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As the nurse practitioner working in a primary care clinic, you have been notified from a hospitalist that your long-term patient with a history of HFrEF (heart failure with reduced ejection fraction) with an ejection fraction of 40% two years ago who is also not on optimal medical therapy has been diagnosed with a myocardial infarction this admission and received emergent placement of a drug-eluting stent to the left anterior descending artery. As the patient’s medical home who will manage this patient after discharge, which of the following would you expect to be a priority in the patient’s care for their heart failure after an acute MI? You Answered Ordering a new transthoracic echocardiogram and order a Lifevest if EF is less than 45% Dual anti-platelet therapy is required for 12 months minimum post-MI. A Holter monitor does not provide any conceivable benefit for this patient as presented. The patient should have a protective mechanism such as an implantable automated cardioverter defibrillator (AICD) or a Lifevest if the EF is less than 35% due to the increased risk of sudden cardiac death with low EF states. Since most patients are not eligible for 90 days for an AICD in this state, optimizing their medication regimen and repeating an echo in 2-3 months to re-evaluate for improvement in their EF is required by most insurance companies. A baseline echo is needed at discharge to provide a baseline for improvement vs their repeat echo in 2-3 months. Ordering aspirin and clopidogrel for 3 months at discharge Ordering a Holter monitor for 7 days post-discharge Correct Answer Ordering a new transthoracic echocardiogram and order a Lifevest if EF is less than 35% Question 2 1 / 1 pts What is the key long-term benefit of using carvedilol for patients with coronary artery disease and heart failure with reduced ejection fraction (HFrEF)? Correct! Potential increase in ejection fraction
EF increase is a key reason for using carvedilol over metoprolol for patients with low EF states. Libido unfortunately can be negatively impacted by any beta blocker. Cardiac output should only improve with long term use, not decrease, and beta blockers may reduce blood pressure slightly, but that is not their key long-term benefit. In fact, they are not even considered for routine anti-hypertensive management per JNC-8 guidelines. Increase in libido Reduction in cardiac output Baseline reduction of blood pressure Question 3 1 / 1 pts Your patient presents with pale, waxy legs, weak peripheral pulses, and states he is having difficulty walking great distances due to the pain in his calves. The most appropriate non-invasive test to evaluate his leg vascular flow quality is which of the following exams? Bilateral popliteal blood pressures Exercise stress test Angiogram of the leg with runoff Correct! Ankle Brachial Index (ABI) ABI is the most effective way to evaluate vascular flow in a non-invasive way, and the angiogram of the leg with runoff is the best invasive way. Bilateral popliteal blood pressures would not show discretion between upper and lower body if both equally low, and exercise stress tests are not used as a diagnostic tool for claudication or PAD. Question 4 1 / 1 pts Which of the following medication classes is the foundation of the care of heart failure and has been shown to reduce mortality?
their long-term care provider, you anticipate they were most likely to be also started on which of the following lipid-lowering agents at discharge? Correct! High intensity statin therapy Patients with proven cardiac disease should be on high intensity statin therapy. PCSK9 therapy is only indicated for homozygous familial hyperlipidemia or proven cardiac disease with proven failure to tolerate multiple attempts at statin therapy. Moderate intensity statin therapy Ezetimibe prior to initiating statin therapy PCSK9 inhibitor therapy Question 7 1 / 1 pts As the nurse practitioner on call on at a long term care facility, a nurse calls you to notify you that your patient who was in normal sinus rhythm has started to have extra premature beats noted on bedside telemetry. The nurse states these extra beats occur approximately every 6 normal beats and has an inverted p wave located after the narrow QRS complex which appears otherwise identical to the normal sinus rhythm QRS complex. What is this nurse likely describing? Correct! Premature Junctional Contractions Sinus exit block does have a pause, but no change in P wave morphology. PACs will maintain an early but otherwise normal P wave/QRS. PJCs will have absent, inverted or retrograde P waves(after the QRS) and be otherwise narrow complex QRS. PVCs will be absent of any P wave and have a wide complex QRS. Premature Atrial Contractions Premature Ventricular Contractions Sinus Exit Block
Question 8 1 / 1 pts A nurse practitioner places a 76-year-old patient on nifedipine (Procardia) 10 mg t.i.d. for angina. The patient is unable to remember to take the medication at the scheduled times. The practitioner should: reinforce the importance of taking the medication. Correct! change the dose to extended release 30 mg daily. discontinue the issue with the patient's daughter. increase the dosage to 20 mg b.i.d. Question 9 1 / 1 pts Which of the following medications does not cause beta 1 stimulation? Correct! phenylephrine Phenylephrine only stimulates alpha 1 receptors. The remaining three all have beta receptor activity. dopamine epinephrine dobutamine Question 10 1 / 1 pts Your 50 year-old male African American (AA) patient was found to have a blood pressure of 160/96 upon arrival to your clinic. He does not have any other medical conditions. For the following 24 hours of self-reported vital signs, it remained between 160-170 systolic and 90-100 diastolic without
increased to help counteract this phemonemon, however a long-term strategy may include consult the psychiatrist about decreasing the dose or altering the medication as this represents a considerable health risk to the patient. As that specifically was not an option, the best option would be to augment the anti-diabetic medication regimen. Stopping the olanzapine without discussing it with the psychiatrist would potentially cause the patient to experience discontinuation syndrome. Question 12 1 / 1 pts All the following are factors associated with a development of type II diabetes EXCEPT: weight greater than 20% of ideal body weight positive family history Correct! peripheral vascular disease delivering an infant greater than 9 lbs. Having peripheral vascular disease does not have correlation to development of DM2, whereas all the other options do. Question 13 1 / 1 pts A 50-year-old man presents with fatigue, muscle weakness, and hyperpigmentation of the skin. Laboratory tests show low sodium, high potassium, and low cortisol levels. What is the most likely diagnosis? Correct! Addison's disease Pheochromocytoma Primary hyperaldosteronism Cushing's syndrome
The clinical traid of hypocortisolism, also known as Addisonian crisis presents with hypotension, hypothermia, and oliguria. Not all patients who exhibit adrenal insufficiency will have this in a severe state, but it is common to look for these findings to support the diagnosis. The patient may also have a recent history of steroid supplementation that was abruptly stopped or a recent stressor which caused an increase in their cortisol levels which their adrenal glands could not support such as surgery, hospitalization, infection, etc. Question 14 1 / 1 pts A 39-year-old male with type 1 DM is seen in the urgent care after a recent hospitalization for DKA. Treated with IV fluids, IV insulin, and potassium correction, His BS decreases to 120 mg/dL and is transitioned from IV insulin to Sub Q. After 6 hours he begins vomiting and ABG is done: pH 7.19, CO2 13, K+ 5.5, glucose 180. Which of the following is the most likely reason for persistent acidosis? Lack of absorption of Sub Q insulin Correct! Premature discontinuation of insulin drip Failure to give bicarbonate Failure to correct hyperkalemia Glucose is only one of the parameters that needs to be followed in DKA. It takes longer for ketones to clear than glucose to normalize. Insulin drip should be continued until ketonemia has resolved and the anion gap has closed. If IV insulin is discontinued prematurely the patient may have rebound acidosis. Bicarbonate replacement has been controversial in DKA. Question 15 1 / 1 pts An adult female who recently returned from a business trip to Japan presents for a recheck appointment. The only remarkable laboratory result is for thyroid-stimulating hormone (TSH), at 0.3 microunits/mL (normal = 0.4–6 microunits/mL). The patient reports that her neck hurts; examination reveals thyroid tenderness. Which of the following laboratory tests should the nurse practitioner order now? Triiodothyronine (T3) resin uptake assay
Instruct the patient to start daily exercise Decrease the overall insulin dose Correct! Refer the patient for diet teaching Increase the overall insulin dose This represents a common issue with diabetics who are coined as "brittle". When the patient is exhibiting both low and high readings, there is no safe answer for what to do with the dosing. Therefore, increasing and decreasing the overall insulin dose is not the right answer. Increasing activity with exercise would consume more glucose and put the patient at increased risk if hypogylcemic. Therefore, the only appropriate answer would be to refer to diabetic education to see what their baseline comprehension is about their management and diet and insulin treatment. Question 18 1 / 1 pts Pheochromocytoma is best diagnosed by which of the following tests: Correct! 24-hour urine for catecholamines/metanephrines and plasma metanephrines Adrenal CT/MRI Blood pressure values and adrenal CT/MRI Plasma metanephrines with blood pressure values Pheochromocytoma is catecholamine producing tumor. Must have diagnostics that reveal increased levels of catecholamines. A negative test virtually excludes pheochromocytoma. Question 19 1 / 1 pts Patients on levothyroxine should be monitored for signs of: Memory deficits and hyperreflexia
Increased nausea and constipation Ankle edema and discomfort Correct! Angina pectoris and dysrhythmias The risk of any supplementation is OVER-supplementation and of the potential options, angina pectoris and dysrhythmias are clinical symptoms associated with hyperthyroidism, or in this case over-treated hypothyroidism causing extrinsic hyperthyroid symptoms. Question 20 1 / 1 pts A starting dose for a elderly adult patient with a BMI of 20 needing levothryoxine 125 mcg 75 mcg 100 mcg Correct! 25 mcg The widely considered best practice for treatment of hypothyroidism in the elderly is to "go slow and start low". 25 mcg is the most appropriate low dose to start with of these options. It is possible that over time the dose will be increased until therapeutic levels are obtained, but the risk of over- dosing the patient outweighs the desire to quickly achieve this state. Question 21 1 / 1 pts An elderly patient is being admitted to the skilled nursing facility and is being screened for the risk of falling. Which of the following information would trigger a complete falls assessment? Living alone and having mild dementia
patient as his advocate by helping the man enjoy the ice cream he requested. Question 23 1 / 1 pts Which of the following gastrointestinal changes is associated with normal aging? Increased salivation Decreased incidence of gallstones Increased esophageal emptying Correct! Decreased production of gastric acid Evidence of the normal aging process includes decreased production of gastric acid, increased incident of gallstones, decrease salvation, and decreased esophageal emptying. Question 24 1 / 1 pts A frail elderly patient presents with constipation. Which of the following normal physiologic changes seen with aging is the most likely cause? Correct! Decreased bowel muscle tone Increased absorption of calcium Decreased pancreatic secretions Increased bile secretion The frail, elderly patient will typically have their GI track decrease bile secretion and decrease absorption of calcium. A decrease in pancreas secretions is not related to presence of constipation, however, decreased bowel muscle tone certainly does reduce the GI motility and increase the
transit time, thereby increasing the drying of stool in the large intestine which leads to constipation Question 25 0 / 1 pts The management of COPD in the elderly is best guided by: arterial blood gases. radiologic imaging. You Answered spirometry. Correct Answer symptomatology. Symptomatology is what guides COPD management since the severity and frequency of symptoms will warrant changes and additions to medications as exacerbations present. Although very useful tool for chronic management and baseline status, spirometry does not typically dictate therapy, rather diagnose the disease state itself. Our blood gases may be used for clinically correlate severity during an exacerbation, and radiologic imaging may showcase severity of stable chronic finding such as somatic, lung tissue or bullae. Question 26 1 / 1 pts Which sphincter tends to be involved with the symptoms associated with patients who have GERD? Pyloric sphincter Internal anal sphincter Ileocecal sphincter Correct! Lower esophageal sphincter
CRP and fecal calprotectin, are typically performed, if elevation is seen in these two levels, then an ileocolonoscopic is warranted for further workup and biopsy Question 29 1 / 1 pts The most specific indicator of the presence of ascites is: A liver scratch test Correct! A prominent fluid wave Costovertebral angle tenderness A positive Murphy test During assessment for ascites, a fluid wave test should produce a prominent fluid wave if the patient is experiencing ascites. Question 30 1 / 1 pts A geriatric female presents with complaints of dyspnea and fatigue. All blood work is normal except for Hgb of 9.0 g/dL, Hct of 33%, and guaiac positive stool. The patient also reports a bowel pattern of alternating constipation and diarrhea, and frequent laxative use. Which diagnostic tests should be ordered? Correct! Colonoscopy MRI scan of abdomen CT scan of abdomen Upper GI series This patient is in need of a colonoscopy to evaluate for the cause of occult bleeding.
Question 31 1 / 1 pts A 29-year-old male presents with severe abdominal pain, he has a history of alcohol abuse, and recurrent pancreatitis. Patients Lipase is elevated, and he has nausea and vomiting as well. Abdominal CT shows inflammatory changes around the pancreas. What is the most important intervention to consider in the acute phase? Pain management with IV narcotics Correct! Admit to the hospital for fluid resuscitation to avoid hypovolemic state, and reduce risk of developing further complications Further imagining and diagnosis with EUS and aspiration for development of necrosis Feeding patient to reduce risk of necrosis Attention to adequate fluid resuscitation should be the priority in addressing abdominal pain, as hypovolemia from vascular leak and hemoconcentration can cause ischemic pain and resultant lactic acidosis. Although Pain should be managed, and patients’ needs feeding typically via NG to avoid development of necrosis. These are not the top priorities. Question 32 1 / 1 pts A 35-year-old man presents with sudden onset of severe flank pain radiating to the groin, nausea, and vomiting. He reports a history of similar episodes. What is the most likely diagnosis? Acute cystitis Pyelonephritis Correct! Renal calculi Chronic kidney disease
hypothyroidism. It is important to note that ribavirin will not treat hepatitis C unless it is taken with another medication called pegylated-interferon α (PEG-IFNα). This therapy is not considered evidence based anymore due to better options now available and the considerable side effect profile of ribavirin which includes depression as it's most significant side effect affecting 30- 40% of those taking it. Question 35 1 / 1 pts A 54-year-old male who is 30 pounds overweight states that he awakens at night with heartburn and the taste of hot acid in his mouth. Stress makes his condition worse, yet baking soda seems to provide some relief. Findings on examination are normal and the stool for occult blood is negative. The preliminary diagnosis should be: helicobacter pylori. esophagitis. esophageal spasm. Correct! gastroesophageal reflux disease. Some common precipitating factors of GERD include obesity, symptoms after eating acidic food, worse at night time, and relieved by a weak base such as sodium bicarbonate. Question 36 1 / 1 pts Which of the following is not a domain of Social Determinants of Health as identified in Healthy People 2030? Social and Community Context Health Care Access and Quality Economic Stability
Correct! Transportation Infrastructure The 5 overarching domains of Social Determinants of Health are Economic Stability, Education Access and Quality, Health Care Access and Quality, Neighborhood and Built Environment, Social and Community Context. Question 37 1 / 1 pts Which of the following risks of patient use of convenient/urgent care may increase the risk of a nurse practitioner to miss subtle changes in the patient’s condition over time? Overtesting Correct! Lack of longitudinal management and trending Repeating of tests Overuse of medical imaging Without awareness of the long-term prognosis and trajectory of a patient’s healthcare, a risk of convenient/urgent care is the inability to trend the patient over time and consider therapies which may require time to evaluate for success or failure. Question 38 1 / 1 pts In a mass casualty situation with presumed anthrax exposure, the drug of choice for prophylaxis is: chloramphenicol (Chloromycetin). amoxicillin (Amoxil). Correct! doxycycline (Doryx).
