TOP 2025 AGACNP CERT TEST WITH Q&A GRADED A+

TOP 2025 AGACNP CERT TEST WITH Q&A GRADED A+ What causes fever? ABCDEFGHIMN Auto-immune - SLE, GCA Blood - Heme/Onc - Leukemia/Lymphoma Cancer Drugs - Amphotericin B, Beta-lactam abx, procainamide Endo - hyperthyroidism, pheochromocytoma Familial mediterranean fever GI - intra-abdominal abscess, IBD Heart- MI, endocarditis Infection - bacterial, viral, fungal, parasites, etc. Misc - Hematoma Neuro - tumor, ICH, MS - interfere w/ thermoregulatory process What is malignant hyperthermia? high fever d/t succinylcholine usu given in OR to relax laryngeal muscle contraindicated to succs? hyperkalemia Tx: dantrolene - reversal for succs What is the treatment for fever? 1. antimicrobials only when a microbe is present 2. antipyretics 3. tx underlying condition What are the causes of non-infectious post-op fever? 1. post-op atelectasis 2. increased basic metabolic rate 3. dehydration 4. drug reactions: Amphotericin B, trimethoprim-sulfamethazole, beta-lactam (abx), procainamide, isoniazid, alpha-methyldopa, quinidine, etc. What would prompt you to think that a post-op fever is infectious? 1. usu accompanied by subjective complaints & a WBC elevation with left shift (i.e., bandemia) 2. WBC >30k is usu not d/t infection 3. surgical incisions 4. point of entry for any catheter, culture it 5. UTI 6. lungs 7. sinusitis 8. abscess (e.g., intra-abd) normal WBC - 5-10k sinusitis - 12k cellulitis - 17k septic shock - 20-22k leukemia - 30k what is the initial tx for post-op fever in the absence of information of infection? Hydration + measures to expand lungs what is the treatment for infectious post-op fever? -IVF + APAP -tx underlying source -gram stain, C&S, all invasive lines or catheters, as indicated **before cultures, do not give APAP or IVF. Do not suppress anti-inflammatory response bec you want to culture at maximum inflammation response, then broad spectrum abx, IVF, & APAP, then narrow once culture comes back. what are the components of headache evaluation? 1. chronology - most impt hx item 2. location, duration, quality 3. associated activity - i.e. exertion, sleep, tension, relaxation 4. timing of menstrual cycle 5. presence of assoc symptoms 6. presence of "triggers" What is the lab/diagnostic test and treatment for tension headache? - no lab/diagnostic test specific for tension h/a - tx is OTC analgesics & relaxation What is the pathophysiology behind migraine headaches? - migraine headaches are related to dilation & excessive pulsation of branches of the external carotid artery - typically lasts 2-72 hours following the trigeminal nerve pathway What are the physical exam findings you may find in a migraine headache? -many times appear normal, +/- neuro deficits, or appear ill -neuro deficits - visual disturbances, aphasia, numbness/tingling, N/V, photophobia/phonophobia *careful neuro exam for focal deficits or findings supportive of tumor What labs/diagnostic tests do you order in pts w/ new migraine h/a? CBC, BMP VDRL - r/o syphilis ESR - elevated in GCA head CT - r/o tumor & bleed, esp in young pt w/ ha other studies as indicated by H&P What is the management for a migraine headache? 1. Avoidance of trigger factors (very impt) 2. relaxation/stress mgt 3. PPX daily if attacks occure >2-3x/month -amitryptyline(Elavil) -divalproex(Depakote) -propanolol(Inderal) -Imipramine(Tofranil) -clonodine(Catapres) -verapamil(Calan) -topiramate(Topamax) -gabapentin(Neurontin) -methysergide(Sansert) -magnesium **not an inclusive list* What is the management for an acute attack of migraine headache? 1. rest in dark, quiet room 2. simple analgesic (ASA) taken right away may provide some relief 3. Sumatriptan(Imitrex) 6mg SQ at onset, may repeat in 1hr (total of 3x/day) 4. Sumatriptan 25mg PO at onset of headache Cluster headaches affect mostly __________? middle-aged men, very painful syndromes What are the causes/incidence of cluster headaches? - middle-aged men - often no FMHx of headache or migraine - may be precipitated by alcohol ingestion - characterized by severe, unilateral, periorbital pain occurring daily for several weeks - usu occurs at night, awakening the pt from sleep - usu lasts <2 hours - usu pain free for weeks or months b/w attacks - ipsilateral nasal congestion, rhinorrhea, & eye redness may occur What are the physical exam findings in cluster headache? - usually normal exam, may see eye redness, rhinorrhea, ipsilateral nasal congestion What is the management for cluster headache? - 100% of O2 - sumatriptan (Imitrex) 6mg SQ - ergotamine tartrate aerosol inh (Ergostat) - tx of indiv attacks w/ oral drugs are usu unsatisfactory What does albumin level of <3.5 indicate? Protein malnutrition Albumin normal - 3.5 to 5 How low does the albumin level when you can expect to see edema? albumin level of <2.7g/dL A hgb of <12g/dL for women & <13.5g/dL for men can indicate lack of iron or protein resulting in _____________? inadequate oxygen perfusion What is the H/H ratio & threshold to transfuse? H/H 1:3 ratio Hgb of 8, HCT of 24 - transfuse, don't discharge without giving 2 units of PRBC What is the earliest indication of malnutrition? Pre-albumin Why do women have lower H/H than men? Testosterone promotes erythropoiesis which is why women have lower Hgb If a patient has an ashened skin color, what could this indicate? Folic acid deficiency Describe the nutritional support decision tree? **Can you use the GI tract? NO => need total parenteral nutrition (TPN) => need support for >2 weeks? - Yes => use central vein (esp dextrose >10%) - No => use peripheral vein (<10% dextrose) YES => need supplements for >6 weeks? - Yes => use enterostomal tube (Peg, J-tube) - No => use nasoenteric tube => is the patient at risk for aspiration? -Yes => use duodenal tube (DHT) or nasoduodenal tube (NDT) -No => use nasogastric tube What the are complications of ENTERAL nutritional support? Enteral = Solution Aspiration Diarrhea (dumping or refeeding syndrome) Dehydration Emesis GIB Hypernatremia Mechanical obstruction of the tube What the are complications of PARENTERAL nutritional support? Parenteral = Mode of Delivery PTX Hemothorax Arterial laceration Air emboli Catheter thrombosis Catheter sepsis Hyperglycemia HHNK Hyponatremia is the most common electrolyte abnormality. What are the steps in evaluation of hyponatremia? 1. I&O (Hypervolemic, hypovolemic, euvolemic) = if I&O is equal, euvolemic 2. Urine sodium (normal Urine Na+ = 10-20 mEq/L) 3. Serum osmolality (usu 2x Na) w/c 275-285 (normal: 280 mOsm) 4. Clinical status Urine sodium >20 mEq/L suggests what? Urine Na >20 suggests renal salt wasting (i.e., problem with the kidneys) Urine sodium <10 mEq/L suggests what? Urine Na <10 suggests renal retention of sodium to compensate for extrarenal fluid losses (i.e., a problem other than the kidneys) Describe isotonic hyponatremia. Serum osmolality 284-295 mosm/kg (high) - occurs w/ extreme hyperlipidemia or hyperproteinemia - body water is normal & the pts are asx Tx: cut down fat (i.e., no fluid restriction) What is the serum osmolality in a patient with hypotonic hyponatremia? serum osmolality <280 mosm/kg (low) - state of body water excess diluting all body fluids - clinical signs arise from water excess If the patient is hyponatremic with low serum osmolality (<280 mosm/kg), what do you assess next? Is the patient hypovolemic or hypervolemic? If the patient is hypovolemic-hyponatremic, how do you assess if hyponatremia is due to extrarenal salt losses versus renal salt wasting? Differentiate using volume status & urine Na - hypovolemic w/ urine Na <10 - hypovolemic w/ urine Na >20 - hypervolemic, hypotonic hyponatremia What are the causes of hypovolemic, hyponatremia (urine Na <10)? - dehydration - diarrhea (like C. diff) - vomiting What are the causes of hypovolemic, hyponatremia (urine Na >20)? - diuretics - ACE-inhibitors - mineralocorticoid deficiency (aldosterone) What are the causes of hypervolemic, hypotonic hyponatremia? - edematous states - CHF - liver disease - advanced renal failure Tx: need to restrict water as most pts have edema What are the causes of hypertonic, hyponatremia (serum osmolality >290 mosm/kg) hyperglycemia (usu HHNK) osmolality is high & Na is low What is the management of hyponatremia? 1. Treatment based on cause/condition 2. If hypervolemic, give NS IV 3. If urine Na >20 (renal), tx the cause 4. If hypervolemic, hyponatremia implement water restriction (i.e. HF, edematous states) 5. if pt is symptomatic, give NS IV w/ a loop diuretic (to give Na+ but get rid of H2O) 6. If CNS symptoms are present, consider 3% NS IV (calculated, NEVER wide open) w/ loop diuretics (furosemide) Hypernatremia is usu. due to _________? excess water loss, which always indicate hyperosmolality (i.e., water deficit). excess Na intake is rare What is the management for hypernatremia? 1. Severe hypernatremia + hypovolemia = tx w/ NS IVF followed by 1/2 NS. If no BP, give isotonic then hypotonic 2. Hypernatremia w/ euvolemia = tx w/ free water (D5W) 3. Hypernatremia w/ hypervolemia = tx w/ free water & loop diuretics - may need dialysis What are the causes of hypokalemia?