NURS 6560 FINAL EXAM 79% (Corrected to 81%) (GRADED 5-6-2019)
NURS 6560 FINAL EXAM (79% GRADED)
This was my FINAL exam for 6560 I just took it, May 2019. It received an 79% grade (corrected grading was 81%). Well worth every penny. The other tests here are old, do not have correct answers, and are not the most updated versions. =) Good luck...we are almost there!!
NURS 6560 MIDTERM EXAM (83% GRADED)
This was my midterm exam for 6560 in April 2019. It received an 83% grade. Well worth every penny. The other test here are old and not the updated versions. =) Good luck...you are almost there!!
NURS6560-Midterm18: All Answers are fully explained. Grade A
S. is a 59-year-old female who has been followed for several years for aortic regurgitation. Serial echocardiography has demonstrated normal ventricular function, but the patient was lost to follow-up for the last 16 months and now presents complaining of activity intolerance and weight gain. Physical examination reveals a grade IV/VI diastolic aortic murmur and 2 lower extremity edema to the midcalf. The AGACNP considers which of the following as the most appropriate management strategy?
A. Serial echocardiography every 6 months B. Begin a calcium channel antagonist C. Begin an angiotensin converting enzyme (ACE) inhibitor D. Surgical consultation and intervention
An ascending thoracic aneurysm of > 5.5 cm is universally considered an indication for surgical repair, given the poor outcomes with sudden rupture. Regardless of the aneurysm’s size, all of the following are additional indications for immediate operation except:
A. Comorbid Marfan’s syndrome B. Enlargement of > 1 cm since diagnosis C. Crushing chest pain D. History of giant cell arteritis
Jasmine is a 31-year-old female who presents with neck pain. She has a long history of injection drug use and admits to injecting opiates into her neck. Physical examination reveals diffuse tracking and scarring. Today Jasmine has a distinct inability to turn her neck without pain, throat pain, and a temperature of 102.1°F. She appears ill and has foul breath. In order to evaluate for a deep neck space infection, the AGACNP orders:
A. Anteroposterior neck radiography B. CT scan of the neck C. White blood cell (WBC) differential D. Aspiration and culture of fluid
Mr. Draper is a 39-year-old male recovering from an extended abdominal procedure. As a result of a serious motor vehicle accident, he has had repair of a small bowel perforation, splenectomy, and repair of a hepatic laceration. He will be on total parenteral nutrition postoperatively. The AGACNP recognizes that the most common complications of parenteral nutrition are a consequence of:
A. Poorly calculated solution B. Resultant diarrhea and volume contraction C. The central venous line used for infusion D. Bowel disuse and hypomotility
Mr. Mettenberger is being discharged following his hospitalization for reexpansion of his second spontaneous pneumothorax this year. He has stopped smoking and does not appear to have any overt risk factors. While doing his discharge teaching, the AGACNP advises Mr. Mettenberger that his current risk for another pneumothorax is:
A. < 10% B. 25-50% C. 50-75% D. > 90
One of the earliest findings for a patient in hypovolemic shock is:
A. A drop in systolic blood pressure (SBP) < 10 mm Hg for > 1 minute when sitting up B. A change in mental status C. SaO2 of < 88% D. Hemoglobin and hematocrit (H&H) < 9 g/dL and 27%
Traumatic diaphragmatic hernias present in both acute and chronic forms. Patients with a more chronic form are most likely to be present with:
The AGACNP is managing a patient in the ICU who is being treated for a pulmonary embolus. Initially the patient was stable, awake, alert, and oriented, but during the last several hours the patient has become increasingly lethargic. At change of shift, the oncoming staff nurse appreciates a profound change in the patient’s mental status from the day before. Vital signs and hemodynamic parameters are as follows: BP 88/54 mm Hg Pulse 110 bpm Respiratory rate 22 breaths per minute SaO2 93% on a 50% mask Systemic vascular resistance (SVR) 1600 dynes ∙ sec/cm5 Cardiac index 1.3 L/min Pulmonary capillary wedge pressure (PCWP) 8 mm Hg This clinical picture is most consistent with which shock state?
A. Hypovolemic B. Cardiogenic C. Distributive D. Obstructive
When counseling patients to prevent postoperative pulmonary complications, the AGACNP knows that with respect to smoking cessation, the American College of Surgeons and National Surgical Quality Improvement Program guidelines are clear that patients who stop smoking _____ weeks before surgery have no increased risk of smokingrelated pulmonary complications.
A. 2 B. 4 C. 6 D. 8
Mitch C. is a 39-year-old male who is brought to the ED by paramedics. According to the report of a neighbor, Mitch was distraught over a breakup with his fiancée and attempted to commit suicide by mixing some chemicals from under his kitchen sink and drinking them; afterward he changed his mind and knocked on his neighbor’s door asking for help. Mitch is awake but stuporous, and the neighbor has no idea what he drank. Visual inspection of his mouth and oropharynx reveals some edema and erythema. He is coughing and has large amounts of pooling saliva. Mitch is not capable of answering questions but he appears in pain. Endoscopy reveals full thickness mucosal injury with mucosal sloughing, ulceration, and exudate. The AGACNP knows that the appropriate course of treatment must include:
A. At least 6 hours of observation in the emergency department B. Periodic esophagram C. Aggressive fluid resuscitation D.Esophagogastrectomy
Jared V. is a 35-year-old male who presents for evaluation of a dry cough. He reports feeling well overall but notices that he gets out of breath more easily than he used to when playing soccer. A review of systems yields results that are essentially benign, although the patient does admit to an unusual rash on his legs. Physical examination reveals scattered erythematous nodules on both shins. There is no drainage, discomfort, or itch. Additionally, diffuse, mildly enlarged lymph nodes are appreciated bilaterally. Results of a comprehensive metabolic panel and complete blood count are within normal limits. Twelve-lead ECG reveals sinus bradycardia at 58 bpm. Chest radiography reveals bilateral hilar and mediastinal lymphadenopathy. The AGACNP suspects:
A. Bronchiectasis B. Pulmonary fibrosis C. Sarcoidosis D.Lung carcinoma
Mrs. Miller is a 44-year-old female who is on postoperative day 1 following a total abdominal hysterectomy. Her urine output overnight was approximately 200 mL. The appropriate response for the AGACNP would be to order:
A.A urinalysis and culture B. 1 liter of NSS over 8 hours C. Encourage increased mobility D.Liberalize salt in the diet
All of the following are risk factors for spontaneous pneumothorax except:
A.Connective tissue disease B. Scuba diving C. Chronic obstructive pulmonary disease (COPD) D.Central line insertion
The AGACNP is going over preoperative information and instructions with a patient who is having a major transverse abdominal procedure tomorrow morning. The patient is very nervous and is asking a lot of questions. The AGACNP prescribes a sleeping agent because he knows that anxiety and sleeplessness may:
A.Lead to hypoxia due to hyperventilation B. Increase the physiologic stress response postoperatively C. Contribute to risk of delirium and prolonged length of stay D.Decrease p.o. intake and produce nutritional risk
In a patient with thyroid nodules, which of the following is the diagnostic study of choice to rule out thyroid cancer?
A. Radioiodine scanning B. Percutaneous needle biopsy C. CT scan D. Ultrasound
When counseling a patient about treatment modalities for achalasia, the AGACNP advised that which of the following is the treatment of choice?
A.Calcium channel antagonists B. Intrasphincter botulinum injection C. Pneumatic dilation D.Myotomy and partial fundoplication
Mr. Liu is a 52-year-old male who has a history of thyroidectomy. He presents complaining of numbness and tingling in his legs and feet and generalized fatigue. Physical examination reveals a positive Chvostek’s sign. Which of the following laboratory studies should be ordered first?
A.Renal function tests B. Parathyroid hormone C. Calcium D.Magnesium
Low magnesium levels in the body can cause numbness, muscle weakness, muscle cramps, convulsions, abnormal eye movements, and generalized fatigue. This condition is known as hypomagnesemia. Three conditions causes a positive Chvostek sign; hypocalcemia, hypomagnesemia , and metabolic alkalosis. From the symptoms presented magnesium level test should be ordered first. Mr. Liu is more likely to be suffering from hypomagnesemia
V. is a 75-year-old male patient who, during a recent wellness evaluation, was found to have a new onset grade II/VI crescendo-decrescendo cardiac murmur at the 2nd intercostal space, right sternal border. He is symptom free and reports no limitations to his usual daily activity. He specifically denies activity intolerance or near syncope, and he is very active physically. Echocardiography reveals a mild aortic calcification. The AGACNP knows that ongoing management for R. V. must include:
A.Annual or biannual serial echocardiography B. Modification of activity level C. Baseline cardiac catheterization D. Statin therapy
From the physical examination, R.V has a murmur of aortic stenosis. Meaning, the aortic calcification has obstructed the flow of blood out of the heart through the aorta. Since he is asymptomatic, there is no need to take any intervention. However, there is need to frequently monitor him for symptoms and an annual or biannual serial echo cardiography, so as to ensure that the calcification is not worsening. If the calcification becomes so severe that is completely blocks the aortic valve, then there will be a need for aortic valve replacement.
Therefore, the correct option is: A. Annual or biannual serial echocardiography.
The lower esophageal sphincter is characterized by periods of intermittent relaxation called transient lower esophageal sphincter relaxations. These relaxations are independent of the relaxation triggered by swallowing and are the most common cause of:
A. Physiologic reflux B. Symptomatic esophagitis C. Barrett’s metaplasia D.Esophageal carcinoma
Transient lower esophageal sphincter relaxations cause a pathological reflux (not physiological reflux) known as GERD (Gastroesophageal reflux disease). The acidic contents of the stomach are able to pass through the loose lower esophageal sphincter and cause ulcerations on the epithelial mucosa. If the condition becomes chronic, then the acid transforms the cells of the esophageal epithelium from squamous cells to columnar cells. This process of cell transformation is known as Barret's metaplasia.
While reviewing morning labs on a postoperative patient, the AGACNP notes that the patient’s basic metabolic panel is as follows: Na 132 mEq/L K 4.6 mEq/L Cl- 87 mEq/L CO2 25 mEq/L A normal saline infusion is ordered in an attempt to avoid:
A.Hyperkalemia B. Hypernatremia C. Metabolic alkalosis D.Metabolic acidosis
Since the normal Cl- levels range between 96 - 106 mEq/L, the patient's Cl- level of 87 mEq/L is below the normal range. Cl- ions are acidic and thus they contribute to the body's acidity.
Since the Cl- levels are below normal, then the patient is at risk of alkalosis. Normal saline can be used to correct Cl- levels since it contains Cl- ions. Therefore, the normal saline given to the patient helps to avoid Metabolic alkalosis.
W. is a 49-year-old man who presents for evaluation. He has a long history of alcohol and tobacco use, with a 65-year pack history and an admitted 14-drink-per-week alcohol habit. He is getting worried because he can no longer swallow his bourbon. He is not a good historian but he does admit to a 1 year history of bloating, heartburn, and progressive difficulty swallowing food. He didn’t worry too much about his symptoms until he stopped being able to swallow bourbon. He thinks he has lost approximately 15 lbs in the last year. He denies any blood in his stool and has not had any vomiting. The AGACNP knows that the most likely diagnosis is:
A.Zenker’s diverticulum B. Achalasia C. Esophageal carcinoma D.Hiatal hernia
Alcohol and tobacco use irritate the epithelium lining of the esophagus and as a result interfere with the opening and closing of the lower esophageal sphincter. When the lower esophageal sphincter is unable to effectively open, then this pathology is known as achalasia. Achalasia causes a buildup of food within the esophagus and can therefore result into bloating and hurtburn. The ineffective opening of the esophagus causes a progressive difficulty in swallowing food.
Which of the following treatment modalities has no role in the treatment of shock?
A.Lactated Ringer’s B. Fresh frozen plasma (FFP) C. Vasopressors D.Colloid solutions
Fresh frozen plasma (FFP) is not one of the treatment modalities that play a role in the treatment of shock. Lactated Ringer's solution is used in the treatment of hemorrhagic shock. Lactated Ringer's solution controls the source of bleeding and replaces the fluid that result from hemorrhagic shock. Colloid solutions are used in the treatment of hypovolemic shock. Colloid solutions have been shown to be more effective than crystalloids. Vasopressors play a role in the treatment of hemorrhagic and hypovolemic shock. For this reason, the fresh frozen plasma (FFP) is the odd one out from the choices
The development of coronary artery disease (CAD) and, ultimately, plaque formation is a multifactorial process that includes endothelial injury from hypertension, cigarette smoking, and dyslipidemia. These events lead to endothelial cell dysfunction, which is theorized to result in:
A.Decreased nitric oxide production B. Smooth muscle cell atrophy C. Collagen degradation D.Enlarged arterial lumen
Mr. Comstock is a 71-year-old male who presents with a general sense of feeling weak and unwell; he thinks he has the flu even though he received a flu vaccination this year. He describes a vague collection of symptoms, including weakness, nausea, dizziness, and “getting out of breath” very easily. He says he can barely climb the steps anymore without stopping to rest. Of the possible differential diagnoses, coronary artery disease (CAD) is high among the probabilities because of his age and gender. His physical examination is unremarkable except that he appears weak. His vital signs are as follows: temperature 98.0°F, pulse 100 bpm, respiratory rate 16 b.p.m., and BP 178/100 mm Hg. A chest radiograph is within normal limits with no acute pulmonary infection. A 12-lead ECG reveals inverted T waves in leads V1 to V5. The AGACNP is suspicious that most of his symptoms are:
A. Psychosomatic B. Early congestive heart failure (CHF) C. Anginal equivalents D.Normal age-related changes
Early congestive heart failure (CHF) occurs when the heart cannot pump enough blood to meet the body's needs. It occurs when the heart pumping efficiency is impaired. The early symptoms of heart failure include; diminished exercise capacity, swelling, and shortness of breath. In class II heart failure, a person may be comfortable at rest but the physical activities such as walking may case shortness of breath fatigue and palpitations. From the symptoms presented, Mr. Comstock might be class II congestive heart failure
Mrs. Carpenter is a 59-year-old female who presents with an acute myocardial infarction. She is acutely short of breath and has coarse rales on auscultation. Physical examination reveals a grade V/VI systolic murmur, loudest at the point of maximal impulse with radiation to the midaxillary line. The AGACP recognizes:
A. Acute mitral valve regurgitation B. Acute aortic valve regurgitation C. Acute cardiac tamponade D. Acute pulmonary embolus
Acute mitral valve regurgitation is associated with fatigue, reduced ability to exercise, shortness of breath when lying flat, palpitations, chest pains and the swelling of the abdomen and veins in the neck. Acute mitral valve regurgitation physical examination includes a grade V/VI systolic murmur that is loudest at the point of maximal impulse with radiation to the midaxillary line. The abnormal heart rhythms make the heart unable to pump effectively. This cases, the murmur at the midaxillary line
Mr. Nelson is a 65-year-old male who has been advised that he is a candidate for coronary artery bypass grafting. He has been doing some internet research and is asking about whether or not he should have a “beating heart” bypass. Regarding off-pump coronary bypass grafting, the AGACNP advises Mr. Nelson that:
A.There is a slightly higher risk of neurologic complications B. Long-term results suggest that the grafts do not stay open as long as those in traditional bypass grafting C. The incidence of off-pump bypass grafting has increased significantly in the last 10 years D.The off-pump procedure is considerably more expensive but is correlated with better long-term outcomes
The traditional methods of performing bypass surgery are not only expensive but they do result in more complications and morbidities. The off pump coronary artery bypass has gained popularity than the traditional methods because it causes less morbidity, inflammation and is more cost effective. Off-pump bypass surgery involves the stabilization of blocked coronary artery by grafting the blood vessel on the pumping heart. As a consequence, the grafts would not stay open as long as those in traditional bypass grafting
Mrs. McCallum is a 48-year-old female who presents for evaluation of a vague set of gastrointestinal symptoms. She feels generally well and has always been healthy, but lately she has had a lot of heartburn and a sense of reflux in her throat. Most recently she has had a recurring sense of food getting stuck in her throat. The AGACNP knows that which diagnostic study should be performed first?
A.Barium swallow B. Upper endoscopy C. Esophageal manometry D.Ambulatory pH monitoring
From the symptoms of heartburn, reflux and the feeling of food getting stuck in the throat; Mrs. McCallum most likely has gastro-esophageal reflux disease (GERD). GERD (gastro-esophageal reflux disease) occurs when the acidic stomach contents are periodically pushed into the esophagus where the acid causes damage to the esophageal epithelium. The gold standard diagnostic study for GERD (gastro-esophageal reflux disease) is ambulatory esophageal pH monitoring. The test determines the presence of excess levels of acid in the esophagus
Mr. Key is a 53-year-old male patient who developed empyema following a serious bout of bacterial pneumonia. He presented as septic and was started immediately on intravenous antibiotics and drainage of the sinus cavity. Forty-eight hours later, he is much improved clinically and drainage has receded. The next step in his care would be:
A.A CT scan B. Eloesser’s procedure C. Decortication D.Reexpansion
Decortication is a procedure that is recommended after the drainage of the sinus cavity and the patient responds positively. Re-expansion is a surgical procedure that gets rid of the restrictive layer of fibrous tissue overlying the diaphragm, chest wall and the lungs. The 53-year-old male patient does not have a chronic empyema and this makes decortication the appropriate procedure. Eloesser's procedure would only be performed if the patient presented with a chronic empyema
Mrs. Bowers is a 41-year-old patient who requires surgical management of osteomyelitis. She has a long history of methamphetamine use and has a BMI of 17.9 kg/m2 . She clearly is nutritionally depleted and volume contracted, but she has no clear chronic medical history except for unmedicated hypertension, which may be due to her chronic stimulant use. She denies alcohol use but admits to a 1½ pack a day cigarette habit. A primary postoperative concern for Mrs. Bowers is:
A.Excess bleeding B. Thromboemboli development C. Poor wound healing D.Renal failure
The congenital diaphragmatic hernia that occurs more often in women and does not usually produce symptoms until midlife is known as:
A.Zenker’s hernia B. Bochdalek’s hernia C. Morgagni’s hernia D.Atraumatic hernia
Atraumatic hernia is a kind of congenital diaphragmatic hernia that occurs more often in women. Atraumatic hernia does not usually produce symptoms until midlife. Atraumatic hernia affects women after midlife. Atraumatic hernia is a rare condition that its effect are secondary in that they do not show up until midlife
B. is a 67-year-old male who is being discharged following inpatient management for unstable angina. S. B. did not know that he had coronary artery disease (CAD) and in fact had not seen a health care provider for many years. While reviewing his lifestyle habits, he admits that he is obese, has poor eating habits, does not engage in any purposeful physical activity, and smokes two packs of cigarettes daily. He verbalizes that he is grateful that this was not a “real” heart attack and does not seem receptive to lifestyle management strategies. The AGACNP advises him that it is important to take this “warning” attack seriously because:
A. 10% of patients with unstable angina will die of cardiovascular disease within 6 months B. 25% of patients with unstable angina will develop congestive heart failure within 6 months C. 65% of patients with unstable angina will have an ST elevation MI within 1 year D. 90% of patients with unstable angina will have cerebrovascular symptoms within 1 year
According to the American College of Surgeons (ACS), who among the following patients should have a chest radiograph as part of preoperative assessment?
A.All patients > 40 years of age B. All patients who smoke cigarettes C. All patients having thoracic procedures D.All patients with cardiac disease
Before surgically operating on any patient with cardiac disease, it is import for a chest radiograph to be done. Through the chest radiograph, effusion, cardiomegally and congestive cardiac failure can be picked out. These conditions complicate surgery and require special surgical preparation. For example, if the cardiac disease has caused cardiomegallt, then the anatomy of the heart and chest cavity will be altered. Also, patients who have developed congestive heart failure from the cardiac disease should not he put on general anaesthesia during surgery. Patients >70 years (not 40 years) should have a chest radiograph to rule out age-related cardiac disease before surgery.
According to the Carpentier classification scheme of mitral valve regurgitation, a type I regurgitation is most likely due to:
A.Cardiomyopathy B. Excessive leaflet motion C. Ruptured papillary muscles D.Rheumatic heart disease
According to Carpentier classification, type I regurgitation occurs due to annular dilatation or a rupture/tear in the leaflet with normal leaflet motion; type III is due to excessive leaflet motion while type III is due to restricted leaflet motion. One of the causes of a rupture/ tear in the leaflet, as seen in type I regurgitation is a rupture of the papillary muscles. Cardiomyopathy and rheumatic heart disease cause restricted leaflet motion which is seen in type III regurgitation. The correct option is therefore C. Ruptured papillary muscles.
V. is a 37-year-old female who is admitted via the emergency room after her roommate called emergency medical services (EMS). She has no significant medical history and does not know what is wrong with her. She has been feeling generally unwell for the last few days, and today she had an episode of confusion that scared her roommate to the extent that the roommate called EMS. Her physical examination reveals a temperature of 101.9°F, pulse of 110 bpm, respiratory rate of 20 breaths per minute, and blood pressure of 92/58 mm Hg. A comprehensive metabolic panel reveals a slightly elevated blood urea nitrogen (BUN)/creatinine but otherwise is normal. A white blood cell differential reveals a leukocyte count of 14,000 cells/µL with neutrophils of 83%. The AGACNP knows that these values are consistent with:
A. Systemic inflammatory response syndrome (SIRS) B. High-output septic shock C. Neurogenic shock D.Multiple organ dysfunction syndrome (MODS)
From the physical examination, V has a fever (temperature of 101.9°F), leukocytosis (leucocyte count of 14,000 cells/microliter) and increased neutraphil levels (83%). A combination of fever, leukocytosis and increased neutrophil levels indicate an infective process/ sepsis. The increased pulse (110 bpm) indicates high-output while the low blood pressure(92/58 mmHg) indicates shock. Therefore, V has an infection which has caused an increase in her heart's output and a decrease in her blood pressure due to increased peripheral resistance. The correct option is thus: B. High-output septic shock
Which shock state is worsened in the setting of mechanical ventilation?
A. Septic B. Cardiac compressive C. Neurogenic D. Cardiogenic
Cardiogenic shock state is worsened in the setting of the mechanical ventilation. Mechanical ventilation has the effect of decreasing venous return due to the external pressure. Additionally, mechanical ventilation increases the right ventricular dilatation shift which reduces the left ventricle filling and cardiac output. We know that cardiogenic shock results from the left ventricular dysfunction. When the mechanical ventilation reduces the left ventricle filling and cardiac output, the cardiogenic shock state is worsened. Mechanical ventilation worsens the left ventricular dysfunction
B. is a 41-year-old male being admitted for surgical reduction of an open femur fracture sustained in a multiple vehicle collision. Preoperative assessment reveals that he is on beta-adrenergic antagonists after having been diagnosed with coronary artery disease approximately 1 month ago. He admits that he feels a little better but says he still gets pain in his chest when he exerts himself. He is pain free now. Vital signs are as follows: temperature 98.1°F, pulse 88 bpm, respiratory rate 18 breaths per minute, and blood pressure 142/86 mm Hg. The AGACNP knows that which of the following is the most important action before R. B. goes to the operating room?
A.A cardiology consultation B. Blood pressure control C. Resuming beta-adrenergic antagonists D. Pain control
R.B's systolic blood pressure is slightly elevated. The normal systolic blood pressure ranges between 120 to 140 mmHg; but R.B has a systolic blood pressure of 142 mmHg, which is slightly elevated. It is important to ensure that his blood pressure is back to normal before he is operated on. Thus, the most important action before he goes to the operating room is Blood pressure control. If not corrected, his elevated blood pressure can cause excessive hemorrhage during the operation.
Cholesteatoma is a condition characterized by a collection of desquamated keratin leading to bony erosion in the ossicular chain and inner ear. The goal of surgery in cholesteatoma is:
A. Production of a dry ear B. Preservation of sensorineural hearing C. Debridement of infection D.Restoration of the tympanic membrane
The principal goal of cholesteatoma surgery is the removal of the disease. The main aim of cholesteatoma surgery is to completely remove the cholesteatoma. For this reason, the cholesteatoma surgery targets the cholesteatoma with an aim of removing the infection from the body. For this reason, the goal of cholesteatoma surgery is the debridement of infection
The AGACNP knows that when managing a patient with acute cardiogenic shock after myocardial infarction, all of the following pharmacologic agents may be used except:
A.Opioids B. Diuretics C. Beta-adrenergic antagonists D.Anticholinergics
Patients with acute cardiogenic shock following myocardial infarction can be treated using: statins, diuretics, opiods, ACE inhibitors, anti-platelet therapy, aldosterone blockers and beta-adrenergic antagonists. Anticholinergics should be avoided in these patients since they decrease the blood supply to the myocardial tissues of the heart, thus they put the patient at risk of a another myocardial infarction.
Mr. Baer is a 79-year-old man who is being admitted for a carotid endarterectomy. While performing his preoperative evaluation, the AGACNP appreciates two positive answers to the CAGE screening questionnaire. This is an indication for:
A. Perioperative benzodiazepines for withdrawal syndrome B. Daily multivitamin and 100 mg of thiamine perioperatively C. Further diagnostic evaluation for alcoholism D.Delay of operation until completion of detoxification
The appreciation of two positive answers to the CAGE screening questionnaire means the patient should be evaluated for alcoholism. Essentially, a CAGE questionnaire is designed to be a screening instrument rather than being a diagnostic test. For this reason, two positive answers call for additional diagnosis for alcoholism in the patient. The CAGE screening questionnaire results indicate the need for further alcoholism diagnosis
According to the American College of Cardiology Foundation and the American Heart Association (ACCF/AHA), the recommendation regarding antiplatelet therapy in patients with cardiovascular disease preoperatively is that:
A.Antiplatelet therapy should be held for 10 days preoperatively B. Cardiac consultation is required before an operation in patients who are on antiplatelet therapy C. Medications should be continued unless concerns about hemostasis are significant D.Antiplatelet therapy should be initiated in all high-risk cardiac procedures
According to the American College of Cardiology Foundation and the American Heart Association (ACCF/AHA), antiplatelet theory should be used by high-risk patients presenting with invasive procedures. Both the start and discontinuation of antiplatelet therapy can result in significant risks. The intensity of the antiplatelet therapy is associated with increased bleeding risk
Mr. Austin is a 64-year-old male who has a long history of mitral valve stenosis. His condition has developed to the extent that he has symptomatic congestive heart failure, and due to a variety of comorbidities he is not a candidate for surgery. Ongoing medical therapy for Mr. Austin should include:
A.Anticoagulants B. Diuretics C. Antibiotics D.Inotropes
The ongoing medical therapy for Mr. Austin should include diuretics. Diuretics not only manage the mitral valve stenosis but also the congestive heart failure. Diuretics can decrease the preload and hypervolemia when the congestive heart failure symptoms are present. Additionally, the diuretics can help decrease the congestion and prevent atrial tachyarrhythmias.
The progression of coronary artery plaque formation can lead to a variety of pathologic conditions. When subtotal plaque disruption occurs resulting in vasoconstriction, platelet activation, and embolization, it most commonly causes which clinical phenomenon?
A.Endothelial cell dysfunction B. Prinzmetal’s angina C. Transmural myocardial infarction D.Non-ST elevation myocardial infarction
When plaque forms within the coronary artery, it obstructs the flow of blood within the artery. Since the myocardium receives its blood supply from the coronary artery, the obstructed blood flow predisposes the patient to myocardial infarction. The plaque also causes platelet activation and vasocontriction of the coronary artery. On EGC examination, the ST-wave is usually normal (not elevated). Thus, the subtotal plaque disruption causes Non-ST elevation myocardial infarction.
D. is a 29-year-old male who presents with a chief complaint of profound dizziness for the past 2 to 3 days. Further clarification reveals that he is having brief but intense episodes of a sense of the room spinning. He denies any history of head injury or discharge from the ear. The vertigo is reproduced easily with cervical rotation. The AGACNP knows that the most likely cause is:
A.Cerebral tumor B. Ménière’s disease C. Adverse drug effect D.Benign paroxysmal positional vertigo (BPPV)
Benign paroxysmal positional vertigo (BPPV) refers to a spinning position and dizziness that occurs with certain head movements such as cervical rotation. Since the vertigo (spinning sensation and dizziness) occurs when D does a cervical rotation, then the most likely cause is Benign paroxysmal positional vertigo (BPPV). Brain tumors that would cause vertigo are cerebellar tumours (not cerebral tumors) since the cerebellum has a role in the maintenance of body balance. Meniere's disease is a disorder of the inner ear and presents with ear discharge; but D does not have ear discharge. Also, she does not have a history of drug medications, thus rules out adverse drug effect.
The correct option is therefore: Benign paroxysmal positional vertigo (BPPV).
P.T. is a 61-year-old male who is seen in follow-up. He was initially seen for evaluation of dysphagia. An endoscopy was negative for malignancy and subsequent esophageal manometry supported a diagnosis of esophageal achalasia. While discussing implications and treatment options with P.T., the AGACNP tells him that the primary complication of achalasia is:
A. Progressive esophageal discomfort B. Aspiration pneumonia C. Squamous cell carcinoma D.Long-term malabsorption problems
Achalasia results into obstructed movement of food down the esophagus. It causes ulcerations along the esophagus which present as discomfort and pain while swallowing (dysphagia). As the ulcerations progress to become wider and deeper, the pain and discomfort worsens. Thus, the primary complication for achalasia is progressive esophageal discomfort. Over time, the ulcerations can transform to become malignant and cause squamous cell carcinoma. Therefore, squamous cell carcinoma is the secondary complication of achalasia.
The correct option is thus: A. Progressive esophageal discomfort
R. is a 51-year-old female who presents in shock following a penetrating injury to the spinal cord—her boyfriend reportedly stabbed her in the back with an unidentified kitchen utensil. The patient’s mental status is deteriorating, and her vital signs are as follows: temperature 97.2°F, heart rate 131 bpm, respirations 14 breaths per minute, and blood pressure 79/49 mm Hg. The AGACNP presumes neurogenic shock, with the injury likely:
A.Not fully transecting the spinal cord B. At the level of T10 C. Precipitating sepsis D. Producing cardiovascular decompensation
The AGACNP presumes neurogenic shock, with the injury has not fully transected the spinal cord. This is because the patient's respiratory system has not been affected. The patient is having the normal respirations of 14 breaths per minute. This means the injury has not fully transected the spinal cord. Generally, the higher the injury on the spinal cord, the more the dysfunctions. In this case, the patient has experienced less dysfunction which indicates that the injury did not fully transect the spinal cord. The injury is not at the level of T10 because the patient has suffered fewer dysfunctions.
Janet is a 34-year-old female with no significant medical history who is being evaluated for a planned uterine ablation. She has significant history of menorrhagia and has been unresponsive to a variety of medical therapies to try to stop the bleeding. Her history and physical examination are within normal limits. The AGACNP knows that Janet will require which one of the following preoperative diagnostic studies?
A. Urinalysis B. Complete blood count C. 12-lead electrocardiogram D.Chest radiography
Since Janet has a significant history of menorrhagia and has been unresponsive to a variety of medical therapies to try to stop bleeding, a complete blood count test should be used as a diagnostic test. A complete blood count test should be administered in order to evaluate the iron deficiency and other conditions such as blood clotting abnormalities or thyroid disorders. A complete blood count include testing for hemoglobin, white blood cell count, platelet count, coagulation and thyroid levels in the body in order to detect the pituitary gland issues that causes menstrual abnormalities. For this reason, the AGACNP knows that Janet will require a complete blood count preoperative diagnostic studies
Best practices for assessing diseases of the thyroid gland include a thorough but targeted history, systematic physical examination, and selective use of appropriate diagnostic evaluation. The AGACNP knows that although serum T3 and T4 are not indicated routinely, a free T4 test is most useful in evaluating patients:
A.With profound symptoms of hypothyroidism B. Following treatment for Graves’ disease C. To rule out autonomous toxic nodule D. At risk for thyroid cancer
Although the TSH (Thyroid Stimulating Hormone) levels are often used to determine a diagnosis of hypothyroidism, when hypothyroidism symptoms are profound, then the free T4 (thyroxine) levels should also be assessed as a confirmatory test. Free T4 levels that are low indicate hypothyroidism. If TSH levels are normal or high, but T4 levels are low, then the findings confirm a diagnosis of hypothyroidism.
Evaluation of cardiac valve disease must include:
A.Chest radiography B. 12-lead ECG C. Echocardiography D.Chemical stress test
Jolene L. is a 36-year-old female who presents for an emergent cholecystectomy; she has had progressive acute pain for almost 1 week and now there is concern about gangrenous tissue. Of particular concern is the fact that she has Graves’ disease and has not been adherent to treatment. On admission, her temperature is 102.7°F, pulse is 158 bpm, and blood pressure is 180/114 mm Hg. She is tremulous and anxious. A 12-lead ECG reveals uncontrolled atrial fibrillation. Before cholecystectomy, Jolene must be treated with:
A.Digitalis for heart rate control B. Radioactive ablation C. Beta-adrenergic antagonists D.Reserpine
W. is discussing his postoperative hip replacement expectations. He is advised that although he will have some discomfort, he should be vocal about asking for pain medication, because it is essential that he get out of bed and begin ambulating as soon as possible after his surgery. He expresses some fear and is concerned that his hip won’t heal properly if he walks on it. The AGACNP reassures him that he must begin ambulating quickly in order to decrease risk for:
A. Decubitus ulcers B. Scar tissue formation C. Pneumonia D.Anxiety
Decubitus ulcers, also known as bed sores, develop with prolonged pressure on the skin. Immobility is one of the causes of bed sores. Therefore, early ambulation reduces the risk for decubitus ulcers. The ulcers develop in areas of the skin with bony prominences such as the hips, ankles and heels
H. is a 71-year-old male with small cell lung cancer; he has been treated with chemotherapy. Initially he had symptom improvement but now appears to have had a recurrence. On examination today, he is quite edematous and has gained 12 lbs since his office visit 1 week ago. A metabolic panel reveals a serum Na of 119 mEq/dL. The AGACNP knows that J. H. likely has:
A.Brain metastasis B. Congestive heart failure (CHF) C. Syndrome of inappropriate antidiuretic hormone (SIADH) D.Metabolic alkalosis
• SIADH is the pathologic state where the kidneys are not appropriately clearing free water.
• It can also be defined by the hyponatremia and hypo-osmolality resulting from inappropriate, continued secretion or action of the antidiuretic hormone arginine vasopressin (AVP) despite normal or increased plasma volume, which results in impaired water excretion. The excess accumulation of water due to anti-diuresis accounts for the weight gain seen in the patient.
• Some of the causes of SIADH include certain cancers such as lung cancer, brain tumors and some GIT tumors. Some drugs have also been shown to cause SIADH, an example is amiodarone.
According to the American College of Surgeons (ACS) and the National Surgical Quality Improvement Program (NSQIP) guidelines for preoperative evaluation of the geriatric patient, the preoperative evaluation should include all of the following except:
A.Cognitive ability B. Functional status C. Competency assessment D. Frailty score
Improvements in both equipment and technique have led to the evolution of video-assisted thoracoscopic surgery (VATS) as being used most commonly for:
A.Mediastinal lymph node dissection B. Resection of malignant tumor C. Metastasectomy D.Thoracic vertebral discectomy
• Video assisted thoracoscopic surgery (VATS) is a minimally invasive surgical approach to the management of thoracic/ chest problems.It is a newer approach that has been preferred due to lower surgical trauma risk, minimal post operative pain, earlier patient mobilization and decreased patient hospital stay
• The procedure has gained fame due to the preference of use for metastasectomy of the lungs. The patients who have lung metastases usually have a significant reduction of their survival. The procedure enables the resection of the part of the lung with the metastasis as part of a lobectomy for instance without making the conventional thoracotomy incision
Which of the following is a normal finding on postoperative day 8 of a carotid endarterectomy?
A.A temperature of 100.5°F B. Serosanguinous drainage with some tenderness C. A flesh-colored induration along the entire length of the incision D.A fluctuant collection of milky fluid
• The healing process after surgery takes quite a while and undergoes several stages of healing. The incision site is always monitored for signs of infection which can hamper and slow the healing process if it occurs
• The signs of an infection would include a fever and thus the temperature of 100.5 Fahrenheit is elevated and hence abnormal finding
• A sero-sanguinous drainage is a thin, watery drainage composed of both blood and serum that may appear slightly pink from the small number of red blood cells that are present. This discharge is normal in the early stages of healing, as the blood is present in small amounts.
• A fluctuant collection of milky fluid may imply formation of an abscess which is an abnormal finding. A flesh coloured induration along the entire length of the incision is also an abnormal finding
Walden University-NURS 6560 Final Exam Latest Study Guide
NURS 6560 Final Exam Study Guide
Liver Biliary Tract, Pancreas, Spleen
Resection of the liver and regeneration and follow up labs pp 546-548
Types of Hepatic Resections: anatomical (based on segmental liver anatomy) and
Follow Up Labs after Resection:
Complications post op resection: include perihepatic fluid collectiaons which may require drainage, hepatic insufficiency (hyperbilirubinemia, ascites, coagulopathy) common but resolves, pleural effusions, atelectasis, and pneumonia (tx with aggressive pulmonary toilet post op).
Hepatic Trauma Post op complications:
Spontaneous Rupture of the Liver:
Primary Liver Cancer:
Hepatocellular Carcinoma (HCC): 85-95% of primary hepatic cancers
Treatment for Liver Cancer: Resection, translation, liver direct therapy, ethanol injection, ablation, embolization and systemic therapy
Ethanol Injection: Tx for Liver Cancers:
Radio-frequency Ablation (RFA): TX for Liver Cancers
Arterial Embolization: TX for Liver Cancers
Metastatic Neoplasms of the Liver:
Hepatic hemangiomas :
Acutely Bleeding Varices
Treatment of Acute Bleeding
Critical initial Steps:
Treatment for whose who have bled:
Extrahepatic Portal Venous Occlusion (Doherty, 573)
Splenic Vein Thrombosis (Doherty, 574)
Splenectomy is curative.
Budd-Chiari Syndrome (Doherty, 575)
Hepatic Encephalopathy (Doherty, 577)
Hepatic Abscess (Doherty, 579)
Cholangitis (bacterial cholangitis)
CT scan is the diagnostic study of choice.
Nonsurgical drainagePancreatic insufficiency
DX Test: Secretin or Cholecystokinin
Fecal Fat Balance Test
Adenocarcinoma of the Pancreas
S/Sx: carcinoma of the head of the pancreas presents with wt loss, obstructive jaundice, and deep-seated ABD pain in 75% of patients. Back pain occurs in 25% of patient and is associated with a worse prognosis.
Smaller tumors of the pancreas have less pain
Wt loss averages 20lbs (44kg)
Hepatosplenomegaly present in half of patients but does not necessarily indicate spread to the liver.
Palpable mass found in 20% of patients nearly always signifies surgical incurability
Jaundice is unrelenting in most patients, fluctuates in about 10%. Jaundice is often accompanied by pruritus, especially of the hand and feet.
Palpable nontender gallbladder in a jaundiced patient suggests neoplastic obstruction of the common duct (COURVOISIER sign) most often d/t pancreatic cancer this is present in about half patient
Diff/DX: the other periampullary neoplasm carcinoma of the ampulla of Vater distal common bile duct or duodenum may also present with pain wt loss, obstructive jaundice and palpable gallbladder. Preoperative cholangiography and gastrointestinal xrays may suggest the correct diagnosis, but laparotomy may be required.
Lab findings and test for:
Hypersplenism (Doherty page 635): Overactive spleen, exaggeration of normal splenic function primarily associated with red pulp. In the past the term hypersplenism or increased splenic function have been used to denote the syndrome characterized by splenic enlargement, deficiency of one or more of the cell lines, normal or hyperplastic cellularity or deficient cell lines in the marrow, and increased turnover of the effected cells.
Hypersplenism is not synonymous with hypersplenism.
Leukemia and lymphoma are diagnosed by marrow aspiration, lymph node biopsy, and examination of the peripheral blood (white count and differential).
Spherocytosis there are spherocytes, osmotic fragility is increased, and platelets and white cells are normal.
Thalassemia major become apparent in early childhood, and the blood smear morphology is characteristic.
Myelofibrosis the bone marrow shows proliferation of fibroblasts and replacement of normal elements
Idiopathic thrombocytopenia purpura (ITP) the spleen is normal or only slightly enlarged and the marrow is fatty.
Before it become palpable an enlarged spleen may cause dullness to percussion above the left costal margin. Splenomegaly is manifested on supine x-ray of the abdomen by medical displacement of the stomach and downward displacement of the transverse colon and splenic flexure. CT scan is useful for differentiating the spleen from other abdominal masses and for demonstrating splenic enlargement or intrasplenic lesions.
Treatment options (please see table 27 -2 on page 636 for surgery options):
The course, response to treatment and prognosis of hyper-splenic syndromes differ widely depending one the underlying disease and its response to treatment and will be decided for or against splenectomy.
Splenectomy may decrease transfusion requirements decrease the incidence and number of infections and prevent hemorrhage and reduce pain.
The course of congestive splenomegaly due to portal hypertension depends upon the degree of venous obstruction and liver damage.
Hypersplenism is rarely a major problem and is almost always overshadowed by variceal bleeding or liver dysfunction.
Chronic Lymphocytic Leukemia (pg. 637)
CLL is a low-grade neoplasm of B cell lineage characterized by accumulations of populations of lymphocytes that are mature morphologically but functionally incompetent.
Makes up 25-30% of all leukemias, mean age dx of 72
Initially causes little to no pain, eventually causes massive splenomegaly.
Most symptoms related to the spleen are from thrombocytopenia and anemia due to hypersplenism.
Decreased cellular production from the bone marrow is another cause of cytopenia.
Splenectomy corrects thrombocytopenia in 70-85% of cases, neutropenia is 60-70% of cases, and anemia in 50-60% of cases.
Myelodysplastic Syndrome (pg. 637)
Heterogenous group of clinical hematopoietic stem cell disorders manifested by pancytopenias, and dysplasia of the bone marrow.
Pathologic changes include extensive bone marrow fibrosis, extramedullary hematopoiesis in the spleen and liver, and a leukoerythroblastic blood reaction that may evolve into acute myeloid leukemia over time.
Bone marrow is usually completely replaced by fibrous tissue.
Symptoms are attributable to anemia (weakness, fatigue, dyspnea) and to splenomegaly (abd fullness, pain).
Pain over spleen from splenic infarcts is common.
Spontaneous bleeding, fatigue, secondary infection, bone pain, and hypermetabolic state are frequent.
Portal hypertension develops in some cases as a result of fibrosis of the liver, increased splenic blood flow or both.
Hepatomegaly is present in 75% of cases and splenomegaly with a firm and irregular spleen in all cases.
Splenectomy often provides relief.
Primarily supportive using transfusions, androgenic steroids, antimetabolites and hematopoietic growth factors.
New therapies include immunomodulatory drugs like thalidomide or antibodies to VEGF and TNF.
Splenectomy indicated in the following: major hemolysis unresponsive to medical treatment, severe symptoms of massive splenomegaly with mass effect of the spleen, life threatening thrombocytopenia, portal hypertension with variceal hemorrhage
Hemolytic Anemia (pg. 641)
Essentials of diagnosis
Signs and Symptoms
Immune Thrombocytopenia Purpura (ITP) (pg. 642)
Essentials of diagnosis
Symptoms and signs
Intestines, Hernias, and Abdominal Wall Lesions
Small Bowel Obstruction:
Short bowel syndrome
symptoms <3 months
1st Tests To Order
erect chest x-ray
plain abdominal x-ray
Consider malignancy in all patients who present with large bowel obstruction.
o Suspect bowel perforation where there is persistent tachycardia, fever, and/or abdominal pain and tenderness
o Differentials- acute colonic pseudo-obstruction, chronic/idiopathic megacolon, toxic megacolon, endometriosis
o Treatment Options: Presumptive- acutely ill: supportive measures, suspected or impending perforation, emergency surgery
no peritonitisor mucosal gangrene
flexible or rigid sigmoidoscopy
peritonitis or mucosal gangrene
foreign body ingestion
transluminal removal or laparotomy
treat underlying cause
percutaneous or transrectal drainage
Cancer – Third leading cause of cancer deaths in the US in men and women.
Rare below 40 years of age. Key Factors
o 1st Tests To Order
Treatment Options: Acute
rectal cancer, suitable for surgery