Final Exam Test Bank
The mother of an 8-year-old boy reports the presence of a round red rash on the child's left lower leg. It appeared 1 week after the child returned from visiting his grandparents, who live in Massachusetts. During the skin exam, the maculopapular rash is noted to have areas of central clearing making it resemble a round target. Which of the following is best described? A) Erythema migrans B) Rocky Mountain spotted fever C) Meningococcemia D) Larva migrans
A) Erythema migrans Erythema migrans is a symptom of early Lyme disease. It is an annular lesion that slowly enlarges with time (days to weeks) and has central clearing. It is caused by a bite from an infected (Borrelia burgdorferi) blacklegged tick. If untreated, infection will spread to joints, nervous system, and heart. Most cases of Lyme disease occur in the Northeast, mid-Atlantic states, Wisconsin, Minnesota, and northern California.
This case is followed by questions and multiple-choice answers specific to the case. A 20- year-old Asian man reports pain in his right knee after twisting it while playing soccer. The injured knee locks up when he attempts to straighten his leg. Which of the following conditions is most likely? A) Injury to the meniscus of the right knee B) Injury to the patella of the right knee C) Injury to the ligaments of the right knee D) Rupture of the quadriceps tendon Which of the following actions is the best course for this patient? A) Refer him to an orthopedic specialist B) Refer him to a chiropractor C) Advise him that the clicking noise will resolve within 2 to 4 weeks D) Advise him to use an elastic bandage wrap during the first 2 weeks for knee support and to see you again for reevaluation
A) Injury to the meniscus of the right knee Pain in the knee with "locking 684 up" while attempting to straighten the leg is highly suggestive of injury to the meniscus. The best imaging test for meniscus injury is the MRI. A) Refer him to an orthopedic specialist Referral to orthopedics is advised for evaluation of the need for treatment and surgery (arthroscopic repair). If the tear is minor and the pain and other symptoms resolve quickly, muscle-strengthening exercises may be all that is needed to recover fully. In this case, a patient is usually referred to physical therapy. A large meniscus tear that causes symptoms or mechanical problems with the function of the knee joint may require arthroscopic surgery for repair.
The Lachman maneuver is used to detect which of the following? A) Instability of the knee B) Nerve damage of the knee due to past knee injuries C) Integrity of the patellar tendon D) Tears on the meniscus of the knee
A) Instability of the knee The Lachman maneuver is a test performed to assess for knee instability (i.e., damage to the motion of anterior translation [laxity] of the anterior cruciate ligament [ACL]) or tear of the ACL. The maneuver should be tested on both knees, comparing the injured and the opposite knee, the uninjured knee is used as the "control." The test is positive if the injured knee slips back further (laxity). Perform the test by bending the knee 30 degrees. Stabilize the femur with one hand. Place the other hand under the proximal tibia at the level of the joint line and then pull forward. The laxity is graded on a 0 (normal)-to-3 scale (1.0-1.5 cm of translation).
What is the significance of a positive Lachman sign? A) Instability of the knee caused by damage to the anterior cruciate ligament of the knee B) Posterior cruciate ligament laxity which may cause locking of the knee C) Achilles tendon rupture D) Patellar tendon rupture
A) Instability of the knee caused by damage to the anterior cruciate ligament of the knee A positive Lachman sign is highly suggestive of damage to (i.e., rupture of) the anterior cruciate ligament (ACL) of the knee. The anterior drawer sign may also be positive. The examiner notes laxity of the abnormal knee joint compared with the normal knee. The Lachman test or maneuver is considered more sensitive for ACL damage than the anterior drawer test.
When Molluscum contagiosum is found on the genital area of children, which of the following is the best explanation? A) It should raise the suspicion of child sexual abuse B) It is not considered a sexually transmitted disease C) It is caused by atypical bacteria D) It is caused by the poxvirus and will resolve on its own
A) It should raise the suspicion of child sexual abuse Molluscum contagiosum is spread by skin-to-skin contact. Lesions found in the genital area of young children should be evaluated for suspicion of child sexual abuse.
A 19-year-old male athlete complains of acute knee pain after a football game. The nurse practitioner elicits McMurray's sign, which is positive on the patient's injured knee. This is a test for: A) Meniscal injury B) Inflammation of the knee joint C) Osteophytes of the knee joint D) Tenosynovitis
A) Meniscal injury With an acute knee injury, the knee should be assessed using McMurray's sign. A positive McMurray's sign indicates a meniscal injury. Inflammation of the knee, osteophytes, and tenosynovitis would not elicit a positive McMurray's sign.
This case is followed by questions and multiple-choice answers specific to the case. A 25-year-old man who was involved in a car accident is brought to the local emergency department. He reports wearing a seat belt and was the driver of the vehicle. The patient is complaining of pain on his right lower leg. The right foot is abducted and the ankle is swollen and bruised. There is a small laceration on the ankle. The patient complains of severe right ankle pain when standing. Which of the following tests would be the initial choice for evaluating for possible fractures on the right lower leg? A) Plain radiographs of the right lower leg, ankle, and foot B) Ultrasound of the right lower leg C) MRI of the right ankle D) Radiograph of the right ankle and knee with special view of the hip In addition to surgical repair of a compound fracture that has broken through the skin, which of the following treatment plans is important to consider in this patient? A) Application of a topical antibiotic BID until the wound is healed B) Wound irrigation C) Use cold packs three times per day D) Tetanus vaccine and systemic antibiotics
A) Plain radiographs of the right lower leg, ankle, and foot Plain radiographs or x-rays are the first exam ordered for suspected or obvious bony fractures. Severe pain on weight bearing and bruising of the right ankle is highly suggestive of a fracture. MRI scan is not an initial test because it is very expensive. MRIs are preferred for joints and soft tissue. D) Tetanus vaccine and systemic antibiotics A break in the skin with a compound fracture is an indication for use of a tetanus vaccine (if last dose is more than 5 years ago) and systemic antibiotics.
A 20-year-old White man is being seen for a physical exam by the nurse practitioner. He complains of pruritic macerated areas in his groin that have been present for the past 2 weeks. Which of the following is the most likely? A) Tinea cruris B) Tinea corporis C) Tinea capitis D) Tinea pedis
A) Tinea cruris Tinea cruris (jock itch) is a common skin infection that is caused by a type of fungus called tinea. The fungus thrives in warm, moist areas of the body and, as a result, infection can affect the genitals, inner thighs, and buttocks. Infections occur more frequently in the summer or in warm, wet climates. Tinea cruris appears as a red, itchy rash that is often ring shaped. Tinea corporis involves the body, tinea capitis involves the head, and tinea pedis involves the feet.
A bulla is defined as: A) A solid nodule less than 1 cm in size B) A superficial vesicle filled with serous fluid greater than 1 cm in size C) A maculopapular lesion D) A shallow ulcer
B) A superficial vesicle filled with serous fluid greater than 1 cm in size This isa blister—a circumscribed, fluid-containing, elevated lesion of the skin, usually more than 5 mm in diameter.
A mother brings in her 6-year-old daughter to see the nurse practitioner (NP). She complains that the school nurse found a few nits in her daughter's hair. The mother states that the school has a "no nits" policy regarding head lice and her daughter cannot go back to school until all the nits have been removed. The child was treated with permethrin shampoo (Nix) twice about 3 months ago. During the physical exam, the NP sees a few nits that are about 2 inches away from the scalp. The child denies itchiness on her scalp. Which of the following is the best action for the NP to follow? A) Prescribe lindane (Kwell) for the child because she may have head lice that are resistant to permethrin B) Advise the mother to use a nit comb after spraying the child's hair with white distilled vinegar, wait for 15 minutes, and then rinse the hair C) Advise the mother to retreat the child with permethrin cream instead of shampoo D) Reassure the mother that the nits will probably drop off after a few weeks
B) Advise the mother to use a nit comb after spraying the child's hair with white distilled vinegar, wait for 15 minutes, and then rinse the hair According to the Centers for Disease Control and Prevention (CDC), nits that are more than 1⁄4 inch from the scalp are usually not viable. The child also does not have an itchy scalp. One method of removal is to soak the patient's head with distilled vinegar (and then rinse after), which will break down the protein of the nit casings, making it easy to comb them out of the hair.
Which of the following factors is associated with increased risk of osteopenia in teenage girls? A) Drinking one glass of low-fat milk daily B) Anorexia nervosa C) Participation in sports D) A normal BMI (body mass index)
B) Anorexia nervosa Anorexia nervosa increases the risk for osteopenia in teenage girls as a result of the poor intake of foods high in calcium and vitamin D.
A 53-year-old crossing guard complains of twisting his right knee while working that morning. The knee is swollen and tender to palpation. The nurse practitioner diagnoses a grade II sprain. The initial treatment plan includes which of the following? A) Intermittent application of cold packs the first 24 hours followed by applications of low heat at bedtime B) Elevation of the affected limb and intermittent applications of cold packs for the next 48 hours C) Rechecking the knee in 24 hours and encouraging isometric exercises D) Application of an elastic bandage wrap to the affected knee
B) Elevation of the affected limb and intermittent applications of cold packs for the next 48 hours Elevation of the injured knee above the heart will reduce the amount of swelling that can occur. Use of ice packs immediately after the injury is most effective and will reduce swelling in the tissue. Ice the affected area for 15 to 20 minutes at a time intermittently to prevent frostbite and further damage to tissue. Allowing 30 to 45 minutes between icing of the limb is recommended.
What does a positive posterior drawer sign in a 10-year-old soccer player signify? A) Normal knee B) Instability of the knee C) Swelling on the knee D) Injury to the meniscus
B) Instability of the knee The drawer test is used to identify mediolateral or anteroposterior plane instability of the knee. The test is performed on the unaffected and affected knee for comparison. The anterior drawer test evaluates the anterior cruciate ligament (ACL). To perform the test, the patient lies supine and the knee is placed at 90-degree flexion. Grasp the posterior aspect of the tibia over the upper calf muscle; then, with a steady force, try to push the lower leg forward and backward. Anterior or posterior movement of the knee is positive. With the leg extended, stabilize the femur with one hand and the ankle with the other. Try to abduct and adduct the knee. There should be no medial or lateral movement.
All of the following are false statements about atopic dermatitis except: A) Contact with cold objects may exacerbate the condition B) It does not have a linear distribution C) It is associated with bullae D) The lesions have vesicles that are full of serous exudate 517
B) It does not have a linear distribution Atopic dermatitis, also known as eczema, is a skin condition in which the lesions occur in a linear fashion. They may have many different stages, including erythematous papules and vesicles, with weeping, drainage, and/or crusting. Lesions are commonly pruritic and are found on the scalp, face, forearms, wrists, elbows, and backs of the knees.
Your female patient of 10 years is concerned about her most recent diagnosis. She was told by her dermatologist that she has an advanced case of actinic keratosis. Which of the following is the best explanation for this patient? A) It is a benign condition B) It is a precancerous lesion and needs to be followed up with her dermatologist C) It will diminish with application of hydrocortisone cream 1% BID for 2 weeks D) It is important for her to follow up with an oncologist
B) It is a precancerous lesion and needs to be followed up with her dermatologist Actinic keratoses are small, raised skin lesions that result from extended sun exposure. Some actinic keratoses may develop into skin cancer; therefore, further evaluation is needed to determine if removal is required.
A positive straight leg raising test is indicative of which of the following? A) Myasthenia gravis B) Inflammation of the sciatic nerve/herniated disk C) Multiple sclerosis D) Parkinson's disease 535
B) Macrocytic and normochromic cells/herniated disk To perform the straight leg test, have the patient lie supine on an exam table. Lift the patient's leg toward his or her head while the knee is straight. If the patient experiences sciatic pain when the straight leg is at an angle between 30 and 70 degrees, then the test is positive and a herniated disk is likely to be the cause of the pain. The straight leg test should be done on the pain-free side first to find out which range of movement is normal and to enable the patient to distinguish between "normal" stretching of muscles and a different sort of pain.
The gold-standard test for visualizing a torn meniscus or joint abnormalities is the: A) Computed tomography (CT) scan B) Magnetic resonance imaging (MRI) scan C) X-ray with special views of the affected knee D) Lachman's maneuver
B) Magnetic resonance imaging (MRI) scan MRIs provide good 707 visualization of soft tissues of the body (most cancers, brain, cartilage, muscles, inflammation, etc.). They are best used to evaluate tissues with high water content. Patients with metal implants, such as cochlear implants and cardiac pacemakers, should be carefully screened. The MRI does not use radiation, but uses strong magnetic and radio waves to visualize body structures.
An 18-year-old female patient is being followed up for acne by the nurse practitioner. During the facial exam, papules and pustules are noted mostly on the forehead and the chin areas. The patient has been using over-the-counter topical antibiotic gels and medicated soap daily for 6 months without much improvement. Which of the following would the nurse practitioner recommend next? A) Isotretinoin (Accutane) B) Tetracycline (Sumycin) C) Clindamycin topical solution (Cleocin T) D) Minoxidil (Rogaine)
B) Tetracycline (Sumycin) First-line treatment for acne vulgaris includes over- the-counter medicated soap and water with topical antibiotic gels. The next step in treatment would be the initiation of oral tetracycline.
What type of cast is used to stabilize a fracture of the scaphoid bone? A) Long arm cast B) Thumb spica cast C) Short leg cast D) Leg cylinder cast
B) Thumb spica cast The scaphoid bone is located on the radial aspect of the wrist (same side as the thumb). Another term for scaphoid fracture is navicular space fracture of the wrist. In patients with this injury, palpating in the anatomic snuffbox area reveals local tenderness. A thumb spica cast is used to stabilize fractures of the wrist. It is applied below the elbow (forearm in neutral position) and extends to the hand (wrist and thumb are immobilized). Sometimes, this type of fracture is stabilized with a screw (surgery) because it has a higher rate of nonunion.
The following skin findings are considered macules except: A) A freckleB) PetechiaeC) AcneD) A flat, 0.5-cm brown birthmark
C) Acne A macule is a flat, nonraised lesion on the skin. Acne lesions are papules because they consist of raised, erythemic lesions on the skin. A freckle, petechiae, and a flat birthmark are all considered macules.
A positive anterior drawer sign of the knee is highly suggestive of? A) Meniscus damage B) Posterior cruciate ligament damage C) Anterior cruciate ligament damage D) Medial collateral ligament damage
C) Anterior cruciate ligament damage A positive anterior drawer sign occurs when there is damage to the anterior cruciate ligament. The patient is tested in supine position with knees flexed at 90 degrees and feet flat on the exam table. Hold the proximal lower leg (upper tibia) and push the leg anteriorly. The test is positive if the affected knee slides or has laxity when compared with the uninjured knee. Refer patient to an orthopedic specialist if the knee is unstable. The best imaging test for joints is the MRI.
A first-grader presents to a school nurse practitioner with a few blisters on one 549 arm and on his face. The child keeps scratching the affected areas. Some of the lesions have ruptured with yellow serous fluid that crusts easily. These findings best describe: A) Acute cellulitis B) Herpes zoster C) Bullous impetigo D) Erysipelas
C) Bullous impetigo Bullous impetigo is an infection of the skin caused by Staphylococcus aureus, which produces exfoliative toxin A. The infection is more common in young children. It is characterized by flaccid large blisters filled with serous fluid. When the bullae rupture, the serous fluid dries up and resembles honey- colored crusts. If the child has a limited number of skin lesions, topical therapy with mupirocin (Bactroban) is effective. But if lesions are extensive, systemic antibiotics, such as Dicloxacillin and cephalexin, are the treatment of choice.
A neighbor's 14-year-old son, who is active in basketball, complains of pain and 553 swelling on both knees. On physical exam, there is tenderness over the tibial tuberosity of both knees. Which of the following is most likely? A) Chondromalacia patella B) Left knee sprain C) Osgood-Schlatter disease D) Tear of the medial ligament
C) Osgood-Schlatter disease Osgood-Schlatter disease is characterized by bilateral pain over the tibial tuberosity upon palpation, along with knee pain and edema with exercise.
A 15-year-old basketball player who is 6 ft tall is seen for complaints of painful lumps on his knees. Upon inspection, the nurse practitioner notes a bonelike growth on the upper tibia midline below the kneecap on both knees. The patient has full range of motion with no joint tenderness, redness, or swelling. Which of the following conditions is best described? A) Osteosarcoma of the tibia B) Juvenile rheumatoid arthritis C) Osgood-Schlatter disease D) Paget's disease of the bone
C) Osgood-Schlatter disease Osgood-Schlatter disease is characterized by pain over the tibial tuberosity with palpation of a bony mass over the anterior tubercle of one or both knees. Exercise worsens the pain.
A 13-year-old boy wants to be treated for his acne. He has a large number of closed and open comedones on his face. The patient has been treating himself with over-the-counter benzoyl peroxide and topical salicylic acid products. Which of the following would be recommended next? A) Isotretinoin (Accutane)B) TetracyclineC) Retin-A 0.25% gelD) Careful face washing with medicated soap at bedtime
C) Retin-A 0.25% gel Topical agents are the first-line treatment for acne vulgaris. Retin-A 0.25% gel would be the next step. Oral preparations (tetracycline) would then be offered, and Accutane would be the final step.
The differential diagnosis for genital ulceration includes all of the following except: A) SyphilisB) Genital herpesC) ChancroidD) Molluscum contagiosum
D) Molluscum contagiosum Genital ulcers may occur with syphilis, genital herpes, and chancroid. Molluscum contagiosum is a viral skin infection. In adults, molluscum contagiosum appears on the face, neck, armpits, arms, and hands. Other common places include the genitals, abdomen, and inner thigh. Lesions often begin as small, firm, dome-shaped growths; have a surface that feels smooth, waxy, or pearly; are flesh-colored or pink; have a dimple in the center (may be filled with a thick, white substance that is cheesy or waxy); and are painless but itch. Scratching or picking can spread the virus.
A new patient is complaining of severe pruritus that is worse at night. Several 540 family members also have the same symptoms. Upon examination, areas of excoriated papules are noted on some of the interdigital webs of both hands and on the axillae. This finding is most consistent with: A) Contact dermatitis B) ImpetigoC) Larva migransD) Scabies
D) Scabies Scabies is a parasitic disease (infestation) of the skin caused by the human itch mite Sarcoptes scabiei. The rash is generally characterized as red, raised excoriated papules. The scabies mite is generally transmitted from one person to another by direct contact with the skin of the infested person and can also be acquired by wearing an infested person's clothing (fomites), such as sweaters, coats, or scarves. Following the incubation period, the infested person will complain of pruritus (itching), which intensifies at bedtime under the warmth of the blankets. Common sites of infection are the webs of fingers, wrists, flexors of the arms, the axillae, lower abdomen, genitalia, buttocks, and feet.
A fracture on the navicular area of the wrist is usually caused by falling forward and landing on the hands. The affected wrist is hyperextended to break the fall. The nurse practitioner is aware that all of the following statements are true regarding a fracture of the scaphoid bone of the wrist except: A) It has a higher rate of nonunion compared with the other bones in the wrist when it is fractured B) The fracture frequently does not show up on an x-ray film when it is taken immediately after the injury C) The x-ray film will show the fracture if the film is repeated in 2 weeks D) These fractures always require surgical intervention to stabilize the joint
D) These fractures always require surgical intervention to stabilize the joint 666 Common signs and symptoms of a fracture of the navicular area include pain, swelling, and tenderness over the thumb side of the wrist, and "crunchiness" and pain with gripping motions. Immediately following the injury, the fracture may not be found on x-ray, leading to misdiagnosis as a sprain. This fracture may be more accurately diagnosed with a bone scan if it does not appear on an x-ray. However, fracture is usually visible if the x-ray is repeated in 2 weeks. Treatment depends largely on the severity and shape of the fracture line. Fractures that are not displaced (those where the break line is small) are immobilized (casting). Nondisplaced fractures that do not heal after 3 to 4 months often require surgical intervention, and the use of other modalities, such as electrical stimulation.
