NR 511 Final Study Guide questions

Question 86. Morris, age 52, is in a new relationship and is not sure whether his erectile dysfunction is organic or is caused by stress about his performance. What simple test could you suggest to determine if he has the ability to have an erection?
1.
Nocturnal penile tumescence and rigidity (NPTR) test.
2.
Penile duplex ultrasonography.
3.
Intracavernous injection.
4.
Serum prostate-specific antigen (PSA).
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Question 86. Morris, age 52, is in a new relationship and is not sure whether his erectile dysfunction is organic or is caused by stress about his performance. What simple test could you suggest to determine if he has the ability to have an erection?
1.
Nocturnal penile tumescence and rigidity (NPTR) test.
2.
Penile duplex ultrasonography.
3.
Intracavernous injection.
4.
Serum prostate-specific antigen (PSA).
1.
Nocturnal penile tumescence and rigidity (NPTR) test.
One of the initial steps in assessing patients with musculoskeletal complaints is to determine whether the complaint is articular or nonarticular in origin. Which of the following is an example of an articular structure?
A.
Bone
B.
Synovium
C.
Tendons
D.
Fascia
B.
Synovium
You have detected the presence of crepitus on examination of a patient with a musculoskeletal complaint. Additionally, there is limited range of motion (ROM) with both active and passive movement. These findings suggest that the origin of the musculoskeletal complaint is:
A.
Articular
B.
Inflammatory
C.
Nonarticular
D.
Noninflammatory
A.
Articular
3. Which of the following signs or symptoms indicate an inflammatory etiology to musculoskeletal pain?
A.
Decreased C-reactive protein
B.
Hyperalbuminemia
C.
Morning stiffness
D.
Weight gain
C.
Morning stiffness
Which of the following statements concerning the musculoskeletal examination is true?
A.
The uninvolved side should be examined initially and then compared to the involved side.
B.
The part of the body that is causing the patient pain should be examined first.
C.
When possible, the patient should not be asked to perform active ROM exercises to avoid causing pain.
D.
Radiographs should always be obtained prior to examination so as not to cause further injury to the patient.
A.
The uninvolved side should be examined initially and then compared to the involved side.
5. You are performing muscle strength testing on a patient presenting with musculoskeletal pain and find that the patient has complete ROM but cannot move it above gravity. Which numeric grade of muscle strength would you give this patient?
A.
1
B.
2
C.
3
D.
4
B.
2
Mrs. Gray is a 55-year-old woman who presents with tightness, pain, and limited movement in her right shoulder. She denies any history of trauma. Her examination reveals a 75% reduction in both active and passive ROM of the right shoulder. Mrs. Gray also is experiencing tenderness with motion and pain at the deltoid insertion. Her medical history is significant for type 1 diabetes mellitus and hypertension. Her social history reveals that she is a secretary and that she is right-handed. Based on her examination and medical history, you suspect adhesive capsulitis, or "frozen shoulder." Which clue in Mrs. Gray's history supports this diagnosis?
A.
History of hypertension
B.
Her affected shoulder is also her dominant arm.
C.
Her history of type 1 diabetes
D.
Her work as a secretary predisposes her to repetitive motions.
C.
Her history of type 1 diabetes
Jennifer is an 18-year-old woman who comes to the emergency room after a fall during a soccer game. Jennifer explains that she fell on her left side and kept her arm out straight to break her fall. She has been experiencing severe pain and limited ROM in her left shoulder. The clinician has diagnosed Jennifer with a dislocated shoulder. Which of the following statements are true concerning shoulder dislocation?
A.
Anterior dislocations are not painful, and ROM is normal.
B.
There is a risk of neurovascular and neurosensory trauma, so the clinician should check for distal pulses.
C.
X-rays are the only diagnostic testing appropriate to assess a dislocation.
D.
Most traumatic dislocations are posterior.
B.
There is a risk of neurovascular and neurosensory trauma, so the clinician should check for distal pulses.
8. Fred has been diagnosed with a trigger finger of the ring finger. Which of the following management strategies is appropriate?
A.
Surgical removal of the tendon sheath
B.
NSAIDs
C.
Local anesthetic injection into the tendon sheath
D.
Splinting
C.
Local anesthetic injection into the tendon sheath
9. Mrs. Anderson is a 35-year-old woman who has been recently diagnosed with carpal tunnel syndrome. She has two young children and asks the clinician what the chances are that they also will develop carpal tunnel syndrome. Which of the following responses would be correct regarding the risk of developing carpal tunnel syndrome?
A.
Carpal tunnel syndrome commonly occurs in families. Genetic factors are thought to account for about one-half the risk of developing carpal tunnel.
B.
People with occupations that require repeated flexion extension of the wrist, use of hand tools that require forceful gripping, or use of hand tools that vibrate are at risk for developing carpal tunnel.
C.
An underlying musculoskeletal disorder must be present for a person to develop carpal tunnel.
D.
Carpal tunnel syndrome only occurs in the presence of a hormonal imbalance.
B.
People with occupations that require repeated flexion extension of the wrist, use of hand tools that require forceful gripping, or use of hand tools that vibrate are at risk for developing carpal tunnel.
Which of the following statements is true regarding the treatment of carpal tunnel syndrome? A. The goal of treatment is to prevent flexion and extension movements of the wrist. B. Splints are not used in carpal tunnel syndrome, because they restrict complete movement of the fingers and wrist. C. Corticosteroid injections are encouraged in the treatment of carpal tunnel syndrome. D. Treatment that encourages fluid retention, to keep the joints lubricated, is an emphasis of treatment.A. The goal of treatment is to prevent flexion and extension movements of the wrist.Sam is a 25-year-old who has been diagnosed with low back strain based on his history of localized low back pain and muscle spasm along with a normal neurological examination. As the clinician, you explain to Sam that low back pain is a diagnosis of exclusion. Which of the following symptoms would alert the clinician to the more serious finding of a herniated nucleus pulposus or ruptured disc? A. Morning stiffness and limited mobility of the lumbar spine B. Unilateral radicular pain symptoms that extend below the knee and are equal to or greater than the back pain C. Fever, chills, and elevated erythrocyte sedimentation rate D. Pathologic fractures, severe night pain, weight loss, and fatigueB. Unilateral radicular pain symptoms that extend below the knee and are equal to or greater than the back pain12. The clinician has instructed Sirius, a 23-year-old patient with low back strain, to use NSAIDs to manage his symptoms of pain and discomfort. Which of the following statements would be most appropriate when teaching Sam about the use of NSAIDs? A. "You should start with the lowest dose that is effective in managing your pain, because long-term use of NSAIDs can result in gastrointestinal (GI) disorders such as ulcers and hemorrhage." B. "You should start with the lowest dose that is effective in managing your pain to avoid developing tolerance to the medication." C. "You should take the maximum recommended dose of NSAIDs so that you will not need to take narcotics to control your pain." D. "It is important to take NSAIDs on an empty stomach in order to increase absorption."A. "You should start with the lowest dose that is effective in managing your pain, because long-term use of NSAIDs can result in gastrointestinal (GI) disorders such as ulcers and hemorrhage."13. Janet is a 30-year-old who has recently been diagnosed with a herniated disc at the level of L5-S1. She is currently in the emergency room with suspicion of cauda equina compression. Which of the following is a sign or symptom of cauda equina compression? A. Gastrocnemius weakness B. A reduced or absent ankle reflex C. Numbness in the lateral foot D. Saddle area anesthesiaD. Saddle area anesthesiaWhich of the following statements is true concerning the management of the client with a herniated disc? A. Muscle relaxants and narcotics can be used to control moderate pain but should be discontinued after 3 weeks of use. B. An epidural injection is helpful in reducing leg pain that has persisted for at least 3 weeks after the herniation occurred. C. Intolerable pain for more than a 3-month period is an indication for surgical intervention. D. Most disc hernias require opioids for long term pain relief.C. Intolerable pain for more than a 3-month period is an indication for surgical intervention.John is a 16-year-old boy who presents to the emergency room after hurting his knee in a football game. He described twisting his knee and then being unable to extend it completely. John tells the clinician that he heard a pop when the injury occurred and has been experiencing localized pain. The clinician suspects a meniscal tear. Which test would be most appropriate to assess for the presence of a meniscal tear? A. Valgus stress test B. McMurray circumduction test C. Lachman test D. Varus stress testB. McMurray circumduction test16. The clinician suspects that a client has patellar instability. In order to test for this, the client is seated with the quadriceps relaxed, and the knee is placed in extension. Next the patella is displaced laterally, and the knee flexed to 30°. If instability is present, this maneuver displaces the patella to an abnormal position on the lateral femoral condyle, and the client will perceive pain. Testing for patellar instability in this way is known as: A. Apprehension sign B. Bulge sign C. Thumb sign D. Lachman signA. Apprehension signThe clinician is caring for Diane, a 22-year-old woman who presents with an injured ankle. Diane asks the clinician if she will need an x-ray. The clinician explains to Diane that an x-ray is not always necessary for an injured ankle and that the decision to obtain radiographs is dependent on the examination and Diane's description of her injury. Which of the following clues in Diane's examination or history would alert the clinician to the need for obtaining radiographs? A. Ability to bear weight immediately after the injury B. Development of minor ankle swelling after the injury C. Slight bruising over the injury site 2 days after injury D. Crepitation with palpation or movement of the ankleD. Crepitation with palpation or movement of the ankle18. Mr. Jackson is a 65-year-old man recently diagnosed with osteoarthritis. The clinician has explained to Mr. Jackson that the goals for managing osteoarthritis include controlling pain, maximizing functional independence and mobility, minimizing disability, and preserving quality of life. Mr. Jackson explains to the clinician that his first choice would be to use complementary therapies to control his condition and asks what therapies are most effective in treating osteoarthritis. What would be the most appropriate response from the clinician? A. "Complementary therapies should be considered only if surgical interventions are not successful." B. "I am unfamiliar with the available complementary therapies for osteoarthritis and prefer to discuss more mainstream treatments, such as NSAIDs and physical therapy, to manage your condition." C. "I would be happy to discuss all the treatment options available to you. Complementary therapies, such as acupuncture, acupressure, and tai chi, are being studied for use in the treatment of osteoarthritis and acupuncture can be used and is safe and well tolerated." D. "It would be crazy to use complementary therapies to treat such a serious condition."C. "I would be happy to discuss all the treatment options available to you. Complementary therapies, such as acupuncture, acupressure, and tai chi, are being studied for use in the treatment of osteoarthritis and acupuncture can be used and is safe and well tolerated."Chris is a 28-year-old male who complains of lower back pain that began 3 days ago. The pain is worse when he stands or bends, and it is somewhat relieved when he sits. The clinician performs the straight-leg raise test and it is negative. Plain film x-ray is positive. Which diagnosis is most likely? A. Osteoarthritis B. Spinal stenosis C. Scoliosis D. Muscle strainD. Muscle strainA clinician has performed a synovial fluid analysis and the results are as follows: visual analysis: turbid and yellow, viscosity: decreased, 52,000 white blood cells (WBCs) per mm3, polymorphonuclear leukocytes (PMNs): 75%, protein: 5 g/dL. Which of the following conditions could this result be attributed to? A. Rheumatoid arthritis B. Osteoarthritis C. Gout D. Septic arthritisD. Septic arthritis21. Normal estrogen function is important for preventing osteoporosis in both men and women. Estrogen works to prevent osteoporosis in which of the following ways? A. By increasing the erosive activity of osteoclasts B. By promoting osteoclastogenesis C. By inhibiting osteoclast apoptosis D. By increasing the activity of osteoblastsD. By increasing the activity of osteoblastsWhich of the following tests is considered the gold standard for definitively diagnosing osteoporosis? A. Bone alkaline phosphatase levels B. Urinary N-telopeptide assay C. Bone mass density measurement by densitometry D. Magnetic resonance imagingC. Bone mass density measurement by densitometryWhat is the recommended daily calcium intake for men 70 years and younger? A. 500 mg/day B. 750 mg/day C. 1,000 mg/day D. 1,500 mg/dayC. 1,000 mg/dayMrs. Allen is a 60-year-old woman who has been diagnosed with osteoporosis. She is very concerned about the risk of breast cancer associated with hormone replacement therapy and is wondering what other treatments are available to her. The clinician explains that bisphosphonates are another class of drugs used in the prevention and treatment of osteoporosis. What teaching should the clinician give Mrs. Allen in regard to taking bisphosphonates? A. Taking bisphosphonates can result in hypercalcemia, so calcium intake should be decreased while taking this class of drugs. B. There is potential for upper GI irritation, so these medications are contraindicated in people with abnormalities of the esophagus or delayed esophageal emptying. C. This class of drugs can be taken at any time of the day without regard to meals. D. This class of drugs should be taken with orange juice to increase absorption.B. There is potential for upper GI irritation, so these medications are contraindicated in people with abnormalities of the esophagus or delayed esophageal emptying.Which of the following medications is appropriate to treat Paget's disease? A. Boniva B. Fosamax C. Reclast D. ForteoC. ReclastWhich of the following statements concerning fibromyalgia is true? A. Muscle pain that is caused by the development of trigger points within the muscle cannot occur concurrently with fibromyalgia. B. A cause of myalgia can be fibromyalgia. C. Bursitis cannot coexist with pain from fibromyalgia. D. Fibromyalgia is an inflammatory musculoskeletal disorder.B. A cause of myalgia can be fibromyalgia.One of the most frequent presenting signs/symptoms of osteoporosis is: A. Goiter B. Abnormal serum calcium C. Elevated urine biochemical markers D. Bony fractureD. Bony fractureMrs. Thomas was seen in the office complaining of pain and point tenderness in the area of her elbow. The pain has increased following a day of gardening 1 week ago. A physical finding that differentiates the diagnosis and is most consistent with lateral epicondylitis (tennis elbow) is: A. Ecchymosis, edema, and erythema over the lateral epicondyle B. Pain at the elbow that radiates into the forearm and pain and weakness with gripping objects C. Inability to supinate and pronate the arm D. Inability to flex or extend the elbow against resistanceB. Pain at the elbow that radiates into the forearm and pain and weakness with gripping objectsA clinician is examining a vertebral fracture, and the examination and diagnostic findings have shown a compression of the anterior column that includes both endplates. What type and subtype are these? A. Compression fracture, type A B. Burst fracture, type B C. Seat-belt type injury, level two D. Fracture-dislocation, shearA. Compression fracture, type AWhich of the following would lead the clinician to suspect a tumor when paired with low back pain? A. Minor trauma with sneezing in elderly with osteoporosis B. History of spinal procedure C. Sudden loss of bowel or bladder function D. Unintended weight loss >10% of body weight in 6 monthsD. Unintended weight loss >10% of body weight in 6 monthsA 70-year-old female fell 2 weeks ago and developed immediate pain in her left elbow on the lateral epicondyle. She thought she just bruised it, but is now worried because it has not improved. She has used Tylenol® and ice at home, and that has helped slightly. During your examination, you find she has moderate swelling and ecchymosis, but no overtly obvious deformity. Her ROM is uncomfortable and severely diminished due to the pain. No crepitus is heard or felt. Her fingers are warm; her pulse is strong; and capillary refill is less than 2 seconds. What should you do? A. Make an immediate referral for an orthopedic surgical evaluation without further assessment. B. Tell her that it takes time for these bruises to improve, so she should be patient. C. Prescribe a splint for her left wrist and begin corticosteroid injections. D. Send her to the emergency room for reduction of this obvious wrist fracture.C. Prescribe a splint for her left wrist and begin corticosteroid injections.Debbie is a 43-year-old female being evaluated for a wrist injury. The clinician is assessing for median nerve compression by having Debbie maintain forced flexion of her wrist for 1 minute with the dorsal surface of each hand pressed together. Which of these tests did the clinician just perform? A. Allen's test B. Phalen's test C. Tinel's sign D. Finkelstein's testB. Phalen's testIn which of these athletes is posterior impingement syndrome most commonly seen? A. Cross country runner B. Swimmer C. Soccer player D. Ballet dancerD. Ballet dancerThe clinician is assessing Sally's diffuse hip pain. How should the clinician begin the examination? A. Begin the range-of-motion examination with an assessment of the motion that causes pain. B. Physical examination of the hip must first assess its position at rest. C. The patient should move the hip prior to radiographic studies to determine whether they are necessary. D. Flexion and extension of the affected hips' extremity should only be performed with the knee straight.B. Physical examination of the hip must first assess its position at rest.*****Felice is a 66-year-old female who complains that walking and prolonged standing causes pain and weakness in her legs and buttocks. She expresses that she has short-term relief when she leans on the shopping cart. When she sleeps on her back, she sometimes wakes up in the night in pain. Which of the following diagnoses is most likely? A. Multiple sclerosis B. Herniated lumbar disc C. Lumbar spinal stenosis D. Cervical spondylosisC. Lumbar spinal stenosisWhich of the following is a risk factor for overuse syndrome with tendonitis? A. Body mass index <18 B. Hypothyroidism C. Rheumatoid arthritis D. Cardiac diseaseC. Rheumatoid arthritisWhich diagnostic test is the diagnostic gold standard for patients that have tendonitis and have failed conservative treatment? A. Plain x-ray films B. Magnetic resonance imaging (MRI) C. Computed tomography (CT) scan D. Surgical explorationB. Magnetic resonance imaging (MRI)Connie is a 63-year-old seamstress who presents with pain at the base of her right thumb on abduction and extension of her right thumb. She also complains of pain on the radial side of her right wrist with lifting. Which of these diagnostic tests will help to determine if she has de Quervain's tenosynovitis? A. Allen's test B. Phalen's maneuver C. Tinel's sign D. Finkelstein's testD. Finkelstein's testGladys has begun taking Prolia for osteoporosis. Which of the following should be included in teaching about this medication? A. This medication is an oral pill daily. B. This medication decreases the risk of infection. C. It is contraindicated in the event of hypocalcemia. D. A drug holiday every 8 months is recommended.C. It is contraindicated in the event of hypocalcemia.Willow is a 67-year-old female and her bone mineral density is more than 1 SD below the young adult reference mean. What is her diagnosis? A. Normal bone mineral density B. Osteopenia C. Osteoporosis D. Severe osteoporosisB. Osteopenia1. A patient is 66 inches in height, weighing 200 lbs, and newly diagnosed with type 2 diabetes mellitus (DM). The A1c is 7.1%. What is the best initial treatment? A. No treatment at this time B. Diet and exercise C. Diet, exercise, and metformin D. Diet, exercise, and exogenous insulinC. Diet, exercise, and metforminThe clinician suspects that a patient seen in the office has hyperthyroidism. Which test should the clinician order on the initial visit? A. Sensitive thyroid-stimulating hormone (TSH) assay and T4 B. Free T4 and serum calcium C. Nuclear scintigraphy with radiolabeled iodine (123I) D. Magnetic resonance imagingA. Sensitive thyroid-stimulating hormone (TSH) assay and T4Which statement made by a patient with type 1 diabetes indicates successful teaching regarding general guidelines for exercise? A. "I will not exercise if my blood sugar is 315." B. "I should just check my blood glucose after exercise." C. "I should eat more carbohydrates if my blood glucose is less than 200." D. "I will exercise when my urine ketones are positive but blood sugar is 260."A. "I will not exercise if my blood sugar is 315."A male patient with type 1 diabetes comes to the clinic complaining of feeling nervous and clammy. He states that he took his insulin this morning but was late for work and did not eat breakfast. Which action should the clinician take first? A. Administer glucagon subcutaneously. B. Have him drink 4 ounces of juice. C. Call 911. D. Ask him about his usual eating habits.B. Have him drink 4 ounces of juice.A patient with type 2 diabetes comes to the clinic after reading about metformin in a magazine. Which condition that the patient also has would be a contraindication to taking metformin? A. Ulcerative colitis B. Inflammatory bowel disease C. Chronic obstructive pulmonary disease D. Renal diseaseD. Renal diseaseA 25-year-old patient presents to the clinic with fatigue, cold intolerance, weight gain, and constipation for the past 3 months. On physical examination, the clinician notices muscular stiffness; coarse, dry hair; and a delay in relaxation in deep tendon reflexes. Which test should be ordered next? A. Serum calcium B. Thyroid-stimulating hormone C. Electrolytes D. Urine specific gravityB. Thyroid-stimulating hormoneThe clinician has been doing diabetic teaching for a patient with type 1 diabetes with no retinopathy. Which statement by the patient would indicate that teaching has been effective? A. "As long as I don't need glasses, I don't have to worry about going blind." B. "I know I need to have my eyes checked every 2 years." C. "My primary doctor will check my eyes." D. "I will see my eye doctor when my vision gets blurry."B. "I know I need to have my eyes checked every 2 years."A 64-year-old man with type 2 diabetes presents to the clinic with the complaint of "my feet feel like they are on fire." He has a loss of vibratory sense and +1 Achilles reflex. Which of the following would be an appropriate treatment? A. Tricyclic antidepressants B. Angiotensin-converting enzyme inhibitors C. Aspirin D. InsulinA. Tricyclic antidepressantsAfter removing a tack from a type 2 diabetic's heel and evaluating the site for infection, what is the best plan for this patient? A. Suggest the patient use a heating pad to improve circulation. B. Refer to a podiatrist for a foot-care treatment plan. C. Send the patient for acupuncture treatments. D. Recommend increased intake of vitamin B12.B. Refer to a podiatrist for a foot-care treatment plan.Joyce is seen in the clinic complaining of vague symptoms of nervousness and irritability. She is also having problems sleeping at night. On physical examination, the clinician finds an irregular heartbeat and hyperactive reflexes. The differential diagnosis should include which condition? A. Myxedema B. Thyrotoxicosis C. Cushing's syndrome D. Pan-hypopituitarismB. ThyrotoxicosisThe patient is prescribed radioactive iodine (RAI) and asks the clinician how this drug works. The clinician's response should include which information? A. RAI prevents the peripheral conversion of T4 to T3. B. RAI binds free T4. C. RAI destroys thyroid tissue. D. RAI reduces freely circulating iodine.C. RAI destroys thyroid tissue.A patient is diagnosed with hypothyroidism. Which electrocardiogram change should the clinician observe as a manifestation of the disease? A. Sinus bradycardia B. Atrial fibrillation C. Supraventricular tachycardia D. U wavesA. Sinus bradycardiaAfter 6 months of Synthroid therapy, the clinician should expect which result in the repeat thyroid-stimulating hormone studies? A. Elevated B. Normal C. Low D. UndetectableB. NormalWhich laboratory finding should the clinician observe in a patient with untreated Graves' disease? A. Elevated TSH B. Decreased T3 C. Decreased TSH receptor antibody test D. Elevated antithyroglobulin antibodiesD. Elevated antithyroglobulin antibodiesThe clinician prescribes glipizide (Glucotrol) for a diabetic patient. Which statement made by the patient would indicate teaching has been effective? A. "I'll take my pill before breakfast." B. "I know to take my Glucotrol at bedtime." C. "It is important to take my medication right after I eat." D. "Since I only like to eat two meals a day, I can take the pill between my meals."A. "I'll take my pill before breakfast."A male patient with diabetes asks the clinician why he needs to check his blood sugar at home even when he feels good. Which response by the clinician would be most appropriate? A. "Control of glucose will help postpone or delay complications." B. "Regularly checking blood sugar will help you." C. "Monitoring glucose will promote a sense of connectedness." D. "Because you know it is the right thing to do for your disease."A. "Control of glucose will help postpone or delay complications."How often should the clinician examine the feet of a person with diabetes? A. Every year B. Every 6 months C. Every 3 months D. Every visitD. Every visitThe clinician sees a patient who has a body mass index (BMI) of 32.4 kg/m2. How would the clinician classify this patient? A. Overweight B. Obesity Class 1 C. Obesity Class 2 D. Obesity Class 3B. Obesity Class 1Mr. S presents in the clinic with pain, tenderness, erythema, and swelling of his left great toe. The clinician suspects acute gout. Which of the following should the clinician expect in the initial test results for this patient? A. Elevated uric acid level B. Elevated blood urea nitrogen C. Decreased urine pH D. Decreased C-reactive proteinA. Elevated uric acid levelWhich blood test would confirm a diagnosis of diabetes mellitus? A. A1c 5.5% B. Fasting plasma glucose level of 120 mg/dL C. Oral glucose tolerance test 250 mg/dL (2-hour level) D. Random plasma glucose level 175 mg/dLC. Oral glucose tolerance test 250 mg/dL (2-hour level)Which test should the clinician order to confirm Charcot foot? A. Bone scan of lower extremities B. Computed tomography (CT) scan C. X-ray of the foot D. Culture of the foot ulcerC. X-ray of the footA vegetarian patient with gout asks the clinician about foods to avoid. The clinician should advise the patient to avoid which of the following foods? A. Rice B. Carrots C. Spinach D. PotatoesC. SpinachThe clinician should question the patient with suspected gout about use of which of these medications? A. Antihypertensives B. Thiazide diuretics C. Cardiac glycosides D. Potassium supplementsB. Thiazide diureticsThe clinician finds numerous nodules on the thyroid of a 65-year-old woman. The clinician suspects thyroid cancer. Which data would be most significant for this patient? A. A history of enlarged tonsils in the 1940s B. Recent exposure to mumps C. Vegetarian diet D. Allergy to iodineA. A history of enlarged tonsils in the 1940sWhich of the following is essential for diagnosing thyroid cancer? A. Fine needle aspiration biopsy B. Thyroid ultrasound C. Computed tomography scan D. Magnetic resonance imagingA. Fine needle aspiration biopsyWhich of the following is a common sign of type 2 DM? A. Anorexia B. Recurrent yeast infection C. Fluid overload D. Elevated high-density lipoprotein cholesterolB. Recurrent yeast infectionWhich medication can cause hyperglycemia? A. Prednisolone (Omnipred) B. Metformin (Glucophage) C. Levothyroxine (Synthroid) D. Cephalexin (Keflex)A. Prednisolone (Omnipred)Which laboratory test result is diagnostic for hypoglycemia? A. A1c 7.0% B. Fasting blood sugar of 75 mg/dL C. Glucose level 43 mg/dL D. Random glucose level 64 mg/dLC. Glucose level 43 mg/dLWhich medication for type 2 diabetes mellitus would be contraindicated during pregnancy? A. Insulin B. Metformin (Glucophage) C. Glipizide (Glucotrol) D. Acarbose (Precose)C. Glipizide (Glucotrol)A 35-year-old woman presents with symptoms of hypoglycemia. There is no history of diabetes mellitus. Which condition should be included in the differential diagnosis? A. Peripheral vascular disease B. Pheochromocytoma C. Cushing's disease D. AcromegalyB. PheochromocytomaWhich action would the clinician take to elicit Chvostek's sign? A. Check serum level of glucose after drinking a glass of juice. B. Tap the facial nerve below the zygomatic arch anterior to the earlobe. C. Press into the lower quadrant of the abdomen and release quickly. D. Pump a blood pressure cuff 20 mm Hg above the patient's systolic pressure.B. Tap the facial nerve below the zygomatic arch anterior to the earlobe.The clinician should examine which area for gynecomastia? A. Female's vagina B. Male's breast C. Male's penis D. Female's ovariesB. Male's breastWhich slightly elevated laboratory result would the clinician observe in a patient with idiopathic hirsutism? A. Free testosterone B. Luteinizing hormone (LH)/follicle-stimulating hormone (FSH) C. Serum calcium D. AlbuminA. Free testosteroneThe clinician is assessing for the most common cause of increased neck size. Which area would the clinician exam? A. Salivary glands B. Lymph nodes C. Thyroid D. TracheaC. ThyroidWhich "P" is a component of "the 3 P's" of diabetes mellitus? A. Pain B. Paresthesia C. Pallor D. PolyphagiaD. PolyphagiaA woman presents with new-onset hoarseness with hemoptysis. For which condition should the clinician focus an examination? A. Hyperthyroidism B. Pheochromocytoma C. Cushing's syndrome D. Thyroid cancerD. Thyroid cancerWhich statement by the patient would indicate teaching has been successful regarding management of Cushing's syndrome at home? A. "I will take cortisone on an empty stomach." B. "I will stay away from large crowds." C. "I will maintain a low-protein diet." D. "I will avoid foods high in potassium."B. "I will stay away from large crowds."The patient presents to the clinic with a "buffalo hump," weight gain, easy bruising, and hyperpigmentation. Which initial diagnostic test should the clinician order? A. 1 mg overnight dexamethasone suppression test B. Abdominal computer tomography scan C. RAI uptake testing D. Early-morning salivary cortisolA. 1 mg overnight dexamethasone suppression testThe clinician suspects a patient has Addison's disease. Which clinical manifestation would the clinician observe upon a physical examination? A. Moon face B. Central obesity C. Hyperpigmentation D. Myxedema comaC. HyperpigmentationWhich hydrocortisone dose would the clinician prescribe for a patient with Addison's disease? A. 25 to 50 mg daily B. 0.5 to 0.2 mg daily C. 20 mg in the morning and 10 mg in early evening D. 2 to 4 mg in the morning and 1 to 2 mg in the eveningC. 20 mg in the morning and 10 mg in early eveningThe patient with type 1 diabetes is exhibiting Kussmaul respirations, anorexia, fatigue, and increased thirst. Which condition should the clinician manage? A. Hypoglycemia B. Somogyi effect C. Diabetic ketoacidosis D. Hyperosmolar hyperglycemic syndromeC. Diabetic ketoacidosisThe patient has hyperosmolar hyperglycemic syndrome. Which laboratory findings would the clinician observe? A. Plasma bicarbonate 8 mEq/L B. Blood glucose level 40 mg/dL C. Serum osmolality 420 mOsm/kg D. Blood pH 7.20C. Serum osmolality 420 mOsm/kgWhich question should the clinician ask to determine the most frequent cause of diabetic ketoacidosis? A. "How often are you taking the insulin?" B. "Which type of infection have you experienced recently?" C. "What type of diet have you been following?" D. "Is there any reason you don't like taking your medications?"B. "Which type of infection have you experienced recently?"A patient with type 1 diabetes has diabetic ketoacidosis. Which first-line treatment should the clinician prescribe? A. NPH insulin B. Regular insulin C. IV normal saline D. ThiazolidinedioneB. Regular insulinA nondiabetic patient has idiopathic hypoglycemia. Which dietary instruction should the clinician share with the patient? A. Follow a low-protein, high-carbohydrate diet B. Allow caffeine at each meal C. Avoid nuts and seeds D. Eat six small meals a dayD. Eat six small meals a dayThe clinician is using the HALT acronym to help a patient identify overeating triggers. What does the "T" represent? A. Tired B. Tense C. Temper D. ThreatsA. TiredThe patient weighs 350 lbs and is on a weight loss program. After 6 months, which ideal weight in pounds should the clinician observe? A. 335 B. 325 C. 315 D. 305C. 315Which instruction should the clinician include in patient teaching regarding management of obesity? A. Occasionally skipping meals is acceptable. B. Try to use nonstick cookware when baking or frying. C. High-intensity physical activity is recommended. D. Exercise for about 100 minutes per week.B. Try to use nonstick cookware when baking or frying.The patient has metabolic syndrome. The patient is at increased risk for which condition? A. Anxiety disorder B. Gallbladder disease C. Diabetes mellitus D. HyperparathyroidismC. Diabetes mellitusA 45-year-old male presents with throbbing podagral pain and tophi in the ear pinnae. Which medication should the clinician prescribe for this acute attack? A. Colchicine (Colcrys) B. Probenecid (Benemid) C. Allopurinol (Zyloprim) D. Pegloticase (Krystexxa)A. Colchicine (Colcrys)Which type of heat-related illness involves a core body temperature of at least 104°F and may present with hot dry skin, acute mental status changes, absent sweat, and tachypnea? A. Heat cramps B. Heat syncope C. Heat exhaustion D. Heat strokeD. Heat strokeWhat percentage of burns is involved using the rule of nines if both front legs are burned? A. 9% B. 18% C. 24% D. 36%B. 18%Which drug commonly prescribed for burns is active against a wide spectrum of microbial pathogens and is the most frequently used agent for partial- and full-thickness thermal injuries? A. Clotrimazole cream (Lotrimin) B. Mafenide acetate (Sulfamylon) C. Silver nitrate D. Silver sulfadiazine (Silvadene)D. Silver sulfadiazine (Silvadene)A sunscreen with a sun-protection factor of at least what number will block most harmful ultraviolet radiation? A. 4 B. 8 C. 10 D. 15D. 15Which clinical feature is a late sign of increased intracranial pressure? A. Dilated, nonreactive pupils B. Altered level of consciousness C. Loss of judgment D. AmnesiaA. Dilated, nonreactive pupilsWhat number represents normal neurological function on the Glasgow Coma Scale? A. 7 B. 9 C. 10 D. 15D. 15Which diagnostic test is the best to diagnose a subdural hematoma? A. History B. Positron emission tomography C. Magnetic resonance imaging (MRI) D. Computed tomography (CT) scanC. Magnetic resonance imaging (MRI)Patients with a spontaneous pneumothorax should be counseled that up to what percentage may experience a reoccurrence at some point? A. 5% to 15% B. 20% to 25% C. 30% to 50% D. 60% to 80%C. 30% to 50%Most adult poisonings are: A. Intentional and self-inflicted B. Accidental C. Caused by someone wishing to do harm to the person D. Not attributed to any reasonA. Intentional and self-inflictedWhich method is used to remove heavy metals, such as lead? A. Chelation B. Dialysis C. Gastric lavage D. Bowel irrigationA. ChelationIf a previously frostbitten area becomes frostbitten again after it has healed, what might occur? A. Permanent tissue damage may occur, resulting in necrosis to that body part. B. The area will be super sensitive. C. The area is prone to a repeat frostbite. D. The area is as susceptible as any other area.A. Permanent tissue damage may occur, resulting in necrosis to that body part.What population represents almost 75% of wounds? A. Boys in the mid-to-late teens B. Men in their early 20s C. Women in the mid-40s D. Toddlers between 18 and 30 monthsB. Men in their early 20sWhich solution should be used when irrigating lacerated tissue over a wound on the arm? A. Dilute povidone-iodine solution B. Hydrogen peroxide (H2O2) C. Saline solution infused with an antibiotic D. Saline irrigation or soapy waterD. Saline irrigation or soapy waterWhich type of burn injury results in destruction of the epidermis with most of the dermis, yet the epidermal cells lining hair follicles and sweat glands remain intact? A. Superficial burns B. Superficial partial-thickness burns C. Deep partial-thickness burns D. Full-thickness burnsC. Deep partial-thickness burnsWhich carboxyhemoglobin (COHb) level correlates with the clinical symptoms of confusion, lethargy, and ST-segment depression on the electrocardiogram? A. Less than 10% B. 20% COHb C. 30% COHb D. 40% to 60% COHbC. 30% COHbWhich causes the greatest percentage of mammalian bites? A. Dogs B. Cats C. Humans D. RodentsA. DogsWhich arthropod bite can contain cytotoxic and hemolytic toxins that may destroy tissue? A. Tick B. Brown recluse spider C. Wasp D. Stinging caterpillarB. Brown recluse spiderWhat condition is sometimes confused with anaphylaxis from an insect sting? A. Heat stroke B. Toxic syndrome C. Vasovagal reaction D. Inflammatory responseC. Vasovagal reactionDelayed serum sickness-type reactions in response to multiple bee, wasp, or fire-ant stings can be managed with which of the following? A. A corticosteroid such as prednisone (Deltasone), 60 to 100 mg, tapered over 2 weeks B. An oral antihistamine, such as hydroxyzine, for 2 weeks C. An H2 blocker such as cimetidine for 1 week D. 0.1 mg (1 mL of 1:10,000 solution epinephrine) in 10 mL of normal saline and administer as a slow IV push over 10 minutesA. A corticosteroid such as prednisone (Deltasone), 60 to 100 mg, tapered over 2 weeksAfter a head injury, what is it called when air enters into the cerebrospinal fluid (CSF)-filled spaces within the head? A. Pneumocephalus B. Hemotympanum C. Battle's sign D. Raccoon signA. PneumocephalusCSF may leak through the cribriform plate region of the skull following a head injury and cause which of the following? A. Ear CSF otorrhea B. Leakage of CSF from the eye C. Nasal CSF rhinorrhea D. Leakage of CSF from the mouthC. Nasal CSF rhinorrheaWhat condition is characterized by a brief loss of consciousness, then a brief "lucid" moment, followed by momentary unconsciousness minutes after the injury? A. Concussive hematoma B. Bleeding dyscrasias C. Subdural hematoma D. Epidural hematomaD. Epidural hematomaA patient with a basilar skull fracture may experience an impaired downward gaze or diplopia from which affected cranial nerve? A. CN II B. CN III C. CN IV D. CN VC. CN IVA history of overuse or excessive force, as opposed to a fall, hyperextension, or the twisting of a joint, is more likely related to which musculoskeletal injury? A. A sprain B. A strain C. A partial fracture D. A fractureB. A strainIn a healthy adult, the process of remodeling after fracture of the humerus takes how long? A. Approximately 4 weeks B. Approximately 2 months C. Approximately 3 months D. Approximately 4 monthsB. Approximately 2 monthsA patient who sustains blunt chest trauma and/or penetrating chest trauma must have which of the following imaging examinations? A. Upright anterior/posterior and lateral chest x-ray B. Supine anterior/posterior and lateral chest x-ray C. Upright bilateral chest x-ray D. Supine anterior/posterior chest x-rayA. Upright anterior/posterior and lateral chest x-rayIf a suspected pneumothorax is discovered in the primary-care setting, what should happen first? A. Emergency medical services should be activated. B. Support cardiovascular and respiratory status as needed. C. Administer supplemental oxygen to reabsorb the pneumothorax. D. Initiate stabilizing treatments, including emergency chest-tube placement.A. Emergency medical services should be activated.Hepatic necrosis with jaundice may occur after ingesting massive doses of which medication? A. Phenobarbital B. Diazepam C. Ritalin D. AcetaminophenD. AcetaminophenPink, cherry-red tissues and skin may result from which type of poisoning? A. Arsenic B. Lead C. Carbon monoxide D. StrychnineC. Carbon monoxideIn which type of burn is the injury more extensive than it appears, and the cardiac conduction system may be affected, leading to sudden death or arrhythmias? A. Chemical burns B. Electrical burns C. Radiation burns D. Thermal burnsB. Electrical burnsEddie, age 4, presents to the emergency department with a live insect trapped in his ear canal causing a lot of distress. What should be your first step? A. Remove the insect with tweezers. B. Immobilize the insect with 2% lidocaine. C. Sedate Eddie with diazepam. D. Shine a light in the ear for the insect to "find its way out."B. Immobilize the insect with 2% lidocaine.When giving discharge instructions to a patient with a laceration injury to his lower leg, which is the most important one? A. Recommend isometric exercises to prevent a deep vein thrombosis (DVT). B. Recommend cleansing the wound every 4 hours to prevent an infection. C. Keep the leg elevated at waist level to prevent any edema. D. Keep the leg completely immobile to prevent extension of the laceration.A. Recommend isometric exercises to prevent a deep vein thrombosis (DVT).Cerebellar function may be assessed by performing which examination/test? A. Gag reflex B. Pupillary response C. Romberg's test D. Apley's testC. Romberg's test********In the epithelialization phase of wound healing, the wound will have only what percentage of its normal tensile strength at 3 weeks? A. Less than 15% B. 15% to 20% C. 25% to 40% D. Greater than 50%B. 15% to 20%Which of the following statements is true about antibiotic prophylaxis for most wounds? A. Antibiotics are not indicated. B. Antibiotics should always be ordered for a wound. C. Antibiotics need to be ordered for at least 2 weeks. D. Antibiotics should be ordered only if sutures are in place.A. Antibiotics are not indicated.Which condition is often an unrecognized contributor to heat-related illness? A. Autonomic neuropathy B. Beta-adrenergic blockade C. Myocardial infarction D. AcclimatizationB. Beta-adrenergic blockade37. Why do benzodiazepines have less potential for toxicity than barbiturates? A. They cause decreased neuronal activity, depressed central sympathetic tone, and inhibit cardiac contractility. B. They increase ligand affinity and the frequency of ion channel opening, but not the duration of time the channel remains open. C. They act directly on inhibitory gamma-aminobutyric acid (GABA) receptors. D. They increase the average opening time of chloride ion channels.B. They increase ligand affinity and the frequency of ion channel opening, but not the duration of time the channel remains open.What is the most common cause of infectious conjunctivitis? A. Adenovirus B. Rhinovirus C. Staphylococcus aureus D. StreptococcusA. AdenovirusA patient presents to the emergency department with delirium, dilated pupils bilaterally, and hypoactive bowel sounds. Skin is flushed and dry; mucous membranes are dry. Upon admission, a urinary catheter was inserted with no output. These clinical manifestations describe which common toxidrome? A. Cholinergic B. Sedative-hypnotic C. Anticholinergic D. SympathomimeticC. AnticholinergicWhy are people with cystic fibrosis (CF) especially vulnerable to heat stroke? A. Intravascular coagulation prevents the production of chloride. B. Blood flow to the skin is impaired in temperatures above 95°. C. Sweat glands are inactive in CF. D. Salts from perspiration are not reabsorbed after sweating.D. Salts from perspiration are not reabsorbed after sweating.What is true about an acclimatized person? A. Aldosterone secretions are diminished B. Heat dissipation is impeded C. Cardiac output increases D. Aerobic muscle metabolism decreasesC. Cardiac output increasesIf no clinical decompensation is noted when evaluating a poisoned patient, what should you do next? A. Evaluate for signs of trauma and central nervous system involvement. B. Evaluate the airway, breathing, and circulation. C. Order a basic metabolic panel and liver function test panel. D. Obtain a urine sample for a toxicology screen.A. Evaluate for signs of trauma and central nervous system involvement.What should you use to alkalinize urine to a pH of greater than 7.0? A. Dextrose B. Sodium bicarbonate C. Activated charcoal D. Ipecac syrupB. Sodium bicarbonateWhat is the most dangerous complication of acute mastoiditis? A. Otitis media with effusion B. Meningitis C. Tympanic membrane rupture D. Intracranial abscessD. Intracranial abscessWhat would confirm if the joint was tapped in a knee fracture? A. A presence of hemarthrosis with fat globules B. The inability to flex the knee joint C. A large effusion D. Pain is elicited during passive range of motionA. A presence of hemarthrosis with fat globulesHyperhidrosis (trench foot) is a differential diagnosis for what condition? A. Hyperthermia B. Necrosis C. Frostbite D. Erythema pernioC. FrostbiteWhat is the aim of gastrointestinal decontamination for poisoned patients? A. Evacuating toxins from the stomach before they can be absorbed. B. Neutralizing the poison by inducing vomiting and diarrhea. C. Restricting the amount of xenobiotic from reaching the systemic circulation. D. Absorbing the toxins that have reached systemic circulation.C. Restricting the amount of xenobiotic from reaching the systemic circulation.What must be present for a diagnosis of acute diarrhea? A. Positive test for bacterial, viral, or parasitic infection B. Passing six or more stools daily without improvement for at least 3 days C. Loose stools with fever greater than 100°F D. Greater than 50%B. Passing six or more stools daily without improvement for at least 3 daysWhich of the following is not a cause of secondary constipation? A. Hard stools B. Diet C. Pregnancy D. MedicationsA. Hard stoolsWhich of the following is not a differential diagnosis of heat stroke? A. Cerebrovascular accident B. Central nervous system infections C. Diabetic ketoacidosis D. Alcohol intoxicationD. Alcohol intoxicationSandra is 70 years old and has just been diagnosed with leukemia. She is complaining of bone and joint pain. Which type of leukemia is most likely the culprit? A. Acute lymphoblastic leukemia (ALL) B. Acute myelogenous leukemia (AML) C. Chronic myelogenous leukemia (CML) D. Chronic lymphocytic leukemia (CLL)D. Chronic lymphocytic leukemia (CLL)Which type of bone marrow transplant is obtained from an identical twin? A. Xenograft B. Autologous C. Allogeneic D. SyngeneicD. SyngeneicDuring treatment for anaphylaxis, which site is used for the initial injection of epinephrine? A. Antecubital vein B. Abdomen C. Upper lateral thigh D. DeltoidC. Upper lateral thighAfter the initial treatment for anaphylaxis, which medication should be added to prevent late-phase anaphylactic reactions? A. Albuterol B. Diphenhydramine C. H2 blocker D. CorticosteroidD. CorticosteroidWhen analyzing synovial fluid, if it has 10,000 white blood cells/mcL with 80% polymorphonuclear neutrophils (PMNs), it may be indicative of which of the following conditions? A. None, this is a normal result B. Scleroderma C. Rheumatoid arthritis D. Sickle cell diseaseC. Rheumatoid arthritisWhich of the following disease-modifying antirheumatic drugs is a folic acid antagonist? A. Methotrexate (Rheumatrex) B. Etanercept (Enbrel) C. Rituximab (Rituxan) D. Anakinra (Kineret)A. Methotrexate (Rheumatrex)Which statement about HIV postexposure prophylaxis (PEP) for health-care workers is the most accurate? A. PEP treatment regimens contain two antiretroviral medications. B. PEP should be started within 72 hours of exposure. C. PEP follow-up requires renal function tests at 6 weeks after beginning PEP. D. PEP will prevent potential hepatitis C infection, if present.B. PEP should be started within 72 hours of exposure.For which patient would the clinician recommend annual HIV testing? A. One who is in a mutually monogamous relationship that engages in anal sex B. One who is a migrant worker C. One who is diagnosed with viral hepatitis D. One who is pregnant with second child from another maleC. One who is diagnosed with viral hepatitisReuben, age 24, has HIV and just had a routine viral load test done. The results show a falling viral load. What does this indicate? A. A favorable prognostic trend B. Disease progression C. The need to be more aggressive with Reuben's medications D. Drug resistance mutationsA. A favorable prognostic trendA patient with atrial fibrillation is taking warfarin (Coumadin) and has an international normalized ratio (INR) of 4.0 with no active bleeding. How should the clinician manage this patient? A. Stop the medication for 1 week, and then repeat the INR. B. Withhold 1 or more days of anticoagulant therapy. C. Restart therapy at a lower dose immediately. D. Slowly increase the dose over 3 days.B. Withhold 1 or more days of anticoagulant therapy.The patient with severe iron deficiency anemia is eating ice chips. Which term should the clinician use to document this finding? A. Cheilosis B. Anorexia C. Hypochromasia D. PicaD. PicaAs a rule of thumb, the estimated level of hematocrit is how many times the value of the hemoglobin? A. Two B. Three C. Four D. FiveB. ThreeWhat is the most common cause of microcytic anemia? A. Anemia of chronic disease B. Sideroblastic anemia C. Iron-deficiency anemia D. Pernicious anemiaC. Iron-deficiency anemiaWhich symptom is the cardinal subjective symptom of sickle cell crisis? A. Pain B. Nausea C. Light-headedness D. PalpitationsA. PainWhich phrase describes rheumatoid arthritis (RA)? A. Localized synovial joint destruction B. Chronic exocrine dysfunction C. Systemic inflammatory disease D. Antibody-mediated cellular cytotoxicity responseC. Systemic inflammatory diseaseWhich blood test is a nonspecific method and most helpful for evaluating the severity and course of an inflammatory process? A. Erythrocyte sedimentation rate B. White blood cell count C. Polymorphonuclear cells D. C-reactive protein (CRP)D. C-reactive protein (CRP)Infectious mononucleosis results from an acute infection with which of the following? A. Epstein-Barr virus B. Acute HIV infection C. Guillain-Barré D. HepatitisA. Epstein-Barr virusWhich condition is the most common cause of generalized musculoskeletal pain in women ages 20 to 55? A. Chronic fatigue syndrome B. Anemia C. Fibromyalgia syndrome D. Sports-related injuriesC. Fibromyalgia syndromeAfter returning from visiting his grandchildren in Connecticut, George, age 59, complains of a flulike illness, including fever, chills, and myalgia. He reports having discovered a rash or red spot that grew in size on his right leg. Which disease should the clinician be considering? A. Rubella B. Lyme disease C. Fibromyalgia syndrome D. ShinglesB. Lyme diseaseDryness of the eyes and mouth is typical of which condition? A. Sjögren's syndrome B. Allergic reaction C. Hypothyroidism D. Sideroblastic anemiaA. Sjögren's syndromeExposure to ultraviolet (UV)-B and UV-A rays is a triggering factor for acute exacerbations of which condition? A. Rheumatoid arthritis B. Gout C. Systemic lupus erythematosus D. Sjögren's syndromeC. Systemic lupus erythematosusWhat is the current goal of treatment for a patient with HIV infection? A. Viral suppression to undetectable levels B. Compete eradication of the virus C. Limit contact with uninfected individuals D. Total abstinenceA. Viral suppression to undetectable levelsWhich test should the clinician use to initially screen for HIV? A. Western blot B. Enzyme-linked immunosorbent assay C. HIV-1/2 antigen/antibody combination immunoassay D. Nucleic acid amplification testingC. HIV-1/2 antigen/antibody combination immunoassayWhich lab test would the clinician order to monitor for a significant side effect from tenofovir disoproxil fumarate? A. Urine protein B. Allele genetic testing C. Sodium level D. HemoglobinA. Urine proteinWhich drug category of antiretroviral (ARV) therapy is generally effective in crossing the blood-brain barrier and may be useful in managing HIV-associated dementia? A. Nucleoside reverse transcriptase inhibitors B. Protease inhibitors C. Integrase inhibitors D. Nonnucleoside reverse transcriptase inhibitorsD. Nonnucleoside reverse transcriptase inhibitorsSpontaneous bruising may be seen with platelet counts below what level? A. 100,000 cells/mL B. 75,000 cells/mL C. 50,000 cells/mL D. 30,000 cells/mLD. 30,000 cells/mLWhich type of fatigue may improve with exercise after awakening? A. Functional B. Acute C. Persistent D. Anemia associatedA. FunctionalWhich assessment finding presents with early rheumatoid disease? A. Pain and swelling in both small and large peripheral joints B. Rigid joints with diminished range of motion C. Joint swelling and immobility on rising D. A cardiac rub with pulmonary friction rubC. Joint swelling and immobility on risingWhich test is diagnostic of RA? A. Rheumatoid factor B. Erythrocyte sedimentation rate C. C-reactive protein D. Anti-citrulline-containing peptide titersD. Anti-citrulline-containing peptide titersWhat is the mainstay of management for infectious mononucleosis? A. Antivirals B. Symptom control C. Corticosteroids D. IsolationB. Symptom controlChronic fatigue syndrome (CFS) tends to occur in which individuals? A. Active, highly functional adults B. Depressed middle-aged adults C. Individuals with a depressed immune system D. Individuals who are hypochondriacsA. Active, highly functional adultsWhat is the bulls-eye rash of Lyme disease called? A. Erythema infectiosum B. Viral exanthem C. Erythema migrans D. Morbilliform exanthemC. Erythema migransWhich condition if left untreated will progress to complaints that include multiple joint arthritis? A. Sjögren's syndrome B. HIV/AIDS C. Guillain-Barré D. Lyme diseaseD. Lyme diseaseKeratoconjunctivitis sicca is a classic sign of which condition? A. Systemic lupus erythematosus B. Sjögren's syndrome C. Fibromyalgia syndrome D. Lyme diseaseB. Sjögren's syndromeWhich person is four times more likely to develop systemic lupus erythematosus (SLE) than a Caucasian? A. One of African descent B. An Asian C. A Hispanic D. One from the Middle EastA. One of African descentThe older adult patient has an infection. The clinician should assess for which clinical manifestation? A. Fever B. Dementia C. Confusion D. EcchymosisC. ConfusionWhich aspect should the clinician consider when trying to determine the cause of lymphadenopathy? A. Prothrombin time B. Marital status C. Patient's age D. Blunt traumaC. Patient's ageThe patient has a fever of 104.2°F (40.1°C). Which condition should the clinician be considering as the etiology of the fever? A. Urinary tract infection B. Infectious hepatitis C. Tuberculosis D. PancreatitisD. PancreatitisWhich type of hypersensitivity reaction should the clinician suspect in a patient who has an elevated IgE level? A. 1 B. 2 C. 3 D. 4A. 1In which area would the clinician evaluate a tender point in a patient with suspected fibromyalgia syndrome (FMS)? A. Fifth rib B. Trapezius C. Maxillary D. MidforearmB. TrapeziusA patient has CFS. Which strategy should the clinician consider to manage this patient? A. Bedrest B. High-impact exercise C. Thermal biofeedback D. Cognitive-behavioral therapyD. Cognitive-behavioral therapyWhich classic rash should the clinician assess for in a patient with SLE? A. Butterfly B. Bulls-eye C. Ringworm D. "Slapped" cheeksA. ButterflyWhich blood cell is excessively elevated in a person who has polycythemia? A. Platelets B. Neutrophils C. Red blood cells D. All types of blood cellsC. Red blood cellsWhich treatment would the clinician recommend for a patient who has relative polycythemia? A. Rehydration B. Antihistamines C. Weekly phlebotomies D. Referral to hematologistA. RehydrationWhich behavior would the clinician advise the patient with sickle cell anemia to avoid? A. Becoming overhydrated B. Taking folic acid supplements C. Becoming physically overtaxed D. Taking rest periods during the dayC. Becoming physically overtaxedThe clinician must differentiate chronic vitamin B12 deficiency anemia from folate deficiency anemia. Which action should the clinician take? A. Obtain a complete blood count B. Assess for peripheral neuropathy C. Inspect for smooth surface on tongue D. Determine the size of the red blood cellB. Assess for peripheral neuropathyWhich finding from the bone marrow aspiration is typical in a patient with CML? A. Schistocytes B. Howell-Jolly bodies C. Hemoglobin S gene D. Philadelphia chromosomeD. Philadelphia chromosomeHow long would the clinician inform the patient to rest after onset of infectious mononucleosis? A. 4 days B. 10 days C. 2 weeks D. 4 weeksD. 4 weeksA patient presents with symptoms of infectious mononucleosis. Which lab chemistry test should the clinician order? A. Viral load B. Hemoglobin A1c C. Western blot assay D. Heterophile antibody testD. Heterophile antibody testThe advance practice registered nurse (APRN) is providing a community health program for the prevention of Lyme disease. Which information should be included? A. Safe sex practices B. Hiking precautions C. Smoking cessation D. Vaccination schedulesB. Hiking precautionsWhich of the following is a correct recommendation of when to begin prostate screening? A. Men with no symptoms of prostate cancer and who are in good health should start screening at age 60. B. Asian American men should start screening at age 45. C. Men who have had a brother diagnosed with prostate cancer before the age of 65 should start screening at 45. D. Caucasian men should start screening at age 55.C. Men who have had a brother diagnosed with prostate cancer before the age of 65 should start screening at 45.A 63-year-old man is seen in the clinic with a chief complaint of nocturia. Which of the following is the most common sign of a prostatic problems in men with nocturia? A. Psychogenic nocturia B. Urethral polyp C. Irritative posterior urethral lesion D. Benign prostatic hypertrophyD. Benign prostatic hypertrophyA 76-year-old man is seen in the office for complaints of urinary tract infection (UTI). The clinician should explore which of these causes of UTI in men? A. Urethral polyps B. Epididymitis C. Selective serotonin reuptake inhibitor (SSRI) medication D. ProstatodyniaB. EpididymitisA 14-year-old male is seen with complaints of severe testicular pain. The clinician suspects testicular torsion. Which of the following is the appropriate action? A. Refer to urologist immediately. B. Obtain a computed tomography (CT) scan. C. Instruct the patient to elevate the scrotum. D. Prescribe ibuprofen.A. Refer to urologist immediately.An 82-year-old man is seen in the primary-care office with complaints of dribbling urine and difficulty starting his stream. Which of the following should be included in the list of differential diagnoses? A. Prostatodynia B. Lupus disease C. Trichomoniasis infection D. Fungal infectionD. Fungal infectionWhich of the following would be an appropriate treatment for a patient with mild benign prostatic hyperplasia (BPH)? A. Referral to urologist for surgery. B. Prescribe a trial of tamsulosin. C. Recommend cranberry supplements. D. Have a period of watchful waiting.D. Have a period of watchful waiting.A 30-year-old man is seen with a chief complaint of loss of libido. Which of the following laboratory tests would help establish a diagnosis? A. Testosterone level B. Prostate-specific antigen C. Nocturnal penile tumescence and rigidity D. Prolactin levelA. Testosterone levelPeter is a 40-year-old male with a recent diagnosis of low testosterone. Which of the following counseling points is correct regarding low testosterone? A. Testosterone deficiency is due to hypergonadism. B. Abstaining from cigarette smoking has no effect on testosterone C. Lowering your HbA1c may improve your testosterone levels. D. Stress has no effect on testosterone levels.C. Lowering your HbA1c may improve your testosterone levels.Which of the following should be considered in a patient presenting with erectile dysfunction? A. Diabetes mellitus B. Hypotension C. Wellbutrin D. UTIA. Diabetes mellitusA 35-year-old man presents with complaints of painful erections, and he notices his penis is crooked when erect. What is the most likely diagnosis? A. Peyronie's disease B. Damage to the pudendal artery C. Scarring of the urethra D. Testicular torsionA. Peyronie's diseaseThe patient with BPH is seen for follow-up. He has been taking finasteride (Proscar) for 6 months. The clinician should assess this patient for which of these side effects? A. Erectile dysfunction B. Glaucoma C. Hypotension D. HeadacheA. Erectile dysfunctionWhich of the following is an aerobic gram-negative bacteria involved in prostatitis? A. Streptococcus faecalis B. Pseudomonas C. Staphylococcus D. DiphtheroidsB. PseudomonasThe 56-year-old man with chronic prostatitis should be treated with levofloxacin for how long? A. 3 to 7 days B. 14 to 21 days C. 4 to 6 weeks D. 6 to 12 weeksC. 4 to 6 weeksJohn presents with complaints of a "weird feeling that hurts" in his buttocks. He notes that he often feels urgency to urinate and defecate, but "nothing comes out" when he tries. Which of the following diagnoses is most likely? A. Urinary tract infection B. Prostatitis C. Erectile dysfunction D. Peyronie's diseaseB. ProstatitisA 46-year-old man presents with urinary hesitancy and low back pain. He has no history of UTI. Digital rectal examination (DRE) reveals a normal prostate. He is not a long-distance runner. Which of the following would lead you to a diagnosis of prostatodynia versus prostatitis? A. Long-distance runners are more likely to have prostatodynia than prostatitis. B. Prostatodynia presents with signs and symptoms of prostatitis, but without inflammation. C. Prostatodynia usually has a bacterial origin, whereas prostatitis has a relation to internal urethral sphincter problems. D. Patients with prostatodynia usually have a history of recurrent UTIs, whereas patients with prostatitis do not.B. Prostatodynia presents with signs and symptoms of prostatitis, but without inflammation.A 23-year-old sexually active man is seen in the clinic with unilateral painful testicular swelling, and he is diagnosed with epididymitis. In order to prescribe the correct drug, the clinician must understand that which of these is the most common causative organism? A. Escherichia coli B. Staphylococcus aureus C. Chlamydia trachomatis D. Pseudomonas aeruginosaC. Chlamydia trachomatisCarl is a 24-year-old male who presents with scrotal pain that radiates to his flank. It manifested 3 hours ago. He also complains of pain at the tip of his penis, cloudy urine, and urethral discharge. Which of the following conditions is most likely? A. Testicular torsion B. Epididymitis C. Prostatodynia D. ProstatitisB. EpididymitisWhich test is used to confirm a diagnosis of epididymitis? A. Urinalysis B. Gram stain of urethral discharge C. Complete blood cell count with differential D. Ultrasound of the scrotumD. Ultrasound of the scrotumTreatment for epididymitis includes which of the following? A. Warm sitz baths B. Scrotal elevation C. Masturbation D. Heat applicationB. Scrotal elevationWhich of the following data is indicative of testicular torsion? A. Absent cremasteric reflex B. Pain relieved on testicular elevation C. Testicle very low in the scrotum D. Swollen scrotum with "red dot sign"A. Absent cremasteric reflexA 60-year-old man presents with an enlarged scrotum. The clinician uses a penlight to transilluminate the scrotum. In a patient with a hydrocele, what would the clinician expect to find? A. The scrotum will be dark. B. The scrotum will appear light pink or yellow. C. The scrotum will appear milky white. D. The internal structures will be clearly visible.B. The scrotum will appear light pink or yellow.During a DRE on a 75-year-old man, the clinician suspects the patient has prostate cancer. What physical finding should make the clinician suspicious? A. A nodular and unusually firm gland B. A smooth gland C. A tender gland D. A boggy glandA. A nodular and unusually firm glandA patient presents complaining of pain and enlarged testes that feel like "a bag of worms." Which diagnosis should the provider most likely assess for? A. Prostate cancer B. Varicocele C. Hydrocele D. Testicular cancerB. VaricoceleWhich of the following is a complementary therapy for BPH? A. Red raspberry leaf tea B. Saw palmetto C. Black cohosh D. Vitamin AB. Saw palmettoA 78-year-old man is diagnosed with C2 prostate cancer, and he asks the clinician what that means. In order to answer the patient, the clinician must have which understanding of the Jewett rating system? A. The cancer involves the seminal vesicles. B. There is metastatic disease to regional lymph nodes. C. The cancer is confined to the capsule. D. There is metastasis to distant organs.A. The cancer involves the seminal vesicles. Although it is no longer commonly used in practice, the Whitmore-Jewett system (also known as ABCD rating) is similar to the TNM system and has approximately equivalent stages.[3] Roman numerals are sometimes used instead of Latin letters for the overall stages (for example, Stage I for Stage A, Stage II for Stage B, and so on). A: tumor is present, but not detectable clinically; found incidentallyA1: tissue resembles normal cells; found in a few chips from one lobeA2: more extensive involvement B: the tumor can be felt on physical examination but has not spread outside the prostatic capsuleBIN: the tumor can be felt, it does not occupy a whole lobe, and is surrounded by normal tissueB1: the tumor can be felt and it does not occupy a whole lobeB2: the tumor can be felt and it occupies a whole lobe or both lobes C: the tumor has extended through the capsuleC1: the tumor has extended through the capsule but does not involve the seminal vesiclesC2: the tumor involves the seminal vesicles D: the tumor has spread to other organsA 58-year-old patient has been receiving leuprolide as treatment for prostate cancer. The clinician should instruct the patient about which of these side effects? A. May have cold flashes B. May have hot flushes C. May have increased libido D. May have testicular torsionB. May have hot flushesA 22-year-old male is seen in the clinic because he found a hard lump in his testicle when performing testicular self-examination (TSE). Which of the following risk factors leads the clinician to suspect potential testicular cancer? A. Patient is 65 years old B. Prior cryptorchidism C. Family history of colon cancer D. Living in a cityB. Prior cryptorchidismWhat is the treatment of choice for a patient diagnosed with testicular cancer? A. Radical orchidectomy B. Lumpectomy C. Radiation implants D. ChemotherapyA. Radical orchidectomyA patient with testicular cancer is being followed after completing treatment 1 year ago. He has been symptom-free with no evidence of disease. How often should he have a CT scan? A. Every month B. Every 3 to 4 months C. Every 6 to 12 months D. Every yearB. Every 3 to 4 monthsTyler is a 16-year-old male who the clinician is counseling on sexually transmitted infections (STIs). Which statement made by the clinician is correct? A. "Untreated gonorrhea can lead to many health problems, and if it is not treated it can lead to a syndrome that affects your entire body called disseminated gonococcal infection." B. "Most STIs are untreatable, and, if contracted, you will have potentially fatal health complications." C. "Though STIs are treatable, gonorrhea isn't and always results in permanent penile damage." D. "The only untreatable STI is chlamydia, and it is also the most common."A. "Untreated gonorrhea can lead to many health problems, and if it is not treated it can lead to a syndrome that affects your entire body called disseminated gonococcal infection."The clinician is seeing Jalissa, a 17-year-old patient, for a well woman's exam. She mentions that she has been depressed and has been yo-yo dieting because she feels "so fat." She marked "no" to whether she feels safe in her home on her intake form, and mentions she is worried about getting STIs from her boyfriend of three months. Which of the following is the correct way to interact with the patient, based on her history? A. "The amount of time allotted for your well woman exam does not allow time to talk about depression today." B. "I know you said you are concerned about your body image, but your weight looks good to me." C. "You mentioned on your intake form that you do not feel safe in your home. Why is that?" D. "You've been dating your boyfriend for three months, but you haven't had an STI screening yet? That's not safe."C. "You mentioned on your intake form that you do not feel safe in your home. Why is that?"Which of these patients needs a cervical cancer screening? A. Lisa, a 45-year-old patient who has atypical squamous cells of uncertain significance (ASCUS) and a human papillomavirus (HPV) positive Pap 1 month ago B. April, a 26-year-old patient who had a negative Pap with negative HPV 1 year ago C. Sondra, a 66-year-old patient who had a negative Pap with negative HPV 11 years, 6 years, and 1 year ago D. Gillian, a 33-year-old patient who had a negative Pap with negative HPV 5 years agoD. Gillian, a 33-year-old patient who had a negative Pap with negative HPV 5 years ago******Which of the following is true of the IUD (intrauterine device)? A. The IUD is 95% effective at preventing pregnancy. B. The IUD has an inhibitory effect on sperm capacitation. C. The IUD can only be inserted at menses. D. The IUD can only be inserted in women with multiparity.B. The IUD has an inhibitory effect on sperm capacitation.Alice has been diagnosed with breast cancer. Its TNM staging is T2, N1, M0. She would like to know what this means. Which statement made by the clinician is accurate? A. "Your tumor is 4 cm, has metastasized to a moveable lymph node, but has not metastasized to another location." B. "Your tumor is 5.5 cm and has not metastasized to lymph nodes or anywhere else." C. "Your tumor is 1.5 cm, has metastasized to a moveable lymph node, but has not metastasized to another location." D. "Your tumor is 3 cm, has metastasized to a moveable lymph node, and has only metastasized to supraclavicular lymph nodes."A. "Your tumor is 4 cm, has metastasized to a moveable lymph node, but has not metastasized to another location."A 23-year-old sexually active woman presents for her first Pap smear. Her history includes nulligravida, age at first intercourse 14, and more than 10 sexual partners. Which of the following conditions should the clinician be particularly alert for during her examination? A. Human papillomavirus B. Endometrial hyperplasia C. Vaginismus D. Polycystic ovarian syndromeA. Human papillomavirusA 20-year-old woman is seen in the clinic because her boyfriend was found to have gonorrhea. Which of the following is the treatment of choice for gonorrhea? A. Ceftriaxone B. Doxycycline C. Acyclovir D. MetronidazoleA. CeftriaxoneA 24-year-old woman presents to the clinic with dysuria, dyspareunia, and a mucopurulent vaginal discharge. Her boyfriend was recently treated for nongonococcal urethritis. What sexually transmitted disease has she most probably been exposed to? A. Gonorrhea B. HPV C. Chlamydia D. TrichomoniasisC. ChlamydiaA 45-year-old woman is seen in the clinic with complaints of a vaginal discharge. The clinician identifies clue cells on the vaginal smear. Which of the following diagnoses is associated with this finding? A. Trichomonas B. Bacterial vaginosis C. HPV D. Herpes simplex virusB. Bacterial vaginosisWhich of the following medications is the treatment of choice for Trichomonas? A. Metronidazole B. Ceftriaxone C. Diflucan D. DoxycyclineA. MetronidazoleA 58-year-old woman presents with a breast mass. Which of the following responses by the clinician would be most appropriate? A. "It is probably just a cyst because that is the most common breast mass." B. "We will order a mammogram and ultrasound to help establish a diagnosis." C. "We will go ahead and schedule you for a biopsy because that is the only way to know for sure." D. "Because your lump is painful, it is most likely not cancer."B. "We will order a mammogram and ultrasound to help establish a diagnosis."Tina is an 18-year-old female who would like to start using the transdermal contraceptive patch. Which of the following instructions should the clinician discuss with Tina? A. Obesity can decrease the effectiveness of the patch. B. The patch should be applied to the buttocks or breasts. C. The patch is changed every 10 days. D. If a patch becomes detached for less than 24 hours, it cannot be reapplied.A. Obesity can decrease the effectiveness of the patch.A 26-year-old woman is seen with complaints of irregular vaginal bleeding. Which of the following tests should be the first priority? A. Pregnancy test B. Pelvic ultrasound C. Endometrial biopsy D. Platelet countA. Pregnancy testA 42-year-old woman presents to the clinic with complaints of painful intercourse for the last month. Which of the following should be explored as the likely cause of her dyspareunia? A. Menopause B. Dehydration C. Excess progesterone D. Excess lubricationA. MenopauseA 36-year-old woman is seen with complaints of vaginal itching, burning, and discharge. On potassium hydroxide (KOH) wet mount of vaginal discharge, the clinician notices hyphae. Which of the following treatments would be appropriate? A. Fluconazole B. Estrogen vaginal cream C. Metronidazole D. DoxycyclineA. FluconazoleA 21-year-old woman is seen in the clinic requesting birth control pills. Which of the following tests is essential before prescribing any oral contraceptive? A. Pregnancy test B. Complete blood cell count C. Thyroid-stimulating hormone D. Urine dip for proteinA. Pregnancy testA 40-year-old woman is seen for her yearly examination. She is single and not in a monogamous relationship. Her social history includes smoking cigarettes "occasionally" and drinking about two beers a day. Her body mass index (BMI) is 25. She is requesting birth control. Which of the following methods would be best and most effective for this patient? A. Transdermal contraceptive patch B. Oral contraceptive C. Condom D. Vaginal contraceptive spongeC. CondomA 44-year-old patient with breast cancer is prescribed tamoxifen by her surgeon. She is complaining about hot flashes. Which of the following responses by the clinician would be most appropriate? A. "You must be having menopause." B. "The hot flashes are a result of the antiestrogenic effects of tamoxifen." C. "Tamoxifen use has no increased incidence of endometrial cancer." D. "The drug will have no effect on vaginal lubrication."B. "The hot flashes are a result of the antiestrogenic effects of tamoxifen."A 32-year-old woman is seen in the clinic because she has been unable to get pregnant after 12 months of unprotected sex. In order to determine the cause of the infertility, the clinician should question her about which of these possible causes? A. Pelvic inflammatory disease B. Oral contraceptive use for 15 years C. Early menarche D. Diet high in soy proteinA. Pelvic inflammatory diseaseWhen assessing a woman for infertility, which of the following tests should be done first? A. Hysterosalpingogram B. Magnetic resonance imaging (MRI) C. Analysis of partner's sperm D. Estrogen levelC. Analysis of partner's spermA 15-year-old girl is seen in the clinic because she has not yet had her first period. Which of the following questions would help the clinician determine the cause? A. "Are you sexually active?" B. "How long have you been underweight?" C. "Was your mother pregnant with you when she was of advanced maternal age?" D. "Have you noticed any changes in your moods lately?"B. "How long have you been underweight?"What is the most common cause of secondary amenorrhea? A. Pregnancy B. Pituitary dysfunction C. Inadequate estrogen levels D. Genetic disordersA. PregnancyA 22-year-old woman is diagnosed with premenstrual syndrome. Which of the following lifestyle changes should the clinician suggest to help minimize the patient's symptoms? A. At least 4 cups of green tea daily B. Regular exercise C. Take vitamin A supplements D. Eat a diet high in ironB. Regular exerciseA 25-year-old woman is seen in the clinic complaining of painful menstruation. Which of the following pelvic pathologies is the most common cause of secondary dysmenorrhea? A. Pelvic inflammatory disease B. Endometriosis C. Sexually transmitted infections D. Ovarian cystB. EndometriosisA 26-year-old woman tells the clinician that she has endometriosis, because she has frequent pelvic pain. The clinician also should consider which of these differential diagnoses? A. Diverticulitis B. Cholelithiasis C. Kidney stones D. Ovarian cystsD. Ovarian cystsWhich of the following would be appropriate treatment for a woman with mild endometriosis? A. Oral contraceptives B. Leuprolide acetate injections C. Nafarelin nasal spray D. HysterectomyA. Oral contraceptives*****A 45-year-old woman is seen in the clinic with abnormal uterine bleeding and pain during intercourse. The clinician should consider which of the following diagnoses? A. Postmenopausal syndrome B. Infertility C. Mittelschmerz D. PolypD. PolypA 48-year-old woman is seen in the clinic with complaints of prolonged heavy menstrual periods. She is pale and states she can no longer exercise. Pelvic exam reveals a single, very large mass. Which of the following diagnostic tests should the clinician order first? A. Transvaginal ultrasound B. Endometrial biopsy C. MRI D. Abdominal computed tomography scanA. Transvaginal ultrasoundDorothy is a 45-year-old female who complains of a mass in her left breast, dull nipple pain, tenderness of the left nipple, and pasty left nipple discharge. Which of the following conditions should the clinician be most suspicious for? A. Intraductal papilloma B. Hamartomas C. Duct ectasia D. FibroadenomaC. Duct ectasiaA 45-year-old woman is seen because of irregular menstrual periods. Her follicle-stimulating hormone (FSH) level is 48 mIU/mL, and her luteinizing hormone (LH) level is elevated. She asks the clinician what this means. Which would be the best response? A. "You are approaching menopause." B. "You have a hormonal imbalance." C. "Your FSH is normal, but your pituitary is making too much LH." D. "There is an imbalance between your ovaries and pituitary."A. "You are approaching menopause."Which of the following tests is essential for a 46-year-old woman who the clinician suspects is perimenopausal? A. Pregnancy B. Estrogen level C. Progesterone level D. LH levelA. PregnancyA 60-year-old woman is seen for an annual checkup. Her obstetric history reveals para 6, gravida 6. She reports that she went through menopause at age 45. Her grandmother died at age 80 of colon cancer, and her father died of lung cancer. What in her history would be a risk factor for ovarian cancer? A. Her numerous pregnancies B. Her age at menopause C. Her father's history of lung cancer D. Her grandmother's history of colon cancerD. Her grandmother's history of colon cancerWhich of the following medications is an oral estrogen product for women with menopause? A. Provera 2.5 mg B. Estrace 0.01% C. Alora 0.025 mg D. Premarin 0.3 mgD. Premarin 0.3 mgWhich of the following is an alternative treatment for breast tenderness with premenstrual syndrome? A. Evening primrose oil 250 mg orally up to 3 times daily 2 to 3 days before menses B. Black cohosh 40 to 200 mg orally daily C. Vitamin B complex 50 mg orally daily D. Jasmine essential oil aromatherapyA. Evening primrose oil 250 mg orally up to 3 times daily 2 to 3 days before mensesA 47-year-old woman presents with complaints of pain with intercourse, intense itching "down there," and states "it looks different down there." She denies bleeding, foul odor. Which of the following diagnoses should the clinician consider most likely? A. Atrophic vaginitis B. Trichomoniasis C. Candidiasis D. Vulvar lichen sclerosusD. Vulvar lichen sclerosusQuestion 1. What is the medication of choice for an initial acute attack of gout? 1. A nonsteroidal anti-inflammatory drug (NSAID). 2. Colchicine. 3. A corticosteroid. 4. Allopurinol (Zyloprim).1. A nonsteroidal anti-inflammatory drug (NSAID). The medication of choice for an initial acute attack of gout is an NSAID. Indomethacin (Indocin) is the most commonly prescribed NSAID for this use. An initial dose of 50 to 75 mg is given, followed by 25 to 50 mg every 8 hours for 5 to 10 days. An alternative to indomethacin is naproxen (Naprosyn). The first dose of naproxen is 750 mg, followed by 250 mg every 8 hours for 5 to 10 days.Question 2. Marsha, age 24, is preparing for radioactive iodine therapy for her Graves disease. Which test must she undergo first? 1. Beta-human chorionic gonadotropin. 2. Basal metabolism rate. 3. Lithium level. 4. Serum calcium.1. Beta-human chorionic gonadotropin. Radioactive iodine therapy is the most commonly used treatment in the United States for Graves disease (hyperthyroidism); however, it is contraindicated during pregnancy. Therefore, for women, a pregnancy test (beta-human chorionic gonadotropin) needs to be performed before initiating therapy. Women of childbearing age should also be told to delay conception for a few months after radioactive iodine therapy. It is also contraindicated in women who are breastfeeding. Older adults or clients at risk of developing cardiac complications may be pretreated with antithyroid drugs (ATDs) before therapy to deplete the thyroid gland of stored hormone, thereby minimizing the risk of exacerbation of hyperthyroidism because of radioactive iodine (131I)-induced thyroiditis.Question 3. When teaching Marcy how to use her new insulin pump, you tell her that she needs to monitor her blood glucose level: 1. At least once a day. 2. Only occasionally because glycemic levels are maintained very steadily. 3. At least 4 times a day. 4. On an as needed basis when she feels she needs to give herself an extra dose of insulin.3. At least 4 times a day. Option 3: Clients using an insulin pump need to monitor their blood glucose levels at least 4 times a day. Clients can develop diabetic ketoacidosis in as little as 4 hours if there is mechanical failure of the pump because the only insulin used in the pump is rapid-acting.Question 4. Joan has severe asthma and has been on high doses of oral corticosteroids for 2 years. She has been reading some home remedy books and stops all of her medications. What condition may she develop? 1. Myxedema crisis. 2. Diabetes insipidus. 3. Hypoparathyroidism. 4. Addisonian crisis4. Addisonian crisis. Option 4: Addisonian crisis is a serious, life-threatening response to acute adrenal insufficiency and may be precipitated by abruptly stopping glucocorticoid medications. Other causes include major stressors, especially if the person has poorly controlled Addison disease, and hemorrhage into the adrenal glands from either septicemia or anticoagulant therapy. The primary problems in Addisonian crisis are severe hypotension, circulatory collapse, shock, and coma. Treatment involves rapid intravenous replacement of fluids and glucocorticoids.Question 5. The process of aging results in: 1. An increase in liver weight and mass. 2. A decreased absorption of fat-soluble vitamins. 3. An increase in enzyme activity. 4. Constricted pancreatic ducts.2. A decreased absorption of fat-soluble vitamins. Option 2: The process of aging results in a decreased absorption of fat-soluble vitamins.Question 6. The most common cause of hyperthyroidism is: 1. Graves disease. 2. A toxic uninodular goiter. 3. Subacute thyroiditis. 4. A pituitary tumor.1. Graves disease. Option 1: The most common cause of hyperthyroidism is an autoimmune condition known as Graves disease, which accounts for 90% of hyperthyroid conditions in young adults.Question 7. 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? 1. A blood chemistry panel. 2. Thyroid-stimulating hormone (TSH) level. 3. Liver function studies. 4. Electrocardiogram.2. Thyroid-stimulating hormone (TSH) level. Option 2: For a client with the symptoms experienced by Sigrid, a TSH level should be ordered first because the symptoms suggest hyperthyroidism. The TSH level is the best screening test for hyperthyroidism. Other laboratory and isotope tests for hyperthyroidism include a free triiodothyronine (T3) or thyroxine (T4) level, T3 resin uptake, and thyroid autoantibodies, including thyrotropin receptor antibody (TRAb). Tests not routinely performed but that may be helpful include radioactive iodine uptake and a thyroid scan (with iodine-123 [123I] or technetium-99m), which help to determine the etiology of the hyperthyroidism and assess the functional status of any palpable thyroid irregularities or nodules associated with a toxic goiter.Question 8. 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? 1. Glipizide (Glucotrol). 2. Sitagliptin (Januvia). 3. Exenatide (Byetta). 4. Metformin (Glucophage).4. Metformin (Glucophage). Option 4: Because of its safety, efficacy, and cost, metformin is the cornerstone of monotherapy unless there is a contraindication, such as renal disease, hepatic disease, gastrointestinal intolerance, or risk of lactic acidosis. Metformin often has beneficial effects on components of metabolic syndrome, including mild to moderate weight loss, improvement of the lipid profile, and improved fibrinolysis. It improves the effectiveness of insulin in suppressing excess hepatic glucose production and increases insulin sensitivity in peripheral tissues. The risk of hypoglycemia with metformin is low. Gastrointestinal side effects can be diminished by starting at the lowest dose of 500 mg daily and gradually increasing as needed to a maximum dose of 2000 mg per day. Use of metformin with alcohol can increase the risk of lactic acidosis.Question 9. Eunice, age 32, has type 2 diabetes. She said she heard she should take an aspirin a day after she reaches menopause for its cardioprotective action. She does not have coronary artery disease, but her father does. How do you respond? 1. "You're right. Your hormones protect you against coronary artery disease until menopause; then you should start on aspirin therapy." 2. "The American Diabetes Association recommends that you start on low-dose aspirin therapy now." 3. "Aspirin therapy is recommended for all patients over age 55 as a precautionary measure." 4. "If you maintain good glycemic control, you don't need aspirin therapy."2. "The American Diabetes Association recommends that you start on low-dose aspirin therapy now." Option 2: The American Diabetes Association's position statement on aspirin therapy in patients with diabetes recommends low-dose (81 mg) aspirin use as a secondary prevention strategy in men and women with diabetes who have evidence of large-vessel disease, such as a history of myocardial infarction, vascular bypass procedures, and stroke, and have no contraindications for the use of aspirin. They also recommend aspirin therapy as a primary prevention strategy in high-risk men and women with type 1 or type 2 diabetes who have a family history of coronary heart disease and for individuals who smoke, are hypertensive or obese, or who have albuminuria, cholesterol levels greater than 200 mg/dL, low-density lipoprotein cholesterol levels greater than 130 mg/dL, high-density lipoprotein cholesterol levels less than 40 mg/dL, and triglyceride levels greater than 250 mg/dL.Question 10. Mr. Reynolds is on the antithyroid drug (ATD) methimazole (Tapazole), so you make it a point to check his: 1. Glycated hemoglobin (HbA1c). 2. Complete blood count (CBC) and liver transaminases. 3. Uric acid level. 4. Total thyroxine (T4).2. Complete blood count (CBC) and liver transaminases. Option 2: ATDs can cause agranulocytosis and hepatic injury; therefore, CBC and liver studies should be done.Question 11. 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 headache, perspiration, and palpitations, with frequent bouts of nausea, pain, weakness, dyspnea, and visual disturbances. He has lost 10 lb over the past 2 months and seems very anxious today. Your next action would be to: PHEOCHROMOCYTOMA 1. Start him on an antianxiety agent. 2. Obtain a 24-hour urine test for catecholamines. 3. Start him on a diuretic or beta blocker. 4. Recheck his blood pressure in 1 week.2. Obtain a 24-hour urine test for catecholamines. Option 2: Steve's signs and symptoms are diagnostic of a pheochromocytoma, which can be detected with an assay of urinary catecholamine (total and fractionated), metanephrine, vanillylmandelic acid, and creatinine levels. A 24-hour urine specimen is usually obtained, but an overnight or shorter collection may also be obtained. Pheochromocytoma typically causes attacks of severe headache (85%), palpitations (65%), and profuse sweating (65%). The absence of all 3 of these symptoms can exclude the diagnosis of pheochromocytoma with 99% certainty.Question 12. Marie, age 50, has type 1 diabetes and checks her blood glucose level several times every day. Her blood glucose level ranges 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 30 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, it has had no effect on her high morning blood glucose level. What is your next course of action? 1. Increase the evening NPH insulin dose by 2 more units. 2. Have her check her blood glucose level between 2 am and 4 am for the next several days. 3. Increase the morning regular insulin dose by 2 units. 4. Order a fasting blood sugar test.2. Have her check her blood glucose level between 2 am and 4 am for the next several days. Option 2: Marie is experiencing the Somogyi phenomenon (rebound hyperglycemia). If her blood glucose level from 2 am to 4 am is greater than 70 mg/dL, the evening dose of NPH insulin should be increased and changed from before dinner to before bedtime. This should prevent most cases of nocturnal hypoglycemia, which results in morning hyperglycemia. Many providers prefer the longer acting insulins, such as insulin glargine (Lantus) and insulin detemir (Levemir), because they are mostly "peakless" and have less risk of hypoglycemia than NPH.Question 13. After an oral cholecystogram, Sam complains of burning on urination. This is because of: 1. A mild reaction to the contrast medium. 2. Biliary obstruction. 3. Contraction of the gallbladder. 4. The presence of dye in the urine.4. The presence of dye in the urine. Rationales Option 4: After an oral cholecystogram, some people experience burning on urination because of the presence of dye in the urine. This is helped by forcing fluids.Question 14. Which class of antihypertensive agents may be problematic for clients with diabetes? 1. Angiotensin-converting enzyme (ACE) inhibitors. 2. Calcium channel blockers. 3. Beta blockers. 4. Alpha blockers3. Beta blockers. Option 3: Beta blockers may be problematic in clients with diabetes because they block what is often the first sign of hypoglycemia—tachycardia. Many clients with diabetes have compelling indications (such as coronary artery disease) for the use of beta blockers. In these clients, the need for a beta blocker outweighs any risk that might occur. Decreasing the possibility of low blood sugar by selecting appropriate agents and adjusting dosages may be necessary. If a client with diabetes is on a beta blocker, it is important to explain that instead of tachycardia, he or she will notice other signs of hypoglycemia (such as sweating) that are not affected by beta blockers.Question 15. The major risk factor for thyroid cancer is: 1. Inadequate iodine intake. 2. Presence of a goiter. 3. Exposure to radiation. 4. Smoking.3. Exposure to radiation. Option 3: The major risk factor for thyroid cancer is exposure to radiation, usually from treatment to the head and neck. Until 1950, radiation treatments were given to children for an enlarged thymus, enlarged tonsils, and acne. Several million children were exposed in this manner. It may also occur in individuals who have had radiation therapy to the face or upper chest.Question 16. Marty has pheochromocytoma. You instruct him to: 1. Void frequently in small amounts. 2. Not exercise for more than 30 minutes at a time. 3. Avoid sleeping in the prone position. 4. Take steroids.1. Void frequently in small amounts. Option 1: Clients with pheochromocytoma should be told to void frequently in small amounts and to avoid a full bladder. In addition, to prevent stimulating a paroxysm, clients should also be advised to avoid smoking; drugs that may influence catecholamine release, such as some anesthetics, atropine, opiates, steroids, and glucagon; and activities that might displace abdominal organs, such as bending, exercising, straining, and vigorous palpation of the abdomen. For women, pregnancy should be discouraged.Question 17. Jeffrey, age 17, has gynecomastia. You should also assess him for: 1. Obesity. 2. Endocrine abnormalities. 3. Testicular cancer. 4. Tuberculosis.3. Testicular cancer. Option 3: Gynecomastia may be the first sign of testicular cancer. It is also associated with breast, adrenal, pituitary, lung, and hepatic malignancies. Hypogonadism produces low testosterone levels in men with normal estrogen levels. Alteration in breast tissue responsiveness to hormonal activity can result in gynecomastia. Gynecomastia can occur secondary to cirrhosis, chronic obstructive lung disease, malnutrition, hyperthyroidism and other endocrine imbalances, tuberculosis, and chronic renal disease.Question 18. Jeremiah, age 72, has gout and is obese. When teaching him about diet, which of the following do you tell him? 1. "Beer and wine are okay because they have no effect on uric acid." 2. "Keeping your weight stable, even if you are a little overweight, is better than fluctuating." 3. "You must go on a restricted, very low calorie diet to effect immediate change." 4. "Fluid intake should exceed three thousand milliliters daily to prevent formation of uric acid kidney stones."4. "Fluid intake should exceed three thousand milliliters daily to prevent formation of uric acid kidney stones." Rationales Option 4: Fluid intake should exceed 3000 mL daily to prevent formation of uric acid kidney stones. Clients should avoid dehydration because it may precipitate an acute attack.Question 19. 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 300 mg/dL, serum cholesterol level is 250 mg/dL, serum potassium level is 3.4 mEq, and she has 4+ glucosuria. Your next course of action would be to: 1. Discontinue her hydrochlorothiazide. 2. Order a glucose tolerance test (GTT). 3. Repeat her FBS and do a glycated hemoglobin (HbA1c). 4. Start insulin therapy.3. Repeat her FBS and do a glycated hemoglobin (HbA1c). Option 3: Jenny's FBS should be repeated along with an HbA1c. An HbA1c of greater than 6.5% can now be used to diagnosis diabetes.Question 20. An elderly client presents with atrial fibrillation. Which of the following lab tests is important in forming the diagnosis? 1. Complete blood count (CBC). 2. C-reactive protein (CRP). 3. Comprehensive metabolic panel (CMP). 4. Thyroid-stimulating hormone (TSH).4. Thyroid-stimulating hormone (TSH). Option 4: Atrial fibrillation is a common presentation in elderly clients with hyperthyroidism. If the TSH is suppressed, a free thyroxine (T4) and triiodothyronine (T3) should be drawn.Question 21. Juanita, age 23, complains of palpitations that started a few weeks ago; they 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 µg daily. Her labs indicate 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: 1. Increase the levothyroxine dosage. 2. Decrease the levothyroxine dosage. 3. Keep the dosage the same. 4. Start propranolol every 8 hours.2. Decrease the levothyroxine dosage. Option 2: It appears that she may be overcorrected. The usual dosage of thyroid replacement is 1.6 µg/kg/d. She could skip a dose and then resume at a lower dosage of 125 to 137 µg per day. In an older individual, the lower dose would be preferred because overcorrection can lead to atrial fibrillation. She should take the levothyroxine on an empty stomach with a full glass of water and wait 30 minutes before eating for maximum absorption.Question 22. 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? 1. Hypoglycemia and glycosuria. 2. Decreased respiratory rate with shallow respirations. 3. Polydipsia and an increased blood pH. 4. Ketonuria and polyuria.4. Ketonuria and polyuria. Signs and symptoms of diabetic ketoacidosis include Kussmaul breathing (very deep respiratory movements), hyperglycemia, glycosuria, polyuria, polydipsia, anorexia, and headache, as well as ketonuria and a decreased blood pH.Question 23. The American Diabetes Association (ADA) recommends which of the following quarterly blood tests be performed on all clients with diabetes? 1. Thyroid-stimulating hormone (TSH). 2. Liver function studies. 3. Glycated hemoglobin. 4. Serum glucose.3. Glycated hemoglobin. Option 3: The ADA recommends that the glycated hemoglobin (HbA1c) test be performed quarterly because it reports the serum glucose concentration of the previous 3 months. HbA1c can now be used for diagnosis of diabetes (greater than 6.5%). The ADA also recommends an annual urine test to assess for urine protein, which might be an early sign of kidney damage.Question 24. A low thyroid-stimulating hormone (TSH) can lead to: 1. Osteoporosis. 2. Weight gain. 3. Bradycardia. 4. Brittle hair.1. Osteoporosis. Option 1: Hyperthyroidism presents with a suppressed TSH and elevated free thyroxine (T4). Manifestations include weight loss, tachycardia, diarrhea, anxiety, and warm, silky skin. The increased metabolic state of hyperthyroidism can cause cardiac dysrhythmias and osteoporosis. The clinical manifestations can also occur when there is excessive thyroid replacement.Question 25. Sara, age 40, has diabetes and is now experiencing anhidrosis on the hands and feet, increased sweating on the face and trunk, dysphagia, anorexia, and heartburn. Which complication of diabetes do you suspect? 1. Macrocirculation changes. 2. Microcirculation changes. 3. Peripheral neuropathies. 4. Autonomic neuropathies.4. Autonomic neuropathies. Option 4: Autonomic neuropathies include anhidrosis (absence of sweating) on the hands and feet, increased sweating on the face and trunk, dysphagia, anorexia, heartburn, constricted pupils, nausea and vomiting, constipation, and diabetic diarrhea.Question 26. 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? 1. Cholecystitis. 2. Acute pancreatitis. 3. Cirrhosis. 4. Cushing syndrome2. Acute pancreatitis. Option 2: Acute pancreatitis is an inflammation of the pancreas caused by the release of activated pancreatic enzymes into the surrounding parenchyma, with subsequent destruction of tissue, blood vessels, and supporting structures. Although pancreatitis may be acute or chronic, acute symptoms include continuous abdominal pain of several days' duration that increases in the epigastric area and radiates to the back, nausea, vomiting, sweating, weakness, pallor, abdominal tenderness, distention, and low-grade fever. Pancreatitis occurs primarily in middle-aged adults and slightly more often in women than in men.Question 27. Your client with diabetes asks you about insulin glargine (Lantus). You tell her that: 1. It may be administered subcutaneously at home or intravenously in the hospital if need be. 2. The onset of action is 15 minutes. 3. Insulin glargine (Lantus) stays in your system for 24 hours. 4. It can be mixed with any other insulin.3. Insulin glargine (Lantus) stays in your system for 24 hours. Option 3: Insulin glargine (Lantus) has an onset of action of just over 1 hour and stays in the system for 24 hours.Question 28. 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: 1. Have an insulin reaction more readily than usual. 2. Have an increased blood sugar level. 3. Need less daily insulin. 4. Need more carbohydrates.2. Have an increased blood sugar level. Option 2: Stress causes the adrenal glands to secrete more cortisol, which leads to gluconeogenesis and insulin antagonism, raising the blood sugar. It is possible, then, that Harriet will have an increased blood sugar level. She will not need less daily insulin or more carbohydrates and will not have an insulin reaction (such as hypoglycemia) more readily than usual. Harriet may, in fact, need to increase her insulin use.******Question 29. 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? 1. Decreasing the am dose of 70/30. 2. Decreasing the pm dose of 70/30. 3. Eating a snack before going to bed. 4. Changing the time of the nighttime insulin injection.4. Changing the time of the nighttime insulin injection. Option 4: The Novolin 70/30 should be given before a meal. Jennifer was not given appropriate instructions on the timing of the injections. She should inject her nighttime dose about 30 minutes prior to the evening meal. Injecting this type of insulin before bed will cause the blood sugar to drop because 30% of the insulin is regular insulin.Question 30. Leah, age 70, has had diabetes for many years. When teaching her about foot care, you want to stress: 1. That her calluses will protect her from infection. 2. The need to assess the bottom of her feet carefully after walking barefoot. 3. That painless ulcerations might occur and feet should be examined with a mirror. 4. That mild pain is to be expected because of neuropathy.3. That painless ulcerations might occur and feet should be examined with a mirror. Option 3: Painless ulcerations are very common in clients with diabetes, and the only way to assess for them in the feet is for clients to use a mirror to examine the bottoms of their feet.Question 31. Mason, age 52, has diabetes mellitus (DM) and is overweight. You now find that he is hypertensive. How should you treat his hypertension? 1. You should treat it the same as in a client without diabetes. 2. Because insulin affects most antihypertensive drugs, you should try diet and exercise first before ordering any antihypertensives. 3. You should treat it very aggressively, preferably with angiotensin-converting enzyme (ACE) inhibitors. 4. You should initiate therapy when the blood pressure is 5 to 10 mm Hg more than the conventional therapeutic guidelines.3. You should treat it very aggressively, preferably with angiotensin-converting enzyme (ACE) inhibitors. Option 3: ACE inhibitors should be initiated in patients with diabetes and an elevated blood pressure and are recommended in normotensive patients with albuminuria.Question 32. 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: 1. A decrease in her daily insulin dosage. 2. An increase in her daily insulin dosage. 3. A high-calorie dietary intake and no insulin change. 4. A change in her insulin from NPH to insulin aspart (NovoLog).2. An increase in her daily insulin dosage. Option 2: For clients with diabetes requiring insulin, an increase in their daily insulin dosage is usually required in the presence of an acute infection. Betty should begin by increasing her regular insulin dose by just 2 units and then monitoring her blood sugar level.Question 33. 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? 1. "Let's adjust your oral antidiabetic agents instead." 2. "That's a myth. People usually change their eating habits when taking this, and that's what causes the weight loss." 3. "With type 2 diabetes, you never want to be on injectable insulin." 4. "Let's try it. Your glycohemoglobin will be lowered and you may lose weight."4. "Let's try it. Your glycohemoglobin will be lowered and you may lose weight." Option 4: Unlike many oral antidiabetic agents, injectable exenatide (Byetta) can cause weight loss in some individuals. The active ingredient is a protein that encourages digestion and the production of insulin. Glucagon-like peptide-1 (GLP-1) injectables like exenatide and liraglutide (Victoza) may be used as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus.Question 34. 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 do 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? 1. "Keep trying to get a fingerstick and call me back with the results." 2. "Call 911 before you collapse." 3. "Drive immediately to the emergency room." 4. "Drink four ounces of fruit juice."4. "Drink four ounces of fruit juice." Option 4: Treatment of hypoglycemia is 15 g of carbohydrates and can be achieved by drinking 8 oz of milk or 4 oz of orange juice. The milk option is preferred to decrease the elevation in blood sugar that occurs with orange juice. The patient should wait for 15 minutes to see if the symptoms subside and repeat the treatment again if needed. All patients on insulin should be prescribed a glucagon pen, and family or friends should be instructed on its use.Question 35. A client with hyperthyroidism presents 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 step for the nurse practitioner is to: 1. Order a thyroid ultrasound. 2. Refer the client for immediate evaluation by an ophthalmologist. 3. Order a total thyroxine (T4). 4. Prescribe a beta-adrenergic blocker.2. Refer the client for immediate evaluation by an ophthalmologist. Option 2: The practitioner should refer the client for an immediate evaluation by an ophthalmologist. Clinically recognized Graves ophthalmopathy occurs in about 50% of cases of Graves disease. A client with Graves orbitopathy with these complaints is at risk of blindness if there is compression of the optic nerve. Additional symptoms include photophobia and diplopia. Autoantibodies present in Graves disease can cause increased muscle thickness in the eye, leading to edema and compression of the optic nerve. Fundal exam may reveal disk swelling. This is an emergency situation that may require hospitalization and treatment with prednisone to diminish the inflammation. Artificial tears are also helpful. In 75% of clients, the onset of Graves orbitopathy occurs within a year before or after the diagnosis of thyrotoxicosis but can sometimes precede or follow thyrotoxicosis by several years.Question 36. You suspect that Sharon has hypoparathyroidism because, in addition to her other signs and symptoms, she has: 1. Elevated serum phosphate levels. 2. Elevated serum calcium levels. 3. Decreased neuromuscular activity. 4. Increased bone resorption, as implied by her bone density test.1. Elevated serum phosphate levels. Option 1: Signs of hypoparathyroidism include elevated serum phosphate levels; decreased serum calcium levels; increased neuromuscular activity, which may progress to tetany; decreased bone resorption; hypocalciuria; and hypophosphatemia.Question 37. 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 the most appropriate? 1. Decreasing the dosage of the metformin. 2. Discontinuing the metformin. 3. Increasing carbohydrate intake. 4. Decreasing the dosage of the sulfonylurea.4. Decreasing the dosage of the sulfonylurea. Option 4: Metformin, dipeptidyl peptidase-4 (DPP4) inhibitors such as sitagliptin (Januvia), and incretin mimetics such as exenatide (Byetta) are gaining favor over sulfonylureas because the risk of hypoglycemia is less than with sulfonylureas.Question 38. Morton has type 2 diabetes. His treatment, which includes diet, exercise, and 3 oral antidiabetic agents at maximum dose, is insufficient to achieve acceptable glycemic control. Your next course of action is to: 1. Give the patient a sliding scale with mealtime coverage with regular insulin. 2. Add a dosage of long-acting insulin at bedtime to the regimen. 3. Discontinue the oral antidiabetic agents and start insulin therapy with N and R. 4. Suggest treatment using an insulin pump.2. Add a dosage of long-acting insulin at bedtime to the regimen. Option 2: If treatment with diet, exercise, and oral antidiabetic agents is insufficient to achieve acceptable glycemic control in clients with type 2 diabetes, adding a dosage of insulin at bedtime to the regimen may be necessary. As a first step, the addition of a bedtime injection of long-acting insulin such as insulin glargine (Lantus) or insulin detemir (Levemir) is recommended. Intermediate-acting insulin such as neutral protamine Hagedorn (NPH) is no longer recommended because of the peaks in drug levels that can cause hypoglycemia. Initially, the dosage is 10 units at bedtime; then the dose is adjusted to reduce overnight hepatic glucose production and achieve a normal or near-normal fasting blood glucose concentration. If this regimen does not achieve the desired effect, the oral antidiabetic agents should be discontinued, and mealtime analogue rapid-acting insulin can be added to the largest meal. Most clients will eventually require 4 injections with the basal-bolus regimen.Question 39. Lynne has Cushing syndrome. You would expect her to have or develop: 1. Onychomycosis. 2. Generalized increased pigmentation of the skin. 3. Hair loss. 4. Excitability and nervousness.1. Onychomycosis Option 1: Cushing syndrome results in an excessive amount of adrenocorticotropic hormone, which stimulates the secretion of glucocorticoids, mineralocorticoids, and androgenic steroids from the adrenal cortex. In the presence of excessive cortisol, fungal infections of the skin, nails, and oral mucosa, such as onychomycosis and tinea versicolor, are common and skin wounds heal very slowly.Question 40. Joy has gout. In teaching her about her disease, which food do you tell her is allowed in the diet? 1. Asparagus. 2. Beans. 3. Broccoli. 4. Mushrooms.3. Broccoli. Option 3: Foods high in purine should be avoided by clients with gout. Broccoli is not high in purine. Foods high in purine include all meats and seafood, meat extracts and gravies, yeast and yeast extracts, beans, peas, lentils, oatmeal, spinach, asparagus, cauliflower, and mushrooms. Wine and alcohol in excessive amounts impair the ability of the kidneys to excrete uric acid and should be used in moderation.Question 41. Tamika, who has diabetes, states that she heard fiber is especially good to include in her diet. How do you respond? 1. "Fiber is important in all diets." 2. "Too much fiber interferes with insulin, so include only a moderate amount in your diet." 3. "Fiber, especially soluble fiber, helps improve carbohydrate metabolism, so it is more important in the diet of persons with diabetes." 4. "You get just the amount of fiber you need with a normal diet."3. "Fiber, especially soluble fiber, helps improve carbohydrate metabolism, so it is more important in the diet of persons with diabetes." Option 3: Fiber is important in the dietary management of diabetes. A diet high in fiber, especially soluble fiber, helps improve carbohydrate metabolism and lowers both total cholesterol and low-density lipoprotein cholesterol. Soluble fiber is found in dried beans, oats, and barley as well as some vegetables and fruits (peas, corn, zucchini, cauliflower, broccoli, prunes, pears, apples, bananas, and oranges).Question 42. Mark has type 1 diabetes and has mild hyperglycemia. What effect does physical activity (exercise) have on his blood glucose level? 1. It may cause it to vary a little. 2. It may decrease it. 3. It may elevate it. 4. It may fluctuate greatly either way.2. It may decrease it. Option 2: Clients with insulin-dependent diabetes mellitus (IDDM)—ie, type 1 diabetes—who have mild hyperglycemia may experience a drop in their blood glucose level during physical activity, whereas those with marked hyperglycemia may experience a rise in their blood glucose level. Clients with IDDM should check their blood glucose level before exercising and refrain from exercising if their level is too high (greater than 300 mg/dL).Question 43. Morris has had type 1 diabetes for 10 years. Several recent urinalysis reports have shown microalbuminuria. Your next step would be to: 1. Order a 24-hour urinalysis. 2. Start him on an angiotensin-converting enzyme (ACE) inhibitor. 3. Stress the importance of strict blood sugar control. 4. Send him to a dietitian because he obviously has not been following his diet.2. Start him on an angiotensin-converting enzyme (ACE) inhibitor. Option 2: Morris should be started on an ACE inhibitor such as enalapril (Vasotec). ACE inhibitors offer renoprotective effects by reducing intraglomerular pressure. They do this by inhibiting the renin-angiotensin system, which causes efferent dilation, and by improving glomerular permeability, which causes a reduction of glomerulosclerosis. ACE inhibitors also have this beneficial effect on clients with diabetes who are normotensive and even hypotensive. Diabetic nephropathy is the leading cause of end-stage renal disease in the United States. Monitoring for microalbuminuria is one method for identifying early nephropathy.Question 44. Jason, age 14, appears with tender discoid breast tissue enlargement (2-3 cm in diameter) beneath the areolae. Your next action would be to: 1. Perform watchful waiting for 1 year. 2. Order an ultrasound. 3. Obtain laboratory tests. 4. Refer Jason to an endocrinologist.1. Perform watchful waiting for 1 year. Option 1: Pubertal gynecomastia is common and is characterized by tender discoid breast tissue enlargement of about 2 to 3 cm in diameter beneath the areolae. The swelling usually subsides spontaneously within a year, and watchful waiting along with reassurance is recommended for that time period.Question 45. Mindy is scheduled to have an oral glucose tolerance test (OGTT). She is instructed to discontinue many of her medications for 3 days before the test. Which one is it safe to continue taking? 1. Vitamin C. 2. Aspirin. 3. Calcium. 4. Oral contraceptives.3. Calcium. Option 3: Calcium does not affect an OGTT. The following medications may interfere with the results of an OGTT and should be discontinued for 3 days before the test: vitamin C, aspirin, oral contraceptives, corticosteroids, synthetic estrogens, phenytoin (Dilantin), thiazide diuretics, and nicotinic acid.Question 46. Jay has had diabetes for 10 years. He recently had a physical and was told he has some evidence of nephropathy. What is the first manifestation of this condition? 1. Microalbuminuria. 2. Development of Kimmelstiel-Wilson nodules. 3. Decreased serum urea nitrogen levels. 4. Decreased serum creatinine levels.1. Microalbuminuria. Microalbuminuria is the first symptom indicative of nephropathy in clients who have had diabetes for about 10 years (although some studies suggest 5 years). There is increased permeability of the capillaries, with resultant leakage of albumin into the glomerular filtrate, causing microalbuminuria.Question 47. Sadie, age 40, has just been given a diagnosis of Graves disease. She has recently lost 25 lb, has palpitations, is very irritable, feels very warm, and has a noticeable bulge on her neck. The most likely cause of her increased thyroid function is: 1. Hyperplasia of the thyroid. 2. An anterior pituitary tumor. 3. A thyroid carcinoma. 4. An autoimmune response.4. An autoimmune response. Option 4: Graves disease is the result of an autoimmune response wherein antibodies are produced that act against the body's own organs and tissues. Thyroid-stimulating immunoglobulins are found in 95% of people with Graves disease and are evidence of this autoimmune process.Question 48. When you inspect the integumentary system of clients with endocrine disorders, a finding of coarse hair may be an indicator of: 1. Addison disease. 2. Diabetes mellitus. 3. Cushing syndrome. 4. Hypothyroidism.4. Hypothyroidism. Option 4: During inspection of the integumentary system of clients with endocrine disorders, a finding of coarse hair may be an indicator of hypothyroidism. Fine hair is seen in clients with hyperthyroidism; hirsutism with Cushing syndrome; hyperpigmentation with both Addison disease and Cushing syndrome; hypopigmentation with diabetes mellitus, hyperthyroidism, and hypothyroidism; and purple striae over the abdomen and bruising with Cushing syndrome.Question 49. Sandra, age 28, has secondary obesity. Which of the following may have caused this? 1. Taking in more calories than are expended. 2. Polycystic ovary syndrome. 3. Antihypertensive medications. 4. A sedentary lifestyle.2. Polycystic ovary syndrome. Option 2: Secondary obesity is rare; possible causes include Cushing disease, polycystic ovary syndrome, hypothalamic disease, hypothyroidism, and insulinoma. Some medications associated with weight gain include glucocorticoids, tricyclic antidepressants, and phenothiazines.Question 50. Which is the only curative treatment option for primary hyperparathyroidism (PHPT)? 1. Type II calcimimetic cinacalcet. 2. Hormone therapy. 3. Parathyroidectomy. 4. Bisphosphonates.3. Parathyroidectomy. Option 3: The only curative treatment option for PHPT is a parathyroidectomy. It is successful in 90% to 98% of cases.Question 51. A patient presents to your primary care office with abnormal lab results. On physical exam, you tap the patient's facial nerve around the zygomatic arch, just anterior to the earlobe. This describes which of the following tests and is associated with which of the following lab abnormalities? 1. Trousseau sign, hypocalcemia. 2. Chvostek sign, hypocalcemia. 3. Chvostek sign, hypercalcemia. 4. Lachman test, hypercalcemia.2. Chvostek sign, hypocalcemia. Option 2: The test described in the question is positive in someone with hypocalcemia and is called Chvostek sign.Question 52. What is the most common cause of gynecomastia? 1. Puberty. 2. Drug use. 3. Testicular failure. 4. Malnutrition.1. Puberty. Option 1: Puberty is the most common cause of gynecomastia; most of these cases are self-limiting.Question 53. Which of the following conditions is a common pathological cause of hirsutism? 1. Polycystic ovary syndrome. 2. Addison disease. 3. Hyperthyroidism. 4. Alopecia.1. Polycystic ovary syndrome. Option 1: Ninety percent of people with polycystic ovary syndrome have associated hirsutism.Question 54. A patient presents to your primary care office complaining of polydipsia, polyuria, and polyphagia. Which of the following diagnoses would not be in your differential diagnosis? 1. Diabetes mellitus (DM). 2. Diabetes insipidus (DI). 3. Psychiatric disorders. 4. Hyperthyroidism.4. Hyperthyroidism. Option 4: Symptoms of hyperthyroidism could include polyphagia due to increased metabolism, but symptoms generally are weight loss, tachycardia, and other physical manifestations of increased metabolism.Question 55. A 35-year-old female presents to your primary care office for review of her laboratory results. Her physical exam shows a blood pressure (BP) of 140/90, pulse (P) of 105, oxygen saturation of 97%, and temperature of 98.6°F. She has complaints of palpitations, weight loss, hair loss, and anxiety. Her labs are all normal except for a low thyroid-stimulating hormone (TSH) and an elevated thyroxine (T4). What would your next course of treatment be? 1. Start metoprolol and propylthiouracil (PTU). 2. Refer the patient to psychiatry for treatment of anorexia. 3. Refer the patient for radioactive iodine treatment. 4. Refer the patient for thyroidectomy.1. Start metoprolol and propylthiouracil (PTU). This is the presentation of a patient with hyperthyroidism. A beta blocker would help treat her tachycardia and hypertension and PTU would help normalize her thyroid hormones.Question 56. Which of the following statements about hypothyroidism is not true? 1. The most common worldwide cause of hypothyroidism is iodine deficiency. 2. The most common cause of autoimmune hypothyroidism is Hashimoto thyroiditis. 3. The rate of hypothyroidism decreases with age. 4. Lithium use is a risk factor for hypothyroidism.3. The rate of hypothyroidism decreases with age. Option 3: This is not true; hypothyroidism becomes more common as we age.Question 57. What is the most common cause of Cushing disease? 1. Pituitary adenoma. 2. Prednisone use. 3. Adrenal tumor. 4. Nonpituitary tumor.1. Pituitary adenoma. Option 1: Pituitary adenomas are the cause of 70% of cases of Cushing disease; they secrete excessive adrenocorticotropic hormone (ACTH).Question 58. A 35-year-old male presents to your office complaining of fatigue, weight loss, nausea, and abdominal pain. On physical exam, you notice he has orthostatic hypotension and hyperpigmented skin. You do a morning cortisol level, which is low. The plasma adrenocorticotropic hormone (ACTH) is elevated. How would you treat this patient? 1. Oral prednisone. 2. Hydrocortisone. 3. Androgen replacement. 4. Fludrocortisone.2. Hydrocortisone. Option 2: Hydrocortisone is the treatment of choice for primary adrenal insufficiency (Addison disease).Question 59. Which of the following statements about diabetes mellitus is untrue? 1. Diabetes mellitus is the most common etiology of renal failure in the United States. 2. Diabetes mellitus is the most common endocrine disorder in the United States. 3. Diabetes mellitus is characterized by impaired insulin secretion and insulin action. 4. Diabetes mellitus is curable.4. Diabetes mellitus is curable. Option 4: Diabetes mellitus is manageable with lifestyle modifications and medications but is not curable.Question 60. What is the primary pathological irregularity associated with diabetes mellitus type 1? 1. Nonfunctioning beta cells. 2. Insulin resistance. 3. Overproducing beta cells. 4. Elevated free fatty acids in the plasma.1. Nonfunctioning beta cells. Option 1: Beta cells in the pancreas secrete insulin. When they don't work, your body can't lower its blood sugar; this is the pathophysiology of diabetes mellitus type 1.Question 61. Which of the following would not confirm a diagnosis of diabetes? 1. Glycated hemoglobin (HbA1c) of 7.0. 2. Fasting glucose of 155. 3. Random glucose of 198. 4. Oral glucose tolerance test with a plasma glucose of 250.3. Random glucose of 198. Option 3: A random glucose greater than 200, with associated symptoms such as weight loss, polyuria, and polydipsia, is diagnostic of diabetes.Question 62. Which of the following is not a risk factor for diabetes mellitus type 2? 1. Body mass index (BMI) greater than 25. 2. History of gestational diabetes. 3. Caucasian race. 4. History of polycystic ovary syndrome (PCOS).3. Caucasian race. Option 3: Caucasians are less likely than African Americans, Asian Americans, Latin Americans, and Native Americans to develop diabetes mellitus type 2.Question 63. Which of the following statements about metformin is untrue? 1. Metformin works by decreasing hepatic glucose production and increasing peripheral cell sensitivity to insulin. 2. Metformin can cause lactic acidosis. 3. Metformin is typically used in conjunction with other diabetes medications. 4. Metformin cannot be used in patients with significant renal impairment.3. Metformin is typically used in conjunction with other diabetes medications. Option 3: Metformin is first-line treatment for diabetes type 2 and can be used as monotherapy.Question 64. Which of the following would not be ordered on a regular basis to evaluate diabetic patients for end organ damage associated with diabetes? 1. Ophthalmology evaluation. 2. Lipid panel. 3. Urinalysis and basic metabolic panel (BMP). 4. Complete blood count (CBC).4. Complete blood count (CBC). Option 4: A CBC should be done in all patients at an annual physical, but diabetics don't typically have end organ damage that would be evident on a CBC.Question 65. A 55-year-old Asian male presents with a history of severe left great toe pain. He states he cannot even touch the toe with a sheet without it causing pain. He denies trauma but states he cannot ambulate without pain. He admits to drinking alcohol but not to excess. On physical exam, he has normal vital signs, and you note erythema of the great toe at the interphalangeal (IP) joint. Which of the following is the gold standard for diagnosis of this problem? 1. Joint aspiration with crystal analysis. 2. Serum uric acid level. 3. X-ray. 4. Diagnosis is made with physical exam only. Rationales Option 1: This is the gold standard diagnostic test for diagnosis of gout.1. Joint aspiration with crystal analysis. Option 1: This is the gold standard diagnostic test for diagnosis of gout.Question 66. Which of the following body mass index (BMI) values defines class 1 obesity? 1. 30. 2. 25. 3. 40. 4. 35.1. 30. Option 1: Class 1 obesity is defined as a BMI of 30 to less than 35.Question 67. To reduce the incidence of flares, foods high in what amino acid need to be limited in the diets of patients with gout? 1. Purine. 2. Glutamine. 3. Phenylalanine. 4. Alanine.1. Purine. Option 1: High-purine foods need to be avoided in order to reduce the risk of gout flares. High-purine foods include fish, red meat, and beans. Beer is also rich in purine.Question 68. A 63-year-old man presents to your office with hematuria, hesitancy, and dribbling. Digital rectal examination (DRE) reveals a smooth, moderately enlarged prostate. The client's prostate-specific antigen (PSA) is 1.2. What is the most appropriate management strategy at this time? 1. Prescribing an alpha-adrenergic blocker. 2. Recommending saw palmetto extract. 3. Prescribing an antibiotic. 4. Referring the client to urology.1. Prescribing an alpha-adrenergic blocker. Option 1: The patient's symptoms appear to be related to benign prostatic hyperplasia (BPH) and not a urinary tract infection. An alpha-adrenergic blocker will relax the smooth muscle of the prostate and bladder, which will improve flow and relieve symptoms.Question 69. Regular testicular self-exams have not been studied enough to show if they lower the risk of dying from testicular cancer. This is why the American Cancer Society and other agencies do not have a recommendation about regular testicular self-exams for all men. Still, some practitioners do recommend that all men examine their testicles monthly after reaching puberty. If you are teaching a patient how to do a testicular self-examination, which of the following do you tell him? 1. "Examine your testicles when you are cold because this makes them more sensitive." 2. "Make sure your hands are dry to create friction." 3. "If you feel firmness above and behind the testicle, make an appointment." 4. "Make an appointment if you note any hard lumps directly on the testicle, regardless of whether they are tender."4. "Make an appointment if you note any hard lumps directly on the testicle, regardless of whether they are tender." Option 4: If you advise men to perform a monthly testicular self-examination, instruct them to call if they notice any hard lumps directly on the testicle, regardless of whether the lumps are tender.Question 70. A male patient presents to the clinic for evaluation of infertility. Subjectively, the patient complains of pain and fullness of the testes and states, "My testicles feel like a bag of worms." On physical examination, the nurse practitioner notes tortuous veins posterior to and above the testes that extend up into the external inguinal ring. Based on the preceding assessment, the nurse practitioner refers the patient to surgery for a diagnosis of: 1. Hydrocele. 2. Orchitis. 3. Urethritis. 4. Varicocele.4. Varicocele. Option 4: A varicocele is caused by abnormal venous dilation of the pampiniform plexus above the testes, which results in pain and swelling. A patient often describes the sensation as feeling like a "bag of worms."Question 71. Bill, age 43, appears with a tender, ulcerated, exudative, papular lesion on his penis. It has an erythematous halo, surrounding edema, and friable base. The nurse practitioner should suspect: 1. A chancre. 2. A chancroid. 3. Condylomata acuminata. 4. Genital herpes.2. A chancroid. Option 2: A chancroid is a tender, ulcerated, exudative, papular lesion with an erythematous halo, surrounding edema, and friable base. It is caused by inoculation of Haemophilus ducreyi through tiny breaks in epidermal tissue.Question 72. Max, age 70, is obese. He is complaining of a bulge in his groin that has been there for months. He states that it is not painful, but it is annoying. The practitioner notes that the origin of the swelling is above the inguinal ligament and directly behind and through the external ring. This finding is most indicative of a(n): 1. Indirect inguinal hernia. 2. Direct inguinal hernia. 3. Femoral hernia. 4. Strangulated hernia.2. Direct inguinal hernia. Option 2: A direct inguinal hernia usually occurs in middle-aged to older men and is the result of an acquired weakness caused by heavy lifting, obesity, or chronic obstructive pulmonary disease (COPD). The origin of the swelling is above the inguinal ligament and directly behind and through the external ring.Question 73. Milton, a 72-year-old unmarried, sexually active white man, presents to your clinic with complaints of hesitancy, urgency, and occasional uncontrolled dribbling. Although the nurse practitioner suspects benign prostatic hyperplasia, what else should the differential diagnosis include? 1. Antihistamine use. 2. Urethral stricture. 3. Detrusor hyperreflexia. 4. Renal calculi.2. Urethral stricture. Option 2: Urethral strictures may develop as a result of sexually transmitted diseases and should be considered in sexually active individuals (primarily males) no matter their age.Question 74. Herb, a 47-year-old with diabetes, is complaining of a rash on his penis. Before examining him, you suspect that he may have: 1. Tinea cruris. 2. Genital herpes. 3. Candida. 4. Intraepithelial neoplasia.3. Candida Option 3: A Candida infection is fairly common in clients with diabetes. Candida on the penis appears as multiple discrete, flat pustules with slight scaling and surrounding edema. It is a superficial mycotic infection that occurs in moist cutaneous sites. Other predisposing factors may include moisture, antibiotic therapy, and immunosuppression.Question 75. Jeb, a 72-year-old male, is seen at your practice for follow-up of several episodes of orthostatic hypotension. After obtaining a review of systems and a digital rectal examination, it also appears that he has benign prostatic hyperplasia (BPH) with lower urinary tract symptoms. The nurse practitioner reviews his recent ultrasound evaluation, which reports a prostate volume of over 40 mL, and the results of the American Urological Association (AUA) symptom index for BPH, which shows his score to be 12. Based on the preceding information and the patient's desire for noninvasive medical therapy, what management should he be offered? 1. Prazosin (Minipress). 2. Doxazosin (Cardura). 3. Finasteride (Proscar). 4. Phenoxybenzamine (Dibenzyline).3. Finasteride (Proscar). Option 3: Finasteride is a 5-alpha-reductase inhibitor and is recommended for individuals with a prostate volume greater than 40 mL to help decrease its size.Question 76. Roger, a healthy 68-year-old man, comes in to see you with a complaint of sudden episodes of an urgent need to void. He has had several episodes of moderate amounts of unintentional urine loss during these times. Other than these episodes, he is voiding in amounts "normal" for him, with no leakage when he coughs or sneezes. The practitioner's initial diagnosis is which type of incontinence? 1. Stress incontinence. 2. Urge incontinence. 3. Overflow incontinence. 4. Mixed incontinence.2. Urge incontinence. Option 2: Urge incontinence results from overactive bladder (OAB) and has many possible etiologies, each of which causes the bladder muscle (detrusor) to contract spontaneously. Common non-neurogenic causes are bladder irritants, infections, medications, urethritis, and pelvic tumors. Neurogenic causes involve the loss of cortical inhibition of the voiding reflex; this is seen in conditions such as dementia, Parkinson disease, multiple sclerosis, and stroke, ie, cerebrovascular accident (CVA) or brain attack.Question 77. Jake, age 62, has a low International Prostate Symptom Score for lower urinary tract symptoms associated with his benign prostatic hyperplasia (BPH). The nurse practitioner should recommend: 1. No treatment at this time. 2. Immediate referral to urology. 3. Balloon dilation. 4. Starting an alpha blocker.1. No treatment at this time. Option 1: Asymptomatic clients with BPH rarely require treatment. Watchful waiting is an appropriate strategy for following the progression of the disease and the development of any complications.Question 78. Drew has erectile dysfunction and says that a friend told him about a method that uses a constricting ring around the base of the penis. What is he referring to? 1. Intracavernous injection therapy. 2. An external vacuum device. 3. Urethral suppositories. 4. Surgery.2. An external vacuum device. Option 2: An external vacuum device is a viable method for alleviating erectile dysfunction regardless of the cause of the disorder. A plastic cylinder is placed around the penis, a vacuum pump causes cavernosal engorgement, and a constrictor ring is applied around the base of the penis, allowing the client to hold an erection for 30 minutes.Question 79. John asks for a prescription for sildenafil (Viagra). He says that the only medication he takes is isosorbide mononitrate (Monoket) oral tablets and that he has diabetes that he controls with diet alone. What should the nurse practitioner tell him? 1. "Let's try a sample and see how you do." 2. "Viagra is contraindicated with isosorbide mononitrate; let's discuss other options." 3. "Because of your history of diabetes, we can't use it." 4. "I'd better refer you to a urologist."2. "Viagra is contraindicated with isosorbide mononitrate; let's discuss other options." Option 2: Because sexual stimulation leads to the release of nitric oxide in the corpus cavernosum of the penis and sildenafil (Viagra) potentiates that release, there is a double hypotensive effect between sildenafil and a nitric oxide donor such as isosorbide mononitrate (Monoket, Imdur, and Ismo). Therefore, the use of sildenafil with Monoket is contraindicated.Question 80. Josh and Martha have 5 children and do not want any more. Josh said he heard about a no-scalpel vasectomy (NSV) and asks the nurse practitioner how it works. What would be the best response? 1. "For the vasectomy to be permanent, you must have the vas deferens excised." 2. "It's safer for Martha to be sterilized." 3. "A loop of vas deferens is delivered through the scrotal skin and occluded." 4. "The testes are twisted, which occludes the vas deferens."3. "A loop of vas deferens is delivered through the scrotal skin and occluded." Option 3: NSV is a method by which a loop of vas deferens is delivered through the scrotal skin for occlusion. A hemostat is used to puncture the scrotal skin, and then the skin is gently stretched to create an opening, which speeds the procedure and avoids the need for cutting through tissue. Postoperative complications are minimized this way.Question 81. A patient is being treated for erectile dysfunction. The patient is morbidly obese and is also being treated for cardiovascular disease and coagulopathy. Which of the following medications would be contraindicated? 1. Topical testosterone (AndroGel). 2. Sildenafil (Viagra). 3. Alprostadil (Caverject). 4. Subcutaneous pellet testosterone (Testopel).3. Alprostadil (Caverject). Option 3: The vasoactive injectable alprostadil (Caverject) should not be used in patients with sickle cell anemia, coagulopathy, severe cardiovascular disease, myeloma, leukemia, morbid obesity, or penile deformity, fibrosis, or implants.Question 82. A patient's chief complaint is heaviness in the scrotum. The nurse practitioner notes swelling of the testes, along with warm scrotal skin. Which of the following diagnoses is most probable? 1. Cryptorchidism. 2. Orchitis. 3. Testicular torsion. 4. Epididymitis.2. Orchitis. Option 2: Orchitis refers to an acute, painful onset of swelling of the testicle accompanied by warm scrotal skin. The client usually complains of a heavy feeling in the scrotum. It is typically unilateral but after 1 week may progress to the other testicle.Question 83. Martin is complaining of erectile dysfunction. He also has a condition that has reduced arterial blood flow to his penis. The most common cause of this condition is: 1. Epilepsy. 2. Multiple sclerosis. 3. Diabetes mellitus. 4. Parkinson disease.3. Diabetes mellitus. Option 3: About 50% of men who have had diabetes for longer than 6 years develop erectile dysfunction to some extent as a result of pathological changes in the vascular wall that lead to a reduction of arterial blood flow to the penis. Many other conditions can cause erectile dysfunction as well. These include cerebrovascular accidents (ie, strokes or brain attacks), spinal cord injury, temporal lobe epilepsy, multiple sclerosis, chronic obstructive pulmonary disease, angina, chronic renal failure, and Parkinson disease.Question 84. Tommy, age 15, comes to the clinic in acute distress with "belly pain." When obtaining his history, the nurse practitioner (NP) finds that he fell off his bike this morning and has vomited. Upon closer examination, the NP determines the belly pain to be left-sided groin pain or pain in his left testicle. He is afebrile and reports no dysuria. Which of the following diagnoses is most likely? 1. Testicular torsion. 2. Epididymitis. 3. Hydrocele. 4. Varicocele.1. Testicular torsion. Option 1: Testicular torsion is a condition in which the testis twists on the spermatic cord, thereby compromising blood flow to the testicle. This is a surgical emergency. Examination usually reveals a tender scrotal mass high in the hemiscrotum, and there is frequently a reactive hydrocele around the testis, obscuring anatomical detail. The scrotum can become erythematous and edematous. The cremasteric reflex is frequently blunted on the side of the torsion.Question 85. The nurse practitioner is performing a rectal examination on James, age 46, for follow-up of melena. What would the provider expect his stool to look like if his condition has not resolved? 1. Grayish tan. 2. Bright red. 3. Pale yellow, greasy, and fatty. 4. Black and tarry.4. Black and tarry. Option 4: Melena is black, tarry stool caused by upper gastrointestinal bleeding.Question 86. Morris, age 52, is in a new relationship and is not sure whether his erectile dysfunction is organic or is caused by stress about his performance. What simple test could you suggest to determine if he has the ability to have an erection? 1. Nocturnal penile tumescence and rigidity (NPTR) test. 2. Penile duplex ultrasonography. 3. Intracavernous injection. 4. Serum prostate-specific antigen (PSA).1. Nocturnal penile tumescence and rigidity (NPTR) test. Option 1: The NPTR test is a simple test the client may do at home by himself to determine if he has the ability to have a nocturnal erection, which would rule out an organic cause of erectile dysfunction. Have the client place the simple device on his penis before going to bed. This device records the frequency, as well as the rigidity, of erections.Question 87. Harry, age 60, has benign prostatic hyperplasia and complains of some incontinence. The nurse practitioner's first step in diagnosing overflow incontinence would be to order a: 1. Urinalysis. 2. Cystometrogram. 3. Cystoscopy. 4. Postvoid residual (PVR) measurement.4. Postvoid residual (PVR) measurement. Option 4: The first step in diagnosing overflow incontinence is to perform a PVR measurement. Clients with overflow incontinence cannot empty their bladders completely, so residual urine remains after voiding and this measurement is elevated.Question 88. Michael complains of a urinary tract infection (UTI). Which of the following is a risk factor for UTIs in men? 1. A history of circumcision. 2. A history of testicular torsion. 3. Unprotected anal sex. 4. Presence of an inguinal hernia.3. Unprotected anal sex. Option 3: Young men can develop a UTI similar to the type of uncomplicated UTI seen in women, which does not require any additional workup. Risk factors include unprotected anal sex, lack of circumcision, a history of prostatitis, unprotected intercourse with a woman who harbors pathogens in her vagina, and unprotected sex with men with AIDS who have a CD4 count less than 200 cells/µL.Question 89. Mikey had an undescended testicle at birth, and at age 2 it remains in the inguinal region. His mother is afraid of surgery and asks for your advice. How do you respond? 1. "In many children, the testicle descends close to the sixth birthday." 2. "Even with only one normal testicle, he will have normal development." 3. "If it hasn't descended by now, it probably won't. He needs to have surgery by age six." 4. "Don't worry; it can remain in that position forever with no problems."3. "If it hasn't descended by now, it probably won't. He needs to have surgery by age six." Option 3: In boys with undescended testes, less than 1% have their testes descend after the first year. Orchiopexy needs to be performed before age 6 to promote normal spermatogenesis and hormone production, prevent tumor formation, and leave the testis in a location where it can be easily palpated.Question 90. Sidney, age 72, presents to the clinic with complaints of a weak urine stream, hesitancy, and painful ejaculation. On digital rectal examination, you note that his prostate is boggy. The most common cause of his symptoms is: 1. Acute bacterial prostatitis. 2. Chronic bacterial prostatitis. 3. Chronic nonbacterial prostatitis with chronic pelvic pain syndrome. 4. Noninflammatory prostatitis.2. Chronic bacterial prostatitis. Option 2: Chronic bacterial prostatitis, a recurrent bacterial infection of the prostate and urinary tract, affects men aged 50 to 80. It is accompanied by bladder obstruction symptoms such as weak urine stream, hesitancy or dribbling, hematuria, hematospermia, and/or painful ejaculation. The most common offending pathogen is Escherichia coli.Question 91. You are performing a school physical examination on Damon, age 5. You are unable to retract his foreskin over the glans while inspecting his penis. This is referred to as: 1. Phimosis. 2. Paraphimosis. 3. Microphallus. 4. Priapism.1. Phimosis. Option 1: An unusually long foreskin or a foreskin that cannot be retracted over the glans penis during physical examination is referred to as phimosis. It occurs in uncircumcised males and is normal in infancy. At Damon's age, however, one should be able to retract the foreskin. He needs referral to a urologist.Question 92. Tim asks the nurse practitioner (NP) about returning to his normal sex life after surgery for benign prostatic hyperplasia. He should be told: 1. "You probably won't be able to have an erection after surgery; we need to discuss alternative ways of lovemaking." 2. "You need to wait several months after surgery to make sure the site has healed." 3. "You may resume sexual activity 4 to 6 weeks after surgery." 4. "You'll have to ask the surgeon."3. "You may resume sexual activity 4 to 6 weeks after surgery." Option 3: Within 4 to 6 weeks after surgery, it is safe to resume a full sex life, including intercourse. Before this time, the spasmodic contractions that occur in the prostatic urethra at the time of ejaculation could trigger delayed bleeding. After 6 weeks, the risk of delayed bleeding is very slight. However, if the area has not completely healed, there may be slight discomfort because of the spasms.Question 93. Jeff, age 20, presents to the college health clinic with complaints of difficulty passing his urine and a discharge from his penis. Upon further investigation, you note that the discharge is urethral in origin. The most common cause of these symptoms in the young adult male population is: 1. Chronic prostatitis. 2. Prostatic abscess. 3. Acute prostatitis. 4. Prostatic hyperplasia.3. Acute prostatitis. Option 3: The etiology of urethral discharge or difficulty voiding can include acute and chronic prostatitis and prostatic abscess. Young adult males in their 20s usually have acute prostatitis from gonorrhea or other bacterial infections.Question 94. Bernard, age 59, presents to the emergency department with a diagnosis of priapism. Despite application of cold compresses and pain medications, relief is unsuccessful. What is the treatment of choice? 1. Terbutaline 0.25 mg subcutaneously. 2. Phenylephrine 0.3 to 0.5 mL injected into the corpora cavernosa. 3. Doxazosin 5 mg sublingually. 4. Lidocaine 1% via the glans.2. Phenylephrine 0.3 to 0.5 mL injected into the corpora cavernosa. Option 2: Phenylephrine (Neo-Synephrine) is the drug of choice for first-line treatment of low-flow priapism because the drug has almost pure alpha-agonist effects and minimal beta activity. In short-term priapism (less than 6 hours), especially drug-induced priapism, intracavernous injection of phenylephrine alone may result in detumescence.Question 95. You are referring a 73-year-old client for management of his prostate cancer with hormonal therapy. It is understood that goserelin acetate (Zoladex) acts as a method of androgen ablation by: 1. Blocking the release of follicle-stimulating hormone (FSH) and luteinizing hormone (LH). 2. Blocking 5-alpha-reductase, which converts testosterone into dihydrotestosterone. 3. Inhibiting the binding of testosterone to cancer cells. 4. Inhibiting the progression of cancer cells through the cell cycle.1. Blocking the release of follicle-stimulating hormone (FSH) and luteinizing hormone (LH). Option 1: Goserelin acetate (Zoladex) and leuprolide acetate (Lupron) block the release of FSH and LH. These preparations are administered intramuscularly.Question 96. Reiter syndrome is a complication of: 1. Bacterial vaginosis. 2. Syphilis. 3. Chlamydia. 4. Gonorrhea.4. Gonorrhea. Option 4: Gonorrhea may precipitate Reiter syndrome (reactive arthritis).Question 97. Jennifer, age 42, presents for her well-woman examination, and you notice "dimpling" on her left breast. Your differential diagnosis includes: 1. Breast cancer. 2. Fibrocystic breast disease. 3. Paget disease. 4. Striae from recent dieting.1. Breast cancer. Option 1: Dimpling on the breast is known as peau d'orange because it looks like an orange peel. It may indicate a tumor is pulling on and retracting the underlying breast tissue.Question 98. Lynne, age 43, comes to your office in tears, stating that last night she had unprotected sex and forgot to take her birth control pill. She wants to know about the "morning-after pill." You tell her: 1. "If your period does not start at the scheduled time, come back and see me." 2. "I'll go ahead and order the estrogen-only postcoital contraception pill." 3. "I'll go ahead and order the Yuzpe regimen." 4. "I'll refer you to a gynecologist."3. "I'll go ahead and order the Yuzpe regimen." Option 3: Emergency contraception, referred to as postcoital contraception, prevents pregnancy after unprotected sexual intercourse. It should ideally be taken within 72 hours after unprotected sex. The Yuzpe regimen consists of taking 2 birth control pills within 72 hours and 2 more 12 hours later. This is 75% effective. A medication for nausea should be taken before the birth control pills.Question 99. Cynthia says that her health care provider wants to do a colposcopy. She asks you what this is. You tell her that a colposcopy: 1. Visualizes the cervical, vaginal, or vulvar epithelium under magnification to identify abnormal areas that may require a biopsy. 2. Involves removal of one or more areas of the endometrium by means of a small device without widening the cervix. 3. Allows visual examination of the uterine cavity with a small scope passed through the cervix. 4. Allows visualization of the abdominal and pelvic cavities through a small scope passed through a small abdominal incision.1. Visualizes the cervical, vaginal, or vulvar epithelium under magnification to identify abnormal areas that may require a biopsy. Option 1: A colposcopy visualizes the cervical, vaginal, or vulvar epithelium under magnification to identify abnormal areas that may require a biopsy. It is performed in the office.Question 100. Which of the following statements do you use when instructing women about their fertile period (ie, when they are most likely to become pregnant)? 1. Ovulation occurs on the 14th day, plus or minus 2 days, before the next menses. 2. Sperm are viable for 24 hours. 3. The ovum is viable for 6 hours. 4. The ovaries always release 1 ovum per month.1. Ovulation occurs on the 14th day, plus or minus 2 days, before the next menses. Option 1: When instructing women about their fertile period (ie, when they are most likely to become pregnant), tell them that ovulation occurs on the 14th day, plus or minus 2 days, before the next menses. Sperm are viable for 3 days, and the ovum is viable for 24 hours. It is essential for women to know these facts if they are using the calendar or rhythm method for preventing a pregnancy.Question 101. Sandra, age 63, says that her previous doctor never discussed why he took her off hormone replacement therapy (HRT) 3 years ago. Her last menstrual period was at age 49, and she started HRT that same year. You share with her some of the results of the Women's Health Initiative (WHI). Which statement regarding the study is true? 1. Estrogen plus progestin increased the risk of a cardiac event in apparently healthy women after 10 years of use. 2. Women on HRT have a higher risk of colorectal cancer. 3. Postmenopausal hormones do not actually prevent fractures of the hip. 4. Estrogen alone is associated with a greater risk of breast cancer than a combination of estrogen plus progestin.1. Estrogen plus progestin increased the risk of a cardiac event in apparently healthy women after 10 years of use. Option 1: The WHI found that estrogen plus progestin increased the risk of a cardiac event in apparently healthy women if used more than 10 years post menopause.Question 102. Mary, age 33, delivered a healthy baby boy 6 months ago by cesarean delivery. Her baby weighed 9 lb 6 oz. Her prenatal care was complicated by gestational diabetes mellitus (GDM). She did not need to take any medications. She asks you about the possibility of getting diabetes later in life. The correct response should be: 1. "Up to 50% of women diagnosed with GDM will eventually develop diabetes." 2. "No, you won't have a problem later in life, but you may have the same problem with another pregnancy." 3. "Most women are fine, but we can check your sugar levels when you turn 50." 4. "If you had to take insulin, then you would have to worry about getting diabetes later on."1. "Up to 50% of women diagnosed with GDM will eventually develop diabetes." Option 1: GDM affects 2% to 10% of pregnancies in the United States. Although the carbohydrate intolerance of GDM usually resolves quickly after delivery, approximately one-third of women who had GDM will have diabetes or impaired glucose metabolism at 4 to 6 weeks postpartum. Up to 50% will develop diabetes in the future.*******Question 103. A 17-year-old female patient requests to start medroxyprogesterone acetate (Depo-Provera) injections as her method of birth control. She discloses that she has had 4 sexual partners in the past year. Her last menstrual period was 12 days ago, and she had unprotected intercourse 3 days ago. The appropriate management for this patient would be to: 1. Administer the injection today. 2. Advise her to use another method for now and return with her next menses. 3. Give the injection after a negative pregnancy test and tell her to use condoms for the next 7 days. 4. Give the injection and tell her to use a barrier method for 7 days.2. Advise her to use another method for now and return with her next menses. Option 2: Depo-Provera is the most commonly used injectable contraceptive and contains depot medroxyprogesterone acetate (DMPA). The DMPA injection can be given any time during the menstrual cycle as long as the woman is reasonably certain she is not pregnant (World Health Organization). If DMPA is given within 5 to 7 days of a normal last menstrual period, no backup is needed. If it is given after the seventh day in the menstrual cycle, backup contraception is needed.Question 104. Gerri, age 26, is thinking about getting pregnant in the near future, and she asks you what kind of vitamins she should be taking. You respond: 1. "You don't need any additional supplementation to your diet until you become pregnant." 2. "You need to increase your iron level by taking one 325-mg iron tablet twice a day." 3. "You need to start taking an extra 1500 mg of calcium a day now to help promote bone growth of the fetus when you become pregnant." 4. "All women capable of becoming pregnant should take a daily supplement of 0.4 mg of folic acid a day to reduce the risk of neural tube defects."4. "All women capable of becoming pregnant should take a daily supplement of 0.4 mg of folic acid a day to reduce the risk of neural tube defects." Option 4: Studies have shown a significant reduction in neural tube defects (spine and brain issues) in women who take at least 0.4 mg of folic acid per day. Supplementation is usually needed, as most women are unable to attain this level of folic acid in their daily diet.Question 105. Which of the following terms describes the bluish or purplish discoloration of the vulva, vagina, and a portion of the cervix that occurs in pregnancy? 1. Goodell sign. 2. Hegar sign. 3. Piskacek sign. 4. Chadwick sign.4. Chadwick sign. Option 4: In early pregnancy, increased vascularity, blood supply, and congestion of the cervix cause a bluish discoloration that is referred to as Chadwick sign.Question 106. On physical exam, Judy has pubic hair that spreads over her mons pubis with a slight lateral spread. In addition, her breast development shows breast enlargement with secondary mound formation by the developing areolae. Which Tanner stage best describes Judy's development? 1. Stage II. 2. Stage III. 3. Stage IV. 4. Stage V.3. Stage IV. Option 3: When a girl has adult-type pubic hair over a smaller area, with none on the medial thigh, she is in Tanner stage IV.Question 107. A vaginal pH of 4.2 is an expected finding in: 1. A healthy girl of prepubertal age. 2. A woman with Trichomonas vaginalis. 3. A postmenopausal woman with atrophic vaginitis. 4. A healthy woman of reproductive age.4. A healthy woman of reproductive age. Option 4: In women of reproductive age, the normal vaginal discharge has a pH of 3.8 to 4.2.Question 108. Marcia, age 59, presents with depression. According to the diagnostic criteria for major depressive disorder (MDD), which of the following must be present? 1. The depression must be related to alcohol, drugs, medication side effects, or physical illness. 2. The symptoms must be severe enough to upset the client's daily routine, impact his or her work, or interfere with relationships. 3. The depression must be a normal reaction to the death of a loved one. 4. There must be some type of sleep disturbance.2. The symptoms must be severe enough to upset the client's daily routine, impact his or her work, or interfere with relationships Option 2: For a diagnosis of MDD to be made, the symptoms must be severe enough to upset the client's daily routine, impact his or her work, or interfere with relationships.Question 109. Julia, age 60, asks you about taking alendronate (Fosamax). What do you tell her about using this medication? 1. "If you decide to take it, stick with a lower dose of 5 mg because the side effects are much worse with a 10-mg dose." 2. "Fosamax works better in younger women, so you should start this now rather than wait until you're 70." 3. "You should take a daily dose because the weekly dose is not as effective." 4. "In addition to its efficacy in the treatment of osteoporosis in postmenopausal women, it is also useful for the prevention of osteoporosis."4. "In addition to its efficacy in the treatment of osteoporosis in postmenopausal women, it is also useful for the prevention of osteoporosis." Option 4: In addition to its efficacy in the treatment of osteoporosis in postmenopausal women, alendronate (Fosamax) is useful for the prevention of osteoporosis.Question 110. Darcy, age 57, is to undergo a core needle biopsy for a suspicious breast mass. This procedure includes: 1. A 21- or 22-gauge needle that is used to aspirate cells from the lesion for analysis. 2. Removal of a large core of tissue from the lesion for histological evaluation utilizing a large-gauge cutting needle. 3. Removal of a wedge of tissue for examination. 4. Removal of the entire lesion.2. Removal of a large core of tissue from the lesion for histological evaluation utilizing a large-gauge cutting needle. Option 2: In a core needle biopsy, a large-gauge cutting needle is used to obtain a large core of tissue from the lesion for histological examination. The results of a core needle biopsy are as accurate as a surgical biopsy, but the procedure is less invasive, with better cosmetic results. A stereotactic or ultrasound-guided biopsy can be performed on nonpalpable lesions.Question 111. Susan, age 28, is 9 months pregnant and asks you about using umbilical cord blood after birth for newborn DNA identification. What do you tell her? 1. "A cord blood sample is identical to the genetic profile of the infant." 2. "The fingerprinting and footprinting that have been done in the past work perfectly." 3. "A better method of obtaining newborn DNA is with a buccal swab." 4. "The traditional method of using a newborn heel stick to obtain a DNA sample is tried and true."1. "A cord blood sample is identical to the genetic profile of the infant." Rationales Option 1: DNA is the only reliable source of newborn identification and is easily obtained from an umbilical cord blood sample at birth.Question 112. Judi, age 24, has a seizure disorder. She would like to conceive within the next year. Her visit is for preconceptual counseling. What is the drug of choice for her during pregnancy? 1. Valproic acid (Depakene). 2. Trimethadione (Tridione). 3. Phenobarbital (Luminal). 4. Phenytoin (Dilantin).3. Phenobarbital (Luminal). Option 3: Phenobarbital (Luminal) is the drug of choice in a pregnant woman with a seizure disorder. Ideally, if the woman has not had a seizure for 5 years prior to becoming pregnant, a prepregnancy trial of withdrawal from seizure medication should be tried. If phenobarbital is used, serum levels should be measured in each trimester, and the dosage should be such that it maintains the serum levels in the low-normal therapeutic range.Question 113. Jennifer, age 27, is complaining of lower abdominal pain. After doing some laboratory studies, you find leukocytosis, an elevated erythrocyte sedimentation rate, and an elevated C-reactive protein level. Which of the following is the most appropriate diagnosis? 1. Ovarian cyst. 2. Pelvic inflammatory disease. 3. Tubal pregnancy. 4. Diverticulitis.2. Pelvic inflammatory disease. Option 2: In clients with pelvic inflammatory disease, leukocytosis is present in about 50% of cases, the erythrocyte sedimentation rate is classically elevated, and the C-reactive protein level is elevated (exceeding 20 mg/L) in about 74% of cases.Question 114. Sharon, age 37, states she has heard that douching effectively washes out sperm after intercourse and that she has been using this as a method of birth control. Which of the following statements about douching is true? 1. Douching prevents sperm from entering the uterus. 2. If not used after intercourse, douching should be used at least once a month after menses. 3. Douching is a reliable contraceptive. 4. Douching may increase the risk of ectopic pregnancy.4. Douching may increase the risk of ectopic pregnancy. Option 4: Douching has been associated with an increased risk of pelvic infection and ectopic pregnancy.Question 115. Joy has been breastfeeding and has developed puerperal mastitis. You tell her: 1. "Using cool compresses to the affected breast before pumping will increase milk expression." 2. "Continue breastfeeding the baby to avoid milk stasis." 3. "Continue doing your normal activities during the acute phase to keep things flowing." 4. "Do not massage the breasts."2. "Continue breastfeeding the baby to avoid milk stasis." Option 2: Puerperal mastitis is a cellulitis that develops in lactating and nonlactating breasts after parturition. It is vital that the infant continue to breastfeed during puerperal mastitis to avoid milk stasis. Because the infection is extraductal, continuing to breastfeed poses no risk to the infant. Antibiotic therapy is traditionally recommended to treat the infection.Question 116. Sarah, age 29, complains of premenstrual syndrome (PMS). She states she was told that changing her diet might help in managing some of the symptoms. What change in her diet do you recommend? 1. Decreased intake of protein. 2. Increased intake of complex carbohydrates. 3. Increased intake of salt and salty foods. 4. Decreased intake of fatty foods.2. Increased intake of complex carbohydrates. Option 2: Advise the client complaining of PMS to increase her intake of complex carbohydrates. A diet high in complex carbohydrates, such as whole grains, cereals, fruits, and vegetables, helps prevent low blood sugar levels and reduces fatigue, jitteriness, and irritability. It may also raise serotonin levels, thus improving mood. Eating several small meals at frequent intervals rather than 3 large ones also keeps blood sugar on an even level and reduces the feeling of bloating.Question 117. The Joneses are thinking about going for infertility counseling because they have been married for 5 years and have been unable to conceive. They ask you whether the man or the woman is usually the cause of infertility. What do you tell them about the etiology of infertility? 1. "In most cases, infertility is related to a female factor." 2. "In most cases, infertility is related to a male factor." 3. "In the majority of cases, the etiology cannot be identified." 4. "Male and female infertility rates are almost the same in the majority of cases."4. "Male and female infertility rates are almost the same in the majority of cases." Option 4: Male and female infertility rates are almost the same (males 30% and females 35%), and in 20% of cases there is a combination of male and female factors. It should also be stressed that infertility is no one's "fault" and that many things may be tried to assist the couple with conception.Question 118. A 27-year-old female presents to your office for a levonorgestrel-releasing intrauterine system (Mirena) insertion. She reports that her menses started 3 days ago and is normal. How soon after insertion will she be able to safely rely on the intrauterine device (IUD) for contraception? 1. Immediately. 2. After 48 hours. 3. In 1 week. 4. In 1 month.1. Immediately. Option 1: The levonorgestrel-releasing intrauterine system (Mirena) is a small T-shaped contraceptive device that releases levonorgestrel (a type of progestin) directly into the endometrial cavity. Although this IUD can be inserted at any time during the menstrual cycle, Mirena is effective immediately if inserted within 7 days after the start of menses.Question 119. A 33-year-old woman complains of dyspareunia in the lower back during orgasm. The nurse practitioner should consider: 1. Endometriosis. 2. Cystitis. 3. Vaginitis. 4. Pelvic inflammatory disease.1. Endometriosis. Option 1: When a client complains of dyspareunia in the lower back during orgasm, you should consider a diagnosis of endometriosis. Causes of dyspareunia are diverse and depend on when and where the pain occurs.Question 120. Marsha, age 42, is having chronic abnormal uterine bleeding (AUB) and cannot take oral contraceptives (OCs) due to a history of a deep vein thrombosis (DVT). Management includes which medication? 1. Medroxyprogesterone. 2. Ethinyl estradiol (EE). 3. Conjugated estrogens. 4. Piroxicam.1. Medroxyprogesterone. Option 1: Management of AUB is directed toward controlling bleeding and preventing recurrence. For women who cannot take OCs, medroxyprogesterone is offered. For teenagers, management includes observation for those with mild cases and no anemia, medroxyprogesterone for clients not sexually active, and OCs for those who are sexually active. For women of reproductive age, treatment is based on the woman's desire for fertility or contraception.Question 121. During a pelvic examination, you ask Mrs. Krane, age 54, to perform a Valsalva maneuver (ie, forcibly exhaling while keeping the mouth and nose closed). While doing this strain maneuver, a pouching is seen on the anterior wall of the vagina. This is indicative of: 1. A cystocele. 2. A rectocele. 3. An enterocele. 4. Uterine prolapse1. A cystocele. Option 1: A cystocele is the prolapse into the vagina of the anterior vaginal wall and bladder. Clinically, a pouching is seen on the anterior wall as the client strains.Question 122. A 21-year-old woman comes to your office and reports a history of genital warts. In reference to the human papillomavirus (HPV) vaccination (ie, Gardasil, Gardasil 9, and Cervarix), she should be educated that: 1. She is not in the correct age group and is not a candidate for vaccination. 2. She should receive HPV vaccination. 3. She has already been exposed to HPV; therefore, she is not a candidate for vaccination. 4. There is a vaccine coming out shortly specifically for those who have been exposed. She should wait.2. She should receive HPV vaccination. Option 2: HPV is the most common sexually transmitted infection (STI). There are more than 40 HPV types that can infect the genital areas, mouth, and throat of males and females. According to the Centers for Disease Control and Prevention (CDC), females should get the vaccine before they become sexually active and prior to becoming exposed to HPV. Females who are sexually active may also benefit from vaccination, but they may get less benefit from it. While this question involves a young woman, the CDC recommends that HPV vaccination be given to both boys and girls at age 11 or 12 so they are protected before ever being exposed to the virus.Question 123. A 26-year-old female comes to your office to discuss birth control options. Her history includes migraine headaches with aura while on combination oral contraceptives in the past. She does not want to become pregnant. Which of the following birth control options would be the best choice for her? 1. Combined hormonal contraceptive pills. 2. Birth control patch (Ortho Evra). 3. Mirena intrauterine device (IUD). 4. Vaginal contraceptive ring (NuvaRing).3. Mirena intrauterine device (IUD). Option 3: Women who have a history of migraine headaches with aura on combination oral contraceptives should not take estrogen-containing contraceptives. The Mirena IUD contains levonorgestrel, which is a progestin.Question 124. Julia is nursing her 8-week-old baby and states that he is very irritable and sleeps poorly. What medication or substance do you ask her if she is taking or using? 1. Cimetidine (Tagamet). 2. Ergotamine tartrate (Ergostat). 3. Nicotine. 4. Caffeine.4. Caffeine. Option 4: Caffeine in large amounts will make the infant who is being nursed irritable and give him or her a poor sleep pattern.Question 125. The best method to diagnose uterine polyps is a: 1. Hysteroscopy. 2. Dilation and curettage. 3. Colposcopy. 4. Laparoscopy.1. Hysteroscopy. Option 1: The best method to diagnose uterine polyps is a hysteroscopy. A hysteroscopy involves visualizing the endometrium through a scope to assess for some types of uterine fibroids, polyps, and structural abnormalities. Tissue sampling and removal of polyps can be done through the hysteroscope.Question 126. Samantha, age 19, has a diagnosis of a Chlamydia vaginal infection. You believe it is questionable whether she will fill the prescription you write or take it for 7 days as ordered. What do you do? 1. Give azithromycin (Zithromax) 1 g orally now. 2. Emphasize the importance of the drug and tell her the consequences of not taking it. 3. Send out the public health nurse to follow up on whether she takes the drug for 7 days. 4. Assume that Samantha is an adult and will follow your instructions.1. Give azithromycin (Zithromax) 1 g orally now. Option 1: An appropriate first-line treatment for a Chlamydia vaginal infection is azithromycin (Zithromax) 1 g orally. Although doxycycline (Vibramycin) 100 mg orally twice daily for 7 days is the most tried and true and least expensive treatment, azithromycin is the most convenient option for single-dose administration. Azithromycin is contraindicated in pregnant women. For this population, erythromycin 500 mg orally 4 times a day for 7 days should be ordered.Question 127. Mrs. Green, age 43, called the office to make an appointment for her annual Pap smear. Which of the following instructions does she need to be given prior to her appointment? 1. "Insert nothing in the vagina for 24 hours before the examination." 2. "Douching enhances visualization of the cervix and should be done before the appointment." 3. "An infection or menstrual period is no reason to cancel the appointment." 4. "The procedure is completely painless."1. "Insert nothing in the vagina for 24 hours before the examination." Option 1: Nothing should be inserted in the vagina for 24 hours before performing a Pap smear.Question 128. Which of the following ovarian tumors or cysts have the potential for malignancy? 1. Follicular cysts. 2. Brenner tumors. 3. Fibromas. 4. Secondary ovarian tumors.4. Secondary ovarian tumors. Option 4: Secondary ovarian tumors account for about 10% of fatal malignant diseases in women. They are usually the result of bowel or breast metastasis to the ovary, and all of the tumors are malignant.Question 129. Joanne, age 23, wants to use some form of birth control, but because she is getting married next year, she wants to be able to stop the birth control method after the wedding and have her fertility restored almost immediately. Which method do you recommend for her? 1. Birth control pills. 2. Vaginal ring. 3. Depot medroxyprogesterone acetate (DMPA) injections. 4. Diaphragm.4. Diaphragm. Option 4: The diaphragm is the only product listed that does not contain hormones that may delay pregnancy after discontinuing use. The dome-shaped silicone device covers the cervix and allows secretions to exit without sperm coming in. The diaphragm is used with spermicide.Question 130. Mrs. Thomas, age 69, comes to your office for the results of her dual-energy x-ray absorptiometry (DXA) scan. She reports that her mother had osteopenia before she died. The DXA scan results show a T score of -2.7 in the hip and -2.8 in the spine. You explain to her that her results show: 1. Normal bone density. 2. Osteopenia. 3. Osteoporosis. 4. Osteoarthritis.3. Osteoporosis. Option 3: The gold standard test for bone mineral density (BMD) is the DXA scan. The National Osteoporosis Foundation recommends that all women over the age of 65 get a DXA scan. The level of bone loss is determined by the T score, which compares the individual's bone density to that of a 30-year-old adult. Peak bone density is reached by age 30 and should ideally be maintained at this level throughout life. A T score less than or equal to -2.5 is indicative of osteoporosis.Question 131. There are many causes of amenorrhea. In ballet dancers and marathon runners, which anatomical structure is the probable cause? 1. Outflow tract. 2. Ovary. 3. Anterior pituitary. 4. Hypothalamus.4. Hypothalamus. Option 4: The hypothalamus is the cause of exercise-induced amenorrhea, such as occurs in dancers and marathon runners.Question 132. Laura, age 65, presents to the office complaining of vaginal bleeding for 12 days. She reports she has not had a menses since the age of 52 and that this bleeding looks much like her menses used to look. The initial workup for postmenopausal bleeding (PMB) should include: 1. A pregnancy test. 2. A diagnostic pelvic laparoscopy. 3. An endometrial biopsy. 4. A colonoscopy.3. An endometrial biopsy. Option 3: Postmenopausal uterine bleeding is defined as uterine bleeding after permanent cessation of menstruation resulting from loss of ovarian follicular activity. In order to exclude or diagnose endometrial cancer, a woman with postmenopausal bleeding needs an initial evaluation with an endometrial biopsy to obtain a sampling of the uterine lining.Question 133. Ms. Russo, age 59, is a postmenopausal woman who comes to your office complaining of vaginal dryness. She has been sexually active with a new partner and says that penetration is very painful. She has tried over-the-counter lubricants but has not found one that works. Her history is significant for hypertension only. After examination and wet prep, you diagnose her with atrophic vaginitis. The treatment for this condition includes: 1. Terconazole cream. 2. Metronidazole gel. 3. Vaginal estrogen cream. 4. Hydrocortisone ointment.3. Vaginal estrogen cream. Option 3: Vaginal dryness usually results from a hypoestrogenic environment in the vagina and is very common in both premenopausal and postmenopausal women in the absence of a secondary vaginal infection. In addition to vaginal dryness, symptoms may include burning, itching, abnormal vaginal discharge, and dyspareunia. Hypoestrogenic states, such as lactation and the use of depot medroxyprogesterone acetate, can also cause atrophic vaginitis. This condition is best treated with topical estrogen.Question 134. Susan, age 35, has been diagnosed with fibrocystic breast disease. Which of the following may exacerbate the condition? 1. A daily dose of aspirin. 2. Spicy foods. 3. Chocolate. 4. Wearing tight bras3. Chocolate. Option 3: There are many interventions that will alleviate the pain of fibrocystic breast disease as well as help decrease the proliferation of breast tissue. Coffee, chocolate, tea, colas, and drugs containing caffeine should be reduced to help alleviate breast tenderness and reduce nodularity. Vitamin E has been shown to decrease the pain and tenderness associated with fibrocystic change as well as the proliferation of breast tissue.Question 135. Mrs. Jameson complains of unilateral blurry vision and partial blindness in the left eye. On physical examination, you find decreased peripheral vision on her left side. Funduscopic examination reveals cotton wool spots. Your most likely diagnosis is: 1. Cryptococcosis. 2. Toxoplasmosis. 3. Cytomegalovirus infection. 4. Herpes simplex virus infection.3. Cytomegalovirus infection. Option 3: The classic signs and symptoms of cytomegalovirus infection on funduscopic examination include cotton wool spots, a "cottage cheese and ketchup" appearance, hemorrhage, and exudates. Decreased peripheral vision, blurriness, and partial blindness are other clinical manifestations. Referral to an ophthalmologist is imperative.Question 136. Your client George, age 60, presents with pruritus and complains of lymphadenopathy in his neck. He also complains of night sweats and has noticed a low-grade fever. He has not lost any weight and otherwise feels well. He is widowed and has been dating a new woman recently. On physical exam, you find enlarged supraclavicular nodes. You suspect: 1. Lung cancer. 2. Hodgkin lymphoma. 3. A lingering viral infection from a bout of flu he had 6 weeks ago. 4. Non-Hodgkin lymphoma.2. Hodgkin lymphoma. Option 2: This presentation is classic for Hodgkin lymphoma. Although often seen in younger adults, this disease has a bimodal incidence that peaks at ages 15 to 35 and again after age 50. Pruritus is not uncommon, and up to 40% of clients have low-grade fever and recurrent night sweats.Question 137. Mindy, age 6, was recently discharged from the hospital after a sickle cell crisis. You are teaching her parents to be alert to the manifestations of splenic sequestration and tell them to be alert to: 1. Vomiting and diarrhea. 2. Decreased mental acuity. 3. Abdominal pain, pallor, and tachycardia. 4. Abdominal pain and vomiting.3. Abdominal pain, pallor, and tachycardia. Option 3: Abdominal pain, pallor, and tachycardia are all manifestations of splenic sequestration. Early recognition of splenic sequestration can be a lifesaving skill. Parents can be taught to recognize signs of increasing anemia and enlarging spleen. Part of the educational plan for parents is teaching them how to recognize increasing abdominal girth or abdominal pain, as well as how to palpate the spleen.Question 138. Your client Mrs. Young, age 64, is here to see you because she has pain in her left breast. She reports no pain in her right breast and no noted lesions or masses on breast self-exam, which she performs monthly. You know that: 1. At her age, you do not need to worry about breast cancer. 2. Initial presentation of breast pain is usually not suspicious for malignancy. 3. She must be sent for a mammogram as soon as possible. 4. She has no personal or family history of breast cancer; therefore, you are not concerned.3. She must be sent for a mammogram as soon as possible. Option 3: In postmenopausal women, pain in one breast is highly suggestive of a malignant process despite past personal and/or family history. Additionally, you know that age 64 puts this client at a high risk of breast cancer. You must send her for a mammogram as soon as possible even if she had a negative one less than a year before.Question 139. Sherri's blood work returns with a decreased mean corpuscular volume (MCV) and a decreased mean corpuscular hemoglobin concentration (MCHC). What should you do next? 1. Order a serum iron level and a total iron-binding capacity (TIBC) level. 2. Order a serum ferritin level. 3. Order a serum folate level. 4. Order a serum iron level, a total iron-binding capacity (TIBC) level, and a serum ferritin level.4. Order a serum iron level, a total iron-binding capacity (TIBC) level, and a serum ferritin level. Option 4: Decreased MCV and MCHC are indicative of a microcytic hypochromic anemia. To make a more final diagnosis, you need to order a serum iron level, a TIBC level, and a serum ferritin level.Question 140. Robin has human immunodeficiency virus (HIV) and is having a problem with massive diarrhea. You suspect the cause is: 1. Cryptococcosis. 2. Toxoplasmosis. 3. Cryptosporidiosis. 4. Cytomegalovirus.3. Cryptosporidiosis. Option 3: When clients with HIV infection have massive diarrhea, a protozoan of the Cryptosporidium genus is the most likely cause. The organism affects primarily the small intestine and produces massive diarrhea accompanied by nausea and fatigue. The diarrhea may exceed 4 L per day and can easily lead to dehydration and electrolyte imbalance if not treated promptly.Question 141. Julia asks how smoking increases the risk of folic acid deficiency. You respond that smoking: 1. Causes small vessel disease and constricts all vessels that transport essential nutrients. 2. Decreases vitamin C absorption. 3. Affects the liver's ability to store folic acid. 4. Causes nausea, thereby inhibiting the appetite and ingestion of foods rich in folic acid.2. Decreases vitamin C absorption. Option 2: Smoking decreases vitamin C absorption, which is necessary for folic acid absorption. Smoking increases vitamin requirements. Clients with a folic acid deficiency should be encouraged to eat foods that are high in folic acid (eg, asparagus spears, beef liver, broccoli, mushrooms, oatmeal, peanut butter, and red beans) daily because the liver can store folic acid for only a limited time.Question 142. Jimmy, age 6 months, is newly diagnosed with sickle cell disease. His mother brings him to the clinic for a well-baby visit. Which of the following should you do on this visit? 1. Tell his mother that Jimmy will not be immunized because of his diagnosis. 2. Tell his mother that Jimmy should not go to day care. 3. Immunize Jimmy with the diphtheria, tetanus, and pertussis (DTaP); Haemophilus influenzae type b (Hib); hepatitis B virus (HBV); and poliomyelitis vaccines. 4. Immunize Jimmy with the measles, mumps, and rubella; Haemophilus influenzae type b (Hib); and hepatitis B virus (HBV) vaccines only.3. Immunize Jimmy with the diphtheria, tetanus, and pertussis (DTaP); Haemophilus influenzae type b (Hib); hepatitis B virus (HBV); and poliomyelitis vaccines. Option 3: At 6 months of age, Jimmy should be immunized with the DTaP, Hib, HBV, and poliomyelitis vaccines. Children with sickle cell disease should receive all the standard well-baby care, but in addition to the standard immunizations, they should receive the pneumococcal vaccine at age 2 years. There is no cure for sickle cell disease.Question 143. Ms. Jones, your client, has an elevated platelet count. You suspect: 1. Systemic lupus erythematosus (SLE). 2. Infectious mononucleosis. 3. Disseminated intravascular coagulation (DIC). 4. Splenectomy.4. Splenectomy. Option 4: Increased platelet count is seen status post splenectomy and in myeloproliferative leukemias and polycythemia vera. Platelets are decreased in coagulation disorders such as disseminated intravascular coagulation (DIC), septicemia, and eclampsia. Increased destruction of platelets is seen in idiopathic thrombocytopenic purpura, systemic lupus erythematosus (SLE), and infectious mononucleosis. Decreased production of platelets is seen secondary to radiation and chemotherapy and in aplastic anemia and most leukemias.Question 144. Allie, age 5, is being treated with radiation for cancer. Her mother asks about the effect radiation will have on Allie's future growth. Although she knows that a specialist will be handling Allie's care, her mother asks for your opinion. How do you respond? 1. "Let's worry about the cancer first and then see how her growth is affected." 2. "Chemotherapy may affect her future growth, but radiation will not." 3. "She will probably have growth hormone problems, in which case she can then begin growth hormone therapy." 4. "That's the least of your worries now; everything will turn out okay."3. "She will probably have growth hormone problems, in which case she can then begin growth hormone therapy." Option 3: Growth complications depend on the direct damage to the endocrine tissue. Children with acute lymphocytic leukemia, brain tumors, nasopharyngeal cancers, and orbital tumors who have received radiation therapy are at the highest risk. Approximately 50% to 90% of these children will have some evidence of growth hormone deficiency, and they may benefit from growth hormone therapy. Spinal radiation inhibits vertebral body growth.Question 145. Maria, age 35, asks if being obese predisposes her to cancer. How do you respond? 1. "No, you have the same risk as a normal-weight individual." 2. "You have less risk of cancer than normal-weight individuals because you have protein stores to combat mutant cells." 3. "Yes, you have an increased risk of hormone-dependent cancers because of your obesity." 4. "Yes, you have an increased risk because you have many more cells in all the organs of your body."3. "Yes, you have an increased risk of hormone-dependent cancers because of your obesity." Option 3: People who are obese have an increased risk of hormone-dependent cancers because of their excess body fat. Because sex hormones are synthesized from fat, these people have excessive amounts of the hormones that feed hormone-dependent malignancies such as cancer of the breast, bowel, ovary, endometrium, and prostate.Question 146. Your client Jeannie, age 64, comes to you complaining of tinnitus and lightheadedness without loss of consciousness. On physical exam, you note splenomegaly. To sort out your differential diagnosis, you order an alkaline phosphatase and vitamin B12 level because you are ruling out a diagnosis of: 1. Liver cancer. 2. Pancreatic cancer. 3. Mononucleosis. 4. Polycythemia vera.4. Polycythemia vera. Option 4: Polycythemia vera causes a hyperviscosity of the blood, which leads to decreased cerebral blood flow, resulting in symptoms of tinnitus, lightheadedness, and occasionally stroke and thrombosis. Alkaline phosphatase and serum vitamin B12 levels are elevated; leukocytosis and thrombocytosis are also present. Red blood cell mass is elevated, and arterial oxygen saturation is more than 92% (ie, the erythrocytosis is not secondary to hypoxia).Question 147. Shelley has esophageal cancer and asks you if cigarettes and alcohol played a part in its development. How do you respond? 1. "Your cancer was caused by your cigarette smoking, nothing else." 2. "Alcohol is also a carcinogen." 3. "Alcohol directly alters DNA and causes mutations." 4. "Alcohol modifies the metabolism of carcinogens in the esophagus and increases their effectiveness."4. "Alcohol modifies the metabolism of carcinogens in the esophagus and increases their effectiveness." Option 4: Alcohol acts as a promoter by modifying the metabolism of carcinogens in the esophagus and liver, thereby increasing their effectiveness in some tissues.Question 148. Julie's brother has chronic lymphocytic leukemia (CLL). She overheard that he was in stage IV and asks what this means. According to the Rai classification system, stage IV is a stage: 1. In which the lymphocyte count is greater than 10,000 mm3. 2. Indicating absolute lymphocytosis, in which the client may live 7 to 10 years or more. 3. Of thrombocytopenia in which the life expectancy may be only 2 years. 4. Of anemia.3. Of thrombocytopenia in which the life expectancy may be only 2 years. Option 3: Stage IV in the Rai classification system of CLL is the stage of thrombocytopenia where the life expectancy may be only 2 years. CLL is the only leukemia in which a staging system is commonly used because CLL has prognostic implications. A client with only absolute lymphocytosis (Rai stage 0) may live 7 to 10 years or more. In the Rai classification system, stage 0 indicates a lymphocyte count greater than 10,000 mm3, stage I indicates enlarged lymph nodes, stage II indicates an enlarged liver and/or spleen, stage III indicates anemia, and stage IV indicates thrombocytopenia.Question 149. When the donor and recipient of a transplant are identical twins, this is referred to as what type of transplant? 1. Isograft. 2. Autograft. 3. Allograft. 4. Xenograft.1. Isograft. Option 1: An isograft is a transplant in which the donor and recipient are identical twins.*****Question 150. Frank, a 66-year-old white male who is on diuretic therapy, presents with an elevated hematocrit. He also has splenomegaly on examination as well as subjective complaints of blurred vision, fatigue, headache, and tinnitus. You suspect: 1. Multiple myeloma. 2. Waldenström macroglobulinemia. 3. Dehydration related to the use of diuretics. 4. Polycythemia vera.4. Polycythemia vera. Option 4: An elevated hematocrit due to contracted plasma volume, rather than increased red blood cell mass, may be due to diuretic use or may occur without obvious cause. However, the associated signs and symptoms of splenomegaly, blurred vision, fatigue, headache, and tinnitus lead you to suspect polycythemia vera. An elevated hematocrit due to contracted plasma volume is often called spurious polycythemia, and a number of conditions, such as hypoxia and high-altitude exposure, can cause a secondary polycythemia, but splenomegaly is absent in these cases. Primary polycythemia vera is an acquired myeloproliferative disorder that causes an overproduction of all 3 hematopoietic cell lines.Question 151. You have a new client, Robert, age 67, who presents with generalized lymphadenopathy. You know that this is indicative of: 1. Disseminated malignancy, particularly of the hematologic system. 2. Cancer of the liver. 3. Sjögren syndrome. 4. Pancreatic cancer.1. Disseminated malignancy, particularly of the hematologic system. Option 1: Generalized lymphadenopathy is usually indicative of disseminated malignancy, typically hematologic in nature (such as lymphoma or leukemia); collagen vascular disease; or an infectious process such as mononucleosis, syphilis, cytomegalovirus, tuberculosis, AIDS, toxoplasmosis, and so on.Question 152. Caroline, 65, is homeless and has iron deficiency anemia. She smokes and drinks when she can and has a stomach ulcer. Which of the following is not one of her risk factors for iron deficiency anemia? 1. Smoking. 2. Poverty. 3. Ulcer. 4. Age greater than 60.1. Smoking. Option 1: Smoking is not one of the risk factors for iron deficiency anemia. The risk of iron deficiency anemia increases in those older than 60, those who live in poverty, and those with a recent illness, such as ulcer, diverticulitis, colitis, hemorrhoids, and gastrointestinal tumors. Iron supplements should be taken.Question 153. Despite successful primary prophylaxis, which infection remains a common AIDS-defining diagnosis? 1. Pneumocystis jiroveci pneumonia 2. Cryptococcosis. 3. Cryptosporidiosis. 4. Candidiasis.1. Pneumocystis jiroveci pneumonia Option 1: Before the appearance of AIDS, Pneumocystis jiroveci pneumonia was a rare disease that immunosuppressed people and those with leukemia sometimes developed. Today, Pneumocystis jiroveci pneumonia is usually the defining characteristic in people with AIDS in both the United States and Europe.Question 154. Joan had a modified radical mastectomy with radiation therapy 10 years ago. She asks when she can have her blood pressure and needle sticks performed in the affected arm. How do you respond? 1. "If it's been 10 years and you've had no problems, you can discontinue these precautions." 2. "Because you didn't have a radical mastectomy, you can do those things now." 3. "You must observe these precautions forever." 4. "As long as you do limb exercises and have established collateral drainage, you can discontinue these precautions."3. "You must observe these precautions forever." Option 3: Lymphedema may occur many years after a mastectomy (whether radical or modified) or radiation therapy on the affected side. Procedures such as venipuncture and blood pressure measurements should never be done on the affected arm because there is a greater risk of infection and compromised wound healing in that limb. About 15% to 20% of women develop lymphedema after treatment for breast cancer by surgery or radiation—some not until many years later. Several interventions have been tried with lymphedema (ranging from nothing to aggressive surgical procedures) and have met with limited success. Most interventions include elevation, exercises, and pneumatic compression devices.Question 155. Your client Mr. Jones has Sjögren syndrome. Which treatment do you suggest? 1. Artificial tears and chewing sugarless gum. 2. Frequent rinsing of the mouth with mouthwash. 3. Drinking at least 1 glass of milk per day. 4. Removing wax from the ears at regular intervals.1. Artificial tears and chewing sugarless gum. Option 1: Sjögren syndrome is a multisystem autoimmune disease characterized by dysfunction of the exocrine glands; it is specifically notable for dry eyes and dry mouth. Treatment is aimed at increasing comfort and lubrication. Artificial tears can be self-administered as needed; preservative-free products are usually better tolerated. For dry mouth, increasing hydration and chewing sugarless gum may be helpful. Oral pilocarpine (Salagen) 5 mg 4 times a day and cevimeline (Evoxac) 30 mg 3 times a day have been shown to increase saliva production.Question 156. Which of the following is a benign neoplasm? 1. Leiomyoma. 2. Osteosarcoma. 3. Glioma. 4. Seminoma.1. Leiomyoma. Option 1: A leiomyoma is a benign neoplasm of the smooth muscle.Question 157. Sally has human immunodeficiency virus (HIV) and asks which method of birth control, other than abstinence, would be best for her. You suggest: 1. Latex condoms. 2. The spermicide nonoxynol-9. 3. An intrauterine device (IUD). 4. An oral contraceptive.1. Latex condoms. Option 1: Latex condoms, when used consistently and correctly, are the preferred contraceptive method for a client infected with HIV because they provide the most effective barrier between partners. Sally should continue to use condoms even when she is postmenopausal and birth control is no longer an issue in order to prevent spreading HIV to her partner.Question 158. Stu, age 49, has slightly reduced hemoglobin and hematocrit readings. What is your next action after you ask him about his diet? 1. Repeat the laboratory tests. 2. Perform a fecal occult blood test. 3. Start him on an iron preparation. 4. Start him on folic acid.2. Perform a fecal occult blood test. Option 2: Tests for fecal occult blood should be done on all clients suspected of having iron deficiency anemia. In the early stages of iron deficiency anemia, both hemoglobin and hematocrit levels are normal to slightly reduced. It is necessary to determine whether the iron deficiency is related solely to inadequate dietary intake or to decreased absorption or chronic blood loss.Question 159. Mandy's 16-year-old daughter has hepatitis A. Which of the following statements made by Mandy indicates she understands the teaching you've just completed? 1. "I guess she needs to be hospitalized until she's recovered." 2. "We'll keep her at home with strict isolation precautions." 3. "We'll stop at the store and buy plastic eating utensils." 4. "We'll stop at the drugstore and pick up prescription medications immediately."3. "We'll stop at the store and buy plastic eating utensils." Option 3: Clients with hepatitis A should have their eating and drinking utensils kept separate, or they should use disposable ones.Question 160. Which of the following white blood cell types are elevated in parasitic infections, hypersensitivity reactions, and autoimmune disorders? 1. Neutrophils. 2. Eosinophils. 3. Basophils. 4. Monocytes.2. Eosinophils. Option 2: Eosinophils are elevated in parasitic infections, hypersensitivity reactions, and autoimmune disorders.Question 161. Which hypersensitivity reaction results in a skin test that produces erythema and edema within 3 to 8 hours? 1. Anaphylactic reaction. 2. Cytotoxic reaction. 3. Immune complex-mediated reaction. 4. Delayed hypersensitivity reaction.3. Immune complex-mediated reaction. Option 3: An immune complex-mediated reaction results in a skin test that produces erythema and edema within 3 to 8 hours. It may result from serum sickness, systemic lupus erythematosus, or rheumatoid arthritis.Question 162. In which of the following circumstances is the reticulocyte count elevated? 1. Aplastic anemia. 2. Iron deficiency anemia. 3. Poisoning. 4. Acute blood loss.4. Acute blood loss. Option 4: The reticulocyte count indicates the percentage of newly maturing red blood cells (RBCs) released into the circulating blood from the bone marrow. As an RBC matures, it loses its endothelial reticulum. The reticulocyte count is elevated in cases of blood loss as the body tries to replace the loss; it might also be elevated during treatment of anemias (eg, iron, folic acid, and vitamin B12) and bone marrow disorders, when immature RBCs are displaced by other proliferating cells.Question 163. Jill has just been given a diagnosis of human immunodeficiency virus (HIV) and has a normal initial Pap smear. When do the Centers for Disease Control and Prevention (CDC) guidelines state she should have a repeat Pap test? 1. In 3 months. 2. In 6 months. 3. In 1 year. 4. She should have a colposcopy every year instead of a Pap test.2. In 6 months. Option 2: The CDC guidelines state that if a woman infected with HIV has a normal initial Pap test, then a second evaluation should be done in 6 months to reduce the likelihood of a false-negative initial test. If the initial 2 Pap smears are both negative, annual Pap smears are then adequate. If severe inflammation with reactive squamous cellular change is found, another Pap smear should be done within 3 months.Question 164. You are examining Joseph, age 9 months, and note a palpable right supraclavicular lymph node. You know that this finding is suspicious for: 1. Candidiasis. 2. Cryptococcosis. 3. Lymphoma of the mediastinum. 4. Abdominal malignancy.3. Lymphoma of the mediastinum Option 3: Palpable supraclavicular lymph nodes are not normal in infants, children, or adults. A palpable right-sided node is more commonly associated with lymphoma of the mediastinum.Question 165. Marsha states that a relative is having a carcinoembryonic antigen (CEA) test done to detect some type of cancer. She wants to know what kind. You tell her a CEA is performed to detect: 1. Adenocarcinoma of the prostate. 2. Medullary cancer of the thyroid. 3. Adenocarcinomas of the colon, lung, breast, ovary, stomach, and pancreas. 4. Multiple myeloma.3. Adenocarcinomas of the colon, lung, breast, ovary, stomach, and pancreas. Option 3: CEA is a tumor marker for adenocarcinomas of the colon, lung, breast, ovary, stomach, and pancreas.Question 166. Tina, age 2, had a complete blood count (CBC) drawn at her last visit. It indicates that she has a microcytic hypochromic anemia. What should you do now at this visit? 1. Obtain a lead level. 2. Instruct Tina's parents to increase the amount of milk in her diet. 3. Start Tina on ferrous sulfate (Feosol) and check the CBC in 6 weeks. 4. Recheck the CBC.1. Obtain a lead level. Option 1: The provider should always check a lead level before starting iron supplementation in children because an elevated lead level will cause anemia despite a normal iron level.Question 167. Jan is having biological therapy for her pancreatic cancer. What kind of treatment is this? 1. Surgery. 2. Radiation therapy. 3. Immunotherapy. 4. Chemotherapy.3. Immunotherapy. Option 3: Immunotherapy is also called biological therapy. It is a form of treatment that uses the body's natural ability (ie, the immune system) to fight disease or to protect itself from the adverse effects of treatment.Question 168. Macrocytic normochromic anemias are caused by: 1. Acute blood loss. 2. An infection or tumor. 3. A nutritional deficiency of iron. 4. A deficiency of folic acid.4. A deficiency of folic acid. Option 4: A folic acid and/or vitamin B12 deficiency causes macrocytic normochromic anemias in which the cell size is large and irregular.Question 169. Which of the following cancers is associated with Epstein-Barr virus? 1. Burkitt lymphoma. 2. Kaposi sarcoma. 3. Lymphoma. 4. Adult T-cell leukemia.1. Burkitt lymphoma. Option 1: Burkitt lymphoma is associated with Epstein-Barr virus.Question 170. Barbara, age 27, had her spleen removed after an automobile accident. You are seeing her in the office for the first time since her discharge from the hospital. She asks you how her surgery will affect her in the future. How do you respond? 1. "Your red blood cell production will be slowed." 2. "Your lymphatic system may have difficulty transporting lymph fluid to the blood vessels." 3. "You'll have difficulty storing the nutritional agents needed to make red blood cells." 4. "You may have difficulty salvaging iron from old red blood cells for reuse."4. "You may have difficulty salvaging iron from old red blood cells for reuse." Option 4: The spleen is not essential for life. When it is removed, the liver and bone marrow assume its functions. Although the bone marrow will produce and store hematopoietic stem cells, from which all cellular components of the blood are derived, it will not remove iron from old red blood cells for reuse.Question 171. Which of the following conditions is an X-linked recessive disorder commonly seen in African American males? 1. Sickle cell anemia. 2. Glucose-6-phosphate dehydrogenase deficiency. 3. Pyruvate kinase deficiency. 4. Bernard-Soulier syndrome.2. Glucose-6-phosphate dehydrogenase deficiency. Option 2: Glucose-6-phosphate dehydrogenase (G6PD) deficiency is an X-linked recessive disorder commonly seen in African American males. It is an enzyme defect that causes episodic hemolytic anemia because of the decreased ability of red blood cells to deal with oxidative stress. The other disorders listed are not X-linked.Question 172. Skip, age 4, is brought to the office by his mother. His symptoms are pallor, fatigue, bleeding, fever, bone pain, adenopathy, arthralgias, and hepatosplenomegaly. You refer him to a specialist. Which of the following tests do you expect the specialist to perform to confirm a diagnosis? 1. An enzyme-linked immunosorbent assay. 2. A monospot test. 3. A prothrombin time, partial thromboplastin time, bleeding time, complete blood count, and peripheral smear. 4. A bone marrow smear.4. A bone marrow smear. Option 4: Skip has the characteristic symptoms of acute lymphoblastic leukemia. Diagnosis is made by the characteristic appearance found on a bone marrow smear.Question 173. Lorie, age 29, appears with the following signs: pale conjunctivae and nail beds, tachycardia, heart murmur, cheilosis, stomatitis, splenomegaly, koilonychia, and glossitis. What do you suspect? 1. Vitamin B12 deficiency. 2. Folate deficiency. 3. Iron deficiency anemia. 4. Chronic fatigue syndrome.3. Iron deficiency anemia. Option 3: Lorie has the classic signs of iron deficiency anemia: pale conjunctivae and nail beds, tachycardia, heart murmur, cheilosis (reddened lips with fissures at the angles), stomatitis, splenomegaly, koilonychia (thin and concave fingernails with raised edges), and glossitis. Signs may also include esophageal webs (Plummer-Vinson syndrome), melena, and menorrhagia.Question 174. Nancy recently had a mastectomy and refuses to look at the site. Her husband does all the dressing changes. When she comes in to the office for a postoperative checkup, what would you say to her? 1. "You'll look at it when you're ready." 2. "You must look at it today." 3. "Everything's going to be okay. It looks fine." 4. "You have to accept this eventually; just glance at it today."4. "You have to accept this eventually; just glance at it today." Option 4: With the loss of a body part, there is an initial stage of shock and denial. It is a protective mechanism and should be neither challenged nor promoted. The best response to Nancy, who refuses to look at her mastectomy scar, would be to say, "You have to accept this eventually; just glance at it today." Then every day she could spend a little more time looking at it until she is able to care for the wound herself.Question 175. Your client Jackson has decreased lymphocytes. You suspect: 1. Bacterial infection. 2. Viral infection. 3. Immunodeficiency. 4. Parasitic infection.3. Immunodeficiency. Option 3: A decrease in lymphocytes would be most consistent with immunodeficiency disorders, long-term corticosteroid therapy, or debilitating diseases such as Hodgkin lymphoma and systemic lupus erythematosus.*****Question 176. Your client Shirley has an elevated mean corpuscular volume (MCV). What should you be considering in terms of diagnosis? 1. Iron deficiency anemias. 2. Hemolytic anemias. 3. Lead poisoning. 4. Liver disease.4. Liver disease. Option 4: MCV indicates the average size of individual red blood cells (RBCs). The normal (normocytic) range is 76 to 96 fL. MCV is increased (macrocytic) in megaloblastic anemias (ie, vitamin B12 deficiency and folate deficiency) and liver disease (such as that resulting from alcohol abuse) as well as with the use of some drugs (eg, zidovudine).Question 177. Samuel, age 5, is receiving radiation therapy for his acute lymphoblastic leukemia. This treatment puts him at increased risk of developing which type of cancer as a secondary malignancy when he becomes an adult? 1. Chronic lymphocytic leukemia. 2. Brain tumor. 3. Liver cancer. 4. Esophageal cancer.2. Brain tumor. Option 2: Children receiving radiation therapy for acute lymphoblastic leukemia are at an increased risk of developing a brain tumor as a secondary malignancy. This has been seen more often in children who were treated with radiation at age 5 or younger. In general, about 3% to 12% of children treated for cancer will develop a new cancer within 20 years of being treated for the primary cancer.Question 178. Which is the best serum test for spotting an iron deficiency early, before it progresses to full-blown anemia? 1. Hemoglobin. 2. Hematocrit. 3. Ferritin. 4. Reticulocytes.3. Ferritin. Option 3: A serum measurement of ferritin, the body's iron-storing protein, can tell exactly how much iron is on hand in the body. It is the best way to spot an iron deficiency early, before it progresses to full-blown anemia. If the ferritin level is borderline, a dietary and supplemental regimen of iron will rebuild the iron stores.Question 179. Which of the following indicate that Jim, a 32-year-old client with AIDS, has oropharyngeal candidiasis? 1. Small vesicles. 2. White, fissured, thickened patches. 3. Removable white plaques. 4. Flat-topped papules with thin, bluish-white spiderweb lines.3. Removable white plaques. Option 3: Oral candidiasis (thrush) appears as white plaques that can be scraped off, revealing an erythematous mucosal surface. Because of this, it is often referred to as a pseudomembranous lesion.Question 180. Sam is being worked up for pancreatic cancer. He states the doctor wants to put a "scope" in and inject dye into his ducts. He wants to know more about this. What procedure is he referring to? 1. Percutaneous transhepatic cholangiography (PTC). 2. Endoscopic retrograde cholangiopancreatography (ERCP). 3. Angiography. 4. Upper gastrointestinal (GI) series.2. Endoscopic retrograde cholangiopancreatography (ERCP). Option 2: An ERCP uses an endoscope, which is inserted via the mouth and passed through the stomach and into the small intestine, where dye is injected into the pancreatic ducts and x-rays are taken to determine if any obstruction is apparent. All of the procedures listed in this question are used to produce pictures of the pancreas and nearby organs to assist in the diagnosis of pancreatic cancer.Question 181. Sara comes today with numerous petechiae on her arms. You know she is not taking warfarin (Coumadin). What other drugs do you ask her about? 1. Aspirin or aspirin compounds. 2. Antihypertensive agents. 3. Oral contraceptives. 4. Anticonvulsants.1. Aspirin or aspirin compounds. Option 1: If your client has numerous petechiae, ask about the use of aspirin or aspirin compounds. Aspirin is a very effective antiplatelet agent. The recommended dosage for clients with chronic stable angina and certain other conditions is 325 mg (1 tablet) per day. Many clients assume if 1 tablet a day is good, 2 tablets a day is better. Depending on the individual clotting time, even 325 mg per day may result in bleeding into the tissues.Question 182. A 28-year-old female presents to your primary care office for an annual physical. She denies any complaints other than heavy menstrual bleeding, which is something she has experienced her whole life. On routine complete blood count (CBC) evaluation, her hemoglobin is 11.0. Other pertinent values include a decreased serum ferritin and elevated total iron-binding capacity (TIBC). Her mean corpuscular volume (MCV) is 75. Which of the following is the likely cause of her anemia? 1. Iron deficiency anemia. 2. Thalassemia. 3. Sideroblastic anemia. 4. Anemia of chronic disease (ACD).1. Iron deficiency anemia. Option 1: This patient's lab values point toward microcytic anemia. With low iron stores and high ability to bind iron, iron deficiency anemia is the best choice.Question 183. Which of the following diagnostic tests confirms the diagnosis of sideroblastic anemia? 1. Prussian blue stain. 2. Complete blood count (CBC). 3. Red blood cell electrophoresis. 4. Erythrocyte sedimentation rate (ESR).1. Prussian blue stain. Option 1: The Prussian blue stain is the diagnostic test used to identify sideroblastic anemia. Ringed sideroblasts would be seen in this stain.Question 184. Which of the following is the most common cause of megaloblastic anemia? 1. Vitamin B12 deficiency. 2. Pernicious anemia. 3. Iatrogenesis. 4. Folate deficiency.2. Pernicious anemia. Option 2: Pernicious anemia is the most common cause of megaloblastic anemia, as it causes vitamin B12 deficiency.Question 185. Which of the following describes the pattern of inheritance that results in sickle cell anemia? 1. Autosomal recessive. 2. Autosomal dominant. 3. X-linked dominant. 4. X-linked recessive.1. Autosomal recessive. Option 1: Sickle cell anemia is an autosomal recessive disorder, which means both parents must have the gene to pass it on to the child.Question 186. A 15-year-old male presents to your office complaining of fatigue, shortness of breath, and joint pain for 2 weeks. The parent has blamed these symptoms on a "growth spurt." On physical exam, you notice multiple areas of bruising. His throat is not erythematous, and no exudates are seen. He has palpable splenomegaly, and his rapid strep and mono tests are negative. Which of the following is the most likely diagnosis? 1. Acute lymphocytic leukemia (ALL). 2. Chronic myelogenous leukemia (CML). 3. Acute myelogenous leukemia (AML). 4. Chronic lymphocytic leukemia (CLL).1. Acute lymphocytic leukemia (ALL). Option 1: ALL is the most common form of pediatric leukemia.Question 187. Which of the following is the most common type of leukemia in the United States? 1. Acute lymphocytic leukemia. 2. Chronic myelogenous leukemia. 3. Acute myelogenous leukemia. 4. Chronic lymphocytic leukemia (CLL).4. Chronic lymphocytic leukemia (CLL). Option 4: CLL is the most common type of leukemia in the United States.Question 188. Which of the following tests is the most specific for diagnosing rheumatoid arthritis? 1. Anticyclic citrullinated peptide (anti-CCP). 2. Rheumatoid factor. 3. C-reactive protein. 4. Anti-Smith antibodies.1. Anticyclic citrullinated peptide (anti-CCP). Option 1: Anti-CCP is the most specific test for diagnosing rheumatoid arthritis.Question 189. A male patient presents to the emergency department complaining of severe knee pain. He admits to social alcohol use and a diet consisting of meat and fish. He states he has had no trauma to his knee but the pain has been getting worse for 4 days. He notes warmth and erythema of the knee as well as decreased range of motion. The patient's x-ray is negative. You aspirate the patient's knee, and the fluid that is aspirated is cloudy and thick. What would you see in the joint aspirate to make a diagnosis of gout? 1. A white blood cell count of 90 000. 2. Negatively birefringent, needle-shaped crystals. 3. Positively birefringent, needle-shaped crystals. 4. Positive Lyme serology.2. Negatively birefringent, needle-shaped crystals. Option 2: This presentation is consistent with a diagnosis of gout.Question 190. A 30-year-old male nurse presents to the emergency department. He was stuck with a needle yesterday while working and found out today that the patient involved in the needle stick is human immunodeficiency virus (HIV) positive. What is the time window for starting postexposure prophylaxis to help prevent the transmission of HIV? 1. This nurse is already past the window for starting postexposure prophylaxis. 2. 24 hours. 3. 48 hours. 4. 72 hours.4. 72 hours. Option 4: Postexposure prophylaxis needs to be started within 72 hours of exposure to HIV in order to be effective in reducing the risk of HIV transmission.Question 191. Which of the following is not considered an AIDS-defining condition? 1. A CD4 count of 150. 2. A human immunodeficiency virus (HIV) positive patient with candidiasis of the throat. 3. A human immunodeficiency virus (HIV) positive patient with Kaposi sarcoma. 4. A human immunodeficiency virus (HIV) positive patient with 1 episode of bacterial pneumonia and a CD4 count greater than 500.4. A human immunodeficiency virus (HIV) positive patient with 1 episode of bacterial pneumonia and a CD4 count greater than 500. Option 4: For bacterial pneumonia to be considered an AIDS-defining condition in someone with a CD4 count greater than 500, the patient would have to have 2 episodes in 1 year.Question 192. 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.3. A slipped capital femoral epiphysis (SCFE). 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.Question 193. 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.1. Supination. Option 1: Turning the forearm so that the palm is up is called supination.Question 194. 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.2. Gout. 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.Question 195. 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.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.Question 196. 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.1. Musculoskeletal pain. Option 1: 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.Question 197. 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.2. Dorsal kyphosis. Option 2: Dorsal kyphosis, an exaggerated convexity of the thoracic curvature, typically accompanies the aging process.Question 198. 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.3. Lachman test. Option 3: The Lachman test assesses the ACL.Question 199. 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.1. Develops when loss of bone occurs more rapidly than new bone growth. Option 1: Osteoporosis develops when bone resorption occurs more rapidly than bone deposition.Question 200. 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.2. Begin a planned exercise program to strengthen back muscles. 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.Question 201. 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.4. Adequate to perform only a few or none of the duties of usual occupation or self-care. Option 4: 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.Question 202. 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).2. Doxorubicin (Adriamycin). Option 2: 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.Question 203. 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.2. Muscle strain. Option 2: 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.Question 204. 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.2. Cervical radiculopathy. Option 2: Cervical nerve root compression of C6 and C7 causes cervical radiculopathy.Question 205. 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."4. "If you have additional pain, an occasional acetaminophen (Tylenol) is permitted in between the usual doses of the NSAID." Option 4: 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.Question 206. 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.2. Cruciate ligament. Option 2: 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.Question 207. 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 nonsteroidal anti-inflammatory drugs (NSAIDs), and oral NSAIDs. Option 4: Topical capsaicin, topical NSAIDs, oral NSAIDs, and tramadol are recommended by the ACR for the treatment of OA of the hand.Question 208. 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.2. Scaphoid 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.Question 209. 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.2. The collagen fibers that connect muscle to bone. Option 2: Tendons are the collagen fibers that connect muscle to bone.Question 210. 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.3. Hematuria. 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.Question 211. 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."1. "Bend your knees and face the object straight on." 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.Question 212. 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.1. A normal foot. 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.Question 213. 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.2. Assessing for an adequate airway. 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.Question 214. 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.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.Question 215. 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.2. Right thoracic curvature. 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.Question 216. 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.3. Beginning lower back strengthening exercises depending on pain tolerance. 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.Question 217. 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.2. Affected joints are swollen, cool, and bony hard on palpation. 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.Question 218. 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.2. Change the position of Joyce's arm every hour. 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.Question 219. 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.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.Question 220. 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.2. Advancing the cane with the ipsilateral leg. Option 2: When teaching clients about using a cane, tell them to advance the cane with the ipsilateral (affected) leg.Question 221. 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.2. Musculoskeletal strain. 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.Question 222. 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.2. Nonsteroidal anti-inflammatory drugs (NSAIDs). Option 2: NSAIDs are the first-line treatment for musculoskeletal signs and symptoms with joint involvement.Question 223. 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.1. To palpate for tenderness, swelling, and crepitus just distal to the lateral epicondyle. 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.Question 224. 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.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.Question 224. 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.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.Question 225. 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.3. Sjögren syndrome. 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).Question 226. 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 pulses3. Establishing an airway. 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.Question 227. 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.3. Point or focal tenderness. 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.Question 228. 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.2. Hyponatremia. 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.Question 229. 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.3. Bulge 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.Question 230. 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).1. Synovial fluid analysis and x-ray. 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.Question 231. 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.2. Salter-Harris III 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.Question 232. 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.3. Bisphosphonates. 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.Question 233. 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(Osgood-Schlatter disease is a common cause of knee pain in growing adolescents. It is an inflammation of the area just below the knee where the tendon from the kneecap (patellar tendon) attaches to the shinbone (tibia).) 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.1. Relative rest; he could benefit from hamstring, heel cord, and quadriceps stretching exercises. 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.Question 234. 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.3. Temporomandibular joint syndrome 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.Question 235. 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).3. Try neutral position wrist splinting and order an oral nonsteroidal anti-inflammatory drug (NSAID). 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.Question 236. 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. 2.2. 4 Option 2: Complete ROM against gravity with some resistance is given a numerical grade of 4 and described as good muscle strength.Question 237. 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."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." 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.Question 238. 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.3. Dupuytren contracture. 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.Question 239. 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.2. A magnetic resonance imaging (MRI) scan. 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.Question 240. 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.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.Question 241. 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.1. Inability to shrug the shoulder. 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.Question 242. 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.3. Vitamin D increases intestinal absorption of dietary calcium and mobilizes calcium from the bone. 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 243. 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.3. Begin a course of glucocorticoids. 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.Question 244. 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.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.Question 245. 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.2. Hyperuricemia. Option 2: To diagnose gout, there should be hyperuricemia and a negative joint culture.Question 246. Which of the following patients would not be a candidate for outpatient treatment of influenza? 1. A 62-year-old male with a history of myocardial infarction 5 years ago. 2. A 2-year-old female with a history of a congenital heart defect. 3. A 72-year-old male without a past medical history. 4. A 15-year-old female with a history of recent outpatient knee surgery.2. A 2-year-old female with a history of a congenital heart defect. Option 2: Patients less than 5 and older than 65, as well as immunocompromised patients, are at great risk of complications from influenza and would be best treated in an inpatient environment.Question 247. What lifestyle choice increases the risk of upper respiratory infection? 1. Smoking. 2. Alcohol use. 3. Cocaine use. 4. Multiple sexual partners.1. Smoking. Option 1: Smoking increases the risk of upper respiratory infection.Question 248. A 65-year-old female presents to your urgent care center complaining of a cough. She has a past medical history of myocardial infarction, hypertension, hyperlipidemia, and diabetes. She states she had this cough last year and received a Z-Pak, and it made her feel better, so she is requesting one now. Her vital signs are as follows: pulse (P) 85, blood pressure (BP) 140/90, oxygen saturation 95% on room air, temperature 99.0°F. Upon further questioning, her cough has been going on for 3 weeks and is nonproductive. She also notes some shortness of breath, mostly with periods of ambulation. She denies chest pain. She notes that recently her feet and legs have become more swollen. You do not have access to an x-ray at your facility. What is the most concerning cause of the patient's cough that would be in your differential diagnosis? 1. Congestive heart failure. 2. Pneumonia. 3. Bronchitis. 4. Deep vein thrombosis.1. Congestive heart failure. Option 1: The patient has dyspnea on exertion, nonproductive cough, and no fever. This is likely not an infectious cough. She also has lower extremity edema.Question 249. A 70-year-old man presents to your urgent care clinic complaining of a cough. He states he has had the cough for 6 weeks. The cough is dry and nonproductive. He denies fevers, chills, and weight loss. The patient admits to a 50-year history of smoking 1 pack per day. His pulse oximetry is 93% on room air. His chest x-ray shows enlarged lung fields. What would you recommend as the next step in his care? 1. That he see his primary doctor to discuss a computed tomography (CT) scan of the chest. 2. Oxygen through a nasal cannula until the cough stops. 3. An albuterol inhaler. 4. A course of oral steroids.1. That he see his primary doctor to discuss a computed tomography (CT) scan of the chest. Option 1: The patient has a greater than 40-pack-year history of smoking; his chronic cough is concerning for lung cancer. A CT scan should be recommended.Question 250. A 5-year-old male presents to your urgent care clinic with his mother. The patient was sent home from school for eye redness. He has bilateral erythema of his conjunctivae and watery drainage. He complains of pruritus of both eyes. The patient also has clear drainage from his nose and a sore throat. On physical exam of his throat, you notice erythema of his tonsils but no exudates. What is the most likely cause of the patient's symptoms? 1. Adenovirus. 2. Rhinovirus. 3. Streptococcus pneumoniae. 4. Moraxella catarrhalis.1. Adenovirus. Option 1: This is the most common cause of viral conjunctivitis.Question 251. Which of the following is not a risk factor for the development of sinusitis? 1. Asthma. 2. Smoking. 3. Deviated septum. 4. History of tonsillectomy.4. History of tonsillectomy. Option 4: Having a history of a tonsillectomy does not increase the risk of sinusitis.Question 252. A 15-year-old female presents to your urgent care center complaining of a sore throat for 3 days. Her vital signs are as follows: temperature 102.1°F, pulse (P) 70, blood pressure (BP) 130/85, oxygen saturation 97%. The patient denies cough. On physical exam, she has pearly white exudates on the tonsils, erythema of the throat, and palpable anterior cervical chain lymphadenopathy. What is the recommended treatment? 1. Starting the patient on antibiotics. 2. Starting the patient on prednisone. 3. Awaiting culture results prior to treatment. 4. Recommending supportive treatment.1. Starting the patient on antibiotics. Option 1: The patient has signs and symptoms of streptococcal (strep) pharyngitis. This requires antibiotic treatment. If you have access to one, a rapid strep test can be done in the office.Question 253. A 10-year-old female presents to your urgent care center with her mother complaining of ear pain. The patient spends most of her summer at the local swim club. She notes right ear pain. She has no fever. She awoke today with green drainage on her pillow. On physical exam, the patient has pain with palpation of the affected ear, and you cannot visualize the tympanic membrane. What is the most likely diagnosis? 1. Otitis externa. 2. Otitis media. 3. Ruptured tympanic membrane. 4. Acute mastoiditis.1. Otitis externa. Option 1: This is the classic presentation of otitis externa.Question 254. A 70-year-old female presents to your emergency department complaining of right hip pain. She cannot ambulate. She had a fall in the bathroom of her house and had to be picked up by the emergency medical technicians (EMTs) her husband called. She complains of groin pain. What would you expect to see on physical exam? 1. Normal leg length on both sides. 2. A shortened and externally rotated right leg. 3. A shortened and internally rotated right leg. 4. A shortened and externally rotated left leg.2. A shortened and externally rotated right leg. Option 2: This is the typical presentation of a right hip fracture.Question 255. An 18-year-old high school cross country runner presents to your office complaining of foot pain for 2 weeks. The patient runs 3 to 6 miles per day. He states it feels better when he runs on the track as opposed to the road. On physical exam, he is tender to palpation over his fifth metatarsal head, but there is no ecchymosis, erythema, or edema of the foot. X-ray of his foot is negative for fracture. What is the best diagnostic study to order for further evaluation of his complaint? 1. Bone scan. 2. Computed tomography (CT) scan. 3. Magnetic resonance imaging (MRI). 4. X-ray in 1 week.1. Bone scan. Option 1: A bone scan is the most sensitive test for diagnosing a stress fracture.Question 256. A 20-year-old male presents to your urgent care center complaining of headaches for 2 weeks. The patient's headaches are intermittent but severe and last 15 to 30 minutes. He has had 3 to 4 severe headaches in the last 2 weeks. He denies a past medical history and has had no recent trauma. The patient's physical exam shows right-sided rhinorrhea, conjunctivitis, and facial swelling. What is the likely cause of the patient's symptoms? 1. Brain tumor. 2. Cluster headaches. 3. Migraine headaches. 4. Sinus infection2. Cluster headaches. Option 2: The patient's symptoms are consistent with cluster headaches.Question 257. Which of the following is not associated with panic disorder? 1. Family history of mental health issues. 2. Female sex. 3. Smoking. 4. History of molestation as a child.3. Smoking. Option 3: Smoking does not increase the risk of panic disorder.Question 258. A patient presents to your primary care clinic with diarrhea. What about the diarrhea would be concerning for a parasitic infection? 1. It presented 8 hours after eating rare fish. 2. It has lasted longer than 7 days. 3. The patient describes it as "rice water." 4. It is bloody.2. It has lasted longer than 7 days. Option 2: Diarrhea that lasts longer than 7 days is concerning for a parasitic infection.Question 259. A 50-year-old female diabetic patient presents to your urgent care center complaining of chest discomfort. Which of the following symptoms would lead you to believe her chest pain is related to gastroesophageal reflux rather than a cardiac etiology? 1. Chest pain radiates to the jaw and left arm. 2. Chest pain is worse with walking. 3. Chest pain started while eating spicy food. 4. Chest pain is associated with nausea.3. Chest pain started while eating spicy food. Option 3: Angina is typically not associated with eating.Question 260. The ABCDEs of skin cancer can help you diagnose a cancerous skin lesion. Which of the following definitions does not accurately describe the corresponding letter of the acronym? 1. A = asymmetry. 2. B = boarder irregularity. 3. C = color. 4. D = diameter greater than 8 mm.4. D = diameter greater than 8 mm. Option 4: A diameter greater than 6 mm would be concerning for cancer.Question 261. A patient presents to your primary care office for a blood pressure check. You have recently started them on an antihypertensive medication. However, on physical exam, the patient continues to have an elevated blood pressure. Which of the following symptoms would not be concerning for a hypertensive crisis? 1. Chest pain. 2. Visual changes. 3. Tinnitus. 4. Severe headache.3. Tinnitus. Option 3: Tinnitus is nonspecific for end organ damage associated with a hypertensive crisis.Question 262. What is the most common cause of a urinary tract infection? 1. Escherichia coli. 2. Enterococcus faecalis. 3. Klebsiella pneumoniae. 4. Proteus mirabilis.1. Escherichia coli. Option 1: This is the most common cause of a urinary tract infection.Question 263. Which of the following headache descriptions does not match the accompanying diagnosis? 1. Worst headache of your life = subarachnoid hemorrhage. 2. Headache associated with aura = migraine headache. 3. Unilateral temporal headache with associated pulsatile sensation = tension headache. 4. Headache associated with loss of consciousness = intracranial pressure change.3. Unilateral temporal headache with associated pulsatile sensation = tension headache. Option 3: Typically, unilateral pulsatile headaches of the temporal area are associated with temporal arteritis. Tension headaches are bilateral.Question 264. In which of the following scenarios is antibiotic treatment necessary following an injury to the skin? 1. Laceration requiring sutures from a knife cut while cutting an avocado. 2. Laceration requiring sutures on the foot of a diabetic. 3. Laceration requiring sutures on the hand of someone who has not had a tetanus booster in the last 5 years. 4. "Road rash" abrasion from a bicycle accident.2. Laceration requiring sutures on the foot of a diabetic. Option 2: The foot in general gets poor blood supply and has a high risk of poor wound healing. Being a diabetic also increases the risk of poor wound healing. Antibiotics should be given in this scenario.Question 265. A 20-year-old female presents to your urgent care clinic complaining of a cat bite. The patient recently adopted a cat. She was playing with the cat yesterday when the cat bit her on the arm. What antibiotic should be prescribed to prevent infection? 1. Augmentin. 2. Amoxicillin. 3. Bactrim. 4. No antibiotic is necessary.1. Augmentin. Option 1: Cat bites have a high risk of infection. Augmentin should be prescribed to reduce the risk of Pasteurella infection.Question 266. A patient presents to your urgent care office complaining of lightheadedness, dizziness, and problems concentrating following a motor vehicle accident 7 days ago. Originally, these complaints were more severe, but they have slowly decreased in intensity. What is the patient's diagnosis? 1. Concussion. 2. Postconcussion syndrome. 3. Cerebral hemorrhage. 4. Malingering.2. Postconcussion syndrome. Option 2: The patient is experiencing postconcussion syndrome. If they have not received one since the car accident, you should refer them to their primary doctor or neurologist to get a computed tomography (CT) scan of the head.Question 267. A patient presents to your urgent care center for evaluation following a motor vehicle accident. On physical exam, the patient seems lethargic and has thin, clear nasal drainage. You also note bruising around the eyes and mastoid process. What injury did the patient sustain in the car accident? 1. Basilar skull fracture. 2. Epidural hematoma. 3. Subdural hematoma. 4. Concussion.1. Basilar skull fracture. Option 1: The drainage from the patient's nose is cerebrospinal fluid. The bruising around the eyes and mastoid process is associated with basilar skull fracture, an emergency condition.Question 268. When a patient is diagnosed with an epidermal hematoma, which artery is ruptured in the brain? 1. Middle meningeal artery. 2. Temporal artery. 3. Basilar artery. 4. Vertebral artery.1. Middle meningeal artery. Option 1: The middle meningeal artery is ruptured, causing an epidural hematoma.Question 269. Which of the following patients needs a computed tomography (CT) scan of the head following a minor head trauma? 1. A patient taking Coumadin. 2. A child under the age of 5. 3. A patient complaining of a headache. 4. A patient with nausea following a head injury.1. A patient taking Coumadin. Option 1: Aspirin therapy alone does not necessitate a CT scan, but use of Plavix or Coumadin does.Question 270. A 25-year-old construction worker comes into the emergency department after a third-story fall at his construction site. The patient's main complaint is bilateral heel pain. The patient's x-rays confirm bilateral calcaneal fractures. Based on the patient's mechanism of injury, what other part of the body should you x-ray? 1. Lumbar spine. 2. Bilateral shoulders. 3. Ribs. 4. Bilateral wrists.1. Lumbar spine. Option 1: Following a fall and calcaneal fracture, you need to be concerned about possible fracture of the lumbar spine and hips. The force from the fall can move through the body and cause other fractures. The patient may not complain of pain in these areas due to being distracted by the pain in both heels.Question 271. Following a sprain/strain injury, the PRICE acronym is helpful in treating a patient's symptoms. Which of the following does not correspond to the PRICE acronym? 1. Rest. 2. Ice. 3. Crutches. 4. Elevation.3. Crutches. Option 3: While the use of crutches can help with a lower extremity injury, the C in this acronym stands for compression.Question 272. According to the Glasgow Coma Scale (GCS), what is the number assigned to someone with a normal level of consciousness? 1. 15. 2. 12. 3. 18. 4. 20.1. 15. Option 1: A normal GCS score is 15. Less than 7 is considered a comaQuestion 273. Ingestion of which of the following objects always requires surgical or endoscopic removal? 1. Button batteries. 2. Coins. 3. Sharp objects. 4. Food bolus.1. Button batteries. Option 1: Batteries must be removed; if the acid in the battery is exposed to the stomach mucosa, it can perforate it.Question 274. If a patient has palsy of cranial nerve (CN) XI, what would they not be able to do? 1. Move the tongue. 2. Smell. 3. Move the neck. 4. Shrug the shoulders.4. Shrug the shoulders. Option 4: CN XI is the motor nerve that shrugs the shoulders.Question 275. You are examining a patient in the emergency department following a closed head injury and you notice their pupils do not constrict when bright light is shone into them. To what cranial nerve would this suggest damage? 1. Cranial nerve (CN) III. 2. Cranial nerve (CN) II. 3. Cranial nerve (CN) IV. 4. Cranial nerve (CN) VI.1. Cranial nerve (CN) III. Option 1: CN III controls pupillary response as well as upward and medial movement.Question 276. A patient presents to the emergency department. You are concerned they have taken too many aspirin. What would you expect to see on an arterial blood gas? 1. Metabolic acidosis. 2. Metabolic alkalosis. 3. A normal blood gas. 4. Respiratory acidosis.1. Metabolic acidosis. Option 1: Aspirin is a salicylate, or salicylic acid; you would see metabolic acidosis.Question 277. What bacterium causes Rocky Mountain spotted fever? 1. Rickettsia rickettsii. 2. Borrelia burgdorferi. 3. Orientia tsutsugamushi. 4. Centruroides exilicauda.1. Rickettsia rickettsii. Option 1: This is the bacterium that causes Rocky Mountain spotted fever; it is transmitted by dog ticks.Question 278. A patient presents to the emergency department by ambulance directly from football practice. The patient is tachycardic, tachypneic, and hypotensive. Their skin is hot and dry, and their core body temperature is 104°F. What is this patient's diagnosis? 1. Heat stroke. 2. Heat exhaustion. 3. Heat syncope. 4. Heat cramps.1. Heat stroke. Option 1: This patient has a core body temperature of 104°F; this is the diagnostic criterion that differentiates heat stroke from heat exhaustion.Question 279. Following a diagnosis of heat stroke, the goal is to decrease the patient's temperature to what number in the first hour? 1. 103°F. 2. 102°F. 3. 100°F. 4. 99°F.2. 102°F. Option 2: The goal is to reduce the patient's temperature to 102°F within the first hour of care.Question 280. Hypothermia is defined as a core body temperature less than? 1. 96°F. 2. 95°F. 3. 93°F. 4. 90°F.2. 95°F. Option 2: Hypothermia is defined as a core body temperature less than 95°F.Question 281. As a general rule, when treating hypothermia, at what rate do you want to warm the patient's temperature? 1. 1-2°C an hour. 2. 0-1°C an hour. 3. 0.5°C an hour. 4. 2-3°C an hour.1. 1-2°C an hour. Option 1: Generally, you want to warm a hypothermic patient's body temperature 1-2°C an hour.Question 282. The remodeling of a scar can take how long? 1. 6 months. 2. 3 months. 3. 1 month. 4. 2 weeks.1. 6 months Option 1: The remodeling of a scar can take up to 6 months, and many surgeons wait 6 months prior to revising a scar due to pain or deformity.Question 283. How soon after a facial laceration should sutures be removed? 1. 4 to 6 days. 2. 3 to 4 days. 3. 7 to 10 days. 4. 10 to 14 days.1. 4 to 6 days. Option 1: Generally, you want to remove facial laceration sutures 4 to 6 days after the injury to avoid excessive scarring.Question 284. Which joint of the hand is most susceptible to a "fight bite"? 1. Metacarpophalangeal (MCP) joint. 2. Distal interphalangeal (DIP) joint. 3. Proximal interphalangeal (PIP) joint. 4. Interphalangeal (IP) joint.1. Metacarpophalangeal (MCP) joint. Option 1: Most fight bites are the result of the other person's teeth lacerating the metacarpophalangeal (MCP) joint during a punch to the mouth.Question 285. A patient on which of the following medications is at risk of sun poisoning? 1. Doxycycline. 2. Lexapro. 3. Labetalol. 4. Percocet.1. Doxycycline. Option 1: Many other antibiotics, including amoxicillin and Bactrim, can also cause sun sensitivity.Question 286. A patient arrives via ambulance with a friend. The patient is not responsive. The friend states the patient was walking across an intersection when a car struck him. The patient was unresponsive for a moment and then got up from the ground and began talking to his friend. He then started to become more confused and eventually became unresponsive. What type of brain injury does the patient have? 1. Epidural hematoma. 2. Subdural hematoma. 3. Concussion. 4. Skull fracture.1. Epidural hematoma. Option 1: This patient had a loss of consciousness associated with a lucid moment after a traumatic injury; this history is likely indicative of an epidural hematoma.Question 287. You are examining a patient in the intensive care unit (ICU) after a motor vehicle accident. The patient is intubated but responds to painful stimuli. What score would you give them on the motor portion of the Glasgow Coma Scale (GCS)? 1. 5. 2. 4. 3. 3. 4. 2.2. 4. Option 2: The patient responds to painful stimuli; therefore, the score on the motor portion of the GCS is 4.Question 288. You are examining a patient in the intensive care unit (ICU) after a motor vehicle accident. The patient is intubated but opens his eyes in response to verbal commands. What score would you give him on the eye-opening portion of the Glasgow Coma Scale? 1. 4. 2. 3. 3. 2. 4. 1.2. 3. Option 2: A score of 3 is for patients that open their eyes to verbal commands.