Transcript
NSG6420 QUIZ 3
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?
Student Answer:
Seasonal allergies
Acute bronchitis
Bronchial asthma
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)
Points Received:
2 of 2
Comments:
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?
Student Answer:
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.
Points Received:
2 of 2
Comments:
Question 3.
Question :
Emphysematous changes in the lungs produce the following characteristic in COPD patients?
Student Answer:
Asymmetric chest expansion
Increased lateral diameter
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)
Points Received:
2 of 2
Comments:
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:
Student Answer:
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)
Points Received:
2 of 2
Comments:
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?
Student Answer:
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
Points Received:
0 of 2
Comments:
Question 6.
Question :
Which of the following imaging studies should be considered if a pulmonary malignancy is suspected?
Student Answer:
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)
Points Received:
2 of 2
Comments:
Question 7.
Question :
A 26-year-old, non-smoker, male presented to your clinic with SOB with exertion. This could be due to:
Student Answer:
Exercise-induced cough
Bronchiectasis
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)
Points Received:
2 of 2
Comments:
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:
Student Answer:
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)
Points Received:
2 of 2
Comments:
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?
Student Answer:
Pulmonary edema
Heart failure
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)
Points Received:
2 of 2
Comments:
Question 10.
Question :
A cough is described as chronic if it has been present for:
Student Answer:
2 weeks or more
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)
Points Received:
2 of 2
Comments:
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?
Student Answer:
Chest X-ray
Methacholine challenge test
Spirometry, both with and without bronchodilation
Ventilation/perfusion scan
Instructor Explanation:
MedU Card #10
Points Received:
2 of 2
Comments:
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:
Student Answer:
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
Points Received:
2 of 2
Comments:
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:
Student Answer:
Age over 40
Fever greater than 101
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)
Points Received:
2 of 2
Comments:
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:
Student Answer:
High-dose inhaled corticosteroid and leukotriene receptor antagonist
Oral corticosteroid—high and low dose as appropriate
Short acting beta2 agonist inhaler and theophylline
Low dose inhaled corticosteroid and long acting beta2 agonist inhaler
Instructor Explanation:
MedU Card #16
Points Received:
2 of 2
Comments:
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:
Student Answer:
Can be treated as an outpatient
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)
Points Received:
0 of 2
Comments:
Question 16.
Question :
Which of the following is considered a “red flag” when diagnosing a patient with pneumonia?
Student Answer:
Fever of 102
Infiltrates on chest X-ray
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)
Points Received:
2 of 2
Comments:
Question 17.
Question :
A 23-year-old patient who has had bronchiectasis since childhood is likely to have which of the following:
Student Answer:
Barrel-shaped chest
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)
Points Received:
2 of 2
Comments:
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:
Student Answer:
Legionnaires' disease
Malaria
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)
Points Received:
2 of 2
Comments:
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:
Student Answer:
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)
Points Received:
2 of 2
Comments:
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:
Student Answer:
Pulmonary embolism
Pleural effusion
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.