? A. Late latent syphilis refers to syphilis infection of at least 6 weeks in duration B. Late latent syphilis refers to syphilis infection of at least 1 year in duration C. Late latent syphilis refers to syphilis infection of at least 6 months in duration D. Late latent syphilis refers to syphilis infection of at least 12 weeks in duration

B. Late latent syphilis refers to syphilis infection of at least 1 year in duration

Patients presenting with s/s associated with pancreatitis may c/o referred pain to what area? A. Right scapula B. Left upper/posterior shoulder/trapezius C. Left upper chest D. Right upper/posterior shoulder

B. Left upper/posterior shoulder/trapezius Patients presenting with s/s of pancreatitis may c/o referred pain to the left upper/posterior shoulder. Referred pain to right scapula can be associated with cholecystitis. Left upper chest referred pain associated with heart issues and right upper/posterior shoulder associated with perforated duodenal ulcer.

Which one of the following tests can be performed to aid the provider in diagnosing a patient with epididymitis? A. Stroking the inner part of the thigh (cremasteric reflex) B. Lifting the scrotum above the pubic symphysis (Prehn's sign) C. Patient is lying supine and then having the patient internally and externally rotate the flexed right hip (Obturator sign) D. Perform deep palpation of LLQ (Rovsing's sign)

B. Lifting the scrotum above the pubic symphysis (Prehn's sign) Rationale: In epididymitis, the pain often improves when the scrotum is elevated above the level of the pubic symphysis (Prehn's sign). The cremasteric reflex test is used to r/o testicular torsion. Obturator and Rovsing's signs are used to r/o etiologies of abdominal pain (e.g., acute appendicitis).

Which one of the following would not be found upon digital rectal exam for a patient with prostatitis? A. Boggy prostate B. Nodular prostate C. Enlarged prostate D. Tender prostate

B. Nodular prostate If a nodular prostate is noted upon DRE, consider prostate cancer as a possible diagnosis. Patients presenting with prostatitis will have a boggy, enlarged and often tender prostate.

A 34-year-old female with a history of diabetes presents with 3 months of chronic nausea, vomiting, postprandial fullness, and epigastric abdominal pain. The vomiting has become more severe and led the patient to self-medicate with daily T. The patient uses an insulin pump and has continuous glucose monitoring. Pertinent physical examination findings include BP 100/60 mm Hg, pulse 80 beat per minute, and respiratory rate of 12 breaths per minute. There is tenderness to palpation in epigastrium with audible bowel sounds and a succussion splash. Laboratory values show the following results: Leukocyte count 6,000/μL Hemoglobin, serum 11.3 g/dL Sodium, serum 137 meq/L Chloride, serum 100 meq/L Bicarbonate, serum 27 meq/L Creatinine, serum 0.9 mg/dL Thyroid-stimulating hormone 2.5 μU/mL Albumin 3.8 g/dL Hemoglobin A1c 6.5% An esophagogastroduodenoscopy shows showing retained gastric food. Gastric biopsies are unremarkable. What is the next appropriate step in managing this patient? A. Initiate metoclopramide B. Obtain a 4-hour scintigraphic gastric emptying test C. Obtain a wireless motility capsule test D. Advise the patient to stop the use of cannabinoids

B. Obtain a 4-hour scintigraphic gastric emptying test You first instinct is to advise the patient to stop the use of cannabinoids. Cannabinoids dramatically improve the symptoms of gastroparesis. Furthermore, an improvement in abdominal pain with cannabinoids represents a breakthrough for gastroparesis-associated abdominal pain treatment, for which there are currently no validated therapies. (this is not in the guideline). According to the guideline, the next step is to obtain a 4-hour scintigraphic gastric emptying test. She has already had and endoscopy. Metoclopramide is an option (although with side effects) if dietary changes do not help. WMC testing may be an alternative to the SGE assessment forthe evaluation of GP in patients with upper GI symptoms (conditional recommendation, low quality of evidence).

John presents with complaints of a "weird feeling that hurts" in his buttocks. He notes that he often feels urgency to urinate and defecate, but "nothing comes out" when he tries. Which of the following diagnoses is most likely? A. Urinary tract infection B. Prostatitis C. Erectile dysfunction D. Peyronie's disease

B. Prostatitis Patients may present with tenesmus (a spasmodic contraction of the anal sphincter), with pain and a persistent desire to empty bowel or bladder. Symptoms of a UTI are typically dysuria, frequency, and urgency. Patient with ED will complain of not being able to obtain and maintain an erection. Peyronie's disease involves the penis being bent rather than straight which can lead to pain and cause ED.

Which one of the following statements is TRUE regarding the epidemiology of gonococcal infections in the United States? A. Oregon is the state with the highest rate of reported cases B. Rates of reported cases are higher in males than in females C. Among different age groups, rates of reported cases are highest in those 35-39 years of age D. Rates of reported cases have decreased significantly in recent yea

B. Rates of reported cases are higher in males than in females

Samuel, a 62-year-old who takes many different medications, is complaining of erectile dysfunction (ED). The nurse practitioner knows that several medications could be the cause of Samuel's problem. Which of his medications is the most likely culprit? A. Furosemide (Lasix) B. Reserpine (Serpasil) C. Omeprazole (Prilosec) D. Isosorbide (Imdur)

B. Reserpine (Serpasil) Diuretics such as furosemide (Lasix) have not been shown to cause ED.The following medications have been shown to cause ED: antiandrogens, antihypertensives such as beta blockers and central sympatholytics (reserpine), anticholinergics, antidepressants, antipsychotics, central nervous system depressants, and drugs of abuse such as alcohol, tobacco, and heroin.Proton pump inhibitors such as omeprazole (Prilosec) have not been shown to cause ED.Vasodilators such as isosorbide (Imdur) have not been shown to cause ED.

Which of the following is a complementary therapy for BPH? A. Red raspberry lead tea B. Saw palmetto C. Black cohosh D. Vitamin A

B. Saw palmetto A recommend complementary therapy for patients with BPH is saw palmetto - 320 mg daily. The other options are not recommended complementary therapies for BPH

A 12-year-old boy presents to the clinic s/p appendectomy 3 days ago. His mom reports that he has been c/o fever of 102.1, chills, N/V, lack of energy for the last 24 hours. Which of the following should the NP be concerned about with this patient? A. Gastroenteritis B. Septicemia C. Food poisoning D. Ulcerative colitis

B. Septicemia Since this patient is status post appendectomy and is c/o fever/chills, N/V, fatigue, septicemia should be considered first. Although the patient could have gastroenteritis or food poisoning, septicemia is a complication of appendectomy.

A 56-year-old male presents with complaints of abdominal bloating and absence of bowel movements for the past six days. He was in a motor vehicle collision and damaged his L2-L3 spine eight months ago, for which he has been taking opioids to relieve the pain. He reports that his stool is soft but he has no more than two bowel movements per week. Polyethylene glycol and several fiber supplements have failed to relieve the symptoms. The addition of bisacodyl caused severe abdominal cramping, prompting its discontinuation. A colonoscopy performed two months ago did not reveal any pathology. In addition to polyethylene glycol, his medications include gabapentin, hydrocodone, fentanyl patch, calcium, and vitamin D. The patient is afebrile and hemodynamically stable. Which of the following is the most appropriate treatment for his constipation? A. Increase the dose of polyethylene glycol and start naloxegol B. Stop polyethylene glycol and start naloxegol C. Stop gabapentin D. Increase the dose of polyethylene glycol and start docusate sodium

B. Stop polyethylene glycol and start naloxegol Oral naloxegol is a peripherally acting mu-opioid receptor antagonist that is FDA-approved for treating opioid-induced constipation in adults with chronic noncancer pain. Chronic opioid analgesic use causes decreased colonic motility and reduced stool frequency. An increased dose of polyethylene glycol will not address the underlying cause as it is an osmotic agent. Surfactants such as docusate sodium or docusate calcium are appropriate for very mild, intermittent constipation.

In the life cycle of Chlamydia trachomatis, which particle is considered infectious and first infects the host cell? A. The rectangular body B. The elementary body C. The elongation body D. The reticulate body

B. The elementary body

Which is true about enterobiasis (pinworm infection)? A. The parasite is in the soil and enters the body through the feet. It can cause anemia. B. The parasite causes pruritus around the anus because the gravid females exit through the anus at night and lay eggs on the skin. The human is the only host of this parasite. C. The eggs of this parasite enter the body by ingestion of dirt (pica) or dirt on unwashed vegetables that contain the eggs, or through water containing the eggs. D. This parasite is a protozoan. The source is usually contaminated water, but it is spread from person to person by fecal-oral contamination.

B. The parasite causes pruritus around the anus because the gravid females exit through the anus at night and lay eggs on the skin. The human is the only host of this parasite. The pinworm parasites reside in the intestine. Females lay eggs on the skin outside the anus, resulting in extreme pruritus. The only host is humans and it is transmitted by the fecal-oral route, easily spreading among households, day cares, and schools. Hookworm larvae reside in the soil, enter the body through the feet, and can cause anemia. When dirt containing roundworm eggs are ingested through pica or unwashed vegetables, or if contaminated water is consumed, an intestinal infestation occurs. Giardiasis results from ingestion of the protozoan Giardia lamblia through contaminated water or oral-fecal transmission.

A 60-year-old man presents with an enlarged scrotum. The clinician uses a penlight to transilluminate the scrotum. In a patient with a hydrocele, what would the clinician expect to find? A. The scrotum will be dark. B. The scrotum will appear light pink or yellow. C. The scrotum will appear milky white D. The internal structures will be clearly visible.

B. The scrotum will appear light pink or yellow. Rationale: When performing transillumination, the trapped fluid appears light pink, yellow, or red. The other options are incorrect.

hat is the recommendation for CRC screening for patients who are older than 85 years? A. They should be screened only once every 2 years B. They should not be screened C. They should be screened once a year D. They should be screened on a case-by-case basis

B. They should not be screened The current recommendation is to not screen patients older than 85 years. Screening for patients aged 76 to 85 years should be done on a case-by-case basis. Adults in this age group who have a history of adequate screening should not be routinely screened. Screening can be considered for ages 76 to 85 years if the patient is not up to date with screening and has a life expectancy of at least 5 to 10 years.

What is the initial diagnostic tool in cholecystitis? A. CT Scan B. Ultrasound C. ERCP D. Plain Abdominal x-ray

B. Ultrasound Do ultrasound first to check for stones. Then you would proceed to do a hida scan. If stones are present and blocking the biliary tract, adjustments might need to be done for the hida scan.

Jordan, age 32, appears with a rapid onset of unilateral scrotal pain radiating up to the groin and flank. The nurse practitioner is trying to differentiate between epididymitis and testicular torsion. Which test should be the provider's first choice? A. X-ray B. Ultrasound C. Technetium scan D. Physical exam

B. Ultrasound Ultrasound is the imaging modality of choice for examination of the scrotum.If your client has a rapid onset of unilateral scrotal pain radiating up to the groin and flank and you are trying to differentiate between epididymitis and testicular torsion, an ultrasound is useful for determining whether the swelling is in the testis or the epididymis and should be your first choice.A technetium scan will show increased uptake in the case of epididymitis and decreased uptake in the case of torsion, but the least invasive and least expensive test is an ultrasound.Initially, before the swelling has reached its peak, a physical examination will probably differentiate between the epididymis and testis, but within a few hours, when the testis also swells, it may not be possible to differentiate between the two by palpation. A reactive hydrocele may also develop.

Which of the following is a true statement about pilonidal disease? A. Treatment of an acute abscess is IV antibiotics only. B. Usually occurs in young, hirsute, white males C. Occur in the skin of the level of the iliac crest D. Rarely develops subcutaneous tracts

B. Usually occurs in young, hirsute, white males Pilonidal disease usually occurs in young, hirsute, white males but can also occur in women. One or several midline or adjacent-to-the-midline pits or sinuses occur in the skin of the sacral region and may form a cavity, often containing hair. The lesion is usually asymptomatic; infected lesions are painful. Treatment of an acute abscess is by incision and drainage. Often develops subcutaneous tracts.

A patient presents complaining of pain and enlarged testes that feel like a "bag of worms." Which diagnosis should the provider most likely assess for? A. Prostate cancers B. Varicocele C. Hydrocele D. Testicular cancer

B. Varicocele Rationale: A varicocele is a dilatation of the veins in the scrotum caused by incompetent valves of the scrotal veins.

George is a 83 y/o male pt of the clinic who presents for his annual check-up. He has abnormal LFTs so you check further labs what would an elevated PT make you consider in the presence of abnormal LFTs? A. Non alcoholic fatty liver disease B. Cirrhosis C. Bile Duct obstruction D. Gilbert's disease

B. cirrhosis Elevations in -AST/ALT consider: liver injury, hepatitis, NAFLD, acute liver failure -ALP consider: thick bone disease, liver disease, obstructed bile ducts -Bilirubin consider: RBC destruction, liver disease, bile duct obstruction, GIlbert's disease -PT (w/ abnormal LFTs) consider: cancer originating in liver, cirrhosis -Albumin consider: usually normal in liver disease

In caring for a patient with symptomatic gastroesophageal reflux, you prescribe a PPI to: A. enhance motility. B. decrease the pH of the stomach. C. reduce lower esophageal pressure. D. reduce lower esophageal pressure.

B. decrease the pH of the stomach. PPIs have superior postprandial and nocturnal acid suppression.

Therapy for hemorrhoids includes all of the following except: A. weight control. B. low-fat diet. C. topical corticosteroids. D. the use of a stool softener

B. low-fat diet a number of clinical conditions and activities increase the risk for development of hemorrhoids, including excessive alcohol use, chronic diarrhea or constipation, obesity, high-fat/low-fiber diet, prolonged sitting, sedentary lifestyle, being a receptive partner in anal intercourse, and loss of pelvic floor muscle tone.

Which of the following is the most likely patient report with anal fissure? A. "I have anal pain that is relieved with having a bowel movement." B. "Even after having a bowel movement, I feel like I still need to 'go' more." C. "I have anal pain for up to 1 to 2 hours after I have a bowel movement." D. "I itch down there almost all the time."

C. "I have anal pain for up to 1 to 2 hours after I have a bowel movement." In anal fissure, there is an ulcer or tear of the margin of the anus; most fissures occur posteriorly. The most common patient report is one of severe anal pain during a bowel movement, with the pain lasting several minutes to hours afterward. The pain recurs with every bowel movement, and the patient commonly becomes afraid or unwilling to have a bowel movement, leading to a cycle of worsening constipation, harder stools, and more anal pain.

Which one of the following best describes a primary syphilis (chancre) lesion? A. A painful soft ulcer that persists for 2 to 4 days B. Multiple, painful, shallow ulcers that have an erythematous base and persist for 3 to 4 days C. A painless, well-circumscribed ulcer that persists for 1 to 6 weeks D. A large serpiginous ulcer that has a soft, beefy edge and persists for 2 to 4 days

C. A painless, well-circumscribed ulcer that persists for 1 to 6 weeks

When a patient presents with acute abdominal pain, which of the following is considered a red flag that should be immediately ruled out? A. GERD B. UTI C. AAA or aortic dissection D. Gastroenteritis

C. AAA or aortic dissection Acute onset of pain should prompt immediate concern for an intraabdominal process. Red flags that should be rule out immediately include a vascular etiology such as AAA or aortic dissection, perforated ulcer, volvulus, or mesenteric ischemia.

A 27 year old male presents with tenderness and involuntary guarding over McBurney's point. You suspect: A. Acute gastroenteritis B. Acute cholecystitis C. Acute appendicitis D. Acute pancreatitis

C. Acute appendicitis Symptoms of an acute abdomen such as appendicitis, include extreme tenderness and involuntary guarding over McBurney's point. You will remember from Advanced Health Assessment, McBurney's point tenderness is described as maximal tenderness at 1.5 to 2 inches from the anterior superior iliac spine (ASIS) on a straight line from the ASIS to the umbilicus (sensitivity 50 to 94 percent; specificity 75 to 86 percent).

Which one of the following would not be a recommended treatment option for acute or chronic prostatitis? A. Ciprofloxacin 500-750mg BID B. Levofloxacin 500-750mg daily C. Amoxicillin 500mg TID D. Bactrim DS BID

C. Amoxicillin 500mg TID Fluoroquinolones (ciprofloxacin or levofloxacin) or Bactrim DS are all options for treatment of acute or chronic prostatitis. Amoxicillin would not an option.

A 23-year-old sexually active man is seen in the clinic with unilateral painful testicular swelling, and his is diagnosed with epididymitis. In order to prescribe the correct drug, the clinician must understand that which of these is the most common causative organism? A. Escherichia coli B. Staphylococcus aureus C. Chlamydia trachomatis D. Pseudomonas aeruginosa

C. Chlamydia trachomatis Rationale: The causes of epididymitis in males younger than 35 years are usually sexually transmitted diseases such as Chlamydia or Neisseria gonorrhea infections.

Marian, age 52, is obese. She complains of a rapid onset of severe right upper quadrant abdominal cramping pain, nausea, and vomiting. Your differential diagnosis might be: A. Appendicitis B. Crohn's disease C. Cholecystitis D. Irritable bowel syndrome

C. Cholecystitis Pain associated with appendicitis would typically be near the navel, progressing to the right lower quadrant.In Crohn's disease, the pain and cramping in the abdomen are more diffuse and not usually accompanied by nausea and vomiting.A rapid onset of severe right upper quadrant (RUQ) abdominal cramping pain with nausea and vomiting is a classic presentation of acute cholecystitis; 90% to 95% of clients with acute cholecystitis also have gallstones. Other symptoms include low-grade fever, epigastric tenderness, guarding, and pain on inspiration during palpation of the RUQ (Murphy sign). The 7 F's of cholecystitis are fair, fat, 40, female, fertile, fat intolerant, and flatulent.In irritable bowel syndrome (IBS), the pain and cramping in the abdomen are more diffuse and not usually accompanied by nausea and vomiting. The pain with IBS originates over some area of the colon, with the left lower quadrant being most often affected.

Which of the following is most consistent with the clinical presentation of Inflammatory Bowel Disease (IBD)? A. Frequent abdominal pain and constipation. B. Weight gain and bloating. C. Diarrhea and weight loss. D. Lactose intolerance.

C. Diarrhea and weight loss. Weight loss and diarrhea are the most consistent with IBD compared to the other choices.

A 26-year-old male has two new recent sex partners and presents with urethral discharge. Which one of the following tests is preferred for detecting Chlamydia trachomatis? A. First-catch urine for culture B. Urethral swab for Gram's stain C. First-catch urine for nucleic acid amplification test (NAAT) D. Urethral swab for culture

C. First-catch urine for nucleic acid amplification test (NAAT)

A 42-year-old patient was diagnosed with ulcerative colitis 15 years ago. His last colonoscopy was about 5 years ago. What are the screening recommendations for him regarding colon cancer? A. He should be screened at age 50 with a colonoscopy B. He should be screened now with a fecal occult blood test C. He should be screened now with a colonoscopy D. He should be screened at age 45 with a colonoscopy

C. He should be screened now with a colonoscopy Colonoscopies are recommended every 1-3 years in patients with colitis, beginning 8-10 years after diagnosis.

An elderly male presents to a clinic with complaints of a decrease in the frequency of stool for a 2-weeks duration. The client passes stool every two to three days. What would the nurse comprehend as the first-line management option in the client? A. Osmotic laxatives B. Saline laxatives C. High fiber diet D. Enema

C. High fiber diet Constipation should be managed with changes in lifestyle, such as adding fiber to one's diet and increasing water consumption. Bulk-forming laxatives, stool softeners, and lubricants can help but they should be offered after a trial of exercise, fiber, and water. A common cause of constipation is the use of medications. One should not take NSAIDs, antihistamines, tricyclic antidepressants, and others. Addiction to laxatives is a common problem and leads to a lazy bowel.

A patient is referred to the gastroenterologist for evaluation of internal hemorrhoids. During examination, the internal hemorrhoid prolapses after Valsalva maneuver and the prolapse requires manual reduction. Based on these findings, the internal hemorrhoid in this patient is classified at which of the following stages? A. I B. II C. III D. IV

C. III The findings on physical examination are suggestive of a Grade III internal hemorrhoid. The findings with choice A would include prominent hemorrhoids with no prolapse. The findings with choice B would include prolapse after Valsalva maneuver, but the prolapse would spontaneously reduce. The findings with choice D would include chronic prolapse with inability to reduce.

A 45-year-old male is seen for anal itching and a rash. Symptoms have been present for 3 months and are worse after a bowel movement and at night. He uses medicated wipes to clean his perianal area several times a day. He notes intense itching, burning, and pain around the anus. He has no comorbidities and is otherwise healthy. He has tried hemorrhoid cream with no relief. The family nurse practitioner suspects pruritus ani. What would be the best treatment for him? A. Topical hydrocortisone cream applied to the perianal area three times a day for 6 weeks B. Antifungal cream applied twice a day for 2 weeks. C. Keep the perianal skin dry and clean with water and avoid severe rubbing. D. Sitz baths four times a day and apply a moisture barrier cream such as zinc oxide daily for 3 weeks.

C. Keep the perianal skin dry and clean with water and avoid severe rubbing. Pruritus ani is an uncomfortable sensation around the anal orifice. It is common and may be associated with hemorrhoids. It affects men more than women and is more prevalent from ages 40-60 years. Idiopathic pruritus ani accounts for most of the cases, up to 75%, whereas secondary causes include proctitis, anal fistula, and psoriasis. The main symptom is intolerable impulse to scratch the perianal region, most often after a bowel movement and at bedtime. Hydrocortisone cream could relieve the symptoms but should be used for only a short period, such as 2 weeks or less. Long-term corticosteroid use can lead to atrophy, infections, and contact dermatitis. Antifungal cream would not be helpful unless there was secondary infection. The skin needs to be kept clean and dry and not vigorously rubbed. Moisture and creams are not helpful because the symptoms will continue. Some food and drink can exacerbate the symptoms and should be avoided, such as coffee, tea, cola, chocolate, and beer. Regular bowel habits are also important.

Peter is a 40-year-old male with recent diagnosis of low testosterone. Which of the following counseling points is correct regarding low testosterone? A. Testosterone deficiency is due to hypergonadism. B. Abstaining from cigarette smoking has no effect on testosterone. C. Lowering your HBA1C may improve your testosterone levels. D. Stress has no effect on testosterone levels.

C. Lowering your HBA1C may improve your testosterone levels. Factors that can suppress testosterone levels include stress, obesity, tobacco, alcohol use, obstructive sleep apnea, diabetes, and illness. Therefore, lowering HBA1C levels may improve testosterone levels.

Which one of the following is a correct recommendation of when to begin prostate screening? A. Men with no symptoms of prostate cancer and who are in good health should start screening at age 60. B. Asian American men should start screening at age 45. C. Men who have had a brother diagnosed with prostate cancer before the age of 65 should start screening at 45. D. Caucasian men should start screening at age 55.

C. Men who have had a brother diagnosed with prostate cancer before the age of 65 should start screening at 45. A man with a first-degree relative (e.g., father or brother) with prostate cancer is twice as likely to develop the disease and to do so at an earlier age. The average age at the time of diagnosis is at 66 years with 60% of men diagnosed at that age and older. Therefore, starting screening at age 60 is appropriate. In the US, those at highest risk for prostate cancer are African Americans, not Asian Americans or Caucasian men.

Which one of the following locations of the urethral opening would likely need referral to a pediatric urologist for surgical intervention? A. Glandular B. Subcoronal C. Midshaft D. Distal penile

C. Midshaft For patients with hypospadias, referral to a pediatric urologist for urethral openings at the midshaft, penoscrotal or perineal regions for surgical intervention.Some parents may want the defect corrected regardless of location due to wanting their child to have a cosmetically normal appearing appearance.

A 2½-year-old has vomited 10 times in the past 18 hours, with the last episode being 4 hours ago. He has retained only sips of water over the last hour. Eight hours ago he started having watery stools with 4 total episodes. Last episode of diarrhea was one hour ago. Mother is unsure if he has voided today due to having watery stools. He has been running a 101.2 temperature, heart rate 110 BPM, and a capillary refill of <3 seconds. His lips are dry and slightly cracked and his oral cavity is slightly moist. He is alert, but laying in his mother's lap. Based on these findings, you consider what level of dehydration? A. Mildly dehydrated B. Severely dehydrated, needing IVF C. Moderately dehydrated, oral rehydration therapy under supervision of nurse practitioner. D. Mild to moderate dehydrated, can go home on brat diet.

C. Moderately dehydrated, oral rehydration therapy under supervision of nurse practitioner. FEEDBACK: Moderate dehydration is considered 6-10% decrease in body weight, decreased tugor, pale, slight increase in pulse, cap refill 3-4 sec, and oliguria. Need to monitor to make sure patient is able to keep fluids down to be able to prevent worsening dehydration.

The 40 year old female with right upper quadrant pain demonstrates a painful arrest of inspiration triggered by the examiner palpating the edge of the inflamed gallbladder. You recognize this sign as: A. Obturator sign B. Psoas sign C. Murphy's sign D. Cullen's sign

C. Murphy's sign Murphy's sign is the inhibition of inspiration by pain on palpation of the RUQ and is associated with acute cholecystitis.

Which of the following would be prescribed by the family nurse practitioner as initial treatment for a 72-year-old female with uncomplicated peptic ulcer disease (PUD) and negative Helicobacter pylori by stool antigen? A. Clarithromycin. B. Tetracycline and metronidazole and a histamine 2 receptor antagonist (H2 RA). C. Pantoprazole (Protonix). D. Bismuth (Pepto-Bismol).

C. Pantoprazole (Protonix). Goals of PUD treatment include removal of the offending agent, relief of pain, healing of the ulcer, and cost-effectiveness. In this case the likely cause of her ulcer would be use of nonsteroidal antiinflammatory drugs (NSAIDS). It is estimated that up to 25% of patients taking NSAIDS chronically will develop ulcer disease and 2%-4% will develop bleeding or perforation. Risk factors for NSAID-induced ulcers include age greater than 65 years, high doses of NSAIDS, daily use, and use of aspirin or anticoagulants or antiplatelet medications. Proton pump inhibitors (PPIs) heal 90% of duodenal ulcers after 4 weeks and 90% of gastric ulcers after 8 weeks, if H. pylori is negative. PPIs, such as pantoprazole, are recommended for ulcers because these drugs provide faster pain relief and more rapid healing than H2 RA because of their ability to decrease acid production. Clarithromycin, tetracycline, metronidazole, and bismuth (Pepto-Bismol) are some of the accepted treatments against active H. pylori-associated ulcers. Eradication of H. pylori requires a recommended regimen of acid blockers, antibiotics, and possibly bismuth in various combinations.

Which one of the following most accurately describes the recommendation regarding routine screening for Neisseria gonorrhoeae in sexually active men who have sex with men? A. Routine screening should be performed every 6 weeks B. Routine screening is not recommended C. Routine screening should be performed at least annually, and more frequent screening (every 3 to 6 months) is indicated for those with increased risk D. One-time screening is recommended for men aged 18-25 years of age, and repeat screening in 3 years is recommended for those with ongoing risk

C. Routine screening should be performed at least annually, and more frequent screening (every 3 to 6 months) is indicated for those with increased risk

You examine a two-year-old child with constipation. Which one of the following should prompt a diagnostic workup beyond the history and physical examination? A. Constipation started around the time of transitioning the child to solid foods. B. The parent says the child clenches their muscles to avoid having a bowel movement because it hurts. C. The child has a family history of cystic fibrosis. D. Stool can be felt in the lower left quadrant of the abdomen on examination.

C. The child has a family history of cystic fibrosis. Functional constipation, for which there is no organic cause, is the most common type of constipation in children and adolescents, accounting for 95% of cases. Only 5% of constipation cases in children and adolescents can be attributed to an underlying etiology such as Hirschsprung disease, cystic fibrosis, Down syndrome, anorectal malformations, neuromuscular disorders, spinal cord abnormalities, or celiac disease.

Which one of the following statements is TRUE regarding the trend in congenital syphilis in the United States? A. The number of cases has stayed about the same in recent years B. The number of cases has declined in recent years C. The number of cases has increased in recent years D. The number of cases is so low that it is difficult to determine any trends

C. The number of cases has increased in recent years

The most common cause of anorectal abscesses and fistulas is A. large fatty stools B. a precancerous lesion C. a bacterial infection of the anal crypt glands D. an parasitic infection causing prolonged diarrhea

C. a bacterial infection of the anal crypt glands The most common cause of anorectal abscesses and fistulas is bacterial infection of the anal crypt glands. These glands may become infected if obstruction with resulting stasis occurs from trauma, hard stools, foreign bodies, or diarrhea. The suppurative process then tracks through the planes of the anorectal tissue, and typically presents as a purulent collection at the anal verge. Other possible causes of anorectal abscesses or fistulas include neoplasms, ruptured diverticula, and inflammatory bowel disorders (e.g., Crohn disease).

Which one of the following should be performed before any radiologic testing for women of childbearing age? A. U/A B. CBC with diff C. β-hCG D. CMP

C. β-hCG Pregnancy test should be performed prior to any radiologic testing on all women of childbearing age.

Match the serology results with the correct interpretation. HBsAG - positive IgM anti-HBc - negative Anti HBc - positive Anti HBs - negative

Chronic Hepatitis B infection

Match the serology results with the correct interpretation. Anti HCV - reactive HCV viral RNA positive Normal to slightly elevated liver enzymes

Chronic Hepatitis C infection

The differential diagnoses related to periumbilical pain in a child includes: A. Early appendicitis, acute gastroenteritis and UTI B. Pneumonia, pleural effusion, and right-sided kidney stone C. Appendicitis, pelvic inflammatory disease D. All of the above

D. All of the above Other medical and surgical conditions may cause an acute abdomen and should also be considered in the differential diagnosis.

Which one of the following would require immediate surgical referral for further evaluation? A. Scrotal tenderness B. Enlarging scrotum C. Hematocele D. B & C

D. B & C Patients that present with scrotal trauma that have an enlarging scrotum due to edema and a hematocele (blood in the tunica vaginalis around the testicles) should be referred for immediate surgical evaluation. Scrotal tenderness and mild bruising are common findings after scrotal trauma.

A first line treatment for fecal incontinence is: A. timed and routine phosphate enemas B. a program of stool regulation perineal exercises C. biofeedback D. B, C, & D E. A & C

D. B, C, & D

In a patient who presents with a history consistent with anal fissure but with notation of an atypical anal lesion, alternative diagnoses to consider include all of the following except: A. condyloma acuminata. B. Crohn's disease. C. anal squamous cell carcinoma. D. C. difficile colitis.

D. C. difficile colitis. A number of other conditions can present similar to anal fissure. If the fissure is off the midline, transverse or irregular, another diagnosis should be considered. These include Crohn's disease, anal squamous cell cancer, and anal condyloma acuminata, among others.

Anorectal fistulas that occur in infants are more common in boys and are most often a result of which of the following? A. Birth trauma B. Cancer C. Diverticulitis D. Congenital

D. Congenital Anorectal fistulas that occur in infants are congenital. Choice A: Birth trauma is unlikely to cause a fistula in an infant. cancer and diverticulitis are not likely to cause a fistula in an infant; however, they can cause an anorectal fistula in pediatric and adult patients.

Regarding non-pharmacologic treatments for gastroparesis, which one of the following is correct? A. Acupuncture is beneficial for symptom control for patients with idiopathic gastroparesis. B. Herbal therapies such as Rikkunshito or STW5 (Iberogast) are recommended for treatment of GP C. Intrapyloric injection of botulinum toxin is recommended for patients with GP based on randomized, controlled trials D. Dietary management of GP should include a small particle diet to increase likelihood of symptom relief and enhance GE

D. Dietary management of GP should include a small particle diet to increase likelihood of symptom relief and enhance GE Dietary management of GP should include a small particle diet to increase likelihood of symptom relief and enhance GE. Acupuncture alone or acupuncture combined with prokinetic drugs may be beneficial for symptom control in patients with DG. Acupuncture cannot be recommended as beneficial for other etiologies of GP. Herbal therapies such as Rikkunshito or STW5 (Iberogast) should NOT be recommended for treatment of GP. Intrapyloric injection of botulinum toxin is not recommended for patients with GP based on randomized, controlled trials.

A 19-year-old woman has Chlamydia trachomatis detected on a screening test of a self-collected vaginal swab. She has a pregnancy test, which is negative. Which one of the following medication regimens should be used for treatment in this case? A. Levofloxacin 250 mg orally once a day for 5 days B. Azithromycin 500 mg orally once daily for 7 days C. Amoxicillin 500 mg orally three times daily for 3 days D. Doxycycline 100 mg orally twice daily for 7 days

D. Doxycycline 100 mg orally twice daily for 7 days

Which one of the following is a condition that results in colicky abdominal pain? A. Peptic ulcers B. Glisson's capsule around the liver C. Peritoneum irritation D. Gallstones

D. Gallstones Acute cholecystitis related to gallstones usually begins with colicky abdominal pain. Peptic ulcers typically have dull pain in the stomach. Irritation of peritoneum has generalized abdominal pain with a feeling of being bloated.

Which of the following would be an appropriate treatment for a patient with mild benign prostatic hyperplasia (BPH)? A. Referral to urologist for surgery. B. Prescribe a trial of tamsulosin. C. Recommend cranberry supplements. D. Have a period of watchful waiting.

D. Have a period of watchful waiting. Most urologists and PCPs have adopted a "watchful waiting" approach for patients with BPH and mild symptoms. A patient with mild BPH symptoms would not warrant referral to a urologist for surgery or require a trial of tamsulosin. Cranberry supplements are often recommended for patients with recurrent UTIs.

Which one of the following is true of appendicitis? A. Appendicitis is more common in Asian countries. B. Family history of appendicitis does not increase a patient's risk of having appendicitis. C. Appendicitis is most common between the ages of 40 and 60. D. If appendicitis occurs in infants, it is associated with higher morbidity.

D. If appendicitis occurs in infants, it is associated with higher morbidity. Infants and older adults have higher morbidity because of delayed diagnosis and intervention. Appendicitis is more common in Western countries where people have diets low in fiber, high in fat, and high in refined sugars or other carbohydrates. Positive FH can increase the risk of appendicitis. Appendicitis is most common between ages 10 and 30.

Based on data from the Gonococcal Isolate Surveillance Project (GISP), which one of the following statements is TRUE? A. In recent years, the percentage of isolates with reduced susceptibility to ceftriaxone (defined as MIC ≥0.125 μg/mL) has been approximately 12% B. In recent years, approximately 15% of gonococcal isolates have reduced susceptibility to cefixime (defined as MIC ≥0.25 μg/mL) C. In recent years, more than 15% of gonococcal isolates have reduced susceptibility to azithromycin (defined as MIC ≥2 μg/mL) D. In recent years, more than 10% of gonococcal isolates have been resistant to ciprofloxacin

D. In recent years, more than 10% of gonococcal isolates have been resistant to ciprofloxacin

An eight month old baby is brought to the clinic with a two day history of vomiting and diarrhea. Your assessment reveals that the child is suffering from mild to moderate dehydration or about 6%. Initial treatment will include: A. Probiotic treatment such as Lactobacillus and isotonic fluid B. Nasogastric rehydration with an ORS C. Normal saline intravenously (20 ml/kg) as rapidly as possible. D. Oral rehydration therapy and adequate dietary intake a.s.a.p.

D. Oral rehydration therapy and adequate dietary intake a.s.a.p.

A 28-year-old patient is seen with complaints of diarrhea. Which of the following responses to the history questions would help the PCP establish the diagnosis of irritable bowel syndrome (IBS)? A. Feels relief after urination B. Pain wakes patient from sleep C. Defecates in the middle of the night D. Pain is precipitated by eating

D. Pain is precipitated by eating More than 50% of patients with IBS describe an overly acute sensory ability with regard to the GI tract and digestive process. Patients have frequent complaints of abdominal distention, gas, and belching. Many of these symptoms occur 2 hours after eating. Often the pain can be relieved with a bowel movement or passing flatus, not after urinating. Therefore, patients are not defecating in the middle of the night. The pain associated with IBS is usually not significant enough to interfere with sleeping.

A 35-year-old female patient is seen in the clinic complaining of abdominal pain. Which of the following should be included in the examination? A. Lumbar puncture B. Family history of cardiac problems C. Contrast venography D. Pelvic exam

D. Pelvic exam Female patients presenting with abdominal pain should receive a pelvic exam to rule out pelvic etiologies such as salpingitis. Lumbar puncture and contrast venography are more invasive diagnostic tools that should not be performed initially. Family history of cardiac problems is not part of the exam but part of your history taking to rule in/rule out DDx.

Harry, age 60, has benign prostatic hyperplasia and complains of some incontinence. The nurse practitioner's first step in diagnosing overflow incontinence would be to order a: A. Urinalysis Postvoid residual (PVR) measurement B. Cystometrogram C. Cystoscopy D. Postvoid residual (PVR) measurement

D. Postvoid residual (PVR) measurement A urinalysis is commonly performed to confirm the cause and diagnosis, but a postvoid residual (PVR) measurement is the most important component of the diagnosis.A cystometrogram is commonly performed to confirm the cause and diagnosis, but a postvoid residual (PVR) measurement is the most important component of the diagnosis.A cystoscopy is commonly performed to confirm the cause and diagnosis, but a postvoid residual (PVR) measurement is the most important component of the diagnosis.The first step in diagnosing overflow incontinence is to perform a PVR measurement. Clients with overflow incontinence cannot empty their bladders completely, so residual urine remains after voiding and this measurement is elevated

Diagnosis of an anorectal fistula is by clinical examination. One or more secondary openings can be seen, and sometimes a cordlike tract in the fistula can be palpated. However, if Crohn disease is suspected as a cause of the fistula, which of the following studies is most appropriate? A. Colonoscopy B. CT colonoscopy C. Fecal immunochemical test D. Sigmoidoscopy

D. Sigmoidoscopy If Crohn disease is suspected as the cause of the anorectal fistula, then sigmoidoscopy is an appropriate next step in diagnosis. Choices A and B: Colonoscopies evaluate the entire colon; therefore, since the location of the fistula does not require imaging of the entire colon, these two choices are incorrect. Choice C: This is a test for colorectal cancer and not necessary in the diagnosis of anorectal fistula as a result of Crohn disease.

hich one of the following would not be included in the management of scrotal trauma? A. Cool compresses B. NSAIDs C. Scrotal support or elevation D. Warm compresses

D. Warm compresses Management of scrotal trauma involves cool compresses to help with edema, NSAIDs for inflammation and/or pain/discomfort, scrotal support or elevation and bedrest. Warm compresses would not help with swelling or bruising.

Which is true of peptic ulcer disease (PUD) in patients over the age of 65 years? A. Smoking does not increase the risk of PUD. B. Duodenal ulcers are more common in older adults. C. Perforation is a common complication. D. Weight loss and anorexia are often the only symptoms.

D. Weight loss and anorexia are often the only symptoms. Patients with a gastric ulcer may not have any symptoms, especially the older adult. Weight loss and anorexia may be present, but the patient may attribute this to "getting older." The patient may not realize an ulcer is present until it bleeds and causes significant anemia. Smoking does increase the risk, and perforation can occur, but it is not common. Gastric ulcers are thought to be more common than duodenal ulcers in older adult patients.

You run a Hepatitis B panel on your patient and your results as follows: HBsAg Negative anti-HBc Positive anti-HBs Negative Interpretation is unclear; what are the possibilities? A. Resolved infection B. False-positive anti-HBc C. "Low-level" chronic infection D. Resolving acute infection E. All the above.

E resolved infection most common

Evaluation of proctitis should include: A. STI testing B. C. difficile C. Sigmoidoscopy D. culture or immunoassay for viral pathogens E. culture for enteric pathogens F. A, B, and D G. All the above

G. All the above Diagnosis of proctitis requires proctoscopy or sigmoidoscopy, which may reveal an inflamed rectal mucosa. Small discrete ulcers and vesicles suggest herpes infection. Rectal swabs should be tested for Neisseria gonorrhoeae and Chlamydia species (by culture or ligase chain reaction), enteric pathogens (by culture), and viral pathogens (by culture or immunoassay).Serologic tests for syphilis and stool tests for C. difficile toxin are done. Sometimes mucosal biopsy is needed.Colonoscopy may be valuable in some patients to rule out inflammatory bowel disease.

Match the serology results with the correct interpretation. Anti HCV reactive HCV viral RNA negative Normal liver enzymes

Hepatitis C infection in past, no current infection

Match the serology results with the correct interpretation. HBsAG - negative Anti HBc - negative Anti HBs - positive

Immunity due to Hepatitis B vaccination

What is the first choice for imaging with an infant that has pyloric stenosis? A. KUB B. Endoscopy C. Barium upper GI D. Ultrasound

Ultrasound, with measurement of the pyloric muscle thickness is used in most centers. An upper GI series may be required if ultrasound is unavailable or inconclusive.

Mr. Z 69-yr-old • Sx: feeling bad, weak, chilling, feverish, muscle aching, urinary urgency, difficulty urinating x 24 hrs. Mental status change. No precipitating factors • PMH: BPH, HTN • Meds: Amlodipine 10 mg • NKDA • DX: Acute prostatitis - toxic appearance Where to tx? What tx? When to f/u?

• Arrange for transfer to ER or Hospital admission IV antibiotics -> oral abt x 6 wks. • FU 1-2 weeks after hospital discharge and monthly

Drew has erectile dysfunction and says that a friend told him about a method that uses a constricting ring around the base of the penis. What is he referring to? A. Intracavernous injection therapy. B. An external vacuum device. C. Urethral suppositories. D. Surgery.

B. An external vacuum device. Intracavernous injection therapy consists of injecting the vasoactive drug alprostadil (Caverject) directly into the corpus cavernosum of the penis, causing an erection that lasts 40 to 60 minutes.An external vacuum device is a viable method for alleviating erectile dysfunction regardless of the cause of the disorder. A plastic cylinder is placed around the penis, a vacuum pump causes cavernosal engorgement, and a constrictor ring is applied around the base of the penis, allowing the client to hold an erection for 30 minutes.Urethral suppositories such as alprostadil are also effective in causing an erection when inserted into the urethra after voiding.Surgery involves inserting a penile prosthesis, of which there are many different types.

A 41-year-old man with HIV presents with headaches and new hearing loss. He has a positive serum Venereal Disease Research Laboratory (VDRL) test with a titer of 1:64. A lumbar puncture is performed and shows 43 white blood cells/mm3 and a cerebrospinal VDRL titer of 1:32. He does not have any antibiotic allergies. What treatment should be recommended for this man? A. Ceftriaxone 1 gram IV daily for 3 days B. Aqueous crystalline penicillin G 18-24 million units per day, administered as 3-4 million units IV every 4 hours or continuous infusion, for 10-14 days C. Doxycycline orally 100 mg twice daily for 7 days D. Ceftriaxone 1 gram IV twice daily for 7 days

B. Aqueous crystalline penicillin G 18-24 million units per day, administered as 3-4 million units IV every 4 hours or continuous infusion, for 10-14 days

Gerard is complaining of a scrotal mass; however, the scrotum is so edematous that it is difficult to assess. How would the nurse practitioner (NP) best determine whether the condition is a hernia or a hydrocele? A. The NP can always return the hernia contents to the abdominal cavity. B. Bowel sounds may be heard over the hernia. C. The NP can transilluminate the hernia. D. With a hydrocele, a bulge appears on straining.

B. Bowel sounds may be heard over the hernia. Some hernias are not able to be returned to the abdominal cavity. A hernia is incarcerated when its contents cannot be returned; it is strangulated when the blood supply to the entrapped contents is compromised.

An older patient presents with LLQ pain. If diverticulitis is suspected, what diagnostic test is most appropriate? A. Chest and abdominal x-ray B. CT scan with IV and oral contrast C. Barium enema D. Ultrasound of the abdomen

B. CT scan with IV and oral contrast CT scan of the abdomen is the diagnostic test of choice for this patient with suspected diverticulitis. The CT scan is able to demonstrate inflammatory changes in the colonic wall, colonic diverticula, thickening of the bowel wall, fistula formation, peritonitis, and other complications associated with diverticulitis. A chest and abdominal x-rays are commonly ordered and can help exclude other causes of abdominal pain, but do not help diagnose diverticulitis. Barium enema would be contraindicated if there were a potential for perforation. Ultrasound is much less widely used than CT.

A 23-year-old male patient with acute bacterial epididymitis should be treated with: A. Trimethoprim/sulfamethoxazole B. Ceftriaxone and doxycycline C. Anti-inflammatories and analgesics D. Ice and scrotal support

B. Ceftriaxone and doxycycline Rationale: In a 23-year-old male with subacute bacterial epididymitis, the most likely organism is Chlamydia or Gonorrhea. Therefore, until cultures are back, he should be treated empirically with Ceftriaxone 250 mg IM in a single dose and Doxycycline 100 mg orally twice a day for 10 days.

After 24 hours at home with no success in rehydration, the parents of an eight-month-old baby phone the clinic for advice. The primary clinic nurse practitioner makes a referral for Emergency Department evaluation based on which indication: A. Report of only four wet diapers during the past 12 hours B. Change in mental status (lethargy) C. Diarrheal stools which are especially foul smelling D. Temperature elevation of 100.4 degrees Fahrenheit

B. Change in mental status (lethargy) Oral rehydration is contraindicated in children with altered levels of consciousness or respiratory distress who cannot drink freely.