NR 661 Ears, Eyes, Nose, and Throat (EENT) Exam (GRADED A+) Questions and Answer elaborations | 100% Guaranteed Pass

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NR 661 Ears, Eyes, Nose, and Throat (EENT) Exam 1. A 30 year old male has been diagnosed with non-allergic rhinitis. What finding is more likely in non-allergic rhinitis than allergic rhinitis? ... Older age of symptom onset Male gender Post nasal drip Sneezing Older age of symptom onset Explanation: Non-allergic rhinitis, often called vasomotor rhinitis, is very common in the US. It is typically diagnosed and differentiated from allergic rhinitis by history. Although both conditions may co-exist in patients, non-allergic rhinitis typically has onset after age 20 years. Allergic rhinitis typically presents prior to age 20 years. The most common symptoms associated with non-allergenic rhinitis are nasal congestion and post-nasal drip. It is predominantly reported in females. Common precipitants of non-allergic rhinitis symptoms can occur with exposure to spicy foods, cigarette smoke, strong odors, perfumes, and alcohol consumption. This is frequently treated with topical azelastine. 2. The throat swab done to identify Streptococcal infection was negative in a 12 year-old female with tonsillar exudate, fever, and sore throat. What statement is true regarding this? A second swab should be done to repeat the test. The patient does not have Strept throat. The patient probably has mononucleosis. A second swab should be collected and sent to microbiology. A second swab should be collected and sent to microbiology. Explanation: A second swab is collected, but it is not used to repeat the test. The second swab is sent to microbiology for culture. The sensitivity varies in office Strept tests. Some are as low as 50% and a second swab should be collected. If beta-hemolytic Strept organisms are grown out, then the patient can be diagnosed with Streptococcal infection 3. What is the usual age for vision screening in young children? 2 years 3 years 4 years 5 years 3 years Explanation: Initial vision screening should take place at 3 years of age. If the child is not cooperative, screening should be attempted 6 months later. If the child is still not cooperative at 3.5 years, it should be attempted at 4 years. Generally, children are cooperative at 4 years of age. The usual vision of a 3 year- old is 20/50 4. Epstein-Barr virus is responsible for: mononucleosis. the most common cause of pharyngitis. most teenage cases of pharyngitis. viral pharyngitis in young children. mononucleosis. Explanation: Infectious mononucleosis is caused by Epstein-Barr virus (EBV). This commonly affects adolescents but can affect various age groups. The most prominent feature of mononucleosis is fever, fatigue and pharyngitis. 5. A patient with environmental allergies presents to your clinic. She takes an oral antihistamine every 24 hours. What is the most effective single maintenance medication for allergic rhinitis? Antihistamine Decongestant Intranasal glucocorticoids Leukotriene blockers Intranasal glucocorticoids Explanation: These agents are particularly effective in the treatment of nasal congestion and would be a good choice for the patient in this scenario. Intranasal glucocorticoids are effective in relieving nasal congestion, discharge, itching, and sneezing. A trial of stopping the oral antihistamine could be tried in this patient. Symptoms would determine whether the antihistamine should be resumed. 6. Conjunctivitis: produces blurred vision in the affected eye. usually begins as a viral infection. produces anterior cervical lymphadenopathy. is common in patients who are nearsighted. usually begins as a viral infection. Explanation: Conjunctivitis or "pink eye" usually begins as a viral infection. As the conjunctiva becomes irritated, the eye is rubbed and fingers introduce bacteria. A secondary bacterial infection develops. Conjunctivitis produces a red (or pink) eye, but should never produce blurred vision. A patient with a red eye and blurred vision should be referred to ophthalmology. The pre-auricular nodes may be palpable when a patient has conjunctivitis, not the anterior cervical ones. 7. At what age would it be unusual to see thrush? At birth 2 months 6 months 8 months At birth Explanation: Thrush is an infection in the oral cavity caused by yeast. Yeast grow in a warm, dark, moist environment. It is not unusual to see thrush in young infants who are breast or bottle fed. It would be unusual to see thrush in a newborn. In fact, this should cause concern regarding an immunocompromised state in the infant or hyperglycemia in the mother. 8. A patient presents with severe toothache. She reports sensitivity to heat and cold. There is visible pus around the painful area. What is this termed? Pulpitis Caries Gingivitis Periodontitis Pulpitis Explanation: The predominant symptom of patients who exhibit pulpitis is pain especially elicited by thermal changes, cold and hot. The pain can become severe and patients are ill appearing. Pus may be seen around the gum area or may be restricted to the pulp cavity. Caries and gingivitis do not produce pus. Periodontitis is characterized by gingival inflammation and pain. Pus is not present in this disease. A periodontal abscess produces pain and pus, but the pus is usually only expressed after probing. 9. How long should a 6 year old with acute otitis media be treated with an antibiotic? 5 days 5-7 days 10 days Until the erythema has resolved 5-7 days Explanation: The recommendations from the American Academy of Pediatrics are 5-7 days of an antibiotic for children 6 years and older who have mild to moderate acute otitis media (AOM). Children less than 2 years of age should be treated for 10 days. Children 2 years and older may be treated for 5-7 days for AOM if they do not have a history of recurrent AOM. 10. A patient is diagnosed with otitis externa. He complains of tragal pain, otic discharge, otic itching, and fever. What is the cardinal symptom of otitis externa? Tragal pain Otic discharge Otic itching Fever Tragal pain Explanation: Otitis externa is "swimmer's ear". This is a superficial infection usually caused by Pseudomonas in the external canal. Fever, a typical systemic symptom is inconsistent with otitis externa since the infection is superficial. The other symptoms listed are typical of patients who are diagnosed with otitis externa. However, the cardinal symptom is tragal pain. 11. A patient presents to a nurse practitioner clinic with paroxysmal sneezing, clear rhinorrhea, nasal congestion, facial pain. Which symptom below is NOT associated with allergic rhinitis? Sneezing Rhinorrhea Nasal congestion Facial pain Facial pain Explanation: Facial pain is not associated with allergic rhinitis. In conjunction with nasal congestion, it is most likely a sinus infection. Patients with allergic rhinitis and nasal congestion are more likely to develop acute and chronic bacterial sinusitis because untreated allergic rhinitis results in impaired mucus flow. This increases the risk of infection. Symptoms of bacterial sinusitis include nasal congestion, purulent post- nasal drip or rhinorrhea, facial pain and maxillary tooth pain. There is no symptom that can differentiate bacterial from viral sinusitis. 12. An NP examines a screaming 2 year-old. A common finding is: nasal discharge. increased respiratory rate. pink tympanic membranes. coarse breath sounds. pink tympanic membranes. Explanation: The tympanic membrane normally becomes pink and can rarely become red when a child is screaming or crying. This is probably due to flushing and hyperemia of the face that occurs with crying. A distorted or erythematous tympanic membrane with decreased mobility is suggestive of otitis media. 13. A patient diagnosed with Strept throat received a prescription for azithromycin. She has not improved in 48 hours. What course of action is acceptable? The patient should wait another 24 hours for improvement. The antibiotic should be changed to a first generation cephalosporin. A different macrolide antibiotic should be prescribed. A penicillin or cephalosporin with beta lactamase coverage should be considered. A penicillin or cephalosporin with beta lactamase coverage should be considered Explanation: The patient should demonstrate improvement after 48 hours if an antibiotic with the appropriate antimicrobial spectra was prescribed. A macrolide would be a poor choice because there are high rates of Strept resistance to macrolide antibiotics. In light of this, strong consideration should be given to an antibiotic with different antimicrobial spectra. Since Strept was diagnosed and azithromycin was ineffective, the prescriber should consider that the causative agent has macrolide resistance and could be beta lactamase producing. An antibiotic with beta lactamase coverage should be considered. Choice d provides this coverage. 14. A 93 year-old demented adult has been recently treated for an upper respiratory infection (URI) but drainage from the right nostril persists. What should the NP suspect? Allergic rhinitis Presence of a foreign body Unresolved URI Dental caries Presence of a foreign body Explanation: Two clinical clues should make the examiner suspect a foreign body. First, the patient has continued drainage despite treatment. Second, the drainage is unilateral. Unilateral drainage from a nostril should prompt the examiner to visualize the turbinates. In this case, a foreign body could probably be visualized. 15. A 32 year-old patient is a newly diagnosed diabetic. She has developed a sinus infection. Her symptoms have persisted for 10 days. Six weeks ago she was treated with amoxicillin for an upper respiratory infection. It cleared without incident. What should be recommended today? Prescribe amoxicillin again. Prescribe amoxicillin-clavulanate today. Do not prescribe an antibiotic; a decongestant is indicated only. Prescribe a decongestant and antihistamine. Prescribe amoxicillin-clavulanate today Explanation: Amoxicillin is no longer indicated for initial treatment in adults who have acute bacterial sinusitis. A bacterial cause can be assumed since she's had symptoms for 10 days. A viral infection likely would have run its course by now. After 10 days of persistent symptoms, treatment is reasonable with an antibiotic; especially since this patient is diabetic. She may be having blood sugar elevations that facilitate growth of the causative organism of the sinus infection. A decongestant could be added depending on her blood pressure and personal history of using decongestants. 16. AV nicking may be identified in a patient with what disease? Glaucoma Cataracts Diabetes Hypertension Hypertension Explanation: Arteriovenous nicking (AV nicking), or nipping, is commonly seen in patients who have hypertension. It represents retinal microvascular changes. These are typically early changes and usually reflective of current and past blood pressures. More severe damage can be seen when flame hemorrhages or cotton wool spots are identified. These often represent current blood pressure elevations since these tend to be more acute evidence of elevated blood pressure. 17. When examining the vessels of the eye: the veins are smaller than the arteries. the arteries are smaller than the veins. the arteries are dark red. the arteries pulsate. the arteries are smaller than the veins. Explanation: The arteries are 2/3 to 4/5 the diameter of the veins. The arteries appear as light red in color; veins are darker red. Interestingly, the veins in the eyes pulsate; the arteries do not. Loss of venous pulsations can be identified in patients with head trauma, meningitis, or elevated intracranial pressure. 18. The nurse practitioner performs a fundoscopic exam on a patient who has recently been diagnosed with hypertension. What is the significance of AV nicking? This is an incidental finding. This is indicative of long standing hypertension. The patient should be screened for diabetes. The patient should be referred to ophthalmology. This is indicative of long standing hypertension Explanation: Normally, veins are larger than arteries in the eyes. The vessels in the eyes are particularly susceptible to increased blood pressure. AV (arterio-venous) nicking can be observed as arteries cross veins when the arteries have narrowed secondary to hypertension. Generally, AV nicking takes time to develop and would be expected in patients with long standing hypertension; especially when it is poorly controlled. Cotton wool exudates should prompt the examiner to screen for diabetes. An ophthalmology referral is not required at this point for AV nicking. In severe hypertension, the retina can become detached. 19. A patient presents to clinic with a complaint of a red eye. Which assessment below rules out the most worrisome diagnoses? Usual visual acuity Normal penlight exam Normal fundoscopic exam Negative photophobia Usual visual acuity Explanation: This is a test that should be done on every patient who presents with an eye complaint; especially if the eye is red. It is not necessary to determine exactly what the visual acuity is; it is necessary to establish that vision is usual. If this is the case, the most worrisome diagnoses can be ruled out: infectious keratitis, iritis, and angle closure glaucoma. 20. Acute otitis media can be diagnosed by identifying which otic characteristic(s)? Decreased mobility of the tympanic membrane ™ Middle ear effusion and erythema of the TM Opacity and erythema of the TM Marked redness of the TM Middle ear effusion and erythema of the TM Explanation: The diagnosis of acute otitis media (AOM) requires the finding of a middle ear effusion (MEE) AND a sign of acute inflammation, such as distinct fullness or bulging of the tympanic membrane (TM), ear pain, or marked redness of the TM. MEE is characterized by the presence of middle ear fluid (bubbles or an air fluid interface) or finding of TM abnormalities (opacity, impaired mobility, or color change). The other finding that constitutes a diagnosis of AOM is the finding of acute, purulent otorrhea that is not due to otitis externa. This characterizes a ruptured TM from otitis media. 21. A teenager with fever and pharyngitis has a negative rapid strept test. After 24 hours, the throat culture reveals "normal flora". Which conclusion can be made? The pharyngitis is not secondary to Strept. The pharyngitis is secondary to a bacterial pathogen but not Strept. The pharyngitis is of undetermined etiology The patient has mononucleosis. The pharyngitis is of undetermined etiology Explanation: The patient has a preliminary culture that indicates the presence of normal flora, i.e. no finding of pathogenic organisms like beta hemolytic Strept. A final culture result generally takes longer than 24 hours to complete. It is premature to make a diagnosis at 24 hours with this culture report. The only conclusion that can be made at this time is "pharyngitis of undetermined etiology". He should be treated symptomatically with antipyretics and analgesics until a final culture is available to help with formulation of a diagnosis. 22. A 61 year-old male presents with a 12-hour history of an extremely painful left red eye. The patient complains of blurred vision, haloes around lights, and vomiting. It began yesterday evening. On examination, the eye is red, tender and inflamed. The cornea is hazy and pupil reacts poorly to light. The most likely diagnosis in this patient is: acute angle glaucoma. increased intracranial pressure. macular degeneration. detached retina. acute angle glaucoma. Explanation: The clinical presentation of a patient with acute angle glaucoma is as this patient has presented, with a hard eyeball, eye pain, along with blurred vision. Nausea and vomiting are common. Pain is usually present when the intraocular pressure rises rapidly. This produces conjunctival redness. Symptoms are more common in the evening when light levels diminish and mydriasis occurs. In chronic angle closure, pressures rise slowly and pain is usually absent. Both can produce blindness. 23. Which antihistamine is preferred for treating allergic rhinitis in an older adult? Diphenhydramine Chlorpheniramine Once daily, non-sedating Long-acting, sedating Once daily, non-sedating Explanation: The preferred antihistamines are the long acting (once daily dosing) and non-sedating. Long-acting is favorable for older adults because of ease of dosing. Non-sedating is important for safety. The first generation antihistamines are sedating and consequently not as favorable to use in older adults. 24. In a patient who is diagnosed with mastoiditis, which of the following is most likely? Recent history of pharyngitis Fever, cough Displaced pinna Nuchal rigidity Displaced pinna Explanation: Mastoiditis is an infection of the mastoid process. The mastoid process is a honeycomb-like structure with air pockets. These become infected with Streptococcus or H. flu most commonly. It is seen in patients (usually less than age 6 years) with chronic otitis media or less frequently in adults with chronic tooth abscesses. Patients may present with recent history of acute otitis media, history of abscess in the teeth and jaw, fever, and a displaced and erythematous pinna or post-auricular area. The tympanic membrane will usually be very red and the patient can become very sick very quickly. Nuchal rigidity is the term used to describe a stiff neck associated with meningitis. 25. A patient who presents with a complaint of sudden decreased visual acuity has a pupil that is about 4 mm, fixed. The affected eye is red. What might be the etiology? Stroke Brain tumor Glaucoma Catarac Glaucoma Explanation: This patient needs urgent referral to ophthalmology. While this is a relatively unusual patient in primary care, the primary care clinician must be able to recognize this patient and the need for urgent referral. In a patient with acute angle closure glaucoma, the patient is usually ill appearing, may have nausea and vomiting. This scenario should prompt urgent referral 26. Which of the following is most likely observed in a patient with allergic rhinitis? Exacerbation of symptoms after exposure to an allergen Nasal congestion and sneezing Post nasal drip and sore throat Worsening of symptoms during a sinus infection Exacerbation of symptoms after exposure to an allergen Explanation: Allergic rhinitis is usually diagnosed on clinical presentation and history. The diagnosis is appropriately made when allergic rhinitis symptoms are reproducible after exposure to the suspected allergen, like pollen. Nasal congestion, sneezing, post-nasal drip and sore throat are not exclusive to allergic rhinitis. Finally, sinusitis does exacerbate allergic rhinitis symptoms. 27. A patient reports a penicillin allergy. What question regarding the allergy should the nurse practitioner ask to determine whether a cephalosporin can be safely prescribed? Have you ever taken a cephalosporin? How long ago was the reaction? What kind of reaction did you have? What form of penicillin did you take? What kind of reaction did you have? Explanation: The most important question to ask the patient is "what kind of reaction did you have?" Unfortunately, many patients who report penicillin allergy are not actually penicillin allergic. About 2-10% of patients who are penicillin allergic have cephalosporin allergy too. Cephalosporins should never be prescribed for penicillin allergic patients if the patient reports hives or an anaphylaxis after having taken penicillin. 28. A patient has been diagnosed with mononucleosis. Which statement is correct? He is likely an adolescent male. Splenomegaly is more likely than not. He cannot be co-infected with Strept. Cervical lymphadenopathy may be prominent. Cervical lymphadenopathy may be prominent. Explanation: Mononucleosis is a common viral infection in adolescents and early twenty year olds. Splenomegaly occurs in about 50% of patients with mononucleosis. While it is not common, it is possible to be co- infected with Streptococcus in the throat. If this is the case, treatment with penicillin should be avoided because of the possibility of an "ampicillin" rash. The most prominent symptoms are fever, fatigue, pharyngitis, and lymphadenopathy. 29. At what age should screening for oral health begin? At birth 3 months 6 months 1 year 6 months Explanation: Examination of the mouth may begin at birth, but oral health screening should begin at 6 months of age. Part of the screening should be for the need for fluoride supplementation. Oral health risk assessment should take place at 6 months, 9 months, and referral to a dental home should take place by one year of age. Oral health risk assessment should continue periodically at health screening visits at 18, 24, and every 6 months until a dental home is established 30. A 70 year-old male has a yellowish, triangular nodule on the side of the iris. This is probably: a stye. a chalazion. a pinguecula. subconjunctival hemorrhage. a pinguecula. Explanation: Pinguecula are common as patients age. They usually appear on the nasal side first and then on the temporal side. This is a completely benign finding. A stye is also called a hordeolum. It is a tender, painful infection of a gland at the eyelid margin. These are self-limiting. A chalazion is a non-tender enlargement of a meibomian gland. A subconjunctival hemorrhage is a blood red looking area on the sclera that does not affect vision. It occurs and resolves spontaneously 31. When does a child's vision approximate 20/20? 2 years 3 years 4 years 5-6 years 5-6 years Correct Explanation: A child's vision should be screened beginning at age 3 years if he is cooperative. The vision of a 3 year- old should be about 20/50. A 4 year-old's vision is usually 20/40. By 5 years of age, vision is usually 20/30. By 6 years of age, a child's vision should be approximately normal, 20/20. 32. The hearing loss associated with aging involves: 8th cranial nerve. sensorineural hearing loss. conductive hearing loss. noise damage. sensorineural hearing loss. Explanation: Hearing loss associated with aging is termed presbycusis and is a form of sensorineural hearing loss. This can be influenced by a number of factors including heredity. Conductive hearing loss involves the external canal and the middle ear. Sound cannot travel beyond the middle ear. The 8th cranial nerve and the inner ear are involved in sensorineural hearing loss. Noise damage can produce a sensorineural hearing loss. This usually occurs over time but is not necessarily associated with aging. 33. A patient has a penicillin allergy. He describes an anaphylactic reaction. Which medication class should be specifically avoided in him? Quinolones Macrolides Cephalosporins Tetracyclines Cephalosporins Explanation: This patient should never have a cephalosporin prescribed for him because of the risk of cross-reactivity between the penicillin and cephalosporin classes. This could potentially give rise to another anaphylactic reaction to the cephalosporin prescribed. A good rule to follow if a patient has had an anaphylactic reaction to a penicillin is to NEVER prescribe a cephalosporin. Although the risk is small, it should not be taken 34. A 6 day-old has a mucopurulent eye discharge bilaterally. What historical finding explains the etiology of the discharge? Infant is Hepatitis B positive. Infant received silver nitrate drops. Mother has chlamydia. Delivery was by C-section. Mother has chlamydia. Explanation: Infants born vaginally to mothers who have chlamydia have a 60-70% risk of acquiring C. trachomatis. Newborns may present with pneumonia and/or conjunctivitis. The most common clinical feature is conjunctivitis that occurs 5 to 14 days after delivery. It is characterized by swelling of the lids and a watery discharge that becomes mucopurulent. The conjunctivae are erythematous. This must be treated orally because topical treatment is not effective. The drug of choice in infants is oral erythromycin 50 mg/kg/day in divided doses for 14 days whether treating pneumonia or conjunctivitis. 35. A patient describes a sensation that "there is a lump in his throat". He denies throat pain. On exam of the throat and neck, there are no abnormalities identified. What is the most likely reason this occurs? Factitious sore throat Lymphadenitis Globus Esophageal motility disorder Globus Explanation: The term used to describe the sensation of "a lump in my throat", or the feeling that there is a foreign body in the throat, is globus. It is not associated with sore throat or pain. The most common cause of globus is GERD or other disorders of the upper esophageal tract. If there is no actual foreign body or abnormality, then other etiologies may be psychologic or psychiatric disorders. 36. The most common cause of acute pharyngitis in children is: S. pyogenes. H. influenzae. M. pneumoniae. respiratory viruses respiratory viruses Explanation: The most common cause of acute pharyngitis is infection with viral agents. The most common viruses are adenoviruses, coxsackie A virus, and parainfluenza virus. The most frequent bacterial cause of acute pharyngitis is Streptococcus pyogenes. The most prevalent time of year for Streptococcus outbreaks is winter. 37. Which of the following symptoms is more indicative of a bacterial sinusitis than viral? Yellow nasal discharge Worsening of symptoms after initial improvement Nasal congestion and rhinorrhea Facial pressure Worsening of symptoms after initial improvement Explanation: There are no specific signs or symptoms that can clearly differentiate viral from bacterial sinusitis, including discolored nasal discharge. Facial pressure is present in both viral and bacterial infections, but facial pain is more likely to be associated with bacterial infection. However, rhinosinusitis symptoms lasting greater than 7 days and purulent nasal discharge, unilateral facial pain or maxillary tooth pain, and worsening of symptoms after initial improvement are suggestive of bacterial infection. 38. A 2 month-old is diagnosed with thrush. An exam of this patient's saliva demonstrates all except: hyphae. yeast. spores. a positive KOH. spores Explanation: The visualization of yeast, hyphae, pseudohypha in saliva usually indicates Candida species. The diagnosis of thrush is usually made on clinical presentation and there is no need for KOH. Spores are a form assumed by some bacteria and fungi that are extremely resistant to heat and consequently are very difficult to kill. 39. A patient who is 52 years old presents to your clinic for an exam. You notice a yellowish plaque on her upper eyelid. It is painless. What should the NP assess? Vision in the affected eye Sedimentation rate Lipid levels Liver function studies Lipid levels Explanation: The description in the question describes a xanthelasma. It is slightly raised and is a well-circumscribed plaque on the upper eyelid usually. One or both lids may be affected. These are often associated with lipid disorders but may occur independent of any systemic or local disease. These plaques do not affect vision. 40. An 80 year-old is having difficulty hearing. When the nurse practitioner examines him, she is unable to visualize the tympanic membrane because of cerumen impaction. This produces what kind of hearing loss? Tympanic Conductive Sensorineural Artificial Conductive Explanation: This is a conductive hearing loss provided he is able to hear when the cerumen is removed. Anything that inhibits the ability of sound to enter the external canal and middle ear will produce a conductive hearing loss. Sensorineural hearing loss can be produced by aging, Meniere's disease, noise trauma, or cranial nerve VIII pathology. 41. The most common complication of influenza is: cough. bacterial pneumonia. viral pneumonia. bronchitis. bacterial pneumonia. Explanation: Pneumonia is the most common complication of influenza; bacterial pneumonia is the most common form. Streptococcus pneumoniae is the most common bacterial pathogen. 25% of deaths associated with influenza are related to pneumonia. Clinical presentation of pneumonia as a complication of influenza is characterized by worsening of symptoms after an initial period of improvement for 1-3 days. Fever, cough, purulent sputum predominate. Cough is a symptom of influenza, not a complication. Bronchitis might be part of the differential of influenza, however, fever is uncommon in bronchitis. 42. The single most effective maintenance therapy for allergic rhinitis is: an antihistamine. a decongestant. a topical nasal steroid. a topical antihistamine. a topical nasal steroid. 43. In a patient with mononucleosis, which laboratory abnormality is most common? Lymphocytosis and atypical lymphocytes Elevated monocytes A decreased total white count Elevated liver enzymes Lymphocytosis and atypical lymphocytes Explanation: Lymphocytosis, a predominance of lymphocytes, is the most common laboratory abnormality seen with infectious mononucleosis (mono). Atypical lymphocytes are a common finding too. An elevation in monocytes is often found, but, does not occur with as high frequency as lymphocytosis. The total white count often is increased and may lie between 12,000-18,000/microL. Elevated liver enzymes, ALT and AST, are noted in the majority of patients but is a benign finding. These usually return to baseline within several weeks of onset of acute symptoms. 44. An older adult has a cold. She calls your office to ask for advice for an agent to help her runny nose and congestion. She has hypertension, COPD, and glaucoma. What agent is safe to use? Pseudoephedrine Oxymetazoline nasal spray Guaifenesin Diphenhydramine Guaifenesin Explanation: Pseudoephedrine will increase her blood pressure. Oxymetazoline can be absorbed across mucus membranes and elevate blood pressure too. Diphenhydramine is a sedating antihistamine with anti- cholinergic properties. This would be contraindicated with glaucoma. Guaifenesin would be the safest agent to use. 45. A patient with diarrhea has a positive enzyme immunoassay for C. difficile. He is on clindamycin for a tooth abscess. How should he be managed? Stop the clindamycin, treat the diarrhea Treat the diarrhea, give metronidazole Stop the clindamycin if possible, give metronidazole Give metronidazole Stop the clindamycin if possible, give metronidazole Explanation: The most important step in treating infection with C. difficile is stopping ingestion of the offending antibiotic. In this case, stopping the clindamycin, if possible, is the most important part of treatment. Metronidazole is recommended initially for non-severe infection. If the antibiotic cannot be stopped, treatment for C. difficile should be continued as long as the patient must take the offending antibiotic. 46. A 3 year-old has been recently treated for an upper respiratory infection (URI) but drainage from the right nostril persists. What should the NP suspect? Allergic rhinitis Presence of a foreign body Unresolved URI Dental caries Presence of a foreign body Explanation: Two clinical clues should make the examiner suspect a foreign body. First, the patient has continued drainage despite treatment. Second, the drainage is unilateral. Unilateral drainage from a nostril should prompt the examiner to visualize the turbinates. In this case, a foreign body could probably be visualized. 47. What symptom triad is most commonly associated with infectious mononucleosis? Fever, lymphadenopathy, pharyngitis Fatigue, fever, pharyngitis Body aches, fever, splenomegaly Headache, lymphadenopathy, tonsillar exudates Fever, lymphadenopathy, pharyngitis Explanation: The triad includes fever, lymphadenopathy, and pharyngitis. Fatigue commonly accompanies mononucleosis ("mono"), but this is not part of the triad. Approximately 50% of patients with mono have splenomegaly. Body aches are probably the effect of fever, but do not characterize the disease. The etiologic agent of mononucleosis is the Epstein Barr virus. It is often spread by intimate contact between susceptible contacts. It is spread via saliva and has been called "the kissing disease". 48. Which of the following will decrease the risk of acute otitis media in a 6 month old? Cigarette smoke exposure Breastfeeding Sucking on pacifiers Vitamin D supplementation Breastfeeding Explanation: Breastfeeding is considered a negative risk factor for acute otitis media because it decreases the risk of otitis media. Exposure to cigarette smoke and sucking on pacifiers increases the risk of acute otitis media. It is unknown whether Vitamin D supplementation increases or decreases the risk. 49. A patient has nasal septal erosion with minor, continuous bleeding. There is macerated tissue. What is a likely etiology? Improper use of a nasal steroid Chronic sinusitis Severe allergic rhinitis Cocaine abuse Cocaine abuse Explanation: The nasal septum separates the right from left nostrils. It is made of thick cartilage and is covered with mucous membrane. It can be injured from foreign substances that contact it, like cocaine. A nasal septal erosion or perforation should always be assumed to have been from sniffing toxic substances in the nose, not nasal steroids. 50. On routine exam, a 15 year-old patient's tympanic membrane (TM) reveals a tiny white oblong mark just inferior to the umbo on the surface of the TM. The patient has no complaints of ear pain and gross hearing is intact. What is this? A variant of normal Scarring of the tympanic membrane A cholesteatoma foreign body Scarring of the tympanic membrane Explanation: A white, chalky mark on the surface of the TM reflects scarring of the tympanic membrane (TM). This can occur secondary to TM rupture or tympanostomy tube placement. The normal color of the TM is pink or pearly gray so this is not a variant of normal. A cholesteatoma is an abnormal growth found in the middle ear or mastoid, not on the surface of the TM. Foreign bodies typically reside in the external canal. 51. A 70 year-old female states that she sees objects better by looking at them with her peripheral vision. She is examined and found to have a loss of central vision, normal peripheral vision, and a normal lens. This best characterizes: glaucoma. cataracts. macular degeneration. detached retina. macular degeneration. Explanation: Macular degeneration presents most commonly with a loss of central vision. The macula is the central part of the retina. As it degenerates, central vision is lost. Questions should be asked about the rate of loss of vision. Reports of rapid vision loss require urgent ophthalmologic evaluation. Known risk factors are age greater than 50 years with the greatest prevalence over age 65, smoking, family history, and history of stroke, MI, or angina 52. A patient is diagnosed with thrush. What might be found on microscopic exam? Budding yeasts, pseudohypha Cocci Spores Rods, spores, cocci Budding yeasts, pseudohypha Explanation: The visualization of yeasts and/or pseudohypha in saliva indicates a fungal infection, often Candida species. Budding is a process by which yeasts reproduce. 53. A patient presents with tragal pain. What is the most likely diagnosis? Otitis media Otitis externa Presbycusis Mastoiditis Otitis externa Explanation: Otitis externa is "swimmer's ear". It is characterized by tragal tenderness. Otitis externa is an infection of the external canal. When the tragus is tender, it will be difficult to insert a speculum to examine the ear. 54. A 3 year-old has fluid in the middle ear that does not appear infected. The eardrum appears normal. This is referred to as: serous otitis media. acute otitis media. otitis media with effusion. middle ear effusion. middle ear effusion. Correct Explanation: Middle ear effusion refers to the presence of fluid in the middle ear. This is present in both otitis media with effusion and acute otitis media. Since the eardrum appears normal and the fluid does not appear infected, there is no reason to suspect otitis media, acute or with effusion. Another name for otitis media with effusion is serous otitis media. Other terms for this are secretory or nonsuppurative otitis media. 55. A patient who is otherwise healthy states that he woke up this morning and has been unable to hear out of his left ear. The Weber and Rinne tests were performed. What is the primary reason for doing this? To assess for progressive hearing loss. It is nearly useless and should not be performed. It can help identify malingerers. It helps differentiate conductive from sensorineural hearing loss. It helps differentiate conductive from sensorineural hearing loss. Explanation: The Rinne and Weber tests can help differentiate conductive from sensorineural hearing loss. Once it is determined that the patient's hearing loss is conductive or sensorineural, the differential can be better developed. Common causes of conductive hearing loss are cerumen impaction, otitis externa, tympanic membrane rupture. Common causes of sensorineural hearing loss are presbycusis, Meniere disease, acoustic neuroma. 56. A patient presents to a nurse practitioner clinic with paroxysmal sneezing, clear rhinorrhea, nasal congestion, facial pain. Which symptom below is NOT associated with allergic rhinitis? Sneezing Rhinorrhea Nasal congestion Facial pain Facial pain Correct Explanation: Facial pain is not associated with allergic rhinitis. In conjunction with nasal congestion, it is most likely a sinus infection. Patients with allergic rhinitis and nasal congestion are more likely to develop acute and chronic bacterial sinusitis because untreated allergic rhinitis results in impaired mucus flow. This increases the risk of infection. Symptoms of bacterial sinusitis include nasal congestion, purulent post- nasal drip or rhinorrhea, facial pain and maxillary tooth pain. There is no symptom that can differentiate bacterial from viral sinusitis. 57. A patient with environmental allergies presents to your clinic. She takes an oral antihistamine every 24 hours. What is the most effective single maintenance medication for allergic rhinitis? Antihistamine Decongestant Intranasal glucocorticoids Leukotriene blockers Intranasal glucocorticoids Explanation: These agents are particularly effective in the treatment of nasal congestion and would be a good choice for the patient in this scenario. Intranasal glucocorticoids are effective in relieving nasal congestion, discharge, itching, and sneezing. A trial of stopping the oral antihistamine could be tried in this patient. Symptoms would determine whether the antihistamine should be resumed. 58. A patient stated that his ears felt stopped up. He pinched his nose and blew through it forcefully. The nurse practitioner diagnosed a ruptured left tympanic membrane. What would indicate this? Bright red blood in the left external canal Pain in the left and right ears Clear fluid in the left external canal Absence of hearing in the left ear Bright red blood in the left external canal Explanation: This patient ruptured his tympanic membrane (TM) traumatically from excessive pressure when he pinched his nose and blew out through it at the same time. It is common to find bright red blood (not clear fluid), but not active bleeding, in the external canal of the affected ear. He may experience pain in the affected ear, but this alone would not be indicative of a ruptured TM. Hearing may be diminished in the affected ear but should not be absent. Patients usually describe hearing as muffled. 59. Which long-acting antihistamine listed below is sedating? Loratadine Cetirizine Azelastine Fexofenadine Cetirizine Explanation: Cetirizine (Zyrtec) is NOT non-sedating. In older patients, the usual dose is decreased from 10 mg daily to 5 mg daily. This is due to the sedative effect of cetirizine. It should be dosed at nighttime to minimize the initial sedative action. It has a prolonged geriatric half-life. Caution is advised. Fexofenadine is the least sedating of the oral agents listed. 60. A patient presents to your clinic with a painless red eye. Her vision is normal, but her sclera has a blood red area. What is this termed? Conjunctivitis Acute iritis Glaucoma Subconjunctival hemorrhage Subconjunctival hemorrhage Correct Explanation: This represents leakage of blood out of the ophthalmic vasculature. It is usually painless and can be the result of coughing, sneezing, hypertension, or trauma. This will resolve without treatment, but, aspirin or other agents that can produce bleeding should be discontinued until the etiology is determined. 61. What clinical finding necessitates an urgent referral of the patient to an emergency department? A fiery red epiglottis Sudden onset of hoarseness Purulent drainage from the external canal Tragal tenderness. A fiery red epiglottis Explanation: A finding of a fiery red epiglottis signals epiglottitis. Since airway obstruction can be rapid with epiglottitis, immediate referral to an emergency department is warranted. Sudden onset of hoarseness does not signal a specific emergency situation. Purulent drainage from the external canal may signify a ruptured tympanic membrane or otitis externa. Tragal pain is significant of otitis externa. 62. A 4 year-old was diagnosed and treated for left acute otitis media 4 weeks ago. She is here today for a well-child visit. There is an effusion in the left ear. She denies complaints. How should this be managed? This should be monitored. She should be given another antibiotic. She should be evaluated with pneumatic otoscopy. She needs a tympanogram. This should be monitored Explanation: About 40% of children have effusion at 4 weeks post-acute otitis media. This should be monitored and not treated with another antibiotic. Effusion is a stage in the resolution of otitis media. Pneumatic otoscopy will identify the presence of fluid or pus behind the TM, but will not help in diagnosis or treatment once an effusion has been established. A tympanogram will establish that her hearing is diminished, a fact which should be assumed since there is fluid in the middle ear 63. A 32 year-old patient is a newly diagnosed diabetic. She has developed a sinus infection. Her symptoms have persisted for 10 days. Six weeks ago she was treated with amoxicillin for an upper respiratory infection. It cleared without incident. What should be recommended today? Prescribe amoxicillin again. Prescribe amoxicillin-clavulanate today. Do not prescribe an antibiotic; a decongestant is indicated only. Prescribe a decongestant and antihistamine Prescribe amoxicillin-clavulanate today. Explanation: Amoxicillin is no longer indicated for initial treatment in adults who have acute bacterial sinusitis. A bacterial cause can be assumed since she's had symptoms for 10 days. A viral infection likely would have run its course by now. After 10 days of persistent symptoms, treatment is reasonable with an antibiotic; especially since this patient is diabetic. She may be having blood sugar elevations that facilitate growth of the causative organism of the sinus infection. A decongestant could be added depending on her blood pressure and personal history of using decongestants. 64. A 3 year-old has been diagnosed with acute otitis media. She is penicillin allergic (Type 1 hypersensitivity reaction). How should she be managed? Amoxicillin Amoxicillin-clavulanate Cefuroxil Clarithromycin Clarithromycin Explanation: This patient experienced a Type I allergic reaction to penicillin. This is characterized by hives, wheezing, or anaphylaxis. It is NEVER considered safe to prescribe a cephalosporin. Macrolides may be prescribed to patients with a true Type 1 reaction to penicillin. Since amoxicillin is a penicillin, it should not be prescribed. 65. A patient with mononucleosis has pharyngitis, fever, and lymphadenopathy. His symptoms started 3 days ago. He will have a positive "Monospot". He will have a normal CBC. He could have negative "Monospot". He could have a positive "Monospot" and a normal CBC. He could have negative "Monospot” Explanation: The "Monospot" detects the presence of heterophile antibodies in mononucleosis (mono). If the "Monospot" is performed too early in the course of the illness, it will be negative even though the patient has mono. If the patient has persistent symptoms suspicious of mono, a "Monospot" should be repeated. It is likely that in several days after a negative result, a positive result will be obtained. Lymphocytosis characterizes mononucleosis; therefore, it is highly unlikely that a patient will not have a normal CBC if he has mono. 66. Swimmer's ear is diagnosed in a patient with tragal tenderness. What other symptom might he have? Otitis media Hearing loss Otic itching Fever Otic itching Explanation: Swimmer's ear is termed otitis externa. It represents an infection of the external canal. This is characterized by tragal tenderness with light touch of the tragus on the affected side. Fever does not occur because this is a superficial infection. It is treated with a topical agents: an antibiotic and steroid placed in the external canal. 67. A teenager with fever and pharyngitis has a negative rapid strept test. After 24 hours, the throat culture reveals "normal flora". Which conclusion can be made? The pharyngitis is not secondary to Strept. The pharyngitis is secondary to a bacterial pathogen but not Strept. The pharyngitis is of undetermined etiology. The patient has mononucleosis. The pharyngitis is of undetermined etiology. Explanation: The patient has a preliminary culture that indicates the presence of normal flora, i.e. no finding of pathogenic organisms like beta hemolytic Strept. A final culture result generally takes longer than 24 hours to complete. It is premature to make a diagnosis at 24 hours with this culture report. The only conclusion that can be made at this time is "pharyngitis of undetermined etiology". He should be treated symptomatically with antipyretics and analgesics until a final culture is available to help with formulation of a diagnosis. 68. A 4 month-old infant has thrush. The mother is breastfeeding. She reports that her nipples have become red, irritated, and sensitive. What should the nurse practitioner advise the mother of this baby to treat thrush? Have the mother exercise good hygiene of her nipples Administer an oral anti-fungal suspension to the mother Administer an oral anti-fungal suspension to the infant Treat the infant with an oral anti-fungal suspension and the mother's nipples with a topical anti-fungal agent Treat the infant with an oral anti-fungal suspension and the mother's nipples with a topical anti-fungal agent Correct Explanation: If the infant has thrush, he should be treated with an oral anti-fungal suspension like nystatin. This is given 4 times daily after feedings. Since the mouth of the infant is in contact with the mother's nipples during breastfeeding, and they sound infected too, the mother and infant should be treated simultaneously. Care should be given so that the mother gently washes her nipples and dries them before breastfeeding. This will minimize or eliminate ingestion of the topical anti-fungal in the infant. 69. A 2 year-old has a sudden onset of high fever while at daycare. The daycare attendant describes a seizure in the child. The child is brought to the clinic; neurologically he appears normal. His body temperature is 99.9 degrees F after receiving ibuprofen. He is diagnosed with otitis media. How should the nurse practitioner manage this? Assess the child and refer to the ER Treat the otitis media and give education about fever management Start the child on seizure precautions Have him admitted to the hospital for observation Treat the otitis media and give education about fever Explanation: The child may have had a febrile seizure at the daycare related to a sudden elevation of body temperature. The sudden rise (or even fall) of body temperature can precipitate a seizure in young children. The most common diagnosis associated with febrile seizures is otitis media. The mother should be advised about behavior to watch for that could indicate the child is having a seizure. If this behavior occurs again, the child should be brought for neurological evaluation. Information should be provided to the caregiver regarding management of elevated body temperature in the child. 70. Most commonly, epistaxis occurs: in women. at Kiesselbach's plexus. in the posterior septum. in patients on anticoagulants. at Kiesselbach's plexus. Explanation: Most nosebleeds occur in men; 80% occur anteriorly. Kiesselbach's plexus is the most common site for any epistaxis to occur because this site represents the anastomosis of branches of three primary vessels: the ethmoidal artery, the sphenopalatine artery, and the facial artery. Anticoagulants place patients at very high risk for nose bleeds, but they do not constitute the majority of patients with nose bleeds. 71. A patient with a bacterial sinusitis cannot spread this to others via: hand contact. droplets. In fomites. urine or stool. urine or stool. Explanation: Bacterial infections of the upper respiratory tract can be transmitted by direct contact with fomites, secretions, or by respiratory droplet. Fomites are inanimate objects where bacterial or viral particles live and are easily transmitted to others who touch the fomite. A doorknob is a common example. Infectious particles remain pathogenic for varying lengths of time depending on the organism, environment, and the fomite. Bacterial and viral particles are denatured once present in the digestive system and are no longer able to produce upper respiratory infection via stool or urine. 72. A patient with allergic rhinitis developed a sinus infection 10 days ago. He takes fexofenadine daily. What should be done with the fexofenadine? Stop the fexofenadine. Stop the fexofenadine and add a nasal steroid. Continue the fexofenadine and prescribe an antibiotic. Continue the fexofenadine and add a decongestant. Continue the fexofenadine and prescribe an antibiotic Explanation: This patient should continue his fexofenadine. This treats his allergies and although he has a sinus infection, he still needs treatment for his allergies. A topical nasal steroid can be added if poor control of allergies exists, otherwise, this probably just increases the cost of treatment of during this sinus infection. If his sinus infection has been present for 10 days, an antibiotic seems prudent at this point. 73. A tympanic membrane (TM) is erythematous. Which factor listed below is NOT the cause of an erythematous TM? Acute inflammation Coughing High fever Crying Coughing Explanation: An erythematous TM can be caused by the conditions listed above. Coughing does not produce an erythematous TM. The tympanic membrane (TM) can take on numerous colors depending on the condition or status of the patient. Under normal conditions, the TM is usually described as pearly gray or pink. When there is fluid behind the TM, it may take on a white, gray, or blue appearance. When pus is present behind the TM, it can appear white or yellow. 74. A nurse practitioner performs a fundoscopic exam. He identifies small areas of dull, yellowish- white coloration in the retina. What might these be? Cotton wool spots Microaneurysms Hemorrhages Exudates Cotton wool spots Explanation: These are cotton wool spots. They are due to swelling of the surface layer of the retina. Swelling occurs because of impaired blood flow to the retina. The most common causes of cotton wool spots are diabetes and high blood pressure. A microaneurysm is the earliest manifestation of a diabetic retinopathy. These appear as small round dark red dots on the retinal surface. Exudates are an accumulation of lipid and protein. These are typically bright, reflective white or cream colored lesions seen on the retina. 75. A 4 year-old child with otitis media with effusion: needs an antibiotic. probably has a viral infection. probably has just had acute otitis media. has cloudy fluid in the middle ear. probably has just had acute otitis media. Explanation: Otitis media with effusion (OME) frequently precedes or follows an episode of acute otitis media. This condition should not be treated with an antibiotic since the middle ear fluid is not infected. However, the fluid acts as a medium for bacterial growth 76. A 39 year-old has a sudden onset of a right red eye. He reports sensitivity to light and the sensation of a foreign body, though his history for a foreign body is negative. He does not wear contact lenses. How should the NP manage this? Refer to ophthalmology Treat for viral conjunctivitis Treat for bacterial conjunctivitis Observe for 24 hours if visual acuity is normal Refer to ophthalmology Explanation: While no clear diagnosis can be made from this scenario, there are several red flags. Collectively, the red flags necessitate referral to ophthalmology. First, the eye is red. He is photophobic and has the sensation of a foreign body. There is no mention of eye discharge but, eye discharge with this scenario would cause the examiner to consider bacterial conjunctivitis or keratitis. The symptoms of photophobia and foreign body sensation are symptoms of an active corneal process. Glaucoma should also be considered in the differential. He should be referred to ophthalmology. 77. Which medication listed below is considered ototoxic? Digoxin Aspirin Ramipril Metoprolol Aspirin Explanation: Many medications are ototoxic in patients who are otherwise healthy. Some patients are at increased risk (for ototoxicity) when they consume ototoxic medications if they have impaired renal function. Renal impairment makes excretion of the ototoxic drug more difficult and ototoxicity becomes more likely. Hearing loss secondary to use of the following medications should always be assessed: aspirin, aminoglycosides, vancomycin, erythromycin, loop diuretics (like furosemide), the anti-malarial medications, sildenafil (tadalafil, vardenafil) and cisplatin. ACE inhibitors, digoxin, and beta blockers are not associated with ototoxicit 78. A 6 month-old infant has a disconjugate gaze. The nurse practitioner observes that the 6 month old tilts his head when looking at objects in the room. Which statement is true? Nystagmus will be present. The infant will have an abnormal cover/uncover test. The patient's vision is 20/200. He needs a CT to rule out an ocular tumor. The infant will have an abnormal cover/uncover test Explanation: The cover/uncover test is used to assess strabismus, a common cause of disconjugate gaze. Strabismus represents a nonparallelism of the visual axis of the eyes. This results in the inability of both eyes to focus on the same object at the same time. At 6 months of age, a disconjugate gaze and tilting of the child's head is a red flag. This child needs referral to ophthalmology. While an ocular tumor could be present, this is unlikely and not the action that should be taken today. 79. What are the most common signs and symptoms associated with mononucleosis? Fatigue and lymphadenopathy Cough and pharyngitis Splenomegaly and fever Rash and pharyngitis Fatigue and lymphadenopathy Explanation: The most common symptoms associated with mononucleosis (mono) are adenopathy (100%) and fatigue (90-100%). Pharyngitis occurs in 65-85% of patients. Cough occurs less than 50%; splenomegaly occurs 50-60%; fever 80-95%. The least common symptom of mono is rash. It occurs in only 3-6% of patients. 80. A patient who is 65 years old states that she has "hayfever" and has had this since childhood. What agent could be safely used to help with rhinitis, sneezing, pruritis, and congestion? Nasal steroid Ipratropium Antihistamine Decongestant Nasal steroid Explanation: A nasal steroid is considered the gold standard for improvement of all symptoms associated with allergic rhinitis (hay fever). Ipratropium helps with rhinitis only. An antihistamine helps will all symptoms listed but is not as effective at relieving symptoms of congestion as a nasal steroid. A decongestant is extremely effective at relieving congestion, but no other symptoms listed. 81. Papilledema is noted in a patient with a headache. What is the importance of papilledema in this patient? It is not related to this patient's headache. It is an incidental finding in patients with migraines. It could be an important finding in this patient. This is a common finding in patients with headaches. It could be an important finding in this patient. Explanation: Papilledema represents swelling of the optic nerve head and disc secondary to increased intracranial pressure (ICP). It is not a common finding in patients with headaches; only those with headache secondary to ICP. The pressure disrupts fluid flow within the nerve and swelling results. The cardinal symptom of ICP is a headache; papilledema is a secondary finding. 82. 70 year-old patient in good health is found to have a large, white plaque on the oral mucosa of the inner cheek. There is no pain associated with this. What is a likely diagnosis? Cheilitis Aphthous ulcer Sjögren's syndrome Leukoplakia Leukoplakia Explanation: The etiology of this white plaque is unclear from the given information, but it cannot be cheilitis. This affects the lips. It cannot be an aphthous ulcer because this is painful. Sjögren's syndrome does involve the mucous membranes but manifests itself as dry mouth, not a plaque or lesion. The differential diagnosis for a white oral plaque should include oral leukoplakia, a premalignant lesion. This is often related to HPV, human papilloma virus. Risk factors include smokeless tobacco. Others in the differential include oral hairy leukoplakia (seen almost exclusively in patients with HIV), squamous cell carcinoma, and malignant melanoma. It may also be a completely benign growth, but this can only be established after biopsy. 83. What medication should always be avoided in patients with mononucleosis? Clindamycin Ibuprofen Amoxicillin Topical lidocaine Amoxicillin Explanation: A generalized rash may be seen in patients with mononucleosis (mono) who are given amoxicillin or ampicillin at the time of the acute phase of the illness. The rash does not represent an allergic reaction, but instead probably represents a reaction between the Epstein Barr virus and the penicillin molecule. The rash is usually described as maculopapular and may be pruritic. The rash has also been described with other beta-lactam antibiotics, azithromycin, cephalexin and levofloxacin. 84. A common complaint in older patients who have cataracts is: sensitivity to sunlight. poor peripheral vision. increased incidence of falls. eye pain in the affected eye. sensitivity to sunlight. Explanation: Loss of peripheral vision and eye pain is typical in patients with glaucoma, not cataracts. Patients with cataracts may be at higher risk for falls because they have difficulty seeing, however, this is not a common complaint of patients who have cataracts. 85. Arcus senilis is described as: normal in people over 50 years of age. copper deposits in the cornea. loss of central vision. degeneration of the arcus and obstruction of tear ducts. normal in people over 50 years of age. Explanation: Arcus senilis describes an arc or circle around the cornea that is common in older adults. The circle is due to deposition of lipids in the cornea but is not necessarily due to hypercholesterolemia. However, when this is seen in young adults, it is termed arcus juvenilis, and is often associated with lipid abnormalities. 86. Acute otitis media can be diagnosed by identifying which otic characteristic(s)? Decreased mobility of the tympanic membrane ™Middle ear effusion and erythema of the TM Opacity and erythema of the TM Marked redness of the TM Middle ear effusion and erythema of the TM Explanation: The diagnosis of acute otitis media (AOM) requires the finding of a middle ear effusion (MEE) AND a sign of acute inflammation, such as distinct fullness or bulging of the tympanic membrane (TM), ear pain, or marked redness of the TM. MEE is characterized by the presence of middle ear fluid (bubbles or an air fluid interface) or finding of TM abnormalities (opacity, impaired mobility, or color change). The other finding that constitutes a diagnosis of AOM is the finding of acute, purulent otorrhea that is not due to otitis externa. This characterizes a ruptured TM from otitis media. 87. An infant is brought to the nurse practitioner because his gaze is asymmetrical. Which finding indicates a need for referral to ophthalmology? He is 2 months of age. He is 3 months of age. He has persistent strabismus. His red reflex is normal. He has persistent strabismus. Explanation: Strabismus may be completely normal in the first few months of life. Persistent strabismus at any age likely indicates eye muscle weakness, cranial nerve abnormalities or a number of other pediatric eye diseases. The infant with a normal red reflex probably does not have retinoblastoma or congenital cataracts, but both of these conditions can result in strabismus. This infant should be referred to an ophthalmologist for evaluation if he has persistent strabismus. 88. A patient has been given amoxicillin for 8 days for sore throat. Today, the patient has developed a pruritic full body rash and diagnosed with penicillin allergy. What describes the skin manifestations of penicillin allergy? The rash will be fine and papular. There will be hives. There will be large, splotchy, non-pruritic areas. The rash will not blanch. There will be hives. Explanation: The usual skin manifestation associated with an allergic reaction is hives. It is urticarial and of rapid onset. Hives are intensely pruritic, well circumscribed, raised, and erythematous. Penicillin is known to be allergenic and should be stopped immediately in these circumstances. An antihistamine should be administered. 89. How should the class effect of the nasal steroids be described? There is a lot of variation among agents within the class. There are no significant systemic effects with these. There are high rates of nasal bleeding. It is generally not well-tolerated. There are no significant systemic effects with these Explanation: One reason these are preferred agents in older adults (and young children) is that there are very few systemic effects. The steroids are absorbed across the mucous membranes and are deposited in the area where they need to work. There is absolutely no sedation associated with their use. They are generally well-tolerated. The class is predictable. There is very little variation between agents. 90. A 70 year-old presents urgently to the nurse practitioner clinic with angioedema. This began less than an hour ago. He is breathing without difficulty. What medication may have caused this? Aspirin Fosinopril Penicillin Metformin Fosinopril Explanation: Angioedema is common in African American patients who take ACE inhibitors. It is an unpredictable event but once it occurs, the culprit medication must be discontinued and never prescribed again. This reaction has occurred with many medications, but ACE inhibitors are classic culprits. Swelling that affects the lips, face, eyelids, tongue, and larynx characterizes angioedema. Not all reactions involve this severe a reaction, but any impairment in airway must be referred to the nearest emergency department. 91. Group A Strept pharyngitis: is characterized by a single symptom. can be accompanied by abdominal pain. usually does not have exudative symptoms. is commonly accompanied by an inflamed uvula. can be accompanied by abdominal pain. Explanation: Group A Streptococcus is usually characterized by multiple symptoms with an abrupt onset. Sore throat is usually accompanied by fever, headache. GI symptoms are common too; nausea, vomiting and abdominal pain are usual. Even without treatment, symptoms usually resolve in 3-5 days 92. A 45 year-old patient describes a spinning sensation that has occurred intermittently for the past 24 hours. It is precipitated by position changes like rolling over in bed. During these episodes, he complains of intense nausea. Which symptom is most characteristic of vertigo with a peripheral etiology? The length of duration of symptoms Sensation of spinning Precipitation with position change Nausea Precipitation with position change Explanation: Vertigo may have either a peripheral or central (brainstem or cerebellum) etiology. The most common form of peripheral vertigo is benign paroxysmal positional vertigo (BPPV). It is usually due to calcium debris in the ear's semicircular canals. Vertigo is a symptom, not a disease. It is characterized by the sensation of moving, having objects around the patient move, or a tilting/swaying sensation. Spinning sensation is a typical description of a patient with BPPV. During acute attacks of vertigo, regardless of the etiology, nausea and vomiting are common. Attacks can be transient and last for days to weeks. 93. A contact lens wearer presents with an erythematous conjunctiva. He denies blurred vision. There is scant drainage and crusting around the eye. He reports that there was crusting when he woke up this morning. How should the exam begin? The patient should wash his hands. His visual acuity should be measured in each eye. Fluorescein staining should be assessed. Extraocular eye movements should be assessed. His visual acuity should be measured in each eye Explanation: This patient's symptoms indicate that he could have conjunctivitis. Assessment of patients with eye complaints should always begin with assessment of vision in each eye. This should be documented. 94. A patient has been diagnosed with acute rhinosinusitis. Symptoms began 3 days ago. Based on the most likely etiology, how should this patient be managed? Amoxicillin with clavulanate Decongestant and analgesic Correct Azithromycin and decongestant Levofloxacin Decongestant and analgesic Explanation: The vast majority of patients who have acute rhinosinusitis have a viral infection. In fact, 2% or fewer cases of acute rhinosinusitis are due to bacteria. When bacteria are the causative agents, Streptococcus and Staphylococcus are common pathogens. Since the most likely pathogen is a virus, symptomatic treatment should occur unless a red flag such as fever, facial pain, purulent drainage, etc. is present. Typically, conservative measures should be used for 7-10 days prior to antibiotic use. In clinical practice, patients typically request antibiotics sooner than 7-10 days. 95. Which statement about serous otitis media is correct? This usually needs treatment with antibiotics. This can be diagnosed with pneumatic otoscopy. Serous otitis media can produce a sensorineural hearing loss. Otitis media and serous otitis are frequently associated with fever. This can be diagnosed with pneumatic otoscopy Explanation: Serous otitis media (SOM) is also called otitis media with effusion (OME) or "glue ear". OME occurs when there is fluid (non-infectious) in the middle ear. This prevents normal mobility of the tympanic membrane and creates a conductive hearing loss. Pneumatic otoscopy is the primary non-invasive diagnostic method because it has a high sensitivity and specificity. It may be present before otitis media develops, or it may follow resolution of otitis media. OME is far more common than otitis media and is not associated with systemic symptoms like fever. Acute otitis media (AOM) describes infected fluid in the middle ear. 96. A patient has 2 palpable, tender, left pre-auricular nodes that are about 0.5 cm in diameter. What might also be found in this patient? Sore throat Ulceration on the tongue Conjunctivitis Ear infection Conjunctivitis Explanation: The eyes are drained partly by the pre-auricular lymph nodes. They are palpated near the ear and can swell in response to eye infections, allergies, or foreign bodies in the eye. 97. A 70 year-old patient has begun to have hearing loss. She relates that her elderly parents had difficulty hearing. Which complaint below is typical of presbycusis? Inability to hear consonants Asymmetrical loss of hearing Inability to hear low pitched sounds Pulsatile noise in the ear Inability to hear consonants Explanation: Presbycusis is age related hearing loss. The significance of this patient's parental hearing loss is important for history. Presbycusis is influenced by genetics as well as noise exposure, medications, and infections. Loss of ability to hear speech in crowded rooms or noisy area, inability to understand consonants, and loss of high-pitched sounds is typical. Hearing loss is symmetrical. Asymmetrical hearing loss is a red flag regardless of the age at which it occurs. Tinnitus is common and is an annoying sensation associated with presbycusis. A pulsatile noise in the ear raises suspicion of a tumor or arteriovenous malformation. [Show More]

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