NR 601 Midterm Exams 100% Accurate Answers.

NR 601 Midterm Exams 100% Accurate Answers. Chapter 1: Principles of Primary Care of Older Adults Which one of the following is most true about the rule of fourths? What used to be called normal aging can be largely explained by processes that are not normal. Which one of the following is most true about aging changes? Stage 3 and 4 sleep decreases. An old woman who is cared for by attentive, cautious, concerned family is particularly likely to suffer from which one of the following complications after an episode of gastroenteritis? Immobility related to overconcern Which one of the following is most true about psychological aging? Ageism can lead to isolation and depression. Of the following conditions, which one is most common and most often preventable? Iatrogenic disease Based on current demographic data, which statement identifies a predictive trend regarding the health care needs of society? More nursing services will be required to serve the needs of the population 85 years of age and older An older adult client shares with the nurse that, "I don't know what it is but it seems that I need more light for reading or even watching television as I get older." The nurse explains that aging may cause this change due to the: Slower ability of the pupil to adjust to changes in lighting Chapter 3: Geriatric Assessment An 86-year-old male who lives in an assisted living facility is at the clinic. He has a history of hypertension and manages his own medications. He admits he takes them sometimes. After speaking to him, you find it unclear if he understands the questions and discussions. Which of the following evidences that the patient has adequate health literacy? He knows the names and doses of his medications and can explain why he takes them. You are performing a geriatric assessment on an 82-year-old female. At the end of the visit, which of the following would require top priority over the others? The death of the patient's caregiver Ms. M's family has noticed memory loss for the past 6 months. She continues to drive but recently had a fender bender and was caught speeding on a 35-mph road. She insists that she is safe and needs to drive to church and for shopping. What is the best next step? Get a driving evaluation. The following are true statements about bipolar disorders in older adults except Bipolar disorder is the most commonly diagnosed psychiatric disorder in older adults. Chapter 5: Wellness and Prevention The US Advisory Committee on Immunization Practices and the Centers for Disease Control currently recommend which one of the following? a. All older adults be immunized against influenza annually and that they receive at least one pneumococcal vaccination. b. All high-risk older adults should receive an additional pneumococcal vaccination 5 years or more after their first immunization. c. Older adults should receive a one-time revaccination for pneumonia if they were initially vaccinated more than 5 years previously and were less than 65 years of age at the time of the initial vaccination. d. All of these are recommended. Healthcare providers should recommend that older adults engage in which one of the following? 150 minutes of moderate intensity physical activity weekly Guidelines for the primary prevention of stroke recommend that aspirin be used in which one of the following? Individuals whose risk is high enough for the benefits to outweigh the risks Even though older adults are less likely to get counseled for smoking cessation, they have which one of the following? The same quit rates as younger individuals When educating the older adult population about the risks to physical health that chronic alcohol abuse presents, the nurse practitioner is especially careful to include the: Identification of the signs and symptoms of gastrointestinal bleeding An older adult client has been voluntarily admitted for treatment of alcohol dependency. In implementing care, the nurse plans which intervention based upon knowledge about alcohol and aging? Assessing the client for both depression and anxiety The nurse practitioner shows an understanding of appropriate influenza vaccination guidelines for a client over the age of 65 when stating: Regardless of your physical health you really should get a yearly flu shot Chapter 6: Cultural Competency and Cultural Humility in Caring for Older Adults Which of the following is true about cultural humility? It places emphasis on power imbalances and promotes interpersonal sensitivity through partnerships with and learning from patients. Racial disparities have been a part of US healthcare for many decades. How might this impact the expectations of older Black Americans? a. Reluctance to participate in medical research because of unethical studies in the past b. Underrepresentation of Black physicians in the geriatric workforce c. Cumulative effects of differences in access to healthcare providers d. All of these Dementia is a relatively common condition in the geriatric population. It becomes more common as people age. Which is the most appropriate description of "personhood" as it relates to people with dementia? The ability to relate to others as people, rather than preserving cognitive independence, is an important aspect of "personhood." Immigrant families bring cultural traditions into healthcare decisions. With regard to older adults, which of the following is true? End-of-life care is particularly sensitive to cultural beliefs and should be explored carefully with the patient and family, as appropriate. It has been projected that the cultural group presenting the greatest growth rate among the older adult population will be the: Hispanic Ethnocentrism is defined as: a belief that one's ethnic group is superior to that of another true Which of the following culturally diverse male clients will most benefit from educational material related to "Staying Healthy into your 80s" Japanese Chapter 7: Appropriate Prescribing Patient GG is an 82-year-old woman with complaints of dysuria and polyuria. A urinalysis is positive for a urinary tract infection. She is 55 kg, her serum creatinine is 1.5 mg/dL, and she has no known drug allergies. Which of the following is the most appropriate antibiotic regimen? Sulfamethoxazole/trimethoprim 400/80 mg BID for 3 days An older woman with a history of mild Alzheimer disease was recently started on oxybutynin 10 mg orally twice daily for urinary incontinence. Her family reports that she has been increasingly disoriented over the past month and she notes some constipation on the review of systems during her office visit. What management is best regarding her urinary incontinence? Change oxybutynin to mirabegron 25 mg orally daily. Patient SL is a 68-year-old man you are seeing for follow-up of uncontrolled hypertension. He is currently prescribed amlodipine 10 mg daily, azilsartan 40 mg daily, metoprolol tartrate 50 mg BID (twice daily), and hydrochlorothiazide (HCTZ) 25 mg daily, and his blood pressure is consistently above target. Secondary causes of hypertension have been ruled out. You ask him about missing doses and he tells you that it is difficult to take so many tablets and the brand-name medication is very expensive. Select the best way to improve this patient's adherence. You decide to discontinue brand name azilsartan and: Initiate losartan/HCTZ 50/25 mg once daily; HCTZ is stopped. Chapter 24: Constipation and Fecal Incontinence Constipation in older adults may result from many factors. Which of the following is not considered a common contributing factor to constipation in older adults? Obesity Risk factors associated with constipation in older women are: a. High number of medications b. Multiple comorbidities c. Female sex d. Black American race/ethnicity e. All of these The first step in developing a treatment strategy for a physically active patient with constipation symptoms that are not caused by other potential causes is to: Recommend higher fiber and water intake Over-the-counter Milk of Magnesia and polyethylene glycol improve constipation by: Promoting secretion of water into the intestinal lumen Supplemental fiber treatment can improve symptoms related to constipation and FI. True or False True Which of the following drugs does not typically cause constipation Magnesium-containing antacid Which of the following is not a common cause of constipation? hypercalcemia Chapter 28: Malnutrition and Feeding Problems Mr. Lee is an 80-year-old man who lives alone who comes to the office for a routine visit. He lost 10 lb in the last 3 months and complains of fatigue, poor appetite, and trouble sleeping. Which of the following is least useful during his initial assessment? Vaccination history During the physical assessment, you notice Mr. Lee has temporal wasting, loss of subcutaneous fat, and decreased handgrip strength. He also complains of dry mouth. His C-reactive protein is within normal limits. What additional lab test(s) are most useful for evaluating his nutritional status? Serum albumin While discussing Mr. Lee's diet, he states that his wife did all the cooking and since she passed away 5 months ago, he eats mostly soups and sandwiches. He does not drive, and he does not like to ask his son to take him to the store because he does not want to be a burden. What nutrition intervention would you recommend? Consult dietician to determine nutritional needs Mrs. Miller is a 78-year-old female admitted to the hospital with pneumonia. She is on oxygen and is fatigued. The nurses notice her coughing when she drinks regular liquids. She states this happens at home as well. Her appetite has been poor in the hospital and she is only eating 50% of her meals. What is your first nutrition intervention? Consult speech therapy for a swallowing evaluation Mrs. Green is an 88-year-old female discharging home from the hospital after sustaining a right hip fracture from a fall. She required surgery to fix the fracture and is now ambulating using a walker. Her Mini-Nutritional Assessment in the hospital was positive for malnutrition risk. She lives alone and only has one family member who lives nearby. What nutrition interventions is least helpful once she discharges home? Recommend she move into a retirement community Which assessment data would not be of particular concern when attempting to manage an older adult's risk for dehydration? Chronic constipation Chapter 30: Pressure Injuries You provide chronic disease management for a 94-year-old male with advanced Alzheimer's dementia. He also goes to an adult day center 5 days per week. You had recently ordered a lift to help him transfer from bed to wheelchair, where he spends most of his day. The wheelchair was assessed by physical therapy and he has a pressure-redistributing cushion. When in bed, he tends to sleep on his back all night unless repositioned by family. He is incontinent of bowel and bladder. At the last visit 3 months ago, the daughter noticed that he had started to pocket his food intermittently. Speech consultation provided education to the family on how to cue the patient for safe swallowing. He has maintained his current weight. Presently he has no pressure injuries. Which care plan will minimize this patient's chances of developing a pressure injury? While in bed, reposition every 2 to 4 hours, order specialized foam overlay, apply barrier cream every shift to protect skin from moisture-associated skin damage, and continue one-to-one feeding. An 84-year-old woman has been readmitted to a long-term care facility after a fall and C6 fracture. Initially, she developed neurogenic shock, resulting in hypotension, bradycardia, and flaccid paralysis. She has a percutaneous endoscopic gastrostomy tube. She spends most of her time in bed, requiring full assistance with turning and repositioning. She has a Foley catheter for urinary retention. She develops copious diarrhea of unclear etiology. C. diff and others were negative. In the past, a rectal tube caused severe gastrointestinal bleeding requiring a blood transfusion; this device was not reconsidered for stool management. Turning her for hygiene care has been a challenge because she will often yell out in pain. She has developed a wound on her right buttock area. The discharge paperwork from the long-term care facility indicates that this started as a purplish discoloration 5 days ago. What is the diagnosis? Unstageable pressure injury A 65-year-old male with Parkinson disease comes to your clinic after a 6-week hospitalization for aspiration pneumonia. He has had worsening mobility in the past year and uses a wheelchair. He developed a stage 3 heel pressure injury. Vascular was consulted and determined that he had adequate arterial flow for wound healing. They recommended wet to dry dressings TID. The wife has been providing his rehabilitative care at home. She notes that the wet to dry dressings are painful to the patient. She gives him oxycodone before dressing changes. The wound has moderate foul-smelling drainage, wet necrotic slough that does not obscure the wound base, and mild erythema. The wife notes that her husband has increasing pain over the past few days and bleeds easily with dressing changes. He has had no fever, chills, or other systemic symptoms. Which of the following signs or symptoms would suggest that a wound is infected? a. Increasing pain b. Foul-smelling drainage c. Necrotic tissue d. Erythema e. All of the above For the patient in question 3, in addition to floating the heels and other pressure reduction techniques, which is the preferred local wound care management plan? Silver-impregnated hydrofiber three times per week and as-needed cleansing Chapter 36: Hypertension An 80-year-old Black woman has a blood pressure (BP) of 168/102 mmHg and is started on amlodipine 5 mg daily. The JNC 8 panel recommends treating this patient to a goal blood pressure of less than 150 mmHg systolic and 90 mmHg diastolic A 54-year-old Hispanic woman has home BP of 155/95 mmHg, confirmed by multiple similar readings and office BP of 154/94 mmHg. She exercises, follows a low-salt diet, and rarely drinks alcohol. Which one of the following medications would be most appropriate for this patient? Chlorthalidone A 72-year-old man with a history of hypertension recently had acute coronary syndrome for which he was hospitalized and treated with a stent to one of his coronary arteries. In addition to antiplatelet therapy, what antihypertensives are recommended to treat his BP and improve outcomes regarding his ischemic heart disease? Lisinopril and metoprolol Chapter 37: Coronary Artery Disease and Atrial Fibrillation The pathophysiology that underlies the formation of atherosclerotic plaque in coronary arteries is primarily associated with which of the following mechanisms? Inflammation An 80-year-old woman is evaluated in your clinic for muscle aches. Her daughter, who is a nurse, states that her symptoms worsened after recently starting atorvastatin 80 mg daily. This medication and dose was selected based on the patient wanting to reduce her chance of a heart attack or stroke. She has a known history of stable coronary artery disease (CAD), without prior coronary revascularization. She takes low dose aspirin and her blood pressure is well controlled on lisinopril 20 mg once daily. You recognize that myalgias and myopathic symptoms are dose related and more common in older adults prescribed statins. Which of the following recommendations would be appropriate at this time? Discontinue atorvastatin until the myopathy has resolved, then consider restarting atorvastatin at a low dose, such as 10 mg once daily or an alternative statin A 75-year-old man with stable ischemic heart disease (SIHD) and moderate angina returns for follow-up. Prior stress testing has documented myocardial ischemia. A coronary angiogram performed 6 months ago showed that he has few options for revascularization and should be managed medically, although high-risk percutaneous coronary intervention (PCI) can be performed for lifestyle limiting symptoms. Reviewing his medications, it appears that he has been taking amlodipine 10 mg daily, in addition to statin, aspirin, and as needed sublingual nitroglycerin. What would be the most appropriate next step in his management? His antianginal regimen should be improved to include the addition of a beta blocker and/or a long acting nitrate. An 88-year-old female patient with Parkinson disease presents to clinic for hospital follow-up for atrial fibrillation (AF) with rapid ventricular response (RVR). Home heart rate monitoring shows good rate control of her AF ventricular rates. She has a history of falls and labile international normalized ratio (INR) with irregular adherence with blood draws. Her current medications include carbidopa-levodopa, metoprolol, and warfarin and she has a robust drug plan that allows for a variety of medication choices. What changes would you recommend to her medication regimen? Convert warfarin to a direct oral anticoagulant Chapter 38: Heart Failure In patients with heart failure, the most useful initial imaging modality is: Transthoracic echocardiogram Compared with angiotensin-converting enzyme (ACE) inhibitors, angiotensin-receptor blocker are less likely to be associated with: Angioedema Which class of drug has not been shown to provide a mortality benefit in heart failure patients with reduced ejection fraction? Diuretics Which of the following would be consistent with the new onset of heart failure in an older patient? a. Dyspnea b. Worsening ability to self-care c. Anorexia d. Confusion e. All of the above Which of the following drugs do not trigger or aggravate a cough? Hydrochlorothiazide Chapter 41: Diabetes Mellitus You are seeing an 85-year-old gentleman with a 15-year history of diabetes mellitus, coronary artery disease and coronary artery bypass grafting 7 years ago, and mild chronic obstructive pulmonary disease. He lives in a senior living community in an independent apartment and gets help from family with shopping and medication management. He feels generally well, but complains of occasional episodes of weakness and nausea in the morning and before lunch. What is the most appropriate advice for this gentleman with respect to treatment goals for his diabetes? Check blood glucose each morning before breakfast and adjust medications to keep HbA1C <8%. Which of the following management strategies would have the lowest risk of hypoglycemia in an older adult with type 2 diabetes mellitus? Metformin You are seeing an 80-year-old woman who recently moved to the area to live closer to her daughter. She reports a 10-year history of diabetes mellitus, which she has managed with metformin and glimeperide. She feels well but admits to having been very busy in the recent past. In fact, she has not seen a doctor in nearly a year. Which of the following health assessment measures would be appropriate in this patient? Brief cognitive testing and examination of gait and balance A client is newly diagnosed with type 2 diabetes mellitus. Which diagnostic test will best evaluate the management plan prescribed for this client? Quarterly hemoglobin A1C Chapter 42: Thyroid Disorders The most common presenting feature of hyperthyroidism in older adults is: Atrial fibrillation. Hyperthyroidism is diagnosed with which of the following: A decreased serum level of thyroid-stimulating hormone (TSH) and an elevated serum level of unbound thyroxine (free T4). Which one of the following is correct about subclinical hypothyroidism? Treatment is controversial. Which of the following is correct about thyroid disease in older adults? Hypothyroidism is associated with weight loss in older adults. Which of the following statements about thyroid cancer are true? Papillary thyroid cancer is more common in older adults. If untreated, subclinical hyperthyroidism: May cause cardiac failure. Which diagnostic laboratory test would the nurse practitioner typically not order for the purpose of evaluating an individual's acute, unexplained weight loss Serum Potassium Weight loss is frequently caused by ingestion of one or more of the following drugs. Antibiotics Digoxin Nonsteroidal anti-inflammatory drugs (NSAIDs) Theophylline Chapter 43: Osteoporosis A 70-year-old postmenopausal female presents to your clinic to discuss treatment options for her low bone density. She has no prior history of hip or vertebral fractures. She has type 2 diabetes mellitus and associated chronic kidney disease (baseline creatinine clearance 29 mL/min). Body mass index (BMI) is 30 kg/m2. She had a myocardial infarction 1 year ago. She was diagnosed with breast cancer 10 years ago, for which she underwent a mastectomy, chemotherapy, external beam radiation, and a course of tamoxifen. She takes a daily calcium and vitamin D supplement. Serum calcium and 25-hydroxyvitamin D levels are normal. She has a family history of maternal hip fracture Current DXA L-spine Total hip Femoral neck T-score −2.4 −2.1 −2.3 FRAX 10-year fracture risk score: Major osteoporotic fracture = 12%, hip fracture = 5% Which of the following is the best treatment option for this pati Denosumab A 71-year-old male with a past medical history of hypertension presents for follow-up of his osteoporosis. He was diagnosed with osteoporosis by DXA scan 5 years ago after an ankle fracture and has been on weekly alendronate 70 mg since that time. He has no prior history of hip or vertebral fractures. He is active and performs aerobic and strength-training exercises four times per week. No kyphosis is noted on examination. BMI is 23 kg/m2. No loss of height while on alendronate. He takes a daily calcium and vitamin D supplement. He does not smoke or consume alcohol. His repeat DXA scan demonstrates a significant increase in his spine bone mass density (BMD) of 5%. Pretreatment DXA L-spine Total hip Femoral neck T-score −2.7 −2.2 −2.5 Current DXA L-spine Total hip Femoral neck T-score −2.0 −2.1 −2.3 Which of the following is the most appropriate trea Discuss initiation of drug holiday A 73-year-old postmenopausal female presents for follow-up of her osteoporosis. Because of gastrointestinal (GI) intolerance to alendronate, she has received 3 years of intravenous zoledronic acid. She has a history significant for type 2 diabetes mellitus with associated peripheral neuropathy and chronic obstructive pulmonary disease treated frequently with glucocorticoids. She has a prior history of a nontraumatic vertebral fracture at T12. She falls frequently. She continues to smoke cigarettes daily. She does not consume alcohol. Her BMI is 25 kg/m2. Since initiating zoledronic acid, she has had stable height and no new vertebral fractures. Current DXA results L-spine Total hip Femoral neck T-score −2.8 −2.5 −2.4 The BMD has remained stable compared with prior DXA measures after 3 years of zoledronic acid. Which of the following is the most appropriate treatment opti Continue zoledronic acid What is osteoporosis? Skeletal disorder characterized by impaired bone strength that predisposes to increased risk of fracture Can occur from not only bone loss but also from failure earlier in life to make sufficient bone. Primary: due to aging (increased bone resorption/reduced new bone formation) Secondary: consequence of underlying medical condition/drug What are diagnostic tests for osteoporosis? XR DEXA (screen all women >65yo, hip/spine; test earlier if major risk factors present; repeat every 3-5yrs depending on degree) What is T-score of -2.5 or lower indicative of? Osteoporosis What is a Z-score of <-1.5 indicative of? Secondary cause of osteoporosis What is a T-score of -1.0 or higher indicative of? Normal Chapter 44: Arthritis and Related Disorders An 80-year-old White female patient comes to your office worried about a repeated positive test of antinuclear antibodies (ANA) 1:80 with a speckled pattern. She was previously diagnosed with systemic lupus erythematosus. The patient is otherwise asymptomatic and functional, and her physical examination is normal. Which one of the following would be the best approach for this patient? Reassure the patient that her ANA do not have clinical significance. A 75-year-old Hispanic woman is admitted to the hospital with atrial fibrillation and started on anticoagulation plus rate control medications. Her past medical history was significant for rheumatoid arthritis (RA), and she was taking weekly methotrexate and daily folic acid. On the third day in the hospital, the patient developed significant right knee pain. Her last methotrexate dose was taken 6 days ago. Physical examination detected a red, swollen right knee. What would your next approach be? Request an arthrocentesis A 90-year-old Black woman is found to have a uric acid of 13 mg/dL with a creatinine of 0.6 mg/dL. She does have a history of osteoarthritis and heart failure and is taking furosemide 80 mg orally daily. She develops acute onset first metatarsal phalangeal joint pain. The best approach for this patient will be: Start colchicine A 90-year-old Black man visits your office and complains of pain in both knees. He has had the problem for several years; he has morning stiffness for less than 1 hour a day and pain mostly in the hands and knees. On physical examination, he has hard nodes on the distal interphalangeal joints and no effusion in the knees, although they look bigger than normal. Laboratory work revealed a low titer-positive rheumatoid factor, and the erythrocyte sedimentation rate and C-reactive protein were within normal limits. The rest of the physical examination was unremarkable. The most likely diagnosis is: Osteoarthritis An 80-year-old non-Hispanic White man was taking cyclooxygenase (COX)-2 inhibitors and heard on the news that it was bad for the heart. He was tolerating the medication, and his knee pain from osteoarthritis was well controlled. When he started having the pain 5 years ago, his primary care provider put him on the COX-2 inhibitor as a first option, and he has been taking the same medication since that time. He has a history of peptic ulcer disease and renal insufficiency. Which is the best option for this patient to try? Topical NSAID and acetaminophen After first managing the pain being experienced by the client with gout, the treatment focuses on Preventing systemic involvement by altering the client's diet Chapter 46: Cancer A 79-year-old woman with a 1.5-cm breast cancer underwent lumpectomy. Pathology revealed ductal carcinoma that is hormone receptor negative (estrogen receptor 0%, progesterone receptor 1%) and HER2/neu negative. Surgical margins were adequate and uninvolved with cancer. Sentinel lymph node sampling was negative for lymph node involvement. She has good performance status and no activities of daily living (ADL) or instrumental (IADL) dependencies. What treatment would you recommend? Hormonal therapy only An 86-year-old man with no ADL deficits who has stopped driving because of macular degeneration is evaluated for a urinary tract infection associated with urinary retention. The consulting urologist places a Foley catheter and sends a prostate-specific antigen (PSA) level that comes back 12 ng/mL. Three months later after the Foley has been removed and he has had a good response to tamsulosin, his PSA is still 10 ng/mL. What is the appropriate next step in managing this man's prostate problem? Repeat PSA in 6 months In which of the following patients is chemical or surgical castration likely to prolong survival? A 78-year-old man who had a radical prostatectomy and external beam radiation therapy 10 years earlier now has a PSA level of 24.5 ng/mL. A CT scan of the pelvis shows an enlarged pelvic lymph node, and a bone scan is positive in the pelvis. On admission to the hospital, an 85-year-old woman was found to have a fungating mass on her right breast. The mass is 9 cm in diameter, partially ulcerated, and associated with edema of the arm and obvious pain. The patient has no children and had lived alone until recently, when a neighbor became concerned for what appeared to be a progressive loss of memory and neglect of the house. The patient appears confused and withdrawn; her appearance is disheveled, but she seems to be independent in her ADLs. The medical history is negative for any serious illnesses. She was able to drive her own car until shortly before this admission. The nephew does not wish to authorize hospice "right now." A positron-emission tomography scan was negative for metastatic disease. In addition to determining the cause of her delirium, which of the following is the best way to address the breast mass? The mass should be biopsied to study hormone receptor and HER2/neu antigen status. A 78-year-old man has an emergency partial colectomy for lower gastrointestinal bleeding. A localized colonic adenocarcinoma is completely resected. The surgeon did not dissect lymph nodes for metastatic sampling. The patient wants to know if he should have chemotherapy. Should he? No because he can be followed with serial carcinoembryonic antigens and CT scans. An 80-year-old woman has no weight loss, no pain, and no distention but over 2 years increasingly complains of constipation despite adequate medical treatment. A colonoscopy is negative. An abdominal CT is performed. It reveals well-circumscribed pelvic masses, the largest adherent to the ovarian ligament. The best first step is: Invite her to return with a family member and have a long talk about the diagnostic and therapeutic options. Chapter 47: Anemia in Older Adults Your patient, a 68-year-old male, presented to the hospital with gastrointestinal bleeding from a duodenal ulcer that was treated endoscopically. His hemoglobin at discharge was stable at 10 g/dL, and he has had no recurrent signs of bleeding. He is now in your office 1 week after hospital discharge for a follow-up visit, being treated for iron deficiency anemia with iron sulfate 325 mg three times daily and is complaining of dyspepsia with iron supplementation. Your next step in management should be: Decrease his iron sulfate to 325 mg once daily. A 72-year-old female with progressive fatigue is found to have a hemoglobin of 9.1 g/dL, mean corpuscular volume of 108 fL, and a platelet count of 67×109/L on a routine laboratory evaluation. She has a normal B12 and folate level. She has never had a history of anemia and does not have signs or symptoms of bleeding or hemolysis. She does not use alcohol, and she has no liver disease. Your next step in management should be: Refer to hematology for bone marrow examination An 83-year-old female presents to your clinic for a routine physical examination. On basic laboratory tests you note a hemoglobin level of 11.2 g/dL (1 year ago was 11.8 g/dL), a hematocrit of 33.6%, a white blood count of 8.1×103 µL (normal differential), a mean corpuscular volume 96.2 fL, a mean corpuscular hemoglobin concentration of 37 g/dL, and a platelet count 287,000×103 µL. Her creatinine clearance is 66 mL/min/1.73m2. On subsequent laboratory testing, she is found to have a ferritin level of 72 ng/mL, a normal transferrin saturation, B12, C-reactive protein, and thyrotropin levels. The most likely diagnosis at this time is: Unexplained anemia Chapter 48: Pulmonary Disease A 65-year-old male is evaluated in a follow-up examination for worsening dyspnea and chronic cough productive of mucoid sputum for the past 6 months. Was diagnosed with (COPD) 3 years ago, and uses inhaled albuterol as needed. The patient has a 40 pack-year history of cigarette smoking but quit smoking 8 months ago. On physical examination, vital signs are normal and the patient is not in any respiratory distress. Breath sounds are decreased, but there is no edema or jugular venous distention. Spirometry shows a forced expiratory volume in the first second (FEV1) of 58% of predicted with no reversibility and an FEV1/forced vital capacity (FVC) ratio of 65%. His COPD symptoms seem poorly controlled and he has had one exacerbation in the past year. A chest radiograph is obtained and shows mild hyperinflation. Which of the following is the most appropriate therapy for this patient? Add a long-acting inhaled bronchodilator. A 65-year-old female is evaluated for dyspnea, chronic cough, and mucoid sputum for the past 4 months. She has noticed that she has to walk slower than she used to and has to stop to catch her breath after walking 5 to 6 city blocks. The patient has a 40 pack-year history of cigarette smoking but quit smoking 1 year ago. She is otherwise healthy. On physical examination, vital signs are normal. Breath sounds are decreased, but there is no edema or jugular venous distention. What is the next best test you would order to make a diagnosis? Obtain spirometry. A 77-year-old female with asthma is evaluated for a very slow increase in the frequency of episodes of wheezing and dyspnea not relieved by short-acting beta-agonist therapy. She uses her controller medications regularly which include an inhaled long-acting beta-agonist and an inhaled low-dose corticosteroid. She has daily daytime and frequent nocturnal symptoms of chest tightness and wheezing. She does not feel acutely ill. The patient is not in any respiratory distress. Her temperature is 98.6° F blood pressure is 140/85 mmHg, pulse is 90 and RR is 18/min. She has bilateral wheezing. In-office spirometry shows an FEV1 of 65% of predicted. After the supervised use of a bronchodilator in the office, there was some relief of her symptoms, and repeat spirometry 15 minutes later showed that the FEV1 increased to 85% of predicted. Which of the following is the appropriate next step in this patient's management? Step up to medium-dose inhaled corticosteroid and have her return in 4 to 6 weeks for evaluation. A 60-year-old woman presents with a chief complaint of uncomfortable breathing on exertion. She has had a minimally productive cough for several years that does not bother her. On further questioning, she states that her breathing gets much worse when she lies down. The most likely cause of her dyspnea is Cardiac The percentage of the FVC expired in one second is FEV1/FVC ratio Chapter 50: Gastroenterology A 65-year-old otherwise healthy woman presents to the office with dysphagia that has been ongoing for nearly a year. She states that sticky foods, such as rice and tougher foods, such as beef or chicken, can transiently get stuck in her esophagus. She has had to vomit food out because it would not pass with time or by drinking water. She has had no weight loss and her symptoms have not been particularly progressive in nature. She has never had an endoscopy, but is up-to-date with her health care maintenance, including colon cancer screening. no significant family history of gastrointestinal (GI) diseases or malignancies. Her examination is notable only for conjunctival pallor. Laboratories are significant for a microcytic anemia. A barium esophagram is performed, which reveals a thin, smooth, transverse filling defect in the midesophagus. Which of the following complications is this patient most at risk for? Achalasia A 70-year-old man undergoes an upper endoscopy for the evaluation of dyspepsia. He has a large nonbleeding ulcer and biopsies reveal the present of Helicobacter pylori infection. He is given a 10-day course of clarithromycin, tetracycline, and omeprazole twice daily. His symptoms resolve. A urea breath test performed 2 weeks later is positive for H. pylori. Which of the following is the best next step in management of this patient? Treatment with bismuth, metronidazole, tetracycline, and omeprazole for 14 days A 72-year-old woman with a history of chronic heartburn comes in to discuss gastroesophageal reflux disease management. She asks whether she should remain on her proton-pump inhibitor (PPI); she has been on lansoprazole 15 mg daily for the past 12 years. With the medication, diet, and lifestyle changes, she has been asymptomatic for almost all of that time. An upper endoscopy performed 4 years ago revealed a small hiatal hernia and mild erosive esophagitis. She is concerned about long-term risks of PPIs. Which of the following is the most appropriate recommendation at this time? Advise her to undergo a repeat upper endoscopy to help determine if it is safe to stop her PPI Which statement made by a client recently diagnosed with diverticular disease would indicate that she needs additional teaching regarding dietary considerations? I'll have to give up eating right before I go to bed." When diagnosed with diverticulosis, a client asks how this problem occurred. Which assessment data identifies a risk factor for diverticulosis? Maintains a diet low in fiber Chapter 54: Skin Problems What is the primary lesion in Fig. 54.21? Papule A 70-year-old patient has scattered nummular plaques with thick scale on his shins that are extremely pruritic. He also has very dry skin. Skin scraping is negative for dermatophyte. He had already completed a course of oral antifungal medication prescribed to him by an urgent care physician. Assuming this is nummular eczema, which of the following topical medication and vehicle is the best choice? Triamcinolone 0.1% ointment A 90-year-old balding farmer who is otherwise healthy and active has diffuse pink, rough scaly papules on his scalp (Fig. 54.22). Which of the following statements is most correct about his condition? One-quarter may spontaneously regress, especially with aggressive sun protection. A 65-year-old man is hospitalized with sudden onset chest pain but has a negative cardiac workup. You notice pink eroded papules along the left sternum and left flank that abruptly stop at the midline, where he thinks electrical leads were placed. He thinks these painful and somewhat itchy bumps are increasing in number. He is afebrile, otherwise stable, and has no other complaints. Which of the following is the most appropriate next step? Empiric valacyclovir. The nurse is teaching a health promotion class at a senior center. Which of the following statements demonstrate that the participant does not understand the topic We need to use caustic soaps and scrub aggressively with a wash cloth bathing to minimize bacteria on the skin The nurse shows understanding of the need to promote healthy skin in the older adult when encouraging the client to all of the following except : clean the skin with a moisturizing soap The abrupt onset of symptoms of stress or urge incontinence is most often due to a urinary tract infection True A 77-year-old client being treated for glaucoma asks the nurse practitioner what causes glaucoma. The nurse bases the response on the knowledge that the increase in intraocular pressure is a result of: a breakdown in the absorption process The greatest risk for injury for a client with progressed Parkinson's disease is: Falls