NR574 UPDATED COMPREHENSIVE EXAM QUESTIONS
AND SOLUTIONS GUARANTEE A+
✔✔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.
✔✔Fluid treatment for rhabdo consist of...? - ✔✔Isotonic sodium chloride fluid initiated
ASAPrate: 400 mL/hrstitrate to maintain a urine output of at least 200 mL per hour.
✔✔If a patient with rhabdo has a CK level greater than 15,000 IU/L, how much fluid
should the patient receive? - ✔✔at minimum 6L of fluid are required
✔✔What electrolyte abnormalities occur with rhabdo? - ✔✔Hyperkalemia,
Hypocalcemia, Hyperuricemia Hyperphosphatemia
✔✔How is hyperkalemia treatment in rhabdo patients? - ✔✔Treatment of hyperkalemia
consists ofIV glucose sodium bicarbonate insulin, sodium polystyrene sulfonate;in
severe or refractory cases, hemodialysis is sometimes required.
,✔✔differential diagnosis of SLE - ✔✔SLE should be considered as a differential
diagnosis in a young person who presents with glomerulonephritis, pleural effusion,
cytopenia, pericarditis, or pleurisy that does not have another underlying etiology.The
differential may include:
-rheumatoid arthritis-mixed connective tissue disease -Sjogren's syndrome-multiple
sclerosis -malignancies.
✔✔systemic lupus erythematosus (SLE) - ✔✔autoimmune disease in which immune
system attacks connective tissue throughout body such as in joints and skin
✔✔SLE clinical manifestations - ✔✔Facial rash (BUTTERFLY RASH in 80%), arthritis,
arthralgie, photsensitivty, pleurisy, pericarditis, anemia, thrombocytopenia- Fatigue,
alopecia, Reynaud's syndrome, renal disorders/damage, seizures, cogni-
tive/neuropsych, mouth/nose ulcers
✔✔classic triad of symptoms for SLE - ✔✔The classic triad of symptoms associated
with SLE includes fever, arthralgia, and rash
✔✔ANA testing for SLE - ✔✔most important autoantibody test is ANA because >95% of
patients will test positive at the onset of symptoms.
✔✔high titer IgG antibodies to anti-double-stranded DNA (anti-dsDNA) are - ✔✔specific
for SLE diagnosis.
✔✔"SOAP BRAIN MD" is used for? - ✔✔Diagnostic criteria for SLE must include at
least 4 of the criteria listed, which can be remembered by the mnemonic
✔✔SOAP BRAIN MD mnemonic for SLE stands for? - ✔✔S - serositis (pleuritis,
pericarditis, peritonitis)
O - oral ulcers (painless)
A - arthralgia/arthritis
P - photosensitivity
B - blood disorder (anemia, thrombocytopenia, hemolytic anemia)
R - renal involvement (nephritic or nephrotic disorders)
A- ANA+
I - immunologic phenomenon (anti-SM, Anti-dsDNA, Ro, La, Anti-histone)
N - neurologic phenomenon (altered mental status, seizures, stroke, headache)
M - malar rash
D - discoid rash
✔✔Lorenzo is newly admitted with pancytopenia, fever, joint pain, and a malar rash.
The nurse practitioner suspects SLE. Which of the following tests is most useful in
diagnosing this condition? - ✔✔antinuclear antibody
, ✔✔Jean-Louis was admitted with a diagnosis of acute kidney injury (AKI). He does not
have a history of previous renal dysfunction but does have a history of SLE The
urinalysis reveals significant proteinuria. Which of the following diagnostic tests is
required when lupus nephritis is suspected? - ✔✔Renal Biopsy
✔✔rheumatoid arthritis (RA) - ✔✔arthritis with swelling, stiffness, pain, and degener-
ation of cartilage in joints caused by chronic soft tissue inflammation; may result in
crippling deformities; an autoimmune disease
✔✔rheumatoid arthritis clinical manifestations. - ✔✔Common symptoms include warm,
tender, swollen joints, and joint stiffness.-swan neck deformity- hyperextension of PIP
with flexion of DIP (distal interpha- langeal) -Boutonniere deformity-firm nontender
nodules that adhere to the periosteum, tendons, or bursae-fatigue, malaise, fever,
anorexia, weight loss, and depression-ulnar deviation
✔✔Juan has a history of rheumatoid arthritis and is taking methotrexate7.5mg once per
week. He reports an acute increase in pain and swelling from baseline for the last 2
days, primarily affecting both hands and both knees. The nurse practitioner suspects an
acute RA flare. What is the most appropriate intervention? - ✔✔Prednisone 40 mg daily
then taper over two weeks
✔✔Antiphospholipid Syndrome (APS) - ✔✔
✔✔Clinical Manifestations of antiphospholipid syndrome - ✔✔DVT PEpregnancy
morbidity migraines strokes/TIA livedo reticularis
✔✔differentials of fibromyalgia - ✔✔Fibromyalgia presents with a multitude of gener-
alized symptoms making the differential diagnosis quite broad.-systemic lupus
erythematosus (SLE),-Sjogren's syndrome,
-gluten sensitivity, -hypothyroidism,-polymyalgia rheumatica,-mixed connective tissue
disease, -multiple sclerosis,
-myasthenia gravis.
✔✔Lo-Wei has fibromyalgia and complains of poorly controlled pain, in- creased
fatigue, and difficulty sleeping. She has a body mass index (BMI)of 31 and a history of
depression. She reports that she has been frequently forgetting to take her medications
(duloxetine and gabapentin). Which of the following are the most appropriate
interventions for Lo-Wei? - ✔✔medication compliance, exercise program, and sleep
hygiene program
✔✔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
AND SOLUTIONS GUARANTEE A+
✔✔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.
✔✔Fluid treatment for rhabdo consist of...? - ✔✔Isotonic sodium chloride fluid initiated
ASAPrate: 400 mL/hrstitrate to maintain a urine output of at least 200 mL per hour.
✔✔If a patient with rhabdo has a CK level greater than 15,000 IU/L, how much fluid
should the patient receive? - ✔✔at minimum 6L of fluid are required
✔✔What electrolyte abnormalities occur with rhabdo? - ✔✔Hyperkalemia,
Hypocalcemia, Hyperuricemia Hyperphosphatemia
✔✔How is hyperkalemia treatment in rhabdo patients? - ✔✔Treatment of hyperkalemia
consists ofIV glucose sodium bicarbonate insulin, sodium polystyrene sulfonate;in
severe or refractory cases, hemodialysis is sometimes required.
,✔✔differential diagnosis of SLE - ✔✔SLE should be considered as a differential
diagnosis in a young person who presents with glomerulonephritis, pleural effusion,
cytopenia, pericarditis, or pleurisy that does not have another underlying etiology.The
differential may include:
-rheumatoid arthritis-mixed connective tissue disease -Sjogren's syndrome-multiple
sclerosis -malignancies.
✔✔systemic lupus erythematosus (SLE) - ✔✔autoimmune disease in which immune
system attacks connective tissue throughout body such as in joints and skin
✔✔SLE clinical manifestations - ✔✔Facial rash (BUTTERFLY RASH in 80%), arthritis,
arthralgie, photsensitivty, pleurisy, pericarditis, anemia, thrombocytopenia- Fatigue,
alopecia, Reynaud's syndrome, renal disorders/damage, seizures, cogni-
tive/neuropsych, mouth/nose ulcers
✔✔classic triad of symptoms for SLE - ✔✔The classic triad of symptoms associated
with SLE includes fever, arthralgia, and rash
✔✔ANA testing for SLE - ✔✔most important autoantibody test is ANA because >95% of
patients will test positive at the onset of symptoms.
✔✔high titer IgG antibodies to anti-double-stranded DNA (anti-dsDNA) are - ✔✔specific
for SLE diagnosis.
✔✔"SOAP BRAIN MD" is used for? - ✔✔Diagnostic criteria for SLE must include at
least 4 of the criteria listed, which can be remembered by the mnemonic
✔✔SOAP BRAIN MD mnemonic for SLE stands for? - ✔✔S - serositis (pleuritis,
pericarditis, peritonitis)
O - oral ulcers (painless)
A - arthralgia/arthritis
P - photosensitivity
B - blood disorder (anemia, thrombocytopenia, hemolytic anemia)
R - renal involvement (nephritic or nephrotic disorders)
A- ANA+
I - immunologic phenomenon (anti-SM, Anti-dsDNA, Ro, La, Anti-histone)
N - neurologic phenomenon (altered mental status, seizures, stroke, headache)
M - malar rash
D - discoid rash
✔✔Lorenzo is newly admitted with pancytopenia, fever, joint pain, and a malar rash.
The nurse practitioner suspects SLE. Which of the following tests is most useful in
diagnosing this condition? - ✔✔antinuclear antibody
, ✔✔Jean-Louis was admitted with a diagnosis of acute kidney injury (AKI). He does not
have a history of previous renal dysfunction but does have a history of SLE The
urinalysis reveals significant proteinuria. Which of the following diagnostic tests is
required when lupus nephritis is suspected? - ✔✔Renal Biopsy
✔✔rheumatoid arthritis (RA) - ✔✔arthritis with swelling, stiffness, pain, and degener-
ation of cartilage in joints caused by chronic soft tissue inflammation; may result in
crippling deformities; an autoimmune disease
✔✔rheumatoid arthritis clinical manifestations. - ✔✔Common symptoms include warm,
tender, swollen joints, and joint stiffness.-swan neck deformity- hyperextension of PIP
with flexion of DIP (distal interpha- langeal) -Boutonniere deformity-firm nontender
nodules that adhere to the periosteum, tendons, or bursae-fatigue, malaise, fever,
anorexia, weight loss, and depression-ulnar deviation
✔✔Juan has a history of rheumatoid arthritis and is taking methotrexate7.5mg once per
week. He reports an acute increase in pain and swelling from baseline for the last 2
days, primarily affecting both hands and both knees. The nurse practitioner suspects an
acute RA flare. What is the most appropriate intervention? - ✔✔Prednisone 40 mg daily
then taper over two weeks
✔✔Antiphospholipid Syndrome (APS) - ✔✔
✔✔Clinical Manifestations of antiphospholipid syndrome - ✔✔DVT PEpregnancy
morbidity migraines strokes/TIA livedo reticularis
✔✔differentials of fibromyalgia - ✔✔Fibromyalgia presents with a multitude of gener-
alized symptoms making the differential diagnosis quite broad.-systemic lupus
erythematosus (SLE),-Sjogren's syndrome,
-gluten sensitivity, -hypothyroidism,-polymyalgia rheumatica,-mixed connective tissue
disease, -multiple sclerosis,
-myasthenia gravis.
✔✔Lo-Wei has fibromyalgia and complains of poorly controlled pain, in- creased
fatigue, and difficulty sleeping. She has a body mass index (BMI)of 31 and a history of
depression. She reports that she has been frequently forgetting to take her medications
(duloxetine and gabapentin). Which of the following are the most appropriate
interventions for Lo-Wei? - ✔✔medication compliance, exercise program, and sleep
hygiene program
✔✔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
