South University:NSG TB Assignment Questions & Answers Graded A

NURSING HEALTH ASSIGNMENT Questions & Answers Question: What is the recommendation of American Cancer Society for screening an average risk 40 year-old Caucasian male for prostate cancer? Question: Which of the following results in a clinically insignificant increase in the prostate specific antigen (PSA)? Question: Hesselbach’s triangle forms the landmark for: Question: Which of the following medications should be avoided in a 65 year-old male with benign prostatic hyperplasia (BPH)? Question: A localized tumor in the prostate gland associated with early stage prostate cancer is likely to produce: Question: Noninfectious epididymitis is common in: Question: The following PSA levels have been observed in a patient. What conclusion can be made following these annual readings? Year 1: 3.2 ng/mL Year 2: 3.8 ng/mL Year 3: 4.2 ng/mL Question: What is the recommendation of American Cancer Society for initial screening of an African-American male for prostate cancer? Question: What is American Cancer Society’s recommendation for prostate screening in a 70 year-old male? He should be screened annually with PSA only.He should be screened annually with PSA and DRE.He should be screened until he has a life expectancy of less than 10 years. CorrectScreening can stop at age 75 years. Question: A 70 year-old male presents to your clinic with a lump in his breast. How should this be evaluated? Palpation and ultrasound IncorrectMammogram and ultrasound CorrectUltrasound onlyMammogram only Explanation: This patient has a lump identified in the breast. Since males can develop breast cancer, it must be evaluated in the same means that a female breast lump would be evaluated. He should have a clinical breast exam to identify the position of the lump, and any other abnormal findings such as nodes or other lumps. Then, he should have mammogram and ultrasound to help evaluate the lump. If the findings were suspicious for a malignancy, the patient would be referred to a surgeon. Question: A 22 year-old male who is otherwise healthy complains of scrotal pain. His pain has developed over the past 4 days. He is diagnosed with epididymitis. What is the most likely reason? His ageInfection with Chlamydia CorrectUnderlying hydroceleUrinary tract infection Explanation: Several factors predispose males to epididymitis. In men under age 35, the most common cause of epididymitis is infection with Chlamydia trachomatis. In older men, urinary tract pathogens are more typical. In pre-pubertal boys, bicycle riding and heavy physical exertion are most common. In pre-pubertal boys, consideration should be given to congenital abnormalities. Question: Digital rectal exam may be performed to assess the prostate gland. Which term does NOT describe a prostate gland that may have a tumor? NodularAsymmetricalBoggy CorrectIndurated Explanation: A boggy prostate describes a gland that is edematous and tender, such as is seen in a patient with bacterial prostatitis. The other terms indicate an abnormality that could represent a prostate gland tumor. Question: A male patient has epididymitis. His most likely complaint will be: burning with cular al pain. Correctpenile discharge. Explanation: The most common complaint is scrotal pain. It usually develops over a period of days. Occasionally, it develops acutely and will be accompanied by fever, chills, and a very ill-appearing patient. Burning with urination is possible if the underlying cause is a urinary tract infection, but, this is not usual. This presentation is seen more commonly in older males. Testicular pain is not a common complaint with epididymitis. Penile discharge would not indicate an infection in the epididymis since the epididymis is a tightly coiled tubular structure located on the testis. Question: What is the effect of digital rectal examination (DRE) on a male’s PSA (prostate specific antigen) level if it is measured on the same day as DRE? The change is insignificant. CorrectA decrease in the PSA will occur.An increase in the PSA will occur. IncorrectThere will be a change, but it is not predictable. Explanation: There is an inconsequential rise in PSA levels within 72 hours after DRE. DRE should not prevent a patient from having a PSA level measured at any time. Question: Hematuria is not a common clinical manifestation in: early prostate cancer. Correctbenign prostatic er cancer. Explanation: Localized tumors confined to the prostate gland are rarely associated with hematuria. In fact, localized tumors in the prostate gland rarely produce symptoms or any clinical manifestations. This fact strengthens the importance of screening for prostate cancer using digital rectal exam (DRE) and measurement of prostate specific antigen (PSA). Hematuria is commonly seen in benign prostatic hyperplasia, bladder cancer and renal cancer. Question: A 25 year-old male patient is training for a marathon. He reports an acute onset of scrotal pain after a 10 mile run. He has nausea and is found to have an asymmetric, high-riding testis on the right side. What should be suspected? Sports herniaEpididymitisTesticular torsion CorrectProstatitis Explanation: The most serious cause of acute scrotal pain is testicular torsion. The most common age group for this to occur is adolescents; however, almost 40% of torsion occurs in males greater than age 21. This is more common after minor testicular trauma or after strenuous exercise. This is an urgent urological referral. The other choices listed do not produce acute scrotal pain in conjunction with these physical findings. Question: A 50 year-old male comes to the nurse practitioner clinic for evaluation. He complains of fever 101F, chills, pelvic pain, and dysuria. He should be diagnosed with: acute bacterial prostatitis. Correctchronic bacterial ry tract cterial prostatitis. Explanation: Acute bacterial prostatitis should always be considered first in a male patient who presents with these symptoms. He may be expected to have cloudy urine and symptoms of obstruction, like dribbling. Chronic bacterial prostatitis presents with a more subtle presentation such as frequency, urgency, and low-grade fever. Urinary tract infection is far less common in men than women and is usually associated with anal intercourse or being uncircumcised. Nonbacterial prostatitis presents like chronic prostatitis except that urine and prostate secretion cultures are negative. Question: 5-alpha-reductase inhibitors work by producing: dilation of the detrusor vessels.a decrease in the size of the prostate. Correctincrease blood flow to the ition in the prostate tissue synthesis. Explanation: The class of drugs known as the 5-alpha-reductase inhibitors reduces the size of the prostate gland but benefits are not usually realized for several months; maybe up to 6-12 months before a symptom decrease is realized. For men who need relief of symptoms related to prostate enlargement, an alpha-blocker will provide significantly faster symptom relief. These two drugs can be used in combination. Question: A 40 year-old male has been diagnosed with acute bacterial prostatitis. His prostate specific antigen (PSA) is elevated on diagnosis. How soon should his PSA be rechecked? 2-3 days1 week2 weeks4 weeks Correct Explanation: Prostate infection or inflammation can cause a sharp rise in PSA values. Elective PSA should be deferred for four weeks after an episode of bacterial prostatitis. Checking prior to this time will likely result in an elevated serum PSA level and unnecessary testing and worry for the patient. Question: A patient with testicular torsion will have a: positive cremasteric reflex on the affected ive cremasteric reflex on the affected side. Correctpositive cremasteric reflex ive cremasteric reflex bilaterally. Explanation: A patient with testicular torsion will have a negative cremasteric reflex and a high riding testis. There can also be profound testicular swelling and an acute onset of scrotal pain. Question: A common presentation of an inguinal hernia is: groin or abdominal pain with a scrotal mass. Correctan abdominal mass without al and abdominal inal pain and scrotal erythema. Explanation: An inguinal hernia is characterized by herniation of bowel or omentum into the scrotum. It typically presents with scrotal pain and a scrotal mass or scrotal swelling. Abdominal or groin pain with a scrotal mass is a common presentation. Bowel sounds may be audible in the scrotum. Question: What class of medications can be used to treat benign prostatic hyperplasia and provide immediate relief? Alpha-1 blockers Correct5-alpha reductase inhibitorsDiureticsAnalgesics Explanation: Alpha blockers (alpha-adrenergic antagonists) provide immediate relief of symptoms. The alpha-1 receptors are abundant in the prostate gland and base of the bladder. The body of the bladder has very few alpha-1 receptors. Those alpha blockers most commonly used are terazosin, doxazosin, tamsulosin, and alfuzosin. Prazosin is a short-acting and so has less utility than the other agents mentioned. Question: A 65 year-old patient has a firm, non-tender, symmetrical enlarged prostate gland on examination. His PSA is 3.9 ng/mL. This probably indicates: prostate n prostatic hypertrophy (BPH). Correctprostate infection.a perfectly normal prostate gland. Explanation: This probably indicates BPH. These findings of the prostate gland do not rule out prostate cancer. A prostate infection usually produces greater elevations in PSA as well as a tender gland. A PSA > 2.5 ng/mL in this instance may reflect PSA changes seen with BPH. An important historical note would be the value of his last PSA for comparison as well as to assess for PSA velocity. Question: What symptom listed below might be seen in a male patient with benign prostatic hyperplasia? DysuriaNocturia CorrectLow back painPain with bearing down Explanation: Men with benign prostatic hypertrophy (BPH) have some classic symptoms that include: hesitancy, urgency, post-void dribbling, and frequency. They will seek help for these symptoms. Although these symptoms are typical of BPH, prostate cancer can also present in the same way. Question: The risk of HIV transmission is increased: when other STDs are present. Correctin patients are aware of their HIV patients with diabetes. Explanation: There are several risk factors for HIV transmission. Viral load is likely the greatest risk factor. The presence of STDs increases the risk of HIV transmission. Specifically, the presence of chlamydia increases the risk of acquiring HIV by 5 times. Lack of circumcision increases the risk of transmission.. Question: A 25 year-old female presents with lower abdominal pain. Which finding below would likely indicate the etiology as pelvic inflammatory disease? Presence of hyphaeHematuriaTemperature > 101F CorrectNormal sedimentation rate Explanation: Symptoms of pelvic inflammatory disorder (PID) include oral temperature > 101 F (38.8C), abnormal cervical or vaginal mucopurulent discharge, presence of abundant WBCs on microscopy or vaginal secretions, elevated sedimentation rate or C-reactive protein. CDC has indicated empiric treatment for PID if lower abdominal pain or pelvic pain is present concurrently with cervical motion tenderness or uterine/adnexal tenderness. Question: A male patient presents with dysuria. He states that his female partner has an STD, but he is not sure which one. Which of these should be part of the differential? Bacterial vaginosis and trichomonasChlamydia and gonorrhea CorrectHIV and herpesSyphilis and chlamydia Explanation: Bacterial vaginosis does not produce a discharge in male patients. Herpes produces lesions that are painful. HIV is not specifically associated with dysuria. Syphilis produces a painless lesion. Chlamydia and gonorrhea are usually associated with dysuria and discharge. Trichomonas can produce dysuria. Question: A 30 year-old male who is sexually active presents with pain during bowel movements. He is negative when checked for hemorrhoids, but has a tender prostate gland. What should be suspected? Acute bacterial prostatitis CorrectProstate cancerBenign prostatic hyperplasiaGonorrhea Explanation: This patient probably has acute bacterial prostatitis. A common presenting symptom is prostate tenderness, especially with bowel movements. A common cause in a 30 year-old male who is sexually active is infection with chlamydia or trichomonas. He should be screened for sexually transmitted diseases. If these are negative, a urinary pathogen is the likely cause. Penile and urine cultures should be collected. Question: A female patient and her male partner are diagnosed with trichomonas. She has complaints of vulval itching and discharge. He is asymptomatic. How should they be treated? She should receive metronidazole. He does not need treatment.They both should receive metronidazole. CorrectShe should be treated with ceftriaxone; he should receive ciprofloxacin.They both should be treated with azithromycin and doxycycline. Explanation: Metronidazole is considered the drug of choice to treat males and non-pregnant females. Even though he is asymptomatic, he needs treatment too. Neither partner should resume sexual intercourse until both have been treated. Tinidazole can also be used for treatment. 2 grams of either agent may be given as a single dose treatment. Question: A 26 year-old male patient has been diagnosed with gonorrhea. How should he be managed? Ceftriaxone onlyCeftriaxone and azithromycin CorrectCefixime and azithromycinPenicillin G Explanation: In 2010, CDC released its most recent guidelines for management of STDs. There was a major update for management of gonorrhea in Fall, 2012. Cefixime is no longer recommended as a cephalosporin for treatment of gonorrhea because of cephalosporin resistant strains of gonorrhea. 250 mg ceftriaxone should be given IM in conjunction with either azithromycin or doxycycline by mouth when gonorrhea is diagnosed. Treatment failure should be reported to CDC. Question: A 24 year-old female presents with abdominal pain. On exam, she is found to have cervical motion tenderness. What finding supports a diagnosis of pelvic inflammatory disease (PID)? A positive pregnancy testVaginal dischargePositive RPROral temperature 102F Correct Explanation: PID is sometimes a difficult diagnosis to make. A high index of suspicion should exist in adolescents and young women who present with the symptoms indicated above. CDC recommends empiric treatment for PID in women who present with abdominal pain and one of these: cervical motion tenderness, fever > 101F, a shift to the left, abnormal vaginal discharge, presence of white cells in the vaginal secretions, and an elevated sed rate or C reactive protein. Question: A male with gonorrhea might complain of: dysuria. Correcta penile inal ue. Explanation: In males, gonorrhea can have a varied presentation. Gonorrhea produces a purulent inflammation of the mucous membranes, urethral discharge, and dysuria. It can be diagnosed with a urethral culture, a urine screen, or nucleic acid tests. Urine screens are not preferred, but are commonly used for people who are difficult to screen, like adolescents or pediatric patients. Question: A patient presents with generalized lymphadenopathy. He has no other symptoms. Based on the most likely etiology, what test should be performed? HIV test CorrectCBCLymph node biopsySedimentation rate Explanation: During asymptomatic infection, patients often have persistent generalized lymphadenopathy (PGL). PGL is defined as enlarged lymph nodes involving at least 2 noncontiguous sites other than inguinal nodes. The lymphatic tissue serves as a primary reservoir for HIV. Studies of lymph nodes in patients at the asymptomatic phase demonstrate high concentrations of HIV. Question: An example of primary prevention is: using a condom to prevent infection with an STD. Correctdiagnosis of chlamydia prior to symptom ment of chlamydia concurrently with treatment of sexual partners. Explanation: Primary prevention refers to preventing an event prior to its occurrence. Using a condom to prevent infection from an STD is primary prevention. Early diagnosis refers to secondary prevention. Tertiary prevention refers to an intervention that has the potential to prevent worsening of the disease. Question: The greatest risk of transmitting HIV is during: the acute time that detectable antibody is present. Incorrecthigh viral load periods. Correctlate infection phase. Explanation: The period of time that risk of transmission is greatest is when the viral load is high. Many times this is before a patient has been diagnosed and so he is capable of transmitting this disease without knowledge that he is doing so. The highest viral load may occur during the earliest stages of HIV and before there is detectable antibody. Question: A 21 year-old female presents with three 0.5 cm human papilloma virus (HPV) lesions on her vulva. An appropriate treatment option for this patient would be: acetic hyllin. Correctacyclovir. Incorrect Explanation: This patient has HPV. This is a viral infection that increases a woman’s risk of cervical cancer. In males there is an increased risk of cancer of the anus and penis. The warts that are produced are painless and usually appear within weeks of infection. There are several topical treatments for HPV, imiquimod, podophyllin, and trichloroacetic acid (TCA). One of these agents may be applied to the warts. Treatments are generally well tolerated. TCA may cause burning. The warts will slough off after one or more treatments. There are no oral antiviral agents indicated for treatment of HPV. Question: An adolescent male reports that he has dysuria. He admits that he is sexually active. How should this be managed? Prescribe azithromycinPrescribe azithromycin and ceftriaxoneUrethral/urine cultures should be collected and screening done for STDs CorrectCollect a urethral culture and schedule a return appointment Explanation: This patient has dysuria. Dysuria could represent infection with an STD like chlamydia, gonorrhea, or trichomonas. Less likely, this patient could have a UTI or some other irritation of the urethral meatus. Cultures should be collected to establish a diagnosis and other STDs should be assessed (HIV, hepatitis B and C, syphilis etc.). Question: Syphilis may present as: a discharge.a rash. Correcta painful ia. Explanation: Secondary syphilis can present as a rash on the body, but more commonly as rash on the palms of the hands or soles of the feet. This can persist for up to 6 weeks. It will resolve without treatment, however the patient will still be infected with syphilis. Primary syphilis is characterized by a chancre. This is a painless lesion that can persist for 1-5 weeks. It will resolve without treatment. Question: Which risk factor has the greatest impact on HIV transmission? Viral load CorrectType of sexual activity IncorrectPresence of other STDsPatient gender Explanation: Viral load at the time of infection is the greatest risk factor in contracting HIV. It also is the greatest predictor of prognosis. High levels of viremia correspond to higher rates of infection. There are equal rates of transmission in sexual intercourse between same and opposite sex couples. The presence of STDs at the time of infection does increase risk of transmission, but not to as great an extent as viral load. Question: A 35 year-old patient who is HIV positive is diagnosed with thrush. A microscopic exam of this patient’s saliva demonstrates: epithelial . C blood cells. Explanation: The visualization of yeast in saliva usually indicates Candida species. Yeast are commonly seen in patients who have thrush, vaginitis secondary to yeast, or intertrigo. While thrush is uncommon in adults, it is not uncommon in patients who are immunocompromised, such as a patient with HIV. Question: In a private NP clinic, a patient presents with trichomonas. State law requires reporting of STDs to the public health department. The patient asks the NP not to report it because her husband works in the public health department. How should this be managed by the NP? Respect the patient’s right to privacy and not report it.Tell the patient that it won’t be reported, but report it anyway.Report it to public health as required by law. CorrectReport it to public health but don’t divulge all the details. Explanation: If state law requires reporting of the STD, it should be reported. Patient names or other identifying data are not part of the reporting process and so, the NP’s patient should not worry about being identified and associated with this finding. If the NP does not report it, she has violated state law. If she reports it but doesn’t tell the patient, she is not being honest with the patient. Reporting data to public health with deliberate elimination of required illness details is inaccurate reporting and doesn’t meet state law. Question: Which of the following statements regarding HIV is correct? There are few conditions that cause depletion of CD4 cells other than HIV. CorrectCD4 cell counts vary very little in individuals infected with HIV.A normal CD4 count is < 200/mm3. IncorrectCD4 counts are the first abnormality seen in patients with HIV. Explanation: HIV specifically attacks the number of circulating CD4 cells. There is very little variability in CD4 counts. There are a number of factors that will cause minor fluctuation in counts. These include things like seasonal and diurnal variations, infections, and steroid intake. The normal CD4 cell count ranges from 800-1050/mm3. Every year after infection with HIV, the CD4 cell count decreases by about 50/ mm3 per year. There is great variation in individual decreases. Some individuals experience very little decrease in counts, other patients experience great decreases in counts. Oral antiretroviral agents slow down the CD4 decreases. Question: Which of the following symptoms is usual in a male patient with trichomonas? No clinical symptoms CorrectUrethritisBurning with urinationTesticular pain Explanation: Trichomonas produces classic symptoms in females of itching and discharge. In males, there are usually no symptoms. Less than 10% of time, men present with symptoms. However, when symptoms occur in males, they include urethritis with clear or mucopurulent urethral discharge and dysuria. Metronidazole can be used to treat this in symptomatic and asymptomatic patients. Prostadynia, also known as prostatitis, is an inflammation of the prostate gland. Sometimes males with trichomonas infections present with prostadynia, but this is not the usual presentation. Question: A healthcare provider was exposed to the blood of a patient through a needle stick. When do the majority of patients seroconvert if they are going to do so? One weekWithin 4 weeks IncorrectWithin 4-6 weeksWithin 3 months Correct Explanation: The majority of patients who are going to seroconvert after HIV exposure will do so within the first 3 months. By 6 months, nearly 100% have seroconverted. Since there have been rare documented conversions between 6 and 12 months after exposure, some learned authorities advocate testing at 1 year after exposure. Question: A female patient has been diagnosed with chlamydia. How should this be managed? Treat with azithromycin CorrectTreat with ceftriaxone by injectionTreat with doxycyclineTreat for gonorrhea also Explanation: Chlamydia is commonly treated with a single dose of azithromycin (one-gram). This patient should be screened for other STDs now, including hepatitis B, C and HIV. According to the 2010 STD guidelines, this patient should not be treated for gonorrhea unless this is diagnosed too. When a patient is diagnosed with gonorrhea, she should be treated for concomitant chlamydia unless this has been ruled out. Question: How should a patient with suspected syphilis be screened? Ask about symptoms in the patientAsk about symptoms of sexual partnersA urethral swab for cultureA serum assessment Correct Explanation: Patients can be screened for syphilis in three ways. The nontreponemal tests are VDRL (venereal disease research laboratory), RPR (rapid plasma regain) or TRUST (toluidine red unheated serum test) tests. The main use of the treponemal tests is to confirm positive nontreponemal tests. These results are reported as reactive or non-reactive and are quantitative in nature, which is why they are used as confirmatory tests. Question: A patient with newly diagnosed genital herpes would appropriately receive a prescription for: clovir. Correct Explanation: Genital herpes is a viral infection affecting the mucus membranes. Some learned authorities consider this to be the most common STD in the United States. Herpes is treated with an oral antiviral agent like valacyclovir, acyclovir, or famciclovir. It is initially prescribed for 7-14 days. Shorter dosing periods may be given after the initial infection has been treated. Suppressive therapy is initiated when patients have multiple outbreaks. The oral antiviral agents are dosed daily for suppressive therapy and given for at least one year. Question: What should be avoided in a patient being treated with metronidazole for trichomonas? Direct sunlightAlcohol CorrectTeaPenicillin Explanation: A disulfiram reaction can take place in a patient who combines alcohol and metronidazole. The disulfiram reaction is described as elevation in body temperature, abdominal cramps, diarrhea, headache, and nausea/vomiting. Question: A patient being treated for trichomoniasis is given a prescription for metronidazole. What instructions should she be given? Take this medication with food.Do not take this medication if you are pregnant.Take this medication on an empty stomach.This medication should not be taken with alcohol. Correct Explanation: Metronidazole may be associated with a disulfiram reaction when mixed with alcohol. Advice that should be given to all patients who take metronidazole is to avoid alcohol entirely while this medication is being taken. Additionally, alcohol should be avoided for 72 hours after the last dose of medication. The disulfiram reaction is characterized by fever, abdominal pain, nausea, vomiting, and headache. This reaction is called the “Antabuse” reaction. Question: A patient requests testing for HIV after a sexual exposure. What are CDC’s recommendations for screening for this patient? There are no recommendations for further testing.She should be tested today, with repeat testing at 6, 12, and 24 weeks. CorrectShe should be re-tested in 6-12 months. IncorrectShe only requires retesting if she develops symptoms of HIV. Explanation: She does require further testing because a negative initial result does not insure that she is not infected. This signifies that she has not seroconverted at this time. The period within 3 months after exposure is termed the “window period” and a negative test must be confirmed. If the test is negative 6 months after the last exposure, she is considered to be negative. If the patient had an exposure and HIV was suspected, a HIV RNA should be performed as well as the rapid HIV. Rapid testing results are usually available in about 20-40 minutes. HIV testing should be performed in any patient who develops symptoms consistent with HIV after an exposure. Question: A patient was exposed to HIV through sexual intercourse. He should be followed with screening tests to identify seroconversion for: 4-6 weeks.3-4 months. Incorrectabout 6 year. Correct Explanation: Greater than 95% of patients who are exposed to HIV will seroconvert within 6 months. The majority of patients convert within 4-10 weeks after exposure. CDC recommends follow up for one year. Question: Chancroid is considered a co-factor for transmission of: HIV. CorrectGonorrhea.Chlamydia.Trichomoniasis. Explanation: Chancroid is an STD caused by Haemophilus ducreyi and is spread by sexual contact or by contacting pus from an infected lesion. This is common in tropical countries but is seen in the US. The ulcer is usually very painful in men, but not usually painful in women. The ulcer begins as a papule, fills with pus, and becomes an open, eroded area. Chancroid is a co-factor in the transmission of HIV. In patients with HIV, the chancroid heals much more slowly than in patients who are immunocompetent. Question: How long should a patient be treated with antibiotics if he has prostatitis secondary to an STD? About 5 days7-10 days14 daysLonger than 14 days Correct Explanation: The prostate gland does not absorb antibiotics very readily. Consequently, antibiotics must be given for 4-6 weeks to enable the gland to achieve high enough concentrations to treat and effectively eradicate prostatitis. Treatment can be very expensive depending on the antibiotic used. ENDOCRINE Question: A patient with a past history of treatment for hyperthyroidism is most likely to exhibit: a euthyroid hyroidism. Cinical hypothyroidism. Explanation: Hypothyroidism is the most likely result when a patient has been treated for hyperthyroidism because treatment typically destroys the gland’s ability to produce thyroid hormone (T3 and T4), in the future. Radioactive iodine or drugs can be used to inhibit synthesis of thyroid hormone. Question: The most appropriate time to begin screening for renal nephropathy in a patient with Type 1 diabetes is: at annually after diagnosis. Incorrect2-3 years after diagnosis.5 years after diagnosis. Correct Explanation: Patients with type 1 diabetes should be screened for renal nephropathy 5 years after diagnosis. Since nephropathy takes several years to develop, it is highly improbable that a newly diagnosed patient will have nephropathy secondary to diabetes. Nephropathy develops in about 30% of patients with diabetes. Diabetic nephropathy is defined as the presence of diabetes and more than 300 mg/d of albuminuria on at least 2 occasions separated by 3-6 months. Question: Which medication used to treat diabetes is associated with diarrhea and flatulence? PioglitazoneInsulinMetformin CorrectGlimepiride Explanation: Metformin is associated with these symptoms---especially in the first two weeks of use. These symptoms can also be seen with increases in the dose of metformin. The other medications listed do not produce lower gastrointestinal symptoms. If the medication can be continued for a couple of weeks, generally, GI symptoms will resolve. Metformin is known to decrease morbidity and mortality associated with diabetes. Question: A patient who has been treated for hypothyroidism presents for her annual exam. Her TSH is 14.1 (normal = 0.4- 3.8). She complains of weight gain and fatigue. How should the NP proceed? Ask what time of day she is taking her medicationAsk if she is taking her medication CorrectIncrease her dose of thyroid supplementRepeat the TSH in 2-3 months Explanation: Her TSH is elevated. This is usually caused by insufficient supplementation in a patient with hypothyroidism. If the TSH was within normal range following her last annual exam, something has changed. The first point that must be established is whether the patient is still taking her medication. If she is still taking her medication, determining when she is taking it is very important. It should be taken on an empty stomach for absorption. These two important facts must be established BEFORE increasing her current dose. The TSH is usually repeated when an abnormal value is measured, but this patient has symptoms of an abnormal TSH. Question: A recently diagnosed patient with type 2 diabetes presents today with fever and burning with urination. She is diagnosed with a urinary tract infection (UTI). Her urine dipstick is positive for protein. Which statement is correct? This patient has microalbuminuria secondary to diabetes. IncorrectThe finding of protein is an incidental finding.The proteinuria is related to the UTI.No specific conclusions can be drawn about the proteinuria. Correct Explanation: No conclusion can be drawn from this particular finding of proteinuria. Transient proteinuria can be found in the setting of fever, during the course of UTI, after intense exercise, poor glycemic control, and other systemic conditions. A diagnosis of microalbuminuria must be made after two positive screens on dipstick at least 3-6 months apart. Question: A patient who is 73 years old was diagnosed with diabetes several years ago. His A1C has remained elevated on oral agents and a decision to use insulin has been made. What is the goal post prandial glucose for him? 100- 120 mg/dL Incorrect120- 150 mg/dL175- 200 mg/dLLess than 180 mg/dL Correct Explanation: In older adults, strong consideration must be given to the risk associated with hypoglycemic states. Falls, accidents, and stroke are more likely; and these are more deleterious in older adults than younger adults who have episodes of hypoglycemia. A1C levels should be < 7% for most older adults; > 7% for frail adults. Good clinical judgment must be exercised in setting a goal A1C for this patient due to age. Question: A 69 year old adult with coronary artery disease is found to have hypothyroidism. Which dose of levothyroxine is considered appropriate for initial treatment? 25 micrograms Correct50 micrograms75 micrograms100 micrograms Explanation: When thyroid replacement is given to someone 50-60 years old, 50 mcg is the usual recommended starting dose. When the patient is older, and always if there are cardiac issues, 25 mcg is considered a prudent starting dose. The prescriber must recognize that all metabolic processes will increase after supplementation; and this includes myocardial oxygen demand, the potential for angina and arrhythmias. It is important to start this medication at a low dose and increase by 12.5 -25 mg increments every 4-6 weeks until therapeutic values are reached or cardiac symptoms occur. Question: Hyperthyroidism may affect the blood pressure: by producing an increase in systolic and diastolic readings. Correctby producing a decrease in diastolic blood the heart rate is increased. Incorrectwith unpredictable results. Explanation: A common effect of hyperthyroidism on blood pressure is an increase in both systolic and diastolic readings over the patient’s usual readings. In fact, hyperthyroidism is a common endocrine cause of secondary hypertension. Other endocrine causes of secondary hypertension are pheochromocytoma, Cushing’s syndrome, and neuroblastoma. It is very common to measure a resting heart rate of greater than 100 bpm in patients who have untreated hyperthyroidism. Question: A 45 year-old female patient has a screening TSH performed. Her TSH value is 13 mU/L. It was repeated in one week and found to be 15 mU/L. What explains this finding? Subclinical hypothyroidism IncorrectHypothyroidism CorrectTransient hypothyroidismHyperthyroidism Explanation: This patient has hypothyroidism because her TSH exceeds 5 mU/L. Common symptoms associated with hypothyroidism include fatigue, weight gain, dry skin, cold intolerance, constipation, menstrual irregularities, and hair and nails that break easily. The diagnosis should be easily realized since the TSH is elevated on two occasions. Question: A female patient has the following characteristics. Which one represents a risk factor for development Type 2 diabetes? DyslipidemiaHistory of gestational diabetes CorrectHypertensionExposure to cigarette smoke Explanation: History of gestational diabetes conveys an 83% chance of developing Type 2 diabetes (within 17 years of delivery). Dyslipidemia and hypertension are not risk factors for diabetes, though they are commonly seen in conjunction with diabetes. A family history of Type 2 diabetes as well as obesity, significantly increase the risk of developing diabetes. Sedentary lifestyle promotes weight gain and so, increases risk of Type 2 diabetes Question: Which choice best describes the most common presentation of a patient with Type 2 diabetes? Acute onset of hyperglycemia with other symptoms IncorrectHyperlipidemia and presence of retinopathyInsidious onset of hyperglycemia with weight gain CorrectMicroalbuminuria Explanation: Most patients with type 2 diabetes mellitus are asymptomatic at presentation. They are identified because of screening and identification of risk factors. Hence, diabetes usually has an insidious onset and is associated with weight gain, especially in adults and adolescents after puberty. An acute onset is typical of patients with type 1 diabetes. Microalbuminuria develops after several years of having diabetes. Question: A 65 year-old diabetic has been on oral anti-hyperglycemic agents and is still having poor glycemic control. His AM fasting glucoses range from 140s-160s. You decide to add insulin. He weighs 127 kilograms. What should the NP order as an initial starting dose? 10 units long-acting insulin at bedtime Correct30 units long-acting before breakfast5 units intermediate insulin at bedtime20 units short-acting insulin at breakfast Explanation: According to American Diabetes Association (ADA) consensus algorithm for initiation and adjustment of insulin therapy (ADA, 2009), an intermediate or long-acting insulin should be started at bedtime or morning as a once daily dosage. A prudent starting dose is either 10 units insulin or 0.2 units per kilogram (approximately 25 units of insulin) Question: A 55-year-old female patient with diabetes has these fasting lipid values: Total cholesterol 200 mg/dL HDL 45 mg/dL LDL levels of 120 mg/dL Triglyceride 309 mg/dL According to American Diabetes Association (ADA) which patient lipid value(s) meet(s) the goal for this patient? Total cholesterol onlyTotal cholesterol, HDL, LDLLDL only IncorrectNone are at goal Correct Explanation: This patient has diabetes. Her target lipid values according to American Diabetes Association should be HDL > 50 mg/dL (> 40 mg/dL for males), LDL < 100 mg/dL, triglycerides < 150 mg/dL. The ADA does not have a recommendation for total serum cholesterol specific for patients with diabetes, but, total cholesterol should be less than 200 mg/dL for the general population according to NCEP (National Cholesterol Education Program). Question: Metformin is a good choice for many older adults with type 2 diabetes. What should be monitored carefully? Hypoglycemia IncorrectFluid retentionLactic alkalosisRenal dysfunction Correct Explanation: Metformin is a good agent to use in older diabetics because it does not produce hypoglycemia. However, renal function typically declines in older patients, lactic acidosis becomes more likely (though not common) when metformin is prescribed. Therefore, renal function should be monitored in all patients, but, especially older patients who have declining renal function due to any acute event (stroke, MI, infection). Question: A diabetic patient with proteinuria (approximately 1 g/d) has been placed on an ACE inhibitor. How soon can the anti-proteinuric effect of the ACE inhibitor be realized in this patient? 6-8 weeks Correct3 months6 months3-5 years Explanation: The effect can be realized as early as 6-8 weeks after starting an ACE inhibitor or ARB. The ACE inhibitor should be titrated upward so that urinary protein is less than 500 mg/d or the patient exhibits deleterious symptoms from ACE or ARB use. A second agent can be added if the ACE or ARB reaches maximum dosage, but goal proteinuria has not been achieved. Monitor the patient’s serum creatinine and potassium levels with dose changes because both can increase to unacceptable levels when drugs affecting the renin-angiotensin-aldosterone system are used. Question: A 55-year-old female patient with diabetes has these fasting lipid values: Total cholesterol 200 mg/dL HDL 45 mg/dL LDL levels of 120 mg/dL Triglyceride 309 mg/dL This patient’s Hgb A1c was measured. It is 9.2%. What is the relationship between Hgb A1c and this patient’s lipid values? There is no specific relationship.Elevated lipids will increase as Hgb A1c increases. IncorrectHgb A1c decreases as triglycerides decrease. CorrectHgb A1c will decrease as HDL values increase. Explanation: Two known factors specifically contribute to elevated Hgb A1c levels: elevated glucose values (measured with a Hgb A1c) and excessive alcohol consumption. Diabetic patients with elevated triglyceride levels and elevated Hgb A1c levels can usually expect to have improved triglyceride levels as Hgb A1c levels begin to normalize. Question: A patient presents with consistently elevated blood glucose before his evening meal. What choice below represents an insulin change that would improve his evening glucose? Current regimen: AM: 22u intermediate-acting insulin, 12u short-acting insulin PM: 10u intermediate-acting insulin, 8u short-acting insulin 24u intermediate-acting insulin in AM Correct14u short-acting insulin in AM12u intermediate-acting insulin in PM10u intermediate-acting insulin in PM Explanation: This patient’s blood sugar is consistently elevated before the evening meal. This indicates that he needs more AM intermediate-acting insulin on board. A prudent increase in insulin dose involves 2-3 unit increases at a time. He is taking 22 units of intermediate-acting insulin in the AM. His dose should be increased to 24 or 25 units in the AM followed by blood sugar checks for 3 days after the insulin change (blood sugar checks before dinner). If he is not at goal, then the AM intermediate-acting insulin can be increased by an additional 2-3 units until blood sugars are at goal, or the patient becomes symptomatic with low blood glucose values. Question: Undiagnosed diabetes may present as: recurrent vaginal candidiasis. Correctchronic ose thesias in the upper extremities. Explanation: Candida is part of the normal vaginal flora. However, when glucose levels rise, Candida dramatically increases in numbers. Patients can present with recurrent vaginal candidiasis since the vagina offers an ideal environment to grow yeast. The other choices listed above do not relate to elevated glucose levels or diabetes. Diabetic paresthesias typically present in the lower extremities. Question: What is the most sensitive laboratory assay for screening and identifying the vast majority of ambulatory patients with primary hypothyroidism? TSH only CorrectTSH and T4TSH, T4, and T3TSH and TRH (thyrotropin releasing hormone) Explanation: TSH assays have become ultra sensitive and so diagnosis of hypothyroidism can take place at a very early stage. Therefore, measurement of thyrotropin releasing hormone (TRH) is no longer necessary. Primary hypothyroidism accounts for 95% of patients with hypothyroidism. There are 2 reasons to order a TSH and T4 in ambulatory patients for screening; if pituitary or hypothalamic disease is known or suspected, or if the patient is receiving medications or has specific diseases that can affect TSH secretion. Examples of drugs and disorders that can increase TSH secretion are metoclopramide, amiodarone, adrenal insufficiency, pituitary adenoma, and generalized thyroid hormone resistance. In hospitalized patients, TSH should not be used as a sole means to evaluate thyroid disease because many different factors in seriously ill euthyroid patients can affect TSH secretion. Question: A female patient has the following characteristics. Which one represents the greatest risk factor for development of Type II diabetes? BMI 26 CorrectLack of exercise IncorrectMediterranean decentLack of regular healthcare Explanation: A BMI of 26 or higher imparts an increased risk of Type II diabetes. Mediterranean decent does not impart a specific risk factor for Type II diabetes, but African-American, Asian-American, and Hispanic races have an increased risk. Question: A female patient has the following characteristics. Which one represents a risk factor for Type II diabetes? BMI 31 CorrectOsteopeniaMediterranean decentHypothyroidism Explanation: A BMI of 26 or higher does increase the risk of developing Type II diabetes. Mediterranean decent does not impart a specific risk factor for development of Type II diabetes, but African-Americans and Asian-Americans are at increased the risk of developing Type II diabetes. Hypothyroidism may be found in some patients with diabetes, but this does not increase the risk Question: What is the AM fasting glucose goal for a 75 year-old patient who has diabetes? 80-100 mg/dL100-120 mg/dL80-120 mg/dL Correct120-140 mg/dL Explanation: Considering this patient’s age and the risk of hypoglycemia, a reasonable goal is 80-120 mg/dL pre-prandial. A value less than 130 mg/dL is desirable, but not less than 80 mg/dL. The goal bedtime glucose goal is 100-140 mg/dL. Hypoglycemia during sleep can result in stroke or seizures in this age group. Question: A patient has non-fasting glucose values of 110 mg/dL and 116 mg/dL. This patient: can be diagnosed with Type 2 impaired fasting glucose. Incorrectshould have a Hgb A1C normal glucose values. Correct Explanation: Non-fasting glucose values less than 125 mg/dL are considered normal values. Question: A diagnosis of Type 2 diabetes mellitus can be made: if risk factors plus a family history of diabetes are an Hgb A1C of 7% or greater. Incorrectif glucose values of 110, 119, and 115 are observed on different wing fasting glucose values of 126 and 130 on different days. Correct Explanation: Type 2 diabetes can be diagnosed under 4 circumstances: In the instance of a glucose value > 126 (and confirmed on subsequent day), a glucose value greater than 200 mg/dL with symptoms of "the 3 P's", an A1C > 6.5% (and confirmed on a different day), or 2 hour plasma glucose > 200 mg/dL during an oral glucose tolerance test. Choice c indicates a patient with pre-diabetes. Question: A 78 year-old has been diagnosed with diabetes about 10 years ago. An older adult with a hypoglycemic episode is more likely to exhibit: ness and weakness. Correctsymptoms of hyperglycemia. Explanation: Hypoglycemia in older adults, like this 78 year-old, is more likely to have deleterious consequences than in younger adults because of the risk of falls and increased association with cardiac events. The symptoms associated with hypoglycemia in older adults tend to be neurological (dizziness and weakness) as compared to younger adults who are more likely to exhibit adrenergic (tremors and sweating) symptoms. In fact, in older adults, hypoglycemic episodes may be misinterpreted as cardiovascular or neurological events. Question: A 37 year-old overweight male is diagnosed today with Type II diabetes. His fasting glucose is 159 mg/dL. He is hyperlipidemic (LDL = 210 mg/dL) and hypertensive (146/102). What medications should be initiated today? Metformin, ASA, and pravastatinMetformin, niacin, MonoprilGlimepiride, ASA, fosinoprilMetformin, atorvastatin, ramipril, ASA Correct Explanation: This patient needs several medications started today. American Diabetes Association recommends starting treatment with metformin. This should be initiated today. The drug class of choice for treatment of his LDL cholesterol is a statin. Dietary modifications are usually attempted for 3 months prior to initiation of a statin. However, considering this patient’s LDLs of 210 mg/dL (goal of less than 100 mg/dL), strong consideration should be given to initiating therapy today with a statin. An ACE inhibitor is the preferred antihypertensive medication to treat blood pressure elevations in this patient. An aspirin should be initiated if there are no contraindications Question: A patient who is taking long acting insulin basal insulin has elevated blood sugars. Which blood sugars are important to review in order to increase the dose of insulin? AM fasting Correct2 hour post prandialPre-prandialBedtime Explanation: Long acting insulin mimics the amount of insulin the pancreas produces at a steady rate throughout the day and night. Adjustments in doses of long-acting insulin are typically based on the AM fasting glucose values. The other blood sugars reflect blood sugars in relation to meals. Question: What is the earliest detectable glycemic abnormality in a patient with Type 2 diabetes? Postprandial glucose elevation CorrectNighttime hyperglycemiaFasting glucose elevation IncorrectAbnormal Hgb A1C Explanation: The earliest glycemic abnormality is postprandial glucose elevation. Early in the pathogenesis of diabetes, glucose levels increase to abnormal levels after eating. Over the next few hours, if the patient does not eat, the glucose levels will fall to a normal range again via many different physiologic mechanisms. This may occur for months or years before glucose levels become consistently elevated and are not able to return to normal despite long periods of fasting. Once glucose levels are elevated and remain elevated, patients usually experience symptoms such as fatigue, thirst, frequent urination, and hunger. Question: The most appropriate time to begin screening for renal nephropathy in a patient with Type 2 diabetes is: at diagnosis. Correctone year after diagnosis.2-3 years after diagnosis.5 years after diagnosis. Incorrect Explanation: Patients with type 2 diabetes should be screened for renal nephropathy at the time of diagnosis. "Serum creatinine should be measured at least annually in all adults with diabetes regardless of the degree of urine albumin excretion" according to American Diabetes Association. Nephropathy develops in about 30% of patients with diabetes. Diabetic nephropathy is defined as the presence of diabetes and more than 300 mg/d of albuminuria on at least 2 occasions separated by 3-6 months. Question: A 65 year-old patient presents to your clinic with evidence of hyperthyroidism. In assessing her cardiovascular status, what should the NP assess immediately? Cardiac enzymesElectrocardiogram CorrectElectrolytesAuscultation of systolic murmurs Explanation: An urgent threat to this patient is the possibility of stroke from atrial fibrillation. A common presentation in older patients who have hyperthyroidism is atrial fibrillation. Unless she is anti-coagulated, she is at very high risk for stroke, especially as her hyperthyroidism is treated and she returns to a normal sinus rhythm. She probably will exhibit a systolic murmur, but this poses little threat to her. She should also be monitored for angina and heart failure. These are commonly found when patients present urgently to a clinic or emergency department. Question: A 52 year-old presents with symptoms of diabetes today. His glucose is 302 mg/dL. How should this be managed today? Have him return tomorrow to recheck his blood glucoseStart metformin IncorrectStart insulin CorrectStart metformin plus pioglitazone Explanation: This patient can be diagnosed with diabetes today because his glucose exceeds 200 mg/dL and he is symptomatic. Most learned authorities would describe him as glucose toxic. Oral agents will have little effect on his glucose and it should be lowered. Insulin is the best agent to reduce the blood sugar so that oral agents can be given a chance. He should return tomorrow for a recheck of blood glucose and adjustment of his medication. Question: A patient has been prescribed pioglitazone. The nurse practitioner must remember to: check a hemoglobin A1C in 3 months. Incorrectorder liver function studies in about 2-3 months. Correctscreen for off metformin. Explanation: Pioglitazone belongs to a class of medications that can cause hepatotoxicity. Therefore, assessment of liver function studies, particularly AST and ALT, should be performed in 1-3 or 4 months after initiation of this medication. The manufacturer has not suggested an ideal schedule to check AST and ALT. Depending on patient history and concurrent medications, a check of the AST and ALT may be prudently done in 1-3 months. Question: Mr. Jones, a patient with type 2 diabetes, brings his obese 15 year old son in to see the nurse practitioner. You examine the 15 year-old son and identify acanthosis nigricans. This probably indicates: undiagnosed in resistance. Correctfamilial skin hygiene. Explanation: Acanthosis nigricans (AN) has been associated with insulin resistance. While the majority of cases are benign and associated with obesity, AN is also associated with certain GI tumors (unlikely in a 15 y/o). However, in a 15 year-old this is particularly important since AN in children and adolescents is often a predictor of development of type 2 diabetes. It is also associated with type 2 diabetes in adults. AN is prevalent on the flexor surfaces of the axillae and neck. The lesions are slightly elevated and have a velvety appearance. Question: Which drug listed below is NOT associated with weight gain? InsulinPioglitazoneCitalopramMetoprolol Correct Explanation: Metoprolol is a beta-blocker and is NOT associated with weight gain. Unfortunately, most drugs used to treat Type 2 diabetes are associated with weight gain. Most patients with Type 2 diabetes are overweight and so weight loss is difficult. Question: A patient has 2 fasting glucose values of 101 mg/dL and 114 mg/dL that were measured on 2 separate days in the same week. This patient: can be diagnosed with Type 2 impaired fasting glucose. Correctshould have further glucose testing done for d have a Hgb A1C performed. Explanation: This patient has impaired fasting glucose. This is diagnosed when 2 fasting glucose values are between 100 mg/dL and 125 mg/dL. There is no need for further testing. At this time, this patient does not meet the criteria for diabetes and does not need further testing to arrive at a diagnosis. Question: A patient has been diagnosed with Grave’s disease. He is likely to have: an elevated alkaline elevated T3 or T4. Correctan elevated TSH.elevated liver function studies. Explanation: Grave’s disease is the most common form of hyperthyroidism. There will be elevated levels of thyroid hormones like T3 and/or T4. Patients become symptomatic with palpitations, elevated blood pressure, inability to sleep, restlessness, and heat intolerance. An elevated TSH can be found in patients with hypothyroidism. Choices A and D do not relate to Grave’s disease. Question: When the serum free T4 concentration falls: the TSH TSH rises. Correctthere is no relationship between T4 and TSH.T3 falls. Incorrect Explanation: As a patient’s T4 concentration falls (although still within normal range), the anterior lobe of the pituitary gland responds by secreting TSH. TSH finds its way to the thyroid gland and causes an increase in T4 secretion. In this manner, T4 concentrations remain within a normal range and help maintain a euthyroid state in the patient Question: A patient with newly diagnosed Type 2 diabetes asks what his target blood pressure should be. The most correct response is: about 130/ the low 140s over the 90s. Incorrectless than 130/80. Correctthe systolic should be in the 120s-130s. Explanation: The 2012 American Diabetes Association's target blood pressure for "most patients with diabetes” is less than 130/80 mm Hg. Less than 130/80 means that the systolic blood pressure should be in the 120s at the highest and the diastolic blood pressure should be in the 70s at the highest. Question: Ideally, a patient should have a fasting glucose that is: between 60-100 mg/dL.less than 126 mg/dL.less than 100 mg/dL. Correctrepeated in a non-fasting state. Explanation: The ideal screening glucose is done during a fasting state and should be less than 100 mg/dL. Abnormal values should always be repeated. If a patient is non-fasting and the glucose value is less than 125 mg/dL, most authorities consider this to be normal. Question: A 38 year-old male patient, thought to be in good health, presents to a primary care clinic. On routine exam the patient’s fasting blood sugar is 242 mg/dl. A repeat value after eating is 288 mg/dL. Which of the following is least helpful in the initial evaluation of this patient? Blood pressureNon-fasting lipids CorrectHgb A1cMicroalbuminuria Explanation: Lipids should be done a non-fasting state. Triglycerides are especially sensitive to non-fasting states and will give an abnormally elevated value if performed in a non-fasting patient. Since triglycerides are frequently elevated in patients with elevated glucose levels, a fasting level should be performed. Initially, a blood pressure, fasting lipids, and microalbuminuria are critical to assessing this patient's diabetic status. Question: In order to determine how much T4 replacement a patient needs to re-establish a euthyroid state, the nurse practitioner considers: the TSH value. Incorrectthe patient’s T patient’s body weight. Correctthe patient’s gender. Explanation: Replacement is based on body weight and is usually calculated in kilograms. The patient’s weight is calculated in kilograms and multiplied by 1.6 to determine the replacement needed in one day. This is the amount that should be prescribed provided the patient is otherwise healthy, is less than 50 years old, and has no evidence of underlying cardiac disease. Question: A 30 year-old female patient who complains of fatigue has a screening TSH performed. Her TSH value is 8 mU/L. What should be done next? Begin thyroid supplementation.Repeat the TSH and add T4. CorrectBegin supplementation and repeat the TSH in 4-6 weeks. IncorrectMeasure the T4 and consider repeating the test in a month. Explanation: TSH values rise and fall continuously. Consequently, TSH levels are repeated and an average is usually calculated. A diagnosis of hypothyroidism can be made after a second abnormal TSH unless the initial value is very elevated and the patient is symptomatic. When an elevated TSH is discovered, it should be repeated and a serum free T4 can be measured. Depending on these results, a diagnosis of thyroid disease can be made. Question: A patient has been diagnosed today with Type II diabetes. A criterion for diagnosis is: an abnormal random blood inuria.a fasting glucose > 126 and confirmed on a previous day. Correctan abnormal post-prandial glucose. Explanation: Type II diabetes is diagnosed after a random fasting glucose > 126 mg/dL and confirmed on a subsequent day. Other diagnostic criteria include a random blood glucose > 200 mg/dL with polyuria, polydypsia, or polyphagia; or an A1C > 6.5% (and confirmed on a subsequent day). A glucose tolerance test may also be used for diagnosis but this is usually reserved for pregnant women. Question: An 80 year-old patient who is overweight and sedentary has developed elevated, fasting glucose levels (142, 153, and 147 mg/dL). She was diagnosed with diabetes today. Considering her age, how should the nurse practitioner proceed? Treat with dietary interventions onlyInitiate insulinStart metformin CorrectStart a sulfonylurea Explanation: This patient should be treated with medication and lifestyle interventions. Metformin would be a good medication to initiate treatment with because it is generally well tolerated and should not produce hypoglycemia if given alone. It should be initiated at 500 mg daily and the dose increased as tolerated. Question: A patient who is diagnosed today with diabetes has microalbuminuria. What can be concluded about this finding? The patient has diabetic nephropathy. IncorrectThere is renal damage.The patient should have a repeat test in one month.The patient might have been diabetic for a long time before diagnosis. Correct Explanation: Microalbuminuria takes years to manifest after diabetes has developed. Microalbuminuria should never be diagnosed on a single reading because many factors can produce false microalbuminuria. Heavy exercise, elevated glucose levels, infection, and others can produce false positive microalbuminuria. The ideal time for microalbuminuria to be repeated is 3-6 months after the first abnormal measurement. This gives some time for glucose values to improve and can help rule out false positive results. Question: The most appropriate screen for diabetic nephropathy is: creatinine albuminuria. CorrectBUN/C creatinine. Explanation: Microalbuminuria literally means “small amounts of protein in the urine”. This is a sensitive and early measure of kidney disease in diabetics. It is an appropriate screen for undiagnosed diabetic nephropathy. Microalbuminuria is screened annually in Type 2 diabetics who are at least 12 years of age. If microalbuminuria is positive, it should be re-assessed in 3-6 months. Many false positives can occur. However, if it is positive after repeating once or twice, it is likely a true positive. Question: A patient with hypothyroidism has been in a euthyroid state for several years. On screening, her TSH is elevated. The most likely cause of this is: change in laboratory’s method of measuring TSH.substitution of levothyroxine for a generic medication. Cg extra doses of T4. Explanation: Generic medications for levothyroxine can have varying bioavailabilities. It is not uncommon to have fluctuations in TSH levels if brand names or generics are substituted for each other. Although there can be only subtle differences between T4 formulations, patients should attempt to use the same manufacturer, whether generic or not. Many learned authorities recommend brand name because less variation in TSH levels occur from prescription to prescription. Question: A pregnant patient took L-thyroxin prior to becoming pregnant. What should be done about the L-thyroxin now that she is pregnant? It should be discontinued during pregnancy.She should continue it and have monthly TSH levels. CorrectShe should be switched to a supplement with a category B rating.She can continue it during pregnancy without concern. Incorrect Explanation: L-thyroxin is thyroid supplement used to treat patients with hypothyroidism. It is safe to use during pregnancy and should be continued. However, during pregnancy, thyroid hormone needs increase and so she will need frequent monitoring because if levels drop to a hypothyroid state, growth of the fetus can be severely affected. Question: A 76 year-old patient has fasting glucose values of 151 mg/dL and 138 mg/dL on different days. This patient: can be diagnosed with Type 2 diabetes. Correcthas impaired fasting d have a Hgb A1C performed for normal glucose values. Explanation: Glucose values that equal or exceed 126 mg/dL on different days constitute a diagnosis of diabetes. Therefore, an A1C is not needed for diagnosis but may be ordered to establish a baseline for this patient. Impaired fasting glucose can be diagnosed when two glucose values are between 100 mg/dL and 125 mg/dL on different days Question: Mr. Smith, an overweight 48 year-old male with undiagnosed type 2 diabetes mellitus presents to your clinic. Which symptom is least likely associated with type 2 diabetes mellitus? FatigueConstipation CorrectAthlete’s foot IncorrectImpetigo Explanation: Fatigue is a common early symptom of diabetes. Athlete’s foot could represent peripheral fungal infections related to sustained elevations in glucose. Impetigo, though not common in adults, could represent a superficial bacterial infection related to elevated glucose levels. Constipation could be due to many factors, but not specifically diabetes. Conversely, the three factors most closely associated with diabetes are fatigue and infections. Question: A nurse practitioner has decided to initiate insulin in a patient who takes oral diabetic medications. How much long acting insulin should be initiated in a patient who weighs 100 kg? About 5 units10 units Incorrect15 units20 units Correct Explanation: A patient who will be starting insulin can have his daily insulin needs calculated by multiplying his weight in kilograms by 0.2. In this patient, (100 x 0.2= 20 units) 20 units could be used for insulin initiation. Once insulin has been initiated, 3 days of AM fasting glucose measurements should be collected and the insulin dose adjusted so that the AM fasting glucose levels are about 100-120 mg/dL. Giving fewer than 20 units will probably be too little to meet this patient’s needs Question: Which laboratory abnormality very commonly accompanies hypothyroidism? HypernatremiaPolycythemiaDyslipidemia CorrectHypoprolactinemia Explanation: Hypothyroidism adversely affects lipid metabolism. A finding of elevated lipids, specifically dyslipidemia, is common when TSH values exceed 10 mU/L. Consequently, patients with dyslipidemia should also have a TSH evaluated. Dyslipidemia should not be treated until the TSH decreases to 10 mU/L or less. Other abnormal laboratory findings associated with hypothyroidism are hyponatremia, hyperprolactinemia, hyperhomocysteinemia, anemia, and elevated creatinine phosphokinase. Question: A patient has fatigue, weight loss, and a TSH of .05. What is his likely diagnosis? HypothyroidismHyperthyroidism CorrectSubclinical hypothyroidismMore tests are needed to establish his diagno