N5334 Advanced Pharmacology Test 2

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According to American College of Cardiology Foundation/American Heart Association (ACCF/AHA) guidelines, when treating elderly patients with hypertension, which of the following medications have a compelling indication for use in the following patient conditions? (The medications listed can be used more than once. A given condition can have more than one medication indicated.) A. thiazide diuretic B. beta blocker C. ACEI D. ARB E. aldosterone antagonist F. calcium channel blocker _______32. heart failure _______33. diabetes mellitus _______34. angina pectoris B _______35. coronary artery disease _______36. aortic aneurysm _______37. recurrent stroke prevention

32. A, B, C, D, E, F. 33. A, B, C, D, F. 34. B, F. 35. A, B, C, F. 36. A, B, C, F. 37. A, C, D, F.

Indicate whether each statement is true or false. 34. Seasonal influenza vaccination is generally recommended for all persons over the age of 6 months. 35. A 66-year-old woman is an acceptable candidate for the high-dose inactivated influenza vaccine shot. 36. Cigarette smokers should not receive the pneumococcal vaccine until 65 years of age. 37. A 52-year-old immunocompetent patient with COPD who receives the pneumococcal vaccine should get revaccinated in 5 years.

34. True 35. True 36. False 37. False

Anemia: True or False? 34. Anemia in children is potentially associated with poorer school performance. 35. During pregnancy, folic acid requirements increase twofold to fourfold. 36.The red blood cell content is approximately 90% hemoglobin. 37. Approximately 90% of the body's erythropoietin is produced by the kidney. 38.The body's normative response to anemia is reticulocytopenia.

34. True 35. True 36. True 37. True 38. False

Match the term with the correct impact on the heart. 101. inotropic 102. chronotropic 103. dromotropic A. cardiac rate B. cardiac conduction C. force of the cardiac contraction

101. C. 102. A. 103. B.

Match the antihypertension medication with its appropriate class. _______6. amlodipine _______7. diltiazem _______8. trandolapril _______9. telmisartan _______10. pindolol A. beta-adrenergic receptor antagonist B. nondihydropyridine calcium channel blocker C. dihydropyridine calcium channel blocker D. angiotensin receptor antagonist E. ACEI

6. C. 7. B. 8. E. 9. D. 10. A.

72 to 76. Weight loss medications: True or false? ________ 72. Lorcaserin (Belviq®) should not be used with medications that have a serotonergic effect. ________ 73. Phentermine/topiramate (Qsymia®) carries a warning about potential teratogenic effects. ________ 74. Phentermine's mechanism of action in weight loss is as a product that reduces gastrointestinal (GI) motility. ________ 75. In general, weight lost post-gastric bypass is significantly more when compared with the postoperative course of a restrictive procedure such as adjustable gastric band or gastric sleeve. ________ 76. Use of naltrexone/bupropion (Contrave®) is associated with increased risk of suicidal ideation.

72. True 73. True 74. False 75. True 76. True

77 to 79. Based on the CURB-65 criteria, indicate which patients should be treated as an inpatient (I) or outpatient (O). 77. a 47-year-old man with no confusion, blood urea nitrogen (BUN) = 22 mg/dL, respiratory rate = 32/min, and blood pressure = 110/72 mm Hg 78. a 56-year-old woman with no confusion, BUN = 22 mg/dL, respiratory rate = 27/min, blood pressure = 88/56 mm Hg 79. a 72-year-old man with confusion, BUN = 18 mg/dL, respiratory rate = 35/min, blood pressure = 102/66 mm Hg

77. O 78. I 79. I

91 to 95. Identify the following organisms as a grampositive, gram-negative, or atypical pathogen. 91. Streptococcus pneumoniae 92. Haemophilus influenzae 93. Legionella species 94. Chlamydophila pneumoniae 95. Mycoplasma pneumoniae

91. gram-positive 92. gram-negative 93. atypical 94. atypical 95. atypical

94 to 96. Match each of the following conditions with its mechanism for contributing to heart failure: 94. pneumonia 95. anemia 96. high sodium intake A. increase in circulating volume of blood B. increased right-sided heart workload C. decreased oxygen-carrying capacity of blood

94. B. 95. C. 96. A.

123. In prescribing niacin therapy for a patient with hyperlipidemia, the NP considers that: A. postdose flushing is often reported. B. periodic creatine kinase monitoring is warranted. C. low-dose therapy is usually effective in increasing LDL level. D. drug-induced thrombocytopenia is a common problem.

131. Which of the following daily doses has the lowest lipid-lowering effect? A. simvastatin 10 mg B. rosuvastatin 5 mg C. atorvastatin 10 mg D. pravastatin 40 mg

133. A program of regular aerobic physical activity can yield which of the following changes in the lipid profile? A. increases HDL, lowers VLDL and triglycerides B. lowers VLDL and LDL C. increases HDL, lowers LDL D. lowers HDL, VLDL, and triglycerides

134. Which of the following laboratory tests can identify the causative organism of bronchiolitis? A. nasal washing antigen test B. antibody test via blood sample C. urine culture D. a laboratory test is not available

142. During a preparticipation sports examination, you hear a grade 2/6 early- to mid-systolic ejection murmur, heard best at the second intercostal space of the left sternal border, in an asymptomatic young adult. The murmur disappears with position change from supine to standing position. This most likely represents: A. an innocent flow murmur. B. mitral valve incompetency. C. aortic regurgitation. D. mitral valve prolapse (MVP).

149. A 23-year-old woman presents with mild mitral stenosis and is without symptoms. Which of the following is correct concerning sports participation? A. Full activity is likely acceptable. B. Prolonged aerobic exercise is discouraged. C. An ACE inhibitor should be prescribed prior to participation. D. Sports participation should be limited to noncontact sports.

15. Clinical presentation of type 1 DM usually includes all of the following except: A. report of recent unintended weight gain. B. ketosis. C. persistent thirst. D. polyphagia.

152. Which of the following characteristics about atrial septic defect is false? A. It is more common in boys than girls. B. Child presentation can range from entirely well to heart failure. C. Full sports participation is typically acceptable with correction. D. Easy fatigability is a sign of atrial septic defect.

153. A 19-year-old man presents with well-controlled hypertension. Which of the following statements is correct concerning sports participation? A. Full activity should be encouraged. B. Weight lifting is contraindicated. C. An exercise tolerance test is advisable. D. A beta-adrenergic antagonist should be prescribed.

154. A 25-year-old woman presents with sinus arrhythmia. Which of the following statements is correct concerning sports participation? A. Full activity should be encouraged. B. Weight lifting is contraindicated. C. An exercise tolerance test is advisable. D. A calcium channel antagonist should be prescribed.

166. Long-term bisphosphonate treatment (i.e., >5 years) has been associated with: A. atypical fractures. B. hyperprolactinemia. C. osteoarthritis. D. bone marrow suppression.

17. You see a 72-year-old woman who reports vomiting and abdominal cramping occurring over the past 24 hours. In evaluating a patient with suspected appendicitis, the clinician considers that: A. the presentation can differ according to the anatomical location of the appendix. B. this is a common reason for acute abdominal pain in elderly patients. C. vomiting before onset of abdominal pain is often seen. D. the presentation is markedly different from the presentation of pelvic inflammatory disease.

170. In counseling a postmenopausal woman, you advise her that systemic estrogen therapy users can possibly experience: A. an increase in breast cancer rates with long-term use. B. reduction in high-density lipoprotein cholesterol. C. a 10% increase in bone mass. D. no change in the occurrence of osteoporosis.

170. Risk factors for acute pancreatitis include all of the following except: A. hypothyroidism. B. dyslipidemia. C. abdominal trauma. D. thiazide diuretic use.

172. Your next best action in caring for Ms. Lane in the previous question is to: A. refer to the acute care hospital for admission. B. attempt office hydration after administration of an analgesic agent. C. initiate therapy with ranitidine (Zantac®) and an antacid. D. obtain serum electrolyte levels.

174. Elevated lipase levels can be a result of all of the following conditions except: A. hepatic failure. B. renal failure. C. perforated duodenal ulcer. D. bowel obstruction or infarction.

179. A 56-year-old man with a history of colon cancer undergoes a follow-up abdominal MRI scan. A small mass is identified on the pancreas that is later diagnosed as a benign pseudocyst. The pseudocyst is not causing any symptoms and measures 8 mm in diameter. You consider: A. repeating the scan in 1 year to check for any changes. B. draining the pseudocyst. C. surgical removal of the pseudocyst. D. initiating a regimen of anti-inflammatory medication to decrease the size of the pseudocyst

18. Which of the following is consistent with the NAEPP comment on the use of inhaled corticosteroids (ICS) for a child with asthma? A. The potential but small risk of delayed growth with ICS is well balanced by their effectiveness. B. ICS should be used only if a leukotriene receptor antagonist fails to control asthma. C. Permanent growth stunting is consistently noted in children using ICS. D. A leukotriene receptor antagonist are equal in therapeutic effect to the use of a long-acting beta2-agonist.

18.The psoas sign can be best described as abdominal pain elicited by: A. passive extension of the hip. B. passive flexion and internal rotation of the hip. C. deep palpation. D. asking the patient to cough.

180. Risk factors for pancreatic cancer include all of the following except: A. hypertension. B. history of chronic pancreatitis. C. tobacco use. D. diabetes mellitus.

183. The clinical presentation of pancreatic cancer involving the head of the pancreas usually includes: A. painless jaundice. B. polycythemia. C. hematuria. D. hyperkalemia.

19. A potential adverse effect from ICS use is: A. oral candidiasis. B. tachycardia. C. gastrointestinal upset. D. insomnia.

2. Which of the following characteristics applies to type 2 DM? A. Major risk factors are heredity and obesity. B. Pear-shaped body type is commonly found. C. Exogenous insulin is needed for control of disease. D. Physical activity enhances IR.

219. Poorly controlled asthma in children can lead to: A. attenuated lung development. B. chronic tracheitis. C. sleep apnea. D. alveolar destruction.

222. Haley is a 6-year-old with moderate persistent asthma who presents for a follow-up visit. The NP administers the Asthma Control Test (ACT) and she scores a 22. This would indicate: A. well-controlled asthma. B. not well-controlled asthma. C. poorly controlled asthma. D. very poorly controlled asthma.

223. Which of the following would you not expect for Haley (question 222)? A. nighttime awakening about once a week B. asthma symptoms occurring about 2 times per week C. asthma having little to no interference with normal activities D. SABA use 2 days or less per week

23. Clinical findings most consistent with appendiceal rupture include all of the following except: A. abdominal discomfort less than 48 hours in duration. B. fever greater than 102°F (>38°C). C. palpable abdominal mass. D. marked leukocytosis with total WBC greater than 20,000/mm3.

23. Which of the following is most likely to be part of the clinical presentation of an otherwise healthy 27-year-old woman with uncomplicated lower urinary tract infection (UTI)? A. urinary frequency B. fever C. suprapubic tenderness D. lower gastrointestinal (GI) upset

24. Which of the following imaging studies potentially exposes the patient being evaluated for abdominal pain to the lowest ionizing radiation burden? A. ultrasound B. barium enema C. CT scan D. abdominal flat plate

26. Which of the following statements is false regarding the use of omalizumab (Xolair®)? A. Its use is recommended for patients with mild persistent asthma to prevent asthma flares. B. The medication selectively binds to immunoglobulin E (IgE) to reduce exacerbations. C. Labeled indication is for patients with poorly controlled asthma with frequent exacerbations. D. Special evaluation is required prior to its use and ongoing monitoring is needed during use.

27. What is the most common adverse effect noted with alpha-glucosidase inhibitor use? A. gastrointestinal upset B. hepatotoxicity C. renal impairment D. symptomatic hypoglycemia

271. Which of the following is the most appropriate antimicrobial for treatment of CAP in a 2-year-old child who is clinically stable and able to be treated in the outpatient setting? A. amoxicillin B. doxycycline C. TMP-SMX D. levofloxacin

28. Which of the following statements best describes the Somogyi effect? A. Insulin-induced hypoglycemia triggers excess secretion of glucagon and cortisol, leading to hyperglycemia. B. Early morning elevated blood glucose levels result in part from growth hormone and cortisol-triggering hepatic glucose release. C. Late evening hyperglycemia is induced by inadequate insulin dose. D. Episodes of postprandial hypoglycemia occur as a result of inadequate food intake.

3. When assessing a 78-year-old man with suspected BPH, the NP considers that: A. prostate size does not correlate well with severity of symptoms. B. BPH affects less than 50% of men of this age. C. he is at increased risk for prostate cancer. D. limiting fluids is a helpful method of relieving severe symptoms.

3. You consider prescribing insulin glargine (Toujeo®, Lantus®) because of its: A. extended duration of action. B. rapid onset of action. C. ability to prevent diabetic end-organ damage. D. ability to preserve pancreatic function.

30. Which of the following is usually not seen in the diagnosis of acute cholecystitis? A. elevated serum creatinine B. increased alkaline phosphatase level C. leukocytosis D. elevated aspartate aminotransferase (AST) level

31. Murphy's sign can be best described as abdominal pain elicited by: A. right upper quadrant abdominal palpation. B. asking the patient to stand on tiptoes and then letting body weight fall quickly onto the heels. C. asking the patient to cough. D. percussion.

31.The mechanism of action of the DPP-4 inhibitors is as: A. a drug that increases levels of incretin, increasing synthesis and release of insulin from pancreatic beta cells. B. a product virtually identical in action to sulfonylureas. C. a drug that increases insulin action in the peripheral tissues and reduces hepatic glucose production. D. a facilitator of renal glucose excretion.

32. Hemorrhagic cystitis is characterized by: A. irritative voiding symptoms. B. persistent microscopic hematuria. C. the presence of hypertension. D. elevated creatinine and BUN levels.

32.The mechanism of action of a GLP-1 agonist such as exenatide (Byetta®) is as: A. a drug that stimulates insulin production in response to an increase in plasma glucose. B. a product virtually identical in action to sulfonylureas. C. a drug that increases insulin action in the peripheral tissues and reduces hepatic glucose production. D. a facilitator of renal glucose excretion.

33. You see an obese 25-year-old man with acanthosis nigricans and consider ordering: A. FBS. B. LFT. C. RPR. D. ESR.

36. Changes to the joint during osteoarthritis can typically include all of the following except: A. widening of the joint space. B. wearing away of articular cartilage. C. formation of bone spurs. D. synovial membrane thickens.

38. In children and the elderly, which of the following conditions can contribute to bladder instability and increase the risk of a UTI? A. constipation B. upper respiratory tract infection C. chronic diarrhea D. efficient bladder emptying

38. You examine a 24-year-old woman with mitral valve prolapse (MVP). Her physical examination findings may also include: A. pectus excavatum. B. obesity. C. petite stature. D. hyperextensible joints.

4. After use, the onset of action of lispro (Humalog®) occurs in: A. less than 30 minutes. B. approximately 1 hour. C. 1 to 2 hours. D. 3 to 4 hours.

4. One of the earliest laboratory markers in evolving macrocytic or microcytic anemia is: A. an increase in RBC distribution width (RDW). B. a reduction in measurable hemoglobin. C. a low MCH level. D. an increased platelet count.

4. Which of the following medications can contribute to the development of acute urinary retention in an older man with BPH? A. amitriptyline B. loratadine C. enalapril D. lorazepam

40. Which is most consistent with the diagnosis of COPD? A. FEV1/forced vital capacity (FVC) ratio equal to or less than 0.70 after properly timed SABA use B. dyspnea on exhalation C. elevated diaphragms noted on x-ray D. polycythemia noted on complete blood cell count

41. Long-term use of which medication has been possibly associated with increased risk for bladder cancer? A. cyclophosphamide B. saxagliptin C. rosuvastatin D. clopidogrel

41. Which of the following best describes the presentation of a patient with OA? A. worst symptoms in weight-bearing joints later in the day B. symmetrical early morning stiffness C. sausage-shaped digits with associated skin lesions D. back pain with rest and anterior uveitis

43. According to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) COPD guidelines, which of the following medications is indicated for use in all COPD stages? A. short-acting inhaled beta2-agonist B. inhaled corticosteroid C. phosphodiesterase 4 (PDE-4) inhibitor D. mucolytic

43. First-line pharmacologic intervention for milder OA should be a trial of: A. acetaminophen. B. tramadol. C. celecoxib. D. intra-articular corticosteroid injection.

43. Pertaining to the use of sliding-scale insulin in response to elevated blood glucose, which of the following best describes current best practice? A. The use of this type of sliding-scale insulin therapy is discouraged as this method treats hyperglycemia after it has already occurred. B. Sliding-scale insulin in response to elevated glucose is a safe and helpful method of treating hyperglycemia. C. Delivering insulin in this manner is acceptable within the acute care hospital setting only. D. The use of the sliding insulin scale is appropriate in the treatment of type 1 DM only.

43. When a heart valve fails to open to its normal orifice size, it is said to be: A. stenotic. B. incompetent. C. sclerotic. D. regurgitant.

44. According to the GOLD COPD guidelines, the goal of inhaled corticosteroid use in severe COPD is to: A. minimize the risk of repeated exacerbations. B. improve cough function. C. reverse alveolar hypertrophy. D. help mobilize secretions.

45. Which of the following is most consistent with the presentation of a patient with acute colonic diverticulitis? A. cramping, diarrhea, and leukocytosis B. constipation and fever C. right-sided abdominal pain D. frank blood in the stool with reduced stool caliber

46. Major risk factors for diverticulosis include all of the following except: A. low-fiber diet. B. family history of the condition. C. older age. D. select connective tissue disorders (e.g., Marfan syndrome).

47. In evaluating mitral valve incompetency, you expect to find the following murmur: A. systolic with radiation to the axilla. B. diastolic with little radiation. C. diastolic with radiation to the axilla. D. localized systolic.

49. Signs and symptoms consistent with endocarditis include all of the following except: A. bradycardia. B. Osler's nodes. C. hematuria. D. petechiae.

49. Which of the following best describes colonic diverticulosis? A. bulging pockets in the intestinal wall B. poorly contracting intestinal walls C. strictures of the intestinal lumen D. flaccidity of the small intestine

51. At what age is it appropriate to recommend dietary changes to parents if overweight or obesity is a concern? A. 12 months old B. 5 years old C. 10 years old D. 18 years old

52. All of the following are consistent with the GOLD COPD recommendation for pulmonary rehabilitation except: A. it is reserved for very severe COPD. B. its goals include improvement in overall well-being. C. it is an underused therapeutic option. D. its components are aimed at reducing the deconditioning common in COPD.

53. Lower GI hemorrhage associated with diverticular disease usually manifests as: A. a painless event. B. a condition noted to be found with a marked febrile response. C. a condition accompanied by severe cramp-like abdominal pain. D. a common chronic condition.

53. Recommended exercises for patients with OA of the knee include all of the following except: A. squatting with light weights. B. straight-leg raises without weights. C. quadriceps sets. D. limited weight-bearing aerobic exercises.

53. Screening children with a known risk factor for type 2 diabetes mellitus is recommended at age 10 or at onset of puberty and should be repeated how often? A. every other year B. every year C. every 6 months D. every 3 years

53. You are examining an 85-year-old woman and find a grade 3/6 crescendo-decrescendo systolic murmur with radiation to the neck. This is most likely caused by: A. aortic stenosis. B. aortic regurgitation. C. anemia. D. mitral stenosis.

54. Which of the following is an unlikely consequence of untreated metabolic syndrome and IR in a woman of reproductive age? A. hyperovulation B. irregular menses C. acne D. hirsutism

55. Criteria favoring knee replacement surgery for a patient with OA should include all of the following except: A. pain control requires daily use of NSAID therapy. B. >80% of articular cartilage is worn away. C. physical functioning is severely compromised. D. patient can tolerate the surgical procedure and rehabilitation.

55.The gastric parietal cells produce: A. hydrochloric acid. B. a protective mucosal layer. C. prostaglandins. D. prokinetic hormones.

56. Criteria favoring hip replacement surgery for a patient with OA should include all of the following except: A. pain control requires daily use of NSAID therapy. B. >80% of articular cartilage is worn away. C. physical functioning is severely compromised. D. patient can tolerate the surgical procedure and rehabilitation.

56. Management of mild aortic stenosis in a 12-year-old boy usually includes: A. ongoing monitoring with ECG and echocardiogram. B. use of a balloon catheter to separate fused valve leaflets. C. valve replacement. D. use of warfarin or other anticoagulant.

57. An acceptable level of total cholesterol (mg/dL) in children and teens is: A. <170 mg/dL or 9.4 mmol/L. B. <130 mg/dL or 7.2 mmol/L. C. 110-130 mg/dL or 6.2 mmol/L-7.2 mmol/L. D. 130-199 mg/dL or 7.2 mmol/L-11 mmol/L.

59.The H2RA most likely to cause drug interactions with phenytoin and theophylline is: A. cimetidine. B. famotidine. C. nizatidine. D. ranitidine.

6. A 68-year-old woman with heart failure presents with tachycardia, S3 heart sound, and basilar crackles bilaterally. Blood pressure is 90/68 mm Hg; BUN is 58 mg/dL (20.7 mmol/L); creatinine is 2.4 mg/dL (212.1 μmol/L). This clinical presentation is most consistent with: A. prerenal azotemia. B. acute glomerulonephritis. C. tubular necrosis. D. postrenal azotemia.

61. Which of the following is an example of an appropriate question to pose to a person with obesity who is in the precontemplation change stage? A. "How do you feel about your weight?" B. "What are barriers you see to losing weight?" C. "What is your personal goal for weight loss?" D. "How do you envision my helping you meet your weight loss goal?"

62.The most common renal stones are composed of: A. calcium. B. uric acid. C. sodium. D. iron.

63. Cyclooxygenase-2 (COX-2) contributes to: A. the inflammatory response. B. pain transmission inhibition. C. maintenance of gastric protective mucosal layer. D. renal arteriole dilation.

63. Of the following individuals, who is most likely to have a physiological split S2 heart sound? A. a 19-year-old healthy athlete B. a 49-year-old with well-controlled hypertension C. a 68-year-old with stable heart failure D. a 78-year-old with cardiomyopathy

63. When advising a person who will be using orlistat (Xenical®, Alli®) as part of a weight loss program, the NP provides the following information about when to take the medication: A. within an hour of each meal that contains fat. B. before any food with high carbohydrate content. C. only in the morning, to avoid sleep disturbance. D. up to 3 hours after any meal, regardless of types of food eaten.

64. You see a 48-year-old woman who has been taking a COX-2 inhibitor for the past 3 years. In counseling her, you mention that long-term use of COX-2 inhibitors is associated with all of the following except: A. hepatic dysfunction. B. gastropathy. C. cardiovascular events. D. cerebrovascular events.

7. Which of the following is found early in the development of chronic renal failure? A. persistent proteinuria B. elevated creatinine level C. acute uremia D. hyperkalemia

7. Which of the following is most likely to appear on a chest radiograph of a person during an acute severe asthma attack? A. hyperinflation B. atelectasis C. consolidation D. Kerley B signs

70.The use of which of the following medications is often associated with weight gain? A. risperidone (Risperdal®) B. topiramate (Topamax®) C. metformin (Glucophage®) D. sitagliptin (Januvia®)

71. A 56-year-old man with a 60 pack-year cigarette smoking history, recent 5-lb unintended weight loss, and a 3-month history of new-onset symptoms of peptic disease presents for care. He is taking no medications on a regular basis and reports drinking approximately six 12-oz beers per week with no more than three beers per day. Physical examination is unremarkable except for mild pharyngeal erythema and moderate epigastric tenderness without rebound. The most helpful diagnostic test at this point in his evaluation is: A. an upper endoscopy. B. a barium swallow. C. an evaluation of H. pylori status. D. an esophageal pH monitoring.

72. Which of the following is a quality of respiratory fluoroquinolones? A. activity against drug-resistant S. pneumoniae (DRSP) B. poor activity against atypical pathogens C. predominantly hepatic route of elimination D. poor activity against beta-lactamase-producing organisms.

74.The primary mechanism of antimicrobial resistance of H. influenzae is through the organism's: A. beta-lactamase production. B. hypertrophy of cell membrane. C. alteration in protein-binding sites. D. failure of DNA gyrase reversal.

75. A 35-year-old woman complains of a 6-month history of periodic "heartburn" primarily after eating tomatobased sauces. Her weight is unchanged and examination reveals a single altered finding of epigastric tenderness without rebound. As first-line therapy, you advise: A. avoiding trigger foods. B. the use of a prokinetic agent. C. addition of sucralfate with meals. D. increased fluid intake with food intake.

79. Which of the following is most likely to be found in a 40-year-old woman with new-onset reflux esophagitis? A. recent initiation of estrogen-progestin hormonal therapy B. recent weight loss C. report of melena D. evidence of H. pylori infection

83.The mechanism of action of radioactive iodine in the treatment of Graves' disease is to: A. destroy the overactive thyroid tissue. B. reduce production of TSH. C. alter thyroid metabolic rate. D. relieve distress caused by increased thyroid size.

84. Which of the following is not an "alarm" finding in the person with GERD symptoms? A. weight gain B. dysphagia C. odynophagia D. iron-deficiency anemia

84. Which of the following medications is a helpful treatment option for relief of tremor and tachycardia seen with untreated hyperthyroidism? A. propranolol B. diazepam C. carbamazepine D. verapamil

According to JNC-8, a 52-year-old well woman with a healthy BMI whose blood pressure is consistently 130-135/82-86 mm Hg is considered to have: A. normal blood pressure. B. hypertension requiring therapy with a calcium channel blocker (CCB). C. hypertension requiring therapy with an alpha blocker. D. hypertension requiring therapy with a thiazide-type diuretic.

In obtaining an office BP measurement, which of the following is most reflective of the best practice? A. The patient should sit in a chair with feet flat on the floor for at least 5 minutes before obtaining the reading. B. The BP cuff should not cover more than 50% of the upper arm. C. The patient should sit on the edge of the examination table without arm support to enhance reading accuracy. D. Obtaining the BP reading immediately after the patient walks into the examination room is recommended.

You see a 59-year-old man with poorly controlled hypertension. On physical examination, you note grade 1 hypertensive retinopathy. You anticipate all of the following will be present except: A. patient report of acute visual change. B. narrowing of the terminal arterioles. C. sharp optic disc borders. D. absence of retinal hemorrhage.

You see a 68-year-old woman as a patient who is transferring care into your practice. She has a 10-year history of hypertension, diabetes mellitus, and hyperlipidemia. Current medications include hydrochlorothiazide (HCTZ), glipizide, metformin, simvastatin, and daily low-dose aspirin. Today's BP reading is 158/92 mm Hg, and the rest of her history and examination are unremarkable. Documentation from her former healthcare provider indicates that her BP has been in the range for the past 12 months. Your next best action is to: A. prescribe an angiotensin-converting enzyme inhibitor (ACEI). B. have her return for a BP check in 1 week. C. advise that her current therapy is adequate. D. add therapy with an aldosterone antagonist.

54. Increased risk for diabetes (prediabetes) in children is defined as which of the following? (Choose all that apply.) A. impaired fasting glucose (glucose level ≥100 mg/dL or 6.2 mmol/L) but ≤125 mg/dL or 7 mmol/L) B. impaired glucose tolerance (2-hour postprandial 140-199 mg/dL or 7.8 mmol/L-11 mmol/L) C. HbA1c ≥7.5% but ≤8.5% D. random plasma glucose ≥250 mg/dL (13.9 mmol/L)

A, B

25. Commonly encountered diagnoses other than acute appendicitis can include which of the following in a 28-year-old with a 2-day history of lower abdominal pain and with right-sided pain slightly worse than left? (More than one can apply.) A. constipation B. pelvic inflammatory disease C. ectopic pregnancy D. splenic infarct

A, B, C

29. Intervention in microalbuminuria for a person with DM includes which of the following? (More than one can apply.) A. improved glycemic control B. strict dyslipidemia control C. use of an optimized dose of an angiotensin-converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB) D. use of an ACEI with an ARB

A, B, C

38. Which of the following best describes the physical activity recommendations such as brisk walking for a 55-year-old woman with newly diagnosed type 2 diabetes mellitus? (More than one can apply.) A. The goal should be for a total increased physical activity of 150 min per week or more. B. Increased physical activity is recommended at least three times per week with no more than 48 hours without exercise C. Some form of resistance exercise such as lifting dumbbells or using an exercise band should be included at least two times per week. D. Vigorous aerobic or resistance activity is potentially contraindicated in the presence of proliferative or severe nonproliferative retinopathy because of the possible risk of vitreous hemorrhage or retinal detachment.

A, B, C, D

77. Which of the following is a possible consequence of obesity? (More than one can apply.) A. obstructive apnea B. steatohepatitis C. female infertility D. endometrial cancer

A, B, C, D

71. You are counseling a patient who is considering gastric bypass surgery for weight loss. You advise the following. (More than one can apply.) A. Calcium absorption will be reduced. B. Rapid weight loss after obesity surgery can contribute to the development of gallstones. C. Chronic constipation is a common postoperative adverse effect. D. Lifelong vitamin B12 supplementation is recommended.

A, B, D

49. Fruit juice intake is acceptable in children 6 months and older per which of the following recommendations? (Choose all that apply.) A. The juice is mixed in small amounts to flavor water. B. Only 100% juice is used. C. Juice replaces no more than one serving of milk. D. The juice is consumed in the morning with breakfast. E. No more than 6 oz (177 mL) per day is recommended for children 6 months to 5 years.

A, B, E

48. Which of the following are risk factors for hypertension in children and teens? (Choose all that apply.) A. obesity B. drinking whole milk C. being exposed to secondhand smoke D. 2 or more hours per day of screen time

A, C

50. In evaluating a 9-year-old child with a healthy BMI during a well visit, a comprehensive cardiovascular evaluation should be conducted by the following methods. (Choose all that apply.) A. Obtain fasting lipid profile. B. Screen for type 2 diabetes mellitus by measuring HbA1c. C. Assess for family history of thyroid disease. D. Assess diet and physical activity.

A, D

22 to 25. With an 8 a.m. dose of the following insulin forms, followed by an inadequate dietary intake and/or excessive energy use, at approximately what time would hypoglycemia be most likely to occur? 22. lispro ____________ 23. regular insulin___________ 24. NPH insulin______________ 25. insulin glargine (Toujeo®, Lantus®)_________________

22. Approximately 8:30 to 9:30 a.m. (with peak of insulin dose) 23. Approximately 10 to 11 a.m. (with peak of insulin dose) 24. Approximately 2 to 10 p.m. (with peak of insulin dose) 25. Because insulin glargine (Toujeo®, Lantus®) has no peak, an episode of hypoglycemia is unlikely. If hypoglycemia were to occur, the episode could be protracted if left untreated because of the protracted duration of activity of the medication.

Match the recommended blood pressure goal for each patient according to JNC-8 guidelines. (An answer can be used more than once.) A. <130/80 mm Hg B. <140/80 mm Hg C. <140/90 mm Hg D. <150/90 mm _______24. a 57-year-old white male with no history of diabetes mellitus (DM) or chronic kidney disease (CKD) _______25. a 62-year-old African American male with diabetes mellitus _______26. a 67-year-old female with CKD _______27. a 62-year-old female with no history of DM or CKD _______28. an 82-year-old male with no history of DM or CKD _______29. a 72-year-old female with DM and CKD

24. C. 25. C. 26. C. 27. D. 28. D. 29. C.

117. A 78-year-old woman has hypertension, a 100 pack-year history of cigarette smoking, peripheral vascular disease, and reduced renal function (GFR = 47 mL/min/1.73 m2). Triglyceride level is 280 mg/dL (3.164 mmol/L); high-density lipoprotein (HDL) level is 48 mg/dL (1 mmol/L); and low-density lipoprotein (LDL) level is 135 mg/dL (3.5 mmol/L). Which of the following represents the most appropriate pharmacologic intervention for this patient's lipid disorders? A. Owing to her age and comorbidity, no further intervention is required. B. Moderate-intensity statin therapy is the preferred treatment option. C. A resin should be prescribed. D. The use of ezetimibe (Zetia®) will likely be sufficient to achieve dyslipidemia control.

117. Agents used for the prevention of thromboembolic events in a patient with atrial fibrillation include all of the following except: A. dabigatran. B. prasugrel. C. rivaroxaban. D. apixaban.

117. Which of the following is true concerning hepatitis B vaccine? A. The vaccine contains live hepatitis B virus. B. Most individuals born after 1986 in the United States who have been fully immunized have received vaccine against HBV. C. The vaccine is contraindicated in the presence of HIV infection. D. Postvaccination arthralgias are often reported.

12. In the treatment of asthma, leukotriene receptor antagonists should be used as: A. controllers to prevent bronchospasm. B. controllers to inhibit inflammatory responses. C. relievers to treat acute bronchospasm. D. relievers to treat bronchospasm and inflammation.

120. When providing care for a patient taking an HMG-CoA reductase inhibitor, initial evaluation when starting medication includes checking which of the following serological parameters? A. potassium B. alanine aminotransferase C. bilirubin D. alkaline phosphatase

121. When prescribing a fibrate, the NP expects to see which of the following changes in lipid profile? A. marked decrease in LDL level B. increase in HDL level C. no effect on triglyceride level D. increase in very low-density lipoprotein (VLDL) level

122. When prescribing niacin, the NP expects to see which of the following changes in lipid profile? A. marked decrease in LDL level B. increase in HDL level C. no effect on triglyceride level D. increase in VLDL level

124. Which of the following hepatitis forms is most effectively transmitted from man to woman via heterosexual vaginal intercourse? A. hepatitis A B. hepatitis B C. hepatitis C D. hepatitis D

124. With the use of ezetimibe (Zetia®), the NP expects to see: A. a marked increase in HDL cholesterol. B. a reduction in LDL cholesterol. C. a significant reduction in triglyceride levels. D. increased rhabdomyolysis when the drug is used in conjunction with HMG-CoA reductase inhibitor.

127. All of the following are risks for statin-induced myositis except: A. advanced age. B. use of a low-intensity statin therapy with a resin. C. low body weight. D. high-intensity statin therapy.

128. What is the average LDL reduction achieved with a change in diet as a single lifestyle modification? A. less than 5% B. 5% to 10% C. 11% to 15% D. 16% to 20% or more

13. Creatinine is best described as: A. a substance produced by the kidney. B. a product related to skeletal muscle metabolism. C. produced by the liver and filtered by the kidney. D. a by-product of protein metabolism.

13. Pernicious anemia is usually caused by: A. dietary deficiency of vitamin B12. B. lack of production of intrinsic factor by the gastric mucosa. C. RBC enzyme deficiency. D. a combination of micronutrient deficiencies caused by malabsorption.

13.The mechanism of action of sulfonylureas is as: A. an antagonist of insulin receptor site activity. B. a product that enhances insulin release. C. a facilitator of renal glucose excretion. D. an agent that can reduce hepatic glucose production

130. Bronchiolitis most commonly occurs in the United States during the months of June to August. A. true B. false

130. Which of the following medications is representative of high-intensity statin therapy? A. pravastatin 40 mg B. rosuvastatin 20 mg C. simvastatin 40 mg D. lovastatin 20 mg

135. In most children with bronchiolitis, intervention includes: A. aerosolized ribavirin therapy. B. supportive care. C. nebulized beta2 agonist therapy. D. oral corticosteroid therapy.

135. The anticipated effect on the lipid profile with plant stanol and sterol use includes: A. increase in HDL. B. decrease in LDL. C. decrease in select lipoprotein subfractions. D. decrease in triglycerides.

136. For patients with documented coronary heart disease, the American Heart Association advises intake of approximately of eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) per day, preferably from oily fish. A. 500 mg B. 1 g C. 2 g D. 4 g

137. Which of the following is an example of moderateintensity statin therapy? A. fluvastatin 10 mg B. atorvastatin 10 mg C. simvastatin 10 mg D. pravastatin 20 mg

144. You are examining an 18-year-old man who is seeking a sports clearance physical examination. You note a mid-systolic murmur that gets louder when he stands. This most likely represents: A. aortic stenosis. B. hypertrophic cardiomyopathy. C. a physiological murmur. D. a Still murmur.

145. A Still murmur: A. is an indication to restrict sports participation selectively. B. has a buzzing quality. C. is usually heard in patients who experience dizziness when exercising. D. is a sign of cardiac structural abnormality.

147. Risk factors for mitral regurgitation include a prior diagnosis of all of the following except: A. rheumatic heart disease. B. scarlet fever. C. endocarditis. D. calcific annulus.

15. Common physical examination findings in patients with pernicious anemia include: A. hypoactive bowel sounds. B. stocking-glove neuropathy. C. thin, spoon-shaped nails. D. retinal hemorrhages.

15. You see a 34-year-old man with moderate persistent asthma who has an asthma flare and a regimen of oral prednisone is being considered. Which of the following is true? A. A taper is needed for prednisone therapy lasting longer than 4 days. B. A taper is not needed if the prednisone regimen is for 7 days or less. C. A taper is not needed regardless of duration of prednisone therapy. D. A taper is needed if the patient is taking concomitant inhaled corticosteroids.

151. You hear a fixed split second heart sound (S2) in a 28-year-old woman who wants to start an exercise program and consider that it is: A. a normal finding in a younger adult. B. occasionally found in uncorrected atrial septal defect. C. the result of valvular sclerosis. D. often found in patients with right bundle branch block.

158. Osteoporosis is more common in individuals: A. with type 2 diabetes mellitus. B. on long-term systemic corticosteroid therapy. C. who are obese. D. of African ancestry.

16. After inhaled corticosteroid is initiated, improvement in control is usually seen: A. on the first day of use. B. within 2 to 8 days. C. in about 3 to 4 weeks. D. in about 1 to 2 months.

16. Which of the following is the most likely candidate to initiate dialysis resulting from chronic kidney disease (CKD)? A. A 46-year-old man with hypertension and GFR = 42 mL/min B. A 64-year-old woman with type 2 diabetes and GFR = 28 mL/min C. A 76-year-old man with anemia and GFR = 55 mL/min D. A 58-year-old woman with heart disease and GFR = 46 mL/min

16. You examine a 47-year-old man who presents with difficulty initiating and maintaining sleep and chronic pharyngeal erythema with the following results on hemogram: Hemoglobin (Hgb) = 15 g (normal 14 to 16 g) Hct = 45% (normal 42% to 48%) RBC = 4.8 million mm3 (normal 4.7 to 6.1 million mm3) MCV = 108 fL (normal 81 to 96 fL) MCHC = 33.2 g/dL (normal 31 to 37 g/dL) These values are most consistent with: A. pernicious anemia. B. alcohol abuse. C. thalassemia minor. D. Fanconi disease.

161. The preferred screening test for osteoporosis is: A. quantitative ultrasound measurement. B. dual-energy x-ray absorptiometry. C. qualitative CT. D. wrist, spine, and hip radiographs.

168. Which of the following patients would be an appropriate candidate for treatment with teriparatide (Forteo®)? A. a 54-year-old woman with osteopenia B. a 64-year-old woman with bone mineral density (BMD) T-score of -2.5 and prior hip fracture C. a 67-year-old man with a BMD T-score of -1 D. a 72-year-old woman who has a stable BMD T-score of -1.5 with bisphosphonate treatment for the past 3 years

169. The bisphosphonate therapy given as an annual infusion is: A. risedronate. B. zoledronic acid. C. ibandronate. D. denosumab.

17. Compared with albuterol, levalbuterol (Xopenex®) has: A. a different mechanism of action. B. the ability potentially to provide greater bronchodilation with a lower dose. C. an anti-inflammatory effect similar to that of an inhaled corticosteroid. D. a contraindication to use in elderly patients.

176. When using the Ranson criteria to evaluate the severity of acute pancreatitis, a severe clinical course is predicted with a score of: A. less than 2. B. 3 or greater. C. 6 or greater. D. 8 or greater.

18. A 68-year-old man who is usually healthy presents with new onset of "huffing and puffing" with exercise for the past 3 weeks. Physical examination reveals conjunctiva pallor and a hemic murmur. Hemogram results are as follows: Hgb = 7.6 g Hct = 20.5% RBC = 2.1 million mm3 MCV = 76 fL MCHC = 28 g/dL RDW = 18.4% Reticulocytes = 1.8% The most likely cause of these finding is: A. poor nutrition. B. occult blood loss. C. malabsorption. D. chronic inflammation.

181. In assessing a person with suspected pancreatic cancer, the nurse practitioner anticipates which of the following findings? A. palpable midline abdominal mass B. midepigastric pain that radiates to the midback or lower back region C. presence of Cullen's sign D. positive obturator and psoas signs

182. All of the following laboratory findings are expected in a patient with pancreatic cancer except: A. elevated total bilirubin. B. diminished platelet count. C. elevated alkaline phosphatase. D. elevated direct bilirubin.

19. You examine a 57-year-old woman with rheumatoid arthritis who is on a disease-modifying antirheumatic drug (DMARD) but continues to have poor disease control and find the following results on hemogram: Hgb = 10.5 g Hct = 33% RBC = 3.1 million mm3 MCV = 88 fL MCHC = 32.8 g/dL RDW = 12.2% Reticulocytes = 0.8% The laboratory findings are most consistent with: A. pernicious anemia. B. anemia of chronic disease. C. beta thalassemia minor. D. folate-deficiency anemia.

19.The obturator sign can be best described as abdominal pain elicited by: A. passive extension of the hip. B. passive flexion and internal rotation of the hip. C. deep palpation. D. asking the patient to cough.

2. Most of the body's iron is obtained from: A. animal-based food sources. B. recycled iron content from aged red blood cells (RBCs). C. endoplasmic reticulum production. D. vegetable-based food sources.

2. When prescribing antihypertensive therapy for a man with BPH and hypertension, the nurse practitioner (NP) considers that: A. loop diuretics are the treatment of choice. B. an alpha1-antagonist should not be used as a solo or first-line therapeutic agent. C. angiotensin receptor antagonist use is contraindicated. D. beta-adrenergic antagonist use often enhances urinary flow.

20. An 18-year-old man with a BMI = 40 kg/m2 presents with periumbilical pain, vomiting, and abdominal cramping over the past 48 hours. Physical examination reveals rebound tenderness, and laboratory analysis shows the presence of bandemia and a total WBC of 28,000/mm3. To support the diagnosis of acute appendicitis with suspected appendiceal rupture, you consider obtaining the following abdominal imaging study: A. magnetic resonance image (MRI). B. computed tomography (CT) scan. C. ultrasound. D. flat plate.

212. Celeste is a 9-year-old girl with moderate persistent asthma. She is not taking a prescribed inhaled corticosteroid but is using albuterol PRN to relieve her cough and wheeze. According to her mother, she currently uses about six albuterol doses per day, in particular for cough and wheeze after active play. You consider that: A. albuterol use can continue at this level. B. excessive albuterol use is a risk factor for asthma death. C. she should also use salmeterol (Serevent®) to reduce her albuterol use. D. active play should be limited to avoid triggering cough and wheeze.

213. In the treatment of asthma, a leukotriene modifier (LTM) should be used as: A. long-acting bronchodilators. B. an inflammatory inhibitor. C. a rescue drug. D. intervention in acute inflammation.

217. Compared with albuterol, levalbuterol (Xopenex®): A. has a different mechanism of action. B. has the ability to provide greater bronchodilation with a lower dose. C. has an anti-inflammatory effect similar to an inhaled corticosteroid. D. is contraindicated for use in children.

218. In caring for a child with an acute asthma flare, the NP considers that, according to the National Asthma Education and Prevention Program, Expert Panel Report 3 guidelines, antibiotic use is recommended: A. routinely. B. with evidence of concomitant bacterial infection. C. when asthma flares are frequent. D. with sputum production.

22. Regarding the use of long-acting beta2-agonists (LABAs), which of the following is true? A. LABAs enhance the ant-iinflammatory action of corticosteroids. B. Use of LABAs is associated with a small increase in risk of asthma death. C. LABA use reduces the risk of asthma exacerbations. D. LABAs can be used as monotherapy to relieve bronchospasms in asthma.

22. When prescribing erythropoietin supplementation, the nurse practitioner (NP) considers that: A. the adrenal glands are its endogenous source. B. the addition of micronutrient supplementation needed for erythropoiesis is advisable. C. its use is as an adjunct in treating thrombocytopenia. D. with its use, the RBC life span is prolonged.

220. Which of the following is most consistent with asthma in a 4-year-old child? A. inspiratory stridor B. expiratory wheezing C. chronic cough with purulent sputum D. loud "barking" cough predominantly during the day

24. Which of the following conditions is unlikely to result in anemia of chronic disease? A. rheumatoid arthritis B. peripheral vascular disease C. chronic renal insufficiency D. osteomyelitis

25. A 36-year-old afebrile woman with no health problems presents with dysuria and frequency of urination. Her urinalysis findings include results positive for nitrites and leukocyte esterase. You evaluate these results and consider that she likely has: A. purulent vulvovaginitis. B. a gram-negative UTI. C. cystitis caused by Staphylococcus saprophyticus. D. urethral syndrome.

26. Rebound tenderness is best described as abdominal pain that worsens with: A. light palpation at the site of the discomfort. B. release of deep palpation at the site of the discomfort. C. palpation on the contralateral side of the abdomen. D. deep palpation at the site of the discomfort.

27. Subcutaneous immunotherapy is recommended for use in patients: A. with well-controlled asthma and infrequent exacerbations. B. with allergic-based asthma. C. with moderate persistent asthma who are intolerant of ICS. D. with poorly-controlled asthma who fail therapy with omalizumab.

270. When treating a 3-year-old well child with community- acquired pneumonia (CAP), the NP realizes that the most likely causative pathogen is: A. Mycoplasma pneumoniae. B. a respiratory virus. C. H. influenzae. D. S. pneumoniae.

28. Intervention in anemia of chronic disease most often includes: A. oral vitamin B12. B. treatment of the underlying cause. C. transfusion. D. parenteral iron.

29. A 43-year-old woman has a 12-hour history of sudden onset of right upper quadrant abdominal pain with radiation to the shoulder, fever, and chills. She has had similar, milder episodes in the past. Examination reveals marked tenderness to right upper quadrant abdominal palpation. Her most likely diagnosis is: A. hepatoma. B. acute cholecystitis. C. acute hepatitis. D. cholelithiasis.

29.The notation of alkaline urine in a patient with a UTI may point to infection caused by: A. Klebsiella species. B. P. mirabilis. C. E. coli. D. S. saprophyticus.

3. Which of the following is most consistent with irondeficiency anemia? A. low mean corpuscular volume (MCV), normal mean corpuscular hemoglobin (MCH) B. low MCV, low MCH C. low MCV, elevated MCH D. normal MCV, normal MCH

30. Hemoglobin A1c should be tested: A. at least annually for all patients. B. at least two times a year in patients who are meeting treatment goals and who have stable glycemic control. C. monthly in patients whose therapy has changed or who are not meeting glycemic goals. D. only via standardized laboratory testing because of inaccuracies associated with point-of-service testing.

32. When counseling a patient about the neurological alterations often associated with vitamin B12 deficiency, the NP advises that: A. these usually resolve within days with appropriate therapy. B. if present for longer than 6 months, these changes are occasionally permanent. C. the use of parenteral vitamin B12 therapy is needed to ensure symptom resolution. D. cognitive changes associated with vitamin B12 deficiency are seldom reversible even with appropriate therapy

34. Which of the following is most likely to be found in a person with acute cholecystitis? A. fever B. vomiting C. jaundice D. palpable gallbladder

35. Risk factors for the development of cholelithiasis include all of the following except: A. rapid weight loss. B. male gender. C. obesity. D. Native American ancestry.

35. With fluoroquinolone use, length of antimicrobial therapy during uncomplicated pyelonephritis is typically: A. 5 days. B. 1 week. C. 2 weeks. D. 3 weeks.

36. A gallstone that is not visualized on standard x-ray is said to be: A. radiopaque. B. radiolucent. C. calcified. D. unclassified.

36. Risk factors for UTI in women include: A. postvoid wiping back to front. B. low perivaginal lactobacilli colonization. C. hot tub use. D. wearing snug-fitting pantyhose.

38. According to the American Cancer Society recommendations, which of the following is the preferred method for annual colorectal cancer screening in a 51-year-old man? A. digital rectal examination B. fecal occult blood test C. colonoscopy D. barium enema study

39. Approximately what percentage of patients with radiological findings of osteoarthritis of the knee will report having symptoms? A. 25% B. 50% C. 70% D. 95%

39. In teaching a patient with type 2 diabetes mellitus and taking basal insulin such as degludec (Tresiba®) about using rapid-acting insulin such as aspart (Novolog®) to help with the management of postprandial hyperglycemia, the NP advises first starting an injection of unit(s) prior to the largest meal. A. 1 B. 4 C. 8 D. 12

4.The use of which of the following medications can precipitate acute renal failure in a patient with bilateral renal artery stenosis? A. corticosteroids B. angiotensin II receptor antagonists C. beta-adrenergic antagonists D. cephalosporins

40. Deformity of the proximal interphalangeal joints found in an elderly patient with OA is known as: A. Heberden nodes. B. Bouchard nodes. C. hallus valgus. D. Dupuytren contracture

41. According to current American Cancer Society data, colorectal cancer is the number _______ cause of cancer death in men and women. A. 1 B. 3 C. 5 D. 7

41. Additional findings in MVP include: A. an opening snap. B. a mid-systolic click. C. a paradoxical splitting of the second heart sound (S2). D. a fourth heart sound (S4).

41. Mr. Samuels is a 58-year-old man with type 2 DM who is using a single 10 unit daily dose of the long-acting insulin glargine. His fasting blood glucose has been between 141 to 180 mg/dL (7.8 to 10 mmol/L). Which of the following best describes the next step in his therapy? A. Continue on the current glargine dose. B. Increase his glargine dose by 4 units per day. C. Increase his glargine dose by 1 unit per day. D. Increase his glargine dose by 6 units per day.

44. When a heart valve fails to close properly, it is said to be: A. stenotic. B. incompetent. C. sclerotic. D. regurgitant.

45. Persistent microscopic hematuria would be the primary finding in about ___ % of individuals with bladder cancer. A. 10 B. 20 C. 30 D. 40

45. Upon detection of a suspected pathologic cardiac murmur, the next step in obtaining a diagnostic procedure usually includes a: A. ventilation perfusion scan. B. echocardiogram. C. pulmonary artery angiography. D. cardiac computerized tomography (CT) scan.

46. An adverse effect associated with the use of glucosamine is: A. elevated alanine aminotransferase (ALT) and aspartate aminotransferase (AST). B. bronchospasm. C. increased bleeding risk. D. QT prolongation.

46. You are evaluating a patient who has rheumatic heart disease. When assessing her for mitral stenosis, you auscultate the heart, anticipating finding the following murmur: A. systolic with wide radiation over the precordium. B. localized diastolic with little radiation. C. diastolic with radiation to the neck. D. systolic with radiation to the axilla.

47. To avoid the development of acute diverticulitis, treatment of diverticulosis can include: A. avoiding foods with seeds. B. the use of fiber supplements. C. ceasing cigarette smoking. D. limiting alcohol intake.

47. Which of the following best describes ethnicity and insulin sensitivity? A. Little variation exists in insulin sensitivity among different ethnic groups. B. African Americans are typically less sensitive to the effects of insulin when compared with people of European ancestry. C. Mexican Americans are likely the most insulinsensitive ethnic group residing in North America. D. The degree of insulin sensitivity has little influence on insulin production.

48. The location of discomfort with acute diverticulitis is usually in which of the following areas of the abdomen? A. epigastrium B. left lower quadrant C. right lower quadrant D. suprapubic

49. Consideration should be given to setting A1c goal in a 22-year-old man with a 8-year history of type 1 diabetes mellitus who has no comorbid conditions equal to or at less than: A. 5.5%. B. 6%. C. 6.5%. D. 7%.

5. Which of the following medications should be used with caution in a person with severe sulfa allergy? A. metformin B. glyburide C. rosiglitazone D. NPH insulin

50. From the following list, the most helpful test in suspected bacterial endocarditis includes: A. urine culture. B. blood culture. C. chest x-ray. D. myocardial biopsy.

50. With a COPD exacerbation, a chest x-ray should be obtained: A. routinely in all patients. B. when attempting to rule out a concomitant pneumonia. C. if sputum volume is increased. D. when work of breathing is increased.

50.The use of GLP-1 agonist has been associated with the development of: A. leukopenia. B. pancreatitis. C. lymphoma. D. vitiligo.

51. In the evaluation of acute diverticulitis, the most appropriate diagnostic approach to rule out free air in the abdomen includes: A. barium enema. B. plain abdominal film. C. abdominal ultrasound. D. lower endoscopy.

51. Of the following patients, who is in greatest need of endocarditis prophylaxis when planning dental work? A. a 22-year-old woman with MVP with trace mitral regurgitation noted on echocardiogram B. a 54-year-old woman with a prosthetic aortic valve C. a 66-year-old man with cardiomyopathy D. a 58-year-old woman who had a three-vessel coronary artery bypass graft with drug-eluting stents 1 year ago

51. Which of the following best describes the role of theophylline in COPD treatment? A. routinely indicated in moderate to very severe COPD B. use limited by narrow therapeutic profile and drug-drug interaction potential C. a potent bronchodilator D. available only in parenteral form

51.The International Diabetes Federation's diagnostic criteria for metabolic syndrome include: A. an obligatory finding of persistent hyperglycemia. B. notation of ethnic-specific waist circumference measurements. C. documentation of microalbuminuria. D. a family history of type 2 DM.

52. Of the following people, who has no significant increased risk for developing bacterial endocarditis? A. a 43-year-old woman with a bicuspid aortic valve B. a 55-year-old man who was diagnosed with a Still's murmur during childhood C. a 45-year-old woman with a history of endocarditis D. a 75-year-old man with dilated cardiomyopathy

52. You perform a digital rectal examination (DRE) on a 72-year-old man and find a lesion suspicious for prostate cancer. The findings are described as: A. a rubbery, enlarged prostatic lobe. B. an area of prostatic induration. C. a boggy gland. D. prostatic tenderness.

52. You see a 67-year-old woman who has been treated for pain due to OA of the hip for the past 6 months and who asks about hip replacement surgery. She complains of pain even at night when sleeping and avoids walking even moderate distances unless absolutely necessary. In counseling the patient, you mention all of the following except: A. arthroplasty can be considered when pain is not adequately controlled. B. arthroplasty is not needed if the patient can walk even short distances. C. arthroplasty candidates must be able to tolerate a long surgical procedure. D. rehabilitation following surgery is essential to achieve maximal function of the joint.

54. A 54-year-old white man with no obvious risk for prostate cancer opted to undergo prostate-specific antigen (PSA) screening and DRE testing. The DRE findings are normal and his PSA is 3.7 ng/mL. You recommend: A. repeating the PSA test immediately. B. repeat screening in 1 year. C. repeat screening in 2 years. D. repeat screening in 5 years

54. Aortic stenosis in a 15-year-old male is most likely: A. a sequela of rheumatic fever. B. a result of a congenital defect. C. calcific in nature. D. found with atrial septal defect.

55. Risk factors for prostate cancer include all of the following except: A. African ancestry. B. history of genital trauma. C. family history of prostate cancer. D. high-fat diet.

56. Antiprostaglandin drugs cause stomach mucosal injury primarily by: A. a direct irritative effect. B. altering the thickness of the protective mucosal layer. C. decreasing peristalsis. D. modifying stomach pH level.

56. Screening cholesterol levels in children with one or more risk factors begins at what age? A. birth B. 2 years C. 5 years D. 10 years

58. According to recent epidemiologic studies, prostate cancer is the number cause of cancer death in men residing within the United States. A. 1 B. 2 C. 3 D. 4

58. You are examining an 18-year-old man who is seeking a sports clearance physical examination. You note a mid-systolic murmur that gets louder when he stands. This may represent: A. aortic stenosis. B. hypertrophic cardiomyopathy. C. a physiological murmur. D. a Still's murmur.

6. Peak expiratory flow meters: A. should only be used in the presence of a medical professional. B. provide a convenient method to check lung function at home. C. are as accurate as spirometry. D. should not be used more than once daily.

60. A grade III systolic heart murmur is usually: A. softer than the S2 heart sound. B. about as loud as the S1 heart sound. C. accompanied by a thrill. D. heard across the precordium but without radiation.

60. Obesity is defined as having a body mass index (BMI) equal to or greater than kg/m2. A. 25 B. 30 C. 35 D. 40

60. Risk factors for renal stones include all of the following except: A. male gender. B. vegetarian diet. C. family history of renal stones. D. obesity.

60. Which of the following is least likely to be found in a patient with gastric ulcer? A. history of long-term naproxen use B. age younger than 50 years C. previous use of H2RA or antacids D. cigarette smoking

61. Medications known to increase the risk of renal stones include all of the following except: A. hydrochlorothiazide. B. moxifloxacin. C. topiramate. D. indinavir.

61.The S3 heart sound has all of the following characteristics except: A. it is heard in early diastole B. a presystolic sound C. it is noted in the presence of ventricular overload D. it is heard best with the bell of the stethoscope

62. The S4 heart sound has which of the following characteristics? A. After it is initially noted, it is a permanent finding. B. It is noted in the presence of poorly controlled hypertension. C. It is heard best in early diastole. D. It is a high-pitched sound best heard with the diaphragm of the stethoscope.

62. Which of the following is an example of an appropriate question to pose to a person with obesity who is in the contemplation change stage? A. "How do you feel about your weight?" B. "What are barriers you see to losing weight?" C. "What is your personal goal for weight loss?" D. "How do you envision my helping you meet your weight loss goal?"

65. A 64-year-old woman presents with a 3-month history of upper abdominal pain. She describes the discomfort as an intermittent, centrally located "burning" feeling in the upper abdomen, most often with meals and often accompanied by mild nausea. Use of an over-thecounter H2RA affords partial symptom relief. She also uses diclofenac on a regular basis for the control of osteoarthritis pain. Her clinical presentation is most consistent with: A. acute gastroenteritis. B. gastric ulcer. C. duodenal ulcer. D. chronic cholecystitis.

67. A 63-year-old man presents with abdominal pain, pain during urination, and red urine. Imaging reveals a renal stone in the ureter. An appropriate treatment option would be: A. percutaneous nephrolithotomy. B. shock wave lithotripsy. C. insertion of a nephrostomy tube. D. insertion of a bladder catheter.

67. With the use of weight loss medications, if the patient has not achieved a 5% weight loss by week of treatment, the therapy should be discontinued. A. 6 B. 12 C. 18 D. 24

68. In a person with obesity, weight loss of % or more yields an immediate reduction in death rates from cardiovascular and cerebrovascular disease. A. 5 B. 10 C. 15 D. 20

68.The most effective strategy for preventing renal stones is: A. daily exercise. B. adequate hydration. C. limiting coffee consumption. D. smoking cessation.

69. When counseling about malabsorptive bariatric surgery, the NP provides the following information: A. Most people achieve ideal BMI postoperatively. B. The most dramatic weight losses are seen in the first few postoperative months. C. The death rate directly attributable to surgery is about 10%. D. Weight loss will continue for years postoperatively in most patients.

7. Finasteride (Proscar®, Propecia®) and dutasteride (Avodart®) are helpful in the treatment of BPH because of their effect on: A. bladder contractility. B. prostate size. C. activity at select bladder receptor sites. D. bladder pressure.

7. Generally, testing for type 2 DM in asymptomatic, undiagnosed individuals older than 45 years should be conducted every . A. year. B. 3 years C. 5 years D. 10 years

70. Common symptoms of community-acquired pneumonia in otherwise well adults include all of the following except: A. cough. B. altered mental status. C. dyspnea. D. pleuritic chest pain.

72. Which of the following medications is a prostaglandin analogue? A. sucralfate B. misoprostol C. esomeprazole D. metoclopramide

76. According to the ATS/IDSA guidelines, what is the usual length of antimicrobial therapy for the treatment of CAP for outpatients? A. fewer than 5 days B. 5 to 7 days C. 7 to 10 days D. 10 to 14 days

76. You see a 62-year-old man diagnosed with esophageal columnar epithelial metaplasia. You realize he is at increased risk for: A. esophageal stricture. B. esophageal adenocarcinoma. C. gastroesophageal reflux. D. H. pylori colonization.

77. In caring for a patient with symptomatic gastroesophageal reflux, you prescribe a PPI to: A. enhance motility. B. increase the pH of the stomach. C. reduce lower esophageal pressure. D. help limit H. pylori growth.

8. A 36-year-old man with asthma also needs antihypertensive therapy. Which of the following products should you avoid prescribing? A. hydrochlorothiazide B. propranolol C. amlodipine D. enalapril

8. A 40-year-old woman with pyelonephritis is taking two medications: ciprofloxacin and ferrous sulfate (for irondeficiency anemia). She asks about taking both medications. You advise that: A. she should take the medications with a large glass of water. B. an inactive drug compound is potentially formed if the two medications are taken together. C. she can take the medications together to enhance adherence to therapy. D. the ferrous sulfate potentially slows gastrointestinal motility and results in enhanced ciprofloxacin absorption.

80. Which of the following is likely to be reported in a patient with persistent GERD? A. hematemesis B. chronic sore throat C. diarrhea D. melena

82. Which of the following best describes the mechanism of transmission in an atypical pneumonia pathogen? A. microaspiration B. respiratory droplet C. surface contamination D. aerosolized contaminated water

82. You prescribe a fluoroquinolone antibiotic to a 54-year-old woman who has occasional GERD symptoms that she treats with an antacid. When discussing appropriate medication use, you advise that she should take the antimicrobial: A. with the antacid. B. separated from the antacid use by 2 to 4 hours before or 4 to 6 hours after taking the fluoroquinolone. C. without regard to antacid use. D. apart from the antacid by about 1 hour on either side of the fluoroquinolone dose.

88. You advise a 58-year-old woman with hypothyroidism about the correct use of levothyroxine. She also takes a calcium supplement. All of the following should be shared with the patient except which instruction? A. "Take the medication on an empty stomach." B. "To help with adherence, take your calcium supplement at the same time as your thyroid medication." C. "You should take the medication at approximately the same time every day." D. "Do not take your medication with soy milk."

88.The most common form of esophageal cancer in the United States is: A. squamous cell cancer. B. adenocarcinoma. C. basal cell carcinoma. D. melanoma.

89.The mechanism of transmission of Legionella species is primarily via: A. respiratory droplet. B. inhalation of aerosolized contaminated water. C. contact with a contaminated surface. D. hematogenous spread.

9. Angiotensin-converting enzyme inhibitors can limit the progression of some forms of renal disease by: A. increasing intraglomerular pressure. B. reducing efferent arteriolar resistance. C. enhancing afferent arteriolar tone. D. increasing urinary protein excretion.

9. Concerning BPH, which of the following statements is true? A. Digital rectal examination is accurate in diagnosing the condition. B. The use of a validated patient symptom tool is an important part of diagnosing the condition. C. Prostate size directly correlates with symptoms and bladder emptying. D. Bladder distention is usually present in early disease.

9. Two months into therapy for pernicious anemia, you wish to check the efficacy of the intervention. The best laboratory test to order at this point is a: A. Schilling test. B. hemoglobin measurement. C. reticulocyte count. D. serum cobalamin.

91. Which of the following is at greatest risk of esophageal cancer? A. a 34-year-old male who eats a high-fat diet B. a 76-year-old male who stopped smoking 15 years ago C. a 45-year-old woman with a history of 6 full-term pregnancies D. a 58-year-old female vegetarian

94. As part of an evaluation of a 3-cm, round, mobile thyroid mass, you obtain a thyroid ultrasound scan revealing a fluid-filled structure. The most likely diagnosis is: A. adenoma. B. thyroid cyst. C. multinodular goiter. D. vascular lesion.

98. The average incubation time for HAV is approximately: A. 10 days. B. 28 days. C. 60 days. D. 6 months.

98. You examine an 82-year-old woman who has a history of heart failure (HF). She is in the office because of increasing shortness of breath. When auscultating her heart, you note a tachycardia with a rate of 104 beats per minute and a single extra heart sound early in diastole. This sound most likely represents: A. summation gallop. B. S3. C. opening snap. D. S4.

A 68-year-old woman presents with hypertension and BP of 152-158/92-96 mm Hg documented over 2 months on three different occasions. Electrocardiogram (ECG) and creatinine are normal, and she has no proteinuria. Clinical findings include the following: BMI 26.4 kg/m2; no S3, S4, or murmur; and point of maximal impulse at fifth intercostal space, mid-clavicular line. Which of the following represents the best intervention? A. Initiate therapy with metoprolol. B. Initiate therapy with hydrochlorothiazide. C. Initiate therapy with methyldopa. D. Continue to monitor BP, and start drug therapy if evidence of target organ damage.

Diagnostic testing for a patient with newly diagnosed primary hypertension should include all of the following except: A. hematocrit. B. uric acid. C. creatinine. D. potassium.

The most important long-term goal of treating hypertension is to: A. strive to reach recommended numeric BP measurement. B. avoid disease-related target organ damage. C. develop a plan of care with minimal adverse effects. D. treat concomitant health problems often noted in the person with this condition.

Which of the following statements concerning postural hypotension in the elderly is false? A. It increases the risk of falls and syncope. B. It is characterized by a drop in blood pressure when going from a standing to a sitting position. C. It increases the risk of cardiovascular events. D. It is associated with the use of vasodilating medications.

You examine a 38-year-old woman who has presented for an initial examination and Papanicolaou test. She has no complaint. Her blood pressure (BP) is 154/98 mm Hg bilaterally and her body mass index (BMI) is 31 kg/m2. The rest of her physical examination is unremarkable. Your next best action is to: A. initiate antihypertensive therapy. B. arrange for at least two additional BP measurements during the next 2 weeks. C. order blood urea nitrogen, creatinine, and potassium ion measurements and urinalysis. D. advise her to reduce her sodium intake.

You see a 62-year-old man without chronic kidney disease or diabetes mellitus who is currently being treated with low-dose HCTZ and losartan. His blood pressure is currently 162/88 mm Hg. All of the following are appropriate next courses of action except: A. increasing the dose of losartan. B. adding a beta-adrenergic receptor antagonist. C. adding a calcium channel blocker. D. increasing the dose of HCTZ.

102. According to American College of Chest Physicians (ACCP) guidelines, annual screening with low-dose CT (LDCT) for lung cancer should occur in 55- to 74-year-old smokers with a smoking history of at least pack-years. A. 15 B. 30 C. 50 D. 70

104. The rationale for using beta blocker therapy in treating a patient with HF is to: A. increase myocardial contractility. B. reduce the effects of circulating catecholamines. C. relieve concomitant angina. D. stabilize cardiac rhythm.

105. An ECG finding in a patient who is taking digoxin in a therapeutic dose typically includes: A. shortened PR interval. B. slightly depressed, cupped ST segments. C. widened QRS complex. D. tall T waves.

105. Current limitations of screening smokers with LDCT include all of the following except: A. a high false-positive rate. B. low sensitivity. C. radiation exposure from multiple CT scans. D. patient anxiety.

106. A potential adverse effect of ACEI when used with spironolactone therapy is: A. hypertension. B. hyperkalemia. C. renal insufficiency. D. proteinuria.

107. The HBV vaccine should not be offered to individuals who have a history of anaphylactic reaction to: A. eggs. B. baker's yeast. C. peanuts. D. shellfish.

11. An increase in creatinine from 1 to 2 mg/dL is typically seen with a ____ loss in renal function. A. 25% B. 50% C. 75% D. 100%

11. Risk factors for folate-deficiency anemia include: A. menorrhagia. B. chronic ingestion of overcooked foods. C. use of nonsteroidal anti-inflammatory drugs. D. gastric atrophy

11. Sharon is a 29-year-old woman with moderate persistent asthma. She is not using prescribed inhaled corticosteroids, but is using albuterol PRN to relieve her cough and wheeze with reported satisfactory clinical effect. Currently she uses about two albuterol metered-dose inhalers per month and is requesting a prescription refill. You consider that: A. her asthma is well controlled and albuterol use can continue. B. excessive albuterol use is a risk factor for asthma death. C. her asthma is not well controlled and salmeterol (Serevent®) should be added to relieve bronchospasm and reduce her albuterol use. D. her asthma has better control with albuterol than inhaled corticosteroids.

110. Which of the following medications is an aldosterone antagonist? A. clonidine B. spironolactone C. hydrochlorothiazide D. furosemide

111. Which of the following best describes orthopnea? A. shortness of breath with exercise B. dyspnea that develops when the individual is recumbent and is relieved with elevation of the head C. shortness of breath that occurs at night, characterized by a sudden awakening after a couple of hours of sleep, with a feeling of severe anxiety, breathlessness, and suffocation D. dyspnea at rest

114. Which of the following characteristics is predictive of severity of chronic liver disease in a patient with chronic hepatitis C? A. female gender, age younger than 30 years B. coinfection with hepatitis B, daily alcohol use C. acquisition of virus through intravenous drug use, history of hepatitis A infection D. frequent use of aspirin, nutritional status

116. To prevent an outbreak of hepatitis D infection, an NP plans to: A. promote a campaign for clean food supplies. B. immunize the population against hepatitis B. C. offer antiviral prophylaxis against the agent. D. encourage frequent hand washing

209. A 6-year-old boy has a 1-year history of moderate persistent asthma that is normally well controlled with budesonide via dry powder inhaler (DPI) twice a day and the use of albuterol once or twice a week as needed for wheezing. Three days ago, he developed a sore throat, clear nasal discharge, and a dry cough. In the past 24 hours, he has had intermittent wheezing, necessitating the use of albuterol two puffs with use of an age-appropriate spacer every 3 hours with partial relief. Your next most appropriate action is to obtain: A. a chest radiograph. B. an oxygen saturation measurement. C. a peak expiratory flow (PEF) measurement. D. a sputum smear for WBCs.

21. Results of hemogram in a person with anemia of chronic disease include: A. microcytosis. B. anisocytosis. C. reticulocytopenia. D. macrocytosis.

210. You see a 4-year-old girl who has a 2-day history of signs and symptoms of an acute asthma flare resulting from viral upper respiratory tract infection. She is using inhaled budesonide and albuterol as directed and continues to have difficulty with increased occurrence of coughing and wheezing. Her respiratory rate is within 50% of upper limits of normal for her age. Her medication regimen should be adjusted to include: A. oral theophylline. B. inhaled salmeterol (Serevent®). C. oral prednisolone. D. oral montelukast (Singulair®).

211. Which of the following is inconsistent with the diagnosis of asthma? A. a troublesome nocturnal cough B. cough or wheeze after exercise C. morning sputum production D. colds "go to the chest" or take more than 10 days to clear

215. A middle-school student presents, asking for a letter stating that he should not participate in gym class because he has moderate persistent asthma. The most appropriate response is to: A. write the note because gym class participation could trigger an asthma flare. B. excuse him from outdoor activities only to avoid pollen exposure. C. remind him that with appropriate asthma care, he should be capable of participating in gym class. D. excuse him from indoor activities only to avoid dust mite exposure.

216. After inhaled corticosteroid or leukotriene modifier therapy is initiated, clinical effects are seen: A. immediately. B. within the first week. C. in about 1 to 2 weeks. D. in about 1 to 2 months.

22. Which of the following best represents the peak ages for occurrence of acute appendicitis? A. 1 to 20 years B. 20 to 40 years C. 10 to 30 years D. 30 to 50 years

221. Signs of respiratory distress during an asthma flare in a 2-year-old child include all of the following except: A. drowsiness. B. confusion. C. respiratory rate <30/minute. D. softer, shorter cry.

23. In the first weeks of anemia therapy with parenteral vitamin B12 in a 68-year-old woman with hypertension who is taking a thiazide diuretic, the patient should be carefully monitored for: A. hypernatremia. B. dehydration. C. hypokalemia. D. acidemia.

23. Which of the following is the therapeutic objective of using inhaled ipratropium bromide? A. as an anti-inflammatory. B. an increase in vagal tone in the airway C. inhibition of muscarinic cholinergic receptors D. an increase in salivary and mucous secretions

24. Which of the following is true regarding the use of systemic corticosteroids in the treatment of asthma? A. Frequent short bursts are preferred over daily inhaled corticosteroids. B. The oral corticosteroid should be started at day 3-4 of the asthma flare for optimal effect. C. The oral route is preferred over parenteral therapy. D. The adult dose to treat an asthma flare should not exceed the equivalent of prednisone 40 mg daily.

25. In health, the ratio of hemoglobin to hematocrit is usually: A. 1:1. B. 1:2. C. 1:3. D. 1:4.

26. An increase in the normal variation of RBC size is known as: A. poikilocytosis. B. granulation. C. anisocytosis. D. basophilic stippling.

26. The most likely causative organism in communityacquired UTI in women during the reproductive years is: A. Klebsiella species. B. Proteus mirabilis. C. Escherichia coli. D. Staphylococcus saprophyticus.

26.The meglitinide analogues are particularly helpful adjuncts in type 2 DM care to minimize risk of: A. fasting hypoglycemia. B. nocturnal hyperglycemia. C. postprandial hyperglycemia. D. postprandial hypoglycemia.

27. Abdominal palpation that yields rebound tenderness is also known as a positive _______ sign. A. Markel's B. Murphy's C. Blumberg's D. Nikolsky's

273. What percentage of children have an episode of pneumonia before age 5 years? A. 18% to 20% B. 9% to 10% C. 3% to 4% D. 20% to 30%

29. Poikilocytosis refers to alterations in a red blood cell's: A. thickness. B. color. C. shape. D. size.

3. A 44-year-old man has a long-standing history of moderate persistent asthma that is normally well controlled by fluticasone with salmeterol (Advair®) via metered-dose inhaler, one puff twice a day, and the use of albuterol 1 to 2 times a week as needed for wheezing. Three days ago, he developed a sore throat, clear nasal discharge, body aches, and a dry cough. In the past 24 hours, he has had intermittent wheezing that necessitated the use of albuterol, two puffs every 3 hours, which produced partial relief. Your next most appropriate action is to obtain a: A. chest radiograph. B. measurement of oxygen saturation (SaO2). C. spirometry measurement. D. sputum smear for white blood cells (WBCs).

3. Common causes of chronic renal failure include all of the following except: A. type 2 diabetes. B. recurrent pyelonephritis. C. hypotension. D. polycystic kidney disease.

30. Which of the following is not consistent with anemia of chronic disease (ACD)? A. NL RDW B. NL MCHC C. Hct less than 24% D. NL to slightly elevated serum ferritin

30. Which of the following is the most accurate information in caring for a 40-year-old man with cystitis? A. This is a common condition in men of this age. B. A gram-positive organism is the likely causative pathogen. C. A urological evaluation should be considered. D. Pyuria is rarely found.

31. Evidence-based factors that prevent or minimize the risk of UTIs include all of the following except: A. male gender. B. longer urethra-to-anus length in women. C. timed voiding schedule. D. zinc-rich prostatic secretions.

33. A 44-year-old woman presents with pyelonephritis. The report of her urinalysis is least likely to include: A. WBC casts. B. positive nitrites. C. 3+ protein. D. rare RBCs.

33. A 58-year-old man reports intermittent right upper quadrant abdominal pain. He is obese and being actively treated for hyperlipidemia. Imaging in a patient with suspected symptomatic cholelithiasis usually includes obtaining an abdominal: A. MRI. B. CT scan. C. ultrasound of the right upper quadrant. D. flat plate.

33. When the cause of a macrocytic anemia is uncertain, the most commonly recommended additional testing includes which of the following? A. haptoglobin and reticulocyte count. B. Schilling test and gastric biopsy. C. methylmalonic acid and homocysteine. D. transferrin and prealbumin.

34. An example of a first-line therapeutic agent for the treatment of pyelonephritis is: A. amoxicillin with clavulanate. B. trimethoprim-sulfamethoxazole. C. ciprofloxacin. D. nitrofurantoin.

36. Metformin should be discontinued for the day of and up to 48 hours after surgery because of increased risk of: A. hypoglycemia. B. hepatic impairment. C. lactic acidosis. D. interaction with most anesthetic agents.

37. All the following medications are recommended as possible first-line medications for treatment of concomitant hypertension when seen with type 2 DM in a 48-year-old man of European ancestry except: A. thiazide diuretic. B. calcium channel blocker. C. alpha-adrenergic receptor antagonist. D. angiotensin receptor blocker.

37. Clinical findings of the knee in a patient with OA include all of the following except: A. coarse crepitus. B. joint effusion. C. warm joint. D. knee often locks or a pop is heard.

38. Radiographic findings of osteoarthritis of the knee often reveal: A. microfractures. B. decreased density of subchondral bone. C. osteophytes. D. no apparent changes to the joint structure.

38. When used in treating COPD, ipratropium bromide (Atrovent®) is prescribed to achieve which of the following therapeutic effects? A. increase mucociliary clearance B. reduce alveolar volume C. bronchodilation D. mucolytic action

39. What is the desired therapeutic action of inhaled corticosteroids when used to treat COPD? A. reversal of fixed airway obstruction B. improvement of central respiratory drive C. reduction of airway inflammation D. mucolytic activity

39. Which of the following is most likely to be noted in a person with colorectal cancer? A. gross rectal bleeding B. weight loss C. few symptoms D. nausea and vomiting

4. You examine Jane, a 24-year-old woman who has an acute asthma flare following a 3-day history of upper respiratory tract symptoms (clear nasal discharge, dry cough, no fever). She has a history of moderate persistent asthma that is in good control and an acceptable peak expiratory flow (PEF). She is using budesonide (Pulmicort®) and albuterol as directed and continues to have difficulty with coughing and wheezing. At home, her PEF is 55% of personal best. In the office, her forced expiratory volume at 1 second (FEV1) is 65% of predicted. Her medication regimen should be adjusted to include: A. theophylline. B. salmeterol (Serevent®). C. prednisone. D. montelukast (Singulair®).

40. You see a 70-year-old woman in a walk-in center with a chief complaint of increased urinary frequency and dysuria. Urinalysis reveals pyuria and positive nitrites. She mentions she has a "bit of kidney trouble, not too bad." Recent evaluation of renal status is unavailable. In considering antimicrobial therapy for this patient, you prescribe: A. nitrofurantoin. B. fosfomycin. C. ciprofloxacin. D. doxycycline.

42. As part of the evaluation of patients with OA, the nurse practitioner (NP) anticipates finding: A. anemia of chronic disease. B. elevated CRP level. C. no disease-specific laboratory abnormalities. D. elevated antinuclear antibody (ANA) titer.

43. A 68-year-old man presents with suspected bladder cancer. You consider that its most common presenting sign or symptom is: A. painful urination. B. fever and flank pain. C. painless gross hematuria. D. palpable abdominal mass.

43. Approximately what percentage of the population will develop diverticulosis by the time they reach 50 years of age? A. 10% B. 20% C. 33% D. 50%

44. In a healthy person, what percentage of the body's total daily physiological insulin secretion is released as basally? A. 10%-20% B. 25%-35% C. 50%-60% D. 75%-85%

44. In a person diagnosed with superficial bladder cancer without evidence of metastases, you realize that: A. the prognosis for 2-year survival is poor. B. a cystectomy is indicated. C. despite successful initial therapy, local recurrence is common. D. systemic chemotherapy is the treatment of choice.

44. In caring for a patient with OA of the knee, you advise that: A. straight-leg raising should be avoided. B. heat should be applied to painful joints after exercise. C. quadriceps-strengthening exercises should be performed. D. physical activity should be avoided.

44. Which of the following is most consistent with the presentation of a patient with colonic diverticulosis? A. diarrhea and leukocytosis B. constipation and fever C. few or no symptoms D. frank blood in the stool with reduced stool caliber

45. Five years or more after type 2 diabetes mellitus diagnosis, which of the following medications is less likely to be effective in controlling plasma glucose? A. metformin B. pioglitazone C. glipizide D. insulin

45. Which of the following systemic corticosteroid doses is most potent? A. methylprednisolone 8 mg B. triamcinolone 10 mg C. prednisone 15 mg D. hydrocortisone 18 mg

46. Preferred therapy for nonmuscle-invasive bladder cancer without evidence of metastases is: A. cystectomy. B. intravesical chemotherapy as first-line, solo agent. C. transurethral resection with intravesical chemotherapy. D. systemic chemotherapy.

46. Which of the following pathogens is often implicated in a COPD exacerbation caused by respiratory tract infection? A. Legionella species B. Streptococcus pyogenes C. respiratory tract viruses D. Staphylococcus aureus

47. A 72-year-old man presents at an early stage of osteoarthritis in his left knee. He mentions that he heard about the benefits of using glucosamine and chondroitin for treating joint problems. In consulting the patient, you mention all of the following except: A. any benefit can take at least 3 months of consistent use before observed. B. glucosamine is not associated with any drug interactions. C. clinical studies have consistently shown benefit of long-term use of glucosamine and chondroitin for treating OA of the knee. D. chondroitin should be used with caution because of its antiplatelet effect.

48. Recommended A1c goal in a 79-year-old woman with a 20-year history of type 2 diabetes mellitus who has difficulty ambulating, uses a walker, and has a cardiac ejection fraction of 35% and a history of heart failure should be equal to or less than: A. 7%. B. 7.5%. C. 8%. D. 8.5%.

48.The American Academy of Orthopaedic Surgeons (AAOS) favors all of the following in the management of symptomatic OA of the knee except: A. low-impact aerobic exercises. B. weight loss for those with a body mass index (BMI) ≥25 kg/m2. C. acupuncture. D. strengthening exercises.

5. A 48-year-old woman developed iron-deficiency anemia after excessive perimenopausal bleeding, successfully treated by endometrial ablation. Her hematocrit (Hct) level is 25%, and she is taking iron therapy. At 5 days into therapy, one possible observed change in laboratory parameters would include: A. a correction of mean cell volume. B. an 8% increase in Hct level. C. reticulocytosis. D. a correction in ferritin level.

50. You are seeing Mr. Lopez, a 68-year-old man with suspected acute colonic diverticulitis. In choosing an appropriate imaging study to support this diagnosis, which of the following abdominal imaging studies is most appropriate? A. flat plate B. ultrasound C. CT scan with contrast D. barium enema

52. A 56-year-old woman is diagnosed with mild diverticulitis. In addition to counseling her about increased fluid intake and adequate rest, you recommend antimicrobial treatment with: A. amoxicillin with clarithromycin. B. linezolid with daptomycin. C. ciprofloxacin with metronidazole. D. nitrofurantoin with doxycycline.

52. Which of the following is not a risk factor for type 2 diabetes mellitus in children and teens? A. hyperinsulinemia. B. abnormal weight-to-height ratio. C. onset of nonorganic failure to thrive in the toddler years. D. Native American ancestry.

53. Cardiovascular effects of hyperinsulinemia include: A. decreased renal sodium reabsorption. B. constricted circulating volume. C. greater responsiveness to angiotensin II. D. diminished sympathetic activation.

56.The average American man has an approximately % lifetime risk of prostate cancer and an approximately % likelihood of clinical disease. A. 15, 5 B. 25, 8 C. 40, 10 D. 60, 15

57. A 24-year-old man presents with a 3-month history of upper abdominal pain. He describes it as an intermittent, centrally located "burning" feeling in his upper abdomen, most often occurring 2 to 3 hours after meals. His presentation is most consistent with the clinical presentation of: A. acute gastritis. B. gastric ulcer. C. duodenal ulcer. D. cholecystitis.

57. A physiological murmur has which of the following characteristics? A. occurs late in systole B. is noted in a localized area of auscultation C. becomes softer when the patient moves from supine to standing D. frequently obliterates S2

58. When choosing pharmacological intervention to prevent recurrence of duodenal ulcer in a middle-aged man, you prescribe: A. a proton pump inhibitor (PPI). B. timed antacid use. C. antimicrobial therapy. D. a histamine2-receptor antagonist (H2RA).

59. According to recommendations of the American Heart Association (AHA), which of the following antibiotics should be used for endocarditis prophylaxis in patients who are allergic to penicillin? A. erythromycin B. dicloxacillin C. azithromycin D. ofloxacin

6. A healthy 34-year-old man asks whether he should take an iron supplement. You respond that: A. this is a prudent measure to ensure health. B. iron-deficiency anemia is a common problem in men of his age. C. use of an iron supplement in the absence of a documented deficiency can lead to iatrogenic iron overload. D. excess iron is easily excreted.

6.The mechanism of action of metformin (Glucophage®) is as: A. an insulin-production enhancer. B. a product virtually identical in action to sulfonylureas. C. a drug that increases insulin action in the peripheral tissues and reduces hepatic glucose production. D. a facilitator of renal glucose excretion.

62. Cyclooxygenase-1 (COX-1) contributes to: A. the inflammatory response. B. pain transmission. C. maintenance of gastric protective mucosal layer. D. renal arteriole constriction

64. Common symptoms of renal stones include all of the following except: A. pink, red, or brown urine. B. sharp pain in the back or lower abdomen. C. marked febrile response. D. pain while urinating.

65. A pound of fat contains approximately stored calories. A. 2500 B. 3000 C. 3500 D. 4000

65.The preferred method to identify the location of small renal stones is: A. x-ray. B. abdominal ultrasound. C. CT scan. D. radionuclide scan.

66. Which of the following statements about Helicobacter pylori is false? A. H. pylori is a gram-negative, spiral-shaped bacterium. B. Infection with H. pylori is the most potent risk factor for duodenal ulcer. C. The organism is often resistant due to the production of beta-lactamase. D. H. pylori is transmitted via the oral-fecal or oral-oral route.

66. You see a 58-year-old man diagnosed with a kidney stone who reports pain primarily during urination. You consider all of the following except: A. improved hydration. B. alpha blocker use. C. prescribing a diuretic. D. analgesia use.

67.The most sensitive and specific test for H. pylori infection from the following list is: A. stool Gram stain, looking for the offending organism. B. serological testing for antigen related to the infection. C. organism-specific stool antigen testing. D. fecal DNA testing.

69. Criteria to distinguish whether pneumonia is community-acquired include all of the following except that the person: A. lives in the community. B. is not a resident of a long-term care facility. C. had no prior antimicrobial use in the previous 3 months. D. had no recent hospitalization.

7. Which of the following is the best advice on taking ferrous sulfate to enhance iron absorption? A. "Take with other medications." B. "Take on a full stomach." C. "Take on an empty stomach." D. "Do not take with vitamin C."

70. An ulcer that is noted to be located in the region below the lower esophageal sphincter and before the pylorus is usually referred to as a(n) ________ ulcer. A. duodenal B. esophageal C. gastric D. stomach

73.The mechanism of resistance of DRSP is through the cell's: A. beta-lactamase production. B. hypertrophy of cell membrane. C. alteration in protein-binding sites. D. failure of DNA gyrase reversal.

75. Which of the following characteristics applies to macrolides? A. consistent activity against DRSP B. contraindicated in pregnancy C. effective against atypical pathogens D. unstable in the presence of beta-lactamase

8. Tamsulosin (Flomax®) is helpful in the treatment of BPH because of its effect on: A. bladder contractility. B. prostate size. C. activity at select bladder receptor sites. D. bladder pressure.

8. You are seeing 17-year-old Amanda. As part of the visit, you consider her risk factors for type 2 DM would likely include all of the following except: A. obesity. B. Native American ancestry. C. family history of type 1 DM. D. personal history of polycystic ovary syndrome.

8. You see a 63-year-old man with a suspected upper gastrointestinal bleed who has no renal health issues. Expected laboratory findings would include: A. elevated BUN; elevated serum creatinine. B. normal BUN; elevated serum creatinine. C. elevated BUN; normal serum creatinine. D. lowered BUN; elevated serum creatinine.

80. Risk factors for pneumonia caused by P. aeruginosa include all of the following except: A. mechanical ventilation. B. cystic fibrosis. C. community residence. D. chronic tracheostomy.

81. A 58-year-old man recently began taking an antihypertensive medication and reports that his "heartburn" has become much worse. He is most likely taking: A. atenolol. B. trandolapril. C. amlodipine. D. losartan.

81. Which of the following most accurately describes sputum analysis in the evaluation of the person with community-acquired pneumonia? A. Gram stain is routinely advised. B. Antimicrobial therapy should not be initiated until sputum specimen for culture has been obtained. C. Sputum analysis is not recommended in the majority of patients with community-acquired pneumonia. D. If required, chest physical therapy can be used to facilitate sputum production.

82. Physical examination findings in patients with Graves' disease include: A. muscle tenderness. B. coarse, dry skin. C. eyelid retraction. D. delayed relaxation phase of the patellar reflex.

83. A 48-year-old man with obesity and a 1-year history of classic GERD symptoms has been on the consistent use of a therapeutic dose of a PPI for the past 6 months. He states he is "really no better with the medicine and I have cut out most of the food that bothers my stomach. I even cut out all alcohol and soda." Physical examination reveals stable weight, mildly erythematous pharynx, and epigastric tenderness without rebound. Next step options include: A. obtaining an upper GI series. B. referral for GERD surgery. C. further evaluation with upper GI endoscopy. D. obtaining FOBT testing.

83. Risk factors for death resulting from pneumonia include: A. viral origin. B. history of allergic reaction to multiple antimicrobials. C. renal insufficiency. D. polycythemia.

84. All of the following antimicrobial strategies help facilitate the development of resistant pathogens except: A. longer course of therapy. B. lower antimicrobial dosage. C. higher antimicrobial dosage. D. prescribing a broader spectrum agent.

85. Findings of increased tactile fremitus and dullness to percussion at the right lung base in the person with CAP likely indicate an area of: A. atelectasis. B. pneumothorax. C. consolidation. D. cavitation.

85. In prescribing levothyroxine therapy for an elderly patient, which of the following statements is true? A. Elderly persons require a rapid initiation of levothyroxine therapy. B. TSH should be checked about 2 days after dosage adjustment. C. The levothyroxine dose needed by elderly persons is 75% or less of that needed by younger adults. D. TSH should be suppressed to a nondetectable level.

86. A 57-year-old male is in need of evaluation for Barrett esophagus. You recommend: A. H. pylori testing. B. CT scan. C. upper GI endoscopy with biopsy. D. barium swallow.

89. Esophageal adenocarcinoma is usually located: A. in the upper esophagus. B. near the upper esophageal sphincter. C. at the junction of the esophagus and stomach. D. in the lower esophagus.

9. Which of the following is inconsistent with the presentation of asthma that is not well controlled? A. a troublesome nocturnal cough at least 2 nights per week B. need for albuterol to relieve shortness of breath at least twice a week C. morning sputum production D. two or more exacerbations/year requiring oral corticosteroids

91. Which of the following is the most cost-effective method of distinguishing a malignant from a benign thyroid nodule? A. ultrasound B. magnetic resonance (MRI) imaging C. fine-needle aspiration biopsy D. radioactive iodine scan

92.The presence of esophageal cancer is commonly associated with: A. renal impairment. B. chronic bronchitis. C. iron-deficiency anemia. D. unexplained weight gain.

95. Periodic routine screening for hypothyroidism is indicated in the presence of which of the following clinical conditions? A. digoxin use B. male gender C. Down syndrome D. alcoholism

96. Cough associated with acute bronchitis can typically last up to: A. 1 week. B. 2 weeks. C. 3 weeks. D. 3 months.

97. In a well adult with modest hepatic enzyme elevation and hepatitis B surface antigen (HBsAg) positive, these findings are most consistent with: A. no evidence of hepatitis B infection. B. resolved hepatitis B infection. C. chronic hepatitis B. D. evidence of effective hepatitis B immunization.

99. You examine a 65-year-old man with dilated cardio - myopathy and HF. On examination, you expect to find all of the following except: A. jugular venous distention. B. tenderness on right upper-abdominal quadrant palpation. C. point of maximal impulse at the fifth intercostal space, mid-clavicular line. D. peripheral edema.

A BP elevation noted only at an office visit is commonly known as hypertension. A. provider-induced B. clinical C. white coat D. pseudo

According to JNC-8 guidelines, all of the following medications are first-line agents for use in a middle-aged white man without diabetes mellitus except: A. lisinopril. B. hydrochlorothiazide. C. metoprolol. D. amlodipine.

Nondihydropyridine calcium channel blockers are contraindicated in patients with: A. type 1 diabetes mellitus. B. a history of venous thromboembolism. C. severe left ventricular dysfunction. D. concomitant treatment with an ACEI.

When compared with Caucasians, African Americans tend to have a reduced effect with monotherapy with all of the following blood pressure medications except: A. ACEIs. B. ARBs. C. CCB. D. beta blockers.

Which of the following can have a favorable effect on a comorbid condition in a person with hypertension? A. chlorthalidone in gout B. propranolol with airway disease C. aldosterone antagonist in heart failure D. methyldopa in an older adult

You examine a 78-year-old woman with long-standing, poorly controlled hypertension. When evaluating her for hypertensive target organ damage, you look for evidence of: A. lipid abnormalities. B. insulin resistance. C. left ventricular hypertrophy. D. clotting disorders.

You start a patient with hypertension who is already receiving an ACEI on spironolactone. You advise the patient to return in 4 weeks to check which of the following laboratory parameters? A. sodium B. calcium C. potassium D. chloride

55. Risk factors for dyslipidemia in children include which of the following? (Choose all that apply.) A. blood pressure at the 70th to 80th percentile for age B. breastfeeding into the toddler years C. family history of lipid abnormalities D. family history of type 2 diabetes mellitus

C, D

1. Which of the following best describes asthma? A. intermittent airway inflammation with occasional bronchospasm B. a disease of bronchospasm that leads to airway inflammation C. chronic airway inflammation with superimposed bronchospasm D. relatively fixed airway constriction

10. A woman who is planning a pregnancy should increase her intake of which of the following to minimize the risk of neural tube defect in the fetus? A. iron B. niacin C. folic acid D. vitamin C

10.The mechanism of action of pioglitazone is as: A. an insulin-production enhancer. B. a reducer of pancreatic glucose output. C. an insulin sensitizer. D. a facilitator of renal glucose excretion.

101. Symptoms of lung cancer caused by a primary tumor include all of the following except: A. chest discomfort. B. dyspnea. C. strider. D. hemoptysis.

103. Guidelines from the National Comprehensive Cancer Network (NCCN) recommend screening high-risk smokers beginning at age: A. 40 years. B. 45 years. C. 50 years. D. 55 years.

108. Which of the following groups should be screened for hepatitis B surface antigen (HBsAg)? A. pregnant women with no history of receiving HBV vaccine B. pregnant women with documented prior HBV infection C. all pregnant women regardless of HBV vaccine history D. all newborn infants born to mothers with chronic HBV infection

109. Routine testing for the presence of HBsAb after immunization with the HBV vaccine is recommended for all of the following except: A. healthcare providers. B. immunocompromised patients. C. restaurant workers. D. dialysis patients.

109. Which of the following is among the most common causes of HF? A. dietary indiscretion B. COPD C. hypertensive heart disease D. anemia

110. A 26-year-old male reports that he has shared a needle with a friend during injection drug use. He is certain that his friend has chronic hepatitis B infection and is uncertain about his own immunization history. You recommend: A. starting the HBV vaccine series. B. administering hepatitis B immune globulin. C. starting the HBV vaccine series and administering hepatitis B immune globulin. D. waiting until the HBsAg results are in before

113. Which of the following statements is true concerning hepatitis C infection? A. It usually manifests with jaundice, fever, and significant hepatomegaly. B. Among healthcare workers, it is most commonly found in nurses. C. At least 50% of persons with acute hepatitis C go on to develop chronic infection. D. Interferon therapy is consistently curative.

114. Which of the following best describes the patient presentation of New York Heart Association stage III heart disease? A. Ordinary physical activity does not cause undue fatigue, dyspnea, or palpitations. B. Ordinary physical activity results in fatigue, palpitations, dyspnea, or angina. C. Less-than-ordinary activity leads to fatigue, dyspnea, palpitations, or angina. D. Discomfort increases with any physical activity.

119. Monitoring for hepatoma in a patient with chronic hepatitis B or C often includes periodic evaluation of: A. erythrocyte sedimentation rate. B. HBsAb. C. alpha-fetoprotein. D. bilirubin.

119. You examine a 64-year-old man with hypertension and type 2 DM. Lipid profile results are as follows: HDL level is 38 mg/dL (1 mmol/), LDL level is 135 mg/dL (3.5 mmol/L), and triglyceride level is 180 mg/dL (1.9 mmol/L). His estimated 10-year ASCVD risk is 5%. His current medications include a sulfonylurea, a biguanide, an angiotensin-converting enzyme inhibitor, and a thiazide diuretic, and he has acceptable glycemic and blood pressure control. He states, "I really watch the fats and sugars in my diet." Which of the following is the most appropriate advice? A. No further intervention is needed. B. His lipid profile should be repeated in 6 months. C. Lipid-lowering drug therapy with a moderateintensity statin should be initiated. D. The patient's dietary intervention appears adequate.

12. In caring for a patient with DM, microalbuminuria measurement should be obtained: A. annually if urine protein is present. B. periodically in relationship to glycemia control. C. yearly. D. with each office visit related to DM.

123. You see a 48-year-old woman with nonalcoholic fatty liver disease. Evaluation of infectious hepatitis includes the following: Anti-HAV IgG—negative Anti-HBs—negative Anti-HCV—negative When considering her overall health status, you advise receiving which of the following vaccines? A. immunization against hepatitis A and B as based on her lifestyle risk factors B. immunization against hepatitis B and C C. immunization against hepatitis A and B D. immunization against hepatitis A, B, and C

129. You are seeing a patient who is taking warfarin and cholestyramine and provide the following advice: A. "Take both medications together." B. "You need to have additional hepatic and renal monitoring tests while on this combination." C. "Separate the cholestyramine from other medications by at least 2 hours." D. "Make sure you take these medications on an empty stomach."

132. The most common causative organism of bronchiolitis is: A. Haemophilus influenzae. B. parainfluenza virus. C. respiratory syncytial virus. D. coxsackie virus.

132. Untreated hypothyroidism can result in which of the following changes in the lipid profile? A. increased HDL and decreased triglycerides B. increased LDL and total cholesterol C. increased LDL, total cholesterol, and triglycerides D. decreased LDL and HDL

133. One of the most prominent clinical features of bronchiolitis is: A. fever. B. vomiting. C. wheezing. D. conjunctival inflammation.

136. Common clinical findings in a young child with bronchiolitis include all of the following except: A. pharyngitis. B. tachypnea. C. bradycardia. D. conjunctivitis.

137. Use of palivizumab (Synagis®) for the prevention of respiratory syncytial virus (RSV) infection should be considered for all of the following except: A. a 1-month-old born at 28 weeks' gestation. B. a 4-month-old with congenital heart disease. C. a 5-month-old born at 39 weeks' gestation who now has recurrent acute otitis media. D. a 3-month-old with chronic respiratory disease.

138. The first dose of palivizumab treatment should be given: A. at birth. B. at 1 month of age. C. immediately prior to the RSV season. D. at the peak of RSV season.

139. A preparticipation physical screening examination should include: A. complete blood count (CBC). B. urinalysis. C. blood pressure measurement. D. radiograph of the spine.

14. An 18-year-old high school senior presents, asking for a letter stating that he should not participate in gym class because he has asthma. The most appropriate action is to: A. write the note because gym class participation could trigger asthma symptoms. B. excuse him from outdoor activities only to avoid pollen exposure. C. assess his level of asthma control and make changes in his treatment plan if needed so he can participate. D. write a note excusing him from gym until his follow-up examination in 2 months.

14. Guidelines recommend considering initiating treatment with an erythropoiesis-stimulating agent (ESA) for patients with chronic renal failure and a hemoglobin (Hg) level: A. less than 8.5 mg/dL. B. less than 9.0 mg/dL. C. less than 10 mg/dL. D. less than 11.5 mg/dL.

14. When caring for a patient with DM, hypertension, and persistent proteinuria, the nurse practitioner (NP) prioritizes the choice of antihypertension and prescribes: A. furosemide. B. methyldopa. C. fosinopril. D. nifedipine.

140. Among individuals younger than 35 years, the most common cause of sudden cardiac death is: A. non-ST-segment myocardial infarction. B. ST-segment myocardial infarction. C. a congenital cardiac malformation. D. aortic stenosis

146. Common signs of high-grade aortic stenosis in an individual during exercise include all of the following except: A. dyspnea. B. angina. C. seizure. D. syncope.

15. Which of the following hemograms would be expected for a 75-year-old woman with chronic renal failure and related anemia? A. Hg = 9.7 g/dL (12 to 14 g/dL); MCV = 69 fL (80 to 96 fL); reticulocytes = 0.8% (1% to 2%). B. Hg = 10.2 g/dL (12 to 14 g/dL); MCV = 104 fL (80 to 96 fL); reticulocytes = 1.2% (1% to 2%). C. Hg = 9.4 g/dL (12 to 14 g/dL); MCV = 83 fL (80 to 96 fL); reticulocytes = 0.7% (1% to 2%). D. Hg = 10.4 g/dL (12 to 14 g/dL); MCV = 94 fL (80 to 96 fL); reticulocytes = 2.6% (1% to 2%).

150. A 22-year-old woman wants to know whether she can start a walking program. She has a diagnosis of MVP, with echocardiogram revealing trace mitral regurgitation. You respond that: A. she should have an exercise tolerance test. B. an electrocardiogram (ECG) should be obtained. C. she may proceed in the absence of symptoms of activity intolerance. D. running should be avoided.

159. Clinical disorders that increase the risk for osteoporosis include all of the following except: A. rheumatoid arthritis. B. celiac disease. C. hyperlipidemia. D. hyperprolactinemia.

16. A 26-year-old man presents with acute abdominal pain. As part of the evaluation for acute appendicitis, you order a white blood cell (WBC) count with differential and anticipate the following results: A. total WBCs, 4500/mm3; neutrophils, 35%; bands, 2%; lymphocytes, 45%. B. total WBCs, 14,000/mm3; neutrophils, 55%; bands, 3%; lymphocytes, 38%. C. total WBCs, 16,500/mm3; neutrophils, 66%; bands, 8%; lymphocytes, 22%. D. total WBCs, 18,100/mm3; neutrophils, 55%; bands, 3%; lymphocytes, 28%.

160. Osteoporosis is defined as having a bone density more than standard deviation(s) below the average bone mass for a healthy young adult. A. 1 B. 1.5 C. 2.5 D. 4

162. Osteoporosis prevention measures include all of the following except: A. calcium supplementation. B. selective estrogen receptor modulator use. C. vitamin B6 supplementation. D. weight-bearing and muscle-strengthening exercises.

163. All of the following are common signs of osteoporosis except: A. gradual loss of height with stooped posture. B. hip or wrist fracture. C. increase in waist circumference. D. patient report of back pain.

164. What is the recommended daily calcium intake for women older than 50 years of age? A. 800 mg B. 1000 mg C. 1200 mg D. 1500 mg

165. Nondairy sources of calcium include all of the following except: A. tofu. B. spinach. C. brown rice. D. sardines.

167. The use of calcitonin to treat osteoporosis has been associated with an increased risk of: A. type 2 diabetes. B. rheumatoid arthritis. C. malignancy. D. systemic lupus erythematosus.

17. Which of the following should be periodically monitored with the use of a thiazolidinedione? A. CK B. ALP C. ALT D. Cr

17. You examine a 22-year-old woman of Asian ancestry. She has no presenting complaint. Hemogram results are as follows: Hgb = 9.1 g (normal 12 to 14 g) Hct = 28% (normal 36% to 43%) RBC = 5.6 million mm3 (normal 4.2 to 5.4 million mm3) MCV = 68 fL (normal 81 to 96 fL) MCHC = 33.2 g/dL (normal 31 to 37 g/dL) RBC distribution width (RDW) = 13% (normal ≤15%). Reticulocytes = 1.5% (normal 1% to 2%) This is most consistent with the laboratory assessment of: A. iron-deficiency anemia. B. Cooley anemia. C. alpha-thalassemia minor. D. hemoglobin Barts.

171. Ms. Lane, a 38-year-old woman with a long-standing history of alcohol abuse, presents with a 4-day history of a midabdominal ache that radiates through to the back, remains relatively constant, and has been accompanied by nausea and three episodes of vomiting. She has tried taking antacids without relief. Her skin is cool and moist with a blood pressure of 90/72 mm Hg, pulse rate of 120 bpm, and respiratory rate of 24/min. Findings that would support a diagnosis of acute pancreatitis include all of the following except: A. elevated serum amylase level. B. elevated lipase level. C. jaundice. D. upper abdominal tenderness without localization or rebound.

175. Which of the following statements is true when evaluating a patient with acute pancreatitis? A. Diagnosis can be made by clinical assessment alone. B. The pancreas can be clearly visualized by abdominal ultrasound. C. Measuring serum lipase level along with amylase level increases diagnostic specificity in acute pancreatitis. D. Hypocalcemia is a nearly universal finding.

177. Common signs and symptoms of a pancreatic pseudocyst include all of the following except: A. abdominal pain that radiates to the back. B. nausea and vomiting. C. jaundice. D. a mass that can be palpated in the upper abdomen.

178. Which of the following diagnostic tests is most effective in determining whether a pseudocyst is benign? A. CT scan B. MRI scan C. analysis of cyst fluid D. serum amylase and lipase levels

20. Clinical findings characteristic of poorly controlled asthma include all of the following except: A. a recurrent spasmodic cough that is worse at night. B. recurrent shortness of breath and chest tightness with exercise. C. a congested cough that is worse during the day. D. wheezing with and without associated respiratory infections

208. Which of the following best describes the pathophysiology and resulting clinical presentation of asthma? A. intermittent airway inflammation with occasional bronchospasm B. a disease of bronchospasm leading to airway inflammation C. chronic airway inflammation with superimposed bronchospasm D. relatively fixed airway constriction

1. All of the following electrolyte disorders are commonly found in a person with chronic renal failure except: A. hypernatremia. B. hypercalcemia. C. hyperkalemia. D. hypophosphatemia.

1. Which of the following is inconsistent with the description of benign prostatic hyperplasia (BPH)? A. obliterated median sulcus B. size larger than 2.5 cm × 3 cm C. sensation of incomplete emptying D. boggy gland

1. Worldwide, which of the following is the most common type of anemia? A. pernicious anemia B. folate-deficiency anemia C. anemia of chronic disease D. iron-deficiency anemia

10. Concerning herbal and nutritional therapies for BPH treatment, which of the following statements is false? A. The mechanism of action of the most effective and best studied products is similar to prescription medications for this condition. B. These therapies are currently considered emerging therapies by the American Urological Association. C. Major areas of concern with use of these therapies include issues of product purity and quality control. D. These therapies are safest and most effective when used with prescription medications.

10. Objective findings in patients with glomerulonephritis include all of the following except: A. edema. B. urinary red blood cell (RBC) casts. C. proteinuria. D. hypotension.

10.The cornerstone of moderate persistent asthma drug therapy is the use of: A. oral theophylline. B. mast cell stabilizers. C. short-acting beta2-agonists (SABA). D. inhaled corticosteroids.

100. All of the following are effective methods to kill the hepatitis A virus except: A. heating food to more than 185°F (85°C) for at least 1 minute. B. adequately chlorinating water. C. cleaning surfaces with a 1:100 bleach solution. D. freezing food for at least 1 hour

100. In patients with heart failure, the point of maximum impulse usually: A. remains unchanged near the fourth intercostal space. B. remains unchanged near the fifth intercostal space. C. shifts lower on the mid-clavicular line. D. shifts laterally by one or more intercostal spaces.

102. A 54-year-old man has been recently diagnosed with HAV infection. You recommend all of the following except: A. eating smaller, more frequent meals to help combat nausea. B. avoiding consumption of any alcohol. C. reviewing current medication use for consideration of discontinuation. D. taking daily acetaminophen to alleviate joint pains.

103. A 38-year-old man with a recent history of injection drug use presents with malaise, nausea, fatigue, and "yellow eyes" for the past week. After ordering diagnostic tests, you confirm the diagnosis of acute hepatitis B. Anticipated laboratory results include: A. the presence of hepatitis B surface antibody (HBsAb). B. neutrophilia. C. thrombocytosis. D. the presence of HBsAg.

105. Risk factors for hepatitis B virus (HBV) infection include all of the following except: A. having multiple sexual partners. B. having an occupation that exposes you to human blood. C. being an injection drug user. D. eating food prepared by a person with an HBV infection.

106. You see a woman who has been sexually involved without condom use with a man newly diagnosed with acute hepatitis B. She has not received hepatitis B immunization. You advise her to: A. start hepatitis B immunization series. B. limit the number of sexual partners. C. be tested for HBsAb. D. receive hepatitis B immune globulin and start hepatitis B immunization series.

112. Antiviral treatment for chronic HBV infection includes all of the following except: A. entecavir. B. tenofovir. C. lamivudine. D. fidaxomicin.

112. Which of the following is unlikely to be noted in the person experiencing HF? A. elevated serum B-type natriuretic peptide (BNP) B. Kerley B lines noted on chest x-ray C. left ventricular hypertrophy on ECG D. evidence of hemoconcentration on hemogram

113. The use of which of the following medications can induce thyroid dysfunction? A. sertraline B. venlafaxine C. bupropion D. lithium

113. Which of the following medications is an alpha/ beta-adrenergic antagonist? A. atenolol B. metoprolol C. propranolol D. carvedilol

115. The risk for digoxin toxicity increases with concomitant use of all of the following medications except: A. amiodarone. B. clarithromycin. C. cyclosporine. D. levofloxacin.

115. When answering questions about hepatitis A vaccine, you consider that all of the following are true except: A. it does not contain live virus. B. it should be offered to individuals who frequently travel to developing countries. C. it is a recommended immunization for healthcare workers. D. it is given as a single dose.

118. Hyperbilirubinemia can cause all of the following except: A. potential displacement of highly protein-bound drugs. B. scleral icterus. C. cola-colored urine. D. reduction in urobilinogen.

118. You examine a 46-year-old male who is a one-half pack per day cigarette smoker with hypertension. He has no evidence of clinical atherosclerotic cardiovascular disease (ASCVD), and his estimated 10-year ASCVD risk is 10%. His lipid profile is as follows: HDL level is 48 mg/dL (1.24 mmol/L); LDL level is 192 mg/dL (4.9 mmol/L); and triglyceride level is 110 mg/dL (1.3 mmol/L). He had been on a low-cholesterol diet for 6 months when these tests were taken. Which of the following represents the best next step? A. No further intervention is required. B. A fibrate should be prescribed. C. A low-intensity 3-hydroxy-3-methylglutaryl- coenzyme A (HMG-CoA) reductase inhibitor should be prescribed. D. A high-intensity HMG-CoA reductase inhibitor regimen should be initiated.

12. Folate-deficiency anemia causes which of the following changes in the RBC indices? A. microcytic, normochromic B. normocytic, normochromic C. microcytic, hypochromic D. macrocytic, normochromic

120. Which of the following is an expected laboratory result in a patient with acute hepatitis A infection (normal values: AST, 0 to 31 U/L; ALT, 0 to 40 U/L)? A. AST, 55 U/L; ALT, 50 U/L B. AST, 320 U/L; ALT, 190 U/L C. AST, 320 U/L; ALT, 300 U/L D. AST, 640 U/L; ALT, 870 U/L

125. With ezetimibe (Zetia®), which of the following should be periodically monitored? A. alkaline phosphatase (ALP) B. lactate dehydrogenase (LDH) C. creatinine phosphokinase (CPK) D. No special laboratory monitoring is recommended.

126. With the use of a lipid-lowering resin such as cholestyramine, which of the following enzymes should be periodically monitored? A. ALP B. LDH C. aspartate aminotransferase (AST) D. No particular monitoring is recommended.

13. According to the National Asthma Education and Prevention Program Expert Panel Report 3 (NAEPP EPR-3) guidelines, which of the following is not a risk for asthma death? A. hospitalization or an emergency department visit for asthma in the past month B. current use of systemic corticosteroids or recent withdrawal from systemic corticosteroids C. difficulty perceiving airflow obstruction or its severity D. rural residence

131. The rate of bronchiolitis is highest in which age group? A. toddlers B. school-aged children C. preschool children D. infants younger than age 2 years

134. The anticipated effect on the lipid profile with high-dose omega-3 fatty acid use includes: A. increase in HDL. B. decrease in LDL. C. decrease in total cholesterol. D. decrease in triglycerides.

14. Pernicious anemia causes which of the following changes in the RBC indices? A. microcytic, normochromic B. normocytic, normochromic C. microcytic, hypochromic D. macrocytic, normochromic

141. During a preparticipation cardiovascular history, all of the following questions should be included except: A. past detection of a heart murmur. B. excessive, unexplained, and unexpected shortness of breath. C. prior occurrence of exertional chest pain/discomfort. D. prior use of NSAIDs.

143. You see a 28-year-old Italian American man who participates in recreational basketball and has hypertension. In thinking about treatment, you consider all of the following as viable options except: A. calcium channel blocker. B. angiotensin-converting enzyme inhibitors. C. angiotensin receptor antagonists. D. beta-adrenergic antagonists.

148. You are examining a 19-year-old man who is diagnosed with a murmur of mitral regurgitation. When he asks about participation in sports activities, you counsel that: A. participation in sports activities should not be affected by his condition. B. he should refrain from any activities requiring physical exertion. C. participation will depend on the degree of atrial atrophy. D. participation will depend on the degree of ventricular enlargement.

15. All of the following are typically noted in a young adult with the diagnosis of acute appendicitis except: A. epigastric pain. B. positive obturator sign. C. rebound tenderness. D. marked febrile response.

155. Among young adults with an implantable cardioverter defibrillator (ICD), participation in sports should be: A. generally cautioned against. B. limited to noncontact sports. C. limited to anaerobic activities. D. determined on an individual basis.

156. Initial preparticipation screening of athletes should include: A. a resting 12-lead ECG. B. echocardiogram. C. both a resting 12-lead ECG and echocardiogram. D. neither a resting 12-lead ECG nor echocardiogram.

157. All of the following are common sites of fracture in patients with osteoporosis except: A. the proximal femur. B. the distal forearm. C. the vertebrae. D. the clavicle.

16. Which of the following should be periodically monitored with the use of a biguanide? A. creatine kinase (CK) B. alkaline phosphatase (ALP) C. alanine aminotransferase (ALT) D. creatinine (Cr)

171. When counseling a patient taking a bisphosphonate such as alendronate (Fosamax®), you advise that the medication should be taken with: A. a bedtime snack. B. a meal. C. other medications. D. a large glass of water.

173. Other than the pancreas, other sources of amylase include all of the following except: A. salivary glands. B. lung cancer. C. ovarian cyst. D. adipose tissue.

18. All of the following are risks for lactic acidosis in individuals taking metformin except: A. presence of chronic renal insufficiency. B. acute dehydration. C. recent radiographic contrast dye use. D. history of allergic reaction to sulfonamides.

184. Which of the following is least likely to be found in a person with pancreatic cancer? A. history of chronic pancreatitis B. lesion identified on abdominal CT C. normocytic, normochromic anemia D. elevation of amylase level

19. Secondary causes of hyperglycemia potentially include the use of all of the following medications except: A. high-dose niacin. B. systemic corticosteroids. C. high-dose thiazide diuretics. D. low-dose angiotensin receptor blockers.

2. All of the following are common precipitating factors in acute renal failure except: A. anaphylaxis. B. infection. C. myocardial infarction. D. type 1 diabetes.

2.The patient you are evaluating is having a severe asthma flare. You have assessed that his condition is appropriate for office treatment. You expect to find the following on physical examination: A. tripod posture. B. inspiratory crackles. C. increased vocal fremitus. D. hyperresonance on thoracic percussion.

20. Hemoglobin A1c best provides information on glucose control over the past: A. 21 to 47. B. 48 to 68. C. 69 to 89. D. 90 to 120.

20. You examine a 27-year-old woman with menorrhagia who is otherwise well and note the following results on hemogram: Hgb = 10.1 g Hct = 32% RBC = 2.9 million mm3 MCV = 72 fL MCHC = 28.2 g/dL RDW = 18.9% Physical examination is likely to include: A. conjunctiva pallor. B. hemic murmur. C. tachycardia. D. no specific anemia-related findings.

21. Which of the following WBC forms is an ominous finding in the presence of severe bacterial infection? A. neutrophil B. lymphocyte C. basophil D. metamyelocyte

21. Which of the following best describes the mechanism of action of short-acting beta2-agonists? A. reducer of inflammation B. inhibition of secretions C. modification of leukotrienes D. smooth muscle relaxation

21. Which of the following statements is not true concerning the effects of exercise and IR? A. Approximately 80% of the body's insulin-mediated glucose uptake occurs in skeletal muscle. B. With regular aerobic exercise, IR is reduced by approximately 40%. C. The IR-reducing effects of exercise persist for 48 hours after the activity. D. Hyperglycemia can occur as a result of aerobic exercise.

214. Which of the following is not a risk factor for asthma death? A. hospitalization or an emergency department visit for asthma in the past month. B. current use of systemic corticosteroids or recent withdrawal from systemic corticosteroids. C. difficulty perceiving airflow obstruction or its severity. D. rural residence.

24. Compared with UTI in younger women, uncomplicated UTI in an elderly woman is more likely to be associated with each of the following signs and symptoms except: A. new-onset urinary incontinence. B. delirium. C. weakness. D. hematuria.

25. Compared with short-acting beta2-agonists, long-acting beta2-agonists: A. are recommended as a first-line therapy in mild intermittent asthma. B. have a significantly different pharmacodynamic profile. C. have a rapid onset of action across the drug class. D. should be added to therapy only when ICS use does not provide adequate asthma control

27. Erythropoietin is a glycoprotein that influences a stem cell to become a: A. lymphocyte. B. platelet. C. neutrophil. D. red blood cell.

27. Which urine culture result is needed to confirm a UTI in an asymptomatic woman who has not had recent use of a urinary catheter? A. 102 cfu/mL or more B. 103 cfu/mL or more C. 104 cfu/mL or more D. 105 cfu/mL or more

272. Which of the following is most likely to be noted in a 3-year-old child with CAP? A. complaint of pleuritic chest pain B. sputum production C. report of dyspnea D. tachypnea

274. Which of the following antimicrobials provides effective activity against atypical pathogens? A. amoxicillin B. cefprozil C. ceftriaxone D. clarithromycin

275. Which of the following is not a criterion for outpatient management of a child with communityacquired pneumonia? A. able to tolerate oral medications B. able to return for follow-up evaluation C. adequately hydrated D. parenteral antimicrobial used for initial therapy

28. Which of the following findings would you expect to encounter in a 33-year-old man with appendiceal abscess? A. leukopenia with lymphocytosis B. positive Cullen's sign C. protracted nausea and vomiting D. dullness to percussion in the abdominal right lower quadrant

28. You see a 34-year-old woman with an uncomplicated UTI. She is otherwise healthy but reports having a sulfa allergy. Appropriate therapy would include: A. TMP-SMX. B. amoxicillin. C. azithromycin. D. nitrofurantoin.

31. In children younger than age 6 years, accidental overdose of iron-containing products is: A. easily treated. B. a source of significant gastrointestinal (GI) upset. C. worrisome but rarely causes significant harm. D. a leading cause of fatal poisoning in the age-group.

32. Which of the following is the most common serious complication of cholecystitis? A. adenocarcinoma of the gallbladder B. gallbladder empyema C. hepatic failure D. pancreatitis

34.The use of a thiazolidinedione is not recommended in all of the following clinical scenarios except: A. a 57-year-old man who is taking a nitrate. B. a 62-year-old woman with heart failure. C. a 45-year-old man who is using insulin. D. a 35-year-old patient with newly diagnosed type 2 DM.

35. In an older adult with type 2 DM with gastroparesis, the use of which of the following medications should be avoided? A. insulin glargine (Toujeo®, Lantus®) B. insulin aspart (NovoLog®) C. glimepiride (Amaryl®) D. liraglutide (Victoza®)

35. Which of the following joints is most likely to be affected by osteoarthritis (OA)? A. wrists B. elbows C. metacarpophalangeal joint D. distal interphalangeal joint

37. All of the following can negatively impact perivaginal lactobacilli colonization except: A. recent antimicrobial use. B. exposure to the spermicide nonoxynol-9. C. estrogen deficiency. D. postcoital voiding.

37. Which of the following is true concerning colorectal cancer? A. Most colorectal cancers are found during rectal examination. B. Rectal carcinoma is more common than cancers involving the colon. C. Early manifestations include abdominal pain and cramping. D. Later disease presentation often includes iron-deficiency anemia.

39. In performing a cardiac examination in a person with MVP, you expect to find: A. an early- to mid-systolic, crescendo-decrescendo murmur. B. a pansystolic murmur. C. a low-pitched, diastolic rumble. D. a mid- to late-systolic murmur.

39. Which of the following is not a gram-negative organism? A. E. coli B. K. pneumoniae C. P. mirabilis D. S. saprophyticus

40. A risk factor for MVP includes a history of: A. rheumatic fever. B. rheumatoid arthritis. C. Kawasaki disease. D. Marfan syndrome.

40. Which of the following does not increase a patient's risk of developing colorectal cancer? A. family history of colorectal cancer B. familial polyposis C. personal history of neoplasm D. long-term aspirin therapy

40. Which of the following patients has prediabetes? A. a 70-year-old man with a fasting glucose of 99 mg/dL (6.05 mmol/L) B. an 84-year-old woman with a 1-hour postprandial glucose of 98 mg/dL (5.44 mmol/L) C. a 33-year-old man with a hemoglobin A1c of 5.4% D. a 58-year-old woman with a 2-hour postprandial glucose of 152 mg/dL (8.44 mmol/L)

41.The most effective nonpharmacologic method to prevent exacerbations in patients with COPD is: A. weight loss for those with a body mass index (BMI) greater than 25 kg/m2. B. avoid exposure to children or day-care centers. C. brisk walking for at least 5 minutes 3-5 times a day as tolerated. D. avoid exposure to pulmonary irritants, such as cigarette smoke.

42. Colonic diverticulosis most commonly occurs in the walls of the: A. ascending colon. B. descending colon. C. transverse colon. D. sigmoid colon.

42. Intervention for patients with MVP often includes advice about which of the following? A. restricted activity because of low cardiac output B. control of fluid intake to minimize risk of volume overload C. routine use of beta-adrenergic antagonists to control palpitations D. encouragement of a regular program of aerobic activity

42. When managing patients with COPD who continue to smoke cigarettes, a discussion on the importance of smoking cessation should occur: A. at the initial diagnosis visit. B. with each COPD flare. C. once inhaled corticosteroid therapy is initiated. D. at every office visit.

42. Which of the following classes of medications is commonly recommended as part of first-line therapy in the newly diagnosed person with type 2 diabetes? A. alpha-glucosidase inhibitor B. meglitinide C. thiazolidinedione D. biguanide

42. Which of the following is not a risk factor for bladder cancer? A. occupational exposure to textile dyes B. cigarette smoking C. occupational exposure to heavy metals D. long-term aspirin use

45.The mechanism of action of glucosamine and chondroitin is: A. via increased production of synovial fluid. B. through improved cartilage repair. C. via inhibition of the inflammatory response in the joint. D. largely unknown.

46.The use of which of the following medications has the potential for causing the greatest reduction in HbA1c? A. a biguanide B. a thiazolidinedione C. a sulfonylurea D. an insulin form

47. Which is the most appropriate choice of therapy in the treatment of a mild acute COPD exacerbation in a 42-year-old man? A. a 5-day course of levofloxacin B. a 7-day course of amoxicillin C. a 10-day course of doxycycline D. antimicrobial therapy usually not indicated

48. In evaluating the person with aortic stenosis, the NP anticipates finding 12-lead ECG changes consistent with: A. right bundle branch block. B. extreme axis deviation. C. right atrial enlargement. D. left ventricular hypertrophy.

48. Which is the most appropriate statement about therapy for a severe COPD exacerbation in a 52-year-old man? A. A 5-day course of azithromycin should be prescribed. B. A 10-day course of amoxicillin/clavulanate is advisable, C. A 7-day course of trimethoprim-sulfamethoxazole (TMP-SMX) is recommended. D. The role of antimicrobial therapy is debated, even for a severe exacerbation.

49. AAOS strongly recommends all of the following therapeutic agents for the management of symptomatic OA of the knee except: A. oral NSAIDs. B. topical NSAIDs. C. tramadol. D. opioids.

49. You see a 67-year-old man with very severe (GOLD 4) COPD who asks, "When should I use my home oxygen?" You respond: A. "As needed when short of breath." B. "Primarily during sleep hours." C. "Preferably during waking hours." D. "For at least 15 hours a day."

5. A 78-year-old man presents with a 3-day history of new-onset fatigue and difficulty with bladder emptying. Examination reveals a distended bladder but is otherwise unremarkable. Blood urea nitrogen level is 88 mg/dL (31.4 mmol/L); creatinine level is 2.8 mg/dL (247.5 μmol/L). The most likely diagnosis is: A. prerenal azotemia. B. acute glomerulonephritis. C. tubular necrosis. D. postrenal azotemia.

5. A 78-year-old man presents with fatigue and difficulty with bladder emptying. Examination reveals a distended bladder but is otherwise unremarkable. The blood urea nitrogen (BUN) is 88 mg/dL (31.4 mmol/L); the creatinine is 2.8 mg/dL (247.5 μmol/L). This clinical assessment is most consistent with: A. prerenal azotemia. B. acute glomerulonephritis. C. acute tubular necrosis. D. postrenal azotemia.

5. For Jane in question 4, you also prescribe: A. amoxicillin. B. azithromycin. C. levofloxacin. D. no antimicrobial therapy.

50. Among surgical and procedural interventions, AAOS strongly recommends the use of which of the following for the management of symptomatic OA of the knee? A. intra-articular corticosteroid use B. hyaluronic acid injections C. arthroscopy with lavage and/or débridement D. none of the above

51. Regarding the current scientific evidence on the use of glucosamine and chondroitin for the management of symptomatic OA of the knee, AAOS: A. strongly favors their use. B. provides a moderate-strength recommendation for their use. C. cannot recommend for or against the use of these supplements (limited evidence). D. cannot recommend the use of these supplements.

52. Metformin has all of the following effects except: A. improved insulin-mediated glucose uptake. B. modest weight loss with initial use. C. enhanced fibrinolysis. D. increased low-density lipoprotein (LDL) cholesterol production.

53. Which part of the prostate is readily palpable during a DRE? A. anterior lobe B. median lobe C. lateral lobes D. posterior lobe

54. Measures to prevent colonic diverticulosis and diverticulitis include all of the following except: A. increased whole grain intake. B. regular aerobic exercise. C. adequate hydration. D. refraining from excessive alcohol intake

54. Recommended exercises for patients with OA of the hip include all of the following except: A. stretching exercises of the gluteus muscles. B. straight-leg raises without weights. C. isometric exercises of the iliopsoas and gluteus muscles. D. weight-bearing aerobic exercises.

55. A risk factor for acquired aortic stenosis is: A. history of pulmonary embolism. B. chronic obstructive pulmonary disease (COPD). C. type 2 diabetes. D. prior rheumatic fever.

55. Acanthosis nigricans is commonly noted in all of the following areas except: A. groin folds. B. axilla. C. nape of the neck. D. face.

57. All of the following can cause an elevated PSA level except: A. current prostate infection. B. recent cystoscopy. C. BPH. D. prostatectomy.

6. Surgical intervention in BPH should be considered with all of the following except: A. recurrent urinary tract infection. B. bladder stones. C. persistent obstruction despite medical therapy. D. acute tubular necrosis.

61. Nonsteroidal anti-inflammatory drug (NSAID)-induced peptic ulcer can be best limited by the use of: A. timed antacid doses. B. an H2RA. C. an appropriate antimicrobial. D. misoprostol.

63. Struvite stones are typically found in people: A. with type 2 diabetes. B. who live in colder climates. C. who abuse alcohol. D. with a history of kidney infections.

64. Idiopathic hypertrophic subaortic stenosis (IHSS) is inherited in: A. a sex-linked recessive manner. B. a sex-linked dominant manner. C. an autosomal-recessive manner. D. an autosomal-dominant manner.

64.The action of which of the following is believed to be most responsible for the sensation of satiety? A. norepinephrine B. epinephrine C. dopamine D. serotonin

66.The commonly recommended physical activity level of 10,000 steps per day is roughly the equivalent of walking ________ miles. A. 1 to 2 B. 2 to 3 C. 3 to 4 D. 4 to 5

68. Which of the following medications is a PPI? A. loperamide B. metoclopramide C. nizatidine D. lansoprazole

69. Peptic ulcer disease can occur in any of the following locations except: A. duodenum. B. stomach. C. esophagus. D. large intestine.

69. You see a 58-year-old woman who is being treated for a renal stone. Analysis of a stone passed in the urine reveals that it is composed of calcium oxalate. In counseling the patient about preventing future stones, you consider all of the following except: A. reducing sodium in her diet. B. limiting consumption of beets, rhubarb, nuts, and chocolate. C. encouraging her to get her daily calcium requirements from food. D. if calcium supplements are needed, this medication should be taken on an empty stomach.

71. A diagnosis of pneumonia is confirmed by: A. sputum culture. B. sputum gram stain C. bronchoalveolar lavage. D. chest radiograph.

73. Long-term PPI use is associated with all of the following except: A. increased risk of pneumonia in hospitalized patients. B. increased risk of C. difficile colitis in hospitalized patients. C. reduced absorption of calcium and magnesium. D. reduced absorption of dietary carbohydrates.

74. To avoid rebound gastric hyperacidity following discontinuation of long-term PPI use, all of the following methods can be used except: A. gradually tapering the PPI dose with supplemental antacid. B. switching to every-other-day dosing of PPI with supplemental antacid. C. switching to a low-dose H2RA therapy with supplemental antacid. D. empiric H. pylori therapy.

78. A 38-year-old nonsmoking man presents with signs and symptoms consistent of GERD. He has self-treated with over-the-counter antacids and acid suppression therapy with effect. His weight is stable, and he denies nausea, vomiting, diarrhea, or melena. Which of the following represents the most appropriate diagnostic plan for this patient? A. fecal testing for H. pylori antigen B. upper GI endoscopy C. barium swallow D. no specific diagnostic testing is needed

85. Risk factors for Barrett esophagus include all of the following except: A. a history of cigarette smoking. B. being older than 50 years of age. C. male gender. D. African American ethnicity.

86. TSH is released by the: A. thyroid follicles. B. adrenal cortex. C. hypothalamus. D. anterior lobe of the pituitary.

87. A 64-year-old male with diagnosed Barrett esophagus has shown no sign of dysplasia in two consecutive evaluations within the past year. You recommend additional surveillance testing should be conducted every: A. 6 months. B. 12 months. C. 2 years. D. 3 years.

87. In the report of a thyroid scan done on a 48-year-old woman with a thyroid mass, a "cold spot" is reported. This finding is most consistent with: A. autonomously functioning adenoma. B. Graves' disease. C. Hashimoto's disease. D. thyroid cyst.

87. While seeing a 62-year-old who is hospitalized with CAP, the NP considers that: A. pneumococcal vaccine should be given when antimicrobial therapy has been completed. B. pneumococcal vaccine can be given today, and influenza vaccine can be given in 2 weeks. C. influenza vaccine can be given today, and pneumococcal vaccine can be given in 2 weeks. D. influenza and pneumococcal vaccines should be given today.

88. Risk factors for infection with DRSP include all of the following except: A. systemic antimicrobial therapy in the previous 3 months. B. exposure to children in day care. C. age older than 65 years. D. use of inhaled corticosteroids.

9. Criteria for the diagnosis of type 2 DM include: A. classic symptoms regardless of fasting plasma glucose measurement. B. plasma glucose level of 126 mg/dL (7 mmol/L) as a random measurement. C. a 2-hour glucose measurement of 156 mg/dL (8.6 mmol/L) after a 75 g anhydrous glucose load. D. a plasma glucose level of 126 mg/dL (7 mmol/L) or greater after an 8 hour or greater fast on more than one occasion.

90. A fixed, painless thyroid mass accompanied by hoarseness and dysphagia should raise the suspicion of: A. adenomatous lesion. B. Graves' disease. C. Hashimoto's disease. D. thyroid malignancy.

92. Heart failure pathophysiology is characterized by: A. impaired atrial filling and ejection of blood. B. incomplete closure of tricuspid valve. C. near normal ventricular function. D. inadequate cardiac output to meet oxygen and metabolic demands of the body.

93. At minimum, at what interval should TSH be reassessed after a levothyroxine dosage is adjusted? A. 1 to 2 weeks B. 2 to 4 weeks C. 4 to 6 weeks D. 6 to 8 weeks

97. Approximately of acute bronchitis cases are caused by a viral infection. A. 15% B. 30% C. 65% D. 90%

97. The condition of a sudden shortness of breath that usually occurs after 2-3 hours of sleep and leads to sudden awakening followed by a feeling of severe anxiety and breathlessness is known as: A. dyspnea. B. orthopnea. C. resting dyspnea. D. paroxysmal nocturnal dyspnea.

99. Current vaccine guidelines recommend administering the immunization against HAV to: A. those living in or traveling to areas endemic for the disease. B. food handlers and day-care providers. C. military personnel. D. any person who wishes to receive the vaccine.

In the person with hypertension, the nurse practitioner (NP) recommends all of the following to potentially reduce BP in a patient with a BMI of 30 kg/m2 except: A. 10-kg (22-lb) weight loss. B. dietary sodium restriction to 2.4 g (6 g NaCl) per day. C. regular aerobic physical activity, such as 30-40 minutes of brisk walking most days of the week. D. consuming at least 1-2 servings of alcohol.

Which of the following is associated with the highest risk of ischemic heart disease? A. presence of microalbuminuria plus heavy alcohol intake B. absence of microalbuminuria plus use of a thiazolidinedione C. absence of microalbuminuria plus chronic physical inactivity D. presence of microalbuminuria plus cigarette smoking

You see a 38-year-old African American male with hypertension who is currently being treated with thiazide-type diuretic. His current blood pressure reading is 156/94 mm Hg and he has no history of diabetes mellitus or chronic kidney disease. Following current best evidence, you consider adding which of the following medications? A. ACEI B. angiotensin receptor blocker (ARBs) C. beta-adrenergic receptor antagonist D. calcium channel blocker

81. Which is following is the least helpful test for the assessment of thyroid disease? A. total T4 B. thyroid-stimulating hormone (TSH) C. free T4 D. thyroid peroxidase (TPO) antibodies

94. A serological marker for acute hepatitis A virus (HAV) infection is: A. HAV IgM. B. HAV viral RNA. C. TNF-alpha. D. IL-10.

79. A 48-year-old woman with newly diagnosed hypothyroidism asks about a "natural thyroid" medication she read about online and provides the drug's name: desiccated thyroid. As you counsel her about this medication, you consider all of the following except: A. this product contains a fixed dose of T3 and T4. B. the medication is a plant-based product. C. its pharmacokinetics differ significantly when compared to levothyroxine. D. the majority of the study on treatment for hypothyroidism has been done using levothyroxine.

93. A 36-year-old man complains of nausea, fever, malaise, and abdominal pain. He shows signs of jaundice and reports darkly colored urine. Diagnostic results show elevated serum aminotransferase less than 10 times the upper limit of normal (ULN). His most likely diagnosis is: A. GERD. B. viral hepatitis. C. Crohn's disease. D. Barrett esophagus.

78. Increased risk of thyroid disorder is found in individuals who are: A. obese. B. hypertensive. C. treated with systemic corticosteroids. D. elderly.

33. When discussing immunizations with a 67-year-old woman with chronic obstructive pulmonary disease (COPD), you advise that she: A. receive live attenuated influenza virus vaccine. B. avoid immunization against influenza because of the risk associated with the vaccine. C. receive inactivated influenza virus vaccine. D. take an antiviral for the duration of the influenza season.

80. Hypothyroidism most often develops as a result of: A. primary pituitary failure. B. thyroid neoplasia. C. autoimmune thyroiditis. D. radioactive iodine exposure.

95. You are caring for a 45-year-old woman from a developing country. She reports that she had "yellow jaundice" as a young child. Her physical examination is unremarkable. Her laboratory studies are as follows: AST, 22 U/L (normal, 0 to 31 U/L); alanine aminotransferase (ALT), 25 U/L (normal, 0 to 40 U/L); hepatitis A virus immunoglobulin G (HAV IgG) positive. Laboratory testing reveals: A. chronic hepatitis A. B. no evidence of prior or current hepatitis A infection. C. resolved hepatitis A infection. D. prodromal hepatitis A.

96.The most common source of hepatitis A infection is: A. sharing intravenous drug equipment. B. cooked seafood. C. contaminated water supplies. D. sexual contact.

114 to 116. Match the condition with the laboratory results: hypothyroidism, hyperthyroidism, or subclinical hypothyroidism. 114. TSH = 8.9 mIU/L (0.4 to 4.0 mIU/L); free T4 = 15 pmol/L (10 to 27 pmol/L) 115. TSH less than 0.15 mIU/L (0.4 to 4.0 mIU/L); free T4 = 79 pmol/L (10 to 27 pmol/L) 116. TSH = 24 mIU/L (0.4 to 4.0 mIU/L); free T4 = 3 pmol/L (10 to 27 pmol/L)

114. Subclinical hypothyroidism 115. Hyperthyroidism 116. Hypothyroidism

116. During a routine physical for a 64-year-old man, the following ECG is revealed: He has no complaints of dyspnea, syncope, or chest pain, and has no history of hypertension. The most likely diagnosis is: A. transient ischemic attack. B. dilated cardiomyopathy. C. NSTEMI. D. atrial fibrillation.

Answer the following questions true or false. 28. Most prescribers are well-versed in the relative potency of ICS and prescribe an appropriate dose for the patient's clinical presentation. 29. Approximately 80% of the dose of an ICS is systemically absorbed. 30. A leukotriene modifier and an ICS are interchangeable clinically because both groups of medications have equivalent anti-inflammatory effect. 31. Little systemic absorption of mast cell stabilizers occurs with inhaled or intranasal use. 32. Due to safety concerns, mast cell stabilizers are no longer available.

28. False 29. False 30. False 31. True 32. False

63-68 According to the American Thoracic Society/ Infectious Diseases Society of America (ATS/ IDSA) Consensus Guidelines on the Management of Community-Acquired Pneumonia in Adults, which of the following is the most appropriate antimicrobial for treatment of community- acquired pneumonia (CAP) in: 63. a 42-year-old man with no comorbidity, no reported drug allergy, and no recent antimicrobial use? A. azithromycin B. cefpodoxime C. trimethoprim-sulfamethoxazole D. ciprofloxacin 64. a 46-year-old well woman with a history of a bilateral tubal ligation who is macrolide intolerant? A. clarithromycin B. amoxicillin C. doxycycline D. fosfomycin 65. a 78-year-old woman with a history of COPD, hypertension, and dyslipidemia who is taking lovastatin and a dihydropyridine calcium channel blocker? A. clindamycin B. high-dose amoxicillin with doxycycline C. clarithromycin D. ceftriaxone 66. a 69-year-old man with heart failure, prior myocardial infarction, and type 2 diabetes? A. respiratory fluoroquinolone B. amoxicillin with a beta-lactamase inhibitor C. cephalosporin D. beta-lactam plus macrolide 67. a 28-year-old woman with a severe beta-lactam allergy who has a dry cough, headache, malaise, no recent antimicrobial use, and no comorbidity who takes no medication? A. clarithromycin B. amoxicillin C. levofloxacin D. ceftriaxone 68. a 47-year-old woman who was recently treated within the past 2 months with a beta-lactam for acute bacterial sinusitis? A. amoxicillin-clavulanate B. high-dose amoxicillin C. clarithromycin D. moxifloxacin

63. A. 64. C. 65. B. 66. A. 67. A. 68. D.

96 to 112. Identify each of the following findings as associated with hyperthyroidism, hypothyroidism, or both. 96. heat intolerance 97. smooth, silky skin 98. goiter 99. frequent, low-volume, loose stools 100. secondary hypertriglyceridemia 101. amenorrhea or oligomenorrhea 102. coarse, dry skin 103. menorrhagia 104. hyperreflexia with a characteristic "quick out-quick back" action at the patellar reflex 105. proximal muscle weakness 106. tachycardia with hypertension 107. hyporeflexia with a characteristic slow relaxation phase, the "hung-up" reflex 108. coarse hair with tendency to break easily 109. thick, dry nails 110. constipation 111. atypical presentation in an elderly person 112. change in mental status

96. Hyperthyroidism 97. Hyperthyroidism 98. Both 99. Hyperthyroidism 100. Hypothyroidism 101. Hyperthyroidism 102. Hypothyroidism 103. Hypothyroidism 104. Hyperthyroidism 105. Hyperthyroidism 106. Hyperthyroidism 107. Hypothyroidism 108. Hypothyroidism 109. Hypothyroidism 110. Hypothyroidism 111. Both 112. Both

1. Which of the following characteristics applies to type 1 diabetes mellitus (DM)? A. Significant hyperglycemia and ketoacidosis result from lack of insulin. B. This condition is commonly diagnosed on routine examination or workup for other health problems. C. Initial response to oral sulfonylureas is usually favorable. D. Insulin resistance (IR) is a significant part of the disease.

100. Lung cancer ranks number as a cause of cancer-related death in men and women. A. 1 B. 2 C. 3 D. 4

101. You see a 27-year-old man who says he ate at a restaurant last week that was later reported to have a worker identified with hepatitis A. He is healthy and shows no sign of infection but is concerned about contracting HAV infection. You recommend: A. HAV vaccine. B. HAV immune globulin. C. HAV vaccine plus immune globulin. D. no intervention at this time and wait until symptoms manifest.

104. Clinical findings in patients with acute hepatitis B likely include all of the following except: A. abdominal rebound tenderness. B. scleral icterus. C. a smooth, tender, palpable hepatic border. D. report of myalgia

104. When compared with screening for breast cancer, screening for lung cancer results in: A. a lower number needed to screen to prevent one death. B. approximately the same number needed to screen to prevent one death. C. a higher number needed to screen to prevent one death. D. a higher percentage of patients identified where cancer can be prevented.

107. ECG findings in a patient with digoxin toxicity would most likely include: A. atrioventricular heart block. B. T wave inversion. C. sinus tachycardia. D. pointed P waves.

108. Patients reporting symptoms of digoxin toxicity are most likely to include: A. anorexia. B. disturbance in color perception. C. blurred vision. D. diarrhea.

11. Which of the following should be the goal measurement in treating a 45-year-old man with DM and hypertension? A. blood pressure less than 140 mm Hg systolic and less than 90 mm Hg diastolic B. hemoglobin A1c equal to or greater than 7% C. triglyceride 200 to 300 mg/dL (11.1 to 16.6 mmol/L) D. high-density lipoprotein (HDL) 35 to 40 mg/dL (0.9 to 1.03 mmol/L)

111. You see a 22-year-old male who is an injection drug user who has recently been diagnosed with chronic HBV infection. You recommend additional testing for all of the following except: A. Lyme disease. B. HIV. C. HAV. D. HCV

12. Creatinine clearance usually: A. approximates glomerular filtration rate (GFR). B. does not change as part of normative aging. C. is greater in women compared with men. D. increases with hypotension.

121. Which of the following is most likely to be reported in a patient on long-term use of a 3-hydroxy-3- methylglutaryl-coenzyme A (HMG-CoA) reductase inhibitor (statin)? A. AST, 22 U/L; ALT, 28 U/L B. AST, 320 U/L; ALT, 190 U/L C. AST, 32 U/L; ALT, 120 U/L D. AST, 440 U/L; ALT, 670 U/L

122. When discussing the use of immunoglobulin (IG) with a 60-year-old woman who was recently exposed to the hepatitis A virus, you consider that: A. IG is derived from pooled donated blood. B. the product must be used within 1 week of exposure to provide protection. C. its use in this situation constitutes an example of active immunization. D. a short, intense, flu-like illness often occurs after its use.

86. You are caring for a 52-year-old man who is currently smoking 1.5 packs per day (PPD), has a 40 pack-year cigarette smoking history, and has CAP. It is the third day of his antimicrobial therapy, and he is without fever, is well hydrated, and is feeling less short of breath. His initial chest x-ray revealed a right lower lobe infiltrate. Physical examination today reveals peak inspiratory crackles with increased tactile fremitus in the right posterior thorax. Which of the following represents the most appropriate next step in this patient's care? A. His current plan of care should continue because he is improving by clinical assessment. B. A chest radiograph should be taken today to confirm resolution of pneumonia. C. Given the persistence of abnormal thoracic findings, his antimicrobial therapy should be changed. D. A computed tomography (CT) scan of the thorax is needed today to image better any potential thoracic abnormalities.

89.The findings of a painless thyroid mass and TSH level of less than 0.1 IU/mL in a 35-year-old woman is most consistent with: A. autonomously functioning adenoma. B. Graves' disease. C. Hashimoto's disease. D. thyroid malignancy.

90. Esophageal squamous cell cancer is usually located: A. in the upper esophagus. B. near the upper esophageal sphincter. C. at the junction of the esophagus and stomach. D. in the lower esophagus

90. Which pneumococcal vaccine offers protection against the greatest number of serotypes? A. Pneumovax® B. Prevnar® C. PCV7 D. LAIV

92. Possible consequences of excessive levothyroxine use include: A. bone thinning. B. fatigue. C. renal impairment. D. constipation.

93. A leading cause of heart failure is: A. hypertensive heart disease. B. atrial fibrillation. C. pulmonary embolism. D. type 2 diabetes.

98. Bacterial pathogens implicated in causing acute bronchitis include all of the following except: A. S. pneumoniae. B. M. pneumoniae. C. C. pneumoniae. D. B. pertussis.

99. A 34-year-old woman presents with a 7-day history of cough with no fever or difficulty breathing. She is otherwise healthy. She is producing small amounts of yellow-tinged sputum. As part of her treatment, you recommend: A. an antitussive. B. an antihistamine. C. a macrolide antimicrobial. D. a beta-lactam antimicrobial.

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