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NURS 6560 Final Exam (2018): Advanced Practice Care of Adults in Acute Care Settings: Walden University (100 Questions)

 

Question 1

 

A patient with suspected Cushing’s syndrome is being evaluated to establish the diagnosis and cause. Patients with an adrenal tumor typically will demonstrate:

 

A.

Low ACTH and low cortisol

B.

Low ACTH and high cortisol

C.

High ACTH and low cortisol

D.

High ACTH and high cortisol

 

 

Question 2

 

Pneumatosis, or gas cysts, may form in the wall anywhere along the gastrointestinal tract; in some cases, they will produce symptoms such as abdominal discomfort, diarrhea with mucus, and excess flatulence. Treatment of pneumatosis most often involves:

 

A.

Several days of oxygen by face mask

B.

Hyperbaric oxygen

C.

Surgical resection

D.

Treatment of underlying disease

 

Question 3

 

Jennifer is an RN applicant for a staff nurse position in the surgical ICU. She has had a screening PPD and comes back in 48 hours to have it read. There is a 12-mm induration at the site of

injection. A chest radiograph is negative. The AGACNP knows that the next step in Jennifer’s evaluation and management should include:

 

A.

No further care, because the chest radiograph is negative

B.

Quantiferon serum assay for exposure

C.

Consideration of prophylactic therapy

D.

Beginning therapy for pulmonary TB pending sputum cultures

 

Question 4

 

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:

 

A.

Blood group substances

B.

Electrolytes

C.

Vitamin B12

D.

Gastric pH

 

 

Question 5

 

M. T. is a 71-year-old female who presents for evaluation of a ―lump on her chest.‖ She denies any symptoms—there is no pain, erythema, edema, ecchymosis, or open areas—it is just a lump. She has no idea how long it has been there and just noticed it a few weeks ago. Physical examination reveals a round, smooth, flesh-colored tumor. It is firm but not hard; it has smooth borders. It measures 6 cm in diameter and is non-tender to palpation. The AGACNP suspects that this is a classic presentation of the most common chest wall tumor known as a:

 

A.

Neurolemma

B.

Lipoma

C.

Hemangioma

D.

Lymphangioma

 

Question 6

 

The AGACNP is receiving report from the recovery room on a patient who just had surgical resection for pheochromocytoma. He knows that which class of drugs should be available immediately to manage hypertensive crisis, a possible consequence of physical manipulation of the adrenal medulla?

 

A.

 

Alpha-adrenergic antagonists

B.

Beta-adrenergic antagonists

C.

Intravenous vasodilators

D.

Arteriolar dilators

 

Question 7

 

In myelodysplastic syndromes, the primary indications for splenectomy include:

 

A.

Major hemolysis unresponsive to medical management

B.

Severe symptoms of massive splenomegaly

C.

Sustained leukocyte elevation above 30,000 cells/µL

D.

Portal hypertension

 

 

Question 8

 

The AGACNP is evaluating a patient who reportedly fell down a flight of steps. Her history is significant for several emergency room visits, but she denies any significant medical conditions. Some documentation in her chart indicates that she may have been subjected to physical abuse. Today she presents with a periorbital ecchymosis of the left eye and swelling in the left side of the face. Her neurologic examination is within normal limits. Which head imaging study would be most useful in assessing for findings consistent with a history of abuse?

 

A.

Radiographs

B.

CT scan without contrast

C.

MRI

D.

PET scan

 

Question 9

 

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:

 

A.

Continue the current regimen

B.

D/C the spironolactone and begin a loop diuretic

C.

Add a loop diuretic to the spironolactone

D.

Proceed to large-volume paracentesis

 

Question 10

 

 

Which of the following is a true statement with respect to the use of corticosteroids in posttransplant patients?

 

A.

High-dose initial steroids are tapered to off over a period of 4 to 6 weeks posttransplant

B.

There is a strong interest in developing corticosteroid-free posttransplant protocols

C.

Better results are demonstrated in corticosteroid-free protocols for second-transplant recipients

D.

Evidence supports corticosteroid-free rejection protocols

 

 

Question 11

 

K. T. presents for a routine wellness examination, and the review of systems is significant only for a markedly decreased capacity for intake and a vague sense of nausea after eating. K. T. denies any other symptoms; the remainder of the GI review of systems is negative. His medical history is significant for complicated peptic ulcer disease that finally required resection for a perforated ulcer. The AGACNP advises the patient that:

 

A.

He will need endoscopy to evaluate the problem

B.

Chronic gastroparesis is a known complication of ulcer surgery

C.

Medication is unlikely to help, and he may need another surgery

D.

His symptoms occur in 5 to 10% of people after ulcer surgery

 

 

Question 12

 

The AGACNP is rounding on a patient following splenectomy for idiopathic thrombocytopenia purpura. On postoperative day 2, a review of the laboratory studies is expected to reveal:

 

A.

Increased MCV

B.

Increased Hgb

C.

Increased platelets

D.

Increased albumin

 

Question 13

 

A patient being monitored post-heart transplant suffers a bradyarrhythmia. The AGACNP knows that which of the following medications is not indicated as part of emergency intervention for bradycardic abnormalities in a posttransplant patient?

 

A.

Isoproterenol 0.2 to 0.6 mg IV bolus

B.

External pacemaking

C.

Atropine 0.5 mg IV

D.

Epinephrine 1 mg IV

 

Question 14

 

Ms. Carpenter is a 28-year-old female who presents in significant pain; she indicates that the discomfort is in the right lower quadrant. The discomfort is colicky in nature and has the patient in tears. Which of the following associated findings increases the index of suspicion for ureteral colic?

 

A.

Temperature > 102°F

B.

White blood cell count > 14,000 cells/µL

C.

Vomiting

D.

Hematuria

Question 15

 

Which of the following is not a true statement with respect to decision making for a cognitively impaired patient?

 

A.

Only a court can declare a patient incompetent

B.

Impaired cognition does not make a person incompetent

C.

Living wills typically are honored if a person is terminally ill

D.

A patient can give informed consent if not declared incompetent

 

 

Question 16

 

Hepatic encephalopathy is a clinical syndrome seen in patients with chronic liver disease; its presentation may range from mild personality changes, to psychosis, to coma. The primary chemical mediators of hepatic encephalopathy include all of the following except:

 

A.

Gamma-aminobutyric acid (GABA)

B.

Ammonia

C.

False neurotransmitters

D.

Serotonin

Question 17

 

Ross A. is a 38-year-old who has just had a kidney transplant. The AGACNP knows that, due to the characteristic and anticipated response of transplanted kidneys, the patient requires:

 

A.

Aggressive rehydration

B.

Controlled hydration

C.

Hypertonic rehydration

D.

Isotonic rehydration

 

Question 18

 

Janice is a 32-year-old female who presents for evaluation of abdominal pain. She has no significant medical or surgical history and denies any history of ulcers, reflux, or gastritis. However, she is now in significant pain and is afraid something is ―really wrong.‖ She describes what started out as a dull discomfort in the upper part of her stomach a few hours ago but has now become more profound and centered on the right side just under her ribcage. She has not vomited but says she feels nauseous. Physical exam reveals normal vital signs except for a pulse of 117 bpm. She is clearly uncomfortable, and palpation of the abdomen reveals tenderness with deep palpation of the right upper quadrant. The AGACNP orders which imaging study to investigate the likely cause?

 

A.

Abdominal radiographs

B.

CT scan of the abdomen with contrast

C.

Right upper quadrant ultrasound

D.

A HIDA scan

 

 

Question 19

 

Justin F. is seen in the emergency department with an 8-cm jagged laceration on the dorsal surface of his right forearm. He says he was working with his brother-in-law yesterday morning building a deck on the back of his home. A pile of wooden planks fell on top of him, and he sustained a variety of cuts and superficial injuries. He cleaned the wound with soap and water but didn’t want to go to the emergency room because he didn’t want to risk being in the waiting room for hours. He wrapped up his arm and went back to work, and then took a normal shower and went to bed last night. This morning the cut on his arm was still flapping open, and he realized he needed sutures. The appropriate management of this patient includes:

 

A.

Proper cleansing and covering of the laceration, along with antibiotic therapy

B.

Local anesthesia, cleansing, and wound exploration for foreign bodies

C.

Local anesthesia, cleansing, and suture repair

D.

Cleansing, covering, antibiotic therapy, and tetanus prophylaxis

 

Question 20

 

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 any relationship 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:

 

A.

Dissecting aortic aneurysm

B.

Acute pancreatitis

C.

Perforated peptic ulcer

D.

Mallory-Weiss tear

 

 

Question 21

 

A 42-year-old woman presents to the emergency department after being raped. The AGACNP examines her and realizes that the patient’s husband is the rapist. The patient does not want to press charges and wants to return home with her husband. The AGACNP’s initial action should be to:

 

A.

Report the physical assault to law enforcement

B.

Have the patient sign a release to go home with her husband

C.

Consult psychiatry for a psych hold

D.

Provide counseling to the patient regarding her options

 

 

Question 22

 

M. R. is a 52-year-old female who presents complaining of significant abdominal pain, which she rates as 8 to 9 on a 1 to 10 scale. The pain has been going on for a matter of hours, and she is afraid it won’t go away on its own. She denies any nausea or vomiting, and she cannot remember precisely when her last bowel movement occurred; probably it was a few days ago. She reports

that she is ―always‖ constipated. On physical examination, she is tachycardic but otherwise has normal vital signs; her abdomen is tensely rigid, but no point tenderness to palpation is appreciated. The entire abdomen percusses as tympanic—there is no distinct dullness over the upper quadrants. Bowel sounds are present but hypoactive and intermittent. There is rebound tenderness to palpation. The AGACNP suspects:

 

A.

Perforated bowel

B.

Peritonitis

C.

Ischemic bowel

D.

Intestinal abscess

 

 

Question 23

 

C. V. is a 70-year-old African American male patient who presents for surgical consultation. His history includes 4 months of severe hypertension that has been poorly responsive to medication. He also complains of intermittent pounding headaches, palpitations, and a vague sense of anxiety with tremors. A 24-hour urine demonstrated elevated metanephrines. The AGACNP recognizes that this patient has a:

 

A.

 

Malignant hyperthyroidism

B.

Catecholamine-secreting tumor

C.

Pituitary adenoma

D.

Hyperaldosteronism

 

Question 24

 

The AGACNP knows that when evaluating a patient with suspected acute pyelonephritis, which of the following is not a common feature?

 

A.

Pyuria

B.

Fever

C.

CVA tenderness

D.

Gross hematuria

 

Question 25

 

B. T. is a 49-year-old male who has been admitted for the management of an episode of diverticulitis. This is his fifth hospitalization this year, and in previous hospitalizations he has had both abscess and stricture as a consequence of his disease. His treatment this hospitalization should include:

 

A.

Extended-spectrum antibiotics

B.

Surgical consultation for colectomy

C.

Expectant treatment with nonabsorbable antibiotics

D.

Colonoscopy

 

 

Question 26

 

Based upon an understanding of the normal relationship between gastrin levels and acid secretion, the AGACNP recognizes that which of the following combinations is almost diagnostic of gastrinoma?

 

A.

 

Hypogastrinemia and acid hyposecretion

B.

Hypergastrinemia and acid hyposecretion

C.

Hypogastrinemia and acid hypersecretion

D.

Hypergastrinemia and acid hypersecretion

 

Question 27

 

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?

 

A.

Veracity and beneficence

B.

Beneficence and nonmalfeasance

C.

Autonomy and beneficence

D.

Justice and autonomy

 

Question 28

 

R. S. is a 66-year-old female with Cushing’s syndrome due to an ACTH-producing pituitary tumor. The tumor is readily isolated by imaging, and the patient had an uneventful surgery. When seeing her in follow-up, the AGACNP anticipates:

 

A.

Rapid reversal of symptoms, with good pituitary function

B.

Transient rebound release of remaining pituitary hormones

C.

Markedly improved dexamethasone suppression test

D.

Hyponatremia and compensatory SIADH

Question 29

 

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

 

Question 30

 

N. C. is a 60-year-old female with primary hyperaldosteronism. She has been referred to your service for surgical management. Anticipated findings on clinical history would include:

 

A.

Palpitations, headaches, and sweating

B.

Polyuria, weakness, and paresthesias

C.

Dry skin, straie, and unplanned weight loss

D.

Early satiety, tremors, and fatigue

 

 

Question 31

 

Mrs. Maroldo is an 81-year-old female who presents for evaluation of pain in her left lower quadrant. She has had this pain before and says she usually takes antibiotics and it goes away. However, this time it seems worse, and she has had it for 4 days even though she says she started taking her leftover antibiotics from the last episode. She denies any nausea or vomiting but says she simply isn’t hungry. She had a little diarrhea yesterday but no bowel movements today. She has a temperature of 100.9°F and a pulse of 104 bpm, respirations of 20 breaths per minute, and a blood pressure of 94/60 mm Hg. She has some discomfort to deep palpation in the left lower quadrant. The AGACNP suspects:

 

A.

Irritable bowel syndrome

 

 

 

B.

 

Inflammatory bowel disease

 

C.

Diverticulitis

 

D.

Appendicitis

 

 

Question 32

 

In the majority of cases, the first clinical manifestation of physiologic stress ulcer is:

 

A.

Epigastric pain

B.

Change in mental status

C.

Fever

D.

Hemorrhage

 

Question 33

 

A patient with chronic hepatic encephalopathy is being discharged home. Discharge teaching centers upon long-term management strategies to prevent ammonia accumulation. Teaching for this patient includes instruction about:

 

A.

Lactulose taken 20 g PO daily

B.

Spironolactone taken 100 mg PO daily

C.

Protein intake of 50 g daily

D.

Zolpidem taken 10 mg PO qhs.

 

Question 34

 

R. R. is a 61-year-old male patient who presents with a chief complaint of fever and urinary symptoms. He was in his usual state of good health when for no apparent reason he developed pain in his back and perineal region, as well as fever and chills. He presents as septic. He had urinary hesitancy and decreased stream but now reports that he has not passed urine in more than 12 hours. Palpation of the lower abdomen is consistent with bladder distention. The AGACNP knows that which of the following is contraindicated in this circumstance?

 

A.

Digital prostate examination

B.

Urinary catheterization

C.

Fluoroquinolone antibiotics

D.

Drainage of prostate abscess

 

Question 35

 

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:

 

A.

Cyclosporine

B.

Azathioprine

C.

Methylprednisolone

D.

Sirolimus

 

Question 36

 

R. R. is a 71-year-old female who presents with left lower quadrant pain that started out as cramping but has become more constant over the last day. She reports constipation over the last few days but admits that for as long as she can remember she has had variable bowel habits. Her vital signs are normal, but physical examination reveals some tenderness in the left lower quadrant. Which diagnostic test is most likely to support the leading differential diagnosis?

 

A.

CT scan with IV, oral, and rectal contrast

 

 

B.

 

CBC with WBC differential

 

 

C.

Colonoscopy

 

 

D.

Barium enema

 

 

Question 37

 

Ms. O’Reilly is a 69-year-old patient who is having a bowel resection for a malignant tumor of the right colon. She has several chronic medical conditions and takes numerous daily medications, including metoprolol 100 mg daily, warfarin 5 mg daily, vitamin E 200 units daily, and metformin 1000 mg bid. Which of the following regimens is the most appropriate approach to managing her medications preoperatively?

 

A.

All medications should be taken up to and including the morning of surgery

B.

The beta blocker may be taken up until the day of surgery, metformin should be held the day of surgery, and the remaining medications should be d/c’d 5–7 days before surgery

C.

Warfarin should be held 5 days before surgery; all other medications may be taken through the morning of surgery

D.

Metformin should be held if the morning blood sugar is < 200 mg/dL; all other medications except warfarin may be given the day of surgery

 

Question 38

 

Mr. Novello is an 81-year old male patient who presents with crampy abdominal pain in the hypogastrum and a vague history as to his last normal bowel movement. Physical examination reveals distention and high-pitched bowel sounds. The patient says he has never has this kind of problem before and denies any history of abdominal surgery. Abdominal radiographs reveal a frame pattern of colonic distention. The AGACNP considers:

 

A.

A stimulant laxative to relieve bowel contents

B.

Carcinoma of the bowel as a leading diagnosis

C.

Decompression of the colon with rectal tube

D.

Angiography to rule out mesenteric ischemia

Question 39

 

Jane S. is a 35-year-old female patient who is at 30 weeks gestation. She is being followed regularly for prenatal care and has always been healthy; she just had an office visit and was told everything was fine. Tonight she presents to the emergency room complaining of significant pain in the upper abdomen. Her vital signs reveal a temperature of 98.4°F, pulse of 110 bpm, respirations of 20 breaths per minute, and blood pressure of 144/90 mm Hg. A urinalysis reveals proteinuria, and a metabolic panel is significant for increased transaminases. Her hemogram is normal, but the CVC reveals platelets of 85,000. The AGACNP knows that which of the following must be evaluated as a cause of her abdominal pain?

 

A.

HELLP syndrome

B.

Placental abruption

C.

Spontaneous hepatic rupture

D.

Preterm labor

 

 

Question 40

 

Which of the following statements is true with respect to adrenal tumors that produce gender symptoms?

 

A.

Feminizing adrenal tumors are almost always carcinomas

B.

Feminizing adrenal tumors are the most common type of adrenal tumor

C.

Virilizing tumors in women are most often localized to the adrenal cortex

D.

Virilizing adrenal tumors are more likely to be malignant in children

 

Question 41

 

G. D. is a 13-year-old male patient who has a history of recurrent fever and flank pain. His parents traditionally are not believers in the health care system, and he has not been seen by a health care provider for many years. Today he has fever, chills, and costovertebral angle tenderness. Urinalysis reveals findings consistent with acute urinary infection. The AGACNP

treats the patient for pyelonephritis and considers which study to evaluate for vesicoureteral reflux?

 

A.

Bilateral renal ultrasound

B.

CT scan of the abdomen and pelvis

C.

Voiding cystourethrograpy

D.

Radioisotope scanning

 

Question 42

 

In which form of hypospadias should circumcision be deferred in order to preserve the prepuce for later surgical repair?

 

A.

Ventral displacement

B.

Proximal displacement

C.

Midscrotal hypospadias

D.

Meatus proximal to the corona

 

 

Question 43

 

T. G. is a 48-year-old female who presents with biliary colic. She has had previous episodes but has resisted operation because she is afraid of anesthesia. Today her physical exam reveals a clearly distressed middle-aged female with right upper quadrant pain, nausea, and vomiting. Which of the following findings suggests a complication that requires a surgical evaluation?

 

A.

A temperature of 101.5°F

B.

A leukocyte count of 18,000/µL

C.

A palpable gallbladder

D.

A positive Murphy’s sign

Question 44

 

Achalasia is a risk factor for:

 

A.

Squamous cell carcinoma

B.

Gastroesophageal reflux disease

C.

Esophageal atrophy

D.

Malabsorption syndromes

 

Question 45

 

Carolyn C. has a history of Crohn’s disease and has been managed with immunologic agents, with moderate success. Today she presents with severe abdominal pain that comes and goes in waves; it started shortly after she ate a little bit of cottage cheese and crackers. This has never happened before with her Crohn’s disease. She has difficulty localizing the pain but seems to indicate the general area of the umbilicus. She had one episode of diarrhea this morning.

Abdominal examination is nonspecific, producing mild tenderness on palpation. Plain abdominal films reveal a dilated small bowel with air fluid levels. The AGACNP suspects:

 

A.

Perforated small bowel

B.

Ulceration through the thickness of small bowel

C.

Small bowel obstruction

D.

Gastroenteritis

 

NURS 6560 Midterm Exam (2018): Advanced Practice Care of Adults in Acute Care Settings: Walden University (100 Questions)

Question 1

S. is a 59-year-old female who has been followed for several years for aortic regurgitation. Serial echocardiography has demonstrated normal ventricular function, but the patient was lost to follow-up for the last 16 months and now presents complaining of activity intolerance and weight gain. Physical examination reveals a grade IV/VI diastolic aortic murmur and 2+ lower extremity edema to the midcalf. The AGACNP considers which of the following as the most appropriate management strategy?

A. Serial echocardiography every 6 months

B. Begin a calcium channel antagonist

C. Begin an angiotensin converting enzyme (ACE) inhibitor

D. Surgical consultation and intervention

Question 2

An ascending thoracic aneurysm of > 5.5 cm is universally considered an indication for surgical repair, given the poor outcomes with sudden rupture. Regardless of the aneurysm’s size, all of the following are additional indications for immediate operation except:

A. Comorbid Marfan’s syndrome

B. Enlargement of > 1 cm since diagnosis

C. Crushing chest pain

D. History of giant cell arteritis

Question 3

Jasmine is a 31-year-old female who presents with neck pain. She has a long history of injection drug use and admits to injecting opiates into her neck. Physical examination reveals diffuse tracking and scarring. Today Jasmine has a distinct inability to turn her neck without pain, throat pain, and a temperature of 102.1°F. She appears ill and has foul breath. In order to evaluate for a deep neck space infection, the AGACNP orders:

A. Anteroposterior neck radiography

B. CT scan of the neck

C. White blood cell (WBC) differential

D. Aspiration and culture of fluid

Question 4

Mr. Draper is a 39-year-old male recovering from an extended abdominal procedure. As a result of a serious motor vehicle accident, he has had repair of a small bowel perforation, splenectomy, and repair of a hepatic laceration. He will be on total parenteral nutrition postoperatively. The AGACNP recognizes that the most common complications of parenteral nutrition are a consequence of:

A. Poorly calculated solution

B. Resultant diarrhea and volume contraction

C. The central venous line used for infusion

D. Bowel disuse and hypomotility

Question 5

Mr. Mettenberger is being discharged following his hospitalization for reexpansion of his second spontaneous pneumothorax this year. He has stopped smoking and does not appear to have any overt risk factors. While doing his discharge teaching, the AGACNP advises Mr. Mettenberger that his current risk for another pneumothorax is:

A. < 10%

B. 25-50%

C. 50-75%

D. > 90

Question 6

One of the earliest findings for a patient in hypovolemic shock is:

A. A drop in systolic blood pressure (SBP) < 10 mm Hg for > 1 minute when sitting up

B. A change in mental status

C. SaO2 of < 88%

D. Hemoglobin and hematocrit (H&H) < 9 g/dL and 27%

Question 7

Traumatic diaphragmatic hernias present in both acute and chronic forms. Patients with a more chronic form are most likely to be present with:

A. Respiratory insufficiency

B. Sepsis

C. Bowel obstruction

D. Anemia

Question 8

The AGACNP is managing a patient in the ICU who is being treated for a pulmonary embolus. Initially the patient was stable, awake, alert, and oriented, but during the last several hours the patient has become increasingly lethargic. At change of shift, the oncoming staff nurse appreciates a profound change in the patient’s mental status from the day before. Vital signs and hemodynamic parameters are as follows: BP 88/54 mm Hg Pulse 110 bpm Respiratory rate 22 breaths per minute SaO2 93% on a 50% mask Systemic vascular resistance (SVR) 1600 dynes ∙ sec/cm5 Cardiac index 1.3 L/min Pulmonary capillary wedge pressure (PCWP) 8 mm Hg This clinical picture is most consistent with which shock state?

A. Hypovolemic

B. Cardiogenic

C. Distributive

D. Obstructive

 

Question 9

When counseling patients to prevent postoperative pulmonary complications, the AGACNP knows that with respect to smoking cessation, the American College of Surgeons and National Surgical Quality Improvement Program guidelines are clear that patients who stop smoking _____ weeks before surgery have no increased risk of smokingrelated pulmonary complications.

A. 2

B. 4

C. 6

D. 8

Question 10

Mitch C. is a 39-year-old male who is brought to the ED by paramedics. According to the report of a neighbor, Mitch was distraught over a breakup with his fiancée and attempted to commit suicide by mixing some chemicals from under his kitchen sink and drinking them; afterward he changed his mind and knocked on his neighbor’s door asking for help. Mitch is awake but stuporous, and the neighbor has no idea what he drank. Visual inspection of his mouth and oropharynx reveals some edema and erythema. He is coughing and has large amounts of pooling saliva. Mitch is not capable of answering questions but he appears in pain. Endoscopy reveals full thickness mucosal injury with mucosal sloughing, ulceration, and exudate. The AGACNP knows that the appropriate course of treatment must include:

A.At least 6 hours of observation in the emergency department

B. Periodic esophagram

C. Aggressive fluid resuscitation

D.Esophagogastrectomy

Question 11

Jared V. is a 35-year-old male who presents for evaluation of a dry cough. He reports feeling well overall but notices that he gets out of breath more easily than he used to when playing soccer. A review of systems yields results that are essentially benign, although the patient does admit to an unusual rash on his legs. Physical examination reveals scattered erythematous nodules on both shins. There is no drainage, discomfort, or itch. Additionally, diffuse, mildly enlarged lymph nodes are appreciated bilaterally. Results of a comprehensive metabolic panel and complete blood count are within normal limits. Twelve-lead ECG reveals sinus bradycardia at 58 bpm. Chest radiography reveals bilateral hilar and mediastinal lymphadenopathy. The AGACNP suspects:

A.Bronchiectasis

B. Pulmonary fibrosis

C. Sarcoidosis

D.Lung carcinoma

Question 12

Mrs. Miller is a 44-year-old female who is on postoperative day 1 following a total abdominal hysterectomy. Her urine output overnight was approximately 200 mL. The appropriate response for the AGACNP would be to order:

A.A urinalysis and culture

 B. 1 liter of NSS over 8 hours

C. Encourage increased mobility

D.Liberalize salt in the diet

Question 13

All of the following are risk factors for spontaneous pneumothorax except:

A.Connective tissue disease

B. Scuba diving

C. Chronic obstructive pulmonary disease (COPD)

D.Central line insertion

Question 14

The AGACNP is going over preoperative information and instructions with a patient who is having a major transverse abdominal procedure tomorrow morning. The patient is very nervous and is asking a lot of questions. The AGACNP prescribes a sleeping agent because he knows that anxiety and sleeplessness may:

A.Lead to hypoxia due to hyperventilation

B. Increase the physiologic stress response postoperatively

C. Contribute to risk of delirium and prolonged length of stay

D.Decreasep.o. intake and produce nutritional risk

Question 15

In a patient with thyroid nodules, which of the following is the diagnostic study of choice to rule out thyroid cancer?

A.Radioiodine scanning

B. Percutaneous needle biopsy

C. CT scan

D.Ultrasound

Question 16

When counseling a patient about treatment modalities for achalasia, the AGACNP advised that which of the following is the treatment of choice?

A.Calcium channel antagonists

B. Intrasphincter botulinum injection

C. Pneumatic dilation

D.Myotomy and partial fundoplication

 

 

Question 17

Mr. Liu is a 52-year-old male who has a history of thyroidectomy. He presents complaining of numbness and tingling in his legs and feet and generalized fatigue. Physical examination reveals a positive Chvostek’s sign. Which of the following laboratory studies should be ordered first?

A.Renal function tests

B. Parathyroid hormone

C. Calcium

 D.Magnesium

Question 18

V. is a 75-year-old male patient who, during a recent wellness evaluation, was found to have a new onset grade II/VI crescendo-decrescendo cardiac murmur at the 2nd intercostal space, right sternal border. He is symptom free and reports no limitations to his usual daily activity. He specifically denies activity intolerance or near syncope, and he is very active physically. Echocardiography reveals a mild aortic calcification. The AGACNP knows that ongoing management for R. V. must include:

A.Annual or biannual serial echocardiography

B. Modification of activity level

C. Baseline cardiac catheterization

D. Statin therapy

 Question 19

The lower esophageal sphincter is characterized by periods of intermittent relaxation called transient lower esophageal sphincter relaxations. These relaxations are independent of the relaxation triggered by swallowing and are the most common cause of:

A. Physiologic reflux

B. Symptomatic esophagitis

C. Barrett’s metaplasia

D.Esophageal carcinoma

Question 20

While reviewing morning labs on a postoperative patient, the AGACNP notes that the patient’s basic metabolic panel is as follows: Na+ 132 mEq/L K+ 4.6 mEq/L Cl- 87 mEq/L CO2 25 mEq/L A normal saline infusion is ordered in an attempt to avoid:

A.Hyperkalemia

B. Hypernatremia

C. Metabolic alkalosis

D.Metabolic acidosis

Question 21

W. is a 49-year-old man who presents for evaluation. He has a long history of alcohol and tobacco use, with a 65-year pack history and an admitted 14-drink-per-week alcohol habit. He is getting worried because he can no longer swallow his bourbon. He is not a good historian but he does admit to a 1+ year history of bloating, heartburn, and progressive difficulty swallowing food. He didn’t worry too much about his symptoms until he stopped being able to swallow bourbon. He thinks he has lost approximately 15 lbs in the last year. He denies any blood in his stool and has not had any vomiting. The AGACNP knows that the most likely diagnosis is:

A.Zenker’s diverticulum

B. Achalasia

C. Esophageal carcinoma

D.Hiatal hernia

Question 22

Which of the following treatment modalities has no role in the treatment of shock?

A.Lactated Ringer’s

B. Fresh frozen plasma (FFP)

C. Vasopressors

D.Colloid solutions

Question 23

The development of coronary artery disease (CAD) and, ultimately, plaque formation is a multifactorial process that includes endothelial injury from hypertension, cigarette smoking, and dyslipidemia. These events lead to endothelial cell dysfunction, which is theorized to result in:

A.Decreased nitric oxide production

B. Smooth muscle cell atrophy

C. Collagen degradation

D.Enlarged arterial lumen

Question 24

Mr. Comstock is a 71-year-old male who presents with a general sense of feeling weak and unwell; he thinks he has the flu even though he received a flu vaccination this year. He describes a vague collection of symptoms, including weakness, nausea, dizziness, and “getting out of breath” very easily. He says he can barely climb the steps anymore without stopping to rest. Of the possible differential diagnoses, coronary artery disease (CAD) is high among the probabilities because of his age and gender. His physical examination is unremarkable except that he appears weak. His vital signs are as follows: temperature 98.0°F, pulse 100 bpm, respiratory rate 16 b.p.m., and BP 178/100 mm Hg. A chest radiograph is within normal limits with no acute pulmonary infection. A 12-lead ECG reveals inverted T waves in leads V1 to V5. The AGACNP is suspicious that most of his symptoms are:

A. Psychosomatic

B. Early congestive heart failure (CHF)

C. Anginal equivalents

D.Normal age-related changes

Question 25

Mrs. Carpenter is a 59-year-old female who presents with an acute myocardial infarction. She is acutely short of breath and has coarse rales on auscultation. Physical examination reveals a grade V/VI systolic murmur, loudest at the point of maximal impulse with radiation to the midaxillary line. The AGACP recognizes:

A. Acute mitral valve regurgitation

B. Acute aortic valve regurgitation

C. Acute cardiac tamponade

D. Acute pulmonary embolus

Question 26

Mr. Nelson is a 65-year-old male who has been advised that he is a candidate for coronary artery bypass grafting. He has been doing some internet research and is asking about whether or not he should have a “beating heart” bypass. Regarding off-pump coronary bypass grafting, the AGACNP advises Mr. Nelson that:

A.There is a slightly higher risk of neurologic complications

B. Long-term results suggest that the grafts do not stay open as long as those in traditional bypass grafting

C. The incidence of off-pump bypass grafting has increased significantly in the last 10 years

D.The off-pump procedure is considerably more expensive but is correlated with better long-term outcomes

Question 27

Mrs. McCallum is a 48-year-old female who presents for evaluation of a vague set of gastrointestinal symptoms. She feels generally well and has always been healthy, but lately she has had a lot of heartburn and a sense of reflux in her throat. Most recently she has had a recurring sense of food getting stuck in her throat. The AGACNP knows that which diagnostic study should be performed first?

A.Barium swallow

B. Upper endoscopy

C. Esophageal manometry

D.Ambulatory pH monitoring

Question 28

Mr. Key is a 53-year-old male patient who developed empyema following a serious bout of bacterial pneumonia. He presented as septic and was started immediately on intravenous antibiotics and drainage of the sinus cavity. Forty-eight hours later, he is much improved clinically and drainage has receded. The next step in his care would be:

A.A CT scan

B. Eloesser’s procedure

C. Decortication

D.Reexpansion

Question 29

Mrs. Bowers is a 41-year-old patient who requires surgical management of osteomyelitis. She has a long history of methamphetamine use and has a BMI of 17.9 kg/m2 . She clearly is nutritionally depleted and volume contracted, but she has no clear chronic medical history except for unmedicated hypertension, which may be due to her chronic stimulant use. She denies alcohol use but admits to a 1½ pack a day cigarette habit. A primary postoperative concern for Mrs. Bowers is:

A.Excess bleeding

B. Thromboemboli development

C. Poor wound healing

D.Renal failure

Question 30

The congenital diaphragmatic hernia that occurs more often in women and does not usually produce symptoms until midlife is known as:

A.Zenker’s hernia

B. Bochdalek’s hernia

C. Morgagni’s hernia

D.Atraumatic hernia

 Question 31

B. is a 67-year-old male who is being discharged following inpatient management for unstable angina. S. B. did not know that he had coronary artery disease (CAD) and in fact had not seen a health care provider for many years. While reviewing his lifestyle habits, he admits that he is obese, has poor eating habits, does not engage in any purposeful physical activity, and smokes two packs of cigarettes daily. He verbalizes that he is grateful that this was not a “real” heart attack and does not seem receptive to lifestyle management strategies. The AGACNP advises him that it is important to take this “warning” attack seriously because:

A. 10% of patients with unstable angina will die of cardiovascular disease within 6 months

B. 25% of patients with unstable angina will develop congestive heart failure within 6 months

C. 65% of patients with unstable angina will have an ST elevation MI within 1 year

D. 90% of patients with unstable angina will have cerebrovascular symptoms within 1 year

Question 32

According to the American College of Surgeons (ACS), who among the following patients should have a chest radiograph as part of preoperative assessment?

A.All patients > 40 years of age

B. All patients who smoke cigarettes

C. All patients having thoracic procedures

D.All patients with cardiac disease

Question 33

According to the Carpentier classification scheme of mitral valve regurgitation, a type I regurgitation is most likely due to:

A.Cardiomyopathy

B. Excessive leaflet motion

C. Ruptured papillary muscles

D.Rheumatic heart disease

Question 34

V. is a 37-year-old female who is admitted via the emergency room after her roommate called emergency medical services (EMS). She has no significant medical history and does not know what is wrong with her. She has been feeling generally unwell for the last few days, and today she had an episode of confusion that scared her roommate to the extent that the roommate called EMS. Her physical examination reveals a temperature of 101.9°F, pulse of 110 bpm, respiratory rate of 20 breaths per minute, and blood pressure of 92/58 mm Hg. A comprehensive metabolic panel reveals a slightly elevated blood urea nitrogen (BUN)/creatinine but otherwise is normal. A white blood cell differential reveals a leukocyte count of 14,000 cells/µL with neutrophils of 83%. The AGACNP knows that these values are consistent with:

A. Systemic inflammatory response syndrome (SIRS)

B. High-output septic shock

C. Neurogenic shock

D.Multiple organ dysfunction syndrome (MODS)

Question 35

Which shock state is worsened in the setting of mechanical ventilation?

A. Septic

B. Cardiac compressive

C. Neurogenic

D.Cardiogenic

Question 36

B. is a 41-year-old male being admitted for surgical reduction of an open femur fracture sustained in a multiple vehicle collision. Preoperative assessment reveals that he is on beta-adrenergic antagonists after having been diagnosed with coronary artery disease approximately 1 month ago. He admits that he feels a little better but says he still gets pain in his chest when he exerts himself. He is pain free now. Vital signs are as follows: temperature 98.1°F, pulse 88 bpm, respiratory rate 18 breaths per minute, and blood pressure 142/86 mm Hg. The AGACNP knows that which of the following is the most important action before R. B. goes to the operating room?

A.A cardiology consultation

B. Blood pressure control

C. Resuming beta-adrenergic antagonists

D. Pain control

Question 37

Cholesteatoma is a condition characterized by a collection of desquamated keratin leading to bony erosion in the ossicular chain and inner ear. The goal of surgery in cholesteatoma is:

A. Production of a dry ear

B. Preservation of sensorineural hearing

C. Debridement of infection

D.Restoration of the tympanic membrane

Question 38

The AGACNP k

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