ANCC FNP Board Exam Study Guide Part 1| 100 questions and answers.

Treatment for chronic bronchitis -Chronic bronchitis is a type of COPD that is characterized by inflammation of the bronchi, causing excess mucus; characteristics of chronic bronchitis include diagnosis after age 35, obesity, copious amounts of purulent sputum, elevated Hct level -Treat with SABA (albuterol), inhaled anticholinergics (ipratropium) -Normal Findings of Lungs: Lower lobes vesicular breath sounds (soft and low) Upper lobes; Bronchial breath sounds louder Actinic keratosis -Older to elderly fair-skinned adults -numerous dry, round, pink to red-colored, slow-growing lesions that do not heal -lesions common on sun-exposed areas (cheeks, nose, face, arms, back) -precancerous precursor of squamous cell carcinoma -frequent sunburns as child places person at higher risk -diagnosed with biopsy -treat with cryotherapy (small number) or 5-FU(5% fluorouracil) cream (large number) follow up with derm. Seborrheic keratosis -soft, round, wart-like fleshy growths on trunk (mostly on back) -can range in color from light tan to black -appear to be pasted on -asymptomatic -benign Fingernail hematoma treatment -Trephination - make hole in nail through drilling or piercing and allow blood to drain Hypothyroid -Primary - elevated TSH; low T4; low or normal T3 -Subclinical - elevated TSH; normal T4; normal T3 -Common cause is Hashimoto's (autoimmune) - Hashimoto and Hypo both have O -Symptoms are variable - may include fatigue -Treatment - levothyroxine (Synthroid) daily in AM on empty stomach -Starting dose of levothyroxine (Synthroid) is 25-50mcg -Check TSH every 6-8 weeks to monitor treatment Hyperthyroid -Primary - low TSH; high T4; normal or high T3 -Subclinical - low TSH; normal T4; normal T3 -Most common cause is Grave's Disease (autoimmune) - Grave and Hyper both have R -Common symptoms - female; rapid weight loss; increased heart rate; tremors; sweating; irritability; anxiety; hyperactivity; insomnia; diarrhea; amenorrhea; hypertension; exophthalmos; heat intolerance; goiter -Treatment - Propylthiouracil (PTU); Methimazole (Tapazole); Radioactive iodine (causes hypothyroid for life, contraindicated in pregnancy) -Thyroid Storm (thyrotoxicosis) - acute worsening of symptoms; may be caused by stress or infection; look for LOC, fever, abdominal pain; life-threatening; immediate hospitalization needed Increased risk of ectopic pregnancy -Risk factors - previous ectopic, salpingitis, tubal surgery, current IUD use, previous cervicitis, history of PID -Symptoms - abdominal pain (worsens when supine or with jarring), vaginal bleeding, amenorrhea, low grade fever, pain referred to right shoulder (may indicate rupture) Hypertension Meds Part 1 -African-American with or without diabetes - initial choices include thiazide diuretic or CCB -Non-Black with or without diabetes - initial choices include thiazide diuretic, CCB, ACE, or ARB -Thiazide diuretic - "ide"; excellent synergist; avoid in sulfa allergy; favorable in osteopenia/osteoporosis; side effects include hyperglycemia (caution in diabetics), hyperuricemia (gout attack), hypertriglyceridemia and hypercholesteremia (check lipid profile), hypokalemia (potentiates digoxin toxicity and increases risk for arrhythmia), hyponatremia (hold diuretic, restrict fluid, replace K+); lowers BP only 2-8 points -ACE inhibitor - "pril" and ARB - "sartan" - use in high renin states; drug of choice in diabetics (protects kidneys); pregnancy category C/D; side effects include dry/hacking cough (more with ACE), hyperkalemia, angioedema (rare, life-threatening); contraindicated in moderate to severe kidney disease; do not use ACE and ARB together. Hypertension Meds Part 2 -Beta blocker - "lol"; good as add-on medication, not uncomplicated HTN; avoid abrupt discontinuation, wean slowly to avoid rebound HTN; contraindications include asthma, COPD, chronic bronchitis, emphysema, second and third-degree heart block (okay with 1st degree), sinus bradycardia; do not use Propranolol for HTN -Calcium channel blocker - "pine"; first choice for ISH (isolated systolic HTN); side effects include headaches (vasodilation), ankle edema (vasodilation, benign), heart block/bradycardia (depresses cardiac muscle and AV node), reflex tachycardia (nifedipine); contraindicated in 2nd and 3rd degree heart block, bradycardia, CHF Hypertension Meds Part 3 -Heart Failure: ACEI or ARB as first-line, plus BB, plus diuretic -DM: ACE/ARB first line, IF African American, can start with CCB or Thiazide -CKD: ACE/ARB first line, can add CCB or Thiazide -Stroke Hx: ACE/ARB first line, add CCb or Thiazide as second-line drugs. -African American even with DM Thiazides and CCBs. -Bilateral Renal artery stenosis: ACE AND ARB will WORSEN or cause acute renal failure. CONTRAIN Risk factors for post-menopausal osteoporosis -older women; white/Asian descent; thin; small body frame; chronic steroids; androgen deficiency; hypogonadism; anorexia; bulimia; gastric bypass; celiac disease; hyperthyroidism; ankylosing spondylitis; RA; low calcium intake; vitamin D deficiency; inadequate physical activity; alcohol/caffeine intake; smoking Legg-Calves-Perthes -Osteonecrosis of the capital femoral epiphysis due to interrupted vascular supply -Common in ages 3-12 (pre-pubescent) -More common in males -Pain in hip or referred to medial aspect of knee (may be present for 2-3 weeks before complaints) -Limp -Positive Trendelenburg's Test (asking child to stand on affected side causes pelvic tilt - affected side lower) Cranial Nerves III, IV, VI to assess Extra Ocular Movement (EOM) -III - oculomotor - eye movements, pupillary constriction, accommodation -IV - trochlear - movement of superior oblique muscle -VI - abducens - movement of lateral rectus muscle -Mnemonic - LR6SO4 (lateral rectus - VI, superior oblique - IV) Dementia – executive function -Ability to manage a calendar How to treat chlamydia in pregnant woman -Azithromycin 1g PO single dose or Amoxicillin 500mg PO TID x 7 days -Test of cure 3 weeks after completion of treatment Untreated gonorrhea -Women - PID, abscess, ectopic pregnancy, infertility, can pass to baby during delivery -Men - epididymitis, infertility -Both - can spread to blood and cause disseminated gonococcal infection (DGI) which is characterized by arthritis, tenosynovitis, and/or dermatitis and may be life-threatening; increases risk for HIV Dacrocystitis -infection of lacrimal sac/tear duct usually caused by blockage -common in infants, adults over 40 also have higher risk of developing -symptoms - thick eye discharge, pain, redness/swelling/warmth of lower eyelid, watery eye/excess tears -treatment - lacrimal sac massage (downward toward mouth) 2-3 times daily; systemic antibiotics 7-10 days Erysipelas -subtype of cellulitis involving upper dermis and superficial lymphatics -usually caused by Group A Strep -symptoms - single large lesion, hot, indurated, red, clear demarcated margins, usually found on lower legs (shins) or cheeks, fever, chills Retinoblastoma -rare type of cancer -diagnosed by noting white pupil or pupil with white spots on it (leukocoria) - hallmark sign -may affect one or both eyes Carotid bruit -caused by carotid stenosis (cholesterol plaque accumulation) Murmur that radiates to the neck -Aortic stenosis Murmurs1 -All diastolic murmurs are abnormal -First time thrill is palpable is grade IV -MR ASS – Mitral Regurg, Aortic Stenosis – Systolic -MR Peyton Manning AS MVP – Mitral Regurg, Physiologic Murmur, Aortic Stenosis, Mitral Valve Prolapse -MS ARD – Mitral Stenosis, Aortic Regurg – Diastolic -rIght-sided – louder on Inspiration · lEft-sided – louder on Expiration -aoRtic – Right side -puLmonic – Left side Murmurs2 -Mitral Regurg – pansystolic/holosystolic; heard best at apex; radiates to left axilla; loud blowing/high-pitched; usually result of congenital condition, rheumatic heart disease, acute endocarditis, MVP, calcified annulus; symptoms include CHF, fatigue, dyspnea, bacterial endocarditis; LV/LA enlarged on XR; Afib common on EKG -Aortic Stenosis – midsystolic; best heart at 2nd ICS on right side; radiates to neck; harsh/noisy; patients should avoid physical overexertion (increased risk of sudden death); complications include angina, syncope, CHF; cardiomegaly occurs late; EKG usually normal; usually audible S4; usually congenital; rheumatic fever 2nd most common cause; monitor with echo; surgical valve replacement if worsens -Mitral Valve Prolapse – systolic; heard best at apex; more common in women ages 14-20; symptoms include palpitations, chest pain, dyspnea, dizziness, numbness; first finding is midsystolic “click”; EKG usually normal. Rule out marfans syndrome in tall thin female with hypermobile joints. Arm span greater than height etc. Murmurs3 Mitral Stenosis – low-pitched diastolic; rumbling; heard best at apex; “opening snap”; etiology is rheumatic fever; 4 stages (1 – long asymptomatic period followed by gradual reduction in exercise tolerance, 2 – pulmonary congestion, 3 – pulmonary HTN, 4 – severe low CO); symptoms include dyspnea, Afib, hemoptysis, RV hypertrophy; loud S1; may radiate toward axilla Aortic Regurg – diastolic; high-pitched; blowing; best heard at 2d ICS on right side of sternum; symptoms include angina, CHF, dizziness, chest pain; etiology includes rheumatic heart disease, congenital deformity, aortic root abnormalities, syphilis; PMI displaced downward and left; water-hammer pulse Patient forgot to start Thanksgiving dinner and husband states she has trouble remembering tasks and trouble with organization. This is indicative of: -Loss of executive function -Executive function includes the ability to manage a calendar, organizing, planning (getting things started), multitasking, processing/storing information Patient with atopic dermatitis would be at risk for what other conditions? -asthma, allergic rhinitis, multiple allergies -atopic dermatitis (eczema) is marked by extremely pruritic rashes on hands, flexural folds (antecubital/popliteal space), and neck; rash is exacerbated by stress and environmental factors; rash appears as multiple small vesicles that rupture and leave painful, bright red, weepy lesions that become lichenified from chronic itching; fissures can form and can be infected with bacteria -treatment - topical steroids (1st line); systemic oral antihistamines; skin lubricants; hydrating baths Patient with history of PID has increased risk for? -infertility -cervical motion tenderness indicates PID -treat symptomatic PID even if Neisseria gonorrhoeae (GC) and chlamydia tests are negative -follow up with vaginal bimanual exam in 2-3 days to make sure symptoms are improving Treatment for gonorrhea -Ceftriaxone (Rocephin) 250mg IM x 1 dose plus Azithromycin (Zithromax) 1gm oral or Doxycycline (Vibramycin) 100mg BID x 7 days Old lady with weakness on 2 HTN meds, 2 DM meds, vitamins -polypharmacy -hypotension -hypoglycemia Wilm’s tumor -nephroblastoma -asymptomatic abdominal mass that extends from flank toward midline -nontender, smooth mass that rarely crosses midline of abdomen -higher incidence in black, female children -peak age 2-3 -most common renal malignancy in children -when performing PE, palpate gently to avoid rupturing renal capsule -initial test is abdominal ultrasound Baby with UTI – follow up? · renal and bladder ultrasound (RBUS) for all infants 2-24 months for first febrile UTI Definitive diagnosis of acute bacterial prostatitis -UA and culture (treat empirically until results are back) -Under age 35, treat like gonorrhea or chlamydia - Rocephin 250mg IM plus doxycycline 100mg PO BID x 10 days -Over age 35, unlikely STD in nature, treat with Cipro PO BID or Levaquin PO daily x 4-6 weeks -Avoid vigorous palpation and massage of prostate - can lead to septicemia AV nicking -HTN stiffens vessels -arteries indent and displace veins -considered "mild" retinopathy Cotton wool spots on fundoscopic exam -can be caused by HTN, DM, or other causes - microinfarct occurs -considered "moderate" retinopathy High triglycerides and pancreatitis -high risk of acute pancreatitis with triglycerides greater than 500 -normal level is less than 150 -if triglycerides are greater than 500, treat with niacin or fibrate or Niaspan to lower triglycerides; if less than 500, consider lifestyle modifications first -once triglycerides are under control, switch target to lowering LDL -recommend low fat diet, weight loss, and increased physical activity Pancreatitis -diagnosed with amylase and lipase lab draw -amylase begins increasing 2-12 hours after onset of symptoms -amylase is most widely used method of diagnosing pancreatitis -lipase begins to increase 4-8 hours after onset of symptoms -lipase more specific and sensitive to alcoholic pancreatitis Osgood Schlatter Disease -common cause of knee pain in young athletes, especially if recent growth spurt -anterior knee pain that increases over time -osteochondritis of tibial tubercle -caused by overuse of knee - repetitive stress on patellar tendon by quadriceps causes pain, tenderness, swelling -usually affects one knee, but can be bilateral -treatment - rest/activity as tolerated; ice; analgesics PRN -rule out avulsion fracture if acute onset of pain post-trauma (lateral x-ray) When to start patient on high intensity statin -LDL >190; History of Coronary Heart Disease (CHD) or stroke -High-intensity statins include Atorvastatin (Lipitor) and Rosuvastatin (Crestor) -Start screening at 20 then every 5 years until 40 if no issues. At 40 every 2-3 years. IF dx then annually etc. Statins -HMG CoA reductase inhibitors -Do not mix with grapefruit juice -Drug-induced hepatitis or rhabdomyolysis higher if mixed with azole antifungals -Also interact with fibrates (except fenofibrate), macrolides, amiodarone, and some CCBs -High-dose Zocor has highest risk of rhabdomyolysis -High intensity statins lower LDL by 35-63% -Moderate intensity statins (Simvastatin, Pitavastatin, Pravastatin) lower LDL by 22-47% -SECONDARY PREVENTION-Atherosclerotic Cardiovascular Disease (ASCVD): Patient with any form of ASCVD history of MI, CAD, Angina, stroke/TIA, PAD, coronary revascularization. If younger then 75 start on HIGH INTENSITY STATIN. Older than 75 (or not a candidate for high intensity) MODERATE INTENSITY statin. -PRIMARY PREVENTION: NO ASCVD hx. LDL at 190 or > HIGH -DM aged 40-75 with LDL 70-189 MODERATE -Without DM or ASCVD age 40-75 with an estimated 10 yr ascvd risk of 7.5% or higher MOD to HIGH. -Lack of any ASCVD but 10year is 5- <7.5% FIRST LINE is heart healthy lifestyle changes. Pap Smear recommendations -Begin Pap at age 21 and repeat every 3 years until age 29 -Age 30 - Pap and HPV (primary screening); repeat every 5 years if negative -Beginning age 65, may stop Pap if negative history x 10 years -Discontinue in patients who have had hysterectomy with removal of cervix and no history of cervical cancer or high-grade lesion -Satisfactory specimen only if both squamous epithelial cells and endocervical cells are present; if endocervical cells are missing, repeat Pap MRSA treatment in patient with allergies -If patient has sulfa allergy, treat MRSA with a tetracycline (doxycycline, minocycline) -If no sulfa allergy, use Bactrim Patient has acute otitis media; gets hives with amoxicillin and n/v with erythromycin; treatment? -Trimethoprim sulfamethazole (Bactrim DS) PO BID -Levofloxacin (Levaquin) or moxifloxacin (Avelox) - only if patient is 18 years or older - increases risk for tendonitis/Achilles tendon rupture -If only Penicillin allergic, use azithromycin x 5 days or clarithromycin PO BID McMurray Sign -Knee pain and a "click" sound upon manipulation of the knee equals positive sign -Suggests injury to medial meniscus -Gold standard test for joint damage is MRI Medial Pain in knee (Valgus/Varus) -Valgus stress test - medial collateral ligament (MCL) Varus stress test - lateral collateral ligament (LCL) - Varus and Lateral both have R -Positive finding is an increase in laxity of the damaged knee (ligament tear) Sickle Cell Teaching -Diagnosis confirmed with hemoglobin electrophoresis (gold standard) -suggest genetic counseling -increased risk for death from infection with encapsulated bacteria due to hyposplenia -recommend all required vaccinations Bumps start on face or trunk and spread to rest of body -Varicella -Classic presentation - pruritic vesicular lesions in different stages of development and healing Adolescent with mild persistent asthma – treatment? -low dose ICS plus SABA (albuterol) PRN (preferred treatment) -alternative treatment - cromolyn, Montelukast, nedocromil, or theophylline -Remember all asthma patients must have SABA as rescue med (safety issue) Infant had 2 episodes of RSV/bronchiolitis; now presents with fever, cough, wheezing; differentials do not include -foreign body Female with yellow/green vaginal discharge and itching? -trichomoniasis -symptoms - frothy, yellow/green discharge; strawberry cervix; dysuria; vulvar irritation; pruritis; pH>5.0 -treatment - metronidazole (Flagyl) 2g x 1 dose or 500mg BID x 7 days; treat partner Most common bug for otitis media -streptococcus pneumoniae -treatment - amoxicillin is gold standard for all ages; if recent amoxicillin use or failed amoxicillin therapy, consider augmentin Most common cause of death in women -heart disease -heart disease is also the most common cause of death in men -cancer is second most common Lab test for Fifth Disease (erythema infectiosum) -Parvovirus B19 -Diagnosis is usually made based on clinical presentation - "slapped cheek" - instead of lab test -more common in children -contagious through respiratory secretions -symptoms include fever, headache, runny nose, rash Person eating and notices a painful lump in jaw that comes and goes -sialolithiasis -can also cause painful lump under the tongue, pain/swelling near ear or under jaw, dry mouth, gritty/strange tasting saliva, difficulty opening mouth, difficulty swallowing -caused by salivary duct obstruction - worse when eating due to increased saliva production ADHD -core symptoms - hyperactivity, impulsivity, inattention (behavior disorder) -diagnostic criteria - symptoms present prior to age 12; symptoms last > 6 months; symptoms should be evident in 2 different settings (school and home - get feedback from caregiver/parent and teacher/coach) -generally treated with Schedule II medications - high potential for abuse Patient complains about upper arm tremor that seems to be hereditary; treatment? -likely essential tremor -treated with beta-blocker (Propranolol 60-320mg per day) -alternative treatment is primidone (50-1000mg per day) Highest suicide rates -Age: 45-54 and >80 -Race: white -Sex: male (females attempt more often, but males have a higher success rate) -Risk factors: loss of spouse; history of attempted suicide; family history of suicide; mental illness; bipolar; depression; history of abuse; terminal or chronic illness; chronic pain; substance/alcohol abuse; significant loss (job, friend, divorce, death of someone close); plan to use gun Fructosamine Test -similar to hemoglobin A1c -indicate the average level of blood glucose control over the past 2-3 weeks -increased level associated with prolonged hyperglycemia for 2-3 weeks prior to testing -higher the level, poorer the degree of the glycemic control -trend from high to normal may indicate treatment regimen is effective -not used for screening Treatment to prevent fracture in patient with low vitamin D, high TSH, low Hct -Vitamin D 600-800 IU/day -Calcium mg/day Temporal Arteritis -gold standard for diagnosis - temporal artery biopsy done by ophthalmologist -screening test - erythrocyte sedimentation rate (ESR) -symptoms - acute onset of unilateral headache located on the temple; jaw claudication (with chewing); fever; visual loss; pain in temple area -treatment - refer to ophthalmologist or ED; high-dose steroids are part of 1st line (prednisone 40-60/daily) complications - permanent blindness if not diagnosed early Patient with one ulcer in mouth -apthous stomatitis (canker sores) -single ulcers could also be caused by: trauma from biting, braces, tooth, hot food, toothbrush; food intolerance or allergy; stress; hormone changes; genes; medications; stopping smoking What should be done before starting a statin? -baseline LFTs -statins affect CYP450 system and increases risk for rhabdomyolysis and drug-induced hepatitis -LFTs should be monitored periodically (more frequent for higher doses) CDC recommendation on screening for Hep C -adults born between 1945 and 1965 -current or former IV drug users (even if use was only once and many years ago) -persons who have HIV infection -persons who have persistently abnormal ALT -persons who received blood, blood components, or organ transplant before July 1992 -known exposure (needlestick, child born to HCV+ mom) Zyprexa (olanzapine) recommendations -high risk of weight gain, metabolic syndrome, and type 2 diabetes -monitor weight every 3 months -monitor TSH, lipids, BMI Treatment for depression -first line for mild-to-moderate – SSRI (sertraline, escitalopram, fluoxetine, paroxetine, citalopram, fluvoxamine) -first line for major – SNRI (duloxetine, Effexor, Pristiq) -other treatment options – TCA (amitriptyline, Pamelor, doxepin, amoxapine) and atypicals (Wellbutrin, trintellix) -benzodiazepines are not used as treatment for depression -SSRIs are safest -TCAs are easiest to overdose on, which has caused a drastic decline in use Treatment for BPH -alpha-adrenergic antagonist - terazosin (Hytrin) or Tamsulosin (Flomax) -5-alpha-reductase-inhibitors - finasteride (Proscar) -Proscar causes prostate to shrink 50%, so PSA should be doubled. To check effectiveness of treatment, obtain PSA and multiply by 2. -Proscar is teratogenic, category X. Reproductive-aged females should not handle with bare hands. -BPH and HTN - start with alpha blocker (Hytrin) first Positive Mantoux test in HIV patient -induration >=5mm -Other cases when >=5mm is considered positive - recent contact with infectious TB, CXR with fibrotic changes consistent with TB, child who had contact with or TB symptoms (before age 5), immunocompromised patients (organ or bone marrow transplant, renal failure, patients on biologics) -Cases when >=10mm is considered positive - recent immigrants (within last 5 years) from high-prevalence countries (Latin America, Asia, Africa, India, Pacific Islands), child/adolescent exposed to high-risk adult, IV drug user, health care worker, homeless, employees/residents from high-risk congregations (nursing home, jail) -Persons with no risk factors for TB are positive if induration >=15mm Optic disc in increased ICP -optic disc swelling expected (papilloedema) -margins of disc will not be sharp/clear upon exam -disc may be pale in color Testicular torsion -usually occurs in adolescents (majority between ages 10 and 20) -abrupt onset; extremely painful, swollen red scrotum; frequently accompanied by nausea and vomiting -affected testicle is closer to the body/higher than unaffected -missing cremasteric reflex -spermatic cord becomes twisted interrupting the blood supply -permanent damage can occur if not corrected in less than 6 hours -medical emergency - call 911, get to ER ASAP -preferred test - Doppler ultrasound with color flow study -treatment - manual reduction or surgery with fixation sutures Meniere’s disease -classic triad of symptoms - vertigo, tinnitus, hearing loss -can resolve spontaneously or be chronic Grades of murmurs 1 – very soft, heard only under optimal conditions 2 – mild to moderately loud murmur 3 – loud murmur that is easily heard once the stethoscope is placed on the chest 4 – louder murmur; first time thrill is present 5 – very loud murmur heard with edge of stethoscope off chest; thrill more obvious 6 – murmur so loud it can be heard even with stethoscope off chest; thrill easily palpable Elderly with progressive hearing loss, loss of high pitch sounds, no lateralization -sensorineural hearing loss -involves inner ear -presbycusis, progressive, symmetric, high-frequency (human speech) lost first Child with left otitis media with effusion -symptoms - aural fullness/pressure; ear being plugged; decreased hearing; pain is not common -Weber test may show lateralization to affected ear Weber -tests CN 8 -tuning fork placed on midline on forehead -normal finding - no lateralization; sound heard equally in both ears -lateralization to affected/"bad" ear - abnormal finding - conductive hearing loss - AC (affected = conductive) -lateralization to unaffected/"good" ear - abnormal finding - sensorineural loss - US (unaffected = sensorineural)