NR MIDTERM EXAM 1

1 1. The percentage of the FVC expired in one second is: a. FEV1/FVC ratio 2. The aging process causes what normal physiological changes in the heart? a. The heart valve thickens and becomes rigid, secondary to fibrosis and sclerosis. 3. A 55yo Caucasian male follows up after referral to cardiologist. He thinks his med is causing a cough and sometimes he has difficulty breathing. Which med was most likely prescribed? a. Lisinopril 4. JM is a 68yo man who presents for a physical. He has T2DM x5yrs, smokes 1/2 PPD, BMI is 30. No other previous medical dx, no current complaints. According to the AHA/ACC guidelines, JM is stage A HF. Treatment goals for him include: a. Heart healthy lifestyle 5. MJ presents with h/o structural damage with current s/s of HF. Treatment will be based on his stage of HF, which is: a. Stage C 6. 65yo Caucasian female presents with mitral valve stenosis, physical exam unremarkable. You know her stage of HF is: a. B 7. DG, 65yo man, presents for eval of CP and L-sided shoulder pain, beginning after strenuous activity, including walking. Pain is dull, aching, 8/10 during activity, otherwise 0/10. Began few mo ago, intermittent, aggravated by exercise, relieved by rest. Occasional nausea. Pain is retrosternal, radiating to L shoulder, affects QOL by limiting activity. Pain is worse today, did not go away after stopped walking. BP 120/80, HR 72 and regular. Normal heart sounds, no murmur, S1, S2. Which differential dx would be most likely? a. Coronary artery dz w/angina pectoris 8. The best way to dx structural heart dz/dysfunction non-invasively is: a. Echocardiogram 9. Chronic pain can have major impact on pt's ability to function and have profound impact on overall QOL. Ongoing pain may be linked to: a. Depression, sleep disturbance, decreased socialization 10. The Beers criteria are appropriate for use in evaluating use of certain meds in pts: a. 65yo 11. Pt presents with c/o increasing SOB, cough w/occasional white sputum, fatigue. As part of the plan you order labs. You know the likelihood of HF is low if the BNP is: a. 100 12. All of the following statements are true about lab values in older adults except: a. Normal ranges may not be applicable to older adults b. Abnormal findings are often due to physiological aging 2 c. Reference ranges are preferable d. References values are not necessarily acceptable values a. B 13. According to the 2017 ACC HTN guidelines, the recommended BP goal for a 65yo African American woman w/a h/o HTN and DM and no h/o CKD is: a. 140/80 14. The pathophysiology of HF is due to: a. Inadequate cardiac output to meet the metabolic and O2 demands of the body 15. A 60yo woman w/30 pack yr hx, presents for eval of persistent, daily cough w/increased sputum, worse in the AM, occurring over past 3 months. She tells you, "I have the same thing year after year." Which of the following choices would you consider strongly in your critical thinking process? a. Chronic bronchitis 16. JM is a 68yo man who presents for a physical. He has T2DM x5yrs, diet controlled. His BMI is 32. He has HTN, smoker (10 cigs/day x20yrs). He denies other medical problems. Fam hx includes CAD, CABG x4 for dad, now deceased; CHF, T2DM, HTN for mom. He is asymptomatic today, exam is normal, EKG NSR. According to AHA/ACC guidelines, JM is at risk for what stage of HF? a. Stage A The volume of air a pt is able to exhale for total duration of the test during maximal effort is: b. FVC 17. According to the 2017 ACC HTN guidelines, normal BP is: a. 120/80 18. Functional abilities are best assessed by: a. Observed assessment of function 19. LB is a 77yo pt w/chronic poorly controlled HTN. You know that goals include prevention of target organ damage. During your eval you will assess for evidence of: a. L ventricular hypertrophy 20. Aortic regurgitation requires medical treatment for early signs of HF with: a. ACEi 21. The volume of air in the lungs at max inflation is: a. TLC (total lung capacity) 22. Preferred amount of exercise for older adults is: a. 30min/day of aerobic activity 5 days/wk 23. The total volume of air a pt is able to exhale in the first second during max effort is: a. FEV1 24. You know the following statements regarding the pain of acute coronary syndrome are true except: a. Present atypically more often in men than women 3 25. Elderly pt presents w/new onset of feeling heart race, fatigue. EKG reveals afib w/rate 100. Pt also has a new tremor in both hands. Which of the following would you suspect? a. Hyperthyroidism 26. 62yo female c/o fatigue, lack of energy. Constipation increased, pt gained 10lbs in past 3mo. Depression is denied although pt reports lack of interest in usual hobbies. VS are WNL, skin is dry/cool. Which of the following must be included in the DD? a. Hypothyroidism 27. Mrs. Black, 87yo, has been taking 100mcg Synthroid x10yrs. She comes for routine follow-up, feeling well. HR is 90. Your first response is to: a. Order TSH 28. Which pt is most likely to have osteoporosis? 29. 80yo underweight male who smokes and has been on steroids for psoriasis 30. When evaluating the expected outcome for hypothyroid elderly pt on levothyroxine, you will: a. Assess TSH in 4-6wks 31. Postmenopausal woman w/osteoporosis is taking bisphosphonate daily PO. What action info statement would indicate she understood your instructions regarding this med? a. Take med w/full glass of water when up in the AM 30min before other food and meds 32. Primary reason levothyroxine sodium is initiated at low dose in elderly pt w/hypothyroidism is to prevent which of the following untoward effects? a. Angina and arrhythmia 33. 6mo ago an elderly pt was dx'd w/subclinical hypothyroidism. Today the pt returns and has TSH of 11 and c/o fatigue. He has taken Synthroid 25mcg daily as prescribed. What is the best course of action? a. Double the dose 34. A fluoroquinolone (Cipro) is prescribed for a male pt w/a UTI. What should you teach him regarding this med? a. Its effectiveness is decreased by antacids, iron, or caffeine 35. Pt has been rx'd metformin (Glucophage). One wk later, he returns w/lowered BGL but c/o loose stools during the week. How should you respond? a. Reassure him that this is an anticipated SE 36. Which of the following s/s of hyperthyroidism commonly manifest in younger populations, but is notably lacking in elderly? a. Exopthalmos 37. 60yo obese male has T2DM and lipid panel of TC = 250, HDL = 32, LDL = 165. You teach him about his modifiable cardiac risk factors, which include: a. DM, obesity, hyperlipidemia 38. Diabetic pt presents w/R foot pain but denies any recent known injury. He states it has gotten progressively worse over past few months. On exam, vibratory sense, as well as sensation tested w/monofilament, was abnormal. Pt's foot is warm, edematous, misshapen. You suspect Charcot foot. What intervention is indicated? 4 a. Referral to orthopedist 39. What is a s/s of insulin resistance that can present in African Americans? a. Acanthosis Nigricans 40. During routine exam of 62yo female, you ID xanthelasma around both eyes. What is the significance of this? a. Abnormal lipid metabolism requiring medical management 41. Mr. White is 62yo, had CKD that has been relatively stable. He also has h/o hyperlipidemia, OA, HTN. He is compliant w/meds, BP has been well controlled on CCB. Last lipids showed: TC = 201, HDL = 40, TG = 180, LDL = 98. He currently takes Crestor 20mg daily. Today his BP is 188/90 and urine dip shows significant proteinuria. He denies changes in dietary habits or med regimen. What would be the best med change at this point? a. Change CCB to ACEi 42. You are working as NP in Fast Track of ER. 76yo male presents w/LUQ pain. There can be many conditions that present as LUQ pain, but which of the following is least likely to cause pain here? a. Acute pancreatitis 43. Which is cardinal feature of failure to thrive? a. Poor nutritional status 44. Feeding gastrostomy tubes at end-of-life Alzheimer's pt's have been associated with: a. Aspiration pna 45. Which of the following nutritional indicators is not an indication of poor nutritional status in elderly? a. BMI 25 46. OA of cervical and lumbar spine causes pain related to all of the following except: a. Crystal deposition 47. In differentiating OA from chronic gout, pseudogout, or septic arthritis, the most valuable diagnostic study would be: a. Synovial fluid analysis 48. Pt's w/OA of hip and knee often have distinguishable gait described as: a. Antalgic 49. Which of the following best describes pain associated w/OA? a. Begins upon arising and after prolonged wt bearing and/or use of the joint 50. Joint effusions typically occur later in the course of OA, especially in the: 51. Knee 52. You ordered CBC for your pt you suspect has polymyalgia rheumatica (PMR). Which 2 clinical findings are common in pt's w/PMR? a. Normochromic, normocytic anemia and thrombocytosis 53. You suspect your pt has PMR and now are concerned that they may have Giant Cell Arteritis (GCA) too. Which of the following 2 symptoms are most indicative of GCA and PMR? 5 a. Scalp tenderness and aching in shoulder and pelvic girdle 54. 63yo Caucasian pt w/PMR will begin Tx w/corticosteroids until the condition has resolved. You look over her records and it has been 2yrs since her last physical exam and any labs or diagnostic tests as she relocated and had not yet ID'd a provider. In prioritizing your management plan, your first orders should include: a. Duel-energy x-ray (DEXA) scan and updating immunizations 55. Which of the following DD for pt's presenting w/PMR can be ruled out w/a muscle biopsy? a. Polymyositis 56. In reviewing lab results for pt's w/suspected PMR, you realize there is no definitive test to dx PMR, rather clinical response to Tx. Results you would expect to see include: a. Elevated erythrocyte sed rate (ESR) 50 57. Which of the following is the most appropriate lab test for monitoring gout therapy over the longterm? a. Serum urate level 58. In providing health teaching related to dietary restrictions, you should advise a pt w/gout to avoid which of the following dietary items: a. Beer, sausage, fried seafood 59. The best method of verifying gout dx in a joint is which of the following: 60. Joint aspiration and polarized-light microscopy 61. The most appropriate first-line Tx for acute gout flare is (assuming no kidney dz or elevated bleeding risk): a. Indomethacin 50mg TID x2 days, then 25mg TID x3 days 62. You order bilat wrist XR on 69yo man c/o pain both wrists x6 wks no related to any known trauma. You suspect early onset RA. The initial XR finding in a pt w/elderly onset RA would be: a. Soft tissue swelling 63. A 72yo female has been dx'd w/gout. She also has h/o chronic HF. The most likely contributing factor to development of gout in this older female is: a. Thiazide diuretics 64. Which of the following statements about OA is true? 65. It affects primarily wt-bearing joints 66. In considering the specificity of lab data, the most reliable diagnostic test listed below would be: a. Synovial fluid analysis to differentiate between infectious versus inflammatory infusion 67. When examining the spine of an older adult you notice a curvature w/a sharp angle. This is referred to as a: a. Gibbus 68. The prevalence of depression in nursing home residents is ___________ greater than adults living in the community. a. 3-4 times 69. The majority of depressed older adults remain untreated because of: 6 a. Misdiagnosis, social stigma, environmental barriers 70. Symptoms of depression distinct to the elderly include: a. Lack of emotions 71. The justification for ordering CBC, TSH, serum B12 for a pt you may suspect have clinical depression is: a. Because of overlapping symptoms w/anemia, thyroid dysfunction, and nutritional deficiencies 72. One major difference that is useful in the DD of dementia versus delirium is that: a. Dementia develops slowly and delirium develops quickly 73. Which of the following is the most appropriate screening tool for delirium? a. Confusion Assessment Method 74. The proposed mechanism by which diphenhydramine causes delirium is: a. Anticholinergic effects 75. The elderly are at high risk for delirium because of: a. Multisensory declines, polypharmacy, multiple medical problems 76. A consistent finding in delirium, regardless of cause, is: a. Reduction in regional cerebral perfusion 77. Older adults w/dementia sometimes suffer from agnosia, which is defined as the inability to: a. Recognize objects 78. In late stages of dementia, a phenomenon called sun downing occurs, in which cognitive disturbances tend to: a. Become worse in the evening 79. Of the following, which one is the most useful clinical eval tool to assist in the dx of dementia? a. St. Louis University Mental Status Exam (SLUMS) 80. The cornerstone of pharmacotherapy in treating Alzheimer's is: a. Cholinesterase inhibitors 81. The comorbid psych problem w/the highest frequency in dementia is: a. Anxiety 82. When treating depression associated w/dementia, which of the following would be a poor choice and should not be prescribed? a. Amitriptyline 83. Which of the following should be avoided in countries where food and water precautions are to be observed? a. Salad buffet