BOARD PRACTICE QUESTIONS - REPRODUCTIVE

All of the following have been classified as nationally notifiable diseases by the Centers for Disease Control and Prevention, except: A. Herpes simplex infections B. Pertussis C. Anthrax D. Lyme disease

Solution: A Herpes simplex infections According to the CDC, herpes simplex infections are not classified as a notifiable disease. Pertussis, anthrax, and Lyme disease are notifi able diseases. To report a disease, contact your local county health department.

A 37-year-old adult male complains of swelling on the right scrotum that is mildly tender for a few weeks. There is a pressure-like sensation. The right scrotum is larger than the left scrotum. Which of the following tests is appropriate for this patient? A. Transillumination B. CBC with differential C. Ultrasound of the scrotum D. Urinalysis

Solution: A Transillumination The patient has a hydrocele on the right scrotum. Transillumination will show that the light glow is much larger and brighter on the affected scrotum, compared with the unaffected one. A urologist referral is the next step in this patient's evaluation.

Which of the following is a cause of primary amenorrhea? A. Turner syndrome B. Hypothyroidism C. Menopause D. Obesity

Solution: A Turner syndrome Turner syndrome is a cause of primary amenorrhea. Menopause, hypothyroidism, and obesity (or extreme weight loss) can cause secondary amenorrhea, which is defined as the cessation of regular menses for 3 months or cessation of irregular menses for 6 months.

Which of the following statements is true regarding a threatened abortion? A. Vaginal bleeding and cramping are present, but the cervix remains closed B. Vaginal bleeding and cramping are present along with a dilated cervix C. The fetus and placenta are both expelled D. The products of conception and the placenta remain inside the uterus along with a dilated cervix

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

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

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

Which of the following antigens is a component of the HIV 1/2 combination antibody/antigen testing? A. p24 B. p20 C. P18 D. P14

Solution: A p24 The p24 antigen appears early in HIV infection and enables earlier detection. The preferred test for HIV screening is the fourth-generation HIV 1/2 combination antibody with p24 antigen test. If strong suspicion of HIV infection, also order the HIV RNA PCR test, which detects the HIV virus directly.

Which assessment finding is associated with a diagnosis of proximal hypospadias? A. Chordee B. Hydrocele C. Micropenis D. Inguinal hernia

Solution: A Chordee. Chordee, the presence of ventral shortening and curvature of the penis, is commonly associated with a more proximal urethral defect. Hydrocele, micropenis, and inguinal hernia are not specifically associated with a diagnosis of proximal hypospadias.

Which of the following conditions is a possible effect of the mumps virus, which can affect male fertility? A. Salivary gland inflammation B. Cryptorchidism C. Orchitis D. Prostatitis

Solution: C Orchitis Orchitis, or inflamed testicle, is a complication of mumps. Among male adults who get a mumps infection, 15% to 25% develop orchitis. Cryptorchidism is testes/testicle that are inside the abdominal cavity, which increases risk of testicular cancer. Prostatitis and salivary gland inflammation do not increase male infertility.

Patients who are diagnosed with gonorrhea should also be treated for which of the following infections? A. Chancroid B. Chlamydia trachomatis C. Herpes genitalis D. None of the above

Solution: D None of the above. The CDC no longer recommends that patients with gonorrhea always be cotreated for chlamydia. They now recommend cotreatment only when chlamydial infection has not been excluded. Do not cotreat if test is negative.

Which test will confirm the diagnosis of prostate cancer? A. Prostate-specific antigen B. Digital rectal exam C. Complete blood count with differential D. Tissue biopsy

Solution: D Tissue biopsy. Biopsy and pathology exam of prostate tissue is used to confirm a diagnosis of prostate cancer. CBC is not used to diagnose prostate cancer. A mass can be palpated with DRE; however, this does not confirm a diagnosis of prostate cancer. PSA is a screening test for prostate cancer, but it is not used to confirm final diagnosis.

There is a higher risk of balanitis in which of the following conditions? A. Renal insufficiency B. Diabetes mellitus C. Graves' disease D. Asthma

Solution: B Diabetes mellitus. Balanitis is a yeast infection of the glans of the penis. Men who are not circumcised and who have diabetes mellitus are at higher risk for developing balanitis.

A sexually active 16-year-old with cervicitis is tested for gonorrhea and chlamydia. The NAAT test result shows that the patient is positive for gonorrhea. Which of the following is appropriate treatment for this patient? A. Cephalosporin B. Cephalosporin and macrolide C. Tetracycline D. Tetracycline and sulfonamide

Solution: A Cephalosporin As of December 2020, the CDC recommends that patients with gonorrhea-positive testing be treated with a higher dose of cephalosporin than previously recommended. Additionally, the recommendation for cotreatment of chlamydia with positive gonorrhea has been removed, provided chlamydia status is confirmed negative. The first-line treatment for gonorrhea-positive culture is ceftriaxone 500 mg IM for patients who weigh ≤150 kg and 1 gram IM for patients who weigh ≥150 kg. If the patient has a cephalosporin allergy, the recommended alternative is 240 mg IM plus azithromycin 2 g PO. Screening for gonorrhea again in 3 months is recommended due to the high rates of reinfection.

A 25-year-old woman with hirsutism, obesity, and oligomenorrhea is diagnosed with PCOS. A woman with PCOS is at higher risk for all of the following except? A. Cervical cancer and atrophic vaginitis B. Endometrial cancer and infertility C. Type 2 diabetes and heart disease D. Obesity and nonalcoholic fatty liver disease

Solution: A Cervical cancer and atrophic vaginitis Women with PCOS are not at increased risk of cervical cancer (HPV infection) and atrophic vaginitis (menopause). Women with PCOS have higher androgen levels with insulin resistance. They are at higher risk of certain diseases such as endometrial cancer, infertility, type 2 diabetes, heart disease, obesity, nonalcoholic fatty liver disease, and sleep apnea.

A multigravida who is at 28 weeks' gestation has a fundal height of 29 cm. Which of the following is the best recommendation for this patient? A. Advise the mother that her pregnancy is progressing well B. Order an ultrasound of the uterus C. Refer her to an obstetrician for an amniocentesis D. Recommend bed rest with bathroom privileges

Solution: A Advise the mother that her pregnancy is progressing well Between 20 and 35 weeks, the fundal height is equal to the number of weeks of gestation plus or minus 2 cm. Fundal height is measured as the distance between the pubic bone and the uterine fundus. For example, a woman who is at 30 weeks' gestation who has a fundal height of 29 cm is within normal limits. But if the fundal height is 27 cm (3 cm difference), it is abnormal. Next step is to order a fetal ultrasound.

A 14-year-old female adolescent is worried that she has not started to menstruate like most of her friends. During the gynecological examination, the NP tells the mother, who is in the room with the patient, that her daughter is starting Tanner stage II. What are the physical exam findings during this stage?. A. Breast buds and some straight pubic hair B. Fully developed breasts and curly pubic hair C. Breast tissue with the areola on a separate mound with curly pubic hair D. No breast tissue and no pubic hair

Solution: A Breast buds and some straight pubic hair Tanner stage II in females is noted for breast and papilla elevated as a small mound and increased areola diameter (breast buds). Tanner II pubic hair for females is sparse, lightly pigmented straight hair along the medial border of the labia.

A 35-year-old smoker is being evaluated for birth control choices. The patient has a history of pelvic inflammatory disease (PID) along with an embolic episode after her last pregnancy. The nurse practitioner will recommend: A. Condoms and the vaginal sponge (Today Sponge) B. Estrogen patches C. Intrauterine device D. Depo-Provera (depot medroxyprogesterone)

Solution: A Condoms and the vaginal sponge (Today Sponge). Contraindications for hormonal contraception include migraine headaches; cigarette smoking or obesity in women older than 35 years; history of thromboembolic disease; hypertension or vascular disease if older than 35 years of age; systemic lupus erythematosus with vascular disease, nephritis, or antiphospholipid antibodies; breastfeeding (may use progestin-only pills); hypertriglyceridemia; coronary artery disease; congestive heart failure; and strokes.

A 20-year-old college athlete presents with weight loss and amenorrhea for 6 months. She had a period 7 months ago and denies sexual activity. The patient's body mass index (BMI) has decreased to 16.4, her pulse is 52 beats/min and weak, and her blood pressure is 84/54 mmHg. What will the nurse practitioner assess next? A. Fingerstick glucose B. Exercise routine C. Eating habits D. Medication use

Solution: A Fingerstick glucose. Assessing blood glucose level on this patient is a priority, as hypoglycemia is a complication from secondary amenorrhea. Exercise, eating habits, and medication use would be assessed to determine differential diagnosis, after the glucose test is administered.

A 44-year-old woman who is undergoing treatment for infertility complains of not having had a menstrual period for a few months. The night before, she started spotting and is now having cramp-like pains in her pelvic area. Her blood pressure (BP) is 160/80 mmHg, pulse is 110 beats/min, and she is afebrile. Her labs reveal mild anemia with mild leukocytosis. On pelvic exam, the uterine fundus is noted to be above the symphysis pubis. The cervical os is dilated at 3 cm. Which of the following is most likely? A. Inevitable abortion B. Threatened abortion C. Incomplete abortion D. Acute pelvic inflammatory disease

Solution: A Inevitable abortion. Inevitable abortion is defined as vaginal bleeding with pain, cervical dilation, and/or cervical effacement. Threatened abortion is defined as vaginal bleeding with absent or minimal pain and a closed, long, and thick cervix. Incomplete abortion involves moderate to diffuse vaginal bleeding, with the passage of tissue and painful uterine cramping or contractions. Acute pelvic inflammatory disease is a sudden onset of inflammation and pain that affects the pelvic area, cervix, uterus, and ovaries, and is caused by infection.

The nurse practitioner refers a 12-year-old boy with a swollen, red scrotum and ascending testicle to the ED with a diagnosis of testicular torsion. Which additional objective finding led the nurse practitioner to this diagnosis? A. Missing cremasteric reflex B. Present cremasteric reflex C. Hematuria D. Pyuria

Solution: A Missing cremasteric reflex. Testicular torsion presents with a sudden onset of pain in the scrotum/ testicles, and initially it may be felt in the abdomen and groin. The scrotum will be swollen, in severe cases acute hydrocele is present, and the affected testicle is higher than the unaffected one. Severe nausea and vomiting are common features. The cremasteric reflex is missing, not present. If not corrected within 24 hours, 100% of testicles become gangrenous and must be surgically removed. Hematuria and pyuria are not symptoms of testicular torsion, and urinalysis is generally normal.

The nurse practitioner notes that an 82-year-old male patient's penile gland and foreskin are inflamed. A reddened, moist macular lesion is present on the prepuce. The patient is being treated for a urinary tract infection with amoxicillin. The nurse practitioner will: A. Obtain a swab of the lesion for a potassium hydroxide (KOH) prep B. Prepare the client for a needle biopsy of the lesion C. Obtain a serum sample for a rapid plasma reagin (RPR) test D. Prescribe 0.05% betamethasone cream twice a day for 4 weeks

Solution: A Obtain a swab of the lesion for a potassium hydroxide (KOH) prep. The patient has symptoms associated with balanoposthitis. Fungal infections, specifically candida infections, are commonly associated with the use of antibiotics and are the most common identifiable infectious etiology associated with balanoposthitis. Therefore, the nurse practitioner will obtain a swab of the lesion for a KOH preparation to confirm the diagnosis of a fungal infection. There is no indication that the patient requires a biopsy to determine the cause of the eruption. An RPR test is used to screen for syphilis; the patient does not present with a chancre-type lesion or other findings consistent with syphilis. Prior to prescribing a 0.05% betamethasone cream, the nurse practitioner will confirm the causative agent associated with the diagnosis, as it can promote the exacerbation of a fungal infection.

A 25-year-old woman complains of dysuria, severe vaginal pruritus, and malodorous vaginal discharge. Pelvic examination reveals a strawberry-colored cervix and frothy yellow discharge. Microscopic examination of the discharge reveals mobile organisms that have flagella. The correct pharmacologic therapy for the condition is: A. Oral metronidazole (Flagyl) B. Ceftriaxone sodium (Rocephin) injection C. Doxycycline hyclate (Vibramycin) D. Clotrimazole (Gyne-Lotrimin) cream or suppositories

Solution: A Oral metronidazole (Flagyl). Trichomoniasis symptoms include dysuria, severe vaginal pruritus, and malodorous vaginal discharge. Wet prep microscopic examination should show trichomonads that are pear shaped and have several flagella (whiplike tails) at one end. The Centers for Disease Control and Prevention (CDC) recommendation for treatment is metronidazole. A single dose is effective treatment in most cases of trichomoniasis infections.

What is an abnormal assessment finding in a male newborn at 39 4/7 weeks' gestation? A. Smooth scrotum B. Pendulous scrotum C. Increased scrotal pigmentation D. Smegma beneath the prepuce

Solution: A Smooth scrotum. An infant at 39 4/7 weeks' gestation is considered term newborn. The presence of a smooth scrotum is associated with prematurity. Scrotal rugae and a pendulous scrotum are anticipated newborn assessment findings for a male infant's genitalia. Increased scrotal pigmentation is an incidental finding associated with ethnicity and can also be familial. The presence of smegma beneath the prepuce is normal assessment finding.

A 30-year-old woman complains of having had no period for the past 12 weeks. She is sexually active, and her partner has been using condoms inconsistently. The urine pregnancy test result is positive. Which of the following is a true statement regarding this pregnancy? A. The fundus of the uterus should be at the level of the symphysis pubis B. The cervix should be dilated about 0.5 inches at this time of gestation C. "Quickening" starts during this period D. Hegar's sign is present during this period of pregnancy

Solution: A The fundus of the uterus should be at the level of the symphysis pubis. At 12 weeks' gestation, the fundus of the uterus should be located approximately at the symphysis pubis.

The nurse practitioner is reviewing the laboratory results of a female patient who states that she has had one menstrual period over the last year and is experiencing problems sleeping. The patient's lab results include an estradiol level of 200 pg/mL, follicle-stimulating hormone (FSH) of 35 IU/L, and an anti-müllerian hormone (AMH) level of 0.2 ng/mL. What do the findings indicate? A. The patient is perimenopausal B. The patient is menopausal C. The patient is fertile D. The patient should be tested for ovarian cancer

Solution: A The patient is perimenopausal. The patient's laboratory results indicate that the patient is perimenopausal. The patient's estradiol level reflects a perimenopausal state. The range of estradiol associated with perimenopause is 30 to 400 pg/mL. FSH >30 mIU/mL is indicative of decreased ovarian function, which is associated with perimenopause. An AMH measurement is predictive of ovarian reserve. The level of the AMH declines with age and is a predictor for menopause. An AMH level of <0.5 ng/mL is associated with perimenopause. The patient's laboratory results are not consistent with menopause, which is diagnosed after the menstrual period has been absent for 12 months. The patient does not require testing for ovarian cancer.

The cytology (Pap smear) results for a 35-year-old woman reveal a high-grade squamous intraepithelial lesion (HSIL) of the cervix. The human papillomavirus (HPV) test is positive for the type 16 strain. Place each action in chronological order by dragging it to the correct location. 1. 2. 3. A. Colposcopy B. Loop electrosurgical excision procedure (LEEP) C. Cervical biopsy

Solution: A1, C2, B3. HPV strains 16 and 18 are highly oncogenic. This patient has cervical cancer and requires immediate biopsy, excisional treatment, and staging for cervical cancer. The correct order of these actions is as follows: (1) Refer the patient for a colposcopy, (2) obtain cervical biopsy specimens for pathologic evaluation, and (3) perform LEEP for removal of cancerous cervical tissue.

During a breast exam of a 30-year-old nulliparous woman, the nurse practitioner palpates several rubbery mobile areas of breast tissue. They are slightly tender to palpation. Both breasts have symmetric findings. There are no skin changes or nipple discharge. The patient is expecting her menstrual period in 5 days. The nurse practitioner will: A. Refer the patient to a gynecologist for further evaluation B. Advise the patient to return 1 week after her period so her breasts can be rechecked C. Advise the patient to return in 6 months to have her breasts rechecked D. Schedule the patient for a mammogram

Solution: B Advise the patient to return 1 week after her period so her breasts can be rechecked. Symptoms of fibrocystic breast disease include cyclic tenderness with prominent breast tissue that is present in both breasts. The symptoms are worse about 1 week before menses. A few days after menses starts, the bloating and breast tenderness resolve. Symptoms are caused by elevated hormone levels (progesterone). Fibrocystic disease is differentiated from breast cancer by the lack of a dominant mass or other symptoms such as peau d'orange, dimpling, retraction, or eczema-like rash on the nipples and areolae.

What is the most common cause of balanitis? A. Pseudomonas B. Candida albicans C. Bacteria D. Virus

Solution: B Candida albicans Balanitis is inflammation of the glans penis. It can be caused by an infection, allergic reaction to a soap, or poor hygiene. The most common infectious organism is the yeast Candida albicans. The glans penis will develop redness, shallow ulcers with white base, and curd-like discharge. Risk factors include diabetes, obesity, and uncircumcised penises. Pseudomonas is not associated with balanitis.

A 29-year-old female patient presents to the clinic with complaints of painful sexual intercourse and pain when urinating. The patient's temperature is 100.1°F. Upon physical examination, the nurse practitioner notes a healthy appearance of the internal and external genitalia. The patient has lower abdominal and cervical motion tenderness in response to palpation. What will the nurse practitioner order to confirm a diagnosis and determine the appropriate treatment? A. Blood cultures B. Cervical culture C. Vaginal cultures D. Ultrasound imaging

Solution: B Cervical culture. The patient presents with subjective and objective findings associated with endometritis. Endometritis, an infection of the uterus, can be caused by different organisms. It is most commonly associated with pelvic inflammatory disease (PID) or invasive gynecological procedures in the nonobstetric population. To determine the appropriate treatment, the nurse practitioner will obtain a cervical culture to identify the type of bacteria causing the infection. Vaginal cultures can be easily contaminated and thus may mislead a provider to prescribe inappropriate or inadequate antibiotic coverage. Blood cultures would be obtained if the patient had signs or symptoms of sepsis or bacteremia. Ultrasound imaging would be useful if the patient were postpartum, as it can rule out endometritis caused by retained products of conception, uterine abscesses, or an infected hematoma.

Which of the following is associated with male aging? A. Increased levels of estrogen B. Decreased sperm production C. Increased production of semen D. Decreased concentration of sperm

Solution: B Decreased sperm production. Sperm production decreases as a result of decreased testosterone levels in the aging male. The secretions from the seminal vesicles and prostate gland decrease, resulting in an overall decrease in the volume of the semen produced. Because of the decrease in the production of sperm and secretions from seminal vesicles, the relative concentration of sperm remains consistent in the semen. Low levels of estrogen are associated with low levels of testosterone consistent in the geriatric male.

Which HPV strains are oncogenic and cause the majority of cervical cancer cases? A. HPV 6 and HPV 11 B. HPV 16 and HPV 18 C. HPV 2 and HPV 4 D. HPV 40 and HPV 51

Solution: B HPV 16 and HPV 18 Most cases of cervical cancer are caused by HPV. HPV 16 and HPV 18 cause 70% of cervical cancer in the United States. There are more than 150 HPV types. HPV can also cause cancer of the vulva, vagina, penis, and anus as well as oropharyngeal cancers.

A 30-year-old male with a history of HIV infection has been on antiretroviral therapy (ART) since diagnosis at age 28 years. Which of the following indicates that the patient's immune system is responding to ART? A. The HIV viral load is higher compared with the previous test B. The CD4 count is higher than the previous test C. The CBC shows an increase in the leukocyte count D. HIV genetic testing of the patient's HIV strain shows that it is sensitive to current HIV regimen

Solution: B The CD4 count is higher than the previous test One of the best indicators that the patient is responding to ART regimen is an increase in the CD4 count. Another indicator is a decrease in the viral load. The leukocyte count in the CBC indicates neutrophils; it does not indicate CD4 status.

The mother of a 16-year-old boy is concerned that her son is not developing normally. On physical exam, the patient is noted to have small testes with no pubic or facial hair. What is the most appropriate statement to the mother? A. Her son is developing normally B. Her son's physical development is delayed and should be evaluated by a pediatric endocrinologist C. Her son should be rechecked in 3 months; if he still does not have secondary sexual characteristics, a thorough hormonal workup should be initiated D. Her son's physiologic development is slower than normal but is within the lower limit of normal for his age group

Solution: B Her son's physical development is delayed and should be evaluated by a pediatric endocrinologist. Puberty may be delayed for several years and still occur normally, in which case it is considered constitutional delay, a variation of healthy physical development. Delay of puberty may also occur due to malnutrition, many forms of systemic disease, or defects of the reproductive system (hypogonadism) or the body's responsiveness to sex hormones. Hypogonadism occurs when the sex glands produce little or no hormones. In men, these glands (gonads) are the testes. A 16-year-old male without secondary sexual characteristics should be referred to an endocrinologist. If there is no testicular development by 14 years of age, an endocrinology consult is warranted.

A 35-year-old primigravida who is at 18 weeks' gestation is expecting twins. What would you expect her alpha-fetoprotein (AFP) values to be? A. Normal B. Higher than normal C. Lower than normal D. None of the above

Solution: B Higher than normal. AFP is produced in the fetal and maternal liver. Higher levels of AFP are commonly seen in multiple gestations because of the growing liver in each fetus, which cumulatively lead to higher AFP levels.

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

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

Which of the following medications increases the risk of erectile dysfunction? A. Amoxicillin B. Paroxetine C. Levothyroxine D. Aspirin

Solution: B Paroxetine Paroxetine (Paxil) is an SSRI that can cause erectile dysfunction in males. There are numerous drugs that cause erectile dysfunction, including diuretics, angiotensin-converting enzyme inhibitors (ACEIs), calcium channel blockers (CCBs), beta-blockers, selective serotonin reuptake inhibitors, benzodiazepines, and antihistamines.

A 28-year-old multipara who is at 32 weeks' gestation presents to your office complaining of a sudden onset of small amounts of bright-red vaginal bleeding. She has had several episodes and appears anxious. On exam, her uterus is soft to palpation. Which of the following is most likely? A. Placenta abruptio B. Placenta previa C. Acute cervicitis D. Molar pregnancy (hydatidiform mole)

Solution: B Placenta previa Placenta previa occurs when the placenta implants abnormally, partially, or wholly in the lower segment of the uterus or over the internal os. A classic presentation is painless bright-red vaginal bleeding in the second and/or third trimester. Do not perform any digital cervical exams in any pregnant woman with bleeding until the position of the uterus is known (abdominal ultrasound). Avoid vaginal exam, sexual intercourse, or rectal exam if placenta previa is suspected.

A 28-year-old multipara who is at 32 weeks' gestation presents to your office complaining of a sudden onset of small amounts of bright-red vaginal bleeding. She has had several episodes and appears anxious. On exam, her uterus is soft to palpation. Which diagnosis is most likely? A. Placenta abruptio B. Placenta previa C. Acute cervicitis D. Molar pregnancy (hydatidiform mole)

Solution: B Placenta previa. Placenta previa occurs when the placenta implants abnormally, partially, or wholly in the lower segment of the uterus or over the internal os. A classic presentation is painless bright-red vaginal bleeding in the second and/or third trimester. Do not perform any digital cervical exams in any pregnant women with bleeding until the position of the uterus is known (abdominal ultrasound). Avoid vaginal exam or rectal exam if placenta previa is suspected, and advise the patient to avoid sexual intercourse.

Which of the following is the most common cause for secondary amenorrhea? A. Polycystic ovaries B. Pregnancy C. Anorexia nervosa D. Physiologic delay of puberty

Solution: B Pregnancy Secondary amenorrhea is defined as no menses for more than three cycles or 6 months in a female who already has a menstrual cycle. The most common cause is pregnancy. Others are ovarian disorders, stress, anorexia, and polycystic ovary syndrome.

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 lb 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

Solution: B Pregnancy-induced hypertension (preeclampsia) This patient is manifesting the classic triad of symptoms of preeclampsia: hypertension, edema (weight gain), and proteinuria.

Hegar's sign is considered a: A. Positive sign of pregnancy B. Probable sign of pregnancy C. Presumptive sign of pregnancy D. Problem in pregnancy

Solution: B Probable sign of pregnancy Hegar's sign is softening of the lower portion of the uterus and is considered a probable sign of pregnancy.

A sexually active adult female presents to the clinic complaining of genital ulcers. Upon examination, white wartlike papules are found in the inguinal area and a maculopapular rash is noted on the palms and soles of the feet. The nurse practitioner will order: A. Gram stain B. Rapid plasma reagin test C. Nucleic acid amplification test (NAAT) D. HIV-1/HIV-2 antibody and P24 antigen test

Solution: B Rapid plasma reagin test. These wartlike lesions (condylomata lata) and rash on palms and soles of feet indicate a probable syphilis infection. Two types of syphilis serologic tests (treponemal and nontreponemal tests) are needed to diagnose syphilis. Step 1—Order screening test (nontreponemal tests): rapid plasma reagin (RPR) or venereal disease research laboratory (VDRL). If reactive, order confirmatory test. Step 2—Order confirmatory test (treponemal tests): fluorescent treponemal antibody absorption (FTA-ABS), microhemagglutination test for antibodies to Treponema pallidum (MHA-TP). A Gram stain to look for gram-negative diplococci in clusters is not typically used in primary care. It is useful in diagnosing gonorrhea. NAATs are highly sensitive tests for both gonorrhea and chlamydia. HIV-1/ HIV-2 antibody and P24 antigen tests (combination assay) are ordered for suspected infection with HIV.

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

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

High-grade squamous interepithelial lesions (HSILs) were found in a Pap specimen for a 26-year-old patient. The nurse practitioner will: A. Test the specimen with a potassium hydroxide slide B. Refer the patient for loop electrosurgical excision procedure C. Refer the patient for colposcopy with cervical biopsy D. Administer vaccination for human papillomavirus (HPV)

Solution: B Refer the patient for loop electrosurgical excision procedure. HSILs are likely to be associated with precancer and cancer. If they are found in patients aged 25 years or older, the patient should be referred for immediate excisional treatment by LEEP or cervical conization surgery. A potassium hydroxide slide is useful in the diagnosis of fungal infections. Colposcopy is appropriate for HSIL found in younger women (aged 21-24). Quadrivalent recombinant vaccination can prevent HPV, which is associated with cervical cancer, but once the patient has HSIL, administration of the vaccination would not be useful.

A 22-year-old presents for her annual gynecological exam and testing. The Pap smear result shows ASC-US. Which of the following is the best management for this patient? A. Check for high-risk HPV B. Repeat Pap in 12 months C. Refer patient for colposcopy D. Refer patient for endometrial biopsy

Solution: B Repeat Pap in 12 months The appropriate follow-up for a 22-year-old with a Pap smear result of ASC-US is to perform a repeat Pap smear in 12 months. HPV testing is not recommended for this age group with ASC-US. A colposcopy is not recommended for ASC-US, as most cases clear spontaneously in young women. An endometrial biopsy is not appropriate follow-up for ASC-US, since it does not involve the endometrium.

The nurse practitioner is evaluating a 72-year-old male patient newly diagnosed with benign prostatic hyperplasia (BPH). The patient has difficulty starting a urine stream, and urinary retention is noted upon exam. The patient takes sublingual nitroglycerin as needed for angina. Which medication will the nurse practitioner prescribe? A. Tadalafil (Cialis) 5 mg PO once daily B. Tamsulosin (Flomax) 0.4 mg PO once daily C. Oxybutynin (Ditropan) 5 mg PO once daily D. Vardenafil (Levitra) 10 mg PO once daily

Solution: B Tamsulosin (Flomax) 0.4 mg PO once daily. Tamsulosin (Flomax), an alpha-adrenergic antagonist, is the first-line agent for the treatment of BPH. Tadalafil (Cialis) and Vardenafil (Levitra) are phosphodiesterase-5 (PDE5) inhibitors used to treat erectile dysfunction (ED). Tadalafil can be prescribed for combined BPH and erectile dysfunction; however, it is contraindicated in patients who take nitrates due to risk of adverse cardiac effects. Oxybutynin (Ditropan) is an anticholinergic agent that is used to treat urinary incontinence.

Puberty begins during which Tanner stage? A. Tanner stage I B. Tanner stage II C. Tanner stage III D. Tanner stage IV

Solution: B Tanner stage II. Puberty is defined as the period in life when secondary sexual characteristics begin to develop, identified as Tanner stage II for boys and girls.

When an adolescent male's penis grows more in length than width, in which of the following Tanner stages is he classified? A. Tanner stage II B. Tanner stage III C. Tanner stage IV D. Tanner stage V

Solution: B Tanner stage III In Tanner stage III in males, the testicular volume increases, the scrotum enlarges, and the penis begins to lengthen. Tanner stages are I: Prepubertal small penis; II: The penis length remains unchanged; III: Penis begins to lengthen; IV: Penis increases in length and circumference; and V: Scrotum and penis are mature size.

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

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

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

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

Which assessment finding is expected in a 3-year-old male with penopubic epispadias? A. Fused pelvic bones B. Urine leakage with stress C. Narrow penis that curves down D. Urinary meatus found along shaft of penis

Solution: B Urine leakage with stress. In penopubic epispadias, the urethral meatus is found near the pubic bone. The position of the meatus helps predict how well the bladder stores urine. When the bladder sphincter is shaped more like a horseshoe than a ring, it does not close all the way. Because of this, urine leaks out. Most boys with penopubic epispadias and about two of three with penile epispadias leak urine with stress. In most cases of penopubic epispadias, the bones of the pelvis do not come together in the front. In boys with epispadias, the penis tends to be broad, short, and curved up. In penile epispadias, the urinary meatus is found along the shaft. In penopubic epispadias, it is found on or near the pubic bone.

An obese 28-year-old female patient is seen in the office with acne, hirsutism, and oligomenorrhea. Blood is drawn for a free androgen index (FAI), and results reveal a 9.8 level. The diagnosis is polycystic ovary syndrome (PCOS), which puts the patient at additional risk for which condition(s)? (Select all that apply.) A. Congestive heart failure B. Metabolic syndrome C. Infertility D. Type 2 diabetes mellitus E. Endometriosis

Solution: B, C, D Metabolic syndrome; infertility; type 2 diabetes mellitus. A diagnosis of PCOS carries with it a risk of developing coronary heart disease (CHD), type 2 diabetes mellitus, metabolic syndrome, and infertility because of the high levels of androgens in the body. Endometriosis and CHF are not complications of PCOS.

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

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

A 32-year-old sexually active female is diagnosed with bacterial vaginosis based on findings of copious milklike vaginal discharge. Speculum exam reveals gray/white discharge on the vaginal walls and fishlike odor based on the whiff test. The patient will be treated with a 5-day course of metronidazole vaginal gel, one application at bedtime, and advised to do which of the following? A. Douche after intercourse B. Ensure that sexual partner is seen and treated C. Abstain from sexual intercourse during treatment D. Use a condom during sexual intercourse

Solution: C Abstain from sexual intercourse during treatment. The patient would be advised to abstain from sexual intercourse until treatment is complete. Douching can alter the normal vaginal pH and be a root cause of overgrowth of bacteria. Bacterial vaginosis is not considered a sexually transmitted infection (STI); therefore, the Centers for Disease Control and Prevention does not recommend treatment of sexual partners.

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

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

The following conditions are absolute contraindications for the use of oral contraceptives, except: A. Sexually active patient with amenorrhea B. History of emboli that resolved with heparin therapy 15 years ago C. Cigarette smoking at the age of 30 years D. Hepatitis C infection

Solution: C Cigarette smoking at the age of 30 years. Cigarette smoking at age 30 years is considered a relative— not absolute—contraindication. However, in a patient aged 35 years or older, smoking is an absolute contraindication. Pregnancy or suspected pregnancy is another absolute contraindication (sexually active woman who presents with amenorrhea). Liver tumors or impaired liver function is also an absolute contraindication (hepatitis C infection).

A 35-year-old woman smokes approximately 10 cigarettes per day. She started smoking at the age of 18 years. She has a new male sexual partner and is interested in contraception. She was recently treated for gonorrhea and chlamydia. She is using condoms inconsistently. The urine pregnancy test is negative. She denies a history of hypertension, blood clots, liver disease, heart disease, and diabetes. Her last menstrual period was 5 days ago. Which of the following contraceptive methods is recommended? A. Oral contraceptive pills B. Copper IUD C. Etonogestrel implant (Nexplanon) D. Vaginal ring (NuvaRing)

Solution: C Etonogestrel implant (Nexplanon) An etonogestrel implant (Nexplanon) is the best option for this patient. It is a progesterone-only method. The 35-year-old patient is a smoker, so she cannot take oral contraceptives, which contain estrogen/progesterone. An IUD (copper or progestin) is contraindicated until the patient is retested (4-6 weeks after treatment) to ensure that her gonorrhea and chlamydia infections are gone. The vaginal ring (NuvaRing) contains estrogen and progesterone; it is contraindicated for this patient.

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

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

While examining the genitalia of a male patient, the nurse practitioner observes distended scrotal veins. The nurse practitioner: A. Examine the patient in a supine position B. Examine the patient in a sitting position C. Instruct the patient to perform a Valsalva maneuver D. Assess the testicular size with an orchidometer

Solution: C Instruct the patient to perform a Valsalva maneuver. The nurse practitioner will instruct the patient to perform a Valsalva maneuver, generally in a standing position. This action will cause the distention of the veins of the pampiniform plexus and assist in evaluation for possible scrotal abnormalities such as varicocele. The patient sitting or laying supine may not yield accurate assessment findings. An orchidometer is used to measure the size of the testes, not to evaluate for scrotal abnormalities.

Which test will the nurse practitioner order for a patient with symptoms of chronic prostatitis? A. Urinalysis B. Prostate-specific antigen C. Meares-Stamey 2-glass test D. Gram stain of urethral swab

Solution: C Meares-Stamey 2-glass test. The Meares-Stamey 2-glass test is used to assess for inflammation and the presence of bacteria in the lower urinary tract, findings that are associated with symptoms of chronic prostatitis. Urinalysis may reveal infection, but it may not be related specifically to chronic prostatitis. A prostate-specific antigen (PSA) level is not a specific test for identifying inflammation or the presence of bacteria associated with chronic prostatitis. A gram stain of a urethral swab can be used to evaluate the patient for a sexually transmitted infection associated with acute bacterial prostatitis.

A 42-year-old female patient presents with difficulty conceiving despite following ovulation indicators and timing intercourse accordingly. The nurse practitioner suspects "false-positive" ovulation results and refers the patient to a fertility specialist for evaluation of all of the following conditions, except: A. Polycystic ovarian syndrome (PCOS) B. Ovarian insufficiency C. Ovarian cancer D. Endometriosis

Solution: C Ovarian cancer. False-positive results in ovulation tests that detect the urinary luteinizing hormone (LH) can occur in women who are menopausal or have PCOS, endometriosis, or ovarian insufficiency. Ovarian cancer is not suspected in this patient because there are no obvious complaints of abdominal pain/back ache, fatigue, or changes in bowel movement.

Which treatment is recommended for an infant with noncommunicating hydrocele? A. Surgery B. Medication C. Reassess in 1 year D. Centesis

Solution: C Reassess in 1 year. A noncommunicating hydrocele occurs when the sac closes normally around the testicle during development, but the body does not absorb the fluid inside it. This type of hydrocele is common in newborns and usually disappears without treatment by 1 year of age. Surgery is recommended for a communicating hydrocele (when the sac does not seal) because the scrotum may swell more over time. There are no drugs available to treat hydrocele. Needle aspiration (centesis) is commonly performed on adult men who are at high risk for complications during surgery.

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

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

A 15-year-old female patient in Tanner stage II states, "I had my first period about 6 months ago, but I haven't had one since." Which diagnostic would be ordered first? A. CT scan B. Prolactin levels C. Serum pregnancy test D. Examination of chromosomes

Solution: C Serum pregnancy test. Tanner stage II indicates normal physical development congruent with menarche. A serum pregnancy test would be ordered first to determine if the patient is not menstruating because of pregnancy. If there is no pregnancy, further testing would be done. Prolactin levels would be high in pregnancy and during lactation. A CT scan of the abdomen and pelvis would identify tumors in the ovaries or adrenal glands. Examination of chromosomes in a sample of tissue (such as blood) would be performed to check for genetic disorders.

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

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

All of the following are true statements about sexuality in the older adult, except: A. Erectile dysfunction is very common B. It may take longer to become aroused C. The elderly are no longer interested in sexuality D. Dyspareunia is a common symptom of atrophic vaginitis

Solution: C The elderly are no longer interested in sexuality Some studies have shown that older adults in their 80s can remain sexually active. By the age of 70 years, about 70% of males have erectile dysfunction (ED). Refer patient to urologist for treatment of ED that is not responding to usual doses of phosphodiesterase (PDE) inhibitors (sildenafil [Viagra], tadalafil [Cialis], vardenafil [Levitra], avanafil [Stendra]) or has medical contraindications. Advise patient to use condoms with new sexual partners to protect from sexually transmitted infections, including HIV infection.

A 13-year-old boy is brought in by his mother for a physical exam. During the genital exam, the nurse practitioner notices that the patient is at Tanner stage II. Which of the following is the best description of this Tanner stage? A. The penis is growing more in length than in width, the testicles become larger with darker scrotal skin, and the pubic hair is starting to curl B. The penis is growing more in width than in length with darker scrotal skin and more numerous pubic hairs that are darker, curly, and more coarse. C. The testicles become larger, and the skin of the scrotum starts to become darker with straight, fine, countable hairs on the genitals and the axilla D. The testicles and penile width and length are developing quickly

Solution: C The testicles become larger, and the skin of the scrotum starts to become darker with straight, fine, countable hairs on the genitals and the axilla. Tanner stage II is when the testicles start to grow. The scrotal skin becomes thicker and starts to get darker (hyperpigmentation). The pubic hair is of a fine texture and straight, and there are few countable hairs on the genitals and the axilla.

A male patient presents with reports of urethritis, migratory arthritis in the large joints, and ulcers on the glans penis secondary to a chlamydial infection. The nurse practitioner will implement all of the following interventions, except: A. Treat with nonsteroidal anti-inflammatory drugs (NSAIDs) B. Prescribe antibiotics to treat infection C. Treat with alpha-linolenic acid (LNA) D. Recommend rest and comfort measures

Solution: C Treat with alpha-linolenic acid (LNA). Reiter's syndrome is an immune-mediated reaction secondary to chlamydia that causes red, swollen joints; ulcers on the skin of the glans penis; and urethritis. It resolves on its own. Treatment is NSAIDs and comfort measures. Treatment with antibiotics will address the underlying cause, which is chlamydia. LNA is used in the treatment of ankylosing spondylosis.

The Jarisch-Herxheimer reaction is a response to treatment of which of the following organisms? A. Neisseria gonorrhoeae B. Chlamydia trachomatis C. Treponema pallidum D. Rickettsia rickettsii

Solution: C Treponema pallidum The Jarisch-Herxheimer reaction is an immune reaction caused by treatment of the spirochete Treponema pallidum (syphilis) with benzathine penicillin G, given by IM injection. When large amounts of treponema are killed, it releases foreign antigens that the body responds to with symptoms such as fever, chills, headache, myalgia, tachycardia, and increased respiratory rate that occurs in the first few hours after treatment and peaks in 6 to 8 hours. It is a self-limited reaction. Treatment is corticosteroids, antipyretics, and general supportive measures. Other spirochete bacteria that may elicit this reaction are Borrelia burgdorferi (Lyme disease) and Leptospira (leptospirosis, also known as Weil's disease or swamp fever).

Which diagnostic test is used to confirm a diagnosis of vaginal candida infection? A. pH B. Whiff test C. Wet mount D. Tzanck smear

Solution: C Wet mount. A wet mount can be used to diagnose vaginal candidiasis. Vaginal pH is not explicitly used to validate a diagnosis of vaginal candida infection. A whiff test is used to diagnose bacterial vaginitis. Although not commonly used, the Tzanck smear can be used to evaluate a herpetic infection.

Which of the following factors will not increase a woman's risk of developing breast cancer? A. Moderate-to-high intake of alcohol B. Onset of menstruation at 10 years of age C. First pregnancy at age 30 years or older D. Body mass index of 23

Solution: D Body mass index of 23 A woman with a body mass index (BMI) of 23 is at normal weight (normal BMI: 18.5-24.9), which is not considered as a risk factor for breast cancer. Risk factors for breast cancer include obesity (BMI of 30 or higher); older age; moderate-to-high intake of alcohol; first pregnancy at age 30 years or older; early menarche (before age 12 years); late menopause (age 55 or older); history of breast mass with atypical hyperplasia; positive family history; and genetic mutations, such as BRCA 1/2 .

A nurse practitioner sees a patient for an evaluation of sexually transmitted diseases. Assessment reveals Fitz-Hugh-Curtis syndrome. The nurse practitioner will prescribe: A. Benzathine penicillin G 2.4 mU IM weekly × 3 weeks B. Doxycycline 100 mg PO BID × 14 days C. Ceftriaxone 500 mg IM × one dose plus azithromycin 1 g PO × one dose D. Ceftriaxone 500 mg IM × one dose plus doxycycline 100 mg BID × 14 days plus metronidazole 500 mg BID × 14 days

Solution: D Ceftriaxone 500 mg IM × one dose plus doxycycline 100 mg BID × 14 days plus metronidazole 500 mg BID × 14 days. Fitz-Hugh-Curtis syndrome should be treated as a complicated gonorrheal/chlamydial infection: Ceftriaxone 500 mg IM × one dose plus doxycycline 100 mg BID × 14 days plus metronidazole 500 mg BID × 14 days for anaerobic coverage. Benzathine penicillin G 2.4 mU IM weekly × 3 weeks is used to treat complicated syphilis infections. Doxycycline 100 mg PO BID × 14 days is an appropriate regimen to treat complicated chlamydial infections. A pregnant patient with confirmed uncomplicated gonorrheal and chlamydial infections would be prescribed ceftriaxone 500 mg IM × one dose plus azithromycin 1 g PO × one dose.

A middle-aged male patient being treated for benign prostatic hypertrophy (BPH) presents to the clinic for a follow-up appointment. He reports that over the past few days, he has experienced painful ejaculation and pain during urination. The patient's prostate is enlarged and boggy, and the patient experiences discomfort during the examination. Which treatment will the nurse practitioner prescribe? A. Cefixime (Suprax) 400 mg single dose PO B. Ceftriaxone (Rocephin) 250 mg single dose IM C. Doxycycline 100 mg PO BID × 10 days D. Ciprofloxacin (Cipro) 500 mg PO BID × 10 days

Solution: D Ciprofloxacin (Cipro) 500 mg PO BID × 10 days. The patient's symptoms and clinical findings are consistent with a diagnosis of acute bacterial prostatitis. The patient can be treated with ciprofloxacin (Cipro) 500 mg PO BID × 10 days. There is no indication that the patient's acute bacterial prostatitis is related to a sexually transmitted infection; therefore, treatment with cefixime (Suprax), ceftriaxone (Rocephin), and doxycycline would not be indicated. Cefixime 400 mg single dose PO and ceftriaxone 250 mg single dose IM are prescribed for patients with acute bacterial prostatitis who are at risk for sexually transmitted infections. If neither cefixime nor ceftriaxone resolves the infection for these patients, doxycycline 100 mg PO BID × 10 days can be prescribed.

A 14-year-old male patient presents with acute pain in his left testicle radiating to the lower abdomen lasting for 2 hours. Which of the following is the best intervention? A. Manual detorsion B. Radioisotope scrotal scanning C. Referral for immediate surgery D. Color Doppler ultrasonography

Solution: D Color Doppler ultrasonography. These symptoms are an indication of testicular torsion, which is a medical emergency. Since all blood for the testicle comes through the spermatic cord, the blood supply is cut off with a twist. The testicle will shrink (atrophy) if the blood supply is not restored within 6 hours. The spermatic cord needs to be untwisted (detorsion) to restore the blood supply. An equivocal diagnosis may be resolved by immediate imaging, if available. Color Doppler ultrasonography of the scrotum is preferred and needs to be performed immediately. Radioisotope scrotal scanning is also diagnostic but takes longer and is less useful. Immediate manual detorsion without imaging can be attempted during the initial examination with variable success. Because testes usually rotate inward, for detorsion the testis is rotated in an outward direction (e.g., for the left testis, detorsion is clockwise when viewed from the front, underneath the testis). More than one rotation may be needed to resolve the torsion. If detorsion fails, immediate surgery is indicated, because exploration within a few hours offers the only hope of testicular salvage. One study found that nearly three in four patients require testicle removal (orchidectomy) if surgery is delayed past 12 hours.

Which assessment finding demonstrates that use of a vaginal dilator for atrophic vaginitis has been effective? A. Atrophic labia B. Decreased rugae C. Narrowing of the vagina D. Decreased discomfort with sexual activity

Solution: D Decreased discomfort with sexual activity. Vaginal atrophy (atrophic vaginitis) is thinning, drying, and inflammation of the vaginal walls that may occur when the body has less estrogen, as with postmenopausal women. If painful sex is a concern, vaginal dilators may relieve vaginal discomfort by stretching to widen the vaginal canal to assist in reducing discomfort during intercourse. Atrophic labia and decreased rugae are symptoms of atrophic vaginitis.

A female patient experiencing frequent urinary tract infections (UTIs) and vaginal infections is being seen in the office for the third time in 7 months with complaints of urinary burning and frequency, vaginal discharge, and severe itching. The nurse practitioner orders testing for which possible underlying condition? A. Diabetes insipidus B. Anemia C. Helicobacter pylori infection D. Diabetes mellitus

Solution: D Diabetes mellitus. Persistent urinary and vaginal infections may indicate underlying glucose metabolism disorders and diabetes mellitus. Diabetes insipidus is a rare metabolic disorder affecting fluid balance (excessive fluid intake and urination) in the body and would not be screened for with the symptomatology of this case. H. pylori is a bacterial infection of the digestive tract and would not manifest as vaginal discharge or itching. Anemia is not a possible underlying cause for frequent UTIs or vaginal infections.

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

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

Following a routine annual exam of a 59-year-old postmenopausal patient, the nurse practitioner refers the patient to a gynecologist, who then orders a pelvic/intravaginal ultrasound. Which finding on the exam most likely prompted the referral and subsequent order? A. Positive Pap smear B. External genital warts C. Vaginal atrophy D. Palpable ovary

Solution: D Palpable ovary. The ovaries of a postmenopausal woman should not be palpable; this is an abnormal finding that needs to be investigated. A referral to the gynecologist and an order for a pelvic/intravaginal ultrasound is standard to rule out cancer. A positive Pap smear LSIS (lowgrade squamous intrathecal lesion) indicates abnormality of the cervix and would be diagnosed further with colposcopy with conization. A finding of external genital warts would prompt internal examination of the vagina and cervix with colposcopy. Vaginal atrophy is an expected finding in postmenopausal women.

A 13-year-old male is brought to an outpatient clinic by his father with a complaint of a sudden onset of severe left testicular pain. The patient is very nauseous and has already vomited a few times. Physical exam reveals a red, swollen, and tender left scrotum. There is no cremasteric reflex. The abdomen is soft, with no rebound or localized tenderness. Bowel sounds are positive. Which of the following is recommended for this patient? A. Recommend increased fluid intake and the BRAT diet (bananas, rice, apple sauce, and dry toast) B. Order an ultrasound of the left scrotum C. Refer the patient to a urologist; give the patient's father the contact information D. Refer the patient to the ED as soon as possible

Solution: D Refer the patient to the ED as soon as possible The sudden onset of testicular pain, with a missing cremasteric reflex accompanied by nausea and vomiting, is highly suggestive of testicular torsion. This is a urological emergency, so refer the patient to the ED as soon as possible. After 6 hours of onset, the risk of the testicle becoming gangrenous increases. The ED will page the urologist on call. An ultrasound of the left scrotum will be done on the ED.

The results of a Pap test performed on a 21-year-old woman state, "Atypical squamous epithelial cells present. No endocervical cells present." The nurse practitioner will: A. Test for human papillomavirus (HPV) B. Perform an endometrial biopsy C. Refer for colposcopy D. Repeat the test as soon as possible

Solution: D Repeat the test as soon as possible. A specimen is satisfactory only if both squamous epithelial cells and endocervical cells are present. If lacking either type of cell, the specimen is incomplete, and the test needs to be repeated. Atypical squamous cells are cause for concern in a complete specimen. When atypical squamous cells of undetermined significance are found in women age 25 to 29, a HPV test should be performed. An endometrial biopsy is indicated if there are atypical glandular cells in the presence of endometrial cells. A referral for colposcopy is needed only if atypical cells are found in an acceptable specimen in women age 30 years or older. A colposcopy would be recommended for a 21-year-old woman only if high-grade squamous intraepithelial lesions were found.

During a routine digital rectal exam, a hard, fixed nodule is detected on the prostate gland of a 55-year-old male patient. The patient's prostate-specific antigen (PSA) is 4.1 ng/mL. Which of the following will the nurse practitioner order? A. CT of the abdomen B. Radionuclide bone scan C. Measurement of serum acid phosphatase D. Transrectal ultrasound-guided needle biopsy

Solution: D Transrectal ultrasound-guided needle biopsy. A PSA level of ≥4 ng/mL is considered an indication for biopsy in men >50 years. Although very high levels are significant (suggesting extracapsular extension of the tumor or metastases) and the likelihood of cancer increases with higher PSA levels, there is no cutoff below which there is no risk. CT or MRI of the abdomen and pelvis is commonly done to assess pelvic and retroperitoneal lymph nodes if the Gleason score is 8 to 10 and the PSA is >10 ng/mL. Radionuclide bone scans are rarely helpful for finding bone metastases (they are frequently abnormal because of the trauma of arthritic changes) until the PSA is >20 ng/ mL. Elevated serum acid phosphatase correlates well with the presence of metastases, particularly in lymph nodes. However, this enzyme may also be elevated in benign prostatic hyperplasia (BPH) and is slightly elevated after vigorous prostatic massage.

A 17-year-old boy reports feeling something on his left scrotum. On palpation, soft and movable blood vessels that feel like a "bag of worms" are noted underneath the scrotal skin. The testicle is not swollen or reddened. The most likely diagnosis is: A. Chronic orchitis B. Chronic epididymitis C. Testicular torsion D. Varicocele

Solution: D Varicocele. Palpation of varicose veins, described as a "bag of worms," in the scrotum is a classic symptom of a varicocele, an abnormal tortuosity and dilation of the veins of the pampiniform plexus within the spermatic cord. It is most common on the left side and may be associated with pain. It occurs in boys and young men and is associated with reduced fertility. The condition is often visible only when the patient is standing. Chronic epididymitis and chronic orchitis are caused by a bacterial infection and commonly cause burning, urinary frequency, and pain. Testicular torsion is an emergent condition in which the testicle becomes twisted, interrupting the blood supply to the testis; to avoid damage, the condition must be corrected within 6 hours.

All of the following would require the nurse practitioner to delay testing a patient's prostate-specific antigen (PSA), except: A. Urinary retention B. Urinary tract infection C. After a digital rectal exam D. Vigorous exercise 3 days prior

Solution: D Vigorous exercise 3 days prior. PSA testing is falsely elevated in a patient with urinary retention, urinary tract infection, and after a digital rectal exam. Vigorous exercise does not have to be stopped 3 days prior to testing; however, vigorous exercise should be discouraged before testing because it will falsely elevate the PSA levels. Ejaculation within 48 hours will also falsely raise the PSA level.