ANCC Exam

Community/herd immnity

Describes the state in which a sufficient proportion of a pop is immune through vaccination or prior illness- even individuals that aren't vaccinated (infants, immunocompromised) are offered some protection because everyone

Secondary

Detecting disease in early asymptomatic stages, screenings -Early cause finding of asymptomatic disease via the use of a screening test Ex. highly abnormal mammo not final word

In beta-lactam allergy

Doxycycline 100 mg PO BID or 200 mg PO daily (gram neg) Levofloxacin Moxifloxacin

Common CYP 450 3A4

Erythro- Clarithromycin block the activity of the isoenzyme, limiting substrate excretion**, allowing increase in substrate levels, and possible risk of substrate-induced toxicity St. John Wart- anti-retrovirals, birth control pills, and cyclosporins (organ trasnplant can lead to rejection)

CNIII Oculomotor

Eyelid and eyeball movement

Asthma flare

FEV1/Peak expiratory flow rate- drops early (even before patient notices) and good indication of severity of asthma

Support for NP practice

Focus on output--> NP practice outcomes

Elderly with RF

Given PPSV23 (Pneumovax) 1 year ago, should be given a dose of PCV13 (Prevnar) today- gives an additional boost

CNVIII Acoustic

Hearing, equilibrium, sensation

When you have drug reisistance

High dose amox-clavu 2000ng/125 mg PO BID Levofloxacin 500 mg PO daily (good for gram neg) Moxifloxacin 400 mg PO daily (gram neg)

Hyperthyroidism

High thyroxine = low TSH TSH= <0.15 Free T4= 79 Tx- Beta-adrenergic antagonist- propranolol to counteract tachycardia, tremor PTU, Methimazole (Tapazole) Radioactive Iodine (RAI) Thyrotoxicosis- can have a fib, check TSH, BNP Preferred tx: Radioactive ablation of overactive thyroid tissue

Clarification

I don't think i see the connection. Can you explain that to me again?

PPD and MMR

IF MMR vaccine is given on the previous day or earlier, the PPD TST should be delayed for at least one month (false positive)

Treatment of analphylaxis

Immediately administer EPI then administer Benadryl then call 911

Passive Immunity

Immunity conferred by an antibody produced in another host, acquired naturally by an infant from mother (onset is within hours of getting dose but time limited only 6-9 months)

Active Immunity

In response to an antigen, presence of an antibody produced in the host (waiting to protect you, 1 month from getting the dose, but LIFELONG=BETTER)

Angle Closure Glaucoma

Increased IOP Funduscopic--> see a deeply-cupped optic disc

CNIV Trochlear

Innervates superior oblique, turns eye downward and laterally

Types of anemia

Iron deficiency anemia-micro, RDW high, Folate deficiency anemia-macro Alpha thalassemia minor- micro Beta thalassemia minor- micro, pale cells Meditarrean HGB HCT 10:30 12:36 15:45

16 y/o male basketball player, which finding on a cardiac exam would warrant immediate eval

LOUD S4- problem! S4 is the sound of diastolic dysfunction Murmur gets louder with position change (from sitting to standing) ----> HCM

Drug induced macrocytosis usually without anemia

MCV high, MCHC NL, RDW NL Meds--> Phenytoin/Dilantin, Valproic Acid/Depakote, Carbamazepine/Tegretol

Macrocytic (MCV>96) high RDW

MCV high, MCHC NL, RDW high Normochromic anemia with elevated RDW Most common etiology: 1) Pernicious anemia 2) Dietary induced Vit B12 deficiency (numbness of fingertips and oral irritation***)- most common 3) folate deficiency anemia- alcohol abusers Alcoholics- AST 80 (0-31) MCV 103 (80-96)

Microcytic (MCV<80) NL RDW

MCV low, MCHC low, RDW NL Hypochromic anemia with NL RDW** Most common etiology: 1) Alpha thalassemia minor (asian, african) 2) beta thalassemia minor (African, middle eastern, Mediterranean)

Microcytic (MCV<80) high RDW

MCV low, MCHC low, RDW high hypochromic anemia with elevated RDW** Most common etiology: 1) Iron deficiency anemia- Low ferritin, high TIBC 2) erosive gastritis, menorrhagia

Normocytic (MCV-80-96, RDW= 11.5-14.5) MCHC: 32-36

MCV=NL MCHC=NL RDW=NL normochromic anemia with NL RDW Most common etiology: acute blood loss or anemia or chronic disease 1) Acute blood loss or GI bleed 2) Lupus

Live virus

MMR, Varicella, FluMist, Zoster Contra-Pregnancy, Immuno/HIV only less than 200, Rotavirus- oral vaccine given to infants

78 y/o woman with fatigue, spoon-shaped nails, and lab results MCV low, RDW incr

Microcytic hypochromic anemia --> examples erosive gastritis menorrhagia so answer is GI blood loss ...then look at Ferritin because its probably IDA

Tertiary

Minimizing negative disease induced outcomes, potentially viewed as a failure of primary prevention Ex- rehab, PT, OT

Diastolic Murmurs

Mitral Stenosis (Rumble) Atrial Regurg (blowing) Diastolic

Systolic Murmurs

Mitral (rad to axilla) Mitral Benign is- negative hx Regurgitation Valve lower grade Physiologic Prolapse no radiation Aortic (rad to neck) PMI WNL Stenosis (harsh) softens w. position change Systolic

Normative aging

Need for increased illumination

Cancer

New Cases- Female breast Male prostate Deaths- M=lung, prostate, colon, pancreas F=lung, breast, colon, pancreas Endometrial cancer- unexpected post-menopausal bleeding (represents 50% of all gyno ca)

Pneumonia vaccine

Not contra in immunosupressed, does not protect against most pneumonia-causing pathogens (just s.pneumococcal), *can give during antimicrobial therapy

Reduced RBC production

Nutrition, vitamin B12- use of **medications such as Metformin and chronic PPIs (b12 and iron malabsorption) PPI use- increased fracture risk, low magnesium- muscle cramps palpitations

Flumist

Only for 2-49 and not in presence of airway disease

68 y/o woman with peripheral numbness, oral irritation, macrocyctic

Pernicious anemia cause is Vit 12 deficiency

Transtheoretical Model of Change

Precontemplation- not interested, minimizes problem Contemplation- considering Preparation- changes in behavior Action- Maintenance/relaspse Ask/Advise/Assess/Assist/Arrange

Primary

Preventing the health problem, most cost effective form of healthcare **IMMUNIZATIONS, ensuring adequate illumination at home (preventing falls)

Gardasil

Quadrivalent vaccine- 6, 11, 16, 18 6 and 11-wart virus 16 and 18- malignancy virus Males- get 9-26, get three dose series

Hypothyroidism

RF: down syndrome, post parttum Normal values- TSH= 0.5-4 Free t4= 10-27 Low thyroxine (FT4) = High TSH TSH= 84 (high) Free T4= 3 (low) Tx- Levothyroxine- **increase needs in pregnancy-increase by 33% increasing demands of developing fetus, check after 8 weeks**, take on empty stomach at same time everyday and not taken within 2 hours of cation such as calcium, iron, aluminum, magnesium Levothyroixine helps to bring down high TSH So if TSH = 4.5 ...should be <4 You would increase the dose by 25 and repeat a TSH in 8 weeks/2 months Elderly dose is 75% less than the dose needed by a young adult SE: bone thinning Recheck after 6-8 weeks TSH- released by anterior lobe of pituitary Subclinical hypothyroidism- elevated TSH and normal free T4 Natural dessicated thyroid- animal sources

Research design

Ranking- highest to lowest Meta-analysis/Systematic Reviews, RCTs, cohort studies, case-control series, case series/reports, expert opinions Research Utilization: Identify the problem Assess published research Design the innovation Evaluate the situation Decide whether to use the innovation

Most important source of body's iron supply

Recycled iron content form aged red blood cells need B12 supplements

AOM

S.penumoniae (gram pos)-40-50%, tx with amox/cephalo, macrolides, resistance protein binding sites H.influenza (gram neg)- can produce beta-lactamase M.catarrhalis (gram neg)- also produces beta-lactamase, can get better without antibiotic Need abnormal ear drum (bulging TM) + pain (otalgia)/rubbing/tugging ear tx- Acetaminophen and otic drops help with ST Watchful waiting- 6 months or older, with non-severe illness, unilateral, fever <102.2, otalgia <48 <6 months-begin antibiotic!! if allergy-Cefdinir], RF: pacifier use for 10 months, feedings in the supine, smoke exposure, day care, <2- 10 days 2-6 yrs- 7 days >6 yrs- 5 days 1st line- Amox 90 BID, Amox clav BID With PCN allergy- **Cefdinir (Cephlosporins)

Acute Bacterial rhinosinusitis

S.penumoniae**, RF-viral infection, allergies, tobacco use, 1st line is Augmentin, penicillin allergy-Cefdinir 2nd line- if not better...Clindamycin and Cefixime

CNX Vagus

Senses aortic blood pressure, slows heart rate, stimulates digestive organs, taste

Presbycusis- age related hearing loss

Slowly progressive, symmetric, predominately high frequency** BAD HEARING LOSS-frequent ear infections, low birth apgar scores, seizures, rubella, CMV

CNI Olfactory

Smell

Group A strep (GABHS)

Streptococcus pyogenes, risk for rheumatic fever and Glomerulo., peritonsillar abscess, tx- amox then try macrolide if doesnt't improve GOLD STANDARD IS THROAT CULTURE

29 y/o woman with allergic rhinitis who is a home daycare provider

THINK NOT SEDATIVE do not give Chlorpheniramine -mine but can give nasal spray, oral loratadine nasal congestion---> 1st line is decongestant

CNIX Glossopharyngeal

Taste, sense carotid, blood pressure

75 y/o male with 60 packyear, COPD, firm, non-tender node

Think malignancy- Squamous Cell carcinoma Next step...biopsy 90% of oral cancers are SCC Dx: FEV1:FVC ration <0.70

CNVI Abducens

Turns eye laterally

CNII Optic

Vision

OPen ended questions

What's on your mind

Tetanus

can get from soil, a depth of the wound is important Preggers- get a tdap in her thirst trimester to pass onto the unborn child (pertusis is a bad outcome!), family members need to be up to date- can cause lockjaw T-dap- 1 at 11-64 and then booster every 10 dTap-five doses Pertussis- uncontrollable cough, vomitting, fatigue, dx: nasopharyngeal culture and PCR testing tx: Azithromycin

Macular degeneration

central vision loss, common cause of new onset blindness in elderly More females Screening tests- Amsler grid test

Murmurs (mitral regurgitation)

common in LVH (also PMI shifts would see dyspnea upon exertion) RF: rheumatic heart disease, endocarditis, calcific annulus sports- depends on degree of LVH

Immune globulin (passive)

concentration solution of antibodies derived from pooled donated blood product (SAFE!)

S4

diastolic dysfunction, common in poorly-controlled hypertension, recurrent myocardial ischemia, unstable angina

Meniere's disease (idio) vs. Meniere's syndrome (secondary)

dizziness, tinnitius, nystagmus, vertigo RF: ototoxic drugs, tx: benzos for rest and corticosteroids for anti-inflam

indoor allergen

dust mites (perennial), pets, cockroaches, mold spores

Hemic murmur

happens with anemia, dehydration, pregnancy goes away with tx

Avoid accidental burn injuries in home

home hot water set at no more than 120 (takes 5 mins in length to cause 3rd degree burn) second degree burns- moist, red skin with peeling borders third degree- you debrided

Benadryl

older, cross BBB, can cause sedation, urinary retention (bad for BPH)

Iron maximum absorbs

on an empty stomach

beta lacatams with allergic reactions

penecillins, cephalosporins, carbapenems rashes with Epstein Barr

primary open angle glaucoma

peripheral vision loss, elevated intraocular pressure, deep-cupping of optic disc, tx with beta-adrenergic antag (Timolol), alpha agonists, prostaglandin analogues Glaucoma screening test- Tonometry

MMR

preggers can't receive (no varicella, or zoster, smallpox, flu mist, rotavirus), but lactation OK! its live but weakened give again to those born after 1957 Give to 6-11 month who are travelling outside US May treat and have an innocent flat pink rash 2 doses ( at 12-15 mon and 4-6 years)

Hep B vaccine

previously unvaccinated adults with DM should be vaccinated immediately upon diagnosis (because can be in group type settings/lancets/equipment not cleaned)

Types of prevention

primary- car restraints, bicycle helmets, immunizations secondary- prevent for those with RF-pap, mammo tertiary-mgmt of established disease- meds, lifestyle

No pap smear

prior to 21 or in elderly

Prevalence vs. Incidence

proportion with disease vs. # of new cases think "p"revalence " p"roportion

herpes zoster

stronger chickenpox vaccine-zoster vaccine post-herpetic neuralgia- persists after 1 month Herpes keratitis is damage to the corneal epithelium caused by the herpes virus, commonly shingles. The patient usually has acute onset of eye pain, photophobia, and blurred vision in the affected eye.

S3

systolic dysfunction or early diastolic, common in HF (dyspnea, crackles, tachycardia- 3 adject/s3), marker of ventricular overload- best heard with bell

Utilization review

the process of evaluating the appropriateness of inpatient hospitalization. Proof of the medical necessity for the patient's hospitalization is done mainly through chart reviews and is part of the utilization review process. A claim can be denied under this process if the reviewer and the payer do not agree with the decision for hospitalization. Payment could be denied to the healthcare facility if utilization review does not deem the treatment necessary.

oral cancer

ulcerated lesion with indurated margins, most common SCC, RF: HPV 16, screening at dental visits

Sensitivity vs. specificity

with a condition vs. without a condition

Breast screening

women at high risk (greater than 20% lifetime risk) should get a MRI and mammo q yr

USPSTF recommendations

women with average risk should have a baseline mammogram at age 50 years. Follow-ups should occur every 2 years. Mammograms can stop at age 74. The American Cancer Society continues to recommend mammograms begin at age 40.

Aortic stenosis

young man, exercise tolerance, harsh systolic murmur, softer when changing position, radiation to the neck (assume it came out of AORTIC VALVE) LVH, congenital defect RF- rheumatic fever, older adults-calcification

Restating

"You said that you got angry when your boyfriend came home last last night" keyword- YOU

Asthmastic

1st test- FEV or PEFV because its the earliest sign/drops early so best estimation of severity compared to Oxygen sat/ABGs (which drop late)

Mitral Valve Prolapse

27 y/o woman, runner, oral contraceptive, funnel chest/pectus excavatum, mid-late systolic murmur which moves forward upon position change HONKING (heard best at apex) Marfan's syndrome, scoliosis Tx: obtaining an echo is a prudent next step Encourage aerobic activity

Mono

30-50 days ago was infected before sxs, give prednisone not amox (rash), at least 50% present with spleen enlargement, wait 1 month to go back to sports Anterior and posterior cervical lymph Pharyngitis with exudate right and left upper quadrant abdominal tendernes Hepatomegaly in 10% of cases Splenomegaly in 50% of cases

Who should not receive influenza vaccine

4 mon old born at 32 weeks gestation receive flu- 6 mon and older can give during pregnancy/lactation give children 2x- 4 months apart

Mitral Regurgitation

62 y/o male with HTN, HF, PMI displaced (big LV), accentuated when rolled to the side, louder with hand grip, holosystolic, blowing murmur

Calcific aortic stenosis

82 y/o woman, dizzy walking up a flight of stairs, harsh systolic murmur radiation to neck,

Leadership role

A process by which a person influences a group of individuals to achieve a common goal Ex. Collaborating with the regional public health department on a initiative to combat obesity through a community-based exercise program (Keyword-collaborating)

Alcohol Abuse Lab results ***

AST/ALT- 3x ULN 83/50 (normal 0-31) MCV- 105 (normal 80-96) Hypertriglyceridemia- TG= 325 (normal <150)

1st line for Acute Bacterial Rhinosinusit

Amox-Clav 875 mg/125 mg PO BID Second line Doxy 100 mg PO BID or 200 mg PO daily

Common ADE from oral decongestants***

An increase in Blood Pressure because they are alpha-adrenergic agonists DO NOT use in hypertensive

65 y/o woman with RA with poor control who is on DMARDS

Anemia of chronic disease

A Fib

Atrial fibrillation is a common arrhythmia characterized by nonsynchronized irregular atrial and ventricular activity. An ECG is confirmatory of atrial fibrillation with absent P waves irregular ventricular rate rhythm of 100 - 160 beats per minute.

Acanthosis Nigicans

CHeck hemoglobin A1c hyperpigmented plaques with a velvet-like appearance at the nape of the neck and axillary region (worsens after puberty cause thats when the hyperinsulinemia Found on Groin folds, over knuckles, elbows Tx--> losing weight

Otitis externa

Caused by fungus- Candidia or Aspergillus/P. aeruginosa hallmark is pain on palpating tragus Tx--> fluoroquinolone

CNV Trigeminal

Chewing, face and mouth, touch and pain

45 y/o woman with AOM 10 days ago, experiencing fullness in ear and diminised ability to discriminate speech

Conductive hearing loss- Weber test lateralizing to the affected ear (something blocking like cerumen, AOM--> it is reversible) AOM with effusion expected; unless >3 months due otological eval... can cause speech delay in children* Tx: Reassurance- ear fullness is an anticipated finding

CNVII Facial

Controls most facial expressions, secretion of tears and saliva, taste

CNXII Hypoglossal

Controls tongue movements

CNXI Spinal accessory

Controls trapezius and sternoclei., controls swallowing movements