NRNP 6560 FINAL EXAM
1. The AGACNP is reviewing a chart of a head-injured patient. Which of the following would alert the AGACNP for the possibility that the patient is over hydrated, thereby increasing the risk for increased intracranial pressure?
A. BUN = 10
B. Shift output = 800 ml, shift input = 825 ml Unchanged weight
C. Serum osmolality = 260
2. A patient who has been in the intensive care unit for 17 days develops hyponatremic hyperosmolality. The patient weighs 132 lb (59.9 kg), is intubated, and is receiving mechanical ventilation. The serum osmolality is 320 mOsm/L kg H2O. Clinical signs include tachycardia and hypotension. The adult-gerontology acute care nurse practitioner's initial treatment is to:
A. reduceserumosmolalitybyinfusinga5%dextrosein0.2%sodiumchloridesolution
B. reduce serum sodium concentration by infusing a 0.45% sodium chloride solution
C. replenish volume by infusing a 0.9% sodium chloridesolution
D. replenish volume by infusing a 5% dextrose in watersolution.
3. A 16-year-old male presents with fever and right lower quadrant discomfort. He complains of nausea and has had one episode of vomiting, but he denies any diarrhea. His vital signs are as follows: temperature 101.9°F, pulse 100 bpm, respirations 16 breaths per minute, and blood pressure 110/70 mm Hg. A complete blood count reveals a WBC count of 19,100 cells/µL. The AGACNP expects that physical examination will reveal:
A. + Murphy’s sign
B. + Chvostek’s sign
C. + McBurney’s sign
D. + Kernig’s sign
4. QMyasthenia gravis is best described as:
A. An imbalance of dopamine and acetylcholine in the basal ganglia Demyelination of peripheral ascending nerves
B. Demyelination in the central nervous system
C. An autoimmune disorder characterized by decreased neuromuscular activation
5. Mrs. Coates is a 65-year-old female who is on postoperative day 1 following a duodenal resection for a bleeding ulcer. She had an uneventful immediate postoperative course, but throughout the course of day 1 she has complained of a mild abdominal discomfort that has progressed throughout the day. This evening the AGACNP is called to the bedside to evaluate the patient for persistent and progressive discomfort. Likely causes of her symptoms include all of the following except:
A. Colic due to return of peristalsis
B. Leakage from the duodenal stump
C. Gastric retention
D. Hemorrhage
6. Mrs. Coates is a 65-year-old female who is on postoperative day 1 following a duodenal resection for a bleeding ulcer. She had an uneventful immediate postoperative course, but throughout the course of day 1 she has complained of a mild abdominal discomfort that has progressed throughout the day. This evening the AGACNP is called to the bedside to
evaluate the patient for persistent and progressive discomfort. Likely causes of her symptoms include all of the following except:
A. Colic due to return of peristalsis
B. Leakage from the duodenal stump
C. Gastric retention
D. Hemorrhage
7. When a patient is hospitalized with a possible stroke, the AGACNP recognizes that the stroke most likely resulted from a subarachnoid hemorrhage when the patient’s family reports that the patient:
A. Has a history of atrial fibrillation
B. Was unable to be aroused in the morning
C. Had been complaining of a headache before losing consciousness
D. Has had several brief episodes of mental confusion and right arm and leg weakness
8. You are asked to see a 29 year old female complaining of abdominal pain. She states she is experiencing constant RUQ pain that radiates to her back. The pain is not relieved by bowel movements, over the counter antacids or food. Review of initial labs shows elevated amylase and lipase and you diagnose her with acute pancreatitis. Which test will you order next to determine the underlying cause of her pancreatitis?
serum cholesterol level blood toxicology
right upper quadrant ultrasound endoscopy
9. Jake is a 32-year-old patient who is recovering from major abdominal surgery and organ resection following a catastrophic motor vehicle accident. Due to the nature of his injuries, a large portion of his jejunum had to be resected. In planning for his recovery and nutritional needs, the AGACNP considers that:
He will probably be able to transition to oral nutrition but will have lifetime issues with diarrhea His procedure has put him at significant risk for B12 absorption problems
Most jejunum absorption functions will be assumed by the ileum
Enteral nutrition will need to be delayed for 3 to 6 months to facilitate adaptation
10. A 32-year-old man comes to the clinic because he has had pain in the back for the past 24 hours. The patient says he first noticed the pain when he awoke in the morning and had difficulty getting out of bed. He had been playing flag football the day before the pain began but did not sustain any injuries during the game. Acetaminophen has provided only minimal relief of the patient's pain. On physical examination, pain is elicited on palpation of the back on the left, lateral to the region of L2-L5. Full range of motion is noted in vertebral flexion, extension, lateral rotation, and lateral bending, with some hesitancy because of pain on the left side. Which of the following is the most appropriate initial step?
Anti-inflammatory and muscle relaxant therapy Epidural injection of a corticosteroid
MRI of the lumbar spine
Strict bed rest and application of moist heat to the lower back
11. On postoperative day 7 following hepatic transplant, the patient evidences signs and symptoms of acute rejection, confirmed by histologic examination. The AGACNP knows that first-line treatment of acute rejection consists of: Cyclosporine
Azathioprine Methylprednisolone Sirolimus
12. H. W. is a 33-year-old female who is being evaluated after a fall from a tree. Anteroposterior and lateral radiographs of the thoracolumbosacral spine are significant for transverse process fractures at T6 and T7. The AGACNP knows that treatment for this likely will include:
Observation
Hyperextension casting Jewett brace
Surgical intervention
13. Acute hepatitis A is usually diagnosed by:
By the constitutional symptoms Within 2 weeks of exposure Detection of IgM-Anti-HAV Jaundice
14. A 30-year-old male patient presents for evaluation of a lump on his neck. He denies pain, itch, erythema, edema, or any other symptoms. He is ^concerned because it won't ^ go away. He says, “I noticed it a few months ago, then it seemed to disappear, and now it is back.” The AGACNP proceeds with a history and physical exam and concludes which of the following as the leading differential diagnosis?
Subclinical infection Non-Hodgkin's lyphoma Catscratch disease Syphilis
15. P. E. is a 61-year-old female who presents for a postoperative visit following a gastric resection after a perforation of peptic ulcer. She reports feeling better, although it is taking longer than she expected. However, she says she is feeling better each day, her appetite is returning, and her incision is healing well. She is being discharged from surgical care and advised to continue her routine health promotion follow-up with her primary care provider. As part of her surgical discharge teaching, the AGACNP counsels P. E. that as a result of her gastric resection she will need lifelong follow-up of: Blood group substances
Electrolytes
Vitamin B12
Gastric pH
16. T. O. is a 31-year-old male patient who is transported to the emergency department via emergency services. He was in a multivehicle accident and was trapped in a crushed car for more than 3 hours. On examination, his right lower extremity is found to be tensely swollen, with 3+ nonpitting edema. The lower leg is profoundly painful with passive range of motion. Given the history and physical findings, the AGACNP recognizes that treatment centers around:
Fasciotomy
Thrombolytics
Surgical
reduction Casting
17. While consulting on a patient who is admitted with a chief complaint of abdominal pain, the AGACNP notes that the initial assessment described the pain as “colicky.” This means that the pain:
Is a result of gas in the bowel Is intestinal in origin
Is characterized by pain-free intervals Is sharp, intense, and nonradiating
18. All of the following are expected findings in a patient with a T10 fracture except:
Paraplegia
Fecal
retention
Priapism
Inability to move fingers
19. T. O. is a 44-year-old female patient who presents for evaluation of sudden, severe upper abdominal pain. She is clear about the onset, which was profound and occurred approximately one hour ago. She denies that the onset had anyrelationship to food or eating, and she denies nausea or vomiting. On examination, she is lying on her right side with her hips and knees flexed to draw her knees to her chest. Vital signs are stable, but examination reveals involuntary guarding. The abdomen is painful and tympanic to percussion in all quadrants. CBC reveals a white blood cell count of 15,600/µL. The AGACNP suspects:
Dissecting aortic
aneurysm Acute
pancreatitis Perforated
peptic ulcer Mallory-Weiss tear
20. The AGACNP is covering an internal medicine service and is paged by staff to see a patient who has just pulled out his ET tube. After the situation has been assessed, it is clear that the patient will go into respiratory failure and likely die if he is not reintubated. The patient is awake and alert and is adamant that he does not want to be reintubated. The AGACNP is concerned that there is not enough time to establish a DNR—the patient needs to be reintubated immediately and already is becoming obtunded. Which ethical principles are in conflict here?
Veracity and beneficence Beneficence and nonmalfeasance Autonomy and beneficence Justice and autonomy
21. In myelodysplastic syndromes, the primary indications for splenectomy include:
Major hemolysis unresponsive to medical management Severe symptoms of massive splenomegaly
Sustained leukocyte elevation above 30,000 cells/µL Portal hypertension
22. Which of the following situations constitute a positive screening after a PPD (purified protein derivative) skin test for tuberculosis?
A patient without risk factors who has a 13mm PPD skin test A patient with HIV who has a 3mm PPD skin test
A homeless patient with a 9mm PPD skin test
A patient with intravenous drug abuse (IVDA) who has an 11mm PPD skin test A healthcare worker who has a 6mm PPD skin test
23. When the patient with jaundice is evaluated, a careful history and physical exam often can help differentiate prehepatic, hepatic, and posthepatic causes. When the patient reports dark discoloration of the urine and light discoloration of the stool, the AGACNP is most suspicious for:
Viral hepatitis Chronic alcoholism
Extrahepatic obstruction Cholestasis
24. Jack R. is a 63-year-old male who is being seen today on rounds after being admitted for profound upper abdominal pain, nausea, and vomiting. He had markedly elevated serum amylase and lipase; he was diagnosed with pancreatitis and admitted for pain management and bowel rest. Today he feels better, but he is upset because he knows that pancreatitisisknownasthe“alcoholic’sdisease.”Hemakesitclearthatheisareligiousmanandthathisreligionforbids alcohol; he says he has never had an alcoholic drink in his life. The AGACNP reassures Jack that approximately 40% of cases of pancreatitis arecausedby as well as a variety of other things, and that he will have a thorough diagnostic evaluation.
hyperlipidemia gallstone disease genetic predisposition hypercalcemia
25. In neurogenic shock, patients are subjected to an abnormal dilation of venules and arterioles in response to failure of the autonomic nervous system. Treatment for neurogenic shock may include all of the following except: Trendelenburg
Intravenous fluids Vasodilators Vasoconstrics
26. Which of the following is a true statement with respect to the use of corticosteroids in posttransplant patients? High-dose initial steroids are tapered to off over a period of 4 to 6 weeks posttransplant
There is a strong interest in developing corticosteroid-free posttransplant protocols
Better results are demonstrated in corticosteroid-free protocols for second-transplant recipients Evidence supports corticosteroid-free rejection protocols
27. The comprehensive serologic assessment of a patient with Cushing’s syndrome is likely to produce which constellation of findings?
Low potassium, high glucose, high white blood cell count High sodium, polycythemia, low BUN
Low sodium, low potassium, high BUN High sodium, high chloride, high RBCs
28. A patient admitted for management of sepsis is critically ill and wants to talk with a hospital representative about donatingherorgansifshedies.Shehasafairlycomplexmedicalhistorythatincludestraumaticbraininjury,breast cancer, and dialysis-dependent renal failure. The patient is advised that she is ineligible to donate due to her: Renalfailure
Traumatic brain injury Systemic infection Breast cancer
29. Elmerisa61-year-oldmalewhoisadmittedvomitingbrightredblood.Hehasnoknownmedicalhistory—hehasnot been in the health care system for most of his adult life. He has lost a lot of volume, and his vital signs are borderline unstable with a blood pressure of 88/58 mm Hg, pulse of 118 bpm, respiratory rate of 12 bpm, and a temperature of 97.6°F. The AGACNP recognizes that the leading differentials include all of the followingexcept:
Peptic ulcer
Portal hypertension Gastritis
Zollinger-Ellison syndrome
30. T. S. is a 31-year-old female who is admitted following a catastrophic industrial accident. She had multiple injuries, and after a 10-day hospital stay that included several operations and attempts to save her, she is declared brain dead. She had an organ donor notation on her driver’s license. Which of the following circumstances precludes her from serving as a liver donor?
Encephalopathy Hepatitis C infection
A long history of alcohol use Biliary cirrhosis
31. M. N. is a 61-year-old male who is referred to the emergency department by a local retail clinic. M. N. has not had regular health care at any time in his adult life; he says he doesn’t know when he last saw a doctor. His daughter finally talked him into going to the local retail health clinic when his abdomen became so distended that he couldn’t pull his pants up. M. N. says that he has put on some weight over the last few weeks but he has not felt ill. He admits to drinking> 4 drinks of whiskey daily; he says he smokes 2 packs of cigarettes a day and is not very active. He has lived alone since his divorce 20 years ago. Physical examination reveals an adult male who is chronically ill in appearance and appears older than stated age. His vital signs are within normal limits, and physical examination is significant only for obviousascites. Paracentesis and subsequent analysis of the fluid reveals an ascites LDH to serum LDH ratio of 0.8. The AGACNP knows that this ratio is highly suspicious for:
Pancreatic disease Cirrhosis
Cancer
Autoimmune hepatitis
32. The AGACNP is treating a patient with ascites. After a regimen of 200 mg of spironolactone daily, the patient demonstrates a weight loss of 0.75 kg/day. The best approach to this patient’s management is to:
Continue the current regimen
D/C the spironolactone and begin a loop diuretic Add a loop diuretic to the spironolactone Proceed to large-volume paracentesis
33. The AGACNP knows that following bilateral total adrenalectomy, the patient will require: Prednisone 15 mg qam and 10 mg qpm
Tapering of IV hydrocortisone, beginning with 100 mg IV q8h on postoperative day 1
Initial fludrocortisone replacement, tapered off once maintenance hydrocortisone dose is achieved Individualized replacement of corticosteroid, mineralocorticoid, and androgen hormones
34. Josh is a 14-year-old male patient who presents for evaluation of blurred vision. His only significant injury is that over the weekend he was playing baseball and was hit in the side of the head by a flying ball. The hit was hard enough to knock him down, but he did not lose consciousness and had no remarkable symptoms. Now on Wednesday he presents with a dull headache that seems to be getting worse, and his mom wants to have him evaluated. Neurologic examination reveals a sluggish pupillary response. CT scan of the head reveals a 1 cm epidural hematoma. The AGACNP knows that the best approach to management would be:
Cautious observation An osmotic diuretic Surgical consultation Emergency evacuation
35. MaryW.isa39-year-oldfemalewhopresentswithpersistentabdominaldiscomfort.Shedeniesactualpainbutsaysshe has this persistent sense of fullness in her abdomen that feels like it would go away if she could have a bowel movement. This finding is knownas:
Somatic pain
Gas stoppage sign
Small bowel obstruction Large bowel obstruction
36. Tim is an 20 year old junior at Notre Dame and injured his right knee during an intramural football game and comes to the ER complaining of severe pain. Tim tells you that he was setting up to pass the football when he was tackled and he immediately felt his knee "pop" and buckle as he fell. You, as the AGACNP, know the most important information to obtain from Tim is:
Insurance information Familyhistory
Socialhistory
What exactly was he doing when he got hurt
37. Mrs. Nguyen is an 84-year-old female who suffered a fall in her long-term care facility. After assessing possible reasons for her fall, a physical examination is performed to look for injuries. Mrs. Nguyen has significant pain in her left upper arm and limited range of motion in her left shoulder; a shoulder trauma series is ordered to evaluate for which type of injury that frequently occurs in these circumstances?
Shoulder dislocation Scapular fracture
Proximal humerus fracture Nursemaid’s elbow
38. A general principle in surgical oncology is that the best approach to curative surgery in a fixed tumor requires: En bloc resection
Adjuvant therapies Neoadjuvant therapies Elective lymph nodedissection
39. Intracranial pressure monitoring is instituted for a patient with a head injury. The patient’s arterial blood pressure is 92/50mmHg,andherintracranialpressureis18mmHg.Usingthesevaluestocalculatethepatient’scerebralpressure (CPP) the AGACNPdetermines:
The CPP is adequate for normal cerebral blood flow
The CPP is high and that ischemia and neuronal death are imminent The blood pressure should be increased to prevent cerebral hypoxia
Lowering the patients blood pressure will reduce the intracranial pressure, increasing cerebral blood flow
40. Mr. Jefferson is a 59-year-old male who presents to the emergency department complaining of severe abdominal pain. His medical history is significant for dyslipidemia, and he takes 40 mgof simvastatin daily. He admits to drinking 6 to 10 bottles of beer nightly and to smoking 1½ packs of cigarettes a day. He denies any history of chest pain or cardiovascular disease. He was in his usual state of good health until a couple of hours ago, when he developed this acute onset of severe pain in the upper abdomen. He says that he tried to wait it out at home but it was so bad he finally came in. His vital signs are as follows: temperature 99.1°F, pulse 129 bpm, respirations 22 breaths per minute, and blood pressure 137/84 mm Hg. The abdomen is diffusely tender to palpation with some guarding but no rebound tenderness. The AGACNP anticipates that which of the following laboratory tests will be abnormal?
A complete blood count and RBC differential Liver function enzymes
Serum amylase, lipase, and glucose A basic metabolic panel
