NSG 554/ NSG554 Exam 3 V1 – Nurse Practitioners in Primary Care I Guide| Wilkes (Latest 2026/ 2027 Update) 100% Verified Questions & Answers | Grade A

NSG 554/ NSG554 Exam 3 V1 – Nurse Practitioners in Primary Care I Guide| Wilkes (Latest 2026/ 2027 Update) 100% Verified Questions & Answers | Grade A Signs and symptoms of a MI -substernal chest pain or discomfort that radiates to the jaw, left shoulder or arm -Dyspnea, nausea, diaphoresis, syncope Diagnostics to confirm MI -Cardiac myocyte necrosis (myoglobin, CK-MB and troponin I and T) -without ST-elevation, abnormal CK-MB or troponin=MI -ECG changes (new Q waves, ST elevation/depression, T-wave flattening/inversion Gouty arthritis Sudden onset and frequently nocturnal Common precipitants are alcohol (beer) Gouty arthritis diagnostics -Serial measurements of serum uric acid -Increased WBC Sodium urate crystals in joint fluid aspirated from tophus -xray later in dx=punched-out erosions with an overhanging rim of cortical bone develop "rat bite" adjacent to soft tissue tophus -Smaller tophi imaged by US Acute gout tx 1. NSAIDS- full dose of naproxen 500 mg BID or indomethacin 25-50 mg Q8 until symptoms resolve (contraindicated in PUD, decreased kidney function) 2. Colchicine-Good if duration of attach is less than 36 hours -Loading dose=1.2mg then 0.6 mg 1 hour later for prophylaxis -0.6mg BID 3. Corticosteroids- IV or PO, 5-10 days with taper 4. Interleukin-1 inhibitors- anakinram canakinumab, and rilonacept not FDA approved Rheumatoid arthritis: Signs and Symptoms- Joints -joint symptoms: symmetric swelling of multiple joints with tenderness and pain -stiffness longer than 30 mins in the morning -may reoccur after daytime inactivity or be more severe after strenuous activity -fingers, wrists, knees, ankles, MTP joints Rheumatoid arthritis: Signs and Symptoms- Rheumatoid nodules - subcutaneous nodules most common over bony prominences -can also occur in the bursae and tendon sheaths -lungs, sclerae, other tissue Rheumatoid arthritis: Signs and Symptoms-Ocular symptoms -dryness of eyes, mouth, mucus membranes especially in advanced disease -episcleritits, scleritis, scleromalacia d/t nodule Rheumatoid arthritis: Signs and Symptoms- Other symptoms -interstitial lung disease -pericarditits -pleural disease -palmar erythema -felty syndrome=splenomegaly, neutropenia Rheumatoid arthritis: lab tests -Anti-CCP antibodies= most specific -rheumatoid factor (IgM)= can occur in other autoimmune disease -ESR and CRP usually elevated based on disease activity Rheumatoid arthritis: imaging -radiographic changes most specific -1st 6 months of symptoms usually normal Rheumatoid arthritis: treatment categories -Corticosteroids -DMARDs: -Synthetic -Biologic DMARDs -Combination DMARDs RA: tx corticosteriods -low-dose for anti-inflammatory (5-7.5 mg) -"bridge" to reduce disease activity RA: tx DMARDs Synthetic (Methotrexate) Methotrexate: usually initial med, well tolerated, effects in 2-6 weeks -7.5-10 mg PO weekly -increase if not response X 1 month -SE: gastric irritation/stomatitis -Rare: cytopenia, hepatoxicity (decrease ETOH) -Monitor LFTs every 12 weeks with a CBC -SE can be reduced with daily folate or weekly leucovorin calcium -teratogenic RA: tx DMARDs Synthetic (Sulfasalazine) Sulfasalazine: 2nd line agent, taper to 3g from 0.5g SE: neutropenia, thrombocytopenia -hemolysis in patients with G6PD def so level should be checked before starting -CBC every 2-4 weeks for the first 3 months then every 3 months RA: tx DMARDs Synthetic (Leflunomide) Leflunomide: Pyrimidine synthesis inhibitor, single daily dose of 20 mg -SE: diarrhea, rash, reversible alopecia, hepatotoxicity -teratogenic, 1/2 life 2 weeks RA: tx DMARDs Synthetic (Antimalarials) Antimalarials: Hydroxychloroquine for mild dx, may be used in combination with other DMARDs -need ophthalmologic exemptions every 12 months Janus Kinase Inhibitors tofacitinib or baricitinib for severe RA that is refractory of methotrexate RA: Biologic DMARDs- Tumor Necrosis Factor Inhibitors -pro-inflammtory cytokine added to patients who have no responded adequately to methotrexate or as initial therapy with methotrexate for patients with poor prognosis -increased risk of bacterial infections, granulomatous infections, reactivate of TB (screening is mandatory prior to starting) *abatacept, rituximab, tocilizumab RA: Combination DMARDs most common used combination= methotrexate with a TNF inhibitor or methotrexate, sulfasalazine and hydroxychloroquine Systemic Lupus Erythematosus: Systemic S&S -fever, malaise, anorexia, weight loss, "butterfly" rash, panniculitis (lupus profundus), alopecia, Raynaud phenomenon Systemic Lupus Erythematosus: Joint S&S with or without active synovitis as an early manifestation Systemic Lupus Erythematosus: Ocular S&S conjunctivitis, photophobia, transient or permanent monocular blindness, blurring vision cotton-wool spots on the retina Systemic Lupus Erythematous: Other pleurisy, pleural effusion, cardiac arrhythmias, hematologic, neurologic complications Osteoarthritis (DJD) -most common joint dx -increases with age -characterized by degeneration of cartilage and by hypertrophy of the bone at the articular margins -inflammation is minimal -heredity and mechanical factors involved in pathogenesis -Risk factors: obesity, recreational running, competitive contact sports, bending/carrying objects frequently Osteoarthritis medication: NSAIDs -NSAIDs; celecoxib only selective cox-2 inhibitor -SE: GI toxicity, renal, increased bleeding time Osteoarthritis medication: Topical therapies -topical NSAIDs -knee and hand -lower rates of systemic SE than oral -early treatment with mild OA especially hand/knee Osteoarthritis medication: Acetaminophen -mild OA -not 1st line for hip/knee Osteoarthritis medication: Intrarticular injections -moderate/severe knee who do not respond to NSAIDs -corticosteroid, hyalurate or platelet rich plasma -not for LT pain or increasing function -not for OA of hand Diagnostic tests for carpal tunnel: Tinel sign tingling or shock like pain on solar wrist percussion Diagnostic tests for carpal tunnel: Phalen sign pain or paresthesia in distribution of median nerve when patient flexes both wrists to 90 degrees for 60 seconds Diagnostic tests for carpal tunnel: Carpal compression test -numbness/tingling induced by direct application of pressure over the carpal tunnel -may be more sensitive and specific -muscle weakness or atrophy especially of the thenar eminence can appear later than sensory disturbances Olecranon bursitis -bursitis presents with focal tenderness and swelling and is less likely to affect range of motion of the adjacent joint -olecranon causes an oval swelling at the tip of the elbow and does not affect. joint motion -tenderness, erythema and warmth, cellulitis, report of trauma, and evidence of a skin lesion are more common in septic bursitis but can be present with aseptic -1/3 with septic olecranon bursitis are afebrile Olecranon bursitis: tests -acute swelling/redness needs to be aspirated to rule out infection (esp. if pt is febrile) -most often staphylococcus aureus olecranon bursitis: treatment NSAIDs, heat, rest, local corticosteroid injection -chronic bursa swelling does not require aspiration -aspiration of site requires a zig zag approach by pulling skin over bursa before introducing it to reduce chronic drainage site Bouchard nodes and Herberden nodes -bony enlargements of the distal interphalangeal joints of the fingers, thumb (Heberden) and -proximal interphalangeal joints (Bouchard) Lumbar spinal stenosis: common findings -pain worsens with extension -reproducible single or bilateral leg symptoms that are worse after walking and relieved with sitting ("neurogenic claudication") -limited extension of the lumbar spine which may reproduce symptoms radiating down the legs Reflexes and spinal involvement: L1 & L2 no reflex Reflexes and spinal involvement:L3 and L4 Knee jerk Reflexes and spinal involvement: L5 Babinski Reflex Reflexes and spinal involvement: S1 Ankle jerk Reflexes and spinal involvement: S2 knee flexor Reflexes and spinal involvement: S2-S4 Anal reflex, rectal tone Lachman test -Performed with patient lying supine, knee flexed to 20-30 degrees. Examiner grasps distal femur from the lateral side and the proximal tibia with the other hand on the medial side -with the knee in neutral position, stabilize the femur and pull the tibia anteriorly using a similar force to lifting 10-15 lb weight -excessive anterior translation of the tibia compared with the other side indicated injury to the ACL McMurry test -Patient lying supine; clinician flexes the knee until the patient reports pain -this test is valid if pain free for beyond 90 degrees -external rotation of patients foot then extends the knee while palpating the medial knee for "click" in the medial compartment or pain reproducing pain from a meniscus injury -to test lateral meniscus: the same maneuver is repeated while rotating the foot internally Modified McMurry -Performed with the hips flexed to 90 degrees -Knee is flexed maximal with internal or external rotation of the lower leg -Knee can be rotated with the lower leg in internal/external rotation to capture the torn meniscus understand the condyles -Positive test is pain over the joint line while the knee is being flexed and internally or externally rotated Spurling Test -Involves asking the patient to rotate and extend the neck to one side -Apply a gentle axial load to the neck -Reproduction of the cervical radiculopathy symptoms is a positive sign of nerve root compression Subtalar tilt test -foot in neutral position with the patient sitting -one hand to fix the tibia and the other to hold and invert the calcaneus -normal inversion at the subtalar joint is approx. 30 degrees -A positive test consist of increased subtalar joint inversion greater than 10 degrees on the affected side with loss of endpoint for the calcanofibular ligament Upper GI bleed -hematemesis or melon -bright red or brown "coffee grounds" -melena, palpitations, dizziness, SOB. Upper GI bleed causes -Peptic Ulcer Disease -Portal HTN (esophageal varices; gastric/duodenal varices; portal hypertensive gastropathy) -Mallory-Weiss Tears (lacerations of the gastroesophageal junction) -Vascular Anomalies (most common: Angioectasias (angiodysplasias) -Gastric neoplasms -Erosive gastritis/esophagitis Lower GI bleed Bright red blood in stool or drips after BM Lower GI bleed causes -Diverticulosis (most common cause; acute, painless, large-volume maroon or bright red blood hematochezia); angioectasias; neoplasms; inflammatory bowel disease (especially ulcerative colitis); anorectal disease (hemorrhoids/fissures); ischemic colitis Crohn Disease -most cases involve small bowel and colon -transmural process which results in mucosal inflammation and ulceration, stricturing, fistula development and abscess formation -cigarette smoking strongly associated with development Crohn's Disease: Sign and Symptoms (Chronic inflammatory disease) *Most common presentation -Malaise, weight loss, loss of energy -with ileitis/ileocolitis = diarrhea (non bloody/intermittent) -with rectum/left colon = bloody diarrhea, fecal urgency (mimics ulcerative colitis) -Cramping/steady right lower quadrant/periumbilical pain -On PE focal tenderness: usually RLQ, palpable tender mass that is thickened or matted loops of inflamed intestine Crohn's Disease: Sign and Symptoms (Intestinal obstruction) -Narrowing of the small bowel as a result of inflammation, spasm or fibrotic stenosis -Postprandial bloating, cramping, loud borborygmi -occurs with active inflammatory symptoms or later in dx with chronic fibrosis Crohn's Disease: Sign and Symptoms (Penetrating disease & fistula) -sinus tracts that penetrate though the bowel where they may be contained or form fistulas to adjacent structures -Penetration through the bowel can result in iata-abdominal or retroperitoneal phlegm or abscess (fever, chills, tender abdominal mass, leukocytosis) -Fistulas between the small intestine and colon are usually asymptomatic but can results in diarrhea, weight loss, bacterial overgrowth and malnutrition * Fistulas to the bladder produce recurrent infection * Fistulas to the vagina produce malodorous drainage/problems with personal hygiene Crohn's Disease: Sign and Symptoms (Perianal Disease) -1/3 of patients with small or large bowel involvement develop perianal disease -Large painful skin tags, anal fissures, perianal abscesses, fistulas Crohn's Disease: Sign and Symptoms (Extaintestinal Manifestations) -Can be seen with CD and UC -Arthralgia's, arthritis, iritis or uveitis, pyoderma gangrenous or erythema nodosum -Oral aphthous lesions common -Increased prevalence of gallstones -Nephrolithiasis Ulcerative Colitis -Idiopathic inflammatory condition involving the mucosal surface of the colon -Results in diffuse friability and erosions with bleeding -Periods of symptomatic flare-ups and remission -Bloody diarrhea is hallmark ** -Severity based on stool frequency, presence & amount of rectal bleeding, cramps, abdominal pain, fecal urgency, tenesmus and extra intestinal symptoms -PE should focus on volume status (orthostatic BPs + pulse + nutrition status) -Abdominal examination look for tenderness, evidence of peritoneal inflammation; red blood may be present on digital rectal examination Ulcerative colitis: Mild 4 stools per day 90 HR Normal hematocrit & albumin, no weight loss, normal temperature 20 ESR Ulcerative colitis: Moderate 4-6 stools per day 90-100 HR 30-40% hematocrit 1-10% weight loss 99-100 temperature 20-30 ESR 3-3.5 albumin Ulcerative colitis: Severe 6 mostly bloody stools per day 100 HR 30% hematocrit 10% weight loss 100 temperature 30 ESR 3 albumin Ulcerative Colitis: Signs and Symptoms - Mild to moderate disease -Fewer than 4-6 bowel movements/day -mild to moderate rectal bleeding -no constitutional symptoms -stools may be formed or loose -Rectal inflammation = fecal urgency & tenesmus -LLQ cramps relieved by defecation -No significant pain or tenderness -Mild anemia and hypoalbuminemia Ulcerative Colitis: Signs and Symptoms - severe -More than 6 bloody bowel movements/day -Severe anemia, hypovolemia, impaired nutrition with hypoalbuminemia -Abdominal pain/tenderness present -"Fulminant colitis" subset of severe disease characterized by rapid worsening symptoms with signs of toxicity Diverticulitis -Macroscopic inflammation of a diverticulum that may reflect a spectrum from inflammation alone to micro perforation with localized paracolic inflammation to macroperforation with either abscess or vernalized peritonitis Diverticulitis: Signs and Symptoms -Localized inflammation/infection= mild/moderate aching abdominal pain usually LLQ -Constipation or loose stools -Frequent N/V Diverticulitis: Physical examination findings -Low-grade fever -LLQ tenderness, palpable mass -Stool occult blood common (hematochezia is rare) -Leukocytosis is mild/moderate * Pts with free perforation present with more generalized abdominal pain and peritoneal signs Irritable Bowel Syndrome -Idiopathic clinical entity characterized by chronic (more than 3 months) abdominal pain that occurs in association with altered bowel habits -Abdominal pain with at least 2 of the following 3: 1. Related to defecation 2. Associated with a change in frequency of stool 3. Associated with a change in form of stool * abdominal pain should be present on average of at least 1 day/week * other S&S include: abnormal frequency, form, passage, bloating, distention * women more likely IBS: Somatic/psychological complaints -Dyspepsia -Heartburn -Chest pain -Headaches -Fatigue -Myalgias -Urologica dysfunction -Gynecologic symptoms -Anxiety/depression IBS: Signs & Symptoms -Abdominal pain that is intermittent, cramps and in lower abdominal region -Associated with change in stool frequency/form and may be improved or worsened with defecation -PE is normal; abdominal tenderness in lower abdominal is common but not pronounced IBS Categories 1. IBS with diarrhea 2. IBS with constipation 3. IBS with mixed constipation & diarrhea 4. IBS not subtyped IBS with constipation -Infrequent BM of less than 3 per week -Hard/lumpy stools -Straining IBS with diarrhea -Loose/watery stools -Frequent stools (more than 3 per day) -Urgency -Fecal incontinence IBS "Alarm symptoms" -Suggest a diagnosis other than IBS & warrant further investigation - Acute onset esp. older than 40-50 yrs - Nocturnal diarrhea, severe constipation or diarrhea, hematochezia, weight loss, fever Hepatitis A -transmitted by fecal-oral rout by either person to person contact or ingestion of contaminated food/water Hepatitis A incubation period -30 days; excreted in feces up to 2 weeks before clinical illness Hepatitis A: Signs and Symptoms *more severe in adults than children (usually asymptomatic) - onset abrupt & insidious with malaise, arthralgia, easy fatiguability, upper respiratory symptoms, anorexia -distaste for smoking may occur early -Nausea and vomiting are frequent and constipation/diarrhea may occur -Low grade fever -Defervescence and fall in pulse rate coincide with onset of jaundice -Abdmoinal pain mild/constant in RUQ or epigastrium -- aggravated by jarring/exertion -Jaundice occurs 5-10 after initial symptoms Hepatitis A: Signs and Symptoms with jaundice -Prodromal symptoms worsen followed by progressive clinical improvement -stools may be acholic -hepatomegaly -splenomegaly -soft, enlarged lump nodes- esp. cervical & epitrochlear Hepatitis A: Acute illness timeframe -Subsides over 2-3 with complete clinical and laboratory recovery by 9 weeks -May have 1-2 relapses -Can be complicated by acute cholecystitis Hepatitis B -Transmitted by inoculation of infected blood or blood products or by sexual contact -Present in saliva, semen, vaginal secretions -can be transmitted during delivery Hepatitis B: Incubation period -6 weeks to 6 months -Average 12-14 weeks Hepatitis B: signs and symptoms -ranges from asymptotic without jaundice to acute liver failure and death -onset may be abrupt or insidious -Low grade fever -fall of pulse with onset of jaundice -Acute illness subsides over 2-3 weeks with complete clinical/laboratory recovery by 16 weeks -May become chronic Acute Cholelithiasis (Gallstones) -more common in women -over age 60 -classified according to chemical composition as cholesterol or calcium bilirubinate stones Acute Cholelithiasis: Signs and Symptoms (asymptomatic) - Asymptomatic, normal lab feature, no treatment Acute Cholelithiasis: Signs and Symptoms (symptomatic gallstones) -Biliary pain, normal lab features, dx via US, tx with laparoscopic cholecystectomy Acute Cholelithiasis: Signs and Symptoms (cholesterolosis of gallbladder) -Usually asymptomatic, normal lab features, dx with oral cholecystography, tx none Acute Cholelithiasis: Signs and Symptoms -Classic biliary pain "episodic" -Infrequent episodes of steady/severe pain in epigastrium or RUQ with radiation to right scapula -Detected on US Acute cholecystitis Usually occurs when a stone become impacted in the cystic duct and inflammation develops behind the obstruction Acute cholecystitis signs and symptoms -Acute attack often precipitated by large/fatty meal -Sudden appearance of steady pain localized to the epigastrium or right hemochondrium which may subside in 12-18 hours -Vomiting with variable relief -Fever -RUQ tenderness (often with Murphy Sign - inhibition of inspiration by pain on palpation of the RUQ); usually associated with muscle guarding/rebound tenderness -15% with palpable gallbladder -25% jaundice (may suggest choledocholithiasis) Acute Pancreatitis -Abrupt onset of deep epigastric pain, often with radiation to the back (worsened with walking and laying supine; better with sitting and leaning forward) -Often relates to alcohol intake -Nausea, vomiting, sweating, weakness - Abdominal tenderness and distention (usually without guarding, rigidity or rebound) -Fever -Leukocytosis, elevated serum amylase & serum lipase Psoas Sign -Pain on passive extension of the right hip -indicative of appendicitis Obturator Sign -Pain with passive flexion and internal rotation of the right hip -indicative of appendicitis Arrhythmias after MI: Sinus Bradycardia -Inferior infarctions or precipitated by medications -Observation/withdrawal of offending agents -Accompanied by signs of low cardiac output, atropine IV is usually effective -Temp pacing rarely required Arrhythmias after MI: Supraventricular tachyarrhythmias -ST is common d/t either increased adrenergic stimulation or hemodynamic compromise -Electrolyte abnormalities/hypoxia should be corrected and causative agents stopped (aminophylline) -Afib controlled with IV beta-blockers, short acting esmolol, amiodarone ; CV os necessary Arrhythmias after MI: Ventricular arrhythmias -Most common in the first hours after in fact and marker of high risks -Sustained VT tx with lidocaine if pt is stable or CV if not -Procainamide, amio, -Vfib = shock -accelerated idoventricular should not be treated with antiarrhythmics which can cause asystole Arrhythmias after MI: Conduction disturbances -Block at the level of the AV node is more common than infra nodal block and occurs with inferior MIs -1st degree: most common, no tx -2nd degree: usually Mobitz type 1 (wenckebach)- tx only is assoc. with low HR -Complete HB: IV atropine, temp pacing * anterior infarcts= site of the block is distal, below the AV node and usually a result of extensive damage of His-Purkinje system -urgent pacing or PPM if 2nd or 3rd degree block Superficial venous thrombophlebitis -usually saphenous vein involved -PICC/venous catheterization may be cause -Usually caused by staphylococcus aureus -Can occur spontaneously often in pregnant/PP women or those with varicose veins; can be secondary to abdominal cancer -Can be associated with occult DVT Superficial venous thrombophlebitis: Signs and symptoms -Dull pain in the region of the involved vein -Local induration, redness, tenderness along course of vein -inflammatory subsides in 1-2 weeks; firm cord may remain for longer -edema is uncommon Superficial venous thrombophlebitis: Treatment -Local heat and NSAIDs -anticoagulation is not usually required (prophylactic low-molecular-weight heparin or fondaparinux recommended for 5cm or longer superficial thrombophlebitis of the lower limb veins -full anticoagulation reserved for concern of extension into the deep system or rapid progression Superficial venous thrombophlebitis: Treatment (septic superficial thrombophlebitis) -intavasulcar abscess require urgent tx with heparin or fondaparinux to limit thrombus formation -Abx, if positive cultures therapy for 7-10 days or 4-6 weeks with endocarditis -surgical excision if necessary to control infection DVT treatment abdominal aortic aneurysms: general Diameter exceeds 3cm - rarely rupture unless diameter exceeds 5cm AAA: signs and symptoms -asymptomatic: usually discovered on US or CT as part of screening -Pain: expansion may be accompanied by mild-severe mid abdominal pain, exacerbated by gentle pressure -Rupture: severe pain, palpable abdominal mass, hypotension AAA: imagine US is diagnostic study of choice for initial screening -CT assessment of diameter -Routine screening of 2 years for smaller than 4 cm, 6 month for 5cm AAA: Screening via US 65-75 men current/past smokers AAA: treatment Elective repair if larger than 5.5cm Thoracic aneurysms D/T atherosclerosis usually asymptomatic Substernal/back of neck pain may occur DX with CT Doppler/vascular findings Ankle-brachial index- below 0.9 Levels below 0.4 = critical limb ischemia