Abdominal & Cardiac Test Bank
When a patient is suspected of having acute pancreatitis, initial testing should include all of the following except: A) Electrolyte panel B) Serum amylase level C) Serum lipase level D) Barium swallow
D) Barium swallow When a patient has acute abdominal pain, initial labs performed are serum electrolytes, amylase, and lipase. Barium swallow would not be performed initially.
The most current Eighth Joint National Committee (JNC 8) recommendation for the blood pressure goal in diabetics is: A) <140/90 mmHg B) <130/85 mmHg C) <130/80 mmHg D) <125/75 mmHg
A) <140/90 mmHg The Eighth Joint National Committee (JNC 8) blood pressure goal for adults and older adults 60 years of age or older who have diabetes (with or without chronic kidney disease) is blood pressure less than 140/90. In addition, all patients with hypertension should have lifestyle intervention (i.e., weight loss, smoking cessation, healthy diet), which should be continued throughout treatment.
According to the guidelines outlined in the Eighth Joint National Committee (JNC 8) the target blood pressure goal for hypertensive patients who are aged 60 years or older is: A) <150/90 mmHg B) <130/85 mmHg C) <120/80 mmHg D) <110/75 mmHg
A) <150/90 mmHg For the general population (no diabetes or chronic kidney disease) the recommended systolic blood pressure (SBP) goal at age 60 years or older goes up by 10 mmHg to blood pressure less than 150/But if the patient is a diabetic and/or has chronic kidney disease, then the blood pressure goal does not change and continues at blood pressure less than 140/90.
An 80-year-old man with hypertension and hyperlipidemia presents with complaints of the rapid onset of severe low-back pain accompanied by abdominal pain that is gradually worsening. The patient appears pale and complains that he does not feel well. During the abdominal exam, the nurse practitioner detects a soft pulsatile mass just above the umbilicus as she palpates this area with her hand. Which of the following conditions is most likely? A) Abdominal aortic aneurysm B) Cauda equina syndrome C) Acute diverticulitis D) Adenocarcinoma of the colon
A) Abdominal aortic aneurysm Elderly males who are ex-smokers are at higher risk for abdominal aortic aneurysm. The aneurysm is usually asymptomatic and is discovered incidentally during a routine chest x-ray or abdominal ultrasound. Although small aneurysms are usually not detectable during abdominal exams, the larger aneurysms may be palpable during an abdominal exam, but abdominal obesity will obscure the findings. The symptoms in this case point toward a rapidly dissecting aneurysm. The best action is to call 911 stat.
A positive obturator sign might signify which of the following conditions? A) Acute appendicitis B) Acute pancreatitis C) Acute cholecystitis D) Acute hepatitis
A) Acute appendicitis A positive obturator sign may indicate acute appendicitis. The test is performed with the patient supine. The examiner rotates the hip, using full range of motion. The test is positive if pain is experienced with movement or flexion of the hip.
Cullen's sign is most commonly associated with which of the following? A) Acute pancreatitis B) Myocardial infarction C) Acute pyelonephritis D) Preeclampsia
A) Acute pancreatitis Cullen's sign is commonly seen in acute pancreatitis. It refers to a yellowish-blue skin color change around the umbilicus. It is thought to occur due to the pancreatic enzymes that run along the ligament and subcutaneous tissues around the umbilicus.
Grey-Turner's sign is highly suggestive of which of the following conditions? A) Acute pancreatitis B) Acute appendicitis C) Acute diverticulitis D) Gastric cancer
A) Acute pancreatitis Grey-Turner's sign is the acute onset of bluish discoloration located on the flank area that is caused by bruising. It is usually associated with severe acute pancreatitis, but it can also be found in some cases of ruptured ectopic pregnancy.
All of the following are possible causes for secondary hypertension except: A) Acute pyelonephritisB) PheochromocytomaC) Renovascular stenosis D) Coarctation of the aorta
A) Acute pyelonephritis Acute pyelonephritis does not involve any vascular change; however, chronic pyelonephritis (reflux nephropathy) is a factor for secondary hypertension. Pheochromocytoma is a rare tumor of the adrenal glands that results in a release of too much epinephrine and norepinephrine, hormones that control heart rate, metabolism, and blood pressure. Renovascular stenosis is a narrowing of one or both arteries leading to the kidneys. It can cause severe hypertension and irreversible kidney damage. Coarctation of the aorta is a congenital heart defect of the aorta; it is a narrowing of the aorta that causes the heart to work harder to get blood to flow through the narrow aortic passageway to other organs, which, in turn, causes an increase in blood pressure.
Rovsing's sign is associated with which of the following? A) An acute abdomen, such as during a ruptured appendix B) Knee instability C) Damage to the meniscus of the knee D) Acute cholelithiasis
A) An acute abdomen, such as during a ruptured appendix Rovsing's sign identifies an acute abdomen, such as occurs in acute appendicitis. With the patient in the supine position, the examiner palpates deep into the left lower quadrant of the abdomen. The maneuver is positive if pain is referred to the right lower quadrant.
A 55-year-old male patient describes an episode of chest tightness in his substernal area that radiated to his back while he was jogging. It was relieved immediately when he stopped. The patient's symptoms are highly suggestive of what condition? A) Angina pectoris B) Acute myocardial infarction C) Gastroesophageal reflux disease D) Acute costochondritis
A) Angina pectoris The classic pain of angina is described as discomfort, pressure, tightness, or heaviness on the center or left side of the chest that is precipitated by exertion and relieved by rest. The pain can be referred to the back, shoulders, neck, or jaw. The pain is not sharp, knife-like, or stabbing in nature. Angina is caused by transient myocardial ischemia. The most common cause of angina is coronary artery disease. If the angina worsens, is not relieved by rest, or lasts more than 20 minutes, it may be due to acute myocardial infarction (MI). If acute MI is suspected, call 911.
Which of the following drugs does the Eighth Joint National Committee (JNC 8) 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults recommend for the initial treatment for White adults with microalbuminuria? A) Angiotensin-converting enzyme (ACE) inhibitors B) Diuretics C) Calcium channel blockers D) Beta-blockers
A) Angiotensin-converting enzyme (ACE) inhibitors According to the Eighth Joint National Committee (JNC 8; James et al., 2014), non-Black and Black hypertensive patients with chronic kidney disease (i.e., microalbuminuria) with or without diabetes can be treated with either angiotensin-converting enzyme (ACE) inhibitors or an angiotensin receptor blocker (ARB), alone or in combination with another drug class. The blood pressure goal for adults and older adults from this risk group is blood pressure less than 140/90 mmHg.
A medium-pitched harsh mid-systolic murmur is best heard at the right second intercostal space of the chest. It radiates into the neck. Which of the following is the correct diagnosis? A) Aortic stenosis B) Pulmonic stenosis C) Aortic regurgitation D) Mitral stenosis
A) Aortic stenosis The murmur associated with aortic stenosis can be auscultated as harsh and high pitched in the right second intercostal space. It typically radiates to the carotid arteries and apex.
You can determine a pulse deficit by counting the: A) Apical and radial pulses at the same time, then finding the difference between the two B) Apical pulse first, then the radial pulse, and subtracting to find the difference between the two C) Apical pulse and the femoral pulse at the same time and finding the difference between the two D) Radial pulse first, then counting the femoral pulse, and subtracting to find the difference between the two
A) Apical and radial pulses at the same time, then finding the difference between the two The pulse deficit is the difference between the apical pulse and the radial pulse. These should be taken at the same time, which will require that two people take the pulse: one with a stethoscope and one at the wrist. Count for 1 full minute. Then subtract the radial from the apical.
While doing a cardiac exam on a 45-year-old man, you note an irregular rhythm with a pulse rate of 110 beats/min. The patient is alert and is not in distress. What is the most likely diagnosis? A) Atrial fibrillation B) Ventricular fibrillation C) Cardiac arrhythmia D) First-degree right bundle branch block
A) Atrial fibrillation Atrial fibrillation is chaotic electrical activity of the heart, caused by several ectopic foci in the atria without any signs of distress. There are three pathological irregular rhythms: (1) ectopic beats (may be atrial, junctional, or ventricular), (2) atrial fibrillation, and (3) second-degree heart block. All are confirmed by EKG.
Which of the following is a true statement regarding acute gastritis? A) Chronic intake of nonsteroidal anti-inflammatory drugs (NSAIDs) can cause the disorder B) Chronic lack of dietary fiber is the main cause of the disorder C) The screening test for the disorder is the barium swallow test D) The gold standard to evaluate the disorder is a colonoscopy
A) Chronic intake of nonsteroidal anti-inflammatory drugs (NSAIDs) can cause the disorder Signs and symptoms of gastritis are nausea/vomiting, upset stomach, loss of appetite, and burning/aching or gnawing pain located in the epigastric area. Nonselective NSAIDs (aspirin, ibuprofen, naproxen, others) have adverse effects on the gastrointestinal (GI) tract, kidneys, central nervous system, and cardiovascular effects, and decrease platelet aggregation (aspirin). Chronic use of nonselective NSAIDs disrupts the production of prostaglandins, which involves cycloxygenase-1 (COX-1) and COX-2. The GI mucosa uses COX-1 to produce mucosal protective factors. Blocking COX-1 decreases these protective factors and increases risk of gastritis, ulcers, and GI bleeding. Selective NSAIDs, such as celecoxib (Celebrex), do less damage to the GI tract because they block only COX-2, which is responsible for pain and inflammation.
An adult patient was recently discharged from the hospital with a prescription 597 of clindamycin. The patient reports that he took his last dose yesterday. He presents in the primary care clinic with complaints of the recent onset of watery diarrhea from 10 to 15 times a day with abdominal cramping. He denies fever and chills. Which of the following conditions is most likely in this patient? A) Clostridium difficile-associated diarrhea B) GiardiasisC) Pseudomembranous colitisD) Irritable bowel syndrome
A) Clostridium difficile-associated diarrhea An important risk factor for 699 Clostridium difficile-associated diarrhea (CDAD) and C. difficile colitis is antibiotic therapy and hospitalization. Almost any antibiotic can cause the condition, but the most common are clindamycin, cephalosporins, and fluoroquinolones. Diarrhea can occur during therapy as well as after therapy (5-10 days; up to 10 weeks). Pseudomembranous colitis is a complication of C. difficile colitis.
The S1 heart sound is caused by: A) Closure of the atrioventricular valves B) Closure of the semilunar valves C) Opening of the atrioventricular valves D) Opening of the semilunar valves
A) Closure of the atrioventricular valves A heart valve normally allows blood to flow in only one direction. A heart valve opens or closes incumbent upon differential blood pressure on each side. A form of heart disease occurs when a valve malfunctions and allows some blood to flow in the wrong direction. The S1 heart sound is caused by turbulence caused by the closure of mitral and tricuspid valves at the start of systole.
All the following signs and symptoms are associated with irritable bowel syndrome except: A) Diarrhea with blood mixed in the stool B) Diarrhea and/or constipation C) Abdominal pain relief after defecation D) Mucus with stools
A) Diarrhea with blood mixed in the stool Irritable bowel syndrome (IBS) is considered a functional disorder because the colon tissue is normal. There is no inflammation or bleeding in IBS. Patients report chronic abdominal pain, flatulence, bloating, and changes in bowel movements. IBS is more common in women than men. Rectal bleeding, blood in stool, anemia, fatigue, and weight loss are associated with inflammatory bowel disease (IBD), such as Crohn's disease or ulcerative colitis.
A nurse practitioner is taking part in a community outreach program for a local hospital. Most of her audience has a diagnosis of hypertension. They are all interested in learning more about a proper diet. When discussing potential sources of potassium and magnesium, which of the following are the best sources for these two minerals? A) Fruits, leafy greens, and nuts B) Whole grains, red meat, and dairy C) Bananas, beef, and yogurt D) Mushrooms, fermented foods, and vegetables
A) Fruits, leafy greens, and nuts The best sources of both potassium and magnesium are fruits (bananas, cantaloupe, papaya, kiwi), leafy greens (spinach, kale, chard), and nuts (cashews, almonds, walnuts, peanuts).
A 21-year-old new mother reports that she has been feeling irritable and jittery almost daily for the past few months. She complains of frequent palpitations and more frequent bowel movements along with weight loss. Her blood pressure is 160/70 mmHg, pulse is 110 beats/min, and she is afebrile. All of the following conditions should be considered in the differential diagnosis for this patient except: A) Mitral regurgitation B) Graves' disease C) Generalized anxiety disorder D) Illicit drug use
A) Mitral regurgitation Signs and symptoms of mitral regurgitation do not include frequent bowel movements with weight loss.
A 20-year-old woman reports that for several years, she has had random episodes of palpitations and shortness of breath that resolve spontaneously. She denies chest pain, arm pain, and syncope. Her past medical and family histories are negative for coronary artery disease, stroke, or lung disease. During the cardiac exam, the nurse practitioner notices a grade 3/6 murmur that is accompanied by a mid-systolic click, which is heard best heard at the apical area. The apical pulse is 78 beats/min, blood pressure is 120/60 mmHg, and temperature is 98.6°F. The cardiac exam is highly suggestive of which of the following conditions? A) Mitral valve prolapse B) Aortic stenosis C) Atrial septal defect D) Pulmonary regurgitation
A) Mitral valve prolapse A systolic murmur that is accompanied by a mid systolic click located at the apical area is a classic finding of mitral valve prolapse (MVP). Most cases of MVP are asymptomatic. To detect MVP, order an echocardiogram with Doppler imaging.
When evaluating the blood pressure on both the arms and legs of an infant who has a diagnosis of coarctation of the aorta, which of the following is the correct finding? A) The blood pressure is higher in the arms than in the legs B) Only the diastolic blood pressure is higher in the legs than in the arms C) The blood pressure is higher in the legs than the arms D) The blood pressure is lower in both arms than in the legs
A) The blood pressure is higher in the arms than in the legs In coarctation of the aorta, blood pressure is higher in the arms than in the legs due to the narrowing in the aorta. Blood pressure must rise to get adequate blood flow to the lower extremities; therefore, the blood pressure above the coarctation rises to compensate for this.
An urgent care nurse practitioner is assessing a 45-year-old White woman with a body mass index (BMI) of 32 for a complaint of intermittent right upper quadrant abdominal pain over the past few weeks that is precipitated by eating fried foods and peanut butter. On exam, the patient's heart and lungs are normal. There is no pain over the costovertebral angle. During abdominal exam, bowel sounds are present in all quadrants. While the nurse is palpating deeply on the right upper quadrant during deep inspiration, the patient complains of severe sharp pain. Which of the following is best described? A) Murphy's sign B) McMurray's sign C) Rovsing's sign D) Obturator sign
A) Murphy's sign Murphy's sign is suggestive of acute cholecystitis and gallbladder disease. It is elicited by palpating the subcostal region on the right upper abdomen; in response, the patient abruptly stops inspiration because of the severe pain.
Which of the following is an accurate description of eliciting Murphy's sign? A) On deep inspiration by the patient, palpate firmly in the right upper quadrant of the abdomen below the costovertebral angle B) Bend the patient's hips and knees at 90 degrees, then passively rotate the hip externally, and internally C) Ask the patient to squat, then place the stethoscope on the apical area D) Press into the abdomen deeply, then release it suddenly
A) On deep inspiration by the patient, palpate firmly in the right upper quadrant of the abdomen below the costovertebral angle Murphy's sign is tested during an abdominal examination for biliary disorders. As the patient breathes in, the abdominal contents are pushed downward as the diaphragm moves down and the lungs expand. As the patient stops/hold the breath, the gallbladder comes in contact with the examiner's fingers and may elicit pain. To be considered positive, the same maneuver must not elicit pain when performed on the left side. A negative Murphy's test in the elderly is not useful for ruling out cholecystitis if history and other tests suggest the diagnosis.
A 21-year-old woman complains to you of a 1-week episode of dysuria, frequency, and a strong odor to her urine. This is her second episode of the year. The previous urinary tract infection occurred 3 months ago. What is the most appropriate followup for this patient? A) Order a urinalysis and urine for culture and sensitivity (C&S), and treat the patient with antibiotics B) Order a urine C&S and hold treatment until you get the results from the lab C) Treat the patient with a 7-day course of antibiotics and order a urine C&S now and after she completes her antibiotics D) Treat the patient with a stronger drug, such as ofloxacin (Floxin), for 10 days
A) Order a urinalysis and urine for culture and sensitivity (C&S), and treat the patient with antibiotics Because this is the second urinary tract infection for the year and the last episode was 3 months ago, the best action is to order the urinalysis and urine C&S to identify the organism causing the infection. Antimicrobial-resistant strains are increasing. Start empiric treatment with an antibiotic for 7-day duration (do not use 3-day regimen).
A 55-year-old woman who has had type 2 diabetes for 20 years is concerned about her kidneys. She has a history of three urinary tract infections (UTIs) within the past 8 months, but is currently asymptomatic. Which of the following is the best course to follow? A) Recheck urine during the visit, send a urine specimen for culture and sensitivity, and refer to a nephrologist B) Order a urinalysis dipstick test to be repeated monthly C) Order a CT scan of the kidneys D) Provide empiric treatment for a UTI
A) Recheck urine during the visit, send a urine specimen for culture and sensitivity, and refer to a nephrologist Although the patient is currently asymptomatic, her history of three urinary tract infections (UTIs) in 8 months warrants testing while she is in the office. A UTI is defined as the presence of 100,000 organisms per milliliter of urine in asymptomatic patients or greater than 100 organisms per milliliter of urine with pyuria (>7 WBCs/mL) in a symptomatic patient. Diabetic patients are at higher risk for UTIs and over time may develop bladder damage (cystopathy) and nephropathy. A nephrology consult is prudent.
Lifestyle modifications are an important aspect in the treatment of 560 hypertension. Which of the following statements is incorrect? A) Reduce intake of sodium, potassium, and calcium B) Reduce intake of sodium and saturated fats C) Exercise at least three to four times per week D) Maintain an adequate intake of potassium, magnesium, and calcium
A) Reduce intake of sodium, potassium, and calcium Lifestyle modifications for hypertension include exercise three to four times a week, diet modifications of reduced intake of sodium and saturated fats, and adequate dietary intake of potassium, magnesium, and calcium.
The bell of the stethoscope is best used for auscultation of which of the following? A) S3 and S4 and low-pitched tones B) S3 and S4 only C) S1 and S2 and high-pitched tones D) S1 and S2 only
A) S3 and S4 and low-pitched tones The bell is most useful for picking up low- pitched sounds; for example, S3, S4, and mitral stenosis. The diaphragm is most useful for picking up high-pitched sounds; for example, S1, S2, aortic or mitral regurgitation, and pericardial friction rubs.
Which of the following laboratory values may be elevated on the liver function panel of patients who are alcohol abusers? A) Serum GGT (gamma glutamyl transaminase) B) Serum creatinine C) Serum bilirubin D) Blood urea nitrogen
A) Serum GGT (gamma glutamyl transaminase) The serum gamma 687 glutamyl transaminase may become elevated in patients who are alcohol abusers.It can be used to screen for chronic alcohol abuse and occult alcoholism. The GGT can become elevated in liver disease and bile duct obstruction. It is a sensitive test for detecting obstructive jaundice, cholangitis, and cholecystitis.
If left untreated, Zollinger-Ellison syndrome can cause which of the following? A) Severe ulceration of the stomach or duodenum B) Toxic megacolon C) Chronic diarrhea D) Malabsorption of fat-soluble vitamins
A) Severe ulceration of the stomach or duodenum Zollinger-Ellison syndrome occurs when tumors (gastrinomas) in the intestine, pancreas, or lymph nodes near the pancreas produce excessive amounts of gastrin, which, in turn, increases the amount of acid produced by the stomach. High amounts of acid in the stomach produce ulcers of the stomach or duodenum. Untreated Zollinger-Ellison syndrome can lead to severe ulceration of the stomach or duodenum.
When evaluating the blood pressure on both the arms and legs of an infant who has a diagnosis of coarctation of the aorta, which of the following is the correct finding? A) The blood pressure is higher in the arms than in the legs B) Only the diastolic blood pressure is higher in the legs than in the arms C) The blood pressure is higher in the legs than the arms D) The blood pressure is lower in both arms than in the legs
A) The blood pressure is higher in the arms than in the legs In coarctation of the aorta, blood pressure is higher in the arms than in the legs due to the narrowing in the aorta. Blood pressure must rise to get adequate blood flow to the lower extremities; therefore, the blood pressure above the coarctation rises to compensate for this.
During the physical exam of a 60-year-old adult, the nurse practitioner performs an abdominal exam. The nurse practitioner is checking the left upper quadrant of the abdomen. During percussion, an area of dullness is noted beneath the lower left ribcage. Which of the following is a true statement regarding the spleen? A) The spleen is not palpable in the majority of healthy adults B) The spleen is 8 to 10 cm in the left midaxillary line at its longest axis C) The spleen is 2 to 6 cm between the 9th and 11th ribs on the left midaxillary line D) The splenic size varies depending on the patient's gender
A) The spleen is not palpable in the majority of healthy adults The spleen is located in the left upper quadrant of the abdomen under the diaphragm and is protected by the lower ribcage. In the majority of adults, it is not palpable. The spleen's longest axis is 11 to 20 cm. Any spleen larger than 20 cm is enlarged. The best test for evaluating splenic (or hepatic) size is the abdominal ultrasound. Disorders that can cause splenomegaly include mononucleosis, sickle cell disease, congestive heart failure, bone marrow cancers (myeloma, leukemia), and several other diseases.
The span of the normal adult liver is: A) 15 to 18 cm in the midclavicular line B) 6 to 15 cm in midclavicular line C) 2 to 6 cm in the midsternal line D) 4 to 8 cm in the midsternal line
B) 6 to 15 cm in the midclavicular line This range is generally less than 12 cm, but 6 to 15 cm is considered normal for adults.
A positive psoas and obturator sign is highly suggestive of which of the following conditions? A) Ectopic pregnancy B) Acute appendicitis C) PeritonitisD) Abdominal aortic aneurysm
B) Acute appendicitis Both the psoas and obturator signs are associated with acute appendicitis. When the appendix becomes inflamed or ruptured, the blood and pus irritate the psoas and/or obturator muscles, which are both located in the retroperitoneal area. Both muscles are hip flexors and assist with hip movement.
Extreme tenderness and involuntary guarding at McBurney's point is a significant finding for possible: A) Acute cholecystitis B) Acute appendicitis C) Acute gastroenteritis D) Acute diverticulitis
B) Acute appendicitis Symptoms of an acute abdomen, such as appendicitis, include extreme tenderness and involuntary guarding at McBurney's point. McBurney's point is the name given to the point over the right side of the abdomen that is one third of the distance (approximately 2 inches) from the anterior superior iliac spine to the umbilicus. This point roughly corresponds to the most common location of the base of the appendix where it is attached to the cecum. (During pregnancy the location of the appendix changes as the uterus grows.)
A 68-year-old woman with hypertension and diabetes is seen by the nurse 529 practitioner for a dry cough that worsens at night when she lies in bed. She has shortness of breath, which worsens when she exerts herself, and has gained 6 lbs during the past 2 months. Her pulse rate is 90 beats/min and regular. She is on a nitroglycerine patch and furosemide daily. The best explanation for her symptoms is: A) Kidney failure B) Congestive heart failure C) ACE inhibitor-induced coughing D) Thyroid disease
B) Congestive heart failure In congestive heart failure (CHF), the heart's ventricular function is inadequate. Symptoms include fatigue, diminished exercise capacity, shortness of breath, hemoptysis, cough, orthopnea, hypertension, nocturnal dyspnea, and edema. The kidneys begin to lose their normal ability to excrete sodium and water, leading to fluid retention. Lung congestion/pulmonary edema causes shortness of breath and a decreased ability to tolerate exercise.
A homeless 47-year-old man with a history of injection drug use and alcohol abuse presents to the public health clinic with a recent history of fever, night sweats, fatigue, and weakness. The patient has recently noticed some thin red streaks on his nailbed and red bumps on some of his fingers that hurt. During the cardiac exam, the nurse practitioner hears a grade 3/6 murmur over the mitral area. The subcutaneous red-purple nodules are tender to palpation. The thin red lines on the nailbeds resemble subungual splinter hemorrhages. Which of the following conditions is most likely? A) Pericarditis B) C) D) Acute bacterial endocarditis Rheumatic fever Viral cardiomyopathy
B) Acute bacterial endocarditis Bacterial endocarditis is also known as infective endocarditis (IC). It is a serious bacterial infection of the heart valves and the endocardial surface. The bacteria most commonly involved are Staphylococcus and Streptococcus species. Subcutaneous red painful nodules on the finger pads are called Osler's nodes. Subungual splinter hemorrhages on the nailbeds are caused by microemboli. Janeway's lesions are caused by bleeding under the skin (usually located on the palms and the soles) and are painless red papules and macules. Other findings are conjunctival hemorrhages, petechiae, cardiac friction rubs, arrhythmias, murmurs, and others. Three blood cultures obtained at separate sites 1 hour apart are used to identify the causative organism. Some of the risk factors are damaged prosthetic valves, history of rheumatic fever, and injection drug use.
You notice a medium-pitched harsh systolic murmur during an episodic examination of a 37-year-old woman. It is best heard at the right upper border of the sternum. What is most likely? A) Mitral stenosis B) Aortic stenosis C) Pulmonic stenosis D) Tricuspid regurgitation
B) Aortic stenosis One of the most frequent pathological systolic murmurs is due to aortic stenosis. The murmur of aortic stenosis is typically a mid-systolic ejection murmur, heard best over the "aortic area" or right second intercostal space, with radiation into the right neck. It has a harsh quality and may be associated with a palpably slow rise of the carotid upstroke. Additional heart sounds, such as an S4, may be heard secondary to hypertrophy of the left ventricle, which is caused by the greatly increased work required to pump blood through the stenotic valve.
A 63-year-old patient with a 10-year history of poorly controlled hypertension 511 presents with a cluster of physical exam findings. Which of the following clusters indicates the target organ damage commonly seen in hypertensive patients? A) Pedal edema, hepatomegaly, and enlarged kidneys B) Arteriovenous (AV) nicking, left ventricular hypertrophy, and stroke C) Renal infection, S3 heart sound, neuromuscular abnormalities D) Glaucoma, jugular vein atrophy, heart failure
B) Arteriovenous (AV) nicking, left ventricular hypertrophy, and stroke AV 636 nicking and copper wire/silver wire arterioles are signs of hypertensive retinopathy, left ventricular hypertrophy affects the heart, and stroke damages the brain. These are all examples of target organ damage.
A 63-year-old patient with a 10-year history of poorly controlled hypertension presents with a cluster of physical exam findings. Which of the following clusters indicates the target organ damage commonly seen in hypertensive patients? A) Pedal edema, hepatomegaly, and enlarged kidneys B) Arteriovenous (AV) nicking, left ventricular hypertrophy, and stroke C) Renal infection, S3 heart sound, neuromuscular abnormalities D) Glaucoma, jugular vein atrophy, heart failure
B) Arteriovenous (AV) nicking, left ventricular hypertrophy, and stroke AV nicking and copper wire/silver wire arterioles are signs of hypertensive retinopathy, left ventricular hypertrophy affects the heart, and stroke damages the brain. These are all examples of target organ damage.
A new patient is being interviewed by the nurse practitioner. The patient reports that she had a gastrectomy procedure 5 years ago to treat severe obesity. Currently, her body mass index (BMI) is 25 and the patient denies complications from the procedure. The nurse practitioner is aware that the patient is at higher risk for which of the following disorders? A) Folate deficiency anemia B) B12-deficiency anemia C) Iron-deficiency anemia D) Normocytic anemia
B) B12-deficiency anemia Intrinsic factor is made by the parietal cells, which are located on the fundus of the stomach. Intrinsic factor is needed to effectively absorb vitamin B12 (found in dairy and meat). Because the gastric fundus is damaged in patients who have undergone gastrectomy, they are at higher risk of B12-deficiency anemia (mean corpuscular volume [MCV] >100).
A 56-year-old mechanic is brought to your office complaining of heavy pressure 568 in the substernal area of his chest that is radiating to his jaw. The pain began while he was lifting up a tire. He now appears pale and is diaphoretic. His blood pressure is 100/60 mmHg, and his pulse is 50 beats/min. What is the most appropriate action? A) Perform a 12-lead EKG B) Call 911 C) Administer a morphine injection for pain D) Observe the patient in the office
B) Call 911 Heavy chest pressure in the substernal area radiating to the jaw, diaphoresis, low blood pressure, and bradycardia are signs of cardiac distress. This patient is exhibiting classic symptoms of a myocardial infarction and needs immediate treatment. Call 911 immediately and transfer the patient to the emergency department.
What is the most common cause of left ventricular hypertrophy in the United 544 States? A) Chronic atrial fibrillation B) Chronic hypertension C) Mitral valve prolapse D) Pulmonary hypertension
B) Chronic hypertension Left ventricular hypertrophy develops in response to some factor, such as high blood pressure, that requires the left ventricle to work harder. As the workload increases, the walls of the chamber grow thicker, lose elasticity, and eventually may fail to pump with as much force as a healthy heart. High blood pressure, a blood pressure reading greater than 140/90 mmHg, is the greatest risk factor.
The S2 heart sound is caused by: A) Closure of the atrioventricular valves B) Closure of the semilunar valves C) Opening of the atrioventricular valves D) Opening of the semilunar valves
B) Closure of the semilunar valves A heart valve normally allows blood to flow in only one direction. A heart valve opens or closes incumbent upon differential blood pressure on each side. A form of heart disease occurs when a valve malfunctions and allows some blood to flow in the wrong direction. The S2 sound results from reverberation within the blood associated with the sudden block of flow reversal.
A 68-year-old woman with hypertension and diabetes is seen by the nurse practitioner for a dry cough that worsens at night when she lies in bed. She has shortness of breath, which worsens when she exerts herself, and has gained 6 lbs during the past 2 months. Her pulse rate is 90 beats/min and regular. She is on a nitroglycerine patch and furosemide daily. The best explanation for her symptoms is: A) Kidney failure B) Congestive heart failure C) ACE inhibitor-induced coughing D) Thyroid disease
B) Congestive heart failure In congestive heart failure (CHF), the heart's ventricular function is inadequate. Symptoms include fatigue, diminished exercise capacity, shortness of breath, hemoptysis, cough, orthopnea, hypertension, nocturnal dyspnea, and edema. The kidneys begin to lose their normal ability to excrete sodium and water, leading to fluid retention. Lung congestion/pulmonary edema causes shortness of breath and a decreased ability to tolerate exercise.
A 55-year-old male patient describes an episode of chest tightness in his substernal area that radiated to his back while he was jogging. It was relieved immediately when he stopped. Which of the following would you recommend to this 55-year-old patient? A) Start an exercise program with walking instead of jogging B) Consult with a cardiologist for further evaluation C) Consult with a gastroenterologist to rule out acute cholecystitis D) Take ibuprofen (Advil) 600 mg for pain every 4 to 6 hours as needed
B) Consult with a cardiologist for further evaluation Blood tests that indicate tissue damage to the heart include troponin and creatine phosphokinase (CPK). Testing ordered should include EKG, nuclear stress test/stress echocardiogram, and coronary angiography. The patient would need a cardiology consultation for abnormal and/or invasive tests.
A woman who is in the third trimester of pregnancy presents to the nurse practitioner for a physical exam. During the physical exam, the nurse practitioner finds all of the following cardiac changes associated with pregnancy except: A) Systolic ejection murmur B) Diastolic murmur C) Displaced apical impulse D) Louder S1 and S2
B) Diastolic murmur Diastolic murmurs are more likely to be pathological. The heart is displaced in a more transverse position that is lateral to the midclavicular line. The systolic ejection murmur is due to increased stroke volume caused by increased cardiac output and higher basal heart rate.
A 21-year-old woman who is complaining of random palpitations is diagnosed with mitral valve prolapse (MVP). Her echocardiogram reveals thickened leaflets. You note a grade 3/6 systolic murmur with an ejection click during physical examination. You would advise her that: A) Endocarditis prophylaxis is recommended for most dental and urological procedures B) C) D) Endocarditis prophylaxis is not necessaryShe requires lifetime anticoagulation therapy with warfarin sodium Endocarditis prophylaxis is recommended for dental procedures only
B) Endocarditis prophylaxis is not necessary Prophylaxis treatment for endocarditis is no longer recommended for patients with mitral valve prolapse (MVP).
Which of the following laboratory tests is a sensitive test for evaluating renal function? A) Electrolyte panel B) Estimated glomerular filtration rate (eGFR) C) Creatinine D) Blood urea nitrogen (BUN)
B) Estimated glomerular filtration rate (eGFR) The estimated glomerular filtration rate (GFR) is a sensitive test used to measure and monitor kidney function and evaluate chronic kidney disease (CKD). GFR can be estimated from serum creatinine. The estimated GFR calculation uses serum creatinine along with age and values assigned for gender and race. The National Kidney Foundation has determined different stages of CKD based on the value of estimated GFR.
A high school teacher complains of a dry cough for the past 6 weeks. It worsens when he is supine. He has episodes of nausea and heartburn, which he self-treats with an over-the-counter (OTC) antacid. He chews mints for his "bad breath." Which of the following is a possible cause for this patient's cough? A) AsthmaB) Gastroesophageal reflux C) PneumoniaD) Chronic postnasal drip
B) Gastroesophageal reflux Classic signs of gastroesophageal reflux disease (GERD) include acid reflux (regurgitation) into the esophagus, heartburn, and nausea. Complications include ulcers, esophageal strictures, Barrett's esophagus, cough, asthma, and throat or laryngeal inflammation. Risk factors include obesity, pregnancy, smoking, and alcohol use.
Which of the following conditions is the most common cause of sudden death 556 among young athletes? A) Brain aneurysm B) Hypertrophic cardiomyopathy C) Left ventricular hypertrophy D) Aortic stenosis
B) Hypertrophic cardiomyopathy Congenital cardiovascular disease is the leading cause of nontraumatic sudden athletic death, with hypertrophic cardiomyopathy being the most common cause. Despite public perception to the contrary, sudden death in young athletes is exceedingly rare. It most commonly occurs in male athletes, who have estimated death rates nearly fivefold greater than the rates of female athletes.
A 75-year-old woman presents complaining of a soft lump on her abdomen that is located on the periumbilical area. She tells the nurse practitioner that she does not know how long she has had the lump or whether it has changed in size or shape. She denies abdominal pain, problems with defecation, loss of appetite, weight loss, or trauma. When performing an abdominal exam, what is the best method to differentiate an abdominal wall mass from an intra-abdominal mass? A) Palpate the abdominal wall while the patient is relaxedB) Instruct the patient to lift her head off the table while tensing her abdominal muscles to visualize any masses and then palpate the abdominal wallC) Instruct the patient to lie still for a few seconds while you palpate the abdominal wallD) Palpate the abdomen deeply, then release the palpating hand quickly
B) Instruct the patient to lift her head off the table while tensing her abdominal muscles to visualize any masses and then palpate the abdominal wall An abdominal wall mass will become more prominent when the abdominal wall muscles are tense. If it is an intra-abdominal mass, it will be pressed down by the muscles and will become less obvious or disappear. Some of the most common abdominal wall masses are hernias (epigastric, umbilical, incisional). This patient has a periumbilical hernia (soft lump on her abdomen that is located on the periumbilical area that is painless).
On auscultation of the chest, a split S2 is best heard at: A) Second intercostal space, right sternal border B) Second intercostal space, left sternal border C) Fifth intercostal space, midclavicular line D) Fourth intercostal space, left sternal border
B) Second intercostal space, left sternal border The S2 heart sound results from closure of the aortic and pulmonic valves. The right ventricular systolic ejection time is longer than the left, so the pulmonic valve closes slightly later than the aortic valve. The slightly different closing times of the valves make the S2 heart sound. It is heard best using the diaphragm of the stethoscope.
A 67- year-old retired clerk presents with complaints of fatigue, shortness of breath, and weight gain over a 2-week period. A nonproductive cough accompanies her symptoms. She reports that climbing up the stairs worsens her dyspnea. The lung exam is positive for fine crackles in the lower lobes with no wheezing. An S3 heart gallop is noted. Which of the following conditions is most likely? A) Acute exacerbation of asthma B) Left-sided heart failure C) Right-sided heart failure D) Chronic obstructive pulmonary disease
B) Left-sided heart failure During left-sided heart failure, the left ventricle cannot pump with enough force to push the blood into the lungs and circulation. Signs and symptoms of left-sided heart failure include dyspnea on exertion, fatigue at rest or with minimal exertion, generalized weakness, orthopnea, and paroxysmal nocturnal dyspnea, cough, and edema. If pulmonary edema occurs, frothy or pink sputum with cough may be seen.
A 67- year-old retired clerk presents with complaints of fatigue, shortness of breath, and weight gain over a 2-week period. A nonproductive cough accompanies her symptoms. She reports that climbing up the stairs worsens her dyspnea. The lung exam is positive for fine crackles in the lower lobes with no wheezing. An S3 heart gallop is noted. Which of the following conditions is most likely? A) Acute exacerbation of asthma B) Left-sided heart failure C) Right-sided heart failure D) Chronic obstructive pulmonary disease
B) Left-sided heart failure During left-sided heart failure, the left ventricle cannot pump with enough force to push the blood into the lungs and circulation. Signs and symptoms of left-sided heart failure include dyspnea on exertion, fatigue at rest or with minimal exertion, generalized weakness, orthopnea, and paroxysmal nocturnal dyspnea, cough, and edema. If pulmonary edema occurs, frothy or pink sputum with cough may be seen.
During a routine physical exam of a 90-year-old woman, a low-pitched diastolic murmur grade 2/6 is auscultated. It is located on the fifth intercostal space (ICS) on the left side of the midclavicular line. Which of the following identifications is correct? A) Aortic regurgitation B) Mitral stenosis C) Mitral regurgitation D) Tricuspid regurgitation
B) Mitral stenosis The low-frequency rumbling murmur of mitral stenosis is mid-diastolic and with severity from a short decrescendo murmur to a longer crescendo murmur. It is best heard at the fifth intercostal space, 8 to 9 cm from the midsternal line, slightly medial to the midclavicular line, and does not radiate. Because it is low pitched, it is heard best with the bell of the stethoscope. Aortic regurgitation is a high-pitched diastolic murmur, heard at the second ICS to the right of the sternum. Mitral regurgitation is a pansystolic murmur that radiates to the axilla, and is loud and high pitched when auscultated.
An elderly woman has been taking digoxin (Lanoxin) for 10 years. Her EKG is showing a new onset of atrial fibrillation. Her pulse is 64 beats/min. She denies syncope and dizziness. Which of the following interventions is most appropriate? A) Order an electrolyte panel and a digoxin level B) Order a serum thyroid-stimulating hormone (TSH), digoxin level, and an electrolyte panel C) Order a serum digoxin level and decrease her digoxin dose by half while waiting for results D) Discontinue the digoxin and order another 12-lead EKG
B) Order a serum thyroid-stimulating hormone (TSH), digoxin level, and an electrolyte panel Obtaining baseline blood work to evaluate for causes of new-onset atrial fibrillation is recommended before decreasing or stopping medications. Thyroid disease is a common cause of new-onset atrial fibrillation.
A 40-year-old cashier complains of periods of dizziness and palpitations that have a sudden onset. The EKG shows P waves before each QRS complex and a heart rate of 170 beats/min. A carotid massage decreases the heart rate to 80 beats/min. These findings best describe: A) Ventricular tachycardia B) Paroxysmal atrial tachycardia C) Atrial fibrillation D) Ventricular fibrillation 567
B) Paroxysmal atrial tachycardia Signs and symptoms of paroxysmal atrial tachycardia include a rapid, regular heart rate that begins and ends very quickly. The atria are beating at a very fast rate, but it is not life-threatening. Ventricular tachycardia is usually associated with heart disease, occurs when the ventricles are beating rapidly and inefficiently, and can lead to death if not treated. Atrial fibrillation is an irregular heartbeat that can be life-threatening if not treated. Ventricular fibrillation occurs when the heartbeat is rapid and chaotic, and death will occur if the condition is not treated.
You note the following result on a routine urinalysis of a 37-year-old primigravida who is at 30 weeks gestation. Leukocyte = trace, nitrite = negative, protein = 2+, blood = negative. Her weight has increased by 5 lbs during the past week. Which of the following is most likely? A) HELLP syndrome B) Pregnancy-induced hypertension (preeclampsia) C) Eclampsia of pregnancy D) Primary hypertension
B) Pregnancy-induced hypertension (preeclampsia) This patient is manifesting the classic triad of symptoms of preeclampsia: hypertension, edema (weight gain), and proteinuria.
A 40-year-old White woman with a body mass index (BMI) of 32 complains of colicky pain in the right upper quadrant of her abdomen that gets worse if she eats fried food. During the physical exam, the nurse practitioner presses deeply on the left lower quadrant of the abdomen. After she releases her hand, the patient complains of pain on the right side of the lower abdomen. What is the name of this finding? A) Rebound tenderness B) Rovsing's sign C) Murphy's sign D) Psoas test
B) Rovsing's sign The Rovsing sign is right lower quadrant pain intensified by left lower quadrant abdominal pressure (i.e., pain referred to the opposite side of the abdomen after release of palpation). It is associated with peritoneal irritation and appendicitis.
A toddler with congenital heart disease is seen for a 1-week history of facial and lowerextremity edema accompanied by shortness of breath. The child's mother reports that the child's appetite has been poor. The chest x-ray reveals that the child has congestive heart failure (CHF). Which of the following heart sounds are found in patients with CHF? A) S1 and S2 B) S1, S2, and S3 C) S1, S2, and S4 D) Still's murmur and S4
B) S1, S2, and S3 Congestive heart failure (CHF) is the inability of the heart to pump a sufficient amount of blood to the organs to meet the body's requirements. It is common to hear S1, S2, and S3 heart sounds on exam. Common signs and symptoms of CHF include fatigue, shortness of breath with activity, and edema of lower extremities.
A middle-aged patient newly diagnosed with type 2 diabetes wants to start an 564 exercise program. All of the following statements are true except: A) If the patient is unable to eat due to illness, antidiabetic agents can be continued with frequent glucose monitoring B) Strenuous exercise is contraindicated for most patients with type 2 diabetes because of a higher risk of hypoglycemic episodes C) Exercise increases the body's ability to metabolize glucoseD) Patients who exercise vigorously in the afternoon may have hypoglycemic episodes in the evening or at night if they do not eat
B) Strenuous exercise is contraindicated for most patients with type 2 diabetes because of a higher risk of hypoglycemic episodes Exercise is recommended because exercise helps to use the glucose stores and reduce blood sugar. When exercising, the patient should monitor blood sugar closely, especially if using insulin, to avoid hypoglycemia.
A 70-year-old woman complains of left lower quadrant abdominal pain and fever for 2 days. Her blood pressure of 130/80 mmHg, pulse is 90 beats/min, respirations are 14 breaths/min, and temperature is 100.5°F. During the abdominal exam, the left lower quadrant of the abdomen is tender to palpation. The nurse practitioner (NP) does not palpate a mass; neither is there guarding or rigidity. Rovsing's sign is negative. Bowel sounds are present in all quadrants. The NP is familiar with the patient, who is alert and is asking appropriate questions about her condition. The nurse practitioner suspects that the patient has acute diverticulitis. Which of the following treatment plans is appropriate for this patient? A) The patient should be referred to the physician as soon as possibleB) The patient has a mild case of acute diverticulitis and can be treated with antibiotics in the outpatient setting with close follow-upC) This patient has a moderate to severe case of acute diverticulitis and needs to be admitted to the hospital for IV antibioticsD) The patient should be referred to the emergency department as soon as possible
B) The patient has a mild case of acute diverticulitis and can be treated with antibiotics in the outpatient setting with close follow-up The patient has a mild case of acute diverticulitis and can be treated as an outpatient with antibiotics and a clear fluid diet. If outpatient treatment is selected, close follow-up (within 24-48 hours) is very important. Instruct patients to go to the hospital if symptoms get worse, if fever increases, if unable to tolerate PO treatment, and if pain worsens. Order a complete blood count (to check for leukocytosis, neutrophils, and possible shift to the left), chemistry profile, and urinalysis (to rule out renal causes).
A split S2 heart sound is best heard at which of the following areas? A) The aortic area B) The pulmonic area C) The tricuspid area D) The mitral area
B) The pulmonic area The S2 heart sound is physiologically split in about 688 90% of people. The second heart sound is produced by the closure of the aorticand pulmonic valves. The sound produced by the closure of the aortic valve is termed A2, and the sound produced by the closure of the pulmonic valve is termed P2. The A2 sound is normally much louder than the P2 due to higher pressures in the left side of the heart; thus, A2 radiates to all cardiac listening posts (loudest at the right upper sternal border) and P2 is usually only heard at the left upper sternal border.
The nurse practitioner is evaluating patients who are at high risk for complications due to urinary tract infections (UTIs). Which of the following patients does not belong in this category? A) A 38-year-old diabetic patient with an A1C of 7.5% B) A woman with rheumatoid arthritis who is being treated with methotrexate and low-dose steroids C) A 21-year-old woman who has a history of irritable bowel syndrome D) A pregnant woman
C) A 21-year-old woman who has a history of irritable bowel syndrome Irritable bowel syndrome is not associated with higher risk for urinary tract infection (UTI). Risk factors for UTI are gender (female), pregnancy, spermicide use during the past year, having a mother with history of UTIs, having a new sex partner during the past year, urinary incontinence, and cystocele.
What is the best description of Cullen's sign? A) The onset of hyperactive bowel sound before the onset of ileus B) A reddish-purple discoloration that is located on the flank area C) A bluish discoloration or bruising that is located on the umbilical area D) The acute onset of subcutaneous bleeding seen during acute pancreatitis
C) A bluish discoloration or bruising that is located on the umbilical area Cullen's sign is the acute onset of bluish discoloration that is located on the umbilical/periumbilical area, caused by bruising underneath the skin. A bluish discoloration located on the flank area is called the Grey-Turner's sign. It is a sign of a severe case of pancreatitis.
Pulsus paradoxus is best described as: A) An increase in systolic blood pressure on inspiration B) A decrease in diastolic blood pressure on exhalation C) A decrease in systolic blood pressure on inspiration D) An increase in diastolic blood pressure on expiration
C) A decrease in systolic blood pressure on inspiration In patients with pulsus paradoxus, systolic pressure drops on inspiration due to the increased pressure (positive pressure). Some pulmonary risks of having increased pressure include asthma and emphysema.
During a routine physical exam of an 82-year-old woman, the nurse practitioner palpates an irregular mass on the midabdomen that is not tender and is about 2 cm in size. Which of the following is the best initial imaging test to further evaluate the abdominal mass? A) CT scan of the abdomen B) KUB study C) Abdominal ultrasound D) MRI of the abdomen
C) Abdominal ultrasound The ultrasound or sonogram is used as an initial imaging test for abdominal tumors and other types of masses. A CT scan is not considered an initial imaging test in the primary care area. But in many emergency departments, it is used as the initial imaging test in certain cases of abdominal trauma, suspected appendicitis, and other conditions.
Which of the following antihypertensive medications should the nurse practitioner avoid when treating patients with emphysema? A) Calcium channel blockers B) Angiotensin-converting enzyme (ACE) inhibitors C) Beta-blockers D) Diuretics
C) Beta-blockers Beta-blockers should be avoided in patients with a history of emphysema. Studies have shown evidence of a reduction in forced expiratory volume in 1 second (FEV1), increased airway hyperresponsiveness, and inhibition of bronchodilator response to beta agonists in patients receiving beta-blockers.
When the nurse practitioner is evaluating a patient for intermittent claudication, he or she would first: A) Order a venogram B) Order TED anti-embolism stockings C) Check the ankle and brachial blood pressures before and after exercise D) Check the pedal and posterior tibial pulses
C) Check the ankle and brachial blood pressures before and after exercise Initial evaluation for intermittent claudication would include checking the ankle and brachial blood pressures before and after exercise.
When the nurse practitioner is evaluating a patient for intermittent claudication, he or she would first: A) Order a venogram B) Order TED anti-embolism stockings C) Check the ankle and brachial blood pressures before and after exercise D) Check the pedal and posterior tibial pulses
C) Check the ankle and brachial blood pressures before and after exercise Initial evaluation for intermittent claudication would include checking the ankle and brachial blood pressures before and after exercise.
All of the following may help relieve the symptom(s) of gastroesophageal reflux disease (GERD) except: A) Losing weight B) Stopping caffeine intake C) Chewing breath mints D) Stopping alcohol intake
C) Chewing breath mints Gastroesophageal reflux disease (GERD) is a condition in which food comes up the esophagus from the stomach because of a weak sphincter. The reflux is usually worsened by lying down, and can cause a cough and esophageal irritation if not treated. Effective treatment may include weight loss, decreased caffeine intake, and avoidance of alcohol.
A 67- year-old retired clerk presents with complaints of fatigue, shortness of breath, and weight gain over a 2-week period. A nonproductive cough accompanies her symptoms. She reports that climbing up the stairs worsens her dyspnea. The lung exam is positive for fine crackles in the lower lobes with no wheezing. An S3 heart gallop is noted. Which of the following drugs is most likely to relieve the patient's symptoms? A) Atenolol (Tenormin) B) Trimethoprim-sulfamethoxazole (Bactrim DS) C) Furosemide (Lasix) D) Hydrocodone/guaifenesin syrup (Hycotuss)
C) Furosemide (Lasix) Loop diuretics, such as furosemide (Lasix), are used to help remove the extra fluid load in hemodynamically stable patients (contraindicated if systolic blood pressure <90 mmHg, severe hyponatremia, acidosis).
While assessing for a cardiac murmur, the first time that a thrill can be palpated is at: A) Grade 2 B) Grade 3 C) Grade 4 D) Grade 5
C) Grade 4 A fine vibration, felt by an examiner's hand on a patient's body over the site of an aneurysm or on the precordium, results from turmoil in the flow of blood and indicates the presence of an organic murmur of grade 4 or greater intensity. A thrill can also be felt over the carotids if a bruit is present and over an arteriovenous fistula in the patient undergoing hemodialysis.
All of the following are correct statements regarding the S3 component of the heart sound except: A) It occurs very early in diastole and is sometimes called an opening snap B) It is a normal finding in some children, healthy young adults, and athletes C) It can be a normal variant if heard in a person aged 40 years or older D) It signifies congestive heart failure (CHF)
C) It can be a normal variant if heard in a person aged 40 years or older The S3 heart sound occurs early in diastole and is sometimes referred to as an opening snap. It is a normal variant in children, healthy young adults, and athletes. Bibasilar crackles in lung bases and the presence of S3 heart sounds are classic findings of congestive heart failure (CHF).
Which of the following is correct regarding the best site to listen for mitral regurgitation? A) It is best heard in the apical area during S2 B) It is best heard at the base during S1 C) It is best heard at the apex during S1 D) It is best heard at the base during S2 569
C) It is best heard at the apex during S1 Mitral regurgitation results from damage to the mitral valve (mitral valve prolapse [MVP], rheumatic heart disease, infective endocarditis). Most patients are initially asymptomatic. The best ausculatory area is the apex or mitral area of the chest. Mitral regurgitation is a systolic (S1) murmur. It may be associated with a midsystolic click if the patient has concurrent MVP. The click is so characteristic of MVP that even without a subsequent murmur, its presence alone is enough for the diagnosis. Immediately after the click, a brief crescendo-decrescendo murmur is heard, usually at the apex. The best imaging test for identifying mitral regurgitation is transthoracic echocardiography.
You note a high-pitched and blowing pansystolic murmur while assessing a 70- year-old male patient. It is grade 2/6 and is best heard at the apical area. Which of the following is most likely? A) Ventricular septal defect B) Tricuspid regurgitation C) Mitral regurgitation D) Mitral stenosis
C) Mitral regurgitation Mitral regurgitation is best heard at the apical area, and manifests as a high-pitched, blowing pansystolic murmur. It occurs when the mitral valve does not close properly. It is the abnormal leaking of blood from the left ventricle, through the mitral valve, and into the left atrium. When the ventricle contracts, there is backflow (regurgitation) of blood into the left atrium. Mitral regurgitation is the most common form of valvular heart disease. Murmurs are graded (classified) depending on how loud they sound with a stethoscope. The scale is 1 to 6 on loudness. A grade 2/6 is a grade 2 on the 6-point scale.
All of the following are true statements about diverticula except: A) Diverticula are located in the colon B) A low-fiber diet is associated with the condition C) Most diverticula in the colon are infected with gram-negative bacteria D) Supplementing with fiber, such as psyllium (Metamucil), is recommended
C) Most diverticula in the colon are infected with gram-negative bacteria Diverticula in the colon can be infected with both gram-negative and gram-positive bacteria.
During the eye exam of a 50-year-old hypertensive patient who is complaining of an onset of a severe headache, you find that the borders of the disc margins on both eyes are blurred. What is the name of this clinical finding? A) Normal optic disc B) Optic neuropathy C) Papilledema D) Hypertensive retinopathy
C) Papilledema The funduscopic examination visualizes vessels and assesses intracranial tension and is recommended in new-onset headaches. Papilledema is optic disc swelling cause by increased intracranial pressure. The swelling is usually bilateral. Signs include venous engorgement, loss of venous pulsation, hemorrhages over and/or adjacent to the optic disc, blurring of optic margins, and elevation of the optic disc. On visual field exam there may be an enlarged blind spot.
A 35-year-old man has a history of an upper respiratory viral infection 4 weeks ago. He reports that he started feeling short of breath and now complains of sharp pain in the middle of his chest that seems to worsen when he lies down. The patient's physical exam is within normal limits with the exception of a precordial rub on auscultation. The most likely diagnosis would be: A) Pulmonary embolism B) Dissecting aneurysm C) PericarditisD) Esophageal reflux
C) Pericarditis Pericarditis is inflammation of the sac around the heart. Common signs and symptoms include chest pain over the center/left side of the chest; shortness of breath, especially with lying down; low-grade fever; weakness; fatigue; dry cough; and abdominal or leg swelling. Pericardial rub may be auscultated.
561. The nurse practitioner orders an ankle-brachial index (ABI) test for a patient. Which of the following disorders is the ABI test used for? A) Venous insufficiency B) Osteoarthritis of the arm or the ankle C) Peripheral arterial disease D) Rheumatoid arthritis
C) Peripheral arterial disease The ankle-brachial index (ABI) is a test that is 702 used to stratify the severity of arterial blockage in the lower extremities for patients with peripheral arterial disease (PAD). An ABI score of 1.0 to 1.4 is normal. Any value less than 1.0 is abnormal. A score of 0.5 or less is indicative of severe PAD.
Which of the following conditions are possible causes of secondary hypertension? A) Leukemia and thalassemia major B) Hashimoto's thyroiditis and polycystic ovaries C) Renal stenosis and adrenal tumors D) Myocardial infarction and coronary artery disease
C) Renal stenosis and adrenal tumors Secondary hypertension is most likely seen following renal stenosis and adrenal tumors. Renal stenosis causes secondary hypertension by plaque formation in the arteries, causing damage to coronary arteries (atherosclerosis). Adrenal tumors initiate secondary hypertension by releasing a large amount of aldosterone, which causes water and salt retention and loss of too much potassium.
Pulsus paradoxus is more likely to be associated with: A) Sarcoidosis B) C) D) Acute bronchitis Status asthmaticus Bacterial pneumonia
C) Status asthmaticus Pulsus paradoxus is most likely to be seen with status asthmaticus. With inspiration, systolic pressure drops due to the increased pressure (positive pressure). Some pulmonary risks of having increased pressure include asthma and emphysema. Cardiac causes for pulsus paradoxus include tamponade, pericarditis, and cardiac effusion.
During a sports physical exam of a 14-year-old high school athlete, the nurse practitioner notices a split of the S2 component of the heart sound during deep inspiration. She notes that it disappears upon expiration. The heart rate is regular and no murmurs are auscultated. Which of the following is correct? A) This is an abnormal finding and should be evaluated further by a cardiologist B) A stress test should be ordered C) This is a normal finding in some young athletes D) An echocardiogram should be ordered
C) This is a normal finding in some young athletes It is common to hear a split S2 heart sound over the pulmonic area of the heart with inspiration. As long as it disappears with expiration, with no other abnormal symptoms, this is a normal finding. The sound is caused by splitting of the aortic and pulmonic components.
A 22-year-old sexually active woman is complaining of amenorrhea and new-onset bloody vaginal spotting. On examination, her left adnexa is tender and cervical motion tenderness is positive. Which test should the nurse practitioner order initially? A) Flat plate of the abdomen B) Complete blood count (CBC) with white cell differential C) Urine pregnancy test D) Pelvic ultrasound
C) Urine pregnancy test The patient's history of amenorrhea and new onset of bloody vaginal spotting combined with positive physical findings of left adnexal tenderness and cervical motion tenderness are highly suggestive of an ectopic pregnancy rather than pelvic inflammatory disease (PID). Refer this patient to the emergency department if ectopic pregnancy is suspected. The presence of amenorrhea should be treated as a pregnancy until proven otherwise.
Symptoms suggestive of ulcerative colitis include all of the following except: A) Bloody diarrhea mixed with mucus B) Nausea and vomiting C) Weight gain D) Abdominal pain
C) Weight gain Symptoms of ulcerative colitis include bloody diarrhea mixed with mucus, nausea/vomiting, abdominal pain, and possible weight loss with long- term diarrhea.
You would associate a positive iliopsoas muscle test result with which of the following conditions? A) Left cerebral vascular accident B) Urinary tract infection C) Heel fractures D) Acute appendicitis
D) Acute appendicitis A positive iliopsoas muscle test may be seen with acute appendicitis. The right iliopsoas muscle lies under the appendix, This test is performed by asking the patient to actively flex the thigh at the hip. A "positive psoas sign" is noted when the patient exhibits pain in the right lower quadrant due to the inflamed tissue.
All of the following factors have been found to increase the risk of atrial 562 fibrillation in predisposed individuals except: A) Hypertension B) C) D) Excessive alcohol intakeTheophylline (Theo-Dur) and pseudoephedrine (Sudafed) Acute esophagitis
D) Acute esophagitis Factors that influence the risk of atrial fibrillation include hypertension, excessive alcohol consumption, and medications such as Theo-Dur and Sudafed.
Which of the following murmurs can radiate to the neck? A) Mitral stenosis B) Mitral regurgitation C) Aortic regurgitation D) Aortic stenosis
D) Aortic stenosis The murmur of aortic stenosis occurs during systole (S1). The aortic area is in the second intercostal space to the right side of the sternum. The murmur can radiate to the right side of the neck if it is severe.
A 65-year-old man with a body mass index (BMI) of 30 and a history of asthma has hypertension that has been well controlled with hydrochlorothiazide 12.5 mg PO daily. His total cholesterol is 230 g/dL. How many risk factors for coronary artery disease (CAD) does he have? A) One risk factor B) Two risk factors C) Three risk factors D) Four risk factors
D) Four risk factors The risk factors for coronary artery disease for this patient are (1) 65-year-old male, (2) overweight (body mass index [BMI] of 30), (3) hypertension, and (4) total cholesterol 230 g/dL.
What type of murmur can radiate to the left axilla? A) Aortic regurgitation B) Aortic stenosis C) Mitral stenosis D) Mitral regurgitation
D) Mitral regurgitation The murmur of mitral regurgitation occurs during systole (holosystolic) and is located in the mitral area of the chest. The location of the mitral area (fifth intercostal space on the left side of the midclavicular line) is near the left axilla, so that a loud murmur can radiate to the left axilla. The causes can be congenital or it may a be sequela of rheumatic fever, mitral valve prolapse, or papillary muscle dysfunction secondary to acute or prior myocardial infarction.
Potential complications of mitral valve prolapse (MVP) include all of the following except: A) Severe mitral regurgitationB) EndocarditisC) Increased risk of stroke and transient ischemic attack D) Mitral stenosis
D) Mitral stenosis Complications of mitral valve prolapse (MVP) include 657 mitral regurgitation, endocarditis, and increased risk of stroke and transient ischemic attacks. The most common complication of mitral valve prolapse (MVP) is mitral valve regurgitation (mitral insufficiency). An abnormal mitral valve increases the chance of developing endocarditis from bacteria, which can further damage the mitral valve. Doctors used to recommend that people with MVP take antibiotics before certain dental or medical procedures to prevent endocarditis (not a current practice). Stroke is a very rare complication of MVP.
A 40-year-old woman comes to the medical office complaining of palpitations and some light-headedness for the past 6 months. These are random episodes. The nurse practitioner notices a mid-systolic click with a late systolic murmur that is best heard in the apical area during auscultation of the chest. You would suspect: A) Atrial fibrillation B) Sinus arrhythmia C) Mitral stenosis D) Mitral valve prolapse
D) Mitral valve prolapse Mitral valve prolapse (MVP) occurs when the mitral 647 valve does not close all the way, causing a late systolic murmur heard best in the apical area during auscultation of the chest. Following a normal S1 and briefly quiet systole, the valve suddenly prolapses, resulting in a mid-systolic click. The click is so characteristic of MVP that even without a subsequent murmur, its presence alone is enough for the diagnosis. Immediately after the click, a brief crescendo-decrescendo murmur is heard, usually best at the apex. Symptoms patients may experience at times include palpitations and dizziness.
Which of the following symptoms in an older male patient with a history of gastroesophageal reflux disease is most worrisome? A) Chronic heartburn B) Recurrent regurgitation of sour-tasting food C) Hoarseness and sore throat D) Odynophagia and early satiety
D) Odynophagia and early satiety Worrisome symptoms in patients with gastroesophageal reflux disease (GERD) include odynophagia, early satiety, weight loss, iron-deficiency anemia, gastrointestinal bleeding, and recurrent vomiting. Symptoms of odynophagia and early satiety in a patient with GERD should prompt a workup to rule out esophageal cancer.
A patient with a history of mitral valve prolapse (MVP) is requesting prophylaxis before her dental surgery. Which of the following would you prescribe this patient? A) Amoxicillin a half hour before and 2 hours after the procedure B) Amoxicillin 1 hour before the procedure C) Amoxicillin 1 hour before and 3 hours after the procedure D) Prophylaxis is not recommended for this patient
D) Prophylaxis is not recommended for this patient Current American Heart Association guidelines (2017) do not recommend endocarditis prophylaxis for most patients with aortic or mitral valve disease, including those with mitral valve prolapse with regurgitation or for patients with hypertrophic cardiomyopathy. Patients at highest risk for infective endocarditis (IE) are those with prosthetic heart valves, including mechanical, bioprosthetic, and homograft valves; prior history of IE; unrepaired cyanotic congenital heart disease; prosthetic material used for valvular repair; repaired congenital heart disease with residual shunts or with catheter-based intervention; and others. The high-risk procedures are dental work with manipulation of tissue, tooth extractions, and certain respiratory tract procedures.
Your 35-year-old patient is being worked up for microscopic hematuria. All of the following are differential diagnoses of microscopic hematuria except: A) Kidney stones B) Bladder cancer C) Acute pyelonephritis D) Renal artery stenosis
D) Renal artery stenosis Renal artery stenosis refers to narrowing of the kidney arteries. It is commonly noted in individuals older than 50 years of age and is associated with atherosclerosis and hypertension. Hematuria is not associated with renal artery stenosis. Evidence of blood in the urine can be seen with kidney stones, bladder cancer, and acute pyelonephritis.
The apex of the heart is located at: 537 A) Second intercostal space to the right of the sternal border B) Second intercostal space to the left of the sternal border C) The left lower sternal border D) The left side of the sternum at the fifth intercostal space by the midclavicular line
D) The left side of the sternum at the fifth intercostal space by the midclavicular line The apex of the heart is directed downward, forward, and to the left. The apex is overlapped by the left lung and pleura. The apex lies behind the fifth left intercostal space, slightly medial to the midclavicular line.
Which of the following antihypertensive medications has beneficial effects for an elderly White woman with osteoporosis? A) Calcium channel blockers B) Angiotensin-converting enzyme (ACE) inhibitors C) Beta-blockers D) Thiazide diuretics
D) Thiazide diuretics Thiazide diuretics have a favorable effect in patients with osteopenia and osteoporosis by slowing down the kidney's excretion of calcium and increasing distal tubule calcium reabsorption. This results in decreased bone demineralization. Thiazide diuretics are a good choice of therapy for this population because they treat hypertension and slow bone loss.
A 74-year-old man presents with recurrent abdominal cramping and pain associated with diarrhea that occurs from four to five times per day. He reports that currently he is having an exacerbation. The stools are bloody with mucus and pus. The patient reports that he has lost weight and is always fatigued. The patient denies recent travel or outdoor camping. Which of the following conditions is most likely? A) GiardiasisB) Irritable bowel syndrome (IBS) C) DiverticulitisD) Ulcerative colitis
D) Ulcerative colitis The most important clue for ulcerative colitis is bloody stools that are covered with mucus and pus along with the systemic symptoms (fatigue, low-grade fever).
Which of the following laboratory tests is the most sensitive test for evaluating an active Helicobacter pylori infection of the stomach or duodenum: A) Helicobacter pylori titer B) Fasting gastrin level C) Upper GI series D) Urea breath test
D) Urea breath test The urea breath test is a very sensitive test used to evaluate a patient for an active Helicobacter pylori infection. It can also be used to document treatment response after a treatment regimen of antibiotics (14 days) and proton- pump inhibitor (PPI) therapy.
