APEA 2025 QUESTIONS AND ANSWERS
When examining a pregnant patient, where should the fundal height be at 22 weeks?
Above the umbilicus
Between 18 and 32 weeks, there is good correlation between fundal height and gestational age of the
fetus. The expected heights are: 10-12 weeks: fundus slightly above the symphysis pubis 16 weeks:
fundus midway between the symphysis pubis and umbilicus 20 weeks: fundus at the level of umbilicus
28 weeks: fundus 3 fingerbreadths above the umbilicus 36 weeks: fundus just below the xiphoid process
What intervention does the American College of Rheumatology recommend as first-line therapy for
osteoarthritis?
Exercise and weight loss
Exercise, weight loss, and rest are recommended by the American College of Rheumatology guidelines
for the initial management of osteoarthritis (OA). Given the adverse effects of medications used to treat
OA, it is best to minimize dosage and delay use as long as possible. An extensive diagnostic workup is
not recommended unless the presentation is in question. Patients who have severe degenerative joint
disease (DJD), joint fusion, or whose pain severity is not relieved by more conservative therapies may be
candidates for joint replacement. Acetaminophen is recommended as a first-line medication.
A 63-year-old male retired accountant complains of pain and stiffness in his feet and hands of several
years duration. He reports that the pain and stiffness become worse with activity. On examination, he is
noted to have Heberden's nodes but no other bony deformities. Which of the following is the most
probable diagnosis?
Osteoarthritis (OA)
,Although his vocation involved sedentary activity, this patient is not at great risk for osteoarthritis.
Rheumatoid arthritis is characterized by several joint deformities, usually bilaterally symmetrical. RA is
characterized by inflammatory processes, while OA is not. RA and OA are chronic conditions. Gout is
characterized by acute exacerbations related to a defect in purine metabolism, increased uric acid
production, or decreased uric acid excretion.
The family of a 78-year-old man moved him into an assisted living center because he can no longer be
left at home alone. He is unable to toilet when asked to do so and he has had several episodes of
incontinence. He has walked out of the facility twice and been unable to find his way back from 3 blocks
away. On examination, he is pleasant but mildly confused. Which of his medications is LEAST likely
contributing to his behavior?
ramipril (Altace®)
Tricyclic antidepressants, like amitriptyline, have anticholinergic side effects which are especially
problematic in the elderly because they contribute to urinary retention. Hydrochlorothiazide is a diuretic
and may contribute to his incontinence. Cimetidine is well known to produce adverse reactions such as
confusion in elders. Ramipril, an ACE inhibitor, is unlikely to contribute to this patient's incontinence or
confusion. Toileting may be a complicated by the anticholinergic medication and/or the diuretic causing
diuresis, urge incontinence, and inability to void at will.
A patient with no significant medical history has varicose veins. She complains of "aching legs". The
intervention that will provide the greatest relief for her complaint is to:
elevate her legs periodically.
The intervention that will provide the greatest relief for this patient is elevating her legs periodically.
This will facilitate venous return. Use of support stockings will prolong the length of time she is able to
stand in place, but will not provide relief after her legs begin aching. Support stockings should be applied
prior to getting out of bed.
,may be aggravated by caffeine or alcohol.
Stress urinary incontinence is not expected as a result of the normal aging process. The primary problem
is sphincter incompetence. The ingestion of caffeine or alcohol decreases sphincter control.
Anticholinergic and antidepressant medications are causative factors related to overflow incontinence.
Detrusor muscle instability is the primary underlying problem causing urge incontinence.
Stress urinary incontinence is:
Which commonly used herbal remedy is NOT associated with anxiety and/or depressive symptom relief?
Ginkgo biloba
Ginkgo biloba is a common herbal remedy associated with enhancement of vascular and cerebral
perfusion and memory. The nurse practitioner should be aware when the patient is taking any herbal
supplement to avoid risk of drug interactions.
Upon ophthalmoscopic examination of a 78-year-old patient, the nurse practitioner observes dark spots
against a red retina. What diagnosis is this finding most consistent with?
Cataract
A cataract opacity is seen as a dark disruption of the red reflex on ophthalmoscopic exam.
, A 72 year old female patient reports a 6 month history of progressively more swollen and painful distal
interphalangeal (DIP) joints of one hand. There are no systemic symptoms but the erythrocyte
sedimentation rate (ESR), antinuclear antibody (ANA), and rheumatoid factor (RF) are all minimally
elevated. What is the most likely diagnosis?
Osteoarthritis
When osteoarthritis affects the hands, the distal interphalangeal (DIP) joints are usually involved.
Rheumatoid arthritis is usually symmetrical, and the proximal interphalangeal (PIP) joints are more often
affected. Inflammation often develops quickly, not gradually. This patient is elderly; therefore, it is
expected that the ESR, ANA, and RF will be only somewhat elevated. Over-interpretation of laboratory
tests without evidence of systemic inflammation can lead to misdiagnosis.
The nurse practitioner is evaluating a 35-year-old female nurse. She has a history of hospitalization for
hepatitis B infection 2 years ago. Her laboratory tests demonstrate positive HBsAg. The nurse
practitioner would most likely diagnose:
chronic hepatitis B infection.
Presence of hepatitis B surface antigen at this time indicates chronic infection with hepatitis B. Lab
studies indicating a positive surface antigen on 2 separate occasions at least 6 months apart indicate
chronic infection. Immunization produces positive hepatitis B antibodies in most instances. Hepatitis B
surface antigen would not be present in a person who has recovered from hepatitis B infection. This
case would not be an acute episode because of the history of hepatitis B infection 2 years prior.
One exception to the recommendation to limit dietary fat intake is:
children under 2 years-of-age.
In order for myelinization of the nervous system to occur, children under 2 years-of-age require > 30%
daily dietary fat.
When examining a pregnant patient, where should the fundal height be at 22 weeks?
Above the umbilicus
Between 18 and 32 weeks, there is good correlation between fundal height and gestational age of the
fetus. The expected heights are: 10-12 weeks: fundus slightly above the symphysis pubis 16 weeks:
fundus midway between the symphysis pubis and umbilicus 20 weeks: fundus at the level of umbilicus
28 weeks: fundus 3 fingerbreadths above the umbilicus 36 weeks: fundus just below the xiphoid process
What intervention does the American College of Rheumatology recommend as first-line therapy for
osteoarthritis?
Exercise and weight loss
Exercise, weight loss, and rest are recommended by the American College of Rheumatology guidelines
for the initial management of osteoarthritis (OA). Given the adverse effects of medications used to treat
OA, it is best to minimize dosage and delay use as long as possible. An extensive diagnostic workup is
not recommended unless the presentation is in question. Patients who have severe degenerative joint
disease (DJD), joint fusion, or whose pain severity is not relieved by more conservative therapies may be
candidates for joint replacement. Acetaminophen is recommended as a first-line medication.
A 63-year-old male retired accountant complains of pain and stiffness in his feet and hands of several
years duration. He reports that the pain and stiffness become worse with activity. On examination, he is
noted to have Heberden's nodes but no other bony deformities. Which of the following is the most
probable diagnosis?
Osteoarthritis (OA)
,Although his vocation involved sedentary activity, this patient is not at great risk for osteoarthritis.
Rheumatoid arthritis is characterized by several joint deformities, usually bilaterally symmetrical. RA is
characterized by inflammatory processes, while OA is not. RA and OA are chronic conditions. Gout is
characterized by acute exacerbations related to a defect in purine metabolism, increased uric acid
production, or decreased uric acid excretion.
The family of a 78-year-old man moved him into an assisted living center because he can no longer be
left at home alone. He is unable to toilet when asked to do so and he has had several episodes of
incontinence. He has walked out of the facility twice and been unable to find his way back from 3 blocks
away. On examination, he is pleasant but mildly confused. Which of his medications is LEAST likely
contributing to his behavior?
ramipril (Altace®)
Tricyclic antidepressants, like amitriptyline, have anticholinergic side effects which are especially
problematic in the elderly because they contribute to urinary retention. Hydrochlorothiazide is a diuretic
and may contribute to his incontinence. Cimetidine is well known to produce adverse reactions such as
confusion in elders. Ramipril, an ACE inhibitor, is unlikely to contribute to this patient's incontinence or
confusion. Toileting may be a complicated by the anticholinergic medication and/or the diuretic causing
diuresis, urge incontinence, and inability to void at will.
A patient with no significant medical history has varicose veins. She complains of "aching legs". The
intervention that will provide the greatest relief for her complaint is to:
elevate her legs periodically.
The intervention that will provide the greatest relief for this patient is elevating her legs periodically.
This will facilitate venous return. Use of support stockings will prolong the length of time she is able to
stand in place, but will not provide relief after her legs begin aching. Support stockings should be applied
prior to getting out of bed.
,may be aggravated by caffeine or alcohol.
Stress urinary incontinence is not expected as a result of the normal aging process. The primary problem
is sphincter incompetence. The ingestion of caffeine or alcohol decreases sphincter control.
Anticholinergic and antidepressant medications are causative factors related to overflow incontinence.
Detrusor muscle instability is the primary underlying problem causing urge incontinence.
Stress urinary incontinence is:
Which commonly used herbal remedy is NOT associated with anxiety and/or depressive symptom relief?
Ginkgo biloba
Ginkgo biloba is a common herbal remedy associated with enhancement of vascular and cerebral
perfusion and memory. The nurse practitioner should be aware when the patient is taking any herbal
supplement to avoid risk of drug interactions.
Upon ophthalmoscopic examination of a 78-year-old patient, the nurse practitioner observes dark spots
against a red retina. What diagnosis is this finding most consistent with?
Cataract
A cataract opacity is seen as a dark disruption of the red reflex on ophthalmoscopic exam.
, A 72 year old female patient reports a 6 month history of progressively more swollen and painful distal
interphalangeal (DIP) joints of one hand. There are no systemic symptoms but the erythrocyte
sedimentation rate (ESR), antinuclear antibody (ANA), and rheumatoid factor (RF) are all minimally
elevated. What is the most likely diagnosis?
Osteoarthritis
When osteoarthritis affects the hands, the distal interphalangeal (DIP) joints are usually involved.
Rheumatoid arthritis is usually symmetrical, and the proximal interphalangeal (PIP) joints are more often
affected. Inflammation often develops quickly, not gradually. This patient is elderly; therefore, it is
expected that the ESR, ANA, and RF will be only somewhat elevated. Over-interpretation of laboratory
tests without evidence of systemic inflammation can lead to misdiagnosis.
The nurse practitioner is evaluating a 35-year-old female nurse. She has a history of hospitalization for
hepatitis B infection 2 years ago. Her laboratory tests demonstrate positive HBsAg. The nurse
practitioner would most likely diagnose:
chronic hepatitis B infection.
Presence of hepatitis B surface antigen at this time indicates chronic infection with hepatitis B. Lab
studies indicating a positive surface antigen on 2 separate occasions at least 6 months apart indicate
chronic infection. Immunization produces positive hepatitis B antibodies in most instances. Hepatitis B
surface antigen would not be present in a person who has recovered from hepatitis B infection. This
case would not be an acute episode because of the history of hepatitis B infection 2 years prior.
One exception to the recommendation to limit dietary fat intake is:
children under 2 years-of-age.
In order for myelinization of the nervous system to occur, children under 2 years-of-age require > 30%
daily dietary fat.
