NR511 Nursing Diagnosis Midterm Exam With Answers (401 Solved Questions)

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1QbankquestionsRespiratoryAnadulthasupperrespiratorysymptomsandcoughforthepast14days.Whatshouldbeconsidered?(Pertussis)Pertussis should always be considered in adults who present with acute cough of greater than 5 days’duration.Theincubationperiodforpertussisisabout7-10days.PatientspresentwithURIsymptomsfor1-2weeks.Theclassicparoxysmalcoughusuallybeginsinthesecondweekoftheillness.Thedurationofsymptoms and cough are about 3 months even when treated with antibiotics. This is highly infectiousandisareportable disease.Mycoplasmapneumoniaeis:(adiseasewithextrapulmonarymanifestations)Mycoplasma is an atypical pathogen and produces atypical pneumonia. It can be difficult to diagnosebecause symptoms can be varied and involve multiple body systems (extrapulmonary manifestations).Infection with Mycoplasma may present with a normal white blood cell count, maculopapular rash, GIsymptoms, tender joints and aches, and, though rare, cardiac rhythm disturbances. Respiratorysymptoms may not be pronounced. On chest X-ray there are some unique findings (peribronchialpattern)withMycoplasma.Theseincludethickenedbronchialshadow,streaksofinterstitialinfiltration,andatelectasis.These aremorelikely tooccurin thelowerlobes.Whichmedicationbelowiscontraindicatedinanasthmapatientbecauseitmayincreaseriskofsuddendeathifusedalone?(Long-acting bronchodilator)Along-actingbronchodilatorcanbeusedtotreatasthmawhenitisusedincombinationwithaninhaledsteroid. Otherwise, using a long-acting bronchodilator like salmeterol is contraindicated. There is anincreased risk of sudden death with asthma exacerbations when this class is used solo to treat asthma.Theotherchoicescanbeusedtotreatasthma.Choicesvarydependingonthepatient.A75-year-oldfemalewithemphysemawhohasbeentreatedwithinhaledsteroidsformanyyearsshould:(shouldbescreenedforosteoporosis)Olderfemalesareathigherriskthanothersforosteoporosis.Thisfemalepatient,whohasusedinhaledsteroids and smokes, has multiple risk factors for osteoporosis. Additionally, she probably hasemphysema because she smoked (or still smokes). If she is Asian or Caucasian, she has still another riskfactor. Screening for osteoporosis should be consideredwhen managing patients with multiple riskfactors.A patient received the pneumonia immunization at age 60 years. He is 65 years old and presents toyourclinictoday.Whatrecommendationshouldbemadeaboutthepneumococcalimmunization?(Heshouldreceiveanotherone today)Thispatientshouldreceiveanotheronetodaybecauseheis65yearsoldandatleast5yearshaselapsedsince his last one. The CDC does not recommend immunizing this patient every 5 years. Twoimmunizations are available, PCV13 and PPSV23. He needs both, but PCV13 should be administeredtoday.PPSV23shouldbeadministeredatleast1yearlater.

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2Whichofthefollowingmedicationsshouldbeusedcautiouslyinapatientwhohasasthma?(Timololophthalmicdrops)Timolol is a beta blocker. This class of medications can precipitate bronchoconstriction in patients whohave asthma. Even though timolol is being administered in the eye, it is absorbed through mucousmembranesandcanexertsystemiceffects.Betablockersshouldbeavoidedinpatientswithasthmaandused cautiously in patients with COPD. The other medications listed have no specific contraindicationsfor patientswith asthma.Themostcommonsymptomassociatedwithacutebronchitisis:(Cough)Fever (temp > 101°F) is an unusual symptom associated with acute bronchitis. Cough is the mostcommon symptom associated with acute bronchitis. Purulent sputum is identified in more than 50% ofpatientswithacutebronchitis.Thecolorimpartedtothesputumisusuallyduetosloughingofepithelialcells,notbacterialinfection.Concurrentupperrespiratorysymptomsaretypicalofacutebronchitis.Pharyngitisiscommon.Mildpersistentasthmaischaracterizedby:(symptomsoccurringmorethantwiceweekly)Mildpersistentasthmaischaracterizedbysymptomsthatoccurmorethantwiceweeklybutnotdaily;or3-4 nocturnal awakenings per month due to asthma. It is treated with an inhaled steroid daily, and abronchodilator PRN for exacerbations. If symptoms occur more than twice weekly, therapy should besteppedup.Generally,along-actingbronchodilatorisaddedtothesteroidwhentherapyissteppedup.Thechestcircumferenceofa12month-oldis:(equaltoheadcircumference)The chest circumference is not routinely measured at well-child visits, but is assessed if there is concernabout the circumference of either the head or the chest. An exception to this observation can occur inpremature infants where the head grows very rapidly. Normally, the head exceeds the chestcircumference by 1-2 cm from birth until 6 months. Between 6 and 24 months the head and chestcircumferenceshouldbeaboutequalandby2yearsofagethechestshouldbelargerthanthehead.Thechestcircumference ismeasured atthe nipple line.Apatientwithcoughandfeverisfoundtohaveinfiltratesonchestx-ray.Whatishislikelydiagnosis?(Pneumonia)Thefindingofinfiltratesonchestx-ray,inconjunctionwithclinicalfindingsoffeverandcough,shoulddirect the examiner to consider pneumonia as the diagnosis. Other common clinical findings withpneumoniaincludechestpain,dyspnea,andsputumproduction.Thoughnotcommon,somepatientswithpneumoniaexhibitgastrointestinalsymptomslikenausea,vomiting,anddiarrhea.Anuncommonsymptomassociatedwithacutebronchitisis:(temperature>101°F)Fever is an unusual symptom associated with acute bronchitis. Cough is the most common symptomassociated with acute bronchitis. Purulent sputum is identified in more than 50% of patients with acutebronchitis. The color imparted to the sputum is usually due to sloughing of epithelial cells, not bacterialinfection.Concurrentupperrespiratorysymptomsaretypicalofacutebronchitis.Pharyngitisiscommonwithinthe first 3 daysof the illness.Patientswhohavecough-variantasthma:(allexhibitcough)

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3One of the most common causes of cough in adults is asthma. Cough due to asthma is oftenaccompaniedbyepisodicwheezingordyspnea,thoughsomepatientswhohaveasthmaonlycough.Thisistermed“cough-variantasthma.”Theclinicalpresentationofasthmavariesbuthyper-responsivenessoftheairwaysisa typicalfinding.Themostcommoncauseofatypicalpneumoniainadultsis:(Mycoplasmapneumonia)Inpatientswhohaveatypicalpneumonia,Mycoplasmaisthemostcommonpathogen.M.pneumoniaeissonamedbecauseofitsatypicalappearanceonchestX-ray.Thisorganismisresponsiblefor“walkingpneumonia” that is prevalent in a young adult population. This accounts for about 15% of pneumoniaandistransmittedviarespiratory droplet.WhichpatientmightbeexpectedtohavetheworstFEV1?(A65-year-oldwithemphysema)FEV 1 stands for “forced expiratory volume in 1 second.” This is the volume of air that is forcefullyexhaledinthefirstsecondofexhalationafteradeepbreath.Patientswithemphysemaarenotabletodo this efficiently because their alveoli are stretched, and mostly contain trapped air. FEV 1 is used toassess airway obstruction. An asthma patient in the green zone would be expected to have a normal(compared to himself) FEV1. An FEV1 measurement or pulmonary function tests would not beperformed on a patient with pneumonia or bronchiectasis because he would have diminishedrespiratorycapacity relatedtohisinfection.A patient who has asthma presents with chest tightness, wheezing, coughing, and fever. He haswheezinganddiminishedbreathsoundsintheupperrightlobe.Hiscoughisnonproductive,andhedeniesnasalsymptoms.Whichsymptomisnotlikelyrelatedtohisasthma?(Fever)Wheezingistypicalofasthma,butonemustconsiderpneumoniainanypatientwhopresentswithdiminishedbreathsoundsinonlyonelobe.Feverisnottypicalofasthmaoranexacerbation.IpratropiumisverywidelyusedinthetreatmentofCOPD.Whichofthefollowingstatementsaboutipratropiumiscorrect?(Itdecreasesparasympathetictoneandproducesbronchodilation)Ipratropium is the most widely studied anticholinergic medication used to treat patients with COPD. Itproduces its helpful effects by reducing cholinergic tone in the lungs. It may be used witha beta agonistifshortnessofbreathispresent.However,betaagonistsincreasesideeffectsliketachycardiaandtremoranddonot improveefficacy.

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4An80-year-oldhasStage3COPD.Heismostlikelytohaveconcomitant:(anxietyordepression)About40%ofolderpatientswhohaveCOPDhaveconcomitantanxietyand/ordepression.ItshouldbetreatedbecauseitaffectstheoverallmanagementofCOPD.COPDischaracterizedbyairflowlimitationanddyspnea.Thismaycontributetofeelingsofchronicanxiety.Additionally,manychronicdiseasesareassociatedwith depression.Thisisthecase withCOPD.A6-year-oldchildwhohasmoderatepersistentasthmaisdiagnosedwithpneumoniaafterchestX-rayand laboratory studies. He developed a sudden onset of fever with chills. He is in no distress. What isthepreferred treatmentfor him?(Amoxicillin)In children who are older than 5 years of age, the most common bacterial pathogen is an atypicalpathogen. Because this child has asthma and uses an inhaled steroid daily, the most likely pathogen isStreptococcus pneumoniae. An abrupt onset of fever and chills is suggestive of Streptococcalpneumonia. Amoxicillin is usually chosen first for its efficacy, cost, and tolerability. The higher dose (80-100mg/kg/d)ischosenbecauseoftheprevalenceofresistantStreptococcuspneumoniae.Azithromycinwould be chosenif an atypical pathogen was more likely. Doxycycline is not an appropriate choicebecauseithaspoorStrepcoverageanditiscontraindicatedinchildrenyoungerthan8years.Whatdiseaseisusuallymanagedwithashort-actingorlong-actinginhaledanticholinergicmedication?(COPD)First-linetreatmentforpatientswithCOPDwhohaveintermittentsymptomsofshortnessofbreathisananticholinergic medication because it improves lung function. Alternatively, a short-acting beta agonistmaybeused.Anticholinergicmedicationsarenotusedasaloneagentstomanagesymptomsofasthma;inhaledsteroidsusuallyare.Bronchitisisaviralinfectionthatisself-limitedandusuallydoesnotrequirean inhaled medication. Bronchiectasis is a disease in which the respiratory tubules are permanentlyenlarged.Symptomsincludechronic productionofpurulentmucous.Apatientwithpneumoniareportsthathehasrust-coloredsputum.Whatpathogenshouldthenursepractitioner suspect?(Streptococcuspneumonia)

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5Clinical descriptions of mucus do not really help in clinical decision-making regarding pneumonia, butcertain clinical characteristics are associated with specific types of pneumonia. Strep pneumonia, alsoknownaspneumococcalpneumonia,isassociatedwithrust-coloredsputum.Scantorwaterysputumisassociated with atypical pathogens like Mycoplasma and Chlamydophila pneumonia. Thick, discoloredsputummaybe associatedwithbacterialpneumonia.A44-year-oldnonsmokerisdiagnosedwithpneumonia.Heisotherwisehealthyanddoesnotneedhospitalization at this time. Which antibiotic can be used for empirical treatment of pneumoniaaccording to the most recent Infectious Diseases Society of America/American Thoracic Societyguidelines?(Azithromycin)The guidelines recommend macrolide use or doxycycline for initial treatment of uncomplicatedpneumonia in outpatients who are otherwise healthy and have not had recent antibiotic exposure. Theinitialchoicescanbeanyofthese:azithromycin,clarithromycin,ordoxycycline.Theseagentsarechosenbecause they cover atypical pathogens, the most likely pathogen in this population. Fluoroquinolonesare commonly used first line in these patients; however, the guidelines strongly recommend usingfluoroquinolonesforpatientswithcomorbiditiesorpatientswhohaverecentantibioticexposure.ThegoldstandardfordiagnosingpneumoniaonchestX-rayisthepresenceof:(Infiltrates)ThefindingofinfiltratesonchestX-ray,inconjunctionwithclinicalfindingsoffever,chestpain,dyspnea,and sputum production on clinical exam, should direct the examiner to consider pneumonia as thediagnosis.An83-year-oldhealthyadultisdiagnosedwithpneumonia.Heisfebrilebutinnodistress.Whatisthepreferredtreatmentforhim?(Levofloxacin)Atageextremes,themostcommonpathogenisStreptococcuspneumoniae.Becauseoftheageofthepatient and the consequences of potential treatment failure, a respiratory quinolone should beconsidered.QuinoloneantibioticscanproduceQTprolongationandshouldbeusedcautiouslyinolderadults. Azithromycin or doxycycline would be chosen if an atypical pathogen was suspected. This isunlikelyinthispatientbecauseof hisage.Thepneumococcalimmunizationininfantshas:(shiftedthepathogenesistofewercasesofS.pneumonia)Theheptavalentpneumococcalconjugatevaccine(PCV13),Prevnar,protectschildrenfrom13typesofpneumococcal bacteria. It has reduced the incidence of ear infections caused by S. pneumo and hasreducedtheincidenceofrecurrentearinfectionsandtubeplacementby10-20%.ThepathogenesisofacuteotitismediahasshiftedtomorecasesofH.influenzae,butthisorganismislesslikelytobecomeresistant,asStrep pneumohas.A 78-year-old adult who has a 50 pack year smoking habit asks the nurse practitioner about thebenefitsofquitting“atmyage.”Whatshouldthenursepractitionerreply?(Thiswilldecreaseyourriskofallcausemortality5 yearsafterstopping)Smoking cessation at any age is beneficial to the person engaging in smoking cessation. Datademonstratesthatafter5yearsofsmokingcessation,thereisasignificantdecreaseintheriskofdeath

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6fromcoronarydisease,cancer,andCOPD.ThepatientalreadyhasCOPDifhehasa50packyearhabit.Allpatientsshould becounseledtoquitsmokingregardlessofage.M.pneumoniaeandC.pneumoniaearerespiratorypathogensthat:(causeatypicalpneumonia)These two organisms are common causes of pneumonia. They are called atypical pathogens becausethey produce atypical pneumonia. They are transmitted via respiratory droplets from the nose andthroatofinfectedpeople.Prolongedclosecontactisprobablyneededfortransmissiontooccur.Patientsareusuallycontagiousfor10daysorso.Mostcommonly,theseinfectionsoccurinyoungerpatients,butall ages may be affected. Generally, the atypical pathogens are eradicated with macrolide antibiotics ortetracyclines.An18-month-oldchildisdiagnosedwithbronchiolitis.Hisrespiratoryrateis28breathsperminute.Whichchoicebelowismostappropriateforpatientmanagement?(Antipyretics)Bronchiolitis is a viral infection and antibiotics would be inappropriate for management. Since fevercommonlyaccompaniesbronchiolitis,antipyreticssuchasacetaminophenandibuprofenarecommonlyused.Bronchiolitisischaracterizedbywheezing.Anormalrespiratoryrateforan18-month-oldis20-30breaths/minute. Bronchodilators, especially nebulized, and inhaled/oral steroids are commonlyemployedtodecreaserespiratoryeffort.However,theseinterventionslackprovenbenefit,increasethecostof care,and havemany sideeffects.Howshoulda20-year-oldcollegeagestudentwhopresentswithcough,nightsweats,andweightlossbescreenedforTB?(ATB skintest)Screening for TB in this patient should take place with a skin test known as the Mantoux. A chest X-ray istypically performed after a positive skin test. A sputum specimen is used for diagnosis, not screening. Aquestionnaire is used for screening patients who have had a history of a positive TB skin test. Ifsymptomsareacknowledgedonthequestionnaire,achestX-raymaybeperformed.Thequestionnaireisused to prevent inappropriate exposure to radiation in patients in whom regular screening is required,likehealthcare providers.Anexampleofashort-actingbetaagonistis:(levalbuterol)Anexampleofashort-actingbetaagonistisalbuterolorlevalbuterol.Theseproviderapiddilationofthebronchioles and can give immediate relief for shortness of breath; hence the term for this class ofmedications: rescue medications. Salmeterol is a long-acting beta agonist. These should never be usedwithout an inhaled steroid to treat a patient with asthma. Mometasone and beclomethasone aresteroidscommonly usedtotreatpatientswithasthma.ApatientwithasthmausesonepufftwicedailyoffluticasoneandhasanalbuterolinhalerforPRNuse. He requests a refill on his albuterol inhaler. His last prescription was filled 5 weeks ago. WhatactionbytheNPisappropriate?(Increasethedoseoftheinhaledsteroid,refillthealbuterol)The patient is using his short-acting bronchodilator excessively if he needs a refill of his inhaler in only 5weeks. Inhalers typically contain 200 puffs. They should be used two or fewer times per week. Hisinhaled steroid dose should be increased and his albuterol inhaler should be refilled. In fact, he shouldnotbewithoutaprescriptionforthealbuterol.Considerationcouldbegiventoprescribingalong-acting

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7bronchodilatorandincreasingthesteroid,butthisisnotthebestchoicebecausethisdoesnotincludearefillofthealbuterolandthispatientcannotbewithoutaccesstoarescueinhaler.Patientswithasthma:(cancoughorwheeze)The second leading cause of cough in adults is asthma. Cough due to asthma is often accompanied byepisodic wheezing or dyspnea, though some patients with asthma only cough. This is termed “coughvariantasthma.”Theclinicalpresentationofasthmavariesbuthyper-responsivenessoftheairwaysisatypicalfinding.A26-year-oldbeingtreatedforcommunity-acquiredpneumonia(CAP)hasbeentakingazithromycin(standard dose) in therapeutic doses for 72 hours. His temperature has gone from 102° F to 101° F.Whatshouldbedone?(Stopazithromycinandinitiatearespiratoryquinolone)A 26-year-old with CAP should show improvement in symptoms in 24-48 hours if heis on appropriateantibiotictherapy.AzithromycintreatsatypicalpathogenslikeMycoplasmaandChlamydophila,but,haspoor Streptococcus coverage. The most likely pathogen in this age group that causes pneumonia is anatypical pathogen, but at this point the most common typical pathogen, Streptococcus pneumoniae,mustbeconsidered.ThebestchoiceistoconsiderStreptococcuspneumoniaeasthepathogenandtreatwith a respiratory quinolone. Specifically, this patientshould receive a respiratory quinolone because oftheincreasedincidenceofresistantStreptococcuspneumoniae (DRSP).A60-year-oldpatientnewlydiagnosedwithCOPDpresentstoyouroffice.Hewouldliketogettheinfluenzaimmunization.Hehasnoevidenceofhavinghadthepneumococcalimmunization.Whatstatementiscorrect?(Heshouldreceivebothinfluenzaandpneumococcalimmunizationstoday)ThispatienthasCOPD.Heshouldreceivethepneumococcalimmunizationtoday.Hebelongstoagroupof patients with chronic illness who are between the ages of 19 and 64 years and so, should beimmunizedforpneumonia.Thefluimmunizationshouldbegiventohimannually.WhichofthefollowingisNOTpartofthedifferentialforapatientwhocomplainsofcough?(Obesity)Alloftheotherconditionslisted,heartfailure,GERD,andasthma,areassociatedwithcough.Obesitydoesnot producecough andisnot associatedwith cough.A65-year-oldhasbeendiagnosedwithasthma.Olderpatientswhohavenewlydiagnosedasthma:(aremorelikelytocough)Asthma is usually diagnosed in children or young adults. Diagnosis after age 65 years is unusual, but 5-10% of newly diagnosed asthma patients are part of this age group. The most common presentation iscough,notwheezing.Exacerbationsaremuchlessvariablethaninyoungeradults.ThisisofteninitiallymisdiagnosedbecausethepatientpresentswithsymptomsthatseemmorelikeheartfailureorCOPD.A 67-year-old patient with COPD presents an immunization record that reflects having last receivedthepneumococcalimmunization(PPSV23)whenhewas60yearsold.Whichstatementbelowreflectsthe current standard of practice recommended by CDC for this patient?(He should be vaccinatedtoday withPCV13)TherecommendationbyCDCispneumococcalimmunizationonceatage65yearsregardlessofotherdiseasespresent.However,iftheinitialimmunizationwasgivenpriortoage65yearsand5yearshas

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8elapsed since the initial one, he should be revaccinated today. Two immunizations are available, PCV13andPPSV23.Heneedsboth,butPCV13shouldbeadministeredtoday.PPSV23shouldbeadministeredatleast1 yearlater.A 24-year-old college student who does not smoke is diagnosed with pneumonia. He is otherwisehealthyanddoesnotneedhospitalizationatthistime.Whatantibioticrepresentsthebestchoicefortreatmentforhim?(Clarithromycin)Amacrolide(likeazithromycinorclarithromycin)oratetracycline(likedoxycycline)isusedforinitialtreatmentofuncomplicatedpneumoniainoutpatientswhoareotherwisehealthyandhavenothadrecent antibiotic exposure. These agents are chosen because they cover atypical pathogens (theorganismmostlikelytohaveinfectedhim)andprovidecoverageagainstnondrug-resistantformsofStreptococcus.Fluoroquinolonesarecommonlyusedfirstlineinthesepatients.However,guidelinesstrongly recommend using fluoroquinolones for patients with comorbidities and/or those who havesuspected macrolide resistant strains of Streptococcus. Inappropriate use of fluoroquinolones willpromotedevelopmentoffluoroquinolone-resistantpathogens.Whatdoesapeakflowmetermeasure?(Expiratoryflow)A peak flow meter measures peak expiratory flow; that is, air flow out of a patient’s lungs. Peak flow issensitive to changes in the respiratory tubules and so reflects narrowing of the airways. The utility of apeakflowmeterisespeciallyimportantforpatientswithasthmabecauseoftherapidchangesthatoccurprior to the onset of an asthma exacerbation. There is minimal to no benefit of measuring these airwaychangesinpatientswith COPDand pneumonia.Themajorlaboratoryabnormalitynotedinpatientswhohavepneumococcalpneumoniais:(leukocytosis)An increased white count is typical in patients with bacterial pneumonia such as pneumococcalpneumonia. Eosinophils can be increased in patients who develop pneumonia secondary to exposure toa very irritating substance like a toxic gas. Gram stain can demonstrate gram-positive or negativepathogens.Leukopeniaisanominousfinding,especiallyinolderpatients.Thisindicatesapoorprognosisbecauseitmeansthattheimmunesystemisnotrespondingtoapotentiallyfatalpathogen.Whichdrugclassisneverusedtotreatchronicobstructivepulmonarydisease(COPD)?(Leukotrieneblockers)ThereisnodatatosuggestefficacyintreatingCOPDpatientswithleukotrieneblockerslikezafirlukastormontelukast.Along-actingbronchodilator(usedtwicedaily)likesalmeteroliscommonlyused.Thelong-acting anticholinergic medication tiotropium can be used once daily. Systemic steroids may be used forexacerbationsof COPD.A patient who has asthma presents with chest tightness, wheezing, coughing, and fever. He haswheezinganddiminishedbreathsoundsintheupperrightlobe.Hiscoughisnon-productive,andhedeniesnasalsymptoms.Whichsymptomismostlikelyrelatedtopneumonia?(Fever)Thepresenceoffevershouldtriggerthepractitionertoconsiderpneumonia.Theothersymptomsaremostlikelysecondarytoasthma.Coughingmaybeduetoasthmaandpneumonia.

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9ApatientwithCOPDhasbeenusingalbuterolwithgoodreliefforshortnessofbreath.Heisusingit3-4timesdailyoverthepast4weeks.HowshouldtheNPmanagethis?(Addalong-actingbetaagonist)Thepatientisusingalbuteroltoofrequently.Itshouldbeusednomorethantwiceweeklybecauseitwillloseitseffectivenessovertime(tachyphylaxis).Albuterolshouldbeusedasarescuemedicationonly.This patient’s medication regimen needs adjusting. The best choice is to consider adding a long-actingbetaagonist(orlongactinginhaledanticholinergic)andhavehimusealbuterolasarescuemedicationonly.WhichofthefollowingmaybeusedtodiagnoseCOPD?(Pulmonaryfunctiontestsorspirometry)Spirometry or pulmonary function tests (PFTs) are essential to diagnose COPD. The most importantmeasures are the FEV1 (forced expiratory volume in one second) and FVC (forced vital capacity). ChestradiographhasapoorsensitivityindiagnosingCOPD.OnlyabouthalfofpatientswithmoderatelysevereCOPD can be diagnosed using chest radiography alone. CT scan is able to identify emphysema, but notchronic bronchitis. Arterial blood gases demonstrate hypoxia, but a specific cause is not able to bedeterminedfrom thistest alone.Apatientwithacutebronchitiswasdiagnosedatanurgentcarecenter10daysago.Hereportsthathereceivedanantitussivefornighttimecough,asteroidinjectionandoralsteroids,andanantibiotic.Whichoftheseinterventionswasofgreatestbenefitinresolutionofhissymptoms?(Noneofthem)Acute bronchitis is almost always due to a viral infection. The antibiotic had no effect in symptomresolution.Unfortunately,antibioticsarecommonlygivenforacutebronchitis.Thereisnoevidencetosupport use of steroids as they do not result in quicker resolution of symptoms than placebo. In fact,multiple studies have failed to demonstrate benefit. Time isof greatest benefit in resolution of acutebronchitissymptoms.A65-year-oldpatienthasCOPD.Shereceivesaprescriptionforanalbuterolinhaler.Whatmedicationinformationshouldbeprovidedtothispatient?(Thismay causetachycardia)An example of an inhaled beta agonist is albuterol or levalbuterol. These agents stimulate the betareceptors in the lungs and in the heart. This helps the patient breathe better because it producesbronchodilation, but it potentially can produce arrhythmias or angina because beta receptors in theheart can become stimulated too. The dose for a patient with underlying cardiac problems is half thedose(andusedwithcaution).Commonsideeffectsoftheseagentsarejitteriness,tremor,nervousness,andpotentially hypokalemiaif usedon aregular basis.A patient presents with symptoms of influenza during influenza season. He has not received theimmunizationagainstinfluenza.Whatshouldbeusedtohelpdiagnoseinfluenzainhim?(Anasalswab)Influenzaisdiagnosedbasedontheresultsofafluswabandthepatient’sclinicalpresentation.Apatientwith influenza usually demonstrates influenza A (the most predominant strain during an outbreak) orinfluenza B (the strain identified occasionally during flu season but more often, throughout the rest oftheyear)if he isinfected.Themostcommoncauseofpneumoniainpeopleofallagesis:(S.pneumonia)

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10Streptococcus pneumoniae (S. pneumo) is the most common pathogen in community-acquiredpneumonia(CAP)worldwide.Itismorecommoninageextremes(theveryyoungandveryold)andduring winter months. Group A Strep can cause a fulminant pneumonia even in patients who areimmunocompetent. Mycoplasma is the most common atypical pathogen that causes pneumonia.Staphylococcuspneumoniaismorecommonpostinfluenzaintheveryyoungandveryold.Apatientrecentlyreceivedlevofloxacinfor7daystotreatpneumonia.Hisrespiratorysymptomshaveresolved,buttodayhecallstheoffice.Hereportshavingseverewaterydiarrhea,abdominalcramping,andlow-gradefever. Whatshouldbedone?(Ordera stoolspecimen)This history of recent antibiotic exposure suggests C. difficile. A stool specimen should be ordered toassessforinfectionwithC.difficile.SomeclinicianswillinitiatetreatmentforC.difficilebasedonthishistory,especiallyifthepatient’ssymptomsaresevereorthepatientiselderly/debilitated.A20-year-oldcollegeagestudenthasapositiveTBskintest.Whichchoicelistedbelowprovidesdefinitive diagnosisof tuberculosis?(Asputumspecimen)Screening for TB is performed with a skin test known as the Mantoux. A chest X-ray is typicallyperformedafterapositiveskintest,butisnotdiagnosticsinceTBcanaffectorgansotherthanthelungs.A sputum specimen is used for definitive diagnosis. A questionnaire is used for screening patients whohave had a history of a positive TB skin test. If symptoms are acknowledged on the questionnaire,generally, a chest X-rayis performed. The questionnaire is used to prevent too frequent exposure toradiationinpatientsinwhomregularscreeningisrequired,likehealthcareproviders.Apatienthascough,pharyngitis,nasaldischarge,andfever.Hehasbeendiagnosedwithacutebronchitis.Whichsymptomisleastlikelyinthefirst3daysofthisillness?(Cough)Cough is the most common symptom associated with acute bronchitis and almost always appears afterday3oftheillness.Inthefirstfewdaysofacutebronchitis,upperrespiratorysymptomspredominate.Infact, it may be impossible to distinguish upper respiratory infection from acute bronchitis. Pharyngitisandnasaldischarge/congestionarecommonondays1-3.Acutebronchitisissuggestedwhencoughlastslonger than 5 days. Fever is a relatively uncommon symptom of acute bronchitis. When fever appearsalongwith cough,pneumonia shouldbe stronglyconsidered.WhichofthefollowingcharacteristicsisalwayspresentinapatientwithCOPD?(Obstructedairways)COPD,chronicobstructivepulmonarydisease,ischaracterizedbyobstructedairways.TheobstructionisNOTcompletelyreversibleevenwithmedicationuse.Productivecoughislikelypresentinpatientswithchronic bronchitis but not necessarily emphysema. Shortness of breath does not have to be present (orperceived in patients with COPD). Hypercapnia is more prevalent in patients with emphysema since airtrappingoccurs.“Goodcontrol”ofasthmaismeasuredbythenumberoftimesweeklyapatientusesarescueinhaler.Whatchoicebelowindicates“goodcontrol”?(Onceweekly)Goodasthmamanagementischaracterizedbyusingshort-actingbronchodilators(rescuemedication)nomore than twice weekly during daytime or twice monthly at nighttime. Using short-acting inhaledbronchodilators 2 times weekly necessitates use of prophylactic medications such as inhaled steroidsandpossibleuseoflong-actingbronchodilatorsinconjunctionwithinhaledsteroids.

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11Mr.Smithhassmokedfor45years.Whichofthefollowingmedicationsmayworsenoneofhisdiseases?(Propanolol)PropanololisanonselectivebetablockerandmightbepotentiallymoreharmfulinapatientwhohasCOPD than a cardioselective beta blocker. Metoprolol is a cardioselective beta blocker. Typically,cardioselectivebetablockersexerttheireffectonthebetareceptorsintheheart,butnotalways.Sometimesthereiseffectonthebetareceptorsinthelungs.Thiscouldproduceshortnessofbreathandwouldbedescribedasadrug-diseaseinteraction.Noncardioselectivebetablockerslikepropanololhavea worse effect than cardioselective ones. In any event, beta blocker use should be avoided or used withcautionin patientswhohavelowerairway disease.Themostcommonsequelaofinfluenzainolderadultsis:(Pneumonia)Morethan90%ofdeathsassociatedwithinfluenzaoccurinolderadults.Pneumoniaisthemostcommon cause of death and most common reason for hospital admission in older patients withinfluenza.AnnualinfluenzaimmunizationisrecommendedforalladultsintheUnitedStates.Ahealthy7-year-oldchildisdiagnosedwithatypicalpneumonia.Heisfebrilebutnotindistress.Whatisthepreferredtreatmentforhim?(Azithromycin)In this age group (> 5 years), the most common atypical pathogens are Mycoplasma or Chlamydophila.Therefore,amacrolideantibioticlikeazithromycinisthepreferredagent.Itisusuallychosenfirstforitscoverageofatypicalpathogens.Doxycyclineisnotanappropriatechoicebecauseitiscontraindicatedinchildrenyoungerthan8years,however,itdoesprovidecoverageagainsttheatypicalpathogens.Amoxicillinprovidesnocoverageofatypicalpathogensandsoitisapoorchoice.A30-year-oldpatientwithintermittentasthmaisusinghis“rescue”medicationoncedaily.Howshouldthisbemanaged?Heshouldreceiveaprescriptionfora(n):(aninhaledsteroid)The patient is using his bronchodilator (“rescue” medication) more than twice weekly. This is a signal tothehealthcareproviderthatthepatient’sasthmaisnotwellcontrolledandanothermedicationneedstobe used. The next step for this patient is atrial of an inhaled steroid. This should relieve his symptomsand decrease the use of his rescue medication. If an inhaled bronchodilator is overused, it will notcontinuetoproducebronchodilation overtime.Whichchoicebelowmostappropriatelydifferentiatesacutebronchitisfrompneumoniainapatientwhohas a productivecough?(ChestX-ray)Nearly all cases of pneumonia can be identified on chest X-ray by the presence of infiltrates. Patientswith bronchitis have a normal chest X-ray unless there are other underlying pathologies. CBCs helpdistinguish bacterial from viral infections. Fever is not used to differentiate acute bronchitis frompneumonia.Sputumspecimensareindicatedwhenthereisaneedtoidentifyorganismsinthesputum.Themostcommoncauseofpneumoniainanotherwisehealthy3-year-oldchildis:(aviralinfection)In children who are 6 months to 5 years of age, the most common cause of pneumonia is a viralpathogen.Rarelyarestudiesperformedtoidentifyviralpathogens,howeveroneofthemostcommonviralpathogensisrespiratorysyncytialvirus(RSV).S.pneumoniaeisacommoncauseofpneumoniain

NR511 Nursing Diagnosis Midterm Exam With Answers (401 Solved Questions) - Page 13 preview image

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12veryyoungchildren,itisalsoimplicatedinolderadultsasacausativeagentinpneumonia.Inyoungandmiddleadults,Mycoplasma isacommon pathogen.Whichmedicationbelowshouldbeavoidedinapatientwithstage3COPD?(Coughsuppressantwithcodeine)Codeineshouldbeavoided(orusedwithextremecaution)becausethesedativeeffectofcodeineoranynarcoticcanpotentiallyworsenrespiratorydepressionandworsenhypercapnia.A patient with acute bronchitis and cough for 5 days calls to report that his cough is productive ofdiscoloredsputum.Hehasnoothernewsymptoms.Howshouldthenursepractitionermanagethis?(Continuetheoriginalplanofcare)This is the typical course of acute bronchitis. Acute bronchitis is characterized by cough lasting greaterthan 5 days, but usually less than 20 days. More than 50% of patients report discolored sputum. Sincetheoverwhelmingmajorityofcasesofacutebronchitisaresecondarytoviralcauses,antibioticsarenotindicated. Discolored sputum is related to sloughing of epithelial cells and is the reason for thediscoloration. Discolored sputum does not indicate bacterial infection. The CDC recommends treatingacute bronchitis with antibiotics ONLY when the etiology is pertussis. In all other cases, the patientshouldbetreatedwithsupportiveandsymptomaticmanagementonly.Apatienthasreceivedaprescriptionforlisinopril.Whichsideeffectmostcommonlyoccurswiththismedication?(Drycough)A common side effect of ACE inhibitors is dry cough. Though estimates vary, 5-20% of patients whoreceiveACEinhibitorsdevelopacough.Angiotensinconvertingenzymeisbelievedtoberesponsibleformetabolism of bradykinin in the lungs. Bradykinin is thought to be responsible for the cough because itinduces production of arachidonic acid metabolites and nitric oxide. These substances may promotecough.ThecoughassociatedwithACEinhibitors appears tobeaclasseffect.A24-year-oldpresentswithfever,rhinorrhea,andparoxysmal,high-pitchedcough.Thisis:(Pertussis)Pertussis is also called “whooping cough.” This is a highly communicable respiratory disease caused byBordetellapertussis.Therearethreerecognizedstagesofpertussis:thecatarrhalphase,theparoxysmalphase,andconvalescence.Moreadultsthanchildrenhavecontractedpertussisinthelastdecade.Sincethe outbreak of pertussis in Iowa in 2005, diminished titers were recognized and adolescents are beinggivena boosterwithTdaPat 11-12yearsofage.A60-year-oldpatientreportschroniccoughandsputumproduction.Hehasalonghistoryofexposuretosecondhandcigarettesmokefromhiswife.Whatdiagnosisismostlikely?(COPD)This patient’s exposure to secondhand cigarette smoke from his wife represents a risk factor for COPDeventhoughthispatientdoesnotsmoke.COPDmustbeconsideredinanyonewithahistoryofchroniccoughandsputumproduction,dyspneaatrestorexertion,andhistoryofexposuretotobaccosmoke.Apatientisdiagnosedwithasthma.Whichquestionismostimportanttoaskwhendecidingonmedicationmanagement?(Howoftendoyoursymptomsoccur?)Diagnosis of asthma, as well as pharmacologic management of asthma, is based on frequency ofoccurrenceofsymptoms(wheezing,shortnessofbreath,cough,etc.).Bronchodilators,bothshortand

NR511 Nursing Diagnosis Midterm Exam With Answers (401 Solved Questions) - Page 14 preview image

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13long-acting, and inhaled steroids, represent the cornerstone of management of most patients who haveasthma.Notallpatientswithasthmawheeze,therefore,askingthatquestionmightnotbeofgreathelp.Severity of symptoms is subjective. Smoking cessation is important, but not a determinant in selectingmedicationsforasthma management.Breathsoundsauscultatedovertheperipheryofthelungfieldsarequietandwispyduringtheinspiratoryphasefollowedbyashort,almostsilentexpiratoryphase.Thesebreathsoundsareconsidered:(Vesicular)Thethreenormalbreathsoundsarevesicular,bronchovesicular,andbronchial.Vesicularbreathsoundsconsist of a quiet, wispy inspiratory phase followed by a short, almost silent expiratory phase. They areheard over the periphery of the lung fields. Bronchial breath sounds consist of a full inspiratory andexpiratory phase with the inspiratory phase usually being louder. They are normally heard over thetracheaandlarynx.Bronchovesicularbreathsoundsconsistofafullinspiratoryphasewithashortenedand softer expiratory phase. They are normally heard over the hilar region. Crackles are adventitioussoundsheardin thelungsandmay bedue toabnormalitiesinthe lungs.GIThetwoteststhatcanindicatecurrentinfectionwithhepatitisBare:(presenceofhepatitisBsurfaceantigenandIgM)The earliest serologic marker that indicates acute hepatitis B infection is the presence of hepatitis Bsurfaceantigen.Itbecomespositiveabout1-10weeksafterinfection,butusuallybeforesymptomonset.ApositiveIgMindicatescurrentinfection.ThepresenceofhepatitisBcoreantibodyidentifieshepatitisBinfection(presentorpast)withcertainty.Itdoesnotindicatetimingofinfection.A mother of a 4-week-old infant visits your office. She states that her baby is vomiting after feedingandthencriesasifheishungryagain.Whatshouldthenursepractitionerassess?(Hisabdomenforanolive shapedmass)The symptoms likely reflect pyloric stenosis. The most common time for this to occur is 3-6 weeks. Itrarelyoccursafter12weeksofage.Babieswhohaveepisodesofprojectilevomitingandwhodemandtoberefedarecalled“hungryvomiters”andadiagnosisofpyloricstenosisshouldbeconsidered.Theolive-shaped mass, if found, probably represents hypertrophy of the lateral edge of the rectus abdominusmuscle. It is most easily felt immediately after vomiting. This diagnosis is made much earlier now than itusedtobe,soproblemswithdehydrationarenotascommonasdecadesago.Apatienthasthefollowinglaboratoryvalue.(anti-HAVIgG:positive).Whatistheclinicalinterpretation?(He has immunitytohepatitisA)ThispatientisimmunetohepatitisbecausehehasapositiveimmunoglobulinG(IgG).Thissignifiesimmunity secondary to: (1) past infection, or (2) immunization. A negative IgG signifies absence ofimmunitytohepatitis Aandsusceptibility if exposed.Theearlysignsandsymptomsofappendicitisinanadult:(aresubtle)Themostconsistentfindingsinadultswithearlypresentationofacuteappendicitisaresubtleanddifficulttoidentify.Symptomsmaybeasvagueasindigestion,flatulence,andafeelingofill-being.

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14Initially,paincanbeinthegeneralabdomen,thenbecomeperiumbilical,andfinallylocalizetothelowerrightquadrant.Earlysymptomsaredifficulttoidentify,especiallyinolderadults.A70-year-oldpresentstothenursepractitioner’sofficeforawellexamtoday.Whatmedicationprobablyhasnoeffectonscreeningforoccultbloodinthestool?(Acetaminophen)The exam for occult blood is a screen for colorectal cancer. Aspirin, clopidogrel, NSAIDs, warfarin alldecrease the positive predictive value of the test because they all can exacerbate bleeding if it isoccurring in the colon secondary to a polyp or tumor. Ideally, the medications mentioned (exceptacetaminophen)wouldbestoppedpriortotheexamtoincreasethelikelihoodoftestsensitivity,butthisisnot alwayspossible.Symptomsofuncomplicatedrefluxdiseaseinolderadultsshouldbetreated:(withempirictreatment)In older patients without signs of complicated GERD (choking, cough, shortness of breath, pain withswallowing or in the chest), empiric treatment is appropriate. Empiric treatment can take place usingprotonpumpinhibitorsorH2blockers.IfH2blockersareused,famotidineandnizatidinearepreferredbecause of their efficacy and low risk of drug-drug interactions. If symptoms of GERD persist despiteinitialtreatment,orifsymptomsaresevere,patientsshouldhavetestingtoruleoutesophagealcancer,Barrett’sesophagitis,orotherconditionsoftheesophagusandthroat.WhichsymptomisINCONSISTENTwithirritablebowelsyndromeinolderadults?(Onsetafter50yearsofage)Irritable bowel syndrome (IBS) is common in adults and lasts into older adulthood, but symptoms startprior to age 50 years. Typical symptoms of IBS are diarrhea and constipation intermittently, abdominalpain(oneofthecriteriafordiagnosis),andbloating.OthersymptomsthatareinconsistentwithIBSareassociated weight loss, blood in the stool, rectal bleeding, and nocturnal diarrhea. These are moreindicativeofinflammatorydiseaseorcarcinoma ofthe bowel.A 20-year-oldfemale patient presents with tenderness at McBurney’s point. Appendicitis isconsidered.Whatlaboratorytestshouldbedoneinitiallytodeterminetheetiologyofthispatient’sabdominalpain?(Serumpregnancy test)A serum pregnancy test should be performed since this patient could have an ectopic pregnancy. Oncepregnancyisruledout,otheretiologiescanbeevaluated.CBCwithanelevatedwhitecountmayindicatethat an infection is present. It does not indicatea specific location of the infection. Urinalysis could helpdetermine if the etiology is a urinary tract infection. Symptoms can mimic an appendicitis. Positivevaginalswabscouldindicatepelvicinflammatorydiseaseasthecauseofthepain.Apatientwithasuspectedinguinalherniashouldbeexamined:(standing)Thepatientshouldbeexaminedwhileheisstanding.Heshouldbeaskedtobeardown,cough,orstrainduring the exam. Though hernias are far more common in males, they can be found in females too. Inmales, the patient should be asked to stand. The examiner should put his 2nd or 3rd finger through thescrotumandintotheexternalring.Whenthepatientisaskedtocough,a“silky”feelwillbuttupagainsttheexaminer’sfinger,andthehernia canbe easilyfelt.

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15A healthcare provider (“the HCP”) was stuck with a needle from a patient suspected to be infectedwithHIV(“thepatient”).ArapidHIVtestwasperformedonthepatientandfoundtobepositive.Thismeansthat:(theHIV statusofthepatientrequiresfurthertesting)TherapidHIVisalwaysperformedonthesourcepatient(“thepatient”).ItisknownasanELISA(enzymelinkedimmunosorbentassay).InthepatientsuspectedofbeingHIVpositive,itisperformedtoestablishwhether or not he was positive at the time of the needle stick. In this case, it was found to be positive,but, this is a screening test, and false positives can occur. Therefore, a confirmatory test, the westernblot, is routinely performed on the patient’s specimen to confirm the findings of the ELISA. Thehealthcare provider will usually be tested with a rapid HIV but it is done to establish HIV status at thetimeoftheneedlestick.Theresultsofarapidtestcanbeperformedinlessthan20minutes.A patient has had right upper quadrant pain that has lasted for the past 3 days, but the pain hasbecomeacuteinthepast12hours.Hehaslow-gradefever.Whichlabtest(s)willbeelevatedifhehaspancreatitis?(Serumamylase)Serumamylaselevelsbegintorise6-12hoursafterpancreaticinsultandremainelevatedfor3-5days.Theothertestsdescribedmaybeabnormalbutarenotspecificfor pancreatitis.Apatientpresentswithcomplaintsofbrightredstoolsoverthepastweek.Thissymptomcouldbeconsistent with:(cancer ofthesigmoidcolon)Brightredbloodinthestoolsismorecharacteristicofleft-sidedcoloncancer(descendingandsigmoidcolon)orrectalhemorrhoids.Ifbloodoccursinthestoolinright-sidedcoloncancers(ascendingcolon)orgastriculcers,the stoolwillbeblackandtarry.A 24-year-old female presents with pain and tenderness in the right lower abdominal quadrant. Herpelvicexamandurinalysisarewithinnormallimits.HerWBCiselevatedandherurinepregnancytestisnegative.Whatispartofthedifferential diagnosis?(Appendicitis)ACBCwithamildelevationinwhitecellcountindicatesthatinfectionislikely.Thisfindingispresentinmost patients who have acute appendicitis. Right lower quadrant abdominal pain, anorexia, andnausea/vomitingareconsideredclassicsymptomsofacuteappendicitis.Pelvicinflammatorydiseaseischaracterized by cervical motion and adnexal tenderness on bimanual examination. Purulentendocervical discharge may be present. This is unlikely in the presence of a normal pelvic exam. Acutepelvicpainandapositivepregnancytestinwomenofchildbearingagemaysuggestectopicpregnancy.The patient’s pregnancy test is negative. Symptoms of a urinary tract infection (UTI) can mimicappendicitis,butthiscanberuledoutwiththepatient’snormalurinalysisreport.WhatmedicationusedtotreatpatientswhohaveGERDprovidesthefastestreliefofheartburnsymptoms?(Calciumcarbonate)Calciumcarbonateisanantacid.ItprovidesrapidchangesingastricpH.Thisprovidesreliefthatcanbenoticed immediately. The increase in pH lasts for about 30 minutes and corresponds with resolution ofsymptoms. However, as pH decreases within 30 minutes, symptoms may return. Ranitidine is an H2blocker.Itprovidesreliefin1-2hours.Thisusuallylastsforabout6-12hours.AmantadineisanantiviralnotusedtotreatGERD.Pantoprazoleisaprotonpumpinhibitor.Thisprovidesreliefafterseveralhoursordaysof dailyconsumption.

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