NRNP 6540 MIDTERM EXAM LATEST 2023 PRIME EXAM

NRNP 6540 MIDTERM EXAM LATEST 2023 PRIME EXAM Selecte d Discuss the risks of herpes zoster and SE of vaccination with the patient and decide on whether to immunize. Herpes Zoster Recombinant zoster vaccine (RZV) was approved by the U.S. Food and Drug Administration in 2017 and recommended by the ACIP in 2017 for use in adults aged 50 years and older. RZV has a significantly higher efficacy than Zoster vaccine live ZVL, with rates of 90% to 97% for the prevention of herpes zoster and rates of 89% for prevention of PHN. Zoster vaccine live (ZVL) became available in 2006 and was recommended by the ACIP in 2008 for use in adults aged 60 years and older. It is a one-dose live attenuated strain of varicella zoster virus. ZVL has an overall vaccine efficacy of 49.1%. RZV is recommended by the ACIP to be given to adults aged 50 years or older. It is a two-dose vaccine series with the second dose given 2 to 6 months after the first. The ACIP recommends using RZV in preference to ZVL. Neither the Centers for Disease Control and Prevention (CDC) nor the World Selecte d A previous severe allergic reaction to influenza vaccine, regardless of the component suspected of being responsible for the reaction, is a contraindication to future receipt of the vaccine. 1 1.When would the influenza vaccine be absolutely contraindicated? 2.You see a 69-year-old patient who recently moved to town and does not remember his last tetanus shot. What would you do? Correct Answer: You could do one of two strategies: perform serologic testing for tetanus and diphtheria antitoxin to see if they are immune, or give one dose of Tdap, followed by Td at least 4 weeks later, followed by another dose of Td 6–12 months later. Tetanus/Tdap: In older adults, if the recommended childhood series was not done at all, the recommendation is one dose of Tdap, followed by Td at least 4 weeks later, followed by another dose of Td 6–12 months later. If vaccination documentation is incomplete, the provider can either consider serologic testing for tetanus and diphtheria antitoxin or assume that no vaccinations have been received and administer vaccine as directed above for patients who have not been vaccinated. 3. E. D. is a 78-year-old woman who does not remember if she has ever had the immunization for herpes zoster. She does remember having chicken pox as a child. What would you recommend for her? Health Organization (WHO) have updated their recommendations since RZV was introduced, regarding zoster vaccination for older adults who are not sure of their zoster vaccination status. Selecte d All influenza vaccines have the potential to cause an egg-related allergic reaction. Persons with a history of egg allergy who have experienced only urticaria after exposure to egg should receive influenza vaccine. 5. Many older adults travel worldwide when they retire. For patients who are planning to travel overseas, what would you recommend? Selecte d Before travel, older adults should be up to date on routine vaccines. Older adults should also receive other vaccines recommended for the countries they are visiting. These are listed by country on the CDC's Destinations Pages. 6. Give three reasons why older adults are especially vulnerable to complications of influenza Correct Answer: Older individuals are more likely to experience a severe infection, develop pneumonia, require hospitalization, or die. Mortality rates in patients 75 years and older are four to eight times higher than those seen for patients aged 65 to 74 years, and over 50 times higher than those seen before the age of 65 years. A total of 90% of deaths attributable to influenza occur in individuals aged 60 years and older. Following an acute care hospitalization, many older adults fail to return to their previous level of function. Nearly 40% of relatively healthy community-dwelling older adults who reported the presence of influenza or influenza-like illness required more than 2 weeks to recover, 20% required new assistance with daily functional tasks, and 13.9% were hospitalized. Aging impairs the ability of the immune system to adequately respond to influenza vaccination and infection, both in terms of humoral (antibody) and cell-mediated responses. The magnitude of these aging-related declines is increased in the presence of both frailty and chronic cytomegalovirus infection. infections. 2 4. Name the most common allergic response to the flu vaccine, 7. You have an 89-year-old patient on hospice care in a long-term care facility. The protocol is for flu vaccine to be given to all patients each fall. Would you vaccinate? Why, or why not? Correct Answer: According to Coll and colleagues, one study of the efficacy of the influenza vaccine in end-of-life cancer patients found that influenza vaccine maintains efficacy despite the decreased immune response in these patients and concluded that the vaccine should be offered to patients in the last few months of life. Reference: Coll, P. P., Costello, V. W., Kuchel, G. A., Bartley, J., & McElhaney, J. E. (2019). The prevention of infections in older adults: Vaccination. Journal of the American Geriatrics Society, 68(1), 207–214. Selected Answer: If the patient is 65-year-old with HIV infection and a CD4 count less than 200/mm, then few immunizations are withheld due to severely immunocompromised health conditions. List of immunizations that are withheld: -Influenza vaccine, live, attenuated (LAIV) -Measles, mumps, and rubella vaccine (MMR) -Varicella vaccine (VAR) -Zoster vaccine live (ZVL) 8. Which immunization would you not give your 65-year-old patient with HIV infection and a CD4 count less than 200/mm? What is your rationale for withholding the immunization? 9. Which influenza vaccine is recommended for the older adult? Selecte d The High-dose IIV3 (Fluzone) vaccine is recommended for the older adult. 10. What is the maximum number of doses of PPSV23 that can be given to high-risk older adults 65 or older? Selecte d The ACIP has clarified that a maximum of three doses of PPSV23 are recommended for high-risk persons. Selecte d Lymphedema is most commonly caused by surgery, radiation, or infection that damages the lymphatic system. 3 11. Identify three common causes of lymphedema. Correct Answer: Your treatment plan for this patient with HZO would be oral antivirals (e.g., acyclovir, famciclovir, valacyclovir), topical corticosteroids for itch and pain as needed, and referral to ophthalmologist immediately to prevent blindness. Early treatment with acyclovir 800 mg po five times/day or famciclovir 500 mg or valacyclovir 1 g po tid for 7 days reduces ocular complications. Referral to ophthalmology is critical as HZO can cause blindness if not treated promptly. The pupil should be dilated with atropine 1% or scopolamine 0.25% 1 drop tid. Intraocular pressure must be monitored and treated if it rises significantly above normal values. Patients with uveitis or keratitis require topical corticosteroids (e.g., prednisolone acetate 1% instilled q 1 h for uveitis or qid for keratitis initially, lengthening the interval as symptoms lessen). Selecte d Cellulitis is most often caused by group A strep (pyrogenes) and 12. Your patient has herpes zoster ophthalmicus (HZO) as shown in the photo. What would your treatment plan for this patient be? 13. Your 78-year-old patient comes in yearly for a skin check. She was a selfproclaimed “sun worshipper” in her younger days. She has multiple freckles over her face, arms, and back. She is concerned about a freckle on her back that seems to be getter larger. This is what you see, what is your impression? Selecte d Because of its irregular border, various colors, and its growth, you suspect a melanoma. 14. Define wheal, pustule, and vesicle. Selecte d A wheal is a plague or papule with a red border and pale center, a pustule is a raised lesion with pus filled fluid; vesicles are lesions up to 1 cm diameter filled with clear fluid. 15. Tinea pedis is also known as “athlete’s foot.” What is the most common presentation of athlete’s foot? Selecte d Tinea pedis, or athlete’s foot, often presents as interdigital erythematous pruritic scaly skin, hyperkeratotic skin of soles, and vesiculobullous painful eruptions on medial foot. 16. Cellulitis is most commonly caused by which pathogens? Correct Answer: Complete decongestive physiotherapy (CDP) is the gold standard for lymphedema management. CDP is a specialized massage technique designed to stimulate the lymph vessels, break up subcutaneous fibrous tissue, and redirect the lymph fluid to areas where lymph flow is normal. It involves four steps: manual lymph drainage (MLD), compression bandaging, exercises, and skin care. Selecte d Basal cell carcinoma typically alternately crusts and heals. Most commonly, the carcinoma begins as a shinypapule, enlarges slowly, and, after a few months or years, develops a shiny, pearly border with prominent engorged vessels (telangiectases) on the surface and a central dell or ulcer. 19. A 75-year-old male patient returns to the clinic with complaints of worsening psoriasis. Describe two treatments you might prescribe for this patient. Selecte d Possible treatments include: corticosteroids, vitamin D analogues, calcipotriene topical, retinoids, tazarotene topical, calcineurin inhibitors, pimecrolimus topical, salicylic acid, anthralin. 20. Based on your primary diagnosis of melanoma, what is your treatment plan for this patient’s Correct Answer: Surgical excision and biopsy. Malignant melanoma arises from melanocytes in a pigmented area (e.g., skin, mucous membranes, eyes, or CNS). Metastasis is correlated with depth of dermal invasion. With spread, prognosis is poor. Diagnosis is by biopsy. Wide surgical excision is the rule for operable tumors. Metastatic disease requires systemic therapy but is difficult to cure. lesion? 5 staph aureus. 17. List the four steps of decongestive physiotherapy (CDP) for lymphedema. 18. Your 78-year-old patient comes to the clinical with the chief complaint of a lesion on his arm that has been there for two years. He states it alternately crusts and heals, and it began as a shiny papule, but now looks like this. You suspect basal cell carcinoma. What would be your primary reason for suspecting it is a basal cell carcinoma? 21. You are performing a Medicare home assessment on an 84-year-old male. Part of this exam is checking for carotid bruits. Describe two reasons this exam is important in an older adult: Selecte d The carotid arteries should be assessed routinely for the presence of bruit. Asymptomatic carotid bruit is a risk factor for stroke (Bickley, 2017). Studies demonstrate that a vessel is occluded more than 50% by the time a bruit can be heard. Selecte d Key symptoms for cardiovascular assessment include dizziness, syncope, orthopnea, angina, edema, and claudication. (Bickley, 2013; Kane, Ouslander, Resnick, & Malone, 2018). 22 When performing an assessment on patients over 65 years of age, what are at least . three (3) key symptoms that may indicate cardiovascular disease? 23. Your 72-year-old patient comes in for a checkup. His BMI is 32, BP is 152/79, and BG 139. He is currently not taking his HTN medications. You check his HgA1C and it is 9. He admits he does not get much exercise and smokes half a pack of cigarettes a day. Describe the three most important strategies you will plan for this patient to decrease his risk for a cardiovascular event. 24. A 78-year-old patient, past one ppd smoker times 10 years (quit 10 years ago) presents with increasing shortness of breath, dyspnea on exertion, and no other symptoms. Name two diagnostic tests you could order to differentiate between asthma and COPD. Correct Answer: Two tests you could order would be spirometry or pulmonary function testing. Forced expiratory volume in 1 second (FEV1), FEV6, forced vital capacity (FVC), and FEV1/FVC ratio before and after bronchodilator challenge, showing an improvement of 12% and 200 mL, indicates reversible airway obstruction (Brigham & West, 2015). This is helpful in differentiating asthma from COPD, particularly in an older adult with a prior smoking history. Correct Answer: Additional proven or postulated risk factors for cardiovascular disease in older adults include obesity, lack of exercise, and impaired glucose tolerance. Older adult individuals are most likely to have a combination of risk factors, which has a cumulative effect of increasing the risk of CAD. Control of hypertension is clearly the most potentially remediable risk factor. Evidence is compelling for discontinuation of cigarette smoking at any age. More information is needed regarding the effectiveness and feasibility of lowering cholesterol levels, weight reduction, improved exercise plans, and strict control of blood glucose levels, with respect to the incidence of CHD, particularly in those of most advanced age. 6 25. According to the GOLD Pocket Guide to COPD Diagnosis, Management, and Prevention, A Guide for Health Care Professionals, 2017, what would the predicted FEV be for GOLD 4 very severe COPD? Selecte d GOLD 4: Very Severe would have an FEV1 <30% predicted Correct Answer: Exposure to allergens, respiratory infections, family history/genetic predisposition, atopy, occupational irritants, tobacco smoke (smoking and passive smoke exposure), high levels of indoor and outdoor pollution, and obesity; rhinitis is a specific factor in older adults (Global Strategy for Asthma Management and Prevention, 2016 update; Miller & Sawlani, 2013; Tarasidis & Wilson, 2015). 7 26. Your 69-year-old African American female patient has a PMH of asthma. You know that In the United States, asthma is more prevalent in African Americans. List at least three (3) factors that contribute to development of asthma. 27. Clara is an 89-year-old African American female who comes to see you in the clinic today. She describes a new complaint of “heartburn” after doing housework. You are concerned these new symptoms might be cardiovascular in etiology and would continue your review of symptoms with her by asking which questions (list at least three ROS questions)? Correct Answer: The older patient may have atypical symptoms of a cardiovascular event. Establish the patient’s usual baseline activities of daily living (ADLs) and activity level and ask how symptoms are affecting this. Some older adults experience palpitations as a nervous feeling, so include that in your questioning. Chest pain may be presented as heartburn or indigestion, particularly if the patient also has gastroesophageal reflux disease (GERD). Shortness of breath may be felt as anxiety but is a more common presentation of an acute coronary event than chest pain. Atypical presentation for MI includes vague symptoms such as nausea, decreased ADL status, and fatigue without chest pain (Cash & Gunter, 2016; Keller et al., 2015)