NR511 Davis Edge Final

1. Betty, age 40, has had type 1 diabetes for 20 years and takes a combination of neutral protamine Hagedorn (NPH) and regular insulin every day. She comes to the office because she has developed a severe upper respiratory infection with chills, fever, and production of yellow sputum. Because of her acute infection, you know that Betty is likely to require: a. A decrease in her daily insulin dosage. b. An increase in her daily insulin dosage. c. A high-calorie dietary intake and no insulin change. d. A change in her insulin from NPH to insulin aspart (Novolog).

An increase in her daily insulin dosage

1. When teaching Marcy how to use her new insulin pump, you tell her that she needs to monitor her blood glucose level: a. At least once a day. b. Only occasionally because glycemic levels are maintained very steadily. c. At least 4 times a day. d. On an as needed basis when she feels she needs to give herself an extra dose of insulin.

At least 4 times a day.

1. Sara, age 40, has diabetes and is now experiencing anhidrosis on the hands and feet, increased sweating on the face and truck, dysphagia, anorexia, and heartburn. Which complication of diabetes do you suspect? a. Macrocirculation changes. b. Microcirculation changes. c. Peripheral neuropathies. d. Autonomic neuropathies.

Autonomic neuropathies

1. Which class of antihypertensive agents may be problematic for clients with diabetes? a. Angiotensin-converting enzyme (ACE) inhibitors. b. Calcium channel blockers. c. Beta blockers. d. Alpha blockers.

Beta blockers.

1. Marsha, age 24, is preparing for radioactive iodine therapy for her Graves disease. Which test must she undergo first? a. Beta-human chorionic gonadotropin b. Basal metabolism rate c. Lithium level d. Serum calcium

Beta-human chorionic gonadotropin

1. Joy has gout. In teaching her about her disease: which food do you tell her is allowed on the diet? a. Asparagus. b. Beans. c. Broccoli. d. Mushrooms.

Broccoli.

1. Mindy is scheduled to have an oral glucose tolerance test (OGTT). she is instructed to discontinue many of her medications for three days before the test period which one is it safe to continue taking? a. Vitamin C. b. Aspirin. c. Calcium. d. Oral contraceptives.

Calcium.

A 55-year-old patient presents with complaints of paresthesias in the lower lateral arm, thumb, and middle finger. The nerve roots most commonly related to these symptoms are C6 and C7. The most likely diagnosis would be: 1. Brachial plexus neuritis. 2. Cervical radiculopathy. 3. Peripheral polyneuropathy. 4. Thoracic outlet syndrome.

Cervical nerve root compression of C6 and C7 causes cervical radiculopathy.

1. Jennifer has diabetes mellitus (DM) and is injecting 30 units of Novolin 70/30 with breakfast and 18 units at bedtime. She is complaining that she woke up once in the middle of the night with palpitations and sweating. Based on this information, what do you recommend? a. Decreasing the am dose of 70/30. b. Decreasing the pm dose of 70/30. c. Eating a snack before going to bed. d. Changing the time of the nighttime insulin injection.

Changing the time of the nighttime insulin injection.

1. a patient presents to your primary care office with abnormal lab results. On physical exam, he the patient's facial nerve around the zygomatic arch anterior to the earlobe. This describes which of the following tests and is associated with which of the following lab abnormalities? a. Trousseau sign, hypocalcemia. b. Chvostek sign, hypocalcemia. c. Chvostek sign hypercalcemia. d. Lachman test hypercalcemia.

Chvostek sign, hypocalcemia.

1. Juanita, age 23, complains of palpitations that started a few weeks ago; the occur 2 to 4 times a day and last 5 to 10 minutes. She feels nervous and is having trouble sleeping. Her stools have been frequent (1-3 per day) and loose. She is taking levothyroxine 150 mcg daily. Her labs indicated free thyroxine (T4) 2.28 and thyroid-stimulating hormone (TSH) 0.022. She has a history of Graves disease and had radioactive iodine (RAI) treatment a few months ago. She has been on thyroid replacement for 2 months. Based on these data, you decide to: a. Increase the levothyroxine dosage. b. Decrease the levothyroxine dosage. c. Keep the dosage the same. d. Start propranolol every 8 hours.

Decrease the levothyroxine dosage.

1. A client with diabetes on a sulfonylurea and metformin with a glycated hemoglobin (HBA1C) Of 6.5% is complaining of episodes of low blood sugar. Which of the following changes would be most appropriate? a. Decreasing the dosage of the metformin b. Discontinuing the metformin c. Increasing carbohydrate intake d. Decreasing the dosage of the sulfonylurea.

Decreasing the dosage of the sulfonylurea.

Mrs. Kelly, age 80, has a curvature of the spine. This is likely to indicate which age-related change? 1. Lordosis. 2. Dorsal kyphosis. 3. Scoliosis. 4. Kyphoscoliosis.

Dorsal kyphosis, an exaggerated convexity of the thoracic curvature, typically accompanies the aging process.

1. Mary, age 72, has been taking insulin for several years. She just called you because she realized that yesterday she put her short-acting insulin in the long-acting insulin box and vice versa. She just took 22 units of regular insulin when she was supposed to take only 5 units. She says that she tried to take a fingerstick to test her glucose level but was unable to obtain any blood. She states that she feels fine. What do you tell her to do first? a. "Keep trying to get a fingerstick and call me back with the results." b. "Call 911 before you collapse." c. "Drive immediately to the emergency room." d. "Drink 4 ounces of fruit juice."

Drink 4 ounces of fruit juice."

1. You suspect that Sharon has hypoparathyroidism because, in addition tto her other signs and symptoms, she has: a. Elevated serum phosphate levels. b. Elevated serum calcium levels. c. Decreased neuromuscular activity. d. Increased bone resorption, as implied by her bone density test.

Elevated serum phosphate levels.

1. Harriet, age 62, has type 1 diabetes that is well controlled by insulin. Recently, she has been having marital difficulties that have left her emotionally upset. As a result of this stress, it is possible that she will: a. Have an insulin reaction more readily than usual. b. Have an increased blood sugar level. c. Need less daily insulin. d. Need mor carbohydrates.

Have an increased blood sugar level.

1. A client with newly diagnosed diabetes who has a glycated hemoglobin (HbA1c) of 7.5 is started on therapeutic lifestyle changes (TLCs) and medical nutrition therapy (MNT). Which oral antidiabetic agent is recommended as monotherapy? a. Glipizide (Glucotrol). b. Sitagliptin (Januvia). c. Exenatide (Byetta). d. Metformin (Glucophage).

Metformin (Glucophage).

Upon assessment, the nurse practitioner notes unilateral back pain of acute onset that increases when standing and bending. A straight leg raise test is negative. The most likely diagnosis is: 1. Herniated nucleus pulposus. 2. Muscle strain. 3. Osteoarthritis. 4. Spondylolisthesis.

Muscle strain is usually located in the low back and is unilateral in location. The onset is acute, and pain increases with standing and bending and decreases with sitting. The straight leg raise test and plain x-ray are both negative.

Marsha, age 34, presents with symptoms resembling both fibromyalgia and chronic fatigue syndrome, which have many similarities. Which of the following is more characteristic of fibromyalgia than of chronic fatigue syndrome? 1. Musculoskeletal pain. 2. Difficulty sleeping. 3. Depression. 4. Fatigue.

Musculoskeletal pain is not characteristic of chronic fatigue syndrome; rather, it is characteristic of fibromyalgia. The musculoskeletal pain, usually an achy muscle pain that may be localized or involve the entire body, is usually gradual in onset, although the onset may occasionally be sudden, such as after a viral illness.

1. Steve, age 42, has never been hypertensive but appears today in the office with a blood pressure of 162/100 mm Hg. He also complains of "attacks" of headaches, perspiration, and palpitations, with frequent bouts of nausea, pain, weakness, dyspnea, and visual disturbances. He ahs lost 10lb over the past 2 months and seems very anxious today. Your next action would be to: a. Start him on an antianxiety agent. b. Obtain a 24-hour urine test for catecholamines. c. Start him on a diuretic or beta blocker d. Recheck his blood pressure in 1 week.

Obtain a 24-hour urine test for catecholamines.

1. Lynne has Cushing syndrome. You would expect her to have or develop: a. Onychomycosis. b. Generalized increased pigmentation of the skin. c. Hair loss. d. Excitability and nervousness.

Onychomycosis.

Margaret, age 55, presents to you for evaluation of left hand and wrist pain and swelling after a slip and fall on the ice yesterday. On examination, you note tenderness at her "anatomical snuffbox." You know this probably indicates a(n): 1. Ulnar styloid fracture. 2. Scaphoid fracture. 3. Hamate fracture. 4. Radial head fracture.

Option 2: There is tenderness over the "anatomical snuffbox" in a scaphoid (aka navicular) fracture, the most common injury of the carpal bones. Poor blood supply puts the scaphoid bone at risk of avascular necrosis; therefore, wrist pain and tenderness in the anatomical snuffbox, even without history of antecedent trauma, warrant a wrist x-ray.

Alan, age 46, presents with a tender, red, swollen knee. You rule out septic arthritis and diagnose gout by confirming: 1. An elevated white blood cell (WBC) count. 2. Hyperuricemia. 3. A significant response to a dose of ceftriaxone (Rocephin). 4. A positive antinuclear antibody test.

Option 2: To diagnose gout, there should be hyperuricemia and a negative joint culture.

When teaching Alice, age 77, to use a cane because of osteoarthritis of her left knee, an important point to stress is: 1. Carrying the cane in the ipsilateral hand. 2. Advancing the cane with the ipsilateral leg. 3. Making sure the cane length equals the height of the iliac crest. 4. Using the cane to aid in joint protection and safety.

Option 2: When teaching clients about using a cane, tell them to advance the cane with the ipsilateral (affected) leg.

The nurse practitioner suspects adolescent idiopathic scoliosis in Victoria, age 15, who is in her "growth spurt." An Adams forward bend test is performed, and it is noted that the patient has a right-sided rib hump. What is this indicative of? 1. Right lumbar shifting. 2. Right thoracic curvature. 3. Right truncal shift. 4. Spondylolysis.

Option 2: When you have a client bend forward to assess the spine (ie, the Adams forward bend test) and you note a right-sided rib hump, this is indicative of a right thoracic curve. Adolescent idiopathic scoliosis is defined as a lateral spinal curvature of greater than 10 degrees with no determined pathologic cause. Management consists of the 3 Os: observation, orthosis, and operation.

1. Tamica, who has diabetes, states that she heard fiber is especially good to include in her diet. How do you respond? a. "Fiber is important in all diets." b. "Too much fiber interferes with insulin, so include only a moderate amount in your diet." c. "Fiber, especially soluble fiber, helps improve carbohydrate metabolism, so it is more important in the diet of persons with diabetes." d. "You get just the amount of fiber you need with a normal diet."

"Fiber, especially soluble fiber, helps improve carbohydrate metabolism, so it is more important in the diet of persons with diabetes."

1. Jeremiah, age 72, has gout and is obese. When teaching him about diet, whick of the following do you tell him? a. "Beer and wine are okay because they have no effect on uric acid." b. "Keeping your weight stable, even if you are a little overweight, is better than fluctuating." c. "You must go on a restricted, very low calorie diet to effect immediate change." d. "Fluid intake should exceed three thousand milliliters daily to prevent formation of uric acid kidney stones."

"Fluid intake should exceed three thousand milliliters daily to prevent formation of uric acid kidney stones."

1. Dan, age 45, is obese and has type 2 diabetes. He has been having trouble getting his glycohemoglobin under control. He has heard that exenatide (Byetta) causes weight loss and wants to try it. What do you tell him? a. "Let's adjust your oral antidiabetic agents instead." b. "That a myth. People usually change their eating habits when taking this, ana that's what causes the weight loss. c. "with type 2 diabetes, you never want to be on injectable insulin." d. "Let's try it. Your glycohemoglobin will be lowered and you may lose weight."

"Let's try it. Your glycohemoglobin will be lowered and you may lose weight."

1. Mr. Reynolds is on the antithyroid drug (ATD) methimazole (Tapazole), so you make it a point to check his: a. Glycated hemoglobin (HbA1c). b. Complete blood count (CBC) and liver transaminases. c. Uric acid level. d. Total thyroxine (T4).

. Complete blood count (CBC) and liver transaminases.

1. Martin, age 62, has acute nontransient abdominal pain that grows steadily worse in the epigastric area and radiates straight through to the back. The pain has lasted for days. He is also complaining of nausea, vomiting, sweating, weakness, and pallor. Physical examination reveals abdominal tenderness and distention and a low-grade fever. What do you suspect? a. Cholecystitis. b. Acute pancreatitis. c. Cirrhosis. d. Cushing syndrome.

Acute pancreatitis.

1. Morton has type 2 diabetes. His treatment, which includes diet, exercise, in three oral antidiabetic agents at maximum dose, is insufficient to achieve acceptable glycemic control. Your next course of action is to: a. Give the patient a sliding scale with mealtime coverage with regular insulin. b. Add a dosage of long-acting insulin at bedtime to the regimen. c. Discontinue the oral anti diabetic agents and start insulin therapy with N and R. d. Suggest treatment using an insulin pump.

Add a dosage of long-acting insulin at bedtime to the regimen.

1. Joan has severe asthma and has been on high dose oral corticosteroids for 2 years. She has been reading some home remedy books and stops all of her medications. What condition may she develop? a. Myxedema crisis. b. Diabetes insipidus. c. Hypoparathyroidism. d. Addisonian crisis.

Addisonian crisis.

1. Sadie, age 40, has just been given a diagnosis of Graves' disease. She has recently lost £25, has palpitations, is very irritable, feels very warm, and has a noticeable bulge in her neck. The most likely cause of her increased thyroid function is: a. hyperplasia of the thyroid. b. An anterior pituitary tumor. c. Thyroid carcinoma. d. An autoimmune response.

An autoimmune response.

Karen, who is postmenopausal, is taking 1200 mg of calcium daily but does not understand why she also needs to take vitamin D. You tell her that: 1. A deficiency of vitamin D results in inadequate mineralization of bone matrix. 2. All vitamins need to be supplemented. 3. Vitamin D increases intestinal absorption of dietary calcium and mobilizes calcium from the bone. 4. Vitamin D binds with calcium to allow active transport into the cells.

Option 3: Advise clients taking calcium supplements that they also need to take vitamin D because vitamin D raises serum calcium levels by increasing the intestinal absorption of dietary calcium and mobilizing calcium from the bone.

Question 36. A nurse practitioner is trying to distinguish between an articular and a nonarticular musculoskeletal complaint in a 26-year-old patient complaining of pain in the elbow area. Which of the following would characterize nonarticular bursitis? 1. Deep or diffuse pain. 2. Limited range of motion (ROM) on active and passive movement. 3. Point or focal tenderness. 4. Swelling and instability.

Option 3: Articular disorders are characterized by deep or diffuse pain, limited range of motion (ROM) on both active and passive movement, swelling, crepitation, instability, and deformity. Nonarticular disorders are characterized by painful active but not passive movement and point or focal tenderness in regions far from articular surfaces.

Daniel, age 45, is of Northern European ancestry and has a dysfunctional and disfiguring condition affecting the palmar tissue under the skin of the distal palm and fourth and fifth fingers. What do you suspect? 1. Hallux valgus. 2. De Quervain tenosynovitis. 3. Dupuytren contracture. 4. Hallux rigidus.

Option 3: Dupuytren contracture affects the palmar tissue under the skin of the distal palm and fingers—most often the fourth and fifth fingers, but also the thumb-index finger web space. It is progressive and results in a flexion contracture, though it does not affect the flexor tendons. Occurring most frequently in males between the ages of 40 and 60, it is common among people of Northern European ancestry. It is dysfunctional and disfiguring. Although it is not actually painful, it may be tender. Surgery is recommended when the inability to straighten the fingers limits the client's hand function.

Mr. McKinsey, age 69, was recently given a diagnosis of degenerative joint disease. Which assessment should the nurse practitioner use to check for effusion of the patient's knee? 1. Thomas test. 2. Tinel test. 3. Bulge test. 4. Phalen test.

Option 3: The bulge test assesses for an effusion of the knee. If effusion is present, a bulge will appear at the sides of or below the patella when the practitioner compresses the area above the patella.

Sam, age 50, presents with Paget disease that has been stable for several years. Recently, his serum alkaline phosphatase level has been steadily rising. The nurse practitioner determines that it is time to start him on pharmacologic management. Which of the following should she initially prescribe? 1. Nonsteroidal anti-inflammatory drugs (NSAIDs). 2. Corticosteroids. 3. Bisphosphonates. 4. Calcitonin.

Option 3: When the serum alkaline phosphatase level rises—which indicates the disease has progressed—bisphosphonates, which decrease bone resorption by inhibiting osteoclast activity, are the treatment of choice.

Jim, age 22, a stock boy, has an acute episode of low back pain. The nurse practitioner orders a nonsteroidal anti-inflammatory drug (NSAID) and should educate him in which of the following? 1. Maintaining moderate bed rest for 3 to 4 days. 2. Calling the office for narcotic medication if there is no relief with the NSAID after 24 to 48 hours. 3. Beginning lower back strengthening exercises depending on pain tolerance. 4. Wearing a Boston brace at night.

Option 3: Years ago, muscle relaxants and bed rest were the treatments of choice for low back pain. Studies have now shown that resuming normal activity within the limits imposed by the pain has an effect as good as, if not better than, 2 days of bed rest. The key here is letting pain be your guide. Exercise should begin as soon as possible after the acute injury and be directed at building endurance and stamina, with consideration given to one's pain tolerance.

Beth, age 49, comes in with low back pain. An x-ray of the lumbosacral spine is within normal limits. Which of the following diagnoses do you explore further? 1. Scoliosis. 2. Osteoarthritis. 3. Spinal stenosis. 4. Herniated nucleus pulposus.

Option 4: A plain x-ray will not show a herniated nucleus pulposus or a muscle strain. It will show spondylolisthesis, scoliosis, osteoarthritis, and spinal stenosis. Note that x-rays of the spine are not indicated in low back pain unless the cause of the pain is thought to be bony in origin or traumatic in nature or there is a need to rule out systemic disease.

Sandy, age 49, presents with loss of anal sphincter tone, impaired micturition, incontinence, and progressive loss of strength in the legs. You suspect cauda equina syndrome. What is your next action? 1. Ordering physical therapy. 2. Ordering a lumbosacral x-ray. 3. Ordering extensive lab work. 4. Referring to a neurosurgeon.

Option 4: A prompt referral to a neurosurgeon is required when a diagnosis of cauda equina syndrome is suspected. Cauda equina syndrome is a widespread neurologic disorder in which there is loss of anal sphincter tone; impaired micturition; incontinence; saddle anesthesia (ie, loss of sensation in the anus, perineum, genitals, and inner thighs); and motor weakness or sensory loss in both legs.

The nurse practitioner (NP) suspects a herniated disk in a 72-year-old patient. The NP elevates the patient's affected leg when she is in the supine position, and it elicits back and sciatic nerve pain, which indicates a positive test. This is known as which test or sign? 1. Femoral stretch test. 2. Crossed straight leg raise test. 3. Doorbell sign. 4. Straight leg raise test.

Option 4: All of the tests listed are tests done to assess for a herniated disk. In the straight leg raise test, you elevate the affected leg when the client is in the supine position; back pain and sciatic nerve pain (ie, radiating leg pain) indicate a herniated disk.

Matthew, age 52, is a chef who just severed 2 of his fingers with a meat cutter. You would recommend that he: 1. Wrap the severed fingers tightly in a dry towel for transport to the emergency department with him. 2. Leave the severed fingers at the scene because fingers cannot be reattached. 3. Immediately freeze the severed fingers for reattachment in the near future. 4. Wrap the fingers in a clean, damp cloth; seal them in a plastic bag; and place the bag in an ice water bath.

Option 4: If a client has severed his fingers, the fingers should be wrapped in a clean, damp cloth; sealed in a plastic bag; placed in an ice water bath; and transported to the emergency room along with the client.

The nurse practitioner (NP) is assessing Maya, a 69-year-old Asian woman, for the first time. When trying to differentiate between scoliosis and kyphosis, the NP recalls that kyphosis involves: 1. Asymmetry of the shoulders, scapulae, and waist creases. 2. A lateral curvature and vertebral rotation on posteroanterior x-rays. 3. One leg appearing shorter than the other. 4. A posterior rounding at the thoracic level.

Option 4: Kyphosis involves a posterior rounding at the thoracic level and a kyphotic curve of more than 45 degrees on an x-ray. There may be moderate pain with kyphosis.

Hilda, age 73, presents with a complaint of low back pain. Red flags in her history of a minor fall, osteopenia, and prolonged steroid use for systemic lupus erythematosus suggest the possibility of which of the following serious underlying conditions as the cause of her low back pain? 1. Cancer. 2. Cauda equina syndrome. 3. Neurologic compromise. 4. Spinal fracture.

Option 4: The red flags for spinal fracture include major trauma or direct blow to the back in an adult, a minor fall or heavy lifting in a potentially osteoporotic or elderly person, prolonged steroid use, and age greater than 70.

1. A low thyroid-stimulating hormone (TSH) can lead to: a. Osteoporosis. b. Weight gain. c. Bradycardia. d. Brittle hair.

Osteoporosis.

1. Which is the only curative treatment option for primary hyperparathyroidism (PHPT)? a. Type 2 calcimimetic cinacalcet. b. Hormone therapy. c. Parathyroidectomy. d. Bisphosphonates.

Parathyroidectomy.

1. Jason, age 14, appears with tender discoid breast tissue enlargement (2-3 cm in diameter) beneath the areolae. Your next action would be to: a. Perform watchful waiting for one year. b. Order an ultrasound. c. Obtain laboratory test. d. Refer Jason to an endocrinologist.

Perform watchful waiting for one year.

1. Sandra, age 28, has secondary obesity. Which of the following may have caused this? a. Taking in more calories than are expended. b. Polycystic ovary syndrome. c. Anti-hypertensive medications. d. A sedentary lifestyle.

Polycystic ovary syndrome.

You are assessing Jamal, age 16, after a football injury to his right knee. You elicit a positive anterior/posterior drawer sign. This test indicates an injury to the: 1. Lateral meniscus. 2. Cruciate ligament. 3. Medial meniscus. 4. Collateral ligament.

Positive anterior and posterior drawer signs indicate injury to the anterior cruciate ligament and posterior cruciate ligament, respectively. The drawer and Lachman tests are utilized to assess for cruciate ligament injury.

1. A client with hyperthyroidism present s with a complaint of a "gritty" feeling in her eyes. Over the past week, her visual acuity has diminished, and her ability to see colors has changed. She also has a feeling of pressure behind her eyes. The next xtep for the nurse practitioner is to: a. Order a thyroid ultrasound. b. Refer the client for immediate evaluation by an ophthalmologist. c. Order a total thyroxine (T4). d. Prescribe a beta-adrenergic blocker.

Refer the client for immediate evaluation by an ophthalmologist.

1. Jenny, age 46, has hypertension that has been controlled with hydrochlorothiazide 50 mg every day for the past 3 years. She is 5 ft 8 in tall and weighs 220 lb. Her fasting blood sugar (FBS) is 300mg/dL, serum cholesterol level is 250 mg/dL, serum potassium level is 3.4mEq, and she has 4+ glucosuria. Your next course of action would be to: a. Discontinue her hydrochlorothiazide. b. Order a glucose tolerance test (GTT). c. Repeat her FBS and do a glycated hemoglobin (HbA1c). Start insulin therapy

Repeat her FBS and do a glycated hemoglobin (HbA1c).

1. Morris has had type one diabetes for 10 years. several recent urinalysis reports have shown Microalbuminuria. Your next step would be to: a. Order a 24 hour urinalysis. b. Start him on an angiotension-converting enzyme (ACE) inhibitor. c. Stress the importance of strict blood sugar control. d. Send him to a dietitian because he obviously has not been following his diet.

Start him on an angiotension-converting enzyme (ACE) inhibitor.

1. Jeffery, age 17, has gynecomastia. You should also assess him for: a. Obesity. b. Endocrine abnormalities. c. Testicular cancer. d. Tuberculosis.

Testicular cancer.

Janine, age 69, has class III rheumatoid arthritis. According to the American Rheumatism Association, which of the following describes her ability to function? 1. Adequate for normal activities despite a handicap of discomfort or limited motion of one or more joints. 2. Largely or wholly incapacitated, bedridden, or confined to a wheelchair, permitting little or no self-care. 3. Completely able to carry out all usual duties without handicap. 4. Adequate to perform only a few or none of the duties of usual occupation or self-care.

The American Rheumatism Association has established functional classes I to IV to describe a client's ability to accomplish activities of daily living. Because Janine is class III, her function would be adequate to perform only a few or none of the duties of usual occupation or self-care.

Mickey, age 18, is on a chemotherapeutic antibiotic for a musculoskeletal neoplasm. Which drug do you think he is taking? 1. Cyclophosphamide (Cytoxan). 2. Doxorubicin (Adriamycin). 3. Methotrexate (Rheumatrex). 4. Cisplatin (Platinol).

The only antineoplastic antibiotic listed is doxorubicin (Adriamycin). All of the other medications are chemotherapeutic agents of other classifications that may be used for musculoskeletal neoplasms.

1. After an oral cholecystogram, Sam complains of burning on urination. This is because of: a. A mild reaction to the contrast medium. b. Biliary obstruction. c. Contraction of the gallbladder. d. The presence of dye in the urine.

The presence of dye in the urine.

1. Sigrid, age 48, appears with a 3-month history of heat intolerance, increased sweating, palpitations, tachycardia, nervousness, irritability, fatigue, and muscle weakness. Which test would you order first? a. A blood chemistry panel. b. Thyroid-stimulating hormone (TSH) level. c. Liver function studies. d. Electrocardiogram.

Thyroid-stimulating hormone (TSH) level.

1. An elderly client presents with atrial fibrillation. Which of the following lab tests is important in forming the diagnosis? a. Complete blood count (CBC). b. C-reactive protein (CRP). c. Comprehensive metabolic panel (CMP). d. Thyroid-stimulating hormone (TSH).

Thyroid-stimulating hormone (TSH).

1. Marty has pheochromocytoma. You instruct him to: a. Void frequently in small amounts. b. Not exercise for more than 30 minutes at a time. c. Avoid sleeping in the prone position. d. Take steroids.

Void frequently in small amounts.

1. Mason, age 52, has diabetes mellitus (DM) and is overweight. You now find that he is hypertensive. How should you treat his hypertension? a. You should treat it the same as in a client without diabetes. b. Because insulin affects most antihypertensive drugs, you should try diet and exercise first before ordering any antihypertensives. c. You should treat it very aggressively, preferably with angiotensin-converting enzyme (ACE) inhibitors. d. You should initiate therapy when the blood pressure is 5 to 10 mm Hg more than the conventional therapeutic guidelines.

You should treat it very aggressively, preferably with angiotensin-converting enzyme (ACE) inhibitors.

Sean, a factory line worker, has osteoarthritis (OA) of the right hand. According to the American College of Rheumatology (ACR), the guidelines for pharmacologic treatment include: 1. Acetaminophen, tramadol, and intra-articular corticosteroid injections. 2. Oral nonsteroidal anti-inflammatory drugs (NSAIDs), tramadol, and articular corticosteroid injections. 3. Acetaminophen, topical capsaicin, and topical nonsteroidal anti-inflammatory drugs (NSAIDs). 4. Topical capsaicin, topical nonsteroidal anti-inflammatory drugs (NSAIDs), and oral NSAIDs.

4. Topical capsaicin, topical NSAIDs, oral NSAIDs, and tramadol are recommended by the ACR for the treatment of OA of the hand.

1. The process of aging results in: a. An increase in liver weight and mass. b. A decreased absorption of fat-soluble vitamins. c. An increase in enzyme activity. d. Constricted pancreatic ducts.

A decreased absorption of fat-soluble vitamins.

1. What is the medication of choice for an initial acute attack of gout? a. A nonsteroidal anti-inflammatory drug (NSAID). b. Colchicine c. A corticosteroid d. Allopurinol (Zyloprim)

A nonsteroidal anti-inflammatory drug (NSAID).

1. Marie, age 50, has type 1 diabetes and checks her blood glucose level several times every day. Her blood glucose levels range from 250 to 280 mg/dL in the morning and is usually about 140 at lunch, about 120 at dinner, and about 100 at bedtime. In the morning, she takes 20 units of neutral protamine Hagedorn (NPH) insulin and 4 units of regular insulin, and before dinner she takes 18 units of NPH insulin and 4 units of regular insulin. Although she has had her insulin dose adjusted several times in the past month m it has had no effect on her high morning blood glucose level. What is your next course of action? a. Increase the evening NPH insulin dose by 2 more units. b. Have her check blood glucose level between 2 am and 4 am for the next several days. c. Increase the morning regular insulin dose by 2 units.

Have her check blood glucose level between 2 am and 4 am for the next several days.

1. When you inspect the integumentary system of clients with endocrine disorders, the finding of course her may be an indicator of: a. Addison disease. b. Diabetes mellitus. c. Cushing syndrome. d. Hypothyroidism.

Hypothyroidism

For an adult patient with a knee injury, the nurse practitioner orders a nonsteroidal anti-inflammatory drug (NSAID) to be taken on a routine basis for the next 2 weeks. Patient teaching should include which of the following? 1. "You may take this medication on an empty stomach as long as you eat within two to three hours of taking it." 2. "If one pill does not seem to help, you can double the dose for subsequent doses." 3. "If you notice nausea, vomiting, or black or bloody stools, take the next dose with a glass of milk or a full meal." 4. "If you have additional pain, an occasional acetaminophen (Tylenol) is permitted in between the usual doses of the NSAID."

If the client is having additional pain, acetaminophen (Tylenol) may be taken in conjunction with an NSAID because it is not an NSAID and will not potentiate gastric bleeding.

1. Your client with diabetes asks you about insulin glargine (Lantus). You tellher that: a. It may be administered subcutaneously at home or intravenously in the hospital if need be. b. The onset of action is 15 minutes. c. Insulin glargine (Lantus) stays in your system for 24 hours. It can be mixed with any other insulin

Insulin glargine (Lantus) stays in your system for 24 hours.

1. Mark has type one diabetes and has mild hyperglycemia. What effect does physical activity (exercise) have on his blood glucose level? a. It may cause it to vary a little. b. It may decrease it. c. It may elevate it. d. It may fluctuate greatly either way.

It may decrease it.

1. Ben, a client with type 1 diabetes, is hospitalized with an admitting diagnosis of diabetic ketoacidosis (DKA). Which of the following signs and symptoms would be consistent with this condition? a. Hypoglucemia and glycosuria. b. Decrease respiratory rate with shallow respirations. c. Polydipsia and an increased blood pH. d. Ketonuria and polyuria.

Ketonuria and polyuria.

The nurse practitioner is considering a diagnosis of calcium pyrophosphate deposition disease (CPPD), or pseudogout, in a 72-year-old man who presents with complaints of pain and stiffness in his wrists and knees. The most useful diagnostic tests to assist in confirming this diagnosis would be: 1. Synovial fluid analysis and x-ray. 2. Bacterial cultures. 3. Bone scan and magnetic resonance imaging (MRI). 4. Anticitrullinated protein antibodies (ACPA) and rheumatoid factor (RF).

Option 1: CPPD (pseudogout) may appear clinically similar to gouty arthritis; however, in CPPD crystals form in the cartilage and lead to inflammation. The typical age of onset is later than that of gout, initially presenting in the sixth decade of life or later. Diagnosis is made through synovial fluid analysis and will reveal positive calcium pyrophosphate dihydrate crystals. An x-ray will show radiographic evidence of chondrocalcinosis or calcification in the hyaline cartilage and/or fibrocartilage of the affected joint.

Jill, age 49, has recently begun a rigorous weightlifting regimen. She presents to the primary care office with a shoulder dislocation. Which of the following clinical manifestations leads the nurse practitioner to suspect an anterior shoulder dislocation over a posterior dislocation? 1. Inability to shrug the shoulder. 2. Absence of pain. 3. Inability to rotate the shoulder externally. 4. Shortening of the arm.

Option 1: Clinical manifestations of an anterior shoulder dislocation, which is far more common than a posterior dislocation, include the inability to shrug the shoulder, pain, and lengthening of the arm.

during assessment of a client's foot, the nurse practitioner notes that the foot is in alignment with the long axis of the lower leg and that weight-bearing falls on the middle of the foot from the heel, along the midfoot, to between the second and third toes. These findings best describe: 1. A normal foot. 2. Hallux valgus. 3. Talipes equinovarus. 4. Hammertoes.

Option 1: If you note during your assessment of your client's foot that the foot is in alignment with the long axis of the lower leg and that weight-bearing falls on the middle of the foot from the heel, along the midfoot, to between the second and third toes, you would diagnose a normal foot.

John, age 16, works as a stock boy at the local supermarket. He is in the office for a routine visit. You notice that he had an episode of low back pain 6 months ago after lifting heavy boxes improperly. In discussing with him proper body mechanics to prevent future injuries, you tell him: 1. "Bend your knees and face the object straight on." 2. "Hold boxes away from your body at arm's length." 3. "Bend and twist simultaneously as you lift." 4. "Keep your feet firmly together."

Option 1: In discussing with John proper body mechanics to prevent future injuries, you tell him to bend his knees and face the object straight on, to hold boxes close to his body and not at arm's length, and to spread his feet about shoulder width apart. Using legs and arms, facing objects straight on, and keeping a wide stance will provide a broad base of support and allow for use of supporting muscles, relieving stress on the back muscles.

James, age 17, has been complaining of a painful knob below his right knee that has prevented him from actively participating in sports. He has recently been given a diagnosis of Osgood-Schlatter disease and asks you about his treatment options. The nurse practitioner should tell him that the initial treatment is: 1. Relative rest; he could benefit from hamstring, heel cord, and quadriceps stretching exercises. 2. Immobilization; a long-leg knee immobilizer is recommended. 3. Surgical intervention; removal of the bony fragments is necessary. 4. Bed rest for 1 week.

Option 1: Osgood-Schlatter disease is an overuse injury that results from the excessive tension and pull of the patellar tendon on the tibial tuberosity. Treating the client conservatively while an adolescent will prevent potential problems as an active adult. Initially, relative rest should be used with hamstring, heel cord, and quadriceps stretching exercises.

Anne, age 67, sustained a fall on an outstretched hand. She presents holding her arm against her chest with her elbow flexed. Based on the specific location of her pain, you suspect a radial head fracture. The best initial strategy to assess for a radial head fracture would be: 1. To palpate for tenderness, swelling, and crepitus just distal to the lateral epicondyle. 2. To palpate for tenderness, swelling, and crepitus along the radial wrist. 3. To palpate for tenderness in the "anatomical snuffbox." 4. To order an x-ray of the wrist.

Option 1: The radial head is the proximal aspect of the radius, located in the elbow joint. Falling on an outstretched hand transfers a significant amount of force to the radial head. Often a fracture line cannot be seen on an x-ray, but the presence of an anterior or posterior fat pad sign (or sail sign) indicates an occult radial head fracture.

In assessing the skeletal muscles, the nurse practitioner turns the patient's forearm so that the palm is up. This is called: 1. Supination. 2. Pronation. 3. Abduction. 4. Eversion.

Option 1: Turning the forearm so that the palm is up is called supination.

Lillian, age 70, was told that she has osteoporosis. When she asks you what this is, you respond that osteoporosis: 1. Develops when loss of bone occurs more rapidly than new bone growth. 2. Is a degenerative joint disease characterized by loss of cartilage in certain joints. 3. Is a chronic inflammatory disorder that affects multiple joints. 4. Is a bone disorder that has to do with inadequate mineralization of the bones.

Option 1:Osteoporosis develops when bone resorption occurs more rapidly than bone deposition.

A 55-year-old patient is able to complete range of motion (ROM) against gravity with some resistance. The nurse practitioner would assign which of the following numerical grades to this manual muscle testing description? 1. 5. 2. 4. 3. 3. 4. 2.

Option 2: Complete ROM against gravity with some resistance is given a numerical grade of 4 and described as good muscle strength.

Paul has a malignant fibrosarcoma of the femur. He recently had surgery and is now on radiation therapy. You want to order a test to determine the extent of the tumor invasion of the surrounding tissues and the response of the bone tumor to the radiation. Which of the following tests should you order? 1. An x-ray. 2. A magnetic resonance imaging (MRI) scan. 3. A computed tomography (CT) scan. 4. A needle biopsy.

Option 2: For Paul, who has a malignant fibrosarcoma of the femur, an MRI scan will determine the extent of the tumor invasion of the surrounding tissues and the response of the bone tumor to the radiation. It will also determine response to chemotherapy and detect recurrent disease.

Cass, age 67, tells the nurse practitioner (NP) that she has been diagnosed with a condition that causes sudden flares of pain, swelling, and redness of the joints in her toes. She cannot remember the name of the diagnosis, but she knows it is caused by urate crystals that "get stuck in the joint and cause pain." She is on hydrochlorothiazide (HCTZ) for management of her hypertension. The NP should suspect a diagnosis of: 1. Septic arthritis. 2. Gout. 3. Rheumatoid arthritis. 4. Charcot neuro-osteoarthropathy.

Option 2: Gout is a disorder that involves abnormal metabolism of uric acid and results in hyperuricemia. High concentrations of urate precipitate into crystals that collect in tissue and joint spaces and can cause pain and inflammation. The patient's symptoms may be aggravated by the use of HCTZ.

Jessie, age 49, states she thinks she has rheumatoid arthritis. Before any diagnostic tests are ordered, the nurse practitioner completes a physical examination and makes a diagnosis of osteoarthritis rather than rheumatoid arthritis. Which clinical manifestation ruled out rheumatoid arthritis? 1. Fatigue. 2. Affected joints are swollen, cool, and bony hard on palpation. 3. Decreased range of motion. 4. Joint stiffness.

Option 2: In osteoarthritis, the affected joints are swollen, cool, and bony hard on palpation. With rheumatoid arthritis, the affected joints are red, hot, and swollen and boggy and tender on palpation.

Mike, age 42, a golf pro, has had chronic back pain for many years. His workup reveals that it is not the result of a degenerative disk problem. His back "goes out" about twice per year, and he is out of work for about a week each time. Which of the following should the nurse practitioner advise him to do? 1. Consider changing careers to something less physical. 2. Begin a planned exercise program to strengthen back muscles. 3. Make an appointment with a neurosurgeon for a surgical consultation. 4. Start on a daily low-dose narcotic to take away the pain.

Option 2: In this case, Mike may benefit from a regular planned exercise program to strengthen his back muscles and attempt to reduce the probability of future episodes of back pain.

Joyce, age 87, broke her wrist after falling off a curb. She just had a plaster cast applied to her wrist. In instructing Joyce and her family on allowing the cast to dry properly, tell them to: 1. Continuously elevate Joyce's arm on a pillow. 2. Change the position of Joyce's arm every hour. 3. Position a fan near Joyce during the night to ensure even drying of the cast. 4. Put a blanket over the cast to absorb the dampness.

Option 2: Instructions to the client and family on how to allow a cast to dry properly should include advising them to change the position of the casted extremity every hour. In this case, Joyce's arm should be repositioned frequently to prevent indentations in the cast itself (caused by continuous placement on a pillow) and to ensure drying of all surfaces of the cast.

You are caring for a patient who has a history of psoriasis and is now showing signs of joint involvement. Seropositivity provides a definitive diagnosis of psoriatic arthritis (PsA). The initial treatment choice for management of the patient is: 1. Disease-modifying antirheumatic drugs (DMARDs). 2. Nonsteroidal anti-inflammatory drugs (NSAIDs). 3. Tumor necrosis factor-alpha (TNF-α) inhibitors. 4. Uricosuric medications.

Option 2: NSAIDs are the first-line treatment for musculoskeletal signs and symptoms with joint involvement.

June, age 67, presents with back pain with no precipitating event. The pain is located over her lower back muscles and spine, without sciatica, and it is aggravated by sitting, standing, and certain movements. It is alleviated with rest. Palpation localizes the pain, and muscle spasms are felt. There was an insidious onset with progressive improvement. What is the most likely diagnosis? 1. Ankylosing spondylitis. 2. Musculoskeletal strain. 3. Spondylolisthesis. 4. Herniated disk.

Option 2: Pain over the lower back muscles and spine, without sciatica, is caused by musculoskeletal strain. Often there is no precipitating event, and there is an insidious onset. It is aggravated by sitting, standing, and certain movements. Palpation localizes the pain, and muscle spasms may be felt. It is alleviated by rest, and there is progressive improvement.

Greg, age 26, runs marathons and frequently complains of painful contractions of his calf muscles after running. You attribute this to: 1. Hypercalcemia. 2. Hyponatremia. 3. Heat exhaustion. 4. Dehydration.

Option 2: Painful contractions of muscles after exertion, such as heat cramps, may be related to hyponatremia or other electrolyte imbalances. Usually the gastrocnemius and hamstring muscles are involved. Treatment of heat cramps includes passive muscle stretching, cessation of activities, transfer to a cooler environment, and drinking cool liquids. Sports drinks that contain electrolytes, such as Gatorade, may be beneficial.

Christian, age 22, is a carpenter who is right hand dominant. He comes to the clinic for follow-up from the emergency department, where he was seen for right forearm pain. He states he was diagnosed with right forearm tendinitis and wants the provider to explain this diagnosis to him. Patient teaching should explain that he has inflammation of one or more tendons, which are: 1. The ropelike bundles of collagen fibrils that connect bone to bone. 2. The collagen fibers that connect muscle to bone. 3. The pouches of synovial fluid that cushion bone and other joint structures. 4. The fibrocartilaginous disks that separate bony surfaces.

Option 2: Tendons are the collagen fibers that connect muscle to bone

Ethan, age 10, jumped off a 2-foot wall, twisting his foot and ankle upon landing. His ankle x-ray demonstrates a fracture of the distal tibia, over the articular surface, through the epiphysis and physis. Based on the Salter-Harris classification of growth plate injuries, you know this is a: 1. Salter-Harris II fracture. 2. Salter-Harris III fracture. 3. Salter-Harris IV fracture. 4. Salter-Harris V fracture.

Option 2: The Salter-Harris classification system of growth plate injuries divides most growth plate injuries into 5 categories based on the damage: A Salter-Harris III fracture travels through the epiphysis and physis. A Salter-Harris I fracture travels through the physis.

Jeffrey, age 16, was involved in a motor vehicle accident. He walks in to the office with an obvious facial fracture and then collapses. What should the first action of the nurse practitioner be? 1. Calling his parents for permission to treat. 2. Assessing for an adequate airway. 3. Obtaining a head and maxillofacial computed tomography (CT). 4. Assessing for a septal hematoma.

Option 2: The primary concern in the management of facial fractures is ensuring an adequate and stable airway. Displaced soft tissues, blood, secretions, or other foreign material may obstruct the airway and cause asphyxia.

A nurse practitioner is driving home from work and stops at the scene of a motorcycle accident that must have just occurred, as there are no rescue vehicles present. The driver is lying unconscious at the side of the road with an obvious open fracture of his femur. Which of the following actions should take priority? 1. Stopping the bleeding from the wound. 2. Determining if there has been a cervical fracture. 3. Establishing an airway. 4. Palpating the peripheral pulses.

Option 3: Follow the ABCs of first aid: airway, breathing, and circulation. Establishing an airway is the first priority, followed by breathing, and then circulation. Stopping the bleeding from the wound, assessing if there has been a cervical fracture, and palpating the peripheral pulses are all important actions, but if the client is not breathing, the other actions will not be necessary.

Sandra, a computer programmer, has just been given a new diagnosis of carpal tunnel syndrome. The nurse practitioner's next step is to: 1. Refer her to a hand surgeon. 2. Take a more complete history. 3. Try neutral position wrist splinting and order an oral nonsteroidal anti-inflammatory drug (NSAID). 4. Order nerve conduction studies and electromyography (EMG).

Option 3: For the client who has just been given a diagnosis of carpal tunnel syndrome, your next step is to try neutral position wrist splinting and order an oral NSAID. For symptoms of less than 10 months' duration, conservative treatment should be tried first.

Steve, age 32, fell off a roof while shingling it. He is complaining of pain in his left hip and leg area. Other than an x-ray, what would make you suspect a fractured pelvis? 1. A clicking sensation when moving the hips. 2. A positive pelvic tilt test. 3. Hematuria. 4. Absence of distal reflexes.

Option 3: If a client has a fractured pelvis, a test for hematuria will usually prove positive. A fracture of the pelvis usually results in hypovolemia due to a generally significant associated blood loss. Surrounding blood vessels rupture, which results in a large retroperitoneal hematoma and shock. Pelvic fractures also commonly injure the urinary bladder or urethra. A client with a fracture in several locations of the pelvis may need a pneumatic antishock garment to control the blood loss and stabilize the pelvis. Only x-ray studies will confirm the diagnosis.

In assessing a patient, you place the tips of your first 2 fingers in front of each ear and ask the patient to open and close his mouth. Then you drop your fingers into the depressed area over the joint and assess for smooth motion of the mandible. With this action, you are checking for: 1. Maxillomandibular integrity. 2. Well-positioned permanent teeth or well-fitting dentures. 3. Temporomandibular joint syndrome. 4. Mastoid inflammation.

Option 3: In assessing your client, place the tips of your first 2 fingers in front of each ear and ask him to open and close his mouth. Then drop your fingers into the depressed area over the temporomandibular joint (TMJ) and check for smooth motion of the mandible. With this action, you are assessing for TMJ syndrome. Clicking or popping noises, decreased range of motion, pain, or swelling may indicate TMJ syndrome. However, an audible and palpable snap or click does occur in many normal people as they open their mouths. In rare cases, this may indicate osteoarthritis.

A 13-year-old obese (body mass index [BMI] above the 95th percentile) boy reports low-grade left knee pain for the past 2 months. He denies antecedent trauma but admits to frequent "horseplay" with his friends. The pain has progressively worsened, and he is now unable to bear weight at all on his left leg. His current complaints include left groin, thigh, and medial knee pain and tenderness. His examination demonstrates negative drawer, Lachman, and McMurray tests; left hip with decreased internal rotation and abduction; and external hip rotation with knee flexion. Based on the above scenario, the nurse practitioner should suspect: 1. A left meniscal tear. 2. A left anterior cruciate ligament (ACL) tear. 3. A slipped capital femoral epiphysis (SCFE). 4. Osgood-Schlatter disease.

Option 3: SCFE is a displacement of the femoral head relative to the femoral neck that occurs through the physis (growth plate) of the femur. The vast majority of clients with this condition are obese, as the added weight increases shear stress across the physis. The mean age at diagnosis is 12 years for females and 13.5 years for males. Surgery is often required via in situ pin fixation (single screw) to stabilize the growth plate to prevent further slippage and avoid complications.

Lois, age 52, who has just been given a diagnosis of sarcoidosis, has joint symptoms, including arthralgias and arthritis. Your next plan of action would be to: 1. Order a bone scan. 2. Obtain a tissue biopsy. 3. Begin a course of glucocorticoids. 4. Order daily doses of vitamin B.

Option 3: Sarcoidosis is the result of an exaggerated immune system response to a class of antigens or self-antigens. Fifty percent of clients experience joint symptoms, including myopathy and polyarthritis; glucocorticoids are prescribed to suppress the immune process, thus relieving symptoms.

Anne Marie states she has a maternal history of rheumatoid disease, but she has never been affected. Today she presents with complaints of dryness of the eyes and mouth. What is the most likely diagnosis? 1. Rheumatoid arthritis (RA). 2. Systemic lupus erythematosus (SLE). 3. Sjögren syndrome. 4. Rosacea.

Option 3: Sjögren syndrome, which affects the salivary and lacrimal glands, causes clients to have dry eyes and mouths. It is an inflammatory disease of the exocrine glands and may be an isolated entity or may be associated with other rheumatic diseases, such as rheumatoid arthritis (RA) or systemic lupus erythematosus (SLE).

Alexander, age 12, sprained his ankle playing ice hockey. He is confused as to whether he should apply heat or cold. What should the nurse practitioner tell him? 1. "Use continuous heat for the first 12 hours and then use heat or cold to your own preference." 2. "Use continuous cold for the first 12 hours and then use heat or cold to your own preference." 3. "Apply cold for 20 minutes, then remove it for 30 to 45 minutes; repeat this for the first 24 to 48 hours while awake." 4. "Alternate between cold and heat for 20 minutes each for the first 24 to 48 hours."

Option 3: Tell a client who has sprained his ankle to apply cold for 20 minutes, then remove it for 30 to 45 minutes, and repeat that procedure for the first 24 to 48 hours while awake. Cold will cause vasoconstriction and decrease edema, preventing any further bleeding into the tissues. After any sprain, use the principles of RICE: rest, ice, compression, and elevation.

The valgus stress test, varus stress test, Lachman test, and thumb sign are all considered standard tests to check the integrity of the ligaments of the knee. Which test would the nurse practitioner choose to assess the anterior cruciate ligament (ACL), which is the most commonly involved structure in severe knee injury? 1. Valgus stress test. 2. Varus stress test. 3. Lachman test. 4. Thumb sign.

Option 3: The Lachman test assesses the ACL.

1. Leah, age 70, has had diabetes for many years. When teaching her about foot care, you want to stress: a. That her calluses will protect her from infection. b. The need to assess the bottom of her feet carefully after walking barefoot. c. That painless ulcerations might occur, and feet should be examined with a mirror. d. That mild pain is to be expected because of neuropathy.

that painless ulcerations might occur, and feet should be examined with a mirror.