NURS 6550N-2 / NURS-6550 Midterm Exam Adv Prac Care in Acute Week 6 - Exam

 

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NURS-6550N-2/NURS-6550F-2-Adv Prac Care in Acute Set I2016 Winter

 Question 1

1 out of 1 points

The AGACNP is caring for a patient who is quite ill and has developed, among other things, a large right sided

pleural effusion. Thoracentesis is sent for pleural fluid analysis. While evaluating the fluid analysis, the

AGACNP knows that a fluid identified as a(n) __________ is the least worrisome type.

Response

Feedback:

“A” is the correct answer. A transudate is essentially just water and can occur as a

consequence of increased hydrostatic pressure in the pulmonary vessels. It typically implies

that the some condition has produced an imbalance in colloid-hydrostatic pressures, such as

CHF or hypoalbuminemia. While it can represent a serious problem, it may also represent a

transient imbalance. Conversely, “B” is not correct as an exudate has more protein in it and

implies a condition characterized by protein leaking from vessels, such as a malignancy or

some serious systemic stressor. “C” is not correct—a chyliform effusion is characterized by

fat and indicates a pathology causing massive triglyceride degradation. “D” is not correct as a

hemorrhagic effusion is blood and typically means traumatic injury.

 Question 2

0 out of 1 points

Mrs. Miller is transported to the emergency department by paramedics. She is having profound, unremitting

chest pain, is diaphoretic and pale. She has jugular venous distention and a widened pulse pressure. Suspecting

ascending aortic aneurysm, the AGACNP order which test to confirm the diagnosis?

Response

Feedback:

“D” is the correct answer. It is the most widely used diagnostic tool as it rapidly and precisely

can outline the thoracic and abdominal aorta. “A” is not the correct answer—there are

radiographic findings that suggest thoracic aneurysm, but they need confirmation by CT. “B”

is not the correct answer as ultrasound is not nearly as precise as a CT scan. “C” is not

correct—MRI is only indicated when the patient cannot have a contrast CT.

 Question 3

1 out of 1 pointsCertain subgroups of the elderly population are at an increased risk for rapid deterioration and long-term care

placement. Which of the following is not considered a high risk factor for long term care placement?

Response

Feedback:

“A” is the correct answer; men are at higher risk for long-term care placement than women.

In addition to male gender, other risk factors include age over 80, living alone, bowel or

bladder incontinence, history of falls, dysfunctional coping, and intellectual impairment.

 Question 4

0 out of 1 points

A patient with anterior epistaxis has been treated with 20 minutes of direct pressure to the cartilaginous portion

of the nose. Following pressure the patient is instructed to gently blow the nose. Expected findings in the

patient who has been successfully treated include all of the following except a:

Response

Feedback:

“C” is the correct answer. If bleeding is successfully stopped with 20 minutes of directed

pressure, there will be residual blood and clot formation. This is evacuated either by gentle

suction or having the patient gently blow. Residual blood and formed clot may present as a

sudden gush of dark blood or discharge with or without a clot—these are all typical expected

findings. However, if bleeding is not stopped, it will continue as a bright red steady trickle.

When this occurs, more invasive measures are indicated.

 Question 5

0 out of 1 points

Kevin is a 14-year-old male who presents for evaluation of a fever of 102.5° F and significant right ear pain.

He appears quite ill and says he feels nauseous. Otoscopic evaluation reveals pain to palpation, a very

erythematous and bulging tympanic membrane with bullous myringitis. The AGACNP knows that antibiotic

therapy must be selected to cover:

Response

Feedback:

“D” is the correct answer. Streptococcus pneumoniae is the most common bacteria that infects

the head and neck in immunocompetent persons, and is the primary treatment target when

treating otitis media, bacterial sinusitis, and bacterial pharyngitis. “A” is not correct—while

likely on broken skin and soft tissue, it is not common in the ear, nose, or throat unless

specific risk factors exist. “B” is not correct—this is much more likely in an

immunocompromised patient or a patient on mechanical ventilation. “C” is not correct—it is

the second most common organism, but strep is the primary treatment target.

 Question 6

1 out of 1 points

P.M. is a 71-year-old gay male patient who presents as an outpatient for evaluation of increasing shortness of

breath. The diagnostic evaluation ultimately supports a diagnosis of community acquired pneumonia. The

AGACNP appreciates right middle lobe consolidation on chest radiography. Pending sputum cultures, empiric

antibiotic therapy must be initiated to cover which organism?Response

Feedback:

“D” is the correct answer. This patient presents from the outpatient population where the most

common cause of pneumonia is Streptococcus pneumoniae, and is the primary treatment target

for any patient being treated empirically. “A” is not correct—while the patient’s sexual

orientation is offered in the provided history, there is no indication that he has HIV/AIDS or

any other condition characterized by immunosuppression that would increase his risk for this

organism. “B” is not correct, as this organism is not typically seen in the outpatient population

without specific risk, e.g. immunosuppression or chronic ventilator therapy. “C” is not the

correct answer as this organism is not likely absent specific risk such as instrumentation or

known colonization.

 Question 7

0 out of 1 points

Which of the following is the greatest risk factor for vascular dementia?

Response

Feedback:

“B” is the correct answer. Vascular dementia is a consequence of vascular disease, and is

more likely to occur in patients with risk factors for target organ damage, such as

hypertension, dyslipidemia, and diabetes. “A” is not a distinct risk factor for vascular

dementia; it is a risk for Alzheimer’s dementia. “C” likewise increases risk for Parkinson’s

dementia, but does not present a risk for vascular dementia. “D” is not a risk factor for

vascular dementia. Although there may be some familial risk for certain vascular diseases that

may lead to vascular dementia, there is no clear familial tendency for this type of dementia.

 Question 8

1 out of 1 points

J.R. is a 55-year-old male who presents for a commercial driver’s license physical examination with a blood

pressure of 170/102 mm Hg. He has no medical history and is without complaint. Which of the following

findings constitutes hypertensive urgency?

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Response

Feedback:

“A” is the correct answer. According to the Joint National Committee (JNC) report,

hypertensive urgency is described as hypertension in the setting of progressive target organ

damage, such as renal involvement with protein leaking, left ventricular hypertrophy, or

retinal changes. “A” is not correct—the headache may or may not be relevant, but because

there are many non-hypertension causes, a headache alone does not constitute target organ

damage. “C” is not correct—it may indicate carotid plaque, but this is not a consequence of

hypertension. “D” is not correct as a 1+ palpable pulse may be a normal finding--it must be

taken in the context of the rest of the examination.

 Question 9

0 out of 1 points

Because of the commonly recognized adverse effects of atypical antipsychotics, annual laboratory assessment

for patients taking these medications should include a:Response

Feedback:

“C” is the correct answer. The atypical antipsychotics such as olanzapine (Zyprexa), clozapine

(Clozaril), and quetiapine (Seroquel) are classically associated with dyslipidemia and annual

lipid panels should be performed in patients of all ages who take these medications. “A” is

incorrect—this is the appropriate annual screening tool for patients on lithium due to lithiumrelated iodine suppression of the thyroid gland. There are no specific indications for “B” and

“D” unique to patients taking atypical antipsychotics. Those laboratory assessments should

only be ordered as indicated by any other significant patient history.

 Question 10

1 out of 1 points

K.R. presents for an evaluation of eye discomfort. He works in a fabricating shop for a custom automobile

restoration company and while working he felt like something flew into his eye. He was wearing eye protection

at the time but still has the sensation that something is there. Physical examination is significant for some

tearing and he reports a persistent sense of something in his eye. Which of the following is not indicated in the

diagnostic evaluation?

Response

Feedback:

“B” is the correct answer. The patient’s history is consistent with a metal injury and so an

MRI should be avoided. “A” may or not be indicated as the history progresses, but there is no

contraindication to it should the examiner determine the need to rule out an abrasion. “C” and

“D” are both mechanisms to visualize behind the cornea which may be necessary if a

penetration injury (which may occur with a high-velocity injury) is suspected.

 Question 11

0 out of 1 points

D.E. is a 41-year-old female who had lumbar surgery two days ago to repair a ruptured nucleus pulposus. She

has been doing well postoperatively but today is complaining of resting fatigue and some shortness of breath at

rest. In ruling out a pulmonary embolus the AGACNP first orders a:

Response

Feedback:

“B” is the correct answer. The D-dimer is a highly sensitive serology and is the least invasive

mechanism by which a pulmonary embolus may be ruled out; a negative D-dimer virtually

eliminates pulmonary embolus from the differential diagnosis. “A” is not correct—while it

can be used to make the diagnosis it is more invasive and less specific than other options. “D”

is not correct—there is no indication that the patient is on warfarin, and in any event it would

not be used to rule in or out pulmonary embolus “C” is not accurate when after surgery, as it

will be positive after surgery.

 Question 12

0 out of 1 points

Mr. Nixon is being treated with unfractionated heparin infusion for acute pulmonary embolus. In order to avoid

a potentially fatal complication of heparin infusion, the AGACNP monitors:Response

Feedback:

“D” is the correct answer. An uncommon but potentially serious consequence of heparin

infusion is heparin-induced thrombocytopenia. Some patients make autoantibodies in response

to exogenous heparin that activate their own platelets. When this occurs, heparin must be

immediately discontinued and thrombin inhibitors started. “A” is not correct—this is not

affected by heparin, but is monitored in those on Coumadin. “B” is not correct—this is also

unaffected by heparin, but monitored on Coumadin. “C” is not correct—this is monitored to

assess therapeutic efficacy, but not for complications.

 Question 13

1 out of 1 points

Differentiating vertigo from near-syncope and ataxia is one of the goals of history-taking when a patient

presents as “dizzy.” The AGACP knows that vertigo is the problem when the patient reports the primary

symptom as:

Response

Feedback:

“A” is the correct answer. Dizzy is a layperson’s term and can mean many different things to

patients and health care providers. When the patient identifies the primary symptom as a sense

of spinning this supports vertigo, which is usually an inner ear problem. This versus ataxia

which is neurologic or near-syncope which may be cardiac, neurological, or neurocardiogenic.

“B” is not correct—this may occur with vertigo, but when it is the primary symptom it is most

likely ataxia and neurological causes should be considered. “C” is not correct as coincident

nausea is not specific and can occur with any of these complaints. “D” is not correct as it is

also not specific; while ataxia cannot occur when supine near-syncope can.

 Question 14

1 out of 1 points

Mr. Banks has been admitted for surgical resection of a metastatic tumor, during surgery it is discovered that

he has widespread, diffuse metastasis throughout the abdomen. Surgery is no longer an option, and his

oncologist says that chemotherapy is unlikely to produce any meaningful benefit. Mr. Banks is concerned that

his sons will not support a transfer to comfort care. The AGACNP advises that he:

Response

Feedback:

“B” is the correct answer. If there is any concern about disagreement among family members,

or any concern at all that a patient’s wishes will not be carried out, the best action is to ensure

that there is a clearly defined legally executed document. “A” is not correct. Living wills are

not legally enforceable documents and when dissention arises among family members they

may not be carried out. “C” is not correct - while the patient should arrange for his care as

long as he is capable of doing so, if Questions arise at such a time that he is not capable of

answering his next of kin will need to do so. “D” is not correct -- identifying the proxy is not

enough without assigning legal rights and responsibilities. While “A,” “C,” and “D” should all

be done and will support his care, the only way to ensure that one’s wishes are carried out is to

ensure that a legally enforceable direction is in place.

 Question 15

1 out of 1 pointsMr. Wilkerson is a 77-year-old male who is being evaluated and treated for his cardiogenic pain. His vital signs

are as follows: Temperature of 99.1° F, pulse of 100 bpm, respirations of 22 bpm, and blood pressure of

168/100 mm Hg. A 12-lead ECG reveals deep ST segment depression in leads V3-V6. The AGACNP

recognizes which of the following as a contraindication to rTPA therapy?

Response

Feedback:

“D” is the correct answer. rTPA is not indicated in patients with ST segment depression; this

is not a ST elevation MI. “A” is not correct as age > 80 is a relative contraindication. “B” is

not correct as a temperature of 99.1° F is an expected response to myocardial necrosis, and

“C” is not correct—the blood pressure is not prohibitive until > 180/110 mm hg.

 Question 16

1 out of 1 points

A 71-year-old patient is recovering from a particularly severe exacerbation of chronic obstructive pulmonary

disease. He has been in the hospital for almost two weeks and was on mechanical ventilation for 7 days. While

discussing his discharge plan he tells you that he is really going to quit smoking this time. He acknowledges

that he has been "sneaking" cigarettes in the hospital for two days, but he has established a timeline to decrease

the number of cigarettes daily. According to his plan his last cigarette will be the last day of the month. This

patient’s behavior is consistent with which stage of the Transtheoretical Model of Change?

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Response

Feedback:

“C” is the correct answer. The Transtheoretical model of change is characterized by 5 stages.

“A” is when the patient has no intention to make a change. “B” is when the patient is

intending to make a change in the next 6 months. “C” is when the patient is ready to take

action or has already taken some action, as this patient has in establishing his plan to quit by

the end of the month. “D” is the overt action that attains a criterion sufficient to reduce disease

risk—in this patient the action stage would be characterized by actual smoking cessation. The

final phase, not presented in the answer choices here, is maintenance.

 Question 17

1 out of 1 points

While assessing a patient with a known psychiatric history, the AGACNP knows that the primary difference

between a psychotic and neurotic disorders is:

Response

Feedback:

“B” is the correct answer. Patients with psychotic disorders are characterized by a distinct

alteration in their perception of reality which may be manifest by visual or auditory

hallucinations or impaired thought processes. Neurotic disorders, while many times very

serious, are seen in patients who remain aware and interactive with the reality. “A” is incorrect

as neurotic disorders may be characterized by a tendency or actual act of harm, such as the

self-mutilating actions classic of a borderline personality, suicide by a depressed patient, or

even murder or torture committed by an antisocial personality. While dangerous, none of

those disorders include a dis-connect from reality as part of the presentation. “C” is incorrect

as antipsychotic medications are used to manage a variety of neurotic disorders such asdepression or oppositional defiant disorder. “D” is incorrect as lack of conscience and remorse

is typical of antisocial personalities.

 Question 18

0 out of 1 points

L.T. is an 85-year-old male who is admitted for evaluation of profound diarrhea that has produced significant

dehydration. He also complains of being very tired lately, and feeling like he is going to vomit all of the time.

His vital signs are significant for a pulse of 41 b.p.m. and a blood pressure of 90/60 mm Hg. A gastrointestinal

evaluation including stool for blood, white blood cells, and ova and parasites is negative. He insists that he has

not started any new medications or made any diet changes; the only thing new is that he got new eye drops for

his glaucoma. The AGACNP correctly assumes that his new eye drops are:

Response

Feedback:

“B” is the correct answer. The accelerated GI motility and bradycardia are cholinergic adverse

effects. Ophthalmic medications are readily absorbed into systemic circulation. All of these

medications are used to treat glaucoma and may cause class-related adverse effects, but

cholinergic drops are the only ones shown that will slow heart rate and accelerate GI motility.

 Question 19

1 out of 1 points

Janice is a 19-year-old female who presents to the emergency department via ambulance. She is pale,

diaphoretic, agitated, and convinced she is having a stroke. Her vital signs include a temperature of 98.9° F,

pulse of 114 beats per minute, respirations of 32 breaths per minute, and a blood pressure of 110/74 mm Hg.

Diagnostic evaluation is negative and Janice is diagnosed with an acute panic attack. The initial treatment of

choice is:

Response

Feedback:

“A” is the correct answer. A panic anxiety attack requires immediate intervention with a short

acting benzodiazepine for immediate symptom control. A calm environment would be helpful,

but is not adequate alone to manage acute episodes characterized by physical symptoms.

Oxygen is not indicated in the absence of organic problems. The numb hands and feet, known

as “stocking-glove paresthesia,” are characteristic of respiratory alkalosis consistent with

tachypnea and will resolve once the patient slows her breathing and retains CO2. While

cognitive behavioral therapy is an important part of chronic anxiety management, is has no

role in acute management of acute panic attack.

 Question 20

0 out of 1 points

Lorraine is a 41-year-old female who presents for an asthma follow-up visit. She says she feels very well, has

almost no daytime symptoms, and is using her inhaled corticosteroid medication daily as prescribed. Her PEFR

is 85% of her personal best. The best approach to this patient is to:Response

Feedback:

“C” is the correct answer. In accordance with EPR-3 guidelines, assessment of asthma followup must include a validated asthma Questionnaire, such as the ACT. The information gathered

so far is encouraging but incomplete and any decision about her care should be made based on

a complete assessment. “A” and “B” are not correct as these are treatments that cannot be

determined until her assessment is complete. “D” is incorrect because it is not required; at

follow-up, objective airflow assessment may be completed with either PEFR or FEV1.

 Question 21

1 out of 1 points

Mr. Owen is a 37-year-old patient who has been admitted for surgical resection of a malignant tumor in his

lung. His physical recovery has been uneventful and he is being prepared for discharge. While discussing his

ongoing cancer therapy with Mr. Owen, the AGACNP determines that he has experienced persistent, excessive

anxiety and worry almost every day for more than one year. What other aspect of Mr. Owen's psychosocial

history would be required to made a diagnosis of generalized anxiety disorder?

Response

Feedback:

“D” is the correct answer. Generalized anxiety disorder (GAD) is an axis I disorder according

to DSM-V. Diagnostic criteria require that the patient report both excessive anxiety and

worry, and difficulty controlling that worry, for more days than not in the last six months.

These two cardinal requirements are accompanied by three of at least six other findings, which

may or may not include choices “A” through “C”; so while sleep disturbances, difficulty

concentrating and muscle tension may or may not occur, excessive anxiety and worry and

difficulty controlling that worry are required for the diagnosis.

 Question 22

0 out of 1 points

Kevin T. is a 49-year-old male who is being discharged after hospitalization for an acute inferior wall

myocardial infarction. This is his first hospitalization and his first chronic medical diagnosis. Aside from his

elevated cardiac isoenzymes and troponins, his laboratory profile was essentially within normal limits. The

only apparent cardiac risk factor is an LDL cholesterol of 200 mg/dL. Initiating an HMG-CoA reductase

inhibitor is an example of which level of prevention for Kevin?

Response

Feedback:

“C” is the correct answer. Controlling his LDL after a myocardial event is about trying to

prevent further events or deterioration. “A” is not correct as primary prevention is about

preventing disease—appropriate exercise in a healthy patient is primary prevention. “B” is not

correct as secondary prevention is about screening for asymptomatic disease and intervening

before disease develops—routine cholesterol screening that reveals an elevated before an MI

would be secondary prevention. “D” is not correct as there is no “restorative” level of

prevention.

 Question 23

1 out of 1 points

You are evaluating a patient who has been admitted to the emergency room after being arrested for starting a

fight in a local sports' bar. The patient is now being cooperative, but reports that he has been in treatment for

PTSD for months. He has been prescribed fluoxetine but has not noticed any improvement in symptoms, andnow has been arrested for violence. The AGACNP knows that the next step in medication management is

likely to include:

Response

Feedback:

“A” is the correct answer. While SSRIs, beta adrenergic antagonists, and even centrally acting

antiadrenergic agonists (clonidine) are all used as first line agents depending upon symptom

presentation, patients who have more severe symptoms and do not respond to initial

treatments often require management with atypical antipsychotics. This patient has been

treated with an SSRI, reports no improvement, and has been arrested for his behavior; these

circumstances are a clear indication for escalation to the nest level of therapy.

 Question 24

1 out of 1 points

Mrs. Salter is an 81-year-old lady who presents for evaluation of near-syncopal episodes. Her 12-lead ECG,

complete blood count, and comprehensive metabolic panel are all essentially normal. A urinalysis shows some

trace protein but is otherwise normal. A 24-hour rhythm monitor demonstrates rare premature ventricular

contractions. Mrs. Salter has been in good health and had her first episode at her aerobics class. She only gets

lightheaded when she exerts herself. Her heart auscultates for a grade III/VI systolic crescendo-decrescendo

murmur at the second intercostal space, right sternal border. The AGACP considers that the likely cause of the

syncope is:

Response

Feedback:

“C” is the correct answer. This is the classic murmur of aortic stenosis, which impedes cardiac

output and as it progresses will produce a symptomatic decrease in carotid perfusion. “A” is

not correct as there is no sign or symptom of seizure activity. “B” is not correct—the rare PVC

is not likely to cause syncope. “D” is not correct—a blood pressure is not given and the

proteinuria could come from any variety of causes.

 Question 25

1 out of 1 points

Who among the following patients is at greatest risk for a pulmonary embolus?

Response

Feedback:

“C” is the correct answer. The primary risk factor for pulmonary embolus is deep vein

thrombosis, for which primary risks are polycythemia and stasis. “A” is not correct—the

concentration of estrogen in most hormonal contraception is so low that it barely increases risk

above that of the general circulation. Of the millions of women on hormonal contraception,

only a handful develop DVT/PE. “B” is not correct—this patient is likely to have problems

bleeding rather than clotting. “D” is not correct—while smoking is a risk factor for many

things DVT is not among them.