APEA Pearls to help pass FNP boards
Terms in this set (255)
inhaled anticholinergic "prevents bronchospasm" ipratropium (atrovent)
one or ide
migraine (constricts cerebral arteries--to not overuse)
h2 blockers (famotidine)
proton pump inhibitor
calcium channel blocker---first line for ISH
diabetic med--no hypoglycemia
alpha adrenergic blockers (tx BPH)
4 indications for cxr with acute cough
>75 years old
Who gets PPSV23 vaccine??
-single dose 65 or older
-single dose 19-64 if chronic illness, smoker, group home
-Immunocompromised receive another dose at 5 YEAR interval
-ALWAYS get dose at 65 even if received earlier doses as long as 5 Years has passed!!
Bacteria responsible for most pneumonia deaths
Strep pneumonae (Gram +)
Three most common bacteria - CAP
S. Pneumoniae (+)
Mycoplasma pneumoniae (walking pneumonia)
Best initial antibiotics for pneumonia if no antibiotic exposure in last 3 months
Doxycycine or Macrolide (Azithromycin or Clarithromycin) ----because they cover for atypicals
Best initial antibiotics for pneumonia if comorbidities or antibiotics in 90 days
-Resp quinolone (levofloxacin, gemifloxacin, moxifloxacin) or IF ALLERGY
-Beta-lactam (PCN or cephalosporin) PLUS macrolide
How long course of antibiotics for pneumonia
3 days longer than s/s of infection.
Pneumonia severity index???
What confirms COPD on PFTs???
Bigger number more severe
What med is crucial for COPD patient
Where are beta1 receptors
Where are beta2 receptors
What is the maintenance drug of choice for all levels of asthma?
What classifies persistent asthma ?
>2 days /wk symptoms; nighttime sx >3 x month
How do postitive PPD readings differ for immunocompromixed patients?
smaller size of induration positive if immunocompromized (>15 mm if healthy, >5mm if HIV)
What does Baciille Calmette Guerin vaccine protect against?
BCG vaccine for TB. Given in other countries.
At what age should you do a f/u CXR after treatment for pneumonia
Anyone over 40
Possible sequelae of long term inhaled steroid use
What cardiac class is bad for COPD /Asthma
-lol; Beta Blockers...opposite affect of SABA and LABAs
Which patients typically should have higher h&h???
Hgh altitudes, smokers, COPDers
What population "generally" has lower h&h?
Range of "normocytic" MCV rbc
on a cbc, the size of rbc is described by the
On a cbc, the hemoglobin content of RBCs is decribed by the
MCH (mean corpucular hgb) hypo/hyperchromic??
RDW - what is it ? What is normal?
indicates degree of variation in RBC size (<15 is normal) ...do not want large variation in rbc sizes!
serum iron measures?
measure of iron in circulation (reciprocal with TIBC) egg carton
serum ferritin measures?
iron in storage
total Iron binding capacity-reciprocal with iron level
Microcytic , hypochromic anemia
Iron deficiency anemia
Most common causes of iron deficiency anemia
impaired rbc production
poor iron absorption (celiac disease)
What do the TIBC and RDW look like in Iron deficiency anemia
TIBC and RDW increased (spitting out small pale cells)
Hgb 8/1%; Hct 24%; MCV 74; MCH 26
Iron deficiency anemia
Foods other than meat rich in iron
dried peas and beans; dark green leafy veggies
When will iron deficient patient start to feel better after placed on supplement
in a few days
Replacement dose of Fe for anemia
150-200 mg/d of elemental iron
What lab value represents adequate iron supplementation has occurred (supplements can stop?)
serum ferritin (normal iron stores)
How do labs for anemia of chronic disease differ from IDA?
Normocytic, normochromic...but can be also Microcytic/ Hypochromic. Serum iron is decreased, but TIBC and Serum Ferritin are normal...Fe will not HELP!!!
hereditary; microcytic, hypochromic...premature hemolysis. Will have normal Fe, TIBC, Ferritin, and RDW!!! DO NOT GIVE FE!!!!
B12 deficiency often ABSORPTION problem..not dietary deficiency! Macrocytic
What other nutrient should you check with a B12?
Elevated levels of MMA and homocystiene indicate what ????
Sensitive measures of B12 deficiency...B12 needed for metabolism of these
s/s of pernicious anemia
dementia, neuopathy, weakness, elderly, vegans, alcholics, bariatric patients
Vit B12 IM every day for one week----then weekly x4----than monthly for life
when do monocytes elevate?
after 24 hours of illness
what does it mean if polys and lymphocytes are close numerically?
Another name for Neutrophils
segs or polys
What if polys are high on WBC
what do bands mean?
bone marrow thinks you are SICK! Sending out immature cells for backup
What if wbc count normal, but shift to left or right??
May be early in infection, or pt immunosuppressed.
what is a shift to the left?
increase in number of bands or "baby" neutrophils in blood smear..indicative of active infection
What is the major concerning sequelae from pseudotumor cerebri?
loss of vision
characteristics of migraine
acute treatment for migraine??
triptans--arterial constriction; expensive...do not overuse or will become ineffective
prophylaxis for migraines
Topiramat; depakote; beta-blockers
who should NEVER get a tryptan??
CAD!! or HTN
h/a with band-like squeeze?
Sudden severe brief unilateral facial pain?? intense, sharp, stabbing
trigeminal neuralgia --CN V ---trigeminal nerve
treatment for trigeminal neuralgia
Treatment for bell's palsy?
High dose steroids! 60 mg x5days prevents future sequelae
What maneuver provokes BPV (benign positional vertigo)?
Treatment for vertigo?
Antihistamines: meclizine, dimenhydrinate
Benzos--alprazolam...for vertigo from hell!!
what neurotransmitter is part of the underlying patho in Parkinsons??
how is parkinson's diagnosed?
response to dopaminergic therapy
Treatment for Parkinsons...
What drug may help with physiologic tremors?
memory impairment PLUS at defecit of at least 1 of aphasia, apraxia, agnosia, executive function
important w/u in assessment for dementia
TSH, B12, Folate, RPR, HIV, CBC, CMP..imaging to r/o injury or bleed
how would you manage a migraine in a hypertensive patient?
Toradol. No tryptan!!!
What cranial nerve might cause hearing loss and vertigo?
pneumonic for cranial nerves (dirty)
oh, oh, oh, to touch and feel vaginas get vinny all hot
You have one nose, so the olfactory nerve is CN I
Optic ---checked with snellen chart
You have two eyes, so the optic nerve is CN II, which functions to produce vision.
what does 20/200 vision mean?
at 20 ft...the person can see what a normal person can see at 200 feet.
oculomotor---eye movements, pupillary constriction, accommodation
Trochlear ---movemnt of superior oblique muscle
Trigeminal-sensation to face, cheek, and teeth. Motor---mastication
Abducens--lateral rectus muscle movement
Facial: facial muscles and taste---think Bells palsy
Vestibulocochlear---hearing balance awareness of position
The number 8 resembles an ear, so CN VIII, the vestibulocochlear/acoustic nerve is a sensory nerve for hearing.
Glossopharyngeal--sensation to tongue, pharynx and tympanic membrane
Spinal accessory ---sternocleidomastoid/trapezius
11 looks like pair of arms /shoulders...
Hypoglossal motor fibers of tongue...stick out tongue
The saying The tongue licks the wound is a reminder that when the hypoglossal nerve (CNXII) is damaged, the tongue deviates to the same side of a lesion to the cranial nerve. (eg, if the tongue deviates to the right, the right side of CNXII is damaged).
Gram + bugs
What are the beta lactams?
The rules with PCN allergy??
NEVER give cepholasporing if pt had anaphalaxis or hives with PCN. If morbilliform rash...may give.
Does augmentin cover atypical pathogens??
NO! Doxy or macrolide!!!
What does PCN cover?
All gram + except MRSA, MSSA
What does Augmentin cover?
Gram +, Gram -, B-lactamase ...but NOT MRSA OR MSSA!!
What history would make you suspect a pathogen that produces beta lactamase
antibiotic in last 90 days
Gram -, Atypicals, MRSA!!!
Can you use doxy to treat strep??
NO! Gram +
Gram -; MRSA!!!!
What are the best options for MRSA
Clindamycin, Tetracyclines, Bactrim
1st gen Cephalosporin
2nd gen Cephalosporin
Cefuroxime, Gram + and Gram -
Should you use cefuroxime to treat infection in pt. who has received antbx in last few months??
NO...probably betalactamase producer..
3rd generation cefalosporin
Cefixime (suprax), Ceftibuten ...weak gram -, gram +...beta lactamase!!!
should you use ceftibuten to treat infection in pt. who has received antbx in last few months??
YES! Beta lactamase cover
Extended spectrum 3rd gen Cephalosporins
Rocephin (ceftriaxone), cefdinir
Gram +, Gram -, B-lactamases!!!
Macrolides (Later gen)
Atypical pathogens! NOT STREP!
Fluoroquinolones 2nd gen
Cipro---gram - ; atypical pathogens
why is cipro a poor choice to treat CAP?
strep pneumo Gram+....doesn't cover for DRSP
Respiratory Fluoroquinolones --3rd gen
Levofloxacin---the idiot's antibiotic! Kill everything except MRSA. SAVE AS LAST RESORT
Resp Fluoroquinolones--4th gen.
moxifloxacin, gemifloxacin, gatifloxacin
Gram+, Gram-, Atypicals, Beta lactamase, DRSP
DO NOT USE BELOW THE BELT!!
What is the most effective fasting time for lipid panel??
Most accurate after 12 hour fast.
What are the CHD equivalents when deciding whether or not to treat hyperlipidemia?
What cardiac class may cause exercise intolerance
Beta Blockers -lol
slows heart rate.
What diuretic bp med should not be given to a patient with hx of severe reaction to bactrim
HCTZ...has a sulfonamide ring!!!
Where would the PMI be felt in a pt. with hert failure?
5th intercostal space to LEFT of midclavicular line.
The most common arrhythmia from valvular heart disease is...
Microscopic exam of tinea would show?
what is the process of screening for Lyme disease??
then confirm with Western blot if positive.
skin lesion which is a solid mass up to 1 cm is described as a
lesion flat and small like a freckle
fluid filled lesion less than 1 cm
fluid filled lesion >1cm
What is koilondychia
spooning of the nails.. common with chronic anemia...always screen with a cbc
What area of the body has the greatest percutaneous absorption???
What is the earliest detectable glycemic abnormality in a patient with type 2 diabetes
postprandial hyperglycemia precedes fasting hyperglycemia
Target blood pressure for diabetic
less than 130/80!!!
How should ACE be managed as treatment for proteinuria in diabetic??
Effect should be seen in 6-8 weeks. Titrate ACE upward til urine protein <500 or pt. has bad side effects from ARB or ACE. Second agent can be added if max dose reached without success. Monitor K and CRE levels with dose changes
What are the ADA goal for diabetic lipid values??
HDL >50 in women; >40 men
no rec for total Chol
How do you dose T4?
Wt in kg. x 1.6 to calcluate daily requirement. Prescribe this unless elderly or with existing CAD. Dose lower.
Triad for mono
fever, lymphadenopathy, pharyngitis
what are the identifying otic characteristics of AOM?
Middle ear effusion AND erythema of TM
How will liver functions ALT/AST be altered in long term alcoholic
both are typically below 40. In alcoholic hepatitis AST:ALT ratio usually 2:1
What is Glucose-6-phosphate dehydrogenase deficiancy???
x-linked disorder; m and f. most common enzymatic disorder of red cells. avoid asa, sulfa, fava beans...cause rapid lysis of cells
How is iron best absorbed?
on an empty stomach
What type of anemias are most likely in an elderly patient with history of chronic illnesses and poor health for over a decade??
folic acid and pernicious----malabsorbption!!!
Hallmark finding with B12 and folate deficiencies???
35 yo with normal paps since 18. Normal pap and hpv..when should she be tested again???
5 YEARS....ACOG says testing no more than every 5 years in women over 30 if BOTH tests are negative and adequate screening has taken place. If PAP ONLY ---rec is every 3 YEARS.
HPV testing in combo with pap is more sensitive.
HPV testing is more SPECIFIC in women over 30.
HPV testing ALONE is NOT recommended.
A localized tumor in the prostate gland associated with early stage prostate CA is likely to produce...
a. urinary hesitancy
b. low back pain
c. urinary frequency
d. an absence of symptoms
these produce no symptoms or clinical manifestations. Thus PSA screening.
hematuria is not a common clinical manifestation in ...
a. early prostate CA
c. bladder CA
d. Renal CA
A. localized tumors in prostate are not associated with hematuria. often have no s/s.
How soon after a diagnosis of acute prostatitis can a PSA be accurate?
4 weeks....infection or inflammation can cause a shharp rise in PSA values. Elective PSA should be deferred for four weeks. Earlier checks will result in elevated levels not associated with cancer...causing unnecessary patient anxiety.
What is the recommendation of the American Cancer Society for initial screening of an AA male for prostate CA?
Discussions starting at 40-45 years....AA males and those with first degree relative with prostate CA before age 65 are HIGH RISK.
What is the PSA threshold?
A carotid bruit in an elderly patient indicates what?
Indicates artery disease in other places. Those with carotid bruit have double stroke risk. Other vessels should be evaluated. MORE LIKELY TO DIE OF CARDIOVASCULAR DISEASE THAN CEREBROVASCULAR DISEASE
How long will it take to evaluate the effectiveness on acetylcholinesterase inhibitor drugs like donezepil used in Alzheimer's?
6-12 months. Eval includes family report. MMSE, ADL assessment, and side effects.
What are the presenting symptoms, treatment for temporal arteritis?
Dx with biopsy. Chronic vasculitis...new onset HA, abrupt visual disturbance, jaw claudication, unexplained fever or anemia, elveated sed rate. Avg. age of onset 72 yo.
Which fingers are not affected by carpal tunnel?
Fifth finger (pinky)
Anosmia...what cranial nerve should be evaluated.
I-olfactory (1 nose!)
Elderly pt. at increased risk for stroke..Daily ASA is an example of what kind of prevention?
PRIMARY....would be secondary if history of stroke.
When should you consider imaging for low back pain in a pt without red flags or hx or cancer, advanced age, or hx of trauma?
4 weeks at earliest
In what part of the hip does osteoarthritis cause pain?
The anterior hip.
What is first line drug for osteo arthritis pain not relieved by nonpharm methods??
Tylenol 650mg qid! Less risk than nsaids. Try first
According to Ottawa ankle rules..when should you image a sprain?
midfoot pain/bone tenderness, bone tenderness at base of the 5th metatarsal or unable to bear weight for 4 steps
Should you routinely screen TSH in pregnant women?
Only if hx of hypothyroidism, family hx, or s/s.
NP scope of practice is influenced by a number of factors. Which of the following does not ?
a.code of ethics
b.state and federal laws
c.Court of law
c. Court of law
it is established legally, ethically, and by boards of nursing and professional organizations. It sets the boundaries and indicates what is permitted legally, etc. It is NOT influenced by court of law and varies from state to state.
Who determines NPs legal authority to practice in any state?
The state legislature of the state. rules and regs may be promulgated by state boards of nursing that reflect scope of practice of nurse practitioners specific to that state.
what constitutes malpractice?
There must be a duty, a breach of that duty, and subsequent injury due to the breach.Comparison of performance is based on the standard of care delivered by nps.
What is negligence?
when one fails to exercise the care that a reasonable person would exercise. Injury does not have to happen for negligence to occur.
loss of interest or pleasure in doing things
you suspect a patient is abusing alcohol. What lab values would support this suspicion?
Elevated ALT, AST, and GGT. Both AST and ALT are usually elevated. AST is usually double ALT. GGT is often elevated when ALT and AST are still normal.
4 criteria diagnostic of anorexia nervosa
Weight below 85% of ideal body weight
Intense fear of weight gain
Severe body image disturbance
Absence of menses
What characterizes bulimia?
Binge eating...followed by either purging or periods of excessive exercise or starvation
What are side effects of tricyclic antidepressants?
anticholinergic effects; sleepiness, weight gain, in ELDERLY---hypotension, bradycardia, and prolonged QT interval! Always get baseline EKG in elderly prior to starting TCA.
What does the peak flow meter measure?
peak expiratory flow
good for asthma...little to no benefit for CoPD and pneumonia
How does Ipratropium work?
decreases parasympathetic tone and produces bronchodilation
rust colored sputum
strep pneumo....most deadly cause of pneumonia
What antibiotic should be used to treat uncomplicated pneumonia in an otherwise healthy patient without recent antibiotic exposure?
a macrolide (azithromycin/clarithromycin) or a tetracycline (doxy). They cover atypical pathogens and provide coverage for non-DRSP.
What risk factor has the greatest impact on HIV transmission.
When do the majority of patients exposed to HIV seroconvert if they are going to do so?
within 3 months
How long should a female patient with an uncomplicated UTI be treated with antibiotics
What should be done in the case of a pregnant woman with hypothyroidism?
Low T4 can affect fetal growth TSH levels should be monitored frequently. Needs can increase as much as 50%
How should you treat a patient diagnosed with Gonorrhea?
Treat both gonorrhea and chlamydia. They are so often found together.
What class of drugs should be avoided in CHF?
ca channel blockers (verapamil) can cause bradycardia...reduce contractility...worsen heart failure
Where do direct and indirect inguinal hernias occur???
indirect-internal inguinal ring
What is Medicare Part A?
hospital insurance; also covers some skilled nursing facilities
. No enrollment fee for most and they are charged montlhly premium based on number of eligible quarters they contributed .
What cranial nerve allows you to stick tongue out and move side to side
What cranial nerve allows you to close eyes tightly, wrinkle forehead, and smile?
CN partly responsible for speaking and tongue movement?
Which mitral valve disorder results from redundancy of the mitral valve's leaflets??
What is kava kava?
herb used to treat anxiety, fibro, hyperactivity and ADD. HEPATOTOXICITY possible ...monitor liver function.
A common early finding in patients with chronic aortic regurg is...
Test of choice for dysplasia of hip in 3 month old...
Ultrasound...xray not useful b/c hip bones still not ossified at this age.
What is the presentation clinically of MVP?
benign, assymptomatic . Most common valve problem in adults. CLICK
What workup needs to be done for fatigue and malaise?
CBC, BMP, TSH, UA
What is the triad of normal pressure hydrocephalus?
gait difficulty, cognitive disturbance, urinary incontinence
What is a case control study?
looks at "what happened"...ideal for discovering cause and effect. Groups would be analyzed to find out what risk factors were present in the "case" groups (those with outcome being studied) vs the control groups...those without those outcomes
What class of meds is used to treat ISH?
Calcium channel blockers...amlodipine, felodipine, etc
What is the presenting complaint and common precipitating events of epididmytis?
sexual activity, heavy physical exertion, bicycle or motocycle riding. (under 35 commonly STD related)
How would you manage a patient with symptoms of diabetes and a glucose of 302??
Diabetes-2 criteria-sx and glucose >200
Use insulin for glucose toxicity! Oral agents wont work. RTC tomorrow for recheck of glucose.
What happens to TIBC in iron deficiency anemia
What is the diff between major and minor depression??
number of symptoms >5/9 MAJOR
How would a pt. with acute cholecystitis present??
URQ or epigastric pain; nausea; very still b/c peritoneal inflammation causes increased pain with movement; + murphy's sign----ELDERLY likely to not have this or classic sx!!
What does leukocytosis indicate??
infection of unknown origin (bacterial or viral)
Niacin. USE, ADVERSE AFFECTS
Increases HDL; DECREASES GLUCOSE TOLERANCE, flushing, hypotension, gout flares. Take at night with ASA to reduce sx. Tolerance improves over time.
What is the correlation with hyperlipidemia and TSH?
If lipids elevated, check TSH. ..may be secondary to hypothyroidism. It is safe to NOT treat hyperlipidemia until TSH is less than 10...if they are still elevated start a statin.
120-139 OR 80-89
Stage 1 HTN?
140-159 OR 90-99
Stage 2 HTN
>or=160 OR > or = 100 diastolic
"2 drugs today"
What are HTN treatment goals for most patients??
HTN treatment goal for pt. with diabetes or chronic kidney disease
How should you treat a patient newly diagnosed with Stage 1 HTN?
What antiHTN classes are contraindicated in pregnancy
ATPIII recommendations for diabetics?
HDL >40 Males; >50 females
ATPIII recs for general population?
Measles; Fever, malaise...3 Cs (conjunctivitis, coryza, and cough) Koplick spots ---1-3mm whitish, bluish, or gray "grains of sand" appear on buccal mucosa, hard and soft palate BEFORE RASH. Rash starts on head and spreads down.
slapped cheek...lacy macular rash
marked lymphadenopathy, maculopapular rash like measles rash. macules on soft palate
vesicular lesions on erythematous base appearing in crops...no school until lesions all crusted over
Ho do you manage CAP in kids?
suspect DRSP! Gram -
HIGH dose Amox 90-100mg/kg/day OR 2nd or 3rd gen cephalosporin
IF PCN allergy....clarithromycin
dont give Hep B vaccine if anaphalaxis with ....
Dont give what vaccines if anaphalaxis with neomycin?
IPV, mmr, varicella
dont give what vaccines of anaphalaxis with gelatin?
varicella zoster, MMR
Pt lying supine , hip flexed at 90 degrees--
+when extension of knee from this position elicits resistance or pain in lower back or posterior thigh (meningitis)
What is the most common cause of stroke?
First line oral antibiotic for bite?
Most common cause of stasis ulcers?
What interventions are commonly needed with MVP?
Usually none...recommend physical activity. Mostly as symptomatic
A murmur that becomes softer as pt. moves from supine to standing...
Mid-systolic murmur gets louder as pt. moves from supine to standing...
think hypertrophic cardiomyopathy!!
How does grade III systolic murmure compare to S1 other heart sounds??
Louder than S2, softer than s1
S3 heart sound
heard in early diastole; noted in presence if ventricular overload, heard best with bell
when is S4 heard?
In presence of poorly controlled hypertension
recommended LDL level in persons with DM and CAD?
ECG in pt. with dig toxicity would show/
PSOAS sign illicits abdominal pain with
passive extension of the hip
obturator sign illicits abdominal pain by
PASSIVE FLEXION AND INTERNAL ROTATION OF THE HIP
Test where examiner applies pressure to top of head with neck bending forward to illicit pain/numbness in upper extremities?
Goal INR when treating dvt?
how frequently should INR be checked?
Every 4-6 weeks if stable...once weekly if underlying condition can affect coagulation.
In treating DM, microalbuminuria should be checked how often?
yearly if urinalysis negative for protein.
A1C provides info on glucose control over the last how many days
Goal A1C in type II?
< or =6.9
AT what interval should TSH be checked after levothyroxine dose changed?
What is the anticipated replacement need of t4?
What is a treatment option for PID with w/ PCN allergy?
quinolone with flagyl
Rocephin 250 IM plus
Doxy bid x 14 days
with or without flagyl x 14 days
Antibiotic for syphillis??
PCN ; if allergy tetracycline or rocephin
what three vaccines are not given until 1 year of age
hep A, MMR, varicella