NR574 UPDATED FINAL PAPER QUESTIONS AND
SOLUTIONS GUARANTEE A+
✔✔imaging to Diagnose AMI - ✔✔Gold standard: CT angio with a 1-mm or thinner cut
should be used to detect mesenteric arterial occlusive disease.
✔✔Hepatic steatosis (fatty liver) - ✔✔Nonalcoholic hepatic steatosis, or nonalcoholic
fatty liver disease (NAFLD), is one of the most common causes of chronic liver disease
in the developed world.It is a spectrum of disease, ranging from hepatic fat
accumulation without inflamma- tion to steatohepatitis, fibrosis, cirrhosis, and end-stage
liver disease.
✔✔risk factors of hepatic steatosis - ✔✔NAFLD is strongly associated with insulin
resistance, overweight/obesity, and metabolic syndromecan occur in thin people with
paucity of adipose depots(lipodystrophy)
✔✔nonalcoholic steatohepatitis (NASH) - ✔✔a more severe form of nonalcoholic fatty
liver disease. it consists of fatty accumulations plus liver-damaging inflammation. in
some cases, this will progress to cirrhosis, irreversible liver scarring or liver cancer
✔✔Imaging used for NASH - ✔✔Hepatic US and CT scan. Unfortunately, at the present
time, no imaging study can accurately distinguish simple fatty liver from NASH.
✔✔blood levels of acetaminophen correlate with severity of hepatic injury - ✔✔levels
>300 ug/mL 4 hours after ingestion are predicative of the development of severe
damage.
✔✔Treatment of Tylenol OD - ✔✔gastric lavage supportive measures oral
administration of activated charcoal or cholestyramine to prevent residual of the drug.
✔✔activated charcoal and cholestyramine should be done how soon after ingestion or
else they wont do anything? - ✔✔>30minutes from ingestion timegastric lavage should
be done before other orals.
✔✔N-acetylcysteine reduces markedly the severity of? - ✔✔hepatic necrosis
✔✔N-acetylcysteine should be given when? - ✔✔4-8 hours after ingestion if the blood
levels of tylenol are >200ug/mL at 4 hours
or
>100 ug/mL at 8 hours.
✔✔IV N-acetylcysteine dose - ✔✔loading dose: 140 mg/kg over 1 hour followed by 70
mg/kg every 4 hours for 15-20 doses.
,✔✔When is liver transplantation indicated in pt with tylenol OD? - ✔✔hepatic failure
signs (jaundice, coagulopathy, confusion) occur after N-acetylcysteine dose, live
transplant may be the only option.
✔✔what does serum lactate tell us about the need for liver transplant? - ✔✔is serum
lactate is >3.5 - likely will require liver transplant to survive.
✔✔A 28-year-old woman is seen in a sexually transmitted disease clinic and is
diagnosed with Chlamydia trachomatis. An HIV antibody test is ordered. Which one of
the following statements
is TRUE regarding laboratory-based HIV antibody tests that are approved for use by the
United States Food and Drug Administration? - ✔✔Recent inocculation with the
influenza vaccine is a known cause of a false-positive result
✔✔A 31-year-old woman has exposure to HIV after a condom broke while having
vaginal sex with her partner who has HIV. She has follow-up HIV testing related to this
exposure. Which one of the following best describes the window period? - ✔✔The CDC
recommends using 45 days as the window period for all laboratory-based IgM/IgG HIV-
1/2 antibody immunoassays
✔✔A 22-year-old man presents for follow-up after a recent diagnosis of HIV. He has an
initial CD4 count of 390 cells/mm3 and his HIV RNA level is46,120 copies/mL; a
baseline genotype resistance assay shows no evidence of antiretroviral resistance. He
is motivated to start antiretroviral therapy and states that he can take medications
without issue. According to the Adult and Adolescent Antiretroviral (ARV) Guidelines,
which one of the following best describes the recommendations for starting antiretroviral
therapy in treatment-naïve persons with HIV? - ✔✔Antiretroviral therapy is
recommended for all persons with HIV
✔✔A 51-year-old transgender woman (she/her/hers) with HIV has been stable for the
last 3 years on an antiretroviral regimen of darunavir-cobicistat and tenofovir DF-
emtricitabine. Despite changing to a healthier diet and increas- ing her exercise, lipid
values remain elevated : total cholesterol 268 mg/dL, low-density lipoprotein (LDL) 198
mg/dL, high-density lipoprotein (HDL) 35 mg/dL, and triglycerides 220 mg/dL. She has a
strong family history of car- diovascular disease, and her father had a myocardial
infarction at age 52.She does not want to consider modifying the antiretroviral regimen
but agrees to start lipid-lowering therapy. Which one of the following HMG-CoA
reductase inhibitors ("statins") is contraindicated for use in this woman? -
✔✔Simvastatin
✔✔What is a TIPS procedure? - ✔✔The TIPS procedure bypasses a portion of the
hepatic circulation by shunting blood flow from the portal vein to the hepatic vein-This
reduces portal pressure and minimizes back pressure on the splanchnic organs. This
also decreases the likelihood of bleeding from the esophageal varies and reduces the
amount of ascites
,*Hemorrhage is a significant risk during TIPS
✔✔What is the treatment of choice for both type 1 and type 2 HRS? - ✔✔Liver
transplant
✔✔What medications are used to tx type 2 HRS? - ✔✔vasoconstrictors (terlipressin,
midodrine in combination with octriotide, norepinephrine) combined with albumin.
✔✔Bridge to transplant in Hepatorenal syndrome - ✔✔The combination of octreotide,
midodrine, and albumin (triple therapy) is used to treat hepatorenal syndrome (HRS)
often as a bridge to liver transplantation (LT).
✔✔Module ** Bridge to transplant** - ✔✔In clients who do not respond to medical
therapy, are not candidates for TIPS but are candidates for liver transplantation or
recovery for their liver disease, continuous renal replacement therapy can be utilized as
a bridge to recovery or transplantation. HRS clients typically do not tolerate
hemodialysis well.
✔✔Joaquin is a 22-year-old male who presents to the emergency department (ED) with
a 1-week history of headache, concentration difficulty, fatigue, nau- sea, and vague
abdominal pain. He became concerned this morning whenhe noticed that the whites of
his eyes appeared yellow. History is significant for epilepsy, which he has had since
childhood but is well-controlled with antiepileptic medication. There is no known history
of liver disease. Notable physical exam findings include scleral icterus, generalized
abdominal tender- ness, and new-onset ascites. Urine alcohol and drug screen were
negative. Labs reveal severe transaminitis, hyperbilirubinemia, hyperammonemia, and
coagulopathy. The most likely diagnosis is - ✔✔Acute liver failure
✔✔Chadwick presents to the ED following a suicide attempt. He reports swallowing
approximately 10,000 milligrams (mg) of acetaminophen 4-hours ago. An hour ago, he
began to develop generalized abdominal pain, nausea, and vomiting at which time he
asked his brother to take him to the hospital. Shortly after arrival, he becomes confused
and agitated. Labs reveal INR of 3.0, acute kidney injury (AKI) with creatinine 2.0,
severe transaminitis, and lactic acidosis. Urine toxicology showed an acetaminophen
level of 200 milligrams per kilogram. Serum alcohol was negative. The AGACNP knows
that the best initial treatment for Chadwick is: - ✔✔Administer N-acetylcysteine
(Mucomyst)
✔✔Rhabdomyolysis - ✔✔Rhabdomyolysis is a potentially life-threatening condition that
occurs following skeletal muscle injury.-dissolution of striated muscle (caused by
trauma, extreme exertion, or drug toxicity;in severe cases renal failure can result)
✔✔When the muscle injury occurs, what is released into the blood stream? - ✔✔muscle
fibers release large quantities of potassium, phosphate, creatinine kinase(CK), and
myoglobin, a small protein that binds oxygen, into the circulation.-As an unbound
, protein, myoglobin is excreted by the kidneys but can precipitate and cause renal
tubular obstruction.
✔✔What happens to myoglobin in Rhabdo? - ✔✔myoglobin is release from skeletal
muscle during injury. it binds to oxygenin excessive amount, as see with rhabdo, it is
unbound. when unbound it has to be excreted through the kidneys which can cause
renal tubular obstruction.
✔✔Risk factors of Rhabdomyolysis - ✔✔Trauma, muscle compression, or
ischemiaHeat-related causesInfection with bacteria or viruses that can directly attack
the muscleMetabolic factorsGenetic factorsMedications that may cause direct
myotoxicity Toxins which may cause indirect myotoxicity Exertional activity Nutritional
supplements which contain substances that may induce muscle injury
✔✔Subjective findings of Rhabdo (patient) - ✔✔muscle pain, dark urine and muscle
weakness.Other symptoms commonly associated with rhabdomyolysis can be
nonspecific such as fever, nausea, and vomiting, which developed over hours to days
✔✔Physical exam findings in Rhabdo - ✔✔muscle tenderness soft tissue
swellingbruisingskin changes consistent with pressure necrosis muscle weakness
confusion, delirium, agitation anuria
✔✔Rhabdomyolysis is diagnosed when the following are present: (2) - ✔✔dark urine or
an acute neuromuscular illness without other symptoms PLUS an acute elevation in
serum creatine kinase (typically at least five times the upper limit of normal).
✔✔Lab work for Rhabdo - ✔✔CK, serum myoglobin, urine myoglobin CBC w/Diff, LFT,
electrolytes, Renal function, serum tox, PTT/aPTT
✔✔What is the most reliable testing for diagnosis of rhabdo? - ✔✔Creatinine kinase
(CK) CK will be markedly elevated, typically > 1000 IU/L (normal = 45-260 IU/L) with
rhabdomyolysis.will start rising between 2-12 hours of injury and will peak at 24-72
hours
✔✔Do you need an EKG for rhabdo? - ✔✔Yes. assessing for arrhythmias associated
with hypocalcemia and hyperkalemia. continuous cardiac monitoring is recommended
✔✔What is the initial management of a rhabdo patient? - ✔✔FLUIDS & electrolyte
maintenance.
✔✔Rhabdo fluid administration is recommended for what? - ✔✔The initial management
of rhabdomyolysis includes fluid resuscitation to prevent end-organ damage such as
acute renal failure.
SOLUTIONS GUARANTEE A+
✔✔imaging to Diagnose AMI - ✔✔Gold standard: CT angio with a 1-mm or thinner cut
should be used to detect mesenteric arterial occlusive disease.
✔✔Hepatic steatosis (fatty liver) - ✔✔Nonalcoholic hepatic steatosis, or nonalcoholic
fatty liver disease (NAFLD), is one of the most common causes of chronic liver disease
in the developed world.It is a spectrum of disease, ranging from hepatic fat
accumulation without inflamma- tion to steatohepatitis, fibrosis, cirrhosis, and end-stage
liver disease.
✔✔risk factors of hepatic steatosis - ✔✔NAFLD is strongly associated with insulin
resistance, overweight/obesity, and metabolic syndromecan occur in thin people with
paucity of adipose depots(lipodystrophy)
✔✔nonalcoholic steatohepatitis (NASH) - ✔✔a more severe form of nonalcoholic fatty
liver disease. it consists of fatty accumulations plus liver-damaging inflammation. in
some cases, this will progress to cirrhosis, irreversible liver scarring or liver cancer
✔✔Imaging used for NASH - ✔✔Hepatic US and CT scan. Unfortunately, at the present
time, no imaging study can accurately distinguish simple fatty liver from NASH.
✔✔blood levels of acetaminophen correlate with severity of hepatic injury - ✔✔levels
>300 ug/mL 4 hours after ingestion are predicative of the development of severe
damage.
✔✔Treatment of Tylenol OD - ✔✔gastric lavage supportive measures oral
administration of activated charcoal or cholestyramine to prevent residual of the drug.
✔✔activated charcoal and cholestyramine should be done how soon after ingestion or
else they wont do anything? - ✔✔>30minutes from ingestion timegastric lavage should
be done before other orals.
✔✔N-acetylcysteine reduces markedly the severity of? - ✔✔hepatic necrosis
✔✔N-acetylcysteine should be given when? - ✔✔4-8 hours after ingestion if the blood
levels of tylenol are >200ug/mL at 4 hours
or
>100 ug/mL at 8 hours.
✔✔IV N-acetylcysteine dose - ✔✔loading dose: 140 mg/kg over 1 hour followed by 70
mg/kg every 4 hours for 15-20 doses.
,✔✔When is liver transplantation indicated in pt with tylenol OD? - ✔✔hepatic failure
signs (jaundice, coagulopathy, confusion) occur after N-acetylcysteine dose, live
transplant may be the only option.
✔✔what does serum lactate tell us about the need for liver transplant? - ✔✔is serum
lactate is >3.5 - likely will require liver transplant to survive.
✔✔A 28-year-old woman is seen in a sexually transmitted disease clinic and is
diagnosed with Chlamydia trachomatis. An HIV antibody test is ordered. Which one of
the following statements
is TRUE regarding laboratory-based HIV antibody tests that are approved for use by the
United States Food and Drug Administration? - ✔✔Recent inocculation with the
influenza vaccine is a known cause of a false-positive result
✔✔A 31-year-old woman has exposure to HIV after a condom broke while having
vaginal sex with her partner who has HIV. She has follow-up HIV testing related to this
exposure. Which one of the following best describes the window period? - ✔✔The CDC
recommends using 45 days as the window period for all laboratory-based IgM/IgG HIV-
1/2 antibody immunoassays
✔✔A 22-year-old man presents for follow-up after a recent diagnosis of HIV. He has an
initial CD4 count of 390 cells/mm3 and his HIV RNA level is46,120 copies/mL; a
baseline genotype resistance assay shows no evidence of antiretroviral resistance. He
is motivated to start antiretroviral therapy and states that he can take medications
without issue. According to the Adult and Adolescent Antiretroviral (ARV) Guidelines,
which one of the following best describes the recommendations for starting antiretroviral
therapy in treatment-naïve persons with HIV? - ✔✔Antiretroviral therapy is
recommended for all persons with HIV
✔✔A 51-year-old transgender woman (she/her/hers) with HIV has been stable for the
last 3 years on an antiretroviral regimen of darunavir-cobicistat and tenofovir DF-
emtricitabine. Despite changing to a healthier diet and increas- ing her exercise, lipid
values remain elevated : total cholesterol 268 mg/dL, low-density lipoprotein (LDL) 198
mg/dL, high-density lipoprotein (HDL) 35 mg/dL, and triglycerides 220 mg/dL. She has a
strong family history of car- diovascular disease, and her father had a myocardial
infarction at age 52.She does not want to consider modifying the antiretroviral regimen
but agrees to start lipid-lowering therapy. Which one of the following HMG-CoA
reductase inhibitors ("statins") is contraindicated for use in this woman? -
✔✔Simvastatin
✔✔What is a TIPS procedure? - ✔✔The TIPS procedure bypasses a portion of the
hepatic circulation by shunting blood flow from the portal vein to the hepatic vein-This
reduces portal pressure and minimizes back pressure on the splanchnic organs. This
also decreases the likelihood of bleeding from the esophageal varies and reduces the
amount of ascites
,*Hemorrhage is a significant risk during TIPS
✔✔What is the treatment of choice for both type 1 and type 2 HRS? - ✔✔Liver
transplant
✔✔What medications are used to tx type 2 HRS? - ✔✔vasoconstrictors (terlipressin,
midodrine in combination with octriotide, norepinephrine) combined with albumin.
✔✔Bridge to transplant in Hepatorenal syndrome - ✔✔The combination of octreotide,
midodrine, and albumin (triple therapy) is used to treat hepatorenal syndrome (HRS)
often as a bridge to liver transplantation (LT).
✔✔Module ** Bridge to transplant** - ✔✔In clients who do not respond to medical
therapy, are not candidates for TIPS but are candidates for liver transplantation or
recovery for their liver disease, continuous renal replacement therapy can be utilized as
a bridge to recovery or transplantation. HRS clients typically do not tolerate
hemodialysis well.
✔✔Joaquin is a 22-year-old male who presents to the emergency department (ED) with
a 1-week history of headache, concentration difficulty, fatigue, nau- sea, and vague
abdominal pain. He became concerned this morning whenhe noticed that the whites of
his eyes appeared yellow. History is significant for epilepsy, which he has had since
childhood but is well-controlled with antiepileptic medication. There is no known history
of liver disease. Notable physical exam findings include scleral icterus, generalized
abdominal tender- ness, and new-onset ascites. Urine alcohol and drug screen were
negative. Labs reveal severe transaminitis, hyperbilirubinemia, hyperammonemia, and
coagulopathy. The most likely diagnosis is - ✔✔Acute liver failure
✔✔Chadwick presents to the ED following a suicide attempt. He reports swallowing
approximately 10,000 milligrams (mg) of acetaminophen 4-hours ago. An hour ago, he
began to develop generalized abdominal pain, nausea, and vomiting at which time he
asked his brother to take him to the hospital. Shortly after arrival, he becomes confused
and agitated. Labs reveal INR of 3.0, acute kidney injury (AKI) with creatinine 2.0,
severe transaminitis, and lactic acidosis. Urine toxicology showed an acetaminophen
level of 200 milligrams per kilogram. Serum alcohol was negative. The AGACNP knows
that the best initial treatment for Chadwick is: - ✔✔Administer N-acetylcysteine
(Mucomyst)
✔✔Rhabdomyolysis - ✔✔Rhabdomyolysis is a potentially life-threatening condition that
occurs following skeletal muscle injury.-dissolution of striated muscle (caused by
trauma, extreme exertion, or drug toxicity;in severe cases renal failure can result)
✔✔When the muscle injury occurs, what is released into the blood stream? - ✔✔muscle
fibers release large quantities of potassium, phosphate, creatinine kinase(CK), and
myoglobin, a small protein that binds oxygen, into the circulation.-As an unbound
, protein, myoglobin is excreted by the kidneys but can precipitate and cause renal
tubular obstruction.
✔✔What happens to myoglobin in Rhabdo? - ✔✔myoglobin is release from skeletal
muscle during injury. it binds to oxygenin excessive amount, as see with rhabdo, it is
unbound. when unbound it has to be excreted through the kidneys which can cause
renal tubular obstruction.
✔✔Risk factors of Rhabdomyolysis - ✔✔Trauma, muscle compression, or
ischemiaHeat-related causesInfection with bacteria or viruses that can directly attack
the muscleMetabolic factorsGenetic factorsMedications that may cause direct
myotoxicity Toxins which may cause indirect myotoxicity Exertional activity Nutritional
supplements which contain substances that may induce muscle injury
✔✔Subjective findings of Rhabdo (patient) - ✔✔muscle pain, dark urine and muscle
weakness.Other symptoms commonly associated with rhabdomyolysis can be
nonspecific such as fever, nausea, and vomiting, which developed over hours to days
✔✔Physical exam findings in Rhabdo - ✔✔muscle tenderness soft tissue
swellingbruisingskin changes consistent with pressure necrosis muscle weakness
confusion, delirium, agitation anuria
✔✔Rhabdomyolysis is diagnosed when the following are present: (2) - ✔✔dark urine or
an acute neuromuscular illness without other symptoms PLUS an acute elevation in
serum creatine kinase (typically at least five times the upper limit of normal).
✔✔Lab work for Rhabdo - ✔✔CK, serum myoglobin, urine myoglobin CBC w/Diff, LFT,
electrolytes, Renal function, serum tox, PTT/aPTT
✔✔What is the most reliable testing for diagnosis of rhabdo? - ✔✔Creatinine kinase
(CK) CK will be markedly elevated, typically > 1000 IU/L (normal = 45-260 IU/L) with
rhabdomyolysis.will start rising between 2-12 hours of injury and will peak at 24-72
hours
✔✔Do you need an EKG for rhabdo? - ✔✔Yes. assessing for arrhythmias associated
with hypocalcemia and hyperkalemia. continuous cardiac monitoring is recommended
✔✔What is the initial management of a rhabdo patient? - ✔✔FLUIDS & electrolyte
maintenance.
✔✔Rhabdo fluid administration is recommended for what? - ✔✔The initial management
of rhabdomyolysis includes fluid resuscitation to prevent end-organ damage such as
acute renal failure.
