NSG 554/ NSG554 Exam 1 V1 – Nurse Practitioners in Primary Care I Guide| Wilkes (Latest 2026/ 2027 Update) 100% Verified Questions & Answers | Grade A

NSG 554/ NSG554 Exam 1 V1 – Nurse Practitioners in Primary Care I Guide| Wilkes (Latest 2026/ 2027 Update) 100% Verified Questions & Answers | Grade A 1. A small, rural hospital is part of an Accountable Care Organization (ACO) and is designated as a Level 1 ACO. What is part of this designation? a. Bonuses based on achievement of benchmarks b. Care coordination for chronic diseases c. Standards for minimum cash reserves d. Strict requirements for financial reporting ANS: A A Level 1 ACO has the least amount of financial risk and requirements, but receives shared savings bonuses based on achievement of benchmarks for quality measures and expenditures. Care coordination and minimum cash reserves standards are part of Level 2 ACO requirements. Level 3 ACOs require financial reporting 2. What was an important finding of the Advisory Board survey of 2014 about primary care preferences of patients? a. Associations with area hospitals b. Costs of ambulatory care c. Ease of access to care d. The ratio of providers to patients ANS: C As part of the 2014 survey, the Advisory Board learned that patients desired 24/7 access to care, walk-in settings and the ability to be seen within 30 minutes, and care that is close to home. Associations with hospitals, costs of care, and the ratio of providers to patients were not part of these results. 3. Which statement made by a health care provider demonstrates the most appropriate understanding for the goal of a performance report? a. "This process allows me to critique the performance of the rest of the staff." b. "Most organizations require staff to undergo a performance evaluation yearly." c. "It is hard to be personally criticized but that's how we learn to change." d. "The comments should help me improve my management skills." ANS: D The goal of the performance report is to provide guidance to staff in the areas of professional development, mentoring, and leadership development. A peer review is written by others who perform similar skills (peers). The remaining options may be true but do not provide evidence of understanding of the goal of this professional requirement. 4. Which assessment question would a health care provider ask when engaging in the previsit stage of the new model for primary care? (Select all that apply.) a. "Are you ready to discuss some of the community resources that are available?" b. "Are you experiencing any side effects from your newly prescribed medications?" c. "Do you anticipate any problems with adhering to your treatment plan?" d. "Are you ready to discuss the results of your laboratory tests?" e. "Do you have any questions about the lab tests that have been ordered for you?" ANS: B, C, E The nursing responsibilities in the previsit stage include assessing the patient's tolerance of prescribed medications, understanding of existing treatment plan, and education about required lab testing. The primary care provider is responsible for screening lab data and discussing community resources during the actual visit. 5. To reduce adverse events associated with care transitions, the Centers for Medicare and Medicaid Service have implemented which policy? a. Mandates for communication among primary caregivers and hospitalists b. Penalties for failure to perform medication reconciliations at time of discharge c. Reduction of payments for patients readmitted within 30 days after discharge d. Requirements for written discharge instructions for patients and caregivers ANS: C As a component of the Affordable Care Act, the Centers for Medicare and Medicaid Service developed the Readmissions Reduction Program reducing payments for certain patients readmitted within 30 days of discharge. The CMS did not mandate communication, institute penalties for failure to perform medication reconciliations, or require written discharge instructions. 6. According to multiple research studies, which intervention has resulted in lower costs and fewer rehospitalizations in high-risk older patients? a. Coordination of posthospital care by advanced practice health care providers b. Frequent posthospital clinic visits with a primary care provider c. Inclusion of extended family members in the outpatient plan of care d. Telephone follow-up by the pharmacist to assess medication compliance ANS: A Research studies provided evidence that high-risk older patients who had posthospital care coordinated by an APN had reduced rehospitalization rates. It did not include clinic visits with a primary care provider, inclusion of extended family members in the plan of care, or telephone follow-up by a pharmacist. 7. A primary care provider administers the "Newest Vital Sign" health literacy test to a patient newly diagnosed with a chronic disease. What information is gained by administering this test? a. Ability to calculate data, along with general knowledge about health b. Ease of using technology and understanding of graphic data c. Reading comprehension and reception of oral communication d. Understanding of and ability to discuss health care concerns ANS: A The "Newest Vital Sign" tests asks patients to look at information on an ice cream container label and answer questions that evaluate ability to calculate caloric data and to grasp general knowledge about food allergies. It does not test understanding of technology or directly measure reading comprehension. It does not assess oral communication. The "Ask Me 3" tool teaches patients to ask three primary questions about their health care and management. 8. What is the main reason for using the REALM-SF instrument to evaluate health literacy? a. It assesses numeracy skills. b. It enhances patient-provider communication. c. It evaluates medical word recognition. d. It measures technology knowledge. ANS: C The Rapid Estimate of Adult Literacy in Medicine-Short Form (REALM-SF) is an easy and fast tool that measures medical word recognition. It does not evaluate numeracy. The "Ask Me 3" tool enhances patient-provider communication. This tool does not evaluate understanding of technology. 9. A female patient who is from the Middle East schedules an appointment in a primary care office. To provide culturally responsive care, what will the clinic personnel do when meeting this patient for the first time? a. Ensure that she is seen by a female provider. b. Include a male family member in discussions about health care. c. Inquire about the patient's beliefs about health and treatment. d. Research middle eastern cultural beliefs about health care. ANS: C It is important not to make assumptions about beliefs and practices associated with health care and to ask the patient about these. While certain practices are common in some cultural and ethnic groups, assuming that all members of those groups follow those norms is not culturally responsive. 10. Which behavior is most characteristic of early adolescence? a. Arguing with parents and teachers b. Assimilating adult roles and thinking c. Exhibiting fatigue more frequently d. Experimenting with sex and risky behaviors ANS: A Early adolescents challenge authority, experience wide mood swings, reject the ideation of childhood, and can be argumentative and disobedient. Middle adolescents experience fatigue and begin experimenting with sex and risky behaviors. Late adolescents begin to assimilate adult roles. 11. What is the initial sign of puberty in the adolescent male? a. Deepening of the voice b. Elongation of the penis c. Nocturnal emissions d. Testicular enlargement ANS: D Testicular enlargement is the initial sign of puberty in adolescent males. Penile growth and nocturnal emissions occur later as does deepening of the voice. 12. What is the focus of the Minority Stress Theory? a. Clarifying the various terms used to describe the LGBTQ community b. Understanding the health needs of select members of the sexual minority community c. Helping health care providers eliminate biases in the care they provide to the members of the LGBTQ community d. Facilitating the management of stress related to the lifestyle choices made by members of sexual minority populations. ANS: B The focus of the Minority Stress Theory is to provide a framework to the understanding of the health disparities in the sexual and gender minority (SGM) communities. The theory may help achieve some aspect of the other options, but that is not its focus. 13. What is the medical diagnostic term used to identify transgender patients? a. Gender dysphoria b. Gender expression disorder c. Gender identity disorder d. Gender role unconformity ANS: A Gender dysphoria is the term used to identify transgender patients in order to justify the medical necessity of treatments for transgender patients. It replaces the previous "gender identity disorder" designation. 14. A woman who is currently pregnant reports that she has had three previous pregnancies: twins delivered at 35-weeks gestation (both living), one at 38-weeks gestation (living), and one miscarriage at 16-weeks gestation. How will this be recorded as her G/TPAL in her electronic medical record? a. G4P:1113 b. G4P:1213 c. G5P:1113 d. G5P:1213 ANS: A Using the notation G (number of pregnancies), T (term deliveries), P (preterm deliveries), A (abortions—elective or spontaneous), and L (living children), this patient is G4P:1113. She is in her fourth pregnancy, so is G4. She has had one delivery at 38 weeks or more, one delivery (of twins) at less than 36 weeks gestation, one spontaneous abortion, and has three living children. 15. A pregnant woman who is overweight has no previous history of hypertension (HTN) or diabetes mellitus (DM). Her initial screening exam reveals a blood pressure of 140/90 and a fasting blood glucose of 128 mg/dL. What will the practitioner do? a. Initiate insulin therapy. b. Monitor blood pressure and fasting blood glucose closely. c. Prescribe an antihypertensive medication. d. Refer the patient to a high-risk pregnancy specialist. ANS: B This woman, although she has no previous history of HTN or DM, is at elevated risk because of obesity. Her initial screening lab values are at the high end of normal, indicating potential development of gestational HTN and gestational DM. The initial response of the practitioner should be to monitor the patient closely and consider treatment at the first signs of development of these complications. Referral is warranted when these conditions become severe. 16. The mother of a 3-day-old newborn reports that her infant health care providers every 4 hours during the day and sleeps 6 hours at night. What will the provider recommend? a. Awakening the baby every 3 hours to health care provider b. Continuing this schedule until the infant is 6 months old c. Ensuring that her infant health care providers for 15 to 20 minutes each time d. Pumping her breasts to maintain her milk supply ANS: A Newborn infants should health care provider 8 to 12 times daily and mothers should be encouraged to awaken a sleepy baby to health care provider every 2 to 3 hours or more often. The feedings will gradually space out as the infant is older. 17. An infant who has just begun nursing develops hyperbilirubinemia. What will the provider tell the mother? a. To decrease the frequency of breastfeeding b. To supplement feedings with extra water c. To switch to formula until the bilirubin level drops d. To use a breast pump to increase her milk supply ANS: D Infants with suboptimal breastfeeding can have starvation jaundice and mothers should be encouraged to increase the frequency of breastfeeding and should be offered a breast pump to increase milk supply. It is not recommended to supplement with water or sugar water or to switch to formula. 18. A mother who has been breastfeeding her infant for several weeks develops a fever, breast warmth, and breast tenderness. What will the provider recommend? a. Ice packs and decreased frequency of nursing b. Ice packs and increased frequency of nursing c. Warm packs and decreased frequency of nursing d. Warm packs and increased frequency of nursing ANS: D This mother has symptoms of mastitis. She should be encouraged to use warm packs for comfort and to increase the frequency of nursing to relieve the pressure. 19. A pregnant woman reports not having had any vaccinations as a child but requests vaccines during her pregnancy. Which vaccines may be given? (Select all that apply.) a. Human papillomavirus (HPV) b. Inactivated influenza c. Live, attenuated influenza d. Measles, mumps, and rubella (MMR) e. Tetanus, diphtheria, and acellular pertussis (Tdap) f. Varicella ANS: A, B, E Tdap is recommended to pregnant woman, optimally between 27- and 36-weeks gestation. Inactivated is strongly recommended and may be given at any point in the pregnancy. Hepatitis B is given to women at risk if needed. Live, attenuated influenza vaccine, MMR, and varicella vaccines are not recommended during pregnancy. 20. An unaccompanied teenager is being treated in the emergency department for stomach pains. Which statement would alert the health care provider to the possibility that the patient may be a victim of human trafficking? a. "I can't pay to see a doctor." b. "I've never been to a hospital before." c. "You are being very nice to me." d. "Please, please, don't hurt me." ANS: D Victims of human trafficking may display a profound fearfulness during examination often focusing on being hurt. None of the other options provide such a trigger for suspicion since poverty and unfamiliarity with established health care providers is not uncommon. 21. What assessment data would trigger the health care provider's suspicion that the patient seen in the emergency department may be a victim of human trafficking? (Select all that apply.) a. Provides details related to cause of injury b. Appears to be illiterate c. Has "$50" tattooed on the left shoulder blade d. Cannot provide a local address of residence e. Looks much younger than state age of 21 ANS: B, C, D, E Victims of sex trafficking may appear younger than their stated age, demonstrate learning disabilities, and have unusual tattoos. Often, the victim will not be able to provide their address, identification documents, and they can be unaware of their location or date. Such a patient is likely to present vague or inconsistent stories related to their illness or injury. 22. An international traveler plans to travel to Kenya in sub-Saharan Africa. Which is an important disease precaution for this person? a. Carrying chloroquine to take as needed b. Starting prophylactic doxycycline before travel c. Taking precautions against Chikungunya fever d. Understanding how Ebola virus is transmitted ANS: B Malaria is a greater concern worldwide than Ebola virus and Chikungunya fever, although both are emerging diseases. Travelers should take antimalarial medications and, in this part of Africa, where there is widespread resistance to chloroquine, doxycycline is a better choice as prophylaxis. Even when chloroquine is appropriate, it must be taken prior to travel and not as needed. Chikungunya fever is a disease of the Western Hemisphere, especially in the Caribbean. Ebola virus is epidemic in western Africa and not in Kenya. 23. A patient who is planning international travel to a developing country asks the provider about vaccinations. Which is true about pretravel vaccines? a. Country-specific guidelines are provided by individual embassies. b. Malaria vaccine is the most important vaccine for worldwide travel. c. Requirements should be reviewed at least 4 to 6 weeks prior to travel. d. There are at least five required vaccines for entry into certain countries. ANS: C Patients seeking immunizations prior to international travel should have these reviewed at least 4 to 6 weeks prior so that antibody responses and completion of vaccine series may occur. Country-specific guidelines may be found on the CDC website. Malaria is not prevented by vaccine, but by prophylactic antimalarial drugs. There are only two vaccines that are required. 24. What is a goal of the Healthy People initiative? a. To increase a patient's quality of life b. To create physical environments that promote proper health c. To achieve health equality by eliminating disparities d. To provide free health care to those unable to pay for care e. To promote healthy behaviors across all life stages ANS: C Overarching goals of the Healthy People initiative are to increase quality and length of life, free of preventable disease, disability, injury, and premature death; to achieve health equality by eliminating disparities; to create social and physical environments that promote proper health; and to promote increased quality of life, healthy development, and healthy behaviors across all life stages, all goals consistent with the definition of wellness. Free health care is not a stated goal of the initiative. 25. A woman who is obese has a neck circumference of 16.5 cm. Which test is necessary to assess for complications of obesity in this patient based on this finding? a. Electrocardiography b. Gallbladder ultrasonography c. Mammography d. Polysomnography ANS: D Women with a neck circumference greater than 16 cm have an increased risk of obstructive sleep apnea and should have polysomnography to assess for this complication. The other tests may be necessary for obese patients but are not specific to this finding. 26. Which medications are associated with weight gain? (Select all that apply.) a. Antibiotics b. Antidepressants c. Antihistamines d. Insulin analogs e. Anticonvulsants ANS: B, C, D, E Antidepressants, antihistamines, insulin and insulin analogs, and seizure medications are all associated with weight gain. Antibiotics are not associated with weight gain. 27. During a preplacement screening for a person hired for a job requiring heavy lifting, a primary care provider notes that a history of gastroesophageal reflux disease (GERD), recurrent eczema, a previous history of an ankle fracture, and normal lower back strength and flexibility. A urine drug screen is negative. What will be included in the report to the employer? (Select all that apply.) a. GERD history b. History of allergies and eczema c. History of ankle fracture d. Lower back screening results e. Urine drug screening results ANS: D, E Only findings related to the ability of the individual to perform position requirements for the job are included in the report. Other findings should not be included, even though they may need to be addressed. 28. A female college student seeks information about emergency contraception. What is the most important part of the assessment of this patient? a. Cultural considerations for use of contraception b. Feelings of guilt about a possible pregnancy c. Possible concerns about confidentiality d. The female's sense of control in sexual situations ANS: D Because college women are at greater risk for sexual violence and assault, a request for emergency contraception must be followed by an evaluation of possible rape or assault. The other considerations may be part of the assessment but are not as important as determining whether a rape has occurred. 29. A female freshman college student tells the primary care provider at the student health center that she has a history of anorexia nervosa that has been well-controlled for several years. What will the provider recommend for this student? a. Dietary counseling b. Participation in sports c. Regular weight assessments d. Stress management strategies ANS: D Students with previous eating disorders may regress when stressed, so stress management is essential. Unless she begins to regress, dietary counseling is not indicated. Many who participate in sports will develop eating disorders to control weight. It is not necessary to evaluate weight regularly. 30. Which patient should have pulmonary function testing as part of the presurgical exam? a. A patient older than 60 years of age b. A patient undergoing major intrathoracic surgery c. A patient with a history of pneumonia in the last 2 years d. A patient with diabetes and morbid obesity ANS: B Any patient undergoing major thoracic surgery should have pulmonary function testing. Age over 60 years, a history of pneumonia, and diabetes and obesity do not require pulmonary function testing unless there is comorbid COPD. 31. During a preparticipation sports physical, the examiner notes a difference in strength of the patient's radial and femoral pulses with the femoral pulses being weaker. What will the provider do? a. Evaluate for orthostatic hypotension. b. Obtain Doppler studies of lower extremity circulation. c. Reassure the patient that this is a normal finding. d. Refer the patient for a cardiologic exam. ANS: D Differences in strength between radial and femoral pulses may indicate coarctation of the aorta and should be evaluated by a cardiologist. This finding does not indicate orthostatic hypotension. The likelihood of decreased circulation is low in a young athlete. 32. A high-school adolescent is being screened for fitness before participating in sports. The adolescent has a normal examination and the examiner notes S1 and S2 heart sounds without murmur, normal blood pressure, and equal pulses. The parent reports that the adolescent's father has a history or Wolff-Parkinson-White syndrome, which has been treated. What will the provider do? a. Clear the adolescent to play sports. b. Perform an electrocardiogram. c. Refer the adolescent to a cardiologist. d. Tell the adolescent that sports are not allowed. ANS: C A positive family history of Wolff-Parkinson-White syndrome requires physician consultation or referral before medical clearance can be given. The adolescent has a normal heart rate and physical exam, so the ECG may not yield significant or useful results. The examiner cannot clear the adolescent without consulting with a specialist. The adolescent may be cleared for sports by the specialist. 33. An overweight adolescent who takes metformin has type 2 diabetes with a HgA1C of 8.5% and asks about sports participation. What will the provider recommend? a. Losing weight prior to initiating sports participation b. Participation in strenuous sports to help with weight loss c. Referral to the endocrinologist for sports clearance d. Switching to insulin therapy prior to participation ANS: C Patients with poorly controlled diabetes should be referred to a specialist prior to clearance for sports participation. This patient has an elevated HgA1C, indicating poor control. The endocrinologist may suggest the other options, but the primary care provider should not clear this patient for participation in sports. 34. A patient diagnosed with asthma has been prescribed three bronchodilator treatments but continues to experience wheezing and shortness of breath. The health care provider caring for the patient notes an oxygen saturation of 90% on room air. What action is indicated? a. Administer oxygen and continue to monitor the patient. b. Contact the respiratory therapist to administer another treatment. c. Notify the patient's physician immediately. d. Reassure the patient that the treatments will take effect soon. ANS: C Patients with bronchospasm who have oxygen saturations less than 92% on room air and who fail to improve with nebulizer treatment given three times, need physician consultation. While oxygen administration and further nebulizer treatments may be indicated, it is incorrect to continue to monitor the patient without notifying the physician. 35. Which symptom in a patient diagnosed with asthma indicates severe bronchospasm? a. Breathlessness with minimal activity or eating b. Pausing to breathe while attempting to talk c. Repetitive, spasmodic coughing at night d. Wheezing after exposure to a trigger ANS: B Inability to speak a full sentences in severe bronchospasm. Breathlessness, repetitive and spasmodic coughing, and wheezing are all common signs of bronchospasm and do not necessarily indicate severe bronchospasm. 36. Which clinical findings are worrisome in a patient experiencing acute bronchospasm, requiring immediate treatment? (Select all that apply.) a. A silent chest after previously wheezing b. Decreasing blood pressure c. Presence of an urticarial rash d. Pulsus paradoxus of 10 mm Hg e. Wheezing on both inspiration and expiration ANS: A, B, C A silent chest indicates severe spasm and is an ominous sign. Decreasing blood pressure and urticarial rash are present with anaphylaxis, which is a respiratory emergency requiring oxygen, diphenhydramine or epinephrine. A pulsus paradoxus greater than 25 mm Hg is worrisome. Wheezing on inspiration and expiration is a common finding and not necessarily an emergency. 37. A man self-administers aqueous epinephrine after experiencing a bee sting and developing angioedema and wheezing. What should the man do next? a. Obtain transport to an emergency department immediately. b. Repeat the epinephrine dose if needed and notify a physician of the episode. c. Resume normal activity if symptom free after 30 to 60 minutes. d. Take oral diphenhydramine and report any symptoms to a provider. ANS: A The man has a history of anaphylaxis and experienced symptoms after contact with a trigger. The aqueous epinephrine should be used immediately but does not prevent the need for follow up in an emergency department for close observation, since continued reaction to the allergen can occur for 6 to 8 hours. The epinephrine dose may be given if needed before emergency personnel arrive, but a second dose is not enough to prevent ongoing reaction to the allergen. 38. A child experiences a snake bite while camping and is seen in the emergency department. The child's parents are not able to identify the type of snake. An inspection of the site reveals two puncture wounds on the child's arm with no swelling or erythema at the site. The child has normal vital signs. Which treatment is indicated? a. Administering antivenom and observing the child for 24 to 48 hours b. Cleaning the wound, giving tetanus prophylaxis, and observing for 12 hours c. Performing a type and cross match of the child's blood d. Referral to a surgeon for incision and suction of the wound ANS: B The child does not have immediate symptoms of envenomation, since there is no swelling or erythema. Because symptoms may be delayed, and the type of snake is unknown, the child should be observed in an ED or hospital for 12 hours after providing wound care and tetanus prophylaxis. Antivenom is not indicated unless envenomation occurs. Type and cross match is done if envenomation is severe. Incision and suction of the sound is not recommended. 39. A patient is seen in the emergency department after experiencing a spider bite. The spider is in a jar and is less than one inch in size, yellow-brown, and has a violin-shaped marking on its back. Depending on the patient treatments and diagnostic evaluations may be ordered? (Select all that apply.) a. Airway management b. An acute abdominal series c. Antivenom therapy d. CBC, BUN, electrolytes, and creatinine e. Coagulation studies f. Tetanus prophylaxis ANS: D, E, F The spider is a brown recluse. If the patient exhibits systemic symptoms, laboratory workup, including CBC, BUN, creatinine, electrolytes, and coagulation studies should be performed. Tetanus prophylaxis is given. Airway management, an acute abdominal series, and antivenom therapy are used for black widow spider bites. 40. A patient prescribed a beta blocker medication is in the emergency department with reports of syncope, shortness of breath, and hypotension. A cardiac monitor reveals a heart rate of 35 beats per minute. Which medication may be used to stabilize this patient? a. Adenosine b. Amiodarone c. Atropine d. Epinephrine ANS: D Epinephrine is indicated if unstable bradycardia is caused by beta blockers. This patient is symptomatic and unstable and should be treated. Adenosine and amiodarone are used to treat tachycardia. Atropine is used for some types of bradycardia, but not when induced by beta blockers. 41. A patient reports heart palpitation but no other symptoms and has no prior history of cardiovascular disease. The clinic provider performs an electrocardiogram and notes atrial fibrillation and a heart rate of 120 beats per minute. Which is the initial course of action in treating this patient? a. Administer atenolol intravenously. b. Admit to the hospital for urgent cardioversion. c. Refer the patient to a cardiologist. d. Initiate steps to begin anticoagulant therapy. ANS: C This patient has no history of serious heart disease and does not have symptoms of chest pressure, acute MI, or congestive heart failure and may be referred to a cardiologist for evaluation and treatment but anticoagulant therapy to minimize the risk of clot formation should be started initially. The 2014 AHA Guidelines for Atrial Fibrillation recommend shared decision making in regard to anticoagulation based on relative risk of the patient for thromboembolic event. Atenolol is given IV for patients who are unstable; the advanced life support treatment guidelines do not recommend treatment of tachycardia if the patient is stable. Urgent cardioversion is rarely needed if the heart rate is less than 150 beats per minute unless there are underlying heart conditions. 42. What is true when considering activated charcoal for gastrointestinal decontamination to treat a toxic substance ingestion? a. It acts by enhancing gastric motility to reduce absorption. b. It is administered only through a nasogastric tube. c. It may be used when petroleum distillates are ingested. d. Its use is controversial, though in specific situations can be used. ANS: D The use of activate charcoal is controversial, though in specific situations can be used for gastrointestinal decontamination. It absorbs ingested substances and reduces absorption and may cause bowel obstruction; it does not increase bowel motility. It may be given orally or by nasogastric tube. Because it is associated with vomiting, it should not be used when caustic substances, alcohols, and petroleum distillates are ingested. 43. A lawn maintenance worker is brought to the emergency department after an accident in which a large amount of pesticide was sprayed all over his clothing. He can relate the details of the accident to the emergency department personnel. What is the priority treatment on admission? a. Administer intravenous diphenhydramine and possibly epinephrine. b. Contact the Poison Control center to ask about appropriate antidotes. c. Place on a cardiorespiratory monitor and establish intravenous access. d. Remove the patient's clothing and irrigate the skin for 15 to 30 minutes. ANS: D Most skin exposure to chemicals must be treated immediately with copious irrigation with water, so this is the initial priority in a stable patient. Since he can converse with staff, he is likely to be stable. If signs of anaphylaxis occur, diphenhydramine and epinephrine are indicated. The Poison Control center should be contacted, but this is not the priority. After irrigation to minimize exposure, other interventions, such as cardiorespiratory monitoring and IV access, may be necessary. 44. A child is brought to the emergency department (ED) when a grandparent suspects ingestion of a tricyclic antidepressant medication found in the bathroom. What symptoms will the ED professionals expect to observe if this is the case? (Select all that apply.) a. Excessive salivation b. Flushed skin c. Hallucinations d. Hypothermia e. Mydriasis f. Urinary frequency ANS: B, C, E Tricyclic antidepressants will cause anticholinergic effects, including flushing of the skin, hallucinations or psychosis, and mydriasis. These medications also cause dry mucous membranes, hyperthermia, and urinary retention. 45. Which immunoglobulin is responsible for initiating the allergic cascade in susceptible individuals who are exposed to allergens? a. IgG b. IgA c. IgM d. IgE ANS: D While IgA, IgG, and IgM are produced to appropriately protect the body, circulating levels of IgE are responsible for the atopic reaction. 46. When performing diagnostic tests to determine which environmental allergens cause symptoms in an atopic patient, which aspects of scratch testing are preferable to other methods? (Select all that apply.) a. It has a lower potential for anaphylaxis. b. It is more sensitive. c. It is safer. d. It produces more rapid results. e. It requires a stepwise approach. ANS: A, C, D Scratch testing involves scratching the surface of the skin. This method has a lower potential for anaphylaxis, is safer, and has more rapid results. It is not as sensitive as the intradermal method, which requires a stepwise approach. 47. A patient is brought to the emergency department after being hit in the head with a baseball. The patient is awake and talking but is confused and disoriented and does not obey simple commands. The patient can point to the area of pain and opens eyes only when commanded to do so. Bystanders report a period of unconsciousness lasting almost 5 minutes. Which severity of traumatic brain injury is likely? a. Normal b. Mild c. Moderate d. Severe ANS: C This patient's Glasgow Coma score (GCS) is 11, based on eye opening to verbal command (3), ability to localize pain (4), and conversing while confused (4). The patient was unconscious less than 10 minutes, which usually indicates less severe injury. A patient with a GCS between 9 and 12 with or without loss of consciousness is considered to have a moderate head injury. 48. A patient is in the emergency department after sustaining a blow to the head in a motor vehicle accident. The patient's Glasgow Coma score (GCS) is 14 and the patient is drowsy. The patient has a small amount of blood in one external auditory canal. Which is a priority in diagnosing the extent of injury in this patient? a. Close monitoring of pulse, respiration, and oxygenation b. Continued assessment of neurological status c. Magnetic resonance imaging of the head d. Non-enhanced computed tomography of the head ANS: D Although this patient's GCS is nonconcerning, the type of injury and the sign of blood in the external auditory canal put this patient at high risk for skull fracture, so a head CT is indicated immediately. Close monitoring of vital signs and neurological status should be continuously performed, the CT is a priority to help determine the treatment needed. MRI is not especially useful but may be performed after CT if more detail of structures is needed. 49. A young adult patient is being treated for hypertension and is noted to have a resting blood pressure of 135/88 mm Hg just after finishing a meal. After standing, the patient has a blood pressure of 115/70 mm Hg. What is the likely cause of this change in blood pressure? a. A hyperglycemic episode b. Antihypertensive medications c. Neurogenic orthostatic hypotension d. Postprandial hypotension ANS: B Medications to treat hypertension may cause orthostatic hypotension. Hypoglycemia may cause hypotension. Neurogenic orthostatic hypotension is less likely since there is no direct connection to the neurological system. Postprandial hypotension occurs in elderly patients. 50. A patient who ingested a bottle of acetaminophen tablets is brought to the emergency department. Which treatment is indicated? a. Flumazenil b. N-acetylcysteine c. Naloxone d. Supportive care only ANS: B N-acetylcysteine is used as an antidote for acetaminophen overdose. Flumazenil is used to treat benzodiazepine overdose. Naloxone is given for opioid overdose. 51. When beginning a health maintenance exam, the health care provider learns that an adult patient has been sexually assaulted the previous day. What is the initial responsibility of the provider? a. Notify the police and encourage the patient to press criminal charges. b. Perform a thorough gynecological exam and obtain cultures. c. Question the patient about the events surrounding the assault. d. Refer the patient to the emergency department (ED) for a forensic examination. ANS: D If a patient has been sexually assaulted within the past 5 days, and especially if within the previous 72 hours, the provider should defer a physical examination and refer the patient to the ED for a forensic examination. It is not necessary to notify the police unless the victim is a child, elderly, or disabled. The provider should not perform the exam—a forensic exam ensures that standard protocol is followed, and appropriate evidence is obtained. Retelling the story of the assault may be traumatizing to the patient, so this should be left to providers performing the forensic exam. 52. A patient who was sexually assaulted one month prior tells her provider that she is concerned about contracting human immunodeficiency virus (HIV). When is it appropriate to perform testing? a. Immediately and then every 6 months for the first year b. Immediately with definitive results c. In 2 weeks and then 3 to 6 months after the assault d. Three to six months after the assault ANS: C Because of the length of time for seroconversion to occur, patients concerned about HIV exposure should be tested 6 weeks after and then 3 to 6 months after the assault. Immediate results will not provide accurate information. The initial testing should be 6 weeks after potential exposure. 53. During a health maintenance examination, 17-year-old female reports having been raped repeatedly at a college party during the previous semester and tells the practitioner that she did not seek help at the time. Which action is a priority for the primary care provider? a. Recommending counseling at a local mental health center b. Referring the patient to the emergency department for sexually transmitted infection (STI) testing c. Reporting the alleged assault to law enforcement d. Suggesting that the patient report the incident to the school ANS: C Any sexual assault perpetrated on a victim younger than 18 years must be reported to the local child or adult protective agency as well as to law enforcement, regardless of whether the patient reports that sexual assault occurred. Counseling, STI testing, and reporting the incident to the school are important, but are not the priority. 54. A healthy 20-year-old patient reports having had 1 or 2 episodes of syncope without loss of consciousness. Which is the most likely type of syncope in this patient? a. Cardiac b. Neurogenic c. Orthostatic hypotensive d. Reflex syncope ANS: D Neurally mediated or reflex syncope is the most common cause of syncope and is primarily seen in young adults. Cardiac, neurogenic, and orthostatic syncope are generally seen in older adults. 55. Which tests are indicated as part of the initial evaluation for women of childbearing age who report syncope? (Select all that apply.) a. 12-lead electrocardiogram b. Cardiac enzyme levels c. Complete blood count d. Electroencephalogram e. Serum glucose testing ANS: A, C, E Initial evaluation for all patients reporting syncope should include a standard 12-lead ECG. Women of childbearing age should have a CBC, serum pregnancy test, and serum glucose testing. Cardiac enzyme levels are obtained if the patient has cardiac risk factors. EEG is performed only if there is a concern for seizure disorder. 56. A provider attending a soccer match on a hot day is assisting a player who feels hot and appears dehydrated, but who is alert and oriented. What does the provider suspect? a. Heat cramps b. Heat exhaustion c. Heat stroke d. Heat syncope ANS: B Heat exhaustion is present when patients have excessive sweating accompanied by sodium and water loss. Heat cramps involve muscle pains or spasms. Heat stroke causes a core body temperature of 106°F. Heat syncope causes fainting or dizziness. 57. A patient is brought to a clinic after fainting while working outdoors on a hot day. The patient has slurred speech and headache and has a temperature of 104°F. What will the provider do? a. Administer antipyretic medications to reduce the temperature. b. Administer intravenous fluids in the clinic and monitoring response. c. Rehydrate the patient with oral fluids containing electrolytes. d. Transport the patient to the emergency department (ED). ANS: D This patient has CNS signs and an elevated temperature with a history consistent with heat stroke. This patient should be sent to an emergency department. Antipyretic medications are not useful for treating thermal injury. The patient will be given IV fluids and electrolytes in the ED. Oral rehydration is not indicated. 58. A child is brought to the emergency department after getting lost while camping on a cold, rainy day. The child is lethargic on admission. The cardiorespiratory monitor shows a normal heart rate and rhythm, a respiratory rate of 8 to 10 breaths per minute, and a normal blood pressure. The assessment reveals erythema and edema of the child's hands and feet. What treatments are indicated? (Select all that apply.) a. Administer antibiotics. b. Apply warmed blankets. c. Elevate the child's extremities. d. Massage the hands and feet. e. Remove all wet clothing. ANS: B, C, E The child has signs of frostbite without other systemic signs. Warming with warm blankets is indicated. The affected areas should be elevated, but not massaged or rubbed. The providers should remove the child's clothing which may be restrictive or wet and examine the child's entire skin surface for other signs of frostbite. Antibiotics are not given unless signs of infection are present. 59. Using molecular polymerase chain reaction (PCR) techniques, a hospitalist identifies the presence of human metapneumovirus (hMPV) in a child who has bronchiolitis. Why is hMPV considered an emerging disease? a. It has become more virulent. b. It has lately been reactivated. c. It is becoming pandemic. d. It is only recently recognized. ANS: D This virus has only recently been identified as being present in children with lower respiratory tract infections because of techniques allowing it to be identified and isolated. It is not considered emerging because of increased virulence, reactivation after a period of dormancy, or because it is becoming pandemic. 60. What are risk factors for the increase in emerging and re-emerging infectious diseases? (Select all that apply.) a. Antibiotic use in animal feeds b. Counterfeit drug sales c. Decreased antibiotic use d. Exotic pet ownership e. Reforestation of farmlands ANS: A, B, D, E Using antibiotics in animal feed has increased the incidence of drug-resistant organisms. Counterfeit drug sales in Southeast Asia have contributed to the emergence of malaria species resistant to certain therapies. Exotic pet ownership has introduced new pathogens to some parts of the world. Reforestation of farmlands has led to the re-emergence of deer herds and a subsequent increase in Lyme disease. A decrease in antibiotic use will lower the risk of antibiotic resistance. 61. A pregnant woman tests positive for human immunodeficiency virus (HIV-1) infection. What will the provider recommend? a. Consideration of termination of the pregnancy b. No treatment and caesarian section for delivery c. Treatment with highly active antiretroviral therapy (HAART) d. Treatment with standard antiretroviral therapy ANS: C An absolute indication for treatment with highly active antiretroviral therapy (HAART) is the treatment of a pregnant woman to prevent mother-to-child transmission. Recommended regimens have no known significant fetal toxicity and can reduce the risk of vertical transmission from approximately 25% to less than 2%, making elective caesarean section no longer indicated in treated pregnant women. MULTIPLE RESPONSE 1. Which patients with documented human immunodeficiency virus (HIV-1) infection may be classified has having acquired immunodeficiency syndrome (AIDS)? (Select all that apply.) a. A patient with a CD4 cell count of 150/mm3 b. A patient with a CD4 cell count of 400/mm3 c. A patient with contact with a partner who has AIDS d. A patient with esophageal candidiasis e. A patient with tuberculosis ANS: A, D, E A 62. 2. A homeless patient who has human immunodeficiency virus (HIV-1) infection has been on antiretroviral therapy (ART) for 18 months and has had normal CD4 counts and viral loads for past year. What will the provider recommend? a. Allow for periods of time off from ART medications b. Begin monitoring viral load and CD4 counts every 6 to 12 months c. Consider beginning highly active antiretroviral therapy (HAART) d. Continue monitoring viral load and CD4 counts every 3 to 4 months ANS: D In patients who are clinically well and highly adherent, who have normal CD4 counts and viral loads, monitoring may begin at 6-month intervals and sometimes annually. Those with risk factors such as homelessness, however, must continue to be monitored every 3 to 4 months. ART medications should never be interrupted unless there are medical reasons for doing so. HAART is given only by clinicians with significant training and experience in its use to patients who meet specific criteria. 63. Which patients with documented human immunodeficiency virus (HIV-1) infection may be classified has having acquired immunodeficiency syndrome (AIDS)? (Select all that apply.) a. A patient with a CD4 cell count of 150/mm3 b. A patient with a CD4 cell count of 400/mm3 c. A patient with contact with a partner who has AIDS d. A patient with esophageal candidiasis e. A patient with tuberculosis ANS: A, D, E Patients with HIV infection are classified as having AIDS either when the CD4 cell count is 200/mm3, or if they have one of a broad spectrum of opportunistic infections, malignant neoplasms, and nonspecific syndromes. Patients with CD4 cell counts 200/mm3 and those living with partners who have AIDS are not classified as having AIDS. 64. A 65-year-old patient who has not had an influenza vaccine is exposed to influenza and comes to the clinic the following day with fever and watery, red eyes. What will the provider do initially? a. Administer LAIV influenza vaccine b. Begin treatment with an antiviral medication c. Observe for improvement or worsening for 24 hours d. Perform a nasal swab for RT-PCR assay ANS: D Samples to isolate the virus should be collected within 12 to 36 hours of onset of illness and this should be performed to confirm the disease. Administration of the LAIV influenza vaccine will not prevent symptoms in this patient, is not recommended in persons over 59 years of age, and is contraindicated when also giving antiviral medications. Antiviral drugs should be started within 48 hours of onset of illness and may be started empirically while waiting on cultures because this patient is higher risk than younger patients. Because identification of the virus and effectiveness of treatment are time-limited, it is not correct to watch and wait for symptoms to worsen. 65. A previously healthy patient develops influenza which is confirmed by RT-PCR testing and begins taking an antiviral medication. The next day, the patient reports increased fever and cough without respiratory distress. The patient's lungs are clear and oxygen saturations are 97% on room air. What will the provider recommend? a. Admission to the hospital for treatment of complications b. Empirical antibiotics to treat a possible secondary infection c. Referral to a specialist for evaluation and treatment d. Symptomatic treatment with close follow-up in clinic ANS: D This patient does not have risk factors for serious complications and may be managed as an outpatient. Symptoms should begin to gradually improve a few days after the onset of symptoms. Because this patient is stable, watchful waiting with symptomatic care and close follow up is acceptable. It is not necessary to admit to the hospital, refer to a specialist, or begin antibiotic therapy currently. 66. The parent of a 4-month-old infant who has had an episode of bronchiolitis asks the provider if the infant may have an influenza vaccine. What will the provider tell this parent? a. The infant should be given prophylactic antiviral medications. b. The infant should have an influenza vaccine now with a booster in 1 month. c. The infant should have the live attenuated influenza vaccine (LAIV). d. The infant should not but family and all close contacts should be vaccinated. ANS: D Infants are not given influenza vaccine until age 6 months. To protect infants younger than 6 months, it is important for other family members and close contacts to be vaccinated. LAIV is approved for use in children over age 2 years. Antiviral prophylaxis is not recommended. 67. A patient is experiencing small-volume, non-inflammatory stools. Which organisms may be suspected in this case? (Select all that apply.) a. Clostridium difficile b. Cryptosporidium c. Escherichia coli d. Giardia e. Shigella ANS: B, C, D Small-volume, non-inflammatory stools occur with infections of the small intestine and are due to enteric viruses, enterotoxic bacteria, such as E. coli, and noninvasive parasites, such as Giardia and Cryptosporidium. Infections of the lower intestine are characterized by frequent, large-volume inflammatory diarrhea and C. difficile and Shigella are among the likely pathogens. 68. A patient has had mild acute diarrhea for 8 days. The patient is alert with normal vital signs and no abdominal discomfort but appears mildly dehydrated. Which tests will the provider perform? (Select all that apply.) a. BUN and creatinine b. Complete blood count c. Serum electrolytes d. Stool for fecal leukocytes e. Stool for occult blood ANS: A, B, C A CBC, serum electrolytes, BUN, and creatinine are standard tests for evaluation of electrolyte derangement and dehydration and should be performed in patients who appear dehydrated. Stool samples for fecal leukocytes and occult blood are taken for patients with high temperatures, bloody diarrhea, and abdominal pain. 69. A patient who has recently traveled has acute diarrhea which began the day after returning home. What are recommended treatments for this type of diarrhea? (Select all that apply.) a. Ciprofloxacin for 3 days, twice daily b. Loperamide at bedtime and after each stool c. Oral fluid replacement d. Quinolones daily for 2 to 4 weeks e. Sulfamethoxazole twice daily for 5 days ANS: A, B, C Ciprofloxacin may be given for 3 days for traveler's diarrhea, as well as loperamide. Oral fluid replacement is recommended. Because of widespread antibiotic resistance to sulfamethoxazole and quinolones, these drugs are not recommended. 70. An adolescent patient has fever, pharyngitis, and cervical lymphadenopathy and has a negative group A beta-hemolytic throat culture. A complete blood count shows absolute lymphocytosis, but a heterophil antibody test is negative for Epstein-Barr virus (EBV). What will the provider tell the patient about the likelihood of infectious mononucleosis (IM)? a. It will be necessary to repeat the heterophil antibody test in a few weeks. b. Liver function tests will help to confirm a diagnosis of EBV-IM. c. The likelihood of EBV infectious mononucleosis is still high. d. This IM is most likely caused by a virus other than Epstein-Barr virus. ANS: C Because heterophil antibodies may not reach detectable levels early in the disease, it is possible to have a negative result. This patient has symptoms and the suspicion for disease remains high. Repeat testing in 7 to 10 days will help confirm the diagnosis. A positive heterophil antibody test with absolute lymphocytosis is diagnostic of acute IM. Epstein-Barr nuclear antigen is measured 6 to 8 weeks after onset of symptoms to distinguish between acute and previous infection. LFTs may be elevated in patients with IM, but this is not diagnostic. 71. An adolescent patient who plays football in high school is diagnosed with Epstein-Barr virus (EBV) infectious mononucleosis and is noted to have splenomegaly. What will the provider recommend to this patient about returning to sports? a. Abdominal ultrasounds are recommended to determine safety. b. Corticosteroid therapy may help shorten the course of the disease. c. He may return to minimal contact practice in 2 to 3 weeks. d. It will be safe to play football in 3 to 4 weeks. ANS: A Patients with splenomegaly should be encouraged to refrain from strenuous activity for 3 to 4 weeks to avoid the risk of splenic rupture. Serial US studies beginning at week 2 to 3 may be helpful in determining the risk of rupture. Corticosteroids have not been shown to reduce the severity or duration of symptoms. Strenuous activity is not recommended until 3 to 4 weeks; without an US, it is not possible to ensure absolute safety for sports. 72. A patient diagnosed with Epstein-Barr virus-associated infectious mononucleosis (EBV-IM) also has group A beta-hemolytic streptococcal pharyngitis and is being treated with amoxicillin. On the third day of treatment, the patient develops a rash. A urinalysis is normal. What does this indicate? a. A reaction to the amoxicillin b. A streptococcal rash c. Hematologic complications d. Hemolytic-uremic syndrome ANS: A 80% to 100% of patients with IM who are taking amoxicillin will develop a rash. A streptococcal rash appears at the onset of symptoms, not 3 days after initiation of antibiotics. This rash does not indicate hematologic complications or hemolytic-uremic syndrome. 73 A parent brings a child to clinic and reports pulling a tick off the child after being outdoors that day. The parent is concerned that the child may have Lyme disease. What will the provider tell this parent? a. A laboratory test today will help identify the presence of the disease. b. Antibiotic prophylaxis is necessary to prevent development of symptoms. c. Transmission of the organism only occurs with prolonged attachment of the tick. d. Unless the child develops systemic symptoms, treatment is not indicated. ANS: C To transmit the spirochete to humans, the tick must be attached for an extended period of time of at least 36 hours. Serologic testing early in the disease may not be helpful. Antibiotic prophylaxis is not recommended. Treatment may begin with the presence of a localized rash. 74. A patient with mild symptoms of babesiosis is diagnosed with a positive polymerase chain reaction (PCR) assay. What is the recommended treatment for this patient? a. Atovaquone and azithromycin for 7 to 10 days b. Clindamycin and quinine for 10 to 14 days c. Intravenous clindamycin and hospitalization d. Symptomatic therapy with observation ANS: A Patients with mild to moderate symptoms and a positive PCR assay should be treated. Atovaquone plus azithromycin is the treatment of choice. Clindamycin and quinine are effective but have more adverse effects. IV clindamycin is given for severe symptoms. Patients without positive assays who have mild symptoms may be observed. 75. A patient presents with fever, severe headache, and rash and has a history of tick bite. Which tick-borne illness is suspected? a. Babesiosis b. Ehrlichiosis c. Lyme disease d. Rocky Mountain Spotted Fever ANS: D The classic triad of fever, severe headache, and rash is consistent with Rocky Mountain Spotted Fever 76. A provider is concerned that a young child may have latent tuberculosis infection (LTBI). Which test will be performed initially to screen for this infection? a. Chest radiograph b. Interferon gamma release assay c. Mantoux test d. Two-step TST ANS: C The Mantoux test is the most cost-effective test to administer as an initial screen. Chest radiograph is not used to detect LTBI because there is no radiographic evidence with latent infection. The IGRA may be used but is more costly and the sensitivity in young children has not been established. The two-step TST is not indicated. 77. A patient who diagnosed with human immunodeficiency virus (HIV) infection has a negative tuberculosis skin test with induration less than 10 mm. The provider learns that the patient lives with a person who has active tuberculosis. What is the next step in managing this patient? a. Begin empirical antibiotic therapy. b. Order a chest radiograph. c. Perform an interferon gamma release assay. d. Refer to an infectious disease specialist. ANS: B Patients who are immunocompromised who have had contact with a person with infectious TB should have a chest radiograph. Until infection is established, empirical antibiotic therapy is not indicated to reduce the risk of antibiotic resistance. IGRA is not indicated. If radiograph results are positive, or if the diagnosis remains unclear, referral is indicated. 78. A 25-year-old patient has a tuberculosis (TB) skin test which reveals an area of induration of 12 mm. The patient is a recent immigrant from Mexico and lives in a homeless shelter. What is the recommended treatment for this patient? a. Administer the bacillus Calmette-Guérin (BCG) vaccine b. Begin isoniazid (INH) preventive therapy c. Order isoniazid (INH) and Rifampin d. Perform regular TB skin testing every few months ANS: B Patients younger than 35 who have any risk factors for TB and with an area of induration 10 mm should be considered for INH preventive therapy. This patient is an immigrant from Mexico and lives in a homeless shelter, so TB preventive therapy is acceptable. BCG vaccine is not helpful. INH and Rifampin are used if patients develop symptoms or if there is antibiotic resistance. 79. A patient expresses concern about contracting West Nile virus (WNV) infection after a family member becomes ill with the disease. What will the provider tell this patient? a. Human hosts may become reservoirs for infection for WNV. b. Humans may transmit the virus to mosquitoes after a bite. c. Humans must be bitten by a mosquito infected by a bird. d. Human-to-human transmission is possible with this disease. ANS: C Birds are reservoir hosts for the virus and avian-mosquito-human transmission is how the disease is contracted. Humans do not sustain high-level viremias long enough to become reservoir or amplifying hosts. Human-to-human transmission does not occur. 80. A patient who reports traveling to an area where West Nile virus (WNV) is endemic presents with fever, arthralgia, and rash for the last 7 days. What initial testing is recommended to confirm a diagnosis of WNV? a. ELISA for CSF antibodies b. ELISA for serum IgM c. PCR assays of CSF d. PCR assays of serum ANS: B Serologic testing is the most effective method to confirm clinical suspicion of WNV infection and ELISA for detection of IgM in serum at 6 to 8 days indicates recent infection. CSF may be tested but is more invasive. PCR assays are low yield because of the transient nature of viremia in humans.