BOARD PRACTICE QUESTIONS - TEST 3

Click on the anatomic location where sensorineural hearing loss occurs.

Sensorineural hearing loss occurs when there is damage to vital ear structures such as the cochlea, vestibule, and/or auditory nerve pathways.

A 28-year-old male nurse of Hispanic descent reports a history of a cold that resolved 2 weeks ago except for a dry cough and pain over his right cheek that worsens when he bends down. The patient denies fever. He tells the employee health nurse practitioner that he is very allergic to both cephalexin (Keflex) and erythromycin. The patient's vital signs are temperature of 99.2°F, pulse of 72 beats/min, and respirations of 12 breaths/min. Which condition is most likely? A. Acute sinusitis B. Acute bronchitis C. Fever secondary to the previous viral upper respiratory infection (URI) D. Hay fever

Solution: A Acute sinusitis. Acute sinusitis symptoms include cough, facial pain, and low-grade fever.

The nurse practitioner notices a gray ring on the edge of both irises of an 80-year-old woman. The patient denies visual changes or pain. She reports that she has had the "ring" for many years. Which of the following causes is most likely? A. Arcus senilis B. Pinguecula C. Peripheral cataracts D. Macular degeneration

Solution: A Arcus senilis. Arcus senilis ( arcus senilis corneae ) is a white, gray, or blue opaque ring in the corneal margin (peripheral corneal opacity) or white ring in front of the periphery of the iris. It is present at birth, but it then fades; however, it is commonly present in older adults. It can also appear earlier in life as a result of hypercholesterolemia. It does not affect vision. Unilateral arcus is a sign of decreased blood fl ow to the unaffected eye due to carotid artery disease or ocular hypotony.

A 13-year-old girl has a throat culture that is positive for strep throat. She reports that her younger brother was recently diagnosed with strep throat and treated. The patient has a severe allergy to penicillin and reports that erythromycin makes her very nauseated. Which of the following antibiotics is the best choice? A.Azithromycin (Zithromax) B.Cephalexin (Keflex) C.Cefuroxime axetil (Ceftin) D.Levofloxacin (Levaquin)

Solution: A Azithromycin (Zithromax). If the patient has a severe penicillin allergy, there is a 10% chance of cross-reactivity to cephalosporins (especially first generation). Because the patient is a child, the levofloxacin is contraindicated. Nausea is a common adverse reaction to erythromycin (it is not an allergic reaction). The best option is to use azithromycin because of its minimal gastrointestinal (GI) adverse effects. Azithromycin has fewer drug interactions compared with other macrolides.

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 agents are most likely to cause confusion in the elderly population? A. Cimetidine (Tagamet), digoxin (Lanoxin), diphenhydramine (Benadryl) B. Acetaminophen (Tylenol), aspirin (Bayer), indomethacin (Indocin) C. Sucralfate (Carafate), docusate sodium (Surfak), psyllium (Metamucil) D. Cephalexin (Keflex), amoxicillin (Amoxil), clarithromycin (Biaxin)

Solution: A Cimetidine (Tagamet), digoxin (Lanoxin), diphenhydramine (Benadryl). These medications are included in the Beers Criteria, a list of medications that are inappropriate for (or should be used with caution in) the elderly. Cimetidine, digoxin, and diphenhydramine have many adverse effects. Elderly patients taking cimetidine are at risk for neuropsychiatric changes, which may be temporarily reversed by physostigmine. Older patients are also more likely to develop toxicity, and diagnosis of digoxin toxicity can be difficult in this group. Benadryl can worsen glaucoma, a consideration for elderly individuals. Thick oral secretions are also a side effect, making the medication unsafe for the elderly with lung disease. It can also cause high blood pressure, a common ailment associated with aging.

A 28-year-old male is evaluated by the nurse practitioner for frequent episodes of psychotic delusions and paranoia. He has taken risperidone (Risperdal) in the past but states that the drug was not effective. Which medication will the nurse practitioner prescribe? A. Clozapine (Versacloz) B. Amitriptyline (Elavil) C. Bupropion (Wellbutrin) D. Lithium carbonate (Eskalith)

Solution: A Clozapine (Versacloz). Clozapine (Versacloz) has been shown to decrease psychotic symptoms and episodes in patients with resistance to first-line antipsychotics. Amitriptyline (Elavil) is a tricyclic antidepressant that is used to treat symptoms of depression. Bupropion (Wellbutrin) is an antidepressant medication used to treat major depressive disorder and seasonal affective disorder. Lithium carbonate (Eskalith) is an antimanic agent used to treat manic-depressive disorder (bipolar disorder).

All of the following findings are associated with the secondary stage of an infection by the organism Treponema pallidum, except: A. Condylomata acuminata B. Maculopapular rash of the palms and soles C. Lymphadenopathy D. Condylomata lata

Solution: A Condylomata acuminata. Findings consistent with the diagnosis of syphilis, caused by the T. pallidum organism, include painless chancre, maculopapular rash of the palms and soles, lymphadenopathy, and condylomata lata. Condylomata acuminata (genital warts) are caused by the human papillomavirus (HPV) and spread to others by skin-to-skin contact.

Which type of leader shares decisions and activities with group participants? A. Democratic B. Autocratic C. Laissez-faire D. Situational

Solution: A Democratic. Democratic leadership is characterized by equality among the leader and other participants. Decisions and activities are shared. Autocratic leadership, also known as authoritarian leadership, is a leadership style characterized by individual control over all decisions and little input from group members. Laissez-faire leadership, also known as delegative leadership, is a type of leadership style in which leaders are hands-off and allow group members to make the decisions. Situational leadership is not based on a specific skill of the leader; instead, the leader modifies the style of management to suit the requirements of the organization.

An elderly Hmong patient, who is originally from Thailand, is seen by the nurse practitioner for a follow-up visit. He is accompanied by his eldest daughter. The patient presented 6 weeks ago with complaints of a recent onset of morning headaches. He was diagnosed with stage 2 hypertension and prescribed hydrochlorothiazide, one 25-mg tablet daily. On this visit, he tells the nurse practitioner that the new medicine cured the headache, so he stopped taking it. What is the best plan to follow during this visit? A. Educate the patient about hypertension, how the medicine works on his body, and the importance of taking his pill daily B. Reassure the patient that he can resume his prescription medicine again the next morning C. Tell the patient that you will lower the dosage of hydrochlorothiazide to 12.5 mg daily D. Speak to the patient in a loud voice and confront him about his behavior

Solution: A Educate the patient about hypertension, how the medicine works on his body, and the importance of taking his pill daily. When Hmong (an ethnic group prevalent in Thailand, Myanmar, Laos, and Vietnam) see a clinician for a symptom, they expect to be treated and "cured" of their illness after one visit. When the symptoms disappear, many will stop taking the medicine. When medication is to be taken on a long-term basis, it is important to educate the patient (and the patient's family) about the disease (in this case, hypertension), how the medicine works on the body, and the reason why the patient has to take the medicine as prescribed (in this case, daily). Many Southeast Asians are very polite and consider speaking in a loud voice, staring, or confrontation to be rude behavior.

A 25-year-old man with schizophrenia comes in for a routine annual physical. He is a heavy smoker and has a body mass index (BMI) of 28. The patient has been on olanzapine (Zyprexa) for 10 years. Which of the following laboratory tests is recommended for monitoring the adverse effects of atypical antipsychotics? A. Fasting blood glucose and fasting lipid profile B. Urinalysis, serum creatinine, 24-hour urine for protein and creatinine clearance C. Liver function tests D. Complete blood count (CBC) with differential and liver function tests

Solution: A Fasting blood glucose and fasting lipid profile. Patients on atypical antipsychotics commonly gain weight and are at risk for obesity, hyperglycemia, and type 2 diabetes. Olanzapine (Zyprexa) will increase lipids (cholesterol, LDL, and triglycerides). Atypical antipsychotics also increase the risk of death among frail elders and older adults living in nursing homes.

In the majority of children, the first permanent teeth start to erupt at the age of 6 years. Which of the following are the first permanent teeth to erupt in this time period? A. First molars B. Second molars C. Lower or upper incisors D. Canines

Solution: A First molars. The first molars are the first permanent teeth to develop; they appear at approximately 6 years of age.

The anti-hepatitis C virus (HCV) test of a 60-year-old female patient is positive. Which test is appropriate for follow-up? A. HCV RNA B. HCV antibody C. HCV core antibody D. HCV surface antigen

Solution: A HCV RNA. The anti-HCV test detects the presence of antibodies to the hepatitis C virus, indicating exposure to HCV. The anti-HCV test cannot distinguish between someone with active and previous HCV infection (reported as positive or negative). The HCV RNA test is qualitative and used to distinguish between a current and past infection. It is reported as "negative" or "not detected." It may also be ordered after treatment is complete to see whether the virus has been eliminated.

According to evidence-based medicine (EBM) experts, which of the following types of research has the highest ranking? A. Meta-analysis B. Randomized controlled trial C. Cohort study D. Expert opinion

Solution: A Meta-analysis. Meta-analyses and systematic reviews offer the highest level of evidence. The ranking of options for this question is as follows: (1) meta-analysis, (2) randomized controlled trial, (3) cohort study, and (4) expert opinion. The best method of correctly answering this type of question is to memorize the categories for the best level of evidence (meta-analysis and/or systematic review and/or randomized controlled trials) and the lowest form of evidence (opinions, editorials). Cohort studies are used to investigate risk factors and causes of disease. An example of a cohort study is the Framingham Study.

A 20-year-old woman reports that for several years, she has had random episodes of palpitations and shortness of breath that resolve spontaneously. She denies chest pain, arm pain, and syncope. Her past medical and family histories are negative for coronary artery disease, stroke, and lung disease. During the cardiac exam, the nurse practitioner notices a grade 3/6 murmur that is accompanied by a midsystolic click, which is best heard at the apical area. The apical pulse is 78 beats/min, blood pressure is 120/60 mmHg, and temperature is 98.6°F. The cardiac exam is highly suggestive of which of the following conditions? A. Mitral valve prolapse (MVP) B. Aortic stenosis C. Atrial septal defect D. Pulmonary regurgitation

Solution: A Mitral valve prolapse (MVP). A systolic murmur that is accompanied by a midsystolic click located at the apical area is a classic finding of MVP. Most cases of MVP are asymptomatic. To detect MVP, order an echocardiogram with Doppler imaging.

A 21-year-old woman complains to you of a 1-week episode of dysuria, frequency, and a strong odor to her urine. This is her second episode of the year. The previous urinary tract infection occurred 3 months ago. What is the most appropriate follow-up for this patient? A. Order a urinalysis and urine culture and sensitivity (C&S), and treat the patient with antibiotics B. Order a urine C&S and hold treatment until you get the results from the lab C. Treat the patient with a 7-day course of antibiotics and order a urine C&S now and after she completes her antibiotics D. Treat the patient with a stronger drug, such as ofloxacin (Floxin), for 10 days

Solution: A Order a urinalysis and urine culture and sensitivity (C&S), and treat the patient with antibiotics. Because this is the second urinary tract infection for the year and the last episode was 3 months ago, the best action is to order the urinalysis and urine C&S to identify the organism causing the infection. Antimicrobial-resistant strains are increasing. Start empiric treatment with an antibiotic for a 7-day duration (do not use a 3-day regimen).

A middle-aged woman who works in the housekeeping department of a hospital presents to the employee health clinic with a complaint of a needlestick to her left thumb. The needle was in one of the garbage bags from the ED. The patient had a little bleeding that stopped spontaneously. Which of the following is the next step? A. Order an enzyme-linked immunosorbent assay (ELISA) test as soon as possible B. Recommend a tetanus booster in 1 week C. Offer the patient hepatitis B immunoglobulin D. Order a chest x-ray

Solution: A Order an enzyme-linked immunosorbent assay (ELISA) test as soon as possible. Employee health clinic protocols for needlesticks recommend ordering an ELISA test as soon as possible to establish baseline blood work for the employee.

The atypical antipsychotic drugs have many adverse effects. Which of the following side effects are most likely to be seen with this drug class? A. Orthostatic hypotension and sedation B. Malignant hypertension and headache C. Skin hyperpigmentation and alopecia D. Severe anxiety and increased appetite

Solution: A Orthostatic hypotension and sedation. Orthostatic hypotension and sedation are common side effects of atypical antipsychotics such as olanzapine (Zyprexa), quetiapine (Seroquel), and risperidone (Risperdal). It is also a common side effect of the older antipsychotics such as haloperidol (Haldol). Antipsychotics do not cause severe anxiety and hyperphagia (increased appetite). They lower anxiety and cause sedation, sleepiness, anorexia, and hypotension and increase the risk of sudden death in frail elders.

Visual fields by confrontation is used to evaluate for: A. Peripheral vision B. Central distance vision C. Narrow-angle glaucoma D. Accommodation

Solution: A Peripheral vision. The visual fields by confrontation test is used to evaluate peripheral vision. The Snellen chart is used to measure central distance vision. A tonometer is used to assess for glaucoma. The ophthalmoscope is used to assess for cataracts.

A 40-year-old nurse complains of a new-onset back pain secondary to her job on the medical-surgical floor of a hospital. She reports lifting some obese patients while working the previous night shift. She reports to the worker's compensation clinic where she was referred. She describes the pain as starting in her right buttock area and radiating down the back of her thigh. It becomes worse when she sits down for long periods. The nurse practitioner suspects: A. Sciatica B. Acute muscle spasm C. Cauda equina syndrome D. Acute muscle strain

Solution: A Sciatica. Sciatica is defined as pain that begins in the buttock area and radiates down one leg. Other symptoms include weakness and tingling sensation. Acute muscle spasm and strain do not cause tingling down the leg. Cauda equina syndrome is an emergent issue, in which there is neurologic involvement and the patient complains of weakness and loss of bladder and bowel control.

The nurse practitioner is reviewing a patient's laboratory results and notes a normal ferritin level, high serum iron, elevated total iron-binding capacity, normal mean corpuscular hemoglobin concentration, and abnormal hemoglobin electrophoresis. Which diagnosis is most likely? A. Thalassemia B. Iron deficiency C. Sickle cell anemia D. Normocytic anemia

Solution: A Thalassemia. Laboratory findings associated with thalassemia include a normal ferritin level, high serum iron, elevated total iron-binding capacity, normal red blood cell color, and abnormal electrophoresis. Laboratory findings associated with iron deficiency include low ferritin level, decreased serum iron, elevated total iron-binding capacity, decreased mean corpuscular hemoglobin concentration, and normal hemoglobin electrophoresis. Laboratory findings associated with sickle cell anemia include abnormal electrophoresis findings. Diagnostic testing for sickle cell anemia does not include ferritin or iron serum level, total iron-binding capacity, or mean corpuscular hemoglobin concentration. Mean corpuscular cell volume is used to assess for normocytic anemia.

When evaluating the blood pressure on both the arms and legs of an infant who has a diagnosis of coarctation of the aorta, which of the following is the correct finding? A. The blood pressure is higher in the arms than in the legs B. Only the diastolic blood pressure is higher in the legs than in the arms C. The blood pressure is higher in the legs than the arms D. The blood pressure is lower in both the arms than in the legs

Solution: A The blood pressure is higher in the arms than in the legs. In coarctation of the aorta, blood pressure is higher in the arms than in the legs because of the narrowing in the aorta. Blood pressure must rise to get adequate blood fl ow to the lower extremities; therefore, the blood pressure above the coarctation rises to compensate for this

Fetal TORCH infections can cause microcephaly, mental retardation, hepatosplenomegaly, and intrauterine growth retardation. The acronym TORCH stands for: A. Toxoplasma gondii, other infections, rubella, cytomegalovirus, and herpes B. Toxic shock syndrome, ocular infections, rubella, cytomegalovirus, and herpes zoster C. Tetanus, ophthalmic infections, roseola, cancer, and head abnormalities D. Toxins, other infections, roseola, candidiasis, and head abnormalities

Solution: A Toxoplasma gondii, other infections, rubella, cytomegalovirus, and herpes. The acronym TORCH stands for Toxoplasma gondii , other infections, rubella, cytomegalovirus, and herpes. Although several of the conditions listed in the other answer options can also cause fetal problems, they do not comprise the TORCH disorders.

Which of the following drugs can increase the risk of bleeding in patients who are receiving anticoagulation therapy with warfarin sodium (Coumadin)? A. Trimethoprim-sulfamethoxazole (Bactrim DS) B. Carafate (Sucralfate) C. Losartan (Cozaar) D. Furosemide (Lasix)

Solution: A Trimethoprim—sulfamethoxazole (Bactrim DS). Warfarin sodium (Coumadin) interacts with Bactrim and will increase the risk of bleeding; therefore, concurrent use is contraindicated.

A 30-year-old primigravida is diagnosed with a possible threatened abortion. The result of the urine pregnancy test is positive. Which of the following statements is true regarding a threatened abortion? A. Vaginal bleeding and cramping are present, but the cervix remains closed B. Vaginal bleeding and cramping are present along with a dilated cervix C. The fetus and placenta are both expelled D. The products of conception and the placenta remain inside the uterus along with a dilated cervix

Solution: A Vaginal bleeding and cramping are present, but the cervix remains closed. Threatened abortion is defined as vaginal bleeding and cramping without the presence of cervical dilation.

A new mother is planning to breastfeed her newborn infant for at least 6 months. She wants to know whether she should give the infant vitamins. Which of the following vitamin supplements is recommended by the American Academy of Pediatrics (APA) during the first few days of life? A. Vitamin D drops B. Vitamin E drops C. It is not necessary to give breastfed infants vitamin supplements, because breast milk contains enough vitamins and minerals that are necessary for the infant's growth and development. D. Folic acid drops

Solution: A Vitamin D drops. According to the American Academy of Pediatrics (APA), all infants should be given vitamin D supplementation within the first few days of life. Mothers who plan to breastfeed their infants should be taught how to use vitamin D drops. Infant formula is supplemented with vitamin D (and many other vitamins, minerals, and omega-3 oil), so there is no need to give it separately.

All of the following children are within the parameters of normal growth and development for their age group, except: A. A 2-month-old who coos and smiles B. A 14-month-old who understands complex commands C. A 20-month-old who can walk without support D. A 3-year-old who can speak in three- to four-word sentences

Solution: B A 14-month-old who understands complex commands. A 14-month-old child should developmentally be able to say "mama" and "dada," know his own name, and know at least two to four words. A 2-year-old is able to understand simple commands.

Which of the following individuals is most likely to be at higher risk for osteoporosis? A. A 70-year-old woman of African ancestry who walks daily for exercise B. A 42-year-old obese woman from Cuba who has been taking prednisone 10 mg daily for the past 12 years to control her severe asthma C. A 55-year-old Caucasian woman who is an aerobics instructor D. A 45-year-old Asian woman who has been on high-dose steroids for 1 week

Solution: B A 42-year-old obese woman from Cuba who has been taking prednisone 10 mg daily for the past 12 years to control her severe asthma. Risk factors for osteoporosis include postmenopause, early menopause, use of chronic steroids, smoking, excessive use of alcohol, sedentary lifestyle, insufficient intake of calcium and vitamin D in the diet, and being an Asian or Caucasian female.

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 larger >1 cm. This is a blister—a circumscribed, fluid-containing, elevated lesion of the skin, usually >5 mm in diameter.

A homeless 47-year-old man with a history of injection drug use and alcohol abuse presents to the public health clinic with a recent history of fever, night sweats, fatigue, and weakness. The patient has recently noticed thin red streaks on his nail bed and red bumps on some of his fingers that hurt. During the cardiac exam, the nurse practitioner hears a grade 3/6 murmur over the mitral area. The subcutaneous red-purple nodules are tender to palpation. The thin red lines on the nail beds resemble subungual splinter hemorrhages. Which of the following conditions is most likely? A. Pericarditis B. Acute bacterial endocarditis C. Rheumatic fever D. Viral cardiomyopathy

Solution: B Acute bacterial endocarditis. Bacterial endocarditis is also known as infective endocarditis (IC). It is a serious bacterial infection of the heart valves and the endocardial surface. The bacteria most commonly involved are Staphylococcus and Streptococcus species. Subcutaneous red, painful nodules on the finger pads are called Osler's nodes. Subungual splinter hemorrhages on the nail beds are caused by microemboli. Janeway's lesions are caused by bleeding under the skin (usually located on the palms and the soles) and are painless red papules and macules. Other findings are conjunctival hemorrhages, petechiae, cardiac friction rubs, arrhythmias, murmurs, and others. Three blood cultures obtained at separate sites 1 hour apart are used to identify the causative organism. Some of the risk factors are damaged prosthetic valves, history of rheumatic fever, and injection drug use.

A 78-year-old woman's dual-energy x-ray absorptiometry (DEXA) scan yields a T score of -2.8. Which of the following pharmacologic options is preferred for treating this condition? A. Selective estrogen receptor modulators (SERMs) B. Bisphosphonates C. Hormone replacement therapy D. Calcium with vitamin D

Solution: B Bisphosphonates. A T score of −2.8 means that the patient has osteoporosis. Bisphosphonates are considered the first-line treatment for osteoporosis. They include alendronate (Fosamax), risedronate (Actonel), ibandronate (Boniva), and others with chemical names that end in -dronate . DEXA scores are reported as either T scores or Z scores, but T scores are more commonly used. A T score of −1 or higher is normal. A T score between −1 and −2.5 indicates osteopenia. A T score of −2.5 or lower indicates osteoporosis.

An infant who does not have a history of reactive airway disease and allergy has both inspiratory and expiratory wheezing accompanied by fever and profuse, clear nasal discharge. Which of the following is most likely? A. Tracheobronchitis B. Bronchiolitis C. Croup D. A small foreign body is lodged on the left main bronchus.

Solution: B Bronchiolitis. Symptoms of tracheobronchitis include prominent dry, nonproductive cough; later, coughing up phlegm is common. Bronchiolitis is a viral infection caused by respiratory syncytial virus (RSV), which is commonly seen during the winter/spring months in infants and young children. Typical signs/symptoms include fever and inspiratory/expiratory wheezing with clear drainage. Croup is a viral infection with a classic "barking" cough; the patient may have a runny nose, but typically no fever. When a child swallows a foreign object, choking, wheezing, and shortness of breath may occur, but no fever or clear drainage is present.

When starting an elderly patient on a new prescription of levothyroxine (Synthroid), the nurse practitioner should keep in mind that the rationale for beginning with a lower dose in such patients relates to the drug's: A. Central nervous system effects B. Cardiac effects C. Renal effects D. Hepatic effects

Solution: B Cardiac effects. Levothyroxine (Synthroid) should be started on the lowest dose in elderly patients because of the severe side effects that can occur. These include palpitations, tachycardia, anxiety, irritability, elevated blood pressure, flushing, and insomnia.

A 40-year-old man complains to the nurse practitioner of severe stabbing pains behind his left eye for the past 2 days. They are accompanied by some nasal congestion and rhinorrhea, which is clear in color. The patient denies pharyngitis and fever. Which of the following conditions is most likely? A. Migraine headache with aura B. Cluster headache C. Tic douloureux D. Cranial neuralgia

Solution: B Cluster headache. Cluster headaches' cardinal symptoms are an excruciating, unilateral, orbital, supraorbital, and/or temporal pain. The attack ranges from 15 minutes to 3 hours or more. Autonomic symptoms include ptosis (drooping eyelid), miosis (pupil constriction), lacrimation (tearing), and rhinorrhea in the nostril on the affected side of the face. Migraine headaches with aura include visual changes, such as blind spots or flashing lights, that appear before the onset of the headache. Trigeminal neuralgia (tic douloureux) is a unilateral headache from compression or inflammation of the trigeminal nerve (cranial nerve V).

Which of the following viral infections is associated with occasional abnormal forms of lymphocytes during an acute infection? A. Cytomegalovirus (CMV) B. Epstein-Barr virus (EBV) C. Human papillomavirus (HPV) D. Coxsackievirus

Solution: B Epstein—Barr virus (EBV). EBV is a member of the herpesvirus family and one of the most common viruses. During adolescence, EBV causes infectious mononucleosis. In most cases of infectious mononucleosis, the clinical diagnosis can be made from the triad of fever, pharyngitis, and lymphadenopathy lasting 1 to 4 weeks. Serology tests show normal to moderately elevated white blood cells and increased numbers of lymphocytes, >10% atypical lymphocytes, and a positive reaction to a mono spot test. The antibody response in primary EBV infection appears to be quite rapid.

A 76-year-old female presents to the primary care clinic for her annual check-up. The nurse practitioner notes that her height has decreased by an inch in the last year and her back has a "hump-like" deformity. How will the nurse practitioner document these findings? A. Lordosis B. Kyphosis C. Scoliosis D. Osteoarthritis

Solution: B Kyphosis. Older adults can lose 1 to 3 inches of height as they age. The height loss is caused by compression fractures of the vertebrae, which most commonly occur after age 70. The type of curvature that is generally caused by osteoporosis of the vertebrae is called kyphosis. It has the appearance of a "hump" in the thoracic region and is most common in elderly females, although it can appear in other age groups because of other causes. Lordosis, or "swayback," is an abnormal curvature in the lumbar spine. Scoliosis is an abnormal lateral curvature that occurs most often during the growth spurt just before puberty.

A kindergarten teacher is diagnosed with acute streptococcal pharyngitis. On exam, her throat is a bright-red color with no tonsillar exudate, and clear mucus is seen on the lower nasal turbinates. The urinalysis shows a large amount of white blood cells and is positive for nitrites. The patient has a sulfa allergy and thinks she is also allergic to penicillins. Which of the following is the best treatment choice? A. Amoxicillin-clavulanic acid (Augmentin) 500 mg PO BID B. Levofloxacin (Levaquin) 250 mg PO daily C. Trimethoprim-sulfamethoxazole (Bactrim DS) 1 tablet PO BID D. Clarithromycin (Biaxin) 500 mg PO BID

Solution: B Levofloxacin (Levaquin) 250 mg PO daily. Streptococcal pharyngitis and urinary tract infection are both covered by using Levaquin, which is a fluoroquinolone. Amoxicillin-clavulanic acid (Augmentin) and trimethoprim-sulfamethoxazole (Bactrim) would not be used because of the patient's allergies. Fluoroquinolones can be used in patients age 18 years or older.

A 55-year-old male presents with a swollen, painful right testicle and burning on urination. Examination reveals edematous scrotum with tenderness and a positive Prehn's sign. The patient states he is heterosexual and has been in a monogamous relationship for the past 5 years. He denies practicing anal intercourse. The nucleic acid amplification test (NAAT) is negative. Which medication will the nurse practitioner prescribe? A. Ceftriaxone (Rocephin) 250 mg IM B. Levofloxacin (Levaquin) 500 mg PO × 10 days C. Doxycycline (Vibramycin) 100 mg PO BID × 10 days D. Ceftriaxone (Rocephin) 250 mg IM and ofloxacin (Floxin) 300 mg PO BID × 10 days

Solution: B Levofloxacin (Levaquin) 500 mg PO × 10 days. The results of the NAAT indicate the patient is negative for chlamydial infection and gonorrhea. In an older male, acute epididymitis, caused by enteric organisms (generally gram-negative Escherichia coli ), is the probable diagnosis. Epididymitis is diagnosis for most commonly gram-negative E. coli. Levofloxacin (Levaquin) 500 mg orally once a day for 10 days is the treatment of choice. Ceftriaxone (Rocephin) 250 mg IM in addition to doxycycline (Vibramycin) 100 mg orally twice a day for 10 days is recommended for patients with epididymitis caused by chlamydial infection and gonorrhea. Ceftriaxone 250 mg IM in addition to ofloxacin (Floxin) 300 mg orally twice a day for 10 days is indicated for patients with acute epididymitis most likely caused by sexually transmitted chlamydial infections and gonorrhea, as well of the probability of enteric organisms obtained by men who practice anal sex.

An elderly female patient who is a retired nurse was recently discharged from the hospital. A few days later, she started having random and recurrent episodes of dizziness, which prompted today's healthcare visit. She denies passing out but describes the sensation of the room spinning or moving, which is worsened by sudden head movement. During the episodes, she is nauseated and sometimes vomits. The patient reports that she was given intravenous (IV) antibiotics and one of them was tobramycin. Which of the following medications is helpful in treating her symptom of dizziness? A. Scopolamine patch (Transderm Scop) B. Meclizine (Antivert) C. Dimenhydrinate (Dramamine) D. Duloxetine (Cymbalta)

Solution: B Meclizine (Antivert). The case is describing vertigo. Meclizine (Antivert) 12.5 mg to 50 mg three to four times a day is used to treat vertigo. Do not forget to also treat nausea, which can be severe. Antinausea medicines, such as dimenhydrinate (Dramamine) or prochlorperazine (Compazine), are effective. Advise the patient that these drugs can cause drowsiness.

A 55-year-old woman with rheumatoid arthritis sees the nurse practitioner for an episodic visit. She has been taking ibuprofen twice daily for many years. All of the following organ systems are at risk for damage from chronic nonsteroidal anti-inflammatory drug (NSAID) use, except: A. Cardiovascular system B. Musculoskeletal system C. Hematopoietic system D. Integumentary system

Solution: B Musculoskeletal system. The musculoskeletal system is not damaged by NSAIDs. In fact, NSAIDs are used to treat muscle and/or joint pain and inflammation. Systems adversely affected by NSAIDs include the cardiovascular, hematopoietic (because aspirin affects platelets), and integumentary (e.g., Stevens-Johnson syndrome).

A 65-year-old man presents to the clinic complaining of random and recurrent episodes of dizziness with nausea. The patient describes it as the sensation of the room moving or of the room spinning. It is worsened by sudden head movement. During the episodes, he becomes very nauseated. He also has tinnitus with hearing loss in his right ear. The patient has type 2 diabetes and is on a prescription of metformin 500 mg PO BID and an angiotensin-converting enzyme (ACE) inhibitor. The blood glucose level during his visit is 80 mg/dL. Which of the following conditions is most likely? A. Vasovagal presyncopal episode B. Ménière's disease C. Atypical migraine D. Hypoglycemia

Solution: B Ménière's disease. The classic triad of symptoms of Ménière's disease is episodic vertigo, tinnitus, and sensorineural hearing loss (low frequency). Tinnitus is usually low pitch (like listening to a conch shell). One may have a strong sensation of ear fullness. The condition can resolve spontaneously or may be chronic. Pathologic lesion in the middle ear is called endolymphatic hydrops. Vasovagal syncope does not cause hearing loss or tinnitus, nor is it episodic. Hypoglycemia is not associated with episodic vertigo, tinnitus, and hearing loss.

The most important job of an institutional review board (IRB) is: A. Protecting the interests of the hospital or the research institution B. Protecting the rights of the human subjects who participate in research done at the institution C. Protecting the researcher and research team from lawsuits D. Evaluating research protocols and methodology for appropriateness and safety

Solution: B Protecting the rights of the human subjects who participate in research done at the institution. Every research institution has an IRB whose job is to review all the research that is conducted in that institution. The IRB's most important role is to protect the rights of the human subjects who participate in research done at the institution of which the IRB is a part (e.g., research hospitals, universities).

A 10-year-old boy complains of a sudden onset of scrotal pain upon awakening that morning. He is also complaining of severe nausea and vomiting. During the physical examination, the nurse practitioner finds a tender, warm, and swollen left scrotum. The cremasteric reflex is negative, and the urine dipstick is negative for leukocytes, nitrites, and blood. What type of follow-up should this patient receive? A. Refer him to a urologist within 48 hours B. Refer him to the ED as soon as possible C. Prescribe ibuprofen (Advil) 600 mg QID for pain D. Order a testicular ultrasound for further evaluation

Solution: B Refer him to the ED as soon as possible. Immediate referral to the ED is required to prevent irreversible ischemia. Success of treatment is usually 100% if treated within the first 6 hours and 0% if treated after 24 hours. The diagnosis of testicular torsion is often made clinically, but if it is in doubt, an ultrasound is helpful in evaluating the condition. Emergency diagnosis and treatment are usually required within 4 to 6 hours to prevent necrosis.

A hypertensive middle-aged male American Indian has recently been diagnosed with renal insufficiency. He has been on lisinopril (Accupril) for many years. Which of the following laboratory values should be carefully monitored? A. Hemoglobin, hematocrit, and MCV (mean corpuscular volume) B. Serum creatinine and estimated GFR (glomerular filtration rate) C. AST (aspartate aminotransferase) and ALT (alanine aminotransferase) D. Serum sodium, potassium, and magnesium

Solution: B Serum creatinine and estimated GFR (glomerular filtration rate). One of the best tests for assessing renal function is the estimated GFR, which requires the creatinine value so that it can be calculated using a mathematical formula (Cockcroft-Gault equation, others). American Indians and Alaska Natives have the highest rate of diabetes of any group in the United States. AST and ALT are used to evaluate liver function. Electrolytes are not used to evaluate renal function.

A sexually active 16-year-old girl is brought by her mother for a physical exam. During the exam, the nurse practitioner notices some bruises on both breasts. All of the following are important areas to evaluate in this patient during this visit, except: A. Depression B. Tanner stage C. Sexual history D. Sexually transmitted diseases (STDs)

Solution: B Tanner stage. The stem of the question is asking for the important areas to evaluate in this patient "during this visit." This is a priority-type question. The priorities to evaluate in this patient are depression, STD testing, and sexual history. The Tanner staging does not have to be done "during this visit."

The Patient Protection and Affordable Care Act, enacted into law under President Obama, sought to expand health insurance coverage for Americans. All of the following are true statements about this law, except: A. Preexisting health conditions cannot be used to exclude individuals from obtaining coverage B. The health plan ensures that all Americans have health insurance coverage C. Young adults up to the age of 26 years who live with their parents are covered under their parents' health insurance plan D. Employers who choose not to participate in the national health insurance plan are fined

Solution: B The health plan ensures that all Americans have health insurance coverage. The national health insurance plan, officially known as the Patient Protection and Affordable Care Act and unofficially nicknamed Obamacare, was enacted in March 2010 with the goal of expanding health insurance for the millions of Americans who were uninsured. It prohibits an insurance company from rejecting people with preexisting health conditions. There is also a penalty for employers (and individuals) who choose not to participate in the national health plan. Although increased numbers of Americans gained insurance as a result of the law's passage, many millions more still lack coverage.

The nurse practitioner notices a gray ring on the edge of both irises of an 80-year-old woman. The patient denies visual changes or pain. She reports that she has had the "ring" for many years. What is the clinical significance of this finding in a 35-year-old patient? A. The patient has a higher risk of blindness B. The patient should be evaluated for hyperlipidemia C. The patient should be evaluated by an ophthalmologist D. The patient should be evaluated for acute glaucoma

Solution: B The patient should be evaluated for hyperlipidemia. Arcus senilis is caused by lipid deposits deep in the edge of the cornea and is quite commonly present in the elderly. However, it can also appear earlier in life as a result of hypercholesterolemia.

Which area of the breast is the most common site for female breast cancer? A. Nipple area B. The tail of Spence C. Subareolar region D. Left lower quadrant

Solution: B The tail of Spence. Breast cancer most often occurs in the upper outer quadrant of the breast, which is known as the tail of Spence.

The best screening test for both hyperthyroidism and hypothyroidism is: A. Free T4 (thyroxine) B. Thyroid-stimulating hormone (TSH) C. Thyroid profile D. Palpation of the thyroid gland

Solution: B Thyroid-stimulating hormone (TSH). The best screening test for both hypothyroidism and hyperthyroidism is TSH level. A normal TSH rules out primary hypothyroidism in asymptomatic patients. Abnormal TSH should be followed by determination of thyroid hormone levels. Overt hypothyroidism is defined as a clinical syndrome of hypothyroidism associated with elevated TSH and decreased serum levels of T4 or T3. Subclinical hypothyroidism is defined as a condition without typical symptoms of hypothyroidism, elevated TSH (>5 μU/mL), and normal circulating thyroid hormone. Overt thyrotoxicosis is defined as the syndrome of hyperthyroidism associated with suppressed TSH and elevated serum levels of T4 or T3. Subclinical thyrotoxicosis is devoid of symptoms, but TSH is suppressed, although there are normal circulating levels of thyroid hormone.

When does an infant triple its birth weight? A. 3 months B. 6 months C. 12 months D. 15 months

Solution: C 12 months. By the age of 12 months, an infant is expected to have tripled its birth weight. At 6 months, the infant is expected to have doubled its birth weight. Birth weight is regained by the second week of life (14 days).

The nurse practitioner is evaluating patients who are at high risk for complications due to urinary tract infections (UTIs). Which of the following patients does not belong in this category? A. A 38-year-old diabetic patient with an A1C of 7.5% B. A patient with rheumatoid arthritis who is being treated with methotrexate and low-dose steroids C. A 21-year-old patient who has a history of irritable bowel syndrome D. A pregnant patient

Solution: C A 21-year-old patient who has a history of irritable bowel syndrome. Irritable bowel syndrome is not associated with higher risk for UTIs. Risk factors for UTIs are gender (female), pregnancy, spermicide use during the past year, having a mother with a history of UTIs, having a new sex partner during the past year, urinary incontinence, and cystocele.

What is the pedigree symbol for a diseased male? A. An empty square B. An empty circle C. A filled-in square D. A filled-in circle

Solution: C A filled-in square. A filled-in square is a diseased or affected male, and a filled-in circle is a diseased or affected female. An empty square is a healthy male, and an empty circle is a healthy female.

Which of the following would you expect to find on a wet-mount slide of a patient diagnosed with bacterial vaginosis? A. Tzanck cells B. A large number of leukocytes and squamous epithelial cells C. A large number of squamous epithelial cells whose surfaces and edges are coated with large numbers of bacteria along with a few leukocytes D. Epithelial cells and a small amount of blood

Solution: C A large number of squamous epithelial cells whose surfaces and edges are coated with large numbers of bacteria along with a few leukocytes. Diagnosis of bacterial vaginosis includes three of four Amsel criteria: (1) white, thick adherent discharge; (2) pH >4.5; (3) positive whiff test (amineodor mixed with 10% potassium hydroxide [KOH]); (4) clue cells >20% on a wet mount (epithelial cells dotted with large numbers of bacteria that obscure cell borders).

A 12-year-old girl is complaining of a 2-week history of facial pressure that worsens when she bends over. She complains of tooth pain in her upper molars on the right side of her face. On physical exam, her lung and heart sounds are normal. Which diagnosis is most likely? A. An acute dental abscess B. Chronic sinusitis C. Acute sinusitis D. Severe allergic rhinitis

Solution: C Acute sinusitis. Signs and symptoms of acute sinusitis include headache, facial pain that worsens with bending over, eye/ear pressure and pain, aching in upper jaw/teeth, reduced smell and taste, cough (especially at night due to the nasal drainage), sore throat, bad breath, and fatigue.

A 44-year-old man with Down syndrome starts to develop impaired memory and difficulty with his usual daily routines. He is having problems functioning at the job where he has been employed for the past 10 years. The physical exam and routine labs are all negative. The vital signs are normal. His appetite is normal. The most likely diagnosis is: A. Tic douloureux B. Stroke C. Alzheimer's disease D. Delirium

Solution: C Alzheimer's disease. Delirium is an acute decline in mental status and is temporary. Common causes are fever, shock, drugs, alcohol, and dehydration. Alzheimer's disease involves a permanent change to the brain that causes short-term memory loss, agnosia, apraxia, and aphasia. In this case, the patient's physical exam is normal; however, he is having memory loss and difficulty working and carrying out his normal tasks.

A patient who is a member of the Jehovah's Witnesses faith refuses a blood transfusion based on religious beliefs. In which manner would the nurse practitioner support the patient's beliefs and practices, while also ensuring that the patient understands the components of informed consent? A. Ask the patient and their family to explain the cultural reasoning behind the decision B. Tell the patient that it is understandable to stand by their beliefs and ask them to complete advance directive paperwork C. Ask a hospital liaison from the patient's faith to counsel them on options and decision-making D. Contact social services to petition the court to obtain temporary guardianship to make decisions for the patient

Solution: C Ask a hospital liaison from the patient's faith to counsel them on options and decision-making. The right to refuse treatment is grounded in the ethical principle of respect for autonomy of the individual. The patient has the right to refuse treatment as long as they are competent and are made aware of the risks and complications associated with refusal of treatment. Therefore, asking a hospital liaison to counsel the patient on decision-making not only will demonstrate support of the cultural practices but also will allow the information to be conveyed by someone they trust. While it is always good practice to demonstrate earnestness by asking about cultural practices, this is not a method of supporting beliefs and gaining an informed consent. Although inquiring about advance directives is standard practice, it is not the primary focus when developing a trusting relationship and demonstrating support. Social services should not petition the court unless the patient is deemed incompetent to make decisions for themselves.

An elderly man is diagnosed with conductive hearing loss in the left ear by the nurse practitioner. Which of the following is the expected result when performing a Rinne test on this patient? A. AC (air conduction) > BC (bone conduction) B. Lateralization to the bad ear C. BC > AC D. Lateralization to the good ear

Solution: C BC > AC. A normal result in the Rinne test is AC > BC. When there is a conductive hearing loss (e.g., ceruminosis, otitis media), the result will be BC > AC. The reason is that the sound waves are blocked (e.g., cerumen, fluid in middle ear). Therefore, the patient cannot hear them as well as through BC.

Which of the following antihypertensive medications should the nurse practitioner avoid when treating patients with emphysema? A. Calcium channel blockers B. Angiotensin-converting enzyme (ACE) inhibitors C. Beta-blockers D. Diuretics

Solution: C Beta-blockers. Beta-blockers should be avoided in patients with a history of emphysema. Studies have shown evidence of a reduction in forced expiratory volume in 1 second (FEV1), increased airway hyperresponsiveness, and inhibition of bronchodilator response to beta agonists in patients receiving beta-blockers.

Which cranial nerve (CN) is being evaluated when patients are instructed to shrug their shoulders? A. CN IX B. CN X C. CN XI D. CN XII

Solution: C CN XI. CNs IX through XII are the glossopharyngeal, vagal, spinal accessory, and hypoglossal, respectively. CN XI tests for spinal accessory. The procedure to test trapezius muscle strength is to have the patient shrug the shoulders against resistance. To test sternocleidomastoid muscle strength, have the patient turn the head to each side with resistance.

A 36-year-old woman is seen by the nurse practitioner for a Pap smear and gynecologic exam. The patient is of Ashkenazi Jewish ethnicity. Her mother died of breast cancer at age 50 years. Her 57-year-old sister has recently been diagnosed with breast cancer. The breast exam is negative for a dominant mass, and the axillae do not contain any masses. All of the following are appropriate measures for this patient, except: A. Mammogram and MRI of the breast B. Referral to a breast specialist C. Check serum carcinoembryonic antigen (CEA) and cancer antigen (CA) 125 levels D. Genetic counseling and BRCA testing

Solution: C Check serum carcinoembryonic antigen (CEA) and cancer antigen (CA) 125 levels. The patient is a woman who is of Ashkenazi Jewish background with a positive family history of breast cancer (mother, sister). She is at very high risk for BRCA1 or BRCA2 mutations (hereditary breast cancer). The U.S. Preventive Services Task Force (2016) recommends that primary care providers screen women for a family history of breast, ovarian, tubal, or peritoneal cancer. Women with positive screening results should receive genetic screening and, if indicated after counseling, BRCA testing. These high-risk women are screened with a mammogram and breast MRI and are best managed by breast cancer specialists.

When the nurse practitioner is evaluating a patient for intermittent claudication, they would first: A. Order a venogram B. Order TED antiembolism stockings C. Check the ankle and brachial blood pressures before and after exercise D. Check the pedal and posterior tibial pulses

Solution: C Check the ankle and brachial blood pressures before and after exercise. Initial evaluation for intermittent claudication would include checking the ankle and brachial blood pressures before and after exercise.

Which of the following antibiotic regimens is recommended as first-line treatment for community-acquired pneumonia in patients with no comorbidity? A. Moxifloxacin 400 mg PO BID B. Amoxicillin-clavulanate 875/125 mg PO BID plus clarithromycin 500 mg PO BID C. Doxycycline 100 mg PO BID D. Cefpodoxime 200 mg PO BID plus azithromycin 500 mg PO on first day, then 250 mg PO daily

Solution: C Doxycycline 100 mg PO BID. The American Thoracic Society (ATS) recommends monotherapy with amoxicillin 1 g PO TID or doxycycline 100 mg PO BID as the first-line treatment for community-acquired pneumonia in patients without comorbidity or risk factors for prior respiratory isolation of methicillin-resistant Staphylococcus aureus (MRSA) or Pseudomonas aeruginosa or hospitalization with receipt of parental antibiotics within the past 90 days. If local pneumococcal resistance is <25%, a macrolide can be used as an alternative—azithromycin 500 mg on first day, then 250 mg daily or clarithromycin 500 mg BID or extended-release 1,000 mg daily. For patients with comorbidity, ATS recommends broader-spectrum coverage consisting of either combination therapy with beta-lactams (i.e., amoxicillin-clavulanate, cefpodoxime, or cefuroxime) plus a macrolide or doxycycline or monotherapy with a respiratory fluoroquinolone (i.e., levofloxacin, moxifloxacin, or gemifloxacin).

A multigravida who is at 34 weeks' gestation wants to know at what level her uterine fundus should be. The best answer is to advise the mother that her fundus is: A. Midway between the umbilicus and the lower ribs B. At the level of the umbilicus C. From 33 to 35 cm D. From 32 to 34 cm

Solution: C From 33 to 35 cm. After 20 weeks' gestation, fundal height in centimeters should measure approximately the same as the number of weeks of gestation.

A middle-aged man who is homeless reports to the local public health clinic complaining of a painless and shallow ulcer on the penile shaft for the past 2 weeks. He is sexually active and had unprotected intercourse with two male partners over the past few months. The patient is tested for HIV, syphilis, gonorrhea, hepatitis B, and herpes types 1 and 2. The syphilis and HIV tests are both positive. The gonorrhea, hepatitis B, and herpes tests are negative. The nurse practitioner is aware of the nationally notifiable infectious conditions. Which of the following is true regarding the reporting of any of these sexually transmitted infections? A. Healthcare providers must obtain the patient's permission before reporting the positive HIV and syphilis test results to the local public health department B. The nurse practitioner should obtain the patient's and sexual partner's permission before reporting the positive test results to the local health department C. Healthcare providers are mandated by law to report certain types of diseases to the local health department even if the patient does not give permission D. The nurse practitioner should consult with the supervising physician about this issue

Solution: C Healthcare providers are mandated by law to report certain types of diseases to the local health department even if the patient does not give permission. Physicians and laboratories are legally mandated to report certain types of diseases. Sexually transmitted diseases, HIV infection/ AIDS, gonorrhea, and syphilis must be reported to the local health department even if the patient does not give permission. Partner tracing and notification are done by the local health department. The Centers for Disease Control and Prevention (CDC) website contains a list of nationally reportable diseases. Reportable diseases include tuberculosis; diphtheria; hepatitis A, B, and C; measles; mumps; pertussis; Lyme disease; and Rocky Mountain spotted fever.

According to the U.S. Preventive Services Task Force (USPSTF), which of the following tests should be used to screen for lung cancer? A. Chest radiograph B. Bronchoscopy with biopsy C. Low-dose computed tomography (LDCT) D. Sputum for cytology

Solution: C Low-dose computed tomography (LDCT). The USPSTF recommends annual screening for lung cancer with LDCT in adults age 55 to 80 years who have a 30-pack-year smoking history and currently smoke (or quit within the past 15 years). Discontinue screening once a person has not smoked for 15 years or develops a health problem that substantially limits life expectancy or willingness to have curative lung surgery.

A 65-year-old woman's bone density result shows severe demineralization of cortical bone. All of the following pharmacologic agents are useful in treating this condition, except: A. Raloxifene (Evista) B. Calcitonin (Miacalcin) C. Medroxyprogesterone (Depo-Provera) D. Calcium with vitamin D

Solution: C Medroxyprogesterone (Depo-Provera). Long-term use (>3 years) of medroxyprogesterone (Depo-Provera) increases risk of bone loss. Avoid with osteopenia, osteoporosis, and long-term amenorrhea and in underweight women with anorexia. First-line treatment of osteoporosis is the bisphosphonates. Lifestyle measures are weight-bearing exercises and adequate calcium and vitamin D intake.

The nurse practitioner notes a high-pitched, blowing pansystolic murmur while assessing a 70-year-old male patient. It is grade 2/6 and is best heard at the apical area. Which of the following is most likely? A. Ventricular septal defect B. Tricuspid regurgitation C. Mitral regurgitation D. Mitral stenosis

Solution: C Mitral regurgitation. Mitral regurgitation is best heard at the apical area and manifests as a highpitched, blowing pansystolic murmur. It occurs when the mitral valve does not close properly. It is the abnormal leaking of blood from the left ventricle, through the mitral valve, and into the left atrium. When the ventricle contracts, there is backflow (regurgitation) of blood into the left atrium. Mitral regurgitation is the most common form of valvular heart disease. Murmurs are graded (classified) depending on how loud they sound with a stethoscope. The scale is 1 to 6 on loudness. A grade 2/6 is a grade 2 on the 6-point scale.

A 15-year-old basketball player who is 6 ft (1.83 m) tall is seen for complaints of painful lumps on his knees. Upon inspection, the nurse practitioner notes a bonelike growth on the upper tibia midline below the kneecap on both knees. The patient has full range of motion with no joint tenderness, redness, or swelling. Which of the following conditions is best described? A. Osteosarcoma of the tibia B. Juvenile rheumatoid arthritis C. Osgood-Schlatter disease D. Paget's disease of the bone

Solution: C Osgood—Schlatter disease. Osgood-Schlatter disease is characterized by pain over the tibial tuberosity with palpation of a bony mass over the anterior tubercle of one or both knees. Exercise worsens the pain.

A 76-year-old woman reports that for the previous 4 months, she has noticed severe stiffness and aching in her neck and both shoulders and hips that is worsened by movement. She reports having a difficult time getting out of bed because of the severe stiffness and pain. It is difficult for her to put on a jacket or blouse or fasten her bra. Along with these symptoms, she also has a low-grade fever, fatigue, loss of appetite, and weight loss. Starting yesterday, the vision in her right eye has progressively worsened. She has annual eye exams and denies that she has glaucoma. Which of the following conditions is most likely? A. Rheumatoid arthritis (RA) B. Degenerative joint disease C. Polymyalgia rheumatica (PMR) D. Fibromyalgia

Solution: C Polymyalgia rheumatica (PMR). PMR is a rheumatic condition that involves joints and arteries. It is associated with a high risk of giant cell arteritis (temporal arteritis; 15%-30%). The new onset of vision loss and the location of the pain (neck, both shoulders/hips) are the most important clues. Temporal arteritis can cause permanent blindness. Patients with PMR have a very high (40-100 mm/hour) sedimentation rate. Almost all will have elevated C-reactive protein levels (up to 99%). These patients are managed by rheumatologists by means of long-term steroids.

A 6-year-old girl who attends preschool part time is brought to the clinic by her mother as a walk-in patient. The mother reports that her daughter has recently begun swim lessons. The symptoms began as redness on the left eye and spread to the second eye within 2 days. The child's eyes are watery and crusted in the morning when she wakes up. Her vital signs are temperature of 98.8°F, pulse of 90 beats/min, and respirations of 16 breaths/min. The eye exam reveals bilateral injected conjunctivae. When the lower eyelid is examined, the nurse practitioner notes that it is pink with a cobblestone appearance. There is ipsilateral preauricular adenopathy. All of the following treatment measures are appropriate, except: A. Prescribe a topical ophthalmic vasoconstrictor to be used two times per day as needed for up to 3 days to reduce redness B. Write a note excusing the child from school because she should not attend until the symptoms resolve C. Prescribe ophthalmic topical antibiotic eye drops, two or three drops to be applied in each eye QID for 7 days D. Advise use of cool compress over closed eyes as needed for comfort, washing hands often

Solution: C Prescribe ophthalmic topical antibiotic eye drops, two or three drops to be applied in each eye QID for 7 days. Treatment for viral keratoconjunctivitis (pink eye) is symptomatic. Cold compresses and slightly chilled artificial tears may help with the itching. Educate the parent and/or child to avoid touching the eyes with hands, avoid sharing towels, perform frequent handwashing, and use tissues if touching the eyes. Viral keratoconjunctivitis is usually caused by an adenovirus (but other viruses can also cause it). It is contagious for 10 to 12 days after the onset of symptoms and is a self-limiting condition. It can be transmitted through swimming pools, fomites, and hands. Children should not attend school until symptoms resolve.

Three days after delivering a healthy baby girl, a mother calls the office with concerns that her daughter's vagina is swollen with a small amount of bleeding. The nurse practitioner will: A. Refer the patient to ED B. Instruct the mother to bring the newborn into the office for evaluation C. Reassure the mother that this is normal D. Instruct the mother to cleanse the newborn's genitals with soap and warm water

Solution: C Reassure the mother that this is normal. At approximately 2 to 3 days of age, a newborn female may have bleeding from the vagina, and the labia may be swollen. This is normal and caused by withdrawal of hormone exposure in the womb. There is no need for evaluation in the office or ED unless the bleeding does not stop or increases in amount. Though it is important to gently cleanse the genitals, there is no need to use soap, which can irritate the vaginal mucosa.

All of the following are hematologic changes associated with pernicious anemia, except: A. Hypersegmented granulocytes B. Mean corpuscular volume of 120 fL C. Red cell distribution width of 12.3% D. Serum cobalamin level of 130 pg/mL

Solution: C Red cell distribution width of 12.3%. Hematologic changes associated with pernicious anemia include hypersegmented granulocytes, elevated mean corpuscular volume (normal range is 80-100 fL), decreased serum cobalamin level (normal range is 200-900 pg/mL), and elevated mean cell hemoglobin concentration (normal range is 31.5-35 g/dL). Red cell distribution width is an indicator of anisocytosis and is significantly higher in the megaloblastic group. Megaloblastic red blood cells are associated with pernicious anemia; therefore, the red cell distribution width for a patient with pernicious anemia will be higher than the normal range of 11.8% to 14.5%.

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.

Pulsus paradoxus is more likely to be associated with: A. Sarcoidosis B. Acute bronchitis C. Status asthmaticus D. Bacterial pneumonia

Solution: C Status asthmaticus. Pulsus paradoxus is most likely to be seen with status asthmaticus. With inspiration, systolic pressure drops because of the increased pressure (positive pressure). Some pulmonary risks of having increased pressure include asthma and emphysema. Cardiac causes for pulsus paradoxus include tamponade, pericarditis, and cardiac effusion.

A 10-year-old boy complains of a sudden onset of scrotal pain upon awakening that morning. He is also complaining of severe nausea and vomiting. During the physical examination, the nurse practitioner finds a tender, warm, and swollen left scrotum. The cremasteric reflex is negative, and the urine dipstick is negative for leukocytes, nitrites, and blood. The most likely diagnosis is: A. Acute epididymitis B. Severe Salmonella infection C. Testicular torsion D. Acute orchitis

Solution: C Testicular torsion. Signs and symptoms of testicular torsion include a sudden onset of unilateral scrotal pain, nausea, vomiting, and abdominal pain. Acute epididymitis causes fever, chills, nausea, and unilateral pain and is most commonly seen in sexually active men. Unilateral scrotal pain does not occur with Salmonella infection. Acute orchitis is often based on having a recent mumps infection (parotitis) with testicular edema.

A patient newly diagnosed with diabetes reports severe hives and swollen lips after taking Bactrim for a bladder infection 2 months ago. Which of the following statements is correct? A. The patient cannot take any pills in the sulfonylurea class B. The patient can take some of the pills in the sulfonylurea class C. The patient can take any of the pills in the sulfonylurea class D. None of the above

Solution: C The patient can take any of the pills in the sulfonylurea class. Available evidence does not support existence of cross-reactivity between the sulfonamide antimicrobials (e.g., sulfamethoxazole) and the nonantimicrobial sulfonamides (e.g., furosemide, thiazide diuretics, sulfonylurea hypoglycemics, protease inhibitors, and carbonic anhydrase inhibitors). This is due to the differences in their sulfa metabolites. The exception is sulfasalazine, a disease-modifying antirheumatic drug (DMARD), which can cause a cross-reaction.

A female adult patient presents with complaints of "bad burns" that are very painful. A large pot of boiling water tipped over and spilled on her arms and her anterior chest and abdomen. During the physical exam, the nurse practitioner notices bright-red skin with numerous bullae on the left arm and hand and large patches of bright-red skin on the anterior chest and abdominal area. On a pain scale of 1 to 10, she reports the pain as 9. Her vital signs are stable with tachycardia (pulse is 100 beats/min). She does not appear to be in shock. Using the rule of nines, what are the total body surface area (TBSA) and the depth of the burns in this patient? A. The patient has a TBSA of 15% with full-thickness burns of the left arm and left hand and partial-thickness burns of the anterior chest and abdominal area B. The patient has a TBSA of 20% with partial-thickness burns on the left arm and left hand and mild burns on the anterior chest and abdominal area C. The patient has a TBSA of 27% with partial-thickness burns on the left arm and left hand and superficial burns on the anterior chest and abdominal area D. The patient has a TBSA of 18% with full-thickness burns of the left arm and left hand and superficial burns on the anterior chest

Solution: C The patient has a TBSA of 27% with partial-thickness burns on the left arm and left hand, and superficial burns on the anterior chest and abdominal area. Using the rule of nines, the anterior thorax is 18% and the left arm/hand is 9%, totaling 27%. A standard Lund-Browder (rule of nines) chart is readily available in most emergency departments. A partial-thickness burn is the same as a second-degree burn. A superficial burn is a first-degree burn.

All of the following drug classes are approved for treating hypertension. Which of the following antihypertensive drug classes is associated with the largest number of research studies? A. Angiotensin-converting enzyme (ACE) inhibitors B. Angiotensin-receptor blockers (ARBs) C. Thiazide diuretics D. Calcium channel blockers (CCBs)

Solution: C Thiazide diuretics. Thiazide diuretics have been used to treat hypertension for many decades, and numerous placebo-controlled studies have documented their effectiveness as antihypertensive drugs.

A 65-year-old patient with a history of chronic obstructive pulmonary disease (COPD) related to 45-pack-year smoking history presents with lower back ache, frequency of urination, and "sometimes pink-tinged" urine. The urine dipstick test is heme positive. The nurse practitioner will order: A. Microscopic urinalysis (UA) B. Urine culture and sensitivity (C&S) C. Urine for cytology D. A 24-hour urine collection for protein

Solution: C Urine for cytology. The patient presents with common risk factors for urothelial or renal malignancy: age, tobacco use, and gross hematuria. Testing of urine for cytology should be ordered. A urine C&S would be ordered if infection were suspected. A microscopic UA would be the next step if the other symptoms were not evident. A 24-hour urine for protein would be ordered to detect conditions or diseases that cause renal inflammation.

A mother brings her 4-year-old daughter, who just started attending preschool, to the health clinic. She tells the nurse practitioner that her child is complaining of burning and itching that started in the left eye. Within 2 days it involved both eyes, and the child developed a runny nose and sore throat. During the physical exam, the child's eyes appear injected bilaterally with no purulent discharge. The throat is red, the inferior nasal turbinates are swollen, and lymph nodes are palpable in front of each ear. Which diagnosis is most likely? A. Herpes keratitis B. Corneal ulcer C. Viral conjunctivitis D. Bacterial conjunctivitis

Solution: C Viral conjunctivitis. The causative organisms of viral conjunctivitis (pink eye) include adenovirus and other virus types. It can present with or without cold symptoms. Patient complains of itchy red eyes and may have clear discharge accompanied by preauricular lymphadenopathy. The condition does not affect vision. If a contact lens wearer, assume bacterial infection and obtain culture of eye discharge.

A female patient diagnosed with emphysema 5 years ago has been taking budesonide with formoterol (Symbicort) twice daily. The nurse practitioner is concerned about the patient's risk for bone fractures. All of the following assessment findings indicate that the patient should be prescribed supplements, except: A. Bone density test of −1.6 B. Calcium level of 8.4 mg/dL C. Vitamin D level of 26 ng/mL D. Estrogen level of 15 pg/mL

Solution: C Vitamin D level of 26 ng/mL. The patient's long-term use of budesonide with formoterol (Symbicort) twice daily increases the patient's risk for bone fractures. Assessment findings that support supplementation include the low bone-density result of −1.6, which indicates osteopenia (osteopenia range is −1.5 to −2.4); low calcium level of 8.4 mg/dL (normal range is 8.6-10.2 mg/dL); and low estrogen level of 15 pg/mL, which indicates that the patient is postmenopausal (<20 pg/mL). The patient's vitamin D level of 26 ng/mL is within normal range (20-40 ng/mL).

An elderly patient has a positive polymerase chain reaction (PCR) for varicella zoster virus and has a recent history of breast cancer. All of the following interventions should be included in the treatment plan, except: A. Acyclovir (Zovirax) five times daily five times daily × 10 days B. Lidocaine 5% patch (Lidoderm) C. Zostavax vaccine D. Gabapentin TID

Solution: C Zostavax vaccine. The treatment plan for an elderly patient who is immunocompromised and diagnosed with shingles is acyclovir (Zovirax) × 10 days, a lidocaine 5% patch (Lidoderm), and gabapentin TID for postherpetic neuralgia (PHN). Because the patient is immunocompromised, the patient should not receive Zostavax (live virus vaccine).

A 3-year-old male toddler was seen in the office 8 days ago and prescribed amoxicillin 200 mg PO (suspension) TID × 10 days for strep throat. He presents for a follow-up visit with fatigue, reduced appetite, and dark-colored urine. A urine dipstick test reveals protein, albumin, and blood in the urine. Which test will the nurse practitioner order next? A. CT scan of the kidneys B. Fasting blood metabolic panel with complete blood count (CBC) with differential C. 24-hour urine collection for protein and creatinine clearance D. 24-hour urine collection for blood, protein, and creatinine clearance

Solution: D 24-hour urine collection for blood, protein, and creatinine clearance. While urine dipstick testing is useful in gross analysis of urine, the test is not definitive for diagnosing disorders. Therefore, a 24-hour urine collection for blood, protein, and creatinine clearance would be appropriate in this case, as it is more sensitive in evaluation of renal function. Urine dipsticks detect only albumin as creatinine clearance, not microalbuminuria. A CT scan or fasting blood metabolic panel with CBC with differential is not the priority testing to be completed next because overall renal function must be determined first.

The nurse practitioner does not need to obtain parental consent from all of the following patients, except: A. A 17-year-old who wants to be treated for a sexually transmitted infection B. A 12-year-old who wants a serum pregnancy test C. A 15-year-old who wants birth control pills D. A 14-year-old who wants to be treated for dysmenorrhea

Solution: D A 14-year-old who wants to be treated for dysmenorrhea. Treatment for teenagers may be done without parental consent for sexually transmitted infections, pregnancy testing, and contraception counseling and treatment. Parental consent is required for any type of physical exam or for other problems that require more invasive testing.

Signs and symptoms of depression include all of the following, except: A. Anhedonia B. Low self-esteem C. Apathy D. Apraxia

Solution: D Apraxia. Apraxia is characterized by loss of the ability to execute or carry out learned purposeful movements despite the desire and the physical ability to perform the movements. Apraxia is not a sign or symptom of depression; it is a disorder of motor planning caused by damage to specific areas of the cerebrum. Common signs of depression include anhedonia (loss of interest in activities that the patient finds pleasurable), unintentional weight loss or gain, fatigue, change in appetite, insomnia or hypersomnia, feelings of guilt and worthlessness, and recurrent thoughts of suicide.

Which of the following drugs that are used to treat attention-deficit hyperactivity disorder (ADHD) is not classified as an amphetamine/stimulant? A. Dexmethylphenidate (Focalin XR) B. Mixed salts of amphetamine (Adderall) C. Methylphenidate (Ritalin) D. Atomoxetine (Strattera)

Solution: D Atomoxetine (Strattera). Strattera is classified as a norepinephrine reuptake inhibitor. It is not a stimulant or an amphetamine. Strattera is contraindicated during/within 14 days of taking a monoamine oxidase inhibitor (MAOI) in patients with narrow-angle glaucoma or a heart disorder that will worsen with increases in blood pressure or heart rate or in those with pheochromocytoma. Children and teenagers should be monitored for suicidal thoughts/plans.

A patient reports a productive cough with excessive light-colored sputum. On physical examination, the nurse practitioner auscultates wheezing and crackles in all lobes. The patient has a 20-pack-year history of smoking. Which of the following conditions is most likely? A. Emphysema B. Acute bacterial pneumonia C. Viral pneumonia influenza D. Chronic bronchitis

Solution: D Chronic bronchitis. Chronic bronchitis is defined by coughing with excessive mucus production for 3 or more months, for a minimum of 2 or more consecutive years. Chronic bronchitis presents with a dry to productive cough with light-colored sputum. Coughing can interrupt a patient's sleep. Emphysema is permanent damage of the alveoli and loss of recoil that causes chronic hyperinflation of the lungs. In patients with emphysema, the expiratory phase of respiration is markedly prolonged, decreased lung and heart sounds are present, and the patient exhibits pursed-lip breathing and may experience weight loss. Acute bacterial pneumonia presents with acute onset of high fever and chills, productive cough of green to rust-colored sputum, and pleuritic chest pain with coughing. Viral pneumonia influenza presents with cough, fever, dyspnea, scanty sputum production, myalgias, and decreased breath sounds and crackles.

A nurse practitioner discusses the condition of a patient with acute myeloid leukemia in the hallway with another nurse. Which of the following statements is correct? A. The dignity of the patient has been compromised B. Patient autonomy has been infringed upon C. The patient's right to know has been neglected D. Confidentiality has been breached

Solution: D Confidentiality has been breached. Discussing the patient's condition in the hallway jeopardizes the patient's right to confidentiality. This action should not jeopardize the dignity of the patient, nor would it neglect the patient's right to know. Discussing the patient's condition in the hallway does not jeopardize the patient's autonomy.

A 5-year-old patient is in the office for a school physical. The child is up to date on immunizations, and the mother denies a history of chickenpox infection. Which of the following immunizations is indicated at this visit? A. Tetanus, diphtheria, acellular pertussis (Tdap), inactivated polio vaccine (IPV), measles-mumps-rubella (MMR) B. Diphtheria, tetanus, acellular pertussis (DTaP), Haemophilus influenzae type b, pneumococcal conjugate vaccine (PCV), IPV C. MMR, hepatitis B, varicella D. DTaP, IPV, MMR, varicella

Solution: D DTaP, IPV, MMR, varicella. Routine immunizations for entry into school are boosters of those given in infancy and toddlerhood. The best clue to this question is that the mother denies a history of chickenpox infection; therefore, this child requires a booster for varicella, as well as the fifth DTaP, the second MMR, and the fourth IPV. Since the child is up to date on immunizations, the hepatitis B and PCV series should be complete. The Tdap is reserved for patients older than 11 years of age.

A 21-year-old woman complains of left-sided pelvic pain accompanied by dyspareunia. During the gynecologic exam, the nurse practitioner notices green cervical discharge. The patient mentions a new onset of a painful and swollen left knee and denies a history of trauma. This best describes: A. Septic arthritis B. Reiter's syndrome C. Chondromalacia of the patella D. Disseminated gonorrheal infection

Solution: D Disseminated gonorrheal infection. Symptoms of pelvic inflammatory disease (PID) with painful, swollen joints of extremities indicate disseminated gonorrheal infection. Untreated disseminated gonorrhea can lead to septic arthritis. Symptoms may be mild, ranging from slight joint pain and no fever to severe joint pain with high fever. PID symptoms do not occur with septic arthritis, Reiter's syndrome, or chondromalacia of the patella.

A 65-year-old man with a body mass index (BMI) of 30 and a history of asthma has hypertension that has been well controlled with hydrochlorothiazide (Dyazide) 12.5 mg PO daily. His total cholesterol is 230 mg/dL. How many risk factors for coronary artery disease (CAD) does he have? A. One risk factor B. Two risk factors C. Three risk factors D. Four risk factors According to the U.S. Preventive Services Task Force (USPSTF), which of the following tests should be used to screen for lung cancer? A.Chest radiograph B.Bronchoscopy with biopsy C.Low-dose computed tomography (LDCT) D.Sputum for cytology

Solution: D Four risk factors. The risk factors for coronary artery disease for this patient are (1) 65-year-old male, (2) overweight (BMI of 30), (3) hypertension, and (4) total cholesterol of 230 mg/dL.

Erythromycin inhibits the cytochrome P450 (CYP450) system. All of the following drugs should be avoided because of a potential for a drug interaction, except: A. Theophylline (Theo-Dur) B. Warfarin (Coumadin) C. Diazepam (Valium) D. Furosemide (Lasix)

Solution: D Furosemide (Lasix). Many medications are contraindicated with the CYP450 system. Lasix is one medication that can be used.

All of the following are classified as activities of daily living (ADL), except: A . Ability to feed self (self-feeding) B. Ability to manage bladder and bowel elimination C. Personal hygiene and grooming D. Grocery shopping

Solution: D Grocery shopping. Grocery shopping, housework, and managing one's finances are considered instrumental activities of daily living (IADLs).

All of the following factors increase the risk of mortality for patients diagnosed with bacterial pneumonia, except: A. Alcoholism B. Very young or old age C. Multiple lobar involvement D. Hypertension

Solution: D Hypertension. Hypertension is not associated with an increase in mortality with pneumonia. But patients with multiple lobar involvement, infants, the elderly, those with chronic illnesses (including cirrhosis of the liver, congestive heart failure), individuals without a functioning spleen, and those who have other diseases that result in a weakened immune system experience complications. Patients with immune disorders or various types of cancer, transplant patients, and AIDS patients also experience complications. An alcohol-impaired pulmonary immune system is no defense against pneumonia-producing bacteria.

Sources of legal risk for the nurse practitioner include all of the following, except: A. Invasive procedures B. Electronic medical record entries C. Prescribing medication D. In-service training

Solution: D In-service training. Legal risks for the nurse practitioner include invasive procedures, electronic medical record entries, and prescribing of medications. In-service training does not directly affect the patient; therefore, legal risks are not a problem.

When examining a 10-year-old patient, where will the nurse practitioner auscultate the point of ?maximal impulse (PMI)? A. Left 4th intercostal space, midclavicular line of chest B. Right 4th intercostal space, midclavicular line of chest C. Right 5th intercostal space, midclavicular line of chest D. Left 5th intercostal space, midclavicular line of chest

Solution: D Left 5th intercostal space, midclavicular line of chest. The heart is located on the left side of the sternum. The loudest point of the heartbeat is heard at the left ventricle. To auscultate the loudest heart sound (apical pulse), the nurse practitioner will place the stethoscope at the left side of the chest, at the midclavicular line down to the 5th intercostal space. This PMI is relevant for children >7 years of age.

A 4-week-old boy is seen in the family practice clinic for a complaint of forceful vomiting that occurs immediately after feeding. The vomitus is composed of infant formula and is not bilious. The infant is bottle-fed with infant formula that was recommended by the pediatrician. The mother reports that the infant seems hungry and sucks on the bottle without any problems. His birth weight was 7 lb, ?5 oz (3.4 kg). The current weight is 7 lb (3.2 kg). Which of the following clinical findings is an important clue regarding the possible cause of the infant's vomiting? A. Irritable and crying infant B. Sunken anterior fontanel and dry lips C. Positive rooting reflex D. Round olive-like mass located in the right upper quadrant of the abdomen

Solution: D Round olive-like mass located in the right upper quadrant of the abdomen. The stem of the question is asking about the "possible cause of the infant's vomiting" (it is not asking about symptoms). Projectile or forceful vomiting after feeding (postprandial vomiting) is a classic symptom of infantile hypertrophic pyloric stenosis. A hypertrophied pylorus is a pathognomonic finding of the disease. An ultrasound of the pylorus is the imaging study of choice. The other signs and symptoms are dehydration (sunken anterior fontanel, dry lips, weight loss), irritability, and crying (usually due to hunger). A positive rooting reflex is a normal finding in a 4-week-old infant.

A male patient has type 2 diabetes mellitus and a "sensitive stomach." Which medication is least likely to cause him gastrointestinal distress? A. Naproxen sodium (Anaprox) B. Aspirin (Bayer's aspirin) C. Erythromycin (E-mycin) D. Sucralfate (Carafate)

Solution: D Sucralfate (Carafate). Naproxen sodium, aspirin, and erythromycin all have gastrointestinal side effects. Sucralfate is used to protect the stomach lining by building a protective layer over the stomach lining; it allows healing to occur.

All of the following statements about common health beliefs of many traditional Asian cultures are true, except: A. An imbalance of the hot and cold (yin/yang) vital forces can cause illness, and treating a hot disease with a "cold" treatment (e.g., certain foods/herbs) can help to restore balance and cure the illness B. If the patient is very ill or dying, immediate family and extended family members will visit the patient daily in shifts to provide emotional support C. Infants and small children may wear an amulet such as a red string on the wrist or a piece of cloth on the neck or the wrist D. Surgical procedures are regarded as important treatment for many illnesses

Solution: D Surgical procedures are regarded as important treatment for many illnesses. Some Asian cultures regard surgery as a last resort and consider loss of blood as depleting the vital forces of the body and causing illness. Western medicine is considered to be "hot," and patients may discontinue or reduce the doses of their medicine without asking. An imbalance of the hot and cold (yin/yang) is believed to cause illness. Treating a "yin" disease (common cold) means avoiding eating yin foods (melons, cucumbers) because they will worsen it. Instead, yin diseases are treated with yang foods (meat, spicy foods) so that the body becomes more balanced.

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.