Nursing 6042 Midterm

Gerontology Class…. Week 1: 1. Question : The major impact of the physiological changes that occur with aging is: Reduced physiological reserve Reduced homeostatic mechanisms Impaired immunological response CORRECT All of the above Instructor Explanation: The major impact of all of these physiological changes can be highlighted with three primary points. First, there is a reduced physiological reserve of most body systems, particularly cardiac, respiratory, and renal. Second, there are reduced homeostatic mechanisms that fail to adjust regulatory systems such as temperature control and fluid and electrolyte balance. Third, there is impaired immunological function: infection risk is greater, and autoimmune diseases are more prevalent. (Kennedy-Malone 3) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file. Question 2. Question : Men have faster and more efficient biotransformation of drugs and this is thought to be due to: Less obesity rates than women Prostate enlargement CORRECT Less estrogen than women Instructor Explanation: Men have faster and more efficient biotransformation, presumably because of serum testosterone. Conditions of increased or decreased liver perfusion alter the overall level of the drug that is absorbed and how it is metabolized. (Kennedy-Malone 5) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file. Question 3. Question : The cytochrome p system involves enzymes that are generally: Inhibited by drugs Induced by drugs CORRECT Inhibited or induced by drugs Associated with decreased liver perfusion Instructor Explanation: Biotransformation occurs in all body tissues but primarily in the liver, where enzymatic activity (cytochrome P [CYP] system) alters and detoxifies the drug and prepares it for excretion. (Kennedy-Malone 5) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file. Question 4. Question : Functional abilities are best assessed by: Self-report of function CORRECT Observed assessment of function A comprehensive head-to-toe examination Family report of function Instructor Explanation: Two well-established tools used to evaluate function in older adults are the Katz Activities of Daily Living Scale (Katz et al., 1963) and the Lawton and Brody scale for Instrumental Activities of Daily Living (Lawton & Brody, 1969). It is important to be cautious about self-report of function (rather than direct observation of function) and to ask, “Do you …?” instead of “Can you …?” in order to determine if patients actually perform the activity. (Kennedy-Malone 40) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file. Question 5. Question : Iron Deficiency Anemia (IDA) is classified as a microcytic, hypochromic anemia. This classification refers to which of the following laboratory data? Hemoglobin and Hematocrit CORRECT Mean Corpuscular Volume (MCV) and Mean Corpuscular Hemoglobin (MCH) Serum ferritin and serum iron Total iron binding capacity and transferrin saturation Instructor Explanation: RBC indices reveal an MCV (mean corpuscular volume/RBC size) that will be decreased to <80 fL in adults; MCH (mean corpuscular hemoglobin/RBC color) will show hypochromia or pale cells; RBC distribution width (RDW)/volume variation will be increased. (Kennedy-Malone page 519) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file. Question 6. Question : When interpreting laboratory data, you would expect to see the following in a patient with Anemia of Chronic Disease (ACD): Hemoglobin <12 g/dl, MCV decreased, MCH decreased Hemoglobin >12 g/dl, MCV increased, MCH increased CORRECT Hemoglobin <12 g/dl, MCV normal, MCH normal Hemoglobin >12 g/dl, MCV decreased, MCH increased Instructor Explanation: Hemoglobin (Hgb): <12 g/dL (120 g/L) women <13 g/dL (130 g/L) men Rarely <10 g/dL (100 g/L) Mean corpuscular volume: 80–96 mcm3 (normocytic) Mean corpuscular hemoglobin Normochromic (normal color) RBC distribution width: normal (Kennedy-Malone page 517) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file. Question 7. Question : The pathophysiological hallmark of ACD is: Depleted iron stores CORRECT Impaired ability to use iron stores Chronic uncorrectable bleeding Reduced intestinal absorption of iron Instructor Explanation: The pathophysiological hallmark of ACD is a disregulation of iron homeostasis, characterized by an increased uptake and retention of iron within the cells of the reticuloendothelial system (liver/spleen), resulting in decreased RBC production. Essentially, iron is present but inaccessible for use in the production of Hgb with the erythrocytes (Bross et al., 2010). A shortened RBC survival is also a contributing factor to ACD. (Kennedy-Malone page 516-517) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file. Question 8. Question : The main focus of treatment of patients with ACD is: Replenishing iron stores Providing for adequate nutrition high in iron CORRECT Management of the underlying disorder Administration of monthly vitamin B12 injections Instructor Explanation: Treatment: Treatment of ACD focuses on management of the underlying disorder. Iron supplementation is of no benefit in ACD, except in cases of coexisting IDA. A therapeutic trial of iron supplementation of no longer than 1 month may be useful in delineating between ACD and IDA. In ACD, there would be no hematological response to iron therapy (Chen & Gandhi, 2004). (Kennedy-Malone page 518) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file. Question 9. Question : In addition to the complete blood count (CBC) with differential, which of the following laboratory tests is considered to be most useful in diagnosing ACD and IDA? Student Answer: Serum iron Total iron binding capacity Transferrin saturation CORRECT Serum ferritin Instructor Explanation: Treatment: Treatment of ACD focuses on management of the underlying disorder. Iron supplementation is of no benefit in ACD, except in cases of coexisting IDA. A therapeutic trial of iron supplementation of no longer than 1 month may be useful in delineating between ACD and IDA. In ACD, there would be no hematological response to iron therapy (Chen & Gandhi, 2004). (Kennedy-Malone page 518) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file Question 10. Question : Symptoms in the initial human immunodeficiency virus (HIV) infection include all of the following except: Sore throat Fever CORRECT Weight loss Headache Instructor Explanation: Signal symptoms: The initial HIV infection is characterized by mononucleosis-like illness with fever, sore throat, lymphadenopathy, headache, and fatigue. A roseola-like rash may also develop. These initial symptoms are followed by an asymptomatic phase, which may last 10 years or more. Later, if untreated, lymphadenopathy, weight loss, myalgias, and diarrhea may develop (Cohen, Kuritzkes, & Sax, 2011). In advanced disease, malignancies and opportunistic infections occur. Co-infection with hepatitis B or C is common (25% to 30%) in IV drug users, so hepatitis symptoms may also appear (Centers for Disease Control and Prevention [CDC], 2010a). (Kennedy-Malone page 521) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file. Question 11. Question : Essential parts of a health history include all of the following except: Chief complaint History of the present illness CORRECT Current vital signs All of the above are essential history components Instructor Explanation: Vital signs are part of the physical examination portion of patient assessment, not part of the health history. Question 12. Question : Which of the following clinical reasoning tools is defined as evidence-based resource based on mathematical modeling to express the likelihood of a condition in select situations, settings, and/or patients? Clinical practice guideline CORRECT Clinical decision rule Clinical algorithm Clinical recommendation Instructor Explanation: Clinical decision (or prediction) rules provide another support for clinical reasoning. Clinical decision rules are evidence-based resources that provide probabilistic statements regarding the likelihood that a condition exists if certain variables are met with regard to the prognosis of patients with specific findings. Decision rules use mathematical models and are specific to certain situations, settings, and/or patient characteristics. Goolsby page 7 Question 13. Question : The first step in the genomic assessment of a patient is obtaining information regarding: CORRECT Family history Environmental exposures Lifestyle and behaviors Current medications Instructor Explanation: A critical first step in genomic assessment, including assessment of risk, is the use of family history. Family history is considered the first genetic screen (Berry & Shooner 2004) and is a critical component of care because it reflects shared genetic susceptibilities, shared environment, and common behaviors (Yoon, Scheuner, & Khoury 2003). Goolsby page 18 Question 14. Question : In autosomal recessive (AR) disorders, individuals need: Only one mutated gene on the sex chromosomes to acquire the disease Only one mutated gene to acquire the disease CORRECT Two mutated genes to acquire the disease Two mutated genes to become carriers Instructor Explanation: In autosomal recessive (AR) disorders, the offspring inherits the condition by receiving one copy of the gene mutation from each of the parents. Autosomal recessive disorders must be inherited through both parents (Nussbaum et al. 2007). Individuals who have an AR disorder have two mutated genes, one on each locus of the chromosome. Parents of an affected person are called carriers because each carries one copy of the mutation on one chromosome and a normal gene on the other chromosome. Carriers typically are not affected by the disease. Goolsby page 28 Question 15. Question : In AR disorders, carriers have: Two mutated genes; two from one parent that cause disease A mutation on a sex chromosome that causes a disease A single gene mutation that causes the disease CORRECT One copy of a gene mutation but not the disease Instructor Explanation: Individuals who have an AR disorder have two mutated genes, one on each allele of the chromosome. Parents of an affected person are called carriers because each parent carries one copy of the mutation on one chromosome and a normal gene on the other chromosome. Carriers typically are not affected by the disease. In pedigrees with an AR inheritance patterns, males and females will be equally affected because the gene mutation is on an autosome. Goolsby page 28 Question 16. Question : A woman with an X-linked dominant disorder will: Not be affected by the disorder herself CORRECT Transmit the disorder to 50% of her offspring (male or female) Not transmit the disorder to her daughters Transmit the disorder to only her daughters Instructor Explanation: Everyone born with an X-linked dominant disorder will be affected with the disease. Transmission of the disorder to the next generation varies by gender, however. A woman will transmit the mutation to 50% of all her offspring (male or female). Goolsby page 29 Question 17. Question : According to the Genetic Information Nondiscrimination Act (GINA): Nurse Practitioners (NPs) should keep all genetic information of patients confidential NPs must obtain informed consent prior to genetic testing of all patients Employers cannot inquire about an employee’s genetic information CORRECT All of the above Instructor Explanation: On May 21, 2008, President George W. Bush signed the Genetic Information Nondiscrimination Act (GINA) to protect Americans against discrimination based upon their genetic information when it comes to health insurance and employment, paving the way for patient personalized genetic medicine without fear of discrimination (National Human Genome Research Institute 2012). Goolsby page 43 Question 18. Question : Which of the following would be considered a “red flag” that requires more investigation in a patient assessment? Colon cancer in family member at age 70 Breast cancer in family member at age 75 CORRECT Myocardial infarction in family member at age 35 All of the above Instructor Explanation: Early onset cancer syndromes, heart disease, or dementia are red flags that warrant further investigation regarding hereditary disorders. Goolsby page 36 Question 19. Question : Your 2-year-old patient shows facial features, such as epicanthal folds, up-slanted palpebral fissures, single transverse palmar crease, and a low nasal bridge. These are referred to as: Variable expressivity related to inherited disease CORRECT Dysmorphic features related to genetic disease De novo mutations of genetic disease Different penetrant signs of genetic disease Instructor Explanation: Assessing for dysmorphic features may enable identification of certain syndromes or genetic or chromosomal disorders (Jorde, Carey, & Bamshad 2010; Prichard & Korf 2008). Dysmorphology is defined as “the study of abnormal physical development” (Jorde, Carey, & Bamshad 2010, 302). Goolsby page 37 Question 20. Question : In order to provide a comprehensive genetic history of a patient, the NP should: Ask patients to complete a family history worksheet Seek out pathology reports related to the patient’s disorder Interview family members regarding genetic disorders CORRECT All of the above Instructor Explanation: Asking the patient to complete a family history worksheet prior to the appointment saves time in the visit while offering the patient an opportunity to contribute to the collection of an accurate family history. Reviewing the family information can also help establish family rapport while verifying medical conditions in individual family members. If a hereditary condition is being considered but family medical information is unclear or unknown, requesting medical records and pathology or autopsy reports may be warranted. Week 2: 1. Question : An 86-year-old patient who wears a hearing aid complains of poor hearing in the affected ear. In addition to possible hearing aid malfunction, this condition is often due to: Acoustic neuroma CORRECT Cerumen impaction Otitis media Ménière’s disease Instructor Explanation: Elderly clients frequently present with complaints of hardened cerumen and decreased hearing resulting from cerumen impaction aggravated by hearing aid wear. (Goolsby 137-138) Conductive hearing loss is caused by a lesion involving the outer and middle ear to the level of the oval window. Various structural abnormalities, cerumen impaction, perforation of the tympanic membrane, middle ear fluid, damage to the ossicles from trauma or infection, otosclerosis, tympanosclerosis, cholesteatoma, middle ear tumors, temporal bone fractures, injuries related to trauma, and congenital problems are some of the causes. (Kennedy-Malone 170-171) Question 2. Question : In examination of the nose, the clinician observes gray, pale mucous membranes with clear, serous discharge. This is most likely indicative of: Bacterial sinusitis CORRECT Allergic rhinitis Drug abuse Skull fracture Instructor Explanation: When examining the nose, assess the mucosa for integrity, color, moistness, and edema/lesions and the nasal septum for patency. The turbinates should be assessed for color and size. Pale, boggy turbinates suggest allergies; erythematous, swollen turbinates are often seen with infection. Any discharge should be noted. Clear, profuse discharge is often associated with allergies. (Goolsby 128-129) Patients with seasonal allergic rhinitis report rhinorrhea, sneezing, obstructed nasal passages, and pruritic eyes, nose, and oropharynx during the spring and fall. Patients with perennial allergic rhinitis have similar symptoms associated with exposure to environmental allergens typically in their homes. Physical examination may reveal a pale, boggy nasal mucosa, injected conjunctiva, enlarged turbinates, dark discoloration or bags under the eyes, and mouth breathing; absence of pale, boggy nasal mucosa does not rule out allergic rhinitis. (Kennedy-Malone 182-183) Question 3. Question : A 45 year old patient presents with ‘sore throat’ and fever for one week. After a quick strep screen you determine the patient has Strep throat. You know that streptococcal pharyngitis should be treated with antibiotics to prevent complications and to shorten the course of disease. Which of the following antibiotics should be considered when a patient is allergic to Penicillin? Amoxicillin CORRECT EES (erythromycin) Bicillin L-A Dicloxacillin Instructor Explanation: MedU Card #1 Question 4. Question : Presbycusis is the hearing impairment that is associated with: CORRECT Physiologic aging Ménière’s disease Cerumen impaction Herpes zoster Instructor Explanation: Presbycusis is an age-related cause of gradual sensorineural hearing loss and involves diminished hairy cell function within the cochlea as well as decreased elasticity of the TM. Although the changes associated with presbycusis often start in early adulthood, the decreased hearing acuity is usually not noticed until the individual is older than 65. (Goolsby 138) Because presbycusis is gradual and insidious, hearing loss may go unnoticed until it has progressed significantly. (Kennedy-Malone 170) Question 5. Question : Epistaxis can be a symptom of: Over-anticoagulation Hematologic malignancy Cocaine abuse CORRECT All of the above Instructor Explanation: Cocaine abuse, which is more common than might be expected, frequently causes epistaxis. Hematologic disorders likely to cause bleeding include thrombocytopenia, leukemia, aplastic anemia, and hereditary coagulopathies. High doses of anticoagulants can cause epistaxis and bleeding from the gums. (Goolsby 142) Epistaxis results from a spontaneous rupture of a blood vessel in the nose, usually in the anterior septum in Kiesselbach's plexus (Nguyen, 2012). The bleeding may be secondary to local infections, systemic infections, drying of the nasal mucous membrane, trauma, arteriosclerosis, hypertension, or bleeding disorders. Trauma is usually the primary mechanism of disruption of the nasal mucosa. Posterior epistaxis can result in nausea and respiratory compromise. In older adults, nasal and paranasal tumors may be involved (Mäkitie, 2010). (Kennedy-Malone 168-169) Question 6. Question : Your patient has been using chewing tobacco for 10 years. On physical examination, you observe a white ulceration surrounded by erythematous base on the side of his tongue. The clinician should recognize that very often this is: Malignant melanoma CORRECT Squamous cell carcinoma Aphthous ulceration Behcet’s syndrome Instructor Explanation: Most oral malignancies are painless until quite advanced, so patients are often unaware of the lesion unless the lip or anterior portion of the tongue is involved. The patient may become aware of the lesion if it bleeds. Squamous cell cancer lesions vary in appearance, from the reddened patches of erythroplakia to areas of induration/thickening, ulceration, or necrotic lesions. Lesions of malignant melanoma have varied pigmentation, including brown, blue, and black. Even lesions that appear flat and smooth may be nodular, indurated, or fixed to adjacent tissue on palpation. Even though patients with squamous cell malignancies often have a history of heavy alcohol and/or tobacco use or poor dentition, these are not risk factors for malignant melanoma. In Behcet’s syndrome, the patient complains of recurrent episodes of oral lesions that are consistent with aphthous ulcers. The number of lesions ranges from one to several; the size of the ulcers varies from less than to greater than 1 cm. Like aphthous ulcers, the lesions are well defined, with a pale yellow or gray base surrounded by erythema. The majority of patients also develop lesions on the genitals and eyes. (Goolsby 153) Tobacco use and heavy alcohol consumption, alone or synergistically, are strongly related to the development of oral cancer. Pipe smoking and sun exposure have been implicated in lip cancer. Leukoplakia and erythroplasia are often precursors to oral cancer. Relationships between oral cancer and Epstein-Barr virus, HPV, herpes simplex virus, and immunodeficiency states also have been found (Stenson, 2011). (Kennedy-Malone 177). Question 7. Question : A 26 year old patient presents with cough and general malaise for 3 days. They note that their eyes have been watering clear fluid and a ‘runny nose’ since yesterday. They note they ‘feel miserable’ and demand something to make them feel better. What would be the best first plan of treatment? CORRECT Saline nasal spray for congestion and acetaminophen as needed for pain. Z-pack (azithromycin) for infection and Cromolyn nasal for congestion Hydrococone/acetaminophen as needed for pain and Guaifensin for congestion Cephalexin for infection and Cromolyn ophthalmic for congestion Instructor Explanation: MedU Card #4 Question 8. Question : Which of the following findings should trigger an urgent referral to a cardiologist or neurologist? History of bright flash of light followed by significantly blurred vision CORRECT History of transient and painless monocular loss of vision History of monocular severe eye pain, blurred vision, and ciliary flush All of the above Instructor Explanation: Amaurosis fugax is a monocular, transient loss of vision. It stems from transient ischemia of the retina and presents an important warning sign for impending stroke. Depending on the circumstances reported, the patient should be immediately referred to either a cardiovascular or neurological specialist. (Goolsby 108) Question 9. Question : Dizziness that is described as "lightheaded" or, "like I'm going to faint," is usually caused by inadequate cerebral perfusion and is classified as? CORRECT Presyncope Disequilibrium Vertigo Syncope Instructor Explanation: MedU Card #5 Question 10. Question : It is important to not dilate the eye if ____ is suspected. Cataract Macular degeneration CORRECT Acute closed-angle glaucoma Chronic open-angle glaucoma Instructor Explanation: If the patient has experienced sudden onset of eye pain, it is important not to dilate the eyes before determining whether acute closed-angle glaucoma is present because dilating the eye may increase the intraocular pressure. (Goolsby 108) Acute glaucoma, also known as angle-closure or narrow-angle glaucoma, is an obstruction to the outflow of aqueous humor from the posterior to the anterior chamber through the trabecular meshwork, canal of Schlemm, and associated structures. It results in an elevation of intraocular pressure, damaging the optic nerve and causing loss of peripheral vision, eye pain, and redness. This type of glaucoma is uncommon but may occur as a primary disease or secondary to other conditions and constitutes an ophthalmic emergency (Kennedy-Malone 161) Question 11. Question : Mr. GC presents to the clinic with nausea and vomiting for 2 days, prior to that time he reports occasional ‘dizziness’ that got better with change in position. He denies a recent history of URI or any history of headaches or migraines. What would the most likely diagnosis be? Vestibular neruitis CORRECT Benign paroxysmal positional vertigo Vestibular migraine Benign hypertensive central vertigo Instructor Explanation: MedU Card #9 Question 12. Question : Which of the following patients with vertigo would require neurologic imaging? CORRECT A 68-year-old woman with a history of hypertension and sudden acute onset constant vertigo. She has right nystagmus that changes direction with gaze and that does not disappear when she focuses. A 45-year-old man with recurrent episodes of brief intense vertigo every time he turns his head rapidly. He has no other neurologic signs or symptoms. He has a positive Dix-Hallpike maneuver. A 66-year-old man with recurrent episodes of vertigo associated with tinnitus and hearing loss. His head thrust test is positive. A 28-year-old otherwise well woman with new onset constant vertigo with no other neurologic symptoms. On physical exam, she has unidirectional nystagmus that disappears when her gaze is fixed. Instructor Explanation: MedU Card #11. There are multiple reasons to be concerned about a central lesion and possible infarct in this patient. Her age puts her at risk as does her hypertension. Her physical exam shows nystagmus that changes direction and that does not inhibit with focus. Both of these findings are consistent with a central lesion. She needs an urgent MRI. Question 13. Question : A patient presents with eye redness, scant discharge, and a gritty sensation. Your examination reveals the palpable preauricular nodes, which are most likely with: Bacterial conjunctivitis Allergic conjunctivitis Chemical conjunctivitis CORRECT Viral conjunctivitis Instructor Explanation: Preauricular nodes are nonpalpable and nontender in allergic conjunctivitis, usually nonpalpable in bacterial conjunctivitis, and palpable in viral conjunctivitis. (Goolsby 112) Question 14. Question : In assessing the eyes, which of the following is considered a “red flag” finding when associated with eye redness? History of prior red-eye episodes CORRECT Grossly visible corneal defect Exophthalmos Photophobia Instructor Explanation: Red flag warnings for eye redness include pain (not discomfort or irritation), decreased vision, profuse discharge, and corneal defect grossly visible. (Goolsby 112) Question 15. Question : A 64-year-old male presents with erythema of the sclera, tearing, and bilateral pruritus of the eyes. The symptoms occur intermittently throughout the year and he has associated clear nasal discharge. Which of the following is most likely because of the inflammation? Bacterium CORRECT Allergen Virus Fungi Instructor Explanation: Patients with seasonal allergic rhinitis report rhinorrhea, sneezing, obstructed nasal passages, and pruritic eyes, nose, and oropharynx during the spring and fall. Patients with perennial allergic rhinitis have similar symptoms associated with exposure to environmental allergens typically in their homes. Physical examination may reveal a pale, boggy nasal mucosa, injected conjunctiva, enlarged turbinates, dark discoloration or bags under the eyes, and mouth breathing; absence of pale, boggy nasal mucosa does not rule out allergic rhinitis. (Kennedy-Malone 182-183) Question 16. Question : Patients that have atopic disorders are mediated by the production of Immunoglobulin E (IgE) will have histamine stimulated as an immediate phase response. This release of histamine results in which of the following? Sinus pain, increased vascular permeability, and bronchodilation CORRECT Bronchospasm, vascular permeability, and vasodilatation Contraction of smooth muscle, decreased vascular permeability, and vasoconstriction Vasodilatation, bronchodilation, and increased vascular permeability Instructor Explanation: Rhinitis may be either allergic or nonallergic. Allergic rhinitis results as a response of the nasal mucosa to airborne allergens in atopic genetically prone individuals. This response is mediated by the production of immunoglobulin E (IgE). IgE antibodies produced in response to the initial and subsequent exposure to allergens bind to the nasal mucosa. With repeated exposure, immediate type 1 hypersensitivity reactions may occur (Simoens & Laekeman, 2009). Antigen-specific T cells are activated through the lymphatic system in response to the antigen. The activated antigen-specific T cells activate B cells, and IgE is created in lymphoid tissue and at local tissue sites (Adelman, Casale, & Corren, 2002; Novak, 2009). The newly created antigen-specific IgE is released by plasma cells and binds to high-affinity IgE receptors located on the basophils and mast cells. This leads to the sensitization of the cells in the tissues of the nose, lung, or skin (Adelman et al., 2002; Cirillo, Pistorio, Tosca, & Ciprandi, 2009). IgE also binds with the antigen protein, beginning degranulation of the mast cells and basophils. These actions start the allergic cascade. Mediators are released as a result of the degranulation and include histamine, proteoglycans, enzymes, leukotrienes, cytokines, and many others. The chain in the release of mediators is responsible for the immediate and late phase responses of the cells. Histamine may be fully released within 30 minutes of degranulation, whereas cytokines may be released over many hours (Adelman et al., 2002; Derendorf & Meltzer, 2008). (Kennedy-Malone 181-182) Question 17. Question : You have a patient complaining of vertigo and want to know what could be the cause. Knowing there are many causes for vertigo, you question the length of time the sensation lasts. She tells you several hours to days and is accompanied by tinnitus and hearing loss. You suspect which of the following conditions? CORRECT Ménière’s disease Benign paroxysmal positional vertigo Transient ischemic attack (TIA) Migraine Instructor Explanation: Ménière's disease commonly involves a triad of symptoms—severe vertigo, tinnitus, and hearing loss (Goolsby 140) Question 18. Question : In examining the mouth of an older adult with a history of smoking, the nurse practitioner finds a suspicious oral lesion. The patient has been referred for a biopsy to be sent for pathology. Which is the most common oral precancerous lesion? Fictional keratosis Keratoacanthoma Lichen planus CORRECT Leukoplakia Instructor Explanation: The cause of most episodes of leukoplakia is not determined. However, this condition, which results in the development of white patches on the oral mucosa, is associated with an increased risk of oral squamous cell cancer. Risk factors for the development of leukoplakia include chronic/recurrent trauma to the affected site and the use of smokeless and smoked tobacco and alcohol. (Goolsby 152) Question 19. Question : Rheumatic heart disease is a complication that can arise from which type of infection? Epstein-Barr virus Diphtheria CORRECT Group A beta hemolytic streptococcus Streptococcus pneumoniae Instructor Explanation: Group A beta-hemolytic streptococcal (GABHS) pharyngitis is a bacterial infection of the pharynx, commonly called strep throat. Complications of GABHS pharyngitis, although rare, include rheumatic heart disease and glomerulonephritis, and the condition requires prompt diagnosis and definitive treatment. Most patients with GABHS pharyngitis are children and youths. Other bacterial causes of pharyngitis include mycoplasmal pneumonia, gonorrhea, and diphtheria. (Goolsby 156) Question 20. Question : A patient complains of fever, fatigue, and pharyngitis. On physical examination there is pronounced cervical lymphadenopathy. Which of the following diagnostic tests should be considered? Mono spot Strep test Throat culture CORRECT All of the above Instructor Explanation: The physical examination for sore throat should include a comprehensive assessment of the upper and lower respiratory systems, including ears, nose, mouth, throat, and lungs. The neck assessment should include, at a minimum, assessment of the cervical lymph nodes. Strep screens, throat cultures, and mononucleosis screens are common diagnostic studies used to narrow the differential diagnosis of sore throat. A CBC with differential count is helpful in determining the cause of sore throat. (Goolsby 156) Week3: 1. Question : Susan P., a 60-year-old woman with a 30 pack year history, presents to your primary care practice for evaluation of a persistent, daily cough with increased sputum production, worse in the morning, occurring over the past three months. She tells you, “I have the same thing, year after year.” Which of the following choices would you consider strongly in your critical thinking process? Seasonal allergies Acute bronchitis Bronchial asthma CORRECT Chronic bronchitis Instructor Explanation: The pulmonary component includes an abnormal inflammatory response to noxious stimuli, principally tobacco, but also occupational and environmental pollutants. The hallmark of chronic bronchitis is a daily chronic cough with increased sputum production lasting for at least 3 consecutive months in at least 2 consecutive years, usually worse on awakening; this may or may not be associated with COPD (GOLD, 2011). Emphysema is characterized by obstruction to airflow caused by abnormal airspace enlargement distal to terminal bronchioles. Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file. (page 206) &Goolsby, Mary J., Laurie Grubbs. Advanced Assessment Interpreting Findings and Formulating Differential Diagnoses, 3rd Edition. F.A. Davis Company, 11/2014. VitalBook file. (page 213) Question 2. Question : A patient presents complaining of a 5 day history of upper respiratory symptoms including nasal congestion and drainage. On the day the symptoms began he had a low-grade fever that has now resolved. His nasal congestion persisted and he has had yellow nasal drainage for three days associated with mild headaches. On exam he is afebrile and in no distress. Examination of his tympanic membranes and throat are normal. Examination of his nose is unremarkable although a slight yellowish-clear drainage is noted. There is tenderness when you lightly percuss his maxillary sinus. What would your treatment plan for this patient be? CORRECT Observation and reassurance Treatment with an antibiotic such as amoxicillin Treatment with an antibiotic such as a fluoroquinoline or amoxicillin-clavulanate Combination of a low dose inhaled corticosteroid and a long acting beta2 agonist inhaler. Instructor Explanation: MedU Card #4. According to the American Academy of Ortolaryngology—Head and Neck Surgery Foundation guidelines (2007) on sinusitis, making the distinction between a lingering viral upper respiratory infection that affects the nose and sinuses (viral rhinosinusitis) or early acute bacterial sinusitis can be difficult. It is more likely to be a viral rhinosinusitis if the duration of symptoms is less than ten days and they are not worsening. In this case, you can continue to observe the patient and reassure him that antibiotics are not necessary at this time. Question 3. Question : Emphysematous changes in the lungs produce the following characteristic in COPD patients? Asymmetric chest expansion Increased lateral diameter CORRECT Increased anterior-posterior diameter Pectus excavatum Instructor Explanation: In COPD, patients commonly develop a barrel-shaped chest due to emphysematous changes in the lungs. A barrel shape is due to an increased anterior-posterior (AP) diameter. In emphysema, there is a 1:1 ratio of AP to lateral diameter; AP diameter equals the lateral diameter. Normally the AP diameter is twice the lateral diameter. Goolsby, Mary J., Laurie Grubbs. Advanced Assessment Interpreting Findings and Formulating Differential Diagnoses, 3rd Edition. F.A. Davis Company, 11/2014. VitalBook file( page 213-214)&Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file. (page 206) Question 4. Question : When palpating the posterior chest, the clinician notes increased tactile fremitus over the left lower lobe. This can be indicative of pneumonia. Areas of increased fremitus should raise the suspicion of conditions resulting in increased solidity or consolidation in the underlying lung tissue, such as in pneumonia, tumor, or pulmonary fibrosis. In the instance of an extensive bronchial obstruction: CORRECT No palpable vibration is felt Decreased fremitus is felt Increased fremitus is felt Vibration is referred to the non-obstructed lobe Instructor Explanation: Areas of increased fremitus should raise the suspicion of conditions resulting in increased solidity or consolidation in the underlying lung tissue, such as in pneumonia, tumor, or pulmonary fibrosis. Conversely, areas of decreased fremitus raise the suspicion of abnormal fluid- or air-filled spaces, such as occurs with pleural effusion, pneumothorax, or emphysema. In the instance of an extensive bronchial obstruction, no palpable vibration is felt in the related field. Goolsby, Mary J., Laurie Grubbs. Advanced Assessment Interpreting Findings and Formulating Differential Diagnoses, 3rd Edition. F.A. Davis Company, 11/2014. VitalBook file. (page 209)&Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file. (page 193) Question 5. Question : Your patient presents with complaint of persistent cough. After you have finished obtaining the History of Present Illness, you realize that the patient may be having episodes of wheezing, in addition to his cough. The most common cause of cough with wheezing is asthma. What of the following physical exam findings will support your tentative diagnosis of asthma? CORRECT Clear, watery nasal drainage with nasal turbinate swelling Pharyngeal exudate and lymphadenopathy Clubbing, cyanosis and edema. Diminished lung sounds with rales in both bases Instructor Explanation: MedU Card #9 Question 6. Question : Which of the following imaging studies should be considered if a pulmonary malignancy is suspected? CORRECT Computed tomography (CT) scan Chest X-ray with PA, lateral, and lordotic views Ultrasound Positron emission tomography (PET) scan Instructor Explanation: For pulmonary malignancy, chest films are often nondiagnostic, although they may reveal a nodule, mass, or other abnormality. A CT scan of the chest is typically diagnostic. Goolsby, Mary J., Laurie Grubbs. Advanced Assessment Interpreting Findings and Formulating Differential Diagnoses, 3rd Edition. F.A. Davis Company, 11/2014. VitalBook file. (page 217-218) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file. (page 251) Question 7. Question : A 26-year-old, non-smoker, male presented to your clinic with SOB with exertion. This could be due to: Exercise-induced cough Bronchiectasis CORRECT Alpha-1 deficiency Pericarditis Instructor Explanation: When younger patients or nonsmokers develop findings consistent with COPD, alpha-1 antitrypsin deficiency should be suspected. Currently, the American Thoracic Society (2003) recommends that all individuals with COPD or asthma with chronic obstructive changes be tested for alpha-1 antitrypsin deficiency. If alpha-1 antitrypsin deficit is suspected, a qualitative serum should be performed as a screen, followed by quantitative study, as indicated. Goolsby, Mary J., Laurie Grubbs. Advanced Assessment Interpreting Findings and Formulating Differential Diagnoses, 3rd Edition. F.A. Davis Company, 11/2014. VitalBook file. (page 213) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file. (page 206) Question 8. Question : Upon assessment of respiratory excursion, the clinician notes asymmetric expansion of the chest. One side expands greater than the other. This could be due to: CORRECT Pneumothorax Pleural effusion Pneumonia Pulmonary embolism Instructor Explanation: The respiratory excursion, or expansion, is determined by placing hands around the patient’s posterior rib cage with the thumbs approximately at the level of the 10th rib between the thumbs, and then asking the patient to take a deep breath and observing the movement of the hands. The motion should be symmetrical. Less than anticipated movement occurs with advanced COPD and many restrictive processes, such as interstitial lung disease. Asymmetry of movement occurs with atelectasis, lobar collapse, pneumothorax, and several other conditions. Goolsby, Mary J., Laurie Grubbs. Advanced Assessment Interpreting Findings and Formulating Differential Diagnoses, 3rd Edition. F.A. Davis Company, 11/2014. VitalBook file (page 208-209) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file. (pages 193 & 227) Question 9. Question : A 72-year-old woman and her husband are on a cross-country driving vacation. After a long day of driving, they stop for dinner. Midway through the meal, the woman becomes very short of breath, with chest pain and a feeling of panic. Which of the following problems is most likely? Pulmonary edema Heart failure CORRECT Pulmonary embolism Pneumonia Instructor Explanation: The problem may occur when these symptoms are attributed to aging or existing comorbidities. Dyspnea (acute onset), anxiety or apprehension, pleuritic chest pain, cough, tachypnea, and accentuation of the pul-monic component of S2 are frequently present and may be accompanied by diaphoresis, syncope, tachycardia, S3 or S4 gallop, hypoxemia, or hemoptysis . Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file. (page 246) Goolsby, Mary J., Laurie Grubbs. Advanced Assessment Interpreting Findings and Formulating Differential Diagnoses, 3rd Edition. F.A. Davis Company, 11/2014. VitalBook file (page 202) Question 10. Question : A cough is described as chronic if it has been present for: 2 weeks or more CORRECT 8 weeks or more 3 months or more 6 months or more Instructor Explanation: Cough is classified as acute (less than 3 weeks in duration), subacute (lasting 3 to 8 weeks), and chronic (8 or more weeks in duration), and these distinctions help to narrow the potential differential diagnoses. Goolsby, Mary J., Laurie Grubbs. Advanced Assessment Interpreting Findings and Formulating Differential Diagnoses, 3rd Edition. F.A. Davis Company, 11/2014. VitalBook file. (page 211) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file. ((page 206) Question 11. Question : Testing is necessary for the diagnosis of asthma because history and physical are not reliable means of excluding other diagnoses or determining the extent of lung impairment. What is the study that is used to evaluate upper respiratory symptoms with new onset wheeze? Chest X-ray Methacholine challenge test CORRECT Spirometry, both with and without bronchodilation Ventilation/perfusion scan Instructor Explanation: MedU Card #10 Question 12. Question : In classifying the severity of your patient presenting with an acute exacerbation of asthma. You determine that they have moderate persistent symptoms based on the report of symptoms and spirometry readings of the last 3 weeks. The findings that support moderate persistent symptoms include: CORRECT Symptoms daily with nighttime awakening more than 1 time a week. FEV1 >60%, but predicted <80%. FEV1/FVC reduced 5% Symptoms less than twice a week and less than twice a week nighttime awakening. FEV1 >80% predicted. FEV1/FVC normal Symptoms more than 2 days a week, but not daily. Nighttime awakenings 3-4 times a month. FEV1 >80% predicted. FEV1/FVC normal Symptoms throughout the day with nighttime awakenings every night. FEV1< 60% predicted. FEV1/FVC reduced >5% Instructor Explanation: MedU Card #15 Question 13. Question : The following criterion is considered a positive finding when determining whether a patient with asthma can be safely monitored and treated at home: Age over 40 Fever greater than 101 CORRECT Tachypnea greater than 30 breaths/minute Productive cough Instructor Explanation: Decision Rule: CURB-65 provides framework for determining whether the patient diagnosed with community-acquired pneumonia can be safely monitored and treated at home. One point is awarded for each of the following factors present: Confusion of new onset BUN greater than 20mg/dL Respiratory rate of ? 30 breaths/minute Blood pressure is less than 90 mmHg systolic or diastolic ? 60 mm Hg Age 65 or older Patients scoring 3 to 5 typically require hospitalization for observation and therapy. Scores of 0 to 1 indicate likelihood that outpatient management is appropriate. A score of 2 is inconclusive. Goolsby, Mary J., Laurie Grubbs. Advanced Assessment Interpreting Findings and Formulating Differential Diagnoses, 3rd Edition. F.A. Davis Company, 11/2014. VitalBook file (page 214-216) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file.( page 241) Question 14. Question : Medications are chosen based on the severity of asthma. Considering the patient that is diagnosed with moderate persistent asthma, the preferred option for maintenance medication is: High-dose inhaled corticosteroid and leukotriene receptor antagonist Oral corticosteroid—high and low dose as appropriate Short acting beta2 agonist inhaler and theophylline CORRECT Low dose inhaled corticosteroid and long acting beta2 agonist inhaler Instructor Explanation: MedU Card #16 Question 15. Question : A 75-year-old patient with community-acquired pneumonia presents with chills, productive cough, temperature of 102.1, pulse 100, respiration 18, BP 90/52, WBC 12,000, and blood urea nitrogen (BUN) 22 mg/dl. He has a history of mild dementia and his mental status is unchanged from his last visit. These findings indicate that the patient: Can be treated as an outpatient CORRECT Requires hospitalization for treatment Requires a high dose of parenteral antibiotic Can be treated with oral antibiotics Instructor Explanation: Decision Rule: CURB-65 provides framework for determining whether the patient diagnosed with community-acquired pneumonia can be safely monitored and treated at home. One point is awarded for each of the following factors present: Confusion of new onset BUN is greater than 20mg/dl Respiratory rate of ? 30 breaths/minute Blood pressure is less than 90 mmHg systolic or diastolic ? 60 mm Hg Age 65 or older Patients scoring 3 to 5 typically require hospitalization for observation and therapy. Scores of 0 to 1 indicate likelihood that outpatient management is appropriate. A score of 2 is inconclusive. Goolsby, Mary J., Laurie Grubbs. Advanced Assessment Interpreting Findings and Formulating Differential Diagnoses, 3rd Edition. F.A. Davis Company, 11/2014. VitalBook file (page 214-216) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file. (page 241) Question 16. Question : Which of the following is considered a “red flag” when diagnosing a patient with pneumonia? Fever of 102 Infiltrates on chest X-ray CORRECT Pleural effusion on chest X-ray Elevated white blood cell count Instructor Explanation: With pneumonia, the chest film typically reveals an area of infiltrate. It is a red flag if a pleural effusion is also visualized, in which case adequate follow-up to exclude development of an empyema is mandatory. This often involves prompt referral to a pulmonologist for possible thoracentesis. Cultures and Gram stains of sputum are usually not ordered for outpatients. The white blood cell count is often elevated. Goolsby, Mary J., Laurie Grubbs. Advanced Assessment Interpreting Findings and Formulating Differential Diagnoses, 3rd Edition. F.A. Davis Company, 11/2014. VitalBook file. (page 214) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file. (page 240) Question 17. Question : A 23-year-old patient who has had bronchiectasis since childhood is likely to have which of the following: Barrel-shaped chest CORRECT Clubbing Pectus excavatum Prolonged capillary refill Instructor Explanation: In bronchiectasis, there is usually a history of chronic, productive cough. Sputum is typically mucopurulent and produced in increased amounts. Other common findings include shortness of breath, wheezing, fatigue, and possibly hemoptysis. Physical examination reveals rhonchi and/or wheezing. In advanced disease, clubbing and cyanosis may be present. Goolsby, Mary J., Laurie Grubbs. Advanced Assessment Interpreting Findings and Formulating Differential Diagnoses, 3rd Edition. F.A. Davis Company, 11/2014. VitalBook file (page 216) Question 18. Question : Your patient has just returned from a 6-month missionary trip to Southeast Asia. He reports unremitting cough, hemoptysis, and an unintentional weight loss of 10 pounds over the last month. These symptoms should prompt the clinician to suspect: Legionnaires' disease Malaria CORRECT Tuberculosis Pneumonia Instructor Explanation: Many times, patients with active tuberculosis are essentially symptom free. Some complain of malaise and/or fevers but have no significantly disruptive complaints. When respiratory symptoms occur with tuberculosis, cough is common; the cough is nonproductive at first and is later associated with sputum production. Additionally, patients with tuberculosis may experience progressive dyspnea, night sweats, weight loss, and hemoptysis. It is important to suspect tuberculosis when the patient has travelled to a country where TB is endemic, such as Asia. Goolsby, Mary J., Laurie Grubbs. Advanced Assessment Interpreting Findings and Formulating Differential Diagnoses, 3rd Edition. F.A. Davis Company, 11/2014. VitalBook file. (page 217) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file. (page 249) Question 19. Question : A 76-year-old patient with a 200-pack year smoking history presents with complaints of chronic cough, dyspnea, fatigue, hemoptysis, and weight loss over the past 2 months. The physical exam reveals decreased breath sounds and dullness to percussion over the left lower lung field. The chest X-ray demonstrates shift of the mediastinum and trachea to the left. These are classic signs of: CORRECT Lung cancer Tuberculosis Pneumonia COPD Instructor Explanation: Dyspnea is the most common symptom associated with pleural effusion, but effusion may be accompanied by cough, pain, and systemic symptoms, such as malaise and fever. Abnormal physical findings become evident as the effusion increases in volume. These include decreased lung sounds, dullness over the effusion, decreased fremitus, egophony, and whispered pectoriloquy. With extremely large effusions, the mediastinum and trachea may shift to the opposite side. The exception involves effusion related to malignancy, in which case the mediastinum and trachea may be pulled toward the malignancy. Goolsby, Mary J., Laurie Grubbs. Advanced Assessment Interpreting Findings and Formulating Differential Diagnoses, 3rd Edition. F.A. Davis Company, 11/2014. VitalBook file (page 217-218) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file.(page 232) Question 20. Question : A 24-year-old patient presents to the emergency department after sustaining multiple traumatic injuries after a motorcycle accident. Upon examination, you note tachypnea, use of intercostal muscles to breathe, asymmetric chest expansion, and no breath sounds over the left lower lobe. It is most important to suspect: Pulmonary embolism Pleural effusion CORRECT Pneumothorax Fracture of ribs Instructor Explanation: Pneumothorax involves air in the pleural cavity. A pneumothorax can occur spontaneously in otherwise healthy individuals or be secondary to trauma or intrinsic lung disease. There is history of sudden onset of shortness of breath associated with chest pain. The patient usually presents in great distress, with tachycardia and tachypnea, and is often splinting the chest. There is decreased fremitus and increased hyperresonance on the affected side. Lung sounds are diminished or absent. The trachea may shift away from the affected side if a large pneumothorax is present. Goolsby, Mary J., Laurie Grubbs. Advanced Assessment Interpreting Findings and Formulating Differential Diagnoses, 3rd Edition. F.A. Davis Company, 11/2014. VitalBook file (page 221) Week 4: 1. Question : Which of the following is the most important question to ask during cardiovascular health history? Number of offspring Last physical exam CORRECT Sudden death of a family member Use of caffeine Instructor Explanation: The sudden death of a family member is an important question to ask in the health history because it reveals the cardiovascular disease risk of the patient. Sudden death is usually due to an acute cardiovascular event, such as myocardial infarction, cardiac dysrhythmia, or stroke. Family history is particularly important for cardiac assessment because CVD, HTN, hyperlipidemia, and other vascular diseases often have a familial association that is not easily ameliorated by lifestyle changes. If there are deaths in the family related to CVD, determine the age and exact cause of death, because CVD at a young age in the immediate family carries an increased risk compared with CVD in an elderly family member. Ask about sudden death, which might indicate a congenital disease such as Marfan's syndrome. This is especially important to ask during pre-sports physicals because sudden death in athletes is often related to congenital or familial heart disease. Familial hyperlipidemia is autosomal dominant and often leads to CAD and MI at a young age. Family history of obesity and type 2 diabetes are also secondary risk factors for heart disease because the familial tendency for these is strong. Ask about smoking in the house, as secondhand smoke is a risk factor for respiratory and cardiac disease. (Goolsby 167-168) Goolsby, Mary J., Laurie Grubbs. Advanced Assessment Interpreting Findings and Formulating Differential Diagnoses, 3rd Edition. F.A. Davis Company, 11/2014. VitalBook file. Question 2. Question : A key symptom of ischemic heart disease is chest pain. However, angina equivalents may include exertional dyspnea. Angina equivalents are important because: a. Women with ischemic heart disease many times do not present with chest pain b. Some patients may have no symptoms or atypical symptoms; diagnosis may only be made at the time of an actual myocardial infarction c. Elderly patients have the most severe symptoms CORRECT A & B only Instructor Explanation: The key symptom of IHD is chest pain, but other common symptoms include arm pain, lower jaw pain, shortness of breath, and diaphoresis. These symptoms are referred to as angina equivalents and can also include fatigue or breathlessness. Some patients may have no symptoms or atypical ones so that CAD may not be diagnosed until they experience a myocardial infarction. (Kennedy-Malone 227) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file. Question 3. Question : A 55-year-old post-menopausal woman with a history of hypertension complains of jaw pain on heavy exertion. There were no complaints of chest pain. Her ECG indicates normal sinus rhythm without ST segment abnormalities. Your plan may include: Echocardiogram CORRECT Exercise stress test Cardiac catheterization Myocardial perfusion imaging Instructor Explanation: Once all the results of the initial laboratory and ECG testing are reviewed, a pretest probability of disease can be generated and additional tests can be ordered.2 The probability of CAD can be calculated by considering the chosen noninvasive test's sensitivity and specificity.2 Selection of the proper cardiac test (see Table 115-1) for an individual depends on the person's risk stratification, age, and tolerable level of activity. The most common and least invasive test for diagnosis of CAD is the stress test, also called the exercise tolerance test (ETT) or treadmill exercise. (Buttaro 488) Buttaro, Terry, JoAnn Trybulski, Patricia Bailey, Joanne Sandberg-Cook. Primary Care, 4th Edition. Mosby, 2013. VitalBook file. Question 4. Question : Jenny is a 24 year old graduate student that presents to the clinic today with complaints of fever, midsternal chest pain and generalized fatigue for the past two days. She denies any cough or sputum production. She states that when she takes Ibuprofen and rest that the chest pain does seem to ease off. Upon examination the patient presents looking very ill. She is leaning forward and states that this is the most comfortable position for her. Temp is 102. BP= 100/70. Heart rate is 120/min and regular. Upon auscultation a friction rub is audible. Her lung sounds are clear. With these presenting symptoms your initial diagnosis would be: Mitral Valve Prolapse Referred Pain from Cholecystitis CORRECT Pericarditis Pulmonary Embolus Instructor Explanation: Pericarditis, inflammation of the pericardium, is usually not a solo disease process but is seen in conjunction with other diseases or conditions. Pericarditis may occur as a complication of MI (Dressler's syndrome) or coronary artery bypass surgery. It is also more commonly seen in patients with connective tissue disorders such as rheumatoid arthritis, systemic lupus erythematosus (SLE), scleroderma, and sarcoidosis. Bacterial, viral, or fungal infections, including HIV, are risk factors for pericarditis. Pericarditis can occur with kidney failure or metastatic neoplasias or as a reaction to medication, particularly phenytoin, hydralazine, and procainamide. Rarely, it is idiopathic and the cause unknown, although a common viral infection is suspected. Cardiac tamponade can occur as a serious complication, and it is an emergency requiring immediate pericardiocentesis. Constrictive pericarditis can occur over time due to scarring of the pericardial sac. Signs and Symptoms Unlike the symptoms associated with ACS, the pain accompanying pericarditis is sharp and stabbing; it may worsen with inspiration or when lying flat or leaning forward. Associated symptoms may include shortness of breath, fever, chills, and malaise. (Goolsby 179) Goolsby, Mary J., Laurie Grubbs. Advanced Assessment Interpreting Findings and Formulating Differential Diagnoses, 3rd Edition. F.A. Davis Company, 11/2014. VitalBook file. Question 5. Question : Which symptom is more characteristic of Non-Cardiac chest pain? Pain often radiates to the neck, jaw, epigastrium, shoulder, or arm CORRECT Pain tends to occur with movement, stretching or palpation Pain usually lasts less than 10 minutes and is relieved by nitroglycerine Pain is aggravated by exertion or stress Instructor Explanation: Palpate chest wall for tenderness and swelling. Chest pain present in only one body position is usually not cardiac in origin. (MSN 194) MSN, Jill C. C., FNP-BC. Family Practice Guidelines: Third Edition, 3rd Edition. Springer Publishing Company, 2014-02-01. VitalBook file. Question 6. Question : What is the most common valvular heart disease in the older adult? Aortic regurgitation CORRECT Aortic stenosis Mitral regurgitation Mitral stenosis Instructor Explanation: Age: Present in 2% to 9% of persons over age 65, aortic stenosis is the most clinically significant cardiac valve lesion (Faggiano, 2006). Isolated aortic regurgitation is rarely seen and is usually accompanied by some degree of mitral valve involvement. Mitral regurgitation is more common than mitral stenosis in elderly individuals. Mitral valve disease, commonly caused by rheumatic heart disease, is usually acquired by younger patients; however, the effects may not be seen until they are in their forties or fifties. Mitral valve stenosis has a progressively slow course with latent symptoms over 20 to 40 years followed by rapid acceleration in later life. (Kennedy-Malone 259) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file. Question 7. Question : Jeff, 48 years old, presents to the clinic complaining of fleeting chest pain, fatigue, palpitations, lightheadedness, and shortness of breath. The pain comes and goes and is not associated with activity or exertion. Food does not exacerbate or relieve the pain. The pain is usually located under the left nipple. Jeff is concerned because his father has cardiac disease and underwent a CABG at age 65. The ANP examines Jeff and hears a mid-systolic click at the 4th ICS mid-clavicular area. The ANP knows that this is a hallmark sign of: Angina Pericarditis CORRECT Mitral valve prolapse Congestive heart failure Instructor Explanation: Mitral valve prolapse Sharp left anterior chest pain, generally occurring in response to stress or emotional events Chest discomfort lasting seconds to days Palpitations and dyspnea Mitral valve click may be noted in systole at left lower sternal border (Buttaro 529) Buttaro, Terry, JoAnn Trybulski, Patricia Bailey, Joanne Sandberg-Cook. Primary Care, 4th Edition. Mosby, 2013. VitalBook file. MVP, also termed click-murmur syndrome, is a variant of mitral regurgitation and occurs in approximately 10% of young women. MVP generally is hemodynamically insignificant and characterized by normal heart size and dynamics, although the process can