NUR 643E/Advanced Health Assessment for Nurse Educators
A 32-year-old attorney comes to your office for her second prenatal visit. She has had two previous pregnancies with uneventful prenatal care and vaginal deliveries. Her only problem was that with each pregnancy she gained 50 lbs (23 kg) and had difficulty losing the weight afterward. She has no complaints today. Looking at her chart, you see she is currently 10 weeks pregnant and that her prenatal weight was 130 lbs (59 kg). Her weight today is 134 lbs (60.9 kg). Her height is 5'4", giving her a BMI of 22. Her blood pressure, pulse, and urine tests are unremarkable. The fetal heart tone is difficult to find but is located and is 150. While you give her first trimester education, you tell her how much weight you expect her to gain.
How much weight should this patient gain during pregnancy?
A) Less than 15 pounds (less than 7 kg)
B) 15 to 25 pounds (7 to 11.5 kg)
C) 25 to 35 pounds (11.5 to 16 kg)
D) 30 to 40 pounds (12.5 to 18 kg)
A 21-year-old receptionist comes to your clinic, complaining of frequent diarrhea. She states that the stools are very loose and there is some cramping beforehand. She states this has occurred on and off since she was in high school. She denies any nausea, vomiting, or blood in her stool. Occasionally she has periods of constipation, but that is rare. She thinks the diarrhea is much worse when she is nervous. Her past medical history is not significant. She is single and a junior in college majoring in accounting. She smokes when she drinks alcohol but denies using any illegal drugs. Both of her parents are healthy. Her entire physical examination is unremarkable.
What is most likely the etiology of her diarrhea?
A) Secretory infections
B) Inflammatory infections
C) Irritable bowel syndrome
D) Malabsorption syndrome
Mr. Maxwell has noticed that he is gaining weight and has increasing girth. Which of the following would argue for the presence of ascites?
A) Bilateral flank tympany
B) Dullness which remains despite change in position
C) Dullness centrally when the patient is supine
D) Tympany which changes location with patient position
• A 73-year-old retired accountant presents to your office for her annual examination. She has incontinence of urine when she coughs or sneezes. She takes several medications for control of hypertension and diabetes. You use the DIAPPERS mnemonic to assess the cause of her incontinence. All of the following are items represented by the mnemonic except for:
• Atrophic vaginitis
• Depression
• Pharmaceuticals
• Restricted mobility
A 53?year?old caterer comes to the clinic for a routine examination. She has type 2 diabetes
mellitus, which is well controlled on medication. Her history from her last visit reveals that she
smoked one pack of cigarettes a day at that time. The 5 As Model is a useful approach to take with
trying to help patients to quit smoking. What is the 5 As Model?
a) Affable, associated manifestations, ask, admonish, available
b) Arrange, aggravating factors, action, attitude, able
c) Agitate, assist, alleviating factors, able, action
d) Ask, advise, assess, assist, arrange
e) Admonish, action, available, assess, alleviating factors
A 75?year?old female in generally good health presents to a new primary care provider after she
recently moved to a new city. She takes no prescribed medications, but she has been told in the
past that her blood pressure was borderline elevated and might require treatment at some time
in the future. Which of the following findings during the physical examine is consistent with the
normal aging process and not a sign of cardiovascular disease?
a) An unchanged pulse pressure with equal increases in both systolic and diastolic
pressures
b) A widened pulse pressure with increased systolic pressure (up to 140) and decreased
diastolic pressure
c) A narrowed pulse pressure with increased systolic and diastolic components
d) An isolated increase in systolic blood pressure to >150 mm Hg
e) A drop in systolic pressure of 25 mm Hg when rising from a supine to standing
position
A physician assistant (PA) has had a long day and has seen many patients. The last patient of the day is an 80-year-old woman brought to the office by her 35-year-old granddaughter. This is the patient's first visit to the office. As part of the patient's past history, the PA obtains information about childhood illnesses and adult illnesses and then moves on to inquire about the family history. Which important area of the past history has she omitted?
A 29-year-old electrician complains of persistent cough and wheezing, particularly when he exercises. He says he smokes "occasionally" but rarely so much that he needs to purchase cigarettes: "mostly, I bum them," he says, chuckling. Upon hearing this information, what is the best next step on the part of the clinician?
A 55?year?old woman with a headache explains to the clinician that she has had headaches before,
but this one is unusual because of some new symptoms. Which of the following symptoms would
prompt an immediate investigation?
a) The patient lost her glasses.
b) The headache comes and goes.
c) The headache is similar in nature to prior ones she has had for decades but more
severe.
d) The patient also has developed fever and night sweats and thinks she lost some
weight.
e) The patient had a car accident and minor head trauma about 3 months ago.
• An 81 year old patient complains of shortness of breath for the past few days. On examination, you note late inspiratory crackles in the lower third of the chest and bilateral pedal edema that were not present a week ago. What is the most likely explanation for these?
• Asthma
• COPD
• Bronchiectasis
• Heart failure
A newborn baby has an embryologic defect affecting the aortic valve. What other cardiac valve is
most likely to be affected?
a) Pyloric valve
b) Mitral valve
c) Pulmonic valve
d) Eustachian valve
e) Tricuspid valve
70?year?old man complains of double vision. Which of the following associated symptoms or signs
would be worrying about an underlying neurological problem (as opposed to pathology in the eye)?
a) Abnormality in extraocular movements on examination
b) Symptoms of flashing lights
c) An associated conjunctivitis
d) Diplopia persisting in the right eye when the left eye is closed
e) Worsening vision bilaterally on examination
A young patient presents with a left-sided mass in her abdomen. You confirm that it is present in the left upper quadrant. Which of the following would support that this represents an enlarged kidney rather than her spleen?
A) A palpable "notch" along its edge
B) The inability to push your fingers between the mass and the costal margin
C) The presence of normal tympany over this area
D) The ability to push your fingers medial and deep to the mass
Abnormal dilation of the vein within the spermatic cord
Hydrocele- Varicocele
True
False
Monique is a 33-year-old administrative assistant who has had intermittent lower abdominal pain approximately one week a month for the past year. It is not related to her menses. She notes relief with defecation, and a change in form and frequency of her bowel movements with these episodes. Which of the following is most likely?
A) Colon cancer
B) Cholecystitis
C) Inflammatory bowel disease
D) Irritable bowel syndrome
A 62?year?old manual laborer presents to an annual physical examination with concerns about skin
cancer screening. He does not have any lesions of concern but was recently told by a friend that
he should have his skin checked by a doctor yearly. What is the best advice for this patient
according to the U.S. Preventive Services Task Force (USPSTF) recommendations on skin cancer
screening from 2009?
a) The USPSTF recommends skin cancer screening only in sun?exposed areas of fair?
skinned individuals every 6 months.
b) The USPSTF recommends that all individual age >50 years be screened yearly for skin
cancer regardless of risk factors.
c) The USPSTF recommendations mirror those of the American Cancer Society (ACS) and
American Academy of Dermatologists (AAD) in recommending and annual skin cancer
screening for patients age >50 years.
d) The USPSTF recommends against routine screening for skin cancer due to lack of
evidence for this intervention across the general population.
e) The USPSTF recommends focused screening of individuals with a history of dysplastic
nevus syndrome.
Mrs. Jaeger is a 67-year-old who went through menopause at age 55. She has now had some vaginal bleeding. Which of the following should be considered?
A) Endometrial cancer
B) Hormone replacement therapy
C) Uterine or cervical polyps
D) All of the above
A 77-year-old retired bus driver comes to your clinic for a physical examination at his wife's request. He has recently been losing weight and has felt very fatigued. He has had no chest pain, shortness of breath, nausea, vomiting, or fever. His past medical history includes colon cancer, for which he had surgery, and arthritis. He has been married for over 40 years. He denies any tobacco or drug use and has not drunk alcohol in over 40 years. His parents both died of cancer in their 60s. On examination his vital signs are normal. His head, cardiac, and pulmonary examinations are unremarkable. On abdominal examination you hear normal bowel sounds, but when you palpate his liver it is abnormal. His rectal examination is positive for occult blood.
What further abnormality of the liver was likely found on examination?
A) Smooth, large, nontender liver
B) Irregular, large liver
C) Smooth, large, tender live
A 55?year?old actress sustains a heart attack and the follow?up electrocardiogram demonstrates a
left bundle branch block. What would be the likely duration of the QRS complex?
a) 95 milliseconds
b) 100 milliseconds
c) 75 milliseconds
d) 90 milliseconds
e) 125 milliseconds
Bill, a 55-year-old man, presents with pain in his epigastrium which lasts for 30 minutes or more at a time and has started recently. Which of the following should be considered?
A) Peptic ulcer
B) Pancreatitis
C) Myocardial ischemia
D) All of the above
A clinician is percussing the lungs of a patient with chronic obstructive pulmonary disease to see if
they sound hyperresonant. Which of the following is an example of good technique for percussion?
a) Put the third and fourth fingers next to each other on the chest.
b) Strike using the finger pad of the fourth finger.
c) Strike using the tip of the third finger.
d) The proximal interphalangeal joint is the joint that is struck.
e) The wrist is kept still during percussion.
A 66?year?old recently retired restaurant worker presents to his primary care provider with a
concern about hearing loss. He relates a history of difficulty distinguishing voices in crowded
settings when significant background noise exists, which hastened his retirement. Which of the
following is true about this patient's experience with hearing and the aging process?
a) Any hearing impairment that causes functional decline warrants formal testing and
evaluation.
b) Early age?related hearing loss initially affects lower?pitched sounds.
c) Decreased hearing acuity associated with aging is formally known as hypoacusis.
d) Age?related declines in hearing does not begin until age ≥75 years.
e) His experience is consistent with the normal aging process.
Which of the following statements is true concerning the mini-mental status exam (MMSE)?
An elderly patient with a history of smoking two packs of cigarettes a day for 50 years complains
to her physician of progressive shortness of breath. On cardiac examination, the physician feels
the most prominent palpable impulse to be in the xiphoid area. This is most likely a result of what
condition?
a) Mitral regurgitation
b) Aortic stenosis
c) Hypertrophic cardiomyopathy
d) Hypertension
e) Pulmonary hypertension
A 73?year?old retired salesman presents to the Emergency Department complaining of chest pain
that started about 2 hours ago. Electrocardiogram, cardiac enzymes, and chest x?ray are normal.
The nurse notes that his blood pressures in the right arm are significantly lower than of blood
pressures in his left arm. Based on history and physical examination, which of the following will
most likely explain his signs and symptoms?
a) Pulmonary embolism (PE)
b) Myocardial infarction (MI)
c) Coarctation of the aorta
d) Pericarditis
e) Dissecting aortic aneurysm
Mr. Jackson, 50 years old, has had discomfort between his scrotum and anus. He also has had some fevers and dysuria. Rectal examination is halted by tenderness anteriorly, but no frank mass is palpable. What is the most likely diagnosis?
Mr. Kruger is an 84-year-old who presents with a smooth lower abdominal mass in the midline which is minimally tender. There is dullness to percussion up to 6 centimeters above the symphysis pubis. What does this most likely represent?
A) Sigmoid mass
B) Tumor in the abdominal wall
C) Hernia
D) Enlarged bladder
A 55?year?old truck driver with obstructive sleep apnea has diastolic heart failure. An
echocardiogram demonstrates significant biatrial enlargement. What portion of his
electrocardiogram would likely be abnormal?
a) S wave
b) R wave
c) P wave
d) T wave
e) QRS complex
A 34-year-old male with a history of complex social and medical needs (including current substance abuse) presents to a primary care teaching clinic. The patient has experienced a number of adversarial relationships with prior clinicians, including voluntarily leaving two practices within the previous year and being asked to leave care at a third clinic due to misbehavior. The attending physician desires to utilize the approaches to this patient that are most likely lead to comprehensive care and patient compliance. Which of the following is the most appropriate interview style for the attending physician to use?
A newborn who is floppy and limp, blue in color, with a heart rate of 60, and minimal respiratory
effort has just been delivered. The infant has no grimace and only a very weak cry. What is the
best immediate response to the infant in this situation?
a) Order a chest x?ray.
b) Suction the infant's mouth while waiting to calculate the 5?minute APGAR score.
c) Dry the infant off and swaddle him.
d) Discuss the infant's poor appearance with the parents who are both in the room.
e) Begin neonatal resuscitation.
A patient presents with vomiting a coffee-ground looking substance; fatigue, postural hypotension; new onset systolic murmur; and cool, pale peripheries.
1. BP 86/42, P 124, R 28 and labored, T 97.5
2. Na 130, Cl 87, K 4.3, Glucose 58, Bun 46, Creat 3.6, Hgb 6.2
3. UA ketone positive
4. pH 7.10, PCO2 20, HCO3 14
Using the information above, evaluate the lab findings (indicate low, normal, or high).
A theoretical laboratory test for infection with HIV is known to have high sensitivity. This means
that the test has which of the following?
a) Good ability to diagnose AIDS
b) High intraobserver reliability
c) Good ability to rule in HIV in those who do have HIV
d) High interobserver reliability
e) Good ability to rule out HIV in those who do not have HIV
A 34-year-old G3P2 at 27 weeks' gestation is referred to the clinic upon discharge from a correctional institution where she was incarcerated for a drug offense. Her behavior is concerning for intoxication, and she smells of alcohol and cigarettes. What is true?
The BRCA1 and BRCA2 mutations increase the risk of which cancer in women?
A 17-year-old presents to the clinic because she desires to use a tanning facility ahead of an upcoming event. Which of the following is true regarding UV exposure and subsequent risk of skin cancer?
A. Tanning beds do not increase risk of skin cancer
B. Water resistant sunscreen has no advantage over water-soluble products
C. Target messaging and practitioner reinforcement in primary care amplify sun-protective behaviors
D. Chronic sun exposure confers greater risk than intermittent intense exposure
E. Sunscreen SPF 15 blocks about 50% of UV-B light.
• A middle-aged man presents because he has noticed multiple small, blood-red, raised lesions over his anterior chest and abdomen for the past several months. They are not painful and he has not noted any bleeding or bruising. He is concerned this may be consistent with a dangerous condition. What should you do?
•
Reassure him, keep monitoring and return with any changes.
•
Do laboratory work to check for platelet problems.
•
Obtain an extensive history regarding blood problems and bleeding disorders.
•
Do a skin biopsy in the office.
A 63?year?old underweight administrative clerk with a 50?pack?year smoking history presents with
a several month history of recurrent epigastric abdominal discomfort. She feels fairly well
otherwise and denies any nausea, vomiting, diarrhea, or constipation. She reports that a first
cousin died from a ruptured aneurysm at age 68 years. Her vital signs are pulse, 86; blood
pressure, 148/92; respiratory rate, 16; oxygen saturation, 95%; and temperature, 36.2ºC. Her
body mass index is 17.6. On exam, her abdominal aorta is prominent, which is concerning for an
abdominal aortic aneurysm (AAA). Which of the following is her most significant risk factor for an
AAA?
a) Family history of ruptured aneurysm
b) Underweight
c) Female gender
d) Hypertension
e) History of smoking
A 45?year?old forklift driver presents to the clinic at 4 o'clock in the afternoon complaining of
intense substernal chest pain and nausea. He appears pale and sweaty. At work that day, he filled
in for an absent co?worker and was asked to perform heavy lifting not normally a part of his job.
The physician assistant (PA) questions the patient in detail about his nausea, eating habits, and
digestive history. Which of the following steps of clinical reasoning has the PA failed to follow?
a) Elicit information about the patient's family history of digestive disorders
b) Match findings against conditions that could cause them
c) Localize findings anatomically
d) Give special consideration to potential life?threatening problems
e) Elicit information about the patient's gastrointestinal (GI) system
Research has shown a link between cancer and which sexually transmitted disease?
"Instability in interpersonal relations, self-image, and affective regulation; impulsivity" describes which personality disorder?
A 22-year-old G1P0 presents for a routine visit at 32 weeks. Leopold maneuvers indicate the fetus is in a transverse lie with skull palpable at the woman's left side. Heart tones are heard at the fundus with a baseline of 140 with beat-to-beat variability noted. What is an appropriate step to take?
Sudent presents with a primary concern of acne. He relates a
history of 2 years of moderate mild acne and closed comedones (whiteheads), which have recently
worsened such that a classmate started calling him a pirate due to a large pustule that developed
at the tip of his nose. He has increasing outbreaks of cyst?like acne as well as a generally poor
complexion with pitting and scarring from prior outbreaks. Which of the following best describes
this condition in the adolescent population?
a) Acne vulgaris is associated with blockage of sebaceous glands, stress, humidity, and
heavy sweating as well as other contributory factors.
b) Acne vulgaris affects <50% of the adolescent population.
c) The primary hormonal stimulus for acne vulgaris is estrogen, causing preferentially
worse cases in females and males with lower testosterone levels.
d) Acne vulgaris is associated with an identified virus for which there is no definitive
treatment.
e) Acne vulgaris is always associated with underlying endocrine disorders and/or
pituitary dysfunction.
A 74?year?old man is being seen because of a 1?day history of a painful right eye. He also mentions
that he has blurred vision in that eye. He thought something had blown into his eye, but after
flushing it out, the pain and blurred vision remains. What is the best course of action?
a) Check his blood pressure.
b) Perform a complete neurological examination.
c) Perform a vision examination.
d) Reassure him that pain from a foreign body can remain for a day or two (even after
the foreign body is removed).
e) Refer to an ophthalmologist emergently with the possibility of corneal ulcer, uveitis,
or acute glaucoma.
Eelevated, irregular-shaped area of cutaneous edema; solid, transient, variable diameter Ex: insect bites, urticaria, allergic reaction
True
False
A 65?year?old farmer who rarely seeks medical care but does have a remote history of coronary
bypass surgery presents to the office with a 2?day history of increasing shortness of breath and
abdominal discomfort. On exam, a protuberant abdomen and lower extremity edema is noted.
The clinician is concerned about possible right?sided heart failure and associated ascites and
decides to proceed with further physical exam techniques to assess for possible ascites. Which of
the following findings will be supportive of ascites?
a) Tapping on one flank sharply transmits an impulse to the opposite flank
b) Dullness to percussion throughout the abdomen
c) Tympany predominant throughout the abdomen
d) Border between tympany and dullness to percussion that does not shift with position
e) Dullness to percussion of the upper quadrants and tympany in the lower quadrants
a) Tapping on one flank sharply transmits an impulse to the opposite
flank
A 28-year-old male business executive presents to a primary care provider with concerns about hair loss. He is otherwise healthy without chronic medical conditions or current medications. He has a chart history of allergy to sulfa medications, although this happened when he was a young child, and he does not recall the incident or the reaction. He is unsure at what age his father went bald, as he never remembers his father having hair. He remarks jokingly that he is losing more hair than his dogs at home, who shed frequently but are otherwise healthy. On examination, he has a single uniform oval patch of hair loss over the left temporal area without any scaling, inflammation, or other skin changes where the hair is missing. What is the disease?
A 68-year-old complains of a 3-month history of recurring pain after ambulating that radiates from her back in the upper lumbar region into both buttocks, bilateral thighs and mid-calf regions. Her pain is improved by sitting or leaning forward. The origin of her pain is secondary to what condition?
An elderly woman with dementia is brought in by her daughter for a “rectal mass.” On examination you notice a moist pink mass protruding from the anus, which is nontender. It is soft and does not have any associated bleeding. Which of the following is most likely?
A)Rectal prolapse
B)External hemorrhoid
C)Perianal fistula
D)Prolapsed internal hemorrhoia
• A 73-year-old retired accountant presents to your office for her annual examination. She has incontinence of urine when she coughs or sneezes. She takes several medications for control of hypertension and diabetes. You use the DIAPERS mnemonic to assess the cause of her incontinence. All of the following are items represented by the mnemonic except for:
•
Atrophic vaginitis
•
Depression
•
Pharmaceuticals
•
Restricted mobility
A 17-year-old male complains of itching, burning, and stinging of his feet. Physical examination reveals erythematous annular patches with distinct borders, central clearing, and fine scales. Fine macerations are visible between the digits. What is the most likely causative organism?
